1

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Pregnancy is the time during which one or more offspring develops (gestates) inside a

woman's uterus (womb). This occurs through sexual intercourse or assisted reproductive

technology procedures (Shehan, 2016). A pregnancy may end in a live birth or stillbirth, a

miscarriage or terminated by induced abortion. Childbirth typically occurs around 40 weeks

from the start of the last menstrual period (LMP); a span known as the gestational age.

Counting by fertilization age, the length is about 38 weeks. Pregnancy is the presence of an

implanted human embryo or foetus in the uterus; implantation occurs on an average of 8–9

days after fertilization. An embryo is the term for the developing offspring during the first

seven weeks following implantation (i.e. ten weeks' gestational age), after which the term

foetus is used until birth (Abman, 2011).

Being pregnant for the first time exposes a woman to many experiences during the

period. To Modh, Lundgren and Bergbom (2011), the experiences of women during first

pregnancy and childbirth are an important outcome of labour and may affect them in future if

the outcomes remain poor. Other problems encountered by most women with first time

pregnancy experience are vague and scanty in academic literature. According to Coggins

(2002) cited in Modh et al. (2011), studies that focus on women tend to address childbirth

rather than pregnancy outcomes, and those about pregnancy are more focused on late rather

than first and early pregnancy. Thus, gaining knowledge and understanding of the women’s

experiences in pregnancy particularly those arising from contact with the health care system

is critical.

Globally, first pregnancy experience and its associated poor outcomes such as

maternal and neonatal mortality, and low birth weight, are still a major public health concern
 2

in Nigeria and many other third world countries. Evidently, about 25 percent of global

maternal mortalities occur during pregnancy. This is likely due to unsafe abortion, violence,

and diseases (WHO, 2016). At least, nearly 830 women die daily from preventable pregnancy

and childbearing related causes (WHO, 2016). Available statistics show that global maternity

mortality ratio continued to reduce by 2.3% annually between 1990 and 2015 while the Sub-

Saharan Africa, Asia, and North Africa also witnessed similar reduction in maternity

mortality ratio (WHO, 2016).

It has been reported that in 2015, an estimated that 303,000 women globally died from

pregnancy and childbearing related causes. The Sub-Saharan Africa and South Asia

accounted for nearly 88 percent of this deaths. That is, a greater percentage of maternal

mortality (546 per 100,000 live births) occurred in the Sub-Saharan Africa; translating into

201, 0000 maternal deaths annually. In the same year, neonatal mortality was projected to be

2.7 million worldwide and 2.6 million stillbirth (WHO, 2016). While neonatal death

accounted for approximately 45 percent of all deaths among children under the age of five, an

estimated 75 percent of these neonatal deaths took place during the first seven days of life,

with 25 to 45 percent occurring in the first 24 hours of life (WHO, 2016). In 2016, 99 percent

of all maternal deaths took place in the developing countries, and only one percent occurred

in developed countries. Disparities exist in adverse pregnancy outcomes between rural and

urban women, between communities with different economic statuses, and between

adolescent and older women (WHO, 2016).

Data related to the Sub-Saharan Africa indicated that neonatal deaths were in the

estimate of 1,026,860, out of which Nigeria contributed 240,106 (UNICEF, 2017; WHO,

2016). Specifically, out of an estimated 7,100,000 new born babies (19,500 per day) in

Nigeria in 2015, approximately 660 died also daily before their first month of life and another

859 involved in stillbirth (UNICEF, n.d.). This prompted a report by the United Nation
 3

International Children Economic Fund that Nigeria’s neonatal mortality rate was in the tune

of 34 deaths per 1,000 live births. Variation between the rural and urban areas of Nigeria

indicated neonatal mortality rate of 44 deaths per 1,000 live births and 34 deaths per 1,000

live births respectively.

A global survey (Global One, 2015) has revealed that an estimated 30-40 of the nearly

180 million pregnant women worldwide reported some form of pregnancy associated

disabilities, and about 15 million reported some form of chronic illnesses from complications

due to obstetric fistula, uterine scarring, severe anaemia, pelvic inflammatory diseases, and

infertility on an annual basis (Global One, 2015). The survey also indicated that for every

maternal death, there were about 30-50 morbidities, either chronic or interim (Global One,

2015). Besides these findings, a recent publication by the International Federation of

Gynaecology and Obstetrics (AllAfrica, 2015) revealed that exposure to toxic chemicals in

food, water, and air causes millions of deaths and costs billions of dollars and is responsible

for poor pregnancy outcomes such as miscarriage and stillbirth in Nigeria.

In Nigeria according to UNICEF (2016), the probability of women dying from

pregnancy and childbirth related causes is 1 in 13. Beside the known causes of death of a

woman in pregnancy, improper management of pregnancy has a major contributor by acting

as a gate way to infection and as a moderating variable through which the pregnant woman is

exposed to cultural and environmental challenges. It is also documented that the lifetime risk

of maternal death in Sub-Sharan Africa is 1 in 36 compared to 1 in 3,300 in the high-income

countries. The increased risk in the African region is attributed to limited access to and low

quality of maternal health services (Fawole, Shah, Tongo, Dara, El-Ladan, Umezulike, Sa’id,

2012; UNICEF, 2016). Maternal mortality occurred due to lack of antenatal care, low level of

education, and abortion. The above information is quite worrisome in the 21 st Century when
 4

the world is counting breakthrough in science, health and in other spheres of human life. This

challenge in Nigeria and indeed in Port Harcourt underscored the need for a study.

1.2 Statement of the Problem

Nigeria continuously records higher rates of maternal deaths, BW, and NM compared

to other countries in the world, except India. The challenges and impacts of MM and its

related outcomes are enormous for the family, community, and the nation at large. Families

that experienced maternal death are often forced to liquidate their assets and borrow money to

settle incurred hospital and funeral costs. Most families spend nearly one-third of their yearly

per capita expenditureon health care access during pregnancy and delivery. After maternal

death, the husband, mother-in-law, or relative assumes the responsibility for most of the tasks

performed by the deceased. The surviving children are often confronted with financial

hardship, dropping out of school, forced into farm labor, suffering malnutrition, and

experiencing early partnership or pregnancy. The root of these problems are the factors that

contribute to poor pregnancy outcomes amongst women with first pregnancy experience

which have not fully addressed in different educational research in the country.

In addition, the studies conducted in Nigeria that focused on pregnancy outcomes

have not adequately addressed the history of previous pregnancy outcomes and some of the

underlying factors that contribute to poor pregnancy outcomes such as socio-demographic,

economic, lifestyle and behavioural pattern of women with first pregnancy experience

(Fawole et al., 2011; Mojekwu and Ibekwe, 2012; as cited in Letam, 2019). This highlights

the need for indigenous study that will generate local evidence and sufficiently account for

these factors to better understand why Nigeria and it cities consistently underperformed on

maternal mortality and its related outcomes compared to most African countries. Therefore,

the problem of the study is an analysis of pregnancy management strategies and outcomes

among women with first-time experience in Port Harcourt City, Rivers State.
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1.3 Objectives of the Study

The general objective of the study is the analysis of pregnancy management strategies

and outcomes among women with first-time experience in Port Harcourt City, Rivers State.

Specifically, the study seeks to:

i) determine the association between the socio-demographic factors of women with first

pregnancy experience and poor pregnancy outcomes in Port Harcourt City.

ii) ascertain the association between the socio-economic factors of women with first

pregnancy experience and poor pregnancy outcomes in Port Harcourt City.

iii) find out the association between the lifestyle of women with first pregnancy experience

and poor pregnancy outcomes in Port Harcourt City.

1.4 Research Questions

In order to achieve the study objectives, the following questions are asked and will

also hereby posed;

i) what is the association between socio-demographic factors of women with first pregnancy

experience and poor pregnancy outcomes?

ii) what is the association between socio-economic factors of women with first pregnancy

experience and poor pregnancy outcomes?

iii) what is the association between lifestyle of women with first pregnancy experience and

poor pregnancy outcomes?

1.5 Statement of Hypothesis

In furtherance of the objectives, the following hypotheses tested at 0.05 level of

significant are hereby projected;

i) There is no significant association between socio-demographic factors of women with first

pregnancy experience and poor pregnancy outcomes.

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iii) There is no significant association between lifestyle of women with first pregnancy

experience and poor pregnancy outcomes.

1.6 Significance of the Study

There is lack of adequate literature on poor pregnancy outcomes in Nigeria. This

study contributed to the existing literature by focusing on the effect socio-demographic

factors, socio-economic factors, behavioural and lifestyle of women with first pregnancy

experience. Study will help steps that will help reduce some of the physiological,

psychological, economic, and financial pains associated with adverse pregnancy outcomes,

specifically, maternal and neonatal death, as well as related morbidities.

It is hoped that the findings of this research will have the possibility of further

enhancing understanding of poor pregnancy outcomes in Nigeria, help public health

practitioners and policymakers design strategies that will take advantage of the cultural and

religious norms of women of childbearing age in promoting reproductive health in Nigeria.

The out come of the study will aid community leaders, and other stakeholders to design

interventions that will take advantage of the educational status of women of childbearing age

in enhancing reproductive health in Port Harcourt City and other parts of the country and it

help mitigate the challenges and impacts of maternal mortality (MM), neonatal mortality

(NM), and low birth weight (LBW) and its related outcomes in families.

Finally, findings of this research will help to provide local evidence that will help

advance knowledge in related field of study for future researchers.

1.7 Scope of the Study

Geographically, this study will be limited to women within the reproductive age of

15- 49 years in Port Harcourt City. Based on content, the study will focus on the socio-

demographic, socio-economic factors, and the behavioural and lifestyle of women with
 7

first pregnancy experience, which determine the strategies women adopt in the management

of their pregnancies.

1.8 Clarification of Terms

The following terms which seemed to have complex meanings are clarified for

purposes of understanding and use as applied in this study:

Pregnancy Outcomes: are affect of pregnancy on mother or baby such as LBW, intrauterine

growth restriction, preterm birth, infants death, stillbirth, placenta previa, and preterm

membrane rupture.

Behavioral and Lifestyles Factor: includes smoking, drug abuse and the use of substances

that can affect maternal life of a pregnant women.

Infant Mortality: Death of infant that occurred within the first 12 months after birth.

Labor and Delivery Nurse (also sometimes called “Antepartum” or “Before Birth” Nurse) –

is a nurse that cares for mother and unborn babies during the labor and delivery process;

Low birth weight (LBW): The weight of a baby born weighing less than 5.5 pounds 8

ounces.

Maternal mortality (MM): Death of a mother immediately after or during delivery.

Neonatal Mortality Rate (NMR): The proportion of newborns who died within the first 28

days of life per 1,000 live births.

Obstetricians: Are doctors with specialised training in obstetrics (medical care before,

during and after childbirth).

Preterm Delivery/Birth: Delivery of a newborn baby between 20 and 37 weeks of gestation.

Poor Pregnancy Outcome: Classified as pregnancy complications, illness or injury, MM

(death), infant morbidity, and infant mortality.

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Socioeconomic Status: is typically as measures of three distinct but related status such as

economic, social, and work status.

Socio-demographic Factors: include age, race, ethnicity, language, culture, income and

education of a pregnant women.

Stillbirth: Infant born with no life signs after nearly 24 weeks conception.
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CHAPTER TWO

REVIEW OF RELATED LITERATURE

2.1 Literature Review

This section examines previous studies on pregnancy and care, pregnancy outcomes

and other related issues. This is to help identify gaps in knowledge in perspective of

achieving the objectives of the study. The review is based on the following sub-headings:

2.1.1 Socio-demographic Factors and Pregnancy Outcomes

There are presently increasing evidence indicating that socio-demographic factors

such as age, race, ethnicity, language and culture and socioeconomic factors for example

income, education and occupation impacts health outcomes(Nwi-ue, 2019). Age has been

recognized as a risk factor for poor pregnancy outcomes. For this reason, most women of

childbearing age in advanced countries increasingly deferred pregnancy after 30 years

(Waldenström, Aasheim, Nilsen, Rasmussen, Pettersson and Shytt, 2014). Studies have

demonstrated a statistically significantly difference among young maternal age, advanced

maternal age and reproductive age in connection with adverse pregnancy outcomes.

Kuyumcuoglu, Guzel, and Celik (2012) for instance, argued that women at advanced

maternal age were more prone to pregnancy risks and may have adverse pregnancies

outcomes compared to young maternal age and reproductive age. In their study,

Kuyumcuoglu, et al., (2012) reported that there were statistically significant differences

between the outcome measures such as Apgar scores 1 and 5 minutes, low birth weight and,

gestational age at birth. The finding further showed that there was a negligible risk in

gestational age at birth for the adolescent age group and, not in the advanced maternal age

group (Kuyumcuoglu, et al., 2012).

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It has been argued that adolescent pregnancies and childbirth are susceptible to the

expanded risk of poor pregnancy outcomes especially in low and middle-income countries.

Approximately, 10 percent of young women have a child at age 16years old, specifically in

Sub-Sahara Africa including Nigeria. Furthermore, 90 percent of teenage birth occurred in

low and middle-income countries (Traisrisilp, Jaiprom, Luewan and Tongsong, 2015). A

multi-country study by the WHO (2016) that compared adolescents age (10-19 years) to that

of reproductive age (20-24 years) revealed that adolescents maternal age (10-19 years) are at

progressively higher risk of adverse pregnancy outcomes such as eclampsia, puerperal

endometritis, infection, low birth weight, preterm delivery and neonatal with undesirable

health conditions. After controlling for gestational age, low birth weight, mode of delivering

and maternal features, neonatal death to adolescent mothers becomes non-significant

(Ganchimeg, et al., 2014).

Similarly, a study carried out by Traisrisilp et al. (2015), compared pregnancies

outcomes among adolescent ≤ 15 years of age to teenage girls (16-19 years) and adults (20-

30 years). Findings showed that early adolescents’ pregnancies outcomes in comparison with

the control groups (20-30 years) were significantly at greater risk of adverse outcomes such

as preterm birth, low birth weight, and growth restriction. The adult's group indicated an

extended level of medical disease complications, for instance, diabetes mellitus and severe

hypertension. In comparing early adolescents group to late adolescents group (16-19 years),

early adolescents group still exhibited significantly greater risks of poor outcomes

(Traisrisilp, et al., 2015). Similar to adolescents maternal age, advanced maternal age also

presents considerable risks of adverse pregnancy outcomes especially when there is an

underlying medical condition or extremely advanced age (greater 40 years old at the time of

first pregnancy). Advanced maternal age is described as greater than 35 years or older at the
 11

time of first pregnancy and, it is increasingly becoming a standard practice in developed

nations for the past decades (Khalil, Syngelaki, Maiz, Zinevich and Nicolaides, 2013).

