CHAPTER ONE INTRODUCTION Background to the Study Children in Africa are faced with lot of risks and highly susceptible to diseases

CHAPTER ONE
INTRODUCTION
Background to the Study
Children in Africa are faced with lot of risks and highly susceptible to diseases. As a result, infant mortality is not an unusual event in several parts of the developing world. Children are extremely susceptible to diseases and death. World Health Organization (2015) has stated that closely to ten million children under the age of five die everyday in the world. Infant mortality can be expressed as the rate of child loss occurring in the first year of life (Webster, 2015). Infant mortality rate is the possibility of dying between birth and precisely five years of age expressed per one thousand live births. Infant Mortality Rate (IMR) is expressed as the number of children that die under one year of age per one thousand live births. Infant mortality rate is frequently utilised as an indicator of the level of health in a country or development, and it is a part of the physical quality of life index. The prominent causes of infant mortality are birth asphyxia, birth defects, measles, diarrhoea, malnutrition, preterm birth (low birth weight), sudden infant death syndrome, maternal death syndrome, injuries and suffocation (Centre for Disease and Control, 2013). Various contributing factors of infant mortality in Nigeria include poor environmental hygiene, malnutrition, low access and use of standard health care services by women and children. Other contributory factors include low female literacy level, poor family health care practices and lack of access to safe water.
On the other hand, the process of estimating infant mortality rate every so often differs widely between countries and the rate of premature infants that are born in the country is always used to determine it. Depending on a nation’s live birth criterion, vital registration system and reporting practices, infant mortality rates can be flawed (Anthopolos ; Becker, 2010). Some methods of measurements have the potential to be underestimated. A statistical way of measuring the standard of residents living in each nation is provided through measurement. When infant mortality rate increases or decreases, it reflect the social and technical capacities of a nation’s population (Bishai, Opuni, & Poon, 2007).
Infant Mortality Rate (IMR) is a reflection of the socioeconomic development and effectively depicts the existence of medical services in a country and not just a group of statistic. Infant mortality rate is an effective instrument always used by the health department to make decision on medical resources reallocation. Infant mortality rate furthermore expresses the global health strategies and help out to appraise the program success.
World Health Organisation (2011) described a live birth as any born human independent signs of life, including breathing, heartbeat, umbilical cord pulsation or definite movement of voluntary muscle movement and heartbeat signs. The infant mortality rate is one of three indicators employed to check achievements in relation to the fourth goals of the eight millennium development goals. The target value of this goal is to reduce by two-thirds, between 1990 and 2015, the under-five mortality rate.
Perinatal mortality can be defined as the death of an unborn offspring (fetus – 22 weeks gestation to birth) or death of a newly born baby up to one week postpartum. Neonatal mortality is the death of a newly born baby happening around 28 days postpartum. Neonatal death is constantly believed to be caused by inadequate access to basic medical care during pregnancy and after giving birth. This has lead to about 40 – 60% of death of children in developing countries. Post-neonatal mortality is defined as the death of children from 29 days after birth to one year. The main causes of post-neonatal death are infectious disease, malnutrition and difficulties with the home environment (Norton, 2005). Generally, ten million babies die every year before they celebrate their fifth birthday; 99% of these losses happen in developing nations. Death of children takes away society’s ability, physical, social, and human capital. In 2013, World Health Organisation reports that 4.6 million (74% of all under five deaths) occurred in the World health Organisation African region (60 per 1000 live births), about the five times higher than in the World Health Organisation European region (11 per 1000 live births). From 1990 to 2013, annual infant deaths have dropped significantly from 8.9 million to 4.6 million.
Furthermore, World Health Organisation (2015) specified that, in urban areas of developing countries, infant mortality areas of developing countries, infant mortality rate remains particularly high at 61 deaths per 1000 live birth in Africa (including 31 countries). In all four regions shown, infants in the poorest 20% urban households are 1.7 – 2.2 times likely to die before age one than infant in the richest 20% urban households. Infant mortality rate has dropped by 20%, 33% and 25% in urban areas of Africa, America and Asia respectively, between 1990-1999 and 2000-2011 for included countries. Death rates for infants in the poorest 20% urban households have fallen by 24%, 35% and 34% in Africa, Americas, Asia, respectively, for the countries included in the analysis. Although significant reductions have been made, especially for children from the poorest households, infant mortality rate is still disproportionately higher amongst the urban poorest populations. According to World Health Organisation (2003), Nigeria in the past years has experienced bad cases of infant mortality. The infant mortality rate computed at 100 per 1000 in 2003 was measured at 87 in 1990. This can be in part put in plain words by the persisting low numbers of births occurring in health facilities and low number of births attended to by trained healthcare service providers. Furthermore, only a little more than one-third of births are attended to by doctors and nurses or midwives. The maternal mortality ratio in Nigeria when computed was 800 per 100,000 live deliveries in the year 2000. It is obvious through the raised mortality rates that the lack of access to or use of quality and standard delivery services is an issue of great importance in Nigeria. Issues such as collecting money for treatment, distance to health facility and having to take transport are some of the many problems stated by women in explaining difficulty with accessing good healthcare. The aforesaid lack of trained health care births in Nigeria is made worse by the fact that only six in ten mothers receive antenatal care from a qualified medical professional.
Nurses and midwives are the most commonly and regular used sources of healthcare. Infant mortality in Nigeria can be prevented by giving excellent antenatal care. It was reported that as at 2003 only 58 percent of pregnant women took iron supplements and only 39 used drugs to prevent and check malaria. The repercussions of the poor condition of pregnant women in Nigeria are many and affect maternal as well as infant mortality. The mortality ratio of under five in Nigeria is 201 per 1000 live births meaning that one in five Nigeria infants do not attain the age of five. With immunization rate of thirteen percent for infants between 12-23 months, Nigeria is one of the African countries with the lowest vaccination rate. Significant presence of Acute Respiratory Infections and diarrhoea can also add to the causes of the elevated rates of infant mortality (WHO, 2003).
Statement of the Problem
Generally, giving birth to a child is an occurrence that attracts celebration, but it is not a time to rejoice or to call for party for many women who experience childbirth as pain and tragedy that may end in death; it carries an enormous burden of grief and pain and it has been known to be a main public health problem in Nigeria. The loss of an infant remains a very sad event for many families and it has a great effect on the health and well-being of families that of the nation. The rate of infant mortality usually served as an indicator to appraise the health and well-being of a nation, all because factors affecting the health of whole populace can also affect the infant mortality rate. Infant mortality is a risk factor for maternal death in the sense that when a mother loses a child at birth, she would want to get pregnant almost immediately not weighing the risk involved.
Poverty and ignorance also play a part as many families faced with challenges of meeting their basic needs also lack adequate resources for taking care of their health challenges. Infant mortality is ascribed to avoidable causes such as diarrhoea, malaria, malnutrition, and acute respiratory infections which include suffocation, prematurity and low birth. More babies die in Nigeria from these simple avoidable and treatable health conditions.
Emotional impact of infant mortality may include trauma, phobia of conceiving or giving birth again, shock, anxiety, depression and insomnia. Loads of investigations have been done on infant mortality. Bolu-steve and Dominic (2015) conducted a study on counselling intervention programme for managing trauma among women experiencing infant mortality they found that the respondents experienced emotional breakdown, phobia, insomnia and panic attacks. Ogunjimi, Ibe and Ikorok (2012) in their study in the presence of over 300 nurses conducted on curbing maternal and child mortality in Calabar found that the factors linked with death of mother and babies are bad and weak socio-economic development, poor health care system and low socio-cultural barriers to care utilization. Also in a study carried out by Adetoro and Amoo (2014) on statistical analysis of child mortality in Ogun state, it was found that mortality rate was very high (49.14%) for babies of uneducated mother and very low (13.29%) among mothers who had gone through higher education.
It has been discovered that not much attention was given to causes and psychological impacts of infant mortality. Hence, the present study is interested in filling the existing gap in the literature regarding infant mortality in Kwara State, Nigeria. To improve infant health, factors and causes of infant mortality must be known and solved at all levels, down to the community. Therefore, the researcher deems it necessary to carry out a study on the causes of infant mortality and emotional impact as perceived by nursing mothers in Kwara State.

