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Assessment of women’s perception and knowledge of pre-conceptual risk in nine municipalities in Matanzas Province, Cuba.

Dr. Odalys Gonzalez Borges
First-degree specialist in Hygiene and Epidemiology “Eliseo Noel Camaño” Pediatric Hospital, Matanzas

Dr. Ernesto Hernàndez Cardenas First-degree specialist in Hygiene and Epidemiology Provincial Center of Hygiene and Epidemiology, Matanzas

ABSTRACT: The historical tendency of Infant and Maternal Mortality shows a gradual descent since the triumph of the Revolution. Special attention has thus been paid to the perinatal period. Preconception reproductive risk is one the issues that call for modification in the National Program for Maternal and Infant Care, due to its influence on the health indicators in this program. This descriptive study was conducted in order to determine the perception and knowledge that fertile women have of preconception risks. It included nine municipalities of the Province of Matanzas whose Infant Mortality Rate is higher than the provincial average. A surveillance site method was applied with multi-stage sampling, including stratification and conglomerates. A sample of 1 982 fertile women were chosen, each of which was assigned a sample value. 28.6% of these women admitted to suffering from some disease, Bronchial Asthma and Arterial Hypertension being the most common ones. 75.6% of these women see their pathologies as a risk, while 60.2% of their partners are aware of it. 74.5% acknowledge receiving orientation, and refer to family doctors, gynecologists, relatives and nurses as the most frequent sources. Pregnant women are 3.8 times more likely to get this information, while it is 1.4 times higher in sick women than in healthy ones. Both figures have statistic significance. In most of the diseases considered there was low risk in treatment, with no statistical significance. 73.7% of these women were using a contraceptive method. IUD was the most common one(66.8%). Use of a contraceptive does not increase the risk of disease; they are used equally by both sick and healthy women.

OBJECTIVES

• To determine how aware fertile women are of preconception reproductive risk in nine municipalities in Matanzas.

• To identify the influence of family doctors and nurses in the perception and orientation of preconception risks.

• To establish a list in order of importance of the main sources of information on preconception risk.

• To assess the behavior of fertile women as regards the use of contraceptives.

METHODS

A sample of fertile women (between 12 and 49 years of age) was taken from the municipalities where Infant Mortality Rate was higher than the provincial average. This was done considering the influence that preconception reproductive risks exert upon this rate.

The nine municipalities whose Infant Mortality Rate was higher than that of the province were:

1- Matanzas

2- Cárdenas

3- Martí

4- Perico

5- Pedro Betancourt

6- Limonar

7- Ciénaga de Zapata

8- Jagüey Grande

9- Calimete

The sampling framework of these municipalities was distributed in 25 health zones with a total number of 116 554 women in fertile age. It was not possible to use a simple random sampling covering the entire population and all the zones because of the limited number of resources and the lack of time. We decided to apply the method of surveillance sites, as an agile instrument to obtain updated information and yield the expected results. (18,19,20,21).

This method has a multi-stage sampling design, which includes stratification and conglomerates. Each of the municipalities that met the inclusion criterion was considered a stratum. This was in fact the first level of multi-stage sampling. The second level included the health areas in each stratum, each of which formed a conglomerate in which the random sampling was first made, selecting a health area from each stratum to make up the sample. This level was called Primary Sample Unit (PSU). (22,23).

In each randomly chosen health area, special conglomerates were built following an epidemiological criterion (20). The population of the health area was distributed in these conglomerates. Then one conglomerate was selected at random from each health area. This stage was Level 3 and was called Surveillance Site. All women between 12 and 49 years of age were interviewed to form the Sampling Units (22,23).

The same procedure was followed in each stratum. The sample finally included 1 982 women.

This sample design may cause an unequal selection of conglomerates (22)for different members of the population. This was taken into account in the data analysis (22), and each participant was assigned a sample bonus. It was then necessary to know the probability of each individual belonging to the first selection stage (PSU) and in all the other stages to the last level. The data base included the corresponding bonuses for each PSU in each stratum. The sample bonus of each represented individual was calculated (22) from the quotient resulting from the division of the total number of women in each health area (PSU) by the total number of women included in each Surveillance Site.

