Birth preparedness and complication readiness for a safe motherhood among antenatal women attending an urban health centre, Pudupet

INTRODUCTION

Pregnancy is an ordinary physiological cycle for a woman that makes joy and expectation in her just as the family and the network. It needs readiness, arranging, care, passionate and social help for the inviting of the new life into the world. Anyway the result of pregnancy is eccentric and a lady can experience troubles during antenatal (AN), intrapartum and postnatal period which can prompt maternal morbidity, mortality and furthermore influence the youngster wellbeing.¹

Reduction of mortality of women is an area of concern for the Governments across the globe. The International conference on population and development in 1994 had recommended reduction in maternal mortality by at least 50 percent of the 1990 levels by the year 2000 and further one half by the year 2015.² The current maternal mortality ratio (MMR) of India is 130.³ Care-seeking is compromised because of the delay in deciding to seek care, identifying danger signs, reaching a health facility, receiving adequate and appropriate treatment at the health facility and many more. It is due to inadequate facilities, inappropriate care, lack of emergency preparedness and referral service which are key component of safe delivery. Other common reason are high illiteracy among female, early marriage, ignorance, malnutrition, and social factors.⁴

Delays can occur at 3 levels: delay in the decision to seek care; delay in the arrival at a health facility; and delay in the provision of adequate care.

Safe motherhood initiatives, a worldwide effect were launched by World Health Organization (WHO) which aimed to reduce the number of death associated with pregnancy and childbirth. Appropriate AN care is one of the pillar of initiatives.⁵ One such international tool is birth preparedness and complication readiness (BPCR) designed by the maternal and neonatal health program of John Hopkin’s program for international education in gynaecology and obstretics. It is a list of skills that addresses factor causing delay at various level such as individual family, community, health care provider to effectively plan the delivery and make pregnancy and postpartum safe for mother and baby.⁶ There are several strategies adopted globally such as safe motherhood programmes, strategies toward ending preventable maternal mortality and in India reproductive and child health (RCH II) and Janani Suraksha Yojana, which aim to lower maternal mortality. As a result of such programmes, MMR has reduced by 44% (annual reduction of 2.3%) during millennium development goals (MDG) era. According to sustainable development goal (SDG), the average global target is an MMR of less than 70 per lakh live births by 2030 and the supplementary national target is that no country should have an MMR greater than 140 per lakh live births. This requires annual reduction rate of 7.3%.⁷

BPCR matrix explains the roles of policymakers, facility managers, health care providers, communities, families and women in ensuring that women and new-borns receive timely skilled maternal and neonatal care supported the speculation that preparing for childbirth and being ready for complications reduce delays in seeking and obtaining appropriate care.⁸ A report from Ethiopia showed that BPCR had a major effect on skilled care use.⁹ Moreover, there's clear evidence from a meta-analysis of 14 randomized studies showing that BPCR interventions, with adequate population coverage, are effective in reducing maternal and death rate in low-resources setting.¹⁰

BPCR includes the following components: knowledge of danger signs, plan for where to give birth, plan for a skilled birth attendant, plan for transportation, a birth companion, identification of compatible blood donors in case of emergency and saving money for expenses.¹⁰

The objective of our study was to assess the status of BPCR among pregnant women and to study the socio-demographic factors affecting BPCR.

METHODS

A community based cross sectional study was conducted in AN women attending urban health centre field practice area under Pudupet after obtaining institutional ethical clearance. The study duration was from October 2018 to November 2018. The sample size was found to be 104. According to Ravish et al the prevalence of BPCR was 43.98 % and adding 5% non-response calculated sample size N= Zα²PQ/L² was 104. The study subject was AN mothers in second and third trimester. Those in first trimester were excluded from the study, the reason being lack of information about components of BPCR and antenatal women whose birth order were 2 and more. AN women those who were not willing to participate were also excluded. The study subjects were selected by simple random sampling.

Data was collected by interview method after taking an informed consent. A pre tested, semi structured questionnaire was used to collect information about socio-demographic profile, parity, husband’s details and his participation in antenatal care, care giver’s details, etc. A validated BPCR index developed by the Johns Hopkin Bloomberg School of public health was used to assess BPCR.

BPCR index was calculated from the following indicators: percentage of the women who knew about >8 danger signs of pregnancy, percentage of the women who knew about financial assistance provided by the government, percentage of the women who knew about transportation provided by the government, percentage of the women who availed antenatal care in 1st trimester by skilled provider, percentage of the women who identified skilled birth attendant for delivery, percentage of the women who identified mode of transportation, and percentage of the women who saved money to pay for expenses.

Statistical analysis

Collected data was consolidated on Excel sheets and further analysed in Epi-info software 7.1.3.0 version. Multivariate logistic-regression analysis was conducted to analyze factors that were independently associated with having a birth plan.

