Formative study to develop intervention package for main caregivers of pregnant women: Qualitative Analysis to improve continuum of care (CoC) for maternal health in rural areas of Yangon Region, Myanmar.

Most of the rural pregnant women practiced incomplete continuum of care in Myanmar. The support of family members is important for adherence of health care among pregnant women. This study intended to explore the perceptions, preferences and needs on continuum of maternal health care for development of health education package among family main caregivers of pregnant women in rural areas of Yangon Region. Three different focus group discussions were done with pregnant women, main care-givers and midwives respectively. Each group discussion consisted of seven to nine participants. Almost all of main caregivers and pregnant women could not mention detail about the continuum between pregnancy, delivery and after delivery. In spite of being aware of suitable place and personnel for safe delivery, pregnant women were still giving birth at home. Minimum required frequency of antenatal visits, fourty-two days puerperium period and three times postnatal additional checks were not well known. Avoidance of food during pregnancy and puerperium; and application of unclean powder into umbilical stump were still present due to the influence of traditional practices. Main caregivers were aware of some danger signs in pregnancy and services given by midwives for pregnant women. Family caregivers were important for pregnant women in receiving health services, decision making and daily household chores. Midwives explored the importance of health education to caregivers of pregnant women to support for continuous and adequate maternal health care. The findings of this formative study were evident to develop the health education package for the main caregivers of pregnant women and hoped to be incorporated in improving maternal heath by approaching continuum of care. Index Term: Intervention Package, Main Caregivers, Pregnant Women, Continuum of Care (CoC), Myanmar I.INTRODUCTION From the start of pregnancy to the end after delivery, antenatal care (ANC) is a key for wellbeing of mothers [1, 2]. The postnatal care (PNC) also plays as a crucial role during the postnatal period for promoting health of the woman by identifying, monitoring and managing health conditions [3]. Health professional with midwifery skills can appropriately manage pregnancy related complications by early recognition of danger signs and an effective timely referral to a well-equipped facility [4]. Therefore, the dimensions of continuum of care (CoC) by World Health Organization (WHO) for maternal health emphasize on different stages of pregnancy, childbirth and postpartum; and address continuous care from home to health center and hospital [5]. International Journal of Scientific and Research Publications, Volume 11, Issue 7, July 2021 213 ISSN 2250-3153 This publication is licensed under Creative Commons Attribution CC BY. http://dx.doi. org/10.29322/IJSRP.11. 07.2021. p11528 www.ijsrp. org In Myanmar, maternal death was related to inability to access, understand and apply health information within women and their families that influence on promotion and maintenance of good maternal health [6]. Especially women from rural areas of Myanmar were not utilizing the antenatal care and postnatal care services adequately [7-9]. Four visits of antenatal care among Myanmar women was 59% within 2015 to 2016 [10]. Being 86.1% and 41% of antenatal care coverage and institutional delivery in 2016, it is urgently needed to reach up to 90% and 80% in 2020 respectively [11]. WHO considered to develop interventions at the individuals, families and communities (IFC) level which increase awareness on need and problems related to maternal health and strengthen social support between women, men, families and communities for improving maternal health [12-14]. Based on the finding of community-based interventions and trials done in different parts of the world, involvement of family members including men and family members were essential for improving health status of pregnant women during antenatal, intrapartum and postnatal periods. Improvement of care-seeking for essential maternal health services including ANC visit, skilled birth attendance, institutional delivery and use of PNC were evidenced by interventions such as men involvement, family and community educational campaigns, group formation and counselling [15-20]. According to previous studies in Myanmar, health education package should be emphasized and extended for improving health of mother [8, 9, 21, 22]. Better understanding of the gaps in seeking care and factors contributing to the gaps are important to be pointed out for successful program implementation. In the Myanmar setting, support of family members is also important for adherence of continuous health care among pregnant women. To my knowledge, there was no previous intervention among main caregivers of pregnant women to improve completion of continuum of