Contextual influences on the use of health facilities for childbirth in Africa.

OBJECTIVES Previous studies of maternal health-seeking behavior focused on individual- and household-level factors. We examined community-level influences on the decision to deliver a child in a health facility across 6 African countries. METHODS Demographic and Health Survey data were linked with contextual data, and multilevel models were fitted to identify the determinants of childbirth in a health facility in the 6 countries. RESULTS We found strong community-level influences on a woman's decision to deliver her child in a health facility. Several pathways of influence between the community and individual were identified. CONCLUSIONS Community economic development, the climate of female autonomy, service provision, and fertility preferences all exert an influence on a woman's decision to seek care during labor, but significant community variation remains unexplained.