Background
Knowledge of obstetric danger signs and birth preparedness are strategies aimed at enhancing the utilization of skilled care during low-risk births and emergency obstetric care in complicated cases in low income countries [
1,
2]. The presence of skilled attendants at births and availability of emergency obstetric care have been shown to greatly reduce maternal deaths due to obstetric complications [
3‐
5]. The above-mentioned success, however, depends on a functional referral system from rural communities to health facilities [
6]. Facilities with skilled attendants and functional emergency obstetric care services are in most low-income countries located in urban centres whereas the majority of the population live in rural areas. Most maternal deaths in resource poor countries such as Uganda where the actual study was conducted, are attributed to the three delays; delay to make a decision to seek care, delay to reach place of care and delay in receiving appropriate and adequate care [
7].
With the assumption that "every pregnancy faces risks" [
8,
9], women should be made aware of danger signs of obstetric complications during pregnancy, delivery and the postpartum [
1,
10]. The knowledge will ultimately empower them and their families to make prompt decisions to seek care from skilled birth attendants [
11]. Moreover, in order for women to reach the place where appropriate care is provided, certain preparations prior to birth are required. Birth preparedness for a woman entails identifying a skilled attendant/health facility with delivery services, making transportation plans, saving money and identifying a blood donor [
1]. The practice of individual women identifying blood donors is, however, discouraged in high HIV/AIDS prevalence countries where voluntary donation to centralised blood banks is preferred [
12,
13].
Studies conducted among women in Tanzania [
11], Ethiopia [
14] and Burkina Faso [
15] indicate low levels of awareness of obstetric danger signs during pregnancy, delivery and postpartum. Similarly studies have also indicated low rates of birth preparedness among women in Kenya [
16], Ethiopia [
14,
17] and Burkina Faso [
15]. The low awareness of danger signs coupled with lack of preparedness contributes to the delay in seeking skilled care henceforth leading to high levels of maternal mortality and morbidity.
With a maternal mortality ratio estimated to range from 215 to 558/100,000 live births [
18‐
20] and with only 42% of women assisted by skilled attendants during birth [
20], Uganda is one of the countries still facing the burden of unsafe motherhood. The country target derived from the Millennium Development Goal five (MDG 5) to reduce maternal mortality ratio to 131/100,000 live births may not be achieved unless well-designed and focused interventions are instituted [
21]. The government of Uganda has embarked on a road map to accelerate the reduction of maternal/neonatal mortality and morbidity so as to achieve the MDG 5 [
22]. One of the strategies laid down in this roadmap is to empower communities to ensure a continuum of care between the household and the health care facility. This will be done by promoting knowledge of danger signs, birth preparedness and complication readiness [
22].
The south-western region of Uganda has consistently reported lower rates of women delivering under the care of skilled birth attendants than other regions in the country. The Uganda Demographic and Health Survey (UDHS) report of 2006 showed that skilled attendants assisted only 32% of women in the region which is lower than the national average [
20]. Interventions are being designed to accelerate improvement of maternal health through promoting increased skilled attendance at birth in the region. The study was undertaken to explore the association between knowledge of obstetric danger signs and birth preparedness among recently delivered women in Mbarara district of south-western Uganda.
Results
Seven hundred and sixty four women, who had delivered within the previous twelve months, were included in the study. Fifty two percent were residents of Kashari while 48% were residents of Rwampara counties (Table
1). The sample age range was 16 to 45 years (mean 27 +/- 6 years) and 40% were young women (16-24 years). The majority were married (95%), Christians (94%), and had lower than secondary education (75%). More than three quarters of the women did not have regular income. However, the majority came from households, which owned mobile phones (63%) or radios (84%). About 60% of the women resided in areas that were located less than one-hour travel time to a health facility offering delivery services. Two thirds of the women had ever been pregnant from 1 to 4 times while nearly a third (32%) had ever been pregnant five or more times.
