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

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.