Many studies have found a statistically significant association between advanced

maternal age and a variety of adverse pregnancy outcomes. An example is Khalil et al. (2013)

that investigated the relationship between advanced maternal age and numerous adverse

pregnancy outcomes and, reported that advanced maternal age (≥40 years old) was associated

with compounded risks of miscarriage, pre-eclampsia, gestational diabetes mellitus (GDM),

small for gestational age (SGA) and caesarean section. However, the risk of stillbirth,

gestational hypertension, spontaneous preterm delivery and large for gestational age (LGA)

was not linked to advanced maternal age. Though, the authors noted that the findings

suggested a rapid increase in risk factors and poor pregnancy outcomes after 40 years (Khalil,

et al., 2013).

A multi-country assessment of advanced maternal age and poor pregnancy outcomes

also revealed a substantially expanded risk of poor pregnancy outcomes. Laopaiboon,

Lumbiganon, Intarut, Mori, Ganchimeg and Vogel (2014) found that advanced maternal age

increasingly contributed to adverse pregnancy outcomes such as near maternal miss, maternal

death, SGA, stillbirth and perinatal mortalities. A similar finding was documented between

advanced maternal age and poor pregnancy outcomes that include stillbirth, preterm birth,

very preterm birth, macrosomia, extremely large for gestational age and cesarean delivery

(Kenny, Lavender, McNamee, O’Neill, Mills and Khashan, 2013).

Studies have also shown that the risk of adverse pregnancy becomes double when

there is an underlying medical condition or in extremely advanced maternal age ≥ 45 years.

Grotegut, Chisholm, Johnson, Brown, Heine and James (2014), examined the risk of

obstetric and medical complications among pregnant women 45 years or older, and found that

pregnant women in this subgroup are prone to medicals and obstetric risk factors that include
 12

maternal death, transfusion, myocardial infarction, cardiac arrest, heart failure, acute renal

failure, pulmonary embolism, deep vein thrombosis, acute kidney failure, caesarean delivery,

gestational diabetes, foetal demise, foetal chromosomal anomaly, as well as placenta

Previa. The reports further highlighted that the risk of adverse pregnancy outcomes is

considerably reduced for women under the age of 35 years old. Advanced maternal age when

combined with a dangerous lifestyle such as smoking during pregnancy increased the risk of

adverse outcomes.

A study that investigated poor pregnancy outcomes in connection with older maternal

age, smoking, and overweight found significant differences among these variables.

Waldenström et al. (2014), studied the risks associated with older maternal age to that of

smoking and overweight during pregnancy and, discovered that neonatal mortality, preterm

birth, moderately preterm birth, SGA, low Apgar score, and stillbirth are progressively linked

to advanced maternal age. Older maternal age is more associated with a higher risk of

maternal death than overweight/obesity or smoking. Though, the outcomes do not indicate

any interaction effects among the lifestyles variables; maternal age, overweight, and smoking,

there is an indication that the risk of adverse pregnancy outcomes started increasing before 35

years. Waldenström et al. (2014) reaffirmed that advanced maternal age is an independent

risk factor for adverse pregnancy outcomes, greater than overweight and smoking altogether.

These lifestyle factors present a considerable risk of poor pregnancy outcomes (Waldenström,

et al., 2014).

Although, there are consensus findings that adolescents’ age and advanced maternal

age increased the risks of adverse pregnancy outcomes, there are conflicting findings

regarding some of the outcomes variables, as well as the particular periods when the

advanced maternal age increased the risk of adverse outcomes. While a study indicated that

the risk of adverse pregnancy outcomes expanded after ≥40 years, another documented that
 13

the risk of adverse pregnancy outcomes increased before ≤35 years of aged (Waldenström, et

al., 2014; Khalil, et al., 2013). The likely causes of these conflicting findings may be due to

differences in age classification and not adequately accounting for all confounders or

mediating variables.

Studies have shown that racial/ethnic background is a risk factor for poor pregnancy

outcomes though disparities exist in adverse pregnancy outcomes in the world. A study

conducted in the United States to determine if maternal race/ethnicity contributed to poor

pregnancy outcomes revealed that maternal race and ethnicity of infants from Black,

Hispanic, and Asian women suffered the risk of adverse pregnancy outcomes between 10 to

20 percent higher compared to White women (Borrell, Rodriguez-Alvarez, Savitz and

Baquero, 2016). The potential for adverse pregnancy outcome becomes greater between

interracial married couples. For instance, between Asian men and White women, or Black

men and Hispanic women, and Asian women and Black or Hispanic men (Borrell,

Rodriguez-Alvarez, Savitz and Baquero, 2016).

Another study of singleton pregnancies also reported maternal racial origin as a

determinant of poor pregnancy outcomes. In a retrospective study by Khalil et al. (2013)

found a significant association between racial foundations and a broad range of adverse

pregnancy outcomes. For example Afro Caribbean women had a progressive risk of

miscarriage, stillbirth, pre-eclampsia, gestational hypertension, spontaneous preterm delivery,

Gestational Diabetes Mellitus (GDM), Spinal Muscular Atrophy (SMA) and Caesarean

section (CS). Although, women from South Asian origin were noted for increased risk of

Gestational Diabetes Mellitus (GDM), Small-for-Gestational-Age (SGA),Caesarean Section

other women from the East Asian race had a progressive risk of Gestational Diabetes Mellitus

(GDM) andSmall-for-Gestational-Age (SGA) (Khalil, et al., 2013).

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Racial/ethnicity as a significant predictor of poor new born outcomes has examined in

many studies. Wilson, Gance-Cleveland and Locus (2011) who investigated the relationship

between ethnicity and neonatal outcomes reported that ethnicity was a statistically significant

predictor of adverse pregnancy outcomes after accounting for hospital setting and physicians

characteristics. The researchers noted further that newborns to African-American women

were associated with lower Apgar score or required admission to

Neonatal intensive care unit (NICU) compared to Native-American women, even with

better insurance, education or perinatal visits.

Racial/ethnic origin is potent factor to risk of miscarriage. A study by Mukherjee,

Velez Edwards, Baird, Savitz and Hartmann (2013) to determine the risk of miscarriage

among White and Black women showed that Black women are at an increased risk of

miscarriage compared with White women. Although the risk of miscarriage in gestational

week 10 was narrowed between the racial groups, an alarming rate of miscarriage was

noticeable for Black women in 10-20 weeks (Mukherjee, et al., 2013). Literature revealed

that the incidence of spontaneous abortions is linked to racial/ethnic foundations. For

example, a retrospective study to assess the association between race and spontaneous

abortions among European, Black African, Black Caribbean, and South Asian women

demonstrated that prior spontaneous abortions are amplified in Black African and Black

Caribbeans women. Though, the potencies of the relationship with Black women increased

with age and, that of South Asian women increased with age, as well as body mass index

(BMI). The adverse pregnancy outcome of preterm birth was associated with spontaneous

abortion in all races, nonetheless, it is commonest in Black African women (Oliver-Williams

& Steer, 2015). Many studies have provided substantial evidence regarding race/ethnicity as

predictors of poor pregnancy outcomes. The black race is noted for poor pregnancy outcomes

even after controlling for confounders variables such as socioeconomic status and age. This is
 15

followed by Hispanic women or South/East Asian women thus suggesting that besides,

culture and diet, the genetic make-up of black women suppressed them to adverse pregnancy

outcomes.

Culture is defined or described as a combined array of human behaviours that

represent language, thoughts, communications, actions, customs, beliefs, values, as well as

institutions of racial, ethnic, religious and social groups (Centres for Disease Control and

Prevention, 2014). A broader understanding of cultural knowledge is necessary to strengthen

and widen the healthcare delivery system through the suitable process of identifying illness

and development of treatment models (Esienumoh, Akpabio, Etowa & Waterman, 2016) .

Culture in most parts of the world, as well as Sub-Sahara Africa, including Nigeria influenced

women reproductive health and pregnancy outcomes. Evidence indicates rhat there is an

association between culture and adverse pregnancy outcomes. according to Ajiboye and

Adebayo (2012) , a statistically significant association exists between socio-cultural factors

and adverse pregnancy outcomes among the Ugu community in Nigeria. However, regardless

of the current stage of civilization, cultural beliefs and practices are still responsible for the

people in making an informed decision about their reproductive health.

It has also been found that cultural practices and beliefs in addition to religious

dogmas have b contributed to pregnant women refusal or delayed acceptance of emergency

obstetric care including caesarean section. A mixed-methods analysis to determine gender

role, religious views, and socio-cultural factors indicated that nearly 22 percent of pregnant

women and 90 percent of caesarean sections are due to delay in accepting caesarean services.

The study findings affirmed that delayed or rejection of caesarean section by pregnant

women is impacted by socio-cultural, gender and religious philosophy (Ugwu and de Kok,

2015). Cultural factor has also been recognized as contributing to differences in perinatal

periods experienced by women of low socioeconomic status.

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A qualitative analysis shared light on how women of different racial, ethnic and socio-

economic backgrounds understood the stressor associated with perinatal periods experienced

through their environments. The study affirmed further that what women experienced during

the perinatal periods are informed by a complex interplay of socio-cultural and environmental

factors (King, 2013). Cultural beliefs and practices, religious dogmas and limited English

Language proficiencies are still a central issue that influenced pregnancy outcomes in Sub-

Sahara Africa, including Nigeria. The factors are more pronounced in the rural areas in

Nigeria, as in most African countries. There is an interchange of local cultures and the

nursing and midwifery cultures during pregnancy and childbirth, these interplays provide the

diversity in childbirth that is eminent in Nigeria (Esienumoh, et al., 2016).

2.1.2 Socio-economic Factors of Women and Pregnancy Outcomes

Socioeconomic status is defined typically as measures of three distinct but related

status such as economic, social, and work status. Economic status is measured through

income, social status measured through educational level, and employment status measured

through the type of occupation (CDC, 2014). Socioeconomic position which is considered the

social, education and economic factors that affects an individual position within the context

of the society is linked to a variety of health outcomes that include mortality, morbidity, and

individual health through a life course, specifically during childhood development and

pregnancy (CDC, 2014).

Studies have reported that socioeconomic variables influence pregnancy outcomes,

either negatively (low socioeconomic status) or positively (high socioeconomic status). A

study conducted in the United Kingdom to determined maternity care outcomes, utilization,

and experience, does not show any statistically significant finding but revealed that pregnant

women of low socioeconomic status are 25 percent less likely to have received antenatal care,
 17

15 percent less likely to have received routine postnatal check-up, 4 percent more likely to

received antenatal hospital admission, 7% more likely to have been transferred during labor,

and 4 percent more likely to have had a caesarean birth (Lindquist, Kurinczuk, Redshaw and

Knight, 2015).

It has been argued that there is a disparity in adverse birth outcomes between rural

and urban residence due to socioeconomic status. The study reported a statistically significant

findings among rural mothers and adverse pregnancy outcomes. Bertin, Viel, Monfort,

Cordier, and Chevrier (2015) found an association between neighborhood poverty in rural

mothers and increased risk of Small for Gestational Age (SGA) and small for gestational age

head circumference (SGC). The finding suggested that neighborhood poverty had statistically

significant effects on small for gestational age (SGA) on the rural and urban position of

maternal residence (Bertin, et al., 2015).

In the developing countries such as Nigeria, women are disproportionality educated

compared to their male counterparts. Studies indicate that education benefit girls and women

both in eliminating maternal and child mortalities, enhancing health and fertility, increasing

the use of contraception, delaying marriage, limiting the number of children, increasing

knowledge about child nutrition and other related needs according to the Population

Reference Bureau quoted in Nwi-ue (2019). In Mali, women that obtained secondary

education or greater have an average of three children, while those without secondary

education gave birth to an average of seven children. In Guatemala, a 35years prospective

study revealed an association between years young women spent in school and the spacing of

children. For an extra year women spent in school, the age at which she had her first child

was extended for approximately six to ten months (PRB, n.d.).

Evidence shows that in Burkina Faso, the probability of women of reproductive age

with secondary education delivering in health facilities is twice those without secondary
 18

education. Also, an extra year of schooling for 1,000 women may likely avert two maternal

mortalities (PRB, n.d.). It is argued that the probability of educated women in 32 countries

having primary knowledge about HIV increased five times than those without education. In

Zambia and Uganda, studies showed that HIV multiplies rapidly among the uneducated

women and for each added year in school the possibility of contracting HIV reduced by 6.7

percent (PRB, n.d.).

It has been reported that inadequate education has been responsible for severe

maternal outcomes in developing countries. A multi country cross-sectional survey showed a

significant relationship between the low level of education and severe maternal results that

include near miss and death. These observed results were more pronounced in countries with

medium to low income compared to those of high-income countries. It is also found that low

education contributed to the odds of organ malfunction on arrival at the hospital or within the

first day. Furthermore, the probability of a woman receiving magnesium sulfate for eclampsia

or caesarean section increased tremendously with an increased level of education (Tunçalp,

Souza, Hindin, Santos, Oliveira and Vogel (2014). Additionally, studies have shown that

insufficient education is linked to adverse neonatal outcomes and the receipt of maternal

health care. Kaplan, Fang and Kirby (2017) have in their study found an association between

adverse new born outcomes such as preterm birth, stillbirth, post term, Low birth weight,

congenital anomalies and low level of education, as well as the impact on the receipt of

maternal health care services.

Education is essential in preparing women not only for positive reproductive health

outcomes but also for social and economic well-being. Literature reveal consistently that poor

education is associated with a wide range of adverse pregnancy outcomes. Education

empowers women to make independent decisions about their reproductive health, economic

freedom and to resist domestic violence. Studies have shown that the probability of women
 19

using modern contraception, delivering in a health facility and having a skilled attendant at

birth, increased with increase empowerment and education (Corroon, et al., 2014).

Income is another measure of socioeconomic status that affects pregnancy outcomes.

