CHAPTER ONE INTRODUCTION 1

CHAPTER ONE
INTRODUCTION
1.1Background to the Study
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.

1.2Statement of the Problem
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.

CHAPTER TWO
LITERATURE REVIEW
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.
2.2Conceptual Framework
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.

CHAPTER THREE
RESEARCH METHODOLOGY
3.1Introduction
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.

CHAPTER FOUR
DATA PRESENTATION, ANALYSIS, INTERPRETATION AND DISCUSSION OF FINDINGS
4.1Introduction
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
30 – 34 31 25.8
35 – 39 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
16 – 20 yrs23 19.2
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
Responses Frequency Observed Frequency
Expected ?cal2?tab2df? P
SA 53 30 A 47 30 D 9 30 56.47 7.82 3 0.05 0.00
SD 11 30 Total 120 120 ?cal2 = 56.47 df=3 P;.05
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
Responses Frequency Observed Frequency
Expected ?cal2?tab2df? P
SA 48 30 A 38 30 D 29 30 33.80 7.82 3 0.05 0.00
SD 5 30 Total 120 120 ?cal2 = 33.80 df=3 P;.05
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
Responses Frequency Observed Frequency
Expected ?cal2?tab2df? P
SA 60 30 A 46 30 D 9 30 74.07 7.82 3 0.05 0.00
SD 5 30 Total 120 120 ?cal2 = 74.07 df=3 P;.05
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.

CHAPTER FIVE
SUMMARY, CONCLUSION, RECOMMENDATIONS AND SUGGESTIONS FOR FURTHER STUDIES
5.1Introduction
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.

References
Abe, E. ; Omo-Aghoja, L. O. (2008). Maternal mortality at the Central Hospital, Benin City, Nigeria: A ten year review. African Journal of Reproductive Health, 12(3), 17-26.

Abimbola, S., Okoli, U., Olubajo, O., Abdullahi, M. J. ; Pate, M. A. (2012). The midwives service scheme in Nigeria. PLOS Medicine, 9(5), e1001211.

Addis, A., Moretti, M., Syed, F., Einarson, T. ; Koren, G. (2001). Foetal effects of cocaine: An updated meta-analysis. Reproductive Toxicology, 15, 341–69.

Adegoke, A. A., Lawoyin, T. O., Ogundeyo, M. O. ; Thomson A. M. (2007). A community based investigation of the avoidable factors in maternal mortality in Nigeria: the pilot experience. African Health Science, 7(3), 176-181.

Armstrong, K. A., Kennedy, M. G., Kline, A. ; Tunstall, C. (1999). Reproductive health needs: Comparing women at high, drug-related risk of HIV with a national sample. Journal of the American Medical Women’s Association, 54(2), 65–78.

Armstrong, M., Lieberman, L. & Carpenter, D. (2001). Early start: an obstetric clinic-based, perinatal substance abuse intervention program. Qual Manag Health Care, 9(2), 6–15.
Benningfield, M. M., Arria, A. M. & Kaltenbach, K. (2010). Co-occurring psychiatric symptoms are associated with increased psychological, social, and medical impairment in opioid dependent pregnant women. The American Journal on Addictions, 19(5), 416–421.

Benningfield, M. M., Dietrich, M. S. & Jones H. E. (2012). Opioid dependence during pregnancy: relationships of anxiety and depression symptoms to treatment outcomes. Addiction, 107(Supplement 1), 74–82.
Campbell. O. M. R. & Graham, W. (2011). Measuring maternal mortality and morbidity: Levels and trends. London: London School of Tropical Medicine and Hygiene. Maternal and Child Epidemiology Unit Publication No. 2.

Chambers, R. (2011). The Best of Both Worlds. Paper prepared for the Workshop on Qualitative and Quantitative Poverty Appraisal held at Cornell University, March 15-16, 2001.

Coleman, F. S. & Kay, J. (2012). Substance abuse in pregnancy: Biology of addiction. Obstetric Gynaecology Clinic North America, 25(1).

Conde-Agudelo, A. & Belizan, J. M. (2004). Maternal morbidity and mortality associated with interpregnancy interval: A cross sectional study. BMJ, 321, 1255–1259.

Cyr, M. G. & Moulton, A. W. (2000). Substance abuse in women. Obstetrics Gynaecology Clinic of North America, 17, 905.

De Brouwere, V. & Van Lerberghe, W. (2008). Les besoins obstetricaux non-couverts. Paris: L’Harmattan.

