Background to the Study
Women of Sub-Sahara Africa face the highest risk of maternal mortality and morbidity than any other region in the world. At least 150,000 African women die of pregnancy-related complications every year, and the number of maternal deaths continues to rise each year in many countries. The population of women of childbearing age is now larger than it was in 1989, and the number of women who die each year from pregnancy-related causes has increased even though there have been a slight decline in the risks of pregnancy (Greenwood, 1991; World Bank, 1993). Of all human development indicators, maternal mortality rates represent the greatest disparity between industrialized and sub-Saharan Africa countries (World Bank, 1993).
World Health Organization-WHO (1999), WHO, United Nations Children’s Fund-UNICEF and United Nations Population Fund-UNFPA (2002) reported that out of the estimated 27 million women of reproductive age, one in thirteen dies due to causes related to pregnancy. Royston and Armstrong (1989) reported that the maternal mortality ratio (MMR) is 800/100,000 live births in Nigeria. However, there are wide regional disparities in the statistics. Whereas the Southwest region reports an MMR of 165, the Northeast region reports 1,549. Maternal mortality rates are twice as high in rural settings as they are in urban ones. Of the annual 3 million pregnancies in Nigeria, approximately 170,000 result in death that is mainly due to complications during pregnancy and childbirth. The main causes of maternal mortality in Nigeria are haemorrhage, which accounts for about a quarter of all maternal deaths, sepsis fifteen per cent, complications of unsafe abortion thirteen per cent, hypertensive diseases of pregnancy twelve per cent and obstructed labour eight per cent.
Only thirty per cent of Nigerian women are in the adult work force according to the United Nations’ World Women Report 2000, which ranks Nigeria at 151 on the gender-related development index among 174 countries. Reasons for this are the low social status and inequality of women which limits their access to education and ultimately, economic resources. This in turn limits their ability to make decisions about their reproductive health (Federal Ministry of Health, 1999; WHO, 1998). Approximately thirty-five per cent of Nigerian women experience their first pregnancy by the age of 19. The 1999 Nigerian Demographic Health Survey further states that only fifteen per cent of married women are currently using contraception, of which only eight and half per cent are using modern methods such as condoms and birth control pills (FMH, 1999).
WHO (1998) further reported that only sixty per cent of women receive antenatal care and approximately thirty-one per cent of all deliveries take place in a health care facility. Moreover, only one-third of all deliveries are handled by skilled attendants in Nigeria. A study conducted by WHO (1999) in the northern part of the country indicated that twenty-five percent of all deliveries take place in the home with no assistance or attendant present. Health care facilities including antenatal care, prenatal care, post-partum and obstetric care facilities in the country are generally in poor condition with chronic shortages of essential equipment, drugs and human resources. The most severe is the lack of adequate skilled attendants, which are the most essential element of quality health care, because they usually migrate to the private sector, or move to other facilities due to lack of resources or proper remuneration (Awosika-Olumo, 2001).
Efforts to reduce maternal mortality and morbidity rates are a top priority, not only because of the scale of preventable suffering, but also because prenatal care and delivery services are among the most cost-effective intervention available to governments to improve maternal and child health (World Health Organization, 1998). This realization informed the establishment of Safe Motherhood Initiative (SMI).
Safe Motherhood is achieved through a programme of inter-linked steps which strive to provide: family planning services to prevent unwanted pregnancies; safe abortions (where abortion is legalized couple with efficient management and treatment of complications of unsafe abortions are accessible); prenatal and delivery care at the community level with quick access to first-referral services for complications; and postpartum care, including family planning services, promotion of breastfeeding, immunization and nutrition services. Safe motherhood services must be integrated into the health delivery system and the necessary inputs such as drugs, equipment, facilities, and properly trained staff-supplied (Daly et al. 1993).
Jatau (2000) defined safe motherhood as a means of saving the lives of women and improving the health of millions of others. He added that safe motherhood initiative (SMI) is aimed at preventing maternal and perinatal mortality and morbidity. He further asserted that SMI aims at enhancing the quality and safety of women’s lives through the adaptation of combination of health and non-health strategies.
