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Original Article

Assessment of knowledge and practice on birth preparedness and complication readiness among women who gave birth in the last 12 months in southwest, Ethiopia 2016

Abita, Zinie MSc; Shikur, Zeru MSc

Author Information
Global Reproductive Health: Winter 2020 - Volume 5 - Issue 3 - p e48
doi: 10.1097/GRH.0000000000000048
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Abstract

Plain English summary

Globally annual maternal deaths due to complications of pregnancy and child birth is estimated to be 287,000 in 2012. In many societies in the world, cultural beliefs and lack of awareness inhibit preparation in advance for delivery and expected baby. Since no action is taken before the delivery, the family tries to act only when labor begins and the majority of pregnant women and their families do not know how to recognize the danger signs of complications.

This study tried to identify birth preparedness and complication readiness of mothers both in knowledge and practice during pregnancy, delivery, and postpartum period. Regarding knowledge of danger signs during pregnancy is considered, vaginal bleeding was the common danger sign during pregnancy among the listed complications elaborated by the women. In this study only around half of the respondents have information about the term birth preparedness and complication readiness. Strengthening health services in promoting early ANC attendance and improving the information given during the follow-up, with special emphasis given to birth preparedness in general and information on danger signs in particular is vital.

Introduction

Birth preparedness is a comprehensive strategy to improve the use of skilled providers at birth and the key intervention to decrease maternal mortality which is the process of planning for normal birth and anticipating actions needed in case of emergency. It encourages women, households, and communities to make arrangements such as identifying or establishing available transport, setting aside money to pay for service fees and transport, and identifying blood donor in order to facilitate swift decision-making and reduce delays in reaching care once a problem arises1. Mothers’ access to care is impeded by delays; delays in deciding to seek care, delays in reaching care and delays in receiving care. These delays have many causes; including logistic and financial concerns, unsupportive policies and gaps in services, as well as inadequate community and family awareness and knowledge about obstetric complication issues. Birth preparedness and complication readiness (BP/CR) are interventions designed to address the delays by encouraging pregnant women, their families, and communities to effectively plan for births and prepare for emergencies if they occur2.

The global maternal death from complication of pregnancy and child birth estimated to be 287,000 per year in 2010 UNMDG database1. Worldwide >70% of all maternal deaths are due to 5 major complications: hemorrhage, infection, unsafe abortion, hypertensive disorders of pregnancy, and obstructed labor. An estimated 40% of pregnant women (50 million per year) were experienced pregnancy-related health problems during or after pregnancy and childbirth with 15% suffering serious or long-term complications. As a consequence, 300 million women suffer from pregnancy-related health problems and disabilities; including anemia, uterine prolapsed, fistula, pelvic inflammatory disease, and infertility3,4.

Results of studies that were conducted in rural areas of some developing countries such as Nepal and Burkina Faso showed that promoting BP/CR improves preventive behavior and knowledge of mothers about danger signs thereby leading to improvement in care-seeking during obstetric emergency5. Malawi has implemented several strategies that aim at reducing the high maternal and neonatal mortality ratios1. Every day, around 1500 women die worldwide from complications related to pregnancy and childbirth. The World Health Organization reported 368,000 deaths in 2009 out of which 99% occurred in developing countries with Sub-Sahara African countries contributing 57% of the deaths6.

Pregnancy and childbirth and their complications are the leading causes of death, disease, and disability among women of reproductive age in developing countries more than any other single health problem. In Ethiopia direct obstetric complication accounts for 85% of the deaths. It includes abortion 32%, obstructed labor 22%, sepsis 12%, hemorrhage 10%, and hypertension 9%, primarily due to frequency of adolescent pregnancy combined with neglected prolonged labor7.

According to the report by Ethiopian Federal Ministry of Health, only 15% of the deliveries are attended by health professionals. In countries like Ethiopia, where the maternal mortality ratio was 673 per 100,000 live and infant mortality ratio (IMR) was 77/1000 and neonatal mortality ratio (NMR) was 39/1000 live births which are the highest in the world. Despite the great potential of birth preparedness and complication readiness in reducing the maternal and newborn deaths it was not well known in most of Sub-Saharan Africa including Ethiopia7. This study was intended primarily to assess the knowledge and practice about birth preparedness and complication readiness among women who gave birth in the last 12 months in the study area.

