CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

Pregnancy and childbirth are normal physiological processes, yet for many women, particularly in low-income settings, they carry a serious risk of death. The most recent global estimates indicate that about 260,000 women died from pregnancy- or childbirth-related causes in 2023, roughly 712 deaths every day. This is 40% lower than in 2000, but progress has slowed and remains well short of the Sustainable Development Goal target of fewer than 70 maternal deaths per 100,000 live births by 2030. Sub-Saharan Africa accounted for about 70% of these deaths (World Health Organization et al., 2025).

Nigeria carries a very large share of this burden. The same inter-agency estimates attribute roughly 29%, or about 75,000, of global maternal deaths in 2023 to Nigeria (World Health Organization et al., 2025) [verify these country figures in the report's Nigeria profile]. Earlier evaluations described a Nigerian woman's lifetime risk of dying in pregnancy or childbirth as about 1 in 30, noted that only around 39% of births were attended by a skilled provider, and reported that up to half of rural primary health facilities surveyed had no midwife at all (Okeke et al., 2016). Variation in the availability of skilled attendance at birth is widely regarded as a main reason why maternal, newborn and child health indicators differ across Nigeria's geopolitical zones and between urban and rural areas (Abimbola et al., 2012).

The Midwives Service Scheme (MSS) was introduced in December 2009 as a response to this shortage of health workers in rural primary care (Abimbola et al., 2012; Okeke et al., 2016). The scheme recruited unemployed, retired and newly qualified midwives through a national exercise and deployed them to government primary health care (PHC) facilities in underserved communities. In its first phase, 2,488 midwives were posted to 652 PHC facilities across the 36 states and the Federal Capital Territory, about 45% of them unemployed midwives, 44% basic midwives completing their mandatory community service year and 11% retired midwives (Abimbola et al., 2012). Four midwives were assigned to each facility to provide round-the-clock cover, and they worked on one-year contracts renewable subject to satisfactory performance (Okeke et al., 2016). Their pay was shared across the three tiers of government: a federal monthly salary of N30,000, a state allowance of N20,000 and a local government allowance of N10,000, together with free accommodation in the community (Okeke et al., 2016).

Evidence on how the scheme has performed is mixed. A large impact evaluation found that the MSS raised antenatal care use by about 5 percentage points overall within the first year, but found no statistically significant effect on skilled birth attendance or on maternal delivery complications (Okeke et al., 2016). Implementation problems, including irregular payment of salaries, inadequate housing, and poor clinic infrastructure and supplies, affected the availability and retention of midwives (Okeke et al., 2016). Abimbola et al. (2012) likewise reported uneven improvement across zones, with retention and training of midwives and variable commitment from state and local governments among the main challenges. A qualitative study of women's experiences reported that most participants saw improvements in maternity care because of the larger number of midwives, but that in one northern state many women still preferred home birth, which participants linked to low awareness (Exley et al., 2016). By contrast, beneficiaries in Oyo State reported strong benefits from skilled birth attendants and antenatal care, although most were dissatisfied with the ambulance service (Adegoke et al., 2016).

These findings show that the success of the scheme depends not only on deploying midwives but also on how the midwives who deliver it and the mothers who use it experience it. This study therefore examines how midwives and mothers in selected Area Councils of Abuja perceive the MSS.

1.2 Statement of the Problem

Skilled attendance at birth has long served as a key indicator of progress toward reducing maternal mortality. Under the MSS, midwives were posted to PHC facilities so that pregnant women could be attended by skilled providers. Communities were informed that skilled providers were available, and the expectation was that mothers would use their services.

However, available evidence points to low patronage. Facility records show that the total number of deliveries in 2012 was 54 at Gwako PHC in Gwagwalada Area Council and 23 at Kuchibuyi in Bwari Area Council, a monthly average of roughly five and two respectively [cite the facility records]. National and regional evaluations report similar patterns of weak uptake of facility births: roughly 70% of home births in one large survey were explained by mothers as 'not necessary', which suggests that many women do not give facility delivery high priority (Okeke et al., 2016). Where women continue to deliver at home, they do not receive the skilled care the scheme was designed to provide, which limits its potential to reduce maternal deaths.

