# Birth Preparedness and Complication Readiness Practice and Associated Factors among Pregnant Women, Northwest Ethiopia

Authors: Yewondwossen Bitew; Worku Awoke; Simachew Chekol
Journal: International Scholarly Research Notices
 (2016)

---

## Abstract

Background. Little is known about birth preparedness and complication readiness (BPCR) plan in resource limited settings to decrease maternal mortality. Therefore, this study was done to assess the status of BPCR and associated factors among pregnant women in South Wollo, Northwest Ethiopia, by involving 819 pregnant women from March to April, 2014. Data were collected by using pretested interviewer administered questionnaire and analyzed using a computer program of SPSS version 20.00.Results. Pregnant women who were prepared for at least three elements of BPCR were 24.1%. Pregnant women knowing at least three key danger signs during pregnancy, delivery, and postnatal period were 23.2%, 22.6%, and 9.6%, respectively. Women having secondary education and higher were 6.20 (95% CI = [1.36, 28.120]) times more likely to be prepared than illiterates. Women having a lifetime history of stillbirth [5.80 (1.13, 29.63)], attending ANC for last child pregnancy [5.44 (2.07, 14.27)], participating in community BPCR group discussion [4.36 (1.17, 16.26)], and having their male partner involved in BPCR counseling during ANC follow-up [4.45 (1.95, 10.16)] were more likely to be prepared.Conclusions. BPCR was very low and should be strengthened through health communication by involving partner in BPCR counseling.


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## Body

## 1. Background

Every pregnancy faces risks and every minute of every day, somewhere in the world, a woman dies as a result of complications arising during pregnancy and childbirth. The majority of these deaths are avoidable by accessing quality maternal health service [1, 2]. Globally, in year 2010, an estimated 287 000 maternal deaths occurred. Sub-Saharan Africa and Southern Asia accounted for 85% of the global burden (245,000 maternal deaths). Maternal mortality in developing regions was 15 times higher than in developed regions. Most of them died because they had no access to skilled routine and emergency care [3].Ethiopia as a sub-Saharan African country is characterized by very high maternal mortality, 676 maternal deaths per 100,000 live births, low coverage of ANC (34%), and low coverage of skilled delivery and immediate postpartum care (10% and 7%, resp.) [4]. About fifteen percent of pregnant women in Ethiopia are estimated to develop obstetric complications which are potentially life-threatening. An estimated 2.6 million births occur each year. Direct complication accounts for 85% of the deaths as well as many acute and chronic illnesses [5]. Maternal deaths in Ethiopia account for 30 percent of all deaths in women age 15–49 [4].Reduction of maternal mortality is a global priority and it is one of the millennium development goals [6]. The key to reducing maternal mortality ratio and improving maternal health is increasing attendance by skilled health personnel throughout pregnancy and delivery [7]. Birth preparedness and complication readiness is one of keys for safe motherhood strategy whose objective is to promote the timely use of skilled maternal and neonatal care during childbirth by making a birth plan and promoting active preparation and decision making for delivery of pregnant women and their families [8–11].In Ethiopia little has been documented on BPCR practice and most studies done on safe motherhood focus on service uptake, quality, and utilization. Therefore, this paper is designed to evaluate BPCR practice and associated factors among pregnant women with second and third trimester in South Wollo of Northwest Ethiopia. This study will contribute to provide evidence based knowledge on the current status of BPCR among pregnant women and provide basic data for service providers, policy makers, development partners, and programmers to design effective BPCR program intervention in an attempt to reduce highly maternal and neonatal mortality rate in Ethiopia.


## 2. Methods

### 2.1. Ethical Considerations

Ethical clearance was obtained from Bahir Dar University and GAMBY College of Medical Sciences. A formal letter for permission and support was taken from the Amhara Regional Health Bureau to South Wollo Zone Health Department and District Health Offices. Pregnant women were informed about the objective of the study and verbal informed consent was obtained before conducting the interview. Client’s privacy and confidentiality of the information was assured during the interview process. After data collected from each client, counseling and education on BPCR and key danger signs are provided for women and their families. Mothers who did not attend or discontinued the ANC services were referred to the nearby health center/hospital using a referral tool for ANC service.


### 2.2. Study Design and Period

A community-based cross-sectional study was conducted among pregnant women of second and third trimester of pregnancy in South Wollo Zone, Northwest Ethiopia, from March 1 to April 30, 2014. South Wollo Zone is one of the ten zones of Amhara National Regional State located 480 KM away from the Regional Capital, Bahir Dar.


### 2.3. Sample Size Determination

The sample size was determined using single population proportion formula. The following assumptions were considered: a level of confidence 95%, a 5% margin of error, and 50% proportion of pregnant mothers prepared for birth. Additional 10% allowance for none response rate and correction for multistage sampling design effect 2 were considered. The final sample size becomes 845 pregnant mothers. Then, the calculated sample size was proportionally allocated to districts of urban and rural Kebele (the smallest administrative unit in Ethiopia) based on the expected number of pregnant women. Each Kebele was selected using simple random sampling method and finally pregnant women were selected by systematic sampling using the updated list of pregnant women from each selected Kebele.


