A BEHAVIORAL APPROACH TO UNCOVER BARRIERS TO MATERNAL CARE IN HAITI A BEHAVIORAL APPROACH TO UNCOVER BARRIERS TO MATERNAL CARE IN HAITI AUTHORS: Emilie Perge and Jimena Llopis LAST UPDATE: 8.23.2021 CONTENTS ABSTRACT 01. INTRODUCTION 02. CONTEXT 03. BEHAVIORAL 04. DEFINING THE 05. DIAGNOSING APPROACH PROBLEM THE PROBLEM 06. DESIGNING 07. CONCLUSION REFERENCES SOLUTIONS ABSTRACT H aiti has the highest maternal mortality rates (MMR) in the Latin America and Caribbean region, and low rates of institutional care con- decision-making process of pregnant women when thinking of accessing institutional care. tribute to high MMR. The behavioral approach sheds light on other factors beyond the standard variables of prices, Although both structural and behavioral bar- distance, and infrastructure, which also affect riers prevent pregnant women from accessing health seeking behavior, including optimism institutional care, behavioral barriers have been bias, uncertainty aversion, status quo, disre- often overlooked. Efforts in Haiti to increase spectful care and discomfort with the model rates of institutional care operate on the as- of care. These insights helped design solutions sumptions that pregnant women do not access that have the potential to be more impactful. care because of the cost, distance to facilities Policymakers must revise their assumptions and poor-quality infrastructure of the health about the factors that influence decision making centers. of pregnant women and look beyond structural factors to ensure policies and programs incor- While these assumptions are surely at play, porate a behavioral science lens. they do not cover all the reasons why pregnant women do not seek institutional care in Haiti. A Future efforts to increase rates of institutional behavioral approach was followed to uncover care must incorporate behavioral insights in both structural and behavioral barriers of the order to reach more efficient policies. 01 01. INTRODUCTION MOST HIGH-RISK PREGNANCIES SHOW EARLY WARNING SIGNS, AND RECEIVING PROFESSIONAL CARE BEFORE, DURING, AND AFTER CHILDBIRTH HAS PROVEN EFFECTIVE IN REDUCING DEATH RATES. H aiti has the highest maternal mortality rates (MMR) in the Latin America and Caribbe- an region. Although there has been a decline approximately 15 percent of pregnancies devel- op complications that can lead to death (WHO 1999). However, most high-risk pregnancies conditions and limited access to transportation. In addition, hospitals receive little financial sup- port from the Government of Haiti (GoH), with since 1990, the latest data (2015) shows that show early warning signs, and receiving profes- less than five percent of the budget spent on MMR remain high, at 529 deaths per 100,000 sional care before, during, and after childbirth health (World Bank 2017), which results in poor live births (IHE and ICF 2018). Based on current has proven effective in reducing death rates quality of healthcare. trends, Haiti will probably not meet the United (Institute of Medicine (US) 2003). Nations’ Sustainable Development Goals to However, there are factors that go beyond the reduce the MMR to less than 70 maternal deaths Structural barriers to access institutional care standard concerns of price and distance and per 100,000 live births by 2030 (World Bank are common in Haiti. There is insufficient health that are more related to the psychological con- 2017). infrastructure, limited healthcare workforce, and structs of behaviors. In this note, we describe few medical resources. Moreover, health services the process of uncovering these other types of Although many factors contribute to high MMR, are expensive considering socioeconomic levels barriers to design more effective solutions. research has shown that low rates of institu- (Gage and Calixte 2006). Distances to health tional care are a significant factor. Worldwide, centers are long and costly due to poor road 02 02. CONTEXT ALMOST HALF OF WOMEN IN HAITI – ESPECIALLY THE POOREST – DELIVER AT HOME WITH THE HELP OF A MATRON. W hile in Haiti 91 percent of women go at least once to a health institution for prenatal care, only 67 percent make the four visits rec- between matrons and pregnant women is based on trust. When in pain or once in labor, pregnant women seek matrons’ advice first and follow have proved insufficient, ultimately acting more as pilot projects than large interventions. Efforts to improve the supply side, such as independent ommended by the GoH, and only 33 percent go what they recommend. Given the insufficient non-governmental