Research Questions
The following research questions are generated to guide the conduct of this study:
1. What are the causes of infant mortality as perceived by nursing mothers in Kwara State, Nigeria?
2. What are the emotional impacts of infant mortality as perceived by nursing mothers in Kwara State?
3. Is there any difference in the causes of infant mortality as perceived by nursing mothers in Kwara State, based on family type?
4. Is there any difference in emotional impact of infant mortality as perceived by nursing mothers in Kwara State, based on family type?
5. Is there any difference in the causes of infant mortality as perceived by nursing mothers in Kwara State, based on educational background?
6. Is there any difference in the causes of infant mortality as perceived by nursing mothers in Kwara State, based on educational background?
7. Is there any difference in the causes of infant mortality as perceived by nursing mothers in Kwara State based on place of residence?
8. Is there any difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara State based on place of residence?
9. Is there any difference in the causes of infant mortality as perceived by nursing mothers in Kwara State based on number of children?
10. Is there any difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara State based on number of children?
Research Hypotheses
The following research hypotheses are postulated for the purpose of this study:
1. There is no significant age difference in the causes of infant mortality as perceived by nursing mothers in Kwara State on the basis of family type.
2. There is no significant age difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara State on the basis of family type.
3. There is no significant difference in the causes of infant mortality as perceived by nursing mothers in Kwara State on the basis of educational background.
4. There is no significant difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara State on the basis of educational background.
5. There is no significant difference in the causes of infant mortality as perceived by nursing mothers in Kwara state on the basis of place residence.
6. There is no significant difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara state on the basis of place of residence.
7. There is no significant difference in the causes of infant mortality as perceived by nursing mothers in Kwara state on the basis of number of children.
8. There is no significant difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara state on the basis of number of children.
Purpose of the study
The purpose of the study is to investigate the causes of infant mortality and its emotional impacts as perceived by nursing mothers in Kwara State, Nigeria. The study also seek to find out whether perception of nursing mothers on the causes of infant mortality rate will be influenced by variables of family type, number of children, educational background and place of residence.
Significance of the Study
Every research work is tailored towards progress and development. This research work is essential because the study would make available relevant information on the causes and emotional impact of infant mortality as perceived by mothers who are nursing babies in Kwara State. It is the hope of the researcher that the discoveries and results of this study would be of great help to the government, nursing mothers, health practitioners, guidance counselors, psychologists, psychotherapists, social workers, families and other nongovernmental organization who are committed to reducing infant mortality. The findings of this study would encourage government to create awareness in dealing with infant mortality to reduce death rate in the society.
The information will assist nursing mothers together with the counselors to educate on infant mortality. The information gathered from this study would enable nursing mothers and counselors to gain more awareness and information causes of infant mortality. Nursing mothers, Medical personnel and counsellors have a lot to do in making sure that the aims, goals and objectives of care services are met. Afterwards, counsellors can now use the information for enlightenment on health counselling for mothers and even adolescents in schools.
This study would also generate information that might provide the push to put in place facilities or agencies in the Nigerian society that would help to reduce infant mortality. Medical personnel should acquire and update skills and should exhibit commitment to work at various duty posts.
The major goal of a counsellor is to understand the behavior of the clients. The importance of counselling is to assist an individual to become fully aware of him/her environment, also to help individual live a meaningful life. Counselling process can help women experiencing infant mortality to overcome their immediate problems and also equip them to face the future with hope. Infant mortality is caused by preventable diseases such as diarrhea, typhoid, malaria, pneumonia, measles, HIV/AIDS, malnutrition etc. Hence, the information that would be obtained from this study is expected to assist counsellors in designing intervention programmes to create awareness and to sensitize nursing mothers, families and nation as a whole to prevent infant mortality. Conclusively, the findings of this study would assist counselors in training, government and post graduate counselors to be well informed about infant mortality.
Operational Definition of Terms
The terms below were operationally defined as they were used in the study:
Causes: The reasons for occurrence of infant mortality as perceived by nursing mothers in Kwara State.
Infant: It is described as a very young person from birth to somewhere between six months or five years of age, demanding continuous care and attention.
Infant Mortality: Is clearly defined as the death of babies before the age of five.
Mortality: Death rate, the number of lives that is lost over a specific time, in a given group, or a form cause.
Nursing Mother: A female who parents a child or bears a baby, and is breast-feeding her baby.
Emotional Impact: An individual’s internal state of being and involuntary physiological reaction to an object or a situation, based on tied to physical state and sensory data.
Scope of the Study
This study focused on the causes of infant mortality as perceived by nursing mothers in Kwara State. The study was limited to Kwara State. For the purpose of this study, the research employed purposive sampling procedure to select 378 nursing mothers across the three Senatorial Districts of Kwara state (i.e. Kwara South, Kwara Central, Kwara North). The study was limited to variables of family type, number of children, place of residences and educational background. The data gathering procedure for this study was limited to the use of researcher designed questionnaire titled “Causes of Infant Mortality and Emotional Impact Questionnaire” (CIMEIQ). The data analysis procedure for this study was limited to frequency counts, percentages, t-test and Analysis of Variance.
CHAPTER TWO
REVIEW OF RELATED LITERATURE
Preamble
In this chapter, a review of relevant literature which provides a theoretical and empirical framework for the study is hereby presented in an attempt to examine the factors responsible for infant mortality among nursing mothers in Kwara State. Review of related literature was carried out on the following subheading:
• Concept of Infant Mortality and Forms of Infant Mortality;
• Causes of Infant Mortality;
• Attributive Beliefs about Infant Mortality;
• Prevalence of Infant Mortality in Nigeria;
• Prevention of Infant Mortality;
• Emotional Impact on Nursing mothers who Experience Infant Mortality;
• Empirical Studies on Causes and Emotional Impact of Infant Mortality;
• Summary of the Reviewed Literature.

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Concept of Infant Mortality and Forms of Infant Mortality
Infant Mortality can be clearly described as the death of children before the age of five after birth. According to Centres for Diseases Control and Prevention (2015), Infant Mortality is defined as the death of a baby before the baby’s first birthday. It is calculated as infant mortality rate (IMR), and this is the number of deaths of babies recorded before the age of one for each one thousand live births. Infant mortality rate is expressed as the number of babies dying before reaching the age of one per 1000 live births in a specified year (UNICEF, 2015). Infant Mortality is the rate of deaths happening in the first year of life (Webster, 2015). According United Nations International Children’s Emergency Fund, Infant Mortality Rate is the possibility of dying between birth and precisely one year of age expressed for each one thousand live births. Infant Mortality is the death of a child caused by diseases and other conditions related to childbirth (Victora & Barros, 2001). World Health Organisation (2011) defined a live birth as any born human being who demonstrates independent signs of life, including breathing, heartbeat, umbilical cord pulsation or definitely moving muscle voluntary and heartbeat signs.
According to United Nations International Children’s Emergency Fund (2008) report, every year nearly 10 million children under age five die globally. Approximately four million newly born babies (40% of under- five deaths) die between the first to forth week of life. Even though, Africa forms only 22% of births in the world, half of the ten million child deaths annually happen in the continent. The major tenets of the fourth and fifth Millennium Development Goal (MDG 4 and 5) are to decrease under-five rate and advancement in maternal health and by implication enhances the possibility of child survival. Under –Five mortality rates represents the probability of a child who survives to age one, dying between age one and age five, (WHO, 2011).
Forms and kinds of infant mortality in the world include:
a. Perinatal mortality is clearly defined as the late fetal death (22 weeks gestation till birth) or death of newly born babies till one week postpartum (Andrews ; Brouillette, 2008).
b. Neonatal mortality is described as the death of newly born babies happening within twenty-eight days postpartum. Neonatal death is constantly believed to be caused by inadequate right to use basic medical care throughout pregnancy period and after giving birth. This has lead to about 40 – 60% of death of babies in developing countries (Norton, 2005).
c. Post-neonatal mortality is defined as the death of children from twenty-nine days after birth to one year. The main causes of post-neonatal death are infectious disease, malnutrition and difficulties with the surroundings of the home (Norton, 2005).
The report of the State of the World’s Mothers, give details of the infant mortality rate in the world to have reduced from 126 to 57 in 1960 and 2001 respectively (UNICEF, 2015). However, infant mortality rate is still remains higher in developing countries. The rate of infant mortality in developing countries (91) in 2001 was about 10 times more than what was recorded for developed countries (8). On average, for less developed countries, the rate of infant mortality is about 17 times higher than that of more developed countries. Also, while both developing countries and more developed countries achieved momentous decrease in infant mortality rates, the decrease in the developing countries are, on average, much less than those among the more developed countries (CIA, 2012). In the 1850, the infant mortality rate in the United States was estimated at 216.8 per 1,000 babies born for whites and 340.0 for each 1,000 for African Americans, but rates have drastically reduced in the West in modern times. This reducing rate happened because of modern developments in basic health support, technology and advancement in medical (Sullivan & Sheffrin, 2003).

Figure 2.1: Infant Mortality Rates of African Countries
Source: CIA World Fact Book (2011)

