Perception of Pregnant Women Regarding Self Care Measures during Postpartum Period

: Postnatal care is one of the most important maternal health care for prevention of maternal impairment and disabilities. So, there is an urgent need to increase women's knowledge regarding self-care measures during postpartum period. Aim: The present study aimed to assess the perception of pregnant women regarding self-care measures during postpartum period. Subjects and method: - Design: A descriptive study design was used. Setting: The study was conducted at the antepartum unit in obstetric and gynecological department at Tanta University Hospital. Subjects : A purposive sample of 250 pregnant women was included in the study . Tools : three tools were used for collection of data. Tool (I): Structured interview schedule: It included : Part (a): Socio-demographic characteristics and part (b): Obstetric history. Tool (II): Women’s knowledge regarding self-care measures during postpartum period. Tool (III): Women's attitude regarding self-care measures during postpartum period. Results: Slightly more than one half of women (51.6%) had poor level of knowledge, slightly less than one third of women (32.4%) had fair level of knowledge, and (16%) had good level of knowledge regarding self-care measures during postpartum period. Additionally, the majority of women (93.2%) had positive attitudes regarding self-care measures during postpartum period. Conclusion: There was poor knowledge, while there was positive attitudes regarding self-care measures during postpartum period among pregnant women. Recommendations: Planning and developing antenatal classes for all pregnant women especially during the last trimester to improve their perception, and increase their awareness and enhance their practice regarding routine self-care during postnatal period


Introduction
Postpartum period is defined as the period beginning immediately after delivery during which the woman's body in general and the genital organs in particular return to the pre-pregnant state.This period is usually considered to be 6 weeks in duration.Much attention is given to women's healthcare during pregnancy and childbirth, while this is not extended after childbirth.3)(4)(5) Postpartum period is subdivided into three categories: the immediate postpartum period, which covers the first 24 hours; the early postpartum period or first week; and late postpartum period, which refers to period from the second week until 6 weeks after delivery. (6,7)Maternal and neonatal mortality rate is still high, because many mothers did not seek proper care in the health care facilities when they were exposed to any complication during pregnancy, childbirth and postpartum period. (8)aternal deaths that occur during the intrapartum and partum period are due to directly preventable or treatable causes such as haemorrhage, eclampsia, and sepsis.Provision of emergency obstetric care is considered the key for reducing maternal mortality worldwide. (8,9,10)Goal 5 of the Millennium Development Goals (MDGs) aimed to reduce maternal mortality through improving maternal health. (11)14)(15) Utilization of the majority of healthcare services is significantly ignored during postpartum period due to lack of perception of postpartum women regarding the services as well as regarding self-care measures during postpartum period.Furthermore, health care providers should give the postpartum women the correct information in the appropriate way so, they can recognize why they need to utilize the services. (16,17)If pregnant women are knowledgeable about all aspects of postnatal care in general and self-care in particular, they can effectively manage their challenging postpartum period. (18,19)aternal self-care is broadly defined as the mother's willingness and ability to look after her physical and emotional needs.(22)(23) Furthermore, one of the most essential measures to reduce maternal mortality and disability is increasing women's awareness of the importance of self-care during this period. (24,25)Self-care elements during postpartum period include personal hygiene, perineal care, breast care, wound care, episiotomy care, checking the fundus, lochia assessment, nutrition, exercise, sleep, sexuality, early ambulation, technique of breastfeeding, immunization of newborn, baby cord dressing, as well as regarding danger signs during postpartum period. (26,27)he role of the postpartum nurse in the early postpartum period is to assist the new postpartum woman in returning to her prepregnant state without suffering from any complications, and to give her a solid knowledge base of postpartum care. (26,28)he desired goal is that the mother feels secure in her ability to care for herself and her newborn and to be ready to return to her normal role in the community.To achieve this, the nurse should assist the woman in learning coping mechanisms and guide her about the expected physiological, emotional, and social changes that occur after delivery.The nurse also plays an important role in facilitating social support and maternal-fetal attachment in the postpartum period to improve postpartum maternal adaptation. (29)ne of the most important aspects in reducing adverse maternal and neonatal outcomes is the early provision of Vol.29.No.2 May, 2023 136 postpartum care services.These services have an impact on the mother's physical and social well-being, which in turn has a positive impact on the infant's health. (30,31)herefor, it is very important to assess the perception of pregnant women regarding self-care measures during postpartum period.
The aim of this study was to Assess perception of pregnant women regarding self-care measures during postpartum period.

