The main purpose of this study was to ascertain the level of knowledge and practice of strategies for promotion of maternal health during pregnancy by childbearing mothers in Enugu State Nigeria . The study adopted a descriptive survey research design. The questionnaire was designed, validated, tested for reliability and used for the study. The population for the study was nine hundred and eight thousand, nine hundred and eight five (908,985) childbearing mothers in Enugu State Nigeria. A sample of four hundred (400) respondents was obtained using Yaro Yemeni formula and was used for the study. Out of the 400 questionnaires administered, 390 were returned. Research question I dealing on knowledge was analyzed using frequency counts and percentage while research questions II and III dealing on practice and constraining factors respectively were analyzed using mean statistic. Chi-square was used for testing the hypotheses relating to knowledge, while t-test statistic was used for testing hypotheses relating to practice and constraining factors. All the hypotheses were tested at .05 level of significance. The findings include that child bearing mothers in Enugu State possessed high level of knowledge of strategies for promotion of maternal health during pregnancy and that some child bearing mothers practice the strategies for the promotion of maternal health during pregnancy. It was also found that certain factors such as cost, distance, false belief, ignorance and poor attitude of health workers constrained some child bearing mothers from practicing the strategies for the promotion of maternal health. It was recommended that seminars, workshops and enlightenment campaign should be carried out to educate childbearing mothers more especially in the rural areas of Enugu State.
Introduction
A healthy motherhood is a joyous experience to all concerned. However, this can only be achieved through the promotion of maternal health. According to World Health Organization (WHO) (2003) maternal health refers to the health of women during pregnancy, childbirth and the post partum period. It encompasses the health care dimension of family planning during preconception, pre-natal and post-natal care in order to reduce maternal morbidity and mortality.
Undoubtedly, the state of maternal health is one of the key indicators of a societys level of development as well as an indicator of the performance of health care delivery system (Okeibunor, Onyeneho, and Okonofua, 2010). Unfortunately, the United Nations and World Bank statistics estimated that 144 women die each day in Nigeria from pregnancy-related complications, thereby making her one of the worst countries to deliver babies in the world (Okeibunor, et al, 2010). This view was also collaborated by the Nigerian Demographic and Health Survey (NDHS) (2008) report of 545 maternal mortality per 100,000 live births (National Population Commission, 2009). This may be the reason why the fifth MDG goal calls for the reduction of maternal deaths by 75% by the year 2015.
Incidentally, notwithstanding Nigerian governments efforts to promote maternal health through their policies and programmes (such as removal of user fees for all maternal health problems in some states including Enugu State), some other factors like reproductive behavior of women through certain practices, may impact on maternal health situation in Nigeria, generally and Enugu State in particular. For instance, in some part of Northern Nigeria, many young girls marry and beget children during their adolescent age when their reproductive systems are yet to mature. In Igbo land, preferences for male children among other reasons; push mothers to have high propensity to beget children even beyond high-risk period of child bearing age (NDHS, 2008). According to National Population Commission (NPC) (2009) childbearing age ranges from 15 to 49 years. However within this period 22 to 35 years is considered as the best period for child bearing. Pregnancies outside this bracket may pose more threat to the life of the mother and hence they are considered high risk (Diana and Margaret, 2003). This notwithstanding, some women still go beyond this period in seeking for children. These may imply that they do not have knowledge of the health implication of their actions.
Knowledge is generally accepted as singular factor that disperses and illuminates the ignorant mind. Knowledge is defined as the general awareness or possession of information, facts, ideas, truths or principles. (Microsoft Encarta, 2009). The level of health knowledge a woman possesses, therefore determines to a great extent the womans appreciation and understanding of health matters including her reproductive health
It is one thing to possess knowledge on an issue, but it is another thing to put into practice that which one has knowledge of. Encarta (2009) defined practice as the process of repeating something many times in order to improve performance because practice, they say makes perfect. Therefore if child bearing mothers know and practice strategies for the promotion of maternal health, the health situation of mothers may be improved. Hence the need for this study which sought to find out the level of knowledge and the extent of practice of strategies for promotion of maternal health among childbearing mothers in Enugu State.
