Background to the study

           Maternal mortality is a serious public health problem especially in African countries including Nigeria and Enugu state in particular. Maternal mortality rates in many countries have remained essentially a public health challenge. Worldwide, over 500,000 women of childbearing age die of complications related to pregnancy and childbirth each year. Over 99 per cent of these deaths occur in developing countries such as Nigeria (World Health Organization-WHO 2007). At least 150,000 African women die of pregnancy related complications each year and the number of maternal deaths continues to rise each year in many countries (WHO 2001). Maternal mortality has generated great concern among United Nations (UN) and International Agencies as well as National Governments in 3rd world countries like Nigeria (Onuzulike, 2006).

          WHO estimates that at least 600,000 women worldwide die every year from pregnancy related causes, though the rate is difficult to calculate with accuracy (Clark, 2002). Partnership for Transforming Health Systems-PATHS(2005), stated that everyday, at least 1,450 women worldwide die from  complications of pregnancy and childbirth, that is a minimum of 600,000 women dying every year .The majority of these deaths (almost 99%) occur in  Asia and Sub-Sahara Africa and less than one per cent in the developed world. PATHS further stated that life time risk of maternal death is 1 in 75, in developed country like America  it is 1 in 2,500, while in West Africa it is 1 in 13  (Khalid 2006). This alarming situation of the maternal deaths in the world may not exclude Nigeria.

Nigeria’s maternal mortality rate continues at unacceptably high rate. Royston and Armstrong (1989), reported that maternal mortality ratio in Nigeria is 800 in 100,000 live births. Audu (2010) estimated Nigeria maternal mortality ratio at 1,500 per 100,000 live births. With this figure, Nigeria accounts for 10 per cent of the world’s maternal deaths. According to State Economic Empowerment and Development Strategy-Seeds (2004), in Enugu State, the maternal mortality rate for the South East zone was 286 per 100,000 live births, North West 1549 per 100,000 live births in the year 2000. Maternal mortality rates are twice as high as in rural setting as they are in urban settings. It has been estimated that 1:18 women of childbearing age in Nigeria face a life time risk of dying from pregnancy related causes compared to 1:2400 in Europe, 1:5100 in U.K and 1:7,700 in Canada (PATHS, 2005). From record, it has been shown that Nigeria is one of the countries with highest maternal mortality ratios in the world.

           Maternal death has been defined as the death of a woman while pregnant or within 42 days of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes (Lewis & Drife, 2001).The complications of pregnancy may be experienced during pregnancy or delivery itself or may occur up to 42 days following childbirth. Maternal mortality in the context of the present study is defined as the death of a woman during pregnancy, in labour or first six weeks after delivery or termination of pregnancy from causes directly due to pregnancy or to conditions aggravated by pregnancy.

           The Nigerian Demographic and Health Survey-NDHS (2008) posited that Nigeria ranks second globally (next to India) in number of maternal deaths. The data also suggest that the ratios are different in the six geopolitical zones of the country. A population-based study indicated that 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 (Chama, 2004). In the North Eastern region, Borno State has an estimated maternal mortality ratio of 1,549 per live births, while 1,732 per 100,000 live births was reported from Bauch State in the same North East region (Glew & Uguru, 2005).These ratios are the worst in the world. In Plateau State, maternal mortality ratio of 740 per 100,000 live births was reported (Uja, Aisien, Mutihir & Vander 2005). A ratio of 1700 per 100,000 live births was reported from Lagos, and that of Sagamu was 1,930 per 100,000 live births, all in South Western Nigeria (Agboghoroma & Emuveyam. 1997). Enugu State as one of the states in Nigeria is not left out of this ugly situation.

      Maternal mortality is high in Enugu State. NDHS (2003), put the maternal mortality ratio (MMR) for Enugu State at 1,400 per 100,000 live births. Okeibunor Onyeneho and Okonofua (2004) stated that maternal mortality ratio is high in Enugu State, with figures ranging from 772 to 998 per 100,000 live births. Early in 2000, several reports indicated that maternal health in Enugu State was deplorable, and that maternal mortality was more than 3000 deaths per 100,000 live births (Enugu State Ministry of Health, 2007). In response to the challenges of the high MMR in the state, Enugu State government initiated a policy on Free Maternal and Child Health (FMCH) care in 2007. The FMCH provides free medical, antenatal, delivery and postnatal services for women. This policy is aimed at reducing maternal mortality. Onah (2009) noted the high rate of pregnancy related complications in Nsukka Zone and posited that childbearing activities are high in the zone.  This may be the reason why maternal deaths are high too.

Graham (2001) grouped maternal deaths into direct and indirect obstetric deaths Direct obstetric deaths are deaths resulting from obstetric complications during pregnancy, labour or puerperium, or from interventions, omissions or incorrect treatments or from a chain of events resulting from eclampsia, postpartum haemorrhage or sepsis. Indirect obstetric deaths are those deaths resulting from a previously existing disease or a disease that developed during the pregnancy. Examples are anemia, HIV and AIDS, malaria or heart disease. These deaths accruing from pregnancy related complications have some causes.

Federal Ministry of Health-FMH (2007) identified haemorrhage, puerperal sepsis obstructed labour, unsafe abortion and pregnancy induced hypertension as major causes of maternal mortality. Other causes indicated by FMH are malaria, anemia, HIV and AIDS, diabetes mellitus and hepatits. Omoruyi (2010) stated that five major causes of maternal deaths are haemorrhage, infection, abortion, hypertensive diseases of pregnancy and obstructed labour. Also, poor access to and non utilization of quality reproductive health services tend to contribute to the high maternal mortality level in Nigeria.

