IMSHIA records zero maternal deaths in 2025: a mixed-methods case study on the role of health insurance in improving maternal health

Background Achieving zero maternal deaths remains a major challenge in Sub-Saharan Africa, largely due to financial barriers and limited access to skilled care. In 2025, the Imo State Health Insurance Agency (IMSHIA) reported zero maternal deaths, presenting a unique opportunity to examine the role of health insurance in improving maternal health outcomes. Methods A descriptive cross-sectional mixed-methods study was conducted among 344 women of reproductive age in Imo State, Nigeria. Quantitative data on awareness, enrollment, and maternal health service utilization were collected using structured questionnaires. Qualitative data were obtained through key informant interviews with IMSHIA officials alongside media content analysis. Logistic regression identified predictors of utilization, while thematic analysis was applied to qualitative data. Results Awareness of IMSHIA was high (96.5%), with 90.7% of women enrolled, largely through government subsidies. Antenatal care was the most utilized service (79.1%). Higher education and prior awareness were significant predictors of utilization. Qualitative findings highlighted IMSHIA’s integrated approach, including financial risk protection, free maternal services, and a functional referral nexus across four zones enabling emergency obstetric interventions within 45 minutes. Over 3,000 successful surgeries were recorded, alongside expanded enrollment of pregnant women and strengthened provider capacity. These combined strategies were associated with improved service uptake and the reported zero maternal deaths in 2025. Conclusion IMSHIA demonstrates how health insurance can contribute to achieving zero maternal deaths through financial protection, improved access, and strengthened health system capacity. Sustaining and scaling such models could accelerate progress toward reducing maternal mortality in Sub-Saharan Africa. Clinical trial number: Not applicable