BMC Public Health Community-Centred Health Governance: The Role of Primary Care Gatekeepers and Family-Level Advocacy in Reducing Maternal and Neonatal Mortality in Peri-Urban Lagos, Nigeria
This mixed-methods study in peri-urban Lagos demonstrates that integrating traditional and faith leaders into primary health care governance significantly improves maternal and neonatal health outcomes by increasing antenatal care uptake and male involvement, suggesting that community-centred advocacy is more critical than clinical capacity alone for reducing mortality.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
In many parts of the world, the path to a healthy birth is often seen as a straight line: a woman feels pregnant, she visits a clinic, and medical staff provide the care she needs. Yet in the rapidly growing, semi-urban neighborhoods on the edge of Lagos, Nigeria, this simple path is frequently blocked not by a lack of hospitals or doctors, but by the invisible walls of family and community life. For decades, public health experts have known that building clinics is only half the battle; the other half involves understanding who actually holds the power to decide when a woman seeks help. In these communities, a pregnant woman's journey is rarely her own. It is shaped by her husband's willingness to pay for transport, her mother-in-law's advice, and the approval of local leaders who command deep respect. When these social circles do not trust the medical system, the clinics remain empty, and the risk of death for mothers and newborns stays dangerously high.
A recent study conducted in the Lagos State local government areas of Ibeju-Lekki and Epe explores exactly how these social dynamics override medical availability. The researchers, led by Bolajoko Ogunwale, set out to understand why, despite the presence of primary health care facilities, many women still give birth without any medical supervision. Instead of simply counting how many clinics exist or how many doctors are available, the team investigated the social gatekeepers who control access to care. They focused on three specific groups: traditional rulers who lead the communities, religious leaders who guide the faithful, and the male heads of households who often control the family budget. The study operated on the idea that health is not just a medical event but a social one, where trust is built through relationships rather than just through brochures or medical signs.
To uncover the truth behind these decisions, the researchers combined two different approaches. First, they spoke with 500 women of childbearing age who had recently been pregnant, asking them detailed questions about where they got their health advice and what stopped them from visiting a clinic early in their pregnancy. Then, to understand the "why" behind the numbers, the team held in-depth conversations with 25 key community figures, including chiefs, pastors, imams, and health workers, as well as four group discussions with men who make household decisions. This mix of broad surveys and deep interviews allowed the team to see not just the statistics, but the human stories and cultural rules that drive them.
The results revealed a striking reality: the source of a message matters far more than the message itself. When women received advice about early prenatal care from a traditional ruler, they were more than three times as likely to visit a clinic in their first trimester compared to women who heard the same advice only from a nurse or doctor. Similarly, when a religious leader endorsed the practice, the likelihood of early clinic visits nearly tripled. The study found that the clinical staff, despite their medical expertise, were often the least effective messengers because they lacked the social authority to grant "permission" for the community to act. In these neighborhoods, a doctor's recommendation is just a suggestion, but a chief's or a pastor's blessing is a command that carries weight.
The study also tackled the critical role of men, who often control the finances and logistics required to get a woman to the hospital. The researchers tested a specific intervention using storytelling through radio and community screenings, designed to show men as caring partners rather than barriers. This narrative approach, which framed health as a family duty, led to a 68 percent increase in supportive behaviors among men. These men began arranging transportation, setting aside money for delivery costs, and even attending prenatal appointments with their wives. This finding suggests that changing the behavior of the entire family unit is far more effective than trying to change the behavior of the pregnant woman in isolation.
Despite these clear successes, the researchers identified a major structural problem: the formal health system and the community leadership systems operate in parallel but rarely touch. Health officials often launch campaigns without telling the traditional rulers, and religious leaders often hear about health drives only by chance. This lack of coordination means that trust is not built systematically, and opportunities to save lives are missed. The study argues that the solution is not to build more clinics, but to build bridges between the clinics and the people who already hold the trust of the community.
The paper concludes with a proposal for a new way of organizing health care, one that formally integrates community leaders into the health system. By creating committees where traditional rulers, religious figures, and health workers plan together, the system can turn social influence into a powerful tool for saving lives. The author emphasizes that in places like Ibeju-Lekki and Epe, the path to a healthy mother and baby does not start at the clinic door; it starts in the living room, the mosque, and the village square. Until the health system recognizes and respects these gatekeepers as essential partners, the gap between available care and actual health outcomes will remain wide. The study offers a clear, evidence-based roadmap for closing that gap, suggesting that the most effective medicine in these communities may be the power of a respected voice.
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