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ORIGINAL ARTICLE
Year : 2020  |  Volume : 23  |  Issue : 3  |  Page : 362-370

Birth preparedness and complication readiness among women of reproductive age group in Abakaliki, Southeast Nigeria


1 Department of Obstetrics and Gynaecology, Federal Teaching Hospital Abakaliki, Ebonyi State, Nigeria
2 National Obstetrics Fistula Centre, Abakaliki, Ebonyi State, Nigeria

Date of Submission26-Dec-2018
Date of Acceptance12-Jan-2020
Date of Web Publication5-Mar-2020

Correspondence Address:
Dr. R C Onoh
Department of Obstetrics and Gynaecology, Federal Teaching Hospital Abakaliki, Ebonyi State, PMB 102, Abakaliki, Ebonyi State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_670_18

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   Abstract 


Background: Birth preparedness and complication readiness (BPCR) reduces delays in obstetric care, improves health-seeking behavior during an obstetric emergency, and improves knowledge on danger signs of pregnancy. Aims: To assess the knowledge, perception, and practice of women on BPCR. Subjects and Methods: This was a cross-sectional study conducted at Federal Teaching Hospital in Ebonyi state, Nigeria at the postnatal ward from June to December 2016. Women who delivered were recruited consecutively on discharge from the postnatal ward. Their knowledge, perception, and practice of BPCR in the last pregnancy were sought. Information obtained were analyzed using 2008 Epi-info™ software version 3.5.1 (Atlanta Georgia USA). Result: A total of 438 of 445 questionnaires were correctly filled and analyzed giving a response rate of 98.4%. Most of the women knew about birth preparedness 384 (87.7%) and complication readiness 348 (79.5%). A significant number of women did not access antenatal care within the first trimester 236 (53.9%), did not know that family planning is important in BPCR 216 (49.3%), and did not identify means of transport in the event of emergency 354 (80.8%). No provision of blood during antenatal care for the blood banking system was a common finding 258 (58.9%). In multivariate logistic regression analysis, choosing a health care provider was a common finding among literate mothers (OR = 2.8,95% CI = 1.02,7.72), woman within 25–29 years (OR = 1.09, 95%CI = 1.02,1.16), and multiparas (OR = 0.82, 95% CI = 0.67,0.99). Conclusion: There is increased knowledge and awareness of BPCR but the comprehensive components and practices of BPCR are still not optimal in our setting.

Keywords: Antenatal care, birth preparedness, complication readiness, maternal and perinatal mortality, pregnancy


How to cite this article:
Onoh R C, Egede J O, Lawani L O, Ekwedigwe K C, Aja L O, Anozie B O. Birth preparedness and complication readiness among women of reproductive age group in Abakaliki, Southeast Nigeria. Niger J Clin Pract 2020;23:362-70

How to cite this URL:
Onoh R C, Egede J O, Lawani L O, Ekwedigwe K C, Aja L O, Anozie B O. Birth preparedness and complication readiness among women of reproductive age group in Abakaliki, Southeast Nigeria. Niger J Clin Pract [serial online] 2020 [cited 2020 Apr 7];23:362-70. Available from: http://www.njcponline.com/text.asp?2020/23/3/362/280040




   Introduction Top


A healthy baby to a healthy mother is the outcome generally expected of every pregnancy. However, maternal as well as perinatal morbidity and mortality still pose serious challenges to this expectation. Generally, about one thousand five hundred (1500) women die every day from complications related to pregnancy and childbirth.[1] United Nation Children Fund Organization (UNICEF) and World Health Organization (WHO) reported that about five hundred and eighty-five thousand (585,000) women die annually following complications related to pregnancy and 99% of these are in developing countries with about 70% of these mortalities occurring in sub-Saharan Africa.[2],[3] In Nigeria, about sixty thousand (60,000) women die annually following pregnancy-related complications.[3] For every one woman who dies, at least twenty (20) women suffer morbidities of varying degrees ranging from crippling obstetric complication to reversible complications.[4]

