Knowledge And Attitude Towards The Causes Of Maternal Mortality Among Women Attending Antenatal Care In Federal Medical Center Birnin Kebbi State

CHAPTER ONE

Introduction

Background to the study

Maternal mortality is a serious public health problem especially in African countries including Nigeria and Birnin Kebbi in particular. Maternal mortality rates in many countries have remained essentially a public health challenge. Worldwide, over 500,000 women of childbearing age die of complications related to pregnancy and childbirth each year. Over 99 per cent of these deaths occur in developing countries such as Nigeria (World Health Organization-WHO 2007). At least 150,000 African women die of pregnancy related complications each year and the number of maternal deaths continues to rise each year in many countries (WHO 2001). Maternal mortality has generated great concern among United Nations (UN) and International Agencies as well as National Governments in 3^rd world countries like Nigeria (Onuzulike, 2006).
WHO estimates that at least 600,000 women worldwide die every year from pregnancy related causes, though the rate is difficult to calculate with accuracy (Clark, 2002). Partnership for Transforming Health Systems-PATHS(2005), stated that everyday, at least 1,450 women worldwide die from  complications of pregnancy and childbirth, that is a minimum of 600,000 women dying every year .The majority of these deaths (almost 99%) occur in  Asia and Sub-Sahara Africa and less than one per cent in the developed world. PATHS further stated that life time risk of maternal death is 1 in 75, in developed country like America  it is 1 in 2,500, while in West Africa it is 1 in 13  (Khalid 2006). This alarming situation of the maternal deaths in the world may not exclude Nigeria.
Nigeria’s maternal mortality rate continues at unacceptably high rate. Royston and Armstrong (1989), reported that maternal mortality ratio in Nigeria is 800 in 100,000 live births. Audu (2010) estimated Nigeria maternal mortality ratio at 1,500 per 100,000 live births. With this figure, Nigeria accounts for 10 per cent of the world’s maternal deaths. According to State Economic Empowerment and Development Strategy-Seeds (2004), in Enugu State, the maternal mortality rate for the South East zone was 286 per 100,000 live births, North West 1549 per 100,000 live births in the year 2000. Maternal mortality rates are twice as high as in rural setting as they are in urban settings. It has been estimated that 1:18 women of childbearing age in Nigeria face a life time risk of dying from pregnancy related causes compared to 1:2400 in Europe, 1:5100 in U.K and 1:7,700 in Canada (PATHS, 2005). From record, it has been shown that Nigeria is one of the countries with highest maternal mortality ratios in the world.
Maternal death has been defined as the death of a woman while pregnant or within 42 days of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes (Lewis & Drife, 2001).The complications of pregnancy may be experienced during pregnancy or delivery itself or may occur up to 42 days following childbirth. Maternal mortality in the context of the present study is defined as the death of a woman during pregnancy, in labour or first six weeks after delivery or termination of pregnancy from causes directly due to pregnancy or to conditions aggravated by pregnancy.
The Nigerian Demographic and Health Survey-NDHS (2008) posited that Nigeria ranks second globally (next to India) in number of maternal deaths. The data also suggest that the ratios are different in the six geopolitical zones of the country. A population-based study indicated that maternal mortality ratio is worst in Northern Nigeria; an average staggering figure of 2,420 (ranging between 1,373 and 4,477) per 100,000 live births was recorded in Kano State (Chama, 2004). In the North Eastern region, Borno State has an estimated maternal mortality ratio of 1,549 per live births, while 1,732 per 100,000 live births was reported from Bauch State in the same North East region (Glew & Uguru, 2005).These ratios are the worst in the world. In Plateau State, maternal mortality ratio of 740 per 100,000 live births was reported (Uja, Aisien, Mutihir & Vander 2005). A ratio of 1700 per 100,000 live births was reported from Lagos, and that of Sagamu was 1,930 per 100,000 live births, all in South Western Nigeria (Agboghoroma & Emuveyam. 1997). Enugu State as one of the states in Nigeria is not left out of this ugly situation.
Kebbi State, one of the states with the highest rates of new-born mortality (under the age of five) in the country, has been rated as one of the states with the highest rates in the world.
The state records 32,514 deaths of children under the age of 5 annually. Following this, the state has been rated fourth by the United Nations’ International Education Fund (UNICEF) on the index of places with the highest infant mortality rates.
 
