How behavioral science can nudge pregnant women to attend prenatal care in Haiti. The Project Haiti has the highest maternal and neo-natal In an effort to provide actionable ideas to reduce mortality rates in the Latin America and mortality rates, the World Bank , with support Caribbean region, at 529 deaths per 100,000 from the Umbrella Facility for Gender Equality, live births, and 24 deaths per 1,000, respectively embarked on a diagnostic to identify structural (IHE and ICF 2018, World Bank 2017). Based and behavioral barriers preventing women on current trends, Haiti is unlikely to meet the from attending prenatal care visits, and from United Nations’ Sustainable Development Goals delivering at a health institution. The objective to reduce the maternal mortality ratio to less is to uncover the drivers to increase safe birth than 70 maternal deaths per 100,000 live births deliveries in Haiti. by 2030 (World Bank 2017). Low rates of prenatal The diagnostic relies on evidence from an and postnatal care, and institutional births, are extensive review of the literature (public all contributing factors. While 91 percent of documents, research articles, and studies) women go at least once to a health institution and key-informant interviews, which informed for prenatal care, only 67 percent made the four the design and implementation of qualitative recommended visits, and only 33 percent go to fieldwork. Thanks to focus group discussions a postnatal visit within 48 hours of delivery (IHE (FGDs) and semi-structured interviews (SSIs) and ICF 2018). with a range of actors including pregnant women, matrons, health workers, family members, In Haiti, most women – especially the poorest – community health workers, and community deliver at home with the help of a matron (traditional leaders, the diagnostic describes how pregnant birth attendant). Matrons have little formal training, women make decisions by exploring: prenatal and often receive knowledge from their elders. But care behaviors, attitudes and opinions around they are essential members of the community, and institutional delivery, perceptions, social the individuals to whom most expecting mothers structures, and relationships, among other turn for advice and guidance. contributing factors. Key Findings The team finds several (sometimes intertwined) structural and behavioral barriers to seeking, reaching, and receiving antenatal care and institutional deliveries. Behavioral biases – including availability and optimism bias – deter women from taking actions. Pregnant women often underestimate the likelihood of pregnancy complications, or of needing complex care beyond the capabilities of the matrons. Likewise, if they cannot immediately recall a family member or friend who might have required more care, they are less likely to pursue care themselves. And matrons similarly fall victim to these heuristics, underestimating the need for care or probability of pregnancy complications, referring women to hospital care too late in a delivery scenario to save lives. Structural barriers are real, and women’s concerns about their impact are often rational and warranted. Often, women are unaware as to when they should seek additional care. Given the bumpy state of the roads, traveling in a motorcycle to reach a hospital while pregnant and during labor can be frightening and dangerous. Women rightly fear that they will suffer injury on the way to the hospital or deliver before arriving. And uncertainty around hospital costs – including the total cost of their stay, medication, and more – makes it less likely for women in situations of poverty to seek out clinical care. The way hospitals and medical staff make women feel, and the perceptions around quality of care, matter as much as the care itself. Even if women are able to go to the hospital for care, many women are averse to the treatment they receive – or that they imagine they will receive. Though some women receive good care, others report being made to feel inferior, receiving condescending or rough treatment, or being forced to deliver in uncomfortable situations. In our interviews, women reported their fears of hospital settings; as one woman stated, “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.” Others reported seeing women being left alone post-operations, of infants receiving negligent care, or simply that the hassle of needing family members to bring food to the hospital was enough to dissuade them from seeking out hospital care. Policy Implications In a context like Haiti where large structural more – and better – information about what to expect barriers are prevalent, a simple awareness campaign during a health visit and their rights during visits may emphasizing the importance of prenatal check-ups also eliminate some of the hearsay and ambiguity and of institution deliveries are probably insufficient women rely on and experience. to create meaningful behavior change. Interventions Interventions that target medical staff may also go that target key potential decision points, beliefs, a long way to improving the perception of care, and and behaviors may provide opportunities for overall therefore the likelihood that women seek it out. improved outcomes for women and children. Training medical and One potentially high-impact administrative staff as to area may be focusing on A simple awareness campaign emphasizing how to make pregnant changing beliefs among the importance of prenatal check-ups and of women feel more at ease, women and matrons. institution deliveries is probably insufficient personalizing models of Providing more (and more care, and helping women persuasive) messaging to create meaningful behavior change. and matrons become about what necessitates an more familiar with their institutional delivery, about what women might closest health institution may all decrease fear of expect to find in hospital settings, and appropriate seeking institutionalized care. A social recognition timing (in the form of calendars) can help lessen the intervention aimed at rewarding matrons who lack of knowledge about when it is essential to go encourage safe deliveries and institutional referrals to a health institution. may also go a long way in incorporating the community- In addition, better, more salient information may recognized role of the matrons into the institutional alleviate some of the hesitation or uncertainty that care system. inhibits care-seeking behaviors. Interventions that Helping pregnant women deliver safely in Haiti is eliminate some of the ambiguities around the cost of complex, but understanding the behavioral barriers hospital care may enable women to feel less uncertainty to action can make a big impact in improving the bias around being able to afford this care. Providing effectiveness of any new policy or program. About eMBeD The Mind, Behavior, and Development Unit (eMBeD), the World Bank’s behavioral science team in the Poverty and Equity Global Practice, works closely with project teams, governments, and other partners to diagnose, design, and evaluate behaviorally informed interventions. By collaborating with a worldwide network of scientists and practitioners, the eMBeD team provides answers to important economic and social questions, and contributes to the global effort to eliminate poverty and enhance equity. Stay Connected eMBeD@worldbank.org #embed_wb worldbank.org/embed bit.ly/eMBeDNews References: IHE and ICF. 2018. Enquête Mortalité, Morbidité et Utilisation des Services (EMMUS-VI 2016-2017). Pétion-Ville, Haïti, et Rockville, Maryland, USA: Institut Haïtien de l’Enfance (IHE) et ICF. World Bank. 2017. Better spending, better care: A look at Haiti’s health Financing. Washington D.C.: World Bank. Last Update: June 18th, 2019