Birth Preparedness and Complication Readiness Among Pregnant Women Attending an Urban Health Centre in Surat, India

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INTRODUCTION
Pregnancy and motherhood are physiological phenomenon. However, approximately 830 women die from preventable causes related to pregnancy and childbirth every day. 1 Approximately 15% of pregnant women develop life-threatening complications which are unpredictable and may progress rapidly to fatal outcome. 2 Postpartum haemorrhage and preeclampsia/eclampsia contribute to 40% of all maternal deaths. 3 Birth preparedness includes prior knowledge of key danger signs; identification of birth place, preferred birth attendant, nearest appropriate health facility, emergency expense related fund, transport and compatible blood donor for emergency use. 4 Birth preparedness and complication readiness elongates maternal and neonatal health continuum of care and thus comes up with one of the important tools for pregnant women to experience better pregnancy outcome and strengthen family and community health. 5 Programmatic approach to improve the use and ef-fectiveness of key maternal and new-born health services, which is based on the premise that preparing for birth and being ready for complications reduces maternal and neonatal deaths. 6 Women who had history of obstetric problems during the previous pregnancy were found to be more knowledgeable on danger signs related to pregnancy compared to those without any complications during previous pregnancy. Women who were knowledgeable on danger signs were four times more likely to be knowledgeable on Birth Preparedness and Complication Readiness (BPACR) as compared to those who were not knowledgeable. 7 Having Skilled Birth Attendant at every delivery has been found to markedly reduce maternal morbidity and mortality in countries such as Malaysia and Sri Lanka. 8 Birth Preparedness and Complication Readiness interventions can improve of preparations for birth and complications. 9 Sustainable Development Goals (SDG) target 3.1 set by United Nations aims at reducing global maternal mortality ratio to less than 70 per 100,000 live births. Maternal Mortality Ratio of India has declined over the years to 103 in 2017-19 from 130 in 2014-2016 10 and of Gujarat has declined over the years to 75 in 2016-18 from 91 in 2014-2016. 11 There is proof from different studies conducted in different parts of the world that enhancing BPACR improves preventive behaviour, knowledge about danger signs among mothers and leads to improvement in reducing delays in care seeking during obstetric emergency.
Literature review revealed minimal data reporting BPACR status of antenatal women in Gujarat. Therefore, this study was done to assess BPACR status among antenatal women and to study sociodemographic factors affecting BPACR among study participants.

MATERIALS AND METHODS
A facility based Cross-Sectional Study was conducted among antenatal women attendees from November 2020 to April 2021 at Urban Health Centre, Althan, Surat, India, which was chosen purposively. Due permission was obtained from health service provider (Surat Municipal Corporation), and Human Research Ethics Committee of Government Medical College, Surat. Antenatal women of more than twenty weeks of pregnancy who were availing services from UHC were included in the study. Participants who did not gave the consent were excluded. This UHC provides primary healthcare services like immunization, antenatal care, family planning, and treatment of minor ailments to the community.
A predesigned, semi-structured, pilot testing was done for pretesting of questionnaire and it was used for data collection. Proper explanation of the study to the participants was done in a local language they can understand and informed consent form was signed.
Sample size: Desk review was done before conducting this study which revealed that around 5 ANC women were attending UHTC OPD per day. Assuming three interviews per day and 20 working days per month; in 6 months of study duration, approximately 300 to 350 ANC were feasible to study after considering a drop out of 15%. A total of 310 antenatal women who attended antenatal clinic of UHC were consecutively included in the study.
Study tool: The questionnaire was divided into four sections assessing "Socio demographic details", "Awareness about danger signs", "Birth preparedness" and "Knowledge about Janani Suraksha Yojana (JSY)". Majority of the questions were close ended with multiple response and few were close ended with binary response.
Sociodemographic details included age, religion, type of family, number of family members, family's monthly income, education of participant, education of husband, occupation of participant, occupation of husband and obstetric history.
For evaluation of awareness about danger signs during pregnancy and labour.
For birth preparedness, firstly awareness about the term birth preparedness was asked. After that the constituents of birth preparedness including identification of mode of transport, saving money, skilled provider and blood donor were enquired about.
Awareness about JSY was evaluated and its benefits were enquired. BPACR index was calculated as ∑Indicator/7 Pre testing of the questionnaire was done prior to the study using a pilot test on 10 participants. Content and Face Validity was established by Expert Analysis and Discussions.
A Knowledge Score was given on the basis of parameters defining Birth Preparedness including knowledge about prior Identification of Skilled Birth Attendant, Blood Donor, Transport and Financial Savings. Participants were also asked if Birth Complications can occur to mother or baby. Each of these responses were graded 1 for Yes and 0 for No. So, Knowledge Score total was 6.
Data collection and analysis: Study Participants were explained about the study in a language they could understand. Informed written consent was obtained from the participants and they were allowed to drop out of the interview anytime. Data collection was done by face-to-face interview using data collection tool. Average duration of interview was 10-15 minutes. Interview was conducted by principal investigator. Data entry was done in Microsoft excel and analysis was done in SPSS trial version 23. Univariate analysis was done including descriptive statistics of mean, standard deviation, frequency and percentage. Bivariate analysis was done by using chi square test between birth preparedness and sociodemographic factors, p<0.05 was taken as statistically significant. Birth preparedness has been measured by making preparedness scale using four items. Participants who scored more than fifty percent were counted as well prepared and who scored less than fifty percent were counted as less prepared. 1 Binomial Logistic Regression was applied for evaluation of predictors of Birth Preparedness.