Location is an important variable that may influence health practices. According to Encarta (2009) location is a particular place where somebody stays or lives. Understandably, some Nigerian mothers are resident in the rural areas where it may be difficult to access some of the facilities offered by the government for the promotion of maternal health (Okonofua et al, 2011). This is a good reason for adopting personal based strategies among such mothers instead of turning to traditional birth attendants and faith based maternal care prevalent in the rural areas. Encarta (2009) refers to strategy as a carefully devised plan of action to achieve a goal. It also refers to promotion as an act of encouraging the growth and development of something. Therefore strategies for the promotion of maternal health refer to carefully devised plans of action geared towards encouraging the growth and development of good maternal health. According to Diana and Margaret (2003) strategies for the promotion of maternal health starts from the adolescent stage when a girl is being taught how to care for her environment and personal hygiene, and continues throughout the child bearing age. Such care and hygienic practices for child bearing mothers include personal hygiene, good nutrition, physical exercises, among others, which are indispensable no matter how often they attend ante-natal clinics when they are pregnant. Early commencement of antenatal, regular taking of routine drugs and required doses of tetanus toxoid are also some of the strategies pregnant women should practice to ensure a good maternal health (NPI, 2004).
Uzochukwu et al (2011) identified long waiting time and distance to the health facility as some of the problems constraining the utilization of free maternal and child health care in Enugu State. Poor and unhealthy attitude to work is also one of the problems affecting the promotion of maternal health in Enugu State. The medical personnel claim that there is an increased workload resulting from the free maternal health care programme but that this is not matched with any corresponding increase in their remuneration (Uzochukwu et al, 2011). Whether the above mentioned constitute constraints towards practice of health promotional strategies among child bearing mothers in Enugu State was also determined by this study.
Research Questions
The following research questions were posed in line with the objective of the study.
What is the level of knowledge of strategies for the promotion of maternal health during pregnancy among childbearing mothers in Enugu State?
What is the extent of practice of strategies for the promotion of maternal health during pregnancy by childbearing mothers in Enugu State?
What are the constraining factors to the promotion of maternal health among childbearing mothers in Enugu State?
Hypotheses
The following hypotheses were formulated for the study, and they were tested at .05 level of significance.
Ho.1 Significant difference does not exist in the responses of rural and urban mothers in their knowledge of the strategies for the promotion of maternal health during pregnancy in Enugu State.
Ho.2 Significant difference does not exist in the mean responses of rural and urban mothers in their practice of strategies for the promotion of maternal health during pregnancy in Enugu State.
Ho3 Significant difference does not exist in the mean responses of rural and urban mothers on the constraining factors for the practice of strategies for the promotion of maternal health in Enugu State.
Research Method
Descriptive survey was the design for this study. According to Wrong (2008) a survey research means the collection and analysis of responses of large samples of people to polls and questionnaires designed to elicit their opinions, attitudes, and sentiments about a specific topic. Data collected through this will be described. This method was adopted because the researcher sought for information from a sample of women considered to be representative of the relevant population aged 15-49, on their knowledge and use of strategies for the promotion of maternal health in Enugu State.
The study was carried out in Enugu State Nigeria. The state has 17 local government Areas and is situated in the South Eastern part of Nigeria. The population comprised all the 908,985 child bearing mothers (15-49 years) in Enugu State (National Population Commission, 2006 Census result projected to 2013).
Sample Techniques
A sample size of 400 mothers (aged 15-49) was used. This was determined by the use of Yaro Yemeni formula. The multi-stage sampling method was adopted in selecting the sample for the study. The 17 LGAs in Enugu State were first grouped into urban and rural LGAs. There are five urban LGAs made up of Enugu North, Enugu South, Enugu East, Nsukka and Oji-River, while the rest were classified as rural LGAs. At this stage, Enugu East, Enugu South and Nsukka LGAs were randomly selected from the five urban LGAs to represent the urban area, while Udi, Nkanu West, Isi-Uzo, Awgu, Udenu and Uzo-Uwani LGAs were equally selected by random sampling to represent the twelve rural LGAs. In the second stage, two urban communities were also randomly selected from each of the three urban LGAs while one rural community was selected by random sampling from each of the six rural LGAs. In all, twelve communities were selected for the study. The sample size of 400 child bearing mothers was equally distributed to these communities. Thus 34 respondents each were drawn from identified health centers, traditional birth centers and spiritual clinics where ante-natal and post natal services are rendered in Federal Housing Estate, Ugbo Paul, Uwani and Awkunanaw, while 33 were drawn from similar health facilities located in the remaining eight communities (See appendix IV for more details). In both the rural and urban communities incidental sampling was used in selecting the respondents. Copies of the instrument were then administered to child bearing mothers who visited the health facilities for antenatal or immunization services on Monday and Wednesdays until the required number for each community was got. With the help of my research assistants this was carried out simultaneously on the same days of the week in all the communities used for the study. The researcher had earlier designed a structured questionnaire which consists of two sections namely: section A and section B. Section A solicited for the demographic data of the respondents, while section B sought for information that supplied answers to the research questions and was divided into three parts. Part I made up of 16 Items used yes or no questions to tests mothers knowledge of maternal health strategies during pregnancy while part II consists of 13 items elicited information on the extent of practice of maternal health strategies during pregnancy. Four point scales with response categories of very great extent (VGE), great extent (GE), Low extent (LE) and very Low extent (VLE) were ascribed with numerical value of 4, 3, 2, and 1 respectively attached to the points. Part III made up of 10 items sought for information on the factors constraining the practice of these strategies. A four points scale of strongly agree, agree, disagree, and strongly disagree were ascribed with numerical values of 4,3,2 and 1 respectively attached to the points. The instrument was validated and tested for reliability using Kudor Richardsons formula for part I, and Cronbach alpha for part II and III. Reliability indices of 0.75, 0.71 and 0.76 were obtained for part I, II and III respectively. Four hundred questionnaires were administered out of which 390 were duly completed and retrieved.
