INTRODUCTION:

Pregnancy is one of the most vital periods in every woman in their life and also for their families in which transition takes place from woman into motherhood. During this phase, every pregnant woman undergoes huge physiological changes to promote the development and growth of the fetus and to prepare the mother for labor and childbirth. Every pregnant woman is at risk of developing complications following childbirth or pregnancy, which are unpredictable and life-threatening.

Childbirth is a notable experience for every woman which can create significant impact on her physical and mental health either positively or negatively. Some women experience fear and insecurity during delivery due to scarcity of proper information regarding childbirth. Therefore, every pregnant woman should be aware of safe labor and delivery that can also affect outcome of postpartum period¹⁸.

It is reported that globally, more than 40 percent of expectant mothers may come across acute obstetrical problems. Of the 99% (286,000) of the global maternal death reported in developed countries, 16% is found in India^{27, 29}. It is also stated that more than 80 percent of maternal death is because of improper obstetric care which can give rise to obstetrical complications such as hemorrhage, infections, obstructed labor, self-induced abortions and lack of appropriate care in hypertensive pregnancy cases. A pregnant woman with other complications such as anemia, malnutrition, diabetes, hepatitis, severe cardiovascular diseases can also lead to inevitable conditions in the mother and her fetus²⁹.

Most of the maternal death occurs during pregnancy, labour and within 24 hours of postpartum period in which globally 75 percent of maternal death occurs due to medical cases that includes severe bleeding, infections, pregnancy induced hypertension, complications from delivery and unsafe abortion. In India, socio-cultural factors are also significantly contributing to the maternal death. One of the major factors related to maternal mortality during pregnancy and childbirth is delay in care seeking. When there is delay in identification of complications, decision making for seeking care, identification and reaching to the health facility and receiving proper treatment at the health facility may lead to delay in care seeking that directly contribute to the maternal death²⁷. Therefore, it is necessary to implement the birth preparedness and complication readiness (BPACR) strategies to prevent worsening of the outcome of pregnancy and to subdue the complications that occur following pregnancy.

Many studies reported that low level of BPACR among antenatal mothers and families can be one of the contributing factors which are leading to the high maternal mortality rate. Therefore, this study will help to emphasize on the elements of BPACR based on the knowledge among antenatal mothers which will be a positive step towards the reduction of maternal mortality and morbidity and promote timely access to skilled maternal health services. It will also permit pregnant women and their families to seek health care without delay in case of obstetric complications and delivery. Obstetrical complications are significant cause in the developing countries leading to maternal death. Although, these complications cannot be anticipated, it can be prevented. Therefore, it is essential to bring up different preventive approaches to defeat with them⁴. Apart from the obstetrical complications, there are other complications which exist before pregnancy and if not treated can worsen the outcome of pregnancy. Approximately 75 percent of maternal deaths are due to hemorrhage, infection, eclampsia and unsafe abortions²⁸. To improve the maternal health, there should be equal accessibility for every woman to the reproductive, maternal and newborn health care services.

The researcher in her experience has found that the pregnant women and their families are not well prepared to handle any emergency that happens during the course of childbirth. Many women are not aware of birth related risks and are not prepared to handle any deviation from normal course of events. Many of the pregnant women are not able to recognize the danger signs which could arise during pregnancy, labour and childbirth. Even though the women arrange the mode of transport and have saved money for childbirth, the most concerning and first step is to identify the danger signs following pregnancy and childbirth. If they are unable to recognize danger signs related to pregnancy and childbirth, they will not be able to seek and reach maternal health care facility at appropriate time. In many societies in the world, cultural belief and lack of awareness inhibit preparation in advance for delivery. Family tries to act only when labour begins and they don’t take any action prior to the delivery.

In India, though many awareness program or class has been conducted on birth preparedness but the accessibility to these programs are very limited. Majority of the society would not be able to reach to these classes except those high-class members of the society. In Indian population, 76.2% people belong to rural areas. So, the mothers from these areas also should be equally benefited. The best possible way to reach them is through antenatal clinics. More than thousands of pregnant women attend antenatal clinics. Hence, these women can be educated about birth preparation to attain safe motherhood and safe delivery.

