Reproductive health knowledge, attitudes and practices of women in Kassala State.

Bedri, Nafisa Mohamed

Abstract

This research paper is based on a baseline study carried out for an intervention project implemented by Ahfad University for Women (AUW), UNFPA Sudan, Italian Cooperation and Kassala State Ministry of Health with local partners in Kassala State, Eastern Sudan with the aim of improving maternal and neonatal health in Kassala State for the strengthening of primary health care and community mobilization so as to contribute to improving the health and wellbeing of mothers, newborns and their families in two localities in Kassala State, namely: Kassala town and rural Kassala. The study worked out to assess knowledge, attitudes and practice of women in the community regarding various reproductive health (RH) issues including use and knowledge of family planning methods, pregnancy danger signs, and opinion on home delivery versus facility delivery, birth plans, HIV/AIDS and opinions on midwives' capabilities. The sample included 800 mothers with a delivery experience not more than 5 years ago. The results indicated that the surveyed women in Kassala State showed very modest knowledge on various danger signs they may encounter during or after their pregnancies. They receive minimal information from health care providers; in this case mostly village midwives (VMWs) and have some knowledge about Family Planning FP methods, modes of prevention and minimum knowledge on about the transmission of HIV/AIDS. The study proposed several recommendations to improve women's knowledge and to help them to have better birth preparedness.

Keywords: Reproductive health knowledge, family planning, primary health care, community mobilization, Kassala State/Sudan

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Introduction

Maternal health and reducing maternal mortality have become increasingly worldwide issues of focus and interest for many development actors. Not only because maternal health is a backbone for every country's development, but also because maternal mortality ratio has become an indicative measure of the country's health system performance. The World Health Organization (WHO) in collaboration with many development partners, has launched the Global Strategy for Women and Child Health which came as wake up call for all governments so as to accelerate the progress towards achieving the Millennium Development Goal (MDG) 5 on Maternal Health (WHO 2010). The need for such global move came as a result of the fact that most of the 350,000 women deaths are from preventable complications related to pregnancy and childbirth and as always almost all of them occur in developing countries. Many of the countries of the world have made progress towards achieving MDG 5, but the vast majority is still struggling with high mortality, morbidity and other social and economic determinants that impede the promotion of women's health such as pervert and prevailing gender inequalities. Low access to information and services have been recognized as key factors influencing maternal health (WHO 2010)

Sudan is one of the countries that suffer high rate of maternal mortality with a ratio of 216/100,000 live birth. This serves as one of the highest in the region. According to the Sudan Household Health Survey SHHS 2010, on average, a Sudanese woman gives birth to six children, and Sudan still maintains a very low contraceptive use about 9% in 2010 with unmet needs for one quarter of women (SHHS 2010). Child marriage is very common; especially in rural areas, where 13% of girls are married before they reach 15 and 38% marry before age 18. The SHHS showed that the age at first marriage is negatively associated with a woman's level of education and urban residence. Moreover, significant maternal morbidities also exist in Sudan, such as vesico-vaginal fistula, which among others is associated with relatively poor level of reproductive health care availability and use (WHO 2010). With regards to reproductive health care use, 47% of pregnant women receive four or more antenatal care visits, but without adequate quality of care. Less than 60% of them receive blood pressure measurement, blood or urine investigations, and 73% of deliveries are carried out by health staff, mostly midwives. Only 21% of deliveries take place at the health facility level and very few (18%) of women who delivered receive postnatal care. The coverage of health services is not distributed equally among all women who need them and most facilities and health providers concentrated in urban areas and large cities (SHHS 2010).

Kassala State, where this study was carried out, lies in the east of Sudan, and is not different from the other distant states of Sudan, which have all similar factors influencing women greatly. The SHHS, 2010 has shown that in Kassala State 70% of deliveries are reported to be assisted by skilled attendants, predominantly, 49.6% by village midwives and a very low contraceptive prevalence rate of 4%. The estimated maternal mortality ratio in Kassala State is estimated at 247 per 100,000 live births, which is among the highest ratios in Sudan (SHHS 2010). Though almost half of the deliveries are reported to be assisted by a skilled attendant (this figure includes births by VMWs), yet, most (83%) of the deliveries in Kassala are taking place at home and without access to supplies and equipment needed in an obstetric emergency.

