Rural Tanzanian women's awareness of danger signs of obstetric complications

Worldwide, in 2005, 535,900 women died from causes related to 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 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 have timely access to appropriate emergency obstetric care [5].

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

In 2002, the Tanzanian government introduced focused antenatal care (FANC), a new model of antenatal care recommended by the World Health Organization [10]. Individual counseling on birth 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 least once, thus it is expected that majority of women would have received information on danger signs of obstetric complications [2]. Despite the high 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 arrive at the referral hospitals [11]. Late or failure of women with obstetric complications to reach referral hospitals may be contributed by many reasons. One reason may be lack of awareness of significance of symptoms or obstetric complications.

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

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 important predictive factor for increased awareness of danger signs. Other factors associated with increased awareness included multiparity, age, more than four antenatal care visits, and woman informed of having a risk or complication during antenatal care visits.

Most women attended antenatal care where they should have 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 difficult to decide whether their knowledge come from the antenatal care, personal experiences or general awareness in the community. Moreover, despite choosing the women who had pregnancy in the last two years there could be still room for the recall bias of the experiences in their last pregnancy.

Women were more aware of danger signs occurring after delivery than during pregnancy and labor/delivery. Severe vaginal bleeding after 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 after delivery is also reported in a poor fishing community in Karachi, Pakistan [14]. The reason excessive vaginal bleeding after 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 after delivery [5, 15]. Furthermore, the mean interval from the onset of severe bleeding to death is two hours in contrast to an average 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 difference in knowledge observed is difficult to explain but it may be due to how interviews were conducted, whether prolonged labour is one among danger signs women are counseled during antenatal care or perception of prolonged labour in these culturally different areas.

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

Women who had completed primary education had higher awareness of danger signs than women with incomplete or no formal education. Better education is associated with enlightenment and awareness of different health conditions although exposure to 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 have shown no association [20, 21]. Despite these conflicting results, we still believe that women's education is important for understanding health messages and to be able to make decisions regarding their health and care. Introducing appropriate Safe Motherhood information in primary schools to girls before 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 deliver in hospital due to risk identified during antenatal care were not more aware of danger signs than those not advised. Provision of information aimed at increasing awareness of risk factors and danger signs in pregnancy is a challenge to antenatal programs and the difficulties involved should not be underestimated. A recent Cochrane [23] review failed to find high quality evidence for the benefit of antenatal education for child birth. Furthermore, a literature review of qualitative studies concluded that interaction between patient and nurse has a complex and multifaceted nature [24]. Studies from The Gambia, Nepal, Tanzania and Zimbabwe, report that less than three minutes are spent on individual counseling per consultation in antenatal clinics [16, 25‐27], whereas, simulation of FANC in Tanzania shows that the necessary time to provide appropriate information is 15 minutes [26]. It is recommended that the sociocultural aspects should be taken into account in modern concepts of information, education and communication (IEC) [28].

In addition to 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 important 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 explore how women perceive the information given.

In this study, although majority 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 woman.

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