Haiti: Improving the Maternal Health Situation through Increased Contraceptive Use

BY RACHEL ARNESEN.
Photography by Jose Jose and Jean Francoise Leblanc.

Each day, about 800 women die from complications related to pregnancy or childbirth.[1] While 800 deaths per day is an alarming statistic, what is even more shocking is that almost all of these deaths—over 99% of which occur in developing countries—are preventable.[2] In the past 20 years, organizations such as the World Health Organization (WHO) have implemented various programs and initiatives in efforts to lower maternal mortality rates worldwide, under the platform of “providing evidence-based clinical and programmatic guidance, setting global standards, and providing technical support to Member States.”[3] Substantial progress has been made, with the global maternal mortality rate decreasing 47% over the past 20 years.[4]However, in addition to these somewhat successful efforts, another important strategy for lowering the global maternal mortality rate worth investigation is how contraceptive devices can be used to limit the number of unwanted or dangerous pregnancies worldwide to thus help lower the global maternal mortality rate. Haiti, a nation whose maternal mortality rates are not only almost twice as high as the worldwide rates,[5] but whose lifetime risk for dying because of childbirth is the highest in the Western Hemisphere at 1 out of 47,[6] is an example of a country that could benefit greatly from increased contraceptive usage. However, in order to make feasible the strategy of using contraceptives to lower maternal mortality rates, the rampant gender inequality present in Haiti first needs to be reduced, and women and girls need to be empowered to take control of their own reproductive health.

One method of investigating the need for contraception in a given region is to look at the difference between a country’s desired fertility rate and the actual fertility rate, or the difference between the number of children a woman wishes have and the number of children she actually has. Haiti’s difference of approximately 1.5 between the actual and wanted fertility rates suggests a fundamental underlying problem in Haiti’s family planning infrastructure.[7] This fundamental problem is further illustrated through the nation’s high percentage of women with an unmet need for family planning, defined as women who are “fecund and sexually active but are not using any method of contraception, and report not wanting any more children or wanting to delay the birth of their next child.”[8] Haiti’s unmet need for family planning for married women is 40%, the highest of the 53 nations for which data is available.[9] Unmet need is an important indicator of a nation’s state of contraceptive usage and maternal health, as women who do not wish to become pregnant but are not using an effective method of birth control account for approximately 82% of unplanned pregnancies globally.[10] Addressing the issue of unmet need would “contribute substantially to reducing levels of unplanned births, induced abortions, maternal deaths and DALYs [disability adjusted life years].”[11]

Studies estimate that providing universal access to modern family planning and thus averting unintended pregnancies could help prevent 20-35% of maternal deaths worldwide, equivalent to approximately 100,000 yearly maternal deaths.[12] The Safe Motherhood Initiative, a global campaign aimed at decreasing maternal mortality, identifies family planning as one of four primary strategies to reduce maternal mortality in developing countries, along with antenatal care, safe delivery, and postnatal care.[i]Despite the apparent numerous benefits of modern contraceptives in developing countries, over 25% of women of childbearing age do not have access to modern contraceptives.[ii] However, merely providing access to areas with high-unwanted pregnancy rates is ineffective unless there is a strong underlying infrastructure in these areas to ensure sustained contraception availability for all demographics of the target population. The target population must also be receptive to increasing contraceptive usage; otherwise no amount of education and increased supply of contraceptives will have a substantial impact. The obstacles encountered in trying to increase contraceptive use in Haiti can be divided into three categories: logistical issues, educational issues, and—the most important in terms of long term sustainability—cultural issues.

