INTRODUCTION
In early pregnancy the placenta may attach low in the uterus and covers a part or all of the entrance to the cervix. This attachment can be seen in early ultrasound scans and called a low-lying placenta. In most cases, when the growing uterus enlarges, the placenta is carried upwards and majority does not cause any problem. However some remain in the lower segment (10%) of the uterus to be called placenta praevia (RCOG 2005).
The predisposing factors to placenta praevia are multiple gestation (Francois et al. 2003) previous uterine scar (caesarean and abortion) (Ananth et al. 1997), increased parity, uterine structure anoma-lies, increased age (more than 35 years old), previous history of placenta praevia, infertility treatment, smoking (Chelmow et al. 1996) and low socio-economic status (Sheiner et al. 2001). Placenta praevia may present with painless vaginal bleeding during pregnancy or other problem such as abnormal lie. Moreover, in chronic cases patients may have anaemia and present with anaemic symptoms resulting from chronic bleeding (Lam et al. 2000).
There are known complications of placenta praevia such as sudden vaginal bleeding, risk of caesarean section, pre-term labour, prone to a repeat placenta praevia in the next pregnancy, as well as hysterectomy with life threatening bleeding, risk in developing morbidly adherent pla-centa (Oyelese & Smulian 2006) in future pregnancies to the extent of maternal and fetal mortality (Hamisu et al. 2003).
Due to possibility of such complications, it requires most of these patients to be admitted to a hospital with adequate facilities as a prevention and anticipation to possible problems. However, this is not always easy and not possible as the women and her family may not com-prehend the medical consequences of her problem. Due to the paucity of data avail-able on the knowledge of placenta praevia, this study was carried out to evaluate the knowledge and attitude of obstetric patients regarding placenta praevia.
METHODS
A cross sectional study was carried out in Hospital Ipoh, Perak Darul Ridzuan from 26th March to 15th April 2007. All the antenatal and postnatal patients in class 2 and 3 obstetric wards in Ipoh Hospital were included in the study. Patients from labour room and high dependency ward were excluded. There was a total of 323 respondents during the survey. Data was collected manually by using purposive or conducive sampling method with a non-probability sampling.
Definition:
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1. Level of knowledge
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·Good :
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respondents answer at least 50% questions re-garding knowledge of pla-centa praevia correctly.
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·Poor :
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respondents answer less than 50% questions re-garding knowledge of pla-centa praevia correctly.
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2. Educational level
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·Primary :
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UPSR, equivalent, or be-low
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·Secondary :
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STPM, matriculation, equivalent or below
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·Tertiary :
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University, Colleges or equivalent
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3. Occupation
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·Professional (white collar):
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those who perform tasks which are less ‘physically laborious’. Such as doctors, airline pilots, IT professional, or lawyer
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·Non professional (blue collar):
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those who perform ma-nual labour. Such as factory workers, building and constructional trades, mechanical work, maintenance or technical installation.
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4. Level of Attitudes
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·Good :
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respondents answer at least 50% questions re-garding positive attitude of placenta praevia correctly.
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·Poor :
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respondents answer less than 50% questions re-garding positive attitude of placenta praevia correctly.
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Socio demographic parameters (ie age, race, parity, occupation, educational level), history of placenta praevia were studied in relation to knowledge and attitude towards placenta praevia. The collected data was analysed by statistical analysis and cate-gory variables were done with chi square-test. A p value of <0.05 was considered to be statistically significant.
RESULTS
There was a total of 323 respondents included in the study. Out of these, twenty women (6.2%) had current or previous history of placenta praevia. Seventeen (5.3%) came to hospital with presence of placenta praevia. Most of the respondents (82.4%) were less than 35 years old. The majority of the women were Malay (65.6%), followed by Chinese (15.5%), Indian (14.2%) and others (Table 1). Most women were multiparae(52.9%) and were housewives (45.8%). The majority was educated until secondary school (76.5%) with a minimal from primary school (9.6%).
Among women with placenta praevia, the prevalence was highest amongst Malays (80%). Sixty percent of those with placenta praevia were multiparae while the remain-ing were grandmultiparae (20%) and primi-gravidae (20%). Increased age was the main predisposing factor found among patients with placenta praevia followed by multiparty, previous caesarean, previous history of placenta praevia and infertility treatment (Figure 1). All women with pla-centa praevia had caesarean section (100%). Eight had history of vaginal bleeding during current or previous preg-nancy. Pre-term labour complicated three women with placenta praevia and only one had postpartum haemorrhage. There were no fetal mortality and morbidity (Figure 2).
The level of knowledge among obstetric patients was distributed almost evenly among those with good (48.9%) or poor (51.1%) knowledge. There were five women (25%) in the placenta praevia group with poor knowledge (i.e. less than two correct answers for four questions). The questions were: the need of haematinics during pregnancy, prohibition of sex during pregnancy, the need to admit to hospital when advised and the need to remain in hospital for a long period. Fifteen patients (75%) had good knowledge. Eightwomen (40%) had poor attitude as they ignored at least two of the four advices given, while 12 of them (60%) followed (pvalue = 0.037).
