Women’s preferences for obstetric care in rural Ethiopia: a population-based discrete choice experiment in a region with low rates of facility delivery M E Kruk, 1 M M Paczkowski, 2 A Tegegn, 3 F Tessema, 4 C Hadley, 5 M Asefa, 4 S Galea 2,6 ABSTRACT Background Delivery attended by skilled professionals is essential to reducing maternal mortality. Although the facility delivery rate in Ethiopia’s rural areas is extremely low, little is known about which health system characteristics most influence women’s preferences for delivery services. In this study, women’s preferences for attributes of health facilities for delivery in rural Ethiopia were investigated. Methods A population-based discrete choice experiment (DCE) was fielded in Gilgel Gibe, in southwest Ethiopia, among women with a delivery in the past 5 years. Women were asked to select a hypothetical health facility for future delivery from two facilities on a picture card. A hierarchical Bayesian procedure was used to estimate utilities associated with facility attributes: distance, type of provider, provider attitude, drugs and medical equipment, transport and cost. Results 1006 women completed 8045 DCE choice tasks. Among them, 93.8% had delivered their last child at home. The attributes with the greatest influence on the overall utility of a health facility for delivery were availability of drugs and equipment (mean b¼3.9, p<0.01), seeing a doctor versus a health extension worker (mean b¼2.1, p<0.01) and a receptive provider attitude (mean b¼1.4, p<0.01). Conclusion Women in rural southwest Ethiopia who have limited personal experience with facility delivery nonetheless value health facility attributes that indicate high technical quality: availability of drugs and equipment and physician providers. Well-designed policy experiments that measure the contribution of quality improvements to facility delivery rates in Ethiopia and other countries with low health service utilisation and high maternal mortality may inform national efforts to reduce maternal mortality. INTRODUCTION The maternal mortality ratio, an indicator of progress on Millennium Development Goal 5 to improve maternal health, is a measure of obstetric risk associated with each live birth. While maternal death is exceedingly rare in developed countries, high rates of death have persisted in poor countries with the result that the global maternal mortality ratio has remained relatively constant over the past several decades. 1 Developing countries that have managed to reduce maternal mortality, such as Malaysia and Sri Lanka, have done so through high- level, sustained political commitment to the survival of mothers, by professionalising delivery care and by improving health system infrastructure to respond to obstetric complications. 2e4 Ethiopia, a country with a widely dispersed and largely rural population of approximately 77 million people, has 1806 physicians, 18 146 nurses, 143 hospitals and 690 health centres. 5 By compar- ison, France, with a population of 61 million, has 207 000 physicians and 486 000 nurses. 6 Most physicians and nurses in Ethiopia practice in Addis Ababa and other urban areas. To address this human resource crisis, the Ethiopian government has trained 30 000 health extension workers to provide health education and preventive services at rural health posts, and is increasing the training of physicians and other health personnel. It has also expanded its network of first-level health posts from 1311 in 2001 to 11 446 in 2007. 7 While some health posts are equipped to provide delivery services, the government has designated health centres and hospitals for the provision of obstetric services. Of those, only hospitals can provide comprehensive emergency obstetric care, including caesarean section and blood transfusion. Health centres can handle some non-surgical obstetric complications and refer others to hospitals. Health centres and hospitals experience frequent shortages of staff, medicines and equipment. Ethiopia’s maternal mortality ratio of 673 per 100 000 live births, however, remains among the highest in the world and has fallen little if at all since 2001. 8 Maternal mortality in Ethiopia is likely linked to extremely low utilisation of skilled birth attendants and facility delivery and to even lower use of emergency obstetric care. The 2005 Demo- graphic and Health Survey found that only 25% of all Ethiopian mothers living in rural areas received any antenatal care from a health professional in their last pregnancy, 3% delivered in a health facility and 0.3% delivered by caesarean section. 8 Women in rural areas have limited access to facili- ties and low social status. 8 For example, one-third of women in Ethiopia report that their husbands make decisions about their healthcare without consulting them, while only 15% of women make their own decision. 8 While there is a growing body of literature about community-level, cultural and socioeconomic factors that may promote or impede facility delivery in < Additional appendices A and B are published online only. To view these files please visit the journal online (http://jech.bmj. com). 1 Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA 2 Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA 3 Department of Epidemiology and Biostatistics, Jimma University, Jimma, Ethiopia 4 Institute of Health Sciences Research, Jimma University, Jimma, Ethiopia 5 Department of Anthropology, Emory University, Atlanta, Georgia, USA 6 Center for Global Health, University of Michigan, Ann Arbor, Michigan, USA Correspondence to Margaret E Kruk, Mailman School of Public Health, Columbia University, 722 W. 168th Street, New York, NY 10032, USA; mkruk@columbia.edu Accepted 2 September 2009 Published Online First 12 October 2009 984 J Epidemiol Community Health 2010;64:984e988. doi:10.1136/jech.2009.087973 Research report