If contraceptive usage increases, gender inequality in Haiti is the primary cultural barrier that must be overcome. Haiti’s constitution technically provides for “equal protection before the law” for both men and women; however, there is no national legislation that bans and punishes discrimination against women.[iii] On July 6, 2005, the Haitian government passed a decree that modified the categorization of rape as “a crime against morals to a crime against the person.”[iv] While this was a very important step towards positive change for women, the decree still does not specify what constitutes rape nor does it recognize sexual harassment or spousal rape as crimes.[v]

Traditional gender norms tend to discourage women from talking about sex or family planning and perpetuate the supposed ideal of a virginal and pure bride. In general, traditional gender roles “establish and reinforce women’s subordination to men and drive poor sexual and reproductive health outcomes for both men and women.”[vi] There is great variability amongst the Haitian population depending on age, education level, and region of the country when it comes to subscription to traditional beliefs and ideals. However, traditional Haitian beliefs, which are still held by substantial subsets of the general population, espouse traditional gender norms that insist that girls not engage in premarital sex but should instead merely prepare themselves for marriage.[vii] Teenage boys, on the other hand, are allowed to have sex before marriage as part of their “training,” as male sexuality is “closely associated with prestige and affirming manhood.”[viii] Equating manliness with having multiple sexual partners and sexual risks while maintaining the female norm of being “passive and under-educated about their sexual and reproductive health”[ix] engenders massive, negative implications for female reproductive health and maternal mortality rates.

Traditional gender roles also impede mass societal acceptance and usage of condoms, one of the simplest methods to help limit unwanted pregnancies and potentially lower maternal mortality rates. In December 2010, the UN found that only 5.3% of Haitian women aged 15-49 who were married or in a union reported their partner wearing a male condom for contraceptive purposes.[x] When doctors told women that they should use condoms to protect against sexually transmitted diseases, many responded: “most men here don’t like to use condoms.”[xi] The refusal of men to wear condoms because they believe that they will experience a decrease in sexual pleasure is a direct result of the dominant masculine society that is still largely prevalent in Haiti today.

Because of the same social values that promote male virility as a sign of manliness, many Haitian women have their reproductive health choices made for them by their male partners. In a survey of pregnant women in rural Haiti, 94% of women reported that their husband or male partner made their health decisions for them, 4% reported that their mother was the primary decision maker for health concerns, and only 2% of the women surveyed reported that they made their own decisions in matters of their own health.[xii] The availability of contraceptives, including condoms, will only be effective in increasing contraceptive usage. This is especially true as there already exists a “functioning health care services and an adequate program infrastructure throughout the country,”[xiii] which includes having a society in which a majority of the population holds views about gender that allow women to make their own decisions about their personal reproductive health.

In recent years, however, there have been some positive signs that traditional gender roles might be shifting. There has been an increase in the number of organizations aimed at empowering Haitian women and ameliorating the overall destitution of much of the Haitian population and lack of women’s rights prevalent in much of Haitian society. In the aftermath of the 2010 earthquake, the Haiti Adolescent Girls Network created a series of “protective girl-only spaces” called “Espas Pa Mwen” or “My Space,”[xiv] to help empower adolescent girls to “build much-needed social capital and economic assets,” by providing a place where girls can feel “unconditionally safe” and interact with trained mentors that help them “focus on their interests, skill building, and each other.”[xv] As of 2012, over 550 teenage girls regularly use the spaces, which are located at seventeen different sites thanks to the sponsorship of over forty different organizations.[xvi] The organization also provides training to women on pertinent issues such as child safety, public health, and different methods to generate income.[xvii]

One of the most prominent women’s organizations in Haiti is “Solidarite Fanm Ayisyen” (SOFA), translated to the title “Haitian Women’s Solidarity,” a nationally run group focused on “women’s right to health, the promotion of the participation of women in decision-making, and stopping feminization of poverty.”[xviii] SOFA has over 5,000 active members from all different backgrounds, and it has introduced new programs promoting female rights and education about violence against women in partnership with local schools.[xix] These organizations and others with similar objectives, while relatively new, are starting to make significant, positive impact on the social status of women in Haiti. Once women bring in their own income and no longer completely depend on their husbands for financial resources, they will no longer be seen as liabilities. Instead, they hopefully will be able to have more of a say in their own reproductive health and family planning.[xx]

Once the primary gender inequality obstacles to women’s access to contraceptives have been addressed, the focus should shift to the secondary issue of family planning education. A system needs to be put in place that provides information about reproductive health issues as well as information about different contraceptive options. In order to increase contraceptive usage rates in the long term, Haitians need to be educated about the different forms of contraception and their respective positives and negatives. Ideally, a system will also be put in place in which Haitian health workers are trained to educate youth about safe sex and contraceptive usage, as well as how to administer different forms of birth control. This model is sustainable, as eventually foreign workers can be phased out so that the reproductive health care and family planning services in Haiti can be run entirely by Haitians.

