Development of Birth Preparedness Tool (BPT) -A tool to assess mother's preparedness for delivery, postnatal and new born care

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1 Development of Birth Preparedness Tool (BPT) -A tool to assess mother's preparedness for delivery, postnatal and new born care Varinder Kaur, Sushma Kumari Saini, Indarjit Walia Abstract : Birth Preparedness is an advance planning and preparation for delivery. Its Components include, Preparation for normal delivery, readiness to deal with complications, post natal and new born care. Preparing mother for the birth is an important part of antenatal counseling and one of the responsibility of health care provider. For giving proper counseling it is important to know how much the mother already knows about birth Preparedness. But in order to assess birth preparedness there is need to have a tool which will help the health care provider to assess it. Hence the need was felt and a methodological study was undertaken with the objective to develop a tool to assess the preparedness of mother for delivery, postnatal and new born care. The study was divided into six phases i.e. Preliminary preparation, Assessment of content validity, Modification phase, Tool feasibility, Try out phase and Reliability phase with different steps. Pilot study and try out phase was undertaken at village Dhanas and Dadu Majra Colony respectively. 30 items original Birth Preparedness Tool (BPT) was developed; the content validity, construct validity and reliability of the tool were ensured by Delphi technique, factor analysis and internal consistency. Value of Cronbach's alpha (unstandardised) was 0.81 and developed tool was found reliable. Results of Factor Analysis confirmed that 20 items must be retained out of 30 items of original tool. The developed tool would help the health care provider to assess preparedness of mother regarding delivery, post natal and new born care. After assessing the preparedness, health care provider can counsel the antenatal mother according to her level of preparation. It would result in better outcome of delivery. Key words : Birth preparedness, Delivery, Post natal care, new born care Correspondence at : Varinder Kaur National Institute of Nursing Education, Chandigarh Introduction Maternal mor tality is a substantial burden in developing countries. The World Health Organization (WHO) estimates that 500, ,000 women die from pregnancy and childbir th-related complications each year, with 99% of these deaths occurring in developing countries. In India the maternal mortality ratio is 300 per 100,000 live births. Reducing maternal mor tality has received 45

2 recognition at the global level as evidenced by the inclusion of reduction of maternal mor tality in the Millennium Development Goals. Since it is not possible to predict which women will experience life-threatening obstetric complications that lead to maternal mor tality. So receiving care from a skilled provider (doctor, nurse) during childbirth has been identified as the single most important intervention in safe motherhood and reducing maternal mortality.however, approach to use skilled providers in developing countries remains low. According to the demographic and health surveys, only 51% of women in developing countries were assisted by a skilled provider at last birth. To tackle this problem the Maternal and Neonatal Health (MNH) Program in developing countries developed the concept of Birth-Preparedness of antenatal mothers Birth-preparedness and complication readiness is a comprehensive strategy to improve the out come of delivery.it is an advance planning and preparation for delivery. Components of birth preparedness include -Preparation for normal delivery, readiness to deal with complications, post natal care and new born care. Preparing mother for the birth is responsibility of the health care provider. For preparing the mother it is important to know her level of preparation about self care and new born care. But in order to assess birth preparedness there is need to have a tool which will help the health care provider to assess it. So that needed help can be provided to woman and time of health care professional can also be saved while preparing the mother on the issues which she already knows. Birth preparedness helps to ensure that women can reach professional delivery care when labor begins. In addition, bir th preparedness can help to reduce the delays that occur when women experience obstetric complications, such as recognizing the complication and deciding to seek care, reaching a facility where skilled care is available and receiving care from qualified providers at the facility. Preparedness also helps pregnant women to acquire skills and confidence needed to make birth a positive experience as it dissolves fears and makes pregnancy a time to remember. Now a days even in maternity hospitals give more emphasis on bir th preparedness. Few institutes have arrangement for classes on maternity issues e.g. exercises, diet, nutrition, birth process, how to look after the baby, breast feeding techniques and its benefits. In developing countries where maternal mortality is high and distance and lack of transportation are the barriers to seek the skilled care. So Activities to improve birth preparedness and recognizing complications at household and community levels have been introduced as a standard component to improve maternal survival. Programs like community mobilization activities, community education, transport and financing schemes have been found effective as a strengthening links between women who need skilled care and health workers who can provide care. 5 46

