In 2013, there were an estimated 289 000 maternal deaths worldwide—most of which may be considered preventable (World Health Organization (WHO), 2014). Direct obstetric causes were a leading factor in maternal deaths. The primary direct causes of maternal death included haemorrhage, hypertensive disorders and sepsis (Say et al, 2014). Millennium Development Goal 5 (MDG 5), officially developed by the United Nations in 2000, had two targets: to reduce the maternal mortality ratio (MMR) by 75% between 1990 and 2015; and to achieve universal access to reproductive health by 2015 (Too-Kong, 2014).
Malaysia has embarked on a pathway to accelerate the reduction of maternal mortality and morbidity since the 1950s. The introduction of rural health infrastructure, particularly maternal and child health clinics, provides accessibility and availability of antenatal care (ANC) for mothers in rural regions. This helped to increase ANC coverage from 30% in 1957 to to 98% in 2010; the average number of antenatal visits per woman has risen from 6 in 1980 to 12 visits in 2010 (Yadav, 2012). Despite longstanding efforts to reduce maternal mortality, so far the progress has been somewhat disappointing (Yadav, 2012; Abd Rahman et al, 2013). The percentage of decline in MMR between 1990 and 2013 was around 48% (WHO, 2014), making it unlikely that the goal of a 75% reduction in MMR by 2015 will be achieved.
‘Danger signs’ in pregnancy
Pregnancy complications can threaten the life of mother and fetus (Pembe et al, 2009). However, not all women regard pregnancy complications as an abnormal condition, owing to lack of knowledge about danger signs and symptoms (Okour et al, 2012). The danger signs of pregnancy are not the actual obstetric complications, but are symptoms that could be recognised by non-clinical personnel (Hailu and Berhe, 2014). Common danger signs of pregnancy complications include vaginal bleeding, convulsions, severe headaches with blurred vision, fever and feeling too weak to get out of bed, severe abdominal pain, and fast or difficult breathing (WHO, 2006).
Benefits of knowledge
Most life-threatening obstetric complications are treatable, therefore most maternal deaths are avoidable provided that women who experience complications have prompt access to obstetric care. Three phases of delay in accessing obstetric care have been identified: delay in making the decision to seek care; delay in reaching a health-care facility; and delay in receiving appropriate treatment after reaching the health facility (Pembe et al, 2009). Knowledge of pregnancy danger signs would empower women to identify signs and symptoms of obstetric complications early, and facilitate decisions to seek appropriate care before the life of the woman or fetus is endangered (Kabakyenga et al, 2011; Okour et al, 2012).
Women's knowledge about danger signs of obstetric complications is influenced by multiple factors. Previous studies have found that socio-demographic characteristics such as age, educational attainment and employment status—along with pregnancy characteristics such as gravidity, parity and number of antenatal visits—contribute to shaping antenatal women's knowledge (Pembe et al, 2009; Okour et al, 2012; Hailu and Berhe, 2014).
Every pregnancy presents potential risks to women (Pembe et al, 2009). Knowledge of pregnancy danger signs is paramount in improving maternal and fetal health outcomes (Hailu and Berhe, 2014). There are minimal available studies about knowledge of pregnancy danger signs in Malaysia. Such data would help nurses, midwives and policy-makers understand the level of knowledge among Malaysian women and facilitate strategic planning of education programmes.
The aim of this study was to assess the level of knowledge about pregnancy danger signs among antenatal women.
Study design and setting
A cross-sectional study was conducted from 1 January to 28 February 2015 in the Antenatal Clinic, Hospital Universiti Sains Malaysia (USM), a teaching and referral hospital located on the northern east coast of peninsular Malaysia.
Population and sampling method
The study population included all pregnant women aged 18 years and above, regardless of gestational age, who attended antenatal follow-up at the clinic. Convenience sampling was used to recruit the mothers to the study. Using the Krejcie and Morgan (1970) table, the authors found the required sample size was 178.
Permission to conduct the study was approved by the Human Research Ethics Committee of USM. A letter of permission was also obtained from the director of Hospital USM.
