Emerging Health Problems among Reproductive Mothers in Abakaliki Urban of Ebonyi State: Implication for Sustainable Development

Reproductive women are currently faced with a lot of health challenges which can be life threatening leading to high maternal morbidity and mortality thus, defeating one of the sustainable development goals (SDGs) of reducing global maternal mortality ratio to less than 70 per 100, 000 live births. This study investigated the emerging health problems among reproductive mothers in Abakaliki urban of Ebonyi State. The descriptive Survey research design was adopted using a population of all reproductive mothers in Abakaliki Urban of Ebonyi State. Samples of 150 pregnant and nursing mothers respectively were selected through purposive sampling method. The Instrument for data collection was a self-constructed health problem among reproductive mothers’ questionnaire (HPARMQ). Results of the study revealed physical, social and economic health problems being experienced by the reproductive mothers. Age (p=0.43), location (p=0.704) and parity (0.276) are not significantly associated with high health problems during pregnancy. The study concluded that reproductive mothers in Abakaliki Urban had physical, social and economic health problems bordering their lives. These call for quick and urgent health education intervention and treatment for the women to avert further spread and danger posed by the health problems. The study recommended among others that government at all levels in collaboration with the ministry of health should organize periodic health education seminars for reproductive mothers in order to sensitize them concerning the prevailing health problems, prevention and control for their optimal health that wi1ll contribute to National growth and development.


Introduction
Globally, research findings indicate that 535,900 women die from pregnancy and birth related causes in 2005. Among these women of reproductive age, about 36 percent of their healthy years are lost to reproductive health problems such as unregulated fertility, maternal deaths morbidity and STDs, HIV/AIDS [1]. Reproductive mothers can be described as pregnant/expecting or nursing mothers. They can also be called reproductive women [2]. These groups of women are faced with a lot of health problems in the course of pregnancy, through childbirth to nursing period and sometimes, beyond. More often than not, they are confronted with health challenges that may be life threatening and capable of impeding the women's daily tasks and safe motherhood consisting in maternal mortality or morbidity due to preventable pregnancy and childbirth related causes [3]. The relevance and indispensable roles of a healthy mother in the society cannot be overlooked.
problems include health problems such as sexual dysfunction, endometriosis, uterine fibroids, gynecological cancer and HIV/ AIDS, intestinal cystitis, polycystic ovary Syndrome (PCOS), sexually transmitted diseases, sexual violence, painful sex, lack of interest in sex, pelvic health disorders, unsatisfying sex, depression and ectopic pregnancy. Others are morning sickness, anaemia, back ache, widowhood, domestic violence, anxiety, stress, divorce, fear, restlessness, poverty, unemployment among others [7]. Some of the problems as stated can be grouped as physical health problems, social health problems and economic health problems. Physical health problems means living with or experiencing a chronic illness or condition that can result in many adjustments and changes such as loss of independence and not being able to do all activities one is used to doing and enjoying. These may include post-partum anxiety and depression [8]. Poor physical health can lead to an increased risk of developing mental health problems. During pregnancy, symptoms and complications can range from mild and annoying discomforts to severe sometimes life-threatening illnesses. Physical health problem during pregnancy may include physical conditions capable of affecting the health of the mother or the baby [7]. They may be minor and mild and not progress or they may be major and harmful to the mother or her baby. Some of these physical health problems are anemia, morning sickness, cramp, urinary tract infections causing pain or burning urinating, fever, tiredness or shakiness, urge to urinate often, pressure in the lower abdomen, urine that smells bad, nausea or back pains. Others are gestational diabetes mellitus, hypertension, obesity and weight gain, infections with HIV, viral hepatitis, STDs, tuberculosis and hyperemesis [7]. WHO reported physical health problem encompassing sexual and reproductive health problems as being responsible for one third of health issues for women between the ages of 15 and 44 years [1]? About 70% of white women and 80% of African American women develop uterine fibroids, a physical health problem. Also, an estimated 13.5 million women in the baby boomer generation have stress urinary incontinence. Nearly 40% of women aged 45-60 experience heavy menstrual periods in Italy [9]. The physical health problems are sometimes manifested more in one prevailing condition of the mother than the other. For instance [10] found that apart from pregnant mothers, nursing mothers also experience some physical health problems after childbirth. These may include pain with vaginal delivery, Pains at the incision site of caesarean sections. Some nursing mothers also experience swollen, lumpy, hard or painful or engorged breasts. There may be incidence of pain with breast feeding, infection at the surgical site of a c-section or a tear in the perineum, post-partum infections can also appear in the uterus, bladder or kidneys. However, Baylor and White pointed out that the infections are uncommon unless in cases of prolonged labour or prolonged rupture of membranes, a prolapsed (whereby the bladder, uterus, or bowel protrudes into the vagina) can be experienced by a new mother. Also, some nursing mothers can be notoriously tired (exhaustion). And there can also be cases of urinary incontinence common for 6 months or longer post-delivery. However, pelvic-floor physical therapy can be of help [10,11].
