ABSTRACT
Women die from a wide range of complications in pregnancy, childbirth or after delivery, and amidst these complications is pre-eclampsia, which is one of the major causes of maternal death and disability in Nigeria. To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed for any intervention program to be effective. The objective of the study was to investigate the factors associated with the health care-seeking behaviours regarding pre-eclampsia among pregnant women attending antenatal centres in Sagamu, Ogun State, Nigeria.
The study designwas cross-sectional, utilizing a pre-tested 42-item questionnaire (Cronbach’s alpha of 0.81) to collect information about knowledge regarding pre-eclampsia, perceived susceptibility, seriousness, and perceived benefits of good health care-seeking behaviour among pregnant women attending maternity centres in Sagamu, Ogun State, Nigeria. Four hundred participants recruited from eight antenatal centres in randomly selected eight communities in Sagamu, participated in the study. Pearson’s bivariate correlation was used to examine relationships between independent and dependent variables while multiple regression was adopted to test for the hypothesis.
Results showed that Knowledge about pre-eclampsia as an important pregnancy complication measured on a 16-point scale recorded a mean score of 6.82 (±3.53)and perception of pre-eclampsia considered in three sub-domains of susceptibility, seriousness and benefit, measured on a 30-point scale, similarly recorded a mean score of 13.41 (±5.39); while health care-seeking behavior, measured on a 30-point scale, showed that participants in the study recorded a mean scored of 9.96 (±8.11). Knowledge about pre-eclampsia was below average (42.6%), perceived susceptibility, seriousness and benefit measured was 39.3%, 50.7%, and 49% respectively, as well as their health care-seeking behaviour (33.2%). There is a significant relationship between the variables and health care-seeking behaviour regarding pre-eclampsia (P=0.0001). However, perception domain regarding pre-eclampsia predicts health care-seeking behaviour more significantly (R – 0.57 = 57%; R2 = 0.33; F-value = 194.44; β = 0.86; P-value = 0.0001 < 0.0005)
In conclusion, there is poor health care-seeking behaviour among respondents regarding pre-eclampsia in the study area which according to the finding, is as a result of low level of knowledge about the disease with low perception level about the condition. Therefore, in order to correct this, there should be an aggressive health promotion intervention designed toempower women with the required knowledge and thereby, increasing their perception level regarding pre-eclampsia, especially perceived susceptibility to pre-eclampsia, that will prompt good health care-seeking behaviour. This will in turn make future interventions effective.
Keywords: Pre-eclampsia, Intervention, Behaviour, Knowledge, Perception, Susceptibility
Word Count: 405
TABLE OF CONTENTS
Content Page
Title Page i
Certification ii
Dedication iii
Acknowledgements iv
Abstract v
Table of Contents vi
List of Tables viii
List of Figures ix
CHAPTER ONE: INTRODUCTION
1.1 Background to the Study 1
1.2 Statement of the Problem 3
1.3 Objective of the Study 4
1.4 Research Questions 4
1.5 Justification for the Study 5
1.6 Hypotheses 7
CHAPTER TWO: REVIEW OF LITERATURE
2.1Maternal Mortality 8
2.2 Three Delays of Maternal Mortality 10
2.3 Overview of Pre-eclampsia 10
2.4 Diagnosis of Pre-eclampsia 11
2.5 Pathophysiology of Pre-eclampsia 12
2.6 Classification of Pre-eclampsia 15
2.7 Causes of Pre-eclampsia 15
2.8 Risk Factors of Pre-eclampsia 15
2.9 Pre-eclampsia Complications 16
2.10 Pre-eclampsia Associated Maternal and Prenatal Mortality 16
2.11 Signs and Symptoms of Pre-eclampsia 17
2.12 Management/Treatment of Pre-eclampsia 17
2.13 Knowledge and Perception about Pre-eclampsia 18
2.14 Health Seeking Behaviour in relation pre-eclampsia 19
Content Page
2.15 Barriers to good health care-seeking during pregnancy 20
2.16 Conceptual Model 22
2.16 Application of HBM to Study 25
CHAPTER THREE: METHODOLOGY
3.0 Introduction 28
3.1 Research Design 28
3.2 Population 28
3.3 Sample size and sampling Technique 30
3.4 Instrument 33
3.5 Validity and Reliability of Instrument 33
3.6 Method of Data Collection 34
3.7 Method of Data Analysis 34
3.8 Ethical Consideration 35
CHAPTER FOUR: DATA ANALYSIS, RESULTS AND
DISCUSSION OF FINDINGS
4.0 Introduction 36
4.1 Data Analysis 36
4.2 Results 37
4.3 Discussion of Findings 54
CHAPTER FIVE: SUMMARY, CONCLUSION
AND RECOMMENDATIONS
5.1 Summary 57
5.2 Conclusion 58
5.3 Recommendations 58
REFERENCES 60
APPENDICES 66
LIST OF TABLES
Table Page
- List of Countries with Highest MMR and IU 9
- Sample Technique and Sample size representation 32
- Socio-demographic & Reproductive Characteristics 38