Research has indicated that pregnant women at the low-income level were more vulnerable to

the increased risk of poor pregnancy outcomes compare to those with middle to higher

incomes. A weak association has been established for household income and preterm birth

and small for gestational age (Mortensen, 2013). The influence of lower income on

pregnancy outcomes cut across both developed and less developed country. A cross-country

research study conducted among pregnant women in the United Kingdom (UK) and Brazil

between 1982-2004 provided information on the increased risk for adverse outcomes for

mothers and infants belonging to the poorer income and less educational levels in both U.K

and Brazil (Matijasevich, Victora, Lawlor, Golding, Menezes, Araújo and Smith, 2012). The

study highlighted an inverse association between the poorer and the least educated with all

the outcomes variables measured such as smoking during pregnancy, delivery without the

services of skilled personnel, preterm birth, intrauterine growth retardation, and less than

three months of breastfeeding. Positive association was only observed in caesarean section

according to Matijasevich, et al., (2012).

The disparity in income has also been found to have a link with poor perinatal

outcomes. Shankardass, O’Campo, Dodds, Fahey, Joseph, Morinis and Allen (2014) reported

a relationship between increased risk for Small for Gestational Age (SGA), spontaneous

preterm birth, and low-income status. Though, the researchers argued that the risk for large

for gestational age was relatively reduced among lower incomes group, as well as other

measurable indicators of socioeconomic position, postnatal mortality was associated with one

or more of the socioeconomic indicators, and neighbourhood maternal poverty was equally

associated with increased risk of perinatal death and SGA. Several literature have also
 20

demonstrated the relationship between income inequality (parental socioeconomic position)

and birth outcomes. An example is a study by Fujiwara, Ito, and Kawachi, (2013) that

revealed a positive correlation between income inequality and poor birth outcomes.

Occupation has been reported among the socioeconomic indicators that predict

adverse pregnancy outcomes. Globally, there is disparity between the participation rate of

men and women in the workforce. Statistics have shown that only 50 percent of working-age

women are in the labour force compared to 77 percent of men. These disparities are even

wider in areas such as Northern Africa, Western Asian and Southern Asian (UN, 2015) cited

in Nwi-ue, (2019). In the five countries in Sub-Sahara Africa, women make-up about 50

percent of the workforce. These are in countries such as Zimbabwe, Malawi, Gambia,

Liberia, and Tanzania. Presently, an increasing number of women are employed during

pregnancy and the postpartum period. Statistics showed that about 67 percent of first-time

mothers worked during their pregnancies and, around 87 percent of these women worked

until the final trimester (Kozhimannil, Attanasio, McGovern, Gjerdingen and Johnson, 2013).

Evidence have shown that maternal occupation has effect on both the mother and the

children particularly the new born. For instance, the Thirteen European birth cohort’s studies

that examined the relationships between maternal occupation and birth weight and length of

gestation revealed that women employed during pregnancies are vulnerable to the risk of

adverse pregnancy outcomes such as low birth weight, small for gestational age and lower

risk of preterm delivery compared to unemployed women (Casas, Cordier, Martínez, Barros,

Bonde, Burdorf and Vrijheid, 2015). Another study finding on the contrary revealed that

being employed in most occupations is not associated with adverse pregnancy outcomes. For

example, working as a nurse was linked to lower risk of SGA infants, and being employed in

the food industry increased the risk of preterm delivery (Casas, et al., 2015).
 21

The correlation between preterm birth and prenatal maternal occupation have also

been documented about ethnicity and nativity. von Ehrenstein, Wilhelm, Wang and Ritz

(2014), found in their study an association between increased risk of preterm birth and

women employed in the healthcare and technical occupations. The finding revealed that the

risk was more severe for Hispanics, and Hispanic foreign-born women in the building,

cleaning, and maintenance trade. It showed further that the US Hispanic-born in a shift and

physical demand work are at increased risk of adverse birth outcomes, but not foreign-born

Hispanic (von Ehrenstein et al., 2014). Also, heavy lifting has been recognized as a potential

factor for poor pregnancy outcomes. The study by Juhl, Larsen, Andersen, Svendsen, Bonde,

Nybo Andersen, and Strandberg-Larsen (2014) reported a possible relationship between

pregnant women who engaged in occupations that regularly involved lifting such as nursing

and nursing assistant, and small-for-gestational-age infants. Although statistically the results

were not significant, there is an increased possibility of risk of SGA for women who lifted

between 501-1,000 per day or ˃ 1,000 per day compared to women without a history of

lifting.

2.1.3 Behavioural and Lifestyles and Pregnancy Outcomes

Behavioural and lifestyle are critical factors that modify individual and can elicit

unexpected outcome. Behavioural lifestyle during pregnancy poses considerable problems to

public health practitioners and policymakers all over the world. For example, harmful

lifestyles and behaviours such as drinking, smoking, substances and drug use, intimate

partner violence, nutritional/vitamins deficiencies have the potentials to trigger adverse

pregnancy outcomes or explicitly put the life of the mothers and the offsprings in danger

(Pool, Otupiri, Owusu-Dabo, de Jonge and Agyemang, 2014).

 22

Academic literature has revealed that most pregnant women throughout the world still

consume alcohol during pregnancies, and alcohol use caused both long and short time effects

on the babies including mothers leading to miscarriage, stillbirth, preterm delivery,

intrauterine growth retardation, and low birth weight (Onwuka, 2016). In essence, there is no

safe amount of alcohol during pregnancy, but the effects on the foetus are directly

proportional to the amount consumed. Maternal alcohol consumption poses a substantial

social and economic burden to family and community. It often leads to the diversion of

resources that could provides the needs of the new born and family. This happens particularly

during the delivery of the new baby. Studies show that the Sub-Saharan Africa carries the

greater burden of maternal alcohol use, specifically South Africa follow by Nigeria (Onwuka,

2016). A recent study in Bayelsa State, Nigeria indicated that almost 90% of adults used

alcohol for celebrations, for oral hygiene and treatment of cold (Ordinioha and Brisibe, 2015)

quoted in Nwi-ue (2019).

Murphy, Mullally, Cleary, Fahey, and Barry (2013) in a study on pregnant women

who continue to consume alcohol during pregnancy showed that women maternal alcohol

consumption was linked to elevated risk of intrauterine growth retardation compared to non-

drinkers (19% versus 13%). This risk was double for women who drink and smoke during

pregnancy compared to non-drinkers (32% versus 9%). Also, the study discovered that

specific nationality or ethnic/racial backgrounds, advanced maternal age and smoking were

factors that contributed to continuous drinking in early pregnancy (Murphy, et al., 2013).

Other factors that encouraged drinking at the beginning-late pregnancy included the history

of drug use and private health insurance (Murphy, Dunney, Mullally, Adnan, Fahey and

Barry ( 2014). It is also reported that women that drink alcohol during first and third

trimesters of pregnancy exhibited similar perinatal outcomes as non-drinkers, and there was

no considerable variance in terms of preterm birth and intrauterine growth retardation

 23

between those that consumed alcohol in first and third trimesters and non-drinkers (Murphy,

et al., 2014).

Many factors including maternal age, use of welfare, violence from a male partner,

have also been reported to perpetuate the use of alcohol in the second trimester specifically

among the pregnant women within the lower-income status (Murphy, et al., 2014). Similarly,

the number of years of education and a higher level of self-esteem were considered protective

factors that discouraged low-income pregnant women from maternal alcohol use (Li, et al.,

2012). Research conducted in Nigeria found out that 22.6 percent of women consumed

alcohol during pregnancy and 35.5 percent of these women have basic knowledge of the

dangerous effects of alcohol on their unborn child (Onwuka, 2016). The report further listed

the maternal age of ≤ 30 years old, multi-parity, women without a college education, pre-

pregnancy use of alcohol and insufficient knowledge of the dangers of alcohol on the foetus

as predictors of maternal alcohol consumptions. According to the report, inadequate or lack

of knowledge about the risk of alcohol on the unborn child were the primary predictors of

maternal alcohol consumption (Onwuka, 2016). Similar investigation carry-out in Port-

Harcourt Teaching Hospital in Nigeria with about 221 study subjects to determine the

prevalence of maternal alcohol consumption revealed that 59.28 percent of the subject were

alcohol drinkers, 62.60 percent were regular drinkers, 37.40 percent non-regular drinkers, and

40.72 percent avoided alcohol altogether during pregnancies (Ordinioha and Brisibe, 2015 in

Nwi-ue, 2019).

Statistics have shown that nearly 21.9 percent of reproductive age women smoked and

22 percent smoked into pregnancies. Also, an estimated 14 percent smoked throughout

pregnancy (Parrish, von Sternberg, Velasquez, Cochran, Sampson and Mullen, 2012).

Characteristically, the factors associated with the risk of a nicotine exposed pregnancy:

expanding the choices preconception counseling model to tobacco. Studies have shown that
 24

smoking is one of the preventable and leading cause of adverse pregnancy outcomes such as

low birth weight, intrauterine growth restriction, preterm birth, infant death, stillbirth,

placenta Previa, and preterm membrane rupture (Jacobson, Dong, Scheuermann, Redmond

and Collins, 2015). It has been reported that majority of women that engaged in maternal

smoking are poor, uneducated, resided in poor and violent neighbourhoods, and mostly single

(Jacobson, et al., 2015; Parrish, et al., 2012).

There is evidence linking maternal smoking and adverse pregnancy outcomes. Studies

conducted in the U.S. to determine smoking behaviours between rural and urban residents

found that belonging to the low-income class and living in the rural areas were significant

factors prompting women to smoke before being pregnant, during and eventually after

pregnancy (Jacobson, et al., 2015). Attainment of education above high school, living in

urban area, having a healthy body weight, no prior children, currently taking multivitamins or

17 years or younger were factors that limit or reduce smoking for the three months preceding

pregnancy (Jacobson, et al., 2015). The risks of Nicotine exposed pregnancy has also been

examined to include consistent use of drug, previous history of drug or alcohol treatment,

clean six months prior to becoming pregnant, married or living with a partner, multiple

partners during the six months preceding pregnancy, physical abuse and inadequate education

(Parrish, et al., 2012). Masho, Bishop, Keyser-Marcus, Varner, White and Svikis (2013)

reported a similar factors that contributed significantly to the risk of maternal smoking to

include maternal age, education below high school, unemployment, criminal history, being

on welfare, alcohol and drug use.

It has also been documented that maternal smoking caused infant mortality and its

related morbidities. Study meant to ascertain the growth of vital organs of the foetus due to

maternal smoking has revealed a significant difference between the exposed and unexposed.

For instance, the exposed demonstrated the decreased growth of foetal brain, lung, and
 25

kidney (Anblagan, et al., 2013). Conversely, after accounting for maternal age, gestational

age, and foetal sex, the exposed continues to indicate reduced volumes. Additionally, the size

of the foetus and placenta were smaller compared to the unexposed (Anblagan, et al., 2013).

Another study to determine if there was a significant difference between passive smokers and

active smokers, as well as non-smokers provided information about the relevant association

between maternal smoking and adverse pregnancy outcomes (Nwi-ue, 2019). According to

the reports, among 223 study subjects, 20.2 percent were classified as active smokers, 42.1

percent were considered passive smokers and 37.7 percent group as non-smokers. The results

indicated a statistically significant variance among the three groups, especially labour and

preterm birth. Active smokers were more associated with preterm birth than non-smokers.

Apgar scores average of five minutes among the active smokers was lower compared to non-

smokers (Nwi-ue, 2019).

Pregnancy outcomes and the characteristics of women that use or abuse drug during

pregnancy are very similar to those that smoked or use alcohol during pregnancy. Outcomes

such as low birth weight, congenital disabilities, small head size, premature birth, sudden

infant death syndrome, developmental, learning, memory, and emotion problems are common

among the two groups. Most women that use drugs or substances during pregnancy also

smoke or drink alcohol (Forray, 2016). Available data in the U.S indicated that 15.8 million

women used illicit drugs, 4.6 million women 18 years and older have misused prescription

drugs in the past year, and it is estimated that every three minutes, a woman is admitted to the

emergency ward for prescription drug abuse (Substances Abuse and Mental Health Services

Administration, 2014). Also, in the U.S. nearly 40 percent of women are classified as having

lifetime drug disorder, 26 percent suffered both alcohol and drugs disorder (Forray, 2016).

Besides, it is also stated that women of childbearing age are more vulnerable to experiencing
 26

drug use disorder, specifically those between 18-29 years old (Forray, 2016). Globally, nearly

23-96 percent of women used prescription drugs during pregnancy (Matsui, 2012).

In most developing countries, for example, Nigeria, there is no legal control of most

prescription drugs and that makes it accessible to pregnant women and at the same time

doubling the risk of prescription drugs abuse during pregnancy. Likewise, many pregnant

women in Nigeria still depend on herbs before, during and after pregnancy which can further

compound the risks of maternal drugs abuse (Bello, Olayemi, Morhason-Bello and Adekunle,

2011). The prevalence of substances abuse during pregnancy in Nigeria is relatively low

compared to developed countries such as the United States (Nyango, Daru, Audu, Musa and

Mutihir, 2012).

Maternal prescription drug and substances abuse results in dire consequences for the

foetus and the mother. Studies have established associations between maternal drugs and

substances used and adverse pregnancy outcomes. For example the use of cannabis during

pregnancy has been documented to be associated with several adverse pregnancy outcomes

such as preterm labour, low birth weight, small for- gestational age, and neonatal admission

into intensive care unit (Forray, 2016). Maternal cocaine used has been linked to adverse

outcomes to include the premature rupture of membranes, placental abruption, preterm birth,

low birth weight, and small-for-gestational-age (Forray, 2016). On the same note, an

association between methamphetamine use during pregnancy and poor outcomes has been

documented to include shorter gestational age, lower birth weight, foetal loss, and gestational

hypertension (Forray, 2016). Maternal opioid exposure is found to be related to the risk of

low birth weight, respiratory issues, and responsible for the third trimester bleeding, as well

as mortality and amplified neonatal self-restraint syndrome (Forray, 2016).

Physical violence against women is found in every society notwithstanding the level

of development or socioeconomic status. It is however more pronounced in some settings

 27

than others (Pool, et al., 2014). Statistics put the prevalence of physical violence between 1.2

to 51percent, and in some developing countries, it is as high as 71 percent (Rahman, 2015;

Pool, et al., 2014). Also, the prevalence of violence against pregnant women is estimated to

be 4 to 29 percent in developing countries. Violence against pregnant women takes many

forms such as sexual abuse, emotional abuse and physical abuse (Rahman, 2015). Several

factors have been considered to contribute to domestic violence or violence against women,

especially during pregnancies. This includes poor education, being single, younger age,

smoking, alcohol, and drug use, depression and stressful life event and poor-quality

relationship (Pool, et al., 2014). Domestic or intimate partner violence against pregnant

women has been recognized to be associated with a range of adverse pregnancy outcomes

such as low birth weight, gestational age, preterm delivery, perinatal death, maternal and

perinatal complications (Rahman, 2015; Pool, et al., 2014).

