International Journal of Community Medicine and Public Health

John NN et al. Int J Community Med Public Health. 2021 Jan;8(1):201-206

http://www.ijcmph.com pISSN 2394-6032 | eISSN 2394-6040

DOI: https://dx.doi.org/10.18203/2394-6040.ijcmph20205693
Original Research Article

Knowledge, attitude and practices for antenatal care, danger signs of

pregnancy and family planning among pregnant women
in a rural area of Kerala, India
Nimmy N. John*, Amrutha George

Department of Pharmacy Practice, N.E.T Pharmacy College, Raichur-584103 Karnataka, India

Received: 28 August 2020

Revised: 13 November 2020
Accepted: 19 November 2020

*Correspondence:
Dr. Nimmy N. John,
E-mail: nimmydale@gmail.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Maternal health services have a potentially critical role in the improvement of reproductive health. The
use of health service related to availability, quality and cost of services as well as the social structures, health beliefs
and personal characteristics of the users. Objective was to determine the level of knowledge, attitude, and practice
related to antenatal care (ANC), danger signs and family planning among the pregnant women.
Methods: This cross-sectional study was carried out in May 2020 to August 2020 in a rural area of Thrissur district of
Kerala, India. 150 pregnant women (aged 18‑35 years) attending the antenatal clinics were interviewed using a
predesigned, pretested questionnaire.
Results: The knowledge and attitude of the participants towards antenatal care, danger signs of pregnancy and
adopting family planning methods was adequate in the study population. The total score of knowledge was 80%,
positive attitude was 91% and practice was 77%. The participants also had knowledge regarding pregnancy danger
signs. Nearly 92% were aware of bleeding per vagina being a danger sign, 85% stated weak or no movement of baby
as a danger sign, 75% knew that pain in abdomen was a danger, 68% knew excessive vomiting as a danger sign while
a mere 41% reported that convulsions were a danger sign.
Conclusions: The role of health workers in increasing awareness among mothers about the importance of ANC, the
danger signs of pregnancy and adopting family planning methods are of paramount concern.

Keywords: Antenatal care, Attitude, Danger signs, Family planning, Knowledge, Obstetrics, Practice, Pregnancy

INTRODUCTION ANC is the care given to pregnant women so that they

have safe pregnancy and healthy babies. The main
Pregnancy is a normal process that results in a set of both objective of ANC is to assure that every pregnancy ends
physiological and psychological changes in expecting in the delivery of a healthy baby without harming the
mothers. It is a very important event from both social and health of the mother. Antenatal care service is an
medical points of view. However, normal pregnancy’s important goal concerning in the health status of the
may be accompanied by some problems and pregnant women during their reproductive period and its
complications which is potentially life threatening to the health beneficial accounting for nearly one quarter of all
mother and foetus. Therefore, pregnant women should pregnant worldwide.2 It helps in early detection, treatment
receive special care and attention from the family, and prevention of conditions that are associated with
community and the health care system.1 maternal morbidity and mortality. Unfortunately, many
women in developing countries do not receive such care.

