摘要：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. According to the World Health Organization, approximately half a million women die each year from complications of pregnancy or childbirth. The level of maternal mortality is disproportionately high in Africa, with a regional maternal mortality ratio of 1000 per 100 000 live births. 1 Most maternal deaths occur during childbirth, and the presence of trained medical staff could substantially reduce the number. 2 Therefore the need exists to understand the factors that encourage childbirth in a health facility attended by a trained medical professional. Previous studies have approached this issue by examining individual- and household-level influences on the decision to deliver a child in a medical institution, 3 – 5 but the role of community factors has been largely ignored. In recent years, there has been growing recognition of the importance of contextual influences on health outcomes; in particular, several studies have found significant effects of community-level factors on reproductive health outcomes. 6 – 9 Furthermore, the application of multilevel modeling techniques has shown that spatial variations in reproductive health outcomes remain after control for individual- and household-level factors. 10 , 11 We examined the influence of individual-, household-, and community-level factors on the decision to deliver a child in a health facility in 6 African countries. We build upon previous studies by including the role of the community in our analysis.