Figure 2.2: Infant Mortality Rates of other Countries
Source: CIA World Fact Book (2011)
Figure 2.1 and 2.2 above shows clearly that Infant Mortality Rate in Nigeria is high when weighed against other countries.
Mortality Rate of infant (For Each 1000 Live Births) in Nigeria was last measured at 71.50% in 2014. Infant mortality rate is described by World Bank as the number of babies dying before reaching the age of one for each one thousand live births in a given year. According to the Maternal and Child Health Survey by the UNICEF in (2013), Nigeria loses approximately 2,300 infants below age of five and 145 women of childbearing age. The country is now known as the second highest contributor to the under-five and maternal mortality rate in the whole wide world.
The deaths of newly born babies in Nigeria were about one-fourth of the total number of deaths of babies below the age of five. Roughly nine out of ten of the newly born babies’ death is avertible. Most of the deaths happen within the first week of giving birth to these babies, majorly because of complications throughout the pregnancy and delivery period showing the close link within newly born survival and the standard of maternal care. To many it is statistics, but to thousands of families who lost their children, wives, mothers and sisters it goes beyond that. One would never understand the grief and misery of losing a close relative to avoidable deaths.
Although Government is making progress though slow in reducing infant and under-five mortality rates, the child death rate dropped from 90 to 46 deaths for every one thousand live births in 2013, there is still a lot to be done to attain the Millennium Development Goals of reducing infant mortality by 30 percent at the end of 2016, especially with regard to nursing mothers to support government’s strenuous effort. With a 13 percent immunization rate for infants between 12 to 23 months, Nigeria has the lowest rate of vaccination in Africa. This recurring issue needs to be quickly addressed; the health of our women and infants in various respective states should be a prime focus now. Nigeria needs to integrate maternal, newly born and infant health interventions into the health care services. Government should support data generation to guarantee evidence-based policies and interventions and also make they are spread nationwide (CIA, 2011).
Factors Responsible for Infant Mortality
Major factors causing infant mortality are malformations, sudden infant death syndrome, maternal complications in the course of pregnancy, accidents and unplanned injuries. Social and Environmental barriers thwarts the use of basic medical resources and as a result contribute to an increasing infant mortality rate. Out of 99 percent of infant deaths happening in developing countries, 86 percent of deaths are caused by infections, premature births, complications in the course of delivery, perinatal asphyxia and injuries in the event of being born (Andrews & Brouillette, 2008).
a) Medical Factors: Medical factors responsible for infant mortality are low birth weight, infectious diseases, sudden infant death syndrome and malnutrition. In developing countries, births of low weight are roughly between 60 to 80% of infant mortality rate. Osel (2008) stated that “The lowest mortality rates occur among infants weighing 3,000 to 3,500g (6.6 to 7.7 lb) or less, the mortality rate rapidly increases with decreasing weight, and most of infants weighing 1,000g (2.2 lb) or less die”. In comparison with normal birth weight infants, infants with low weight at birth are about 40 times more probable to die in the period of neonatal. For babies with small weight at birth, the relative danger of neonatal death is about 200 times greater. Infant mortality caused by low weight of birth is normally a direct cause stemming from other health problems such as bad maternal nutritional status, preterm birth, lack of prenatal care, maternal sickness in the course of pregnancy and unhygienic home (Andrews & Brouillette, 2008).
Sudden Infant Death Syndrome (SIDS) is a major cause of many of infant deaths for each year. The syndrome is a mysterious death that happens usually in sleep of a hale and hearty baby. Even though the main cause of the syndrome remains unidentified and many doctors believe that there are numerous factors and that baby have high tendency of having the syndrome. These factors include children sleeping on bellies, contact with cigarette smoke while in the womb or after birth, sleeping with parents on the same bed, premature birth, being born to teen mother, a twin and a triplet birth and poverty. Even though the cause cannot be identified and presently cannot be clarified, doctors have concluded that the syndrome is most likely to happen between two and four months and these deaths happen in the winter time.
Malnutrition often accompanies these health conditions and this is a foremost factor adding to problems of both diarrhoea and pneumonia, even though the causal links and mechanisms remain unclear. Other factors apart from nutrition can also influence the occurrence of diarrhoea, including socioeconomic status, disruption of traditional lifestyles, access to hygienic water and facilities for sanitation, age and breastfeeding status. Micronutrient deficiency and protein energy malnutrition are two main causes of stunted growth in infants of five years old and below in a worst developed countries. Malnutrition usually cause diarrhoea and dehydration, and can lead early death. In developing countries, many women are stunted because of the malnutrition at their early stage of life (Andrews & Brouillette, 2008). Women’s bodies are as a result underdeveloped and possibilities of withstanding giving birth reduce. The possibility of having an obstructed pregnancy is very high due to underdeveloped bodies. Protein energy deficiency results in low quality breast milk that is not as caloric as nutritious. Vitamin A deficiency can lead to stunted growth, blindness and increased morality due to the lack of nutrients in the body. Two hundred and fifty million infants are infants are affected by Vitamin A deficiency. Among women in developing countries, 40% have iron deficiency anemia. Iron deficiency anemia increases maternal and infant mortality rates, chances of stillbirth, case of low birth weight babies, premature delivery and probability of fetal brain damage (Andrews ; Brouillette, 2008). One way to prevent vitamin A deficiency from occurring is to educate the mother on the many benefits of breastfeeding. Breast milk is a natural producer of Vitamin A, therefore supplying the infant with sufficient amounts of Vitamin A while at breastfeeding age (WHO, 2013).
Infectious diseases, babies born in low to middle income countries in sub-Saharan Africa and southern Asia are at the highest risk of neonatal death. Bacterial infections of the bloodstream, lungs, and the brain’s covering (meningitis) are responsible for 25% of neonatal deaths. Newborns can acquire infections during birth from bacteria that are present in their mother’s reproductive tract. The mother may not be aware of the infection, or she may have an untreated pelvic inflammatory disease or sexually transmitted disease. These bacteria can move up the vaginal canal into amniotic sac surrounding the baby. Maternal blood borne infection is another route of bacterial infection from mother to baby.
Neonatal infection is also more likely with the premature rupture is also more likely with the premature rupture of the membranes (PROM) of the amniotic sac. (Santosham, Grace, Anne, Abudullah ; Robert, 2013). Seven out of ten childhood deaths are due to infectious diseases such as acute respiratory infection, diarrhea, measles and malaria. Acute respiratory infection such as pneumonia, bronchitis, and bronchiolitis account for 30% of childhood deaths, 95% of pneumonia cases occur in the developing world. Diarrhea is the second largest cause of childhood mortality in the world, while malaria causes 11% of childhood deaths. Measles is the fifth largest cause of childhood mortality. (Andrews ; Brouillette,2008).Folic acid for mothers is one way to combat iron deficiency.
A few public health measures used lower levels of iron deficiency anemia include iodize salt or drinking water, and include vitamin A and multivitamin supplements into a mother’s diet (Andrews & Brouuillette, 2008). A deficiency of this vitamin causes certain types of anemia (low red blood cell count).
b) Environmental Factors: Infant mortality rate can be a measure of a nation’s of a nation’s health and social conditions. It is a composite of a number of component rates which have their separate relationship with various social factors and can often be seen as an indicator to measure the level of socioeconomic disparity within a country (Gortmaker, 1997). Organic water pollution is a potent indicator of infant mortality than health expenditures per capital. Water contaminated with various pathogens houses a host of parasitic and microbial infections. Infectious disease and parasites are carried via water pollution from animal wastes (Jorgenson, 1997). Areas of low socioeconomic status are more prone to inadequate plumbing infrastructure, and poorly maintained facilities. The burning of inefficient fuels doubles rate of children under 5 years old acute respiratory tract infections. Climate and geography also play a role in sanitation conditions. For example, the inaccessibility of clean water exacerbates poor sanitation conditions (Jorgenson, 1997). People who live in areas where particulate matter (PM) air pollution is higher tend to have more health problems across the board. Short term and long term effects of ambient air pollution are associated with an increased mortality rate, including infant mortality.
Air pollution is consistently associated with post neonatal mortality due to respiratory effects and sudden infant death syndrome. Specifically, air pollution is highly associated with sudden infant death syndrome in the United States during the post neonatal stage (Woodruff, 2008).
High infant mortality is exacerbated because newborns are a vulnerable subgroup that is affected by air pollution (Glinianaia, 2004). Newborns that were born into these environments are no exception. Women who are exposed to greater air pollution on daily basis who are pregnant should be closely watched by their doctors, as well as after the baby is born. Babies who live in areas with less air pollution have a greater chance of living until their first birthday. As expected, babies who live in environments with more air pollution are at greater risk for infant mortality. Areas that have higher air pollution also have a greater chance of having a higher population also have a greater chance of having a higher population density, higher crime rates and lower income levels, all of which can lead to higher infant mortality rates.
The three key pollutants for infant mortality rates are carbon monoxide, particulate matter less than 10 um in diameter and ozone. Particulate matter and ozone have no noticeable effects on infant deaths, but exposure to high levels of carbon monoxide does increase the mortality rates. Carbon monoxide is a colorless, odorless gas that does harm especially to infants because of their immature respiratory system. Another major pollutant is second hand smoke, which is a pollutant that can have detrimental effects on a fetus.
According to the (Benjamin, 2006), more than 42,000 Americans died of second hand smoke attributable diseases, including more than 41,000 adults and nearly 900 infants, fully 36% of the infants who died of low birth weight caused by exposure to maternal smoking in utero were Blacks, as were 28% of those dying of other respiratory distress syndrome, 25% dying of other respiratory conditions, and 24% dying of sudden infant death syndrome.
Also, Benjamin,( 2006), stated that ”Compared with nonsmoking women having their first birth, women who smoked less than one pack of cigarettes per day a 25% greater risk of mortality, and those who smoked one or more packs per day a 56% greater risk”. Among women having their second or higher birth, smokers experienced 30% greater mortality than nonsmokers. Modern research in the United States on racial disparities in infant mortality suggests a link between the institutionalized racism that pervades the environment and high rates of African American infant mortality remains elevated due to the social arrangements that exist between groups and the lifelong experiences responding to the resultant power dynamics of these arrangements (Osel, 2008).
c) Socio-Economic Factors: Social class is a major factor in infant mortality, from time immemorial. Over the period between 1912 and 1915, The Children’s Bureau examined data across eight cities and nearly 23,000 live births. They discovered that lower incomes tend to correlate with higher infant mortality. As well, differences between races were apparent during this time period. African-American mothers experience an infant mortality at a rate 44% higher than average (Haines, 2006). However, research indicates that socio-economic factors do not totally account for the racial disparities in infant mortality (Osel, 2008). While infant mortality is normally negatively correlated with GDP, there may indeed be some opposing short term effects to a recession. A recent study by the Economist shows that economic slowdowns reduce the amount of air pollution, which results in a lower infant mortality rate. During the late 1970s and early 1980s, the recession’s impact on air quality is estimated to have saved around 1,300 US babies. It is only during deep recessions that infant mortality increases. According to Norbert Schady & Marc-Francois Smitz, recessions where GDP per capita drops by 15% more have a negative impact on infant mortality (Schady & Smitz, 2009). Social class dictates which medical services are available to an individual and usually, the various levels within the socioeconomic hierarchy receive different quality of medical services. Disparities due to socioeconomic factors have been exacerbated by advances of technology in the medical field. Developed countries, most notably the United States, have seen dichotomization from technological advances. Those living in poverty cannot afford medical advanced resources which leads to an increased chance of infant mortality (Gortmaker, 1997).
d) War: In policy, there is a lag time between realization of a problem’s possible solution and actual implementation of policy solutions (Farahani, 2009). Infant mortality rates are related to war, political unrest, and government corruption (Andrews ; Brouillette, 2008). In most cases, war affected areas will experience a significant increase in infant mortality rates. Having a War taking place where a woman is planning on having a baby is not only stressful on the mother and fetus, but also has several detrimental effects. (Andrews; Brouillette, 2008) reported that ”in the years since 1990, Iraq has seen its child mortality rate soar by 125 per cent, the highest increase of any country in the world. Its rate of deaths of children under five now matches that of Mauritania. Also, Figures collated by the charity show that in 1990 Iraq’s child mortality rate for under fives was 50 per 1,000 live births. In 2005 it was 125.While many other countries have rates Angola, Somalia and the Democratic Republic of Congo, for instance, all have rates above 200, the increase in Iraq is higher than elsewhere” according to commondreams.org. The primary causes of the increase are external factors such as murder and abuse. However, many other significant factors influence infant mortality rates in war torn areas. Health care systems in developing countries in the midst of war often collapse. Attaining basic medical supplies and care becomes increasingly difficult. During the Yugoslav Wars in the 1990s Bosnia experienced a 60% decrease in child immunizations. Preventable diseases can quickly become epidemic given the medical conditions during war (Krug, 2002).
Many developing countries rely on foreign aid for basic nutrition. Transport of aid becomes significantly more difficult in times of war. In most situations the average weight of a population will drop substantially (Asling, 2003). Expecting mothers are affected even more by lack of access to food and water. During the Yugoslav wars Bosnia the number of premature babies born increased and the average birth weight decreased (Krug, 2002). There have been several instances in recent years of systematic rape as a weapon of war. Women who become pregnant as a result of war rape face even more significant challenges in bearing a healthy child. Studies suggest that women who experience sexual violence before or during pregnancy are more likely to experience infant death in their children (Asling, 2003). Causes of infant mortality in abused women range from physical side effects of the initial trauma to psychological effects that lead to poor adjustment to society. Many women who became pregnant by rape in Bosnia were isolated from their hometowns making life after childbirth exponentially more difficult (Fisher, 1996).
e) Medicine and Biology: Developing countries lack access to affordable and professional health care resources and skilled personnel during deliveries (Farahani, 2009). Countries with histories of extreme poverty also have a pattern of epidemics, endemic infectious diseases, and low levels of access to maternal and child healthcare (Shandra, 2004). The American Academy of Pediatrics recommends that infant need multiple doses of vaccines such as diphtheria-tetanus-acellular pertussis vaccine, Haemophilus influenza type b (Hib) vaccines, Hepatitis B (Hep B) vaccine, inactivated polio vaccine (IPV), and pneumococcal vaccine (PCV). Research was conducted by the Institute of Medicine’s Immunization Safety Review Committee concluded that there is no relationship between these vaccines and risk of Sudden infant death syndrome in infants. This tells us that not only is it extremely necessary for every child to get these vaccines to prevent serious diseases, but there is no reason to believe that if your child does receive an immunization that it will have any effect on their risk of Sudden infant death syndrome (Stratton ; Donna, 2003).
f) Economics: Political modernization perspective, the neo-classical economic theory that scare goods are most effectively distributed to the market, say that the level of political democracy influences the rate of infant mortality. Developing nations with democratic governments tend to be more responsive to public opinion, social movements, and special interest group for issues like mortality. In contrast, non-democratic governments are interested in corporate issues. Democratic status affects the dependency a nation has towards its economic state via export, investments from multinational corporations and international lending institutions (Shandra, 2004). Levels of socioeconomic development and global integration are inversely related to nation’s infant mortality rate (Fuse, 2006).
Dependency perspective occurs in a global capital system. A nation’s internal impact is highly influenced by its position in the global economy and has adverse effects on the survival of children in developing countries.(Jorgenson, 2004) .Countries can experience disproportionate effects from its trade and stratification within the global system (Moore, 2004). It aids in the global division of labor, distorting the domestic economy of developing nations.
The dependency of developing nations can lead to a reduce rate of economic growth, increase income inequality inter and intra national, and adversely affects the well being of a nation’s population. A collective cooperation between economic countries plays a role in development policies in the poorer, peripheral, countries of the world (Shandra, 2004). These economic factors present challenges to government’s public health policies (Jorgenson, 2004). If the nation’s ability to raise its health service programs, including services that aim in decreasing infant mortality rates (Shandra, 2004). Peripheral countries face higher levels of vulnerability to the possible negative effects of globalization and trade in relation to key countries in the global market (Jorgenson, 2004). Even with strong economy and economic growth (measured by a country’s gross national product), the advances of medical technologies may not be felt by everyone, lending itself to increasing social disparities (Gortmaker, 1997).
g) Cultural factor: High rates of infant mortality occur in developing countries where financial and material resources are scarce and there is a high tolerance to high number of infant deaths. There are circumstances where a number of developing countries to breed a culture where situations of infant mortality such as favoring male babies over female babies are the norm (Andrews ; Brouillette, 2008).
In developing countries such as Brazil, infant mortality rates are commonly not recorded due to register for death certificates. Failure to register is mainly due to the potential loss of time and money and other indirect costs to the family. Even with resource opportunities such as the 1973 Public Registry Law 6015, which allowed free registration for low income families, the requirements to qualify hold back individuals who are not contracted workers. Instead of providing incentives for families to self report, researchers for infant mortality rates in developing countries should be culturally sensitive in figuring out why families fail to accurately report infant mortality, even when questioned by death recorders. Researchers can be more cultural sensitive in the collection of mortality data by administrating ”popular death reporters” (members of the community who witness infant deaths, people such as traditional healers, coffin workers, grave diggers). This alternative method of collecting infant mortality data is both accurate and a culturally sensitive method of collecting data in the most humane approach, taking special consideration to those suffering the difficulty of an experiencing an infant death within their family (Nation ; Amaral, 1991).
Another cultural reason for infant mortality, such as what is happening in Ghana, is that besides the obvious, like rutted roads, there are prejudices against wives or newborns leaving the house (McNeil, 2012). Because of this it is making it even more difficult for the women and newborns to get the treatment that is available to them and that is needed. Cultural influences and lifestyle habits in the United States can account for some deaths in infants throughout the years. According to the Journal of the American Medical Association ”the post neonatal mortality risk (28 to 364 days) was highest among continental Puerto Ricans” compared to babies of the non- Hispanic race. Examples of this include teenage pregnancy, obesity, diabetes and smoking. All are possible causes of premature births, which is second highest cause of infant mortality (McNeil, 2012). Ethnic differences experienced in the United States are accompanied by higher prevalence of behavioral risk factors and socio-demographic challenges that each ethnic group faces (McDonard, 2012).
h) Gender Favoritism: Historically, males have had higher infant mortality rates than females. The difference between male and female infant mortality rates have been dependent on environmental, social, and economic conditions. More specifically, males are biologically more vulnerable to infections and conditions associated with prematurity and development. Before 1970, the reasons for male infant mortality were due to infections and chronic degenerative diseases. However, since 1970, certain cultures emphasizing males has led to decrease in the infant mortality gap between males and females. Also, medical advances have resulted in a growing number of male infants surviving at higher rates than females due to the initial high infant mortality rate of males.
Genetic components results in newborn females being biologically advantaged when it comes to surviving their first birthday. Males, biologically, have lower chances of surviving infancy in comparison to female babies. As infant mortality rates saw a decrease on a global scale, the gender most affected by infant mortality changed from male experiences a biological disadvantage, to female facing a societal disadvantage (Drevenstedt, 2008). Some developing nations have social and cultural patterns that reflect adult discrimination to favor boys over girls for their future potential to contribute to the household production level. A country’s ethnic composition, homogeneous versus heterogeneous, can explain social attitudes and practices. Heterogeneous level is a strong predictor in explaining infant mortality (Fuse, 2004).
i) Birth Spacing: Birth spacing is the time between births. Births spaced at least three years apart from one another are associated with the lowest rate of mortality. The longer the interval between births, the lower the risk for having any birthing complications, infant, childhood and maternal mortality. Higher rates of pre-term births, and low birth weight are associated with birth to conception intervals of less than six months. Shorter intervals between births increase the chances of chronic and general under nutrition, 57% of women in 55 developing countries reported birth spaces shorter than three years, 26% report birth spacing of less than two years. Only 20% of post-partum women report wanting another birth within two years, however, only 40% is taking necessary steps such as family planning to achieve the birth intervals they want (Norton, 2005). Unplanned pregnancies and birth intervals of less than twenty-four months are known to correlate with low birth weights and delivery complications. Also, women who are already small in stature tend to deliver smaller than average babies, perpetuating a cycle of being underweight (Rutstein, 2005).
J) Education: The mother’s educational attainment and literacy are correlated with age of first pregnancy, and probability that the mother attain prenatal and postnatal care. Mothers with a secondary education have a higher probability of waiting until a later age to get pregnant. Once pregnant, they are also more likely to get prenatal and postnatal care, and deliver their child in the presence of a skilled attendant. Women who finish at least a primary level education have improved nutrition, medical care, information access, and economic independence. Infants reap benefits such as healthy environments, improved nutrition, and medical care. Mothers with some level of education have a higher probability to breastfeeding (Andrews ; Brouillette, 2008). The duration of breastfeeding has the potential to influence the birth space (Rutstein, 2005). Women without any educational background tend to have children at an earlier age, thus their bodies are not yet mature enough to carry and deliver a child (Andrews ; Brouillette, 2008).
Attributive Beliefs about Infant Mortality
Our beliefs, attitude, and values about deaths, grief and loss are molded by societal dictates. Within societies, various religious, philosophical, and ethnic groups further determine and refine the range of appropriate responses, feelings, behaviors and rituals (Alexander ; Radisch, 2005). While there are certainly wide differences among individuals within any society or culture, particularly in their psychological processing of grief, they are often more subtle than the profound differences among culture. Societal and cultural influences may be difficult to recognize (Bartkowski, John, Xiaohe ; Ginny (2011). These contextual determinants are so fundamental to our way of seeing the world that we often overlook their profound impact on how we feel and behave about loss (Alexander ; Radisch, 2005).
According to Shandra (2004), severe poverty is the root cause of high mortality rates in the developing world. Poverty results in malnutrition, overcrowded living conditions, inadequate sanitation and contaminated water. Routine vaccination is often unavailable for both children and adults, and basic clinical care for the acutely ill is in short supply. Thus, poverty creates a fertile environment for infectious and parasitic diseases. Poverty also leads to illiteracy and inadequate education (Shettima, 2008). Deficient education, especially of females, closely correlated with poor health in developing. Attribution of deaths to specific diseases is difficult for several reasons. Most developing countries have rudimentary national health statistics or none at all. In addition, protein energy malnutrition and micronutrient deficiencies, are contributing to many deaths (Shandra, 2004; Shettima, 2008).
According to Muhuri, MacDorman ; Ezzati-Rice (2004), malaria is the most the serious parasitic disease in the world. Death from malaria usually occurs in early childhood, 68% of all malaria deaths are in children under 5. Children and adults who harbor malaria parasite worldwide rarely die from it but may suffer occasional attacks of debilitating illness.
Neonatal tetanus also causes death among children, resulting from unhygienic childbirth practices, especially non- aseptic cutting of the umbilical cord, and from lack maternal tetanus immunization. Most of the deaths of children under five are not due to infectious diseases, but result from peri-natal conditions. These include all include deaths in the first week of life from abruption placentae, compression of the umbilical cord, premature rupture of membranes, obstructed labor, birth trauma, congenital malformations, infection of the amniotic fluid, sepsis, and other poorly defined causes. The most serious single disease in this age group is tuberculosis without treatment (Alexander, Wingate, Bader ; Kogan, 2008; Shandra, 2004; Shettima, 2008).