Haemorrhage refers to excessive bleeding more than 500 meals during late pregnancy, delivery or after delivery. This accounts for about 23 per cent of maternal deaths (FMH, 2007). Hypertensive diseases of pregnancy occur in about 4 per cent of pregnancies, especially in the last stage of pregnancy (United Nations Fund-UNICEF & WHO, 1990). Hypertensive diseases include pre-eclampsia and eclampsia. The clinical manifestations are high blood pressure protein in urine oedema convulsion and coma. Obstructed labour may be caused by ineffective uterine contractions, cephalopelvic disproportion, (CPD) malpresentation or malposition (Diana & Copper, 2003). Obstructed labour always put the mother at risk of developing vesico-vaginal fistula(VVF), recto-vaginal fistula (RVF), infection  rupture of the uterus fetal  maternal exhaustion and death. This contributes 11 per cent of maternal deaths (FMH, 2007).

          Unsafe abortion is defined as the termination of unwanted pregnancy either by persons lacking the necessary skills or in an environment lacking the minimal standards, or both (Warriner & Shah, 2006). Globally, it has been estimated that some 68,000 women die each year as a consequence of unsafe abortion and 5.3 million suffer disability (Ahman & Shah, 2002). It accounts for 11 per cent of maternal deaths in Nigeria (WHO, 2005). Kanyghe (2008) indicated that puerperal sepsis causes about 17 per cent of maternal deaths. It is characterized by high fever abdominal pains vomiting headache and loss of appetite. These types of deaths occur mostly in women of childbearing age.

Women of childbearing age are referred to as women aged 15 -45 years (Samuel 2010). Women of childbearing age in this study refer to women aged between 15 -49 years in Nsukka health district of Enugu state. WHO (1998) asserted that some groups of women of childbearing age are more at risk than others. WHO also stated that girls and adolescent women have high risk of pregnancy related complications. This may be because they lack adequate knowledge for prevention of maternal mortality due their under age. Lack of knowledge of maternal mortality may be a reason for negative attitude towards maternal mortality. Nigeria Demographic and Health Survey-NDHS (2003) reported that adolescents constitute a high proportion of maternal mortality cases as a result of complications of unsafe abortion. However, deaths of WCA during pregnancy and childbirth can be prevented.

Sinclair (1992) defined prevention as action that hinders something from happening. Udeinya (1995) explained that in order to reduce maternal mortality, every woman must be educated on the need to accept and practice family planning as a way of achieving improved health and economic well being. WHO (2001) opined that reducing maternal mortality will depend on identifying and improving services that are critical to the health of Nigerian women including antenatal care, emergency obstetric care, adequate post partum and family planning. UNICEF (2008) posited that interventions for improving maternal health should focus on quality and affordable antenatal care, skilled birth attendance, access emergency obstetric care and postnatal care. Okonofua (2008) identified four main components of interventions as critical to reducing maternal mortality in developing countries as family planning, antenatal care, skilled birth attendance and emergency obstetrics care. Prevention of these regrettable deaths among women of childbearing age could be influenced by their knowledge.

Knowledge is critical to man’s quality of life because everything we do depends on knowledge. WHO (1996) asserted that knowledge is prerequisite for any health action. WHO further maintained that many of the ailments people suffer are to a large extent, self-influenced by anti-health practices due to lack of knowledge. Nigerian Education Research Council-NERC (1972) indicated that an educated, informed and knowledgeable person is the one who understands among other things, the basic facts concerning health and diseases, protects his or her health and that of his or her dependants. Knowledge in the context of this study refers to the ability of women of childbearing age to understand the concept of maternal death, possible causes and preventive measures.

Knowledge about how to take care of pregnant mothers, detect complications and tackle them has existed for centuries. This notwithstanding, millions of mothers continue to die from severe complications associated with pregnancy and childbirth probably because they lack the knowledge inherent in the effective management of pregnancy related problems (Jatua, 2000 & WHO, UNICEF and United Nations Population Fund-UNFPA, 2002). There is need for the possession of adequate knowledge by women regarding maternal deaths resulting from pregnancy and childbirth. Such knowledge is likely to impact positively on the women’s attitude toward maternal mortality.

Abosi (1992) viewed attitude as a person’s position or disposition towards another individual event or thing. Morse (1993) stressed that attitudes are perceptual feelings and beliefs which enables an individual to respond favourably or unfavourably towards persons, groups, ideas, things, objects and events. Nauman (1997) referred to attitude as a mental state of readiness, organized through experience, exerting a dynamic influence upon the individual’s response to all objects and situations with which it is related. Attitude in the context of this study could be emotions, thoughts and feelings that predispose women to respond either favourably or unfavourably to causes of maternal mortality and its preventive practices.

Positive attitude without knowledge may be undesirable or ineffectual, while knowledge without positive attitude is sterile (Wheeler, 1980). Opara (1993) maintained that knowledge and positive attitude must be present for desired change to occur. Knowledge influences attitude positively and positive attitude reinforces knowledge (Onwudinjor, 1998). It is a fact that it could be impossible to form proper attitude on how to avert maternal deaths without first knowing the causes of death in pregnancy and childbirth. Both knowledge and attitude of women of childbearing age can be influenced by certain socio-demographic variables.

One of such variables that seem to influence knowledge of and attitude to maternal mortality among women of childbearing age in Nsukka health district is age. Muokwogwo (1992) indicated that a woman’s age is the most universal factor predisposing a woman to risk of injuries and or death during pregnancy and childbirth. Muokwogwo also indicated that adolescents (15-19) with little or no knowledge of prevention of maternal mortality recorded higher rate of maternal deaths than older mothers of 35 years and above. WHO (1998) indicated that mothers of 35 years and above though may have knowledge of maternal mortality tend to exhibit negative attitude to maternal deaths.