TITLE PAGE

KNOWLEDGE AND ATTITUDE TOWARDS RHESUS FACTOR

INCOMPATIBILITY AMONG WOMEN OF CHILDBEARING AGE

ATTENDING GENERAL HOSPITAL UWANI ENUGU

BY

ONU UGOCHINYERE JULIET

2018/243324

A RESEARCH PROJECT SUBMITTED TO THE

DEPARTMENT OF NURSING SCIENCES

FACULTY OF HEALTH SCIENCES AND TECHNOLOGY

COLLEGE OF MEDICINE

UNIVERSITY OF NIGERIA ENUGU CAMPUS

IN PARTIAL FULFILLMENT OF THE AWARD OF BACHELOR IN

NURSING SCIENCES (BNSc) CERTIFICATE.

SUPERVISOR: MRS. NGOZI OMOTOLA

APRIL, 2024

1
 DECLARATION

This is to declare that this research project titled “Knowledge and Attitude towards Rhesus

Factor Incompatibility among Women of Childbearing Age Attending General Hospital

Uwani Enugu” was carried out by Onu Ugochinyere Juliet and is solely the result of my

work except where acknowledged as being derived from other person(s) or resources.

Registration Number: 2018/243324

In the: Department of Nursing Sciences, University of Nigeria, Enugu Campus

Signature:___________________________

Date:_______________________________

2
 APPROVAL

This is to approve that this research project by Onu Ugochinyere Juliet with the Registration

Number: 2018/243324 has been examined and approved by the Department of Nursing

Sciences, Faculty of Health Sciences and Technology, College of Medicine, University of

Nigeria Enugu Campus in partial fulfillment of the award of bachelor in nursing sciences.

______________________________ __________________
ONU UGOCHINYERE JULIET DATE
(Student)

______________________________ __________________
MRS. NGOZI OMOTOLA DATE
RN, RM, BNSC, [Link].
(Project Supervisor)

3
 CERTIFICATION

This is to certify that this research project was carried out by Onu Ugochinyere Juliet with

Registration Number: 2018/243324 for the award of Bachelor in Nursing Sciences (BNSc)

Degree.

______________________________ __________________
MRS. NGOZI OMOTOLA DATE
(RN, RM, BNSC, [Link].)
(Project Supervisor)

______________________________ __________________
DR IHUDIEBUBE SPLENDOR, C.N DATE
(RN, RM, BSc, MSc, Ph.D, FWAPCNM)
(Head of Department)

______________________________ __________________
EXTERNAL EXAMINER DATE

4
 DEDICATION

This piece of work is dedicated to Almighty God who gave me the strength to carry out this

research.

5
 ACKNOWLEDGEMENTS

To God Almighty for His strength and Grace He bestowed on me throughout the period of this

research. I would like to express my heartfelt gratitude to my project supervisor Mrs. Ngozi

Omotola, for her invaluable guidance, support and expertise throughout the research and

development process. Her constructive feedback and continuous encouragement was

instrumental in shaping this project. To the Head of Department and members of the staff of

Department of Nursing Sciences, my appreciation has no bound to all of you for the great

knowledge.

I extend my thanks to my, caring and wonderful parents (Mr. and Mrs. Onu Harrison) and to my

lovely sisters, Ukwueze Jennifer and Onu Ogonna for their unwavering support and

encouragement during this journey. Their understanding and patience were vital in helping me

stay focused and motivated. I sincerely thank you all for your assistance and prayers. God bless

you all.

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 TABLE OF CONTENTS

Title Page i

Declaration Page ii

Approval iii

Certification iv

Dedication v

Acknowledgments vi

Table of Contents vii

List of Tables x

Abstract xi

CHAPTER ONE: INTRODUCTION

Background to the Study 1

Statement of Problem 4

Purpose of the Study 5

Objectives of Study 6

Research Questions 6

Hypotheses 6

Significance of the Study 7

Scope of the Study 8

Operational Definition of Terms 9

CHAPTER TWO: LITERATURE REVIEW

Conceptual Review 10

Theoretical Review 27

Empirical Review 29

Summary of Literature Review 33

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CHAPTER THREE: RESEARCH METHODOLOGY

Research Design 35

Area of Study 35

Population of Study 36

Sample Size 37

Sample Technique 38

Inclusion Criteria 39

Instrument for Data Collection 39

Validity of Instrument 40

Reliability of Instrument 40

Procedure for Data Collection 41

Method of Data Analysis 41

Ethical Consideration 42

CHAPTER FOUR: PRESENTATION OF RESULTS

Results 43

Summary of Major Findings 53

CHAPTER FIVE: DISCUSSION OF FINDINGS

Discussion of Findings 54

Implications to Nursing 58

Limitations of the Study 59

Summary 59

Conclusion 60

Recommendations 61

Suggestion for Further Studies 61

References 62

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APPENDIX I: Informed Consent 66

APPENDIX II: Questionnaire 67

APPENDIX III: Reliability Test 69

Appendix IV: Identification Letter

Appendix V: Ethical Clearance

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LIST OF TABLES

Table 1: Demographic Characteristics Woman. 44

Table 2: Knowledge of Rhesus Factor Incompatibility 46

Table 3: Knowledge of Rhesus factor Incompatibility Contd. 47

Table 4: Attitude towards Rhesus Factor Incompatibility 49

Table 5: Relationship between Knowledge and Attitude of Rhesus Incompatibility 51

Table 6: Relating the Knowledge of Rhesus Factor Incompatibility and the Women‟s
Demographic Characteristics 52

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 ABSTRACT
The study focused on assessing the knowledge and attitude towards Rhesus factor
incompatibility among women of childbearing age attending general Hospital Uwani Enugu.
The guiding objective of the study are to; ascertain the level of knowledge of Rhesus
factor incompatibility among women of child bearing age attending general Hospital Uwani
Enugu; determine the attitude towards Rhesus factor incompatibility among women of child
bearing age attending general Hospital Uwani Enugu; determine the association between
knowledge of Rhesus factor incompatibility and attitude towards Rhesus factor incompatibility
among women of child bearing age attending general Hospital Uwani, Enugu. The target
population of study included every consenting woman of childbearing age attending general
Hospital Uwani. The sample size of 212 was gotten through Taro Yamane finite population
size. The instrument used for data collection was researcher developed questionnaire and
analyzed using descriptive and inferential statistics with the aid of statistical package for social
sciences (SPSS) 25 and Microsoft excel where for scaled items assessed with mean and
standard deviation, mean (M) = 2.5 was used as the criterion for decision; item with mean
above 2.5 was considered to be accepted by the respondents; item with mean 2.5 and below
was considered rejected. Data analysis was done using frequencies, percentage, mean and
standard deviation and presented in tables according to the objectives of the study. The findings
of the study reveal that not many of the women had good knowledge of rhesus factor
incompatibility (45.2%). More so, almost all the women had preventive attitude towards
rhesus factor incompatibility (99.0%). Finally, the study reveals that there was no significant
relationship between knowledge and attitude towards rhesus factor incompatibility among the
women (p = .502); there was a preventive attitude irrespective of knowledge. The researcher
concludes that the knowledge of childbearing women on Rhesus factor incompatibility is poor
and these women generally have a preventive attitude towards rhesus incompatibility. The
study recommends that hospital management commit to health education and enlightenment
on the knowledge and prevention of Rh incompatibility in antenatal clinics

Keywords: Knowledge, Attitude, Rhesus factor, Incompatibility, childbearing women.

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 CHAPTER ONE

INTRODUCTION

Background to the Study

The antigen and hereditary protein known as Rhesus factor is located on the surface of red

blood cells. Red blood cells with the antigen are referred to as Rh positive (Rh+) while those

lacking the antigen are referred to as Rh negative (Rh), (Scott & Ricci, 2018). Historically,

following the description of the A, B, O blood types, a fourth, the Rhesus system was

discovered by Landsteiner and Weiner in 1940 (Farhud & Zarif, 2020). This followed

experiments which made use of Rhesus monkeys, hence the statuses of Rhesus Positive or

Rhesus negative depending on the presence or absence of the antigen respectively on the red

blood cells of a person (Avent et al., 2020). The most typical blood type is rhesus positive. An

Rh negative blood type is not a disease and typically has no impact on one's health. However,

it could be a significant problem for incompatible couples, particularly during pregnancy. For

instance, a pregnancy needs special attention if the mother is Rh negative and the baby is Rh

positive. This indicates Rh incompatibility (Scott & Ricci, 2018).

Rh incompatibility can occur by two main mechanisms. The most common type occurs when

an Rh-negative pregnant mother is exposed to Rh-positive fetal red blood cells secondary to

feto-maternal hemorrhage during the course of pregnancy from spontaneous or induced

abortion, trauma, invasive obstetric procedures or normal delivery (Salem, 2022). Rh

incompatibility can also occur when an Rh-negative individual receives an Rh-positive blood

transfusion.

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The amount of fetal blood necessary to produce rhesus incompatibility varies. In one study, less

than one milliliter of rhesus positive blood was shown to sensitize volunteers with rhesus

negative blood. Conversely, other studies have suggested that 30% of persons with rhesus

negative blood never develop rhesus incompatibility, even when challenged with large

volumes of rhesus positive blood. Once sensitized, it takes approximately one month for rhesus

antibodies in the maternal circulation to equilibrate in the fetal circulation. In 90% of cases,

sensitization occurs during delivery. Therefore, most firstborn infants with rhesus-positive

blood type are not affected because the short period from first exposure of rhesus-positive fetal

erythrocytes to the birth of the infant is insufficient to produce a significant maternal

immunoglobulin (IgG) antibody response (Salem, 2022).

During pregnancy of a Rh-negative mother carrying a Rh-positive baby, there is a potential

for the maternal body to produce antibodies that could be harmful during pregnancy. Much of

high infant mortality is related to problems from pregnancy and early infancy such as

maternal-fetal blood incompatibility (Kio et al., 2019). Firstborn infants are often not affected

unless the mother had past miscarriages or abortions. If the mother gets pregnant again with

an Rh-positive baby, the antibodies already in her blood could attack the baby‟s RBCs. This

can cause the baby to have anemia, jaundice, or more serious problems. If Rh antibodies

cross the placenta to the fetus, some of the red blood cells (RBCs) of the fetus may be

destroyed, leading to anemia. This damage is called fetal erythroblastosis fetalis or hemolytic

disease of the neonate (HDN) which occurs due to incompatibility between fetal and maternal

blood group (Khatun & Begum, 2019). A yellow pigment named bilirubin is produced when

RBCs are destroyed causing jaundice, and in severe cases the brain may be damaged

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(kernicterus) and severe anemia can result to fetal death (Flegel, 2019). The clinical picture of

HDN includes lethargy, pallor, jaundice, sclera icterus, tachycardia, tachypnea, and

hypotension. Hydrops fetalis, which is the most severe form of erythroblastosis fetalis could

also occur and it is associated with a significant mortality rate estimated to be more than 50%

(Hendrickson & Delaney, 2019)

The World Health Organization (2019) states that rhesus incompatibility has varying

prevalence and complications around the world, and that the low incidence of rhesus

negativity frequently results in the neglect of incompatibility. The distribution of Rh D

negative varies widely; In a study carried out in the United states of America, only 15% of the

population lack the Rh erythrocyte surface antigen and are considered Rh-negative. The vast

majority (85%) of individuals is considered Rh positive (Salem & Singer, 2022). Rh

sensitization occurs in approximately 1 per 1000 births to women who are Rh negative. The

Southwest United States has an incidence approximately 1.5 times the national average,

which likely is caused by immigration factors and limited access to medical care, since blood

typing is a routine part of prenatal care. Even so, only 17% of pregnant women with

Rh-negative blood who are exposed to Rh-positive fetal blood cells ever develop Rh

antibodies (Salem & Singer, 2022).

Approximately 15-20% of White patients, as opposed to 5-10% of Black patients, have the

Rh-negative blood type (Salem & Singer, 2022). Among individuals of Asian and American

Indian descent, the incidence of Rh-negative blood type is less than 5%.

Knowledge about blood groups and Rh Incompatibility and its complication during

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pregnancy and after child birth is very low despite the fact that it is cheap and easy to detect.

