|Year : 2019 | Volume
| Issue : 4 | Page : 179-187
Perception and determinants of knowledge and practice of birth preparedness and complication readiness in a rural community
Abdulhadi Diyo Saidu1, Mansur Oche Oche2, Mansur Olayinka Raji2, Daniel Chukwunyere Nnadi1, Bello Alhaji Mohammed3, Jamila Abubakar Garba1, Jamila Amin2, Ismail Raji2
1 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
2 Department of Community Health, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University, Sokoto, Nigeria
|Date of Submission||07-Dec-2017|
|Date of Acceptance||11-Jun-2018|
|Date of Web Publication||29-Nov-2019|
Dr. Abdulhadi Diyo Saidu
Department of Obstetrics and Gynaecology, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Background: Maternal deaths are thought to occur due to delay in making appropriate decision to seek care, delay in reaching appropriate health facility, and delay in the provision of care in the health facility. Birth preparedness and complication readiness (BP/CR) ensure that women access care when needed. Objective: This study aimed to assess the knowledge, perception, and practice of BP and CR in a rural community of Sokoto State. Materials and Methods: This was a community-based cross-sectional study; a total of 198 women who were either pregnant or had their last child birth within 2 years of the study were recruited using a systematic sampling method. Result: The study showed that 185 (93.4%) had poor knowledge and 162 (81.2%) had a poor practice of BP/CR although 159 (80.3%) had good perception. Only husband's education was a significant predictor of knowledge of BP/CR, while knowledge of BP/CR and husband's occupation were the predictors of practice. Conclusion: The study revealed that women in the study area had poor knowledge and practice of BP/CR although perception was good. Education of the husband was the only significant predictor of knowledge of BP/CR, while husband's occupation and respondent's knowledge of BP/CR were the significant predictors of practice. Efforts should be made to improve the educational status of the community since education is a predictor of knowledge.
Keywords: Birth preparedness, complication readiness, knowledge, perception, practice
|How to cite this article:|
Saidu AD, Oche MO, Raji MO, Nnadi DC, Mohammed BA, Garba JA, Amin J, Raji I. Perception and determinants of knowledge and practice of birth preparedness and complication readiness in a rural community. Sahel Med J 2019;22:179-87
|How to cite this URL:|
Saidu AD, Oche MO, Raji MO, Nnadi DC, Mohammed BA, Garba JA, Amin J, Raji I. Perception and determinants of knowledge and practice of birth preparedness and complication readiness in a rural community. Sahel Med J [serial online] 2019 [cited 2019 Dec 7];22:179-87. Available from: http://www.smjonline.org/text.asp?2019/22/4/179/272149
| Introduction|| |
The birth of a infant is a major reason for celebration around the world. Societies expect women to bear children, but in most parts of the world, pregnancy and childbirth are a perilous journey. Maternal mortality is a serious public health problem in Nigeria. It is estimated that there are about 576 maternal deaths per 100,000 live births in Nigeria. The main causes are hemorrhage, hypertensive diseases, infection, and indirect causes.
Many strategies have been put in place including risk screening during antenatal care and training of skilled birth attendants, emergency obstetric care and birth preparedness (BP) and complication readiness (CR). Every pregnant woman faces the risk of sudden, unpredictable complications that could end in death or injury to herself or to her infant. It is necessary to employ strategies to overcome such problems as they arise. Lack of advanced planning for the use of a skilled birth attendant for normal births, and particularly inadequate preparations for rapid actions in the event of obstetric complications are well-documented factors contributing to delay in receiving skilled obstetric care.
Maternal deaths are thought to occur due to delay in making appropriate decision to seek care, delay in reaching appropriate health facility, and delay in provision of care in the health facility. These delays may not occur when pregnant women and their families are prepared for birth and complications of delivery.
BP and CR are a strategy that encourages pregnant women, their families, and communities promote timely access to skilled maternal and neonatal care during childbirth or obstetric emergencies by reducing the delays. It involves early preparation before labor to ensure that pregnant women are prepared for delivery and possible complications. The preparation includes the awareness of expected date of delivery, identifying a skilled birth attendant, identifying a place of birth, birth companion, someone to care for other children, saving money for services, arrangement for transportation, and compatible blood donor. The World Health Organization in 2001 recommended focused antenatal care of which BP and CR are a component; this was reiterated in the 2015 guideline. Although the number of visits was increased to eight in the 2016 guideline, there was no modification of BP/CR.
