RESEARCH ARTICLE

Individual and community level factors

associated with health facility delivery: A cross
sectional multilevel analysis in Bangladesh
Tanvir M. Huda ID1,2*, Morseda Chowdhury3, Shams El Arifeen1, Michael J. Dibley2

1 The University of Sydney, Faculty of Medicine and Health, School of Public Health, NSW, Australia,
2 International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh, 3 Health Nutrition
and Population Programme, BRAC, Dhaka, Bangladesh

* [email protected]
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Introduction
Improving maternal health remains one of the targets of sustainable development goals. A
maternal death can occur at any time during pregnancy, but delivery is by far the most dan-
OPEN ACCESS
gerous time for both the woman and her baby. Delivery at a health facility can avoid most
Citation: Huda TM, Chowdhury M, El Arifeen S, maternal deaths occurring from preventable obstetric complications. The influence of both
Dibley MJ (2019) Individual and community level
factors associated with health facility delivery: A
individual and community factors is critical to the use of health facility delivery services. In
cross sectional multilevel analysis in Bangladesh. this study, we aim to examine the role of individual and community factors associated with
PLoS ONE 14(2): e0211113. https://doi.org/ health facility-based delivery in Bangladesh.
10.1371/journal.pone.0211113

Editor: Astrid M. Kamperman, Erasmus Medical

Methods
Center, NETHERLANDS
This cross-sectional study used data from the Bangladesh Maternal Mortality Survey. The
Received: April 25, 2018
sample size constitutes of 28,032 women who had delivered within five years preceding the
Accepted: January 8, 2019
survey. We fitted logistic random effects regression models with the community as a random
Published: February 13, 2019 effect to assess the influence of individual and community level factors on use of health facil-
Copyright: © 2019 Huda et al. This is an open ity delivery services.
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and Results
reproduction in any medium, provided the original Our study observed substantial amount of variation at the community level. About 28.6% of
author and source are credited.
the total variance in health facility delivery could be attributed to the differences across the
Data Availability Statement: All data are available community. At community level, place of residence (AOR 1.48; 95% CI 1.35–1.64), concen-
from MEASURE Evaluation Dataverse (Carolina
tration of poverty (AOR 1.15; 95% CI 1.03–1.28), concentration of use of antenatal care ser-
Population Center, University of North Carolina at
Chapel Hill) https://dataverse.unc.edu/dataset. vices (AOR 1.11, 95% CI 1.00–1.23), concentration of media exposure (AOR 1.20, 95% CI
xhtml?persistentId=hdl:1902.29/11389. 1.07–1.34) and concentration of educated women (AOR 1.12, 95% CI 1.02–1.23) were
Funding: The authors received no specific funding found to be significantly associated with health facility delivery. At individual level, maternal
for this work. age, educational status of the mother, religion, parity, delivery complications, individual
Competing interests: The authors have declared exposure to media, individual access to antenatal care and household socioeconomic status
that no competing interests exist. showed strong association with health facility-based delivery.

PLOS ONE | https://doi.org/10.1371/journal.pone.0211113 February 13, 2019 1 / 13

 Individual and community level factors associated with health facility delivery

Conclusion
Our results strongly suggest factors at both Individual, and community level influenced the
use of health facility delivery services in Bangladesh. Thus, any future strategy to improve
maternal health in Bangladesh must consider community contexts and undertake multi-sec-
torial approach to address barriers at different levels. At the individual level the programs
should also focus on the need of the young mother, the multiparous the less educated and
women in the poorest households.