Price (2002) conceptualized safe motherhood as a means of ensuring women’s accessibility to needed care through antenatal programmes in order to facilitate their safety and optimal health throughout pregnancy and childbirth. He further affirmed that safe motherhood is a vital economic and social investment. Also, he emphasized the need that all national development (Nigeria inclusive) plans and policies should include safe motherhood initiative in recognition of the enormous cost that women’s death and disability imposed on national health care systems, the labour force, communities and families.
Nigerian Partnership for Safe Motherhood-NPSM (2003) defined safe motherhood as concerted collective efforts by a pregnant woman herself her immediate and extended family members, her community and all health personnel at the primary, secondary and tertiary levels of health care system to ensure safety of a pregnant woman and her baby during pregnancy, delivery and after delivery.
Partnership for Transforming Health Care System (2005) asserted that safe motherhood comprises pre-natal care, nutrition and personal hygiene, clean and safe delivery, postpartum care including family planning, emergency obstetric care and child care, sexually transmitted infections, prevention of mother to child transmission (PMTCT) of HIV/AIDS and post-abortion care.
Maclean (1994) attested that efforts to save women’s lives through safe motherhood initiative focused on three key areas, namely: expanding and strengthening maternal health services; increasing access to family planning services and improving the status of women through improved cultural and legal status; women’s access to educational and economic opportunities. He further reiterated that SMI is a global effort to reduce drastically maternal mortality and morbidity rates.
Women most especially childbearing mothers (15-49 years) should be the important target in any government’s policy formulation and implementation with reference to SMI because the maintenance of adequate health particularly of infants, children and mothers is critical to attainment of optimum maternal health and national development. Also, women form the backbone of African economies. They produce most of the food necessary for a household, cook for the family, fetch water, clean the house and care for the children, the sick and the elderly at home. The death of a women results in both economic and social hardship for the family and community. At least 7 million pregnancies worldwide result in stillbirths or infant deaths as a result of maternal illness. Among infants who survive the death of the mother, fewer than 10 percent live beyond their first birthday (WHO, 1996; WHO, 1999; WHO/UNICEF/UNFPA, 2002). This justifies the selection of childbearing age mothers as the primary population for the present study.
Discussing the importance of safe motherhood, Daly et al. (1993), Jatau (2000) and NPSM (2003) affirmed that the health risks that confront childbearing mothers particularly teenage mothers for both mother and child are serious, which include preeclamptic toxaemia, anaemia, malnutrition, cephalopelvic disproportion, obstetric fistulae, obstructed labour, low birth weight and perinatal mortality. They further attested that these complications and abnormalities associated with pregnancy and childbearing are preventable through valid safe motherhood programmes in MCH clinics.
Regrettably, as laudable as safe motherhood initiative is, Nigeria still appears to portray lukewarm attitude towards it. This bizarre phenomenon may have resulted to poor knowledge and practice of safe motherhood among childbearing mothers in Nigeria including childbearing mothers in Nsukka Health District. Consequently, this situation has precipitated unprecedented infant and maternal mortality and morbidity rates in Nigeria (Awosika-Olumo, 2001). No wonder WHO, UNICEF and UNFPA (2002) reported that out of the estimated 27 million women of reproductive age, one in thirteen die due to causes related to pregnancy. Recent figures indicate that the maternal mortality ratio (MMR) is 800/100,000 live births in Nigeria. This situation calls for a timely investigation of this inordinate phenomenon such as this particular study.
WHO (1993) and Awosika-Olumo (2001) submitted that it is often difficult for childbearing mothers to utilize appropriate safe motherhood programmes or services such as family planning and reproductive health services because of several problems which include: poor knowledge of safe motherhood initiative; poor knowledge of sexual behaviour; unsafe motherhood practices; unavailability of services which are designed to meet the needs of childbearing mothers at a cost affordable to them’; dearth of trained health care providers to provide counselling and services to mothers; and government policies and legislation often work at odds with promoting family planning and reproductive health services and education programmes for childbearing mothers.
Knowledge is critical to man’s quality of life because everything we do depends on knowledge. Though knowledge alone may not be enough to ensure modified behaviour, Oberteuffeur (1960) insisted that human’s capacity to understand and solve own problems is enhanced by his or her ability to judiciously use the knowledge obtained from various sources.