Method

Study area and period

The study was conducted from March to April 2016 in Mizan Aman town which is the capital city of Bench Maji zone, south nation, nationalities and peoples regional state (SNNPRS). Mizan Aman is one of the oldest town which is located 561 km far from AddisAbaba southwest Ethiopia. Based on the 2007 census conducted by CSA, Mizan Aman town has a total population of 48,934 of whom 23,977 are men and 24957 are women. In the town there are 5 kebeles (the smallest administrative unit), 1 hospital, 1 health center, and 5 private clinics.

Study design

Cross-sectional community based study was conducted to assess knowledge and practice of birth preparedness and complication readiness among women who gave birth in the last 12 months in Mizan Aman town.

Population

Source population

  • All child-bearing age women who gave birth in the last 12 months in Mizan Aman town.

Study population

  • All women who gave birth in the last 12 months in Mizan Aman town in the selected kebele.

Eligibility criteria

Inclusion criteria

  • Women aged 15–49 year who gave birth with in the last 12 months regardless of the outcome and who lived in the study area at least 6 months.

Exclusion criteria

  • Women who do not respond due to sever medical and mental illness( 4 were excluded).

Sample size determination

Sample size was determined by using single population proportion based on the following assumptions: 95% confidence level, finding (17%) [Practice on BPCR study conducted in sidama zone aleta wondo district] from previous study8, and a 5% margin of error.

With the above inputs the minimum sample required was 217. Taking 10% of nonresponse rate the final sample size was 239. Totally 230 households were approached and the response rate was 100%.

Sampling technique and procedure

From the 5 kebele’s in the town we have used lottery method to select 2 kebele’s, and systematic random sampling technique was used to select the house holds (239) from commeta and ediget kebele. The first house was selected by lottery method to avoid bias. If 2 or more women who gave birth in the last 12 months is present in 1 household, only 1 woman will be consider in the study on random to avoid intraclass correlation. If we will not get the woman who gave birth in the last 12 months in the house hold will not labeled we give a number for every house and then select the house hold every Kth interval.

Data collection methods and procedures

Data was collected using structured interviewer administered questionnaire. The interviewees were women who gave birth in the last 12 months in the selected kebele in Mizan-Aman town. The data collection was conducted by 6 midwifery students after one day training has been given.

A structured questionnaire adopted from the survey tools developed by JHPLEGO maternal neonatal health program3 developed in English in such a way that it includes all the relevant variables to meet the objective. to keep the consistency of the questionnaire, a study team member fluent in both Amharic and English conducted the survey translation and another member fluent in both languages conducted the back translation. A pretest was done from 5% of nonselected kebele 1 week before data collection and some modification was made on the way of questioning based on the findings.

Data analysis

The data was entered coded, cleaned by using SPSS and descriptive statistical analysis was also done through frequency, mean, SD, and graphical presentations.

Ethical considerations

Ethical clearance was obtained from Mizan-Tepi university institute of health science research committee and College of Health Sciences Institutional Review Board. Written permission was requested from selected kebele administrator. Clients was provided with information about the objective of the study, client’s privacy, confidentiality of the information obtained during interview and verbal informed consent was obtained from participants.

Results

Of 239 women identified for the study, 239 (100%) responded to the interview. About 32.8% of the respondents were between ages 21 and 26 years. The mean age was 26.9. About 51% of the participant were Orthodox in religion and 154 (64.6%) were bench. Majority 213 (89.3%) of the women were married and most 143 (59.9%) of the respondents were housewives. Fifty-five (23.2%) had completed secondary school and about 103 (43%) respondents have <500 birr income during the survey. Regarding their husbands, 115 (48.3%) husbands were business man (Table 1).