organizations (NGOs) train- to a postnatal visit within 48 hours of delivery health infrastructure, matrons offer public ser- ing nurses to increase Haiti’s workforce since (IHE and ICF 2018). Furthermore, less than 40 vices as they are rooted in the communities and 2006, remain insufficient to meet demand, and percent of births take place in a health facility, are the ones in charge of referring women with the quality of care remains low. compared to 70 percent in other low-income risky cases to the hospitals. countries (World Bank 2017). In this context, we look beyond structural barri- Most of the work to date by the GoH and its ers and bring in behavioral science techniques Almost half of the women in Haiti – especially partners has focused on addressing structural to examine behavioral barriers – the social and the poorest – deliver at home with the help of barriers, such as the financial costs of and physi- psychological factors that affect what pregnant a matron (traditional birth attendant). Matrons cal access to health care. Despite efforts to pro- women think and do – to access institutional have little formal training, are usually illiterate, vide free maternal health services to low-income care. and often receive knowledge from their elders women, as well as bringing mobile prenatal clin- rather than formal training. The relationship ics to the population living in remote areas, these 03 0 3 . B E H AV I O R A L APPROACH THIS SYSTEMATIC APPROACH STARTS BY DEFINING A PROBLEM OR STATING A DESIRED BEHAVIOR TO BE ACHIEVED. T he application of behavioral sciences to design solutions to development challenges follows a standard conceptual structure that, in achieved, and applying qualitative and quan- titative research instruments to diagnose the roots of the problem or barriers to that behavior. Through the case of Haiti, we describe the first three steps of the behavioral approach, describ- ing how to get from a development challenge to essence, represents the application of the sci- After an iterative process of problem redefinition a set of potential solutions to test. entific method to the understanding of human and continuous hypothesis testing of potential behavior (Data and Mullainathan 2014). barriers, a set of barriers is identified and prior- itized, and potential solutions are designed and The Mind, Behavior, and Development Unit of implemented following insights from behavioral the World Bank Poverty and Equity Global Prac- sciences. The effectiveness of the proposed tice along with the Health, Nutrition and Popu- intervention is then assessed following experi- lation Global Practices set out to apply this this mental and statistical methods, and finally the conceptual framework in the approach defined results are used to provide evidence and inform in Figure 1. This approach starts by defining policy by adjusting or scaling up the solutions. a problem or stating a desired behavior to be 04 FIGURE 1 DIAGRAM OF THE BEHAVIORAL APPROACH 03. 01. Implementation Definition & Evaluation & Diagnosis 05. Re-define & Re-diagnose 02. 04. Design Adapt 05 04. DEFINING THE PROBLEM IN HAITI, HIGH MATERNAL MORTALITY RATES OCCUR EVEN IN PLACES WHERE THERE IS ACCESS TO ROADS AND SUFFICIENT HEALTH INSTITUTIONS. T he behavioral approach begins with a prob- lem. In Haiti, high MMR occur even in places where there is access to roads and sufficient ies) among pregnant women. We break down these behaviors into several parts. Do pregnant women intend to attend prenatal care visits? health institutions. Even when the infrastructure If they don’t, the barrier might be the point of is there, pregnant women do not attend prenatal decision. If they do, the barrier might be related care visits and do not deliver in health institu- to an action, either when trying to reach care or tions. when they are receiving it. Figuring out which of these barriers is most relevant requires the use Our desired outcome is to increase take-up of diagnostic tools. institutional care (both prenatal and deliver- 06 05. DIAGNOSING THE PROBLEM O nce there is a clear understanding of the problem, a set of question generation begins leading to the diagnostic phase. Diagnostics can in two healthcare centers, focus group discus- sions, and semi-structured interviews with a purposively selected range of actors: pregnant and uncertainty regarding the inability to plan in advance the final cost of the service (uncertain- ty aversion) (Kyei-Nimakoh, Carolan-Olah and be qualitative and/or quantitative. In Haiti, we women, matrons, health