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The Right to Democracy (21)

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Elections

At time of writing, nearly all elected national and local positions were open or filled by appointees; the only exceptions were the president and one-third of Haiti's senators. Negotiations between the provisional electoral council, executive branch, and political parties culminated in a March presidential decree mandating three election dates: first-round legislative elections on August 9; second-round legislative, first-round local and municipal, and presidential elections on October 25; and a presidential run-off election on December 27.

Haitian human rights groups raised concerns about some acts of violence in the pre-election period. They also documented irregularities in the August elections, leading to a repeat of first-round legislative elections in 22 of 119 districts, held concurrently with the first-round presidential elections.

The October 25 elections were mostly nonviolent, but were marked by low voter turnout. Approximately a quarter of registered voters participated and some electoral monitors and watchdogs raised concerns about voter fraud and transparency at voting centers and at the tabulation center where votes were counted. Police fired tear gas at and arrested protesters at recurring protests contesting the first-round presidential results. On November 18, two presidential candidates alleged that police fired on them at a protest, one saying he was struck in the head by a rubber bullet.

Election authorities rejected calls for an independent commission to verify the first-round presidential election votes. Eight presidential candidates, including first-round second place finisher Jude Célestin, issued a joint statement on November 29 stating that fair elections could not take place without reforms to the electoral commission and police, and that, absent such changes, the December 27 elections should be cancelled and a transitional government established to conduct a national dialogue, draft a new constitution, and prepare for free and fair elections at a much later date. The government's response to the joint statement and outcome of the December elections were not known at time of writing.

Criminal Justice System

Haiti's prison system remains severely overcrowded with many inmates living in inhumane conditions. Analysts trace much of the overcrowding to high numbers of arbitrary arrests and overuse of pretrial detention (according to the United Nations, more than 70 percent of suspects are held pending trial), which is often prolonged as cases take a long time to come to trial. The UN and other international partners have supported a number of initiatives to address this, including opening new legal aid offices and computerizing the case registry system in one jurisdiction in Port-au-Prince.

The limited capacity of the Haitian National Police (HNP) contributes to overall insecurity in the country. While the government and the United Nations Stabilization Mission in Haiti (MINUSTAH), the UN peacekeeping operation in the country, have made police reform a priority, there have been difficulties training sufficient numbers of entry-level cadets. Training of 1,500 new cadets began in August, along with screening of another 7,700 candidates, suggesting the target number of police could be met by the 2016 deadline.

Barriers to Education and Illiteracy

Approximately one in two Haitians age fifteen and older is illiterate. The UN independent expert on Haiti said in 2015 that action to eradicate illiteracy is one of the top human rights priorities in Haiti.

The quality of education in Haiti is generally low, and 90 percent of schools are run by private entities. Human Rights Watch found in 2014 that even some newly constructed schools lack adequate water and sanitation facilities. The minister of education said in September that the national education budget needed to at least double if his reform efforts were to survive.

Accountability for Past Abuses

Former President Jean-Claude Duvalier, who returned to Haiti in January 2011 after nearly 25 years in exile, was accused of financial and human rights crimes allegedly committed during his 15-year tenure as president from 1971 to 1986.

When the Port-au-Prince Court of Appeal ruled in 2014 that the statute of limitations could not be applied to crimes against humanity, and ordered additional investigation into the charges against Duvalier, victims of serious human rights violations, including arbitrary detentions, torture, disappearances, summary executions, and forced exile, hoped that they might finally see justice. However, Duvalier died six months after the ruling, without ever having been brought to trial. The Human Rights Committee and the UN independent expert on Haiti have both called on Haiti to continue the investigation and bring to justice all those responsible for serious human rights violations committed during Duvalier's tenure. At time of writing, a reopened investigation into crimes committed by Duvalier's collaborators was still pending.

Violence against Women

Gender-based violence is a widespread problem. Haiti does not have specific legislation criminalizing rape, domestic violence, sexual harassment, or other forms of violence suffered by women. The shutdown of parliament in 2015 prevented any progress towards consideration of a draft law to address this gap in protection.

Child Domestic Labor

Use of child domestic workers-known as restavèks-continues. Restavèks, most of whom are girls, are sent from low-income households to live with wealthier families in the hope that they will be schooled and cared for in exchange for performing light chores. Though difficult to calculate, some estimates suggest that 225,000 children work as restavèks. These children are often unpaid, denied education, and physically or sexually abused.

Haiti's labor code does not set a minimum age for work in domestic services, though the minimum age for work in industrial, agricultural, and commercial enterprises is 15. Most of Haiti's trafficking cases are restavèks. In 2014, Haiti passed legislation outlawing many forms of trafficking, including hosting a child for the purpose of exploitation.

Key International Actors

MINUSTAH has been in Haiti since 2004 and has contributed to efforts to improve public security, protect vulnerable groups, and strengthen the country's democratic institutions. In January 2015, permanent representatives of the UN Security Council traveled to Haiti for the first time in three years on a mission led by US Ambassador to the UN Samantha Power and Chilean Ambassador Cristian Barros Melet.

In March 2015, MINUSTAH began reducing its personnel, operations, and geographical presence in accordance with a drawdown plan adopted by the Security Council in October 2014. The UN Security Council extended MINUSTAH's mandate through October 15, 2016.

In March and September 2015, the UN independent expert visited Haiti and highlighted the poor conditions that Haitians deported by the Dominican Republic face in camps on the border between the two countries.

In 2012, a member of the 2011 Independent Panel of Experts on the Cholera Outbreak in Haiti convened by the UN secretary-general stated that "the most likely source of the introduction of cholera into Haiti was someone infected with the Nepal strain of cholera and associated with the United Nations Mirebalais camp."

Responding to the UN's dismissal of claims for compensation from 5,000 victims of the epidemic, the victims' representative, the Institute for Justice and Democracy in Haiti, and the Bureau des Avocats Internationaux filed a lawsuit in 2013 before a US court. In January 2015, the case was dismissed. At time of writing, an appeal was pending. To date, there has been no independent adjudication of the facts surrounding the introduction of cholera and the question of the UN's involvement.

According to figures from the UN Office of Internal Oversight Services, at least 102 allegations of sexual abuse or exploitation have been made against MINUSTAH personnel since 2007, including 7 between January and July 2015.

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World Report 2016: Rights Trends in Haiti

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The terms of the majority of lawmakers in Haiti ended in January 2015 without new elections to replace them, shutting down the parliament. While President Michel Martelly governed pursuant to constitutional provisions permitting government institutions to continue operations, the lack of a legislature and protracted political stalemates over elections hindered the Haitian government's ability to meet the basic needs of its people, resolve longstanding human rights problems, or address continuing humanitarian crises.

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The Right to Education (26)

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Education | Haiti | U.S. Agency for International Development

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nid:190386]]Lack of access to education remains a key obstacle to social and economic development in Haiti, with less than half of Haitian school-aged children enrolled in primary school and an adult literacy rate of just over 50 percent.

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-  Don't Discriminate (2)
-  The Right to Privacy (12)
- Marriage and Family (16)

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We write in advance of the Committee on the Elimination of Discrimination against Women's upcoming review of Haiti to highlight areas of concern regarding the Haitian government's compliance with the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).

This submission focuses on two key elements of the State party's obligations under the Convention: 1) the availability of effective legal mechanisms to address violence against women; and 2) the rights to water and sanitation, and associated rights, including to health and education.

This submission is based on Human Rights Watch research and experience working on women's rights in Haiti, including its 2011 report, Nobody Remembers Us: Failure to Protect Women's and Girls' Right to Health and Security in Post-Earthquake Haiti, on-going advocacy related to gender-based violence, and research in 2014 regarding water and sanitation.[1]
Violence Against Women in Haiti (Articles 2, 12, and 16)
Violence against women was a major concern in Haiti even prior to the 2010 earthquake, and conditions after the earthquake exacerbated the challenges faced by victims of violence seeking health care or legal recourse. Six years after the devastating natural disaster, survivors of violence against women still do not have basic legal redress available to them or access to necessary health care.

Gender-based violence remains a significant concern in Haiti, and the legal protections afforded to women and girls remain weak. Haiti lacks comprehensive legislation on violence against women. The country has no specific legislation criminalizing marital rape, domestic violence, sexual harassment, or other forms of violence suffered by women. Rape is prohibited by a modification of the criminal code introduced by executive decree in 2005.[2]

The women's ministry, in collaboration with Haitian women's civil society groups, has worked towards a draft comprehensive violence against women law since the State party's last review by the CEDAW Committee.[3] In addition, a draft criminal code reform supported by international donors includes new crimes and criminal sanctions related to violence against women.[4] However, neither piece of legislation has been presented to Parliament. The delayed elections which led to the shutdown of Parliament in 2015 have prevented any progress towards addressing this gap in legal protection.

Moreover, victims of gender-based violence continue to face challenges in accessing medical care. Human Rights Watch has spoken over the last four years with Haitian activists who support victims of gender-based violence seeking health care and they confirm these challenges. According to some women's rights activists, there are some promising efforts to include gender-based violence screening and treatment in the medical school curriculum. Legal reform is also needed to ensure that such victims can get the health care they need, including decriminalizing abortion after rape. Abortion is currently illegal, even in cases of rape.

The lack of legislation on violence against women and access to post-rape health care indicates that Haiti is failing to meet its obligation to prevent, investigate, prosecute, and punish acts of gender-based violence. International cooperation is necessary to support the State party in meeting this obligation.
The Rights to Water and Sanitation (Articles 2, 10, 12, and 14(h))
The rights to water and to sanitation undergird many of the rights specifically addressed within the Convention. Lack of access to clean water and sanitation directly affect the rights to health and to education, and even the risk of violence or death faced by women and girls in Haiti.

Lack of access to clean water and sanitation shapes the lives of many Haitian women, particularly those living in rural areas. Poor drainage and large-scale erosion have left many homes, communities, and agricultural plots at risk of flooding. Women and girls spend many hours of their days fetching water or traveling to rivers and streams to do their families' laundry. Those duties keep some girls from getting to school on time, causing them to miss important lessons and fall behind their male classmates. Women are also burdened with the unpaid work of caring for family members, often young children, sickened by contaminated water.[5]

In Human Rights Watch's research in 2010 and 2011 in the displacement camps, women and girls connected their fear of sexual violence with their poor access to water and sanitation. They told Human Rights Watch that they sometimes feared going to the bathrooms in camps because they feared sexual assault. They described being pinched, poked, or leered at by boys and men in the displacement camps when they washed themselves out in the open, since there was no safe and private place to bathe. Women and girls also raised many other ways that lack of water and sanitation negatively impacted their lives. Some gave birth in the dirt in tent camps or in the street without access to running water. Many women and girls in the camp had terrible vaginal infections and were not able to manage their personal hygiene, particularly during menstruation.[6] While the number of internally displaced has reduced significantly in Haiti over the last six years, tens of thousands of people still live in displacement camps.