Table 1
Socio-demographic and reproductive characteristics (N = 764)
County
| | |
Kashari | 389 | 51.7 |
Rwampara | 375 | 48.3 |
Location of residence
| | |
Rural | 641 | 77.2 |
Semi-urban | 123 | 22.8 |
Age (years)
| | |
<25 | 303 | 39.6 |
≥25 | 461 | 60.4 |
Marital status
| | |
Not married | 37 | 4.6 |
Married | 726 | 95.4 |
Education level
| | |
Less than secondary (low) | 588 | 75.3 |
≥Secondary (high) | 175 | 24.7 |
Occupation
| | |
Irregular income | 605 | 76.5 |
Regular income | 157 | 23.5 |
Religion
| | |
Christians | 734 | 94.5 |
Others | 29 | 5.5 |
Household assets ownership
| | |
Low (0-1) | 214 | 27.0 |
High (≥ 2) | 550 | 73.0 |
Parity
| | |
1 | 163 | 21.5 |
2-4 | 355 | 46.2 |
≥5 | 246 | 32.3 |
ANC Attendance
| | |
<4 visits | 247 | 32.4 |
≥ 4 visits | 517 | 67.6 |
Travel time to health facility
| | |
<1 hour | 418 | 59.9 |
≥1 hour | 339 | 40.1 |
More than two thirds (68%) of the women had attended the minimum recommended four visits of antenatal care and the majority had received education about danger signs (98%), where to go for complications (98%), where to deliver from (98%), identifying a skilled health professional (88%), identifying transport (97%) and saving money (98%). Regarding knowledge of key danger signs, severe vaginal bleeding was the most frequently mentioned complication by women during the following phases; pregnancy (49%), childbirth (64%) and postpartum (57%) (Table
2). Prolonged labour, which is one of the top five major causes of maternal mortality and topmost cause of morbidity in low-income countries, was only reported by 18.3%. The majority of the respondents were able to mention at least one key danger sign in the following phases; during pregnancy (51.8%), childbirth (71.8%) and postpartum (71.6%). However when the scores were combined for the three periods only 18.7% could mention at least 3 key danger signs in all three periods.
Table 2
Proportion of women who reported knowledge of key danger signs during pregnancy, childbirth and postpartum (N = 764)
Severe vaginal bleeding | 368 | 49.2 | | | | |
Swollen hands/face | 58 | 8.7 | | | | |
Blurred vision | 15 | 1.6 | | | | |
Severe vaginal bleeding | | | 484 | 63.8 | | |
Retained placenta | | | 271 | 35.1 | | |
Labour lasting more than 12 hours | | | 133 | 18.3 | | |
Convulsions/fits | | | 16 | 1.7 | | |
Severe vaginal bleeding | | | | | 449 | 56.7 |
High fever | | | | | 254 | 31.0 |
Foul smelling vaginal discharge | | | | | 75 | 9.4 |
Of the four birth preparedness practices considered in our study; 61% of the respondents had identified a health professional, 91% had saved money and 61% had identified means of transport, while 71% had bought delivery kits/birth materials during their most recent pregnancy. Overall 35% of the respondents were found to have made arrangements in 3 of the four birth preparedness practices and were classified as "well birth prepared".
Table
3 shows the association between selected socio-demographic, reproductive characteristics, knowledge of danger signs and birth preparedness. Women who were from households that had high assets ownership score were more likely to be birth prepared than those with lower household assets ownership score, though this relationship was not statistically significant (OR 1.5, 95% CI: 1.0-2.3). Attendance of antenatal care of four or more times was not associated with being well birth prepared. Women with knowledge of at least one key danger sign during pregnancy or during postpartum were more likely to be birth prepared than those without this knowledge and this relationship was statistically significant with OR 1.9, 95% CI: 1.3-2.7 and OR 2.1, 95% CI: 1.3-3.3 respectively. However the relationship regarding women who had knowledge of at least one key danger sign during childbirth or women who had knowledge that prolonged labour was a key danger sign and birth preparedness was not statistically significant. Table
4 shows stepwise multivariable logistic regression analyses performed to account for age, education and household assets ownership as possible confounders of the association between knowledge of at least one key danger sign during pregnancy or during postpartum as the main exposures and birth preparedness as the outcome. In model one age was adjusted for whereas in model two, education was introduced into the model. In model three household assets ownership score was also added to the model. The association between knowledge of at least one key danger sign during pregnancy (OR 1.8, 95% CI: 1.2-2.6), knowledge of at least one key danger sign during postpartum (OR 1.9, 95% CI: 1.2-3.0) remained statistically significant after adjusting for age, education and household assets ownership as potential confounders.
