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ORIGINAL ARTICLE
Year : 2021 | Volume
: 10
| Issue : 4 | Page : 293-299
Birth preparedness and complication readiness among pregnant women visiting a government hospital in Delhi, India
Meenakshi Bhilwar, Poornima Tiwari, Pragyan Paramita Parija, Priyanka Sharma, Sunil Kumar Saha
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
Correspondence Address:
Dr. Pragyan Paramita Parija
Department of Community Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi - 110 029
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijhas.IJHAS_44_20
BACKGROUND: According to the WHO, about 830 women die from pregnancy or childbirth-related complications globally and can be attributed to the three delays that influence the outcome of any pregnancy. Birth preparedness and complication readiness (BPCR) is one of the most conceptual and logical means of addressing these delays.
OBJECTIVE: The objective was to study BPCR among pregnant women visiting ANC clinic at a tertiary care government hospital in Delhi.
MATERIALS AND METHODS: It was a cross-sectional study conducted among 200 pregnant women, irrespective of gestational age visiting the hospital. Information was gathered using a pre-designed, pre-tested, semi-structured questionnaire by an interview about BPCR. Descriptive analysis was done and tests of significance were applied to determine association.
RESULTS: Awareness about dangers signs during pregnancy and childbirth and symptoms indicating onset of labor were all found to be poor, none of subjects were aware of all the signs. About 76% believed they should identify an institution for delivery ahead of time, while 68.5% had identified one and 64 (32%) had arranged a mode of transport. One hundred sixteen women (58%) believed that they should save money for the incurring costs of pregnancy, while 105 (52.5%) were saving money for the same. Sixty-three women (31.5%) agreed that it is necessary to identify a blood donor; however, only 7.5% had identified one. The BPCR index for the current study was 37.12.
CONCLUSION: Efforts should be targeted to increase the awareness about various components of BPCR along with increased involvement of community health workers and health-care providers.
Keywords: antenatal women, birth preparedness, birth preparedness and complication readiness, BPCAR, complication readiness, India, reproductive health
According to the WHO, about 830 women die from pregnancy or childbirth-related complications around the world every day and 99% of all maternal deaths occur in developing countries.[1] Reduction of maternal mortality has long been a global health priority and a target in the Sustainable Development Goals (SDG).[1],[2],[3] Improvement in maternal health and reduction in maternal mortality have been slower than anticipated.[4] India's maternal mortality rate reduced from 212 deaths per 100,000 live births in 2007 to 178 deaths in 2012; however, there is still more left to achieve.[5]
Majority of maternal deaths are attributed to direct causes such as hemorrhage, sepsis, and hypertension, while the rest are due to indirect causes.[6] Thaddeus and Maine outlined three delays that influence the outcome of any pregnancy. According to them, delay can occur at three different levels: (1) delay in decision to seek care, (2) delay in reaching the appropriate facility, and (3) delay in receiving adequate care in the facility.[7] The reasons for the first delay may be late recognition of the problem, lack of awareness, fear of the hospital, lack of money, or lack of an available decision-maker. The second delay is usually caused by difficulty in transport, long distance from a health facility, and multiple referrals and the third delay is often due to difficulty in getting blood supplies, equipment, and operation theater.[7] Low socioeconomic status of women, illiteracy, and residence in rural areas may be the main factors responsible for delays in receiving care during delivery.[8],[9]
Birth preparedness and complication readiness (BPCR) is one of the most conceptually compelling and logical means of addressing these delays. BPCR includes preparation for taking action in emergencies and building an enabling environment for maternal and newborn survival. The concept of BPCR includes knowing danger signs, planning for a birth attendant and birth location, arranging transportation, identifying a blood donor, and saving money in case of an obstetric complication.[10],[11] Evidence from studies reveals that with adequate population coverage, BPCR interventions are effective in reducing maternal and neonatal mortality, even in low-resource settings.[12]
With this background, the current study was planned to assess the awareness and practices related to BPCR among antenatal women visiting a government hospital in Delhi, India.
