BY MARA BLUMENSTEIN
“Reproductive rights … rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing of their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.”
-International Conference on Population and Development, 1994
Reproductive and sexual rights encompass a woman’s right to control her body by making and implementing her own decisions.1 These rights include the right of access to information and the right to decide and control the spacing and timing of reproduction. Importantly, these rights are not limited to a woman’s right to make decisions about her personal reproductive choices. Rather, they also encompass the right to implement those decisions in order to establish control of her body, life, and livelihood.
In urban Haiti, demand for contraception is higher than in rural areas because people generally want fewer children. In urban areas, more children means more mouths to feed whereas in rural areas, more children means more hands to help produce food. Focusing on urban Haiti allows for an understanding of how well the demand for contraception is met. Two studies are highlighted, both conducted in urban parts of Haiti, to understand urban family planning. In the first, researchers from Duke University interviewed sixteen women from Leogane, Haiti, about their use of and views on contraception. In the second, researcher Catherine Maternowska observed a clinic in the city of Cite Soleil and interviewed the clinic’s patients. Both studies included extensive interviews with Haitian women, which provided valuable insight into the nuances of their family planning decisions. Although the opinions and experiences of these women do not represent those of all Haitian women, the interviews provide a personal look into Haitian family planning. A holistic investigation of reproductive rights may elucidate the path forward towards universal reproductive rights.
DEMOGRAPHICS OF HAITI
While numbers only capture a small part of the story, they do provide a necessary background on the current state of reproductive rights. As of 2001, Haiti was the only country in the western hemisphere that fell into the “high risk” group when looking at pregnancy and childbirth. Haiti’s maternal mortality rate is among the highest in the world.2 Forty percent of Haitian women who are fertile, sexually active, and do not currently want to become pregnant do not have access to contraception.3 As of May 2013, the fertility rate was 1.5 children higher than the desired fertility rate, a difference that stems from the huge unmet demand for family planning. Furthermore, thirty-two percent of married women of childbearing age do not want to become pregnant and are not using contraception, and in both urban and rural Haiti, forty-six percent of women are not satisfied with their current contraceptive options.4 These statistics provide a glimpse into the dire state of reproductive rights in urban Haiti. Many women lack access to a reliable form of birth control, and many end up with more children than they can reasonably care for. Unwanted pregnancies also contribute to the high maternal mortality rate. The large difference in desired versus actual birth rates causes a strain on the already fragile Haitian economy and environment, as the high birth rate results in more mouths to feed and bodies to house.
EXPANDED DEFINITION OF REPRODUCTIVE RIGHTS
While the core tenant of reproductive rights is that people should be in direct control of their bodies5, it is important to note that a larger goal of modern movements toward more secure reproductive rights is to ensure woman’s empowerment and gender equality. It is not enough to focus solely on individuals when trying to improve reproductive rights. Cultural, religious, and economic factors are key to a woman’s ability to make and implement her own decisions. Given the myriad of factors that impact a woman’s decision1, investigating the barriers that Haitian society impose on women’s reproductive rights is the first step in overcoming those barriers and guaranteeing women their rights.
CASE STUDY: LEOGANE
In June 2012, a group of researchers working under Fan Yang of Duke University interviewed sixteen women of varying ages and socioeconomic statuses in Leogane, Haiti, a suburb of about 30,000 outside of Port-au-Prince. The goal of the study was to learn about the women’s uses and views of modern birth control methods.6
The study found several notable barriers to modern contraceptive use among the sixteen women. Many of the women mentioned that it was “widely recognized” that they should only begin using contraception after having had their first child for fear of becoming infertile. All sixteen women said they only began using contraception after having at least one child. Experiencing negative side effects or even just hearing about side effects from others also decreased birth control use. Another barrier was the use of traditional methods of contraception in place of modern methods. Some of the women in the study believed in the effectiveness of traditional methods such as the consumption of salt water and parsley as a means of contraception. This served as an indication that some of the women in Leogane lacked factual information about modern birth control methods.