In as much as reproductive women 's health is affected by their biology as seen in physical health problems, it is also affected by social conditions such as poverty, employment and family responsibilities leading to social health problems and these aspects should not be over shadowed [12]. Social health problems of reproductive mothers refer to social diseases that impact on women's physical, mental or social health. A major burden of the social health problems in reproductive women is related to their reproductive function and reproductive system, and the way society treats or mistreats them. Some of these social health problems may include female genital mutilation, sexual abuse and domestic violence [6,13]. Worldwide, about 10% of pregnant women and 13% of nursing mothers experience depression. It is higher in the developing countries with 15.6% during pregnancy and 19.8% after childbirth. In severe cases, the suffering may be too much that the mother may even commit suicide. Nevertheless, such mental and social disorders are treatable. Effective interventions can be delivered by well-trained non-specialist health providers [1]. On economic health problem, Blog Network [12] as well identified poverty, employment and family responsibilities as economic health problems. WHO [14] posited that with economic health problem, there continues to be a large disparity in maternal and child health indicators between high-and low-income countries? The highest levels of mother and child health can be found in European and higher income countries in Asia. Most of the countries with the highest mortality rates are those experiencing war and conflict. Almost all 99% of maternal deaths occur in low-income countries with the highest maternal deaths in African and poorer parts of Asia [14]. Two countries India and Nigeria account for a third of global maternal deaths. The highest infant mortality rates are also found in the same countries with maternal deaths [15]. Blog Network [12] revealed that women have traditionally been disadvantaged in terms of economic and social status and power which in turn reduces their access to the necessities of life including health care. Mcbarnette [16] held that health status of women declines as their socio-economic status including income, declines. Mcbannette further pointed out that relationship existed between poverty and several indicators of reproductive health status of women. A study [17] indicated a crucial role of economic factor in influencing the Polish women's health. It was found by the same study that reproductive women whose financial position was poor indicated more likelihood to assess their health as less than good to suffer from respiratory and circulatory system's diseases.
