|Year : 2016 | Volume
| Issue : 4 | Page : 206-214
A comparative assessment of the awareness of danger signs and practice of birth preparedness and complication readiness among pregnant women attending rural and urban general hospitals in Lagos State
Babatope Oni1, Oluwakemi Ololade Odukoya2, Adeyemi Adebola Okunowo3, Omobola Y Ojo4, Yetunde O Abatan4
1 Department of Obstetrics and Gynaecology, Ikorodu General Hospital, Ikorodu, Nigeria
2 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos State, Nigeria
3 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Idi Araba, Lagos State, Nigeria
4 Department of Community Health, Lagos University Teaching Hospital, Idi Araba, Lagos State, Nigeria
|Date of Web Publication||21-Dec-2016|
Oluwakemi Ololade Odukoya
Department of Community Health and Primary Care, College of Medicine, University of Lagos, Idi Araba, Lagos State
Background: Nigeria still experiences a high burden of unsafe motherhood. The knowledge of obstetric danger signs and the effective application of the principles of birth preparedness and complication readiness (BPACR) have the potential to significantly reduce the high maternal and perinatal morbidity and mortality rates. However, rural-urban differences may exist in the knowledge and practice of BPACR among women, and these may limit its potential benefit. We set out to assess and compare the knowledge of obstetric danger signs and practice of BPACR among pregnant women attending Rural (Agbowa) and Urban (Gbagada) Hospitals in Lagos State. Materials and Methods: In this cross-sectional comparative study, pregnant women attending antenatal clinics in each health facility were recruited into the study using a systematic sampling method. A structured interviewer administered questionnaire adapted from the safe motherhood John Hopkins Program for International Education in Gynecology and Obstetrics prototype questionnaire was used for data collection. Data were analyzed using SPSS version 17.0. Results: Awareness of obstetric danger signs during pregnancy was good among rural and urban study participants accounting for 62.4% and 68.4%, respectively. The most commonly identified danger sign in pregnancy, labor, and after delivery was bleeding from the genital tract. The awareness of danger signs during labor and after delivery identified by the women was low in both settings, though relatively higher in the urban area. The level of BPACR was low in both groups of women but was higher among women attending the urban center (31.6%) compared with the rural center (13.2%) P-value < 0.001. Conclusion and Recommendations: Activities aimed at improving birth preparedness practices particularly among rural women should be considered.
Keywords: Birth preparedness and complication readiness, danger signs, pregnancy
|How to cite this article:|
Oni B, Odukoya OO, Okunowo AA, Ojo OY, Abatan YO. A comparative assessment of the awareness of danger signs and practice of birth preparedness and complication readiness among pregnant women attending rural and urban general hospitals in Lagos State. Sahel Med J 2016;19:206-14
|How to cite this URL:|
Oni B, Odukoya OO, Okunowo AA, Ojo OY, Abatan YO. A comparative assessment of the awareness of danger signs and practice of birth preparedness and complication readiness among pregnant women attending rural and urban general hospitals in Lagos State. Sahel Med J [serial online] 2016 [cited 2019 Oct 13];19:206-14. Available from: http://www.smjonline.org/text.asp?2016/19/4/206/196364
| Introduction|| |
In most cultures and societies all over the world, the birth of a newborn baby is celebrated with joy, happiness, and fulfillment. The society, especially in Africa, places a high premium on childbirth. It expects that women should conceive and bear children. Unfortunately, in Nigeria and sub-Saharan Africa (SSA), pregnancy and childbirth is a perilous journey.  Worldwide, in 2011, more than 600,000 women died from causes related to pregnancy and childbirth; everyday about 800 women die, out of which 440 of these deaths occurred in SSA.  In 2013, SSA had the highest maternal mortality ratio (MMR) worldwide with 510 maternal deaths per 100,000 live births.  The lifetime risk of a woman dying as a result of pregnancy-related complications in SSA is 1 in 38, compared with that of developed countries, which 1 in 3700. 