care for maternal health in Myanmar. By exploring the maternal health related perception, preferences and needs within pregnant women, their main caregivers and midwives, this formative study intended to develop health education package for main caregivers of pregnant women to strength their involvement and support for completion of continuum of maternal health care among women in rural areas of Yangon Region. II.METHODOLOGY 2.1 Study area This study was conducted in Taik Kyi township, Yangon Region where there is adequate rural setting and different classes of people with different ethnic and religious groups. Moreover, according to the health statistics of Yangon Regional Health Department, there is more than 3000 pregnant women, MMR was round about one per 1000 live births and rate of AN care for four and more times was less than 85% in Taik Kyi township during 2018. 2.2 Sampling The qualitative study was carried out as first portion of the exploratory sequential design for development of intervention package. Purposive non-probability sampling was applied for participant selection. Selection criteria for maincare givers was those who were currently living with pregnant women under the same shelter and age of over 18 years. Pregnant women with any gestational periods who came to township hospital for seeking care from different villages under this township were selected and midwives (MW) who were currently working at RHCs and subcenters were purposively chosen. All participants were informed and invited by the help of local authorities including Township Medical Officer, Maternal and Child Health Medical Officer, Township Health Nurse and Health Assistant of study area. 2.3 Data collection Three focus groups discussions (FGDs) were carried out including 7 pregnant women, 7 main care givers and 9 midwives respectively in each session. The FGD guideline was developed in both English and Myanmar languages and pretested in Thanlyin township of Yangon Region. The major topics in discussions included participants’ socioeconomic backgrounds, perceptions on continuum of care, practices for ANC, child birth and PNC, preferred health care during pregnancy, child birth and postnatal period, International Journal of Scientific and Research Publications, Volume 11, Issue 7, July 2021 214 ISSN 2250-3153 This publication is licensed under Creative Commons Attribution CC BY. http://dx.doi. org/10.29322/IJSRP.11. 07.2021. p11528 www.ijsrp. org needs and the barriers for continuum of care, role of main care giver for pregnant women for antenatal care, safe delivery and postnatal care. Suggestions from midwives on health education intervention for main caregivers were also explored. The data collection took place during February, 2020. In each FGD, purpose of conducting FGDs were explained. Written informed consent and permission to record their insights were obtained with maintenance of confidentiality and anonymity. The FGDs were held at a meeting hall of township hospital with privacy and absence of environmental disturbances. All other persons (non-participants) were requested to stay away while holding discussions. Researcher did as a moderator and note taking was done by three trained note-takers. Every participant was encouraged to involve in discussion and non-verbal cues were also recorded. About forty-five minutes to one hour was taken for each FGD. Before conclusion of each session, information obtained were confirmed with the participants and they were also allowed to add or modify the facts at the end of each FGD. 2.4 Data analysis Data management was started from data collection to until it ended to develop main themes for intervention package. Content analysis was used and the interviewed data was analyzed manually. The researcher transcribed recordings as well as the field notes in Myanmar language and checking was done by listening of audio records repeatedly. After that, data files (transcripts) were saved as Microsoft word files in both Myanmar and English language. Coding of the data was done by three coders who did as note takers during FGDs. Then researcher reviewed and verified the codes several times in order to obtain an overall understanding of the data and then transferred into pre-categorized themes. The data was again sorted and organized into themes by taking consensus with co-investigators. After analysis, the findings were presented in the document as well as in qualitative matrix to reflect the deeper insights. For credibility of the study’s results, themes were triangulated using data collected from three different types of respondents; pregnant women, main caregivers of pregnant women and midwives. Moreover, audio records, field notes, transcripts and documented data analysis provided a research trail. Ethical considerations Participation in the study was voluntary and participants can withdraw from the study at any time. Each and every participant were explained about the study objectives and their signed consent forms were taken prior to the start of each discussion. The permission for audio r