Determinants Of Maternal Mortality In General Hospital Calabar, Cross River State

Medical and Health Science Project and Seminar Material

Determinants Of Maternal Mortality In General Hospital Calabar, Cross River State


Abstract


The purpose of the study is to understand the determinants of maternal mortality in General Hospital, Calabar, Cross River State. Methods. The study was a descriptive survey design where the researcher investigated several cases of maternal death from the period of Jan, 2012-Dec, 2014 in General hospital. The researcher was motivated to carry out this study based observation and experience while on clinical posting towards the rate at which pregnant women die during childbirth as a result of post partum hemorrhage or eclampsia. The sample size selected for the study was files containing records of all those who were attended to in labour ward, antenatal, and post natal ward. The findings revealed that most of the recorded maternal mortality cases recorded within the period understudied was caused by complications of pregnancy such as; obstructed labour and postpartum sepsis. There is a significant relationship between socio-cultural factors and maternal mortality, this implies that current efforts already put in place by different institutions must be stepped up to further reduce or eradicated maternal mortality. Conclusion. This study revealed that there is need for the involvement of the stakeholders in bridging the gap effective health education among pregnant women. A revised health education programme for pregnant women should be implemented to enlighten women on the need to utilize ante-natal services.


Chapter One


Introduction

1.1 Background of the Study

The growing concern on improving reproductive health at the global level has created a demand for research especially in the area of maternal health. Maternal health, which is the physical well being of a woman during pregnancy, childbirth, and postpartum period (WHO, 2011; Fadeyi, 2007), has been a major concern of several international summits and conferences since the late 1980s, which culminated to the Millennium Summit in 2000 (WHO, 2007).

It is obvious that maternal mortality is a key constituent of maternal health. The World Health Organization in the international statistical classification of diseases and related health problems (ICD), has defined maternal mortality as the death of a woman while pregnant or within 42 days of a termination of a 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 and incidental causes (WHO 2007; Ogunjuyigbe and Liasu, 2007; Khama, 2006). It is within this conceptual framework that the Millennium Development Goal Target 5A, calls for a reduction in maternal mortality ratio by three-quarters by 2015. At its present rate, however, the world will fall short of the target for maternal mortality reduction because the data so far collated suggest that to reach the target, the global Maternal Mortality Rate (MMR) would have had to be reduced by an average of 5.5% a year between 1990 and 2015.

Nigerian constitutes only two percent of the world‟s population, but Nigeria accounts for over 10% of the world maternal deaths, and ranks second globally only to India (Okonofua, 2007; Abdul‟Aziz, 2008). The status of maternal health is poor in Nigeria, defined by maternal mortality of 59,000 per annum due to pregnancy-related causes. This has been identified as the leading cause or determinant of death among women of reproductive age in Nigeria (Idris, 2010).

Although opinion differ on the determinants of maternal mortality, Herfon, (2006), noted that the cause of maternal mortality is an outcome of nexus interaction of a variety of factors namely: the distant factors (socio-economic, cultural) which include; occupation, income level and illiteracy act through the proximate or intermediate factors (health and reproductive behavior, access to health services) and in turn influence outcome (pregnancy complication mortality).Idris, (2010) further identified other factors responsible for maternal mortality as socio-cultural factors which include; traditional practices, norms, believes, education and religion.

Several attempts have been made in the past aimed at reducing maternal mortality in Nigeria, such attempts, especially by the Federal and state governments, have generally not proved very successful in achieving the desired results. Some promising results however have recently begun to be recorded through some policy initiatives by a few state governments. In Cross River state, the state house of assembly approved a bill in 2007, guaranteeing free maternal health services to pregnant women (Shiffman and Okonofua, 2007). The state commissioner of health, who is an obstetrician and gynaecologist, played a central role in its development and adoption.

The introduction of the safe motherhood programme in 1995,midwife service scheme (MSS) in (2011) and subsidy reinvestment program (SURE-P) IN 2012 introduced a range of interventions which included antenatal care, labour and delivery care, postnatal care, family planning, prevention and management of unsafe abortions, and health education but still MMR has not been encouraging over the years and improvements are so slow.

The former state commissioner of health together with some senior obstetrician and gynaecologist, played central roles in creating this positive environment for maternal health. Hence , today pregnant women in Cross River now assess free medical services in General hospital, Calabar as part of measures put in place by the state government to reduce maternal mortality rate in the state (Media Global,2010). However, other states like Jigawa, as part of measure in checking maternal mortality, have provided funds for the upgrading of obstetric care facilities in hospitals, the recruitment of obstetricians and gynaecologists and the provision of ambulances at the local level to transport pregnant women experiencing delivery complications to health facilities. The former executive secretary for primary health care, who subsequently became state commissioner for health, stood behind these initiatives.


