ISSN: 2376-127X
Journal of Pregnancy and Child Health
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Research Article Open Access

Women’ s Perceptions about Pregnancy and Childbirth and Their Perceived Maternal and Newborn Health Problems in Tigray District, Ethiopia

Kyung-Sook Bang, Insook Lee, Sun-Mi Chae*, Hagos G. Debeb, Hyunju Kang, Juyoun Yu and Ji-Sun Park
Seoul National University College of Nursing & the Research Institute of Nursing Science, 103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
Corresponding Author : Sun-Mi Chae
Seoul National University College of Nursing
& the Research Institute of Nursing Science
103 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
Tel: 82 2 740 8816
Fax: 82 2 740 8816
E-mail: schae@snu.ac.kr
Received: December 30, 2014; Accepted: April 19, 2015; Published: April 23, 2015
Citation: Bang KS, Lee I, Chae SM, Debeb HG, Kang H, et al. (2015) Women’s Perceptions about Pregnancy and Childbirth and Their Perceived Maternal and Newborn Health Problems in Tigray District, Ethiopia. J Preg Child Health 2:155. doi: 10.4172/2376-127X.1000155
Copyright: © 2015 Bang KS, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: The death of women during pregnancy or childbirth period remains a major problem in developing countries. Ethiopia has higher maternal mortality than other developing countries and its high rate is remaining steady. Objective: To identify the perceptions of women about pregnancy and childbirth and their perceived serious maternal and newborn health problems in North Ethiopia. Methods: A total of 1,216 women aged 15-49 years in Tigray, Ethiopia participated in this community-based study. Data were collected using a structured questionnaire through interviews. The t-test and analysis of variance were used for data analysis. Results: The mean age of the women was 32.56 years, and they had an average of 3.89 children. Whereas almost all of them perceived women to have authority in birth planning and health facility visits for antenatal care and childbirth, about a third did not perceive roles for fathers in childbirth and child care. They also showed limited perceptions of serious health problems in pregnancy, childbirth, postpartum, and newborn care. Women’s perceptions of health problems during pregnancy differed significantly by having a husband. Conclusion: Our study findings suggest the need for community-based health education for women in North Ethiopia to increase their perceptions of maternal health and newborn care. We also recommend empowering women to maintain perinatal health and encouraging fathers to be actively involved in child care.

Keywords
Women; Perception; Pregnancy; Childbirth; Newborn; Ethiopia
Introduction
Annually, 141 million infants are born worldwide, and the vast majority (90%) of the births occurs in developing countries [1]. Developing countries with high birth rates report that greater than 60% of their entire populations are women and children. Ethiopia is one of those countries. The women and children of Ethiopia comprise approximately 70% of the total population [2]. Women and children should be carefully considered in terms of global health because of their vulnerability and because they make up a large proportion of the national population [3]. The United Nations (UN) declared the Millennium Development Goals (MDGs) to reduce extreme poverty worldwide [4]. Among the 8 MDGs, MDG 5 is to improve maternal health. The death of women during pregnancy or childbirth period remains a major problem in developing countries, although it has been decreasing [3]. In order to accelerate improvement of women’s health by the year 2015, the 2010 UN summit announced an additional commitment to women’s and children’s health through the Global Strategy for Women’s and Children’s Health.
Ethiopia is the second most populous country in sub-Saharan Africa. About 47% of the population is under 15 years of age and women’s median age of first marriage is 16.5 years [2]. Early marriage, childbirth at a young age, high parity, and short time spacing between pregnancies are likely to increase the number of maternal deaths [5]. A young population and early marriage in Ethiopia can lead women to suffer from health problems related to pregnancy and childbirth. Complications associated with pregnancy and childbirth, such as obstructed labor, ruptured uterus, and vesicovaginal fistula result in high mortality and morbidity of mothers and their newborns in Sub- Saharan Africa [6]. Statistics show that Ethiopia has higher maternal mortality than other developing countries and that its high rate is remaining steady [7]. Regardless of governmental efforts to reduce the maternal mortality rate, the maternal mortality rate of Ethiopia was 590 deaths per 100,000 live births in 2008, which is still much higher than 110 for the East Asian and Pacific countries and 64 for Europe and Central Asia [5].
