INTERNATIONAL JOURNAL OF RESEARCH AND SCIENTIFIC INNOVATION (IJRSI)  
ISSN No. 2321-2705 | DOI: 10.51244/IJRSI |Volume XII Issue XI November 2025  
Improving Maternal Health Outcomes Through Skilled BirthAttendance  
in Hard-To-Reach Communities ofAdamawa State, Nigeria.  
Ala Margwa Carlos1*, Minkailu Abubakar Amadu2, Friday E. Okonofua3, Lorretta F.C Ntoimo, PhD4,  
Yakubu Suleiman, PhD5, Danlami Hammayidi Ismail6, Suleiman Saidu Babale7,  
1Public Health, Adamawa State College of Health Science and Technology, Michika, Nigeria  
2Health Information Management, Federal University of Health Sciences, Azare, Nigeria  
3Centre of Excellence in Reproductive Health Innovation (CERHI), University of Benin, Benin City,  
Nigeria.  
4Demography and Social Statistics, Federal University of Oye-Ekiti, Nigeria  
5Community Health, Adamawa State College of Health Science and Technology, Michika, Nigeria  
6Disease Control and Immunization, Gombe State Primary Health Care Development Agency, Nigeria  
7Health Information Management, Adamawa State College of Health Science and Technology, Michika,  
Nigeria  
*Corresponding Author  
DOI: https://doi.org/10.51244/IJRSI.2025.1215PH000214  
Received: 21 November 2025; Accepted: 27 November 2025; Published: 11 December 2025  
ABSTRACT  
Maternal mortality remains a major public health challenge in Nigeria, particularly in hard to reach  
communities where access to skilled birth attendance is limited. This study investigates the impact of skilled  
birth attendance on maternal health outcomes in five underserved local government areas of Adamawa State.  
Using a mixed methods approach, quantitative data were collected from 300 women of reproductive age and  
analyzed alongside qualitative insights from interviews with mothers, skilled birth attendants, and health  
administrators. Findings revealed that only 42 percent of births were attended by skilled personnel, with  
significantly lower rates of postpartum hemorrhage, prolonged labor, and neonatal complications among those  
who received skilled care. Barriers to access included geographic isolation, lack of transportation, cultural  
preferences for traditional birth attendants, and perceived poor quality of facility based care. The study applied  
the Three Delays Model to interpret how skilled birth attendance mitigates delays in seeking, reaching, and  
receiving adequate care. Recommendations include deploying mobile clinics, integrating traditional birth  
attendants into the formal health system, improving transportation and referral networks, and enhancing  
community health education. The study concludes that expanding skilled birth attendance coverage is essential  
for reducing maternal mortality and improving maternal health equity in Adamawa State.  
Keywords: Maternal health, Skilled birth attendance, Adamawa State, Nigeria, Hard to reach communities,  
maternal mortality, Three Delays Model, Health systems, Traditional birth attendants, Public health  
intervention  
INTRODUCTION  
Maternal health is a cornerstone of public health and a critical indicator of a nation’s development. Globally,  
maternal mortality remains a pressing concern, with sub-Saharan Africa accounting for approximately 70  
percent of all maternal deaths (World Health Organization, 2024). Nigeria, Africa’s most populous country,  
continues to grapple with high maternal mortality rates, particularly in its northern regions. According to the  
Nigeria Demographic and Health Survey, the national maternal mortality ratio stands at 512 deaths per  
100,000 live births, with Adamawa State recording even higher figures due to its unique socio-political and  
geographic challenges (National Population Commission, 2023).  
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Adamawa State, located in northeastern Nigeria, is characterized by a mix of urban centers and vast rural, hard  
to reach communities. These areas are often underserved due to poor infrastructure, insecurity from insurgent  
activities, and limited health workforce deployment. Women in these communities face significant barriers to  
accessing quality maternal care, including long distances to health facilities, lack of transportation, cultural  
norms favoring traditional birth attendants, and inadequate health education. These factors contribute to  
preventable complications such as postpartum hemorrhage, obstructed labor, and sepsis, which are leading  
causes of maternal death in the region (Afape et al., 2024).  