Questionnaire design and modification
The questionnaire used in this study was a modified version of one developed by Pembe et al (2009), which aimed to assess awareness of danger signs of obstetric complications and identify associated factors among rural Tanzanian women who had been pregnant in the 2 years before the study began.
For the purpose of this study, some modifications were made to the design. The interviewer-administered questionnaire was modified to a self-administered questionnaire to prevent bias resulting from the presence of an interviewer when women answered the questionnaire. Open-ended questions used to elicit responses for pregnancy danger signs were modified to pre-coded closed-ended questions, to save the women's time and increase the response rate. Questions about experience during previous pregnancies were removed because the targeted population in this study included primigravida women. Questions believed to be relevant to women's knowledge were added. The modified questionnaire used in this study contained 13 items, compared with 14 items in the original questionnaire.
The questionnaire comprised three sections:
Women were asked whether they had heard of pregnancy danger signs and their sources of information. They were then asked whether they thought it was important for antenatal women to know the pregnancy danger signs. Women were also asked about actions that would be taken if they were to experience pregnancy danger signs. Finally, the women's level of knowledge on pregnancy danger signs was determined through 20 questions with ‘True’, ‘False’ and ‘Don't know’ options. One mark was awarded to each correct response and zero was given to each wrong or ‘Don't know’ response. The total marks obtained were converted into a percentage mark from raw mark using the following formula: (raw mark x 100)/20. The level of knowledge was interpreted based on the percentage marks obtained, which were classified in three categories: poor (<50%), fair (≥50 to <80%) and good (≥80%).
Validity and reliability
To ensure content validity, a draft version of the questionnaire was reviewed by three experts, including a specialist in maternal and child health and two senior lecturers specialising in obstetrics and gynaecology nursing. The questionnaire was pilot-tested on 30 antenatal women with similar characteristics but who were not included in the final sample. Following this pilot, necessary modifications were made. The Cronbach's alpha was 0.89 for level-of-knowledge questions, which was indicative of good reliability.
Data were collected through a modified questionnaire. A research information sheet was distributed on the spot by researchers to women while they were waiting for ANC services at the clinic. Women who visited the antenatal clinic for the second time or for subsequent follow-up during the 2-month period of data collection were only approached to participate in the study at their first visit. The women were informed that participation was entirely voluntary and they could refuse or were free to withdraw from the study at any time, without any loss of benefits to which they were entitled. Women who did not wish to take part in the study were not asked to complete the questionnaire. Written informed consent was obtained from those women who agreed to participate in the study.
The questionnaire was distributed and collected from women by study researchers. Women were given approximately 15–20 minutes to complete the questionnaire. The research team wished to assess women's spontaneous responses without referring to any source of information when answering the questionnaire. Although this was not specifically mentioned before the women undertook the questionnaire, it was expected that women would complete the questionnaire without access to any information resources.
Data collected were coded and analysed using Statistical Package for Social Sciences (SPSS) software (version 21.0). Frequencies and percentages were used to describe the data. Pearson's chi-square test was used to determine the association between each independent variable and knowledge level; P value of ≤0.05 was considered to be statistically significant.
A total of 178 women completed the questionnaire. Findings of this study are presented under three headings: women's socio-demographic and pregnancy characteristics; knowledge of pregnancy danger signs; and factors associated with knowledge of pregnancy danger signs.
Socio-demographic and pregnancy characteristics
Table 1 summarises the socio-demographic and pregnancy characteristics of all the women who participated in this study. Median age of the study group was 30 years (range: 19–45). Most mothers were 25–29 years old (n=58; 32.6%); were educated to tertiary level (n=93; 52.2%); were working (n=103; 57.9%); and had a monthly household income of less than RM 2000 (Malaysian ringgit; equivalent to around £300) (n=83; 46.6%). In total, 100 (56.1%) women had been pregnant twice to four times; 106 (59.6%) women had previously given birth once to three times; 129 (72.5%) women booked for ANC at 12 weeks’ gestation or earlier; and 106 (59.6%) women had attended for ANC 10 times or fewer.