They also reported more neurotic problems. Other indicators of poor economic health of the mothers were lack of employment and low educational level especially among young reproductive mothers [18] recorded a positive and significant relationship Global Journal of Reproductive Medicine between income of Pakistan women and their health. Be it as it may, with the unveiling of various prevailing health problems among reproductive mothers as viewed worldwide, in Africa and in a neighboring Enugu state, it is not out of place to determine emerging health problems among the selected reproductive mothers in Abakaliki Urban of Ebonyi State which harbors a significant population of reproductive mothers in active workforce. They were purposively selected from the catholic Christian denomination given to the large number of reproductive women that can be found among them. This may not be unconnected with the church's permissive attitude to childbearing devoid of artificial birth controls. Nevertheless, certain sociodemographic variables have been associated with women's health problems. They include age, parity and location getting older as it concerns age, can bring on health problems as a woman's body changes. Some medical conditions become more common and more serious as she goes up [19]. The risk for chronic diseases and other health problems increases with age. The problem varies however among women. Women in their 40s are more at risk for breast, ovarian and endometrial cancers [20]. Another investigation [21] revealed significant association of advanced maternal age with high maternal morbidity and infant mortality. No significant association was found between parity and women's health problems. Result of the study that investigated relationship between parity and physical health are less consistent. High parity was found to be detrimental to physical health. In some other studies, no relationship was found [22]. Parity was also associated with the presence of certain problems in the postpartum period. On relationship of location with women's health problem, rural women tend to have poorer health outcomes and also have limited access to health care than urban women. It can be attributed to restricted number of health care providers for the women [23]. What do all these imply for sustainable development? Sustainable development entails development that measures up with the needs of the present without compromising the ability of future generations to meet their own need [24]. Meeting the reproductive women's health needs if urgently tackled, cannot in any way disrupt or impede health of future mothers. Such attempt shall rather improve and lead to overall health development of the nation. Good health usually facilitates development while development often promoted improved health. While improved health may be a prerequisite for development, some behavioral determinants like attitude, environment and people's lifestyles as well as consumption patterns can impede the sustainability of the development process in the longer-term. Equally, development which is economically desirable e.g. in agriculture and industry, may have harmful consequences for health and the environment [24]. The link between health, poverty reduction and long term economic growth are powerful much stronger than is generally understood. The burden of disease in some Su-Saharan Africa, stands as a stark barrier to economic growth and therefore must be addressed as a central component of any comprehensive development strategy.
Malaria alone is estimated to slow economic growth in Africa up to 1.3% each year. The situation would probably have raised Africa's GDP 100 billion higher if malaria had been tackled 30 years ago, when effective control measures first became available. Even today, half a billion cases of malaria each year lead to loss of several bellion days of productive work [25]. Regardless of what the result of the study may be, with the result of the study, best approach and intervention shall be mounted taking into consideration with particular emphasis on age, parity and location of the women. This in effect, would curtail further hindrance to the women's health and smooth motherhood. Given to the status of mothers in developing countries, Nigeria inclusive with its component States of which Ebonyi state is one, a mother's death is much more than an emotional crisis, often leading to long term social and economic breakdown both for her immediate family and the wider community [26]. These then imply a sound health education for reproductive mothers for enhanced health promotion, maintenance and longevity. Health education refers to any combination of learning experiences designed to help individuals and communities improve their health by increasing their knowledge or influencing their attitudes [1]. Through health education, health behaviors of the mothers will be positively enhanced and influenced as well as their living and working conditions. There will be a positive change in their general knowledge, attitude and practice with regards to the various health problems and their solutions. Nevertheless, the muchneeded intervention cannot happen without determining the emerging health problems as it concerns the reproductive women and also determining the association of the independent variables of age, parity and location with the health problems of the women. These in the main, necessitated the present investigation.

Materials and Methods
The study adopted the descriptive survey research design. According to Iwuagwu and Ofuebe [27] it was recognized Nworgu [28] as appropriate for describing situations as they exist in their natural setting and determines relationships that exist between specific events. The population comprised all pregnant and nursing mothers in Abakaliki urban of Ebonyi State. A sample of 150 pregnant and nursing mothers was picked respectively through purposive sampling technique involving the use of 5 out of 7 catholic parishes in Abakaliki urban. It was due to their locations in densely populated areas and high attendance by people of the denomination. Using simple random sampling technique, 30 pregnant and 30 nursing mothers were picked from each of the chosen parishes leading to a total of 150 pregnant mothers and 150 nursing mothers selected for the study. In order to gain access to the study population, consent was first sought through consent letters from the parish priests (PPs) of the parishes involved prior to the time for data collection. They gave their consents and with the assistance of the women leaders, the instrument was shared Global Journal of Reproductive Medicine among the chosen reproductive mothers on the day of their general meetings. The items in the instrument were interpreted to the illiterate ones also by these women leaders acting as research assistants. On completion, the instruments were collected back immediately, and this action ensured 100 per cent return rate. The Instrument was a self-constructed health problem among reproductive mothers' questionnaire (HPARMQ). It was in 6 sections with each representing the 6 variables of the study having a total of 72 items. The responses were on 2 points rating of yes and No. The instrument was given face and content validation by 3 experts in the department of Human kinetics and health education, Ebonyi State University, Abakaliki.
