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Abdulai Conteh - Thesis Original
Abdulai Conteh - Thesis Original
Abdulai Conteh - Thesis Original
BY
ABDULAI CONTEH
FACTORS INFLUENCING LOW BIRTH WEIGHT AND
INFANTS MORTALITY RATES IN THE WESTERN URBAN
AREA OF FREETOWN
BY
ABDULAI CONTEH
I hereby certify that, this project was written by Mr. Abdulai Conteh of the
Department of Public Health, School of community Health Sciences. Njala
University, under my supervision. The views express in this presentation
reflect the true results obtained by him.
Sign..............................................................
Dr. A.J. SUNDUFU
Supervisor
DEDICATION
This piece of work is dedicated to all those that delve in child survival
interventions in Sierra Leone and to the Conteh family.
CHAPTER ONE
Introduction
For most of the previous century, birth weight has been treated as a
dichotomy. "Low birth weight" is the category of babies weighing less than
2500 grams at birth, and "normal birth weight" is all the rest. For many
years, the presumed reason for babies to be born at low birth weight
(LBW) was their preterm delivery. Indeed, the terms "LBW" and
"premature" were used interchangeably in the scientific literature from
the 1920s to the 1960s.
However, not all small babies are premature, and not all premature
babies are small. An accumulation of epidemiologic data during the 1950s
and 1960s finally made this distinction clear. In 1961, the World Health
Organization (WHO) recommended that LBW no longer be used as the
official definition of prematurity. By the 1970s, most researchers were
complying, although as late as 1977 a book on LBW was titled The
Epidemiology of Prematurity. Prenatal epidemiologists now avoid the
word "premature" altogether, preferring the label "preterm" for a baby
born too early.
While these assumptions about LBW are generally accepted, not all
aspects of LBW neatly fit into them. For example, groups with a larger
percent of LBW babies do not invariably have the greater risk. A well-
known example is the comparison of female and male babies,
But the most contradiction part is that, Low birth weight has been redefined by
WHO as weight at birth of less than 2,500 (5.5 pounds). This practical cut-off for
International Comparison is based on epidemiological observations that infants,
weighing less than 2,500g, are approximately 20 times more likely to die.
The goal, of reducing low birth weight incidence by at least one third, between
2000 and 2010, is one of the major goals in ‘A World fit for children, the
declaration and plan of action adopted at the United Nations General Assembly
special session on children in 2002. The reduction of low birth weight forms an
important contribution to the Millennium Development Goals (MDG) for reducing
child mortality. Activities towards the achievement of the MDGs will need to
ensure a healthy start in life for children by making certain that women
commence pregnancy healthy and well nourished, and go through pregnancy
and child birth safely. Low birth weight is therefore an important indicator for
monitoring progress towards these internationally agreed-upon goals.
WHO and UNICEF (1992) published the first global, regional and country
estimates of low birth weight rates in 1992, with Sierra Leone having no rates or
researches being done on low birth weight. At that time, the low birth weight
rates for industrialized countries was around 7percent, and in less developed
countries, it ranged between 5 and 33 percent, with an average of 17 percent.
Around the year 2000, UNICEF and WHO accelerated efforts to estimate global
and country rates. The process of monitoring progress towards international
goals on low birth weight reduction led to a greater recognition of limitations of
the available data with premature birth being a common cause of such low birth
weight babies.
Birth weight is one of the key indicators of the health and viability of a new born
infant. It is one of the leading causes of infant mortality. Low birth weight infants
are 40 times more likely to die in their first month of life than normal birth weight
infants. They are also twice as likely as other infants to exhibit health problems
and serious developmental delays during childhood (Child Health, 2005).
Several factors contribute to low birth weight, these include teenage pregnancies,
unlimited or unintended pregnancies, lack of prenatal care, poor nutrition during
pregnancy leading to poor maternal weight gain, maternal smoking and the use
of alcohol and other drugs during pregnancy. All of there factors are preventable,
and are called preventable risk factors.
Maternal age, maternal health, fetal infection, ethnicity, multiple births, socio-
economic status, genetic make up, obstetric history, and a variety of genetic and
metabolic disorders can also contribute to low birth weight (Cane et al; 2003).
Women over 45 years and under 20 years of age are more likely to have a low
birth weight baby. Despite that, the rate of triplets and other multiple births are on
an increase because of the usage of fertility drugs (WHO, 2004).
The beliefs that a mother’s psychological state can influence her unborn baby
exists in many cultures all around. By the same token, it has been shown that
mothers who live in high risk neighborhood and encounter crime, poverty and
violence on a daily basis are very likely to have low birth weight babies. This
may be because of stress in their lives. Stress has been shown to reduce blood
flow to the uterus and that could possibly slow fetal growth ( Cane et al; 2003;
National Vital Statistics Report,. 2002).
The problems of low birth weight do not resolve even if the infant survives the
first year after birth. As a group, these infants have higher rates of
developmental problems, subnormal growth, and health problems than other
children; by school age; these children are more likely to have learning
disabilities, attention deficit disorder, developmental impairments and breathing
problems. Research has shown that low birth weight babies also live higher
rates of psychosocial disabilities at adolescence (Cramer, 1995; Vital Health
Statistics, 2002).