Introduction
Global maternal mortality ratio has fallen by nearly 44% between 1990 and 2015[1]. Despite the
significant reduction over the last two decades, the mortality ratio is still unacceptably high in
many low and middle-income countries. In 2015, approximately 5500 women died (95% CI
3900 to 8800) in Bangladesh from maternal causes[2]. The lifetime risk of women to die from
maternal causes is estimated to be 1 in 240 in Bangladesh[2]. Improving maternal health thus
remains one of the targets of Sustainable Development Goals (SDG). SDG has set a goal of
reducing the maternal mortality ratio (MMR) to less than 70 per 100,000 live births by 2030[3].
As the delivery process can result in unexpected complications, health facility delivery or
delivery by a skilled attendant is crucial. It is now well established that ensuring skilled attendant
at birth, or health facility delivery, can avoid most maternal deaths occurring from preventable
obstetric complications and thus can make a critical difference to the survival of the mother[4,
5]. An analysis of secondary data from 48 low and middle-income countries reported that in
Sub Saharan Africa, South Asia, and Southeast Asia, more than 70% of all births in the lowest
two wealth quintiles occurred at home [6]. In Bangladesh only around 37% of women delivered
in a designated health care facility[7]. Critical to improving these rates is an understanding of
the multilevel factors associated with utilisation of health facility delivery services.
Several studies conducted in Bangladesh and other similar settings have attempted to iden-
tify the determinants of health facility delivery. Most studies have focused on individual and
health system factors and demonstrated a significant effect of those factors on the use of health
facility delivery services[8–13]. Although studies have reported similar sets of determinants,
the effect size differs from one geographic area to another. Therefore, it is possible that unob-
served community factors also influenced the location where women deliver. Few studies have
already documented the role of community or social factors in the utilisation of maternal
health services in South Asia and Africa[14, 15]. However, the role of community factors on
the utilisation of health facility delivery services is still less understood in Bangladesh. We,
therefore, planned to examine a range of individual and community factors and measure their
extent of influence on health facility-based delivery in Bangladesh.

Methods
Data sources
We used data from 2010 Bangladesh Maternal Mortality Survey[16], the largest national
household survey designed to provide the national estimate of maternal mortality ratio
(MMR) and information on family planning, antenatal, delivery, postnatal, and emergency
obstetric care.

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 Individual and community level factors associated with health facility delivery

The sampling frame for the BMMS survey was divided into urban and rural areas. The pri-
mary sampling unit (PSU) for the urban and rural areas was the ward and union respectively. For
each selected PSU, two mohallas (the next administrative unit for urban area) or a mouza (the
next administrative unit for rural area) were randomly selected and segmented into clusters. A
cluster was then randomly selected from each selected mohallas or mouza. A total of 2,708 clus-
ters were selected including 1,142 urban and 1,566 rural clusters. From these clusters, 175,600
households (around 65 household from each cluster) were then randomly selected for the survey,
of which 168,629 were successfully interviewed. From these 168,629 households, 175,621 women
were interviewed for the measurement of maternal mortality. Among them, information on ante-
natal, delivery and postnatal care were collected from 28,032 women who had a birth in the five
years preceding the survey. We have included all 28,032 women in our study.

Variables
Outcome variable. Our outcome variable is whether a mother delivered at home or in a
health facility. A birth is categorised as health facility-based if it occurred at a private, public or
non-governmental clinic.
Explanatory variables. We selected explanatory variables based on Andersen’s health-
seeking behavioral model. According to Andersen’s behavioral model, predisposing, enabling,
and need factors at the individual and community levels are responsible for increasing health-
seeking behavior and health facilities utilization[17–19]. We have included need factors at the
individual level while predisposing and enabling factors were included at community level.
For community-level factors, we have developed several binary variables by aggregating the
individual level characteristics at the cluster level.
Individual level factors. Age at birth (less than 20, 20–34 years, 35 years and above)
1. Maternal Education (No education, primary incomplete, primary completed, higher). Pri-
mary complete is defined as completing grade 5 and secondary complete is defined as com-
pleting grade 10.
2. Religion (Islam, Hinduism and others)
3. Parity (1, 2, 3 and 4 or more),
4. Maternal care seeking practices (at least 3 ANC or any ANC from a medically trained pro-
vider that is a qualified doctor, nurse, midwife, paramedic, community skilled birth atten-
dant (CSBA) and others as designated by Govt of Bangladesh[7]),
5. Exposure to mass media (watch TV or read the newspaper at least once in a week)
6. Pregnancy complications in her last pregnancy (convulsion/fits, High BP or Edema, Severe
bleeding, mal-presentation and prolonged labour).
7. Household wealth index as a proxy for the women socioeconomic condition.

