ST JOHN’S UNIVERSITY OF TANZANIA

BACHELOR OF SCIENCE IN NURSING (BSCN) PROGRAMME

RESEARCH METHODOLOGY IN NURSING
GNU 447

PREVALENCE AND FACTORS ASSOCIATED WITH PRETERM BIRTH IN DODOMA

CITY.

STUDENT’S NAMES:
S/N NAME REG PHONE NUMBER EMAIL
NUMBER

1 AYUBU HAULE 2017/0295 0762490336 ayubuhaule1806@gmail.com

2 DORICAS DOMINICK 2017/0274 0787590478 dorydomi2@gmail.com

3 NELIGWA NELIGWA 2017/0465 0766397619 neligwais@gmail.com

4 JOSEPH ELIA 2017/0505 0767762067 eliajmwasubila@gmail.com

5 JAMILA LWAMO 2017/0441 0629421068 jamilalwamo@gmail.com

RESEARCH PROPOSAL OF LIMITED SCOPE SUBMITTED IN PARTIAL

FULFILMENT OF THE REQUIREMENT FOR THE DEGREE OF ST. JOHN’S
UNIVERSITY OF TANZANIA

2020-2021

SUPERVISOR: MR. MSAFIRI CHILIMO, BScN, RN, MSc PN

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 TABLE OF CONTENTS
COPYRIGHT STATEMENT ...............................................................................................ii

CERTIFICATION ...............................................................................................................iii

DECLARATION .................................................................................................................iv

DEDICATION ..................................................................................................................... v

LIST OF TABLES ..............................................................................................................ix

LIST OF APPENDICES ..................................................................................................... x

ACKNOWLEDGEMENTS ................................................................................................. xi

ABBREVIATIONS ............................................................................................................ xii

CHAPTER ONE .................................................................................................................1

INTRODUCTION ............................................................................................................... 1

1.1. Chapter overview ........................................................................................................1

1.2. Background of the study. ............................................................................................1

1.3. Problem statement ..................................................................................................... 4

1.4. Justification of the study ............................................................................................. 5

1.5. Objectives of the study ............................................................................................... 5

1.5.1 General objective ......................................................................................................5

1.5.2 Specific objectives .................................................................................................... 5

1.6. Research questions ....................................................................................................5

1.7. Purpose and significance of the study ....................................................................... 6

1.8. Chapter summary ....................................................................................................... 6

CHAPTER TWO ................................................................................................................ 7

LITERATURE OVERVIEW ................................................................................................7

2.1 Chapter overview .........................................................................................................7

2.2 Awareness of preterm birth among post-natal mothers ..............................................7

2.3 Prevalence of preterm birth among post-natal mothers. ............................................ 9

2.4 Factors associated with preterm birth among post-natal mothers. .......................... 10

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2.5 Theoretical definitions of key terms ...........................................................................13

CHAPTER THREE .......................................................................................................... 14

RESEARCH METHODOLOGY ....................................................................................... 14

3.1 Chapter overview .......................................................................................................14

3.2 Research design ........................................................................................................14

3.3 Description of the study area .....................................................................................14

3.4 Study population ........................................................................................................ 15

3.4.1 Inclusion criteria ......................................................................................................15

3.4.2 Exclusion criteria .................................................................................................... 15

3.5 Sample size estimation ..............................................................................................15

3.6 Sampling method and recruitment procedures .........................................................16

3.7 Study protocols or procedures .................................................................................. 17

3.8 Data collection methods and tools ............................................................................ 17

3.9 Methods for ensuring validity and reliability .............................................................. 18

3.9.1 Data validity ............................................................................................................ 18

3.9.2 Data reliability ......................................................................................................... 18

3.10 Data analysis methods ............................................................................................ 19

3.11 Ethical considerations ..............................................................................................19

3.12 Plan for dissemination of research results .............................................................. 19

3.13 Limitations of the study ............................................................................................20

3.14 Chapter summary .................................................................................................... 20

APPENDIXES .................................................................................................................. 21

APPENDIX A: PROPOSED WORK PLAN ..................................................................... 21

APPENDIX B: RESEARCH BUDGET .............................................................................22

APPENDIX C: INFORMED CONSENT FORM ...............................................................23

APPENDIX D: QUESTIONNAIRE (ENGLISH VERSION) ..............................................27

APPENDIX E: PERMISION LETTER FROM BENJAMIN MKAPA HOSPITAL ............. 32

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APPENDIX F: PERMISION LETTER FROM DODOMA REGIONAL REFERRAL
HOSPITAL ....................................................................................................................... 33

APPENDIX G: RESEARCH ETHICAL CLEARANCE CERTIFICATE ............................34

REFERENCES ................................................................................................................ 35

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 LIST OF TABLES
Table 3.1: Hospital proportional sample
size………………………………………………..17

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 LIST OF APPENDICES
APPENDIX A: PROPOSED WORK PLAN............................................................................ 21
APPENDIX B: RESEARCH BUDGET.................................................................................... 22
APPENDIX C: INFORMED CONSENT FORM..................................................................... 23
APPENDIX D: QUESTIONNAIRE (ENGLISH VERSION).................................................. 27
APPENDIX E: PERMISION LETTER FROM BENJAMIN MKAPA HOSPITAL............... 32
APPENDIX F: PERMISION LETTER FROM DODOMA REGIONAL REFERRAL
HOSPITAL...................................................................................................................................33
APPENDIX G: RESEARCH ETHICAL CLEARANCE CERTIFICATE...............................34

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 ACKNOWLEDGEMENTS
First, we would like to thank our almighty God for giving us health and strength.
Secondly, we express our deepest gratitude to our supervisor Mr. Msafiri Chilimo for his
great help and support during the whole process of this research study. Also, to Dr.
Zawadi Nkulikwa, our course instructor and all staffs of school of nursing (SONU) for
knowledge and ideas that they shared to us. And finally, we express our gratitude to
HESLB and parents for financial support and all not acknowledged one by one who
contributed to make this work successful.

