|DR. P.C. SEN BEST PAPER AWARD
|Year : 2013 | Volume
| Issue : 3 | Page : 147-153
Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal
Dipta Kanti Mukhopadhyay1, Sujishnu Mukhopadhyay2, Sharmistha Bhattacharjee3, Susmita Nayak4, Asit K Biswas5, Akhil B Biswas6
1 Assistant Professor, Community Medicine, B.S. Medical College, Bankura, India
2 Associate Professor, Community Medicine, College of Medicine and Sagore Dutta Hospital, Kolkata, India
3 Assistant Professor, Community Medicine, North Bengal Medical College, Sushrutanagar, Darjeeling, India
4 Consultant, Community Medicine, Institute of Health and Family Welfare, Salt Lake, Kolkata, India
5 MAE, TO, SPSRC, Department of Health and Family Welfare, Salt Lake, Kolkata, India
6 Professor, Community Medicine, Institute of Health and Family Welfare, Salt Lake, Kolkata, India
|Date of Web Publication||14-Oct-2013|
Dipta Kanti Mukhopadhyay
Assistant Professor, B.S. Medical College, Lokepur, Near N.C.C. Office, Bankura - 722 102, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Birth Preparedness and Complication Readiness (BPCR) is crucial in averting maternal morbidity and mortality. Objectives: To find out awareness and practices regarding BPCR among pregnant and recently delivered women in Uttar Dinajpur, West Bengal. Materials and Methods: This is a cross-sectional, community-based, mixed methods study. Two-stage, 40 cluster sampling technique was used to select three pregnant and six recently delivered women separately. Information on socio-demographic variables as well as awareness and practices regarding BPCR were collected through semi-structured interview. In-depth interviews with one respondent per cluster were also conducted. For statistical analysis Z test was used. Results: Around 50% of the respondents planned for first antenatal check-up (ANC) within 12 weeks, four or more ANCs and institutional delivery. Proportion of women aware of at least one key danger sign each of pregnancy, labor, postpartum, and newborn ranged from 12.1% to 37.2%, whereas 58.3% knew at least one key component of essential newborn care. Around two-thirds and one-third of women, respectively, especially those from backward and below poverty line (BPL) families knew about cash incentive and referral transport schemes. Proportions of women with first ANC within 12 weeks, four or more ANCs, institutional delivery, saving money, identifying transport, and blood donor were 50.4%, 33.6%, 46.2%, 40.8%, 27.3%, and 9.6%, respectively. Hindu religion, backward castes, BPL status, and education ≥ 5 years influenced the practices except for two regarding ANC. Overall BPCR index of the study population was 34.5. Conclusion: Preparedness in health system, ensuring competence, and motivation of workers are needed for promoting BPCR among the study population.
Keywords: Birth preparedness, Complication readiness, Pregnant women, Delivered women, West Bengal, India
|How to cite this article:|
Mukhopadhyay DK, Mukhopadhyay S, Bhattacharjee S, Nayak S, Biswas AK, Biswas AB. Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal. Indian J Public Health 2013;57:147-53
|How to cite this URL:|
Mukhopadhyay DK, Mukhopadhyay S, Bhattacharjee S, Nayak S, Biswas AK, Biswas AB. Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal. Indian J Public Health [serial online] 2013 [cited 2019 May 19];57:147-53. Available from: http://www.ijph.in/text.asp?2013/57/3/147/119827
| Introduction|| |
Every year, worldwide, approximately 8 million women suffer from pregnancy-related complications and over half a million die.  Majority of these deaths could be prevented through proven, effective, and affordable actions. 