### 2.4. Inclusion Criteria

Those women with at least 3 months of current pregnancy, permanent resident of the study area, and who gave oral consent to participate were interviewed.


### 2.5. Exclusion Criteria

Women who were severely ill and incapable of being interviewed and those who were not able to give the oral consents to participate in the study were excluded.


### 2.6. Data Collection and Analysis

Structured questionnaires were adapted from a survey tool developed by JHPIEGO Maternal, Neonatal Health Program and translated into local Amharic language. Training was given for data collectors and supervisors on how to maintain a face-to-face interview, keeping the quality of data and ethical issues. The collected data were checked, cleaned, coded, entered, and analyzed using a computer program of SPSS version 20.00. Bivariate and multivariate logistic regression analyses were done. Crude and adjusted odds ratio (OR) with a corresponding 95% CI (confidence interval) was calculated to determine relationships between predictor variables and practice of birth preparedness and complication readiness.


## 2.1. Ethical Considerations

Ethical clearance was obtained from Bahir Dar University and GAMBY College of Medical Sciences. A formal letter for permission and support was taken from the Amhara Regional Health Bureau to South Wollo Zone Health Department and District Health Offices. Pregnant women were informed about the objective of the study and verbal informed consent was obtained before conducting the interview. Client’s privacy and confidentiality of the information was assured during the interview process. After data collected from each client, counseling and education on BPCR and key danger signs are provided for women and their families. Mothers who did not attend or discontinued the ANC services were referred to the nearby health center/hospital using a referral tool for ANC service.


## 2.2. Study Design and Period

A community-based cross-sectional study was conducted among pregnant women of second and third trimester of pregnancy in South Wollo Zone, Northwest Ethiopia, from March 1 to April 30, 2014. South Wollo Zone is one of the ten zones of Amhara National Regional State located 480 KM away from the Regional Capital, Bahir Dar.


## 2.3. Sample Size Determination

The sample size was determined using single population proportion formula. The following assumptions were considered: a level of confidence 95%, a 5% margin of error, and 50% proportion of pregnant mothers prepared for birth. Additional 10% allowance for none response rate and correction for multistage sampling design effect 2 were considered. The final sample size becomes 845 pregnant mothers. Then, the calculated sample size was proportionally allocated to districts of urban and rural Kebele (the smallest administrative unit in Ethiopia) based on the expected number of pregnant women. Each Kebele was selected using simple random sampling method and finally pregnant women were selected by systematic sampling using the updated list of pregnant women from each selected Kebele.


## 2.4. Inclusion Criteria

Those women with at least 3 months of current pregnancy, permanent resident of the study area, and who gave oral consent to participate were interviewed.


## 2.5. Exclusion Criteria

Women who were severely ill and incapable of being interviewed and those who were not able to give the oral consents to participate in the study were excluded.


## 2.6. Data Collection and Analysis

Structured questionnaires were adapted from a survey tool developed by JHPIEGO Maternal, Neonatal Health Program and translated into local Amharic language. Training was given for data collectors and supervisors on how to maintain a face-to-face interview, keeping the quality of data and ethical issues. The collected data were checked, cleaned, coded, entered, and analyzed using a computer program of SPSS version 20.00. Bivariate and multivariate logistic regression analyses were done. Crude and adjusted odds ratio (OR) with a corresponding 95% CI (confidence interval) was calculated to determine relationships between predictor variables and practice of birth preparedness and complication readiness.


## 3. Results

### 3.1. Sociodemographic Characteristics

A total number of 845 pregnant women of second and third trimester were approached and 819 participated making the response rate 96.9%. As shown in Table1, 84.1% of women were from the rural area, 93.5% of them were married by their marital status, 76.4% were Muslim by their religion category, and 81.1% were housewives. The majority (60.2%) has an average monthly income of less than 1000 Ethiopian birr (Table 1).Table 1
Sociodemographic characteristics of mothers (N = 819) in South Wollo Zone, Northeast Ethiopia, April, 2014.
Characteristics
N
%
District
Tehuledere
172
21
Kalu
257
31.4
Woreyilu
161
19.7
Borena
229
28
Residence
Rural
689
84.1
Urban
130
15.9
Age
15–24
306
37.4
25–34
406
49.6
≥35
107
13.1
Marital status
Married
766
93.5
Other
53
6.5
Maternal education
Unable to read and write
442
54
Primary education
235
28.7
Secondary education and above
142
17.3
Occupation
Housewife
664
81.1
Employed
89
10.9
Farmer
66
8.1
Religion
Muslim
626
76.4
Orthodox
193
23.6
Income
≤1000 birr
493
60.2
≥1001 birr
326
39.8
Travel time
≤one hour
464
56.7
>one hour
355
43.3
Family size
1–3
345
42.1
4–6
326
39.8
≥7
148
18.1