The main direct causes of maternal death in Sudan are hemorrhage, infections, pregnancy-induced hypertension and unsafe abortion, while malaria, anemia and hepatitis contribute indirectly to maternal death. Also, women's knowledge and practices in relation to antenatal care, preparation for delivery, postnatal care and care of the newborn is very poor. Studies on causes of maternal mortality and morbidity and on interventions to promote maternal health have identified several factors that in many instances are interrelated and work together to influence the overall health of women and girls across their life cycles (UNFPA 2012; WHO 2010). Most of these have agreed on the role of women's perceptions, attitudes and practices with regards to their reproductive health, as major factors influencing their health positively or negatively. It is well documented that women's perception of their need to use care and knowledge about when to seek these services, are key determinants to their actual use of care (UNFPA 2012; Ndola et al. 2010; Khan et al. 2006; Ronsmans et al. 2006). This study hence aims to uncover the knowledge, attitudes and practices of women at community level regarding various reproductive health (RH) issues such as their use and knowledge of FP methods, pregnancy danger signs, opinion on home delivery versus facility delivery, birthing plans, HIV/AIDS and opinions on midwives' capabilities.

Methods

The study included women who had a pregnancy experience during the past 5 years. The sample size was 800 women, 500 from rural Kassala and 300 from Kassala town. The sample size was estimated using a formula (N = ([Z.sup.2]*P(l-P)/[[??].sup.2]) *D) based on the number of women of reproductive age in the state (466,614 women) and the number of pregnancies expected/year using the crude birth rate in Sudan, the percentage of skilled birth attendance and births attended by a village midwife, with 95% confidence level. The total was 768, thus 800 women were used. Both localities, although classified as urban and rural are considered similar (in terms of demographic and household characteristic features) and the comparison was within the State, not between states (i.e. no clustering features). Therefore, both localities acted as one target population. Yet, due to differences in the average size of households this was considered in the sampling procedure. Hence, for the sampling, the total sample was divided between the two localities proportionally using multi-stage sampling, where from the catchment villages, the 10 most populated villages in each locality were chosen, and from these, five villages were chosen randomly (primary sampling units). Since the 10 villages in each locality are not equal in size, the five chosen villages were selected using Probability Proportional to Size method (PPS). Then, random numbers using the number of digits equivalent to the total number of households to be sampled, were obtained from tables of random numbers. The villages containing the random numbers were the villages from which samples were taken. The overall response rate was 90%.

For data collection, a questionnaire was developed by the AUW team to be filled in by recruited trained interviewers, who had significant past experience of conducting interviews. A pretest was performed on a sample of 100 households. Data collection commenced on 23rd December 2011 and concluded on 7th Jan 2012. The questionnaire was written in Arabic. The questions are categorized into five sections. Options included both open and closed questions. Responses to the questions did not contain long recall periods but concentrated mostly on current practices.

Results

The general demographic characteristics of the targeted women

The sample consisted of women at the reproductive age who have given birth at least 5 years ago. Almost 30% of these women were young mothers (less than 25 years old) and almost 70% of them had a very low level of education (illiterate or basic level education). 60% had a child less than 3 years ago; 15% were pregnant at the time of the survey and 25 had a child less than 5 years old. Therefore, the survey reflected recent rather than old experiences.

Ante-natal care (ANC) experience

The study examined the ANC experience of the sample women and the type and quality of care they received during their last pregnancy. Almost 44% of the women said they had ANC during their last pregnancy in a health facility (HF) only, while 21% had ANC both in a HF and from a midwife. Just 5% stated they had ANC from VMW only, mainly because it was a family tradition (98%). Regarding frequency of visits, 66.6 % of women stated that they went to ANC every month during their last pregnancy. A small percentage stated they received no ANC during their last pregnancy (2.4%), while 4.4% had one ANC visit. 17% said they had one visit every trimester and 10% had one visit at the beginning of pregnancy and one towards the end of pregnancy.

Regarding the quality of the visits they received, almost all (94%) of the women stated that they had received good care, in terms of checking their history of previous pregnancies and deliveries, measuring blood pressure, and had abdominal examinations. Yet, when examining individual procedures during the check up, 42% said that they did not have an eye examination for anaemia or chest examination, 90% did not receive a breast examination, and 90% did not receive advice or information on HIV/AIDS prevention and testing. 61% did not have their lower limbs examined for oedema. However, 89% stated that their caregiver did request laboratory tests for urine and Haemoglobin.

