Multilevel Determinants of Adverse Maternal–Fetal Outcomes in Resource-Constrained Settings: An Integrated Obstetric and Health Systems Analysis from Nigeria

Abstract

In Nigeria, adverse maternal foetal outcomes continue to be disproportionately high despite extended coverage of antenatal and delivery services, which suggests a systemic, persistent gap in clinical and contextual failures and health outcomes. This paper examines the multilevel factors underlying unfavourable maternal-foetal outcomes in Nigeria through an integrated obstetric and health systems approach. The research analysis was based on nationally representative data from 6,842 women aged 15-49 years who were pregnant at the time of the recent outcomes. The effects of individuals, communities, and the health system were assessed using multilevel logistic regression models, supported by interaction, mediation, stratified, and predicted probability analyses. Findings: The poor maternal- foetal outcomes were 31.7/100 behind expectations, with even rural pregnant women (36.5/24.1) and those who had less than four antenatal care (ANC) visits (38.8/21.9). In fully adjusted models, the strongest predictors were inadequate ANC (aOR = 1.82; 95% CI: 1.59-2.09) and non- facility delivery (aOR = 1.94; 95% CI: 1.67-2.25). Clustering at the community level also accounted for 18.6% of the outcome variance, which was reduced to 9.4% with adjustment. The impact of poor ANC was higher among rural residents (aOR = 1.27; 95% CI: 1.05-1.54), whereas it was greater in northern Nigeria (aOR = 2.09). Of the protective influence of maternal education, 33.6% was mediated by ANC. Projected probabilities indicated a risk of 49.3% among rural women who received insufficient care, compared with 19.2% among well-served urban women. Adversarial maternal-foetal outcome in Nigeria is system-mediated and context-dependent and necessitates equity- centred health system strengthening that enhances access, and thus quality and continuity of maternal care.