Community level factors

1. Region (Sylhet, Barisal, Chittagong, Dhaka, Khulna, Rajshahi)
2. Area of residence (Urban and Rural)

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 Individual and community level factors associated with health facility delivery

3. High concentration of exposure to mass media in the community (whether or not more
than 50% population of the cluster read the newspapers at least once in a week or watch TV
at least once in a week),
4. High concentration of use of ANC in the community (whether or not more than 50% pop
of the cluster had at least 1 ANC check from a medically trained provider or had at least 3
ANC checks),
5. High concentration of educated women in the community (whether or not more than 50%
pop of the cluster had at least eight years of education)
6. High concentration of wealth in the community (whether or not more than 50% of the pop-
ulation are in the top 3 wealth quintiles)

Statistical analysis
We performed multilevel regression analyses to assess the individual, household and commu-
nity level factors associated with health facility delivery. We used random effects logistic model
(also known as the mixed effect or random intercept model) with two levels to assess the influ-
ence of individual and community factors on the use of health facility-based delivery services.
Multilevel modelling technique was used to take account the hierarchical structure of our data.
In our survey, women were nested within households and households were nested within clus-
ters. We have considered clusters as our random effect to account for the unexplained variabil-
ity at the community level. All analysis was done on weighted data.
We first constructed an empty” model (model i), which only includes a random intercept.
An empty random effect model will provide an estimation of the degree of correlation in the
health facility delivery that exists at the community level (cluster). We then included all indi-
vidual factors in the model (model ii). Finally, we added the community level factors (model
iii) to examine which contextual factors have the most influence on the use of a health facility
for delivery care. For all models, we presented the odds ratio and associated 95% confidence
intervals. We did all statistical analyses using the Stata statistical software, version 15.

Ethics
The present study relied upon secondary analysis of anonymous, publicly available household
survey data from BMMS 2010. The BMMS 2010 survey was approved by the Ethical Review
Committee (ERC) of the Bangladesh Medical Research Council (BMRC). All study partici-
pants gave informed consent before participation. The raw data of BMMS 2010 is publicly
available. We have downloaded the data with permission from the Measure Evaluation.

Results
We included 28,032 mothers in our analysis. We presented the percentage of women using
health facility delivery by the individual, characteristics in Table 1. The overall use of health
facility delivery services in our sample was 21.6% (95% CI 20.8%, 22.5%). The results showed
significant differences in the use of health facility-based delivery services between catergoreis
of maternal age, education, religion, parity, exposure to mass media, household wealth and
complications experienced during pregnancy. The utilisation of health facility delivery service
was higher among the younger, educated and women from affluent households. The rate was
slightly lower among the Muslim women. Also, women who reported three or more ANC visit
from any provider had a higher rate of health facility delivery than women who only reported

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 Individual and community level factors associated with health facility delivery

Table 1. Descriptive analysis of individual characteristics according to place of delivery.

