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Women’s Perceptions of the Causes of Maternal Mortality: Qualitative Evidence From Nsukka, Nigeria.:

Women’s Perceptions of the Causes of Maternal Mortality: Qualitative Evidence From Nsukka,... There have been reports of growing rate of maternal mortality in most rural areas in Nigeria. This study examined women’s perception of the causes of maternal mortality in Nsukka, a semi-urban area in South Eastern Nigeria. the study seeks to find out what rural women know about maternal mortality. Qualitative research design was adopted for the study. The study was conducted between the months of March and April, 2020. Two health facilities were used for the study (Nsukka Health Centre and University of Nigeria Teaching Hospital, Obukpa). In each of the health facilities, one Focus Group Discussion involving 10 women was conducted while 10 in-depth interviews comprising women not using antenatal was also conducted in a separate arrangement to complement the FGD. The participants were married and single mothers aged 18 to 40 years. Participants identified personal factors such as delay in seeking healthcare and poverty as contributing to maternal mortality. Among other Findings, result showed that lack of education and exposure, and sole reliance on the advice of relatives and other rural women within the immediate environment indirectly contributed to maternal mortality in the area. Despite advances in healthcare system and increased access to education, there are still superstitious and primordial beliefs that have continued to impact on healthcare seeking behavior of women. We recommend that massive orientation and sensitization in the area of public health should be carried out especially in the rural areas to address some of these issues identified. Keywords beliefs, culture, maternal mortality, superstitions, qualitative population and on the health of women and children. Every Statement of Significance (SOS) day, about 830 women die from complications related to There is still a high case of maternal mortality especially in pregnancy or childbirth (World Health Organization [WHO], developing countries (Nigeria inclusive) where access to 2019). It further reported that in low-income nations, one healthcare is limited. Various studies have shown that there are woman out of every 41 dies from maternal causes, and each a number of factors that causes maternal mortality. Such fac- maternal death has a significant impact on the health of sur- tors include neglect, hospital related factors, physiological fac- viving family members and the community’s resilience. In tors, etc. Unfortunately, such factors are unlikely to explain the 2015, it was estimated that about 303,000 women died dur- role of culture, environment and primordial belief in explain- ing and following pregnancy and childbirth (World Health ing maternal mortality. This present study provides qualitative Organization WHO [WHO,], 2015). Despite the efforts of evidence of how superstition and primordial beliefs have con- Safe Motherhood Programs, maternal mortality remains an tinued to influence women perception of the causes of mater- issue, according to the research, with developing regions nal mortality and how such held beliefs directly or indirectly impact on the rate of maternal mortality. University of Nigeria, Nsukka, Nigeria Introduction Corresponding Author: Nicholas Uchechukwu Asogwa, Philosophy department, University of Maternal mortality is a global phenomenon that has attracted Nigeria, Nsukka, Nigeria. international attention due to its deleterious effects on Email: Nicholas.asogwa@unn.edu.ng Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open accounting for almost 99% (302,000) of global maternal review and thematic synthesis, Bradley et al. (2016) reported fatalities in 2015. According to the UN Interagency Group that disrespectful intrapartum care during facility-based for Child Mortality Estimation (2013), the global maternal delivery is extoled by women as being responsible for poor mortality ratio was predicted to drop by 44% between 1990 quality care that leads to maternal mortality in Sub-Saharan and 2015, from 385 to 216 deaths per 100,000 live births. Africa. This translates into an average annual rate of 2.3%. However, Nigeria is the most populous country in Africa. It has a this decrease is insufficient to reach the Sustainable population of 201 million people (World Bank, 2019) with Development Goals (SDGs), which call for a global maternal more than 250 ethnic identities. It has one of the highest death rate of fewer than 70 per 100,000 live births by 2030. maternal mortality ratios in the world. WHO (2015) report WHO in its continued effort to reduce the rate of maternal that Nigeria and India accounted for over one third of all mortality globally has in recent past advocated for the estimated global deaths in 2015. It indicates that Nigeria strengthening of Traditional Birth Attendants’ (TBAs) pro- had approximately 58,000 maternal deaths which translate grams as an interim solution in pursuit of the greater goal of into 19% of global total. The report further states that giving all women and children access to acceptable, profes- Nigeria is second worldwide, after India in the number of sional, and modern healthcare. However, failure of the TBAs maternal deaths and the highest in Africa. The global mater- educational interventions has been identified as an obstacle nal mortality ratio (the number of maternal deaths per against maternal mortality reduction. As Roost et al. (2004) 100,000 live births) decreased between 1990 and 2015 but have posited, it has not been possible to confirm a positive the pace of reduction has been much slower in Nigeria outcome in terms of decreased mortality from TBAs’ train- compared to the rest of Africa (WHO, 2015). In their study ing programs. of the factors influencing maternal morbidity and mortality The 53 low-income nations with a gross national income among rural communities in South Western Nigeria, Azuh (GNI) per capita of $905 or less account for nearly all mater- et al. (2017), noted that malaria and fever were the most nal mortality (Piane, 2019). Sub-Saharan Africa accounts for prevalent illnesses contributing to maternal mortality in the more than half (60%) of these nations (Azuh et al., 2017; research regions, with 80.3% indicating that they were the Piane, 2019; WHO, 2010). United Nations International most common. Typhoid (13.9%), headache (1.9%), cold/ Children and Educations Fund (UNICEF, 2016) reported that cough (3.3%), diarrhea (0.3%), and diabetes accounted for Sub-Saharan Africa has the highest maternal mortality ratio the remainder (0.3%). Okonofua et al. (2018) conducted a at 535 maternal deaths per 100,000 live births. It explained study to better understand the causes of maternal death in that there are significant differences between countries, as low-income countries, and found that women were aware well as within countries, and between women with high and of the medical causes of death. While a few ladies stated low incomes, as well as those who live in rural and urban heavenly reasons, the main causes mentioned by women areas. Furthermore, in contrast to the scenario in industrial- were delays in getting to hospitals or delays once they ized regions, developing countries account for the vast arrived in hospitals. majority of maternal mortality each year. (Azuh et al., 2017). Studies have looked into the phenomenon of maternal Similarly, Piane (2019) reports that about one million African mortality in Nigeria (Olonade et al., 2019; Tasneem et al., mothers die every 4 years from preventable diseases, but 2019; (Adegoke et al., 2013; Ijadunola et al., 2010; Okonofua, women in wealthier countries give birth with little chance of 2010). Nonetheless, there is a paucity of study on women’s mortality. By means of a systematic review and meta- perceptions of reasons for maternal mortality in South analysis, Montoya et al. (2014) studied the inequalities in Eastern Nigeria and in particular, Nsukka taking into cogni- maternal mortality levels in Sub-Saharan Africa. They zance the socio-cultural belief system of the people. Nsukka claimed that in Sub-Saharan Africa, maternal mortality has people are rooted in tradition and socio-cultural belief with a declined. However, this reduction is insufficient to satisfy the unique custom; hence the motivation to conduct a study of Sustainable Development Goals (SDGs). Because there were women’s perception of reasons for maternal deaths in the so few published papers from specific African regions, the area. It is speculated that they have always held on to ele- study urged additional research in Sub-Saharan Africa and an ments of their culture and not letting go certain superstitious increase in the number of published papers from Africa over- and primordial belief system. As Opata and Asogwa (2017) all. According to WHO (2014), women in developing coun- opined, the Nsukka Igbo of Southeastern Nigeria have tries have many more pregnancies than women in developed numerous ways of recreating and upholding their cultural countries and their lifetime risk of death as a result of beliefs and inheritances. Women are at the centre of maternal pregnancy is higher. Laing et al. (2017) in their study of mortality; therefore, their perspectives are critical in identi- barriers to antenatal services in The Gambia reported that in fying areas in which maternal healthcare could be improved. sub-Saharan Africa, pregnancy is regularly perceived to be a The general objective of this study was to examine women’s time of great vulnerability, with the women reporting feel- perceptions of the causes of maternal mortality. The study ings of insecurity and fear of dying. Adopting systematic also attempted to uncover socio-cultural determinants that Asogwa et al. 3 would serve as a starting point for future research into mater- despite the moderate link to obstructed labor and consequent nal mortality and its contributing factors in the region. The mother and newborn death, Cutie (2007) and WHO (2006) specific objectives of the study are have observed that none of the published journal publica- tions or popular press pieces mention female genital 1. To investigate women’s perception of reasons for mutilation as a contributing factor. Worthy of note is that maternal mortality in Nsukka. socio-economic and cultural factors impact on access to and 2. To examine if there are socio-cultural belief factors acceptance of modern family planning methods with atten- ascribed to maternal mortality in Nsukka. dant effect on maternal mortality (Piane, 2019). This present study investigates what women know about the causes of maternal mortality in Nsukka area of Nigeria. Nigeria is a Primordial Beliefs and Maternal multi-ethnic society with over 250 ethnic groups. These eth- Mortality in Nigeria nic groups have different cultural and historical backgrounds. According to Piane (2019), the professional literature on cul- Therefore, a study of this nature among the Nsukka people is tural factors that contribute to maternal mortality in Nigeria apt owing to their unique culture and dearth of literature on is scarce. However, Muoghalu (2010) pointed out that there maternal mortality in the area. are taboos against eating giant plantains, milk, eggs, snails, snakes, and okra soup during pregnancy in certain earlier Methodology writings. However, he said that it is still unknown whether this causes vitamin shortages in pregnant women. A Study by Study Design and Study Area Abubakar et al. (2018) observed that cultural norm such as Qualitative research designs were used to gain a deeper “Kunya” (shyness, especially on anything that relates to sex- understanding of the perceptions of women on the causes of ual acts) in Hausa cultural context, which is more prominent maternal mortality. The study was conducted in Nsukka area in the first pregnancy, usually restricts women from seeking of Nigeria between the months of March and April, 2020. health related assistance in pregnancy and childbirth. A sur- The area is situated in Enugu state which is an Igbo society. vey conducted by Gazali et al. (2012) in Maiduguri, Northern It plays host to the University of Nigeria, Nsukka. The 2006 Nigeria revealed many socio-cultural factors influencing census puts the population of Nsukka Local Government maternal health utilization. These include large family size, Area (LGA) at 309,633 persons (National Bureau of polygamy, purdah, traditional medicine, low self-esteem Statistics, 2010). With an annual growth rate of 2.3% among women. Furthermore, through supernatural theories (National Population Commission & [NPC, 2006), the 2016 of causation, behavioral taboos are thought to contribute to population of Nsukka LGA was put at 316,922 persons. maternal difficulties and deaths. Women may die during or Verbal as well as written informed consent and cooperation after childbirth as a result of these cultural practices. For of the respondents were solicited and obtained from each example, Muoghalu (2010) report that a pregnant woman in participant after having been fully briefed on the study some Nigerian communities is believed to bleed or die dur- objectives, risks, benefits, and steps taken to ensure confi- ing her pregnancy as a result of witchcraft, supernatural abil- dentiality. Permission to conduct the study was also obtained ities, infidelity, or being disrespectful to her husband. Piane from the principal officers of the health centers that were (2019) stressed that families who believe in supernatural used for the study. diagnosis will seek care from religious or traditional healers rather than medical physicians. Also, Maduforo (2011) had equally revealed that a significant number of the study Participants Recruitment respondents (pregnant women) adhere to traditional beliefs and food taboo. The sample population comprised of ten (10) women who Abasiattai et al. (2006) in a survey among the Annang in are not attending antenatal services and twenty (20) women South-South Nigeria showed that most of the participants who seek antenatal services. Those who were attending ante- felt that hospitals generally connote sickness and were places natal care were used for the Focus Group Discussions (FGDs) reserved for sick people only. For them, the most common while those who do not seek antenatal care were used for the causes of maternal death were spiritual attacks from enemies In-depth interview (IDI) sessions. Pregnant women attend- and punishment by the gods for infidelity. According to