Published on August 2026 | Primary healthcare

Enabling-Resource Deficits as the Primary Driver of Incomplete Postnatal Care in Sub-Saharan Africa: A Critical Interpretive Synthesis for Nigeria

Background: Global endorsement of the World Health Organization’s (WHO) four-contact postnatal care (PNC) schedule has not translated into commensurate completion rates, particularly across sub-Saharan Africa. The prevailing model, attributing low completion to deficient maternal knowledge, is increasingly contradicted by studies reporting high awareness alongside persistently low completion. Objective: This critical interpretive synthesis interrogates the assumed knowledge-practice relationship in PNC utilization and advances an alternative explanation using Andersen’s Behavioral Model of Health Services Use. Methods: A critical interpretive synthesis was conducted, employing iterative constant comparison and contradiction-mapping of the literature rather than sequential reporting of findings. Twenty-seven sources, including peer-reviewed primary studies, systematic reviews, and official WHO and Nigerian Demographic and Health Survey reports published between 2018 and 2026, supplemented by foundational theoretical works from 1995-2006, were retained. Results: Maternal knowledge of danger signs and the recommended visit schedule was frequently moderate to high (50–91%), yet completion of all four WHO contacts ranged from 10% to 84.8%, varying almost exclusively with enabling conditions rather than knowledge. Divergence in completion despite comparable knowledge reflected differences in health workforce adequacy, commodity availability, physical access, and partner involvement. We argue this reflects an enabling-resource gap, not a knowledge-practice gap: predisposing knowledge is necessary but insufficient, while enabling resources gatekeep its conversion into completed utilization. Conclusion: Interventions must shift from passive health education to active system-strengthening. The priority is to measure and mitigate enabling-resource deficits rather than maternal knowledge. Ogbomoso, Nigeria, is identified as a priority site for testing this reframed, system-centric model.