3 Safe motherhood programs in developing country like Nepal have included the use of birth preparedness cards as one method of increasing timely use of skilled care. The bir th preparedness cards help women and families to plan for safer births. They include basic information on danger signs, guidance on choosing a birth location and attendant, arrangements for supplies, transport, fees and finding a blood donor in case of emergency. 6 Another study conducted in district Siraha of Nepal in , was to determine the effectiveness of the Bir th preparedness program (BPP) to positively influence planning for births, household-level behaviors that affect the health of pregnant and postpartum women and their newborns, and their use of selected health services for maternal and newborn care. The result of study showed that the BPP can positively influence knowledge and immediate health outcomes. The BPP can be implemented by government health services with minimal outside assistance but should be comprehensively integrated into the safe motherhood programme rather than implemented as a separate intervention. 7 A cross-sectional sur vey was conducted in 2003 in Burkina to measure the impact of bir th-preparedness and complication readiness on the use of skilled providers at birth. Out of the 180 women who had given birth within 12 months of the survey, 46.1% had a plan for transportation, and 83.3% had a plan to save money. Women with these plans were more likely to give birth with the assistance of a skilled provider. Controlling for education, parity, average distance to health facility, and the number of antenatal care visits, planning to save money was associated with giving birth with the assistance of a skilled provider at bir th. Qualitative interviews with women who had given birth within 12 months of the survey support these findings. Most women saved money for delivery, but had less concrete plans for transpor tation. These findings highlight how bir th-preparedness and readiness to take care of complication may be useful in increasing the use of skilled providers at birth, especially for women with a plan for saving money for delivery. Women and new born need timely access to skilled care during pregnancy, childbirth and postpartum period. So every pregnant woman and new born is at risk of complications. These complications can be prevented by doing the 'planning and preparations for the birth' well in advance. Bir th preparedness is an essential part of antenatal care and it is the responsibility of health worker. It helps to reduce the complications and results in better outcome of delivery. Health worker needs a tool to know weather a pregnant mother is prepared for birth or not.but no such tool has been developed for the health worker to assess the preparedness of bir th in Indian settings. Hence need was felt to prepare such kind of tool to assess the preparedness of the mother. 47

4 Objective To develop a tool to assess the mother's preparedness for delivery, postnatal and new born care Methodology and results A methodological research design was adopted to carry out the present study.the study was divided into six phases with different steps Phase 1 was Preliminary preparation that further includes three steps. In step -1 literature was reviewed related to bir th preparedness in step 2 related content was analyzed after reviewing the literature and in STEP-3 the related items was selected from the content and divided into main headings that is preparation for delivery, postnatal and new born care and first draft of tool was prepared. Phase 2 was Assessment of content validity that was ensured by twelve experts from the field of nursing and public health department by using Delphi technique in three Delphi rounds. The experts were requested to validate Content revision, Item order revision, Item wording. Phase 3 was Modification phase Experts opinion were taken into consideration changes were made into the tool and modifications were made as Only antenatal women of third trimester were included in the study according to experts in Indian setting mother's prepare themselves only in the last trimester, Format of the tool was changed and separate scoring sheet was developed,four items were deleted as per recommendation of the exper ts, Language (sentence) modification of three items were done, Replication of three items were removed,sequential organization of items was done. A modified interview schedule was prepared to assess the mother's preparedness for delivery, postnatal and new born care. Separate scoring sheet was also prepared. According to scores obtained, the antenatal mother was categorized into well, moderate and insufficiently prepared. Guidelines to use the interview schedule were also developed. It was divided into five parts Part - A - it comprises of socio demographic profile of antenatal mothers,part - B - comprises of obstetric history, Part - C - comprises of preparation for delivery Part - D - comprises of preparation for postnatal care, Part - E - comprises of preparation for new born care. Phase 4 - Tool feasibility-in order to establish feasibility pre testing of the tool was conducted in the village Dhanas. Tool was applied on 10 antenatal mothers of third trimester. Village Dhanas was selected for the pre testing of the tool because it is similar in setting as per study population in Dadu majra colony where the 2nd try out of the tool was carried out. Tool was found feasible. Language of the questions was clear and it took minutes to complete one interview schedule. 48