The researcher also witnessed during clinical experience that the pregnant women were untrained about birth preparation. The pregnant women and family members lack knowledge towards preparation of birth and its complication and they waste a great deal of time in recognizing the problems following pregnancy and childbirth, making arrangement for emergency transport and money for delivery along with getting all physical arrangement to receive newborn and reaching to the closest health care facility. In order to propose strategies that help women and their families cope better during emergencies there is a need for education and counseling. Hence, the investigator wanted to explore the awareness of pregnant women and their attitude and practice towards birth preparedness and complication readiness.

MATERIALS AND METHODS:

A quantitative approach with descriptive design was used to assess the knowledge, attitude and practice regarding BPACR among pregnant women in the outpatient department of Obstetrics and Gynecology, CMC, Vellore. The sample size was calculated based on the study done by Ogonna ME, (2018)²¹. According to this study, awareness on birth preparedness and complication readiness among pregnant women was 64.4%. By assuming 5% precision 95% confidence level, 360 pregnant women were included in the present study.

DATA COLLECTION METHOD:

The data was collected after getting approval and permission from Head of the department, Obstetrics and Gynecology and Nursing Superintendent, CMC, Vellore. The data was collected for a period of six weeks. The investigator selected 360 samples from antenatal mothers who attended OG OPD and fulfilled inclusion criteria. The investigator visited the antenatal OPD in CMC, Vellore from Monday to Saturday and worked from 7.30am to 4.30 pm for 6 days in a week. The investigator enquired from the Medical Records Officer of the OG OPD about the antenatal women who had registered for follow up. The antenatal folder of the women was reviewed to identify the samples by using non-probability convenience sampling technique. Brief summary of self and the purpose of the study were explained to them using the participant information sheet and written informed consent was obtained from the samples. The data was collected using the structured self –administered questionnaire to assess knowledge, attitude and practice regarding birth preparedness and complication readiness. Every day, the questionnaires were administered to 10-12 samples. The entire process of data collection took 10-15 minutes for each sample.

INSTRUMENTS:

The instrument used for data collection was birth preparedness and complication readiness questionnaire which was developed by the investigator. The instrument consisted of structured questionnaires to assess knowledge and practice and three-point Likert scale to assess attitude. The Cronbach’s alpha for internal consistency of self-administered questionnaire for the assessment of knowledge was found 0.74. The questionnaire consisted of 13 items, in which the correct answer was given the score of ‘1’ and ‘0’ for wrong answer. The total score was interpreted as inadequate knowledge (0-6), moderately adequate knowledge (7-9) and adequate knowledge (10-13)⁶.

The Cronbach’s alpha for internal consistency of self-administered questionnaire for the assessment of practice was found 0.76. The questionnaire consisted of 15 items. The total score was 30. The tool was presented on a two scale of YES or NO. A response of YES was scored as 2 point and a response of NO was scored as 0 point. The total score was interpreted as well prepared (16-30) and not prepared (0-15)²¹.

The Cronbach’s alpha for internal consistency of self-administered questionnaire for the assessment of attitude was found 0.75. The questionnaire consisted of 8 items. Each response was graded according to Likert scale. Each item was scored between 0 to 2 points. The options were: 2 points for strongly agree, 1 point for agree and 0 point for disagree. The question numbers 1,2,5,6,7 and 8 represented positive statements and question numbers 3 and 4 represents negative statements. The total score was 16. The total score was interpreted as unfavorable attitude (0-8), moderately favorable attitude (9-12) and favorable attitude (13-16)⁶.

The tool was constructed by the researcher, adapted from JHPIEGO and 8 indicators given by WHO that has been widely used across different settings. Content validity for knowledge, attitude and practice questionnaire along with the objectives, blue print and the criteria checklist was submitted to one medical expert and four nursing experts in the field of obstetrics and gynaecology. Suggestions and comments given by the experts were considered and the tool was modified. Content validity index for self-administered questionnaire for the assessment of knowledge, attitude and practice was found 0.90, 0.87 and 0.98 respectively.

