First of two parts

Unsafe abortions: Haiti’s abortion crisis

 

Banned

Six of the 34 countries in Latin America and the Caribbean do not permit abortion under any circumstances, or there is no explicit legal exception to save a woman’s life. They are:

•  Chile

•  Dominican Republic

•  El Salvador**

•  Haiti*

Honduras

•  Nicaragua**

•  Suriname

*In Haiti, abortion is governed under Article 262 of Haiti’s penal code, which is based on an 1810 French penal code. Under Haitian law the unborn child is considered to be a life; interruption of pregnancy is forbidden. While doctors say this means that even abortion to save the life of a mother isn’t permitted, some say the clause “etat de necessite" (necessity) allows for termination if the life of the mother is in danger.

**El Salvador and Nicaragua recently revised their law to make all abortions illegal, including in cases of rape, incest or to save the life of the mother or fetus.

Source: Guttmacher Institute, Haiti Penal Code


More information

Photos from Haiti of the abortion crisis


jcharles@MiamiHerald.com

After one clinic failed to remove the 16-week-old fetus growing inside her, the desperate high school student turned to the “doctor” known to her only as Little Old Father, Ti Le Pè.

Standing in her sparse bedroom, the bearded man with a baseball cap first prepared a special bath — a mixture of Haitian moonshine, essential oil and a “special soap.” He then put her in bed, strapped her swollen stomach and disappeared. At 5 the next morning, he returned with a cold, murky herbal concoction.

The young woman, who had been secretly hiding her pregnancy, sipped the herbal remedy and waited for her contractions to finally expel the embryo.

After three days of vomiting, heavy bleeding and agonizing pain, she stumbled into a maternity hospital. Doctors rushed her into surgery where they stopped the bleeding, and repaired her perforated uterus, botched in the first abortion attempt.

“I thought everything would be OK,” said Marie, 20, her voice, like her emaciated body, devoid of strength a month into her two-month hospitalization. “If I knew things would end up like this, I wouldn’t have done it. I nearly died.”

Abortion is illegal in Haiti but women and girls are losing their uteruses and their lives as they turn to clandestine, increasingly deadly ways to terminate their pregnancies. These unsafe abortions are leading to a public health crisis in a region with one of the world’s highest rates of unintended pregnancies, experts say.

The long hidden crisis has started to emerge publicly as women’s groups, physicians and human rights advocates push for changes in Haiti’s strict ban on interrupting a pregnancy. The push comes as reports of rape and sexual violence increased after the devastating January 2010 earthquake, and as the country’s moribund economy and adolescent pregnancies make taboo practices such as abortion no longer unthinkable.

“A woman or girl who has decided she cannot keep a pregnancy will find a way, and will accept the health risks that go with an unsafe abortion,” said Catrin Schulte-Hillen, a reproductive health advisor with Médecins Sans Frontières/Doctors Without Borders (MSF) in Geneva, Switzerland. “There is a huge gap between the reality and legality of abortion. The price we pay ... is the lives of women.”

At MSF’s emergency maternity hospital in Delmas where Marie was admitted, women suffering post-abortion complications account for nearly 12 percent of the 560 pregnancy-related admissions the facility averages monthly, staff said. Access to safe abortion care for women is a serious medical-humanitarian issue, the aid group argues, especially in a country like Haiti where more women die from pregnancy-related causes than anywhere in the region.

“We know in countries where there has been a legalization or liberalization, as they call it in South Africa, of abortion on request, immediately they have seen an impact on maternal mortality,” Schulte-Hillen said. “And we know that in countries where the legal frame around abortion is restricted, maternal mortality related to unsafe abortion is the highest.”

When a 7.0 earthquake buckled the ground nearly four years ago, it unearthed many of this nation’s buried social ills. Tent cities exploded, and so did pregnancies. As Human Rights Watch and other groups documented the alarming “tent babies” crisis, doctors and nurses quietly noted the increased cases of incomplete abortions and premature bleeding by women, said Amanda Klasing of Human Rights Watch.

The troubling diagnosis eventually prompted an investigation by the Haitian Society of Obstetrics and Gynecology (SHOG) that found widespread use of the drug misoprostol in camps. Sold without a prescription under the brand name Cytotec, the anti-ulcer drug also induces abortion, experts said.

While the small pill has been linked to saving women’s lives in places where abortion is highly restricted or illegal, in Haiti’s unregulated pharmacy-on-foot environment, incorrect doses also lead to death and suffering.