5 Phase 5 - Try out phase Tool was again implemented on 93 antenatal mothers of third trimester in Dadu majra colony of Chandigarh. This is resettled colony with 2670 houses having population of about The colony is situated at a distance of five kilometers from National Institute of Nursing Education, PGIMER, Chandigarh and ten kilometers away from Inter State Bus Stand, Sector 43, Chandigarh. Interview technique was used to gather information in this phase. Ethical issues were taken into consideration in this phase as antenatal mother were informed about the objectives of study their verbal consent was taken and they were free to participate and withdraw from the project at any time. Phase 6 : Reliability phase -Reliability of Birth preparedness tool (BPT) To find out internal consistency and reliability of the present tool Cronbach's alpha (unstandardised) is used. Overall Cronbach's alpha coefficient of present tool is 0.81 which suggests reliability and internal consistency of the tool. (Ideally Cronbach's alpha coefficient should be above 0.70). There were total thirty three items in the original tool, three items were removed before applying Cronbach's alpha as these items had uniform responses, these items were inverted nipples of mother, articles kept ready by mother for home delivery and where the mother would contact if new born had danger signs. When Corrected item to total correlation was applied on thirty items of the tool, it showed that 22 items had item score to total score correlation between (The optimal lower value for item to total correlation should be at least ) where as 8 items in the tool had item score to total score correlation < 0.2 showing there incompatibility with the overall tool. These items were registration for pregnancy (0.12). No. of visits done by antenatal mother (0.17), No. of TT received by antenatal mother (0.4), Antenatal exercises (0.15), contact after danger signs of pregnancy (0.7), Blood donors arranged for emergency (0.14), Assistance to mother in post natal period (0.6), Awareness about post natal exercises (0.16). None of the item in this tool showed correlation > 0.8. But when alpha if item deleted was applied none of the item in tool showed increase in Cronbach's alpha coefficient if that item is deleted rather the value of Cronbach's alpha coefficient either remained same or it decreased. This indicates that all the 30 items were uniformly contributing for the reliability of the tool. (Table 1) 49

6 Table 1- Reliability analysis of the 30 item version of the Birth Preparedness Tool (BPT) by using Cronbach's alpha Items Scale Corrected Cronbach's mean** item total alpha if if item correlation item deleted deleted 1. Expected date of delivery Registration for pregnancy * No. of visit done by antenatal * No. of TT received by antenatal mother * Essential laboratory tests Blood group of antenatal Antenatal exercises * Awareness of danger signs during pregnancy Contact after danger signs during pregnancy * Planning of mother to deliver her baby Approximate distance of the institute Transportation facility Articles kept ready for hospital delivery Accompany of mother for hospital delivery Financial arrangements for emergency Blood donors for emergency * Awareness of mother for post natal danger signs Birth control measures after delivery Assistance to mother in post natal period * Diet during post natal period Awareness about episiotomy care Awareness about post natal exercises * Articles kept ready for baby Awareness about exclusive breast feeding When to feed baby after delivery Schedule of breast feeding the baby Awareness about importance of colostrum Awareness about new born danger signs Knowledge about essential care of baby Knowledge about vaccination schedule of baby Overall reliability of tool is 0.81 (unstandardised Cronbach's alpha) **Over all scale mean is * Items in the tool which shows item to total correlation <

