KNOWLEDGE, AND PRACTICES OF SAFE MOTHERHOOD AMONG WOMEN

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The promotion of safe motherhood remains a major global public health concern, particularly in developing countries such as Nigeria, where maternal mortality rates remain alarmingly high. Safe motherhood has become a critical component of the global women's health agenda, representing an international effort aimed at reducing maternal deaths and illnesses associated with pregnancy and childbirth. The Safe Motherhood Initiative was first launched in Kenya in 1987 to increase global awareness of maternal mortality and morbidity and encourage governments, donor agencies, United Nations organisations and other relevant stakeholders to take meaningful action towards addressing the problem. Maternal mortality, as defined by the World Health Organization (WHO), refers to the death of a woman during pregnancy or within a specified period after the end of pregnancy, provided that the death results from causes related to or aggravated by the pregnancy or its management, rather than accidental or incidental causes.

The Safe Motherhood Initiative subsequently gained recognition at several United Nations conferences, where a major target was established to reduce maternal mortality by half by the year 2000. This objective was to be pursued through two major approaches: improving the general status of women and strengthening maternal healthcare services. The initiative seeks to improve the quality of life and safety of women and girls through a combination of health-related and non-health-related interventions. It also emphasises the importance of providing accessible and quality maternal health services, expanding family planning education and services, and introducing effective measures to improve women's social and economic positions.

The global commitment to safe motherhood received further attention when the World Health Organization selected it as the theme for World Health Day on April 7, 1998. This commitment was reinforced in December 2000 when representatives of 149 governments, out of the 191 United Nations member states, pledged to work towards achieving the Millennium Development Goals (MDGs). The fifth goal focused on improving maternal health, with a target of reducing the maternal mortality ratio by three-quarters between 1990 and 2015.

The Safe Motherhood Initiative, through the different approaches adopted by individual countries, forms part of the international effort to achieve the Millennium Development Goals, particularly the reduction of maternal mortality and morbidity.

For many years, the provision of high-quality healthcare services was regarded as difficult to achieve, especially in developing countries where access to adequate healthcare remained limited. However, healthcare quality is now widely recognised as an important factor influencing treatment effectiveness, patient compliance and continuity of care. This is particularly relevant to antenatal services, where women's experiences and perceptions of care influence how they evaluate the services provided. Nwaeze et al. (2013) observed that women's perceptions of antenatal visits play an important role in determining their assessment of healthcare quality. Consequently, measuring patient satisfaction has become an essential part of evaluating healthcare system performance. Patient satisfaction is generally associated with the quality of services received and the extent to which individual healthcare needs are addressed. Women who are satisfied with the services provided are more likely to return for further care and recommend such services to others. Previous studies have identified several factors that influence patient satisfaction, including healthcare workers' attitudes, the cost of services, waiting time and the quality of communication between healthcare providers and patients (Nwaeze et al., 2013).

Globally, maternal mortality has remained a serious public health challenge. Earlier international estimates indicated that approximately 529,000 women died annually from complications related to pregnancy and childbirth, representing roughly one maternal death every minute. Most of these deaths occurred in developing countries, where women faced a considerably greater lifetime risk of dying from pregnancy-related complications than women in developed nations. The highest levels of maternal mortality have historically been recorded in sub-Saharan Africa and south-central Asia, with some countries reporting maternal mortality ratios exceeding 1,000 deaths per 100,000 live births.

Women in sub-Saharan Africa experience some of the highest risks of maternal mortality and morbidity worldwide. Thousands of women across the region die every year from complications associated with pregnancy and childbirth, while many others experience serious health conditions. Although improvements have been recorded in some countries, maternal deaths have remained a major concern. Population growth and the increasing number of women of reproductive age have also contributed to the continued burden of maternal deaths, despite some reductions in individual women's risks of dying during pregnancy.

Nigeria, despite having a relatively small proportion of the world's population, accounts for a substantial share of global maternal deaths. Historical estimates indicate that tens of thousands of Nigerian women die annually from pregnancy-related complications. The country's maternal mortality ratio has consistently been among the highest globally. There are also significant differences in maternal health outcomes between developed and developing countries, as well as within individual countries. Poor, less-educated and rural women are more likely to experience adverse maternal health outcomes than women who are educated, financially stable and living in urban areas. Maternal mortality therefore reflects substantial inequalities in access to healthcare and the wider social and economic conditions affecting women. In some parts of Africa, the lifetime risk of maternal death has historically been estimated at one in twelve, compared with approximately one in 4,000 in parts of northern Europe.

