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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 1  |  Page : 21-29

Women’s awareness and perceptions about maternal mortality in rural communities in Assiut and Fayoum Governorates, Egypt


1 Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Assiut University, Assiut, Egypt
2 Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Fayoum University, Fayoum, Egypt

Date of Submission13-Jun-2017
Date of Acceptance28-Jan-2018
Date of Web Publication3-Sep-2018

Correspondence Address:
Ghadah A Mahmoud
Department of Obstetrics and Gynecological Nursing, Faculty of Nursing, Assiut University, Assiut, 71111
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_28_17

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  Abstract 


Background Awareness among women about maternal mortality is a very important step as a preventive measure to reduce its rate and to understand misconception of women’s knowledge about its issues.
Aim This study aimed to assess the awareness and perceptions of women about maternal mortality issues in rural areas in both Assiut and Fayoum Governorates.
Patients and methods A descriptive comparative research was conducted in this study. A total of 600 rural women were included and divided into two equal groups in Assiut and Fayoum Governorates (300 and 300, respectively). A structured interviewing questionnaire was designed by the researcher to assess the awareness and perceptions of these women who lived in rural communities about maternal mortality issues.
Results There are no statistical significance differences between both groups regarding the levels of awareness about maternal mortality (P>0.05). More than two-thirds of rural women in both groups considered post-partum period as the commonest time for maternal deaths (71 and 67%, respectively). The rural women in both groups perceived lack of maternal health awareness as the main cause of maternal deaths (60 and 64% in Assiut and Fayoum Governorates, respectively). Age of women and their family size were considered as risk factors affecting the levels of awareness among these women.
Conclusion There are no statistical significance differences between both groups in rural communities regarding the levels of awareness about maternal mortality.
Recommendations Educational programs should be conducted about maternal health issues through Ministry of Health to raise the awareness of women about these issues especially in rural communities of Egypt.

Keywords: awareness, maternal mortality, perceptions


How to cite this article:
Mahmoud GA, Omar AM. Women’s awareness and perceptions about maternal mortality in rural communities in Assiut and Fayoum Governorates, Egypt. Egypt Nurs J 2018;15:21-9

How to cite this URL:
Mahmoud GA, Omar AM. Women’s awareness and perceptions about maternal mortality in rural communities in Assiut and Fayoum Governorates, Egypt. Egypt Nurs J [serial online] 2018 [cited 2018 Oct 15];15:21-9. Available from: http://www.enj.eg.net/text.asp?2018/15/1/21/240350




  Introduction Top


Maternal mortality (MM) is one of the main indicators for improving maternal health worldwide and especially in developing countries. Each pregnant woman wishes to have a safe childbirth, but unfortunately it does not happen in developing countries (Balchandani and Rai, 2007). Maternal death is ‘the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes’ (WHO, 2004). Maternal death owing to pregnancy or childbirth complications is a tragic event, because it can be preventable and treatable. Because of the negligence of this important problem, ∼28 7000 maternal deaths occur globally (WHO, UNICEF, UNFPA and The World Bank, 2012), with 1600 women dying owing to pregnancy and childbirth complications. Moreover, 80% of them can be preventable and treatable (WHO, UNICEF, UNFPA, The World Bank, and the United Nations Population Division, 2014).

In Egypt, maternal mortality ratio (MMR) reached to 53 deaths per 100 000 live births in 2003, but it gradually declines to be 43.5 per 100 000 live births in 2015 (UNICEF, WHO, The World Bank, and the United Nations Population Division, 2013). According to Millennium Development Goals, 2015, some Egyptian Governorates have high rates of MMR, that is, ‘60–65 deaths per 100 000 live births’ in Assiut, Gharbia, Beni Suef, Qena, and Sohag, whereas others have low rates of MMR ‘24–37 deaths per 100 000 live births’ in New Valley, Ismailia, Suez, and Port Said (Balchandani and Rai, 2007). According to Egyptian Ministry of Health, maternal mortality rate is higher in upper Egypt than lower Egypt (74–61%, respectively). Moreover, the most common cause of maternal mortality in Egypt is post-partum hemorrhage (19.7%), whereas the most common indirect cause is cardiovascular disease (16%) (Kassebaum et al., 2014). In Egypt, 1400 women and 50% of their newborns die each year due to pregnancy and childbirth complications. According to the global standards, MMR is still high in Egypt, so further efforts should be made to apply the main health strategies for reducing it (Hogan et al., 2010). Assiut Governorate has the highest percentage of maternal mortality in Egypt (81 deaths/100 000 live births).

