Primigravidae ’ s knowledge about « bstetric complications in an urban health centre in Malawi

Correspondence address: Professor PA Mclnerney School of Nursing University of KwaZulu-Natal Howard College Campus P O Dalbridge 4041 Abstract: Curationis 29(3): 41-49 Pregnant women in Malawi receive information about pregnancy, labour and delivery during routine antenatal visits. This study aimed to explore knowledge of obstetric complications amongst primigravidae attending an urban health centre in Blantyre, Malawi. A descriptive study design was used. Recognition of obstetric complications in pregnancy, during labour and after delivery and actions that participants would take if they developed any complications in pregnancy and after delivery were explored. Actions that women would take for complications that occur during labour were not probed, as women have little control over actions taken when complications arise during labour.


Background
Since the 1980's various attempts have been made by various organisations to address women's health problems..The United Nations dedicated 1985-1995 as the decade for women, World Health Day in 1998 was declared Safe Motherhood Day by the World Health Organisation.The latter was an attempt to highlight the morbidity and mortality associated with pregnancy and childbirth, especially in developing countries (Lalonde 1998: 889).The Malawi mortality ratio has almost doubled at 1120/100,000 live births from 2000 to date according to available records in Malawi (National Statistical O ffice and ORC M acro 2001:181).However, WHO.UNICEF AND UNFPA (2000) estimated the maternal mortality ratio for Malawi at 1800/100,000.In 1995, in an attempt to reduce the maternal mortality, Malawi adopted the four pillars o f the Safe M otherhood Programme and established the National Safe Motherhood Initiative.The initial goal was to halve the number of maternal deaths by the year 2001.As this goal could not be attained, the date was moved to 2004.Emphassis of the Safe motherhood Programme is on improving obstetric care A chievem ents so far include development of: obstetric life saving skills trainers manual and service providers manual; obstetric management protocols and information, education and communication (IEC) strategy and materials for safe motherhood; inservice training of health workers in obstetric life saving skills, infection prevention and maternal audit; and upgrading of health facilities to equip them w ith basic amenities and provision of ambulances (Reproductive Health Unit and World Health Organisation, 2003).This is in line w ith the fo u r p illa rs o f the safe Motherhood Programme which are family planning antenatal care, clean safe delivery and essential obstetric care (Maternal Health and Safe Motherhood Programme 1994:xi).The Safe M otherhood In itiativ e in M alaw i in clu d ed com m unity participation.One of the strategies used to generate community participation were in fo rm atio n , ed u c atio n and com m unication (IEC) cam paigns on pregnancy risks and appropriate actions to take (M alaw i Safe M otherhood Programme, Malawi Safe Motherhood Project and M inistry o f H ealth and Population 2000: 5).This strategy aimed to empower individuals and families so that appropriate decisions could be made and prompt actions taken when faced with a situation.C reating com m unity aw aren ess o f obstetric complications has been found to increase w om en's use o f health services (Kwast 1995: S72; Opoku, Kyei-Faried, Twum, Djan, Browne and Bonney 1997: S205 -S206 &.Olaniran, Offiong, Ottong, Asuquo and Duke 1997: S88 -S89).T hem m en (1995: 30) and Alisjahbana, Williams, Dharm ayanti, Hermawan, Kwast and Koblinsky (1995: S84) state that women must be able to recognise the danger signs of obstetric complications for them to seek medical care.Likewise Gummi, Hassan, Shehu and Audu (1997: S 196) and Olaniran et al. (1997: S183) found th at poor knowledge of obstetric complications was a barrier to seeking health care.In Nigeria haemorrhage was considered normal for cleansing the mother after delivery (Olaniran et al. 1997: S183).Castro, Campero, Hernandez and Langer (2000:683) also make the point that some complications are considered normal.Ratsma(2001:1) found delay in reporting to a health facility as the highest (34.3%) contributing factor to maternal deaths.
Age is an important factor in maternal deaths.In 1990, Phoya et.al (Malawi National Safe Motherhood Programme, undated: 16) found that of 118 deaths maternal deaths in Malawi 33% of the women were aged between 16 and 20 years.A review of maternal deaths in the southern region of Malawi showed that 20% of the maternal deaths were below 20 years of age (Ratsma, 2001:1).G lobally, the five direct causes o f maternal deaths are due to hamorrhage, sepsis, unsafe abortion, eclampsia and obstructed labour (Abouzar, Wardlaw, Stanton and Hill 1996: 77;World Health Organization 1999:13).In 2000, M alaw i's sta tis tic s w ere co n sisten t w ith the global picture.A b o rtio n s ac co u n ted fo r 18%, haemorrhage for 24%, obstructed labour/ ruptured uterus for 20%, sepsis for 24% and eclam psia for 4% (M alawi Safe Motherhood Programme, Malawi Safe M otherhood Project and M inistry of Health and Population 2000:4).The same figures are still used up to date except th at a c o n fid e n tia l en q u iry into institutional m aternal deaths in the southern region found a slightly different pattern .P u erp eral sepsis w as the h ig h est, 20% , o b stru cted lab o u r/ ruptured uterus for 15%, haemorrhage for 11%, abortion complications for 6.4% and p re eclam p sia/ ec la m p sia for 5.1% (Ratsma, 2001:1)