Research question
What is the perception of pregnant women regarding self-care measures during postpartum period?

Subjects and method Study Design
A descriptive study design was used.

Setting
The study was carried out at the antepartum unit of obstetrics and gynecological department at Tanta University Hospital.

Subjects
A purposive sample of 250 pregnant women was selected from previously mentioned study settings according to the following inclusion criteria: -Age range between 20-35 years.
-Pregnant women at the last trimester of pregnancy.This tool was developed by the researcher after reviewing recent related literatures (14,22) and consisted of two parts as follows: part ( A likert scale was adapted from Chembe (2017) (14) to assess mothers' attitude regarding self-care measures during postpartum period.It consisted of 15 statements.The total score of women's attitudes ranged from (0-30).
The scoring system of attitude regarding self-care during post-partum period was as follows: Each statement was rated by using 3-point likert scale, where: -Agree answer was given score (2).
-Disagree or didn't know answer was given score zero (0).There was only one statement (No: 5) which had a different rate as follows: -Agree answer was given score (0).
-Disagree or didn't know answer was given score zero (2).The total score of women's attitudes was calculated as follows: -Positive attitude ≥ 60% (18-30 degree)   of the total score.

Method
The study was implemented according to the following steps-1.Administrative design: Written approvals: official letter clarifying the purpose of the study was obtained from the Faculty of Nursing and was submitted to the responsible authorities of the selected setting to obtain their approval and cooperation for carrying out the study.

Operational Design
The study was implemented according to the following steps: A. Ethical considerations: Informed consent was obtained from women who accepted to participate in the study after explaining the purpose of the study, confidentiality of information was maintained, benefits and right of women to withdraw from the study at any time if desired.The nature of the study did not cause any harm and/or pain for the subjects.B. Tool development a. Tools (I and II) were developed by the researcher after reviewing recent literature. (14,22).Tool (III) was adapted from Chembe (2017). [14].The study tools were translated into Arabic language and then tested for construct and content validity by five experts in the field of Obstetrics and Gynecology nursing before conducting the study.The tools were also tested for reliability by using statistical analysis.

C. pilot study
After development of the tools, a pilot study was carried out on 10% of the sample (25) pregnant women from the previously mentioned setting.This pilot study was conducted before the actual data collection.Data obtained from the pilot study were excluded from the current study sample.
The purposes of the pilot study were to: -Ascertain the feasibility and applicability of the developed tools.
-Detect any problems peculiar to clarity of the statements that might interfere with the process of data collection.The results of the pilot study: -The pilot study revealed that the statements of the tools were clear and relevant.

D. Actual study (field work)
-Data was collected during the morning shifts at antepartum unit of obstetrics and gynecological department from 9:00 a.m. to 12.00 p.m.The researcher interviewed with 4 subjects per day three times per week until the predetermined sample size was collected.
-Data collection was conducted in a period of six months ranged from the beginning of October 2021 to the end of March 2022.
-The structured interview schedule was applied individually for each woman at the antepartum unit.
-All subjects who had the inclusion criteria at the time of data collection were included in the study.Data were collected within 45 minutes.
-Data were collected by the researcher using the previously mentioned study tools, Tool I: used to collect data about sociodemographic characteristic and obstetric history of the women, Tool II: used to assess women's knowledge regarding selfcare measures during postpartum period, Tool III: used to assess women's attitude regarding self-care measures during postpartum period.

Statistical analysis:
The collected data were organized, tabulated and statistically analyzed using SPSS software (Statistical Package for Social Sciences, version 19, SPSS (Armonk, Ny, IBM crop).For quantitative data, the range, mean and standard deviation were calculated.For qualitative data, which describe a categorical set of data frequency, percentage or proportion of each category was used, comparison between two groups and more was done using Chi-square test ( 2 ).Correlation between variables was evaluated using Pearson's correlation coefficient (r).Significance was adopted at p<0.05 for interpretation of results of tests of significance.

