Pregnant and Poor

PORT-AU-PRINCE, Haiti For all the American and international efforts to fight global poverty, one thing is clear: Those efforts won’t get far as long as women like Nahomie Nercure continue to have 10 children.

Global family-planning efforts have stalled over the last couple of decades, and Nahomie is emblematic both of the lost momentum and of the poverty that results. She is an intelligent 30-year-old woman who wanted only two children, yet now she is eight months pregnant with her 10th.

As we walked through Cité Soleil, the Haitian slum where she lives, her elementary-school-age children ran stark naked around her. The $6-a-month rental shack that they live in — four sleep on the bed, six on the floor beside it — has no food of any kind in it. The family has difficulty paying the fees to keep the children in school.

There’s simply no way to elevate Nahomie’s family, and millions like it around the world, unless we help such women have fewer children. And yet family-planning programs have been shorn of resources and glamour for a generation now.

Nahomie is one of 200 million womenworldwide who, according to United Nations estimates, have what demographers call an “unmet need” for safe and effective contraception. That is, they don’t want to get pregnant but don’t use a modern form of family planning.

This “unmet need” results in 70 million to 80 million unwanted pregnanciesannually, the United Nations says, along with 19 million abortions and 150,000 maternal deaths.

The push for contraception was at the center of development efforts in the 1960s and 1970s, but then waned. In part, it was tarnished by its own zealotry, including coercion in China and India. Another reason was abortion politics, which led to a cutoff in American financing for the United Nations Population Fund — even though the upshot was more unwanted pregnancies and more abortions.

In addition, family planning turned out to be harder than many enthusiasts had expected, for it requires far more than condoms or the pill. Haiti has family-planning clinics, spending on contraception is fairly high, and women say they want fewer children — yet only one-quarter of Haitian women use contraceptives.

Nahomie’s story helps explain the enigma. She tried injectables, but she says they caused excess bleeding that frightened her. The clinic had little counseling to explain and reassure her, so she stopped after nine months.

A sexually transmitted infection at the time meant that she couldn’t use an IUD just then, and a doctor told her that the pill would be inappropriate because she has vascular problems. Reluctant to return to a clinic that seemed scornful of poor women, she drifted along with nothing.

A couple of babies later, her first husband left her, and her next husband wanted to have children with her, so she acquiesced. A few children later, she began to push back, but in Haiti’s social structure she felt she had to accede to her husband’s whims. “I asked to use condoms,” Nahomie said, “but he refused.” Last fall, shortly after she became pregnant with her 10th child, her husband ran off.

A book published a few years ago, “Reproducing Inequities,” notes that we are, painstakingly, learning what does work. The effective strategies go beyond the contraceptive devices themselves to include better counseling, more dignity for women in clinics, a greater choice of methods that are completely free — and a broad effort to raise the status of women.

The best way to elevate women, by far, is to educate girls and to give them opportunities to earn income through micro-loans, factory jobs or vocational training. It is sometimes said that the best contraceptive isn’t the pill or the IUD, but education for girls.

(A side note: Whenever I write about efforts to save children from malaria or diarrhea, I get cynical letters from neo-Malthusians who argue that saving children’s lives is pointless until birthrates drop. That’s incorrect. There’s abundant evidence that when parents are confident that their children will live, they will have fewer and invest more in each of them.)

In any case, the mounting academic evidence underscores what is intuitively obvious in Haiti: unless family planning is more successful in poor countries, they won’t be able to overcome poverty. “There’s no other way,” says Tania Patriota, the representative of the United Nations Population Fund in Haiti. “It’s indispensable.”

President Obama has already lifted the ban on aid for the Population Fund, and we now have an opportunity to lead a global effort to regain lost momentum for family planning. And while Nahomie’s story shows that this won’t be easy, it also underscores that there’s simply no alternative.

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Giving Birth in Haiti

Giving birth is dangerous business for Haiti's poor, who suffer the highest maternal mortality rate in the Western Hemisphere. Some 630 of every 100,000 women died of pregnancy-related causes in 2006 -- more than five times the Latin American and Caribbean average, according to the United Nations.

The problem is heartbreakingly simple: Millions of women either cannot access health care, or cannot afford it.

Haitian health officials made significant strides last year with a program to waive entrance fees -- the equivalent of 25 to 64 cents a day -- for pregnant mothers at public hospitals. But the women must pay for almost everything else, from doctors' gloves and syringes to medicine, food and transportation, said Jacqueline Ramon, a maternity ward nurse at Port-au-Prince's General Hospital.

So many like Aristide still give birth at home, often with untrained midwives who administer traditional care using leaves made into tea, oil, smoke or steams.

"It's never, ever going to work unless we say some things are not meant to be sold, and safe motherhood is one of them," said Dr. Paul Farmer, a Harvard physician. In rural towns where his nonprofit Partners in Health provides free health care, Farmer said the maternal mortality rate is less than one-tenth the national average.

Maternal health is one of the issues the Clinton Global Initiative and U.N. agencies are emphasizing, part of a wider call for increased aid and investment that Bill Clinton and U.N. Secretary-General Ban Ki-moon made in a visit to Haiti last week.

For $40 million a year, and likely even less, Farmer said, comprehensive care could be given to all pregnant Haitian women.

The issue is likely to be discussed at a long-delayed international donors conference on Haiti scheduled for April 13-14 in Washington. Haiti faces as much as a $100 million budget shortfall after large-scale emergency spending following four destructive storms in 2008.

Other steps are also needed in this country of nearly 10 million, including preventing unwanted pregnancies and lowering the highest birthrate in the Western Hemisphere -- almost 36 births per 1,000 people.

The situation turned critical last fall when Port-au-Prince's public hospitals went on strike during the fall peak birthing season -- nine months after Carnival.

With mothers forced to turn to a handful of not-for-profits, the cramped, 66-bed Jude Anne maternity hospital run by Doctors Without Borders Holland in central Port-au-Prince became, in the words of obstetrician Dr. Wendy Lai, a "war zone."

Women were giving birth on the floor, in the waiting room, on staircases and in bathrooms. One died before doctors, caught up with other life-threatening emergencies, could attend to her.

"They had nowhere to go," said Lai, a Canadian who previously worked in the Democratic Republic of Congo. "This has been described as a baby factory. On a normal day, we line them up and catch the babies."

Some things are improving. Doctors Without Borders recently moved to a larger facility after 21/2 years in a building so cramped, doctors could not walk around some patients' beds.

At the old facility in January, women lay in rows, legs open and knees in the air, as professionally trained midwives chatted quietly and watched for signs that birth was imminent. Some of the mothers sang to get through the pain.

Haitian mothers are disproportionately threatened by the disorders of eclampsia and pre-eclampsia, which bring high blood pressure, excess protein and swelling, and can cause seizures, heart failure, brain hemorrhages and death.

Though seen all over the world, the incidents are much higher in Haiti -- 14 in every 2,000 pregnancies compared to a rate of 1 in 2,000 to 3,000 pregnancies in the U.S., according to the National Institutes of Health.

Because they are caused by pregnancy, the only cure for the disorders is to deliver the baby.