After the October 2010 outbreak of cholera, women and girls described to Human Rights Watch their anxiety around access to clean drinking water. Many mothers, often the primary caregivers in the household, described caring for children with diarrhea caused by water they knew made them sick. Some women Human Rights Watch spoke with outside of Port-au-Prince had lost children or partners to the cholera epidemic, which has killed at least 9,800 people and sickened nearly 800,000 in Haiti since 2010. Often, these women continued to drink from the same water source that killed their loved ones.[7]

In 2014, Human Rights Watch investigated the impact of poor water and sanitation in schools, visiting a number of schools in the Central Plateau of Haiti to assess water and sanitation conditions of educational facilities. These schools, including recently constructed ones, lacked adequate water and sanitation facilities. None of the schools Human Rights Watch visited complied with the government's guidelines for the promotion of hygiene in schools. Teachers, students, and government officials all told us that the situation was dire and has a negative impact on students' education. These schools Human Rights Watch visited are not anomalous in Haiti.

Although the Haitian government's guidelines call for the promotion of hygiene in schools, safe, clean latrines and water for drinking and hand washing are extremely scarce in Haitian schools. Most students and teachers have nowhere to relieve themselves, wash their hands with soap, obtain clean water, or, for women and girls, maintain menstruation hygiene. Where facilities do exist, they may not be sufficient in number, may not function, or may not be clean or safe. Nearly 60 percent of schools lack toilets and more than three-fourths of schools lack water access.

Girls suffer additional harms from the lack of access to water, sanitation, and hygiene at home or at school, including absenteeism for collecting water or due to lack of adequate menstrual hygiene management. Human Rights Watch spoke with girls in Haiti who leave school to go home to wash and change the materials they use to manage their menstruation, because they cannot do that at school-leaving some to miss as much as 30 minutes of instruction every time they need to change their materials. Some teachers told Human Rights Watch that girls sometimes stay at home during menstruation because they have no option to manage their hygiene at school. Girls in Haiti need access to clean water and sanitation facilities, as well as hygiene education and materials, to ensure their consistent attendance in school.[8]
In your review of Haiti in February 2016, Human Rights Watch encourages the Committee to ask the State party questions about the following issues, and recommend that the State party take steps to address them:

What steps is Haiti taking to pass comprehensive legislation to address gaps in legal protection related to violence against women? In particular, how will Haiti's new Parliament prioritize legislation protecting the rights of women and girls?

What steps is Haiti taking to address the lack of access to safe and legal abortion for women and girls, including for those who are victims of sexual violence?

How does Haiti propose to address the continuing challenge of lack of water and sanitation in schools, markets, health centers, and other public facilities?

How will Haiti ensure women's participation in the planning and execution of national policies and plans related to violence against women and to household water and sanitation?

What steps is Haiti taking to promote collaboration across ministries to ensure that the rights to water and to sanitation are promoted and fulfilled, including by ensuring that:

Sanitation facilities are safe and guarantee privacy;

Women and girls have materials, information, and access to spaces that guarantee their privacy to manage their menstruation with dignity;

National policies and plans related to safe drinking water take into consideration the safety and unpaid work of women and girls and seek to reduce their burden; and

Any plans to remedy the harms associated with the cholera epidemic address the burdens experienced by caregivers, most of whom are women.

What plans does the Ministry of Education have to make mandatory its guidelines related to water and sanitation in schools, including addressing menstruation hygiene management?

We hope you will find these comments relevant to your examination of the Haitian government's compliance with the Convention, and would welcome an opportunity to discuss them further with you.

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Submission on the combined eighth and ninth periodic reports of Haiti to the United Nations Committee on the Elimination of Discrimination against Women

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We write in advance of the Committee on the Elimination of Discrimination against Women's upcoming review of Haiti to highlight areas of concern regarding the Haitian government's compliance with the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).

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- Don't discriminate (2)
- The right to life (3)

- Safe place to live (14)

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Reproductive and maternal health is not ancillary to the larger reconstruction progress. Rather, for women and girls, the fulfillment of their rights-including the right to exercise control over the number and spacing of children, and to safer motherhood, and to live free of violence- is fundamental to any effort to rebuild their lives after the devastation and disruption caused by the earthquake. This is true for all women and girls in Haiti, and not only those living in the camps who are the focus of this report. As Haiti slowly struggles to move forward with reconstruction and relocate those displaced by the earthquake into safe housing, it is important that lack of access to reproductive and maternal care, and gender-based violence, does not exacerbate women's and girls' economic and health vulnerabilities.

Design programs to increase women's and girls' access to information on maternal and reproductive care, availability of post-rape care, availability of medical services, and general information about the reconstruction effort.

Identify and implement measures that can be put in place to ensure adequate oversight, monitoring, and reporting of programs to allow accountability between rights-holders and the state, as well as between the state and donors. This is essential to assess whether responses on the ground are effectively meeting human rights obligations and if not, what remedial action should be taken to fulfill those obligations.

Design and fund programs to increase women's and girls' access to information on maternal and reproductive care, availability of post-rape care, availability of medical services, and general information about the reconstruction effort.

Ensure adequate oversight, monitoring, and reporting of programs to allow accountability between donors (and implementing NGOs) and the government of Haiti.

Ensure adequate oversight, monitoring, and reporting of commission-approved programs.

This report is based on research conducted by two Human Rights Watch researchers in the metropolitan area of Port-au-Prince in November 2010 and January, February, and June 2011.

Human Rights Watch interviewed 128 women and girls living in displacement settlements who were pregnant or had given birth since the January 12, 2010 earthquake. Human Rights Watch also conducted 16 female-only group interviews and 11 mixed-gendered group interviews. Human Rights Watch interviewed women from 15 camps ranging in size from 100 to 60,000 people in 7 of the 12 communes affected by the earthquake, including: Carrefour, Cité Soleil, Delmas, Pétion-Ville, Port-au-Prince, Croix-des-Bouquets, and Petit-Goâve.

Human Rights Watch interviewed 61 representatives from NGOs working on health, women's health, women's rights, and gender-based violence. We also interviewed 24 representatives from United Nations Stabilization Mission in Haiti (MINUSTAH) Human Rights section/ Office of the High Commissioner for Human Rights (OHCHR); MINUSTAH Gender section; UN WOMEN (the United Nations entity for gender equality and the empowerment of women, formerly UNIFEM); United Nations Population Fund (UNFPA); United Nations Children's Fund (UNICEF); the office of the United Nations High Commissioner for Refugees(UNHCR); Office of the United Nations Special Envoy to Haiti; Office for the Coordination of Humanitarian Affairs (OCHA); the sub-clusters on Gender-Based Violence and on Reproductive Health; and the cluster on Nutrition.

In most instances, these interviews were conducted in person. In a small number of cases they were conducted telephonically. Human Rights Watch also interviewed the coordinator of Haiti's National Commission to Reconstruct the Health System and six representatives from three state hospitals, all affiliated with the Ministry of Public Health and Population. Human Rights Watch requested interviews with the Ministry of the Condition of Women and Women's Rights, including through contacts with the gender focal point of the Office of the UN Special Envoy, but had not yet secured an interview at the time of writing.

Interviews were conducted in Haitian Kreyòl with the assistance of an interpreter, where necessary. Female interviewers and, when possible, female interpreters conducted all interviews. Researchers attempted to create private spaces within individual tents or elsewhere in the camp environment for interviews. Most interviews were conducted individually, except in a few instances where interviewees preferred to speak in small groups.

Human Rights Watch used a multi-step sample strategy. First, camps were selected to ensure representation of a range of types (including: managed, unmanaged, small, large, easily accessible to main roads, and those less accessible). Additional criteria for camp selection included safety and the availability of interlocutors to provide an introduction to camp residents.

Second, women and girls who met the inclusion criteria of being currently pregnant or having given birth since the earthquake were identified in each camp either through interlocutors in the camp or by visiting individual households (tents) and asking whether women and girls who met the criteria were available to speak.

A total of 128 women and girls in 15 camps were initially identified by Human Rights Watch. After initial interviews, 103 (92 women and 11 girls) were found to meet inclusion criteria. The most common disqualifier was giving birth prior to the earthquake. The interviews in these cases were continued to provide background information on camp conditions, access to family planning, women's access to livelihoods, security, and health.

Of the 103 women and girls meeting inclusion criteria, 28 were currently pregnant and 75 had given birth since the earthquake. Eleven of the interviewees were girls ages 14-17, and three were 18-year-olds whose pregnancies began when they were 17.

All participants provided oral informed consent to participate and were assured anonymity. As a result, pseudonyms or first names only have been used for each individual interviewed. Individuals were assured that they could end the interview at any time or decline to answer any questions, without any negative consequences. All participants were informed of the purpose of the interview, its voluntary nature, and the ways data would be collected and used.

No interviewee received compensation for providing information. Four women and girls interviewed by Human Rights Watch asked to be interviewed outside the camp for added security and received compensation for expenses they incurred while traveling to the interviews. Where appropriate, Human Rights Watch provided contact information for organizations offering legal, counseling, or social services.

In this report, the word "child" refers to anyone under the age of 18, with "girl" referring to a female child. The Convention on the Rights of the Child states, "For the purposes of the present Convention, a child means every human being below the age of eighteen years unless under the law applicable to the child, majority is attained earlier."

Haiti was struggling to reduce one of the highest maternal mortality rates outside of sub-Saharan Africa when the January 2010 earthquake wrought unprecedented damage on its capital and surrounding areas. For women and girls giving birth in the minutes, weeks, months and now years after the earthquake, the risks associated with pregnancy remain, with the added challenges created by the post-earthquake destruction.

In the displacement settlements that Human Rights Watch visited these factors remain obstacles for women and girls seeking access to health services and improved health status.

Prior to the 2010 elections, only 6 of the 129 legislators in the Senate and Chamber of Deputies were women and there were only 3 women in a cabinet of 18 ministers, despite the fact women and girls comprise over 50 percent of the population. No woman served on the Cour de Cassation (Supreme Court). Women's political participation continued to lag behind in the latest elections, even though a woman, Mirlande Manigat, was a leading presidential candidate.

The electoral code provides incentives for the inclusion of women: it mandates that political parties that nominate at least 30 percent of female candidates and elect 20 percent of those nominated will receive double the amount of public financing for the same positions in the next elections. Not one of the more than twenty political parties met these criteria in the November 2010 elections.

Haiti's health infrastructure was in disrepair before the earthquake. The public health system was plagued by lack of coverage, inequality in provision of services, poor finances and inefficiencies, poor decentralization and organizational dysfunction, and "a human resource deficit and weak productivity." The precarious state of the health infrastructure and high levels of gender inequality resulted in poor health indicators for Haitian women and girls, including those related to maternal and reproductive care.

Maternal Health

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.

Family Planning

Even if a woman gains access to family planning, she may face other obstacles to using it. The ability of women and girls to make decisions about the number and spacing of children may be limited by their partners. According to one study, less than half of women in relationships reported being able to independently make decisions about contraceptive use, and 26 percent reported that their partner alone made decisions for them about their own health.

