Individual-Level and Community-Level Determinants of Skilled Birth Attendance in Nigeria: A Multilevel Analysis of DHS Data

Every year, millions of women around the world face the profound risk of dying while giving birth. For decades, public health experts have known that the single most effective way to prevent these tragedies is to ensure a trained professional—a doctor, a nurse, or a midwife—is present at the moment of delivery. This presence, known as skilled birth attendance, allows for the immediate management of complications like severe bleeding or infection, turning what could be a fatal event into a safe one. Yet, despite this knowledge, the reality on the ground in many parts of the world remains starkly different. In countries like Nigeria, a nation with a massive population and a history of maternal health challenges, a significant number of women still give birth without this critical support. The question that has long puzzled researchers is not just why this happens, but exactly where the barriers lie. Is it simply a matter of a woman's personal choices, her education, or her family's money? Or are there deeper, invisible forces in the communities where she lives—such as the distance to a clinic, the local culture, or the quality of the health system itself—that shape her fate just as powerfully?

A team of researchers set out to untangle this complex web using the most recent and comprehensive data available from Nigeria. They turned to the 2024 Nigeria Demographic and Health Survey, a massive national study that interviewed nearly 14,000 women who had recently given birth. Instead of looking at these women as isolated individuals, the researchers treated the data as a layered story, recognizing that every woman is nested within a household, which is nested within a community, which sits within a specific region of the country. By using advanced statistical methods that could account for these layers simultaneously, they were able to separate the influence of personal circumstances from the influence of the environment. Their goal was to paint a clear picture of who is getting skilled help during childbirth in Nigeria today, and more importantly, to understand the mix of personal and community factors that drive the decision to seek it.

The results of this analysis reveal a nation still struggling to reach its most vulnerable mothers. Overall, only about 45 percent of women in Nigeria had a skilled attendant present at their last delivery. This means that for more than half of the births in the country, a trained professional was absent, leaving mothers and newborns exposed to preventable risks. The data shows that this is not a uniform problem across the country; rather, it is a landscape of deep inequality. The researchers found that a woman's chances of receiving skilled care depend heavily on where she lives. In the southern part of the country, particularly in the South East region, the rate of skilled attendance is remarkably high, reaching nearly 88 percent. In stark contrast, in the North West region, the figure plummets to just 24 percent. This gap is so wide that a woman in the South East is nearly four times more likely to have a skilled attendant than a woman in the North West. Even within the same region, the differences are sharp; in some states, nearly all women have access to skilled care, while in others, fewer than one in ten do.

When the researchers looked at the individual factors, the patterns were clear and consistent with what has been observed globally, but the scale of the disparities in Nigeria is profound. Education emerged as a powerful driver of safety. Women with no formal education were far less likely to have a skilled attendant compared to those with higher education, whose rates of skilled attendance were nearly nine times higher. Similarly, household wealth played a decisive role. The poorest women were the most likely to give birth without help, while the wealthiest women were almost guaranteed to have a skilled professional present. The number of children a woman already had also mattered; as the number of previous births increased, the likelihood of using skilled care decreased. Perhaps most significantly, the researchers found a tight link between prenatal care and the final delivery. Women who attended four or more antenatal care visits during their pregnancy were vastly more likely to deliver with a skilled attendant than those who skipped these visits entirely.

However, the study's most revealing insight came from looking beyond the individual. The researchers calculated that a staggering 64 percent of the variation in skilled birth attendance is not explained by the women themselves—their education, their money, or their age—but by the communities in which they live. This finding is crucial because it challenges the idea that maternal health is solely a matter of personal choice or individual behavior. It suggests that even if a woman is educated and wealthy, if she lives in a community with poor health infrastructure, a lack of trained staff, or cultural barriers to seeking care, her chances of getting help drop significantly. The study confirmed that the environment acts as a powerful gatekeeper. For instance, women living in rural areas were far less likely to have skilled attendance than those in cities, regardless of their personal wealth. This indicates that the physical distance to a health facility and the availability of services in a village are just as important as the woman's own resources.

The researchers also examined what happens when these factors are considered together. They found that while education and wealth remain important, the influence of the community does not disappear even when accounting for them. This means that simply educating women or giving them money is not enough to solve the problem if the health system in their village is broken or inaccessible. The study argues that the solution must be two-pronged. First, efforts must continue to empower women through education and financial support, ensuring they have the means and the knowledge to seek care. Second, and perhaps more urgently, there must be a massive investment in the health systems of the most underserved areas, particularly in the rural North. This includes deploying more skilled health workers to remote villages, ensuring that clinics are staffed and equipped, and making sure that the cultural and logistical barriers preventing women from accessing these services are removed.

The study concludes that the path to saving mothers' lives in Nigeria requires a shift in perspective. It is not enough to view the lack of skilled birth attendance as a failure of individual women to make the right choice. The data shows that the choice is often constrained by the world around them. The wide gap between the South and the North, and between the rich and the poor, is a reflection of systemic inequalities that have built up over time. To close this gap, the researchers suggest that policies must be tailored to the specific needs of different regions and communities. A one-size-fits-all national plan will not work when the reality on the ground varies so dramatically from one state to another. Instead, resources must be directed where they are needed most, with a focus on building robust health systems in the areas where the gap is widest. By addressing both the personal circumstances of women and the structural realities of their communities, Nigeria can begin to move toward a future where every mother, regardless of where she lives or how much she earns, has the skilled support she needs to survive childbirth.