practitioners, family McCann 2017); and because of their tendency conducted qualitative research to better capture members, community health workers (CHW), to prefer maintaining what they are familiar individual experiences, choices, perceptions, and and community leaders. with (status quo) (i.e. their mothers delivered at attitudes towards institutional care. The diag- home with help of a matron). Secondly, barriers nostic started with an extensive desk review of A careful analysis of the qualitative data al- delaying pregnant women to reach institutional existing literature and reports. The team then lowed us to develop a shortlist of six key be- care include distance to healthcare centers and interviewed key informants such as health prac- havioral barriers hindering pregnant women high transportation costs, and safety and se- titioners, national counterparts at the Ministry of from institutional care, grouped by whether curity during transport (Gage and Calixte 2006, Public Health and Population and other minis- these barriers delay the moment to seek, reach, Kyei-Nimakoh, Carolan-Olah and McCann 2017, tries, international partners, and NGOs working or receive adequate care (Thadeuss and Maine Essendu and Samuenl Mills 2010). Finally, barri- on health in Haiti. We conducted fieldwork in 1994). Although most barriers have been found ers delaying women’s decision to receive institu- the Nippes department, which had the highest in similar contexts in other countries, some are tional care include disrespectful care (Bohren, et presence of hospitals with obstetrician care per unique to the case of Haiti, such as optimism al. 2015) and discomfort with the model of care women (IHE and ICF 2018, DSF 2017). Within bias and status quo. Firstly, pregnant women do given at healthcare centers (Kyei-Nimakoh, Ca- Nippes, we selected one communal section with not consider seeking institutional care because rolan-Olah and McCann 2017). Table 1 summa- a low percentage, and one with high percent- of their belief that their chances to experience a rizes the identified barriers and the type of care age, of births at an institution. To identify the negative pregnancy or birth event are low (op- at which they occur. barriers (Table 1), we conducted observations timism bias); because of economic constraints 07 TABLE 1. SUMMARY OF BARRIERS, BY TYPE OF CARE Type of care 3-delay model BARRIER PRENATAL CARE DELIVERY Women underestimate the risks associated Unless the case gets complicated, women with not seeking care. They believe that if generally prefer home birth, as their belief of OPTIMISM BIAS they do not feel any pain there is no need the probability of experiencing an unexpected to seek prenatal care. complication is low. Care is perceived as expensive and final Institutional delivery is more expensive and SEEK ECONOMIC CONSTRAINTS/ cost fluctuates greatly creating uncertainty uncertain than home delivery; women must pay UNCERTAINTY AVERSION and reducing women’s ability to plan. apart for any the medicines and materials used. Pregnant women´s mothers and relatives delivered at home with the family matron, so STATUS QUO BIAS they prefer to maintain the norm that they are familiar with. TRANSPORTATION Hospitals are far and women cannot afford transportation. There is only a limited number of vehicles REACH CONSTRAINTS; DISTANCE, in some areas. Bad state of roads and absence of lighting make the transportation unsafe for the COST AND SAFETY women and fetus. At night, it becomes impossible to reach health centers as newborns arrive. Women report receiving an apathic Women either experienced or heard of rumors welcome from health staff who ask many of physical and verbal mistreatment from health DISRESPECTFUL CARE questions, including some on their sex- staff, as well as being abandoned during labor. ual habits which may make women feel uncomfortable. RECEIVE Women dislike the model of care given at health centers because they do not like giving birth without their family members, they are dis- DISCOMFORT WITH THE pleased with the birthing seat, scared by the MODEL OF CARE materials used and medicines given, and annoyed by being asked to walk before giving birth. When analyzing these barriers, we understood that matrons have a great influence on women’s decisions to seek, reach and receive care. However, matrons lack incentives to refer women to hospitals, as matrons are paid when performing birth deliveries. Even though matrons say they provide referrals to save lives, matrons reported that small and non-monetary