Gender-Based Violence (GBV)

Gender-based violence has a direct impact on women's health. A 2000 study found a correlation between the experience of spousal abuse and poor reproductive health outcomes, defined in the study as having a non-live birth, a sexually transmitted infection (STI) or symptoms of an STI, or having an unwanted birth. A study in rural Haiti in 2005 found that "women whose current pregnancy was unplanned were 1.7 times more likely to have experienced forced sex," which is defined in the study as rape, sexual coercion, and other forms of sexual violence. The same study found strong correlations between sexually transmitted infections and forced sex. Several symptoms related to sexually transmitted infections, including chronic pelvic pain, excessive vaginal discharge, discolored vaginal discharge, burning or pain when urinating, and lesions around the mouth or vagina, were found to be associated with a history of forced sex. The survey data from 2005 to 2006 confirmed this, finding the number of women who reported a sexually transmitted infection to be significantly higher among women who had experienced sexual violence. A 2009 study of youth aged 15 to 24 found sexual violence to be a significant risk factor for pregnancy. In a 2008 report, Amnesty International found that approximately 20 percent of girls seeking treatment for rape at a medical facility in Port-au-Prince became pregnant. Moreover, for pregnant women the odds of a terminated pregnancy, defined as an abortion, miscarriage, or still birth, were significantly higher for women who report intimate partner violence.

Reforms and Efforts to Reduce Maternal Mortality before the Earthquake

The Haitian government had taken a number of steps to address the maternal and reproductive health crisis. The Ministry of Public Health and Population (MSPP) included maternal health as one of its priorities and the government included the reduction of maternal mortality as an important goal in its 2007 Growth and Poverty Reduction Strategy paper. The MSPP's 2005 National Strategic Plan for the Reform of the Health Sector ( Plan Stratégique National pour la Reform du Secteur de la Santé), included maternal and reproductive health in its strategy to deliver basic integrated health services through Haiti's public health system.

Midwives, or skilled birth attendants, are also seen as an important component in decreasing maternal death. A school for midwives was established in 2001, graduating about 35 midwives each year. In addition, the UN Population Fund (UNFPA) supported programs to train traditional birth attendants, women who assist with deliveries, but have no formal medical training, to become auxiliary midwives. The Free Obstetric Care project (SOG) includes funding to reimburse traditional birth attendants for bringing women with high-risk pregnancies into medical facilities for delivery.

The Haitian government and donors identified other factors frustrating efforts to reduce maternal mortality and put mechanisms in place to address them. For example, the United State Agency for International Development (USAID) found that the highly centralized and poor health system management of the health ministry presented problems. The ministry, working with USAID, sought to address the management problems by building central level institutions and strengthening planning capacity at the department level.

Humanitarian aid actors responded quickly to fill gaps in the emergency phase, setting up free health facilities throughout the affected areas. The UN put in a cluster system through UN's Office for the Coordination of Humanitarian Affairs (OCHA), which allows for the coordination of humanitarian actors throughout a variety of sectors, including protection, health, nutrition, and water and sanitation. Over 400 health NGOs participated in the response efforts through the health cluster. Many believed that despite the dire conditions left by the earthquake some health indicators would actually improve because of the influx of health professions and free health services. But almost 9 months after the earthquake, a study found that only 20 percent of camps had any sort of health facility on site.

In spite of their losses, many of the medical NGOs operating in the emergency phase, including Médecins Sans Frontières, Médecins du Monde, Partners In Health/Zanmi Lasante, and Save the Children, provided medical services, including maternal care, for free. The Free Obstetric Care project (SOG) also continued to operate, despite suffering the loss of offices, computers, and damage to participating medical institutions.

Public health professionals began noting a "pregnancy bubble" or an increase in pregnancies in the first three months after the quake. A pregnancy bubble after a natural disaster is not uncommon and may be attributable to a variety of causes. Women and girls interviewed by Human Rights Watch identified some of the following factors for their own pregnancy: a desire to compensate for the loss of a child in the earthquake; the hope of strengthening a relationship with a new partner; and a lack of access to information or to methods of contraception. A number of those interviewed also reported rape as the cause of their pregnancy.

Haiti's Human Rights Obligations

However the capacity of the Haitian state to act in terms of available resources, and the need to rely on international assistance and cooperation, is a legitimate factor in assessing what measures Haiti is reasonably expected to implement.

The UN Commission on Human Rights (now the Human Rights Council) and the UN special rapporteur on the right to health have consistently stated that the right to health includes the right to sexual and reproductive health, including maternal health, the right to health care, and to the underlying determinants of health.

To address its obligations after the earthquake, the Haitian government included maternal health in its recovery plan and sought to provide, or encourage non-state actors to provide, free prenatal and obstetric care. Removing financial barriers to health care is an essential measure to enable access to health services for poor and vulnerable groups.

Human Rights Watch found that despite the government's attempts to remove the cost of care as a primary barrier, many obstacles remain that prevent women and girls living in displacement settlements in the Port-au-Prince metropolitan area from accessing the health care they need.

I don't want any more babies. Life is too hard in the camps.

-Yvonne, camp in Croix-des-Bouquets, January 22, 2011

More unplanned pregnancies increase the poverty in this camp...

- Margalie, camp in Croix-des-Bouquets, January 22, 2011

Gender inequality and violations of women's and girls' rights that existed before a disaster can worsen after a disaster. In particular, pregnant women and lactating mothers face increased hardships, as do women with disabilities and elderly women, due to constrained mobility and greater need for health services, food, and water. However, women and girl survivors of natural disasters remain rights-holders, entitled to seek the realization of their basic human rights.

Rachelle was a 17-year-old student when the earthquake hit. Terrified of the falling buildings, she immediately sought refuge in the open spaces of a public square in front of the Presidential Palace. She stayed in the spontaneous settlement that sprang up there and became pregnant while living in the camp. Though Rachelle did not reveal details regarding her relationship to the father of the child, she said:

Yes, I wanted to use family planning, but I wasn't able to get it. There was a clinic here [in the camp] and they had planning, but unfortunately the clinic closed.

Human Rights Watch research suggests that some women and girls in displacement settlements are not able to make this choice for themselves. Human Rights Watch found that obstacles to family planning services included lack of access to information and the means to practice family planning. Women and girls interviewed by Human Rights Watch faced additional obstacles to effectively utilizing contraceptive methods that were available to them because of their inability to negotiate use of available contraception, namely condoms, with their partners.

Lack of Access to Information

Tamara, a 17-year-old mother, lives with her parents and brother in a camp in Delmas 33. She is sometimes scared in the camp because fights often break out between young men and strangers will pop into her tent if it starts to rain. Tamara became pregnant while living in the camp, but was reluctant to discuss the circumstances of the pregnancy. She did say:

Nobody told me about planning, but if I knew planning, I would use it. It's only I don't know.

There was no information available in the camps where they lived;

Information on family planning was given at prenatal checkups and therefore too late to prevent pregnancy; and

Information about side effects, proper usage, and when to begin postnatal family planning was either unavailable or incorrect.

This evidence is consistent with data from the UN Population Fund (UNFPA), which indicate that 74 percent of persons living in displacement settlements reported a need for information regarding family planning. That number rose to 4 out of 5 respondents for the 25 to 29-year-old age group.

Many women and girls told Human Rights Watch that no organization provided information on family planning in the camps where they lived. While some women and girls interviewed by Human Rights Watch reported having access to information, some women and girls from each camp we visited reported having no access to information. Like Tamara, Lovely lives in a camp in Delmas 33. She has two children and recently gave birth to another. As she held her infant, she told Human Rights Watch, "I wish I had stopped from getting pregnant." She said she had not planned to have the baby she held, and had lacked information about contraception, which she would have used if only she knew how.

Human Rights Watch found that many women and girls we interviewed relied on information provided by social networks rather than medical professionals on side effects and usage of different forms of family planning, often because they could not find that information easily. Several women admitted that they did not use family planning because friends or relatives had told them that it makes women feel bad, bleed, or gain weight. At least three women told Human Rights Watch that they had stopped using contraceptives because it caused bleeding that worried them. Widney said:

I was hemorrhaging in January after the earthquake [from the contraception I was on], and I went to the hospital. They gave me pills [to stop it] but it was useless.

Scared, Widney stopped taking oral contraception. Like the other two women interviewed, she became pregnant after discontinuing contraception.

The government of Haiti should ensure women and girls have access to health-related information. This includes access to information and advice on family planning and access to the information and education necessary so that they will be able to make and implement decisions about the number and spacing of children. The government may need to seek assistance from donor and NGO partners to fund and implement programs to ensure access to information, as it did in cholera-related informational campaigns.

Access to Contraception and the Right to Decide on the Number and Spacing of Children

Girls who don't have parents, it's easy to become pregnant.

They don't have resources and have to have relationships with

men to survive ... Condoms are available but they don't use them...

-Valmie, camp in Mais Gaté, January 23, 2011

Human Rights Watch found that some women and girls living in displacement camps could not physically access contraception when they needed or wanted it. For others, when some forms of contraception such as condoms were available, their partners refused to wear them, and the women and girls were unable to negotiate or demand they change their mind.

I don't like the way I live. I am in a tent and I don't have anybody to help me. I would like to keep on with my studies after the delivery. I was not planning to get pregnant ... I was a student, but I didn't have access to family planning. I would like to become a nurse.

Some women and girls interviewed by Human Rights Watch knew where to access family planning services outside the camps, but stated that such services were physically inaccessible to them because it was difficult to leave due to reasons that varied from transportation costs, which without livelihoods is too expensive even if amounting to less than US$1, to concerns about theft of property if they left their tent unattended. Charlot, a woman living in a camp in Delmas 33, explained that she knew where free care was available at a clinic in another camp, but it "is hard to get to...you have to pay for transportation."

Condoms are more easily available in the camps, where a large number were reportedly distributed immediately after the earthquake. Condoms are a reliable form of contraception and provide protection from sexually transmitted infections (STIs); however, their use requires the consent of both partners. Human Rights Watch found that many women and girls, particularly young girls, living in precarious camp conditions lacked the power to negotiate condom use with their partners.

Several camp committee members confirmed that, while available, condoms had not been widely used. Many men interviewed by Human Rights Watch asserted that they prefer not to use condoms and expected their partners to protect themselves in other ways.

There is no contraception in the camp except condoms.... We [men] don't want to use [condoms]; we don't like them. [Sex] doesn't feel sweet when we use them. So, it's good for [women and] girls to have access [to other forms of contraception].

Evidence that Human Rights Watch documented, which is consistent with information from other sources, clearly indicates that provision of condoms in the camps as the only means for family planning does not ensure women and girls are able to exercise the right to decide on the number and spacing of children. The difficulty women and girls face to convince partners to use condoms is not unique to the camp setting. However, it is important that the government identify measures that it can take within its resources, including in conjunction with other actors, to remove barriers that women and girls face in displacement camps in accessing diverse information about family planning.