In developing countries like Nigeria, this knowledge is considerably lower as it is an under

discussed topic. A lot of people are ignorant about their blood groups and rhesus factor

therefore are also unaware of the dangers that rhesus incompatibility can pose to mothers and

their infants. According to the World Health Organization (2019) neonatal mortality is

responsible for about 46% of deaths of children under 5 years and a large amount out of it is

caused by problems like rhesus incompatibility. Despite the fact that Rhesus immunoglobulin

was introduced in 1968, hemolytic diseases of the new-born poses a serious concern and

ignorance about it is higher due to inadequate knowledge and educational programs.

Although Rh Incompatibility is inexpensive and simple to test, relatively little is known about

it and the complications it might cause during pregnancy and after childbirth especially

among rural dwellers in Nigeria. Hence this study aims to assess the knowledge and attitude

towards Rhesus factor incompatibility among women of childbearing age attending general

hospital Uwani, Enugu.

Statement of Problem

Some women, particularly pregnant primiparous women that have not been sensitized are

ignorant of what rhesus factor and incompatibility entails, this is evidenced by the result of

the study conducted by Ojo (2021) on assessment of pregnant women‟s knowledge and

attitude about Rhesus incompatibility prevention at Babcock university teaching hospital

Ilishan-remo, Ogun state which reported that the level of knowledge concerning

maternal-fetal blood incompatibility (during and after pregnancy) of expectant mothers was

15
low (less than 30%). This shows that they are also ignorant of the danger it poses and those

that are aware of the importance may not know how to go about the prevention of rhesus

incompatibility.

Lack of knowledge about rhesus incompatibility causes women who are affected by it to

believe they are cursed or bewitched, leading them to seek assistance from witchdoctors or

other supernatural beings. Some of these women visit churches to be prayed for, but when all

of these efforts fail, the majority of them fall into depression, or take their own lives. This is

solely a result of lack of knowledge which would otherwise have been prevented if the

subject of Rhesus incompatibility and it‟s prevention is well understood.

There is also sparse research work conducted in Enugu, Nigeria on the subject of Rhesus

incompatibility. In the light of the above, this study seeks to analyze the knowledge and

attitude towards rhesus factor incompatibility among women of child bearing age attending

care at General Hospital Uwani, Enugu.

Purpose of the Study

This study aims to investigate the Knowledge and attitude towards Rhesus factor

incompatibility among women of childbearing age attending general hospital Uwani, Enugu.

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Objectives of the Study

The specific objectives of the study are:

1. To ascertain the level of knowledge of Rhesus factor incompatibility among women of

child bearing age attending General Hospital Uwani, Enugu.

2. To determine the attitude towards Rhesus factor incompatibility prevention among

women of child bearing age attending General Hospital Uwani, Enugu.

3. To determine the association between knowledge of Rhesus factor incompatibility and

attitude towards Rhesus factor incompatibility prevention among women of child bearing

age attending General Hospital Uwani, Enugu.

Research Questions

1. What is the level of knowledge about Rhesus factor incompatibility among women of

child bearing age attending General Hospital Uwani, Enugu?

2. What is the attitude of women to Rhesus factor incompatibility prevention among women

of child bearing age attending General Hospital Uwani, Enugu?

3. What is the association between knowledge of Rhesus factor incompatibility and attitude

towards Rhesus factor incompatibility prevention among women of child bearing age

attending General Hospital Uwani, Enugu?

Hypothesis

There will be no significant relationship between the women‟s demographic characteristics

and their knowledge of Rhesus factor incompatibility.

17
Significance of Study

To women of childbearing age

Rhesus factor incompatibility contributes greatly to the outcome of pregnancy of women of

childbearing age. By gaining knowledge about this condition, women can make informed

decisions about their reproductive health, pregnancy planning, and prenatal care. This

awareness empowers them to advocate for appropriate healthcare services and preventive

measures, ultimately enhancing their chances of having healthy pregnancies and babies.

Additionally, understanding their attitudes towards Rhesus factor incompatibility allows for

tailored interventions to address any concerns or misconceptions they may have, fostering a

sense of control and confidence in managing their own health and that of their future

children.

To nursing profession

The findings of this study when disseminated will be beneficial, as it addresses a critical

aspect of maternal health. Understanding women's awareness and attitudes towards Rhesus

factor incompatibility can contribute to improving prenatal care and minimizing potential

risks during pregnancy (Costumbrado et al., 2022).

Secondly, it will guide healthcare interventions and educational programs to enhance

awareness among the target population, ultimately promoting healthier outcomes for both

mothers and infants.

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Lastly, the findings of this study will serve as a reference for further research by other nurse

researchers.

To the government

The findings of this study when disseminated will provide valuable insights into the gaps in

awareness and understanding of this condition among the population, which can inform

public health policies and initiatives aimed at improving maternal and child health outcomes.

By identifying areas of low knowledge and misconceptions, the government can develop

targeted educational campaigns to raise awareness and promote preventive measures, such as

Rhesus immunoglobulin administration during pregnancy. Additionally, understanding

women's attitudes towards Rhesus factor incompatibility can aid in the design of culturally

sensitive and effective healthcare interventions, contributing to overall improvements in

reproductive healthcare services and outcomes in Nigeria. Ultimately, addressing these issues

can reduce healthcare costs associated with managing complications related to Rhesus factor

incompatibility and improve the well-being of women and children across the country.

Scope of the Study

This study is delimited to assessing the knowledge and attitude towards Rhesus factor

incompatibility among women of childbearing age attending general hospital Uwani, Enugu.

It will also assess the association between knowledge and attitude towards Rhesus factor

incompatibility.

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Operational Definition of Terms

Rhesus factor: The Rhesus factor, or Rh factor, is a certain type of protein found on the

outside of red blood cells.

Rhesus incompatibility: When a mother and her unborn baby carry different rhesus protein

factors,

Knowledge on Rhesus factor Incompatibility: Participants' understanding of the causes,

consequences, and preventive measures related to Rhesus factor incompatibility. For this

study, the knowledge score was grouped as good (if score is above 50%) and poor (if score is

50% or below).

Attitude towards Rhesus incompatibility: Participants' responses indicating their

perceptions, beliefs, and emotional responses towards Rhesus factor incompatibility, gauged

using a four (4) likert scale. The mean response value of >2.5 was considered a positive

attitude.

Women of Childbearing Age: Females aged 18 to 45 years

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 CHAPTER TWO

LITERATURE REVIEW

This chapter presents reviewed literature from texts, journals, articles and reports under the

following subheadings: (a) conceptual review on – Rhesus factor, transfusion and rhesus factor,

rhesus incompatibility, prevalence of rhesus incompatibility in Nigeria, risk factors of rhesus

incompatibility, implications of rhesus incompatibility (b) theoretical review (c) empirical

review and (d) summary of reviewed literature.

Conceptual Review

Rhesus factor

The Rhesus factor (Rh factor) is a surface antigen of erythrocytes. The term “Rhesus” was

coined when discovered in Rhesus monkeys. The Rh blood group system is clinically the most

important of the protein antigens, and remains the commonest cause of hemolytic disease of

the newborn (HDN). The antigens are exclusively found on the red cells antigen. The

antibodies directed to the antigens are primarily Immunoglobulin G (Ig-G), and rarely fixed

complements; the antibody response may either be primary or secondary. The Rh antigens

consist of a family of inherited antigens of which Race and Fisher earlier proposed three pairs:

Dd, Cc, Ee. It is now known that the Rh blood group comprise of more than 50 individual

antigens of which five are routinely identified: D, C, c, E, and e (Avent & Reid, 2019). D

antigen is mainly responsible for Rh disease due to its high immunogenicity. A person can be

rhesus positive or negative based on the presence or absence of D antigen on the surface of red

21
blood cells respectively.

Transfusion and Rhesus factor

Blood groups classify into four types, depending on the presence of glycoproteins on the

surfaces of red blood cells (antigens) and the plasma contents of antibodies; this is what is

called ABO system (Omolbanin et al., 2019). In which, group A defines the presence of

antigen-A in red blood cells and antibody-B in the blood plasma, group B defines antigen-B in

red blood cells and antibody-A in the blood plasma, groups AB refers to the presence of

antigen-A and antigen-B in red blood cells, but no antibodies in blood plasma and the fourth

group O indicates no antigens in the red blood cells, but the blood plasma contains antibody-A

and antibody-B (Muhammed et al., 2019)

Blood can be transferred from one person to another, depending on their antibodies. For

example, groups A and B patients transfer blood to group AB because these do not have

antibodies in the plasma. Group A cannot transfer to group B due to the presence of antibodies

to antigen-B in the plasma, which will cause blood agglutination and hemolysis. Likewise, any

recipient group has an antibody to the antigen of the donor should avoid transfusion to avoid

antigen-antibody interaction that leads to blood clotting (Shanima et al., 2021). On the other

hand, group O is able to transfer to all other groups due to the presence of antibodies for both

antigens. For safe blood transferring, the type of the donor blood group should also be

compatible with that of the recipient.

The second important factor that must be taken into account during blood transfusion is the

Rhesus (Rh) factor, which is one of the most important systems in blood transfusion along with

22
(A-B-AB-O) system. Rh factor was first discovered in 1940 when researched on a type of

monkey called Rhesus monkeys. The same factor is present in humans as a protein molecule

found on the surfaces of red blood cells. Its presence on the surface makes it with positive Rh

family (Rh+) and represents about (85%) of the population in the world, but its absence makes

it with negative Rh family (Rh-) and it represents about (15%) of the world‟s population.

Therefore, safe blood transfusion requires compatibility between blood groups of the donor

and acceptor, as well as, their Rhesus factors, to avoid blood clotting, breakage and

sedimentation in the kidney, which causes death to the recipient (Sai Prasad et al., 2020).

As it is important for newly married couples to test blood group, the type of Rh is of high

importance to the fetus in certain cases. The following cases should be under consideration for

newly married couples:

If the pregnant mother has (Rh+) and the husband has either Rh+ or Rh- factor, there is no

negative effect on the fetus because the blood of Rh+ accepts the blood of the Rh- due to the

absence of antibodies. If the mother‟s blood is of Rh- and her husband is of Rh+ factor; If the

fetus‟s blood has Rh-, there is no negative effects but If the fetus‟s blood has Rh+, Possible

negative effects occur on the fetus once delivered. At birth, fetus‟s blood transfer to his mother

at a small extent (through cutting the umbilical cord), which force her immune system to form

antibodies as a normal response to the foreign protein (Rh+). Thus, a certain risk is expected for

the next pregnancy, where the fetus will be exposed to severe jaundice or even death due to

blood decomposition. To overcome such fetal danger, anti-D injection is required for the

mother within 72 hours after the first delivery. The anti-D injection will help the mother to get

23
rid of any blood that has leaked from the first fetus during childbirth so that her blood will not

produce antibodies, which could affect the next pregnancy (Sreelatha et al., 2019).

Fetus‟s blood form in the bone marrow and spleen during the second month of pregnancy, and

oxygen and food transfer from mother to fetus by the placenta with the property of osmosis.

This explains why the first child is unaffected by jaundice and blood clotting even though his

Rh+ is different from that of his mother (Rh-). During birth, when the umbilical cord is cut, a

small amount of the child‟s blood is transferred to the mother‟s blood through the umbilical

cord. This causes the mother‟s immune system to recognize the foreign body (Rh+) and start

forming antibodies against it. However, if the mother did not receive anti-D injection after the

first pregnancy, her blood will form antibodies against Rh+ and this will transfer through the

placenta to the second fetus and causes jaundice and blood clotting and may lead to the death of

the fetus in some cases.