Haiti’s health ministry, which has sought to take charge of the abortion debate, has estimated that unsafe abortions account for 20 percent to 30 percent of maternal mortality. But the reality is, the annual number of abortion-related deaths is unknown.

Fearful of criminal prosecution, health facilities don’t always register cases like Marie’s. Even an attempt by the health ministry to track abortion in its most recent nationwide survey came with a disclaimer: it’s difficult to accurately measure incidents of abortion because of its legal ban, and cultural, social and religious stigmatization, the report said.

Marie’s ordeal

Like many women seeking care from a failed abortion, Marie didn’t tell MSF doctors what she had done when she arrived on Sept. 5. Her pregnancy and the perforated uterus were later detected with an ultrasound, said Dr. Rodnie Senat-Delva, the hospital’s medical director.

“Her condition was very bad,” Senat-Delva said.

Marie later told the Miami Herald that a clinic in the Cité Soleil slum had attempted to remove the fetus by shoving an unknown object inside her.

Uterine perforation, Senat-Delva said, is a common complication among Haitian women under 20 years old. Sometimes the goal isn’t even to successfully abort the fetus but to provoke bleeding by using hangers, bicycle spokes or other objects, so that a woman can see a qualified doctor.

“When they come to the hospital, we have to do something because it’s life-saving,” Senat-Delva said. “They have to go to surgery and more often, they lose their uterus very young. They have to live all of their lives without having the possibility of becoming pregnant again. This is really the reality.”

Marie said she was forced to wait until her 16th week to abort because she didn’t have the $20 the “doctor” charged. If Marie had the money, she could have spared herself the punishing ordeal. Qualified doctors charge at least $300 to secretly do the procedures in their private clinics, or even a hospital.

In an overwhelmingly poor Haiti, where seven out of 10 people live on less than $2 a day, it is poor women who suffer the most from the abortion ban, said Danièle Magloire, who helped conduct one of the few abortion studies in Haiti.

“Women with means have abortions under good conditions. The majority don’t have means and they have abortions under bad conditions,” she said. “This is a social injustice because it’s all based on your means. A lot of women are dying because a lot of abortions are taking place under bad conditions.”

Magloire said abortion came close to being legalized in Haiti in 1998 after she and other feminists presented a proposed law to the Haitian parliament. The proposal, however, never made it out of the Haitian Senate. Despite her ongoing legalization push, Magloire concedes that getting Haiti’s abortion ban lifted could be much tougher this time around because current parliamentarians are much more conservative. Some human rights advocates, meanwhile, have lobbied a presidential commission charged with overhauling Haiti’s archaic criminal laws, which are based on Napoleonic code, to do away with the ban entirely.

Amid the daily hustle on the streets of this clogged capital, market women hawk traditional herbs known to provoke bleeding in pregnant women on one side, while men, carrying oversized cone-shaped buckets, hustle on the other. The walking pharmacies are loaded with colorful packets of unregulated antibiotics — and Cytotec. One pill could sell for as much as $3.50.

Not far from the largest public hospital are rows of clinics; some are de facto abortion mills.

One seedy clinic tucked off a crowded street could be easily overlooked. It accepts only referrals. Inside, a receptionist and security guard sitting on tattered fake leather furniture laugh heartily at an American crime movie blaring in French. The receptionist looks away just long enough to ask a visitor, “Who referred you?”

After more than an hour, the wooden door opens and a young woman steps out. She leaves quickly. The doctor motions to step into his cramped office that also doubles as an examination room.

“If you had come here yesterday, you would not have been able to see me. It was nonstop from 8 a.m. to 8 p.m.,” said the doctor, wearing a white coat, who asked for his name to be withheld because his $80 abortions are illegal.

He shows a month’s worth of records. There are nearly 300, including that of a young girl who terminated a pregnancy at five months with her parents’ consent.

“You don’t call that an abortion,’’ he clarified, “you call that a delivery.”

As a small TV fields images of an exterior surveillance camera, the man leans back in his chair. He boasts that doing an “abortion is like cocaine. Once you start, you can’t stop because the money is so good.”

Feminists and human rights activists say unregulated mills and unscrupulous doctors are why Haiti’s ban needs reform, because women’s lives are being put at risk.

“Having abortion that is legal and that is regulated, and allowing health centers to openly provide quality care across the board to women, ensures healthier women and girls,” said Klasing of Human Rights Watch, which supports legalization.

But the crisis isn’t just confined to the capital.

At a rural clinic in Petite Rivière in the Artibonite Valley, at least 20 women a month are admitted for abortion-related complications, said Dr. Eddy Jonas, an obstetrician-gynecologist at the clinic.

