KNOWLEDGE, AND PRACTICES OF SAFE MOTHERHOOD AMONG WOMEN

CHAPTER ONE

Introduction

Background to the Study

Making motherhood safe is a topical global issue of public health challenge especially in developing countries like Nigeria where the maternal mortality ratios are unacceptably high. Safe motherhood has become so critical a public health problem that it became a programme of the women’s global health imperative; this is a worldwide effort that aims to reduce the number of deaths and illness associated with pregnancy and childbirth.1 The safe motherhood initiative was first launched in Kenya in 1987 to help raise global awareness about the impact of maternal mortality and morbidity and to galvanize commitment among governments, donors, UN agencies and other relevant stakeholders to take steps to address this public health tragedy 2 Maternal mortality as defined by the World Health Organization is the death of a woman who was pregnant at the time of death or has recently been so and whose death was related to pregnancy either directly or indirectly.

The goal of the safe motherhood initiative later adopted at several United Nations conferences was to reduce maternal mortality by half by the year 2000. This target is to be achieved by two main strategies: improving women’s overall status and improving maternal health services. The initiative aims at enhancing the quality and safety of girl and women’s lives through the adoption of a combination of health and non health strategies and emphasizes the need for better and more widely available maternal health services, the extension of family planning education and services and effective measures aimed at improving the status of women.

The commitment to safe motherhood initiative was further strengthened when safe motherhood was named the theme of the world health organization [W.H.O] world health day, April 7th 1998. The international commitment to safe motherhood was reaffirmed in December 2000 when 149 government leaders from 191 United Nations member states committed themselves to achieving a set of millennium development goals. The goal number 5 of the millennium development goals is to improve maternal health and the target is to reduce by three quarter between 1990 and 2015 the maternal mortality ratio.

The safe motherhood initiative with its different strategies [countries adopt different strategies] is part of the global effort being made to meet the millennium development goals especially reducing maternal morbidity and mortality.

For many years, high standards of care were considered a luxury particularly in developing countries where service coverage was largely inadequate. Quality of health care is seen as a factor closely related to effectiveness, compliance and continuity of care particularly for ethical reasons. Women’s perceptions of antenatal visits significantly influence their assessment of the quality of services that are provided (Nwaeze et al, 2013). As a result of this new focus, measurement of customer satisfaction has become equally important in assessing system performance. Patient satisfaction has traditionally been linked to the quality of services given and the extent to which specific needs are met. Satisfied patients are likely to come back for the services and recommend services to others (Nwaeze et al, 2013). Various factors including the attitude of staff, cost of care, time spent at the hospital and doctor communication have been found to influence patient satisfaction in previous studies (Nwaeze et al, 2013).

It is estimated that 529,000 women die annually from complications of pregnancy and childbirth [Globally]. This is about one woman every minute. Some 99% of these deaths occur in developing countries like ours where a woman’s life time risk of dying from pregnancy related complications is forty five times higher than that of her counterpart in developed countries. The risk of dying from pregnancy related complications is highest in sub- Saharan Africa and south- central Asia, where some countries’ maternal mortality ratios [MMR] are more than 1000 deaths per 100,000 live births.

Women of sub-Saharan Africa face the highest risk of maternal mortality and morbidity of any region in the world. At least 150,000 African women die of pregnancy related complications every year in Africa and the number of maternal deaths continues to rise each year in many countries. The population of women of child bearing age is now larger than it was 1987, and the number of women who die each year from pregnancy related causes has increased even though there may have been a slight decline in the risk of pregnancy.

Despite having only about 2% of the world’s population, Nigeria contributes about 10% of the world’s maternal deaths. Each year, as many as 60,000 Nigeria women die due to pregnancy related complications.8 In Nigeria, maternal mortality ratio is one of the highest in the world. Currently, it stands at above 1000 per 100,000 births. This translates to 59,000 women dying annually, next only to India that has the highest global maternal mortality ratio.9 There is a wide disparity in maternal mortality ratio between developed and developing countries. Even within countries this disparity equally exists: poor, uneducated and rural women suffer disproportionately compared to their educated, wealthy and urban counterparts. Of all the statistics monitored by the World Health Organization, maternal mortality has the largest disparity: the lifetime risk of a woman dying during pregnancy or childbirth is higher in developing countries than in developed countries (one in 12 for women in east Africa compared with one in 4,000 in northern Europe).10 The rate of development within and among the nations of Sub- Saharan Africa is uneven. The morbidity associated with pregnancy and childbirth is equally high. For every woman who dies, 30 to 50 suffer injury, infection or disease. Long term complications include uterine prolapse, fistula, pelvic inflammatory disease and infertility. Pregnancy related complications are among the leading cause of death and disability for women aged 15-49 years in developing countries.

