Unsafe by necessity: system-driven childbirth risks in primary health centres serving insurgency-affected communities in north east nigeria
1
Public Health, Modibbo Adama University, Yola, Yola, Nigeria
2
Foundation Comprehensive College, Yola, Yola, Nigeria
3
Public Health, Federal University of Technology, Kashere, Gombe, Nigeria
Popul. Med. 2026;8(Supplement Supplement 1):
ABSTRACT
INTRODUCTION:
Prolonged armed conflict in north east nigeria has weakened maternal health systems and constrained safe childbirth service delivery. In primary health centres (PHC) operating under insecurity, health workers increasingly adopt unsafe but pragmatic practices to prevent immediate maternal and neonatal deaths. This study assessed the prevalence, drivers, and health implications of dangerous childbirth practices in insurgency-affected PHC.
METHODS:
A mixed-methods cross-sectional study was conducted between january and september 2025 across 24 purposively selected PHC in three conflict-affected states in north east nigeria. Quantitative data were extracted from delivery registers and direct structured observations of 684 facility-based births. Qualitative data were collected through in-depth interviews with 42 skilled and semi-skilled birth attendants. Practices assessed included unsterile assisted delivery, delayed referral, manual placental removal without analgesia, and task shifting beyond professional scope. Quantitative data were analysed descriptively and using logistic regression, while qualitative data were analysed thematically. Ethical approval and informed consent were obtained.
RESULTS:
At least one unsafe childbirth practice was documented in 58.3% of observed deliveries. Manual placental removal without adequate analgesia occurred in 31.6% of cases, while delayed referral linked to insecurity and transport barriers affected 44.9%. Facilities experiencing frequent security disruptions had higher odds of unsafe practices compared with relatively stable areas (adjusted odds ratio 2.41). Complication-related referrals were significantly higher in facilities with recurrent supply stockouts. Qualitative findings revealed that health workers viewed these practices as necessary adaptations driven by fear of maternal death, absence of referral options, and community pressure to intervene despite risks.
CONCLUSIONS:
Dangerous childbirth practices in insurgency-affected PHC reflect systemic inequities and structural violence against women rather than individual provider failure. Conflict-sensitive maternal health policies, protected supply chains, guaranteed emergency referrals, and inclusion of frontline workers in adaptive guideline development are essential to achieving equitable and sustainable maternal care in fragile settings.
Prolonged armed conflict in north east nigeria has weakened maternal health systems and constrained safe childbirth service delivery. In primary health centres (PHC) operating under insecurity, health workers increasingly adopt unsafe but pragmatic practices to prevent immediate maternal and neonatal deaths. This study assessed the prevalence, drivers, and health implications of dangerous childbirth practices in insurgency-affected PHC.
METHODS:
A mixed-methods cross-sectional study was conducted between january and september 2025 across 24 purposively selected PHC in three conflict-affected states in north east nigeria. Quantitative data were extracted from delivery registers and direct structured observations of 684 facility-based births. Qualitative data were collected through in-depth interviews with 42 skilled and semi-skilled birth attendants. Practices assessed included unsterile assisted delivery, delayed referral, manual placental removal without analgesia, and task shifting beyond professional scope. Quantitative data were analysed descriptively and using logistic regression, while qualitative data were analysed thematically. Ethical approval and informed consent were obtained.
RESULTS:
At least one unsafe childbirth practice was documented in 58.3% of observed deliveries. Manual placental removal without adequate analgesia occurred in 31.6% of cases, while delayed referral linked to insecurity and transport barriers affected 44.9%. Facilities experiencing frequent security disruptions had higher odds of unsafe practices compared with relatively stable areas (adjusted odds ratio 2.41). Complication-related referrals were significantly higher in facilities with recurrent supply stockouts. Qualitative findings revealed that health workers viewed these practices as necessary adaptations driven by fear of maternal death, absence of referral options, and community pressure to intervene despite risks.
CONCLUSIONS:
Dangerous childbirth practices in insurgency-affected PHC reflect systemic inequities and structural violence against women rather than individual provider failure. Conflict-sensitive maternal health policies, protected supply chains, guaranteed emergency referrals, and inclusion of frontline workers in adaptive guideline development are essential to achieving equitable and sustainable maternal care in fragile settings.
| eISSN: | 2654-1459 |
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