- Level of Knowledge of Respondents 40
- Aggregate Perception Variables 42
- Level of Perception Susceptibility, Seriousness, and Benefit 43
- HCSB of Respondents (Mean Score) 45
- HCSB of Respondents (Frequency Distribution) 46
- Relationship between Knowledge and HCSB 48
- Relationship between Perceptions and HCSB 50
- Factor with Greater Significance 52
LIST OF FIGURES
Figure Page
- Pathophysiology of pre-eclampsia 14
- Health Belief Model (Theoretical Framework) 24
- Health Belief Mode (Conceptual Model) 27
CHAPTER ONE
INTRODUCTION
1.1 Background to the Study
Pregnancy and delivery for most women, include physiological and psychosocial changes in the body constituting a major life event. Pregnancy throughout the world is regarded as a perfect normal stage, mile stone to motherhood, and a moment of celebration. However to many, especially in the developing Countries, it is a moment of sadness, pain, disability, and death (Zhianian, Zareban, Ansari, & Rahimi, 2015).
Globally, approximately 830 women die from pregnancy or childbirth-related complications around the world every day and about 99% occur in developing countries (World Health Organization [WHO], 2015).Nearly 80% of the maternal deaths are caused by the five direct obstetric causes namely haemorrhage, hypertension, sepsis, obstructed labour and complications of abortion (WHO, 2015). Hypertensive diseases of pregnancy (pre-eclampsia and eclampsia) are considered to be common causes of maternal deaths world-wide, contributing to 18% of the deaths, being the second after haemorrhage as the most common cause of maternal deaths (WHO, 2015).Pre-eclampsia is one of the leading causes of maternal mortality and morbidity worldwide (WHO, 2014).
In both developed and developing countries, preeclampsia continued to be a significant public health issue contributing to maternal and perinatal mortality and morbidity. However, the effect of the disease is felt more severely in developing countries where, unlike hemorrhage and sepsis, medical interventions may be ineffective due to late presentation of pre-eclampsia cases (Osungbade & Ige, 2011).
In Nigeria, pre-eclampsia is one of the leading causes of maternal mortality and morbidity due to late presentation of women at hospital (Onakewhor & Gharoro, 2008). Furthermore, there are frequent severe cases of pre-eclampsia, following delays in identification/management at the community level and further delays in referral and transportation of women to higher facilities when necessary (Onakewhor & Gharoro, 2008).
The opinion pregnant women have toward the cause of their health problems varies, while some view it as a result of traditional black magic or spiritual attack, others have no clue of the cause of their health problem in their pregnant state. These opinion of theirs therefore have effect on their health care-seeking behaviour (Egbuniwe, Egboka, & Nwankwo, 2016). Furthermore, Martina and Franklin (2015), contributed that maternal and perinatal mortality and morbidity constitutes a major challenge around the world especially in the developing countries. These are associated with inappropriate health seeking behaviour during pregnancy (Martina & Franklin, 2015).
The Millennium Development Goals (MDGs) which was adopted by the international community in 2000, had ‘improving maternal health’, as one of the eight MDGs. Under MDG five, there have been compliance in reducing maternal mortality by 3 quarters between 1990 and 2015 globally. However, in 2015, despite the significant gains in reduction, an estimated 303,000 maternal deaths occur globally, representing a decline of only 43 % since 1990 (estimated 535,000 maternal deaths) and a similar reduction since the adoption of the MDGs in 2000,(estimated 529,000 deaths) which is still far from the target of 75 % reduction (WHO, 2015).In the Sustainable Development Goals, the achievement of the new targets which is to end preventable maternal and new-born mortality, will require universal access to improved delivery of evidence-based solutions for preventable maternal conditions, such as hypertensive disorders of pregnancy (Bhutta et al., 2014).
Utilization of health care facility by pregnant women include antenatal care (ANC), which is the care a pregnant woman receives during her pregnancy through a series of consultations with trained health care workers such as midwives, nurses, and sometimes a doctor who specializes in pregnancy and birth (Nigeria Demographic and Health Survey [NDHS], 2013). However, an analytical review of recent world health statistics showed that ANC coverage in Nigeria is low and is indirectly correlated with the high maternal mortality ratio recorded. The poor maternal health outcome in Nigeria could be a result of poor utilization of maternal health care services (WHO, 2014).
