“I am alive; my baby is alive”: Understanding reasons for satisfaction and dissatisfaction with maternal health care services in the context of user fee removal policy in Nigeria

Autoři: Anthony Idowu Ajayi aff001
Působiště autorů: Population Dynamics and Reproductive Health and Right Unit, African Population and Health Research Center, APHRC Campus, Nairobi, Kenya aff001
Vyšlo v časopise: PLoS ONE 14(12)
Kategorie: Research Article
doi: 10.1371/journal.pone.0227010



The main policy thrust in many sub-Saharan Africa countries’ aim at addressing maternal mortality is the elimination of the user fee for maternal healthcare services. While several studies have documented the effect of the user fee removal policy on the use of maternal health care services, the experiences of women seeking care in facilities offering free obstetrics services, their level of satisfaction and reasons for satisfaction or dissatisfaction are poorly understood.


This study adopted a mixed study design involving a population survey of 1227 women of reproductive age who gave birth in the last five years preceding the study (2011–2015), 68 in-depth interviews, and six focus group discussions. Simple descriptive statistics were performed on 407 women who benefitted from the user fee removal policy, while the qualitative data were analysed using thematic analysis.


The overall level of satisfaction with care received was remarkably high (97.1%), with birth outcomes being the central reason for their satisfaction. Participants were also satisfied with both the process aspect of care (which includes health workers’ attitude and privacy) and the structural dimension of care (such as, the cleanliness of health care facilities and availability of and access to medicine). From the qualitative analysis, prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space were the main reasons why a few women were dissatisfied with care under free maternal health care.


The findings establish a high level of beneficiaries’ satisfaction with care under free maternal health policy in Nigeria, raising the need for sustaining the policy in expanding access to maternal health services for the poor. Nevertheless, issues relating to prolonged waiting-time, the limited scope of coverage, mistreatment, disrespect and abuse, inadequate infrastructure and bed space require attention from policymakers.

Klíčová slova:

Allied health care professionals – Health care facilities – Health care policy – Labor and delivery – Maternal health – Nurses – Pregnancy – Quality of care


1. Yesuf EA, Kerie MW, Calderon-Margalit R. Birth in a health facility—inequalities among the Ethiopian women: results from repeated national surveys. PloS one. 2014;9(4):e95439. doi: 10.1371/journal.pone.0095439 24751600

2. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. The Lancet. 2015.

3. World Health Organization. State of inequality: reproductive, maternal, newborn and child health. 2015.

4. World Health Organization, UNICEF. Trends in maternal mortality: 1990–2015: estimates from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015.

5. Ajayi AI, Akpan W. Who benefits from free institutional delivery? evidence from a cross sectional survey of North Central and Southwestern Nigeria. BMC Health Services Research. 2017;17:620. doi: 10.1186/s12913-017-2560-1 PMC5581419. 28865462

6. Ononokpono DN, Odimegwu CO. Determinants of maternal health care utilization in Nigeria: a multilevel approach. The Pan African medical journal. 2014;17(Suppl 1).

7. Ezegwui HU, Onoh RC, Ikeako LC, Onyebuchi A, Umeorah J, Ezeonu P, et al. Investigating maternal mortality in a public teaching hospital, Abakaliki, Ebonyi State, Nigeria. Annals of medical and health sciences research. 2013;3(1):75–80. doi: 10.4103/2141-9248.109511 23634334

8. De Allegri M, Ridde V, Louis VR, Sarker M, Tiendrebéogo J, Yé M, et al. Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso. Health Policy. 2011;99(3):210–8. doi: 10.1016/j.healthpol.2010.10.010 21056505

9. Ponsar F, Van Herp M, Zachariah R, Gerard S, Philips M, Jouquet G. Abolishing user fees for children and pregnant women trebled uptake of malaria-related interventions in Kangaba, Mali. Health policy and planning. 2011;26(suppl 2):ii72–ii83.

10. Witter S, Dieng T, Mbengue D, Moreira I, De Brouwere V. The national free delivery and caesarean policy in Senegal: evaluating process and outcomes. Health Policy and Planning. 2010:czq013.

11. Nimpagaritse M, Bertone MP. The sudden removal of user fees: the perspective of a frontline manager in Burundi. Health policy and planning. 2011;26(suppl 2):ii63–ii71.

12. Wilkinson D, Gouws E, Sach M, Karim SSA. Effect of removing user fees on attendance for curative and preventive primary health care services in rural South Africa. Bulletin of the World Health Organization. 2001;79(7):665–71. 11477970

13. Lagarde M, Barroy H, Palmer N. Assessing the effects of removing user fees in Zambia and Niger. Journal of health services research & policy. 2012;17(1):30–6.

