Knowledge on birth preparedness and complication readiness in Eastern Region of Nepal

Birth preparedness and complication readiness (BP/CR) strategy encourage women to be informed of danger signs of obstetric complications and emergencies which will help them to recognize problem and reduce the delay on deciding to seek care, making the care-seeking process more efficient. The objective of this study was to assess the knowledge regarding birth preparedness and complication readiness and its effect on the place of delivery. A descriptive cross sectional study was conducted from November to December, 2012. A total of 93 mothers who gave birth in the last 12 months preceding the survey in Jhorahat VDC of Morang district were interviewed. Data were analyzed using Chi-square test at 0.05 level of significance. Only 45.2% and more than half (58.1%) of the mothers spontaneously mentioned at least three components of BP/CR and three danger signs during pregnancy respectively. Education of mother was significantly associated with knowledge of BP/CR. More than half (58.1%) of the mothers had institutional delivery. Knowledge of BP/CR was associated with place of delivery. Literate mothers were more aware of BP/CR than illiterate. Thus, provision of information, education and communication targeting women, family and the general community o n BP/CR are recommended.


INTRODUCTION
Birth preparedness and complication readiness (BP/CR) is a comprehensive package aimed at promoting timely access to skilled maternal and neonatal services (Markos and Bogale, 2014;Kaso and Addisse, 2014).It includes knowledge of danger signs, planning for a birth attendant and birth location, arranging transportation, identifying a blood donor, and saving money in the case of an obstetric complication (Mbalinda et al., 2014;Urassa and Pembe, 2012).
Birth preparedness has been globally endorsed as an essential component of safe motherhood programs to reduce delays to care-seeking for obstetric emergenciesdelay in recognition of problem, delay in seek ing care, and delay in rec eiving care at facility.These delays represent barriers that often result in preventable maternal deaths.The presence of a skilled birt h attendant (SBA) at delivery is recognized as essential t o preventing maternal mortality (JHPIE GO, 2004b;McPherson et al., *Corresponding author.Email: pathakprativ a@gmail.com.Tel: +9779844022806. Author(s) agree that this article remain permanently open access under the terms of the Creativ e Commons Attribution License 4.0 International License

2006).
The principle and practice of BP/CR in a third world setting where there is prevailing illiteracy, inefficient infrastructure, poor transport system, and unpredictable access to skilled care provider have the potential of reducing the existing high maternal and neonatal morbidity and mortality rates.BP/CR promotes skilled care for all births and enc ourages decision making before the onset of labor (Ekabua et al., 2011).
The safe motherhood plan of the Ministry of Health and Population defines a range of complementary interventions to improve maternal and newborn health, one of which is the birth-preparedness package (BPP).The purpose of the package is to encourage pregnant women, their fami lies, and communities to plan for normal pregnancies, deliveries, and postnat al periods and to prepare to deal effectively with emergencies if they occur.The BPP is a demand-creation int ervention that promotes key messages and behaviour change via interpersonal communication through community health volunteers (McPherson et al., 2006;DOHS, 2014) Knowledge on BP/CR improves problem recognition of the problem and reduces the delay in deciding to seek care.It provides information on appropriat e sources of care making the care-seeking process more efficient.It also encourages households and communities to set aside money for transport and service fees, avoiding delays in reaching care caused by the search for funds (Ekabua et al., 2011).The majority of pregnant women and their families do not know how to recogniz e the danger signs of complications and when complications occur they will waste a great deal of time in recognizing the problem, getting organized, getting money, finding transport and reaching the appropriate referral facility (Moore et al., 2002).With the assumption that "every pregnancy faces risks", women should be made aware of danger signs of obstetric complications during pregnancy, delivery and t he postpart um.The knowledge will ultimately empower them and their families to make prompt decisions to seek care from skilled birth attendants (Kabakyenga et al., 2011).In t his context, it is necessary to evaluate the knowledge on BP/CR and obstetric danger signs.
The objective of this study was to determine knowledge regarding birth preparedness and complication readiness of Eastern Nepalese mothers and to find out the association between knowledge regarding birth preparedness and complication readiness and place of delivery.