Studies have established associations between domestic or IPV and several poor

pregnancy outcomes. A study to estimate the experience prior to and during pregnancy and

adverse pregnancy outcomes in Canada revealed no significant associations between preterm

birth and small-for-gestational-age, before and after accounting for potential confounding

variables. The report however revealed associations between postpartum depression, and

anxiety in the form of threats and physical violence that commenced before, and continued

throughout pregnancy (Urquia, et al., 2011). A similar positive statistically significant

association was also reported between perinatal mortality and NM but not with early

pregnancy loss (Pool, et al., 2014). A study conducted in Bangladesh among married women

to determined IPV and termination of pregnancy indicated that amongst 1,875 study subjects,

31.3 percent experienced physical/sexual IPV, 13.4 percent experienced sexual violence, 25.8

percent experienced only physical abuse, 21.0 percent reported termination of pregnancy, and

5.8 percent reported termination of pregnancy in the last five years (Rahman, 2015).
 28

Pregnancy is the most sensitive period in women lives and its warrant adequate

nutritious in the form of vitamins and other essential elements. Under-nutrition or over

nutrition may impact foetal growth and development (Lindsay, et al., 2012). Deficiencies of

any micronutrients such as iron, folate, copper, zinc, magnesium, iodine, calcium, vitamin D

and vitamin A, may result in adverse pregnancy outcomes, for instance, anaemia, natural tube

defects, low birth weight, neonatal mortality (Shen, Gong, Xu and Luo, 2015).

In Nigeria, it has been reported that both pregnant and non-pregnant women lack

adequate micronutrients and there is disparity in nutritional intakes between urban and rural

residents (Lindsay, Gibney and McAuliffe, 2012). Several factors account for the

malnutrition among women of childbearing age in Nigeria. These includes poverty, low

status of women, cultural beliefs (prohibiting pregnant women to eat certain foods during

pregnancy), and poor educational status (Lindsay, et al., 2012). The most important reasons

women of reproductive age absent themselves from certain foods during pregnancy is fear of

caesarean section due to costs and religious beliefs, as well as to avoid giving birth to large

babies (Lindsay, et al., 2012). Studies have investigated trace elements in pregnant women to

ascertain their relationship to adverse pregnancy outcomes. Nwi-ue (2019) found that

deficiencies of some essential elements during pregnancy may lead to undesirable

consequences. The study documented that lack of iron and zinc resulted in miscarriage or

preterm delivery. Also, premature rupture of membranes was associated with lower zinc

level, and intrauterine growth restriction linked to lower levels of zinc, copper, calcium, and

iron.

The report highlighted trace elements that were essential during pregnancy for

efficient foetal growth and development. A report from Alberta Canada showed that vitamins

and nutritional supplements are not necessary for healthy and low-risk nutritional deficiencies

pregnant women (Fayyaz, et al., 2014). The report added that only 3 percent folate deficiency
 29

was observed among the cohort of pregnant women. Though 24 percent of the 599 pregnant

women in their first trimester experienced suboptimal Red Blood Cell Folate concentration

(RBCF) (<906 nmol. L-1), percentage was reduced in the second and third trimesters to 9

percent and 7 percent respectively. Nearly half of the women experienced high-RBCF (>1360

nmoi-L-1), and only 1percent of the cohort were considered to have vitamin B12 and B6

deficiencies (Fayyaz, et al., 2014).

2.1.4 Concept of Pregnancy

Pregnancy is the state of carrying a developing embryo or foetus within the female

body. This condition can be indicated by positive results on an over-the-counter urine test,

and confirmed through a blood test, ultrasound, detection of foetal heartbeat, or an X-ray.

Pregnancy lasts for about nine months, measured from the date of the woman's last menstrual

period (LMP). It is conventionally divided into three trimesters, each roughly three months

long (Davis, 2021). Pregnancy is divided into three trimesters of approximately three months

each. The first trimester includes conception, which is when the sperm fertilizes the egg. The

fertilized egg then travels down the Fallopian tube and attaches to the inside of the uterus,

where it begins to form the embryo and placenta. During the first trimester, the possibility of

miscarriage (natural death of embryo or foetus) is at its highest. Around the middle of the

second trimester, movement of the foetus may be felt. At 28 weeks, more than 90% of babies

can survive outside of the uterus if provided with high-quality medical care, though babies

born at this time will likely experience serious health complications such as heart and

respiratory problems and long-term intellectual and developmental disabilities (Abman,

2011).

According to Davis (2021) the most important tasks of basic foetal cell differentiation

occur during the first trimester, so any harm done to the foetus during this period is most
 30

likely to result in miscarriage or serious disability. There is little to no chance that a first-

trimester foetus can survive outside the womb, even with the best hospital care. Its systems

are simply too undeveloped. This stage truly ends with the phenomenon of quickening: the

mother's first perception of foetal movement. It is in the first trimester that some women

experience "morning sickness," a form of nausea on awaking that usually passes within an

hour. The breasts also begin to prepare for nursing, and painful soreness from hardening milk

glands may result.

Studies have revealed that as pregnancy progresses, the mother may experience many

physical and emotional changes, ranging from increased moodiness to darkening of the skin

in various areas. During the second trimester, the foetus undergoes a remarkable series of

developments. Its physical parts become fully distinct and at least somewhat operational.

With the best medical care, a second-trimester foetus born prematurely has at least some

chance of survival, although developmental delays and other handicaps may emerge later. As

the foetus grows in size, the mother's pregnant state will begin to be obvious. In the third

trimester, the foetus enters the final stage of preparation for birth. It increases rapidly in

weight, as does the mother. As the end of the pregnancy nears, there may be discomfort as the

foetus moves into position in the woman's lower abdomen. Edema (swelling of the ankles),

back pain, and balance problems are sometimes experienced during this time period. It has

been found that most women are able to go about their usual activities until the very last days

or weeks of pregnancy, including non-impact exercise and work. During the final days, some

feel too much discomfort to continue at a full pace, although others report greatly increased

energy just before the birth. Pregnancy ends when the birth process begins (Davis, 2021).

Several studies have reported that the usual signs and symptoms of pregnancy do not

significantly interfere with activities of daily living or pose a health-threat to the mother or

baby. However, pregnancy complications can cause other more severe symptoms, such as
 31

those associated with anaemia (Vazquez, 2010). Common signs and symptoms of pregnancy

according to Vazquez (2010) includes tiredness, morning sickness, constipation, pelvic girdle

pain, back pain, Braxton Hicks contractions. Occasional, irregular, and often painless

contractions that occur several times per day, and Peripheral edema swelling of the lower

limbs. Common complaint in advancing pregnancy. Can be caused by inferior vena cava

syndrome resulting from compression of the inferior vena cava and pelvic veins by the uterus

leading to increased hydrostatic pressure in lower extremities. It also include low blood

pressure often caused by compression of both the inferior vena cava and the abdominal aorta

(aortocaval compression syndrome and increased urinary frequency. A common complaint,

caused by increased intravascular volume, elevated glomerular filtration rate, and

compression of the bladder by the expanding uterus. There also the effect of urinary tract

infection and varicose veins. Common complaint caused by relaxation of the venous smooth

muscle and increased intravascular pressure; Hemorrhoids (piles). Swollen veins at or inside

the anal area. Caused by impaired venous return, straining associated with constipation, or

increased intra-abdominal pressure in later pregnancy; regurgitation, heartburn, and nausea,

stretch marks; breast tenderness is common during the first trimester, and is more common in

women who are pregnant at a young age; and, Melasma also known as the mask of

pregnancy, is a discoloration, most often of the face. It usually begins to fade several months

after giving birth.

2.1.5 Pregnancy Management Strategy for women with first Time Experience

The first among the management strategies is pre-conception counselling. Pre-

conception counselling is care that is provided to a woman or couple to discuss conception,

pregnancy, current health issues and recommendations for the period before pregnancy

(Lyons, 2015). Prenatal medical care is the medical and nursing care recommended for
 32

women during pregnancy, time intervals and exact goals of each visit differ by country

(Dowswell, Carroli, Duley, Gates, Gülmezoglu, Khan-Neelofur and Piaggio, 2015). Women

who are high risk have better outcomes if they are seen regularly and frequently by a medical

professional than women who are low risk. A woman can be labelled as high risk for

different reasons including previous complications in pregnancy, complications in the current

pregnancy, current medical diseases, or social issues (Hurt, 2011). The aim of good prenatal

care is prevention, early identification, and treatment of any medical complications. A basic

prenatal visit consists of measurement of blood pressure, fundal height, weight and foetal

heart rate, checking for symptoms of labour, and guidance for what to expect next (Lyons,

2015).

The second of the management strategy is nutrition type and pattern. Nutrition during

pregnancy is important to ensure healthy growth of the foetus. Nutrition during pregnancy is

different from the non-pregnant state. There are increased energy requirements and specific

micronutrient requirements (Lammi-Keefe, Couch and Philipson, 2008). Women benefit

from education to encourage a balanced energy and protein intake during pregnancy (Ota,

Hori, Mori, Tobe-Gai and Farrar, 2015). Some women may need professional medical advice

if their diet is affected by medical conditions, food allergies, or specific religious/ ethical

beliefs. Adequate pre-conception (time before and right after conception) folic acid (also

called folate or Vitamin B9) intake has been shown to decrease the risk of foetal neural tube

defects, such as spina bifida. The neural tube develops during the first 28 days of pregnancy,

a urine pregnancy test is not usually positive until 14 days post-conception, explaining the

necessity to guarantee adequate folate intake before conception. Folate is abundant in green

leafy vegetables, legumes, and citrus. In the United States and Canada, most wheat products

(flour, noodles) are fortified with folic acid (CDC, 2008).

 33

The amount of healthy weight gain during a pregnancy varies (Viswanathan, Siega-

Riz and Moos, 2008). Weight gain is related to the weight of the baby, the placenta, extra

circulatory fluid, larger tissues, and fat and protein stores. Most needed weight gain occurs

later in pregnancy (American College of Obstetricians Gynaecologists, 2013). The Institute

of Medicine recommends an overall pregnancy weight gain for those of normal weight (body

mass index of 18.5–24.9), of 11.3–15.9 kg (25–35 pounds) having a singleton pregnancy.

Women who are underweight (BMI of less than 18.5), should gain between 12.7 and 18 kg

(28–40 lb), while those who are overweight (BMI of 25–29.9) are advised to gain between

6.8 and 11.3 kg (15–25 lb) and those who are obese (BMI ≥ 30) should gain between 5–9 kg

(11–20 lb) ( ACOG, 2013).

It has argued that during pregnancy, insufficient or excessive weight gain can

compromise the health of the mother and foetus. The most effective intervention for weight

gain in underweight women is not clear. Being or becoming overweight in pregnancy

increases the risk of complications for mother and foetus, including caesarean section,

gestational hypertension, pre-eclampsia, macrosomia and shoulder dystocia. Excessive

weight gain can make losing weight after the pregnancy difficult. Some of these

complications are risk factors for stroke (Bushnell, McCullough, Awad, Chireau, Fedder and

Furie, 2014). Around 50 percent of women of childbearing age in developed countries like

the United Kingdom are overweight or obese before pregnancy. Diet modification is the most

effective way to reduce weight gain and associated risks in pregnancy.

Studies have found that intrauterine exposure to environmental toxins in pregnancy

has the potential to cause adverse effects on prenatal development, and to cause pregnancy

complications. Air pollution has been associated with low birth weight infants. Conditions of

particular severity in pregnancy include mercury poisoning and lead poisoning. To minimize

exposure to environmental toxins, the American College of Nurse-Midwives recommends:

 34

checking whether the home has lead paint, washing all fresh fruits and vegetables thoroughly

and buying organic produce, and avoiding cleaning products labelled "toxic" or any product

with a warning on the label (Cunningham, et al., 2014). Pregnant women can also be exposed

to toxins in the workplace, including airborne particles. The effects of wearing an N95

filtering face piece respirator are similar for pregnant women as for non-pregnant women,

and wearing a respirator for one hour does not affect the foetal heart rate (CDC, 2008).

Evidence show that pregnant women or those who have recently given birth in the U.S. are

more likely to be murdered than to die from obstetric causes. These homicides are a

combination of intimate partner violence and firearms. Health authorities have called the

violence "a health emergency for pregnant women," but say that pregnancy-related homicides

are preventable if healthcare providers identify those women at risk and offer assistance to

them (Wallace, 2022).

It has also been reported that most women can continue to engage in sexual activity,

including sexual intercourse, throughout pregnancy. Research suggests that during pregnancy

both sexual desire and frequency of sexual relations decrease during the first and third

trimester, with a rise during the second trimester (Cunningham, et al., 2014). Sex during

pregnancy is a low-risk behavior except when the healthcare provider advises that sexual

intercourse be avoided for particular medical reasons. For a healthy pregnant woman, there is

no single safe or right way to have sex during pregnancy (Cunningham, et al., 2014). Also,

regular aerobic exercise during pregnancy appears to improve (or maintain) physical fitness.

Physical exercise during pregnancy appears to decrease the need for C-section, and even

vigorous exercise carries no significant risks to babies and provides significant health benefits

to the mother. Bed rest, outside of research studies, is not recommended as there is no

evidence of benefit and potential harm (Di Mascio, Magro-Malosso, Saccone, Marhefka and

Berghella, 2016).
 35

Another management strategy is the skill of handling complications. Studies have

shown that each year, ill health as a result of pregnancy is experienced (sometimes

permanently) by more than 20 million women around the world. In 2016, complications of

pregnancy resulted in 230,600 deaths down from 377,000 deaths in 1990 (Naghavi, 2016).