Illegal and Unsafe Abortion as a Response to Lack of Access to Family Planning

Nurse Caillot, the head nurse at Chancerelles said:

We see a lot of [cases of complications due to] abortion, both from Cytotec [brand name for misoprostol] and instruments. This is a big problem for women's health. Women come in with infections that are dangerous.

Tesol explained how she took the risk of having an unsafe, illegal abortion because the pregnancy was unplanned and she had no means to care for the child.

I took a lot of medication to abort this baby. Because the medication didn't work, that's why I gave birth. I took a beer and a medication that cost US$3.15. I got the drugs at a pharmacy. A person, a friend, told me about it.... [Then] I was unconscious; I had fainted.... The doctor had told me if I abort, I will have a problem, because I was four months pregnant. The doctor didn't help me have the abortion; he told me it was illegal.

Tesol told Human Rights Watch that even after this experience and then giving birth in the hospital, she felt she did not have adequate access to contraception, exposing her to the risk of another unwanted pregnancy.

When women and girls in Haiti do become pregnant, they have a right to prenatal care. Prenatal consultations in the earthquake-affected areas are widely available for free or at a nominal cost due to the increase services by organizations such as Médecins Sans Frontières (MSF), Médicins du Monde, and Save the Children, as well as the increased use of the Free Obstetric Care project (SOG) facilities. Nevertheless, Human Rights Watch found that barriers other than the cost of the visit prevented some women and girls from accessing prenatal care or completing the four prenatal visits that the WHO recommends. These barriers include lack of knowledge related to the need for care, where to access it, and economic barriers not directly associated with the cost of a prenatal check-up, such as transportation or sonogram costs.

Lack of Access to Information

Ellen, a 17-year-old new mother in a camp in Mais Gaté, lost both her parents in the earthquake. She lives with her older sister in a tent in a displacement settlement near the airport. She became pregnant shortly after the earthquake. The father of the child has left her. She did not attend prenatal check-ups, and when she went into labor, she gave birth in the camp with her sister's help. She said she did not go to prenatal visits or to the hospital to give birth because it was her first child and she was inexperienced.

He's my first child and I didn't have anyone to give me advice to go to a clinic [for prenatal care].... I gave birth in the camp because no one told me to go to the hospital. No one helped me but my sister.

Early pregnancies, like Ellen's, can have a detrimental impact on health. Pregnant girls should have access to information about pregnancy, childbirth, and health services tailored to their particular needs.

Nevertheless, in interviews with Human Rights Watch, women and girls-especially pregnant adolescent girls-who did not have prenatal care said they lacked access to information about the importance of care and where to seek it. The earthquake destroyed many of the neighborhood medical facilities where women previously sought care. After the earthquake many women and girls had settled in parts of the city or neighborhood unfamiliar to them, and were unsure where to seek care. Mardin lives in the displacement camp near the airport, and told Human Rights Watch she had gone for prenatal checkups when she was pregnant with her other children. With her latest pregnancy she did not go for prenatal care because the earthquake had decimated the hospital she had previously used. A doctor with years of experience in Haiti said:

The earthquake destroyed social systems and many of the physical reference points for communities disappeared: churches, small clinics, et cetera. People moved to new neighborhoods and the geography was completely changed. They didn't know what existed before, what clinics or hospitals, or what is available now. The daily struggle in the camps is difficult, and families can't foresee their health needs in the future. When the need arises, people don't know where to go. They ask other people, and most only know the general hospital, which is too far and has a reputation for lacking drugs or doctors.

Human Rights Watch also found that a significant number of women and girls we interviewed who did not seek prenatal care encountered difficulties with their delivery. Setania became ill in the seventh month of her pregnancy. She was one of the lucky ones because she was able to reach the hospital and have her labor induced. She delivered a premature baby and at the time of the interview, she and her baby were recovering. Michelin however, did not seek antenatal care, and suffered a stillbirth in March 2010. She had not experienced problems during the pregnancy, so did not know she should have gone for prenatal checkups.

Information about the importance of prenatal care and where to seek it is important if maternal mortality is to be reduced via prenatal assistance. The earthquake fundamentally changed the landscape of facilities providing prenatal care and forced some women and girls out of neighborhoods where they knew what health services were available. The government needs to identify targeted measures it can take to provide women and girls displaced by the quake with information necessary for accessing available care. This will require coordination with NGO and donor partners, both to establish what services are available and to disseminate accurate information regarding available services to women and girls.

Economic Accessibility

Vyola, a 27-year-old living in a camp in Delmas 33, told Human Rights Watch "[i]t was difficult to get to [prenatal] check-ups" because she had to go on foot. Vyola would have had to walk about three kilometers on a busy main thoroughfare and up steep hills to go to prenatal checkups. This became more challenging as her pregnancy progressed. Yet, Vyola was happy she received free care.

For many women and girls interviewed by Human Rights Watch, removing the cost of prenatal visits alone was not sufficient to make it economically accessible. Instead, they discontinued their prenatal visits because of financial barriers, including the cost of transportation to health care facilities and the costs associated with a prescribed sonogram. Their experience reaffirms that to be 'affordable' in practice, means ensuring that "[p]ayment for health-care services, as well as services related to the underlying determinants of health ...whether privately or publicly provided, are affordable for all, including socially disadvantaged groups"(emphasis added).

Transportation costs can render free prenatal care economically inaccessible in Haiti. Taxis and motorbike taxis ( motos), costing a few US dollars, were too expensive for most women and girls by Human Rights Watch interviewed to use for prenatal checkups. Most women and girls reported either walking long distances to prenatal visits, or taking semi-public transportation ( taptaps), which is usually cheaper than taxis. Some reported not having money to afford even taptaps; others complained that as their pregnancy progressed, it became more difficult to walk to the medical facility or to ride in the taptaps. Those women and girls we interviewed able to access prenatal appointments on foot raised concerns about how they would access care when they are in labor. Anita, a 27-year-old living near Champ de Mars explained:

I go by foot to the hospital. It is a three-hour walk to the hospital. I don't have money to pay for a car. When I am in labor, I hope someone will pay for me.

Travel costs are reimbursable under the Free Obstetric Care project (SOG), which Anita did not know. A February 2011 review of the previous three months of the SOG project found that less than 8 percent of SOG participants utilized this component of the program; only 0.3 percent received reimbursement through SOG for transportation to the university hospital for prenatal care. Evidence suggests women and girls may not know about this entitlement, as those women and girls interviewed by Human Rights Watch consistently said transportation was an obstacle to accessing care.

Many women and girls we interviewed also reported that the cost of sonograms was a significant barrier to continuing access to prenatal care. While high-risk pregnancies can be diagnosed and monitored without sonograms, they are useful in "diagnos[ing] fetal death at any age, assess[ing] fetal well-being, evaluat[ing] amniotic fluid volume, and diagnos[ing] a broad variety of fetal malformations."

Sonograms are not available in most public clinics or health facilities, and women and girls must go to a private laboratory or facility to have one. Moreover, the SOG program does not include sonograms as a free part of care.

Human Rights Watch found that the costs of sonograms created an obstacle to care not because they are a necessary pre-condition for maternal health, but because many women and girls we interviewed thought they could not return for follow up care without the results from a sonogram. Some women and girls interviewed sought prenatal care at multiple facilities to avoid seeing the doctor who originally prescribed the sonogram, resulting in further and more expensive travel.

Several pregnant women and girls reported to Human Rights Watch that they discontinued prenatal visits altogether because they could not afford sonograms. Myrlande, a 22-year-old living in Champ de Mars, became pregnant after three men sexually assaulted her. She began prenatal care but stopped. She said:

[The doctors at the general hospital] gave me an appointment and told me to come back with the results of the sonogram.... I don't remember the last time I went to the doctor.... I would have kept going if I had had the sonogram.

Some women and girls who discontinued care like Myrlande also reported periodically having severe pain associated with their pregnancy.

In a small number of cases considered by Human Rights Watch, the cost of sonograms even impacted a woman's decision to seek obstetric care. Several women and girls interviewed said they believed they could not return to the same facility to give birth if they were unable to pay for the sonogram. Adeline described how she discontinued checkups because she could not afford the sonogram, and when she went into labor, she went to a hospital much further away because she did not think she could do so at the same facility she had gone for checkups.

Yvonne, 30, from a camp in Croix-des-Bouquets, also thought she could not give birth at the same hospital that had asked her to have a sonogram. She was resigned to giving birth in the camp but had to seek emergency obstetric care at a health facility after having difficulties in labor.

I went to several different hospitals for check-ups before I gave birth [because] ... when they asked me to do a sonogram, and I didn't have money to do the sonogram, I changed hospitals.... No one told me that I would have a difficult birth ... [but] I had pain when I went into labor. I arrived at the hospital at 9, at 10 I had not given birth, and by 11 I had the C-section.

Another woman, Benita, was also unable to pay for a sonogram that was prescribed for her and discontinued prenatal visits. Her baby died shortly after she gave birth in her tent.

While the Haitian government has taken important steps to remove the economic barriers to prenatal care by providing free care, costs still remain that prevent women from seeking the potentially life-saving care they need. Human Rights Watch found that ancillary costs to prenatal care continue to make prenatal care economically inaccessible for the most vulnerable women and girls it interviewed, frustrating the government's efforts. This is a problem that may not be isolated to the displacement camps, but that many women and girls in Haiti may face. Women and girls who are unable to access free prenatal care provided by the state because they cannot pay ancillary costs do not have the same access to these services as those who can pay these additional costs.

Obstacles Accessing Obstetric Care

When Tamara, the 17-year-old who wishes she had access to family planning, went into labor, she gave birth in her tent without the help of trained medical personnel. The tent she shares with her family looks like an old canvas army tent with barely room for a cot. It is perched precariously on a slope and opens onto a narrow alleyway. Tamara wanted to go to the hospital, but when she went into labor, it was decided she would not have time to reach the hospital, so her mom helped her deliver the baby in the tent. Tamara mused, with little emotion "[i]t was really difficult to give birth in here."

Lack of Access to Information on When and Where to Access Obstetric Care

Many women and girls interviewed by Human Rights Watch said they wanted to give birth in hospitals, but did not have time to get to health facilities once they went into labor. Human Rights Watch found that often the lack of timing was related to not having information about the signs of early labor and where to go for care and how to do so. Others reported speaking to the doctor about signs of labor, but also appeared confused about the information provided.

Carlene, 28, who lives in a camp in Pétion-ville, was in labor for almost a day before going to the hospital to seek care:

I was in labor for a day. I was at home first, but I knew to go to the hospital when I felt my bellyache. The doctor talked to me about the signs of labor and to go to the hospital. The head of the child was outside of my vagina when I got to the hospital.

Had Founa, Carlene, or the other women and girls interviewed who did not recognize signs of labor, encountered an obstetric emergency, the delay in seeking care created by that lack of information may have cost them their lives.