Many of the women also mentioned the role of the community in spreading information about birth control. However, this means of inter-communication may be more harmful than helpful if it helps propogate misinformation within the community. One woman explained her contraception education: “It is not in a seminar. It is not in school. It is during [a] sitting with adult people. When people say I’ll use birth control, you understand! When I asked what the timeline is, something to be taken for injection for not having more children. Afterwards, I got started on things.”6 Spreading birth control information via word of mouth often leads to misinformation. Yet, this persistent spreading of misinformation in Leogane exemplifies the existence of a strong community network.
The Leogane study highlights the fact that examining reproductive rights solely at the individual level does not provide a complete picture. The choices a woman makes are influenced enormously by her society. Factors like the beliefs of peers and family members, inadequate knowledge, and fear of side effects may limit women’s reproductive rights even if it seems that women are able to independently make their own choices. Capitalizing on strong Haitian social networks with the creation of community groups to increase the flow of knowledge about modern contraceptives could support women’s abilities to make informed decisions about contraception. In summation, the Leogane women interviewed generally had a positive view of birth control and, though they held some misconceptions, they fully understood the independence that family planning could help them achieve.6
CASE STUDY: CITE SOLEIL
Cite Soileil, a densely populated city of 400,000 on the northern edge of Port-au-Prince, provides the perfect urban location for an investigation of women’s reproductive rights. Catherine Maternowska, an anthropologist specializing in reproductive health, conducted interviews with residents and observed a family planning clinic in Cite Soleil to analyze the correlation between health, contraceptive use, and quality of life of the women in the city. The clinic Maternowska observed receives most of its funding from USAID, which operates under the “quality of care” framework.2 This framework dictates that women should feel comfortable, taken care of, informed, and in control of their treatment. Clinics following these guidelines prioritize creating positive experiences for their patients instead of trying to maximize the number of patients served or the amount of contraception dispensed.2
While beneficial in theory, these guidelines did not actually lead to quality care for the women served by the clinic. Maternowska observed that some doctors at the clinic did usually ask women what method of birth control they preferred, but would then typically ignore the answer the women provided when prescribing a method of contraception.2 Women typically waited over an hour for a meeting with a doctor that lasted, on average, two minutes. Once they finally met with a doctor, women experienced harsh treatment and generally reported that many of their questions were left unanswered.
Maternowska proposes an explanation for this treatment of patients in the stratification of social classes in Haiti. Clinic doctors would purposefully “distance [themselves] from social inferiors by emotional and physical means,” a practice that contradicts the USAID framework.2 Maternowska concluded that the clinic did not provide adequate care for the women it served. Not only did doctors ignore women’s questions, concerns, and preferences, but they also created a hostile environment that made procuring contraception difficult. Doctors took advantage of the power they had over the women, due to their socioeconomic status and education level, by treating them as inferiors and making reproductive decisions for them.2 Maternowska found it clear that, “the clinic ‘had little do with satisfying people’s real needs.’”2 If this clinic is representative of other clinics in Haiti, then even women with access to a family planning resources are not guaranteed their full reproductive rights.
Although the Cite Soleil clinic failed to implement its “quality of care” guidelines, the underlying framework centered on helping each individual woman did, at least, exist. From this study, we can glean the valuable lesson that while the quality of care framework seems to be a good starting point, focus must be put on the actual implementation of the ideals it promotes.