In addition, a recent national survey reported a low level of antenatal and postnatal care use in women of Ethiopia [2]. Of the women with a live birth in the last 5 years, less than a half (43%) received antenatal care, and only 8% received a postnatal checkup. A very low institutional delivery rate of 4% was also found in Ethiopia [7]. Inappropriate health care during the pregnancy, childbirth, and postnatal periods and young maternal age lead to poor health outcomes of newborns as well as mothers. Young maternal age is significantly associated with a high death rate of infants and high prevalence of low birth weight [8]. Low birth weight infants are at high risk of neonatal death [9]. The neonatal mortality rate of Ethiopia was 37 deaths per 1,000 live births, and perinatal mortality was 46 deaths per 1,000 pregnancies [2]. Hence, maternal and child health during the pregnancy, childbirth, and newborn periods in Ethiopia needs to be improved.
As demonstrated in a study from Ethiopia showing women’s awareness on contraceptives was significantly correlated with their family planning practice [10], understanding women’s perceptions about health or health problems should be the first step in carring out a health intervention for them in a community. Of socio-demographic factors, education level was found to be a significant factor affecting antenatal care and institutional delivery [11] and contraceptive use [10] in Ethiopia. Therefore how women, especially those with lack of education perceive about health during pregnancy and childbirth needs to be examined.
Women’s health status related to family planning, pregnancy, and childbirth has been investigated in Ethiopia; however, their perceptions about serious maternal and newborn health problems have drawn little attention. Further investigations are necessary to understand Ethiopian women’s perceptions of prenatal, childbirth, and postnatal health care.
The purpose of this study was to investigate Ethiopian women’s perceptions about pregnancy and childbirth and their perceived maternal and newborn health problems. The research questions of the study were as follows: 1) how the Ethiopian women viewed about birth planning, husband’s roles, and local health facility use; 2) which maternal and newborn health problems the women considered serious during pregnancy, childbirth, and neonatal periods; and 3) how their perceived health problems were different according to their general characteristics.
Materials and Methods
Study design
The study design was a community-based cross-sectional descriptive study.
Participants of the study
A total of 1,216 women aged 18 to 49 years in Ethiopia participated in this study. The inclusion criteria of the study were women aged 15 to 49 who were married, able to communicate using the local language, Tigrigna, and resided in two rural areas of the Tigray regional state, Kihen and Mesanu, in north Ethiopia. Kihen and Mesanu are small villages called kebeles, the smallest administrative unit in Ethiopia. These two kebeles are included in the Kilte Awulaelo district (woreda) of Tigray. The residents in the Kilte Awulaelo district speak Tigrigna, an official language in Tigray region. The total population of the Kilte Awulaelo district in 2007 was about 112,000, and teff, wheat, barley, and beans are the main grains grown there [12]. To recruit eligible women for this study, a cluster sampling method was used. First, one regional health center at Agulae was chosen out of 5 health centers in Tigray because of the accessibility. Second, two health posts at the Kihen and Mesanu areas were selected because they were the nearest to the Agulae health center. Since Kihen was the main target area of a global maternal child health (MCH) project supported by the South Korean government, all 947 households with married women aged 15 to 49 from Kihen were included. For the Mesanu area, 307 households were randomly selected based on the unit of a village. A total of 1,216 women participated in the study.