The most common cause is preeclampsia and its complications. The MMR in Fayoum Governorate is 54 deaths/100 000 live births (Egypt Ministry of Health, 2011). There are many strategies to reduce maternal mortality rate, represented by high quality of emergency obstetric care in the form of optimization of antepartum, intrapartum, and post-partum care; effective family planning services; and standardized abortion care (WHO, 2015).

For reducing maternal mortality, it is important to understand the main direct and indirect causes of it. The most common direct causes of maternal deaths are post-partum hemorrhage (24%), hypertensive disorders, and infection (Nour, 2008). In contrast, the indirect causes include anemia, malaria, and cardiovascular diseases (Lawn, 2014). For the reduction of the high rate of maternal mortality in Egypt, many challenges should be overcomed, especially the availability of standardized emergency obstetric management (Egypt Ministry of Health, 2014).

Raising the awareness of women especially who are living in rural communities by applications of interventional programs about maternal health is considered as one of the preventive measures of reducing maternal mortality (Conde-Agudelo et al., 2014). Awareness of women about causes of maternal mortality is a very important step as a preventive measure to reduce the rate of maternal mortality and to understand misconception of women’s knowledge. So the researchers decided to assess awareness and perceptions of women about maternal mortality issues in rural areas in both Assiut and Fayoum Governorates.

Significance

There are many global strategies for reducing maternal mortality to three-quarters by 2015 for achieving the Millennium Development Goals. The fifth goal is to improve maternal health (UN, 2015). It is necessary to focus on the target population that needs more awareness about maternal health such as poor and rural population (Sachs and McArthur, 2005). Reporting the magnitude, causes, and trends about maternal mortality is used to design a creative educational program for reducing it (Graham and Hussein, 2006). In Egypt, changing the behaviors of communities about maternal health is the illuminating road for reducing maternal mortality (Metwally, 2012).


  Aim Top


The aim was to assess the awareness and perceptions of women about maternal mortality issues in rural areas in both Assiut and Fayoum Governorates.

Research question

What are the levels of awareness and perceptions of women living in rural areas about maternal mortality issues in both Assiut and Al Fayoum Governorates?


  Patients and methods Top


Research design

A descriptive comparative research was carried out in this study.

Setting

The study was done in Maternal and Child Health Centers. They provide health services for rural women in both Assiut and Fayoum Governorates.
  1. The centers included Kafr Emera Maternal and Child Health Center, which provides maternal services for ∼750 women monthly from the following villages of Fayoum Governorate: Kafr Emera, Escandar, Rostom, Mrad Abdelmola, and Elshaeaie villages.
  2. El Fath Medical Center, which provides maternal services for ∼370 women monthly from the following villages of Assiut Governorate: Elfayma, Dronka, Elzawya, Elkawata, Elmaesra, and Arab Moteer villages.


Sampling

A simple random sample was used in this study. The sample was calculated by using EpiInfo Statistical Package, version 3.3 with power 80%. A value of 2.5 is chosen at the acceptable limit of precision (D) at 95% confidence level with expected prevalence of 16% and worst acceptable limit of 44%. Accordingly, sample size was estimated to be 600+10% of individuals to guard against nondespondence rate.

Inclusion criteria

The following inclusion criteria were applied:
  1. Women at reproductive age.
  2. Women who lived in rural areas.


Exclusion criteria

Women who refused to participate in the study were excluded.

Tools

A structured interviewing questionnaire schedule was used in this study, which was designed by the researchers and includes the following data:
  1. Sociodemographic characteristics such as name, age, level of education, occupation of both the mother and her husband, and family size.
  2. Obstetric history such as number of gravidity, parity, abortion, and living children.
  3. Data related to women’s awareness and perceptions about maternal mortality issues such as the definition of maternal mortality, the most common age group for maternal death, the most common time for maternal death, its direct and indirect causes, barriers for saving mothers, the three delays for maternal mortality, previous family history for maternal death, the preventive measures for reducing maternal mortality.



  Methods Top


An official permission was obtained from the Scientific Research Ethics Committee at the Faculty of Nursing, Assiut University, directed to the managers of both El Fath and Kafr Emera Maternal and Child Health Centers of Assiut and Fayoum Governorates, respectively. The researcher interviewed each woman who was seeking maternal healthcare in these centers and began to explain the nature and purpose of the study to take oral consent from these women to be included in the research. The time of filling the questionnaire took from 10 to 15 min, depending on the response of women to complete the following information. The questionnaire included sociodemographic data, obstetric history, and assessment of women’s knowledge and perceptions about the different issues of maternal mortality such as the definition of maternal mortality, its direct and indirect causes, and the preventive measures for reducing maternal mortality. The researcher provided health education about the unknown information about maternal mortality issues. Each woman was reassured that the information obtained would be confidential and used only for the purpose of the study.