The Chief of Health ,UNICEF, Dr.Sanjana Bhardwaj stated that “The state is one of the highest in Nigeria, with a record of 32,514 children under the age of 5 dying yearly,” she said. She said, considering the steady drop in Nigeria’s mortality rate, the issue of Kebbi was worrisome and affects the country’s mortality rate.Graham (2001) grouped maternal deaths into direct and indirect obstetric deaths Direct obstetric deaths are deaths resulting from obstetric complications during pregnancy, labour or puerperium, or from interventions, omissions or incorrect treatments or from a chain of events resulting from eclampsia, postpartum haemorrhage or sepsis. Indirect obstetric deaths are those deaths resulting from a previously existing disease or a disease that developed during the pregnancy. Examples are anemia, HIV and AIDS, malaria or heart disease. These deaths accruing from pregnancy related complications have some causes.
Federal Ministry of Health-FMH (2007) identified haemorrhage, puerperal sepsis obstructed labour, unsafe abortion and pregnancy induced hypertension as major causes of maternal mortality. Other causes indicated by FMH are malaria, anemia, HIV and AIDS, diabetes mellitus and hepatits. Omoruyi (2010) stated that five major causes of maternal deaths are haemorrhage, infection, abortion, hypertensive diseases of pregnancy and obstructed labour. Also, poor access to and non utilization of quality reproductive health services tend to contribute to the high maternal mortality level in Nigeria.
Haemorrhage refers to excessive bleeding more than 500 meals during late pregnancy, delivery or after delivery. This accounts for about 23 per cent of maternal deaths (FMH, 2007). Hypertensive diseases of pregnancy occur in about 4 per cent of pregnancies, especially in the last stage of pregnancy (United Nations Fund-UNICEF & WHO, 1990). Hypertensive diseases include pre-eclampsia and eclampsia. The clinical manifestations are high blood pressure protein in urine oedema convulsion and coma. Obstructed labour may be caused by ineffective uterine contractions, cephalopelvic disproportion, (CPD) malpresentation or malposition (Diana & Copper, 2003). Obstructed labour always put the mother at risk of developing vesico-vaginal fistula(VVF), recto-vaginal fistula (RVF), infection  rupture of the uterus fetal  maternal exhaustion and death. This contributes 11 per cent of maternal deaths (FMH, 2007).
Unsafe abortion is defined as the termination of unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal standards, or both (Warriner & Shah, 2006). Globally, it has been estimated that some 68,000 women die each year as a consequence of unsafe abortion and 5.3 million suffer disability (Ahman & Shah, 2002). It accounts for 11 per cent of maternal deaths in Nigeria (WHO, 2005). Kanyghe (2008) indicated that puerperal sepsis causes about 17 per cent of maternal deaths. It is characterized by high fever abdominal pains vomiting headache and loss of appetite. These types of deaths occur mostly in women of childbearing age.
Women of childbearing age are referred to as women aged 15 -45 years (Samuel 2010). Women of childbearing age in this study refer to women aged between 15 -49 years in Nsukka health district of Enugu state. WHO (1998) asserted that some groups of women of childbearing age are more at risk than others. WHO also stated that girls and adolescent women have high risk of pregnancy related complications. This may be because they lack adequate knowledge for prevention of maternal mortality due their under age. Lack of knowledge of maternal mortality may be a reason for negative attitude towards maternal mortality. Nigeria Demographic and Health Survey-NDHS (2003) reported that adolescents constitute a high proportion of maternal mortality cases as a result of complications of unsafe abortion. However, deaths of WAAC during pregnancy and childbirth can be prevented.
Sinclair (1992) defined prevention as action that hinders something from happening. Udeinya (1995) explained that in order to reduce maternal mortality, every woman must be educated on the need to accept and practice family planning as a way of achieving improved health and economic well being. WHO (2001) opined that reducing maternal mortality will depend on identifying and improving services that are critical to the health of Nigerian women including antenatal care, emergency obstetric care, adequate post partum and family planning. UNICEF (2008) posited that interventions for improving maternal health should focus on quality and affordable antenatal care, skilled birth attendance, access emergency obstetric care and postnatal care. Okonofua (2008) identified four main components of interventions as critical to reducing maternal mortality in developing countries as family planning, antenatal care, skilled birth attendance and emergency obstetrics care. Prevention of these regrettable deaths among women of childbearing age could be influenced by their knowledge.
Knowledge is critical to man’s quality of life because everything we do depends on knowledge. WHO (1996) asserted that knowledge is prerequisite for any health action. WHO further maintained that many of the ailments people suffer are to a large extent, self-influenced by anti-health practices due to lack of knowledge. Nigerian Education Research Council-NERC (1972) indicated that an educated, informed and knowledgeable person is the one who understands among other things, the basic facts concerning health and diseases, protects his or her health and that of his or her dependants. Knowledge in the context of this study refers to the ability of women of childbearing age to understand the concept of maternal death, possible causes and preventive measures.
Knowledge about how to take care of pregnant mothers, detect complications and tackle them has existed for centuries. This notwithstanding, millions of mothers continue to die from severe complications associated with pregnancy and childbirth probably because they lack the knowledge inherent in the effective management of pregnancy related problems (Jatua, 2000 & WHO, UNICEF and United Nations Population Fund-UNFPA, 2002). There is need for the possession of adequate knowledge by women regarding maternal deaths resulting from pregnancy and childbirth. Such knowledge is likely to impact positively on the women’s attitude toward maternal mortality.