Most studies of pre-eclampsia (McClure, Saleem, Pasha, & Goldenberg, 2009; Osungbade & Ige, 2011; Shah, 2009) focus on management and treatment of preeclampsia, while few others focus generally on determinants of health care seeking behaviour in pregnancy (Akeju, et al., 2016; Furuta & Salway, 2006; Titaley & Dibley, 2010). However, understanding the individual perceptions, and modifying factors associated with health care-seeking behaviour of women regarding pre-eclampsia is critical in addressing this problembecause even though efforts to minimize and cure the complication of pre-eclampsia have been recorded, additional steps are need to be taken to achieve the preventive goal.
1.2 Statement of the Problem
Illness and death related to pregnancy and childbirth are significant health problems in the world especially in developing countries. Nigeria is among the countries with the greatest burden of maternal mortality in the world with 15% (45, 000) of global maternal deaths (Singh, Ahmed, Egondu, & Ikechukwu, 2015), and a high maternal mortality ratio of 814/100,000 live births was recorded for Nigeria (WHO, 2015).According to the United Nations Population Fund (UNFPA, 2016) this is equivalent to about one woman every two minutes and for every woman who dies 20 or 30 encounter complications with serious or long-lasting consequences.
Pre-eclampsia is a problem in Nigeria. A recent statistics carried out in Nigeria shows that, approximately 37, 000 women die annually due to pre-eclampsia and its complications(Adeosun, Ayebatonyo, Ogundahunsi, & Ogunlewe, 2015). In Sagamu, Ogun State, a high maternal mortality ratio of 7, 480/100,000 live births was recorded and pre-eclampsia contributed to about 60% of these deaths. (Olukoya & Sodipo, 2015)
Pre-eclampsia is associated with high risks of maternal complications such as abruption placenta, premature delivery, disseminated coagulopathy, pulmonary oedema, acute renal failure, eclampsia, liver failure, haemorrhage, and maternal death. It is also associated with higher risks of adverse perinatal outcomes such as low birth weight, intrauterine foetal growth restriction, hypoxia-neurologic injury and foetal death. Pre-eclampsia also impacts the social and economic life of a pregnant woman. In addition, infants who are born after a pregnancy complicated by preeclampsia are at increased risk of metabolic syndrome, stroke and cardiovascular disease later in life (Brown, et al., 2013; Raymond & Peterson, 2011).
The recognition of pre-eclampsia today is largely healthcare provider dependent, which as a result, the disease still remains essentially unpreventable. Low pre-eclampsia knowledge and lack of information on pre-eclampsia signs and symptoms are closely linked to delay in decision to seek care and ultimately compromises the survival of the mother and expected new-born because they have not understood the need to utilize health care facility for quality care (Adekanle, Adeyemi, Olowookere, & Akinleye, 2015).To improve maternal health, barriers that limit access to quality maternal health services must be identified and addressed at all levels of health system.
Therefore, the purpose of this study is to investigate individual perceptions, and modifying factors associated with health care-seeking behaviour regarding pre-eclampsia among pregnant women attending ANC in Sagamu, Ogun State, Nigeria, and to determine the extent to which their knowledge, perception of seriousness and susceptibility to pre-eclampsia may contribute to present situation of health care-seeking behaviour.
1.3 Objective of the Study
The main objective of this study is to investigate the factors associated with the health care-seeking behaviours regarding pre-eclampsia among pregnant women attending antenatal centres in Sagamu, Ogun State, Nigeria. The specific objectives are to;
- assess the level of knowledge of pregnant women in the study area about pre-eclampsia.
- determine the perceptions of pregnant women attending maternity centres in Sagamu Ogun State about pre-eclampsia.
- identify the health care-seeking behaviours regarding pre-eclampsia among pregnant women attending maternity centres in Sagamu, Ogun State.
- examine the relationship between knowledge of pre-eclampsia and health care-seeking behaviours forperceived pre-eclampsia among pregnant women attending maternity centres in Sagamu, Ogun State.
- examine the relationship between perceptions of pre-eclampsia and health care-seeking behaviours for perceived pre-eclampsia among pregnant women attending maternity centres in Sagamu, Ogun State.
- determine the variables that will predict the health care-seeking behaviour of pregnant women more significantly.
1.4 Research Questions
- What is the level of knowledge about pre-eclampsia among pregnant women attendingmaternity centres in Sagamu Ogun State?
- What is the perceptions of pre-eclampsia and its warning signs and symptoms among pregnant women attending maternity centres in Sagamu Ogun state?