WHO (1996) asserted that knowledge is prerequisite for any health action. WHO further maintained that many of the ailments people suffer from are to a large extent, self-inflicted by anti-health practices due to lack of knowledge. Comfort (1956) viewed knowledge as the totality of our conceptions, views and propositions, which have been established and tested as correct reflections as far as they are objective reality. This implies that the root of knowledge lies in the sense of perceptions, the reliability of which is seen in human practice. Dowell (1969) defined knowledge as understanding familiarity, gained by experiences or range of information.
Nigeria Education Research Council (1972) indicated that an educated, informed and knowledgeable person is the one who understands among other things, the basic facts concerning health and disease, protects his or her own health and that of his or her dependents. The council further explained that such an informed individual improves the health of the community and does everything possible to stimulate healthful living and promote knowledge, attitude and practice within his or her locality. In other words, the informed individual referred to above could be a childbearing mother in Nsukka Health District where the present study was conducted.
Horn (1979) conceived knowledge as the accumulated facts, truths, principles and information to which the human mind has access. He emphasized that knowledge is the outcome of specified rigorous enquiry, which originated within the framework of human experience. He concluded that knowledge could be seen as the product of the operation of man’s intellect, either within or apart from human experiences.
Sinclair (1992) conceptualized knowledge as information and understanding about a subject, which someone has in mind his or her mind. When applied in the context of this study, knowledge is defined to mean the ability to recall into memory what are known facts, concepts, views, proposition and principles related to safe motherhood. World Bank (1993) conceived knowledge as light, weightless and intangible, which can travel round the world, enlightening the lives of people everywhere. They further observed that yet millions of people still live in darkness (ignorance) as regard safe motherhood initiative and health-related issues.
Stuart and Achterbergh (2004) conceptualized knowledge as information that changes something or somebody either by becoming ground for actions or by making an individual or an institution capable of different or more effective action. Knowledge in this sense or circumstance has to be enough because partial or low knowledge according to Florio and Stafford (1969) confers unwarranted sense of security, which beclouds one’s alertness to risk dangers and hazards. This unwarranted sense of security could be very dangerous among childbearing mothers attending MCH clinics including childbearing mothers in Nsukka Health District.
Knowledge about how to take care of pregnant mothers and treat such simple ailment or complications as delayed labour has existed for centuries. This notwithstanding, hundred of millions of mothers and children continue to die from severe complications associated with pregnancy, labour and afterbirth (post-natal care) because of unqualified women who are devoid of the technical know-how or expertise inherent in effective management of pregnancy-related problems (WHO, UNICEF & UNFPA, 2002; & Jatau, 2000). In consonance with the foregoing, Price (2002), Lucas and Gilles (2003) posited that increased awareness of the need for knowledge of safe motherhood positively enhances maternal and child health.
The hierarchy of Bloom’s Taxonomy of educational objectives as reported by Opara (1993) revealed that knowledge is acquired and utilized from simple to a more complex form. This involves knowledge of facts, understanding of information, its application to solve daily life problems, analysis and synthesis of facts, and final evaluation of the result. According to him, dealing with health behaviour from the perspective of knowledge and how it influences behaviour is a multidimensional problem because of the various alternatives that exist in the knowledge component. It is imperative to emphasize that the present study shall be restricted to knowledge of components of safe motherhood programme among childbearing mothers attending maternal and child health (MCH) clinics in Nsukka Health District.
Practice, another concept in this study was described by Borne (1986) as performance, thinking, feeling and behaving normally towards something or somebody in the environment. Practice has to do with actions taken by the individual mother, which automatically impinges on her health, family health and other social communities. Gove (1993) conceptualized practice as the actual performance or application of knowledge. He also perceived it as a repeated customary action.
Robinson and Davidson (1998) described practice as a habitual activity, procedure or custom. They further expounded practice as a concept, which entails making of a habit of something. Funks and Wagnalls (2003) defined practice as any customary action or proceeding regarded as individual’s habit. When health relates to practice it is termed health practice.
Bucher (1994) perceived health practice as the application of good health actions to one’s daily living such as proper care of feet, hair and regular brushing of teeth (personal hygiene) and nutrition. WHO, UNICEF and UNFPA (2002) submitted that in Nigeria, maternal mortality rates are twice as high in rural settings as they are in urban ones. Of the annual 3 million pregnancies in Nigeria, approximately 170,000 result in death that is mainly due to complications during pregnancy and childbearing.