Skilled birth attendance, defined as care provided by trained health professionals such as midwives, nurses, or  
doctors during childbirth, is a proven intervention for reducing maternal and neonatal mortality. The World  
Health Organization emphasizes that the presence of skilled birth attendants during delivery can prevent up to  
75 percent of maternal deaths by ensuring timely interventions and referrals (World Health Organization,  
2024). Despite this, skilled birth attendance coverage in Adamawa’s remote communities remains alarmingly  
low. Recent data suggest that fewer than half of births in these areas are attended by skilled personnel  
(Adepoju and Yusuf, 2024).  
This study seeks to explore the impact of skilled birth attendance on maternal health outcomes in hard to reach  
communities of Adamawa State. By examining both quantitative health indicators and qualitative experiences  
of mothers and health workers, the research aims to provide evidence based recommendations for improving  
maternal care delivery. The findings are expected to inform policy decisions, guide resource allocation, and  
support the design of culturally sensitive interventions that enhance skilled birth attendance uptake in  
marginalized populations.  
LITERATURE REVIEW  
Improving maternal health outcomes through skilled birth attendance has been widely recognized as a  
cornerstone of global health strategies. The World Health Organization (2024) asserts that skilled birth  
attendants trained professionals such as midwives, nurses, and doctors play a critical role in preventing  
maternal and neonatal deaths by managing complications and ensuring timely referrals. This section reviews  
existing literature on the relationship between skilled birth attendance and maternal health outcomes, with a  
focus on Nigeria and, more specifically, Adamawa State.  
Global Perspectives on Skilled Birth Attendance: Globally, countries that have successfully reduced  
maternal mortality have done so by expanding access to skilled birth care. Campbell and Graham (2006)  
emphasized that strategies focusing on skilled attendance at birth and emergency obstetric care are among the  
most effective interventions. In countries such as Sri Lanka and Malaysia, maternal mortality rates declined  
significantly following the implementation of nationwide SBA programs. These successes underscore the  
importance of political commitment, health system strengthening, and community engagement.  
Maternal Health in Nigeria: Nigeria remains one of the countries with the highest maternal mortality ratios  
in the world. According to the Nigeria Demographic and Health Survey (NPC, 2023), only 43 percent of births  
nationwide are attended by skilled personnel, with significant disparities between urban and rural areas.  
Northern Nigeria, including Adamawa State, consistently reports lower SBA coverage due to factors such as  
poverty, insecurity, and cultural preferences for traditional birth attendants (TBAs). Studies by Okonofua et al.  
(2022) and Afape et al. (2024) highlight that young women aged 15 to 24 in northern states are particularly  
vulnerable, with limited access to skilled care and high rates of maternal complications.  
Barriers to Skilled Birth Attendance in Adamawa State: Adamawa State presents unique challenges to  
maternal health service delivery. The regions hard to reach communities suffer from poor road networks,  
limited health infrastructure, and frequent disruptions due to conflict and displacement. Adepoju and Yusuf  
(2024) conducted a statistical appraisal of maternal health trends in Adamawa and found that SBA coverage  
was below the national average, with maternal mortality ratios exceeding 500 deaths per 100,000 live births.  
Cultural norms also play a significant role; many communities prefer TBAs due to their accessibility,  
familiarity, and perceived empathy, despite their lack of formal training.  
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Interventions and Policy Responses: Recent policy efforts have aimed to improve maternal health outcomes  
through increased SBA deployment. The Federal Ministry of Health’s 2025 Joint Annual Review reported a 17  
percent drop in maternal deaths nationally, attributing the improvement to targeted investments in health  
worker training and mobile clinic programs (Federal Ministry of Health, 2025). However, these interventions  
have yet to fully penetrate remote areas of Adamawa. Community-based strategies, such as training TBAs to  
collaborate with SBAs and expanding health education, have shown promise in pilot programs but require  
broader implementation.  
Gaps in the Literature: While existing studies provide valuable insights into the importance of skilled birth  
attendance, few have focused specifically on hard to reach communities within Adamawa State. Moreover,  
there is limited qualitative research capturing the lived experiences of mothers and health workers in these  
areas. This study seeks to fill these gaps by combining quantitative health data with qualitative interviews to  
offer a comprehensive understanding of the barriers and opportunities for improving maternal health through  
SBA.  
