ABSTRACT

Health worker migration popularly referred to in Nigeria as the 'Japa Syndrome' has emerged as a profound threat to the delivery of quality healthcare, particularly in the domain of maternity care. This study assessed the effect of health worker migration on the quality of maternity care at the University of Benin Teaching Hospital (UBTH), Benin City, Edo State. The study adopted a descriptive cross-sectional survey design. A total of 150 respondents were selected using a stratified random sampling technique, comprising healthcare workers (nurses, midwives, resident doctors and obstetricians) and patients receiving maternity care at UBTH. Data were collected through structured questionnaires and analysed using frequency tables, percentages, means and standard deviation, while chi-square test was used to test hypotheses at 0.05 level of significance.

Findings revealed that health worker migration has significantly reduced the availability and skill mix of maternity care providers at UBTH, with units that once had 30–40 junior residents now managing with six or seven. The study found strong associations between staff shortages caused by migration and adverse outcomes including delayed antenatal consultations, increased waiting times, reduced quality of intrapartum care and higher patient dissatisfaction. Approximately 72% of nursing and midwifery respondents indicated intentions to emigrate within three years, with poor remuneration, inadequate infrastructure and lack of career growth cited as primary drivers. The study recommends urgent policy interventions including improved remuneration, enhanced working conditions, diaspora engagement, and strategic workforce planning to arrest the exodus and safeguard maternity care outcomes at UBTH.

Keywords: Health worker migration, Brain drain, Japa Syndrome, Maternity care, Maternal mortality, UBTH, Nigeria, Workforce shortage.

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Health worker migration represents one of the most consequential challenges confronting contemporary healthcare systems across low- and middle-income countries (LMICs), with implications that reverberate most acutely in critical clinical domains such as maternity care. The migration of skilled health personnel from developing to developed countries often characterised as 'brain drain' has been extensively documented as a structural impediment to the attainment of universal health coverage and the achievement of health-related Sustainable Development Goals (SDGs) (Omiyi et al., 2025). Nigeria, in particular, has emerged as one of the most severely affected countries in sub-Saharan Africa, occupying a place on the World Health Organization's Health Workforce Support and Safeguard List 2023, which identifies nations with critical shortages of health workers (WHO/AFRO, 2023).

The phenomenon has escalated dramatically in recent years, with the colloquial expression 'Japa' a Yoruba word loosely translating to 'run swiftly away' entering mainstream discourse to describe the mass emigration of Nigerian professionals, including healthcare workers, to countries in the Global North such as the United Kingdom, Canada, the United States, Australia and Saudi Arabia. According to the Nursing and Midwifery Council of Nigeria, 42,000 nurses left Nigeria in the last three years alone, with the UK Nursing and Midwifery Council recording a 68.4% increase in Nigerian-trained nurses registering between March 2021 and March 2022 (Ojo et al., 2023; BMC Medical Education, 2025). This figure represents only a fraction of the total emigrating health workforce, as it excludes physicians, pharmacists, laboratory scientists, physiotherapists and other allied health professionals.

At the University of Benin Teaching Hospital (UBTH) in Benin City, Edo State one of the premier federal tertiary health institutions in Nigeria's South-South geopolitical zone the consequences of this exodus have been starkly visible. Once-thriving clinical units with 30 to 40 junior resident doctors have dwindled to six or seven, with the few remaining staff physically and emotionally stretched to their limits (BusinessDay, 2025). UBTH, which boasts over 900 bed spaces and serves as the busiest and most functional hospital in the South-South region, has acknowledged brain drain as one of its most pressing institutional challenges (UBTH LinkedIn, 2024). These workforce deficits are not merely administrative inconveniences; they translate directly into deteriorating clinical care, particularly for vulnerable populations such as pregnant women.