Nigeria is one of the main countries experiencing the burden of unsafe motherhood with a high MMR which accounts for more than 10% of the global estimates of maternal mortality.  The current MMR in Nigeria is 560 and 576 maternal deaths per 100,000 live births according to 2013 World Health Organisation and 2013 Nigeria Demographic and Health Survey estimates, respectively. , Lifetime risk of a woman dying as a result of pregnancy-related causes in Nigeria is 1 in 30 and only 38% of Nigerian pregnant women are assisted by skilled attendants during childbirth.  The common causes of maternal deaths include hemorrhage, sepsis, hypertensive disorders, unsafe abortion, and obstructed labor.  These life-threatening complications are often preventable and treatable, if proactive and prompt interventions are administered. Such interventions include a good awareness of danger obstetric signs and practice of birth preparedness and complication readiness (BPACR) by pregnant women, in view of the poor health care infrastructure and inefficient health service delivery system in the country. ,
Maternal mortality is often attributed to delays at three different levels.  Delay in making the decision to seek care, delay in arrival at a health facility, and delay in receiving appropriate treatment after arriving at the health facility.  These delays can be anticipated and effectively minimized by good awareness of the danger signs of obstetric complications and the practice of BPACR by pregnant women, their communities, and health care providers. This will facilitate early decision making to seek help and timely referral for emergency obstetric and newborn care, thus reducing the first and second phases of delay. 
BPACR is the process of planning for normal birth and anticipating the actions needed in case of an emergency.  Birth preparedness is a strategy that promotes the timely use of skilled maternal care, especially during childbirth, based on the concept that preparing ahead for childbirth reduces delays in obtaining care when its need arises.  The principle and practice of BPACR has the potential to reduce the existing high maternal and neonatal morbidity and mortality rates, particularly in developing countries such as Nigeria where there is prevailing illiteracy, inefficient infrastructure, poor transport system, and unpredictable access to skilled care providers. ,
A birth plan or emergency preparedness plan includes identification of the following elements: A skilled birth attendant that would be present at delivery, the location of the closest, and preferred care facility where delivery will take place, funds for birth-related and emergency expenses, mode of transportation to the health facility for the birth and obstetric emergency, purchase of delivery kit or birth materials, and identification of compatible blood donors in case of emergency. ,
The awareness of danger signs, level of BPACR may vary among pregnant women especially with regards to the level of development of the areas in which these women reside or seek care. Low levels of awareness of obstetric danger signs, BPACR have been reported in several studies in Africa including Nigeria. ,,, However, majority of these studies have not assessed the possible rural-urban differences that may exist among these women. This study therefore aims to assess and compare knowledge of obstetric danger signs and practice of BPACR among antenatal patients attending Rural and Urban Hospitals in Lagos State. This information will be useful for policy makers and other stakeholders in designing tailored interventions to reduce maternal mortality among these groups of women.
| Materials and methods|| |
Background to the study area
Lagos State is the smallest state in Nigeria with an area of 356,861 square kilometer, yet it has the second highest population of over 9 million inhabitants.  Lagos State is divided into 20 local government areas (LGAs), of which 16 are classified as urban and 4 as rural. The study was carried out at Agbowa (rural) and Gbagada (urban) areas of Lagos State after both areas had been randomly selected by simple balloting from the list of rural and urban areas in Lagos State.
Agbowa is a rural settlement located in Epe LGA which is one of the four rural LGAs in the state. It has a population of about 3, 24, 000 dwellers whose occupation is majorly farming and fishing. Agbowa has one major link road. Most of the houses are old and dilapidated. It has one general hospital and only one primary health center. Agbowa General Hospital is located in the outskirts of the town, and it has 41 skilled birth attendants, which comprise 20 doctors and 21 midwives. It has a capacity for 28 beds with facilities for emergencies, medical and surgical out-patients, and maternity and child care services.
