The factors affecting the level of women’s awareness of birth preparedness and complication readiness in the lake zone, tanzania: A cross-sectional study

Background: The concept of birth preparedness and complication readiness (BP/CR) has continued to generate interest in the last decade. Unfortunately, there is a paucity of published data regarding this subject in Tanzania and the Lake Zone in particular. This study aimed to determine the factors affecting the level of awareness of BP/CR among Tanzanian women in the Lake Zone. Methods: Between May and June 2016, a cross-sectional study on 737 postnatal or pregnant women was conducted in the Lake Zone Tanzania. A systematic random sampling technique was employed to select the study participants. A structured questionnaire adopted from the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) questionnaire was used to collect the data. Data analysis was carried out through SPSS (v.21) using statistical tests including descriptive Statistics, Chi-square tests and Multivariate logistic regression. A significance level of 5% was considered. The odds of the occurrence of events were assessed using Odds Ratios (OR) at a 95% confidence interval (CI). Results: The majority of women were multigravida (512=69.5%) with up to three living children (409=80%). Awareness of danger signs and BP/CR was low at 40% and 35%, respectively. Predictors of the level of awareness on BP/CR were multi-gravidity (P=0.04), awareness of at least three danger signs (P<0.001), and use of public transport (P=0.01). Conclusion: Low awareness of BP/CR in this study calls for strengthened efforts from policy-makers and healthcare providers to design effective programs geared towards educating women on the importance of BP/CR that will reduce the delays of seeking care, hence reducing maternal and neonatal deaths. This is a descriptive cross-sectional study that employed a quantitative approach. The design had been selected to get a snapshot of the level of awareness on BP/CR among pregnant women attending antenatal care clinics in Nyamagana District in Mwanza City. The study was carried out form 15th May to 16th June 2016. Nyamagana District is one of the two districts in Mwanza City. It has a population of 363,452, of which 115, 337 are women of reproductive age. 29 It has 4 hospitals, 7 health centers, 17 dispensaries, 4 maternity homes, and 7 private clinics. The study sites were Nyamagana Hospital and Makongoro Health Centre (MHC), which were both facilities within the Nyamagana District. The two health facilities were purposefully selected as they have the highest referral of pregnant women in the District. The study included the mothers who had given birth within two years before the study and brought their children to the clinics for growth monitoring at the two study sites. Also, pregnant women attending antenatal care clinics who had stayed in the district for more than 6 months and expected to give birth while still in the district were included in the study. A verbal and written informed consent to participate in the study was signed by the participants before the commencement of the study. Mothers with critically ill children were excluded from the study because it was thought that they may not be able to concentrate on the questions being asked and hence may provide unreliable information. The sample size of respondents was calculated using Epi-Info version 7.1.1.14. Clients were selected by systematic random sampling method from pregnant and postnatal mothers in the RCHC at Nyamagana hospital and MHC. It was estimated that 45-50 mothers of children under two years of age and pregnant women attend MHC and 35-50 refer to Nyamagana hospital on clinic days. Using a sample interval of every second woman to get time to interview women without keeping them waiting, were interviewed 22-25 women daily at Nyamagana hospital and 17-20 women at MHC. An average of 40 women were interviewed at both sites in a day and in two-week’s time a total of 737 respondents were interviewed. The first woman to be interviewed on each day was the first woman to come at the clinic. Data were collected using a standar-dized, structured, interviewer-administered questionnaire. The questionnaire was adopted from the safe motherhood questionnaire developed by maternal and neonatal health program of JHPIEGO, affiliated to John Hopkins University, 1 with some modification based on the aim of the study. The questionnaire was pretested for validity and reliability. The items on the questionnaire were reviewed by the supervisors, colleagues and other experts for scrutiny, corrections, readability, clarity and comprehensiveness for face and content validity. The reliability of the items on the questionnaire was established using Cronbach’s alpha as a measure of internal consistency. The test has a reliability of 0.85 (F1-internal), 0.88 (F2-exaggerated) and 0.97 (F3-mediator). The BP/CR has been found to have excellent construct validity with a range of 0.85-0.95. To determine the reliability of the questionnaire, the validated version of the questionnaire was pretested with 5% of participants who agreed to take part in the pretest at Igoma health center. After pre-testing the questionnaire, Cronbatch’s Alpha was calculated using SPSS window version 21.0 to test the internal consistency (reliability) of the item and Cronbatch’s Alpha greater than 0.7 was considered as reliable. The Cronbach’s Alpha coefficient for the pretest questionnaires was 0.902 and 0.931 in the actual study implying that the items on the questionnaire correlate to each other. The questionnaire consists of five parts with a total of 42 questions. Part one of questionnaires gathered socio-demographic information of the respondents (12 questions). Part