The main cause of maternal mortality in Nigeria is haemorrhage, which accounts for about a quarter of all maternal deaths, sepsis fifteen percent, complications of unsafe abortion thirteen per cent, hypertensive diseases of pregnancy twelve per cent and obstructed labour eight per cent. This unprecedented situation is attributed to paucity of knowledge of safe motherhood programmes and prevalent of unsafe motherhood practices among childbearing mothers (FMH, 1999 & WHO, 1998).
The above gory statistics revealed by FMH (1999) and WHO (1998) justifies the urgent need to determine knowledge and practice of safe motherhood initiative or programme among childbearing mothers attending MCH clinics including childbearing mothers in Nsukka Health District. This study, therefore, is aimed at ascertaining childbearing mother’s level of knowledge and practice of components of SMI.
Some of the ways to determine knowledge and practice of safe motherhood are ascertain the level of knowledge of concepts of SMI and extent of practice or participation in SMI components. Level of knowledge and practice can be ascertained in numerous ways. Ashur (1977) opined that a proportion of less than 40 per cent correct response should be taken as indicator of low level of knowledge 40 to 50 per cent of correct responses in any aspect of the variable being investigated should be considered average while 6 to 80 per cent should considered high and above 80 per cent very high level of knowledge. This established principle was adopted in the present study to determine childbearing mother’s level of knowledge of safe motherhood components.
The desire to effect change in behaviour for reducing the risk of future illness according to Philips (1991) should be based upon theoretical models that identify predictors of behavioural change. Several models or theories concentrate on the significance of socio-cognitive variables in preventive health. Theoretical models relevant to childbearing mother’s knowledge and practice of safe motherhood in the context of the present study will include the following: health action process approach (Schwarzer, 1992), health belief model (Rosenstock, Strecher & Becker, 1994). Others include Transtheoretical model of behaviour change (Prochaska, DiClemente, & Norcross, 1992), and precaution-adoption process model (Weinstein, 1988). Some of these theories emphasize the importance of volitional decisions by individuals about perceived utility of their actions.
The health action process approach propounded by Schwarzer (1992) contends that different factors are at work when a person is deciding which health action(s) to adopt-a period of time he calls the motivation phase (decision-making phase). This decision is operative during the action (volition) phase. The model further states that the most important predictors of intentions are risk perception outcome expectancies and self-efficacy. One outstanding thing about this theory is that it postulates that actions are not only a function of intentions and cognitive control but also are influenced by perceived and actual environment (Wallston & Armstrong, 2002).
The health belief model (HBM) maintains that health habits are a function of perceived vulnerability to a disorder and the belief that a particular health measure will be sufficient to overcome this vulnerability. This facilitates the understanding why people practice health behaviours and prediction of some of the circumstances under which their health behaviours and prediction of some of the circumstances under which their health behaviour will change. However, undertaking numerous health behaviours requires a sense of personal control, that is, a belief that it is actually feasibly to perform the health behaviour (Gracey, Stanley, Burke, Corti & Belin, 1996).
The precaution-adopting process model propounded by Weinstein (1988) suggests that the process of adopting precaution against any disease or incapacitation involves a progression through distinct stages, which differ quantitatively from each other. According to him, the factors that are important at any particular time, therefore, depend upon which stage of adoption process and individual has reached.
In Transtheoretical model, the individual goes through several series of decision-making stages before actually adopting health behaviours. This concept of stages of change has been applied to a large volume of research situations in health behaviour and the concept has proved very effective (Prochaska, Diclemente, & Norcross, 1992).
In addition, this study will examine the influence of such socio-demographic variables such as age at time of pregnancy, geographical location and level of education on knowledge and practice of safe motherhood of childbearing mothers attending MCH clinics in Nsukka Health District. Studies conducted by WHO (1998); Nakajima (1995); Roth (1998); Berg and Atrash (1998); and Senanoyake (1998) indicated that the aforementioned socio-demographic characteristics exert significance influence on childbearing mothers’ knowledge and practice of safe motherhood irrespective of race, culture, religion and geographical location.
Berg and Atrash (1998) observed that age of women at time of pregnancy determines to a great extent the manifestations of certain complications during and after pregnancy. They further attested that the risk of dying from pregnancy and delivery-related complications transcends all races but it is more prevalent among black women most especially black women who have attained the age of 40 years and above. According to them, such women are likely to die as a consequence of pregnancy-related complications than their white women counterparts in the same age group due to improved socio-economic status (SES).