METHODOLOGY  
Research Design: This study adopted a mixed methods research design, combining quantitative and  
qualitative approaches to provide a comprehensive understanding of maternal health outcomes in hard to reach  
communities of Adamawa State. The quantitative component utilized a cross sectional survey to assess the  
prevalence and impact of skilled birth attendance, while the qualitative component employed a  
phenomenological approach to explore the lived experiences of mothers and health workers. This design  
enabled triangulation of data sources and enhanced the validity of findings through methodological  
complementarity.  
Study Area and Population: The study was conducted in five local government areas of Adamawa State  
identified as hard to reach due to geographic isolation, limited infrastructure, and security challenges. These  
areas included Michika, Madagali, Gombi, Song, and Lamurde. The target population comprised women of  
reproductive age who had delivered within the past two years, skilled birth attendants working in primary  
health centers, and health administrators overseeing maternal health programs. The selection of these groups  
was based on their direct involvement in childbirth and maternal health service delivery.  
Sampling Technique and Sample Size: A stratified random sampling technique was used for the quantitative  
survey to ensure representation across the selected local government areas. A total of 300 women were  
selected based on proportional allocation from each area. For the qualitative component, purposive sampling  
was employed to select 30 mothers, 10 skilled birth attendants, and 5 health administrators. The sample size  
was determined using Cochran’s formula for finite populations, adjusted for expected response rates and  
logistical feasibility.  
Data Collection Instruments: Quantitative data were collected using structured questionnaires designed to  
capture demographic information, birth history, access to skilled birth attendants, and maternal health  
outcomes. Secondary data were obtained from health facility records covering the period from 2022 to 2024.  
Qualitative data were gathered through semi structured interviews and focus group discussions. Interview  
guides were developed to explore perceptions of skilled birth attendance, barriers to access, and  
recommendations for improvement. All instruments were administered by trained field researchers fluent in  
English and local languages.  
Pretesting and Reliability: The data collection instruments were pretested in a neighboring local government  
area not included in the main study to assess clarity, relevance, and reliability. Feedback from the pretest was  
used to revise ambiguous questions and improve the flow of interviews. Reliability of the quantitative  
instrument was assessed using Cronbach’s alpha, which yielded a coefficient of 0.82, indicating acceptable  
internal consistency. Interrater reliability for qualitative coding was ensured through independent coding by  
two researchers and reconciliation of discrepancies.  
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Ethical Considerations: Ethical approval was obtained from the Adamawa State Health Research Ethics  
Committee. Informed consent was secured from all participants after explaining the purpose, procedures, risks,  
and benefits of the study. Participants were assured of confidentiality, anonymity, and their right to withdraw  
at any stage without penalty. Data were stored securely and used solely for research purposes.  
Data Analysis: Quantitative data were analyzed using the Statistical Package for the Social Sciences version  
26. Descriptive statistics such as frequencies and percentages were used to summarize demographic  
characteristics and maternal health indicators. Inferential statistics including chi square tests and logistic  
regression were employed to examine associations between skilled birth attendance and maternal outcomes.  
Qualitative data were transcribed verbatim and analyzed using NVivo software. Thematic analysis was  
conducted to identify recurring patterns and insights, with coding performed independently by two researchers  
to ensure consistency.  
Conceptual Framework Application: The study was guided by the Three Delays Model, which identifies  
delays in seeking care, reaching care, and receiving adequate care as key contributors to maternal mortality.  
This framework informed the design of data collection instruments and interpretation of findings. By  
examining how skilled birth attendance addresses each of these delays, the study provides a structured  
understanding of the mechanisms through which maternal health outcomes can be improved in hard to reach  
communities.  
RESULTS  
This section presents findings from both the quantitative and qualitative components of the study. The results  
are organized according to key variables including demographic characteristics, skilled birth attendance  
coverage, maternal health outcomes, barriers to access, and thematic insights from interviews and focus group  
discussions.  
Demographic Characteristics of Respondents: A total of 300 women participated in the quantitative survey.  
Table 1 summarizes their demographic characteristics.  