Results
Table (1): Shows distribution of the studied pregnant women according to their sociodemographic characteristics.It is noticed that slightly more than one half of women (52.4%) were more than 25 to 35 years old with a mean age mean±SD (26.06 ± 3.95).Slightly less than one third of women (32.0%) had a university educational level.Concerning occupation, more than two thirds of women (68.8%) were housewives.Slightly more than three quarters of women (76.8%) were from urban areas.Also it is founded that slightly more than three fifth (60.8%) had insufficient family income.Table (2): Shows distribution of the studied pregnant women according to their Obstetric history.It is noticed that slightly more than one third (33.6%) were gravida two, slightly more than one quarter of women (25.6%) were nullipara and slightly less than one third of women (33.2%) experienced one previous delivery and slightly more than two fifths of them had cesarean section.Additionally more than four fifths of women (83.2%) hadn't any disease before pregnancy and (16.8%) of them suffered from diseases before pregnancy and less than three quarters (73.8%) of those women who had diseases had anemia before pregnancy.Concerning antenatal care visits; the table presents that (84.8%, 88.4% respectively) of women had regular antenatal care visits during the previous and the current pregnancy.It is noticed that the vast majority (92.1%) of women who didn't attend to antenatal visit during previous pregnancies were due to insufficient income.It is also noticed that only (7.2%) of women followed up their current pregnancy in MCH center.As regard to the time of initial antenatal visit, it noticed that (0.9%) of the studied pregnant women seek the initial antenatal visit at the third trimester.The table also illustrate that slightly less than four fifths of women (79.6%) attended today for the reason of recurrent follow up the pregnancy.Regarding the presence of complications during the previous postpartum period, it is noticed that (0.8%) of the studied pregnant women suffered from bleeding.Figure ( 1): Shows distribution of the studied pregnant women according to their total score level of knowledge regarding post-partum period and self-care measures during postpartum period.Regarding the total knowledge level about postpartum period, the figure illustrates that less than one third of the studied pregnant women (30%) had a low level of knowledge, slightly more than two fifths (41.6%) had a moderate level of knowledge, and less than one third (28.4%) had a high level of knowledge.Regarding the total knowledge level about self-care measures during postpartum period, it is observed that slightly more than one half of the studied pregnant women (51.6%) had a low level of knowledge, slightly less than one third (32.4%) had a moderate level of knowledge, and less than one fifth of women (16%) had a high level of knowledge.Figure ( 2): Shows the distribution of the studied pregnant women according to their total attitude regarding self-care measures during postpartum period.It is noticed that only (6.8%) of the studied pregnant women had a negative attitude regarding self-care measures during postpartum period, while the vast majority of them (93.2%) had a positive attitude regarding self-care measures during postpartum period.Table (3): Shows the relationship between total knowledge level of the studied pregnant women and their sociodemographic characteristics.It revealed that there was a highly significant association between total knowledge level of the studied pregnant women and their educational level (p=0.0001*) and between their occupation (p=0.011*).The table also illustrates that there was no significant association between total knowledge level of the studied pregnant women and their age in years, work sector, residence and family income (p>0.05).Table (4): Shows correlation between total attitude, total knowledge, and age in years of the studied pregnant women.It is noticed that there was a significant positive correlation between knowledge scores about self-care measures during postpartum period and total attitude (p=0.016*), and between knowledge scores about postpartum period and knowledge scores about self-care measures during postpartum period (P=0.0001*).It is noticed that there was no significant correlation between total attitudes, age years, and knowledge about postpartum period, and total knowledge (p>0.05).The table also illustrates that there was no significant correlation between age in years, knowledge about postpartum period, knowledge about self-care measures during postpartum period, and total knowledge (p>0.05).

