Does Provider Bias Affect Choice of a Facility for Family Planning Services by Women in Urban Senegal?

Few studies to date have determined the effect of provider bias based on age, parity, and marital status on women's method and facility choice. Using data from women using modern methods in six cities of Senegal and a facility survey that included a facility audit and provider interviews, we undertake conditional logit analyses to determine whether women's choice of a family planning facility is associated with provider bias at the facility, controlling for other facility characteristics (e.g., size, sector, and number of methods available). We find that women bypass facilities where there is greater provider bias to attain their current family planning method. Women also bypass facilities of lower quality. This is the first study to demonstrate the effects of provider bias on women's contraceptive seeking behaviors and suggests the importance of training providers to reduce age and parity bias that affect access to a full range of methods and facilities for all women.

The Examination of Diffusion Effects on Modern Contraceptive Use in Nigeria.

This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.

Longitudinal examination of changing fertility intentions and behaviors over a four-year period in urban Senegal.

BACKGROUND: Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use. METHODS: Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods. RESULTS: Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon. CONCLUSIONS: These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.

The caloric and sugar content of beverages purchased at different store-types changed after the sugary drinks taxation in Mexico.

BACKGROUND: Following the 2014 sugary drinks tax implementation in Mexico, promising reduction in the volume of purchases of taxed beverages were observed overall and at different store-types. However, the tax's effects on purchasing patterns of calories and sugar remain unclear. METHODS: Using longitudinal data from Mexican households (n = 7038), we examined changes in volume, calories and total sugar of packaged beverages purchased from 2012 to 2016 overall and by store-type. We used fixed effects models to estimate means for volume, calories, and sugar of households. To address the potential selectivity from households shopping at different stores, we calculated inverse probability weights to model the purchases changes over time by store-type. RESULTS: For taxed beverages, the volume of purchases declined by - 49 ml and -30 ml in the first year and second year post tax (2014 and 2015, respectively), while purchases leveled off in the third year of the tax (2016). Calories and sugar from taxed beverage purchases decreased over time, with the majority of the declines occurring in the first two years post-tax implementation. The volume of untaxed beverage purchases increased, whereas changes in calories and total sugar of untaxed beverages were minimal. Store level purchases of taxed beverages significantly decreased in the first two years post taxation (2014 and to 2015) only in supermarkets and traditional stores. The steepest declines in purchases of taxed beverages in 2014 were observed at supermarkets (- 40 ml or - 45%). The volume of purchases of untaxed beverages increased over time in almost all store-types, while calories and sugar minimally decreased over time. CONCLUSION: Although the Mexican tax on SSBs has lowered the purchases of sugary drinks 3 years after the tax implementation, the tax should be strengthened and store-specific interventions should be implemented to further reduce SSBs purchases in the Mexican population.

Assessing the sustainability of the Nigerian urban reproductive health initiative facility-level programming: longitudinal analysis of service quality.

BACKGROUND: To date, there is little information on the sustainability of family planning (FP) service quality after completion of a donor-funded program. This paper examines the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI) program on quality of FP services in two cities: Ilorin, where the program ended in March 2015 and Kaduna where the program continued. METHODS: Data come from three time periods: 2011, before program implementation; 2014, near Phase 1 completion; and 2017, two-years post Phase 1. In 2011, we undertook a facility audit and provider surveys in all public sector facilities in each city as well as all private facilities mentioned as the source for FP or maternal, newborn, and child health services in a 2010 women's household survey. In 2014 and 2017, we returned to the same facilities to undertake the facility audit and provider surveys. Quality is measured from principal component analyses of 30 items from the facility audit and provider surveys. Service use outcomes are measured as the ratio of FP clients (total and new) to the number of reproductive health staff members. Multivariate random effect models are estimated to examine changes in the outcomes over time, between NURHI and non-NURHI facilities and by city. RESULTS: We demonstrate that NURHI facilities had better quality and higher service use than non-NURHI facilities. Further, while quality of services was higher in Ilorin in 2011, by 2014 and three years later (2017), the quality was better in Kaduna where the program continued. In addition, while no difference was found in service utilization between Ilorin and Kaduna in 2014, by 2017, Kaduna had significantly more new FP users than Ilorin. CONCLUSIONS: In Ilorin, quality of services did not continue its strong upward trend after the program ended. Programs need to consider long-term strategies that support continuation of program components post program implementation. This may include ensuring continued training of providers and addressing equipment and commodity stock-outs through system changes rather than specific facility-level changes. The findings from this study can be used to inform future programs seeking to improve quality of FP services in a sustainable manner.

