Determinants of Skilled Birth Attendance in Nigeria: A Population-Based Analysis of the 2018 Demographic and Health Survey

Abstract Background Nigeria accounts for approximately 19% of global maternal deaths, yet skilled birth attendance (SBA) coverage stood at only 44.9% in 2018. Understanding the independent determinants of SBA after controlling for confounding is essential for evidence-based policy prioritisation. Methods We conducted a cross-sectional analysis of 21,465 women with a birth in the five years preceding the 2018 Nigeria Demographic and Health Survey (NDHS). Survey-weighted multivariable logistic regression was used to estimate adjusted odds ratios (aOR) for seven sociodemographic predictors of SBA. Confounding was quantified by comparing crude and adjusted estimates. Results Overall SBA prevalence was 44.9%, ranging from 17.7% in the North West to 85.6% in the South West. Higher education (aOR = 7.01, 95% CI: 5.68–8.67), richest wealth quintile (aOR = 6.27, 95% CI: 5.27–7.46), and attending ≥4 antenatal care (ANC) visits (aOR = 3.80, 95% CI: 3.51–4.11) were the strongest independent predictors. Confounding was substantial: 89.0% of education’s crude effect and 87.1% of the wealth effect were attributable to correlated socioeconomic factors. ANC utilisation showed the least confounding (56.3% attenuation), consistent with a more direct causal pathway. Conclusions ANC utilisation is the most modifiable and directly actionable determinant of skilled birth attendance in Nigeria. Geographically targeted investment in ANC coverage, demand-side financing, and girls’ education are urgently needed to close Nigeria’s SBA gap.