the probability of having problems during their pregnancy. Unless they are in pain, they do not seek care. Optimism bias seems to decrease with age, but women with children are less likely to attend ANC or to deliver in a health institution.

Lack of transportation is an important barrier to reaching care. Women without access to transportation are less likely to reach maternal healthcare services. Conversations with women revealed that, without access to transportation, they often have to walk long hours or rely on motorbikes or tap-taps (public buses or pick-up trucks). While common in urban areas, motorbikes or tap-taps are rather scarce in rural areas. Moreover, given the poor conditions of rural roads women often fear for their own safety and that of their baby. As is the case with seeking care, the high transportation costs may prevent them from going to healthcare centers despite intending to. Structural barriers are real, and women’s concerns about their impact are often rational and warranted.

Finally, when receiving care, the way hospitals and medical staff make women feel, and the perceptions around the quality of care, matter as much as the care itself. Qualitative findings reveal that women often perceive the care they receive from nurses and doctors as disrespectful. Women are usually not welcomed or treated as they would like. Moreover, women dislike the model of care provided in hospitals, finding that they do not respect local customs such as choosing the birthing positions or being surrounded by family members for labor. Quantitative data shows that women living in clusters where a large share of women have attended ANC consultations are more likely to do the same, suggesting that peer effects or role models may trigger knowledge sharing about their experiences in a positive manner. It is important for hospitals and medical staff to prioritize good communication and respectful treatment of patients to ensure that women feel comfortable seeking the care they need.

Surprisingly, interviews revealed that husbands may play a key role in encouraging their wives to attend institutional care. Not only are they often convinced of the benefits, but husbands also seem to care for the social status attached to being able to afford institutional care.

These findings indicate that interventions solely focused on improving access to health centers (through roads or by setting up new health centers) and on decreasing costs although necessary, might not be sufficient in achieving the desired outcomes. The presence of optimism bias requires that women be made aware of the risks and complications related to pregnancy and delivery. Thus, for example targeting younger women with powerful stories or vignettes that show all potential risks, even when there is no pain, could be effective. To reduce or avoid discomfort with the model of care and ensure respectful practices, health workers should undergo awareness training on how to welcome and treat patients and how to adapt the care to local cultural norms that include different delivery modalities, such as delivering in a seat position. Pregnant women could be offered a “promise contract” where medical staff agrees to her wishes and requirements during labor. Moreover, it is important for medical staff to prioritize good communication in terms of what to expect from institutional maternal healthcare services and the different medicines and techniques that could be used way ahead of the delivery date. Alternatively, involving women from the community to share their experiences at health institutions could be key to shaping pregnant women’s beliefs and expectations of the type of care they will receive at health institutions. As cost uncertainty seems to be a key barrier, mechanisms to increase cost predictability from the beginning of pregnancy could help.

Finally, while interventions should target pregnant women, involving their partners could be beneficial, as they seem to both help shape their decisions and support institutional care. The proposed recommendations are contextual and relatively low-cost compared to structural ones, and thus may have a higher potential for impact at a lower cost.

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