The effects of health facility access and quality on family planning decisions in urban Senegal.

Research in developing countries is rarely focused on examining how supply side factors affect family planning decisions due to a lack of facility-level data. When these data exist, analyses tend to focus on rural environments. In this paper, we study the effects that health facility access and quality have on contraceptive use and desired number of children for women in urban Senegal. Unlike related studies focusing on rural environments, we find no evidence that greater access to health facilities and pharmacies increases contraceptive use among urban women. However, we do find that contraceptive use among urban women is higher with greater facility quality. For example, we find that increasing the proportion of pharmacies employing multiple pharmacists from 0% to 50% would increase contraceptive use by 6.0 percentage points, and increasing the proportion of facilities with family planning guidelines/protocols from 50% to 100% would increase use by 2.1 percentage points.

Impact of the Urban Reproductive Health Initiative on family planning uptake at facilities in Kenya, Nigeria, and Senegal.

BACKGROUND: The 2012 London Summit on Family Planning set ambitious goals to enable 120 million more women and adolescent girls to use modern contraceptives by 2020. The Urban Reproductive Health Initiative (URHI) was a Bill & Melinda Gates Foundation funded program designed to help contribute to these goals in urban areas in India, Kenya, Nigeria, and Senegal. URHI implemented a range of country-specific demand and supply side interventions, with supply interventions generally focused on improved service quality, provider training, outreach to patients, and commodity stock management. This study uses data collected by the Measurement, Learning & Evaluation (MLE) Project to examine the effectiveness of these supply-side interventions by considering URHI's influence on the number of family planning clients at health facilities over a four-year period in Kenya, Nigeria, and Senegal. METHODS: The analysis used facility audits and provider surveys. Principal-components analysis was used to create country-specific program exposure variables for health facilities. Fixed-effects regression was used to determine whether family planning uptake increased at facilities with higher exposure. Outcomes of interest were the number of new family planning acceptors and the total number of family planning clients per reproductive health care provider in the last year. RESULTS: Higher program component scores were associated with an increase in new family planning acceptors per provider in Kenya (ß = 18, 95% CI = 7-29), Nigeria (ß = 14, 95% CI = 8-20), and Senegal (ß = 7, 95% CI = 3-12). Higher scores were also associated with more family planning clients per provider in Kenya (ß = 31, 95% CI = 7-56) and Nigeria (ß = 26, 95% CI = 15-38), but not in Senegal. CONCLUSIONS: Supply-side interventions have increased the number of new family planning acceptors at facilities in urban Nigeria, Kenya, and Senegal and the overall number of clients in urban Nigeria and Kenya. While tailoring to the local environment, programs seeking to increase family planning use should include components to improve availability and quality of family planning services, which are part of a rights-based approach to family planning programming.

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.

Reaching Urban Female Adolescents at Key Points of Sexual and Reproductive Health Transitions: Evidence from a Longitudinal Study from Kenya.

Urban areas include large numbers of adolescents (ages 15-19) and young adults (ages 20-24) who may have unmet sexual and reproductive health (SRH) needs. Worldwide, adolescents contribute 11% of births, many of which are in low and middle-income countries. This study uses recently collected longitudinal data from urban Kenyan women to examine the association between targeted intervention activities and adolescents' SRH transitions. The focus was on a female adolescent (15-19) sample and their transition to first sex and first pregnancy/birth. Multinomial logistic regression methods were used to examine whether exposure to program activities was associated with delays in transitions. Overall, a high percentage of adolescents were exposed to television activities with family planning messages. About a third were exposed to community events, program posters, or the Shujaaz comic book that included themes related to relationships and positive health outcomes using recognizable characters. Multivariate analyses found that exposure to the Shujaaz comic book was associated with remaining sexually inexperienced and never pregnant at end line. Future programs for urban adolescents should implement interventions that test novel media strategies, like the Shujaaz comic book, that may be more interesting for young people. Innovative strategies are needed to reach female adolescents in urban settings.

Examination of youth sexual and reproductive health transitions in Nigeria and Kenya using longitudinal data.