ing antenatal care services in two health facilities—Nsukka Okolocha et al. (1998), Nigerian women had a good under- Health Centre and University of Nigeria Teaching Hospital, standing of obstetric heamorrhage as a cause of maternal Obukpa were chosen for the FGD. The FGDs were con- death, but their attitudes, habits, and circumstances hindered ducted within the premises of the hospitals. These hospitals them from seeking or delaying modern obstetric care. They were therefore, venues for the FGDs and in each, one FGD highlighted those causes such as infidelity, witchcraft/evil involving 10 pregnant women each was conducted. Thus, forces and disobedience constituted 8.3% of the causes of making it a total of two FGDs with 20 participants overall. death mentioned by their study participants. Surprisingly, Special arrangements were made with Participants of the 4 SAGE Open FGD. The exercise took place in the selected hospitals’ “Pidgin” [this is a type of English, also called Broken English, premises on Wednesdays and Thursdays which were the which is spoken in most parts of Nigeria]. Both data (FGD & 2 days fixed for the weekly antenatal services in the two IDI) were collected by the authors. However, a note-taker and health facilities. The reason for choosing hospitals as venues a moderator were always present to take notes and moderate for the FGDs was to get access to as many pregnant women each session. Both the FGD and IDI guides were structured to as possible at the same time. To be eligible for inclusion, elicit information on women’s perceptions of causes of mater- participants were expected to have met the following criteria: nal deaths. Participants were specifically asked if they had (i) must be pregnant and (ii) must be a native of Nsukka. heard of pregnant women dying, what they knew about For the IDI, Interview participants were selected using maternal fatalities, and the medical and other reasons of a purposive sampling procedure. In doing this, we appro- maternal mortality. They were also asked to describe the ached prospective participants at their places of residence. events that led to maternal deaths that they were aware of. Participants who showed interest were screened for eligibility The women were asked a series of questions in no particular and were selected as part of the study sample. However, order, and they were told they could answer or not answer any because it was difficult to identify women who were not of them. FGD and IDI were chosen to identify variations in attending antenatal clinics, we also adapted by asking the the responses that women give. already selected participants to refer us to other members of their community who share the same attribute for inclusion. Data Analysis Accordingly, new willing participants were identified and selected until the sample size of 30 (both FGD and IDI) eligi- Thematic analysis was used to analyze the data. We did this ble participants were gotten. The number of the study partici- by reading and rereading the transcripts, noting any similari- pant was limited to 30 as a result of the unwillingness of some ties and discrepancies between and within the accounts of the pregnant women to participate in the study. Some women who participants. Qualitative computer package (Nvivo 11, QSR) met the criteria for inclusion declined the request to participate was used to organize and assist in the task of first-level anal- due to lack of time and other undisclosed personal reasons. ysis. Responses were further categorized within relevant themes. The content and format of transcripts were also described during the data analysis process. We were able to Data Collection obtain insight into women’s perspectives of the causes of Both in-depth interviews [IDI] and focused group discussion maternal fatalities and what might be done to prevent them [FGD] were employed for the study. The study participants as a result of the findings. were grouped into two: those attending antenatal care ser- vices and those not attending. FGD was used to elicit infor- Ethical Approval mation from women attending antenatal services while IDI was the instrument used to get information from women not In accordance with the Nigerian national guidelines and reg- attending antenatal care services. One FGD was conducted ulations, ethical approval is not required for this study as it in each of the two health facilities used for the study (Nsukka did not involve human or animal subjects in a way that might Health Centre and the University of Nigeria Teaching cause harm by any means [National Health Research Ethics Hospital, Obukpa). Each FGD consisted of ten pregnant committee (NHREC, 2020). Educated assent was properly women attending antenatal section in the hospital. For ease gotten from all members included within the study. However, of identification and comparison, after each FGD section, the for purposes of confidentiality, all participants were anony- audio records were labeled FDG1 and FGD2, respectively. mized. Participants were informed before the start of the For the IDI sections, Individual, in-depth interviews (IDI) interview that they had the option to ignore any question(s) were conducted in person using an unstructured interview they did not want to answer and to end the interview when- guide. Verbal consent was obtained before the commence- ever they wanted. Table 1 showing the socio-demographic ment of the IDI sessions. Ten women who were not attending characteristics of the respondents. antenatal care services were purposively selected. The reason for purposively selecting them was to ensure that women with Results the required attributes were selected for inclusion. Interviews were conducted at the participants’ places of residence at a Socio-Demographic Characteristics of the scheduled date and time. After each interview, interview Participants records of each participant were labeled (e.g., PP1, PP2, PP3, etc.) to ensure easy identification during data management Four broad themes emerged from the responses of the par- and analysis processes. The interviews were digitally audio- ticipants: personal factors, hospital staff and equipment recorded and later transcribed verbatim. The IDI and FGDs related reasons, physiological factors and cultural factors/ sessions were conducted in English, Igbo and occasionally superstition. Asogwa et al. 5 Table 1. Respondents’ Demographic Characteristics. with doctors’ prescriptions and instructions or indulgence in self-medication. She narrated thus: Characteristics Frequency (%) I do not doubt in my mind that some women are the architecture Age of their death. This is how I lost my neighbour who is my friend 18–25 6 (20) as well. During her pregnancy, she refused to enroll for antenatal 26–33 14 (46.7) care against all bits of advice. Instead, she chose to be taking 34–40 10 (33.3) concoctions from one local medicine man. One day she took one Occupation of those concoctions and after a while, she started bleeding Civil servant 9 (30) heavily and lost her life (FGD2, 33 years, University of Nigeria Trader 17 (56.7) Teaching Hospital, Obukpa). Artisan 4 (13.3) Level of Education Most of the women were of the view that most women do Primary education 3 (10) not visit the hospital until their conditions get critical. Such Secondary education 20 (66.7) an attitude complicates the delivery process. One FGD par- Tertiary education 7 (23.3) ticipant noted that “some women in the village delay going Marital status to the hospital until their conditions get worse and sometimes Married 25 (83.3) when they get to the hospital the doctor will not be there to Single mother 5 (16.7) Religion attend to them” (FGD1, 31 years, Nsukka Health Centre). Christianity 18 (60) Corroborating this, an IDI participant who opined that she ATR 8 (26.7) does not attend antenatal for reasons of pride and family tra- Others 4 (13.3) dition, explained that “some other women too do not go to Income level hospital early because they want to deliver at home and enjoy 18,000 and below 21 (70) the pride that come with it but when it gets complicated they 19,000–100,000 7 (23.3) may try to see doctors” (PP7, 37 years). Above 100,000 2 (6.7) We further probed to know why these women delay seek- Area of residence ing for antenatal services. Prominent among their responses Nsukka 30 (100) were religious belief, illiteracy and to an extent poverty. Some of the participants believed that some religious groups instruct their members not to take medications when they are Personal Factors sick. Rather, they asked them to pray fervently or to come to the religious house to be prayed for to get healed. Many par- The participants enumerated a lot of personal factors that ticipants, therefore, lamented, that some women held this could lead to maternal mortality. These factors ranged from misconception, which motivated them to avoid health clin- delay in seeking care, poverty, non-compliance with doctor’s ics. Their resolve not to seek antenatal care was fueled by prescriptions, preference for home delivery, non-usage of opinions expressed by their religious leaders toward it. As health facility, illiteracy, and ignorance, among others. The one participant put it; “some women are brainwashed into delay in seeking care was one of the most prominent per- believing that they can get healed from their sicknesses sonal factors identified by the women. Many of the partici- through prayers alone” (FGD2, 34 years, University of pants claimed that many women die from maternal-related Nigeria Teaching Hospital, Obukpa). Another participant causes as a result of their failure to seek medical help in a also quipped that “instead of seeking medical care, the timely manner. A participant in one of the FGD sessions woman or her relatives will engage spiritual or traditional commented thus: herbalist” (FGD1, 30 years, Nsukka Health Centre). Buttressing these points, a participant stated thus: Many pregnant women take their health for granted. Some women don’t even like going to the hospital. My experience with some women has shown me that they visit the hospital There are some religions that admonish their members not to during their pregnancy only when they get signs of sickness. take drugs during illnesses. At least I am aware of one but I Others will tell you that it is not good to start visiting antenatal don’t think it is wise for me to mention it here. Surprisingly, care clinics in the first few months of pregnancy because some some women buy this idea and leave themselves at the mercy of the drugs they give affect the development of the child. of death. I know of a woman who during her pregnancy kept on Because of this, they seek antenatal care at later stages of their visiting prayer houses. Seven months into her pregnancy, she pregnancy when things might be late (FGD1, 40 years, Nsukka started bleeding and some people were invited to pray for her. Health Centre). The bleeding continued after all until one of her relatives angrily rushed her to the hospital where her life was saved Similarly, another FGD participant maintained that most (FGD2, 25 years, University of Nigeria Teaching Hospital, Obukpa). women die during and after childbirth due to noncompliance 6 SAGE Open Illiteracy was also identified by the women as militating and complaints about lack of equipment in a few of the hos- against the use of antenatal care by some women. They pitals and clinics around. They particularly pointed out that explained that some women are either unaware of the impor- nurses do not help matters during child delivery. According tance of antenatal care or are ill-informed about it. They to them, some nurses, especially those who have never been emphasized that many women are illiterate, and as a result, to labor are fond of maltreating pregnant women. One of the are unaware of essential antenatal care services. One partici- participants commented: “the attitude of some of these nurses pant observed that “there are some pregnant women who do is nothing to write home with. . . they treat you with levity” not know much about antenatal care. Even when you try to (FGD1, 28 years, Nsukka Health Centre). Continuing fur- educate them on the importance, some of them will see you ther, this participant stated: “some of these nurses are just as trying to show off” (FGD2, 40 years, University of Nigeria wicked. I think they take pleasure watching you suffer and Teaching Hospital, Obukpa) Equally, some of the partici- that is why they behave the way they do, mostly when doc- pants averred that some women are not properly informed tors are not around.” Continuing in this line, a participant about the need for antenatal care. Their expression was that further shared her knowledge and experiences thus: some women are ill-informed (most probably by those who When you go into the labour ward, at times, you will wonder if lack the basic knowledge of antenatal) on the importance of women were born to be cruel to women. If you see the level of antenatal. An FGD participant stated that some women might cruelty meted out to pregnant women! Just imagine that a have embraced antenatal care but because they were misin- woman is screaming in pains and the nurses will be shouting formed about the whole thing, they started avoiding it. This ‘madam abeg allow person hear word oh. . . When una dey do d FGD participant explained: thing e dey sweet you I dey there? [This loosely means stop making noise because you enjoyed the sex before you conceived Education is very important in the life of every woman. In my and I was not there]. . . this is dehumanizing and could make a village (Edem), a lot of girls get married at a very tender age woman give up (FGD2, 35 years, University of Nigeria Teaching without even completing secondary education. So they have Hospital, Obukpa). little or no knowledge of antenatal care. They mostly rely on whatever the old women in the village might tell them. In most This participant was not particularly happy with the non- cases, they seek the help of Traditional Birth Attendants (TBA). chalant attitude of some nurses as shown by her explanation. I am not saying that the TBAs do not work; I believe that it Another participant shared her experience thus: works because I patronize them sometimes (it however, does not stop me from going to the hospital to check the state of my baby) In November (2019), an incident took place in one of the but it should not be substituted for antenatal care. A girl from my hospitals around here; I will not mention the name please, where clan nearly lost her life during pregnancy. She never attended I used to go for antenatal