Background: With an aim to prevent adverse pregnancy outcomes, ‘birth preparedness and complication readiness’ (BP/CR) promotes timely access to skilled maternal and neonatal services. Objective of this study was to assess implementation of BP/CR among pregnant women admitted with obstetric emergencies in rural Rwanda. Methods: A cross-sectional study among pregnant women who were referred to Ruhengeri hospital between July and November 2015. The ‘Safe Motherhood questionnaire’ as developed by Jhpiego’s Maternal and Neonatal Health Program was used to collect data. Women were asked to mention key danger signs and respond as to whether they had identified: (A) skilled birth attendant, (B) location to give birth, (C) mode of transport, (D) money to cover health care expenditure. Women who answered ‘yes’ to three or four items were labeled ‘well prepared’. Multivariate logistic regression analysis was conducted to compare the ‘well prepared’ and ‘less prepared’. Results: With regard to complication readiness, out of 350 women, 296 (84.6%), 271 (77.4%) and 288 (82.3%) could mention at least one key danger sign during pregnancy, labor and postpartum respectively, but only 23 (6.6%) could mention three or more key danger signs during all three periods. With regard to birth preparedness, 46 (13.1%) women had identified a skilled birth attendant, 68 (19.4%) birth location, 76 (21.7%) mode of transport, and 306 (87.4%) had saved money for health care costs. Seventy-eight women (22.3%) were ‘well prepared’, associated factors being first time pregnancy (adjusted Odds Ratio (aOR) = 3.2; 95% CI; 1.2–5.8), knowledge of at least two danger signs (aOR = 2.8;95% CI;1.7–3.9) and having been assisted by a community health worker at the antenatal clinic (aOR = 2.2,95% CI;1.3–3.7). Conclusion: Knowledge of obstetric danger signs was suboptimal and birth preparedness low. We recommend review of practices regarding health promotion in antenatal care, taking care not to exclude multiparous women from messages related to birth preparedness, and do promote use of community health workers to enhance effectiveness of BP/CR. Keywords: Birth preparedness, Complication readiness, Obstetrics, High-risk pregnancy, Health promotion, Rwanda Background a key component of safe motherhood programs around Maternal mortality remains a major global concern, the world [4, 5]. especially in sub-Saharan Africa where the maternal BP/CR is a comprehensive package to promote timely mortality ratio, although declining, is still high [1–3]. access to skilled maternal and neonatal health services. It One of the reasons is lack of Birth Preparedness and also promotes active preparation and decision making for Complication Readiness (BP/CR), which is recognized as birth among pregnant women and their families [5–7]. A birth plan includes identifying a skilled birth attendant and location of the closest appropriate care facility, saving funds for birth-related and emergency expenses, arranging * Correspondence: email@example.com transport to a health facility for birth and obstetric emer- Department of Obstetrics, Leiden University Medical Center, Leiden, the gencies and identification of compatible blood donors in Netherlands Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Smeele et al. BMC Pregnancy and Childbirth (2018) 18:190 Page 2 of 7 case of need . The latter criterion does not apply in procure missing items from private pharmacies. During Rwanda, where centralized blood banks taking blood from the study period, medical staff consisted of one specialist voluntary donors are in place . obstetrician, four medical officers, two intern doctors Whilst BP/CR has been associated with reduced ma- and 18 midwives. ternal and neonatal mortality , improved preventive behaviors [10–12], increased knowledge of danger signs Data collection [13–15] and more frequent seeking of professional care The study included all pregnant women who were during emergencies [11, 16, 17], previous studies have referred to the maternity ward who consented to partici- shown low rates of BP/CR among women in Uganda pation, using the consent form given in Additional file 1. , Ethiopia [4, 14, 15] and Burkina Faso . The rate Participants were followed up to discharge or death. of BP/CR among women in Rwanda is unknown. Two trained research assistants identified possible partic- In 2003, Rwanda adopted BP/CR as part of ‘focused ipants while the principal investigator verified suitability