Results
Table 1: Frequency and percentage scores of child bearing mothers on knowledge of strategies for the promotion of maternal health during pregnancy.
n = 390
S/No
Items
Strategies for promoting maternal heal during pregnancy include:
Correct Responses
Incorrect Responses
Decision
Freq
%
Freq
%
1
Taking of bath regularly is one of the strategies for promotion of maternal health.
355
91.0
35
9.0
VHL
2
Personal hygiene such as washing of hand before eating is among the strategies for promotion of maternal health.
343
87.9
47
12.1
VHL
3
Pregnancy test must be carried out before a woman is confirmed pregnant.
248
63.6
142
30.4
HL
4
A pregnant woman should register for antenatal care within the first two months of pregnancy.
277
71.0
113
29.0
HL
5
Early laboratory investigations to detect abnormalities that might endanger the life of the mother and the fetus are important for pregnant women.
315
80.8
75
19.2
VHL
6
Good nutrition is very important for pregnant women.
363
93.1
27
6.9
VHL
7
A pregnant woman can obtain drugs from patent medicine stores.
238
61.0
142
39.0
HL
8
A pregnant woman must attend antenatal clinic in a hospital, maternity or health center.
317
81.3
73
18.7
VHL
9
A pregnant woman can take drugs not prescribed by a medical professional.
257
65.9
133
34.1
HL
10
A pregnant woman can take herbs prepared by traditional medicine practitioners.
254
65.1
139
34.9
HL
11
A pregnant woman can go to traditional medicine men/women to find out the cause of her illness.
254
65.1
136
34.9
HL
12
A pregnant woman can attend antennal service in a church for deliverance from spiritual attack.
260
66.7
130
33.3
HL
13
Taking of tetanus toxiod is very necessary for pregnant women who are not suffering from tetanus.
329
84.4
61
15.6
VHL
14
Routine drugs/other drugs prescribed by the health professional are important and should not be omitted.
323
82.8
67
17.2
VHL
15
Pregnant women should report in time to the appropriate health professional for child delivery.
314
80.5
70
19.5
HL
16
Pregnant women should provide all required materials for child delivery.
314
80.5
76
19.5
VHL
On the whole, an average of 288 respondents (75.12%) indicated high level of knowledge of strategies for the promotion of maternal health during pregnancy. This means that majority of child bearing mothers in Enugu State possessed a high level knowledge of strategies for the promotion of maternal health during pregnancy.
Table 2: Mean ratings of respondents on the extent of practice of strategies for the promotion of maternal health during pregnancy in Enugu State.
n = 390
S/No
Items
I practice the following
SD
D
A
SA
Mean
SD
Decision
17
I take my bath regularly and especially cleaning my private part
10
12
102
266
3.60
.67
VGE
18
I wash my hands before eating and after toileting
6
25
133
226
3.48
.68
GE
19
I care for my nails and clothes
13
31
134
212
3.39
.77
GE
20
I wash my mouth and brush my teeth twice daily
29
49
112
200
3.23
.93
GE
21
I register for antennal care in hospital, maternity or health centre at the onset of my pregnancy.