### 3.2. Obstetric Characteristics of Respondents

The majority of (77.2% and 86.9%) the mothers were gravida and parity of five and above, respectively. Before the current pregnancy, only 39.6% of the respondents received ANC at health center and hospital level and 60.4% did not get ANC for last child pregnancy. Only 15.7% of women delivered at health facility and 5.9% of them experienced a lifetime history of stillbirth and only 10.1% received PNC services for last childbirth (Table2).Table 2
Obstetric characteristics of respondents in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
Gravidity (n
=
819)
<5
632
77.2
≥5
187
22.8
Parity (n
=
819)
<5
712
86.9
≥5
107
13.1
History of stillbirth (n
=
593)
Yes
35
5.9
No
558
94.1
ANC for last child pregnancy (n
=
593)
Yes
235
39.6
No
358
60.4
Delivery for last child (n
=
593)
Home/TBA home
501
84.3
Health facility
92
15.5
PNC for last childbirth (n
=
593)
Yes
60
10.1
No
533
89.9
Trimester (n
=
891)
Second
372
45.4
Third
447
54.6


### 3.3. Pregnant Women Attending Antenatal Care (ANC)

Majority (71.8%) of pregnant mothers attended the ANC service at health facility level; however only 68.0% received information about BPCR. More than half of them (66.7%) decided to give birth at the health facility and more than a quarter (26.1%) still undecided the place where they will give birth for the current pregnancy. From all mothers who attended the ANC, only 41.3% of their partners were counseled to BPCR by health care providers. According to pregnant women response, only 44.5% of their partners decided on place of birth and the majority of them decided health facility as the place of delivery (Table3).Table 3
Proportion of pregnant women attending antenatal care in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
ANC practice for current pregnancy (n
=
819)
None attended
231
28.2
Attended 1st visit
318
54.1
Attended 2nd-3rd visit
164
27.8
Attended 4th and above visit
106
18.1
Receive BPCR counseling during ANC visit (n
=
588)
Yes
400
68
No/I do not remember
188
32
Partners counseled about BPCR (n
=
547)
Yes
226
41.3
No
321
58.7
Married couples’ male partner decision on place of birth for current childbirth (n
=
766)
Yes
341
44.5
No/I do not know
425
55.5
Place of male partner decision on place of birth (n
=
341)
Health institution
313
91.8
Home/TBA home
28
8.2
Pregnant women’s decision on place of delivery (n
=
819)
Health institution
546
66.7
Undecided
214
26.1
Home/TBA home
59
7.2


### 3.4. Knowledge of Respondents on Obstetric Danger Sign

According to the findings of this study, the proportions of pregnant women who know at least three danger signs during pregnancy, delivery, and postnatal period were 23.2%, 22.6%, and 9.6%, respectively (Table4). Regarding knowledge of key danger signs, severe vaginal bleeding has been the most frequently mentioned complication by women during the following phases: pregnancy (37.4%), labor and delivery (44.6%), and postpartum period (32.1%). Prolonged labor, which is one of the top five major causes of maternal mortality and top most causes of morbidity in low-income countries, was reported by 49.7% of mothers (Table 5).Table 4
Proportion of women (n
=
819) reporting key danger signs of pregnancy, childbirth, and postnatal period in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
Knowing at least three danger signs of pregnancy
190
23.2
Knowing at least one danger sign of pregnancy
533
65.1
Knowing at least three danger signs of labor and delivery
185
22.6
Knowing at least one danger sign of labor and delivery
591
72.2
Knowing at least three danger signs of postnatal period
79
9.6
Knowing at least one postnatal period danger sign
409
49.9Table 5
Proportion of women (n
=
819) who reported types of key danger signs during pregnancy, childbirth, and postpartum period in South Wollo Zone, Northeast Ethiopia, April, 2014.
Key danger signs
⁢Pregnancy
⁢Labor and delivery
PNC
N
%
N
%
N
%
Vaginal bleeding
306
37.4
365
44.6
263
32.1
Severe headache
80
9.8
50
6.1
47
5.7
Blurred vision
49
6
—
—
21
2.5
Convulsion
22
2.7
14
1.7
11
1.3
Swelling of face and feet
86
10.5
—
—
47
5.7
Fever
171
20.9
84
10.2
110
13.4
Loss of consciousness
28
3.4
24
3
—
—
Difficulty of breathing
30
3.7
—
—
14
1.7
Sever weakness
79
9.6
—
—
68
8.3
Severe abdominal pain
148
18
—
—
—
—
Accelerated/reduced fetal movement
166
20.3
—
—
—
—
Water breaks without labor
25
3
—
—
—
—
Prolonged labor
—
—
407
49.7
—
—
Placenta not delivered within 30 minutes
—
—
275
33.6
—
—
Malodorous vaginal discharge
102
12.5


