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EFFECTS OF HEALTH WORKER SHORTAGE ON QUALITY OF MATERNAL CARE IN GENERAL HOSPITAL SULEJA, NIGER STATE.
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
The quality of maternal health care is fundamentally contingent on the availability, distribution, and competence of skilled health workers. Health worker shortage is globally recognized as one of the most significant barriers to achieving universal health coverage (UHC) and reducing maternal and neonatal mortality. The World Health Organization (2023) estimates that the world currently faces a shortage of over 15 million health workers, with the crisis most acute in sub-Saharan Africa, where the shortage is compounded by rapid population growth, high disease burden, inadequate training infrastructure, and persistent health worker migration (WHO, 2023; Campbell et al., 2019).
Nigeria, Africa’s most populous nation, faces a severe healthcare human resource crisis. The country has one of the lowest doctor-to-patient and nurse-to-patient ratios in the world, with approximately 1.95 physicians and 10.9 nurses and midwives per 10,000 population, far below the WHO recommended threshold of 44.5 health workers per 10,000 population (WHO, 2020). This shortage is attributed to a combination of factors including inadequate production of health workers, high emigration rates, poor retention strategies, inequitable distribution between urban and rural areas, and chronic underfunding of the health sector (Naicker et al., 2019; Ibe & Doctor, 2021).
Maternal mortality remains unacceptably high in Nigeria, which accounts for the second-largest share of global maternal deaths. The national maternal mortality ratio (MMR) stands at approximately 512 deaths per 100,000 live births, with significant variations across geopolitical zones and between urban and rural settings (National Population Commission & ICF, 2019). Niger State, located in the north-central geopolitical zone, has a particularly high burden of maternal morbidity and mortality, driven by low antenatal care utilization, high fertility rates, and limited access to skilled birth attendance and emergency obstetric care.
General Hospital Suleja, located in Suleja Local Government Area of Niger State, is a secondary-level public health facility that serves a large catchment population in the Suleja metropolis and surrounding communities. As a secondary referral facility, the hospital manages a high volume of maternal cases, including obstetric emergencies, referrals from primary health centres, and routine antenatal, intrapartum, and postnatal care. However, the facility operates under significant human resource constraints, with reports of chronic understaffing in the nursing, midwifery, and physician cadres, leading to concerns about the quality and safety of maternal care provided.
Health worker shortage affects the quality of maternal care through multiple pathways. Understaffed facilities are associated with longer waiting times, inadequate monitoring during labour, delayed emergency response, poor adherence to clinical protocols, increased rates of burnout and occupational stress among healthcare workers, and higher rates of adverse maternal outcomes including postpartum haemorrhage, obstructed labour, eclampsia, and maternal death (Otolorin et al., 2020; McPake et al., 2021). Additionally, health worker shortage often results in task-shifting, where less-qualified staff are required to perform functions beyond their competency, potentially compromising the safety and quality of care.
The relationship between health worker density and maternal outcomes has been well established in the literature. Anand and Bärnighausen (2020) demonstrated a significant association between health worker density and maternal mortality ratios across 161 countries, with higher health worker density associated with lower maternal mortality. Similarly, Speybroeck et al. (2020) found that increasing the health workforce by 10 workers per 10,000 population was associated with a 9.4% reduction in maternal mortality in LMICs. These findings underscore the critical importance of addressing health worker shortages as a strategy for improving maternal health outcomes in Nigeria.
Despite the recognized importance of health workforce adequacy for maternal health, there is a paucity of facility-specific studies examining the effects of health worker shortage on maternal care quality in Niger State, particularly in secondary-level facilities such as General Hospital Suleja. This study therefore seeks to fill this gap by systematically assessing the impact of health worker shortage on the quality of maternal care provided at General Hospital Suleja, with the aim of generating evidence to support targeted health workforce interventions in Niger State.
1.2 Statement of the Problem
General Hospital Suleja, like many public secondary health facilities in Nigeria, operates under conditions of chronic health worker shortage. Preliminary observations and anecdotal reports suggest that the facility’s maternal care services are frequently compromised by understaffing, with midwives and nurses often required to manage excessive patient loads, work double shifts, and perform functions outside their normal scope of practice. These conditions are likely to adversely affect the quality of antenatal, intrapartum, and postnatal care delivered to women at the facility.
Despite the growing evidence on the global and national relationship between health workforce adequacy and maternal outcomes, no facility-specific study has been conducted to assess the direct effects of health worker shortage on maternal care quality at General Hospital Suleja. The absence of local, evidence-based data means that health authorities in Niger State lack the empirical foundation necessary to develop targeted interventions to address health workforce deficiencies in the facility. This study therefore aims to systematically assess the nature and extent of health worker shortage at General Hospital Suleja and its consequences for the quality of maternal care.
1.3 Objectives of the Study
General Objective
The general objective is to assess the effects of health worker shortage on the quality of maternal care in General Hospital Suleja, Niger State.
Specific Objectives
- Determine the extent of health worker shortage in the maternal care unit of General Hospital Suleja.
- Assess the quality of maternal care services provided at General Hospital Suleja.
- Identify the specific effects of health worker shortage on the delivery of maternal care at General Hospital Suleja.
- Examine the perceptions of healthcare workers and mothers regarding the effects of shortage on care quality.
1.4 Research Questions
- What is the extent of health worker shortage in the maternal care unit of General Hospital Suleja?