BACKGROUND: The adolescent (ages 15-19) and young adult (ages 20-24) years are a crucial time as many sexual and reproductive health (SRH) transitions take place in these years. The study of youth SRH transitions in sub-Saharan Africa is limited due to a paucity of longitudinal data needed to examine the timing and circumstances of these transitions. METHODS: This paper uses recently collected longitudinal data from select urban areas in Kenya and Nigeria that include a large youth sample at baseline (2010/2011) and endline (2014). We control for unobserved heterogeneity in our modelling approach to correct for selectivity issues that are often ignored in similar types of analyses. RESULTS: We demonstrate that the transition patterns (i.e., sexual initiation, first marriage, and first pregnancy/birth) differ within and across the urban areas and countries studied. Urban Kenyan youth have more premarital sex and pregnancy than youth from the Nigerian cities. Further analyses demonstrate that more educated and wealthier youth transition later than their less educated and poorer counterparts. CONCLUSIONS: The findings from this study can be used to inform programs seeking to serve young people based on their varying reproductive health needs in different contexts over the adolescent and young adult years.

Instrumental-Variables Simultaneous Equations Model of Physical Activity and Body Mass Index: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

We used full-system-estimation instrumental-variables simultaneous equations modeling (IV-SEM) to examine physical activity relative to body mass index (BMI; weight (kg)/height (m)(2)) using 25 years of data (1985/1986 to 2010/2011) from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (n = 5,115; ages 18-30 years at enrollment). Neighborhood environment and sociodemographic instruments were used to characterize physical activity, fast-food consumption, smoking, alcohol consumption, marriage, and childbearing (women) and to predict BMI using semiparametric full-information maximum likelihood estimation to control for unobserved time-invariant and time-varying residual confounding and differential measurement error through model-derived discrete random effects. Comparing robust-variance ordinary least squares, random-effects regression, fixed-effects regression, single-equation-estimation IV-SEM, and full-system-estimation IV-SEM, estimates from random- and fixed-effects models and the full-system-estimation IV-SEM were unexpectedly similar, despite the lack of control for residual confounding with the random-effects estimator. Ordinary least squares tended to overstate the significance of health behaviors in BMI, while results from single-equation-estimation IV-SEM were notably different, revealing the impact of weak instruments in standard instrumental-variable methods. Our robust findings for fixed effects (which does not require instruments but has a high cost in lost degrees of freedom) and full-system-estimation IV-SEM (vs. standard IV-SEM) demonstrate potential for a full-system-estimation IV-SEM method even with weak instruments.

Choice of a family planning outlet in urban areas: The role of distance and quality of services in Kenya and Uganda.

Introduction: Quality of care and physical access to health facilities affect facility choice for family planning (FP). These factors may disproportionately impact young contraceptive users. Understanding which components of service quality drive facility choice among contraceptive users of all ages can inform strategies to strengthen FP programming for all potential users of FP. Methods: This study uses data from Population Services International's Consumer's Market for Family Planning (CM4FP) project, to examine drivers of facility choice among female FP users. The data collected from female contraceptive users, the outlet where they obtained their contraceptive method, and the complete set of alternative outlets in select urban areas of Kenya and Uganda were used. We use a mixed logit model, with inverse probability weights to correct for selection into categories of nonuse and missing facility data. We consider results separately for youth (18-24) and women aged 25-49 in both countries. Results: We find that in both countries and across age groups, users were willing to travel further to public outlets and to outlets offering more methods. Other outlet attributes, including signage, pharmacy, stockouts, and provider training, were important to women in certain age groups or country. Discussion: These results shed light on what components of service quality drive outlet choice among young and older users and can inform strategies to strengthen FP programming for all potential users of FP in urban settings.

Longitudinal Examination of Which Married Young Women Use Contraception to Delay a First Pregnancy in Bihar and Uttar Pradesh, India.

Early marriage and childbearing put young women and their babies at risk of poor health and well-being. This study uses two rounds of longitudinal data from young women ages 15-19 in 2015-2016 and followed in 2018-2019 to determine factors associated with contraceptive use before a first pregnancy among young, married women in Bihar and Uttar Pradesh, India. Discrete time hazard models were used to analyze time to first use starting from the month of marriage. Overall, use of contraception prior to a first pregnancy was low in this sample (between 12 to 20% used before a first pregnancy). Young women who reported that someone discussed the importance of delaying a first birth at the time of marriage were significantly more likely to have used a method of family planning (FP) before a first pregnancy than those who did not receive this information. Further, women who discussed FP with their husband before a first pregnancy were more likely to use contraception. Finally, among recently married young women, those who experienced pressure to have a child were less likely to use before a first pregnancy. As young women recognize the advantages of delaying a first birth and adopt FP to meet their needs, social norms around early childbearing will slowly adjust and early use to delay a first pregnancy will become more normative.

Family planning use among urban poor women from six cities of Uttar Pradesh, India.