METHODOL OGY
A descriptive cross sectional study w as conducted from November to December 2012 in Jhorahat Village Development Committee (VDC) of Morang district w hich w as selected randomly.A sampling frame w as made enlisting all eligible subjects, that is, mothers w ho gave birth in the last one year preceding the data collection period.Total mothers meeting the inclusion criteria w ere 93.So, all the mothers residing in Jhorahat V DC w ere taken as sample.Ethical approval w as taken from Institutional Ethical Review Board of BP Koirala Institute of Health Sciences, Dharan.Per mission from the office of VDC w as taken before collecting the data.Infor med verbal consent w as obtained from each mother after explaining the objectives of the study.Pretested semi structured self-developed interview schedule w as used to collect the data.All the mothers were visited door to door and interview ed face to face by investigator herself.All information obtained w as kept confidential.
Know ledge r egarding birth preparedness and complication readiness (categorized as adequate and inadequate) w as taken as dependent variable.In this study, mothers w ere classified as having adequate know ledge if they w ere able to answ er at least three components of BP/CR and at least three danger signs during pregnancy.Data w ere collected including several independent variables; age, religion, caste (categor ized on the basis of Nepal government system), education of mother and spouse, occupation of mother and spouse, per capita income, parity, number of antenatal visits and place of delivery (categorized as institution and home).
Data w ere cleaned and entered in Microsoft Excel 2007 sheet for preparing master chart.Entered data w ere verified and converted in Statistical Package for Soc ial Sc iences (SPSS) version 16 for statistical analysis.Descriptive statistics w ere presented in frequencies, percentage, mean, median and standard deviation.Bivariate analysis (Chi-square test) w as used to test the significant association betw een independent and dependent variables.The significance level w as set at p=0.05.

RESULTS
Table 1 presents the socio-demographic profile of mothers which showed that 88.2% were aged 20-34 years with mean age 25.23; more than half (54.8% ) were Dalit; 31.2% were illiterate; 91.4% were hous ewife; 88.2% were living below poverty line.

Socio-demographic profile of spouse
Secondary level of education was obtained by 31.2% of the spouse.Almost half (48.4%) of t he spouse were daily wage laborers.

Obstetric characteristics
More t han half (58.1%) of the mothers were multiparous with mean parity of 1. 86 (SD=0.92).Almost all (98.9%) mothers had attended ANC at least once.Among them 76.3% had attended at least four A NC visit.Only 58.1% of the mothers delivered in institution.Majority (88.2%) had spontaneous vaginal delivery.

Knowledge of mother about BP/CR
Table 2 shows that saving of money, clothes for mother and baby and arrangement of transportation were mentioned by 61.3, 52.7 and 49.5% of the mothers , respectively.Only 45.2% of the mothers spontaneously mentioned at least three components of BP/CR.

Knowledge of mother about danger signs during pregnancy
Table 3 illustrates that severe abdominal pain, vaginal bleeding and passage of foul smelling discharge were mentioned as danger signs during pregnancy by 61.3, 60.2 and 44.1 of the mothers, respectively.More than half (58.1%) of the mothers spontaneously mentioned at least three danger signs during pregnancy.Table 4 shows that if the respondents were able to answer any of t he three components then it was categoriz ed as adequate if they were not able to answer any of the three components then it was categorized as inadequate.Education of the mother was one of t he  56 (60.2)  3 (3.2)  57 (61.3)  41 (44.1)  8 (8.6) *Multiple response.significant factors (p=0.006) which affect the knowledge regarding birth preparedness and complication readiness.

Association between knowledge regarding danger signs during pregnancy and socio-demographic variables
It is also important for a woman to know about abnormal pregnancy besides normal pregnancy.There are some important danger signs during pregnancy which point towards underlying abnormalities.If the respondents were able to answer any of the three components then it was categorized as adequate if they were not able to answer any of t he three components then it was categoriz ed as inadequat e. Caste and education of the mothers were found to be significantly associated with the adequacy of knowledge regarding danger signs during pregnancy with p=0.011 and p=0.008, respectively.
Table 5 shows that there was a significant association between knowledge of BP/CR and place of delivery.
Those mothers who had adequate knowledge of BP/CR were more likely to deliver at institution.

