Monitoring childbirth care in primary health facilities: a validity study in Gombe State, northeastern Nigeria

Assessing the validity of maternal report on breastfeeding counselling in Kosovo's primary health facilities

BACKGROUND

Improving the quality of breastfeeding counselling delivered by primary care providers can improve breastfeeding outcomes and ultimately reduce mortality and morbidity of children and mothers. Accurate data on coverage and quality of primary care breastfeeding counselling is essential for monitoring progress; however, global and national indicators are limited. To help address this gap, this study validated indicators of receipt and quality of breastfeeding counselling during routine consultations for infant care at seven primary health facilities across Kosovo.

METHODS

Mothers' reports of breastfeeding counselling received during routine consultations for their infants (0-12 months of age) were collected by exit interview in 2019 and 2021 (n = 609). Responses were compared against direct observation of their consultation using a structured checklist (reference standard) by a trained third-party observer at the primary care facility. We assessed 13 indicators; ten were related to the receipt and content of breastfeeding counselling, and three were specific to the provider's interpersonal skills. We calculated sensitivity, specificity, and area under the receiver operating curve (AUC) to determine individual-level reporting accuracy.

RESULTS

Ten indicators had an agreement rate above 70% and seven indicators had high overall individual-level validity (AUC ≥ 0.7). High prevalence indicators recorded high sensitivity and low specificity, and the inverse for low prevalence indicators. More subjective indicators were less reliable, e.g., mothers over-reported the prevalence of all three indicators related to providers' interpersonal skills.

CONCLUSIONS

This study offers evidence on breastfeeding counselling quality by validating maternal reports of whether a provider discussed breastfeeding, the clinical content of that counselling, and how it was delivered. It is also situated in a primary care setting within a fragile state of which there is limited evidence. We observed that mothers reported accurately when asked directly to recall breastfeeding counselling services received. However, there is a need to further validate subjective questions about interpersonal skills and other measures for the 'experience of care' quality dimension.

Implementation and evaluation of the WHO maternity care model: a convergent parallel mixed-methods study protocol

Background

According to the World Health Organization (WHO), intrapartum care is considered a platform for providing respectful, personalized, and women-centered services to women. This study aims to investigate the intrapartum care model proposed by WHO.

Methods

This convergent parallel mixed-methods study will be carried out in qualitative and quantitative phases. In the quantitative phase (a quasi-experimental study), 108 pregnant women admitted to the maternity ward will be randomized to intervention (receiving intrapartum care based on the WHO model) and control group (receiving routine hospital care) before the beginning of the active stage of labor (cervix dilatation equal to 5 cm) and Wijma's delivery fear scale (DFS) will be completed for them and again at 7-8 cm dilatation. The participants of both groups will be followed up for 6 weeks after labor and then they will be invited to a relatively quiet place to complete the Childbirth Experience Questionnaire (CEQ 2.0), the Edinburgh Postpartum Depression Scale (EPDS), the Post-Traumatic Stress Disorder (PTSD) Symptom Scale (PSS-I), the Pregnancy and Childbirth Questionnaire (PCQ), exclusive breastfeeding and a checklist on willingness to give birth to another child. The qualitative phase will employ content analysis to explain mothers' views about the effects of this model especially subjective components of this model on their labor process after 4-6 weeks. The two phase's results will be discussed in combination.

Discussion

The implementation of such care models is expected to prevent mental disorders caused by negative experiences of childbirth, and also, prevent uncontrolled increases in cesarean sections.

Clinical Trial Registration

https://fa.irct.ir/user/trial/68313/view, identifier (IRCT20120718010324N69).

Understanding rural women's preferences for telephone call engagement with primary health care providers in Nigeria: a discrete choice experiment

BACKGROUND

The COVID-19 pandemic has accelerated the use of mobile phones to provide primary health care services and maintain continuity of care. This study aims to understand rural women's preferences for telephone call engagement with primary health care providers in Nigeria.

METHODS

A discrete choice experiment was conducted alongside an action research project that empowered primary health care workers to develop and implement a telephone call intervention to assess and enhance experiences with facility childbirth care. Between January and March 2022, 30 providers from 10 primary health care facilities implemented the choice experiment among rural women who had institutional childbirth to elicit service user preferences for telephone call engagement. The women were asked to express their preferred scenario for telephone call engagement with their primary health care providers. Generalised linear mixed models were used to estimate women's preferences.

RESULTS

Data for 460 women were available for the discrete choice experiment. The study showed that rural women have preferences for telephone call engagement with primary health care providers. Specifically, women preferred engaging with female to male callers (β=1.665 (95% CI 1.41, 1.93), SE=0.13, p<0.001), preferred call duration under 15 min (β=1.287 (95% CI 0.61, 1.96), SE=0.34, p<0.001) and preferred being notified before the telephone engagement (warm calling) (β=1.828 (95% CI 1.10, 2.56), SE=0.37, p<0.001). Phone credit incentive was also a statistically significant predictor of women's preferences for engagement. However, neither the availability of scheduling options, the period of the day or the day of the week predicts women's preferences.

CONCLUSIONS

The study highlights the importance of understanding rural women's preferences for telephone call engagement with healthcare providers in low-income and middle-income countries. These findings can inform the development of mobile phone-based interventions and improve acceptability and broader adoption.

Effect of the Mamás del Río programme on essential newborn care: a three-year before-and-after outcome evaluation of a community-based, maternal and neonatal health intervention in the Peruvian Amazon

Background

Despite remarkable progress in maternal and neonatal health, regional inequalities persist in Peru. In rural areas of Amazonian Loreto, access to quality care is difficult, home births are frequent, and neonatal mortality is high. We conducted a prospective before-and-after study to assess the effect after implementation and over time of a community-based intervention on essential newborn care (ENC).