The content validity

Testing validity was done for reassuring clarifications of the tools by a panel of three experts in the specialty of obstetrics and gynecological nursing.

Pilot study

It was carried out on 10% of the studied women before to test feasibility of the tools and the time needed for applying it. The necessary modifications were done to be consistent with the study.

Field work

The study started in March 2016 and ended in June 2016.

Ethical considerations

An oral consent was obtained from each woman before their participation in the study.

Data analysis

Data were analyzed using the statistical package for social science, version 16. χ2-test and t-test were used for analytical analysis. P values less than 0.05 were considered to be statistically significant. Scoring for the knowledge items are converted into percentage score. The women’s knowledge was considered satisfactory if the percent score was 60% or more and unsatisfactory if less than 60%. Finding the most risk factors that affected the level of awareness was done using multivariate analysis.


  Results Top


[Table 1] shows that nearly one-third of rural women in both groups aged from 28–32 years, and more than one-third of them had secondary school education (36.3 and 38.4% in El Fath and Kafr Emera, respectively). In general, there are no statistical significant differences between both groups in relation to sociodemographic data (P>0.05) except family size (P<0.01).
Table 1 Distribution of the studied women by sociodemographic data

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The study explores that more than two-thirds of the rural women in both groups had multigravidity and multiparity (66.7 and 70.0% in El Fath, respectively, and 73 and 73% in Kafr Emera, respectively). In general, there are no statistical significant differences between both groups regarding obstetric history (P>0.05), as shown in [Table 2].
Table 2 Distribution of the studied women according to obstetric history

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[Table 3] shows that more than half of rural women had satisfactory knowledge of both groups about maternal mortality issues (52 and 45% in El Fath and Kafr Emera, respectively), with no statistical significant differences (P>0.05).
Table 3 Distribution of studied women according to knowledge level about maternal mortality

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Regarding women’s awareness about the meaning of maternal mortality, the common age of maternal deaths, and the common countries for maternal deaths, there are statistical significant differences between both the groups (P<0.01), as shown in [Table 4].
Table 4 Comparison between Assuit and Al Fayoum regarding women’s awareness about maternal mortality issues

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[Figure 1] shows that more than one-third of women in both groups knew the meaning of maternal mortality (43 and 33% in El Fath and Kafr Emera, respectively), with no statistically significant differences (P>0.05). Regarding women’s awareness about the most common age of maternal deaths and the common countries for maternal deaths, there are statistically significant differences between both the groups (P<0.01).
Figure 1 Women’s knowledge about definition of MM.

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Regarding women’s perception about causes and barriers of maternal mortality, there are statistically significant difference between both the groups (P<0.01), as shown in [Table 5].
Table 5 Comparison between women’s perception about the common causes and barriers of maternal deaths

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[Figure 2] shows that there are statistically significant differences between both the groups regarding direct causes of maternal mortality (P<0.01).
Figure 2 Women’s knowledge about direct causes of MM.

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[Figure 3] shows that there are statistical significant differences between both the groups regarding indirect causes of maternal mortality (P<0.01). Concerning women’s awareness about three delays for maternal death, [Table 6] shows that there are statistical significant differences between both the groups (P<0.01).
Figure 3 Women’s knowledge about indirect causes of MM.

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Table 6 Family history of maternal deaths among women

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Regarding family history of maternal deaths, only 8 and 9% had an family event of maternal deaths in El Fath and Kafr Emera, respectively. Regarding women’s awareness about preventive measures for maternal death, [Table 7] shows that there are statistically significant differences between both the groups (P<0.01).
Table 7 Comparison between women’s knowledge about preventive measures for reducing maternal deaths

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By using multivariate analysis, [Table 8] shows that the risk factors that affect the level of awareness of women about maternal mortality issues are age of women and their family size, whereas other factors do not affect it.
Table 8 Risk factors affecting levels of awareness of women about maternal mortality by using multivariate analysis

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  Discussion Top


Although there is a continuous reduction of MMR in Egypt from 68 deaths per 100 000 live births in 2003 to 53 deaths per 100 000 live births in 2013. These statistical results still do not meet the Millennium Development Goals target to reach the MMR in Egypt to 43.5 deaths per 100 000 live births in 2015 (Jogdand et al., 2013).

One of the main interventions to reduce maternal mortality in Egypt is to raise the awareness of women about its issues especially in rural communities where there are low levels of education and incomes. So the aim of the present study was to assess the awareness and perception of women about maternal mortality issues in rural areas in both Assiut and Al Fayoum Governorates.