30
80
87
185
3.11
.99
GE
22
I register for antenatal care with the traditional birth attendant and I take traditional medicine
162
60
58
99
2.24
1.25
LE
23
I submit myself for early laboratory investigations to detect abnormalities that might endanger my life and that of my baby
26
69
87
208
3.22
.96
GE
24
I report to my doctor all illnesses for early treatment
18
435
108
219
3.35
.85
GE
25
I take balanced diet
6
33
138
213
3.43
.71
GE
26
I care for my breast especially the nipples
12
52
110
216
3.35
.82
GE
27
I attend ante-natal clinic regularly
21
44
125
200
3.29
.87
GE
28
I make regular exercises
48
62
132
148
2.97
1.01
GE
29
I take traditional medicine as prescribed by the herbalist
151
67
78
94
2.29
1.21
LE
Grand Mean
3.15
.90
GE
The data also shows a grand mean of 3.15, which indicates that childbearing, mothers generally a great extent, level of practice of maternal health strategies by the respondents during pregnancy.
Table 3: Mean ratings of respondents on the constraining factors that affect the practice of strategies for the promotion of maternal health among child bearing mothers in Enugu State.
n = 390
S/No
Items
SD
D
A
SA
Mean
SD
Decision
30
Unaffordable cost of healthcare
16
36
113
225
3.40
.82
A
31
Health facilities are too far from my location.
24
58
179
129
3.05
.85
A
32
Lack of transport to health facility.
42
78
138
132
2.92
.98
A
33
Lack of belief in conventional medicine as a solution to maternal health problem.
46
88
141
115
2.83
.98
A
34
Tenacious belief in traditional medicine
97
77
110
106
2.57
1.13
A
35
Ignorance about health need and available solution
57
54
130
149
2.95
1.05
A
36
Poor attitude to work by health workers
32
66
133
159
3.07
.94
A
37
Belief that maternal ill-health are caused by spiritual attack and as such needs deliverance but not drug treatment.
91
70
112
117
2.65
1.13
A
38
Some husbands prevent their wives from utilizing health services.
54
52
136
148
2.96
1.03
A
39
Lack of knowledge about the existence of certain health services.
42
42
147
159
3.08
.97
A
Grand mean
2.97
.96
A
The above result showed that all the items were accepted as constraining factors towards the practice of maternal health strategies. The grand mean of 2.97 and standard deviation of .96 also justifies this assertion. The smaller the standard deviation, the more the values are concentrated around the mean.
Table 4: Chi-square result of comparison of urban and rural mothers on their knowledge of strategies for the promotion of maternal health during pregnancy.
S/No
Items
Chi-Square Value
Df
Critical Value
Decision
1
Taking of bath regularly is one of the strategies for promotion of maternal health.
2.33
1
.156
Null Rejected
2
Personal hygiene such as washing of hand before eating is among the strategies for promotion of maternal health.
41.09
1
.000
Null Rejected
3
Pregnancy test must be carried out before a woman is confirmed pregnant.
14.82
1
.000
Null Rejected
4
A pregnant woman should register for antenatal care within the first two months of pregnancy.
31.48
1
.000
Null Rejected
5
Early laboratory investigations to detect abnormalities that might endanger the life of the mother and the fetus are important for pregnant women.
15.35
1
.000
Null Rejected
6
Good nutrition is very important for pregnant women.
23.44
1
.000
Null Rejected
7
A pregnant woman can obtain drugs from patent medicine stores.
42.90
1
.000
Null Rejected
8
A pregnant woman must attend antenatal clinic in a hospital, maternity or health center.
39.51
1
.000
Null Rejected
9
A pregnant woman can take drugs not prescribed by a medical professional.
64.55
1
.000
Null Rejected
10
A pregnant woman can take herbs prepared by traditional medicine practitioners.
87.07
1
.000
Null Rejected
11
A pregnant woman can go to traditional medicine men/women to find out the cause of her illness.
84.21
1
.000
Null Rejected
12
A pregnant woman can attend antennal service in a church for deliverance from spiritual attack.
22.38
1
.000
Null Rejected
13
Taking of tetanus toxiod is very necessary for pregnant women who are not suffering from tetanus.
24.98
1
.000
Null Rejected
14
Routine drugs/other drugs prescribed by the health professional are important and should not be omitted.
54.31
1
.000
Null Rejected
15
Pregnant women should report in time to the appropriate health professional for child delivery.
66.05
1
.000
Null Rejected
16
Pregnant women should provide all required materials for child delivery.
26.49
1
.000
Null Rejected
Result from table 4 above shows that the null hypotheses were rejected in all the 16 items. This then means that location exerted significance influence on the knowledge of strategies for the promotion of maternal health during pregnancy among mothers in Enugu State.
Table 5: t-test result of the mean ratings of rural and urban child bearing mothers on the practice of strategies for the promotion of maternal health during pregnancy in Enugu State.
