COMPLETE SCHOOL PROJECT TOPICS & MATERIALS :
CHAPTERS: Chapter 1-5
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Abstract
Socio-cultural risk factors for maternal mortality was noticed by the researcher during
her community posting programme in Amechi Awkunanaw, where 2 out of every 20
deliveries resulted in death of a mother in addition to unregistered deaths. It was also
observed that those deaths were most often connected with poor knowledge of risk
factors for maternal mortality and issue of decision making to seek health care.
Descriptive survey research design was used and the target population was childbearing
mothers (15 -49 years) who are indigene of the community. Sampling technique was
done using purposive sampling to select the community and 22% of the women’s
population was used to get the target population (childbearing women). A sample size of
377 respondents, who met the inclusion criteria, was drawn from the target population
using Taro Yameni’s formula. A proportionate sampling method (Amogu, 2001) was
used to get the sample size of each of the 9 villages in the community. Data was
collected using researcher’s developed interview guide and household data collection
was adopted to reach the subjects. Data was analyzed using simple descriptive statistics
ranging from frequency, percentage of various categories, chi-square goodness of fit test,
chi-square test of association and fishers exact test. Conclusions were made at α =0.05.
Early marriage, female circumcision and hard labour in the farm were neither existing
nor practiced in Amechi Awkunanaw (P<.001). Male dominance was significantly
(P<.001) existing in Amechi Awkunanaw, however, not to the extent of denying the
childbearing women the right to decide on attending for maternal health care in case of
obstetric emergency.
Son preference was also significant (P<.001) but the desire for male child did not
influence the child bearing attitude of women nor the number of children they wish to
have in this community. Food restriction was observed among childbearing women but
the restriction on snail and bush meat was more significant (P<.001) than on egg and
milk. There was no sufficient evidence to conclude that childbearing women were
exempted from taking decision on matters that concerns their health (P=.135). A
significant proportion (P<.001) of the childbearing women of Amechi Awkunanaw did
not know that early marriage, male dominance, male preference and exemption from
decision making on issues concerning maternal health can lead to a woman’s death. A
significant (P<.001) proportion of respondents knew that female circumcision can lead to
death of a woman. Meanwhile, there was no significant difference (P=.959 & P=.149)
between those respondents who knew that food taboo and early pregnancy can lead to a
woman’s death. Significantly, the childbearing women of Amechi Awkunanaw knew
that prolonged labour, bleeding in pregnancy/child birth can lead to maternal mortality.
A significant number of respondents in Amechi Awkunanaw perceived that lack of
trained personnel and worsening condition of mother and/or baby were the major
consequences of delivering baby outside government hospital. A significant proportion
of respondents attended their antenatal/delivery/postnatal care in hospital/health center
while only 10 respondents had this maternal care with TBAs/family elderly women in
the community. The major reason given the childbearing women in Amechi Akunanaw
for early marriage in this study was poverty; for female circumcision it was to prevent
promiscuity; for bearing more children after having 5 children, was the desire to have as
many children as God would give; for taking permission from husband to attend for
maternal health care, it was lack of money; for attending for maternal care with TBAs
family elderly women in the community, were easy accessibility and affordability. A
significant relationship existed between the knowledge of the respondents on the
association between the practice of early marriage, food taboo, and male preference and
maternal mortality and the extent of their practice.It was therefore recommended that
necessary legislations be made on various aspects of health issues about the childbearing
women and to involve men in maternal health care issues in order to achieve a unified
positive outcome.
CHAPTER ONE
INTRODUCTION
Background of the Study
Maternal and perinatal health has emerged as the most important issue that determines global
and national wellbeing. This is because every individual, family and community is at some
point intimately involved in pregnancy and the success of childbirth (WHO, 2006). Despite
the honour bestowed on womanhood and the appreciation of the birth of ababy, however,
pregnancy and child birth is still considered a perilous journey (Ladipo, 2005). WHO in 2010
estimated that 630/100,000 live birth resulted in maternal death. The picture however is
different in developing world and more alarming. The disparity in death between developed
and developing countries are greater for maternal mortality than for any other global health
problem (WHO, 2006). For instance, Nigerian women face a 1 in 29 chance of dying from
childbirth whereas the average risk throughout Sub Saharan Africa is 1 in 39 and the risk in
developed countries in as low as 1 in 3,800 (Epstain, 2013). According to the UN and World
Bank Statistics (2010) an estimate of 144 women die each day in Nigeria from pregnancy
related complications, ranking her the 10th most dangerous countries for women to deliver
babies in the world. Available data in Enugu state which is one of the six states in the South
East geopolitical zone of Nigeria indicated that maternal mortality is high with a figure
ranging from 772 to 998 per 100,000 ( Chigbu, Okaro, Onah & Umeh, 2009). ).