DATA ANALYSIS AND RESULTS:

The data was collected from 360 participants who fulfilled the inclusion criteria by using non-probability convenient sampling technique. Self-administered questionnaire was administered to the participants by the researcher to collect data and for the assessment of knowledge, attitude and practice regarding birth preparedness and complication readiness among pregnant women.

Table 1: Distribution of pregnant women based on demographic variables

(n=360)

Variables

Frequency (n)

Percentage (%)

Age (Years)

18-23

24-29

30-35

>35

198

16.4

55.0

25.0

3.6

Religion

Hindu

Muslim

Christian

Others

295

81.9

13.1

4.7

0.002

Educational status

Primary

Higher secondary school

Graduate and above

262

7.5

19.7

72.8

Income (Per month)

Rs < 1000

Rs 1000-5000

Rs 5001-10000

Rs >10000

100

201

0.3

16.1

27.8

55.8

Place of residence

Urban

Rural

173

187

48.1

51.9

Occupation

Housewife

Working Woman

307

85.3

14.7

Type of family

Nuclear family

Joint family

118

242

32.8

67.2

Table 1. Shows the frequency and percentage distribution of demographic variables of pregnant women. With respect to age, 198(55.0%) of the pregnant women were in the age group 24-29years. 295(81.9%) pregnant women were from Hindu religion and 262(72.8%) pregnant women were graduates. 201(55.8%) had an income of Rs.10000. 173(48.1%) pregnant women were residing in urban areas and 187(51.9%) pregnant women were residing in rural area. 307(85.3%) pregnant women were housewives and most of the pregnant women 242(67.2%) were from joint family.

Table 2: Distribution of pregnant women based on clinical variables (n=360)

Variables

Frequency (n)

Percentage (%)

Gravidity of mother

First

Second

Third

Fourth and above

179

146

49.7

40.6

6.9

2.8

No of living children

No child

1 Child

2 Children

3 Children and more

191

143

53.1

39.7

5.3

1.9

Total No of antenatal visits

1 Visit

2 Visits

3 Visits

4 Visits and more

234

5.8

6.7

22.5

65.0

Past Obstetrical Complications

Yes

286

20.6

79.4

Any chronic illness

Yes

288

20.0

80.0

Any treatment

Yes

308

14.4

85.6

Information received on birth preparedness and complication

readiness

Yes

169

191

46.9

53.1

Table 2. Shows the frequency and percentage distribution of clinical variables. 179(49.7%) pregnant women were primigravida and 191(53.1%) pregnant women had no children. Most of the pregnant women of about 234(65%) had more than 4 visits to the antenatal clinic. 74(20.6%) pregnant women had obstetrical complications and 72(20.0%) had chronic illness. 52(14.4%) pregnant women were on medication. Among 360 samples, only 169(46.9%) pregnant women had received information on BPACR.

Figure 1: Overall knowledge regarding birth preparedness and complication readiness among pregnant women (n=360)

Figure 1. Depicts that out of 360 pregnant women, only 145(40.3%) of the pregnant women had adequate knowledge, 117(32.5%) had moderately adequate knowledge and 98(27.2%) had inadequate knowledge regarding birth preparedness and complication readiness.

Figure 1: Overall knowledge regarding birth preparedness and complication readiness among pregnant women

Figure 2: overall attitude regarding birth preparedness and complication readiness among pregnant women (n=360)

Figure 3. Depicts that 73(20.3%) of the pregnant women had unfavorable attitude, 117(32.5%) had moderately favorable attitude and 170(47.2%) had favorable attitude regarding birth preparedness and complication readiness.

