| Abstract|| |
Introduction: Birth preparedness and complication readiness (BP/CR) improve preventive behavioral practices among to be mothers; thereby leading to improvement in care-seeking during obstetric emergency. Objectives: The objective of the study is to assess the knowledge and practices with respect to BP and CR and to find the determinants affecting them. Methods: A community-based cross-sectional study was carried out at urban slum area of Ahmedabad city, Gujarat, India from August 2015 to February 2016. Personal interviews of 350 antenatal women were conducted. Sociodemographic details, information of antenatal care pursuing and information pertinent to BP and CR were reviewed. Total ten variables, suggesting their knowledge and practices toward BP/CR were assessed. Correct response with at least five variables or more than that was considered as positive knowledge and practices for BP/CR. Results and Conclusion: The study sample mainly comprised of 21–25 years of age group (48%) of participants. Overall, 229 (65.43%) of total participants were found to have positive knowledge and practices in terms of BP/CR. The variables which had statistically significant effect on BP and CR were: level of education, socioeconomic class, age at the time of marriage, order of pregnancy, mode of last delivery, number of live children, history of abortion, and duration of current pregnancy. Fair numbers of women were lacking proper knowledge regarding dangers signs during pregnancy, labor or postpartum, prior identification of doctor for them as well for new born and saving money for pregnancy related needs.
Keywords: Antenatal women, birth preparedness, complication readiness
|How to cite this article:|
Dave VR, Rana BM, Khanpara HJ, Sonaliya KN, Tolani J. Assessment of the birth preparedness and complication readiness among antenatal women at Ahmedabad city, India. Ann Trop Med Public Health 2017;10:1278-85
|How to cite this URL:|
Dave VR, Rana BM, Khanpara HJ, Sonaliya KN, Tolani J. Assessment of the birth preparedness and complication readiness among antenatal women at Ahmedabad city, India. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 23];10:1278-85. Available from: http://www.atmph.org/text.asp?2017/10/5/1278/217518
| Introduction|| |
There is a wide variation between different nations in their maternal and child health status. Maternal and child health status; in terms of morbidity and mortality suggest the overall development of a country. India is lagging behind in status of mother and child health as far as their mortalities are concerned, compared to its overall development. Being profoundly populous and constituted by a large number states, India is having wide inter-state variation among the data suggesting mother and child health status. Different states had the variable pace of progress toward decreasing maternal and child mortality and morbidities. In 2010, India recorded 56 000 maternal and 1.3 million infant deaths, the highest for any country.
In India, women of the child-bearing age (15–44 years) constitute 22.2% and children under 15 years of age about 35.3% of the total population. Together, they constitute nearly 57.5% of the total population. By virtue of their numbers, mothers and children are the major consumers of health services, of whatever forms. Global observations show that in developed regions maternal mortality ratio averages at 13/100,000 live births; in developing regions, the figure is 440 for the same number of live births. Infant, child and maternal mortality rates are high in developing countries, much of the sickness and deaths among mothers and children is largely preventable by improving the health of mothers and children. Reduction in maternal and infant mortality has been an utmost priority of Indian health Services. However, India still lags behind in achieving Millennium Development Goals 4 and 5. The greater part of maternal deaths occurs during labor, delivery, and within the 24 h postpartum period. Some of the factors that contribute to the high maternal and neonatal mortality deaths include delays in making the decision to seek care and delay in transportation to the health facility.
Birth preparedness and complication readiness (BP/CR) are interventions designed to address the delays by enabling antenatal women in making the right decision and cope with the stress and challenges she is likely to face during delivery. Results of studies that were conducted in rural areas of some developing countries such as Nepal, Burkina Faso, Ethiopia, and India show that promoting BP/CR improves preventive behavior and knowledge of mothers about danger signs thereby leading to improvement in care-seeking during obstetric emergency. BP/CR is a strategy to promote the timely use of skilled maternal and neonatal care, especially during childbirth, based on the theory that preparing for childbirth and being ready for complications reduces delays in obtaining this care. BP and CR include many elements, including: (a) knowledge of danger signs; (b) plan for where to give birth; (c) plan for a skilled birth attendant; (d) plan for transportation; (e) a birth companion; and (f) identification of compatible blood donors in case of emergency.
