Abstract / Summary
Abstract Background: Social Health Insurance (SHI) despite providing financial protection to pregnant women “Antenatal care - delivery mismatch" persists where women complete recommended antenatal care (ANC) at booked health facility but deliver at home without skilled birth attendance. This study investigated the pattern and determinants of ANC-delivery mismatch, especially among Kano State Contributory Healthcare Management Agency (KSCHMA) enrollees in Kano State, Nigeria. Methods: We conducted a sequential mixed-methods study across 20 accredited KSCHMA facilities in Kano State between January and June 2026. We collected quantitative data from a multistage cluster sample of 1,080 enrollees who had delivered within the preceding 12 months and attended ANC at any of the selected facilities. Multinomial logistic regression identified independent determinants of ANC-delivery mismatch. Qualitative data from 6 sessions of Focus Group Discussions (FDGs) with women and 12 Key Informant Interviews (KIIs) with stakeholders were analysed using thematic framework analysis based on Andersen’s Behavioural Model of Health Services Use. Results: The pattern of ANC-delivery mismatch among enrollees was (50.7%) among those booked at Primary Health Care (PHC) facility but delivered at home, (31.9%) booked at PHC and delivered at Secondary Health Care (SHC) or private facility, (6.8%) booked and delivered elsewhere (SHC or private facility), and (10.6%) booked and delivered at PHC. Multinomial regression modelling showed that the primary determinants of mismatch included rural residence [aOR 5.171; 95% CI (1.026–26.047); p = 0.046] and being a full-time housewife [aOR 25.027; 95% CI (1.282–488.451); p = 0.034],which were significantly associated with home delivery, bypassing the booked PHC. Women in semi-urban areas were more likely to deliver in a booked PHC [aOR 23.163; 95% CI (1.951–274.9720); p = 0.013], which significantly reduced the odds of PHC bypassing. Qualitative themes reinforced supply-chain failures, referral and system fragmentation, and gendered decision-making norms as pivotal systemic barriers. Conclusions: Social health insurance financial protection is necessary but insufficient to ensure facility delivery. Reducing ANC–delivery mismatch requires strengthened supply chains, respectful maternity care, emergency referral transport, and male involvement in birth preparedness. Clinical Trial Number: Not applicable