Health Equity as a Peace Dividend? Antenatal Care in the Conflict-Affected North-East of Nigeria

Abstract Background. Antenatal care (ANC) is the primary point of contact between pregnant women and the health system, and equitable access to basic services is a component of positive peace. Protracted insurgency has destroyed much of the health infrastructure of Nigeria’s North-East, yet little is known about how far antenatal care has recovered relative to the rest of the country. Objective. To compare antenatal care in the North-East with that in the other zones, and to separate the difference into a part explained by women’s characteristics and a part that remains. Methods. Cross-sectional analysis of the 2023-24 Nigeria Demographic and Health Survey (fieldwork December 2023 to May 2024). The sample was 13,968 women whose most recent live birth or stillbirth fell in the three years before the survey, of whom 2,972 lived in the North-East. Outcomes were four or more visits, eight or more visits, and skilled-provider care. We used survey-weighted estimates, Erreygers-corrected concentration indices, and a Blinder-Oaxaca decomposition with bootstrap confidence intervals, and tested the main result across 15 specifications and in a bounding analysis. All analyses were done in R. Results. Four or more visits were 51.9% nationally and 50.2% (95% CI 46.4 to 54.1) in the North-East, compared with 40.1% in the North-West. The other zones exceeded the North-East by only 2.1 percentage points (95% CI − 2.7 to 5.9), although women’s education and wealth alone predicted a gap of 14.8 points. The North-East therefore did 12.7 points better than expected (95% CI: 8.8 to 16.5), a result that held across all specifications (9.5 to 13.6 points). For eight or more visits, the North-East had the lowest coverage of any zone (4.0% compared with 19.4% elsewhere), with a 6.0-point unexplained shortfall. The advantage was concentrated among the poorest women (38.0% of the poorest wealth quintile in the North-East made four or more visits, against 20.9% elsewhere), and counting community health extension workers raised North-East skilled-provider coverage from 59.5% to 74.6%. Conclusions. Basic antenatal contact in the North-East exceeds what its socioeconomic profile would predict, most strongly among the poorest women, whereas continuity of care, as measured by eight or more visits, lags behind. This is consistent with, but not evidence of, humanitarian and community-level provision. Zone is a proxy for conflict, and the findings are associations.