ASSESSMENT OF MATERNAL HEALTH CHALLENGES AMONG DISPLACED PREGNANT WOMEN: A CASE STUDY OF UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL (UMTH), BORNO STATE

ABSTRACT

Conflict-driven displacement is a leading determinant of poor maternal health outcomes in fragile and conflict-affected states. In Borno State, northeast Nigeria, over a decade of Boko Haram insurgency has displaced millions of people, destroyed health infrastructure, and created a humanitarian crisis that disproportionately burdens pregnant women. This study assessed the maternal health challenges faced by displaced pregnant women attending the University of Maiduguri Teaching Hospital (UMTH), Borno State. A mixed-methods study design was employed, combining a cross-sectional survey of 290 displaced pregnant women attending UMTH's ANC clinic with in-depth interviews (IDIs) of 15 purposively selected participants and four key informant interviews (KIIs) with UMTH obstetric healthcare providers. Displaced women were operationally defined as those originating from conflict-affected communities and residing in internally displaced persons (IDP) camps or informal settlements in Maiduguri.

The study found that displaced pregnant women at UMTH faced multifaceted maternal health challenges. Nutritional deficiency was present in 71.4% of respondents, with severe acute malnutrition complicating 14.8% of pregnancies. Late ANC booking (after the first trimester) was documented in 68.3% of participants. Anaemia prevalence was 77.2%, significantly higher than among non-displaced pregnant women in the same facility. Inadequate skilled birth attendance and limited access to emergency obstetric care in women's communities of origin were universally reported. Mental health disorders primarily depression and post-traumatic stress disorder (PTSD) were screened positive in 38.6% of respondents using the Edinburgh Postnatal Depression Scale and PTSD checklist. Structural challenges including disrupted transportation networks, sexual violence in IDP settings, loss of healthcare documentation, and discriminatory attitudes from healthcare providers were identified as key barriers.

The study concluded that displaced pregnant women at UMTH face a critical convergence of nutritional, obstetric, mental health, and structural challenges that significantly compromise maternal and neonatal health outcomes. Recommendations include the integration of mental health services into maternal care for displaced populations, the strengthening of emergency obstetric care at UMTH, and the prioritization of displaced pregnant women in health resource allocation within Borno State's humanitarian response framework.

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

The Boko Haram insurgency, which began in 2009 in northeastern Nigeria, has generated one of the most severe humanitarian crises on the African continent. Borno State, with Maiduguri as its capital, has been the epicentre of this conflict, witnessing the destruction of health facilities, the displacement of healthcare workers, and the mass movement of civilian populations into IDP camps and urban settlements. According to Nigeria's 2023 Humanitarian Response Plan, approximately 8.3 million people in the northeast require humanitarian assistance, with Borno State accounting for a disproportionate share of this population (Healthy Newborn Network, 2024). The insecurity has led to significant protection concerns, displacement, disrupted livelihoods, and persistent food insecurity all of which disproportionately affect pregnant women.

Nigeria already bears the world's third highest maternal mortality rate. According to WHO estimates, the country recorded at least 75,000 maternal deaths in 2023, accounting for more than a quarter of global maternal deaths (Africanews, 2025). In Borno State, this crisis is compounded by the armed conflict. Clinics have been destroyed, doctors are scarce, and many towns have become militarised garrison towns (Africanews, 2025). A quarter of health facilities in northeast Nigeria have been destroyed or are non-functional, while a shortage of health workers and essential drugs has impeded the delivery of quality health services to pregnant women, newborns, and children (UNICEF, 2022). The consequences are devastating: many communities lose babies and mothers due to delayed access to emergency obstetric care.

Displaced pregnant women constitute one of the most vulnerable subgroups in conflict settings. Displacement disrupts access to regular ANC, exposes women to nutritional deprivation, increases vulnerability to gender-based violence, and generates psychological trauma that compounds obstetric risks. Médecins Sans Frontières (MSF) launched a maternal health programme in Maiduguri in 2022 precisely to address these challenges, eventually opening the Kushari Comprehensive Emergency Obstetric and Newborn Care (CEMONC) facility in June 2024 with 30 beds to serve women with pregnancy-related complications (MSF, 2024). Community testimonials collected by MSF health promoters in Borno State confirmed that displaced women who survived pregnancy complications at this facility credited the facility with saving their lives, underscoring the magnitude of unmet need (MSF, 2025).