For Vania, a woman living in a camp in Mais Gaté, this lack of information may have contributed to her child's death. Vania gave birth in October 2010 on the floor of her tent. She was alone in her tent when she went into labor. She did not know the date she was going to give birth, but she did know she had hypertension. By the time she recognized that she was in labor it was too late to go to a hospital. A friend from her church helped her give birth, but the baby died shortly after. Vania does not know why the baby died. She had no postnatal care and has not seen a doctor since she gave birth.

Human Rights Watch found that some women and girls we interviewed also lacked information about where to give birth. In post-earthquake Haiti, developing a birth plan, including where to go to give birth, is important. Eighty-one percent of medical facilities interviewed by the UN Population Fund in October 2010 provided prenatal care, but only 22 percent were equipped to provide obstetric services. Thus, the majority of women that have access to prenatal care at one facility must choose a different facility to give birth. Few women or girls we interviewed had discussed a birth plan with their doctor. Thus, when these women or girls went into labor or encountered difficulty with their delivery, some did not know where to go to receive free or emergency care.

Human Rights Watch found that lack of access to information is a primary factor in delaying some women and girls from seeking appropriate care and that the Haitian government should identify measures it can take within its available resources to address this lack of access to information. It should also work with NGO and donor partners to develop and fund programs to fill informational gaps the government lacks the capacity to address.

Obstacles to Accessing Available Obstetric Care

Before the earthquake, Claire had been assisted by skilled birth attendants when she went into labor with her first five children. But she was living in a camp in Delmas 33 when she went into labor with her sixth child, and gave birth alone in her tent. Claire told Human Rights Watch: "The tent causes trouble and diseases. I wouldn't give birth in the tent [if I didn't have to]." The earthquake displaced Claire to a new neighborhood she did not know well. She was uncomfortable leaving the camp on foot at night, and had no money for transportation.

No one helped me with this one. God gave birth to him, though, because there were no problems. God helped me, and I didn't have to leave the camp at night. [Otherwise,] I would have needed a car; I would have had to pay transportation.

Human Rights Watch found that women and girls like Claire encountered barriers to accessing available obstetric care, including emergency care, because of the cost and availability of transportation. In a small number of cases, women and girls also reported to Human Rights Watch that concerns about their safety delayed or prevented them from traveling to the hospital when they went into labor at night.

When 23-year-old Benita went into labor, she did not have money to get to a hospital. She gave birth in the camp she lived in near Mais Gaté: her baby died less than 24 hours later. Benita said:

The hospitals are free, but you have to pay for transportation, and I didn't have that.... It was difficult. I suffered much.... At four in the afternoon I went into labor, I gave birth at 7 p.m. The baby died the day after at two in the afternoon. He did everything right ... no problems ... but then he was dead. We didn't call an ambulance or go to the hospital. We went for a funeral instead. [Neither his birth or his death was registered]. It was difficult for me.

Mona's sister recently died in childbirth. Her sister lived somewhere outside of the camp in Delmas 33 where Mona, 36, lived and also recently gave birth. She did so in her tent, without any assistance. "I just gave birth on the ground," she said. "I had no drugs for pain during delivery. I saw a doctor three days later, and he gave me acetaminophen."

Five women interviewed by Human Rights Watch lost their babies within 24 hours of birth. Of these, none reported having access to postnatal care.

Human Rights Watch found that some women and girls interviewed did have access to traditional birth attendants to assist with delivery. Such attendants live in almost every camp Human Rights Watch visited, and provide elementary care for women and girls. However, access to unskilled birth attendants is insufficient in many cases where an obstetric emergency arises, and in most cases the attendants would be unable to save a woman or infant. Charging up to US$30, they are often prohibitively expensive for poor women and girls.

Jessie, from a camp in Croix-des-Bouquets, was alone in her tent with her two children when she went into labor. A traditional birth attendant came to assist. For months she has not been able to pay the fee and the birth attendant now visits her tent each day asking for her money.

The government of Haiti has an obligation to protect women's and girls' right to health, which requires it to take measures to prevent women from dying in childbirth in pregnancy, including providing regular and emergency obstetric care. Women and girls facing obstetric emergencies need to be able to reach care to prevent maternal morbidity or death. The government has an obligation to not only make health services economically accessible by providing free care, but should identify and implement measures that it can take to ensure it is economically feasible for the most vulnerable of women and girls to reach the free care.

Obstacles to Quality Care at Medical Facilities

While many facilities in the metropolitan area of Port-au-Prince provide free emergency obstetric care, Human Rights Watch interviewed several women and girls who were unaware of this and who went to non-SOG participating hospitals for emergency obstetric care. They encountered difficulties getting treatment because they could not pay for it.

Yvette was not so fortunate. She had attended prenatal visits as instructed, but the facility did not provide obstetric care, so she had to go to another hospital to give birth. When she went into labor in the evening in a camp near the airport, she did not have money for a taxi, and started walking to a hospital about eight kilometers away, until a friend with a car picked her up. She arrived at the private hospital, but the guard would not let her in. When Yvette was finally admitted, a doctor examined her and could not find the baby's heartbeat; he believed the baby was dead and told her she would need a C-section. She could not pay for the operation, and was asked to leave the hospital. Still in labor, she left the hospital and delivered on the street corner:

It was midnight until 2 a.m., and the baby was born then ... for two hours we were on the corner and I was by myself. I was very afraid, terrified.... [At 2 a.m.] the doctor from [the hospital] cut the umbilical cord for me for US$50. When they cut the umbilical cord, I didn't have any money to pay.... So he took the car of the friend that brought me to the hospital [until I could pay him back].

The baby was born alive and healthy.

I gave birth in Chancerelles, on the ground. I don't have faith in the midwife (traditional birth assistant) and ... so I went to the hospital. All the beds were full so I didn't have any place [to lie down to give birth]. The doctor only cut the umbilical cord and cut the placenta. My husband was there but he didn't see when I gave birth to the baby; they made him sit outside. They didn't put anything on the ground for me. At 10 a.m. I went into labor; I got to the hospital at 1 p.m. I gave birth to the baby at 4:50 p.m..... They sent me home by 10 p.m..... No doctor, nurse, or midwife was there to help with the birth. They only came after to cut the cord.

Martine had an infection after the birth that required treatment, which she sought elsewhere.

Impact of Food Insecurity on Reproductive and Maternal Health

Food insecurity in the displacement camps may have an impact on the health of pregnant women and lactating mothers. Human Rights Watch found that food insecurity led some vulnerable women and girls we interviewed to engage in informal transactional sex, compounding the health impact of the lack of access to family planning in camps, and contributing to unintended and unwanted pregnancies.

Food Insecurity for Pregnant and Lactating Mothers

Many pregnant women and girls and lactating mothers told Human Rights Watch that food insecurity was a prime concern. As an underlying determinant of health, pregnant women and lactating mothers have a right to adequate nutrition during pregnancy and lactation.

Prior to the earthquake, many women and girls in Haiti struggled to meet their basic needs and those of their children: 23.8 percent of the population was chronically malnourished and 9.1 percent acutely malnourished. People fared better in Port-au-Prince, where the number of malnourished people was half that in rural areas.

For pregnant women and lactating mothers, not having access to food can impact their health. USAID found that hunger and malnutrition were one of the principal maternal and child health issues facing Haiti. Poor nutrition is reflected in the 4 percent of babies born with low birth weight. Moreover, according to USAID, the underlying cause of Haiti's high maternal and neonatal mortality in Haiti is chronic malnutrition.

For women and girls like Tamara and Adeline, adequate nutrition is an important determinant of maternal and infant health. The government has few resources to immediately address the immense gaps in fulfilling the right to food in Haiti. However, it should ensure that food assistance programs are designed, to the fullest extent that resources allow, to address women's and girls' right to health, including maternal health.

Food Insecurity and Increased Vulnerability to Unintended and Unwanted Pregnancy

Human Rights Watch found that food insecurity exacerbated the impact of the lack of access to family planning. Human Rights Watch found evidence that a high number of women and girls we interviewed either formed relationships with men for economic security or engaged in transactional or survival sex without adequate access to methods of contraception that would protect them from unwanted pregnancy.

Margalie, a member of a camp committee in Croix-des-Bouquets, confirmed such relationships exist in her camp:

150 babies have been born in this camp. 83 women are pregnant, some of them are girls, because their parents don't take care of them so they look for a man to survive ... but the men don't actually take care of them. As soon as they hear the girl is pregnant, they just leave her.

A member of a women's committee in a camp in Mais Gaté noted that unaccompanied adolescent girls in the camp faced unique difficulties:

After the earthquake, all the young girls have adult men under their tent, and now they are pregnant and some give birth under the tent-14, 15, 16 years-old, they are obligated to do this. They don't have parents to take care of them, so if a man can help her, she'll make love and live under his tent.... It's not easy when you are hungry.

The problem is not limited to adolescent girls. Adult women, already mothers, also reported engaging in risky behavior to feed themselves or their children, including trading sex for money. Gheslaine said:

People will try to survive by the way they can. Women have relationships with men so they can feed their children. That happens a lot. My daughter is 12 and does not have friends in the camps, because it happens that even girls are pressured to have sex for things. I don't work. I don't have parents to help. Many times women get pregnant, and they don't have anyone to take care of them. So, for US$0.60 or $1.25, you have sex just for that. Unfortunately, women sometimes get pregnant, but if we had access to planning, we'd protect ourselves.... It's not good to make prostitution, but what can you do? You have to eat.

Women and girls repeatedly told Human Rights Watch that their partner had left them when they heard they were pregnant, and that they were subsequently left with no access to work or food. Some relied on the informal exchange of sex for food or money, with men who were not their partners, and subsequently became pregnant. In the commercial sex industry in Haiti, men pay higher prices for sex without condoms. In the informal exchanges of sex for food or money occurring in the camps, women lack the ability to negotiate condom use.

Women and girls who engage in these informal transactions are often desperate and have exhausted other sources of help:

People tell me that I have to stop asking for help, so now I give sex for money, but some of them don't give me money after sex. I have been doing this since I've had the baby. I don't do it very often, but whenever I'm hungry, or for example if I don't have soap to do laundry, I'll do it. When I do, I go far away. For example, when I see an old man I ask him for money, but he usually says "you are too young, too beautiful, but if you have sex, I'll give money...." I do it secretly.

Secretly engaging in this behavior exposes women and girls to increased risks of violence, because they lose what little protection may be available to them from social networks or the community.

Regardless of whether women and girls who exchange sex for food or money are at greater risk for sexual violence, they are at risk of involuntary or unintended pregnancy and sexually transmitted infections, and all the associated health risks. Haiti's government should take measures to design specific interventions that it can take to improve access to services for vulnerable women and girls engaged in informal transactional sex.

Vulnerability to Gender-Based Violence

Human Rights Watch found that women's and girls' vulnerability to violence due to low social status, limited protections in the law, and lack of education and livelihood has been compounded by the destruction of their homes, social and familial networks, basic infrastructure, and by limited access to food or livelihood. Some women and girls have lost their small commerce, which gave them financial independence and security. They have lost the security afforded by familial and community relationships, and from having a house with walls and doors that lock. There is no electricity or consistent lighting at night, and some have lost husbands or other family breadwinners. They have no means to feed themselves or their children or to send their children to school.