Consequently, the reduction in maternal mortality is a major agenda of many global
initiatives such as millennium development goals (MDGs).
Nevertheless, the year 2015, was targeted for achieving a global reduction in maternal
mortality, but the continuing high rate of maternal mortality ratios in Nigeria remains
worrisome. However, not all hope is lost. Although Nigeria is fighting an uphill battle with
regards to achievement of MDG 5, the “Abiye and Save Life at Birth” are two grand
strategies for development currently working to decrease maternal death in Nigeria. The
progress of Abiye began with extensive surveys at the community level, allowing
programmers to gain a better understanding of why Nigeria suffers high maternal mortality
rate.
Abiye (Safe Motherhood) was launched by Ondo State Government and has been making
progress in diminishing maternal death in the region. In this regard the centre for Strategic
and International Studies highlights Abiye progress as a major success and encourage other
states to seek similar innovative approaches towards improving maternal health.
Nonetheless, Nigeria maternal death rate dropped to 224/100,000 live birth in December
2013 (Prof. Onyebuchi Chukwu, 2013) against 545/100,000 live birth (report from UN World
Population Prospects and Institute for Health Metrics, 2010).
According to Storeng, (2010), maternal care and maternal death have an inversely parallel
relationship. His historical review also revealed the complexity and multifactoral aspects of
maternal mortality. And as such, the causes of maternal mortality cannot be categorized as
social, political, economic, demographic or clinical rather an outcome of nexus of interaction
of a variety of factors. For instance, the distant factors [socio-economic and cultural] act
through the proximate or intermediate factors (health and reproductive behavior, access to
health services) which in turn influence outcome (pregnancy complications/mortality) (WHO,
2012).
Poor maternal health status in Nigeria and indeed in Enugu state is, therefore, largely
attributed to poor antenatal care practices, lack of access to and use of skilled attendants at
birth and weak health care delivery system (Ezugwu, Ezugwu & Okafor 2005). However,
socio-cultural risk factors such as harmful traditional practices and other factors that act as
barriers to utilization of available services have influenced the maternal death rate in Nigeria
(Hartfield, 2009). Major traditional/cultural practices that affect maternal health adversely
include early marriage and female genital cutting (WHO 2010).
Child marriage is a violation of human rights, compromising the development of girls and
often results in early pregnancy and social isolation, with little education and poor vocational
training reinforcing the gendered poverty. Also early marriage predisposes girls to maternal
mortality since their reproductive organs are not yet well developed and cannot cope with the
process of childbirth. Female circumcision is a practice that involves removing all or part of
the external genitalia and/or stitching and narrowing the vaginal orifice. This practice affects
maternal mortality because a woman with a circumcised vulva is more likely to experience
difficult labour, perineal tear and post partum haemorrhage which may lead to maternal
mortality. According to WHO, (2012) the rate of maternal death is doubled by genital
mutilation and the risk of still birth increased. Social, cultural, religious and personal reasons
support the persistence of this practice in some parts of Nigeria. Some of these reasons include maintaining tradition and custom, promoting hygiene, upholding family honour,
controlling women’s sexuality and protecting women’s virginity until marriage (Population
References Bureau 2008).
Son preference also contributes in deteriorating women’s health in most rural community.
This is because high parity in most rural women is most times associated with the desire for
male child in order to satisfy the custom and value of the community (AL-Meshari 2012). A
woman that has no male child may continue bearing children in trying to get one thereby
jeopardizing her health status.Male dominancy and gender role impact great influence on
maternal mortality. For instance, because of the subordinate position of women in the rural
communities, even when they can make genuine decision as regards their health, they are not
allowed to initiate and carry them out. Traditionally, women are assigned most domestic
duties including working in the farms, in-spite of the stresses of childbearing. All these
contribute to impoverishing women’s health and eventual death (Fletschner and Kerr 2008).
Religious factors and food taboos have also been shown to be important in increasing
maternal mortality in Nigeria. Food taboos and restrictions create problems for childbearing
women since some of the restricted foods contain essential nutrients needed during pregnancy
and peurperium. Some foods like eggs and snail which pregnant mothers are not allowed to
eat in some families/communities are good sources of protein and calcium needed by these
women.
