Testing the effectiveness of Community-Based Continuous Training Project on Improving the Domains of Birth Preparedness and Complication Readiness Intention Among Expecting Couples in Rural Settings of Rukwa Tanzania, A Controlled Quasi Experimental Study

Background: According to theory of planned behavior, the intention to engage into a behavior predicts the behavior to occur. The intention to engage into a behavior is inuenced by three domains which are the attitude towards the behavior, the perceived subjective norms and the perceived behavior control. The study aimed at testing the effectiveness of a Community Based Continuous training (CBCT) intervention on improving the three domains of Birth Preparedness and Complication Readiness (BPCR) intention. Method: The quasi-experimental study design with control was done from June 2017 until March 2018. A multi-stage sampling technique was used to obtain 561 couples. Pre-test and end-line information were collected using semi-structured questionnaires developed using theory of planned behavior. The effectiveness of the intervention on improving domains of BPCR intention was assessed by using both independent t-test and pared t-test. Results: In comparison between groups at posttest assessment, there was a signicant increase in mean scores only on perceived subjective norms in the intervention group if compared to the control group among pregnant women. Among male partners, none of the domain showed a signicant difference between the intervention group and control group. In the comparison within groups, mean scores in all three domains had signicant increase at posttest in both groups among male partners while among pregnant women the signicant increase in the three domains were only among pregnant women in the intervention group. The predictor of change on attitudes and subjective norms mean scores were only the intervention β=0.065, p<0.05 and β=0.112, p=0.001 respectively. Predictors of change in perceived behavior control mean scores towards birth preparedness were level of education (secondary school, β=0.066, p<0.05), age at marriage (more than 24 years, β=0.069, p<0.05) and ethnic group (others, β=-0.067, p<0.05). Conclusion: The improvement brought by the intervention indicates that the intervention has the potential to signicantly change the attitude and subjective norms domains of BPCR intention. The study recommends the CBCT intervention to be used in rural community to improve attitude and perceived subjective norms of BPCR intention.


Background
BPCR is a strategy that encourages pregnant women, their families, and communities to effectively plan for births and be ready for emergencies if they occur [1]. The strategy empowers them with knowledge about danger signs (during pregnancy, labor and childbirth, post-delivery and neonatal period), awareness on the antenatal routine and services offered and to prepare a birth plan and ready for emergency. BPCR strategy has a potential to eliminate the three delays (delay to make decision to seek care, delay to reach health facility and delay to receive maternal care services in the health facility) to access maternal health services [2]. The rst delay (delay to make decision to seek maternal care) is mostly contributed by poor knowledge on danger signs [3]. When these signs occur, the decision to seek care is delayed due to lack of correct interpretation of the danger sign. Some they wrongly interpret the signs as needing some rituals, which in turn leads to delay the right decision [4]. Previous studies have identi ed several barriers towards eradication of rst delay such as pregnancy at younger age, ignorance, poverty, unemployment, poor health service utilization, a lower level of assertiveness among women, poor knowledge about obstetric danger signs, and cultural beliefs [5].
Similarly, the second delay (delay to reach the health facilities) also contribute to delay in accessing maternal health services. Rural settings in developing countries have poor roads, some of which are seasonal roads and unreliable mode of transport which are the key barriers towards timely accesses to maternal health services [5]. Preparation for birth and anticipated emergencies has the ability to reduce the second delay. It is a routine for every pregnant woman and her family to develop and implement a birth plan. The birth plan has the following item; saving money for emergency readiness, arrange for a means of transport to facilitate timely reach to health facility during labor or emergency, identify a skilled birth attendant, prepare items which will be used during childbirth such as; warm clothes to cover the baby, pads, a container for dirty clothes, a pair of glove, a razor blade, a mackintosh, identify a female relative to accompany the couple to the health facility, Identify a blood donner and identify a relative who will stay with other siblings during childbirth [6]. The third delay (delay to access care upon arrival) is the delay which occur in health facility. This delay is mostly contributed by limited resources, both human and non-human resources. It can be contributed by lack of good referral system.
Evidence has shown that BPCR strategy has the potential of minimizing the three delays to access maternal health services and hence reduction of maternal and neonatal deaths [7]. It is a key component of safe motherhood which can promote care seeking behavior and timely utilization of health facility delivery service [8]. Despite of the well-established prospective of BPCR strategy on facilitating timely access to maternal services, the uptake of the practice is surprisingly low in developing countries including Tanzania[8-10]. One wonders why such majority of families are not prepared for child birth and its unanticipated complications in a situation with poor infrastructures and unreliable transport. The possible explanation could be the low risk perception towards pregnancy and childbirth as evidenced by a qualitative study done in Sumbawanga rural community among parents who decided to have home childbirth assisted by unskilled birth attendants [4]. Another possible reason could be the belief that birth outcome is pre-determined by a supernatural power in such that cannot be changed by preparations or health facility birth [4].
Low male involvement in BPCR in developing countries has been cited as one of the barriers towards BPCR [11,12]. Unlike the global north, low male involvement in BPCR in the global south is entrenched in the structural setups of the health facilities and culture beliefs [13]. Health facilities setups and the arrangement of the maternal health services excluded male partners in such a way that male partners are less informed on BPCR [14]. In addition, male partners perceived the role of maternal services utilization is the responsibility of women. Their role is to provide nancial support. It is now recognized that reaching male partners directly to maternal services utilization is a corner stone towards improving BPCR [15].
Theory of planned behavior postulate that intention to engage into a behavior predicts the occurrence of the behavior [16]. The intention to engage into a behavior is shaped by three domains, the attitude towards the behavior, the perceived subjective norms and the perceived behavior control [16]. Attitude towards the behavior is in uenced by the belief about the behavior and the evaluation of the behavior outcome. The perceived subjective norms domain is in uenced by the normative beliefs and motivation to comply to the behavior. This is the perception on whether the important others approve for one engaging to the behavior. The perceived behavior control domain is in uenced by the control belief one has about the behavior and the perceived power to engage into the behavior.
Community based continuous training intervention was designed using theory of planned behavior to improve the three domains of BPCR intention. Little was known on the effectiveness of the intervention on improving the three domains of BPCR intention.

