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Background: Maternal mortality can be particularly high in conflict and chronic emergency settings, partly due to inaccessible maternal care. This paper examines associations of refugee-led health education, formal education, age, and parity on maternal knowledge, attitudes, and practices among reproductive-age women in refugee camps in Guinea. Methods. Data comes from a 1999 cross-sectional survey of 444 female refugees in 23 camps. Associations of reported maternal health outcomes with exposure to health education (exposed versus unexposed), formal education (none versus some), age (adolescent versus adult), or parity (nulliparous, parous, grand multiparous), were analysed using logistic regression. Results: No significant differences were found in maternal knowledge or attitudes. Virtually all respondents said pregnant women should attend antenatal care and knew the importance of tetanus vaccination. Most recognised abdominal pain (75%) and headaches (24%) as maternal danger signs and recommended facility attendance for danger signs. Most had last delivered at a facility (67%), mainly for safety reasons (99%). Higher odds of facility delivery were found for those exposed to RHG health education (adjusted odds ratio 2.03, 95%CI 1.23-3.01), formally educated (adjusted OR 1.93, 95%CI 1.05-3.92), or grand multipara (adjusted OR 2.13, 95%CI 1.21-3.75). Main reasons for delivering at home were distance to a facility (94%) and privacy (55%). Conclusions: Refugee-led maternal health education appeared to increase facility delivery for these refugee women. Improved knowledge of danger signs and the importance of skilled birth attendance, while vital, may be less important in chronic emergency settings than improving facility access where quality of care is acceptable. © 2011 Howard et al; licensee BioMed Central Ltd.
Methodology was published in detail elsewhere [13]. Maternal healthcare as used here focuses on the continuum of care during antenatal, natal, and postnatal periods [8]. The target population was female refugees of reproductive age (15 to 49) from an estimated population of 125,000 women living in 48 camps across Guinea’s Forest Region where RHG had been active for four years. Sampling was multi-stage. First, 45 clusters of households were randomly selected in 23 camps, with probability of selection proportional to camp size. Second, a stratified sample of ten women per cluster was randomly selected from household lists. Sample size was calculated to detect a difference of 10% versus 20% between strata of equal size with 80% power and 95% confidence level (95%CI), accounting for clustering. Participation was voluntary, with no reimbursement beyond travel costs. Ethical approval was provided by the Ministry of Public Health in Guinea and the London School of Hygiene & Tropical Medicine (LSHTM) in the UK. The questionnaire was adapted from those used and validated in similar developing-country settings and piloted in a camp excluded from the study [13]. Additional questions were added relevant to specific RHG maternal health education content. To improve reliability, questions were read verbatim in English, the language used by most respondents, and only translated or rephrased if a respondent did not understand. Prompting was only used for certain questions where multiple answers were possible (e.g. danger signs for pregnant women). Female interviewers were recruited from the refugee community, trained for four days, and given instruction on issues including privacy, prompting, and translations. Data was double-entered in Epi-Info™6, with range and consistency checks to reduce transposition error [13,14]. Analysis was conducted using Stata®11. Associations of maternal health variables with exposure to RHG facilitators, parity, education level, and age, were analysed using logistic regression. The study assessed maternal knowledge, attitudes and practices of women on topics previously taught through RHG activities. Exposure to RHG-led health education was categorised as exposed if participants reported their main source of family planning (FP) information as an RHG facilitator or drama group and unexposed if not. Women receiving family-planning advice also received pregnancy-related information. Authors also used arrival at camp before or after 1996 as a comparative proxy, as all participants who had been in camp prior to 1996 could be assumed to have been exposed to RHG activities [13]. Formal educational attainment was categorised as some (any primary education or more) or none (no formal education). Education was selected as it is a social determinant of health, positively affecting knowledge, social skills, and discussion about health, all of which better equip women to access and use health information and services [15]. Women with some formal education could be expected to have improved knowledge, attitudes and practices compared to women without any formal education. Age was categorised as adolescent (15-19) or adult (20-49). Age was explored because adolescents have specific reproductive needs that are often not as well-addressed as those of women 20 years and above [16]. For example, young mothers’ physical immaturity heightens their risk of mortality or morbidity from obstructed labour, fistula, and premature birth [17]. Parity was categorised as nulliparous, parous or grand multiparous (having delivered five or more infants), the last being considered a risk factor in subsequent pregnancies. Parity was explored because it seemed logical that women who have given birth would have increased maternal knowledge and possibly different attitudes and practices. Previous research in this population showed parity had a significant association with FP knowledge, indicating it might have a significant association with general reproductive health knowledge and practices [13]. Period of arrival in camp was categorised as pre-1996 or post-1995 to account for different waves of migration. Location of most recent delivery was categorised as home (i.e. with or without skilled assistance) or facility (e.g. delivery at a hospital, health post, or health centre with skilled assistance). Home deliveries typically took place without the assistance of a skilled birth attendant [6]. Obstetric need was defined as having experienced penetrative sex and not currently abstaining or using any modern family planning method, as this could lead to pregnancy and the need for maternal healthcare. Clustering was accounted for using robust standard errors. Potential confounders, including RHG exposure, age, formal education, arrival period in camp, religion, and marriage age, were selected according to published literature on maternal health and refugees and expert discussion. To maintain the strength of multivariate models, potential confounders (except marriage age and religion) were coded as binary after determining that this did not alter odds ratios (ORs). Confounders were retained in multivariate models if they changed odds ratios by at least 10%.
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