Table 1 - Distribution of socio demographic and economic variables of respondent’s, of Mizan-Aman town 2016 (n=239).
Variables Frequency (N) (%)
Age (y)
 15–22 43 (18)
 23–30 79 (32.8)
 31–38 70 (29.7)
 39–46 47 (19.5)
 Total 239 (100)
Marital status
 Single 4 (1.7)
 Married 213 (89.3)
 Widowed 14 (5.6)
 Divorced 8 (3.4)
 Total 239 (100)
Religion
 Orthodox 122 (51.4)
 Catholic 8 (3.4)
 Protestant 87 (36.5)
 Muslim 22 (8.5)
 Total 239 (100)
Ethnicity
 Oromo 10 (4.2)
 Amara 31 (13)
 Guragae 16 (6.6)
 Bench 154 (64.6)
 Keffa 21 (8.8)
 Tigray 7 (2.9)
 Total 239 (100)
Occupation
 House wife 143 (59.9)
 Government employee 20 (8.4)
 Private employee 16 (7)
 Business 60 (24.7)
 Total 239 (100)
Educational status
 Illiterate 88 (36.8)
 Read and write primary 94 (39.3)
 Secondary and above 57 (23.9)
 Total 239 (100)
Respondent’s income
 100–300 55 (23.2)
 301–500 47 (19.8)
 501–1000 42 (17.5)
 >1000 95 (39.5)
 Total 239 (100)
Husbands occupation
 Government employee 44 (25.9)
 Private employee 48 (23)
 Business man 115 (48.3)
 Other 6 (2.5)
 Total 239 (100)
Husbands education
 Illitrate 52 (21.8)
 Read and write 69 (28.7)
 Primary 78 (32.8)
 Secondary and above 40 (16.7)
 Total 239 (100)
Family size
 1–3 165 (68.9)
 4–6 58 (24.3)
 >6 16 (6.8)
 Total 239 (100)

Obstetric characteristics of the respondents

Sixty-four (26.6%) women were primigravida (pregnant for the first time) and about 176 (73.5%) had >2 pregnancies and 11 (4.6%) of the respondent had history of still birth (Table 2).

Table 2 - Obstetric characteristics of respondents, in Mizan-Aman town 2016.
Variables Frequency (N) (%)
No total pregnancy
 1 64 (26.6)
 2-3 119 (49.7)
 4 and above 56 (23.7)
 Total 239 (100)
Total number of birth
 1 63 (26.6)
 2-3 118 (49.2)
 >3 58 (24.3)
 Total 239 (100)
Live birth
 1 72 (29.9)
 2 74 (31.1)
 3 and above 93 (39)
 Total 239 (100)
Still birth
 0 228 (95.4)
 1 7 (3.1)
 2 and above 4 (1.5)
 Total 239 (100)

Knowledge on danger signs during pregnancy

Of the 239 respondents, 160 (67.1%) reported that they had the information about danger sign during pregnancy. From those who had the information 101 (63.2%) identified vaginal bleeding as danger sign while severe headache was indicated as danger sign by 100 (62.3%) of the respondents. Convulsion 81 (50.9%) (Table 3).

Table 3 - Knowledge of respondents on danger signs during pregnancy, in Mizan Aman town, 2016 (n=160).
Variables Responded “Yes,” n (%)
Stated vaginal bleeding as danger sign 101 (63.2)
Stated severe headache as danger sign 100 (62.3)
Stated blurred vision as danger sign 57 (36%)
Stated convulsion as danger sign 81 (50.9)
Stated edema as danger sign 10 (6.1)
Stated fever as danger sign 46 (28.9)
Stated fainting as danger sign 32 (20.2)
Stated difficulty of breathing as danger sign 36 (22.8)
Stated weakness as danger sign 56 (35.1)
Stated abdominal pain as danger sign 8 (5.3)
Reduction/acceleration of fetal movement as danger sign 21 (13.2)

Knowledge of danger signs during labor/childbirth and postpartum

Of the total 239 respondents, 121 (50.6%) of them stated that they had the information about danger sign during labor and delivery. The reported symptoms were severe vaginal bleeding by 91 (75.6%) and severe headache by 47 (79.1%).

Of the 239 respondents, 104 (43.53%) stated that they know the information about danger sign during postpartum period. Out of those who had the information, 84 (81.1%) reported vaginal bleeding and 20 (19.4%) blurred vision as a danger sign.

Source of information about birth preparedness

From the total respondent (239), 91 (53.5%) of them were informed about birth preparedness. Mothers were also asked about the source of information of birth preparedness; they stated that they gained the information as it is displayed on the graph below (Fig. 1).

Figure 1
Figure 1:
Distribution of mothers by their source of information in Mizan-Aman town, 2016. CHW indicates community healthy worker; HW, health workers; MM, mass media; TTBA, trained traditional birth attendant.