Materials and MethodsStudy area and study population
It was a cross-sectional study conducted among pregnant women (irrespective of gestational age) visiting ANC clinic at a government hospital in New Delhi during September 2016–November 2016. Pregnant women irrespective of their gestational age and parity who gave written consent to participate were included in the study.
Sample size and sampling technique
The sample size was calculated based on the findings of a prior study conducted by Mukhopadhay et al. in West Bengal.[13] This study used 12 key indicators for assessing BPCR among their study population. The minimum prevalence among these was that of “aware of at least one key danger sign of pregnancy” and was 12%. Using this prevalence, an error of 5%, and 10% nonresponse rate, the sample size was calculated as 186, but it was decided to include 200 pregnant women. The study respondents were selected by nonprobability convenient sampling. All pregnant women were approached and after explaining the study objectives, those who consented were included.
Process of data collection
Information was gathered using a predesigned pretested, semi-structured questionnaire. The questionnaire was divided into the following groups: (1) sociodemographic profile; (2) obstetric history and current pregnancy; (3) awareness about BPCR; and (4) practices in relation to BPCR. Socioeconomic status of the population was calculated using the BG Prasad Scale, (2016).[14] During data collection, all pregnant women (irrespective of gestation age) were explained in detail about the study, nature of their involvement in the study, and its expected outcomes.
Statistical analysis
BPCR was estimated on the basis of presence of the following four practices – save money for pregnancy and childbirth, identify an institution for delivery, arrange a mode of transport , and identify a blood donor. BPCR index was computed as an un-weighted average of these four indicators and expressed as a score out of hundred. Based on a previous study, women who followed three or more practices were considered “well prepared” and women had followed <3 were considered “less prepared.”[13]
The data collected were entered into Microsoft Excel 2010 and analyzed using SPSS version 20 (Chicago, IL, USA). Mean and standard deviation (SD) were used to summarize continuous variables. Categorical data were represented in the form of proportions. Chi-square test or Fisher's exact test was used for comparing variables and P < 0.05 was considered statistically significant.
Ethical clearance
This study has been conducted within the boundaries of the Helsinki Declaration. Permission to conduct the study was obtained from the department. Patient confidentiality was maintained and informed written consent was obtained.
ResultsSociodemographic profile
The mean age of participants was 24.77 (±3.45 SD) years. About 90% (180) were urban; majority were Hindus (89.5%); 14.5% (29) were graduates, while 10.5% (21) were illiterate and 44.6% of women were housewives; 40.5% of women belonged to lower middle socioeconomic class [Table 1].
Table 1: Sociodemographic characteristics of the study population (n=200)Obstetric profile
The mean age at marriage and first pregnancy was 20.4 ± 2.7 and 22.3 ± 3.02 years, respectively. About 43% (86) were primi-gravidae and the median family size was 2 (Q1–Q3: 1–2). Of all the respondents, 6% (12) were in the first trimester, 42.5% (85) were in the second trimester, and the rest 51.5% were in the third trimester. Nearly 11.5% of women gave a history of abortions in previous pregnancies. More than half of the antenatal women (52.5%) were referred to the ANC clinic by a family member, mostly husband or mother in law, while 33.7% came by themselves and the rest were referred by local health providers. Majority of the women (92, 46%) made their first ANC visit in the first trimester of current pregnancy, followed by another 46.5% of women in the second trimester. Only 10 (7.5%) women made their first ANC visit in the last trimester of pregnancy, namely the 7th and 8th months.
Awareness about danger signs of pregnancy
The respondents were asked about 10 major danger signs during pregnancy – 58% (116) of women were not aware of any danger sign; 13% (26) of women were aware of only one danger sign while only 4% (6) were aware of six signs. None of the respondents were aware of all the danger signs [Table 2]. Awareness about at least one danger sign was found to be more in educated women (P = 0.006); women belonged to a higher socioeconomic status (P = 0.004) and resided in urban areas (P < 0.001). Awareness was not found to be associated with religion, gravida status, and trimester of pregnancy (P > 0.05).