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 ABBREVIATIONS
AIDS Acquired Immune Deficient Syndrome

ANC Ant- Natal Care

APH Antepartum Hemorrhage

FANC Focused Ant-Natal Care

HIV Human Immune Virus

LNMP Nast Normal Menstrual Period

MoHSW Ministry of Health and Social Welfare

NBS National Bureau of Statistics

NICU Neonatal Intensive Care Unit

PIH Pregnancy Induced Hypertension

PPROM Preterm Premature Rupture of Membrane

PROM Premature Rupture of Membrane

SJUT St John University of Tanzania

SPSS Statistical Package for Social Science

UTIs Urinary Tract Infections

WHO World Health Organization

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 CHAPTER ONE
INTRODUCTION
1.1. Chapter overview
The chapter contains background of the study, problem statement, research objectives
(general objective and specific objectives), research questions, purpose and significant
of the study, and the chapter summary.

1.2. Background of the study.

Preterm birth is defined as all births before 37 completed weeks of gestation (WHO,
2015). There are sub-categories of preterm birth based on the gestational age,
extremely preterm which is less than 28 weeks, very preterm from 28 to 32 weeks, and
moderate to late preterm from 32 to 37 weeks (Deressa et al., 2018).

Preterm birth has a diversity of causes which can be grouped into two broad subtypes
which are spontaneous preterm birth and induced preterm birth (Adewumi et al., 2017).
Preterm birth also carries greater disease burden due to long-term adverse
consequences for health as children who are born preterm have higher incidence of
respiratory diseases, sensory deficit, cerebral palsy, impaired learning ability in
comparison to those born at term (WHO, 2017).

Globally, prematurity is a leading cause of neonatal morbidity and mortality in almost all
countries worldwide including Tanzania and is a second cause of under-five death in
the world (WHO, 2018). Distribution of premature birth rates seems not to be uniform
and the rate of preterm birth is increasing and ranges from 5 to 7% in developed
countries and significantly higher in least developed countries (Deressa et al., 2018).

The prevalence of preterm birth has been reported to be higher (12%) in developing
countries compared with the developed countries 9% (WHO, 2018). It is estimated that
1 million children die each year due to complications of pre-term birth and many babies
who survive face a life time disability including learning impairment, visual disorders and
affecting long term physical health with a higher risk of disease (Deressa et al., 2018).

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In Sub-Saharan Africa and South Asia is where most of these preterm births and deaths
occurs in the world as they account for more than 60 percent of the preterm births and
over 80 percent of deaths directly related to preterm births complications (WHO, 2017).
This can be attributed to the fact that almost half of these births do take place at home
under the supervision of unskilled midwife (National Bureau of Statistics,2016). Other
studies which were done in some West African Countries like Gabon, Togo and
Cameroon showed the variation in the rate of prematurity ranging from 11.1% to 57%
(Njunwa, 2016).

In Tanzania, 236,000 babies are born too soon each year and 10,800 children under
five die due to direct preterm complications (National Bureau of Statistics, 2016), the
complications of preterm birth contribute to about 23% of newborn deaths (MoHSW,
2015). A study done in Tanzania found that the prevalence of preterm birth rate is 11%
(National Bureau of Statistics, 2016), also, previous hospital-based study in North-
Eastern Tanzania reported prevalence of preterm birth of 14.3% which was higher
compared with that reported in developing countries (Theresia et al., 2016). Another
study done at Muhimbili National Hospital the prevalence reported prevalence of 17.9%
(Temu et al., 2016). Other study done at Dar es salaam in three municipal hospital
Amana, Mwananyamala and Temeke reported prevalence of preterm birth of 18.5%
(Pembe et al., 2015)

Factors or events that lead to preterm births are still not adequately understood since
preterm birth is a complex health problem and the causes or factors are thought to be
multiple (Barros et al., 2015). It is not clear whether preterm birth do come about
through the interaction of several pathways or the independent effect of each pathway
(Hidayat et al., 2016). Preterm birth has been linked to medical conditions of the mother
or fetus such as infections, diabetes, hypertensions, multiple gestations and even
genetics (WHO, 2017).

Previous studies have reported on the factors associated with the preterm birth,
retrospective study conducted in Irbid governorate of Jordan reported that fetal gender
is a contributing factor of preterm birth, although fetal gender contributes least to having
a preterm birth, more males are likely to be born preterm compared with female babies
(Abu et al., 2015). It is proposed that male fetal hormones are involved in labor onset
and shorten the duration of pregnancy (Khitam et al., 2015).

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Birth order is another contributing factor to the risk of preterm birth, previous studies
have also shown that a second born baby is at lower risk of being preterm compared
with first-born baby (Astolf et al., 2015). Also, in order to enhance clear understanding
of preterm birth and improved targeted interventions, Barros and his colleagues came
up with the study based on several maternal, fetal and placental factors associated with
preterm births (Barrous et al., 2015).

A study conducted at kenyata national hospital reported many factors contributing to the
preterm birth, these factors are antenatal factors obstetric factors and delivery factors,
where by in antenatal factors, mothers who had not attended any antenatal clinic were
more likely to deliver preterm (Alijahn et al., 2014). In obstetric factors the study shown
that mothers with pregnancy induced hypertension (PIH) and those with antepartum
hemorrhage (APH) had high risk of delivering preterm, and in delivery factors mothers
who delivered via Caesarean section were nearly two times more likely to deliver
preterm than those who delivered vaginally (Wagura et al., 2018).

Stress during pregnancy is the other factor that associate with preterm birth, the study
reported that mothers who has stress during pregnancy has higher risk of delivering
preterm birth than those with no stress during pregnancy (Zhang et al., 2012). Also, the
study reported that living in poor condition like those mothers living in rural areas are at
high risk of having preterm birth than those who live in urban areas (Theresia et al.,
2016). In addition, diabetes, preeclampsia, preterm premature rupture of membranes,
and maternal infections have also been associated with an increased risk of preterm
delivery (Alijahn et al., 2014).

A study by Akintayo and his colleagues in Nigeria revealed that multiple pregnancy was
associated with preterm births (Akintayo et al., 2015). This finding was supported by the
result of another study in Cameroon, which showed multiple gestation and presence of
fetal malformation to significantly influenced the occurrence of preterm births among the
study participants (Chiabi et al., 2013).

This study aims to assess the prevalence and factors associated with preterm birth in
Dodoma city. The result will be of great importance in predicting the occurrence of
preterm birth in order to reduce the incidence of preterm birth. This will help to improve
the neonatal outcome and facilitate the reduction of neonatal mortality which will go a
long way in reducing child mortality.