Measurement
A safe motherhood population-based survey questionnaire developed in English [13] was used after adapting it appropriately to the objectives of this study to examine Ethiopian women’s perceptions of pregnancy, childbirth, and newborn care. Validity of the adapted questionnaire was evaluated by 2 nursing professors with specialties in maternal and neonatal health. The English version was translated into Tigrigna for the study by an Ethiopian nursing professor in the study area. To measure the women’s perceived health problems during the pregnancy, childbirth, and neonatal periods, they were asked to choose serious health problems that could be occurred during those periods.
The women’s perceptions on birth planning, husband’s roles, and local health facility use were measured using 9 items with a 4-point Likert scale (strongly agree, agreed, disagreed, and strongly disagree) whose reliability coefficient was .67 in this study. Regarding birth planning, the women were asked how much they agree or disagree to plan ahead of time where to give a birth or how to get there. For husband’s roles, we asked how the women considered for their husbands to accompany with them for antenatal care visit or delivery and husband’s roles on giving birth to their child and child rearing. The items of local health facility use were about travel cost to, accessibility to, and staff of the facility. In addition, socio-demographic characteristics of the women collected included years of education, religion, and economic status. We asked the women to self-report their household’s economic status as low, middle, or high.
Data collection
Data were collected from October 18 to December 6, 2012. Ethical approval was obtained from the institutional review board of the authors’ institute (IRB No. 2012-37). We received information on potential study participants from health extension workers of the health posts in the study areas. Nine research assistants involved in data collection were all Ethiopians who were able to speak both English and Tigrigna. They were provided 3-hour training on the questionnaire items and the interviewing process before initiating data collection. Our trained research assistants visited participants’ homes and interviewed them face-to-face using the survey questionnaire after obtaining written informed consents. The research assistants explained medical terms on the questionnaire using common words so that lay people were able to understand. A total of 1,254 households were contacted, and only those who had agreed to participate in the study were administered the questionnaire. About 30~50 minutes were spent for data collection per household. The response rate was about 97%. A research supervisor was assigned to oversee throughout the process of data collection and check the quality of the questionnaires collected.
Data analysis
The collected data were analyzed using SPSS version 21.0. Descriptive statistics were calculated for the study variables. A t-test and analysis of variance (ANOVA) were used to identify the differences in the number of perceived health problems by the general characteristics of the participants. The differences with a probability of less than 0.05 were considered statistically significant.
Results
General characteristics of the participants
Of the total of 1,216 women, the largest age group comprised women aged 26 to 35 years (n=446, 36.7%). The majority of them (n=938, 77.9%) had husbands. Orthodox Christianity was the most common religion (n=1,173, 97.3%). Greater than two-thirds (n=870, 74.4%) had never been educated in school. Their socioeconomic status was generally low (n=1,068, 89.5%). The average number of living children was 3.89 (SD 2.44, Range 0-12), and almost a half (n=484, 40.1%) had 5 or more children (Table 1).
Perceptions about pregnancy and childbirth
We asked about the Ethiopian women’s perceptions about birth planning, husband’s roles, and local health facility use (Table 2). Almost all of the women agreed that they should plan in advance a place of childbirth (n=1,206, 99.7%) and transportation to the childbirth place (n=1,194, 98.7%). Regarding the roles of their husbands, the vast majority agreed that their husbands should go along with them for antenatal visits (n=1,104, 91.5%) and childbirth (n=1,161, 95.9%). Still, about one third of them perceived childbirth (n=394, 32.7%) and childrearing (n=346, 28.6%) to be the women’s responsibility rather than men’s. Almost all did not agree with the suggested reasons for not using local health facilities.
Perceived health problems related to pregnancy, childbirth, and neonates
The women were asked which health problems were considered serious during pregnancy, childbirth, and newborn periods (Table 3). Of the health problems during pregnancy, the majority of them perceived bleeding (n=1,006, 82.7%) and loss of consciousness (n=973, 80.0%) to be serious; however, severe headache (n=581, 47.8%), severe abdominal pain (n=500, 41.1%), high fever (n=495, 40.7%), changes in fetal movement (n=378, 31.1%), premature rupture of membranes (n=247, 20.3%) and convulsions (n=214, 17.6%) were less frequently identified as severe conditions.
