Evaluation of the Impact of Nigeria’s Free Maternal Surgery Policy on Operative Obstetric Outcomes Across Three Geopolitical Zones

Nigeria has implemented free maternal healthcare initiatives in several states to reduce financial barriers to emergency obstetric surgery, yet rigorous evaluation of the policy's impact on operative obstetric outcomes across geopolitical zones is absent. This dissertation evaluates the impact of state-level free maternal surgery policies on operative obstetric outcomes in the South West, South East, and North West geopolitical zones of Nigeria using a quasi-experimental interrupted time-series design. Health facility data spanning 10 years (2013 to 2023) were obtained from 18 tertiary and secondary hospitals across the three zones. Outcomes analyzed included caesarean section rates, operative delivery complications, maternal mortality ratios, and surgical access equity indicators. Interrupted time-series regression with zone-level fixed effects was applied. Free surgery policy implementation was associated with a significant immediate increase in caesarean section rates in all three zones (incidence rate ratio 1.31, p<0.001). Maternal mortality ratios declined post-policy in South West and South East but not significantly in North West, where supply-side constraints including theatre capacity and blood availability limited policy impact. Health equity indicators improved significantly in South West but minimally in North West. The study identifies supply-side capacity as the critical moderator of maternal surgery policy effectiveness, recommending differentiated policy implementation strategies that pair financial protection with facility readiness investments across geopolitical zones. Keywords: free maternal surgery, caesarean section, maternal mortality, policy evaluation, Nigeria