                 Total number of women between 12 and 49 years of age in each health area
BONUS ---------------------------------------------------------------------------------------------------------
                 Total number of women in the Surveillance Site

A survey was designed to obtain the data. It included questions regarding the knowledge of preconception risk of each individual, as well as her most frequent health problems, the information she had received, use of contraceptives, educational level, and other questions related to this topic, in order to determine the most probable factors.

The data analysis was made in the C Sample Program of EPI INFO, version 6.04. The frequency of each variable was obtained in relative values and reliability intervals. The analysis also rendered relative risk and differential risk, and their respective reliability intervals, with a 95% reliability value. The standard error of the sample and sub samples is presented, and the design effect in the study received an admissible value of up to 3.

RESULTS AND DISCUSSION

Table 1 shows the distribution of the sample in age groups. The 25 to 34 age group is the most highly represented with 39.2% of the total. It is followed by the 15-24 age group (28.2%), and the 35-44 age group (22,4%). It is stands out that 66.4% of the total number of women in the sample are between 15 and 34 years old, a range in which the highest number of pregnancies occur. The general process of descent in the level of fertility in Latin America and the Caribbean(24),has been accompanied by changes in its structure towards a juvenescence in the fertility calendar and a concentration of pregnancy in central ages (20 – 35 years), which is the most numerous group in the sample studied.

The reliability intervals of the percentage of each sub sample in each age group are presented. They are acceptably narrow in each of the sub samples; the design effect value falls within the limit of 3.

Table 2 shows the education rates. 47.3% of the women considered in the study have a high school education, while 37% concluded their junior high school studies. These figures are far from those of women with primary education (7.3%), and university level (8.2%). In other words, 92.5% of these women show a level of instruction of ninth grade or higher. This result from the study coincides with the rise in educational level of Cuba’s female population between 1970 and 1981 (25). The proportion of fertile aged women with a junior high education doubled in urban areas from 31% to 61%, while it tripled in rural areas to over 30%. This fact plays a role in reproductive behavior, fostering a reduction of fecundity.

It should be noted that child death risks are associated with the mother’s education, and that this risk increases from 31 per thousand in children whose mothers have had 7 to 9 years of instruction to up to 47 per thousand in children whose mothers have had less than 4 years of primary education (27).

Another factor affecting general fecundity is women’s increased participation in economic activities, as they play new social roles that differ from their traditional functions of childbearing and upbringing. Table 3 shows a distribution of the surveyed women according to their occupational categories: 42.1% were housewives, 36.8% were clerks, 11.1% students, 6.6 % professionals, 2.7% production workers, and 0.5% were retired. Therefore, 57.7% of the total are women who are someway involved with society, or were at a time, as is the case of those who have retired. This figure coincides with Cuban reality (28), in which a high percentage(60%)of fertile aged women are involved in economic activities outside their homes.

The reliability intervals of these percentages are accurately presented. The highest standard error was found in the group of clerks, and the design effect is practically non-existent.

Table 4 groups together the rates of other variables that were also studied. 4.3% of the total number of women were pregnant at the moment of the interview. 28.6% said they were suffering from some kind of disease; 75.8% of these women were under treatment for their illness. Among the diseases considered, bronchial asthma (11.7%), and arterial hypertension (8.7%) top the list, and they are followed by obesity (2.6%), thyroid pathologies (2.6%), diabetes mellitus (1.6%), and malnutrition (0.9%).

Chronic–degenerative diseases are one of three factors of preconception risk. They hold a very close cause-effect relationship with maternal and perinatal mortality (29).

Arterial hypertension is the second most frequent disease found in the study. Epidemiological research (30,31) has shown a very high occurrence of arterial hypertension in fertile age women. Thus it is a very important risk factor for maternal and perinatal morbidity and mortality, as it provokes gravid toxemia, low birth weight, as well as intrauterine fetal death and hemorrhagic complications such as the loosening of the normoinserta placenta, to which it is often associated. Of the above mentioned complications, gravid toxemia is the most important one, because in addition to the fact that once arterial hypertension has occurred, the danger of its reoccurrence increases, and there is also an increase in the seriousness and precocity of the toxemia.

Arterial hypertension, with a rate of incidence that ranges from 2% to 13%, is considered by most authors (32) as a negative factor for the fetus and the mother. It is the most important medical complication a pregnant woman may have. It is the primary cause of death in many countries, while it is the third to fourth cause in Cuba (33). At the same time, arterial hypertension affects the newborn’s morbidity, contributing to a low Apgar and to fetal malnutrition (34, 35). Perinatal mortality is the highest price pregnant women pay as a result of hypertension, as they are both directly proportional (36).