Table 3
Association between socio-demographic, reproductive characteristics, knowledge of key danger signs and birth preparedness
County
| | |
Kashari | 124/382 (31.3) | 1.0 (ref) |
Rwampara | 142/361 (39.4) | 1.5 (0.9-2.6) |
Type of residence
| | |
Rural | 237/625 (37.7) | 1.0 (ref) |
Semi-urban | 29/118 (26.5) | 0.6 (0.3-1.1) |
Age (years)
| | |
<25 | 108/292 (37.4) | 0.8 (0.6-1.2) |
≥25 | 158/451 (33.8) | 1.0 (ref) |
Marital status
| | |
Not married | 13/36 (37.4) | 0.9 (0.4-2.2) |
Married | 253/707 (35.1) | 1.0 (ref) |
Education level
| | |
Less than secondary(low) | 192/571 (32.8) | 1.0 (ref) |
≥Secondary (high) | 74/172 (42.4) | 1.5 (1.0-2.3) |
Occupation
| | |
Irregular income | 200/590 (33.5) | 1.0 (ref) |
Regular income | 66/153 (40.8) | 1.5 (0.9-2.3) |
Household assets ownership score
| | |
Low (0-1) | 63/207 (31.3) | 1.0 (ref) |
High (≥2) | 203/536 (36.6) |
1.5 (1.0-2.3)
|
Parity
| | |
1 | 58/157 (35.2) | 0.9 (0.6-1.4) |
2-4 | 130/346 (37.7) | 1.0 (ref) |
≥5 | 78/240 (31.6) | 0.7 (0.5-1.1) |
Attendance of ANC
| | |
<4 visits | 89/241 (36.7) | 1.0 (ref) |
≥4 visits | 177/502 (34.5) | 1.0 (0.7-1.5) |
Travel time from health facility
| | |
<1 hour | 146/411 (35.8) | 1.0 (ref) |
≥1 hour | 120/332 (35.8) | 0.9 (0.6-1.3) |
Knowledge of at least 1 key danger sign
| | |
During pregnancy | | |
No | 104/364 (27.7) | 1.0 (ref) |
Yes | 162/379 (42.2) |
1.9 (1.3-2.7)
|
During childbirth | | |
No | 60/210 (27.9) | 1.0 (ref) |
Yes | 206/533 (38.1) | 1.5 (0.9-2.3) |
During postpartum | | |
No | 51/195 (26.0) | 1.0 (ref) |
Yes | 215/548 (38.9) |
2.1 (1.3-3.3)
|
Knows labour lasting more than 12 hours is a danger sign
| | |
No | 219/612 (34.9) | 1.0 (ref) |
Yes | 47/131 (36.6) | 0.8 (0.5-1.4) |
Table 4
Association (Odds Ratio, 95% CI) between knowledge of at least 1 key danger sign during pregnancy/postpartum and birth preparedness. Multivariable logistic regression
Factors
| | | |
Knowledge of at least 1 key danger sign during pregnancy: Yes vs. No
| 1.8 (1.2-2.6) | 1.8 (1.2-2.6) | 1.8 (1.3-2.7) |
Knowledge of at least 1 key danger sign during postpartum: Yes vs. No
| 1.9 (1.2-3.0) | 1.9 (1.2-3.1) | 1.9 (1.2-3.1) |
Age (years): ≥25 vs. under 25
| 0.8 (0.6-1.2) | 0.8 (0.6-1.2) | 0.8 (0.6-1.2) |
Education: ≥Secondary vs. <Secondary
| | 1.6 (1.0-2.4) | 1.5 (1.0-2.3) |
Assets ownership: high vs. low
| | | 1.5 (1.0-2.3) |
Table
5 shows the result of the possible synergistic effect of age, education and household assets ownership on the relation between knowledge of one key danger sign during pregnancy and birth preparedness. A high level of education seemed to have a synergistic effect on the relation between knowledge of key danger signs during pregnancy and birth preparedness. Similarly young age also appeared to have synergistic effect on the association between knowledge of one key danger sign during pregnancy and birth preparedness. However, household assets ownership seemed to have no such synergistic effect on the above relationship.