Family planning (FP) experience

The second section of the questionnaire explored the experience and knowledge of women regarding different types of family planning methods. The types of FP most commonly used by the women were oral contraceptive pills (CoP & PoP) (48%). In terms of knowledge, oral contraceptive pills were the best known FP method among women (62%), followed by breastfeeding (Lactational Amenorrhoea (LAM)) (56%). 82% of women did not know about condoms as a FP method, 49% did not know about hormonal injection and 74% did not know about "safe period" as a contraceptive method.

Knowledge about danger signs during pregnancy

The study also explored the knowledge of the surveyed women regarding danger signs during pregnancy, labour and among newborns. The best-known danger sign during pregnancy was vaginal bleeding (92.5%), followed by decreased or no foetal movement (79%), dizziness and/or loss of consciousness (74%), and convulsions (74%). Sudden generalized oedema was recognized as a danger sign mentioned by 72% of the women. Knowledge of important signs of pre-eclampsia was low; 67% did not know that severe headaches are a danger sign, 64.3% did not know that severe vomiting is a danger sign, and 53.3% did not know that blurring of vision is a danger sign. 62% of women did not know that "burning micturition" or fluids escaping from the vagina are danger signs during pregnancy.

Knowledge on danger signs during labor

Exploring the women's knowledge of danger signs during labour revealed that, the best-known danger sign during labour was severe vaginal bleeding after placental removal (82%), followed by delay in placental removal by more than half an hour (75%). Knowledge of risks for precipitating vaginal fistula was low; 57% did not know that being in labour for more than 12 hours is a danger sign, while 48% did not know that pushing out the baby for more than 3 hours is a danger sign. 54% did not know that sudden loss of the feeling of bearing down during labour (a sign for ruptured uterus) is a danger sign.

Knowledge on danger signs during puerperium

The best-known danger signs during puerperium were severe vaginal bleeding (84%), convulsion (79%), difficulty in breathing (66%) and fever (64%). The least known signs were signs of puerperal sepsis: foul-smelling lochia (68.2%), and pus from episiotomy (65.6). Knowledge of signs of pre-eclampsia during puerperium was also low: 70.5% did not know nausea and vomiting, and 63% did not know severe headaches.

Knowledge on danger signs for newborns

Among newborns, most (82%) of the women mentioned slow breathing or difficulty in breathing as a danger signs for newborns, decreased or refusal of feeding (80%), tremors or convulsions (80%), yellow skin/eyes (62.5%) and pus from the umbilical cord stump (51%). 76% did not know that blue lips/nails are a danger sign that warrants prompt referral to a health facility. Also, 60% did not recognize that lower consciousness or stuperosis in a newborn is a danger sign.

Knowledge on HIV/AIDS

93% of the women had heard about HIV/AIDS. 22% did not know that the virus could be transmitted from an infected mother to her unborn child. 41% did not know it could be transmitted to the unborn child during vaginal delivery, and 53% did not know it could be transmitted via breastfeeding. 83% did not know that there are drugs that prevent mother to child transmission of the virus and 43% did not know that pregnant women should undergo routine VCT for HIV, and 20% did not approve this routine testing.

Birth experience and birthing plans

The questionnaire explored the women's latest birth experience and the existence of a birthing plan if they were currently pregnant. Almost 66% had home deliveries in their last pregnancy and 70% of them indicated that this is because they themselves insisted to deliver at home. For women who did deliver in a health facility, the topic on which they received the most advice after delivery was on breastfeeding (83%). The topic on which they received the least advice was on was FP (83% did not receive advice on FP), cleaning episiotomy (66%) and on danger signs during puerperium (65%). 41% of women who were pregnant at the time of the survey did not have a birthing plan. 80% of those that claimed they did have a birthing plan, only did so by preparing emergency funds. Midwives had inputs in only 30% of those birthing plans. For any future pregnancy, 60% of women still insisted that they preferred home delivery and 86% thought that their VMWs were capable of handling pregnancy complications.

Discussion

Women in the two localities had a high rate of home deliveries, with a strong conviction in their value among the mothers themselves, who insisted on doing the same in the future. This, coupled with the absence of birthing plans prepared by the women, is an alarming fact. Women insisted on delivering at home with low access to qualified health personnel and a lack of access to nearby Emergency Obstetric Care Services (EmOC) facilities. Interventions targeted at social and cultural beliefs should be initiated to encourage the use of health facilities for birth.