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1.3. Problem statement
Preterm birth is a global health problem, in middle and low-income countries including
Tanzania (Omondi, 2019). Globally 15 million babies are born too early every year and
approximately 1 million of them die each year due to complications of preterm birth
(WHO, 2018). In Tanzania 236,000 preterm births occur each year, the estimated
number of newborn deaths is 38,611 out of these 9,394 deaths were due to preterm
complications such as hypoglycemia, hypothermia and respiratory distress syndrome
(National Bureau of Statistics, 2016).

Preterm babies face high morbidity and mortality rates from infections and respiratory
distress as half of them dies due to lack of feasible, cost-effective care such as warmth,
breastfeeding support and basic care for infections and breathing difficulties compared
to high-income countries where almost all these babies survives (Muhe et al., 2019). On
the other hand, those who survived infancy have higher incidences of learning
difficulties, recurrent respiratory illnesses and psychomotor problems since their growth
and developmental milestones are adversely affected extending to later life which
results into physical, social, psychological and educational problems (Omondi, 2019).

Sustainable development goal number three target number two was established aiming
to reduce neonatal mortality to at least as low as 12 per 1000 live births and under five
mortality to at least low as 25 per 1000 live births until 2030, however, in Tanzania
neonatal mortality rate is 29 deaths per 1000 live birth and under five mortality rates is
67 deaths per 1000 live births (National Bureau of Statistics, 2016).

Very few studies in Tanzania have done on awareness, prevalence, and factors that
associated with preterm birth, this can contribute to the fact that no much awareness on
the factors that contributes to the preterm birth is available. In the absence of this
awareness, the occurrence of preterm birth together with its consequences will continue.
On the other hand, preterm birth has not been prioritized as a health problem in the
absence of standardized collection of data showing the burden or prevalence and
factors of preterm birth and its related mortality and morbidity in Tanzania regions and
nationally at large. Therefore, this study design will assess the prevalence and factors
associated with preterm birth.

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 1.4. Justification of the study
The findings from the study will help researchers to know the awareness of mothers on
the factors associated with prematurity, prevalence and risk factor of preterm birth and
publication of these information will serve as a base for other researcher on related
problems through a research gap. Also, the findings will provide the current database
on the prevalence and risk factors associated with preterm birth that will help the
government to formulate policies that will help and support health sectors on provision
of preventive measures on preterm birth. Also, the study findings will help health care to
improve maternal, newborn and child health services.

Not only will the research findings benefit the researcher, the health care provides but
also the community by creating awareness in the community about the problem and
contribute towards formulating locally appropriate interventions to prevent preterm birth
through making right choices and decisions about their health and their babies.

1.5. Objectives of the study

1.5.1 General objective
To assess prevalence and factors associated with preterm birth among post-
natal mothers in Dodoma city.

1.5.2 Specific objectives

i. To assess awareness of preterm birth among post-natal mothers in Dodoma city.

ii. To determine the prevalence of preterm birth among post-natal mothers in

Dodoma city.

iii. To assess factors associated with preterm birth among post-natal mothers in
Dodoma city.

1.6. Research questions

i. Are post-natal mothers in Dodoma city have awareness on factors associated with
preterm birth?

ii. What is the prevalence of preterm birth among post-natal mothers give preterm
birth in Dodoma city?

iii. Which factors associated with preterm birth among post-natal mothers in Dodoma
city.

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1.7. Purpose and significance of the study
The purpose and significant of the study is to increase awareness to the reproductive
women on the factors that contribute to the pre term birth, so that they can avoid those
factors contributing to the pre term birth.
Also, the study will be useful to inform and give alternative solutions to the government
and policy makers regarding the prevalence and factors contributing to the pre-term
birth among women of reproductive age

Furthermore, the study will be useful for other researchers as they will get knowledge
from the study concerning prevalence and factors associated with pre-term birth.

1.8. Chapter summary

In chapter one, generally analyses the background of the preterm birth, which includes
the prevalence and the factors that contributing to the preterm birth.
The chapter also analyses that preterm birth remains one of the most serious problems
in obstetrics care. Its etiology is complex and multifactorial, most of the factors can be
individual factors such as lifestyle, biological factors placental previa and abnormal
implantations, and physiological factor such as pre-eclampsia, other factors are
psychological factors such as stress, lack of support and maternal anxiety. Also, this
chapter explains about the aim of the study and significance of study.

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 CHAPTER TWO
LITERATURE OVERVIEW
2.1 Chapter overview
This chapter explore literature related to the study, it reviews various of books, articles
and different report to particular research area in which it describes in detail the
prevalence and factors associated with preterm birth and awareness of mothers on the
factors associated with preterm birth, with various of combined publishers that providing
guiding in appropriate validity and well progression of research proposal. The chapter
has the conceptual framework which describe the factors associated with preterm birth
as identified in difference previous studies or articles, this chapter also has the
theoretical definitions of key terms and the summary of the chapter.

2.2 Awareness of preterm birth among post-natal mothers

A study done by Harini 2020 was conducted for a sample size of 100 samples in India
to analyze the awareness about preterm births and its causes among females of
reproductive age group, all women of reproductive age of 15-49 years was included, the
study showed that an average of 65% of the females of the reproductive age group
were aware of preterm birth and its causes and the age group 20-30 years females of
the study sample were more aware about the causes of preterm birth than the 18-20
years aged group( Harini, 2020).

Other study done in Portugal, showed that more than 90% of the participant
acknowledge multiple pregnancy and 10% were not aware of multiple pregnancy as a
risk factor (Matos et al., 2020), another study done in Malawi showed that Malawi has
the highest rate of premature deliveries, with estimates ranging 7.9% to 29.7% due to
poor obstetric care, infections, chronic disease, lack of knowledge and awareness on
benefits of antenatal visits (Antony et al., 2018).

A cross sectional study done in California showed that 25.4% of postnatal mothers
presented to be unaware about low number of antennal visits and low education level
contributes to preterm delivery and others poor pregnancy outcome (Martin et al.,2011),
also another study done in Ethiopia showed that 81% of mothers knew that infections,
chronic disease, previously history of preterm delivery, antenatal attendance, poor
knowledge among mothers were significant predictor of adverse pregnancy outcome
(Tsegaye et al.,2017) .