BARRIERS TO FULL REPRODUCTIVE RIGHTS IN HAITI
1. Side Effects
As discussed in both the Leogane and Cite Soleil case studies, a fear of side effects constitutes a large barrier for women in exercising their reproductive rights. In general, providers of family planning services often underestimate or even ignore the influence that side effects may have on a woman’s decision whether or not to use birth control effectively.7
2. Cost / Financial Burden
The financial burden of contraception acts as a significant barrier for many Haitians. Some family planning administrators argue that when people have to pay even just a small amount for their method of contraception (as opposed to getting it at no cost), they are more likely to use it due to its increased perceived value. Maternowska questions this argument based on its lack of evidence, as well as the fact that this mindset belittles the client and his or her ability to make autonomous decisions.2 Moreover, patients at the Cite Soleil clinic discussed the “hidden costs” involved when seeking contraception. While the clinic was advertised as providing services at low to no cost, follow-up appointments and other expenses could lead to a substantial financial burden.2 Women in the Leogane study mentioned that the cost of transportation often prohibited them from being able to go to the free clinic.6
PARTNERS AND GENDER ROLES
Neither study provided considerable insight on the influence of male partners on a woman’s reproductive choices. However, according to a 2010 UN study, only 5.3% of Haitian women ages 15 to 49 reported their partner using a condom regularly. Haitian men’s refusal to use condoms because of the possibility of decreased sexual pleasure relates to the culture of male superiority that still permeates Haitian society.2 Similarly, a study of pregnant women in rural Haiti found that 94% of women had their health choices made by their husband or partner.2 Equivalent statistics for urban Haiti were unavailable, but it is likely that many Haitian women in urban areas also lack autonomy when making health decisions. The doctors of the Cite Soleil clinic seemed to view women as inferiors, resulting in poor treatment and unanswered questions. While socioeconomic differences between doctors and patients contributed to this disparaging treatment, gender roles also influenced the actions and attitudes of the male doctors.
CONCLUSION
Currently, many women in urban Haiti are not guaranteed their full reproductive rights. In the future, family planning should not be based on an attempt to lower the birth rate and control population growth. Rather, the motive for family planning should be to improve the level of universal rights in Haiti by providing women with the information and means to implement their family planning choices. Capitalizing on the strong information networks already present in Haitian communities could be one way to improve the level of family planning knowledge. In both aforementioned case studies, women received the majority of their family planning information from friends and family. Increased collaboration between medical professionals and communities to take advantage of these networks and spread information would improve the accuracy of information that women receive. Regardless of what tangible steps are taken, the first priority should be to guarantee women their full array of reproductive rights. This will not only expand women’s individual freedoms and opportunities but will also promote economic growth and prosperity.
Mara Blumenstein is a sophomore in Silliman College. Mara is a Molecular, Cellular, and Developmental Biology major. She can be contacted at mara.blumenstein@yale.edu.
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REFERENCES
1. Mann, J., Grodin, M.A., Gruskin, S., & Annas G.J. (1999). Health and Human Rights: A reader. New York: Routledge.
2. Maternowska, M.C. (2006). Reproducing inequities: Poverty and the politics of population in Haiti. New Brunswick, N.J.: Rutgers University Press.
3. Arnesen, R. (2014, April 30). Haiti: improving the maternal health situation through increased contraceptive use. Yale Global Health Review, 1(2). Retrieved from https://yaleglobalhealthreview.com/2014/04/30/haiti-improving-the-maternal-health-situation-through-increased-contraceptive-use/.
4. Pierce, M. (2013, May 31). The present state of Haitian fertility and the international response. Focus on Haiti Initiative. Retrieved from http://focusonhaiti.org/2013/05/31/the-present-state-of-haitian-fertility-and-the-international-response/.
5. Yang, F. (2013). Health Beliefs and Contraception Use in Leogane, Haiti: A Qualitative Study. Duke University Libraries. Retrieved from http://dukespace.lib.duke.edu/dspace/handle/10161/7326.
6. Russell, A., Sobo, E., & Thompson, M. (2000). Contraception Across Cultures: Technologies, Choices, Constraints. New York: Bloomsbury Academic.
7. Report of the International Conference on Population and Development. (1994). United Nations Population Information Network. Retrieved from http://www.un.org/popin/icpd/conference/offeng/poa.html.
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