Common causes include bleeding (72,000), infections (20,000), hypertensive diseases of

pregnancy (32,000), obstructed labor (10,000), and pregnancy with abortive outcome

(20,000), which includes miscarriage, abortion, and ectopic pregnancy (Naghavi, 2016). The

following are some examples of pregnancy complications according to (Saccone, Berghella,

Sarno, Maruotti, Cetin and Greco, 2016): Pregnancy induced hypertension; Anaemia;

Postpartum depression, a common but solvable complication following childbirth that may

result from decreased hormonal levels; Postpartum psychosis; Thromboembolic disorders,

with an increased risk due to hypercoagulability in pregnancy. These are the leading cause of

death in pregnant women in the US; Pruritic urticarial papules and plaques of pregnancy

(PUPPP), a skin disease that develops around the 32nd week. Signs are red plaques, papules,

and itchiness around the belly button that then spreads all over the body except for the inside

of hands and face; Ectopic pregnancy, including abdominal pregnancy, implantation of the

embryo outside the uterus; Hyperemesis gravidarum, excessive nausea and vomiting that is

more severe than normal morning sickness; Pulmonary embolism, a blood clot that forms in

the legs and migrates to the lungs; and, acute fatty liver of pregnancy is a rare complication

thought to be brought about by a disruption in the metabolism of fatty acids by mitochondria.

It has observed that a pregnant woman may have a pre-existing disease, which is not

directly caused by the pregnancy, but may cause complications to develop that include a

potential risk to the pregnancy; or a disease may develop during pregnancy (Saccone, et al.,

2016). Diabetes mellitus and pregnancy: deals with the interactions of diabetes mellitus (not

restricted to gestational diabetes) and pregnancy. Risks for the child include miscarriage,
 36

growth restriction, growth acceleration, large for gestational age (macrosomia),

polyhydramnios (too much amniotic fluid), and birth defects (Saccone, et al., 2016). Thyroid

disease in pregnancy: can, if uncorrected, cause adverse effects on fetal and maternal well-

being. The deleterious effects of thyroid dysfunction can also extend beyond pregnancy and

delivery to affect neurointellectual development in the early life of the child. Demand for

thyroid hormones is increased during pregnancy, which may cause a previously unnoticed

thyroid disorder to worsen (Saccone, et al., 2016).

Untreated celiac disease is known to cause a miscarriage, intrauterine growth

restriction, small for gestational age, low birth weight and preterm birth. Often reproductive

disorders are the only manifestation of undiagnosed celiac disease and most cases are not

recognized. Complications or failures of pregnancy cannot be explained simply by

malabsorption, but by the autoimmune response elicited by the exposure to gluten, which

causes damage to the placenta. The gluten-free diet avoids or reduces the risk of developing

reproductive disorders in pregnant women with celiac disease (Saccone, et al., 2016). Also,

pregnancy can be a trigger for the development of celiac disease in genetically susceptible

women who are consuming gluten (Tersigni, Castellani, de Waure, Fattorossi, De Spirito, &

Gasbarrini, 2014). Also, Lupus in pregnancy usually confers an increased rate of fetal death

in utero, miscarriage, and of neonatal lupus. Hypercoagulability in pregnancy: is the

propensity of pregnant women to develop thrombosis (blood clots). Pregnancy itself is a

factor of hypercoagulability (pregnancy-induced hypercoagulability), as a physiologically

adaptive mechanism to prevent postpartum bleeding. However, in combination with an

underlying hypercoagulable state, the risk of thrombosis or embolism may become

substantial (Gresele, 2008).

 37

2.1.6 The Concept of Low Birth Weight (LBW)

It has argued that at a population level, the proportion of infants with a low birth

weight is an indicator of a multifaceted public health problem that includes long-term

maternal malnutrition, ill-health and poor health care in pregnancy (UNICEF-WHO, 2019).

Low birth weight is included as a primary outcome indicator in the core set of indicators for

the Global Nutrition Monitoring Framework. It is also included in the WHO Global reference

list of 100 core health indicators (UNICEF-WHO, 2019).

Low birth weight has been defined by WHO as weight at birth of < 2500 grams (5.5

pounds). It is normally caused by intrauterine growth restriction, prematurity or both. It

contributes to a range of poor health outcomes; for example, it is closely associated with fetal

and neonatal mortality and morbidity, inhibited growth and cognitive development, and

NCDs later in life. Low birth weight infants are about 20 times more likely to die than

heavier infants (WHO, 2017). Low birth weight is more common in developing than

developed countries. However, data on low birth weight in developing countries is often

limited because a significant portion of deliveries occur in homes or small health facilities,

where cases of infants with low birth weight often go unreported. These cases are not

reflected in official figures and may lead to a significant underestimation of the prevalence of

low birth weight (WHO, 2014).

The World Health Organization (WHO) defined low birth weight (LBW) as weight

less than 2500 g at birth. Low birth weight contributes to a variety of pitiable health outcomes

(UNICEF, 2004). The majority of cases involving low birth weight in low income countries

is due to IUGR, while it is mostly due to preterm birth in high income countries. Although in

many cases, the causes of prematurity are vague, they may include maternal high blood

pressure, acute infections, hard physical work, multiple births, stress, anxiety, and other

psychological factors such as gender-based violence. The causes of IUGR include, poor
 38

nutritional status of the mother at conception, low weight gain during pregnancy due to

insufficient dietary intake or extra expenditure of calories (hard work), short maternal height

due to youthful under-nutrition and infections, anaemia, acute and chronic infections that

could result in under-nutrition and consecutive poor pregnancy outcomes including low birth

weight (Family Health Bureau ministry of health, 2013).

Low birth weight is a global public health challenging problem. Its high priority stems

from the fact that it is the major determinant of infant morbidity and that it contributes

markedly to the overall burden of childhood death. LBW has also been linked to the high

prevalence of stunting seen in low income countries and may be important in the ethology of

chronic dietary diseases such as obesity, diabetes and cardiovascular diseases in

adulthood (FHBMH, 2013). Worldwide more than 20 million low birth weight occur

annually with the incidence of 15 to 20%, majority of this occur in low- and middle-income

countries and 95.6% occur in developing nations. Its regional estimate was 28% in South

Asia, 13% in sub-Saharan Africa and 13% in least developed country as EDHS 2011 report in

Addis Ababa, Ethiopia 11.4% are LBW (WHO, 2014).

As indicated in many studies, being born with LBW is generally recognized as a

disadvantage for the infant. Among all neonatal death 60 to 80% occur due to LBW. It is an

important cause of perinatal mortality and both short- and long-term infant and childhood

morbidity. Mortality rate of LBW infant were up to 40 times higher than infants with birth

weights of at least 2500 g, and they are many times more likely to end up with long-term

handicapping conditions (Ghimire, Phalke, Phalke, Banjade and Singh, 2014). A recent

study done in India has reported that maternal age (< 19 years), rural residence, maternal

weight (< 45 kg), gestational age (< 37 weeks), bad obstetric history and Pregnancy-induced

hypertension have a strong association with low birth weight. A number of studies have

shown correlates of infant’s maternal nutritional status, young maternal age, bad obstetric
 39

history, maternal anaemia and rural settlements, antenatal care received, prematurity, the

birth interval with low birth-weight (Muftah, 2016).

2.1.7 The Concept of Maternal Mortality

Maternal death or maternal mortality is defined in slightly different ways by several

different health organizations. The World Health Organization (2016)defines maternal death

as the death of a pregnant mother due to complications related to pregnancy, underlying

conditions worsened by the pregnancy or management of these conditions. This can occur

either while they are pregnant or within six weeks of resolution of the pregnancy (Indicator

Metadata Registry Details, 2019). The CDC definition of pregnancy-related deaths extends

the period of consideration to include one year from the resolution of the pregnancy Centers

for Disease Control and Prevention (2019). Pregnancy associated death, as defined by the

American College of Obstetricians and Gynaecologists (ACOG), are all deaths occurring

within one year of a pregnancy resolution (CDCP, 2019). Identification of pregnancy

associated deaths is important for deciding whether or not the pregnancy was a direct or

indirect contributing cause of the death.

There are two main measures used when talking about the rates of maternal mortality

in a community or country. These are the maternal mortality ratio and maternal mortality rate,

both abbreviated as "MMR". By 2017, the world maternal mortality rate had declined 44%

since 1990; however, every day 808 women die from pregnancy or childbirth related causes

(United Nations Population Fund, 2017). According to the United Nations Population Fund

(UNFPA) 2017 report, about every 2 minutes a woman dies because of complications due to

child birth or pregnancy. For every woman who dies, there are about 20 to 30 women who

experience injury, infection, or other birth or pregnancy related complication (UNFP, 2017).

The UNFPA estimated that 303,000 women died of pregnancy or childbirth related causes in

2015. The World Health Organisation divides causes of maternal deaths into two categories:
 40

direct obstetric deaths and indirect obstetric deaths. Direct obstetric deaths are causes of death

due to complications of pregnancy, birth or termination. For example, these could range from

severe bleeding to obstructed labour, for which there are highly effective interventions

(Ozimek, & Kilpatrick, 2018). Indirect obstetric deaths are caused by pregnancy interfering

or worsening an existing condition, like a heart problem (Indicator Metadata Registry Details,

2021).

Maternal Mortality as death of either a pregnant woman or death of a woman within

42 days of delivery, miscarriage, termination or ectopic pregnancy providing the death is

associated with pregnancy or its treatment (Payne, 2016). Most maternal mortality occurs in

the developing world; every day in 2015, 830 women died worldwide as a result of a

pregnancy-related problem, the vast majority in sub-Saharan Africa. Maternal mortality has

decreased significantly between 1990 and 2015 but not quickly enough to achieve the

Millennium Development Goal of a reduction of 75% in the number of deaths per live births

by 2030. However, some countries have made significant improvements, both as a result of

improved access to healthcare but also, for example, by increasing the proportion of girls

accessing education (Alkema, Chou and Hogan, 2015). The risk factors for direct maternal

deaths in the according to Nair, Kurinczuk, & Brocklehurst (2015) include gestational

diabetes; hypertensive disorders of pregnancy; anaemia; and, multiple pregnancy. It has

observed that inadequate use of antenatal care services, whether due to lack of access or other

reasons.

According to UNFPA, there are four essential elements for prevention of maternal

death. These include, prenatal care, assistance with birth, access to emergency obstetric care

and adequate postnatal care. It is recommended that expectant mothers receive at least four

antenatal visits to check and monitor the health of mother and foetus. Second, skilled birth

attendance with emergency backup such as doctors, nurses and midwives who have the skills
 41

to manage normal deliveries and recognize the onset of complications (UNPF, 2017). Third,

emergency obstetric care to address the major causes of maternal death which are

haemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour. Lastly,

postnatal care which is the six weeks following delivery. During this time, bleeding, sepsis

and hypertensive disorders can occur, and new-borns are extremely vulnerable in the

immediate aftermath of birth. Therefore, follow-up visits by a health worker to assess the

health of both mother and child in the postnatal period is strongly recommended (UNPF,

2017).

Studies have reported that maternal death surveillance and response is another

strategy that has been used to prevent maternal death. This is one of the interventions

proposed to reduce maternal mortality where maternal deaths are continuously reviewed to

learn the causes and factors that led to the death. The information from the reviews is used to

make recommendations for action to prevent future similar deaths (WHO, 2013). Maternal

and perinatal death reviews have been in practice for a long time worldwide, and the World

Health Organization (WHO) introduced the Maternal and Perinatal Death Surveillance and

Response (MPDSR) with a guideline in 2013. Studies have shown that acting on

recommendations from MPDSR can reduce maternal and perinatal mortality by improving

quality of care in the community and health facilities.

2.1.8 The Concept Neonatal Mortality

The World Health Organization (WHO, 2016) defines neonates as live-born infants

whose age is within 28 complete days of birth. Neonatal mortality (NM) is defined as infant

death, which occurred during the first four weeks of life after birth FMOH, (2014). The

analysis of Demographic and Health Surveys from 25 sub-Saharan African countries from

2000 to 2016 showed that the percentage of all live births occurring in health facilities ranged
 42

from 22% to 92% In Ethiopia, below fifty percent (48%) of pregnant women gave birth at

health facilities in 2019 (Central Statistical Agency, 2019). Evidently, between 1990 and

2017, the global Neonatal Mortality Rate (NMR) decreased by 51%, from 36·6 deaths per

1000 livebirths in 1990, to 18.1 deaths per 1000 live births in 2017 In 2018, an estimated 2.5

million neonatal deaths happened worldwide. Out of these, more than 1.1 million deaths were

contributed by sub-Saharan African countries (UNICEF, (2018). In Ethiopia, neonatal

mortality rate ranges between 23.4 deaths per 1000 live births and 44 deaths per 1000 live

births. Though Ethiopia has made great progress in the reduction of neonatal mortality rates

from 2000 (49 per 1000 live births) to 2019 (30 per 1000 live births), the neonatal mortality

reduction in Afar region is at stable state (45 per 1000 in 2000 and 39 per 1000 live births in

2019) compared to other developed regions of the country (CSA, 2019).

Studies conducted in developing countries have been identified various risk factors

associated with neonatal mortality. These include maternal education level, multiple births,

lack of antenatal cares, maternal infections during pregnancy, prematurity, birth asphyxia and

neonatal sepsis (Edward, Alcock, Azad, Bapat and James (2015). Moreover, studies

conducted across Ethiopia have been identified different causes of neonatal deaths. Of these,

67% of neonatal deaths were attributed to birth asphyxia, neonatal infections and prematurity

respectively (Mehretie, 2016). Globally, different strategies, and policies have been tried to

reduce neonatal, infant and under five mortalities. These include Millennium Development

Goals (MDG-4) that was implemented to reduce child mortality by three-fourth at the end of

2015. The second is the Sustainable Development Goal (SDGs-3) which has 13 specific

targets to reduce the burden of neonatal mortality (i.e. 20 to 12 deaths per 1000 live births) by

the end of 2030 (WHO, 2016).

 43

2.1.9 Empirical Related Studies

Fentie, Yeshita, & Bokie (2022) conducted a study to compare the prevalence of low

birth weight and their associated factors among HIV+ and HIV- mothers delivered in

Northwest Amhara region referral hospitals. A comparative cross-sectional study was

conducted from September 2016 to September 2019. A simple random sampling technique

was used to select 474 participants. Data were collected from the mothers’ chart by using a

data extraction sheet and then entered into Epi-data and exported into SPSS for analysis.

