Effects of the 2010 Haiti Earthquake

on Womens Reproductive Health

Julia Andrea Behrman and Abigail Weitzman

This article explores the effects of the 2010 Haiti earthquake on womens reproductive health, using geocoded data from the 2005 and 2012 Haiti Demographic and Health Surveys. We use geographic variation in the destructiveness of the earthquake to conduct a difference-in-difference analysis. Results
indicate that heightened earthquake intensity reduced use of injectablesthe
most widely used modern contraceptive method in Haitiand increased current pregnancy and current unwanted pregnancy. Analysis of impact pathways
suggests that severe earthquake intensity significantly increased womens unmet need for family planning and reduced their access to condoms. The earthquake also affected other factors that influence reproductive health, including
womens ability to negotiate condom use in their partnerships. Our findings
highlight how disruptions to health care services following a natural disaster
can have negative consequences for womens reproductive health. (Studies in
Family Planning 2016; 47[1]: 317)

he 2010 Haiti earthquake was one of the most catastrophic natural disasters of the
early twenty-first century. The epicenter of the earthquake was 25 miles southwest
of the capitalPort-au-Princethe largest urban area and most densely populated
part of the country. Estimates of the death toll ranged from 50,000 to 230,000 fatalities (Kolbe
et al. 2010; Doocy, Cherewick, and Kirsch 2013). An estimated 97,000 homes were destroyed,
with another 188,000 homes damaged (WHO 2010). The earthquake also had a devastating
effect on health care infrastructure in Port-au-Prince and surrounding areas. The Ministry of
Health was destroyed; the national midwife school and nursing college both collapsed; and
half of all public-sector health facilities were destroyed or damaged to the point of being unusable (Roberts 2010). In addition, many medical providers and health administrators were
killed, including 14 percent of Ministry of Health employees (ibid.). The full impacts of the
earthquake on the health of the people in Port-au-Prince and the surrounding areas are only
beginning to be understood.
Significant sociological and demographic research indicates that preexisting gender and
socioeconomic inequalities are often exacerbated by disasters (Klinenberg 1999; Cutter,
Boruff, and Shirley 2003; Hartman and Squires 2006; Neumayer and Plmper 2007; Farmer

Julia Andrea Behrman is a doctoral student, New York University, Department of Sociology, 295 Lafayette
Avenue, 4th Floor, New York, NY, 10012. E-mail: Jab965@nyu.edu. Abigail Weitzman is an NIA
postdoctoral research fellow, University of Michigan, Population Studies Center, Ann Arbor, MI.
3

Effects of 2010 Haiti Earthquake on Womens Reproductive Health

2011). Public health researchers and practitioners have advocated for more attention to the
reproductive needs of women following natural disasters (Martine and Guzman 2002; Nour
2011; Ellington et al. 2013). Changes in womens reproductive health care following a natural
disaster can lead to increases in unwanted pregnancy, sexually transmitted infections (STIs),
pregnancy complications, and maternal mortality.
Our study uses geocoded data from the 2005 and 2012 Haiti Demographic and Health
Surveys to implement a difference-in-difference (DID) analysis. We exploit geographic variation in the destructiveness of the earthquake to assess how severe natural disaster affects
womens reproductive health and, in particular, contraceptive use and unwanted pregnancy.
We then use the same DID strategy to explore potential pathways through which the earthquake could have affected reproductive health. First, we look at the effect of the earthquake on
access to family planning. Next, we explore the effect of the earthquake on other contextual
factors that influence reproductive health, including sexual activity, partnership dynamics,
and fertility preferences.
Most public health research on disasters and reproductive health uses a nave prepost
comparison or cross-sectional comparison of affected and unaffected areas, and moreover,
the wider applicability of these studies is often limited by very small sample sizes. We use nationally representative data and a DID research design that improves upon nave estimation
by better accounting for potential confounders. Our study demonstrates the importance of a
broader focus on reproductive healthincluding access to and use of contraceptionrather
than a more narrow focus on fertility rates, in order to more fully understand the demographic consequences of natural disasters.

