ABSTRACT

Maternal health is one of the major concerns of the global health community. Pregnancy-related mortality is avoidable if preventive measures are taken and adequate care is available. Yet women in sub-Saharan Africa continue to die due to pregnancy-related complications. This study set out to examine the socio-cultural context of pregnant women and how that context precipitates maternal morbidity and mortality. The study was prompted by the high rate of maternal death despite all efforts and the observation that studies had concentrated on the proximate determinants of maternal mortality, rather than also considering the social determinants. Five objectives were considered which were to: identify the social factors that precipitate the medical proximate determinants of maternal health, determine the cultural beliefs and stereotypes that are associated with maternal health, examine how role conflict influences maternal health, investigate how mothers’ working conditions affect maternal health, and evaluate how social support influence maternal health. Systematic review of literature was carried out while the study utilized Functionalism, Agency Structure Theory and Gender and Development (GAD) Theory for its theoretical framework. The study was conducted in the four selected Local Government Areas (LGAs) of Lagos State from November, 2011to January, 2012 using 1,362 respondents to whom a structured questionnaire was administered, 20 key informants were interviewed and 4 case studies were analysed. Five hypotheses were tested. The first hypothesis revealed age, education, occupation, income, religion, marital status and type of marriage are significant determinants of maternal health complications. Women in age group 20-24, 25-29 and 30-34 are 0.631, 0.621 and 0.756 respectively less likely to have health complications. The second hypothesis estimated significant influence of cultural beliefs and practices on maternal health. With p-values 0.021, 0.001, 0.050 and 0.011 respectively, women who experience swollen feet, dizziness, fatigue or more than one of these symptoms are more likely to be at risk of complication. The third hypothesis also indicated a significant influence of role conflict on maternal health. Women’s working conditions were found to significantly influence maternal health complications in the forth hypothesis. And the finding of the fifth hypothesis revealed that there is a significant influence of social support availab le to women on maternal health. The findings presented in this study show that maternal health

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CHAPTER ONE

INTRODUCTION

1.1 Background to the study

The growing concern on improving reproductive health in the global south 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). At that summit, it was generally agreed that maternal health care has a crucial role to play in the improvement of reproductive health and that women deserve to be well informed and empowered to have unhindered access to safe, effective, affordable, acceptable and appropriate health care service. These will enable them to go safely through pregnancy and child birth and provide couples with the best chance of having healthy infants (United Nations, 1996).

While motherhood is often a positive and fulfilling experience, for too many women in sub-Saharan Africa, it is associated with suffering, ill-health and even death. More pathetic is the fact that, pregnancy-related complications are avoidable if appropriate measures are taken and adequate care is available (WHO, 2011; Idris, 2010). Yet more than half a million women die annually due to pregnancy related complications with 95% of these coming from the developing world (UNICEF, 2008). For this reason among others, maternal health deserves attention because pregnancy involves normal, life-enhancing process of procreation which carries a high risk of death. This process of women‟s reproduction has been socially constructed by medical sciences as “pathological” “abnormal” and “unnatural” or at least in need of continual monitoring (Fausto and Sterling, 1992; Riessman, 1983; Zita, 1997; in Dillaway, 2005). The mother‟s body goes through a lot of physiological, anatomical and psychological metamorphosis that need to be handled properly in order to reduce morbidity, and mortality rates (Hunter, 1994).

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In the literature, there is the indication that women encounter challenges in their attempts to ensure good health but sadly they still die due to pregnancy-related causes. Many strategies by Non Governmental Organizations (NGOs), government health ministries and international organizations such as WHO, have been adopted in an attempt to improve maternal health outcomes around the world through the provision of maternal and child health (MCH) programmes, aimed at improving primary prevention through education and services, early detection and treatment. Specific programme interventions include emphasizing prenatal attention, clean and safe deliveries, postnatal care, family planning, and essential obstetric care (Fadeyi, 2007; Lubbock and Stephen, 2008). While these programmes encourage women‟s access to maternal health services, women continue to be susceptible to health complications due to some extraneous social and cultural factors.