Convulsions (n=267, 22.0%), high fever (n=367, 30.2%) and severe headache (n=445, 36.6%) during labor and childbirth were also considered less serious whereas almost all of the women perceived severe bleeding (n=1,144, 94.1%), prolonged delivery of the placenta (n=1,136, 93.4%), and prolonged labor (n=1,057, 86.9%) to be serious. Regarding the health problems of newborns during the first 7 days after birth, more than half of the women did not consider jaundice (n=580, 47.7%), being small for gestational age (n=559, 46.0%), lethargy (n=439, 36.1%), skin problems (n=371, 30.5%), or eye infection (n=281, 23.1%) to be serious. Only about 40% of the women perceived that eye care should be given to the newborns immediately after birth.
Differences in perceived health problems during pregnancy, childbirth, and newborn periods
We analyzed differences in perceived health problems during pregnancy, childbirth, and newborn periods according to the general characteristics of the women. Of their general characteristics, the variable of having a husband showed a significant difference in the number of perceived serious health problems (Table 4).
Discussion
Our study found that Ethiopian women perceived their spouse’s role in childbirth and childrearing work to be limited. About a third of the Ethiopian women in the study perceived childbirth and childrearing to be primarily women’s responsibility although almost all of them agreed that their spouses should accompany them for antenatal health care visits and childbirth. The women’s roles in traditional Ethiopian culture are mainly to take care of children and manage housework whereas husbands are the dominant figure in family who make decisions [10,14]. This cultural expectation of women’s roles excludes involvement of their husbands in childbirth or childrearing. However, the value of a husband’s role in promoting the perinatal health of women and infants has been emphasized in previous studies. Redshaw and Henderson reported that women were more likely to receive antenatal and postnatal care and less likely to have postnatal problems when their husbands were highly engaged during the pregnancy and childbirth periods [15]. In addition, the father’s involvement in childrearing has been found to be associated with children’s development and wellbeing [16]. Therefore, Ethiopian women’s perception of their spouse’s involvement in childbirth and childrearing should be strengthened in order to improve maternal and child health and well-being. According to Bond and his colleagues, paternal roles could be improved through research, policy, and practice [17]. With regard to practice, they suggest providing information on paternal involvement and simple counseling to husbands during antenatal visits, which can positively impact both women and their children. Since the Ethiopian women of this study perceived that their husbands should accompany them to antenatal visits and childbirth, health care professionals could utilize this opportunity to educate and counsel the couples about a husband’s role in childbirth and childrearing.
Tsegay et al. reported that local health facility use for antenatal services and childbirth was low in women residing in Tigray, Ethiopia [11]. Our study findings demonstrated that the women in this study did not agree with the proposed reasons for not using health facilities: cost, difficulty of transportation, and lack of respect from staff at the facility. This might indicate that they do not perceive health facility use to be necessary for their antenatal care and childbirth. To prevent health problems associated with pregnancy and childbirth, community-based health education needs to be strengthened for the women to become aware of the necessity of care during pregnancy and childbirth provided by health professionals.
The Ethiopian women of this study reported a low level of perceptions on some serious health problems during pregnancy, childbirth, and newborn periods. Although they were able to perceive critical health conditions like bleeding and prolonged labor as serious, other rather common conditions including severe headache, convulsions, and high fever were not considered serious. The latter health conditions might seem insignificant to the women because those conditions only become serious when they are associated with pregnancy or labor. In addition, only about 20% of the women in this study identified premature rupture of membranes (PROM) as serious. PROM is a warning that labor and delivery will occur shortly afterward, which may cause the birth of a premature infant if it happens before 37 weeks’ gestation [18]. Lack of perceptions of these serious conditions could result in missing an opportunity for treatment and finally put both the women and their neonates in a life-threatening situation. Increasing women’s perceptions of pregnancy, childbirth, and newborn health problems will help them seek early intervention and ultimately reduce maternal and newborn mortality.