The concept of Rhesus Incompatibility

Costumbrado et al. (2021) describes Rhesus (Rh) incompatibility as the discordant pairing of

maternal and fetal Rh types. It is associated with the development of maternal Rh sensitization

and hemolytic disease of the neonate (HDN). An individual can be classified as Rh-positive if

their erythrocytes express the Rh D antigen; individuals without the Rh D antigen are classified

as Rh-negative. This phenomenon becomes clinically significant if a mother that is

Rh-negative becomes sensitized to the D antigen and subsequently, produces anti-D antibodies

(i.e., alloimmunization) that can bind to and potentially lead to the destruction of Rh positive

erythrocytes. After this sensitization, these maternal alloantibodies (IgG immunoglobulin) may

24
persist for life and move freely across the placenta to the fetal circulation during subsequent

pregnancies, where they lead to the destruction of fetal erythrocytes after forming

antigen-antibody complexes with their surface D antigen. This results in alloimmune

hemolytic anemia in the fetus, known as erythroblastosis fetalis. The severity of illness

depends greatly on the number of immunoglobulin, the gestational age, and the enzymatic

activity of the fetus. (Nassar & Wehbe, 2023)

Prevalence of Rhesus factor Incompatibility in Nigeria

The prevalence of Rhesus factor (Rh factor) incompatibility varies among populations. In

general , the distribution of Rh-positive and Rh-negative individuals is approximately 85%

Rh-positive and 15% Rh-negative globally. The prevalence can also differ by ethnic and

geographical factors. For instance Rh-negative frequencies are often lower in some Asian and

African populations compared to the caucasians. Additionally, regional variations within

countries may exist. It is important to note that the prevalence of Rh incompatibility

specifically during pregnancy (when an Rh-negative mother carries a Rh-positive baby) is

influenced by the frequency of Rh-negative individuals and the occurrence of rhesus

sensitization (Smith & Jones, 2022)

Because of the possible effects on maternal and neonatal health, the prevalence of Rh

incompatibility in Nigeria has drawn attention. The prevalence of this condition in various part

of the nation has been made clear by a number of research. The frequency of Rh

incompatibility among pregnant women visiting a tertiary healthcare facility in Jos, Nigeria,

was the subject of a study undertaken by Egesie et al. (2019). The study found a 4.8% overall

25
prevalence in the studied population, which shows that Rh incompatibility is a major problem

in the area.

Similar to this, Adewuyi et al. (2019) investigated the prevalence of Rh incompatibility in

southwest Nigeria in a multi-center research. The study, which included more than 2,500

expectant mothers, discovered a prevalence rate of 3.6%, indicating Rh incompatibility as a

significant health issue in the area. Nkwo et al. (2020) observed a prevalence rate of 5.7%

among pregnant women attending prenatal clinics in another study they did in Enugu, Nigeria.

This result emphasizes the significant impact of Rh incompatibility in Nigeria, with variations

seen across several geographic regions.

Additionally, Okafor et al. (2018) conducted a retrospective study to examine the prevalence of

Rh incompatibility among pregnant women in a tertiary hospital in the Nigerian state of

Anambra. According to the study, the prevalence rate was 3.2%, highlighting the need for

effective treatments to deal with this problem. With rates ranging from 3.2% to 5.7%, these

studies combined show a considerable frequency of Rh incompatibility among pregnant

women in Nigeria. It is crucial to remember that these research concentrated on particular areas

or healthcare facilities, and that prevalence rates may range across the nation. In addition to the

aforementioned findings, a number of other academic works (Ekeh et al., 2020; Nwogu-Ikojo

et al., 2019) support Nigeria's high prevalence of Rh incompatibility. These studies help us

understand how widespread Rh incompatibility is in Nigeria and highlight how critical it is to

address it in order to enhance maternal and newborn health outcomes. The perceived benefits

of Rh compatibility appear not to have been properly emphasized or publicized, hence the high

26
prevalence of Rh incompatibility in the country.

Numerous research carried out across various locations have shown that the prevalence of Rh

incompatibility in Nigeria is a substantial concern. These studies' rates, which vary from 3.2%

to 5.7%, show the significant impact this disorder has on maternal and newborn health in the

nation.

knowledge on Rhesus factor incompatibility

Ogbonna (2020) is of the view that there is low knowledge about Rh incompatibility among

young girls because sex education is discouraged in Nigerian schools and homes. He argues

that this is responsible for the high rate of rhesus incompatibility among teenage girls who

give birth as single or unmarried mothers. Knowledge of Rh incommutability is influenced by

education and access to antenatal care. The twin factors of poverty and ignorance play

significant roles in the low knowledge among members of the public on Rh incompatibility.

People with good education may have the knowledge of Rh incompatibility and hence, this

affects their attitude towards the prevention.

Adeyemi & Bello-Ajao (2019) conducted a study on Prevalence of Rhesus D-negative blood

type and the challenges of Rhesus D immunoprophylaxis among obstetric population in

Ogbomoso, Southwestern Nigeria and found that of the 596 booked patients attending

Ladoke Akintola University of Technology Teaching Hospital Ogbomoso, 33, 5.5% were Rh

negative and almost 50% of the Rh negative women were primipara. They also found that

only nine, 39.1% of these Rh negative women had the Rh anti-D immunoglobulin following

delivery or abortion, the prevalence of Rh negativity remains low and the risk of hemolytic

27
disease of the new-born with its attendant perinatal morbidity and mortality is real in our

community.

Attitude towards rhesus incompatibility

Pregnant women‟s attitude to rhesus incompatibility, its management and prevention is

important. It includes their attitudes towards preventive measures such as Rh

immunoglobulin (RhIg) administration during pregnancy and after childbirth, understanding

whether women are receptive to these interventions, their willingness to undergo the

necessary procedures, and any barriers they may perceive to accessing preventive care.

Kio et al. (2019) conducted a study assessing expectant mother‟s knowledge and practice

regarding maternal-fetal blood incompatibility among pregnant women in Olabisi Onabanjo

University Teaching Hospital and found that although the respondents exhibited average

positive attitude towards incompatibility test (56%) and low negative attitude (38%), about

56% of the women felt the test procedure will be embarrassing. The result showed that

pregnant women in the study area did not really see maternal-fetal blood incompatibility as a

serious problem which is clearly as a result of the low level of knowledge concerning it.

Implications of Rhesus factor incompatibility

Severe early-onset fetal disease

From early in the second trimester maternal IgG antibodies to fetal red cell antigens can cross

the placenta and access the fetal circulation (Fox et al., 2019). Early-onset hemolytic disease

arising prior to 20 weeks‟ gestation carries greater risk of adverse consequences for the fetus

28
and neonate. This scenario is more commonly seen amongst patients who have had a

previously severely affected alloimmunised pregnancy (Yinon et al., 2020). The earlier onset

of disease is not only associated with more severe anaemia, higher risk of fetal hydrops and in

utero demise, but a greater degree of difficulty in management with the standard therapy of

intravenous IUT. Safe access to fetal or umbilical cord vasculature is rarely possible at such

early gestations (Zwiers et al., 2021). A number of strategies to delay progression to severe

fetal anaemia and prolong pregnancy to a gestation where intravascular IUT is possible have

been investigated, including maternal plasmapheresis and intravenous immunoglobulin (IVIg),

and serial fetal intraperitoneal transfusion.

Administration of IVIg to women during Rhesus alloimmunised pregnancies is thought to

competitively block the placental transfer of the maternal antibodies responsible for fetal

hemolysis, and potentially suppress the formation of new maternal IgG antibodies to fetal red

cell antigens (Castleman & Kilby, 2020). The role of plasmapheresis is to remove red blood

cell antibodies from the maternal circulation, thus decreasing the number of antibodies that can

cross the placenta and destroy fetal erythrocytes (Schwartz et al., 2019). Small retrospective

case series have suggested potentially beneficial effects of these therapies. Ruma et al. (2020)

reported a retrospective case series of 9 patients with either a previous early second trimester

pregnancy loss due to red cell alloimmunization (7 cases), or high levels of maternal antibodies

early in pregnancy (2 cases). Patients were treated with serial plasmapheresis followed by

weekly IVIg infusions. All fetuses subsequently underwent transfusion in utero, with a survival

rate of 100 %, and a mean gestational age of 34 weeks at the time of delivery.

29
A further intervention aimed at improving outcomes for fetuses affected by early-onset

severe disease is the use of early intra-peritoneal intrauterine transfusion (IPT). Historically,

the approach to fetal transfusion was via the intra-peritoneal route, however intravenous

Intrauterine transfusion (IUT) has replaced this as the preferred method of treatment for the

anaemic fetus since the 1980′s. Intravascular fetal transfusion has numerous advantages

compared with IPT, including improved survival rates (particularly in hydropic fetuses),

more advanced gestation at delivery, fewer neonates requiring exchange transfusions, and

the ability to perform concurrent fetal blood sampling. However, prior to 20 weeks‟ gestation,

the fetus is at higher risk of death after intravascular transfusion. Lindenburg et al. (2022)

reported a 24 % perinatal loss rate in a cohort undergoing IUT prior to 20 weeks‟ gestation,

compared with 8% in the group receiving IUT after 20 weeks‟ gestation. This was due to the

greater severity of disease inherent in its earlier onset, along with the technical challenges of

administering this therapy in a small fetus (Lindenburg et al., 2022). The use of early IPT in

fetuses at risk of severe disease prior to 20 weeks‟ gestation may maintain fetal hemoglobin

at sufficient levels to avoid hydrops or fetal demise, until a time when intravascular IUT can

be attempted.

Rhesus hemolytic disease and the newborn infant: postnatal course and long-term

outcomes

Hemolytic disease of the newborn (HDN), also known as Erythroblastosis fetalis, is a

hemolytic disorder that primarily affects Rhesus positive (Rh+) fetuses and newborns born

to Rhesus negative (Rh-) mothers. A French midwife first described the disorder in 1609;

30
however, it was not until the 1950s when the underlying cause was clarified (Jackson &

Baker, 2021). The pathogenesis of HDN begins with the attack of fetal red blood cells

(RBCs) by maternal antibodies due to incompatibility of maternal and fetal blood based on

the Rhesus and ABO antigen systems. Usually, when the first child inherits paternal D

antigen, whose inheritance has been shown to follow an autosomal dominant pattern, and

there occurs an event that leads to mixing of maternal and fetal blood, the mother starts

producing anti-D antibodies through a process referred to as alloimmunization, as she lacks

the D antigen (Gupta et al., 2020). Immunologically, antibody secretion initially starts with

IgM, which cannot cross the placental barrier, but is then followed by isotype switching,

which produces IgG antibodies. IgG antibodies can cross the placental barrier, and they do

so during the second and or subsequent pregnancies, attacking the fetal RBCs and causing

hemolysis and associated complications such as Hydrops fetalis and jaundice (Alaqeel,

2019). Although, the IgG antibodies can enter fetal circulation through feto-maternal

hemorrhage (FMH) as well. HDN has been estimated to affect 3 to 8 for every 100,000

patients yearly. Before developing anti-D prophylaxis, it was responsible for fetal loss in

1% of all pregnancies (Routray et al., 2021). The occurrence of HDN is directly

correlated with the inheritance pattern in females that results in the absence of the Rhesus

(D) antigen; however, the incidence of HDN is seen to vary with ethnicity (Doll, 2021). For

instance, it has been found that whites have the highest prevalence, and Asians and

American Indians have the lowest. Furthermore, among the Rh antigens in existence, the

most immunogenic one is the D antigen. It is approximated that about 10% of pregnant

white women are Rh incompatible.

31
Hemolytic disease of the fetus and newborn secondary to Rhesus incompatibility in pregnancy

is associated with high risk of neonatal morbidity and mortality. Fetuses with Rhesus hemolytic

disease are at risk of preterm birth and its associated short and long term sequelae, including

perinatal death. The major clinical challenges for the newborn infant with Rhesus hemolytic

disease include anaemia, both early and late in the postnatal period, and hyperbilirubinaemia

which, if severe, may manifest with clinical signs of bilirubin-induced neurological

dysfunction. A known predictor of postnatal course for the infant born with Rhesus hemolytic

disease is history of fetal Intrauterine transfusion. Intensive care management of the newborn

infant with Rhesus hemolytic disease may include phototherapy, transfusion of blood products,

and exchange transfusion. Additional blood transfusions may be required to manage late

anaemia observed in a proportion of infants, more likely in those who received blood

transfusion in the fetal period.

Postnatal anaemia

Early anaemia

The use of IUT in the management of Rhesus hemolytic disease reduces the risk of severe early

postnatal anaemia. Despite this, a proportion of infants will have symptomatic anaemia, and

will receive urgent blood transfusion in the early hours after birth, followed by exchange

transfusion. Infants with severe Rhesus hemolytic disease complicated by hydrops are at higher

risk of death, and their early management in the delivery room or in intensive care may include

drainage of fluid-filled cavities, most frequently pleural effusions and then ascites, and

intubation and mechanical ventilation, particularly if pleural effusions have impaired fetal lung

32
growth and development culminating in pulmonary hypoplasia (Smits-Wintjens, 2019). Infants

with severe anaemia and/or hyperbilirubinaemia in the early postnatal period may receive

exchange transfusion, which may be repeated as indicated by disease progression. For infants

with mild, asymptomatic anaemia, blood transfusion may be avoided, and consideration given

to treatment with erythropoietin. Judicious use of iron supplementation must be balanced with

the risk of iron-overload secondary to hemolysis and fetal and postnatal blood transfusion. At

birth, approximately 70 % of infants will have evidence of iron-overload, with the potential to

cause liver, cardiac, and endocrine organ injury (Ree et al., 2019).