Essig, A. M. (2010). The World Health Organization’s abortion agenda. IORG White Paper No. 11.
Family Care International (2005). Millennium Development Goals and sexual and reproductive health. New York: Briefing Cards.

Fawcus, S. R., Van Coeverden de Groot, H. A. & Isaacs, S. (2012). A 50-year audit of maternal mortality in the Peninsula Maternal and Neonatal Service, Cape Town (1963–2012). British Journal of Obstetrics and Gynaecology, 112, 1257–2022.

Federal Office of Statistics (1997). Population census of Nigeria. Abuja, Nigeria: Government of the Federal Republic of Nigeria.

Federal Republic of Nigeria (2010a). MDG report 2010: Nigeria Millennium Development Goals. Abuja, Nigeria: Government of the Federal Republic of Nigeria.

Federal Republic of Nigeria (2010b). Countdown strategy 2010 to 2015, Millennium Development Goals (MDGs). Abuja, Nigeria: Government of the Federal Republic of Nigeria.

Ganatra, B. R., Coyaji, K. J. & Rao, V. N. (2008). Too far, too little, too late: A community-based case–control study of maternal mortality in rural west Maharashtra, India. Bull World Health Organ, 76(6), 591–598.

GBD (2013). Mortality and causes of death, collaborators (17 December 2014). Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, 385, 117–71.
Ghebrehiwet, M. et al. (2008). Determinants of Maternal Mortality in Eritrea. Journal of Eritrean Medical Association (JEMA), 3(1).

Glantz. J. C. & Woods, J. R. (2001). Obstetrical issues in substance abuse. Paediatrics Ann, 20, 531.

Graham, W. J., Fitzmaurice, A. E., Bell, J. S. & Cairns, J. A. (2014). The familial technique for linking maternal death with poverty. Lancet, 363, 23–27.

Greenwood, M. (2014) Medical statistics from Graunt to Farr: The Fitzpatrick Lectures for the Years 1941 and 1943. Cambridge: Cambridge University Press. A review.

Grosse, R. N. & Auffrey, C. (1989). Literacy and health status in developing countries. Annual Review of Public Health, 10, 281–297.

Gwatkin, D. R., Bhuiya, A. & Victora, C. G. (2012). Making health systems more equitable. Lancet, 364, 1273–1280.

Haddad, L. (1999). Women’s status: levels, determinants, consequences for malnutrition, interventions, and policy. Asian Development Review, 17(1-2), 96–131.

Harrison, K. A. (1997). Maternal mortality in Nigeria: The real issues. African Journal of Reproductive health, 1(1), 2-13.

Heberlein, A., Leggio, L., Stichtenoth, D. ; Hillemacher, T. (2012). The treatment of alcohol and opioid dependence in pregnant women. Current Opinion in Psychiatry, 25(6), 559–564.

Hogan, M. C., Foreman, K. J., Naghavi, M., Ahn, S. Y., Wang, M., Makela, S. M., Lopez, A. D., Lozano, R. ; Murray, C. (2010). Maternal mortality for 181 countries, 1980–2008: A systematic analysis of progress towards Millennium Development Goal 5. Lancet, 375, 1609–1623.
Hoj, L., da Silva, D. ; Hedegaard, K. (2003). Maternal mortality: Only 42 days? BJOG, 110(11), 995-1000.

Jha, P. (2002). Avoidable mortality in India: Past progress and future prospects. The National Medical Journal of India, 15(Suppl 1), 32–6.

Kaltenbach, K., Berghella, V. ; Finnegan, L. (1998). Opioid dependence during pregnancy: Effects and management. Obstetrics and Gynaecology Clinics of North America, 25(1), 139–151.

Kateja, A. (2007). Role of Female Literacy in Maternal and Infant Mortality Decline. Social Change, 37, 29-39.

Kayani, S., Walkinshaw, S. ; Preston, C. (2003). Pregnancy outcome in severe placental abruption. British Journal of Obstetrics and Gynaecology,110, 679–83.

Kelly, R., Russo, J. ; Holt. V. (2002). Psychiatric and substance use disorders as risk factors for low birth weight and preterm delivery. British Journal of Obstetrics and Gynecology, 100(2), 297–304.
Khan, K. S., Wojdyla, D., Say, L., Gulmezoglu, A. M. ; Van Look, P. (2013). WHO systematic review of causes of maternal deaths. Lancet, 367, 1066–1074.