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A cross-sectional study of 2470 women who presented in king Abdulaziz University,
which conducted in Saudi Arabia population to determine the awareness of the
pregnant women on the factors associated with the prematurity found that, many of the
women were not largely informed of the common associated risk factors, and the study
concluded that the better prenatal counseling can help create better awareness
(Bukhari, Alaama and Alkhalili, 2018). Another study conducted in Australia to find out
the important factors that could be addressed to increase the intake of omega-3 fatty
acids by pregnant women so as to reduce the number of prematurity, this study was
also revealed a key finding of the low level of awareness of preterm birth, its definition,
and its consequences, this this study suggests that preterm birth awareness needs to
be increased in Australia (Seymour et al., 2019).

Study done in Nigeria showed that only few mothers 37.8% were aware and 62.2% of
mothers were not aware and haven’t knowledge that being pregnant at age 35years
and above could results in giving birth to babies with developmental disabilities and
prematurity, the attitude of the mothers as revealed in this study showed that majority
56.6% do not see anything wrong in being pregnant on yearly basis (Eni-olorunda et al.,
2015).

A study conducted in turkey by Mehemet Yalaz and SirmenKizilcan with the aim of
assessing awareness of mothers on prematurity and its related problems, 150 mothers
were interviewed, although 87.9% of the study population knew what prematurity was,
69.2% of mothers lacked knowledge about complications of prematurity, quality and
adequacy of health care team involved in the care of prematurity babies by (Yalazand
Kizilcan, 2017).

Therefore, according to these articles, it seems that most of the mothers have low level
on the risk factors that is associated with the preterm birth, so this study will also find
out the awareness of mothers on factors associated with preterm birth at Dodoma city-
Tanzania Mainland.

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2.3 Prevalence of preterm birth among post-natal mothers.
Globally the previous study reported the prevalence of preterm birth to be
approximately14.9 million (11.1%) per year (Deressa et al., 2018), the lowest incidence
of preterm birth has been reported in Europe (6.2%) and Oceania mainly Australia and
New Zealand (6.4%) followed by Latin America and the Caribbean (8.1%) and Asia
(9.1%) and finally Africa of which the incidence has been shown to be as high as
(11.9%) (Beck et al., 2010). This indicate that, the prevalence of the preterm birth was
reported to be higher in developing countries mostly in African countries than that in
developed countries.

Previous study conducted in United State of America showed that the overall rate of
preterm birth rose from 9.63% in 2015 to 9.85% in 2016 and 9.93% in 2017, this shows
that the prevalence of preterm birth in USA increasing gradually year after year
(Kondracki et al., 2019). In Brazil a previous study done by Leal et al., 2016 showed
that the prevalence and risk factor related to preterm birth to be 11.5% which was
higher than that of USA but it is lower as compared to that of African developing country
which is 11.9%. The study conducted in India found that the prevalence to be 18.01%
(Shetty et al., 2017), this indicate that the prevalence of preterm birth in India is high
than that of USA and African countries.

More than 60% of the global estimate of preterm births occurred in Sub-Saharan Africa
(Deressa et al., 2018). An institutional based cross section that was conducted in Axum
and Adwa town public hospital 2017 in Northern Ethiopia the prevalence of preterm
birth was found to be 13.3% (Aregawi et al., 2019). Another study dones in Shire
General Hospital, Northwest Tigray, Ethiopia 2018 revealed that the prevalence of
preterm birth to be 16, the findings of this study was found to be in line with those
studies done in Nigeria 16.8%, and Malawi 16.3% (Kelkay et al., 2019). Another cross-
sectional study was conducted in Lusaka Zambia at the University Teaching
Hospital on the Spontaneous Preterm Birth which was included a sample size of
210 women, this study showed that among sample size of 210 women that was
collected,105 had preterm and 105 term deliveries, then the study showed the
result of preterm birth to be 7.7% (Mwansa, Ahmed and Vwalika, 2020).

In Kenya, report released by the ministry of health indicates that out of 1.5 million live
births annually, 188, 000 are born preterm which means that one out of every eight

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children born in the county is a preterm and this is a concern since preterm birth is the
major contributor of neonatal mortality in the country (Ooko, 2014). Other cross-
sectional study done in Kenyatta national hospital in Kenya revealed the prevalence of
preterm among live birth to be 18.3% (Wagura et al., 2018).

In Tanzania various studies was conducted concerning the prevalence of preterm birth,
according to Tanzania demographic and health survey there are about 236,000 preterm
birth per year and a study found that the prevalence of preterm birth rate is 11% also
about 11,500 children under five years die due to direct preterm complications(National
Bureau Statistics, 2016), A previous study was conducted in the hospital of northern
Tanzania at Kilimanjaro Christian Medical Center which was included a sample size of
371 women, the study identified the prevalence of the preterm birth was 14.2% (Temu
et al., 2016).

Also, at Dar es salaam the study was done in three municipal hospital Amana,
Mwananyamala and Temeke hospital the study involved 377 pairs of women with
preterm birth (cases) and term birth (controls) (Mahapula et al., 2016), this study
reported that other study conducted by mpembeni et al., 2015 was reported that the
pre-term birth account for 18.5% of all perinatal deaths.

2.4 Factors associated with preterm birth among post-natal mothers.

Various studies done worldwide suggest that there are some socio-demographic,
maternal and fetal factors that are associated with preterm birth and they are going to
be discussed here. Maternal age has been shown to be an important determinant of
adverse pregnancy outcome (Temu et al., 2016). A cohort study done in Utah looking at
an association of young maternal age with adverse maternal outcome involving 134,088
teenage mothers aged 13 to 24 years old, found that, those aged 13-17years old had
higher risk of preterm births, the reason for this association was thought to be the
biological immaturity of these teenage mothers (Njunwa, 2016).

Advanced maternal age of 35years or older has also been found to be associated with
higher incidences of preterm birth, early neonatal mortality, low birth weight and
neonatal intensive care unit (NICU) admissions when compared with women aged 20-
34 (Mehari et al., 2020). This is due to the fact that advanced aged women tend to be
associated with medical and obstetrical conditions such as hypertension, diabetes
mellitus, antepartum hemorrhage, placenta Previa and chromosomal abnormalities

10
which can lead to fetal congenital malformation (Carolan et al., 2013). Epidemiologic
study in Saud Arabia have also identified that the maternal age less than 17 years
underweight or overweight pre-pregnancy body weight, and short body stature are the
risk factors that can contribute to the prematurity (Bukhari, Alaama and Alkhalili, 2018).