Abosi (1992) viewed attitude as a person’s position or disposition towards another individual event or thing. Morse (1993) stressed that attitudes are perceptual feelings and beliefs which enables an individual to respond favourably or unfavourably towards persons, groups, ideas, things, objects and events. Nauman (1997) referred to attitude as a mental state of readiness, organized through experience, exerting a dynamic influence upon the individual’s response to all objects and situations with which it is related. Attitude in the context of this study could be emotions, thoughts and feelings that predispose women to respond either favourably or unfavourably to causes of maternal mortality and its preventive practices.
Positive attitude without knowledge may be undesirable or ineffectual, while knowledge without positive attitude is sterile (Wheeler, 1980). Opara (1993) maintained that knowledge and positive attitude must be present for desired change to occur. Knowledge influences attitude positively and positive attitude reinforces knowledge (Onwudinjor, 1998). It is a fact that it could be impossible to form proper attitude on how to avert maternal deaths without first knowing the causes of death in pregnancy and childbirth. Both knowledge and attitude of women of childbearing age can be influenced by certain socio-demographic variables.
One of such variables that seem to influence knowledge of and attitude to maternal mortality among women of childbearing age in Nsukka health district is age. Muokwogwo (1992) indicated that a woman’s age is the most universal factor predisposing a woman to risk of injuries and or death during pregnancy and childbirth. Muokwogwo also indicated that adolescents (15-19) with little or no knowledge of prevention of maternal mortality recorded higher rate of maternal deaths than older mothers of 35 years and above. WHO (1998) indicated that mothers of 35 years and above though may have knowledge of maternal mortality tend to exhibit negative attitude to maternal deaths.
Nakajima (1995) opined that education is crucial to knowledge of causes and prevention of maternal mortality among women. Nakajima further stated that educated women have more knowledge of causes and prevention of maternal mortality and exhibit more positive attitude to its prevention than non-educated women. Educated women avoid early marriages, teenage pregnancy, high parity and attend ante-natal and post-natal services more frequently than the illiterate ones.
Preventing Maternal Mortality Network-PMMN-(2005) indicated that educated women are more knowledgeable about maternal mortality and also exhibit more positive attitude than their uneducated counterparts. PMMN also indicated that educated women have more understanding of the physiology of reproduction and so are more disposed to understand the complications and risks of pregnancy than illiterate mothers. Educated women tend to seek for maternal health care services in standard health facilities with skilled birth attendants while the illiterate women preferred maternity homes with quacks.
Besides age and education, another variable that seems to influence knowledge of and attitude to maternal mortality is location. Omeje (2000) observed that there is a high level of knowledge of causes and positive attitude to prevention of maternal mortality among urban dwellers while low level of knowledge and negative attitude were found among rural dwellers. Umoh (2010) reported that low level of knowledge and negative attitude to maternal mortality among rural dwellers may be attributed to few health facilities and health practitioners in the rural areas. Moreover the quality of health services provided in the rural areas is far lower than the services provided in urban health facilities.
Another variable is occupation. When WAAC are not gainfully employed, it reduces their will power to access maternal health services and to maintain good health condition. Onuzulike (2006) stated that poverty is a major economic factor associated with maternal death. Onuzulike pointed out that poor women are less likely to be in good health and seek or receive medical care when pregnant. When they could not seek for maternal health care due to poverty, knowledge gained while receiving these services (health education) elude them and attitude too tend to be negative.
Relevant theories and models in the present study include: theory of reasoned action, health action process approach and the three delays model. The theory of reasoned action states that individual’s behaviour is primarily determined by a person’s intention. The health action process approach contends that different factors are at work when a person is deciding which health action(s) to adopt. The three delays model which states that women’s delay in decision making, reaching health facility and obtaining maternal health care services predispose them to maternal death.
Nsukka health district is a typical rural settlement in Enugu State. The district comprises mainly of Igbo ethnic nationality. Women of childbearing age in this district are mostly peasant farmers, hawkers and petty traders. Many of these women are illiterates and are not gainfully employed. They lack adequate finance to eat balanced diet or seek for medical assistance timely. Some are malnourished which put the mothers at risk of anaemia in pregnancy. Also there are few health centres which are not well equipped and are poorly staffed. The available staff may not be disposed to educate these women appropriately about pregnancy and childbirth. The poor distribution of the health systems together with the poor socio-economic status in this district may be affecting the knowledge and attitude of women of childbearing age in Nsukka health district, hence the topic knowledge of and attitude to maternal mortality among women of childbearing age in Nsukka health district. 

