Prioritization of MNH services in Yobe State
These findings are organized according to the subthemes that emerged from the interviews in alignment with the HPA framework components. When asked about MNH policies, guidelines, implementation and funding, participants identified commendable initiatives by the government and areas of critical gaps.
Content:
Policy: According to the respondents, national policies and guidelines are adopted for state-level implementation, with minor adaptations to meet the unique requirements and characteristics of Yobe state. A critical data review revealed that a national health policy aimed at achieving health for all Nigerians was first disseminated in 1988 and later revised in 2004. The updated policy outlines the goals, structure, strategy, and direction of Nigeria’s health care delivery system [12]. We found that MNH is a significant priority in response to the high maternal mortality ratio in NE Nigeria. Various government policies and initiatives have been established with the aim of reducing maternal death, such as the following: 1) Free maternal, newborn, and child health services, which provide free medical services for pregnant women and children under five years of age. The goals of the MNH component of this policy are to improve access to and the number of deliveries conducted by skilled birth attendants; 2) HIV/TB and malaria prevention policies for pregnant women and newborns, which provide free antiretroviral treatment and malaria prevention for pregnant women living with HIV; 3) Renovation and equipment in health facilities; 4) Provision of ambulance services to improve access to emergency care; and 5) The Midwifery Service Scheme, which is a national policy that continues in the State to offer immediate employment opportunities for midwives. However, our review revealed some regional disparities in health service delivery and resource availability from the national level to the state level [13]. This disparity is reflected in several health outcomes reported in the 2008 Nigerian Demographic and Health Survey (DHS), which reported a child mortality rate ranging from a low of 32 deaths per 1,000 children in the Southwest Zone to 139 deaths per 1,000 children in the Northwest Zone [14]. A list of selected policy documents from 2009–2022 in relation to MNH prioritization in Yobe State is presented in Table 2.
Table 2
Policies related to MNH prioritization.
| Policy | Year established |
| Midwifery service scheme | 2009 |
| National policies on the implementation of HIV, TB, and malaria response | 2011 |
| Yobe State strategic health development plan | 2013–2015 |
| National Policy on task shifting and sharing | 2014 |
| Yobe State human resource for health | 2014 |
| National strategic health development plan | 2021–2025 |
| Nigerian National Gender Policy | 2021 |
| Yobe State Social equity initiative | 2022 |
Other policies and new initiatives in response to emergency MNH service demand include the Yobe State Contributory Health Management Agency [15], the Yobe State Drug and Medical Consumables Management Agency [16], and the Yobe State Emergency Medical Ambulance Service [17], which were established to cater to patients at all levels. The state government provides medications and other essential services at no cost to pregnant women. The basic healthcare and social equity policy launched in June 2022 [18] addresses the National Mandate for Gender Equity and Social Inclusion policy and ensures free health services for women with disabilities.
Funding and collaboration
Among policymaker respondents, MNH prioritization was discussed in terms of budget allocation for specific sectors. Although this varies annually and changes on the basis of government priorities and funding availability, the MNH still receives higher budget allocation than other sectors do. According to two of the participants
“Initially, the state budget for health was approximately 9.7%,... he [the governor] recommended an increase to 13%. He also asked for an increase in the primary healthcare budget to at least 25% of the health budget. Therefore, what is allocated to other ministries and agencies is the remainder.” Policymaker 11.
“...the free drug program is a fund that comes every month for the past thirteen years. It is specifically meant for maternal child health. It has increased from ten million Naira to eighteen million and currently thirty-five million Naira. This fund cannot cover all the facilities, so representative beneficiaries from each facility are selected for support. This may not be adequate but at least the support is there...” CSO 12.
In addition, funding from development partners such as the World Health Organization, the United Nations International Children’s Emergency Fund, the United Nations Fund for Population Activities, and the United Kingdom’s foreign commonwealth development office complements access to MNH services. Various respondents among healthcare workers and civil society organizations mentioned that the government prioritizes funding allocation for MNH services by investing in upgrading colleges and health facilities and regularly paying salaries for staff motivation and retention.
Importantly, some participants highlighted deficiencies in budgetary distribution related to political interests in budget allocation, disbursement, and management. This hinders the comprehensive implementation of MNH policies and initiatives in the State.
Processes:
Policy implementation and utilization
Due to high maternal and neonatal mortality rates, Uneke et al. [14] highlighted the need for context specific, evidence-informed policies for MNH implementation. Decision-making policies that translate theories to reality in practice are needed. This study revealed multiple MNH policies as well as gaps in dissemination to end users. Our findings suggest that strong cooperation and collaboration exist between MNH stakeholders and actors. In communities, traditional rulers and health providers work as teams to implement MNH services through advocacy and demand creation. The state government, schools and hospitals collaborate to ensure that health care workers (HCWs) are trained and deployed to facilities, especially in rural areas. Through the midwifery service scheme, the government employs and reintegrates retired midwives into the workforce to mentor younger midwives. To ensure the availability of midwives in rural communities, Yobe State has implemented a newly accredited 2-year community midwifery program to rapidly educate and deploy graduates to primary health centers. Another policy implementation example highlighted by the participants is the gender-based violence policy and guidelines, which are implemented through a referral pathway between health facilities and the Ministry of Women Affairs. This pathway establishes structured mechanisms for identifying, referring, and supporting victims and survivors.