checks. A nurse neglected a woman antenatal and was equally consuming alcohol on a daily basis. who was in serious pain after childbirth. The nurse ignored the At a stage, the foetus died in her womb four days without her woman and by the time her husband came in and raised an alarm knowledge. As a result, she developed complications and lost for doctors to come, it was too late. Unfortunately, the woman consciousness. It took the efforts of doctors to save her life died and it took the intervention of the police as the husband (FGD2, 39 years, University of Nigeria Teaching Hospital, almost beat the woman to death. That is why I never visited the Obukpa). hospital again (FGD2, 25 years, University of Nigeria Teaching Hospital, Obukpa). The participants also mentioned poverty as one of the rea- sons some women do not visit antenatal clinics. Most of the Continuing, the participant further expressed her anger by participants stated that some women avoid going to hospitals saying that Nigerians are fond of leaving things to God. She because they feel that it is expensive. According to them, stressed that “God will not come down from heaven to exer- there are still a couple of women out there who still avoid the cise our rights for us.” According to her, the hospitals and hospital. These set of people perceive the hospitals as a place persons involved should be sued for professional negligence. for the rich. An IDI participant stated thus: “I don’t have the Another participant who, at the time of this discussion was money to visit the hospital. . . so I use local herbs. Besides if animated while recalling her experience, has this to say: God says that I will die, I will die whether I visit the hospital or not” (PP10, 40 years). Affirming this, a woman in the FGD I once went to a private hospital to deliver my first child, the section stressed: “I can tell you that there are a lot of women nurses who attended to me after the doctor left rained abuses on out there, especially in the rural villages, who still see hospi- me after I challenged one of them for heating my stomach and tals as a place for the rich. making jest of me. They did not even mind my condition. They lacked the manners of professionals. I don’t know if it was because I did not attend my antenatal care services with them Hospital Staff and Equipment Related Reasons during the pregnancy period. I almost died during delivery. I left Among the factors raised during our discussion with the the place feeling emotionally bad because of their unprofessional women was their displeasure with some of the hospital staff act (FGD1, 34 years, Nsukka Health Centre). Asogwa et al. 7 Another FGD participant also quipped: Attending antenatal care clinics is important for safe delivery, knowing where to go for the actual delivery is Some have argued that there are good nurses but I am yet to equally important according to the women. Most of them come across a truly caring nurse in this country. Nurses here are resigned their fate to God stressing that anything can happen easily irritated and they yell at you at the slightest provocation. I during pregnancy. A participant stated thus: “where do I start don’t know why. And the funny thing is that some of these from; it’s with the grace of a God we deliver safely here and nurses are not qualified. . . they are auxiliary nurses and most of even elsewhere. I have heard of laboratory mishaps in the us don’t know that (FGD1, 32 years, Nsukka Health Centre). Western world that lead to the death of women during child- birth” (FGD2, 31 years, University of Nigeria Teaching Regarding the lack of equipment in most hospitals, partici- Hospital, Obukpa). pants blamed the government and owners of private hospi- tals. They acknowledged that some women have died during delivery because of a lack of equipment especially those Death Due to Physiological Factors requiring Cesarean Section (CS). Reacting to this, a partici- Apart from other factors earlier mentioned as causes of pant stated that: maternal mortality, many participants, especially the FGD participants, demonstrated knowledge of some of the physi- The number one problem is medical facilities. Can you imagine a ological causes of maternal mortality. In the course of the clinic without ECG, a clinic with miserable thermometers, poor discussions, the participants identified some physiological electricity, degraded laboratory tools, miserable surgical room with condition that leads to maternal deaths. Prominent among no difference from a carpenter’s workshop. Do you know the those factors include obstetric hemorrhage, prolonged labor, cause of all these (she queried)? I tell you; it’s the government (FGD2, 32 years, University of Nigeria Teaching Hospital, ectopic pregnancy, maternal and postpartum sepsis, abortion, Obukpa). hypertensive disorders. Commenting on this, a participant stated that “sometimes women die during pregnancy due to Further expounding on the issue, most of the participants excessive bleeding during or even after delivery” (FGD1, believed that the problem with some primary health care cen- 38 years, Nsukka Health Centre). Another participant also ters is not just in the establishment of structures, or labora- quipped that “excessive bleeding is very dangerous. . . a lot tory facilities but also the provision of equipment. Some of of women die as a result of this, especially immediately after the participants were of the view that it makes no sense to delivery,” (FGD1, 26 years, Nsukka Health Centre). Stressing build primary health care centers without equipping them more on this another participant said and/or not staffing them properly. Participants further lamented that in some government health centers, you find To be honest with you, this is one of the things I fear most whenever I get pregnant. It scares me a lot because I have seen cases where people queue for long hours to see the doctor people die as a result of this. Just recently, a colleague in our and their fear is compounded when it involves CS. Stressing workplace lost his wife due to too much bleeding after delivery. on this, a participant stated: It happens everywhere (FGD2, 37 years,University of Nigeria Teaching Hospital, Obukpa). Childbirth can be easy and uncomplicated and when that is the case, there is always great joy in the family. The problem with Prolonged labor also featured during the discussions. Nigeria is when there are serious complications with the birth Most of the participants acknowledged that maternal mortal- - our doctors in Nigeria don’t seem able to grapple with these ity occurs due to prolonged labor. They affirmed that many complications or our facilities are not up to it. I don’t know what it is. In the UK and US and other western countries, if you women had died as a result of prolonged labor. However, have your baby from 26 weeks - they will try to save your baby. they expressed a lack of knowledge as to what causes pro- I know two families that this happened to and their kids are longed labor. One participant stated: “I am well aware of very fine now but if it were to be in Nigeria, birth at 26 weeks women dying as a result of prolonged labor but I do not – the possibility of saving the child is at 1/100. The reason is know what the cause could be” (FGD1, 23 years, Nsukka simple; they don’t have the facilities to care for a baby that Health Centre). Another participant also said that “when young. My prayer for everyone giving birth in this area is that labor lasts longer than necessary, the implication is that the their birth should be a straightforward one because when the woman becomes weaker and weaker and could die from it” story enters, it’s only God and a very well trained doctor that (FGD2, 30 years,University of Nigeria Teaching Hospital, can help. If the mother dies during childbirth in the UK, an Obukpa). Shifting a bit from the positions of others, a partici- inquiry is launched but here it is hardly done. I am not being pant from one of the FGDs elaborated that: sentimental oh; I lost my auntie to childbirth in Nigeria many years ago. Till today, I don’t know what caused it. Her kids have had to grow up without their mother and it is said that Some of the women who die because of prolonged labour one many years on, it is still happening (FGD1, 34 years, Nsukka way or the other contributed to it. There are some pregnant Health Centre). women who when told that they cannot deliver through the 8 SAGE Open normal process (through the vagina) but through CS (Caesarean Prominent among them were witchcraft and evil spirits. Section) will insist on normal delivery. At times they will invite Other factors identified were wicked relatives and to an ‘prayer warriors’ to pray for them. Some die as a result of their extent, infidelity. They averred that there are so many people stubbornness (FGD1, 27 years, Nsukka Health Centre). especially in the villages that do not wish for your progress either financially or children-wise. Consequent upon this, References were also made to cases where fertilized ovum they will do everything possible to scuttle your progress. An develops outside the uterine cavity (ectopic pregnancy). Few IDI participant stated that “you have to be careful here espe- of the FGD participants expressed awareness of the existence cially when you are pregnant to avoid stories that touch the of such cases while most of the IDI participants indicated a heart” (PP10, 40 years). Another participant equally stated: lack of knowledge of such cases and wondered how possible “you don’t need to ask the question as to whether women die that could be. An FGD participant stated thus: “I know about here during pregnancy or not. Haven’t you heard of the it having been diagnosed with it in the past during my first atrocities committed by witches and other forces? It is real pregnancy but till today I cannot still comprehend what my brothers” (PP9, 30 years). This perception is shared by caused such abnormality in my body” (FGD1, 29, Nsukka almost all the IDI participants as evidenced by their Health Centre). On the other hand, an IDI participant responses. Commenting further, a participant stated thus: expressed surprise as to what that could be. She said: “I don’t know what that means because I have not even heard of such When you are a pregnant woman in this village, on no account thing before and I am not even sure if that kind of thing is should you disclose how far you have gone, if not witches and possible. It’s not from God” (PP4, 36 years). Concerning wizards from your village or husband’s village that doesn’t want to see you deliver safely will all gather for your sake in the women dying due to illness before or after delivery, the par- delivery ward on your delivery date (PP1, 20 years). ticipants demonstrated awareness of the occurrences of such a situation but maintained that seldom does it happen, at least Another participant equally stated that: to their knowledge. One participant stated that "a woman can die due to sickness during pregnancy or after delivery. It can When you are a pregnant woman in Nigeria, you are not happen to anybody but it is not common” (PP2, 35). expected to disclose it to even your siblings, if possible your Unsafe abortion was another cause of maternal death mother, until the first trimester passes by. . . now you are sure according to the participants. According to them the majority that the pregnancy will stay against all household witches and of abortions performed in Nigeria are unsafe and are done in wizards (PP5, 33 years). secret and are terminated by persons lacking the necessary skills. Commenting on this an IDI participant said: Another participant narrated how her close female friend’s situation impacted on her belief toward the reality of We have a lot of quack Chemist (patent medicine dealers) witchcraft. around here. Sometimes some of these young girls who get pregnant for their boyfriends seek their help for abortion. And A friend of mine was due for delivery but could not. She stayed without giving concern to the number of months of the in labour room for five days or more. One of her sisters suggested pregnancy, they will just prescribe drugs for them to take. In this could be the handiwork of witches. She urged the husband some cases, they will just go home and bleed to death while to take her to a particular herbal home but the husband refused those who survived do not fancy recalling their ordeals (PP4, and she left in anger. Meanwhile, in the midst of all these, 36 years). doctors have advised that she should go for CS in other to save the mother and her child. It was not long until her sister returned Commenting on the same abortion, another IDI partici- with a small bottle containing some liquid which she claimed to pant narrated an experience thus: have gotten from the herbalist. She went straight and rubbed it on her sister’s belly and legs and to my surprise, after like This abortion stuff is a dangerous thing. I have seen people die 20 minutes or so she was delivered of a baby girl. Since then I as a result of abortion. Currently, my younger sister is in the started believing that these people (witches) are working indeed hospital because of an unsafe abortion. She got pregnant without (FGD2, 19 years, University of Nigeria Teaching Hospital, our knowledge and secretly went to abort the child in one of the Obukpa). chemist shops around. She bled profusely and almost died in the process if not that we intervened when we got the information Besides witchcraft, participants also identified evil spirits (PP8, 30 years) as contributing to maternal mortality. Some of them believe that this is one dimension of the problem that is overlooked. Cultural Factors and Superstition Commenting on this, an IDI participant stated that “death of a mother during pregnancy or child delivery as well as miscar- From our analyses of the responses of the participants, many riage is not of God but the devil” (PP6, 33 years). Another of them, especially the IDI participants, admitted their belief participant was of the view that even though physical factors in the workability of humans conjured supernatural forces could contribute to maternal mortality, one cannot be blind to that work against the safe delivery of pregnant women. Asogwa et al. 9 the fact that evil spirit is at work. According to her, “there are understand the context of pregnancy and as a result do not few physical factors that can cause it like a man beating the attend an antenatal clinic and chose to seek healthcare only wife, too much stress, hitting the stomach on the floor but as when it is too