A total of 422 pregnant women were interviewed (response rate = 96.0%). The mean age of participants (±SD) was 27.9 (±4.8) years. Almost half of the women (196, 46.4%) were in their first pregnancy and the median gestational age was 34 weeks (IQR 26, 38). Three-quarters of the women (309, 73.2%) were in the third trimester of their pregnancy and a quarter of them (112, 26.5%) had come for their 7th – 10th ANC visits.
In their past obstetric history, one woman was admitted for gestational hypertension or pre-eclampsia, three women had experienced stillbirths and 13 women reported at least one child who had died under five years of age. Among multigravid women, none had a “bad obstetric history” (Rh incompatibility of parents’ blood groups, three or more consecutive spontaneous abortions, birth weight of past child less than 2500 grams or more than 4500 grams). Table 1 summarizes the basic demographic and clinical characteristics of the participants.
Table 1. Demographic and clinical characteristics of pregnant women attending antenatal clinic at Gyaltsuen Jetsun Pema Mother and Child Hospital, Thimphu, Bhutan, May 2019 – July 2020 (n = 422)
Basic characteristics
|
n
|
(%)
|
Total
|
422
|
(100)
|
Mother’s age (years)
|
|
|
18 – 24
|
107
|
(25.4)
|
25 – 34
|
276
|
(65.4)
|
35 – 40
|
39
|
(9.2)
|
Mother's level of education
|
|
|
None
|
47
|
(11.1)
|
Non-formal education
|
10
|
(2.4)
|
Primary
|
26
|
(6.2)
|
Secondary
|
243
|
(57.6)
|
Tertiary
|
96
|
(22.7)
|
Father's level of education
|
|
|
None
|
41
|
(9.7)
|
Primary
|
33
|
(7.8)
|
Secondary
|
201
|
(47.7)
|
Tertiary
|
147
|
(34.8)
|
Residence
|
|
|
Urban
|
376
|
(89.1)
|
Rural
|
46
|
(10.9)
|
Type of family
|
|
|
Extended
|
223
|
(52.8)
|
Nuclear
|
199
|
(47.2)
|
Current gravida
|
|
|
Primigravid
|
196
|
(46.4)
|
Two to four
|
218
|
(51.7)
|
Five or more
|
8
|
(1.9)
|
Trimester during visit
|
|
|
1st trimester
|
6
|
(1.4)
|
2nd trimester
|
107
|
(25.4)
|
3rd trimester
|
309
|
(73.2)
|
Number of ANC visits at the time of interview
|
|
|
1-3 visits
|
119
|
(28.2)
|
4-6 visits
|
191
|
(45.3)
|
7-10 visits
|
112
|
(26.5)
|
Number of past abortions*
|
|
|
0
|
368
|
(87.2)
|
1
|
42
|
(10.0)
|
2
|
12
|
(2.8)
|
Surgery on reproductive tract in past**
|
|
|
No
|
394
|
(93.4)
|
Yes
|
28
|
(6.6)
|
*Primigravida women were excluded
**Surgeries included caesarean section, salpingotomy, salpingectomy, myomectomy etc.
ANC: antenatal care
|
Sources of information on danger signs
Over three-quarters of women (335, 79.4%) had heard of obstetric danger signs. Most women cited ‘Nurse/midwife’ as their source of information on danger signs (258, 77.0%). Among 375 literate women, 308 (82.1%) reported having read the MCH Handbook and 165 (44.0%) reported the MCH Handbook as a source of information on obstetric danger signs. Figure 1 lists the frequency of each source cited by the pregnant women as their source(s) of information regarding obstetric danger signs.
Knowledge of Obstetric Danger Signs
The mean knowledge score (±SD) was 12.0 (±2.5) out of 20. Twenty women (4.7%) had “good knowledge” on obstetric danger signs. Most women (245, 58.1%) had “satisfactory knowledge” while a third of them (157, 37.2%) had “poor knowledge”. The median number of danger signs recalled was 2 (IQR 1, 3). Among the 335 women who reported having heard of danger signs previously, 68 (20.3%) could not recall any danger sign. Most women recalled vaginal bleeding (227, 67.8%) while very few women recalled “symptoms of pulmonary embolism” (6, 1.8%) among the seven danger signs.
Of the 13 questions, over 90% of women chose the correct response to five questions related to: pre-labour rupture of membranes (96.0%), vaginal bleeding with fleshy parts (95.5%), preterm labour pain (92.7%), puerperal sepsis (91.0%) and reduced foetal movements (90.5%). Three questions with most incorrect answers were related to: spotting during pregnancy (19.9%), postpartum haemorrhage (75.8%) and symptoms of pulmonary embolism (78.6%). The details of knowledge assessment using the twenty items are shown in Figure 2.
Factors associated with knowledge of obstetric danger signs
Knowledge score (r = 0.17, p <0.001) and number of danger signs recalled (r = 0.12, p = 0.033) had significant correlation with the period of gestation. There was a significant association, based on Kruskal-Wallis test, between the number of danger signs recalled with mother’s level of education (p < 0.001), father’s level of education (p = 0.011) and having read the MCH handbook (p < 0.001). Level of knowledge had significant association, based on t-test, with number of ANC visits (p = 0.002) and gestational age (p = 0.033).