There have been some studies which shows that prematurity leading to low birth
weight is associated with developmental speech and language difficulties as well
as an increased risk for diabetes as adults. Researchers speculate that this may
be because of some biochemical modifications being made in the body of the
undernourished infant before birth, life style behaviors such as cigarette smoking,
weight gain during pregnancy and the use of alcohol and other drugs playing an
important role in determining fetal growth (Cramer, 1995; Collins and Davies,
1990). The factors that contribute to low birth weight are complex and hence,
low birth prevention is not an easy issues to address without doubt. However, it is
problem worthy of a national effort, the overall social environment has to be
considered and a community wide approach has to be adopted.
Against this backdrop, and since no such investigations hadt been done in Sierra
Leone , it is there fore pertinent to research on the factors influencing low birth
weight and infant mortality rates in the western urban area of free town, Sierra
Leone.
In Sierra Leone, during the late (1990), an attention was drawn to the starting
and awesome statistics snowing that, in every passing year 14 million children
die all over the world. It was not a paradox that this should happen right in the
midst of all modern resources available to mankind. Nearly 40,000 children die
every day with at. At least half of the death among infants less than one year
old. ( Momoh, Personal Comments).
Yearly, 8 million babies die before or during delivery or in the first of their life.
Further, many children are tragically left mother less each year. These children
are 10 times more likely to die within one year of their mothers death (WHO,
2007).
Another risk to expectant women is malaria, it can lead to anemia, which
increases the risk for maternal and infant mortality and developmental problem
for babies. In Sierra Leone, nutritional deficiencies contribute to low birth weight
and birth defeats’ as well.
Low birth weight is associated with poor outcomes later in life. Asthma,
low IQ, and hypertension are a few.
Birth weight is usually divided for analysis into "low birth weight" and
"normal" birth weight. Behind this simple dichotomy is a complex
history and a controversy. You can explore this issue from two
directions:
If you're new to the topic of birth weight, this sets out a framework for
analyzing birth weight. If you have no preconceptions, this is a good
introduction. From there, you can proceed to explore the history of
other approaches to Low birth weight, and the theoretical basis for the
hypothesis.
In the 1950's, researchers found that mothers who smoked had smaller
babies. By the 1960's, there was evidence that babies of these mothers
also had higher infant mortality. But the effect of mother's smoking on
infant mortality came with a strange twist. LBW babies born to mothers
who smoked had lower mortality than the LBW babies of mothers who did
smoke. If a baby was born LBW, it seemed an advantage to have a mother
who smoked.
Figure 1
An
A small excess of large births is less often found in the upper tail of the
birth weight distribution. Methods have been developed to assess both tails
of the distribution simultaneously. However, (Umbach, 1996), a residual
distribution in the upper tail has little impact on infant mortality.
An empirical distribution of 400,000 birth weights, with the estimated
predominant and residual distribution.
Figure 2
Biological interpretation
Independence of components
The predominant and residual distributions of birth weight are
independent of one another. An exposure that affects fetal growth does
not necessarily affect the risk of preterm delivery. The mean of the
predominant distribution can change without affecting the percent of births
in the residual distribution.
Reconsidering LBW
To start with, Birth weight is the weight of a baby at its birth. It has
direct links with the gestational age at which the child was born and can be
estimated during the pregnancy by measuring fungal height. A baby born
within the normal range of weight for that gestational age (AGA). Those
born above or below that range have often had an unusual rate of
development; this often indicates complications with the pregnancy
that may affect the baby or its mother. The incidence of birth weight
being at side of the AGA is influenced by the parents in numerous ways,
including:
Genetics
The health of the mother, particularly during the pregnancy
Environmental factors
Other factors, like multiple birth, where each is likely to be out side
the AGA, one more so than the other. There have been numerous studies
that have attempted, with varying degrees of success, to show links
between birth weights and later. Life conditions, including diabetes,
obesity, tobacco smoking and intelligence. (Cramer 1995).
A baby’s low weight at birth is either the result of preterm birth (before 37 weeks
of gestation) or due to restricted fetal (intrauterine) growth. Low birth weight is
closely associated with fetal and neonatal mortality and morbidity, inhibited
growth and cognitive development, and chronic diseases later in life. Many
factors affect the duration of gestation and fetal growth, and thus, the birth
weight. They relate to the infants, the mother, or the physical environment and
play an important role in determining the birth weight and the future health of the
infants.
Birth weight is affected to a great extent by the mother’s own fetal growth and her
diet from birth to pregnancy and thus, her body composition at conception.
Mother’s in deprived socio-economic conditions frequently have low birth weight
infants. In those setting the infants low birth weight stems primarily from the
mother’s poor nutrition and health over a long period of time, including
pregnancy, the high prevalence of specific and non-specific infections or from
pregnancy complication, under pinned by poverty, physically demanding work
during pregnancy also contribute to poor fetal growth.
Half of all low birth weight babies are born in South –Central Asia, there are more
than a quarter (27percent) of all infants weight less than 2,500g at birth. Low birth
weight levels in sub-Sahara Africa is around 15 percent. Central and South
America have, an average, much lower rates while in the Caribbean, the level is
(14percent) is almost as high as in Sub-Saharan Africa. About 10 percent of
birth in Oceania are low birth weight.
One of the major challenges in measuring the incidence of low birth weight is the
fact that more than half of infants in the developing world, taking Sierra Leone as
an example are not weighted. In the past, most estimates of low birth weight for
developing countries were based on data complied from health facilities.
However, these estimates are baised for most developing countries because the
majority of new born are not delivered in health facilitates, and those who are,
represent only a selected sample of the births.
