Structural and Behavioral Barriers to Improving Development Outcomes: The Case of Maternal Care in Haiti
Summary — This paper examines structural and behavioral barriers preventing pregnant women from accessing institutional maternal care in Haiti, where maternal mortality remains critically high. The study uses mixed-methods to identify transportation, poverty, optimism bias, and quality concerns as key barriers to maternal healthcare access.
Key Findings
- Haiti has 480 maternal deaths per 100,000 live births in 2017, far exceeding the SDG target of 70 deaths per 100,000 births by 2030.
- Only 67% of Haitian women receive antenatal care and 31% receive postnatal care, compared to regional averages of 91% and 88%.
- Transportation difficulties and poverty are significant structural barriers that decrease likelihood of accessing maternal health services.
- Women suffer from optimism bias, underestimating pregnancy complication risks and need for skilled care.
- Quality concerns about hospital treatment, including fear of rough treatment and uncomfortable delivery conditions, deter women from seeking institutional care.
Full Description
This World Bank policy research working paper investigates the complex interplay between structural and behavioral barriers that discourage pregnant women from accessing institutional maternal care in Haiti. Despite some improvements over past decades, Haiti continues to face significant challenges with maternal mortality, recording 480 deaths per 100,000 live births in 2017, far exceeding the Sustainable Development Goal target of fewer than 70 deaths per 100,000 births by 2030.
The study employs a mixed-methods approach, combining data from the 2017 Haiti Demographic and Health Survey, the 2017 service provider assessment, and qualitative data collected through fieldwork in May 2018. The analysis uses multilevel modeling to account for women nested within geographic clusters with similar health service availability, examining factors that influence women's decisions to seek, reach, and receive adequate maternal care.
The research confirms that structural barriers including transportation difficulties and poverty significantly decrease the likelihood of attending maternal health services. Only 67% of Haitian women receive antenatal care and 31% receive postnatal care, compared to regional averages of 91% and 88% respectively. Additionally, only 42.1% of women deliver with skilled health professionals, while 48% rely on matrons or traditional birth attendants with limited formal training.
Beyond structural barriers, the study reveals important behavioral factors including optimism bias, where women underestimate pregnancy complication risks, and discomfort with current care models. Women express concerns about hospital treatment quality, fear of being left alone, and uncomfortable delivery conditions. The paper recommends addressing both structural barriers and behavioral factors to improve maternal health outcomes in Haiti.