### 3.5. Birth Preparedness and Complication Readiness

The prevalence of birth preparedness and complication readiness among pregnant women prepared for birth by practicing at least three of the following variables: identify place of delivery, save money, identify skilled provider, be aware of key danger signs and act on immediately, designate decision maker, identify source of support in case of emergency, arrange transport, EMOC, blood donor, and emergency, was found to be 197 (24.1%). 366 (44.6%) reported that they identified place of delivery, 354 (43.2%) saved money, and 286 (34.9%) prepared essential items for clean and safe delivery for birth preparation. The same as that of the practice 43.7%, 37.5%, 36.6%, and 30.4% pregnant women mentioned place of delivery, saving money, preparing essential items to clean and safe delivery, and emergency fund, respectively. But arranging transport, emergency obstetric care (EMOC), and blood donor are less mentioned and practiced by mothers (Table6).Table 6
Proportion of women who know BPCR plan and practice in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
Know at least three BPCR plans
218
26.6
Practice at least three BPCR plans
197
24.1
Identify place of delivery
358
43.7
Save money
307
37.5
Prepare essential items for clean and safe delivery
300
36.6
Identify skilled provider
176
21.5
Identify danger signs
66
8
Designate decision maker to her
24
2.9
Identify source of support
28
3.4
Arrange emergency fund
252
30.7
Arrange transport
89
10.8
Arrange blood donor
9
1
Emergency obstetric care (EMOC)
56
6.8


### 3.6. Source of Information

The majority (72.2%) heard about the term BPCR and their source of information is health care providers (82.9%). More than half (60.8%) of mothers participated in community meetings and/or pregnant women group discussions BPCR health communication organized by health extension workers and health care providers working at the Primary Health Care Unit (Table7).Table 7
Proportion of women who heard about BPCR and their source of information in South Wollo Zone, Northwest Ethiopia.
Variable
N
%
Participated BPCR related community meeting/pregnant women group discussion (n
=
819)
498
60.8
Heard about BPCR (n
=
819)
591
72.2
Source of information (n
=
591)
Health care providers
490
82.9
Pregnant women group discussion
172
29.1
Health development army
141
23.9
Mass media
90
15.2


### 3.7. Factors Associated with BPCR Practice

On the bivariate logistic regression analysis, variables like place of residence, educational status, occupation, travel time to reach nearby HC/hospital, income, parity, gravidity, previous lifetime history of stillbirth, history of ANC follow-up for last child pregnancy, history of institutional delivery for last childbirth, history of postnatal care for last delivery, gestational age, knowledge of pregnant women of at least three key danger signs of pregnancy and labor and delivery and postnatal period, women’s participation in BPCR related community meetings and/or pregnant women’s group discussions, and ANC follow-up were found to be significantly associated factors with BPCR practice.After analysis of confounding factors educational status of secondary education and above, previous history of lifetime stillbirth, history of ANC follow-up for last childbirth, the third trimester, women’s participation in BPCR community meetings and/or pregnant women’s group discussion, and current ANC follow-up of two and above visits, and partner involvement in BPCR counseling during women’s ANC follow-up were found to be highly significant with BPCR practice. Pregnant mothers with educational status of secondary education and above were more likely to be prepared for birth and complication by 6 times (AOR = 6.20, 95% CI = [1.36, 28.12]) as compared to pregnant women who are unable to read and write. Women who face a lifetime history of stillbirth were about 6 times (AOR = 5.80, 95% CI = [1.13, 29.63]) more likely to be prepared than women’s who did not. Mothers with a history of ANC visits during the last child pregnancy were more likely to be prepared for birth and complication by 5 times (AOR = 5.44, 95% CI = [2.07, 14.27]) than women who did not undertake ANC follow-up. Women with gestational period of the third trimester were more likely prepared for birth and complication by 8 times (AOR = 7.60, 95% CI = [2.82, 20.45]). Pregnant women who were participating in community level BPCR plan meeting and/or pregnant women group discussion on BPCR plan and antenatal care follow-up were also found to be strong predictors for BPCR practice. Pregnant women who participate in community level meeting and/or pregnant women group discussion on BPCR plan were prepared for birth and complication by 4 times (AOR = 4.36, 95% CI = [1.17, 16.21]) as compared to nonparticipants. Mothers attending two-three ANC visits and four and above visits for current pregnancy were more likely prepared for BPCR practice by 6 times (AOR = 6.20, 95% CI = [2.62,14.68]) and 7.6 times (AOR = 7.69, 95% CI = [19.02,31.09]), respectively, as compared to non-ANC attendant mothers and mothers attending only one ANC visit. Those pregnant women whose partners are involved in BPCR counseling with pregnant women during ANC follow-up were prepared for BPCR practice by 4 times as compared to noncounseled married couples on women’s ANC follow-up (AOR = 4.45, 95% CI = [1.95,10.16]) (Table 8).Table 8
Factors associated with BPCR practice in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
⁢BPCR practice
COR (95% CI)
AOR (95% CI)
Yes
No
Education
Unable to read and write
59
383
1
1
Primary
57
178
2.07 (1.38, 3.11)
0.86 (0.33, 2.26)
Secondary and above
81
61
8.61 (5.60, 13.26)
6.20
(
1.36,28.12
)
∗
Lifetime history of stillbirth
No
126
432
1
1
Yes
25
10
8.57 (4.01, 18.32)
5.80
(
1.13,29.63
)
∗
Practice ANC for last child pregnancy
No
47
311
1
1
Yes
104
131
5.25 (3.52, 7.84)
5.44
(
2.07,14.27
)
∗
Delivery practice for last childbirth
Home
95
406
1
1
Health institution
104
36
6.64 (4.13, 10.68)
0.37 (0.09, 1.54)
PNC practice for last childbirth
No
111
420
1
1
Yes
38
22
6.42 (3.65, 11.29)
1.22 (0.31, 4.78)
Trimester
Second
31
341
1
1
Third
166
281
6.49 (4.29, 9.83)
7.60
(
2.82,20.45
)
∗
Knowledge of at least three danger signs of pregnancy
No
93
536
1
1
Yes
104
86
6.69 (4.69, 9.67)
2.13 (0.85, 5.28)
Knowledge of at least three danger signs of labor and delivery
No
96
538
1
1
Yes
101
84
6.73 (4.69, 9.67)
0.99 (0.39, 2.47)
Knowledge of at least three danger signs of postnatal period
No
420
22
1
1
Yes
111
38
6.42 (3.65, 11.29)
2.48 (0.65, 9.35)
Women BPCR plan community meeting participation
No
15
306
1
1
Yes
182
316
11.74 (6.78, 20.35)
4.36
(
1.17,16.21
)
∗
ANC attendance (visit)
Less than or equal to one visit
44
505
1
1
Attended 2-3 visits
75
89
9.67 (6.26, 14.94)
6.20
(
2.62,14.68
)
∗
Attended 4 and above visits
78
28
31.97 (18.81, 15.3)
76.91
(
19.02,31.09
)
∗
Male partner counseled on BPCR during women ANC follow-up
No
97
270
1
1
Yes
129
51
7.04 (4.72, 10.49)
4.45
(
1.95,10.16
)
∗
Remark:∗(significant at P value < 0.05).


