Abortion As A Causative Factors To The Increase In Mortality Rate Among Adolescent (Ages 13 – 20)
This study is on abortion as a causative factor to the increase in mortality rate among adolescent in Plateau State of Nigeria. Four research questions were stated to guide the study, with specific objectives which include: to explain the manifestations of mortality; to determine the extent to which socio-cultural factors are responsible for high-risk abortions and to investigate respondents knowledge of maternal mortality in relationship to their indulgence in abortions. Relevant literatures were reviewed. Both primary and secondary data were explored for the study and quantitative and qualitative techniques of data collection were triangulated for analysis. Using the Yamane’s sample size determination technique, 400 respondents were selected for the study. Questionnaires were administered on 300 respondents who were women within reproductive ages (15-49); in-depth interviews were conducted on 16 key informants drawn from medical personnel’s and women within reproductive ages in the study area. In addition, 7 focus group discussions (FGDs) consisting of 84 participants (12 in each group) were carried out. Data were analyzed and findings revealed that abortions were major contributory factors to the high-rate of mortality among adolescents in Plateau state. Every abortion was found to be associated with high-risk due to obstetric factors, medical conditions and unpredicted outcomes. Findings on the first objective indicated that abortions are practiced in Plateau state, but early pregnancies were more common as compared to order forms. This suggests that most girls are sexually active early and give birth before age 25. Findings on the second objective indicated that mortality as a result of abortions is still a social problem in Plateau state. Findings on the third objective indicated that social factors like non-attendance of antenatal clinics, son preference, poverty and caesarean section (CS) predispose respondents to having abortions. This implies that socio- cultural factors are capable of causing abortions and maternal mortality. Findings on the fourth objective indicate that respondents still indulge in abortions but early pregnancies were commonly practiced and most respondents have knowledge of maternal mortality. Based on these findings, the study recommends among others areas that Social Workers and Sociologists as well as Medical Personnel should educate women on the need to prevent unwanted and early pregnancies and to engage in family planning, as well as regular attendance of ante- natal clinics. In addition, women should be educated on the risk involved in continuous child bearing after having a large number of children and also on the risk of poor birth spacing.
1.1 Background of the Study
The World Health Organization (1993) defined maternal mortality as the death of a woman while pregnant or within forty two days after termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Late maternal death is defined as the death of a woman from direct or indirect obstetric causes occurring more than 42 days but less than one year after the termination of the pregnancy (WHO, 1993).
The issue of maternal deaths emerged as a world health concern through the United Nations’ call for “Safe Motherhood” in the l980’s. Despite such early advocacy, there appear to be little improvement in maternal health care delivery in Nigeria. The Millennium Development Goal (MDG) target 5; which aimed to reduce the number of women who die in pregnancy and childbirth by three quarters by 2015 recommends an annual decline of 5.5 per cent in maternal mortality ratios between 1990 and 2015in order to achieve MDG 5, unfortunately, figures released by WHO, UNICEF, UNFPA and the World Bank show an annual decline of less than 1 per cent (United Nations, 1990). Mortality associated with pregnancy and delivery complications was highest among poor women in Nigeria (Olusola, 2011).
The maternal mortality ratio in Nigeria is estimated to be 545 deaths per 100,000 live births (Olusola, 2011). Nigerian women die as a result of complications associated with pregnancy or child birth, as about one woman dies every three minutes. This suggests that the maternal mortality rate in Nigeria is about 100 times worse than in the industrialized countries, highlighting what is one of the widest disparities in international public health (National Population Commission & ICF Macro, 2009). In terms of the actual number of maternal deaths, Nigeria is ranked second in the world behind India and Nigeria is part of a group of six countries in 2008 that collectively accounted for over 50% of all maternal deaths globally. In terms of the maternal mortality ratio, Nigeria is ranked eighth in Sub- Saharan Africa behind, Angola, Chad, Liberia, Niger, Rwanda, Sierra Leone and Somalia (National Demographic and Health Survey, 2008).
Reproductive health experts define abortions as pregnancies that occurs when mothers’ are too young or too old; when children are born at less than a two-year birth interval, and when there are high-birth order children (NPC & ICF Macro, 2009). Very young mothers may experience difficult pregnancies and delivery because of their physical immaturity. Older women may also experience age-related problems during pregnancy and delivery. A mother is considered to be” too young” if she is less than18 years and “too old” if she is older than 34 years at the time of delivery. A “short birth interval” is a birth occurring within 24 months of a previous birth (NPC & ICF Macro, 2009). Abortions cover both medical and obstetric factors, but this research will focus on four (4) basic factors: early pregnancies (before 18 years), late pregnancies (34 years and above), poor birth spacing, continuous child bearing after having large number of children, as well as socio-cultural factors such as religion, poverty, lack of attendance of ante-natal clinics, and son preference; in addition to medical and obstetric factors. The risk categories are: (a) unavoidable risk category (first order births between ages 18 and 34years) and (b) Single high-risk category (when the mothers’ age is less than 18 or greater than 34 and birth intervals are less than 24 months and birth orders greater than 3) (NPC & ICF Macro,2009).