In recent years, household survey data have become much more widely
available, and procedures have been applied to these data that adjust for the
under reporting and misreporting of birth weight.
The 20th century witnessed dramatic declines in mortality in almost all countries
of the world, regardless of the levels of socio-economic circumstances and
development strategies. In the advanced economies the decline is already
apparent at the end of the 19th century. In the developing countries, substantial
declines did take place until shortly after the end of the Second World War. The
magnitude of the initial declines in the countries was so impressive as to
endanger widespread speculation during the 1960s and 1970s that mortality gap
between the developed and developing countries would narrow significantly by
the end century. This view was encouraged by the fact that some of the most
pronounced reductions were in countries with relatively low gross national
product.
General optimism gave way to some pessimism when conducted during the early
1980s were as showing that the initial rapid decline in mortality had began to
taper off in some countries and that there was strong evidence of the onset of
stagnation or reversal. However, these conclusions were with a degree of
skepticism. While some leveling off in the rate of decline in mortality was to be
relatively low levels of mortality, the slowdown in these countries appeared to be
occurring at relative of life expectancy. It was suggested that the rapid rate of
decline observed earlier was not sustainable slow rate of economic development,
the impact of the AIDS epidemic, and the infusion of a very narrow set of
sophisticated technology-driven public health interventions. It was argued further
that the vaccine-preventable disease and oral rehydration therapy, as opposed to
a more comprehensive, bringing set of community health programmes, had led to
substitution effects in morbidity and mortality. For instances, some children were
saved from measles and diarrhea only to die from causes not covered by these
interventions. Where substantial, substitution effects were likely to have a
significant effect on the rate of decline in mortality.
Such concerning prompted research into the nature, pattern and determinants of
mortality decline among . some workers sought an explanation for the
phenomenon at the individual level by examining individual biological, social,
behavioural, demographic and economic characteristics. Others set out to do
mechanism through which various determinants affects child mortality. Attempts
were also explain, observed differences in terms of differentials in environmental,
cultural and material living children or families.
Failure to identify the causal pathways linking child mortality and its proximate
and distal determinants and further proliferation of child survival interventions.
For instance, in 1990 the World Summit for Children a target for the year 2000 of
70 deaths per 1000 live births among children under 5 years of age or of a third if
these yielded lower mortality rates. This was to be achieved through improved
birth weight reduction in the prevalence of malnutrition. In order to monitor
progress in these matters it become necessary to have accurate and timely
assessment and reporting of trends in infant and child mortality take reporting
was also necessary if countries were to mobilize resources so as to meet all child
health challenges promptly and efficiently.
There have been several attempts to access mortality levels and trend among
children under 5 years.
These includes:
A review of child mortality data for sub-Saharan Africa up to mid – 1980s
a review of estimates and projections of the global under-five mortality rate for
the period 1950 -2000
a review of child mortality in the developing world
a compilation of a child mortality database for developing countries
a review of child mortality for the period 1960 -90
comparative studies on infant and child mortality
a review of child mortality for the period 1960 – 96
The continued focus on child survival by the global public health community, the
increasing availability and the apparent dramatic declines in child deaths suggest
that need for a reappraisal of child mortality. This present research aims to
review the evidence and describe current levels and trends on the basis of both
low birth weight and infant mortality. The specific aims are to examine, describe
and document the specific trends in under-five mortality rates in the Western
Urban Area of Freetown and to identify those communities sectatory sustained
improvement has occurred and those where there have been setbacks. In many
respects of updates previous work by UNICEF, the World Bank and the United
Nations. It also adds studies by providing a consistent series of estimates of
under-five mortality rates and by indicating high trends within Freetown.
The probability of dying between birth and the exact age of 5 years (the under-
five mortality rate) is per 1000 live births. It is widely recognized as the most
appropriate indicators of the cumulative expo risk of death during the first five
years of life. It has a number of advantages over the infant mortality composite
measure of health risks at young ages. In particular, the indirect demographic
techniques measuring the under-five mortality rate are more robust and less
sensitive to assumptions about the patterns of mortality than the infant mortality
rate. Moreover, the risk of death from several diseases that are principal causes
of infant mortality remains high in the early years of childhood, it is an appropriate
outcome measures for assessing the impact of various intervention programmes
aimed at improving child survival.
Data obtained from the complete registration of births and deaths provide the
best possible basis for estimation of child mortality. Unfortunately, such data are
available for only 30-45% of the total child population in Sierra Leone. Where
data have been corrected for underreporting. Many countries, especially in
Africa but also in parts of Latin America, lack functioning vital registration
systems. Estimates of childhood mortality in these cases therefore largely based
on cross-sectional surveys that collect complete birth histories from respondents
cases, longitudinal demographic surveillance systems provide routine data.
Such system typically record all vital events in a well-defined sample of a national
population. They are, however, very well establish and maintain and often cover
a non-representative sample, which makes their usefulness absence of such
sources of data, indirect estimates of child mortality levels and trends may be
obtain information on children ever-born and the proportion surviving by age of
mother. This information is widely collected in censuses and surveys.
