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

1

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

2

(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

3

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 4

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

5

& 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.