Theoretical Modelling of Obstetric Transition Across Nigerian States: Health System, Demographic, and Epidemiological Drivers

The obstetric transition framework posits that as populations develop, the leading causes and rates of maternal mortality evolve predictably from direct obstetric causes toward indirect causes and lower overall mortality. Nigeria presents a uniquely heterogeneous obstetric transition landscape across its 36 states, yet no theoretical modelling of the drivers and pace of this transition at state level has been conducted. This dissertation develops an original theoretical model of obstetric transition across Nigerian states, integrating health system, demographic, and epidemiological determinants. Secondary data analysis used state-level data from the 2018 and 2023 Nigeria Demographic and Health Surveys, National Health Facility Survey, and FMOH routine health information system. Principal component analysis identified three composite transition drivers: health system capability index, demographic modernisation index, and epidemiological burden index. Hierarchical cluster analysis classified the 36 states and FCT into four transition stages: pre-transitional (12 states, primarily North West and North East), early transitional (10 states), transitional (8 states), and late transitional (7 states plus FCT). The dissertation introduces the Nigeria Obstetric Transition State Classification System (NOTSCS) as an original analytical contribution, providing a framework for differentiated maternal health policy design. Simulation modelling projects that universal skilled birth attendance would advance 14 states by one full NOTSCS category within a decade. The dissertation advances obstetric transition theory by demonstrating its applicability at sub-national level within a single low-income country. Keywords: obstetric transition, Nigeria, maternal mortality, theoretical modelling, health system