Late anaemia

Late anaemia, defined as anaemia presenting after the first postnatal week, occurs in 83 % of

infants with HDFN delivered after 34 weeks of gestation (Ree et al., 2019). Late anaemia may

be due to hemolysis resulting from continued immune destruction of erythroid progenitors, or

suppression of erythropoiesis in the infant secondary to fetal or neonatal blood transfusion.

With regard to immune destruction of erythroid progenitors and risk of anaemia, maternal

antibodies can remain in the infant‟s circulation for up to 3 months after birth. In infants who

had received IUT, transfused donor erythrocytes are eventually replaced by the infant‟s own

erythrocytes which are susceptible to hemolysis in the presence of residual maternal antibodies.

Improvement in fetal oxygenation following receipt of donor erythrocytes has been associated

with decreased erythropoietin levels in infants. Late hypo-regenerative anaemia, characterized

by a low reticulocyte count, contributes to the need for „top-up‟ blood trans- fusions in infants

exposed to IUT (Ree et al., 2019). De Boer et al. (2021) reported a rate of blood transfusion

33
within the first 6 months of age of approximately 58% in term and late preterm infants with

HDFN. For infants who had received IUT, 77 % had „top-up‟ transfusions compared with

26.5 % of those who had not received IUT. The effectiveness of administration of

erythropoietin to infants in the early postnatal period to reduce the need for top-up transfusions

for late anaemia due to HDFN is yet to be established, and therefore its routine use is not

currently recommended (Ree et al., 2019).

Hyperbilirubinaemia and bilirubin-induced neurologic dysfunction (BIND)

The immune-mediated destruction of fetal and neonatal erythrocytes by maternal antibodies

results in the release of biliverdin from the heme molecules within the red cell cytoplasm,

which is then converted into bilirubin. Elevated serum bilirubin levels in the newborn infant

can manifest as jaundice, and due to the ability of unconjugated bilirubin to cross the

blood-brain barrier, may cause bilirubin-induced neurologic dysfunction (BIND) The initial

phase of neurologic injury, acute bilirubin encephalopathy (ABE), presents clinically as poor

feeding, lethargy, irritability, and abnormal tone, and later as seizures. Newborn infants are at

risk of acute bilirubin encephalopathy when serum bilirubin levels are severely elevated (>360

μmol/L), or when serum bilirubin levels rise at a rapid rate (>8.5 μmol/L/hr). Following the

acute injury, chronic bilirubin encephalopathy (also referred to as classic kernicterus) may

ensue. This permanent neurologic damage manifests as athetoid cerebral palsy, sensorineural

deafness, Parinaud‟s phenomenon (failure of upward gaze), seizures, and cognitive impairment

(Trevett et al., 2020). Without rapid treatment, hemolytic disease of the newborn can lead to

adverse short and long term neurologic injury, and death.

34
The initial treatment of hyperbilirubinaemia is phototherapy, and where this is unsuccessful or

insufficient, exchange transfusion is performed to reduce bilirubin levels and remove maternal

antibodies to neonatal erythrocyte antigens. Whilst phototherapy is a safe and effective

intervention for lowering neonatal bilirubin levels, exchange transfusion is associated with a

high risk of morbidity and mortality for the infant. The frequency with which exchange

transfusion is performed has declined markedly in recent years making it a relatively rare

procedure in the management of hyperbilirubinaemia. This is a result of diminishing rates of

Rhesus-D alloimmunization due to anti-D prophylaxis, as well as advances in fetal

management of the alloimmunised pregnancy. Accordingly, exchange transfusion is now more

likely to be used in the setting of more severely affected, preterm infants resulting from Rhesus

incompatible pregnancies, who are already at greater risk of morbidity and mortality. Reported

mortality rates associated with exchange transfusion range from 0.3 %–10 % in term and

preterm infants, respectively (Ree et al., 2019). Serious complications associated with

exchange transfusion include: metabolic disturbances (metabolic acidosis, hypocalcaemia,

hyperkalaemia, and hyperglycaemia); cardiac arrhythmias; need for respiratory support;

central line complications, such as vascular or visceral perforation, or thrombosis; sepsis;

thrombocytopenia; coagulopathy. Whilst the need for exchange transfusion has declined in

more recent years, infants affected by Rhesus hemolytic disease comprise the majority who

receive this therapy, accounting for approximately 70 % of neonatal exchange transfusions

being performed for Rhesus hemolytic disease of the newborn (Ziegler, 2019). The effect of

administration of intravenous immunoglobulin to the neonate in an attempt to reduce the need

for exchange transfusion was assessed in a 2018 systematic review. The authors concluded

35
there was insufficient evidence to support the use of IVIg in this setting. (Zwiers et al., 2021).

Of note, a further neonatal complication associated with Rhesus incompatibility in pregnancy

is the increased risk of neonatal cholestasis or conjugated hyperbilirubinaemia. This is thought

to be in part due to the iron overload associated with hemolysis and frequent transfusion. In a

review of 313 infants treated with and without IUT, neonatal cholestasis was found to occur in

13 % of neonates with hemolytic disease of the newborn due to red cell alloimmunization.

Investigations for other causes of cholestasis were negative, and six of the 41 affected infants

required treatment (medical and nutritional therapy), one of whom underwent iron chelation

therapy (Smits-Wintjens et al., 2020).

Risk factors of Rhesus factor incompatibility

Rhesus status of the parents

The primary risk factor is the Rhesus status of the parents. If the mother is rhesus negative and

the baby inherits rhesus positive blood from the father, there is a risk of rhesus incompatibility.

Previous Rh-Positive Pregnancy

Women who have had a previous pregnancy with a rhesus positive baby and were not treated

with rhesus immunoglobulin (RhIg) are at an increased risk of rhesus incompatibility. This is

because sensitization May occur during the first pregnancy leading to the production of Rh

antibodies.

Abdominal trauma or invasive procedures

36
Events that can cause mixing of the maternal and fetal blood such as abdominal trauma or

certain invasive medical procedures (amniocentesis, chorionic villus sampling) increased the

risk of rhesus sensitization.

Blood transfusions

Rhesus negative individuals receiving rhesus positive blood during a blood transfusion can

develop rhesus antibodies, increasing the risk of rhesus incompatibility during future

pregnancies.

Miscarriage or ectopic pregnancies

Any event that involves bleeding during pregnancy such as a miscarriage or ectopic pregnancy

can lead to rhesus sensitization.

Ineffective RhIg prophylaxis

Inadequate or absent administration of RhIg during a sensitizing event such as after delivery or

a miscarriage increases the risk of rhesus incompatibility.

Unknown rhesus status

Lack of knowledge about the mother‟s rhesus status or inadequate prenatal care may contribute

to the risk as timely administration of RhIg is crucial for preventing sensitization.

Ethnic and regional variations

Rhesus negative prevalence can vary among different ethnic groups and geographical regions

37
influencing the overall risk of rhesus incompatibility.

Genetic factors

Certain genetic factors may influence the likelihood of rhesus incompatibility although the

primary determinant is the rhesus status of the parents

Theoretical Review

The theory that underpinned this study is the Social Cognitive theory.

Social Cognitive Theory (SCT)

Social Cognitive Theory (SCT) started as the social Learning Theory (SLT) in the 1960s by

Albert Bandura. It developed into the SCT in 1968 and posits that learning occurs in a social

context with dynamic and reciprocal interaction of the person, environment, and behavior. The

unique feature of SCT is the emphasis on social influence and it‟s emphasis on external and

internal social reinforcement (Wayne, 2022). SCT considers the unique way in which

individuals acquire and maintain behavior, while also considering the social environment in

which individuals perform the behavior. The theory takes into account a person‟s past

experiences, which factor into whether behavioral action will occur. These past experiences

influences reinforcement, expectations, and expectancies, all of which shape whether a person

will engage in a specific behavior and the reasons why a person engages in that behavior

(Wayne, 2022).

According to the theory, behavioral decision-making is the result of the interaction of

38
individual and environmental factors. Individual factors reflect internal factors such as the

knowledge, experiences, attitudes and psychological states of an individual, while

environmental factors are external factors that shape interactions between an individual and the

environment. Self-efficacy and trust are two important concepts of social cognitive theory.

Specifically, self-efficacy reflects an individual‟s cognition of his or her own ability, rendering

it an important individual factor (Hohnston, 2010), and trust reflects one‟s trust in the

environment and thus is an environmental factor (Chen & Hung, 2010).

Social cognitive theory is widely used to understand and predict the behavioral characteristics

of individuals in terms of health behaviors and medical information system acceptance

behaviors. In the research of health behaviors, many researchers advocate the use of social

cognitive theory to identify the important antecedents of health behavior.

Overall, social cognitive theory highlights the role of social interactions, modeling and

cognitive processes in shaping human behavior and development.

Application of Social Cognitive Theory

Social Cognitive Theory emphasizes observational learning, where individuals learn by

observing others. Applying social cognitive theory to this study involves examining how

individuals' knowledge and attitudes towards Rhesus factor incompatibility are shaped by

social influences, observational learning, and self-efficacy. Factors such as family, peers, and

healthcare professionals can influence women's perceptions, while observing others'

experiences may impact their understanding. Additionally, fostering self-efficacy through

education and empowerment could enhance women's ability to make informed decisions

39
regarding Rhesus factor compatibility during pregnancy.

Empirical Review

In a study carried out by Ojo and Osuntusa (2021) on “Assessment of pregnant women‟s

knowledge and attitude about Rhesus factor incompatibility prevention at Babcock university

teaching hospital Illishan-remo, Ogun state. The research design adopted in the study was a

non-experimental descriptive survey. The sample size of 140 was derived using Taro Yamane‟s

formula. Convenience sampling technique was adopted to select the study subjects. Data

collection was done by the use of structured questionnaire designed by the researcher. The data

collected was subjected to descriptive and inferential statistics. The findings of the result

revealed that pregnant women have a fair knowledge of rhesus factor and incompatibility but

are not aware of the importance of taking the test and the complications it posed to the health of

their babies. It was recommended among others that there is need for consistent education on

the knowledge and prevention of rhesus incompatibility among pregnant women.

In a study carried out by Temesgen et al. (2022) on the knowledge about Rh incompatibility

and its associated factors among antenatal care recipients in public hospitals of Wolaita zone, a

cross sectional study was employed in four selected hospitals. The systematic random

sampling method was used as a technique of selecting the study participants. The study was

performed using a structured questionnaire. The data were coded and entered into EPI DATA

V.4.6, and then the analysis was done using SPSS V.23 software program. The sample size

was 414 women. The result showed that the women had poor knowledge of Rhesus factor

incompatibility with only 35.3% of women having a good knowledge of Rh- incompatibility.

40
Knowledge on Rh incompatibility was higher among women who attended tertiary education

and among multigravida as compared to primigravida. Among the respondents, only 48%

knew their blood group. Regarding women’s attitudes toward Rh blood group screening,

82.9% of participants had a positive attitude toward Rh blood group screening, whereas 17%

had a negative attitude

In another study carried out by Minwulyelet (2021) on the Assessment of knowledge, attitude,

practice and associated factors towards rhesus incompatibility among mothers attending

antenatal care at saint Paul‟s hospital millennium medical college, Addis Ababa Ethiopia. It

was a cross- sectional analytical or comparative study conducted among 299 selected pregnant

women who were attending antenatal care at SPHMMC. Eligible participants were selected by

systematic random sampling technique. The study result showed that only 39.1% of mothers

had good level of knowledge towards Rh incompatibility. More than two third of mothers

(66.7%) did not know their husband‟s blood group and Rh. Only 5.7% of mothers knew that

rhesus incompatibility is because of Rh-negative mother carrying a Rh-positive fetus, only

38.5% of mothers knew what measures to be taken to prevent Rh incompatibility. More than

96% of mothers had positive attitude and 87.6% of mothers had good level of practice towards

Rh incompatibility. Only 13% of mothers did check their blood group and rhesus before

pregnancy. If they had frequent stillbirths or miscarriage because of Rh incompatibility, 78.6%

of mothers stated that they will go to the hospital for help and the remaining 21.4% of mothers

responded that they will not go to the hospital (church or mosque 9.7%, herbalist 9.0%, and

2.7% of mothers believed that it is from God)

41
In a study carried out by Ofubebe (2019) on Awareness of Rhesus incompatibility and its

Preventive Measures among Intending Couples Attending Marriage Counseling Class at

Orthodox Churches in Nsukka Metropolis of Enugu State. The population of the study was 57

intending couples attending marriage counseling class at three purposively selected orthodox

churches. A valid and reliable questionnaire was used for data collection. Percentages were

used to answer the research questions and chi-square statistic was used to test the null

hypothesis at 0.05 level of significant. Results of the study, among others indicated that high

(65.1%) proportion of intending couples are aware of rhesus incompatibility and average

(55.2%) proportion are aware of preventive measures of rhesus incompatibility. Male and

female intending couples showed no difference in their level of awareness of rhesus

incompatibility (p=0.534>=0.05). Based on the findings of the study, it was recommended;

among others that marriage counseling committee in various churches should include rhesus

incompatibility counseling as an integral part of the marriage counseling class. They should

also encourage couples who are rhesus negative to adopt preventive measures and seek

specialized health care.