On the provider side, the researcher, who was once part of the scheme, observed that some midwives posted to PHC facilities were not always present when expected. This is consistent with wider reports that irregular salaries and poor accommodation undermined midwives' availability and retention (Okeke et al., 2016). Policymakers have regarded the MSS as a worthwhile intervention (Abimbola et al., 2012), but its success rests on how its two key groups, the midwives who provide care and the mothers who use it, perceive it. Midwives also have a new role as the sole professionals in charge of maternal and child health in their facilities, unlike in a conventional hospital. Their views, and those of mothers, therefore need to be established. This gap motivated the study.

1.3 Purpose and Objectives of the Study

The purpose of the study was to find out how mothers and midwives in selected Area Councils in Abuja perceive the Midwives Service Scheme.

The specific objectives were to:

1. Assess midwives' perception of the implementation of the MSS.
2. Determine midwives' views of their role in the MSS.
3. Ascertain midwives' perception of their remuneration in the MSS.
4. Ascertain mothers' perception of the services of the midwives in the MSS.
5. Determine whether there is an association between mothers' demographic characteristics and their perceived reasons for the MSS.
6. Determine the factors midwives perceive as negatively influencing service provision in the MSS.

1.4 Research Hypotheses

The following null hypotheses were tested at the 0.05 level of significance:

H01: Mothers' parity will not significantly influence their perception of the MSS.

H02: There will be no significant difference between midwives' qualification and their perception of the MSS.

H03: There will be no significant difference between midwives' years of service in the MSS and their perception of the scheme.

1.5 Significance of the Study

The study is expected to document how midwives and mothers view the MSS. Because midwives deliver the scheme and mothers are its users, their opinions can help identify its strengths and weaknesses in design and operation, as well as the factors that support or limit its effectiveness. This may guide policymakers in deciding whether to improve or adjust the programme, particularly in light of evaluations showing that scaling up midwife supply alone may not be enough to improve outcomes (Okeke et al., 2016). The findings will also add to the body of knowledge and serve as a reference for researchers working on related questions. They are relevant to government efforts toward national and global maternal health goals, which were formerly framed as Millennium Development Goals 4 and 5 and are now set out in the Sustainable Development Goals (World Health Organization et al., 2025), and they may be useful to non-governmental organisations and agencies concerned with women's health.

1.6 Scope of the Study

The study was delimited to midwives recruited into the MSS who work in MSS PHC facilities in Bwari and Gwagwalada Area Councils, and to mothers of childbearing age who were pregnant at the time of the study or who had at least one previous pregnancy and childbirth since the scheme began in their communities. For midwives, it was limited to their views on implementation, their role in the scheme and their remuneration. For mothers, it was limited to their views on the services provided by midwives and to whether mothers' demographic characteristics are associated with their perceived reasons for the MSS.

1.7 Operational Definition of Terms

Perception of the Midwives Service Scheme: Midwives' opinion about the implementation of the scheme, their role in it and their remuneration.

Perception of role in the Midwives Service Scheme: What midwives view as their functions in the PHC facility and whether the work stipulated in the scheme is appropriate or excessive.

Perception of remuneration in the Midwives Service Scheme: Midwives' view of their salaries and allowances in the scheme.

Mothers' perception of the Midwives Service Scheme: Mothers' view of the ability of midwives to care for women during pregnancy and childbirth.

References

Abimbola, S., Okoli, U., Olubajo, O., Abdullahi, M. J., & Pate, M. A. (2012). The Midwives Service Scheme in Nigeria. PLoS Medicine, 9(5), e1001211. https://doi.org/10.1371/journal.pmed.1001211

Adegoke, B. A., Fawole, O. P., & Badiru, I. O. (2016). Perceived effectiveness of the Midwives Service Scheme among beneficiaries in Oyo State, Nigeria. Nigerian Journal of Rural Sociology

Exley, J., [add remaining authors]. (2016). Persistent barriers to care: A qualitative study to understand women's experiences in areas served by the Midwives Service Scheme in Nigeria. BMC Pregnancy and Childbirth, 16, 232. https://doi.org/10.1186/s12884-016-1026-5

Okeke, E., Glick, P., Chari, A., Abubakar, I. S., Pitchforth, E., Exley, J., Bashir, U., Gu, K., & Onwujekwe, O. (2016). The effect of increasing the supply of skilled health providers on pregnancy and birth outcomes: Evidence from the Midwives Service Scheme in Nigeria. BMC Health Services Research, 16, 425. https://doi.org/10.1186/s12913-016-1688-8

World Health Organization, UNICEF, UNFPA, World Bank Group, & UNDESA/Population Division. (2025). Trends in maternal mortality 2000 to 2023. World Health Organization. https://www.who.int/publications/i/item/9789240108462