IMPACT OF FREE MATERNAL HEALTH POLICIES ON THE UTILIZATION OF SKILLED BIRTH SERVICES IN NIGERIA: A LITERATURE REVIEW

Abstract

Nigeria continues to face significant maternal health challenges, with maternal mortality ratios among the highest globally. In response, various state and federal governments have implemented free maternal health policies aimed at increasing the utilization of skilled birth services. This review integrates evidence from previous studies examining the impact of these policies through the lens of the Andersen Behavioral Model of Health Services Use, which conceptualizes healthcare utilization as a function of predisposing, enabling, and need factors. The review reveals that while free maternal health policies have demonstrated positive impacts in some contexts particularly when combined with comprehensive health system strengthening their effects remain heterogeneous across Nigeria. Programs such as the Abiye initiative in Ondo State achieved substantial increases in facility-based deliveries (from 56.5% to 85.6%) and antenatal care coverage (reaching 98%), while other state-level programs showed mixed or limited impacts. Predisposing factors, including education, religion, and ethnicity, consistently predict service utilization, with higher education associated with greater uptake of skilled birth services. Enabling factors, particularly wealth, distance to facilities, and quality of care, remain critical barriers even when user fees are removed. The evidence underscores that cost removal alone is insufficient; persistent supply-side constraints, cultural barriers, transport challenges, and quality-of-care issues continue to limit access to skilled birth services. Future maternal health policies must adopt comprehensive approaches that address financial, geographical, cultural, and health system barriers simultaneously to achieve equitable improvements in maternal health outcomes across Nigeria's diverse contexts.