Group
No of
22.Cases
Mean
SD
Df
t-Cal
t-Crit
Decision
Rural
186
60.1828
10.76174
388
-7.017
1.96
Reject Null
Urban
204
67.1569
8.83984
Total
329
Results from table 5 show that calculated t-value of -7.017 is greater than the critical value of 1.96 at 388 degree of freedom and at 0.05 level of significance. The null hypothesis was therefore rejected.
Table 6: t-test result of the comparison of the mean ratings of rural and urban child bearing mothers on the constraining factors affecting practice of strategies for the promotion of maternal health in Enugu Stat
Group
No of
Cases
Mean
SD
df
t-Cal
t-Crit
Decision
Rural
186
30.8495
5.04026
388
3.980
1.96
Reject Null
Urban
204
28.3235
7.19491
Total
366
Data on table 6 reveals that calculated t-value of 3.980 is greater than critical value of 1.96 at 388 degree of freedom and at 0.05 level of significance. Hence the null hypothesis is rejected. Thus location exerts significance influence on the constraining factors for the practice of strategies for the promotion of maternal health among childbearing mothers in Enugu State.
Discussion
Results on research question one in table 1 show that child bearing mothers in Enugu State generally posses high level of knowledge of the strategies for the promotion of maternal health during pregnancy. This contradicts NHDS (2008) report which portrays child bearing mothers in Enugu State as having low knowledge of maternal health. On the influence of location on knowledge of strategies for the promotion of maternal health during pregnancy as tested on hypothesis 1 (Ho.1), results in table 4 show that the rural and urban child bearing mothers differ in their knowledge of strategies for the promotion of maternal health during pregnancy. A closer look at their mean ratings shows that while urban scored a mean of 16.05, rural scored 11.09. This is not surprising given the fact that urban dwellers are believed to be generally more enlightened than rural dwellers. Whether this will result in better practice as postulated by KAP model will be seen in hypothesis two.
Results in table 5 show that child bearing mothers generally practice strategies for the promotion of maternal health during pregnancy. This is contrary to NDHS (2008), which reported low practice of maternal healthcare among childbearing mothers in Enugu State. Given the high level of knowledge of maternal health strategies possessed by child bearing mothers in Enugu State as shown in table 1 above, a great extent of practice is expected. KAP model posits that knowledge begets practice and this situation applies to the findings of this study. Result in item 22 however show that many of them still register with traditional birth attendants (low extent) while items 29 shows that many of them too take traditional medicine prescribed by the herbalist (low extent).
Although high extent of practices was indicated, hypothesis test presented in table 5 show that location exerted significant influence on the extent of practice. What this means is that with this high extent of practice, there exists significant difference practice of these strategies between mothers who live in the urban and those who live in the rural communities with urban having a mean rating of 67.7816 and rural having 60.1806. This is not surprising when we know that urban dwellers have more access to health facilities than their rural counterparts.
Results presented in table 3 indicate that generally all the identified factors posed constraints to the practice of maternal health among the respondents. This is in consonance with Chime (2011), Uzochukwu et al (2011) and okeinbunor et al (2010) who identified unaffordable cost, health facilities being to far, belief that maternal health are caused by spiritual attack etc as possible constraing factors. However, high level of practice observed in this research point to the fact that only few mothers who did not practice these strategies were affected by the constraining factors.
On whether location exerts significant influence on the constraining factors table 6 indicates that there is significant differences between urban and rural child bearing mothers on their constraining factors for the practice of the aforementioned strategies. This may be due to the fact that health facilities and qualified health personnel are more accessible in the urban than in the rural area.
Conclusions
Based on the findings of this study, the following conclusions were drawn:
Child bearing mothers in Enugu State possess high knowledge of strategies for the promotion of maternal health during pregnancy.
Child bearing mothers in Enugu State practice strategies for the promotion of maternal health during pregnancy.
Certain factors such as distance, costs, ignorance, and poor attitude of health workers constrained some child bearing mothers in Enugu State from practicing strategies for the promotion of maternal health.
Recommendations
The following recommendations are made based on the findings of this study.
Although high level of knowledge and practice were indicated, some child bearing mothers are still suffering from ignorance and false belief about maternal health strategies. This is more pronounced in the rural areas. In view of this, seminars, workshops and enlightenment campaign should be carried out to educate child bearing mothers more especially in the rural areas of Enugu state.
Government should improve health workers welfare packages to boost up their morale and improve their attitude and performance.
Since todays girls in schools would become future mothers, secondary school curriculum in health and physical education should include strategies for promotion of maternal health. This would have acquainted women with this knowledge even before they become mothers.
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