In a similar study carried out by Kwamboka (2019) on the knowledge, attitude and practice of

rhesus incompatibility among women attending antenatal care in Kampala international

university teaching hospital. It was a cross sectional descriptive study, data was collected with

the use of close ended questions questionnaire. The results showed that only 17.5% knew what

rhesus incompatibility is the majority 82.5% had no idea. 12.5% knew how it occurs, 7.5%

weren‟t sure, and 80% did not know, only 15% had knowledge of Anti D used to prevent

rhesus incompatibility, the majority 85% had never heard of it. 7.5% attributed the

42
complications (stillbirths/miscarriages) due to rhesus incompatibility to witchcraft and curses.

The price of Anti D was thought to be so expensive by 20%of women the majority 80% said

it was worth it. Only 25% acknowledged supernatural powers as a solution to rhesus

incompatibility, the majority 75% would visit a hospital for a solution to this.

In a cross sectional study carried out by Nisreen et al. (2020) on “Assessment of awareness of

Saudi Arabia females about complications of rhesus factor (Rh) incompatibility during

pregnancy in Taif city, Saudi Arabia”. [Link] cross sectional research design was

employed. Data were collected from 224 Rh negative participants, whether pregnant or not,

with age ranging from 18-55 years and excluding non-Saudi females and those females with an

age of more than 55 and less than 18 years. The results shows that 39.7% of studied females

knew RH incompatibility, 64.7% reported that RH incompatibility leads to abortion or early

labor, 84.8% said that negative blood group needs close follow up during pregnancy, 55.4%

reported that negative Rh affect baby condition after delivery, and 72.8% mentioned that Rh

incompatibility needs more care during pregnancy. The highest percentage of questions

answered yes was for the question about the negative impact of the negative blood grouping

during pregnancy ( > 80% ), the highest percentage of questions not known by the studied were

about knowledge about the death of the first baby if the mother is untreated Rh-negative and

about the injection around delivery. About 64.7% of them knew the RH incompatibility leads

to abortion or early labor. 10.7% said there are injections given to the mother of Rh–ve blood

group, 7% of them mentioned it‟s given after delivery the baby.

43
Summary of Literature Review

The Rhesus factor is a surface antigen found on the surface of red blood cells. A person can be

rhesus positive or negative depending on the presence or absence of D antigen on the surface of

red blood cells respectively. Rhesus incompatibility occurs when a mother that is rhesus

negative becomes sensitized to the D antigen and subsequently, produces anti-D antibodies (i.e

alloimmunization) that can bind to and potentially lead to the destruction of Rh positive

erythrocytes. The implications of rhesus incompatibility includes; severe early onset fetal

disease, rhesus hemolytic diseases, abortion, miscarriage. The risk factors of Rhesus factor

incompatibility are; Rhesus factor of the parents, previous rhesus positive pregnancy,

abdominal trauma or invasive procedures which can cause mixing of maternal and fetal blood,

blood transfusions, ectopic pregnancies or miscarriages.

The social cognitive theory underpinned this study and it posits that learning occurs in a social

context with dynamic and reciprocal interaction of the person, environment and behavior. It

emphasizes observational learning, self efficacy and behavior modeling. Women may acquire

knowledge about Rhesus factor incompatibility through observing and imitating others such as

family members, friends or healthcare providers who discuss or demonstrate the importance of

Rhesus factor incompatibility testing and it‟s complications.

Empirical studies were reviewed in relation to the knowledge and attitude of women towards

Rhesus factor incompatibility. Majority of the studies were carried out abroad and few of them

here in Nigeria. The results of some of the previous studies carried out show fair knowledge

while others show poor knowledge of Rhesus factor incompatibility. There is limited research

44
work on this topic carried out in Enugu and in other states in Nigeria. This study‟s findings will

contribute to understanding the importance of raising awareness on Rhesus factor

incompatibility among women of childbearing age.

45
 CHAPTER THREE

RESEARCH METHODOLOGY

This chapter entails the research design, area of study, population of study, sample size and

sampling technique, instrument for data collection, validity of instrument, reliability of

instrument, ethical consideration, and procedure for data collection and method of data

analysis.

Research Design

This was a non-experimental descriptive study involving knowledge and attitude towards

Rhesus factor incompatibility among women of child bearing age attending care at General

Hospital Uwani, Enugu. This design was used in a similar study carried out by Ojo and

Osuntusa in 2021 on "Assessment of pregnant women‟s knowledge and attitude about rhesus

incompatibility prevention at Babcock university teaching hospital Ilishan-remo, Ogun state".

Therefore, this design is considered appropriate for this study which sought to determine the

knowledge and attitude towards Rhesus factor incompatibility among women of childbearing

age attending general hospital Uwani, Enugu

Area of Study

Enugu state is one of the 36 states of the Federal Republic of Nigeria located in the South

Eastern part of the country. This study will be conducted in General Hospital Uwani, Enugu.

The General Hospital, Uwani was established in February 1st 2005 and it is located at

number 9, Amigbo lane, Uwani east in Enugu south local government area. It is registered as

46
a primary health care center by the Nigeria ministry of health with facility code of

14/05/1/1/1/0104. The services rendered at Uwani General Hospital includes; antenatal care,

labor management, obstetrics and gynecology, General outpatient services (GOPD), general

surgery, family planning, laboratory and blood banking services, immunization/vaccination

services, radiology, optometry/optical services and newborn care. The hospital operates on all

days of the week. This setting was used for this study because it provides assess to a diverse

and representative population. General hospital Uwani serves the community making it easier

to gather relevant insights on the level of knowledge, attitude and potential gaps in

understanding the Rhesus factor incompatibility.

Population of Study

The target population for this study was 450 which included every consenting adult female

client attending care at General Hospital uwani, Enugu. However, only those that were

physically and mentally fit to respond to our questionnaire was included in the study. The

antenatal ward, immunization ward, labor ward, postnatal ward, family planning and GOPD

was identified as the wards where women of childbearing age are seen. The estimated number

of clients in the listed wards was 450.

47
The number of clients in each ward

Hospital wards Number of client

Antenatal ward 180

Immunization ward 160

Labor ward 20

Postnatal ward 14

Family planning unit 35

GOPD 41

Sample Size

The sample size was determined using Yamane Taro formula as stated below

Where n = Sample size

N = Population size

e = Sampling error (5%)

1 = Constant

Working is as follows:

48
n= 212

Sample Technique

To avoid bias the researcher used proportionate sampling technique in order to improve the

precision of the sample by reducing sampling errors. Therefore, the proportionate sampling

method was employed to determine the sample size of each subgroup of the population in

relation to their population size. After which convenient sampling method was used to select

the study subjects. It is a non probability sampling method in which the researcher uses all

those that are available at the time of data collection.

49
Calculation for respondents in each ward

Hospital ward Target Population Sampling (ns= NS Sample size

(n) x n/N)

Antenatal ward 180 85 212

Immunization ward 160 75 212

Labor ward 20 9 212

Postnatal ward 14 7 212

Family planning unit 35 17 212

GOPD 41 19 212

Inclusion Criteria

Although all women of child bearing age, including nulliparous, primiparous and multiparous

women have been identified as the population of the study, the researcher considered the

following criteria to guide inclusion in the study. The client must:

Be willing to participate

Be 18 to 45 years of age;

Be attending Uwani general hospital;

The exclusion criteria were women that were not willing to participate.

Instrument for Data Collection

A self-structured questionnaire was the instrument for data collection. It was designed by the

researcher based on the objectives of the study and the literature review. The questionnaire

contained multiple choice questions and closed ended questions and it was divided into three

50
sections. Section A was used to elicit the social demographic data of the respondents and it

consists of seven (7) items. Section B was used to assess the level of knowledge on Rhesus

factor incompatibility with twelve (12) questions. Section C was used to assess the attitude of

women of childbearing age towards Rhesus factor incompatibility prevention and it consists

of ten (10) items.

Validity of Instrument

To establish validity of the instrument based on adequate coverage of objectives of the study,

the researcher-structured questionnaire was presented to the project supervisor for necessary

corrections, face validity and approval. The corrections, modifications and inputs made by the

project supervisor was effected before the final copy was approved.

Reliability of Instrument

To ensure reliability of the instruments for data collection, before distribution of the instrument,

a test-retest pilot study was conducted using 10% (21.2) of the total questionnaire to be

administered. The questionnaire was administered to 21 women at Poly general hospital,

Enugu. Poly general hospital is located along Udi road, Asata Enugu and has similar social and

demographic characteristics with general hospital Uwani. The administration of the

questionnaire was repeated after the interval of two weeks. The data collected was analyzed

using Cohen‟s Kappa (for intra-rather reliability). The average value of .988 was obtained and

this shows that the instrument was reliable.

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Procedure for Data Collection

The researcher administered copies of questionnaires with the help of two research assistants

who are nursing students. They were trained on the purpose of the study, selection process

and administration of questionnaire. Distribution of the copies of questionnaire took place

during morning hours within Tuesday, 13th of February and 27th of February 2024 at General

Hospital Uwani. Two hundred and twelve (212) copies of questionnaire was administered.

Method of Data Analysis

Data was analyzed using both descriptive and inferential statistics. The descriptive statistics –

frequency, percentage, mean and standard deviation were used to summarize the items of the

questionnaire. For scaled items assessed with mean and standard deviation, mean (M) = 2.5

was used as the criterion for decision; item with mean above 2.5 was considered to be

accepted by the respondents; item with mean 2.5 and below was considered rejected.

An overall knowledge score was obtained for each respondent by scoring and summing each

correct response of the knowledge. The knowledge score was grouped as good (if score above

50%) and poor (if score 50% or below). An overall mean score for attitude was obtained for

each respondent by taking the mean response scores (after reversing the negatively framed

items). The mean score was grouped as positive (if mean is above 2.5) and negative (if mean

is 2.5 and below).

The inferential statistics – Fishers Exact test was used to analyze research question 3 at 5%

level of significance; the Fishers exact test was used as data failed to meet Chi-Square test

assumption. Significant relationship hence existed if p-value is less than .05; otherwise, no

52
significance. These analyses were done with the aid of the Statistical Package for Social

Sciences (SPSS) version 25 and Microsoft Excel.

Ethical Consideration

An introductory letter was obtained from the researchers‟ Head of Department. Ethical

clearance was obtained from the federal ministry of health. The recruitment of the respondents

was based on their permission. Informed consent was obtained after explaining to the

participants that the data collected will be used for research purposes, kept confidential and that

participation was voluntary. To maintain confidentiality of the participants during and after the

collection of data, data was kept in a secured place where public access to it was restricted. No

identifier such as names or address of respondents was written on the questionnaire in order to

ensure anonymity.

53
 CHAPTER FOUR

PRESENTATION OF RESULTS

This chapter presented the result of the findings. 212 copies of the questionnaire were

administered. However, 211 copies were correctly filled and retrieved. Hence 99% response

rate was used for the analysis. The results were presented in tables and charts using

percentages, frequencies and inferential statistics with the aid of Statistical Package for Social

Sciences (SPSS) version 25 and Microsoft Excel.