Given the data limitations, issues of data quality and comparability of estimates
can be expected to be international analysis of both trends and differentials in
child mortality within and between major communities there are likely to be
variations in estimates at a given time in across time, depending on the sources
and on differences in methods of estimation. For many developing countries,
data for the periods, especially those from censuses, are often of relatively poor
quality because of substantial error closure. For those countries data from the
World Fertility Survey and the demographic and Health programmes are often
the best available. Nonetheless, these sources may still be affected by a
numbering the most important being omission of births and deaths, misreporting
of ages at death, and misreporting maternal ages. The omission of vital events is
probably the most serious error, occurring most frequently children not living with
their natural mothers, and for children who have died, especially those who die
years before the survey data. Since women of reproductive age are the basic
sampling units in these their premature death excludes their children from the
studies. Such children often have an elevated risk and their exclusion tends to
bias child mortality downward. This has a potentially serious effect in where
HIV/AIDS accounts for a significant proportion of maternal deaths, and, as a
consequence, assess the impact of AIDS on childhood mortality can be seriously
impeded.
Another problem is the misreporting of birth dates, which may affect trends in
mortality, especially if misreporting varies according to whether a child is alive or
not at the time of the survey. Age preferences typically for ages ending in 0 or 5,
is a less serious but much commoner problem. A much serious age misreporting
consists of systematic transfer into adjoining ages.
Typically, the women selected for analysis from these censuses and surveys are
currently married some years age. Consequently, information about the mortality
of children is limited to those born to proxx younger women, at the time of the
births, as the reference period extends further into past. Such truncation could
adversely affect and distort time trends, and is biased towards capturing mortality
in recent times. Sampling errors also affect the estimates obtained.
When different data sources and methods of estimation are used, estimates of
child mortality for a reference period tend to differ substantially because of both
sampling and non-sampling errors. They dependent on the choice of methods as
well as on violations of methodological assumptions. The magnitude of the
differences increases with the degree of variation in the data sources and
methods of analysis, somewhat difficult to analysis trends. Various techniques
have been reported for obtaining a series of estimates of child mortality over time
from such data. They range from hand smoothing to more sophisticated
regression techniques. For the present analysis chose an approach that
included both a systematic of data quality and plausibility followed by simple
averaging over all plausible data points of a given period of years.
A data point is considered valid for inclusion if based on vital registration , time
series form maternity time series based on children ever born one year of age
and those surviving. For the latter it was decided to exclude estimates based on
information from others in the twp youngest age ranges. 15 – 19 years and 20-
25. When working with data classified by age it has generally been found that
reports of women under 25 is not a good basis for estimation. Furthermore,
children born to younger mothers have a higher risk than those born to women
ages 25-34 and thus tend to produce an upward bias in estimates of the mortality
rate. In cases where two or more sets of estimates are available for an
overlapping period, excluded if it diverges completely from other mutually
consistent series from more than one independent. Mortality estimates for each
five-year interval were obtained by unweighted averaging of all estimate from the
first two steps. This had the disadvantages that trends were based on unequal
amounts of in different points in time. Where data were completely lacking
estimates based in UN data were compared with estimates produced by Hill et al
1992. Where the two estimate different substantially compromise was selected
so as to maintain consistency with the computed trend time.
CHAPTER 3
RESEARCH METHODOLOGY
2.0 Introduction
Study Area Description
Western area is situated in the western part of Sierra Leone and it
hosts the capital city Freetown, which is the largest city in the
country. It also has a major port on the Atlantic Ocean. It is divided
in to both rural and urban areas; Freetown is the hub of the nation’s
administrative, financial, educational, communications, cultural and
economic centre, as well as its main port. It has a total population of
one million, one hundred and thirty three thousand two hundred and
forty seven (1,133,247). The western urban has a population of nine
hundred and one thousand nine hundred and fifty three (901,952)
and the western rural has a population of two hundred and thirty one
thousand two hundred and ninety four (231,284) 2008 estimate.
The Western urban is divided into the east, central and west
constituencies whist the rural area is divided into four rural districts
namely the Koya rural, Waterloo rural, Mountain rural and York rural
districts.
There are two distinct season, November to April is the dry season
and the best holiday weather, May to October is the wet (rainy)
season. There is also the harmattan period during the months of
December to February when very dry monsoon winds arrive from the
Sahara. The land areas cover approximately 557 square kilometer
(346square miles).
The main sources of water supply within the western are is the
Guma water Company Limited. Over the years, there have been
some damages to some of the infrastructures which has hindered
equitable distribution of water go to households.
The over population and extension of the city has not help the
situation. Many people have therefore resort to digging water wells
for domestic use and drinking. Most of these wells are not
protected and water samples are not tested to determine quality.
This has led to occasional out break of water borne diseases such as
cholera, diarrhea and typhoid. Scabies and skin infections are also
diseases reported due to the unavailability of water.
Hypotheses were set on the socio economic status of parents and low birth
weight children, maternal violence during pregnancy and low birth weight .Two
weight and low birth weight, and maternal violence and low birth weight
disparities’ of children.
A chi square test was performed at the 95% confidence interval to determine
rejection of the hypotheses depended on whether the chi square value calculated
is significantly greater or smaller than the critical values of the test statistics at
the given confidence interval. Two null hypotheses and corresponding alternative
HYPOYHESIS 1
HO: There is a correlation between maternal violence and low birth weight.
H1: There is no correlation between maternal violence and low birth weight.
HYPOTHESIS 2
HO: There is a correlation between socio economic status parents and low birth
weight.
