Knowledge and Associated Factors of Obstetric Danger Signs among Pregnant Women at Tumu Government Hospital: A Health Facility Based Cross-Sectional Study

Introduction

Pregnancy is crucial period in women and requires critical medical care [1]. During pregnancy, expectant mothers are exposed to obstetric danger signs that worsen their wellbeing and that of the baby [2], leading to maternal and neonatal mortalities particularly in underdeveloped regions of the world [3]. Given that maternal mortalities arising from obstetric danger signs are on ascendency particularly in underdeveloped countries who are hardest hit, in spite of these signs being preventable when detected earlier [4]. The sustainable development goal three. [3] which aimed at reducing avoidable pregnancy related deaths to <70 per 100 000 live births and neonatal mortality to 12 per 1000 live births [5], in addition to the introduction of antenatal care in the 20th century as a strategy to ensure early prevention and management of pregnancy associated complications [6]. Per this, it is expected that, every pregnant woman is aware of the onset of dangerous obstetric conditions, helping pregnant mothers to make the rightful decisions by taking appropriate health intervention and prompt care to improve of their health [3].

Worldwide, thousands of pregnant women lose their precious lives due to pregnancy associated complications [7]. Evidently, on daily basis about 830 pregnant die due to pregnancy danger signs and about 66% of these deaths occurs in Sub-Saharan Africa [3, 8]. Nearly 15% of pregnancies that end in obstetric complications such as bleeding, pre- eclampsia and infections contribute to global estimate of 10.7million of maternal mortality over last two decades [9]. Available data indicates that, the poor knowledge of pregnant women on obstetric danger signs is a major determinant of pregnancy complications in Africa [10, 11, 12]. Additionally, it is revealed that, the inadequate knowledge of expectant mothers on pregnancy danger signs contributes to poor pregnancy health outcome [4, 13]. In Ghana, available evidence found that, the increase in maternal death despite significant interventions such as focused antenatal care and routine clinical care are attributed to mother’s inability to recognise obstetric danger signs particularly those in rural settings [14].

Although, Ghana had recorded a significant improvement in enhancing maternal knowledge on pregnancy danger signs, available literature established in the northern part of Ghana indicated that, about 45% of pregnant women are unable to recognise obstetric danger signs, making them unable to report to early antenatal care [15]. Expectant mothers accessing health care at the Sissala East District is still battling with challenges of obstetric complications. For the past two years, there had been an increase of obstetric danger signs of expectant mothers from 13.3% to 16.3% at the Tumu Government Hospital contributing to both maternal and neonatal complications. Additionally, there is dearth of data on expectant mother’s knowledge on obstetric danger signs [16]. To address these gaps, this study aimed at determining knowledge and associated factors of obstetric danger signs among pregnant women at the Tumu Government Hospital, so that appropriate interventions and policies would be instituted to increase expectant mothers understanding and early recognition of obstetric danger signs.

Results

The study involved 399 pregnant women and there was a 100% response rate. The mean age of participants was 27±6.0 years. About 33.3% (n=133) of the participants were between the ages 18-23 years whilst 42.6% (n=170) fell between 24-30 years and 18.8% (n=75) of the participants fell between the ages 31-36 years. About 54.1% (n=216) of the participants lived in a rural area whilst 45.9% (n=183) resided in urban settings. Concerning respondent’s marital status, 79.9% (n=319) were married. With regards to level of education, about 29.6% (n=118) had basic education, 25.8% (n=103) had secondary education and 24.8% (n=99) had tertiary education. About 42.9% (n=171) of the participants were self-employed, 25.8% (n=103) were unemployed. About 62.2% (n=248) of the participants were Sissalas’ whilst 37.8% (n=151) were non-Sissalas’. About (45.6% (n=182) of participants travelled less than 1km to reach a health facility whilst 31.1% (n=124) travelled between 2-4km to get to a health facility (Table 1).