In this day and age, Haiti’s high maternal mortality rate and high unmet need for contraception is utterly unacceptable. As Hernando Clavijo, a United Nations Population Fund Haiti Representative stated, “‘[Haiti’s] population is growing very fast [but] the environmental and economic situations are terrible. Every sector must realize contraception is a key factor for long-term development of the country…It’s also a human rights issue, a woman should have the right to decide how many children she’ll have.”[xxi] The underlying social beliefs and traditions of Haiti must be altered in order to enact long-term, sustainable change that will eventually lead to lower maternal mortality rates. The changes that must be made to empower women to allow them to make their own reproductive choices will have a ripple effect well beyond the realm of maternal health. The empowerment of women could not only lead to a decrease in the unmet contraceptive need, reduce the number of unplanned and unwanted pregnancies and lower the maternal mortality rate, but also help lessen the widespread extreme poverty found throughout much of Haiti. Increased contraceptive usage is by no means the only method of lowering maternal mortality rates. However, contraception is certainly an important factor that once implemented, will hopefully effect positive change in multiple realms of Haitian society, improving not only Haiti’s maternal health situation but also the situation for women throughout the country.

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[1] “Maternal Mortality,” updated May 2012, http://www.who.int/mediacentre/factsheets/fs348/en.

[2] “Maternal Mortality.”

[3] “Maternal Mortality.”

[4] WHO, UNICEF, UNFPA, and the World Bank, Trends in Maternal Mortality: 1990 to 2010,Geneva, Switzerland: World Health Organization, 2012, http://whqlibdoc.who.int/publications/2012/9789241503631_eng.pdf.

[5] “Haiti Health Data–2013 Accountability Profile,” published May 2013, http://www.countdown2015mnch.org/documents/2013Report/Haiti_Accountability_profile_2013.pdf.

[6] Allie Torgan. “Haitians Living in Fear Under the Tent,” CNNHeroes, October 18, 2012, http://www.cnn.com/2012/10/18/world/americas/cnnheroes-haiti-rape.

[7] Gilda Sedgh et al., Women with an Unmet Need for Contraception in Developing Countries and Their Reasons for Not Using a Method, Rep. no. 37, New York: Guttmacher Institute, 2007, http://www.guttmacher.org/pubs/2007/07/09/or37.pdf.

[8] World Health Organization. “Unmet Need for Family Planning.” Updated 2013. http://www.who.int/reproductivehealth/topics/family_planning/unmet_need_fp/en/

[9] Sedgh et al., Women with an Unmet Need…

[10] Jacqueline Darroch et al., Contraceptive Technologies: Responding to Women’s Needs, New York: Guttmacher Institute, 2011, http://www.guttmacher.org/pubs/Contraceptive-Technologies.pdf.

[11] Darroch et al., Contraceptive Technologiess.

[12]N. Simelela, “Women’s Access to Modern Methods of Fertility Regulation,” International Journal of Gynecology and Obstetrics 94 (2006): 292, doi: 10.1016/j.ijgo.2006.04.014.

[i]Islam, Monir. “The Safe Motherhood Initiative and Beyond.” Bulletin of the World Health Organization 85.10 (2007): 735. Oct. 2007. Web. 5 Nov. 2013.

[ii] “By Choice, Not by Chance: Family Planning, Human Rights and Development.”. UNFPA, 2012. Web. 08 Nov. 2013. ii.