Birth preparedness and complication readiness by the pregnant women, their spouses, their family and community has been identified as a key strategy for reducing the number of deaths from pregnancy-related complications. The death of a woman has a devastating effect on the family, community, and society at large. The associated fetal wastage is very high and an estimated 90% of babies in the index pregnancy suffer intrauterine or neonatal death or die within one year.[3]

Lack of advanced birth plan and inadequate preparation for emergency obstetric care contribute to the delays in assessing skilled obstetric care with the resultant bad obstetric outcome. This plan and preparation constitute the birth preparedness and complication readiness which tries to address the fact that every pregnant woman faces the risk of sudden and unpredictable life-threatening complications that could end in maternal or neonatal morbidity and mortality.[5] It has been globally endorsed as an essential component of safe motherhood programs to reduce delays for obstetric care.[6]

Evidence from Nepal, Burkina Faso, India, and Nigeria have also shown that promoting birth preparedness and complication readiness improved knowledge of women about danger signs and had led to an improvement in health-seeking behavior during an obstetric emergency.[7],[8],[9],[10],[11]

Therefore, we aim to assess the level of birth preparedness and complication readiness among women who delivered at a Federal Teaching Hospital in Abakaliki, Ebonyi state, Southeast Nigeria.


   Material and Methods Top


This study was done at Federal Teaching Hospital Abakaliki in Ebonyi state. Ebonyi State was created in 1996 from the old Abakaliki division of Enugu State and old Afikpo division of former Abia State, has 13 local government areas (LGAs): one urban, one semiurban, and the rest rural. It has an estimated population of 4.3 million and occupies a land mass of 5935 km2, sharing boundaries in the west with Enugu State, Cross River in the east, Abia in the south-east, and Benue in the north. About 75% of the population dwells in the rural area with farming as their major occupation. Federal Teaching hospital Abakaliki is located in the state capital and serves as the major referral center in the state. The road network within the state capital is good and mostly tarred but within the rural areas majority of the roads are not tarred. The farthest distance from the rural to the urban area ranges from 70–100 km and could take up to 1 h to 2 h to reach the Teaching Hospital. In the rural areas, the majority of the inhabitants are subsistent farmers, whereas in the urban areas, the majority of the people are civil servants and businessmen/women. The remuneration of the civil servants are based on the Government approved wages rates for the Federal and State public/civil servants. Most families in the rural setting are polygamous, while the common family system in the urban settings is monogamous.

This was a cross-sectional descriptive study. The study involved consecutive recruitment of women who had delivered vaginally or by operation on the day of discharge from the postnatal ward of Federal Teaching Hospital, Abakaliki, in Ebonyi State, Southeast of Nigeria from 1st June to 31st December 2016. Federal Teaching Hospital, Abakaliki (FETHA) is a major tertiary health facility located in the capital city of the state and receives referrals mostly from all parts of the State and also from the neighboring States of Benue, Enugu, Cross River, and Abia State. The Department of Obstetrics and Gynecology of FETHA has five teams/units with each subdivided into two subunits. Each subunits is managed by at least two consultants with attached resident doctors and house officers. These five teams in the department are divided in line with the subspecialties of Obstetrics and Gynecology and they include Oncology, Urogynecology, Infertility and Reproductive Health, Endoscopy and Reproductive Endocrinology, and Fetal and Maternal Medicine. The department has full accreditation in both West Africa and National colleges for the training of resident doctors with about 80 resident doctors in training and other supporting hospital staff. The antenatal, postnatal, and gynecology clinics run daily from Monday to Friday. The department offers intrapartum (labor ward) and obstetrics and gynecology emergency daily. The average annual delivery range is about 2500 and the annual antenatal booking range is approximately 3200.

