Status of birth preparedness and complication readiness among recently delivered women: a community based study in a slum of Kolkata, West Bengal

INTRODUCTION

Pregnancy related complications cannot be predicted completely. Unexpected complications may arise at any stage of her pregnancy that could end in death or injury to herself or to her infant. Although the global maternal mortality ratio is declining it is far away from Sustainable Development Goal of reducing the global maternal mortality ratio to less than 70 per 100000 live births between 2016 and 2030.¹ In India 15% of life threatening pregnancy related complications and MMR of 174/100,000 live birth.^2,3 must be reduced in a rapid pace and must be given the top priority in order to do justice to SDG. Regarding key factors of maternal and neonatal mortality, the three delays model, categorizes delays into three aspects: in seeking care, in reaching care and in receiving adequate care at the point of service.⁴ To overcome this problem, BPACR (Birth preparedness and complication readiness) a globally accepted safe motherhood program has started which actually is a comprehensive package aimed to addresses these three delays timely and encourage pregnant women and their families for making early birth plan and for any unpredictable complications.^4,5

In many societies in the world different cultural and rituals factors as well as lack of awareness are the principal barriers for birth preparedness. When complications arise, the unprepared family wastes important time in recognizing the problem, getting organized, and reaching the appropriate referral facility. Though strategies have been formulated at programmatic level to resolve the problem of the three delays. India still remains far from achieving an optimum maternal mortality ratio. With this background a study was conducted in a slum of Kolkata to assess the awareness and practices of BPACR among women who had delivered in last 24 months and to identify the factors that might have association with favourable BPACR. The findings of this study will be helpful for health planners and administrators to take appropriate measures for improvement of all activities related to safe and healthy motherhood.

METHODS

A cross sectional, descriptive, community based study was conducted in a slum of Chetla, Kolkata, which is the urban field practice area of All India Institute of Hygiene and Public Health, Kolkata during June –August 2016.The study subjects were recently delivered women who had given birth during a reference period of June 2014May 2016 (last 2 years). Those women who were unwilling to participate or were severely ill, were excluded from the study. Considering estimated prevalence of 57% well birth prepared, found in a community based study and 10% allowable absolute error, minimum sample size calculated was 94. Now considering 10% as non-response rate, the final sample size was calculated to be 104.⁶

There are three units (A, B and C) under service area of Urban Health Unit and Training Centre Chetla. A sampling frame was prepared with a list of all eligible subjects fulfilling the stated criteria residing in Unit A and B (Unit C was used for pretesting purpose). From this sampling frame the required list of study subjects were included by simple random sampling technique. Selected study subjects were approached at their households.

The schedule included the following

• • Questions regarding socio-demographic profile, details about antenatal care services, birth history, knowledge of danger signs during pregnancy and new born
• • Questions regarding preparedness of last pregnancy or confinement
• • Medical records.

This tool was translated into the local language (Bengali) and pretested in 20 households and was finalised after due modification.

Informed consent was obtained from the study subjects after explaining to them the study objectives and procedures and also assuring them their right to refuse to participate in the study at any of time.

Operationally in this study, a woman was considered as well prepared for birth and its complication -having 4 and more components from following six birth preparedness complication readiness items.⁷

• 1) Knowledge of danger signs or early signs of emergency;
• 2) Plan for where to give birth &/or Arrangement with a skilled birth attendant;
• 3) Made some financial savings towards delivery or for obstetric emergency;
• 4) Identifying nearest institution with 24 hour emergency obstetric care services;
• 5) Arranged for transport before delivery;
• 6) Arrangement of blood donor during obstetric emergency.

Data processing and analysis

Data were entered and analyzed in Statistical Package for the Social Sciences (SPSS) version 20. Descriptive statistics along with bivariate and multivariate analysis was performed.

RESULTS

Out of the total 104 selected women, 6 study subjects refused to participate and 98 were successfully interviewed yielding the response rate of 94%.