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Understanding knowledge and practices of the collected by interviewing all the eligible subjects willing
community regarding care during pregnancy and delivery to participate in the study. A 25 item predesigned,
are required for the program implementation.3 pretested questionnaire was used to assess the knowledge
attitude and practice for antenatal care, danger sign during
Danger signs of pregnancies are a warning signs that pregnancy and method of adopting family planning
women encounter during pregnancy, child birth and method after marriage and present pregnancy. Women
postpartum. Awareness of the danger signs of obstetric were asked regarding registration of pregnancy, minimum
complications is the essential first step in accepting 4 antenatal check-up visits, taking iron and folic acid
appropriate and timely referral to obstetric and newborn tablets, type of family planning method adopted by them
care. Raising awareness of women on danger signs of after marriage and what is their knowledge to adopt the
pregnancy, childbirth and the postpartum period improve family planning method. They were also asked about the
mother’s attitude to seek medical care and is crucial for danger sign during pregnancy. The danger signs were
safe motherhood.4 dizziness, swelling of feet, persistent vomiting, bleeding
per vagina, and blurring of vision, less movement of baby
Family planning is defined by WHO as “a way of inside uterus and pain abdomen.
thinking and living that is adopted voluntarily, upon the
basis of knowledge, attitudes and responsible decisions RESULTS
by individuals and couples, in order to promote the health
and welfare of family groups and thus contribute A total of 150 pregnant women completed the study and
effectively to the social development of a country”. The the demographic status is depicted in Table 1.
three main elements that contribute to achieving these
purposes are knowledge, attitude, and practices and the Table 1: Socio demographics of participants (n=150).
disproportion between any of these elements affect family
planning outcome.5 Variables Frequency Percentage
Age in years
Barriers that limit access to quality maternal health <20 4 3
services must be identified and addressed at all levels of 20-25 46 29
the health system to improve the maternal health. Health 25-30 47 29
knowledge is an important element to enable women to 30-35 63 39
be aware of their health status and the importance of
Education
appropriate ANC. Very few studies were carried out in
India especially in Kerala about this aspect of maternal Primary 2 1
health and hence data in this regard is barely available. Secondary/senior
20 13
With this background the present study was conducted to secondary
determine the knowledge, attitude and practice (KAP) Degree/diploma 112 75
score to ANC among the pregnant women and to assess Post-graduation 16 11
the awareness about their own health during pregnancy. Occupation
House wife 80 53
METHODS Others 70 47
Gestational age in months
Study design and subjects 1-3 37 25
3-6 62 41
A cross sectional study was conducted for a period of 6-9 51 34
three months from May 2020 to August 2020 in the rural Total number of children
areas of Thrissur district, Kerala. The study used a
0 49 32
prospective audit of 150 pregnant women living in the
1 45 30
rural areas of Thrissur district aged from 20 to 45
attending antenatal clinics (ANCs). Pregnant mothers 2 54 36
who were unable to hear, speak and severely ill and those 3 2 2
who were not willing to participate were excluded from
the study. The knowledge attitude and practice for antenatal care,
danger sign during pregnancy and method of adopting
Participant recruitment and study method family planning method after marriage and present
pregnancy is shown in Table 2-4 respectively. The score
Permission was obtained from ethical clearance of knowledge about antenatal care, danger sign during
committee before beginning of study. 150 pregnant pregnancy and adopting family planning methods was
females attending antenatal clinics were included in the 80%, attitude was 91% and practice was 77%.
study after obtaining their prior consent. The data was

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Table 2: knowledge about antenatal care, danger sign during pregnancy and adopting family planning methods.

Responds
Knowledge of pregnant women
Correct Incorrect
1 Knowledge about registration of pregnancy 125 (83%) 17 (17%)
2 Knowledge on minimum five antenatal check-ups throughout pregnancy 74 (49%) 76 (51%)
3 Knowledge regarding urine and blood test before pregnancy 97 (65%) 53 (35%)
4 Knowledge on intake of non- prescription medicines 144 (96%) 6 (4%)
5 Knowledge on doses of injection TT should be given to pregnant mother 102 (68%) 48 (32%)
6 Knowledge on iron and folic acid tablets given to pregnant women 121 (81%) 29 (19%)
7 Knowledge on changes to be made in diet during pregnancy 144 (96%) 6 (4%)
8 Knowledge on danger signs of pregnancy 139 (93%) 11 (7%)
9 Knowledge on what to be done in case of danger signs 150 (100%) 0
10 Knowledge regarding contraceptive methods 111 (74%) 39 (26%)

Table 3: Attitude about antenatal care, danger sign during pregnancy and adopting family planning methods.

Responds
Attitude of pregnant women
Agree Disagree Can’t say
Antenatal check-up is necessary for women after becoming pregnant to monitor
11 120 (80%) 2 (1%) 28 (19%)
mother’s and foetus health
12 Blood pressure should be checked regularly during pregnancy 129 (86%) 14 (9%) 7 (5%)
13 Pregnant women should change dietary habit as advised by doctor 146 (97%) 0 4 (3%)
14 Supplementation of iron and folic acid are good for the mother and foetus 146 (97%) 0 4 (3%)
15 Screening of blood for infections should be carried out during antenatal check-up 131 (87%) 12 (8%) 7 (5%)
16 Hospital delivery is better than home delivery 146 (97%) 4 (3%) 0
17 Pregnant women should know about danger signs during pregnancy 143 (95%) 7 (5%) 0
Necessary to know about which family planning method to adopt after marriage
18 131 (87%) 0 19 (13%)
and after child birth

Table 4: Practice about antenatal care, danger sign during pregnancy and adopting family planning methods.