1.2 Statement of the Problem

Maternal mortality is the most important indicator of maternal health and well being in any country (Herfon, 2006). Maternal mortality is a tragedy, many children are rendered motherless, such children are deprived of maternal care which goes a long way to affect adversely both their physiological and psychological development. The majority of these pitiable situations are due to maternal mortality.

From recent estimates, the number of deaths each year from maternal causes worldwide decreased from 536,000 in 2005 to an estimated 358,000 in 2008 and 273,500 in 2011. For every woman that dies, approximately 20 more suffer injuries, infection and disabilities in pregnancy or childbirth (IHME, 2012; UNICEF 2008; WHO, 2007). The situation is even more alarming in Nigeria. For example, in the year 2000, the maternal mortality ratio per 100,000 live births was 800 compared to 540 for Ghana and 240 for South Africa.

Consequently, the chance of a Nigerian woman dying from reproductive health disorders and complications was put at 1 in 10 in 2002 (Population Reference Bureau, 2002), 1 in 18 in 2005, and 1 in 23 in 2008, placing the Nigerian woman at far greater risk than her counterpart in the developed world, where the risk is estimated to be 1 in 17,800 and 1 in 10000 in countries such as the Republic of Ireland and Singapore respectively (World Bank, 2011; UNICEF, 2010; Media Global, 2010; UNICEF, 2008; UNFPA, 2005). Some of the implications of these estimates are the depletion of the country‟s workforce and the overall stifling of rapid development.

This study focuses on determinants of maternal mortality in General hospital Calabar, Cross River State. The researcher was motivated to carry out this study based observation and experience while on clinical posting towards the rate at which pregnant women die during childbirth as a result of post partum hemorrhage or eclampsia. The poser is what are the causes of women death?: thus this question can only be answered when this study is concluded.


1.3 Purpose of the Study

The purpose of the study is to understand the determinants of maternal mortality in General Hospital Calabar, Cross River.


1.4 Objectives of the Study

  1. To assess the influence of poor maternal health care on maternal mortality
  2. To identify the influence of education on maternal mortality
  3. To determine the influence of occupation on maternal mortality

1.5 Research Questions

In order for the researcher to achieve the objectives of the study, the following research questions were developed to guide the study;

  1. To what extent does poor maternal health influence maternal mortality?
  2. How does education factors influence maternal mortality?
  3. Can occupation influence maternal mortality?

1.6 Research Hypothesis

There is no significant relationship between maternal level of education and causes of maternal mortality in General Hospital, Calabar


1.7 Scope of the Study

The study is narrowed to all pregnant women with pregnancy related issues resulting to maternal mortality in General Hospital Calabar.


1.8 Significance of the Study

The findings of this study will help health workers to identify factors responsible for maternal mortality, this will guide them on adopting more effective measures to ensure that women experience uneventful pregnancy, labour and peuperium. It will help women of child bearing age in the prevention of maternal mortality even in future pregnancies by obtaining adequate prenatal care.

Similarly, the study will also be of value to government both state and federal, policy makers as well as researchers for further research.


1.9 Limitations

The major limitation encountered during this study was the attitude of health record official in providing relevant information for the researcher. Also some retrieval of information was very cumbersome due to the manual nature of keeping information.


1.10 Operational Definition of Terms

Hospital:

Is a place or building where people who are ill/sick or injured are giving medical treatment and care.

Primary Health Care:

Is the medical treatment one received first when sick.

Pregnancy:

Is a period where a woman is having a baby developing inside her.

Maternal Mortality:

Is the death of a woman during or after delivery.

Maternal health:

Is the physical well being of a woman during pregnancy, childbirth, and postpartum period


Chapter Five


Discussion of Finding, Summary, Conclusion and Recommendation

5.0 This chapter deals with the discussion of the findings that emanated from the study. The findings were discussed based on the research objectives and the research hypothesis.


5.1 Discussion of Findings

5.1.1 Influence of poor maternal health and maternal mortality

The findings revealed that majority of maternal mortality cases recorded in General hospital, Calabar within the period understudied was caused by complications of pregnancy such as; hemorrhage, hypertensive disorder, cardiac disease, obstructed labour and post partum sepsis.

This findings are in line with WHO (2008) which indicates that globally, about 80 percent of maternal deaths are due to four major causes- severe bleeding, infections, hypertensive disorders in pregnancy and obstructed labour. Complications after unsafe abortion cause 13% of maternal deaths. Among the indirect causes of maternal death are diseases that complicate pregnancy or are aggravated by pregnancy, such as malaria, anaemia, hepatitis, anaesthetic death, meningitis, HIV/AIDS, sickle cell , anaemia and acute renal failure, which could be a complication of eclampsia. Women also die because of poor health at conception and a lack of adequate care needed for the healthy outcome of the pregnancy for themselves and their babies.

