Article Text

Reframing the Three Delays framework: factors influencing referrals to facilities by matrones in rural Haiti
  1. Milenka Jean-Baptiste1,
  2. Christophe Millien2,
  3. Pierre Ricard Pognon3,
  4. Meredith Casella Jean-Baptiste4
  1. 1Department of Health Behavior, The University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
  2. 2Medical Direction, Hopital Universitaire de Mirebalais, Mirebalais, Haiti
  3. 3Strategic Health Information System (SHIS), Partners In Health - Sierra Leone, Freetown, Sierra Leone
  4. 4Maternity, Hôpital Universitaire de Mirebalais, Mirebalais, Haiti
  1. Correspondence to Milenka Jean-Baptiste; milenka{at}


In Haiti, there has been limited research on the experiences of traditional birth attendants/matrones when they decide to refer and accompany pregnant women to the facility for giving birth. Understanding this contextualised experience could help to strengthen programming aimed at improving maternal, neonatal, and child health (MNCH) outcomes in rural Haiti. This paper describes the qualitative findings from seven focus group discussions (FGDs) with matrones regarding their experience of referring pregnant women to facilities in Haiti’s Central Plateau. Each FGD was conducted in Haitian Kreyol and audio recorded. Recordings were transcribed, translated to English, and thematically analysed. A conceptual model visualising factors influencing matrone decision-making was then developed using an adapted version of the Three Delays framework. Findings from this study show that matrones face a complex, multilayered web of intertwining factors related to attitudes and beliefs around their role, resource availability, and perceptions around quality of care and treatment. Each factor corresponds to a delay in the Three Delays framework. The factors can occur at the same time or each can occur individually at different times, and influence the decision to refer. The complexity of factors identified reflects the need to reassess the Three Delays framework so that it accounts for the intertwining, cyclical complexities faced by those trying to access the facility amidst the backdrop of both time and the community/social contexts. Results further reflect the need for strengthened health systems that better facilitate matrone facility-based referrals, improving outcomes for all parties involved and bridging the gap between homes/ communities and facilities. This calls for better integration of the matrones into the formal health system to systematically strengthen the continuum of MNCH health services provided from home to facility.

  • maternal health
  • public health
  • qualitative study
  • health systems

Data availability statement

Data are available on reasonable request.

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • In Haiti, traditional birth attendants, also known as matrones, support approximately 50% of births. They are usually preferred to formally trained providers.


  • By presenting the contextualised experiences of the matrones as they support pregnant women in their birthing journey, this study sheds light on what happens before a pregnant, labouring woman reaches the facility, as a part of the continuum of care in MNCH. It also helps in reframing the Three Delays framework in relation to the matrone experience. In doing so, important questions are raised around the integration of matrones into the formal health system, the feasibility of this given the context, and what ‘comprehensive’ and ‘respectful’ maternal service provision looks like in rural Haiti.


  • This study presents the opportunity to shift the traditional discourse around traditional birth attendants and formally trained providers from one which pits them against each other, to one which shows how they can work together as part of a larger MNCH continuum. To focus on the community aspect of this continuum, this study emphasises the need for investment of resources at both the community and facility levels to strengthen the development of multicomponent approaches that can comprehensively tackle MNCH issues in Haiti.


Traditional birth attendants (TBAs) have played significant roles in the delivery of maternal health services globally, particularly in low-income and middle-income countries.1–3 TBAs typically practise in resource-poor settings that have limited access to quality essential care during birth.3 4 Thus, they render much needed maternal services to which pregnant women may not have access otherwise. Multiple studies have pointed out the positive impact that TBAs have on several maternal, neonatal, and child health outcomes (herein referred to as “MNCH”),5 6 including helping to increase facility-based births.7 In these instances TBAs serve as a bridge between local communities and the more formal health system,8 9 by caring for other children or cooking during labour or the provision of guidance and advice.2 10 In many contexts, TBAs also assist pregnant women in giving birth at home.11–14

Despite their roles in supporting pregnant women throughout the birthing process, interest in TBA work as a strategy for improving global MNCH outcomes has waxed and waned over the past few decades. Prompted by the Alma Ata of 1978, initial interest in TBA work focused on training TBAs as a strategy to improvng MNCH outcomes. However, this interest shifted to promoting the presence of formally trained providers capable of managing emergencies during birth .14–16 As a result, the presence of formally trained providers persists as a key strategy for improving MNCH outcomes. This led many countries to phase out, de-prioritise, or in some instances, ban TBAs in favour of formally trained providers.2 Recently, there has been renewed interest in TBAs as an approach for improving MNCH outcomes as critiques over its initial de-prioritisation have arisen.14 This renewed interest presents an opportunity to strengthen the relationship between TBAs and formal healthcare facilities such as clinics and hospitals (hereinafter referred to as “facilities”) and improve MNCH care services.

