EFFECT OF SECURITY CHALLENGES ON SKILLED BIRTH ATTENDANCE UTILIZATION: A CASE STUDY OF UNIVERSITY OF MAIDUGURI TEACHING HOSPITAL (UMTH), BORNO STATE

ABSTRACT

Skilled birth attendance (SBA) is universally recognized as one of the most effective strategies for reducing maternal and neonatal mortality during childbirth. In conflict-affected settings such as northeast Nigeria, however, security challenges fundamentally disrupt access to skilled birth attendants and institutional delivery services, with devastating consequences for maternal and child survival. This study examined the effect of security challenges on skilled birth attendance utilization among women attending the University of Maiduguri Teaching Hospital (UMTH), Borno State. A cross-sectional descriptive design was employed, with 310 women who delivered at UMTH in the previous twelve months recruited through systematic random sampling at postnatal and immunization clinics. Data were collected via a structured questionnaire assessing sociodemographic profiles, previous delivery histories (including place and attendant), experiences of insecurity during pregnancy and childbirth, perceived security-related barriers to SBA, and attitudes toward institutional delivery.

The study found that 63.2% of respondents reported that security challenges had directly prevented them or women in their communities from accessing institutional delivery services in at least one previous pregnancy. Specific security-related barriers included road blockades and checkpoints by armed groups (55.3%), curfews and restrictions on nighttime movement (47.1%), destruction of health facilities in communities of origin (61.4%), fear of attack en route to health facilities (58.7%), and displacement from communities containing skilled birth attendants (43.9%). Among respondents with a previous birth outside UMTH, 44.7% had delivered without a skilled birth attendant a figure consistent with evidence from Kano State showing over 60% of women delivering at home without skilled attendance (Evans et al., 2024). Multinomial logistic regression identified displacement status (OR=5.21, p<0.001), distance from nearest health facility (OR=4.18, p<0.001), experience of armed conflict in the immediate community (OR=3.87, p<0.001), and previous unskilled delivery as significantly associated with reduced likelihood of utilizing SBA for the current delivery.

The study concluded that security challenges in Borno State constitute a critical structural barrier to skilled birth attendance utilization, operating through multiple pathways including physical inaccessibility of health facilities, displacement, fear of violence, and destruction of healthcare infrastructure. Recommendations include the scaling up of mobile obstetric teams to conflict-affected communities, the establishment of maternity waiting homes near UMTH for women from insecure areas, and the strengthening of community-based skilled birth attendance as a complementary strategy.

CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND TO THE STUDY

Skilled birth attendance defined as the care provided during childbirth by an accredited health professional (midwife, nurse, or doctor) with midwifery competencies is a cornerstone intervention for the prevention of intrapartum maternal and neonatal mortality. The WHO estimates that the presence of a skilled birth attendant during delivery could prevent up to 70% of maternal deaths and a substantial proportion of neonatal deaths. Despite this evidence, a significant proportion of births in sub-Saharan Africa, including Nigeria, continue to occur outside health facilities and without skilled birth attendants, particularly in rural, remote, and conflict-affected areas.

In Nigeria, the national rate of skilled birth attendance remains concerningly low, with significant regional disparities. The North-East zone, anchored by Borno State, has consistently recorded the lowest rates of institutional delivery and SBA utilization in the country. Evidence from northern Nigeria indicates that over 60% of women in Kano State had their last delivery at home, with 41.6% not assisted by a skilled birth attendant (Evans et al., 2024). In Borno State, where the Boko Haram insurgency has been most intense, the situation is considerably worse. The insurgency has led to the destruction of health facilities, displacement of healthcare workers, and disruption of maternal and newborn health services, with research from neighbouring Yobe State showing that only about 32% of births occur at health facilities (Yobe Conflict-Affected Care Study, 2025).

Security challenges in northeast Nigeria operate through multiple interacting pathways to undermine SBA utilization. Direct pathways include the physical destruction of health facilities, the abduction and displacement of healthcare workers, and attacks on ambulances and health convoys that prevent emergency obstetric referral. Indirect pathways include road blockades and checkpoints that restrict civilian movement, curfews that prevent nighttime travel to hospitals when a disproportionate number of obstetric emergencies occur and the psychological fear of violence that deters women from venturing outside IDP camps or displacement settlements to seek institutional delivery. Research from Borno State has documented that women are unable to access maternal health facilities due to armed group activity along road routes, particularly in Konduga and Dikwa local government areas (Africanews, 2025).

UMTH, as the apex tertiary health institution in northeast Nigeria, serves as a critical referral centre for obstetric emergencies from across Borno State and beyond. Understanding the specific security-related barriers that influence whether women reach UMTH for delivery and the mechanisms through which these barriers operate is essential for designing effective interventions. This study was designed to provide this systematic analysis.

1.2 STATEMENT OF THE PROBLEM

Nigeria has the highest absolute number of maternal deaths in Africa and the third highest globally. In Borno State, this national crisis is dramatically amplified by the consequences of armed conflict and insecurity. Clinics have been burned, doctors have fled, and women who go into labour in remote conflict-affected communities frequently have no access to skilled birth attendants, emergency obstetric care, or transportation to reach referral hospitals. The cost is measured in preventable maternal and neonatal deaths.

