Women’s Health Services at Hôpital Sacré Coeur

By David G. Butler, M.D.

The Daunting Challenge
The vast majority of women in Haiti give birth under deplorable conditions without medical care. The attendant at the birth is usually a village elder or lay person with some personal experience in birthing. In the United States, the number of women dying in childbirth or with some pregnancy related illness is 16/100,000 live births. In Haiti, this rate is 631/100,000. In the U.S., when a child is delivered, the umbilical cord is clamped off with a 25 cent disposable plastic clamp before being cut. Lacking even this basic piece of equipment in some of the Haitian villages, the umbilical cord is sometimes tied off with horse hair, or cut with a rusty instrument. If the horse hair or instrument is contaminated with tetanus, the infant will die within 2 weeks. These are the kind of grim facts which have led us to make Mother and Infant care such a large part of our mission at CRUDEM.

Mother and daughterHSC Maternity Services Meets the Need
The growth of the Maternity Service over the past 25 years, not only mirrors the growth of the hospital, but in fact, outpaces it. It is often said that the hospital could easily be turned into a purely Maternity Center because the demand is so great. The number of deliveries has grown from 5 – 10/year in the early days to 1300 – 1500/year today.

At the present time, because of the tremendous influx of patients due to the earthquake, we have had to convert the existing Delivery Room into a 3rd Operating Room. The patients often labor in a large multi-bed room, sometimes among patients hospitalized for other illnesses. They are then delivered in a separate room and most are discharged within 24 hours. One of the great joys of a trip to Hôpital Sacré Coeur (HSC) is to witness the family of a newborn, dressing them in bright, often home-made clothes and blankets for the trip home. It is truly a sight to behold!

MidwifeIn addition to 2 full-time obstetrician-gynecologists, the hospital is staffed with trained midwives who perform the majority of deliveries. There are also Community Health nurses and midwives who go out into the surrounding villages to bring Prenatal care to those who are unable to travel to the hospital.

Prenatal care at the hospital is provided by the Ob-Gyns, nurses and midwives in a clinic setting which is held 3 days a week and is very heavily attended. Pregnant women dressed in their “Sunday-best” will sit for hours in the extreme heat, waiting to be seen. There are separate clinics for Diabetes, those with hypertension and HIV as a complication of pregnancy. Malaria and Tuberculosis in pregnancy are also major complications in Haiti. The hospital receives special funding for the prevention of Mother to child transmission of AIDS and this is involved in about 3% of hospital births.

As important as the pre-natal care on the campus of the hospital is, the care provided by the Community Health nurses and midwives, who travel to the adjoining villages, is crucial. They provide not only patient care, but also education to those in the villages who will be attending the births. This is an extremely important part of the system which helps to keep the hospital from being overwhelmed by the sheer numbers of deliveries.

Unique Aspects of Maternity Care in Haiti
Another unique aspect of maternity care at HSC which we do not have to deal with in the States, is the occurrence of “strikes” at the government hospital in Cap Haitien, about 10 miles away. These “strikes” always result in a significant increase in the number of deliveries at HSC and, more importantly, the number of emergency Cesarean Sections. It is common during these “strikes” to see women in great pain, who have survived the bone-jarring 10 mile trip over barely passable roads, being wheeled directly from a car or a pick-up truck into an Operating Room to have an emergency Cesarean Section performed.

Infant on BedA scene from January 2010, in the immediate post-earthquake weeks, crystallizes all the incredible obstacles involved in caring for pregnant women in Haiti. My function in Milot at that time was to supervise the functions at the hospital as part of a shared work schedule which had been devised by the Board of Directors. A U.S. Navy helicopter had just landed with four badly injured patients and we were rushing two of them into the hospital for immediate surgery. On our way through the front entrance, we had to pass a pickup truck which was unloading a pregnant woman in labor who was convulsing. This is a situation referred to as “Eclampsia”, probably the most dangerous complication in obstetrics.