late. This attitude could lead to pregnancy- far as I am concerned, I still attribute them to demonic manip- related morbidities and mortality as some women take early ulations” (PP2, 35 years). Participants further expressed belief signs of danger for granted. It therefore heralds the need to in the efficacy of certain objects tied on the body to ward off educate women, especially rural women, on the importance evil spirits. They explained that at times, safety pin or tiny of antenatal so that they can discover danger signs early and stick is attached to the woman’s cloth or hair to ward off witch take appropriate actions. Concerning poverty, participants or evil spirits. A participant explained that “safety pin or a said that some pregnant women avoid antennal services due strand of the stick is usually attached to their clothes/wears or to their inability to foot the bills. Because of this, several even somewhere around their hairs to protect fetus and the women stay away from hospitals and could die due to com- mother against evil spirit/demon especially at noon and night plications during childbirth. These findings are in line with (PP5, 33 years). The participants also expressed fear and con- those of Okonofua et al. (2018), who identified poverty and cern about some neighbors and relatives whom they termed a delay in seeking medical help as factors that may predis- “wicked ones.” Some of the women were of the view that pose women to maternal death. Furthermore, our findings some neighbors and relatives could also cause maternal death revealed that illiteracy contributes to maternal mortality. through diabolic means. One participant explained thus: Participants averred that due to lack of education and expo- When you are a pregnant woman in this area, you are sup- sure, some women especially in rural villages lack the basic posed to be very careful, you don’t have to show neighbors health knowledge and rely solely on the advice of relatives how happy you are, because some of them might get jealous and rural women. This finding aligns with that of Adeniran and cause you miscarriage, even death” (PP7, 37 years). et al. (2015) who had earlier found a similar result. Furthermore, infidelity was also mentioned as contributing to Our result also revealed that the women were of the view maternal mortality. Some participants explained that married that some maternal deaths are caused by negligence on the women who engaged in extra-marital affairs are likely to die part of hospital personnel especially nurses. They com- during pregnancy as a form of punishment from the gods. plained that some nurses abuse pregnant women and delay They explained that this was instituted by their forefathers unnecessarily before attending to women in labor. The fact decades ago. A participant commented: that women associate such views with maternal mortality emphasizes the need for more action. Women may be hesi- It is a taboo for a married woman here to engage in extra-marital tant to seek help because they are afraid of being assaulted. affairs. . .one of the obvious punishments was suffering and These delays, according to Okonofua et al. (2018, p. 13), can death during child delivery as a form of punishment from the be addressed in a variety of methods, including “staff train- gods which also serve as a deterrent to others. Our forefathers ing and retraining, regular use of maternal death reviews and made it so and no one has been able to undo it (PP9, 30 years). surveillance to address management gaps, staff monitoring/ evaluation.” Hussein and Okonofua (2012) and Hussein In the same vein, an FGD participant added: et al. (2016) in their studies of maternal mortality in Nigeria have found similar results wherein women linked poor staff I have heard about deities striking people mad as a result of attitudes to maternal death. Linking poor staff attitudes to adultery, but I have not seen a victim myself. Although I kind of maternal mortality does not speak well of the country and believed the narrative because it came from people I trust. But deterring women from seeking care is one of the immediate the thought of going mad is dreadful (FGD1, 26 years, Nsukka results. Equally, our findings showed that the lack of needed Health Centre). medical types of equipment contributes to maternal mortal- ity. The complaint was that when a complication is devel- Discussion oped during pregnancy, most of the hospitals around lack the Using a qualitative approach, the study investigated wom- necessary equipment to handle the situation. In such cases, en’s perceptions of the reasons for maternal deaths in Nsukka they are referred to hospitals outside the locality and life local government area taking into cognizance that Nigeria is could be lost in the process. Nnebue et al. (2016) has equally a country having a high maternal mortality rate. The results found that none of the health facilities studied could deliver indicate that most of the women, especially the FGD partici- even the full range of basic essential obstetric care (EOC). pants were well aware of the prominent causes of maternal Concerning the physiological factor that causes maternal mortality. The disparity in the responses of the FGD and the mortality, the participant demonstrated awareness and enu- IDI participants in some of the issues raised may not be merated some of the common medical factors influencing unconnected to education and exposure. The participants maternal mortality such as obstetric hemorrhage, prolonged identified personal factors such as delay in seeking health- labor, ectopic pregnancy, maternal and postpartum sepsis, care, poverty, and illiteracy as contributing to maternal abortion, etc. Reasons for such awareness may not be uncon- mortality. They explained that most women do not fully nected with the fact some of the participants attained some 10 SAGE Open levels of secondary and tertiary educations. Similar to other Conclusion and Recommendations findings (Okonofua et al., 2018; Say et al., 2014), our find- In this stage of human and technological development, when ings showed that some of these physiological causes of education and modernity are thought to have eliminated maternal death are still prevalent in the study area especially some risky health behaviors, there are still traces of people obstetric hemorrhage and abortion. The participants admit- who, because of certain cultural and superstitious beliefs, are ted that obstetric hemorrhage is till high because of negli- yet to embrace modern healthcare delivery system. Even gence on the part of some women who do not attend antenatal with the knowledge of antenatal care services, some women clinics either because of lack of education or awareness. are still reluctant to embrace it. The University of Nigeria is Furthermore, our findings also revealed that unsafe abortion situated in Nsukka and there is this undocumented argument is still carried out clandestinely in this area and it has that the inhabitants of the surrounding communities and vil- remained one of the prominent causes of maternal mortality lages are dropping some of their primordial beliefs while among teenagers in most rural villages. These unsafe abor- embracing Western education and lifestyle. This study there- tions are usually aided by poorly trained patent medicine fore concludes that some of these primordial and supersti- dealers who mainly use the rural areas as a safe haven to tious beliefs that are detrimental to maternal and child perpetrate this unhealthy act. This is a dangerous trend that well-being are still upheld and practiced. This attitude is not needs urgent attention from the government. necessarily influenced by demographic elements such as age Another interesting finding was that many of the respon- but was, however, influenced by elements of the social struc- dents hold superstitious and primordial believes about mater- tures such as residence, the level of sexual education of the nal mortality. Our findings showed that they believed that women, traditional beliefs and other personal factors. The witchcraft, evil spirits as well as infidelity are among the implication is that when individuals such as those we have causes of maternal mortality. The findings indicated a belief studied hold such beliefs to the detriment of their health, they among most of the participants that some wicked people are predisposed to several reproductive health problems like attack pregnant women through witchcraft. They explained heamorrhage and delayed delivery which could lead to that there are people within your immediate environment maternal mortality. Therefore, finding a feasible way to who do not wish for your success and could revert to witch- reduce maternal mortality requires community-centered craft and other diabolic means to harm you. Furthermore, our approach to maternal health. This involves engagement of analyses of the results demonstrated that evil spirits were informed community members, mobilization and empower- also held as a factor causing maternal death. Some of the ment of women. When a community is well mobilized, participants believed that maternal mortality is not of God engaged and empowered, they will be in a good position to but rather another ungodly means through which evil spirits find ways that will work for them in order to reduce maternal express themselves. This sort of belief and superstitions may mortality. We therefore, recommend that massive orientation not be scientifically proven, however, it is remarkable to note and sensitization in the area of public health should be car- how high these beliefs and superstitions are held among ried out especially in the rural areas to address some of these these people. We also found that marital infidelity is believed challenges identified in the study. Furthermore, we believe to contribute to maternal mortality. A woman who indulges that socioeconomic empowerment of women, reorientation in extra-marital sex stands greater chances of death during of health providers, community engagement, the establish- childbirth. These findings are similar to other findings in ment of more health facilities, and improvements in care maternal mortality literature. For example, Muoghalu (2010) quality are critical in efforts to improve women’s access to reported that in some communities in Nigeria, it is believed maternity care and reduce maternal mortality in the country. that a pregnant woman is could bleed or die during preg- Thus, our findings may be instructive to health sociologists, nancy because of witchcraft, spiritual manipulations and public health professionals and policymakers in the efforts to infidelity. While the findings are related to findings else- reduce maternal mortality. where (e.g., muoghalu, 2010 & Piane, 2019), they accentuate There were some limitations of the study. First, The the cultural practices that continue to impact on risky health FGDs was small in number and had just one focus—women practices in a place like Nigeria and other parts of sub-Saha- attending antenatal care. We thought that for wider repre- ran Africa, where certain customs have defied necessary sentation, we should have conducted different FGDs for change. As Piane (2019, p. 86) stressed; “families that pregnant women attending antenatal care services that are believe in supernatural etiology will seek care from faith or educated, those not educated or for different age brackets. traditional healers and not medical providers.” The findings Secondly, we felt that there may have been a selection bias have important implications on healthcare for women initia- as we did not include the perceptions of women who were tives as they could help in reconstructing those obstructive not pregnant. This may have presented a broader viewpoint socio-cultural practices to consistent use of antenatal on the issue. Furthermore, we also felt that the number of services. participants was not adequate. This may have limited a Asogwa et al. 11 comprehensive understanding of women’s perceptions of Bradley, S., McCourt, C., Rayment, J., & Parmar, D. (2016). Disrespectful intrapartum care during facility-based deliv- reasons for maternal death. Moving forward, further ery in sub-Saharan Africa: A qualitative systematic review researches should address these limitations identified in the and thematic synthesis of women’s perceptions and experi- study. ences. Social Science & Medicine, 169, 157–170. https://doi. Despite the limitations, the findings improve our under- org/10.1016/j.socscimed.2016.09.039 standing of reasons for maternal mortality and the cultural Cutie, C. R. (2007). Associated social, economic and political practices that continue to impact on risky health practices in factors. Women’s Health Journal/Isis International, Latin places like Nigeria and other parts of sub-Saharan Africa, American and Caribbean Women’s Health Network, 3, where certain customs have defied necessary changes in the 75–90. healthcare system. The study findings also provide important Gazali, W., Mukhtar, F., & Gana, M. (2012). Barrier to utilization insight for policy-making aimed at improving health care- of maternal health care facilities among pregnant and non preg- seeking behavior and creating awareness on the dangers of nant women of child bearing age in Maiduguri Metropolitan Council (MMC) and Jere LGAs of Borno State. Contemporary maternal mortality in the country. Journal of Tropical Medicine, 6, 12–21. Hussein, J., Hirose, A., Owolabi, O., Imamura, M., Kanguru, L., & Authors’ Note Okonofua, F. (2016). Maternal death and obstetric care audits This article is not simultaneously submitted to any other journal for in Nigeria: A systematic review of barriers and enabling fac- review and/or publication. tors in the provision of emergency care. Reproductive Health, 13(1), 47–11. https://doi.org/10.1186/s12978-016-0158-4 Declaration of Conflicting Interests Hussein, J., & Okonofua, F. (2012). Time for action: Audit, accountability and confidential enquiries into maternal deaths The author(s) declared no potential conflicts of interest with respect in Nigeria. African Journal of Reproductive Health, 16(1), to the research, authorship, and/or publication of this article. 9–14. Ijadunola, K. T., Ijadunola, M. Y., Esimai, O. A., & Abiona, T. Funding C. (2010). New paradigm old thinking: The case for emer- The author(s) received no financial support for the research, author- gency obstetric care in the prevention of maternal mortality ship, and/or publication of this article. in Nigeria. 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Women’s Perceptions of the Causes of Maternal Mortality: Qualitative Evidence From Nsukka, Nigeria.:

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Abstract

There have been reports of growing rate of maternal mortality in most rural areas in Nigeria. This study examined women’s perception of the causes of maternal mortality in Nsukka, a semi-urban area in South Eastern Nigeria. the study seeks to find out what rural women know about maternal mortality. Qualitative research design was adopted for the study. The study was conducted between the months of March and April, 2020. Two health facilities were used for the study (Nsukka Health Centre and University of Nigeria Teaching Hospital, Obukpa). In each of the health facilities, one Focus Group Discussion involving 10 women was conducted while 10 in-depth interviews comprising women not using antenatal was also conducted in a separate arrangement to complement the FGD. The participants were married and single mothers aged 18 to 40 years. Participants identified personal factors such as delay in seeking healthcare and poverty as contributing to maternal mortality. Among other Findings, result showed that lack of education and exposure, and sole reliance on the advice of relatives and other rural women within the immediate environment indirectly contributed to maternal mortality in the area. Despite advances in healthcare system and increased access to education, there are still superstitious and primordial beliefs that have continued to impact on healthcare seeking behavior of women. We recommend that massive orientation and sensitization in the area of public health should be carried out especially in the rural areas to address some of these issues identified. Keywords beliefs, culture, maternal mortality, superstitions, qualitative population and on the health of women and children. Every Statement of Significance (SOS) day, about 830 women die from complications related to There is still a high case of maternal mortality especially in pregnancy or childbirth (World Health Organization [WHO], developing countries (Nigeria inclusive) where access to 2019). It further reported that in low-income nations, one healthcare is limited. Various studies have shown that there are woman out of every 41 dies from maternal causes, and each a number of factors that causes maternal mortality. Such fac- maternal death has a significant impact on the health of sur- tors include neglect, hospital related factors, physiological fac- viving family members and the community’s resilience. In tors, etc. Unfortunately, such factors are unlikely to explain the 2015, it was estimated that about 303,000 women died dur- role of culture, environment and primordial belief in explain- ing and following pregnancy and childbirth (World Health ing maternal mortality. This present study provides qualitative Organization WHO [WHO,], 2015). Despite the efforts of evidence of how superstition and primordial beliefs have con- Safe Motherhood Programs, maternal mortality remains an tinued to influence women perception of the causes of mater- issue, according to the research, with developing regions nal mortality and how such held beliefs directly or indirectly impact on the rate of maternal mortality. University of Nigeria, Nsukka, Nigeria Introduction Corresponding Author: Nicholas Uchechukwu Asogwa, Philosophy department, University of Maternal mortality is a global phenomenon that has attracted Nigeria, Nsukka, Nigeria. international attention due to its deleterious effects on Email: Nicholas.asogwa@unn.edu.ng Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open accounting for almost 99% (302,000) of global maternal review and thematic synthesis, Bradley et al. (2016) reported fatalities in 2015. According to the UN Interagency Group that disrespectful intrapartum care during facility-based for Child Mortality Estimation (2013), the global maternal delivery is extoled by women as being responsible for poor mortality ratio was predicted to drop by 44% between 1990 quality care that leads to maternal mortality in Sub-Saharan and 2015, from 385 to 216 deaths per 100,000 live births. Africa. This translates into an average annual rate of 2.3%. However, Nigeria is the most populous country in Africa. It has a this decrease is insufficient to reach the Sustainable population of 201 million people (World Bank, 2019) with Development Goals (SDGs), which call for a global maternal more than 250 ethnic identities. It has one of the highest death rate of fewer than 70 per 100,000 live births by 2030. maternal mortality ratios in the world. WHO (2015) report WHO in its continued effort to reduce the rate of maternal that Nigeria and India accounted for over one third of all mortality globally has in recent past advocated for the estimated global deaths in 2015. It indicates that Nigeria strengthening of Traditional Birth Attendants’ (TBAs) pro- had approximately 58,000 maternal deaths which translate grams as an interim solution in pursuit of the greater goal of into 19% of global total. The report further states that giving all women and children access to acceptable, profes- Nigeria is second worldwide, after India in the number of sional, and modern healthcare. However, failure of the TBAs maternal deaths and the highest in Africa. The global mater- educational interventions has been identified as an obstacle nal mortality ratio (the number of maternal deaths per against maternal mortality reduction. As Roost et al. (2004) 100,000 live births) decreased between 1990 and 2015 but have posited, it has not been possible to confirm a positive the pace of reduction has been much slower in Nigeria outcome in terms of decreased mortality from TBAs’ train- compared to the rest of Africa (WHO, 2015). In their study ing programs. of the factors influencing maternal morbidity and mortality The 53 low-income nations with a gross national income among rural communities in South Western Nigeria, Azuh (GNI) per capita of $905 or less account for nearly all mater- et al. (2017), noted that malaria and fever were the most nal mortality (Piane, 2019). Sub-Saharan Africa accounts for prevalent illnesses contributing to maternal mortality in the more than half (60%) of these nations (Azuh et al., 2017; research regions, with 80.3% indicating that they were the Piane, 2019; WHO, 2010). United Nations International most common. Typhoid (13.9%), headache (1.9%), cold/ Children and Educations Fund (UNICEF, 2016) reported that cough (3.3%), diarrhea (0.3%), and diabetes accounted for Sub-Saharan Africa has the highest maternal mortality ratio the remainder (0.3%). Okonofua et al. (2018) conducted a at 535 maternal deaths per 100,000 live births. It explained study to better understand the causes of maternal death in that there are significant differences between countries, as low-income countries, and found that women were aware well as within countries, and between women with high and of the medical causes of death. While a few ladies stated low incomes, as well as those who live in rural and urban heavenly reasons, the main causes mentioned by women areas. Furthermore, in contrast to the scenario in industrial- were delays in getting to hospitals or delays once they ized regions, developing countries account for the vast arrived in hospitals. majority of maternal mortality each year. (Azuh et al., 2017). Studies have looked into the phenomenon of maternal Similarly, Piane (2019) reports that about one million African mortality in Nigeria (Olonade et al., 2019; Tasneem et al., mothers die every 4 years from preventable diseases, but 2019; (Adegoke et al., 2013; Ijadunola et al., 2010; Okonofua, women in wealthier countries give birth with little chance of 2010). Nonetheless, there is a paucity of study on women’s mortality. By means of a systematic review and meta- perceptions of reasons for maternal mortality in South analysis, Montoya et al. (2014) studied the inequalities in Eastern Nigeria and in particular, Nsukka taking into cogni- maternal mortality levels in Sub-Saharan Africa. They zance the socio-cultural belief system of the people. Nsukka claimed that in Sub-Saharan Africa, maternal mortality has people are rooted in tradition and socio-cultural belief with a declined. However, this reduction is insufficient to satisfy the unique custom; hence the motivation to conduct a study of Sustainable Development Goals (SDGs). Because there were women’s perception of reasons for maternal deaths in the so few published papers from specific African regions, the area. It is speculated that they have always held on to ele- study urged additional research in Sub-Saharan Africa and an ments of their culture and not letting go certain superstitious increase in the number of published papers from Africa over- and primordial belief system. As Opata and Asogwa (2017) all. According to WHO (2014), women in developing coun- opined, the Nsukka Igbo of Southeastern Nigeria have tries have many more pregnancies than women in developed numerous ways of recreating and upholding their cultural countries and their lifetime risk of death as a result of beliefs and inheritances. Women are at the centre of maternal pregnancy is higher. Laing et al. (2017) in their study of mortality; therefore, their perspectives are critical in identi- barriers to antenatal services in The Gambia reported that in fying areas in which maternal healthcare could be improved. sub-Saharan Africa, pregnancy is regularly perceived to be a The general objective of this study was to examine women’s time of great vulnerability, with the women reporting feel- perceptions of the causes of maternal mortality. The study ings of insecurity and fear of dying. Adopting systematic also attempted to uncover socio-cultural determinants that Asogwa et al. 3 would serve as a starting point for future research into mater- despite the moderate link to obstructed labor and consequent nal mortality and its contributing factors in the region. The mother and newborn death, Cutie (2007) and WHO (2006) specific objectives of the study are have observed that none of the published journal publica- tions or popular press pieces mention female genital 1. To investigate women’s perception of reasons for mutilation as a contributing factor. Worthy of note is that maternal mortality in Nsukka. socio-economic and cultural factors impact on access to and 2. To examine if there are socio-cultural belief factors acceptance of modern family planning methods with atten- ascribed to maternal mortality in Nsukka. dant effect on maternal mortality (Piane, 2019). This present study investigates what women know about the causes of maternal mortality in Nsukka area of Nigeria. Nigeria is a Primordial Beliefs and Maternal multi-ethnic society with over 250 ethnic groups. These eth- Mortality in Nigeria nic groups have different cultural and historical backgrounds. According to Piane (2019), the professional literature on cul- Therefore, a study of this nature among the Nsukka people is tural factors that contribute to maternal mortality in Nigeria apt owing to their unique culture and dearth of literature on is scarce. However, Muoghalu (2010) pointed out that there maternal mortality in the area. are taboos against eating giant plantains, milk, eggs, snails, snakes, and okra soup during pregnancy in certain earlier Methodology writings. However, he said that it is still unknown whether this causes vitamin shortages in pregnant women. A Study by Study Design and Study Area Abubakar et al. (2018) observed that cultural norm such as Qualitative research designs were used to gain a deeper “Kunya” (shyness, especially on anything that relates to sex- understanding of the perceptions of women on the causes of ual acts) in Hausa cultural context, which is more prominent maternal mortality. The study was conducted in Nsukka area in the first pregnancy, usually restricts women from seeking of Nigeria between the months of March and April, 2020. health related assistance in pregnancy and childbirth. A sur- The area is situated in Enugu state which is an Igbo society. vey conducted by Gazali et al. (2012) in Maiduguri, Northern It plays host to the University of Nigeria, Nsukka. The 2006 Nigeria revealed many socio-cultural factors influencing census puts the population of Nsukka Local Government maternal health utilization. These include large family size, Area (LGA) at 309,633 persons (National Bureau of polygamy, purdah, traditional medicine, low self-esteem Statistics, 2010). With an annual growth rate of 2.3% among women. Furthermore, through supernatural theories (National Population Commission & [NPC, 2006), the 2016 of causation, behavioral taboos are thought to contribute to population of Nsukka LGA was put at 316,922 persons. maternal difficulties and deaths. Women may die during or Verbal as well as written informed consent and cooperation after childbirth as a result of these cultural practices. For of the respondents were solicited and obtained from each example, Muoghalu (2010) report that a pregnant woman in participant after having been fully briefed on the study some Nigerian communities is believed to bleed or die dur- objectives, risks, benefits, and steps taken to ensure confi- ing her pregnancy as a result of witchcraft, supernatural abil- dentiality. Permission to conduct the study was also obtained ities, infidelity, or being disrespectful to her husband. Piane from the principal officers of the health centers that were (2019) stressed that families who believe in supernatural used for the study. diagnosis will seek care from religious or traditional healers rather than medical physicians. Also, Maduforo (2011) had equally revealed that a significant number of the study Participants Recruitment respondents (pregnant women) adhere to traditional beliefs and food taboo. The sample population comprised of ten (10) women who Abasiattai et al. (2006) in a survey among the Annang in are not attending antenatal services and twenty (20) women South-South Nigeria showed that most of the participants who seek antenatal services. Those who were attending ante- felt that hospitals generally connote sickness and were places natal care were used for the Focus Group Discussions (FGDs) reserved for sick people only. For them, the most common while those who do not seek antenatal care were used for the causes of maternal death were spiritual attacks from enemies In-depth interview (IDI) sessions. Pregnant women attend- and punishment by the gods for infidelity. According to ing antenatal care services in two health facilities—Nsukka Okolocha et al. (1998), Nigerian women had a good