Family planning has widespread positive impacts for population health and well-being; contraceptive use not only decreases unintended pregnancies and reduces infant and maternal mortality and morbidity, but it is critical to the achievement of Millennium Development Goals. This study uses baseline, representative data from six cities in Uttar Pradesh, India to examine family planning use among the urban poor. Data were collected from about 3,000 currently married women in each city (Allahabad, Agra, Varanasi, Aligarh, Gorakhpur, and Moradabad) for a total sample size of 17,643 women. Participating women were asked about their fertility desires, family planning use, and reproductive health. The survey over-sampled slum residents; this permits in-depth analyses of the urban poor and their family planning use behaviors. Bivariate and multivariate analyses are used to examine the role of wealth and education on family planning use and unmet need for family planning. Across all of the cities, about 50% of women report modern method use. Women in slum areas generally report less family planning use and among those women who use, slum women are more likely to be sterilized than to use other methods, including condoms and hormonal methods. Across all cities, there is a higher unmet need for family planning to limit childbearing than for spacing births. Poorer women are more likely to have an unmet need than richer women in both the slum and non-slum samples; this effect is attenuated when education is included in the analysis. Programs seeking to target the urban poor in Uttar Pradesh and elsewhere in India may be better served to identify the less educated women and target these women with appropriate family planning messages and methods that meet their current and future fertility desire needs.

The direct and indirect effects of community beliefs and attitudes on postpartum contraceptive method choice among young women ages 15-24 in Nigeria.

Understanding what factors influence postpartum contraceptive use among young people (ages 15-24 years) is important since this group often has closely spaced and unintended births. Using secondary data gathered for an evaluation of a Bill & Melinda Gates Foundation funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria, we determine the direct and indirect effects of community beliefs and attitudes on adolescent and youth postpartum contraceptive method choice. Our statistical methods control for the endogenous timing of the initiation of sexual activity and the timing and number of births to each respondent by simultaneous estimation of equations for these choices with the choice of postpartum contraceptive method. We find that community beliefs and attitudes have important effects on our primary outcome of postpartum contraceptive use and we quantify the size of both direct and indirect effects on postpartum contraceptive method choice using simulations. The findings from this study can be used to inform programs seeking to increase young women's postpartum contraceptive use for healthy spacing and timing of births.

Associations Among Select State Policies and the Nutritional Quality of Household Packaged Food Purchases in the United States from 2008 Through 2017.

BACKGROUND: Policy interventions are important public health tools because they can reach large numbers of people. State context has been associated with health outcomes, yet few studies have examined the extent to which state-level policies are associated with dietary quality. OBJECTIVES: The objective of this study was to evaluate whether state policies are associated with the nutritional quality of household packaged food purchases. DESIGN: This observational study used data from Nielsen Homescan, an open-cohort household panel where participants track purchases, and a combination of state-level food and social safety net policy variables from 2008 through 2017. PARTICIPANTS AND SETTING: This study included 615,634 household-year observations in the United States from 2008 through 2017. Household-year observations were excluded in the case that a household did not make a minimum number of purchases and in the case that they had incorrect geographic information. The final analytic sample was 611,719 household-years. MAIN OUTCOME MEASURES: Study outcomes included a set of nutrition-related measures of public health interest, including nutrients of concern (eg, sugar, saturated fat, and sodium) and calories from specific food groups (eg, fruits, nonstarchy vegetables, processed meats, mixed dishes, sugar-sweetened beverages, and desserts and snacks). STATISTICAL ANALYSIS: This study used multilevel generalized linear models with state fixed effects on three samples: all households, only households with low income, and only households with low educational attainment. RESULTS: Few significant associations were found between healthy food retail policies and the nutritional quality of purchases, and mixed associations were found between social safety net policies and lower or higher quality packaged food purchases. CONCLUSIONS: Little evidence was found that state policy context in 2008 through 2017 was associated with the quality of packaged food purchases. However, variation in state policies is increasing over time, warranting future research into the relationship between these policies, the quality of packaged food purchases, and the rest of the diet.

Longitudinal trends in gasoline price and physical activity: the CARDIA study.

