Haitian Cultural Norms in the Context Ofunions

Haitian Cultural Norms in the Context Ofunions


Haiti has one of the highest percentages of women who have an unmet need for contraceptives in the western hemisphere.In 2000, the unmet need for contraceptives in Haiti was 39.8% (1). Countries with high percentages of the female population with an unmet need, such as in Haiti implies that there are not enough contraceptive services available to them. These reproductive health issues are compounded by the extreme poverty that Haiti faces, as well as the high infant and maternal mortality rates that exist in Haiti. The country is considered the most poor in the western hemisphere. It is estimated that 80 % of the population lives below the poverty line and 54% live in abject poverty (2,3). The infant mortality rate in 2005 was84 deaths per 1,000 live births and the adjusted maternal mortality ratio in 2000 was 670 deaths per 100,000 live births(4).

The purpose of this paper is to examine why Haitian women have such a highunmet need for family planning and recommend a programmatic response designed to increase access of family planning services among women living in rural areas.

Haitian Cultural Norms in the context ofUnions

Haiti is a patriarchal society and the role of men impact the health of women. Haitians participate in at least eight different types of unions (5). These unions are legal marriage, plasé, vivav́ ek, menaj, remen, fyansé, antente, flirté, and wike ́en. Some of these unions are a result of socio-economic class. For instance, a legal marriage is rare and seen mostly among couples who are wealthy. This is due to the elaborate cultural traditions that are involved all of which require substantial amounts of money (5). A more common union is one which involves couple who is not legally married but cohabitates. This relationship is based on steady income and is generally viewed by society as the next best arrangement after a legal marriage. Relationships such as vivav́ ek, menaj, remen,antente, flirté, and wike ́en are viewed as unstable because of the varied length of each relationship. They are usually short term and based on casual sex. They don’t require commitment between the partners. It is socially accepted that men have multiple unions. These unions include an overlap of the above stated unions. As a result of this societal norm, women also end up being involved in multiple relationships as well (5).

Defining Unmet Needin the Context of Family Planning

The concept of an unmet need for family planning was developed by Westoff in the early 1980s. Since 1991, DHS has refined and produced review reports addressing the unmet need for family planning in developing countries. These reports measure review the unmet of needs of married women. The report also includes information pertaining to all methods of contraception. The report has evolved though to also consider the needs of those women who are not married and the unmet need for modern contraceptive methods.(1)

According to DHS, “unmet family planning need” is defined as a woman of child bearing years who is not pregnant and is not using contraception but is sexually active and does not want children or wants to space the children by two years (1). This information is further broken down into sub-categories which provide specific information regarding the likelihood of women to utilize family planning services. Understanding the unmet need for family planning in a country also provides critical information about fertility rates because of the strong association between contraceptive prevalence and fertility (1). This information provides policy makers and other organizations with a measure of the demand for family planning for that country.

Availability and Accessibility of Contraceptives in Haiti

Health services in Haiti include public, private, and mixed sector clinics. There are a total of 615 health service delivery outlets in the country. Of these delivery outlets 209 are public, 241 are private, and 151 are mixed. As of 2002, it was estimated that 32% of Haiti’s health clinics were operated by NGOs. Since 2007, USAID has worked to strengthen the MOHs capacity. The private sector has been responsible for providing most of the family planning services for the country. Knowledge of modern contraceptives in Haiti is universal; however, not all methods are equally recognized. The most popular modern methods are injectables, condoms, and the pill. Modern contraceptive methods are attained through private clinics. It is estimated that 37% of women requiring injectables received their supplies through the private sector which includes hospitals, clinics, and pharmacies, 32% received their supplies through the public sector, and 13% received them in the mixed sector. However, 47% of women who received a sterilization procedure had done so through the public sector. According to the existing family planning norms in Haiti there is a clear delineation for who can administer the various family planning services in Haiti. The following personnel are ranked in order of ascending degrees of responsibility along with what they are able to administer: health promoters (the pill, condoms, and natural family planning methods), health agents and nurse auxiliaries (the pill, condoms, natural family planning methods, and injectables), nurses (the pill, condom, natural family planning methods, injectables, and implants), and doctors (all methods to including female and male sterilizations and vasectomies) (6).

