KNOWLEDGE , ATTITUDES AND PRACTICES RELATED TOPREGNANCYAMONG PREGNANT WOMEN IN SAMAR , PHILIPPINES

Maricel M. Tizon, RN. Pregnancy is one of the most profound times in a woman’s life. It is marked by variety of physical changes, as well as the thoughts and feelings that sometimes overwhelm the pregnant woman to be conscious about her pregnancy. Health knowledge, attitudes and practices are vital elements to enable the pregnant women to be aware of their health status and the importance of appropriate maternal self care.This study assessed the knowledge, attitudes and practices related to pregnancy among pregnant women in Barangay San Andres, Catbalogan City, Province of Samar, Philippines. A descriptive-cross sectional method was adopted for this research and the data were collected over a period of two months from April 18 to August 17, 2013. One hundred pregnant women who were presented as the sample respondents were requested to complete the questionnaires regarding pregnancy. More than half (63%) of the respondents (n = 63) scored within the score range of 12 to 15 which is interpreted as “Good Knowledge”. In general, respondents have “positive attitude” and their typical practice related to pregnancy was interpreted as “poorly practiced” as supported by the grand means of 4.19 of 2.50 respectively.Vast majority of the pregnant women had very good knowledge (pregnant women were sufficiently knowledgeable with the concepts with regards to pregnancy), positive attitude (m = 4.19), and poorpractice (m = 2.5) in relation to pregnancy. The researchers would like to recommend that pregnant women should indulge in activities; campaign and other program and there should be a foregoing analysis that will help improve their knowledge, attitudes and practices and will enable them to provide appropriate health teachings on pregnancy related concepts.

This instrument was developed by Muhamad et al. with modifications and this assesses the psychological result of perception, learning and reasoning of a particular woman towards pregnancy. The knowledge of the participant is being examined by various pregnancy related questions which are based on prenatal check-up and follow up, nutrition in pregnancy, screening test and preparation for delivery. It is consisted of twenty (20) statements. The respondents were given three alternatives indicating their reactions to each statement. The following point assignments were used: Uncertain (0), No (1), and Yes (2) response.

Attitude Related to Pregnancy Questionnaire:-
This instrument was developed by Muhamad et al. with modifications and this expresses the feeling of a particular person related to pregnancy. The attitude of the participant is being examined by various pregnancy related questions which are based on prenatal check-up and follow up, nutrition in pregnancy, screening test and preparation for delivery. The attitude rating scale consisted of fourteen (14) statements. The respondents were given five alternatives indicating their reactions to each statement in the scale. The following point assignments to five different types of responses were used: Strongly Disagree (1), Disagree (2), Undecided (3), Agree (4), and Strongly Agree (5).

Practices Related to Pregnancy:-
The researchers established the questionnaire concerning the respondent's practices toward pregnancy. This determines the way of life of a particular pregnant woman towards pregnancy. The practices of the participant is being examined by various pregnancy related questions which are based on prenatal check-up and follow up, nutrition in pregnancy, screening test and preparation for delivery. The rating scale consisted of fifteen (15) statements. The respondents were given five alternatives indicating their reactions to each statement in the scale. The following point assignments were used: Never practice (1), Unsure (2), Sometimes Practice (3), Often Practice (4), and Always Practice (5).

Data Collection Protocol:-
Before the actual distribution of the questionnaire, a pilot study was undertaken to test the reliability and score distribution. The final distribution of the questionnaire was conducted after incorporating the modifications from the pilot study into the main study questionnaire. Letters of invitation with complete information about the study protocol were sent to the pregnant women in Barangay San Andres. After identifying potential study participants based on the eligible criteria, signed consent was obtained from the participants and data collection was carried out.