The burden of maternal morbidity is also considerable across sub-Saharan Africa. For every woman who dies from pregnancy-related complications, many others experience injuries, infections and long-term illnesses. These complications may include uterine prolapse, obstetric fistula, pelvic inflammatory disease and infertility. Pregnancy-related conditions remain among the major causes of death and disability among women of reproductive age, particularly those between 15 and 49 years, in developing countries.

The death of a woman during pregnancy or childbirth goes beyond an individual or family tragedy. It has serious social and economic consequences for her household, community and country. When a mother dies, her children lose an important caregiver, the family loses her contributions to household activities and income generation, and the community loses her participation in social and economic development. Women play essential roles in African societies. They contribute significantly to food production, food preparation, household maintenance, childcare and the care of sick and elderly family members. Consequently, maternal death can create considerable emotional, financial and social difficulties for families and communities. Furthermore, maternal illnesses can affect the survival and wellbeing of newborns. Millions of pregnancies worldwide have been associated with stillbirths and infant deaths resulting from maternal health complications. Children who lose their mothers during infancy are particularly vulnerable to poor health and survival outcomes.

Adolescent pregnancy is another major concern in sub-Saharan Africa. Young women below the age of 20 in the region are more likely to experience early childbearing than their counterparts in several other parts of the world. In some African countries, a considerable proportion of girls have already given birth before reaching the age of 18. Adolescent pregnancies are associated with increased health risks because young mothers may be physically, socially and economically unprepared for pregnancy and childbirth. First pregnancies also require appropriate monitoring because complications may arise during pregnancy and delivery. Babies born to adolescent mothers may face increased risks of adverse health outcomes, including infant mortality. In addition, adolescent childbearing places further demands on healthcare systems because young mothers require antenatal care, skilled delivery services and appropriate maternal and child healthcare.

A considerable number of pregnancies, whether occurring within or outside marriage, are unintended at the time of conception. Some may eventually become unwanted pregnancies, leading some women to consider induced abortion. The weakening of traditional systems of social support and changing social circumstances have contributed to concerns about unintended pregnancies and unsafe abortion practices. Studies conducted in different sub-Saharan African countries have reported that adolescents constitute a substantial proportion of women seeking treatment for abortion-related complications. However, unintended pregnancies and abortion-related health risks are not limited to adolescents, as women at different stages of their reproductive lives may experience unwanted pregnancies.

Nigeria, the most populous country in Africa, continues to face significant challenges in reducing maternal mortality. Earlier estimates by the World Health Organization indicated that the country had a very high maternal mortality ratio and that Nigerian women faced a substantial lifetime risk of dying from pregnancy, childbirth or postpartum complications. Unsafe abortion has also been identified as a contributor to maternal deaths in the country. Many women who experience complications following unsafe abortion procedures may not reach healthcare facilities in time to receive appropriate treatment. Consequently, the actual number of deaths associated with unsafe abortion may be higher than officially reported. Historical WHO estimates also identified unsafe abortion as an important contributor to maternal mortality in West Africa, including Nigeria.

In 2000, Nigeria and other United Nations member states adopted the eight Millennium Development Goals as a framework for improving health, reducing poverty and promoting socioeconomic development. The fifth goal focused specifically on improving maternal health, with the target of reducing maternal mortality by 75% between 1990 and 2015. Most maternal deaths recorded globally during that period occurred in developing countries. The major direct causes included severe bleeding or haemorrhage, infections, unsafe abortion, eclampsia and obstructed labour. Other maternal deaths resulted from indirect causes, including pre-existing or pregnancy-aggravated conditions such as malaria, anaemia, hepatitis, cardiovascular diseases and HIV/AIDS. These conditions may not originate from pregnancy but can become more severe during pregnancy or complicate its management. In addition, many women experience pregnancy-related illnesses after childbirth, demonstrating that maternal healthcare should continue beyond delivery.

Some women who survive serious obstetric complications may experience long-term health problems. Conditions such as organ failure, uterine rupture, obstetric fistula and poorly managed episiotomy or perineal injuries can result in lasting complications. These may include urinary incontinence, uterine prolapse, persistent pain and other reproductive health difficulties. When such conditions are not properly treated, they can lead to prolonged illness, disability and, in severe cases, death.