14. Meessen B, Hercot D, Noirhomme M, Ridde V, Tibouti A, Tashobya CK, et al. Removing user fees in the health sector: a review of policy processes in six sub-Saharan African countries. Health Policy and Planning. 2011;26(suppl 2):ii16–ii29.

15. Meessen B, Van Damme W, Tashobya CK, Tibouti A. Poverty and user fees for public health care in low-income countries: lessons from Uganda and Cambodia. The Lancet. 2006;368(9554):2253–7.

16. Ridde V, Robert E, Meessen B. A literature review of the disruptive effects of user fee exemption policies on health systems. BMC Public Health. 2012;12(1):289.

17. Yates J, Cooper R, Holland J. Social protection and health: experiences in Uganda. Development Policy Review. 2006;24(3):339–56.

18. Xu K, Evans DB, Kadama P, Nabyonga J, Ogwal PO, Nabukhonzo P, et al. Understanding the impact of eliminating user fees: utilization and catastrophic health expenditures in Uganda. Social Science & Medicine. 2006;62(4):866–76.

19. Ridde V, Diarra A. A process evaluation of user fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Services Research. 2009;9(1):89.

20. Ridde V, Queuille L, Ndour M. Nine misconceptions about free healthcare in sub-Saharan Africa. Development Studies Research An Open Access Journal. 2014;1(1):54–63.

21. Kruk ME, Mbaruku G, Rockers PC, Galea S. User fee exemptions are not enough: out‐of‐pocket payments for ‘free’delivery services in rural Tanzania. Tropical medicine & international health. 2008;13(12):1442–51.

22. Paudel YR, Mehata S, Paudel D, Dariang M, Aryal KK, Poudel P, et al. Women’s satisfaction of maternity care in Nepal and its correlation with intended future utilization. International journal of reproductive medicine. 2015;2015.

23. Bramadat IJ, Driedger M. Satisfaction with childbirth: theories and methods of measurement. Birth. 1993;20(1):22–9. doi: 10.1111/j.1523-536x.1993.tb00175.x 8503963

24. Srivastava A, Avan BI, Rajbangshi P, Bhattacharyya S. Determinants of women’s satisfaction with maternal health care: a review of literature from developing countries. BMC pregnancy and childbirth. 2015;15(1):97.

25. Bitew K, Ayichiluhm M, Yimam K. Maternal satisfaction on delivery service and its associated factors among mothers who gave birth in public health facilities of Debre Markos Town, Northwest Ethiopia. BioMed research international. 2015;2015.

26. Dzomeku M. Maternal satisfaction with care during labour: a case study of the Mampong-Ashanti district hospital maternity unit in Ghana. International Journal of Nursing and Midwifery. 2011;3(3):30–4.

27. Lumadi T, Buch E. Patients' satisfaction with midwifery services in a regional hospital and its referring clinics in the Limpopo Province of South Africa. Africa Journal of Nursing and Midwifery. 2011;13(2):14–28.

28. Melese T, Gebrehiwot Y, Bisetegne D, Habte D. Assessment of client satisfaction in labor and delivery services at a maternity referral hospital in Ethiopia. The Pan African Medical Journal. 2014;17.

29. Sadler LC, Davison T, McCowan LM. Maternal satisfaction with active management of labor: a randomized controlled trial. Birth. 2001;28(4):225–35. doi: 10.1046/j.1523-536x.2001.00225.x 11903210

30. Bohren MA, Vogel JP, Tunçalp Ö, Fawole B, Titiloye MA, Olutayo AO, et al. Mistreatment of women during childbirth in Abuja, Nigeria: a qualitative study on perceptions and experiences of women and healthcare providers. Reproductive health. 2017;14(1):9. doi: 10.1186/s12978-016-0265-2 28095911

31. Izugbara CO, Wekesah F. What does quality maternity care mean in a context of medical pluralism? Perspectives of women in Nigeria. Health policy and planning. 2017;33(1):1–8.