Methods

Mamás del Río consists of tablet-enhanced educational home visits by Community health workers (CHW) to pregnant women and mothers of newborns, with supportive training on ENC of traditional birth attendants and facility staff. The study area comprised 79 rural communities of three districts in Loreto. Primary outcomes were ENC practices in home births, secondary outcomes were ENC in facility births as well as healthcare seeking, measured at baseline before and at year 2 and year 3 after intervention implementation. Community censuses included questionnaires to women aged 15-49 years with a live birth. We calculated prevalence of outcomes at each time point and estimated adjusted prevalence differences (PD) between time points using post-estimation based on logistic regression.

Findings

Following implementation early 2019, 97% of communities had a trained CHW. At year 2 follow-up, 63% (322/530) of women received a CHW visit during pregnancy. Seven out of nine ENC indicators among home births improved, with largest adjusted prevalence differences in immediate skin-to-skin contact (50% [95% CI: 42-58], p < 0.0001), colostrum feeding (45% [35-54], p < 0.0001), and cord care (19% [10-28], p = 0.0001). Improvements were maintained at year 3, except for cord care. At year 2, among facility births only three ENC indicators improved, while more women gave birth in a facility. Sensitivity analyses showed ENC prevalence was similar before compared to after onset of Covid-19 lockdown.

Interpretation

ENC practices in home births improved consistently and changes were sustained over time, despite the onset of the Covid-19 pandemic. A community-based approach for behaviour-change in home-based newborn care appears effective. Process evaluation of mechanisms will help to explain observed effects and understand transferability of findings.

Funding

Grand Challenges Canada and Peruvian National Council of Science and Technology.

Availability of priority maternal and newborn health indicators: Cross-sectional analysis of pregnancy, childbirth and postnatal care registers from 21 countries

Data from national health information systems are essential for routinely tracking progress, programmatic decision-making and to improve quality of services. Understanding the data elements captured in patient registers which are building blocks of national HMIS indicators, enables us to standardize data collection and measurement of key indicators for tracking progress towards achieving maternal and newborn health goals. This analysis was done through a review of antenatal care (ANC), childbirth and postnatal care (PNC) registers from 21 countries across five geographic regions. Between July and October 2020, country-based maternal and newborn experts, implementing agencies, program managers, and ministry of health personnel were asked to share the registers in use. Both paper-based and electronic registers were obtained. Twenty ANC registers, eighteen childbirth and thirteen PNC were available and analyzed. Both longitudinal and cross-sectional ANC and PNC registers were obtained, while the childbirth registers included in the analysis were all cross-sectional. Fifty-five percent (11/20) ANC registers and 54% (7/13) PNC registers were longitudinal. In four countries, the registers were electronic, while the rest were paper-based (17 countries). Sub-analysis of registers from four countries (Ghana, Kenya, Nigeria, and Zambia) where the 2017/2018 and 2019/2020 registers were available showed that the latest versions included 21/27 (78%) of data elements that are critical in the computation of key maternal and newborn care indicators. This analysis highlights some areas in where there are data gaps in data on pregnancy and childbirth. Program managers and health workers should use data gathered routinely to monitor the performance of their national health system and to guide the continuous improvement of health care services for women and newborns. The findings can help to inform the standardization of pregnancy and childbirth registers, and provide information for other countries seeking to introduce indicators in their health systems.

How valid are women's reports of the antenatal health services they receive from Community Health Workers in Gombe State north-eastern Nigeria?

BACKGROUND

Community health workers (CHWs) in low- and middle-income countries are key to increasing coverage of maternal and newborn interventions through home visits to counsel families about healthy behaviours. Household surveys enable tracking the progress of CHW programmes but recent evidence questions the accuracy of maternal reports. We measured the validity of women's responses about the content of care they received during CHW home visits and examined whether the accuracy of women's responses was affected by CHW counselling skills.

METHODS

We conducted a criterion validity study in 2019, in Gombe State-Nigeria, and collected data from 362 pregnant women. During accompanied CHW home visits the content of CHW care and the presence or absence of 18 positive counselling skills were observed and documented by a researcher. In a follow-up interview three months later, the same women were asked about the care received during the CHW home visit. Women's reports were compared with observation data and the sensitivity, specificity, and area under receiver curve (AUC) calculated. We performed a covariate validity analysis that adjusted for a counselling skill score to assess the variation in accuracy of women's reports with CHW counselling skills.

RESULTS

Ten indicators were included in the validity analysis. Women consistently overestimated the content of care CHWs provided and no indicator met the condition for individual-level accuracy set at AUC ≥ 0.6. The CHW counselling skill score ranged from 9-18 points from a possible 18, with a mean of 14.3; checking on client history or concerns were the most frequently missed item. There was evidence that unmarried women and the relatively most poor women received less skilled counselling than other women (mean counselling scores of 13.2 and 13.7 respectively). There was no consistent evidence of an association between higher counselling skill scores and better accuracy of women's reports.

CONCLUSIONS

The validity of women's responses about CHW care content was poor and consistently overestimated coverage. We discuss several challenges in applying criterion validity study methods to examine measures of community-based care and make only cautious interpretation of the findings that may be relevant to other researchers interested in developing similar studies.

Measurement of respectful maternity care in exit interviews following facility childbirth: a criterion validity assessment in Nigeria

Background

Valid methods for assessing women’s experiences of maternity care are essential to the global efforts toward providing positive childbirth environments for all women in all health facilities.

Methods

This criterion validity study used observation of childbirth as the reference standard compared to exit interviews with women upon discharge with a live baby, usually within 24 hours of childbirth. We investigated eight positive and sixteen negative maternity care experience indicators. Data were collected from ten primary healthcare facilities in Gombe State, northeast Nigeria, in August 2018 and August 2019. Data analysis involved tabulation of demographic characteristics of women and childbirth context, computation of individual level validity metrics including the area under the receiver operating curve (AUC) and estimating population level validity using the inflation factor (IF).

