Birth Preparedness in Ethiopia (2022) PDF

# Birth preparedness, complication readiness and associated factors among pregnant women attending public health facilities in Chelia District, Central Ethiopia (2022): a cross-sectional study ## Abstract **Background** Birth preparedness and complication readiness (BPCR) are essential components...

# Birth preparedness, complication readiness and associated factors among pregnant women attending public health facilities in Chelia District, Central Ethiopia (2022): a cross-sectional study ## Abstract **Background** Birth preparedness and complication readiness (BPCR) are essential components of maternal health that encourage proactive planning and decision-making during pregnancy and childbirth. However, there is limited information available regarding the status of BPCR, particularly in our study area. Therefore, this study aimed to assess birth preparedness, complication readiness and associated factors among pregnant women attending public health facilities in the Chelia District. **Methods** A facility-based cross-sectional study was conducted among 410 pregnant women at public health facilities, using a systematic random sampling method. Descriptive statistics, such as frequencies, and summary statistics were calculated for the relevant variables. Bivariate and multivariate binary logistic regression analyses were performed to evaluate the relationship between dependent and independent variables. The strength of the association was measured using an OR with a 95% CI. Statistical significance was determined at a p value of 0.05. **Results** A total of 406 mothers participated in the study, resulting in a 99% response rate. The study found that 245 (60.3%) respondents were well-prepared for birth and complication readiness. Several factors such as: family size (adjusted odds ratios (AOR)=0.18; 95% CI (0.09 to 0.35)), decision-making with husbands (AOR=2.43, 95% CI (1.44 to 3.32)), parity (AOR=0.32; 95% CI (0.16 to 0.62)), lack of awareness about birth preparedness (AOR=0.30; 95% CI (0.16 to 0.57)), not knowing about the existence of a waiting home (AOR=0.31; 95% CI (0.19 to 0.48)) and not participating in a pregnant women's conference (AOR=0.50; 95% CI (0.32 to 0.79)) were significantly associated with BPCR. **Conclusion** The study found that the level of BPCR is low in the study area. Family size, decision-making with husbands, awareness of maternity waiting homes, participation in pregnant women's conferences, knowledge about BPCR and parity were significantly associated with BPCR. Therefore, strengthening pregnant women's conferences, encouraging husband involvement in decision-making and ensuring maternity waiting homes at health facilities are important. ## Strengths and Limitations of this study - Efforts were made to minimize recall bias. - The cross-sectional design may limit the ability to establish direct cause-and-effect relationships between dependent and independent variables. - The study only included pregnant women attending antenatal care at public health facilities, excluding those who sought care at private health institutions. - Additionally, the results of this facility-based cross-sectional study may not be generalisable to the entire population. ## Introduction Birth preparedness and complication readiness (BPCR) are strategies designed to promote the timely use of skilled maternal and neonatal care, particularly during childbirth. These strategies are based on the theory of preparing for childbirth and being ready for potential complications during the birth process. Birth preparedness involves identifying a skilled healthcare provider and making necessary arrangements to ensure access to skilled care for all births. In the context of emergency obstetric care, greater emphasis is placed on complication readiness, which includes preparing emergency funds, arranging transportation, identifying a blood donor and appointing a decision-maker. Birth preparedness and complication readiness (BPCR) is a critical component of the antenatal care (ANC) package recommended by the WHO. This approach is designed to enhance the utilization and effectiveness of essential maternal and newborn health services. The BPCR programme emphasizes the importance of being prepared for childbirth and ready to address any complications that may arise. The primary factors preventing women from accessing or receiving care during pregnancy and childbirth include poverty, distance from healthcare facilities, and lack of information, inadequate and poor-quality services, as well as cultural beliefs and practices. BPCR promotes active birth planning and decision-making among women and their families. It involves selecting a skilled birth attendant (SBA), determining the most suitable care facility, arranging transportation for both birth and obstetric emergencies, and identifying two potential blood donors. Additionally, it includes saving money for delivery and emergency expenses, designating someone to care for the