Pregnancy-related falls are a common occurrence . These present a unique challenge because two patients need to be considered, the mother and the fetus. After motor vehicular accidents, accidental falls in pregnancy rank as the leading cause of trauma-associated visits by pregnant women to the emergency department or hospital admissions. Generally, the rate of falls during pregnancy (27%) is similar to what obtains in women above the age of 70 (28%), thus they are the most common cause of non-obstetric injuries in pregnant women [2-6]. Maternal injuries following falls in pregnancy could include joint sprains, muscular strains, fractures, ruptured viscera, including the uterus, and occasionally, death. Other complications include placental separation, rupture of the fetal membranes, or fetal death [3, 7-10].
In other to prevent these falls and their possible complications, there must be a logical balancing of the real risk of maternal falls and the perceived risks by the women themselves . Risk perception is the composite manner by which individuals judge and evaluate the risks they might be exposed to , and this strongly influences the decisions pregnant women make about prenatal care and the options of care they seek in high-risk gestations . Thus, maternal rating of the risks they face from accidental falls may vary from the assessments by the health care providers.
Although falls during pregnancy have assumed a public health dimension, there are no studies on maternally perceived risks of accidental falls in Nigeria, and no fallsrisk assessment or preventive guidelines. This study has been designed to close this information gap, and provide a basis for campaigns on prevention of accidental falls during pregnancy.
This health facility-based, multicentre, cross-sectional cohort survey of women of childbearing age was conducted within Ado - Ekiti, the capital city of Ekiti State, southwest Nigeria, between February and March, 2019. Ado - Ekiti has a population of 2,398,957, who are mostly Yoruba-speaking Christians, and facilities providing maternal and child health services across the different tiers of healthcare .
Four public health centres were selected for this survey because of their adequate geographical spread across the capital, and the population of clients that were cared for. These are: (i) Ekiti State University Teaching Hospital, Adebayo, Ado - Ekiti, (ii) Comprehensive Health Centre, Okeyinmi, Ado - Ekiti, (iii) Basic Health Centre, Irona, and (iv) Basic Health Centre, Odo - Ado. They receive clients from the capital, other towns in Ekiti State, and from neighbouring Ondo, Kogi, and Osun states.
Case definition: Accidental fall was defined as a loss of balance during pregnancy in which a part of the body, besides the feet, touched the ground. All women within the childbearing ages (15- 49 years) who attended the maternal and child health clinics at the study locations during the survey duration, and who gave consent were interviewed. During the routine health education of the women, the purpose of the survey was explained to them, and semi-structured questionnaires were handed out to the consenting mothers. They were informed that though their responses would be held in confidence, they could opt-out.
The survey instrument was developed as an adaptation of other validated instruments for injury study [6, 15], and written in English, the official language of Nigeria. After pretesting, it was also decoded into Yoruba, to improve its comprehensibility. It enquired about the social and demographic characteristics of the respondents, including age, area of residence, occupation, marital status, parity, partner's occupation, level of education and religion. The socioeconomic class was calculated after the model by Olusanya et al, with I being the highest and V the least .
In other to fulfil the study's objectives, three blocks of questions were asked relating to perception of accidental maternal falls, complications that may occur after a fall, and when to seek medical help after a fall in pregnancy. The self-reported questionnaires
were then retrieved by the trained assistants, perused for completeness, and further inquiries made from the respondents if necessary. Where missing values occurred, the mean or modal values (whichever was appropriate) were imputed. The respondents were also asked if they had a fall in their previous pregnancies.
The three blocks of questions were designed in a Likert-scale fashion with five options, 'strongly agree,' 'agree,' 'don't know,' 'disagree,' and 'strongly disagree.' Each was assigned a numerical value of +2, +1, 0, -1, and -2 respectively. Thus, the total score for the responses on perception was 8; good perception was ≥ 6, while poor perception was < 6. The total score for the questions on knowledge was 24; ≥ 20 was regarded as good knowledge, 12 - 19 fair knowledge, and ≤ 11 poor knowledge.
Ethical approval for the survey was given by the Ethics and Research Committee of the Ekiti State University Teaching Hospital, Ado - Ekiti, and the National Primary Health Care Development Agency, Ekiti State.