Whatever the cause may be, the growing concern among the civil society about unacceptable
level of maternal mortality in Nigeria has spear headed efforts to improve maternal and child
health. For example, the Association of Reproductive and Family Health (ARFH), Planned
Parenthood Federation of Nigeria and Pathfinder International Nigeria have worked
throughout the decade to expand reproductive health services in Nigeria. The Federal
Ministry of Health produced a National Reproductive Health policy in 2001 (FMOH, 2001)
and a National Reproductive Health Strategic Framework in 2002 with specific objective of
reducing maternal mortality (FMOH, 2002).
As the Millennium Development Goals (MDGs) target date is at hand (2015), there is a
growing sense of urgency among international agencies to intensify efforts of global
challenge of maternal health, in order to achieve MDG 5 by the end this date. The African
Union made maternal and child health a keystone of their respective annual summits, and the
United Nations launched the Global Strategy for Women’s and Children’s Health at a special
General Assembly event. These are efforts to achieve the MDG target of reducing the global
maternal mortality by 75%.
From the above overview of maternal health services, one would expect a comprehensive
health system that would impact women’s reproductive health and bring maternal death to the
barest minimum level. Despite the wide range of maternal health services available, the full
achievement of MDG 5 in Nigeria in this 2015 is still question marked. This is not
unconnected with the weak management and implementation of health policy and services
compounded with socio-economic and cultural factors. Worthy of note is the fact that the
federal government and health policy makers had developed several strategies to tackle other
causes of maternal death in the country while the socio-cultural factors had received very
little attention. Moreover, those responsible for resolving these maternal health challenges
may not be aware that some of these socio-cultural risk factors still exist in many rural
communities in the country and the extent of these practices are obviously under estimated
Statement of Problem
Thousands of Nigerian children are left motherless and 59,000 women die yearly as a result
of complications of childbirth (FMOH/WHO 2013). Socio-cultural practices such as early
marriage, early pregnancy, female genital mutilation, marginalization of women in decision
making regarding issues that concern women and low status of women within the rural
communities in Nigeria have been associated with maternal mortality (Soyata 2009).
Statistics show that 24.4% of girls in Enugu State between the ages 15-19 are married while
the figure for boys is insignificant (1%) (Chukwuezi, 2010). The WHO estimates that
between 100-140 millions of girls and women worldwide are presently living with female
genital mutilation and every year about 3 million girls are at risk (WHO, 2008). In Nigeria,
genital mutilation averages 50% with the prevalence rate of 48% in the South East Zone
(WHO, 2008). Also, socio-cultural factors have placed women in abject poverty as a result
of societal roles which placed male gender at advantaged position over women, such as
having more access to education and material resources. Socio-cultural beliefs such as male
child preference and low status of women have sentenced some rural women of childbearing
age to their graves in trying to get male children for their husbands (Acholonu C, Nwadiaro C
& Okorafor, 2008).
In Amechi Awkunanaw Community of Enugu South Local Government Area, the researcher
observed during community posting in Amechi community that average of 2 out of every 20
deliveries resulted in death of the mother and most often connected with male dominancy
over the women, female genital mutilation, and issue of decision to seek health care and other
socio-cultural practices. Moreover, the population officer covering the community reported
that some deaths are not registered by the people of this community except when properties
are to be claimed. The researcher also observed that the majority of these women reported
late to the available health centre with already existing complications such as ante/post
partum haemorrhage, puerperal sepsis, anaemia, cervical/perineal tears and obstructed labour.
The questions, therefore, are: are these risk factors for maternal mortality still existing in
Amechi community, what are their reasons for the practice and to which extent do they
engage in these risk factors as no study in this field known to the researcher has been done in
this locality. These questions prompted the researcher to empirically assess these risk factors
for maternal mortality among child bearing women of Amechi Awkunanaw.
Purpose of the Study
The purpose of the study is to assess the socio-cultural risk factors for maternal mortality and
the awareness of the childbearing women of the risk factors in Amechi Awkunanaw, Enugu.
Objectives of the Study
The specific objectives of the study are to:
1. Identify the currently existing social risk factors for maternal mortality in Amechi
Awkunanaw.
2. Identify the currently existing cultural risk factors for maternal mortality in Amechi
Awkunanaw.
3. Determine the child bearing women’s knowledge of the association between these
socio-cultural risk factors and maternal mortality.
4. Determine the extent to which these socio-cultural risk factors are practiced by these
women of child bearing age in Amechi Awkunanaw.
5. Determine their reasons for the practice of these identified socio-cultural factors for
maternal mortality.
