From Delays to Systems in Maternal Healthcare Utilisation: A Conceptual Framework Study

To develop an operational, systems-oriented framework for analysing sustainable maternal healthcare utilisation, grounded in Nigerian evidence and intended for contextual adaptation and testing.

Conceptual framework study using narrative synthesis, structured comparative evidence synthesis and independent face and content appraisal.

Nigeria, with consideration of applicability to other maternal healthcare settings.

Purposively selected peer-reviewed Nigerian maternal healthcare studies; three independent external appraisers comprising two maternal-health researchers and one healthcare professional.

We synthesised empirical evidence into linked domains and hypothesised relationships, compared it with established maternal-health and health-systems frameworks and challenged it against additional Nigerian studies. Appraisers assessed relevance, clarity, completeness, cross-domain plausibility, and practical utility.

Conceptual coherence, domain relevance, completeness, explanatory plausibility, practical utility, and candidate indicators of sustainable maternal healthcare utilisation; no patient-level clinical outcomes were measured.

We specified six linked domains: policy and governance, health-system capacity, community engagement, equity, quality of care, and monitoring, evaluation and learning. Governance provides structural conditions; capacity, quality and community engagement interact; equity modifies pathways; and monitoring supports feedback and adaptation. External appraisal offered qualified support and identified boundaries requiring refinement.

The framework offers a testable systems structure for diagnosing interacting barriers and guiding context-appropriate indicators and multilevel interventions. Prospective testing is needed to establish construct validity, responsiveness and transferability.