CHAPTER ONE INTRODUCTION 1
Subjects admin July 1, 2019
1.1	Background to the study
These days business is faced with an ever stressful work environment. Many employees are faced with the challenge of hanging a balance between work and their own family life. Sustaining a healthy work-life balance is an issue that is increasingly recognized as of strategic importance and of significance to employees. Employee performance is a fundamental determinant in the realization of organizational goals. Thus, agencies have devised extraordinary approaches of motivating their employees, so as for them to offer their best to the organization.
WLB includes adjustment of working patterns to allow employees combine work with their different family demands. The demerits associated with WLB can have a negative effect on both the employee and the employer. For employers the results of bad WLB are negative performance, ill leaves, higher staff turnover, and accelerated absenteeism. While on the employee the outcomes include mental health, bodily fitness, and terrible person performance in an organization.
In a highly competitive labour market an employer needs to hold its treasured employees. It's a strong motivating factor for increased organizational awareness and action in regards to implementing and control of work-life balance strategies. WLB is an area of interest in human resource management and it is receiving lots attention from researchers, trade unions and media.
Work-life balance from the employees' perspective is the protection of equilibrium between duties at work and at home. Employers view the benefits or the working conditions that they offer to help employees balance their family and the work domains as work life benefits (Okeke, 2017). First of all the idea of work life conflic focused on the effect of own family and personal demands on work. It now extends to the effect work has on individual strain, relationships and family well-being (Russell & Bowman, 2000).
Work-to-family conflict occurs when experiences at work interfere with family life, rigid work hours, work overload, interpersonal conflict at work and unsupportive supervisor within the organization. Family-to-work conflict occurs when experiences within the family interfere with work, life's primary responsibility for children, elder care obligations, interpersonal conflict within the family unit and unsupportive own family members.
Running efficiently and keeping a well-balanced social life, has to strike a balance between work and emotional wellbeing. This translates to improved organizational, character emotional balance and proper societal functioning (Grady, 2014). Individuals experience more divergence linking work and personal life as they continue to pursue the quality of life that they need (Kim, H. K. 2014). Consequently, successfully balancing work and family life is one of the most important challenges facing modern-day employees (Uusiautti, S., ;Määttä, K. 2018).
Traditionally, work-life balance issues were considered personal issues (Irungu, 2017) and employers have just responded to their employees' needs by means of presenting extra benefits such as on-site childcare service and paid maternity leave in the work place. Despite the fact that, with environmental shifts and value adjustments of employees, choice for work-life balance has accelerated and employers have started to offer more active help of their employees' work-life balance (Kim, 2014).
Fortune magazine in its listing of the 100 high performing organizaions to work for identifies agencies that take the time to aid employees in dealing with the obligations of work and family (Firfiray; Mayo 2017). As a result, organizational efforts for ensuring employees' work-existence balance are required and prized greater than ever.
The multi-tasking between domestic responsibilities and work have assumed increased relevance for employees in the service sector in modern years. That is due to work place and demographic changes, which includes; technological advancement, transformation in family unit structures, increased reluctance for 'long working hours', greater number of women in the work force and culture acceptance (Sharma, & et al 2016). End result employees may have stress in prioritizing between their private lives and work roles. poor organizational culture; like commutation of leave of employees, inconvenient period of leave for employees and the inability of employers to stick to leave policy of their employment agreement all these may also result in difficult-pressed workloads which bring about different issues to the employee. Those difficulty involve the psychologically and the emotional well-being of employee and these can bring about reduction in employee overall performance in areas along with, poor service delivery and health associated issues
According to (Ngari, & Mukururi, 2014), many service sector organizations and groups in Kenya have did not recognize the significance of working environment for employee job satisfaction and as a consequence face a whole lot of difficulties during their work. To meet the standards of organization, employees want a working environment that permits them to work freely without problems which restrain them from performing up to the level of their complete capability. It's therefore essential for the service industry to have a good working environment improving the work, technical, human, and organizational factors vital to enhancing the organization's competitive role by means of attracting certified human asset.
Sullivan, & Skelcher, (2017), states that the service industry covers a wide area with a myriad of environmental and physical elements that employees work in. This spatial detail affords a unique trouble in occupation health and safety faced by employees together with lengthy travel hours to and from; long operating hours at work, lengthy away time from family, workload, strain, over time, fatigue and boredom are a few elements to reduce employee performance (Caesar, & Fei, 2018). Then again provision of appropriate working environment, refreshment, health & safety facility, fun at workplace and clear work-life balance guidelines and policies which accommodate out of workplace preoccupations will go a long way in growing the degree of employee performance (Hartnell, 2010).
This project therefore intends to evaluate the extent to which work life balance impacts employee overall performance and additionally introduce suitable employment practices to help employees obtain a higher work life balance which can offer tangible benefits to the organization as well as the persons involved. This project additionally examines the way to promote top WLB practices in the service and telecommunication sector of Kenya and highlights a few merits for the agencies.
1.1.1	Work life balance in the insurance industry
Introduction of the Insurance Act, CAP 487 of the Laws of Kenya, supervision and regulation of insurance business has substantially stepped forward the industry overall performance. The insurance industry has over the last decade continued to check in double digit increase in gross written premium profits with insurance penetration at around 3% that's similar to nations within the developing countries. These trends have bestowed on the industry some demanding situations and opportunities key of that are the specified human resource capacities and compliment to drive the growth agenda as set out within the imaginative and Vision 2030 (IRA Report, 2015).
Insurance companies are basically human extensive, and human assets act as an absolute differentiator. Quality manpower and its retention could act as a Litmus test. Turnover of the workforce has been excessive due to low exit and entry barriers within the industry (IRA record, 2016). Taylor et. al. (2017) in a study conducted on the connection among worker commitment and their performance, determined that organizational culture characterized with the aid of excessive adaptability and a HRM system emphasizing excessive overall performance work practices had, a direct and profound effect on employee commitment. Martin and Beaumont (2014) study on employee commitment points out that there may be need for employees to conduct themselves consistent with the requirements of the company's preferred brand. The success of this hinges at the potential of businesses to win employee loyalty to the brand and growing dedication to the employer.
The upward thrust of technological development ,the move by insurance firms to acquire and merge has led to changes in the social surroundings forcing new organizational restructuring, task re-engineering and ultimately downsizing of employees who had come of age as a result retiring and rendering employees redundant. These changes have expanded pressure on employees, in terms of adjusting to the change itself and managing its ensuing consequences. Increased pressure from workloads and a need to develop new skills is of key challenge in the insurance sector in Kenya. Hence the objective of finding the possible answers to enhancing work lifestyles balance is paramount on this project.
1.1.2	Work-life balance and employee performance in the Mobile Telecommunication industry in Kenya
Kenya's mobile Telecommunication sector has grown tremendously over the years. The mobile telecommunication sector contributes over KES 300 billion and as much as a in addition KES 100 billion from intangible benefits to clients. It employs roughly 25,000 people in Kenya on permanent and contract terms. Mobile Network operators have undertaken civil works together with contributing to the power roll out (Williams et al., 2016). The mobile Telecommunication sector is very dynamic; there's cut throat competition in the sector. Employees are faced with challenges concerning their work environment especially their operating hours due to shifts and lack of mobility in the place of work in terms of promotions. With the intention to reach their organizational top performance, the cell agencies need to be capable of create a work environment where employees are encouraged to work.
UNCORP (2012) report indicates that Safaricom PLC has initiated numerous mechanisms to cushion mothers from personal and job related stress. a number of this includes day care facilities, Flexi time for lactating mothers, fitness facilities for both men and women, even prayer rooms for spiritual nourishment. The strategies are deemed to boost work life balance to diffuse employees pressure, beautify performance, and productivity; consequently the want to explore greater work life balance practices at Safaricom in comparison to others in the service industry working under similar circumstances.
1.2	Statement of the problem
Despite the effort to come up with numerous work life Initiatives (WLBI) in the service industry to enhance employees' overall performance, the performance of most employees has remained dismal. Furthermore, the mechanism and extent to which the flexible work arrangements, HR financial incentives, HR work family support services, work-life balance, employee behavior and attitudes affect employees' overall performance continues to be doubtful and unclear (Wang and Walumbwa, 2011; Snape and Redman, 2010; Wright and McMahan, 2011; Groen, B. A., van Triest, S. P., Coers, M., & W tenweerde, N. 2018; Wang, E. S., & Lin, C. L. 2018).
Empirical research carried out in developed countries by Wright and MacMahan, (2010); Kuvaas and Dysvik, (2010); Boxall,(2013); Allen, (2013) in addition to studies performed in Kenya by Shitsama, (2011) and Bosibori,(2012) reveal that HR practices have a high effects and statistically relationship with performance. but, those research have centered on HRM functions of employee development and attraction practices such as training and development, performance appraisal, profession career management, recruitment and selection (Teseema and Soeters, 2006; Mutua, Karanja and Namusonge, 2009).There is a scanty empirical study exploring the telecommunication and insurance industry in terms of work life balance on employee performance. This research will try to identify whether there is a relationship between work life balance and employee performances in insurance and telecommunication industry in Kenya so as to add to the existing literature more ingredients that will spice up human resource practices as far as employees are concerned.
1.3 Objectives of the study
1.3.1 General objective
The general objective of the study will be to evaluate the effect of work life balance on employee performance in the service industry.
1.3.2 Specific objectives
The specific objectives will be to;
i.	To establish the effect of work family priorities on employee performance in the service industry
ii.	To examine the influence of Flexible Working Options on Employee Performance the service industry
iii.	To determine the effects of Employee Assistance Programs on Employee Performance in the service industry
1.4 Research questions
a)	What is the influence of work family priorities on employee performance in the service industry?
b)	Which Flexible Working Options are available to the Service industry employee?
c)	What are the effects of Employee Assistance Programs on Employee Performance in the service industry?
The study will benefit various groups in Kenya and also in other developing countries. First it brings light to HR managers and future managers on the importance of integrating work life initiatives in the strategic objectives of the organization.
The research is of importance to organizational policy makers by providing relevant information about employees' perception on the availability of work life initiatives to employees and its effect on organizational behavior. Specifically, the government policy makers can use the research findings when drafting statutory polices by including those initiatives not included in the employment Act of Kenya such as flexible work arrangements, onsite and offsite baby care centers as requirements in organizations with a certain number of female employees.
The study is also of use to other human resource management students and scholars who might want to carry out their research in the area of work life initiatives and employees' performance.
1.6 Assumptions of the study
The study assumes that first, involvement in one role necessarily impedes attention of family and social life and that such interference between role commitments leads to work-life conflict if not balanced. Further the study assumes that Organizations can implement various work-life balance initiatives that may assist employees to better balance their work, family and social life responsibilities, gain improvements in well-being and provide organizational benefits.
1.7 Limitations of the study
The influence of work life balance on employee performance is not restricted to the service industry in Kenya only as there are many industrial sectors whose settings may not be related to the ones in the service industry. The area of study in Kenya is under researched and it may be difficult to compare the different sectors of the population and come up with a cross cutting generalization because different factors could affect one sector and not another. This issue will be mitigated by ensuring that similar questions are asked cutting across the sectoral lines to ensure that uniformity of the answers could be achieved for comparison.
Access to the respondents may also pose a challenge due to the stringent policies by most of the organizations not to allow any form of research within their premises. This challenge will be mitigated by using a research permit from the National Commission for Science, Technology and Innovation and an introduction letter given by the University which will easily enable access to the organizations under study.
Some respondents are likely to be reluctant to give confidential information which would be vital for the study. The Researcher will assure the employees that the information given would be treated with confidentiality and would not use the information for other purposes other than for the research.
1.8	Operational Definition of Terms
Employee performance- The favorable expected employee outcomes in terms of productivity and efficiency in the organizations
Flexible work arrangements- Working arrangements which allow the employee to differ the amount, timing and location of his/her work.
Human resource practices- Human resource management control activities.
Organizational performance- Refers to achievement of Human resource management short and long term goals and objectives in terms of employee performance, retention of employees, provision of quality services and the ability to attract better applicants.
Productivity- Refers to the perceived work effort expended by an employee.
Service efficiency- Employee service behaviors such as carrying out the right task at the right time with the right speed of delivery.
Work life balance -Managing work and family responsibilities without the influence either into work and family responsibilities.
Work life conflict- The interference between work and non-work responsibilities
Work life initiatives- Practices and programmes beyond and above the statutory requirements offered by the employer for the use and benefit of the employ
2.1 Theoretical Review
This study is anchored on three theories; spillover theory by Guest (2002), Hertzbergs Two Factor Theory by psychologist Frederick Hertzberg (1959) and The Demand–Control Model by Karasek (1979).
2.1.1 Spill over theory
Spill-over may be defined as a procedure through which work and family impacts each other, which in turn, generates similarities between the two domain names (Edwards and Rothbard, 2000). it can be both positive and negative. If work family interactions are rigidly structured in time and space, then spill over in term of energy, time and behavior is negative. When flexibility occurs which permits individuals to integrate and overlap work and family responsibilities in time and space result in positive spill over that is instrumental in reaching healthful work life balance.
According to guest (2002), the determinants of work life balance are placed in the work and domestic contexts. Contextual determinants consist of needs of labor, culture of labor, demands of home and culture of home. Individual determinants consist of work orientation (i.e. the extent to which work (or domestic) is a primary life interest), personality, energy, personal control and coping, gender and age, life and career level. The variables of the have a look at are under the contextual determinants, which are leave policy and service delivery. The leave policy is the culture of work, while the service delivery is the demand of work.
The nature of work life balance was described both objectively and subjectively. The objective indicators encompass hours of labor and hours of uncommitted or free time out of work.
Subjective indicators refer to the states of balance and imbalance. He additionally stated that balance may be reported while identical weight is given each to work and domestic or, when domestic or work dominates by choice. Spill over occurs while there is interference of one sphere of life with other. Additionally, several outcomes of work life balance which include personal satisfaction and wellbeing at work, domestic and entire existence, overall performance at work life, impact on others at work, family and friends.
The relevance of this theory to the study is that organizations are expected to adopt positive work life balance policies that will enable employee have a positive work life balance which will make them be effectively committed to achieving the organization's goals.