The majority, 73.2% (n=292) of the participants initiated antenatal care late whilst 26.8% (n=107) initiated late. Most, 71.2% (n=284) of the participants were in their first trimester and 21.6% (n=86) in the second trimester. About 32.3% (n=129) were nulli-gravid and 52.1% (n=208) were multi-gravid. About 24.8% (n=99) had conceived once, 74.4% (n=297) had two or three pregnancies and 24.1% (n=96) had more than four pregnancies. With regards to participants’ birth spacing, about 74.4% (n=297) had two or three years and 19.0% (n=76) above four years. About

41.1% (n=164) had a history of obstetric danger signs whilst 58.9% (n=235) had no records of obstetric danger signs. The majority, 93.7% (n=374) of participants had counselling on obstetric danger signs. Slightly above half, 51.6% (n=206) of participants reached antenatal within 30 minutes, 35.6% (n=142) between 30 to 60 minutes. The majority, 95.5% (n=381) prefer to give birth at the health facility whilst 3% (n=12) prefer traditional birth attendants. Concerning skilled delivery of previous birth, the majority, 89.7% (n=358) of participants had professional delivery (Table 2).

The majority 367(92%) knew that anaemia was a significant obstetric danger sign while 32(8.0%) knew not. Most 347(87.0) knew weight loss was a danger sign while 52(13.0%) knew not. In addition, the majority 369(92.5%) were aware of vomiting as an obstetric danger sign while 30(7.5%) were not aware. More than half 230(57.6%) of participants knew lethargy as a danger sign while 169(42.4%) did not know. most 358(89.7%) of the participants knew about bleeding during pregnancy as a danger sign, 221(55.4%) knew pallor as a danger sign while 178(44.6%) were uninformed of yellow pallor as a complicated sign. Moreover, 274(68.7%) of the participants knew diarrhoea as a danger sign while 125(31.1%) did not know diarrhoea as a danger sign. Furthermore, 334(83.7%) participants knew about respiratory distress, 225(56.4%) about abdominal distention and 189(47.4%) knew cyanosis as an obstetric danger sign, However, 210 o (52.6%) were uninformed of cyanosis as a danger sign (Table 3).

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Participants knowledge on obstetric danger signs was scored based on a response to obstetric danger signs. The total score of knowledge on obstetric factors sums up to ten.

A respondent is said to poses Good Knowledge when the score was equal to or greater than five whilst Poor Knowledge to obstetric danger sign when the score is less than five. Most 83.0% (n=331) of participants had Good knowledge of obstetric danger signs whilst about 17.0% (n=68) of the participants had Poor knowledge of obstetric danger signs (Figure 1).

Pearson chi-square set at a 95% confidence interval was used to determine the association between knowledge of obstetric danger signs and the socio-demographic characteristics of participants. Occupation of participants associated with knowledge of obstetric danger signs [X2 =17.1, p=0.001]. However, there was no association between age, marital status, education, ethnicity, place of residence, and knowledge on danger signs (Table 4).

Table 4: Association between sociodemographic factors and knowledge of obstetric danger sign. X2: Chi-square, P: p-value, *: <0.05: Statistically significant Pearson Chi-Square set at a 95% confidence interval was used to determine the association between knowledge of obstetric danger signs and obstetric characteristics of participants. Participants’ trimester of pregnancy [X2 =85.08, p=0.001]. In addition to participants’ parity and gravidity associated with knowledge of danger signs [X2 =9.96, p=0.007], [X2 =8.0, p=0.018] respectively. Participants’ previous skilled birth associated with knowledge of obstetric danger signs [X2 =15.6, P=0.001]. Binary logistic regression set at a 95% confidence level was applied to determine the odds of relationship between the dependent and independent variables. After controlling for possible confounders, participants who had previous skilled birth were less likely to possess poor knowledge of obstetric danger signs as compared to those with no previous skilled birth and such a relationship was significant [aOR=0.266(95% CI=0.133-0.531), p=0.0001]. Participants who were in their first and second trimester of pregnancy had reduced odds of poor knowledge of obstetric danger signs [aOR=0.33(95%CI=0.012-0.71), p=0.001], [aOR=0.252(95%CI=0.094-0.672), p=0.016] respectively. Multigravida participants had decreased odds of poor knowledge of obstetric danger signs [aOR=0.30(95%CI=0.127-0.711), p=0.006] (Table 5).