In India, several initiatives were undertaken under the National Rural Health Mission to ensure access to skilled care at birth and emergency obstetric care for complications.  It also included financial benefits for availing antenatal and intranatal care including free referral transport.  However, for optimum utilization of services, demand by women and the community is equally important. Thaddeus and Maine have documented "three delays" in seeking, reaching, and obtaining appropriate care as the crucial factors for maternal mortality.  Birth preparedness and complication readiness (BPCR) is one of the most conceptually compelling and logical means of addressing these delays.  BPCR; a strategy for care of mother and the newborn during pregnancy, childbirth, and postpartum period; includes preparation for taking action in emergencies and building an enabling environment for maternal and newborn survival.  This concept was given priority in framing national programs for maternal health. , However, two studies in rural and urban setting showed that status of BPCR indicators in India are unacceptable. ,
In this background, the present study was conducted to find out the perceptions and practices regarding BPCR at individual level and the related factors among pregnant and recently delivered women in Uttar Dinajpur district of West Bengal, India.
| Materials and Methods|| |
Study design, setting, and duration
A community-based, cross-sectional, descriptive, mix-methods study was conducted during September - December 2011, in all the blocks and Municipality of Uttar Dinajpur district.
Study subjects comprised of women currently pregnant in their second/third trimester and women who had delivered recently, that is, within the last 12 months preceding the date of survey, living permanently in the study area.
Sample size and sampling technique
As published data on BPCR in this part of the country were scarce, assuming the prevalence of 50%, 95% confidence level, 7.5% absolute precision, and design effect of 2, sample size was 342. Considering 5% non-response rate, the final sample size was 360.
Two-stage, 40-cluster sampling technique was used to select study subjects. First, villages and urban wards of Uttar Dinajpur district were listed. Then, 40 villages and urban wards were selected through probability proportional to size (PPS) sampling technique. The cluster sample size was nine. In each village, separate list of pregnant and recently delivered women was prepared with the help of local volunteers. If the total number of study subjects were less than required, the target population of the adjacent village(s) was also included in the list. From separate lists in each of these villages, six recently delivered women and three pregnant women were selected through stratified random sampling.
After taking informed consent, socio-demographic information like age in completed years, caste, religion, duration of formal education, occupation, total family income, parity, below poverty line (BPL) card holding, distance from nearest delivery hub (24 × 7) were collected with a semi-structured questionnaire. Perception and practices regarding BPCR of study subjects were assessed with a pilot-tested, semi-structured questionnaire. In-depth interviews were conducted with one study subject per cluster to explore the issues influencing their perceptions and practices regarding BPCR.
Severe vaginal bleeding, swollen hands/face and blurred vision were considered as key danger signs of pregnancy. Severe vaginal bleeding, prolonged labor, convulsions, and retained placenta were considered as key danger signs of labor.  Severe vaginal bleeding, foul smelling vaginal discharge, and high fever during first 7 days after childbirth were considered as key danger signs of postpartum period.  Key danger signs of neonates were convulsion, difficult/fast breathing, very small baby, lethargy/unconsciousness, and unable to suck/drink during first 7 days of life.  Exclusive breastfeeding, keeping the baby dry and warm, care of cord, and care of eyes were considered as four key components of essential newborn care. 
Birth preparedness and complication readiness index
To measure BPCR among recently delivered women, a set of indicators has been identified in earlier studies. , The indicators for individual level are quantifiable and expressed in percentage of women having specific characteristics. Such 13 indicators were chosen in the present study to construct BPCR index, which was unweighted average of those indicators and expressed as a score out of hundred [Box 1] [Additional file 1]. Two indicators namely four or more antenatal check-ups (ANCs) and institutional delivery were excluded in calculating BPCR index of pregnant women and study population as they were only relevant for recently delivered women. Such a scoring was found to be useful for monitoring of the situation over time and comparing with other areas.
Data were entered in MS Excel spreadsheet and the indicators were expressed in proportions. Z tests were applied to examine difference in BPCR indicators according to socio-demographic variables of study subjects.