[iii] “A Profile of Police and Judicial Response to Rape in Port-au-Prince.” Mission des Nations Unies pour la Stabilisation en Haïti. June 2012. Web. 8 Nov. 2013.

[iv] “A Profile of Police and Judicial Response to Rape in Port-au-Prince.” Mission des Nations Unies pour la Stabilisation en Haïti. June 2012. Web. 8 Nov. 2013.

[v] “2010 Human Rights Report: Haiti.” Bureau of Democracy, Human Rights, and Labor. U.S. Department of State, 2011. Web. 8 Nov. 2013.

[vi]WHO, UNICEF, UNFPA, and The World Bank. Trends in Maternal Mortality: 1990 to 2010 : WHO, UNICEF, UNFPA, and The World Bank Estimates. Geneva: World Health Organization, 2012. Print. 40.

[vii]Colin, Jessie M. “Cultural and Clinical Care for Haitians.” Haiti. LCDR US Public Health Service, Indian Health Services, 2004. Web. 8 Nov. 2013.

[viii] Colin, Jessie M. “Cultural and Clinical Care for Haitians.” Haiti. LCDR US Public Health Service, Indian Health Services, 2004. Web. 8 Nov. 2013.

[ix] “By Choice, Not by Chance: Family Planning, Human Rights and Development.” State of World Population 2012. UNFPA, 2012. Web. 08 Nov. 2013. 40.

[x] “World Contraceptive Use 2011.” UN Population Division. United Nations Department of Economic and Social Affairs, Population Division, 2011. Web. 3 Nov. 2013.

[xi]Leys, Tony. “Family Planning Is a Delicate Subject in Haiti.” Haiti: Family Planning and Women’s Health. Pulitzer Center on Crisis Reporting, 29 Apr. 2013. Web. 08 Nov. 2013.

[xii]White, Kari, Maria Small, Rikerdy Frederic, Gabriel Joseph, Reginald Bateau, and Trace Kershaw. “Health Seeking Behavior Among Pregnant Women in Rural Haiti.” Health Care for Women International 27.9 (2006): 822-38. Taylor & Francis Online. Web. 19 Oct. 2013. 830.

[xiii]Simelela, N. “Women’s Access to Modern Methods of Fertility Regulation.” International Journal of Gynecology and Obstetrics 94.3 (2006): 292-300. ScienceDirect. Web. 4 Nov. 2013. 296.

[xiv] “Haiti Adolescent Girls Network.” Abundance Foundation. Tomorrow Partners, 2013. Web. 14 Nov. 2013.

[xv] Siddiqi, Anooradha. “Missing the Emergency: Shifting the Paradigm for Relief to Adolescent Girls.” The Coalition for Adolescent Girls. The Coalition for Adolescent Girls, 2012. Web. 14 Nov. 2013. 6.

[xvi] Siddiqi, Anooradha. “Missing the Emergency: Shifting the Paradigm for Relief to Adolescent Girls.” The Coalition for Adolescent Girls. The Coalition for Adolescent Girls, 2012. Web. 14 Nov. 2013. 6.

[xvii] “Women’s Empowerment.” HAC-Haiti. Haitian American Caucus-Haiti, 2013. Web. 14 Nov. 2013.

[xviii] Remy, Mina. “SOFA’s Violence Against Women Campaign in Haiti, One Year On.” Grassroots International. Grassroots International, 21 Nov. 2012. Web. 14 Nov. 2013.

[xix] Coriolan, Anne-Marie. “Solidarite Fanm Ayisyen (SOFA).” Haitian Women Network. Haitian Women Network, 2010. Web. 14 Nov. 2013.

[xx] Golla, Anne Marie. “Measuring Women’s Economic Empowerment.” International Center for Research on Women. ICRW, 2012. Web. 29 Nov. 2013.

[xxi]Bracken, Amy. “Haiti’s Children Pay the Price of Poverty.” NACLA Report on the Americas 39.5 (2006): 22-25. PRISMA. Web. 3 Nov. 2013. 22.