Pregnancy Risk Perception, Knowledge of Obstetric Danger Signs and Attitude Towards Skilled Delivery Service Utilization Among Pregnant Mothers in a Rural Setting in South Ethiopia: A Community-Based Cross-Sectional Study

Background

In 2017, too many women died from pregnancy-related causes and childbirth-related causes. Complications during and after childbirth claimed the lives of close to 300,000 women. Most of these deaths (94%) were avoidable and took place in low-income settings. Two-thirds (196,000) and one-fifth (254,000) of all maternal deaths occurred in sub-Saharan Africa and Southern Asia, respectively. Sub-Saharan Africa accounted for approximately 86% (254,000) of all maternal deaths (58,000).^1,2

Ethiopia is one of the nations most affected by high maternal and newborn deaths. Obstetric problems such as bleeding, obstructed labor/ruptured uterus, pregnancy-induced hypertension, puerperal infection, and unsafe abortions are the main causes of mother death in Ethiopia. Anaemia and malaria were the two most reported indirect causes of maternal death.³ Ethiopia’s maternal and infant mortality rates have reduced by 50% since 2000; however, they are still excessively high at 412 per 100,000 live births and 67 per 1000, respectively.

Risk perception is the way that individuals judge and assess the hazards to which they may be exposed.^3,4 It appears that a higher perception of health danger enhances protective motivation, thus it is critical to comprehend how people view health risks, how correct these views are, and how their perception influences their behaviour.⁵ High-risk pregnant women’s decisions about prenatal care and the care they receive during their pregnancies are greatly influenced by their risk perception. Risk perception is a significant concern, particularly during pregnancy when behavioural changes in health have the potential to affect both the mother and the fetus.⁶

Pregnancy-related risk perception is a subject that has attracted a lot of attention globally. According to a recent concept analysis, women’s perceptions about risk during pregnancy have an impact on their decision-making during pregnancy and childbirth.⁷ Pregnancy-related risk perception is a complicated topic because it affects both the mother and the fetus. Because even well-intentioned measures may not be successful without this understanding, prenatal care professionals must be aware of how women perceive risk.^4,8

Unexpected events that happen to pregnant women during pregnancy, labor, childbirth, or postpartum are known as obstetric danger indicators.^9,10 Among the most frequently observed obstetric danger symptoms include impaired vision, the absence of fetal movements, vaginal bleeding, a gush of fluid from the vagina, high temperature, foul-smelling vaginal discharge, convulsions, abdominal pain, and severe headaches. More than 75% of maternal mortality in developing nations are caused by pregnancy-related conditions which are preventable.^11–14 Maternal health promotion and education for women, men, and community members to enhance awareness about obstetric danger signs are effective measures that can prevent birth-related complications.¹⁵ Henceforth, the World Health Organization (WHO) suggests educating all pregnant women about obstetric danger signs at each prenatal visit.¹⁶ Doing so will enable early detection of obstetric danger signs and facilitate appropriate emergency obstetric care.⁵

Numerous studies revealed that the level of knowledge of obstetric danger signs was low in sub-Saharan Africa and Asia, even though recognizing and understanding them plays an important role in reducing both maternal and child mortality by prompting the decision to seek emergency interventions.^6–8

Studies have shown that pregnant women put off making decisions to seek obstetric treatment because of poor understanding of the risks and difficulties in pregnancy-related complications.^17,18 Studies done in Ethiopia revealed that there is a lack of awareness of obstetric danger signs among pregnant women.^19,20 The majority of the research on pregnant women’s awareness of obstetric danger signs in Ethiopia was conducted in urban and institutional settings. This study helps in identifying the gaps in the community’s understanding of obstetric danger signs, level of knowledge of pregnancy risk perception, and attitude toward skilled delivery service use among pregnant women in rural areas. It will also be a resource for health service providers, policymakers, and program managers as they develop intervention strategies to increase community awareness of obstetric danger signs and pregnancy risk. As far as we are aware, there has never been a published study done in the rural environment on the topic. Therefore, this study sought to evaluate pregnant women’s perceptions of pregnancy risks, degree of understanding of obstetric danger signs, attitudes toward using skilled delivery services, and related factors in rural areas of Hadiya Zone, Southern Ethiopia.