There is currently no systematic case management or data collection specific to gender-based violence since the earthquake, although the gender-based violence subcluster and the women's ministry are working towards this. In the absence of such data, NGOs and some UN agencies have attempted to provide a better picture of the rates of sexual violence through small-scale studies or reporting the number of women who have sought treatment at their facilities.

Data from these groups also show that gender-based violence impacts women's and girls' reproductive health. SOFA reported that of the 114 sexual assaults it treated from January to June 2010, 6.36 percent resulted in pregnancy. The grassroots group, Centre d'Appui pour les Femmes Victimes d'Abus Sexuels (CAFVAS), reported that of the 45 rapes it recorded from February to March 2010, 9-a full 20 percent-resulted in pregnancy.

Six of the women and girls whom Human Rights Watch interviewed were pregnant because of rape that occurred after the earthquake. Three of these were adolescent girls, aged between 14 and 15. This suggests that women and girls do not have access to the reproductive and sexual health services they need after they have been victims of sexual violence, namely access to emergency contraceptive and prophylaxis for STIs, including HIV. Some women's groups told Human Rights Watch that emergency contraception and other post-rape care were sometimes unavailable at medical facilities designated as referral facilities for victims of sexual violence. Human Rights Watch found in its interviews that women and girls failed to access timely post-rape care because they did not know what to do or where to go for treatment, or they were ashamed to report the rape.

Prior to the earthquake, a study found that 26 percent of women who experienced sexual violence in Haiti reported that they had sought assistance from their own relatives. According to the study, victims identified mothers as the single most important source of help, followed by friends and neighbors. In contrast, only two percent of survivors of sexual violence reported seeking assistance from the police, a lawyer, or a doctor. The earthquake destroyed the social network of many women and girls, including family connections, neighbors, schools, churches, and local clinics, disrupting the ability of women and girls to seek assistance after experiencing sexual violence.

Women and girls interviewed reported that they were reluctant to seek timely medical care after a rape because they were shy or ashamed. Mary Loudy, 15, waited eight days before telling an adolescent cousin about a sexual assault.

After eight days, I talked to my cousin about it because she had been raped also after the earthquake. She advised me to go to GHESKIO (the acronym for the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections) Center. I had an infection. Before I talked to her about my rape, I was really shy but I told myself that she was raped so I can talk to her about my situation.

The delay meant she did not receive timely medical care and faced an unwanted pregnancy. Mary Loudy's cousin is 17 and remains in the same camp where she suffered the rape.

Naomi, 25, had a relationship with a man who raped her. After the rape, he gave her payment. Naomi went to the hospital and the police, but became pregnant. After she gave birth, the man who raped her wanted to take the baby away from her. She refused and the man came to her tent one night with his several of his friends. Each of the men raped Naomi. After that, she was too ashamed to seek post-rape care.

I went to the hospital and police after the first rape, but not after the second one because.... I feel ashamed to repeat rape. I have been to the hospital since because I had appointment for planning. I didn't tell them I had been raped, because I was ashamed.

When Naomi attended an appointment for family planning after she had been raped, the attending medical professional did not recognize that she might have been a victim of violence. She sought no care for her second rape.

Human Rights Watch found that women and girls it interviewed with pregnancies caused by rape face the same difficulties accessing maternal care as other women interviewed, with similar impacts on these women's health or the health of their children. Florence is barely 15-years-old, is 5 months pregnant, and has no parents. She lived with a family and did domestic chores for them. After the earthquake, she and the family moved to a camp in Mais Gaté. Her employer raped her, then threatened her and told her not to tell anyone. She became pregnant, and someone in the camp took her to one prenatal appointment. Florence discontinued prenatal care because she could not afford ancillary tests.

I went one time to the doctor who gave me a prescription. I don't have money to get the blood test and stool sample. The doctor said to come back, but he advised me to come back with the test results.... I don't have a mother or father, I live with an "aunt," but she doesn't take care of me now. Now I live in the camp with someone else, since I was raped.

Florence is a high-risk pregnancy because of her age and small size, and she has no access to care.

Human Rights Watch does not have evidence to draw a direct connection between rape and poor maternal and infant health. However, the acute vulnerability of women and girls who become pregnant as a result of rape means that even those with access to health care appear to face grim prospects in pregnancy and child birth. One woman had a stillbirth.

Another, Mary Loudy, lost her baby within 24 hours of delivery-and she had better access to care than other women and girls Human Rights Watch interviewed: prenatal care, and a free sonogram that a private technician offered her because of her situation. When Mary Loudy went into labor, she went to an NGO clinic where it was determined she needed emergency obstetric care. It transported her free of cost to the general hospital, then to Chancerelles, where she received the care she needed for free. She gave birth and was sent home with the baby, who appeared fine but died shortly after she returned to the camp.

This does not change in a post-disaster setting, as the Minimal Initial Service Package for Reproductive Health in Crisis Situation makes clear that the state is required to prevent and respond to sexual violence in post-disaster settings.

Lack of Accountability in Addressing Women's and Girls' Health and Security in Displacement Camps

We have no information. Nothing. I would like to know what will happen to us.

-Vyola, resident of a camp in Delmas 33, November 11, 2010

We are ready to move on, but we don't know how they [the government and NGOs] will get us into this process.

-Claudine, resident of a camp in Cite Soleil, January 31, 2011

Many NGOs, donors, and experts on maternal health have sought to address the needs of women and girls in post-earthquake Haiti. Most notably, Human Rights Watch found that the Free Obstetric Care project (SOG) allowed many women and girls access to care they previously could not afford. Yet for many women and girls Human Rights Watch interviewed access to reproductive and maternal care is a matter of luck: for example, whether or not they fall within the catchment area of a public facility participating in SOG, or a successful NGO; and whether they even learn of the services available.

The lack of information among women and girls interviewed by Human Rights Watch in the displacement camps pervaded all aspects of their lives and impacted the realization of a wide range of rights. Women and girls reported to Human Rights Watch that they generally had no information about what medical services were available nearby, or for what price. They also knew nothing of the specific health plans for the camps where they lived, or for the country as a whole. Moreover, Human Rights Watch found many women and girls we interviewed lacked access to basic information necessary to seek accountability, including which NGOs operated in the camps where they lived, what services they provided, and who to speak to if there was a problem. They also lacked the information necessary to report or seek redress for problems related to maternal or reproductive health services.

The government, which should be exercising oversight in the provision of maternal health care, does not have current and comprehensive maternal health data for women and girls living in camps who do not reach one of its facilities for care. Nor does it have data on women and girls who discontinue care. Without that information, it is not possible to identify and implement measures to develop redress mechanisms for mistakes or grievances, to correct systemic failures, or to replicate effective programs.

Human Rights Watch found that important information that is necessary for the Haitian government to monitor progress related to maternal health is not recorded in camps: for example, none of the five infant deaths recounted by women and girls interviewed by Human Rights Watch were reported or registered with any NGO or government body. Camp residents told Human Rights Watch that deaths in the camp, regardless of cause, generally went unregistered. Thus, if women and girls die of maternal-related deaths in the camps, they would not be recorded. This basic data on maternal and infant deaths is fundamental to determining whether the government is making progress on its obligations related to the right to health.

The lack of accountability mechanisms, either through grievance systems or other avenues for providing feedback to actors operating in the camps, impacts other rights as well. For example, United Nations Stabilization Mission in Haiti (MINUSTAH), UNPOL, and Haitian National Police (HNP) began regular patrols of certain camps at high-risk for gender-based violence. Women and girls interviewed by Human Rights Watch in some of these camps reported a degree of improvement in the security situation and were grateful for the patrols; others said the patrols had become too predictable. "[Thugs] know the hours of patrols," said Ani. These women and girls did not know how to report this concern.

NGOs and UN agencies also installed lights to prevent gender-based violence in the camps. A resident in one camp reported that despite initial gains made after the lights appeared, the NGO that supplied them soon ran out of funding to purchase the fuel needed to power them. Three rapes occurred in the first four weeks after lighting in the camp was no longer available. Yet women's groups in the camp knew of no avenue for seeking redress or assistance for this loss of security.

Human Rights Watch found that for many women and girls we interviewed lack of access to information is a considerable barrier to the enjoyment of their maternal health rights. Better coordination and linking of sources of information would give the government of Haiti tools to ensure women and girls have current and reliable information related to their rights. Human Rights Watch also found that data was lacking that would allow for monitoring the implementation of rights.

Statistical systems would allow for the monitoring of progress towards the realization of certain rights, including progress related to maternal health. Moreover, planning, monitoring, and country-led evaluations would provide data necessary for the government to correct systemic failures and replicate programs that work, in line with the human rights principle of accountability.

The Haitian government is the primary guarantor of human rights in Haiti. Even in the aftermath of a disaster and facing the limitations on resources that it does, it must take steps to respect and protect the core minimum content of the rights of women and girls. However, to demand that the government alone address the obstacles to the fulfillment of these rights would be to ignore the political and economic realities that the country faces.

A rights-based approach draws upon the principles and legal framework of human rights, and requires that respect for the human rights of those affected by any aid or development activity is central to planning and operationalizing that activity. It recognizes beneficiaries of aid as rights-holders with legal entitlements and identifies governments and their partners as duty-bearers with correlating obligations to meet those entitlements. A rights-based approach requires particular attention to the needs of vulnerable groups, the impact of programs on their rights, and the establishment of procedures to ensure accountability and participation in an organization's operations. It also requires that human rights standards guide all stages of programming.

Human Rights Watch researched whether certain human rights standards related to women's and girls' right to health were met in the camps. While the Haitian government has the correlative obligation related to the rights at issue, it relies on support from the donor community to fulfill its obligations.

The government of Haiti developed a post-disaster needs assessment (referred to as the PDNA) and national plan for recovery to address the needs of the population after the earthquake, including women's and girls' health and security. The national plan for recovery "[concentrates] on the improvement in access to and quality of primary healthcare, with an emphasis on high-impact, low-cost actions targeting maternal and infant health..."

Some NGOs already engage in monitoring and evaluation of the impact of their work. PSI (Population Services International), for example, focuses on the measurable outcomes of its family planning education work and shares this information with the ministry of health and with the reproductive health subcluster. "The value of our approach is that we know if we succeed, if things get better," says Dr. Mardel Sherley David, director of family planning at PSI. The SOG project has also conducted considerable evaluation of patient satisfaction in participating facilities. Not all NGOs or donor-funded projects, however, are equipped for the rigorous monitoring and evaluation of their work. And, the sharing of data and reporting that is done in Haiti is sometimes limited. "I wasn't prepared for how difficult it would be to get information. No one is sharing data. No one is evaluating their impact and then changing what they do. If they are, I don't see the reporting, the results," one United Nations agency staff member working to coordinate health efforts told Human Rights Watch.

