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  • Research article
  • Open Access
  • Published:
  • Andrea B Pembe1,3,
  • David Phường Urassa2,
  • Anders Carlstedt3,4,
  • Gunilla Lindmark3,
  • Lennarth Nyström5 &
  • Elisabeth Darj3 

BMC Pregnancy and Childbirth volume 9, Article number: 12 (2009) Cite this article

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Abstract

Background

Awareness of the danger signs of obstetric complications is the essential initial step in accepting appropriate and timely referral to lớn obstetric and newborn care. The objectives of this study were to lớn assess women's awareness of danger signs of obstetric complications and to lớn distinguish associated factors in a rural district in Tanzania.

Methods

A complete of 1118 women who had been pregnant in the preceding two years were interviewed. A list of medically recognized potentially life threatening obstetric signs was obtained from the responses given. Chi- square test was used to lớn determine associations between categorical variables and multivariate logistic regression analysis was used to lớn distinguish factors associated with awareness of obstetric danger signs.

Results

More than thở 98% of the women attended antenatal care at fewest once. Half of the women knew at fewest one obstetric danger sign. The percentage of women who knew at fewest one danger sign during pregnancy was 26%, during delivery 23% and following delivery 40%. Few women knew three or more danger signs. According to lớn multivariate logistic regression analysis having secondary education or more increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8–19) in comparison with no education at all. The likelihood to lớn gain more awareness increased significantly by increasing age of the mother, number of deliveries, number of antenatal visits, whether the delivery took spot at a health institution and whether the mother was informed of having a risks/complications during antenatal care.

Conclusion

Women had low awareness of danger signs of obstetric complications. We propose the following in order to lớn increase awareness of danger signs of obstetrical complications: to lớn improve quality of counseling and involving other family members in antenatal and postnatal care, to lớn employ radio messages and educational sessions targeting the complete community and to lớn intensify provision of formal education as emphasized in the second millennium development goal.

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Background

Worldwide, in 2005, 535,900 women died from causes related to lớn pregnancy and childbirth; half of these deaths occurred in sub-Saharan Africa [1]. Tanzania, located in sub-Saharan Africa has an estimated maternal mortality ratio ranging from 578 to lớn 950 per 100,000 live-births [1, 2]. The common causes of maternal deaths are hemorrhage, postpartum infection, hypertensive disorders, obstructed labor and abortion complications [3, 4]. These life-threatening complications are treatable thus most of these deaths are avoidable if women with the complications gain timely access to lớn appropriate emergency obstetric care [5].

Three phases of delay to lớn access care gain been described [6]: delay in making the decision to lớn seek care; delay in arrival at a health facility; and delay in receiving appropriate treatment following arriving at the health facility. Awareness of the danger signs of obstetric complications among pregnant women and in their communities is the initial step to lớn accepting appropriate and timely referral to lớn essential obstetric and newborn care, thus, reducing the initial and second phases of delay [5, 7, 8]. The danger signs occurring during pregnancy are predictive of destitute outcome rather than thở historic risk factors [9].

In 2002, the Tanzanian government introduced focused antenatal care (FANC), a recent model of antenatal care recommended by the World Health Organization [10]. Individual counseling on beginning preparedness and complication readiness including danger signs of obstetric complications during antenatal and postnatal visits is emphasized. At present in the country, 94% of women attend antenatal care at fewest once, thus it is expected that bulk of women would gain received information on danger signs of obstetric complications [2]. Despite the elevated antenatal care attendance, a study in Rufiji showed that compliance with emergency referral advice is low. Half of the women with obstetric complications referred did not reach at the referral hospitals [11]. Late or failure of women with obstetric complications to lớn reach referral hospitals may be contributed by many reasons. One folly may be lack of awareness of significance of symptoms or obstetric complications.

The target of this study was to lớn assess women's awareness of danger signs of obstetric complications and to lớn distinguish associated factors in a rural district in Tanzania. This information is essential for service providers and district-health management teams for improving the quality of antenatal care services provided in both the initial line and referral health institutions.

Methods

Study setting

This was a cross-sectional study undertaken in Rufiji district, between November and December 2006. Rufiji district is one of the six districts of Coastal Region in Tanzania. The district covers an area of about 14,500 km2. It has an estimated population of 203,000 with approximately 52% females, according to lớn the 2002 Census [12]. The bulk of the population are peasants, with 38% living below the national essential needs poverty line [13]. Geographically, the Rufiji district consists of flood plain, coastal-delta, and plateau zones. Most road networks in the district are challenging to lớn pass particularly during the rainy season. The district has five divisions divided into 19 wards: eight wards in the flood plain, four in the coastal-delta, and seven in the plateau zone. The complete number of villages is 128, each with an usual population of 1600.

