Our study sought to assess women’s perceptions of PCMC at high-caseload public health facilities in Northeast Nigeria, a region where conflict and violent insecurity have severely impacted healthcare delivery. Overall, participants did not consistently receive high PCMC during childbirth, as reflected in an average PCMC score of 70 out of 100, indicating gaps in the provision of respectful, individualized, and responsive care. The subdomains of communication and autonomy received notably low scores, signaling important shortcomings with ensuring the meaningful engagement and involvement of women in care decisions. In contrast, the respect and dignity and supportive care subdomains scored higher, though many areas require attention and improvement. PCMC scores were significantly higher among women who delivered in the only PHC in Yobe State with an average of at least five births per day compared to those who delivered in hospitals with similar delivery caseloads. We identified significant disparities in PCMC based on education and displacement status, highlighting the heightened vulnerability of displaced and lower income individuals to suboptimal care. Further, our findings suggest that both providers and women generally feel safe within healthcare facilities, with women reporting slightly higher levels of safety than providers.

Our findings on the status of PCMC align with other studies, which highlight gaps in the quality of care [32], [33] [8], [34], [35]. A review examining the extent of PCMC during childbirth in low- and middle-income countries (LMICs) found that mean PCMC scores varied by region, with generally lower scores observed in Africa (below 75), moderate scores in Asia (ranging from 60 to over 90), and comparatively higher scores in the United States (above 80) [36].

There is an urgent need to ensure that women receive care that is responsive to their needs, as negative experiences with maternal care can deter women from seeking care altogether. Indeed, a study in Nigeria identified the negative attitudes of healthcare providers as a major barrier to seeking care among women [37] [36]. As in our study, a study conducted in Enugu State, in the southeast of Nigeria, found that the communication and autonomy domain tended to receive the lowest scores [8]. This was attributed to limited consented care and, similar to our study, inadequate explanations of medicines and low involvement of women in decisions about their care. The finding that 33% of women in our study reported feeling like they could not ask questions of their providers highlights the importance of fostering an environment where women feel empowered to actively participate in their care. Additionally, the finding that more than one-tenth of women could not request to be in the position of their choice during childbirth or did not understand the medicines being administered to them underscores the critical need to enhance communication strategies and ensure that care practices prioritize women’s autonomy and informed decision-making in these facilities. Several interventions evaluated in other settings have shown promise in enhancing communication between patients and providers. For example, communication skills training for midwives and doctors has been found to improve the quality of the information they give to women. Other interventions include offering women individualized information and giving women their own maternity records (referred to as women-held maternity records), with women who held their own records showing improvement in several aspects of communication [38].

Our scores for the respect and dignity and supportive care sub-domains were higher compared to other studies conducted in Nigeria [39], [40], [41], [42]. One study in Kano, in Northwest Nigeria found prevalence of obstetric violence to be high at 32% with almost 40% of women reporting neglect and abandonment and 23% reporting physical abuse [43]. In another review of studies examining obstetric violence in Nigeria, non-dignified care in the form of negative, poor and unfriendly provider attitude was frequently reported [42]. In contrast, in our sample most women felt like they were treated with respect and in a friendly manner all or most of the time.

Notably, women who gave birth in the urban, high-caseload PHC tended to have more positive experiences compared to their counterparts who gave birth in nearby public hospitals with similar or greater caseloads. This aligns with studies showing that maternity care quality often varies by facility level, with lower-level facilities often providing better person-centered treatment and more respectful care [44], [45]. This may be explained by the fact that lower-level care tends to be more individualized and person-focused, due to a confluence of factors that include lower patient loads, closer community ties, and greater provider-patient interaction. Our findings that providers in the PHC tended to report more frequent training in respectful maternity care and counselling and bereavement support could additionally explain the disparity in patient experience. In Nigeria, the National Primary Health Care Development Agency (NPHCDA) is the parastatal body responsible for supporting the planning, management and implementation of primary healthcare while higher-level facilities are under the authority of the state or Federal Ministry of Health [46], [47]. NPHCDA’s investments in training providers is an important step in improving the responsiveness of services to women’s needs and preferences, and evidence suggests that when done well, trainings and educational workshops can improve empathy and communication skills among healthcare professionals [48], [49], [50], [51]. Still, while training is one potential determinant of quality care, poor communication and limited autonomy during childbirth have been shown to stem from other factors such as high workload, inadequate staffing, and hierarchical cultures that prioritize medical decisions over patient preferences [52], [53], [54].