DISCUSSION
Age, parity and number of ANC visits were not significant factors in having knowledge of BP/CR and danger signs during pregnancy which is contradictory to the finding in the study done in rural Tanzania (P embe et al., 2009).
This study shows association bet ween education of mothers and knowledge regarding BR/ CR and danger signs during pregnancy which is similar t o the study done by Pembe et al. (2009).K abakyenga et al. ( 2011) also reported that high level of education modify the relationships between knowledge of key dangers signs and birth preparedness in a synergistic direction.This finding s uggests the educated are able to better understand the health messages acquired from various sources.Caste was also a significant factor which affects the knowledge of danger signs during pregnancy.This study shows that more than half (54.8% ) of the mothers were Dalit.Dalits are more likely to be deprived of education due to the economic status, reducing their level of understanding.This study revealed that occupation was not associated with the knowledge of BP/CR and danger signs during pregnancy which is contradictory to the finding of the study done in Uganda (Mbalinda et al., 2014).As compared to housewife, government employ ee women were about four times more likely to mention at least three danger signs during labour.This could be explained by the fact that, a woman who has her own income might be autonomous in seeking better health care than housewife who does not have her own income.Knowledge regarding danger signs of obstetric complications is the first step in the appropriate and timely referral for essential obstetric care (JHPE IGO, 2004a, b).Knowledge of BP/CR and danger signs during pregnancy was associated with plac e of delivery.Tura et al. (2014) concluded that women who knew three or more key danger signs during labor were more likely to use skilled care as compared to those who did not know any key danger sign (OR = 1.59; 05%CI: 1.05, 2. 43).The study done in Tanzania stated that low awareness may be a cause of failure to recognize the complication when it occurs; thus, delaying the decisions to seek care (Urassa and Pembe, 2012)

Conclusion
Less than half of the mot hers had adequate knowledge regarding BP/CR.Women who were literate were more aware of BP/CR and danger signs during pregnancy than illiterate.Education on BP/CR and danger signs is an important factor in inc reasing utilization of institutional delivery.Delivery at home and low awareness of danger signs are serious bottleneck in the reduction of maternal mortality as home delivery is associated with more delay to get appropriate care when a complication arises.Healt h professional should give due emphasis on BP/CR to improve the access to skilled obstetric care.Thus, provision of information, education and communication targeting women, family and the general community on BP/CR and obstetric danger signs is recommended.
participants without whom this study would not have been possible.

INTRODUCTION
Early breastfeeding initiation (EBFI) is recommended within the first hour following giving birth as a simple strategy in enhancing neonatal health and survival (World Health Organisation [WHO] and UNICEF, 2010; Hailemariam et al., 2015).The value of EBFI lies in colostrum which is the first breast milk to be produced within 72 h following giving birth.Colostrum contains bioactive immune factors that have protective effect against early neonatal infections (American Academy of Paediatrics, 2012; Vijayalakshmi et al., 2015).According to WHO (2010), EBFI is the provision of the mothers' first breastmilk within an hour following giving birth.This definition entails that the newborn has to receive some colostrum within that hour not just mere being on the breast.breastfeeding as initiating breastfeeding within 24 h of birth.More so operational variations still exist on the attributes or characteristics of EBFI making it difficult to measure the concept for quality.This time to initiation variation gap leads to unstandardized operation as well as loopholes for continued escalating neonatal deaths.

Problem statement
Evidence drawn from a meta -analysis study of 67 developing countries, proven that EBFI prevents neonatal sepsis and hypothermia that are major causes of neonatal deaths (Mullany et al., 2008).Describing the concept, EBFI will help bridge the variation gap with regards to description or practice.

Justification of the study
The [WHO] stands as a template body of excellence in all matters related to health hence its principles are to be aligned with.Outstanding deviations from stated standards with regards to EBFI have detrimental effects to neonatal health during the critical period following birth.Describing what EBFI is, by explain its attributes will help in standardising operations in the maternity units.

Purpose of the study
The purpose of the study was to describe the concept EBFI by stating and explaining its antecedents and attributes for the purpose of being able to measure it and also to evaluate performance towards reducing neonatal deaths.

Objective
The objective of the study was to describe the concept EBFI by assigning measurable attributes or characteristics.

METHODOL OGY
Walker and Avant concept analysis model w as used to guide the study.A literature review of 39 articles w as conducted betw een the years 1999 to 2016 in a period of tw o w eeks from the 1 st to the 15 th of July 2016.The follow ing search engines w ere used: Cochrane data base, Journal of human Lactation, Pub-med and MEDLINE.Sixteen studies that met the inclusion criteria w ere considered for defining, describing the concept of interest and also in the discussion.

