In Africa, a woman's decision to give birth at a health facility—a choice that may be lifesaving if complications arise—is linked to community factors such as family size, male approval of family planning and level of female schooling.1 In an analysis based on nationally representative survey data from six African countries, the patterns of association varied by country; and some variation across communities in women's decisions could not be explained, even after accounting for individual, household and community factors.
Researchers analyzed data from women aged 15–45 who participated in Demographic and Health Surveys in six countries in East Africa (Kenya, Malawi and Tanzania) and West Africa (Burkina Faso, Côte d'Ivoire and Ghana). In the surveys, which were conducted between 1998 and 2000, women provided social, demographic and reproductive information about themselves and their husbands, including fertility preferences, attitudes toward family planning and health care seeking during pregnancy and childbirth, as well as information about their household assets. Information about each community was derived by averaging the individual data from the surveys, and by using information from geographic databases.
For each of the six countries, the researchers used multilevel modeling to identify associations between individual, household and community factors and women's decision to give birth in a health facility instead of at home. Analyses were restricted to women who had given birth in the past three years and focused on the most recent birth. Sample sizes ranged from 1,131 women in Côte d'Ivoire to 6,318 women in Malawi.
With respect to individual-level factors, women in Malawi, Tanzania and Ghana who lived in urban settings had higher odds than their rural counterparts of having delivered their last child in a health facility (odds ratios, 1.4–3.1).
Compared with 20–29-year-olds, younger and older women in Malawi, Tanzania, Ghana and Côte d'Ivoire were more likely to have delivered in facilities (odds ratios, 1.2–2.3); this was the case only for younger women in Burkina Faso (1.3) and only for the two older age-groups in Kenya (1.4–1.9). In all three countries in East Africa and in Ghana, women who had had three or more births were less likely than those with 1–2 births to have delivered their last child in a health facility (0.4–0.8); in Côte d'Ivoire, this was true only for women who had had 3–4 births (0.7).
In Kenya, compared with their counterparts in monogamous marriages, women in other types of relationships had reduced odds of having used a health facility for their last birth (0.7–0.8); in Malawi, women who were formerly married or who were in polygamous marriages had higher odds (1.1), whereas in Côte d'Ivoire, women in such relationships had lower odds (0.5–0.6). Women's likelihood of having delivered in a facility was elevated if they had a primary education in Tanzania (1.6), a secondary education in Kenya, Burkina Faso and Ghana (1.6–2.9) and either level of education in Malawi and Côte d'Ivoire (1.1–2.0).
In all countries except Côte d'Ivoire, having seen or heard family planning messages in the media was associated with elevated odds of facility use (odds ratios, 1.2–1.4). And in all countries except Burkina Faso, women who had made no visits for prenatal care during their last pregnancy were less likely than those who had made 1–3 visits to have delivered in a facility (0.1–0.7), whereas those who had made at least four visits were more likely to have done so (1.3–3.9). In Burkina Faso, women who had made at least four visits also had elevated odds of delivery in a facility (1.7). In all six countries, having previously given birth in a hospital was positively associated with having used a health facility for the last birth (2.0–2.9).
With respect to household-level factors, women living in a household with a low or medium asset index score were less likely than those whose household had a high score to have used a health facility for their last birth, regardless of country (odds ratios, 0.3–0.7). Except in Burkina Faso, having no household assets at all was associated with reduced odds of having used a facility (0.2–0.4).
Some community-level factors were also associated with delivery in a health facility. In Malawi, Tanzania and Ghana, the higher the average number of children ever born per woman in the community, the lower women's odds of having had their last birth in a health facility (odds ratios, 0.5–0.9). In all three East African countries, but none of the West African ones, the greater the proportion of husbands approving of family planning (as reported by wives), the more likely women were to have used a health facility (1.4–4.4). The odds of facility delivery in Malawi, Kenya, Burkina Faso and Ghana also rose with the proportion of women in the community who had at least a secondary education (2.4–20.5).
Except in Kenya, the odds of delivery in a health facility rose sharply with the average number of women in the community who had delivered at least once before in a facility. A variety of other community factors—transportation infrastructure, type of habitat, predominant religion and proportion of women desiring HIV testing—did not significantly influence facility use in any of the countries studied.
After the effects of individual and household factors were accounted for in each of the six countries, the addition of controls for community factors somewhat reduced the variation across communities in women's level of use of health facilities for their most recent birth. Nonetheless, the variation in use across communities remained significant.
In Africa, the community in which women live may shape their decision on whether to give birth in a health facility through several different pathways, the researchers say; female autonomy, availability of health facilities, prevailing fertility preferences and the extent of the community's economic development may all play a role. This new information, they assert, can be used to design interventions to increase women's use of facilities. "The range of community factors identified and their variation across the study settings demonstrate that any such interventions must be context specific, and should reflect the characteristics and dominant influences present in the community," they conclude.
1. Stephenson R et al., Contextual influences on the use of health facilities for childbirth in Africa, American Journal of Public Health, 2006, 96(1):84–93.