Independent variables with p-values < 0.2 in the bivariate analysis were entered into

multivariable logistic regression models with backward logistic regressions method to control

confounders and identify the factor. The overall prevalence of low birth weight was 13.9

percent (95% CI: 10.8%-17.1%). The prevalence was higher among HIV+ 17.7 percent (95%

CI: 14.1%-22.8%) than HIV- mothers 10.1 percent (95% CI: 6.3%—13.8%). CD4 count <

200 cells/mm3 [AOR 3.2, 95%CI (1.05, 9.84)] and between 200–350 cells/mm3 [2.81, 95%

CI (1, 08, 7.28)], Mothers with MUAC <23 cm [AOR 3.39, 95% CI (1.41, 8.18)] and

gestational age <37 weeks [AOR 7.34, 95% CI (3.02, 17.80)] were significantly associated

with LBW in HIV+ mothers. While, rural residence [AOR 3.93, 95% CI (1.356, 11.40)],

PROM during current pregnancy [AOR 4.96, 95% CI (2.55, 15.83)] and gestational age <37

week [AOR 8.21, 95% CI (2.60, 25.89)] were significantly associated with LBW in HIV

negative mothers. It was concluded that, the prevalence of LBW was significantly higher

among HIV+ mothers as compared to HIV-mothers and this study suggests to emphasize

nutritional supplementation of HIV positive mothers, needs to focus on nutritional

counselling during ANC/PMTCT follow up and encourage HIV positive mothers to delay

their pregnancy until their immune status improve.

Nwafor, Onuchukwu, Obi, Ugoji, Onwe, Ibo and Obi (2019) conducted a study is to

determine the association between threatened miscarriage and adverse maternal and perinatal
 44

outcomes. This was a retrospective case-control study undertaken at the Alex Ekwueme

Federal University TeachingHospital, Abakaliki. The study involved 228 women presenting

with threatened miscarriage in the first trimester and 228 asymptomatic matched controls.

The statistical analysis was done using Epi info version 7.1.5, March 2015(CDC, Atlanta,

Georgia, USA). It found that women with threatened miscarriage were more likely to have

preterm delivery (OR = 7.1, 95% CI = 3.51-14.32, P <0.0001), placenta Previa (OR = 2.4,

95% CI = 1.13 - 5.26, P = 0.03), placental abruption (OR = 3.6, 95%CI = 1.40 - 9.03, P =

0.01) and retained placenta (OR = 2.9, 95% CI = 1.18 - 6.97, P = 0.02). Similarly, women

with first trimester threatened miscarriage were more likely to develop postpartum

haemorrhage (OR = 2.4, 95%CI = 1.17 - 5.06, P = 0.02). There was no significant differences

in the stillbirth rate, Apgar scores at 5 minutes less than 7, admission into neonatal intensive

care unit and early neonatal death. Threatened miscarriage was associated with intrauterine

growth restriction (OR = 3.5, 95% CI = 1.77 - 6.88, P <0.0001) and low birth weight <2.kg

(OR = 3.2, 95% CI = 1.33 - 7.69, P = 0.01). It was concluded that women with threatened

miscarriage in the first trimester are at increased risk of adverse pregnancy outcomes and the

risk factors should be taken into consideration when deciding upon antenatal surveillance and

management of their pregnancies.

Gyimah, Annan, Apprey, Asamoah-Boakye, Aduku, Azanu, Lutterodt and Edusei

(2021) also conducted a study that examined the relationship between nutritional status and

birth outcomes among Ghanaian pregnant adolescents in selected districts of the Ashanti

Region, Ghana. In this prospective cohort study, we followed 416 pregnant teenagers

recruited at health centers during antenatal care until delivery. We measured weight and

height to calculate Body Mass Index (BMI), and Mid-Upper Arm Circumference (MUAC),

and nutrient intakes using a repeated 24 hr dietary recall were collected. Hemoglobin (Hb),

serum levels of ferritin, prealbumin, vitamin A, Total Antioxidant Capacity (TAC), C-

 45

reactive protein (CRP), and Zinc Protoporphyrin (ZPP) were analysed. Birth outcome data of

interest were low birth weight (LBW) and preterm births (PTB). About 15.2 % had LBW,

12.5 % had PTB, and 3.1 % neonatal deaths. The majority of the pregnant adolescents

consumed below Estimated Average Requirements (EAR) for thiamin (75.7 %), riboflavin

(84.6 %), folate (82.9 %), vitamin A (87.3 %), iron (93.5 %), zinc (83.7 %), and calcium

(96.9 %) intakes, while energy (96.6 %), protein (84.6 %), and dietary fiber (74.4 %) were

below the Recommended Dietary Allowance (RDA). Anaemia and wasting prevalence were

57.1 % and 27.8 %. The mean intakes for carbohydrates (p = 0.042) and dietary fiber (p =

0.012) were significantly higher among adolescent mothers with term birth (276.7 ± 111.2 g,

23.7 ± 11.2 g) than those with PTB (237.3 ± 83.7 g, 19.4 ± 9.0 g), respectively. Preterm birth

proportions were higher in severely wasted (18.8 %) adolescents than moderately wasted (6.2

%) and normal MUAC (14.0 %) adolescents (p = 0.184). LBW proportions were higher

among anaemic (18.1 %) than the non-anemic (12.1 %), among low (30 %) compared with

normal (14.9 %) serum ferritin, among low (15.7 %) compared with normal (0 %) serum

prealbumin, and among low (16.2 %) compared with normal (11.1 %) serum vitamin A status

pregnant adolescents. Pregnant adolescents with moderate wasting had lower odds (Adjusted

odds ratio = 0.2, p = 0.017, 95 % confidence interval = 0.1–0.8) of having LBW infants

compared with those with normal MUAC. The odds of preterm births were significantly

higher among pregnant adolescents with dietary fiber intake below the RDA (Unadjusted OR

= 2.8, p = 0.042, 95 % CI = 1.0–7.3). In conclusion, adverse birth outcomes were associated

with poor nutritional status among pregnant adolescents studied.

Girma, Fikadu and Agdew (2019) conducted a study on Factors associated with low

birth weight among new borns delivered at public health facilities of Nekemte town, West

Ethiopia. Facility based unmatched case control study was employed from February to April

2017. The data were collected using structured, pretested interviewer administered
 46

questionnaire in all public health facilities of Nekemte town. Consecutive live births of less

than 2500 g in each of the hospitals and health centres were selected as cases and succeeding

babies with weights of at least 2500 g. as controls. Data were entered in to Epi-data software

version 3.1 and exported to SPSS Version 21 and analysed using frequency, cross-tabs and

percentage. Factors with p-value < 0.25 in bivariate analysis were entered in to multivariable

logistic regression and statistical significance was considered at p-value < 0.05. A total 279

(93 cases &186 controls) were included in the study with a mean birth weight of 2138.3 g ±

SD 206.87 for cases and 3145.95 g ± SD 415.98 for controls. No iron-folate supplementation

(AOR = 2.84, 95% CI, 1.15–7.03), no nutritional counselling (AOR = 4.05, 95%CI, 1.95–

8.38), not taking snacks (AOR =3.25, 95%CI, 1.64–6.44), maternal under nutrition (AOR

=5.62, 95%CI, 2.64–11.97), anaemia (AOR = 3.54, 95%CI, 1.46–8.61) and inadequate

minimum dietary diversity score of women MDDS-W (AOR = 6.65, 95%CI, 2.31–19.16)

were factors associated with low birth weight. It was concluded that lacking nutrition

counselling during pregnancy, lacking iron/folic acid supplementation during pregnancy, not

taking snacks during pregnancy, maternal under-nutrition, maternal anaemia and inadequate

minimum dietary diversity score of women (MDDS-W) were independently associated with

LBW. Thus, public health intervention in the field of maternal and child health should

address these determinants.

2.2 Theoretical Framework

The Social Cognitive Theory (SCT) was adopted in this work to provide the empirical

background needed to guide the study. According to Miller and Dollard (1941) the social

cognitive theory (SCT) assesses the predictors of poor pregnancy outcomes in women. This

theory was first developed by Miller and Dollard (1941) and was initially known as social

learning theory. Later, Bandura (1997) advanced the theory by incorporating concepts from
 47

psychology and renamed it social cognitive theory (SCT) (Glanz, Rimer and Viswanath,

2008). The Social Cognitive Theory is widely used in social science research, especially in

public health for program intervention, assessment, and evaluation (Wilson, 2012).

This theory assumes that the interchange of personal factors, behaviour and

environmental factors help impact or shape human behaviour. The theory further highlights

the abilities of people to amend or build their desired environment through the knowledge of

collective actions (Glanz et al., 2008). This theoretical framework provides the following

primary concepts, namely smoking, age, ethnicity, use of drug, education, employment, race,

nutrition and mineral salts and trace elements, which was tailored in this study to explain the

association between them adverse pregnancy outcomes such as maternal mortality, neonatal

mortality and low birth weight (Glanz et al., 2008).

The reciprocal determinism as indicated in the diagram assumes that behaviour can be

amended in several ways through interaction with people and the environment, either through

changing the personal attitude or making a modification to the environment. In this research,

this implies that individual demographic factors such as cultural and religious beliefs, age,

female empowerment, socioeconomic factors (education, income, and occupation), and

environmental factors, which include availability of health facilities and health professionals,

and affordability of care can be influenced to help expectant mothers make positive

behaviour changes such as early booking and selection of skilled antenatal care to help select

the appropriate mode of delivery based on the situation (Wilson, 2012; Glanz et al., 2008).

Such positive behaviour modifications will translate to improving pregnancy outcomes in

Nigeria. Outcome expectation is the anticipated outcome of a behavioural choice or model

leading to positive outcomes of healthful behaviour. In the current research context, every

pregnant woman expects a positive pregnancy outcome, which is paramount to personal

factors such as early antenatal booking, use of antenatal services and proper nutrition to
 48

reduce chances of preterm delivery, adherence to medical advice and instruction to mitigate

history of poor pregnancy outcomes, and the use of skilled professional attendants during

vaginal delivery.

Self-efficacy shown in the diagram implies the capability or confidence in a person’s

own ability to take action and overcome obstacles. The concept of self-efficacy is task-

specific; either increase or decrease depends on the task. In this research, self-efficacy refers

to the ability of a pregnant woman to take a concrete step or action towards improving her

pregnancy outcomes. For example, such steps include not becoming pregnant until after 20

years of age, avoiding unwanted pregnancy and unnecessary abortion, booking early for

antenatal care services when pregnant, using trained professionals during labour, and using

dietary supplements and proper nutrition to reduce the chances of preterm delivery.

It is important to note that taking such steps during pregnancy and in the postnatal

period will improve pregnancy outcomes (Shorey, Chan, Chong and He, 2015; Glanz et al.,

2008). Collective efficacy implies the capability or confidence of groups or communities to

become involved in bringing about the desired change. In this research, desired behaviour

changes to reduce maternal mortality, neonatal mortality and low birth weight to improve

pregnancy outcomes in Nigeria can be accomplished through collective actions of community

members by promoting and educating pregnant women and women of childbearing age on

the importance of early booking and the use of antenatal care services, hospital facilities, and

skilled attendants during labour and delivery. Instead of utilizing untrained personal or

delivery at home, collective actions of the community can also include educating pregnant

women and women of childbearing age on how to cut across ethnic, religious, and cultural

barriers to embrace modern medicine. Likewise, governments at all levels can bring about the

desired changes by developing and implementing appropriate interventions and policies that
 49

will be tailored toward positive behaviour changes, thereby improving pregnancy outcomes

for women of reproductive age in Nigeria (Glanz et al., 2008).

As indicated in the diagram, observational learning suggests that behaviour can be

acquired by observing or watching the actions and outcomes of the behaviour of others or the

behaviour of a role model. In this research context, several behaviours that increase the risk

of poor pregnancy outcomes can be overcome by allowing pregnant women or women of

childbearing age to observe the actions and outcomes of other women who have successfully

changed their behaviours and improved their pregnancy outcomes. Therefore, an aggressive

health campaign, education, and promotions featuring women who have adjusted or modified

their behaviours and improved outcomes would motivate other pregnant women or women of

reproductive age to do the same (Glanz et al., 2008).

Also, as shown in the diagram, incentive motivation involves the use of rewards and

punishments to amend behaviour. Studies conducted in Nigeria had demonstrated that women

who reside in rural areas in the northwest region and those with lower socioeconomic status,

some cultural and religious barriers, and less than 20 years of age are consistently noted for

poor pregnancy outcomes (Awoleke, 2012). To improve pregnancy outcomes for these

women, local, state, and federal governments as well as community programs need to provide

incentives and rewards. For example, cash assistance, transportation services to and from the

hospital for antenatal care related services, skilled attendant home visits during pregnancy

and postnatal period, provision of vitamin and other nutritional supplements, and educational

programs that help reduce maternal mortality, neonatal mortality and low birth weight and

improve pregnancy outcomes for these women (Glanz et al., 2008).

Facilitation listed in the diagram indicates provision or availability of resources, tools

or changes within the environment that foster behavioural change. Resources can be provided

through knowledge and skill-based training intervention programs aimed at improving the
 50

socioeconomic status (education, income, and occupation) of reproductive age

women. Furthermore, childbearing age women could be empowered to foster an environment

where they can strive to make an independent decision regarding their reproductive health,

such as when to get pregnant, the number of children to bear, use of contraceptives for proper

spacing of pregnancies, and to become pregnant only after 20 years of age (Glanz et al.,

2008). Self-regulation or self- control implies self-monitoring, setting goals, self-reward,

accepting feedback, self-instruction, and seeking social support when necessary. In this

context, it implies reproductive age women setting personal goals of when to becomes

pregnant, the number of children to bear, and the use of contraceptives for adequate spacing

of children. Such realistic goal setting and monitoring to ensure the success desired will

improve pregnancy outcomes and reduce maternal mortality, neonatal mortality and low birth

weight among childbearing age women in Nigeria (Glanz et al., 2008).

An important concept in the diagram which is moral disengagement indicates the

process of thinking relating to dangerous behaviour. A person can learn the moral standard

for self-regulation, and violation of this moral standard is considered moral disengagement

(Glanz et al., 2008). In this research context, engaging in a moral standard for self-regulation

involved pregnant women or women of childbearing age engaging in healthy behaviours such

as avoidance of alcohol, smoking, and use of illegal drugs or entirely abstain from behaviours

that will be harmful to foetuses. This includes the use of antenatal care services, early

booking, and the use of skilled personnel during labor and delivery, all of which will help

minimize fatal pregnancy outcomes.