Universal access to contraceptives in Haiti is a major problem in Haiti. Approximately, 62% of the population lives in rural areas (3). One explanation of why women who live in rural areas have increased difficulty in accessing family planning services is because of chronic sociopolitical issues that exist in Haiti (7). These sociopolitical problems partially explain the reduction in contraceptive services. The reduction in services available to this target group is further compounded by lost interest on the parts of both health personnel and decision makers (7).

Family Planning Programs in Haiti

As mentioned the unmet need for contraceptives among women in Haiti is very high. Of the women with an unmet need for contraceptives in Haiti, 44.9% have an unmet need for modern contraception(1). According to the Demographic Health Survey completed in 2000, the unmet need is fairly equal among women living in urban and rural areas in Haiti, 38% and 40% respectively (1). DHS also reports that of those women who have never used contraceptives, 35.7% intend to use contraceptives and 17.5% do not intend to use any contraceptives. The percent of women who have used contraceptives in the past and intend to continue to use contraceptives is 31.8% and those who do not intend to use contraceptives again is 15%.

The need for family planning in Haiti was recognized by the government during the 1970s, however, family planning services were available through the private sector in the 1960s (6). The national family planning program fell under the Division of Family Hygiene (DHF). The DHF was established to provide health services for the burgeoning population in Haiti, which was extremely impoverished(8). The DHF worked through hospitals and health clinics, initially and then extended its presence in Haiti by providing mobile clinics and community outreach workers.(8)

Family planning services in the early 1980s were spread out through the country, to include coverage in both urban and rural areas. USAID provided the funds for a program designed to support the private sector. The objective of this program was to reinforce the efforts that were being carried out by the public sector. The program, whose name was the Private Sector Family Planning Project (PSFPP), and their main objective was to deliver family planning services to private clinics, community based distribution programs and private voluntary organizations (5).

A study conducted in 1996 described the relationship between contraceptive use and socio-economic status. The study conducted surveys in three places: Port-Au-Prince (urban), Pignon (rural) and Leogane (rural). The study revealed that the choice of contraceptive device was mainly a result of what was being offered in the area. The rural areas of Pignon and Leogane had lower rates of contraceptive use due to the inaccessibility of the products. Also, these rural areas had lower levels of literacy than urban areas which meant that these populations were not as educated about reproductive health as those living in urban areas (2,5,6,9). The study also noted that women were the primary or shared decision-makers in determining whether to use contraceptives. Women living in Port-Au-Prince were more likely to make the decision to use contraceptives and this trend was similar in both Pignon and Leogane. (5). The study identified that women who did not use contraceptives were usually pregnant, desired more children, had to accept husband’s opposition, or were concerned with adverse side-effects (5). It is important to understand the underlying cultural belief regarding children in Haiti, which is that having many children is believed to connote virility and fertility. The ability of women to produce children also secures their financial position in society (5). Reducing the number of children may have socio-cultural ramifications.

Other family program initiatives in Haiti include the AWARENESS project funded by USAID and the Institute for Reproductive Health (IRH) at Georgetown University. This project implemented a family planning program in Haiti that used the standard day method (SDM) in 2007. The SDM method was designed by IRH and is a natural family planning method. SDM helps women gain a better understanding of their menstrual cycle by using color coded beads. The beads help women know when they are most fertile and that during this fertile period they should either abstain from intercourse or use other contraceptive methods (10). This method received a great deal of support from the Ministry of Health (MOH) in Haiti, mostly because it does not violate their religious beliefs (7,7). This program concluded in 2007 but the report stated that the MOH, providers and clients expressed a continued interest in this program (11). Another example of an ongoing family planning program in Haiti is the ACCESS program. This program is funded by USAID and is implemented by Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) in conjunction with other NGOs like Save the Children and Constella Futures. The program intends to test alternative service delivery approaches to contraceptive options; increase the use of modern contraceptives;improve the Lactational Amenorrhea Method by transitioning to longer-term modern contraceptive methods; educate and counsel on birth spacing and identify ways to strengthen family planning in maternal, neonatal, and child health programs(11). This program was started in 2004 and received funding for five years. At this time there is no published evaluation on the progress of this program.

