For more than two decades, maternal health policy in sub-Saharan Africa has been guided by a powerful and intuitive idea: if women can physically reach a health facility, maternal deaths will fall. This logic has driven billions of dollars in investment toward building clinics, training health workers, subsidising care, and expanding coverage. On paper, the strategy has worked. Skilled birth attendance in sub-Saharan Africa rose from just 38% in 2000 to approximately 74% by 2023.1 Facility density has increased; user fees have been reduced or abolished in many countries; and maternal health has remained central to global development agendas. Yet maternal mortality remains catastrophically high. Sub-Saharan Africa still accounts for nearly 70% of all maternal deaths globally, with an estimated 182,000 maternal deaths recorded in 2023 alone.2 The region’s maternal mortality ratio, 454 deaths per 100,000 live births, is more than 150 times higher than that of high-income countries.2 Maternal health interventions have long operated under what might be called the access fallacy: the assumption that availability naturally leads to use. Build clinics and women will come. Train midwives and women will trust them. Remove fees and financial barriers will disappear. This logic has shaped national strategies and donor priorities across the region. But evidence increasingly shows that access alone is a weak predictor of care utilisation. In several sub-Saharan African countries, facility availability is near universal, yet only around two-thirds of births occur in health facilities.1 Even when services are free or subsidised, women frequently opt for home births attended by traditional birth attendants.
Josephine Aikpitanyi (Tue,) studied this question.