THE EFFECTS OF NATURAL DISASTERS ON WOMENS

REPRODUCTIVE HEALTH
A growing number of studies document the relationship between disaster and reproductive
health. For instance, several public health studies find that women faced increased difficulty
obtaining contraception after the Indian Ocean tsunami in Indonesia (Hapsari et al. 2009)
and after Hurricanes Ike and Katrina in the Gulf Coast of the United States (Kissinger et al.
2007; Hapsari et al. 2009; Leyster-Whalen, Rahmen, and Berenson 2011). A related study
found increased genital tract infections, pelvic disorders, and menstruation disorders after
the Wenchuan earthquake in China (Liu et al. 2010). In the demographic literature, fertility
increases have been documented following the Indian Ocean tsunami and following highmortality earthquakes in Turkey, India, and Pakistan (Finlay 2009; Nobles, Frankenberg, and
Thomas 2015). Taken together, these studies provide a foundation for understanding the effects of natural disasters on reproductive health, although small sample sizes and issues of
selection limit the generalizability of several of the aforementioned studies.
Womens reproductive health may be negatively affected by natural disaster if their access
to reproductive health care and modern contraception is diminished (Martine and Guzman
2002; Nour 2011; Ellington et al. 2013). Reduced access to contraception and health care could
result from the destruction of health care services or from increased difficulty in gaining access to services because of destroyed infrastructure or diminished economic resources (ibid.).
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Natural disasters may also affect womens use of contraception and health care by shifting
institutional medical priorities away from reproductive health and toward emergency relief
(Martine and Guzman 2002; Claeys 2010).
The effects of diminished reproductive health care on womens health and wellbeing are
multifaceted. Diminished contraceptive access could force women to change from more effective to less effective means of contraception or to stop using contraception. High unmet need
for family planning makes women more vulnerable to unwanted pregnancy (Casterline and
Sinding 2000). Womens risk of pregnancy complications and death during childbirth, already
common in poor countries, can become heightened when health infrastructure is damaged
(Nour 2011). Lack of reliable access to condoms puts both women and men at higher risk
of sexually transmitted infections, with evidence suggesting that women are more vulnerable
than men to STIs (Padian, Shiboski, and Jewell 1991).
Natural disasters also affect other social and contextual factors that influence womens reproductive health. For example, natural disasters frequently coincide with increases in sexual
trafficking and sexual violence against womensituations where women have little control
over reproduction and contraceptive use (Martine and Guzman 2002; Nour 2011). Demographic research suggests that high-mortality disasters may also alter womens fertility preferences in ways that contribute to fertility increases. The common explanation for changing fertility preferences following disasters is that women want to replace deceased family
members or compensate for family and community loss (Schultz 1997; Finlay 2009; Nobles,
Frankenberg, and Thomas 2015). Post-disaster rises in fertility may reflect proximity-seeking
and increased attachment in response to threat (Cohan and Cole 2002); reaffirmed commitment to traditional institutions such as the family or the community (Rodgers, St. John, and
Coleman 2005); or discounting the future at higher rates (Raschky and Wang 2012).

REPRODUCTIVE HEALTH CARE IN HAITI BEFORE AND

AFTER THE EARTHQUAKE
Prior to the earthquake, Haiti had the highest levels of malnutrition and maternal mortality
in the Western hemisphere, and the highest HIV rate outside of sub-Saharan Africa (Claeys
2010; World Bank 2012). For decades, public health infrastructure had been undermined by
chronic underinvestment and political instability (Farmer 2011). Ancillary health services
were provided by a large number of international NGOs, although critics argued that the proliferation of NGOs led to further deterioration of the public health system and fragmentation
of health services (ibid.). Nonetheless, concerted efforts by health care providers led to improvements in womens reproductive health care over time. For example, between 1994 and
2012 the proportion of sexually active women using modern forms of contraception more
than doubled, from 12 percent to 26 percent (DHS 2012).
The health care infrastructure in Haitis capital region was severely damaged by the earthquake, including the destruction of hospitals and medical training facilities (Roberts 2010).
Medical centers that were not destroyed faced considerable operational challenges such as
lack of equipment, staff, and salaries. In response to these challenges, there was an enormous outpouring of humanitarian aid providing emergency care and basic health services,
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Effects of 2010 Haiti Earthquake on Womens Reproductive Health

including reproductive health care. Organizations such as PROFAMIL, the Haitian Institute
for Health and Community Action, and UNFPA provided contraception and obstetric care
in mobile clinics throughout Port-au-Prince (Claeys 2010; UNFPA 2011). Nevertheless, postearthquake relief efforts were often poorly coordinated, leaving significant gaps in coverage
(Farmer 2011).
Approximately 63,000 women in Port-au-Prince were pregnant at the time of the earthquake (Claeys 2010), and a recent study found that post-earthquake births were at higher risk
of being low birth weight, calling attention to the likelihood that the disaster diminished prenatal health care (Harville and Do 2015). A study of women residing in displacement camps
five months following the earthquake found that almost 12 percent were pregnant and that
two-thirds of these pregnancies were unwanted (UNFPA 2011). Moreover, increases in sexual assault and violence against women were also reported in displacement camps (Farmer
2011), thus highlighting womens need for emergency contraception and STI testing.