The numbers spike, he said, during the abortion peak. Just like the birth peak — it begins with premature births five months after the pre-Lenten carnival — the abortion peak is the two to three months after the festivities.

“The problem has taken on a dimension where it’s screaming to come out of hiding,” said Jonas, who works as women’s health coordinator for Boston-based Partners In Health. Haitian women, he said, are aborting for all kinds of reasons.

“Abortion was something that wasn’t accepted in the Haitian culture,” Jonas said. “But with the changes that have occurred in the people’s economic situation, you start to find people reconsidering values they once held. ”

Shrouded in secrecy, the decision is often motivated by fear and shame in a country where the Roman Catholic Church — it has traditionally opposed abortion — is deeply rooted, and Evangelical Christians are gaining a strong grip post-quake. The faith community voiced its opposition to legalized abortion during a recent health ministry workshop.

“We don’t encourage abortion but recognize that in certain cases, such as the life of the mother being in danger, it may be a consideration. But it’s a decision that should not be solely taken by a doctor,” said the Rev. Sylvain Exantus, president of the Federation of Protestants in Haiti, which along with the Catholic Church, has formed committees to study the issue. “In no case should abortion be used as a method of family planning.”

Exantus said they encourage abstinence for young people and birth control for married people.

“Legalized abortion will encourage prostitution, and irresponsible behavior. We need to educate the population, especially the youth,” he said. “If that education happens, we will have less problems.”

The health ministry has asked religious leaders, physicians, human rights activists and feminists to help craft an abortion bill. It wants consensus for allowing therapeutic abortion in the case of rape, incest, and if the life of the mother or fetus is at risk, said Dr. Reynold Grand’ Pierre, the director of family health for Haiti’s Ministry of Public Health and Population.

“We decided it was time to address things frankly, the way they actually are,” said Grand’ Pierre, who acknowledges that the ministry’s work is slow and difficult.

In Haiti, a doctor or healthcare professional who performs an abortion can face five to 15 years of hard labor, while a woman who self-aborts can face three to nine years in prison. The law governing abortion is based on an 1810 French law, and states that the unborn child is a life. There is disagreement in Haiti about whether a clause in the code allows for termination when the life of the mother is at risk. Some legal experts say it does, but several doctors, including Grand’ Pierre, say it does not.

Grand’ Pierre, an obstetrician-gynecologist, doesn’t think Haiti is ready for legalized abortion. He advocates a measured approach.

“We are living in a hypocritical society,” he said, noting how Haitians often use religion as a barrier. “But even with religion, clandestine abortions are taking place.”

A 2009 study by SHOG, the Haitian physicians group, showed that 41 percent of those surveyed said they had used Cytotec, but most people do not favor legalized abortion. The paradox isn’t lost on Dr. Vladimir Larsen, the head of SHOG. He said while legalization is an issue for Haitians to debate, doctors desperately need termination guidelines.

“There are certain situations where we are medically obligated to intervene. And the law doesn’t authorize us to do it,” said Larsen, advocating “regularization” over legalization. “Even when we do, we put ourselves at risk, where the law requires us to be sanctioned.

“Even in cases of a rape, which can have psychological repercussions, the law doesn’t permit for you to intervene on their behalf,” he said.

The first time Jocelyne, 17, realized she was pregnant after being raped by a relative’s husband, she aborted the pregnancy. She took misoprostol, she said, without complications. But the man continued violating her, she and her lawyer said on a recent Sunday in a rural city south of Haiti’s capital. After the fifth violation, she was pregnant again.

The man offered to give her medication to terminate, she said. “I refused, so people could see,” she said, hoping her growing bump would finally free her of the sexual assaults.

Asked if she could love a baby that results from a rape, Jocelyne, in her child-like voice, said, “I’ll manage to love it.”

“If you ask me my personal opinion, I believe it’s a double victimization when a woman, after having been a victim of violence, becomes pregnant and is obligated to hold onto the pregnancy,” Grand’ Pierre said.

“For the moment, you are at the mercy of any district attorney,” he said. “And he has the law on his side.”

Information on the prosecution of cases involving abortions in Haiti is sketchy, though a court clerk acknowledged there was currently an allegation being investigated by a judge.

Port-au-Prince’s district attorney Francisco René said prosecuting abortion is not a priority for him, but he’s legally obligated to act if someone files a complaint.

Editor’s note: The Miami Herald changed the names of the young women who had abortions to protect their identities.

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