The study proposal was cleared by the Institutional Ethics Committee of Bankura Sammilani Medical College, Bankura and the study followed the ethical standards for observational study.
| Results|| |
Filled up questionnaires of 355 study participants (117 pregnant women and 238 recently delivered women) were included in final analysis rejecting five inconsistent schedules. Mean age of respondents was 23.8 (±0.28) years. Around one-fourth (26.5%) were teenagers. Mean duration of formal education of the study subjects was 4.4 (±0.29) years among whom 36.3% were illiterate and 16.6% had formal education for 10 years or more. Around one-third (33.8%) were Muslim and 45.4% belonged to scheduled castes, scheduled tribes, and other backward classes (SC/ST/OBC). Average monthly family income of the respondents was Rupees 4432 (±392.7) and 24.5% women contributed to the family income through earning wages. Family of less than half (43.9%) of the respondents possessed BPL card, whereas according to the recommendation of the Tendulkar Committee, at least 60.8% families were BPL (Rs. 673/- per capita per month).  Average number of childbirth (both still and live) was 2.2 (±0.11) among the respondents with 42.3% primipara. A delivery hub with 24 hours delivery services was present within a distance of 5 km to 52.1% of the respondents.
When enquired about birth planning, 65.8% pregnant women and 73.9% of recently delivered women were not aware of the concept of birth planning. As shown in [Table 1], money was most commonly cited component of birth planning followed by identification of delivery hub and transport. Identification of blood donor was found to be a neglected issue and more so among pregnant women. Around half of the study women planned for first ANC within first trimester, four or more ANCs, and institutional delivery. Around two-thirds were aware of the location of nearest comprehensive emergency obstetric care facility and nearly one-third planned for postnatal check-ups.
|Table 1: Awareness and status of birth planning among study population in Uttar Dinajpur district|
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[Table 2] showed that the proportion of respondents aware of at least one key danger sign each of pregnancy, labor, postpartum, and newborn were 20.6%, 20.6%, 12.1%, and 37.2%, respectively. The socio-demographic, individual, and health service-related factors under study did not have any significant association with participants' knowledge on key danger signs. On further analysis, it was found that not a single respondent could enumerate all key danger signs of pregnancy, labor, postpartum, or newborn. Proportion of women who knew at least two danger signs of pregnancy, labor, postpartum, and newborn were 2.3%, 2.0%, 1.1%, and 3.4%, respectively. More than half of the study subjects (58.3%) were aware of at least one key component and 3.7% knew two key components of essential newborn care. Multi-para women were found to be more likely to know about it than their primipara counterpart (Z = 2.38, P = 0.017). Awareness on Government cash incentive and referral transport schemes was found among 63.7% and 38.6% respondents respectively. Hindu religion (P = 0.011 and 0.000), backward castes, that is, SC/ST/OBC (P = 0.000 and 0.000), and formal education for 5 years or more (P = 0.005 and 0.00002) were significantly associated with awareness of those two schemes. Possession of BPL card (Z = 2.38, P = 0.017) was a significantly associated factor for awareness on Government cash incentive scheme, whereas teenage (Z = 2.27, P = 0.023) and primiparity (Z = 3.01, P = 0.003) were significantly associated with awareness on Government sponsored referral transport scheme.
|Table 2: Distribution of study population according to perceptions regarding birth preparedness and complication readiness|
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[Table 3] revealed that proportion of women who had their first ANC within first trimester, saved money, identified vehicle for emergency transport, and blood donor beforehand were 50.4%, 40.8%, 27.3%, and 9.6%, respectively. Proportion of recently delivered women who had four or more ANCs and institutional deliveries were 33.6% and 46.2%, respectively. On further analysis, coverage of three or more ANCs was found to be 61.3%. Hindu women were more likely to have institutional delivery (Z = 2.48, P = 0.013), saved money (Z = 2.07, P = 0.038), identified transport (Z = 2.84, P = 0.005), and blood donor (Z = 3.05, P = 0.002). Institutional delivery (Z = 3.64, P = 0.0002), saving money (Z = 2.10, P = 0.035), and identification of transport (Z = 3.94, P = 0.00008) were more commonly noted among women of backward castes. Women having BPL cards were more likely to have institutional delivery (Z = 2.42, P = 0.015) and identify transport (Z = 3.09, P = 0.002). However, saving money (Z = 2.04, P = 0.041) was more commonly found among women without BPL card. Formal education for 5 years or more had positive association with institutional delivery (Z = 2.95, P = 0.003), saving money (Z = 2.88, P = 0.004), identification of transport (Z = 4.96, P = 0.000), and blood donor (Z = 4.33, P = 0.00001) beforehand. All practices were found to be better among women who had access to a delivery hub (24 × 7) within 5 km of their residence than their counterpart, but difference was significant in saving money (Z = 2.83, P = 0.005).