Inclusion and exclusion criteria
Inclusion criteria w ere based on the subject topic: Early breastfeeding or early initiation, factors associated w ith EBFI, consequences of delayed breastfeeding, EBFI and neonatal outcomes or definition of EBFI.
The excluded studies described breastfeeding in general w ithout specifying any antecedents or attributes in the interactional process of EBFI.These articles stressed on breastfeeding in the context of HIV in a bid to prevent mother to child transmission (MTCT) and also more on the structural process of breastfeeding at programme level.Such processes included items in the ten successful steps to breastfeeding like having a breastfeeding policy in place w ithout spelling out w hat exactly constitutes EBFI.
Search terms w ere applied w ith various Boolean operators based on the core concept: Early Breastfeeding Initiation or Timing of Breastfeeding.Such terms as early skin to skin contact (ESSC), proper position and attachment, suckling and colostrum w ere also used.

RESULTS
39 Articles were reviewed (Figure 1).All selected articles to some extent assisted in defining the concept of interest (WHO, 2010;Debes et al., 2013).Some variations did existed on how EBFI was defined, but it gave a platform for discussion and to pave away for concept description.Eighteen articles were dropped for several reasons: Six articles described breastfeeding in general without specifying any antecedents or attributes in the interactional process.These articles stressed on breastfeeding in the context of HIV in a bid to prevent mother to child transmission (MTCT) and also more on the structural process of breastfeeding at programme level.Such processes included items in the ten successful steps to breastfeeding like having a breastfeeding policy in place without spelling out what exactly constitutes EBFI (Hoddinott et al., 2014, Sayer et al., 1995, Kalies et al., 2005, UNICEF and WHO, 2010;Trickey and Newburn, 2014;Wagh et al., 2013).
Five articles described the determinants of EBFI which assisted in identifying antecedents in the interactional process of EBFI (Dewey, 2001;Montigny and Lacharite, 2005;Nice and Luo, 2010;Patel et al., 2015;Khanal et al., 2015).The main antecedents highlighted in all articles were the maternal age, mode of delivery, knowledge on the benefits of EBFI, parity and baby's condition at birth.Four of the five articles mentioned above dealt with issues surrounding breastfeeding and were considered appropriate for this paper.One article (Moran, 1999) however, showed no elements of actual breastfeeding, but focussed on modesty to breast feeding and was not included in this concept paper.Three other papers  (Mulder, 2006, Bell et al., 1998, Norton, 2013) were considered relevant on this concept paper EBFI.These papers, though had some variations, they had familiar antecedents as well as attributes of interest with this paper.Twelve articles assisted in the discussion section (Dennis, 2002;Edmond, 2006;Mullany et al., 2008;Tawiah-Agyemang, 2008;Oddy, 2008;Klaus and Kennel, 2008;Orun et al., 2010;Amin et al., 2011;Debes et al., 2013;Montgomery, 2014 andSeid et al., 2013).