Statement of the Problem

When women possess adequate knowledge of and positive attitude to maternal death, they will always desire quality maternal health care services to enable them stay healthy during pregnancy, childbirth and even throughout life. Adequate knowledge and positive attitude will enable them to book early for antenatal in a hospital with emergency obstetric care during pregnancy and to deliver in a standard hospital with skilled birth attendants. WAAC are supposed to practice family planning attend post-natal care services after delivery and report to hospital early for treatment of health problems.
When WAAC have inadequate knowledge of and exhibit negative attitude to maternal deaths, they will seek for maternal health care services in health facilities without skilled health attendants and emergency obstetric care. They register in maternity homes with quacks who cannot manage emergency obstetric problems so, when they have any problem during pregnancy or delivery without emergency services, it may lead to maternal death. Some women even do not book for antenatal at all and only report to hospital in labour with problems. Some WAAC even reject family planning for religious and cultural reasons to the detriment of their health and that of the unborn babies. Even some that managed to deliver in the hospitals fail to report to post-natal care services where they can be examined for early detection of post delivery sepsis.
There is evidence that maternal mortality is a public health concern with higher rates in developing countries including Nigeria than in developed countries of the world. Women die from many causes such as heamorrhage, hypertension, unsafe abortion, sepsis, obstructed labour, anaemia, malaria among others. Of great importance to this ugly situation is the fact that knowledge and attitude of women may be implicated to further compound the problem particularly as they affect their understanding the causes and preventive measures regarding the maternal mortality. But whether WAAC have knowledge of these services and can apply them is another issue that needs to be addressed. Following from the forgoing, there seem to be a need to investigate the Knowledge and attitude towards the causes of maternal mortality among women attending antenatal care in federal medical center Birnin Kebbi state