OBJECTIVE: To investigate longitudinal associations between community-level gasoline price and physical activity (PA). METHOD: In the Coronary Artery Risk Development in Young Adults study, 5115 black and white participants aged 18-30 at baseline 1985-86 were recruited from four U.S. cities (Birmingham, Chicago, Minneapolis and Oakland) and followed over time. We used data from 3 follow-up exams: 1992-93, 1995-96, and 2000-01, when the participants were located across 48 states. From questionnaire data, a total PA score was summarized in exercise units (EU) based on intensity and frequency of 13 PA categories. Using Geographic Information Systems, participants' residential locations were linked to county-level inflation-adjusted gasoline price data collected by the Council for Community & Economic Research. We used a random-effect longitudinal regression model to examine associations between time-varying gasoline price and time-varying PA, controlling for age, race, gender, baseline study center, and time-varying education, marital status, household income, county cost of living, county bus fare, census block-group poverty, and urbanicity. RESULTS: Holding all control variables constant, a 25-cent increase in inflation-adjusted gasoline price was significantly associated with an increase of 9.9 EU in total PA (95% CI: 0.8-19.1). CONCLUSION: Rising prices of gasoline may be associated with an unintended increase in leisure PA.

Environment and Physical Activity Dynamics: The Role of Residential Self-selection.

OBJECTIVES: Within the socio-ecologic framework, diet and physical activity are influenced by individual, interpersonal, organizational, community, and public policy factors. A basic principle underlying this framework is that environments can influence an individual's behavior. However, in the vast majority of cross-sectional and even the few longitudinal studies of this relationship, the question of whether individuals select their area of residence based on physical activity-related amenities is ignored. In this paper, we address a critical methodological issue: self-selection of residential location, which is generally not accounted for, and can significantly compromise research on the relationship between environmental factors and physical activity behaviors. METHOD: We define and discuss the problem of residential self-selection in the study of neighborhood influences on health and health behavior, review methods used to control for residential self-selection in the literature, and present our strategy for addressing this potentially important source of bias. CONCLUSION: Existing research has built our understanding of residential self-selection bias, but important gaps remain. Our strategy uses data from a longitudinal cohort study linked to contemporaneous environmental measures to create a multi-equation model system to simultaneously estimate residential choice, environmental influences on physical activity, and downstream health outcomes such as obesity and clinical cardiovascular disease risk factor measures.

Residential self-selection bias in the estimation of built environment effects on physical activity between adolescence and young adulthood.

BACKGROUND: Built environment research is dominated by cross-sectional designs, which are particularly vulnerable to residential self-selection bias resulting from health-related attitudes, neighborhood preferences, or other unmeasured characteristics related to both neighborhood choice and health-related outcomes. METHODS: We used cohort data from the National Longitudinal Study of Adolescent Health (United States; Wave I, 1994-95; Wave III, 2001-02; n = 12,701) and a time-varying geographic information system. Longitudinal relationships between moderate to vigorous physical activity (MVPA) bouts and built and socioeconomic environment measures (landcover diversity, pay and public physical activity facilities per 10,000 population, street connectivity, median household income, and crime rate) from adolescence to young adulthood were estimated using random effects models (biased by unmeasured confounders) and fixed effects models (within-person estimator, which adjusts for unmeasured confounders that are stable over time). RESULTS: Random effects models yielded null associations except for negative crime-MVPA associations [coefficient (95% CI): -0.056 (-0.083, -0.029) in males, -0.061 (-0.090, -0.033) in females]. After controlling for measured and time invariant unmeasured characteristics using within-person estimators, MVPA was higher with greater physical activity pay facilities in males [coefficient (95% CI): 0.024 (0.006, 0.042)], and lower with higher crime rates in males [coefficient (95% CI): -0.107 (-0.140, -0.075)] and females [coefficient (95% CI): -0.046 (-0.083, -0.009)]. Other associations were null or in the counter-intuitive direction. CONCLUSIONS: Comparison of within-person estimates to estimates unadjusted for unmeasured characteristics suggest that residential self-selection can bias associations toward the null, as opposed to its typical characterization as a positive confounder. Differential environment-MVPA associations by residential relocation suggest that studies examining changes following residential relocation may be vulnerable to selection bias. The authors discuss complexities of adjusting for residential self-selection and residential relocation, particularly during the adolescent to young adult transition.

Measurement Error in Discrete Health Facility Choice Models: an Example from Urban Senegal.

We use individual-level health facility choice data from urban Senegal to estimate consumer preferences for facility characteristics related to maternal health services. We find that consumers consider a large number of quality related facility characteristics, as well as travel costs, when making their health facility choice. In contrast to the typical assumption in the literature, our findings indicate that individuals frequently bypass the facility nearest their home. In light of this, we show that the mismeasured data used commonly in the literature produces biased preference estimates; most notably, the literature likely overestimates consumer distaste for travel.