There is a dearth of publication on this subject from the study area which underscores the need for this study. Therefore, this study aims to assess the knowledge, perception, and practice of BP and CR and to identify the determinants of knowledge and practice among women who were pregnant or women who had delivered within 2 years of the study in Boye village, Wamakko Local Government Area, Sokoto State. The outcome of this study could be of use in making future policies and adoption of the concept of BP/CR in the region.
| Materials and Methods|| |
This study was conducted at Boye village, under Wamakko District in Wamakko Local Government Area of Sokoto State. Boye village is comprised of two parts; Boyen Mari-Mari and Boyen Dutsi both separated by a narrow road. The 2015 projected population of the village was 2096. Wamakko Local Government has an area of 697 km2 and projected population of 233,504 in 2015. The local government is mainly populated by Hausa/Fulani people who are mostly farmers and animal rearers. Most of the inhabitants are Muslims. The village has a primary school with two blocks of classrooms that were recently renovated. It also has a dispensary with one Community Health Extension Worker (CHEW) who has 5-year working experience. He is responsible for the treatment of common ailments and dispensing of routine medications during pregnancy. He does not provide full antenatal care services. More serious conditions including labor and its complication are referred to the Primary Health Centre in Wamakko which is about 12 km away. Most of the women deliver at home unsupervised. The facility has a motorcycle which is used to convey seriously sick patients to Wamakko Primary Health Centre which is about 15 min drive from Boye. Sokoto is one of the oldest states in Nigeria and is located in the northwestern part of the country. The state is made up of 23 Local Government Areas and the projected population in 2015 was 4,886,888. The area has an annual mean rainfall of 500–1300 mm with raining season lasting between May and October. The orthopedic hospital is located in Wamakko Local Government but they do not offer antenatal care services and there is no general hospital in the local government. There is a stand-by ambulance at Wamakko Primary Health Centre for conveying patients to Usmanu Danfodiyo University Teaching Hospital which is about 20 km away.
This was a cross-sectional study among women of reproductive age group who were either pregnant or had their last childbirth <2 years before the time of commencement of this study.
Systematic sampling technique was applied. There were 531 households in Boye and the sample size was 198 and sampling interval was approximated to 2. The households were numbered starting from the household of the village head. A bottle was rolled and household numbering commenced in the direction of the bottle opening which was to the right. At the end of each road, a clockwise direction was taken until the numbering was completed. The first household was selected by simple random sampling (balloting) among the first two households, thereafter every alternate household was selected until the desired sample size was obtained. Where there was more than one eligible wife in a selected household, only one of the wives was selected using simple random sampling (balloting) procedure. In households where no woman met the inclusion criteria, the next household was chosen.
Women of reproductive age group who were pregnant or whose last childbirth was <2 years as at the time the survey was carried out were enrolled into the study.
- Primigravidae with early pregnancy because they have no previous experience and may not have started preparing for delivery for the index pregnancy
- Women who are temporary visitors and had not stayed more than 6 months before commencement of this study of Boye village.
Instrument of data collection
A semi-structured interviewer-administered questionnaire with close- and open-ended questions in English was used for data collection. It was adapted and modified from similar studies (Agarwal et al., 2010, Deblew et al., 2014, Ekabua et al., 2011, and Hailu et al., 2011). The questionnaire was translated into Hausa before it was administered. The tool sought information on respondents' sociodemographic characteristics, obstetrics history, knowledge, and perception of BP/CR. The research instrument was pretested to check for appropriateness and also to acquaint the research assistants with the research instrument. Twenty questionnaires were administered in Danchadi community of Bodinga Local Government Area of Sokoto State for the pretest. Level of significance was set at P < 0.05.
Data cleaning, entry, processing, and analysis were done with IBM SPSS statistics for windows 21.0. Armonk, NY: IBM Corp. Chi-square test was used to compare proportions. Logistic regression analysis was used to determine the predictors of knowledge of BP and CR.
Indices of assessment, scoring, and grading
There were eight components of BP/CR listed in the questionnaire and each correct answer was given a score of one and zero for wrong answers. The study participants were asked to list these eight components and they were scored accordingly. Afterward, they were told all the eight components and their perception was assessed. The different knowledge and perception aspects were scored in percentage (%). A modification of Bloom's cutoff (Nahida et al., 2007) was used to group the knowledge and perception scores into two. The score of 50% and above was good and score of <50% was considered poor.
