This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan’s largest hospital between May 2019 and July 2020.
Bhutan is situated in the eastern Himalayas with a population of 0.7 million; Thimphu is its capital and largest city . In 2015, Bhutan had 196,297 women in the reproductive age group (15 – 49 years) with 24,846 residing in Thimphu . The national general fertility and total fertility rates were 57.3 and 1.7 per 1,000 women, respectively .
The state provides free-health care services across all levels (primary, secondary, and tertiary) . MCH services including antenatal care (ANC) and post-natal care are provided free of cost through hospitals and out-reach clinics initiated to increase coverage . As part of its Reproductive, Maternal, Neonatal and Child Health Program, the Ministry of Health introduced the MCH Handbook in 2007, and revised it in 2014 and 2019 [12, 13]. Each Handbook has a unique identification number that tracks the pregnancy through the Druk Health Management & Information System .
The MCH Handbook is a recording tool as well as an information booklet. The handbook records parents’ demographic details, mother’s antenatal records, birth preparedness plan, birth details of the child, maternal and neonatal records, child’s growth charts, and vaccination records. It provides information on breastfeeding and nutrition, vaccination schedules, obstetric danger signs, monitoring developmental milestones, dental care, and general advice on antenatal and postnatal care . The MCH Handbook of Bhutan outlines seven key obstetric danger signs: 1) vaginal bleeding, 2) high fever, 3) preterm labour, 4) severe abdominal pain or vomiting, 5) severe headache, blurred vision or convulsions, 6) fast or difficult breathing, and 7) reduced or absent foetal movements .
This study was conducted at the MCH wing of the Gyaltsuen Jetsun Pema Mother and Child Hospital, which is a part of the Jigme Dorji Wangchuck National Referral Hospital complex in Thimphu.
A pregnant woman is issued the MCH Handbook during her “booking visit” . Health workers explain the contents of the MCH Handbook during each antenatal visit. Staffs deliver key health messages in their daily talk (15 – 20 minutes) to the group of clients gathered in their respective units. Obstetric danger signs are discussed in these talks by health workers (health assistants, nurses or midwives) from the ANC Unit. These health messages are reinforced during subsequent ANC and postnatal visits.
All pregnant women aged 18 years and above, and attending ANC at Gyaltsuen Jetsun Pema Mother and Child Hospital were eligible for the study. Participants were selected using systematic random sampling: every third pregnant woman registering for their routine ANC visit for the day was invited to participate in the study; those who consented were interviewed. Repetition of study participants was avoided by careful assessment of their MCH tracking number.
Variables and data sources
Data were collected by the authors through an interviewer-administered questionnaire that was designed for the purpose of this study (supplementary material). The questionnaire was pilot-tested among 20 pregnant women at Gyaltsuen Jetsun Pema Mother and Child Hospital in March 2019.
Mother’s knowledge of obstetric danger signs was assessed with a knowledge score. Recall was assessed against seven obstetric danger signs outlined in the MCH Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Every danger sign recalled and each correct response was awarded a score of one. Knowledge was scored out of 20 points by adding the number of danger signs recalled and the number of correct responses to the 13 questions.
Demographic characteristics (age, educational level of both partners, place of residence, family type), obstetric characteristics (gravida, parity, previous stillbirth, past surgery on reproductive tract and “bad obstetric history”), and whether pregnant woman had read the MCH Handbook were collected.
In the absence of a baseline knowledge level of obstetric danger signs among Bhutanese women, we calculated a sample size of 441 for a finite population of 24,846 based on the following assumptions: 50% probability for good knowledge, 5% margin of error, and 15% drop out rate.
Data entry and analysis
Data were entered into EpiData Entry version 3.1 and analyzed in EpiData Analysis version 2.2.3 (EpiData Association, Odese, Denmark) and STATA version 13.1 (StataCorp LP USA).
Knowledge was categorized as “good” (≥80%, score 16 – 20), “satisfactory” (60–79%, score 16 – 20) and “poor” (<60%, score ≤15). Continuous variables are reported as mean, standard deviations, median and interquartile range. Categorical variables are reported as frequencies and percentages. Normality for continuous variables was tested using Shapiro-Wilk test. Association between knowledge score and participant characteristics were tested using Chi-square, Fisher’s Exact and t-tests. Corresponding non-parametric test (Kruskal-Wallis test) was performed where appropriate. Pearson’s correlation coefficient was calculated between knowledge score as well as number of danger signs recalled and mother’s age, period of gestation, gravidity and parity. Results with p<0.05 were considered significant.
Ethics clearance was obtained from the Research Ethics Board of Health, Ministry of Health, Bhutan. Informed written consent was taken from each participant prior to the interview.