|Table 3: Distribution of study population according to practices regarding birth preparedness and complication readiness|
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Although around two-thirds of respondents (63.7%) in the present study were aware of government cash incentive scheme, only one-sixth (16.3%) could name the scheme. Among pregnant women 59.8% were eligible for Janani Suraksha Yojana (JSY) benefit but only 28.2% fulfilled the precondition of three ANCs till the day of survey and 23.1% received the cash benefit of Rs. 500/- till the day of survey. Among recently delivered women, 42.9% were eligible for JSY, 31.5% conformed to all criteria for receiving cash benefit, and 41.2% received at least one time cash incentive of Rs. 500/-. Slightly more than one-third of the study subjects (38.6%) knew about government sponsored referral transport scheme but only a small proportion (6.2%) could name it. A total of 31.7% of pregnant women and 25.6% of recently delivered women identified vehicle beforehand but only 13.0% of recently delivered women could avail it at the time of need. (Not shown in the table.)
[Table 4] revealed that the BPCR index (based on 11 indicators) of pregnant women and study population were 32.1 and 34.5, whereas BPCR index of recently delivered women (based on 13 indicators) was 35.8.
|Table 4: Distribution of birth preparedness and complication readiness indicators among study population in Uttar Dinajpur district|
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The lack of in-depth planning in antenatal period was revealed from the stage of conception; 42.9% of the pregnancies have been accidental. The most important determinant of planning the other parts of childbearing and delivery was community behavior. Muslim faith could be singled out as the factor behind so many home deliveries. It had affected the various components like saving money and identifying transport and blood donors adversely. Education, especially if accompanied by higher income and urban residence, did tilt the balance toward a more favorable outcome. However, in some of those cases, people chose private facilities for care and given the round-the-clock access, recipients desisting themselves from actively knowing (the danger signs), and planning.
Despite an acceptable level antenatal visit, in only about 4.8% cases healthcare providers discussed about the various components of birth planning. The only area that received some attention was saving money, possibly because it was related to JSY. Information from various sources, liquid cash, and procedural simplicity helped the respondents to use JSY over cashless transport. Inherent complexity of availing the transport seemed to be the deterrent in this case. Preparation for complications and postnatal care was neither promoted by health workers nor discussed in community. Preparedness on these issues was regarded necessary by, respectively, 4.8% and 8.1% of the interviewee.
BPCR practices depended on situation as in some of the rural setting, the community practice was found to be the principal reason behind paying adequate antenatal visits. A satisfied group of women advocated for institutional deliveries, especially in case of primi mothers, expecting presence of quality doctors there. In rare circumstances, if the health worker resided in the locality and had developed exceptional rapport with the villagers, she could influence the decision of her clients.
