Worldwide, about 287,000 women die from pregnancy and childbirth related complications in 2010 (WHO, 2012). It is estimated to be about 99 percent of these deaths occur in Sub-Saharan Africa (Wilmoth & Gemmill, 2012). According to World Health Organization (WHO), maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes, Maternal death could be prevented if action is taken early and promptly.

Pregnancy and childbirth are natural processes in a woman’s life. Motherhood should be a time of expectation and joy for a woman, her family and her community but they are by no means risk-free, for some women in certain parts of the globe particularly in developing countries the reality of motherhood is often grim. For those women, motherhood is often marred by unforeseen complications or even a loss, Some women loose the fetus even before being born or shortly after birth; whiles some loss both their live and that of the baby (Macro, 2011).

Most countries within Sub-Saharan region have high rates of maternal mortality for example Uganda stands at a rate of 454 deaths per 100,000 live birth (NBS & Macro, 2011). The major complications that account for 80 percent of all maternal deaths are severe bleeding, infections, high blood pressure during pregnancy, obstructed labor and unsafe abortion (Lerberghe, 2005). Women are expected to receive health education about pregnancy including outcomes, danger signs during pregnancy, nutrition and family planning as well as other services when they attend clinic for antenatal care. However other women do not attend antenatal clinic and they may receive the information about danger signs through media or close friends/relatives (Moran, et al., 2006). Despite various safe motherhood initiatives and interventions in East Africa, studies in Tanzania, Ethiopia and Uganda have shown that even within the last five years awareness of danger signs during pregnancy was still low (Pembe, et al.,2009).

According to World Health Organization (WHO), United Nations Children’s Funds (UNICEF) and United Nations Funds for Population Affairs (UNFPA) joint estimates, 515 000 women die each year of pregnancy related causes. Of these over half takes place in Africa, 42% in Asia, 4% in Latin America and Caribbean, and less than 1% in the more developed countries. In other words over 99% of maternal deaths take place in developing countries (2). This extraordinary difference in maternal mortality rates between the industrialized and the developing countries is the most striking fact in the world today about maternal health and furthermore, the difference in levels of maternal mortality between developed and developing countries show the greatest disparity than any other public health indicator monitored by WHO, (WHO, 2012).

Antenatal consultations is said to provide opportunities for health education, health promotion and social support at both the individual and community level (Sugathan K.S et al 2007).

In addition to the above, the ministry of health has adopted a goal oriented, focused ANC model for the implementation of ANC services, Focused ANC involves attending at least four visits starting early in the first trimester and receiving all necessary interventions for ANC package. According to the UDHS 2006, only 47 percent of mothers attended ANC four times; only 17 percent made their first visit during the first three months while 41percent of pregnant women had their first visit during the fourth or fifth months of pregnancy and 37 percent attended ANC late in their sixth month or later.

A global report released this month (May 2014) reveals that maternal deaths have declined by 45% since 1990. There were 523,000 deaths that occurred from complications in pregnancy or childbirth in 1990; in 2013, that number was 289,000. This new data published in “Trends in maternal mortality estimates 1990 to 2013” is under the collective authorship led by World Health Organization (WHO) and includes UNFPA, the United Nations Children’s Fund (UNICEF), the United Nations Population Division (UNPD) and the World Bank Group.

The immediate cause of pregnancy-related complications, ill-health and death are inadequate care of mother during pregnancy and delivery. More detailed factors include women‘s subordinate status, poor health and inadequate nutrition. The health of pregnant women through effective antenatal care increases a mother‘s chances of giving birth to a healthy baby. While any woman can develop complications during pregnancy and delivery, many such complications can be prevented or treated before becoming life-threatening emergencies and all can be managed by appropriately trained and equipped health care providers that are sometimes not available in rural areas like Lira main hospital lira district. Basing on this background this study therefore intends to investigate into the causes of maternal mortality in Uganda a case of Lira main Hospital.

1.1 Problem Statement

According to World Health Organization, (2012) Uganda is one the countries with highest maternal mortality which is rated at 454 per 100,000 live births, this is despite of the funding by the government, international organizations and foreign donors in the country apart from that the ministry of health in Uganda is one of the most well funded, however there is still high persistence of the maternal mortality.