Khlat, M. ; Ronsmans, C. (2009). Deaths Attributable to Childbearing in Matlab, Bangladesh: Indirect Causes of Maternal Mortality Questioned. American Journal of Epidemiology, 151(3), 300-306.
Kilbride, H. ; Thibeault, D. (2001). Neonatal complications of preterm premature rupture of membranes: Pathophysiology and management. Clinical Perinatology, 28(4), 761–85.

Last, J. M. (2008). Survival rate. A Dictionary of Epidemiology (4th ed.). Oxford: Oxford University Press. p. 240.

Lee, T. ; Silver, H. (2001). Etiology and epidemiology of preterm premature rupture of the membranes. Clinical Perinatology, 28(4), 721–34.
LeVine, R. A., LeVine, S. E. ; Schnell, B. (2001). Improve the women: mass schooling, female literacy, and worldwide social change. Harvard Educational Review, 71(1), 1–51.

Loudon, I. (2012). Death in childbirth: An international study of maternal care and maternal mortality. Oxford: Clarendon.

Major, B. (2000). Psychological responses of women after first-trimester abortions. Archives of General Psychology, 777, 780.
McTavish, S., Moore, S., Harper, S. ; Lynch, J. (2010). National female literacy, individual socio-economic status, and maternal health care use in sub-Saharan Africa. Social Science and Medicine, 71(11), 1958–1963.

Meyerhoefer, C. ; Sahn, D. E. (2006). The relationship between poverty and maternal morbidity and mortality in Sub-Saharan Africa. A presentation for the AERC/Hewlett Foundation Workshop, “Poverty and Economic Growth: The Impact of Population Dynamics and Reproductive Health Outcomes in Africa”.

Morgan, K. J. ; Eastwood, J. G. (2014). Social determinants of maternal self-rated health in South Western Sydney, Australia. BMC Research Notes, 7(1), 1-12.
National Population Commission ; United Nations Population Fund (2014). Domestic violence against women from the 2008 Nigeria Demographic and Health Survey. Abuja, Nigeria: National Population Commission and United Nations Population Fund.

National Survey on Drug Use and Health (NSDUH) (2012). Summary of national findings and detailed tables. In NSDUH Series H-44 (2012). Substance Abuse and Mental Health Services Administration. Rockville, Md, USA: HHS, Publication No (SMA) 12-4713.

Nwakeze, N. M. (2007). The demand for children in Anambra State of Nigeria: a logit analysis. Etude de la Population Africaine, 22(2), 175–201.

Omo-Aghoja, L. O., Aisien, O. A., Akuse, J. T., Bergstrom, S. ; Okonofua, F. E. (2010). Maternal mortality and emergency obstetric care in Benin City, South-south Nigeria. Journal of Clinical Medicine and Research, 2(4), 55-60.

Panting-Kemp, A., Nguyen, T. ; Castro, L. (2002). Substance use and polyhydramnios. American Journal of Obstetrics Gynecology, 187(3), 602–5.
Patrick, S. W., Schumacher, R. E., Benneyworth, B. D., Krans, E. E., McAllister, J. M. ; Davis, M. M. (2012). Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. Journal of the American Medical Association, 307(18), 1934–1940.

Pinto, A., Scheer, P., Tuqa, S., Ebrahim, G. J., Abel R. ; Mukherjee, D. S., (1985). Does health intervention ameliorate the effects of poverty related diseases? The role of female literacy. Journal of Tropical Paediatrics, 31(5), 257–262.

Porta, M. (2014). Cumulative death rate. A Dictionary of Epidemiology (5th ed.). Oxford: Oxford University Press. p. 64.

Porta, M. (2014). Death rate. A Dictionary of Epidemiology (5th ed.). Oxford: Oxford University Press. p. 69.

Razzak, J. ; Kellermann, A. (2002). Emergency care in developing countries: Is it worthwhile? Bull, 80, 900-904.

Reardon, D. C. (2000). Abortion is four times deadlier than childbirth. The post-abortion review. Retrieved on 29th January, 2016. http://www.afterabortion org/PAR/V8/n2/finland.html.
Ronsmans, C. ; Graham, W. J. (2006). Maternal mortality: Who, when, where, and why. Lancet, 368, 1189–1200.

Ronsmans, C., Vanneste, A. M., Chakraborty, J. ; Van Ginneken, J. A. (2008). Comparison of three verbal autopsy methods to ascertain levels and causes of maternal deaths in Matlab. Bangladesh International Journal of Epidemiology, 27, 660–666.

Rothman, K. J. (2012). Epidemiology: An Introduction. Oxford: Oxford University Press. pp. 49–50.

