Knowledge of Postnatal Danger Signs and Associated Factors among Mothers in Nepal

BACKGROUND: The postpartum period is crucial, and it is essential to recognize warning signs. Unfortunately, maternal mortality rates remain high due to postpartum complications, especially in developing countries like Nepal. Many mothers are not aware of postnatal warning signs, which can delay them from seeking necessary medical care and increase the risk of maternal mortality. The main objective of study to identify mothers' knowledge of postnatal danger signs and the relevant factors. METHOD: A study was conducted in Chitwan, covering three municipalities: Madi, Rapti, and Ratnanagar. A stratified proportionate-based simple random sampling technique was used to recruit 527 mothers for the study. Data was collected through face-to-face interviews using a structured questionnaire, and statistical analysis was conducted using SPSS version 21. A multivariate logistic regression was used to determine the factors associated with the knowledge of postnatal danger signs. RESULT: Out of the total respondents, only 209 (39.7%) demonstrated good awareness regarding postpartum danger signs. To be considered informed, a woman must be able to list at least three common warning signs. However, the majority of respondents consistently identified vaginal bleeding as a dangerous sign postpartum. The study found that modern health care seeking behavior (AOR=1.63, 95% CI:1.04-2.55), occupation in service (AOR=3.19, 95% CI:1.39-7.29), and time to reach the health facility (AOR=1.96, 95% CI:1.18-3.25) were significantly associated with knowledge of postnatal danger signs. Of these, 67 (12.7%) faced postnatal danger signs during their postpartum period. Among those, the majority (39 or 7.4%) had a good practice of seeking a health facility for care and treatment. CONCLUSION: It is encouraging that mothers become more aware of postnatal danger signs despite their initial low level of awareness. Factors such as the mother's age, occupation, educational background, age of marriage and first childbirth, number of ANC visits, and healthcare-seeking behavior are significantly associated with their awareness of postnatal danger signs. Therefore, healthcare providers should focus on these factors to improve the mothers' knowledge of postnatal danger signs.