Preterm PROM has been seen to be highly associated with spontaneous onset of labor
leading to preterm delivery (Bayingana et al., 2010), this leaves the fetus prone to
infections due to lack of barrier preventing the ascending microbes from getting into the
uterus, obi et al in their retrospective study on pre-term premature rupture of fetal
membranes found that large percent of women having PPROM ended in delivering
preterm babies (Obi et al., 2017).

Preterm PROM on the other hand has been seen to be associated with antepartum
vaginal bleeding in more than one trimester, current cigarette smoking and previous
preterm delivery (Offiah, Donoghue and Kenny, 2011), other study found that the
relative risk of preterm PROM to be 7.4, 2.1 and 2.5 among women with antepartum
vaginal bleeding in more than one trimester, current cigarette smoking and previous
preterm delivery respectively (Wagura, 2014).

Both subtypes of preterm births, spontaneous preterm birth, medically induced preterm
birth and recurrence subsequent Preterm birth are implicated to be the factors of
preterm birth, other reason such as inflammation of the placental membranes seems to
be a contributing factor to this condition (Bayingana et al., 2010).

Risk behaviors that mother have during pregnancy such as smoking, excessive alcohol
consumption substance abuse in general increase the risk of preterm birth (Vannuccini
at al., 2016). One population-based study done in USA found that prenatal alcohol use
elevated the risk of preterm birth (Manuela et al., 2013). Smoking indirectly increases
the risk of early preterm birth by increasing the likelihood of preterm premature rupture
of membranes and preterm labor (Kondracki et al., 2019)

Multiple fetuses are associated with preterm birth due to over distension of the uterus
particularly higher order multiple gestation, increased intrauterine volume and cervical
incompetence. Multiple gestations accounts for merely 2 to 3% of all births and 10% of
all preterm births (Field et al., 2016). According to a report from a finding in the United
State in 2013, 9.7% of singleton birth were preterm compared with 56.6% of twin births

11
and 93.3% of triplet births which could be attributed to increased use of medically
assisted reproductive technique in the treatment of infertility (National Center of Health
and Statics, 2015).

Inadequate number antenatal visits have been found to increase the number of preterm
births. In Cameroon one cross-sectional study done by Chiabi et al., 2013 found that
the risk of preterm births was higher among those women who had few antenatal care
visits. Similar findings were observed in another study done in Nigeria where they also
found that the likelihood of preterm birth was higher among women with few (less than
four) number of antenatal care visits as compared to those with adequate visits (Njunwa,
2016). Various studies demonstrated that maternal medical and obstetric disorders play
important role in ascending up preterm birth rates globally, the conditions like
antepartum hemorrhage, pregnancy induced hypertension, diabetes mellitus, thyroid
dysfunction have been shown to increase the odds of preterm birth (Morisaki et al.,
2016).

Furthermore, short interval between one pregnancy and the other increases the risk of
preterm birth, although no optimal inter-pregnancy interval has been established
(Hidaya et al.,2016). Most studies have found that the risk of preterm delivery is greater
when the interval is less than 12 months, this is likely due to the fact that the mother
has not yet replaced essential nutrients for maintaining the pregnancy such as iron and
folic acid depleted by the previous pregnancy (King, 2003)

Additional studies have shown that some infections like, urinary tract infection, bacterial
vaginosis, malaria, sexually transmitted infections like syphilis and HIV during
pregnancy are highly associated with preterm birth (Zack et al., 2014), exposure to
severe life events, has also been linked to very and extremely pre-term births (Offiah,
Donoghue and Kenny, 2011).

A prospective study done in Tanzania by Mahande et al found that 17% of women with
preterm birth had 2.7-fold risk of recurrent preterm birth in the subsequent pregnancies
as compared to those with previous term birth (Mahande et al.,2013). Other study done
in the hospital of northen Tanzania at Kilimanjaro Christian Medical Center, the study
identified Numerous factors were associated with preterm delivery including living
alone, no formal education , heavy physical works during pregnancy, being a
peasant, business women and history of still birth, history of miscarriage,

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preeclampsia placenta previa, abruption placenta, caesarean section delivery,
inadequate ANC visits, multiple pregnancy, low birth weight, and UTIs during
pregnancy (Temu et al., 2016).

2.5 Theoretical definitions of key terms

Preterm birth- is defined as all births before 37 completed weeks of gestation or fewer
than 259 days since the first day of a woman's last menstrual period (WHO, 2018)

Prevalence- is the proportion of a population who have specific characteristics in a

given time period or is a number of people in the sample with the characteristics of
interest divided by the total number of people in the sample (NIH, 2017).

Risk factors- is a something that increase a person’s chance of developing a disease

or a certain medical condition (NIH, 2017).
Dependent variable- is the variable that have being measured or tested in an
experiment, it is something that depend on other factors

Independent variable- is the variable that stand alone and it is not changed by the
other variable, and is assumed to have a direct effect on dependent variables.

Parity- is defined as a number of times that she has given birth to a foetus with a
gestational age of 24 weeks or more regardless of whether the child was born alive or
was still born

Awareness- is a state or condition or quality of being aware on the factors of preterm

birth or having knowledge consciousness.

Gestation age- is a measure of the age of pregnancy which is taken from the beginning
of the woman’s last normal menstrual period (LNMP), or the corresponding age of the
gestation as estimated by a more accurate method.

13
 CHAPTER THREE
RESEARCH METHODOLOGY
3.1 Chapter overview
This chapter includes description of the research design, description of the study area,
targeted population of the study area, sample size estimation, sampling and recruitment
procedures, study protocols or procedures, data collection methods, data tools and
instruments, methods for ensuring validity and reliability, data analysis methods, ethical
considerations, operational definitions, plan for dissemination of research results,
limitations and delimitations of the study, and chapter summary.

3.2 Research design

Cross-sectional research design will be used in determining the prevalence, awareness
of mothers on the risk factors associated with preterm birth and the risk factors
associated with preterm birth at Dodoma city hospitals using a quantitative approach,
where by a structured questionnaire will be used for data collection from the sample of
the study population. This design will be appropriate to this study, because it will involve
collection of information about the state of a problem in a particular point in time to give
a picture or
results of the existing health condition.