Methods

Study Design and Setting

This study was conducted in two districts of Hadiya Zone: Lemo and Ameka districts. Hadiya Zone is situated 232 kilometers from Addis Ababa, the capital city of Ethiopia, in the South nation and nationalities regional state of Southern Ethiopia. The study took place between February 10 and March 25, 2023. A cross-sectional study with a focus on the community was used.

All of the pregnant women who lived in the two districts during the study period comprised the source population. Participants who were gravely ill and unable to communicate were not included in this study. This study was part of a cluster randomized control trial study that examined the effectiveness of engagement of religious leaders in maternal health education. It is part of the baseline survey. The sample size was determined based on a cluster randomized control trial study design. According to the Ethiopia Demographic and Health Survey 2019, skilled birth attendance in a rural area of Ethiopia was predicted to be 43%.⁹ The sample size was based on 80% power to detect a 15-percentage point anticipated difference in the proportion of skilled delivery service utilization (an increase from 43% to 58%) (With a 5% error level) and design effect of 2. A sample size of 50 pregnant mothers per cluster was required, and accordingly, the final calculated sample size was 341 per pregnant mothers per group after considering a 10% loss (682).

Twelve clusters from two Hadiya Zone districts were involved in this study (Lemo and Ameka districts). In order to locate clusters (kebeles), a simple random sampling technique was used. Pregnant women were then contacted using a cluster sampling technique. Interviews with pregnant women who met the inclusion requirements were conducted for the study. The participants in the baseline study did not intend to leave their current residence before the completion of the follow-up period. In cooperation with health extension workers and kebele leaders, a census was carried out to determine all eligible pregnant women of reproductive age (15–49 years) who permanently resided in the selected districts from the selected clusters. Once pregnancy was detected through census work, the women would be recruited for the study.

Data Collection and Procedure

We used questionnaires that already existed from studies done before and adapted them to fit our needs. The questionnaires were pretested and administered by an interviewer. They were developed by the Johns Hopkins Program for International Education in Gynaecology and Obstetrics (JHPIEGO) maternal and neonatal health program, and we tweaked them to fit the local context and our research goals.¹⁰ We pre-tested a survey among 25 pregnant mothers who were not a part of the main study. The survey had five sections – socio-demographic, obstetrics, risk perception, danger signs during pregnancy, labor/delivery, and postpartum period and attitude. The data collectors went to respondents’ houses and interviewed them in person to gather the data. We recruited data collectors (clinical nurses and BSc nurses) and 2 supervisors (BSc degree in public health). We chose them based on their data collection experience and fluency in the language of the community. They were then trained on the objectives of the study, the survey, and the data collection process. The principal investigators and supervisors double-checked the surveys to make sure they were complete and relevant.

Quality Control

Internal consistency (reliability) was tested by calculating Cronbach’s Alpha using SPSS window version 23. Furthermore, health behavior experts crosschecked the content validity of the tool. Data collectors and supervisors were trained about the study instrument and data collection procedure. The principal investigator and the supervisors checked the collected data for completeness.

Measurement and Operational Definitions of the Scale Variables

Pregnancy risk perception was assessed using the questionnaire developed from a previous study.¹¹ This questionnaire is made up of nine questions which assess how a pregnant women perceive potential dangers during pregnancy. In this study, the questionnaire consists of two subscales that include four questions about the risk to self (mother) (for example “Is the risk of having a caesarean section”) and five questions about risk to the baby (for example “is a risk of baby having a birth defect”). Respondents were asked to rate on a five-point scale (1 no risk at all, 2 = unlikely, 3 = possible, 4 = High, 5 = extremely high), how they perceived the pregnancy risk.¹² The scores from each of the 9 items were added up to get a total pregnancy risk perception score. A higher score means that the person has a greater perception of risk. The mean score was used to divide people into two groups: those with a high perception of risk and those with a low perception of risk.

Pregnant women in this study mentioned danger signs during pregnancy, delivery, and postpartum period. We measured how much they knew about these danger signs by asking them to name them without giving leading questions. We sorted their knowledge into two categories: pregnant women with good knowledge and pregnant women with poor knowledge. In this study, a pregnant woman was deemed to be knowledgeable about the danger signs if she could, either spontaneously or upon prompting name at least three significant danger signs for each of the three periods of pregnancy, childbirth, and postpartum. The mothers were prompted by giving them more time to attempt and recall these periods.¹³

Attitude toward skilled delivery service utilization has 10 items that were measured by using a Likert scale where respondents were supposed to strongly agree, agree, neutral, disagree, and strongly disagree.¹⁴ The overall attitude score was computed by summing up the items after performing the reverse scoring for negatively worded sentences. A higher composite score indicated a more positive attitude. The Mean score was used to categorize attitudes into positive and negative attitudes.