|Variable||Knowledge level, n (%†)||χ2 (df)||P value*|
|19–24||12 (48.0)||7 (28.0)||6 (24.0)||18.932 (6)||0.004|
|25–29||15 (25.9)||17 (29.3)||26 (44.8)|
|30–34||13 (23.2)||16 (28.6)||27 (48.2)|
|≥35||2 (5.1)||10 (25.6)||27 (69.2)|
|Secondary||30 (35.3)||31 (36.5)||24 (28.2)||27.080 (2)||<0.001|
|Tertiary||12 (12.9)||19 (20.4)||62 (66.7)|
|Working||20 (19.4)||24 (23.3)||59 (57.3)||7.873 (2)||0.020|
|Not working||22 (29.3)||26 (34.7)||27 (36.0)|
|Monthly household income (RM)|
|<2000||29 (34.9)||29 (34.9)||25 (30.1)||28.936 (4)||<0.001|
|2000–4000||12 (18.8)||17 (26.6)||35 (54.7)|
|>4000||1 (3.2)||4 (12.9)||26 (83.9)|
|Number of pregnancies|
|1||18 (37.5)||10 (20.8)||20 (41.7)||8.575 (4)||0.073|
|2-4||20 (20.0)||32 (32.0)||48 (48.0)|
|≥5||4 (13.3)||8 (26.7)||18 (60.0)|
|Number of previous births|
|0||18 (34.6)||11 (21.2)||23 (44.2)||7.580 (4)||0.108|
|1–3||21 (19.8)||35 (33.0)||50 (47.2)|
|≥4||3 (15.0)||4 (20.0)||13 (65.0)|
|Weeks of gestation at first booking of ANC|
|≤12 weeks||33 (25.6)||33 (25.6)||63 (48.8)||1.859 (2)||0.395|
|>12 weeks||9 (18.4)||17 (34.7)||23 (46.9)|
|Number of ANC visits|
|≤10||24 (22.6)||28 (26.4)||54 (50.9)||0.738 (2)||0.692|
|>10||18 (25.0)||22 (30.6)||32 (44.4)|
RM–Malaysian Ringgit, ANC–Antenatal care
Refers to percentage within that variable e.g. percentage of 19–24-year-olds with poor/fair/good level of knowledge
Pearson chi-square test, P ≤ 0.05 was considered to be statistically significant
Knowledge of pregnancy danger signs
Table 2 outlines women's knowledge of pregnancy danger signs. A total of 149 (83.7%) women had heard about pregnancy danger signs and the most common source of information was health-care providers (n=121; 68.0%). Most of the women (n=175; 98.3%) said it was important for antenatal mothers to know the pregnancy danger signs, and 176 (98.9%) mothers said they would seek medical care if they experienced danger signs during pregnancy.