Stemming from the above maternal mortality has remained high in Uganda despite the high economic growth the country has achieved over the past 20 years. According to 2011 Uganda Demographic Health Survey, Uganda’s maternal mortality rate was found to be 438 per 100,000 live births. However, this was within 95% confidence within the confidence interval of 368 – 507 per 100,000, The report reveals that the proportion of women delivering in health units remains low at 41%, although the percentage that attends antenatal care is about twice as high, The study therefore intends to investigate into the causes of maternal mortality in Uganda using a case study of Lira main Hospital.

1.2 Objectives of the study

1.2.1 General objectives of the study

To examine the causes of maternal mortality in Uganda

1.2.2 Specific objectives of the study

To find out the age of the mothers in Lira main hospital.

To examine the level of education of the mothers in lira main hospital.

To examine access to medical services by the mothers in lira main hospital.

1.3 Hypothesis of the study

Ho₁ There is no difference in age of mothers.

H_o2There is no difference in level of education of mothers.

H_o3There is no difference in access to medical services by mothers.

1.4 Scope of the Study:

1.4.1 Subject scope

This research intends to investigate into the causes of maternal mortality in Uganda by assessing, finding out the age of the mothers in Lira main hospital, the level of education of the mothers in lira main hospital and accessing to medical services by the mothers in lira main hospital.

1.4.2 Geographical scope

The study will be conducted in Lira main hospital; the study will be carried out from February to September 2017.

1.5 Significance of the Study

This study will help the government in making the different decision to help in reducing the maternal mortality at ministry of Health.

Also some volunteers can be trained to provide health education within the community about danger signs of pregnancy and the importance of attending to a health facility early enough to prevent severity of the problem.

The study will help the researcher in getting award for Bachelors degree in economics and statistics.

This study will also help to avail the information on the prevalence of maternal mortality in Uganda to different international organizations and the government of Uganda, which will enable future academicians to be in position to act and reduce on the situation.

The information obtained from this study will give an insight to the future academicians on the knowledge of danger signs during pregnancy and if it correlate with appropriate health seeking behavior after recognizing a danger sign.

The study will help provide the future academicians with literature on the importance of increased access to medical services for pregnant women.

1.6 LITERATURE REVIEW

1.6.1 To compare the age of the mothers in Lira main hospital.

WHO estimates that at least 600,000 women worldwide die every year from pregnancy related causes, though the rate is difficult to calculate with accuracy (Clark, 2002). Partnership for Transforming Health Systems-PATHS(2005), stated that everyday, at least 1,450 women worldwide die from complications of pregnancy and childbirth, that is a minimum of 600,000 women dying every year.The majority of these deaths (almost 99%) occur in Asia and Sub-Sahara Africa and less than one per cent in the developed world. PATHS further stated that life time risk of maternal death is 1 in 75, in developed country like America it is 1 in 2,500, while in West Africa it is 1 in 13 (Khalid 2006). This alarming situation of the maternal deaths in the world may not exclude Nigeria.

It has been shown that there are many factors which potentially attributed to the occurrence of the adverse neonatal outcomes. Several clinical conditions like diabetes mellitus, hypertension, chronic renal failure, etc often have been found to complicate pregnancy for both fetus and mothers. There is increase risk by 2.5 fold in patient with diabetes mellitus to get fetal death(16). The women with children of less than 1.5kg and 1.5-2.5kg had increased risk of being hypertensive with renal disease by 17 and 2.5 respectively(17). Infections like malaria, STDs, other viruses are also having significant risk for the fetus. It was found when examining the stillbirths in Zimbabwe among the 104 stillbirths 17-33% of specimens had bacteria growth and in Sweden 50-70% adults had parovirus B19 and in that population pregnancy was associated with adverse neonatal outcome(18). Prepregnancy BMI has impact on pregnancy in terms of neonatal outcomes. The study of poor pregnancy outcome versus BMI had found pregnant women with BMI of >25 had 4 times risk of late fetal death(19). Another study in Dar es salaam found weight loss, low weight gain during pregnancy and low maternal height were significantly related to increased about two fold risk of fetal death, preterm delivery. LBW was about three times more after adjusting for height, primiparity, baseline weight, malaria, CD4 cell count, HIV disease stage, and intestinal parasitoses. The association with fetal death was stronger for weight loss during the 2nd trimester, whereas increased risks of preterm delivery and LBW were higher for weight loss during the 3rd. Weaker associations were found with low weight gain during pregnancy (20). Maternal age has found to cause adverse neonatal outcome. In Muhimbili Hospital studies showed teenagers were at about one and half increased risk for LBW. Elderly mothers had one and half higher risk for LBW (21). Various studies have shown many other factors to be implicated with adverse prenatal outcomes. These are social status, life style, attendance to antenatal clinic, spacing where both short and long interpregnancy intervals(22).