54
Table 1: Demographic Characteristics Woman. n = 211
Frequency Percent M±SD
Age 27.89±5.69
- < 20 17 8.1
- 20-29 114 54.3
- 30-39 76 36.2
- 40-45 3 1.4
Marital status
- Single 31 14.8
- Married 170 81.0
- Divorced/separated 3 1.4
- Widowed 2 1.0
- No response 4 1.9
Number of children
- None yet 40 19.0
- One 51 24.3
- Two 79 37.6
- Three and above 40 19.0
Educational attainment
- No school 1 0.5
- Primary school 8 3.8
- Secondary school 73 34.8
- Tertiary 123 58.6
- No response 5 2.4
Employment status
- Employed 62 29.5
- Unemployed 19 9.0
- Self-employed 71 33.8
- Student 54 25.7
- No response 4 1.9
Ward
- Antenatal ward 84 40.0
- Labour 10 4.8
- Postnatal 7 3.3
- Immunization ward 73 34.8
- OPD 19 9.0
- FP 17 8.1
Do you know your blood group
- Yes 176 83.8
- No 29 13.8
- No response 5 2.4

55
Table 1 present the demographic characteristics of the women. Their age mean and standard

deviation was 27.89±5.69 and modal age group, 20-29 years (54.3%). Most of them were

married (81.0%). Majority had tertiary education (58.6%). As regarding occupation, the

self-employed were more in number (33.8%) while for no. of children, those with 2 children

were more (37.6%). The women were recruited from these wards: antenatal (40.0%), labour

(4.8%), postnatal (3.3%), immunization (34.8%), OPD (9.0%) and FP (8.1%). Most of them

revealed they knew their blood group (83.8%).

56
Research Question 1: What is the level of knowledge about rhesus factor incompatibility
among women of child bearing age attending General hospital Uwani, Enugu?

Table 2: Knowledge of Rhesus Factor Incompatibility n = 211

Frequency Percent
What is the Rh factor in blood?
- A protein found in red blood cells* 127 60.5
- A type of white blood cell 13 6.2
- A hormone regulating blood pressure 55 26.2
- An enzyme involved in blood clotting 8 3.8
- Don't know 6 2.9
Rh factor incompatibility is associated with?
- Environment problems 28 13.3
- Blood group incompatibility* 122 58.1
- Certain diseases 50 23.8
- Body weight 3 1.4
- Don't know 5 2.4
Rh incompatibility due to?
- A RH negative woman carrying a RH positive baby* 83 39.5
- A Rhesus positive woman carrying a Rh positive baby 12 5.7
- A Rhesus negative woman carrying a Rh negative baby 58 27.6
- A Rhesus positive woman carrying a Rh negative a Rh 41 19.5
negative baby
- Don't know 15 7.1
Why is Rhesus factor incompatibility a concern during
pregnancy
- It causes morning sickness 13 6.2
- It may lead to complication for the baby* 149 70.6
- It determines the baby's gender 34 16.1
- It causes cravings for certain foods 4 1.9
- Don't know 11 5.2
Why is knowledge on Rh status important
- To determine the baby's gender 27 12.8
- To choose baby's age 6 2.8
- To identify potential risks of incompatibility* 142 67.3
- To plan for a C-section 27 12.8
- Don't know 8 3.8
Rh incompatibility can also occur through 7*
- Receiving mismatched blood* 121 57.4
- Taking wrong medication 27 12.8
- Lack of balanced diet 25 11.9
- Inadequate exercise 26 12.3
- Don't know 15 7.1

57
Table 3: Knowledge of Rhesus factor Incompatibility Contd. n = 211
Frequency Percent
When should rhesus investigation be carried out?
- After childbirth 48 22.8
- Before marriage and pregnancy* 139 65.9
- After breastfeeding 6 2.8
- Before nurturing 13 6.2
- Don't know 1 0.5
Rhesus incompatibility mostly affects which pregnancy
- First pregnancy 149 70.6
- Subsequent pregnancies* 49 23.2
- No pregnancy 4 1.9
- Fifth pregnancy 2 0.1
- Don't know 1 0.5
Which drug is used to prevent rhesus sensitization in Rhesus
negative woman who gave birth to Rhesus positive child?
- Rhogam (Rh immunoglobulin)* 123 58.3
- Antibiotics 26 12.3
- Amatem 4 1.9
- Diclofenac 15 7.1
- Don't know 4 1.9
Which of the blood group needs follow up during pregnancy
- A+ 19 9.0
- O+ 42 19.9
- AB+ 61 28.9
- A-* 54 25.6
- Don't know 33 15.6
The injection given to a rhesus mother who had a rhesus positive
baby is administered when?
- Within 1 year 65 30.8
- Within 72 hours* 67 31.8
- Within 3 months 54 25.6
- Within 5 year 8 3.8
- Don't know 16 7.6
Complication of rhesus incompatibility includes.
- Abortion* 122 58.1
- Jaundice* 38 18.1
- Miscarriage* 135 64.3
- Blindness 4 1.9
- Obesity 6 2.9
- Anemia* 60 28.6
- Rashes 20 9.5
- Fetal death* 71 33.8
Overall Knowledge

58
From Table 2 and 3, not many of the women had good knowledge of rhesus factor

incompatibility (45.2%). However, what was majorly known included: that rhesus

incompatibility may lead to complication for the baby (70.6%), that Rh status is important to

identify potential risks of incompatibility (67.3%), that rhesus investigation should be carried

out before marriage and pregnancy (65.9%), that miscarriage is a complication of rhesus

incompatibility (64.2%) and that rhesus factor in blood is a protein found in red blood cells

(60.5%).

59
 Research Question 2: What is the attitude of women to rhesus factor incompatibility
prevention among women of child bearing age attending General Hospital Uwani,
Enugu?

Table 4: Attitude towards Rhesus Factor Incompatibility Prevention n = 211

SD D A SA M±SD
**Rhesus incompatibility cannot be prevented 69 106 20 15 1.91±0.84*
Rhesus compatibility test is very important - 1 119 90 3.42±0.50
especially for pregnant woman
I am open to the health professional about issues - 7 120 83 3.36±0.55
relating to rhesus incompatibility
I am willing to attend antenatal classes during my - 2 116 92 3.43±0.51
pregnancy in order to identify potential risk during
pregnancy
I am willing to take Rhogam for prevention of 2 4 111 93 3.40±0.58
sensitization if there is a case of maternal fetal
incompatibility
**I am reluctant about doing rhesus incompatibility 54 135 16 5 1.87±0.64*
test because I am afraid to be negative
I believe it is crucial for expectant parents to 1 2 115 92 3.42±0.54
undergo Rh compatibility testing as part of routine
prenatal care
I think that administering Rh immunoglobulin 1 1 117 91 3.42±0.53
(RhIg) to prevent rhesus incompatibility
complications is a necessary and beneficial practice
Healthcare providers should prioritize education - 4 116 90 3.41±0.53
pregnant woman about the implication of rhesus
incompatibility and available preventive measures
I support the idea of routine screening for Rh 2 3 115 90 3.40±0.57
compatibility for all pregnant individuals to
minimize the risk of complications.
Overall attitude 3.05±0.31
Overall attitude grouped
Frequency Percent
- Positive (mean attitude score > 2.5) 208 99.0

- Negative (mean attitude score ≤ 2.5) 2 1.0

Any item with mean (M) > 2.5 was considered to be accepted by the respondents; rejected
items are asterisked; Negative items are double asterisked

60
From Table 4, almost all the women had positive attitude towards rhesus factor

incompatibility prevention (99.0%). Their attitudes were majorly that of the willingness to

attend antenatal classes during pregnancy in order to identify potential risk during pregnancy

(3.43±0.51), the belief that rhesus compatibility test is very important especially for pregnant

women, (3.42±0.50), the belief that it is crucial for expectant parents to undergo rhesus

compatibility testing as part of routine prenatal care (3.42±0.54) and the view that that

administering Rh immunoglobulin (RhIg) to prevent rhesus incompatibility complications is

a necessary and beneficial practice (3.42±0.53).

61
 Research question 3: What is the association between knowledge of Rhesus factor

incompatibility and attitude to Rhesus factor incompatibility prevention among women

of childbearing age attending general hospital Uwani, Enugu

Table 5: Association between Knowledge and Attitude of Rhesus Incompatibility

prevention
Attitude of Rh Factor Fishers Exact
Incompatibility p-value
Positive Negative Total
Knowledge of Rh factor .502
incompatibility
- Good 95(100.0) 0(0.0) 95
- Poor 113(98.3) 2(1.7) 115

Table 5 shows there was no significant relationship between knowledge and attitude of rhesus

factor incompatibility prevention among the women (p = .502). There was generally a

positive attitude not only for women with good knowledge (100.0%), but also for those with

poor knowledge (98.3%).

62
Hypothesis: There will be no significant relationship between the women’s demographic

characteristics and their knowledge of Rhesus factor incompatibility.

Table 6: Relating the Knowledge of Rhesus Factor Incompatibility and the Women’s

Demographic Characteristics
Knowledge Statistic p-value
Good Poor Total
Age 5.563c .062
- <20 12(70.6) 5(29.4) 17
- 20-29 52(45.6) 62(54.4) 114
- 30 and above 31(39.2) 48(60.8) 79
Marital status 12.718f .001
- Single 23(74.2) 8(25.8) 31
- Married 70(41.2) 100(58.8) 170
- Once married 1(20.0) 4(80.0) 5
Number of children 28.783c .000
- None yet 33(82.5) 7(17.5) 40
- One 16(31.4) 35(68.6) 51
- Two 32(40.5) 47(59.5) 79
- Three and above 14(35.0) 26(65.0) 40
Education attainment 72.566f < .001
- None & Primary 0(0.0) 9(100.0) 9
- Secondary 9(12.3) 64(87.7) 73
- Tertiary 85(69.1) 38(30.9) 123
Knowledge of their 19.236c < .001
blood group
- Yes 89(50.6) 87(49.4) 176
- No 2(6.9) 27(93.1) 29
There was a significant relationship between the women‟s knowledge of rhesus factor
incompatibility and their marital status (p = .001), no. of children (p < .001), educational
attainment (p < .001) and knowledge of their blood group (p < .001). The knowledge was
higher among the singles [single (74.2%), married (41.2%) & once married (20.0%)], those
with no children yet [none (82.5%), one (31.4%), two (40.5%) & three and above (35.0%)],
those with tertiary education [no-primary (0.0%), secondary (12.3%) & tertiary (69.1%)] and
those who knew their blood group [yes (50.6%) & no (6.9%)]. There was no significant
relationship between age and knowledge (p = .062).

63
Summary of Major Findings

1. Not many women had good knowledge of rhesus factor incompatibility (45.2%).

2. Almost all the women had a positive attitude towards rhesus factor incompatibility

prevention (99.0%).

3. There was no significant relationship between knowledge and attitude towards rhesus

factor incompatibility prevention among the women (p = .502); there was a positive

attitude irrespective of knowledge.

4. There was a significant relationship between the women‟s knowledge of rhesus factor

incompatibility and their marital status (p = .001), no. of children (p < .001), educational

attainment (p < .001) and knowledge of their blood group (p < .001). There was no

significant relationship between age and knowledge (p = .062).

64
 CHAPTER FIVE

DISCUSSION OF FINDINGS

This chapter dealt with the discussion of the major findings of the research study. The

discussion was done based on the objectives of the study, explaining the findings in order to

aid better comprehension and professional development. The discussion was done under the

following headings: discussion of findings, implication of the study, limitations of the study,

summary, conclusion and recommendations.

Discussion of Major Findings

The demographic characteristics of the respondents suggest a diverse group of women of

childbearing age with a significant representation of those in the 20-29 age group, having

tertiary education and engaging in personal businesses. The majority of the participants have

two (2) children, and over half of them are married.

Objective One: Knowledge of Rhesus factor incompatibility among child bearing

women

The findings revealed a poor knowledge of Rhesus factor incompatibility among the women.

This is very worrisome as poor knowledge might increase the risk of occurrence and

complications for the baby, thus increasing infant and maternal mortality. This might be

attributed to the unwillingness to pay attention to antenatal classes during pregnancy. Access

to information has improved in the 21st century, therefore having a poor knowledge might be

due to the unwillingness and passivity in seeking information on Rh incompatibility. This

65
result is consistent with the study by Minwulyelet (2021) on the assessment of knowledge,

attitude, practice and associated factors towards rhesus incompatibility among mothers

attending antenatal care at Saint Paul‟s hospital millennium medical college, Addis Ababa,

Ethiopia, which revealed that very few mothers (39.1%) had good level of knowledge

towards Rh incompatibility. The result is also consistent with the findings of Temesgen et al.

