DETERMINANTS OF MATERNAL MORTALITY IN GENERAL HOSPITAL CALABAR, CROSS RIVER STATE.
CHAPTER ONE
INTRODUCTION
1.1 Background of the study
The growing concern on improving reproductive health at the global level  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).
          It is obvious that maternal mortality is a key constituent 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 accidental and incidental causes (WHO 2007; Ogunjuyigbe and Liasu, 2007; Khama, 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.
Nigerian constitutes only two percent of the world?s population, but Nigeria accounts for over 10% of the world 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 or determinant of death among women of reproductive age in Nigeria (Idris, 2010).
Although opinion differ on the determinants of maternal mortality, Herfon, (2006), noted  that the cause of maternal mortality is an outcome of nexus interaction of a variety of factors namely: the distant factors (socio-economic, cultural) which include; occupation, income level and illiteracy act through the proximate or intermediate factors (health and reproductive behavior, access to health services) and in turn influence outcome (pregnancy complication mortality).Idris, (2010) further identified other factors responsible for maternal  mortality as socio-cultural factors which include; traditional practices, norms, believes, education and religion.
Several attempts have been made in the past aimed at reducing maternal mortality in Nigeria, such attempts, especially by the Federal and state governments, have generally not proved very successful in achieving the desired results. Some promising results however have recently begun to be recorded through some  policy initiatives by a few state governments. In Cross River state, the state house of assembly approved a bill in 2007, guaranteeing free maternal health services to pregnant women (Shiffman and Okonofua, 2007). The state commissioner of health, who is an obstetrician and gynaecologist, played a central role in its development and adoption.
The introduction of the safe motherhood programme in 1995,midwife service scheme (MSS) in (2011) and subsidy reinvestment program (SURE-P) IN 2012 introduced a range of interventions which included antenatal care, labour and delivery care, postnatal care, family planning, prevention and management of unsafe abortions, and health education but still MMR has not been encouraging over the years and improvements are so slow.
The former state commissioner of health together with some senior obstetrician and gynaecologist, played central roles in creating this positive environment for maternal health. Hence , today  pregnant women in Cross River now assess free medical services in General hospital, Calabar as part of measures put in place by the state government to reduce maternal mortality rate in the state (Media Global,2010).  However, other states like Jigawa, as part of measure in checking maternal mortality,  have provided funds for the upgrading of obstetric care facilities in hospitals, the recruitment of obstetricians and gynaecologists and the provision of ambulances at the local level to transport pregnant women experiencing delivery complications to health facilities. The former executive secretary for primary health care, who subsequently became state commissioner for health, stood behind these initiatives.
1.2 Statement of the Problem
Maternal mortality is the most important indicator of maternal health and well being in any country (Herfon, 2006). Maternal mortality is a tragedy, many children are rendered  motherless, such children are deprived of maternal care which goes a long way to affect adversely both their physiological and psychological development. The majority of these pitiable situations are due to maternal mortality.
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). 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.
  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 Ireland and Singapore respectively (World Bank, 2011; UNICEF, 2010; Media Global, 2010; UNICEF, 2008; UNFPA, 2005). Some of the implications of  these estimates are the depletion of the country?s workforce and the overall stifling of rapid development.
This study focuses on determinants of maternal mortality in General hospital Calabar, Cross River State. The researcher was motivated to carry out  this study based observation and experience while on clinical posting towards the rate at which pregnant women die during childbirth as a result of post partum hemorrhage or eclampsia. The poser is what are the causes of women death?: thus this question can only be answered when this study is concluded.
1.3 Purpose of the study
The purpose of the study is to understand the determinants of maternal mortality in General Hospital Calabar, Cross River.
1.4 Objectives of the study                   
(i)   To assess the influence of poor maternal health care on maternal mortality
 (ii)      To identify the influence of education on maternal mortality
(iii)         To determine the influence of occupation on maternal  mortality
 1.5 Research Questions
In order for the researcher to achieve the objectives of the study, the following research questions were developed to guide the study;
(i)                            To what extent does poor maternal health influence maternal mortality?
(ii)                         How does education factors influence maternal mortality?
(iii)                       Can occupation influence maternal mortality?
1.6 Research hypothesis
There is no significant relationship between maternal level of education and causes of maternal mortality in General Hospital, Calabar
1.7     Scope of the study
          The study is narrowed to all pregnant women with pregnancy related issues resulting to maternal mortality in General Hospital Calabar.
1.8       Significance of the study
          The findings of this study will help health workers to identify factors responsible for maternal mortality, this will guide them on adopting more effective measures to ensure that women experience uneventful pregnancy, labour and peuperium. It will help women of child bearing age in the prevention of maternal mortality even in future pregnancies by obtaining adequate prenatal care.
Similarly, the study will also be of value to government both state and federal, policy makers as well as researchers for further research.
1.9     Limitations
          The major limitation encountered during this study was the attitude of health record official in providing relevant information for the researcher. Also some retrieval of information was very cumbersome due to the manual nature of keeping information.
1.10 Operational definition of terms
Hospital:  Is a place or building where people who are ill/sick or injured are giving medical treatment and care.
Primary Health Care:  Is the medical treatment one received first when sick.
Pregnacy:  Is a period where a woman is having a baby developing inside her.
Maternal Mortality:  Is the death of a woman during or after delivery.
Maternal health: Is the physical well being of a woman during pregnancy, childbirth, and postpartum period