Traditional birth attendants (TBAs) are highly utilized in Nigeria, especially in rural areas [19], due to a shortage of midwives and a lack of access to health care facilities. The government encouraged training TBAs to identify danger signs and the need for referrals. Through such training, TBAs can form a bridge to achieve safe motherhood objectives [19]. To prevent and reduce maternal and infant mortality and morbidity, the HCWs engaged and educated TBAs and encouraged them with stipends of five hundred Naira to refer pregnant women to health facilities. The inclusion and engagement of TBAs has expanded access to MNH services in communities. Even though the stipend is no longer given, TBAs still refer pregnant women for services.
There were several other examples of collaboration between policymakers and health facilities during supportive supervision and monitoring visits. Meeting with the local government and primary healthcare leadership enhances community collaboration. The collaboration between healthcare facilities and NGOs was identified as a positive factor by healthcare professionals and policymakers. This enhances the capacity to provide supplemental structures, supplies, and additional workers to help meet MNH service needs.
Evaluation and accountability
According to the respondents, to ensure quality implementation and accountability among service providers, implementation processes are monitored by various mechanisms. HCWs are held accountable through monitoring and supportive supervision for services such as task-shifting/task-sharing, audit/review meetings, standard quality requirements for suppliers, and the maternal and perinatal death surveillance and response (MPDSR) system [20], along with the action obstetric quality assurance platform. The effectiveness of these mechanisms is often undermined by the actions of administrators and health providers. For instance, the MPDSR is not always completed. According to one of the policymakers
“This has a serious issue... because when a woman dies inside or outside a facility, nobody checks what led to her death. They will just say, this is her time”. Policymaker 09.
Feedback mechanisms
The participants reported that feedback channels for clients include suggestion boxes at various locations in health facilities and customer care hotlines. These mechanisms create a feedback loop that promotes communication and accountability among HCWs and contributes to improved practices. The suggestion boxes provide confidential platforms for individuals to anonymously submit suggestions, complaints, or feedback, thereby identifying implementation successes and challenges. The respondents mentioned that customer care hotlines help offer direct and accessible avenues for clients to express their concerns, seek assistance, or provide feedback on MNH services through the hospital administration office.
Another effective feedback mechanism according to the participants is ward development committees, which constitute a community structure that plays a pivotal role in fostering community engagement and feedback at the community level. They enable clients to advocate for their needs and provide input on local service delivery.
Context:
Religious and sociocultural factors
We found that MNH services are generally accepted. However, the respondents expressed the importance of cultural and religious awareness among HCWs, as these awareness levels may impact service uptake and client satisfaction. For example, there is a religious belief that home births are divinely sanctioned, which can hinder implementation and timely access to MNH services. According to one of the participants
“... seeking healthcare is an indicator that you do not believe in God” CSO 19.
Additionally, gender and cultural norms require spousal permission to access medical care. Some male partners prefer female HCWs for all MNH service delivery:
“…in some places, the husbands will not want a male midwife or nurse to care for their wives. Sometimes the women prefer female providers.” Policymaker 01.
Some respondents contend that male staff are prohibited from entering labor and delivery wards; this restriction may underutilize male midwives and impact service quality and accessibility.
Impact of crises on MNH prioritization
The crisis in Yobe State has resulted in limited access to MNH services due to the destruction of infrastructure and displacement, which has led to long distances from functional health facilities. According to a policymaker:
“… because of the seriousness of the Boko haram insurgency in the state, … many maternal health clinics and facilities were shut down. Approximately seventy to eighty facilities were destroyed completely by the insurgents. Drugs were looted, and the facilities were burned to ashes....” Policymaker 13.
Additionally, women had to seek care from TBAs due to HCW shortages or nonavailability and facility closure. A health provider stated that:
“...during the Boko haram crisis, for 4–5 months, nobody was in the facility. It truly affected the women. Only TBAs were attending to the women. When issues arise, they will have to reach Geidam, which is very far, most times a woman who is seriously bleeding dies before reaching there.” HCW 02.
While Boko Haram's violence remains the primary cause of population displacement, community clashes and natural disasters are also contributing factors in some states. More than 1.2 million people have been displaced in northern and central Nigeria due to the Boko Haram insurgency, which continues to drive large-scale population movements [21]. The International Organization for Migration and Displacement Tracking Matrix identified 1,188,018 internally displaced persons in Nigeria's Northeast Region, covering Adamawa, Bauchi, Borno, Gombe, Taraba, and Yobe states. Additionally, Nigeria’s National Emergency Management Agency has registered 47276 IDPs in the central regions of the country. This results in the total number of displaced persons identified being 1,235,294 in northern and central Nigeria[21].