Discussion

In order to assess how well pregnant women, pay special attention to improving and maintaining their health, a thorough knowledge of pregnant women about obstetric danger signs is very important, as they can recognize danger signs in pregnancy that affect their health and that of the developing foetus. This present study found that about 17.0% of the pregnant women who attended the maternity clinic had poor knowledge of obstetric danger signs. Although the knowledge deficit of pregnant women about obstetric dangers was low compared to most studies reported in the literature, it should be noted that a single reported case of obstetric dangers requires immediate medical attention and assistance. Comparing the results of this present study with other studies reported in the literature, it is found that approximately fifty percent of pregnant women had insufficient knowledge of obstetric danger signs, which did not correlate well [12]. In addition, a cross-sectional study [15] found that approximately 45% of pregnant women failed to recognize obstetric danger signs and therefore the results did not support this current study. In a cross- sectional study conducted among pregnant women to assess their knowledge of obstetric danger signs, it was found that approximately 16.8% had adequate knowledge of obstetric danger signs. This means that approximately 83.2% of pregnant women had insufficient knowledge of obstetric signs and the results do not agree well with the result of this recent study [3]. In Kenya, it is reported that few pregnant women are aware of obstetric danger signs, which also does not agree well with the result of this study [8]. Likewise, in Tanzania, it was found that about 50% of pregnant women had insufficient knowledge of obstetric danger signs and the results do not correlate well [10]. In addition, the results of a systematic review and meta-analysis in Ethiopia showed that approximately 48% of pregnant women had adequate knowledge of obstetric danger signs, and the results do not agree well with this new study [9]. Again, a cross-sectional study conducted to assess pregnant women’s knowledge of obstetric danger signs found that approximately 37.5% of participants were familiar with obstetric danger signs. This means that a significant proportion of pregnant women had insufficient knowledge of pregnancy risk signs and the results do not agree well [17]. It had been reported that approximately 57.7% of pregnant women had adequate knowledge of obstetric danger signs and as such findings do not support this present study outcome [8]. Further, it is reported that about 37.3% of the pregnant women had a good knowledge of pregnancy danger signs, which also does not collaborate well with current study findings [18]. In Ghana it is established that, about 16.4% of pregnant women had insufficient knowledge of obstetric danger signs, which supported the finding of this current study [19]. The differences in study findings could be attributed to the variations of methodologies of previous studies. The finding that the occupation of pregnant women is associated with a poor of knowledge about obstetric danger signs is consistent with the finding of a cross-sectional study conducted in Ethiopia, which found that the occupation of pregnant women contributes to obstetric danger signs [9]. In addition, a cross- sectional survey in Indonesia found that the occupation of pregnant women, plays an important role in determining knowledge of obstetric signs, supporting the results of this present study [20]. The available body of knowledge had shown that pregnant women with obstetric risk signs are influenced by their occupation, which also agrees well with the finding of this recent study [21].