The district has two hospitals, both providing comprehensive emergency obstetric care, four rural health centers and 48 dispensaries. Health workers supply maternal care in all health institutions.

Sampling method

Sampling was with a two-stage cluster. In the initial stage, two wards were randomly selected in each zone, and in the second stage, two villages were randomly selected from each of the six wards (n = 12). In each of the 12 villages, all women who had been pregnant during the previous two years were selected for interview using structured questionnaires. Women who were pregnant for the initial time at the time of the data collection were excluded.

Sample size

The crude beginning rate in Tanzania is approximately 4% [2] which means 8% of the population is expected to lớn gain been pregnant or delivered in the preceding two years: this made 16,000 women eligible for the study. Assuming that 25% of the women were aware of obstetric danger signs, with a desired precision of 5% (95% confidence interval), a design effect of two and a non-participation rate of 10%, a complete of 974 women were required for the study. The number of women selected for the study was 1 151 and of these, 33 (2.8%) were absent at the initial and second visit and were regarded as non-respondents; thus, 1 118 women were interviewed.

Data collection

The questionnaire, translated and posterior translated, Swahili to lớn English to lớn Swahili, to lớn ensure relevance and accuracy. The questionnaire was then piloted in a similar district (Mkuranga) in the same region. The interviews were evaluated by the researchers and essential changes made.

The questionnaire included socio-demographic characteristics including age, marital status, education level and occupation; pregnancy characteristics including number of deliveries, number of pregnancies and whether the women were pregnant or not at the time of the interview; experiences during their final pregnancy including whether they attended antenatal care, month of pregnancy booked for care, the number of visits made and if were informed of any risk or complication during antenatal care and danger signs of obstetric complications.

The antenatal cards used in their final pregnancy were available for 636 women and were reviewed for more information on the advice given to lớn deliver in a hospital. Information on awareness of danger signs was collected by asking women if they knew any danger signs that may take place during pregnancy, delivery and following delivery separately in the same interview and those who knew danger signs were asked to lớn mention them. Probing was used to lớn elicit further responses.

The village leaders were informed of the research activities earlier data collection. House-to-house visits were made on the day of data collection. All women who had been pregnant in the preceding two years were identified and interviewed by pre-trained research assistants (nurse midwives).

Based on the recommendations of the national antenatal care guideline and the Safe Motherhood Initiative, a list of medically recognized life threatening obstetric signs were obtained from the women's responses. The list included vaginal bleeding during pregnancy and delivery, severe vaginal bleeding following delivery, anemia, swelling of lower limbs, fits of pregnancy, severe headache, elevated grade fever, child does not plod, severe abdominal pain, awareness of rapid heart beats, elevated blood pressure, prolonged labor, loss of consciousness and retained placenta.

Data analysis

After data collection, responses for open-ended questions were reviewed, categorized, and coded for computerization. Data were entered with Epi Info and subsequently analyzed with SPSS. Awareness of danger signs of obstetric complication in this study was defined as the capacity to lớn mention at fewest one recognized danger sign during pregnancy, delivery or following delivery. Chi-square test was used to lớn determine associations between categorical variables. The differences were deemed meaningful when p < 0.05. Bivariate logistic regression analysis was used to lớn distinguish factors associated with awareness of obstetric danger signs. Variables meaningful in the bivariate analysis were then entered into a multivariate logistic regression analysis. The associations between awareness and each independent variable were estimated by odds ratio (OR) and 95% confidence interval (CI). A CI was considered statistically meaningful when the interval between the upper and lower values did not include one.

Ethical approval

The Muhimbili University of Health and Allied Sciences (MUHAS) research and publication committee gave honorable clearance to lớn conduct the study. Permission to lớn conduct the study was obtained from Rufiji district and village authorities. The purpose of study, benefits, accurate to lớn refuse participation, and liberty to lớn refuse or leave the study at any time was explained to lớn each participant earlier the interview. Verbal permit was regarded as sufficient to lớn be included in the study. To ensure confidentiality, women's names were not written on the questionnaires.

Results

Socio-demographic and pregnancy characteristics

The complete number of women interviewed was 1 118. Median age was 26 (Range: 15–45) and median parity was three (Range: 1–14). A bulk of women were married/cohabiting (80%) and peasants (77%). Almost half (46%) of the women had completed primary education. One thousand one hundred (98%) of the women attended antenatal care at fewest once and the median number of visits was four (Range: 0–10).