2.1.2	Hertzbergs Two Factor Theory
The Two Factor Theory was developed by a psychologist Frederick Hertzberg in 1959, who theorized that job satisfaction and job dissatisfaction act independently of each other. The characteristics related to job satisfaction included advancement, recognition, the work itself, achievement, growth and responsibilities. Hertzberg referred to these characteristics as motivators. The characteristics related to dissatisfaction, which included working conditions, supervision, interpersonal relationships, company policy and administration were referred to as hygiene factors. It states that there are certain factors in the workplace that cause job satisfaction, while a separate set of factors cause dissatisfaction. The theory perceives workplace as independent variable and job satisfaction as dependent variable. These variables concur with the study variables which are technical environment, physical environment and organizational environment and job satisfaction (Spearritt, 2010).
According to Schermerhorn (2003), Herzberg's two-factor theory is an important frame of reference for managers who want to gain an understanding of job satisfaction and related job performance issues. Schermerhorn asserts that Herzberg's two-factor theory is a useful reminder that there are two important aspects of all jobs: what people do in terms of job tasks (job content), and the work setting in which they do it (job context). Schermerhorn suggests that managers should attempt to always eliminate poor hygiene sources ofjob dissatisfaction in the workplace and ensure building satisfier factors into job content to maximize opportunities for job satisfaction. Therefore, this theory is relevant and significant to this study in that it recognizes that employees have two categories of needs that operate in them and that both should be addressed. This theory therefore can guide a researcher in establishing work life balance and its effects on employee performance in the Service industry
2.1.3 The Demand–Control Model
The Demand–Control Model by Karasek (1979) points out that job demands and job control jointly predict the occurrence of individual mental strain. Based on comparative empirical findings, the causal relationship between job characteristics and strain outside the work-sphere is furthermore essential to the model. Karasek (1979) however implicitly acknowledged a wider range of demands and resources. Accordingly, the Job Demands–Resources Model (Bakker and Demerouti, 2007; Demerouti, 2001) claims that demands and resources determine job-related stress. Although the Job Demands–Resources Model exclusively refers to work-related demands and resources – given the bi-directional nature of work–family conflict – a conflict occurs if demands from the family and/or the work sphere compete with and exceed individual resources (Demerouti, 2007).
According to Greenhaus and Parasuraman (1999), a high level of involvement in unpaid work leads to a high level of conflict in paid work. Similarly, previous research revealed that children in the household – inducing higher family demands – are associated with a higher level of conflict (Crompton and Lyonette, 2008; Greenhaus and Parasuraman, 1999), particularly for women (Hennig et al., 2012). Martinengo et al. (2010) reveal that younger children – who demand more time – are predictors of family to-work conflict. As women still tend to be more responsible for childcare than men (Sayer, 2010), regardless of hours worked in paid employment, they work a second shift at home (Asher, 2011; Hochschild, 2003). Thus, household and family responsibilities are family demands which potentially increase the family-to-work conflict. The work-related demand that is most often discussed is the number of working hours, possibly causing work-to-family conflict (Sayer, 2010).
Long working hours limit the time resources for one's private life (Chung, 2011; Golden and Wiens-Tuers, 2006; Jacobs and Gerson, 2004; Tausig and Fenwick, 2001), while shorter working hours and part-time employment might contribute to a better work–life balance (Bonney, 2005; Crompton and Lyonette, 2008). In a European comparative study, Fahlén (2012) discovers that shorter working hours reduce conflict in both directions; that is, home-to-work and work-to-home. Related to high work demands, job position/level (Crompton and Lyonette, 2008; Steiber, 2009; Tausig and Fenwick, 2001) and educational level (Jacobs and Gerson, 2004) were also found to increase work–life conflict.
Along the same line of reasoning, Bakker and Demerouti (2007), Bakker and Geurts (2004), Demerouti et al. (2001), Parasuraman, (1996) and Pocock (2005) interpret individual temporal, spatial and organisational control over the work sphere as a job resource. Relating individual control to work flexibility, Hill et al. (2008) defined workplace flexibility as 'the ability of employees to make choices influencing when, where, and for how long they engage in work-related tasks. Thus, individual flexibility can be seen as a job resource since flexibility allows control over devoting resources to one or the other life spheres. This in turn decreases the likelihood of negative interference. Control in this context can have a buffering effect on job-related demands such as long working hours (Gerson, 2004).
2.2.1	The effect of work family balance on employee performance
Work and family are most important parts in human life that are not easily separated. When trying to balance between the work and family, the employees often end with conflict and dilemma in giving priority to both career and family. The incompatible of demand between career and family seem to create a personal pressure to the employees. More often than not, conflict tends to create pressure to the employees as they try to balance the two roles that need to be performed simultaneously. The last decades have seen dramatic changes in family life, including increases in dual-earner households and single-parent families as well as greater numbers of employed adults who are also caring for elderly or infirm relatives (Neal ; Hammer, 2007), that mean many employees are simultaneously juggling paid work and unpaid family work.
Work–family conflicts are a common source of stress and have been linked to employees' health and family functioning, as well as labor market decisions and fertility decisions (Gornick& Meyers, 2003). Stress has the implications for the individual as well as the organization and it can no longer be considered merely as the individuals or managers problem (Menon and Akhilesh, 2007). It is now generally accepted that prolonged or intense stress can have a negative impact on an individual's mental and physical health. When trying to balance work and family responsibilities, many employees experience conflict between these two roles (Day and Chamberlain, 2006). Work – family conflict has been defined as a mutual compatibility between the demands of the work role and demand of the family role. Juggling work and family responsibilities is a common experience for many employees. Although engaging in both work and family roles can have positive effects for individuals, but if employees are unable to balance the responsibilities associated with both roles, the potential for conflicts between roles increases (Frone, Russell and Cooper, 2010).
In the work setting, Rees (2005) researched on the uneven development of gender mainstreaming in Europe and found that women encounter more stress as compared to men. The main reason is women have to balance their responsibilities towards their work and family. While Carnicer et al., (2004) have found that gender is not a significant variable to explain work-family conflict. As the consequences of work – family conflict, De Janasz (2007), found that the conflict of work and family may lower job satisfaction and it may decrease the organizational commitment. In order to overcome the work – family conflict, Boyar et al (2008) suggested that organizations can work to reduce work family conflict by adopting family-friendly programs that help employees balance work and family demands. Specifically, their study implies that organizations should find ways to hold constant or reduce perceptions of work and family demand, along with other direct antecedents of work interfering with family and family interfering with work (Cooper, 2010).
2.2.2	The influence Flexible Working Options on Employee Performance
Pruchno, Litchfield and Fried (2007), conducted a research to find out impacts of workplace flexibility which shows that the most workplace flexibility turns into a win-win situation for both the company and the employee, the research also concluded that flexible working hours increases the employee productivity and allow him to do proper scheduling to move with official and personal life. Employees who are using alternative work schedule are conscious that all the other staff has not been able to utilize it. It is the responsibility of the managers to recognize the staff that will be more productive for opting flex schedule (Fried, 2007).
Employees, who are giving maximum output, will continue to sustain the same output. Supervisor evaluates an employees capability and job performance with the flexible work schedule while maintaining productivity. By decrease in the time, supervisor believes that they can improve employee confidence, loyalty, thus enhancing productivity. Flexible working intended at making convenience for employees to change when, where and for how many hours they want to work. Flexible working persuades employees to bring in new ideas for the conflicts occurring and they convinced line managers to take flexible working options more sincerely. According to the research when organization environment are not reactive to the needs for substitute work schedule, the probability is that staff work less than their capability (Nkereuwem, 2006).
Broadly acknowledged statement is that better workplace environment produces better results. It is considered with due significance to the nature of job and the individuals that are going to work in that office. The employee performance is actually considered by the output that the individual produces and it is related to productivity. Efficiency is affected at business level by such factors such as employees, technology and objectives of the organization. Employees performance and health also affected by the physical environment of the organization (Nkereuwem, 2006).
Morgan (2014) found that flexible time effects on employee behavior. The impact of flexi time is also highly dependent on nature of job like low wage employees get waged on daily basis at hour regulation so they could not make full use of flexi timing. Scandura and lankau (2007), in their research show the relationship between flexible working hours, personal (family) responsibilities and gender differences to job satisfaction and commitment toward organization.
According to Hurtz and Donovan (2000), Better significance is the opportunity that the relationship between personality characteristics and specific work environments may influence performance. Researchers distinguished that the effects of exhaustion, are mostly related to a wide range of physical and mental health problems. People cannot give their output to maximum capacity without good health and proper functioning conditions, which cause failure for the employees' to reach their own proficient potential and the output required to make the organization perform efficiently and effectively. The secret to the job satisfaction is our ability to control our moods on a daily basis strain. Emotional balance enhances the employees' ability to handle work pressure and stress, to consistently carry out the responsibilities, and self-indulgence (Worral, 2009).
Emotionally stable people are able to sustain an analytical approach when dealing with a nerve-racking work conditions. Costa and McCrae, (1985, 2002) say that people with neuroticism behavior are those who experience more negative emotions, which would be reflected in poor job attitudes and high levels of job stress. Neuroticism is a propensity to experience harmful effects such as panic, depression, humiliation, annoyance, guiltiness, and hatred. The findings of Van Vianen and De Dreu in 2001 are that high levels of emotional balance contributed to social consistency in teams, and high levels of neuroticism predict irritation and ignorance in relationships. James and Galinsky, 2006, the higher income employees are more offered with the flexible work arrangements than the lower income. This creates a sense of inequality at the workplace and decreases the motivational level.
Worral and cooper (2009) conducted a research to find out effects of working hours patterns in general and by managerial level, and the way they tradeoff between official work and personal life related issues like health, moral, time to family and productivity. The research shows a strong relationship between working hours and increasingly negative impact. Findings regarding tradeoff clearly demonstrate that it's a very difficult for many managers. The results also disclose the fact that specifically the junior managers and those who are working in non-profit organization are more concerned toward their social life but picture is different for senior managers who works for profit oriented firms they are more concerned toward their office. The research also concluded that long working hours have negative impact of managers' productivity and on their social life like with family and moral (Cooper, 2009).
2.2.3	Employee Assistance Programs
Employee assistance program can be defined as work-based intervention program designed to identify and assist employees in resolving personal problems (e.g., marital, financial or emotional problems; family issues; substance/alcohol abuse) that may be adversely affecting the employees performance. Employee assistance program plans are usually 100% paid by the employer and can include a wide array of other services, such as nurse lines, basic legal assistance and referrals, adoption assistance or assistance finding elder care services. Employee assistance services can be made available to not only the employee but also to immediate family members or anyone living in their home. (SHRM, 2015).
Employers are recognizing that a holistic approach to wellness results in a happier, more productive employee. According to the Employee Assistance Professionals Association, an employee assistance program utilizes specific core technologies to enhance employee and workplace effectiveness through prevention, identification, and resolution of personal and productivity issues. An employee assistance program, typically consists of a group of professionals, such as lawyers, therapists, counselors and financial experts, who contract with an employer to provide advice and guidance to employees. EAPs help them address personal, non-work issues, and concerns that could possibly affect their work life. Employee assistance programs (EAPs) began in the 1940s by providing employee services that primarily focused on the affect of alcohol use and abuse on job performance.
Over time, this emphasis was broadened to include other personal issues that negatively affect job performance. Tremendous growth in EAP services began in the early 1970s. During that period, EAPs helped employers address a growing list of employee concerns and proactively deal with workplace problems that could lead to violence, physical and mental health issues or declining morale among employees. Today, the vast majority of Fortune 500 companies offer EAPs that deliver a variety of health and productivity services to improve organizational performance, as well as assist individual employees and their dependents. (Attridge, 2005).
Worsening health status and stagnating productivity are major concerns of large employers nationwide. Some employers are experiencing alarming increases in absence rates due to the growing number of claims for short- and long-term disability and Family Medical Leave (FML). Stress is a major concern for employers and managers, and mental health and substance-use conditions continue to be a leading cause of illness and lost productivity for most employers (Nkereuwem, 2006).
According to Roman (2005), factors such as mental health conditions, sleep problems, mental health stigma and substance use and abuse affect business performance by reducing productivity and increasing both planned and unplanned absences. Many of these factors are either preventable or modifiable. While stress is known to affect productivity, few employers have found successful strategies to reduce the negative effects of chronic stressors. Many employees experience damaging levels of stress due to problems they experience in their home or work lives (Roman, 2005).
Todays workforce faces many new causes of stress, including the economy, long commutes, the time and energy required to care for ailing parents or young families and the availability of new technologies that blur the line between work and home. Furthermore, common behavioral health conditions such as depression can negatively affect productivity. Depression itself can be life-threatening, but it may also increase an individual's risk for developing common medical conditions such as heart disease. Two decades of research show that persons with depression are at a greater risk for developing heart disease than healthy persons. Left untreated, depression may have a negative impact on comorbid (co-occurring) disease outcomes and reduce an individual's ability to comply with treatment. (Rees, 2005).
2.3 Empirical Literature Review
2.3.1	Work life balance
Iqan, (2010) Conclude that, a successful balance between work and non-work roles are beneficial for both employee and employer. And this balance in work and life domains enhances quality of personal relationship and organizational outcomes. Work/life balance is a broad concept that encompasses prioritizing between work (including career and ambition) on one hand, and life (including areas such as health, leisure, family, pleasure and spiritual development) on the other. There are also two key concepts related to work/life balance – achievement and enjoyment (Bowman 2013).
According to Susi (2010), Work life balance is drive for satisfaction of employees. Many organizations feel the need of work life balance which include retention of valuable work force, reduce work family conflict, and reduce employee stress, job satisfaction and better life balance. Work life balance practices need to be supported and encouraged at workplace culture. Strong and supportive organizational culture increase employee intent to remain in the organization. Felicity, Asiedu, Appiah, (2013) concludes that work life balance is important in enhancing employee performance at work and home. Gender difference exists in work life balance needs because work and non-work responsibilities are different for male and females. Some research results show that female demonstrated more need for work life balance as compared to male. An individual derive satisfaction in life from work and family domains. Researches find that work balance practices effect overall organization and individual performance.