Table 5
Analysis of effect modification between age, education, assets ownership and knowledge of at least one key danger sign during pregnancy regarding birth preparedness presented as adjusted OR with 95% CI
Less than 25 years/no knowledge of key danger sign | 43 (16.2) | 1.0 (ref) |
Less than 25 years/had knowledge of key danger sign | 65 (24.4) | 2.3 (1.3-4.1) |
≥ 25 years/no knowledge of key danger sign | 61 (22.9) | 0.9 (0.5-1.6) |
≥ 25 years/had knowledge of key danger sign | 97 (36.5) | 1.6 (1.0-2.7) |
Total | 266 (100) | |
Education/knowledge of 1 key danger sign during pregnancy | n (%) | OR (95% CI) |
Less than secondary/no knowledge of key danger sign | 76 (28.6) | 1.0 (ref) |
Less than secondary/had knowledge of key danger sign | 116 (43.6) | 1.6 (1.0-2.4) |
≥ Secondary education/no knowledge of key danger sign | 28 (10.5) | 1.0 (0.5-1.8) |
≥ Secondary education/had knowledge of key danger sign | 46 (17.3) | 3.7 (2.0-6.8) |
Total | 266 (100) | |
Household assets ownership/knowledge of 1 key danger sign during pregnancy | n (%) | OR (95% CI) |
Low assets ownership/no knowledge of key danger sign | 20 (7.5) | 1.0 (ref) |
Low assets ownership/had knowledge of key danger sign | 43 (16.2) | 2.5 (1.2-5.2) |
High assets ownership/no knowledge of key danger sign | 84 (31.6) | 1.9 (1.0-3.6) |
High assets ownership/had knowledge of key danger sign | 119 (44.7) | 3.4 (1.8-6.5) |
Total | 266 (100) | |
Table
6 shows the result of the possible synergistic effect of age, education and household assets ownership on the relation between knowledge of at least one key danger sign during the postpartum period and birth preparedness. A high level of education seemed to have a clear synergistic effect on the mentioned association. Young age also appeared to have a synergistic effect on the relationship between knowledge of at least one key danger sign during postpartum and birth preparedness. However, high household assets ownership seemed not to have any effect on the relationship between knowledge of key danger signs during postpartum and birth preparedness.
