High Numbers of Maternal Deaths Plague Health System

Abraham Axicinean, 5 months old, takes a nap at the home of Eriana Alce in Batey San Isidro. His mother was only 17 when she died giving birth to him.
Abraham Axicinean, 5 months old, takes a nap at the home of Eriana Alce in Batey San Isidro. His mother was only 17 when she died giving birth to him. Photo by Lauren Gilger

Cronkite Borderlands Initiative

SANTO DOMINGO, Dominican Republic – Abraham’s mother was just 17 when she died. The same day that he came into this world was the day she left.

Abraham was delivered by Cesarean section at Hospital Materno-Infantil San Lorenzo de Los Mina, a bustling public hospital in the Dominican capital city. His mother, Nana Charlie, died from excessive bleeding.

Maternal hemorrhaging is one of the main reasons for the Dominican Republic’s relatively high maternal mortality rate.

But many come too late. In the Dominican Republic, the lifetime risk of maternal death is one in 320, according to UNICEF. That’s almost seven times higher than in the U.S.

Medical experts say a high maternal mortality rate usually correlates to limited medical access. But in the Dominican Republic, skilled medical personnel attend nearly 98 percent of births, only one percentage point less than in this country.

So many women die in childbirth in the Dominican Republic not because they can’t get to a doctor, but because they get there so late – and because they come in such great numbers.

“These hospitals are free,” said Los Mina Hospital Director Pablo Wagner. “And because they are free, people come from everywhere, from all the surrounding villages.”

Centro Materno Infantil San Lorenzo de los Mina is the second largest maternity ward in Santo Domingo.
SLIDESHOW: New and expectant mothers wait to be seen at Los Mina Hospital.
Women wait outside of Centro Materno Infantil San Lorenzo de los Mina in Santo Domingo. Hospital staff cleans medical equipment in front of the Centro Materno Infantil San Lorenzo de los Mina. Women wait in the crowded lobby of Centro Materno Infantil de los Mina. An empty hallway in the Centro Materno Infantil San Lorenzo de los Mina. Patients wait in a hallway of the Centro Materno Infantil San Lorenzo de Los Mina, the second-largest maternity ward in Santo Domingo. Up to 35 percent of the patients seen at this Dominican hospital are Haitian, according to its director. Hospital staff members sort through hospital records in the lobby of Centro Materno Infantil San Lorenzo de los Mina. Norkis Cruz, 21, looks at her cell phone as she stands with Luz Brito, 32, in the hallway of the Centro Materno Infantil San Lorenzo de los Mina. Cruz is in labor and waiting to deliver her baby. Norkis Cruz, 21, stands outside her hospital room between contractions as she waits to deliver her baby. Luz Brito, 32, wanders the hallways of Centro Materno Infantil San Lorenzo de los Mina in Santo Domingo hours after losing her baby. Luz Brito, 32, holds her own IV bag hours after miscarrying. She was six months pregnant when she lost the baby. (From left to right) Yirandy Contrera, Yatrona Santos and Rosalba Castillo share a room with their newborn babies hours after giving birth at Centro Materno Infantil San Lorenzo de los Mina in Santo Domingo. They did not know each other before coming to the hospital. Yirandy Contrera reaches down to comfort her newborn son as he cries. Yirandy Contrera, 22, stands at the window of her hospital room at the Centro Materno Infantil San Lorenzo de los Mina trying to get service on her cell phone. Her newborn son lies in the bed behind her. A certificate of birth sits next to Rosalba Castillo and her newborn child on her hospital bed. Unlike the United States, a birth certificate in the Dominican Republic does not mean that the child is a citizen of the country. A patient lies in a hospital bed in the Centro Materno Infantil San Lorenzo de los Mina. Arelis Florian, a nurse at Centro Materno Infantil San Lorenzo de los Mina in Santo Domingo, stands in the hallway of the hospital. She is eight months pregnant. A woman looks out from her hospital room in Centro Materno Infantil San Lorenzo de los Mina in Santo Domingo while a group of nurses talks in the hallway. Sandrade Jesus sits at a desk in the doorway of her hospital room. She is hooked up to an IV and is being monitored throughout her pregnancy due to complications. Yirandy Contrera, 22, sits next to her newborn son on her hospital bed hours after his birth in the Centro Materno Infantil San Lorenzo de los Mina in Santo Domingo.

Wagner said the hospital is equipped to handle 1,500 to 2,000 births a year. Instead, it is handling 12,000 to 13,000 births annually. Many of the mothers are poor, undocumented women who have had little or no prenatal care. Many of these are from Haiti, where the maternal death rate is even worse – three times higher than in the Dominican Republic.

Those are the facts Los Mina deals with every day. So is this one: 24 mothers died in childbirth at the hospital last year. That’s about the same number of deaths per 100,000 live births in the U.S.

To medical professionals in the Dominican Republic, health care is a human right. No woman in need of maternal care will be turned away, regardless of her immigration status or ability to pay.