Lockwood (2012) defines work life balance as a managing work and personal responsibilities. Work-life programs require support from senior management. For work/life benefits in work environment it is helpful to have a corporate culture that encourages employees to look at business in an entirely different way and supports and accepts employees as individuals with priorities beyond the workplace. Work life balance programs increased employee motivation and productivity. Work-life environment is a concept that supports the efforts of employees to split their time and energy between work and the other important aspects of their lives. Work-life environment is a daily effort to make time for family, friends, community participation, spirituality, personal growth, self-care, and other personal activities, in addition to the demands of the workplace. Organizations are social systems where human resources are the most important factors for effectiveness and efficiency and need effective managers and employees to achieve their objectives. Organizations cannot succeed without their employees efforts and commitment (Hobson, 2009).
Job satisfaction is critical to retaining and attracting well-qualified employees. Exceptional organizations have leaders that create work environments where people can achieve work-life balance and well-being as they define it for themselves (Spinks, 2004). A satisfied work force is essential for the success of organizations and their businesses. Dissatisfied employees make organizations dysfunctional, damaging their financial performance. Job satisfaction and work life balance are more likely to drive employees to remain with their current employers than Work-life balance is assisted by employers who institute policies, procedures, actions, and expectations that enable employees to easily pursue more balanced lives. The pursuit of work-life balance reduces the stress employee experience. When they spend the majority of their days on work-related activities and feel as if they are neglecting the other important components of their lives, stress and unhappiness result. Work-life balance enables employees to feel as if they are paying attention to all the important aspects of their lives.
Because many employees experience a personal, professional, and monetary need to achieve, work-life balance is challenging. Employers can assist employees to experience work-life balance by offering such opportunities as flexible work schedules, paid time off (PTO) policies, responsible time and communication expectations, and company-sponsored family events and activities. Managers are important to employees seeking work-life balance. Managers who pursue work-life balance in their own lives model appropriate behavior and support employees in their pursuit of work-life balance. They create a work environment in which work-life balance is expected, enabled, and supported. They retain outstanding employees to whom work-life balance is important (Spinks, 2004).
Literature shows that managers have valuable role in encouraging employees to manage their work and life activities. Strong relationship exists between work life balance and employee satisfaction, hence companies should make policies and programs for employees. Managers can apply different roles of work-life balance to manage employees work life balance and provide success to the company (Rani 2011). When employees are not clear about their roles to be performed then employees are unable to meet organizational goals and it also has an impact on their personal life and employees become dissatisfied towards their job and organization faces lack of effectiveness (Spearritt, 2010).
A study conducted in Pakistan by Nadeem and Abbas, (2009) on the relationship among work life conflict and employee job satisfaction at all levels of the management in public and private organizations, showed that job satisfaction at top level of management has negative correlation with family to work interference, family to work interference and stress and job satisfaction has positive correlation with job autonomy. Job satisfaction at the middle level of employees decreases when work life conflict and stress increases. Job satisfaction at the lower level of employees has negative correlation with stress and family to work interference and positive correlation with job autonomy.
A study by Hanglberger (2010) on the effect of work-life balance, specifically working hours on employees' job satisfaction found a positive relationship between them. The same was analyzed by Gash, (2010) for women in UK and Germany and the findings supported Hanglberger studies, showing a positive effect of reduced working hours on employees' life satisfaction. Another study (Malik, 2010) was conducted in Pakistan to investigate the relationship between work-life balance, job satisfaction and turnover intentions among medical professionals in hospitals.
The level of employees' job satisfaction increases by many factors and when employees are satisfied with their work, they feel motivated (Noor, 2011). The demand of employees work life balance is increased by change in trends in the business such as change in organizations structure, diversity of work force and female employees working in organizations. Organizations should provide work life balance facilities to their employees so that employees can perform their duties effectively and leads organization to the success (Parvin and Kabir, 2011).
Another study by Dev 2012, conducted in India indicates that work-life balance is significantly correlated with job satisfaction in the service industry. It suggested that female employees should be given more facilities such as flexi time, job sharing, child care, etc. to gain their organizational commitment. It was revealed that those doctors who are better in managing their work-life shows higher satisfaction with jobs and less turnover intentions. Job satisfaction has negative correlation with work stress, family to work interference and work to family interference but have positive correlation with workload. Employees productivity is reduced and their turnover and absenteeism are increased due do work life strain and most of the institutions also complain that they cannot much facilitate their employees to balance their work and family responsibilities (Dev, 2012).
Fatima and Sahibzada (2012) conducted a study on work-life balance in the universities. They concluded that due to heavy workload in universities, staff becomes dissatisfied. Hence, universities should develop strategies that could facilitate faculty needs to balance between work and life activities to achieve competitive advantage. A study was conducted by Maren, (2013) to analyze work-life balance and job satisfaction among teachers exposed a negative relationship between work-life conflicts and job satisfaction. The study suggested that if organizations offer facilities to reduce work-life conflicts, it will lead to improvement in employees job satisfaction. Chahal, (2013) suggested to increase the efficiency of the employees bank should timely appraise their employees and encourage them to work hard because satisfied employees are reason for the success of the organization. When employees are satisfied with their jobs they become loyal and committed to the organization. Saleem, (2013) say that organization should make strategies and policies that will help employees to have clear understanding regarding their job tasks and objectives and if employees are not satisfied with their job they will not pay attention to their work and will not make customers happy.
2.4	Summary of Literature
Konrad and Mangel, (2000), found no relationship between a composite measure of work-life initiatives and productivity. However, while there is not strong evidence for the universalistic approach for work-life policies regarding their effects on job performance; Perry, Smith and Blum (2000), provide evidence for the configuration approach. Specifically, organizations with a greater range of work-family policies (including leave policies, traditional dependent care and less traditional dependent care) had higher organizational performance, market performance and profit-sales growth.
Furthermore, the research has been dominated by North American and North European academics. This reflects the fact that the contemporary debate is partly about affluence and its consequences and according to Crompton (2006), Work Life Balance may be a misleading phrase as it implies that employees.
It is also argued that the conceptualization of work-life balance is not applicable to all types of people, for certain low income employees the concept of work-life balance may be unthinkable if they must struggle to find enough work to make ends meet (DeBruin and Dupuis, 2004). Employees may work longer hours because flexible arrangements increase their availability for work and reduce their commuting time, or because they are exchanging leisure time for flexibility. There is also ambiguity around the definition of work. The term work often refers to paid employment but may also refer to that which includes unpaid work at home and in the community (Eby, 2005). Greenhaus,(2003) have also questioned the self-evident assumption that work-family balance always leads to favorable outcomes since according to them this is an empirical question which has not yet been firmly answered due to miscellaneous definitions of work-family balance.
Additionally, the use of family-friendly provisions such as regular leave entitlements, flexibility and part-time work may inadvertently indicate less career commitment, reducing the likelihood of career progression (Hosking and Western, 2008). While part-time work is likely to reduce general experiences of work-life conflict, it is also widely observed that part-time hours often involve work that is lower paid and less secure, involving less autonomy and skill discretion (Bardoel, 2007). Hence, reduced hours may improve work-life outcomes, but other important aspects of job quality, opportunity and financial security are substantially reduced.
2.5 Research Gap
Researcher(s)	Focus of the Study Research Gap
Beauregard Henry (2009)	Making the link between work life balance practices and organizational performance	These scholars have concentrated their studies in the developed countries; it is with this in mind that this study will attempt to fill this gap by addressing work life balance and employees performance in the service industry in Kenya.
Mordi, (2011) Extent to which work-life balance policies/practices are a reality for employees in the banking sector	Study sought to establish the levels of awareness of the availability of work life balance policies in the banking sector in Nigeria. Thus does not look at the effect these policies have on the performance of employees. This study will therefore seek to fill these gaps.
Lilian, Menezes and Kelliher (2011)
Flexible working arrangements, work related outcomes and employee outcomes
Study looked at performance at organizational level, and individual level which mostly inferred large surveys done making it secondary data hence mixed findings reported. Generalizing the findings is therefore a problem for this study.
Gillian andMarilyn(2004)	Connections between macro, organizational and individual levels of WLB policy and practice in UK	Carried seven case studies–five in the public sector and two in the voluntary sector. They found a connection between organizational and individual levels in terms of mutuality in both needs and benefits are arguably necessary for the effective development and implementation of WLB. While this study recognizes the connectivity of organizational and individual levels in the use of WLB practices it does not concentrate on these connections but on the effect of these practices on the performance of employees. This study seeks to investigate this in Kenyan companies as opposed to UK with specific WLB practices under scrutiny.
Lockwood(2003)	Work life balance: Challenges and solutions in the USA Identifies three factors-global competitions, personal lives/family values, and an aging workforce–as present challenges that impair work life balance. Suggests companies capitalize on factors using work/life initiatives to gain a competitive advantage .Recognizes the importance of organizational culture in the use of work life balance practices, but did not point the role it plays on performance of employees when specific WLB practices are used. This study seek to address this and focus on specific WLB practices and how they affect the performance of employees in the service sector in the developing countries context
Quazi,	Koh and Huang, Khoo(2011)
Flexible work arrangements, child care facilities, employee support schemes, perceived supervisor support
Study used hierarchical regression analysis indicating both perceived availability and utilization of work life initiatives were positively related to job satisfaction, commitment and negatively associated with turnover intentions. Questionnaire was developed from scales developed by other researchers and were tested for content validity and clarity by subject experts, this is a large number which is good for any research. The study suggested a further study to incorporate moderating and mediating variables such as gender differences and perceived organizational support.
2.6	Conceptual Framework
Independent variables Dependent variable
Source: Author, 2018
RESEARCH DESIGN AND METHODOLOGY
This chapter outlines the research design, study area, study population, sampling techniques, instruments, data presentation and data analysis and ethical considerations of the study.
3.1 Study Area
To achieve the study objectives the researcher will use the employees in Safaricom PLC Ltd and Jubilee Insurance Kenya which will comprise of the managerial staff and non-managerial staff.
The study will employ descriptive survey method as this method gives wider room for the researcher to study the subject matter. It also ensures that inferences can be made on characteristic, attitude and behavior of the population under study. Kasomo (2007) defines descriptive research methods as methods that are concerned with the conditions or relationships that exist. Such methods are designed to investigate the current status and nature of the phenomenon.
3.3 Target Population
The target population is the entire set of units for which the data are to be used to make inferences. For this study the target population will be drawn from a population of 593 employees working in various positions in the selected companies. The study will target key informants like the managers, supervisors and other employees who have an understanding of the operations of the company.
Company records (2016) indicate that Safaricom PLC has over 4,000 employees spread across the country employed as either permanent or contractual employees and the Company records (2016) of Jubilee Insurance Kenya Ltd also has 878 employees employed on either permanent or contract terms. This study will focus on permanent employees of both organizations.
Table: 3.1 Target population
Size	Sample
Insurance	Jubilee Insurance Kenya Ltd	Top level
Section heads	30	6
Other staff	210	42
Tele -communication	Safaricom PLC	Top level
Section heads
Total target population	593
Sample size	119
Source: Company records 2016
3.4 Sampling Procedure and Sample Size
The technique to be used is stratified random sampling which according to Kasomo (2007) helps in identifying groups in the population. Sampling is to be used on about 20% of staff in each category of the selected companies. This will ensure that the sample is a good representative of the study population as Kerlinger (2003) recommends 10% minimum sample for a descriptive research. Purposive sampling will also be used to identify the various managers for interview since they will be key informants who may have certain information, because of their expertise, that employees may not have or allowed to give (KIM,2015).To arrive at the sample size of the respondents, the study will adopt a sample determination table used in social research. From Table3.1, a total of 593 populations is equivalent to 119 sample size.
3.3 Data Collection Instruments
3.3.1 Questionnaire
Kasomo (2007) defines a questionnaire as a carefully designed instrument (written, typed or printed) for collecting data direct from people. That a typical questionnaire consists of questions and statements. Two types of questions are normally asked; close ended questions and open ended questions. Closed ended questions are normally questions that are structured in such a way the respondents are provided with a list of responses from which to select an appropriate answer. The open ended questions enable the researcher to receive the answer open to what the respondent wishes to give. The advantage of using this type of instrument is the ease with which it accords the researcher. Moreover, they are easy to administer and economical to use in terms of time and money.
In this study the both questionnaires will be used to get uniform responses from given companies since the study targets persons in management who have adequate information (managers/supervisors) and the employees under them. The structured questionnaires are accompanied by a list of all possible alternatives from which respondents will select the suitable answer that describe their situation by simply ticking.
3.4 Measurements of Variables
According to Kothari (2004) measurement is the process of mapping aspects of a domain onto other aspects of a range according to some rules of correspondent. It involves devising form of scale in range and then mapping the properties of the object to be measured on this scale. The study seeks to investigate the effect of work life balance on the performance of employees in selected companies in the service industry in Kenya specifically in Nairobi County. The Likert scale will be calibrated to adequately bring out the most fairly honest opinion of the respondents regarding the questions covering the dependent and independent variables. Kothari (2004) argues that a Likert scale is relatively easy to construct and permits the use of statements that are not manifestly related. He further explains that they are not only useful with respondent centered studies but are also considered more reliable.
Table 3.2: Summary of the Operationalization and measurement of the study variables
i) Work Life Balance Practices
Indicators	Instrument
Work Family Priorities
Adopting family-friendly programs that help employees balance work and family demands with other direct antecedents of work interfering with family and family interfering with work
•	Balanced work and family
•	Higher Role Conflict
•	Tensioned interpersonal Relations
Questionnaire Likert Scale
Flexible Working Options
Programmes /schedules that enable employees to vary the number of work hours daily as long as they maintain regular number of work hours on a weekly basis.	•	Flexible work schedules/
Programmes and Working Hours
•	Childcare Facilities
•	Leave policy
An arrangement where employees share the duties and responsibilities of one job.
•	Professional referrals
•	Financial backups
•	Counseling
ii) Employee Performance
Performance	The outcomes of activity and endeavor which can be assessed qualitatively by reference to standards of performance defined in the form of meeting the required standards.	•	Competence
•	Customer satisfaction
•	job satisfaction
•	improved service delivery
•	Employee loyalty and commitment
•	Competence
•	Customersatisfaction
•	Employee loyalty andcommitment
Questionnaire Likert Scale/nominal scale
3.5 Validity of Research Instruments
In research, the fundamental rule of the thumb is that every information collected must be accurate (Kasomo, 2007). This implies that what is used to obtain that information must also be accurate thus the concept of validity. It implies that if whatever is used in the study makes it possible to get what should be gotten then there is validity. Fraenken (1993) explains that the instrument should be given to an individual who can be expected to render an intelligent judgment about the adequacy of the instrument. The instrument is then amended according to the expert's comments and recommendations before being administered. For the validation of the instrument therefore, the researcher will consult supervisors and experts in the Human Resource Department who will give expert advice and suggestions on the instrument. The aim is to determine whether the items are adequate in content, wording, sequence, form, layout, question difficulty and instruction. The feedback obtained will be used to correct the questionnaire.