When asked about the camps of internally displaced persons, most of the participants reported that many women experienced rape, violence, psychological disturbances, and/or teenage pregnancies. Additionally, women’s access to family planning services is sometimes nonexistent. Insurgency undermines HCWs' effectiveness, impacting their income and investments and restricting their access to clients and communities. The stressors faced by HCWs are heightened, with reported cases of threats, abductions, and murder. They reported that wearing health care uniforms makes HCWs vulnerable to kidnapping. Newly employed HCWs are hesitant to accept postings in insecure areas because of the significant challenges faced by those who are already working in those locations. Reported stressors also include physical and mental exhaustion, a shortage of HCWs resulting in heavy workloads and limited accommodation. An NGO respondent shared the following:
“The critical issue is a lack of accommodation in rural areas. Additionally, when [community midwifery] students graduate and return to their communities, they do not have senior midwives to mentor them. This affects the quality of the services rendered.” NGO 14.
The participants emphasized the pressing need for increased compensation for personnel in remote and insecure areas, given the harsh conditions they endure, especially the scarcity of trained staff in most health facilities.
Actors
Stakeholder collaboration is essential for supporting government efforts in terms of maternal and newborn health. These collaborations bring together diverse expertise, resources, and perspectives, enhancing the overall effectiveness of MNH initiatives. However, the dynamics of relationships and power can significantly influence the policymaking and implementation processes, often determining the success or failure of these initiatives.
Key Actors in MNH Decision-Making
MNH prioritization is deeply influenced by several key actors. Community leaders, who represent the interests of their community members, play a crucial role. They are trusted figures within the community and can mobilize support for MNH initiatives because of their perceptions and interests. Their endorsement significantly impacts the uptake of MNH services.
Institutions that produce and employ health workers, such as medical and nursing schools, are critical in ensuring a steady supply of qualified personnel. These institutions not only train future healthcare workers but also shape the standards and expectations for MNH service delivery. Hospital administrators constitute another pivotal group that is responsible for implementing health policies. They manage resources, oversee operations, and ensure that MNH services are delivered efficiently and effectively.
Donors and implementing organizations, including international agencies and nongovernmental organizations (NGOs), provide vital financial support and resources. They often bring innovations, technical expertise, and additional funding that complement government efforts. However, a few respondents highlighted the need to strengthen coordination and collaboration platforms among stakeholders. Effective coordination can reduce duplication of efforts and minimize rivalry, especially among NGOs, ensuring that resources are used efficiently and that efforts are not fragmented or counterproductive.
Political leaders, such as governors, legislators, health commissioners, executive secretaries, and primary health leaders, play decisive roles in creating MNH policies and allocating the necessary funding. Their decisions directly impact the availability and quality of MNH services. Healthcare workers (HCWs) and consumers also play significant roles through active engagement in service delivery. HCWs are on the front lines, implementing policies and providing care, whereas consumer feedback and participation can drive improvements in service quality and accessibility.
Politics and Power Dynamics:
The prioritization of MNH services is influenced by broader governance structures, continuity, and shifting priorities. Policymakers noted that Nigeria's complex governance structure impacts decision-making at various levels. For example, any change in leadership can lead to changes in key positions, such as legislators, health commissioners, executive secretaries, and primary health leaders. This often necessitates a realignment of relationships and priorities, which can disrupt established implementation timelines, objectives, and funding allocations. Frequent changes in leadership can lead to instability in policy direction and inconsistent support for MNH initiatives. Moreover, there can be challenges with the perception of health as a priority over other sectors. Some political leaders may prioritize areas such as infrastructure, security, or education over health, affecting the amount of attention and resources dedicated to MNH services. This can result in insufficient funding, delayed implementation of policies, and inadequate support for HCWs.
“… one of the biggest challenges is making health a priority. Looking at the Nigerian context, this will remain a problem because I was talking to one of the governors, and he said, look, with the salary of one health worker, I can employ four teachers” Policymaker 09.
This perception affects the continuity and prioritization of MNH services, especially with changes in governance.
Gender inclusion and decision making
When asked about gender disparity in decision-making roles, many participants stated that only a few women occupy senior administrative positions. Some of the respondents indicated that women face marginalization and purposeful frustration in senior leadership positions because at the health facility level, female employees are rarely involved in decision making, and the majority of female workers are frontline health providers.
“Environmental health staff will be in charge of the facility when a senior nurse is there because the nurse is a female; she reports to him very rarely in fact I have a very good friend of mine who has been contesting for one of the Federal Medical Centers looking for the position of the Chief Medical Director, she did not get it.” NGO 14.
Additionally, the respondents highlighted that the involvement of women and women-led organizations, such as the Ministry of Women's Affairs, Initiatives such as the Ward Development Committee, which is aimed at appointing female representatives in communities, has been instrumental in enhancing women's participation in decision-making as implementers rather than decision makers. Poor awareness and training of end users of policies and guidelines were identified as a gap, especially in relation to the Nigerian National Gender Policy [18], which protects individuals from discrimination.