From Delays to Systems in Maternal Healthcare Utilisation: A Conceptual Framework Study

OBJECTIVE: To develop an operational, systems-oriented framework for analysing sustainable maternal healthcare utilisation, grounded in Nigerian evidence and intended for contextual adaptation and testing. DESIGN: Conceptual framework study using narrative synthesis, structured comparative evidence synthesis and independent face and content appraisal. SETTING: Nigeria, with consideration of applicability to other maternal healthcare settings. POPULATION OR SAMPLE: Purposively selected peer-reviewed Nigerian maternal healthcare studies; three independent external appraisers comprising two maternal-health researchers and one healthcare professional. METHODS: We synthesised empirical evidence into linked domains and hypothesised relationships, compared it with established maternal-health and health-systems frameworks and challenged it against additional Nigerian studies. Appraisers assessed relevance, clarity, completeness, cross-domain plausibility, and practical utility. MAIN OUTCOME MEASURES: Conceptual coherence, domain relevance, completeness, explanatory plausibility, practical utility, and candidate indicators of sustainable maternal healthcare utilisation; no patient-level clinical outcomes were measured. RESULTS: We specified six linked domains: policy and governance, health-system capacity, community engagement, equity, quality of care, and monitoring, evaluation and learning. Governance provides structural conditions; capacity, quality and community engagement interact; equity modifies pathways; and monitoring supports feedback and adaptation. External appraisal offered qualified support and identified boundaries requiring refinement. CONCLUSIONS: The framework offers a testable systems structure for diagnosing interacting barriers and guiding context-appropriate indicators and multilevel interventions. Prospective testing is needed to establish construct validity, responsiveness and transferability.