Figure 2: Overall attitude regarding birth preparedness and complication readiness among pregnant women

Table 4. Shows that 13(3.6%) of the pregnant women had not planned the place of delivery and 19(5.3%) did not arrange for transport ahead of time to go to the health care facility for delivery. 34(9.4%) of the pregnant women wanted to deliver at local health care centre as it is cheaper than tertiary care hospital and 68(18.9%) did not prefer to go to health care facility as they were not treated respectfully. 205(56.9%) didn’t want husband to accompany her whereas 45(12.5%) didn’t want mother/mother-in-law to accompany her during the time of delivery. 38(10.6%) didn’t agree that a pregnant woman should bring pregnancy reports and materials needed for delivery. 54(15%) didn’t agree that a pregnant woman should arrange for money and other expenses related to childbirth.

Figure 3: Overall practice regarding birth preparedness and complication readiness among pregnant women

Figure 3. Depicts that out of 360 pregnant women, majority of pregnant women 321(89.2%) were well prepared regarding birth preparedness and complication readiness. Only 39(10.8%) of the pregnant women were not prepared regarding birth preparedness and complication readiness.

Figure 3: overall practice regarding birth preparedness and complication readiness among pregnant women

Table 4: Subjects’ mean score on knowledge, attitude and practice regarding birth preparedness and complication readiness

Aspects	Minimum	Maximum	Mean ± SD
Knowledge score	1	13	8.32±2.95
Attitude score	5	16	11.67±2.88
Practice score	6	30	21.79±5.17

Table 4. Shows that the mean knowledge score was 8.32±2.95, mean attitude score was 11.67±2.88 and mean practice score was 21.79±5.17.

DISCUSSION:

A descriptive study was conducted with 360 participants selected by non-probability convenience sampling technique. A structured self-administered questionnaire was used to assess the knowledge, attitude and practice regarding birth preparedness and complication readiness. The data was analyzed using descriptive and inferential statistics.

Demographic and clinical variables of the pregnant women:

The demographic data of the samples in this study included age, religion, educational status, income per month, area of residence, occupation and type of family. Analysis of these variables revealed that in this study, the age of the subjects ranged from 18-40years. Majority of the respondents were in the age group of 24-29 years and the mean age of the pregnant women was 27±4.27 years. 81.9% belonged to Hindu religion, 85.3% respondents were housewives, 72.8% of the participants were graduates, 48.1% respondents resided in urban area and 51.9% respondents resided in rural areas. This current study also stated that 67.2% of the participants were from joint family.

The findings of the present study showed that 49.7% of the subjects were primi and majority of the respondents i.e., 53.1% had no children. 65% of the respondents had antenatal checkup with more than 4 visits. 20.6% of the participants had previous obstetrical complications and 20% of the participants had chronic illness in which 10.8% diabetes mellitus and 8.3% thyroid disorder. 14.4% of the respondents were on treatment, in which 0.6% of the respondents were on steroids, 0.3% anticoagulants, 0.9% immuno-modulatory drugs and 12.8% other mode of treatment. Additionally, 46.9% of the respondents received information on birth preparedness and complication readiness in which 13.7% received from internet, 32.6% from family, support or friends, 1.7% from radio or newspaper or TV and 2.8% from other sources.

A study in the year 2019 reported that only 46.1% of the participants had received information on birth preparedness and complication readiness in which 89.3% received from health workers¹³. Another study has found that majority 64.4% of the participants received information on BPACR; in which 65.9% participants received from media (Television, radio, etc), 97.8% from health workers (Doctor, Nurses), 26.3% from family, 29.3% from friends and 0.9% from internet²¹.

First objective of the study was to assess the knowledge, attitude and practice regarding birth preparedness and complication readiness among pregnant women:

The study findings showed that 27.2% (98) of the subjects had inadequate knowledge, 32.5% (117) of the subjects had moderately adequate knowledge and 40.3% (145) of the subjects had adequate knowledge with the mean knowledge score was 8.32±2.949. This study findings was supported by a descriptive cross-sectional study in which 63.6% (229) participants had good knowledge and 35.6% (128) of the respondents had poor knowledge regarding birth preparedness and complication readiness. The knowledge gap was found in community support system that included financial support system, transport system and blood donor system, which is 4.4%, 8.1% and 0.8% of knowledge score respectively²¹.