32. Oyekale AS. Assessment of primary health care facilities’ service readiness in Nigeria. BMC health services research. 2017;17(1):172. doi: 10.1186/s12913-017-2112-8 28249578

33. Aluko JO, Anthea R, Modeste RM. Manpower capacity and reasons for staff shortage in primary health care maternity centres in Nigeria: a mixed-methods study. BMC health services research. 2019;19(1):10. doi: 10.1186/s12913-018-3819-x 30616598

34. Ijadunola MY, Olotu EA, Oyedun OO, Eferakeya SO, Ilesanmi FI, Fagbemi AT, et al. Lifting the veil on disrespect and abuse in facility-based child birth care: findings from South West Nigeria. BMC pregnancy and childbirth. 2019;19(1):39. doi: 10.1186/s12884-019-2188-8 30669981

35. Sato R. The impacts of quantity and quality of health clinics on health behaviors and outcomes in Nigeria: analysis of health clinic census data. BMC health services research. 2019;19(1):377. doi: 10.1186/s12913-019-4141-y 31196212

36. Witter S, Khalid Mousa K, Abdel‐Rahman ME, Hussein Al‐Amin R, Saed M. Removal of user fees for caesareans and under‐fives in northern Sudan: a review of policy implementation and effectiveness. The International journal of health planning and management. 2013;28(1):e95–e120. doi: 10.1002/hpm.2146 23108997

37. McKinnon B, Harper S, Kaufman JS, Bergevin Y. Removing user fees for facility-based delivery services: a difference-in-differences evaluation from ten sub-Saharan African countries. Health policy and planning. 2015;30(4):432–41. doi: 10.1093/heapol/czu027 24816570

38. Ameur AB, Ridde V, Bado AR, Ingabire M-G, Queuille L. User fee exemptions and excessive household spending for normal delivery in Burkina Faso: the need for careful implementation. BMC health services research. 2012;12(1):412.

39. El-Khoury M, Hatt L, Gandaho T. User fee exemptions and equity in access to caesarean sections: an analysis of patient survey data in Mali. Int J Equity Health. 2012;11(49):1–7.

40. Hatt LE, Makinen M, Madhavan S, Conlon CM. Effects of user fee exemptions on the provision and use of maternal health services: a review of literature. Journal of health, population, and nutrition. 2013;31(4 Suppl 2):S67.

41. Ajayi A, Akpan W. Maternal Outcomes in the Context of Free Maternal Healthcare Provisioning in North Central and South Western Nigeria. Studies in the Sociology of Population: Springer; 2019. p. 301–18.

42. Hong QN, Pluye P, Fàbregues S, Bartlett G, Boardman F, Cargo M, et al. Mixed methods appraisal tool (MMAT), version 2018. IC Canadian Intellectual Property Office, Industry Canada. 2018.

43. Kotrlik J, Higgins C. Organizational research: Determining appropriate sample size in survey research appropriate sample size in survey research. Information technology, learning, and performance journal. 2001;19(1):43.

44. National Population Commission [Nigeria] and ICF International. Nigeria demographic and health survey 2013. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF International.; 2014.

45. Halpern J. What is clinical empathy? Journal of general internal medicine. 2003;18(8):670–4. doi: 10.1046/j.1525-1497.2003.21017.x 12911651

46. Weiner SJ, Auster S. From empathy to caring: Defining the ideal approach to a healing relationship. The Yale journal of biology and medicine. 2007;80(3):123. 18299724

47. Creanga AA, Gullo S, Kuhlmann AKS, Msiska TW, Galavotti C. Is quality of care a key predictor of perinatal health care utilization and patient satisfaction in Malawi? BMC pregnancy and childbirth. 2017;17(1):150. doi: 10.1186/s12884-017-1331-7 28532462

48. Fagbamigbe AF, Idemudia ES. Assessment of quality of antenatal care services in Nigeria: evidence from a population-based survey. Reproductive health. 2015;12(1):88.

49. Miltenburg AS, Kiritta RF, Meguid T, Sundby J. Quality of care during childbirth in Tanzania: identification of areas that need improvement. Reproductive health. 2018;15(1):14. doi: 10.1186/s12978-018-0463-1 29374486

50. Okonofua F, Ogu R, Agholor K, Okike O, Abdus-Salam R, Gana M, et al. Qualitative assessment of women’s satisfaction with maternal health care in referral hospitals in Nigeria. Reproductive health. 2017;14(1):44. doi: 10.1186/s12978-017-0305-6 28302182

51. Amole T, Tukur M, Farouk S, Ashimi A. Disrespect and abuse during facility based childbirth: The experience of mothers in Kano, Northern Nigeria. Tropical Journal of Obstetrics and Gynaecology. 2019;36(1):21–7.

52. Ishola F, Owolabi O, Filippi V. Disrespect and abuse of women during childbirth in Nigeria: a systematic review. PloS one. 2017;12(3):e0174084. doi: 10.1371/journal.pone.0174084 28323860

53. Samb OM, Ridde V. The impact of free healthcare on women's capability: A qualitative study in rural Burkina Faso. Social Science & Medicine. 2018;197:9–16.

Článek vyšel v časopise


2019 Číslo 12