INTRODUCTION
During the postpartum period, some symptoms can indicate possible complications that may occur within six weeks after giving birth.Severe vaginal bleeding, foul-smelling vaginal discharge, and high fever are key maternal danger signs (World Health Organization, 2018).1 Identifying danger signs during postpartum is crucial for saving lives.Even non-medical personnel can play a vital role in recognizing these warning signs and seeking medical assistance promptly (Bakar et al., 2019).2Age, educational status, family income, and decision-making power were significantly associated with knowledge of obstetric danger signs (Woldeamanuel, Lemma, & Zegeye, 2019).3 A study revealed that 37% of maternal deaths occur within 42 days after birth, and an additional 23.6% occur between 43 days to 1 year after birth, according to data from 14 maternal mortality review committees (2008-2017) (Davis, 2019).It is estimated that globally, there were 303000 maternal deaths due to complications related to pregnancy and childbirth (Darmstadt et al., 2006).5 Study shows that most participants could not recognize all postpartum danger signs, and 25% could not recognize any.The study linked awareness of these warning signs with hospital delivery, income, and education on warning signs before discharge (Adams & Yound, 2022).6 The main causes of maternal death in Nepal were hemorrhage (Suvedi et al., 2008(Suvedi et al., /2009)).7 Postpartum hemorrhage and long obstructive labor were the leading causes of maternal death in rural areas, whereas unsafe abortion, infection, and hypertension with preeclampsia were the leading causes of maternal death in urban areas (Bogale & Markos, 2015).8Most of the evidence shows poor knowledge of obstetric danger signs not only during pregnancy but also during delivery and after childbirth (Bhandari & Dangal, 2012).9Septic abortion was the leading cause of maternal death in Kathmandu Valley in the study of Rana et al. 2009.10A study finding shows the postnatal danger signs include fast or difficult breathing, convulsions, being too weak to get out of bed, blurred vision and headaches, pain in calf muscles, redness or swelling, urinary incontinence, swollen or tender breasts or nipples, increased perineal pain and depression within 42 days of birth.8 The study conducted in Turkey indicated that cultural influences were linked to delay in seeking care when they experience complications during the postpartum period, and this was contributed by factors such as age, educational level, health insurance, getting antenatal care, family structure, and knowledge of the danger signs during pregnancy (Hoque, 2011).11Visiting a health facility for care is the best way to identify any problem that may endanger the health of the mother/unborn baby and take action early and promptly (Ay et al.,2009).12Reviews of maternal deaths indicate that lack of knowledge about the signs of maternalcomplications among patients and families is a contributing factor in many deaths (Teshoma et al., 2020).13Association for Women's Health, Obstetric and Neonatal Nursing (AWHONN) and the Council on Patient Safety in Women's Health Care have developed standardized warning signs education materials (Petersen, et al., 2019).14Globally, the majority (80%) of maternal deaths are happening due to direct obstetric complications.These include hemorrhage, unsafe abortion, pregnancy-induced hypertension, infection, and obstructed and prolonged labor (Killion, 2020).15Approximately one-third of maternal deaths occur during pregnancy, and another one-third occur between 7 days and one year postpartum (Venn, 1013).16 Postpartum death is linked to the quality of maternal care provided during pregnancy and delivery (Bhutta et al., 2014).17Raising awareness among women about obstetric danger signs can lead to early detection of obstetric complications, resulting in timely medical care and reduced mortality (Mahara et al., 2016).18 Almost half of all postnatal maternal deaths occur within the first 24 hours, and 66% within the first week.Proper postnatal care can help ensure the well-being of both mother and newborn during this critical period (Nambala & Ngoma, 2013).19 Various contextual factors influence maternal health, and it is a social phenomenon.Social factors like governance, policies, cultural values, and laws create hierarchies based on social class, ethnicity, gender, education, occupation, and income (WHO, 2015).20 The World Health Organization's global maternal mortality ratio is 211 in 2021.Of concern is the highest reported MMR of 1150 in South Sudan (Damayanti, Wulandari, & Ridlo, 2023).21MMRhas significantly increased in developing countries, while developed countries have only slightly increased.
Low-income countries have an MMR of 462 per 100,000 live births, compared to 11 per 100,000 in high-income countries .(WHO, 2018).22Theissue of high maternal mortality rates is more prevalent in developing countries, where 99% of maternal deaths occur ( (Solar & Irwin, 2010).23 The late pregnancy, childbirth, and the postpartum period to bring down the number of maternal and neonatal deaths, which can be avoided with proper care (WHO, 2014).24Knowledge is essential in the formation of behavior.Health-conscious behavior will maintain and improve the health status of individuals (Belay & Limenih, 2020).25 The determinants of awareness of maternal danger signs include education, poverty, nutrition, lack of social amenities, inadequate healthcare, insufficient family planning, low status of women, gender-based violence, paternity and sex preference (Alemayehu, 2020).26Maternal Mortality Rate is an essential measure of women's health and is included in the development index and sustainable development goals (Tjandraprawira & Ghozali, 2019).27 To achieve the Sustainable Development Goals set by the United Nations in 2015, which include reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 (Ayoga, 2016-2030).28Nepal's maternal mortality ratio is 151 per 100,000 live births.The primary cause of maternal deaths was obstetric hemorrhage, accounting for 26% of all deaths MoHP, 2021).29

METHODS AND METERIALS Study Setting and period:
The study occurred in Chitwan -Nepal's central region district.Nepal is a federal republic comprising seven federal provinces and 77 districts, with Chitwan being one of them.It is situated in the southwest corner of Bagmati Province, which has 13 districts and features the secondlargest city in Nepal, Bharatpur.Chitwan spans 2,238.39square kilometers, divided into one metropolitan city, one rural municipality, and five municipalities -Bharatpur Metropolitan City, Kalika, Khairahani, Madi, Ratnanagar, Rapti Municipality, and Ichchhakamana Rural Municipality.The name "Chitwan" comes from the Chitwan Valley, nestled between the Mahabharat and Siwalik ranges -the foothills of the Himalayas. 30According to the 2021 Census, Chitwan has a population of 720,000, with a 2.07% growth rate compared to the previous year, surpassing the national average of 0.92%.Females constitute 53.91% of the population.Chitwan is home to diverse ethnic groups, religions, and cultures.29 It boasts a wide range of public and private healthcare facilities, making it a popular destination for medical care.It is regarded as Nepal's second-largest medical hub, featuring seven public health centers, three NGO-run facilities, and 175 private institutions.The district also has 24 birthing centers, three primary emergency obstetric neonatal care sites, and three comprehensive emergency obstetric neonatal care sites.However, maternal and child health in Chitwan still requires attention despite these resources.Several grassroots and district-level initiatives have been implemented to address this issue, but there is still scope for improvement.As per the Annual Report of the District Health Office, there are 36 health posts, three primary healthcare centers, and three hospitals in the area.The study was carried out from October 2021 to March 2022.Study Population: All eligible mothers who gave birth the previous year and had an infant aged between 45 to 365 days in the selected clusters during the data collection period were included, while those who were seriously ill throughout the data collection period were excluded.