In 54.7% of the cases of stillbirth. Increased maternal BMI was associated with IUFD rate (P<001), as was increased maternal age (P = .0012). There was no association between stillbirth rate and maternal ethnic group, maternal smoking, maternal Rhesus status, or fetal sex(23).

Although adolescent motherhood certainly has a substantial role in maintaining the high rates of child and infant mortality in India and elsewhere, it is unclear whether this is truly a consequence of early marriage, and hence early childbirth, or if heightened social vulnerability for mothers married as minors drives heightened health risk for their children.

Research with young adult women in India has shown that those reporting child marriage have higher rates of infant and child mortality and low infant birth weight even into their majority years compared with those not reporting child marriage, but in these unad-justed analyses the findings could be attributed to social marginalisation or fertility. Extensive data show that adolescent women are more likely than those marrying in adulthood to remain poor, uneducated, and within rural communities, and to have low access to health care, all factors that contribute to increased risk for infant and child morbidity and mortality.

Furthermore, women who get married and begin childbearing at a younger age are also more likely to have a greater number of children, which is also linked to increased likelihood of poor maternal, infant, and child health outcomes.

Such findings show the need for analysis of the relative contribution of child marriage to poor infant and child health beyond that accounted for demographic vulnerabilities of the mother.

Maternal death has been defined as the death of a woman while pregnant or within 42 days of delivery, miscarriage or termination of pregnancy, from any cause related to or aggravated by pregnancy or its management, but not from accidental or incidental causes (Lewis & Drife, 2001).The complications of pregnancy may be experienced during pregnancy or delivery itself or may occur up to 42 days following childbirth. Maternal mortality in the context of the present study is defined as the death of a woman during pregnancy, in labour or first six weeks after delivery or termination of pregnancy from causes directly due to pregnancy or to conditions aggravated by pregnancy.

1.6.2 Education of women on maternal mortality

A few studies indicate a protective effect of education on maternal mortality, but the size of the effect varies between the studies. One reason for this is that different measurements are used to assess education.

Education level is often assessed by years of schooling and categories span from any or no schooling to more differentiated assessments such as one-to-four (or six) years of schooling, or primary, secondary, or university-level education. The UNESCO International standard Classification proposes to use the categories: primary (one-to-six years), lower secondary

(seven-to-nine years), upper secondary (10-12 years) and post secondary/tertiary education.

This has been used in a Global Survey on Birth Outcomes by WHO [74]. Other studies have used literacy as the measurement of educational level. Maternal education has predominantly been assessed; few studies investigated the association between paternal education and maternal mortality.

The pathway by which education might influence maternal mortality is via increased utilization of health care but also better health status. Better education might also reflect family and childhood background, which might reduce the likelihood of harmful traditional practices such as food restriction being present in familial norms and beliefs. Higher education might also correlate with higher social and economic status, factors that are often described as reducing maternal mortality. Education has consistently been recognised as an important determinant of other health outcomes as well, for example infant mortality.

Data from a study of Kenyan government hospitals in 1993, Magadi et al estimated a reduced maternal mortality, odds ratio (OR 0.56, 95%CI 0.3 – 1.1) in women with secondary education compared to women with only primary education. A population-based study in Guinea-Bissau reported a 60% increase in mortality among women with no schooling compared to women with any schooling (OR 1.6, 95% CI 0.9 – 3.8) [78]. Hoyert estimated, based on national data from the United States and Canada, a 50% protective effect of more than 12 years of schooling compared to 12 or fewer years (MM-ratio 6.3 compared to 9.5 per 100,000 respectively) [79]. These findings are similar to other reports from the United States [80, 81].

