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Birth preparedness & complication readiness of pregnant women in Meghalaya, India
For correspondence: Dr Sandra Albert, Indian Institute of Public Health Shillong, Shillong 793001, Meghalaya, Indiae-mail: sandra.albert@iiphs.ac.in
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Received: ,
Accepted: ,
Abstract
Background & objectives
Maternal mortality remains a major global health issue, with India, particularly Meghalaya, contributing significantly to the burden. The three delays: decision-making, reaching a healthcare facility, and receiving care are key factors contributing to maternal deaths. Birth preparedness and complication readiness (BPCR) interventions aim to address these delays by preparing women for childbirth and its complications. This study evaluated the BPCR index and the quality of antenatal care (ANC) in Meghalaya, considering the perspectives of both pregnant women and healthcare providers.
Methods
A mixed-methods design was employed in different blocks of East Khasi Hills District, Meghalaya. A quantitative design was used to assess the BPCR index among 200 pregnant women. Direct observations of a subset of over 10 per cent of the ANC checkups were done to assess their quality. Additionally, in-depth interviews with 14 pregnant women and eight healthcare providers explored factors influencing BPCR and the quality of ANC.
Results
The BPCR index from this study was 43.4 per cent. Only 5 per cent of pregnant women could identify at least one danger sign of pregnancy. Direct observations revealed that the quality of ANC concerning BPCR was poor, with none of the ANC check-ups incorporating BPCR counselling. In-depth interviews also revealed that none of the healthcare providers were aware of BPCR counselling.
Interpretation & conclusion
The study revealed a critical lack of awareness about danger signs, contributing to the low birth preparedness and complication readiness. The absence of related counselling during ANC visits highlights a significant gap in maternal care and preparedness in the region.
Keywords
ANC
Antenatal care
BPCR
birth preparedness
complication readiness
healthcare providers
pregnancy
In the year 2023, ⁓700 women died each day due to pregnancy- and childbirth-related causes1, with 87 per cent of these deaths occurring in developing countries of Africa and Asia, particularly in sub-Saharan Africa and South Asia2. The high maternal mortality has been associated with significant costs to the health systems and society globally3; thus, prevention of such deaths is necessary. While India has made considerable progress over the years in reducing maternal mortality4, it still contributes to the global burden of maternal deaths. The northeastern region of the country, particularly Meghalaya, continues to struggle with high maternal mortality rates, exacerbating the country’s overall burden5. Meghalaya, with a predominantly tribal population6, reported 228 maternal deaths in the year 2021-20225 (HMIS 2021-22), the highest in the northeast.
The majority of maternal deaths can be prevented by facility-based skilled birth delivery and emergency obstetric care; however, access to these services can be hindered by the three delays7,8. These three delays, as documented by Thaddeus and Maine4, include (i) delay in seeking care, (ii) delay in reaching a health care facility, and(iii) delay in receiving appropriate and adequate quality care7. Birth preparedness and complication readiness (BPCR), globally recommended as a safe motherhood strategy, aims to address the three delays by enhancing preventive behaviours, increasing maternal knowledge, and improving care-seeking behaviour9. BPCR, as an essential component of antenatal care (ANC) packages10, is designed to help a pregnant woman seek timely healthcare, thereby reducing maternal mortality and morbidity11. This study aims to assess the BPCR index among pregnant women and factors associated with it. It also aims to assess the quality of ANC with regard to BPCR and explore healthcare providers’ perspectives regarding the quality of ANC in Meghalaya.
Material & Methods
This study was conducted by the Indian Institute of Public Health, Shillong, Meghalaya, India between December 2023 to May 2024. It was approved by the Institutional Ethics Committee. Written informed consent was obtained from all pregnant women involved in the study. A mixed-methods approach was used, comprising quantitative surveys, qualitative interviews, and direct observations at the selected health centres in the East Khasi Hills (EKH) district, Meghalaya.