Gbagada is an urban city situated in Kosofe LGA; an urban LGA in the state and it has a population of about 935000 residents. Gbagada has modern buildings, recreational amenities, and many health facilities. Gbagada General Hospital is located within the town metropolis with 294 skilled birth attendants and a capacity for 133 beds. The hospital has facilities for emergencies, medical and surgical out-patients, maternity and child care services, radiology, physiotherapy, and dialysis (renal care) unit.
In both Agbowa and Gbagada General Hospitals, as with all General Hospitals in Lagos State, women who register for antenatal clinics usually attend routine antenatal classes in preparation for childbirth.
This was a cross-sectional comparative study carried out among patients attending the antenatal clinics of the General Hospitals at Agbowa and Gbagada areas of Lagos State. The minimum sample size for each group was determined using the formula for comparison of proportions.  The proportions of women adequately prepared for delivery and its complications in urban and rural areas were 22%  and 35%,  respectively, from previous studies. Using a confidence interval of 95% and a power of 80%, it was found that a minimum sample size for each group was 186. This was increased by 10% to make allowances for nonresponses and incomplete questionnaires. The final minimum calculated sample size for each group was 205.
Pregnant women from 30 weeks gestation attending antenatal clinics in each of the health facility were recruited into the study using a systematic sampling method. The sampling interval was determined and every n th eligible and consenting woman was interviewed. In Agbowa General Hospital, every second eligible pregnant woman attending antenatal care was recruited for the study while in Gbagada General Hospital, every 8 th eligible pregnant woman was enlisted for the study.
Method of data collection
A structured interviewer administered questionnaire adapted from the Safe Motherhood John Hopkins Program for the International Education in Gynecology and Obstetrics prototype questionnaire was used for data collection.  The questionnaire was divided into four sections; sociodemographic characteristics, reproductive health data, information about knowledge of danger signs in pregnancy, labor and postpartum, and BPACR. It was pretested and appropriate corrections were made thereafter. Eight research assistants were trained on the data collection tool and techniques and were recruited as data collectors. Data were collected in October 2012 over a period of 4 weeks and before the start of each interview, informed verbal consent was sought from each respondent.
Data were analyzed using SPSS 17.0. SPSS Inc., (2008), Chicago. Frequency tables were generated for all categorical variables, whereas means ± standard deviation were computed for continuous variables. Respondents were classified as having adequate knowledge if they were able to mention at least three out of the 12, 7, and 8 danger signs listed in pregnancy, labor, and puerperal periods, respectively.  Women who practiced at least four of the seven BPACR practices were considered adequately prepared for birth and its complication.  Bi-variate analyses using Chi-square and t-tests were conducted to look for significant differences between both groups of women for categorical and continuous variables, respectively. The value of P < 0.05, were considered statistically significant.
Ethical approval was obtained from the Lagos University Teaching Hospital Research and Ethical Committee.
| Results|| |
Two hundred and five questionnaires were each distributed to both urban and rural hospital respondents in Gbagada and Agbowa, respectively. However, only 195 and 193 questionnaires were retrieved and analyzed, yielding a response rate of 92.6% and 92.1%, respectively, for the urban and rural respondents.
Sociodemographic and gestational history of the respondents
The mean age of respondents attending the urban center was significantly higher than the rural (31.2 ± 4.21 years vs. 28.7 ± 3.02 years, respectively, P = 0.006). In both centers, majority of respondents were married and were Christian. Expectedly, the women in the urban areas were more educated compared with those in the rural areas and this difference was statistically significant (P < 0.001). Other sociodemographic details are shown in [Table 1].
|Table 1: Sociodemographic characteristics and gestational history of the respondents |
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Awareness of danger signs in pregnancy, labor and postpartum
In general, respondents in the urban hospital had better knowledge of the danger signs and complications that can arise in pregnancy compared to their counterparts in the rural hospital. The commonly identified danger signs in pregnancy by both groups of women were bleeding per vagina (rural: 92.1%, urban: 97.9%, P < 0.01), severe weakness (rural: 60.3%, urban 50.5%, P = 0.055), and swollen hands/face (rural: 45.0%, urban 44.2%, P > 0.05). Other details are shown in [Table 2]. Overall, respondents in the urban areas were more knowledgeable about the danger signs of pregnancy, labor and the peupereum than those in the rural areas [Figure 1].