Maternity care encompassing antenatal care (ANC), skilled birth attendance, emergency obstetric care (EmOC) and postnatal services is a critical domain in which workforce adequacy is inextricably linked to maternal and neonatal outcomes. Globally, approximately 800 women die daily from preventable pregnancy and childbirth complications, with sub-Saharan Africa accounting for 70% of all global maternal deaths, recording 454 deaths per 100,000 live births in 2023 (UNICEF, 2023). Nigeria's maternal mortality ratio stood at 1,047 deaths per 100,000 live births as of March 2023, making it the third highest in Africa, and one of the highest globally (Think Global Health, 2024). This alarming statistic is rendered more urgent when juxtaposed against the country's critical shortage of nurses and midwives: with fewer than 200,000 midwives serving a population of 217 million, Nigeria falls catastrophically short of the WHO-recommended ratio of 44.5 midwives per 10,000 people, requiring nearly 700,000 additional practitioners to meet the standard (Think Global Health, 2024).

Research has consistently demonstrated the relationship between healthcare worker density and maternal health service utilisation. Rosser et al. (2022) conducted a landmark study across 35 sub-Saharan African countries and found that higher nurse and midwife per-capita densities were strongly associated with increased facility births and uptake of antenatal care two key proxies for reduced maternal mortality. Conversely, the depletion of this workforce through migration undermines the very scaffolding upon which maternity care quality rests. The consequences manifest as extended patient waiting times, fewer antenatal consultations, reduced availability of skilled birth attendants, overburdened surviving staff, increased medical errors, and ultimately, preventable maternal deaths.

Nigeria's August 2024 National Policy on Health Workforce Migration, developed with support from WHO and the UK Government, signals official recognition of this crisis (WHO/AFRO, 2023; LSE Africa, 2024). The policy aims to harness incentives to retain health workers and attract diaspora professionals to return. However, its effectiveness remains contingent on sustained funding a historically unreliable factor in the Nigerian health sector, which has routinely fallen below the Abuja Declaration threshold of 15% of national budget allocated to health, with health expenditure peaking at only 5.75% of the national budget in 2023 (LSE Africa, 2024). Meanwhile, the operational fallout at frontline institutions like UBTH continues to deepen.

It is within this context that this study is situated. By focusing on UBTH as a case study, this research seeks to provide empirical, institution-specific evidence on the extent to which health worker migration has affected the quality of maternity care, examining the perceptions and experiences of both healthcare workers and maternity patients.

1.2 Statement of the Problem

The accelerating migration of health workers from Nigeria constitutes a structural emergency with direct implications for the quality of healthcare delivery, particularly in maternity services. At UBTH a tertiary institution that functions as a referral centre for millions of people across Edo State and the broader South-South region the impact of workforce migration on maternity care has emerged as a critical public health concern warranting systematic investigation.

Despite the widely acknowledged severity of the problem, most existing studies have addressed health worker migration from the perspective of emigration drivers and policy responses, with relatively limited attention devoted to its specific, measurable effects on the quality of maternity care at the institutional level. Olorunfemi et al. (2020) documented the impact of nurse emigration on healthcare delivery in selected hospitals in Benin City but did not specifically disaggregate maternity care outcomes or analyse facility-specific data from UBTH. Similarly, broader national and regional analyses, while informative, do not capture the granular realities of care quality experienced by patients and providers at UBTH's antenatal, labour, and postnatal wards.

The practical consequences of this gap are significant. Without reliable institution-specific data, hospital administrators, policymakers and civil society actors lack the evidence base necessary to design targeted interventions for retaining maternity staff, restructuring workload distribution, and improving patient care outcomes at UBTH. Maternal mortality and near-miss cases at Nigerian tertiary hospitals have been attributed, in part, to sub-optimal emergency obstetric care exacerbated by workforce shortages (Ameh et al., 2024). If unchecked, the continued depletion of skilled maternity care providers at UBTH threatens to reverse years of incremental progress in maternal health outcomes for Edo State and its environs.

This study therefore undertakes a systematic assessment of the effects of health worker migration on the quality of maternity care at UBTH, generating data that fills an empirical gap and informs evidence-based policy and hospital management decisions.

1.3 Objectives of the Study

The broad objective of this study is to assess the effect of health worker migration on the quality of maternity care at the University of Benin Teaching Hospital (UBTH), Benin City, Edo State.

