Influence of Distance to Health Facilities on the Use of Skilled Attendants at Birth in Kenya

We sought to determine the spatial variation in the use of skilled providers during deliveries across Kenya and the relationship between distance to health facilities and the use of skilled delivery. We found that women who resided 5 km or less from the nearest health facility were more likely to use skilled care at delivery than women residing at greater distances, although the pattern of choice of health facility level for delivery differed at this distance. Outreach maternity services are urgently required in counties with remote communities in order to improve access to skilled attendants during deliveries in these areas.     

Bypassing health facilities in rural Mozambique: spatial,institutional, and individual determinants

Background

Access to sexual and reproductive health (SRH) services is critical for such outcomes as pregnancy and birth, prenatal and neonatal mortality, maternal morbidity and mortality, and prevention of vertical transmission of infections like HIV. Health facilities are typically set up where they can efficiently serve the nearby targeted population. However, the actual utilization of health care can be complicated as people sometimes bypass the closest or nearby facilities for various reasons such as service quality. A better understanding of how people actually utilize health services can benefit future health resource allocation as well as health program planning.

Methods

In this study, we use prenatal care as an example of a basic, widely available service to investigate women’s choice and bypassing of SRH facilities as well as potential influencing factors at the geographic, clinic, household, and individual levels. The data come from a population-based survey of women of reproductive age in rural Mozambique. The spatial pattern of utilization of health clinics for prenatal care is explored by geographical information system (GIS)-based spatial analysis. Logistic regression is fitted to test the hypotheses regarding the effect of distance, service quality, and household/individual-level factors on the bypassing of the nearest clinic.

Results

The results indicate that most women living near clinics tend to utilize the closest facilities for prenatal care and those who travel farther mainly do so to seek better services. Further, for women who live far from a clinic (>?5.5?km), service quality still plays an important role in the facility bypassing while the effect of distance is no longer significant. The bypassing of nearest facility is also affected by individual characteristics such as age, HIV status, and household economic conditions.

Conclusions

The findings help to better understand health facility choice and bypassing in developing settings, in general, and in resource-limited Sub-Saharan settings, in particular. They offer valuable guidance for future health resource allocation and health service planning.

     

Preferences for home delivery in Ethiopia: Provider perspectives

More than half of the maternal deaths worldwide occur in sub-Saharan Africa, most commonly during childbirth or the immediate post-partum period. Although delivery in health care facilities can avert maternal deaths, many women in sub-Saharan Africa continue to deliver at home. Factors influencing mothers' decisions to use facility-based delivery services in rural, low-income settings are not well understood. Health care professionals who provide delivery services in these areas may have unique insights about factors specific to such settings. Accordingly, we conducted a qualitative study of health care professionals in rural Ethiopia to determine key factors influencing facility delivery, using in-depth interviews and the constant comparative method of data analysis. Results suggest multiple influences on women's decisions to deliver at home, including inadequate resources in facilities; unappealing aspects of delivery in facility settings; and known barriers to accessing services such as distance, transportation and cost. Our findings suggest that local health care providers offer valuable insight into why many rural Ethiopian women deliver their babies at home, despite major efforts to promote facility-based delivery. Their perspectives underscore the importance of a patient-centred approach to delivery services, which is often lacking in low-resource settings but may be fundamental to encouraging facility-based deliveries.     

Health-care facility choice and the phenomenon of bypassing.

Health policy-makers in developing countries are often disturbed and to a degree surprised by the phenomenon of the ill travelling past a free or subsidized local public clinic (or other public facility) to get to an alternative source of care at which they often pay a considerable amount for health care. That a person bypasses a facility is almost certainly indicative either of significant problems with the quality of care at the bypassed facility or of significantly better care at the alternative source of care chosen. When it is a poor person choosing to bypass a free public facility and pay for care further away, such action is especially bothersome to public policy-makers. This paper uses a unique data set, with a health facility survey in which all health facilities are identified, surveyed, and located geographically; and a household survey in which a sample of households from the same health district is also both surveyed and located geographically. The data are analyzed to examine patterns of health care choice related to the characteristics and locations of both the facilities and actual and potential clients. Rather than using the distance travelled or some other general choice of type of care variable as the dependent variable, we are able actually to analyze which specific facilities are bypassed and which chosen. The findings are instructive. That bypassing behaviour is not very different across income groups is certainly noteworthy, as is the fact that the more severely ill tend to bypass and to travel further for care than do the less severely ill. In multivariate analysis almost all characteristics of both providers and facilities are found to have the a priori expected relationships to facility choice. Prices tend to deter use, and improved quality of services to increase the likelihood of a facility being chosen. The answer to the bypassing dilemma seems to be for providers to provide as good quality care relative to the money charged (if any), as other, often further away, providers.     