Antenatal care's effect on maternal mortality has been under great debate. More and more systematic reviews of ANC in developing countries illustrate that a greater frequency of ANC visits does not necessarily reduce maternal mortality. They highlight the effect of the quality of the visits as more significant. ANC should be a means to detect women at a higher risk of developing complications during pregnancy and/or birth. Maternal mortality in developing countries was shown to be more obstetrical-related and occurring during birth rather than during pregnancy. Post partum mortality also contributes significantly to maternal mortality in developing countries. According to this survey, women in Kassala State did have regular ANC visits as recommended but it is clear the quality of the visits was substandard. They received services during the visits that are clearly not designed to identify women who are at risk. Women, especially seen by VMWs in the community, did not regularly have their blood and urine monitored. ANC seems to be just a routine procedure and has failed to accomplish its purpose as a mechanism of early detection, counselling and advice.

The best-known types of FP as perceived by women were injectables and combined pills, but there is limited knowledge, and access of women to various types of family planning, as women wanted to use FP, but they could not have an access to these methods through midwives and had to travel to the nearest health facility to get them. This result was not surprising, as in an accompanying study to access facilities in the target localities by the researchers, it was found out that the FP methods most widely available in the targeted Primary Health Care Unit/s (PHCUs) were only oral contraceptive pills. These centres periodically lack supplies due to inefficient supply chain management. When these commodities are available, they are provided at a charge. Women have to purchase FP products from their own pocket and according to the Reproductive Health Centers RHCS assessment 2007, UNFPA satisfies 12% of the country's demand for family planning.

With regard to women's knowledge about HIV/AIDS, the results in this study were found to be worse compared to the findings of SHHS 2010, especially with regards to the knowledge on mother to child HIV transmission. The SHHS 2010 also revealed that only 2% of women in Kassala State have been tested, and only 0.6% of these have actually received their results. This indicates the pressing need to target these localities with interventions to spread knowledge and provide primary health care services.

Women in rural and urban Kassala still believe that their VMW is capable of handling any emergency that could happen to them during pregnancy or labour, and the women still have a preference for home deliveries, which s is also in line with results from the SHHS 2010. Overall, women still feel satisfied with the services of midwives.

Women did not know the various danger signs related to eclampsia and knowledge about danger signs during labour was low compared to danger signs during puerperium, but they are knowledgeable regarding danger signs in a newborn.

Conclusion

Women in Kassala showed modest knowledge on various danger signs they may encounter during and after their pregnancies. They are receiving minimal information from health care providers, in this case mostly VMWs or PHC in general. It is clear that the role of PHC in providing education and disseminating knowledge is not met in these localities. Also, there is evidence of low knowledge among women and hence VMWs in terms of FP methods, modes of prevention and transmission of HIV/AIDS and training on knowledge transfer to women during ANC.

PHC in Kassala is weak and even weaker in the rural parts of Kassala. PHC in a country plays a major role in enhancing or weakening a community's sexual and reproductive health. Universal access to SRH services means equal access for everyone with equal needs. To achieve universal access to sexual and reproductive health at the level of primary care, equality and rights have to be core components in designing any RH programmes. The Sudanese health system provides a minimum package of PHC that has reproductive health (RH) as a central component, but this study concludes that in the target areas of the study, the components provided are weak and sporadic in nature.

Recommendations

Based on our conclusions above, it is recommended that programmes should concentrate more on altering women's perception about ability of VMWs to handle emergency situations during birth and they need to be encouraged to have a birthing plan, especially in terms of putting aside funds for emergencies during labour or pregnancy.

We believe that if VMWs were officially employed by nearby health facilities, women could be gradually persuaded to deliver in facilities. it is recommended that the Kassala State Ministry of Health bridges the gap in FP commodities supply and to strengthen its supply chain management and logistics in its health systems. There is a need to create demand by awareness-raising in the community with an emphasis on the benefits of family planning, and we need to increase access to FP commodities at the community level.

Intensifying community awareness raising on pregnancy danger signs and delivery preparedness, and dealing with factors associated with low access to knowledge, social and traditional barriers to access to quality care are greatly needed.

Note on contributor/s

Nafisa Bedri is an associate professor and director of the Gender & RHR Resource & Advoccay Center (GRACe) at Ahfad University for Women,

References

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