Two descriptive studies of the prevalence of arterial hypertension carried out in a health area in Matanzas City, and in the whole country respectively, rendered a percentage of 28.2% in the former (37) and 30.6% in the latter. In other countries, like the United States, this percentage ranges between 18.5% and 29.8%, but these data include the population in general, with no distinction of sex (39).

In the First National Survey of Risk Factors in Cuba (38), a 28.5% of known hypertension was found in women in general. This figure lies far from what was found in this study including only women in fertile ages. This result is of course only applicable to the territories included in the study.

Diabetes Mellitus was mentioned by 1.6% of the women who said they had a disease. It is well known that diabetes during pregnancy affects one out of every one hundred births in our country. It is the cause of serious complications. In order to prevent these complications, effective family planning is necessary, so that a good metabolic control is achieved in the period previous to pregnancy. In other words, the wanted child must be conceived at the right moment with medical advice (40) and appropriate primary and secondary medical care (41).

In a study carried out in his health area, Carrasco (42) found a prevalence of obesity in women (35%). In the present study, the result found is much lower than this estimate. It should be taken into account that this data is based on interviews with the surveyed women, and it may be biased by Cuban women’s idiosyncrasy with no perception of what is meant by being overweight or obesity, and also by the design of the study.

The nutritional state of the mother plays a decisive role in fetal growth and in birth weight. There is concrete evidence that the total weight increase during pregnancy can help predict birth weight, even when the latter is also affected by the mother’s nutritional state and height before pregnancy. This is important from the point of view of Public Health, as birth weight is the parameter that is most closely related to the newborn’s survival, anthropometric growth and posterior mental development (43).

Bronchial Asthma ranks first in the study with 11.7%. Research carried out in Cuba by the National Asthma Commission (44) and the National Risk Survey (38) in the province of Matanzas gives an 8.2% and 6.4% prevalence of Asthma respectively in the general population, with a discrete predominance in rural areas and in women. The results in the present study are above those in these surveys. We must consider two factors: these women’s possible lack of knowledge of what it is like to suffer from bronchial asthma, or the possibility that a large number of asthmatic women in fertile ages are by chance concentrated in the chosen surveillance sites. It should be mentioned that when asthma and pregnancy coexist, the former may cause unfavorable effects upon the pregnancy and the fetus. On the other hand, the effect of pregnancy upon asthma varies on an individual basis. In the first case, hypoxia, the medication required by the pregnant woman and other associated effects are responsible for an increase in the number of premature babies, lower birth weight, and for an increase in neonatal death and in the frequency of neonatal hypoxia. In the second case (effects of pregnancy upon asthma): 28% of pregnant women improve their condition in relation to their asthma, 29% remain the same, and 33% become worse (45).

Tables 5 and 6 show the knowledge ill women and their partners have about the risk her disease poses. Of a total number of 586 sick women, 75.6% acknowledge their illness is a risk. 24,4%, almost one fourth of the sick women, however, do not perceive any risk. 60.2% of their partners, in turn, acknowledged a risk in their women’s condition, while more than 39% showed a complete lack of knowledge.

These results do not meet expectations if we consider that the National Program of Maternal and Infant Care outlined in its Methodological Instructions (45) the actions to achieve an improvement in this sense. These instructions call for a continuous assessment and risk evaluation of the universe at risk, their control, and negotiation with women and their partners as to when is the best moment for conception. These are just some of the actions that as a whole should stem from the educational program directed to fertile aged women in terms of reproductive health. All this should allow us to assume that 100% of women and their partners are aware of preconception risks.

As a result of the assessment it was shown that the perception of risk is far from the goals fixed in the program.

To continue assessing the perception and level of knowledge of preconception risk that the interviewed women have, table 7 shows the rate of orientation about preconception risk and the means through which it flowed. 74.5% of these women considered themselves informed, and 40.2% regarded their family doctor as their main source of information. 30.6% received information from their obstetrician, 22.5% from their family and 22.1% from their nurse.

