|Year : 2013 | Volume
| Issue : 1 | Page : 9-13
Knowledge and practices on maternal health care among mothers: A Cross sectional study from rural areas of mid-western development region Nepal
Kapil Gyawali1, Damaru P Paneru2, Bina Jnawali3, Kalpana Jnawali4
1 Department of Public Health Administration, Faculty of Public health Health, Mahidol University, Thailand
2 Department of Public Health, KLE University, Belgaum, Karnataka, India
3 Department of Public Health, School of PMER, Kathmandu, Nepal
4 International Development Enterprises, Department of Health (SanMark) Project, Rupandehi, Nepal
|Date of Web Publication||28-Mar-2013|
Damaru P Paneru
Department of Public Health, School of health and Allied Sciences, Pokhara University, Kaski, Nepal
Source of Support: None, Conflict of Interest: None
Background: Safe motherhood is a priority program in Nepal, aiming to restrain maternal deaths. Meanwhile, knowledge, practices, accessibility, and service quality are considered keys to improve service utilization. This study was conducted to identify knowledge and practices of maternal health care among mothers having < 1-year-old child in the Mid-western Development Region, Nepal. Materials and Methods: A community-based cross-sectional study was conducted during January-April 2011 in rural, Mid-western Development Region, Nepal. Three Village Development Committees (VDC) from Bardiya (plain) and two VDCs from each of the Salyan and Pyuthan (hill) and Jumla (mountain) districts were selected randomly. Hence, there were 81 clusters (1VDC = 9 clusters) and 7-8 participants were selected randomly from each cluster. Data were collected by interview using structured questionnaire and Focus Group Discussion Guideline (18 FGDs), analyzed by SPSS (16.0). CD recorded qualitative data were transcribed and narrated. Percent mean and standard deviation were calculated. Results: Three quarters of the participants had correct knowledge regarding minimum numbers of antenatal visits to be done by a pregnant woman (WHO guideline). Nearly two-fifth participants knew schedule of antenatal care (ANC) visits. Almost 60% had done ≥ 4 ANC visits during last pregnancy. Majority visited Sub Health Post/Health Post/Primary Health Care Centre for ANC Checkup. About 90% had taken Iron and folic acid tablets. About 57% were home deliveries (last childbirth), 40% deliveries were assisted by relatives/husband, and only 32% did postnatal health checkup. Conclusions: There were gaps in the knowledge and practices for health care during pregnancy, childbirth and in the postpartum period. A high rate of home deliveries with the low postnatal service utilization was prevalent. Intensive awareness progam and behavioral change interventions, regular pregnancy monitoring may promote the health service utilization.
Keywords: Cross-sectional, knowledge, maternal health, mid-west, practice, rural
|How to cite this article:|
Gyawali K, Paneru DP, Jnawali B, Jnawali K. Knowledge and practices on maternal health care among mothers: A Cross sectional study from rural areas of mid-western development region Nepal. J Sci Soc 2013;40:9-13
|How to cite this URL:|
Gyawali K, Paneru DP, Jnawali B, Jnawali K. Knowledge and practices on maternal health care among mothers: A Cross sectional study from rural areas of mid-western development region Nepal. J Sci Soc [serial online] 2013 [cited 2019 Oct 13];40:9-13. Available from: http://www.jscisociety.com/text.asp?2013/40/1/9/109682
| Introduction|| |
Pregnancy and childbirth is a normal physiological phenomenon. Moreover; many cases terminate with the complications such as abortion, maternal or fetal disability and even maternal death or fetal loss or both. , Global evidences shows that all pregnancies are at risk and complications during pregnancy, childbirth, and the postnatal period are difficult to predict.  Pregnancy and childbirth process are still overlooked as a natural phenomenon; consequently, maternal mortality and disability are unexpectedly high in Nepal.  And 281 maternal deaths occur/100,000 live births with estimated 32,000 mothers dying every year in Nepal. Despite the structural network of safe-motherhood service delivery in Nepal,  more than 70% of deliveries take place at home without the assistance of health workers,  And less than a quarter of deliveries occur with the assistance of skilled birth attendants (doctors, nurses, and auxiliary nurse midwives). 