3.3 Description of the study area

The study will be conducted at Dodoma region in Dodoma city hospitals. The Region is
located at the centre of Tanzania which constitutes an area of 41,310 square kilometres
which is equivalent to 5% of the whole area of Tanzania, and it lies in the eastern-
central part of the country. The region is bordered by Manyara Region to the North,
Singida Region to the West, Iringa Region to the South, and Morogoro Region to the
South-East. The main tribe in Dodoma Region are Gogo, Rangi and Sandawe.
According to national census 2012, the Dodoma Region had a total population of
2,083,588 in which male population is 1,014,974 and female population is 1,068,614.
The total of under-five children population in Dodoma region is 213,608 of which
103404 are male and 110204 are female (DRCHR, 2015). The region is divided into
seven districts which are Bahi, Chamwino, Chemba, Dodoma urbun, Kondoa, Kongwa,
and Mpwapwa. The study will be conducted in the maternity department in each
selected hospital in Dodoma city.

14
3.4 Study population
The study population will comprise all post-natal mothers who attended at post-natal
wards during the study period.

3.4.1 Inclusion criteria

All post-natal mothers who will be willing and able to give an informed consent to
participate in this study.

3.4.2 Exclusion criteria

Post-natal mothers who will be too sick to give consent and critically ill to withstand the
interviewing process will be excluded from the study

3.5 Sample size estimation

The estimated sample size will be calculated using the Kish formula which was
formulated 1965 (Kish, 1965)

n=Z2P(1-P)
e2
Where by
n= Desired sample size
Z= standard deviation (1.96) which correspond to 95% confidence interval
P= prevalence of preterm birth in Tanzania = 11.1% (National Bureau of Statistics, 2016)
e= maximum error (5%)
From literature study, p=11.1%
Now, From,
n=Z2P(1-P)
e2
n= 1.962 x 0.111(1-0.111) 0.052
n=152.
From the above non-respondent rate will be 10% of the sample size,
Thus 152 + (152 x 10/100) =167
Therefore, the sample size used in the study will be 167.

15
3.6 Sampling method and recruitment procedures
The purposive sampling method will be used to select the purposefully hospitals at
Dodoma city where the study was conducted. The study will be conducted in three
purposive hospitals at Dodoma city. Purposive sampling method will be used because it
will enable us to capture eligible adequate sample size or study population who will
meet the inclusion criteria from the purposefully selected hospitals. According to
Mugenda (2003), purposive sampling technique allowed the researcher to access the
subject that had the information which will be relevant to the study objectives. Simple
random sampling method will be used to select mothers in post-natal ward who will be
willingly to participate in the study. Small piece of papers which will be assigned with a
number 1 and number 2 was prepared, these pieces of papers were put in a box, after
that, the simple random sampling technique will be employed so as to find the
appropriate sample size by a means of lottery method, where by a mother with the files
assigned “1” will be included in the study and those mothers whom their files will be
assigned “2” will not include the study. In order to ensure selection of the sample size
from each selected hospital in Dodoma city according to population size, proportional
sampling method was employed according to Wilkinson and Bhanderkar

formula:

ni= n/P x Pi whereby;

n = sample size
P = total population
ni = sample size of the strata
Pi = population strata
but, n=167,
P=17095

16
Table 3.1: Hospital proportional sample size
Population of
sample size of the Hospital sample
Hospital mothers give birth
strata (ni= n/P x Pi) size
in a year (p)
Dodoma Region
Referral 7300 167/17095×7300 71
Hospital
Benjamin Mkapa
5745 167/17095×5745 56
Hospital
St. Gemma Hospital 4050 167/17095×4050 40

3.7 Study protocols or procedures

Questionnaires will be used because a lot of information was collected within a short
period of time with minimal resources, the questionnaire employed both closed ended
questions and open-ended questions.

3.8 Data collection methods and tools

Structured questionnaire as a primary data collection method will employ in data
collection, questionnaires will be used because a lot of information’s will be collected
within a short period of time with minimal resources. A structured questionnaire
consisted of five parts. The first part of data collection will include socio-demographic
factors namely maternal age, educational level, residence, marital status, occupation,
hard physical work, smocking, living with a person who smokes and alcohol drinking.
The second part will contain a close ended question that will ask about the awareness
of mother on the risk factors that contributes to the preterm birth, this question may help
us to find out the percentage of the mothers who will be aware about the factors
contributing to the preterm birth regardless of what risk factors she knew. The third part
of data collection will include Medical factors such as recent hemoglobin (g/dl) level in
the current pregnancy, diabetes mellitus during current pregnancy, hypertension during
the current pregnancy, history of urinary tract Infection during current pregnancy, history
of epilepsy, HIV status during current pregnancy and malaria in current pregnancy. The
fourth part of data collection will include psychosocial factors such as fight or arguments
with husband/partner in current pregnancy and worries in current pregnancy. The fifth
part of data collection will include fetal factors such as sex of the newborn, congenital

17
abnormality of the current newborn, and current birth weight of the newborn. The sixth
part of data collection will include obstetrics factors such as parity, gestational age of
most recent pregnancy, type of pregnancy, previous preterm birth, mode of delivery,
gestational age at first antenatal attendance, history of abortion, previous still birth,
PPROM, attendance of antenatal care during current pregnancy, number of visits of
antenatal clinic, history of APH during pregnancy, premature rupture of membranes in
current pregnancy, interval between current pregnancy and the previous pregnancy,
and gestation age of current pregnancy. The questionnaire will be written in English
language which composed of both open-ended questions and closed ended questions.
After obtaining consent, the respondents will be interviewed by the investigators using
questions prepared from the questionnaire and the data collected will be filled by
researcher in the structured questionnaire and preserved in confidentiality. Privacy will
be employed throughout data collection process.

3.9 Methods for ensuring validity and reliability

Pretesting of the research instruments will be done at Makole Hospital to ensure clarity,
validity and reliability involving 16 respondents which is 10% of the total sample size.
This will be done to ensure proper adjustments and standardization of the research
instruments which will be performed before the actual data collection exercise. This will
be done one week before starting data collection.