TBAs are known as ‘matrones’ in Haiti. Matrones work in areas that lack adequate medical and material resources.11 They provide in-home and community-based services to pregnant women, ranging from counselling and social support to assisting pregnant women during birth. They can also facilitate access to facilities by accompanying pregnant women from their homes to facilities. In the process, they help pregnant women and their families identify resources needed to access these facilities. This is particularly important as the main barriers influencing MNCH outcomes in Haiti are lack of transport, limited access to formally trained providers and poverty.17 Thus, matrone services are of particular importance in remote areas which are often accessible by foot only.18

Matrones also often have close relationships with the communities where they work or live.12 These relationships and their engrained roles in the community allow them to provide culturally acceptable services that are in closer proximity to pregnant women.19 Performing what can be viewed as protective rituals for mother and child,19 20 they further represent a nexus of herbal, childbirth ritual and spiritual knowledge.11 21 For instance, matrones have specialized knowledge of plants that can help the uterus contract or help women express breastmilk. Matrones may also perform specific rituals such as giving the pregnant woman a steam bath after birth (11). These types of services and knowledge are uncommon within facilities. Matrones lack the formal training received by healthcare providers such as physicians, midwives and nurses.2 19 Instead, their knowledge and skillset have been passed down from generation to generation and can be viewed as a spiritual calling.11 21

Matrones support approximately 50% of the births in Haiti22 despite the promotion of formally trained providers being present at birth.13 In fact, in some instances, women have indicated a preference for giving birth at home with matrones, as opposed to doing so at facilities with formally trained providers.23–25 This pattern has also been observed in other countries.26–33 For instance, a study in Ethiopia showed that pregnant women like being assisted by TBAs even during facility-based births.28

To improve access to formally trained providers in Haiti, multiple studies have recommended working with matrones to bridge the gap between facilities and homes/ communities. In fact, programmes to train matrones have been underway since the 1950s.13 26 These programmes have traditionally centred on training matrones to identify warning signs during pregnancy for referral to facilities.11 Despite such programming, limited research has been undertaken to understand the dilemmas faced by matrones as they refer. Additionally, much research exists assessing factors affecting facility access from the perspective of the pregnant women.23 However, not much research describes the experience of accessing facilities from the perspective of matrones, particularly during the birthing stage.21 While it is important to center the experience of pregnant women, understanding the experiences of matrones, as those supporting her, can also contribute to a broader understanding of the referral experience, from home/ community to facility.

This study aims to understand the factors influencing matrones’ decision to refer pregnant women to facilities in Haiti’s Central Plateau when labouring or giving birth. By doing so, this study sheds light on the contextualised experience of matrones, as an under-recognised traditional health cadre. Results from this study will contribute to informing conversations around whether matrones can be integrated into Haiti’s formal healthcare sector. On a global scale, this study contributes to the literature focused on the challenges TBAs encounter. Finally, by including the matrone experience as part of the health system, this study also emphasizes the need to consider the experiences of pregnant, labouring women and those who support them, even before arrival at the facility. In doing so, this study suggests the need to consider assets available outside of facilities that can strengthen MNCH outcomes.


The qualitative data used in this study come from a larger mixed-methods study in which both qualitative and quantitative data collection occurred simultaneously. This paper is based on the qualitative data collected in the larger study. Data for this qualitative study were collected in June 2015 at Hopital Universitaire de Mirebalais (HUM). HUM is a tertiary care referral facility that provides healthcare services to over 185 000 people living in the Mirebalais region and surrounding communities in Haiti’s Central Plateau department. Of the 300 beds at HUM, approximately 100 are dedicated to obstetrics and gynaecology services.

Development of the focus group discussion guide

A semistructured discussion guide was developed to collect qualitative data. Topics in the discussion guide were informed by the research question and a review of global literature on issues that TBAs face at facilities. Topics in the discussion guide were also informed by informal discussions with staff working within the research team (figure 1).

Figure 1

Core topics in the final semistructured discussion guide.

The guide was developed in English, translated into Haitian Kreyol, pilot tested in Haitian Kreyol and finalised for use. The in-country team was then trained in administering the guide.

Data collection

Focus group discussion (FGD) participants were conveniently sampled from those who already worked with HUM and had attended HUM training. To be eligible for participation, one had to be a matrone who serviced pregnant women in HUM’s catchment area. FGDs were administered by trained moderators and co-moderators in Haitian Kreyol, using the semistructured discussion guide. Moderators and co-moderators were either Haitian or Haitian American, either fluent in Haitian Kreyol or had working knowledge of Haitian Kreyol. FGDs took place at HUM in private, confidential spaces. They were audio recorded. All participants provided verbal consent prior to participation. After each session, matrones were provided with light refreshments and compensated in Haitian Gourdes for their time and transport to the facility.

Seven FGDs were conducted at HUM, representing 71 matrones from 5 subregions (section communal) of Mirebalais. Each FGD had between 7 and 14 participants (table 1). The duration of the FGDs ranged from approximately 45 to 120 min. Due to interest in participation and a limitation of staff and time, there were multiple large FGDs. To mitigate this, where possible, FGDs were split into two groups from a subregion.

