Birth preparedness and complication readiness among pregnant women in Tehulederie district, Northeast Ethiopia: a community-based cross-sectional study

Motherhood is a time of expectation and joy for a woman, her family, and her community. However, for thousands of women, the experience is not as pleasurable an event as it should be [1].

Each year in Africa 30 million women become pregnant, and about 250,000 of them die from pregnancy-related causes [2]. It is not possible to predict which women will experience life-threatening obstetric complications that lead to maternal mortality. On the whole, 42% of all pregnancies suffer complications – in rich and poor countries alike – and in 15% of all pregnancies, the complications are life-threatening. Scaling up birth preparedness and complication readiness (BPCR) practices and providing care by skilled providers (doctor’, nurse’ or midwives) during pregnancy, childbirth, and in the immediate postnatal period are fundamental for maternal health [2].

In many societies in the world, cultural beliefs and lack of knowledge of BPCR inhibit in advance preparations for delivery and expected babies. Since no action is taken prior to delivery, the family tries to act only when labor begins. To this end, the utilization of BPCR is the cornerstone for most developing countries, including Ethiopia. It is a strategy to promote a timely use of skilled maternal and neonatal care, especially during pregnancy, childbirth, and through the two-day post-partum period. The role of BPCR is to improve the use and effectiveness of key maternal and neonatal services through reducing the deadly delays (the first two delays) in deciding to seek care. Due to increases in the level of knowledge about complication readiness and the recognition of danger signs, the identification of problems and the delays in seeking health care services have been improved [3‐8].

The Ministry of Health (MOH) has designed & initiated the application of BPCR in different maternal and neonatal health interventions to reduce maternal and newborn morbidity and mortality in Ethiopia. Currently, the Maternal Mortality Rate (MMR) of Ethiopia is 420 per 100,000 live births. Only 15% of the births in Ethiopia are at health facilities, 14% at public and 1% at private [9, 10].

Women’s BPCR practices were examined by different authors who no doubt used sound methods. For instance, a study conducted in India on BPCR among slum women recognized steps; like identifying a trained birth attendant, selecting a health facility, arranging transport for delivery and obstetric emergency, and saving money for delivery; responding positively to at least three of the four elements was considered as an appropriate preparation [11].

In community-based cross-sectional studies conducted by Mpwapwa district of Tanzania, Plateau district in Nigeria, and a rural district of Ghana on BPCR among women showed that only a few of the women knew three or more obstetric danger signs [12‐14].

According to a study conducted in rural Uganda, 52% of women knew at least one key danger sign during pregnancy, 72% during delivery and postpartum periods. Overall, 35% of the respondents who made arrangements in three of the four birth preparedness practices were classified as “well prepared for birth” [15].

A similar study conducted by Ife Central Local Government, Nigeria, on BPCR among pregnant women showed that 158 (39.3%) respondents knew no danger signs of pregnancy, childbirth, and postpartum periods. Only 24 (6.0%) had adequate knowledge of obstetric danger signs without prompting. Three hundred and forty (84.8%) of women identified birthplaces and 312 (78.3%) began saving money for delivery. However, 304 (79.4%) of the women made no arrangements for blood donors [16]. Other studies conducted in Adigrat and Goba districts of Ethiopia showed that only 118 (22.1%) and 128 (29.9%) of the total respondents, respectively, were found to be well prepared ahead of childbirth [17, 18].

A study done in Aleta Wondo district using five measures of BPCR that included identifying health provider, health facility and potential blood donor, the arrangement of transportation, and saving money for costs of delivery and emergency showed that among 743 pregnant women, only 20.5% identified skilled providers. In the same study, only 8.1% identified health facilities for delivery and/or for obstetric emergencies. On the other hand, the majority (87.9%) of the respondents reported that they intended to deliver at home, whereas only 60(8%) planned to deliver at health facilities, and 17% of the pregnant women were well prepared [19].

