Research Article: Utilization and quality: How the quality of care influences demand for obstetric care in Nigeria

Date Published: February 7, 2019

Publisher: Public Library of Science

Author(s): Evan D. Peet, Edward N. Okeke, Seth Adu-Afarwuah.


This paper examines the association between health facility quality, subjective perceptions, and utilization of obstetric care. We draw on unique survey data from Nigeria describing the quality of care at rural primary health care facilities and the utilization of obstetric care by households in the service areas of these facilities. Constructing a quality index using the detailed survey data, we show that facility quality is positively related to perceptions of quality and utilization. Disaggregating quality into structural, process and outcome dimensions, we find a consistently strong relationship only between utilization and structural measures of quality. The results suggest that efforts to improve quality may involve a trade-off between investing in dimensions that are more easily observed by households, which will influence utilization, and investing in dimensions that are more closely related to outcomes.

Partial Text

Despite global reductions in mortality and increasing life expectancies, large gaps remain, particularly in maternal and newborn health [1]. In 2015, 303,000 women died during and following pregnancy and childbirth, 4.2 million infants died within the first year of life, and 2.6 million babies were stillborn [2–4]. Nearly all maternal and child deaths occur in low- and middle-income countries: women living in poor countries are nearly 23 times more likely to die from pregnancy and childbirth-related complications than their counterparts living in developed countries [5]. Pregnancy-related morbidity and mortality has serious economic and social consequences, with estimates of the global productivity losses attributable to maternal and newborn deaths reaching approximately US $15 billion annually [6].

This paper addresses three questions: first, does quality of care influence utilization of obstetric care; second, if so, what dimensions of quality matter; and third, is objective quality related to subjective perceptions? Our results indicate that quality is positively correlated with utilization. Disaggregating by domains of quality suggests that the structural dimension of quality is the key driver of utilization. We also find that subjective perceptions are strongly related to objectively measured quality. We observe statistically significant relationships for structure and process but not for outcomes. The results are consistent across multiple empirical methods. Compared to the estimates generated using ordinary least squares described above, the propensity score estimates described in the Appendix only differ slightly in magnitude. The lack of model dependence lends credibility to the estimates, if not a causal interpretation. A causal interpretation of these estimates relies on the weak unconfoundedness assumption; specifically that assignment to treatment is as good as random within subpopulations that are homogenous in observed pre-treatment variables [38]. If this assumption holds, the estimates can be interpreted as causal.

Proper obstetric care is critical for birth outcomes, yet remains underutilized in many low and middle-income countries. Using matching facility and household survey data from Nigeria, this paper has examined the association between health facility quality and utilization of obstetric care. We also explored whether subjective perceptions of quality carry information about objective quality. We find that quality of care is an important determinant of obstetric care utilization, though this relationship appears to be explained by more observable, structural dimensions of quality. We also find that perceptions of quality are strongly related to actual quality suggesting that perceptions carry important information. The results in this paper provide useful evidence to policy makers on the relationship between facility quality and demand for obstetric care.




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