7 Factor analysis To assess the suitability to carry out factor analysis in present tool Kaiser-Meyer- Olkin (KMO) and Bartlett's test of Sphericity were used. Value of KMO was where as p value of Bartlett's test of sphericity was which was significant. (Table 2) So tool was suitable to proceed for factor analysis Table 2 - Assessment of suitability of Birth Preparedness Tool for undertaking factor analysis Test Value Kaiser-Meyer-Olkin(KMO)* Bartlett's of Sphericity (p value)** * KMO value must be >0.60 ** Value of Bartlett's test of sphericity must be <0.05 Rotated component matrix by using principal component analysis On applying Rotated component matrix by using principal component analysis tool had generated 10 components listed as 1, 2, (Table 3). Factor 1 has loaded total five items. However one item 'awareness about importance of colostrum' loaded significantly on factor 1 as well as factor 2 with same factor loading of So this item was deleted from the tool. The factor 2 has loaded five items. Two of these items also loaded simultaneously on factor 3 as well. However both of these items were retained in factor 2 as their factor loading was significantly higher in factor 2 as compared to factor 3 ( at least a difference of 0.1 between two factor loading ) Factor 3 retained five items out of which one is deleted due to simultaneous loading to three factors. This item was registration of pregnancy. Factor 4 retained only four items. Factor 5 retained only three items. Remaining factors that is 6 to 10 have failed to load minimum three items in each component. So by using Principal component analysis (PCA) out of 10 factors and thirty items only five factors and 20 items were retained in the tool 51

8 Table 3 - Factor analysis of Birth Preparedness Tool using Principal component analysis and varimax rotation Items Components of tool * 7* 8* 9* 10* 1. Planning of mother to deliver her baby Accompany to mother to hospital delivery Approximate distance of the institute Transportation facility Awareness about importance of colostrum Schedule of breast feeding the baby Diet during post natal period Knowledge about vaccination schedule of baby Awareness about exclusive breast feeding Knowledge about when to feed the baby after delivery Awareness about newborn danger signs Awareness of mother about post natal danger signs Knowledge about essential care of new born Awareness about danger signs of pregnancy Registration of pregnancy Expected date of delivery

9 Items Components of tool * 7* 8* 9* 10* 17. Financial arrangements for emergency Blood group of antenatal Blood donors for emergency No. of visits done by antenatal Assistance to mother in post natal period Essential laboratory tests Articles kept ready for baby Articles kept ready for hospital delivery Antenatal exercises Awareness about episiotomy care Where to contact after danger signs of pregnancy No. of TT received by antenatal Awareness about post natal exercises Birth control measures after delivery 0.51 * The factors not retained in the tool since these factors are failed to load minimum three items in each component. Principal component factor analysis with varimax rotation Principal component analysis technique with varimax rotation items yielded a total of ten factors each having Eigen value of 1 or above. The ten components or factor so generated accounted for 70% of total variance. Out of these 70% variance, first five components alone were responsible for 50% of variance, remaining five factors accounted for just 20% variance (Table 4). So it was logical to retain only first five components in the tool and the next five factors need to be deleted. 53

10 Table 4 - Principal component factor analysis of Birth Preparedness Tool with varimax rotation Component of tool Extraction sums of squared loadings of Component of tool Eigen value of % of variance of Cumulative % of components components components ` Scree plot Scree plot of 30 items of tool was drawn and it showed the point of inflection at fifth component (Figure1). Though there is not clear cut break in the bending of scree plot, but by keenly looking at the plot it looks logical to retain only first five component which are explaining more of total variances than the remaining components. This plot confirms our previous observation derived from the total variance (table 5) explained that five component best describes principal component solution 54

11 6 Scree Plot 5 4 Eigenvalue Component Number Figure 1 - Scree plot of Birth Preparedness Tool showing amount of variance accounted for each factor Results A tool to assess mother s preparedness for delivery, post natal and new born care was developed. Initial tool had 30 items and three components i.e., preparation for delivery, preparation for postnatal care and preparation for new born care. After factor analysis only 20 items tool was retained with five factors. These factors are plan for delivery, preparation for post natal and neonatal care, awareness of danger signs essential care of baby, emergency preparation, monitoring for delivery and plan for postnatal care. Other ten items were deleted. These items are also important as per experts opinions & can be included in the tool. These items were listed under the heading other items. Discussion Maternal and new born mortality is a global burden especially in the developing countries. The barriers like cost, distance, transportation and lack of awareness lead to reduced use of skilled care during delivery. Bir th preparedness helps the woman and family to plan for safe birth. Components of birth preparedness include preparation for normal delivery, readiness to deal with complications, post natal and new born care. Preparing mother for birth is an important aspect of antenatal counseling and is one of the responsibilities of health care providers. 55