There are several limitations of SCT, which should be considered when using this theory in

public health. Limitations of the model include the following:

 51

a. The theory assumes that changes in the environment will automatically lead to

changes in the person, when this may not always be true.

b. The theory is loosely organized, based solely on the dynamic interplay between

person, behavior, and environment. It is unclear the extent to which each of these

factors into actual behavior and if one is more influential than another.

c. The theory heavily focuses on processes of learning and in doing so disregards

biological and hormonal predispositions that may influence behaviors, regardless of

past experience and expectations.

d. The theory does not focus on emotion or motivation, other than through reference to

past experience. There is minimal attention on these factors.

e. The theory can be broad-reaching, so can be difficult to operationalize in entirety.

The SCT theoretical model was used to explore the process of interaction between personal

and environmental factors that shape the behaviour of reproductive age women and how it

influences pregnancy outcomes. The study used primary data from May, to determine the

predictors of poor pregnancy outcomes among Port Harcourt City women in relation to SCT

and how that influenced the behaviour of women of childbearing age (15-35 years).
 52

CHAPTER THREE

RESEARCH METHODOLOGY

3.1 Research Design

The study employed a descriptive survey design. According to Gay, Geoffrey

and Peter (2012) descriptive research is a survey research. It involves collecting data in order

to test hypotheses or to answer questions about the opinions of people on some topic or issue.

Besides, Creswell, (2012) stated that survey research designs are procedures in quantitative

research in which investigators administer a survey to a sample or to the entire population of

people to describe the attitudes, opinions, behaviours, or characteristics of the population.

The survey research abhors the manipulation of the study subjects. This study was to a

descriptive study. Data was collected at nominal level basically on issues that relate with the

objectives of the study.

3.2 Area of Study

Port Harcourt Local Government Area (PHALGA) is a local government area of

Rivers State in southern Nigeria. It is one of the 23 local government areas created for the

state. Its administrative seat is located in Port Harcourt. Although the local government

consists of two different ethnic groups the Ikwerre and Obulom. Port Harcourt local

government area is situated within Rivers state, South-south geopolitical zone of Nigeria. The

headquarters of the LGA are in the town of Port Harcourt which doubles as the capital city of

Rivers state. Port Harcourt LGA is bordered by Okrika, Degema, Eleme, and Obio Akpor

LGAs. Port Harcourt LGA is made up of several districts such as Orolozu, Nkpogu,

Rumuobiekwe, Ogbunabali, Abuloma, New GRA, Diobu, and Oroabali. The current

estimated population of Port Harcourt LGA is put at 669,732 inhabitants with the area

hosting members of diverse ethnic colourations. The English and Pidgin English languages
 53

are commonly spoken in Port Harcourt LGA while the religion of Christianity is

predominantly practiced in the area. Notable landmarks in Port Harcourt LGA include the

Rivers state University and the Methodist Girls High School, Diobu.

Port Harcourt LGA covers an area of 109 square kilometres and has an average tewmperature

of 26 degrees centigrade. The LGA witnesses two distinct seasons which are the rainy and the

dry seasons with the area having an average humidity level of 72 percent.

Trade is an important feature in the economy of Port Harcourt LGA with the area

hosting several markets such as the Mile one and the Obio Akpor international markets which

attract thousands of buyers and sellers of varying commodities. Port Harcourt LGA also hosts

several banks, private establishments, industries, educational and health facilities, relaxation

spots, hotels, restaurants, and government owned institutions which all contribute massively

to the economic development of the LGA. There are many hospitals, clinics and health

centres located in strategic place where pregnant women visit for antenatal postnatal care.

Upon these visits, it has been observed that many women with first pregnancy experience in

the area usually have poor pregnancy outcomes. This fact makes the study are suitable for the

present study.

3.3 Population of the Study

The population for the study was 550 labour/delivery nurses. The study population is

infinite, as it comprises of only labour/delivery nurses-women in the reproductive age of 25-

39 years.

3.4 Sample Size and Sampling Procedure

Stratified random sampling was used to select 11 maternity hospitals/clinics in Port

Harcourt Local Government Area. While purposive sampling was used to sample 226

labour/delivery nurses out of the 550 target population from the maternity hospitals/clinics

located strategically in the area of study. These maternity hospitals/clinics include University of
 54

Port Harcourt Teaching Hospital (UPTH); Braithwait Memorial Hospital (BMH), Rivers State

University Teaching Hospital (RSUTH), East Land Hospital and Maternity, Worlu St.; Francal

Memorial Clinic and Maternity, Chief Ali St.; Caprin Hospital and Maternity Ltd. Enema Road; Rac

Faith Home Maternity, Marine Base Road; Citadal Hospital and Maternity, Okorji St.; Emmaculate

Clinic And Maternity, Ikwerre Road; The Omega Clinic for Children, ADC Close; and Tehilah

Children Hospital, Maxwell Adoki St. Three sampling techniques namely, stratified random

sampling, purposive and cluster and simpling was deplored to select the samples.

In the study, 20 respondents or samples was selected from every maternity

hospitals/clinics except the University of Port Harcourt Teaching Hospital (UPTH) where 26

was selected, thus, implying the use of purposive sampling method. Since the study focused

on women within the reproductive of 25-39 particularly those with pregnancy, the

concentration was at the maternity and PHC sections in the 11 selected hospitals and clinics.

The maternity and PHC sections in the hospitals and clinics are considered as clusters and the

purposive sampling procedure was used to select the respondents for the study.

3.5 Sources of Data

The data used in this study was obtained from a source, that is, from primary source.

Data from the primary source constituted the ones elicited from the respondents directly by

the researcher. No secondary data was conversely obtained from books, journals, pamphlets,

newspapers, magazines and the internet.

3.6 Research Instrument

The instrument used for ths study was a self structured questionnaire titled “Analysis

of Pregnancy Management Strategies and Outcomes Among Women with First-Time

Experience” (APMSOAWFTE) which was developed by the researcher based on literatures

reviewed. The instrument has four sections. Section A sought information about the category
 55

and bio data of the respondents. Section B consisted of items from 1-4 and sought

information about the association between socio-demographic factors of women with first

pregnancy experience and poor pregnancy outcomes in Port Harcourt City. Section C

consisted of items from 5- 8 and sought information about the association between socio-

economic factors of women with first pregnancy experience and poor pregnancy outcomes in

Port Harcourt City. Section D consisted of items from 9- 12 and sought information about the

association between lifestyle of women with first pregnancy experience and poor pregnancy

outcomes in Port Harcourt City. Sections B to D were rated on a four point rating scale of

Strongly Agreed (SA) with 4 points; Agreed (A) with 3 points; Disagreed (DA) with 2 points

and Strongly Disagreed (SDA) with 1 points. The respondents were expected to tick on the

option that best described their agreement with the questionnaire item.

3.7 Validation of the Instrument

The research instrument was faced content validated by the supervisor and the two

experts in the field of study. This was enhanced owing to series of corrections and criticisms

that were put in place before the instrument was final administered.

3.8 Reliability of the Instrument

The test-retest reliability approach was used to conduct the pilot study. The

computation was done using the responses of 10 expectant women at from Ahoada East and

Wast Local Government Area, Rivers State which is outside the study location. The result of

the tests was processed manually using the Pearson Product Moment Correlation (PPMC) and

a reliability coefficient of 0.84 was obtained, this guaranteed the reliability of the instrument.
 56

3.9 Procedure for Data Collection

The data was obtained by means of the structured questionnaire. The maternity

hospitals/ used as samples for the study were visited by the researcher. The researcher toke

permission from obstetricians/doctors of the maternity hospitals/clinic and they directed their

labour/delivery nurses to assist the researcher in filling of the questionnaires when they are

not busy. The researcher explain the purpose of the questionnaire to the respondents and

made them understand that the information given will not be used against them but will be

treated as confidential. The researcher employed the services of three (3) research assistants

to administer the instruments to the respondents. A total of 226 copies of the instrument

were administered to the respondents. The respondents were guided by the researcher and

the research assistance in filling of the instrument and the copies of the questionnaires were

retrieved immediately. This was to ensure accurate completion and high rate of return of the

instrument. However, all 226 copies of the instruments administered to pregnant women

were retrieved. These were used for data analysis.

3.10 Data Collection Techniques

Mean was used to answer and analyzed the research questions posed for the study.

The mean was obtained by the summation of all responses as assigned to the rating scale in

an item divided by the total number of responses. The decision rule was based on the

criterion mean score of 2.50 and above which is the benchmark for acceptance, while any

item with a mean score below 2.50 was rejected. Chi-square (x 2) statistic specifically, Yates's

Correction Formula for Continuity (or Yates's Chi-squared Test), was used to test the

hypotheses formulated for the study at 0.05 level of significance. If X 2Yates -calculated is equal

to or greater than X2Yates -critical or table value, the hypothesis is rejected but if otherwise, the

hypothesis will be accepted.

 57

Criterion Mean (x) = 4+3+2+1/4 = 15/5 = 2.5 or 2.50.

3.11 Ethical Issues

This study will adhere to ethical requirements. Permission to obtain and use this data

was obtained from maternity hospitals/clinics obstetricians/doctors. The data obtained from

the respondents did not include their names. All the information was held in absolute

confidence by the researcher and the data was stored in a personal computer and protected

with a password only the researcher had access to.

 58

CHAPTER FOUR
DATA PRESENTATION, ANALYSIS AND DISCUSSION OF FINDINGS

After retrieving all the copies of the questionnaire, they were subjected to inspection and it

was observed that they were properly completed. They were then used for data analysis as

shown below:

4.1 Data Presentation and Analysis

Research Question 1: what is the association between social-demographic factors of women

with first pregnancy experience and poor pregnancy outcomes?

Table 4.1: Responses and Mean Score Analysis of the Association between Socio-
demographic Factors of Women with First pregnancy Experience and Poor Pregnancy
Outcomes
S/N ITEMS SA A D SD TOTAL DECISION
M
1 Women at advanced and 78 89 38 21 226 2.99 Agree
young maternal age are (312) (267) (76) (21) (676)
more prone to pregnancy
risks and adverse
pregnancies outcomes.
2 Adolescent pregnancies 67 97 30 32 226 2.88 Agree
and childbirth are (268) (291) (60) (32) (651)
susceptible to the
expanded risk of poor
pregnancy outcome.
3 Some delayed or rejection 78 74 41 33 226 2.87 Agree
of cesarean section by (312) (222) (82) (33) (649)
pregnant women is
impacted by socio-
cultural, gender and
religious philosophy.
Pregnant women at the 70 92 24 40 226 2.99 Agree
low-income level were (312) (276) (48) (40) (676)
4 more vulnerable to the
increased risk of poor
pregnancy outcomes
compare to those with
middle to higher incomes.
Grand mean 2.93
Source: Field Work, 2023
 59

From table 4.1 above, it can be observed that all the items in the questionnaires for the

labour/delivery nurses or respondents attracted mean scores above 2.50 indicating that all the

respondents perceived and agreed that socio-demographic factors of women with first

pregnancy experience can lead to poor pregnancy outcomes amongst.

Research Question 2: what is the association between social-economic factors of women

with first pregnancy experience and poor pregnancy outcomes?

Table 4.2: Responses and Mean Score Analysis of the Association between Socio-
economic Factors of Women with First pregnancy Experience and Poor Pregnancy
Outcomes in Port Harcourt City

S/N ITEMS SA A D SD TOTAL DECISION

M
5 Pregnant women of low 74 110 25 17 226 3.06 Agree
socioeconomic status are (296) (330) (50) (17) (693)
less likely to have
received antenatal care
and less likely to have
received routine
postnatal checkups.
6 Pregnant women of low 86 100 22 18 226 4.12 Agree
socioeconomic status are (430) (400) (66) (36) (932)
more likely to have
transfusions during
labor, and more likely to
have a cesarean birth.
7 Educated pregnant 68 27 39 148 226 2.56 Agree
women increases (272) (81) (78) (148) (579)
knowledge about child
nutrition and other
related needs.
8 Women employed 60 87 40 39 226 2.74 Agree
during pregnancies are (240) (261) (80) (39) (620)
vulnerable to the risk of
adverse pregnancy
outcomes such as LBW
compared to
unemployed women.
Grand mean 3.12

Source: Field Work, 2023

 60

From table 4.2 above, it can be observed that all the items in the questionnaires for the

labour/delivery nurses or respondents attracted mean scores above 2.50 indicating that all the

respondents perceived and agreed that socio-economic factors of women with first

pregnancy experience can lead to poor pregnancy outcomes .

Research Question 3: what is the association between lifestyle of women with first

pregnancy experience and poor pregnancy outcomes?

Table 4.3: Responses and Mean Score Analysis of the Association between Lifestyle of
Women with First pregnancy Experience and Poor Pregnancy Outcomes

S/N ITEMS SA A D SD TOTAL DECISION

M
9 Pregnant women at the 57 102 30 37 226 2.79 Agree
low-income level are (228) (306) (60) (37) (631)
more vulnerable to the
increased risk of poor
pregnancy outcomes
compare to those with
middle to higher
incomes.
10 Maternal alcohol use 56 100 32 38 226 3.77 Agree
caused both long and (224) (300) (64) (38) (626)
short time effects on the
babies such as
miscarriage, stillbirth,
preterm delivery,
intrauterine growth
retardation, and LBW.
11 Deficiencies of any 60 78 37 51 226 2.65 Agree
micronutrients such (240) (234) (74) (51) (599)
zinc, magnesium,
iodine, calcium, vitamin
D and vitamin A, may
result in adverse
pregnancy outcomes
school games.
12 Maternal smoking causes 59 78 37 52 226 2.63 Agree
infant mortality and its (236) (234) (74) (52) (596)
related morbidities.
Grand mean 2.96

Source: Field Work, 2023

 61

From table 4.3 above, it can be observed that all the items in the questionnaires for the

labour/delivery nurses or respondents attracted mean scores above 2.50 indicating that all the

respondents perceived and agreed that lifestyle of women with first pregnancy experience

can lead to poor pregnancy outcomes .

4.2 Testing of Hypotheses

Hypothesis 1: There is no significant association between social-demographic factors of

women with first pregnancy experience and poor pregnancy outcomes.

Table 4.4: Yates Chi-square Statistics Test of Association between Social-demographic

Factors of Women with First Pregnancy Experience and Poor Pregnancy Outcomes

Variables N df Sign/L x2Yates - x2Yates-tab Decision

cal
Social- Poor 226 1 0.05 7. 36 3.84 Rejected
demographi Pregnance
c Factors Outcomes

At 0.05 level of significance and 1 degree of freedom, x2Yates -cal is 7.36 and x2-table is 3.84.