Knowledge of respondents about preparation for birth and its complication

About 127(53.5%) of the respondents reported that they heard the term birth preparedness. In case, it seems that the respondents consider that anything which is done before child birth like preparing clothes, food material, and flour for porridge as birth preparedness. However, the recommended elements which have to be done as birth preparedness, 126 (71.2%) of the respondents mentioned identify place of delivery, 141 (79.4%) mentioned saving money. Out of the total respondents, 44.7% are considered knowledgeable on danger sign during pregnancy, 50.6% were considered knowledgeable on danger sign during delivery, 31.8% considered knowledgeable on identifying danger sign during postpartum period. Regarding birth preparedness 46.2% of the respondents considered knowledgeable.

Practice on birth preparedness

Majority of the respondents reported that they made some arrangement for the birth of their baby, of these 86 (68.4%) answered that they identified place of delivery, 96 (76.3%) saved money, 48 (38.4%) prepared material for safe delivery, 44 (35%) identified skilled provider.

Discussion

Education and counseling on different aspects of birth preparedness and complication readiness is still not fully addressed to all clients. Many respondents do not know about birth preparedness and have no plans for emergencies. Knowledge and practices of birth preparedness in the study area is not comprehensive as identified in this study.

In this study, when knowledge of danger signs during pregnancy is considered, 101 (63.2%) mentioned that vaginal bleeding as a danger sign. This is high when compared with the study done in Adigrat and Tanzania in which (10.9%) and (9.6%) mentioned vaginal bleeding as danger sign, respectively4,9. This may be due to an increasment of health education by health professional in this specific area.

The proportion of respondents who reported that they have the information about danger signs of pregnancy was 160 (67.1%). Out of these respondents, considered knowledgeable (those respondents who listed at least 3 danger signs) and well prepared for birth and its complication were 72 (44.7%), 37 (23.6%), 51 (31.8%), during pregnancy, delivery, and postpartum, respectively. This finding is higher than the finding from Kenya, in which only 6.9%) mothers knew at least 3 danger signs of pregnancy10. The reason could be due to the difference in accessibility for health service facility to ANC service in our study area and that of Kenya.

Arranging transport ahead of time reduces the delay in seeking and reaching service. In this study 28.8% of the respondents, spontaneously mentioned that they could identifying mode of transportation for childbirth which is higher when compared with a study from Nepal (in base line study) in which only 1.5%11. In our study 53.5% of the respondents have information about the term birth preparedness which is higher than results from Sidama zone which was 20.5%8. This improvement could be result from government’s attention to decrease maternal mortality and morbidity by providing comprehensive health education through CHW, HW, and mass media. As a limitation this study assesses in a retrospective way it might lead to recall bias. But it has a strength of good response rate.

Generally, knowledge on danger sign of obstetrics complications and information given about danger signs and birth preparedness during the ANC follow-up is not as much as enough.

Conclusions

Education and counseling on different aspects of birth preparedness and complication readiness is still not fully addressed to all clients. Respondent’s knowledge of danger signs in postpartum is low which is 43.53%. Many respondents do not know about birth preparedness and have no plans for emergencies. Knowledge and practices of birth preparedness in the study area is not comprehensive as identified in this study. Generally, knowledge on danger sign of obstetrics complications and information given about danger signs and birth preparedness during the ANC follow-up is not as much as enough.

On the basis of our conclusion we recommended Bench Maji zone health bearue should Strengthen health services in promoting early ANC attendance and improving the information given during the follow-up, with special emphasis given to birth preparedness in general and information on danger signs in particular. And repeated capacity building workshops for skilled providers to enhance their capabilities for improving the efficiency of antenatal services.

Author contribution

Z.A. and Z.S. contributed to the conceptualization, data analysis, original draft preparation and editing, writing-review and editing of the manuscript. Both authors read and approved the final manuscript.

Conflict of interest disclosures

The authors declare that they have no financial conflict of interest with regard to the content of this report.

Acknowledgments

The authors would like to express their deepest gratitude and sincere thanks to their advisors Tigist and Alemnew for their encouragement and great support in providing constructive comment, guidance, and suggestion for the development of this research paper. The authors appreciation also goes to Mizan-Tepi University College of Health Science Department of Midwifery for their cooperation.

References

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Keywords:

Birth preparedness; Complication readiness; Practice; Women; Ethiopia

Copyright © 2020 The Authors. Published by Wolters Kluwer on behalf of the International Federation of Fertility Societies.