3.6 Reliability of the Instruments
According to Kosomo (2007), reliability refers to how consistent a research procedure or instrument is. It is the degree of consistency demonstrated in a study. In this study therefore the provisional draft of the questionnaire will be pre-tested on a pilot group similar to the sample to which the questionnaire will be given. The test–retest method will thus be used on the pilot group. The score on the two sets of measures will then be correlated to obtain an estimated coefficient of reliability. The coefficient will be computed using the Karl Pearson's product moment coefficient of correlation given as r. A coefficient of between 0.5and 0.7 will be acceptable for this study. The items will be scored individually and aggregated to get the total score on the whole instrument for both test and retest administration.
For this purpose then ten questionnaires will be used for piloting by the researcher. Cronbach's alpha, ? (or coefficient alpha), developed by Lee Cronbach in 1951, measures reliability, or internal consistency. "Reliability" is how well a test measures what it should. For example, a company might give a job satisfaction survey to their employees. High reliability means it measures job satisfaction, while low reliability means it measures something else (or possibly nothing at all).
Cronbach's alpha tests to see if multiple-question Likert scale surveys are reliable. These questions measure latent variables — hidden or unobservable variables like: a person's conscientiousness, neurosis or openness. These are very difficult to measure in real life. Cronbach's alpha will tell you if the test you have designed is accurately measuring the variable of interest.
N = the number of items.
c? = average covariance between item-pairs.
v? = average variance.
Data analysis will be done at two levels; first the data collected through questionnaires will be coded manually and analyzed using SPSS (statistical programme for social sciences).The data will then be organized under different variables and the frequency established. Percentages and the ratios will be calculated to allow for the use of descriptive statistics. The results will then be presented in the frequency tables and charts. The second level of the data analysis will involve inferential statistics where the Pearson's coefficient of correlation will be used to establish the relationship among the variables.
3.8 Ethical Considerations
The study will put in place a series of ethical considerations. A letter of introduction from the University will be provided to the researcher to identify her as a bonafide student permitted to carry out the research. The researcher will then obtain a research permit and a letter from the National Commission for Science; Technology ; Innovation copied to the top management of the companies clearing her to collect data from the target respondent highlighting the topic of research. On all the questionnaires to the various respondents, there will be a forward note assuring them on anonymity, confidentiality and the voluntary participation.
1 CHAPTER ONE
CHAPTER TWO LITERATURE REVIEW Introduction The purpose of the research is to identify a relationship of occupational stress and job satisfaction of sewage workers in operations and maintenance in an organisation
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Pregnancy is not a disease, and pregnancy related mortality is almost always preventable. Yet more than half a million women die each year due to pregnancy related complications. According to the latest estimates of the World Health Organisation (WHO) and the United Nations International Children's Emergency Fund (UNICEF), 289,000 women still die every year from complications of their pregnancy, and nearly 90% of these deaths are in sub-Saharan Africa and Asia (WHO, UNICEF ; UNPF, 2013). Obstetric complications continue to represent the major cause among women of childbearing age, far ahead of tuberculosis, suicide, sexually transmitted diseases, or AIDS (WHO, 2005). While developed countries have made enormous progress in bringing down the huge death rates associated with pregnancy, women in developing countries continue to face very high risks of death and disability as a result of pregnancy. The risk of a woman dying as a result of pregnancy or childbirth during her lifetime is about 1 in 6 in the poorest parts of the world compared with about 1 in 30,000 in Sweden (Ronsmans ; Graham, 2006).
Maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (WHO, 2001). According to Hoj, da Silva ; Hedegaard (2003), maternal mortality refers to the death of either a pregnant woman or death of a woman within 42 days of delivery, spontaneous abortion or termination provided the death is associated with pregnancy or its treatment. Maternal Mortality Rate (MMR) however, is the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes). The MMR includes deaths during pregnancy, childbirth, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, for a specified year.
Factors that increase maternal death can be direct or indirect. Generally, there is a distinction between a direct maternal death that is the result of a complication of the pregnancy, delivery, or management of the two, and an indirect maternal death (Khlat ; Ronsmans, 2009). That is a pregnancy-related death in a patient with a pre-existing or newly developed health problem unrelated to pregnancy. Fatalities during but unrelated to a pregnancy are termed accidental, incidental, or non-obstetrical maternal deaths.
The most common causes are postpartum bleeding, complications from unsafe abortion, hypertensive disorders of pregnancy, postpartum infections, and obstructed labour (GBD, 2014). Other causes include blood clots and pre-existing conditions. Indirect causes are malaria, anaemia, HIV/AIDS, and cardiovascular disease, all of which may complicate pregnancy or be aggravated by it (WHO, 2014).
Sociodemographic factors such as age, access to resources and income level are significant indicators of maternal outcomes. Young mothers face higher risks of complications and death during pregnancy than older mothers (WHO 2014), especially adolescents aged 15 years or younger (Conde-Agudelo, Belizan, ; Lammers, 2004). Adolescents have higher risks for postpartum hemorrhage, puerperal endometritis, operative vaginal delivery, episiotomy, low birth weight, preterm delivery, and small-for-gestational-age infants, all of which can lead to maternal death (Conde-Agudelo, Belizan, ; Lammers, 2004).
Unsafe abortion is another major cause of maternal death. According to the World Health Organization, every eight minutes a woman dies from complications arising from unsafe abortions. Complications include hemorrhage, infection, sepsis and genital trauma (Morgan ; Eastwood, 2014) Globally, preventable deaths from improperly performed procedures constitute 13% of maternal mortality, and 25% or more in some countries where maternal mortality from other causes is relatively low, making unsafe abortion the leading single cause of maternal mortality worldwide (UNICEF ; WHO, 2012; UNFPA ; World Bank, 2012).
Structural support and family support influences maternal outcomes. Furthermore, social disadvantage and social isolation adversely affects maternal health which can lead to increases in maternal death (Morgan ; Eastwood, 2014). Additionally, lack of access to skilled medical care during childbirth, the travel distance to the nearest clinic to receive proper care, number of prior births, barriers to accessing prenatal medical care and poor infrastructure all increase maternal deaths.
At the Millennium Summit in September 2000, the Millennium Development Goals (MDGs) were developed by nations and world leaders to inspire cooperation and partnership to reduce extreme poverty and improve the status of health, education, and the environment of the global community (UN General Assembly, 2000). Specific time-bound targets were established with an achievement deadline of 2015. The achievement of these targets was measured using established indicators of health and poverty.
The fifth of the eight MDGs was to improve maternal health (MDG 5) with a key indicator to measure this goal identified as the maternal mortality ratio (MMR), a ratio of the number of maternal deaths that occur for every 100,000 live births. The target established at the Millennium Summit was to reduce the MMR by three-quarters between 1990 and 2015. Although the world mortality rate has declined by 45% since 1990, still 800 women die every day from pregnancy or childbirth related causes. Developing countries account for about 99% of an estimated half a million maternal deaths that occur each year (Hogan, Foreman, Naghavi, Ahn, Wang, Makela, Lopez, Lozano ; Murray, 2010). A review of the Millennium Development Goals suggests that limited progress is being made to reduce maternal mortality especially across developing countries including Nigeria (WHO, 2007; UNICEF, 2008).
Nigeria is Africa's most populous country with a population of over 140 million people (National Population Commission, 2011). Within the country, there are about 31 million women of childbearing age (Abimbola, Okoli, Olubajo, Abdullahi & Pate, 2012). Maternal mortality is estimated to be more than twice as high in the rural areas (828 deaths per 100,000 live births) than in the urban areas (351 deaths per 100,000 live births) (Abimbola et al., 2012). Regional variations abound in maternal mortality figures across Nigeria. Evidence suggests that maternal mortality rates (MMR) are significantly higher in northern Nigeria compared to the southern part of the country. The North East and North West zones with MMR of 1,549 deaths per 100,000 live births and 1,025 deaths per 100, 000 live births respectively have rates about ten and six times higher than in the South West (165 deaths per 100,000 live-births) (Abimbola et al., 2012; Adegoke, Lawoyin, Ogundeji & Thomson, 2007). High MMRs in the northern part of the country significantly impacts on the national MMR, estimated at 545 deaths per 100, 000 live births (Hogan et al., 2010) which is among the highest in the world (Adegoke et al., 2007).
There are significant maternal mortality intra-country variations, especially in nations with large equality gaps in income and education and high healthcare disparities. Women living in rural areas experience higher maternal mortality than women living in urban and suburban centres (WHO, 2014) because those living in wealthier households, having higher education, or living in urban areas, have higher use of healthcare services than their poorer, less-educated, or rural counterparts (Wang, Alva, Wang & Fort, 2011). These figures indicate the need for high impact interventions to reduce maternal mortality, while paying particular attention to rural Nigerian communities. It is in the light of this that the researcher deems it fit to assess maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Every single day, Nigeria loses about 145 women of childbearing age. This makes the country the second largest contributor to the maternal mortality rate in the world.
Underneath the statistics lies the pain of human tragedy, for thousands of families who have lost their loved ones. Even more devastating is the knowledge that, according to recent research, essential interventions reaching women on time would have averted most of these deaths. Although analyses of recent trends show that the country is making progress in cutting down maternal mortality rates, the prevalence is still high.
A woman's chance of dying from pregnancy and childbirth in Nigeria is 1 in 13. Although many of these deaths are preventable, the coverage and quality of health care services in Nigeria continue to fail women. Presently, less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants.
There are disturbing stories of pregnant women in the villages in Gwer-West with no access to healthcare or facilities for delivery. These women either give birth in their homes unattended to, or are hurried off to the nearest town, which may be several miles away in search of maternity clinics or hospitals, and that is, provided they have the right means of transportation. Good roads are also scarce in some of these places. All of these can endanger the life of a mother and her unborn baby and in severe cases, result in death.
Healthcare disparities exist between urban and rural communities in Benue and Gwer-Wet in particular. The effects of this are felt mostly by pregnant women living in rural areas. Most situations that result in maternal mortality are sometimes preventable, yet there seems to be a high maternal mortality rate in Gwer-West Local Government Area of Benue State. The assessment of effects of socio-demographic characteristics on maternal mortality constitutes the problem of this research.
1.3Purpose of the Study
The main aim of this study is to assess maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State. Specifically, the study intends to assess the;
Effect of lack of medical facilities on maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Effect of poverty on maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Effect of illiteracy on maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Effects of abortion on maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Effect of drugs and alcohol abuse on maternal mortality among women of child bearing age in Gwer-West Local Government Area.
1.4Research Questions
Does lack of medical facilities affect maternal mortality among women of child bearing age in Gwer-West Local Government Area?
Does poverty lead to increased rate of maternal mortality among women of child bearing age in Gwer-West Local Government?
Does illiteracy influence maternal mortality among women of child bearing age in Gwer-West Local Government Area?
Does abortion increase the level of maternal mortality among women of child bearing age in Gwer-West Local Government Area?
Does drugs and alcohol abuse lead to maternal mortality among women of child bearng age in Gwer-West Local Government Area?
1.5Research Hypotheses
Lack of medical facilities will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Poverty will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Illiteracy will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Abortion will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area.
Drugs and alcohol misuse will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area.
1.6Significance of the Study
This study is significant to the women of Gwer-West Local Government Area because it will open their eyes to the causes of maternal mortality and the measures to avert it.
The study will also be of help to students and other researchers who may want to carry out a further research on this topic. It will serve as a reference and an empirical source.
The study will be of help to the nation as a whole as it will reduce maternal mortality. It will also aid the government in putting forward interventions programmes that will solve the problem of maternal mortality in order to meet the Millennium Development Goals.
1.7Scope of the Study
The scope of the study includes the assessment of maternal mortality among women of child bearing age in Gwer-West Local Government Area. It involves the assessment of the socio-demographic causes of maternal mortality, in the study area. These include lack of facilities, poverty, literacy, abortion and drug/alcohol misuse.
Geographically, the study covers both private and public hospitals and clinics in Gwer-West Local Government Area
1.8Definition of Terms
Assessment: The act of making a judgment about something; an idea or opinion about something;
Maternal: Relating to a mother, especially during pregnancy or shortly after childbirth.
Mortality: The state or condition of being subject to death; mortal character, nature, or existence.
Maternal Mortality: Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes
Maternal Mortality Rate: The annual number of deaths among women of reproductive age (15 – 49 years) per 100,000 live births per year from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes).
Maternal Mortality Ratio: The number of women who die from pregnancy-related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births.
2.1Introduction
This chapter presents a detailed review of literature related to the research topic which is assessment of maternal mortality among women of child bearing age. The chapter deals with conceptual review where the concepts of mortality and maternal mortality are discussed. It also reviews literature related to the research objectives and finally, it gives a detailed empirical review of previous research works by renowned authors.
2.2.1Concept of Mortality
Mortality refers to the relative incidence of death within a particular group categorized according to age or some other factor such as occupation. The term mortality refers in part to the quality of being mortal. This refers to what has died or is subject to death – the opposite of life. Mortality at the population level, is the relationship between the number of deaths over a period of time, usually one year, and the total population of one geographic entity. For thousands of years, mortality was very high throughout the world therefore, the population growth was very slow. From the Industrial Revolution, however, the progressive decline in the birth rate in the currently developed countries began a descent that became widespread in the developing countries in the mid-20th century, when they substantially improved the levels of medical-sanitary assistance.
The quality of mortals is contrary to immortality or eternal existence. Mortality is a measurable value, and can be made in relation to anything alive, for example, fish mortality, of animals in danger of extinction, pets and so on, which is carried out in a given period of time, in general annual., to find a mortality rate. Mortality is a variable, which, together with birth and migration, determine the demographic dynamics – changes in the number of the population of a place in a period considered.
