The effect of a new maternity unit on maternal outcomes in rural Haiti: an interrupted time series study

Background
In Haiti where there are high rates of maternal and neonatal mortality, efforts to reduce mortality and improve maternal newborn child health (MNCH) must be tracked and monitored to measure their success. At a rural Haitian hospital, local surveillance efforts allowed for the capture of MNCH indicators. In March 2018, a new stand-alone maternity unit was opened, with increased staff, personnel, and physical space. We aimed to determine if the new maternity unit brought about improvements in maternal and neonatal outcomes.

Methods
We conducted an interrupted time series analysis using data collected between July 2016 and October 2019 including 20 months before the opening of the maternity unit and 20 months after. We examined maternal-neonatal outcomes such as physiological (vaginal) births, caesarean birth, postpartum hemorrhage (PPH), maternal deaths, stillbirths and undesirable outcomes (eclampsia, PPH, perineal laceration, postpartum infection, maternal death or stillbirth).

Results
Immediately after the opening of the new maternity, the number of physiological births decreased by 7.0% (β = − 0.070; 95% CI: − 0.110 to − 0.029; p = 0.001) and there was an increase of 6.7% in caesarean births (β = 0.067; 95% CI: 0.026 to 0.107; p = 0.002). For all undesirable outcomes, preintervention there was an increasing trend of 1.8% (β = 0.018; 95% CI: 0.013 to 0.024; p < 0.001), an immediate 14.4% decrease after the intervention (β = − 0.144; 95% CI: − 0.255 to − 0.033; p = 0.012), and a decreasing trend of 1.8% through the postintervention period (β = − 0.018; 95% CI: − 0.026 to − 0.009; p < 0.001). No other significant level or trend changes were noted. Conclusions The new maternity unit led to an upward trend in caesarean births yet an overall reduction in all undesirable maternal and neonatal outcomes. The new maternity unit at this rural Haitian hospital positively impacted and improved maternal and neonatal outcomes.

Endoscopic Third Ventriculostomy With Choroid Plexus Cauterization for the Treatment of Infantile Hydrocephalus in Haiti

Objective: Untreated hydrocephalus poses a significant health risk to children in the developing world. In response to this risk, global neurosurgical efforts have increasingly focused on endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of infantile hydrocephalus in low- and middle-income countries (LMICs). Here, the authors report their experience with ETV/CPC at the Hospital Bernard-Mevs/Project Medishare (HBMPM) in Port-au-Prince, Haiti.

Methods: The authors conducted a retrospective review of a series of consecutive children who had undergone ETV/CPC for hydrocephalus over a 1-year period at HBMPM. The primary outcome of interest was time to ETV/CPC failure. Univariate and multivariate analyses using a Cox proportional hazards regression were performed to identify preoperative factors that were associated with outcomes.

Results: Of the 82 children who underwent ETV/CPC, 52.2% remained shunt free at the last follow-up (mean 6.4 months). On univariate analysis, the ETV success score (ETVSS; p = 0.002), success of the attempted ETV (p = 0.018), and bilateral CPC (p = 0.045) were associated with shunt freedom. In the multivariate models, a lower ETVSS was independently associated with a poor outcome (HR 0.072, 95% CI 0.016-0.32, p < 0.001). Two children (2.4%) died of postoperative seizures.

Conclusions: As in other LMICs, ETV/CPC is an effective treatment for hydrocephalus in children in Haiti, with a low but significant risk profile. Larger multinational prospective databases may further elucidate the ideal candidate for ETV/CPC in resource-poor settings.

Abortion care in Haiti: A secondary analysis of demographic and health data.

BACKGROUND:
Abortion-related mortality accounts for 8% of all global maternal deaths and 97% of the estimated 25 million unsafe abortions performed each year occur in low- and middle-income countries. Haiti has the highest rate of maternal mortality in the western hemisphere and to further understand the circumstances of induced abortion in Haiti, the current work uses data from the 2012 Demographic and Health Survey (DHS) to describe the methods of induced abortion in Haiti between 2007-2012 and to identify potential factors associated with use of different abortion methods.

METHODS:
This is a secondary analysis of nationally representative cross-sectional data from the 2012 Haitian DHS, a two-stage cluster randomized household survey. Analysis included descriptive statistics on participant demographics, methods of abortion, and location of / assistant for the abortion. Multivariate regression was conducted to determine if demographic characteristics were associated with: 1) increased or decreased odds of having an abortion; or 2) increased or decreased odds of reporting an evidence based or non-evidence based method of abortion.

RESULTS:
Among the 14,287 women of childbearing age who completed the 2012 Haiti DHS survey, 289 women reported having an induced abortion in the previous five years. Recommended methods, manual vacuum aspiration (MVA) or misoprostol alone, were used in 26.6% of the abortions (n = 77). Additionally, 13.8% (n = 40) of abortions used these recommended methods in combination with a non-evidenced based method such as injections, plants or tablets. A total of 92 women had a dilation and curettage (D&C) abortion, either alone (n = 77) or in combination with another method (n = 15) and over a quarter (n = 80) of reported abortions were conducted by non-evidence based methods (n = 80). A majority of abortions using a recommended method were assisted by a relative/friend (n = 28) or were unassisted (n = 34). Most abortions occurred in private homes (n = 174) with hospitals/clinics being the second most common location (n = 84). Women in the middle (OR = 3.3, 95% CI = 2.0-5.6) and highest (OR = 7.4, 95% CI = 4.4-12.3) wealth brackets were more likely to have had an abortion in comparison to women in the lowest wealth bracket. Women who had ever been in a marital union were more likely to have had an abortion than those who had not. The only demographic factor predictive of aborting using a recommended method was living in an urban area, with urban-dwelling women being less likely to use a recommended abortion method (OR = 0.4, 95% CI = 0.2-0.9) in comparison with women living in rural settings.

CONCLUSION:
In a nationally representative survey in Haiti, 2% of women of childbearing age reported having an abortion in the five years prior to the survey. A large proportion of these abortions were carried out using non-evidence based methods and over half occurred outside of the formal health care system. Understanding women’s attitudes, knowledge and barriers around abortion is paramount to improving knowledge and access to evidence-based abortion care in an effort to decrease maternal morbidity and mortality in Haiti.