Prevalence of Infant Mortality in Nigeria
Table 2.1: Prevalence of Infant Mortality Rate per 1000 Life Birth in Nigeria
Country 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Nigeria 74.18 73.34 72.49 71.35 70.49 98.8 97.14 95.52 95.74 94.35 92.99 91.54
Source: CIA World Fact Book (2011)
Infant mortality has implication only to family and community but also to nation at large. With high incidence of infant mortality, a nation is regarded as a developing country. Nigeria, in the past few years has experienced some worsening of child mortality. The infant mortality rate evaluated at 100 per 1000 in 2003 was measured at 87 in 1990. This can be in part explained by the persisting low numbers of births occurring in health facilities and the low number of births attended by trained healthcare service providers. In 2003, two thirds of the births in Nigeria still occurred at home. In addition only slightly more than one third of births in are attended by doctors, nurses, or midwives. In 2000 the maternal mortality ratio in Nigeria was 800 per 100,000 live births (CIA, 2011; WHO 2011).
It is apparent through the elevated mortality rates that the lack of access to or use of quality delivery service is an issue of immense importance in Nigeria. Problems such as obtaining money for treatment, distance to health facility and having to take transport are some of the many difficulties stated by women in describing difficulty with accessing healthcare (Shandra, 2004).
The aforementioned lack of trained health care attended births in Nigeria is compounded by the fact that only six in ten mothers receive antenatal care from a trained medical professional. Nurses and midwives are the most frequently used sources of healthcare. Good antenatal care can prevent the major causes of neonatal mortality in Nigeria such as neonatal tetanus, malaria, and maternal anemia. However, as of 2003 only 58 percent of pregnant women received iron supplements and only 39 received drugs to prevent (UNICEF, 2008; Ogunjimi, Ibe ; Ikorok, 2012).
The consequences of poor state of pregnant women in Nigeria are numerous and affect maternal as well as child mortality. The under five mortality ratio in Nigeria is 201 per 1000 live births meaning that one in five Nigerian children never reach the age of 5. Infant death, which account for half of child mortality have increased from what they were in 1990. With a 13% immunization rate for children between 12-23 months, Nigeria is the African country with the lowest vaccination rate. Substantial presence of Acute Respiratory Infections and diarrhoea also contribute to the elevated mortality rates for children (WHO, 2003).