Study design and setting
The study used a quasi-experimental study design consisted of a pre-and post-intervention assessment of two non-equivalent groups; an intervention group and a control group. The study was conducted in Rukwa Region in the Southern Highlands of Tanzania. Rukwa Region [14,17] .

Study population
Expecting couples in Rukwa Region with gestation age ≤ 24 weeks at the time of study. Study population was selected for training in this gestational age range in order to allow enough time to observe the required indicators on domains of birth preparedness.

Sample size calculation and sampling technique
Sample size calculation The sample size for couples involved in the study, was calculated by using the following formula [18] Where: n = minimum sample size Za = Standard normal deviation (1.96) at 95% con dence level for this study b = standard normal deviate (0.84) with a power of demonstrating a statistically signi cant difference before and after the intervention between the two groups at 90% Πo = Proportion at pre-intervention (Use of skilled delivery in Rukwa region 65%) Π1= proportion after intervention (Proportion of families which will access skilled birth attendant 75%) The required sample size in the intervention group = 187 couples Intervention: control ratio = 1:2 (using age groups in ve years and parity) which aimed at increasing comparability of these two groups. The sample size in the control group = 374 couples. Therefore, the total sample size was 561 couples [15] Sampling technique The multi-stage sampling technique was used to obtain the required sample size [17].

Data collection
Semi-structured questionnaires developed using Theory of Planned behavior was used for data collection [17].

Data collection tools
A semi-structured questionnaire had questions on the predictors of intention and intention. They were developed using the Theory of Planned Behavior [20]. The project involved discussions about behavior beliefs, normative beliefs and behavior control beliefs, which hindered the health facility birth preparedness, male involvement and maternal services utilization.
In addition to that, the project involved teaching about birth preparedness (antenatal services, danger signs and preparations for health facility birth), signs of labor and newborn care [15].

Data analysis procedures
Data were checked for completeness and consistency; then were coded and entered in to computer by using statistical package IBM SPSS version 23. Descriptive statistics were used to generate frequency distribution and cross tabulation was used to describe the characteristics of the study participants. The comparisons between groups were determined by using independent t-test and comparisons within groups (pre/post) were estimated using paired t-test. Factor analysis was used to extract the statements used to measure the domains of birth preparedness intentions (Table 1)   Table 1 Analysis procedure Majority of pregnant women in intervention group (58.3%) and control group (59.6) were younger than 25 years while majority of male respondents in intervention group (65.9%) and in the control group (70.4%) were older than 25 years. More than 70% of pregnant women in both groups were married at younger age of less than 18 years. Majority of the cohort had at least primary education. Majority of them were of low socio-economic status (earned less than 1 dollar per day), get basic obstetric care services from dispensaries, not covered by health insurance, and walking distance to a nearby health facility were less than ve kilometers (Table 2).

Domains of birth preparedness Intention (Attitudes, Subjective norms and Perceived behavior control)
Descriptive characteristics of attitudes, subjective norms and perceived behavior control towards birth preparedness. Among both pregnant women and their male partners all three domains were slightly higher among control group if compared to intervention group. At post-test all three domains were slightly higher in the intervention group as compared to control group ( gure 2 and 3 and Table 4). The effectiveness of CBCT on improving domains of birth preparedness intention among expecting couples.

a. Comparison between group both at baseline and end-line on birth preparedness
An independent t-test was performed to compare attitudinal mean score, subjective norms means score and perceived behavior mean score at baseline assessment and end-line assessment among both pregnant women and male spouses. At end-line assessment subjective norms towards birth preparedness revealed a signi cant mean score differences between the intervention group and control group among pregnant women (p<0.05) ( Table 5)  c. Predictors of change in attitude, subjective norms and perceived behavior control towards birth preparedness.
The predictor of change on attitudes towards birth preparedness was only the intervention β = 0.065, p<0.05. Predictor of change on subjective norms towards birth preparedness was as well the intervention β = 0.112, p=0.001. Predictors of change in perceived behavior control towards birth preparedness were level of education (secondary school, β = 0.066, p<0.05), age at marriage (more than 24 years, β = 0.069, p<0.05) and ethnic group (others, β=-0.067, p<0.05) Table 7.