Discussion
Postpartum period is a critical physiological adaptation phase and therefore has a meaningful impact on the future of maternal and neonatal health.The women during this period exposed to much risk which may increase the morbidity and mortality rate.So, the woman needs more social, educational, and medical support to protect herself and her infant from many health problems. (31)ystematic examination of the women and their infants as well as providing appropriate health advices to them during postpartum period will prevent impairments and disabilities resulting from childbirth. (21)Maternal self-care is broadly defined as the woman's ability and willingness to take care of herself both physically and emotionally.Improper perception and lack of appropriate care during postpartum period may result in death or disability, as well as missed opportunity to promote healthy behavior for both the women and their newborns.The essential dimension of initiating postpartum care is enhancing the perception, knowledge and attitude, in order to enable them to handle themselves and their infants during difficult situations.As regards to the socio-demographic characteristics of the studied pregnant women, the current study revealed that slightly more than half of women were above 25 to 35 years old with mean ± SD (26.06 ± 3.95).This finding is in line with Asgharnia M et al., (2015) (33) who assessed woman's knowledge regarding postpartum complications and cares.They illustrated that the mean age of the studied women was 26.5 years ± 0.3 years.In addition, Omran A et al., (2020) (34]) implied that the age of women in their study ranged from 20 ≤ 30 years with mean ± SD (24.8 ± 5.61) years.On the other hand, this finding is dissimilar to Mohamed D et al., (2018) (35) who studied "Mother's personal care during postpartum period in Ain Shams University in Egypt".They reported that more than one half of the studied mothers aged between 20 -24 years old.According to the women educational level, the findings of the present study revealed that slightly less than one third of the studied pregnant women had a university education.This finding is in line with Adam L (2015) (36) who implied that slightly more than one third of women had a university education in her study to assess mother's knowledge regarding postpartum self-care in National Ribat University Hospital.On the other hand, this finding is inconsistent with Altuntuğ K et al., (2018) (37) who studied " Traditional practices of mothers in the postpartum period: Evidence from Turkey".They reported that more than three fifths of women read and write.The discrepancy between these results and the results of the present study may be attributed to difference in the setting and cultural profile.As regards to the women occupation, the findings of the present study revealed that more than two thirds were housewives.This result is in agreement with Hamed A et al. (2018) (38) who conducted the study in Egypt about Egyptian status of continuum of care for maternal, newborn, and child health: Sohag Governorate as an example who stated that more than two thirds of women were housewife.In addition, Behal M et al., (2018) (39) assessed mother's knowledge towards pregnancy, childbirth, postpartum and essential new born care in District Solan and revealed that more than two thirds of women were housewife.Regarding women residence, the present study declared that slightly more than three quarters were from urban areas.This result is in agreement with Beraki G et al., (2020) (18) who assessed knowledge on postnatal care among postpartum mothers during discharge in maternity hospitals.They mentioned that nearly three quarters of studied women were from urban areas.On the other hand, this finding is dissimilar to Ganiga P et al., (2020) (40) who found that more than three fifths of women were from rural areas in their study on "awareness of postnatal mothers regarding self and newborn care in a tertiary care center in Mangalore, Karnataka".The discrepancy between these results and the results of the present study may be attributed to difference in the setting of these studies.Concerning the family income; the present study revealed that slightly more than three fifths of the studied pregnant women had insufficient family income.This finding is in line with Gaafar H et al., (2021) (41) who assess the effect of young rural women's general characteristics on their knowledge and compliance with healthy practices during postpartum period.They mention that more than three fifths had insufficient family income.Concerning women's reproductive history, the results of the present study clarified that around one quarter of the studied pregnant were nullipara and nearly one experienced one previous delivery.This result doesn't match with Nazari S et al., (2021) (42) who found that three quarter of the studied women were nullipara and the rest of them were multipara in their study of postpartum care promotion based on maternal education needs.Additionally, Moumita M et al., (2018) (43) who assessed knowledge regarding post natal care among antenatal mothers reported that more than one half of women were multipara.As regard to the type of delivery, the findings of the present study demonstrated that more than two fifths of the studied pregnant women had a cesarean section delivery.This finding is contradicted with Adam L (2015) (36) and Mokhtar K et al., (2020) (44) who found that about four fifths of the studied women had a normal vaginal delivery, and only one fifth had a cesarean section delivery.In addition, Ahmadinezhad M et al., (2022) (45) and Milani H et al., (2017) (46) found that more than three fifths of the studied women had a normal vaginal delivery in their study to assess postpartum home care and its effects on mothers' health.In relation to attendance of antenatal care, the findings of the present study showed a good pattern of early antenatal care; as more than four fifths of the studied women attended for antenatal care regularly especially at first trimester and had more than four antenatal visits through the pregnancy course.The finding of the present study is in harmony with Hassan S et al., (2019) (47) and Milani H et al., (2017) (46) who stated that more than four fifths of the studied women received antenatal care during the first trimester and had more than four visits through the pregnancy course.
