RESEARCH ARTICLE Do Physical Proximity and Availability of Adequate Infrastructure at Public Health Facility Increase Institutional Delivery? A Three Level Hierarchical Model Approach Rachana Patel 1 *, Laishram Ladusingh 2 1 International Institute for population Sciences (IIPS), Mumbai, India, 2 Department of Mathematical Demography and Statistics, International Institute for population Sciences (IIPS), Mumbai, India * contact.rachi@gmail.com Abstract This study aims to examine the inter-district and inter-village variation of utilization of health services for institutional births in EAG states in presence of rural health program and avail- ability of infrastructures. District Level Household Survey-III (2007–08) data on delivery care and facility information was used for the purpose. Bivariate results examined the utili- zation pattern by states in presence of correlates of women related while a three-level hier- archical multilevel model illustrates the effect of accessibility, availability of health facility and community health program variables on the utilization of health services for institutional births. The study found a satisfactory improvement in state Rajasthan, Madhya Pradesh and Orissa, importantly, in Bihar and Uttaranchal. The study showed that increasing dis- tance from health facility discouraged institutional births and there was a rapid decline of more than 50% for institutional delivery as the distance to public health facility exceeded 10 km. Additionally, skilled female health worker (ANM) and observed improved public health facility led to significantly increase the probability of utilization as compared to non-skilled ANM and not-improved health centers. Adequacy of essential equipment/laboratory ser- vices required for maternal care significantly encouraged deliveries at public health facility. District/village variables neighborhood poverty was negatively related to institutional deliv- ery while higher education levels in the village and women’s residing in more urbanized dis- tricts increased the utilization. “Inter-district” variation was 14 percent whereas “between- villages” variation for the utilization was 11 percent variation once controlled for all the three-level variables in the model. This study suggests that the mere availability of health facilities is necessary but not sufficient condition to promote utilization until the quality of ser- vice is inadequate and inaccessible considering the inter-districts variation for the program implementation. PLOS ONE | DOI:10.1371/journal.pone.0144352 December 21, 2015 1 / 20 OPEN ACCESS Citation: Patel R, Ladusingh L (2015) Do Physical Proximity and Availability of Adequate Infrastructure at Public Health Facility Increase Institutional Delivery? A Three Level Hierarchical Model Approach. PLoS ONE 10(12): e0144352. doi:10.1371/journal.pone.0144352 Editor: Vikrant Sahasrabuddhe, National Cancer Institute, UNITED STATES Received: May 16, 2014 Accepted: November 17, 2015 Published: December 21, 2015 Copyright: © 2015 Patel, Ladusingh. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Due to ethical restrictions, data from the DLHS-3 survey are available upon request from the IIPS Ethics Committee via an online request form at http://www. iipsindia.org. Hard copies of the Data Request Form must be sent to: In-Charge, ICT Unit, International Institute for Population Sciences (IIPS), Deonar, Mumbai-400088. Funding: The authors have no support or funding to report.