Impact of Decentralization of Reproductive Health Governance on Maternal and Newborn Health Outcomes in Nigeria`s Sub- national Levels: A Systematic Review

Abstract

Decentralization is often hailed as a vital reform aimed at bolstering health systems and enhancing service delivery in low- and middle-income countries (LMICs). However, Nigeria still grapples with troubling maternal and newborn health outcomes, despite the existence of federal policies and donor initiatives, which vary significantly from state to state. This study delves into how decentralization and the autonomy of state-level policies influence reproductive health governance and outcomes in Nigeria. It brings to light both global and regional evidence while examining the differences in maternal and newborn health indicators within the framework of Nigeria’s decentralized governance. Methodology: In August 2025, we carried out a thorough search across various platforms like PubMed, Scopus, Web of Science, African Journals Online, and Google Scholar. Our goal was to explore how decentralization and state-level policy autonomy affect maternal and newborn health in Nigeria. We ended up including two hundred studies from the years 2000 to 2024, all centered around decentralization, health governance, and the outcomes for mothers and newborns. The studies we considered provided either quantitative or qualitative insights on key indicators such as maternal mortality rate (MMR), neonatal mortality rate (NMR), antenatal care (ANC), skilled birth attendance, and immunization rates. These studies spanned global, African, and specifically Nigerian contexts, and also referenced reports from WHO, UNICEF, the Federal Ministry of Health, and the National Primary Health Care Development Agency. We made sure to exclude any non-English and non-empirical articles, and we removed duplicates to keep our findings clean and relevant. Results & Discussion: Recent findings highlight significant differences in maternal and newborn health outcomes across Nigeria’s six geo-political zones. The maternal mortality ratio (MMR) is alarmingly high in the North West at 1,012 per 100,000 live births and in the North East at 930, which is nearly five times greater than the South West's rate of 211. Similarly, the newborn mortality rate (NMR) shows a concerning pattern, with the North West at 37 per 1,000 and the North East at 35, both far surpassing the South West's rate of 19. These disparities point to the varying abilities of states to exercise policy autonomy. States with stronger autonomy, like Lagos, Ekiti, and Anambra, report lower MMRs (ranging from 200 to 280) and NMRs (between 18 and 21), while states with less autonomy, such as Kano, Zamfara, and Yobe, face much higher MMRs (920 to 1,050) and NMRs (38 to 42). The coverage of skilled birth attendance also varies dramatically: high-autonomy states see 80 to 89% coverage, while low-autonomy states lag behind at just 19 to 23%. Overall, these results suggest that decentralized governance and enhanced state-level policy autonomy could lead to more effective maternal and newborn health interventions, especially by improving access to skilled health professionals. Conclusion: The Nigerian case confirms that decentralization, when paired with accountability, political will, and equitable resource distribution, can improve reproductive health outcomes. However, without adequate oversight and fiscal equity mechanisms, decentralization risks exacerbating disparities in maternal and newborn health across states. There is need to connect resource allocation and technical support to tangible evidence of progress on the agreed RMNH outcome indicators.