This article describes the experiences of a midwife and retired nursing professor, a labor and delivery registered nurse (RN), and a family medicine physician working together to provide sexual health education in rural Haiti in January 2019. Our hope is that these reflections may provide insights that will be helpful to other health professionals who are providing sexual health information to teens and young adults in developing countries.
Our 2019 health team consisted of Barbara Floyd, DNP, CNM, Cassandra Zinke, RN, BSN, and Caroline Barrett, MD. This was Barbara’s 7th service trip to Haiti. Cassy Zinke joined Barbara’s team for the second time; she was formerly Barbara’s student in nursing school and is now a labor and delivery nurse at Providence St. Vincent Medical Center in Portland, Oregon. Caroline Barrett, MD, recently completed her residency in family medicine with Community Health Care in Tacoma, WA, and is now working for the Providence Health System in Hillsboro, Oregon. This was Caroline’s first trip to Haiti. Completing the team, our most important team member was our female Haitian translator who has worked with Barbara Floyd every year since 2015.
During Barbara’s first Haiti trip in 2010, while volunteering with Midwives for Haiti she met a young man whose university education had been disrupted by the earthquake earlier in the year. He shared his dream of building and operating the first middle and high school in his home community, a rural area in Haiti, and invited Barbara to visit the community two years later when the school was under construction. Barbara has visited this rural community (the subject of this article) annually since 2015. The focus of activities when visiting the community has been developing relationships with students and their families, providing education on various health topics, and helping students practice English. Small groups of undergraduate college students and some health care professionals have participated in these visits since 2016. On arrival in May 2018, the school principal informed our group that he wanted our classroom activities in all grades to focus on preventing pregnancy. We followed that directive, and then returned with a new team in January 2019 with the goal of reviewing pregnancy prevention methods and adding a focus on preventing sexually transmitted infections (STIs). In order to protect the privacy of the students, school, and community, we will not name the school, the community, or any individuals other than trip participants in this narrative.
What We Did
During the 2019 visit we had three full days to provide classroom teaching to students from grades 7 through 13. As experienced health professionals, the 2019 team enjoyed presenting information and answering lively questions from students in grades 7 through 13. The youngest students are preteens of age 12, and the oldest are in their young twenties with a few outliers as old as 26-28 years of age. It is a wide range of ages and developmental stages, as it has been common for Haitian students to have had interruptions to their education and return as circumstances permit. We aimed to have two class sessions of one hour with each grade, to have a session for older girls only, and to have a session for only the older boys. We started each class with introductions and a song to break the ice; this year our song was, “This Time for Africa” by Shakira. During the first session with each class, we passed out blank pieces of paper and asked students to write down questions for us, which we aimed to answer that day or in the next session. Our translator, a Haitian teacher who teaches English and French, interpreted for us in class and translated the written questions.
After introductions and soliciting written questions, we continued with discussions of many topics relating to preventing pregnancy, avoiding early sexual activity, and preventing and treating infections. We used resources from Centers for Disease Control for teaching basics facts about above topics, as well as drawing upon the expertise and clinical experiences of our team. When we asked the students to tell us what they knew about preventing pregnancy, they mentioned condoms, pills, and abstinence; no one mentioned long-acting contraceptives. We also asked students what sexually transmitted infections they had learned about. Students in all grades had awareness of human immunodeficiency virus (HIV), gonorrhea, and syphilis. There was little or no awareness of chlamydia, human papillomavirus (HPV), or herpes. We asked students to tell us where they could get condoms and other methods of birth control. In each class, the students told us there is no place to get a condom in the immediate neighborhood. They must go to the town, usually on foot, 3-4 miles down the road, and the condoms are expensive. No one acknowledged any ability to access condoms nearby. The students said that some birth control is available at the community hospital in the nearby town, but it is also expensive.
The first afternoon we had an appointment to meet with leaders at the community hospital that is several miles away down a dirt and rock road. We aimed to increase our knowledge of what services are available to students and at what cost. We were enlightened to find that the family planning clinic has a diverse range of contraception including oral contraceptives, intrauterine devices (IUDs), and progesterone-only implants, and that all services are free to the community. We also learned that a community health worker lives near the school and can aid students in obtaining condoms as well as health information. The visit culminated in the hospital administrator offering the services of hospital clinic staff to join our classroom teaching the following two days.
Two hundred twenty-two students signed our attendance logs over our three days of teaching, and they submitted more than 200 written questions. Student questions covered several themes: students wanted basic information about sexuality and relationships, pregnancy, preventing pregnancy, and prevention and treatment of sexually transmitted infections, especially HIV. At the end of our 2nd and 3rd days, family planning staff from the local hospital talked first to female students from grades 11-13, and then to the male students in those grades. Our interpreter gave us a running dialogue throughout these classes, and it was gratifying to hear our teaching reinforced by the Haitian physician who works with the local family planning program. We heard no factual discrepancies between our teaching and his. It was exciting to hear his messages of empowerment to the young women, encouraging them to protect themselves from pregnancy and infection. As the topic of “forcing sex” had come up in one of the classes and was also a written question, we asked the presenter to specifically address this with the male students. The physician gave a powerful message to the young men, talking about emotional, verbal, physical, and sexual violence. He told the boys that these were common in older generations, but that they are part of a new generation that is different. At the end of each of those classes, the community health worker and the school principal handed out condoms from boxes labeled with USAID stickers to each of the students present. The principal also assured students that he would excuse absences from class to attend the family planning clinic, which is only open during school hours. It was a powerful message of empowerment from the principal that he wants students to protect themselves.
