A year after the devastating earthquake in Haiti last January, the situation on the ground remains grim: more than a million people are still living in tents, less than 5 percent of the rubble has been cleared from Port-au-Prince, and now a cholera epidemic, which has already taken thousands of lives, is raging across the country. Despite pledges to "build back better," international efforts in Haiti are struggling just to provide relief. The window for transformative change is closing. Donor fatigue is setting in, and new commitments are slowing to a trickle. Reality demands doing more with less, which is why it is so critical to invest in women. As demonstrated in other post-conflict and post-disaster situations, investments in women can have a significant payoff in terms of health, economic growth, and stability for the whole society. In Haiti's case, one area in particular -- midwifery training for women -- deserves support.
Haiti has the worst maternal health statistics of any country in the Western hemisphere (and among the worst in the world). Prior to the earthquake, only a quarter of births were attended by trained personnel, compared with 98 percent of births in the neighboring Dominican Republic. Its maternal mortality ratio of 630 deaths per 100,000 live births ranks it alongside some of the poorest countries in Africa. A Haitian woman is seventy times more likely to die in childbirth than an American woman, a fact that serves as a marker of the country's nonexistent healthcare system, poor transportation, low education levels, and deeply rooted cultural practices that encourage women to stay at home during delivery. The challenge of fixing all these problems is overwhelming, but there are some cost-effective solutions that can make a difference.
Experience from Afghanistan has shown that investing in midwifery can significantly reduce maternal mortality, even under the harshest circumstances. Midwives are significantly less expensive to train and maintain than doctors, they can be drawn from local populations with low educational levels, and as "local daughters," they are more likely to be accepted and trusted by, and continue to serve, hard-to-reach rural communities. Over the past seven years, the number of midwives in Afghanistan has risen from fewer than 500 to more than 2,000. Deliveries attended by skilled personnel have more than tripled, and maternal mortality has fallen significantly, albeit from extraordinarily high levels. As important, the midwifery programs in Afghanistan are creating a generation of young, empowered women involved in the healthcare of their whole community. They are teaching mothers how to care for themselves and their infants, and helping to improve hygiene and nutrition for the family. Midwives also earn a decent living, and as professional women in the community, serve as role models to society. Becoming a midwife is now such an attractive career path for Afghan girls in rural areas across the country that applicants outstrip availability of spots, even in some of the most conservative districts where women rarely venture outside of their homes.
An expansion of midwifery programs in Haiti would not only help address the country's dire maternal mortality statistics, but also create economic, educational, and training opportunities for women. By almost every measure, women lag behind men in Haiti and their low status in society compounds many social ills. Haitian midwives can also be conduits for increasing access to family planning, as they have successfully been doing in Afghanistan and other countries. Some 40 percent of women of childbearing age in Haiti have unmet contraceptive needs. Not surprisingly, Haitian women have high fertility -- 4.7 children per woman on average. They also have the highest rate of HIV infection in Latin America, and the rate for women is higher than men. Midwives can be trained to counsel patients on family planning and HIV prevention.
Expanding midwifery and family planning programs to women across Haiti can yield long-term gains that will benefit all Haitians. Prior to the earthquake, the Haitian government had a program that was graduating 40 midwives a year, but the main training hospital in Port-au-Prince was devastated. Several non-governmental organizations, like Partners in Health and Haitian Health Foundation, also run midwifery programs with great success, but the critical need is to bring these programs to scale across the country. Building back better in Haiti increasingly seems like a pipe dream, but smart investments in programs with demonstrated high returns, like midwifery programs, can give the next generation a chance.