|Women had heard about pregnancy danger signs|
|Source(s) of information*|
|Health-care providers||121 (68.0)|
|Mass media||71 (39.9)|
|Women think it important to know pregnancy danger signs|
|Action(s) taken if women experienced pregnancy danger signs*|
|Seek medical care||176 (98.9)|
|Seek help from traditional healer||9 (5.1)|
|Seek help from family members||76 (42.7)|
|Consult friends||36 (20.2)|
The results showed that more than half of the women had a fair (n=50; 28.1%) or poor (n=42; 23.6%) level of knowledge about pregnancy danger signs. Table 3 shows the distribution of women's knowledge of specific danger signs. The most-recognised were:
|Question||Danger sign||Correct response n (%)||Wrong response n (%)||‘Don't know’ response n (%)|
|1||Heavy vaginal bleeding||153 (86.0)||4 (2.2)||21 (11.8)|
|2||Lack of blood (anaemia) with a reading of haemoglobin (Hb) less than 11.0 g/dl||155 (87.1)||10 (5.6)||13 (7.3)|
|3||Fits of pregnancy||128 (71.9)||19 (10.7)||31 (17.4)|
|4||Severe and persistent abdominal pain in the early stages of pregnancy||129 (72.5)||18 (10.1)||31 (17.4)|
|5||High-grade fever||131 (73.6)||18 (10.1)||29 (16.3)|
|6||High blood pressure with a reading of 140/90 mmHg or more||144 (80.9)||9 (5.1)||25 (14.0)|
|7||Severe headache||118 (66.3)||22 (12.4)||38 (21.3)|
|8||Sudden swelling of the face, hands and feet and increase in body weight||121 (68.0)||30 (16.9)||27 (15.2)|
|9||Awareness of fast heartbeat||108 (60.7)||17 (9.6)||53 (29.8)|
|10||Reduced or absence of fetal movement||159 (89.3)||9 (5.1)||10 (5.6)|
|11||Blurred vision during pregnancy||85 (47.8)||35 (19.7)||58 (32.6)|
|12||Sudden gush of amniotic fluid and no signs of labour||130 (73.0)||25 (14.0)||23 (12.9)|
A smaller number of women recognised blurred vision (n=85; 47.8%) and awareness of fast heartbeat (n=108; 60.7%) as danger signs in pregnancy.
Factors associated with knowledge of pregnancy danger signs
Pearson's chi-square test for analysis of socio-demographic and pregnancy characteristics versus level of knowledge about pregnancy danger signs was performed (Table 1). Knowledge level was significantly associated with age (P=0.004), education level (P<0.001), working status (P=0.020) and monthly household income (P<0.001).
Direct obstetric causes are a leading factor in maternal deaths (Ministry of Health Malaysia, 2008). Lack of knowledge about pregnancy danger signs may lead to women ignoring obstetric complications or not regarding such complications as an abnormal condition. This could result in delayed decisions to seek care, endangering the life of mother and fetus (Okour et al, 2012). Studies have shown that education about pregnancy danger signs targeting women of reproductive age would raise knowledge and the ability to identify complications, thus motivating women to seek timely care (Purdin et al, 2009; Pembe et al, 2010).
Women's knowledge of pregnancy danger signs
Findings showed that the majority of the women had heard about pregnancy danger signs, and had obtained this information from health-care providers. Despite this, some women had only a poor or fair level of knowledge of pregnancy danger signs. Other studies have reported similar findings (Pembe et al, 2009; Kabakyenga et al, 2011; Nambala and Ngoma, 2013). A possible reason could be that poor-quality counselling around pregnancy danger signs was offered to women who attended antenatal clinics (Rashad and Essa, 2010). Additionally, women may not inform health professionals of any pregnancy danger signs during ANC consultations (Duysburgh et al, 2013). This indicates that antenatal counselling practice may be poor and inefficient, leading to insufficient knowledge of pregnancy danger signs among women. Therefore, it is necessary to ensure that nurses or midwives inform all antenatal women about danger signs of pregnancy complications to meet the need for safe motherhood, as emphasised in MDG 5 (Rashad and Essa, 2010; Okour et al, 2012).
The WHO (2006) guidelines on pregnancy and childbirth include counselling on danger signs as one of the key recommendations during ANC. Having adequate knowledge regarding danger signs in pregnancy might alert the woman to seek care on time in case of complications (Rashad and Essa, 2010; Sangal et al, 2012; Mbalinda et al, 2014). In this study, women realised the importance of knowing pregnancy danger signs and indicated that they would seek medical care if they experienced danger signs. However, the findings of this study revealed a substantial number of women still lack knowledge about pregnancy danger signs, which is a concern.
Some women in this study demonstrated a good level of knowledge of pregnancy danger signs. Studies in India (Fernandes, 2014) and Ghana (Aborigo et al, 2014) have also reported that a small proportion of mothers had good knowledge of pregnancy danger signs. The importance of knowledge about pregnancy danger signs in shaping women's health-seeking behaviours is emphasised by researchers as it contributes to saving women's lives from preventable causes of maternal death (Rashad and Essa, 2010; Sangal et al, 2012; Mbalinda et al, 2014).