The corrected version of the instrument was given to reproductive women in a Presbyterian church and using Cronbach alpha test of reliability, a reliability coefficient of 0.74 was established. This was high enough considering [29] acceptance of instrument with reliability coefficient of 0.60 and above as good instrument. The completed copies of the questionnaire were coded and analysed using logistic regression analysis to answer the 6 research questions. Health problems with scores above 50% were considered major emerging health problems while those with score below 40% were considered minor emerging health problems. Result in Table 1 shows the distribution of physical health problems faced by selected pregnant mothers in Abakaliki Urban of Ebonyi State. The major physical health problems that affects more than 50% of the pregnant mothers are, "Abnormal vaginal Global Journal of Reproductive Medicine discharge" 109 (72.7%), "Abnormal Vaginal Itching" 106 (70.1%), "Morning sickness" 101 (67.3%), "Fatigue" 92 (61.3%), "Itchy belly" 92 (61.3%), "Premature labour" 82 (54.7%), and "Back ache" 78 (52.0%). Others that are above 40% physical problems experienced by pregnant mothers include, "Pica (strive for strange food)" 73 (48.7%), "Indigestion" 69 (46.0%), "High blood pressure" 65 (43.3%) and "Infections e.g. reburial, chicken pox, whooping cough" 63 (42.0%). However, the least physical health problem affecting below 20% of the pregnant mothers are HIV/ AIDS 14 (9.3%), Oedema 22 (14.7%), Cramp 26 (17.3%), and Eclamsia. Within the group, further logistic regression analysis indicated 0-49% of the pregnant women with low physical health problem were 107(71.3%) while 50% and above of the women had high physical health problem 43 (28.7%) From the result in Table 2 it goes to explain the emerging cases of physical health problems in the lives of the pregnant mothers. The result of the study was in line with [27] who found that 56.5% of pregnant women in their study area indicated physical health problems such as anaemia, nausea, vomiting, oedema, waist pain among others. The findings according to [27] were also in line with [30] that nearly 75 per cent of all pregnant women experience back ache, depression, anaemia and increased breathlessness [31] also found that nausea and back ache were the most commonly reported major physical health problems of pregnant women. The result did not come as a surprise. It could mean that the physical health problems are normally triggered off by pregnancy conditions hence their occurrences during pregnancies. Result in Table 3 shows the physical health problem of the nursing mothers.  Majority of the nursing mothers 114 (76.0%), 95 (63.3%), 89 (59.3%) and 81 (54.0%) have milk supply problem, breast problem (engorgement & abscess), abnormal nipple discharge and intense breast pain. Other physical health problems of the nursing mothers are 66 (44.0%) sepsis (fever or drainage), 65 (43.3%) vaginal tear and 59 (39.3%) dislocation of the hip. However, the physical health problems that least affect the nursing mothers were diarrhea 44 (29.3%) and mastitis 28 (18.7%). The result as further shown by the logistic regression analysis also indicated the group physical health problem among 0-49% of the nursing mothers with low physical health problem to be 56(37.3%) while 50% and above of the women had high physical health problem 79 (52.7%) The result of the study did not come as a surprise as Brown and Lumley [11] had earlier reported post-natal health problems such as depression six to seven months post-partum among some of group reproductive women under their investigation. The authors also found urinary incontinence, back pain, sexual problems, more cough, colds and minor illnesses than usual. The Authors however, found these to be significantly associated with poorer levels of emotional wellbeing. Figure 1 shows the social health problems of pregnant mothers in Abakaliki Urban of Ebonyi State. Majority 133 (88.70%), 116 (77.30%) and 94 (62.70%) were difficulty in copying with pregnancy, inadequate provision of health facilities, and inadequate provision of basic social amenities. However, few 65 (43.30%), 48 (32.00%) and 30 (20.00%) are violence, divorce and widowhood. Further regression analysis showed group 0-49% of pregnant women with low social health problem to be 14(9.3%) while 50% & above of the women indicated 124 (82.7%) high social health problem. The result of the study is in line with Blog Network [12] where it was posited that in as much as reproductive women 's health is affected by their biology, it is also affected by