Haitian women, many of them victims of sexual violence, receive sewing lessons | Photo: Tracy Wilkinson / Los Angeles Times)

Haiti women and girls badly neglected in recovery efforts

Nearly 20 months after Haiti's devastating earthquake, women and girls have been badly neglected in recovery efforts, subjected to sexual violence and left without access to obstetric care even as they give birth to scores of babies in squalid tent cities, human rights activists say.

Despite a mammoth humanitarian-care push in the wake of the Jan. 12, 2010, quake that killed as many as 300,000 people, serious gaps exist in the healthcare that women and girls are receiving, according to a report released Tuesday by the New York-based Human Rights Watch.

Pregnant women reported having to give birth in alleyways or on floors; being unable to afford transportation to hospitals, and not having access to prenatal care.

Human Rights Watch also documented widespread sexual violence and "transactional sex," where women trade sex for food or other basic survival needs. Three girls, ages 14 and 15, and three women interviewed by the organization had become pregnant through rape but had been too fearful or too ashamed to seek help.

The 78-page Human Rights Watch report is entitled "Nobody Remembers Us."

"It is inconceivable that, 18 months after the quake, with so much money pledged … that women and girls are giving birth in muddy tents," Amanda Klasing, the report's main author and a fellow in the group's women's rights division, said in a telephone interview from Port-au-Prince, the Haitian capital.

Most Haitians face extraordinary hardships even today. More than half a million continue to live in ramshackle collections of tents with minimal sanitation. Food and jobs are scarce, a cholera epidemic persists and street violence is on the rise.

It's worse for women, largely excluded from the reconstruction process despite their importance to the informal economy, the report's authors said. In a country already beset by the highest maternal mortality rate in the Western Hemisphere before the quake, women and girls face unwanted pregnancies, unhealthy conditions for their children, a lack of access to education, poverty and the risk of eviction from already precarious living quarters.

Heavy rains this time of year also add to the woes by flooding tents and spreading filth. Very little post-rape care has been made available to the majority of female victims.

"The earthquake has exacerbated the vulnerabilities of this already vulnerable group," the report says.

Klasing said resorting to "survival sex" by women had become common. Women trade sex for food as a way to provide for themselves and their families. "You have to eat," a woman named Gheslaine, who lives in the crowded Croix-des-Bouquets camp outside Port-au-Prince, told the investigators.

Tragically, Klasing said, the women's lack of access to healthcare comes despite numerous international programs that exist in Port-Au-Prince which could help. The Haitian government has failed to distribute information about available care to females in the camps and has failed to protect them, the report says.

The group noted that of $5.3 billion pledged by international donors after the quake, $258 million was dedicated to healthcare — of which only $118.4 million has been disbursed.

"For all women and girls in Haiti," the report concludes, "fulfillment of their rights to reproductive and maternal health and to live free of violence is fundamental to any effort to rebuild their lives after the devastation and disruption caused by the earthquake."

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Human Rights Watch

Report: Nobody Remembers Us

Maternal Health

Haiti has the highest maternal mortality rate in the Western hemisphere, and lags far behind the rest of Latin America and the Caribbean. Its maternal mortality ratio was 630 deaths per 100,000 live births in 2005-06, up from 523 deaths per 100,000 between 1993 and 2000. Health professionals attributed this sharp increase in maternal mortality to the continued practice of home deliveries and instability in the country, which left women and girls without adequate delivery and postnatal care. Haiti has failed to keep up with the improvements attained in the other countries in the region.

Before the earthquake, obstacles preventing women and girls from accessing maternal care included: lack of services or services that were uneven, inadequate, and funded only in the short-term; difficult or delayed access to services; and fear of sexual violence, which prevented them from leaving home to seek care. A 2009 report showed that the prevalence of home deliveries increases during crises in Haiti and the “fear of rape often inhibits women and girls from seeking the care they need, including safer deliveries by a trained healthcare worker.” Further evidence shows that women and girls still “face[d] significant risk due to poor quality of service and insufficient availability of equipment and supplies” even when delivering in health facilities and emergency obstetrical centers, while neonatal care remained largely unavailable. “Every day is a crisis,” one public health professional said in 2008. Before the earthquake, the health system in Haiti, under the auspices of the Ministry of Public Health and Population (MSPP), struggled to implement even the Minimal Initial Service Package (MISP) for Reproductive Health in Crisis Situation.

Some improvements have been made to increase the number of women and girls receiving prenatal care. In 2005-06, 85 percent of women and girls benefitted from some access to prenatal care, compared to 68 percent a little over a decade before. Nevertheless, only half of pregnant women and girls have the 4 prenatal visits that the World Health Organization (WHO) recommends.

But improvements in access to prenatal care have not equally benefitted all women and girls in Haiti, where physical accessibility of health facilities is a strong predictor of their use. Women and girls living in rural communities and outside the Port-au-Prince metropolitan area are less likely to have access to antenatal care. Despite this, before the earthquake, some progress had been made in increasing the number of women and girls in rural areas who received care.

Increased access to prenatal care did not necessarily translate into increased numbers of women and girls delivering in facilities. In 2005-06, less than 25 percent of births took place in a health facility. Overwhelmingly, these births were to women with greater incomes. Just over 78 percent of births attended by medical professionals were to women in the top economic quintile, while only 5.9 percent were to women from the poorest quintile. A 2007 study found that security concerns, cost of transportation and other economic barriers, as well as expectations of poor care at public facilities, account for the low number of births attended by medical professionals.

Gender-Based Violence (GBV)

Gender-based violence is common in Haiti. Over the past two decades, high rates of domestic and sexual violence against women and girls exacerbated already high levels of economic and political insecurity. Furthermore, various regimes in Haiti have used sexual violence as a tool of repression. Some evidence suggests that politically motivated sexual violence occurred under the dictatorships of François and Jean-Claude Duvalier between 1957 and 1986. Human Rights Watch and other organizations documented the use of rape and assault as a form of political oppression during the Cédras regime and post-coup period from October 1991 to May 1993. By 2000, criminal gangs used sexual violence and threats of sexual violence to terrorize communities.

In the 2004 to 2006 political conflicts, “widespread and systematic rape and other sexual violence against girls” remained a concern. The UN estimated that up to 50 percent of girls living in conflict zones in Port-au-Prince were victims of rape or sexual violence, with reports of widespread collective or “gang” rape. A survey of the metropolitan area found that 3.1 percent of women and girls, or an estimated 35,000, were sexually assaulted from February 2004 to December 2006, with over half of all victims younger than 18 years old, and almost 1 in 6 aged less than 10 years of age.

A Médecins Sans Frontières (MSF) facility in Port-au-Prince provided treatment to 500 rape survivors during roughly the same period (January 2005 to June 2007). Its statistics also reveal that a significant proportion of the victims of sexual violence were girls: 2 percent of the victims were under 5 years old; 10.6 percent were between 5 and 12; and 27.5 percent were between 13 and 18. MSF also found that 67 percent of victims did not know their attackers; 68 percent of victims reported multiple attackers; and 66 percent of victims were threatened with a gun. The Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO Center), a medical center in Port-au-Prince, reported treating 422 cases of rape in 2005; the same year women’s organizations Solidarity of Haitian Women (Solidarité Fanm Ayisyen, SOFA) and Kay Fanm treated 112 and 188 cases of rape respectively.