family in the mother's absence and preparing all necessary supplies for the baby and postnatal care. This planning is done with consideration of the expected delivery date and awareness of key warning signs for obstetric complications. The global maternal mortality ratio (MMR) is estimated at 211 deaths per 100 000 live births. Sub-Saharan Africa and Southern Asia together account for approximately 66% and 20% of the global maternal deaths, respectively. In Sub-Saharan Africa, the maternal mortality rate is 18.2%, compared with just 0.5% in Europe. The rate is notably high in landlocked developing countries, at 17.5%. In Ethiopia, the maternal mortality rate was 401 deaths per 100 000 live births in 2017. Each year, approximately half a million women die worldwide due to pregnancy-related complications. Major causes of maternal mortality include: haemorrhage, 27.1% (with more than 72.6% of these deaths classified as postpartum haemorrhage); hypertension, 14.0%; sepsis, 10.7%; abortion outcomes, 7.9%; and embolism and other direct causes, 12.8%. These complications during pregnancy and childbirth are significant contributors to maternal mortality." Ethiopia experiences high maternal and neonatal mortality rates due to insufficient use of BPCR plans. Contributing factors include low awareness of danger signs, inadequate transportation, insufficient funds and a lack of prepared blood donors. According to the Ethiopia Demographic and Health Survey (EDHS) 2016 and Ethiopian Mini Demographic and Health Survey (EMDHS) 2019, BPCR in Ethiopia remains low. The EDHS 2016 reported a pregnancy-related mortality ratio of 412 deaths per 100 000 live births and a neonatal mortality rate of 29 deaths per 1000 live births. The EMDHS 2019 showed a slight increase in neonatal mortality, with a rate of 30 deaths per 1000 live births. Ethiopia is among the countries with low BPCR practices, at just 32%. The MMR stands at 401 per 100 000 live births, reflecting a 61% reduction from 2000 to 2017, with a lifetime risk of maternal death of 1 in 55. The 2016 EDHS also reported neonatal, infant and under-5 mortality rates of 29, 48 and 67 deaths per 1000 live births, respectively. These high mortality rates can be attributed to the low implementation of BPCR. Few studies reported BPCR status in Ethiopia. Study conducted in Abeshige District, Adigrat, Wolaita and Jardega Jarte reported 37.2%, 22%, 18.3% and 27.5% magnitude of BPCR, respectively. BPCR are key strategies for reducing maternal mortality, and various initiatives have been launched across the country to implement them. Although BPCR is a component of the ANC package designed to lower maternal mortality, its awareness and implementation remain limited, especially in our study area. This study aimed to assess birth preparedness, complication readiness and associated factors among pregnant women attending ANC in Chelia District, Central Ethiopia. ## Methods and Materials ### Study area and periods The study was conducted at governmental health facilities in Chelia District, located in the West Shoa Zone of the Oromia Regional State. Chelia is situated 179km west of Addis Ababa, the capital city of Ethiopia, and 65 km from Ambo Zonal Town. The district is divided into 18 rural kebeles and two urban kebeles. According to the 2007 Ethiopian National Population and Housing Census, the district has a population of approximately 107 429, with 50 116 females and 57 313 males. There are 23 774 women of childbearing age, including 3728 who are expected to be pregnant. The district has four government health centres and one general hospital. The study was conducted from 15 May to 30 June 2022. ### Patient and public involvement The research questions and study design were developed by the investigators and approved by the Institutional Review Board at Ambo University. None of the participants were involved in the conception, execution or dissemination of the study. ### Study design and population An institution-based cross-sectional study design was conducted. All pregnant women attending ANC visit in the study area and randomly selected pregnant women were source and study population, respectively. Pregnant women attending ANC and other obstetric care were included in the study. ### Sample size determination and sampling procedures #### Sample size determination The sample size was determined by using the single population proportion formula with the assumptions of a 95% confidence level, 41.3% prevalence of BPCR among mothers from previous study and a 5% margin of error (Z)2xp (1-p) and by using this formula: n = The final d2 sample size required was 410 with 10% non-response rate. #### Sampling technique and sampling procedures In this study, all public facilities providing antenatal care (ANC) services were included. The average total monthly ANC visits for the 3 months preceding the study period were obtained from all health facilities in the district, total of 1166 visits. Based on this figure, the sample size was proportionally