Background

Risk perception is a person’s expectancy of an adverse event [1]. The concept of risk during pregnancy has expanded following advances in knowledge and technologies employed during antenatal care, and increased community awareness [2]. A high-risk pregnancy is one in which the health or life of the mother, infant or both are jeopardized due to a disorder coincidental with or unique to pregnancy [3]. Reported obstetric risk factors include: poor obstetric history, short stature (<1.52 m), extremes of maternal age, very young maternal age (<15 years), and advanced maternal age (≥35 years). The latter is associated with several adverse pregnancy outcomes, including preterm birth, low birth weight, stillbirth, chromosomal defects, labour complications, and higher rates of cesarean section [4, 5, 6, 7, 8]. Other risk factors are nulliparity or grandmultiparity, size-date discrepancy, unwanted pregnancy, extreme social deprivation, history of preterm labour, multiple gestation, abnormal lie, and previous gynecologic surgery. Other risk factors include history of previous fetal abnormality, perinatal or neonatal death, chronic medical disorders, and infertility.

Danger signs are pointers to serious complications during pregnancy, labour, and postpartum. The common danger signs during pregnancy are vaginal bleeding, swollen hands and face, and blurred vision. During labour and childbirth, they include severe vaginal bleeding, prolonged labour, seizures, and retained placenta. Further, during the postpartum period, key danger signs include severe vaginal bleeding, loss of consciousness, and fever [9, 10].

Researchers have suggested that pregnancy risk perception and danger sign recognition are critical influencers of health seeking behaviour, place of delivery and acceptance of medical interventions [11, 12, 13]. Risk perception is also central to behavioural health models, such as the health belief model [14], protection motivation theory [15], and prospect theory [16].

There have been reports on obstetric risk perception and danger sign recognition in Nigeria [17, 18, 20, 27]. Studies in other parts of Africa found that the proportion of women with knowledge of at least one obstetric danger sign ranged from 53% in Tanzania to 82.5% in Ethiopia [24, 28]. Similarly, among men, it varied from 42% in southern Ethiopia to 92.2% in Kenya [29, 30]. In Asia, the corresponding figures among women were higher in Bangladesh (99.3%) than in Pakistan (64%) [32]. Studies in developing countries identified age at marriage, education, parity, extended family, place of residence, employment status, wealth, and previous hospital delivery as predictors of obstetric risk perception [27, 37]. Similarly, age, parity, education, knowledge and practice of antenatal care, previous institutional delivery, and experiencing maternal death in an acquaintance predicted awareness of obstetric danger signs [27, 36].

However, little research has been documented on community members’ obstetric risk perception and danger sign recognition in northern Nigeria, a region with one of the poorest maternal health indices in the country [18]. The objective of this study was to assess obstetric risk perception, recognition of pregnancy-related danger signs, and their predictors among adult community members in Kano metropolis, northern Nigeria.

Methods

Results

Discussion

Maternal age, parity, history of abortion, previous operative delivery, and post-partum haemorrhage were identified as obstetric risk factors by participants. Specifically, severe abdominal pain, vaginal bleeding, and seizures were perceived to portend danger during pregnancy. In addition to these, loss of consciousness was recognised as ominous during labour. Further, severe vaginal bleeding, seizures, and high fever were acknowledged as the top three danger signs during the postpartum period. Respondent’s sex, ethnic group, occupation, and parity predicted obstetric risk perception, while ethnic origin and obstetric risk perception predicted ability to recognise obstetric danger signs.

Not surprisingly, vaginal bleeding and seizures were frequently mentioned by our respondents as danger signs during pregnancy and puerperium. These results are similar to findings from previous studies among men in Kano, where sickness (48.1%), pregnancy while breastfeeding (26.5%), short pregnancy intervals (25.4%), younger mothers (23.7%), previous operative delivery (19.8%), and twin or higher order multiple pregnancies (1.8%) were considered as high risk. Similarly, 51.9%, 37.8%, 33.2%, 21.6% and 15.4% of men identified vaginal bleeding, seizures, loss of consciousness, pallor, and cessation of fetal movement as danger signs [40]. Higher proportions of women in rural (62.4%) and urban (68.4%) communities of Lagos, Nigeria had good knowledge of obstetric danger signs. Vaginal bleeding was the most commonly identified danger sign [41]. However, three-quarters of women in another study in suburban Lagos disagreed with vaginal bleeding as an obstetric danger sign. The respondents justified their position by the expectation that every pregnant woman would bleed during labour, and they had no way of ascertaining when blood loss becomes excessive [27]. Similar to our findings, slightly more than half (53%) of women studied in Tanzania knew at least one obstetric danger sign. Specifically, 26%, 23%, and 40% of them knew at least one danger sign during pregnancy, delivery, and puerperium, respectively [28]. A higher proportion of participants (82.5%) in a study in Tigray, Ethiopia knew at least two danger signs of pregnancy compared to 51.2% observed among our respondents [24]. However, only 42% of men were aware of danger signs of pregnancy in southern Ethiopia compared to 51.7% in our study [29]. In contrast, Kenyan men displayed good knowledge of obstetric danger signs, as 92.2%, 91.6%, and 90.4% of them recognised severe abdominal pain, absence of fetal movement, and long labour, respectively, as obstetric danger signs [30]. It is noteworthy that none of our respondents mentioned high blood pressure as a danger sign. This could be due to its asymptomatic nature. These results are in contrast with the more visible, frightening, and dramatic seizures of eclampsia mentioned by over half of the respondents.