RESULTS

Majority (20-35 years), n=83 (79.8%) and mean age of the study was 26.01 years. Among 104, 86 (82.7%) were house wife and others were working women which was 17.3%. Hinduism (78%) was found to be most common religion. Among 104 AN mothers, 54 (51.9%) belongs to joint family, 46 (44.2%) to nuclear type and 4 (3.8%) belong to three generation type (Figure 2 A-C).

In the Table 2, this shows awareness among study participants regarding antenatal care and danger signals during pregnancy. 100% were aware towards immunization against tetanus, iron and folic acid (IFA) tablets. Among 104, 94 (90.4%), AN mothers aware of common danger signals during pregnancy regarding awareness. Only 13.5% had awareness over blood donor. Most of them aware of their transport mode and their visit to UHTC by walk were 51.9% and others 37.5% had own transportation and 10.6% was using public transport. Money savings either cash or insurance was kept ready by 49 (47.1%). Articles kept ready by 42 (40.4%) AN mothers. Among 104, 71 (68.3%) had awareness over birth control measures.

BPACR status

96.15% of women scored 3 and above (Table 3). A total of 100 AN women were aware of BPCR: knowledge of danger sign, plan for where to give birth, plan for skilled birth attendant, plan for transportation, birth companion, money and blood donor.

Factors associated with BPCR among pregnant women with sociodemographic variables.

Table 4 shows the factors associated with BPCR among pregnant women attending public health centre (PHC). The variables are independently associated with birth plan. Factors like age and religion shows positive association with BPCR. While education shows a positive association. Occupation of study participants shows a negative association with BPCR, similarly husbands who are professionalist showed a positive association.

Table 5 shows multivariate logistic-regression analysis was conducted to analyze factors that were independently associated with having a birth plan. Mother’s education was significant (0.004).

DISCUSSION

Maternal mortality continues to be alarming in India. There are several causes which result in MMR, perinatal and neonatal mortality rate and these causes might be sudden and severe resulting in unpredictable outcomes. There's need for planning the birth and emergency preparedness so as to remember and reduce the delays in seeking healthcare services. BPCR is one such tool and has also been adopted by WHO AN care model and also the integrated management of pregnancy and childbirth. This tool also involves interpersonal communication among the relations to have interaction themselves within the planning of the birth, making the pregnant women and therefore the relations alert and ready to face any complications thus promoting as killed maternal and neonatal care during childbirth. The current study revealed BPCR index of 96.15. This is like Acharya et al study where majority identified skilled birth attendant (SBA) for delivery.¹¹

One of the key components of BPCR is assessing knowledge about danger signs of pregnancy. Early and immediate identification of obstetric complications is necessary to seek care and also for timely referral services. 90 were knowledge with danger signs.

This study has shown that education of the women and their husbands, parity, type of family play a vital role in improving the BPCR status. Woman’s education (p=0.001) and her spouse’s education (p=0.02) up to graduate and above were strong predictors of BPCR which is similar to a study done in rural Uganda where women’s education and her spouse’s education are significantly associated with BPCR.¹²

Due to better health information educated women have better pregnancy outcome compared with uneducated women, are likely to make better choices, develop and implement a birth plan, and are more socially or financially empowered to make the necessary decisions in case of obstetric emergencies.¹³

In the present study, the components of complication readiness were assessed by actors like identifying blood donors (13.5) and identifying transportation services (82). The latter two components were good but only a few perceived identifying blood donors during obstetric emergency was necessary. The findings with respect to identifying blood donor are consistent with a study by Patil et al (29.75), whereas it was low in a study done by Mukhopadhyay et al (9.6) and Hailu in Southern Ethiopia (2.3).^15-18

Our findings are in agreement with others that many patients are admitted when they already have life threatening complications.^15-18 This is a reflection of the quality of antenatal care at peripheral units, the quality of obstetric care at the referring units and the efficiency of the referral system. The finding that many of the referrals were in critical condition at admission suggests possible delays in making the decision to refer (possibly due to difficulty in diagnosis), delays in reaching the referral hospital or poor quality of care at the referring health facility. Indeed, diagnostic delays and misdiagnosis are responsible for many of the near-miss mortality and are common among emergency obstetric referrals.^16,17 Women’s ability to seek health care or implement lessons is often determined by the household head who usually is the husband who learned from health education interventions (by developing their own birth plans).^19,20

CONCLUSION

As the level of awareness regarding BPCR is very high i.e. 96.15 individual women, families and communities need to be empowered to contribute positively to make pregnancy safer. The knowledge and practice of birth preparedness and complication readiness among pregnant women studied was fairly good. The study identified that educational level was not a good predictor of practice of birth preparedness and complication readiness, rather women who registered for ante natal clinic rely heavily on the health education received from the care givers. Therefore, it is important that pregnant women are well educated regarding birth preparedness and complication readiness before birth. Nonetheless, the study showed that majority of the women were well informed and adequately prepared in case of complications during child birth.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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