Results

A total of 724 women were observed and interviewed at the time of discharge (exit) following facility childbirth, 15% of whom were adolescents, 99% were married, 43% had no formal education, and a skilled birth attendant had attended only 12%. The prevalence of positive maternity care experience indicators ranged between 25% and 96% in childbirth observations. For these positive indicators, the agreement between childbirth observations and exit interviews ranged from 55% to 97%. Six of the eight positive maternity care experience indicators had high overall validity, meaning AUC≥0.70 and 0.75<IF<1.25, with high sensitivity (89% to 99%) and moderate to high specificity (44% to 84%). The prevalence of the 16 negative maternity care experience indicators ranged between 0.1% and 18% in childbirth observations. For these negative indicators, agreement ranged from 87% to 99%. Just six of the 16 negative maternity care experience indicators met the criteria for validation analysis; and these showed low to moderate sensitivity (32% to 74%), high specificity (97% to 100%) and moderate (0.60<AUC<0.70) to high (AUC≥0.70) individual-level validity.

Conclusions

In this high mortality setting with relatively low coverage of skilled attendance at birth, exit interviews with women following facility-based childbirth care provided responses consistent with the observation of childbirth for eight positive and six negative maternity care experience indicators.

Quality of routine health facility data used for newborn indicators in low- and middle-income countries: A systematic review

Background

High-quality data are fundamental for effective monitoring of newborn morbidity and mortality, particularly in high burden low- and middle-income countries (LMIC).

Methods

We conducted a systematic review on the quality of routine health facility data used for newborn indicators in LMIC, including measures employed. Five databases were searched from inception to February 2021 for relevant observational studies (excluding case-control studies, case series, and case reports) and baseline or control group data from interventional studies, with no language limits. An adapted version (19-point scale) of the Critical Appraisal Tool to assess the Quality of Cross-Sectional Studies (AXIS) was used to assess methodological quality, and results were synthesized using descriptive analysis.

Results

From the 19 572 records retrieved, 34 studies in 16 LMIC countries were included. Methodological quality was high (>14/19) in 32 studies and moderate (10-14/19) in two. Studies were mostly from African (n = 30, 88.2%) and South-East Asian (n = 24, 70.6%) World Health Organization (WHO) regions, with very few from Eastern Mediterranean (n = 2, 5.9%) and Western Pacific (n = 1, 2.9%) ones. We found that only data elements used to calculate neonatal indicators had been assessed, not the indicators themselves. 41 data elements were assessed, most frequently birth outcome. 20 measures of data quality were used, most along three dimensions: 1) completeness and timeliness, 2) internal consistency, and 3) external consistency. Data completeness was very heterogeneous across 26 studies, ranging from 0%-100% in routine facility registers, 0%-100% in patient case notes, and 20%-68% in aggregate reports. One study reported on the timeliness of aggregate reports. Internal consistency ranged from 0% to 96.2% in four studies. External consistency (21 studies) varied widely in measurement and findings, with specificity (6.4%-100%), sensitivity (23.6%-97.6%), and percent agreement (24.6%-99.4%) most frequently reported.

Conclusions

This systematic review highlights a gap in the published literature on the quality of routine LMIC health facility data for newborn indicators. Robust evidence is crucial in driving data quality initiatives at national and international levels. The findings of this review indicate that good quality data collection is achievable even in high-burden LMIC settings, but more efforts are needed to ensure uniformly high data quality for neonatal indicators.

Sustainability of the Effects and Impacts of Using Digital Technology to Extend Maternal Health Services to Rural and Hard-to-Reach Populations: Experience From Southwest Nigeria

Background

Nigeria has one of the worst health and development profiles globally. A weak health system, poor infrastructure, and varied socio-cultural factors are cited as inhibitors to optimal health system performance and improved maternal and child health status. eHealth has become a major solution to closing these gaps in health care delivery in low- and middle-income countries (LMICs). This research reports the use of satellite communication (SatCom) technology and the existing 3G mobile network for providing video training (VTR) for health workers and improving the digitization of healthcare data.

Objective

To evaluate whether the expected project outcomes that were achieved at the end-line evaluation of 2019 were sustained 12 months after the project ended.

Methods

From March 2017 to March 2019, digital innovations including VTR and data digitization interventions were delivered in 62 healthcare facilities in Ondo State, southwest Nigeria, most of which lacked access to a 3G mobile network. Data collection for the evaluation combined documents' review with quantitative data extracted from health facility registers, and 24 of the most significant change stories to assess the longevity of the outcomes and impacts of digital innovation in the four domains of healthcare: use of eHealth technology for data management, utilization of health facilities by patients, the standard of care, and staff attitude. Stories of the most significant changes were audio-recorded, transcribed for analysis, and categorized by the above domains to identify the most significant changes 12 months after the project closedown.

Results

Findings showed that four project outcomes which were achieved at end-line evaluation were sustained 12 months after project closedown namely: staff motivation and satisfaction; increased staff confidence to perform healthcare roles; improved standard of healthcare delivery; and increased adoption of eHealth innovations beyond the health sector. Conversely, an outcome that was reversed following the discontinuation of SatCom from health facilities is the availability of accurate and reliable data for decision-making.

Conclusion

Digital technology can have lasting impacts on health workers, patients, and the health system, through improving data management for decision-making, the standard of maternity service delivery, boosting attendance at health facilities, and utilization of services. Locally driven investment is essential for ensuring the long-term survival of eHealth projects to achieve sustainable development goals (SDGs) in LMICs.

Improving maternal and newborn health services in Northeast Nigeria through a government-led partnership of stakeholders: a quasi-experimental study

OBJECTIVES

This study aimed to quantify change in the coverage, quality and equity of essential maternal and newborn healthcare interventions in Gombe state, Northeast Nigeria, following a four year, government-led, maternal and newborn health intervention.

DESIGN

Quasi-experimental plausibility study. Repeat cross-sectional household and linked health facility surveys were implemented in intervention and comparison areas.

SETTING

Gombe state, Northeast Nigeria.

PARTICIPANTS

Each household survey included a sample of 1000 women aged 13-49 years with a live birth in the previous 12 months. Health facility surveys comprised a readiness assessment and birth attendant interview.

INTERVENTIONS

Between 2016-2019 a complex package of evidence-based interventions was implemented to increase access, use and quality of maternal and newborn healthcare, spanning the six WHO health system building blocks.