A significant effect of reduced mortality with more years of formal maternal education was reported from Matlab, Bangladesh, which compared odds of maternal mortality between women with one-to-four, five-to-seven or eight or more years of education with no education (OR 0.8, 95% CI 0.7 – 1.1; OR 0.6, 95% CI 0.4 – 0.7; OR 0.4, 95% CI 0.2 – 0.5 respectively. In Egypt, illiterate women had a seven-fold higher MM-ratio than women with secondary school education [82]. Also, in a slum in Delhi, India, the odds of dying were two times higher in illiterate women than in literate women (OR 2.2, 95% CI 1.2 – 3.9). A multi-country study supported by the WHO indicated that the effect of education was even present in women who delivered in a hospital. The odds of dying were three times higher in women with no education compared to women with post-secondary or tertiary education (Adjusted OR of 2.7, 95% CI 1.6 – 4.5) This study provides some evidence that increasing education has an effect on maternal mortality beyond increasing uptake of care, However, a few studies reported no association between education and maternal mortality. Some of these studies were smaller case-control studies and might have missed the effect due to small numbers

1.6.3 Access to maternal mortality

Globally, in the year 2008, there were an estimated 358,000 maternal deaths and of this, the developing world accounted for (355,000) or 99% (WHO, UNICEF, UNFPA, & The World Bank, 2010). These figures have financial implications for the health sector of affected countries. On the one hand, high income countries with high standards of living spend an average of 7.0% of Gross Domestic Product (GDP) on health and on the other hand, low income countries, with low standards of living, spend an average of only 4.2% on the health sector (Cieza & Holm, 2010). Apparently, approximately one half of the global population lives in rural areas, but these areas are served by less than a third of the total nursing workforce and by less than a quarter of the total physician workforce (Dayrit, Dolea, & Braichet, 2010).

A study carried out in Ethiopia on the utilization of maternal health care services found out that there was low coverage of maternity service in the country. The place of residence, woman’s education, marital status, religion, parity and number of children under five years were found to have an important influence on utilization of maternal health services by women of reproductive ages. There was high level of utilization of maternal health services among urban women compared with their rural counterparts (Mekonnen & Mekonnen, 2002).

In the year 2000, 251,000 maternal deaths occurred in Africa and 40% of the deliveries were attended by a Skilled Birth Attendant (World Health Organization, 2005). Sub.Saharan Africa accounted for slightly more than half (270,000) of the maternal deaths in 2005. An increase in maternal deaths over the years can be observed. Nearly three fifths (204,000) of the maternal deaths in 2008 occurred in the sub-Saharan Africa (WHO et al., 2010). Though there is a slight drop in maternal mortality rates from 2005-2008, the number is still high.

Kenya is one of the countries that suffered 65% of maternal deaths in 2008. It accounted for 7,900 (2.2%) of the global maternal deaths (WHO et al., 2010). According to the 2008-09 Kenya Demographic and Health Survey (KDHS) maternal mortality in Kenya remains high at 7.9% as only 44% of births are managed by health professionals and 43% are delivered in health facilities. These statistics clearly show that over half (56%) of deliveries are done by non-professionals and more than half (57%) of deliveries are done outside healthcare facilities. Between the periods 2003 – 2008/09, there was a rise in maternal mortality rates in Kenya from 0.6% to 0.8%, indicating an increase of 0.2% (Kenya National Bureau of Statistics (KNBS) & ICF Macro, 2010). This is not a good indication especially that MDG number five aims at improving maternal health care. According to an official in the Ministry of Public Health, (Masha Joseph, 2011), quoted in the Standard Newspaper of Wednesday 11th May 2011, only 44% of deliveries in the Coastal Region are done in hospitals with many pregnant women relying on Traditional Birth Attendants (TBAs), while about 70% of 170,000 women still give birth at home.

Health behaviour is the activity undertaken by individuals for the purpose of maintaining or enhancing their health, preventing health problems, or achieving a positive body image (Cockerham, 2012). In this discourse, health care utilization refers to the use of health care services by people (Awoyemi, Obayelu, & Opaluwa, 2011). Accessibility of health services has been shown to be an important determinant of utilization of health services in developing countries (Mekonnen & Mekonnen, 2002) . Thus, in order for an individual to utilize health services, they must have both physical access to a health facility and the health facility must also be able to provide the required services; the patient must also be able to pay for the health care services offered either through cash or by use of health insurance or any third party means (Shauri, 2010).