Motherhood Programme
This commenced in 1996.The four pillars of safe motherhood are being addressed through d iffe re n t co m p lem en tary programmes in Malawi.The last pillar includes the use of life-saving skills and timely emergency obstetric care when the need arises.In 1998, Matinga found that people had adequate knowledge of family planning but little awareness of antenatal care and clean safe delivery and lim ited kn o w led g e o f o b ste tric complications.The latter was suported by the findings in 1998 and 1999, where needs asessm ent surveys found that there was a severe lack of IEC materials and inform ation on com plications of pregnancy and childbirth in the clinics.None o f the health w o rk ers w ho participated in the study could name the five com plications and only 18% of people in the com m unity recognised bleeding as a problem w h ilst none mentioned infection (Ngaiyaye and Safe Motherhood Project undated: 7).These findings identified the need to empower both health workers and the community through the interventions of IEC.

Problem statement
Malawi has a high maternal mortality ratio (1120 / 100 000 liv e b irth s) w ith haem orrhage, sep sis, a b o rtio n s, obstructed labour and eclampsia being the main causes of the maternal deaths.The Malawi National Safe Motherhood Programme was implemented in 1996 in an effort to reduce the high maternal mortality ratio.In 1998 Matinga found that w hilst people had an adequate knowledge of family planning, they had lim ited kn o w led g e o f o b ste tric com plications.F urtherm o re, needs assessments conducted in 1998 and 1999 revealed a lack of information materials on the complications of pregnancy and ch ild b irth in the clin ics.A study undertaken by Simpson (1998: 15)

Purpose of the study
It was against this background ih«at this study attempted to explore whether primigravidae were being provided with adequate inform ation about obstetric co m plications to e n a b le them make informed decisions.

Research Design
A descriptive research design was used to determine what primigravidae knew about obstetric complications that may occur during pregnancy, labour and the purperium.This design was appropriate to enable the researchers to determine the conditions primigravidae identified as complications for which they would seek treatment (Polit and Hungler 1997:19).

The Setting
The study was conducted in an urban health centre in Blantyre district.The district has 21 health centres, witJi eight in the urban and thirteen in the rura.1 areas.One urban and one rural health centre were randomly selected from the eight and th irte e n rural h ea lth cc n tre s respectively.In this paper the fi ndings of the urban health centre will be re ported.The findings from the rural component of the study have already been reported (Kumbani and Mclnerney, 2002).

The Population
The population consisted o f all women who were pregnant for the first tim e at the time o f the study and who were attending the antenatal clinic at an urban health centre in Blantyre.Only primigravidae w ere used in the study to elim inate th e influence o f previous childbirth experiences and since the first pregnancy is a new experience for the woman, care givers should be p ro v id in g in fo rm a tio n re latin g to pregnancy and childbirth.The antenatal clinic is one o f the sources from which pregnant women can obtain information and since 93% of pregnant women in Malawi attend antenatal clinic a.t least once in their pregnancy and 63% attend more than four times (National Statistics Office, 1994), the antenatal clinic provided a suitable population from which to draw the sample.The urban health centre had 287 primigravidae -an average of 47 primigravidae per month.