A high risk pregnancy can be further defined as any pregnancy where maternal and/or fetal conditions may lead to an adverse prenatal outcome (Ramsey &Goldenberg, 2002). Preterm labor (PTL) and delivery, premature rupture of membranes, multiple gestation, preeclampsia, diabetes, maternal substance abuse, and vaginal bleeding, are common high risk conditions. A pregnancy may be identified as high risk during the ante-partum or intra-partum period. Indeed, lack of, limited, or late prenatal care, in and of itself, is a common high risk condition seen in urban prenatal centers (Ramsey &Goldenberg, 2002). A pregnancy is considered high-risk when there are potential complications that could affect the mother, the baby, or both (http://www.webmd.com/news/default.htm- 5/10/2013).
The risk factors for abortions are: maternal age, medical conditions that exist before pregnancy, medical conditions that occur during pregnancy and pregnancy related issues. One of the most common risk factors for aabortion is the age of the mother-to-be. Women who will be under 17 or over 35 when their baby is due are at greater risk of complications than those between their late teens and early 30s. The risk of miscarriage and genetic defects further increases after age 40.Conditions such as highblood pressure; breathing, kidney, or heart problems; diabetes; autoimmune disease;
sexually transmitted diseases (STDs); or chronic infections such as human immunodeficiency virus (HIV) can present risks for the mother and/or her unborn baby. A history of miscarriage, problems with a previous pregnancy or pregnancies, or a family history of genetic disorders is also risk factors for a abortion. Even if a woman is healthy when she becomes pregnant, it is possible to develop or be diagnosed with problems during pregnancy that can affect her and the baby (Icon Group International, 2004).
Pregnancy-related issues are classified as high risk because of issues that arise from the pregnancy itself and that have little to do with the mother’s health. These include: premature labor, multiple births, placenta previa and fetal problems. Premature labor is labor that begins before the 37th week of pregnancy. Although there is no way to know which women will experience preterm labor or birth, there are factors that place women at higher risk, such as certain infections, a shortened cervix, or previous preterm birth. Multiple births means to be conceived of more than one baby (twins, triplets, quadruplets, etc.). Multiple pregnancies, which are more common as women are using more infertilitytreatments, increase the risk of premature labor, gestational diabetes, and pregnancy- induced high blood pressure. Placenta previais a condition in which the placenta covers the cervix(Icon Group International, 2004). The condition can cause bleeding, especially if a woman has contractions. If the placenta still covers the cervix close to delivery, the baby may have to be delivered by a cesarean sectionto reduce bleeding risks to the mother and baby. Fetal problems can sometimes be seen on ultrasound. Approximately 2% to 3% of all babies have a minor or major structural problem indevelopment.
Sometimes there may be a family history of fetal problems, but other times these problems are completely unexpected (Icon Group International, 2004).
The early age at which many Nigerian girls begin child–bearing is a serious cause of concern. It was reported that 44 percent of women aged 20-24 had given birth before they were 20 years old, 27% before they were 18 years old and 8.5 percent before they were 15 years old. The figures were much higher in the rural areas and northern part of the country (NPC &ICF Macro, 2000). The report further suggested that early pregnancy is likely to be one of the main reasons for the much higher maternal mortality in northern Nigeria. Almost half of women in Nigeria are married by age 18; 1 in 5 is married by age 15. The median age at first marriage is 18.3 for women aged25–49.
In addition, the likelihood of a mother dying is higher in her first pregnancy than in the second and third. Thereafter, the risk may gradually reduce with successive pregnancies. A birth interval of less than two years is associated with higher maternal and foetal risk, while a prolonged interval of more than four years increases the risk, particularly after a period of infertility. The large number of children born by most Nigerian women is another risk enhancing factor as Nigerian women want to have 6 children on the average (NPC & ICF Macro, 2009).
It is on the basis of the above observations that the researcher investigated the issue of abortions and maternal mortality in Nigeria, specifically in Plateau State, with a view to having holistic understanding of the problem in the area.
