education program. According to the WHO, there were a total of 2,606 physicians in Haiti in 2018 while the combined number of nurses and midwives was 4,424 for a population of over 11 million<sup>7</sup> . Health centers, on average, do not have two out of the six recommended medications needed for childbirth delivery (IHE and ICF, 2018).

The Government of Haiti and its partners have recently focused on improving physical access to healthcare. For example, the 2008-2013 maternal health services program provided free services to low-income women in selected health centers, with funding from the United Nations Population Fund (UNFPA) and the Canadian International Development Agency (CIDA). UNFPA and non-governmental organizations (such as Midwives for Haiti) also attempted to bring mobile prenatal clinics to populations in remote areas with limited access. Additionally, Midwives for Haiti has provided training to nurses since 2006 to increase the number of skilled midwives, while other NGOs focus on promoting continuing education for official midwives after they have received their diploma. However, to the extent of our knowledge, rigorous evaluations of these approaches are missing.

# **2.1 Literature on barriers to institutional care**

Timely access to institutional care is a key factor to reducing maternal mortality rates, as most of the pregnancy and labor complications that can lead to death can be detected and treated by timely medical attention (Pfeiffer and Mwaipopo, 2013). Thaddeus and Maine (1994) organized barriers to accessing healthcare in a conceptual framework known as the three-delay model, which groups barriers around three different moments: (i) decision to seek care, (ii) identifying and reaching care facility, and (iii) receiving adequate and appropriate care. For each of these moments, several types of barriers have been documented.

# **Structural barriers**

- Financial and opportunity costs. Through interviews in Kenyan slums, Essendi et al. (2010) observe that most residents want their children to be born at the hospital. However, the high cost of a hospital-based delivery and additional indirect costs (e.g for transportation) prevent them from doing so. Kyei-Nimakoh et al. (2017) conclude that the uncertainty of the delivery cost at a health institution due to the complexity of the billing system also discourages women from seeking care. Whether or not a woman has a social support network can play an important role in the decision to seek care (Thaddeus and Maine, 1994), as this network can help reduce women’s opportunity cost to seek care by, for example, taking care of other children or helping with household chores.

- Distance to the health facility. Besides the physical distance other factors come into play. Thaddeus and Maine (1994) posit that the effect is even stronger when combined with lack of transportation and poor roads. For example, pregnant women that would have to walk for hours over rugged terrain will be disincentivized from even seeking care.

- Physical accessibility to health facilities. Shortage of health facilities is so substantial that even if women intend to deliver in a health facility, they may be simply unable to do so (Gage and Calixte, 2006), especially at night when transportation options are scarcer.

- Lack and/or high cost of available means of transportation results in women having to rely on walking or motorcycles to reach the health facility (Llopis Abella et al., 2020; Kyei-Nimakoh et al., 2017).

> 7Global Health Observatory data repository, WHO

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