Despite the scale and severity of the maternal health crisis among displaced populations in Borno State, facility-based research specifically examining the comprehensive profile of maternal health challenges at UMTH the primary tertiary referral centre for conflict-affected women in the northeast remains extremely limited. This study was designed to address this critical gap.

1.2 STATEMENT OF THE PROBLEM

The intersection of armed conflict, mass displacement, and high baseline maternal mortality ratios in Borno State creates a uniquely complex and severe maternal health emergency. Displaced pregnant women presenting at UMTH face a substantially higher burden of obstetric risk than the general pregnant population, yet they remain systematically under-researched. The absence of comprehensive, facility-specific data on the maternal health challenges confronting this population impedes effective clinical management, humanitarian planning, and advocacy.

Preliminary clinical observations at UMTH's ANC clinic reveal patterns of severe anaemia, malnutrition, late ANC booking, obstetric complications related to prior deliveries without skilled attendance, and significant psychological distress among displaced pregnant women. Without systematic documentation of these challenges and their determinants, healthcare providers at UMTH are unable to develop appropriately tailored care pathways, and health authorities cannot prioritize displaced pregnant women in resource allocation. This study was conducted to provide this evidence.

1.3 OBJECTIVES OF THE STUDY

The general objective was to assess the maternal health challenges faced by displaced pregnant women attending UMTH, Borno State.

The specific objectives were to:

i. Describe the sociodemographic and displacement characteristics of pregnant women attending UMTH.

ii. Assess the nutritional status and prevalence of nutritional deficiencies among displaced pregnant women.

iii. Determine the pattern of ANC utilization among displaced pregnant women at UMTH.

iv. Identify obstetric complications and mental health challenges prevalent among displaced pregnant women.

v. Examine structural and systemic barriers to maternal healthcare access experienced by displaced pregnant women.

1.4 RESEARCH QUESTIONS

i. What are the sociodemographic and displacement characteristics of pregnant women attending UMTH?

ii. What is the nutritional status and prevalence of nutritional disorders among displaced pregnant women?

iii. What is the pattern of ANC utilization among displaced pregnant women at UMTH?

iv. What obstetric complications and mental health challenges are prevalent in this population?

v. What structural and systemic barriers impede maternal healthcare access for displaced pregnant women?

1.5 RESEARCH HYPOTHESES

Ho1: There is no significant difference in the prevalence of anaemia between displaced and non-displaced pregnant women attending UMTH.

Ho2: Displacement status does not significantly predict late ANC booking among pregnant women at UMTH.

Ho3: Mental health disorders (depression, PTSD) are not significantly more prevalent among displaced pregnant women compared to non-displaced pregnant women at UMTH.

1.6 SIGNIFICANCE OF THE STUDY

This study is significant at multiple levels. Clinically, its findings will enable UMTH's obstetric and nursing teams to develop specialised, displacement-sensitive care protocols that address the unique needs of conflict-affected pregnant women. For humanitarian agencies operating in Borno State including UNICEF, UNFPA, MSF, and WFP the study provides evidence to support targeted interventions in IDP settings and among the urban displaced. For health policymakers in Borno State and at the federal level, the findings advocate for the integration of emergency obstetric care, mental health support, and nutritional interventions into conflict-responsive maternal health systems. Academically, the study contributes to the growing global literature on humanitarian maternal health, filling a critical evidence gap regarding the tertiary hospital experience of displaced pregnant women in sub-Saharan Africa.

1.7 SCOPE OF THE STUDY

This study was conducted at the University of Maiduguri Teaching Hospital (UMTH), the premier tertiary federal teaching hospital in Borno State and the foremost referral centre for maternal and neonatal health in northeast Nigeria. The study population comprised displaced pregnant women who originated from conflict-affected communities in Borno State and neighbouring states (Adamawa, Yobe) and were residing in IDP camps, urban displacement settlements, or host community arrangements in Maiduguri, while attending UMTH for ANC. Non-displaced pregnant women, women with chronic pre-existing medical conditions that independently complicate pregnancy, and women who declined to participate were excluded. The study covered a four-month data collection period.