12 It was felt by the researcher in her day to day experience that ante natal women have some level of birth preparedness. The media and other sources are continuously making the women aware of bir th preparedness. Hence it was felt that before counseling the antenatal women on this aspect it is important to know her level of birth preparedness and counsel them accordingly as per her need. This will in turn save the time of mother as well as of health providers. For assessing their level of preparedness there is need of a birth preparedness tool to assess the level of birth preparedness of mother. In literature no such kind of tool was found though efforts were taken to prepare protocols and information cards on bir th preparedness. Such kind of work was done in Nepal in preparing antenatal cards in a manner to prepare antenatal mothers them for delivery. These cards give basic information about bir th preparedness that includes danger signs, guidance on choosing a birth location and attendant, arrangements for supplies, transport, fees and finding a blood donor in case of emergency. In another study conducted in district Siraha of Nepal in to determine the effectiveness of the Birth preparedness program (BPP) The result of study showed that the BPP can positively influence knowledge and immediate health outcomes. This study also did not talk about assessment of level of the mothers preparedness for delivery. Hence the need was felt to prepare a tool to assess of the mother's preparedness for delivery, post natal and newborn care, so that her preparedness is checked and then need based counseling is provided. Keeping this fact in mind present study was undertaken with the objective to develop a tool to assess the preparedness of mother for delivery, postnatal and new born care The present study aimed at developing the Birth preparedness tool and testing the psychometric properties of the newly formed tool.the study was divides into six phases with different steps. Phase 1 was preliminary preparation phase and first draft of the tool was prepared in the form of interview schedule with scoring sheet. In Phase 2 assessment of content validity was under taken with Delphi technique. Twelve exper ts from the field of nursing and School of Public health depar tment validated the tool. As common consensus was reached and there was no difference found between second and third round so Delphi rounds were terminated after three rounds. Similar technique was used by Michelle et al to determine nursing research priorities in the Nor th Glasgow University Hospitals. They also found that three Delphi rounds were sufficient to reach common consensus. 8 Phase 3 was modification phase in which changes were incorporated as per expert opinion. Modified Interview Schedule was divided into five parts, Part A comprising of socio demographic profile, part B obstetric history, part C preparation for delivery, part D preparation for post natal care and part E was preparation for new born care. As suggested by the expert panel during Delphi rounds, 56