The Effect of the Removal of User Fees for Delivery at Public Health Facilities on Institutional Delivery in Urban Kenya

Objectives In 2013, Kenya removed delivery fees at public health facilities in an effort to promote equity in access to health services and address high maternal mortality. This study determines the effect of the policy to remove user fees on institutional delivery in a population-based sample of women from urban Kenya. Methods Longitudinal data were collected from a representative sample of 8500 women from five cities in Kenya in 2010 with a follow-up interview in 2014 (response rate 58.9%). Respondents were asked about their most recent birth since 2008 at baseline and 2012 at endline, including the delivery location. Multinomial logistic regression is used, controlling for the temporal time trend and background characteristics, to determine if births which occurred after the national policy change were more likely to occur at a public facility than at home or a private facility. Results Multivariate findings show that women were significantly more likely to deliver at a public facility as compared to a private facility after the policy. Among the poor, the results show that poor women were significantly more likely to deliver in a public facility compared to home or a private facility after policy change. Conclusions for Practice These findings show Kenya’s progress towards achieving universal access to delivery services and meeting its national development targets. The removal of delivery fees in the public sector is leading to increased use of facilities for delivery among the urban poor; this is an important first step in reducing maternal death.     

Equity in access to maternal and child health services in five developing countries: what works

People living in rural areas are yet to have equitable access to maternal and child health services in many developing countries. This article examines selected health service delivery models that improved access to services in five developing countries. The article is based on the review of background papers on Bangladesh, Pakistan, Cambodia, Ghana, and Tanzania, prepared as part of a multi-country study on health systems and maternal and child health. Findings suggest that equity in access to health services largely depends on a system that ensures a combination of facility-based service delivery and outreach services with a functioning referral network. A key factor is the availability of health workforce at the community level. Community-based deployment of service providers or recruitment and training of community health workers is critical in enhancing service coverage and linking local populations to a health facility. Incentive is necessary to keep community health workers' interest in providing services. However, health workforce alone cannot ensure good health outcomes. They must be embedded in a functioning service delivery network to transform structural inputs into outcomes. Moreover, local-level health systems should have the ability to allocate resources in strategic ways addressing the pressing health needs of the people.     

Barriers Faced by the Health Workers to Deliver Maternal Care Services and Their Perceptions of the Factors Preventing Their Clients from Receiving the Services: A Qualitative Study in South Sudan

Objective The study objective was to explore challenges and barriers confronted by maternal and child healthcare providers to deliver adequate quality health services to women during antenatal care visits, facility delivery and post-delivery care. Methods We conducted 18 in-depth-interviews with maternal and child health professionals including midwives/nurses, trained traditional birth attendants (TBAs), gynecologists, and pediatricians in three public health facilities in Juba, South Sudan. We purposively selected these health professionals to obtain insights into service delivery processes. We analyzed the data using thematic analysis. Results Limited support from the heath system, such as poor management and coordination of staff, lack of medical equipment and supplies and lack of utilities such as electricity and water supply were major barriers to provision of health services. In addition, lack of supervision and training opportunity, low salary and absence of other forms of non-financial incentives were major elements of health workers’ de-motivation and low performance. Furthermore, security instability as a result of political and armed conflicts further impact services delivery. Conclusions for Practice This study highlighted the urgent need for improving maternal and child healthcare services such as availability of medical supplies, equipment and utilities. The necessity of equal training opportunities for maternal and child healthcare workers at different levels were also stressed. Assurance of safety of health workers, especially at night, is essential for providing of delivery services.     

Perceived quality of and access to care among poor urban women in Kenya and their utilization of delivery care: harnessing the potential of private clinics?