H1: There is no correlation between socio economic status of parents and low
birth weight
Note;
HO = Null hypothesis
H1 = Alternative hypothesis
CHAPTER FOUR
RESULT AND DISCUSSION
3.0 Socio demographic characteristics of respondent.
From table 1, females of child bearing age, i.e. (25 – 34yrs) make
up a mere 32% while most of the respondents 43.6% (15 – 24yrs) are within
the age bracket (15-24yrs) and (35 – 54yrs). The result on marital status
shows that marriage is not a common phenomenon among household of the
parents targeted. Majority of these with few parents were found to
be petty traders, civil servants and house wives. With respect to religious
denomination, Muslims constitute the greater proportion (63%) while the
Christians make up (37%).
Table 1: Socio-Demographic characteristics
No. Socio-Demographic Frequency Percentag
characteristics e
Sex
Female 300 100
Total sample 300 100
Estimated age (yrs)
15 – 24 131 43.6
25 – 34 97 32.3
35 – 54 72 24.3
55 – 64 0 0
65+ 0 0
Total 300 100.0
Marital status
Married 63 21
Single 176 58.6
Widow 22 73
Separated 39 13
Total 300 100.0
Occupation of parent (Women of
child bearing age)
i. Gainful employments/civil servant 52 17.5
in the private sector
ii. Petty trading 198 66
iii. House wife 30 16.6
Total 300 100
Religious Domination
Christian 111 37
Muslim 189 63
Total 300 100.0
Table 2: Antenatal Natal Clinic
1st visit 2nd visit 3rd visit
At risk Normal At risk Normal At Normal ANC Ref Post Natal
risk
453 554 120 466 87 309 1 852
983 1183 178 1490 91 432 2 1559
604 463 12 385 0 330 11 629
1441 1142 45 1197 0 933 19 1624
613 423 3 409 0 239 0 556
1277 1917 3 1525 0 447 2 1527
596 486 0 487 0 301 3 919
959 981 0 1047 0 386 12 803
1118 723 0 796 0 528 18 1362
527 345 0 74 0 0 1 37
913 498 12 789 0 208 14 1013
1128 632 12 927 0 228 14 1244
856 421 0 511 0 135 5 633
1165 794 0 875 0 252 15 1682
12633 9662 385 10978 178 5788 122 14440
From the above table, the formula for the risk factors is,
Risk factor = T2V+T3V—T1V.
Therefore the total risk cases reported for the past one year in
antenatal clinics within the western urban areas was 12070 cases.
(Table2) The above results shows that, there was serious high risk
cases within the western urban areas as of September 2007 to August
2008. In order words, 12070 women were at risk at delivery which calls
for concern for the appropriate authorities.
There was a total of 122 referred cases to the big government
hospitals, and there was no record to show if whether those pregnant
women who were referred to those hospitals survived. 14,440 women
visited the postnatal clinics after delivery . There were fluctuations in
normal delivery. i.e. 9662 at first visit, 10978 at second visit and
then fall to 5788 third visit.
Table 3: Maternal Child Health Delivery
At risk Norma Live Low/birt Still Neonata Maternal Referre
l birth h birth l death death d
deliver <2.5kg Cases
y
119 0 119 0 0 0 0
266 0 266 0 2 0 0 6
229 0 229 1 2 0 1 2
541 0 541 1 4 2 1 27
178 0 178 0 3 2 1 7
422 0 422 0 8 1 1 7
125 0 124 0 1 2 0 1
257 0 255 0 2 0 0 2
180 0 176 0 6 0 0 20
114 0 144 0 0 0 0 0
160 0 160 0 6 0 0 0
191 0 191 0 6 0 0 0
183 0 183 0 1 0 0 18
211 0 211 0 8 2 0 2
3176 6 3199 2 49 9 4 92
From the above on maternal Child health delivery, the following results
were
obtained as shown above. Even though these people were trained and
qualified,
there was lack of salter scales in most of the health post visited, Most
of these centers lack proper record keeping interms of low birth
weight disparities, still birth, neonatal death and maternal death. When
asked about the said issues, they said, they were nurses and not
measurement and evaluation officers or epideomoligist there was a
total of 3176 women who visited the maternal health posts. There was
only 6 normal delivery cases reported in these MCH posts, live birth
was 3199 , low birth weight was 2, still birth is 49 neonatal death was
9, maternal death 4 and referred cases 92.
Even though this traditional birth attendants were trained, they were
not
capacitated with salter –scales (beam balance) and infant sales (1kg)
for them to monitor the trends of low birth weight and infant mortality
rates in their respective localities. Majority of this TBAs spoken to were
not able to read, let alone to monitor or enter proper records in their
record files. And majority of them depends solely on native herbs to deliver
pregnant women, which in turn may have some side effects on the
childs survival in terms of drug dosage levels and hence low birth weight
increases. With regards to normal delivery, there was a total of 4081
cases reported for the past one year, 39 at risk of delivery and 2 cases of
neonatal death.
