Systemic Design Approaches to Addressing Maternal Healthcare Access Inequalities in Rural North East Nigeria

Maternal mortality rates in rural North East Nigeria remain among the highest globally, driven by a systemic failure of healthcare access characterised by geographic isolation, shortage of trained birth attendants, absence of functional referral systems, and inadequate maternal health information infrastructure. This doctoral study applies systemic design methodology to investigate the complex web of factors sustaining maternal healthcare access inequalities in rural communities of Gombe, Adamawa, and Taraba states, and develops original systemic design interventions tested through a two-year participatory implementation programme. Drawing on systemic design theory, public health systems thinking, and feminist design scholarship, the research employs causal loop modelling, participatory systems mapping with community health workers, traditional birth attendants, and district health management teams, and iterative design prototyping to develop, test, and refine three interconnected design interventions: a community maternal health information kit, a birth preparedness planning tool, and a referral coordination communication system. Each intervention is evaluated through implementation science frameworks assessing adoption, fidelity, and health outcome indicators across twenty intervention communities. The study develops an original Systemic Design for Health Equity Framework specifying the theoretical conditions under which design-led system interventions can achieve durable impact in structurally inequitable healthcare systems. Contributions advance systemic design theory, global health systems research, and the design for social innovation literature in Sub-Saharan African contexts. Keywords: systemic design, maternal health, health equity, North East Nigeria, participatory design.