Table 2: Distribution of study population according to the awareness of danger signs during pregnancy (n=200)Awareness about danger signs during labor/childbirth
About 14% (28) of the respondents were aware of at least one danger sign, while 71% (142) were not aware of any danger sign during childbirth; 3.5% (7) women were aware of five danger signs, while none of them were aware of all the danger signs. Excessive bleeding was the most commonly recognized danger sign among the study participants, 22% (44) [Table 3]. Multigravidae and women residing in urban areas were more aware of danger signs during labor (P = 0.04 and 0.01, respectively). The awareness was found to higher in more educated women and those who belonged to a higher socioeconomic status; however, this difference was not statistically significant (P > 0.05).
Table 3: Distribution of the study population according to the awareness of danger signs during labor/childbirth (n = 200)Awareness about symptoms indicating onset of labor
Of the four key symptoms indicating onset of labor, 30% (60) antenatal women were aware of at least one symptom, while 24.5% (49) were not aware of any. None of the women were aware of all four the symptoms. Majority (69.5%) women were familiar with regular painful contractions as a symptom of labor onset [Table 4]. Awareness regarding at least one symptom indicating onset of labor was found to be more among multigravidae (P < 0.001). Women in the second and third trimesters were more aware about these symptoms as compared to women in the first trimester (P = 0.02). Awareness about symptoms of onset of labor showed no difference in distribution according to education, socioeconomic status, religion, and type of residence (P > 0.05).
Table 4: Distribution of the study population according to the awareness about symptoms indicating labor (n=200)Source of information regarding pregnancy and childbirth
Among the various sources of information related to childbirth and its complications, 118 (59%) women said they received it from doctors when they visited the ANC clinics; 36 (18%) received it from family members and friends; and a mere 7% received it from community health workers like ASHA. The remaining 16% received the information via other sources such as media and hoardings.
Birth preparedness and complication readiness attitudes and practices
Majority of women (76%) believed that a woman should plan ahead of time regarding where will she give birth and how will she get to the place; 68.5% had identified an institute for delivery (68.5%) and 64 (32%) had arranged a mode of transport. One hundred sixteen women (58%) believed that a family should save money for incurring costs of delivery and obstetric emergencies, while 105 (52.5%) said they were saving money for the same. Sixty-three women (31.5%) agreed that it is necessary to identify a blood donor prior to delivery; however, only a small fraction of participants had identified a blood donor (7.5%). The BPCR index for the current study is 37.12 [Table 5].
Table 5: Distribution of the study participants according to the birth preparedness and complication readiness (n=200)Fifteen percent of women were totally unprepared for birth, while only 3% of women were completely prepared. Women who followed more than two BPCR practices were said to be well prepared. Only 15% (30) of antenatal women were well prepared, while 85% (170) were less prepared. Compared to less prepared mothers, well-prepared mothers were literate (P = 0.01) and belonged to a higher socioeconomic class (P = 0.04). The preparedness status of these participants was also associated with age ≥ 25 years; age of marriage ≥ 20 years; and age at first pregnancy of 22 years or more and urban residence; however, these differences were not statistically significant (P > 0.05) [Table 6].