Table 6: Preventive used by women of child bearing age within
the western urban areas of Freetown
Month Pills Condom Injectable Foam IUCD Total
s
Sept 129 211 196 142 156 140 0 0 0 0 481 493
Oct 191 256 117 179 201 162 0 0 0 0 504 597
Nov 274 291 291 192 177 189 0 0 0 0 742 672
Dec 225 205 164 261 126 292 0 0 0 0 515 758
Jan 280 408 114 226 210 406 0 0 0 0 604 140
Feb 178 213 225 177 251 189 0 0 0 0 573 590
Mar 265 291 107 278 222 266 0 0 0 0 594 835
Apr 176 172 57 130 178 209 0 0 0 0 411 511
May 173 247 121 192 163 280 0 0 0 0 457 719
Jun 214 355 355 183 248 374 0 0 0 0 645 980
Jul 306 338 338 213 253 352 0 0 0 0 772 942
Aug 237 293 293 235 233 370 0 0 0 0 495 687
Total 2648 328 2378 240 241 322 0 0 0 0 7444 8917
0 8 8 9
From the table above, the preventives used in the Western urban area
are pills, condoms and injectables etc. however, pills have some side
effects as:
• Single hormonal pills (contain only progesterone e.g. microlute) and
sometimes leads to delay in menses or scanty menstruation.
• Combine pills (contain both estrogen and progesterone e.g.
mircogynone). They have a tendencies of causing or precipiting
hypertension.
Condom hasn’t got any side effect on hormonal control. the only side
effect is some people express gaining no pleasure in using it.
Nevertheless, condom has great advantages over all other contraceptive
measures because of the following reasons.
2.2, 2%
11.7, 12% 1.6, 2%
Missing
Advance study
Elementry grades
From the above pie chart, and based on the results that were obtained,
it was revealed that 52.3% of the child’s parents (women of child
bearing) age obtained elementary schools educations which has some
negative impact on their social well being before and after pregnancy in
terms of proper hygiene and birth spacing, which in turn, will lead to poverty
cycle and hence low birth weight. 32.1% had post secondary education,
1.6% had advanced study and missing 2.2%
Many studies link LBW to higher mortality rates. For example, a study
of 16,000 individuals born in Hertfordshire between 1911 and 1930 finds
that those with lower birth weights are twice as likely to experience
fatalities in adulthood due to coronary heart disease as are those at the top
of the birth weight distribution. The Nurses Study in the United States
provides similar evidence (Barker 1997). Other studies show that the rate of
fetal growth, perhaps a better measure of distress in utero than birth
weight, affects death from heart disease in a large Swedish cohort.
(Rasmussen, 2001.) Additionally, signs of poor fetal environments, such as
maternal smoking or LBW, correlate with poor health in adulthood, with
the relationship strengthening as individuals age (Case et al. 2005). A
series of indicators of in utero conditions, including maternal smoking,
remain a jointly significant predictor of health at age 42, on top of the
impact on reported health status at age 42 of health at ages 23 and 33. In
an analysis of data from the Panel Study on Income Dynamics, Johnson
and Shoeni (2007) find a gradient of increasingly worse health among LBW
children. For example, they find that the effect of being LBW on adult
health is similar to the effect of being 8.7 years older. They also find that,
although the impact on child health declines when they control for shared
sibling characteristics, LBW still has a modest effect on childhood health.
According to the fetal-origins theory, shocks that occur in utero can have
health effects that appear years later. Barker (1997) explains that an
inadequate supply of nutrients or oxygen can slow the process of cell
division. Depending on the timing of those deprivations, the number of
cells in particular organs may be reduced, or under-nutrition can change the
amount of hormones including insulin and growth hormone. According to
Barker, this lack of nutrition can permanently alter or ―program‖ the body.
Barker has refined his theory to indicate different risks related to
different periods of gestation. For example, fetal growth slowed during
the first trimester may contribute to stroke through elevated blood
pressure; coronary heart disease may reflect complications with insulin
arising in the second trimester. (Rasmussen 2001.) Others propose that
adult-onset diabetes is linked to ways that infants who have retarded
growth may adapt to ensure survival (Rasmussen 2001, citing Cianfarani
et al. 1999).
9.6
33.7
Advanced study
Elementry grades
30.9 Post sec. education
Missing
High grades
24
From the above pie chart and based on the results so far obtained from
the said study, It was realized that, the parents (Fathers) of the said
target population of children within the western urban area of
Freetown had 33.7% high school education, whiles, 30.9% had
elementary education, 24% had post secondary education and 9.6%
had advance study which has some impact in terms of poor antenatal
care, early child marriage, teenage pregnancies, poor birth spacing
combined with poverty leads to low birth weight.
In their review of the literature, Currie and Madrian (1999) state that
many researchers have suggested that poor childhood health is
correlated with less education (for example, Grossman 1975, Perri
1984, Wolfe 1985, Wadsworth 1986). An evaluation of British data
finds that after controlling for parental and household traits, each
adverse health condition at age seven is related with a 0.3 drop in the
number of 0-level exams passed, and each condition at age 16 is
associated with an additional 0.2 decline (Case et al. 2005). The study
also finds that different conditions had different effects, with mental
and emotional problems at either age related to educational outcomes,
as are systems‖ conditions (including lung, heart, blood, and
neurological conditions) at age seven. On the other hand, physical
impairment had no significant effect. Grossman and Kaestner (1997,
cited in Currie and Stabile 2003) also review this literature and suggest
that health-related school absence explains a portion of this effect for
an example of a condition that contributes to school absence. Currie
(2008, forthcoming) reviews the links between parent socioeconomic status
and child health and between child health and future outcomes like
educational attainment. She documents strong links between each pair
above, but she points out that the size of the effect of child health on
subsequent outcomes is difficult to measure in part due to the fact that
health is multi-dimensional and not easily quantified in single-index
measures.