There was a significant relationship between patient’s educational backgrounds to the level of knowledge regarding placenta praevia (Table 2). With a history of placenta praevia in their previous pregnancy, their knowledge regarding the same problem had an increment, as shown in Table 2. There was also a significant difference between occupation and level of knowledge regarding placenta praevia (Table 3), as the knowledge was higher among those of ‘white collar’ jobs as compared to ‘blue collar’ and housewives. There was a significant relationship between increased age and incidence of placenta praevia (Table 1) as it was higher amongst those of age 35 years old and above (p<0.05).
However there were several non-significant findings during the study on obs-tetric patients in Hospital Ipoh including no relationship between level of knowledge and maternal age (p=0.54), parity (p=0.91), race (p=0.052)and complication of placen-ta praevia (p=0.79).
DISCUSSION
The increasing incidence of caesarean sections and maternal age globally predis-posed more to the incidence of placenta praevia in the obstetric population (Ikechebelu & Onwusulu, 2007). The prevalence of placenta praevia in the current study was higher (6.2%) than seen in previous statistics of Hospital Ipoh (2002-1.4%, 2003-1.26%, 2004-1.23%, 2005-0.91%).This might be due to short duration of the study with smaller number of patients including the exclusion of the first class and high dependency ward patients. Malay women were seen to be the majority having placenta praevia which was likely due to more Malay women being obstetric clients in Hospital Ipoh.
As shown in the current and previousstudy several predisposing factors were recognised for placenta praevia, which were multiparity, previous uterine scar (caesarean section), increasing maternal age, previous history of placenta praevia, and infertility treatment (Faiz et al. 2003). In this study, the commonest predisposing factor of placenta praevia was increasing maternal age (30%, 6 cases), followed by multiparity (20%, 4 cases) as shown in Figure 1. All of the respondents with placenta praevia in the study had caesa-rean section (20 out of 20 patients with placenta praevia) with a range of compli-cations (Figure 2) as had been reported by other studies (Anath et al. 1997) with no other detrimental complication of hyste-rectomy as experienced by others (Choi et al. 2008).
There was slightly more obstetric patients with poor knowledge regarding placenta praevia (ie mean score of knowledge is 11.18, full marks of the knowledge are 23). This might be due to most of the patients in obstetric wards of Hospital Ipoh have low to moderate educational background as shown in Table 2. Also, Hospital Ipoh receives patients from suburban areas like Grik, Chemor, Sungai Siput and aborigine settlement.
The knowledge of placenta praevia was affected by current or previous history of placenta praevia. According to the study, patients with current or previous history of placenta praevia had higher knowledge compared to those who did not have history of placenta praevia. Seventy five percent of those women with current or previous history of placenta praevia had good knowledge while only 47.2% of patients without history of placenta praevia had good knowledge about placenta praevia (Table 2). This may be contributed to the counseling by doctors when they were diagnosed to have placenta praevia or from their previous experience. The women who had placenta praevia also took the initiative to know more about placenta praevia by surfing the internet, reading books and medical articles.
The background level of patients’ education also affected the knowledge about placenta praevia. It was seen that those who had a higher educational status had higher knowledge about placenta praevia (Table 2) which may due to a higher interest level with extra knowledge, as they understood more readily.
The knowledge of placenta praevia was also related to the occupation of the respondents. White-collar workers have higher knowledge about placenta praevia than blue-collar workers and housewives (p=0.018). Some ‘white-collar’ workers came from the medical field like nurses, paramedics who were more accessible to information about placenta praevia.
Most respondents in the study with placenta praevia who had good knowledge about placenta praevia also had good attitude for preventing the complications, which included admission for a longer duration in a well equipped hospital once diagnosed to have placenta praevia. This was practiced in other countries as re-ported earlier (Love et al. 2004). Those who had higher knowledge of placenta praevia realised the danger of its com-plications. Compliance to doctor’s ad-vice (eg prohibition of sexual intercourse and compliance to haematinics) and medication to ensure their health and fetuses. All had further support from their husbands ren-dering them to have a harmonious mind despite the long stay in hospital. Expe-riencing complications of placenta praevia did not show significance to good know-ledge most likely because only a small proportion had experienced the problem.
In general further education and expo-sure on placenta praevia with its possible complications should be emphasised to ob-stetric patients, to ensure proper attitude towards the medical advice given and be compliant to medication in order to achieve optimum care for women with placenta praevia. Therefore, efforts to improve the knowledge regarding placenta praevia through quality improvement programs are very important in order to prevent avoid-able complications such as fetal mortality and maternal death secondary to uncon-trolled bleeding.
CONCLUSION
The knowledge and attitude towards placenta praevia among the obstetric patients in Hospital Ipoh was better in those who had higher level of education, in ‘white-collar’ occupation and those with current history of placenta praevia.
ACKNOWLEDGEMENT
We would like to express our sincere grati- tude to the Director of Hospital Ipoh, Head of Department of O&G of Hospital Ipoh, Dr. Mukudan, all the doctors from O&G department especially Dr. Zeity and other medical staff in Hospital Ipoh for their contributions to this study.