Discussion
Majority of study respondents in both intervention and control groups had negative attitudes towards birth preparedness at baseline assessment. This nding could be due to low risk perception towards pregnancy and childbirth. A previous study done in the same setting has reported that parents perceive pregnancy and childbirth as a natural normal process which is not associated with risks [4]. The low risk perception was largely contributed by low knowledge on obstetric danger signs [14]. The negative attitude towards health facility birth in uence the intention to engage into the behavior and hence the occurrence of the behavior [16]. Different nding was reported by a previous study that majority of interviewed respondents had positive attitudes towards birth preparedness [21]. The difference could be due to differences in study population, the study interviewed pregnant women attending antenatal while this study interviewed pregnant women and their male partners in the community. Sampling pregnant women who are attending antenatal clinic could have included those who perceive pregnancy and childbirth are associated with risks.
The perceived subjective norms domain was also low among both pregnant women and their male partners at baseline assessment. Majority of interviewed women perceived that the behavior towards birth preparedness is not approved by important others. This could be due to cultural practice which in uenced the acceptability of birth preparedness [22]. In the community the study was carried on, majority of pregnant women used traditional birth attendants. The cost of childbirth is relatively chip and sometimes paid in kind. The persistent use of traditional birth attendants could have in uenced the perceived subjective norms in the sense that a traditional birth attendant who is sometimes your mother in law may be perceived to disapprove the health facility birth preparedness.
The study also revealed that the perceived behavior control was low among the respondents at baseline assessment. Majority of them perceive they are not able to prepare for health facility birth. This can be contributed to the low socio-economic status of the study community. The low risk perception stimulates the low priority setting in allocating resources for birth preparedness.
In comparison between groups at posttest assessment, there was a signi cant increase in mean scores only on perceived subjective norms in the intervention group if compared to the control group among pregnant women. This means CBCT project is effective in improving pregnant women perceived subjective norms. Among male partners, none of the domain showed a signi cant difference between the intervention group and control group. All three domains showed an increase in mean score in the intervention group when compared with control group but the increase was not statistically signi cant.
The increase in mean score in the intervention group provides an indicator that the CBCT project has the potential in changing these domains. The lack of signi cant change in the intervention group could be due to the dosage of the intervention and the time allowed for posttest assessment. The study recommends a future project which will add the dosage and duration of posttest assessment.
When the comparison was done within the group, mean scores in all three domains had signi cant increase at posttest in both groups among male partners while among pregnant women the signi cant increase in the three domains were only among intervention group. Signi cant increase in mean scores of all three domains among male partners was a surprising nding. The possible reason could be due to the effect of change in time.
Predictors of change in attitudes mean scores and perceived subjective norms mean scores were only the CBCT project. This means that the CBCT project has the ability to improve attitude and perceived subjective norms. The author recommends the use of CBCT intervention to improve the two domains (attitude and perceived behavior control) of birth preparedness intention.
The predictors of change of perceived behavior control mean scores were level of education, age at marriage and ethnic group. The CBCT project had no effect on the change perceived behavior control mean scores. This could be the behavior itself to occur requires the availability of resources. Their perception towards the ability to execute the behavior is in uenced by the low socio-economic status. The CBCT project alone could not change their beliefs about their ability to prepare for birth and unanticipated emergencies. The study recommends for another community-based intervention to work out an innovative strategy to improve socio-economic status of expecting couples.
The improvement brought by the intervention indicates that the intervention has the potential to signi cantly change the attitude and subjective norms domains of BPCR intention. The study recommends the CBCT intervention to be used in rural community to improve attitude and perceived subjective norms of BPCR intention.

Conclusion
The improvement brought by the intervention indicates that the intervention has the potential to signi cantly change the attitude and subjective norms domains of BPCR intention. The study recommends the CBCT intervention to be used in rural community to improve attitude and perceived subjective norms of BPCR intention. Committee. Government authorities at regional and council levels ( Sumbawanga and Kalambo) were contacted for permission to conduct the study. Both written and oral informed consent was obtained from the study participants. For pregnant women who were younger than 18years, a consent to participate to the study was sought from their husbands. All methods were carried out in accordance with relevant guidelines and regulations.  Domains of birth preparedness intention among male partners