From the start of the Program of the Family Doctor in Cuba, Public Health has achieved remarkable advances, and has widened the scope of this program throughout the country (46). This program, in addition to the mass media, mass organizations and schools, has increased the information flow on family planning to women and the family. The results of the study fall short of what it supposedly should be, if we consider the data obtained as to whether women feel they are informed.

Family doctors and nurses are the two mainstays that carry out all of the primary health care programs (47). Their orientation and that of the gynecologist of the Basic Work Group must render better results than those gathered in this study, much more when the answers to the questionnaire are not limited in this case. It must be pointed out, however, that even when the answers in relation to the sources of orientation are not limited, the design effect in the results of the orientation of the family doctor drifts considerably away from the parameters for this study. This makes the values found in this sub sample questionable. In the case of the gynecologists, the design effect moves 4.4 away, which makes it more acceptable than those of the family doctor and other sources that are less close to the health system.

Tables 8 and 9 show the frequency of use of contraceptives, as well as their popularity and selection. 73.7% of the women in the sample used some kind of control. IUD were used by 66.8%, way over tied tubes and contraceptive pills whose rate of use was 19.2% and 9.9% respectively. This finding matches that of other authors who state that the use of contraceptives in developed countries ranges from 57% to 71%, IUD being the most common (48, 49, 50, 51).

It was also observed that in 55% of the cases the contraceptives had been selected by the women themselves, and only in 32% of the cases had it been their doctor’s choice. Considering the role of the doctor in orientating the choice of a certain method, the latter percentage should be higher. The present situation may be the result of the characteristics of Cuban women, their habits, life style and conditions, their educational and professional background which lead them to use contraceptives just to avoid pregnancy, and not to control a present risk. For that reason they select the method themselves.

Tables 10 and 11 show the percentage of pregnant women in each age group. Of a total of 102 gestating women, 54% fall within the 25-34 year old group, and 38% to the 15-24 age group. This matches the criterion that the 25-34 age group is the most fertile one (52).

86.8% of the pregnant women were between 18 and 35 years old, while 13.2% were younger than 18 or older than 35. This shows that despite the achievements in preconception risk, there are still women who become pregnant at ages in which they shouldn’t, as they are likely to face additional risks.

Several studies on maternal and perinatal mortality agree that the ideal period for reproduction in women is that between the age of 20 and 29. There is a slight increase of risk between 30 and 34. Women who become pregnant when they are younger than 18 or older than 35, are more likely to run risks of mortality (53, 54, 55), resulting from a higher frequency of certain factors and complications such as an increased incidence of gravid toxemia, premature birth and low birth weight in cases of women younger than 18. In women older than 35, the complications include an increased incidence of gravid toxemia, contraction dystocias, abnormal placenta insertions or adhesions, birth malformations and such chronic-degenerative diseases as diabetes mellitus and arterial hypertension.

Regardless of the above-mentioned factors, it is frequent for women in these groups not to visit their doctors periodically for perinatal control. This adds a new dangerous element to maternal and perinatal prognosis.

In table 12 pregnant women are 1.2 times more likely to suffer from some disease. Although the reliability interval is 95%, it shows a lower limit under one, which makes the association insignificant.

As regards orientation, there is 3.8 times higher probability for pregnant women to receive orientation, with a 95% reliability interval and a lower limit of 3.18, which attaches significance to this statistical association. This orientation is 3.9 times more likely to be received from the family doctor, followed by friends, family members and nurses, with 2.7, 2.2 and 1.18 probabilities for each of them, with statistical significance. This is not the same for the gynecologist whose probability in offering orientation is 1.5 times, but has a non-significant association with the other doctors and other sources whose risk of offering orientation is practically null.

The attributed risk of getting ill and being pregnant is null in relation to healthy pregnant women. Thus, suffering from one of the diseases recorded in the interviews is not a factor that can influence the perception of the risk the interviewed pregnant women run.

However, in evaluating the impact of the perception of feeling oriented, we found high and significant differential risks when the orientation comes from the family doctor, friends and family members. Also high were the risks when it came from the gynecologist and the nurse, but the association in these cases was not significant.

Table 13 shows how orientation in sick women works. The probability for them to be oriented is 1.4 times higher than for healthy women, with a significant statistical association. The gynecologist and other doctors show a higher possibility of offering orientation with a 1.2 times higher probability, with a 95 % reliability interval and a lower limit higher than 1, making the statistical association significant. As regards the family doctor and friends, the risk is practically null, while family members and other doctors show the lowest probability in providing orientation.