Table 1

Participant distribution by subregion


FGD audio recordings were transcribed verbatim from Haitian Kreyol to English by a team of Haitians and Haitian Americans. Transcriptions were quality-checked by having a study team member review the entire transcript and compare it against the audio recording. Any differences in transcription were highlighted for further review and discussed with a third reviewer who then finalised the transcript for coding. Thus, quotations presented in this manuscript are translations from Haitian Kreyol.

Data analysis took place iteratively over multiple rounds of transcript review and coding. A mix of inductive and deductive techniques was used to develop the codebook. Deductively, codes were developed from the Three Delays framework and discussion guide questions. Additionally, concepts arising from transcript review and memoing that were not present among the original set of codes were inductively added. As coding occurred, study team members also used memoing and discussion to reflect on different codes and reach a consensus when there were differences in the interpretation of data.

As explained by Saldaña, coding is: ‘a method that enables you to organize and group similarly coded data into categories or ‘families’….’34 Thus, codes were grouped into larger categories. Building off the work of MacDonald et al27 and Thaddeus and Maine’s Three Delays framework,35 these categories were organised into larger families or themes based on each delay in the Three Delays framework. For instance, sample codes of matrones’ confidence in their own ability to carry out a home birth or their perception of the hospital were grouped under the larger category of matrone attitudes and beliefs. This category was then grouped under the corresponding theme represented by each phase in the Three Delays framework. This led to the development of a conceptual framework explicating the varied factors influencing matrone decision-making when referring pregnant women to facilities. Further, there were several categories that fell outside of the original three phases found within the Three Delays framework. Through discussion, this led the team to reframe the Three Delays framework to be inclusive of these categories while also reimagining the connections existing between the different phases of each delay.

Saturation was assessed at the analytical level during coding. Each FGD was observed as the unit of analysis to assess code saturation. Code saturation refers to the point in which no additional codes emerge and there are sparse changes to the codebook.36 For this study, code saturation was defined as the point in which no new emerging codes were identified and added to the codebook. This was achieved in the fifth FGD.


Those coding were either Haitians, Haitian Americans, or those living in Haiti and working directly with matrones (online supplemental appendix 1). All authors have worked in maternal healthcare as clinicians, public health practitioners, or health informatics professionals working in facilities or communities. Thus, all authors have positive perceptions of matrones and are very sensitive to women’s suffering. Through their interactions with matrones at facilities, authors have observed how critical the work of matrones is to MNCH outcomes in Haiti. Despite this, little is known about the experience of matrones and the difficulties they face. Thus, through this research, authors have witnessed how important it is to illuminate contextual factors influencing key issues affecting the ability of matrones to deliver quality MNCH services in the community. This is being done as an act of respect to acknowledge matrones’ critical work in this space. This is also being done to show that the community encompasses both community members and the facility as an institution. Bridging the gap between these entities can be complex. Through this research, the authors have come to believe that matrones cannot be excluded from the Haitian healthcare system and should be partners in improving MNCH in the country.

Supplemental material

Patient and public involvement

Matrones were engaged in this study as research participants. They were not involved in developing the study design. However, they aided in recruiting other matrones. Study results have been shared with hospital-based leadership that is responsible for women’s health programming in Haiti. It has subsequently led to discussion around the possibility of hospital-based interventions aimed at improving matrone integration into the healthcare system.


The data analysis revealed a complex web of underlying factors that influence the decision to refer to a facility from the perspective of the matrones. These factors aligned with each phase of Thaddeus and Maine’s Three Delays framework but was specific to the matrone experience. Thus, they were subsequently organised into an adapted version of this framework’s three phases: (1) deciding to seek care—factors influencing referral decision, (2) reaching medical facility—resources and (3) adequate and appropriate treatment—quality care (figure 2). At each phase, matrones are faced with questions that compound and contribute to the larger question of whether they can and should refer to the facility. These delays are set against the backdrop of community/social factors and time which are also described in this section. As described by the matrones, each of these factors ultimately influences MNCH outcomes around giving birth. These factors also influence matrone personal outcomes such as their own reputations in the community and their relationships with facilities.

Figure 2

Web of factors influencing matrone decision-making to refer pregnant women.

Phase 1: deciding to seek care—factors influencing referral decision

One of the first steps in the referral process is making the decision to go to the facility. Several factors emerged from FGDs that influenced this decision, namely matrones’ perception of their own role, their attitudes, and beliefs about home and facility-based births, and having a sense of validation and acknowledgement.