their social conditions such as poverty, availability of social amenities, employment and spousal relationship. [6,13] also in accordance with the present study reported female Global Journal of Reproductive Medicine genital mutilation, sexual abuse and domestic violence as social health problems experienced by nursing mothers and further reported that worldwide, about 10% of pregnant women and 13% of nursing mothers experience depression and are higher in the developing countries with 15.6% during pregnancy and 19.8% after childbirth. The results are expected because a good home and society with adequate social amenities, comforts of life, cordial inter-spousal relationships and family love will make life worthwhile for pregnant women and thus hinder occurrence of any sickness. Bar    high social health problems. The result of this investigation is in accordance with [32] finding that socio-environmental conditions including poverty, inadequate provision of social amenities such as insufficient transport system, gender bias, lack of social acceptance, poor working condition are positively related to maternal health Global Journal of Reproductive Medicine complications and as such calls for urgent policy intervention to address social and work-related pressures on potential mothers. Figure 3 shows the economic health problems of pregnant mothers in Abakaliki Urban of Ebonyi State. Majority 107 (71.3%) indicated increased cost of medical service. Others, 97 (64.7%) were lack of income, 92 (61.3%) were lack of employment and 81 (54.0%) indicated poverty as their economic health problem. Further regression analysis with 0-49% of the pregnant mothers have low economic health problem 18(12.0%) while 50% & above of the women indicated 121 (80.7%) high economic health problems. The result of the study was expected as many previous studies had associated most of the factors indicated by the findings as source of burden to reproductive mothers' health. Blog Network [12] revealed that women have traditionally been disadvantaged in terms of economic and social status and power which in turn reduces their access to the necessities of life including health care [16] held that health status of women declines as their socioeconomic status including income, declines. Mcbarnette noted that relationship existed between poverty and several indicators of reproductive health status of women [17] also indicated crucial role of economic factor in influencing the Polish women's health. It was found by the same study that reproductive women whose financial position was poor indicated more likelihood to assess their health as less than good to suffer from respiratory, neurotic and circulatory system's diseases [33] equally found that indicators of poor economic health of the mothers include lack of employment and low educational level especially among young reproductive mothers. Figure 4 shows the economic health problems of nursing mothers in Abakaliki Urban of Ebonyi State. Majority 122 (81.3%) and 108 (72.0%) indicate increased cost of medical services as their economic problem. Others, 92 (61.3%) are increased transportation for fares for postnatal cares, and 77 (51.3%) are inadequate money faring. Further regression analysis with 0-49% of the nursing mothers have low economic health problem 6(4.0%) while 50% & above of the women indicated 123 (82.0%) high economic health problems. The results as shown in Figure 4 were expected based on previous findings by Adenike, Edewor and amoo [32] where it was explicitly shown that socioenvironmental factors for instance poverty is closely related with maternal morbidity. This reason undoubtedly must have accounted for the majority 122 (81.3%) attributed to increased cost of medical services as shown by the Figure 4. Many of the women's problems arose from their financial incapacity to foot their medical care bills. Table 4 shows that women with higher age (25-30yr: AOR=.045, 35-40yr: AOR=.281)who reside in the rural (AOR=.672), are less likely to be associated with high health problems during pregnancy compared to women of lower age, and who resides in the urban. Table 5 further reveals that women that have 3-4 and more than 5 children are 8.908 and 5.342 times respectively more likely to have high health problems than those with 1-2 children. However, the respective confidence interval and P-value for age, location and parity indicates that these variables are not significantly associated with high health problems during pregnancy. Consequently, the null hypothesis of no significant association is hereby accepted for location and parity.

