|Year : 2022 | Volume
| Issue : 2 | Page : 134-140
Evaluation of birth preparedness and complication readiness index among women of central India: A community-based survey of slums
Tripti Chandrakar1, Nirmal Verma1, Shubhra A Gupta1, Diwakar Dhurandhar2
1 Department of Community Medicine, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India
2 Department of Anatomy, Pt. J.N.M. Medical College, Raipur, Chhattisgarh, India
|Date of Submission||14-May-2022|
|Date of Decision||03-Jun-2022|
|Date of Acceptance||07-Jun-2022|
|Date of Web Publication||29-Aug-2022|
Dr. Tripti Chandrakar
Department of Community Medicine, Pt. J.N.M. Medical College, Opposite Jail Road, Raipur - 492 001, Chhattisgarh
Source of Support: None, Conflict of Interest: None
Background: Chhattisgarh is one of the worst performing states of India in terms of maternal mortality ratio figures. Slums carry the unfortunate burden of maximum maternal deaths. Birth Preparedness and Complication Readiness(BPCR) advocates planning of birth and being ready for any obstetric complications. Aim: To evaluate the BPCR index among first and second trimester pregnant women and those delivered within 6 months living in urban slums of Raipur city. Methods: A population-based, cross-sectional descriptive study was conducted among 160 pregnant and 70 recently delivered women residing in urban slums of Raipur city selected by multistage random sampling using an interview method. BPCR index was calculated using Johns Hopkins Program for International Education in Gynaecology and Obstetrics guidelines. BPCR components were correlated for any association with sociodemographic variables of the participants using Z test. Results: BPCR index came out to be 34.1%, which was very low. Factors associated with ≥4 antenatal care visits were general category women (P = 0.0375) and homemakers (P = 0.0057). Identifying skilled provider was higher in educated women (P = 0.0001), those with educated husbands (P = 0.0085), working (P = 0.0167) and with higher socioeconomic status (P = 0.0013). Saving money for childbirth was more among general category (P = 0.0067), educated (P = 0.0094) and women with low socioeconomic status (P = 0.0004). Conclusions: BPCR index of the study area was found to be very low.
Keywords: BPCR Index, birth preparedness, complication readiness, Maternal Mortality
|How to cite this article:|
Chandrakar T, Verma N, Gupta SA, Dhurandhar D. Evaluation of birth preparedness and complication readiness index among women of central India: A community-based survey of slums. J Med Evid 2022;3:134-40
|How to cite this URL:|
Chandrakar T, Verma N, Gupta SA, Dhurandhar D. Evaluation of birth preparedness and complication readiness index among women of central India: A community-based survey of slums. J Med Evid [serial online] 2022 [cited 2022 Oct 5];3:134-40. Available from: http://www.journaljme.org/text.asp?2022/3/2/134/354985
| Introduction|| |
The maternal mortality ratio (MMR) in India is 103/100 000 live births. Chhattisgarh is among the low-performing states with one of the worst MMR of 160/100,000 live births. Women of slums constitute a vulnerable group and disproportionately represent highly in overall maternal mortality figures.,
Birth Preparedness and Complication Readiness (BPCR) is preparing for birth and being ready for any obstetric emergency. With already proven evidence that women of slums contribute majorly in maternal mortality figures and only one previous study on assessment of BPCR in slum population, the present study was conducted in randomly selected urban slums of Raipur city. No previous study was found adapting the Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO) manual for the assessment of BPCR index in India to the best of our knowledge.
| Materials and Methods|| |
Chhattisgarh is a state in Central India whose capital city is Raipur. Population of Raipur city is 1,010,433 according to the Census 2011.
Study design and period
A cross-sectional study was conducted at household level between January 2018 and March 2019. The population-based survey was done rather than client exit interview as it is more accurate and valid.
Selected urban slums of Raipur city.
- Pregnant women in the 3rd trimester residing in that area for a minimum period of 6 months
- Women delivered within 6 months' duration from the date of survey.
All those not giving consent for the interview or found absent during survey.