allocated to each health facility according to their monthly flow of pregnant women attending ANC. Individual study participants were then selected using a systematic random sampling technique, with every third client being interviewed at the exit of each facility until the required sample size of 410 was achieved (figure 1). ### Operational and term definitions #### Birth preparedness and complication readiness The behaviours and actions undertaken to ensure the survival of mothers and newborns during pregnancy, delivery and the postpartum period are categorised as 'well prepared' or 'not well prepared' based on their scores. Participants were assessed using a series of questions. A woman was classified as 'well prepared' if she had prepared for four or more components, and as 'not well prepared' if she had prepared for fewer than four components. - Knowledge. Women of childbearing age having knowledge of danger sign during pregnancy, delivery and after delivery. She was considered knowledgeable/informed if she can mention at least four of the listed key danger signs during pregnancy, childbirth and postpartum, respectively. #### Data collection tool and procedure The data collection tool was adapted from the 'Monitoring Birth Preparedness and Complication Readiness Tool and Indicators for Maternal and Newborn Health', developed by the Johns Hopkins Program for International Education in Gynecology and Obstetrics. The questionnaires were initially prepared in English and then translated into the local language, Afan Oromo, with a back translation to English by experts to ensure consistency. The questionnaires were pretested on 5% of the sample size in a nearby district. Five diploma-level clinical nurses collected the data through face-to-face interviews as women exited the service. Supervisors closely monitored the data collection process. Six key elements were used to assess the women's level of preparedness: choosing a place of delivery, planning for a SBA, arranging transport in case of an emergency, saving money for potential obstetric emergencies, preparing a blood donor and identifying a designated decision-maker for the current pregnancy. Women who were prepared in four or more of these six areas were classified as 'well prepared', while those with fewer than four were considered 'not well prepared'. The knowledge of pregnant women regarding pregnancy, childbirth and the postpartum period was assessed through a series of questions. A mother was considered knowledgeable if she could identify four danger signs during pregnancy (such as severe vaginal bleeding, swollen hands/face, blurred vision, reduced foetal movement, abdominal pain, high fever, convulsions and difficulty breathing), during childbirth (such as severe vaginal bleeding, prolonged labour lasting more than 12 hours, convulsions, retained placenta, severe abdominal pain, blurred vision, difficulty emptying the bladder and the urge to push) and during the postpartum period (such as severe vaginal bleeding, prolonged labour, convulsions, retained placenta, severe abdominal pain, blurred vision and difficulty emptying the bladder). ### Data quality control Pretested and structured questionnaires were used to collect data. One-day orientation was given for data collectors and supervisors. The filled questionnaires were checked daily for completeness, legibility and consistency. Then, before running analysis, data were cleaned and checked for outliers. We have used probing questions and relating events to known holidays to minimise problem of recall. ### Data processing and analysis First, the data were visually checked for completeness and then coded. After that, the data were entered into Epi-Data V.3.1 and exported to SPSS version 25 for analysis. Descriptive statistics such as frequency, proportion, mean and SD were calculated for the relevant variables. Bivariable logistic regression analysis was used to identify factors associated with BPCR practices. Variables with a p value of ≤0.25 in the bivariable analysis were selected for multivariable logistic regression analysis. The multivariable logistic regression was then performed to identify factors independently associated with BPCR. The strength of the associations was reported using adjusted odds ratios (AOR) with 95% CI. A p value of less than 0.05 was considered statistically significant. ### Ethics approval and consent to participate All methods used in this study adhered to the ethical principles outlined in the Declaration of Helsinki for medical research involving human subjects. Ethical approval was obtained from the Ethical Review Committee of Ambo University, College of Medicine and Health Sciences (Ref. No: PGC/02/2022). An official letter was sent to the Chelia District Health Office, and permission letters were delivered to the selected health facilities in the district. Written informed consent was obtained from each participant, and confidentiality and privacy were strictly maintained. Participants were also