Inclusion criteria
In order to be included in the study the following criteria were identified: • That the woman was a primigravida in whom a viable outcome of the pregnancy was expected; • Her period of gestation was between 28 and 42 weeks at the time of data collection.

The sample
Purposive sampling was used to select primigravidae who met the stated criteria.M aternal a n ten a tal card s o f all primigravidae women were reviewed to identify those who were eligible to participate in the study.The sample size was determined in consultation with a sta tistic ia n .A sam ple size o f 45 primigravidae was chosen based on the assum ption that 60% had sufficient know ledge to know w hen to go to hospital and this estimate was accurate to within 10%, with a confidence level of 95%.

Research Instrument
One of the researchers (LK) developed the instrument (Kumbani and Mclnerney 2002: 47).The items soliciting obstetric complications were sourced from the existing literature.Information collected included primigravidae's demographic and obstetric data and information about obstetric complications in pregnancy, during and after birth.The interview schedule consisted of three sections.Section A contained six questions related to demographic data; Sections B and D had nine questions related to obstetric information and Section C had thirteen questions related to know ledge and actions about obstetric complications in pregnancy, during and after birth.The interview was chosen as a means of data collection because many women are illiterate and therefore unable to complete a questionnaire.

Validity and Reliability
Content validity was maintained through consultation with experts in the field.A pilot study was conducted to pre-test the reliability of the instrument.Five women who met the inclusion criteria were in terv iew ed .No p ro b lem s w ere experienced and therefore no changes were made to the instrument.In addition the researcher conducted the interviews and this promoted consistency in the way the questions were asked.

Data Collection
Data were collected over a six week period, using the research instrument which had been designed and pretested for the study.The matemals cards were re v iew ed by the re se a rc h e r and primigravidae who met the inclusion criteria were identified.These women were then approached by the midwife in the clinic and told about the study.If they were willing to particpate in the study they were directed to the researcher.The women were approached when they had completed their antenatal visit and were leaving the clinic to avoid disturbing the flow of activities in the clinic.The women who agreed to p a rtic ip a te w ere interviewed in private, in a room made av ailab le to the re searc h er for the in terv iew s.The in terv iew s w ere conducted by the main researcher (L K .).
The researcher introduced herself to the women and explained the purpose of the study.The interview m ethod was a suitable m ethod o f data co llectio n because many of the women were illiterate and w ould not have been able to com plete a se lf ad m in iste red questionnaire.Unclear responses were probed by the interviewer.All the women approached to be interviewed, agreed and data collection continued until 45 primigravidae at the urban health centre had been interviewed., 1997: 72; 53).However, the level of educational attainment did not necessarily improve the knowledge of obstetric complications am ong the urban participants.This finding suggests that in the first place, there is need for women to be given in fo rm atio n on the o b ste tric complications for them to know.The majority of the participants, 89%, were married.All the 11% participants who were single were also unemployed.Only one of the participants was employed.Information provided to this group needs to be relevant such as considering the participants socio-economic status in how they could p re v en t d elay s in reaching a health facility in case of complications.

Antenatal clinic attendance and problems experienced
Most, 80%, of the participants started attending an antenatal clinic in the second trimester while 8.9% booked in the first and five 11% in the third trimesters respectively.This indicates th at m ost w om en sta rt atten d in g antenatal clinic late, therefore there is need to establish alternative forums to com m unicate w ith w om en early in preg n an cy about the signs and symptoms of obstetric complications, and what actions women should take.The largest group of participants, 69%, had been to the clinic three to four times and two participants made the most visits (9 and above).The number of visits the primigravidae made to the clinic did not necessarily improve their knowledge of o b ste tric co m p licatio n s.T he tw o participants who made the most visits knew about obstetric com plications during pregnancy but only one of them knew about complications during and after the birth of the baby.This suggests that women need to be given sufficient inform ation for them to know about obstetric complications and when to go to a health facility.Just over half, 53%, of the participants reported that they had ex p erien ced p ro b lem s d u rin g the pregnancy.Abdominal pain was the most mentioned problem (see Table 1).Most of the participants 67% mentioned minor disorders of pregnancy as problems they had experienced.Just above half, 58%, of the participants who had problems received treatment.The participants' explanation for not getting treatment was mostly that they were not aware that they needed any treatment.This is probably because minor disorders of pregnancy

Knowledge of obstetric complications
Firstly, the participants were asked to name problems which might occur during pregnancy, labour and the puerperium.Thereafter, they w ere asked to state w h eth er c e rta in p ro b lem s w ere associated with pregnancy, labour and the puerperium.This was to cater for those participants who could have had problem s w ith the form er questions because they had forgotten.