OUTCOME MEASURES

Eighteen indicators of maternal and newborn healthcare.

RESULTS

Between 2016 and 2019, the coverage of all indicators improved in intervention areas, with the exception of postnatal and postpartum contacts, which remained below 15%. Greater improvements were observed in intervention than comparison areas for eight indicators, including coverage of at least one antenatal visit (71% (95% CI 62 to 68) to 88% (95% CI 82 to 93)), at least four antenatal visits (46% (95% CI 39 to 53) to 69% (95% CI 60 to 75)), facility birth (48% (95% CI 37 to 59) to 64% (95% CI 54 to 73)), administration of uterotonics (44% (95% CI 34 to 54) to 59% (95% CI 50 to 67)), delayed newborn bathing (44% (95% CI 36 to 52) to 62% (95% CI 52 to 71)) and clean cord care (42% (95% CI 34 to 49) to 73% (95% CI 66 to 79)). Wide-spread inequities persisted however; only at least one antenatal visit saw pro-poor improvement.

CONCLUSIONS

This intervention achieved improvements in life-saving behaviours for mothers and newborns, demonstrating that multipartner action, coordinated through government leadership, can shift the needle in the right direction, even in resource-constrained settings.

Operationalising effective coverage measurement of facility based childbirth in Gombe State; a comparison of data sources

Estimating effective coverage of childbirth care requires linking population based data sources to health facility data. For effective coverage to gain widespread adoption there is a need to focus on the feasibility of constructing these measures using data typically available to decision makers in low resource settings. We estimated effective coverage of childbirth care in Gombe State, northeast Nigeria, using two different combinations of facility data sources and examined their strengths and limitations for decision makers. Effective coverage captures information on four steps: access, facility inputs, receipt of interventions and process quality. We linked data from the 2018 Nigerian Demographic and Health Survey (NDHS) to two sources of health facility data: (1) comprehensive health facility survey data generated by a research project; and (2) District Health Information Software 2 (DHIS2). For each combination of data sources, we examined which steps were feasible to calculate, the size of the drop in coverage between steps and the resulting estimate of effective coverage. Analysis included 822 women with a recent live birth, 30% of whom attended a facility for childbirth. Effective coverage was low: 2% based on the project data and less than 1% using the DHIS2. Linking project data with NDHS, it was feasible to measure all four steps; using DHIS2 it was possible to estimate three steps: no data was available to measure process quality. The provision of high quality care is suboptimal in this high mortality setting where access and facility readiness to provide care, crucial foundations to the provision of high quality of care, have not yet been met. This study demonstrates that partial effective coverage measures can be constructed from routine data combined with nationally representative surveys. Advocacy to include process of care indicators in facility summary reports could optimise this data source for decision making.

Can routine health facility data be used to monitor subnational coverage of maternal, newborn and child health services in Uganda?

Background

Routine health facility data are a critical source of local monitoring of progress and performance at the subnational level. Uganda has been using district health statistics from facility data for many years. We aimed to systematically assess data quality and examine different methods to obtain plausible subnational estimates of coverage for maternal, newborn and child health interventions.

Methods

Annual data from the Uganda routine health facility information system 2015–2019 for all 135 districts were used, as well as national surveys for external comparison and the identification of near-universal coverage interventions. The quality of reported data on antenatal and delivery care and child immunization was assessed through completeness of facility reporting, presence of extreme outliers and internal data consistencies. Adjustments were made when necessary. The denominators for the coverage indicators were derived from population projections and health facility data on near-universal coverage interventions. The coverage results with different denominators were compared with the results from household surveys.

Results

Uganda’s completeness of reporting by facilities was near 100% and extreme outliers were rare. Inconsistencies in reported events, measured by annual fluctuations and between intervention consistency, were common and more among the 135 districts than the 15 subregions. The reported numbers of vaccinations were improbably high compared to the projected population of births or first antenatal visits – and especially so in 2015–2016. There were also inconsistencies between the population projections and the expected target population based on reported numbers of antenatal visits or immunizations. An alternative approach with denominators derived from facility data gave results that were more plausible and more consistent with survey results than based on population projections, although inconsistent results remained for substantive number of subregions and districts.

Conclusion

Our systematic assessment of the quality of routine reports of key events and denominators shows that computation of district health statistics is possible with transparent adjustments and methods, providing a general idea of levels and trends for most districts and subregions, but that improvements in data quality are essential to obtain more accurate monitoring.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06554-6.

Coverage of antenatal, intrapartum, and newborn care in 104 districts of Ethiopia: A before and after study four years after the launch of the national Community-Based Newborn Care programme

BACKGROUND

Access to health services across the continuum of care improves maternal and newborn health outcomes. Ethiopia launched the Community-Based Newborn Care programme in 2013 to increase the coverage of antenatal care, institutional delivery, postnatal care and newborn care. The programme also introduced gentamicin and amoxicillin treatment by health extension workers for young infants with possible serious bacterial infection when referral was not possible. This study aimed to assess the extent to which the coverage of health services for mothers and their young infants increased after the initiation of the programme.

METHODS

A baseline survey was conducted in October-December 2013 and a follow-up survey four years later in November-December 2017. At baseline, 10,224 households and 1,016 women who had a live birth in the 3-15 months prior to the survey were included. In the follow-up survey, 10,270 households and 1,057 women with a recent live birth were included. Women were asked about their experience of care during pregnancy, delivery and postpartum periods, as well as the treatment provided for their child's illness in the first 59 days of life.

RESULTS

Between baseline and follow-up surveys the proportion of women reporting at least one antenatal care visit increased by 15 percentage points (95% CI: 10,19), four or more antenatal care visits increased by 17 percentage points (95%CI: 13,22), and institutional delivery increased by 40 percentage points (95% CI: 35,44). In contrast, the proportion of newborns with a postnatal care visit within 48 hours of birth decreased by 6 percentage points (95% CI: -10, -3) for home deliveries and by 14 percentage points (95% CI: -21, -7) for facility deliveries. The proportion of mothers reporting that their young infant with possible serious bacterial infection received amoxicillin for seven days increased by 50 percentage points (95% CI: 37,62) and gentamicin for seven days increased by 15 percentage points (95% CI: 5,25). Concurrent use of both antibiotics increased by 12 percentage points (95% CI: 4,19).