The WHO recommends that pregnant women should go to a health facility immediately if they experience vaginal bleeding, convulsions, severe headaches with blurred vision, fever and feeling too weak to get out of bed, severe abdominal pain, or fast or difficult breathing (WHO, 2006). In this study, the most common danger signs identified by the women were reduced or absence of fetal movement, anaemia and vaginal bleeding. Only a small number of women identified blurred vision, convulsion and severe abdominal pain as danger signs of pregnancy. This reflects that nurses and midwives should prioritise those life-threatening danger signs when providing health education to women, to enable them recognise these symptoms and seek care immediately, before the life of mother or fetus is endangered.
Factors associated with women's knowledge
Socio-demographic factors affect women's knowledge of danger signs in pregnancy. The findings showed that age was significantly associated with women's level of knowledge. Similar results have been reported in studies from Tanzania (Pembe et al, 2009), South Africa (Hoque and Hoque, 2011) and Zambia (Nambala and Ngoma, 2013). Increased knowledge of danger signs in pregnancy among older mothers may be related to their own prior experiences of pregnancy and labour, which serve as an important source of information, particularly to those who have had experience of obstetric complications during previous pregnancies (Duysburgh et al, 2013). Therefore, young mothers who lack pregnancy and childbirth experiences may need more attention and consideration from nurses or midwives during antenatal health education sessions to enhance their knowledge and understanding.
Level of education is also a factor that influenced women's knowledge. This was in line with studies from Jordan (Okour et al, 2012), India (Sangal et al, 2012) and Ethiopia (Hailu and Berhe, 2014). This could be explained by the fact that women with higher education may have less difficulty processing and understanding the information received during ANC visits (Duysburgh et al, 2013). In addition, the better-educated women may have greater autonomy than less-educted women in making decisions to use quality health-care services (Hailu and Berhe, 2014).
Working status seems to play a part in influencing women's knowledge. Studies in Egypt (Rashad and Essa, 2010) and Jordan (Okour et al, 2012) revealed similar results, whereas studies in Tanzania (Pembe et al, 2009) and Ethiopia (Hailu and Berhe, 2014) have shown no association. Despite these conflicting findings, the authors of the current study believe that working women have more opportunities to gain and share experiences with others than those who do not work, which allows them to receive more information and knowledge (Okour et al, 2012).
Monthly household income had a positive effect on increasing women's knowledge about pregnancy danger signs; a similar finding was reported in Nigeria (Doctor et al, 2013). This implies that mothers with higher socioeconomic status may be less deterred by cost barriers when making decisions to seek medical care than mothers with lower socioeconomic status. This may allow them to hear and learn more about danger signs in pregnancy when making visits to health facilities (Doctor et al, 2013).
Antenatal education can be targeted to women in younger, less-educated or lower-income groups through opportunities to attend antenatal classes and the provision of written information about antenatal care and danger signs during pregnancy. Such information regarding their care is important and can be used to support antenatal women engaging in decision-making to seek medical attention (Say et al, 2011).
There were some limitations to this study. Women who participated in the study were recruited via non-probability convenience sampling and were restricted to those who attended an antenatal clinic in a tertiary teaching hospital in Malaysia. Thus, the results are difficult to generalise to all antenatal women residing in Malaysia, or those in other countries.
Another limitation was that the survey questionnaire was distributed to women who were sitting close to one another while waiting for antenatal services. Inadequate space and close proximity between women when answering the questionnaire may have affected the responses that some women provided.
Despite the achievement of a reduction in the MMR in Malaysia of around 48%, which represents some progress as reported by the WHO (2014), this study has revealed that knowledge on danger signs of pregnancy among antenatal women in Malaysia is poor. Therefore, there is a need to intensify efforts to provide health education on danger signs during pregnancy among antenatal women. Recognition of danger signs for pregnancy-related complications and what to do if they arise would significantly empower antenatal women to take appropriate steps to ensure a safe birth and to seek timely care in emergencies.