Table 6: Distribution of well-prepared and less-prepared women according to the various characteristics (n=200) Discussion Over the past decade, the international public health community has amplified its focus on reducing maternal mortality and morbidity. “Birth preparedness and complication readiness (BPCR)” has been considered an important strategy in this direction; however, this concept is yet to get its due recognition in India. This study attempted to study the concept of BPCR in women visiting a tertiary government hospital in Delhi, India. The study was conducted among antenatal women attending the ANC clinic at the institution. The mean age of these women was 24.77 years. Almost half (46%) of these women made their first ANC visit in the first trimester of their current pregnancy, more than that found in a study at Jammu and Kashmir but less than the one conducted in Bankura, West Bengal.[15],[16]
Improved knowledge of obstetric danger signs, birth preparedness practices, and readiness for emergency complications have proved to be among the strategies intended toward enhancing utilization of maternal health services as well as increasing access to skilled care during childbirth, particularly for women with obstetric complications.[17],[18],[19] This knowledge was found to be poor among the study population; more than half of the women were not aware of a single danger sign. Awareness was more in educated women and those belonging to a higher socioeconomic status, probably because they are better informed due to more access to information and health-care services. The awareness about symptoms indicating onset of labor was also found to be poor. The awareness was more among multigravidae and women in second and third trimesters, which is expected as women who have had previous pregnancies or are nearing labor will be more informed. Another study on BPCR conducted in Delhi observed similar results where awareness regarding danger signs during pregnancy, labor, and puerperium was found to be as low as 27.8%, 6.7%, and 0.7%, respectively.[20] Similar results have been found in studies conducted in other countries such as Ethiopia and Nigeria.[21],[22],[23]
To overcome the financial barriers and increase utilization of health services by antenatal women, conditional cash transfer schemes are operating successfully around the world.[24] The government of India also introduced various cash incentive schemes such as Janani Suraksha Yojna, Janani Shishu Suraksha Yojna, and Mamta Scheme, to promote institutional deliveries and in turn reduce maternal and neonatal mortality. The awareness about these schemes was found to be poor among the subjects and only 20% of the women had heard about any such schemes. Increased knowledge and utilization of such schemes have shown to increase in the number of antenatal visits, institutional deliveries, and skilled attendance at birth, thus leading to a safe pregnancy and childbirth, and therefore, their promotion should be given priority.[25],[26]
Attitudes and practices related to BPCR were also found to be poor in our study. The BPCR index for the respondents in our study was 37.12. Only 3% of women were completely prepared for childbirth. About 58% of women had saved money for incurring costs of delivery and obstetric emergencies and 68.5% had identified an institute for delivery and 7.5% had arranged a blood donor. These results were similar to the study conducted in Uttar Dinajpur, West Bengal, where proportions of women with first ANC within 12 weeks, four or more ANCs, institutional delivery, saving money, identifying transport, and blood donor were 50.4%, 33.6%, 46.2%, 40.8%, 27.3%, and 9.6%, respectively.[13] In a study in Indore, 69.6% of women had identified a trained birth attendant for delivery and 63.8% had identified a health faculty for obstetric emergency.[27] Similar results were also found from the study by Acharya et al. in Delhi where 81.1% of participants had identified a skilled attendant at birth for delivery; nearly half of the women (48.9%) had saved money for delivery and 44.1% of women had also identified a mode of transportation for the delivery.[20] More educated and women belonging to higher socioeconomic status were more prepared for their childbirth. More than half of the study respondents received information on pregnancy and childbirth from doctors at ANC clinics, while only 7% said they were made aware by community health workers like ASHA. Studies have shown that ASHAs can successfully help to reduce maternal and neonatal mortality through participatory meetings with women's groups, supporting them during pregnancy through puerperium and thereafter.[28] As ASHA workers are the primary health contact in the community, BPCR training should be made fundamental to them so that they can help increase awareness among antenatal women about BPCR and prepare them for pregnancy and childbirth.
This study is among the very few studies on BPCR that have been conducted in India. However, it has a few limitations, and therefore, its findings must be viewed in the light of these limitations. It was an institution-based study; however, the study population was mixed in terms of socioeconomic status, religion, education, etc., and hence may be compared to similar studies conducted on BPCR. Second, some studies on BPCR have included both pregnant and postnatal women; however, keeping in view the limited resources and time constraints, we have only included pregnant women.
Conclusion and Recommendationsthe study showed poor awareness regarding BPCR among the study subjects. Efforts should be targeted to increase the awareness about various components of BPCR along with increased involvement of community health workers and health-care providers. This study is only a beginning and further studies should explore the awareness of BPCR at not only at the individual level but also at the level of family, health-care provider, and community, as their involvement is elemental to achieve the Sustainable developmental goal five of providing safe motherhood and reducing maternal mortality.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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