3.9.1 Data validity

To ensure validity of the collected data, we will cross check the data collection tool with
our supervisor, research expert, obstetric specialists, and staff nurses work in post-natal
ward. A standardized questionnaire will be used as data collection instrument which will
be designed to meet the stated objectives of the study, some of the questions in the
questionnaire will be asked more than once so as to assure if there will be consistency
in their responses also.

3.9.2 Data reliability

The questionnaires were given to 16 post-natal mothers in postnatal ward at Makole
Hospital who will meet the inclusion criteria and those mothers who will not part of the
study participants. The same questionnaires will be re-administered again to the same
mothers 20 to assess for the stability and consistency of the questionnaires which will
be a test retest reliability measure. A pre-test of data collection tools will be done for the
purpose of avoiding information bias, checking whether questions will be clear and well
18
understood, estimating the time to be used to administer one questionnaire and to
ensure that data collection tools will be reliable.

3.10 Data analysis methods

The data collected will be analyzed, coded and entered in the statistical package for
social science SPSS. The SPSS package version 20 will be employed in this study.
Through this frequency, mean and proportion of variables will be computed and tested
for significant difference or association between independent variables and dependent
variables using Chi-square test where appropriate, and 95% confidence interval. P
value < 0.05 will be considered significant. And finally, the data will be presented by
using frequency tables, pie chart, and graphs, also descriptive statistics will be used to
determine percentages so as to present a summary of the data obtained.

3.11 Ethical considerations

Ethical clearance to conduct the study will be obtained from St. john’s University of
Tanzania research and publication committee. Each of the respondents will be
explained
to on the purpose of the study, benefits of the study and that there will be no any risk
during participation. Respondents will be informed their right to voluntary participation.
Informed consent will be signed from each respondent by the written signature or thumb
print on voluntary basis with an assurance of confidentiality. Mothers who will be below
the age of 18 years signed or used thumb print on the assent form before proceeding to
participate in the study. Participants’ names will not be included on the questionnaire for
confidentiality purposes with only letters being used for accountability and the data
collected will be shared with only authorized people. Also, the participants will be
allowed to ask questions for more clarifications.

3.12 Plan for dissemination of research results

The findings of this study will be first disseminated to our supervisor at St John
university
of Tanzania and to the SJUT research administration, thereafter the results will be
disseminated in all Hospitals at Dodoma city where the study will be conducted. Also,
people will get information about the research finding through books, journal article, and
copy of research report will remain at SJUT library for SJUT community.

19
3.13 Limitations of the study
The following will be the limitations of this study, misunderstanding with the
respondents due to the lack of knowledge about the study, language barrier, disagree
to participate in answering question and low level of education.

3.14 Chapter summary

This chapter in general discussed the whole process that will be done in collections of
data and preparing well elaborated data in manner that will be well understood,
disseminated and provided channel for writing a well composed research.

20
 APPENDIXES
APPENDIX A: PROPOSED WORK PLAN
TASK TO BE PERFORME DURATION IN MONTHS

MARCH APRIL MAY JUNE JULY AUGUST SEPTEMBER

Writing and submission of

the research proposal to
supervisor

Finalizing a proposal for

permission of data
collection.

Prepare data collection

tools and seeking
permission to conduct study
in the study areas

Data collection

Data analysis and

Possessing

Draft of final report and

submission

Final report submission,

discussion, and
recommendations

21
 APPENDIX B: RESEARCH BUDGET
Item Quantity Unit Cost Total Cost

Printing proposal 2 100 X 70 pages 7,000

Pens 10 200 x 10pieces 2,000

Meals during the day of data collection 5 10000 x 10days 100000

Transport to the study area 5 15,000 x 10days 150,000

Binding proposal 2 2 X 1000 2,000

Printing questionnaire 5 100 x 5pages 500

Photocopying questionnaires 850 100 x 850pages 85,000

Printing research report 1 100 x 60 copies 6,000

Photocopying research report 5 100 x 300pages 30,000

Binding research report 5 5 x 1,000 5,000

Contingence money 10% of the budget 23,750 40,550

TOTAL 446,050

22
 APPENDIX C: INFORMED CONSENT FORM
ST. JOHN’S UNIVERSITY OF TANZANIA

P.O. BOX 47 DODOMA-TANZANIA

Email: admin@sjut.ac.tz

Tel. +255-26-2390044

Fax. +255-26-2390025

Website address: www.sjut.ac.tz

ID NO

CONSENT TO PARTICIPATE IN A RESEARCH STUDY

RESEARCH TITLE: PREVALENCE AND FACTORS ASSOCIATED WITH PRETERM

BIRTH IN DODOMA CITY.

PRINCIPLE INVESTIGATORS

 HAULE AYUBU

 DOMINICK DORICAS

 NELIGWA NELIGWA

 JOSEPH ELIA M.

 LWAMO JAMILA M.

INTRODUCTION

We are fourth year students at ST JOHNS UNIVERSITY OF TANZANIA pursuing

Bachelor of Science in Nursing. We respectfully like to invite you to participate in this
study, for clear reasons for your inclusion in this study, please read the detailed
information in this form. If you agree to participate in this study, please sign this form at
the end. You can ask for more clarification about this consent form and the study

23
PURPOSE OF THE STUDY

You are being asked to take part in this study to help us know about the prevalence and
factors associated with preterm birth in Dodoma city hospitals. Also, this study will help
to increase awareness to the reproductive women on the factors that contribute to the
preterm birth, so that they can avoid those factors contributing to the preterm birth.

PROCEDURE:

In this study you will be requires you to answer some basic questions which aimed to
assess awareness, prevalence and factors associated with preterm birth. Also, if you
agree to participate in this study, you will be requested to tell the correct answers
among the questions which you will be asked. The questionnaires will be marked with
numbers for purpose of data analysis only. Your part in the study will last for about
fifteen (15) minutes while you are interviewed.

BENEFITS

This study will increase awareness to the reproductive women on the factors that
contribute to the preterm birth, so that they can avoid those factors contributing to the
preterm birth. Also, the study will be useful to inform and give alternative solutions to
the government and policy makers regarding the prevalence and factors contributing to
the preterm birth among women of reproductive age

Furthermore, the study will be useful for other researchers as they will get knowledge
from the study concerning prevalence and factors associated with preterm birth.

RISKS

We don’t expect that any harm will happen to you during and after your participation in
this study.