## 3.1. Sociodemographic Characteristics

A total number of 845 pregnant women of second and third trimester were approached and 819 participated making the response rate 96.9%. As shown in Table1, 84.1% of women were from the rural area, 93.5% of them were married by their marital status, 76.4% were Muslim by their religion category, and 81.1% were housewives. The majority (60.2%) has an average monthly income of less than 1000 Ethiopian birr (Table 1).Table 1
Sociodemographic characteristics of mothers (N = 819) in South Wollo Zone, Northeast Ethiopia, April, 2014.
Characteristics
N
%
District
Tehuledere
172
21
Kalu
257
31.4
Woreyilu
161
19.7
Borena
229
28
Residence
Rural
689
84.1
Urban
130
15.9
Age
15–24
306
37.4
25–34
406
49.6
≥35
107
13.1
Marital status
Married
766
93.5
Other
53
6.5
Maternal education
Unable to read and write
442
54
Primary education
235
28.7
Secondary education and above
142
17.3
Occupation
Housewife
664
81.1
Employed
89
10.9
Farmer
66
8.1
Religion
Muslim
626
76.4
Orthodox
193
23.6
Income
≤1000 birr
493
60.2
≥1001 birr
326
39.8
Travel time
≤one hour
464
56.7
>one hour
355
43.3
Family size
1–3
345
42.1
4–6
326
39.8
≥7
148
18.1


## 3.2. Obstetric Characteristics of Respondents

The majority of (77.2% and 86.9%) the mothers were gravida and parity of five and above, respectively. Before the current pregnancy, only 39.6% of the respondents received ANC at health center and hospital level and 60.4% did not get ANC for last child pregnancy. Only 15.7% of women delivered at health facility and 5.9% of them experienced a lifetime history of stillbirth and only 10.1% received PNC services for last childbirth (Table2).Table 2
Obstetric characteristics of respondents in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
Gravidity (n
=
819)
<5
632
77.2
≥5
187
22.8
Parity (n
=
819)
<5
712
86.9
≥5
107
13.1
History of stillbirth (n
=
593)
Yes
35
5.9
No
558
94.1
ANC for last child pregnancy (n
=
593)
Yes
235
39.6
No
358
60.4
Delivery for last child (n
=
593)
Home/TBA home
501
84.3
Health facility
92
15.5
PNC for last childbirth (n
=
593)
Yes
60
10.1
No
533
89.9
Trimester (n
=
891)
Second
372
45.4
Third
447
54.6


## 3.3. Pregnant Women Attending Antenatal Care (ANC)

Majority (71.8%) of pregnant mothers attended the ANC service at health facility level; however only 68.0% received information about BPCR. More than half of them (66.7%) decided to give birth at the health facility and more than a quarter (26.1%) still undecided the place where they will give birth for the current pregnancy. From all mothers who attended the ANC, only 41.3% of their partners were counseled to BPCR by health care providers. According to pregnant women response, only 44.5% of their partners decided on place of birth and the majority of them decided health facility as the place of delivery (Table3).Table 3
Proportion of pregnant women attending antenatal care in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
ANC practice for current pregnancy (n
=
819)
None attended
231
28.2
Attended 1st visit
318
54.1
Attended 2nd-3rd visit
164
27.8
Attended 4th and above visit
106
18.1
Receive BPCR counseling during ANC visit (n
=
588)
Yes
400
68
No/I do not remember
188
32
Partners counseled about BPCR (n
=
547)
Yes
226
41.3
No
321
58.7
Married couples’ male partner decision on place of birth for current childbirth (n
=
766)
Yes
341
44.5
No/I do not know
425
55.5
Place of male partner decision on place of birth (n
=
341)
Health institution
313
91.8
Home/TBA home
28
8.2
Pregnant women’s decision on place of delivery (n
=
819)
Health institution
546
66.7
Undecided
214
26.1
Home/TBA home
59
7.2