RESULTS
A total of 310 women participated in the study. BPACR index was found to be 62.3% and association between type of family and awareness about severity of health problems during pregnancy was statistically significant (p<0.01). Table 2 shows the awareness of study subjects regarding various aspects of antenatal care. Majority of participants (96.7%) were registered in first trimester. Around seven tenth (68.4%) participants taken at least four ANC visits. Table 3 shows association between sociodemographic factors and Birth Preparedness, chi square test was applied between birth preparedness and various sociodemographic factors. It revealed that there was a statistically significant association between occupation of spouse and birth preparedness. Otherwise, Education of women, Education of spouse, Occupation of women, Parity and knowledge score had no significant relation with birth preparedness level.   Participants belonging to age group of 28-32 years and Occupation of Spouse were the independent predictor for well birth preparedness in this study.

DISCUSSION
Birth preparedness component motivates people to identify skilled provider beforehand, to save money for any complication if arise in emergency, to prepare for transport and to identify compatible blood donor. This study was conducted among 310 antenatal women to understand awareness about complications and extent of birth preparedness.
In this study, BPACR index came out to be 62.3%. BPACR index of our study was lower than that observed by Sharma et al. 13 (66.9%) on the contrary it was higher than that observed by Patil et al. 14 (55.83%), Gupta et al. 15 (46.2%), Acharya et al. 12 (41%) and Mukhopadhyay et al. 16 (34.5%). This study was conducted in a health care setup with antenatal women more than 20 weeks included in this study. Participants have undergone regular checkups and counselling which might have increased their knowledge. Our study reported that majority of women (41.0%) belong to joint family followed by three generation family (33.9%) and nuclear family (25.2%). Similar results were met with the study of Acharya A et al, in Delhi, India revealed that more than half (56.6%) the subjects stayed in joint families, whereas 43.4% belonged to nuclear families showing similarity in Study settings. 12 In this study, the proportion of women aware of at least one key danger sign each of pregnancy, labor and postpartum were 98.06%, 99.35% and 93.87% respectively. However, the study by Mutiso et al. found that 67% of the respondents knew at least one danger sign in pregnancy while only 6.9% knew of three or more danger signs. 2 20 All four Birth preparedness constituents are equally important and help in risk reduction of a wide range of complications. Hence emphasis should be given to all these rather than according to convenience of preparation.
In this study, type of family was not significantly associated with birth preparedness level. However, type of family is significantly associated with birth preparedness in study by Teekhasaenee T et al. 22 In study conducted at Delhi, parity, younger age, education, joint family system, and husband's education and occupation were associated with having a birth plan 12 similarly, husband's occupation significantly associated with birth preparedness in our study. On the contrary, age, type of family, education, occupation, husband's education, parity and knowledge score were not significantly associated with birth preparedness in our study. Woman's education and her spouse's education were strong predictors of BPACR in the study done in rural Uganda 23 3 In Developing Countries, knowledge related to pregnancy and preparedness is passed on across generations or gained through experience. This might be a major reason for higher age group having better birth preparedness in this study and studies with similar study settings. Support from spouse and his ability to help in preparedness would also be a major factor for a smooth pregnancy experience.

CONCLUSION
This is a cross sectional study among 310 antenatal women. This study shows BPACR index was 62.3%. Higher Age group and Employed Status of Spouse were found to be significant predictors of Well Birth Preparedness. However, the four major constituents are not given equal significance with factors like Identification of blood donor lagging behind.

RECOMMENDATION
ANC women should be empowered by meaningful counselling for birth preparedness and complications readiness. A well planned and well-designed IEC should be created among community.

LIMITATION
This was a cross sectional study which will not reveal temporality. This study results cannot be gener-alised as Urban health centre was selected purposively.