THE RIGHT TO PARTICIPATE/REFUSE PARTICIPATION

You are allowed to decide whether to participate or not to participate in the study after
reading and understanding the consent form. You are requested to participate
voluntarily. To withdraw from the study will not affect you and your baby to get services.

24
CONFIDENTIALITY

All information collected by the questionnaires will marked using special identification
code number without including your names and will be kept confidential. Nobody will be
able to associate the information from the questionnaire with your actual/ personal
information. The questionnaire and the report of the study will not include your names.
Your information will be protected and will remain confidential all the time.

COMPENSATION

Because of limited budget we will not be able to provide you any allowance or gift for
being in this study.

CONSENT

I have read and understand the above information about the study entitled,
PREVALENCE AND FACTORS ASSOCIATED WITH PRETERM BIRTH IN DODOMA
CITY. I have been given an opportunity to ask for any question about the study and I
am satisfied with clarification about this study. Therefore, I agree to participate as a
volunteer participant.

----/-----/------- ---- ------------------------------

Date Participant’s Signature

I certify that the purpose, benefits and possible risks associated with participation in this
study have been well explained to the participant above whose code number
is ………………

____/____/______ ______________________________

Date Researcher’s signature

Contact information.

If you have any question or concern about this study or if any problems arise, please
contact.

 HAULE AYUBU – 0762490336

 DOMINICK DORICAS – 0787590478

 NELIGWA NELIGWA – 0766397619

25
 JOSEPH ELIA M -0767762067

 LWAMO JAMILA M. -0629421068

26
 APPENDIX D: QUESTIONNAIRE (ENGLISH VERSION)
INSTRUCTIONS:
 Do not write your name to this questionnaire

 Your response will be confidential

 Please give honestly response as possible

Fill the gaps with the right response

1. Date of interview ………………
2. Questionnaire number ……………...

PART A: DEMOGRAPHIC INFORMATION

1. How old are you?....................

2. Marital status
A. Single [ ] B. Married [ ] C. Divorced/Widow [ ]

3. The education level of your husband/spouse

A. No formal education [ ] B. Primary education level [ ]
C. Secondary education level [ ]

4. Your occupation
A. Peasant [ g] B. Employed [ ] C. Businesswoman [ ]

5. By average, how much do you spend per day (in shillings)?

A. Less than 1dollar [ ] B. More than 1dollar [ ]

6. How many pregnancies have you had before this one?...................

PART B: AWARENESS OF PRETERM BIRTH

1. What do you know about preterm birth?

A. All births occur after 37 weeks of gestation

B. All births occur before 37 weeks of gestation [ ]

C. All births occur before 28 weeks of gestation

27
The following are the factors associated with preterm birth, respond ‘YES’ for
correct statement and ‘NO’ for incorrect statement
QUESTION YES NO
1 Stress during pregnancy

2 Multiple pregnancy
3 Infections (urinary tract infections, gonorrhea, syphilis)
4 An interval of less than six months between pregnancies
5 Advanced maternal age
6 Maternal age less than 17 years
7 Inadequate number of ant-natal visit (less than four ANC)
8 Smoking
9 Heavy exercise
10 Having a previous premature birth
12 Hypertension during pregnancy
13 Birth defect
14 Low social economic status
15 Anemia
16 Abortion
17 Low educational level

28
The following are the complications that face preterm baby, respond ‘YES’ for
correct statement and ‘NO’ for incorrect statement
QUESTION YES NO
1 New-born jaundice
2 Anaemia
3 Neonatal infections
4 Visual disorder
5 Learning impairments
6 Hypoglycemia
7 Hypothermia
8 Respiratory distress syndrome
10 Hearing problems
11 Mental retardation

PART C: PREVALENCE AND FACORS ASSOCIATED WITH PRETERM BIRTH

1. What is the gestational age of your baby at birth in weeks?.................

A. Less than 37 weeks

B. 37-42 weeks (If the answer is B or C go to question number 3 ).

C. Above 42 weeks

2. Did you suffer from preterm premature rupture of membrane during pregnancy?

A. Yes [ ] B. No [ ]

3. Did you perform any heavy physical work during pregnancy?

A. Yes [ ] B. No [ ]

4. Did you smoke during pregnancy?

A. Yes B. No [ ]

5. Alcohol use during pregnancy

A. Yes [ ] B. No [ ]

6. Hemoglobin (g/dl) level during pregnancy?...................

29
7. Did you suffer from gestational diabetes mellitus?

A. Yes [ ] B. No [ ]

8. Did you suffer from Hypertension (Pregnancy Induced Hypertension, Pre-eclampsia

and eclampsia) during pregnancy?

A. Yes [ ] B. No [ ]

9. Did you have history of Urinary Tract Infection during current pregnancy?
A. Yes [ ] B. No [ ]
10. Do you have a history of Epilepsy?
A. Yes [ ] B. No [ ]
11. HIV status
A. Negative [ ] B. Positive [ ]
12. Did you suffer from malaria in your current pregnancy period?
A. Yes [ ] B. No [ ]
13. Did you have any fight or arguing with your husband/partner in your current
pregnancy?

A. Yes [ ] B. No [ ]

14. Did you have any worries during your current pregnancy?

A. Yes [ ] B. No [ ]

15. What is the sex of the newborn?

A. Male [ ] B. Female [ ]
16. Does the newborn baby have any congenital abnormally?

A. Yes [ ] B. No [ ]

17. What is the current birth weight of your newborn?.............

18. Pregnancy outcome

A. Singleton [ ] B. Twins or more [ ]

19. Have you ever delivered a baby before term?

A. Yes [ ] B. No [ ]

30
20. Have you ever had an abortion/ miscarriage?
A. Yes [ ] B. No [ ]

21. Did you attend Antenatal care during current pregnancy?

A. Yes [ ] B. No [ ]

22. Did you have a history of antepartum hemorrhage during pregnancy?

A. Yes [ ] B. No [ ]

23. How many times did you attend Antenatal clinic?............

31
APPENDIX E: PERMISION LETTER FROM BENJAMIN MKAPA HOSPITAL

32
APPENDIX F: PERMISION LETTER FROM DODOMA REGIONAL REFERRAL
HOSPITAL

33
APPENDIX G: RESEARCH ETHICAL CLEARANCE CERTIFICATE

34
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