This paper uses data from a maternal health study carried out in 2006 in two slums of Nairobi, Kenya, to: describe perceptions of access to and quality of care among women living in informal settlements of Nairobi, Kenya; quantify the effects of women's perceived quality of, and access to, care on the utilization of delivery services; and draw policy implications regarding the delivery of maternal health services to the urban poor. Based on the results of the facility survey, all health facilities were classified as 'appropriate' or 'inappropriate'. The research was based on the premise that despite the poor quality of these maternal health facilities, their responsiveness to the socio-cultural and economic sensitivities of women would result in good perceptions and higher utilization by women. Our results show a pattern of women's good perceptions in terms of access to, and quality of, health care provided by the privately owned, sub-standard and often unlicensed clinics and maternity homes located within their communities. In the multivariate model, the association between women's perceptions of access to and quality of care, and delivery at these 'inappropriate' facilities remained strong, graded and in the expected direction. Women from the study area are seldom able to reach not-for-profit private providers of maternal health care services like missionary and non-governmental organization (NGO) clinics and hospitals. Against the backdrop of challenges faced by the public sector in health care provision, we recommend that the government should harness the potential of private clinics operating in urban, resource-deprived settings. First, the government should regulate private health facilities operating in urban slum settlements to ensure that the services they offer meet the acceptable minimum standards of obstetric care. Second, 'good' facilities should be given technical support and supplied with drugs and equipment.     

Availability, distribution and use of emergency obstetric care in northern Tanzania

The objective of this study is to determine the availability, distribution and quality of facilities providing delivery services, as well as their use by pregnant women. The study is a survey of all facilities providing delivery services (n = 129) in six districts in northern Tanzania. The framework provided by the UNICEF/UNFPA/WHO (UN) Guidelines is applied. An attempt is made to answer the first three questions in this audit outline: are there enough emergency obstetric care (EmOC) facilities? Are they well distributed? And are enough women using them? The results show that there is a very low availability of basic emergency obstetric care (BEmOC) units (1.6/500,000), and a relatively high availability of comprehensive emergency obstetric care (CEmOC) units (4.6/500,000), both with large urban/rural variation. The percentage of expected deliveries in EmOC facilities is 36%, compared with the UN Guidelines minimum accepted threshold of 15%. Nevertheless, the distribution shows a much higher utilization in urban districts compared with rural, indicating that mothers have to travel long distances to receive adequate services when in need of them. The paper also discusses the provisional context of the services in terms of level of facilities providing them and their public/private mix. Most facility deliveries are conducted at CEmOC facilities. Pregnant women tend to utilize the services of voluntary agencies to a greater degree than government services in rural areas, while the government services have a higher burden of the workload in urban areas. A majority (86%) of the deliveries occurring in voluntary agency facilities occur in a qualified EmOC facility. Against a backdrop of a large availability of any facility regardless of their emergency obstetric care status (41.9/500,000), this paper argues that given the large number of potential BEmOC facilities, it seems more efficient to shift resources within the BEmOC level, compared with from CEmOC level down to BEmOC level, to improve access to quality services. There is a large potential for quality improvement, in particular at dispensary and health centre levels. We argue that the main barrier to access to quality care is not the mother's ignorance or their ability to get to a facility, but the actual quality of care meeting them at the facility.     

Quality of Care for Maternal and Newborn Health in Health Facilities in Nepal

Introduction

Nepal has pledged to substantially reduce maternal and newborn death by 2030. Improving quality of intrapartum health services will be vital to reduce these deaths. This paper examines quality of delivery and newborn services in health facilities of Nepal.

Methods

Data were sourced from the Nepal Health Facility Survey 2015, which covered a national representative sample of health facilities. The datasets were analysed to assess service readiness, availability and quality of delivery and newborn care in a sample of 992 health facilities.

Results

Of the 992 facilities in the sample, 623 provided delivery and newborn care services. Of the 623 facilities offering delivery and newborn care services, 13.3% offered comprehensive emergency obstetric care (CEmONC), 19.6% provided basic emergency obstetric care (BEmONC) and 53.9% provided basic delivery and newborn service. The availability of essential equipment for delivery and newborn care was more than 80% in health facilities. Except for the coverage of vitamin K injection, the coverage of immediate newborn care was more than 85% in all health facilities. The coverage of use of chlorhexidine ointment to all newborns was more than 70% in government hospitals and primary health care centers (PHCCs) and only 32.3% in private hospitals.