EMPIRICAL STRATEGY
Data
Data for this analysis come from the 2005 and 2012 Demographic and Health Survey (DHS)
in Haiti. The DHS, a population-based survey of women aged 1549 collected by ICF International in collaboration with host-country governments, includes information about fertility
history, fertility preferences, contraceptive use, contraceptive access, prenatal care, and child
mortality. The 2012 DHS also contains a detailed module on the 2010 earthquake, including
questions on displacement, destruction, mortality, and morbidity.

Sample and Treatment Assignment

Haiti is divided into ten administrative departments, and the epicenter of the earthquake
occurred in the Ouest department close to Port-au-Prince (Figure 1). We use the Mercalli Intensity Scale to quantify geographic variation in earthquake-related destruction. The Mercalli
Intensity Scale is an internationally recognized scale that quantifies the effect of earthquake
destruction independent of seismic magnitude. It is the preferred measure of social science
researchers because it captures the effect of earthquakes on people, buildings, and the environment (Scawthorn 2003). Measures focused on earthquake magnitude, such as the Richter
Scale, may be misleading because an average-magnitude earthquake may cause sizable destruction in a poor country with weak infrastructure and minimal damage in a wealthier
country with sound infrastructure.
We combine geocoded DHS data with United States Geological Survey (USGS) generated Mercalli Intensity Scales for each administrative cluster in the DHS data (the smallest
geographic unit in the DHS). This allows for the calculation of the mean score for each department (Table 1). Analysis is conducted at the department, rather than the cluster level,
because clusters are not constant between the 2005 and 2012 DHS. Furthermore, conducting
analysis at the department level helps to mitigate concerns about bias due to earthquakeinduced migration. Average department-level Mercalli scores for Haiti varied considerably,
ranging from 7.95 (violent) in the Ouest to 4.61 (moderate) in the Nord.
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FIGURE 1 Intensity of the 2010 earthquake in Haiti

Difference-in-Difference
Our analysis uses department-level variation in the destruction of the earthquake to assess
the effects of the earthquake on reproductive health outcomes using a difference-in-difference
(DID) analysis. We estimate the DID by running an OLS regression of reproductive health
outcomes on a time period indicator (t) where t = 0 if the survey year is 2005 and t = 1 if
the survey year is 2012; an earthquake intensity (i) variable that takes the continuous value of
the average Mercalli score for the department; and an interaction between intensity and time
period (DID) (equation (1)). The coefficient 3 in equation (1) is the difference-in-difference
term and can be interpreted as the effect of a one-unit change in the departmental Mercalli
score on the outcome of interest.
 
(1)
E y = 0 + 1t + 2 i + 3t i + . . . k Xk
We use linear models for all DID analyses (Puhani 2012). All standard errors are clustered at the primary sampling unit level. Covariate controls are included for respondent background characteristics including age (<19 years, 2029 years, 3034 years, and 35 years or
older), religion (Catholic, Protestant, other), parity at earthquake (0 children, 1 child, 2
3 children, 4 or more children), schooling (no formal schooling, primary schooling, secondary schooling), and urban residence.1 We do not include controls that could be considered
1 For women in the 2012 sample, we calculate parity at the time of the earthquake using the child birth/death register. For
women in the 2005 sample, we calculate parity in a comparable reference period two years prior to the survey using the child

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Effects of 2010 Haiti Earthquake on Womens Reproductive Health

TABLE 1

Descriptive statistics comparing 2005 and 2012 (mean)

Modern contraception
Injectable as main method
Condoms as main method
Condom at last sexa
Current pregnancy
Current unwanted pregnancy
Birth in last 12 mo.
Unmet need for contraception
Access to condoms
Sexually activeb
Can ask partner to use condomc
Can refuse sex with partnerd
Desire no more childrene
Desire children in next yearf
Preferred interval to next child (years)f
Catholic
Protestant
Other religion
<19 years
2029 years
3034 years
35+ years
0 children at earthquake
1 child at earthquake
23 children at earthquake
4+ children at earthquake
No schooling
Primary schooling
Secondary schooling
Urban residence
Residing in camp
Sample size