CONCLUSION

The Community-Based Newborn Care programme was an ambitious initiative to enhance the access to services for pregnant women and newborns. Major improvements were seen for the number of antenatal care visits and institutional delivery, while postnatal care remained alarmingly low. Antibiotic treatment for young infants with possible serious bacterial infection increased, although most treatment did not follow national guidelines. Improving postnatal care coverage and using a simplified antibiotic regimen following recent World Health Organization guidelines could address gaps in the care provided for sick young infants.

Nigerian neonatologists perception and experience with retinopathy of prematurity

BACKGROUND

Retinopathy of Prematurity (ROP) is an avoidable condition that affects premature infants exposed to oxygen stresses at or soon after birth. In low- and middle-income countries, like Nigeria, neonatal mortality rates are high and very few infants live to develop ROP. With recent better care, ROP is now being diagnosed.

OBJECTIVE

This study aimed to characterize what Nigerian neonatologists understand about ROP.

METHODS

At a joint meeting of Nigerian pediatric ophthalmologists and neonatologists in Kebbi State held 26-29 July 2018, questionnaires collected attendees' perspective and experience with ROP including causes, risk factors and experiences.

RESULTS

Fifty-one neonatologists out of 71 returned a completed questionnaire (response rate: 71.8%). The male:female ratio was 1:1.8, and approximately 40% were aged 41-50 years (n=20, 39.22%). Only 3 (6.39%) had experience managing infants below 500g that survived. A majority managed babies with a mean weight of 913g ± 300.37 and age of 27.87 weeks ±2.37. Most had no access to oxygen monitors (n=39,78%). Most had 10 babies to one monitor and used average settings of 90-95%. One third had seen a case of ROP (n=15,29.41%). Only 5.88% (n=3) were unaware of uncontrolled oxygen use as a risk factor. Only 4 (8.89%) had a functional screening team. None were aware of local screening guidelines.

CONCLUSIONS

Regular educational programs, collaborative clinical presentations and webinars about ROP targeted at the neonatologists and parents, including establishment of screening programs across country will likely help reduce the burden of ROP blindness in Nigeria.

Identification of seven tumor-educated platelets RNAs for cancer diagnosis

BACKGROUND

Tumor-educated platelets (TEPs) may enable blood-based cancer diagnosis. This study aimed to identify diagnostic TEPs genes involved in carcinogenesis.

MATERIALS AND METHODS

The TEPs differentially expressed genes (DEGs) between healthy samples and early/advanced cancer samples were obtained using bioinformatics. Gene ontology (GO) analysis and Kyoto encyclopedia of genes and genomes (KEGG) pathway enrichment analysis were used to identify the pathways and functional annotation of TEPs DEGs. Protein-protein interaction of these TEPs DEGs was analyzed based on the STRING database and visualized by Cytoscape software. The correlation analysis and diagnostic analysis were performed to evaluate the diagnostic value of TEPs mRNAs expression for early/advanced cancers. Quantitative real-time PCR (qRT-PCR) was applied to validate the role of DEGs in cancers.

RESULTS

TEPs mRNAs were mostly involved in protein binding, extracellular matrix, and cellular protein metabolic process. RSL24D1 was negatively correlated to early-stage cancers compared to healthy controls and may be potentially used for early cancer diagnosis. In addition, HPSE, IFI27, LGALS3BP, CRYM, HBD, COL6A3, LAMB2, and IFITM3 showed an upward trend in the expression from early to advanced cancer stages. Moreover, ARL2, FCGR2A, and KLHDC8B were positively associated with advanced, metastatic cancers compared to healthy controls. Among the 12 selected DEGs, the expression of 7 DEGs, including RSL24D1, IFI27, CRYM, HBD, IFITM3, FCGR2A, and KLHDC8B, were verified by the qRT-PCR method.

CONCLUSION

This study suggests that the 7-gene TEPs liquid-biopsy biomarkers may be used for cancer diagnosis and monitoring.

Survey of women's report for 33 maternal and newborn indicators: EN-BIRTH multi-country validation study

BACKGROUND

Population-based household surveys, notably the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), remain the main source of maternal and newborn health data for many low- and middle-income countries. As part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study, this paper focuses on testing validity of measurement of maternal and newborn indicators around the time of birth (intrapartum and postnatal) in survey-report.

METHODS

EN-BIRTH was an observational study testing the validity of measurement for selected maternal and newborn indicators in five secondary/tertiary hospitals in Bangladesh, Nepal and Tanzania, conducted from July 2017 to July 2018. We compared women's report at exit survey with the gold standard of direct observation or verification from clinical records for women with vaginal births. Population-level validity was assessed by validity ratios (survey-reported coverage: observer-assessed coverage). Individual-level accuracy was assessed by sensitivity, specificity and percent agreement. We tested indicators already in DHS/MICS as well as indicators with potential to be included in population-based surveys, notably the first validation for small and sick newborn care indicators.

RESULTS

33 maternal and newborn indicators were evaluated. Amongst nine indicators already present in DHS/MICS, validity ratios for baby dried or wiped, birthweight measured, low birthweight, and sex of baby (female) were between 0.90-1.10. Instrumental birth, skin-to-skin contact, and early initiation of breastfeeding were highly overestimated by survey-report (2.04-4.83) while umbilical cord care indicators were massively underestimated (0.14-0.22). Amongst 24 indicators not currently in DHS/MICS, two newborn contact indicators (kangaroo mother care 1.00, admission to neonatal unit 1.01) had high survey-reported coverage amongst admitted newborns and high sensitivity. The remaining indicators did not perform well and some had very high "don't know" responses.

CONCLUSIONS

Our study revealed low validity for collecting many maternal and newborn indicators through an exit survey instrument, even with short recall periods among women with vaginal births. Household surveys are already at risk of overload, and some specific clinical care indicators do not perform well and may be under-powered. Given that approximately 80% of births worldwide occur in facilities, routine registers should also be explored to track coverage of key maternal and newborn health interventions, particularly for clinical care.