Responds
Practice of pregnant women
Yes No Can’t say
19 Registered during first trimester 126 (84%) 22 (15%) 2 (1%)
20 Regular in your antenatal visits for check-up 110 (73%) 16 (11%) 24 (16%)
21 Taken tetanus toxoid injection 129 (86%) 17 (11%) 4 (3%)
22 Taken IFA (iron folic acid ) supplementation 129 (86%) 16 (11%) 5 (3%)
23 Ever smoked or consumed alcohol during pregnancy 2 (1%) 146 (98%) 2 (1%)
24 Ever taken medicine without consulting doctor 0 148 (99%) 2 (15%)
25 Use of any contraceptive methods 27 (18%) 123 (82%) 0

The study also determined the knowledge of obstetric Score of knowledge about antenatal care, danger sign
danger signs and its associated factors among pregnant during pregnancy and adopting family planning methods
women and it is shown in Table 5. The results suggest was 80%.
that vaginal bleeding was found to be the most commonly
Sum of positive responds given by all respondents
cited danger sign 138 (92%) and convulsion was the least Score of positive attitude =
Total number of responds
× 100
commonly cited danger sign 61 (41%).
120 + 129 + 146 + 146 + 131 + 146 + 143 + 131
Sum of correct responds given by all respondents × 100
Score of knowledge = × 100 8 x 150
Total number of responds

125 + 74 + 97 + 144 + 102 + 121 + 144 + 139 + 150 + 111 Score of positive attitude = 91%
× 100
10 x 150
Score of positive attitude about antenatal care, danger
Score of knowledge = 80% sign during pregnancy and adopting family planning
methods was 91%.

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 John NN et al. Int J Community Med Public Health. 2021 Jan;8(1):201-206

Sum of responds given by all respondents

Score of good practice =
Total number of responds
× 100 Some participants were having secondary/senior
secondary 20 (13%), post-graduation 16 (11%) and
126 + 110 + 129 + 129 + 146 + 148 + 27 primary 2 (1%) educational levels. Higher level of
× 100 education tends to positively affect health seeking
7 x 150
behaviours and the education may increase a women’s
Score of good practice = 77% control over her pregnancy. Majority of the participants in
the study were house wives 80(53%) which signifies that
Score of good practice about antenatal care, danger sign they were unemployed followed by others 70 (47%)
during pregnancy and adopting family planning methods including nurses, dentists, government employees,
was 77%. teachers, etc. of participants (41%) are at 2nd trimester i.e.
3-6 months of pregnancy, followed by 51 (34%) at 3rd
Table 5: Knowledge of danger signs in pregnancy trimester and 37 (25%) at 1st trimester of pregnancy. The
among the study participants. same is shown in Table 1.