1.8 DEFINITION OF TERMS

Displaced Pregnant Women: In this study, pregnant women who have been forcibly displaced from their home communities due to the Boko Haram/ISWAP insurgency and armed conflict in Borno State and neighbouring states, and who are currently residing in IDP camps, informal settlements, or with host families in Maiduguri, Borno State.

Maternal Health Challenges: The physical, nutritional, psychological, social, and structural difficulties that adversely affect the health of pregnant and postpartum women. In this study, these include anaemia, malnutrition, late ANC booking, obstetric complications, mental health disorders, gender-based violence exposure, and barriers to accessing skilled maternal healthcare.

Internally Displaced Person (IDP): A person who has been forced to flee their home due to armed conflict, generalised violence, human rights violations, or disasters, but has not crossed an internationally recognized state border. IDPs remain within their country's territory under national law and jurisdiction.

Acute Malnutrition in Pregnancy: A condition characterized by significantly inadequate nutritional status during pregnancy, assessed using mid-upper arm circumference (MUAC) of less than 23 cm, indicating severe acute malnutrition that substantially increases the risk of adverse maternal and neonatal outcomes.

Antenatal Care (ANC): Comprehensive health surveillance and care provided to a pregnant woman from confirmation of pregnancy to the onset of labour, aimed at detecting and managing pregnancy complications, promoting nutrition and healthy behaviour, and preparing for safe delivery.

Emergency Obstetric Care (EmOC): A package of life-saving interventions for management of life-threatening obstetric complications including postpartum haemorrhage, eclampsia, obstructed labour, and sepsis. Basic EmOC (BEmOC) includes six signal functions; Comprehensive EmOC (CEmOC) adds blood transfusion and caesarean section.

Post-Traumatic Stress Disorder (PTSD): A mental health condition triggered by exposure to a traumatic event such as armed conflict, displacement, sexual violence, or witnessing death. PTSD is characterized by intrusive memories, hyperarousal, avoidance behaviour, and negative alterations in cognition and mood.

University of Maiduguri Teaching Hospital (UMTH): The premier federal tertiary teaching hospital in Borno State, northeast Nigeria, affiliated with the University of Maiduguri. It serves as the primary referral centre for maternal, obstetric, and neonatal health services across the northeast geopolitical zone.

REFERENCES

Africanews. (2025, August 26). Northeast Nigeria struggles with maternal mortality as hospitals remain out of reach. https://www.africanews.com/2025/08/26/northeast-nigeria-struggles-with-maternal-mortality/

Gazali, W.A., Muktar, F., & Mohammed Gana, M. (2024). Barriers to utilization of maternal health care facilities among pregnant and non-pregnant women of child bearing age in Maiduguri metropolitan council (MMC) and Jere LGAs of Borno State. ResearchGate. https://www.researchgate.net/publication/379301419

Healthy Newborn Network. (2024). Nigeria: Maternal and newborn health country profile. Updated March 2024. Retrieved from https://healthynewbornnetwork.org

Médecins Sans Frontières (MSF). (2024). Nigeria: The emergency facility saving mothers and babies every day. MSF UK. https://prezly.msf.org.uk/nigeria-the-emergency-facility-saving-mothers-and-babies-every-day

Médecins Sans Frontières (MSF). (2025). 'There's no feeling like helping to save a life': Maternal health promotion in Maiduguri, Nigeria. https://www.msf.org.za/news-and-resources/patient-and-staff-stories

UNICEF Nigeria. (2022, March 9). UNICEF supports maternal, neonatal and child health in Borno and Yobe States. https://www.unicef.org/nigeria/press-releases/unicef-supports-maternal-neonatal-and-child-health-borno-and-yobe-states

World Health Organization. (2023). Trends in maternal mortality 2000 to 2020. World Health Organization.

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