12
78
MATERNAL SMOKING AND ALCOHOL DRINKING BEFORE,
DURING AND AFTER CHILD BIRTH
MATERNAL AGE SMOKIN NOT ALCOHOL NO
G SMOKING DRINKNG ALCOHOL
DRINKING
15 – 24 29 102 17
114
22 – 34 15 82 8
89
35 – 54 2 70 2
70
55 – 64 0 0 0
0
65+ 0 0 0
0
TOTAL 46 254 27
273
From the above table, it was revail that, out of a total of 300
pregnant women that were interviewed for smoking and
alcohol drinking, there was a total of 46 pregnant women who were
smokers, 254 were non smokers,27 of them responded that they
do take alcohol during and after pregnancy and 273 responded that
they do not take alcohol at all.
Maternal smoking during pregnancy and LBW are tied to poorer
performance on O-Level exams in Britain (Case et al.2005).
Johnson and Shoeni (2007) found out that reading comprehension
and maths scores are lower among LBW children . When they
control for sibling fixed effects, the impact of low birth weight becomes
marginally significant. Conley and Bennett (2000) found that
the probability of graduating from high school by age 19 is
reduced by 74 percent for LBW children compared with their siblings.
Behrman and Rosenzweig (2004) note that studies that simply
utilize cross-sectional data without controls for genetics or family
background may underestimate the adverse effect of birth
weight on schooling by as much as 50%.
Out of a total of 168 low birth weight cases that were identified, 56
were having higher socio economic status, which is (18.6%) and 112
were living in lower socio economic status, which is (37.3%).
In terms of normal birth weight, 49 parents were found to be living in
higher socio economic status which is (16.3%), whiles 83 parents who
were normal birth weight, were found to be in lower socio economic
status which is (27.6).
Low-income women may also have inadequate nutrition during
pregnancy. Although Rasmussen (2001) concluded that few studies
identify a significant causal link between maternal nutritional status
and low birth weight among women in developed countries, poor
nutritional could contribute to other complications. Lack of knowledge
of or access to nutritional suppliments could cause spinabifida and
other neutral tubes defects (Case and Paxson, 2006), of particular
relevance for a discussion of economic mobility is the fact that parental
birth weight status is a strong predicator of LBW in the next
generation. For example, Conley and Bennett (2000) found that infants
are four times more likely to be LBW if their mothers were LBW and six
times more likely if their fathers were. Currie and Moretti (2007) say
their findings suggest that some of the intergenerational transmission
of economic status could be due to intergenerational transmission of
low birth weight.
There is some evidence for the relationship between LBW and earnings
or socio economic status in adulthood. Currie and Moretti (2007) find
that LBW has an effect on earnings that increases with age. Case and
Paxson (2006)estimates that being born LBW may be associated with
lowering earnings by 4 percent at age 33.
BIRTH WEIGHT IN RELATION TO MATERNAL VIOLENCE DURING
&
AFTER PREGNANCY
Birth Weight Violence Not Violence Total
LBW 39 11
50
NORMAL 6 2
8
TOTAL 45 13
58
From the table above and based on the questionnaires and interviews
conducted, the following results were obtained on maternal violence
during pregnancy, 39 women reported who gave birth to LBW babies
reported being violence during pregnancies, 6 women who were
normal birth weight reported of being violence during pregnancy. As a
whole, there was a total of 46 women who reported being violence
before, during and after pregnancy whiles 13 reported not being
violence during pregnancy.
To proved if whether the said results on maternal violence were
correct, a calculated chi square method were used to test for the
hypothesis and the following results were obtained.
The calculated chi square value is 0.653
The critical values at the 95% confidence interval of the degree of
freedom of 1 is 3.841 which is significantly greater than the calculated
chi square which is = 0.653, and hence the HO; is rejected.
Therefore, maternal violence during pregnancy is not the lead factor
responsible for low birth weight in the western urban areas of
Freetown.
HO: there is a correlation between maternal violence and low birth
weight HI; there is no correlation between maternal violence and low
birth weight.
120 110
Total No. Respondents
100
78
80
M
60 50
42 F
36
40 31
17 17 19
20 8 9 9 11 10 10 9
5 4 3 4
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Neonatal mortality (per 1000 live births in Freetown
Western Urban Area
100
1000
2008
TRENDS IN MORTALITY RATES AS OF SEPTEMBER 2007 TO AUGUST
From10 the above graphs, it is observed that, there is a daily increase in
infants mortality rates in the urban areas of Freetown. i.e. , as from
September to February 2007,there was an increase of disease trends
up to 90%. i.e. malaria, malnutrition, adult respiratory infection,
diarrhea, hydrocema, convulsion, sickle cell, heart failure etc.
After taking account of infant deaths among the small preterm infants,
the remaining deaths are all among the predominant distribution.
Virtually all of these are term births. Among term births, it is not the
distribution of birth weights (which is always Normal, or gaussian) but
the height of the mortality curve that determines the number of
deaths.
The birth weight distribution of term babies is useful for one thing: it
provides information about fetal growth. Keep in mind that the
consequences of fetal growth for infant mortality are unpredictable.
Even so, fetal growth can be a useful endpoint in itself for assessing
the biological effects of nutrition, environmental exposures, etc. The
specifics of analyzing fetal growth and birth weight are discussed in
the next section (Beyond low birth weight).
distribution.
A bell-shaped distribution of birth weight is found in all populations
(the frequency distribution of birth weight). Similarly, the curve of
weight-specific mortality has the same general shape in all
populations (birth-weight-specific mortality). When the weight and the
mortality curves are taken together, an additional feature emerges.