Selection of participants by multistage random sampling technique is illustrated in [Figure 1].
|Figure 1: Flow diagram showing selection of study participants by multistage random sampling. No non-responder found in the study|
Click here to view
Sample size was 230, which was obtained as follows:
where n = sample size, Z = standard normal distribution for 95% confidence interval (its value is 1.96), P = expected prevalence and d = precision. As there is no available literature on BPCR index of women of Chhattisgarh, the following assumptions are made for estimating the sample size: prevalence – 50%, confidence interval 95% and precision – 7.0%.
Adjustment for non responders was 10% which came out to be 20. Sample size = 204 + 20 = 224 rounded off to 230. Thus, the final sample size was 230.
Tools used in the study were as follows:
- Pre-formed, pre-tested, semi-structured questionnaire to assess the sociodemographic profile of the subjects
- JHPIEGO manual toolkit was used for the assessment of BPCR among study participants. The questionnaire used in the present study was developed from JHPIEGO and validated for Indian population and also allows for standardisation, comparison of data from two different countries and tracking the impact made by safe motherhood schemes
- Questionnaire regarding media usage, frequency and preferred modes of receiving messages about BPCR was also administered as given in JHPIEGO manual.
Interviews and observation.
Study proposal was drafted and presented to the institute ethics committee for approval. The approval was given vide letter MC/Ethics/107 dated 17.09.2018. The study was conducted using interview method, before which participants were informed about the purpose and intent of the present research. Autonomy to withdraw from the interview were given due respect. Each participant was assured of confidentiality of the data. Procedures laid down in the declaration of Helsinki were duly followed.
Training of interviewer
It was done before the start of the pilot study under supervision of the head of the department. A set of training manual for the interview was discussed extensively including The guide for interviewer in JHPIEGO manual. Other training methodologies such as role play and improvement of communication skills were given due weightage.
This was done for testing the feasibility of the study by administering a semi-structured Prototype safe motherhood questionnaire from JHPIEGO manual. Study population of 10% of the total sample size (23 women) were interviewed from area different from the study area of Raipur city. After conducting the pilot study, study participants' criteria as standardised in the JHPIEGO manual were modified. Manual defined recently delivered women as those who had given birth 2 years before the interview. It was found that such women had problems in recalling the pregnancy events and services used. Thus, those delivered within 6 months were included in the study as participants to eliminate recall bias. Pregnant women of the early 2nd trimester had not yet faced many of the events; therefore, only pregnant women of the 3rd trimester were included as study participants.
As per the methodology standardised in the JHPIEGO manual, a key informant of the respective wards such as a Anganwadi worker with good repute and understanding of the area was interviewed about the presence of community transport system, community financial system and community blood donor system in the respective slums. If a community support system was not found in existence, assessment of knowledge regarding that community support system was not done on the participants of that slum. Thus, for calculating the indicator %, denominator of the total women interviewed was decreased. Demographic records were obtained from the Anganwadi centre. Selection of the subjects was done from this demographic record using Lottery Method. The interview was conducted in Hindi, which is easily understood and most commonly spoken language in Chhattisgarh. If nobody was seen in the household or was found locked, follow-up visit was done to reach the participant selected by random sampling.
Assessment of sociodemographic profile and knowledge regarding danger signs of the study area had already been reported in the previous research paper.
The components of BPCR index were assessed according as follows:
- Percentage (%) of study participants who could recollect and tell all three key danger signs of pregnancy period
- Percentage (%) of study participants who could recollect and tell all four key danger signs of labour
- Percentage (%) of study participants who could recollect and tell all three key danger signs of post-partum period
- Percentage (%) of study participants who could recollect and tell all four key danger signs in newborn
- Percentage (%) of study participants who went for attending or planned to attend at least 4 antenatal care (ANC) visits
- Percentage (%) of study participants who went for first ANC visit during the first trimester of pregnancy
- Percentage (%) of study participants who either gave birth or planned to give birth with a trained health service provider
- Percentage (%) of study participants who saved or planned to save money for delivery
- Percentage (%) of study participants who have earmarked or planned to earmark a transport modality to health facility
- Percentage (%) of study participants who could successfully tell about the presence of community financial support system
- Percentage (%) of study participants who could successfully tell about the presence of community transport system
- Percentage (%) of study participants who could successfully tell about the presence of community blood donor system
- BPCR index was calculated as unweighted average of above 12 indicators.