Danger signs Aware Not aware Among 150 pregnant women, maximum number of
Swelling of hand/feet/face 89 (59%) 61 (41%) respondents 125 (83%) knew about the registration of
Giddiness/weakness 102 (68%) 48 (32%0 pregnancy and almost half of the 74 (49%) respondents
Visual disturbance 83 (55%) 67 (45%) knew that pregnant women need to go for at least 5
antenatal check-ups. About 97 (65%) participants knew
Convulsion 62 (41%) 88 (59%)
regarding the blood and urine test and 144 (96%)
Weak or no movement of participants knew that the medicines other than those
127 (85%) 23 (15%)
baby prescribed by doctor can cause harm to their baby.
Pain in abdomen 112 (75%) 38 (25%) Almost 81 (73.6%) participants responded that 2 tetanus
Excessive vomiting 96 (64%) 54 (36%) toxoid doses required to immunize against tetanus during
Vaginal bleeding/discharge 138 (92%) 12 (8%) pregnancy. 121 (81%) pregnant women had awareness
regarding the iron and folic acid supplementation during
DISCUSSION pregnancy and 144 (96%) had knowledge regarding
changes to be made in diet during pregnancy. 139 (93%)
Maternal health services have a potentially critical role in pregnant females reported that they know about the
the improvement of reproductive health. The use of health danger signs during pregnancy and all the participants
service related to availability, quality and cost of services (100%) knew that they should report to health centre in
as well as the social structures, health beliefs and personal case of danger signs. Around 111 (79%) participants
characteristics of the users. The ANC provides an knew about contraceptive method to be used after
estimate of essential health issues, including health marriage. This observed that more number of participants
promotion, disease prevention, screening, and diagnosis. had adequate knowledge and it is presented in Table 2.
All struggles commenced to preserve the physical and The total score for knowledge among the pregnant
mental well-being of the mothers, to prevent premature women was 80%. The data suggests that many women
labour, to predict difficulties and complications at birth. were well informed about the aspects of ANC, danger
Thus, ANC aims at reducing maternal, neonatal and signs of pregnancy and family planning. The reason of
infant mortality and increasing institutional deliveries. good knowledge among the pregnant women was might
be because of health education given to them by doctors,
A cross sectional study was carried out by assessing the nurses and social workers or by the accredited social
knowledge, attitude and practices among 150 pregnant health activists in the villages or through books,
women about ante natal care, danger sign during magazines and media. This finding was similar to other
pregnancy and adopting family planning method. study Eram et al in which the respondents had adequate
knowledge about need to go for ANC checkups (95%),
Among the total participants, age was taken into ANC registration, IFA tablet supplementation, TT
consideration by dividing into 4 age groups being kept an injection, and increase in food intake.7
interval of 5 years each. Maximum number of participants
was found in age group of 30-35 (39%) followed by 25- In this study, outcome on the attitude towards the ante-
30 and 20-25 (29%) and least were found in age group of natal care revels that around 120 (80%) participants
<20 (3%). The age group characteristics were similar to believe that antenatal check-up is necessary for women
the study conducted by Prachi et al.6 The data suggests after becoming pregnant to monitor mothers and foetus
that increase in age increases the use of ANC. So it can be health. 129 (86%) participants have an attitude that blood
inferred that the increase in ANC visits with the increase pressure should be checked regularly during pregnancy
in age could be attributed to the fact that better health and 146 (97%) have an attitude that pregnant women
education is given to pregnant mothers during previous should change dietary habit as advised by doctor. Around
antenatal care sessions. Pregnant women enrolled in the 146 (97%) of pregnant women agreed that
study had a mixed educational background. Majority of supplementation of iron and folic acid are good for the
the participants 112 (75%) were having degree/diploma. mother and foetus and 131 (87%) agreed that screening of

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blood for infections should be carried out during antenatal abdomen 112 (75%), giddiness/weakness 102 (68%),
check-up. Majority of the participants 146 (97%) excessive vomiting 96 (64%), swelling of hand/feet/face
considered that hospital delivery is better than home 89 (59%) and visual disturbance 83 (55%). Only 61
delivery. 143 (95%) and 131 (87%) of pregnant women (41%) of study participants reported convulsion as danger
believe that it’s necessary to know about the danger signs sign in pregnancy. The results suggest that vaginal
during pregnancy and about the family planning method bleeding was found to be the most commonly cited
to adopt after marriage and after child birth, respectively. danger sign. This could be because danger signs such as
These results suggest that pregnant women’s have better bleeding are visible and perceived to cause maternal
attitude towards antenatal care, danger signs of pregnancy deaths. Table 5 represent the same. A similar finding was
and family planning except few and the same is shown in reported in a study conducted by Haleema et al in which
Table 3. Score for positive attitude of pregnant women’s 67.10% were aware of bleeding per vagina being a danger
was 91%. Akhtar et al in their study showed that the sign, 50.0% stated excessive vomiting as a danger sign,
outcome on attitude towards ante-natal care among the 23.50% knew that blurring of vision was a danger, while
interrogated females was positive (69.6%).8 But as per the a mere 20.0% reported that convulsions were a danger
study conducted by Patel et al 100% of pregnant women sign.10
were having a positive attitude toward ANC.9 According
to health belief model, the individual perception of a In Kerala, few studies were carried out for assessing the
health condition and likelihood adoption of positive quality and utilisation of ANC/maternity care services
attitude and practices depend on four parameters such as among pregnant women. Moreover, no studies were
perceived seriousness of the condition, perceived carried out to assess the Knowledge, attitude and
susceptibility to the condition, perceived benefits of practices of pregnant women regarding antenatal care,
positive attitude and perceived barriers that prevent the danger signs and family planning. The study conducted
individuals from making the positive changes. by Satheesh and Rajeev showed that around 96% of
mothers received full antenatal care during pregnancy
In our study, observation on practices of pregnant showing better utilization of antenatal care services.11 On
women’s showed that around 126 (84%) registered the the other hand Soman et al in their study in coastal areas
pregnancy during first trimester and majority of the of Kerala reported insufficient antenatal care services in
participants 110 (73%) are regular in their antenatal visits coastal areas compared to other areas of Kerala.12 In a
for check-up. Around 129 (86%) took tetanus toxoid state like Kerala with high human development index,
injection and regular doses of IFA supplementation. Only there is a scope to improve antenatal care services by
2 (1%) told that they smoked or consumed alcohol during creating awareness among the women of reproductive
pregnancy. No participants (0%) are having the practice age.
of taking medicines without consulting doctor. Only few,
27 (18%) had the practice of using contraceptives and The one main limitation of the study was that it was
adopting family planning methods. Score for good conducted in a small number of pregnant women.
practice of pregnant women’s was 77%. The result shows Therefore the finding cannot be generalized to women
that women were practicing adequately on antenatal care who live in urban areas. In addition, our study failed to
except few and practicing poorly on adopting family measure the statistical significance of knowledge, attitude
planning methods. The same is represented in Table 4. and practice of each pregnant woman with the
As per the study conducted by Patel et al 69.3% study independent variables such as education.
subjects followed adequate ANC practices and has
showed the results similar to our study.9 CONCLUSION