Awareness of danger signs

Five hundred and seventy one (51.1%) of the women knew at fewest one obstetric danger sign. The percentage of women who knew at fewest one danger sign related to lớn pregnancy was 26%, in relation to lớn delivery 23%, and to lớn the period following delivery 40%. Few women knew three or more danger signs, particularly for the delivery period (Figure 1).

Figure 1

figure 1

Percent of women who knew 0, ≥ 1, ≥ 2, and ≥ 3 obstetric danger signs during pregnancy, delivery and following delivery.

Full size image

One in four women recognized severe vaginal bleeding following delivery as a danger sign. Vaginal bleeding during pregnancy (9.6%) and delivery (13%) were mentioned as danger signs. Other danger signs established were anemia and seizures during pregnancy. Prolonged labor was established by only 1.5% of the women, while retained placenta was recognized by 8.0% (Table 1).

Table 1 Women's awareness of obstetric danger signs during pregnancy, during delivery and following delivery (N = 1118).

Full size table

Factors associated with awareness of danger signs

There were no differences in the awareness of danger signs during pregnancy, during delivery or following delivery as related to lớn age, educational level, number and spot of deliveries, number of antenatal care visits and lady informed of a risk/complication during antenatal care (p < 0.05) (Table 2).

Table 2 Women's awareness of danger signs during pregnancy, during delivery and following delivery presented by socio-demographic, obstetric characteristics, experience in the final pregnancy, and antenatal care attendance (N = 1118).

Full size table

The independent variables marital status, occupation, and advice to lớn deliver in hospital were not associated with awareness of a danger sign during pregnancy, delivery and following delivery in the bivariate logistic regression analysis, and were thus not included in the multivariate logistic regression analysis. Having secondary education or higher increased the likelihood of awareness of obstetric danger signs six-fold (OR = 5.8; 95% CI: 1.8–19). Moreover, the likelihood of awareness of obstetric danger signs increased with age, number of deliveries, number of antenatal visits, when delivery was at a health institution, and when the mother had been informed of having a risk factor or complication during antenatal care. (Table 3)

Table 3 Bivariate and multivariate logistic regression analysis of the likelihood of knowing one or more danger sign during pregnancy, during delivery and following delivery.

Full size table

Discussion

In this rural district in Tanzania, almost half of the women were not aware of any danger sign of obstetric complications which is the sign of low awareness. A higher level of education was the most vital predictive factor for increased awareness of danger signs. Other factors associated with increased awareness included multiparity, age, more than thở four antenatal care visits, and lady informed of having a risk or complication during antenatal care visits.

Most women attended antenatal care where they should gain been informed about danger signs. However, a limitation of this study is that women were not asked of the source of information of the danger signs. Therefore it is challenging to lớn choose whether their information advance from the antenatal care, personal experiences or general awareness in the community. Moreover, despite choosing the women who had pregnancy in the final two years there could be still room for the recall favoritism of the experiences in their final pregnancy.

Women were more aware of danger signs occurring following delivery than thở during pregnancy and labor/delivery. Severe vaginal bleeding following delivery was the most recognized danger sign, and was mentioned twice as often as other signs, such as vaginal bleeding during pregnancy and delivery, anemia, and fits in pregnancy. Higher awareness of vaginal bleeding following delivery is also reported in a destitute fishing community in Karachi, Pakistan [14]. The folly excessive vaginal bleeding following delivery is most commonly recognized as a danger sign may be that it is the most visible sign and the most common cause of maternal death immediately following delivery [5, 15]. Furthermore, the mean interval from the onset of severe bleeding to lớn death is two hours in contrast to lớn an usual of 12 hours for bleeding during pregnancy and delivery [15].

Few women were aware of prolonged labor as an obstetric danger sign despite its association with both maternal and fetal morbidity and mortality. In a study in The Gambia, involving urban and rural women attending antenatal care, prolonged labor was not recognized as a danger sign [16], a similar finding was reported from Malawi [17]. However, a study in Pakistan [14] reported that 23% of women are aware of this danger sign. The contrast in information observed is challenging to lớn elaborate but it may be due to lớn how interviews were conducted, whether prolonged labour is one among danger signs women are counseled during antenatal care or insight of prolonged labour in these culturally exceptional areas.

Increased awareness among older and multiparous women may be related to lớn their own experiences of pregnancy or events in the community. Women's own experience was an vital source of information, as women who had experienced obstetric risk or complication in their final pregnancy were more aware of danger signs. This implied that adolescent women in their initial pregnancy may need more consideration when providing counseling and health education.