Emotional Impact on Nursing mothers who Experience Infant Mortality
The loss of a child is like an earthquake that fractures the emotional landscape of mothers. Death of a baby is a tragedy that can initiate intense emotional reactions in nursing mothers. According to NICHID (2011) incidence of depressive symptoms guilt, prolonged grieving and feelings of loss are all common among nursing mothers experiencing infant mortality. Reoccurrence of distressing event such as the death of a child often leads to painful and shocking experience that have lasting mental and physical effect on the psyche of the nursing mothers.
Trauma is a word that is used to denote the experience or situation that is emotionally painfully and distressing which overwhelms one’s ability to cope with life. It is could be regarded as a bodily or mental injury caused by an external agent. Medically trauma refers to a serious or critical injury, wound or shock. Emotional and psychological trauma is has a result of extraordinary events that shatters a person’s sense of security, making one feel helpless. The more frightened and helpless a person feels, the more likely the person is traumatized. Emotional and psychological can be caused by, the sudden death of someone close or deeply disappointing experience. An event will most likely lead to emotional or psychological trauma if it happened unexpectedly (UNICEF, 2008).
Emotional and psychological symptoms of trauma includes depression, shock, denial, anger, mood swings, feeling sad, hopeless, anxiety, fear and withdrawing from others. Physical symptoms of trauma include insomnia, nightmares, aches, pains, fatigue, fatigue, loss of confidence, stigmatization and difficulty concentrating (Ogunjimi, Ibe ; Ikorok, 2012).
The natural reaction to loss is grief. Grief is associated with feelings of sadness, yearning, guilt, regret and anger. Some people may a sense of meaninglessness, and others can feel a sense of relief (Toole, Galson ; Brady, 1993). Emotions are often surprising in their strength or mildness, and they can also be confusing, such as when a person misses a painful relationship. Thoughts during grief can vary from “there’s nothing I can do about it”, “she had a good life”, it wasn’t her time. They can be troubling, and people in grief can bounce between different thoughts as they make sense of their loss. Grieving behavior run from crying to laugher, and from sharing feelings to engaging silently in activities like cleaning, writing or exercising (Schady & Smitz, 2009).
According to Aveyard, Cheng, Manaseki and Gardosi (2002), the different feelings, thoughts, and behaviors people express during grief can be categorized into two main styles of grieving:
• Instrumental grieving involves focusing primarily on problem solving tasks while controlling or minimizing emotional expression.
• Intuitive grieving is based on a heightened emotional experience that leads to sharing feelings, exploring the lost relationship and identifying meaning to life.
Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. It affects how one feel, think and behave and can lead to a variety of emotional and physical problems. A person with a depressed mood can feel sad, anxious, empty, hopeless, worthless, guilty, irritable, angry, ashamed, or restless. A prolonged depressed mood, may lead to a diagnosis of a psychiatric or medical condition which may benefit from treatment (Aveyard, Cheng, Manaseki & Gardosi, 2002).
Shock is an intense emotional reaction to a stressful situation or bad news. It is an unpleasant feeling one feels or experience when something new or unusual happens. Denial is a psychological defense mechanism in which confrontation with personal problem or with reality is avoided by denying the existence of the problem or reality. Denial is a refusal to accept or believe in someone or something (Ogunjimi, et al, 2012).
Mood swing is an extreme or rapid change in mood. Mood swings or rapid changes in one’s emotional state, may occur as a reaction to circumstances or environment, as a result of a physical or mental condition. Mood might also be affected by sleep, diet, medication, and other lifestyle factors, and shifts in these may affect the stability of a person’s of a person’s mood (Norton, 2005).
Sadness is feeling or showing sorrow; unhappy. A mental depression that involves presentation of depressive symptoms only during a specific season of the year. Anxiety is an emotion characterized by an unpleasant state or inner turmoil, often accompanied by nervous behavior such as pacing back and forth, somatic complaints and rumination. It is the subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent death (Ogunjimi, et al, 2012).
Fear is an unpleasant emotion caused by the threat of danger, pain or harm. Fear is a feeling induced by perceived danger or threat that occurs in certain types of organisms, which causes a change in metabolic and organ functions and ultimately a change in behavior, such as fleeing, hiding, or freezing from perceived traumatic events (Nussbaum, 2011).
Therapy for Grief
According to Worden (2015), a professional counselor or a qualified mental health professional will be needed when person’s grief related thoughts, behaviors, or feelings are extremely distressing or unrelenting. Therapy is an effective way to cope with the stressors associated with loss and to manage symptoms with techniques such as relaxation or meditation.
Each experience of grief is unique, complex, and personal, and therapists will tailor treatment to meet the specific needs of each person. The counsellor or therapist will help the bereaved find different ways to maintain healthy connections with decreased through memory, reflection, or dialogue about the decreased (Onyemunwa, 1998).
In addition to individual therapy, group therapy can be helpful for those who find solace in the reciprocal sharing of thoughts and feelings and recovery results are rapid in this setting. Similarly, family therapy may be suitable for a family whose members are struggling to adapt to the loss of a family member.
According to Worden (2015), he created a stage based model for coping with the death of a loved one. He called his model the Four Tasks of Mourning:
• To accept the reality of the loss
• To work through the pain of grief
• To adjust to life without the decreased
• To maintain a connection to the decreased while moving on with life.
Margaret Stroebe and Hank Schut developed a dual process model of bereavement. They identified two tasks associated with bereavement:
• Loss oriented activities and stressors are those directly related to the death. These include crying, yearning, experiencing sadness, denial or anger, dwelling on the circumstances of the death, and avoiding restoration activities.
• Restoration oriented activities and stressors are associated with secondary losses with regards to lifestyle, routine and relationships. These include adapting to a new role, managing changes, developing new ways of connecting with family and friends and cultivating a new way of life. Stroebe and Schut suggest that people will invariably oscillate between the two processes.
Diagnostic and Statistical Manual of Mental Disorders (DSM) and Grief
Therapy for Trauma
Somatic experiencing focuses on bodily sensations, rather than thoughts and memories about traumatic event. By concentrating on what’s happening in your body, you can release pent up trauma related energy through shaking, crying, and other forms of physical release (Colson ; Joslin, 2002).
• Eye Movement Desensitization and Reprocessing incorporates elements of cognitive behavioral therapy with eye movements or other forms of rhythmic, left-right stimulation that can unfreeze traumatic memories.
• Cognitive behavioral therapy helps clients process and evaluate their thoughts and feelings about trauma. It aims at solving emotional and cognitive problems. It also helps the traumatized client to develop new emotional and behavioral pattern.
• Offer practical support to help client get back to normal routine.
• Be patient and understanding, healing from trauma takes time.
According to Arnold and Fernbach (2000).The role of the counselor is to give support and assist people who have been traumatized in finding various kinds of help. The primary goal of the therapy is to:
• To make meaning of the experience.
• To examine the role the traumatic, experience in the context of the client’s life, currently and historically.
• To learn skills to manage symptoms and to develop alternative ways of coping.
• To build or rebuild the ability to trust within a relationship in order to view the world as an increasingly tolerable place to function.
Counsellors must have:
• A variety of clinical skills to address the specific needs of the client.
• An understanding of power imbalance that exists in therapy and a willingness to work toward empowerment of the client.
• A view of the client as the expert on his or her own life and as an active partner in therapy.
• Awareness of their own biases and the limits of their skill, and willingness to refer client to other professionals if necessary.
Counsellors must be:
• genuine
• willing to share information about themselves as helpful and appropriate
• have respect and high positive regard for their client
• warm and empathic
• responsive and hopeful
• firm but not domineering
Prevention of Infant Mortality
Governments, World Health Organisation and others, United Nations International Children’s Emergency Fund aims to scale up proven, high impact, cost effective health and nutrition interventions to reduce the number of neonatal and young child deaths from preventable and easily treatable causes.
UNICEF is the world’s largest purchaser of vaccines, procuring more than 40 percent of all vaccines used in the developing world. While global immunization rates have risen from less than 20 percent in the 1970s to about 74 percent in 2002, millions of children must still be reached. United Nations International Children’s Emergency Fund negotiates favourable prices and forecasts vaccines requirements to ensure sustained supplies. Targets include increasing immunization coverage to at least 90 percent at the national level and 80 percent in all districts, with particular focus on reaching population groups with low coverage levels, and final eradication of polio (UNICEF, 2003).
When delivering vaccines UNICEF adds micronutrient supplement supplements to offset malnutrition, another critical factor in child survival. Supplements of Vitamin A taken four to six months can reduce infant mortality from all causes by as much as 23 percent from diarrhoea by 33 percent.
UNICEF advocates for and promotes programmes to increase rates of exclusive breastfeeding. The strongest foundation of baby health is nutrition, stimulates their immune systems and improves response to vaccinations, and contains many hundreds of health enhancing molecules, enzymes, proteins and hormones (UNICEF, 2003).
A mother’s health is also critical to newborns, particularly in the light of new research that suggests a sound neonatal environment is an important predictor of future health .Together with World Health Organisation and United Population Fund, United Nations International Children’s Emergency Fund advocates and lends technical and financial support to comprehensive community health programs for expectant women. This would ideally providing micronutrient supplements, vaccines, anti-malaria drugs and insecticide treated bed nets. Millennium Development Goals were created to improve the health and well being of people worldwide. Its fourth goal is to decrease the number of mortalities within the infant and childhood population by two thirds, meaning it will decrease mortality from 95 to 31 deaths per 1000 (Andrews ; Brouillette, 2008). Countries slow to abide by Millennium Development Goal by 2015 are projected to have difficulty in reaching goal four (Farahani, 2009). United Nations International Children’s Emergency Fund (2008) noted that progress has been made in reducing infant mortality in every region of the world. Mother needs to be educated on the benefits of breastfeeding in order to prevent Vitamin A deficiency. Vitamin A helps to prevent to blindness and lower the risk for death from diarrhea, malaria, and measles. Breast milk provides a natural Vitamin A, therefore supplying the infant with sufficient amounts of Vitamin A while at breastfeeding age. Babies not exclusively breastfed for the first months of life are at an elevated risk for under nutrition and disease. Exclusive breastfeeding for the first six months has the capability to prevent 13% of all under five deaths in developing countries. Improving sanitation, access to clean drinking water, immunization against infectious diseases, and other public health measures could help to reduce high rates of infant mortality.
Public Health
Reductions in infant mortality are possible in any stage of a country’s development (Bishai, 2007). Rate reductions are evidence that a country is advancing in human knowledge, social institutions and physical. Governments can reduce the mortality rates by addressing the combined need for education (such as universal primary education), nutrition, and access to basic maternal and infant health services. A policy focus has the potential to aid those most at risk for infant and childhood mortality allows rural, poor and populations (Farahani, 2009).
Reduction chances of babies being at low birth weights and contracting pneumonia can be accomplished by improving air quality. Improving hygiene can prevent infant mortality. Home based technology to chlorinate, filter, and solar disinfection for organic water pollution could reduce cases of diarrhea in children by to 48% (Andrews ; Brouillette, 2008). Improvements in food supplies and sanitation has been shown to work in the united states’ vulnerable populations, one being African Americans. Overall, women’s health status need to remain high (Gortmaker, 1997).Simple behavioral changes, such as hand washing with soap, can significantly reduce the rate of infant mortality from respiratory and diarrheal diseases (Curtis ; Cairncross, 2003). According to UNICEF, hand washing with soap before eating and after using the toilet can save more lives of children than any single vaccine or medical intervention, by cutting deaths from diarrhea and acute respiratory infections (UNICEF, 2008).
Future problems for mothers and babies can be prevented. It is important that women of reproductive age adopt healthy behaviors in everyday life, such as taking folic acid, maintaining a healthy diet and weight, being physically active, avoiding tobacco use, and avoiding excessive alcohol and drug use. If women follow some of the above guidelines, later complications can be prevented to help decrease the infant mortality rates. Attending regular prenatal care check-ups will improve the baby’s chances of being delivered in safer condition and surviving.
Focusing on preventing preterm and low birth weight deliveries throughout all populations can help to eliminate cases of infant mortality and decrease health care disparities within communities. In the United States, these two goals have decreased infant mortality rates on a regional population, it has yet to see further progress on a national level (Macdonard, 2012).
Medical Treatments
Technological advances in medicine would decrease the infant mortality rate and an increased access to such technologies could decrease racial and ethnic disparities. It has been shown that technological determinants are influenced by social determinants. Those who cannot afford to utilize advances in medicine tend to show higher rates of infant mortality. Technological advances have, in a way, contributed to the social disparities observed today. Providing equal access has the potential to decrease socioeconomic disparities in infant mortality (Gortmaker, 1997). Specifically, Cambodia is facing issues with a disease that is unfortunately killings infants. The symptoms only last 24 hours and the result is death. As stated if technological advances were increased in countries it would make it easier to find the solution to diseases such as this (McDonald, 2012).
Cultural Changes
Educated females practice a healthier lifestyle. The more educated a woman is the more likely she is to seek out care, give birth in the presence of a skilled attendant, breastfeed, and understand the consequences of HIV/AIDS (Andrews & Brouillette, 2008).More educated women tend to decrease infant mortality rate by reducing their fertility. Improving women’s health and social status is one way to ameliorate infant mortality (Norton, 2005). Providing women access to family planning centers can educate mothers on how to plan ahead for their families. Educational means can also teach mothers on the beneficial health practices such as a possible health intervention is now working towards making affordable contraception available (Rutstein, 2005).
Economic Policies
Granting women employment raises their status and autonomy. Having a gainful employment can raise the perceived worth of females. This can lead to an increase in the number of women getting an education and a decrease in the number of female infanticide (Fuse, 2006). In the social modernization perspective, education leads to development. Higher number of skilled workers means more earning and further economic growth. According to the economic modernization perspective, this is one type economic growth viewed as the driving force behind the increase in development and standard of living in a country. This is further explained by the modernization theory, economic rises, so do technological advances and thus, medical advances in access to clean water, health care facilities, education, and diet. These changes may decrease infant mortality (Fuse, 2006).
Economically, governments could reduce infant mortality by building and strengthening capacity in human resources. Increasing human resources such as physicians, nurses, and other health professionals will increase the number of skilled attendants and the number of people able to give out immunized against diseases such as measles. Increasing the number of skilled professionals is negatively correlated with maternal, infant, and childhood mortality. Between 1960 and 2000, the infant mortality rate decreased by half as the number of physicians increased by half as the number of physicians increased by four folds (Farahani, 2009). With the addition of one physician to every 1000 persons in a population, infant mortality will reduce by 30%.
Use of Child Survival Strategies
Child survival is a field of health concerned with reducing infant mortality. Child survival interventions are designed to address the most common causes of the estimated ten million child deaths that occur each year including diarrhea, pueumonia, malaria and neonatal conditions. These programs are inexpensive, basic interventions that save the lives of children under five from the leading causes of infant mortality and promote healthy and productive families and communities. Some of these programs according to State of the World are:
Mosquito prevention and treatment: In sub- Saharan Africa, one in six deaths is caused by malaria. The use of insecticide treated nets (ITNs) and anti-malaria drugs are essential and can reduce the incidence. Although the cost of these are minimal, only eight percent of children under five in Sub- Saharan Africa sleep under treated nets and only one in three children are treated with anti- malaria drugs (Intermittent Preventive Treatment – IPT) .
Immunizations: There is a great need to scale up immunization of children. Immunizing children against vaccines preventable diseases before the first year of life is life saving. Despite significant progress in immunizing children, a significant percentage of children still do not receive the complete regimen of vaccinations for their first year. 24 million children, almost 20% of all children born in 2007 did not receive the complete regimen of vaccinations for their first year (State of the World Mother, 2008). According to Shettima (2007), Zambia’s record on immunization stands as one of the best in the region with polio completely eliminated, maternal and neonatal tetanus eradicated and measles on course of being eradicated. The report also noted a scaling up of the Prevention of Mother Child Transmisson (PMCT). Information on birth preparedness and emergency readiness should be provided. Such information includes:
– Proper nutrition: Adequate nutrition for pregnant mothers is necessary for the nourishment for babies from the womb.
– Family planning: Family planning to cut down family size and proper spacing which gives enough time for the mother to fully recover and the young baby to grow and become strong before another pregnancy.
– Community participation: Community participation in integrated health care services to ensure holistic primary health care.
– Skilled care during pregnancy, childbirth and postpartum (first one month after birth) and post abortion care services.
– Prevention of mother to child to child transmission (PMCT) of HIV and management of childhood illnesses.
Efforts Made In Nigeria to Reduce Infant Mortality
Infant mortality needs a concerted approach which must involve all. In Nigeria, conscientious effort is made by the government towards addressing the problem. Some of these interventions include:
National child health weeks:
This is a programme by the Nigerian government in close collaboration with UNICEF aimed at reducing high mortality among Nigeria children. This has proven to be highly effective strategy to save lives and prevent illness. It has the propensity of reducing infant and maternal mortality. This exercise which holds twice in a year aims at delivery of high impact, low cost child survival interventions. During this period, ( the course of the week) about 30 million children are expected to receive immunization including polio, de-worming medicines, insecticide treated bed nets while mothers are counseled on key household practices like breastfeeding and basic hygiene, clean water, proper sanitation, hand washing with soap etc.
National midwives service scheme (NMSS):
In Nigeria, only 30% births take place with assistance of medically trained personnel, and immunization coverage ranges between 32.8 to 60%. The low coverage rates translate into high rates translates into high rates of infant and maternal mortality. In many health facilities across the country, there is shortage of skilled attendants and this has reported to impact negatively on utilization of services by women (FMO and NPHCDA). The importance of skilled attendant at every birth for improving maternal health has been severally highlighted in various safe motherhood conferences and technical sessions.
Skilled care refers to the care provided to a woman and her newborn during pregnancy, childbirth and immediately after birth by an accredited and competent health care provider who has at his/her disposal, the necessary equipment, drugs, and supplies and the support of functional health system including transport and referral facilities for emergency obstetric care. A skilled birth attendant is an accredited health professional such as midwife, doctor or who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, child birth and the immediate post natal period, and the identification, management and referral of complications in women and newborns. Traditional birth attendants trained or not are excluded from the category of skilled attendant.
The Nigeria Federal Ministry of Health, the Integrated Maternal, Newborn and Child Health (IMNCH) strategy was to put together to fast track a programme designed to revitalize primary health care in every local government and considerably extend coverage of key maternal and child health interventions, thereby reducing maternal, new born and under five mortality in line with the 4th and 5th Millennium Development Goals targets (UNICEF, 2015a).
Also part of intervention to reduce infant mortality, the wife the Senate President, Mrs. Toyin Saraki, on July 7th, 2015 decried the estimated death of 110 women daily during child birth. Mrs. Saraka, who spoke when she received the Resident Representative of the United Nations Population Funds (UNFPA), Mrs. Ratidzai Ndalovu, in Abuja, also called for concerted awareness and sensitization campaign in the fight against infant mortality. She also presented 200 Training Arm Models donated by Merck Stopes to 98 midwifery schools in the country and urged midwife tutors to ensure effective use of equipment. The Media Office of the Senate President in a statement in Abuja quoted Mrs. Saraki as saying that the government will continue to collaborate with relevant stakeholders in its efforts to curb the menace. She said the government will not relent in acquiring modern facilities that would help reduce the spate of maternal mortality among the women folks. She added that government will also address inadequacies in the training of midwives, saying, ” there is a need for Nigeria Conference on midwifery where practitioners will update their technical knowledge and skills to confront the ugly trend. ”
While highlighting the danger posed by maternal mortality among the rural women in Nigeria, Mrs. Saraki urged international donors, governments at all levels and the Nursing and Midwifery Council of Nigeria (NNCN) to address the schallenge of ignorance and cultural barriers plaguing Nigeria women. She said: “the importance of midwifery services cannot be underestimated. Their motive is to record drastic reduction in maternal mortality rate across the country”.
Based on the 2013 Nigeria Demographic Health Survey figures, 111 women die everyday during children birth and pregnancy related complications. The awareness should facilitate the teaching of the implant contraceptives. There is a scientific evidence that 30 per cent of maternal death can be prevented by increasing access to update of contraceptives. We should further encourage midwifery education in Nigeria. The pre- service training is critical in sustained strengthening of a trained workforce.
The Resident Representatives of United Nations Population Funds (UNFPA), Mrs. Ndalovu, said the passion of her organization was to save lives of new born and their mothers. She pledged the unflinching commitment of the United Nations Population Funds (UNFPA) to support the government, partner with the Nursing and Midwifery Council of Nigeria in capacity building and provision of modern equipment to reduce prevented deaths among women and children.
The Chairman, Board of Nursing and Midwifery Council of Nigeria, Alhaji Mustapha Jumare, he pledged continued partnership with all stakeholders to make efficient health care a reality for all women in Nigeria.( Daily post, 2015).
It is important for all women of reproductive age to adopt healthy behaviours such as:
– taking folic acid
– maintaining a healthy diet
– weight, being physically active regularly
– quitting tobacco use
-not drinking excessive amounts of alcohol
-talking to your health care provider about screening and proper management of chronic diseases
– talking with your health care provider about taking any medications
– visiting your health care provider at the recommended scheduled time periods for age and discuss if or when you are considering becoming pregnant
– using effective contraception correctly
– consistently if you are sexually active, but wish to delay or avoid pregnancy
– preventing injuries and considering the safety of your home and family.
Empirical Review on Causes and Emotional Impact of Infant Mortality
Various studies have been conducted by researchers to examine issues pertaining to infant mortality. Ellen, Owen and Eddy (2009) conducted a research to investigate What Explains the Rural-Urban Gap in Infant Mortality: Household or Community Characteristics. It was revealed that infant mortality rates in rural areas mainly derive from the rural disadvantage in household characteristics, both observed and unobserved, which explain two-thirds of the gap. Among the observed characteristics were environmental factors, a safe source of drinking water, electricity, and quality of housing materials are the important contributors. Community characteristics explain less than one-quarter of the gap, with about two-thirds of this coming from community unobserved heterogeneity and one-third from the existence of a health facility within the community. The effect of disadvantageous environmental conditions such as limited electricity and community level infrastructure and from the inability of some households to exploit it when available. Policy needs to operate at both the community an households levels to correct deficiencies.
Also a Journal epidemiology and community health in 2003 also conducted a study on infant mortality rate as an indicator of population health. It was revealed that there is little evidence that the use of Infant Mortality Rate as measure of population health has negative impact on older groups in the population. Infant Mortality Rate remains an important indicator of health for whole populations, reflecting the intuition that structural factors affecting the health entire populations have an impact on the mortality rate of infants.
An earlier study comparing two socio-structurally identical South-west villages Ido, with a well staffed hospital and Isinbode, without any modern health facility within 40 kilometres (Orubuloye & Caldwell, 1975) found the maternal education differential in the average number of dead children in Ido to be twice as wide as that in Isinbode. This findings supports the argument that is the education of mothers which ensures their maximum utilization of existing health services for the benefit of their children. In a later study with the same data, maternal education in the absence of health services was to be associated with a 33% improvement in child survival, compared to 87% when they are available (Caldwell & Caldwell,1975).
Three studies did not provide an empirical demonstration of how the suggested mechanisms of maternal education act on child survival. Some scholars accept the primacy of maternal schooling as a determinant of early mortality in developing areas, but strongly argue for the relative unimportance of better health service utilization and superior health knowledge, or of the devotion of more resources to child care linked with enhanced female status within the family, a mechanism (Cleland & Van Ginneken, 1989).Instead, they suggest improved domestic care of children by way of better home and child hygiene, more intensive child supervision and more effective use of modern remedies.
Nevertheless, there are strong grounds for suspecting that beneficial effect of maternal schooling on early mortality in Nigeria may have been exaggerated. First, the Ibadan study, for an example, did not account for the influence such proximate factors as birth interval size, parity, or birth order which, as will be shown later, are crucial determinants of early mortality.
Later analyses of child mortality data from Nigeria have tried to account for some of the factors omitted by earlier studies. According to United Nations 1985, study of 15 developing countries, including Southwest Nigeria, simultaneously considers many variables using ordinary least square regression methods. The Nigeria data shows that, with the exception of mothers with Koranic schooling (showing higher child mortality than unschooled mothers), there is a declined in child mortality as mothers’ years of schooling increases. Bivariate results indicate the persistence of this pattern irrespective of husband’s education, area of residence and water supply categories. As for paternal education, the downward trend is broken at the intermediate level which leads the authors to argue that maternal education has a greater impact on early mortality than paternal education.
Recent data from Benin city in the Midwest, based on a five year birth history, also indicates that mothers’ schooling produced the expected effect, women with no education experienced higher risks of child mortality, 133 compared to those with some education, even in the presence of controls for parity, type of refuse, disposal facilities, toilet facilities and timing of antenatal clinic visits (Onyemunwa, 1998). However, when immunization of the live birth (whose distribution shows no notable socioeconomic variation) is incorporated in the controls, the significance is reduced to marginality. Similarly, a study of nearby Ilorin provides findings suggesting weak maternal education effects (Oni, 1988). Although women with no schooling recorded a child mortality index four times higher than that observed for women educated up to secondary level, this effect turns out to be insignificant when the effects of husbands’ education, women’s occupational status, parity, contraceptive use, residential milieu, and presence of indoor tap water, were accounted for within a multiple regression model.
All the post- 1990 studies in Nigeria revealed that mother’s work outside the home in non-white collar occupations is associated with higher child mortality than economic inactivity, a finding supported by data from many countries in Africa and Asia (Hobcraft, McDonald & Rutstein, 1984). In particular, women working in farming and the informal economic sectors have the highest mortality, and Sulaiman’s study shows this to be due to the very low income they earn and their residence in large households lacking modern toilets or water facilities. But the Ile-Ife study indicates that this effect is due largely to reduced devotion to child care ( as measured by intensity of breastfeeding).
The United Nations study and Sulaiman’s work indicate that once other variables, especially income and education, are taken into account, fathers’ white collar occupational status conveys no notable advantage for child survival. This is somewhat at variance with the results from the 1979 Ibadan study, and data from Senegal, Lesotho, Kenya and Northern Sudan, which indicate the preeminence of paternal occupational status as a determinant of child mortality risks ( Hobcraft et al,1984). However, the contrast may be due to the non-inclusive of income or wealth and health service availability factors in these other studies.
Other intimate factors include residential milieu, marital status, family structure and religion. The influence of area of residence on early mortality may be expected because easier access to health services and health enhancing resources may be result of their greater concentration in cities in most African countries (Cantrelle et al, 1986; Mosley, 1985), as well as the greater exposure of their residents to modernizing influences.
In Ibadan a higher child mortality level in the old core areas than in the newer areas was observed. The Ilorin study observed a statistically significant lower early mortality level in medium and high status areas relative to low status areas. By contrast, the Benin study found lower child mortality in the old core areas, this is not sustained when other variables are held constant. Results from the United Nations study in Southwest Nigeria reveal a 20% child mortality disadvantage at the univariate level to residing in rural areas, an affect which disappears once other variables are controlled for. This suggests that it is the socioeconomic characteristics of the urban population rather than residence in the city which accounts for the lower urban early mortality levels observed.