There is a possibility of recall bias, especially in those whose last childbirth was close to 2 years; all the respondents were Hausa/Fulani and Muslims and hence influence of tribe and religion on BP/CR could not be determined.
Approval for the study (Protocol no: SKHREC/032/015) was obtained from the Sokoto State Ethical Review Committee on 9th of June 2015, while permission was obtained from the Wamakko local government authority and the Village Head of Boye, with verbal informed consent obtained from the study participants. All procedures followed 2013 Helsinki Declaration guidelines.
| Results|| |
A total of 198 women who had delivered in the last 2 years or currently having advanced pregnancy were interviewed. The ages of the respondents ranged from 15 to 42 years with a mean age of 26.53 ± 6.23 years. Level of formal education was generally low in the community with none of the respondents having tertiary education. Most of the respondents had no formal education (172 [86.9%]) and only 15 (7.6%) of the husbands had up to secondary school level of education. Most of the respondents were either full-time housewives (89 [44.9%]) or engaged in petty trading (101 [51%]) and the husbands were mainly farmers (116 [58.6%]). Majority of the women (147 [74.2%]) had between one and four previous deliveries. The frequencies of complications in their last pregnancies were quite high and the most common was stillbirth/neonatal deaths experienced by 66 (33.3%) of respondents [Table 1].
|Table 1: Sociodemographic and obstetric characteristics of the respondents|
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Knowledge of components of BP and CR was generally low, identifying a birth location was the most known item of BP which was mentioned by 67 (33.8%) of respondents.
The knowledge of danger signs was equally low, with only 71 (35.9%) of respondents mentioning fever as a danger sign [Table 2].
The perception of BP and CR was good. Among the respondents, 133 (67.2%) perceived knowledge of expected date of the delivery to be good, 162 (81.8%) for identifying a birth location, and 92 (46.5%) for identifying blood donor [Table 3].
The practice of BP/CR was poor. Expected date of delivery was known by only 30 (15.2%) of respondents. Birth location was identified by 84 (42.4%), 47 (23.7%) identified skilled birth attendant, 58 (29.3%) planned for companion, and 44 (22.2%) arranged for someone to care for other children at home. Only 17 (8.6%) planned for cost, 26 (13.1%) planned for transportation, and 1 (0.5%) arranged for blood during labor or in the event of emergency [Table 4].
Most of the respondents, 185 (93.4%) had poor knowledge of BP and CR while only 13 (6.6%) had good knowledge. Among the respondents, 159 (80.3%) had good perception, while 39 (19.7%) had poor perception. Good practice was observed by 36 (18.2%) respondents, while 162 (81.2%) had poor practice [Table 5].
Respondents occupation (χ2 = 11.361, P = 0.001) and parity (χ2 = 5.740, P = 0.017) and husband education (χ2 = 9.769, P = 0.002) were found to have statistically significant association with knowledge of BP/CR [Table 6].
Educational status of husband was the main predictor of knowledge of BP/CR. Women whose husbands had formal education were 4.5 times more likely to have good knowledge of BP and CR compared to women whose husbands had informal education and it was statistically significant (odds ratio [OR] = 4.59, P = 0.015, confidence interval [CI] =1.345–15.648) [Table 7].
In the assessment of variables associated with practice of BP/CR, age, educational status, occupation, parity, knowledge of BP/CR, husband education, and occupation were considered. Occupation (χ2 = 11.567, P = 0.001), knowledge of BP/CR (χ2 = 32.27, P = 0.001), and husband's occupation (χ2 = 4.706, P = 0.030) had statistically significant association with practice of BP/CR [Table 8].
Knowledge of BP/CR is a significant predictor of practice. Respondents with good knowledge were 17.9 times more likely to practice BP and CR when compared with those with poor knowledge (OR = 17.93, P < 0.001, CI = 4.000–80.424).