under- Health Centre and University of Nigeria Teaching Hospital, standing of obstetric heamorrhage as a cause of maternal Obukpa were chosen for the FGD. The FGDs were con- death, but their attitudes, habits, and circumstances hindered ducted within the premises of the hospitals. These hospitals them from seeking or delaying modern obstetric care. They were therefore, venues for the FGDs and in each, one FGD highlighted those causes such as infidelity, witchcraft/evil involving 10 pregnant women each was conducted. Thus, forces and disobedience constituted 8.3% of the causes of making it a total of two FGDs with 20 participants overall. death mentioned by their study participants. Surprisingly, Special arrangements were made with Participants of the 4 SAGE Open FGD. The exercise took place in the selected hospitals’ “Pidgin” [this is a type of English, also called Broken English, premises on Wednesdays and Thursdays which were the which is spoken in most parts of Nigeria]. Both data (FGD & 2 days fixed for the weekly antenatal services in the two IDI) were collected by the authors. However, a note-taker and health facilities. The reason for choosing hospitals as venues a moderator were always present to take notes and moderate for the FGDs was to get access to as many pregnant women each session. Both the FGD and IDI guides were structured to as possible at the same time. To be eligible for inclusion, elicit information on women’s perceptions of causes of mater- participants were expected to have met the following criteria: nal deaths. Participants were specifically asked if they had (i) must be pregnant and (ii) must be a native of Nsukka. heard of pregnant women dying, what they knew about For the IDI, Interview participants were selected using maternal fatalities, and the medical and other reasons of a purposive sampling procedure. In doing this, we appro- maternal mortality. They were also asked to describe the ached prospective participants at their places of residence. events that led to maternal deaths that they were aware of. Participants who showed interest were screened for eligibility The women were asked a series of questions in no particular and were selected as part of the study sample. However, order, and they were told they could answer or not answer any because it was difficult to identify women who were not of them. FGD and IDI were chosen to identify variations in attending antenatal clinics, we also adapted by asking the the responses that women give. already selected participants to refer us to other members of their community who share the same attribute for inclusion. Data Analysis Accordingly, new willing participants were identified and selected until the sample size of 30 (both FGD and IDI) eligi- Thematic analysis was used to analyze the data. We did this ble participants were gotten. The number of the study partici- by reading and rereading the transcripts, noting any similari- pant was limited to 30 as a result of the unwillingness of some ties and discrepancies between and within the accounts of the pregnant women to participate in the study. Some women who participants. Qualitative computer package (Nvivo 11, QSR) met the criteria for inclusion declined the request to participate was used to organize and assist in the task of first-level anal- due to lack of time and other undisclosed personal reasons. ysis. Responses were further categorized within relevant themes. The content and format of transcripts were also described during the data analysis process. We were able to Data Collection obtain insight into women’s perspectives of the causes of Both in-depth interviews [IDI] and focused group discussion maternal fatalities and what might be done to prevent them [FGD] were employed for the study. The study participants as a result of the findings. were grouped into two: those attending antenatal care ser- vices and those not attending. FGD was used to elicit infor- Ethical Approval mation from women attending antenatal services while IDI was the instrument used to get information from women not In accordance with the Nigerian national guidelines and reg- attending antenatal care services. One FGD was conducted ulations, ethical approval is not required for this study as it in each of the two health facilities used for the study (Nsukka did not involve human or animal subjects in a way that might Health Centre and the University of Nigeria Teaching cause harm by any means [National Health Research Ethics Hospital, Obukpa). Each FGD consisted of ten pregnant committee (NHREC, 2020). Educated assent was properly women attending antenatal section in the hospital. For ease gotten from all members included within the study. However, of identification and comparison, after each FGD section, the for purposes of confidentiality, all participants were anony- audio records were labeled FDG1 and FGD2, respectively. mized. Participants were informed before the start of the For the IDI sections, Individual, in-depth interviews (IDI) interview that they had the option to ignore any question(s) were conducted in person using an unstructured interview they did not want to answer and to end the interview when- guide. Verbal consent was obtained before the commence- ever they wanted. Table 1 showing the socio-demographic ment of the IDI sessions. Ten women who were not attending characteristics of the respondents. antenatal care services were purposively selected. The reason for purposively selecting them was to ensure that women with Results the required attributes were selected for inclusion. Interviews were conducted at the participants’ places of residence at a Socio-Demographic Characteristics of the scheduled date and time. After each interview, interview Participants records of each participant were labeled (e.g., PP1, PP2, PP3, etc.) to ensure easy identification during data management Four broad themes emerged from the responses of the par- and analysis processes. The interviews were digitally audio- ticipants: personal factors, hospital staff and equipment recorded and later transcribed verbatim. The IDI and FGDs related reasons, physiological factors and cultural factors/ sessions were conducted in English, Igbo and occasionally superstition. Asogwa et al. 5 Table 1. Respondents’ Demographic Characteristics. with doctors’ prescriptions and instructions or indulgence in self-medication. She narrated thus: Characteristics Frequency (%) I do not doubt in my mind that some women are the architecture Age of their death. This is how I lost my neighbour who is my friend 18–25 6 (20) as well. During her pregnancy, she refused to enroll for antenatal 26–33 14 (46.7) care against all bits of advice. Instead, she chose to be taking 34–40 10 (33.3) concoctions from one local medicine man. One day she took one Occupation of those concoctions and after a while, she started bleeding Civil servant 9 (30) heavily and lost her life (FGD2, 33 years, University of Nigeria Trader 17 (56.7) Teaching Hospital, Obukpa). Artisan 4 (13.3) Level of Education Most of the women were of the view that most women do Primary education 3 (10) not visit the hospital until their conditions get critical. Such Secondary education 20 (66.7) an attitude complicates the delivery process. One FGD par- Tertiary education 7 (23.3) ticipant noted that “some women in the village delay going Marital status to the hospital until their conditions get worse and sometimes Married 25 (83.3) when they get to the hospital the doctor will not be there to Single mother 5 (16.7) Religion attend to them” (FGD1, 31 years, Nsukka Health Centre). Christianity 18 (60) Corroborating this, an IDI participant who opined that she ATR 8 (26.7) does not attend antenatal for reasons of pride and family tra- Others 4 (13.3) dition, explained that “some other women too do not go to Income level hospital early because they want to deliver at home and enjoy 18,000 and below 21 (70) the pride that come with it but when it gets complicated they 19,000–100,000 7 (23.3) may try to see doctors” (PP7, 37 years). Above 100,000 2 (6.7) We further probed to know why these women delay seek- Area of residence ing for antenatal services. Prominent among their responses Nsukka 30 (100) were religious belief, illiteracy and to an extent poverty. Some of the participants believed that some religious groups instruct their members not to take medications when they are Personal Factors sick. Rather, they asked them to pray fervently or to come to the religious house to be prayed for to get healed. Many par- The participants enumerated a lot of personal factors that ticipants, therefore, lamented, that some women held this could lead to maternal mortality. These factors ranged from misconception, which motivated them to avoid health clin- delay in seeking care, poverty, non-compliance with doctor’s ics. Their resolve not to seek antenatal care was fueled by prescriptions, preference for home delivery, non-usage of opinions expressed by their religious leaders toward it. As health facility, illiteracy, and ignorance, among others. The one participant put it; “some women are brainwashed into delay in seeking care was one of the most prominent per- believing that they can get healed from their sicknesses sonal factors identified by the women. Many of the partici- through prayers alone” (FGD2, 34 years, University of pants claimed that many women die from maternal-related Nigeria Teaching Hospital, Obukpa). Another participant causes as a result of their failure to seek medical help in a also quipped that “instead of seeking medical care, the timely manner. A participant in one of the FGD sessions woman or her relatives will engage spiritual or traditional commented thus: herbalist” (FGD1, 30 years, Nsukka Health Centre). Buttressing these points, a participant stated thus: Many pregnant women take their health for granted. Some women don’t even like going to the hospital. My experience with some women has shown me that they visit the hospital There are some religions that admonish their members not to during their pregnancy only when they get signs of sickness. take drugs during illnesses. At least I am aware of one but I Others will tell you that it is not good to start visiting antenatal don’t think it is wise for me to mention it here. Surprisingly, care clinics in the first few months of pregnancy because some some women buy this idea and leave themselves at the mercy of the drugs they give affect the development of the child. of death. I know of a woman who during her pregnancy kept on Because of this, they seek antenatal care at later stages of their visiting prayer houses. Seven months into her pregnancy, she pregnancy when things might be late (FGD1, 40 years, Nsukka started bleeding and some people were invited to pray for her. Health Centre). The bleeding continued after all until one of her relatives angrily rushed her to the hospital where her life was saved Similarly, another FGD participant maintained that most (FGD2, 25 years, University of Nigeria Teaching Hospital, Obukpa). women die during and after childbirth due to noncompliance 6 SAGE Open Illiteracy was also identified by the women as militating and complaints about lack of equipment in a few of the hos- against the use of antenatal care by some women. They pitals and clinics around. They particularly pointed out that explained that some women are either unaware of the impor- nurses do not help matters during child delivery. According tance of antenatal care or are ill-informed about it. They to them, some nurses, especially those who have never been emphasized that many women are illiterate, and as a result, to labor are fond of maltreating pregnant women. One of the are unaware of essential antenatal care services. One partici- participants commented: “the attitude of some of these nurses pant observed that “there are some pregnant women who do is nothing to write home with. . . they treat you with levity” not know much about antenatal care. Even when you try to (FGD1, 28 years, Nsukka Health Centre). Continuing fur- educate them on the importance, some of them will see you ther, this participant stated: “some of these nurses are just as trying to show off” (FGD2, 40 years, University of Nigeria wicked. I think they take pleasure watching you suffer and Teaching Hospital, Obukpa) Equally, some of the partici- that is why they behave the way they do, mostly when doc- pants averred that some women are not properly informed tors are not around.” Continuing in this line, a participant about the need for antenatal care. Their expression was that further shared her knowledge and experiences thus: some women are ill-informed (most probably by those who When you go into the labour ward, at times, you will wonder if lack the basic knowledge of antenatal) on the importance of women were born to be cruel to women. If you see the level of antenatal. An FGD participant stated that some women might cruelty meted out to pregnant women! Just imagine that a have embraced antenatal care but because they were misin- woman is screaming in pains and the nurses will be shouting formed about the whole thing, they started avoiding it. This ‘madam abeg allow person hear word oh. . . When una dey do d FGD participant explained: thing e dey sweet you I dey there? [This loosely means stop making noise because you enjoyed the sex before you conceived Education is very important in the life of every woman. In my and I was not there]. . . this is dehumanizing and could make a village (Edem), a lot of girls get married at a very tender age woman give up (FGD2, 35 years, University of Nigeria Teaching without even completing secondary education. So they have Hospital, Obukpa). little or no knowledge of antenatal care. They mostly rely on whatever the old women in the village might tell them. In most This participant was not particularly happy with the non- cases, they seek the help of Traditional Birth Attendants (TBA). chalant attitude of some nurses as shown by her explanation. I am not saying that the TBAs do not work; I believe that it Another participant shared her experience thus: works because I patronize them sometimes (it however, does not stop me from going to the hospital to check the state of my baby) In November (2019), an incident took place in one of the but it should not be substituted for antenatal care. A girl from my hospitals around here; I will not mention the name please, where clan nearly lost her life during pregnancy. She never attended I used to go for antenatal checks. A nurse neglected a woman antenatal and was equally consuming alcohol on a daily basis. who was in