Since x2Yates -calculated is greater than x2Yates-table, the null hypothesis is therefore rejected,

and the alternate hypothesis is accepted. This implies that the social-demographic factors of

women with first pregnancy experience can results to poor pregnancy outcomes. It also

implies that there is an association between social-demographic factors of women with first

pregnancy experience and poor pregnancy outcomes.

Hypothesis 2: There is no significant association between socio-economic factors of women

with first pregnancy experience and poor pregnancy outcomes.

 62

Table 4.5: Yates Chi-square Statistics Test of Association between Social-economic

Factors of Women with First Pregnancy Experience and Poor Pregnancy Outcomes

Variables N df Sign/L x2Yates-cal x2Yates-tab Decision

Social- Poor 226 1 0.05 9.52 3.84 Rejected

economic Pregnancy
Factors Outcomes

At 0.05 level of significance and 1 degree of freedom, x2Yates -cal is 9.52 and x2-table is 3.84.

Since x2Yates -calculated is greater than x2Yates-table, the null hypothesis is therefore rejected,

and the alternate hypothesis is accepted. This implies that the social-economic factors of

women with first pregnancy experience can results to poor pregnancy outcomes. It also

implies that there is an association between social-economic factors of women with first

pregnancy experience and poor pregnancy outcomes.

Hypothesis 3: There is no significant association between lifestyle of women with first

pregnancy experience and poor pregnancy outcomes in Port Harcourt City.

Table 5.6: Yates Chi-square Statistics Test of Association between Lifestyle of Women
with First Pregnancy Experience and Poor Pregnancy Outcomes

Variables N df Sign/L x2Yates-cal x2Yates-tab Decision

Lifestyle of Poor 226 1 0.05 4.45 3.84 Rejected

Women Pregnancy
Outcomes

At 0.05 level of significance and 1 degree of freedom, x2Yates -cal is 4.45 and x2-table is 3.84.

Since x2Yates -calculated is greater than x2Yates-table, the null hypothesis is therefore rejected,

and the alternate hypothesis is accepted. This implies that the lifestyle of women with first

pregnancy experience can results to poor pregnancy outcomes. It also implies that there is an

association between lifestyle of women with first pregnancy experience and poor pregnancy

outcomes in Port Harcourt City.

 63

4.3 Summary of the Findings

The findings of the study is summarized as show below:

1. Social-demographic factors of women with first pregnancy experience results to poor

pregnancy outcomes. This was observed in table 4.1 with the respondents grand mean

scores of 2.93 above the criterion mean score of 2.50 and hypothesis 1 was rejected which

indicated a association between social-demographic factors of women with first pregnancy

experience and poor pregnancy outcomes.

2. Social-economic factors of women with first pregnancy experience results to poor

pregnancy outcomes. This was observed in table 4.2 with the respondents grand mean

scores of 3.12 above the criterion mean score of 2.50 and hypothesis 2 was rejected which

indicates a statistical association between social-economic factors of women with first

pregnancy experience and poor pregnancy outcomes.

3. Lifestyle of women with first pregnancy experience results to poor pregnancy outcomes.

This was observed in table 4.3 with the respondents grand mean scores of 2.96 above the

criterion mean score of 2.50 and hypothesis 3 was also rejected which indicates a statistical

association between lifestyle of women with first pregnancy experience and poor

pregnancy outcomes.
 64

4.4 Discussion of Findings

The results of the data analysis are discussed below on the bases of the research

questions and hypotheses associated with them.

Research Question 1 (RQ1)

What is the Association Between Social-demographic Factors of Women with First

Pregnancy Experience and Poor Pregnancy Outcomes

From the research question 1 which concerns the the association between social-

demographic factors of women with first pregnancy experience and poor pregnancy

outcomes in table 4.1, it was observed that all the items in the questionnaire attracted mean

scores above 2.50. Hypothesis 1 which is about the same subject matter produced a calculated

x2Yates of 7.36, against the x2Yates value of 3.84 with the degree of freedom of 1 at alpha level of

0.05. The value of x2Yates -calculated and x2Yates -critical or value shows a statistical association

between social-demographic factors of women with first pregnancy experience and poor

pregnancy outcomes . Since the value of x2Yates -calculated is greater than x2Yates-critical, the

hypothesis 1 was rejected. This finding is in accordance with the earlier assertion made by

Kuyumcuoglu, et al. (2012) who found that, women at advanced maternal age were more

prone to pregnancy risks and may have adverse pregnancies outcomes compared to young

maternal age and reproductive age and there was a negligible risk in gestational age at birth

for the adolescent age group and, not in the advanced maternal age group.
 65

Research Question 2 (RQ2)

What is the Association Between Social-economic Factors of Women with First

Pregnancy Experience and Poor Pregnancy Outcomes

From the research question 2 which concerns the association between social-

economic factors of women with first pregnancy experience and poor pregnancy outcomes

in table 4.2, it was observed that all the items in the questionnaire attracted mean scores

above 2.50. Hypothesis 2 which is about the same subject matter produced a calculated x2Yates

of 9.52, against the x2Yates value of 3.84 with the degree of freedom of 1 at alpha level of 0.05.

The value of x2Yates -calculated and x2Yates -critical or value shows a statistical association

between social-economic factors of women with first pregnancy experience and poor

pregnancy outcomes . Since the value of x2Yates -calculated is greater than x2Yates-critical, the

hypothesis 2 is rejected. This finding is in consonant with that of Cordier, and Chevrier

(2015) who found an association between neighborhood poverty in rural mothers and

increased risk of Small for Gestational Age (SGA) and small for gestational age head

circumference (SGC). Their finding suggested that neighborhood poverty had statistically

significant effects on small for gestational age (SGA) on the rural and urban position of

maternal residence. The finding is also in line with that of Girma et al. (2019) who found that

lacking nutrition counselling during pregnancy, lacking iron/folic acid supplementation

during pregnancy, not taking snacks during pregnancy, maternal under-nutrition, maternal

anaemia and inadequate minimum dietary diversity score of women (MDDS-W) were

independently associated with the poor pregnancy outcome LBW.

 66

Research Question 3 (RQ3)

What is the Association Between Lifestyle Factors of Women with First Pregnancy

Experience and Poor Pregnancy Outcomes

From the research question 3 which concerns the association between lifestyle of

women with first pregnancy experience and poor pregnancy outcomes in4.3, it was observed

that all the items in the questionnaire attracted mean scores above 2.50. Hypothesis 3 which

is about the same subject matter produced a calculated x2Yates of 4.45, against the x2Yates value

of 3.84 with the degree of freedom of 1 at alpha level of 0.05. The value of x2Yates -calculated

and x2Yates -critical or value shows a statistical association between lifestyle of women with

first pregnancy experience and poor pregnancy outcomes. Since the value of x2Yates -calculated

is greater than x2Yates-critical, the hypothesis 3 is rejected. This finding is in conformity with

that of Pool et al. (2014) who found that, harmful lifestyles and behaviours such as drinking,

smoking, substances and drug use, intimate partner violence, nutritional/vitamins deficiencies

have the potentials to trigger adverse pregnancy outcomes or explicitly put the life of the

mothers and the offsprings in danger.

 67

CHAPTER FIVE

SUMMARY, CONCLUSION, AND RECOMMENDATIONS

5.1 Summary of the Study

This study was basically design to investigate comparative analysis of pregnancy

management strategies and outcomes among women with first-time experience in Port

Harcourt Local Government Area, Rivers State. The study was triggered off by the

observation of poor pregnancy outcomes and strategies to manage the outcomes in the

study area. Three hypotheses were formulated to guide the study from three specific purpose

of the study and research questions. There are;

There is no significant association between socio-demographic factors of women with first

pregnancy experience and poor pregnancy outcomes.

There is no significant association between socio-economic factors of women with first

pregnancy experience and poor pregnancy outcomes.

There is no significant association between lifestyle of women with first pregnancy

experience and poor pregnancy outcomes.

Literature related to the variables under study was reviewed according to the purpose

and hypotheses of the study and the study was based on Social Cognitive Theory (SCT).

According to Miller and Dollard (1941) the social cognitive theory (SCT) assesses the

predictors of poor pregnancy outcomes in women. This theory was first developed by Miller

and Dollard (1941) and was initially known as social learning theory. This theory assumes

that the interchange of personal factors, behaviour and environmental factors help impact or

shape human behaviour. The theory further highlights the abilities of people to amend or

build their desired environment through the knowledge of collective actions.

 68

Descriptive survey design was used in the study. The population of the study was 550

labour/delivery nurses from 11 public schools in the area of study. Stratified random

sampling was used to select 11 maternity hospitals/clinics in Port Harcourt Local

Government Area. While purposive sampling was used to sample 226 labour/delivery nurses

out of the 550 target population from the maternity hospitals/clinics located strategically in

the area of study. The instrument used for this study for data collection was a questionnaire

titled "The instrument used for ths study was a self structured questionnaire titled “Analysis

of Pregnancy Management Strategies and Outcomes Among Women with First-Time

Experience” (APMSOAWFTE) which was developed by the researcher based on literatures

reviewed. The instrument was faced and content validated by the supervisor and two experts

in the field of study. It yielded test-retest reliability coefficient of 0.84. Mean was used to

answer the research questions while Chi-square (x2) statistic specifically, Yates's correction

Formula for continuity (or Yates's chi-squared test) was used to test the hypotheses at 0.05

significance level.

The study analysis showed that, there is a significant association between Social-

demographic factors of women with first pregnancy experience, Social-economic factorm of

women with first pregnancy experience and lifestyle of women with first pregnancy

experience and poor pregnancy outcomes in the study aera and recommendations and

suggestions for further studies were made.

5.2 Conclusion

Consequent upon outcomes of the statistical analysis of data collected in respect of

this study, it is concluded that poor pregnancy outcomes of pregnant women with first

experience are associated with social-demographic factors, social-economic factors and the
 69

expectant mothers lifestyles-lacking iron/folic acid supplementation during pregnancy,

maternal under-nutrition, drinking and smoking.

5.3 Recommendations

Based on the major findings of this study and conclusion made thereof, the folling

recommendations were made;

1. Government at all levels should provide enough funds for public health intervention in the

field of maternal and child health care as strategy for improving poor pregnancy outcomes.

2. Government should alway organise workshops and seminars for expectant mothers and

labour/delivery nurses to education women with first pregnancy experience.

3. Maternity doctors should always give pregnant women the needed professional medical

advice if their diet is affected by medical conditions, food allergies, or specific religious/

ethical beliefs.

4. Pregnant women should alway check their weight as becoming overweight in pregnancy

increases the risk of complications for mother and foetus, including caesarean section,

gestational hypertension, pre-eclampsia, macrosomia and shoulder dystocia.

5.4 Limitation of the Study

Understanding that, a research work is a project that requires commitment of time,

money and energy both intellectual and physical. Balancing research work with academic

going to meet respondents for questionnaires responses is a herculean task that takes time and

intellectual stamina.
 70

The level of accuracy of data in this study is proportional to the availability of information

that respondents are willing to give. There is this uncertainty that this information given is

without bias. All the above stated point serves as the limitation to the study.

5.5 Suggestion for Further Research

At the conclusion of this study, some areas were identified for further research, thus,

the following areas are suggested for further study:

1. A replication of this present study in other local government areas, states, nations and

institutions should be carried out.

2. A research study should be carried out on the influence of the individual factors -

social-demographic, economic - factors and lifestyle of women with first pregnancy

experience using the same or different study area and also other variables not used

for this study should be address.

3. Research students under supervision should be recommended to review this research

work to enable them carry out more objective research studies.

5.6 Contribution for Knowledge

Below are the contributions of knowledge of this work to the body of existing

literatures;

1. Regular exercise by pregnant women can reduce excess weight gain by pregnant women

which can endanger their lives and that of their fetus.

2. Medical professional advice on the lifestyle and nutritional impact is strategy to mitigate

poor pregnancy outcomes amongst expectant mothers.

 71

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 81

Department of Sociology and Anthropology

Faculty of Social Sciences,
University of Uyo, Uyo

25thMarch, 2023.

Dear Respondent,

I am a postgraduate ( Masters Degree) student of the above named department, faculty

and institution carrying out a research on the topic “Comparative Analysis of Pregnancy

Management Strategies and Outcomes Among Women with First-Time Experience".

Please respond to these items and be sure your responses will be treated in strict confidence.

Thanks for your cooperation.

Yours Faithfully,

Amos, Catherine Ulumma

Researcher
 82

Section A

Tick ( √ ) and fill the appropriate information in section as applicable to you

Name of hospital/clinic: ........................................................................
Gender: Male ( ) Female ( )
Position: --------------------------------------------------------------------------------------
Years of work/medical experience -------------------------------------------------------
Section B:

Please read the items below carefully and indicate by ticking ( √ ) in the appropriate columns.

SA – Strongly Agree

A – Agree

D – Disagree

SD – Strongly Disagree

S/A ITEMS SA A D SD
1 Women at advanced and young maternal age are more
prone to pregnancy risks and adverse pregnancies
outcomes.
2 Adolescent pregnancies and childbirth are susceptible to
the expanded risk of poor pregnancy outcome.
3 Some delayed or rejection of cesarean section by pregnant
women is impacted by socio-cultural, gender and religious
philosophy.
4 Pregnant women at the low-income level were more
vulnerable to the increased risk of poor pregnancy
outcomes compare to those with middle to higher incomes.
5 Pregnant women of low socioeconomic status are less
likely to have received antenatal care and less likely to
have received routine postnatal checkups.
6 Pregnant women of low socioeconomic status are more
likely to have transfusions during labor, and more likely
to have a cesarean birth.
7 Educated pregnant women increases knowledge about
child nutrition and other related needs.
8 Women employed during pregnancies are vulnerable to
the risk of adverse pregnancy outcomes such as LBW
compared to unemployed women.
9 Pregnant women at the low-income level are more
vulnerable to the increased risk of poor pregnancy
outcomes compare to those with middle to higher incomes.

10 Maternal alcohol use caused both long and short time

 83

effects on the babies such as miscarriage, stillbirth,

preterm delivery, intrauterine growth retardation, and
LBW.
11 Deficiencies of any micronutrients such zinc, magnesium,
iodine, calcium, vitamin D and vitamin A, may result in
adverse pregnancy outcomes.
12 Maternal smoking causes infant mortality and its related
morbidities.