informed that their participation was entirely voluntary. ## Results ### Sociodemographic characteristics of respondents A total of 406 study participants were included, resulting in a 99% response rate. Among the respondents, 53.7% were aged 20-29 years (mean age 27 years with a SD of 5.4). The majority, 98.5% (400 women), were married, and 69.7% (283 women) were housewives. Additionally, 38.9% (158 women) had not attended formal education, and 56.7% (230 women) were rural residents. Concerning health service decisions and family size, 56.7% (230 women) made decisions with their husbands about seeking health services, and 68.5% (278 women) had a family size of fewer than three (table 1). ### Obstetric related characteristics Among the women surveyed, 163 (40.1%) had a history of four or more pregnancies. Additionally, 156 (38.4%) reported having three or more live births. Of the 318 respondents, 219 (53.9%) reported having two or more live births. Furthermore, 293 (72.2%) reported having no abortions, and 304 (74.9%) reported having no stillbirths (table 2). ### Health service utilisation-related characteristics Two hundred eighty-eight (70.9%) of the women had ANC follow-up. Among those women, 151 (37.2%) started their ANC at greater than 16 weeks of gestational age, and 142 (35%) had four and more visits. The majority, 295 (72.7%), of women heard about birth preparedness, and 271 (66.7%) respondents were prepared for the last child. One hundred ten (27.1%) women had obstetric complications (table 3). ### Birth preparedness and complication readiness characteristics Most of the pregnant women in this study, 245 (60.3%) (95% CI 55 to 65), were well-prepared, and 161 (39.7%) were not well-prepared. The majority, 376 (92.6%), of respondents planned a place of delivery, and 325 (80%) chose a health centre to deliver. Two hundred forty-three (59.9%) women were planning skilled assistants, with 180 (44.3%) midwifery professionals. The majority, 301 (74.1%) of respondents, planned to save money, and 314 (77.3%) planned a mode of transport. Of them, 226 (55.7%) respondents planned an ambulance mode of transport during an emergency. A hundred and five (25.9%) of women planned to gate blood donors, and nearly half (202; 49.8%) of the respondents were knowledgeable on obstetric danger signs during pregnancy, labour and postpartum. ### Obstetric complications-related information Women faced obstetric complications during their pregnancy, childbirth and postpartum periods. Some of the complications mentioned by the respondents were excessive vaginal bleeding (49; 12.1%), prolonged labour (34; 8.4%) and mal-presentation (12; 3%), respectively. The other common complications were foetal death (7%) and retained placenta (3%) (online supplemental figure 1). ### Knowledge of respondents about obstetric danger signs Severe vaginal bleeding 128 (31.5%) and blurred vision 62 (15.3%) were the most known danger signs in pregnancy mentioned by respondents. During labour, 97 (57.1%) respondents mentioned severe vaginal bleeding, and 74 (43.5%) mentioned prolonged labour. Additionally, during postpartum period, severe vaginal bleeding (138; 82.6%) and foul-smelling vaginal bleeding (35; 21%) were among the danger signs mentioned by respondents. The majority (58; 14.3%) of women were knowledgeable about danger signs during pregnancy, and 46 (11.3%) respondents were knowledgeable about danger signs during labour, while 33 (8.1%) women were knowledgeable about danger signs during postpartum. Two hundred thirty-one (56.9%) women knew about the presence of waiting homes in the health facilities; 214 (52.7%) knew pregnant women's conferences, while 226 (55.7%) of them participated in pregnant women's conferences (online supplemental table). ### Factors associated with birth preparedness and complication readiness On multivariable logistic regression analysis, decision made to seek health services, family size, hearing about BPCR, parity, knowing availability of maternity waiting home and women participated in pregnant women conference were identified as factors associated with BPCR. Women who decide on health service seeking with their husbands were 2.8 times more likely to be prepared for BPCR than those who decide by themselves (AOR=2.43; 95% CI (1.44 to 3.32)). Women who had three or more family sizes were 82% times less likely to be prepared for BPCR when compared with women who had family sizes less than three (AOR=0.18; 95% CI (0.09 to 0.36)). Women who did not hear about birth preparedness were 70% times less likely to be prepared for BPCR than women who heard about birth preparedness (AOR=0.30; 95% CI (0.16 to 0.57)). Regarding parity, women who had less than or equal to 2 parities were 68% less likely to be prepared for BPCR when compared with women who had a parity of three and above (AOR=0.32; 95% CI (0.16 to 0.62)). Mothers who did not know the presence of waiting homes at health facilities were 69% less likely to prepare themselves for BPCR than mothers who knew (AOR=0.31; 