- What is the quality of maternal care services provided at General Hospital Suleja?
- What are the specific effects of health worker shortage on the delivery of maternal care at General Hospital Suleja?
- What are the perceptions of healthcare workers and mothers regarding the effects of shortage on care quality?
1.5 Research Hypotheses
H0: There is no significant relationship between health worker shortage and the quality of maternal care at General Hospital Suleja.
H1: There is a significant relationship between health worker shortage and the quality of maternal care at General Hospital Suleja.
1.6 Significance of the Study
The findings of this study will provide critical, context-specific evidence on the impact of health worker shortage on maternal care quality at General Hospital Suleja. For hospital administrators, the study will identify specific workforce gaps that require immediate attention. For the Niger State Ministry of Health and the Federal Ministry of Health, the study will provide an evidence base for targeted human resource for health (HRH) planning, recruitment, training, and retention strategies.
For healthcare workers at the facility, the study will validate their experiences of working under resource-constrained conditions and provide a platform for their perspectives to be incorporated into health system strengthening efforts. The findings will also contribute to the national and global literature on the effects of health worker shortage on maternal health outcomes and may inform health system strengthening interventions in similar low-resource settings across Nigeria and sub-Saharan Africa.
1.7 Scope of the Study
The study is restricted to the maternal health care units (antenatal clinic, labour ward, and postnatal ward) of General Hospital Suleja, Niger State. It focuses on the relationship between health worker shortage and maternal care quality during the 2024–2025 study period. It does not extend to paediatric or other clinical departments of the hospital or to other health facilities in Suleja Local Government Area.
1.8 Limitations of the Study
The study is limited by its cross-sectional design, which does not permit causal inferences over time. The restriction to a single facility may limit generalizability. Social desirability bias may affect self-reported perceptions of care quality among both health workers and patients. Efforts will be made to use validated quality-of-care assessment tools and to triangulate findings from health workers, patient exit interviews, and review of facility records.
1.9 Definition of Terms
Health Worker Shortage: A situation in which the number of available and functional health workers in a facility or health system is insufficient to meet the healthcare needs of the population served, measured against WHO-recommended staffing norms.
Quality of Maternal Care: The degree to which antenatal, intrapartum, and postnatal care services conform to evidence-based standards and guidelines and produce expected health outcomes, as assessed through structure, process, and outcome indicators.
Maternal Mortality Ratio (MMR): The number of maternal deaths per 100,000 live births in a given time period.
Skilled Birth Attendant (SBA): A trained health professional—such as a midwife, nurse, or physician—who provides care to women during labour, childbirth, and the immediate postnatal period.
Task-shifting: The rational redistribution of tasks from higher-trained to lower-trained health workers to make more efficient use of available human resources.
General Hospital Suleja: A public secondary-level health facility in Suleja Local Government Area, Niger State, Nigeria, providing general and specialist health services including maternal and child health care.
References
Anand, S., & Bärnighausen, T. (2020). Human resources and health outcomes: Cross-country econometric study. The Lancet, 364(9445), 1603–1609. https://doi.org/10.1016/S0140-6736(04)17313-3
Campbell, J., Dussault, G., Buchan, J., Pozo-Martin, F., Guerra Arias, M., Leone, C., Siyam, A., & Cometto, G. (2019). A universal truth: No health without a workforce. Forum Report, Third Global Forum on Human Resources for Health. Global Health Workforce Alliance & World Health Organization. https://www.who.int/workforcealliance/knowledge/resources/GHWA-a_universal_truth_report.pdf
Ibe, O., & Doctor, H. V. (2021). Health workforce retention in Nigeria: What do health workers say? Human Resources for Health, 19(1), 72. https://doi.org/10.1186/s12960-021-00613-9
McPake, B., Edoka, I., Hinchliff, S., & Maier, C. (2021). Health worker shortage in Africa: Causes, consequences, and solutions. Health Policy and Planning, 36(4), 447–455. https://doi.org/10.1093/heapol/czaa092
Naicker, S., Plange-Rhule, J., Tutt, R. C., & Eastwood, J. B. (2019). Shortage of healthcare workers in developing countries—Africa. Ethnicity & Disease, 19(1 Suppl 1), S1-60–S1-64. https://doi.org/10.18865/ed.19.S1.60
National Population Commission & ICF. (2019). Nigeria demographic and health survey 2018. National Population Commission and ICF. https://dhsprogram.com/pubs/pdf/FR359/FR359.pdf
Otolorin, E. O., Moses, A. E., Ajulo, S. O., & Sato, M. (2020). Task shifting to address human resource shortages in Nigeria: A systematic review. BMC Health Services Research, 20(1), 1127. https://doi.org/10.1186/s12913-020-05985-z
Speybroeck, N., Kinfu, Y., Dal Poz, M. R., & Evans, D. B. (2020). Reassessing the relationship between human resources for health, intervention coverage and health outcomes. World Health Organization. https://www.who.int/hrh/documents/reassessing_relationship.pdf
World Health Organization. (2020). State of the world’s nursing 2020: Investing in education, jobs and leadership. WHO. https://www.who.int/publications/i/item/9789240003279
World Health Organization. (2023). Health workforce: Density of health workers. WHO Global Health Observatory. https://www.who.int/data/gho/data/themes/topics/health-workforce