Data Processing and Analysis

Data were cleaned and entered using Epidata version 4.6 and analyzed using SPSS version 23. Logistic regression was carried out to identify determinants of obstetric danger signs’ knowledge. Variables with p < 0.25 in the bivariate analysis were selected as candidate variables for multivariate logistic analysis to control the effect of confounders. Adjusted odd ratios (AORs) with their 95% confidence interval and p < 0.05 were considered to have a significant association between the outcome and independent variables. The model fitness was checked using Hosmer and Lemeshow and was found fit.

Results

Socio-Demographic Features of the Respondents

Overall 668 pregnant women participated, with a response rate of 98.0%. More than half, 439 (65.7%) and 371 (55.5%) of the respondents were in the age range of 25–34 years and had primary education status, respectively. A majority, 418 (62.6%) of the respondents were protestant and 202 (30.2%) were Orthodox (Table 1).

Table 1 Socio-Demographic Characteristics of Pregnant Mothers Hadiya Zone, Southern Ethiopia, 2023 (N = 668)

Obstetric History of Respondents

Among the total participants, 421 (63%) were multigravida. Most of the respondents 489 (73.2%) visited antenatal care at least once (Table 2).

Table 2 Obstetric Characteristics of Pregnant Mothers Hadiya Zone, Southern Ethiopia, 2023 (N = 668)

Pregnancy Risk Perception

The findings revealed that participants had a low mean score of 23 for their perception of pregnancy risk with a standard deviation of 5.8. Less than half of the study participants 273 (40.9%) had high levels of pregnancy risk perception. This study showed that pregnancy risk perception was high among mothers in the age group of 25–34 years 174 (63.7%), mothers with educational status of primary education 168 (61%), mothers who visited ANC once twice 199 (72%) and multigravida mothers 148 (54%). One hundred sixty (24%), 125 (18.7%), and 299 (38.3%) respondents thought that they had the possibility of losing too much blood, having a cesarean section, and dying during their pregnancy, respectively. The majority of study participants thought that the pregnancy risk to themselves and their babies was unlikely (Table 3).

Table 3 Pregnancy Risk Perception of Pregnant Mothers Hadiya Zone, Southern Ethiopia, 2023 (N = 668)

Knowledge of Obstetric Danger Signs Among Pregnant Mothers

Only 153 (22.9%) of respondents had knowledge about obstetric danger signs in all categories (pregnancy, childbirth, and postpartum period). 147 (22%), 130 (19.5%) and 128 (19.2%) of study subjects mentioned at least three danger signs during pregnancy, labor, postpartum, and childbirth, respectively. Only 159 (23.8%) of respondents were knowledgeable about danger signs during pregnancy. One hundred thirty-nine (20.8%) of respondents were knowledgeable about danger signs during labor and childbirth and 137 (20.5%) of respondents were knowledgeable about danger signs during the postpartum period. Weakness 173 (25.9%), vaginal bleeding 145 (21.7%), and reduced fetal movement 105 (15.7%) were frequently mentioned danger signs by respondents during pregnancy. Labor of more than 12 h 174 (26%) and abnormal fetal position 109 (16.3%) were frequently mentioned danger signs by study participants during labor and childbirth. One hundred ninety-six (29.3%) of respondents mentioned vaginal bleeding as a danger sign during the postpartum period (Table 4).

Table 4 Obstetric Danger Signs Reported by Pregnant Mothers, Hadiya Zone, Southern Ethiopia, 2023 (N = 668)

Related Factors with Knowledge of Obstetric Danger Signs

In the multivariate logistic regression analysis, the age of respondents, maternal education, and parity were significantly related with knowledge of obstetric danger signs. Pregnant mothers in the age group of 25–34 years were 1.966 times more likely to be knowledgeable of obstetrics danger signs than pregnant mothers who were in the age group of 15–24 years (AOR = 1.966, CI: 1.185–3.261). Pregnant mothers with the educational status of primary education were 1.965 times more likely to be knowledgeable of obstetrics danger signs than pregnant mothers with the educational status of illiterate (AOR = 1.96, CI: 1.002–3.854). It was also observed that the probability of knowing obstetric danger signs decreased by 53% among primipara mothers compared to nullipara mothers (AOR = 0.534, CI: 0.305–0.933) (Table 5).