|Figure 1: Adequate knowledge of danger signs during pregnancy, labor and puerperium|
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|Table 2: Knowledge of possible complications that may occur during pregnancy, labor, and the puerperium |
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Prior discussions about preparations for birth and complication readiness
A higher proportion of respondents in the urban hospital had had prior discussion on all aspects of preparation for child birth and readiness for complication than those in the rural hospital. These differences were all statistically significant except for the discussion on the place of delivery (P = 0.07) [Table 3].
Mode of transportation to the health facility
The identified primary means of transportation by the respondents in the rural area were commercial buses (29.6%), foot (28.0%), and private vehicle (15.9%). In the urban area, the identified primary means of transportation were commercial buses (43.7%), private vehicles (30.5%), and motorbike (13.7%). More respondents in the rural area chose to use foot and motorbikes (Okada) as means of transportation to the health facility compared with those in urban area; whereas respondents that chose to use privately owned vehicles were higher in the urban area than in the rural area (P < 0.01) [Table 4]. Overall, the level of adequate BPACR was significantly higher in the urban area (31.6%) compared with that of the rural area (13.2%) (P < 0.001).
|Table 4: Respondents means of transportation, preferred place of delivery and primary decision maker regarding pregnancy and delivery |
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| Discussion|| |
BPACR is a proven and effective health care strategy in preventing maternal mortality especially in countries with prevailing high risk of maternal deaths and inefficient health care system. , The aim of BPACR is to reduce delay in deciding to seek care and in the process of seeking care. This is achieved by enhancing the knowledge of obstetric danger signs among pregnant women and encouraging proactive preparations toward child birth and against occurrence of any complications ahead of time. The knowledge of key obstetric danger signs is thus essential for motivating women to seek skilled attendance at birth and to seek care in case of complication. ,
The awareness of obstetric danger signs in pregnancy, labor, and puerperium was significantly higher among women in the urban center compared to those in the rural setting. This was not surprising as the women in the urban center had significantly higher level of education, professional occupation and earning capacity compared to those in the rural area. These socioeconomic indices may suggest a high literacy level among women in the urban center. Some studies  had shown association between educational level, occupation, and good knowledge of obstetric danger signs, but a contrary finding was observed in another study in West Bengal. 
Similar rural-urban differences were observed when findings from studies done in rural and urban areas in other African countries were compared. In Ethiopia, the level of awareness of obstetric danger signs during pregnancy and labor was higher in urban community  compared to the rural community.  Similarly the level of awareness was higher in an urban center in Ghana  compared to that of a rural district in Ghana. 
The level of awareness of obstetric danger signs during pregnancy was significantly higher compared to the level of awareness of obstetric signs in labor and in the puerperium. A different pattern was observed in another study  in Ethiopia, where the awareness of postpartum danger signs was the most common (26%), followed by pregnancy (19%) and delivery (15.4%) danger signs; and in India. 
The higher knowledge of danger signs during pregnancy observed in both rural and urban areas may be due to the quality of antenatal education received during the antenatal classes that were routinely carried out in the hospitals in the state. Likewise, the low level in the knowledge of danger signs during labor and after delivery in both groups may be due to inadequate attention to problems of labor and puerperal by the women or the failure of emphasis on the danger signs in labor and puerperium.
In this study, the ability to mention three or more health problems without prompting was categorized as having an adequate knowledge of obstetric danger signs. The proportion of women with adequate knowledge about danger signs in pregnancy was 62.4% and 68.4% for both rural and urban dwellers, respectively. This was relatively high compared to 4.2%  and 28.3%  that were observed in similar studies in Ile-Ife and 0.9% among respondents in a rural area in Ethiopia.  However, a higher level of 74% was observed in an Urban Tertiary Hospital in Ghana. 