Table 1: Demographic Profile of Respondents (n = 300)  
Variable  
Age  
Category  
15–19  
Frequency  
42  
Percentage (%)  
14.0  
20–34  
186  
72  
62.0  
35 and above  
Married  
24.0  
213  
48  
71.0  
Marital Status  
Education Level  
Occupation  
Single  
16.0  
Widowed/Divorced  
No formal education  
Primary  
39  
13.0  
174  
69  
58.0  
23.0  
Secondary and above  
Farming/Trading  
Civil service  
Unemployed  
57  
19.0  
201  
36  
67.0  
12.0  
63  
21.0  
Skilled Birth Attendance Coverage: Only 42 percent of respondents reported that their most recent delivery  
was attended by a skilled birth attendant. Table 2 shows the distribution of delivery locations and attendant  
types.  
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Table 2: Delivery Location and Attendant Type  
Delivery Location  
Home  
Attendant Type  
Traditional birth attendant  
Skilled birth attendant  
Skilled birth attendant  
Mixed  
Frequency  
Percentage (%)  
174  
82  
38  
6
58.0  
27.3  
12.7  
2.0  
Primary health center  
Secondary facility  
Other (mission/private)  
Maternal Health Outcomes: The study found a strong association between skilled birth attendance and  
improved maternal health outcomes. Table 3 compares complications reported by women with and without  
skilled birth attendance.  
Table 3: Maternal Complications by Birth Attendant Type  
Complication  
With SBA (n = 120)  
7 (6.0%)  
Without SBA (n = 180)  
32 (17.8%)  
Postpartum hemorrhage  
Prolonged labor  
Neonatal asphyxia  
Sepsis  
9 (7.5%)  
41 (22.8%)  
5 (4.2%)  
27 (15.0%)  
3 (2.5%)  
19 (10.6%)  
Logistic regression analysis revealed that women attended by skilled personnel were 3.4 times more likely to  
experience safe delivery outcomes (p < 0.01).  
Barriers to Skilled Birth Attendance: Respondents identified several barriers to accessing skilled birth care.  
Table 4 presents the frequency of reported barriers.  
Table 4: Reported Barriers to Skilled Birth Attendance  
Barrier  
Frequency  
234  
Percentage (%)  
78.0  
64.0  
52.0  
39.0  
31.0  
Long distance to health facility  
Lack of transportation  
192  
156  
Cultural preference for TBAs  
Perceived cost of facility delivery  
Absence of female health workers  
117  
93  
Qualitative Insights: Thematic analysis of interviews and focus group discussions revealed four major  
themes:  
a. Trust and Familiarity with Traditional Birth Attendants: Women expressed strong emotional and  
cultural ties to traditional birth attendants, citing their accessibility and empathetic care.  
b. Perceived Quality of Care at Health Facilities: Negative experiences such as verbal abuse, long wait  
times, and lack of privacy discouraged women from seeking skilled care.  
c. Gender Dynamics and Decision Making: In many households, decisions about delivery location were  
made by male partners or elders, limiting women’s autonomy.  
d. Impact of Community Health Education: Communities with active health education programs showed  
increased awareness and utilization of skilled birth services.  
Health Facility Records: Review of facility records from 2022 to 2024 supported survey findings. Facilities  
with higher SBA coverage reported lower maternal mortality ratios. Table 5 summarizes the comparison.  
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Table 5: Maternal Mortality Ratios by SBA Coverage  
Facility Type  
SBA Coverage (%)  
MMR (per 100,000 live births)  
>70  
<40  
210  
540  
High SBA coverage  
Low SBA coverage  
DISCUSSION  
The findings of this study provide compelling evidence that skilled birth attendance significantly improves  
maternal health outcomes in hard to reach communities of Adamawa State. This section interprets the results in  
relation to existing literature, policy frameworks, and the unique sociocultural context of the study area.  
Skilled Birth Attendance and Maternal Outcomes: The quantitative data revealed that only 42 percent of  
births in the study areas were attended by skilled personnel, a figure consistent with national trends in rural  
northern Nigeria (National Population Commission, 2023). Women who received skilled care experienced  
markedly lower rates of postpartum hemorrhage, prolonged labor, and neonatal complications. These findings  
align with global evidence that skilled birth attendance is one of the most effective interventions for reducing  
maternal and neonatal mortality (World Health Organization, 2024; Campbell and Graham, 2006).  