2005

2012

0.18
0.07
0.06
0.11
0.06
0.04
0.12
0.25
0.76
0.80
0.76
0.86
0.37
0.20
3.90
0.47
0.46
0.07
0.25
0.35
0.12
0.28
0.47
0.14
0.19
0.20
0.23
0.39
0.38
0.47
0.00
10,757

0.22
0.12
0.06
0.21
0.06
0.04
0.11
0.24
0.84
0.81
0.86
0.83
0.37
0.17
4.18
0.39
0.53
0.08
0.23
0.37
0.13
0.27
0.50
0.17
0.19
0.14
0.15
0.36
0.49
0.47
0.04
14,287

NOTE: Weighted using survey weights provided by DHS. With the exception of interval to next child, all variables are dichotomous indicators
with values ranging from 0 to 1.
a
Asked only of women who are sexually active (n = 17,276).
b
Missing information on 7 respondents.
c
Asked only of women in current partnerships (n = 14,225)missing response to this question for 3,087 women in current partnerships.
d
Asked only of women in current partnerships (n = 14,225)missing response to this question for 3,377 women in current partnerships.
e
Excludes infecund women and missing information (n = 592).
f
Excludes women who do not desire more children and women who gave non-numeric responses (n = 11,825).

post-treatment, for example wealth in 2012, because the earthquake may have affected these
variables. The one exception is urban residence, which we include because the earthquake
disproportionately affected urban areas. As a sensitivity analysis we rerun all models without
the urban variable and find the results to be substantively similar (available upon request).
The DID is an improvement over nave prepost comparisons of affected areas or nave
cross-sectional comparisons of affected and unaffected areas because there may be unobserved differences between individuals or departments that cannot be accounted for by controlling for respondent background characteristics. If this is the case, nave estimates will
misstate the estimate by partially incorporating unobservable characteristics. Thus, it would
be impossible to know whether it was the earthquake or unobserved characteristics that led
to the changes in contraceptive use and other reproductive outcomes. Researchers have previously used DID to examine the effects of natural disasters on health outcomes, including
birth weight (Torche 2011), sex ratios at birth (Torche and Kleinhas 2012), and total fertility
(Finlay 2009).
birth/death register. It is important to calculate parity prior to the earthquake because fertility preferences and behaviors may
be altered by child mortality during the earthquake.

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Assumptions and Limitations of the Model

The largest limitation of our analysis is the fact that the Ouest, the most severely affected
department, has historically had the highest level of urbanization, thus making it difficult to
find an appropriate counterfactual for what would have happened in the Ouest in the absence
of the earthquake. To address this point, we control for potential confounders such as urban
residence and conduct a sensitivity test to assess the robustness of our results to alternative
treatment specifications (Appendix 1).2 We also conduct a sub-group analysis where we interact the DID term with the urban residence variable to assess whether the earthquake had
differential impacts on urban and rural communities (Appendix 2). The results of both of
these analyses are discussed in the section on sensitivity tests.
Another concern with our analysis is whether earthquake-induced mortality altered the
population composition in a way that biases our estimates. Earthquake fatalities were largely
concentrated in the Ouest (Kolbe et al. 2010; Doocy, Cherewick, and Kirsch 2013). A cholera
epidemic following the earthquake also led to high mortality throughout the country (Farmer
2011). Post-disaster mortality is often concentrated among poorer populations because of
pre-existing social, economic, and health vulnerabilities (Klinenberg 1999; Cutter, Boruff,
and Shirley 2003; Hartman and Squires 2006). If mortality was concentrated among the poor
in post-earthquake Haiti, then our effects may be downwardly biased because the poorest
women who would likely face the greatest difficulty obtaining reproductive health care following the earthquake could have been at higher risk of earthquake mortality and may therefore be disproportionately unrepresented in our sample.
A final concern is the potential for bias from earthquake-induced migration from the
Ouest into other regions of Haiti. The mass destruction of the earthquake in the Ouest
led to enormous population displacement, including an estimated 1.5 million people who
moved into internally displaced person camps in Port-au-Prince and surrounding areas
(Bengtsson et al. 2011; Lu, Bengtsson, and Holme 2012; Sherwood et al. 2014). Nonetheless,
earthquake-induced migration was predictable and highly localized. Analysis of cellular network data found that over 70 percent of people who moved after the earthquake stayed within
50 kilometers of the center of Port-au-Prince (Lu, Bengtsson, and Holme 2012). International
migration was minimal following the earthquake since wealthier countries in the Western
Hemisphere maintained closed-border policies and the neighboring Dominican Republic
also sought to limit migration.
Earthquake-induced migration could introduce upward bias if wealthier populations
had resources that made them more likely to leave the Ouest than poorer populations. Alternatively, migration could induce downward bias if wealthier populations were less affected by the earthquake and therefore more likely to stay in the Ouest than poorer populations. Nonetheless, concerns about migration-related bias are mitigated by the fact that
most long-term migration occurred within the Ouest (Lu, Bengtsson, and Holme 2012), and
our analysis is conducted at the department level. Furthermore, a prepost comparison of
observable household characteristics in the Ouest indicates that basic characteristics
including age and education of household head, number of household members, and
2 Appendixes are available at the supporting information tab at wileyonlinelibrary.com/journal/sfp.

