Abstract
Background: Nigeria faces significant health challenges, with a maternal mortality ratio of 1,047 per 100,000 live births and a perinatal mortality rate of 45 per 1,000. The northern region has disproportionately worse health indices. Skilled Health Personnel (SHP) working in an enabling environment is critical to improving care quality and reducing maternal and perinatal mortality. This PhD investigated factors influencing SHP effectiveness in delivering maternal and newborn health (MNH) care in Northern Nigeria.Methods: A systematic review was conducted to identify strategies for enhancing SHP effectiveness in low- and middle-income countries. Findings informed a mixed-methods study that assessed the enabling environment in 48 health facilities across three northern states, Kaduna, Kwara, and Bauchi, covering primary, secondary, tertiary, and private/faith-based levels. Health facility assessment was conducted using the WHO SARA tool. Work-related Stress(WRS) was assessed among 194 SHPs using a structured tool developed by the Union of Shop, Distributive and Allied Workers (USDAW), and training needs among 187 SHPs were examined. Informed by the training needs assessment, a competency-based Emergency Obstetrics and Newborn Care (EmONC) training program was integrated into the Nursing and Midwifery Council of Nigeria’s Continuing Professional Development (CPD) system and evaluated for effectiveness. Qualitative data from focus group discussions and key informant interviews explored facilitators and barriers to SHP performance. Quantitative data were analysed using SPSS version 28, and qualitative data using NVIVO version 12.
Results: The review identified systemic barriers to SHP performance and highlighted the role of mid-level cadres in bridging MNH gaps (Objective 1). Facility assessments showed that only 38% had 24/7 electricity, and 13% had emergency supplies. There were no written standard operating procedures in any facility. Although average staff numbers met national benchmarks,(Workload Indicators of Staffing Need) WISN analysis revealed a misalignment between staffing levels and actual service workload, with shortages of nurse-midwives and overstaffing of CHEWs in some facilities. (Objective 2). Work-related stress prevalence was 76%; 37% worked over 60 hours weekly, and 25% attended over 40 patients daily. Stress was highest among Junior CHEWs and House Officers (p < .05). Key stressors included workload (r = 0.58), inadequate breaks (r = 0.50), and patient harassment (r = 0.36). Coping strategies included peer support, self-care, and intrinsic motivation. Institutional support was absent in 88% of facilities (Objective 2). Fewer than 40% of SHPs felt competent in managing MNH emergencies. In-service training was sporadic and primarily NGO-led, with barriers including inequitable selection and workload pressures (Objective 3). EmONC training significantly improved knowledge and skills (p < .001), and participants reported it aligned with clinical needs (Objective 3).
Conclusion: This research highlights the interplay between systemic barriers, stress, and training gaps affecting SHP performance. EmONC training addressed competence needs, but sustained impact requires stronger commitment from professional bodies
| Date of Award | 6 Oct 2025 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Charles Ameh (Supervisor), Justin Pulford (Supervisor) & Abera Tura (Supervisor) |