Study Variables Dependent/ Outcome Variable: Awareness of postnatal danger signs
Independent Variables: This study focuses on awareness of postnatal danger signs as the dependent variable and uses independent variables to assess social factors that may affect it.The social factors include a mother's age, economic status, education, occupation, religion, ethnicity, distance of health facility, decision-making and healthcare-seeking.The obstructive factors include parity, age at marriage, age at first childbirth, number and timing of ANC and PNC visits, and several childbirths.The study found a significant relationship between these factors and PNS.Designs: A study was conducted in Chitwan to identify the social factors that influence mothers' awareness of postnatal danger signs.The research used quantitative methods; the primary aim was to identify the factors that affect postnatal danger signs in specific municipalities within Chitwan in Nepal.
For finite population, where N=total postnatal mother i.e 1633 n0 n= 1+ n0-1 N where n= required sample size, α= level of significant, z=standard normal distribution curve value for 95% confidence level= 1.96, P= proportion of mother's awareness about postnatal danger sign, d= margin of error.To conduct the sampling process, we utilized a multistage technique incorporating a design effect of two, and we factored in a 5% non-response rate.Chitwan district has five municipalities, and three municipalities (Rapti, Madi, and Ratnanagar) were selected by simple random sampling.House-to-house visits were carried out in the selected clusters to identify eligible mothers.All eligible mothers in the selected clusters were interviewed.Finally, because of the cluster effect, 527 mothers were interviewed.Various aspects of awareness of postnatal danger signs were examined, focusing on social factors that influence it.Random sampling techniques were employed to draw samples from each stratum.Data Collection Tools and Techniques: Data was collected through closed-ended, structured questionnaires administered during direct face-to-face interviews with participants.Data Collection Procedure: Face-to-face interviews were conducted using a structured questionnaire to obtain quantitative data.The questionnaire was developed in English after a literature review and then translated into Nepali.The principal investigator was present to offer guidance and ensure data quality.Written consent was obtained from participants, and their privacy was maintained throughout the data collection process.Confidentiality was also ensured by using de-identified data when disseminating the results.

Data Management and Analysis:
To ensure accuracy, the data was meticulously checked for completeness, inconsistencies, and missing values.Descriptive statistics were used to describe the study population based on socio-demographic and other relevant variables.Bivariate analysis was conducted confidently to determine the association between each independent variable and awareness of postnatal danger signs management.Only variables with a p-value of less than 0.05 were included in the multivariable analysis.Mothers' social characteristics and knowledge of postnatal danger signs were analyzed with utmost diligence using SPSS.Significant variables were identified through crosstabulation, and binary logistic regression was used to study the determinants of independent variables on postnatal danger signs with unwavering confidence (Kabakyenga, 2011).31 The dependent variable, awareness of postnatal danger signs, was categorized into two levels: good awareness and poor awareness, with the categorization of the level of awareness adapted from a Tanzanian study (Mwilike et al.,2018).32 The adjusted odds ratio was utilized to ascertain the degree and direction of the association of the significantly linked variables, with complete confidence in our conclusions (Salem et al., 2018).33Ethical Approval: Ethical approval was obtained from Nepal Health Research Council (Ref.No. 2827) Review Committee.Participants were given a clear explanation of the study's purpose and confidentiality guarantee, and verbal consent was obtained from each survey participant.No discrimination based on caste or religion occurred, and participation was voluntary.Anonymity was protected with a code system.