13 separate scoring sheet and guidelines for using the tool were prepared, so that any health care provider using the tool can apply it in practice effectively. For the convenience of health care provider interview schedule was also translated into Hindi and retranslated back to English to see the validation of translation to prevent any changes in the meaning of the items. Thus this phase led to development of a modified draft of tool which could be used by the investigator for assessing its feasibility. In phase 4, pilot study was done on ten antenatal mothers at village Dhanas to ensure its feasibility. Result of pilot study showed that the language of the tool was clear and it was feasible to carry out the study. In phase 5, tool was implemented on 93 antenatal mothers of third trimester interview technique was used to collect the data in this phase. In phase 6 internal consistency (reliability) and construct validity of tool was checked by using Cronbach's alpha (unstandardised) and factor analysis. Ho Chung William et al also used Cronbach's alpha to find out reliability of short form of Chinese version of anxiety state for children. The Cronbach's alpha coefficient of their tool was 0.83 showing the reliability of the tool thus suggesting that the tool developed was successful. In a study by Joseph C. etal 9 on development of a questionnaire to measure patient satisfaction with injected and inhaled insulin for type I diabetes, the Cronbach's alpha coefficient of their tool was 0.82 showing the reliability of the tool. Similarly, the present study also reveals overall Cronbach's alpha coefficient of the tool as 0.81 which suggests its reliability and internal consistency. It also revealed that all items were uniformly contributing for the reliability of the tool. Construct validity of tool was assessed by doing factor analysis. Factor analysis is most frequently used as a par t of the instrument development process. It can be used as to reduce the number of items in a scale by eliminating factors with low factor loadings or items that load approximately equal levels on two or more factors. Minimum criteria for inclusion of an item in a component are at least a factor loading of 0.3 and above.chien Lin Kuoand et al developed a scale to measure peer caring behavior (PCM) of nursing students by using factor analysis in Southern Taiwan. There were 27 items in the original tool out of which only 17 items were retained after applying factor analysis.. In another study by Ho Cung William etal 10 on development and validation of a short form of the Chienese version of the state anxiety scale for children, there were 20 items in the original tool which on applying factor analysis retained only 10 items. One more study by Douglas L. Policin etal 11 on factor analysis of the alcohol and drug confrontation scale, an original of 72 items instrument was prepared which after applying factor analysis reduced to 64 items scale Similarly in the present study, after factor analysis of Bir th Preparedness Tool (BPT) it generated ten factors but only five factors were retained, remaining factors have failed to load minimum 3 items in each 57

14 component which is an essential criteria for retention of component in the final scale. It has a total of 20 items out of 30 items of original tool and ten items were deleted due to inadequate factor loading. So it is evident that factor analysis deletes unnecessary items while retaining useful items. All these findings suggest that the developed Bir th Preparedness tool is reliable, valid and suitable to be used by health care providers in assessing mothers' preparedness for delivery, post natal and new born care. Other ten items important as per expert opinion ans can also included in the tool. So these items wer listed at the end of tool under the heading other items. This tool has been tested on 3rd trimester antenatal mothers of Dadu majra Colony. It can be tried in other settings to check its feasibility in other settings and it can also be tested on the antenatal mothers of 1st and 2nd trimester. The developed tool would help the health care provider to assess preparedness of mother regarding delivery, post natal and new born care. After assessing the preparedness, health care provider can counsel the antennal mother according to her level of preparation. It would result in better outcome of delivery. References 1. Stanton CK. Methodological issues in the measurement of birth preparedness in support of safe motherhood. Lancet 2004; 28: Ronsmans C, Graham WJ, and Lancet Maternal Survival Series Steering Group. Maternal mortality: who, when, where, and why. Lancet 2006; 368: Essential Newborn Care: Report of a Technical Working Group WHO - OMS 1996: Yuster Ea. Rethinking the role of the risk approach and antenatal care in maternal mortality reduction. International journal of Gynecology &Obstetric 1995; 50: Fortney J. Antenatal risk screening and scoring: a new look. International journal of Gynecology & Obstetrics 1995; 50: Manandhar DS, Osrin D, Shrestha BP, Mesko N, Morrison J, Tumbahangphe KM et al. Effect of a participatory intervention with women's groups on birth outcomes in Nepal: clusterrandomised controlled trial. Lancet 2004; 364: Mullany LC, Darmstadt GL, Khatry SK, Tielsch JM. Traditional mass-age of newborns in Nepal: implications for trials of improved practice. Journal of Trop Pediatric 2005; 51: Michelle Kirkwood, Ann Wales, Anne Wilson. Delphi study to determine Nursing research priorities. International journal of Nursing studies2005; 43: Joseph CC, Ione AK, Rober t AG. Development of a questionnaire to measure patient satisfaction with injected and inhaled insulin for type I diabetes mellitus. Journal of diabetes 2000; 23 (12): Ho Chung William Li,Violeta Loppez. Development and validation of short form of Chienese version of state anxiety tool. International journal of Nursing studies 2005; 44: Douglas LP, Gantt PG, Alan Bestrom. Factor analysis of the alcohol and drug confrontation scale. Journal of addiction behavior 2007; 32 (10):