PORT-AU-PRINCE -- Sitting outside the black door facing the open courtyard of the maternity center, Judeline Bertilus became increasingly impatient.
The visit was supposed to be brief. At least thats what she told her live-in boyfriend and father of her 4-year-old daughter when she slipped out of the house, saying she had to lend a friend some money.
I am doing it without him knowing, Bertilus said, explaining that she was secretly on birth control and had come to the center at Petite Place Cazeau to get her regular three-month contraceptive shot.
Financially, things are not good, she said. There are no opportunities. I already have one child, so I have to think about her before I think of having another.
Bertilus is part of a changing dynamic in Haiti. In this male-dominated nation, women dont always have access to modern birth control, which leads to unsafe, clandestine abortions for unwanted pregnancies. Bertilus is part of a growing number of women who are breaking away from social and religious taboos about the use of contraception and taking control of their own bodies even if they have to do it secretly.
The change is happening as health and human-rights advocates sound the alarm over the number of women and girls losing their lives and wombs to unsafe abortions in a country where abortion is illegal, and as Haitis health ministry tries to get a grip on the countrys maternal mortality crisis.
Every woman who wants to do planning will find a way, said Reynold Grand Pierre, the Ministry of Public Health and Populations director of family health.
President Michel Martelly, who has publicly urged Haitians to consider having smaller families, issued a presidential decree earlier this year requiring all public and private health institutions to provide free contraceptives and counseling to any woman who wants them. If an institution, for religious reasons, is not comfortable doing so, it must refer the woman to a place that will.
To bolster the push, the ministry in January plans to blanket the country with billboards, text messages and mass-media messages about the benefits of contraception, Grand Pierre said.
Right now, 35 percent of health institutions dont offer family planning of any kind. Thats why we are working so hard to change that and to ensure they have all of the supplies they need to provide free family planning. That is the fight we are engaged in, Grand Pierre said.
For every 100,000 babies born in Haiti, 630 women die of pregnancy-related causes, according to 2005 national health statistics, the latest year available. And while some international aid organizations believe the number has dropped to 350 maternal deaths since then, the ratio is still more than twice that of the neighboring Dominican Republic.
Maternal mortality is defined by the World Health Organization as the death of a woman while pregnant, or within 42 days of terminating a pregnancy.
The number of post-abortion deaths in Haiti is unknown, but physicians say post-abortion complications are a leading cause of maternal death, with the health ministry estimating it could possibly account for as many as 30 percent of them.
This is a public-health problem, said Danièle Magloire, a leading feminist who believes decriminalizing abortion in Haiti will help decrease the number of maternal deaths because many young girls and poor women, fearing criminal prosecution, do not seek medical attention after abortion complications arise.
A lot of young girls are having abortions because there isnt any access to contraception, Magloire said. The issue isnt that they are having sexual relations. The issue is that when you are engaged in sex, you could become pregnant because in Haiti access to contraception for women is very weak.
But advocates of access to universal birth control view the matter differently.
The best way of preventing abortion from happening and the best way of making sure women are safe is to provide them access to family planning, said Ramiz Alakbarov, Haiti representative to the United Nations Population Fund (known by its French acronym UNFPA).
Reducing maternal mortality without access to family planning is not possible, he added.
The use of modern contraceptives in Haiti by married women increased this year to 31 percent from 25 percent in 2006, according to the recently published Ministry of Health demographics health study.
Despite the increase by six percentage points, the use of condoms and injectables remains among the lowest in the Western Hemisphere. Meanwhile, 35 percent of married women said they would like to space out or limit their children, but lack access to modern methods. That unmet need can be seen in the countrys staggering birth rate.
Six out of 10 women in Haiti who already have two kids say they would like to remain there. But the fact is, the average is 3.5 kids per woman, so there is a gap, said Grand Pierre.
Haitis contraception challenge can be seen at any maternity hospital, including the neighborhood clinic established by UNFPA and the health ministry in Petite Place Cazeau, an impoverished community in the capital. The clinic offers a range of basic services from free contraceptives to posnatal care.
At one end of the earthquake-ready building, pregnant women walk up and down a dusty parking lot holding their swollen stomachs, trying to induce labor. Inside, amid the merciless screams of natural childbirth, new mothers shrug off going on birth control. Some invoke social and religious taboos, while others insist their partners wont agree. Others said they tried it but stopped after frightening missed menstrual periods, raised blood pressures and other ailments.
I will just be careful, Wilaine Dessources, 29, said as head midwife Mariame Ovedrago showed her how to properly breastfeed week-old son Aschna Jean-Baptiste. The baby, she concedes, was unplanned.
For every Dessources, however, there are those who quietly slip into the buildings other wing, and take a seat outside the family counseling door with logo of the U.S. Agency for International Development (USAID). Waiting their turn, the women say they no longer subscribe to the old Creole adage that children are poor peoples riches, and instead cite the difficult financial times as their main reason for seeking help.
Day by day things become increasingly difficult. You have to do planning so you dont bring more children into this misery, said Berna Louis, 28, who said she would like to have two children but for now is sticking with just her 18-month-old daughter, Michaella Noijuste.
Sitting not far away, a soft-spoken Juvukha Laguerre, 16, listens. The teen is pregnant, and is just weeks away from delivery. Birth control, she said, isnt a priority. She said she plans to practice abstinence after her child is born.
I am just going to stay to myself, she said as she waited for her check-up appointment.
Dr. Joan Lysias, a public-health doctor with UNFPA, said family planning counselors hear myriad excuses from married women and single girls about why they dont want to go on birth control from their religious faith to not being in a steady relationship to the belief that contraceptives are only for married women.
But Lysias also sees women and men increasingly making decisions about sex, a subject that is taboo in Haiti. Some women, she said, even ask that birth control implants be hidden so their partners cant see them.
Sometimes, when you explain to the men why family planning is good for them, too, they get it and agree, she said.
Officials with UNFPA and USAID say they welcome the Haitian governments family planning initiative. Together, they are training counselors and working with various organizations to ensure that free contraceptives are available throughout Haiti.
The challenge in Haiti is to make sure every woman is educated about family planning and make sure every woman has access to the methods, Alakbarov said. For us, what is most important is to always provide women with good education, prenatal care, post-natal care and access to family planning so that the issue of abortion does not arise.