(2022) on the knowledge about rhesus incompatibility and it‟s associated factors among

antenatal care recipients in public hospitals of Wolaita zone. The respondents had poor level

of knowledge of Rhesus factor incompatibility (35.3%), this is very similar to the current

study which elicited a poor knowledge as well. Kwamboka (2019), also asserted the

prevalence of poor knowledge of Rh incompatibility among mothers, which is in agreement

to the findings of the study.

The findings of Abimbola and Olasubomi, (2021) on Assessment of pregnant woman‟s

knowledge and attitude about Rhesus factor incompatibility prevention at Babcock university

teaching hospital Illishan-remo, Ogun state, where the women reported a fair knowledge of

rhesus factor incompatibility, somewhat negates this finding. This may be due to the fact that

majority of the respondents care about their Rhesus factor and they do discuss maternal-fetal

incompatibility with their partners.

Objective Two: Attitude of child bearing mothers towards Rhesus factor incompatibility

prevention

The findings revealed that the attitude of the respondents were positive towards rhesus factor

incompatibility prevention. This is highly applaudable because positive attitude improves the

66
likelihood of these women taking both proactive and preventive measure to prevent

complications of incompatibility. Measure such as; undergoing appropriate screening tests

during pregnancy, leading to early detection of potential issues and better management,

ultimately improving pregnancy outcomes for both mother and baby.

Majority of the pregnant women agreed that they are open to health professional about issues

relating to rhesus incompatibility, also majority asserted that they are willing to take Rhogam

for prevention of sensitization if there is any case of incompatibility. This is very encouraging

as it fosters empowerment thus reducing neonatal and maternal mortality and morbidity. In

correspondence to this study, Minwulyelet (2021), revealed that a very high number of

mothers had positive attitude towards rhesus incompatibility. Howbeit, moderate level of

attitude of pregnant women found in the study of Abimbola and Olasubomi (2021), is

somewhat contrasting. This may be due to the lack of awareness of the women on the

complications incompatibility poses to the health of their babies and lack of knowledge on

the importance of taking rhesus test.

Objective Three: Association between knowledge and attitude of child bearing women

towards Rhesus factor incompatibility prevention.

There is no significant relationship between knowledge and attitude of Rhesus factor

incompatibility prevention. The positive attitude was the same for both those with good and

poor knowledge. This is quite interesting because knowledge was expected to be in a direct

relationship with attitude. Even if the women have insufficient knowledge about rhesus factor

incompatibility, other factors might play a more significant role in determining their attitude.

67
This could indicate that interventions focusing solely on education may not be effective in

improving incompatibility occurrence. The study suggests that factors beyond knowledge,

such as cultural beliefs, social support networks, personal experiences, prior education and

individual health literacy can influence their understanding and adherence to incompatibility

prevention practices. The findings of Abimbola & Olasubomi (2021) negate this finding.

Hypothesis: Association between the socio-demographic characteristics of the women

and their knowledge of Rhesus factor incompatibility

Based on the findings of the study, it was concluded that there is a significant relationship

between the socio-demographic characteristics of the women such as their marital status,

number of children, educational attainment, knowledge of their blood group, and their

knowledge on Rhesus factor incompatibility. The knowledge was higher among the single

women of childbearing age and those with no children yet. This may be due to the reason that

the single women particularly those planning to have children in the future may actively seek

out information on Rhesus factor incompatibility as part of their reproductive health

education. The married women on the other hand, might not encounter sufficient information

on rhesus incompatibility until they become pregnant depending on their access to health care

services. Knowledge was also higher among those with tertiary education compared to those

with secondary and primary education only. In correspondence to this finding, the study by

Temesgen, (2022) reveals that knowledge of Rhesus factor incompatibility was higher among

women that had tertiary education. This could be because individuals with tertiary education

may have access to higher quality healthcare information through formal education channels.

Conversely, those with secondary, primary or no education at all may have limited access to

68
information about rhesus incompatibility. The knowledge was higher among those that know

their blood group than among those who do not know their blood group. This could be

because people who know their blood group may have encountered information about the

potential risks of rhesus incompatibility leading to increased awareness. There was no

significant relationship between age of the women and knowledge on Rhesus factor

incompatibility.

Implications of the Study

To women of childbearing age

The knowledge and attitude of childbearing mothers towards Rh factor incompatibility have

significant implications for maternal and fetal health A good understanding and positive

attitude of Rh factor incompatibility among mothers makes them likely to take preventive

measures and adhere to recommended interventions and seek timely medical care. Good

knowledge and attitude also enables empowerment of women to advocate for themselves and

actively participate in discussions with healthcare providers regarding Rh factor testing and

management.

To nursing

Nurses play a very important role in educating women about rhesus incompatibility.

Implementation of targeted educational programs for nurses will enhance their knowledge

and communication skills regarding Rh factor incompatibility and this in turn will Improve

prenatal counseling by nurses, leading to better informed decision-making and potentially

69
reducing the incidence of Rh factor-related complications during pregnancy.

Significantly, the finding highlights the need for nurses and midwives to improve

commitment to antenatal clinics, as it serves as an avenue for improved knowledge on

reproductive issues among child bearing women.

Limitations of the Study

The study was limited by the sample size and sampling technique. The sample size used by

the researcher was a total of 212 women attending general hospital Uwani, Enugu. This

sample size potentially reduces the generalizability of the findings of this study to a larger

population. The convenience sampling technique was adopted by the researcher to select the

study subjects, this technique was based on easy access to participants rather than random

selection. Hence, not everyone was given an equal chance of being included in the study.

Summary of the Study

The study was designed to assess the knowledge and attitude of child bearing mothers

towards Rhesus factor incompatibility at General Hospital, Uwani Enugu. The objectives of

the study were constructed; research questions and hypothesis were formulated according to

the purpose of the study. The literature was reviewed under the following headings:

conceptual review, theoretical framework, and empirical studies. A non-experimental

descriptive research design was adopted and a convenience sampling technique was used to

select a sample size of 212 mothers from a population of 450. Data was collected using a

researcher-constructed questionnaire while the organization and analysis of data was done

70
using the descriptive statistics. The study was arranged from chapters 1- 5; Chapter one

covered the background to the study to operational definition of terms; Chapter two contained

the literature review while chapter three comprised of research design, sampling techniques,

method of data collection and analysis. Data were presented in tables with frequency,

percentage, and p-value in chapter four while discussion of major findings, summary,

conclusion and recommendations were done in chapter five. Findings of the study revealed

poor knowledge and a positive attitude towards Rh factor incompatibility among child

bearing mothers. The null hypothesis was rejected.

Conclusion

In conclusion, the study highlights a concerning gap in knowledge regarding Rhesus factor

incompatibility among women of childbearing age. However, despite this lack of

understanding, there is a positive attitude towards prevention measures. This underscores the

importance of targeted educational interventions to bridge this knowledge gap and empower

women to make informed decisions regarding Rhesus factor incompatibility prevention

during pregnancy. Addressing this issue could ultimately lead to improved maternal and fetal

health outcomes.

Based on the findings, it was concluded that there was poor knowledge on Rhesus factor

incompatibility and positive attitude towards Rh factor incompatibility prevention among

childbearing mothers. Surprisingly, their poor knowledge is not significant in the positive

attitude.

71
Recommendations

Based on the result of the study, it is recommended that:

1. Hospital management should commit to health education and enlightenment on the

knowledge and prevention of Rh incompatibility in antenatal clinics.

2. Hospital management should provide free Rhesus laboratory investigation for pregnant

women attending antenatal clinics.

3. Government should invest more in provision of centers that specifically provides genetic

counseling for couples.

4. Mothers should be willing to attend and listen to antenatal teachings on various topics,

and also be proactive in seeking out useful reproductive information necessary for their

health and that of the baby.

Suggestion for Further Studies

Conduct a study to investigate barriers to practice of preventive measures of Rh factor

incompatibility among mothers. Also, assess the knowledge and attitude of men towards Rh

factor incompatibility.

72
REFERENCES

Alaqeel, A. A. (2019). Hypo regenerative anemia and other complications of rhesus

hemolytic disease: to treat or not to treat is the question. a cross-sectional study. 23(1).
[Link]

Aljuhaysh, R. M., El-Fetoh, N. M., & Alanazi, M. I. (2019). Maternal-fetal Rhesus (Rh)
factor incompatibility in Arar, northern Saudi Arabia. Electron Physician.
9(12):59085913. [Link]

Aryan, H., Razmara, E., Farhud, D., Zarif-Yeganeh, M., Zokaei, S., Hassani, S. A., &
Tavasoli, A. R. (2020). Novel imaging and clinical phenotypes of Condsias disorder
caused by a homozygous frameshift variant: a case report. BMC neurology, 20 (1), 11.
[Link]

Atire, F. A. (2020). Analysis of the blood type and group among undergraduate physics
students of Dilla University, Ethiopia, Hereditary Genet 4(1) 1-8.
[Link]

Avent, A., Neil, D., Reid, J., & Marion, E. (2020). The Rh blood group system: a review.
Blood 2000; 95 (2): 375-387. [Link]

Castleman, J. S., & Kilby, M. D. (2020). Red cell alloimmunization: a 2020 update.
[Link]

Costumbrado, J., Mansour, T., & Ghassemzadeh, S. (2022). Rh Incompatibility. StatPearls -

NCBI Bookshelf. [Link]

Crawford, N. H., Parasuraman, R., & Howe, D. T. (2020) Intraperitoneal transfusion for severe,
early-onset rhesus disease requiring treatment before 20 weeks of gestation: a
consecutive case series. [Link]

Doll, P. (2021). Hemolytic disease of newborn: symptom and causes.

Pediatrics.132(3) :e145–e232. https:// [Link]/10.2342/peds.114.2.e143

Ejimofor, R. O. (2023). Review on knowledge of issues of rhesus incompatibility among

Nigerians. [Link]

Farhud, D. D., & Zarif, M. Y. (2020). A brief history of human blood groups. Iranian journal
of public health 42 (1), 1, 2. [Link]

Flegel, W. A. (2019). The genetics of the Rhesus blood group system. Blood Transfus. 5(2):
5057. [Link]

Fox, C., Martin, W., Somerset, D. A., Thompson, P. J., & Kilby, M. D. (2019). Early
intraperitoneal transfusion and adjuvant maternal immunoglobulin therapy in the

73
 treatment of severe red cell alloimmunization prior to fetal intravascular transfusion.
[Link]

Gupta, G. K., Balbuena-Merle, R., Hendrickson, J. E., & Tormey, C. A. (2020).

Immunohematologic aspects of alloimmunization and alloantibody detection: a focus
on pregnancy and hemolytic disease of the fetus and newborn. Transfus Apheresis Sci.
10:102946. [Link]

Hemalatha, N. R. (2019). ABO and Rh blood group distribution among medical students in
Mandya, International Journal of Contemporary Medical Research 4(8), 1655- 1658.

Hendrickson, J. E., & Delaney, M. (2019) Hemolytic Disease of the Fetus and Newborn:
Modern Practice and Future Investigations. Transfus Med Rev. 30(4):159-164.
[Link]

Izetbegovic, S. (2019). Occurrence of ABO and RhD Incompatibility with Rh Negative

Mothers. Mater Sociomed. 5(4):255258. [Link]

Jackson, M. E., & Baker, J. M. (2021). Hemolytic disease of the fetus and newborn: historical
and current state. Clin Lab Med; 41(1):133–151.
[Link]

Kanko, T. K., & Woldemariam, M. K. (2021) Prevalence of rhesus D negativity among

reproductive age women in southern Ethiopia: a cross-sectional study. BMC Women's
Health. 21(1):161. [Link]

Khatun, J., & Begum, R. (2019). Effect of Rhesus Negative in Pregnancy. Medicine Today.
30(1), 23-25. . [Link]

Kio, J., Agbede, C., & Oroniyi, F. (2019). Assessing expectant mother's knowledge and
practices regarding Maternal-Fetal Blood Incompatibility: Evidence from Ogun

Lindenburg, I., Van Kamp, I., Van Zwet, E., Middeldorp, J., Klumper, F., & Oepkes, D. (2022).
Increased perinatal loss after intrauterine transfusion for alloimmune anaemia before 20
weeks of gestation. [Link] 1471-0528.12063

Minwuyelet, A. (2021). Assessment of knowledge, attitude, practice and associated factors

towards rhesus incompatibility among mothers attending antenatal care at saint Paul‟s
hospital millennium medical college, Addis Ababa Ethiopia

Mohammed, A. F., Wafaa, S. H., Al-Zuhairi, A. I., & Nuha, A. I. (2019). The influence of stress
on erythrocyte sedimentary rate (ESR) for the staff of College of Science – Diyala
University. [Link]

Mokaya, E. K. (2014). Knowledge, attitude and practices of rhesus incompatibility among

women attending antenatal care in Kampala international university teaching hospital.