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Effects of 2010 Haiti Earthquake on Womens Reproductive Health

urban residenceremained fairly stable before and after the earthquake (Appendix 3).
If earthquake-induced migration had led to a major change in population composition, then we would expect these characteristics to have changed between pre and post
periods.
As a crude assessment of how our estimates might be biased by migration, we limit our
DID analysis to the sample of respondents currently living in the same home as they did prior
to the earthquake (Appendix 4). This sample should be unbiased by long-term displacement,
though potentially biased in other dimensions.3 These results are substantively similar to our
main results, further limiting concerns about migration-related bias.

Outcomes: Modern Contraceptive Use, Pregnancy, and Unwanted Pregnancy

We first consider the effects of the earthquake on modern contraceptive use, pregnancy, and
unwanted pregnancy. We measure modern contraceptive use with a dichotomous indicator of current use of any modern method such as oral contraceptive pills, implants, injectables, intrauterine devices, male or female condoms, male or female sterilization, lactational
amenorrhea, and emergency contraception (WHO 2015). Next, we look at current use of injectables as the main method of contraception. Injectables were the most commonly used
form of contraception prior to the earthquake (Table 1) and are viewed by medical practitioners as more reliable and less prone to human error than condoms (WHO 2015). We also
look at a dichotomous indicator for current use of condoms as the main method of contraception. Condoms were the second most widely used contraceptive prior to the earthquake
(Table 1) and also protect against STIs. As an additional measure we consider a dichotomous indicator of whether the respondent used a condom during her most recent sexual
encounter.
We assess the effect of the earthquake on current pregnancy with a dichotomous indicator of whether the respondent is currently pregnant at the time of the survey. In addition,
we include a dichotomous indicator of whether the respondent is currently pregnant with a
pregnancy that is unwanted at the time of survey.4 One limitation of the pregnancy outcome
variable is that rates of pregnancy may be correlated with seasonal variation and may reflect
the differential timing of data collection between survey rounds.5 To account for this, we also
include an outcome indicator for whether the respondent had a birth in the last 12 months,
with the caveat that not all pregnancies might be carried to term, particularly in a high-stress
context.

3 The 2012 DHS included a special module on the 2010 earthquake that asked whether the respondent was living in the current
residence at the time of the earthquake. However, the DHS does not generally collect information about change of residence
in the recent past. For this robustness check we exclude only women who report living in a different residence at the time
of the 2010 earthquake. We recognize that this is a crude assessment since (a) we are unable to exclude women in the 2005
survey who changed residence in the recent past because of the lack of data; and (b) women in the 2012 sample who reside
in the same home as they did prior to the earthquake may have been less affected by the earthquake than women who no
longer reside in the same home.
4 All current pregnancies that are reported to be unwanted at this time are coded as unwanted.
5 The 2005 DHS was collected between October 2005 and May 2006, and the 2012 DHS was collected between January 2012
and June 2012.