“We have had always an open door policy that we would take anyone who comes,” said Leonard Ziur, a Los Mina doctor from Cuba who has also practiced in Miami. “We don’t send them back.”

Haitians Flood System

Three strangers and their newborns, just hours old, share a bare, dimly lit room at Los Mina. Water leaks onto the tile floor.

Yirandy Contrera sits on a narrow hospital bed, wearing a pink cotton baby doll dress, her inflated belly still visible beneath the thin fabric. Her newborn son, wrapped in white terrycloth embroidered with his name, lies on the mattress next to her.

Giving Light
VIDEO: Many Haitian women who cross the border to give birth in Dominican hospitals don’t realize that their children may end up without citizenship rights.

There is no recognizable chime of a hospital gadget monitoring vitals. No hospital bracelets or visitors’ badges. No call button to ensure a nurse is just a ring away. There are just the familiar cries of infants and the comforting coos of their mothers.

The care is mediocre by U.S. standards, but it is far superior to what is available in neighboring Haiti, and, as a result, pregnant Haitian women regularly cross the border illegally into the Dominican Republic to have their babies.

No one knows how many of them come – only that it’s many and that the numbers have grown substantially since last year’s devastating earthquake in Haiti, which destroyed many hospitals.

“The cost of this hasn’t been estimated because there isn’t a system that counts the total number of Haitian citizens who live in this country,” said Jose Delancer, director of the Department of Women and Children within the Dominican Ministry of Public Health. “How do you count an illegal population, a population that is registered nowhere?”

“The Dominican laws and the Constitution of the Republic guarantee universal access to health care to anyone, no matter their descent, their races, their nationalities, their immigration status,” Delancer added. “We as a health care system are not here to question immigration policies. We are here simply to provide quality services to the extent that our capacities allow us to, to anyone who asks for it.”

Delancer said the Dominican government has budgeted for public health services for 7 million people in a country with a population of 10 million, although wealthier segments of the population mainly use private health care. The undocumented Haitian population is estimated to represent at least a tenth of the population, some who enter the Dominican solely to deliver their babies.

Many of them have never had a pre-natal check-up, and, as a result, doctors are often unable to anticipate problems and are unprepared for complications that could have been prevented.

Approximately one third of Los Mina patients are Haitian and arrive in poor health, said Wagner, the Los Mina hospital director.

“They don’t have a monthly examination, and when they come to the hospital, they come in an awful condition, in a bad situation,” he said. “They are mothers that don’t have the proper conditions to support nine months of pregnancy. They are without nutrition, without education.”

Eriana Alce, 23, is three months pregnant. She already cares for four children at her home in Batey San Isidro – two are her biological children and two are orphans whom she took in.
SLIDESHOW: Eriana Alce, 23 and five months pregnant, lives with four young children in squalid conditions.
Children's clothes hang in Eriana Alce's small home in Batey San Isidro. Dirty dishes sit on a table in Eriana Alce's home in Batey San Isidro. Eriana, who is from Haiti, cannot work because she has no documents. With a fifth child on the way, Eriana says she does not know how she will continue to provide for her family. Abraham Axicinean, 5 months old, sleeps on the bed in Eriana Alce's home in Batey San Isidro. His mother died giving birth to him in Centro Materno Infantil San Lorenzo de los Mina hospital in Santo Domingo. She was 17 years old. Eriana Alce's daughter Cristina is two years old. Eriana Alce's oldest daughter, Veronica, 4, chews on the arm of a doll. Eriana Alce’s daughter, Veronica, wears shoes and clothes that are a few sizes too big for her. A child's backpack hangs on the wall in the home of Eriana Alce in Batey San Isidro. Eriana is trying to raise four children, but as a Haitian immigrant she cannot work without papers in the Dominican Republic. Annabelle and Cristina, both 2 years old, play on the floor next to the only bed in Eriana Alce's home in Batey San Isidro. Annabelle is an orphan whom Eriana took in after Annabelle’s mother died giving birth to Annabelle’s younger brother. Neither child has papers. Tin sheets and loose boards hold together Eriana Alce's home in Batey San Isidro, a tight-knit, impoverished Haitian community on the outskirts of Santo Domingo. Dirty clothes pile up in the second bedroom of Eriana Alce's makeshift home in Batey San Isidro.

Abraham’s mother was one such patient, according to local religious leader Malia Duval and other members of the community who are familiar with the case. When she arrived at the hospital to give birth, she was in poor condition. She was undernourished and battling sickle-cell anemia and wasn’t strong enough to survive surgery. She bled to death after undergoing a Cesarean section.

Language Barriers

More than five months after the death of his mother, Abraham sleeps on a bed in a home in Batey San Isidro, an impoverished community made up mostly of Haitian immigrants on the outskirts of Santo Domingo. Flies drift freely around his head.