In the unadjusted analyses, having read the MCH Handbook (OR 8.9, 95% CI 1.1 – 73.8 p = 0.043), previous surgery on the reproductive tract (OR 3.9, 95% CI 1.2 – 12.7, p = 0.022) and father's level of education (OR 15, 95% CI 1.4 – 163.2, p = 0.026) had significant association with ‘good’ level of knowledge. However, in the adjusted analysis, only one factor – ‘having previous surgery on the reproductive tract’ – had significant association (OR 5.1, 95% CI 2.5 – 10.1, p<0.001) with ‘good’ level of knowledge. Table 2 summarizes the results of the logistic regression analysis.
Table 2. Factors associated with knowledge of obstetric danger signs among pregnant women attending antenatal clinic at Gyaltsuen Jetsun Pema Mother and Child Hospital, Thimphu, Bhutan, May 2019 – July 2020 (n = 422)
Variable
|
Good Knowledge
|
Poor and Satisfactory Knowledge
|
Unadjusted analyses
|
Adjusted analyses
|
|
n
|
(%)
|
n
|
(%)
|
OR (95% CI)
|
p value
|
aOR (95% CI)
|
p value
|
Mother's age group
|
|
|
|
|
|
|
|
|
18 to 24 years
|
2
|
(2)
|
105
|
(98)
|
0.3 (0.1 - 1.4)
|
0.122
|
Ref
|
|
25 to 34 years
|
16
|
(6)
|
260
|
(94)
|
Ref
|
|
9.2 (0.0 – 25675)
|
0.584
|
35 to 40 years
|
2
|
(5)
|
37
|
(95)
|
0.9 (0.2 - 4.0)
|
0.866
|
9.6 (0.0 - 26811)
|
0.576
|
|
|
|
|
|
|
|
|
|
Mother's level of education
|
|
|
|
|
|
|
|
|
None
|
0
|
(0)
|
47
|
(100)
|
Ref
|
|
|
|
Non-formal education
|
2
|
(20)
|
8
|
(80)
|
1.2 (0.1 - 17.6)
|
0.869
|
|
|
Primary education
|
0
|
(0)
|
26
|
(100)
|
-
|
-
|
|
|
Secondary education
|
10
|
(4)
|
233
|
(96)
|
0.2 (0.0 - 2.0)
|
0.178
|
|
|
Graduate education
|
7
|
(8)
|
83
|
(92)
|
0.4 (0.0 - 4.1)
|
0.458
|
|
|
Others*
|
1
|
(17)
|
5
|
(83)
|
-
|
-
|
|
|
|
|
|
|
|
|
|
|
|
Father's level of education
|
|
|
|
|
|
|
|
|
None
|
1
|
(2)
|
40
|
(98)
|
Ref
|
|
Ref
|
|
Primary education
|
0
|
(0)
|
33
|
(100)
|
-
|
-
|
0.0 (0 - 0)
|
0.998
|
Secondary education
|
6
|
(3)
|
195
|
(97)
|
1.2 (0.1 - 10.5)
|
0.849
|
0.5 (0.0 - 15.4)
|
0.669
|
Graduate education
|
10
|
(7)
|
126
|
(93)
|
3.2 (0.4 - 25.6)
|
0.278
|
2.8 (0.2 - 44.9)
|
0.460
|
Others*
|
3
|
(27)
|
8
|
(73)
|
15 (1.4 - 163.2)
|
0.026
|
13.4 (0.7 - 239.4)
|
0.077
|
|
|
|
|
|
|
|
|
|
Place of Residence
|
|
|
|
|
|
|
|
|
Rural
|
2
|
(4)
|
44
|
(96)
|
Ref
|
|
|
|
Urban
|
18
|
(5)
|
358
|
(95)
|
1.1 (0.2 - 4.9)
|
0.895
|
|
|
|
|
|
|
|
|
|
|
|
Death of child aged <5 years
|
1
|
(8)
|
12
|
(92)
|
1.7 (0.2 - 13.8)
|
0.615
|
|
|
|
|
|
|
|
|
|
|
|
Surgery on reproductive tract
|
4
|
(14)
|
24
|
(86)
|
3.9 (1.2 - 12.7)
|
0.022
|
5.1 (2.5 - 10.1)
|
<0.001
|
|
|
|
|
|
|
|
|
|
Family type
|
|
|
|
|
|
|
|
|
Nuclear
|
10
|
(5)
|
189
|
(95)
|
Ref
|
|
|
|
Extended
|
10
|
(4)
|
213
|
(96)
|
0.9 (0.4 - 2.2)
|
0.794
|
|
|
|
|
|
|
|
|
|
|
|
Read MCH Handbook
|
|
|
|
|
|
|
|
|
No
|
1
|
(1)
|
103
|
(99)
|
Ref
|
|
Ref
|
|
Yes, some of them
|
12
|
(5)
|
218
|
(95)
|
5.7 (0.7 - 44.2)
|
0.098
|
-
|
-
|
Yes, all of them
|
7
|
(8)
|
81
|
(92)
|
8.9 (1.1 - 73.8)
|
0.043
|
-
|
-
|
*Includes post-secondary certificates or diplomas and post-graduate degrees including masters or doctorates
OR: Odds Ratio
aOR: Adjusted Odds Ratio
CI: Confidence Interval
MCH: Mother and Child Health
|