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Impact Pathways
Access to Contraception

To explore the effect of the earthquake on access to contraception and reproductive health services, we use a dichotomous indicator of current unmet need for family planning constructed
using the most recent DHS specification (Bradley et al. 2012). A woman has an unmet need
for family planning if she does not want to become pregnant at the time of survey but is not
using contraception. In addition, we include a dichotomous indicator of current knowledge
about where to obtain condoms.
Sexual Activity, Partnership Norms, and Fertility Preferences

We examine additional contextual factors that could influence womens use of contraception
independent of access to contraception. First, we look at the effect of the earthquake on sexual
activity and partner dynamics related to contraceptive use. We use dichotomous indicators for
whether the respondent is sexually active, whether the respondent can ask her partner to use
a condom (partnered women only), and whether the respondent can refuse sex (partnered
women only).6
Finally, we look at indicators of fertility preferences to gauge whether preferences changed
in a high-mortality context. These indicators include a dichotomous measure of desire for no
more children, a dichotomous measure of desire for more children in a year or less, and a
continuous measure of desired interval to the next child. The latter two outcomes are asked
only of women who report a desire for more children.

RESULTS
Effect of the Earthquake on Contraceptive Use, Pregnancy, and Unwanted
Pregnancy
Between 2005 and 2012 the proportion of women in Haiti using a modern method of contraception rose from 18 percent to 22 percent (Table 1), consistent with the upward trend in
contraceptive use before the earthquake. The proportion of all women using injectables as
their main form of contraception increased from 7 percent in 2005 to 12 percent in 2012, and
the proportion of contracepting women using injectables as their main form of contraception increased from 39 percent to 54 percent. Meanwhile, the proportion of all women using
condoms as their main form of contraception remained constant at 6 percent between 2005
and 2012, and the proportion of contracepting women using condoms as their main form of
contraception declined from 31 percent to 27 percent over the same period. The proportion
of all women who reported using a condom during their last sexual encounter increased from
11 percent to 21 percent between 2005 and 2012.
The DID analysis indicates that the earthquake had heterogeneous effects on contraceptive use. There are no significant effects on womens probability of currently using any
modern method of contraception (Table 2, column 1). Upon disaggregating by type of
6 When we re-run all analyses limiting the sample to sexually active women, results are unchanged.

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12

TABLE 2 DID estimates of the effect of earthquake intensity on current contraceptive use and
current pregnancy
(1)

(2)

(3)

(4)

(5)
Pregnant

(6)
Current
pregnancy
unwanted

Variable

Modern
method

Injectables

Condoms

Condom
at last sex

Intensity
Year 2012
Intensity Year 2012
Observations

0.00
0.10**
0.01
25,044

0.00
0.12***
0.01**
25,044

0.00
0.01
0.00
25,044

0.00
0.14***
0.01
17,276

(7)
Birth in last
12 mos.

0.01***
0.07***
0.01***
25,044

0.01***
0.05***
0.01***
25,044

0.01*
0.05*
0.01*
25,044

*Significant at p < 0.05; **p < 0.01; ***p < 0.001.

Estimates weighted using survey weights provided by DHS. Robust standard errors clustered at the primary sampling unit level. All models
control for respondent age (<19 years, 2029 years, 3034 years, 35+ years), religion, education, parity at earthquake (0 children, 1 child, 23
children, 4+ children), and urban residence.

modern method, we find that a one-unit increase in the departmental Mercalli score led to
a one-percentage-point reduction in a womans probability of currently using injectables as
her main form of contraception (column 2). This suggests sizable cumulative effects in injectable use across departments, given that there was a 3.3-point difference on the Mercalli
scale between the most and least affected departments. On the other hand, we find no significant effect of earthquake intensity on the probability of currently using condoms as the main
method of contraception or on the probability of using a condom during the most recent
sexual encounter (columns 34). The fact that we find negative effects on injectable use but
null effects on condom use could be because injectables require outside medical assistance
and thus are more difficult to distribute than condoms.
Between 2005 and 2012 the proportion of women reporting a current pregnancy and a
current unwanted pregnancy at the time of the survey remained constant at 6 percent and
4 percent respectively (Table 1). The proportion reporting a birth in the last 12 months decreased slightly from 12 percent to 11 percent. In the DID analysis, a one-unit increase in the
departmental Mercalli score led to a one-percentage-point increase in a womans probability
of current pregnancy, a one-percentage-point increase in the probability of current unwanted
pregnancy, and a one-percentage-point increase in the probability of having a birth in the last
12 months (Table 2, columns 57). Taken together, these results suggest that earthquake intensity had sizable cumulative effects on fertility in the most severely affected departments.