Sample selection
EKH district was purposively selected as it reported the highest number of maternal deaths in Meghalaya5. Within the district, Mylliem block was chosen due to its highest reported number of maternal deaths in the year 2021-22 (data from the State health department)12. A total of nine health centres were selected from this block: four primary health centres (PHCs), four sub-centres (SCs), and one community health centre (CHC) based on accessibility. Pregnant women were sampled based on the number of ANC participants at each health centre. Due to variations in ANC attendance across health centres, the sample was not stratified. Instead, health centres with higher ANC attendance were allocated a proportionately larger number of participants, ensuring the sample accurately represented the distribution of pregnant women across the centres.
Based on a reported BPCR index level of 41 per cent in a study done in Delhi13, this study required a sample size of 194 to estimate the expected proportion with 25 per cent relative precision and a 95 per cent confidence interval, accounting for a design effect of two per cent. Anticipating a non-response rate of 10 per cent, a sample of 200 pregnant women was considered for the study. Exit interviews with the pregnant women following their antenatal check-ups were conducted at the selected health centres using the structured questionnaire adapted from John Hopkins Programs for International Education in Gynaecology and Obstetrics (JHPIEGO)14.
The BPCR index was calculated using the following seven indicators: (i) identification of the danger signs of pregnancy; (ii) arrangement of a healthcare provider; (iii) arrangement of a health facility; (iv) arrangement of a blood donor; (v) arrangement of transport for delivery; (vi) arrangement of a birth companion; and (vii) saving money for delivery13. A score of 1 was given if each BPCR indicator was fulfilled. Pregnant women who could identify at least three danger signs were considered to be complication-ready and received a score of one for that component, as used by similar studies15-18. Pregnant women who could fulfil five of the seven indicators were considered better prepared19. The BPCR score for each pregnant woman was calculated as the sum of the number of indicators fulfilled divided by seven (BPCR score = indicators/7). The BPCR index was then calculated as the average of all the participants’ BPCR scores (BPCR index = average of BPCR scores)16. Participants who fulfilled five or more indicators (i.e., BPCR score ≥71%), were classified as better prepared, while those with scores below the threshold were considered less prepared.
To observe ANC check-ups conducted by healthcare providers, over 10 per cent of the sample size, equating to 26 real-time observations, were performed. These observations followed the checklist guidelines for antenatal care and skilled attendance at birth by auxiliary nurse-midwife (ANMs), lady health visitors (LHVs), and staff nurses (SNs) (2010) with regard to BPCR20,21.
For the qualitative component of the study, an interview guide was prepared for in-depth interviews with 14 pregnant women at the selected health centres to assess their perspectives regarding factors associated with BPCR. Additionally, eight healthcare providers who were performing ANC, including doctors, mid-level healthcare providers (MLHPs), and ANMs, were also interviewed to assess their perspectives regarding the quality of ANC. The guide was pre-tested and revised to improve clarity and flow. Interviews were conducted in the local Khasi language and were audio-recorded. Participants were interviewed until data saturation was achieved.
Data analysis
Quantitative data were entered into Microsoft Excel, and the analysis was performed on STATA 16 (StataCorp; 2019, TX). Descriptive statistics were reported for all the demographic variables in the study. The BPCR index was calculated for each participant based on the indicators. For logistic regression analysis, BPCR was dichotomized as ‘better prepared’ (BPCR score ≥71%) and ‘less prepared’ (BPCR score <71%) to examine the influence of key study variables. Proportion, odds ratio (OR), and adjusted OR with 95 per cent confidence intervals for the BPCR were reported as outcome measures. The qualitative data were transcribed and translated from the audio recording by the research team. To ensure accuracy and consistency, all translations were reviewed and validated by a second independent bilingual researcher. The data were coded, categorised, and arranged into themes using a thematic content analysis approach.