## 3.4. Knowledge of Respondents on Obstetric Danger Sign

According to the findings of this study, the proportions of pregnant women who know at least three danger signs during pregnancy, delivery, and postnatal period were 23.2%, 22.6%, and 9.6%, respectively (Table4). Regarding knowledge of key danger signs, severe vaginal bleeding has been the most frequently mentioned complication by women during the following phases: pregnancy (37.4%), labor and delivery (44.6%), and postpartum period (32.1%). Prolonged labor, which is one of the top five major causes of maternal mortality and top most causes of morbidity in low-income countries, was reported by 49.7% of mothers (Table 5).Table 4
Proportion of women (n
=
819) reporting key danger signs of pregnancy, childbirth, and postnatal period in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
Knowing at least three danger signs of pregnancy
190
23.2
Knowing at least one danger sign of pregnancy
533
65.1
Knowing at least three danger signs of labor and delivery
185
22.6
Knowing at least one danger sign of labor and delivery
591
72.2
Knowing at least three danger signs of postnatal period
79
9.6
Knowing at least one postnatal period danger sign
409
49.9Table 5
Proportion of women (n
=
819) who reported types of key danger signs during pregnancy, childbirth, and postpartum period in South Wollo Zone, Northeast Ethiopia, April, 2014.
Key danger signs
⁢Pregnancy
⁢Labor and delivery
PNC
N
%
N
%
N
%
Vaginal bleeding
306
37.4
365
44.6
263
32.1
Severe headache
80
9.8
50
6.1
47
5.7
Blurred vision
49
6
—
—
21
2.5
Convulsion
22
2.7
14
1.7
11
1.3
Swelling of face and feet
86
10.5
—
—
47
5.7
Fever
171
20.9
84
10.2
110
13.4
Loss of consciousness
28
3.4
24
3
—
—
Difficulty of breathing
30
3.7
—
—
14
1.7
Sever weakness
79
9.6
—
—
68
8.3
Severe abdominal pain
148
18
—
—
—
—
Accelerated/reduced fetal movement
166
20.3
—
—
—
—
Water breaks without labor
25
3
—
—
—
—
Prolonged labor
—
—
407
49.7
—
—
Placenta not delivered within 30 minutes
—
—
275
33.6
—
—
Malodorous vaginal discharge
102
12.5


## 3.5. Birth Preparedness and Complication Readiness

The prevalence of birth preparedness and complication readiness among pregnant women prepared for birth by practicing at least three of the following variables: identify place of delivery, save money, identify skilled provider, be aware of key danger signs and act on immediately, designate decision maker, identify source of support in case of emergency, arrange transport, EMOC, blood donor, and emergency, was found to be 197 (24.1%). 366 (44.6%) reported that they identified place of delivery, 354 (43.2%) saved money, and 286 (34.9%) prepared essential items for clean and safe delivery for birth preparation. The same as that of the practice 43.7%, 37.5%, 36.6%, and 30.4% pregnant women mentioned place of delivery, saving money, preparing essential items to clean and safe delivery, and emergency fund, respectively. But arranging transport, emergency obstetric care (EMOC), and blood donor are less mentioned and practiced by mothers (Table6).Table 6
Proportion of women who know BPCR plan and practice in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
N
%
Know at least three BPCR plans
218
26.6
Practice at least three BPCR plans
197
24.1
Identify place of delivery
358
43.7
Save money
307
37.5
Prepare essential items for clean and safe delivery
300
36.6
Identify skilled provider
176
21.5
Identify danger signs
66
8
Designate decision maker to her
24
2.9
Identify source of support
28
3.4
Arrange emergency fund
252
30.7
Arrange transport
89
10.8
Arrange blood donor
9
1
Emergency obstetric care (EMOC)
56
6.8


## 3.6. Source of Information

The majority (72.2%) heard about the term BPCR and their source of information is health care providers (82.9%). More than half (60.8%) of mothers participated in community meetings and/or pregnant women group discussions BPCR health communication organized by health extension workers and health care providers working at the Primary Health Care Unit (Table7).Table 7
Proportion of women who heard about BPCR and their source of information in South Wollo Zone, Northwest Ethiopia.
Variable
N
%
Participated BPCR related community meeting/pregnant women group discussion (n
=
819)
498
60.8
Heard about BPCR (n
=
819)
591
72.2
Source of information (n
=
591)
Health care providers
490
82.9
Pregnant women group discussion
172
29.1
Health development army
141
23.9
Mass media
90
15.2