Poor maternal health outcomes are influenced by several social, economic and cultural factors that affect women's health and nutritional conditions before, during and after pregnancy. These factors are also associated with the low utilisation of available maternal healthcare services. Limited access to healthcare, inadequate nutrition, poor hygiene, poverty, insufficient health education and cultural beliefs can increase the risk of pregnancy-related complications. Nevertheless, many maternal deaths can be prevented through timely access to essential maternal healthcare, skilled birth attendance and emergency obstetric services during pregnancy, childbirth and the postpartum period.

The Safe Motherhood Initiative marked its twentieth anniversary in 2007. During the two decades following its introduction, several countries recorded improvements in maternal and newborn health. However, countries with the highest levels of maternal mortality and morbidity made slower progress, while inequalities in healthcare access continued to increase. Differences were also observed within countries, particularly between women living in favourable socioeconomic conditions and those facing poverty, poor living conditions and limited access to healthcare. Despite the progress recorded in some areas, global maternal and newborn deaths remained a major concern. Many stillbirths, neonatal deaths and maternal deaths were considered preventable through appropriate healthcare interventions. Furthermore, conditions such as HIV/AIDS and malaria during pregnancy continued to threaten maternal health and could undermine improvements already achieved.

A significant proportion of maternal deaths occurs during childbirth and the postpartum period. This highlights the importance of providing adequate attention to women during labour, delivery and the period immediately following childbirth. These stages are particularly critical because unexpected complications can develop rapidly and threaten the lives of both mothers and newborns. Inadequate attention to postpartum care can also expose women to preventable complications after delivery. Similarly, a considerable proportion of stillbirths and early neonatal deaths occurs in low- and middle-income countries, with obstetric complications during labour contributing significantly to these outcomes. Therefore, quality maternal healthcare is essential not only for reducing maternal deaths but also for improving newborn survival and overall health.

1.2 Statement of the Problem

The assessment of antenatal care among pregnant women is an important component of building trust, maintaining effective communication and promoting respectful relationships between women and nurses or midwives. Such assessment should be patient-centred and focus on identifying the physical, emotional and healthcare needs of pregnant women. There is therefore a need for healthcare institutions to establish effective systems for assessing maternal care and evaluating patients' experiences. These assessments can serve as important tools for improving the quality of antenatal services and overall maternal healthcare delivery.

Despite ongoing efforts to improve maternal healthcare, many health institutions continue to experience difficulties in implementing effective antenatal care assessment systems. Although a large proportion of pregnant women in developing countries attend antenatal clinics at least once during pregnancy, access to skilled and professional childbirth services remains inadequate in many communities. This includes access to institutional delivery services, skilled care during home births and emergency obstetric and newborn care.

Furthermore, regular and systematic follow-up after childbirth is not consistently available in many healthcare settings. Even women who give birth in health facilities may be discharged within a few hours after delivery without receiving adequate postpartum monitoring or follow-up care. In some cases, they may not return for further assessment until a considerable period has passed. This situation can delay the identification and treatment of postpartum complications and place the health and lives of mothers and newborns at risk.

These challenges demonstrate the need to assess women's knowledge, attitudes and practices regarding safe motherhood, particularly among women attending antenatal clinics. Understanding their attitudes towards antenatal care, nutrition, personal hygiene, essential obstetric care and childcare can provide useful information for identifying gaps in maternal health knowledge and practice. It can also support the development of appropriate interventions to improve maternal health outcomes in Nkpor Urban, Anambra State.

1.3 Purpose of the Study

The main purpose of this study is to assess the knowledge and practices of safe motherhood among women receiving antenatal care in Nkpor Urban, Anambra State.

Specifically, the study seeks to examine the following:

The attitudes of pregnant women towards prenatal or antenatal care.

The attitudes of pregnant women towards proper nutrition during pregnancy.

The attitudes of pregnant women towards maintaining personal hygiene during pregnancy.

The attitudes of pregnant women towards essential obstetric care.

The attitudes of pregnant women towards childcare.

The attitudes of pregnant women towards the Safe Motherhood Initiative in relation to their educational levels.

1.4 Research Questions

The following research questions were formulated to guide the study:

What are the attitudes of pregnant women towards prenatal or antenatal care?

What are the attitudes of pregnant women towards nutrition during pregnancy?

What are the attitudes of pregnant women towards personal hygiene during pregnancy?

What are the attitudes of pregnant women towards essential obstetric care?

What are the attitudes of pregnant women towards childcare?

What are the attitudes of pregnant women towards the Safe Motherhood Initiative based on their educational levels?

1.5 Research Hypothesis

The following null hypothesis was formulated and tested at a 0.05 level of significance:

H₀: Pregnant women's attitudes towards the components of the Safe Motherhood Initiative are not significantly associated with their levels of education.