A study on the elements of BPCR in Jimma, Ethiopia, reported that 12.5%, 65.7%, 81%, 20.2%, and 58.9% of the pregnant women made prior decisions regarding skilled birth attendance, money, place of delivery, mode of transportation, and potential blood donor, respectively. On the whole, the study identified that less than one-third, 106 (29.4%) of the study participants were prepared for BPCR, indicating the prevalence or existence of poor practices or preparedness for birth and its complications in the area [20].

With regard to risk factors, studies done in Adigrate and Goba districts showed that residence, occupation, educational level, family size, ANC follow up, knowledge of danger signs during pregnancy, labor and postnatal period, as well as gravida and parity were found to have statistically significant associations with BPCR [17, 18].

Generally, almost all of the findings in the above studies revealed that BPCR remains almost unutilized to improve maternal and neonatal health in most developing countries, especially in sub-Saharan Africa. Hence, one can clearly understand that among the population studied, BPCR is comparatively low. The findings can also tell us BPCR is very low, especially in Ethiopia, compared to findings in other developing countries. As a result, the majority of the pregnant women did not give birth at health institutions; therefore, it is necessary to further investigate knowledge and practice of BPCR and possible associated factors.

As a matter of fact, not only were studies on BPCR in this particular area scarce but also the studies available varied in terms of time and place of study, geographic location, and population. Most previous studies focused on urban communities and among non- pregnant women [17‐21]. In addition, the level of BPCR practice and its associated factors among pregnant women was not clearly examined in the study areas. So, the aim of this study was to assess BPCR practices and associated factors among pregnant women in Tehulederie district, Amhara National Regional State, northeast Ethiopia. Hence, the findings of the study will be crucial for the study woreda health officials, South Wollo zone health departments, the Amhara National Regional Health Bureau, and other maternal and neonatal health program implementers.

The aim of this study was to examine mainly the BPCR practice of pregnant women. Our study revealed that only less than half of the participants were practicing BPCR (217 or 43.4%) and that a nearly equal number of women were knowledgeable about the practice (223 or 44.6%).

The majority of the respondents reported that they made some arrangements on some of the recommended elements of BPCR. Out of five hundred respondents, 391 (78.2%) identified a health facility for delivery, 175 (35%) identified a skilled birth attendant, 336 (67.2%) saved money for delivery and any possible obstetric emergency, 202 (40.4%) determined mode of transport, 104 (20.8%) identified potential blood donor in case of emergency, 352 (70.4%) selected temporary family care giver, 348 (69.6%) nominated birth companion, 380 (76%) identified medical facility in case of obstetric emergency, and 346 (69.2%) selected decision maker in case of obstetric emergency. Generally, only 217 (43.4%) of the participants made BPCR arrangements.

In this study, 391 (78.2%) pregnant women identified health facility for delivery. This is almost comparable with the findings of studies done in Jimma town and Goba woreda, Oromia Region, Ethiopia, which reported 285 (81%) and 432 (76.9%), respectively [18, 20]. However, the finding of this study is lower than that of a study done in Mpwapwa district Tanzania which detected 583 (97.3%) [12]. The likely explanations for this dissimilarity might be differences in study subjects and settings. On the other hand, this finding is higher than those of studies done in Adigrat town, northern Ethiopia, and Aleta wondo, southern Ethiopia, which reported 209 (39.1%) and 59 (8.1%), respectively [17, 19]. This difference might be due to variations in the times of investigations in that currently some more attention is being to the issue by maternal health implementers. Accessing health extension workers nearby in the community might increase the number of ANC attendants and improve decision on the identification of health facility for delivery.

The finding of the current study showed that 175 (35%) of the respondents identified skilled birth attendants. This finding was lower than those of studies done in Indore City, India, which noted 217 (69.6%), Mpwapwa district, Tanzania 436 (86.2%), and Chamwino district, Tanzania 333 (77.8%) [11, 12, 24]. The observed discrepancy might be due to study settings, target populations, and knowledge of women about BPCR and obstetric danger signs during pregnancy, labour, and postpartum period. Conversely, it was higher than the findings of studies conducted in Adigrat and Duguna Fango district, Wolayta Zone which reported 56 (10.5%) and 62 (10.9%), respectively [17, 25]. The difference could be due to the study period, an increased number of ANC visits which might have increased access to information. The expansion of Health Extension Workers (HEWs) to the rural community might have created an opportunity for raising women’s knowledge regarding the role of skilled attendants at birth.

