The Present State of Haitian Fertility and the International Response
Photo: Johns Hopkins Public Health

By Meghan Pierce, Undergraduate Research Assistant

The right of the individual to decide how many children to have and when to have them has consistently been the guiding principle in international reproductive health standards, according to the World Health Organization.  Since 2010, Haiti’s rising annual birth rate has been increasingly referred to as a “fertility crisis” by international population demographers.

Haiti’s population is expected to reach 15.7 million by 2050, targeting the need for a reproductive health program to decrease the total fertility rate, currently 3.9 children per woman. In the aftermath of the 2010 earthquake, an influx of international aid arrived to Haiti, with specific funds allocated for family planning initiatives, prioritized because of the ballooning population and dwindling natural resources. However, like many aid programs in Haiti, the funds have been poorly allocated and inefficiently managed. Since 2010, Haiti has been experiencing a “baby boom” in urban areas like Port-au-Prince, due in part to the destruction of infrastructure that once included clinics with contraceptive supplies and counseling. According to the United Nations Population Fund, the Haitian fertility rate has tripled since the disaster.

The unmet need for contraception, defined as the percentage of fertile, married women of reproductive age who do not want to become pregnant and are not using contraception, is currently 32%. For women in the poorest quintile, the majority of whom live in rural areas, the unmet need reaches 44%.The lack of contraception access is especially troublesome in light of the sharply increasing fertility rates, particularly among adolescents.

The risk factors of the urban baby boom are numerous. A 2007 UNFPA study reported that, given irregular or no access to contraception, Haitian women are more inclined to use abortion as a regulatory fertility method. However, the performance of abortions is governed by the provisions of the Haitian Penal Code, which declares the practice to be illegal. Thus, women are more likely to seek riskier abortions, whether self-induced or by an unqualified practitioner.  Haiti is also at risk of increased HIV and STI rates, because of the lack of contraceptive methods that protect against infection, such as female and male condoms. Currently, about 2% of the adult population of Haiti has HIV, and the infection is considered a growing health concern.

The Haitian government has yet to respond to the “fertility crisis” with an effective family planning program. 1995 saw the launch of an ambitious decentralization plan that relied on a network of Communal Health Units for the delivery of basic health services, which included reproductive health services. However, progress has been limited, and not all communities benefit from rally health posts, mobile clinics, health agents, and locally trained birth attendants. Furthermore, because of the enormous need and limited staffing, clinics are at risk of a significant drop-off in the quality of care women receive.

USAID reports that the difficulty of access to contraceptive methods is due to frequent stock-outs of contraceptives and a limited range of method choice in most health facilities, which is especially true for long-term methods like IUDs and birth control implants.  The stock-outs have led to the creation of parallel procurement and distribution systems by international organizations, private clinics, and hospitals. This lack of coordination of service delivery is exacerbated in rural areas, as the limited number of health centers and district hospitals are primarily found in urban areas. Furthermore, instruction on the proper use of birth control is frequently overlooked. For example, it has been reported that condoms are not understood as a family planning method to some Haitians, but only as a method of prevention of HIV and STIs. As a result, condoms are not frequently used by couples in committed relationships, as to do so would be to admit unfaithfulness, according to the same report. The lack of proper contraception instruction is further evidenced in that only 21% of Haitian women can situate the fertility period in their menstrual cycle, according to a USAID demographic health survey.

The sheer number of family planning NGOs and US-sponsored organizations working to “manage” Haitian fertility, with few results in recent years, evidences the mismanaged coordination between such groups. The lack of strategic resource distribution and the disparity of urban and rural access to contraception pose many questions about future action. For example, it is questionable if a single family planning service provider would be the most “ideal” response to the high fertility levels. Because of the current political climate, an overhauled government-driven health care system which accommodates family planning services does not seem likely. Yet, the coordination of all family planning funding, staff training, and service distribution by a single NGO, whether domestic or international, seems equally as unlikely. Given the importance of family planning as a gender, economics, and human rights issue, Haiti is at pivotal point as it responds to rising population levels, although perhaps it is not itself ready to define the issue as a “fertility crisis.”