antenatal care’ to increase access to skilled birth attend- for study inclusion. The ‘Safe Motherhood questionnaire’ ance [20, 21]. Part of this strategy is that health workers developed by the Maternal Neonatal Program of JHPIEGO, explain women the obstetric danger signs that may an affiliate of John Hopkins University was used, and occur during pregnancy, childbirth and the postpartum adapted to the local context to include a question regard- period as well as methods to prevent mother-to-child ing purchase of birth materials as a common birth pre- transmission of HIV . The introduction of focused paredness practice (Additional file 1). The expert translator antenatal care may have contributed to the reduction of translated it from the English version to the local language the maternal mortality ratio by roughly two-thirds (Kinyarwanda), and then another translator translated this from 750 in 2005 to 210 per 100,000 live births in text back into English to check whether the original mean- 2015 and to the increased skilled birth attendance ing was still present. rate from 28 to 91% [22, 23]. The questionnaire pertained to socio-demographic This study aimed to assess practices around and factors variables such as age, residence, religion, education level, associated with BP/CR among pregnant women admitted marital and employment status, and other variables with with obstetric emergencies in a rural Rwandan hospital. regard to antenatal care (including type of advice re- ceived and type of health worker seen), obstetric history, Methods reasons for referral. With regard to knowledge of obstet- Design ric danger signs, we assessed whether a woman, when This was a cross-sectional study among pregnant prompted, could mention danger signs and symptoms women who were referred for obstetric emergencies to such as vaginal bleeding, fits, swelling of face or limbs, Ruhengeri hospital, Musanze district, Rwanda, between fever, loss of consciousness, headache, abdominal pain, July and November 2015. prolonged labor and retained placenta. Lastly, four ‘BP/CR questions’ verified whether the Setting woman had taken one of the following four steps: A) According to the Population Census, Musanze district identification of a skilled birth attendant, B) identifica- had a population of 368,267 inhabitants with a total fer- tion of the location of the closest appropriate care facil- tility rate of 4.6 births per woman in 2012. Health insur- ity, C) identification of a means of transport to that ance coverage was 85.1%, and 65.3% of women who gave facility, D) saving money for hospital costs/birth mate- birth with assistance from a skilled birth attendant. Up- rials. Women answering ‘yes’ to at least three of these take of postnatal care by skilled personnel was 4.5% . four BP/CR questions were labeled ‘well prepared’. Health promotion and counseling as part of BP/CR are Remaining women were labeled ‘less prepared’. We also provided by community health workers in addition to assessed whether mentioning of at least two danger signs other facility-based professionals. Community health during pregnancy, childbirth or postpartum was associ- workers sometimes escort laboring women to health ated with being well prepared. facilities. Ruhengeri hospital acts as a provincial referral hospital Data analysis for women with high-risk pregnancies and referrals from Data were entered, coded, cleaned and analyzed using SPSS health centers and other district hospitals in the north- for Windows Version 18.0. After the initial descriptive ana- ern province. Medical services offered are covered by lysis, bivariate analysis was done to test for associations be- community-based health insurance (‘Mutuelle de Santé’) tween the dependent variable BP/CR and independent at contribution of an annual fee of RWF 3000 (US$4.5), variables using Pearson’s chi square or Fischer’sexact test. with a 10% surcharge for each episode of illness. In case Factors that were found to have p-values below 0.2 in the of shortages of supplies, patients are requested to bivariate analysis were entered into multivariable logistic Smeele et al. BMC Pregnancy and Childbirth (2018) 18:190 Page 3 of 7 regression model to compare women who were well pre- complications (73.1%) and where to give birth (76.3%), pared with those who were less prepared. identifying transport (67.1%), identifying a skilled birth at- tendant (17.7%) and saving money (76.9%) (Table 2). Results Regarding