At UMTH, clinicians receive women who have already suffered complications from deliveries conducted without skilled attendance in insecure communities, often presenting with sepsis, obstetric fistula, ruptured uterus, or severe haemorrhage. The facility lacks comprehensive, facility-specific data on the proportion of women whose previous deliveries were unattended due to security constraints, the specific security-related barriers most predictive of SBA non-utilization, and the pathways through which insecurity interacts with other sociodemographic determinants of skilled delivery. Without this evidence, policy responses remain generic rather than targeted to the unique epidemiology of conflict-driven maternal health failure in Borno State. This study sought to address this problem.

1.3 OBJECTIVES OF THE STUDY

The general objective of this study was to assess the effect of security challenges on skilled birth attendance utilization among women at the University of Maiduguri Teaching Hospital (UMTH), Borno State.

The specific objectives were to:

i. Determine the sociodemographic characteristics of women attending UMTH who delivered in the previous twelve months.

ii. Assess the place of delivery and skilled birth attendance status of previous deliveries among the respondents.

iii. Identify the specific security-related barriers that prevented access to skilled birth attendance.

iv. Examine the relationship between security challenges and SBA utilization, controlling for sociodemographic factors.

v. Assess women's perceptions and attitudes toward institutional delivery in the context of ongoing insecurity.

1.4 RESEARCH QUESTIONS

i. What are the sociodemographic characteristics of women who delivered in the previous year attending UMTH?

ii. What proportion of respondents' previous deliveries were conducted with or without skilled birth attendants, and where?

iii. What specific security-related barriers prevented access to skilled birth attendance?

iv. What is the relationship between security challenges and SBA utilization among women at UMTH?

v. What are the perceptions and attitudes of women toward institutional delivery in an insecure environment?

1.5 RESEARCH HYPOTHESES

Ho1: Security challenges do not significantly affect the utilization of skilled birth attendance among women in Borno State.

Ho2: There is no statistically significant relationship between displacement status and SBA utilization among women at UMTH.

Ho3: Destruction of community health facilities is not significantly associated with reduced skilled birth attendance utilization.

1.6 SIGNIFICANCE OF THE STUDY

The findings of this study carry profound implications for maternal health programming in conflict-affected settings. For health policymakers at federal, state, and humanitarian agency levels, the study provides empirical evidence to support the allocation of resources to mobile obstetric units, community-based SBA deployment, and the construction of maternity waiting homes near UMTH. For UMTH's obstetric and emergency care teams, the study offers insight into the clinical profiles and backgrounds of women arriving from insecure communities, enabling more responsive triage and care protocols. For international humanitarian organisations such as UNICEF, UNFPA, and MSF which have ongoing programmes in Borno State the findings provide evidence to strengthen advocacy for sustained investment in maternal health infrastructure in conflict zones. Academically, the study addresses a significant gap in the literature on SBA utilization in conflict-affected sub-Saharan African settings.

1.7 SCOPE OF THE STUDY

The study was conducted at the University of Maiduguri Teaching Hospital (UMTH), Borno State. The study population comprised women who had delivered at least once in the previous twelve months and were attending UMTH's postnatal or immunization clinics. The study focused specifically on women from conflict-affected communities in Borno State and neighbouring northeast states. Women who had exclusively delivered at UMTH across all their pregnancies and had no personal experience of insecurity barriers to healthcare access were identified and a comparative sub-analysis conducted. The study was cross-sectional in design, with data collected over a four-month period. It did not extend to community-based surveys of women who never reached UMTH due to security barriers, though qualitative data from IDIs partially addressed this limitation.

1.8 DEFINITION OF TERMS

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

Skilled Birth Attendance Utilization: In this study, the actual delivery of a live or stillborn infant by a skilled birth attendant in any health facility or community setting. Non-utilization refers to delivery conducted by a traditional birth attendant (TBA), family member, or the woman alone, without the presence of a trained health professional.

Security Challenges: In the context of this study, the range of armed conflict-related and insecurity-driven barriers that prevent or deter pregnant women from accessing skilled birth attendance and emergency obstetric care. These include attacks on health facilities, road blockades by armed groups, nighttime curfews, destruction of transportation infrastructure, fear of violence, displacement, and abduction of healthcare workers.

Institutional Delivery: Childbirth that takes place within a recognized health facility (hospital, health centre, or maternity home) under the supervision of a trained health professional, as opposed to home delivery or delivery in non-medical settings.

Boko Haram/ISWAP Insurgency: The jihadist armed conflict in northeast Nigeria, initiated by the Boko Haram terrorist organization in 2009, subsequently involving the Islamic State West Africa Province (ISWAP), a splinter faction. The insurgency has resulted in widespread destruction of civilian infrastructure including health facilities across Borno, Yobe, and Adamawa states.

Emergency Obstetric Care (EmOC): A set of life-saving clinical interventions for the management of life-threatening obstetric complications including severe postpartum haemorrhage, eclampsia, obstructed labour, uterine rupture, and puerperal sepsis. Comprehensive EmOC (CEmOC) includes blood transfusion capability and caesarean section, as provided at UMTH.

Obstetric Fistula: An abnormal opening between the vagina and bladder or rectum resulting from prolonged or obstructed labour without timely access to emergency caesarean section. Obstetric fistula is a marker of failed access to skilled birth attendance and emergency obstetric care, and is disproportionately prevalent in conflict-affected regions.

Traditional Birth Attendant (TBA): A person who assists women during childbirth and who initially acquired their skills through apprenticeship or observation rather than formal medical or nursing education. TBAs are frequently the only available birth attendants in conflict-affected communities where healthcare infrastructure has been destroyed.

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