Table 1 Socialdemographic characteristics of respondents
Of the 527 respondents, 37.2% were aged between 20 and 24, while only 5.1% were aged 35 or above.Regarding education, the majority (53.5%) had received secondary education, and only 2.7% had received a bachelor's degree or higher.Concerning occupation, 63.2% were involved in household work, 7.0% in service, and 1.3% in daily wages.Regarding family type, 75.7% belonged to a joint family, and 3.5% belonged to a single family.Concerning ethnicity, 65.5% were Janajati, and 2.8% were Muslim.Regarding religion, 81% were Hindu, and 19.0% were non-Hindu (Buddhist, Christian, and Muslim).Among them, 59.4% of respondents' healthcare-seeking behaviors followed modern and traditional methods, and at least 7.6% followed the modern approach ( Out of 527 respondents, the majority, 55.6%, had their first childbirth at the age of 20 or more, and 8.2% had their first childbirth at the age of 16 or younger.Of these respondents, 82.0% had two children, with only 1.1% having five or more children.In terms of delivery, most 82.5% had a spontaneous vaginal delivery, while 17.1% had a cesarean section.The survey found that 97.2% of respondents attended antenatal clinics for checkups, and 67.4% attended four or more checkups during their last pregnancy (Table 2).According to the table provided, it is evident that a vast majority of the respondents, 99%, were aware of severe headaches, blurred vision, high-grade fever, paleness, and weakness as symptoms of maternal danger signs.Furthermore, a significant percentage (ranging from 43.6% to 86.5%) were also aware of other danger signs such as excessive vaginal bleeding, offensive vaginal discharge, lower abdominal pain, and fits or loss of consciousness.Out of the 527 respondents, 12.7% had experienced postnatal health problems, including 6.5% with excessive vaginal bleeding and 1.3% who had a fever.Interestingly, only 7.4% of respondents sought medical attention from a hospital, while 0.9% used traditional treatment ( Table 3)..0Based on the data, 60.3%, displayed poor level of awareness when recognizing warning signs of potential postpartum complications.Conversely, 39.7% demonstrated a good understanding of these warning signs, which required listing at least three common indicators, such as severe vaginal bleeding, foul-smelling vaginal discharge, and high fever, in order to be considered well-informed (Table 4).5 indicates that single-type families had 0.86 times greater awareness of PDS than joint or extended families.This difference was statistically significant, with a p-value of 0.015.Additionally, individuals 20 or older were 1.03 times more likely to understand PDS than those under 19, with a statistically significant variance below 0.05.Furthermore, those with at least a secondary education were 2.94 times more aware of PDS than those with a secondary level or lower education.Occupation was also a significant factor, with individuals in business and service being significantly more knowledgeable about PDS than those in household work.Specifically, according to the data, the former group was 5.21 and 6.91 times more knowledgeable than the latter group.Studies have shown that individuals with one or two children are 2.07 times more likely to know PDS compared to those with three or more children.Similarly, those who attended at least four ANC visits had 2.18 times higher chances of knowing about PDS than those who had fewer than four visits.Living within a 30-minute radius of a health facility also increased the likelihood of PDS awareness.In terms of ethnicity, the Janajati group had a 1.52 times higher chance of being knowledgeable about PDS.Similarly, the Madhesi group had 1.69 times higher likelihood, and Muslims were 2.53 times more likely to be aware.The Brahmin/Chhetri individuals were the most knowledgeable, with 3.15 times higher chances of being informed about PDS.However, the Dalit group respondents needed to be more familiar with PDS; this difference was statistically significant.6 presents a multivariate logistic regression analysis, revealing the factors linked to PDS awareness.The data indicates that respondents employed in the agriculture, business, and service industries had 1.33 times, 3.40 times, and 3.19 times more PDS awareness, respectively, compared to those involved in household work, which was statistically significant.Additionally, those who could reach a health facility within 30 minutes were 1.96 times more aware of PDS than those who needed to travel longer.Furthermore, the analysis shows that respondents who adopted modern healthcare-seeking behavior had 1.63 times more PDS awareness than those who relied on traditional methods.

