A Theoretical Framework for Understanding the Social Ecology of Maternal Mortality in Northern Nigeria: Integrating Structural, Cultural, and Health System Determinants

Maternal mortality in northern Nigeria remains persistently elevated despite national intervention programmes, suggesting that existing explanatory frameworks inadequately capture the multi-level structural, cultural, and health system determinants operating in this context. This dissertation develops an original theoretical framework for understanding the social ecology of maternal mortality in northern Nigeria, integrating social ecology theory, feminist political economy, and health system science into a comprehensive explanatory model. A mixed-methods longitudinal design was employed across four northern states spanning the North West (Kano, Zamfara) and North East (Borno, Adamawa) zones. Quantitative secondary data analysis of state-level maternal mortality ratios, facility delivery rates, and health workforce density was combined with ethnographic fieldwork in 12 rural communities, 40 in-depth interviews with bereaved families and community leaders, and systematic analysis of 60 maternal death cases using the social autopsy method. The framework introduces three original theoretical constructs: Patriarchal Gatekeeping as a structural delay mechanism, Sacred Silence as a cultural barrier to emergency disclosure, and Peripheral Facility Failure as a health system collapse pattern. The framework advances beyond the three-delays model by situating delays within a multi-level social ecological system where determinants interact non-linearly. Empirical validation demonstrates that the framework predicts maternal death risk concentration at the community level with an explained variance of 68 percent, substantially exceeding the predictive capacity of single-determinant models. Implications for health policy, community engagement, and facility readiness are theorised. Keywords: maternal mortality, social ecology, northern Nigeria, theoretical framework, three-delays model