during their pregnancy, skilled care during childbirth, and postnatal care (PNC) and support in the weeks after childbirth.<sup>1</sup> Haiti has the lowest rates of ANC and PNC in the region, with 67 and 31 percent of Haitian women receiving these services in 2017, respectively, compared to 91 and 88 percent for the whole region (UNICEF, 2022). Only 42.1 percent of women deliver with a skilled health professional, while 48 percent of women deliver with a _matron_ or traditional birth attendant (IHE and ICF, 2018), who have little formal training, and often receive knowledge only from their elders. The remaining 10 percent delivers with family members, community health workers or on their own.

Low utilization rates of health care services can be explained by structural barriers, which do not depend on the individual such as costs, distance to facilities (either because of physical distance or poor state of roads), and poor quality of health centers infrastructure, or by individual behaviors and beliefs (Datta and Mullainathan, 2014), such as optimism bias<sup>2</sup> , uncertainty aversion<sup>3</sup> , status quo bias<sup>4</sup> , or discomfort with the quality of care. Pregnant women may 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. _Matrons_ may also fall victim to these heuristics and underestimate the need for care or probability of pregnancy complications, referring women to hospital care too late in a delivery scenario to save lives. Therefore, in order to improve outcomes it is essential to address both structural issues and individual behaviors. As Charter and Loewenstein (2022) highlight, policies focusing on the individual (i-frame) should be seen as complementing policies addressing the system in which individuals operate (s-frame).

This paper documents the structural and behavioral barriers that discourage pregnant women from attending institutional care during their pregnancy and delivery in Haiti. It builds on earlier research by Gage and Calixte (2006) and Wang et al. (2017), which examined the impact of physical access to health services on the use of ANC and delivery care services. Using data from Haiti, Gage and Calixte (2006) found that limited access to obstetric services and limited use of existing facilities discourage delivery at a hospital.

This paper uses data from the 2017 Haiti Demographic and Health Survey (DHS), the 2017 service provider assessment (SPA), and qualitative data collected during fieldwork in May 2018 to shed light on other factors that influence women’s decisions and emphasizes the importance of the quality of health services in shaping these decisions. The quantitative analysis uses a multilevel model, which accounts for the fact that women are nested within geographic clusters with similarly available health services, to identify determinants of women’s decision to seek and reach care and to receive adequate care. This is then complemented by the analysis of perceptions and attitudes through the qualitative data.

We find that structural factors, including difficult access to healthcare centers, can be significant for women seeking care. Many women have rational concerns about the impact of these barriers on their health. For example, traveling on rough roads by motorcycle during pregnancy and labor can be frightening and dangerous. Additionally, uncertainty about the

> 1During the pregnancy, the World Health Organization (WHO) recommends four visits providing essential evidence-based interventions such as identification and management of obstetric complications (preeclampsia), and of infections (HIV, syphilis...) as well as promoting the use of skilled attendance at birth and healthy behaviours. After delivery, the WHO recommends that all mothers and babies have at least four postnatal checkups in the first 6 weeks.

> 2A cognitive bias that causes someone to believe that they themselves are less likely to experience a negative event.

> 3Preference for known risks over unknown risks

> 4Preference for the maintenance of one’s current state of affairs, or a preference to not undertake any action to change this current state.

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