Improving maternal health is one of the health-related Millennium Development Goals (MDG) and the government of Nepal has its commitment to attain these goals by addressing barriers.  Accordingly, the minimum package of essential safe-motherhood services was developed in Nepal and services under the package are supplementation of iron and folic tablets, counseling about nutrition, rest, recognition of danger signs, and preparedness/readiness for service consultation and motherhood during pregnancy, arrangement of place for delivery, and clean/safe delivery practices and postnatal care practices. 
In spite of these efforts, ANC practices in the Midwestern development region of Nepal is rather poor and dropout rate (first ANC vs. fourth ANC visit) is very high (50.0%, four ANC visits), and only half of the expectant mothers had one postnatal visit which is the lowest achievements in the national statistics.  Several pieces of evidence suggest that lack of knowledge among the expectant mother/relatives, poor access, and acceptance of maternity services including delay in seeking care, reaching care, and receiving care are some of the identified barriers in Nepal.  In response, government of Nepal has adopted the promotional strategies for awareness, readiness, and preparedness on complication of pregnancy and extension of obstetric services in the country.  Therefore, promotion of health and trim down adverse pregnancy outcomes require the continuum of care; starting right from conception to the postpartum period. In this context, a study was carried out to (i) assess the mother's knowledge on antenatal care and danger signs during pregnancy, (ii) identify antenatal, intranatal and postnatal care practices, (iii) find out the accessibility and utilization of safe motherhood funds in rural, Midwestern Development Region of Nepal.
| Materials and Methods|| |
This was a community-based descriptive cross-sectional mix method study carried out from January to April 2011. It was conducted in four districts of the Midwestern Development Region of Nepal namely Bardiya (Plain), Salyan, and Pyuthan (Hill) and Jumla (Mountain) representing from each ecological zone. Geographical coverage under the Village Development Committee is considered rural areas in Nepal. Altogether, 618 samples were selected for this study with the consideration of the design effect (2) at 5% tolerable error. A multistage random sampling technique was used. First and second stage: Random selection of 4 (out of 15 districts of the region) district; 3 Development Committees (VDC) from Bardiya and 2 VDCs from each of Salyan, Pyuthan, and Jumla districts. Each ward of the selected VDC constituted a cluster. Thus, there were 81 clusters (1 VDC = 9 wards). In the third stage, mothers having child ≤1 year of the selected VDC were identified from the records maintained by Female Community Health Volunteers and 7-8 mothers were selected randomly from each cluster. Data were collected by interview using pretested, structured questionnaire. And 18 Focus Group Discussions (FGD) were conducted (two FGDs in each VDC). Ten percent of the filled questionnaires were cross-checked by supervisors. All quantitative data were analyzed by SPSS (16.0 version). CD recorded qualitative data were transcribed and narrated accordingly. Percentage, mean, and standard deviation were calculated.
| Results|| |
Socio-demographic profile of the participants
About one-third of the participants were from Bardiya followed by a quarter of them were from Pyuthan. Mean age of the participants was 24.7 ± 2.9 years. Majority were Brahmin/Chhetri (41.2%) followed by Tharus (26.5%). Majority (58.2%) were living in joint families and almost all were Hindus. More than 40% had their annual family income between (Nepalese Rupee) 20,000 and 50,000 (median/mode: 50,000.0) as shown in [Table 1].
Knowledge of antenatal care
[Table 2] shows the participant's knowledge of antenatal care (ANC). Nearly three-quarter of the participants were known about the minimum antenatal visits (four visits or more) to be done by a pregnant woman. Only 43.0% participants had correct idea regarding the correct schedule of ANC visits according to the WHO guideline, while substantial (12.4% and 44.4%) numbers of them were either unknown or had an incorrect idea about the appropriate time interval of pregnancy checkups respectively. Participants reported that ante-partum hemorrhage, lower abdomen pain, severe headache, edema, eclampsia, etc., are the common danger signs during pregnancy.