Questions from the Students
The following examples of student questions provide insights into the thirst for knowledge about reproductive health in a group of teens and young adults in this rural Haitian community.
- When can we have a boyfriend or girlfriend, and when can we have sex?
- At what age can a girl have menstruation?
- Can you get pregnant without menstruating?
- How many days after menstruation is done can we have sex?
- Why must someone have sex? Do we need sex?
- What makes a man or woman feel like having sex?
- What are the dangers of having sexual relations too early?
- Is sex good for your body? Is sex important for everyone?
- What can you do if you are having sex with several partners?
- Is it possible to be abstinent for all of life?
- When a boy is having sex with his girlfriend and he is about to ejaculate but waits, does sperm enter her?
- Can someone stay faithful until he/she gets married?
- Is it important for people to have abstinence?
- What can a person do who feels like having sex but does not want to have a sexual relationship?
- Is it ok to force someone to have sex?
- Is it possible for a woman to have sex during her period?
- What kind of precautions can you take when you feel like having sex?
- How do you prevent the desire to have sex?
- At what age can we become pregnant, or cause a pregnancy?
- Can a six-year-old or 10-year-old girl become pregnant?
- Why avoid early pregnancy?
- What problems does it cause?
- If a 15 or 16-year-old girl has a child will it cause a problem?
- Can a girl continue in school?
- Can a boy cause a pregnancy if his voice has not changed?
- Can pregnancy happen if you have sex in a river or in the sea?
- Can a 90-year-old man father a baby
- Can a 45-year-old woman near menopause have a “good” baby? If you reach your menopause, can you get pregnant?
- If a lady births a child, how many times can she get pregnant again?
- What advice can you give us to avoid early pregnancy?
Birth control and abortion
- Where and how can we get birth control?
- Is birth control safe? Can birth control make you sick?
- Can you get pregnant after using birth control or having an abortion?
- What problems can happen if you have an abortion?
- What causes abortion?
- Can you get pregnant just before or during menstruation?
- How can you know when it is safe to have sex? (Lots of in interest in calendar method of family planning)
- Does family planning work well? Why does a person need family planning?
- What is the best method for a girl who has not yet had a baby?
- If a girl uses family planning will she have problems when she has a baby?
- What types of family planning are there?
- How do we use condoms (boys and girls)?
Sexually transmitted infections
- What kind of illness can you get from sex?
- Do infections have treatments?
- What is the best way to avoid infection when having sex?
- Is having sex the only way to get an infection?
- If a woman has HIV, can she give it to her unborn baby?
- What can happen to a woman who has sex with a partner who has a sexually transmitted infection? If she becomes pregnant what can happen?
- If a woman has syphilis how can she give it to people? Can she give HIV to a man?
- If someone is not having sexual contact can they catch HIV?
- How can we prevent HIV? Can a person with HIV find treatment?
- I would like to know who invented HIV.
- How does a person know if they have HIV?
- How was HIV discovered?
- Is it easy to use a condom every day? What happens if a condom breaks?
- If you are living in the same house with a person who has AIDS and you don’t have a sexual relation with that person can you get AIDS also?
Reflections and Discussion
Students in this rural community in Haiti are eager for information about sexuality; they expressed strong interest in learning how to protect themselves from early pregnancies, and from STIs. Here are two comments from grade 8 students: “I don’t want to get a girl pregnant during school because I want to reach my dreams;” and, “I want to practice medicine so I can teach others like we are.” A grade 13 student wrote, “I don’t have any questions, but I like you giving us many good explanations so that we don’t have pregnancies too early and that you show us how to protect ourselves too.” We were especially impressed with the maturity of the grade 8 student who wrote the following comment, “If you get pregnant while in school, it is not only hard for the girl but also for the parents because they love you, but it is hard to support their child and a baby.”
This team of visiting health professionals found the school principal strongly motivated in encouraging student opportunities to learn accurate health information, and to use health services in order to protect themselves and their partners from pregnancy and infections. There remain significant barriers for these young adults to access health services. The family planning clinic is more than three miles away down a rocky dirt road, and clinic hours correspond to school hours. There is no public transportation, and walking is the most common mode of transportation. A few individuals may have access to a bicycle or may be able to hire a motorcycle taxi to transport them. The principal stated that student absences for health service are excused, but they must ask permission for this. Students may also experience embarrassment and shame in requesting these services. We look forward to future visits to this community and hope to find students utilizing the family planning services at the community hospital, and that family planning clinic personnel will maintain contact with the school.
Readers of this article may be aware of recently published ACNM global health competencies and skills for midwives. Our efforts in this small community addressed health equity and justice in recognizing barriers that Haitian students must overcome in order to access reproductive health services. Our respectful communications with students, school educators, community health professionals, and interpreters demonstrate ethical professionalism and competency in communication. We manifested cultural humility in teaching the students and in learning from them as we were teaching. In forging a formal connection between the school and the nearby community hospital, we hope that we have shown leadership in initiating a collaboration that will continue.
Barbara O’Malley Floyd, CNM, DNP
Member: Division of Global Engagement Education Committee
Caroline Mary Floyd Barrett, MD
Cassandra Zinke, RN, BSN
ACNM DGE has not participated in the planning of this publication, has no financial interest, and is not responsible for the content.