From Insurance Coverage to Maternal Health: Understanding Determinants of Antenatal Care Delivery Mismatch among enrollees of the Kano State Contributory Healthcare Scheme: A Mixed- Methods study

In many parts of the world, having health insurance is often seen as the golden ticket to safe motherhood. The idea is straightforward: if a woman does not have to worry about the cost of a doctor's visit or a hospital bed, she will seek care when she is pregnant and give birth in a safe place with skilled help. This financial shield is meant to protect families from the crushing debt that often accompanies medical emergencies, and it is a cornerstone of efforts to save mothers' lives. However, money is only one part of a much larger puzzle. A woman might have a valid insurance card and attend all her scheduled checkups, yet still choose to give birth at home without a doctor or midwife present. This gap between the promise of insurance and the reality of where a baby is born is what researchers call a "mismatch." It is a frustrating disconnect where the system works on paper but fails in practice, leaving women vulnerable to complications that could have been prevented in a hospital.

This story takes place in Kano State, in the northwest of Nigeria, a region where the government launched a specific program called the Kano State Contributory Healthcare Management Agency, or KSCHMA. The goal was simple and noble: to provide free maternal and child health services to everyone, from formal workers to those in the informal economy. The researchers wanted to understand why, despite this free coverage, so many women who booked their pregnancy care at a clinic ended up delivering at home. They set out to find the specific reasons behind this choice, looking beyond just the price tag to see what was actually happening on the ground. They combined hard numbers from over a thousand women with deep conversations to get the full picture of why the system was breaking down.

The study involved a massive effort to gather information from twenty different health facilities across the state, ranging from small primary health centers in rural villages to larger secondary hospitals and private clinics. The team interviewed 1,080 women who had given birth in the year before the study began. These were all women who had been enrolled in the insurance scheme and had attended their prenatal checkups at an accredited facility. The researchers asked them where they had booked their delivery, where they actually gave birth, and what factors influenced that decision. To get the deeper story, they also held group discussions with women and sat down for one-on-one interviews with hospital managers, midwives, and community leaders. They wanted to hear the voices of the people who lived this reality every day.

The results revealed a startling pattern. More than half of the women who had booked their delivery at a primary health center—a small local clinic—ended up giving birth at home instead. Only about one in ten of these women actually delivered at the clinic where they had made their appointment. Another significant group, roughly one-third, started their care at a small clinic but ended up going to a larger hospital or a private facility for the birth. The data showed that where a woman lived and what her daily life looked like were the strongest predictors of this outcome. Women living in rural areas were far more likely to deliver at home, even after booking a spot at a local clinic. Similarly, women who were full-time housewives were much more likely to bypass the clinic entirely compared to those with other occupations.

When the researchers dug into the reasons behind these choices, the answers were not about a lack of money or insurance. The women had coverage, but the system around them was failing them in other ways. One major issue was the lack of staff at night. While the clinics were open and staffed during the day for prenatal checkups, the skilled midwives often left after their shifts ended. If a woman went into labor at two in the morning, she might find only a security guard or a health worker with less training at the door. The women knew this, and they were afraid to take the risk. One community leader explained that the insurance scheme brought thousands of women to the clinics, but the government had not hired enough midwives to handle the increased workload, especially for night shifts.

Another critical barrier was the reliability of the facilities themselves. Many primary health centers lacked consistent electricity and running water. One hospital manager described the danger of delivering a baby in the dark, using a flashlight or a kerosene lamp, when the power grid failed. Without reliable power, the generators could not run, and without generators, there was no light for a safe delivery. In some cases, the water supply was so unreliable that staff had to buy water from vendors just to keep things clean, or women were forced to go to larger hospitals that had better infrastructure. The fear of infection and the lack of basic utilities made the small clinics feel unsafe for the most critical moment of a woman's life.

The financial promise of the insurance also hit a wall when it came to supplies. Although the scheme was supposed to cover all costs, delays in payments from the insurance agency meant that clinics often ran out of essential medicines and equipment. When a woman went into labor, the clinic might have no gloves, no sutures, or no drugs to stop bleeding. In these moments, the staff would hand the family a prescription slip and tell them to buy the supplies from a private pharmacy next door. For a family with no cash on hand, this sudden out-of-pocket cost was a dealbreaker. They could not pay, so they went home. The insurance had protected them from the bill for the doctor, but it could not protect them from the empty shelves.

Transportation was another piece of the puzzle that the researchers found to be crucial. There was no organized emergency transport system to move a woman from a small clinic to a larger hospital if complications arose. If a woman started having trouble during labor at a primary center, the staff had to beg neighbors or commercial drivers for a ride, a process that could take hours. Knowing this, many husbands decided to skip the small clinic entirely and drive straight to the large general hospital from the start of labor, just to be safe. This meant that even though the woman had booked at the local clinic, the lack of a reliable ambulance system pushed her to bypass it.

The study also highlighted the role of trust and family dynamics. In many communities, the decision to give birth in a facility is not made by the woman alone. She often needs permission from her husband or elders, and she needs them to arrange the transport. If the husband is away or if the family does not believe the local clinic is safe enough for a life-or-death event, the woman stays home. Even though the insurance card gave women the means to choose, the social and logistical barriers often overrode that choice. The researchers found that women trusted the doctors at the large hospitals more than the midwives at the small clinics, viewing the hospital as the only place where true safety could be guaranteed.

The researchers concluded that while financial protection is a necessary first step, it is not enough on its own to ensure that women give birth in safe facilities. The mismatch between antenatal care and delivery is driven by a combination of broken supply chains, a lack of staff at night, unreliable electricity and water, and the absence of emergency transport. To fix this, the study suggests that the government and insurance agency must do more than just pay bills. They need to ensure that clinics have stockpiles of essential medicines so that no woman is asked to pay at the point of care. They need to train staff in respectful care so that women are not humiliated or ignored. Most importantly, they need to build reliable transport networks and involve men in the planning process so that when labor starts, the family is ready to move to a safe facility without delay. The paper makes it clear that saving mothers' lives requires a system that works from the first checkup to the final moment of birth, not just a piece of paper that says the care is free.