Utilization of health services is a complex behavioural phenomenon, related to the availability, quality and cost of services, social structure, health beliefs and characteristics of the users (Chakraborty, Ataharasul, Chowdhury, Bari, & Akhter, 2003; Ebuehi et al., 2006). More critical for this study, women’s utilization of maternal health care facilities is an important health issue with regard to the well being and survival of both the mother and the child during pregnancy, child birth and postpartum period and has implications on the maternal and child mortality rates in human society (Gazali et al., 2012; WHO, 2012).

1.7 METHODOLOGY

1.7.1 Research Design

The study shall use quantitative methods of research so as to obtain the viable data and this shall include structured secondary data in the records of Lira Hospital main Hospital.

1.7.2 Data type and sources.

Secondary data will be obtained from the data base, records, publications and journals in the Lira Hospital main Hospital.

The information for secondary data will also be obtained from the ministry of Health and the internet publication of maternal mortality.

1.7.3 Data collection methods and procedures

Upon receiving the university permission to carry out the area of study will be visited for purpose of familiarization. The researcher will seek permission from the Hospital administrator and once allowed the researcher will obtain secondary data from the hospital records officer.

1.7.4 Data processing and Data analysis techniques

The process of data processing will involve editing in order to check for errors and omissions and coding to reduce the data to a meaningful pattern of responses. Model specification and soft wares employed in the tabulation and processing of the findings will be done in order to prepare data, analyze and compile a research report.

The study will use time series analysis and descriptive statistics will be used to describe the information got from the field this will be inform of graphs and tables

Data Analysis will involve applying statistical techniques on it for easy presentation. It will include the interpretation of research findings in the light of the research questions, and objectives to determine if the results are consistent with those research questions.

Time series analysis

By the nature of data which is the time series

The analysis however will concentrate on trend and seasonality of maternal prevalence

Assuming a multiplicative model, then 𝑌𝑡=𝑇𝑡∗𝑆𝑡

Where 𝑌𝑡 is the mortality series, 𝑇𝑡 is Trend and 𝑆𝑡 is the seasons.

This employs ARIMA modeling and it includes the following data exploration techniques.

a. Graphical presentation

This will involve plotting the series 𝑌𝑡 against time t.

b. Non parametric tests for trend

Run’s test: The runs test (Bradley, 1968) can be used to decide if a data set is from a random process.

A run is defined as a series of increasing values or a series of decreasing values. The number of increasing, or decreasing, values is the length of the run. In a random data set, the probability that the (i+1)^th value is larger or smaller than the i^thvalue follows a binomial distribution, which forms the basis of the runs test. Testing procedure

Ho: the maternal prevalence series is stationary

Ha: the maternal prevalence series is non-stationary.

Test statistic

Where m=number of pluses Decision rule is at α=0.05

The researcher will reject Ho if Z>𝑍_∝_/2 i.e. if the computed Z statistic is greater than the notable value and then conclude with (1-α)*100% confidence, the series has trend.

Test for seasonality

In this research, the researcher will use the Kruskal-Wallis test which is an alternative for the parametric one-way analysis of variance test, if there are two or more independent groups to compare (Siegel & Castellan 1988).

The test is described as below; Ho: the series has no seasonality Ha: the series has seasonality

Test statistics, H to compare with (Chi square)

n_i is the number of observations in the i^thseason N is the total number of specific seasons

Ri= 𝑟𝑎𝑛𝑘 (𝑦𝑖) Yi is the specific season for time t. Critical region

Reject Ho if

Logit model

The logiot regression model will take the form of,

P is the probability of being a mother, 1-p is the probability of not being a mother, ,

1.7.6 Reliability and validity

To ensure validity of instrument close guidance of the supervisor will be adopted and the researcher will further get the data from the Lira main hospital. This is mainly to eliminate getting wrong information and data from the website and from unconfirmed sources.

Reliability tests and analysis shall be carried out. Reliability will be checked using the test –retest practice advocated for by Amin (2005). In other words, the researcher will carry the data from Lira main hospital will be given to the lecturer to confirm its accuracy and credibility.

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research consultancy

1.0 Background of the study