Matrone role

Results showed that matrones play a multifaceted role in referring pregnant women to facilities. Some of the roles they took on include making the decision to refer, facilitating the referral and accompanying pregnant women to the hospital. At times, they also made the decision to go to the hospital or convinced other family members to do so. If the birth occurred at home, matrones also described their role in supporting home-based births when needed. Each of these roles required a level of interpersonal engagement that was reflected in matrones feeling responsible for the labouring woman and her child, expressing a sense of protection, commitment and dedication:

But us as matrones, it is us who are supposed to protect the person, we accompany the person, for us to help them for us not to see her suffer at her house. (FGD2: Grande Boucan)

Matrones took on whatever role they felt was needed to ensure that the woman being referred had a healthy outcome. For instance, as facilitators, matrones sought to guide the referral process and enable: (1) discussion around going to the hospital with pregnant women and their families, and (2) identification of resources to go to the hospital with pregnant women. In multiple instances, matrones described trying to find transport to the facility and in many instances going as far as funding the women’s transport to the hospital:

When we see the person’s life is in danger, when we see it is in danger like this, we are obliged to go look for a car; go look for a place that has cars. When the driver says, I don’t have gas, we are forced to go get gas on credit because they don’t have gas. (FGD7: Mache Canard)

Further, in urgent circumstances or instances in which matrones encountered resistance to go to the hospital from the woman’s family or others, matrones were put in the difficult situation of going against key members of the pregnant woman’s social network. Sometimes, it was the pregnant woman herself who did not want to go to the hospital to deliver her child, even if prompted by the matrone to do so.

Attitudes and beliefs about home and facility-based births

The willingness of the matrones to refer to facilities reflected their positive attitudes and beliefs regarding facility-based services, particularly for addressing complications. Matrones perceived the hospital as a place which provided a higher level of services, beyond their own capacity. This was especially true for emergency cases that they could not manage.

….When they are at the hospital, they are in the doctor’s hands. If the person needs pills [medications] they give it to them, when they need serum [IV solution], they give it to them. And when after the woman delivered as well, there are medications that they can give her. It’s for that reason why in deliveries in the hospital, I feel I am more satisfied with those compared to deliveries that are done outside. (FGD4: Haut Sarazin)

Despite the positive perception of hospitals, across FGDs, there were multiple instances in which matrones did not agree with each other over whether a home-based birth or a facility-based birth was better. Across all FGDs, matrones expressed feeling competent in their ability to deliver a child at home, provided there were no complications. Such attitudes and beliefs indicated that some matrones did not have any convictions against doing so if they felt that they could handle it. However, others felt that all pregnant women needed to be sent to the facility, no matter the circumstance. These differences of thought might reflect evolving matrone perspectives around their roles and responsibilities, particularly in light of training received.

Acknowledgement and validation

Lack of acknowledgement and validation of the work of matrones also emerged as an undercurrent in many FGDs. Matrones hinted that the hospital staff did not acknowledge their experiences as matrones and the effort it took to bring a pregnant woman to the hospital:

…This is why I feel I have a problem with this…When I come, I never find a nurse who gives me $100 to pay for cars. They don’t need to know if I came by foot, if I came from far or near. As long as I come and give the woman to the hospital; if I stay in street, I stay there or if I want to go back home… I don’t like it like that… (FGD2: Grande Boucan)

Here, the matrone acknowledges multiple ways in which their work goes unacknowledged, including a lack of financial support for their work. Additionally, the use of the words ‘they don’t need to know’ signals the matrone feeling that the hospital does not care to know about their experience or process for getting there. They only care about whether a pregnant woman can be brought to the hospital to give birth.

Matrones also made requests for resources during FGDs. Some of these requests also reflect their want for acknowledgement and validation. For instance, one matrone requested having a badge and uniform like hospital staff, so that they could wear it proudly in the community when working. Others, being cognisant of the fact that home births were still bound to occur, requested supplies to help assist during childbirths at home, should the occasion arise. Some also requested resources such as stretchers, an ambulance or small payments to help cover monetary costs associated with the referral.

Phase 2: reaching medical facility—resources

Matrones faced the arduous task of figuring out how to get the pregnant woman to the hospital. They described several factors that affect their ability to reach the facility. These include transport and funds, the terrain and the referral system.

In some FGDs, the terrain was identified as a factor influencing the decision to refer. The mountainous terrain, high altitudes and rivers made it difficult for hospital referrals:

There are problems we face, since everyone stays high in the mountains, there are times if the woman cannot deliver, it is on the door of a house we have to use to bring her down. We don’t have things to bring her down. It is wood, two pieces of wood we tie together. We put the person on it and tie the person down with string so we can hold it and put the person on the path (trail). When we put the person on the path, we make a group of young men carry that person on the path. Then you have to go up and get the car bed ready, they will carry that person for you, so that the person can be transferred to the hospital. (FGD4: Haut Sarazin)

The difficult terrain also necessitated that additional supplies such as portable stretchers be used to bring a pregnant woman from higher altitudes to a paved road where transport to the hospital could be accessed. These supplies were often lacking which led to makeshift solutions for transporting pregnant women. Throughout the FGDs, transport to the facility was described as a critical resource. When vehicular transport was not accessible, matrones mentioned using domestic animals to transport pregnant women:

Yes, on foot. There is no road, neither bicycles nor motorcycles, it’s a path. For example, if the person isn’t in a bad condition, you can take an animal and put the person on it. (FGD4: Haut Sarazin)

Even when transport was accessible, funds were needed to pay for passengers. Pregnant women could go to the hospital by themselves. However, there was concern about the pregnant woman delivering on the way without having any support:

There are cases when the woman could have given birth to the child in the car… So I always come with her… (FGD7: Mache Canard)

Thus, throughout some of the FGDs, matrones felt it was necessary for them to travel alongside the pregnant woman to help her along the way to the facility. To alleviate the financial burden this posed, matrones suggested both funds and transport be available to successfully secure transport to facilities.