Results
All the pregnant women in the study were tribals, with a mean (Standard Deviation) age of 26.4 (5.4) yr. Their demographic characteristics are shown in table I.
| Characteristics | Categories | Frequency (%) |
|---|---|---|
| Age (yr) | ≤25 | 104 (52) |
| >25 | 96 (48) | |
| Religion | Niam Khasi | 99 (49.5) |
| Christian | 101 (50.5) | |
| Marital status | Cohabitation | 160 (80) |
| Married | 40 (20) | |
| Education | Professional degree | 3 (1.5) |
| Graduate | 13 (6.5) | |
| High school | 41 (20.5) | |
| Middle school | 102 (51) | |
| Primary school | 29 (14.5) | |
| Illiterate | 12 (6) | |
| Socio-economic status | Lower Middle (III) | 25 (12.5) |
| Upper Lower (IV) | 175 (87.5) | |
| Gravida | Primigravida | 66 (33) |
| Multigravida | 134 (67) | |
| Parity | Nulliparous | 70 (35) |
| Primiparous | 32 (16) | |
| Multiparous | 98 (49) | |
| History of stillbirth | Yes | 24 (12) |
| History of abortion | Yes | 28 (14) |
| Registration of pregnancy | 1st trimester | 133 (66.5) |
| 2nd trimester | 58 (29) | |
| 3rd trimester | 9 (4.5) | |
| Number of ANC Visits | < 4 | 139 (69.5) |
| ≥ 4 | 61 (30.5) |
ANC, antenatal care
BPCR status
On assessing the indicators for BPCR, it was revealed that the majority of the pregnant women had decided on a health facility (75%), saved money (68%) and arranged for a healthcare provider (66%). However, only 29 per cent had made transportation arrangements and 8.5 per cent had arranged for a blood donor. None of the pregnant women were complication-ready (i.e. they could not identify at least three danger signs of pregnancy) and only 5 per cent could identify only one danger sign of pregnancy. Among the 200 pregnant women in the study, the mean (SD) BPCR index was 43.4 (21.3) per cent; with a median 42.9 per cent [interquartile range (IQR): 28.6-57.1%]. Overall, 16 per cent of the pregnant women were better prepared, while the remaining 84 per cent were less prepared.
Factors associated with BPCR
To assess the factors associated with BPCR, a multivariable logistic regression analysis was done, indicating that religion, marital status, educational status, number of ANC visits, and history of stillbirth were significant predictors of BPCR (Table II)21.
| Variable | Categories | Crude model | Adjusted model | ||
|---|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | ||
| Age (Ref = ≤25) | >25 | 1.84 (0.85-3.94) | 0.11 | 1.63 (0.42-6.33) | 0.47 |
| Religion (Ref = Niam Khasi) | Christian | 1.40 (0.66 -2.99) | 0.37 | 4.03 (1.02 -15.85) | 0.04 |
| Marital status (Ref = Married) | Cohabitation | 0.67 (0.24-1.87) | 0.44 | 8.92 (1.74-45.62) | <0.001 |
| Education (Ref= Middle school & below) | High school & above | 20.55 (7.79 -54.14) | <0.00 | 196. 76 (18.51-2091.11) | <0.001 |
| Socio-economic status a (Ref = Upper -Lower category) | Lower Middle | 5.06 (2.06 -12.42) | <0.00 | 1.33 (0.33-5.28) | 0.68 |
| Gravida (Ref = Primigravida) | Multigravida | 1.38 (0.60-3.16) | 0.44 | 0.76 (0.02-26.91) | 0.88 |
| Parity (Ref = Nulliparous) | Primiparous | 0.4 (0.08-1.94) | 0.25 | 0.73 (0.01-51.78) | 0.88 |
| Multiparous | 1.63 (0.71-3.73) | 0.24 | 3.38 (0.09 -125.71) | 0.50 | |
| Stillbirth (Ref = No) | Yes | 3.02 (1.16-7.79) | 0.02 | 78.74 (6.54 – 947.58) | <0.001 |
| Abortion (Ref = No) | Yes | 1.11(0.39-3.18) | 0.83 | 0.30 (0.04-2.10) | 0.22 |
| Months of pregnancy (Ref =1st trimester) | 2nd trimester | 2.58 (0.93-7.12) | 0.06 | 2.10 (0.34-12.99) | 0.80 |
| 3rd trimester | 2.44 (0.85-6.99) | 0.09 | 2.14 (0.32-14.09) | 0.80 | |
| Registration of pregnancy (Ref = 1st trimester) | 2nd and 3rdtrimester | 1.58 (0.73-3.40) | 0.23 | 0.84 (0.22-3.16) | 0.79 |
| No of ANC (Ref = <4) | ≥4 | 3.46 (1.60-7.45) | <0.001 | 5.88 (1.57-21.94) | <0.001 |
Additionally, qualitative analysis of in-depth interviews with pregnant women to assess factors associated with BPCR revealed the following themes.