Ethical approval for this study was obtained from hospital Ethics and Research Committee. The first three authors trained 6 nurses from FETHA as research assistants who thereafter administered the pretested semistructured questionnaires to the consenting postnatal women and those who were not literate were assisted by the research assistants.

The pretested semistructured questionnaires administered to the consenting postnatal woman contained information on the sociodemographic characteristics, knowledge, perception, and practice of the women on birth preparedness and complication readiness.

The sample size for this study was determined using the formula by Taylor DW. The following assumptions were undertaken for calculation of the sample size and they include 95% confidence level (5% margin of error between the sample and the population), proportion of persons free from the disease, constant for standard normal deviation (1.96), and 78.7% proportion of women who practice BPCR in reference to the previous study in Enugu, Nigeria.[12] Attrition rate of 10% was done to allow for dropouts. An approximated minimum sample size of 280 was calculated but was increased to 445 during the study to increase power.

Data was analyzed using the 2008 Epi-info™ software package version 3.5.1 (CDC Atlanta USA). Initial univariate analysis was generated by the statistical package and further multivariate analysis of the sociodemographic variables was modeled with the level of birth preparedness and complication readiness using logistic regression to contend for the confounding variables, and level of significant was set at P value < 0.05.

For clarity, some terms used in this paper are defined as follows:

  1. Birth preparedness and complication readiness (BPCR) is the process of planning for normal birth and anticipating the actions needed in case of an emergency.[11]
  2. Danger signs include fever, headache, bleeding per vagina, rupture of fetal membranes, foul-smelling lochia, fetal heart irregularities, chest pains, convulsion, unconsciousness, history of chronic illnesses like hypertension, etc.
  3. Signs of labor include passage of show, labor pain, and spontaneous rupture of fetal membranes at term.
  4. Second stage of labor includes full cervical dilatation, irresistible urge to bear down, and intense labor pains.
  5. Exclusive breastfeeding is the practice of feeding only breast milk (including expressed breast milk) to the baby and allows the baby to receive vitamins, minerals, or medicine.



   Results Top


Four hundred and forty five women were interviewed but 438 properly filled and returned the questionnaires, giving a response rate of 98.4%, and were analyzed. The mean age of the participants was 29.1 (5.0) years.

[Table 1] showed that the majority of the postnatal women 285 (65.1%) were within the age range of 25–34 years. Most of the participants 176 (40.2%) had at least secondary education, while only 29 (6.6%) had no formal education. About 395 (90.2%) were Christians, among which were mainly 180 (45.6%) Catholics, the remainder practiced other religious faith. The majority 388 (88.6%) were in monogamous relationship and more than half were married for less than 2 years. Only 4 (0.9%) were married up to 25 years with a mean duration of marriage of 6.67 (6.28). The majority 331 (75.6%) were multiparous women, booked 320 (76.1%), and the commonest 312 (71.2%) mode of their last childbirth was a spontaneous vaginal delivery.
Table 1: Sociodemographic variables of postnatal women who participated in the study

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Knowledge of birth preparedness and complication readiness was common among the respondents as shown in [Table 2]. During the antenatal period majority, 384 (87.7%), 340 (77.6%), 348 (79.5), and 385 (87.9%) acknowledged that they were taught birth preparedness, complications of pregnancy, how to get ready for the pregnancy complications, and exclusive breastfeeding, respectively. The majority 375 (85.2%) were aware of their expected date of delivery. Only 202 (46.1%) of the respondent registered for antenatal care within the first trimester. Three hundred and four (69.4%) understood the danger signs that could result from pregnancy complications. A total of 295 (67.4%) and 385 (87.5%) were aware of the signs of labor and second stage of labor, respectively. Almost all participants 405 (92.5%) were aware that exclusive breastfeeding is important for the babies. Just 222 (50.7%) made informed choice of family planning option after delivery. The majority of participants 376 (95.8%), 367 (83.8%), and 316 (82.4%) made 4 antenatal visits, chose hospital for their delivery, and chose skilled birth attendant for the index delivery in case of emergency, respectively. However, only 84 (19.2%) identified means of transportation in case of emergency in this index pregnancy. Two hundred and fifty nine (59.1%) and 258 (58.9%) saved money or made prior arrangement for transportation in the night and day, respectively, in case need arises during the pregnancy. In addition, 412 (94.1) each saved money for the delivery and bought babies materials prior to delivery. Approximately, 200 (45.7%) were aware that the community or government could be of support during the pregnancy and childbirth.
Table 2: Knowledge of postnatal women on birth preparedness and complication readiness (BPCR)