The death of a woman is more than a personal tragedy. It represents an enormous cost to her nation, her community and her family. When a woman dies children lose their primary care giver, communities are denied her paid and unpaid labour and countries forgo her contributions to their economic and social development. 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 elderly at home. The death of a woman results in both economic and social hardship for the family and community.12. At least 7 million pregnancies worldwide result in stillbirths or infant deaths as a result of maternal illness. Among infants who survived the death of their mothers, fewer than 10% live beyond their first birthday.

Adolescent pregnancy is an exploding problem in Sub-Saharan Africa. Young women under age 20 in Africa are more likely to have a child than those in other regions. By age 18 more than 40% of the women in Cote d’Ivoire, Mali and Senegal had given birth already.13 Most of the births by teenagers are first births which carry a higher risk of serious medical complications. Babies who are first births are known to have higher infant mortality rate than higher order babies and this risk is even greater for teenage mothers. Adolescent child bearing imposes a heavy burden on each country’s health care system as these young mothers also need antenatal, maternal and child health services. A large proportion of pregnancies, both within and outside a marital union are unintended as at the time of such conception. Some of these will eventually be unwanted. The collapse of traditional socialization system has led to an alarming increase in the number of women resorting to induced abortions to deal with unwanted pregnancies. Studies in Sub-Saharan African countries found that adolescents represented between 39-72 percent of all women presenting with abortion related complications. They are not alone in seeking abortions: women in all phases of their reproductive life-cycle experience unwanted pregnancies and seek abortions.

Nigeria the most populous country in Africa has one of the highest maternal mortality ratios in the world. Newly revised estimates of the World Health Organization (WHO) indicate that there are 1,100 maternal deaths for every 100,000 live births in the country and that a woman’s lifetime chance of dying during pregnancy, childbirth or the postpartum period is one in 18. The World Health Organization further estimates that every year, 59,000 Nigerian women being treated in hospitals for complications from such procedures die each year; however, since many women having unsafe abortions die before reaching a facility, the true number of such deaths is likely to be much higher. According to WHO, 13% of maternal deaths in 2003 in West Africa, of which Nigeria is the largest country were due to unsafe abortion. Taken together, these findings are disappointing.

In 2000, Nigeria and 146 other members of the United Nations agreed on eight Millennium Development Goals (MDGS) to improve the health and socioeconomic wellbeing of the people in their countries in the 21st century. The fifth goal, MDG 5, calls for the reduction of maternal deaths by 75% by the year 2015. Most of the half million maternal deaths in the world each year occur in developing countries. The major direct causes of maternal death in these countries are severe bleeding (hemorrhage, which accounts for 25% of the deaths), infections (15%), unsafe abortions (13%), eclampsia (12%) and obstructed labour and other direct causes (16%). Maternal deaths from indirect causes account for the remaining 20% of deaths. These deaths result from diseases (present before or during pregnancy) such as malaria, anaemia, hepatitis, heart diseases and HIV/AIDS that are not complications of pregnancy, but that complicate pregnancy or are aggravated by it. In addition, at the global level, approximately 20 million of the 136 million women who give birth each year experience pregnancy-related illness after childbirth.

Recovery from organ failure, uterine rupture, fistulas and other severe complications, and the sequelae of poorly repaired episiotomies or perineal tears, can have Lasting health consequences, such as urinary incontinence, uterine prolapse and pain. If untreated, some of these post delivery complications can lead to chronic ill-health or maternal deaths.

The contributing causes of poor health are generally attributed to a range of social, economic and cultural factors that affect health and nutritional status before, during and after pregnancy and are linked to women’s low utilization of available health services. However, maternal mortality is caused mainly by obstetric complications that could be prevented solely by improving women’s overall health status, nutrition and hygiene. Most maternal deaths could be prevented if women have access to basic and emergency medical care during pregnancy, childbirth and the post partum period.

Safe Motherhood initiative celebrated its 20th anniversary 2007. Many countries have been able to improve the health and well-being of mothers and newborns over the last 20 years. However, countries with the highest burdens of mortality and illness have made the least progress, and inequalities between countries are increasing. In many places, inequalities within countries are increasing too, between those who live in better conditions and have access to care, and those who for a variety of reasons are excluded. Globally, the numbers remain staggering: each year there are at least 3.2 million stillborn babies, 4 million neonatal deaths and more than half a million maternal deaths. The majority of these deaths are avoidable. HIV/AIDS and malaria in pregnancy are having an impact on maternal mortality and could reverse the progress that has been made.

A total of 11-17% of maternal deaths occurs during childbirth itself; 50-71% occurs in the post-partum period. The time spent in labour and giving birth, the critical moments when a joyful event can suddenly turn into an unforeseen crisis, needs more attention, as does the often-neglected post-partum period. These periods account not only for the high burden of post-partum maternal deaths, but also for the associated large number of stillbirths and early newborn deaths. A total of 98% of stillbirths and newborn deaths occur in low- and middle income countries: obstetric complications, particularly in labour, are responsible for perhaps 58% of them. The care that can reduce maternal deaths and improve women’s health is also crucial for newborns’ survival and health.