Health facility Delivery
No Yes P value
N (%) N (%)
Maternal Age
<20 2,494 (77.1%) 740 (22.9%) 0.0000
20–34 16,888 (77.5%) 4,892 (22.5%)
35+ 2,720(85.1%) 477(14.9%)
Parity
1 5,948(66.5%) 2,993 (33.5%) 0.0000
2 6,438(78.2%) 1,795 (21.8%)
3 4,246(84.3%) 791 (15.7%)
>=4 5,470(91.2%) 529 (8.8%)
Religion
Muslim 20,434(79.3%) 5,342 (20.7%) 0.0000
Hindu 1,506(68.2%) 701 (31.8%)
Others 162(71.0%) 66.2 (29.0%)
Maternal Education
No Education 6,516(91.6%) 594 (8.4%) 0.0000
Incomplete Primary 3,991(87.5%) 570 (12.5%)
Completed Primary 3,718(84.5%) 681 (15.5%)
Secondary or Higher 7,877(64.9%) 4,264 (35.1%)
ANC from a Medically Trained Provider
No 12,935(92.5%) 1,050 (7.5%) 0.0000
Yes 9,167(64.4%) 5,059 (35.6%)
At least 3 ANC from any Provider
No 16,106(87.9%) 2,217 (12.1%) 0.0000
Yes 5,996(60.6%) 3,892 (39.3%)
Watch TV Daily
No 16,084(86.7%) 2,465 (13.3%) 0.0000
Yes 6,018(62.3%) 3,644 (37.7%)
Read Newspaper at least weekly
No 20,618(81.4%) 4,707 (18.6%) 0.0000
Yes 1,484(51.4%) 1,402 (48.6%)
Complication 0.0000
Severe headache and blurred vision 4,415 (81.7%) 991 (18.3%)
Convulsion/fits 199(68.6%) 91(31.4%)
High Blood Pressure 221(52.3%) 202(47.7%)
Severe heavy bleeding 154(59.6%) 104(40.4%)
Leaking membrane 751(51.8%) 700(48.2%)
Oedema 2,298(75.4%) 749(24.6%)
None of the above 14,056(81.2%) 3,260(18.8%)
Wealth Index 0.0000
Poorest 5,267 (92.5%) 426(7.5%)
Second 5,055 (89.0%) 623(11.0%)
Middle 4,563(82.1%) 993(17.9%)
Fourth 4,186(74.0%) 1,469(26.0%)
Richest 3,031(53.8%) 2,598(46.2%)
https://doi.org/10.1371/journal.pone.0211113.t001

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 Individual and community level factors associated with health facility delivery

one ANC visit. Similarly, women who reported ANC from a medically trained provider had a
higher rate of health facility delivery than women who reported ANC from a non-medically
trained provider. Also, women with exposure to mass media had a higher rate of health facility
delivery.
Table 2 showed the percentage of women using health facility delivery by community level
factors. Urban women were more likely to deliver in a health facility compared to rural
women. Women residing in communities with a higher concentration of educated mothers,
affluent households, women who have access to media and women who reported to use ANC
were also more likely to deliver in a health facility.

Measures of variation (Random-effects)

We first presented an empty, intercept-only model to assess if our data justify the decision to
evaluate random effects at the cluster level. As shown in Table 3, Model 1 (the empty model),
there was a significant variation in the odds of delivery in a health facility across the clusters or
communities (variance = 1.315 95% CI 1.192, 1.452 p—.001).

Table 2. Descriptive analysis of community characteristics according to place of delivery.

Health facility Delivery
No Yes P value
N (%) N (%)
Place of Residence
Urban 4,340 (64.8%) 2,353 (35.1%) 0.0000
Rural 17,762 (82.5%) 3,756 (17.5%)
Region
Barisal 1,416 (84.9%) 253 (15.1%) 0.0000
Chittagong 4,948 (80.8%) 1,172 (19.2%)
Dhaka 7,137 (75.9%) 2,266 (24.1%)
Khulna 2,011 (71.4%) 806 (28.6%)
Rajshahi 4,976 (79.0%) 1,321 (21.0%)
Sylhet 1,615 (84.7%) 291 (15.3%)
Community exposure to newspaper
No 22,017 (78.9%) 5,882 (21.1%) 0.0000
Yes 85 (27.1%) 227 (72.9%)
Community exposure to TV
No 17,771 (84.0%) 3,369 (16.0%) 0.0000
Yes 4,332 (61.3%) 2,740 (38.7%)
Community education concentration
Low 17,232 (82.%3) 3,709 (17.7%) 0.0000
High 4,870 (67.0%) 2,400 (33.0%)
Community wealth concentration
Low 16,161 (84.1%) 3,052 (15.9%) 0.0000
High 5,941 (66.0%) 3,057 (34.0%)
Community ANC utilization
Low 18,008 (83.4%) 3,578 (16.6%) 0.0000
High 4,094 (61.8%) 2,531 (38.2%)
Community ANC utilization (Medically Trained Provider)
Low 13,202 (87.6%) 1,870 (12.4%) 0.0000
High 8,900 (67.7%) 4,239 (32.3%)
https://doi.org/10.1371/journal.pone.0211113.t002

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 Individual and community level factors associated with health facility delivery

Table 3. Community level clustering in use of health facility delivery services.