The data were entered into MS Excel. Data analysis was done as follows:
Distribution of various components of BPCR Index was tabulated
It was done using MS Excel with MegaStat add-in. Association of various components of BPCR index with sociodemographic variables was done using Z test.
No subgroup analysis was done between pregnant and recently delivered mothers due to the problems of multiplicity and decreased sample size, which may decrease statistical power leading to spurious results.
| Results|| |
Sociodemographic variables of the study participants were evaluated in a previous research.
BPCR index and its components are illustrated in [Table 1] and [Figure 2].
|Table 1: Birth Preparedness and Complication Readiness index of the study participants according to Johns Hopkins Program for International Education in Gynaecology and Obstetrics guidelines|
Click here to view
|Figure 2: BPCR index of the study population with its indicators in percentage of women interviewed. BPCR index was calculated as unweighted average of its 12 indicators as illustrated in the figure. BPCR: Birth Preparedness and Complication Readiness|
Click here to view
Not a single study subject was able to spontaneously recollect all the key danger signs. Out of 230 subjects, 89 (38.7%) did not know or remembered anything about ANC visits. The percentage of women who had done/planned more than equal to 4 ANC visits was 53.9%. 77.4% of women were reported to attend their first ANC visit in the first trimester of pregnancy. Among study participants, only 87 (37.8%) identified a skilled provider for childbirth. Only about 35 (15.2%) subjects saved money for childbirth. More than one-third, i.e., 81 (35.2%) study subjects, earmarked a transport modality to reach health facility. Ninety percentage of women were aware of their community transport system, whereas community-run financial system and blood donor system were known to 71.4% and 28.6%, respectively.
As depicted in [Table 2], factors associated with more than 4 ANC visits were general category women (P = 0.0375) and homemakers (P = 0.0057). Lesser educated women (with <5 years of formal education) (P = 0.0377) had better tendency to visit 1st ANC with a skilled provider within the first trimester. Identifying skilled provider was significantly higher in educated women (P = 0.0001), those with educated husbands (P = 0.0085), working women (P = 0.0167) and with higher socioeconomic status (P = 0.0013). Saving money for childbirth was more among general (P = 0.0067), educated (P = 0.0094) and women with low socioeconomic status (P = 0.0004). Knowledge regarding community transport system was found more in women belonging to joint family (P = 0.0196).
|Table 2: Distribution of study subjects as per their sociodemographic variables and their knowledge regarding components of Birth Preparedness and Complication Readiness|
Click here to view
As shown in [Table 3], when asked about the media usage, 139 (60.4%) respondents reported that they never read newspapers, whereas only 43 (18.7%) responded that they daily read newspapers. One hundred and twenty-six (54.8%) respondents never used to listen to radio, whereas 34 (14.8%) women used to listen to radio daily. Among those who listened to radio, 61.9% preferred to listen to local FM radio channels, whereas Akashvani was preferred by 38.1%. One hundred and ninety-nine (86.5%) respondents answered that they watch television daily. The most preferred modality of media was newspaper (29.1%), followed by hospitals (25.2%) and street drama (20%). Weekend and evening were the preferred timing to hear messages related to birth planning.
|Table 3: Distribution of study participants according to their preferred media modalities to receive Birth Preparedness and Complication Readiness messages|
Click here to view
| Discussion|| |
BPCR index evaluation survey has been standardised by the Maternal and Neonatal Health (MNH) Program of JHPIEGO in collaboration with Family Care International. It elaborates every aspect of conducting a safe motherhood survey such as study design, participant inclusion criteria, training of interviewer before the commencement of the study, ethical Considerations, conduct of pilot phase, data collection and analysis of the results. This formalisation of every aspect of BPCR index allows not only comparison of MNH scenarios between two countries but also one can track the progress and impact of various safe motherhood initiatives with time. Many researches have been conducted in India regarding BPCR index, the components of which vary widely in different literature., The present study strictly adheres to the JHPIEGO manual guidelines which allows future comparisons of impact of safe motherhood initiatives in different settings. Target of reducing the global MMR to below 70/lakh live births has been set as part of Sustainable Development Goal 3. This target can be achieved only by tracking the progress of BPCR interventions by evaluating them and getting rid of the shortcomings of the programme. Evaluating and keeping track of BPCR index assumes even more significance in slum settings, which are known to be a major contributor to MMR.