5.1.2 Educational level influencing maternal mortality

The findings revealed that illiteracy among pregnant women played a mojor role in maternal mortality. Lack of education leads result in women having no knowledge of maternal and child health service available, even if they had the knowledge, they lack skilled job and money to utilize these health care services. However the occurrence of maternal mortality in educated women is as a result of lack of gainful occupation. Those working lack adequate time to access health care services. Increase in age and late marriage also contribute to maternal mortality among the educated. This findings are in line with Idris, (2010) who identified other factors responsible for maternal mortality as socio-cultural factors which include; traditional practices, norms, believes, education and religion. This finding is also in line with Okaro (2001), who carried out retrospective comparative analysis of maternal deaths at the University of Nigeria Teaching Hospital, Enugu for two ten-year periods (1976-1985 and 1991-2000) in order to evaluate the effect of Safe Motherhood Initiative on maternal mortality in the hospital. The main finding of the study was that since the launching of the Safe Motherhood Initiative, maternal mortality ratio increased five-fold as a result of institutional delays and deterioration in the living standards of Nigerians.

5.1.3 Influence of occupation on maternal mortality

The findings revealed that Being gainfully employed is a big factor in earning enough income for the sustenance of households and individuals. Unfortunately, many Nigerian women are not gainfully employed and they work in occupations. Many of them work in their husbands’ farms and in their homes and are not paid for these services. In situations where there employment positions are few such as in Nigeria, the few vacant positions are given to men. As such, many educated women find it difficult to secure employment. Furthermore, with the introduction of Structural Adjustment Programmes in the middle 1980s in Nigeria, many Nigeria women lost their jobs because of the unskilled nature of their jobs and low positions and because they do not have the educational qualifications to benefit from globalization.

However, this findings validates Herfon, (2006),who noted that the cause of maternal mortality is an outcome of nexus interaction of a variety of factors namely: the distant factors which include; occupation, income level and illiteracy act through the proximate or intermediate factors (health and reproductive behavior, access to health services) and in turn influence outcome (pregnancy complication mortality).

5.1.4 Relationship between educational level and maternal mortality

The findings of the study revealed that there is a significant relationship between educational level and maternal mortality. The finding agrees with Lawoyin, (2007), who carried out a cross-sectional, community-based study to assess men’s perception of maternal mortality in Nigeria and found that efforts were required to improve men’s attitudes and knowledge in order to make them active participants in the fight to reduce maternal mortality. Maternal deaths in this study were blamed on healthcare workers not being skilled enough, financial barriers, failure to use family planning, emergency, antenatal, and delivery care services


5.2 Summary

The purpose of the study was to examine the determinants of maternal mortality in General Hospital, Calabar. The specific Objectives of the Study were: To determine the influence of occupation on maternal mortality, to identify the influence of educaton on maternal mortality, to assess the influence of poor maternal health on maternal mortality in General Hospital, Calabar. Three research questions were raised and a hypothesis formulated to guide the study as follows: There is no significant relationship between education and maternal mortality.
The study was a retrospective research where the researcher investigated several cases of maternal mortality from the period of January, 2012- December, 2014 in General hospital, Calabar. Data was collected through the use of checklist. The data collected through a checklist was presented using frequency tables and percentages. The findings of the study revealed that there is a significant relationship between socio-cultural factors and maternal mortality, this implies that current efforts already put in place by different institutions must be stepped up to further reduce or eradicated maternal mortality.


5.3 Conclusion

Based on the discussion of findings, it could be concluded that most recorded maternal mortality cases is as a result of refusal of mothers to seek treatment from hospitals on time and poor treatment from care providers mostly in rural areas which eventually results to poor maternal health. However, Several attempts have been made in the past aimed at reducing maternal mortality in Nigeria, such attempts, especially by the Federal and state governments, have generally proved successful to some extent in achieving the desired results. Some promising results however have recently begun to be recorded through some policy initiatives by a few state governments.


5.4 Recommendations

Based on the findings of the study, the researcher recommends that:

  1. There is need for the involvement of the stakeholders in bridging the gap effective health education among pregnant women.
  2. Free education, gainful employment and interest free loan should be given to women to enable them have financial freedom.
  3. Free antenatal care for pregnant women should also be put in place by government.
  4. A revised health education programme for pregnant women should be implemented to enlighten women on the need to utilize ante-natal services.
  5. Health personnel should always encourage women to utilize antenatal services to prevent pregnancy complications.
  6. Health personnel should avoid discrimination of pregnant women and to show them positive attitude to that will encourage them to continue to antenatal services.
  7. The government should provide more health centres in rural areas so as to provide access to health facilities to all, especially among women resident in rural areas.
  8. Government should implement policies that will encourage free medical services to pregnant women. This will encourage women to utilize antenatal services.

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