Model I � Model II �� Model III ���
Estimate 95% CI Estimate 95% CI Estimate 95% CI
Community variance (SE) 1.31 1.19 1.45 .63 .55 .73 .44 .37 .53
ICC (%) .286 .266 .306 .162 .143 .182 .119 .102 .138
�
Model I: Empty model
��
Model II: Individual factors only
���
Model III: All factors (individuals and community)

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The intra-class (ICC) correlation in the empty model for health facility delivery is 0.286
(95% CI 0.266, 0.306). The ICC indicates a considerable between cluster heterogeneity. A little
less than one-third of the total variance in health facility delivery was attributable to the differ-
ences across the cluster or community-level factors (ICC). The variations across clusters
remained statistically significant, even after controlling for all factors in the full model.

Measures of association (Fixed-effects)

Individual-level factors. We then presented the full model that assessed the effect of indi-
vidual, household and community level factors in the use of health facility delivery services in
Table 4. The age of the women showed a significant association with the use of health facility
delivery service. Relative to very young women (<20 years), women of other age groups were
more likely to deliver in a health facility. Women tended to give birth at a health facility if they
were educated especially with the secondary or higher level of education. Muslim women were
less likely to report delivering in a health facility. The odds of delivery in a health facility
decreased with increasing parity. The use of prenatal health services emerged as a strong pre-
dictor of health facility delivery. Women who had at least one ANC from a medically trained
provider or had at least three ANC from any provider are more likely to use the health facility
for delivery. The experience of complications during pregnancy or childbirth had increased
the odds of health facility delivery. Maternal access to electronic media increased the odds of
using health facility. The socioeconomic condition of the women was positively associated
with the use of health facility delivery services with women in the highest wealth quintile hav-
ing a 3-fold increase in the odds of delivery in a health facility compared to those in the lowest
wealth quintile (OR 3.15, 95% CI 2.72–3.64). Women from urban areas were more likely to
deliver in a health facility compared to women who reside in a rural community (OR 1.48,
95% CI 1.34 to 1.63).
Community level factors. We found concentration of affluent households (OR 1.15, 95%
CI 1.03 to 1.28); educated women (OR 1.12, 95% CI 1.02 to 1.23); use of ANC (OR 1.25, 95%
CI 1.13 to 1.39); access to electronic media (OR 1.20, 95% CI 1.07 to 1.34) in a community is
strongly associated with health facility delivery. The geographic region also showed a strong
association with health facility delivery services. Adjusting or all other factors in the model we
found the odds of using health facility delivery services were higher in Khulna, Rajshahi and
Dhaka and lower in Chittagong and Barisal.

Discussion
We found along with individual factors, community factors also have a significant influence
on the use of health facility delivery services in Bangladesh. It thus confirms the findings of a

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 Individual and community level factors associated with health facility delivery

Table 4. Multilevel logistic regression analysis of individual, household and community level factors associated
with health facility delivery.
Model II Model III
AOR (95% CI) AOR (95% CI)
Maternal Age
<20 1 1
20–34 1.27 (1.14, 1.42) 1.26 (1.13, 1.41)
35+ 1.73 (1.47, 2.03) 1.64 (1.38, 1.95)
Parity
1 1 1
2 2.67 (2.35, 3.03) 2.55 (2.23, 2.92)
3 1.69 (1.50, 1.90) 1.61 (1.42, 1.82)
>=4 1.34 (1.19, 1.52) 1.30 (1.14, 1.48)
Religion
Hindu 1 1
Muslim 0.58 (0.40, 0.83) 0.43 (0.30, 0.63)
Others� 0.89 (0.61, 1.30) 0.66 (0.45, 0.98)
Maternal Education
No Education 1 1
Incomplete Primary 1.01 (0.89, 1.14) 1.01 (0.89, 1.15)
Completed Primary 1.01 (0.89, 1.15) 1.03 (0.90, 1.18)
Secondary or Higher 1.42 (1.26, 1.59) 1.43 (1.27, 1.61)
ANC from a Medically Trained Provider
No 1 1
Yes 2.77 (2.56, 3.00) 2.59 (2.38, 2.83)
At least 3 ANC from any provider
No 1 1
Yes 2.05 (1.91, 2.20) 1.91 (1.77, 2.06)
Watch TV daily
No 1 1
Yes 1.35 (1.24, 1.45) 1.13 (1.04, 1.23)
Read Newspaper at least weekly
No 1 1
Yes 1.40 (1.28, 1.53) 1.40 (1.27, 1.54)
Complication
Headache & blur vision 1.22 1.38 (1.26, 1.52)
(1.12, 1.33)
Convulsion/fits 2.01 (1.52, 2.67) 2.20 (1.63, 2.98)
High Blood Pressure 3.15 (2.57, 3.85) 3.35 (2.70, 4.16)
Severe heavy bleeding 2.58 (1.91, 3.49) 2.80 (2.05, 3.83)
Leaking membrane 3.70 (3.26, 4.21) 3.89 (3.41, 4.44)
Oedema 1.19 (1.08, 1.31) 1.24 (1.12, 1.38)
None of the above 1 1

