Nigeria has the highest maternal deaths counts globally (1), and this reflects poor access to quality maternal health care services. Only 36% of all deliveries occurred in health facility delivery in 2013 (27). To reverse this trend and improve the use of maternal health care services, and as a late push to achieve the Millennium Development Goal 5, the Nigerian government through the Ministry of Health and each state government implemented a range of maternal and child health care policies (3, 28, 29). However, the extent to which these policies have led to improved use of health facility delivery in Nigerian states have received limited research attention. We address this gap by examining the progress, challenges, and opportunities in expanding access to health facility delivery in Nigeria as well as across the states. Our analysis shows that facility delivery only increased by 3.6 percentage points between 2013 and 2018 surveys. Also, we found that progress in the use of health facilities for child delivery is uneven among Nigerian states. While some states recorded a substantial increase in health facility delivery, others stagnated, and several states recorded a decline.
The progress and lack thereof observed in our analysis reflects the differences in the maternal health policy landscape and existing inequality in health system infrastructure and resources across the Nigerian states (3, 28, 30–33). The health system governance structure of the country is devolved, allowing states to formulate and implement health policies in line with the guidelines issued by the federal ministry of health. Also, resources available to states vary (33), letting some states wiith lrger resources to allocate significant budget to maternal health to fully implement policies as recommended by the Federal Ministry of health while others are only able to allocate meagre budget for partial implementation of policies. For example, while some states in Nigeria implemented free maternal health programme in all government-owned health facilities—as was the case in Ondo State (3, 4)—, several other states partially implemented the policy in selected primary healthcare facilities, as was done in Ekiti State (34). It is therefore not surprising that progress in expanding access to health facility delivery remained uneven across Nigerian states.
The five states (Ondo, Abia, Benue, Cross River, and Jigawa states) that made substantial progress in increasing access to health facility delivery invested substantially in their health systems since 2010 (3, 4, 29, 34–40). Ondo state expectedly recorded the highest percentage point (24.5%) improvement in health facility delivery of all the 36 states in Nigeria. Ondo state implemented the "Abiye" (Safe Motherhood) programme, which was evidence-based and directed resources to building primary and tertiary health facilities where needed while also removing user fees for health facility delivery in all government-owned facilities as well increasing the health workforce (3, 17, 19, 20). The "Abiye" programme was funded by the state government, the federal government through the subsidy reinvestmet programme and grants from Bill and Melinda Gates, Department of International Development (DFID), Society for Family Health (SFH), World Health Organisation (WHO), and Ford Foundation (28). The programme gained the attention of public health experts and institutions both nationally and internationally, with UNICEF, World Bank, UNDP, and Center for Strategic and International studies touting the programme as a model for reducing maternal mortality (28).
Meanwhile, Abia state, the second-best performing state, embarked on massive health infrastructure development, ensuring that women have access to health facilities within five kilometres of their place of residence in line with WHO's and the Federal Ministry of Health's guidelines and recommendations (29, 41, 42). Through this initiative, 210 additional primary health care facilities were built, increasing the number of PHC facilities to 527 by 2012 (43). Similarly, in Benue state, massive health infrastructure and human resources for health were provided to tackle the health challenges in the state and particularly the burden of HIV. The state also benefitted from several HIV programmes implemented or being implemented in the state with grants from international donors to improve access to maternal care. Jigawa State government introduced the "successful delivery program" in 2007, which freely covers all the services rendered during pregnancy period to 6 weeks post-partum/delivery (37–39). Besides this programme, Jigawa was among the 12 states to implement the national health insurance scheme (NHIS), and MDG's free maternal and child health programme were implemented (44). Finally, Cross River state's progress is attributable to its implementation of free maternal health care programme, backed by legislation in the state's parliament, under a programme titled "project hope"(29, 35). Besides this, the state embarked on improving its primary health care infrastructure, and 64 midwives were recruited for the state under the federal government's Midwives Service Scheme, being the first state to sign a memorandum of understanding (22). Besides, Cross River state was among the 12 states where the NHIS-MDG free maternal health programme was implemented, with the state providing counterpart funding (45). International non-government organisations like World Bank, UNICEF, USAID, Population Council, Pathfinder International Initiative, and Family Health International also contributed to the progress in the state through various maternal health interventions implemented in the state over the past decade (46–50).
The parallel in all these five states that recorded marked progress expanding access to maternal health services is striking. All these states focused on addressing both the demand and supply sides of maternal health care services. They all recognised that while removing user fees for maternal health care services is crucial, free health alone is not sufficient to increase access to services significantly, especially in settings where there is a shortage of health facilities and health workforce (4). It requires, as implemented in Ondo State, the strengthening of health systems, which include hiring additional health workers, building more primary and tertiary health care centres, re-training health workers and task shifting. The partnership and investment of global developmental partners are also important, given that most Nigerian states lack the fund to implement comprehensive interventions to address lack of access to maternal health care services. It is, however, worth noting that the progress recorded would be impossible without visionary and committed leadership from the state government and through the ministry of health in these states. As noted by Kuruvilla et al. (51), the key success factors in reducing maternal and child mortality include leadership and partnership, good governance, women's participation in politics and workforce, decision-making and accountability and approach to sustain progress.
What it takes to increase access to maternal health care services are well known (51, 52), yet approximately half of the Nigerian states are either stagnating or retrogressing in expanding access to services. The challenges in these states are the lack of leadership, insufficient partnership, inadequate budget allocation to maternal health, lack of sustainability and funding of existing maternal health programmes (4, 10, 34, 44, 45, 51). This is the case especially in Kwara and Ekiti States, where the use of health facilities for child delivery has declined by approximately 22 and 15 percentage points, respectively (3). While there is a strong case to be made on the paucity of funds in these states to expand access to maternal health care services, other key challenges hindering progress include lack of sustained effective leadership to mobilise resources, seek partnership, institute sustainability and accountability plans. The examples of the over five states that recorded a marked improvement in the proportion of women delivering in health facilities show that with leadership, progress is possible. Also, the fact that states in the northeast region managed to sustain progress despite being plagued with the Boko Haram conflict further buttress the point that progress is possible with effective and sustained leadership are needed to address lack of access to maternal health care services. It is, however, important to accentuate the role of global developmental partners, Non-Governmental Organisations working in the conflict zones in ensuring progress made in expanding access to health facility delivery is sustained.
Policy recommendations
As a signatory to the SDG, Nigeria consistently lags behind in achieving the goal of reducing maternal mortality. Progress in expanding access to health facility delivery remains slow and uneven across the country. Since access to quality health facility delivery is critical to reducing maternal and child mortality, we hope that our paper will draw the attention of policymakers in underperforming states to draw lessons on what works in expanding access to maternal health care services from states that recorded marked improvement over the period in review. Specifically, these states need political will to institute effective policies, seek partnership, investment in health infrastructure and human resources by budgeting adequately and ensuring accountability. It is also critical to ensure interventions that work are sustained in the states that recorded some improvements for continued use of health facilities for child delivery.