Implication for Reproductive Health Education
Based on the findings of the study, it is obvious that the reproductive women investigated are confronted by numerous health challenges ranging from physical health challenges to social and economic health problems. As reviewed, the various health problems whether regarded as major or minor can be hurtful to the women as well as her spouse, children and the entire society. This state of affair suggests urgent preventive interventions geared towards reducing the prevalence of the health problems or at least bring them to the barest minimum among the women. Be it as it may, this aim may not be achieved without firstly offering factual information to the reproductive mothers on the incidence of health problems, their susceptibility, vulnerability and severity of such problems if allowed to escalate. Inculcatig health ideas into the women can only be done through health education targeted at the reproductive mothers. Health education is defined as a means of assisting people to acquire information, knowledge, attitudes and Global Journal of Reproductive Medicine skills for effecting desired behaviors. It is a means of sensitizing and influencing individuals to acquire desireable knowledge, attitude and behaviors that are favorable to health and reject those that are damaging to individual, family and community health [34]. As it concerns the reproductive mothers, health education can indeed be a tool with which to educate and disseminate relevant health knowledge as well as skills towards attainment of optimal health among the women. They can be informed through health education on the various physical, social and economic health problems, their consequences to pregnancy and infant children [35]. Information on the causes, signs and symptoms, control and importance of prompt medical treatment in times of occurrence can be presented to the reproductive women. Such pieces of information are necessary which every pregnant and nursing mother should be imbibed with. From the findings of the study, it implies also involving the reproductive mothers although minor in number with HIV/AIDS in the health education intervention by informing them on their heightened risk of developing more health problems than the rest of the groups and as such letting them know the need to adopt all possible preventive measures [36]. In order to reach out to massive number of reproductive women, health education intervention can be mounted in churches, women associations, women community meetings, antenatal and post-natal visits. The reproductive mothers ought also to be informed through such women for the connection between most of the health problems and childbearing and as such can be informed about family planning including artificial and natural methods in order to make more informed decisions. This will reduce their vulnerability to the health problems. Other activities to be included in reproductive mothers' health education should include safe motherhood, post-abortion care, female genital mutilation, reproductive tract cancers, and prevention of motherto--child transmission of HIV. By the findings, it then implies urgent call for active involvement of all health care delivery team especially health educators whose tasks are primarily to carry out health education interventions in order to promote, maintain and improve the reproductive women's' health.

Conclusion
Based on the findings, it can be established that reproductive mothers comprising pregnant and nursing mothers are faced with numerous health problems classified as physical, social and economic health problems. While some are considered major based on the number and percentage of those having it, others are considered minor. Regardless of the number and prevalence, the health problems are challenging enough and capable of endangering a reproductive woman's life. Nevertheless, with proper health education intervention in place, the health problems can be surmounted or at least reduced to a very insignificant level. Thus we recommend that:

Global Journal of Reproductive Medicine
i.
Government at all levels in collaboration with the ministry of health should organize periodic health education seminars for reproductive mothers during ante natal and post-natal visits in order to reach out to the reproductive women and sensitize them on all relevant information concerning the prevailing health problems.
ii. The federal government in collaboration with Non-Governmental Organizations (NGOs) should train more health educators to be involved in the health education intervention so as to ensure wider coverage of rural and urban areas.