Fertility

In the United States we tend to worry about infertility, but the last two days opened my eyes to the problem of fertility in Haiti.  It started in morning clinic.  A woman reporting to be in her thirties, although she looked much older, was complaining of lower abdominal pain.  I do my due diligence and ask about her menstruation - LMP November.  "Is there any chance you could be pregnant?"  "No."  Trust but verify.  That's one of the biggest things I've learned in my time as a medical student.  So that's what I did.  Urine pregnancy tests are cheap enough such that nearly all women of child-bearing age end up getting one in U.S. emergency rooms.  There's just too many consequences for missing so basic.  

#Positive.  She had an infant with her, so I knew it wasn't her first.  Plus, maternity is what many Haitian women aspire for and she was nearing the end of her fertile years.  She had to have had at least one other child by now.  She had 9.  And she didn't want another.  I've never been in a situation where I've had to discuss abortion with an expecting mother, so I let Dr. Angie do it.  #ChickenedOut

She was committed to an abortion.  While I have yet to come across any previous instances where it was mentioned, from speaking with the patient it's an accepted and common act around Arcahaie.  She knew where to go.  She knew the process.  "You insert one pill into your vagina.  You swallow two pills with a beer.  And in one to two months your baby will come out.  Dead."  She called the pill 'Citrodex' (Cytotec is the brand name of misoprostol, so I'm assuming they are one in the same).  

Safe?  Of course not.  Even the patient knew women who had died during the process, probably due to hemorrhage.  But this was a risk she was willing to take.  She couldn't support 10 kids.  So I asked, "If there were a procedure that could prevent pregnancies forever, would you want that?"  "Yes."  She wanted it right now.

The story stuck with me, so naturally I added the question to my repertoire of extremely personal questions that I seem to get away with asking because I'm #1 white and #2 working under the guise of healthcare.  My next true test was during a survey the next day.  I was walking into a yard with my interpreter to check on one of my helpers when a woman started talking to us.  She wanted me to help her with 2 kids she said she couldn't support.  Money?  Food?  What?  No, she didn't want temporary measures.  She wanted me to keep them.  Back to the compound?  Sure.  Home?  She didn't care.  She couldn't support them.  

I thought about it.  How would the logistics look?  How feasible would it be to turn the Matana Mission into an orphanage?  Not very.  And anything beyond that would be borderline unethical and highly illegal.  They were adorable, and not the only children from that house that were offered to me or to some mysterious orphanage that they thought I had built.  Another woman had five and didn't want any more.  Four out of the five adult women said they would love to have a procedure that made it impossible to get pregnant again.  One said she wasn't done having children yet.  #Insight.  The women have it.  But existing methods of birth control are hard to come by in Arcahaie.  You can but a Depo shot every three months.  You can buy a pill to take daily.  You could try and find condoms.  But with budgets stretched thin most women can't reliably utilize any of these forms of contraception.  

#Ethics come to the forefront in this discussion.  And so does appearance.  What message would we be sending if we brought a bunch of white doctors to Haiti and began sterilizing everyone?  It would be a PR nightmare.  Giving out medication is an easy thing to justify and even if done inappropriately will garner a positive press.  But eliminating the ability of a population to reproduce, even if 'elective', is a tough sell.  

Personally, I see both angles.  The women I talked about in my story would likely benefit from the comfort of knowing they won't unexpectedly have another mouth to feed.  Budgets are tight.  Children are a huge investment, even in Haiti.  They eat.  They get sick.  They need to go to school.  All of those things cost money.  And my experience so far has shown that families end up trying to get a little bit of everything for all of their kids, which means they have food insecurity, poor healthcare follow-up, and attend school 3 days a week for 4 hours a day.  But at the same time, women in any culture may have buyer's remorse.  The number 1 predictor of regret with a tubal is a young age, according to U.S. data.  And all the women I talked to were young.  They weren't 37, nearing the end of their child-bearing years.  They were maybe 30, in their prime reproductive years, but with "too many" mouths to feed already.  

Like I said, other ventures are no-brainers.  "Let's treat this infection."  "Let's control their blood pressure and blood sugar."  "Let's repair this hernia."  "Let's cut out this woman's ectopic pregnancy."  "Let's build a school and staff it so more kids can get a reliable education."  "Let's organize a community garden to improve food security."  But when you're talking about tubal ligations or vasectomies, the water becomes as muddy as the canal water most people drink from.  Wonder what Paul Farmer, in all of his wisdom and insight, would have to say on such an issue?