Wealth Index
Poorest 1 1
Second 1.10 (0.97, 1.25) 1.13 (0.99, 1.30)
Middle 1.45 (1.28, 1.64) 1.53 (1.34, 1.74)
Fourth 1.70 (1.51, 1.93) 1.79 (1.57, 2.04)
Richest 2.75 (2.41, 3.15) 3.15 (2.72, 3.65)
(Continued )

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 Individual and community level factors associated with health facility delivery

Table 4. (Continued)

Model II Model III

AOR (95% CI) AOR (95% CI)
Place of Residence
Urban 1.48 (1.35, 1.64)
Rural 1
Region
Sylhet
Barisal 1.16 (0.97, 1.39)
Chittagong 0.76 (0.65, 0.88)
Dhaka 1.26 (1.08, 1.46)
Khulna 1.78 (1.51, 2.11)
Rajshahi 1.51 (1.28, 1.77)
Community exposure to newspaper
No 1
Yes 1.64 (1.21, 2.23)
Community exposure to TV
No 1
Yes 1.20 (1.07, 1.34)
Community education concentration
Low 1
High 1.12 (1.02, 1.23)
Community wealth concentration
Low 1
High 1.15 (1.03, 1.28)
Community ANC utilization (At least 3 ANC)
Low 1
High 1.11 (1.00, 1.23)
Community ANC utilization (Medically Trained Provider)
Low 1
High 1.25 (1.14, 1.39)
�
Other religion included Buddhism and Christianity
��
Model II: Individual factors only
���
Model III: All factors (individuals and community)

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previous study and reiterate the importance of community factors with respect to use of health
facility delivery services[20].
Similar to other studies we found a high concentration of wealthier households in a com-
munity positively influences health facility delivery in that community[14, 21]. It is possible in
communities where there is a high concentration of wealthier households, health facility deliv-
ery practice may become a norm, that other women from poorer households may follow[21].
It is also possible that in communities where there is a high concentration of wealth, health
facilities function better and provide quality services, which in turn, can have a positive influ-
ence on the overall health service utilisation in the community. Our findings suggest women
socioeconomic condition has a strong positive influence on health facility delivery[11, 13, 22].
These findings indicated delivering at a health health facility is influenced by the economic
resources available to an individual.

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 Individual and community level factors associated with health facility delivery