6. Determine the relationship between the knowledge of the association between sociocultural
risk factors and maternal mortality and the extent of practice of these risk
factors.
Research Questions
Based on the specific objectives formulated for this study, the following research questions
were asked.
1. What are the social risk factors for maternal mortality existing in Amechi
Awkunanawaw?
2. What are the cultural risk factors for maternal mortality existing in Amechi
Awkunanaw?
3. What knowledge do women in Amechi Awkunanaw have on the association
between these risk factors and maternal mortality?
4. To what extent do women in Amechi Awkunanaw practice the identified sociocultural
risk factors for maternal mortality?
5. What reason(s) do women in Amechi Awkunanaw have for engaging in the
practice of these socio-cultural risk factors for maternal mortality?
6. What relationship is there between their knowledge of the association between
socio-cultural risk factors and maternal mortality and the extent of practice of
these risk factors?
Significance of the Study
The public health significance of this study cannot be overemphasized as the result of this
study will reveal the socio-cultural risk factors for maternal mortality still being practiced in
Amechi Awkunanaw. It will also reveal the reasons why these risk factors for maternal
mortality are practiced in this community. It will help elicit the knowledge of these mothers
on the association between these risk factors and maternal mortality including the extent to
which they practice these risk factors. When the existing socio-cultural risk factors for
maternal deaths are identified, their eradication will become easier by making them parts of
the antenatal health education components and the government can legislate against such
risks on the ground of their bio-medical justifications as well as human right violation. The
findings from the study will also provide a baseline for health programme designers to create
programmes that will involve these women as stakeholders, rather than mere audience
without active participation. The result of this study will also equip the health policy makers
with the information that may help them to enlarge their scope into multi-sectoral approach in
order to curb all the cultural and social dimensions of maternal mortality. It is therefore
necessary that the health care providers and health policy makers should look into the
practice of these socio-cultural risk factors for maternal mortality in order to plan, develop
and implement effective strategies to check them especially in the rural communities and thus
reduce maternal mortality. And for this, they would need information on these socio-cultural
factors currently existing rural communities, the motive for practicing them and the women’s
knowledge on the consequences of these risk factors for maternal mortality.
The end result of all the above will facilitate the achievement of Millennium Development
Goal 5 (improve maternal health), targeted to reduce maternal death ratio by three quarter by
the end of 2015. The outcome of this study may also be valuable to future researchers
interested in working in this field.
Scope of the Study
This study will be delimited to the childbearing women of Amechi Awkunanaw Community
of Enugu South Local Government Area. It will also be delimited to the assessment of social
and cultural risk factors for maternal mortality in this community. Specifically it is delimited
to identifying the existing social and cultural risk factors for maternal death, the knowledge
of these women on the association between these risk factors and maternal mortality, the
extent to which these risk factors are practiced, the motives for the practice of these risk
factors and the relationship between the women’s knowledge on the association between
these risk factors and maternal mortality and the extent of such risk factors.
Operational Definition of Terms
Socio-Cultural Risk Factors: In this study means beliefs, practices, values, notions and
behaviours held and handed down from generation to generation which constitute dangers to
maternal health and can eventually lead to the death of childbearing women. These include
the following social and cultural beliefs and practices.
Social Risk Factors for Maternal Mortality: These include early marriage (less than 21
years; section 18 of marriage act), early pregnancy, exemption of women in decision making
in health matters concerning themselves.
Cultural Risk Factors: These include food taboos, female circumcision, male preference
and male dominance.
Knowledge of the association between socio-cultural risk factors and maternal
mortality: This means whether these women know that these cultural risk factors can lead to
their ill-health/death or not and complications that can arise from specific risk factors. For
instance, whether they know that female circumcision can lead to prolonged labour, perineal
tear or obstructed labour and consequent death; if they believe that that these complications
are serious and may lead to death; if they believe that they are susceptible to these
complications and consequent death; if they are aware of women who have had these
complications or died due to these risk factors.
Extent of Practice: This means, how often these socio-cultural risk factors for maternal
mortality are practiced. For example how often they practice female circumcision, early
marriage or exemption from decision making e.g. the percentage of childbearing women
studied who were circumcised; their siblings and daughters that were circumcised; the
percentage that were giving out early in marriage and which of these risk factors are practiced
more.
Reasons for the Practice: This means their motives for practicing these risk factors for
maternal mortality. For example, why do they engage in these risk factors for maternal death?
Why do they prefer male children to female children? Why do they place males’ interest over
females’?