95% CI (0.19 to 0.48)). Women who did not participate in the pregnant women's conference were 50% less likely to be prepared for BPCR than women who participated in the conference (AOR=0.50; 95% CI (0.32 to 0.79)) (table 4). ## Discussion In this study, we assessed the level of BPCR and its associated factors in Chelia District, Oromia, Ethiopia. We found that 60.3% of women in the study area were well-prepared for BPCR. This finding is similar to those reported in Ambajogai, India (55.83%), Bamenda, Cameroon (65%); and Plateau, Nigeria (61.8%). However, the proportion in Chelia is higher than that reported in Jhansi, India (46.2%); Adjumani, Uganda (44.25%); Mizan Aman Hospital, Ethiopia (23.8%); and Mizan Tepi, South West Ethiopia (41.1%) (15, 19, 22, 23). Conversely, it is lower than the figures found in Karnataka, India (79.3%); Vajira, Thailand (78.6%); Ado Ekiti, Nigeria (70.6%); and Addis Ababa (72.6%).19–22 The variations in these findings could be attributed to differences in study areas, sociocultural contexts and the timing of the studies. The study also found that women with a family size of three or more were less likely to be prepared for BPCR compared with those with fewer than three family members. This may be due to the higher costs associated with providing necessities for larger families, which could lead to shortages of important materials for preparation. This finding contrasts with a study conducted in Vajira, Thailand, which reported that women with larger family sizes were twice as likely to be prepared for BPCR compared with those with smaller families. Women who made decisions with their husbands about seeking health services during pregnancy, labour and the postpartum period were more likely to be prepared for BPCR compared with those who made decisions on their own. This finding is consistent with results from a study conducted in the Hadiya Zone of Ethiopia. One possible explanation for this finding is that when decisions are made jointly with a husband, who often acts as the head of the family, it may facilitate the implementation of those decisions. This joint approach can help ensure that the necessary budget and materials are allocated from family resources without significant challenges. Additionally, mothers with fewer parities were less likely to be prepared for BPCR compared with multiparous mothers. This difference may be due to the fact that less experienced mothers are less familiar with the essential needs for pregnancy, childbirth, and the postpartum period, whereas more experienced mothers are better acquainted with these requirements. The study also found that women who had not heard about birth preparedness were less likely to be prepared for BPCR compared with those who had received information about it. These findings align with studies conducted in the Basso Liben Amhara region of Ethiopia and Ado Ekiti, Nigeria. This suggests that being informed about birth preparedness can alert pregnant women to the necessary materials and facilities needed to manage complications during pregnancy and childbirth. Knowing about the presence of a maternity waiting home at a health facility is also an important factor in BPCR. The study found that mothers who were unaware of this service were less likely to be prepared for birth and complications. Promoting the availability of maternity waiting homes can offer comfort similar to home, including services like a coffee ceremony and food, while also providing follow-up for potential complications. This may encourage mothers to stay at health facilities before and after childbirth. Similarly, mothers who did not participate in pregnant women conferences were 50% less likely to be prepared for birth and complications compared with those who did participate. Attending these conferences can provide opportunities for ANC, early identification of birth complications and information on key components of BPCR preparedness. Additionally, conferences create a supportive environment where mothers can share experiences and encourage each other on birth preparation and related maternal services. This study was carried out in public health institutions; pregnant women who attend ANC at private health facilities were not included in the study. Due to the nature of study design, it does not establish the cause-effect relationship between the outcome and independent variables. These are some of the study limitations. ## Conclusions The magnitude of BPCR in the study area is low. Factors significantly associated with BPCR include family size, decisions made with husbands, knowledge of the existence of maternity waiting homes, participation in pregnant women conferences, awareness of birth preparedness and parity. Therefore, to improve BPCR in the study area, it is recommended that governments and stakeholders focus on strengthening pregnant women conferences, involving husbands more actively in decision-making and ensuring the availability of maternity waiting homes at health facilities.