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[Table 3] assessed husband's involvement in birth preparedness and complication readiness. The majority of the respondents 360 (82.2%) accepted that their husbands provided financial and social support during antennal period, 395 (90.2%) made provision for foodstuff in preparation for the delivery, 399 (91.1%) made provision for maternity materials, 355 (76.5%) showed willingness to donate blood in case of emergency, and 296 (67.6%) accompanied them to the hospital at the onset of labor. However, only 64 (14.6%) of the respondents benefitted from their husband's companionship during delivery and only 180 (41.1%) actually donated blood when the need arose.
Table 3: Husband's involvement in birth preparedness and complication readiness

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[Table 4] showed that the identified sources of fund and support for the planned deliveries and care of the baby which were mainly through the husband's savings 409 (93.8%) and personal savings 170 (38.8%). Church, friends, and other supports contributed 5 (1.1%) each. About 178 (40.6%) knew that they could obtain financial help from the government or community during pregnancy and childbirth, while 18 (4.1%) and 13 (3.0%) knew they could receive transportation and blood transfusion services, respectively. During emergencies, the decision to access help was mainly made by the husband 386 (88.1%), whereas the wife (participants) made 100 (22.8%). The identified means of transportation was mainly through cars 273 (62.3%), tricycle 110 (25.1%), and motor cycle 96 (21.9%).
Table 4: Support and funding of birth preparedness and complication readiness

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[Figure 1] showed that the identified danger signs that could result in maternal morbidity and mortality include bleeding per vagina 252 (57.5%), fever 182 (41.6%), hypertension in pregnancy 159 (36.3%), and severe headache 259 (36.3%). The majority identified more than one danger signs.
Figure 1: Identified danger signs that could result in maternal morbidity and mortality

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The majority of the participants 412 (94.1%) identified teaching hospital as their choice place of birth while 3 (0.7%) each identified private hospital and traditional place of birth attendants' home as choice place of birth [Figure 2].
Figure 2: Identified place for possible delivery

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[Table 5] showed logistic regression of factors that influenced birth preparedness. Those who had tertiary education were found to be about 2.8 times more likely to have prepared for the delivery than those who had no formal education. [95% CI: 1.0168–7.7211]. Similarly, the odds of birth preparedness increased by 1.09 for every unit increase in age [95% CI: 1.0168–1.1610] and 0.8 for every unit increase in parity [95% CI: 0.6689–0.9920].
Table 5: Logistic regression analysis on birth preparedness and complication readiness

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The logistic regression to determine factors that influenced complication readiness among the respondents showed that women who were unbooked were 0.3 times less likely to have made preparations for complications that arose during the pregnancy and childbirth. [95% CI: 0.2344–0.6339]. The odds of complication readiness among the postnatal women increased by 1.06 for every year increase in the duration of marriage [95% CI: 1.0021–1.1163]. Those who had any form of education were more prepared for complications than those who had none. Those with primary education were more than 4 times likely to be complication prepared than those with no education [95% CI: 1.5274–11.9240]. Those with secondary education were 3.3 times more likely to be complication ready before delivery than those with no education [95% CI: 1.2006–9.2434]. Those who had tertiary education were 6.7 times more likely to have made preparation for complication during pregnancy and childbirth than those with no formal education [95% CI: 2.2992–19.3878].