Mortality rate, or death rate, is a measure of the number of deaths (in general, or due to a specific cause) in a particular population, scaled to the size of that population, per unit of time (Porta, 2014a). Mortality rate is typically expressed in units of deaths per 1,000 individuals per year; thus, a mortality rate of 9.5 (out of 1,000) in a population of 1,000 would mean 9.5 deaths per year in that entire population, or 0.95% out of the total. It is distinct from the so-called "morbidity rate" (a vague term sometimes used to refer to either the prevalence or incidence of a disease), and also from the incidence rate (the number of newly appearing cases of the disease per unit of time) (Porta, 2014b).
Mortality may also be expressed in terms of survival (Rothman, 2012). Thus, the survival rate is equivalent to "1 minus the cumulative death rate" (with "death from all causes", for example, being expressed in terms of overall survival) (Last, 2008). Censored survival curves that incorporate missing data by using the Kaplan–Meier estimator can sometimes be compared using statistical tests such as the log-rank test or the Cox proportional hazards test.
Early recording of mortality rate in European cities proved highly useful in controlling the plague and other major epidemics (Greenwood, 2014). Public health in industrialised countries was transformed when mortality rate as a function of age, sex and socioeconomic status emerged in the late 19th and 20th centuries (Jha, 2012). This track record has led to the argument that inexpensive recording of vital statistics in developing countries may become the most effective means to improve global health (Jha, 2012). Gathering official mortality statistics can be very difficult in developing countries, where many individuals lack the ability or knowledge to report incidences of death to National Vital Statistics Registries. This can lead to distortion in mortality statistics and a wrongful assessment of overall health (Jha, 2001).
2.2.2Maternal Mortality
The WHO definition of maternal mortality very clearly establishes those deaths we can include when we talk about maternal mortality. The death must have been caused by a complication related to a woman's pregnancy. This complication can occur while she is pregnant, during delivery, or up to 42 days after the pregnancy ends either through delivery, caesarean session or safe or spontaneous abortion.
Traditionally, a death is defined as maternal if it occurs during pregnancy or within 42 days of its termination (Campbell & Graham, 2011). The length of the postpartum period at risk has varied substantially, however, and the tenth revision of the International Classification of Diseases (ICD-10) now acknowledges the need for an extended time period referring to "late maternal deaths," which occur after 42 days and up to 1 year after delivery (WHO, 2012).
Not all deaths during or shortly after pregnancy are due to the pregnancy. Traditionally, deaths from direct and indirect obstetric causes have been included in the maternal mortality statistic, while deaths from accidental and incidental causes have not. Deaths from direct obstetric causes such as eclampsia, haemorrhage, obstructed labour, or puerperal sepsis are undoubtedly attributable to the pregnancy as such conditions can only occur in pregnant women. Far less certainty exists, however, regarding indirect obstetric causes, particularly those due to infectious diseases. The notion of "diseases aggravated by the pregnancy" is not straightforward, and some diseases may merely coincide with the pregnancy without being aggravated by it. In addition, the verbal autopsy methods on which most cause-of-death ascertainment are based may be unreliable, particularly for indirect causes of maternal death (Ronsmans, Vanneste, Chakraborty & Van Ginneken, 2008). In settings that rely on verbal autopsy methods, all deaths in pregnant or recently delivered women are commonly included in the maternal mortality statistic (whether or not they are attributable to the pregnancy), except for deaths due to unintentional and intentional injuries (Ronsmans et al, 2008; West, Katz & Khatry, 2009). However, it is becoming increasingly clear that the burden of indirect causes may have been underestimated, particularly in Africa, where the prevalence of HIV is high (Fawcus, Van Coeverden & Isaacs, 2012).
Many pregnancy-related deaths still go unnoticed or unreported, and substantial errors in the estimates of maternal mortality persist (Bouvier-Colle, Varnoux & Costes, 2011; Campbell & Graham, 2011). Correctly measuring maternal mortality requires not only a complete registration of deaths in women of reproductive age, which in many countries may be lacking, but also the recognition that the woman was pregnant or recently delivered at the time of her death. Deaths during early pregnancy, such as those due to abortion or ectopic pregnancy, are often not recognised or reported as pregnancy related, and death certificates often omit the notion of pregnancy. The verbal autopsy techniques on which many cause-of-death assignments are based may have poor reliability (Ronsmans et al, 2008).
Maternal mortality is usually expressed in two different ways: the maternal mortality rate and the maternal mortality ratio. The maternal mortality rate therefore, is the annual number of female deaths per 100,000 live births of women of reproductive age from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) (WHO, 2006). The maternal mortality rate includes deaths during pregnancy, childbirth, or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, for a specified year. The maternal mortality ratio—sometimes erroneously called the maternal mortality rate—refers maternal deaths to the numbers of live births. The maternal mortality rate and ratio measure very different kinds of risks. The ratio measures the risk of death a woman faces with each pregnancy, whereas the rate measures the risks to women, whether or not they are pregnant. The rate is a compound measure of the level of fertility and the risks associated with each pregnancy. Any intervention lowering fertility will automatically lower the maternal mortality rate but not necessarily the ratio. As many assessments of progress in Safe Motherhood aim at separating the effects of lowering fertility from those directly aimed at improving the health of women once they are pregnant, the maternal mortality ratio has now become the preferred statistic (Khan, Wojdyla, Say, Gulmezoglu & Van Look, 2006). Denominator information for the maternal mortality ratio is also easier to capture routinely, from hospital records or vital registration.
Accurate estimation of maternal mortality, particularly in developing countries, is made difficult by the lack of complete vital registration systems. The evaluation of safe motherhood programs and the monitoring of progress in achieving Millennium Development Goal-5 (MDG 5)—reducing the maternal mortality ratio by three-quarters between 1990 and 2015—remains a major challenge because of difficulties measuring maternal mortality in the face of weak information systems. Only 60% of 230 countries have at least 90% birth registration coverage, and only 47% of countries have at least 90% death registration coverage (United Nations, 2014). According to the World Health Organizations (WHO), more than 100 developing countries do not have a functioning vital registration system (WHO, 2014). Even where a good vital registration system is available, as in most developed countries, misclassification and underestimation of maternal mortality is common.
In the absence of complete vital registration with good attribution of causes of deaths, the most commonly employed methods for estimation of maternal mortality are household surveys with direct death inquiry, indirect and direct sisterhood methods, and Reproductive Age Mortality Surveys (RAMOS). For countries that have no data available on maternal mortality, regression-based methods are used to estimate maternal mortality (Graham et al., 2008b).
The Demographic and Health Surveys (DHS) Program has long been the primary source of data and information to monitor and track key indicators of a country's health status through its population. The 2015 Nigeria DHS indicates that maternal deaths account for 32 percent of all deaths among women of child bearing age – 15-49 years. The maternal mortality ratio was 576 maternal deaths per 100,000 live births for the seven-year period preceding the survey. This ratio is not significantly different from the ratio reported in the 20013 NDHS. The lifetime risk of maternal death indicates that 1 in 30 women in Nigeria will have a death related to pregnancy or childbearing.
Maternal mortality is an aspect of adult mortality that is of particular interest in the Nigerian context. Worldwide, the 10 countries with the highest maternal mortality ratios are in Africa, and an estimated 14 percent of maternal deaths globally occur in Nigeria (United Nations Economic Commission for Africa (UNECA, 2013). Data from Nigeria's Five-Year Countdown Strategy for achieving Millennium Development Goals (MDGs) show that although maternal mortality fell from 800 deaths per 100,000 live births in 2003 to 545 deaths per 100,000 live births in 2008, progress related to this goal has been slow and challenges remain (Federal Republic of Nigeria, 2010b). In addition to other interventions designed to reduce maternal mortality and achieve the MDG target of 250 deaths per 100,000 live births in Nigeria, the government, in collaboration with development partners, has continued to improve access to quality maternal health services through the Community Health Insurance Scheme and the Midwives Service Scheme (Federal Republic of Nigeria, 2010b, 2012). Maternal mortality is an important indicator for women's programmes and reproductive health programmes in the country (National Population Commission, 2014).
2.2.3Lack of Medical Facilities and Maternal Mortality
Hundreds of poor, rural, pregnant women in Nigeria are dying because they are effectively being denied the same health services other women in the country receive. Nigeria has one of the highest rates of maternal mortality in the world. Pregnant women in Nigeria die because they face barriers, including lack of access to emergency obstetric care, unavailability of information on maternal health, and lack of health staff and medical facilities to take care of emergencies. According to the 2013 Nigerian Demographic and Health Survey, nearly 60 per cent of the communities covered by the survey did not have access to a health facility (National Population Commission, 2014).
Although the need for caution in the interpretation or making conclusions based on 'Facility based Maternal Mortality Rate' (MMR) is obvious, looking at the numbers and trends of facility based maternal mortality is informative. In 2006 a total of 66 (263.8/100,000) maternal deaths including deaths due to abortion (49 from delivery report and 17 from inpatient) were reported from health facilities, which declined by 14 percent as compared with that of 2005. In 2007 a total of 60 (220.5/100,000) maternal deaths were reported from health facilities, which declined by 9 percent as compared with that of 2006 (Mismay ; Morro, 2006).
The problem of poor organization and access to maternal health services has always been a major challenge in Nigeria. Omo-Aghoja et al (2008) asserted that maternity care in Nigeria is organized around three tiers: primary, secondary and tertiary care levels. Primary health centres are located in all the 774 local government councils in the country. Pregnant women are to receive antenatal care, delivery and postnatal care in the primary health centres nearest to them. In case of complications they are referred to secondary care centres, managed by states, or tertiary centres, managed by the federal government.
The Nigerian health system as a whole has been plagued by problems of service quality, including unfriendly staff attitudes to patients, inadequate skills, decaying infrastructures, and chronic shortages of essential drugs. Electricity and water supply are irregular and the health sector as a whole is in a dismal state. In 2000, the World Health Organization ranked the performance of Nigeria's healthcare system 187th among 191 United Nations member states. A 2003 study revealed that only 4.2 percent of public facilities met internationally accepted standards for essential obstetric care (Harrison, 2009). Approximately two-thirds of all Nigerian women deliver outside of health facilities and without medically skilled attendants present. The weak performance of the health system must be understood in the context of the country's long-standing problems with governance. Corruption in the political system is endemic while social development, including the promotion of the health of Nigerian citizens, has been more a rhetorical than a real aim of the state.
As with any medical emergency, the chances of survival in the event of an obstetric emergency are directly related to the effectiveness of initial triage – action taken at the time of onset or as close to it as possible. Unfortunately, due to the heavy reliance on primary care since the mid to late 1970s, very little attention has been given in many resource-poor states in addressing the need to build adequate and appropriate emergency response systems, including referral systems and facilities that can deal with all types of medical emergencies, especially obstetric emergencies (Razzak ; Kellermann, 2012). A skilled attendant would however be able to provide appropriate triage, and thus help minimize delays in receiving appropriate treatment, as well as institute timely action at all points of the potential delay chain, but without adequate facilities, there would be little he can achieve.
2.2.4Poverty and Maternal Mortality
Poverty exists when people lack the means to satisfy their basic needs. These may be defined narrowly as those needs necessary for survival or broadly as those needs reflecting the prevailing standard of living in the community (Safra, 2013). Reproductive ill health is both a cause and consequence of poverty (Family Care International, 2005). Sexual and reproductive health problems account for approximately 20 percent of the ill-health of women globally due to lack of appropriate sexual and reproductive health services (WHO, 2014).
There is no doubt that the poorest countries suffer the highest burden of reproductive health in general and maternal mortality in particular. The maternal mortality ratio is often quoted as the statistic that most clearly highlights the huge gap between developed and developing countries. The women's lifetime risk of maternal death is almost 40 times higher in the developing than in the developed world; and the highest maternal mortality ratios of 1,000 per 100,000 live births found in some regions of eastern and western Africa are as much as 100 times higher than those observed in some Western countries (Ronsmans & Graham, 2006)..
The relationship between high levels of maternal mortality and poverty is not straightforward. When De Brouwere, Tonglet, and Van Lerberghe (2008) mapped the maternal mortality ratios by Gross National Product (GNP) per capita for countries with a GNP per capita below US $1,000, the estimates ranged from 22 to 1,600 per 100,000 without any clear association with the level of economic development. Countries with a similar GNP per capita such as Vietnam, Uganda, and Burundi (US $170–180), for example, had maternal mortality ratios of 160, 1,200, and 1,300 respectively. Similarly, Loudon (2012) remarked that, maternal mortality, unlike infant mortality, was remarkably insensitive to social and economic factors per se but remarkably sensitive to standards of obstetric care.
In most countries, the better-off are more fully covered by maternal health services than the poorest, and poor–rich differences are greater for higher-level than for primary care (Gwatkin, Bhuiya & Victora, 2012). Data on within-country variation in maternal mortality are scarce, although a study suggested strong associations in six countries with demographic and health survey data (Graham, Fitzmaurice, Bell & Cairns, 2014). In Indonesia, a third of all maternal deaths were in women from the poorest quintile of the population, whereas fewer than 13% of maternal deaths were in women in the richest quintile (Graham, Fitzmaurice, Bell & Cairns, 2014).
According to joint estimations by the WHO, UNICEF, and UNFPA, the maternal mortality rate of maternal deaths per 100,000 live births is 920 in Sub-Saharan Africa, compared to 20 among all developed regions. Despite the fact that Asia accounted for a slightly larger number of total maternal deaths than Africa, no other region in the world came close to the high mortality risk per birth found in Sub-Saharan Africa. When the region's risk of mortality per pregnancy is combined with the prevailing fertility rate in the calculation of an individual's lifetime risk of maternal death, the disparity is even more pronounced. Over a women's lifetime, the risk of maternal death in Sub-Saharan Africa is 1 in 16, compared to 1 in 2,800 in the developed world, and 1 in 46 in the region with the next highest risk, South-Central Asia (WHO/UNICEF/UNFPA, 2012). This is why the United Nations has set as one of its eight Millennium Development Goals (MDGs), the reduction of the maternal mortality ratio (MMR) by two-thirds in the developing world by the year 2015. By most accounts, however, Sub-Saharan Africa has not reached this goal.
There is no doubt that poverty in the region contributes to the significant disparities that exist in maternal mortality between Sub-Saharan Africa and the developed countries, in addition to explaining a large share of the within country inequality of health in Africa (Meyerhoefer ; Sahn, 2006).
Indeed, there are many ways in which poverty might lead to high maternal mortality. For example, extreme poverty is often associated with limited access to necessary antenatal medical care as well as appropriate medical resources during and after delivery (Chambers, 2011).