Before the commencement of the data collection, enumeration areas were surveyed for the presence of community support systems such as financial, transport and blood donor systems by the key informant of the respective wards. These were Anganwadi workers who had good knowledge of the prevailing community support systems. This can also be called as BPCR assessment at community level. It was found that all the wards had community transport system. Only two wards had community financial system, whereas one ward had informal community blood donor system in place. Thus, the participants of only those wards were asked about the presence of community support systems where such support mechanisms were actually found to be in place.
Overall, BPCR index was found to be 34.1% and it was found to be little higher in mothers (40.8%) than pregnant women (31.5%). This observation was similar as found in the study of Mukhopadhyay et al. who assessed BPCR index in rural settings, in which the overall BPCR index was 34.5%, whereas that in pregnant women and mothers was 32.1% and 35.8%, respectively. The statement is correct and requires no correction. However, the higher BPCR index of mothers might be due the fact that they are exposed to whole set of events in the journey from pregnancy to childbirth, which made them more knowledgeable and sensitive than pregnant women of the 3rd trimester of pregnancy. Rajesh P et al. found the value of BPCR index to be 47.5% which was higher than in the present study. This could be due to the different indicators chosen by their study.
None of the participants could spontaneously recollect all the key danger signs of pregnancy, labour, post-partum or neonatal period. More than one-third of the study subjects did not know or remember about number of ANC visits attended, which shows their casual attitude towards pregnancy. More than half of the women had done/planned more than or equal to 4 ANC visits. It is amply proven with the available literature that those pregnant women undergoing three or more ANC check-ups are more likely to have institutional delivery.,, The distribution in the present study is far less than the data of women having ≥4 ANC visits from the District-level Household Survey-4 (2015–2016), which is 89.2% in urban area. This is reflective of poor utilisation of maternity services among women residing in slums. Subjects visiting a skilled provider for more than 3 times was found to be 40% in the study of slums of Indore supporting the above causation. It was more than the finding of Kalisa and Malande. (Rural Rwanda study) and Sumankuuro et al. (Ghana), who got 36.9% and 33% of subjects attending more than 4 ANC visits. Further, less number of non-general participants visited ≥4 ANC to the skilled provider. This might suggest further poor status of maternal services utilisation among non-general category of women belonging to slums. Homemakers usually do not have time and job constraints, which might be a factor explaining more tendency to visit skilled provider for ANC check-ups than working women.
More than three-fourth of the participants had attended first ANC visit within 12 weeks. Scientific evidence are there to strongly suggest that women attending first ANC visit within the first trimester usually have better pregnancy outcomes., In the present study, almost 77% of women were registered before 12 weeks. This is close to the data from the District-level Household Survey-4 (2015–2016), which gave this percentage to be 86%. Only about one-third of the women identified skilled provider for childbirth. An educated, working women with educated husband and better socioeconomic status has the requisite positive environment to identify skilled provider for childbirth.
Only about one-sixth of the women saved money for childbirth. Non-general and less educated women had lesser tendency to save money, suggesting their lack of orientation towards birth planning. This practice of not saving money for emergency expanses can also be due to the reason that government schemes such as Janani Suraksha Yojana and Rashtriya Swastha Bima Yojana (Smart card) are present in Chhattisgarh state, which covers whole expenditures from reaching the health facility to coming back home from hospital. It was a positive finding that women with poor socioeconomic status saved money, thus not completely relying on government schemes which are often fraught with delays and procedural bottlenecks.
It was good to find the presence of informal community transport system in every slum selected for the present study. Auto drivers and tempowalas of slums share their contact numbers to every pregnant women of the area with the help of local Anganwadi worker. This is the only positive finding of community-level assessment despite the presence of government-sponsored Sanjeevani Express, which helps in transportation of pregnant women to health facility and back to home. Women belonging to the joint family had better knowledge regarding community transport system as the fellow females in the house guide the pregnant female with their friendly advices and their own experiences. In contrast, no community financial system was in place in most of the slums. This can be attributed to the presence of better functioning of Janani Suraksha Yojana, which provides financial assistance for childbirth and post-natal care. Community blood donor system was in place in only one slum. Further strengthening of this can be done under the leadership of local Anganwadi worker and auxiliary nurse midwife by mobilising the community and sensitising them.