In the present study, saving money for delivery and any possible obstetric emergency was 336 (67.2%). This result was consistent with 388 (69%) of a study conducted in Goba woreda, Oromia Region [18]. However, our finding was lower than those of studies conducted in Indore City, India, Chamwino district, Tanzania, West Bengal, India, Mpwapwa district, Tanzania, and in Plateau State, Nigeria which reported 240 (76.9%), 360 (84.1%), 84.6%, 536 (89.3%), and 209 (83.6%), respectively [11‐13, 24, 26]. This could be due to differences in settings, resulting in variations in socio-economic status, culture, and level of female empowerment. If women are empowered educationally and economically, they could have a better understanding of obstetric danger signs or complications and benefit from BPCR and save money for delivery and obstetric complication services. However, the current finding was higher than those of studies conducted in Duguna Fango district, Wolayta Zone 308 (54.1%) and Adigrat 190 (35.6%) [27, 17]. The difference might be due to variations in the study period and knowledge status of women about BPCR. The knowledge level of the respondents about BPCR was higher compared to the above studies. This fact showed that women who knew that money could help them to buy important medical supplies or pay for transportation in case of delivery and obstetrics emergency made better BPCR arrangements.

This study revealed that 202 (40.4%) of the pregnant women arranged the mode of transportation for delivery/obstetric emergency. This finding corroborated a study conducted in Adigrat and noted 40.8% [17]. However, the finding was lower compared with those of studies conducted in Mpwapwa district, Tanzania and Plateau State, Nigeria which reported 494 (82.3%) and 135 (54%), respectively [12, 13]. This could be because of variations in study settings, resulting in differences in socio-economic status and access to transportation. But our finding was higher than the result of a study (103/18.1%) done in Fango district, Wolayta Zone [27]. This could be due to an increase in the number of HEWs and repeated ANC visits which might have created awareness on the benefits of early arrangement for transportation. In cases of geographical inaccessibility or financial problems, our community arranged traditional ways of transportation such as donkeys, horses, or mules and local stretchers. Identifying transportation ahead of childbirth and improvement in decision-making can reduce maternal and neonatal mortality.

Our study found that 104 (20.8%) of the women identified potential blood donors in cases of emergency. This finding was similar to that of a study done in Plateau State, Nigeria which reported 58 (23.2%) [13]. But it was higher than the results of studies done in Fango district, Wolayta Zone 17 (3.0%), Goba woreda, Oromia Region 51 (9.1%), Robe woreda, Arsi Zone 57 (9.9%) and Adigrat 4 (0.7%) [17, 18, 21, 27]. This might be due to an improvement in the knowledge of pregnant women and their families about the importance of early identification of blood donors. In this study, nearly 100% of the pregnant women attended ANC which created a good opportunity for getting appropriate information on the elements of BPCR by skilled birth attendants. Making arrangements for blood donors is important because women giving birth may need a blood transfusion in the event of hemorrhage or cesarean section.

This study indicated that 352 (70.4%) of the pregnant women identified temporary family caregivers. This finding was lower than that of a study done in Mpwapwa district, Tanzania and documented 548 (91.3%) [12]. This could be due to differences in study settings resulting in variations in the quality of counseling and strength of applying BPCR strategy in order to reduce maternal and child mortality.

In the current study, 380 (76%) of the women identified the medical facility in preparation for the obstetric emergency. The result of this study was higher than the result of a study done in Fango district, Wolayta Zone, Goba woreda, Oromia Region, and Adigrat town, northern Ethiopia, which found out 43.6%, 47.5% and 6.6%, respectively [17, 18, 27]. This could be due to the expansion of the Health Extension Program which might have improved the number of ANC attendants in the health facilities- which probably increased awareness on obstetric danger signs and arrangements for medical facilities to cope with obstetric emergencies.