74
Muhammad, T., Hamid, R., Maqsood, A., Muhammad, S., Shahida, H., Aamir, H., & Nadia, R.
(2019) Determination of weak “D” antigen among Rhesus negative Pakistani blood
donors, Ann. Pak. Inst. Med. Sci. 12(3) 131-135.

Nassar, G. N., & Wehbe, C. (2023). Erythroblastosis Fetalis. StatPearls Publishing; Treasure
Island (FL)

Niharika, M., & Rachna, L. (2021). A hospital based study to find the distribution of ABO and
Rh blood group in the local population of Sikkim, North-Eastern India, The Journal of
Medical Research 3(6) 273-276. [Link]

Ojo, E. A., & Osuntusa, A. O. (2021). Assessment of Pregnant women‟s Knowledge and
Attitude About Rhesus Incompatibility Prevention at Babcock University Teaching
Hospital Ilishan-Remo Ogun State. [Link]

Omolbanin, A., Alireza, R., Abolghasem, A., Reza, V., Zahra, H., Mehrdad, H., & Ghasem, J.
(2019). Blood groups: in health and diseases, Res. Mol. Med. 3(4), 1-9.

Ree, I. M., Smits-Wintjens, V. E., van der Bom, J. G., van Klink, J. M., Oepkes, D., & Lopriore,
E. (2019). Neonatal management and outcome in alloimmune hemolytic disease.
[Link] 17474086.2017.1331124.

Routray, S. S., Behera, R., & Mallick, B. (2021) The spectrum of hemolytic disease of the
newborn: evaluating the etiology of unconjugated hyper-bilirubinemia among
neonates pertinent to immunohematological workup. Cureus. 13(8):110

Sai Prasad, B. V., Prasad, M. D., Khader, N. V., & Rajesh, K. (2020). Demographic distribution
and prevalence of ABO and rhesus blood groups in blood donors: study from a tertiary
care centre in southern region of Andhra Pradesh, IOSR Journal of Dental and Medical
Sciences 17(7) 01-05. [Link]

Salem, L., & Singer, A. (2022). Rh incompatibility; Practice essentials, pathophysiology,

epidemiology. [Link] [Link]/article/797150-overview?form=fpf

Schwartz, J., Padmanabhan, A., Aqui, N., Balogun, R. A., Connelly-Smith, L., & Delaney, M.
(2019). Frequency Distribution of ABO, RH Blood Groups and Blood Genotypes
among the Cell Biology and Genetics Students of University of Lagos, Nigeria.
African Journal of Biotechnology, 5(22), 202-2065 31:149–62.
[Link] jca.21470.

Shamima, N. S., Rabiul, I, M., & Moazzem, H. A. (2021). ABO and Rhesus blood group
distribution among garment factory workers, Acta Scientific Microbiology 1(7), 68-71.

Smith, J. A., & Jones, B. C. (2022). Rhesus factor (Rh factor) incompatibility: Global
prevalence and regional variations. Journal of Reproductive Immunology.
[Link]

75
Smits-Wintjens, V. E., Rath, M. E., Lindenburg, I. M., Oepkes, D., Van Zwet, E. W., & Walther,
F. J. (2020). Cholestasis in neonates with red cell alloimmune hemolytic disease:
incidence, risk factors and outcome. Neonatology 101:306–10.
[Link]

Smits-Wintjens, V. E., Walther, F. J., & Lopriore, E. (2019). Rhesus haemolytic disease of the
newborn: postnatal management, associated morbidity and long-term outcome. Fetal
Neonatal Med 2008;13:265–71. [Link] siny.

Sreelatha, S., Vandana, C. S., & Satish, D. (2019). Maternal and neonatal outcome in rhesus
positive women in a tertiary care center, MOJ Women’s Health 5(2) 202-204.
[Link]

WHO Reproductive Health Library. WHO recommendation on antenatal anti-D

immunoglobulin prophylaxis. (2019). Retrieved from:
[Link]
-care/antenatal-care/who-recommendation-antenatal-anti-d-immunoglobulin-prophyla
xis

Yinon, Y., Visser, J., Kelly, E. N., Windrim, R., Amsalem, H., & Seaward, P. R. (2020). Early
intrauterine transfusion in severe red blood cell alloimmunization.
[Link]

Zwiers, C., Scheffer-Rath, M. E, Lopriore, E., De Haas, M., & Liley, H. G. (2021).
Immunoglobulin for alloimmune hemolytic disease in neonates.
[Link]

Zwiers, C., Van der Bom, J. G., Van Kamp, I. L., Van Geloven, N., Lopriore, E., & Smoleniec,
J. (2021). Postponing Early intrauterine Transfusion with Intravenous immunoglobulin
Treatment; the Petit study on severe hemolytic disease of the fetus and newborn.
[Link] e1-291.e9.

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 APPENDIX I
Informed Consent
Department of Nursing Sciences,
Faculty of Health Sciences and Technology,
College of Medicine,
University of Nigeria Enugu Campus,
Enugu State.
February, 2024

RESEARCH QUESTIONNAIRE

Dear Respondent

I am Onu Ugochinyere Juliet, a final year student of Nursing Sciences Department,

University of Nigeria Enugu Campus conducting a research project on the topic “Knowledge

and attitude towards Rhesus factor incompatibility among women of childbearing age

attending General hospital Uwani Enugu”. Please kindly answer the questions below with

honesty and sincerity. I assure you that all information provided will be treated with utmost

confidentiality and your identity will remain anonymous. Thank you for your anticipated

cooperation.

Thank you.

Yours Sincerely,

Onu Ugochinyere Juliet

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 APPENDIX II

QUESTIONNAIRE

SECTION A: SOCIO-DEMOGRAPHIC DATA OF THE RESPONDENT

Instructions: please read the question below carefully and tick [ √ ] in the boxes provided for the
responses that are applicable to you.

1. Age as at last birthday: (a) Below 20 [ ] (b) 20-29 [ ] (c) 30-39 [ ] (d) 40-45
[ ]

2. Marital status: (a) Single [ ] (b) Married [ ] (c) Divorced/separated [ ] (d)

Widowed [ ]

3. Number of children: (a) None yet [ ] (b) One [ ] (c) Two [ ] (d) Three and above
[ ]

4. Educational attainment: (a) No school [ ] (b) Primary school [ ] (c) Secondary school [ ] (d)

Tertiary [ ]

5. Employment status: (a) Employed [ ] (b) Unemployed [ ] (c) Self-employed [ ] (d) Student

[ ]

6. Ward: (a) Antenatal ward [ ] (b) Labor ward [ ] (c) Postnatal ward [ ] (d) Immunization ward

[ ] (e) OPD [ ]

7. Do you know your blood group: (a) Yes [ ] b) No [ ]

SECTION B: WHAT DO KNOW ABOUT RHESUS FACTOR INCOMPATIBILITY

Instructions: please read the question below carefully and tick in the boxes provided as it

applies to you
8. What is the Rh factor in blood?
a) A protein found in red blood cells [ ] b) A type of white blood cell [ ]
c) A hormone regulating blood pressure [ ] d) An enzyme involved in blood clotting [ ] e)
I don‟t know [ ]
9. Rh factor incompatibility is associated with?
a) Environment problems [ ] b) Blood group incompatibility
c) Certain diseases [ ] d) Body weight
e) I don‟t know [ ]

10. Rh incompatibility occurs due to?

a) A Rh negative woman carrying a. Rh positive baby [ ] b) A Rhesus positive woman carrying a

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Rh positive baby [ ]
c) A Rhesus negative woman carrying a Rh negative baby [ ] d) A Rhesus positive woman carrying
a Rh negative baby [ ]
e) I don‟t know [ ]
11. Why is Rhesus factor incompatibility a concern during pregnancy
a) It causes morning sickness [ ] b) It may lead to complications for the baby [ ]
c) It determines the baby‟s gender [ ] d) It causes cravings for certain foods e)
I don‟t know [ ]

12. Why is knowledge on Rh status important?

a) To determine the baby‟s gender [ ] b) To choose baby‟s age [ ]
c) To identify potential risks of incompatibility [ ] d) To plan for a C-section [ ]
e) I don‟t know [ ]
13. Rh incompatibility can also occur through
a) Receiving mismatched blood [ ] b) Taking wrong medications [ ]
c) Lack of balanced diet [ ] d) Inadequate exercise [ ]
e) I don‟t know [ ]

14. When should rhesus investigations be carried out?

a) After childbirth [ ] b) Before marriage and pregnancy [ ]
c) After breastfeeding [ ] d) Before
nurturing [ ] e) I don‟t know [ ]
15. Rhesus incompatibility mostly affects which pregnancy
a) First pregnancy b) Subsequent pregnancies
c) No pregnancy d) fifth pregnancy
e) I don‟t know [ ]

16. Which drug is used to prevent rhesus sensitization in Rhesus negative women who gave birth to Rhesus
positive child?

a) Rhogam (Rh Immunoglobulin) [ ] b) Antibiotics [ ] c) Amatem [ ]

d) Diclofenac [ ] e) I don‟t know [ ]

17. Which of the blood group needs follow up during pregnancy

a) A+ [ ] b) O+ [ ] c) AB+ [ ] d) A– [ ] e)

I don‟t know [ ]

18. The injection given to a rhesus negative mother who had a rhesus positive baby is administered when?
a) Within 1 year [ ] b) Within 72 hours [ ]

c) Within 3 months d) Within 5 years

79
 [ ] e) I don‟t know [ ]
19. Complications of rhesus incompatibility includes. Tick all that apply
a) Abortion [ ] b) Jaundice [ ] c) Miscarriage [ ] d) Blindness [ ] e)
Obesity [ ]
f) Anemia [ ] g) Rashes [ ] h) Fetal death [ ] i) I don‟t know
[ ]

SECTION C: TO DETERMINE THE RESPONDENTS ATTITUDE TOWARDS RHESUS

FACTOR INCOMPATIBILITY

What is your attitude towards rhesus factor incompatibility prevention?

Strongly Disagree Agree Strongly

Disagree agree
20 Rhesus incompatibility cannot be prevented
21 Rhesus compatibility test is very important especially for pregnant women
22 I am open to the health professionals about issues relating to rhesus
incompatibility
23 I am willing to attend antenatal classes during my pregnancy in order to
identify potential risks during pregnancy
24 I am willing to take Rhogam for prevention of sensitization if there is a case
of maternal fetal incompatibility.
25 I am reluctant about doing rhesus incompatibility test because I am afraid to
be negative
26 I believe it is crucial for expectant parents to undergo Rh compatibility
testing as part of routine prenatal care
27 I think that administering Rh immunoglobulin (RhIg) to prevent rhesus
incompatibility complications is a necessary and beneficial practice
28 Healthcare providers should prioritize educating pregnant women about the
implications of rhesus incompatibility and available preventive measures
29 I support the idea of routine screening for Rh compatibility for all pregnant
individuals to minimize the risk of complications.

80
 APPENDIX III
Reliability Test
Kappa P -value
Participant 1 1.000 <.001
Participant 2 1.000 <.001
Participant 3 .951 <.001
Participant 4 1.000 <.001
Participant 5 1.000 <.001
Participant 6 1.000 <.001
Participant 7 .946 <.001
Participant 8 1.000 <.001
Participant 9 .908 <.001
Participant 10 1.000 <.001
Participant 11 .949 <.001
Participant 12 1.000 <.001
Participant 13 1.000 <.001
Participant 14 1.000 <.001
Participant 15 1.000 <.001
Participant 16 1.000 <.001
Participant 17 1.000 <.001
Participant 18 1.000 <.001
Participant 19 1.000 <.001
Participant 20 1.000 <.001
Participant 21 1.000 <.001
- Average .988

A pilot was carried out on 21 subjects, which is 10% of the sample size. From the collected
data, the reliability of the instrument was ascertained using the Cohen‟s Kappa (for intra-rater
reliability), which measures the consistency of responses of subjects. The reliability
coefficient for the subjects ranged from .908 to 1.000; the average reliability was .988.

81