Knowledge related to antepartum period
Fourty percent stated that they did not know of any problems that could occur during pregnancy.T his was higher com pared w ith 15% from the rural settting.The responses from the urban and rural setting differed significantly (p= 0049) w ith re sp e c t to in ad eq u a te knowledge (40% vs 15%).happening (n = 1).Two participants gave both a reason for going and the time factor.The remaining participant stated that she would inform her m other in-law if she had any problems during pregnancy.The 26 participants, who stated that they would go quickly and/or gave the reason for going, were deemed to have had access to information that would alert them to the importance of making this decision.Fifty-eight percent (95% co n fid en ce in terv al: 42-7 3 ) o f the primigravidae had some knowledge and could make an informed decision to go to the hospital.

Knowledge related to the intrapartum period
Seventy three percent of the participants did not know any problems that could occur during the birth.This was higher than the rural participants (73% vs 55%) but there was no significant difference between the two groups (p= 0.115).Bleeding was the only problem that was mostly mentioned by five participants (see Table 3).Only one participant identified fitting and none mentioned obstructed labour.Even the participants th at m en tio n ed the in trap a rtu m complications had limited knowledge as reflected by the type of responses.The p a rtic ip a n ts ' id e n tific a tio n of p roblem s th at needed im m ediate treatment was low and two participants did not know of any problems (refer F ig .2). P a rticip an ts h o w ev er gave appropriate responses as the majority, 69% mentioned obstructed labour as requiring im m ediate treatm ent and vom iting was only m entioned once.The low freq u en c y was p ro b ab ly a reflection of the participants' lack of knowledge on obstetric c o m p lic a tio n s that could occur during the birth o f the baby (Refer Table 3).All the problems presented in Fig. 2 re q u ire immediate treatm ent.This m eans that the participants were not aware of how the p re sen ted problems adversely affect pregnancy outcome.If the cause is identified basing on these beliefs it will delay the decision to seek medical care for the complication.
Information on obstetric complications should be given in such a way that it will promote awareness of problems requiring prompt treatment.A study done by the Safe Motherhood Project (1999a: 44) found no clear differentiation between serious obstetric complications needing prom pt treatm en t (d an g er signs in pregnancy) and those that did not.This ju stifie s the need to em phasise the urgency in seeking medical care when complications that need prompt treatment occur.

