Health System Leadership and Maternal Healthcare Service Utilisation: A Mixed-Methods Study of Rural-Urban Inequities in Anambra State, Nigeria

Abstract Background Maternal mortality remains a major public health challenge in Nigeria, contributing approximately 14% of global maternal deaths. Enhancing access to maternal healthcare services is central to achieving Sustainable Development Goal (SDG) 3, and effective healthcare leadership can influence how services are organised, delivered, and accessed. Objective This study assessed the utilisation of maternal healthcare services (MHS) among rural and urban women in Anambra State, Nigeria, and examined the leadership styles within healthcare facilities. Methods A descriptive cross-sectional study using a mixed-methods approach was conducted among 640 women of reproductive age selected from rural and urban communities. Quantitative data were collected using a semi-structured, pre-tested, interviewer-administered questionnaire adapted from the Access to Health Services Questionnaire (AHSQ) and the Maternal Health Belief Questionnaire (MHBQ). Data were analysed using STATA/BE version 17. Qualitative data were collected through 10 key informant interviews (KIIs) conducted with purposively selected heads of healthcare facilities, using an interview guide adapted from the Multifactor Leadership Questionnaire (MLQ). Qualitative data were analysed thematically using NVivo 14. Results Overall utilisation of the full continuum of maternal healthcare, defined as at least four antenatal visits, skilled birth attendance, and postnatal care within 42 days postpartum, was low, with only 33.1% of women meeting all criteria. Urban women demonstrated higher utilisation across antenatal care, skilled delivery, and postnatal care compared to rural women. Leadership across facilities was predominantly transformational in both settings, contributing to staff motivation and patient satisfaction, although structural limitations in rural facilities constrained service delivery. Conclusion Transformational healthcare leadership should be sustained and augmented to improve continuity of care and maternal health outcomes across the State.