knowledge of key danger signs, vaginal bleed- Of all 350 women who were interviewed, mean age was ing was the most frequently mentioned complication by 27.7 years. Characteristics are shown in Table 1. women during pregnancy (61.1%), labor/birth (73.1%) and All respondents had attended ANC at least once during postpartum (58%) (Table 3). Prolonged labor, which is one this pregnancy; 131 women (37.4%) had completed the of the leading causes of maternal morbidity, was reported recommended four or more antenatal visits. Mean ante- by only 13.7%. Most women knew at least one key dan- natal visits were 2.9 ± 0.9. Almost two out of three women ger sign during pregnancy (n = 296; 84.6%), labor/birth (59.4%) had received education on the importance of (n = 271; 77.4%) and postpartum (n = 288; 82.3%). Only knowing danger signs, knowing where to go in case of 23 women (6.6%) had knowledge of three or more key danger signs during the three periods. In practice, 46 women (13.1%) had identified a skilled Table 1 Socio-demographic and obstetric characteristics birth attendant, 68 (19.4%) a facility to give birth, and 76 Characteristics Number (n) Percent (%) (21.7%) a means of transportation. Most women (n =306; Age (Years) (Mean ± SD; 27.7 ± 6.0) 87.4%) had saved money for hospital costs/birth materials < 20 35 10.0 Table 2 Antenatal care uptake and advice given 21- 29 188 53.7 Characteristics Number Percent > 30 127 36.3 Antenatal attendance (Mean ± SD; 2.9 ± 0.9) Marital status ≥ 4 131 37.4 Married 327 93.4 2-3 185 52.9 Not currently married 23 6.6 1 34 9.7 Residence (district) Gestational age at first antenatal visit Musanze 267 76.3 1st trimester 267 76.3 Others 83 23.7 2nd trimester 60 17.1 Education 3rd trimester 23 6.6 None 114 32.6 Personnel checked Primary 193 55.1 Health professional 147 41.7 Secondary and Above 43 12.3 Community health workers 203 58.3 Occupation Advice on danger signs during pregnancy, childbirth, or postpartum Housewife 195 55.7 Yes 208 59.4 Own business/private employee 98 28.0 No 142 40.6 Government/salaried employee 57 16.3 Advise on where to go if danger signs happen Religion Yes 256 73.1 Christianity 318 90.9 No 94 26.9 Islam 32 9.1 Advise on identifying health facility Parity (Mean ± SD; 2.6 ± 1.9) Yes 267 76.3 1 123 35.1 No 83 23.7 2–4 176 50.3 Advise on arrangement for transport > 5 51 14.6 Yes 235 67.1 Prior stillbirth No 115 32.9 No 290 82.9 Advise on saving money for delivery or emergency Yes 60 17.1 Yes 269 76.9 Travel time to health facility No 81 23.1 < 1 h 215 61.4 Advise on identifying skilled birth attendant ≥ 1 h 135 38.6 Yes 62 17.7 Mean ± Standard Deviation Single, divorced and widowed No 288 82.3 Other Nyabihu/Rubavu/Burera/Gakeke Smeele et al. BMC Pregnancy and Childbirth (2018) 18:190 Page 4 of 7 Table 3 Women’s awareness of obstetric danger signs during pregnancy, birth and postpartum Obstetric danger signs Awareness Pregnancy Labor/Childbirth Postpartum n % n % n % Vaginal bleeding 214 61.1 256 73.1 203 58.0 Fits of pregnancy 15 4.3 11 3.1 2 0.6 Swelling of face/lower limbs 52 14.9 98 28.0 High grade fever 20 5.7 13 3.7 18 5.1 Loss of consciousness 41 11.7 3 0.9 29 8.3 Severe headache 39 11.1 19 5.4 67 19.1 Dizziness/blurred vision 31 8.9 22 6.3 Severe abdominal pain 50 14.3 46 13.1 Baby does not move 22 6.3 Difficulty in breathing 14 4.0 9 2.6 Severe weakness 67 19.1 41 11.7 Water breaks without labor 88 25.1 Prolonged labor 48 13.7 Retained placenta 125 35.7 Foul smelling vaginal discharge 30 8.6 Do not know any of the above 54 15.4 79 22.6 62 17.7 (Table 4). About one in five women (n = 78; 22.3%) were considered ‘well prepared’ in terms of BP/CR. The adjusted multivariate model showed that sig- nificant predictors for being well prepared were first time pregnancy (adjusted odds ratio (aOR) = 3.2; 95% CI 1.2–5.8), knowledge of at least two danger signs Table 4 Birth preparedness among pregnant women during pregnancy (aOR = 2.8; 95% CI 1.7–3.9) and Level of birth preparedness Number Percent having seen a community health worker (aOR = 2.2, Identified health facility 95% CI 1.3–3.7) (Table 5). Yes 68 19.4 No 282 80.6 Discussion Our findings show that involving community health Arranged for transport workers in antenatal care, as well as counseling on danger Yes 76 21.7 signs during pregnancy may be two effective strategies to No 274 78.3 promote birth preparedness. Although factors such as ad- Saved money vanced maternal age, higher education, better antenatal Yes 306 