Studies show variations in KAP scores in pregnant The study observed that the knowledge and attitude of the
females. In our study, the knowledge (80%), attitude participants towards antenatal care, danger signs of
(91%) and practice (77%) score has not reached towards pregnancy and adopting family planning methods was
100%. The knowledge and attitudes are better in adequate in the study population. These higher scores of
percentage than practices towards antenatal care and knowledge and attitude do not warrant equal scores of
family planning. The study highlights that knowledge and practice. Despite of good literacy rate in the study
awareness doesn’t always lead to the good practice. There population there seemed a discrepancy in the practices.
is still a need to educate and motivate the pregnant The poor practice of participants on adopting family
women and improve antenatal care and family planning planning methods in spite of the availability of various
services to achieve more effective and appropriate methods of temporary contraception indirectly reflects the
practices. insecurities they feel towards the contraceptive methods.
Majority of the study participants had adequate
The study also determined the knowledge of obstetric knowledge of danger signs in pregnancy including the
danger signs and its associated factors among pregnant knowledge of specific obstetric danger signs. To improve
women. Knowledge about vaginal bleeding/discharge community, spousal and family awareness on ANC,
was found to be highest 138 (92%), which was followed information, education and communication activities
by weak or no movement of baby 127 (85%), pain in should be increased on ANC through community

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 John NN et al. Int J Community Med Public Health. 2021 Jan;8(1):201-206

campaigns and mass media like local television channel, 6. Prachi R, Das GS, Ankur B, Shipra J, Binita K. A
radio and local newspapers. study of knowledge, attitude and practice of family
planning among the women of reproductive age
ACKNOWLEDGEMENTS group in Sikkim. J Obstet Gynecol India.
2008;58(1):63-7.
The authors thank the women who participated in this 7. Eram U, Anees A, Tamanna Z. Knowledge
study, for their time and willingness to share their regarding antenatal care services in mothers (15-49
experiences and perceptions. They also thank the local years) in rural areas of Aligarh. Int J Sci Stud.
people and health centers of the study area. 2016;4(9):67-70.
8. Akhtar S, Hussain M, Majeed I, Afzal M.
Funding: No funding sources Knowledge attitude and practice regarding antenatal
Conflict of interest: None declared care among pregnant women in rural area of Lahore.
Ethical approval: The study was approved by the Int J Soc Sci Manag. 2018;5(3):155-62.
Institutional Ethics Committee 9. Patel BB, Gurmeet P, Sinalkar DR, Pandya KH,
Mahen A, Singh N. A study on knowledge and
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