By Joseph Giere, M.D.
The high infant mortality in Haiti inspired Dr. Harold Prévil to begin a special program for newborns (neonates) when he became Medical Director for Hôpital Sacré Coeur in 2008. With the help of funds from St. Cecilia Parish in Wilbraham, MA, a special space was carved out of the pediatric ward to become a 10-bed “NICU” (Neonatal Intensive Care Unit.)
Dr. Prévil developed priorities and focused on the careful use of limited resources. In order to achieve the goal of lowering mortality, he targeted his efforts at the “near term” patients, infants at 34-37 weeks. This group of infants generally shows more significant progress with NICU care.
Infection Prevention Receives Top Priority
Simple low-tech measures to prevent infection were embraced. Specially constructed closed entry doors limit access to the NICU. A strategically placed sink ensures “no excuses” for not washing hands. Strict, long proven precautions for any contact with vulnerable newborns were introduced and mandated for all parents, nurses and physicians (who are recognized in the U.S. as the worst offenders.) These new measures became a top priority for all!
Separate isolette beds provide optimum care for vulnerable neonates. In designing the NICU, even the spacing between each bed was considered of medical importance. In the U.S., High Risk Level II Nursery Standards require certain spacing for infection control, a critical control not often practiced in Haitian medical facilities.
For example, in the main maternity hospital in the Haitian capital of Port Au Prince, premature infants lay side by side on slanting shelves, positioned at chest height, along the perimeter of the room. Only a partition board separates the infants. Such a practice encourages rather than eliminates down cross infection.
In Hôpital Sacré Coeur this approach works! Neonatal mortality is down when compared to country statistics. There is progress.
Specialty Training Increases Skill Sets of Haitian Staff
Dr. Prévil’s ongoing plan includes continuing specialty training for the medical staff. When dealing with newborns, even routine procedures require much practice, and patience. Even, the task of extracting blood from a small premature baby by a heel prick, and then milking the droplet of blood for lab analysis had to be taught.
As staff discovered, to be meticulous, to maintain aseptic technique can be a daunting challenge. No matter where in the world you practice medicine, working with the smallest patients is a big challenge.
Sometimes threading an upholstery needle is easier than placing an intravenous medication line in a tiny neonate’s blood vessel, which is more akin to slippery strands of angel hair pasta.
In 2009, Drs. Chalumeau and Prévil came to Washington, D.C. Before unpacking, they taxied directly from Reagan airport to Georgetown University Medical Center to meet Dr. Siva Subramanian, the Chairman of Neonatology and neonatologist, The Rev. Deb-Hoy Jones, M.D. Both doctors have practical experience working in low resource settings in Central and South American. The chemistry and working relationship that developed, prompted Dr. Prévil to refer to Dr. Siva as “my new best friend” by the time Prévil left Georgetown.
Both Georgetown doctors came to Milot in May 2010 and returned again in May and June 2011. In Haiti, they conducted courses in neonatal resuscitation for Hôpital Sacré Coeur physicians and nurses. Not only were the thirty Haitian medical staff members trained, but they were also certified as neonatal resuscitation instructors.
Drs. Siva and Jones brought “Baby Natalie” to help with instruction. Baby Natalie is a teaching baby that can cry, breathe, show pulse and does not seem to mind multiple intubations. She can be filled with water to change her weight and her lifelike body is useful in practicing birth management.
She can be used to demonstrate multiple nursing techniques until the techniques are completely mastered by the students.
Evidence of Progress Continues to Mount
Good change is certainly happening. Premature newborns in particular, accumulate bilirubin. Bilirubin in high amounts poisons brain cells. The treatment is a blue spectrum light to break down the bilirubin into products that can pass into urine and a diaper. Two years ago, two infants might have had to share an open crib and a warming light in Milot. Now, temperature controlled individual isolettes are in use. At any given time HSC has preemies “under the light”– out fitted with “Jackie Onassis’ outsized eye protectors.
There is progress. It can be told in the story of new born baby Ariside Wideline who came to pediatric clinic. She was brought for help 21 days after her home birth with abdominal swelling. This little girl had a recto-vaginal fistula. By itself, some fistulas can heal if a catheter is in place for a short time. Not for this Wideline.
The cause of her problem was the complete absence of an anal opening. HSC was fortunate to have the presence in Milot of surgeon Dr. Abe Huang, on his fifth return visit, and one of his residents, Dr. Courtney Quinn, who is working for fellowship training in pediatric surgery.
The fistula/imperforate anus was properly diagnosed by the pediatric staff. (HSC has 2 full time and one part time staff pediatricians.) Surgery was performed to open a temporary colostomy. Post op care in the special care nursery followed with discharge on day 27 day of life. Follow up surgical treatment to make a functioning anus is now planned for two years of age in HSC.
Aggressive Tackling of Maternal and Infant Mortality Remains a Top Priority
Future plans are to continue to reinforce basic care and staff education in order to continue to prevent death from infection. The next priority is to recognize there is an unacceptable high prematurity rate in Haiti. Significant breathing problems are almost always seen in undeveloped 30-34 weeks babies who require even more sophisticated care. In the Northern department of Milot (HND) prenatal care is minimal. The majority of births like Aristide’s occur at home (66% at home – 34% in “health facilities”) with local traditional birth attendants (less than 15% have help from what are recognized as “skilled birth attendants with some level of training.) This lack of basic care, leads to a high prevalence of eclampsia and preeclampsia.
It is common for laboring women to arrive at HSC in advanced labor, often convulsing or with blood pressure elevations so uncontrollable that the only solution is immediate delivery to prevent strokes and save the infant and mother’s life. Without pre-natal care and early intervention in a troubled labor, Dr. Prévil writes, “In order to save babies who I see at 32 weeks, C-Section is mandated.” (HSC delivers 24% of babies this way whereas WHO statistics for the Northern department is less than 2% C-section.)
“In HSC we have adopted and adapted many treatment protocols from the U.S., but we are limited in training and supplies,” explains Dr. Prévil.
Future plans for neonatal care focus on continuing to develop skills and training and to maintain equipment for breathing support for the earlier preemies. Georgetown neonatologists are advising an inexpensive breathing apparatus that can be made on site with easily available local materials for about $20.00. This step and the training experience will help HSC continue to lower the rates of infant and maternal mortality.
In 2000, 189 UN member nations developed the MILLENNIUM DECLARATION GOALS (MDG), a set of shared values for improving human health.
Goal #4: Reduce Child Mortality
Goal #5: Improve Maternal Health World Health Organization (WHO) Perinatal mortality “possibility of death between birth and one year of age per 1,000 births”
Haiti 2009 64/1000 UNICEF
United States 2009 7/1000
Joseph Giere, M.D. has almost fifty years of experience practicing obstetrics and gynecology in private practice in Washington, D.C. A graduate of Georgetown University School of Medicine, Dr. Giere was an intern at Rochester General Hospital and completed his residency at Georgetown University Hospital. He maintains affiliations with Georgetown University Hospital and Sibley Memorial Hospital. Dr. Giere serves on the CRUDEM Board of Directors and is a member of the Medical and Education Committees. When not making frequent trips to Milot, Dr. Giere lives in Potomac, MD with his wife Mary.
