Eclampsia, a severe form of hypertensive disorder during pregnancy (HDsP), labor, and post birth, characterized by seizures, even life-threatening cerebral hemorrhage, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, multi-organ failure continues to be a real concern around the world, especially low-resource countries. There is enough evidence that it places the woman and her baby at higher risk of adverse outcome and is one of the leading causes of severe maternal morbidity and mortality. Awareness can greatly contribute to prevention, early diagnosis, and timely appropriate management. Bartal et al. [1] reported an incidence from 1.6 to 10 per 10,000 births in developed countries, and 50 to 151 per 10,000 births in developing countries. In addition, women from low-resource countries who develop eclampsia have substantially higher maternal and perinatal mortality and morbidity than those of developed countries. A meta-analysis by Bhadoria et al. [2] revealed 1 out of 11 pregnant women in India suffered HDsP. Joshi et al. [3] did a study to know about knowledge of HDsP among postpartum women treated for preeclampsia and eclampsia in Ghana which revealed HDsP as major causes of maternal morbidity and mortality, yet patients’ perspectives and diagnosis were not well understood. 

A Community based study was conducted to know the awareness of eclampsia in pregnant women of a rural, remote and hilly region.

Study setting

The study was carried out in 140 villages and the village with a health facility, being the study headquarter.

Study design

This is an observational cross-sectional study.

Study sample

Using the formula for calculating sample size, considering 95% Confidence Interval with 5% margin of error, the required sample size was small, but to further improve the authenticity of the study, robust data was collected. A minimum of 10 women study subjects from each village aged 15 to 45 years were randomly included, however the eldest was less than 40, making a total of 2,000 pregnant women study subjects as some villages were small and others were bigger.

Exclusion criteria

Women less than 15 years of age or more than 45 years of age, non-pregnant women, women not willing or not in a position to answer were excluded.

After the Institute's ethics committee's approval and after obtaining consent, women were interviewed in villages at mutually convenient places. Information of awareness and perceptions about eclampsia among pregnant women was collected using a pre-designed tool, consisting of some questions which needed yes or no answers and others for short answers. Information was recorded on the hard tool. The study subjects were not asked to fill the tool.

The information obtained from 2,000 participants was analyzed. Out of the total, 70.3% women had availed antenatal care (ANC). Among these 1,405 pregnant women, more than half (53.9%) were of 20-29 years, only 15% were between 30-45 years of age (eldest was less than 40), with a significant number of teenage pregnancies too (30.7%). Although more than one-third of the study subjects were illiterate, 61.1% of them had sought ANC. All (100%) graduates had sought ANC. Almost 65% of the upper (64.7%) and lower class (65.5%) had sought ANC with 87.6% of all middle class women, many of whom were agricultural laborers (44.1%). Overall, 87.8% of shopkeepers and 58.1% of all home makers had sought ANC. Many of the study subjects had previous births. Of 1,405 women, only 22.3% were primigravidae.

*Small scale, (food, shoes making, bamboo items) industry, welding workshop, brick furnace

SC: Sub Centre; PHC: Primary Health Center; DH: District Hospital; SDH: Sub District Hospital; RH: Rural Hospital

The information obtained from 2,000 participants was analyzed. Out of the total, 70.3% women had availed antenatal care (ANC). Among these 1,405 pregnant women, more than half (53.9%) were of 20-29 years, only 15% were between 30-45 years of age (eldest was less than 40), with a significant number of teenage pregnancies too (30.7%). Although more than one-third of the study subjects were illiterate, 61.1% of them had sought ANC. All (100%) graduates had sought ANC. Almost 65% of the upper (64.7%) and lower class (65.5%) had sought ANC with 87.6% of all middle class women, many of whom were agricultural laborers (44.1%). Overall, 87.8% of shopkeepers and 58.1% of all home makers had sought ANC. Many of the study subjects had previous births. Of 1,405 women, only 22.3% were primigravidae.

Among the women interviewed with less than 28 weeks of pregnancy, 58.7% had availed ANC, indicating late ANC care seeking practices, mainly at Anganwadi or Sub Centres (SC) or Primary Health centers (PHC), but 6% did seek care from private centers. Around half of these, 703 women were aged 20-29 years, agricultural workers, belonged to low economic class and had 1-2 previous viable pregnancies, 41.3% had primary education, 27.8% with secondary or higher secondary level, and 28% were illiterate. Also, those who were above 28 weeks of gestation also primarily availed ANC at Anganwadi or SC or PHC (57.7%) and 8.3% visited Private Centres (Table 2). A little more than half (56.5%) of them were between 20-29 years of age and 63.3% belonged to low economic class. Around 39.6% of these 702 women were illiterate, with one or two previous births and 38.3% were agricultural laborers.

*Small scale, (food, shoes making, bamboo items) industry, welding workshop, brick furnace

SC: Sub Centre; PHC: Primary Health Center; DH: District Hospital; SDH: Sub District Hospital; RH: Rural Hospital

Overall, 61.1% of the study subjects i.e. 1,222 were aware of the possibility of convulsions in pregnancy and 38.9% did not know anything. There were no differences between ANC sought or not or whether less than or more than 28 weeks pregnant. Those who knew (44%) said convulsions could occur during labor, less (32%) during pregnancy, while still less (24%) were aware about the occurrence of the same after birth. Age and parity were not significant factors, but education, profession, and economic status did affect the numbers of awareness significantly (Table 1). The sources of information about convulsions were ASHA workers (39.4%), nurses (30%), doctors (18.6%), and 12% had multiple sources including local religious people, even quacks. The awareness was found to be lowest among the illiterate, home-makers, and low middle class, while no significant difference was found with parity and age.