Furthermore, the lack of access to family planning and reproductive health services may result in a demographic profile, such as young age of first birth and high overall fertility, which increases the reproductive risks to mothers and their offspring. The poor may not have access to fresh water, and may live in sub-standard dwellings and be at greater risk of contracting malaria or parasitic infections that compromise a woman's immunity during pregnancy (Smith, Barrett, & Box, 2011).
Of course, the relationship between poverty and maternal morbidity and mortality also goes in the opposite direction. Clearly, illness or death resulting from childbirth will limit a women's future productivity in the labour market and earning power, thereby contributing to a cycle of poverty and poor maternal health outcomes. The result is a poverty trap whereby mothers are more likely to die or become ill during or after pregnancy because they are poor, and more likely to be poor in the future as a result of negative health shocks during this period (Meyerhoefer ; Sahn, 2006).
2.2.5Illiteracy and Maternal Mortality
The net effects of female literacy on maternal mortality ratios vary considerably. In 1970–1980 female literacy was significant only in Latin America. The negative effect of female literacy on maternal mortality ratios become significant for more regions during 1980–1990 and 1990–2000. UNICEF (1999) reported that out of the estimated 885 million adults who are functionally illiterates throughout the world, two-thirds are women. According to UNICEF 2001, the educational access of girls who have historically been disadvantaged relative to boys and the closely related problem of female illiteracy which has been far more prevalent than illiteracy among men and has serious implications both for women themselves and for the care of their children. The missionary education trained women for subordinate positions which affected the girl child education. Furthermore, many cultures in Nigeria do not encourage the education of the girl child. Where resources are limited, family will rather send the boy child to school at the expense of the girl child (UNICEF 2001). All over Nigeria, the gender disparity in education exists at all levels of education but it is especially glaring at the tertiary level and this trend reflects even at the teaching level. According to Federal Office of Statistics (FOS) 1997, the trend is that the higher the level of educational institutions and cadre within the professions, the less the proportion of females.
This girl child's lack of access to education in Nigeria contributes to women's poverty in Nigeria in the sense that education is a prerequisite for getting a good job and a good income. Education also enhances a woman's participation in decision making at home, which has a lot of implications for maternal mortality. Bankole and Eboiyehi (2003) argue that if education stands as the most powerful lever to improve the capacity of any individual, it means that the Nigeria women cannot benefit from development and globalization. The fact that many Nigerian women are still illiterates has negative implications for maternal mortality because lack of education limits the extent to which women can help themselves including fighting for their own lives. Women deprived of education and decision-making power face serious constraints in rearing healthy productive children. They also tend to have more children than they wish compounding the pressures on themselves and their families. Better-educated women are able to communicate better with their spouses about family decisions, use contraceptive more effectively and have higher aspirations for their children (World Bank, 2000).
The relationship between literacy on maternal mortality is both direct and indirect through availability of reproductive health care facilities. Literate women are less likely to experience poverty (Grosse & Auffrey, 1989; Sandiford, Cassel, Montenegro & Sanchez, 1995), more likely to maintain adequate nutritional status (Pinto, Scheer, Tuqa, Ebrahim, Abel, & Mukherjee, 1985; Haddad, 1999) and make decisions with respect to health and well-being (Thaddeus & Maine,1994; McTavish, Moore, Harper, & Lynch, 2010), access and use information (LeVine, LeVine, & Schnell, 2001; Vavrus, 2006), and have fewer children (Nwakeze, 2007). These gains resulting from improvements in female literacy reduce maternal morbidity and maternal mortality. As female literacy levels increase, maternal mortality levels are expected to decrease. In addition, positive growth in female literacy rates over time is expected to be associated with decreases in maternal mortality growth rates.
The relationship between women's education and maternal mortality is relatively well established. Using data from 11 demographic and health surveys, Graham and colleagues showed a strong association between maternal education and maternal mortality (Graham, Fitzmaurice, Bell ; Cairns, 2014).
A cross-country analysis conducted by Shen and Williamson (2009) also showed that women's level of education relative to men's education was a strong predictor of maternal mortality level, together with two other women's status variables (age at first marriage and reproductive autonomy). Interestingly, others have also shown that while maternal education was not associated with an increased risk of maternal death, a higher level of education in men was protective against maternal mortality (Ganatra, Goyaji & Rao, 2008). These studies highlight the importance of women's educational status in safe motherhood.
Kateja (2007) demonstrates an inverse relationship between female literacy and maternal mortality, which means that as female literacy increases, maternal mortality decreases. The assumption behind this correlation is that when a woman is educated and literate, she has more control of her life. Not only will she be better informed about her health, she will be more likely to utilize healthcare services available, she will be more confident in asking questions, and thus more capable of making important health decisions in her life (Kateja. 2007). This theory is supported by Wolfe and Behrman (2014) presents the fact that a woman's education has a direct and positive impact on her healthcare utilization. In essence, this viewpoint suggests that an educated and literate woman will be better informed about her health which will lead to greater healthcare utilization which will decrease the chances of her death from maternal mortality. Although there are those who believe literacy does not affect how people utilize healthcare services, the majority of maternal health literature supports the idea that literate mothers have more information and knowledge that helps them make better healthcare decisions.
2.2.6Abortion and Maternal Mortality
According to the World Health Organization (2013), every 8 minutes a woman in a developing nation will die of complications arising from an unsafe abortion. An unsafe abortion is defined as "a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both. WHO deems unsafe abortion one of the easiest preventable causes of maternal mortality and a staggering public health issues.
A single induced abortion increases the risk of maternal death by 45 percent compared to women with no history of abortion (Coleman, Reardon, & Calhoun, 2012). In addition, each additional abortion is associated with an even higher death rate. According to them, women who had two abortions are 114 percent more likely to die during the period examined, and women who had three or more abortions had a 192 percent increased risk of death.
Elevated rates of death are also observed among women who experienced miscarriages, ectopic pregnancies or other natural losses. Women with a history of successful deliveries are the least likely to die during the 25 years examined. Women who had never been pregnant had the highest mortality rate. Among women with a history of multiple pregnancies, women with a history of both abortions and natural losses, but no live births, had the highest mortality rate (Reardon, Coleman, 2012).
Although sometimes it is necessary to deliver a baby early to save the life of a mother, resulting in the pre mature birth of a baby that may not survive, it is never necessary to deliberately kill a baby to save the life of a mother (Essig, 2010).
The world's largest abortion provider, International Planned Parenthood Federation (IPPF), recently acknowledged an alarming "surge" in maternal deaths in South Africa even though that country, since 1996, has had some of the most permissive abortion laws on the African continent.
On the other hand, Mauritius, which has some of the most restrictive abortion laws in Africa, has the lowest maternal mortality rate on the continent.
In contrast, Ethiopia, which liberalized abortion laws in response to pressure from the World Health Organization (WHO) and the UN, has a maternal death rate that is 48 times higher than in Mauritius. In South America, Chile (which protects the lives of the unborn in its constitution) has a maternal death rate that is 30 times lower than in Guyana where abortion has been allowed without restriction since 1995.
Nepal places no restriction on abortion procedures, but has the highest maternal mortality rate in Southeast Asia. Sri Lanka, whose maternal death rate is 14 times lower than that of Nepal, has some of the most restrictive abortion laws in the world (WHO, 2007).
Abortions carry serious health risks and can contribute to maternal mortality whether they are legal or not. About 17 percent of women undergoing "safe" (i.e., legal) abortion procedures in the U.S. experienced physical complications (such as abdominal bleeding or pelvic infection) after the abortion (Major, 2000). The percentage is likely higher when long-term physical effects are considered, not to mention psychological effects. According to United Families International (2007), some of the short- and long-term adverse effects include:
Accidental tearing of uterine artery, tearing of the cervix, or scarring of the uterine wall
Heavy bleeding, requiring blood transfusions
Abdominal cramping, nausea, vomiting, diarrhoea, and infection
Allergic reaction to drugs or anaesthesia, sometimes causing convulsions, or worse
Heart attack, embolisms (caused by blood clots or other foreign matter in blood vessels)
Perforation of the uterus and damage to other internal organs
Miscarriage of future pregnancies, infertility or sterility
Increased risk of subsequent tubal pregnancies
Death (it is estimated that 20 percent of maternal deaths are due to abortion).
2.2.7Drugs/Alcohol and Maternal Mortality
Substance abuse during pregnancy is more prevalent than commonly realized, with up to 25% of Nigeria using illicit drugs (Glantz ; Woods, 2001). In fact, substance abuse is more common among women of reproductive age than among the general population (Cyr ; Moulton, 2000). The average pregnant woman will take four or five drugs during her pregnancy, with 82% of pregnant women taking prescribed substances and 65% using non-prescription substances, including illicit drugs (Glantz ; Woods, 2001). Substance abuse during pregnancy is difficult to detect because the signs and symptoms of this behaviour are often subtle, self-reports of substance use may be misleading or infrequently elicited, physicians may fail to routinely screen for use, and substance abusing pregnant women may seek little or no prenatal care.
Drug dependence and alcohol use and misuse in pregnancy complicates the clinical management of an already vulnerable group of patients. Dependence increases the risk of poor maternal and perinatal outcomes including mortality (Benningfield, Arria, ; Kaltenbach, 2010; Benningfield, Dietrich, ; Jones, 2012; Shainker, Saia, ; Lee-Parritz, 2012). Women of reproductive age who use and abuse drugs, both prescription and illegal, are more likely to have a lower socioeconomic status, family instability, receive inadequate prenatal care, and suffer from alcohol, tobacco, and illicit drug use (Winklbaur, Kopf, Ebner, Jung, Thau, ; Fischer, 2008; Heberlein, Leggio, Stichtenoth, ; Hillemacher, 2012). In addition to the risks associated with dependence, these comorbid conditions further increase the risk of adverse perinatal outcomes (Kaltenbach, Berghella, ; Finnegan, 1998; Armstrong, Kennedy, Kline, ; Tunstall, 1999).
Increasing at an alarming rate, drug dependence and alcohol use in pregnancy underwent an estimated 3-4-fold increase between 2000 and 2009 (Patrick, Schumacher, Benneyworth, Krans, McAllister, ; Davis, 2012; Salihu, Mogos, Salinas-Miranda, Salemi, ; Whiteman, 2014). The 2011 International Survey on Drug Use and Health reports found 5% of pregnant women 15 to 44 years of age report using illicit drugs (NSDUH, 2012). These data suggest an urgent need to evaluate, on an international level, the negative health outcomes and possible death associated with maternal alcohol use during pregnancy.
Maternal drug use during pregnancy is also associated with pregnancy-related maternal/foetal morbidity and mortality (Whiteman, Salemi, Mogos, Cain, Aliyu, ; Salihu, 2014). Even after adjusting for sociodemographic, behavioural, and chronic pre-pregnancy conditions, drug use is associated with increased odds of threatened preterm labour (Whiteman et al., 2014).
The use of illicit drugs and alcohol during pregnancy has been associated with both maternal and infant morbidity. Women who use illicit drugs during pregnancy have higher risks of placental abruption, premature rupture of membranes (Addis, Moretti, Syed, Einarson ; Koren, 2001), and polyhydramnios (Panting-Kemp, Nguyen ; Castro, 2002), and their infants have higher rates of prematurity and low birth weight (Armstrong, Lieberman ; Carpenter, 2001; Kelly, Russo ; Holt, 2002). These health outcomes, by themselves, have been associated with increased maternal mortality (Kayani, Walkinshaw ; Preston, 2003; Lee ; Silver, 2001; Kilbride ; Thibeault 2001).
2.3Empirical Review
Omo-Aghoja, Aisien, Akuse, Bergstrom and Okonofua (2010) conducted a study on maternal mortality and emergency obstetric care in Benin City, South-south Nigeria. Data for the study was obtained through a review of maternity records between January 1, 2005 and December 31, 2007, to determine current trends in the maternal mortality ratio. Data were analyzed with Epi-Info software, and univariate and bivariate tables were generated for assessment and comparisons. Statistical comparisons of rates and proportions were made with Chi-Square test, with Yates correction as appropriate. The results of the study revealed, among other things that, the causes of maternal mortality were lack of blood, oxygen and necessary equipment in the hospital. They recommended that hospitals should take steps to improve its emergency care facilities, increase the number of trained midwifery staff, and also improve its communication and transportation systems.
Ghebrehiwet, Sharan, Rogo, Gebreamlak, Haile, Gaim, Andemariam and Gebreselasie (2008) investigated the magnitude and causes of maternal deaths at health facilities in Eritrea. The study was a cross-sectional survey of all hospitals and all health centres that provide maternity service and a random sample of around a third of health stations in Eritrea (18 hospitals, 47 health centres and 53 health stations from the six Zobas). The data were collected from Medical records of all (6,315) patients who encountered obstetric complication from January 1 to December 31, 2007. Results of the study revealed that the main causes of obstetric complications among hospital admissions in 2007 were abortion complications (45.6%). They recommended that as abortion is very common problem and the prevailing abortion practice is unsafe, it is crucial to discourage unsafe abortion practices by promoting protection against unwanted pregnancy through prompting life skills to delay sex among adolescents and use appropriate and effective contraceptive when necessary.
Abe and Omo-Aghoja (2008) in a ten year retrospective study of maternal mortality at the central hospital in Benin City, Nigeria documented the number and pattern of obstetric deaths at the Central Hospital, Benin City, over a ten year period and identified common causes of maternal deaths. The leading direct causes of maternal deaths were sepsis, haemorrhage, obstructed labour and pre-eclampsia/eclampsia, while the major indirect causes are institutional difficulties and anaemia. The study also found that low literacy, high poverty levels, extremes of parity and non-utilization of maternity services were associated with maternal mortality. The overall maternal mortality ratio (MMR) was 518/100,000. MMR was 30 times higher in unbooked as compared to the booked patients, while 60% of maternal deaths occurred within 24 hours of admission.