Family and community support
Family and community support emerged as a crucial factor affecting BPCR. Pregnant women often relied on advice from their husbands and family members when selecting healthcare facilities and providers. Similarly, financial assistance from the family and the community was indispensable for managing delivery logistics. Peer networks also helped in knowledge sharing through informal conversations and shared experiences, which enhanced women’s understanding of risks during pregnancy.
“I can utilize a family member’s or neighbor’s cab when I start to have labor pains”
(Pregnant woman/33 yr/EKH).
Previous experiences
Prior positive experiences with healthcare providers and institutions substantially influenced subsequent healthcare-seeking behaviour. Women who had received satisfactory care during previous pregnancies demonstrated a greater likelihood of returning to the same facilities, thereby reinforcing continuity of care. The perceived availability of immediate medical interventions within these settings also fostered a sense of security, which contributed to prior arrangements for healthcare providers, leading to better preparedness.
Lack of information on BPCR
Pregnant women reported a lack of information regarding BPCR and therefore did not prepare for such arrangements. Some women reported that they were not informed, even during their ANC check-ups.
“Even at checkups, they don’t discuss it, so I don’t know about it”
(Pregnant woman/35 yr/EKH).
The lack of awareness of government schemes like Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakram (JSSK), aimed at improving logistical barriers, further impedes their preparedness for childbirth.
Perceptions regarding BPCR
Perceptions regarding childbirth also affected the BPCR of the pregnant women. Some women held inaccurate beliefs about the risk of blood loss, revealing misunderstanding or confusion about the concept of blood loss and therefore did not arrange for a blood donor.
“How can I have less blood? When a large amount of blood is being released, when a knife cuts.”
(Pregnant woman/28 yr/EKH).
Household traditional beliefs regarding traditional birth attendants and preference for home deliveries further derailed arrangements with trained healthcare providers.
Lack of decision-making
Lack of decision-making authority often shifted planning responsibilities to other family members, which limited their agency in preparations. Pregnant women whose families trusted traditional birth attendant soften favoured home deliveries, as their families decided on their behalf. Additionally, the lack of financial decision-making, particularly among pregnant women living in poverty, further hindered their ability to prepare adequately for birth.
Quality of ANC with regard to BPCR
Direct observations of ANC sessions performed by the healthcare providers were performed in accordance with the ANC observation checklist for antenatal care and skilled attendance at birth with regard to BPCR20,21. Among the observed ANC check-up sessions, all (100%) included registration of pregnant women and conducting physical examinations. However, none of these sessions included components of BPCR counselling as part of their regular ANC check. Seven out of the eight (88%) components of BPCR were absent from all the observed sessions, indicating a low quality of ANC concerning BPCR.
Qualitative analysis of in-depth interviews with healthcare providers to assess perspectives regarding the quality of ANC revealed the following themes:
Focus of quality ANC
Healthcare providers reported that each ANC check up lasted up to 15-20 min to complete these procedures. They largely acknowledged quality ANC in terms of registration, history taking, and physical and laboratory examinations. These include physical measurements of blood pressure, weight, height, blood sugar, haemoglobin, and abdominal examinations. Laboratory examination includes haemoglobin, random blood sugar, urine, blood grouping, HIV and VDRL tests. Additionally, medications such as iron and folic acid, along with tetanus injections, were also considered important components.
Inadequate emphasis on communication and education
Healthcare providers did not initially identify counselling as a component of ANC; however, when prompted, they acknowledged its importance, particularly in areas such as nutrition, family planning, and birth spacing, which they recognized as essential for minimising risks and promoting maternal and newborn health. Notably, none of the providers mentioned Birth Preparedness and Complication Readiness (BPCR) as part of ANC counselling. Moreover, health providers were unaware that BPCR-related counselling is a part of ANC as outlined by World Health Organization (WHO) guidelines22,23.