The present Maternal Mortality Ratio of India is 174/100000 Live Births. Although this indicator has improved a lot over the last 25 years, India is still ranked 55th in terms of MMR. Despite the fact that BP and CR are essential for further improvement of maternal and child health (especially in terms of maternal/infant mortality); little is known about the current magnitude and influencing factors in India, especially urban areas.
The present study was conducted with objectives of: (a) to assess the knowledge and practices with respect to BP and CR and (b) to find the determinants affecting BP and CR among antenatal women.
| Methods|| |
A community-based cross-sectional study was conducted at a field practice area of Urban Health Training Centre (UHTC) of one of the Medical College at Ahmedabad, India from August 2015 to February 2016 including 3 months dedicated to data collection at UHTC. It is an urban slum area nearby the medical college where medical graduates are taught Community Medicine's field aspects. The necessary approval was taken from Institutional Ethical Committee. The study subjects were antenatal women residing at the study area.
The sample size was decided in the following manner: As a part of convenient sampling, data collection was scheduled for 3 months. UHTC serves an urban population of about 70,000. For urban area Crude Birth Rate as per Census 2011, India, was 17.4, taken as 18 to round off the figure.
Probable no. of Pregnancies = Population of that area × Birth rate/1000
70,000 × 18/1000 = 1260/year.
So approximately, 1260/4 = 315 total births would be there for 3 months for urban area. Again considering 10% of rise/wastage  in final figure, 346 was the sample size. It was rounded off to 350. Personal interview of antenatal women was conducted by house-to-house visit till the decided sample size was met. Starting from central part of the said area, all four directions were tried to cover with equal distribution of sample size unanimously. Pretested pro forma was used for data collection. Sociodemographic details, information of antenatal care pursuing and information pertinent to BP and CR were reviewed.
For socioeconomic classification of the study participants, modified Prasad classification  – a widely used tool in the Indian subcontinent for sociodemographic data was applied. All India Consumer Price Index for December 2015 was retrieved from Labour Bureau, Government of India.
Different variables (10 in numbers) suggesting their knowledge and practices toward BP and CR were assessed. These include: danger signs during pregnancy, symptoms of true labor pain, danger signs during labor, identified place for delivery, identified transportation mode when in need, identified decision taker in case of emergency, identified place for emergency referral, identified doctor for new born, danger signs during postpartum period, and saved money for pregnancy-related expenses. Revealing answer to all these ten questions from each participant, correct response with at least five variables or more than that was considered as positive knowledge and practices for BP and CR.
Severe vaginal bleeding, swollen hands/face, and blurred vision were considered as key danger signs of pregnancy. Severe vaginal bleeding, prolonged labor, convulsions, and retained placenta were considered as key danger signs of labor. Severe vaginal bleeding, foul smelling vaginal discharge, and high fever during first 7 days after childbirth were considered as key danger signs of postpartum period. Correct knowledge of any of two characteristic for individual question was considered as a right answer.
Data were entered into MS Excel and analyzed using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. For statistical significance, Cramer's V association was applied. Cramer's V varies from 0 (corresponding to no association between the variables) to 1 (complete association) and P values were retrieved accordingly from Cramer's V. P < 0.05 was considered as statistically significant difference at 95% confidence level.
| Results|| |
The study sample mainly comprised of antenatal women of 21–25 years of age group (48%). Although legally underage for marriage, 3 antenatal women were <18 years of age. Again, pregnancy with advanced age is also one of the risk group of its own kind, 10 women were more than 35 years age group. Majority of the participants (68.3%) were following Hindu religion. The socio-economic classification was done as per modified Prasad Classification and one-third of the participants were covered under Class II. Almost one-fifth of the participants was either Illiterate (10.3%) or just literate (10.9%). Only 12.9% of the participant had their education up to graduation or above [Table 1].
