Toward improving respectful maternity care: a discrete choice experiment with rural women in northeast Nigeria

Introduction: There is a limited understanding of the importance of respectful maternity care on utilisation of maternal and newborn health services. This study aimed to determine how specific hypothetical facility birth experience of care attributes influenced rural Nigerian women's stated preferences for hypothetical place of delivery.

Methods: Attributes were identified through a comprehensive review of the literature. These attributes and their respective levels were further investigated in a qualitative study. We then developed and implemented a cross-sectional discrete choice experiment with a random sample of 426 women who had facility-based childbirth to elicit their stated preferences for facility birth experience of care attributes. Women were asked to choose between two hypothetical health facilities or home birth for future delivery. Choice data were analysed using multinomial logit and mixed multinomial logit models.

Results: Complete data for the discrete choice experiment were available for 425 of 426 women. The majority belonged to Fulani ethnic group (60%) and were married (95%). Almost half (45%) had no formal education. Parameter estimates were all of expected signs suggesting internal validity. The most important influence on choice of place of delivery was good health system condition, followed by absence of sexual abuse, then absence of physical and verbal abuse. Poor facility culture, including an unclean birth environment with no privacy and unclear user fee, was associated with the most disutility and had the most negative impact on preferences for facility-based childbirth.

Conclusion: The likelihood of poor facility birth experiences had a significant impact on stated preferences for place of delivery among rural women in northeast Nigeria. The study findings further underline the important relationship between facility birth experience and utilisation. Achieving universal health coverage would require efforts toward addressing poor facility birth experiences and promoting respectful maternity care, to ensure women want to access the services available.