Ethical Considerations:-
The study protocol was reviewed and approved by the Health Ethics of Samar State University. Pregnant women rights were maintained through disclosure of the nature, benefits, and lack of known risk of the study. After the informed consent was signed, the researcher distributed the questionnaires at the respective site and collected them in sealed envelope upon completion. To maintain confidentiality and anonymity of the pregnant women, code numbers, instead of their names, were used in the questionnaires. Data were collected over a period of 3 months, from April 18 to August 17, 2013.
Data Management and Analysis:-Data were analyzed using statistical Package for the Social Science (SPSS) version 16 (SPSS inc., Chicago, IL, USA) for descriptive and inferential statistics. Descriptive statistics such as frequencies, means, percentages, and standard deviations were utilized to qualify the responses of the respondents. Table 1 There were 100 respondents in the study. Majority of the respondents or 50 (50%) were ages between 19 to 23 years old with mean age of 23.4 years and great number (41%) of were married while 23 are single. Moreover, most of the respondents (37%) were elementary level, in contrast only 1% had given the opportunity to graduate in college. And for the occupation, vast majority (51%) were housewife and, more than of the respondents have family' monthly income between 100-1,000 pesos per month. In Table 2, majority of the respondents (n= 91) agreed that pregnant women need to go for prenatal check-up and 87% believe that prenatal class is good to prepare expecting mothers mentally. However, the statements, "pregnant woman sees the doctor for prenatal care only if she has pregnancy complication" and "diabetic women have higher risk of having big babies" attained the lowest percentages 14% and 24% respectively. Table 3 presents the scores of the respondents on the questionnaires with regards topregnancy. More than half (63%) of the respondents scored within the score range of 12 to 15 which is interpreted as "Good Knowledge", while 21% scored within the score range of 16 and above which is interpreted as "Very Good Knowledge ". In general, mothers possess "Very Good Knowledge" being supported by the weighted mean of 20.   Table 4 attitudes related to pregnancy   Table 4 presents the mean weighted ratings of the statements intended to measure the attitudes of pregnant womenrespondents related to pregnancy. Majority of the respondents (n= 58) agreed that they will go for prenatal check-up if pregnant, and more than half (57%) believed that vitamin supplement is good for the fetus. However, n= 6 respondents felt that smoking is harmful to the fetus and 5% believed that alcohol drinking will affect fetal growth. In general, a pregnant woman has "positive attitude" related to pregnancy as supported by the grand mean of 4. 19. Table 5 presents the mean weighted ratings of the statements intended to determine the way of life of a particular pregnant woman towards pregnancy.Majority of the respondents (n=100, 100%) never smokes during pregnancy,more than half (n=65) doesn't drink alcoholic beverages and 59% eat nutritious food like fruits and vegetables. Meanwhile, highest degree of practice of the respondents were noted, that 52% never gone to a doctor when sick (52%, never), never intake of maternal milk (94%), and 95% never checked their blood sugar level one to three times a day. The typical practice of pregnant women related to pregnancy is interpreted as "poorly practiced" being supported by the grand mean of 2.5033.   Table 6 shows the correlation analysis between respondents' knowledge on pregnancy and selected variables. The rvalue between knowledge on pregnancy and age (p= 0.062), marital status (p= 0.365), educational attainment (0.487), occupation (p= 0.646) and family's monthly income (p= 0.281). For the correlation analysis between respondents' attitudes on pregnancy and their selected profile reveals that age (p= 0.829), marital status (p= 0.579), educational attainment (p= 0.829), occupation (0.158) and family's monthly income (p= 0.191). However for the