1.2 Statement of Research Problem
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 (Kapadia, Shah& Sikri, 1997). In addition, another cause of concern is women’s apathetic attitude towards their own health and its management during illness. Women were found to seek treatment only when their health problem caused great physical discomfort or when it affected their work performance (Kapadia, Shah& Sikri, 1997). The North East zone has the highest Maternal Mortality Rate (1,549 per 100,000 live births), which is almost ten times higher than in the South West. The rate in the North West (1,025 per 100,000 live births) is six times higher than in the South West (NPC, UNICEF, 2001; cited in James, 2008). The manifestations of maternal mortality in Plateau state were however not explained.
Most African cultures value children highly, but few people including women themselves understand the risks involved in bearing children. About one third of the total disease burden among women aged 14 to 44 years in Africa is linked to health problems arising out of pregnancy, childbirth, abortion and reproductive infections (Arkutu, 1995; Olusola, 2011). For instance, Arkutu (1995) observed that women in Africa die much more frequently from the complications of pregnancy and childbirth than women in Europe and North America. This view has been similarly expressed by various stakeholders in Plateau State, where cases of maternal mortality and morbidity are high. The maternal mortality ratio of Plateau was reported to be 1,060 deaths per 100,000 live births (Ujah, Uguru, Sagay & Otubu 1999).
Nigeria makes up 2% of the world’s population, but it accounts for 10% of its maternal deaths. In a report by World Health Organization (WHO, 2008), Nigeria was identified as having the world’s second-highest number of maternal deaths with approximately 59,000 of such deaths taking place annually. Similarly, Obadaki (2009) observed that a woman in Nigeria has 1 in 8 risk of dying in child birth or from pregnancy-related causes during her life time, which is higher than the overall 1 in 22 risks of women throughout sub- Saharan Africa. The risks of maternal deaths are even greater for certain Nigerian women such as those in the Northern region of the country, rural women and low income women without formal education. He further opined that early pregnancy and early child bearing, which in most cases result from early marriage (a custom that is prevalent in northern Nigeria) presents a much higher risk of complications during pregnancy and delivery as well as maternal mortality and morbidity. Early childbearing and limited access to the highest attainable standard of health, including sexual and reproductive health, causes high level of obstetric fistula and other maternal morbidities as well as maternal mortality. The socio-cultural determinants of abortions have not been investigated.
Furthermore, most studies on maternal mortality and morbidity have concentrated on other causes of maternal mortality and morbidity, ignoring abortions, such as: early child bearing, late child bearing, poor child spacing, large number of children, non-attendance of ante-natal clinics, poor nutrition, and poverty. According to World Health Organization (WHO, 2005) one out of every 22 women in Africa dies from pregnancy-related complications. For every woman who dies, about 50 to 100 other women suffer from an illness or disability caused by childbearing. This means that every year, more than 150,000 African women die and millions of women suffer a serious illness, because of pregnancy and child birth (Arkutu, 1995). In particular, the National Demographic and Health Survey (NDHS, 1990) reported that more than 67.68% of all pregnancies in Nigeria (from 1985-1990) were abortions. The report also revealed that a total of 21% of married women in Nigeria have an “unmet need” for family planning. The desire to space births is highest among women within 20-29 years of age while older women’s need is to limit births. It was therefore important to know the contributory percentage of high risk pregnancies to the issue of maternal mortality using Plateau state as a reference point.
1.3 Statement of Research Questions
This study is predicated upon the following research questions:
- To what extent is abortions practiced in Plateau State?
- What are the manifestations of maternal mortality in Plateau State?
- What are the socio-cultural determinants of abortions in Plateau State?
- What is the relationship between practices of abortions and knowledge of maternal mortality in Plateau State?
1.4 Objectives of the Study
Generally, this study is aimed at investigating abortions by explaining the relationship between the socio-cultural attributes of respondents and their indulgence in abortions, to know if such can lead to maternal mortality in Plateau State.
However, the specific objectives of the study are as follows:
- To investigate the practices of abortions in Plateau state.
- To explain the manifestations of maternal mortality in Plateau state.
- To determine the extent to which socio-cultural factors are responsible for abortions in Plateau state.
- To investigate respondents indulgence in abortions and its relationship to their knowledge of maternal mortality in Plateau state.
1.5 Significance of Study
The research is significant, because it identified the socio-cultural factors associated with abortions and perceptions of maternal mortality. More specifically, it is very important because it provided written and theoretical information which can be used by the government for a coherent, maternal welfare policy. The research was necessary because it helped reveal the relationship between knowledge of maternal mortality and practices of abortions in Plateau state. In addition, this research will serve as a source of material for students who may have interest in the study of maternal mortality, abortions and related issues. Finally the result of this study can be used as a basis for developing new and refined maternal welfare programs, services and strategies, including those aimed at the prevention of maternal mortality as well as preventing abortions.