WHO (1998) further asserted that some groups of childbearing mothers are more at risk than others, specifically, teenage girls under the age of 15 or women in their mid or late forties. Health risks of teenage childbearing for both the mother and child are serious, including pre-eclamptic toxaemia, anaemia, malnutrition, cephalopelvic disproportion, obstetric fistulae, obstructed labour, low birth weight and perinatal mortality. However, most adolescent do not protect themselves against unwanted pregnancies; more than 30 per cent of currently married teenagers in 8 of the 11 Sub-Sahara African countries looked at in the DHS study have an unmet need for family planning (Population Reference Bureau, 1992). According to them, the social costs of teenage pregnancies are also high: teenage girls who are pregnant are threatened with school expulsion and ostracism by their families and often seek to terminate their pregnancies.
Zabin et al. (1998) and Kurz et al. (2005) concluded that the wide variety of lower age of childbearing prevalent among mothers portends negative consequences and that high degree of its prevalence in developing nations including Nigeria make child marriage a serious threat to maternal and child health, nutritional status, girl’s education, earning power of women and practice of safe motherhood programme. In the light of the above empirical findings, the present study shall adopt two age groups, that is, childbearing mothers within 15-20 years old and 21-49 year for the purpose of determining impact of age on knowledge and practice of safe motherhood components.
Nakajima (1995) opined that education is crucial to adoption of safe motherhood practices among childbearing mothers. He asserted that a woman that has access to education in a community is empowered to make crucial decisions on family planning, prevention of STIs/HIV/AIDS and periodic self-examination such as cervical cancer screening and able to reject harm practices that may imperil her health.
Senanoyake (1998) supported the above assertion when he submitted that educated women derive health benefits associated with safe motherhood initiative both for themselves and their respective families. He further stressed that these women are likely to take t he advantages of health services such as prenatal care, intrapartum care and postpartum care, which are integral parts of SMI.
Since childbearing women’s lack of knowledge and usage of unsafe motherhood practices are inimical to maternal and child health, which in turn precipitate severe reproductive health hazards such as pre-eclamptic toxaemia, anaemia, malnutrition, cephalopelvic disproportion, obstetric fistulae, obstructed labor, low birth weight, infant mortality (perinatal and neonatal mortalities), maternal mortality and morbidity, investigations such as Greenwood (1991), WHO (1993), Daly et al. (1993), Jatau (2000), UNICEF (2000) and Awosika-Olumo (2001) recommended investigation of knowledge and practice of safe motherhood among child bearing mothers in different geographical locations and among specific populations such as childbearing mothers attending MCH clinics in Nsukka Health District. Nsukka Health District is made up of three Local Government Areas of Enugu State. Each local government area has give functional MCH clinics (Nsukka District Health Board, 2006).
Statement of the Problem
A study conducted by World Health Organization (1999) and United Nations Children’s Fund (2000) reported that out of the estimated 27 million women of reproductive age, one in thirteen die due to causes related to pregnancy. Recent figures indicate that the maternal mortality ratio (MMR) is 800/100,000 live births in Nigeria. However, there are wide regional disparities in the statistics. Whereas the southwest region reports an MMR of 165, the Northeast region reports 1,549. Maternal mortality rates are twice as high in rural settings as they are in urban ones. Of the annual 3 million pregnancies in Nigeria, approximately 170,000 result in death that is mainly due to complications during pregnancy and childbirth. The main causes of maternal mortality in Nigeria are haemorrhage, which accounts for about a quarter of all maternal deaths, sepsis fifteen per cent (15%), complications of unsafe abortion thirteen percent (13%) hypertensive diseases of pregnancy twelve per cent (12%) and obstructed labour eight per cent.
The above gory statistics indicate the sordid sate of maternal and child health in Nigeria, which imposes devastating reproductive health consequences (pre-eclamptic toxaemia, anaemia, malnutrition, cephalopelvic disproportion, obstetric fistulae, obstructed labour, low birth weight, infant mortality-perinatal and neonatal mortalities, maternal mortality and morbidity childbearing mothers) childbearing mothers in Nigeria.