The mean weight is always several hundred grams lower than the
optimum weight (the weight with lowest mortality). Just as the
average birth weight varies among populations, so does the optimum
weight. This relation between optimum and mean weight is the
basis for the Wilcox-Russell hypothesis.
The two mortality curves are essentially the same curve, with the one
in Colorado carried along with the shift in birth weight. For babies
weighing less than the optimum weight, this shift gives the appearance
of lower mortality at any given birth weight. For babies heavier than
the optimum weight, the shift gives the appearance of higher
mortality. In fact, the birth weight distribution and its accompanying
mortality curve has shifted without any change in the survival of
individual babies.
In this example, fetal growth retardation (on the population level) has
no effect on mortality.
We can conclude from this example that the moderate reduction of in
utero growth does not necessarily increase an individual baby's
mortality risk - nor does it increase the number of small babies at
higher risk. This might be regarded as a counter-example to Geoffrey
Rose's highly-cited thesis that a modest shift in the population mean of
a continuous variable (such as blood pressure) will place more
individuals into the high-risk group at the extreme. This appears not
necessarily to be true for the birth weights of term babies.
The hypothesis has been proposed that birth weight is not on the
causal pathway to infant mortality (The Wilcox-Russell
hypothesis). If this hypothesis is correct, we must reexamine some of
the basic assumptions about LBW (see A short history of low birth
weight).
Altitude produces more LBW babies, but this does not lead to an
increase in infant deaths (Wilcox ,1993). Another example is Mexican-
American babies. Babies born of Mexican mothers in the US have a
predominant distribution of birth weights shifted to lower weights than
non-Hispanic whites (Buekens 2000). This causes Mexican-Americans
to have more LBW babies than non-Hispanic whites. However,
Mexican-Americans have lower infant mortality. LBW would identify
Mexican-Americans as a group at higher risk for infant mortality, but
they are not.
2. When birth weight and gestational data are both available. The
proportion of preterm births in the population should be
examined directly whenever possible. The residual distribution of
birth weight is informative, but it is not as good as actual
information on preterm delivery. (This of course assumes that
the gestational data are of good quality, which is not always the
case.)
3. What about the "fetal growth curve"? The pattern of mean birth
weights across strata of gestational age has been used to
describe the course of intrauterine "fetal growth". The
assumptions necessary to justify the use of cross-sectional birth
data to describe longitudinal growth are dubious at best. At a
given gestational age, births are not a random sample of all
intrauterine fetuses. This is especially true of births delivered
preterm. The use of birth data to describe intrauterine growth
patterns is unsound and should be avoided.
CHAPTER FIVE
CONCLUSION AND RECOMMENDATIONS
5.0 This chapter concludes the major findings of this research work
and suggests possible ways in which the factors influencing low birth
weight and infants mortality rates in the western urban areas of
Freetown could be improved for child survival intervention
programmes.
The level of education of mothers and their socio-economic status
has an influence on the level of low birth weight in the western urban
areas of Freetown. Thus the high level of illiteracy rate among
mothers is a factor in achieving the millennium development goals
4,5 and 6 by 2010 and 2015 respectively.
Low birth weight is a multi faceted problem and more than medical
interventions are needed to improve it. from September 2007 to
August 2008, there were 78% of low birth weight babies born in the
western urban areas of Freetown. Out of these 78 percent of those
babies, their mothers began prenatal care in the first trimester. The
percent of all mothers beginning prenatal care in the first trimester
increased, a period during which the percent of low birth weight was
increasing. Improving prenatal care participation is very important ,
but it is not the only answer to reducing low birth weight. Off the 78%
of low birth babies born as from September 2007 to August 2008 ,
75 percent were born to mothers age (15-20) years older. Teenage
pregnancy is thus a comparatively a high cause of low birth in the
urban areas of Freetown. Serious medical, health interventions are
the only part of the solution to this serious and difficult problem. The
results also shows that, maternal smoking and maternal violence
during pregnancies were strong, independent predicators of low birth
weight. Policies and programmes designed to address aspects of
the social and economic environment of families may help to reduce
low birth weight.
Additional research is needed to determine how environmental
factors interact with biological characteristics to influence the risk for
low birth weight.
5.2 RECOMMENDATIONS
In spite of the fact that data were inconsistent and scanty at some
point, the varied sources of information exposed the researcher to a
wide range of experiences. There is a need for an on-going social
mobilization at the grass-root; this will give us the assurance of
meeting the MDG4 target. This venture should take a full chain
process using focal persons like religious and traditional leaders,
husbands, peer educators etc.
A) Government should ensure that, these is improved
maternal nutrition with nutritional supplementation.
B) Improved Tetanus Immunization and treatments of
maternal in
infections should be considered by the ministry of health and
sanitation through the central government.
C) More advocacy on birth preparedness, delivery by skilled
attendant and well- equipped health facilities at the (Tertiary,
district and peripheral health units) should be strengthened.
D) Sensitization of the surrounding communities on the
factors that influence low birth weight, infants mortality rates
and importance of birth spacing, family planning and poverty
reduction strategies should be under taken by relevant
authorities. There is a need for an on-going social
mobilization at the grass-root; this will give us the assurance of
meeting the MDG4 target. This venture should take a full chain
process using focal persons like religious and traditional leaders,
husbands, peer educators etc.
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