The present study also reveals that 20.3% (73) of the participants had unfavorable attitude, 32.5% (117) had moderately favorable attitude and 47.2% (170) had favorable attitude regarding birth preparedness and complication readiness and the mean attitude score was 11.67±2.882. A similar descriptive cross-sectional study was done on 115 pregnant women by using non-probability purposive sampling technique method in a primary health center and it was found that 68.7% of the participants had positive attitude and 31.3% of the participants had negative attitude regarding birth preparedness and complication readiness²⁶. There was a positive correlation between the awareness and attitude among pregnant women regarding birth preparedness and complication readiness which is statistically significant at r=0.046, p<0.05²⁶.

The present study revealed that 89.2% of the respondents were well prepared regarding birth preparedness and complication readiness and only 10.8% of the respondents were not prepared regarding birth preparedness and complication readiness with the mean practice score of 21.79±5.17. A study conducted in the year 2018 showed that 56.7% of respondents had practiced birth preparedness and complication readiness, 58% of the respondents had identified skilled provider, 59.6% saved money, 92.8% arranged transport and 99.8% selected place of delivery. There was a statistically significant association between knowledge of danger signs during pregnancy, during and following childbirth, attitude and practice regarding birth preparedness and complication readiness⁵. A study done in India, in 2010 revealed that 47.8% of the participants were well prepared for birth and its complication².

Second objective of the study was to assess the relationship between knowledge, attitude and practice regarding birth preparedness and complication readiness among pregnant women:

In this study, it was found that there was positive correlation between the knowledge and attitude regarding birth preparedness and complication readiness among pregnant women which is statistically significant with the Pearson’s correlation coefficient r=0.464, (p=0.01). A study done in the year 2008 found that there was a positive correlation between knowledge and attitude regarding birth preparedness and complication readiness r=0.029, which is significant at p<0.05 level¹⁹.

Likewise, there was positive correlation found between the knowledge and practice regarding birth preparedness and complication readiness among pregnant women which is statistically significant with the Pearson’s correlation coefficient r= 0.402, (p=0.01). Contradicting this study finding, a study revealed that there was no correlation between the level of knowledge and practice of birth preparedness and complication readiness in which P=0.321³.

The present study also found that there was positive correlation between the attitude and practice regarding birth preparedness and complication readiness among pregnant women which is statistically significant with the Pearson’s correlation coefficient r= 0.379, (p=0.01). Another study found that there was a positive correlation between attitude and practice regarding birth preparedness and complication readiness which is statistically significant at P=0.023, p<0.01³.

Third objective of the study was to determine the association between knowledge, attitude and practice regarding birth preparedness and complication readiness among pregnant women and their selected socio-demographic and clinical variables:

There was a significant association between knowledge and demographic variables such as religion, occupation, income per month and type of family. It also revealed that there is a significant association between knowledge and clinical variables such as parity of mother, no of living children, no of antenatal visits, gestational age and past obstetrical complications. In another study, it was found that there was a statistically significant association between the level of education, caste and knowledge of BPACR, p=0.006; p=0.011 respectively. Pregnant women who were literate had more knowledge of BPACR compared to those who were illiterate¹¹. This finding was similar to another studies, which stated that higher level of education is associated with adequate knowledge regarding BPACR^15,20.

The present study also illustrated that there is a significant association between attitude and demographic variables such as religion, education and type of family and number of antenatal visits. A study has found that there was statistically significant association between attitude and other demographic variables such as age, income per month, type of family, place of residence with attitude score of primigravida mothers. The respondent’s age in between 21-30 years was found to have highest level of positive attitude (92.31%) regarding BPACR followed by 31years (91.30%)¹⁷.

In the present study, it is revealed that there is a significant association between practice and demographic and clinical variables such as religion, education and type of family and number of antenatal visits. In the present study, it is observed that there is a statistically significant association between knowledge and attitude regarding birth preparedness and complication readiness, p=0.000, p<0.05. It also reveals that there is a statistically significant association between knowledge and practice regarding birth preparedness and complication readiness, p=0.003, p<0.05. It is also depicted that there is a statistically significant association between attitude and practice regarding birth preparedness and complication readiness, p=0.000, p<0.05. A cross sectional study conducted in Nepal revealed that better knowledge led to better birth preparedness status and practice. Education and counseling during ANC visits played a crucial role in birth preparedness²³.