There are various reasons why some NGOs are not sharing data with the government or each other. Some NGOs with better performance indicators do not want their data to be aggregated and reported alongside data from less efficient or effective operations, as this may hide others' poor performance and skew the overall picture. For example, one NGO representative self-identifying as one of the more effective groups told Human Rights Watch it was reluctant to share certain types of data. "The fact that we mobilized quickly in recovery efforts should not be seen as a reflection of successful donor-led recovery, but of our own efficiency." By contrast, some NGOs undoubtedly do not want to advertise their ineffectiveness or inefficiencies. Also, the government has not created easy and centralized avenues for reporting, making it confusing and time-consuming for NGOs to comply with all reporting requirements, guidelines, and requests. The government is working to create a better streamlined mechanism for such reporting, and initial feedback from NGOs is that they would more readily comply with reporting guidelines if this occurred.

Whatever the reason, the paucity of data transmitted to the government makes it difficult for the state and human rights monitors to assess progress on the implementation of the health plan and its impact on the realization of rights. It is even more difficult to know who to blame when progress stalls.

The Haitian government does not have the capacity to go into the field to see if NGOs provide the services they claim to, if there are gaps in services, or if NGOs are duplicating their work. The government does not know if there is an impact on the fulfillment of rights from all of the aid. In other words, there is no accountability regarding outcomes. Without donors and NGOs, Haiti would, according to one government official, be "in big trouble," but there needs to be "stronger government engagement ... [with] a structure and regulations to ensure that the proper things are done in the appropriate ways."

The declaration recognizes the "shared interest" of donors and partners "in being able to monitor progress." To this end, recipient countries and donors should "establish mutually agreed frameworks that provide reliable assessments of performance, transparency and accountability of country systems." In keeping with the principle of mutual accountability, donors have also undertaken to "provide timely, transparent and comprehensive information on aid flows."

In the Accra Agenda for Action, donor states and institutions reiterated a commitment to accountability, but agreed to be held accountable before their "respective parliaments and governing bodies for these outcomes." Recognizing that "greater transparency and accountability for the use of development resources-domestic as well as external-are powerful drivers of progress," they committed to taking several measures to further such transparency and accountability. These include the commitment of developing countries and donors to "assess the impact of development policies and adjust them as necessary," through better coordination and linking of sources of information, statistical systems, planning, monitoring, and country-led evaluations of performance. To this end, donors committed to supporting and investing in the statistical capacity and information systems of developing countries.

Donors and the government of Haiti should commit to all components of mutual accountability related to recovery and reconstruction aid. Such accountability should provide the government with tools to be accountable to its citizens and rights-holders, including data that would allow for monitoring progress towards the realization of its reconstruction goals and the rights of its citizens. It would allow the government to ensure that individuals have current and reliable information related to their rights. Weak accountability between the government and donors (and donor-funded NGOs) may lead to weak accountability for rights-holders.

Yet 18 months after the earthquake, the Haitian government and the UN have failed to produce data on the scale of the problem, without which it is difficult to assess if and where the authorities are succeeding and failing in their obligations. Further, the UN's sub-cluster on gender-based violence has not issued standard operating procedures for service providers identifying and treating survivors of sexual violence.

Investing in women is the best investment we can make in any country. And investing in the Haitian women will fuel the long-term economic recovery and progress, not only for them, but for their families.

-Hillary Clinton, Haiti Donor's conference, UN, New York, March 31, 2010

Many women and girls in Haiti lost husbands or partners, children, and parents in the earthquake. They lost their homes. Those engaged in the informal economy, lost their means to a livelihood. Many can no longer send their children to school, or consistently ensure an adequate supply of food for their families. In some camps, up to a hundred people share a single latrine. Some still share chemical latrines, port-o-potties, installed over 18 months ago. The free provision of water is transitioning to a pay-per-use model. And the threat of cholera still exists. While the number of people living in the displaced settlements has reduced from its peak after the earthquake, women or adolescent girls continue to head the majority of households in the camps.

Children in the camps are sick from the heat of the tents and the lack of nutritious food. Some women and girls cannot even realize the basic right to choose when to have children. They cannot be sure they will give birth in a safe facility, attended by someone trained in obstetric health.

Haitian women and girls are not just victims of violence, discrimination, or circumstance. They are an integral part of the Haitian economy and society. Yet many women and girls interviewed by Human Rights Watch felt that their concerns have been excluded from Haiti's rebuilding process. Investing in the women and girls of Haiti requires more than words or vast donor pledges: it requires a fundamental shift in how the state and international community approach women and girls, especially those displaced by the earthquake.

The UN independent expert on human rights in Haiti suggests that a rights-based approach be extended to the reconstruction process, as overseen by the interim Haiti Recovery Commission. Such an approach, he argues, would allow for:

a greater focus on the most vulnerable groups, such as women, children and persons with disabilities; the systematic involvement of civil society organizations, in particular those representing women, peasants and vulnerable groups, in the reconstruction effort; the inclusion of gender-specific analyses of and concrete gender-equality targets in reconstruction plans and budgets; and the introduction of measures to ensure that labour-intensive reconstruction programmes are not concentrated solely in the economic sectors traditionally occupied by men.

Such a fundamental shift would allow for reconstruction aimed at realizing human rights denied to most of Haiti's women and girls long before the earthquake hit.

Design programs to increase women's and girls' access to information on maternal and reproductive care, availability of post-rape care, availability of medical services, and general information about the reconstruction effort.

Identify and implement measures that can be put in place to ensure adequate oversight, monitoring, and reporting of programs to allow accountability between rights-holders and the state, as well as between the state and donors. This is essential to assess whether responses on the ground are effectively meeting human rights obligations and if not, what remedial action should be taken to fulfill those obligations.

Create opportunities for political participation of women and girls, particularly those from vulnerable groups, including those living in camps and women with disabilities.

Strengthen and support the Ministry of Women to fulfill its mandate to eliminate all forms of violence against women and to make the constitutional and legislative reforms to ensure the equality of men and women before the law.

Sign and Ratify the International Covenant on Economic, Social and Cultural Rights, and the Additional Protocol of the American Declaration on the Rights and Duties of Man on Economic, Social and Cultural Rights (Protocol of San Salvador), which further protect women's and girls' right to health.

Introduce necessary legislative measures that will lead to greater gender equality, particularly those proposed by the Concertation Nationale, including a Family Code for Haiti, a specific law on prevention of domestic violence and intimate partner rape, and assigning legal rights to certain forms of informal unions between men and women, and those currently under review by the Women's Ministry and its partners.

Implement a gender policy consistent with the recommendation above.

Establish a clear bill of rights for reproductive and maternal health patients to be posted in every health facility and orally communicated to every female patient participating in the Free Obstetric Care project (SOG). The bill of rights should include:

A description of all services covered under the program;

An explanation of how reimbursements of the costs of transportation or traditional birth attendants are made;

The right of the patient to continue to receive care under the SOG program, even if she is unable to pay for ancillary services not covered by the program, such as a sonogram or blood test.

Provide guidelines for medical professionals to explain to patients why these ancillary care services are not covered by the SOG program and why such tests and medicine are nonetheless medically recommended, and to explain that patients may continue to attend prenatal checkups, even if they are unable to pay for the ancillary care.

Develop procedures and checklists for medical professionals in both public and private facilities to discuss birthing plans with women and girls. The procedures should include discussing: how to recognize signs of early labor, and when to go to the hospital or clinic to give birth; where a women or girl plans to give birth and how she will get there; and how to recognize signs of an obstetric emergency, and where to go in case an emergency arises.

Train medical professions in state-run and private health facilities on how to recognize signs of gender-based violence in patients, and ensure all staff in such facilities know how to respond to victims of gender-based violence, including which services they should be referred to.

Design a program for strengthening traditional maternal health expertise that already exists at the camp and community levels and work with NGOs and UN agencies to execute a training program. Include in the training how to recognize signs of gender-based violence, and referral pathways for seeking post-rape care.

Develop a model for community outreach on family planning, maternal health services and gender-based violence, building on the successful outreach programs implemented in the urban areas to educate the population about cholera prevention.

Ensure all state-run and private health facilities are stocked with post-rape care kits, including emergency contraceptive and anti-retrovirals.

Begin developing accountability mechanisms for reporting and investigating maternal deaths in state-run health facilities.

Raise awareness through information campaigns about the availability of free maternal and reproductive health services in state run health facilities, including emergency contraception.

Refresh medical professionals on all methods of family planning, including surgical methods.

Implement a robust medical school curriculum that recognizes women and girls right to health and includes training on all methods of family planning, including training on surgical methods of contraception, on how to communicate effectively with women and girl patients, how to recognize signs of gender-based violence, and referral pathways for victims of gender-based violence.

Identify and implement measures that can be put in place to ensure adequate oversight, monitoring, and reporting of programs to allow accountability between rights-holders and the state, as well as between the state and donors. This is essential to assess whether responses on the ground are effectively meeting human rights obligations and if not, what remedial action should be taken to fulfill those obligations

Develop and communicate a gender policy consistent across the organization or agency. The policy should require:

A focus on the rights of women and girls, including their rights to reproductive and maternal health;

All data be disaggregated by gender;

Disaggregated data should be shared with relevant actors, including government entities;

Inclusion of gender-specific analysis in program and policy design, implementation, and monitoring;

Establishment of concrete gender-specific benchmarks and indicators;

Clear avenues for women's and girls' participation.

Identify traditional birth attendants, nurse auxiliaries, or others trained in basic first aid living in camps. Provide training to them to increase their capacity and knowledge. Communicate clear referral pathways for obstetric emergencies and ensure they have the means to access these pathways, including by providing cellular phones and emergency telephone numbers. Supply traditional birth attendants with clean birthing kits. Educate traditional birth attendants to contact agencies or NGOs should an infant or maternal mortality occur in the camp.

Provide timely reporting to the ministry of health on the number of prenatal visits, institutional births, and maternal and infant deaths in NGO-managed facilities.

Camp managers should provide the ministry of health with timely and accurate reports of maternal and infant deaths in camps.

Coordinate with the Ministry of Health to prioritize reproductive and maternal health services.

Work with the Ministry of Health and the Free Obstetric Care project (SOG) to establish Maternal Mortality Surveillance Committees in earthquake-affected areas to connect communities to health institutions, following the successful model of Port-Salut and Aquin but adapted for the urban area of Port-au-Prince.

Develop and communicate a gender policy consistent across the commission and proposing organizations. The policy should require:

A focus on the rights of women and girls, including their rights to reproductive and maternal health;

All data be disaggregated by gender;

Disaggregated data should be shared with relevant actors, including government entities;

Inclusion of gender-specific analysis in program and policy design, implementation, and monitoring;

Establishment of concrete gender-specific benchmarks and indicators;

Clear avenues for women's and girls' participation.

Encourage proposals that invest in women's and girls' health and security.