The women whose husband was civil servant were more likely to have good practice (OR = 3.04, P = 0.002, CI = 0.145–0.637) [Table 9].
|Table 9: Regression analysis of practice of birth preparedness and complication readiness|
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| Discussion|| |
The knowledge of BP and CR was low among the respondents and only a few (6.6%) were adjudged to have good knowledge. Lack of knowledge is a major setback in the practice of BP, as it is unlikely to practice what one does not know. Higher level of knowledge was observed in a community-based study in West Bengal, where 24.2% and 26.1% of pregnant and recently delivered women, respectively, had knowledge of BP. Knowledge level was much higher in a cross-sectional, multicenter, descriptive study carried out in Benin Central Hospital and University of Benin Teaching Hospital, where the knowledge levels were 51% and 63%, respectively. Similarly in Cross River, 70.6% of the women had knowledge of BP. The study was hospital based, and some of the participants were in Calabar which is an urban area.
It is expected that knowledge of danger signs of pregnancy may influence the practice of BP and CR, and in this study, the knowledge of danger signs was poor. Women with poor knowledge of danger signs are unlikely to seek care, as life-threatening complications may not be recognized. Only 1.5% of respondents had good knowledge of danger signs in Boye village which is grossly poor compared to other studies. Knowledge of danger signs was better in Punjab Province of Pakistan, where 22% of respondents had good knowledge of danger signs during pregnancy and 31% had the knowledge danger signs in labor. Although the study was a community-based cross-sectional survey, the community was more educated than our study area and this may be responsible for the higher level of knowledge of danger signs. In a hospital-based study in the southeastern Nigeria, knowledge of specific danger signs was also poor. Much higher knowledge was observed among respondents in central Ethiopia, where 63.8% of the women had knowledge of danger signs. The study was conducted in the community and it was cross sectional.
Fever was the most known danger sign commonly mentioned by the respondents (35.9%), followed by severe vaginal bleeding mentioned by 18.7%. The reason for this poor knowledge may be because a dispensary was the only health facility in the whole community and the only health personnel in the facility was CHEW who was not a skilled birth attendant and did not offer antenatal care services which would have been an avenue for giving health information about pregnancy and delivery. Some of the danger signs mentioned could have been as a result of previous experience of pregnancy and childbirth. Similarly, in Kano, fever was the most known danger sign and was mentioned by 95.9% of the respondents. However, in the study from Edo state, Nigeria vaginal bleeding was the most known danger sign during labor as mentioned by 87.4% of the respondents. Among the respondents in study done in Southeastern Nigeria, 58.7% mentioned severe vaginal bleeding which was the most known danger sign. Similarly, in India  and Ghana, severe vaginal bleeding was the most mentioned danger among their respondents, 20.1% and 79%, respectively.
Some sociodemographic characteristics may influence the knowledge of BP and CR., In this study, respondents occupation, parity, and husband's education had statistically significant association with knowledge of BP and CR. Women who were gainfully employed and those of higher parity had better knowledge. Husband's education was the only significant predictor of knowledge of BP and CR. Women whose husbands had formal education were 4.5 times more likely to have good knowledge of BP and CR compared to women whose husbands had informal education and this was statistically significant.
The perception of BP and CR was very good, as up to 80.3% of the respondents had good perception of the strategy. Although knowledge was poor, when the components of BP and CR were listed for the respondents, they perceived them to be good. Therefore, negative perception was not a major problem among the respondents in this study. This means that if community is given health education on BP/CR, they are likely to accept and practice the intervention. Although previous studies have not really considered perception of BP/CR, some studies have shown negative perception of some maternity services for several reasons including cultural beliefs, cost, and attitude of health-care providers (Mannava 15, WHO 2005)., In an Indian study, 19.8% of those who did not practice BP/CR was due to lack of perceived need.
The practice of BP/CR was poor, and only 18.2% of the respondents practiced at least 50% of the components of BP and CR in the current or last pregnancy. The level of practice was a little higher than the level of knowledge, and this may not be logical. Obviously, some of the respondents were practicing some of the components without a formal knowledge perhaps because they lacked access to ANC services and health talks. It's likely that some of the practices were from their experiences of childbirth or from some cultural norms. Similarly, in a study in the southern part of Ethiopia, only 17% of pregnant women were well prepared. In a study conducted among pregnant women in rural and urban districts of Jimma Zone, southwest Adis Ababa, the proportion of respondents that portrayed a good level of BP and CR was slightly higher and 23.3% were birth prepared. Much higher proportion of 34.9% and 34.5% were observed in Ife, Nigeria and West Bengal, India  respectively. In another Indian study, about 47.7% of mothers were well prepared. In a study conducted in a primary health center in Edo state, the number of women who were BP was very high and 87.4% were graded as well prepared.