More than half of the participants were married during the age group of 18–20 years. The lack of contraception or failure can be suspected in 52 (14.9%) of participants, as they considered their pregnancy unplanned. More than half (52%) of the study participants were primigravida while rest were having 2nd or higher order of pregnancy. Nearly, half of the participants (46%) had one or more live children at the time of the study. The women who had undergone cesarian section delivery during last pregnancy were 69 (19.7%). More than half of the study participants (201, 57.4%) were in their second trimester of pregnancy at the time of the study [Table 2].
[Table 3] reveals the levels of Antenatal care, the women under study were undergoing while their pregnancy. Almost one-fourth of eligible women (pregnant women with the first trimester were excluded) had not received Tetanus Toxoid vaccine. Five women never received any prophylaxis in the form of iron, folic acid, calcium, or vitamin D. Majority of the study participants were receiving nutritional prophylaxis from local health worker visiting their area (35.4%) and Urban Health Center nearby (28.3%). Other providers of nutritional supplements were: private consultant (15.9%), civil hospital (12.3%), and in few cases, it may be pharmacist or their peer counterparts. Sixty-five (18.6%) participants were not taking their prescribed nutritional supplements regularly; among them, majority were not taking them regularly due to felt adverse effects (n = 60). The participants were receiving health and antenatal care-related advice from multiple stake holders such as health professional (58.5%), community health worker (47.1%), friends and relatives (30%), and media (9.8%). Majority of the women (245, 70%) had received advices related to antenatal care while 65 (18.6%) had not received any significant advice during their pregnancy from their health care provider.
As depicted in methodology, the BP and CR were assessed among study participants taking into consideration their knowledge and practices regarding peri-birth events [Figure 1]. It was found that knowledge regarding danger signs during pregnancy and symptoms of true labor were correctly perceived by only 28 (8%) and 33 (9.43%) of the participants, respectively. Again, poor results were found in terms of knowledge about danger signs during postpartum period (72, 20.57%) and practice like prior identification of doctor for new born, if need arise (57, 16.29%). Almost, half of the study participants (184, 52.57%) had practice of saving money for pregnancy-related expenses. Good practices were found in terms of prior identification of decision taker in case of emergency (309, 88.29%), place of delivery (303, 86.57%), place for emergency referral (288, 82.29%), and mode of the transportation when needed (267, 76.29%). Overall, 229 (65.43%) of total participants were found to have positive knowledge and practices in terms of BP and CR.
|Figure 1: Birth Preparedness and complication readiness among study participants (n = 350)|
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[Table 4] describes the effect of various characteristics of study participants on their birth preparedness and CR among the study participants. The correlation between them was statistically analyzed using Cramer's V association. The strongest statistically significant association was found between mode of last delivery and current status of birth preparedness and CR (Cramer's V: 0.58 and P = 0.00) followed by the age of the participants at the time of marriage (Cramer's V: 0.321 and P value: 0.00). It explains that the participants who had to undergo cesarean section due to one or more complication were more attentive (BP/CR knowledge 91.30%) during current pregnancy than who had previous normal/vaginal delivery (BP/CR knowledge 32.32%). The participants, who were an elder at the time of marriage, had better BP/CR knowledge compared to their younger counterparts (≤18 years, 19–24 years and ≥25 years: BP/CR knowledge 52.9, 64.24, and 96.72%, respectively). The other variables which had statistically significant effect on birth preparedness and CR were: level of education, socioeconomic class, order of pregnancy, number of live children, history of abortion, and duration of current pregnancy.
|Table 4: Cramer's V association between different variables under study and birth preparedness/complication readiness|
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| Discussion|| |
The positive birth preparedness and CR is a boon to end up pregnancy with positive outcome both for mother and newborn. It is an important mean to decrease the maternal and perinatal mortality. In the present study, 65.43% of total participants were found to have positive knowledge and practices in terms of birth preparedness and CR. Similar study conducted by Gebre et al. found 18.3% pregnant women were well prepared for birth and complication readiness. Another similar study at India  and Uganda  found the birth preparedness and complication readiness about 47.8% and 35%, respectively. This could be due to the fact that socioeconomic development in India is geared up in recent years and well planned and vigilantly implemented national health programs by the government are running successfully at grass root level.