Mojekwu and Ibekwe (2012) carried out a study titled Maternal Mortality in Nigeria: Examination of Intervention Methods. The study mainly used data extracted from the Annual Abstract of Statistics of the National Bureau of Statistics (NBS) 2009 and the Nigeria Demographic and Health Survey (NDHS) 2008. Data on xxx variables of interest from the 36 states of the Federation and the Federal Capital Territory, Abuja were extracted from these sources. Multiple regression analysis was used with the natural logarithm of the fourteen independent variables of interest regressed simultaneously on the natural log of the maternal mortality ratio. Stepwise regression model was applied for robustness and also for the purpose of selecting the most effective determinants of the level of maternal mortality. The model was checked to confirm that the underlying assumptions were met. The study indicates that one of the main factors affecting maternal mortality ratio, as determined by this study, is the availability of skilled professional birth attendants providing care during childbirth. A second important factor is the absence of formal education, especially education of women.
Whiteman, Salemi, Mogos, Cain, Aliyu, and Salihu (2014) conducted a study on maternal Opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. The study employed a cross-sectional analysis of pregnancy-related discharges from 1998 to 2009. Survey logistic regression was used to assess the association between maternal drug use and each outcome; generalized linear modelling was used to compare hospitalization costs by drug use status. Results of the study revealed that women who used drugs during pregnancy experienced higher rates of depression, anxiety, and chronic medical conditions. After adjusting for confounders, drug use was associated with increased odds of threatened preterm labour, early onset delivery, poor foetal growth, and stillbirth. Users were four times as likely to have a prolonged hospital stay and were almost four times more likely to die before discharge. They recommended that there is an urgent need to evaluate, on a national level, not only the negative health outcomes associated with maternal drug use during pregnancy, but also the related economic cost burden on the healthcare system.
2.4Summary of Literature Review
This chapter reviewed literature related to assessment of maternal mortality among women of child bearing age. The discussion was based on the following subheadings; conceptual framework which discussed the meaning and concepts of mortality, maternal mortality, effects of availability of medical facilities, poverty, illiteracy, abortion and drug/alcohol use on maternal mortality. Detailed empirical works of other renowned researchers was also reviewed in relation to maternal mortality among women of child bearing age.
The area under study is not covered by any of the related empirical studies reviewed hence the need to fill the gap.
This chapter explains the methods and approaches that will be adopted in the study. It describes research design, area of study, population of the study, sample and sampling, instrumentation, validation of instrument, method of data collection and method of data analysis.
3.2Research Design
The descriptive survey design will be adopted for the study. Descriptive research design deals with the collection of data for the purpose of describing, interpreting, evaluating and analyzing existing conditions and prevailing situations (Akem, 2007). Since this study aimed at assessing maternal mortality among women of child bearing age in Gwer-West LGA of Benue State, the descriptive survey research design was found to be appropriate because, it determines the nature of a situation as it exists at the time of the study.
3.3Area of Study
The study will be carried out in Gwer-West Local Government Area located at longitude 8°5?E and 8°3?E and latitude 7°48?N (Survey Development Naka, 2016). It is located south-west of Makurdi town running alongside the river Benue. It was created during the General Ibrahim Babangida's administration on the 23rd September, 1991.
Gwer-West Local Government has a landmass of about 456,45km2 with a population of 73,396 (NPC, 2006). It is made up of fifteen (15) council wards. The local government shares boundaries in the north with Doma Local Government Area of Nassarawa State, in the south with Otukpo, in the west with Apa and Agatu Local Government Areas.
The inhabitants of the area are mainly Tiv speaking people (Tyoshin) but of course some tribes like Hausa, Idoma, Yoruba and Igala settle there on a temporary basis for one reason or the other. The main occupation of the people in the area is farming, though others are civil servants, traders, tailors and so on. Animal husbandry is also practiced in some parts of the area. There are a lot of primary, secondary and tertiary schools which every child of school age enrolled for learning to be harnessed in order to obtain knowledge.
There are huge disparities in the provision of healthcare in urban and rural communities in Nigeria and Benue State in particular. The effects of this are felt mostly by pregnant women living in rural areas. Coupled with other social inequalities like level of education, poverty, and so on, most situations that result in maternal mortality are sometimes preventable, yet there seems to be a high mortality rate in Gwer-West Local Government Area of Benue State. This situation pricked the researcher's curiosity to assess maternal mortality among women of child bearing age in the study area.
3.4Population of the Study
The population of the study consist of all the healthcare practitioners in private and public hospitals in Gwer-West Local Government Area. There are about 1015 healthcare practitioners in the six hospitals in Gwer-West Local Government Area (Ministry of Health, 2016).
3.5Sample and Sampling
Simple Random Sampling technique will be used to select 123 participants for the study. The sample will include obstetricians as well as other medical doctors and nurses. The researcher will select participants based on proportion from each hospital. The participants will then be randomly issued with questionnaires until the number specified for each hospital will be attained. In order to select participants, the formula propounded by Taro Yamene (1967) was used (See Appendix C).
3.6Instrumentation
The questionnaire will be used to collect data from respondents. The questionnaire will be a four point likert type rated as Strongly Agree (SA) = 4, Agree (A) = 3, Disagree (D) = 2 and Strongly Disagree (SD) = 1. The questionnaire will be divided into two sections. Section A will collect demographic information of the respondents while sections B will elicit information required to answer the research questions.
3.7Validation of Instrument
A face and content validation will be carried out by two experts, one senior lecturer from the Department of Human Kinetics and Health Education, Faculty of Education, Benue State University, and another senior lecturer from the Department of Vocational and Technical Education, Faculty of Education for necessary corrections and expert comments. The instrument will then be presented to the supervisor who will further criticize and correct the instrument after which the items structured in the questionnaire will be certified reliable.
3.8Method of Data Collection
Data collection in this study will mainly involve the use of questionnaires administered to the respondents selected to participate in the study. Hand delivery method will be used to administer the questionnaire on respondents. The researcher will be assisted by a research assistant trained to aid in the collection of data. The respondents will be issued with questionnaires and waited upon to fill and return the completed copies to the researcher or his assistant. This will be done in order to avoid the cost of travelling to retrieve the questionnaire on a later date.
3.9Method of Data Analysis
Both descriptive and inferential statistics will be used to analyse the data collected in the study. The descriptive statistics of percentages and mean scores will be used to answer the research questions while chi-square will be used to test the hypotheses at 0.05 level of significance. The Statistical Package for Social Sciences (SPSS) will be used to analyse the data collected.
DATA PRESENTATION, ANALYSIS, INTERPRETATION AND DISCUSSION OF FINDINGS
This chapter dealt with the data presentation, analysis, interpretation and discussion of findings. The data collected were subjected to descriptive and statistical analysis of mean, standard deviation to answer research questions and chi-square to test the hypotheses. The findings are presented as shown below:
4.2Data Presentation, Analysis and Interpretation
A total of 123 questionnaires were distributed to participants. On retrieval, 3 copies of the questionnaire were not answered, only 120 out of the 123 questionnaires distributed were valid for analysis making a response rate of 97.5%. This section presents the analysis of data collected in the study. It covers the analysis of demographic characteristics of respondents and analysis of research questions.
4.2.1Analysis of Demographic Characteristics of Respondents
Table 1: Demographic Characteristics of Respondents
Variable Frequency (N=120) Percentage (%)
Age 18 – 24 17 14.2
25 – 29 23 19.2
40 and above 26 21.7
Sex Male 52 43.3
Female 68 56.7
Rank Mid Wife 43 35.8
Nurse 61 50.8
Medical Doctor 16 13.3
Working Experience 1 – 5 yrs 22 18.3
6 – 10 yrs 25 20.8
11 – 15 yrs34 28.3
21 yrs and above 16 13.3
Table 1 above presents data on demographic characteristics of respondents. Based on the data collected, 17(14.2%) of the respondents fall within the age range of 18 – 24 years, 23 (19.2%) respondents fall within the age range of 25 29 years, 31 (25.8%) respondents fall within the age range of 30 – 24 years, 23 (19.2%) respondents fall within the age range of 35 – 39 while 26 (21.7%) respondents were 40 years and above. Data collected indicate that 43 (35.8%) respondents were males while 68 (56.75) respondents were female.
Based on rank, 43 (35.8%) respondents were mid wives, 61 (50.8%) were nurses while 16 (13.3%) respondents were medical doctors. Results available in Table 1 also indicate that 22 (18.3%) respondents had worked for a period of 1 – 5 years, 25 (20.8%) respondents had worked for 6 – 10 years, 34 (28.3%) respondents had worked for 11 – 15 years, 23 (19.2%) respondents had worked for 16 – 20 years while 16 (13.3%) respondents had worked for 21 years or more.
4.2.2Analysis of Research Questions
Table 2: Mean and Standard Deviation Distribution on the Variables
Item xSTD Decision
Effect of lack of medical facilities on maternal mortality 2.98 0.87 Accepted
Effect of poverty on maternal mortality 2.94 0.94 Accepted
Effect of illiteracy on maternal mortality 2.86 0.85 Accepted
Effect of abortion on maternal mortality 3.06 0.87 Accepted
Effect of alcohol/drug misuse on maternal mortality 3.00 1.40 Accepted
Table 2 above presents mean and standard deviation on the effect of lack of medical facilities, poverty, illiteracy, abortion and alcohol/drug misuse on maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State. The table answered all the research questions. Results available showed that lack of medical facilities has a mean score of 2.98 and standard deviation of 0.87. Since the mean is above the cut-off point of 2.50, it therefore implies that lack of medical facilities affects maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
The results available indicate that poverty has a mean score of 2.94 and standard deviation of 0.94. Since the mean score is greater than the cut-off point of 2.50, it therefore implies that poverty affects maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Results available in Table 2 also indicate that illiteracy has a mean score of 2.86 and a standard deviation of 0.85. Since the mean score is greater than the cut-off mean of 2.05, it then implies that illiteracy affects maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Table 2 also shows that abortion has a mean score of 3.06 and a standard deviation of 0.87. Since the mean is higher than the cut-off point of 2.05, it implies that abortion significantly affects maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Concerning the research question on alcohol and drug misuse, results available indicates that it has a mean score of 3.00 and standard deviation of 1.40. since the mean is greater than the cut-off point of 2.50, it therefore implies that alcohol/drug misuse by pregnant women affects maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
4.2.3Testing of Hypotheses
Hypothesis 1: Lack of medical facilities will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area. This hypothesis was tested using chi-square at 0.05 level of significance and the results are presented in the table below.
Table 3:Summary of Chi-Square (?2) Analysis on effect of Lack of Medical Facilities on Maternal Mortality
Responses Frequency Observed Frequency Expected ?cal2?tab2df? P
SA 29 30 A 65 30 D 22 30 65.53 7.82 3 0.05 0.00
SD 4 30 Total 120 120 ?cal2 = 65.53 df=3 P;.05
Table 3 presents the summary of chi-square analysis on the effect of lack of medical facilities on maternal mortality among women of child bearing age in Gwer-West Local Government Area. From the result of the analysis, since the calculated value of ?cal2 65.53 is greater the critical value of ?tab2 7.82, the null hypothesis which states that lack of medical facilities will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area is rejected and the alternate hypothesis accepted. This implies that lack of medical facilities will significantly affect maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Hypothesis 2: Poverty will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area. This hypothesis was tested using chi-square at 0.05 level of significance and the results are presented in the table below.
Table 4:Summary of Chi-Square (?2) Analysis on effect of Poverty on Maternal Mortality
Responses Frequency Observed Frequency
Expected ?cal2?tab2df? P
SA 53 30 A 47 30 D 9 30 54.00 7.82 3 0.05 0.00
SD 11 30 Total 120 120 ?cal2 = 54.00 df=3 P;.05
Table 4 presents the summary of chi-square analysis on the effect of poverty on maternal mortality among women of child bearing age in Gwer-West Local Government Area. From the result of the analysis, since the calculated value of ?cal2 54.00 is greater the critical value of ?tab2 7.82, the null hypothesis which states that poverty will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area is rejected and the alternate hypothesis accepted. This implies that poverty will significantly affect maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Hypothesis 3: Illiteracy will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area. This hypothesis was tested using chi-square at 0.05 level of significance and the results are presented in the table below.
Table 5:Summary of Chi-Square (?2) Analysis on effect of Illiteracy on Maternal Mortality
Table 5 presents the summary of chi-square analysis on the effect of illiteracy on maternal mortality among women of child bearing age in Gwer-West Local Government Area. From the result of the analysis, since the calculated value of ?cal2 56.47 is greater the critical value of ?tab2 7.82, the null hypothesis which states that illiteracy will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area is rejected and the alternate hypothesis accepted. This implies that illiteracy will significantly affect maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Hypothesis 4: Abortion will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area. This hypothesis was tested using chi-square at 0.05 level of significance and the results are presented in the table below.
Table 6:Summary of Chi-Square (?2) Analysis on effect of Abortion on Maternal Mortality
Table 6 presents the summary of chi-square analysis on the effect of abortion on maternal mortality among women of child bearing age in Gwer-West Local Government Area. From the result of the analysis, since the calculated value of ?cal2 54.00 is greater the critical value of ?tab2 7.82, the null hypothesis which states that abortion will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area is rejected and the alternate hypothesis accepted. This implies that abortion will significantly affect maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
Hypothesis 5: Alcohol/Drug misuse will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area. This hypothesis was tested using chi-square at 0.05 level of significance and the results are presented in the table below.
Table 7:Summary of Chi-Square (?2) Analysis on effect of Alcohol/Drug misuse on Maternal Mortality
Table 7 presents the summary of chi-square analysis on the effect of alcohol/drug misuse on maternal mortality among women of child bearing age in Gwer-West Local Government Area. From the result of the analysis, since the calculated value of ?cal2 74.07 is greater the critical value of ?tab2 7.82, the null hypothesis which states that alcohol/drug misuse will not significantly influence maternal mortality among women of child bearing age in Gwer-West Local Government Area is rejected and the alternate hypothesis accepted. This implies that alcohol/drug misuse will significantly affect maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State.