| Discussion|| |
BPCR is considered by the world community as an important strategy to avert maternal and perinatal death. The concept of BPCR is yet to spread its root in Indian socio-cultural setting. ,
Both quantitative and qualitative surveys revealed that birth planning was a neglected issue. Scientific evidences were there to propose first ANC within first trimester in order to make pregnancy safer. , In the present study, around half of the women received their first ANC within 12 weeks of pregnancy, which is almost 10% higher than the corresponding figures reported in District Level Household and Facility Survey (DLHS)-3 for Uttar Dinajpur and West Bengal as well as National Family Health Survey (NFHS)-3 for West Bengal and India. ,,, The corresponding figure in Rewa, India and north Ethiopia also was far less. ,
As evident from earlier research, pregnant women receiving four or more ANCs were more likely to have skilled attendance at birth. ,, However, only around one-third participants in the present study received four or more ANCs. It was comparable with the figure noted in NFHS-3 for India, but far less than that of north Ethiopia and rural Uganda. ,, However, coverage of three or more ANCs was better than the figures reported in DLHS-3 for Uttar Dinajpur and West Bengal as well as by Agarwal et al. ,, In this study, less than 50% women had institutional delivery, which is much higher than the corresponding figures noted in DLHS-3 report for Uttar Dinajpur and comparable with that of NFHS-3 report for West Bengal and India. ,, The picture in Indore city was far gloomy, whereas that of north Ethiopia and Burkina Faso was fair compared with the present study. ,, The linkage of monetary incentives like JSY and referral transport scheme might be the reason, especially in poor and marginalized section. 
Lack of liquid cash in resource constrained setting and availability of vehicle especially in remotest areas in emergencies are a major hindrance to access skilled care. , Therefore, saving money to meet the cost of accessing skilled healthcare and arrangement of a vehicle for emergency transportation are two vital steps in BPCR. , However, less than half of the study population had saved money or identified a vehicle for transportation in emergency. Comparable proportion of women in Rewa saved money, but the figures were better in Indore and Burkina Faso. ,, Identifying a vehicle beforehand was better in Rewa, Burkina Faso, and Kenya but comparable in Indore. ,,, Ethiopian figures in both the indicators were far less.  Awareness of Government cash incentive was found to be high and that of referral transport schemes was poor, corroborating the findings of Kushwah et al. 
Knowledge of the danger signs of obstetric complications is the first step to seek timely care at appropriate health facility.  In the present study, proportion of women aware of at least one key danger sign each of pregnancy, labor, postpartum, and newborn ranged from as low as 12.1% to 37.2%, which indicated a dismal picture of health communication with the beneficiaries. Condition was far better in all other previous studies. ,,,,
Identification of a blood donor for obstetric emergency did not seem to be an important issue to the respondents. The corresponding figures from north Ethiopia were far less, whereas that of Kenya was much better. ,
Interestingly, women of backward castes and BPL families were more likely to follow BPCR practices. As reported in earlier studies, Muslim women and those having less than 5 years of education showed reluctance in it. Community practice and religious belief played crucial role in accessing formal care. Education was also recognized as a change agent. Similarly awareness on availability of government schemes was more prevalent among women of Hindu religion, backward castes, BPL families, and those with 5 or more years of education. This paradoxical finding of better picture among women of backward castes and BPL families might be linked to the availability of cash incentives.
The very low BPCR index in the present study was contributed by lower level of BPCR practices and low awareness about key danger signs of obstetric complications and neonates.
Around half of the respondents enrolled for antenatal care in first trimester and opted for institutional delivery, whereas one-third received at least four ANCs. Birth preparedness was also low. Around 40% saved money, less than one-third identified transport, and nearly one-tenth identified blood donor for emergency. Awareness about at least one key danger sign of obstetric complication was noted in less than one in five, whereas awareness on at least one key danger sign of neonatal complication was seen in one-third women. Nearly two-thirds and one-third knew about cash incentive and cashless transport schemes, respectively.
Qualitative surveys also emphasized the role of health workers influencing awareness and practices regarding BPCR of the community.
| Conclusion|| |
To bring about tangible changes in maternal health status, the status of BPCR in the study area needs further improvement. The present study emphasizes the need of preparedness of health system and workers and making them equipped with the concept of "focused antenatal care" to utilize every contact with the beneficiaries in promoting BPCR.  It will in turn empower women and their family to take decision, plan, and implement BPCR practices.
| Acknowledgement|| |
The authors gratefully acknowledge the help by faculty members and postgraduate students of different medical colleges of the state of West Bengal during data collection. The authors also acknowledge Prof. Apurba Sinhababu and Prof. Dilip K. Das for their help in editing the final draft.
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[Table 1], [Table 2], [Table 3], [Table 4]
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