Media usage preferences will allow us to deliver messages to the beneficiaries in most efficient manner. Message delivery timings and days can be adjusted according to the availability of the target populations as most working women are usually unavailable during the daytime. Innovative approaches such as street drama, pamphlets and pictorial posters in easy-to-understand local language can serve as an effective tool for community mobilisation.
As for all studies, there are certain limitations of the present study. Irrespective of communication skills training to the interviewer, it becomes very difficult to elicit the responses of women due to the strong cultural beliefs and taboos regarding pregnancy and childbirth. There is a great difference in planning and actual execution; thus, women in the 3rd trimester may give positive response to say planning to give institutional delivery. This overestimation of BPCR is a drawback, which can be negated by doing follow-up survey of all 160 pregnant women.
| Conclusions|| |
The BPCR Index in the study population was found to be low. These women belonging to slums form focus groups which if intervened with Political commitment and a definite plan of implementation might help in reducing overall Maternal death figures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Usmani G, Ahmad N. Health status in India: A study of urban slum and non-slum population. J Nurs Res Pract 2018;2:09-14.
Urban Health Resource Centre. “Health of the Urban Poor in India; Key Results from the NFHS, 2005-2006”; 2007.
Jhpiego. Monitoring Birth Preparedness and Complication Readiness: Tools and Indicators for Maternal and Newborn Health; 2004. p. 1-338. Available from: http://pdf.usaid.gov/pdf_docs/Pnada619.pdf
. [Last accessed on 2022 Jul 12].
Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH. Birth preparedness and complication readiness among slum women in Indore city, India. J Health Popul Nutr 2010;28:383-91.
Mukhopadhyay D, Mukhopadhyay S, Nayak S, Biswas A, Biswas A, Bhattacharjee S. Status of birth preparedness and complication readiness in Uttar Dinajpur District, West Bengal. Indian J Public Health 2013;57:147.
] [Full text]
Chandrakar T, Verma N, Gupta SA, Dhurandhar D. Assessment of awareness regarding obstetric and newborn danger signs among pregnant women and recently delivered mothers in urban slums of Raipur city, Chhattisgarh. Indian J Community Health 2019;31:104-11.
Dijkman B. Users' Guide: How to work with subgroup analysis. Can J Surg 2009;52:515-22.
Rajesh P, Swetha R, Rajanna MS, Iyengar K, Mahesh SH, Gowda C. A study to assess the birth preparedness and complication readiness among antenatal women attending district hospital in Tumkur, Karnataka, India. Int J Community Med Public Health 2016;3:919-24.
Moran AC, Sangli G, Dineen R, Rawlins B, Yaméogo M, Baya B. Birth-preparedness for maternal health: Findings from Koupéla District, Burkina Faso. J Health Popul Nutr 2006;24:489-97.
WHO U. Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities: An Analysis of Trends, Levels and Differentials, 1990-2001. Geneva, Switzerland: WHO U; 2003.
Maternal Health Division M of H and F, Welfare. Antenatal Care and Skilled Attendance at Birth by ANMs/LHVs/SNs. New Delhi Maternal Health Division M of H and F, Welfare; 2010.
International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey (NFHS-4) District Fact Sheet Raipur Chhattisgarh, India, 2015-16: Chhattisgarh. Mumbai: IIPS. Available at http://rchiips.org/nfhs/FCTS/CT/CT_FactSheet_410_Raipur.pdf
. [Last accessed on 2022 Jul 12].
Kalisa R, Malande OO. Birth preparedness, complication readiness and male partner involvement for obstetric emergencies in rural Rwanda. Pan Afr Med J 2016;25:91.
Sumankuuro J, Crockett J, Wang S. The use of antenatal care in two rural districts of Upper West Region, Ghana. PLoS One 2017;12:e0185537.
Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, et al
. WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001;357:1565-70.
Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizán J, Farnot U, et al
. WHO antenatal care randomized trial for the evaluation of a new model of routine antenatal care. Lancet 2001;357:1551-64.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]