Summary of the Review of Related Literature
In this chapter, the researcher examined various literatures relating to the topic of the study. The literature review was done the following sub heading; meaning of infant mortality; forms of infant mortality; causes of infant mortality; prevention of infant mortality. Review of literature revealed on that; every single day, Nigeria loses about 2,300 under five year olds and 145 women of childbearing age. This makes the country the second largest contributor to the under five and maternal mortality in the world.
Underneath the statistics lies the pain of tragedy, for thousands of families who have lost their children. Even more devastating is the knowledge that, according to recent research, essential interventions reaching women and babies on time would have averted most of these deaths.
Preventable or treated infectious diseases such as malaria, pneumonia, diarrhoea, measles and HIV/AIDS account for more than 70 per cent of the estimated one million under five deaths Nigeria. Malnutrition is the underlying cause of morbidity and mortality of a large proportion of children under 5 in Nigeria. It accounts for more than 50 per cent of deaths of children in this age bracket.
The deaths of newborn babies in Nigeria represent a quarter of the total number of deaths of children under five. The majority of these occur within the first week of life, mainly due to complications during pregnancy and delivery survival and the quality of maternal care. Main causes of neonatal deaths are birth asphyxia, severe infection including tetanus and premature birth.
Similarly, a woman’s chance of dsying from pregnancy and childbirth in Nigeria is 1 in 13. Although many of these deaths are preventable, the coverage and quality of health care services in Nigeria continue to fail women and children. Presently, less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants.
This shows the close relationship between the well being of the mother and the child, and justifies the need to integrate maternal, newborn and child health interventions.
It is important to note that wide regional disparities exist in child health indicators with the North-East and North-West geopolitical zones of the country having the worst child survival figures.
Under the auspices of Nigeria’s Federal Ministry of Health (IMNCH) strategy was put together to fast track a programme designed to revitalize primary health care in every local government and considerably extend coverage of key maternal and child health interventions, thereby reducing maternal, newborn and under five mortality in line with the 4th and 5th Millennium Development Goals targets. The strategy is being implemented in three phases of three years each, to benchmark progress towards the 2015 Millennium Development Goals deadline.