two was developed to collect information regarding obstetric characteristics of the respondents (6 questions). Part three was structured to capture information regarding the knowledge of danger signs and birth preparedness (7 questions). Part four gathered information regarding attitude towards BP/CR (8 questions) and Part five gathered information on personal experience with the last pregnancy (9 questions). The questionnaire was translated into Kiswahili language (the primary language spoken by most of the study participants) by a linguist proficient in both English and Kiswahili languages. The translated questionnaire was then reviewed by a third person who was also proficient in both languages. The questionnaire, originally written in English, was translated into local language (Kiswahili) and back to English in order to ensure that the translated version gives the proper meaning. The questionnaire was administered by two assistants (one at each site) who were trained nurses and who were also fluent in the local dialects, including Kiswahili. The assistants participated in specialized training for two days before piloting the tool. The questionnaire was pretested at Igoma health center on 5% of the sample size prior to the real data collection, which was excluded from the final study. Questionnaires were administered at the exit after receiving the health services in a special room set aside specifically for questionnaire administration at each site. This was done to allow the women to receive the services they came for first and to provide privacy during the data collection. Once the data were collected, each questionnaire was checked for completeness. Assessment of the level of awareness of danger signs: If the respondent mentioned a total of five danger signs in all three phases with at least one in each phase, that is, one danger sign during pregnancy (vaginal bleeding, severe headache, blurred vision, swollen hands/face, high fever, convulsions, loss of consciousness, water breaks without labor, accelerated/reduced fetal movements, and tiredness/breathlessness); delivery (severe bleeding, severe headache, loss of consciousness, convulsions, high fever, labour lasting >12 hours, and placenta not delivered 30 minutes after baby); and post-partum period (severe bleeding, severe headache, blurred vision, convulsions, swollen hands/face, high fever, loss of consciousness, difficulty in breathing, and severe weakness) plus at least two more danger signs from any of the three stages of childbirth, this respondent was considered to have good knowledge; otherwise, it was regarded as one with poor knowledge. 11 , 20 Assessment of the level of awareness of BP/CR: The respondent was considered to have awareness of BP/CR if she mentioned at least 3 components among five basic components of BP/CR, i.e. out of 5 options given (preparing for a place to give birth, identifying transport in case of emergency, identifying skilled attendant, saving money, and identifying a blood donor). Participants who had planned or had an intention to follow at least 4 of the five basic steps of BP/CR were considered well prepared for childbirth; otherwise, they were regarded as unprepared. Recall and interviewer bias was the potential source of bias in this study. To minimize such a bias-, we used a standardized, structured, interviewer administered questionnaire adopted from JHPIEGO to maximize the accuracy and completeness. The questionnaire consisted of closed end, easy to understand questions with appropriate response options. Also, to minimize the recall bias in this study, only mothers who had given birth within the two years before the study and brought their children to the clinics for growth monitoring at the two study sites were involved. Statistical data analysis was done using SPSS , Version 21. Categorical data were summarized using frequency distributions and the charts were used to enhance the visibility. Numerical data were summarized using descriptive statistics. Comparisons of categorical data were done using Chi-square testing attested at a statistical significance of P<0.05. The odds of occurrence of events were assessed using Odds Ratios (OR) at a 95% confidence interval (CI). Mean differences for the continuous data were tested using independent samples t-test. Study variables that were found to be statistically significant in univariate analysis were subjected to multivariate logistic regression analysis to determine the predictor variables that predict BP/CR. Ethical clearance was sought and obtained from the Muhimbili University of Health and Allied Sciences (MUHAS), Directorate of Research and Publications (Ref.No.MU/PGS/SAEC/Vol.IX). Permission to conduct the study was sought from the Regional Administrative Secretary (RAS) through the Regional Medical Officer (RMO) and Medical Officer in-charge (MO i/c) of the two health facilities selected in Nyamagana. Informed consent (verbal and written) was obtained from the respondents by reading to them the consent instructions, assuring them that their identity and the information they provided was kept confidential by having their names concealed by using codes. In participants younger than 18 years of age, informed consent was sought from parents or relatives. To minimize dishonesty, complete information was given to the participants by explaining the rationale of the research. The respondents were informed that participation in the study was entirely voluntary and they had the right to withdraw at any stage of the interviewing process with no negative impact on their future access to services at the health facility. The participants were protected following the four principals of Non maleficent, No harm to the client, Autonomy and Practicing justice.