A Population-Level Analysis of the Effectiveness of Community-Based Skilled Birth Attendant Programmes on Maternal Mortality Reduction in Four Nigerian States

Community-based skilled birth attendant (CBSBA) programmes have been implemented across rural Nigerian states to extend skilled delivery coverage, but rigorous population-level effectiveness evaluations using robust quasi-experimental designs are absent from the literature. This dissertation conducts a population-level quasi-experimental evaluation of CBSBA programme effectiveness on maternal mortality reduction in Kogi (North Central), Yobe (North East), Imo (South East), and Edo (South South) States. Difference-in-differences analysis compared maternal mortality ratio trajectories in CBSBA programme implementation zones against matched control zones without programme exposure across a nine-year period (2015 to 2023), using facility-based maternal death surveillance data supplemented by community maternal death notification records. Interrupted time series analysis of skilled birth attendance coverage provided programme mechanism verification. CBSBA implementation was associated with a significant reduction in maternal mortality ratio in programme zones (difference-in-differences estimate: -128 per 100,000 live births, 95% CI -198 to -58), with the largest effect observed in Yobe State. Skilled birth attendance coverage increased by 19 percentage points above the secular trend in programme zones. The effect was moderated by community health worker density, suggesting complementarity between CBSBA and community health worker systems. The dissertation provides the first quasi-experimental population-level effectiveness estimate of CBSBA programmes in Nigeria and contributes an original methodological framework for evaluating maternal health programmes in resource-limited settings. Keywords: skilled birth attendant, maternal mortality, community programme effectiveness, quasi-experimental, Nigeria