In Haiti, more than 60 percent of pregnant women deliver at home with a matron (a traditional birth attendant). When there are no complications, these home deliveries often result in a healthy baby and mother.

However, when faced with complications, delivering at home can be fatal for women and their babies. And not all complications can be predicted in advance. Haiti’s maternal mortality rate of 529 deaths per 100,000 live births and neonatal mortality rates of 24 deaths per 1,000, are far higher than the regional average.

While most high-risk pregnancies can be identified during antenatal care (ANC) visits, one-third of women do not attend these visits, and consequently, do not know whether they have signs of complications and if it is safer for them to deliver at a hospital. And about half of women who attend antenatal care still decide to deliver at home.

To ensure that pregnant women in Haiti deliver safely, we used qualitative data to explore the barriers that discourage pregnant women from (i) attending antenatal care visits and (ii) delivering in a health institution. These data were collected through semi-structured interviews and focus group discussions with matrons, pregnant women, and their families, medical staff, and community leaders.

During pregnancy, women face three types of barriers to antenatal care visits. First, when they are considering the idea of going to ANC, they experience “optimism bias.” As reported by a community health worker during the study, “If they notice that everything is fine, they decide not to come.”

Second, even if they overcome these barriers and are willing to go to the visits, women often lack the transportation means and financial resources to travel to these centers. Many women are afraid of the uncertainty around costs of medical tests and medicines. Some women also expressed concern that bumpy roads in Haiti increase the risk of accidents and potential miscarriage.

Third, those who make their way to the health center are welcomed by questions perceived as judgmental and dismissive, discouraging women who do not understand the rationale behind the questions.

Similar barriers occur at the time of delivery. Women do not seek to deliver at a health institution as it is not the status quo: Pregnant women mimic the behaviors as their mothers who delivered with a matron. Even though women pay the matron when they deliver at home, most were uncertain regarding the costs of delivering at a hospital, creating the same feelings of financial insecurity.

Those who find the motivation and intend to deliver at a hospital face again transport and financial resources constraints. These barriers create a situation in which women fear what might happen to them, and can also cause them to delay the decision to seek care until they are already in labor: i.e. “I was giving birth on the way. I did not arrive at the hospital.”

Finally, many women report that they do not feel comfortable with the “model of care” they could receive, either because of their own experiences, or rumors they have heard about hospital care: “I was afraid to give birth in the hospital because of rumors that we have to give birth alone in a room while at home we are surrounded by the family.” Women also distrust the medical staff, who are often perceived as negligent and mistreating women.

Matrons, long-standing, respected members of their communities, from whom pregnant women seek advice, play a big role in this journey. Matrons lack incentives to refer women to hospitals. They have low trust toward medical staff, and when they bring pregnant women to deliver at a hospital, matrons feel mistreated “Sometimes, some nurses are very hostile. Once you arrive with the patient, she is received, and you are expelled.”

These findings suggest cost-effective interventions can be key to nudge matrons and pregnant women to encourage institutional care. For example, various communication channels could be used to inform pregnant women about the risks of pregnancy and benefits of antenatal care visits, while fixed prices of consultations and tests could be publicly posted and made available in advance, to allow them to plan. In addition, information on what to expect during antenatal care visits could be tailored to women’s educational levels.

Similarly, informing women on what to expect during labor and building a relationship between matrons and the health center can reduce the biases women and matrons have against delivering at a health institution. Finally, given that matrons play a key role, appropriate incentives could be put in place to make them feel proud of their contribution to society. Non-monetary incentives and social recognition events have been proven effective in similar contexts.

The World Bank is working with the Ministry of Public Health and Population to design a pilot to test these approaches and see what works in Haiti. The World Bank is also supporting complementary investments to improve the quality and access to maternal care services. We hope these efforts will move us closer to our common goal of making delivery safer for all women in Haiti.