Purpose of the Study

The purpose of the study is to determine the Knowledge and attitude towards the causes of maternal mortality among women attending antenatal care in federal medical center Birnin Kebbi state Specifically, the study attempted to:

1. determine the level of knowledge of concept of maternal mortality among Women Attending Antenatal Care (WAAC);
2. determine the level of knowledge of causes of maternal mortality among WAAC;
3. determine the level of knowledge of prevention of maternal mortality among WAAC;
4. find out the difference in the level of knowledge of maternal mortality by women according to age;
5. find out the difference in the level of knowledge of maternal mortality by women according to level of education;
6. find out the difference in the level of knowledge of maternal mortality by women according to location;
7. find out the difference in the level of knowledge of maternal mortality by women according to occupation;
8. determine attitude to concept of maternal mortality among WAAC;
9. determine attitude to causes of maternal mortality among WAAC;
10. determine attitude to prevention of maternal mortality among WAAC;
11. find out the difference in the attitude to maternal mortality by women according to age;
12. find out the difference in the attitude to maternal mortality by women according to level of education;
13. find out the difference in the attitude to maternal mortality by women according to location;
14. find out the difference in the attitude to maternal mortality by women according to occupation.

Research Questions

To guide this study the following research questions are posed.

1. What is the level of knowledge of concept of maternal mortality among WAAC?
2. What is the level of knowledge of causes of maternal mortality among WAAC?
3. What is the level of knowledge of prevention of maternal mortality among WAAC?
4. What is the difference in the level of knowledge of maternal mortality by the women according to age?
5. What is the difference in the level of knowledge of maternal mortality by the women according to level of education?
6. What is the difference in the level of knowledge of the women according to location?
7. What is the difference in the level of knowledge of maternal mortality by the women according to occupation?
8. What is the attitude to concept of maternal mortality among WAAC?
9. What is the attitude to causes of maternal mortality among WAAC?
10. What is the attitude to prevention of maternal motility among WAAC?
11. What is the difference in the attitude to maternal mortality by women according to age?
12. What is the difference in the attitude to maternal mortality by women according to level of education?
13. What is the difference in the attitude to maternal mortality by women according to location?
14. What it the difference in the attitude to maternal mortality by women according to occupation?

    Hypotheses

The following null hypotheses were formulated to guide this study. Each of the null hypotheses was tested at .05 level of significance at the appropriate degrees of freedom.

1. There is no significant difference in the level of knowledge of maternal mortality by the women according to age.
2. There is no significant difference in the level of knowledge of maternal mortality by the women according to level of education.
3. There is no significant difference in the level of knowledge of maternal mortality by women according to location.
4. There is no significant difference in the level of knowledge of maternal mortality by women according to occupation.
5. There is no significant difference in the attitude to maternal mortality by women according to age.
6. There is no significant difference in the attitude to maternal mortality by women according to level of education.
7. There is no significant difference in the attitude to maternal mortality by women according to location.
8. There is no significant difference in the attitude to maternal mortality by women according to occupation.