In addition, Murthy N et al., (2016) (48) assessed the utilization of antenatal care services by mothers attending immunization sessions at a primary health center in Mysore district, Karnataka, India, and reported that the majority of mothers received full antenatal care services and had more than four antenatal visits.From the researcher's point of view, these similarities may be due to the pregnancy is a critical period which need regular antenatal follow up to save maternal and neonatal health.On the other hand, this finding is inconsistent with Hassan H et al., (2020) (49) who mentioned that nearly two thirds of women didn't receive antenatal care.From the researcher's point of view, this dissimilarity may be due to the different socio demographic of the study subjects.Regarding the place of antenatal care, it noticed that nearly one half of the studied pregnant women had antenatal care at private hospitals and the minority of them had antenatal care at MCH centers.This finding is contradicted with Ahmadinezhad M et al., (2022) (45) who mentioned that slightly less than three quarters of women had antenatal care at MCH center.From the researcher's point of view this may be due to lack of perception of the studied women regarding self-care measures during postpartum period, as well as lack of awareness about the health services provided by MCH centers and their attitudes and believes that the services provided in private clinics and hospitals are better than the services provided in MCH centers.Concerning the total knowledge level about self-care measures during postpartum period, the results of the present study revealed that less than one fifth of the studied pregnant women had a high level of knowledge.This finding is supported by Joshi N et al., (2017) (50) who found that the minority of the studied women had a high level of knowledge in their study to assess "the effectiveness of structured teaching program on knowledge about postnatal care among mothers".Additionally, the findings of the present study are not in accordance with Memchoubi K et al., (2017) (51) who illustrated that more than two thirds of women (70%) had a high level of knowledge.The findings of the present study are also contradicted with Moumita M et al., (2018) (43) and Omran A et al., (2020) (35) who found that the majority of women had high level of knowledge.From the researcher's point of view, the findings of the present study may be due to that more than one quarter of women were nullipara and may had insufficient health education, and/or counseling during the antenatal period.Consequently, they are in need for awareness programs to improve knowledge, attitude, and perception of the studied women on different aspects of postpartum self-care measures.Concerning the studied pregnant woman's total attitudes regarding self-care measures during postpartum period, the results of the present study revealed that the vast majority of them had a positive attitude regarding self-care measures during postpartum period although they had insufficient knowledge in this regard.The findings of the present study is supported with Doaa M et al., (2018) (25) who found that the majority of women had positive attitudes towards post-partum self-care.Abd El-Razek A (2013) (52) evaluated the teaching guidelines enhancement of mothers about self-care practice during the post-partum period at postnatal unit and outpatient clinics of obstetric department of El-Basher Hospital and reported that the majority of the studied mothers had positive attitudes towards post-partum self-care.On the other hand, the finding of the present study is contradicted with Darling B et al., (2014) (53) who assessed knowledge and attitude of post natal mothers regarding self-care after childbirth in selected maternity centers in Madurai and mentioned that the majority of postpartum mothers had negative attitudes towards self-care after childbirth.From the researcher point of view, the result of the present study may be due to that about one third of women had a university educational level which affect their abilities to change their believes and attitude.Concerning the relationship between sociodemographic characteristics and total knowledge level of the studied women, the current study revealed significant association between total knowledge level of the studied pregnant women and their educational level.This finding is in the same line with Bakr A et al., (2019) (54) who revealed that there was a highly statistically significant association between women's educational level and their knowledge regarding postpartum warning signs in their study to assess "women's knowledge regarding postpartum warning signs".In addition to Timilsina S et al., (2015) (55) explored the knowledge regarding postnatal care among postnatal mothers.They reported that there was a significant association between level of women's knowledge regarding postpartum self-care and their educational level.From the researcher point of view this result of the present study may be due to that the women with educational background had correct knowledge than women with limited educational background.The current study also revealed that there was a significant association between total knowledge level of the studied pregnant women and their occupation.This finding is supported by Bakr A et al., (2019) (54) and Ibrahim A et al., (2017) (56) who revealed that there was a highly statistically significant association between women's job and knowledge regarding postpartum warning signs.From the researcher's point of view, the result of the present study may be due to that more than three fifths of the studied women were housewives and haven't better opportunity to share experience with others than working women.Concerning the relationship between total knowledge level of the studied pregnant women and women's residence, the current study revealed that there was no association between total knowledge level and women's residence.This finding is supported by Ibrahim A et al., (2017) (56) who revealed that there was no association between total knowledge level and women's residence.On the other hand, the current study findings disagree with Bakr A et al., (2019) (54) and Hailu D et al., (2014) (57) who reported that urban residence had a significant association with at least two danger signs during postpartum period.Again, the findings of the current study showed that there was no correlation between women's age and knowledge regarding postpartum self-care.This result is in harmony with Darling B et al., (2014) (53) who found that there was no association between women's knowledge regarding postpartum self-care and their age.In addition to El-Nagar A et al., (2017) (56) who assessed knowledge and practice of pregnant women regarding danger signs of obstetrics complications in postnatal medical centers in Tanta city found that there was no statistically significant association between women's knowledge regarding postpartum danger signs and age.Meanwhile, the present study finding is contrasted with Doaa M et al., (2018) (25) and Lalitha H (2016) (58) who found a significant association between mothers' knowledge regarding postpartum self-care and age.As regards to correlation between total attitude score and knowledge score of the studied pregnant women regarding selfcare measures during postpartum period, the current study reported that there is a statistically significant positive correlation between knowledge score and total attitude score of the studied women regarding selfcare measures during postpartum period.This result is similar to the finding of the study done by Bakr A et al., (2019) (54) and Darling B et al., (2014) (53) who reported that there was a positive correlation between knowledge and attitudes of postnatal mothers regarding self-care after childbirth.On the other hand, the result of the current study is not matched with Doaa M et al., (2018) (25) who assessed women's self-care practice during postpartum period, and reported that there was no correlation between women's knowledge and attitude regarding self-practice during postpartum period.

