Structural Determinants of Maternal Mortality in Northern Nigeria: A Theoretical and Empirical Examination Through a Nursing Lens

Background: Nigeria accounts for one of the highest maternal mortality burdens globally. Despite extensive epidemiological data, structural determinants mediated through nursing system capacity remain undertheorised and empirically underexamined in Northern Nigeria. Aim: This study examined the structural determinants of maternal mortality with particular attention to nursing system capacity in Zamfara, Kebbi, and Sokoto States. Methods: An explanatory sequential mixed-methods design combined state-level secondary data analysis of maternal mortality records over five years with a cross-sectional survey of 250 nurses and 40 qualitative in-depth interviews with maternal health stakeholders. Structural equation modelling and thematic analysis provided complementary findings. Results: Nurse-to-population ratios, nurse midwifery skill certification rates, and facility-level nursing supervision intensity were the strongest structural predictors of county-level maternal mortality variation. Qualitative data revealed that cultural gatekeeping, inadequate nurse authority in obstetric decision-making, and supply chain failures compound structural gaps. Conclusion: Nursing system strengthening is a critical and underinvested strategy for reducing maternal mortality in Northern Nigeria. The study advocates for targeted midwifery workforce expansion, nurse authority frameworks in obstetric emergencies, and culturally adapted nursing outreach models. Keywords: maternal mortality, structural determinants, nursing, Northern Nigeria, midwifery.