The present study explored that more than half of rural women in both groups had unsatisfactory awareness about maternal mortality issues (48 and 55% in El Fath and Kafr Emera, respectively). These findings disagreed with Jogdand et al. (2013), who mentioned in their study in India that more than two-thirds of women (69%) had satisfactory knowledge about maternal mortality issues. The variations in awareness may be relate to the differences of women’s age groups and levels of education between both studies.

On the same line, a Nigerian study by Butawa et al. (2010) stated that nearly half of women has poor knowledge about maternal mortality issues. This highlights the importance of education women about all maternal health issues for reducing maternal mortality. Another study in rural communities of Nigeria by Okereke et al. (2013) reported that most women (90%) displayed poor knowledge about maternal mortality issues.

This study explored the associated factors for this lack of knowledge such as poor antenatal care visits and its importance. According to the present study, nearly two-thirds of rural women in both groups perceive that the main cause of maternal mortality is the lack of maternal health awareness and nearly one-third considered literacy is another cause of maternal deaths.

These findings are congruent with Abbas et al. (2016) who reported in his study about maternal mortality in upper Egypt that there are additional causes for maternal deaths such as poor nutritional status and poor quality of care given to them. Moreover, recent studies about maternal mortality in developing countries showed that high quality of antenatal care can decline it (Paxton et al., 2005).

According to the study by Jogdand et al. (2013), the ccommonest cause of maternal deaths mentioned by women was obstetric hemorrhage (73.8%). It has similar results to our study which showed that the commonest causes of maternal deaths were bleeding and obstructed labor. On the same line, it is congruent with Abbas et al. (2016) who identified that the main causes of maternal mortality were obstetric hemorrhage, sepsis, and obstructed labor.

Another study by Friday et al. (2009), identified that the most common causes of maternal deaths were obstetric hemorrhage, malaria during pregnancy, and eclampsia. It stated that women’s perceived other social factors such as cultural beliefs and women as obstacles for obtaining regular antepartum, intrapartum, and post-partum care. Moreover, the global causes of maternal death in developing countries show that obstetric hemorrhage is the commonest cause of it (Say et al., 2014).

According to women’s awareness about the common three delays of maternal mortality, present study reported that a small percentage were aware about them. These findings disagreed with Jogdand et al. (2013), who mentioned that most of the women were aware about the three types of delays as an associated factors of maternal deaths.

Regarding the time of maternal death, the present study revealed that the rural women perceived post-partum period as the commonest period for maternal death. These findings were congruent with a Moroccan study about maternal mortality reported by Abouchadi et al. (2013) who showed that most women perceived post-partum period as an important time for maternal deaths.

In contrast, the finding is inconsistent with Ronsmans and Graham (2006), who mentioned in their study about maternal mortality in the UK that the commonest period for maternal deaths is the intrapartum period. Our study reported that the most common preventive measures perceived by rural women in both groups were high quality of antenatal and intrapartum care. These findings were incongruent with Parta et al. (2010) who reported in their study about maternal mortality in developing countries that the main interventions for reducing maternal mortality were effective family planning programs and prevention of sexually transmitted diseases.

These variations indicate the spread of unwanted pregnancy and mother-to-child transmission of sexual transmitted diseases in the most South African countries. In contrast, multivariate analysis in the present study showed that the most common risk factors affecting the awareness of these women were age of the women and their family size. These results are inconsistence with Campbell (2005) who mentioned in his study about maternal mortality in Nigeria that 39% of rural women were unaware about maternal mortality issues and referred this to financial weakness for reducing maternal mortality.

Limitations

  1. The study was limited to two areas of rural communities in two governorates, so it cannot be generalized as upper and lower Egyptian rural communities.
  2. There were some difficulties in convincing women to participate in our study because it is just a descriptive noninterventional study.



  Conclusion Top


The present study concludes that there are no statistical significance differences between rural women in both groups about the level of awareness about maternal mortality issues. The most important risk factors affecting the level of awareness about maternal mortality issues among rural women are the age of the women and their family size.

Recommendations

  1. Educational programs about maternal health issues are needed through Ministry of Health to raise the awareness of women about these issues especially in rural communities of Egypt.
  2. Further research studies are needed to investigate the different levels of awareness about maternal mortality issues in both rural and urban communities in Egypt.


Acknowledgements

The researchers express their deep appreciations for all the studied women who agreed to participate in the research. Continuous thanking for nursing staffs who have a vital role in facilitating the implementation of the study.[28]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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