Conclusion
Based on the findings of the present study, perception of the studied pregnant women included their knowledge and attitudes regarding self-care measures during postpartum period.So, it can be concluded that slightly more than one half of the studied pregnant women revealed low level of knowledge regarding self-care measures during postpartum period.On the other hand, the majority of the studied pregnant women had positive attitudes toward postpartum self-care measures.Again, significant positive correlation was found between total knowledge and total attitudes score level among the studied pregnant women and self-care measures during postpartum period, as well as between total attitudes score level and between women's socio demographic characteristics and reproductive history.Thus, the research questions of this study have been answered regarding the perception of pregnant women about selfcare measures during postpartum period.Recommendations Based on the results of the present study, the following recommendations are suggested: -Planning and developing antenatal classes for all pregnant women especially during the last trimester to increase their awareness, enhance their practice regarding routine self-care during postnatal period and regarding seeking medical care at proper time.
-Constant supervision by the Ministry of Health and population through Council Health Management Teams to improve quality of counseling provided by nurses during antenatal care about postpartum care .

Figure ( 1
Figure (1): Distribution of the studied pregnant women according to their total score level of knowledge regarding post-partum period and self-care measures during postpartum period (n= 250).

Figure ( 2 )
Figure (2): Distribution of the studied pregnant women according to their total attitude regarding self-care measures during postpartum period (n= 250).

Table ( 1
): Distribution of the studied pregnant women according to their sociodemographic characteristics (n= 250).

Table ( 2
): Distribution of the studied pregnant women according to their Obstetrichistory (n= 250).

Table ( 2
) Continue: Distribution of the studied pregnant women according to their Obstetric history (n= 250).

Table ( 3
): Relationship between total knowledge level of the studied pregnant women regarding self-care measures during postpartum period and their socio-demographic characteristics (n= 250).