Education both at individual and community level exerts a positive influence on the overall
health service utilisation within the community. Several studies in Bangladesh and elsewhere
have reported a strong association between women’s education and use of health facility deliv-
ery and other maternal health services [23–27]. Formal education can influence the use of
health facility delivery in multiple pathways. Reproductive health education can improve
knowledge and reduce reproductive health problems among adolescents in developing coun-
tries[28]. Living in a neighborhood with an educated majority expose the mother to women
who are more capable of deciding on appropriate care seeking[29]. An educated woman can
better catch health messages delivered through newspapers, billboards, and other media. Over-
all, formal education challenges traditional beliefs about health and health-seeking and trans-
forms women’s attitudes towards safe delivery[20].
Exposure to media was also a significant predictor of health facility delivery services. Several
studies have reported the effectiveness of media in influencing health service utilisation includ-
ing health facility delivery[30, 31]. Higher concentration of media exposures in the community
also plays an influential role in overall health service utilisation of that community. Increased
media exposure might help to increase discussion of maternal issues within the community.
This finding is similar to a study in Nigeria which reported the mothers residing in communi-
ties with a higher proportion of exposure to electronic and print media had higher odds of
using health facility delivery services [32].
The findings that women who had more contact with antenatal care service have higher
odds of using health facility delivery services might be an indication that such women are bet-
ter informed about the importance of safe delivery from the counselling during antenatal care
attendance. The finding is similar to the results of previous studies done in other countries [23,
24, 33, 34]. Community ANC service utilisation is also a strong predictor of health facility
delivery. Higher community utilisation of ANC services indicates availability or better access
to health facilities in these communities. Also, women attending antenatal care service are
likely to be better informed about the danger of home delivery and could motivate their neigh-
bours who did not participate in antenatal care service.
Place of residence and region were found to be significant predictors of health facility deliv-
ery. The result is consistent with other studies elsewhere [32, 35–37]. The difference in service
utilisation among the urban and rural community as well as the different geographic region
could be due to health service availability, quality of health services as well as access to health
facilities. Our findings indicate that the likelihood of health facility delivery is higher among
older women[20, 38] as well as multiparous women[13, 39, 40]. Earlier studies suggested older
women are better aware of availability and accessibility of such services [20, 38] while multipa-
rous woman develop confidence about childbirth from the experience and knowledge
acquired from their earlier delivery[12, 26, 39]. Finally, similar to the findings of another study
in Bangladesh we found Muslim women to have less probability of using health facility delivery
services than women from other religions [26]. Muslim women may use fewer services at a
health facility due to their conservative behaviour. After adjusting for individual and commu-
nity variables, we found that there was still unexplained variance. Some of this variance might
be explained by other potentially important health system level variables which we did not
have data (e.g., quality of health services, availability of service provider, distance to the nearest
health health facility).

Limitations
There are few limitations in this study. We used cluster—the primary sampling unit of our
research as our definition of a community. However, a cluster has an arbitrary boundary and may

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 Individual and community level factors associated with health facility delivery

not represent an actual community. We did not include some known predictors of health facility
service utilisation because the data were not available in the survey examined. These included the
availability of health services in the community or distance to the nearest health facility. Also, we
could not include husband education status or decision-making power of the women.

Conclusion
Our findings provide valuable information to the policymakers that can be used when plan-
ning interventions to promote health facility delivery in Bangladesh. In addition to the individ-
ual attributes of women that influenced the use of health facility delivery services, we also
highlighted the community determinants that contributed significantly in health facility deliv-
ery service utilization. Several community level factors significantly predicted the uptake of
health facility delivery care which reinforce the need for community empowerment and focus
on less privileged communities. The evidence suggests the need to go beyond addressing chal-
lenges at individual levels to improve the uptake of facility delivery services. Thus, increasing
the use of health facility delivery services will require strategies that target high-risk groups,
which may be most effectively defined, based on contextual factors such as community pov-
erty, community education status, community exposure to mass media and community use of
other health services. The fact that women education and household wealth are important
determinants for health facility delivery services reinforces the needs for addressing current
disparities in women education and wealth. Promoting intersectoral actions would thus be
vital in improving maternal health. Overall, action is required at all levels–level of the individ-
ual woman and her community.

Acknowledgments
We thank MEASURE Evaluation for granting permission to use the BMMS 2010 data.

Author Contributions
Conceptualization: Tanvir M. Huda.
Data curation: Tanvir M. Huda.
Formal analysis: Tanvir M. Huda.
Methodology: Tanvir M. Huda, Michael J. Dibley.
Resources: Tanvir M. Huda.
Supervision: Michael J. Dibley.
Writing – original draft: Tanvir M. Huda.
Writing – review & editing: Tanvir M. Huda, Morseda Chowdhury, Shams El Arifeen,
Michael J. Dibley.

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