Less than a half of the Ethiopian women considered being small for gestational age as a serious neonatal health problem. This could stem from the small average size of infants in Ethiopia. Correct information on the association between a newborn’s birth weight and health should be provided to Ethiopian women. The study of Mesfin and others pointed out a high prevalence of trachoma in the Tigray region, which could lead to blindness without proper treatment [19]. They proposed the expansion of primary eye care in this region. However, only a few women in Tigray perceived eye infection as serious in newborns, which indicates that the majority of the women did not consider neonatal eye care as basic newborn care. Neonates are more vulnerable to health problems than adults. Appropriate perceptions of mothers regarding basic newborn care will enable their neonates to receive proper care immediately after birth and ultimately prevent serious health problems. Hence, it is necessary to develop a community-based intervention to raise women’s perceptions of basic newborn care in Tigray, Ethiopia.
Previous studies have demonstrated that demographic factors of women in developing countries including Africa are significant to their health status. A systematic review of studies performed in developing countries found that women’s and their husbands’ education level, their marital status and household income, and women’s employment influenced their use of antenatal care [20]. McTavish and others also reported a positive association between maternal health care use and women’s age, education, household income, and urban residence [21]. A study on women in southern Ethiopia found that their literacy level, number of children ever born, and media exposure were associated with the use of antenatal and postnatal care [22].
Unlike the results of these previous studies, the women’s age, education, number of births, and socioeconomic status were not significantly associated with perceptions of pregnancy, childbirth, and newborn health problems, whereas women with 5 or more children were less aware of basic newborn care than those with 1 to 4 children. Our results indicate that Ethiopian women, regardless of their age, education, parity, or economic status, need to enhance their perceptions of pregnancy, childbirth and newborn health problems. Given that reported that media exposure affected antenatal and postnatal care [22], use of mass media would be a good method to increase maternal and child health awareness of the women in Ethiopia. According to Ethiopian national statistics, radio is a common media that 34% of the households in rural areas possess, while only 1.1% has television [23]. Therefore, community health education using radio could be useful for Ethiopian women to increase their perceptions of perinatal health problems.
The results of this study should be considered in light of some limitations of the study. One of the limitations was related to the sampling method. Since the focus area of our MCH project in Tigray was Kihen, we had to survey all of the women there eligible for the study. Unlike in Kihen, it was not possible to include all the eligible women in Mesanu in the study due to the lack of trained research assistants, which may not support generalization of the study findings. Another limitation is measures of the study variables. Through face-toface interviews using structured questionnaires, we only asked about perceptions of prenatal, childbirth, and postnatal health of women in Ethiopia. Their health care practices may be different from their perceptions. Future studies are needed to explore the relationships between health care practices and perceptions of the women during the perinatal period. Despite these limitations, our findings illustrate the need for improvement of women’s perceptions on prenatal, childbirth, and postnatal health in north Ethiopia.
Conclusion
Although the Ethiopian government began a health extension program to increase health awareness and improve health status in 2003, improvement of maternal health in Ethiopia has not been achieved for Millennium Development Goal 5 [11]. Our study results show north Ethiopian women’s perceptions of health problems during pregnancy, childbirth, and newborn periods remain limited. Furthermore, the women perceived of a father’s roles in childbirth and child care to be much more limited than a woman’s own role. Community-based health education should be strengthened for the women in north Ethiopia in order to enhance their perceptions of health care during prenatal, childbirth, and postnatal periods. In addition, paternal involvement and empowerment of women with regard to perinatal health and child care need to be strengthened.
Acknowledgements
This study was supported by Korea International Cooperative Agency from 2012 to 2013.

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Women’ s Perceptions about Pregnancy and Childbirth and Their Perceived Maternal and Newborn Health Problems in Tigray District, Ethiopia
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