Referral system

For a successful referral system, matrones had to be aware of the set of steps needed for a facility-based referral to occur, including access to resources to facilitate each step of the process. Throughout the FGDs, it became evident that matrones lacked adequate resources to carry out referrals and that there were points for improvement in the referral process. For instance, matrones described pregnant women not giving referral slips to hospital staff when they arrived at the hospital, or losing the slip en route. Thus, referrals could not be tracked back to them. Additionally, matrones also described not having the hospital phone number or point of contact to call the hospital when they were referring a pregnant woman to the hospital. This was important as they wanted to alert hospital staff that they were coming and to be prepared. Additionally, in every FGD, matrones talked extensively about women and their families not having funds to pay matrones and needing to lend pregnant women funds to access transport.

Because they don’t have the possibilities to pay. Because personally, I usually assist some childbirth in the [mountains] countryside, there is no bed I have to ask for help to bring the person down who is delivering, the person don’t even have one Gourdes [Haitian currency] instead of getting paid, I have to sell things to get the money that was borrowed because the husband doesn’t work and cannot give me back the money. I resign myself to that… (FGD5: Ba Sarazin)

Further, in some of the FGDs, matrones described how their affiliation with the hospital led some community members to think they were getting paid by the hospital as an employee. Thus, there were instances in which community members denied payment to matrones.

They do not give us money because they think we are paid…. We say we don’t get paid by the hospital. (FGD5: Ba Sarazin)

This created a difference in expectations. One expectation held by matrones was that they would be paid by the pregnant woman or her family for the services rendered. As matrones have been trained to refer pregnant women to facilities to give birth, the perception of their role within communities might change. Whereas previously, they might have been viewed as independent agents, over time they come to be seen as facility-based employees who are already getting paid for their services. As a result, they no longer should be paid by them and their families. This difference in expectations presented the opportunity for conflict between matrones and those they serviced.

Phase 3: adequate and appropriate treatment—quality of care

The perception of facility-based quality of care also impacted whether matrones decided to refer women to the hospital. Thus, phase 3 of the framework was characterized by pregnant women’s perception of hospital-based birthing services and matrone reception at the hospital.

Pregnant Women’s perception of hospital services

Across several FGDs, matrones described the fear pregnant women conveyed to them of the obstetric and gynaecological services provided at the hospital. Matrones described pregnant women being afraid of getting cut with ‘scissors,’ or the need to be shaved.

They don’t want, for example, they will use the scissors on them [episiotomy]. They will, they will cut their pubic hair…(laughing)…They don’t like that stuff…They prefer to suffer in misery at home. (FGD4: Haut Sarazin)

The fear of being cut with scissors was further augmented by the lack of touch at the facility. Matrones referred to ‘touch’ as a massage of the pregnant woman’s belly that was offered when supporting home-based births that helped to ease her pain and make her feel supported. ‘Touch’ was raised in all FGDs as a service they provide as matrones. This was not offered at the hospital.

They say that they won’t come because when they come, they will suffer. They will not find people to touch their stomachs for them. They are afraid to come to the hospital (laughing). They are afraid to come to the hospital but up there [referencing a different hospital], they find it easy to find people taking oil, touching them, massaging their stomachs for them. But now, they don’t touch them anymore. And since I have come to the health facility, the nurse has told me that they don’t touch them anymore [they do not massage them]… (FGD1: Crete Brule)

The lack of touch in the services provided at the hospital impacted how matrones and pregnant women alike perceived such services. As described by one matrone:

We would ask that when the women come to the hospital, that the nurse or doctors would touch them. Because they say that they are just left to the side and that when they have pain, they are screaming, screaming, and there are times they don’t pass near them. I would like them to hold them (support them), understand, hold them like they are in their room [home]…. (FGD4: Haut Sarazin)

Another reason pregnant women may not want to deliver at the hospital was the lack of familial support there. Matrones explained that family members could not be present in the birthing room at the hospital. In contrast, in their own homes, members of the family were present to provide the emotional support the women needed:

…and there is a problem too…the woman knows that when she is in the house, there might be a cousin holding her, another cousin holding her, this aunt will be with her, and others doing stuff for her. But when she is at the hospital, it is only the doctor who is with her alone at the hospital. So, they tell you that they will not go by themselves to the hospital. (FGD2: Grande Boucan)