Safra, J. E. (2003). The New Encyclopaedia Britannica Volume 9. Chicago: Encyclopaedia Britannica.

Salihu, H. M., Mogos, M. F., Salinas-Miranda, A. A., Salemi, J. L. ; Whiteman, V. E. (2014). National trends in maternal use of opioid drugs among pregnancy-related hospitalizations in the United States, 1998 to 2009. The American Journal of Perinatology, 2014.

Sandiford, P., Cassel, J., Montenegro, M. ; Sanchez, G. (1995). The impact of women’s literacy on child health and its interaction with access to health services. Population Studies, 49(1), 5–17.

Shainker, S. A., Saia K. & Lee-Parritz, A. (2012). Opioid addiction in pregnancy. Obstetrical and Gynaecological Survey, 67(12), 817–825.

Shen, C. E. & Williamson, J. B. (2009). Maternal mortality, women’s status, and economic dependency in less developed countries: a cross national analysis. Social Science and Medicine, 49, 197–214.
Smith, K., Barrett, C. B. ; Box, P. W. (2011). Not Necessarily in the same boat: Heterogeneous risk assessment among East African pastoralists. Journal of Development Studies, 37(5), 1-30.

Thaddeus, S. ; Maine, D. (1994). Too far to walk: Maternal mortality in context. Social Science and Medicine, 38(8), 1091-110.
UNFPA ; World Bank (2012). Trends in maternal mortality: 1990 to 2010. New York: World Bank.

United Families International (2007). Guide to Family Issues: Abortion http://unitedfamilies.org/down loads/Abortion_GuidetoFamilyIssues.pdf. Retrieved on 29th January, 2016.

United Nations Economic Commission for Africa (2013). Report on progress in achieving the Millennium Development Goals in Africa. Addis Ababa, Ethiopia: United Nations Economic Commission for Africa.

United Nations General Assembly (2002). Road map towards the implementation of the United Nations Millennium Declaration: Report of the secretary-general. New York: United Nations General Assembly.

Vavrus, F. (2007). Girls’ schooling in Tanzania: The key to HIV/AIDS prevention? AIDS Care, 18(8), 863–871.

Wang, W., Alva, S., Wang, S. & Fort, A. (2011). Levels and trends in the use of maternal health services in developing countries. Calverton, MD: ICF Macro; p. 85.
West, K. P., Katz, J. & Khatry, S. K. (2009). Double blind cluster randomised trial of low dose supplementation with vitamin A and B carotene on mortality related to pregnancy in Nepal. BMJ, 318, 570–575.

Whiteman, V. E., Salemi, J. L., Mogos, M. F., Cain, M. A., Aliyu, M. H. & Salihu, H. M. (2014). Maternal opioid drug use during pregnancy and its impact on perinatal morbidity, mortality, and the costs of medical care in the United States. Journal of Pregnancy, 906723, 1-8.

WHO (2001). Putting women first: Ethical and safety recommendations for research on domestic violence against women. Geneva, Switzerland: World Health Organization.

WHO (2002). World health report: Reducing risks to health, promoting healthy life. Geneva, Switzerland: World Health Organization.

WHO (2005). World health report 2005: Make every mother and child count. Geneva: World Health Organization.

WHO (2012). Civil Registration and Vital Statistics: PMNCH Knowledge (Summary 17). Geneva, Switzerland: World Health Organization.

WHO, UNICEF, UNFPA (2013). Maternal mortality in 2000: estimates developed by WHO, UNICEF, UNFPA. Geneva: World Health Organization.

Winklbaur, B., Kopf, N., Ebner, N., Jung, E., Thau, K. & Fischer. G. (2008). Treating pregnant women dependent on opioids is not the same as treating pregnancy and opioid dependence: A knowledge synthesis for better treatment for women and neonates. Addiction, 103(9), 1429–1440.

Wolfe, B. L. & Behrman, J. R. (2014). Determinants of Women’s Health Status and Health-Care Utilization in a Developing Country: A Latent Variable Approach. Review of Economics and Statistics, 66(4), 696.

APPENDIX A
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.

Thanks.

Yours sincerely,
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
S/N Item SA A D SD
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
S/N Item SA A D SD
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
APPENDIX C
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

APPENDIX D
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
Item SA A D SD xSTD
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
Item SA A D SD xSTD
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
Item SA A D SD xSTD
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
Cluster Mean 2.81 0.86

Research Question 2: Alcohol/Drug Misuse by pregnant women and Maternal Mortality
Item SA A D SD xSTD
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
Cluster Mean 3.00 0.91