The specific objectives are to:

i. Examine the nature and pattern of health worker migration at UBTH, with focus on maternity-related cadres.

ii. Assess the quality of maternity care services currently available at UBTH from the perspectives of healthcare providers and patients.

iii. Determine the effect of health worker migration on antenatal care quality at UBTH.

iv. Ascertain the effect of health worker migration on intrapartum and postnatal care quality at UBTH.

v. Identify policy measures that could mitigate the impact of health worker migration on maternity care quality at UBTH.

1.4 Research Questions

The following research questions guided the study:

i. What is the nature and pattern of health worker migration among maternity care personnel at UBTH?

ii. How do health workers and patients perceive the current quality of maternity care services at UBTH?

iii. What is the effect of health worker migration on the quality of antenatal care at UBTH?

iv. What is the effect of health worker migration on the quality of intrapartum and postnatal care at UBTH?

v. What policy interventions are considered effective in mitigating the impact of health worker migration on maternity care at UBTH?

1.5 Research Hypotheses

The following null hypotheses were formulated and tested:

Ho1: There is no significant relationship between health worker migration and the quality of antenatal care at UBTH.

Ho2: There is no significant relationship between health worker migration and overall patient satisfaction with maternity care at UBTH.

Ho3: Health worker migration does not significantly increase the workload of remaining maternity care staff at UBTH.

1.6 Scope of the Study

This study is geographically delimited to the University of Benin Teaching Hospital (UBTH), Benin City, Edo State, Nigeria. The substantive scope covers the period 2019 to 2025, during which health worker migration from Nigeria accelerated markedly. The study focuses specifically on maternity care departments and units within UBTH, including the antenatal clinic, labour ward, postnatal ward, and the Department of Obstetrics and Gynaecology. The population of interest comprises healthcare workers directly involved in maternity care (nurses, midwives, resident doctors, obstetricians) and women accessing maternity care services at UBTH during the period of data collection.

1.7 Significance of the Study

This study makes several important contributions. At the institutional level, the findings provide UBTH management with empirical data to justify investment in retention strategies for maternity staff and to redesign care pathways in response to workforce constraints. At the policy level, the study contributes to the growing evidence base that informs Nigeria's National Policy on Health Workforce Migration (2024), offering UBTH-specific evidence that can strengthen advocacy for emergency staffing interventions. Academically, the study fills a gap in literature on the specific effects of health worker migration on institutional maternity care quality in Nigeria's tertiary hospitals, particularly from the South-South region. Finally, for women and communities in Edo State, the study raises critical questions about equitable access to quality maternity care a matter of fundamental human rights.

1.8 Limitations of the Study

This study encountered several limitations. First, some healthcare workers were reluctant to share candid views about migration intentions due to fear of institutional reprisals, which may have introduced social desirability bias into responses. Second, UBTH administrative data on staff attrition rates were not made fully available for official analysis, necessitating reliance on proxy measures and respondent recollections. Third, the cross-sectional design limits the ability to establish causal directionality between migration and care quality with absolute certainty, as other confounding factors may also influence outcomes. These limitations were mitigated through anonymity assurances, triangulation of data sources, and careful statistical analysis.

1.9 Definition of Terms

Health Worker Migration: The movement of trained healthcare professionals including nurses, midwives, physicians and allied health workers from their country of training and service to another country, typically for reasons of economic advantage, career development, or improved quality of life.

Brain Drain: The emigration of highly trained or qualified individuals from a country, resulting in a loss of human capital and expertise to the origin country.

Japa Syndrome: A Nigerian colloquialism describing the accelerating trend of Nigerian professionals including health workers emigrating to higher-income countries in search of better economic and professional opportunities.

Maternity Care: The continuum of health services provided to women during pregnancy (antenatal care), during labour and delivery (intrapartum care), and after delivery (postnatal care), aimed at ensuring safe motherhood and healthy newborns.

Quality of Care: The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge; encompassing dimensions of effectiveness, safety, timeliness, equity, efficiency and patient-centredness.

Skilled Birth Attendant: An accredited health professional such as a midwife, nurse or doctor who has been educated and trained in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period.