Conclusions

These findings show gaps in equipment and drugs, especially in PHCCs and private health facilities. Improving readiness and availability of equipment and drugs in PHCCs and private health facility will help improve the quality of care to further reduce maternal and newborn mortality in Nepal.

     

Costs of maternal health care services in three anglophone African countries

This paper is a synthesis of a case study of provider and consumer costs, along with selected quality indicators, for six maternal health services provided at one public hospital, one mission hospital, one public health centre and one mission centre, in Uganda, Malawi and Ghana. The study examines the costs of providing the services in a selected number of facilities in order to examine the reasons behind cost differences, assess the efficiency of service delivery, and determine whether management improvements might achieve cost savings without hurting quality. This assessment is important to African countries with ambitious goals for improving maternal health but scarce public health resources and limited government budgets. The study also evaluates the costs that consumers pay to use the maternal health services, along with the contribution that revenues from fees for services make to recovering health facility costs. The authors find that costs differ between hospitals and health centres as well as among mission and public facilities in the study sample. The variation is explained by differences in the role of the facility, use and availability of materials and equipment, number and level of personnel delivering services, and utilization levels of services. The report concludes with several policy implications for improvements in efficiency, financing options and consumer costs.     

‘A Normal Delivery Takes Place at Home’: A Qualitative Study of the Location of Childbirth in Rural Ethiopia

To identify reasons why women who access health facilities and utilise maternal newborn and child health services at other times, do not necessarily deliver at health facilities. Forty-six semi-structured interviews were conducted with mothers who had recently delivered (n = 30) or were pregnant (n = 16). Thematic analysis of the interview data resulted in emerging trends that were critically addressed according to the research objective. Of the 30 delivered cases, 14 had given birth at a health facility, but only 3 of those had planned to do so. The remaining 11 had attended due to long or complicated labours. Five dominant themes influencing location of delivery were identified: perceptions of a normal delivery; motivations encouraging health facility delivery; deterrents preventing health facility deliveries; decision-making processes; and level of knowledge and health education. Understanding the socio-cultural determinants that influence the location of delivery has implications for service provision. Alongside timely health education and maximising the contact between women and healthcare professionals, these determinants should be actively incorporated into maternal newborn and child health policy and programming in ways that encourage the utilisation of health facilities, even for routine deliveries.     

Can contracted out health facilities improve access,equity, and quality of maternal and newborn health services? Evidence from Pakistan

Background

The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. We present an in-depth assessment of the comparative advantages of contracting out on MNCH access, quality, and equity, using a case study from Pakistan.

Methods

An end-line, cross-sectional assessment was conducted of government facilities contracted out to a large national NGO and government-managed centres serving as controls, in two remote rural districts of Pakistan. Contracting out was specific for augmenting MNCH services but without contractual performance incentives. A household survey, a health facility survey, and focus group discussions with client and spouses were used for assessment.

Results

Contracted out facilities had a significantly higher utilization as compared to control facilities for antenatal care, delivery, postnatal care, emergency obstetric care, and neonatal illness. Contracted facilities had comparatively better quality of MNCH services but not in all aspects. Better household practices were also seen in the district where contracting involved administrative control over outreach programs. Contracting was also faced with certain drawbacks. Facility utilization was inequitably higher amongst more educated and affluent clients. Contracted out catchments had higher out-of-pocket expenses on MNCH services, driven by steeper transport costs and user charges for additional diagnostics. Contracting out did not influence higher MNCH service coverage rates across the catchment. Physical distances, inadequate transport, and low demand for facility-based care in non-emergency settings were key client-reported barriers.

Conclusion

Contracting out MNCH services at government health facilities can improve facility utilization and bring some improvement in  quality of services. However, contracting out of health facilities is insufficient to increase service access across the catchment in remote rural contexts and requires accompanying measures for demand enhancement, transportation access, and targeting of the more disadvantaged clientele.