The most common identifiable obstetric danger sign in pregnancy, labor, and puerperium was bleeding per vagina in both urban and rural areas. This was similar to findings in other studies ,,, whereas eclampsia was identified as the most common danger sign in labor in another study. , Majority of the danger signs in pregnancy such as vaginal bleeding, severe headache, high fever, loss of consciousness, and accelerated/reduced fetal movements were better identified by the urban women and these danger signs were statistically significant. All danger signs in labor and after delivery were more commonly identified by the urban pregnant women. The least identified danger signs in both group of women were similar and they include loss of consciousness during pregnancy, fever in labor and facial and hand swelling after delivery. The least known danger sign in pregnancy and childbirth in a Ghana study was prolonged labor. 
The level of adequate BPACR observed in the study was significantly higher among the urban participants, accounting for 31.6% compared with 13.2% among the rural pregnant women. This finding was similar to the 20.5% lower level of BPACR found in the urban area of Aleta Wondo, South Ethiopia.  Similarly, lower levels of preparedness were found in urban regions such as Northern Nigeria (27.5%)  and in Northern Ethiopia (22%).  Higher level of BPACR was observed in Tanzania (58.2%).  In a rural locality in Central Ethiopia,  a slightly higher level of 16.5% birth preparedness complication readiness was reported, whereas 35% was observed in rural Uganda.  This may be due to the fact that the respondents in the Tanzanian and Ugandan studies were recently delivered women and not currently pregnant women.
We also assessed some components of BPACR in order to determine the level of BPACR among the study participants in both urban and rural centers. Unfortunately, inspite of the good awareness of obstetrics danger signs observed among the pregnant women the level of the practice of birth preparedness was low in both urban and rural areas. There was a better preparation for births and its complications among the urban dwellers than in the rural dwellers as observed in the study. A significant majority of the urban respondents compared to their rural counterpart had discussed in advance the place of delivery, health provider to visit in case of complication, transportation arrangement, emergency funds, and blood donation. Furthermore, they were more proactive than their rural counterparts by putting in place significant arrangement for transportation during emergency, availability of money for emergencies, and ensuring blood was already donated in case of its need. This will in no doubt reduce major forms of delay to care, thereby reducing mortality. Similar preparedness has been reported in another study in Uganda. 
Transportation is a major barrier to seeking care as well as identifying and reaching health facilities.  Findings from our study suggested that transportation was a major challenge for pregnant women both in urban and rural areas. In the rural area, trekking to the hospital was a popular means of transportation whereas urban dwellers patronize the usage of motor bikes, which has been found to be unsafe in pregnancy and during emergencies.  Findings in this rural area was similar to what was found in rural Uganda,  in which donkey cart and local stretchers were means used to carry patients to the health facility. Furthermore, it was noticed that people in the rural area (13.2%) patronized traditional birth attendants' (TBA) homes more than those in the urban area (5.5%). In Uganda, 87.9% of women reported that they intended to give birth in the TBA homes and only 8% planned to deliver in health facilities.  Contrary to this, a large proportion of women in our study chose to deliver in a health facility especially government owned health facilities.
For both groups of women, decision making regarding pregnancy and delivery was primarily by their husbands. This was similar to what was found in Uganda.  This shows that husbands play key roles in the management of pregnancy and pregnancy-related complications, hence need to be included in the strategies used for the reduction of maternal mortality in Nigeria.
| Conclusion|| |
The awareness of birth preparedness in both rural and urban settings was adequate however birth preparedness practices were poor. A greater percentage had knowledge of danger signs during pregnancy in urban areas as compared to those in the rural areas. The knowledge on danger signs, BPACR was poorer in the rural area compared to the urban areas. Activities designed to improve BPACR are recommended particularly for rural women.
We are grateful to the heads of departments of the general hospitals for allowing us access to the patients. We also appreciate the pregnant women for their time and cooperation during questionnaire administration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]