In Latin America, an exception to falling birth rates draws new scrutiny

Dramatic progress has masked the fact that poor communities are lagging far behind wealthier ones in controlling family size—perpetuating inequality.

Simeus holds the youngest of his four daughters in Central Plateau, Haiti.© 2014 C. Hanna-Truscott/Midwives for Haiti, Courtesy of Photoshare

Like most of her peers, Renata Stuart has—and wants—only one child. That’s a big change from previous generations: Ms. Stuart grew up in Rio de Janeiro with three siblings, while her mother had 10.
“I saw the effect it had on [my mother and grandmother’s] lives,” she says, as she totes her 3-month-old son around a buzzing children’s party. For Stuart, who is in her late 30s, completing her education and advancing her career were priorities.

Across Latin America, the stereotype of the large, young family is being challenged as fertility rates plummet. Girls’ access to education has improved, greater numbers of women have entered the workforce and gained more control over their finances, and family planning methods have expanded in recent decades. In Brazil, one of the most dramatic examples, mothers now have 1.7 children on average—from 6.3 children in 1960. That’s lower than the U.S. birth rate, and signals a shrinking population.

The trend is generally viewed as a good thing—evidence of a wealthier and healthier society, where parents aren’t operating under the assumption that a child may die from malnutrition or disease. It reflects a higher number of girls staying in school and then working. And it signals changed attitudes toward women’s central roles.

But falling national fertility rates may mask a nagging problem across the region: inequality. While Stuart and her peers are choosing the number of children they would like to have, women in rural areas or in poorer urban enclaves are often having more children than they express wanting, outpacing national and regional averages.

The rich-poor divide has been overlooked, in part, due to the positive national declines that led to the withdrawal of or decreases in funding for maternal health efforts, experts say. But from southern Mexico to Brazil, and El Salvador to Panama, awareness of the dichotomy is growing, and prompting efforts to get more nuanced assessments of what’s really happening in order to ease poverty and inequality.

Mama Juana Perugachi, a midwife working at Jambi Huasi, a primary health clinic in Otavalo, Ecuador, focused on integrating western medicine and traditional Andean practices.© 2014 Kimberly Salazar, Courtesy of Photoshare

“What really surprised me … in this region is that there were still some communities that had the same low access to services and quality care as we find in the poorest communities in Africa and Asia,” says Mariam Claeson, director of maternal and newborn health for The Bill and Melinda Gates Foundation and who works on the Mesoamerican Health Initiative, a public-private partnership that targets the poorest 20 percent of populations in Central America and southern Mexico to provide increased access to maternal health services and education.

“We have been a little too comfortable with our average indicators for maternal and newborn health,” adds Emma Margarita Iriarte, who manages the Inter-American Development Bank’s (IADB) contributions to the same project.

So far, the Mesoamerican health program has seen some positive results in short order, suggesting that awareness has been crucial. In an 18-month time frame, for example, almost all of Nicaragua’s poorest health clinics were able to offer modern family planning methods, a 30 percent rise. Panama also boosted availability of supplies to nearly 100 percent of its poorest community clinics, up from 10 percent. And in El Salvador, almost 80 percent of clinics now have working refrigerators—a crucial supply storage tool—up from about 43 percent before the intervention was launched. Guatemala and El Salvador have also seen progress.

Community health workers conduct home visits to deliver health education, vaccines, and checkups to children under five in rural Léogâne Commune, Haiti.© 2014 Lauren Zalla, Courtesy of Photoshare

‘Unsatisfied Demands’ for Family Planning

In Mexico, where women have 2.2 children on average, there’s been nearly a one-third drop in fertility since the 1970s. But the disparity based on income and region is readily evident.
Fruit-seller Lara Torres, who grew up with four siblings and whose mother had seven brothers and sisters, decided early on that she wanted to keep her family small.

“I wanted more flexibility to give my kids things my parents couldn’t give me, to move [my family] ahead,” says the Mexico City resident, mentioning the possibility of luxuries like a bilingual education or family vacations.

But Ms. Torres says she got pregnant unintentionally when she was 18. She now has four kids, two more than she’d hoped or planned for.

That’s troubling for people like Ms. Iriarte from the IADB. She says even when most women across the region are reporting they want fewer children than past generations, those in the poorest 20 percent of the population often end up having more than their “ideal” number.

Many Latin American countries have national healthcare systems, but most still struggle to deliver widespread, high-quality services. Some, like Mexico, Brazil, Nicaragua, and Honduras tie a handful of such services—like giving birth in a hospital or using contraceptives after delivering a child—to conditional cash-transfer welfare programs, which are linked to recipients’ behavior.

In some cases, governments have difficulty supplying health clinics in rural areas or informal urban settlements. A lack of sexual education or qualified health providers is common in the most impoverished communities, experts say. Some countries, like Honduras, require that medical students spend the last year of their education programs working in less desirable posts like rural towns, which can lead to frequent turnover and less experienced service providers.

A pregnant woman in Central Plateau, Haiti, waits for care given by a graduate of Midwives for Haiti.© 2014 C. Hanna-Truscott/Midwives for Haiti, Courtesy of Photoshare

Getting kids to stay in school is also important, but rural schools in particular may not teach past the fifth grade. In Brazil, the most recent government data shows that women with four or fewer years of study have on average one more child than they want.

In Panama, about 68 percent of the overall population uses some form of contraception, while that figure is just 9 percent in typically poor indigenous communities.

“That’s a [nearly] 60 percent gap in the same country. In a country that’s one of the richest in the region, that has resources,” says Iriarte.

In Chiapas, one of the poorest states in Mexico and home to one of the country’s largest indigenous populations, midwife Cristina Alonso Lord points to discrimination and a lack of cultural understanding. She says many rural, indigenous communities are misinformed about what contraception methods are available to them and how they might affect their bodies. Myths, like the idea that taking birth control will increase a woman’s sexual appetite, are also deterrents in these typically conservative communities.

A grandfather in Central Plateau, Haiti, smiles as he holds his granddaughter, while the baby's father exchanges smiles with his daughter.© 2014 C. Hanna-Truscott/Midwives for Haiti, Courtesy of Photoshare

“There isn’t great communication between doctors and patients in Mexico,” says Ms. Alonso Lord, who practiced in the state before opening a practice in Mexico City two years ago. “But it’s even worse when it comes to indigenous populations.” She cites examples like hospitals that won’t let a mother leave after giving birth without a method of contraception, yet don’t give the mother a chance to really ask questions.

“What is needed is … for mothers to be able to make decisions based on their vision for their own lives instead of being told by a doctor what they are required to do,” she says.

Still, progress has come quickly in some areas that have gotten more targeted help.

“There are unsatisfied demands for family planning,” says Esteban Caballero, the Latin America regional director for the United Nations Population Fund. “It creates a situation where child rearing and education, and the possibility of helping children to take advantage of certain opportunities, becomes more difficult and challenging.

“The consequences of not having [the tools] to decide family size reach into the future,” says Mr. Caballero. “The poor are more likely to stay poor.”

Women in Central Plateau, Haiti, wait for access to skilled prenatal, postpartum, and gynecological care provided by graduates of Midwives for Haiti.© 2014 C. Hanna-Truscott/Midwives for Haiti, Courtesy of Photoshare

A family planning user and a health promoter discuss contraceptive methods in El Quiché, Guatemala.© 2014 Haydee Lemus/PASMO PSI Guatemala, Courtesy of Photoshare

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