LIMITATIONS:

· The study was limited to antenatal mothers.

· The study was limited to the pregnant women attending OG OPD, CMC Vellore.

· The study was limited to the pregnant women with gestational age 36weeks and above.

· The subjects were selected by using non-probability convenience sampling technique.

NURSING IMPLICATIONS:

The findings of the study showed that majority of the respondents had inadequate knowledge, attitude and practice regarding birth preparedness and complication readiness. The health care providers should emphasis more on education, counseling and awareness programs on different aspects and indicators of birth preparedness and complication readiness among the pregnant women.

Nursing practice:

The nurses have to encourage every pregnant woman, their families and communities in effectively planning for childbirth and dealing with any obstetrical complications or emergencies if it arises. The health care personnel need to initiate awareness programs for the pregnant women visiting antenatal clinics and provide information to improve their knowledge about birth preparedness and counsel them to identify the complications so that they will be able to seek health care facility at appropriate time without any delay.

Nursing education:

The study findings reveals that majority of the subjects had inadequate knowledge and unfavorable attitude towards birth preparedness and its complication. The nurses or midwives should be offered short-term courses by the experts on birth preparedness and complication readiness and can be appointed as nurse educator or counselor in antenatal clinics and community settings to encourage and instruct pregnant women and their families the importance of BPACR.

Nursing administrations:

The nurse administrators need to ensure availability of the necessary infrastructure, educational material and personnel for the conduct of regular awareness program on BPACR. Provision should be made for nurses working in antenatal clinics to attend continuing nursing education programs related to BPACR.

CONCLUSION:

Birth preparedness and complication readiness is a comprehensive strategy to achieve safe motherhood and is a fundamental approach to reduce the maternal and child mortality in both developed and developing countries. Education and counseling every pregnant woman is the positive step towards the reduction of maternal mortality and promotion of health and wellbeing both for the mother and newborn. Increasing knowledge offers favorable attitude and positive outcome. Birth preparedness and complication readiness should be introduced to every antenatal mother to make them aware about being prepared for giving birth as well being able to identify danger signs in order to seek early intervention and skilled care at appropriate time.

CONFLICT OF INTEREST:

The authors have no conflicts of interest regarding this investigation.

ACKNOWLEDGMENTS:

The authors would like to thank Dr. Swati Rathore, Associate Professor, Obstetrics and Gynecology Department, Unit IV CMC, Vellore for expert guidance and scholastic suggestions during the period of study in spite of her busy schedule. The investigator is extremely grateful to statistician, Dr. Thenmozhi Mani for her immense contribution and expert statistical guidance which has given meaning to my study. The investigator would like to convey her deepest gratitude to Dr. Vathsala Sadan, Dean, College of Nursing and Dr. Bala Seetharaman, Nursing Superintendent, Christian Medical College, Vellore for granting me the permission to undertake this study.

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Received on 10.12.2024 Revised on 13.01.2025

Accepted on 28.01.2025 Published on 18.02.2025

Available online from March 10, 2025

Int. J. of Advances in Nursing Management. 2025;13(1):25-32.

DOI: 10.52711/2454-2652.2025.00006

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

Items	Attitude
	Favorable		Moderate		Unfavorable
	n	%	n	%	n	%
Plan for the place of delivery	223	61.9	124	34.4	13	3.6
Arrangement of transport	188	52.2	153	42.5	19	5.3
Delivery at local health care centre	209	58.1	117	32.5	34	9.4
Don’t prefer to go to health care facility	159	44.2	133	36.9	68	18.9
Husband to accompany during delivery	42	11.7	113	31.4	205	56.9
Mother/Mother-in-law to accompany during delivery	199	55.3	116	32.2	45	12.5
Bring pregnancy reports and materials needed for delivery	228	63.3	94	26.1	38	10.6
Arrangement of money	202	56.1	104	28.9	54	15.0