DISCUSSION
EBFI has been inconsistently defined within the same health profession.The inconsistent definition of EBFI has resulted in variations in the timing of breastfeeding following giving birth.Early breastfeeding initiation is defined as provision of the mothers' breast milk to the baby within an hour following birth (WHO, 2010).According to Debes et al. (2013), early breastfeeding entails initiating breastfeeding within 24 h following birth.These two definitions though they are in agreement on the provision of breast milk to the newborn, their time to initiation differ greatly.The variation in time to initiation makes it a challenge to standardise operations in maternity units.
Despite the appropriate timing of breastfeeding initiation following birth by WHO, both definitions do not closely tie the attributes of EBFI (early skin to skin contact, proper positioning and attachment, rooting and a strong suckling reflex as well as colostrum transference into the baby's mouth) in the interactional process in the achievement EBFI.
Attributes according to Walker and Avant (2005), are those traits or characteristics which make it possible to measure a concept objectively.
According to Walker and Avant (2005), attributes make it possible to measure if an event has really taken place.In the context of this study, it would be very questionable if someone claims to have initiated breastfeeding early without tangibly stating presence of these attributes.
According to Mbada et al. (2013), EBFI goes beyond mere putting the baby to the breast rather a combination of putting the baby to the breast and the actual transference of colostrum into the baby's mouth followed by swallowing.All the attributes should come into play in the interaction process of achieving effective EBFI.In view of this, Walker and Avant (2005), speaks of a model, borderline and a contrary case.A model case is when all the EBFI attributes are present within a time frame of an hour following birth.The model case is the ideal standard if neonatal mortality is to be averted.In a systematic review on EBFI, Nepal initiated breastfeeding within an hour and reduced neonatal deaths by 19% (Mullany et al., 2008).Variations in defining EBFI makes us have either boarder line or contrary cases where critical attributes of EBFI will be partially present of even missing.
Contrary cases was seen as rounds were made in the maternity units, involving delivery of the baby onto the mother's chest, and subsequent interruption of skin to skin contact because the baby has been dressed and laid besides the mother.The baby is set for breastfeeding, but the mother is fast asleep without even facing the baby.Four to six hours later, the mother starts to initiate breastfeeding.In some cases, if the in-laws are around at time of giving birth, the baby can be given either water with sugar or ordinary milk to stop it from crying.According to Yalan (2016) cultural beliefs have bearing effects on EBFI and some of the effects compound negatively on neonatal health and survival.
If a cross checking of this case is done with the delivery record under the section "Breastfeeding initiated within an hour", that section is usually ticked yes.In view of this, one begins to wonder if EBFI is really known.Poor practice in maternity units with regards to EBFI has costed the public due to preventable neonatal deaths (Mullany et al., 2008, Tawiah-Agyemang et al., 2008; Oddy, 2013).Early breastfeeding initiation is evidenced by skin to skin contact maintenance (Dennis, 2002).In view of this, dressing the baby soon after births interrupts this process.Ideally, the baby's skin should be in contact with that of its mother and both covered with a warm blanket.
According to Klaus and Kennel (2008) and Debes et al. (2013), skin to skin contact facilitates the Breast Crawl Behaviour.In their studies they cited that breast crawl behaviour enables every newborn that is placed on the mothers' abdomen or chest following birth to search for the breast.
For effective EBFI, antecedents should also be taken into consideration for they can impact negatively to early initiation.Antecedents are incidents that occur prior the prevailing concept (Walker and Avant, 2005).In the context of this study, these include: Maternal age and experience, knowledge, attitudes, mode of delivery, gestational age and wellness of the mother -baby pair.According to Orun et al. (2010) mode of delivery especially vaginal interacts positively with EBFI as opposed to operative delivery where the woman experience some degree of stress, discomfort and altered level of consciousness as in the case of effects of general anaesthesia.Stressful stimuli as a result of either operative or prolonged deliveries interfere with EBFI by inhibiting oxytocin release thereby milk production (Montgomery, 2014;Seid et al., 2013;Moore et al., 2016).According to Amin et al. (2011), increased maternal age and multiparty were found to be positive predictors or attributes for EBFI.In view of this, midwives have the responsibility of predicting those women who are likely to face challenges in EBFI and offer practical support accordingly.

Conclusion
The concept was chosen for analysis for the purpose of standardizing operations in terms of timing and measuring EBFI.A lot of studies have been carried out in view of delayed BFI, but no study that has been conducted to describe EBFI and explaining its antecedents and attributes.Taking into cognisant the attributes of EBFI and applying them in the maternity unit has a potential of averting neonatal deaths by a significant percentage (Lamberti et al., 2011).
Despite the clear definition by WHO on EBFI, some variations still exists across board on what exactly EBFI Initiation is.Debes et al. (2013) define early *Corresponding author.E-mail: gladys.maryvincent.mugadza@gmail.com.Tel: + 263 772595446 (Author(s) agree that this article remain permanently open access under the terms of the Creativ e Commons Attribution License 4.0 International License

Table 1 .
Distribution of socio-demographic profile of mothers.

Table 2 .
Birth preparedness and complication readiness mentioned by mothers.

Table 3 .
Danger signs during pregnancy mentioned by mothers.

Table 4 .
Association betw een know ledge regarding BP/CR and socio-demographic characteristics.

Table 5 .
Association betw een know ledge regarding BP/CR and danger s igns during pregnancy w ith place of delivery.
*Significant p value.