87.4 care attendance and occupation of a woman or her part- No 44 12.6 ner were previously found to be associated with increased BP/CR in other studies [12, 15, 25], this was not the case Identified skilled birth attendant in our population. Yes 46 13.1 Similar to other settings, a high proportion of women No 304 86.9 reported to have received advice on BP/CR [13, 18, 19]. Number of steps taken This may be explained by the wide availability of com- 0 81 23.1 munity health workers throughout Rwanda. Community 1 129 36.9 health workers engage women and their families into formulating birth plans on a one-to-one basis prior to 2 62 17.7 childbirth . Still, a number of women do miss out on 3 66 18.9 BP/CR advice, even if they attend antenatal care. More- 4 12 3.4 over, a considerable number of women had not followed At least 3 steps taken 78 22.3 the advice they were given, perhaps due to poor Smeele et al. BMC Pregnancy and Childbirth (2018) 18:190 Page 5 of 7 Table 5 Characteristics of well-prepared women versus those less-prepared Characteristics Birth preparedness COR (95% CI) aOR (95% CI) Well (n = 78) Less (n = 272) Age (Years) < 25 41 (52.6) 167 (61.4) 0.9 (0.4-2.0) 0.6 (0.5-1.4) ≥ 25 37 (47.4) 105 (38.6) 1.0 Marital status Married 70 (89.7) 257 (94.5) 1.0 Not currently married 8 (10.3) 15 (5.5) 2.0 (0.8-4.8) 1.2 (0.3-4.2) Occupation Irregular income 66 (84.6) 227 (83.5) 1.0 Regular income 12 (15.4) 45 (16.5) 1.0 (0.4-1.9) 0.7 (0.3-2.1) Education None or Primary 68 (87.2) 239 (87.9) 1.0 Secondary and above 10 (12.8) 33 (12.1) 1.3 (0.5-3.0) 0.8 (0.5-1.1) Parity 1 38 (48.7) 85 (31.3) 2.5 (1.4-4.3) 3.2 (1.2–5.8) 2-4 27 (34.6) 149 (54.8) 1.0 ≥ 5 13 (16.7) 38 (13.9) 1.9 (0.9-4.0) 0.7 (0.3-1.3) Prior stillbirth No 64 (82.1) 226 (83.1) 1.0 Yes 14 (17.9) 46 (16.9) 1.1 (0.5-2.0) 0.8 (0.5-1.4) Antenatal attendance < 4 times 3 (3.8) 216 (79.4) 1.0 1.0 ≥ 4 times 75 (96.2) 56 (20.6) 1.9 (1.7-2.4) 1.3 (0.8-2.1) Personnel checked during ANC Health professional 22 (28.2) 125 (46.0) 1.0 1.0 Community health worker 56 (71.8) 147 (54.0) 1.4 (1.2-1.9) 2.2 (1.3-3.7) Knowledge of at least 2 danger signs during pregnancy Yes 41 (52.6) 70 (25.7) 3.1 (2.2-4.6) 2.8 (1.7-3.9) No 37 (47.4) 202 (74.3) 1.0 1.0 Knowledge of at least 2 danger signs during childbirth Yes 31 (39.7) 27 (9.9) 2.3 (1.1-4.6) 1.6 (0.8-2.7) No 47 (60.3) 245 (90.1) 1.0 Knowledge of at least 2 danger signs during postpartum Yes 16 (20.5) 38 (14.0) 1.5 (0.8-2.8) 0.8 (0.5-1.4) No 62 (79.5) 234 (86.0) 1.0 CI confidence interval, OR odds ratio Any 3 of 4 steps: identified a skilled birth attendant, identified a health facility, arranged for transport and saved money for emergency Adjusted for all the independent variables indicated in the table Single, divorced and widowed understanding of what the components of BP/CR actu- There were marked differences with regard to how ally entail, or to poor delivery of the messages. This find- frequent various danger signs were mentioned. In line ing stresses the importance of improved training for with previous reports by others, vaginal bleeding during health providers on how to better communicate BP/CR- pregnancy, childbirth and postpartum was the most related messages and the need to address additional bar- commonly reported key danger sign [16, 18]. On the riers to the uptake of BP/CR. contrary, prolonged labor, which is another leading cause Smeele et al. BMC Pregnancy and Childbirth (2018) 18:190 Page 6 of 7 of maternal deaths in Rwanda [22, 23] was mentioned by considerable improvements in pregnancy outcome in only few women in this study. Rwanda [21, 33, 34]. Our findings indicated low levels of knowledge of dan- ger signs and birth preparedness respectively, lower than Conclusions in other low-income countries [14, 18]. This may be due This study revealed low levels of knowledge of obstetric to our facility-based rather than community-based study danger signs and low levels of birth preparedness among setting. In addition, we applied the criterion of three out women referred to a Rwandan hospital. Prenatal advice of four BP/CR components for being ‘well prepared’, by community health workers and knowledge of danger where another study applied three out of five . signs during pregnancy are associated with being better Nevertheless, the underlying principles and methods prepared for birth. Investments in health promotion used to study BP/CR are the same. with regard to BP/CR, at all stages of a woman’s repro- Nulliparous women