Only few study subjects who had awareness, could also associate convulsions with consequences like vaginal bleeding (17.3%), dangers to health of the mother (17%), and death of the baby (25.3%). Some talked of abdominal pain (13.1%), death of the mother (11.5%) and 8.9% could associate it with dangers to the health of the baby. However, 8.1% of the participants were totally oblivious to the dangers due to convulsions, though they were aware of possibilities of convulsions.

A considerable proportion of the women (72.1%) who knew about the possibility of convulsions, had awareness about the possibility of prevention of convulsions but not all. 7.9% of these 881 women were not versed with any modes that could be adopted for prevention of convulsions, 40.2% did attribute the possibility to proper ANC, 35.2% to adequate control of blood pressure and 16.7% to other methods, which they could not specify. Women with age between 30 to 45 years, illiterate, parity more than 3, shopkeepers and middle-class economic women had comparatively lower percentages in their respective group of prevention and modalities of prevention.
 

*Small scale, (food, shoes making, bamboo items) industry, welding workshop, brick furnace
 

*Small scale, (food, shoes making, bamboo items) industry, welding workshop, brick furnace
 

*Small scale, (food, shoes making, bamboo items) industry, welding workshop, brick furnace
 

*Small scale, (food, shoes making, bamboo items) industry, welding workshop, brick furnace

Joshi et al. [3] reported that 74% of women admitted in the hospital with a diagnosis of eclampsia or preeclampsia reported having a complication during pregnancy, but only 32% women with preeclampsia were able to identify the diagnosis, and no woman with eclampsia could even identify the diagnosis. Women’s awareness about eclampsia is important for taking the right and timely actions required and also for ANC, better self-recognition of warning signs and informed healthcare decisions, which can ultimately reduce morbidity and mortality of the mother and the baby. There was awareness among some women in the present study. Overall, 61.1% of the total were aware about the occurrence of convulsions during pregnancy, but many thought convulsions could occur during labor and most reported to have received information from village health workers. Education, profession, and economic status were significant factors, but age and parity did not seem to play a role, irrespective of whether ANC was sought or not. While, in the study conducted by Joshi et al. [3] thirty-one percent of participants reported receiving no information from providers, and only 11% received information in all four categories of study subjects adjusting for age, parity, higher level of education, and the number of antenatal visits. However, even when counseled, 40–50% of participants reported having little understanding. Counseling by healthcare providers was associated with better performance and higher scores on a knowledge assessment. Study by Angelina et al. [4] from Tanzania, revealed that there was a critical knowledge deficiency in relation to prevention and management of eclampsia among nurses. Research revealed that effective regular training on prevention and management of eclampsia for front line nurses was required in order to aid them in helping women and improving maternal and neonatal survival. This is further emphasized in the present study, that the major source of information regarding convulsions was through nurses and village health workers. A study conducted by Zohora et al. [5] among the pregnant women in Tangail, Bangladesh revealed that the age, area of residence, educational status, occupation, and socioeconomic status were significantly associated with the knowledge and awareness about consequences of HDsP, as was also seen in the present study adjusting for area of residence since all subjects belonged to tribal area and age not found to be a significant factor in the present study. It was found that 67% of the participants had some awareness about the possibility of convulsions, 48.5% were unaware of the complications, 40% were unaware about the need of treatment, about 28% did not believe, and 20.5% were not aware of the preventive measures for the dire-consequences. In the present study, 61.1% were aware of convulsions, not even one-third pregnant women were aware of various complications in case of convulsions and 27.9% did not even know that prevention was possible.

Another study by Osman et al. [6] in Al Baha region of Saudi Arabia in the recent past revealed that around 70% of the participants were familiar with severe pre-eclampsia with half of them being aware of the symptoms, with lower awareness for deadly maternal outcomes and poor fetal outcome. It concluded that knowledge gaps regarding the consequences as well as lack of understanding of the symptoms and risk factors, hamper timely management leading to unfortunate outcomes. These findings corresponded with the various results incurred from the present study where very few women were aware of possibilities, such as death of the baby, serious illness, and even death of the mother, but the majority of pregnant women did not have awareness for unfortunate outcomes. Education, profession, and economic status of the women were significantly related to more numbers having awareness about convulsions as well as their prevention. However, many women of lower class did have awareness. Age and parity did not seem to play a role. Also, there was a significant gap between the numbers availing ANC and those having awareness about convulsions, which needs to be bridged. ASHA workers and Nurses were found to be the sources of information regarding convulsions in most of the cases. So keeping them in loop for awareness is imperative, as is provision for their regular training programs to improve any knowledge deficiencies. There is a need for mobilizing individuals from the communities to improve communication. With a multifaceted approach and support from all walks of life, it should be possible to increase awareness among these communities and prevent maternal deaths as well as morbidity, along with adverse perinatal outcomes from such fatal disorders like eclampsia.

Present study highlighted the facts about lack of awareness amongst pregnant, rural women. One third of the study subjects were not at all aware about the occurrence of convulsions during pregnancy and among those who were aware, most were oblivious to the dangerous consequences of the same, and some of them were totally unaware that it was possible to identify warning signs and prevent convulsions altogether.