1.6 Significance of the Study

Pregnancy and childbirth complications remain major causes of death and disability among women of reproductive age in developing countries, despite the introduction of the Safe Motherhood Initiative several decades ago. Safe motherhood practices are important strategies for reducing maternal mortality and morbidity. The inclusion of maternal health in international development goals has also increased attention towards improving maternal healthcare services in Nigeria. Since reducing maternal mortality has remained a major international development priority, this study is expected to provide useful information on safe motherhood among women in Nkpor Urban and contribute to evidence that may support government policies and programmes aimed at improving maternal health.

The study is also important because many developing countries lack reliable and comprehensive information on maternal and newborn deaths and illnesses. In addition, the availability of national data on postpartum healthcare remains limited in several settings. Compared with some disease-specific health programmes, maternal and child health interventions have not always received adequate attention in terms of monitoring, evaluation and the effective use of available data. As a result, policies and programme decisions may sometimes be made without sufficient evidence concerning the actual needs of mothers and newborns.

Furthermore, the study is expected to contribute to the existing body of knowledge on safe motherhood in Anambra State. Available literature suggests the need for further research into the implementation and outcomes of safe motherhood programmes at the community level. The findings may therefore help identify gaps in women's knowledge and practices and provide recommendations for improving maternal healthcare services, obstetric care delivery and healthcare planning.

The findings may also be beneficial to the following groups:

Pregnant Women: The study may increase awareness of the importance of antenatal attendance, proper nutrition, personal hygiene, essential obstetric care and appropriate childcare practices.

Nurses and Midwives: The findings may help healthcare professionals understand the attitudes and needs of pregnant women, thereby supporting improved health education, counselling and maternal care.

Healthcare Institutions: The study may provide information that can assist health facilities in identifying weaknesses in maternal healthcare services and improving the quality of antenatal and related services.

Government and Policymakers: The findings may serve as useful information for developing policies and interventions aimed at improving maternal health and reducing preventable maternal deaths.

Future Researchers: The study may provide background information and serve as a reference for further research on safe motherhood, maternal health knowledge and maternal healthcare practices.

1.7 Scope of the Study

This study focuses on assessing the knowledge and practices of safe motherhood among women receiving antenatal care in Nkpor Urban, Anambra State. The study area is Nkpor Urban, while the respondents comprise women attending antenatal services within the selected study setting. The research examines women's attitudes towards antenatal care, nutrition, personal hygiene during pregnancy, essential obstetric care and childcare. It also investigates the relationship between women's educational levels and their attitudes towards the components of the Safe Motherhood Initiative.

1.8 Limitations of the Study

During the course of the research, the researcher encountered certain challenges that affected the conduct of the study. One of the major difficulties was the reluctance of some respondents to complete the questionnaires. In addition, some distributed questionnaires were reported missing and had to be replaced, resulting in additional financial expenses for the researcher.

Time constraints also affected the research process, as the researcher had to combine the study with other academic responsibilities and coursework. Furthermore, the study was limited to women receiving antenatal care in Nkpor Urban, Anambra State, because it was not possible to cover all healthcare institutions and pregnant women across the wider area. These limitations were considered during the conduct and interpretation of the study.

1.9 Operational Definition of Terms

Knowledge: This refers to the level of awareness, understanding and information possessed by women concerning safe motherhood and its recommended practices.

Practice: This refers to the extent to which women receiving antenatal care in Nkpor Urban adopt and apply recommended safe motherhood practices in their daily lives.

Safe Motherhood: This refers to the promotion of conditions and healthcare interventions that enable women to experience pregnancy and childbirth safely while reducing the risk of maternal illness, disability and death. It involves access to appropriate antenatal care, skilled childbirth services, emergency obstetric care and postpartum support.

1.10 Organisation of the Study

This research is structured into five chapters. Chapter One presents the background to the study, statement of the problem, purpose of the study, research questions, research hypothesis, significance, scope, limitations and operational definitions of key terms.

Chapter Two reviews relevant literature related to the research topic, including theoretical and empirical studies on safe motherhood.

Chapter Three describes the research methodology, including the research design, study area, study population, sampling procedures, research instrument, methods of data collection and techniques for data analysis.

Chapter Four presents the results of the data analysis and discusses the major findings in relation to the research questions and existing literature.

Chapter Five provides the summary of the study, conclusions drawn from the findings and recommendations based on the outcome of the research.