Study design and site
The study was a community- based cross sectional study. Recruitment and data collection was conducted in July 2019, at Babati Rural district, situated in Manyara region in the northern Tanzania among women who had delivered within previous 24 months.
Manyara region is divided into six districts which are Babati Rural, Babati Urban, Hanang, Kiteto, Mbulu and Simanjiro district. The administrative capital of the district is Babati town, 172 kilometers south of Arusha City. The Babati Rural district covers an area of 5,460 kilometers square, with a total population of 312,392 of which males are 158,804 and females are 153,588 according to the 2012 census report. Their main economic activities are small scale farming of maize and potatoes, livestock keeping and fishing business.
Babati Rural district has 25 wards with 102 villages and 68,968 households. The district has 35 dispensaries, 7 health centers and 8 private hospitals.
According to TDHS of 2015-2016, Manyara region has poor maternal and newborn indicators compared to the national level. For example; 45% of women had four or more ANC visits, skilled attendance during childbirth is at 48% and newborns receiving postnatal care within 48 hours was 26%, which is low compared to the National average of 4+ ANC visits of 51%, SBA use of 64% and PNC use of 34% respectively [5].
Study population, sampling and data collection procedures
The study population was women who gave birth in the past 24 months prior to the study in Babati Rural district and consented to participate in the study. The study excluded women who are not permanent residents in the study area.
Sample size: Sample size for this study was estimated by using the formula for precision
N= Z2p (1-p)/d2
Where 𝑁 is estimated minimum sample size; 𝑍 is confidence level at 95% (standard value is 1.96); 𝑃 is expected proportion in population based on previous studies (knowledge of at least one danger sign) =51% [17]
d is precision at 95 % CI = 0.05.
The minimum sample that was required for this study was 384 women. Addition of 10% for non-response gave a minimum sample of 422 women delivered within previous 24 months to the study.
Sampling: Multistage sampling technique was used to obtain women who participated in the study. The multistage sampling techniques involved the following stages. Stage 1: Babati rural district was selected purposively out of 6 districts of Manyara Region. Stage 2: Two wards were randomly selected (Dareda and Magugu) out of 25 wards at Babati Rural district. Stage 3: At Magugu ward, 3 villages, Magugu, Mapea and Matufa, were randomly selected out of 7 villages. At Dareda ward, 4 villages, Bashnet, Gidewali, Maganjwa and seloto were randomly selected out of 12 villages. Stage 4: two hamlets were randomly selected from each village. At Magugu, 6 hamlets, Msimbazi, Majengo A, Majengo B, Mapea A, Mapea B and kwa rangi were randomly selected. At Dareda 8 hamlets, Bermi, Dabir, Endegau, Gisambalang, Mandi, Semak, Daktara, Leodesh were randomly selected. Stage 5: The Community Health Workers developed a list of households with women who have children of 2 years or less, 70 household in each of the villages were randomly selected. Out of the sampling frame and women in those households were invited to participate.
Study procedures: Ethical clearance was obtained from the KCMU college Ethical committee before starting the research. The ethical clearance was delivered to District Medical Officer (DMO) of Babati rural, where permission to conduct the study was sought from the DMO office. DMO gave us introductory letter that was presented to Ward and Village leaders.
At Magugu and Dareda, permission to cooperate with RCH team was given by the Medical officer in charge at Magugu Health center and Dareda Hospital, and delegated us to the RCH coordinator. The RCH coordinator familiarized us to the RCH clinics and also delegated us to the village chairpersons and village health workers (CHWs). The CHWs developed a list of households with women who have children of 2 years or less, we did a lottery random sampling method selecting 70 household in each of the villages in both Dareda and Magugu wards. At the field starting point was identified at the village with assistance of village chairperson and data was collected from one house to another with aid of CHWs. Data collection started at 9 a.m in the morning to 6pm in the evening. Before interviewing, the participant was informed of the aims and objectives of the study and was asked for consent to participate in the study. Six undergraduate medical students in their 4th year collected the data after undergoing one day training on data collection.
Pre-testing of the tool before the onset of the study was conducted in Moshi Municipal at Majengo Health centre. Five women who delivered in the last 12 months were interviewed to check for consistency, clarity and flow of the questions in the questionnaire.
Data collection tool and methods
A Swahili questionnaire was used to collect information from the participants. The questionnaire had closed and open-ended questions and consists of six sub-sections. The first part collected information on socio-demographic and socio-economic characteristics, second was reproductive and maternal health history, and third part collected information on ANC use, place of delivery and use of skilled birth attendant during the last pregnancy. The fourth section collected information on knowledge of danger signs during pregnancy, labor and childbirths and after delivery, and fifth on having birth preparedness and complication readiness plan for the last pregnancy. Post-Natal Care practice after delivery was the last section.
The interviews were conducted at either participant’s home, or at health facility room depending on the preference of the participant. After finishing data collection verbal observation from the field was shared with the DMO, which will be followed by a full research report of the study after completion.
Data Analysis
The data was entered and analyzed using SPSS 20. Before analysis, data was cleaned by running frequency of each variable. Categorical variables were summarized into frequency and percent while continuous variables were summarized using measure of central tendency and their respective measure of dispersion. Odds ratio with their 95% confidence interval were used to measure the strength of association between knowledge of danger signs and 4+ANC visits, having Birth preparedness and Complication readiness plan and SBA use during childbirth. Multivariable logistic regression analysis was conducted to control for confounders and get independent predictors for ANC 4+, having a BPCR plan and use of SBA. P-value of < 0.05 was considered statistically significant.
Categorization of variables:
Knowledge on ODS was measured by asking the study participant to mention spontaneously any danger sign she knows either by being told by the health care providers or by experience. If the study participant mentioned at least one key danger sign in each phase (during pregnancy, during delivery and after delivery) or could mention at least three danger signs in any phase (during pregnancy, delivery or immediate post-delivery) were considered to have good knowledge of obstetric DS. A participant who mentioned 1-2 DS was considered to have poor knowledge and the one who could not mention any DS was considered to lack knowledge on obstetric DS.
Birth preparedness has 6 components, women were categorized as well prepared if they prepared 3 or more components and not well prepared if they prepared less than 3 components. SBA use during childbirth is reported if a woman reported to be delivered by skilled health providers while assistant with TBA or relatives at home was categorized as lack of SBA use.