Women who had completed primary education had higher awareness of danger signs than thở women with incomplete or no formal education. Better education is associated with enlightenment and awareness of exceptional health conditions although exposure to lớn information is crucial [17]. Studies in Tanzania and elsewhere indicate that a higher level of education is associated with lower maternal mortality [4, 18, 19] whereas other studies gain shown no association [20, 21]. Despite these conflicting results, we still convinced that women's education is vital for understanding health messages and to lớn be skilled to lớn build decisions regarding their health and care. Introducing appropriate Safe Motherhood information in primary schools to lớn girls earlier they become pregnant may further improve women understanding of health messages including awareness of danger signs of obstetric complication [22].

In this study, 98.4% of the women had attended antenatal care. Women who made four or more antenatal care visits were more aware of danger signs, independent of gestational age at booking. It is worth noting that women advised to lớn deliver in hospital due to lớn risk identified during antenatal care were not more aware of danger signs than thở those not advised. Provision of information aimed at increasing awareness of risk factors and danger signs in pregnancy is a challenge to lớn antenatal programs and the difficulties involved should not be underestimated. A recent Cochrane [23] review failed to lớn find elevated quality evidence for the benefit of antenatal education for child beginning. Furthermore, a literature review of qualitative studies concluded that interaction between tolerant and nurse has a complicated and multifaceted nature [24]. Studies from The Gambia, Nepal, Tanzania and Zimbabwe, report that less than thở three minutes are spent on individual counseling per consultation in antenatal clinics [16, 25–27], whereas, simulation of FANC in Tanzania shows that the essential time to lớn supply appropriate information is 15 minutes [26]. It is recommended that the sociocultural aspects should be taken into trương mục in contemporary concepts of information, education and communication (IEC) [28].

In addition to lớn the antenatal and postnatal care counseling, other sources of information including community-based radio messages and educational sessions for women's groups, husbands, mothers in-law, and other family members, who play an vital role in the decision making process, require strengthening [7, 29]. Further studies on the quality of counseling on danger signs and utilization of health services, and appropriate training modalities for health workers are needed. Qualitative approaches, such as in-depth interviews, can be used to lớn explore how women perceive the information given.

Conclusion

In this study, although bulk of the women attended antenatal care but generally had low awareness of danger signs of obstetric complications. Better awareness of danger signs was strongly associated with higher level of education of the lady.

We propose the following in order to lớn increase awareness of danger signs of obstetrical complications: To improve quality of counseling to lớn women on health messages particularly danger signs of obstetric complication, and involving husbands and other family members in antenatal and postnatal care; to lớn employ radio messages and educational sessions targeting the complete community and to lớn intensify provision of formal education as emphasized in the second millennium development goal to lớn enable women better understand information given.

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Pre-publication history

  • The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2393/9/12/prepub

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Acknowledgements

Special thanks depart to lớn the research assistants involved in data collection. The study was funded by the Swedish International Development Cooperation Agency (Sida/SAREC) through MUHAS reproductive health research program.

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Author notes

    Authors and Affiliations

    1. Department of Obstetrics and Gynecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Phường. O. Box 65117, Dar es Salaam, Tanzania

      Andrea B Pembe

    2. Department of Community Health, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Phường.O. Box 65015, Dar es Salaam, Tanzania

      David Phường Urassa

    3. International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, SE-751 85, Uppsala, Sweden

      Andrea B Pembe, Anders Carlstedt, Gunilla Lindmark & Elisabeth Darj

    4. Department of Surgery, Central Hospital, 65230, Karlstad, Sweden

      Anders Carlstedt

    5. Department of Public Health and Clinical Medicine, Umeå University, SE-901 85, Umeå, Sweden

      Lennarth Nyström

    Corresponding author

    Correspondence to Andrea B Pembe.

    Additional information

    Competing interests

    The authors declare that they gain no competing interests.

    Authors' contributions

    ABP participated in the design of the study, data collection, performed statistical analysis and drafted the initial manuscript. DPU participated in design of the study and data collection. AC participated in design of the study and helped to lớn draft the manuscript. GL participated in design of the study and reviewed the manuscript. LN participated in design of the study, helped to lớn performed statistical analysis and interpretation. ED conceived of the study, participated in the design and helped to lớn draft the manuscript. All authors read and approved the conclusive manuscript.

    David Phường Urassa, Anders Carlstedt, Gunilla Lindmark, Lennarth Nyström and Elisabeth Darj contributed equally to lớn this work.

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    Pembe, A.B., Urassa, D.P., Carlstedt, A. et al. Rural Tanzanian women's awareness of danger signs of obstetric complications. BMC Pregnancy Childbirth 9, 12 (2009). https://doi.org/10.1186/1471-2393-9-12

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    Keywords

    • Antenatal Care
    • Danger Sign
    • Vaginal Bleeding
    • Obstetric Complication
    • Postnatal Care

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