## 3.7. Factors Associated with BPCR Practice

On the bivariate logistic regression analysis, variables like place of residence, educational status, occupation, travel time to reach nearby HC/hospital, income, parity, gravidity, previous lifetime history of stillbirth, history of ANC follow-up for last child pregnancy, history of institutional delivery for last childbirth, history of postnatal care for last delivery, gestational age, knowledge of pregnant women of at least three key danger signs of pregnancy and labor and delivery and postnatal period, women’s participation in BPCR related community meetings and/or pregnant women’s group discussions, and ANC follow-up were found to be significantly associated factors with BPCR practice.After analysis of confounding factors educational status of secondary education and above, previous history of lifetime stillbirth, history of ANC follow-up for last childbirth, the third trimester, women’s participation in BPCR community meetings and/or pregnant women’s group discussion, and current ANC follow-up of two and above visits, and partner involvement in BPCR counseling during women’s ANC follow-up were found to be highly significant with BPCR practice. Pregnant mothers with educational status of secondary education and above were more likely to be prepared for birth and complication by 6 times (AOR = 6.20, 95% CI = [1.36, 28.12]) as compared to pregnant women who are unable to read and write. Women who face a lifetime history of stillbirth were about 6 times (AOR = 5.80, 95% CI = [1.13, 29.63]) more likely to be prepared than women’s who did not. Mothers with a history of ANC visits during the last child pregnancy were more likely to be prepared for birth and complication by 5 times (AOR = 5.44, 95% CI = [2.07, 14.27]) than women who did not undertake ANC follow-up. Women with gestational period of the third trimester were more likely prepared for birth and complication by 8 times (AOR = 7.60, 95% CI = [2.82, 20.45]). Pregnant women who were participating in community level BPCR plan meeting and/or pregnant women group discussion on BPCR plan and antenatal care follow-up were also found to be strong predictors for BPCR practice. Pregnant women who participate in community level meeting and/or pregnant women group discussion on BPCR plan were prepared for birth and complication by 4 times (AOR = 4.36, 95% CI = [1.17, 16.21]) as compared to nonparticipants. Mothers attending two-three ANC visits and four and above visits for current pregnancy were more likely prepared for BPCR practice by 6 times (AOR = 6.20, 95% CI = [2.62,14.68]) and 7.6 times (AOR = 7.69, 95% CI = [19.02,31.09]), respectively, as compared to non-ANC attendant mothers and mothers attending only one ANC visit. Those pregnant women whose partners are involved in BPCR counseling with pregnant women during ANC follow-up were prepared for BPCR practice by 4 times as compared to noncounseled married couples on women’s ANC follow-up (AOR = 4.45, 95% CI = [1.95,10.16]) (Table 8).Table 8
Factors associated with BPCR practice in South Wollo Zone, Northeast Ethiopia, April, 2014.
Variable
⁢BPCR practice
COR (95% CI)
AOR (95% CI)
Yes
No
Education
Unable to read and write
59
383
1
1
Primary
57
178
2.07 (1.38, 3.11)
0.86 (0.33, 2.26)
Secondary and above
81
61
8.61 (5.60, 13.26)
6.20
(
1.36,28.12
)
∗
Lifetime history of stillbirth
No
126
432
1
1
Yes
25
10
8.57 (4.01, 18.32)
5.80
(
1.13,29.63
)
∗
Practice ANC for last child pregnancy
No
47
311
1
1
Yes
104
131
5.25 (3.52, 7.84)
5.44
(
2.07,14.27
)
∗
Delivery practice for last childbirth
Home
95
406
1
1
Health institution
104
36
6.64 (4.13, 10.68)
0.37 (0.09, 1.54)
PNC practice for last childbirth
No
111
420
1
1
Yes
38
22
6.42 (3.65, 11.29)
1.22 (0.31, 4.78)
Trimester
Second
31
341
1
1
Third
166
281
6.49 (4.29, 9.83)
7.60
(
2.82,20.45
)
∗
Knowledge of at least three danger signs of pregnancy
No
93
536
1
1
Yes
104
86
6.69 (4.69, 9.67)
2.13 (0.85, 5.28)
Knowledge of at least three danger signs of labor and delivery
No
96
538
1
1
Yes
101
84
6.73 (4.69, 9.67)
0.99 (0.39, 2.47)
Knowledge of at least three danger signs of postnatal period
No
420
22
1
1
Yes
111
38
6.42 (3.65, 11.29)
2.48 (0.65, 9.35)
Women BPCR plan community meeting participation
No
15
306
1
1
Yes
182
316
11.74 (6.78, 20.35)
4.36
(
1.17,16.21
)
∗
ANC attendance (visit)
Less than or equal to one visit
44
505
1
1
Attended 2-3 visits
75
89
9.67 (6.26, 14.94)
6.20
(
2.62,14.68
)
∗
Attended 4 and above visits
78
28
31.97 (18.81, 15.3)
76.91
(
19.02,31.09
)
∗
Male partner counseled on BPCR during women ANC follow-up
No
97
270
1
1
Yes
129
51
7.04 (4.72, 10.49)
4.45
(
1.95,10.16
)
∗
Remark:∗(significant at P value < 0.05).