Effect of the Earthquake on Access to Contraception

Between 2005 and 2012 the proportion of women who reported an unmet need for contraception decreased slightly from 25 percent to 24 percent (Table 1). Over the same period the
proportion who reported knowing where to obtain condoms increased from 76 percent to
84 percent. Nonetheless, the DID analysis indicates that earthquake intensity had significant
negative effects on contraceptive access. A one-unit increase in the departmental Mercalli
score led to a one-percentage-point increase in a womans probability of unmet need for contraception and a 4-percentage-point reduction in a womans probability of knowing where to
obtain condoms (Table 3, columns 12). Thus, aggregate-level improvements in contraceptive use were not shared equally between departments that were differentially affected by the
earthquake.
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TABLE 3 DID estimates of the effect of earthquake intensity on access to contraceptives, sexual
activity, partnership norms, and fertility preferences
(1)

Variable
Intensity
Year 2012
Intensity x Year 2012
Observations

(2)

(3)

(4)

(5)

(6)

Unmet
need

Access to
condoms

(7)
(8)
Desires
Desired
next child
Can ask Can refuse
Desires no in less than interval to
Sexual partner to use sex with
a year next child
partner more children
condom
activity

0.00
0.09*
0.01**
25,044

0.02*
0.31***
0.04***
25,044

0.01
0.04
0.00
25,037

0.01
0.21***
0.02*
13,907

0.01
0.06
0.01
14,197

0.00
0.01
0.01
24,452

0.01**
0.01
0.00
13,219

0.07**
0.44*
0.02
13,219

*Significant at p < 0.05; **p < 0.01; ***p < 0.001.

Estimates weighted using survey weights provided by DHS. Robust standard errors clustered at the primary sampling unit level. All models
control for respondent age (<19 years, 2029 years, 3034 years, 35+ years), religion, education, parity at earthquake (0 children, 1 child, 23
children, 4+ children), and urban residence.

Effect of the Earthquake on Sexual Activity, Partner Dynamics, and Fertility

Preferences
Between 2005 and 2012 the proportion of women in the sample who were sexually active rose
marginally from 80 percent to 81 percent (Table 1). Over the same time period, the proportion who reported being able to ask their partner to use a condom rose from 76 percent to 86
percent, and the proportion of partnered women who reported that they could refuse sex declined from 86 percent to 83 percent. Our DID models indicate that earthquake intensity had
no significant effect on the probability of being sexually active (Table 3, column 3). However,
a one-unit increase in the departmental Mercalli score led to a 2-percentage-point reduction
in the probability that a woman could ask her partner to use a condom, although there was
no significant effect on the probability a woman could refuse sex with her partner (columns
45).
Between 2005 and 2012, the proportion of women who reported that they desired no
more children stayed constant at 37 percent (Table 1). Among women who desired more
children, the proportion who wanted children within the next year declined from 20 percent
to 17 percent, and the average desired interval to the next child rose from 3.9 years to 4.2
years. In the DID models, departmental earthquake intensity had no significant effect on
reporting a desire for no more children (Table 3, column 6). Among women who desired
more children, earthquake intensity had no significant effect on the probability of desiring
the next child within a year or on the desired interval to the next child (columns 78). Thus,
there is minimal evidence that the earthquake affected fertility preferences in a way that would
be consistent with observed fertility increases.

Sensitivity Tests
To assess the robustness of our results, we conducted sensitivity tests with alternative specifications of treatment assignment. We created a three-category variable defined as moderate
for an average department Mercalli score of less than 5; severe for an average department
Mercalli score between 5 and 7; and devastating for an average department Mercalli score
above 7. Our difference-in-difference is a comparison between changes in the most severely
affected areas (devastating) and changes in the least-affected areas (moderate). Results
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Effects of 2010 Haiti Earthquake on Womens Reproductive Health

from this sensitivity analysis are substantively the same as those of the main analysis (Appendix 1).
We also conducted a sub-group analysis where we interacted the DID term with our
indicator of urban residence to determine whether the earthquake had differential impacts
on urban and rural communities. We found no significant differences by urban residence
on use of modern methods, use of injectables or condoms, or having a birth in the last 12
months (Appendix 2). The estimated effects on condom use at last sex, unwanted pregnancy,
and unmet need for family planning were significantly lower for women who lived in urban
areas than for women who did not, indicating that the earthquake had a smaller effect on these
outcomes for women who lived in urban areas (Appendix 2). Likewise, the predicted value
of access to condoms was significantly higher for women who lived in urban areas than for
women who did not, indicating that the earthquake had a smaller effect on condom access
for women who lived in urban areas (Appendix 2). Thus, although the earthquakes most
devastating destruction occurred within Haitis most urban department, rural populations
were more seriously affected by the earthquakes destruction than urban areas. This may be
because foreign aid and reconstruction efforts primarily occurred in urban areas.