Immediate newborn care and breastfeeding: EN-BIRTH multi-country validation study

BACKGROUND

Immediate newborn care (INC) practices, notably early initiation of breastfeeding (EIBF), are fundamental for newborn health. However, coverage tracking currently relies on household survey data in many settings. "Every Newborn Birth Indicators Research Tracking in Hospitals" (EN-BIRTH) was an observational study validating selected maternal and newborn health indicators. This paper reports results for EIBF.

METHODS

The EN-BIRTH study was conducted in five public hospitals in Bangladesh, Nepal, and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data on EIBF and INC practices (skin-to-skin within 1 h of birth, drying, and delayed cord clamping). To assess validity of EIBF measurement, we compared observation as gold standard to register records and women's exit-interview survey reports. Percent agreement was used to assess agreement between EIBF and INC practices. Kaplan Meier survival curves showed timing. Qualitative interviews were conducted to explore barriers/enablers to register recording.

RESULTS

Coverage of EIBF among 7802 newborns observed for ≥1 h was low (10.9, 95% CI 3.8-21.0). Survey-reported (53.2, 95% CI 39.4-66.8) and register-recorded results (85.9, 95% CI 58.1-99.6) overestimated coverage compared to observed levels across all hospitals. Registers did not capture other INC practices apart from breastfeeding. Agreement of EIBF with other INC practices was high for skin-to-skin (69.5-93.9%) at four sites, but fair/poor for delayed cord-clamping (47.3-73.5%) and drying (7.3-29.0%). EIBF and skin-to-skin were the most delayed and EIBF rarely happened after caesarean section (0.5-3.6%). Qualitative findings suggested that focusing on accuracy, as well as completeness, contributes to higher quality with register reporting.

CONCLUSIONS

Our study highlights the importance of tracking EIBF despite measurement challenges and found low coverage levels, particularly after caesarean births. Both survey-reported and register-recorded data over-estimated coverage. EIBF had a strong agreement with skin-to-skin but is not a simple tracer for other INC indicators. Other INC practices are challenging to measure in surveys, not included in registers, and are likely to require special studies or audits. Continued focus on EIBF is crucial to inform efforts to improve provider practices and increase coverage. Investment and innovation are required to improve measurement.

Chlorhexidine for facility-based umbilical cord care: EN-BIRTH multi-country validation study

BACKGROUND

Umbilical cord hygiene prevents sepsis, a leading cause of neonatal mortality. The World Health Organization recommends 7.1% chlorhexidine digluconate (CHX) application to the umbilicus after home birth in high mortality contexts. In Bangladesh and Nepal, national policies recommend CHX use for all facility births. Population-based household surveys include optional questions on CHX use, but indicator validation studies are lacking. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study assessing measurement validity for maternal and newborn indicators. This paper reports results regarding CHX.

METHODS

The EN-BIRTH study (July 2017-July 2018) included three public hospitals in Bangladesh and Nepal where CHX cord application is routine. Clinical-observers collected tablet-based, time-stamped data regarding cord care during admission to labour and delivery wards as the gold standard to assess accuracy of women's report at exit survey, and of routine-register data. We calculated validity ratios and individual-level validation metrics; analysed coverage, quality and measurement gaps. We conducted qualitative interviews to assess barriers and enablers to routine register-recording.

RESULTS

Umbilical cord care was observed for 12,379 live births. Observer-assessed CHX coverage was very high at 89.3-99.4% in all 3 hospitals, although slightly lower after caesarean births in Azimpur (86.8%), Bangladesh. Exit survey-reported coverage (0.4-45.9%) underestimated the observed coverage with substantial "don't know" responses (55.5-79.4%). Survey-reported validity ratios were all poor (0.01 to 0.38). Register-recorded coverage in the specific column in Bangladesh was underestimated by 0.2% in Kushtia but overestimated by 9.0% in Azimpur. Register-recorded validity ratios were good (0.9 to 1.1) in Bangladesh, and poor (0.8) in Nepal. The non-specific register column in Pokhara, Nepal substantially underestimated coverage (20.7%).

CONCLUSIONS

Exit survey-report highly underestimated observed CHX coverage in all three hospitals. Routine register-recorded coverage was closer to observer-assessed coverage than survey reports in all hospitals, including for caesarean births, and was more accurately captured in hospitals with a specific register column. Inclusion of CHX cord care into registers, and tallied into health management information system platforms, is justified in countries with national policies for facility-based use, but requires implementation research to assess register design and data flow within health information systems.

Uterotonics for prevention of postpartum haemorrhage: EN-BIRTH multi-country validation study

BACKGROUND

Postpartum haemorrhage (PPH) is a leading cause of preventable maternal mortality worldwide. The World Health Organization (WHO) recommends uterotonic administration for every woman after birth to prevent PPH. There are no standardised data collected in large-scale measurement platforms. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) is an observational study to assess the validity of measurement of maternal and newborn indicators, and this paper reports findings regarding measurement of coverage and quality for uterotonics.

METHODS

The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania, from July 2017 to July 2018. Clinical observers collected tablet-based, time-stamped data. We compared observation data for uterotonics to routine hospital register-records and women's report at exit-interview survey. We analysed the coverage and quality gap for timing and dose of administration. The register design was evaluated against gap analyses and qualitative interview data assessing the barriers and enablers to data recording and use.

RESULTS

Observed uterotonic coverage was high in all five hospitals (> 99%, 95% CI 98.7-99.8%). Survey-report underestimated coverage (79.5 to 91.7%). "Don't know" replies varied (2.1 to 14.4%) and were higher after caesarean (3.7 to 59.3%). Overall, there was low accuracy in survey data for details of uterotonic administration (type and timing). Register-recorded coverage varied in four hospitals capturing uterotonics in a specific column (21.6, 64.5, 97.6, 99.4%). The average coverage measurement gap was 18.1% for register-recorded and 6.0% for survey-reported coverage. Uterotonics were given to 15.9% of women within the "right time" (1 min) and 69.8% within 3 min. Women's report of knowing the purpose of uterotonics after birth ranged from 0.4 to 64.9% between hospitals. Enabling register design and adequate staffing were reported to improve routine recording.

