A discrete choice experiment to determine facility-based delivery services desired by women and men in rural Ethiopia

Abstract

Objectives Despite global efforts to increase facility-based delivery (FBD), 90% of women in rural Ethiopia deliver at home without a skilled birth attendant. Men have an important role in increasing FBD due to their decision-making power, but this is largely unexplored. This study aimed to determine the FBD care attributes preferred by women and men, and whether poverty or household decision-making are associated with choice to deliver in a facility. Setting and participants We conducted a cross-sectional discrete choice experiment in 109 randomly selected households in rural Ethiopia in September-October 2015. We interviewed women who were pregnant or who had a child <2 years old and their male partners. Results Both women and men preferred health facilities where medications and supplies were available (OR=3.08; 95% CI 2.03 to 4.67 and OR=2.68; 95% CI 1.79 to 4.02, respectively), a support person was allowed in the delivery room (OR=1.69; 95% CI 1.37 to 2.07 and OR=1.74; 95% CI 1.42 to 2.14, respectively) and delivery cost was low (OR=1.15 95% CI 1.12 to 1.18 and OR=1.14; 95% CI 1.11 to 1.17, respectively). Women valued free ambulance service (OR=1.37; 95% CI 1.09 to 1.70), while men favoured nearby facilities (OR=1.09; 95% CI 1.06 to 1.13) with friendly providers (OR=1.30; 95% CI 1.03 to 1.64). Provider preferences were complex. Neither women nor men preferred female doctors to health extension workers (HEW) (OR=0.92; 95% CI 0.59 to 1.42 and OR=0.74; 95% CI 0.47 to 1.14, respectively), male doctors to HEW (OR=1.33; 95% CI 0.89 to 1.99 and OR=0.75; 95% CI 0.50 to 1.12, respectively) or female over male nurses (OR=0.68; 95% CI 0.94 to 1.71 and OR=1.03; 95% CI 0.77 to 2.94, respectively). While both women and men preferred male nurses to HEW (OR=1.86; 95% CI 1.23 to 2.80 and OR=1.95; 95% CI 1.30 to 2.95, respectively), men (OR=1.89; 95% CI 1.29 to 2.78), but not women (OR=1.47; 95% CI 1.00 to 2.13) preferred HEW to female nurses. Both women and men preferred female doctors to male nurses (OR=1.71; 95% CI 1.27 to 2.29 and OR=1.44; 95% CI 1.07 to 1.92, respectively), male doctors to female nurses (OR=1.95; 95% CI 1.44 to 2.62 and OR=1.41; 95% CI 1.05 to 1.90, respectively) and male doctors to male nurses (OR=2.47; 95% CI 1.84 to 3.32 and OR=1.46; 95% CI 1.09 to 1.95, respectively), while only women preferred male doctors to female doctors (OR=1.45; 95% CI 1.09 to 1.93 and OR=1.01; 95% CI 0.76 to 1.35, respectively) and only men preferred female nurses to female doctors (OR=1.34; 95% CI 0.98 to 1.84 and OR=1.39; 95% CI 1.02 to 1.89, respectively). Men were disproportionately involved in making household decisions (X 2 (1, n=216)=72.18, p<0.001), including decisions to seek healthcare (X 2 (1, n=216)=55.39, p<0.001), yet men were often unaware of their partners' prenatal care attendance (X 2 (1, n=215)=82.59, p<0.001). Conclusion Women's and men's preferences may influence delivery service choices. Considering these choices is one way the Ethiopian government and health facilities may encourage FBD in rural areas.