CONCLUSION
Using a case study of the 2010 Haiti earthquake, this study draws attention to the importance
of considering womens reproductive health needs in post-disaster contexts. Evidence suggests that some aspects of reproductive health improved over time at the aggregate level. For
example, use of modern contraception increased between 2005 and 2012 in Haitia change
largely driven by greater use of injectables. These increases in contraceptive use could reflect upward trends in modern contraceptive use that were occurring prior to the earthquake
or they could be due to the large presence of NGOs following the earthquake. In any event,
our difference-in-difference analysis shows that greater earthquake intensity had a negative
effect on use of injectablesthe most widely used modern contraceptive method in Haiti
and a positive effect on current pregnancy and current unwanted pregnancy. Thus, our DID
analysis indicates that aggregate-level descriptive statistics of improvements in womens reproductive health over time present a misleading picture, because different departments of
the country were differentially affected by the earthquake.
Our analyses of impact pathways suggest that reduced access to contraception and family
planning services likely played a role in the decreased use of injectables and other modern
methods following the earthquake. Heightened earthquake intensity significantly increased
unmet need for contraception and significantly decreased knowledge about where to obtain
condoms. These changes were in contrast to the absence of an effect of the earthquake on
condom use. One explanation for this apparent discrepancy is that knowledge of condom
access decreased among the two-thirds of women who did not use condoms as their main
form of contraception. Alternatively, there might be gender dimensions to condom use and
knowledge. For example, mens knowledge of where to find condoms may not have been as
greatly affected by the disaster as womens. If men primarily make decisions about condom
use, then their consistent knowledge of where to find condoms may have led to similar levels
of condom use before and after the earthquake.
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We also explore how earthquake intensity might have affected other factors that would
influence reproductive health independent of access to contraception. We find evidence that
earthquake intensity had a negative effect on partnership dynamics related to womens ability
to negotiate condom use. This evidence further highlights the importance of promoting the
use of long-acting reversible contraceptive methods that women can control independently of
their partners. However, we find no evidence that the earthquake affected fertility preferences
in a way that would be consistent with observed pregnancy increases.
One limitation of our analysis is that we are unable to assess whether womens diminished access to injectables was due to decreases in the overall supply of contraception or to
diminished knowledge about where to obtain contraception following the disaster. We are
also unable to measure all possible impact pathways and unable to directly link our impact
pathways to the reproductive health outcomes of interest. For example, we cannot directly
attribute increases in unwanted pregnancies to decreases in use of injectables.
Nonetheless, our findings contribute to how researchers and policymakers understand
womens reproductive health following natural disasters. Past demographic research suggests
that high-mortality natural disasters may lead to preferences to have children sooner because
women want to replace deceased family members or compensate for family and community
loss. While our findings on the effects of the earthquake on pregnancy and recent births are
consistent with studies from other disaster contexts, we find no effects of disaster on fertility preferences. Instead, our analysis of impact pathways suggests that the post-earthquake
fertility increase in Haiti was more likely attributable to related decreases in contraceptive
availability and in womens ability to negotiate condom use.
From a policy perspective, our study shows the importance of integrating access to contraception and reproductive health care into both immediate and long-term disaster relief
strategies. It also shows the importance of a broader focus on reproductive health, rather
than a narrow focus on fertility rates, providing a more complete understanding of the demographic consequences of natural disasters.

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ACKNOWLEDGMENTS
We are grateful to Jere Behrman, Monica Caudillo, Amber Peterman, Erica Soler, Delia Baldassari, and Jennifer
Jennings for helpful comments on this article. Background support for this study was provided by the grant Team
1000+ Saving Brains: Economic Impact of Poverty-Related Risk Factors for Cognitive Development and Human
Capital 0072-03 provided to the Grantee, The Trustees of the University of Pennsylvania, by Grand Challenges
Canada. Additional support was provided by the National Science Foundation (ID: 2011117755), the William and
Flora Hewlett Foundation, and the International Institute for Education (ID: 20127263).

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