4.3Discussion of Findings
This section presents the discussion of findings made in the study based on the data collected. The results of the study revealed that lack of medical facilities will significantly affect maternal mortality among women of child bearing age in the study area. ?cal2= 65.53, df = 3, p;0.05. This implies that lack of medical facilities will significantly affect maternal mortality in the study area. This finding is in congruence with that of Omo-Aghoja, Aisien, Akuse, Bergstrom and Okonofua (2010) who carried out a study on maternal mortality and emergency obstetric care in Benin City, South-south Nigeria. The results of their study revealed, among other things that, the causes of maternal mortality were lack of blood, oxygen and necessary equipment in the hospital. Mojekwu and Ibekwe (2012) also found out that one of the main factors affecting maternal mortality ratio is the unavailability of skilled professional birth attendants providing care during childbirth. As with any medical emergency, the chances of survival in the event of an obstetric emergency are directly related to the effectiveness of initial triage – action taken at the time of onset or as close to it as possible. Unfortunately, due to the heavy reliance on primary care since the mid to late 1970s, very little attention has been given in many resource-poor states in addressing the need to build adequate and appropriate emergency response systems, including referral systems and facilities that can deal with all types of medical emergencies, especially obstetric emergencies. A skilled attendant would however be able to provide appropriate triage, and thus help minimize delays in receiving appropriate treatment, as well as institute timely action at all points of the potential delay chain, but without adequate facilities, there would be little s/he can achieve.
The results of the study also revealed that poverty will significantly affect maternal mortality among women of child bearing age in the study area ?cal2= 54.00, df = 3, p;0.05. This implies that the poor in the society may die from childbirth or its complications because they have no money to seek antenatal care or afford quality obstetric care. This finding is in agreement with that of Abe and Omo-Aghoja (2008) who carried out a retrospective study of maternal mortality at the central hospital in Benin City, Nigeria and found out that high poverty levels, extremes of parity amongst other things, were associated with maternal mortality. Poverty affects maternal mortality in various ways. For example, poverty causes malnutrition which increases vulnerability to serious and chronic illness, mental retardation and early death, poverty is often associated with limited access to necessary antenatal medical care as well as appropriate medical resources during and after delivery which increases the chances of maternal mortality, it increases lack of access to family planning and reproductive health services which may result in high overall fertility, and young age at first birth which in turn increases the reproductive risks to mothers and their offspring. There is no doubt that poverty in the region contributes to the significant disparities that exist in maternal mortality between rural and the urban cities in Benue State.
The findings of the study reveal that illiteracy significantly affects maternal mortality among women of child bearing age in the study area ?cal2= 56.47, df = 3, p;0.05. This implies that illiteracy will affect health seeking behaviour of pregnant women. This finding agrees with that of Mojekwu and Ibekwe (2012) who carried out a study titled Maternal Mortality in Nigeria. Their findings revealed that an important factor that determines maternal mortality is the absence of formal education, especially education of women. Abe and Omo-Aghoja (2008) in a ten year retrospective study of maternal mortality at the central hospital in Benin City also found that low literacy, amongst other factors was associated with maternal mortality. When a woman is educated and literate, she has more control of her life. Not only will she be better informed about her health, she will be more likely to utilize healthcare services available, she will be more confident in asking questions, and thus more capable of making important health decisions in her life. An educated and literate woman will be better informed about her health which will lead to greater healthcare utilization which will decrease the chances of her death from maternal mortality.
The findings of the study also reveal that abortion significantly affects maternal mortality among women of child bearing age in the study area ?cal2= 54.00, df = 3, p;0.05. This means that abortion of unwanted pregnancies, safe abortion of complicated pregnancies pose a great risk to women's health and maternal mortality. This finding is in congruence with that of Ghebrehiwet, Sharan, Rogo, Gebreamlak, Haile, Gaim, Andemariam and Gebreselasie (2008) who investigated the magnitude and causes of maternal deaths at health facilities in Eritrea. Results of the study revealed that the main causes of obstetric complications leading to death among hospital admissions in 2007 were abortion complications (45.6%). Abortions carry serious health risks and can contribute to maternal mortality whether they are legal or not. The adverse effects include: accidental tearing of uterine artery, tearing of the cervix, or scarring of the uterine wall, heavy bleeding, requiring blood transfusions, perforation of the uterus and damage to other internal organs, and death.
Finally, findings of the study reveal that alcohol/drug misuse by pregnant women significantly affects maternal mortality ?cal2= 74.07, df = 3, p<0.05. This implies that women who misuse alcohol and drugs during pregnancy are at a higher risk of death than non-users. This finding is in line with that of Whiteman, Salemi, Mogos, Cain, Aliyu, and Salihu (2014) who found that women who used drugs during pregnancy experienced higher rates of depression, anxiety, and chronic medical conditions. After adjusting for confounders, drug use was associated with increased odds of threatened preterm labour, early onset delivery, poor foetal growth, and stillbirth. Users were four times as likely to have a prolonged hospital stay and were almost four times more likely to die before discharge. Substance abuse during pregnancy is more prevalent than commonly realized, among women of reproductive age than among the general population. Drug dependence and alcohol use and misuse in pregnancy complicates the clinical management of an already vulnerable group of patients. Dependence increases the risk of poor maternal and perinatal outcomes including mortality. The use of illicit drugs and alcohol during pregnancy has been associated with both maternal and infant morbidity. Women who use illicit drugs during pregnancy have higher risks of placental abruption, premature rupture of membranes and their infants have higher rates of prematurity and low birth weight. These health outcomes, by themselves, have been associated with increased maternal mortality.
SUMMARY, CONCLUSION, RECOMMENDATIONS AND SUGGESTIONS FOR FURTHER STUDIES
This chapter presents the summary of findings, conclusions, recommendations and suggestions for further studies.
5.2Summary
This study assessed maternal mortality among women of child bearing age in Gwer-West Local Government Area of Benue State. Five objectives and five hypotheses were postulated in the study.
The study included an extensive review of concepts, related literature and empirical studies by other renowned researchers on this topic. A descriptive survey design was adopted for the study which involves the use of questionnaires to collect information from respondents. The study involved a total of one hundred and twenty participants. Descriptive statistics – frequency counts and mean scores – were employed to answer the research questions while Chi-square was used to test the hypotheses at 0.05 level of significance.
5.3Conclusion
Maternal mortality in Gwer-West has remained high and the trend is rising. The main direct causes of maternal mortality as identified by the study are lack of medical facilities, poverty, illiteracy, abortion and alcohol and drug misuse by pregnant women.
From the results obtained, it is concluded that;
Lack of medical facilities will significantly affect maternal mortality among women of child bearing age in the study area.
Poverty will significantly affect maternal mortality among women of child bearing age in the study area
Illiteracy significantly affects maternal mortality among women of child bearing age in the study area
Abortion significantly affects maternal mortality among women of child bearing age in the study area
5. Alcohol/drug misuse by pregnant women significantly affects maternal mortality among women of child bearing age in the study area.
5.4Recommendations
The following recommendations are made based on the findings of the study.
Poverty eradication policies that sincerely focus on the general populace will help alleviate the plight of reproductive mothers.
Abortion is a very common problem and the prevailing abortion practice is unsafe, it is crucial to discourage unsafe abortion practices by promoting protection against unwanted pregnancy through prompting life skills to delay sex among adolescents and use appropriate and effective contraceptive when necessary.
Government's intervention on highlighting the negative consequences of abortion by enforcing existing laws on abortion will go a long way in saving the lives of women.
Funds should be made available by the appropriate authorities for the acquisition of relevant medical equipment to be used in hospitals during childbirth or obstetric emergencies. Hospitals should take steps to improve its emergency care facilities, increase the number of trained midwifery staff, and also improve its communication and transportation systems.
There is an urgent need to evaluate, on a national level, not only the negative health outcomes associated with maternal drug use during pregnancy, but also the related economic cost burden on the healthcare system.
5.6Suggestions for Further Study
Similar studies should be carried out by interested researchers on other causes of maternal mortality in the study area such as medical and cultural factors affecting maternal mortality in the study area.
Similar research should also be carried out in other local governments of the state and other states of the country to warrant a more valid generalisation of findings.
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LETTER OF INTRODUCTION
Department of Human Kinetics,
Faculty of Education,
Benue State University,
Makurdi.
Dear Respondent,
I am an undergraduate student of the above named department carrying out a study on the topic, assessment of maternal mortality among women of child bearing age in Gwer-West Local Government Area.
As a medical practitioner, I am confident that you will provide the information needed in the study. I hereby solicit your maximum cooperation in answering the questions to the best of your knowledge.
Be rest assured that the information you provide will be used strictly for academic purposes and will be treated with utmost confidentiality.
Ogenyi, Innocent OchogaAPPENDIX B
MATERNAL MORTALITY QUESTIONNAIRE
Instructions: Please in each of the questions provided, tick the appropriate option that best suites you.
SECTION A: Demographic Information
Age:18 – 24 25 – 29 30 34 35 – 39 40 and above
Sex:Male Female
Rank: JCHEW CHEW CHS Lab Technician Nurse Medical Doctor
Years of work Experience: 1 – 5yrs 6 – 10yrs 11 – 15yrs 16 – 20yrs 21yrs and above
SECTION B:
S/N Item SA A D SD
Availability of Medical Facilities and Maternal Mortality 1 Lack of health facilities negatively affect maternal mortality 2 The majority of maternal deaths are due to a lack of basic health care 3 In most cases, women die because there are no facilities to handle the complications 4 Women often die from excessive loss of blood because there was no blood in the blood bank 5 Many women die from complications during child birth as a result of chronic shortages of essential drugs from the hospital
Poverty and Maternal Mortality 6 poverty is often associated with limited access to necessary antenatal medical care as well as appropriate medical resources during and after delivery which increases the chances of maternal mortality 7 Poor–rich differences where the rich are more fully covered by maternal health services than the poor makes poor women die from preventable maternal complications 8 Poverty causes malnutrition which increases vulnerability to serious and chronic illness, mental retardation and early death 9 It increases the risk of infection, particularly among women of reproductive age increasing the chances of maternal death 10 Lack of access to family planning and reproductive health services may result in high overall fertility, and young age at first birth which increases the reproductive risks to mothers and their offspring Illiteracy and Maternal Mortality SA A D SD
11 Lack of education limits the extent to which women can help themselves including fighting for their own lives 12 Uneducated women often prefer to explore traditional methods of child delivery which cannot handle complications and results in maternal death 13 Illiterate women most often fail to attend antenatal care when pregnant and this increases the chances of complications 14 Uneducated women often lack the basic obstetric knowledge concerning child birth and hence, may not know how to take care of a pregnancy Abortion and Maternal Mortality SA A D SD
15 Most maternal deaths are caused by illegal abortions 16 Abortions (whether legal or not) carry serious health risks and contribute to maternal mortality 17 Accidental tearing of uterine artery, tearing of the cervix, or scarring of the uterine wall pose great risk of maternal mortality during abortion 18 Heavy bleeding, requiring blood transfusions as a result of abortion often result in death
Drug and Alcohol Abuse and Maternal Mortality 19 Alcohol and drug use during pregnancy pose threat to the live of the woman 20 Drug and alcohol use during pregnancy affects the health of the baby and this may result in stillbirth 21 Addicted mothers often do not take good care of themselves while pregnant and this may increase the chances of maternal death 22 If there s a complication, management of complications in drug and alcohol abusive mothers is more difficult
DETERMINATION OF SAMPLE SIZE
n= N1+Ne2Where n = sample size
N = total population of the study area
e = margin or error which research is ready to allow
the total population of caregivers in Makurdi metropolis = N = 1,015 (NPC, 2006).
Error allowed = 0.09
n= 1,015 1+1,015 0.092n = 110.07 = 110
FREQUENCY, MEAN AND STANDARD DEVIATION OF RESEARCH QUESTIONS
Research Question 1: Lack of Health Facilities and Maternal Mortality
Item SA A D SD xSTD
Lack of health facilities negatively affect maternal mortality 29 65 22 4 2.99 0.75
The majority of maternal deaths are due to a lack of basic health care 34 47 29 10 2.88 0.92
In most cases, women die because there are no facilities to handle the complications 39 60 10 11 3.06 0.88
Women often die from excessive loss of blood because there was no blood in the blood bank 35 47 26 12 2.88 0.95
Many women die from complications during child birth as a result of chronic shortages of essential drugs from the hospital 39 62 8 11 3.08 0.87
Cluster Mean 2.98 Research Question 2: Lack of Health Facilities and Maternal Mortality
poverty is often associated with limited access to necessary antenatal medical care as well as appropriate medical resources during and after delivery which increases the chances of maternal mortality 53 47 9 11 3.18 0.93
Poor–rich differences where the rich are more fully covered by maternal health services than the poor makes poor women die from preventable maternal complications 57 43 9 11 3.22 0.94
Poverty causes malnutrition which increases vulnerability to serious and chronic illness, mental retardation and early death 35 65 9 11 3.03 0.86
It increases the risk of infection, particularly among women of reproductive age increasing the chances of maternal death 15 43 51 11 2.52 0.83
Lack of access to family planning and reproductive health services may result in high overall fertility, and young age at first birth which increases the reproductive risks to mothers and their offspring 35 47 9 29 2.73 1.13
Cluster Mean 2.94 Research Question 2: Illiteracy and Maternal Mortality
Lack of education limits the extent to which women can help themselves including fighting for their own lives 15 46 47 12 2.53 0.84
Uneducated women often prefer to explore traditional methods of child delivery which cannot handle complications and results in maternal death 15 62 32 11 2.68 0.81
Illiterate women most often fail to attend antenatal care when pregnant and this increases the chances of complications 53 48 9 10 3.20 0.90
Uneducated women often lack the basic obstetric knowledge concerning child birth and hence, may not know how to take care of a pregnancy 33 68 8 11 3.30 0.85
Cluster Mean 2.93 0.85
Research Question 2: Abortion and Maternal Mortality
Most maternal deaths are caused by illegal abortions 48 38 29 5 3.08 0.90
Abortions (whether legal or not) carry serious health risks and contribute to maternal mortality 39 60 10 11 3.06 0.88
Accidental tearing of uterine artery, tearing of the cervix, or scarring of the uterine wall pose great risk of maternal mortality during abortion 35 47 26 12 2.88 0.95
Heavy bleeding, requiring blood transfusions as a result of abortion often result in death 44 66 4 6 2.23 0.74
Research Question 2: Alcohol/Drug Misuse by pregnant women and Maternal Mortality
Alcohol and drug use during pregnancy pose threat to the live of the woman 60 46 9 5 3.34 0.79
Drug and alcohol use during pregnancy affects the health of the baby and this may result in stillbirth 57 43 9 11 3.22 0.94
Addicted mothers often do not take good care of themselves while pregnant and this may increase the chances of maternal death 34 39 21 26 2.68 1.11
If there s a complication, management of complications in drug and alcohol abusive mothers is more difficult 20 59 33 8 2.76 0.81
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