Reception of matrones at hospital

In every FGD, matrones repeatedly felt confident in facility staff’s ability to save a pregnant woman’s life and that of her newborn during childbirth. They also felt confident in facility-based equipment and supplies to help a pregnant woman while giving birth. However, across several transcripts, matrones described feeling unwelcome upon arriving at the hospital with the pregnant woman. In some instances, matrones described being excluded from this part of the pregnant woman’s journey:

They don’t welcome me, it’s that (Hmm). There are some (certain) people inside; I get mad because they annoyed me and I say I’m a matrone, they made me turn around [leave]. And even when we refer here, I was really mad. (FGD5: Ba Sarazin)

Even if the matrones held favourable attitudes and beliefs about the hospital and the quality of services provided there, the factors described above negatively impacted how pregnant women viewed the quality of care there, making it difficult for matrones to refer the women to the facility.

Larger context: time and community/social setting

Throughout the FGDs, matrones indirectly described the impacts of time and social/community settings and how these influenced whether a pregnant woman was referred to the hospital. Each phase existed amidst the backdrop of both these factors. Thus, while both time and the community/social settings were factors influencing the decision to refer, they existed across all three phases and could be seen as part of the larger contextual environment.

Time was mentioned by matrones in a multitude of ways. For instance, when making the decision to refer, matrones considered whether they could handle the birth (phase 1), the time of day in which the birth was occurring and the resources available at that time of day (phases 1–2), the amount of time it would take for the referral to occur (phase 2) and whether the facility would be open (phase 3). As described by one matrone:

…I arrived by foot. When I arrived, at the time it was, I was able to take some control over the woman and saw that the child was coming out bad. The child was coming out in ‘traverse’. I said OK. I told the father to organize himself because I am going to wait until after midnight because there are times when the hospital is closed. And then in 1–2 hours, we left and found a car because you know that cars don’t circulate all the time. (FGD2: Grande Boucan)

The time of day in which the birth occurred seemed to impact referrals in two ways: whether transport to the facility would be readily available, and whether the nearest facility would still be open at that time. What this reflects is that time is a resource impacting facility referrals across multiple phases of the framework that is not often described.

The community/social setting also significantly influenced referral decisions across all three phases. As described above, community perceptions of matrones and the expectations around the types of services that should be provided during the birthing process (phase 1) could impact their decision to seek care. The availability of resources (eg, transport) within the community (phase 2) could impact whether one was able to reach the facility. Finally, social norms surrounding what quality care entailed during the birthing process could impact whether facility-based services were adequate enough to merit a referral (phase 3). Thus, the community/social setting involved the interplay between multiple entities such as pregnant women, their families, facilities, and matrones and necessitated constant interaction, trust, and engagement.

Updated framework

Results showed that in making the decision to refer to facilities, matrones faced factors that extended beyond the three phases of Thaddeus and Maine’s Three Delays framework35 and involved community beyond the fourth accountability phase proposed in MacDonald et al’s framework.27 Rather, it sets the three delays in the context of community/social factors and time. Like MacDonald et al’s research, the factors identified in this study occurred in a non-linear way and could cyclically impact the decision to go to the facility. However, unlike MacDonald et al’s framework, community is not presented as a delay but as part of the general context. A reframed version of the Three Delays framework that is set within both community and time contexts is proposed based on the findings (figure 3).

Figure 3

Reframed version of the Three Delays framework.

In this reframed framework, both home and the facility spheres are considered a part of the community. However, they exist in different spheres that are connected through the cyclically intertwined three delays. This was important to note as situating the facility outside of the community context insinuates that it is a separate entity siloed and different from other community resources such as schools or stores. The perception of facilities as separate from existing communities could cast the facility as a foreign institution, thereby negatively impacting facility service uptake as it could influence how facilities are accepted and trusted. However, our work shows that the facility was seen to be a resource within the community. For instance, matrones’ general depiction of the facility as a place that could save a pregnant woman’s life shows that it was viewed as a community resource by matrones. Similarly, community members’ perception of the facility as a place paying matrones further reveals evidence of the facility being viewed as a resource by community members.

Finally, in this framework, the impact of reaching the facility is bidirectional as the decision to go to the facility could be reversed if one’s ability to go to the facility is compromised. This reflects the importance of the second delay in bridging the facility and home/ community spheres. The cyclical nature of this framework differs from the sequential nature of the original framework and shows how each of the delays interconnects. This is also important to acknowledge as it also reflects how treatment and prevention are intertwined and influence one another.


This study describes the experience of matrones as they walk with pregnant, labouring women during their birthing journeys. The results of this study confirm previous research findings on the challenges faced by pregnant women in Haiti when accessing care during childbirth.23 24 27 These results can be used to inform future programming focused on working with matrones in Haiti to improve MNCH outcomes in Haiti.