Table 6
Analysis of effect modification between age, education, assets ownership and knowledge of at least one key danger sign during postpartum regarding birth preparedness presented as adjusted OR with 95% CI
Less than 25 years/no knowledge of key danger sign | 21 (7.9) | 1.0 (ref) |
Less than 25 years/had knowledge of key danger sign | 87 (32.7) | 2.3 (1.1-4.6) |
≥ 25 years/no knowledge of key danger sign | 30 (11.3) | 0.9 (0.4-1.9) |
≥ 25 years/had knowledge of key danger sign | 128 (48.1) | 1.8 (0.9-3.6) |
Total | 266 (100) | |
Education/knowledge of 1 key danger sign during postpartum | n (%) | OR (95% CI) |
Less than secondary/no knowledge of key danger sign | 37 (13.9) | 1.0 (ref) |
Less than secondary/had knowledge of key danger sign | 155 (58.3) | 1.7 (1.0-2.9) |
≥ Secondary education/no knowledge of key danger sign | 14 (5.3) | 0.9 (0.4-2.0) |
≥ Secondary education/had knowledge of key danger sign | 60 (22.6) | 3.7 (1.8-6.4) |
Total | 266 (100) | |
Household assets ownership/knowledge of 1 key danger sign during postpartum | n (%) | OR (95% CI) |
Low assets ownership/no knowledge of key danger sign | 13 (4.9) | 1.0 (ref) |
Low assets ownership/had knowledge of key danger sign | 50 (18.8) | 1.7 (0.7-4.0) |
High assets ownership/no knowledge of key danger sign | 38 (14.3) | 2.5 (1.0-5.9) |
High assets ownership/had knowledge of key danger sign | 165 (62.0) | 3.6 (1.6-8.1) |
Total | 266 (100) | |
Discussion
Our results show a clear association between knowledge of key danger signs during pregnancy or during the postpartum period with birth preparedness among women in rural areas of Mbarara district. The association remained statistically significant even after controlling for possible confounding of age, education and ownership of household assets. A surprising finding in our study was lack of a clear association between knowledge of danger signs during childbirth and birth preparedness. This may be explained by sub-standard health education offered by health care professionals; especially during antenatal care visits. A study conducted in eastern Uganda on the quality of antenatal care provided by midwives found the quality to be poor as less than half of antenatal clinic exit clients interviewed were able to spontaneously recall warning signs of pregnancy complications. About 40% had not been advised where to deliver and that staff were allegedly unfriendly [
25]. Another study conducted in the neighbouring district of Rakai [
26] reported that most women attended antenatal care to get the ANC card which would grant them access to the health unit or hospital in case of complications. According to our knowledge, there are no published studies conducted in Uganda, which have explored the relationship between knowledge of key danger signs during pregnancy, childbirth and birth preparedness. However studies conducted in Ethiopia [
14] and in India [
27] found no significant association between key danger signs and birth preparedness after multivariate analyses.
In our study high level of education was found to modify the relationships between knowledge of key danger signs during pregnancy/postpartum and birth preparedness in a synergistic direction. The explanation for this finding could be that women who have attained high levels of education are able to better understand the health messages acquired from various sources. Similarly studies conducted in other countries have separately showed a clear relationship between high education and awareness of danger signs in Tanzania [
11] and in Kenya [
16]. High levels of education among women have also been associated with increased birth preparedness practices in Ethiopia [
14,
17] and Kenya [
16]. General programmes promoting education of the girl child such as universal secondary education currently being implemented in Uganda [
28] would go a long way in promoting better maternal health if safe mother hood is promoted in the syllabus. In our analyses young age was also found to have a possible synergistic effect on the association between knowledge of key danger signs during pregnancy/postpartum and birth preparedness. In support of this observation, the Uganda demographic and health survey 2006 report indicated that young women below the age of twenty years had higher rates of antenatal care attendances and deliveries assisted by skilled birth attendants than older women [
20].
The prevalence of birth preparedness of 35% estimated in our study appears to be higher than what was reported from Kenya 7% [
16], or 20%- 22% reported in studies from Ethiopia [
14,
17] but lower than 48%, which was reported by a study conducted in India [
27]. It is difficult, however to compare our study findings with those from other as the measures used to determine birth preparedness had some variations and the general environments differed somewhat. Nevertheless, the underlying principles regarding birth preparedness are the same and the methods used to study birth preparedness are similar. The most common birth preparedness practice observed in our study was saving money, which may be explained by the fact that both women and their partners know that money is required to facilitate referral in case of complications. Other studies on birth preparedness in Ethiopia [
14] and India [
27] have reported similar findings. Studies conducted in Burkina Faso [
15] and in Ethiopia [
17], however, found that most women had identified skilled birth attendants and health facility as the main birth preparedness practices respectively.