serious pain after childbirth. The nurse ignored the At a stage, the foetus died in her womb four days without her woman and by the time her husband came in and raised an alarm knowledge. As a result, she developed complications and lost for doctors to come, it was too late. Unfortunately, the woman consciousness. It took the efforts of doctors to save her life died and it took the intervention of the police as the husband (FGD2, 39 years, University of Nigeria Teaching Hospital, almost beat the woman to death. That is why I never visited the Obukpa). hospital again (FGD2, 25 years, University of Nigeria Teaching Hospital, Obukpa). The participants also mentioned poverty as one of the rea- sons some women do not visit antenatal clinics. Most of the Continuing, the participant further expressed her anger by participants stated that some women avoid going to hospitals saying that Nigerians are fond of leaving things to God. She because they feel that it is expensive. According to them, stressed that “God will not come down from heaven to exer- there are still a couple of women out there who still avoid the cise our rights for us.” According to her, the hospitals and hospital. These set of people perceive the hospitals as a place persons involved should be sued for professional negligence. for the rich. An IDI participant stated thus: “I don’t have the Another participant who, at the time of this discussion was money to visit the hospital. . . so I use local herbs. Besides if animated while recalling her experience, has this to say: God says that I will die, I will die whether I visit the hospital or not” (PP10, 40 years). Affirming this, a woman in the FGD I once went to a private hospital to deliver my first child, the section stressed: “I can tell you that there are a lot of women nurses who attended to me after the doctor left rained abuses on out there, especially in the rural villages, who still see hospi- me after I challenged one of them for heating my stomach and tals as a place for the rich. making jest of me. They did not even mind my condition. They lacked the manners of professionals. I don’t know if it was because I did not attend my antenatal care services with them Hospital Staff and Equipment Related Reasons during the pregnancy period. I almost died during delivery. I left Among the factors raised during our discussion with the the place feeling emotionally bad because of their unprofessional women was their displeasure with some of the hospital staff act (FGD1, 34 years, Nsukka Health Centre). Asogwa et al. 7 Another FGD participant also quipped: Attending antenatal care clinics is important for safe delivery, knowing where to go for the actual delivery is Some have argued that there are good nurses but I am yet to equally important according to the women. Most of them come across a truly caring nurse in this country. Nurses here are resigned their fate to God stressing that anything can happen easily irritated and they yell at you at the slightest provocation. I during pregnancy. A participant stated thus: “where do I start don’t know why. And the funny thing is that some of these from; it’s with the grace of a God we deliver safely here and nurses are not qualified. . . they are auxiliary nurses and most of even elsewhere. I have heard of laboratory mishaps in the us don’t know that (FGD1, 32 years, Nsukka Health Centre). Western world that lead to the death of women during child- birth” (FGD2, 31 years, University of Nigeria Teaching Regarding the lack of equipment in most hospitals, partici- Hospital, Obukpa). pants blamed the government and owners of private hospi- tals. They acknowledged that some women have died during delivery because of a lack of equipment especially those Death Due to Physiological Factors requiring Cesarean Section (CS). Reacting to this, a partici- Apart from other factors earlier mentioned as causes of pant stated that: maternal mortality, many participants, especially the FGD participants, demonstrated knowledge of some of the physi- The number one problem is medical facilities. Can you imagine a ological causes of maternal mortality. In the course of the clinic without ECG, a clinic with miserable thermometers, poor discussions, the participants identified some physiological electricity, degraded laboratory tools, miserable surgical room with condition that leads to maternal deaths. Prominent among no difference from a carpenter’s workshop. Do you know the those factors include obstetric hemorrhage, prolonged labor, cause of all these (she queried)? I tell you; it’s the government (FGD2, 32 years, University of Nigeria Teaching Hospital, ectopic pregnancy, maternal and postpartum sepsis, abortion, Obukpa). hypertensive disorders. Commenting on this, a participant stated that “sometimes women die during pregnancy due to Further expounding on the issue, most of the participants excessive bleeding during or even after delivery” (FGD1, believed that the problem with some primary health care cen- 38 years, Nsukka Health Centre). Another participant also ters is not just in the establishment of structures, or labora- quipped that “excessive bleeding is very dangerous. . . a lot tory facilities but also the provision of equipment. Some of of women die as a result of this, especially immediately after the participants were of the view that it makes no sense to delivery,” (FGD1, 26 years, Nsukka Health Centre). Stressing build primary health care centers without equipping them more on this another participant said and/or not staffing them properly. Participants further lamented that in some government health centers, you find To be honest with you, this is one of the things I fear most whenever I get pregnant. It scares me a lot because I have seen cases where people queue for long hours to see the doctor people die as a result of this. Just recently, a colleague in our and their fear is compounded when it involves CS. Stressing workplace lost his wife due to too much bleeding after delivery. on this, a participant stated: It happens everywhere (FGD2, 37 years,University of Nigeria Teaching Hospital, Obukpa). Childbirth can be easy and uncomplicated and when that is the case, there is always great joy in the family. The problem with Prolonged labor also featured during the discussions. Nigeria is when there are serious complications with the birth Most of the participants acknowledged that maternal mortal- - our doctors in Nigeria don’t seem able to grapple with these ity occurs due to prolonged labor. They affirmed that many complications or our facilities are not up to it. I don’t know what it is. In the UK and US and other western countries, if you women had died as a result of prolonged labor. However, have your baby from 26 weeks - they will try to save your baby. they expressed a lack of knowledge as to what causes pro- I know two families that this happened to and their kids are longed labor. One participant stated: “I am well aware of very fine now but if it were to be in Nigeria, birth at 26 weeks women dying as a result of prolonged labor but I do not – the possibility of saving the child is at 1/100. The reason is know what the cause could be” (FGD1, 23 years, Nsukka simple; they don’t have the facilities to care for a baby that Health Centre). Another participant also said that “when young. My prayer for everyone giving birth in this area is that labor lasts longer than necessary, the implication is that the their birth should be a straightforward one because when the woman becomes weaker and weaker and could die from it” story enters, it’s only God and a very well trained doctor that (FGD2, 30 years,University of Nigeria Teaching Hospital, can help. If the mother dies during childbirth in the UK, an Obukpa). Shifting a bit from the positions of others, a partici- inquiry is launched but here it is hardly done. I am not being pant from one of the FGDs elaborated that: sentimental oh; I lost my auntie to childbirth in Nigeria many years ago. Till today, I don’t know what caused it. Her kids have had to grow up without their mother and it is said that Some of the women who die because of prolonged labour one many years on, it is still happening (FGD1, 34 years, Nsukka way or the other contributed to it. There are some pregnant Health Centre). women who when told that they cannot deliver through the 8 SAGE Open normal process (through the vagina) but through CS (Caesarean Prominent among them were witchcraft and evil spirits. Section) will insist on normal delivery. At times they will invite Other factors identified were wicked relatives and to an ‘prayer warriors’ to pray for them. Some die as a result of their extent, infidelity. They averred that there are so many people stubbornness (FGD1, 27 years, Nsukka Health Centre). especially in the villages that do not wish for your progress either financially or children-wise. Consequent upon this, References were also made to cases where fertilized ovum they will do everything possible to scuttle your progress. An develops outside the uterine cavity (ectopic pregnancy). Few IDI participant stated that “you have to be careful here espe- of the FGD participants expressed awareness of the existence cially when you are pregnant to avoid stories that touch the of such cases while most of the IDI participants indicated a heart” (PP10, 40 years). Another participant equally stated: lack of knowledge of such cases and wondered how possible “you don’t need to ask the question as to whether women die that could be. An FGD participant stated thus: “I know about here during pregnancy or not. Haven’t you heard of the it having been diagnosed with it in the past during my first atrocities committed by witches and other forces? It is real pregnancy but till today I cannot still comprehend what my brothers” (PP9, 30 years). This perception is shared by caused such abnormality in my body” (FGD1, 29, Nsukka almost all the IDI participants as evidenced by their Health Centre). On the other hand, an IDI participant responses. Commenting further, a participant stated thus: expressed surprise as to what that could be. She said: “I don’t know what that means because I have not even heard of such When you are a pregnant woman in this village, on no account thing before and I am not even sure if that kind of thing is should you disclose how far you have gone, if not witches and possible. It’s not from God” (PP4, 36 years). Concerning wizards from your village or husband’s village that doesn’t want to see you deliver safely will all gather for your sake in the women dying due to illness before or after delivery, the par- delivery ward on your delivery date (PP1, 20 years). ticipants demonstrated awareness of the occurrences of such a situation but maintained that seldom does it happen, at least Another participant equally stated that: to their knowledge. One participant stated that "a woman can die due to sickness during pregnancy or after delivery. It can When you are a pregnant woman in Nigeria, you are not happen to anybody but it is not common” (PP2, 35). expected to disclose it to even your siblings, if possible your Unsafe abortion was another cause of maternal death mother, until the first trimester passes by. . . now you are sure according to the participants. According to them the majority that the pregnancy will stay against all household witches and of abortions performed in Nigeria are unsafe and are done in wizards (PP5, 33 years). secret and are terminated by persons lacking the necessary skills. Commenting on this an IDI participant said: Another participant narrated how her close female friend’s situation impacted on her belief toward the reality of We have a lot of quack Chemist (patent medicine dealers) witchcraft. around here. Sometimes some of these young girls who get pregnant for their boyfriends seek their help for abortion. And A friend of mine was due for delivery but could not. She stayed without giving concern to the number of months of the in labour room for five days or more. One of her sisters suggested pregnancy, they will just prescribe drugs for them to take. In this could be the handiwork of witches. She urged the husband some cases, they will just go home and bleed to death while to take her to a particular herbal home but the husband refused those who survived do not fancy recalling their ordeals (PP4, and she left in anger. Meanwhile, in the midst of all these, 36 years). doctors have advised that she should go for CS in other to save the mother and her child. It was not long until her sister returned Commenting on the same abortion, another IDI partici- with a small bottle containing some liquid which she claimed to pant narrated an experience thus: have gotten from the herbalist. She went straight and rubbed it on her sister’s belly and legs and to my surprise, after like This abortion stuff is a dangerous thing. I have seen people die 20 minutes or so she was delivered of a baby girl. Since then I as a result of abortion. Currently, my younger sister is in the started believing that these people (witches) are working indeed hospital because of an unsafe abortion. She got pregnant without (FGD2, 19 years, University of Nigeria Teaching Hospital, our knowledge and secretly went to abort the child in one of the Obukpa). chemist shops around. She bled profusely and almost died in the process if not that we intervened when we got the information Besides witchcraft, participants also identified evil spirits (PP8, 30 years) as contributing to maternal mortality. Some of them believe that this is one dimension of the problem that is overlooked. Cultural Factors and Superstition Commenting on this, an IDI participant stated that “death of a mother during pregnancy or child delivery as well as miscar- From our analyses of the responses of the participants, many riage is not of God but the devil” (PP6, 33 years). Another of them, especially the IDI participants, admitted their belief participant was of the view that even though physical factors in the workability of humans conjured supernatural forces could contribute to maternal mortality, one cannot be blind to that work against the safe delivery of pregnant women. Asogwa et al. 9 the fact that evil spirit is at work. According to her, “there are understand the context of pregnancy and as a result do not few physical factors that can cause it like a man beating the attend an antenatal clinic and chose to seek healthcare only wife, too much stress, hitting the stomach on the floor but as when it is too late. This attitude could lead to pregnancy- far as I am concerned, I still attribute them to demonic manip- related