The results of the study do not match the role of the family doctor and nurse, and that of the gynecologist in the Basic Work Group in orientating the population they assist. This is more important when it comes to fertile aged women who suffer from some kind of disease, who should be under continuous assessment, risk evaluation, and control.

The impact that the intervention of the different variables analyzed as orientation elements show that though some of them are higher than null, they are not very far from this value, and their reliability intervals show lack of association.

As regards the differential risk, 10.4 appears as a fraction that may be attributed to general orientation, 7.1 to the gynecologist variable and 6.9 to other means of orientation. All of them show a significant association.

Table 14 shows that the relative risk for treatment in diabetes mellitus is null. In other words, the probability of risk is the same if treatment is received or not. In arterial hypertension, obesity and epilepsy, the probability of being treated is lower, with a higher limit in the reliability interval over 1, and there is no statistic significance. In the case of thyroid pathologies the probability is 1.9 times higher of receiving treatment, with a significant association. In bronchial asthma, in addition to the fact that the probability barely surpasses 1, the lower limit of the reliability interval is 1, which makes it lose significance.

This table reflects a low impact of health services upon women in reproductive ages who suffer from non-transmissible diseases that influence the mother – fetus binomial. It is only the thyroid pathologies in the sample taken that reflect some indications of treatment. In the differential risk analysis the treatment of thyroid pathologies is the only one with a significant impact.

It is also noted that the risk in the use of a contraceptive in sick women is null. This substantiates the results in tables 8 and 9.

CONCLUSIONS

1. 67.4% of the women in the sample were between 15 and 34 years of age. 92.5% had reached secondary school education or higher, and 57.7% were incorporated into socioeconomic activities.

• 4.3% were pregnant and 28.6% were sick. Bronchial asthma and arterial hypertension were the most frequent diseases. 75.8% of the women who acknowledged being sick are under medical treatment.

3. 75.6% of sick women understand their disease as a preconception risk, while 60.2% of their partners do too.

4. 74.5% of the women said they had received orientation, in a descending order of frequency from the family doctor, the gynecologist, relatives and the nurse.

5. Pregnant women are 3.8 times more liable to receive orientation, and they receive it from their family doctor, friends, relatives and nurses. Sick women are 1.4 times more liable to receive orientation; the gynecologist and other doctors are the most frequent providers of orientation.

6. 73.7% of the women in the sample use some kind of contraceptive. IUD is the most commonly used method. 55% of these methods were chosen by the women themselves. The risk in the use of contraceptives in sick women is null.

7. There is a very low probability women receive treatment for their diseases, except for those with thyroid pathologies.

TABLE 1 - DISTRIBUTION BY AGE GROUPS

Source: Surveys

TABLE 2 - EDUCATIONAL LEVEL RATE S

Source: Surveys

TABLE 3 - OCCUPATION CATEGORY RATES

Source: Surveys

TABLE 4 - RATE OF PREGNANT WOMEN, SICK WOMEN AND THEIR CARE.

Source: Surveys

TABLE 5 - KNOWLEDGE OF RISK OF GETTING SOME DISEASE.

Source: Surveys

TABLE 6 - RATE OF SPOUSE´S KNOWLEDGE OF THE RISK.

Source: Surveys

TABLE 7 - ORIENTATION RATE AND SOURCE.

Source: Surveys

TABLE 8 - RATES OF CONTRACEPTIVE USE.

Source: Surveys

TABLE 9 - RATE S OF SELECTION OF CONTRACEPTIVE DEVICES.

Source: Surveys

TABLE 10 - RATE OF PREGNANT WOMEN BY AGE GROUP (Variant 1)

Source: Surveys

TABLE 11 - RATE OF PREGNANT WOMEN BY AGE GROUP. (Variant 2).

Source: Surveys

TABLE 12 - PREGNANT WOMEN´S CHANCES OF GETTING SICK AND RECEIVING ORIENTATION.

Source: Surveys

TABLE 13 - ORIENTATION GIVEN TO SICK WOMEN

Source: Surveys

TABLE 14 - RELATIONSHIP BETWEEN HAVING A DISEASE AND RECEIVING INFORMATION.

Fuente: Encuestas.

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