By understanding the birthing journey from the perspective of the matrones, this study draws attention to a larger systemic issue that the MNCH continuum of care should be provided to pregnant, labouring women, beginning in their homes and extending to facilities.37 Our research shows that pregnant, labouring women in Haiti have a myriad of crucial, urgent decisions that must be made even before arrival at the facility to give birth. This leads us to consider two important questions. The first is what are the needs of pregnant, labouring women in Haiti even before arriving at a facility? The second is who can best support these needs?

The WHO recommends continuous companionship during the labour and birthing process for improving women’s satisfaction with services.38 What became evident in our research was that, in Haiti, matrones are a trusted source of this continuous companionship. They have traditionally supported pregnant, labouring women as they give birth, at times, even serving as a bridge to facilities. Thus, our research sheds light on the work that must take place to support pregnant, labouring women’s needs even before arrival at the facility. Upon admission to a facility, matrones can also play a role in continuing to provide companionship and support. This is important as, in Haiti, the sense of isolation within facilities has been a reported issue for pregnant women when deciding to have a facility-based birth.24 From this vantage point, matrones could potentially act as ‘doulas’,2 those who provide emotional and physical support to pregnant, labouring women.39

Like community health workers, matrones can be viewed as the first point of access into the formal health system for pregnant women.40 Thus, better integration into the formal healthcare sector is needed as it can be effective in improving access to formally trained providers who can address complex maternal cases.41 Multiple reviews have been undertaken to identify the essential factors for the integration of TBAs into the formal healthcare system. Across these reviews, training, partnership with the hospital staff, improved communication systems between TBAs and the trained providers, and clear identification of the TBA role are conducive to their integration into the formal healthcare sector.41 42 In addition, Miller and Smith point out that barriers to successful TBA integration include negative attitudes between formally trained providers and TBAs, resistance to changing traditional ways and lack of TBA remuneration.42 From this standpoint, successful matrone integration into the health system first requires an understanding of their contextualised experiences, existing activities, knowledge, attitudes, beliefs, practices and of the factors contributing to the three delays.41 Our research findings contribute to this understanding. This is particularly important in a country like Haiti where matrones support half the births.22

We concur with Byrne and Morgan41 that it is feasible to integrate matrones into the formal health system. The results of our study suggest that for matrones in Haiti’s Central Plateau, the best integration strategy into the healthcare system would involve strengthening communication systems for triage and community-based referral, collaboration with formally trained providers at the facility, and inclusion at facilities for shared care, task shifting and role definition. This is not to say that integration would not be difficult as the entire health system battles issues of limited resources and funds. Our study findings have also shown that there may be existing negative perceptions of facility-based care. Further, integration into the formal health sector would require regulations and limitations related to the roles and responsibilities of matrones to be established, as it is for other categories of healthcare providers (eg, scope of practice).4 However, integration of matrones into the formal health system could help strengthen existing MNCH service provision across the continuum of care. This reflects the need to involve matrones in discussions around integration, necessitating a community-based approach that involves multiple voices. This is particularly needed when approaching MNCH issues in remote areas.27 43

Additionally, as with other TBAs, the lack of acknowledgement or sense of validation from the hospital could be discouraging for matrones, particularly as they surmount many challenges to making a referral. Studies in Ghana and South Africa have shown that this acknowledgement is critical for TBA collaboration.3 44 Our research has shown that hospital referrals may not always put matrones in good standing with the communities with which they work, especially if the community or family members disagree with facility-based births. Referrals may also put matrones in the precarious position of community members no longer needing their services, which could put them out of work. Matrone engagement and newly developed relationships with the hospital could thus present new challenges to their community relationships, even creating conflict, particularly if community members prefer matrone-assisted births to facility-based births.

To ease this burden, the hospital could offer a sense of acknowledgement, validation and belonging to matrones. According to the WHO, TBAs should be welcomed by the healthcare system and be seen as an extension of it. This would help to promote an environment in which TBAs are part of the continuum of care and seen as part of a larger team.37 Further, our research has shown that matrones provide a certain level of care and support that is vital to the people they serve and may be lacking at the facility level. Studies of pregnant women in other countries have shown that many prefer to give birth with TBAs over facility-based birth due to the interpersonal relationships they already have with their TBA and whether they view care to be respectful at the facility.23 45 Thus, there may be opportunities for more formal healthcare systems to learn from the community-based practices of matrones and other TBAs. Doing this in a reciprocal and humble way could help to foster stronger connections and better-quality care offered to pregnant women. This can result in a more respectful care.