CONCLUSIONS

Routine registers have potential to track uterotonic coverage - register data were highly accurate in two EN-BIRTH hospitals, compared to consistently underestimated coverage by survey-report. Although uterotonic coverage was high, there were gaps in observed quality for timing and dose. Standardisation of register design and implementation could improve data quality and data flow from registers into health management information reporting systems, and requires further assessment.

Electronic data collection for multi-country, hospital-based, clinical observation of maternal and newborn care: EN-BIRTH study experiences

BACKGROUND

Observation of care at birth is challenging with multiple, rapid and potentially concurrent events occurring for mother, newborn and placenta. Design of electronic data (E-data) collection needs to account for these challenges. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) was an observational study to assess measurement of indicators for priority maternal and newborn interventions and took place in five hospitals in Bangladesh, Nepal and Tanzania (July 2017-July 2018). E-data tools were required to capture individually-linked, timed observation of care, data extraction from hospital register-records or case-notes, and exit-survey data from women.

METHODS

To evaluate this process for EN-BIRTH, we employed a framework organised around five steps for E-data design, data collection and implementation. Using this framework, a mixed methods evaluation synthesised evidence from study documentation, standard operating procedures, stakeholder meetings and design workshops. We undertook focus group discussions with EN-BIRTH researchers to explore experiences from the three different country teams (November-December 2019). Results were organised according to the five a priori steps.

RESULTS

In accordance with the five-step framework, we found: 1) Selection of data collection approach and software: user-centred design principles were applied to meet the challenges for observation of rapid, concurrent events around the time of birth with time-stamping. 2) Design of data collection tools and programming: required extensive pilot testing of tools to be user-focused and to include in-built error messages and data quality alerts. 3) Recruitment and training of data collectors: standardised with an interactive training package including pre/post-course assessment. 4) Data collection, quality assurance, and management: real-time quality assessments with a tracking dashboard and double observation/data extraction for a 5% case subset, were incorporated as part of quality assurance. Internet-based synchronisation during data collection posed intermittent challenges. 5) Data management, cleaning and analysis: E-data collection was perceived to improve data quality and reduce time cleaning.

CONCLUSIONS

The E-Data system, custom-built for EN-BIRTH, was valued by the site teams, particularly for time-stamped clinical observation of complex multiple simultaneous events at birth, without which the study objectives could not have been met. However before selection of a custom-built E-data tool, the development time, higher training and IT support needs, and connectivity challenges need to be considered against the proposed study or programme's purpose, and currently available E-data tool options.

Assessment of the validity of the measurement of newborn and maternal health-care coverage in hospitals (EN-BIRTH): an observational study

BACKGROUND

Progress in reducing maternal and neonatal deaths and stillbirths is impeded by data gaps, especially regarding coverage and quality of care in hospitals. We aimed to assess the validity of indicators of maternal and newborn health-care coverage around the time of birth in survey data and routine facility register data.

METHODS

Every Newborn-BIRTH Indicators Research Tracking in Hospitals was an observational study in five hospitals in Bangladesh, Nepal, and Tanzania. We included women and their newborn babies who consented on admission to hospital. Exclusion critiera at admission were no fetal heartbeat heard or imminent birth. For coverage of uterotonics to prevent post-partum haemorrhage, early initiation of breastfeeding (within 1 h), neonatal bag-mask ventilation, kangaroo mother care (KMC), and antibiotics for clinically defined neonatal infection (sepsis, pneumonia, or meningitis), we collected time-stamped, direct observation or case note verification data as gold standard. We compared data reported via hospital exit surveys and via hospital registers to the gold standard, pooled using random effects meta-analysis. We calculated population-level validity ratios (measured coverage to observed coverage) plus individual-level validity metrics.

FINDINGS

We observed 23 471 births and 840 mother-baby KMC pairs, and verified the case notes of 1015 admitted newborn babies regarding antibiotic treatment. Exit-survey-reported coverage for KMC was 99·9% (95% CI 98·3-100) compared with observed coverage of 100% (99·9-100), but exit surveys underestimated coverage for uterotonics (84·7% [79·1-89·5]) vs 99·4% [98·7-99·8] observed), bag-mask ventilation (0·8% [0·4-1·4]) vs 4·4% [1·9-8·1]), and antibiotics for neonatal infection (74·7% [55·3-90·1] vs 96·4% [94·0-98·6] observed). Early breastfeeding coverage was overestimated in exit surveys (53·2% [39·4-66·8) vs 10·9% [3·8-21·0] observed). "Don't know" responses concerning clinical interventions were more common in the exit survey after caesarean birth. Register data underestimated coverage of uterotonics (77·9% [37·8-99·5] vs 99·2% [98·6-99·7] observed), bag-mask ventilation (4·3% [2·1-7·3] vs 5·1% [2·0-9·6] observed), KMC (92·9% [84·2-98·5] vs 100% [99·9-100] observed), and overestimated early breastfeeding (85·9% (58·1-99·6) vs 12·5% [4·6-23·6] observed). Inter-hospital heterogeneity was higher for register-recorded coverage than for exit survey report. Even with the same register design, accuracy varied between hospitals.

INTERPRETATION

Coverage indicators for newborn and maternal health care in exit surveys had low accuracy for specific clinical interventions, except for self-report of KMC, which had high sensitivity after admission to a KMC ward or corner and could be considered for further assessment. Hospital register design and completion are less standardised than surveys, resulting in variable data quality, with good validity for the best performing sites. Because approximately 80% of births worldwide take place in facilities, standardising register design and information systems has the potential to sustainably improve the quality of data on care at birth.

FUNDING

Children's Investment Fund Foundation and Swedish Research Council.

