“I don't like to be seen by a male provider”: health workers’ strike, economic, and sociocultural reasons for home birth in settings with free maternal healthcare in Nigeria

BACKGROUND: Ending maternal mortality has been a significant global health priority for decades. Many sub-Saharan African countries introduced user fee removal policies to attain this goal and ensure universal access to health facility delivery. However, many women in Nigeria continue to deliver at home. We examined the reasons for home birth in settings with free maternal healthcare in Southwestern and North Central Nigeria. METHODS: We adopted a fully mixed, sequential, equal-status design. For the quantitative study, we drew data from 211 women who reported giving birth at home from a survey of 1227 women of reproductive age who gave birth in the 5 y before the survey. The qualitative study involved six focus group discussions and 68 in-depth interviews. Data generated through the interviews were coded and subjected to inductive thematic analysis, while descriptive statistics were used to analyse the quantitative data. RESULTS: Women faced several barriers that limited their use of skilled birth attendants. These barriers operate at multiple levels and could be grouped as economic, sociocultural and health facility–related factors. Despite the user fee removal policy, lack of transportation, birth unpreparedness and lack of money pushed women to give birth at home. Also, sociocultural reasons such as hospital delivery not being deemed necessary in the community, women not wanting to be seen by male health workers, husbands not motivated and husbands’ disapproval hindered the use of health facilities for childbirth. CONCLUSIONS: This study has demonstrated that free healthcare does not guarantee universal access to healthcare. Interventions, especially in the Nasarawa state of Nigeria, should focus on the education of mothers on the importance of health facility–based delivery and birth preparedness.