Whereas 10 years ago, this would have brought the hospital to a complete standstill, in 2010, I was comfortable enough with our obstetrical staff to simply triage the woman by instructing the attendants to “Get her upstairs to see Dr. Jean-Pierre” and having complete confidence that the situation would be handled in an entirely appropriate manner. Meanwhile, I was able to continue with the other two patients to get them to the Operating Room where they were speedily brought to surgery. This was a truly a wondrous example of how our entire staff performs and the confidence which the Obstetrical Department has earned.

The future of Maternal-child Care at HSC
The future of Maternal-child Care at HSC is very promising. In Haiti, a child born before 32 weeks gestation faces a grim prognosis. We are attempting to alter this outlook by constructing a Neonatal Intensive Care Unit at the hospital which contains six beds. The Nursing Staff and physicians are undergoing specialized training supplied in part by Georgetown University through the efforts of Dr. Joe Giere.

We are attempting to build up the hospital’s outreach program to the surrounding villages by the Community Health Nursing Department. The better the prenatal care that is supplied to those unable to reach the hospital, the better the outcomes will be. We need to decrease the incidence of prematurity and pregnancy induced hypertension so the maternal mortality rate and other quality indications can begin to reflect the care and concerns of all those involved in maternity care at HSC.

Baby with hydrocephalus–a heartbreaking occurrence seen way too often in Haiti. We are in the process of constructing a new obstetrical suite with dedicated Delivery Rooms, a Cesarean Section room and a Post-Partum unit so that the mothers and infants can be sequestered from some of the more desperately ill hospitalized patients.

Meeting the Need for Expanded Preventive Care Services
The other aspects of Women’s Health Care in Haiti involve extremes of conditions common to all women. Because preventive care and “yearly visits” are not yet a part of the culture, for obvious reasons, the pathologic conditions found are often for more advanced than what we typically see in the U.S.

We are attempting to establish cervical cancer screening as part of a yearly health maintenance program for women. Over the past 25 years, we have moved from doing an occasional Pap Smear to our present clinic set-up which now offers Colposcopy and Ultrasound exams. We are going to be participating in studies devised to implement new screening techniques involving HPV testing as appropriate.

Fibroid tumors are commonly seen in a greatly advanced stage
Fibroid tumors are commonly seen in a greatly advanced stageUterine growths known as “fibroids” are a fairly common condition worldwide, but in the U.S. they are usually detected in an early stage and dealt with in a preventive manner. In Haiti, they are often seen when they are greatly advanced, the size of pumpkins, basketballs or even a full term pregnant uterus. It is common place at HSC for visiting GYN teams to remove these gigantic growths, in concert with the staff gynecologists.

Two particular gratifying cases for me were the surgery performed to remove a benign ovarian cyst in a 19 year old girl which had grown so large that she was unable to walk and at the other end of the spectrum, in the post-earthquake era, removing a cyst in a 4 year old girl which on ultrasound was thought be malignant, but fortunately turned out to be benign.

Mammography, so important in our country, can not be offered yet at HSC, as we lack the equipment and the expertise, but this is definitely on our wish list.

infant being heldOur hope is that the next 5 years will see growth in the area of Women’s Health Care which will equal that of the previous 20 years. Ambitious? Yes! but this can only happen with the prayers, cooperation and generosity of those who have raised us to our present level of excellence.

David Butler, MDDavid G. Butler, M.D. is a Fellow in the American College of Obstetricians & Gynecologists and has worked in private practice in Englewood, NJ for 38 years. He is an attending at both Englewood Hospital and Holy Name Medical Center, both in NJ. Dr. Butler received his M.D. from SUNY Downstate Medical Center, Brooklyn, NY and completed his residency as Chief Resident OB/Gyn at St. Vincent’s Hospital & Medical Center in New York City. Dr. Butler serves as Vice President of the CRUDEM Foundation Board of Directors and is also Chairman of the Board of Trustees of Holy Name Medical Center. He and his wife, Mary Ann Butler, M.D., live in New Jersey and are the proud parents of five children.