Further, in a cross-sectional study conducted to determine maternal knowledge of pregnancy danger signs, it was reported that, occupation was found to have a significant association with knowledge of obstetric danger signs, which also supports the results of this present study [3]. More so, a cross-sectional study [12] found that pregnant women’s occupations are associated with obstetric dangers, and this is consistent with the findings of the new study. Similarly [22] has pointed out that pregnant women’s knowledge of obstetric signs is related to their occupation. A comparison of this report with the results of this present study shows that these results matched well. However [23] noted that there is no association between pregnant women’s occupations and their knowledge of obstetric danger signs and that these results do not support the report of this present study. Obstetric factors such as trimesters of pregnancy, parity, gravidity and prior childbirth preparation of pregnant women were found to have a significant association with poor of knowledge of pregnancy risk signs. According to [12], pregnant women with multiple pregnancies are less likely to have sufficient knowledge of pregnancy risk signs which related well to present study findings. The available body of knowledge had also indicated that pregnant women in the third trimester do not influence their knowledge of obstetric danger signs, and this did not correlate well with recent study report [8]. In addition, it has been shown that pregnant women with two or more pregnancies are more likely to have adequate knowledge of obstetric danger signs and the results are different [24]. One study [8] found that the trimester of pregnancy strongly affects pregnant women’s knowledge of obstetric danger signs, and this is consistent with the report of this recent survey. However, it is indicated that pregnant women’s parity is not related to knowledge of obstetric danger signs, and this is inconsistent with the present study report. In the Democratic Republic of the Congo, a cross-sectional study found that multigravida women significantly improve pregnant women’s knowledge of obstetric danger signs, and the results were consistent when compared to current study [13]. Parity has been reported to be an important factor in pregnant women’s knowledge of obstetric dangers, and this finding is similar to the finding of this present study [20]. A cross-sectional study by [1] had shown that parity in pregnant women was related to their knowledge of obstetric danger signs, and this also supports the finding of this current study. A safe birth is very important for every pregnant woman, as it contributes to the safe delivery of the child and the prevention of birth-related complications [25]. A study conducted by [25] found that pregnant women with earlier childbirth preparations were associated with increased knowledge of obstetric danger symptoms, and this finding supports this current study outcome. In addition [22] pointed out that a pregnant woman’s history of skilled delivery has a significant association with obstetric danger signs, and this also correlates well with the result of this present study. Pregnant women’s knowledge of obstetric danger signs is of paramount for pregnant women’s attitudes towards resorting to skilled births. A good knowledge of pregnant women of obstetric danger signs reduces the pregnant woman’s exposure to pregnancy-related complications and promotes positive maternal behavior that ensures early screening for foetal development and detection of abnormalities. However, pregnant women’s lack of awareness of obstetric danger signs results in poor recognition of pregnancy danger signs, leading to delays in referral to emergency obstetric care, which is an important predictor of maternal death. Understanding and recognizing pregnancy-related danger signs is essential for pregnant women [3]. However, the poor of knowledge of pregnant women about obstetric signs poses a serious risk to the health of the mother and the developing foetus [26]. Therefore, pregnant women who are unaware of obstetric signs are less likely to give birth at health facilities and through skilled care [13]. This contributes to putting pregnant women at increased risk of maternal and neonatal morbidity and mortality, particularly in low- and middle-income countries with inadequate health resources [3, 4, 8, 27]. For example, there is evidence that a pregnant woman’s inability to recognize signs of pregnancy is known to contribute to approximately hundreds of maternal deaths each day [3]. Pregnant women’s poor knowledge of obstetric signs increases their risk of pregnancy and delivery complications such as frequent cesarean sections [4, 28]. In addition, pregnant women’s lack of awareness of obstetric dangers is a major reason pregnant women delay seeking prenatal care, thereby reducing the use of skilled care and increasing birth complications such as stillbirth [3, 4, 10]. Moreover, the poor knowledge of pregnant women about obstetric danger signs contributes to poor maternal nutrition, which increases the risk of poor foetal growth, increased number of cesarean sections [4, 29] and neonatal jaundice in babies, which leads to poor foetal development [30], low birth weight [31], preterm delivery, prolonged labor and postpartum psychiatric disorders [31].

Conclusion and Recommendations

The study concluded that slightly less than twenty percent of pregnant women in the municipality seeking antenatal care had poor knowledge of obstetric danger signs. It was also concluded that, occupation, first and second trimester of pregnancy associates with pregnant woman poor knowledge of obstetric danger signs. Additionally, it was concluded that multigravida pregnant women were less likely to associate with poor knowledge of obstetric danger sign. The study further concluded that pregnant women with previous skilled delivery had reduced odds to influence pregnant women’s poor knowledge of obstetric danger signs. There should be intensification of health education to raise awareness of the complications of obstetric signs. Future qualitative study should be investigated into traditional practices that influences the presence of obstetric danger signs among pregnant women in the municipality.

Acknowledgement

The authors thank the pregnant women who volunteered to take part in the study. Again, the health management team and the employees of the maternity clinic of the hospital as well as everyone who contributed in various ways to the success of the study.

Conflict of Interest

The authors declare that there was no conflict of interest between them

Source of Study Funds

The authors solely financed the study.

Contribution of Authors

MOP and DH: developed the topic and drafted the introduction. FA and CAP: Developed the methodology. DH, EK, TBE and MOP: Collected and analysed the study data. DS and MOP wrote the discussion. MOP, TBE and FA: drafted the manuscript and reviewed it. All authors proof read the paper and accepted it for submission.