Discussion
The study reveals that people who have completed their secondary and higher education are 2.94 times more aware of postnatal danger signs than those who have only completed their secondary education or lower (p<0.001).A similar study shows that secondary or tertiary education participants are more likely to know postnatal danger signs than their counterparts.A higher education level makes a woman more likely to understand the information received, leading to better decisions (Hibstu & Siyoum, 2017).34Educatedwomen can better understand the information provided during postnatal care, making it easier to report danger signs and manage problems on time.According to a recent study, a mere 39.7% of postpartum women were familiar with warning signs related to postnatal complications.To earn the label of knowledgeable, a woman needed to recognize at least three of the following danger signs: severe vaginal bleeding, foul-smelling vaginal discharge, and high fever.In contrast, another study revealed that only 55.1% of postpartum women were aware of maternal danger signs Nabugwere et al., (2022).35 The most commonly recognized danger signs were severe vaginal bleeding, high fever, and foul-smelling vaginal discharge, which aligns with earlier research conducted in Tanzania and Kenya (Mwilike et al., 2018;Phanice & Zachary, 2018).36,37According to research, individuals who attended at least four antenatal care appointments were 2.18 times more knowledgeable about PDS than those with fewer than 3 ANC visits.This finding is statistically significant (p<0.001) and consistent with similar studies conducted in Thailand and Ethiopia (Kaewkiattikun & Lekbornvornwong, 2019;Wassihun et al., 2020).38,39Regular attendance of antenatal care appointments in Nepal is beneficial in gaining awareness about potential health risks and exchanging information with other expectant mothers during health education sessions at the clinic.According to the study, mothers with one or two children have a significantly higher awareness of PDS than those with more than two children (p=0.003).However, Hailu, D., & Berhe, H. (2014) found a contradictory result, showing a significant association between knowledge of postnatal danger signs and mothers with more than two children.40Mothers' occupation is also linked to their knowledge of obstetric danger signs.Those employed in the service sector are 6.19 times more aware of PDS than those engaged in household work (adjusted 6.19, 95% CI: 2.90-13.23).Similarly, a study by Teshoma et al. (2020) found that government employees were 3.28 times more likely to have good knowledge of obstetric danger signs than housewives (adjusted OR=3.28, 95% CI: 1.98-5.42).41These findings could be attributed to the fact that women with their source of income may have better decision-making power when seeking healthcare services.

Strength and limitations
In cross-sectional studies with a retrospective design, participants are often asked to remember information from memory, which can introduce recall bias and lead to potential inaccuracies in the study's findings.Moreover, our study revealed a need for more literature on factors associated with postnatal danger signs, emphasizing the importance of future research to supplement the current literature and obtain a more comprehensive understanding of the factors influencing awareness on postnatal danger signs.

Recommendations
According to the study, many mothers lack knowledge about the warning signs that may arise after giving birth.This could result in a delay in seeking medical attention.Therefore, it is crucial to implement effective strategies, such as tailored health education and information dissemination, to increase maternal awareness.This will facilitate early detection of potential health complications during pregnancy, delivery, and postpartum.Moving forward, research should incorporate mixed study designs to establish causal links and explore the factors that impact maternal recognition of danger signs.

Conclusion
According to a recent study conducted in a municipality in Chitwan, Nepal, many mothers have a limited understanding of postnatal danger signs.However, the research also revealed that attending multiple antenatal care visits, giving birth at 19 years or older, working in business or services, and residing close to a health facility correlated with a better understanding of these PDS.Therefore, providing mothers with specialized health education during pregnancy and childbirth is important.In order to increase awareness, healthcare providers and local governments should incorporate IEC materials in the mother's native language.Further qualitative studies should be conducted to understand women's comprehension of danger signs better.Additionally, conducting an interventional study to evaluate the effectiveness of various health education methods on knowledge of danger signs may be beneficial.

Table 3
Respondents Awareness of Postnatal Danger Signs and Method of Treatment Source: Field Survey, 2022, **Multiple responses

Table 4
Respondents' Awareness of Postnatal Danger Signs

Table 5
Bivariate Analysis of Awareness of Postnatal Danger Signs and Social Variables Significance at 95%CI, OR=Odd Ratio: CI= Confidence Interval

Table 6
Multivariate Analysis of Awareness of Postnatal Danger Signs with Selected Variables