Abstract
<title>Abstract</title> <p>Background Maternal mortality remains disproportionately high in low- and middle-income countries (LMIC), driven by weak health systems, inadequate infrastructure, and persistent poverty. Despite ongoing efforts to expand access to skilled birth attendance, only about 43% of births in Nigeria occur in health facilities, contributing to the country’s first place ranking in the number of maternal deaths globally. Understanding women’s delivery preferences is critical to improving institutional delivery uptake and maternal health outcomes. Methods This qualitative study explored factors influencing women’s delivery choices using the Theory of Planned Behaviour as a conceptual framework. Forty-eight focus group discussions and sixty key informant interviews were conducted between July and September 2024 with women of reproductive age, spouses, mothers-in-law, traditional and skilled birth attendants, health administrators, and community leaders across six Nigerian states representing the country’s six geopolitical zones. Data were transcribed, translated where necessary, and analyzed thematically using Braun and Clarke’s framework. Results Women’s delivery preferences were shaped by the interplay of perceived quality of care, economic constraints, social influences, and access-related barriers. Institutional delivery was often discouraged by experiences of provider disrespect, prolonged waiting times, hidden costs, distance, and transportation challenges. In contrast, traditional and mission birth attendants were valued for their accessibility, empathy, cultural familiarity, and spiritual support. Family members, particularly husbands and mothers-in-law, also played important roles in delivery-related decision-making. Conclusion Women’s childbirth preferences reflect a balance between perceived clinical safety and respectful, culturally responsive care. Efforts to increase institutional delivery uptake should combine health system strengthening with respectful maternity care, improved affordability, community engagement, and stronger provider-client relationships.</p>