As matrones operate within multiple contexts to provide life-sustaining care, they should not be left alone or without resources when complex situations arise. When an emergency occurs in a facility setting, clinicians usually have human resources and infrastructural support. They often operate within the bounds of standardised procedures and systems to ensure the best quality of care possible. A similar need exists for matrones in home/ community settings. When a matrone is faced with an emergency that merits a facility-based birth, they should have access to tools, resources and people operating within a system to ensure the best quality of care possible. This could help reduce Haiti’s maternal mortality by shortening the three delays pregnant women face in accessing facilities.35 Leaving matrones alone in this battle for MNCH without proper tools, human resources, or other systemic support is unfair to them and the women they service. Research in other countries has similarly shown that equipping TBAs with resources, tools and training has helped to improve MNCH outcomes.2 46 47

Finally, our research sheds light on the need to reassess the Three Delays framework and its linearity. While other studies have challenged the linearity of this framework, few have situated facilities as part of the larger community/social context, acknowledging its role as part of the community, not separate from it.48 The more facilities are viewed and framed as external institutions of communities, the more friction is created that disrupts acceptance of services by community members. Further, none of the critiques of the framework have acknowledged the role that time plays, aside from its implicit role as a delay. By setting the three framework phases against both the community/social context and time, this research explicitly brings time to the forefront. Thus, our work acknowledges the need to further study the multidimensional role it plays in affecting facility access during the labour and birth process.

The absence of the cyclical nature and the role of prevention in the Three Delays framework has been criticised. It has even led to a reframed Three Delays framework called the Women’s Health Empowerment Framework that spans across antenatal, intrapartum and postpartum periods.48 While helpful in elucidating factors influencing improved health outcomes for pregnant women, this framework does not show the cyclical nature of each of the delays. It also includes community as a delay, thus not accounting for existing actors within the community, such as TBAs/matrones who can help to promote healthy outcomes for pregnant women and newborns. By doing so, it leaves out their perspectives, thereby neglecting a potential measure for acknowledging and leveraging existing community resources and bridging the gap between home and facility.48


Matrones who had previously been trained at HUM and had existing relationships with the hospital were the participants in this study. Further, the FGDs took place at the facility where the matrones were trained. Thus, there was a potential for the matrones to be influenced by this setting and respond in ways which were in line with more formal facility-based standards for birth that they learnt during their training at the hospital. To help mitigate this, FGD facilitators were those who were not involved in the training of the matrones.


Although on the surface, the act of referring pregnant women to the hospital seems simple, there is a network of complex, intertwining factors influencing this process which must be considered. While some of these factors are within the control of matrones, many are not. Each of these factors might be impacting the decision-making of the matrones either simultaneously or at different time points. For this reason, the Three Delays framework, while valuable in demarcating the different phases involved in accessing facilities during emergencies, needs to be reassessed to account for the intertwining, cyclical complexities faced by those trying to access the facility amidst the backdrop of both time and the community/social contexts. Additionally, the referral by matrones is a sensitive and complicated process that matrones should not have to bear the weight of alone. This work points to the need to better bridge the gap between home/community and facility settings. This could be done by improving the referral process, integrating matrones into the healthcare system, acknowledging their work, and treating them respectfully.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the Zanmi Lasante Institutional Review Board (reference #: ZLIRB11242022). Participants gave informed consent to participate in the study before taking part.


We would like to thank the matrones who participated in this research and for their continuous work to uplift and improve the lives of pregnant women in Haiti. We would also like to thank everyone who helped with the discussion guide testing, data collection, transcription, and translation, particularly Manite Garcon, Marlene Damas Borgella, Ashley Henry, Martine Fleurius, Vicky Louissant. Finally, we would like to thank those who supported thinking through the qualitative analytical process, including Dr. Clare Barrington and members of the HBEH 754 class. Finally, we would like to thank our funders whose financial contributions made this work possible.


Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.


  • Handling editor Manasee Mishra

  • Contributors CM, a local OB-GYN, working at HUM originally requested this study be done. Once this happened, MJ-B (who at the time worked at PIH) and MCJ-B worked together with a team of other researchers to begin study design as part of a larger project that MCJ-B was leading related to training matrones. MJ-B worked to train local data collectors, while MCJ-B and a few others worked to recruit matrones. PRP and MJ-B were part of data collection efforts, either leading FGDs and/or taking notes on them. For analysis, FGDs were translated into English and transcribed by MCJ-B and MJ-B. CM and MCJ-B quality-checked the transcriptions. Qualitative analysis was led by MJ-B and MCJ-B. However, all team members supported the analysis by coding at least one transcript. Key messages were discussed as a group and manuscript development was led by MJ-B and MCJ-B. However, each coauthor contributed to the development of different manuscript sections. The team has developed a dissemination plan which outlines the various manuscripts this work supports. Within this dissemination plan, each person has an opportunity to serve as primary and last author on different manuscript topics. MJ-B serves as the guarantor for this manuscript.

  • Funding In 2015, two funders supported the conduct of this research activity at HUM: Every Mother Counts (EMC) and the Kagle Fund, which supported the data collection. EMC supported the matrones' training and activities and the Kagle grant through the Nursing Center of Excellence (NCOE) activities at HUM.

  • Competing interests None declared.

  • Patient and public involvement While patients were not involved in the design, conduct, reporting, or dissemination plans of this research, matrones supported this research through snowball recruitment efforts and as research participants themselves.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.