Furthermore, an MCH approach has often focused on medical and facility-based interventions, whereas the issues involved in maternal health also include social, cultural, economic, legal and even religious factors, which equally need to be addressed for any meaningful improvement in maternal health (HERFON, 2006). Consequently, safe motherhood which eludes many women due to inadequate knowledge about reproductive health is complicated by unmitigated socio-cultural and economic backgrounds of women (Okemgbo, Kutey, and Odimegwu, 2002) such as poverty, high risk social environment, inconsiderate working policies as well as role conflicts that lead to both emotional and physical stress which ultimately induce complications during pregnancy. This scenario seems to explain why several women lose their lives daily as a result of pregnancy-related complications (WHO, 2008).

From the foregoing, it is obvious that maternal morbidity and mortality are key constituents 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

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accidental and incidental causes” (WHO 2007; Ogunjuyigbe and Liasu, 2007; Khama, et.al., 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. The current average rate of reduction is less than 1% a year. The estimated 0.1% annual rate of reduction in sub-Saharan Africa, where levels of mortality are highest, is slower than what obtains in other regions (UNICEF, 2008). This is further compounded by the region‟s poor economic base and internal wars.

Although Nigerian constitutes only two percent of the world‟s population, Nigeria accounts for over 10% of the world‟s 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 of death among women of reproductive age in Nigeria (Idris, 2010).

Reducing maternal health complications was one of the critical issues which received attention at the Beijing conference on women development in 1995 (Kaba and Dagnachew, 2001; Lule et.al 2005; Daily Independent, 2010). Unfortunately, the Beijing declaration has not been fully implemented in Nigeria despite its poor record of maternal health as many women still die prematurely or suffer debilitating ill-health from reproductive processes which are, to a large extent, preventable (Alubo, 2010).

Consequently, it will be reasonable to submit that the reduction of maternal mortality and morbidity requires a multifaceted approach that includes addressing both medical and social risk factors associated with increasing susceptibility among women. Complications just do not appear in a day as a challenge, they are as a result of constellation of many precautions that ought to have been in place before and during

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pregnancy. Availability of health care service is only one component necessary for safe pregnancy. There are other militating factors against healthy pregnancy that need to be considered to ensure maternal health and to prevent maternal complications. The issue of maternal mortality in Nigeria has been adduced to both medical and social factors and it is believed that the way to take on maternal mortality is to deal with all factors simultaneously (HERFON, 2006; Global Medial, 2010). However, while numerous studies have focused on the medical factors that are inimical to maternal health, very few studies have focused on the socio-cultural context of maternal health. It is therefore important to identify these factors that are associated with the health outcomes of pregnancy to adequately inform healthcare policy makers. These background socio-cultural factors associated with maternal mortality, though subtle, are profound in determining maternal health. This study is initiated to examine the socio-cultural background of maternal heath with particular reference to Lagos State, Nigeria.

1.2 Statement of the Problem

Maternal mortality is the most important indicator of maternal health and well being in any country (HERFON, 2006). 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). Even though maternal mortality is a worldwide phenomenon, the critical issues associated with it are most profound in developing countries. Hence, of the estimated figure for maternal deaths worldwide, developing countries account for 99 per cent (WHO, 2008), with an estimated 265,000 maternal deaths occurring in sub-Saharan Africa (UNICEF, 2008).

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. However, by 2003, the maternal mortality ratio in Nigeria had risen to 948/100,000, in 2005 it was 1100/100,000 and 840/100,000 live births in 2008, while Nigeria Demographic Health Survey (NDHS) 2008 has put it at 545 per 100,000

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live births (Berlin Institute for Population and Development, 2011; UNICEF, 2010; Zozulya, 2010; NDHS 2008; Ogujuyigbe and Liasu, 2007). 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