## 4. Discussion

The study revealed that only 24.1% of currently pregnant women of second and third trimester were prepared for delivery and obstetric emergency by practicing at least three elements of BPCR (identify place of delivery, save money, prepare essential items for clean and safe delivery, identify skilled provider, be aware of key danger signs and act on immediately, designate decision maker, identify source of support in case of emergency, arrange transport, EMOC, blood donor, and emergency fund). This result is encouraging as compared to the study done at Aleta Wondo (7%) [12] and Adegerat (22%) [13] but much less as compared to Uganda (35%) [14]. Some of them had made decisions on critical components of birth preparedness and complication readiness, including identifying the place of delivery (44.6%), saving money (43.2%), preparing essential items for clean and safe delivery (34.9%), and arranging for emergency fund (30.8%). Only a few (13.3%) of pregnant women made adequate arrangements for transportation to a health facility in case of an obstetric emergency. This is far reaching as compared to Uganda, Burkina Faso, and Nigeria [14–16].The level of BPCR preparation was significantly associated with ANC follow-up for the current pregnancy, maternal education, community level BPCR meeting and/or pregnant women’s group discussion participation, previous history on ANC follow-up for last child pregnancy and lifetime history of stillbirth, gestational age, and male partner involvement in BPCR counseling on women ANC follow-up period after adjusting possible confounding factors. Regarding maternal education, secondary and above educated mothers were more likely prepared for birth and complication readiness practice by six (6) times as compared to pregnant women who are unable to read and write. The finding was consistent with studies done in Nigeria [17], Kenya [18], and Ethiopia [13]. A woman who faced a lifetime history of stillbirth was about 6 times more likely than women’s who did not. This finding was in agreement with study done at Adegerat, Ethiopia [13].Mothers, attending two-three ANC visits, were more likely prepared for BPCR practice by 6 times and 7.6 times, respectively, as compared to non-ANC attendant mothers and mothers attending only one ANC visit. Studies conducted in Aleta Wondo, Ethiopia [13], and Burkina Faso [15] showed that women who follow an optimum number of ANC visits prepared for birth and complication as compared to non-ANC. Moreover, mothers with a history of ANC practice for last child pregnancy are more likely prepared for birth and complication by 5 times than women who did not undertake ANC follow-up for last child pregnancy. This may be due to BPCR readiness counseling that women received for last child pregnancy on their ANC follow-up.Pregnant women who participated in community level meeting and/or pregnant women group discussion on BPCR plan were prepared for birth and complication by 4 times as compared to nonparticipants. This finding revealed the effectiveness of pregnant women small group discussion and/or community level behavioral change intervention Federal Ministry of Health of Ethiopia FMOH strategy to improve service uptake of institutional delivery [19]. Pregnant women with male partner involved in BPCR counseling during ANC follow-up were prepared for BPCR practice by 4 times as compared to noncounseled married couples on women’s ANC follow-up. This may show how the decision making power in the family affects BPCR practice.Knowledge of danger signs of obstetric complication is the first step motivating women to seek timely, skilled birth attendance care at appropriate health facility. Every woman should be made aware of the likelihood of complications during pregnancy, childbirth/labor, and the postpartum periods. Women and their spouses and community members should be given all the information on danger signs [20]. The proportion of women with knowledge of at least three key danger signs each of pregnancy (23.2%), labor (22.6%), and postpartum period (9.6%) is low but encouraging as compared to Kenya (pregnancy danger sign, 6.9%) [18] and Adegerat, Ethiopia (knowledge of at least three danger signs of pregnancy (3.9%), labor and childbirth (0.4%), and postpartum period (0.4%)) [13].Regular attendance to antenatal care in the course of pregnancy is important in monitoring the physical status of the women and the fetus, detecting diseases and complications, and providing appropriate treatment and care. It also provides an opportunity to inform and educate pregnant women about pregnancy, childbirth, and care of the newborn and therefore enable pregnant women acquire information on danger signs of pregnancy or childbirth. Furthermore, it gives an opportunity for the woman to be counseled and make an appropriate plan for delivery [10]. In the study area, majority of the women (72%) attended antenatal care from nearby health centers and hospitals. This finding is much higher and encouraging than the EDHS 2010 (34%) [4]. A large proportion, 66.7%, of women reported that they intended to give birth at the health institution, and only 7.2% planned to deliver at home and the remaining 26.6% are still undecided on the place where they plan to give birth. This finding is much encouraging as compared to the study conducted at Aleta Wondo District of Southern Ethiopia, where only 8% of pregnant women plan to deliver at health institution [12]. Though birth preparedness and complication readiness (BPCR) plan is known as a fundamental component of all antenatal care (ANC) programs to decrease maternal mortality, it is very low in such similar resource limited settings. Using such findings is vital for evidence based decision making.


## 5. Conclusion

BPCR of pregnant women in the study area was low. Pregnant women of secondary and above educational level face lifetime history of stillbirth, with previous history of ANC follow-up for last child pregnancy, gestational period of third trimester, ANC follow-up of two and above visits, participated community level BPCR discussions, and their male partner counsel with her on BPCR which were main factors associated with BPCR practice. As recommendation, the health sectors should strengthen efforts of initiating all pregnant women in getting quality and optimum numbers of ANC visits and involving their partner in BPCR counseling during women’s ANC follow-up period and strengthen community level BPCR health communication with pregnant women group discussion, families, and communities and strengthen efforts of taking appropriate decision in case of complications to reach health facilities for normal or complicated childbirth.



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*Source: 8727365-2016-09-18.xml*