rewards such as transport fees, delivery kits, and being recognized by the medical staff are what ultimately motivate them. 09 05. DESIGNING SOLUTIONS O nce the barriers were identified, the de- sign phase of suitable interventions began. Through internal brainstorming sessions inspired by a thorough literature review of what worked to overcome similar barriers elsewhere, the team came up with a list of 10 interventions that matched the barriers found (World Bank 2019). This long list was then shared with the coun- terpart and experts, and each intervention was assessed and ranked in terms of foreseen feasi- bility and potential to impact. Two interventions were selected to be tested given their high rank in feasibility and potential impact (Figure 2). 10 FIGURE 2 THEORY OF CHANGE (TOC) INTERVENTIONS DIRECT OUTCOMES INDIRECT OUTCOMES IMPACT 1. BEHAVIORALLY Increase number INFORMED of risk cases detected MESSAGE and traced BEHAVIORAL TOOL Increase pregnant women’s attitudes Increase pregnant and willingness to women’s understanding attend prenatal care of risk/benefits with not going to institutional care Increase number of institutional deliveries Increase number of prenatal care visits Decrease MMR Increase number 2. SOCIAL of postnatal visits RECOGNITION Increase matron’s willingness to refer Incentivize matrons to refer and actual referrals pregnant women to prenatal to prenatal care care (in health facilities) Increase health indicators of mother & baby Pregnant women Matrons have the ASSUMPTIONS Knowledge changes are unaware of ability to incentivize MMR are preventable behavior pregnancy risks pregnant women Matrons lack Social recognition incentives to refer is enough to incentivize matrons 11 Intervention 1 intends to overcome optimism bias with a 10-minute video for pregnant women and matrons with testimonials from mothers, matrons, nurses, and community health work- ers recognizing the importance of prenatal care and highlighting the potential risks. The video finishes with a descriptive norm gain message: “Pregnant women who attend at least four pre- natal care visits increase their chances of having a safe delivery and a healthy baby” (Downs, et al. 2004). Intervention 2 aims to overcome the lack of incentives of matrons to refer pregnant women to health institutions through a social recognition mechanism (Gauri, et al. 2019, Ashraf, Bandeira and Jack 2014). This consists of giving matrons a plaque of honor signed by the main doctor in the health facility where matrons advise pregnant women to attend prenatal care and by participating in a lottery to win a small token conditional on having advised pregnant women to attend prenatal care. The ToC (Figure 2) shows how these interventions can increase women’s willingness to attend prenatal care and the number of referrals by matrons, as well as the number of prenatal care visits. More women attending the four recommended prenatal care visits means that more risky cases can be detected and treated; that more women would deliver in a health institution and do prenatal care; and that women’s and unborn baby’s health can be monitored. In the long term this would reduce MMR. OUR AIM NOW IS TO TEST THESE INTERVENTIONS IN A PILOT AND ASSESS WHETHER OUR HYPOTHESIS AND THEORY OF CHANGE ARE CORRECT WITH THE HOPE OF INFORMING BETTER POLICY DECISIONS. 12 06. CONCLUSIONS EVEN IF WOMEN HAVE ACCESS TO AND CAN AFFORD INSTITUTIONAL CARE, BEHAVIORAL BARRIERS TO ACCESSING CARE EXIST AND REQUIRE THE USE OF BEHAVIORAL INTERVENTIONS. B ased on this behavioral approach, we iden- tify key barriers that are often overlooked when looking only at structural barriers. It tional care, behavioral barriers to accessing care exist and require the use of behavioral interven- tions. The video intervention informs women barriers (disrespectful care and discomfort with the model of care), they are meant to be easily applicable and well understood by stakeholders becomes clear in our analysis that these barriers about the process they would go through in a with different appreciation on how behavioral are deeply rooted and that clearly identifying health institution, making the unknown more interventions can be integrated to design more these barriers is necessary to improve maternal familiar. It also highlights through real stories efficient solutions. health in Haiti. At the same time, the analysis the potential risks they could experience if they also sheds light on the importance of structural don’t get screened. 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