Beyond Attitude: A Health-Systems Access Comparison of Exclusive Breastfeeding Practices in Northern and Southern Nigeria
Abstract
Exclusive breastfeeding is one of the most cost-effective child survival interventions possible but the national average rate of EBF in Nigeria has been stagnating at around 29% for well over a decade now. Most of the studies carried out on Nigerian EBF mostly use individual/household factors, mother's education, income, antenatal visit mostly from the Behavioral Model of Andersen to explain subnational variation in EBF rates in Nigeria. The comparison of North-South at health system/supply side factors is uncommon despite the obvious regional variations in primary healthcare provision and distribution of health workers in Nigeria. To compare Northern and Southern Nigeria in the five dimensions of Penchansky and Thomas's theory of access, that is, availability, accessibility, affordability, accommodation and acceptability and to what extent these supply-side factors relate to North-South disparities in the prevalence of EBF. It is a full desk-based, cross-sectional and trends comparison of secondary data (MICS 2021; NDHS 2023-24 and Mini-DHS 2025-26 Key Indicator Reports; State of Health of the Nation Report 2024; National Health Accounts of 2017 and peer-reviewed facility-based and population-based studies). A population- weighted zonal composite has been developed to make North-South comparison. No micro data linkage and regression modeling since there is no NDHS/National Health Facility Survey data; findings are pure structured narrative synthesis. Access indicators have traditionally been lower for Northern Nigeria compared to Southern Nigeria: skilled IJMEPR attendance at birth (16.6%-23.1% North West/ North East compared to 83.6%-84.6% South West/South East); facility delivery (16.4% North West compared to 80.8% South East); health workforce distribution (62% of medical practitioners in the South compared to 28% in the North); PHC quality-of-care scores. However, EBF does not exhibit a North lagging behind the South trend in a clear fashion: according to 2021 MICS zonal EBF prevalence figures, South West (52.6%) had the highest rate, South East (20.3%) and South South (22.2%) had the lowest rate, whereas all three Northern zones had an intermediate rate (29.6%-38.5%). According to the weighted average of the three zonal regions, North had ≈33.1%, while South had ≈34.5%, making the difference smaller compared to the other access indicators. The access indicators of the health care system are capable of explaining a great deal about the North-South difference in obstetric statistics, yet EBF cannot be explained in such a way and depends on Accommodation and Acceptability factors rather than the mere Availability/Acessibility approach. Facilities will have to be increased in the North West and North East regions; however, this is insufficient to address the EBF problem without focusing on the region-specific breast-feeding competencies and the community's trust in them in the South East and South South regions.
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