Knowledge of key danger signs is essential for motivating women to seek skilled attendance at birth and also to seek referral in case of complications [
11]. In our study the prevalence of knowledge of at least three key danger signs during the three phases; pregnancy, childbirth and postpartum was very low (19%). This may indicate that key danger signs are not emphasised during antenatal care, as our study shows that the majority of the respondents (68%) had attended at least four antenatal care visits during their last pregnancy. Few studies are published on the effectiveness of ANC education however a Cochrane review [
29] failed to establish the effectiveness of antenatal education on childbirth and parenthood. Severe vaginal bleeding during pregnancy, childbirth and postpartum was the key danger sign reported by most respondents which may be an indication of awareness by women that bleeding is the main and fastest cause of maternal mortality. However prolonged labour which is a major cause of mortality and debilitating mortality in south-western Uganda [
30] was only known by a small proportion of women as a key danger sign in this study. This finding, however, of low knowledge of prolonged labour as a danger sign, is not unique to our study. Studies conducted in eastern Uganda [
25], The Gambia [
31] and Tanzania [
11] have similarly reported that women appear to be unaware of the risk they take by subjecting themselves to prolonged labour in the community.
The finding of high prevalence of mobile phones and radios in households is an opportunity to be exploited by intervention programmes on safe motherhood programmes. Through innovative approaches the mobile phones can be used as channels of providing a continuum of care between families and health care workers. The use of mobile phones has already proved successful in HIV programmes in Uganda [
32].
Every woman should be made aware of the likelihood of complications during pregnancy, childbirth/labour and the postpartum periods. Women and their spouses and community members should be availed all the information on danger signs. Our findings indicated low levels of knowledge of danger signs and low levels of birth preparedness (35%) in the rural population studied; however, the same findings would most likely apply to different parts of the country with slight variations. Interventions targeting improvement of maternal health need to consider the quality of antenatal care, including the quality of information offered to pregnant women and their spouses. Knowledge of key danger signs needs to be given priority as it prepares the women and their families for timely and appropriate decision making in case of complications whereas birth preparedness offers readiness to reach health facilities for normal or complicated childbirth.
Study Limitations
It is possible that there may have been different degrees of recall bias between women who did have complicated pregnancies and those who had uneventful ones. If women with low level of knowledge were more prone to have complicated pregnancies and also better recalled the advices given, this would bias the findings towards the null. However, recall bias could theoretically have worked in the opposite direction as well, i.e. so that the found differences were inflated. Taking this uncertainty into account, we find it unlikely that recall bias distorted our finding to any important degree. There is likelihood that the birthing experience of some women could have modified their responses to questions on knowledge of danger signs or birth preparedness but this could not have adversely affected the findings observed in this study. The explanation is that birth outcome was not an outcome variable in the study. Moreover, it is not feasible to handle the mentioned situation as confounding since it could just as well be a mediating mechanism, since the outcome was determined at the time of the interview. Selection bias was minimised by the random method used to select 112 villages, which were spread out in the various parts of the two counties. The sample of women in our study, most likely represent the population of recently delivered women in rural Mbarara district. Confounding was controlled for in the analysis by stepwise multivariable logistic regression. Possible confounders were introduced into the regression stepwise and they did not have significant effect on the association between knowledge of at least one key danger signs during pregnancy or during postpartum and during birth preparedness.
Acknowledgements
Funding for this study was made possible through grants offered by Global Health Research Initiative (GHRI), Swedish International Development Agency (Sida) and Health Child Uganda (HCU). The authors are grateful to the respondents who offered their time to participate in this study. Special thanks go to the following research assistants who participated in data collection and data entry; Phionah Kyomuhendo, Bruce Natukunda, John Baptist Mwebesa, Angella Natukunda, Bob Harold Ashabahebwa, Innocent Tukashaba, Joanita Tumwikirize, Godwig Atuhaire, Angel Kyompaire, Elizabeth Ayebazibwe, Peace Nagyemba, Eleanor Byaruhanga and Edmund Akatuhamya.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
JK participated in the study design, data collection and analysis. JK wrote the first draft. P-OO participated in the analysis and reviewed the manuscript. ET participated in data collection and performed statistical analysis. KOP participated in the study design and reviewed the manuscript. All authors read and approved the final manuscript.