Findings from the focus group discussions are also in consistent with individual interview (illustrated in the given box).
Findings from Focus Group Discussion are also in concurrent to the quantitative results. Majority of the mother groups reported; the pregnant woman must do at least four times ANC visits during pregnancy. Majority of the mothers from Bardiya district had correct knowledge while others had scanty knowledge of ANC visits schedule according to WHO Guideline (first, visit as soon as she missed period or within the fourth month, second during the sixth month, third during the eighth month, and fourth during the ninth month). Excessive vaginal bleeding, headache; high blood pressure, body swelling, and convulsions were perceived the most commonly occurring danger signs during pregnancy. Furthermore, they revealed that most of the deliveries take place in home; however, there is increasing acceptance of institutional deliveries since the past 5 years. Although there is increasing awareness and utilization of ANC and delivery care services, postnatal health is less likely utilized considering that the health problems during the postpartum period are perceived to be less dangerous than the pregnancy and child birth.
Maternal care practices
About 62.1% participants had ≥4 times ANC checkup in their last pregnancy. Majorities (77.2%) of respondents visited to Health Post (HP)/Sub Health Post (SHP)/Primary Health Care Ccentre (PHC) for their ANC checkup followed by Nursing Home/Hospitals (21.0%). Of the ANC service users, more than 85.7% received two doses of Tetanus Toxoid. More than nine-tenth (90.7%) had taken iron tablets; however, only 55.4% had taken full course during pregnancy [Table 3].
Majority (57.1%) were home deliveries followed by nearly a quarter (23.9%) were institutional deliveries. Likewise, 44.9% home deliveries were assisted by relatives/women/husband while altogether, 35.5 delivered with the assistance of health personnel including paramedical staffs. Surprisingly, only 32.3% had used the home delivery kit (HDK) while a great majority (67.7%) did not use HDK. Only 32.0% did postnatal health checkups; nonetheless 86.4% had taken Vitamin-A. Nearly nine-tenth participants had received advices for neonatal care whereas four-fifth had postpartum family planning counseling services [Table 4].
Only very few participants (7.4%) knew about the safe-motherhood fund. Of those knowledgeable participants, almost a quarter (26.1%) utilized it whereas nearly three-quarter (73.9%) did not have access to the safe-motherhood fund [Table 4].
| Discussion|| |
About three quarters of the participants answered correctly regarding the minimum frequency of antenatal visits to be done by a pregnant woman according to the WHO guideline. Nearly two-fifth participants had a correct idea of ANC visit schedule. Ante-partum hemorrhage followed by low abdominal pain, including severe headache, edema, eclampsia, etc., were perceived to be the most frequently observed danger signs during pregnancy. Similar findings were reported form the Focus group; discussions and findings of this study concurred with the study conducted in Uganda where 52% of women knew at least one key danger sign during pregnancy. 
Only three-fifth participants had done ≥4ANC visits during their last pregnancy. Findings of this study show better practices than Sanjel et al., consistent with studies of DOHS and Pradhan in Nepal and poorer than Yenita et al. in Indonesia. ,,, Majority (77.2%) of the participants visited Sub Health Post/Health Post/Primary Health Care Centre for ANC Checkup and 85.5% had taken TT-2. Nine out of every 10 participants had taken iron and folic acid tablet (IFA) while only around half of them had taken full course of IFA.