The logistic regression analysis further confirmed that skilled birth attendance was a strong predictor of safe  
delivery outcomes. This reinforces the argument that increasing skilled birth attendance coverage in  
underserved areas is not merely a health system improvement but a lifesaving strategy.  
Barriers to Accessing Skilled Care: The study identified several barriers that hinder women from accessing  
skilled birth services. Long distances to health facilities and lack of transportation were the most frequently  
cited challenges, affecting over 70 percent of respondents. These findings echo those of Adepoju and Yusuf  
(2024), who reported that geographic isolation and poor infrastructure are major impediments to maternal  
health service delivery in Adamawa.  
Cultural preferences for traditional birth attendants also emerged as a significant barrier. Many women  
expressed trust and familiarity with traditional birth attendants, whom they viewed as more empathetic and  
accessible than formal health workers. This sentiment was particularly strong among older women and those  
with limited education. While traditional birth attendants play an important role in community support, their  
lack of formal training poses risks during obstetric emergencies. Integrating traditional birth attendants into the  
formal health system through training and collaboration could help bridge this gap.  
Gender Dynamics and Decision Making: Qualitative data highlighted the influence of gender norms on  
maternal health decisions. In many households, male partners or elders determined where women should  
deliver, often favouring home births or traditional birth attendant assisted deliveries. This lack of autonomy  
limits women’s ability to seek skilled care, even when they are aware of its benefits. Addressing gender  
dynamics through community education and male engagement programs is essential for improving skilled  
birth attendance uptake.  
Perceived Quality of Care: Negative experiences at health facilities, including verbal abuse, long wait times,  
and lack of privacy, were reported by several participants. These issues contribute to mistrust and discourage  
future use of skilled services. Improving the quality of interpersonal care, ensuring respectful maternity  
services, and training health workers in patient cantered communication are critical steps toward increasing  
skilled birth attendance utilization.  
Role of Health Education: Communities with active health education programs showed higher awareness and  
utilization of skilled birth services. This suggests that targeted health promotion can effectively shift cultural  
norms and improve health seeking behavior. Programs that involve community leaders, religious figures, and  
peer educators are particularly effective in rural settings.  
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Facility Performance and System Strengthening: Health facility records confirmed that centers with higher  
skilled birth attendance coverage had significantly lower maternal mortality ratios. This underscores the  
importance of strengthening primary health care systems, deploying skilled personnel, and ensuring functional  
referral mechanisms. Investments in infrastructure, equipment, and continuous training are necessary to sustain  
improvements in maternal health outcomes.  
Conceptual Framework Reflection: The application of the Three Delays Model provided a useful lens for  
interpreting the findings. The first delay, deciding to seek care, is influenced by cultural beliefs, gender norms,  
and health education. The second delay, reaching care, is shaped by geographic and transportation barriers.  
The third delay, receiving adequate care, is affected by facility readiness and quality of services. Skilled birth  
attendance addresses all three delays by promoting timely decision making, facilitating access through  
outreach services, and ensuring competent care upon arrival.  
CONCLUSION  
This study has demonstrated that skilled birth attendance plays a pivotal role in improving maternal health  
outcomes in hard to reach communities of Adamawa State, Nigeria. The findings revealed that women who  
delivered with the assistance of skilled personnel experienced significantly fewer complications such as  
postpartum haemorrhage, prolonged labour, and neonatal distress. These outcomes affirm the global consensus  
that skilled birth attendance is a critical intervention for reducing maternal and neonatal mortality.  
Despite its proven benefits, the coverage of skilled birth attendance in the study areas remains low, with only  
42 percent of respondents reporting access to such care during their most recent delivery. The barriers  
identified including geographic isolation, lack of transportation, cultural preferences for traditional birth  
attendants, and perceived poor quality of care highlight the multifaceted challenges that must be addressed to  
improve maternal health services.  
