| Summary: | Idjwi Island, DRC, has a total fertility rate of 8.3, one of the highest in the world. Rapid population growth has led to widespread environmental degradation and food insecurity. Meanwhile family planning services are largely unavailable. We conducted a representative survey of 2,078 households measuring standard reproductive health indicators. We also interviewed local women, community leaders, and clinicians about access to reproductive services. In the survey, over half of all women reported an unmet need for spacing or limiting births. Interviews revealed that Idjwi’s extremely high fertility is associated with a weak health care system, poor funding, deteriorating infrastructure, and discrimination and violence against women. Modeling proximate determinants of fertility, we predicted that an increase in contraceptive prevalence (from 1% to 30%) could reduce TFR on Idjwi to 6 children per women, the average desired number. To improve the status of women and curb unsustainable population growth, we recommend: adding family planning services at health centers, reaching out to women during regular medical and maternal health visits, pursuing a community health worker program, promoting extended periods of breastfeeding, and implementing programs to end gender-based violence. Lessons from Idjwi may be applied to other densely populated, low-income settings with high fertility.
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