Mean age of study subject’s was 25.67 years and mean age of their husbands was 31.22 yrs. Most of them were Hindus (70.4%) and the rest were Muslims. Out of them 59.2% belonged to SC, ST and OBC category. Joint and nuclear family were more or less of the same ratio. Most of the women were housewife (87.8%). Their spouses were mostly labourer (46.9%) and driver (22.4%) by occupation. Among the study subjects 93% registered their pregnancy within 1^st trimester, 83.7% of respondents had attended ≥4 antenatal check-up and 100% of respondents had received 2 tetanus toxoid and had undergone Institutional delivery. 12.2% of mothers suffered from pregnancy related complications (Table 1).

83.7% women were aware about early registration of pregnancy. More than three fourths of the women were aware about tetanus (TT) immunization but only 18.4% were aware about transportation and 32.7% about government financial assistance scheme. 32.7% women knew about danger signs of pregnancy and 44.9% women knew about new-born danger sign. In practice 100% of study participants identified the place of delivery and made a birth plan after discussion with family members (Table 2).

OR- Odds ratio; CI-Confidence interval; AOR-Adjusted odds ratio; $- Statistically significant (p<0.05)

Only 43 (43.9%) study subjects were well prepared for birth and its complication in their last pregnancy whereas the remaining 55 (56.1%) study subjects were less prepared for birth and its complication. The women obtained their knowledge from health workers (63%) followed by doctors (17%).

Bivariate logistic regression shows education status of study subject (OR 4.34), education status of their spouse (OR 2.92) and per capita income (OR 7.18) have significant association with birth preparedness. In final multivariable logistic regression after adjustment only per capita income remained significant (AOR 5.82). Our final model is fit for predicting the variation for birth preparedness as Hosmer Lemeshow statistics (p=0.184) was not significant (p>0.05). All the independent variables explained 27.3% variation of birth preparedness using Nagelkerke (Table 3).²

DISCUSSION

In the present study, proportion of women who registered for pregnancy within first trimester, took at least four antenatal check-ups, having institutional delivery were 93%, 62.2%, and 100% respectively. The corresponding figures reported in DLHS4 for Kolkata quite similar ^{[ 8]} but National and state level figures as reported in National family Health Survey (NFHS4) were low in comparison to this study.⁹

This study showed that, 43.9% of the respondents were prepared for birth and its complication in their last pregnancy. The result was more or less consistent with another study conducted in Madhya Pradesh (47.8%) and West Bengal (57%).^6,10 On the other hand, the finding was not in agreement with the result of the other studies.^5,11,12

About 32.7% women knew about danger signs of pregnancy. Other studies had shown similar results like 27.8% and 28.3% women knew about danger sign of pregnancy.^13,14 In Darjeeling district, West Bengal, ^[6] knowledge status was slightly more for danger signs during pregnancy (43.6%). The most common danger signs known were severe bleeding (70.3%) followed by reduced foetal movement, pain abdomen. In Delhi also most common known danger sign was severe bleeding.¹³

Identifying place of delivery and /or skilled birth attendant and making a birth plan were the most mentioned BPACR practices which was quite similar to findings of different study.^6,13,14 The least mentioned BPACR practices were financial savings towards delivery or for obstetric emergency (55.1%) and arranged for transport before delivery (33.7%). In Ethiopia, in Nigeria and in Tanzania saving money was a commonly mentioned practice but in Tanzania practice of identifying transport was quite same in our study.^5,14,15 There was desirable level of practices among study participants in spite of poor knowledge may be due to provision of door to door service and regular sensitization about available services by health workers.

Bivariate logistic regression showed education status of study subject and their spouse had significant association with birth preparedness. In Nigeria maternal educational status was the only predictor of birth preparedness whereas in Delhi women’s education and her spouse’s education found to be significant.^12,13 In this study only income was found significant in both bivariate and multivariable model.

CONCLUSION

The performance regarding BPCAR was not up to standard. Therefore, health personnel at all levels must come forward to impart appropriate high quality IEC services which in the long run will help in improving BPCAR and reducing maternal morbidity or complications.

ACKNOWLEDGEMENTS

Researchers acknowledged to the officer in charge of UHU and TC Chetla for his kind support and permission for this community based research work. Researchers also acknowledged to the field staff of UHU and Chetla for their technical help in field work.

Funding: No funding sources

Conflict of interest: None declared

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

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