In the present study, women with first pregnancy were more prepared (73.63%) than 2nd or 3rd pregnancy (56.82%, 52.11% respectively). However, again women with 4th or more order of pregnancy had better preparedness (88.89%) than their counterparts. Gebre et al. also find similar findings that women with first pregnancy were more prepared than their counterparts.
The study revealed that women with a history of obstetric complication like history of abortion or delivery by cesarean section were more likely to be well prepared than their counterparts. Similar findings were revealed by Gebre et al. and Hiluf and Fantahun  at Ethiopia.
Prior identification of mean of transport is utmost important in obstetric emergency. In present study 76.29% of women had identified mode of transport well in advance.
Gebre et al., Hiluf and Fantahun  and Agarwal et al. found that the percentages of pregnant women who had identified mode of transport were 18.1%, 24.7%, and 29.5%, respectively.
The level of education and order of pregnancy were independent statistically significant factors deciding the level of BP/CR in the current study. Markos and Bogale  in their similar study at Ethiopia also found similar findings. Mukhopadhyay et al., in their similar studies at west Bengal, India also found that duration of formal education more than 5 years and parity were statistically significant factors deciding the level of BP/CR in their study.
Ekabua et al. in their similar study at Southeastern Nigeria found that 80.1% of participants had planned to save money for child birth while 83.5% had planned to identify mode of transport to place of childbirth while in the present study the results for both variables were 52.57% and 76.29%, respectively. The possible reason for less amount of readiness may be lesser “felt need” as free of cost and easily approachable transport vehicles and free access to the public health services are made available by the government in the state of Gujarat.
Kushwah et al. in their similar study at one of the district in central part of India found that BP/CR index was 47.5. BP/CR index was significantly high in higher educational level (63.6) and primipara (50.9) as compared to multipara (40.1). The results are quite comparable with the findings of present study.
Hailu et al. in their similar study found the level of BP/CR as follow: identified a skilled birth attendant (20.5%), identified facility for emergency (8.1%), arranged transport (7.7%), and saved money (35.5%). In the same study, the first pregnancy was found to be statistically significant variable deciding well preparedness. The finds are quite low compared to the findings of the current study may be due to comparatively developed status of India and even Gujarat province.
Urassa et al. in their study at Tanzania found that the majority (86.2%) of the women had decisions made on place of delivery, a person to make final decision. They found that the age of the women, higher level of education and those who knew obstetric complications were more prepared for birth and complications.
Limitations of the study
The study area included only one urban slum cluster at one of the metro cities of India. Multiple clusters from wide geographic area including other metro cities and rural areas may give better representation. Political leaders and policy makers may be guided further for required interventions in ongoing national health programs for mother and child health accordingly.
| Conclusion|| |
A good number of respondents were found to be prepared for birth-related events and its complications during their pregnancy. The variables which had statistically significant effect on birth preparedness and complication readiness were: level of education, socioeconomic class, age at the time of marriage, order of pregnancy, mode of last delivery, number of live children, history of abortion, and duration of current pregnancy. Although having fair number of antenatal care visits, many women were lacking proper knowledge regarding dangers signs during pregnancy, labor or postpartum and practices like prior identification of doctor for them as well for new born and saving money for pregnancy related needs.
Besides medical examinations, proper time should be allotted to give basic minimum information regarding danger signs during antenatal care visits by health professionals. Community health workers can improve the knowledge and practices of antenatal women by ensuring discussion of alarming obstetrics points during their regular household visits. In many parts of India, sex education is incorporated or planned to be incorporated in higher secondary education. This opportunity can be used to teach adolescents, the crucial information regarding imperative symptoms during their reproductive life related to pregnancy and newborn. Most of the women in the Indian context are going to be a mother in their early thirties – the critical education provided at high school intermingled with sex education can be proved life-saving during their pregnancy or for their infants.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Viral R Dave
Department of Community Medicine, GCS Medical College Hospital and Research Centre, Opp. DRM Office, Naroda Road, Ahmedabad, Gujarat
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]