1.6 Scope and Limitation of the Study
The scope of this study was limited to Plateau state, Nigeria, due to the fact that cases of maternal mortality and abortions are more rampant in the North compared to other parts of Nigeria and Plateau state is one of the Northern states. Also, in terms of time and funds, Plateau state is more convenient. There are many factors influencing maternal mortality, but this research focused on abortions such as: early pregnancies (before 18 years), late pregnancies (34 years and above), poor birth spacing, continuous child bearing after having large number of children, as well as socio-cultural factors such as religion, poverty, lack of attendance of ante-natal clinics, and son preference.
1.7 Justification of Study
My reason for selecting Plateau State is because abortions and maternal mortality is more prevalent in the Northern part of Nigeria as stated in the research problem and Plateau State is one of the Northern States. Also, Jos North local government area was chosen because it is situated in the heart of Plateau state of Nigeria and it has a council which has an important recognition and function in the country through the local government’s performance and its transformation of rural areas. In addition, this local government was chosen because of the cosmopolitan nature of Plateau state and due to the fact that it gives a wide coverage of various groups from different socio-cultural backgrounds.
Summary, Conclusion and Recommendations
5.1 Summary of Findings
The first objective of the study was to investigate the practices of abortions in Plateau state and to that end findings revealed that women in Plateau state practice abortions especially through early pregnancies (below 18years), poor birth spacing, and continuous child bearing after having many children, and this puts them at risk of maternal mortality.
The second objective of the study was to explain the manifestations of maternal mortality in Plateau state and as suggested by other previous research findings revealed that younger women tend to die mostly due to complications, and compared to single or divorced women, the married category are more at risk of mortality because there is a tendency of continuous child bearing among them. It is evident that poor women die most because they often cannot afford to pay their health bills.
The third objective which was to determine the extent to which socio-cultural factors are responsible for abortions in Plateau state resulted in findings which revealed that socio-cultural issues like demand for a particular sex of child, especially male child preference can lead to abortions, because a woman may be forced to keep going through the risk of bearing children until she gives birth to a child of the preferred sex, and this may lead to having many children. The prominence of non-attendance of ante-natal clinics poses risk to women, because the lack of medical pregnancy history makes it challenging in case of emergency. Poor nutrition has an effect on the health of women; they become anemic if they do not eat well especially after giving birth, because they lose a lot of blood which must be replaced by proper feeding. Also, non-practice of family planning can lead to poor birth spacing, which is abortion.
The fourth objective explained the relationship between practices of abortions and perceptions of maternal mortality in Plateau state. Findings revealed that abortions are a major contributory factor to the high rate of maternal mortality in Plateau State.
Our findings revealed that abortions were major contributory factors to the high-rate of maternal mortality in Plateau state. Every abortion was found to be associated with high-risk due to obstetric factors, medical conditions and unpredicted outcomes. Social factors like non-attendance of antenatal clinics, son preference, poverty, caesarean section (CS), illiteracy/lack of education, lack of knowledge/ practice of family planning, and poor nutrition predispose respondents to having abortions. This implies that socio-cultural factors are capable of causing abortions and maternal mortality. Also, early pregnancies were more common as compared to late pregnancies in Plateau State. This suggests that most women get pregnant as earlier than 20 years. Very young mothers experienced difficult pregnancies and delivery because of their physical immaturity. Older women also experienced age-related problems during pregnancy and delivery; poor birth spacing can lead to anemia among other morbidities, which can lead to maternal mortality. This is the thesis of this research. Abraham Lilienfeld (1980), a prominent epidemiologist, very appropriately remarked, “the better we know about the root cause of a problem, the better we are in a position to address the problem,” and in his book, Foundations of Epidemiology, cites Benjamin Disraeli’s, “The more extensive a man’s knowledge of what has been done, the greater will be his power of knowing what to do”.
- Women within child bearing age should be educated by government of the country, medical personnel’s, sociologists and social workers on reproductive health issues. Educating women improves their health and that of their children. Some studies have shown for example, that high literacy rates among women are more important for reducing the number of infant and maternal deaths, than having a large number of doctors. Why? Because the more education a woman has, the more likely she is to make the right decisions concerning her health and that of her children and also take some measures to prevent diseases (such as following proper hygiene and using mosquito nets) and avoid harmful traditional practices.