Nearly three-fifth (57.1%) delivered their last child in home. Results of this study are consistent with DOHS; however the home delivery rate was higher than that reported by Pradhan in Nepal. , About two-fifth deliveries were assisted by relatives/women/husband whereas only two-fifth deliveries were assisted by health personnel including doctors. Pradhan reported higher proportion of deliveries assisted by doctor in Mahankal, Kathmandu. This differentiation may be due to geographical variation and accessibility of services. HDK was used in the case of only one-third home deliveries. This study shows better HDK utilization compared to Sreeramareddy et al.'s in Pokhara (only 16.2% used HDK).  Only 32% of the participants had their postnatal health checkup, 86.4% had taken vitamin A. Findings of the study are below the national and regional average.  Nearly nine-tenth of participants were advised for neonatal care and slightly lesser number of the participants had received postpartum family counseling. Less than one-tenth participants were known about the safe-motherhood fund and only a quarter of the mothers who have had idea of safe-motherhood fund utilized it.
| Conclusion|| |
Three-quarters of the mothers had correct knowledge on frequency of ANC visits and two-third had knowledge on the schedule/timings of ANC visits. About 60% had ≥4 ANC visits in the last pregnancy and majority (77.2%) had taken ANC services form SHP/HP/PHCC. About nine-tenth participants had taken IFA and 85.5% had taken TT-2. Majority (57.1%) delivered their last baby in home; 35.5% deliveries were assisted by health personnel. Only 32% mothers had done postnatal health checkup and very few (10.0%) mothers had knowledge about the safe-motherhood fund; of them a quarter mothers utilized the same fund. There are considerable gaps in knowledge and practices with high rate of home delivery and low postnatal service utilization practices. Intensive awareness progamme and behavioral change interventions, regular pregnancy monitoring may promote maternal health service utilization.
| Acknowledgments|| |
The authors are thankful to the study participants for their cooperation and University Grants Commission, Nepal for the financial support.
| References|| |
|1.||Ghai OP, Gupta P, Paul VK. Essential pediatrics. 6 th ed. New Delhi, Bangalore, India: CBS Publishers and Distributors; 2005. |
|2.||Park K. Park′s text book of preventive and social medicine. 18 th ed. Jabalpur, India: M/s. Banarasidas Bhanot; 2005. |
|3.||Department of Health Service, Nepal. Annual report: F/Y 2010/11. Management Division, Department of Health Service, Teku, Kathmandu, Nepal.; 2011. http://www.dohs.gov.np. [Last accessed on 2012 Oct 10]. |
|4.||World Health Organization. Working together for Health. Geneva, Switzerland: World Health Report; 2006. |
|5.||Dhakal S, Van ET, Raja EA, Dhakal KB. Skilled care at birth among rural women in Nepal: Practice and challenges. J Health Popul Nutr 2011;29:371-8. |
|6.||New Era/MACRO International/MOHP. Nepal Demographic and Health Survey: Preliminary Report, MOHP. Kathmandu, Nepal: Government of Nepal; 2011. |
|7.||MOH. National maternity guideline. Nepal: Ministry of Health; 1996. |
|8.||DOHS. Safe-motherhood and Neonatal Health Long Term Plan (SMNHLTP; 2006-2017). Nepal: Department of Health Services; 2006. |
|9.||Jerome KK, Per-Olof O, Eleanor T, Karen OP. Knowledge of obstetric danger signs and birth preparedness practices among women in rural Uganda. Reprod Health 2011;8:33. |
|10.||Sanjel S, Ghimire RH, Pun K. Antenatal care practices in Tamang community of hilly area in central Nepal. Kathmandu Univ Med J (KUMJ) 2011;9:57-61. |
|11.||Pradhan A. Situation of antenatal care and delivery practices. Kathmandu Univ Med J (KUMJ) 2005;3:266-70. |
|12.||Yenita A, Higeko H. Factors influencing the use of antenatal care in rural West Sumatra, Indonesia. BMC Pregnancy Childbirth 2012;12:1-8. |
|13.||Pathak LR. A study of maternal mortality in Nepal. Teku, Kathmandu, Nepal: Department of Health Service; 1998. |
|14.||Sreeramareddy CT, Joshi HS, Sreekumaran BV, Giri S, Chuni N. Home delivery and newborn care practices among urban women in western Nepal: A questionnaire survey. BMC Pregnancy Childbirth 2006;27:1-10. |
[Table 1], [Table 2], [Table 3], [Table 4]