The retrieved data was coded into, and analysed using the Statistical Software for the Social Sciences (SPSS) package version 20. Responses were expressed using descriptive statistics, while chi-square and regression analyses were done for inferential purposes, with level of significance set at p < 0.05.
Of the 745 questionnaires distributed to the women, nine (1.2%) were returned by women who decided to opt-out of the survey, while 2 (0.3%) were excluded because they were filled by women who were no longer in the childbearing years. Thus, the data analysis was based on 734 (98.5%) respondents. The mean age of the respondents was 30.2 +/- 5.0. One hundred and ninetyone women reported at least a fall in their erstwhile pregnancy, giving a fall rate of 26%.
Seven hundred and three (95.8%) respondents were between the ages of 20 and 39 years, while 5 (0.7%) were teenagers. Most of the respondents were urban dwellers 485 (66.1%), unskilled workers 278 (37.9%), and married 706 (96.2%) multiparous 482 (65.7%) women. About two-thirds (66.5%) were educated to the tertiary level, with 440 (59.9%) being in the middle and lower socioeconomic classes (Table 1).
From Table 2, the perception of the women about accidental maternal falls was significantly poorer amongst the women who were rural-dwellers (χ2 = 10.26; p = 0.001), unskilled workers (χ2 = 22.48; p < 0.001), had no more than a secondary education (χ2 = 29.95; p < 0.001), and were in the lower- and middlesocioeconomic classes (III - V) (χ2 = 24.22; p < 0.001).
The women's knowledge of accidental falls during pregnancy was predicted by their occupation (χ2 = 13.68; p = 0.03) and socioeconomic class (χ2 = 20.38; p = 0.01) (Table 3).
Table 4 showed the relationship between the knowledge and perception of the respondents and their actual experience of falling in their erstwhile pregnancy. Women with good perception scores about accidental maternal falls were significantly less likely to have fallen during their pregnancies (adjusted odds ratio: 0.395; 95% C. I. 0.19 - 0.81; p = 0.017).
The fall rate identified from this survey was 26%. This is inkeeping with the figures quoted by studies from south-eastern Nigeria (32.5%) , and other parts of the world [1, 6, 18]. Thus, it is clear that accidental maternal falls are issues of public health importance in Nigeria. Efforts at prevention are already long overdue. Our survey found that accidental falls during pregnancy was significantly predicted by having a poor perception about the risks of maternal falls. Risk perception has been found to be a cardinal component of many theories on health behaviour including the Health Belief Model [13, 19]. Perception influences the health-seeking behaviour and uptake of prenatal services among pregnant mothers . Thus, having such perceptions as the notion that supernatural and diabolical forces could influence pregnancy outcomes, could make mothers seek spiritual help rather than formal medical attention when they have complications .
Poor perception of the riskiness of maternal falls was, in turn, predicted by having no more than a secondary education. Pregnant women contextualize health recommendations about falls, and have their own views about its riskiness . These views are determined by the level of their academic exposure, and culture  especially for the rural dwellers, who were also more likely to occupy the lower- and middle-socioeconomic classes. Reshaping maternal perceptions about the riskiness of accidental falls could be achieved through effective risk communication methods which can be understood with minimal cognitive effort, and addressing myths/misconceptions about maternal falls for the benefit of the rural dwellers.
Women who were skilled workers and in the upper socioeconomic classes were significantly more aware of accidental maternal falls from this study. Although these groups of respondents were more likely to have higher education, the level of education was not a significant predictor of the knowledge of maternal falls from our survey. Thus, more education may not always translate to more awareness of health risks . The selection of facility-based respondents could bias this survey. However, its strengths derive from the use of geographically-diverse centres, and the participation of childbearing women from various societal strata within the state.
In conclusion, at least one in four mothers fall during pregnancy in our environment. Women who had a poor perception of their risks of accidental falls were more likely to have fallen during pregnancy. Rural dwellers, with at most a secondary education, and unskilled workers, in the lower- and middle-socioeconomic classes were significantly more likely to have a poor perception of their risks of falling; while fall awareness was more amongst skilled women in the upper classes. Scaling up fall awareness campaigns using effective risk communication models that can shape maternal perception of their fall risks is advised.
The authors wish to acknowledge the contributions of Toyin Akinyemi RN, Esther Owoeye RN, and Janet Ogunyemi BSc during the data collection for the survey.
Conflict Of Interest
The authors declare no competing interests concerning this work.