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This Article Figures Only Full Text Full Text (PDF) Supplemental Data All Versions of this Article: AJPH.2008.146209v1 99/9/1666    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Google Scholar Articles by Kruk, M. E. Articles by Galea, S. PubMed PubMed Citation Articles by Kruk, M. E. Articles by Galea, S. Related Collections Global Health Health Care Facilities/Services Access to Care Quality of Care Other Maternal and Infant Health Women's Health

Margaret E. Kruk, MD, MPH, Magdalena Paczkowski, MPH, Godfrey Mbaruku, MD, PhD, Helen de Pinho, MBBCh, FCCH and Sandro Galea, MD, DrPH

Margaret E. Kruk is with the Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, and the Averting Maternal Death and Disability Program, Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, NY. Magdalena Paczkowski and Sandro Galea are with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor. Sandro Galea is also with the Center for Global Health, University of Michigan, Ann Arbor. Godfrey Mbaruku is with the Ifakara Health Institute, Dar es Salaam, Tanzania. Helen de Pinho is with the Averting Maternal Death and Disability Program, Heilbrunn Department of Population & Family Health, Mailman School of Public Health, Columbia University, New York, NY.

Correspondence: Correspondence can be sent to Margaret E. Kruk, University of Michigan School of Public Health, Department of Health Management and Policy, 109 Observatory Rd, SPH II M3166, Ann Arbor, MI 48109 (e-mail: mkruk{at}umich.edu). Reprints can be ordered at http://www.ajph.org by clicking the "Reprints/Eprints" link.

Objectives. We fielded a population-based discrete choice experiment (DCE) in rural western Tanzania, where only one third of women deliver children in a health facility, to evaluate health-system factors that influence women's delivery decisions.

Methods. Women were shown choice cards that described 2 hypothetical health centers by means of 6 attributes (distance, cost, type of provider, attitude of provider, drugs and equipment, free transport). The women were then asked to indicate which of the 2 facilities they would prefer to use for a future delivery. We used a hierarchical Bayes procedure to estimate individual and mean utility parameters.

Results. A total of 1203 women completed the DCE. The model showed good predictive validity for actual facility choice. The most important facility attributes were a respectful provider attitude and availability of drugs and medical equipment. Policy simulations suggested that if these attributes were improved at existing facilities, the proportion of women preferring facility delivery would rise from 43% to 88%.

Conclusions. In regions in which attended delivery rates are low despite availability of primary care facilities, policy experiments should test the effect of targeted quality improvements on facility use.