Date of Award


Document Type

Open Access Dissertation


Health Services and Policy Management


The Norman J. Arnold School of Public Health

First Advisor

Mahmud M. Khan


Given poor maternal services utilization and associated high maternal mortality risk in Nigeria, we document policy-amenable supply and demand factors impacting women’ use of skilled ANC and institutional delivery services. Using a cross-sectional design, we analyzed data from the Nigeria State Health Investment Project health facility and household surveys on 418 health facilities and 3,726 women with a pregnancy within 24 months prior to survey living in 241 geographic wards of two states. Logistic regression was used to study associations of women’s use of each maternal service with ward facilities’ ANC outpatient satisfaction, healthcare staff job satisfaction, surveyorverified facility infrastructure, and maternal socio-demography. Skilled ANC use was predicted by staff satisfaction with work context and benefits (Adjusted Odds Ratio [AOR] 1.09, 95% CI 1.03-1.15), ownership of motorized means of transport (AOR 1.35, 95% CI 1.11-1.64), and frequent media exposure (AOR 1.45, 95% CI 1.06-1.97). Institutional delivery was associated with skilled ANC use (AOR 3.49, 95% CI 2.66- 4.57), ANC outpatients’ perceptions of a treatment-facilitating climate (clear care-related communication and ease of drug access, AOR 1.40, 95% CI 1.01-1.94), and availability functional delivery and neonatal care equipment (AOR 1.02, 95% CI 1.01-1.04) in the facilities. Skilled ANC utilization rate could be improved by mass media and community based maternal health education, community-based ANC service expansion to communities with poor public transportation network coupled with incentivizing of local leaders to recruit women into care, payment structure that incentivizes service quality and continuous technical and interpersonal relations training of providers. Improvement in ANC use supplemented by new patient flow design allowing easier access to medicines and other appended services for maternal clients and improved availability of functioning obstetric and neonatal equipment in health facilities will increase Nigeria’s institutional delivery rate.