Require that all proposals to the commission include gender-specific analysis in program and policy design, implementation, and monitoring, and have concrete gender-specific benchmarks and indicators. Data provided to the commission should be disaggregated by gender.

Require that projects that the commission approves follow rights-based principles, including the indivisibility and interdependence of all human rights, non-discrimination and attention to vulnerable groups, accountability, and participation.

Increase women's participation on the commission, including by increasing the number of Haitian women representatives.

Fund projects in line with the Ministry of Health's priorities for maternal and reproductive care.

Develop and communicate a gender policy consistent across the agency. The policy should require:

A focus on the rights of women and girls, including their rights to reproductive and maternal health;

All data be disaggregated by gender;

Disaggregated data should be shared with relevant actors, including government entities;

Inclusion of gender-specific analysis in program and policy design, implementation, and monitoring;

Establishment of concrete gender-specific benchmarks and indicators;

Clear avenues for women's and girls' participation.

Require implementing partners to include gender-specific analysis in bids, program and policy design, implementation, and monitoring and have concrete gender-specific benchmarks and indicators.

Avoid disruptions in aid money that could cause discontinuity in health care services and have an impact on women's health.

Disburse pledged funding.

Collaborate with the Ministry of Health to develop an electronic mapping of the health sector to identify geographical or other gaps in medical services.

Ensure adequate oversight, monitoring, and reporting of programs to allow accountability between donors (and implementing NGOs) and the government of Haiti.

Ensure implementing partners adopt a rights-based approach, including providing opportunities for beneficiaries to participate in project planning or seek redress for violations of their rights.

Ensure proper follow-up when cases of gender-based violence are identified.

Ensure victims of gender-based violence understand what medical services are available to them and have access to these services.

Seek feedback from camp representatives, particularly women and girls, living in patrolled camps on the efficacy of patrols and identify ways to improve security for women and girls in the camps.

Continue to follow the Department of Peacekeeping Operations Guidelines for Integrating a Gender Perspective into the Work of United Nations Military in Peacekeeping Operations and monitor implementation across all forces in the mission.

The special rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health should visit Haiti to assess the impact of the earthquake and recovery on the right to health and health-systems.

The special rapporteur on violence against women, its causes and consequences, should make a follow up to her June 1999 country visit.

The independent expert on the situation of human rights in Haiti should continue his significant efforts to date to encourage the Interim Haiti Reconstruction Commission and humanitarian actors to adopt a rights-based approach to recovery and reconstruction. He should continue to monitor the adoption of a rights-based approach by these actors.

This report was written and researched by Amanda M. Klasing, fellow in the Women's Rights Division, based on research she conducted with Meghan Rhoad, researcher with the Women's Rights Division. The report was reviewed by Liesl Gerntholtz, director of the Women's Rights Division, Joe Amon, director of the Health and Human Rights Division, Lois Whitman, director of the Children's Rights Division, Daniel Wilkinson, deputy director of the Americas Division, Tom Porteous, Deputy Program Director, Danielle Haas, senior program editor, and Aisling Reidy, senior legal counsel.

Daniela Ramirez and Rumbidzai Chidoori, coordinator and associate in the Women's Rights Division, provided production assistance. Additional production assistance was provided by Grace Choi, publications director; Anna Lopriore, creative manager; and Fitzroy Hepkins, mail manager. The report was translated into French by Françoise Denayer and Danielle Serres.

We are grateful to the women and girls who agreed to share their stories with us and we admire their courage and resilience.

We are grateful to the many women's rights organizations, medical service providers, and human rights organizations throughout the country that supported this research and analysis. Human Rights Watch takes full responsibility for any errors and omissions in the report.

The Women's Rights Division of Human Rights Watch gratefully acknowledges the financial support of Arcadia, the Moriah Fund, the Trellis Fund, Donna and Gary Slaight, and other supporters.

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"Nobody Remembers Us" | Failure to Protect Women's and Girls' Right to Health and Security in Post-Earthquake Haiti

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This documents the lack of access to reproductive and maternal care in post-earthquake Haiti, even with unprecedented availability of free healthcare services. The report also describes how hunger has led women to trade sex for food and how poor camp conditions exacerbate the impact of sexual violence because of difficulties accessing post-rape care.

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People of Haitian decent being forced out of the Dominican 

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People of Haitian decent being forced out of the Dominican 

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- Freedom to move (13)
- Safe place to live (14)
- Don't discriminate (2)

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(Santo Domingo) - Tens of thousands of Dominicans of Haitian descent remain in legal limbo, unable to exercise their basic rights, Human Rights Watch said in a report released today. The situation remains unresolved despite government efforts to remedy it.

The 43-page report, " We are Dominican: Arbitrary Deprivation of Nationality in the Dominican Republic," documents hundreds of cases from 13 provinces around the country. Human Rights Watch found that Dominicans of Haitian descent are still unable to access basic civic functions such as registering children at birth, enrolling in school and college, participating in the formal economy, or travelling around the country without risk of expulsion.

"The Dominican Republic is denying tens of thousands of citizens their right to a nationality, and despite mixed messages, people are being detained and shoved over the border," said José Miguel Vivanco, Americas director at Human Rights Watch. "The government needs to immediately stop expelling Dominicans of Haitian descent, and guarantee them their rights."

Human Rights Watch conducted research in the Dominican Republic between February and May of 2015, interviewing over 100 victims, community leaders, legal experts, government officials, and representatives of local human rights organizations. Human Rights Watch documented over 60 cases in which Dominicans of Haitian descent were arbitrarily detained, and in some instances forcibly removed to Haiti, despite having proper Dominican documentation. Human Rights Watch also verified hundreds of cases in which Dominicans of Haitian descent are still unable to exercise full rights as Dominican citizens.

The Dominican Republic is denying tens of thousands of citizens their right to a nationality, and despite mixed messages, people are being detained and shoved over the border. The government needs to immediately stop expelling Dominicans of Haitian descent, and guarantee them their rights.

In 2013, the Dominican Constitutional Tribunal, the country's highest court of appeals on constitutional matters, summarily removed citizenship from tens of thousands of Dominicans, based on a retroactive reinterpretation of the country's nationality law. It ruled that although the Constitution provides that Dominican citizenship is a birthright to anyone born in the Dominican Republic between 1929 and 2010, those born to parents who were in the Dominican Republic as undocumented migrants at the time of their birth were not covered by this constitutional protection, and were, retrospectively, not citizens. This decision violated international human rights law and made thousands of people vulnerable to expulsion.

In 2014, President Danilo Medina's administration attempted to mitigate the high court ruling with a "Naturalization Law" aimed at remedying the situation. However, the law has been fraught with design and implementation flaws that have thwarted the re-nationalization process.

In the case of Dominicans of Haitian descent whose citizenship was already a matter of record with the government, Human Rights Watch found that government agencies responsible for civil registries have refused to restore original nationality documents. Instead, officials have begun segregating those affected by the 2013 decision into completely new civil registries. This so-called transcription process is unnecessary, takes a huge amount of extra work for government authorities, and as a result is causing delays that keep thousands of people from being able to exercise their full citizenship rights.

Moreover, military and immigration authorities have repeatedly profiled Dominicans of Haitian descent, detaining and forcibly expelling them, even when they possess valid Dominican documentation.

In the case of Dominicans who had not yet been able to register with the government, Human Rights Watch found that Dominicans, mostly children, are being forced to register as "foreigners" in order to be naturalized as Dominican citizens, violating their rights. Onerous documentation requirements summarily excluded many from registration, especially given the brief 180-day implementation window.

This process appears to have disproportionately affected children whose mothers lack identity papers and could not obtain documentation before the February cutoff. Additionally, military and immigration authorities have harassed, detained, and expelled people trying to register.

To further complicate implementation of the Naturalization Law, since 2014, the government also has been carrying out a "regularization" plan for undocumented Haitian migrants who went to the Dominican Republic from Haiti for work. The Dominican government has offered migrants an opportunity to obtain temporary workers permits. While the effort is laudable, this process has also been rife with design and implementation failures.

The Dominican government should immediately restore the full nationality of all those affected by the 2013 decision, and ensure they are protected from expulsion to Haiti. The government should develop deportation procedures consistent with international standards, which examine and adjudicate on the individual case for each person who may lawfully be deported, and preserve family unity.

"In the past year, the administration of President Medina has taken some steps to address the situation of tens of thousands of Dominicans of Haitian descent," Vivanco said. "While the government's naturalization efforts have been positive, it needs to call a halt to wholesale expulsions and threats while it fixes the process."

Selected Cases
On February 19, Wilson, 25, was detained near the town of Mao. Officers refused to let him go to his house nearby to get his Dominican birth certificate. They forced him onto a truck, took him the border town of Dajabón, and ordered him and 32 other detainees to walk across the border into the town of Ouanaminthe, Haiti.

He had never been in Haiti, and had no money, no means of communication, and no identification with him. Wilson's employers got his birth certificate and met him at the office of the General Directorate of Migration office at the border in Dajabón. The immigration official in charge claimed that despite a valid birth certificate, Wilson was Haitian and refused to give him a letter granting passage back to his home in the Valverde province. Wilson was able to get home through multiple checkpoints accompanied by his employers and showing his birth certificate.

Karina, 35, was born in the Dominican Republic to Haitian parents, and registered as Dominican. Although she obtained a valid identification card at 18, when she was 24, the government refused to issue her documents necessary to enroll in a university, allegedly because her claim to nationality was under investigation. Unable to continue her studies, Karina began working as a chambermaid in a large beach resort, where she has been for 10 years.

In October 2014, Karina made a two-hour trip from the province of Altagracia, where she lives, to the capital for an interview concerning the validity of her nationality. Officials were satisfied with her responses, but told her that she couldn't renew her identification card until the auditing process was finalized. She has taken time off work to make four more trips to Santo Domingo to check on the status of her case. Then, in early 2015, officials told her the process had been transferred to El Seibo, the province where Karina was born. As of late April, her audit was still not complete.

Because Karina has been unable to renew her identification card, which expired last fall, she says she cannot use her medical insurance, and must pay out of pocket when she goes to the doctor. She no longer has full access to her bank account or her credit card, and has had trouble paying both outstanding utility bills and the mortgage on her house. And she still can't continue her studies.

Rosanna, 17, was born in the Dominican Republic to Haitian parents who had migrated from Haiti 20 years earlier. After the 2013 denationalization decision she was forced to quit public school and now picks and sells fruit in the countryside for less than US$3 a day. Rosanna wanted to register under the Naturalization Law, but was unable to do so. Faced with an inscrutable bureaucratic process, and unable to afford a lawyer, she turned to thinly stretched nongovernmental organizations, which couldn't help her complete the process by the deadline. She is now unable to register as a Dominican citizen, and has no way of continuing her studies.

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Dominican Republic: Thousands at Risk of Expulsion to Haiti

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(Santo Domingo) - Tens of thousands of Dominicans of Haitian descent remain in legal limbo, unable to exercise their basic rights, Human Rights Watch said in a report released today. The situation remains unresolved despite government efforts to remedy it.