     

Barriers to Formal Emergency Obstetric Care Services’ Utilization

Access to appropriate health care including skilled birth attendance at delivery and timely referrals to emergency obstetric care services can greatly reduce maternal deaths and disabilities, yet women in sub-Saharan Africa continue to face limited access to skilled delivery services. This study relies on qualitative data collected from residents of two slums in Nairobi, Kenya in 2006 to investigate views surrounding barriers to the uptake of formal obstetric services. Data indicate that slum dwellers prefer formal to informal obstetric services. However, their efforts to utilize formal emergency obstetric care services are constrained by various factors including ineffective health decision making at the family level, inadequate transport facilities to formal care facilities and insecurity at night, high cost of health services, and inhospitable formal service providers and poorly equipped health facilities in the slums. As a result, a majority of slum dwellers opt for delivery services offered by traditional birth attendants (TBAs) who lack essential skills and equipment, thereby increasing the risk of death and disability. Based on these findings, we maintain that urban poor women face barriers to access of formal obstetric services at family, community, and health facility levels, and efforts to reduce maternal morbidity and mortality among the urban poor must tackle the barriers, which operate at these different levels to hinder women's access to formal obstetric care services. We recommend continuous community education on symptoms of complications related to pregnancy and timely referral. A focus on training of health personnel on “public relations” could also restore confidence in the health-care system with this populace. Further, we recommend improving the health facilities in the slums, improving the services provided by TBAs through capacity building as well as involving TBAs in referral processes to make access to services timely. Measures can also be put in place to enhance security in the slums at night.     

Use of Health Professionals for Delivery Following the Availability of Free Obstetric Care in Northern Ghana

Objectives To assess the factors associated with the use of health professionals for delivery following the implementation of a free obstetric care policy in the poorest regions of Ghana. Methods All 4,070 women identified in the Navrongo demographic surveillance system with pregnancy outcomes in the Kassena-Nankana district between January 1 and December 31, 2004 were eligible for the study. Three thousand four hundred and thirty three women completed interviews on socio-demographic and pregnancy related factors. Information on 259 communities including travel distance to the nearest health facility was also obtained. Multilevel logistic regression analyses were conducted. Results ninety eight percent of women received antenatal care but only 38% delivered with the assistance of health professionals. In a multilevel logistic model, physical access factors {such as availability of public transport, odds ratio (OR) = 1.50 (1.15-1.94), travel distance to the district hospital [for 20+ km, OR = 0.31 (0.23-0.43)] as well as community perception of access to the nearest health facility [for highest quintile, OR = 4.44 (2.88-6.84)]} showed statistically significant associations with use of health professionals at last delivery. Women who knew that delivery care was free of charge were 4.6 times more likely to use health professionals. Higher parity was strongly negatively associated with use of health professionals [OR = 0.37 (0.29-0.48) for parity >/=4 compared to parity 0-1]. However, community perception of quality of care was not associated with use of health professionals for delivery. Conclusion Physical access factors remain strong determinants of use of professional delivery care in rural northern Ghana.     

The tyranny of distance: maternity waiting homes and access to birthing facilities in rural Timor-Leste

Objective

To examine the impact of maternity waiting homes on the use of facility-based birthing services for women in two remote districts of Timor-Leste.

Methods

A before-and-after study design was used to compare the number of facility-based births in women who lived at different distances (0–5, 6–25, 26–50 and > 50 km) from the health centre before and after implementation of maternity waiting homes. Routine data were collected from health centre records at the end of 2007; they included 249 births in Same, Manufahi district, and 1986 births in Lospalos, Lautem district. Population data were used to estimate the percentage of women in each distance category who were accessing facility-based care.

Findings

Most facility-based births in Same (80%) and Lospalos (62%) were among women who lived within 5 km of the health centre. There was no significant increase in the number of facility-based births among women in more remote areas following implementation of the maternity waiting homes. The percentage of births in the population that occurred in a health facility was low for both Manufahi district (9%) and Lautem district (17%), and use decreased markedly as distance between a woman’s residence and the health facilities increased.

Conclusion

The maternity waiting homes in Timor-Leste did not improve access to facility-based delivery for women in remote areas. The methods for distance analysis presented in this paper provide a framework that could be used by other countries seeking to evaluate maternity waiting homes.     

Improving poor women's access to maternity care: Findings from a primary care intervention in Burkina Faso

To date, there has been little progress in reducing wealth inequities in access to maternity care. This paper describes the results of a maternal health intervention in Burkina Faso that was aimed at increasing access to skilled maternity care by improving availability and quality of maternity care, particularly at primary care health facilities, and promoting its use before, during, and after delivery. Post-intervention data show a large overall increase in use of facility-based maternity care in the intervention district, particularly at primary care facilities, but little change in the comparison district. In addition, large wealth inequities in the use of professional care during childbirth were almost eliminated in the intervention district while they increased in the comparison district—both among all women, and among the subset of women who reported experiencing complications during delivery. Study results suggest that efforts to upgrade maternity services at primary care facilities may be key for improving poor women's access to and use of skilled care during childbirth.     