CHAPTER THREE
METHODOLGY
Preamble
This chapter covers the procedure adopted for collection of information and analyses. It describes the research design, sample and sampling procedure, instrumentation including validity and reliability procedure, procedure for data collection and method of data analysis.
Research Design
The research design employed for this study is descriptive survey type. According to Adana (1996), descriptive survey is a systematic description of an event in a factual and accurate manner. Hassan (1995) also stated that survey research requires the systematic collection of data or information from sample of a population or a population through the use of personal interview and/ or scale opinion questionnaire. Ibrahim, Landu and Opadokun (2004) maintained that the survey research is the best to be used for a descriptive study that is aimed at collecting large and small samples from population. Mustapha (2006) observed that it involves theoretical conditions, research experience and findings of the other studies.
According to Daramola (1998), it involves the description, recording, analysis and interpretation of existing conditions. The survey research method was deemed appropriate by the researcher for this study because it is used to find meaning and obtain an understanding of the present condition associated with causes and emotional impact of infant mortality as perceived by nursing mothers in Kwara state; considering variables such as family type, number of children, place of residence and educational qualification.
Population, Sampling and Sampling Procedure
The population for this study comprises all 11,518 registered nursing mothers in Kwara State (Kwara State Ministry of Health, 2014), while the target population consists of all nursing mothers drawn from three selected Local Government Areas in each of the Senatorial Districts in Kwara State. The minimum sample for this study is 378 based on the recommendation of the Research Advisor (2006), against population size of 11,518 under 95% confidence level and 5.0% error margin. Sample is defined by Daramola (2006) as the selected group which act as a fair representation of the population of interest. It is thus a systematic process employed to select a required proportion of a target population. The sample for this study was drawn from a selected Local Government Areas in each of the Senatorial Districts in Kwara State. Considering the fact that Kwara State has three senatorial districts (Kwara Central, Kwara North, Kwara South) three local government areas were selected. The researcher used purposive sampling technique to select the three local government areas. A total of 126 respondents were selected from each of three local government areas using simple random sampling.
Instrumentation
Adewumi (1998) described instrumentation as the process of selecting or developing measuring devices and methods appropriate to a given evaluation or research problem. The instrument that was used to collect data for research study was questionnaire which was tagged ”Causes of Infant Mortality and Emotional Impact Questionnaire” (CIMEIQ). The questionnaire was a self-report designed instrument structured to assess individuals view on the causes and emotional impact of infant mortality as perceived by nursing mothers in Kwara State. All items in the questionnaire were constructed in simple sentences to allow for easy comprehension by respondents. It was made up of two sections A and B.
Section A sought the demography data which ranges from family type, number of children, place of residence, educational background. Section B contains items on causes of infant mortality. The respondents responded on a four (4) point Likert type rating scale thus,