Improving the quality of routine maternal and newborn data captured in primary health facilities in Gombe State, Northeastern Nigeria: a before-and-after study

OBJECTIVES

Primary objective: to assess nine data quality metrics for 14 maternal and newborn health data elements, following implementation of an integrated, district-focused data quality intervention.

SECONDARY OBJECTIVE

to consider whether assessing the data quality metrics beyond completeness and accuracy of facility reporting offered new insight into reviewing routine data quality.

DESIGN

Before-and-after study design.

SETTING

Primary health facilities in Gombe State, Northeastern Nigeria.

PARTICIPANTS

Monitoring and evaluation officers and maternal, newborn and child health coordinators for state-level and all 11 local government areas (district-equivalent) overseeing 492 primary care facilities offering maternal and newborn care services.

INTERVENTION

Between April 2017 and December 2018, we implemented an integrated data quality intervention which included: introduction of job aids and regular self-assessment of data quality, peer-review and feedback, learning workshops, work planning for improvement, and ongoing support through social media.

OUTCOME MEASURES

9 metrics for the data quality dimensions of completeness and timeliness, internal consistency of reported data, and external consistency.

RESULTS

The data quality intervention was associated with improvements in seven of nine data quality metrics assessed including availability and timeliness of reporting, completeness of data elements, accuracy of facility reporting, consistency between related data elements, and frequency of outliers reported. Improvement differed by data element type, with content of care and commodity-related data improving more than contact-related data. Increases in the consistency between related data elements demonstrated improved internal consistency within and across facility documentation.

CONCLUSIONS

An integrated district-focused data quality intervention-including regular self-assessment of data quality, peer-review and feedback, learning workshops, work planning for improvement, and ongoing support through social media-can increase the completeness, accuracy and internal consistency of facility-based routine data.

Provision of essential evidence-based interventions during facility-based childbirth: cross-sectional observations of births in northeast Nigeria

OBJECTIVES

To measure the provision of evidence-based preventive and promotive interventions to women, and subsequently their newborns, during childbirth in a high-mortality setting.

DESIGN AND PARTICIPANTS

Cross-sectional observations of care provided to women, and their newborns during the intrapartum and immediate postpartum period using a standardised checklist capturing healthcare worker behaviours regarding lifesaving and respectful care.

SETTING

Ten primary healthcare facilities in Gombe state, northeast Nigeria. The northeast region of Nigeria has some of the highest maternal and newborn death rates globally.

MAIN OUTCOME MEASURES

Data on 50 measures of internationally recommended evidence-based interventions and good practice.

RESULTS

1875 women were admitted to a health facility during the observation period; of these, 1804 gave birth in the facility and did not experience an adverse event or death. Many clinical interventions around the time of birth were routinely implemented, including provision of uterotonic (96% (95% CI 93% to 98%)), whereas risk-assessment measures, such as history-taking or checking vital signs were rarely completed: just 2% (95% CI 2% to 7%) of women had their temperature taken and 12% (95% CI 9% to 16%) were asked about complications during the pregnancy.

CONCLUSIONS

The majority of women did not receive the recommended routine processes of childbirth care they and their newborns needed to benefit from their choice to deliver in a health facility. In particular, few benefited from even basic risk assessments, leading to missed opportunities to identify risks. To continue with the recommendation of childbirth care in primary healthcare facilities in high mortality settings like Gombe, it is crucial that birth attendant capacity, capability and prioritisation processes are addressed.

A, Salim N, Zaman SB, Shamba D, Blencowe H, Ruysen H, El Arifeen S, Boggs D, Gordeev VS, Rahman QSU, Hossain T, Joshi E, Thapa S, Poudel RP, Poudel D, Chaudhary P, Karki R, Chitrakar B, Mkopi N, Wisiko A, Kitende AP, Shirati MR, Chingalo C, Semhando AO, Mtei C, Mwenisongole V, Bakuza JM, Kombo J, Mbaruku G, Lawn JE. Labour and delivery ward register data availability, quality, and utility - Every Newborn - birth indicators research tracking in hospitals (EN-BIRTH) study baseline analysis in three countries

BACKGROUND

Countries with the highest burden of maternal and newborn deaths and stillbirths often have little information on these deaths. Since over 81% of births worldwide now occur in facilities, using routine facility data could reduce this data gap. We assessed the availability, quality, and utility of routine labour and delivery ward register data in five hospitals in Bangladesh, Nepal, and Tanzania. This paper forms the baseline register assessment for the Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study.

METHODS

We extracted 21 data elements from routine hospital labour ward registers, useful to calculate selected maternal and newborn health (MNH) indicators. The study sites were five public hospitals during a one-year period (2016-17). We measured 1) availability: completeness of data elements by register design, 2) data quality: implausibility, internal consistency, and heaping of birthweight and explored 3) utility by calculating selected MNH indicators using the available data.

RESULTS

Data were extracted for 20,075 births. Register design was different between the five hospitals with 10-17 of the 21 selected MNH data elements available. More data were available for health outcomes than interventions. Nearly all available data elements were > 95% complete in four of the five hospitals and implausible values were rare. Data elements captured in specific columns were 85.2% highly complete compared to 25.0% captured in non-specific columns. Birthweight data were less complete for stillbirths than live births at two hospitals, and significant heaping was found in all sites, especially at 2500g and 3000g. All five hospitals recorded count data required to calculate impact indicators including; stillbirth rate, low birthweight rate, Caesarean section rate, and mortality rates.

CONCLUSIONS

Data needed to calculate MNH indicators are mostly available and highly complete in EN-BIRTH study hospital routine labour ward registers in Bangladesh, Nepal and Tanzania. Register designs need to include interventions for coverage measurement. There is potential to improve data quality if Health Management Information Systems utilization with feedback loops can be strengthened. Routine health facility data could contribute to reduce the coverage and impact data gap around the time of birth.

Coverage and equity of maternal and newborn health care in rural Nigeria, Ethiopia and India

BACKGROUND

Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India.

METHODS

We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity.

RESULTS

In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%-25%) to 43% (95% CI 33%-54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%.

INTERPRETATION

Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.

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.