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Women's preferences for obstetric care in rural Ethiopia: a population-based discrete choice experiment in a region with low rates of facility delivery
  1. M E Kruk1,
  2. M M Paczkowski2,
  3. A Tegegn3,
  4. F Tessema4,
  5. C Hadley5,
  6. M Asefa4,
  7. S Galea2,6
  1. 1Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
  2. 2Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan, USA
  3. 3Department of Epidemiology and Biostatistics, Jimma University, Jimma, Ethiopia
  4. 4Institute of Health Sciences Research, Jimma University, Jimma, Ethiopia
  5. 5Department of Anthropology, Emory University, Atlanta, Georgia, USA
  6. 6Center for Global Health, University of Michigan, Ann Arbor, Michigan, USA
  1. Correspondence to Margaret E Kruk, Mailman School of Public Health, Columbia University, 722 W. 168th Street, New York, NY 10032, USA; mkruk{at}


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 β=3.9, p<0.01), seeing a doctor versus a health extension worker (mean β=2.1, p<0.01) and a receptive provider attitude (mean β=1.4, 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.

  • Maternal mortality
  • facility utilisation
  • facility delivery
  • stated preference
  • discrete choice experiment
  • decision-making PR
  • developing country CG
  • health services research
  • maternal DI

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  • Funding This study was supported in part by a grant from the National Institutes of Health (HD047861) and grants from the Robert Wood Johnson Foundation Health and Society Scholars Program.

  • Competing interests None.

  • Ethics approval This study was conducted with the approval of the Jimma University IRB and the University of Michigan IRB.

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