Qualitative insights further emphasized the importance of community trust, gender dynamics, and health  
education in shaping maternal health behaviours. Women’s experiences and perceptions of care, as well as the  
influence of household decision makers, play a significant role in determining whether skilled services are  
utilized.  
The application of the Three Delays Model provided a useful framework for understanding how skilled birth  
attendance can mitigate delays in seeking, reaching, and receiving adequate care. By addressing these delays,  
skilled birth attendance contributes not only to safer deliveries but also to broader improvements in maternal  
health equity.  
In conclusion, expanding access to skilled birth attendance in Adamawa’s hard to reach communities is both a  
public health imperative and a moral obligation. It requires coordinated efforts across government, health  
systems, and communities to overcome structural and cultural barriers. The evidence presented in this study  
offers a strong foundation for policy makers, health planners, and development partners to design targeted  
interventions that will save lives and promote maternal wellbeing.  
RECOMMENDATIONS  
Based on the findings of this study, the following recommendations are proposed to improve maternal health  
outcomes through increased access to skilled birth attendance in hard to reach communities of Adamawa State:  
1. Strengthen Deployment of Skilled Birth Attendants: The government and health authorities should  
prioritize the recruitment, training, and equitable distribution of skilled birth attendants across rural and  
underserved areas. Incentive packages such as rural service allowances, housing support, and career  
development opportunities can encourage skilled personnel to work in remote locations.  
2. Establish Mobile Maternal Health Clinics: Mobile clinics equipped with skilled birth attendants and  
essential obstetric supplies should be deployed to reach isolated communities. These clinics can operate  
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on scheduled visits and provide antenatal care, safe delivery services, and postnatal follow up. This  
approach has proven effective in similar settings and can bridge the gap in facility access.  
3. Integrate Traditional Birth Attendants into the Formal Health System: Rather than excluding  
traditional birth attendants, efforts should be made to train and integrate them into the formal health  
system. This can include basic obstetric training, referral protocols, and collaboration with skilled  
personnel. Such integration respects cultural norms while enhancing safety and continuity of care.  
4. Improve Transportation and Referral Systems: Investment in community based transportation  
schemes such as emergency transport services, tricycle ambulances, and road infrastructure is essential.  
Strengthening referral systems between primary and secondary health facilities ensures timely  
management of complications and reduces maternal mortality.  
5. Promote Community Health Education and Engagement: Health education campaigns should be  
intensified to raise awareness about the benefits of skilled birth attendance. These campaigns should be  
culturally sensitive and delivered through trusted community channels including religious leaders,  
women’s groups, and local radio. Engaging men and elders in maternal health education can also shift  
decision making dynamics in favor of facility based care.  
6. Enhance Quality of Care in Health Facilities: Improving the quality of care in health facilities is critical  
to building trust and increasing utilization. This includes training health workers in respectful maternity  
care, ensuring privacy and dignity during childbirth, and addressing complaints promptly. Facilities  
should also be adequately equipped with essential drugs, supplies, and emergency obstetric equipment.  
7. Implement Monitoring and Evaluation Systems: Robust monitoring and evaluation systems should be  
established to track skilled birth attendance coverage, maternal health indicators, and service quality. Data  
collected should inform policy adjustments and resource allocation. Community feedback mechanisms  
can also be incorporated to ensure accountability and responsiveness.  
8. Foster Multi Sectoral Collaboration: Improving maternal health requires coordinated efforts across  
sectors including health, transportation, education, and finance. Partnerships with non-governmental  
organizations, donor agencies, and community based organizations can mobilize resources and expertise  
to support maternal health initiatives.  
LIMITATIONS  
This study was limited to five local government areas in Adamawa State, which may not represent the entire  
region. Security challenges restricted access to some communities. Data were largely self-reported, introducing  
potential recall bias. The cross sectional design limits causal inference, and resource constraints affected  
sample size and depth of qualitative engagement. Despite these limitations, the findings provide valuable  
insights into maternal health in underserved areas.  
REFERENCES  
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2. Adepoju, A., & Yusuf, M. (2024). An appraisal of statistical trends in maternal health outcomes in  
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3. Campbell, O. M., & Graham, W. J. (2006). Strategies for reducing maternal mortality: Getting on with  
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