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Background: Improving access to supervised and emergency obstetric care resources through fee reduction/exemption maternity care initiatives has been touted as one major strategy to avoiding preventable maternal deaths. Evaluations on the effect of Ghana's fee exemption policy for maternal healthcare have largely focused on how it has influenced health outcomes and patterns of use of supervised care with little attention to understanding the main factors influencing use. This study therefore sought to explore the main individual and health system factors influencing use of delivery care services under the policy initiative in the Central Region.Methods: A cross-sectional study was conducted using 412 mothers with children aged less than one year in one largely rural and another largely urban districts in the Central Region of Ghana from September to December 2013. Data were collected using a questionnaire survey on the socio-demographic characteristics of mothers, their knowledge and use of care under the fee free policy. Chi-square and Binary Logistic Regression tests were used to evaluate the main determinants of delivery care use under the policy.Results: Out of the 412 mothers interviewed, 268 (65 %) reported having delivered their most recent birth under the fee exemption policy even though awareness about the policy was almost universal 401 (97.3 %) among respondents. Utilization however differed for the two study districts. Respondents in the Cape Coast Metropolis (largely urban) used delivery service more (75.7 %) than those in the largely rural Assin North Municipal area (54.4 %). Binary logistic regression results identified maternal age, parity, religion, place of residence, awareness and knowledge about the fee exemption policy for maternal healthcare as significantly associated with the likelihood of delivery care use under the policy. The likelihood of using supervised delivery care under the policy was lower for mothers aged 20-29 compared to those in the age bracket of 40-49 (Odds ratio (OR) = 0.069, p = 0.003). For their index (last child), mothers who already had 1, 2 or 3 births were more likely to deliver under the policy than those with five or more births. Mothers living in urban areas were 3.79 times more likely to use delivery services under the policy than those living in rural areas (OR = 3.793, p = 0.000). The likelihood of using delivery services under the policy was higher for mothers who were aware and had full knowledge of the total benefit package of the policy (OR = 13.820, p = 0.022 and OR = 2.985, p = 0.001 for awareness and full knowledge respectively).Conclusions: Delivery service use under the free maternal healthcare policy is relatively low (65 %) when compared with nearly universal awareness (97.3 %) about the policy. Factors influencing delivery service use under the policy operate at both individual and policy implementation levels. Effective interventions to improve delivery service use under the policy should target the underlying individual and health policy implementation factors identified in the study. [ABSTRACT FROM AUTHOR]