were better prepared than multip- ductive life, and with support from community health arous women, perhaps due to the misconception that workers are much needed. We recommend a review of after the first pregnancy BP/CR may not be required the quality and methods of antenatal care education, in- anymore. This is an indication that the frequency or cluding an evaluation of how multiparous women are quality of BP/CR messages given to multiparous women also to benefit from such education, in order to improve may be reduced, although these should clearly aim to the effectiveness of BP/CR. also target multiparous women. Women who knew at least two key danger signs were Additional file found more likely to be well prepared, which is similar to previous studies [12, 16, 18]. This illustrates that knowing Additional file 1: Consent form and questionnaire. Consent form as used in the study and questionnaire adapted from the ‘Safe Motherhood danger signs may be an essential step towards behavioral questionnaire’, as developed by the Maternal Neonatal Program of change. This opens up possibilities for a number of poten- JHPIEGO, an affiliate of John Hopkins University. (DOCX 63 kb) tial interventions, such as the need for community-based health promotion programs and health promotion efforts Abbreviations at the facility in all stages of a woman’s reproductive life aOR: Adjusted odds ratio; BP: Birth Preparedness; CR: Complication Readiness; OR: Odds ratio . In addition, BP/CR requires that health services are equipped to meet the increased demand for care [28, 29]. Acknowledgements Women who had seen community health workers We are grateful to the administration and staff of Ruhengeri hospital. We thank Desire Dusegimana, in particular, for support with data collection. had better outcomes with regard to BP/CR [26, 30]. This may be explained by the high level of community Availability of data and materials recognition for community health workers in Rwanda The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. . Therefore, in general, and particularly in settings where other health workers are scarce, community Authors’ contributions health workers should receive appropriate recognition RK designed the study and wrote the protocol. PS, RK collected data, RK and support [26, 31, 32]. worked on the data analysis, assisted by JvR and TvdA. PS and RK drafted the manuscript. MvE, JvR and TvdA critically revised the draft manuscript. All The strength of this study is that the interview took authors read and approved the final manuscript. place shortly after birth, minimizing recall bias. The fact that these women were referred for complications makes Ethics approval and consent to participate The Rwanda National Ethical Committee granted ethical clearance for the for a selected study population and it is difficult to infer study (reference identification: N°582/RNEC/2013). Interviewers explained to our results to the general pregnant population. More- the participants the contents of a written consent form, including their right over, some women may recall or provide information to withdraw from participating at any point during data collection. All participants provided written informed consent to participate. All interviews about BP/CR selectively, depending on their experience were conducted in private and every precaution was taken to ensure during birth or pregnancy outcome. confidentiality. Nevertheless, we believe our study provides relevant Competing interests information on possible opportunities to improve BP/ Two of the authors are members of the editorial board of the journal: JvR is CR. The fact that Rwanda is a densely-populated country a section editor and TvdA an associate editor. with relatively widespread availability of health facilities (most women live less than an hour’stravelaway from a Publisher’sNote facility), combined with increasing government invest- Springer Nature remains neutral with regard to jurisdictional claims in ment in community-based health programs, performance- published maps and institutional affiliations. based financing, innovative community health insurance Author details and SMS-based alert systems are all reasons why better 1 Department of Medical Humanities, VU University Medical Center, implementation of BP/CR has the potential to lead to Amsterdam, the Netherlands. Department of Obstetrics and Gynecology, Smeele et al. 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