[Table 6] showed the logistic regression to ascertain factors that influenced the willingness to donate blood by the husbands during emergencies. Duration of marriage was the only factor that significantly influenced the decision to make blood available during emergencies and the odds increased by 1.11 for every unit increase in the duration of marriage [95% CI: 1.0403–1.1878].
Table 6: logistic regression on willingness to provide a blood donor for the blood banking services

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   Discussion Top


Birth preparedness and complication readiness is a comprehensive approach to promote timely utilization of skilled maternal and neonatal care based on the premise that childbirth preparation and being ready for complications reduces delay in obtaining this care. This is important as unprepared families would waste precious time in attempt to recognize the problem, get organized, source for fund, and find means of transportation before reaching the appropriate referral facility. Birth preparedness programs can positively influence future health-seeking behavior of the family beyond the index pregnancy and puerperium.

The knowledge of birth preparedness and complication readiness concept was high in this study. This was similar to the findings in Calabar, Nigeria where over 70% were aware of birth preparedness and complication readiness.[11] It was also similar to a study in Enugu where 78.7% had good knowledge of BPCR.[12] However, it was higher than the findings in Edo[13] where only 38% were aware of BPCR. The increased level of awareness of the concept of the BPCR in this study may be attributed to increased access to antenatal care as 85.5% had more than 4 antenatal visits and 46.1% booked early in the first trimester, which was more than 16.1% from a previous study in the study facility.[14] Other factors that influenced birth preparedness and complication readiness awareness and implementation in this study include maternal level of education, age, booking status, and duration of marriage.

Only 19.2% of the population could identify means of transportation. Unlike the study in Calabar[12] where motorcycle is the major means of transportation, car was identified in 62.3% and tricycle in 25.1% of the cases. However, more than half of the population saved money and made arrangement for transportation both in the day and at night should emergency arise. This is important as lack of transportation means and often poor accessible road, especially in rural areas, are major contributors to delays in accessing maternal health in case of emergency.

In this study, 94% of the respondents saved money for delivery and bought required materials before giving birth. The major source of income was through husband and personal savings, 93.8% and 38.8%, respectively. This was higher than the findings of Ibrahim et al.[13] in Edo state, Mutiso et al.[15] in Burkina Faso, and Moran et al.[16] in Kenya. Many families in developing countries live below the poverty line, struggle to provide the basic necessity of life, and may find it difficult to save money for obstetrics emergencies.[16],[17] This often contributes to undue delay in accessing appropriate health care services[13] and subsequent perinatal and maternal morbidity and mortality. This calls for strengthening of the national health insurance scheme so that nonemployees of the Federal Government could benefit from the scheme.

Knowledge of danger signs that result to obstetric complications is essential and may act as a stimulus for women to seek, early and timely, skilled birth attendants and help them make advanced preparation should such complications develop. Nearly 70% of the participants were aware of the danger signs that result in obstetric complications. The commonly identified danger signs included bleeding per vaginam, fever, reduced fetal movement, and severe headache. This is similar to the findings in Imo state, Kenya, Oroma and Basoliben in Ethiopia where 80%, 67%, 79.9%, and 78.3%, respectively, were aware of the danger signs of pregnancy.[16],[18],[19],[20] It was higher than the findings in Edo state, rural Uganda, Tanzania, and Adigrat Ethiopia where 42%, 30.4%, 14.8%, and 10.9% were aware of danger signs of pregnancy.[13],[21],[22],[23]

Antenatal care (ANC) avails the opportunity to monitor fetomaternal status, detect diseases and complications, and provide appropriate treatment. It is a period to educate and inform the women as well as their partners about pregnancy, childbirth, and newborn care. Access to health education given at the regular antenatal visits increases women knowledge and awareness of risks of pregnancy and childbirth as well as the required measures to handle them.[18] This study showed that only 46.1% of the women started ANC visit in the first trimester and 82.4% made at least 4 antenatal visits. This is higher than the findings in Ife where 10% booked in the first trimester and 55.5% made at least 4 visits; Onayade et al. found 60.7% made four antenatal visits and national average of 22.2% for women in urban areas for early booking and 68.8% for at least four visits.[24],[25],[26] It is also similar to the finding in Ethiopia and Nepal where 73.2% and 75.1% of the pregnant women made at least four antenatal visits.[23],[27] Early and regular attendance at antenatal clinics improves women access to information and knowledge about birth risks and ways to prevent and handle them.