morbidities and mortality as some women take early ulations” (PP2, 35 years). Participants further expressed belief signs of danger for granted. It therefore heralds the need to in the efficacy of certain objects tied on the body to ward off educate women, especially rural women, on the importance evil spirits. They explained that at times, safety pin or tiny of antenatal so that they can discover danger signs early and stick is attached to the woman’s cloth or hair to ward off witch take appropriate actions. Concerning poverty, participants or evil spirits. A participant explained that “safety pin or a said that some pregnant women avoid antennal services due strand of the stick is usually attached to their clothes/wears or to their inability to foot the bills. Because of this, several even somewhere around their hairs to protect fetus and the women stay away from hospitals and could die due to com- mother against evil spirit/demon especially at noon and night plications during childbirth. These findings are in line with (PP5, 33 years). The participants also expressed fear and con- those of Okonofua et al. (2018), who identified poverty and cern about some neighbors and relatives whom they termed a delay in seeking medical help as factors that may predis- “wicked ones.” Some of the women were of the view that pose women to maternal death. Furthermore, our findings some neighbors and relatives could also cause maternal death revealed that illiteracy contributes to maternal mortality. through diabolic means. One participant explained thus: Participants averred that due to lack of education and expo- When you are a pregnant woman in this area, you are sup- sure, some women especially in rural villages lack the basic posed to be very careful, you don’t have to show neighbors health knowledge and rely solely on the advice of relatives how happy you are, because some of them might get jealous and rural women. This finding aligns with that of Adeniran and cause you miscarriage, even death” (PP7, 37 years). et al. (2015) who had earlier found a similar result. Furthermore, infidelity was also mentioned as contributing to Our result also revealed that the women were of the view maternal mortality. Some participants explained that married that some maternal deaths are caused by negligence on the women who engaged in extra-marital affairs are likely to die part of hospital personnel especially nurses. They com- during pregnancy as a form of punishment from the gods. plained that some nurses abuse pregnant women and delay They explained that this was instituted by their forefathers unnecessarily before attending to women in labor. The fact decades ago. A participant commented: that women associate such views with maternal mortality emphasizes the need for more action. Women may be hesi- It is a taboo for a married woman here to engage in extra-marital tant to seek help because they are afraid of being assaulted. affairs. . .one of the obvious punishments was suffering and These delays, according to Okonofua et al. (2018, p. 13), can death during child delivery as a form of punishment from the be addressed in a variety of methods, including “staff train- gods which also serve as a deterrent to others. Our forefathers ing and retraining, regular use of maternal death reviews and made it so and no one has been able to undo it (PP9, 30 years). surveillance to address management gaps, staff monitoring/ evaluation.” Hussein and Okonofua (2012) and Hussein In the same vein, an FGD participant added: et al. (2016) in their studies of maternal mortality in Nigeria have found similar results wherein women linked poor staff I have heard about deities striking people mad as a result of attitudes to maternal death. Linking poor staff attitudes to adultery, but I have not seen a victim myself. Although I kind of maternal mortality does not speak well of the country and believed the narrative because it came from people I trust. But deterring women from seeking care is one of the immediate the thought of going mad is dreadful (FGD1, 26 years, Nsukka results. Equally, our findings showed that the lack of needed Health Centre). medical types of equipment contributes to maternal mortal- ity. The complaint was that when a complication is devel- Discussion oped during pregnancy, most of the hospitals around lack the Using a qualitative approach, the study investigated wom- necessary equipment to handle the situation. In such cases, en’s perceptions of the reasons for maternal deaths in Nsukka they are referred to hospitals outside the locality and life local government area taking into cognizance that Nigeria is could be lost in the process. Nnebue et al. (2016) has equally a country having a high maternal mortality rate. The results found that none of the health facilities studied could deliver indicate that most of the women, especially the FGD partici- even the full range of basic essential obstetric care (EOC). pants were well aware of the prominent causes of maternal Concerning the physiological factor that causes maternal mortality. The disparity in the responses of the FGD and the mortality, the participant demonstrated awareness and enu- IDI participants in some of the issues raised may not be merated some of the common medical factors influencing unconnected to education and exposure. The participants maternal mortality such as obstetric hemorrhage, prolonged identified personal factors such as delay in seeking health- labor, ectopic pregnancy, maternal and postpartum sepsis, care, poverty, and illiteracy as contributing to maternal abortion, etc. Reasons for such awareness may not be uncon- mortality. They explained that most women do not fully nected with the fact some of the participants attained some 10 SAGE Open levels of secondary and tertiary educations. Similar to other Conclusion and Recommendations findings (Okonofua et al., 2018; Say et al., 2014), our find- In this stage of human and technological development, when ings showed that some of these physiological causes of education and modernity are thought to have eliminated maternal death are still prevalent in the study area especially some risky health behaviors, there are still traces of people obstetric hemorrhage and abortion. The participants admit- who, because of certain cultural and superstitious beliefs, are ted that obstetric hemorrhage is till high because of negli- yet to embrace modern healthcare delivery system. Even gence on the part of some women who do not attend antenatal with the knowledge of antenatal care services, some women clinics either because of lack of education or awareness. are still reluctant to embrace it. The University of Nigeria is Furthermore, our findings also revealed that unsafe abortion situated in Nsukka and there is this undocumented argument is still carried out clandestinely in this area and it has that the inhabitants of the surrounding communities and vil- remained one of the prominent causes of maternal mortality lages are dropping some of their primordial beliefs while among teenagers in most rural villages. These unsafe abor- embracing Western education and lifestyle. This study there- tions are usually aided by poorly trained patent medicine fore concludes that some of these primordial and supersti- dealers who mainly use the rural areas as a safe haven to tious beliefs that are detrimental to maternal and child perpetrate this unhealthy act. This is a dangerous trend that well-being are still upheld and practiced. This attitude is not needs urgent attention from the government. necessarily influenced by demographic elements such as age Another interesting finding was that many of the respon- but was, however, influenced by elements of the social struc- dents hold superstitious and primordial believes about mater- tures such as residence, the level of sexual education of the nal mortality. Our findings showed that they believed that women, traditional beliefs and other personal factors. The witchcraft, evil spirits as well as infidelity are among the implication is that when individuals such as those we have causes of maternal mortality. The findings indicated a belief studied hold such beliefs to the detriment of their health, they among most of the participants that some wicked people are predisposed to several reproductive health problems like attack pregnant women through witchcraft. They explained heamorrhage and delayed delivery which could lead to that there are people within your immediate environment maternal mortality. Therefore, finding a feasible way to who do not wish for your success and could revert to witch- reduce maternal mortality requires community-centered craft and other diabolic means to harm you. Furthermore, our approach to maternal health. This involves engagement of analyses of the results demonstrated that evil spirits were informed community members, mobilization and empower- also held as a factor causing maternal death. Some of the ment of women. When a community is well mobilized, participants believed that maternal mortality is not of God engaged and empowered, they will be in a good position to but rather another ungodly means through which evil spirits find ways that will work for them in order to reduce maternal express themselves. This sort of belief and superstitions may mortality. We therefore, recommend that massive orientation not be scientifically proven, however, it is remarkable to note and sensitization in the area of public health should be car- how high these beliefs and superstitions are held among ried out especially in the rural areas to address some of these these people. We also found that marital infidelity is believed challenges identified in the study. Furthermore, we believe to contribute to maternal mortality. A woman who indulges that socioeconomic empowerment of women, reorientation in extra-marital sex stands greater chances of death during of health providers, community engagement, the establish- childbirth. These findings are similar to other findings in ment of more health facilities, and improvements in care maternal mortality literature. For example, Muoghalu (2010) quality are critical in efforts to improve women’s access to reported that in some communities in Nigeria, it is believed maternity care and reduce maternal mortality in the country. that a pregnant woman is could bleed or die during preg- Thus, our findings may be instructive to health sociologists, nancy because of witchcraft, spiritual manipulations and public health professionals and policymakers in the efforts to infidelity. While the findings are related to findings else- reduce maternal mortality. where (e.g., muoghalu, 2010 & Piane, 2019), they accentuate There were some limitations of the study. First, The the cultural practices that continue to impact on risky health FGDs was small in number and had just one focus—women practices in a place like Nigeria and other parts of sub-Saha- attending antenatal care. We thought that for wider repre- ran Africa, where certain customs have defied necessary sentation, we should have conducted different FGDs for change. As Piane (2019, p. 86) stressed; “families that pregnant women attending antenatal care services that are believe in supernatural etiology will seek care from faith or educated, those not educated or for different age brackets. traditional healers and not medical providers.” The findings Secondly, we felt that there may have been a selection bias have important implications on healthcare for women initia- as we did not include the perceptions of women who were tives as they could help in reconstructing those obstructive not pregnant. This may have presented a broader viewpoint socio-cultural practices to consistent use of antenatal on the issue. Furthermore, we also felt that the number of services. participants was not adequate. This may have limited a Asogwa et al. 11 comprehensive understanding of women’s perceptions of Bradley, S., McCourt, C., Rayment, J., & Parmar, D. (2016). Disrespectful intrapartum care during facility-based deliv- reasons for maternal death. Moving forward, further ery in sub-Saharan Africa: A qualitative systematic review researches should address these limitations identified in the and thematic synthesis of women’s perceptions and experi- study. ences. Social Science & Medicine, 169, 157–170. https://doi. Despite the limitations, the findings improve our under- org/10.1016/j.socscimed.2016.09.039 standing of reasons for maternal mortality and the cultural Cutie, C. R. (2007). Associated social, economic and political practices that continue to impact on risky health practices in factors. Women’s Health Journal/Isis International, Latin places like Nigeria and other parts of sub-Saharan Africa, American and Caribbean Women’s Health Network, 3, where certain customs have defied necessary changes in the 75–90. healthcare system. The study findings also provide important Gazali, W., Mukhtar, F., & Gana, M. (2012). Barrier to utilization insight for policy-making aimed at improving health care- of maternal health care facilities among pregnant and non preg- seeking behavior and creating awareness on the dangers of nant women of child bearing age in Maiduguri Metropolitan Council (MMC) and Jere LGAs of Borno State. Contemporary maternal mortality in the country. Journal of Tropical Medicine, 6, 12–21. Hussein, J., Hirose, A., Owolabi, O., Imamura, M., Kanguru, L., & Authors’ Note Okonofua, F. (2016). Maternal death and obstetric care audits This article is not simultaneously submitted to any other journal for in Nigeria: A systematic review of barriers and enabling fac- review and/or publication. tors in the provision of emergency care. Reproductive Health, 13(1), 47–11. https://doi.org/10.1186/s12978-016-0158-4 Declaration of Conflicting Interests Hussein, J., & Okonofua, F. (2012). Time for action: Audit, accountability and confidential enquiries into maternal deaths The author(s) declared no potential conflicts of interest with respect in Nigeria. African Journal of Reproductive Health, 16(1), to the research, authorship, and/or publication of this article. 9–14. Ijadunola, K. T., Ijadunola, M. Y., Esimai, O. A., & Abiona, T. Funding C. (2010). New paradigm old thinking: The case for emer- The author(s) received no financial support for the research, author- gency obstetric care in the prevention of maternal mortality ship, and/or publication of this article. in Nigeria. 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Journal

SAGE OpenSAGE

Published: Feb 21, 2022

Keywords: beliefs; culture; maternal mortality; superstitions; qualitative

References