An example of an effective campaign that produced positive results by increasing access to condoms was social marketing condom campaign. The goal of this campaign was to prevent HIV/AIDS and STIs by increasing access to condoms among Haitians living in remote rural areas of Haiti. Population Services International PSI) began working on social marketing of condoms in Haiti in 1989. The social marketing model used in Haiti was community-based distribution (CBD). This model utilizes non-professional sales agents who represent specific groups within the general population. These agents receive basic training in Information, Education, and Communication (IEC) and sales. These agents receive small financial incentives based on how many products they sell. The advantages of this program in Haiti were that the sales agents had a substantial amount of credibility within their communities because they were from the community that they served. Also, clients knew where their distributers lived and this increased their access to condoms. The agents also provided their clients with privacy and discretion because they created a one-on-one sales relationship. The agents also provided counseling for those that had individual needs and they also provided educational services that included proper condom usage and frequency of use.

Challenges Faced by Family Planning Programs in Haiti

The research by Maynard-Tucker in 1996 suggestedthat the following factors contribute to low use of contraceptives in Haiti: strong pronatal values within Haitian society, ambiguity of unions, women’s desire for children as a means of emotional and economic stability, and high levels of illiteracy among both genders(5). This study also found that those that express an interest in using family planning will not always follow up with usage. At the time of this study, individually tailored family programs where women can receive one-on-one counseling do not exist. The study also found that family planning providers lack cultural competence and as a result providers are not able to connect with their clients (5). Further results of the mini-surveys conducted indicate that women require support from their community health workers when making family planning decisions because even though they make decisions regarding family planning on their own it can lead to conflict between themselves and their partners. Maynard-Tucker also recommends that information, education, and communication (IEC) be used to help combat the high levels of illiteracy among both men and women. Maynard-Tucker also recommends that more women be added to the community health worker task force because women providers can increase trust between the providers and the clients based on shared physiology (5)

The limitations of the AWARENESS program were that it was not able to follow the designated plan because of political upheaval during the implementation phase (7). Second, there was a lack of commitment on the side of the stakeholders which meant that there was a break down in the central supervision system (7). In addition there was a lack of funding for technical assistance and the ability to procure commodities (7).

The limitations of the PSI social marketing condom campaign were that there was conflict between the missions of NGOs and the social marketing missions. Also, the program found that socio-economic status weighed heavily on client access to condoms. Those living in the cities and who were wealthy were more likely to be reached than those who lived in the target rural areas. Also, as a result of the selective selling process the intended educational goals were not being reached either. This problem was however, caught early in the program and was remedied with strict monitoring and training modules. The program also noted that political strife impacted the project because of the periodic coups that occurred during the mid 1990s. Also, the economic embargoes on fuel and raw materials cause a spike in unemployment which affected condom sales. The CBDs diligently worked through these obstacles by creating innovative selling outlets and continued advocacy on the prevention of AIDS. By doing so the CBDs provided stability to the program.


The key stakeholders includethe clients, the people at the receiving end of these services. These are the women and men of reproductive age. Other stakeholders include medical providers. The health providers need to work with the clients and find the most suitable family planning method for their needs. The MOH is critical because they represent the public health sector. Donors like USAID are critical in funding the MOH and building their capacity. The NGOs are important stakeholders because they comprise a third of the private health sector in Haiti.In order to increase usage of modern contraceptives, it will be necessary to work with all the stakeholders and to observe the sensitive nature of the existing cultural values.

Programmatic Response

The family planning programs mentioned have all worked within the constructs of the national framework. They have noted deficiencies that have arisen and they include the power relationship between women and men, the need for more funding, as well as the need for increased cultural competency among health care providers, and the obstacles that are imposed sociopolitical issues.

The overall goal of this program is to increase access to family planning services for women living in rural and remote areas in Haiti in an effort to address the unmet need for modern contraception for this vulnerable population. The specific objectives for this program are as follows:

  1. Increase cultural competency among health care providers in order to provide quality family planning services
  2. Increase access to existing family planning service outlets in remote areas by increasing the number of intermediate service delivery points
  3. Increase awareness of modern contraceptives available to women through the use of mass media campaigns

Proposed Interventions in the context of the Program Objectives

Objective 1: To increase cultural competency among health care providers in order to provide quality family planning services