- What are the health care-seeking behaviours regarding pre-eclampsia among pregnant women attending maternity centres in Sagamu, Ogun State?
- Is there a relationship between knowledge of pre-eclampsia and health care-seeking behaviours for perceived pre-eclampsia among pregnant women attending maternity centres in Sagamu, Ogun State?
- Is there a relationship between perceptions of pre-eclampsia and health care-seeking behaviours for perceived pre-eclampsia among pregnant women attending maternity centres in Sagamu, Ogun State?
- Which of thevariableswill predict the health care-seeking behaviour more significantly?
1.5 Justification for the Study
Women die from a wide range of complications in pregnancy, childbirth or after delivery especially in the developing world, and amidst these complications is pre-eclampsia, which is one of the major causes of death and disability in Nigeria (Gharoro & Onakewhor, 2008).
Although number of studies and interventions (Akeju et al., 2016; Furuta & Salway, 2006; McClure, Saleem, Pasha, & Goldenberg, 2009; Osungbade & Ige, 2011; Shah, 2009; Titaley & Dibley, 2010), have been carried out in Nigeria to treat and manage pre-eclampsia, the problem still persists and little is known about pregnant women’s individual perceptions towards pre-eclampsia and the modifying factors that are associated with their pattern of health care-seeking behaviour. Therefore, this study will reveal pregnant women level of knowledge about pre-eclampsia, their perceptions, and pattern of health care-seeking regarding pre-eclampsia, thereby equipping them with appropriate knowledge, adequately motivated and encouraged to develop better health care-seeking behaviour for good maternal and perinatal outcome.
In recent years, safe motherhood programs was initiated to focus on improving recognition of complications by family members and traditional providers, as well as facilitating use of skilled care for women with complications, and strengthening the availability and quality of obstetric care. Programs were developed to disseminate messages on recognition of warning signs that may indicate life-threatening complications, planning for transportation to a selected secondary facility if a complication occurs, and saving money to pay for care. Unfortunately, there is no evidence that these strategies work, and care is typically sought too late or not at all (Khlat & Ronsmans, 2009). This study will focus on pregnant women for these interventions to work effectively.
The practice of good health care-seeking behaviour by pregnant women is important as it will help in prompt diagnosis, management, and treatment of any underlying health problem especially pre-eclampsia, which will reduce or halt maternal and perinatal mortality and morbidity. Hence, pregnant women’s individual perceptions regarding pre-eclampsia and modifying factors associated with their pattern of health care-seeking behaviour needs to be explored using the Health Belief Model, so as to identify relevant areas that will facilitate designing appropriate intervention programmes. This constitutes the focus of this study in Sagamu, Ogun State, Nigeria.
During pregnancy, child-birth, or after delivery, women die from several complications. Most of these deaths are avoidable if women are able to identify pre-eclampsia signs, and seek timely and appropriate emergency obstetrics care (Killewo, Anwar, Bashir, Yunus, & Chakraborty, 2006; Mwilike, 2013). The information obtained from this study will give an insight on pregnant women individual perceptions regarding pre-eclampsia and modifying factors (which include socio-demographics and knowledge) associated with health care-seeking behaviour, which will be beneficial to the following;
Pregnant women – This study will reveal their level of knowledge about pre-eclampsia, perceptions, and pattern of health care-seeking, thereby equipping them with appropriate knowledge, adequately motivated and encouraged to develop better health care-seeking behaviour for good maternal and perinatal outcome
Family and Community – Complications from pre-eclampsia affects not only the woman but her family and community at large. When the woman is healthy, the family is happy, and she can contribute her resources to the growth of the community.
Policy Makers – This study might enable policy makers to effectively plan how to combat the avoidable factors in this study that militate against good health care-seeking behaviours among pregnant women.
Public Health – This study might enable the planning of intervention program to be administered to reduce pre-eclampsia related maternal and perinatal mortality and morbidity. The intervention program will include the development of training materials and posters that emphasize information about pre-eclampsia, training of volunteers to provide health education within the community about pre-eclampsia and the importance of health care-seeking early enough to prevent complications.
1.6 Hypotheses
The following research hypotheses were tested for the study;
H01: There is a significant relationship between the knowledge of pre-eclampsia and health care-seeking behaviours among pregnant women attending maternity centres in Sagamu, Ogun State.
H02: There is a significant relationship between perceptions about pre-eclampsia and health care-seeking behaviours among pregnant women attending maternity centres in Sagamu, Ogun State.
H03: There is a significant difference in the health care-seeking behaviour regarding pre-eclampsia across variables of study.
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