Hansel and Jimal, both 5 years old, play with sticks in Batey San Isidro, an impoverished Haitian community on the outskirts of Santo Domingo.
SLIDESHOW: One of the poorest neighborhoods in the Dominican Republic reveals both poverty and perseverance.
Hansel plays in Batey San Isidro. Juleci Garcia in Batey San Isidro. Jolie stands outside a house in Batey San Isidro. A child plays under sagging power lines in the streets of Batey San Isidro. Children, teenagers and adults sit together in the center of Batey San Isidro. Houses in Batey San Isidro are made of brightly colored tin sheets. QueQue, 4, stands in front of Elisabel, 5, in Batey San Isidro. Maria Osto sits outside in Batey San Isidro. Children in Batey San Isidro: Elisabel, QueQue and Juleci. A woman stands in the town center of Batey San Isidro. The deep scar from a Cesarean section is visible on her stomach. Roni stands under a row of laundry in Batey San Isidro. Deborah Juan Medlete, 15, holds her infant son, Solomon Felipe. Maribelle Casado, 20, sits outside a house in Batey San Isidro. A child watches a dog stretch in Batey San Isidro. Children run along a wall in Batey San Isidro. Two men cut sugar cane in Batey San Isidro. Kids gather at the gate of the school in Batey San Isidro. Only some of the families in town can afford to buy their children the books and uniforms required to attend school. Bags of thousands of plastic bottles are stacked up outside a house in Batey San Isidro. QueQue, 4, walks barefoot in the rocky roads of Batey San Isidro. Ludy Jampie, 19, sits in a kitchen chair in the home of her friend Juliana Perez, 26. Juliana’s son, 10-month-old Wilson, crawls on the floor. Juliana Perez, 26, holds her 10-month-old son, Wilson, in their home in Batey San Isidro. Onesi, 10, and two younger boys in Batey San Isidro. Aldo Najana sits in the doorway of her home in Batey San Isidro. Layers of paint peel off of a doorway in Batey San Isidro. A young boy sits next to a pregnant woman as she eats a mango in an alley in Batey San Isidro.

With the whereabouts of their father unknown, Abraham and his 2-year-old sister, Annabelle, live in the care of Eriana Alce, a neighbor of their deceased mother. At 23, Eriana is four months pregnant and already has two children of her own. One of them, a toddler, sits on the dirty cement floor, biting and occasionally swallowing pieces of a torn plastic bag.

An immigrant from Haiti, Eriana does not have Dominican citizenship and can’t legally work. Her husband works at a nightclub, but the couple struggle to feed the children they have.

Asked what she is going to do with another baby coming, Eriana replies, “Nada.”

There is nothing she can do.

Like many immigrants from Haiti, Eriana speaks only a little Spanish. Her native language is a dialect of French-Creole, and that presents yet another challenge to health care professionals.

“Usually they come when they are almost at time of delivery,” said Ziur, the Cuban doctor at Los Mina. “They live in Haiti. They get here and they tell you, ‘No, I don’t speak Spanish. I don’t speak English. I don’t speak anything, only Creole.’”

Translators are sometimes available at the hospital, but not always. Ziur said he handles an average of 40 patients a day. In a typical eight-hour day, that’s five patients per hour, and nearly one third do not speak Spanish.

The Dominican Ministry of Public Health is trying to overcome the language problems by adopting a common form for perinatal histories and translating it into Creole. The ministry has disseminated the translated document throughout Dominican hospitals and also has sent the form to Haiti.

Common Problems

The maternal health problems in the Dominican Republic are not unique, and, in fact, many are the same as those facing immigrant populations in the U.S.

Many undocumented women in the U.S. have little or no access to pre-natal care during pregnancy, according to a 2010 Amnesty International report. Private insurance is too expensive, and they don’t qualify for Medicaid because they are in the country unlawfully.

Although U.S. law requires that all women in active labor have access to medical care regardless of immigration status, many arrive at hospitals in poor condition, according to the report. They frequently lack pre-natal care and don’t speak the language.

Medical care for undocumented immigrants is being increasingly debated in the U.S. In Arizona, for example, a bill introduced in the state Legislature last year would have required hospitals to identify suspected illegal immigrants. While those in need of emergency services would get them, the bill would have denied services to others.

The bill failed to pass after hospital and medical associations voiced strong opposition to checking patients’ immigration status. However, state Sen. Steve Smith, a Republican who represents a large district south and east of Phoenix, has said he intends to reintroduce the bill next session.

Such a debate has not yet surfaced in the Dominican Republic, despite evidence that treating illegal immigrants has stretched the health care system beyond its capabilities and even though the two countries – the Dominican and Haiti – have a long history of antagonistic relations.

Ziur is typical of doctors who say that if the Dominican Republic adopted a law requiring hospitals to notify authorities of a patient’s immigration status, he would refuse.

Treating undocumented population may be hurting the Dominican health care system, but not treating people in need would be more painful.

“I will not do it. I will just resist,” he said.

Medical care, he said, is not about policy or politics.

“Your duty’s not that. I’m here to save lives.”