Maternal and child healthcare-seeking among victims of violence in armed conflict: A quasi-experimental study in northeast Nigeria∗

Armed conflict severely impacts health, with indirect deaths often exceeding direct casualties 2–4 times, disproportionately affecting women and children. Although the magnitude of these effects is well-documented, the mechanisms driving them remain insufficiently understood. This study shifts the focus from supply-side factors, such as the destruction of infrastructure, to demand-side processes, particularly healthcare-seeking behavior, and from broader conflict exposure to individual-level violent victimization.

Methods

Data come from a representative survey (n = 3,006) of caregivers of young children in northeastern Nigeria, a region heavily affected by armed insurgency. Unlike previous studies, our survey included dedicated measures of victimization, health-seeking outcomes, and potential mediating factors within a single instrument, enabling precise measurement and analysis. To compare maternal and child healthcare-seeking behavior between victimized and non-victimized caregivers, we employed a quasi-experimental observational design using propensity-score matching on demographic and contextual characteristics. Causal mediation analysis was then used to identify the mechanisms linking victimization to health behaviors.

Results

Victimization was widespread, with 21% of respondents (n=651) having experienced a severe form of violence in the past 3 years. While maternal healthcare-seeking behavior appeared unaffected, victimization significantly reduced healthcare-seeking for child health. Children of victimized caregivers were markedly less likely to be fully immunized (Odds ratio (OR): 0.43, p<0.001) and to receive care at government health facilities (OR: 0.23, p<0.001). This decline was primarily driven by increased distrust in the health system (PM: 0.42–0.70, p<0.05), stemming from negative experiences during the conflict, particularly health worker absenteeism and victimization by state security forces.

Conclusion

Addressing fear and mistrust is key to improving healthcare-seeking in conflict-affected populations. Efforts should focus on providing security for government-run health facilities, reducing violence against civilians by state security forces, and restoring trust in healthcare and state institutions. Future research should explore effective strategies for achieving these objectives.

What is already known?

• Armed conflict has severe negative consequences for maternal and child health, yet the underlying mechanisms remain understudied.

• Recent research has called for a greater focus on how exposure to violence shapes the demand for health services and healthcare-seeking behavior—a gap this study addresses with a representative survey (n = 3,006) in northeastern Nigeria.

What are the new findings?

• Rather than approximating exposure through proximity to conflict, this study directly measures individual-level victimization and examines potential mediating mechanisms with high precision.

• 21% of respondents reported severe victimization; these individuals showed markedly lower child immunization rates (OR = 0.43, p < 0.001) and were less likely to use government health facilities (OR = 0.23, p < 0.001).

• These differences are driven by mistrust of healthcare workers, predicated on absenteeism and prior victimization by state security forces.

What do the new findings imply?

• Preventing further erosion of trust likely requires reliable health service delivery and restraint by security forces.

• To improve child health outcomes, trust-building in healthcare and state institutions should be integrated in recovery programs.