Knowledge related to postpartum period
The majority, 84%, of the participants could not identify problem s that could develop after delivery.
The responses from the urban and rural settin g d iffered significantly (p= 0.001) with only less than half, 45%, o f the rural participants having inadequate knowledge.The rem aining participants demonstrated limited knowledge of the actual complications that could develop because the frequency of the identified problems were very low (see Table 4).O nly four percen t the o f participants m entioned p o stp artu m haemorrhage (PPH).This finding is below the findings o f a participatory needs assessm ent done in two d istricts in Malawi, where bleeding was mentioned as a complication by only 18% of the women.However, in this study 6.7% of the participants identified sepsis, which was not m en tio n ed in th e needs assessm ent study (Safe M otherhood Project 1998:15).In response to problems that needed immediate treatment 15.6% of the participants stated that they did not know any.S epsis w as the complication that was mostly mentioned by ju st ab o v e half, 56% , o f the p artic ip a n ts.O ther co m p lic a tio n s mentioned and their frequencies are illustrated in Fig. 3.All of the problems in Fig. 3 require immediate treatment because they can result in the death of the mother.It is therefore of concern that less than 50% of participants identified PPH, fitting and retained placenta as problems needing immediate treatment.It can be assumed that this is because the participants were not aware of these complications (refer Table 4) and therefore it was impossible for them to have information about its management.Information on obstetric com plications should be provided in such a way that it promotes awareness o f problem s re q u irin g p ro m p t management.As already stated there is need for a clear demarcation between serious obstetric complications needing prompt treatment and those that do not.The primigravidae should know when and where to go w hen an o b stetric complication occurs.This may prevent  Kershbaumer (1998: 194) state that postpartum care is not val ued.They stated that a comment made regarding postpartum care was, "The baby is already born, so what is the point?"However it is important for the primigravidae to understand the im p o r tance of early management of ma ternal com plications during the puerperium .H aem orrhage and sepsis account for 48% of m ater nal deaths in M alaw i, both at 24% respectively.Primigravidae need to be informed about likely postpartum problems in order for them to recognise the problems and access care promptly.This is significant because it has been noted that women are discharged postnatally with inadequate ad vice about possible problem s, such as fever, o ffen siv e d is charge or continued bleeding (Malawi Safe M otherhood Pro gramme undated: 27).In addi tion, 75% of maternal deaths glo bally occur in the postpartum period (UNICEF 1999: 19).Twenty-four percent (95% con fidence interval: 11; 38) of the prim igravidae had some know l edge and could make an informed decision to go to the hospital.This is very low considering that timelý decision to seek care is very important in preventing ad verse effects.In conclusion, 27 (60%) of the participants had received some inform ation about preg n an cy com plications com pared with o n ly l9 (42.2% ) who had in fo r m ation on childbirth problem s.This was reflected in the p ar ticip an ts' responses during the study in that the 27 participants 47 Curationis August 2006 stated they knew about complications that could occur in pregnancy.This is in contrast to 12 (27%) and 7 (16%) of the p a rtic ip a n ts w ho knew about complications that could occur during the birth and after the birth o f the baby respectively.

Limitations
The use of only prim igravidae who attended antenatal clinics lim its the g en e ra lisa b ility o f the fin d in g s to p rim ig rav id ae w ho do not attend an ten atal c lin ic s, as w ell as to m u ltigravidae.P urposive sam pling limited a wider representation of pregnant women as they did not have an equal chance fo r in clu sio n .T h erefo re, generalisation of the results to other primigravidae is limited.Polit and Hungler (1997: 230) note that it is risky to generalise findings from a purposive sample to a broader population.The data were based on the women's ability to recall what they knew and they may not have remembered, although they were informed.The findings, therefore, should be approached with caution.

Recommendations Midwifery practice
There is need to make a clear distinction between minor disorders of pregnancy and o b stetric co m p lications during health education for women to know d iffe ren c e.It is also im p o rta n t to emphasise which obstetric complications need immediate treatment and why.These complications should be written on the maternal card in the local language, to rem ind the wom en about them.The com m unity as w ell needs to be empowered with knowledge on obstetric complications.This is important, because from the findings of this study women start antenatal care late.

Midwifery education
Students and graduates of midwifery programmes need to be given a strong component of Safe Motherhood and lifesaving knowledge and skills.This is im p o rtan t b ecau se from the study findings these women were attending antenatal care in an urban health centre but they did not have adequate in fo rm atio n about o b stetric complications.There is also a need for continued refresher courses to update health personnel on current issues about Safe Motherhood.This could ensure that relevant information is provided to the women.

Midwifery Research
The study needs to be replicated to include multigravidae and using a larger sample to enable generalisations of the results.

Conclusion
Most of the participants knew about obstetric complications in pregnancy in contrast with complications during the birth and after the birth of the baby.P rim igravidae therefore, should be provided with sufficient information on obstetric complications that may occur during pregnancy, childbirth and after birth.This m ay enable them m ake appropriate decisicions to seek care for complications when they occur.

REFERENCES
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Table 1 Pregnancy problems experienced by respondents (n = 24).
* Respondents could name more than one complication South, in Malawi.Ethical clearance from the Committee for Research on Human Subjects of the University of Witwatersrand was obtained.w om en who w ere b etter educated.Slightly more than half, 55.1%, of the women with secondary education or higher education identified abortion or stillbirth, while only 20% of women with no education and 28.9% of women with prim ary education id en tified these problems (National Statistics Office

Table 4 Problems that may occur after the birth of the baby (n = 45)
Anaemia 2.