title: Factors associated with institutional delivery in Ghana: the role of decision-making autonomy and community norms.
abstract: BACKGROUND
  In Ghana, the site of this study, the maternal mortality ratio and under-five mortality rate remain high indicating the need to focus on maternal and child health programming. Ghana has high use of antenatal care (95%) but sub-optimum levels of institutional delivery (about 57%). Numerous barriers to institutional delivery exist including financial, physical, cognitive, organizational, and psychological and social. This study examines the psychological and social barriers to institutional delivery, namely women's decision-making autonomy and their perceptions about social support for institutional delivery in their community.
  
  
  METHODS
  This study uses cross-sectional data collected for the evaluation of the Maternal and Newborn Referrals Project of Project Fives Alive in Northern and Central districts of Ghana. In 2012 and 2013, a total of 2,527 women aged 15 to 49 were surveyed at baseline and midterm (half in 2012 and half in 2013). The analysis sample of 1,606 includes all women who had a birth three years prior to the survey date and who had no missing data. To determine the relationship between institutional delivery and the two key social barriers-women's decision-making autonomy and community perceptions of institutional delivery-we used multi-level logistic regression models, including cross-level interactions between community-level attitudes and individual-level autonomy. All analyses control for the clustered survey design by including robust standard errors in Stata 13 statistical software.
  
  
  RESULTS
  The findings show that women who are more autonomous and who perceive positive attitudes toward facility delivery (among women, men and mothers-in-law) were more likely to deliver in a facility. Moreover, the interactions between autonomy and community-level perceptions of institutional delivery among men and mothers-in-law were significant, such that the effect of decision-making autonomy is more important for women who live in communities that are less supportive of institutional delivery compared to communities that are more supportive.
  
  
  CONCLUSIONS
  This study builds upon prior work by using indicators that provide a more direct assessment of perceived community norms and women's decision-making autonomy. The findings lead to programmatic recommendations that go beyond individuals and engaging the broader network of people (husbands and mothers-in-law) that influence delivery behaviors.
authors.affiliation: Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Ilene_speizer@unc.edu.
authors.forename: Ilene S
authors.initials: IS
authors.lastname: Speizer
authors.forename: William T
authors.initials: WT
authors.lastname: Story
authors.forename: Kavita
authors.initials: K
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D000328:Adult; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D003657:Decision Making; D036861:Delivery, Obstetric / Q000592:standards* / Q000639:trends; D003906:Developing Countries; D005260:Female; D005869:Ghana; D006268:Health Facilities / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008427:Maternal Health Services / Q000458:organization & administration*; D008429:Maternal Welfare; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D026684:Personal Autonomy; D012016:Reference Values; D012111:Residence Characteristics; D018570:Risk Assessment; D012959:Socioeconomic Factors; D055815:Young Adult