Perceived barriers to maternal healthcare utilization: insights from skilled birth attendants in six high-burden states of northern Nigeria

BACKGROUND: Maternal mortality remains a major public health concern globally despite significant progress over the past two decades. Nigeria is among the countries with the highest maternal mortality rates. Within the country, marked regional disparities persist, with northern Nigeria experiencing a significantly higher burden. These disparities are shaped by a complex interaction of sociocultural norms, household power relations, geographic constraints, and health system limitations that influence women's access to skilled birth attendance and facility-based delivery. The study explored skilled birth attendants' perceived barriers to the provision of maternal healthcare services that prevent pregnant women from seeking appropriate care in government-based facilities. METHODS: This study employed a qualitative research design to explore skilled birth attendants' perspectives on barriers preventing women from accessing maternal healthcare services. Twenty-four skilled birth attendants were purposively selected from primary healthcare facilities across six high-burden northern Nigerian states: Bauchi, Kaduna, Katsina, Kano, Jigawa, and Niger. Data were collected through in-depth interviews using a semi-structured and pretested interview guide. The Three Delay Model guided the study to examine factors affecting women's decisions to seek care, their ability to reach healthcare facilities, and their experiences receiving care within facilities. RESULTS: The findings revealed multiple barriers across the three phases of delay. At the household level, cultural expectations, generational beliefs, and patriarchal decision-making structures limited women's autonomy to seek skilled care. Mothers-in-law and husbands often influenced or determined childbirth decisions, sometimes discouraging facility delivery. Structural barriers also affected women's ability to reach health facilities, including long travel distances, poor road infrastructure, and limited transportation options. Even when women arrived at health facilities, systemic challenges such as shortages of skilled health workers, inadequate medical supplies, insufficient delivery beds, financial constraints, and weak referral systems contributed to delays in receiving appropriate care. CONCLUSION: In conclusion, maternal healthcare service utilization in northern Nigeria is shaped by interconnected sociocultural, economic, and health system factors that contribute to delays in seeking, reaching, and receiving care. Therefore, addressing maternal mortality in this context requires comprehensive strategies that strengthen health system capacity, improve transportation and referral systems, reduce financial barriers, and promote gender-equitable decision-making within households and communities. Such integrated efforts are essential for improving access to skilled birth attendance and advancing progress toward global maternal health targets.