A study in Bangladesh found that nearly all (99.33%) respondents recognised ‘water break’, severe nausea and vomiting (87.67%), and vaginal bleeding (85%) as prominent danger signs of pregnancy [31]. In contrast, a study in Pakistan reported poor knowledge of serious pregnancy-related complications. Participants in that study identified absent/decreased fetal movement (5%), premature uterine contractions (3%), premature rupture of membranes (3%), seizures (13%), obstructed labour (23%), and bleeding per vaginum (39%) as danger signs during pregnancy [32]. Considering the high proportion of births that occur at home in our study area [18], prompt recognition of danger signs during pregnancy, labour, and puerperium is critical in order to inform care seeking decisions. Well-informed women are likely to notify their partners and close confidants if they notice any deviation from the norm, which in turn could trigger remedial action.

Appropriate risk perception by pregnant women and their families is important, as exaggerated risk perception could also cause anxiety and trigger false alarms thereby overwhelming health care providers and de-sensitizing the response systems. Similarly, incongruence between health care professionals’ risk assessment and those made by women and their partners and differences in risk perception by socio-economic status, where women of higher socioeconomic stratum were reported to be more worried about pregnancy risk compared with those in the lower category (although risk was more prevalent in the latter) requires targeted communication [13]. It is important to bear in mind that risk can change suddenly and predictive utility of obstetric risk factors among high risk women varies. For instance, in Zimbabwe, a study found that 42.3% of cases of cephalopelvic disproportion could be predicted, compared with only 35.0% of those with post-partum haemorrhage, hence the need for individualized care during pregnancy, labour, and the postpartum [33].

Recent advances in obstetric management and technology has not decreased women’s obstetric risk perception [34]. Rather, the range of modern prenatal investigations, surveillance, medico-legal milieu, high-tech infertility treatment, and use of the internet and social media have all combined to heighten women and their partners’ anxiety about pregnancy in developed countries [35]. Whether this is the case in low-resource settings needs to be investigated. Stress, anxiety, and depression resulting from increased perception of risk during pregnancy could also have far reaching implications for the health of mothers, babies, families and the health system [35]. Conversely, women who downplay their risk status as a result of ignorance, non-utilization of antenatal care, and appropriate investigations, as is the case in low-resourced settings [36], require targeted information, education, and communication interventions.

Respondent’s sex, ethnic group, occupation, and parity predicted obstetric risk perception. Other researchers identified place of residence, employment status, wealth, and previous hospital delivery as the predictors [27]. Our finding of an inverse relationship between parity and obstetric risk perception in our sample is surprising, as previous reports indicate otherwise [17, 43, 44]. In Ethiopia, for example, women with high parity (4–6 pregnancies) were three times as likely to be aware of obstetric danger signs compared to those of lower parity [24]. That seems more logical, as one might expect that the more children one has, the more experience and greater obstetric risk perception the person would have. Our finding could be related to the peculiar cultural setting of northern Nigeria, where women of high parity tend to be over-confident and feel invulnerable. These highly parous women avoid health facilities, prefer to deliver at home as a mark of pride, and consider hospital delivery as a last resort [42, 43]. They are, therefore, more likely to downplay the risks associated with pregnancy and delivery. On the contrary, women of low parity and their partners are more likely to be anxious about pregnancy and its outcome and are more likely to seek knowledge about danger signs. Health care workers should be aware of this apparent paradox and closely monitor women with high parity. The low proportion of antenatal clients reportedly informed about danger signs during antenatal care in the study area from previous studies (58.4%) [18] could partly explain the apparent disparity, and underscore the need for effective communication during pre-conception and prenatal care.

In contrast to our findings, the Lagos study earlier cited found that knowledge of antenatal care and experiencing maternal death in an acquaintance predicted awareness of obstetric danger signs [27]. The experience could be a constant reminder of obstetric risk. Similarly, in the health belief model, health literacy informs attitude and behaviour [14]. In Rural Tanzania, acquiring at least secondary education increased by six-fold the likelihood of obstetric danger sign awareness compared with those with no education at all. Other determinants were age, parity, antenatal visits, and previous institutional delivery [36].

A study in Nepal found that while women perceived some susceptibility to adverse events during pregnancy, they did not feel it was serious enough to necessitate biomedical care. Similar to our study setting, antenatal care attendance was higher than health facility births and postnatal attendance [37]. Further, education, parity, age at marriage, and extended family predicted risk perception [37]. Another study in Canada identified five factors as significant predictors of perception of pregnancy risk. These include: pregnancy-related anxiety, maternal age, medical risk, perceived internal control, and gestational age, accounting for 47% to 49% of the variance in risk perception [38].

While there are no certainties about the perinatal outcomes of pregnancies based on self or professional risk assessment, as apparently low risk pregnancies can result in poor outcomes and vice versa, some women take extreme measures to have what they perceive as normal deliveries. For instance, many Somalian women voluntarily decreased food intake during pregnancy in order to have a smaller foetus, an easier delivery and to avoid caesarean section [39].

In considering these findings, however, a few limitations merit mention. First, regarding the study setting and study participants, respondents were urban residents and were more likely to be better educated and hence more knowledgeable than their rural counterparts. Their obstetric risk perception is expected to be better than rural dwellers. Second, although individual interviews were conducted privately by trained interviewers from the same culture, social desirability bias cannot be ruled out, as respondents knew that the interviewers were medical students.

In conclusion, we found that perception of obstetric risk and recognition of danger signs were influenced by participant sex, employment status, and ethnicity among a cross section of respondents in Kano, northern Nigeria. The low obstetric risk perception and danger sign recognition require targeted information, community-based education and communication strategies to enhance timely utilization of emergency obstetric services.