Insecure Birth: A Qualitative Study of Everyday Violence During Pregnancy in Port au Prince, Haiti.

INTRODUCTION: While the city offers economic opportunities for women in many countries, their safety and security remain vulnerable to urban violence, especially in poor areas. In Haiti, poor urban women may be subjected to multiple forms of physical, sexual, and structural violence leading to adverse birth outcomes. We explored some of the complexities of how pregnancy is experienced under the reality and threat of urban violence in Haiti. METHODS: We examined data from focus group discussions with fourteen women who lived in severely disenfranchised neighborhoods in Port au Prince and who were pregnant or had recently delivered at the time of the study. RESULTS: We report on three recurring themes that emerged from the discussion: (a) ways in which the threat or experience of violence affected women's ability to access maternal healthcare, (b) ways in which women altered their behavior to accommodate everyday violence, and (c) the extent to which violence was embedded in women's consensual and non-consensual sexual encounters with perpetrators. We found that Haitian women considered violence, labeled ensekirite (insecurity), to be an everyday threat in their lives and that they strategized ways to access maternal health care and other services while navigating ensekirite. DISCUSSION: Pregnancy adds another layer of vulnerability that may necessitate further negotiations with the threat and presence of violence. The pervasiveness and impact of urban violence in women's daily lives needs to be better evaluated in maternal and newborn health research and programs.

Last mile research: a conceptual map.

Background: The term 'last mile' has been used across disciplines to refer to populations who are farthest away, most difficult to reach, or last to benefit from a program or service. However, last mile research lacks a shared understanding around its conceptualization.Objectives: This project used a concept mapping process to answer the questions: what is last mile research in global health and, how can it be used to make positive change for health equity in the last mile?Methods: Between July and December 2019, a five-stage concept mapping exercise was undertaken using online concept mapping software and an in-person consensus meeting. The stages were: establishment of an expert group and focus prompt; idea generation; sorting and rating; initial analysis and final consensus meeting.Results: A group of 15 health researchers with experience working with populations in last mile contexts and who were based at the Matariki Network institutions of Queen's University, CAN and Dartmouth College, USA took part. The resulting concept map had 64 unique idea statements and the process resulted in a map with five clusters. These included: (1) Last mile populations; (2) Research methods and approaches; (3) Structural and systemic factors; (4) Health system factors, and (5) Broader environmental factors. Central to the map were the ideas of equity, human rights, health systems, and contextual sensitivity.Conclusion: This is the first time 'last mile research' has been the focus of a formal concept mapping exercise. The resulting map showed consensus about who last mile populations are, how research should be undertaken in the last mile and why last mile health disparities exist. The map can be used to inform research training programs, however, repeating this process with researchers and members from different last mile populations would also add further insight.

Perceptions of isolation during facility births in Haiti - a qualitative study.

BACKGROUND: Haiti's maternal mortality, stillbirth, and neonatal mortality rates are the highest in Latin America and the Caribbean. Despite inherent risks, the majority of women still deliver at home without supervision from a skilled birth attendant. The purpose of this study was to elucidate factors driving this decision. METHODS: We conducted six focus group discussions with women living in urban (N = 14) or rural (N = 17) areas and asked them questions pertaining to their reasons for delivering at a facility or at home, perceptions of staff at the health facility, experiences with or knowledge of facility or home deliveries, and prior pregnancy experiences (if relevant). We also included currently pregnant women to learn about their plans for delivery, if any. RESULTS: All of the women interviewed acknowledged similar perceived benefits of a facility birth, which were a reduced risk of complications during pregnancy and access to emergency care. However, many women also reported unfavorable birthing experiences at facilities. We identified four key thematic concerns that underpinned women's negative assessments of a facility birth: being left alone, feeling ignored, being subject to physical immobility, and lack of compassionate touch/care. Taken together, these concerns articulated an overarching sense of what we term "isolation," which encompasses feelings of being isolated in the hospital during delivery. CONCLUSION: Although Haitian women recognized that a facility was a safer place for birthing than the home, an overarching stigma of patient neglect and isolation in facilities was a major determining factor in choosing to deliver at home. The Haitian maternal mortality rate is high and will not be lowered if women continue to feel that they will not receive comfort and compassionate touch/care at a facility compared to their experience of delivering with traditional birth attendants at home. Based on these results, we recommend that all secondary and tertiary facilities offering labor and delivery services develop patient support programs, where women are better supported from admission through the labor and delivery process, including but not limited to improvements in communication, privacy, companionship (if deemed safe), respectful care, attention to pain during vaginal exams, and choice of birth position.