Some sociodemographic characteristics of respondents have been shown by studies to influence the practice of BP and CR. Age, educational status, parity, and occupation of respondent, husband's educational level, and occupation were considered in this study, but only occupation, education, and knowledge of BP/CR of the respondents, and husband's occupation significantly influences practice.
There was statistically significant association between husbands' education and respondents' practice of BP and CR. In this part of the country, decision is mainly with the husband; therefore, his educational status which is associated with knowledge is likely to influence practice. In India, respondents' and spouses' education was found to be strong predictors of BP/CR. Similarly, in Kano, Nigeria husband's education was observed to be associated with their participation in maternity care and men with formal education were more likely to participate in maternity care compared to those with no formal education.
There was a statistically significant association between respondents' occupation and practice of BP/CR but was, however, not a good predictor. The woman who earns money will be able to save money and make arrangement for transportation during labor or in the event of emergency. In an Ethiopian study, occupation of the respondents was shown to have statistically significant association with BP and CR and was a significant predictor of practice of BP/CR.
Husbands' occupation had statistically significant association with practice of BP and CR and it was a good predictor of practice. This means that wives of civil servants were more likely to demonstrate better practice than wives of traders and farmers. In southwest Ethiopia, husband's occupation was found to positively influence BP and CR. From a study in New Delhi, occupation of husband was also significantly associated with the women who made arrangements for transport before delivery.
Knowledge of BP/CR had statistically significant association with practice of BP and CR and it was a significant predictor of practice. Women who had good knowledge were more likely to have good practice. Most studies looked at the relationship between BP and knowledge of danger signs and they positively associated knowledge of BP/CR and its practice. In Burkina Faso, it was observed that information on BP and CR may increase institutional deliveries where institutional births were low (Soubeiga et al; 2014).
Age had no statistically significant association with practice of BP and CR. In a study in Ife, the higher the age of respondent, the less the utilization of skilled birth services and this is similar to the work of Kuganab-Lem et al., who found that the age of a woman has significant relationship with skilled delivery services. Similar finding was made in an Indian study by Mukhopadhyay et al.
It is expected that a woman's educational status should have association with level of BP. Educated women may have better access to information through reading different materials that will help them in preparing for birth. However, in this study, the educational status of the respondents had no statistically significant association with their level of BP. This may be because educational status was generally low and only 1% of the respondents had up to secondary school education and none had tertiary education. However, in rural Tanzania, Mrisho et al. noted that, as woman's educational level increased, she became more empowered to take decisions that could affect her health and the health of her children (Mrisho et al.) this was in consonance with findings of Baral et al. and Mukhopadhyay et al. In two other studies in India  and Ethiopia, respondents' education was found to be strong predictors of practice of BP/CR.
The parity of the respondents had no statistically significant association with the practice of BP and CR. A contrasting finding was made in Egypt where increasing parity was associated with home delivery. This was attributed to the fact that they were more experienced and not afraid of dangers of home delivery. Birth order of four was found to be significantly associated with BP and CR in Central Ethiopia. As birth order increased, BP and CR decreased. In rural Ghana, women who were delivering for the first time were found to have a birth plan and were better prepared for birth compared to those who had a multiple number of deliveries. Acharya in India found that the number of deliveries by respondent was a significant factor that affected BP and CR. The higher their parity the more likely women were to be birth prepared.
| Conclusion|| |
The study revealed that women in the study area had poor knowledge and practice of BP/CR, but they had good perception. Education of the husband was the only significant predictor of knowledge of BP/CR, while husband's occupation and respondent's knowledge of BP/CR were the significant predictors of practice.
Efforts should be made to improve the educational status of the community since education is a predictor of knowledge. Periodic health education and awareness campaigns on BP and CR should be taken to the community, making women the main target. This may be achieved through governmental and nongovernmental organizations with community involvement. The health facility in Boye needs to be upgraded to provide services for antenatal care and delivery. Skilled birth attendants resident in the study area should be employed in the health facility to facilitate prompt response in the event of emergency. This could be achieved through compulsory midwifery scheme that allows midwives to be posted to rural areas after graduation. Enrollment of qualified youths of the community into nursing and midwifery should be a long-term plan.
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], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]