The cost and efficiency of public and private health care facilities in Ogun state,Nigeria

During the 1980s, Nigeria faced difficult economic conditions resulting in a severely constrained budget for public health services. To assess more carefully the costs and efficiency of the public and private health sectors, the Federal Ministry of Health in Nigeria undertook a comprehensive survey of health care facilities in Ogun State in 1987, the analysis of which is presented in this study. The findings suggest that there is potential to increase service delivery within existing budgets by more cost-effective allocation of inputs. Many public and private providers are not operating at full technical capacity. It also appears that public facilities are not using cost-minimizing combinations of high and low-level health workers, in particular, too many low-level staff are being used to support high-level workers. The cost analysis indicates that there are short-run increasing returns to scale for inpatient and nearly constant returns to scale for outpatient services. Economies of scope for joint production of inpatient and outpatient services are not being realized. A major implication of such analysis is that improved resource allocation decisions heavily depend on the existence of information systems at the health facility level which carefully integrate financial information with other appropriate and adequate measures of service inputs, health care quality, facility utilization and ultimately health status.     

The quality of free antenatal and delivery services in Northern Sierra Leone

Background

The number of maternal deaths in sub-Saharan Africa continues to be overwhelmingly high. In West Africa, Sierra Leone leads the list, with the highest maternal mortality ratio. In 2010, financial barriers were removed as an incentive for more women to use available antenatal, delivery and postnatal services. Few published studies have examined the quality of free antenatal services and access to emergency obstetric care in Sierra Leone.

Methods

A cross-sectional survey was conducted in 2014 in all 97 peripheral health facilities and three hospitals in Bombali District, Northern Region. One hundred antenatal care providers were interviewed, 276 observations were made and 486 pregnant women were interviewed. We assessed the adequacy of antenatal and delivery services provided using national standards. The distance was calculated between each facility providing delivery services and the nearest comprehensive emergency obstetric care (CEOC) facility, and the proportion of facilities in a chiefdom within 15 km of each CEOC facility was also calculated. A thematic map was developed to show inequities.

Results

The quality of services was poor. Based on national standards, only 27% of women were examined, 2% were screened on their first antenatal visit and 47% received interventions as recommended. Although 94% of facilities provided delivery services, a minority had delivery rooms (40%), delivery kits (42%) or portable water (46%). Skilled attendants supervised 35% of deliveries, and in only 35% of these were processes adequately documented. None of the five basic emergency obstetric care facilities were fully compliant with national standards, and the central and northernmost parts of the district had the least access to comprehensive emergency obstetric care.

Conclusion

The health sector needs to monitor the quality of antenatal interventions in addition to measuring coverage. The quality of delivery services is compromised by poor infrastructure, inadequate skilled staff, stock-outs of consumables, non-functional basic emergency obstetric care facilities, and geographic inequities in access to CEOC facilities. These findings suggest that the health sector needs to urgently investigate continuing inequities adversely influencing the uptake of these services, and explore more sustainable funding mechanisms. Without this, the country is unlikely to achieve its goal of reducing maternal deaths.

     

Bypassing health providers: the quest for better price and quality of health care in Chad

This paper investigates individuals' bypassing behavior in the health sector in Chad and the determinants of individuals' facility choice. We introduce a new way for measuring bypassing which uses the patients' own knowledge of alternative health providers available to them, instead of assuming perfect information as previously done. We analyze how objective and perceived health care quality and prices impact patients' bypassing decisions. The analysis uses data from a health sector survey carried out in 2004 covering 281 primary health care centers and 1801 patients. We observe that income inequalities translate into health service inequalities. We find evidence of two distinct types of bypassing activities in Chad: (1) patients from low-income households bypass high quality facilities they cannot afford and go to low-quality facilities, and (2) rich individuals bypass low-quality facilities and aim for more expensive facilities which also offer a higher quality of care. These significant differences in patients' facility choices are observed across income groups as well as between rural and urban areas.