The finding showed that 346 (69.2%) of the respondents identified decision makers for cases of obstetric emergency. This finding is lower than that of a study conducted in Mpwapwa district, Tanzania, and noted 564 (94.0%) [12]. This difference might be due to variations in the socio-economic and educational status of women and the implementation of BPCR strategies. But the finding was higher than 12 (2.2%) reported from Adigrat, northern Ethiopia [17]. This could be due to differences in study periods. That is, currently the Ethiopian government has given special attention to BPCR integration and implementation at the grass-root levels by each primary health care unit and the emphasis given to male involvement in maternal health care services which might have encouraged women to identify decision-makers in cases of obstetric emergencies.

In this study, 217 (43.4%) respondents practiced BPCR. The finding was lower than the results of studies done in Indore City, India, Chamwino district, central Tanzania, Edo State, Nigeria, and the rural area of Darjeeling West Bengal, India, which reported (47.8%), (58.2%), (87.4%), and (57%), respectively [11, 24‐26]. The possible reason could be the differences in study areas as the current study included both rural and urban/city communities. However, it was higher than those of studies done in rural Uganda, Aleta Wondo, southern Ethiopia, Adigrat town, northern Ethiopia, Jimma town southwest Ethiopia, Goba woreda, Oromia Region, Ethiopia, Robe woreda, Arsi zone, Oromia Region, central Ethiopia, and Dugna Fango district, Wolayta Zone, Ethiopia, which found (35%), (17%), (22.1%), (29.4%), (29.9%), (18.3%), and (16.5%), respectively [15, 17‐21, 27]. The likely reason for the difference could be that the recommended BPCR elements might have been given more focus in these healthcare setups.

In the multivariate logistic regression analysis, knowledge of BPCR was two times more likely to encourage BPCR practice compared to no knowledge. This finding is inconsistent with that of a study done in Goba woreda [18]. The possible reason for the difference could be the quality of information given to women about BPCR. Increasing the number of ANC attendants and knowledge on the elements of BPCR to pregnant women during each visit might motivate them to prepare for birth and to be ready for obstetric complications.

Participants knowledgeable about danger signs during pregnancy were three times more likely to practice BPCR compared to those who had no knowledge. This finding is similar to those of studies done in Goba and Robe woredas, Ethiopia, but differs from that of a study done in Adigrat [17, 18, 21]. The possible reason could be the study period and the clarity of information on BPCR addressed at times of repeated ANC visits. Besides, their partners might have been involved in BPCR. Knowledge about the danger signs of obstetric complications is important for recognizing complications early and taking immediate actions to access essential emergency obstetric care.

Pregnant women who started their ANC services within three to four months of pregnancy were three times more likely to be prepared to practice BPCR compared with those who started late. This finding was in line with those of studies conducted in Robe woreda, Arsi Zone, Fango district, Wolayta Zone and Goba woreda [18, 21, 27]. This might indicate that there was a better exposure to information on BPCR during the repeated visits.

Rural pregnant women were 0.44 times less likely to be prepared for BPCR. That is, urban dwellers were more likely to be prepared for BPCR. This finding is similar to that of a study done in Goba woreda [18]. The possible reason could be that urban residence improves access to information, service, and BPCR practice.

Limitations of this study were since the design of our work was cross-sectional; it might not have been strong enough to demonstrate the cause and effect relationships between dependent and independent variables. In addition, as the data collectors were health professionals, there was a possibility of social desirability bias in the responses to some of the variables.

The present study identified that there has been poor preparedness for birth and complications. Residence, knowledge about BPCR and danger signs during pregnancy, gestational age, and the starting time of ANC service were significantly associated with BPCR practice.

Health professionals should create awareness on birth preparedness and complication readiness among pregnant mothers, families, or communities. Government officials, partners, and health care providers that are working in areas of maternal and child health should work together to ameliorate factors that influence the low practice of birth preparedness and complication readiness. Researchers need to conduct qualitative studies to explore the main reasons for their poor preparedness of pregnant women for birth and in cases of obstetric complications in order to bring significant changes in the reduction of maternal and neonatal deaths.