- Females should be advised by medical professionals, sociologists and social workers to delay marriage and child bearing until they are prepared for it physically, emotionally and financially.
- Men should be educated by medical personnel’s, sociologists and social workers on how to help their wife’s avoid abortions, and on the need to appreciate both female and male children and treat them equally; this will go a long way in reducing socio-cultural factors like male child preference and abortions such as poor birth spacing and continuous child bearing after having a large number of children.
- Women within reproductive ages should be educated during their ante-natal clinics on how to use family planning’s to space their pregnancies and limit the total number of children they will bear.
- Most maternal deaths are avoidable, if the health-care solutions to prevent or manage complications are well known. Government should ensure that all women needs of access to antenatal care in pregnancy, skilled care during childbirth, and care and support in the weeks after childbirth are met. It is particularly important that all births are attended by skilled health professionals, as timely management and treatment can make the difference between life and death.
- Severe bleeding after birth can kill a healthy woman within two hours if she is unattended. Injecting oxytocin immediately after childbirth effectively reduces the risk of bleeding; therefore every hospital should ensure that they never run out of oxytocin injection.
- Infection after childbirth can be eliminated if good hygiene is practiced and if early signs of infection are recognized and treated on time. Therefore, women should be educated on the need for proper hygiene and also the need for proper ante-natal care.
- Pre-eclampsia should be detected and appropriately managed before the onset of convulsions (eclampsia) and other life-threatening complications. Administering drugs such as magnesium sulfate for pre-eclampsia can lower a woman’s risk of developing eclampsia.
- If a woman has a medical condition, it is important to consult a doctor before she decides to become pregnant. The doctor may run tests, adjust medications, or advise her of precautions she needs to take to optimize her health and that of her baby.
- To avoid maternal deaths, it is also vital to prevent unwanted and too-early pregnancies. All women need access to family planning. In addition, women should be educated on the risk involved in continuous child bearing after having a large number of children and poor birth spacing. This can be done during their ante-natal clinics.
- To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of the health system. There should be birth preparedness on the path of the women and medical personnel’s. Concrete and detailed preparation should be made before delivery to avoid some unpredicted outcomes. There is also need for emergency preparedness by medical personnel’s and developments by government to handle such high-risk cases. Health facilities should be equipped to provide emergency services.
- Women should be educated by medical personnel’s, sociologists and social workers on danger signs of pregnancy. Service providers should be very responsive in handling high-risk cases so as to avoid maternal mortality.
- There is indeed currently a window of opportunity for Nigeria to join the rest of the world in the effort to meet the target of MDG 5. Efforts to ensure that this opportunity is not missed must include a multipronged approach to improve women’s health and reduce maternal mortality in the country. Although appropriate policies are a step in the right direction, further actions must be taken to implement those policies and to ensure that all the disparate program efforts to increase safe motherhood are integrated and monitored at the central level. A major impediment to improving policies and programs to reduce maternal mortality in Nigeria is the lack of continuity in the government. Every new policy seems to lapse with the exit of the commissioner, the governor or the minister who was in power or who initiated the program. It is essential to put in place mechanisms that will ensure continuity of health policies at the federal, state and local government levels.
- Despite much lofty policy formulation, the serious lack of commitment to implementing these proposals can be seen in the gross under budgeting of the health sector over the years. It is thanks only to the efforts and funding of NGOs and international donors that maternal mortality in Nigeria has not deteriorated even further. It is only through their efforts that awareness of the magnitude of the problem has been maintained and kept in constant focus.
- The number of skilled birth attendants in Nigeria is certainly not sufficient, and the situation is aggravated by the fact that those who are available are concentrated in urban centers, where only about 40% of the population lives. Better results could be achieved through better distribution of this manpower, by providing incentives to promote work in rural areas. The Nigerian government must be willing to commit adequate resources, particularly financial resources, to meet the needs of the health system. This system must be significantly overhauled to promote proper coordination among the three levels of government—federal, state and local—both to reduce bureaucratic bottlenecks and wastages of resources and to ensure availability of the trained providers, up-to-date equipment and supplies needed to provide appropriate contraceptive, prenatal and obstetric services.
- Improved capacity and resources will be essential to reducing high-risk and unintended pregnancies and making pregnancy and delivery safer. The lack of credible data on maternal and pre-natal outcomes is a serious barrier to effective advocacy and programming. Therefore, crucial ancillary efforts needed to support Nigeria’s safe motherhood services include the establishment of a system to register births and maternal deaths, and a national level effort to investigate the causes of all maternal deaths in the country.
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