Significance of the Study

The present study provided information on the knowledge of and attitude to maternal mortality among WAAC in Birnin Kebbi. The information obtained will be useful to health educators, nurses, midwives, state ministry of health, and women in general.
The study generated data on the knowledge of concept of maternal mortality. The findings will be beneficial to health educators who will utilize the result to educate women on the meaning of maternal mortality. When women acquire adequate knowledge about maternal mortality, their attitude will also become positive.
The study also generated data on the knowledge of causes of maternal mortality.
The findings will be useful for nurses and midwives who will enlighten women on the causes of maternal mortality in the course of rendering maternal health care services for women. Nurses and midwives will utilize the findings to educate women on the causes and early signs of obstetric complications. When women have adequate knowledge of causes and early signs of obstetric complications, their attitudes toward the causes of maternal mortality will become positive.
The study generated data on the knowledge of prevention of maternal mortality. The findings will be beneficial to the health educators who will organize an enlightenment campaign to educate women on preventive practices to avert maternal mortality. When women are educated on these preventive practices, they will appreciate the need to utilize maternal health care services such as antenatal, postnatal and family planning. Adequate knowledge on the preventive practices will lead to positive attitude to prevention of maternal mortality.
The study generated information on the attitude to concept of maternal mortality. The findings will be useful to health educators who will educate women so that they will have better understanding of the meaning of maternal mortality. This will assist women to avoid conditions that predispose them to death and make effort to prevent death during pregnancy and childbirth, thereby possessing positive attitude.
Data generated on the attitude to causes of maternal mortality will be of great value to the health educators, nurses and midwives who will diligently explain the causes and predisposing factors to women. When women are adequately educated on the causes and predisposing factors, they are likely to exhibit positive attitude to causes of maternal mortality.
The data generated on the attitude to prevention of maternal mortality will be useful to health educators. The data will provide basis for health educators who will health educate and enlighten women on how to avoid pregnancy related complications. The enlightenment programme can be carried in a community level to create awareness on the intervention programmes and where those services can be obtained. It will also help women to change their feelings, thoughts and actions so as to prevent maternal mortality. Positively this will enable women to seek for medical help at the appropriate health facility instead of going to prayer houses or diviners in other to prevent pregnancy complications or even death.
The study generated data on the level of knowledge of maternal mortality by women according to level of education. The findings on the influence of education on knowledge of and attitude to prevention of maternal mortality among WAAC will be beneficial to health educators who will educate women and young girls on the need to pursue education in place of early marriages. In pursuit of education, women will avoid early marriages childbirth, and its consequences Women will also be out to oppose harmful traditional practices inflicted on them that predispose them to maternal mortality. When women are educated their level of knowledge of prevention will be high and their attitude to prevention will be positive. Government may utilize the result to pass a policy on compulsory free female education to tertiary institution.
The study generated data on the influence of age on knowledge of and attitude to maternal mortality. The result of the findings will be useful to health educators in identifying the age groups with high risks of maternal mortality for counselling. When the high risk age groups are properly counseled, their knowledge of proper age of marriage and childbirth will help them to posses’ positive attitude to prevention of maternal mortality. The information will also be useful to health policy-makers in the ministry of health to enact laws on the right age of marriage and childbirth so as to enable young girls to be matured enough before becoming pregnant.
The study generated data on the influence of location on knowledge of and attitude to maternal mortality. The findings will be beneficial to state ministry of health who will identify the areas where maternal mortality is high so as to beef up maternal health care services. The ministry will also utilize the result to ensure equitable distribution of health facilities and health professionals, and at the same time monitor the activities of health professionals especially in the rural areas. When the quality of maternal health services are improved, women’s knowledge will be high and their attitude will be improved.
The data generated on the influence of parity on knowledge of and attitude to prevention of maternal mortality will be useful to the health educators, nurses and midwives. They will utilize the findings to counsel and educate women on the consequences of high parity. With adequate knowledge on the consequences of high parity, their attitude will become positive. This information will assist women to stop at forth childbirth and practice family planning.
Scope of the Study
The present study was delimited to women attending antenatal care (WAA) in FMC Birning Kebbi. he study focused on knowledge of and attitude to maternal mortality among WAAC in the FMC. Independent variables such as level of education, age, location and occupation were examined to indicate if they have influence on the knowledge of and attitude to maternal mortality among WAAC.