Discussions:-
Pregnancy is a unique and one of the most precious moments for women, however complications can occur during pregnancy. They can involve the mother's health, the baby's health, or both 13 .Hence, along with the Millennium Development Goal (MDG) 5 which is to improve maternal health 14 , every woman needs to be aware of the key danger signs of obstetric complications during pregnancy, delivery and the postpartum period 15 .
In order to address maternal complications, knowledge, attitudes and practices of maternal needs to be evaluated to provide correct and proper intervention. In the current study, pregnant women are knowledgeable over the importance and implications of prenatal check-up, which are in congruence with the previous study by Greg (1995), where it is stress that prenatal care has long been endorsed as a means to identify mothers at risk of delivering a preterm or growth-retarded infant and to provide an array of available medical, nutritional, and educational interventions intended to reduce the determinants and incidence of low birth weight and other adverse pregnancy conditions and outcomes 16 . However, there are still pregnant who doesn't believe that being diabetic may cause them to have a big baby and according to Akadiri (2011), obesity and diabetes in pregnancy have independent and additive effects on obstetric complications, and both require proper management 17 .And thus regular follow-up, controlled diet and life style are essential to control the hyperglycemia in diabetic pregnancies. And in addition it can be noted that, only few believed that they only have to see a doctor for prenatal care if they are sick and according to Warren (2010) the care seeking behavior of a person is related to recognition of the cause and severity of the complication 18 . However there are many factors to consider why availing of maternal health services becomes a hindrance this is also supported with the study conducted in Ethopia some of the women who reported complications did not seek services due to reasons, like inability to judge the graveness of the condition, distance/transport problems, lack of money/cost considerations and use of traditional options at home 19 .
As to attitude, findings indicated that pregnant women agreed having an interpretation of positive attitude concerning pregnancy especially with regards to prenatal check-up and according to Sherbini et al. (1993) where in 80% of pregnant women also observed that prenatal check-up is important to maternal and fetal well-being 20 . Taking nutritional supplement during pregnancy is also a favourable attitude wherein it helps the growth and development of fetus and that is intended to cover gaps in maternal nutrition and to decrease the risk of adverse outcomes such as neural tube defects 21 . Moreover, findings indicated that pregnant women strongly agreed having high positive attitude with regards to avoidance of maternal smokingand it is believed that one of the effects of maternal smoking during pregnancy and environmental tobacco smoke are asthma and wheezing in children 22 . In one study conducted it revealed that there was a strong relationship with significant relationship between smoking and all observed birth outcomes, there were significant reductions in birth weight (by 205 g), birth length (by 1.28 cm), head circumference (by 0.38 cm) and chest circumference (by 0.66 cm) found to be associated with an average daily smoking of 10 or more cigarettes after adjustment was made for potential confounders 23  Aside from the attitude and knowledge, it also believed that good maternal practices, utilization of maternal services and behavioral factors 24 help reduce the incidence of perinatal morbidity and mortality and to help women address complications. In this study it can be seen that all of the respondentspractice not to smoke during pregnancy. However, majority of them do not drink maternal milk wherein it is emphasized in the study by Borazjani, et.al, thatthe rate of growth of fetus was highly influenced by maternal milk and protein intake by the mother 25 .Findings also indicated that significant numbers of mothers also do not check blood sugar level that does not comply with the guidelines on prenatal care. With practice fetuses are put in higher risk for complications 26 . Factors determination and effects association are very important. The implications of the study findings highlight the need for prospective mothers to prepare a safe pregnancy plan as a strategy for improving birth preparedness. Safe pregnancy plans should start with ensuring that prospective mothers have adequate knowledge and information about safe motherhood practices while taking into consideration their obstetric history 27 . It has been identified in the study that there were no relationship between knowledge and the confounding variables. This finding is in complete disagreement with that of Dr.Kathia Van Egmond (2002) study, wherein the educational attainment has intent with regards to knowledge on pregnancy, which the longer the pregnant woman went to school, the better her knowledge parameters in general, especially when it comes to maternal and child care 28 . Knowledge of key danger signs isalso an essential for motivating women to seek skilled attendance at birth and also to seek referral in case of complications.
As to attitude it is further indicated that no matter what the age, marital status, educational attainment, occupation and family's monthly income of the respondent, it won't affect her attitude to pregnancy.This is contrast in the study by Chang that Mothers and children benefited when maternal attitudes were consistent with the mothers' actual employment status 29 . Among consistently employed mothers, those with positive attitudes about employment had better psychological well-being and could give a better nutrition but when mothers were unemployed, it is believed that maternal employment would have positive consequences for their children's development, and likely to show a low level of psychological well-being and poor quality of mother-child relation.
As to practices, no correlation were seen in the study wherein it contradicts in the result conducted by Barbara L. Cannella (2005) that the higher the income of the family perceived, the more pregnant women engaged in good health practices 30 . According to UNAIDS (2005) report, education plays an important role in predicting how well an individual is able to incorporate current lifestyle messages into their sexual behavior 31 . The level of education of the sample may have accounted for the increased self-care practices during pregnancy, mean score 24.32 out of 42 with a corresponding improved birth outcomes, mean score 8.99 out of 15 32 .

Conclusions:-
It could be inferred from this study that there are no relation of knowledge, attitude and practices as to maternal variable (age, marital status, educational attainment, occupation and monthly income). However, researchers would like to recommend that pregnant women should indulge in activities; campaign and other program and there should be a foregoing analysis that will help improve their knowledge, attitudes and practices and will enable them to provide appropriate health teachings on pregnancy related concepts.