Background
Pakistan has a high burden of maternal and newborn mortality, which would be largely preventable through appropriate antenatal and delivery care. While the influence of socio-economic status on institutional delivery is well established in the literature, relatively little is known about the relationship between the quality of antenatal care and institutional delivery.

Methods
A household survey of 4,000 currently married women who had given birth in the two years before the survey was conducted in Sindh province in 2013. The survey collected data on socio-economic and demographic variables, the quality of antenatal care provided during a woman’s last pregnancy and whether she delivered at a health facility. Logistic regression was used to estimate adjusted odds ratios and 95 % confidence intervals around independent variables for institutional delivery.

Results
In the multivariate analysis, a variable measuring quality of antenatal care showed the strongest association with institutional delivery. Moreover, there was a dose-response relationship between the number of elements of quality provided and the odds of institutional delivery: receiving one element of quality increased the odds of institutional delivery 1.7 times, receiving three elements increased the odds 3.8 times and receiving seven elements increased the odds 10.6 times. Household wealth had a statistically significant relationship with institutional delivery but the effect was weaker than that of quality of care. Urban-rural differentials in institutional delivery did not remain significant after adjusting for household wealth and education.

Conclusions
The quality of antenatal care provided to a woman during her pregnancy is more strongly associated with institutional delivery than household wealth. Improving the quality of care at health facilities in Sindh should be the foremost priority. Improving the quality of antenatal care services is likely to contribute to rapid increases in skilled birth attendance and better health outcomes for women and children.