SA – Strongly Agree – 4 points
A – Agree – 3 points
D – Disagree – 2 points
SD – Strongly Disagree – 1 point
Psychometric Properties of the Instrument
Psychometric properties are those qualities or characteristics that are used to standardize psychological instruments such as tests, questionnaire, inventories, etc (Abiri, 2006). An instrument must possess certain qualities or properties such validity and reliability.
Validity
The validity of a test refers to the extent to which a test measures what it actually intends or is developed to measure (Kolo, 2001). According to Ajayi and Razak (2000), Validity of an instrument is the extent to which the instrument can be relied upon to measure what it suppose to measure accurately. An instrument is said to be valid according to Margaret (2003) when it measures what is supposed to measure. To ensure the validity of the instrument, the content validity was established by experts in the Department of Counsellor Education including the researcher’s supervisor .They examined the items on the instrument and made corrections and suggestions. The vetted questionnaire was finally submitted to the researcher’s supervisor for screening, comments and approval. The questionnaire was then modified and was considered appropriate for measuring what the study seeks to measure.
Reliability
Reliability refers to the consistency and stability of an instrument to measures what it supposes to measure (Daramola, 2006). It shows how far the same tester on different occasion ensures the consistency of the items of the questionnaire. Reliability also refers to the degree to which a test yields consistent scores when it is administered over time. Therefore, the reliability of CIEPIQ was established using test re-test method. Questionnaire forms were administered on 20 nursing mothers in Kwara State who did not take part in the research study twice with an interval of four weeks. Pearson’s Product Moment Correlation Coefficient procedure was used for the two sets of scores and yielded a reliability coefficient of 0.71. This was considered adequate for the instrument.
Procedure for Instrument Administration and Data Collection
The questionnaire forms were personally administered to the respondents by the researcher. The questionnaires forms were administered on three hundred and seventy eight respondents by the researcher moving round the designated local government areas for the study. This allowed the researcher to give the respondents necessary assistance, vivid explanation and clarification of the items in the questionnaire. The method helped to prevent any wrong interpretation of the questionnaire items by the respondents. The researcher gave out three hundred and seventy-eight (378) questionnaire forms. The presence of the researcher made the collection of the distributed questionnaire form very easy.
Method of Data Analysis
For analysis of data collected for this study, frequency counts and percentages were used to analyse the demographic data while t-test and Analysis of Variance (ANOVA) were used to analyse the hypotheses. The t-test is a parametric statistics used to compare the means of two groups while ANOVA is an inferential statistics used to compare the means of more than two groups (Adana, 1996). Hypotheses 1, 2, 5 and 6 would be tested using t-test statistical tool while hypotheses 3, 4, 7 and 8 would be tested using Analysis of Variance (ANOVA).

CHAPTER FOUR
RESULTS
Preamble
The study focused on the causes of infant mortality and emotional impact as perceived by nursing mothers in Kwara State, Nigeria. Moderating variables such as family type, educational qualification, place of residence and number of children were also taken into consideration. Data analysis was done on a total of 378 copies of the questionnaire that were properly filled and accounted for and therefore used for this study. Descriptive and inferential statistics were employed in analyzing the collected data. The demographic data of the respondents was evaluated using percentage, while the causes of infant mortality and emotional impact as perceived by nursing mothers in Kwara State were tabulated in mean and rank order. Analysis of Variance (ANOVA) and t-test statistical tools were used to test the eight formulated hypotheses at 0.05 level of significance. Hypotheses 1, 2, 5 and 6 were tested using t-test while hypotheses 3, 4, 7 and 8 were tested using Analysis of Variance (ANOVA).
Demographic Data
This section presents the results of data obtained from the respondents in percentage.

Table 1: Percentage Distribution of Respondents Based on Family Type, Number of Children, Place of Residence and Educational Qualification
Variable Frequency Percentage
Family Type
Monogamy
Polygamy

Number of Children
1-3
4-6
7 and above

Place of Residence
Rural
Urban
217
161
378

82
212
84
378

144
234
57.4
42.6
100

21.7
56.1
22.2
100

38.1
61.9

Educational Qualification
School Leaving Certificate
Secondary Education
Post Secondary Education
Tertiary Education
378

122
72
76
108
378 100

32.3
19.0
20.1
28.6
100

Table 1 shows that 217 (57.4%) of the respondents were from monogamous family, while 161 (42.6%) of the respondents were polygamous family. Based on number of children, 82 (21.7%) of the respondents had between 1-3 children, 212 (56.1%) of the respondents had between 4-6 children, while 84 (22.2%) of the respondents had 7 and above children. Based on place of residence, 144 (38.1%) of the respondents were from rural area while 234 (61.9%) of the respondents from urban area. Also, 122 (32.3%) of the respondents had school leaving certificate, 72 (19.0%) of the respondents had secondary education, 76 (20.1%) of the respondents had post secondary education while 108 (28.6%) of the respondents had tertiary education.
Research Question One: What are the causes of infant mortality as perceived by nursing mothers in Kwara State, Nigeria?

Table 2: Mean and Rank Order of the Respondents’ Perception on the Causes of Infant Mortality
Item No. Causes of infant mortality are: Mean Rank
16 Malaria 3.59 1st
4 infectious diseases 3.48 2nd
1 inadequate access to basic medical care (during pregnancy or after delivery) 3.44 3rd
2 poor maternal nutrition status 3.34 4th
18 environmental factors (living in unhygienic environment) 3.31 5th
7 low exclusive breastfeeding habit 3.33 6th
3 low birth weight 3.27 7th
11 Malnutrition 3.24 8th
5 malformation of the child 3.24 9th
12 birth injuries 3.18 10th
9 Pneumonia 3.17 11th
6 extreme poverty on the part of the couple 3.12 12th
13 premature birth 3.06 13th
10 accidents( before, during or after birth) 3.05 14th
15 Diarrhoea 3.05 14th
20 inadequate access to clean water 3.03 16th
17 behavioural factors( poor attitude of parents towards immunization) 3.01 17th
19 anaemia ( shortage of blood) 2.91 18th
14 asphyxia ( loss of consciousness due to the interruption of breathing during delivery) 2.90 19th
8 sudden infant death syndrome (babies sleeping on their stomach) 2.72 20th
Table 2 presents the mean and rank order of respondents’ perception on the causes of infant mortality. The table indicates that items 16, 4 and 1 with the mean scores of 3.59, 3.48 and 3.44 ranked 1st, 2nd and 3rd respectively. The items state that causes of infant mortality are: malaria; infectious diseases; and inadequate access to basic medical care (during pregnancy or after delivery) respectively, while items 19, 14 and 8 with mean scores of 2.91, 2.90 and 2.72 ranked 18th, 19th and 20th and state that causes of infant mortality are: anaemia ( shortage of blood); asphyxia ( loss of consciousness due to the interruption of breathing during delivery); and sudden infant death syndrome (babies sleeping on their stomach) respectively. All the twenty items listed have mean scores that are above the mid-mean score of 2.50, then it can be said that respondents attested positively to the listed causes of infant mortality.

Research Question Two: What are the emotional impacts of infant mortality as perceived by nursing mothers in Kwara State?

Table 3: Mean and Rank Order of the Respondents’ Perception on the Emotional Impacts of Infant Mortality
Item No. In my perception infant mortality has the following emotional impacts: Mean Rank
13 Anxiety 3.68 1st
3 Sadness 3.64 2nd
1 emotional trauma 3.59 3rd
2 Grief 3.52 4th
11 mood swings 3.48 5th
10 tendency to withdraw from others 3.46 6th
16 Depression 3.45 7th
17 panic attack during child birth 3.40 8th
5 emotional breakdown 3.37 8th
20 Aggression 3.37 10th
19 difficulty in concentrating 3.37 11th
12 Hopelessness 3.31 12th
15 fear of conceiving another child 3.30 13th
9 loss of confidence 3.29 14th
14 Shock 3.27 14th
4 Guilt 3.26 14 th
7 Nightmares 3.25 17th
18 Anger 3.14 18th
8 Fatigue 3.11 19th
6 Insomnia 3.03 20th
Table 3 presents the mean and rank order of respondents’ perception on the emotional impacts of infant mortality. The table indicates that items 13, 3 and 1 ranked 1st, 2nd and 3rd respectively with mean scores of 3.68, 3.64 and 3.59 and state that emotional impacts of infant mortality are: anxiety; sadness and emotional trauma respectively. While items 18, 8 and 6 ranked 18th, 19th and 20th respectively with mean scores of 3.14, 3.11 and 3.03 and state that emotional impacts of infant mortality are: anger; fatigue; and insomnia respectively. Since all the items listed have mean scores that are above the mid-mean score of 2.50, then it can be said that respondents attested positively to the emotional impacts of infant mortality of nursing mother listed on the table.
Hypotheses Testing
Eight research hypotheses were postulated for this study and were tested using t-test and Analysis of Variance (ANOVA) at 0.05 alpha level. The results are presented in tables 4 to 14.
Hypothesis One: There is no significant difference in the causes of infant mortality as perceived by nursing mothers in Kwara State on the basis of family type
Table 4: Mean, Standard Deviation and t-test of the Respondents’ Perception on the Causes of Infant Mortality on the Basis of Family Type
Family N Mean SD df Cal. t-value Crit. t-value p-value
Monogamy 217 72.50 6.28
376
0.30
1.96
.760
Polygamy 161 72.34 2.81

Table 4 shows a calculated t-value of 0.30 is less than a critical t-value of 1.96 with the corresponding p-value of .760 which is greater than 0.05 alpha level of significance. Since the calculated t-value is less than critical t-value, the null hypothesis which stated that there is no significant difference in the causes of infant mortality as perceived by nursing mothers in Kwara State on the basis of family type is therefore accepted.
Hypothesis Two: There is no significant difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara State on the basis of family type
Table 5: Mean, Standard Deviation and t-test of the Respondents’ Perception on the Emotional Impact of Infant Mortality on the Basis of Family Type
Family N Mean SD df Cal. t-value Crit. t-value p-value
Monogamy 217 73.03 4.18
376
0.17
1.96
.861
Polygamy 161 72.96 3.50

Table 5 shows a calculated t- value of 0.17 is less than the critical t-value of 1.96 with the corresponding p-value of .861 which is greater than 0.05 alpha level of significance. Since the calculated t-value is less than the critical t-value, therefore, the null hypothesis is accepted. This indicates that there is no significant difference in the emotional impact of infant mortality as perceived by nursing mothers in Kwara State on the basis of family type.
Hypothesis Three: There is no significant difference in the causes of infant mortality as perceived by nursing mothers in Kwara State on the basis of educational background

Table 6: Analysis of Variance (ANOVA) showing the Respondents’ Perception on the Causes of Infant Mortality on the Basis of Educational Background
Source SS df Mean Squares Cal. F-ratio Crit. F-ratio p-value
Between Groups 1096.220 3 365.407 15.71* 2.60 .000
Within Groups 8696.351 374 23.252
Total 9792.571 377
*Significant, p