About 84% of the participants in this study chose birthplace and 82.4% chose health attendants. This is closely similar to the Ethiopia study where 78% chose a place of birth before childbirth.[23] This is higher than 45.1% found in Goba Woredia[19] and in another Southern Ethiopia study where among 743 pregnant women, only 20.5% identified skilled provider and 8.1% identified health facility for delivery and for obstetric emergencies.[28] Prior knowledge of a place of birth and skilled birth attendant at delivery or emergency is an essential factor in the prevention of delays in accessing health care when such need arises. The majority 94.1% of the participants chose tertiary hospital as the place of birth. Only 2.7% chose primary health center, 0.9% chose secondary health, and 0.7% chose traditional birthplace. This may be because of the “near comatose” state seen in primary and secondary health facility in our setting. Emphatically, it is due to the absence of health personnel and dearth of infrastructures in the primary and secondary health facilities in the developing countries like ours and these put pressure on the only exiting tertiary center.

The inclusion of men in reproductive health interventions can optimize positive health outcomes. Information and education passed to the pregnant woman and her partner during the antenatal care visits are likely to be better implemented than when such is passed to the woman alone. Often, the husband who is usually the head of the family determines the women's ability to seek health or implement lessons learnt from antenatal health education such as birth preparedness and complication readiness.[29],[30] The husbands made the decision for the wives to present during emergencies in 88.1% of the cases while the women made in 22.8%. This could be explained by the fact that the source of income was mainly through the man's personal savings as compared to the woman's savings, 93.8% versus 38.8%.

In this study, the husbands helped in the antenatal and preparation by ensuring that funds are available, house items and delivery items are purchased. About 53% of the women were accompanied by their husbands to the antenatal clinic, while only 14.6% accompanied them to the labor room during delivery, though 49.8% actually wanted their husbands in the labor room. This is similar to the finding of Ugandan[31] study where 49.2% accompanied their wives to the antenatal period and 68.2% accompanied their wives during labor. Women who had a birth plan were more likely to be accompanied by their spouses to health facilities during antenatal care and to the labor ward during labor. They were also more likely to receive more financial support from their husbands or assistance with household chores during pregnancy.

In addition, 76.5% of the women reported that their husbands were ready to donate blood but 41.1% actually donated blood when there was a need. The major factor that affected blood donation by the husbands was the duration of marriage. Hemorrhage was a major contributor to maternal morbidity and mortality. Identification of compatible blood donors and their availability and willingness to donate in case of an obstetric emergency could be life-saving, especially in a poor resource environment where blood-related products are not readily available. Inadequate arrangement for blood during emergencies may contribute to delays associated with road to maternal death.


   Conclusion Top


In conclusion, birth preparedness and complication readiness was high among women in Abakaliki. The determinants include maternal level of education, age, booking status, and duration of marriage. Therefore, we recommend that the gains already made on birth preparedness should continue and there should also be continued enlightenment on blood donation. Women financial and educational empowerment will help them seek medical care, particularly during emergencies without waiting for their husband to give the order. There should be an improvement in the operation of the National health insurance scheme in order to reduce the burden of out of pocket health care financing.

Acknowledgements

We wish to acknowledge the management of Federal Teaching Hospital Abakaliki, Ebonyi State Nigeria, for providing the enabling environment for this study and our gratitude goes to the departmental consultants, resident doctors, research assistants, and all staff of Federal Teaching Hospital Abakaliki who supported us in the course of this research.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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