Discussion
This study provides a detailed exploration of birth preparedness and complication readiness among pregnant women in Meghalaya, a northeastern State of India facing significant health challenges24, including one of the highest maternal mortality rates in the country4. Our findings revealed a BPCR score of 43.4 per cent, which is lower compared to studies done in Madhya Pradesh (47.5%)16, Maharashtra (59.5%)25, and Karnataka (79.3%)15, as well as in several global studies26-28. While early identification of danger signs and timely medical intervention could largely prevent maternal mortality29, only 5 per cent of the pregnant women in the study could identify a single danger sign of pregnancy, lower than studies done in Karnataka (80%)15, Varanasi (35.2%)18, and Maharashtra (21.8%)25, indicating a critical knowledge gap. Direct observations of healthcare providers during ANC check-ups revealed that pregnant women were not counselled on BPCR, similar to studies done globally30,31 and in India32. This is compounded by healthcare providers’ lack of awareness on BPCR counselling, highlighting a deficiency in service delivery.
The low preparedness in this study is primarily attributed to the limited preparations for transport (29%) and arrangements for a potential blood donor (8.5%), findings that are similar to previous studies16,25. A primary issue in Meghalaya is the hilly terrain and poor road infrastructure33 which hinders transport access; therefore, arranging for a cab during an emergency poses logistical difficulties. Similarly, the lack of arrangements for blood donors for delivery, a critical step in managing obstetric emergencies, is a concern given the high prevalence of anaemia among women in the State34, which increases the risk of complications such as excessive blood loss during delivery35. The lack of awareness regarding danger signs also represents a critical issue in tribal populations, where cultural preferences favour home deliveries36, thereby increasing the likelihood of complications going undetected and untreated. Without these prior arrangements, pregnant women are more likely to face delays in receiving care, which can be life-threatening in emergencies. The situation is further exacerbated by the absence of BPCR counselling during ANC visits, depriving pregnant women of essential information due to the limited communication skills of healthcare providers. The lack of awareness among healthcare providers on BPCR and its role as a key component of ANC indicates a considerable deficiency within the healthcare workforce. This represents a missed opportunity to deliver life-saving knowledge, ultimately underutilising a powerful tool for maternal risk reduction.
Amid these challenges, the study also identified enablers of BPCR. Most pregnant women (75%) have planned for facility-based deliveries and reported saving money (68%) for emergencies through family and community support. The close-knit nature of tribal communities36, where families live nearby and often provide logistical and emotional support, likely contributed to enhancing preparedness. Such community and peer networks served as vital sources of information and encouragement through the sharing of resources and experiences, which supported these women in preparing for birth and its complications. Furthermore, the study revealed that certain cultural practices unique to Meghalaya, such as cohabitation without formal marriage, were positively associated with better BPCR. This may reflect locally embedded social dynamics in reproductive health decisions within such arrangements.
This cross-sectional survey through exit interviews among pregnant women provided estimates of the BPCR index for Meghalaya, adding valuable evidence from a previously underrepresented region. The mixed methods design further enhanced understanding by providing patient and provider perspectives regarding BPCR. Direct observations of ANC gave additional insights into the quality of ANC, albeit in a small sub-sample. However, since the research was limited to East Khasi Hills, the most populous district, the findings may limit the generalisability to other districts in the State. Further studies across diverse geographical and cultural settings within Meghalaya can aid in better informing State-wide maternal health strategies.
The findings of this study reveal systemic failures in the delivery of antenatal care, particularly in the communication of essential information related to BPCR. These gaps highlight the urgent need for comprehensive training programs for healthcare providers that go beyond clinical skills to include communication and other elements of respectful maternal care. Furthermore, the study underscores the importance of understanding the sociocultural context in which maternal healthcare is delivered. In community-oriented regions like Meghalaya, cultural norms strongly influence healthcare decision-making and perceptions of risks; therefore, integrating families and communities into maternal health strategies can enhance the effectiveness of BPCR interventions.
Acknowledgment
Authors acknowledge the study participants and Health Department, Directorate of Health Services, Meghalaya.
Financial support & sponsorship
None.
Conflicts of Interest
None.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
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