The finding that women who reported displacement in their household tended to have worse PCMC scores than their non-displaced counterparts warrant attention. This finding is consistent with other studies that find displacement status to be associated with disrespect and mistreatment during childbirth [55]. While studies exploring the experiences of Nigerian displaced persons are scant, studies in other LMICs [56], [57] highlight the differential treatment of women during pregnancy, labor, childbirth and the postpartum period based on social categories of vulnerability. Women who are less educated or who are displaced are often deprived of social support networks, experience increased poverty, and are consequently at a heightened risk of encountering discriminatory and stigmatizing treatment from healthcare providers [58] [59], [60]. Our findings underscore the importance of recognizing and addressing the specific challenges faced by internally displaced and lower income women.

Finally, our findings that both maternity care providers and postpartum women tended to report low levels of perceived insecurity in facilities and on the way to facilities is a positive one and underscores the importance of continuing to protect health facilities and providers. The Yobe State government has taken significant steps to enhance healthcare security and delivery. At the time data collection for our study began, government efforts were underway to rehabilitate and equip damaged health facilities through international partnerships, training and deploying healthcare workers, and constructing or upgrading 138 PHCs to improve access and safety [61], [62] [63], [64].

Our study holds significant implications for policy and programming, particularly in improving the quality of maternity care in Yobe State. Our findings underscore the pressing need to enhance PCMC in healthcare facilities, with a particular focus on ensuring that the perspectives, needs, and preferences of women are fully integrated into the design and delivery of care. This requires the development of mechanisms that systematically gather and incorporate women’s feedback, as well as the establishment of robust accountability frameworks that hold healthcare providers accountable. In Yobe State, a Quality Improvement Committee, which is a senior management body, oversees quality initiatives and quality of care. Opportunities to leverage the committee to advance person-centered care include integrating PCMC metrics into routine service quality assessments, ensuring that women’s voices are represented, and strengthening provider training on respectful and dignified maternity care.

Additionally, our study highlights the importance of designing and implementing interventions that are specifically tailored to meet the unique needs of vulnerable women, such as those of low socioeconomic status and internally displaced women. These targeted interventions should address the specific challenges faced by these women, including the erosion of social support networks, heightened security risks, and increased exposure to discriminatory attitudes from healthcare providers [65]. By addressing these gaps, policies and programs can significantly improve maternal health outcomes and foster a more inclusive, responsive healthcare system for all women, particularly those in vulnerable and marginalized positions.

Although our study focused on only four of the 275 public health facilities providing maternity services in Yobe, these four facilities accounted for nearly 20% of the facility births (12,771 of 66,484 births) reported in the state’s health information system in the year preceding the assessment and thus provides valuable insights into the quality of care available to women with facility births. Nevertheless, because data collection was limited to these four sites, all of which are located in urban centers, caution should be exercised in extrapolating findings to other lower-caseload PHCs and hospitals across Yobe State. Our study findings should also be interpreted in light of several additional limitations. First, our assessment of PCMC was based on the subjective perceptions of women, who may have low expectations of the health system and may normalize disrespect, abuse, and insecurity, particularly those who had healthy newborns and did not experience pregnancy or birth complications. Second, our inclusion criteria of facilities with an average of five or more births per day may have unintentionally limited our sample to facilities in safer locations, and as such, perceptions of care could differ in other, less secure facilities. Finally, we cannot rule out the possibility of social desirability bias and other biases that may have influenced women’s responses to our questions.