Table 5 Factors Associated with Knowledge of Obstetric Danger Signs in Hadiya Zone, South Ethiopia, 2023 (n = 668)

Attitude Toward Skilled Delivery Service Utilization

This study revealed that participants had a mean score of 30.4 for their attitude toward skilled delivery service utilization with a standard deviation of 7.8. More than half of the study participants 337 (50.4) had a positive attitude toward skilled delivery service utilization (Table 6).

Table 6 Attitude Towards Skilled Delivery Service Utilization Among Pregnant Mothers in Hadiya Zone, Southern Ethiopia, 2023 (N = 668)

Factors Associated with Attitude Toward Skilled Delivery Service Utilization

In the multivariate logistic regression analysis, perception of pregnancy risk and parity were significantly associated with attitude towards skilled delivery service utilization. Pregnant mothers with a high perception of pregnancy risk were 14.7 times more likely to have a positive attitude towards skilled delivery service utilization than pregnant mothers with low pregnancy risk perception (AOR = 14.7, CI: 9.849–22.235). Parity was another factor that was independently associated with the attitude towards skilled delivery service utilization, pregnant mothers who were multiparous were 2.27 times more likely to have a positive attitude towards skilled delivery service utilization than nulliparous pregnant mothers (AOR = 2.27, CI: 1.381–3.733) (Table 7).

Table 7 Factors Associated with Attitude Towards Skilled Delivery Service Utilization in Hadiya Zone, South Ethiopia, 2023 (n = 668)

Discussion

The majority of preventable maternal deaths in developing countries are due to delays in the pregnant mother or her family’s decision to seek care, delays in visiting the place of delivery, and delays in receiving adequate hospital care.¹⁵ In such cases, the lack of knowledge about pregnancy risk and obstetric danger signs and attitude towards skilled delivery service utilization contribute to the delays in seeking emergency obstetric care, resulting in high mortality and morbidity rates.¹⁶ Pregnant mothers can avoid obstetric complications if they can identify the forewarning pregnancy risks and obstetric danger signs. In resource-limited countries like Ethiopia, increasing the level of awareness of obstetric danger signs and skilled delivery service utilization among women are feasible strategies to reduce maternal mortality and morbidity related to obstetric complications.²¹ However, the pregnancy risk perception and level of knowledge are low among women in Southern Africa including Ethiopia.^{6,7,17,22–24} This study was conducted to assess the current pregnancy risk perception, attitude towards skilled delivery service utilization, and level of pregnant women’s knowledge of obstetric danger signs and related factors in rural areas in Hadiya Zone, Southern Ethiopia.

The result showed that more than half of pregnant mothers had a low perception of obstetric risks and the total and a low mean score of pregnancy risk perception of 23. This finding is lower than the one reported using different instruments to measure pregnancy risk perception in Northern Ethiopia. This study found that 48% of respondents had a high level of pregnancy risk perception.¹⁸ The mean score in our study score is lower than the findings reported in Canada (mean score 29.67) which utilized the same instrument to measure pregnancy risk perception among nulliparous Canadian women of advanced maternal.¹⁹ Similarly, a study in Thailand found that women of advanced maternal age had mean scores of perception of pregnancy risk that fell below (32.9).¹² This difference might be because of the difference in maternal age and measurement instruments. Another possible explanation is that risk perception in pregnancy is multifaceted and influenced by multiple personal factors.

In this research, the overall proportion of knowledge of obstetric danger signs among pregnant mothers was 22.9%. This finding is consistent with the finding reported in South Ethiopia in Yirgachefe city (21.9%)²⁰ and Eastern Democratic Republic of the Congo (21.9%).²⁵ Our study was done among rural mothers. In this study, the knowledge of obstetric danger signs was higher than the findings reported in Wolayita Sodo City in Southern Ethiopia (16.8%)²⁶ and Jordan (15.2%).²⁷ In addition, it is lower than the values reported by studies conducted in Chamwino District, Tanzania (25%),²⁸ Angolela Tera District in Northern Ethiopia (37.5%), Hossan Town Southern Ethiopia (63%),²⁹ Shashemane Town in the Oromia region in Ethiopia (40%)²⁷ and KwaZulu Natal in South Africa (52%).²⁷ This discrepancy could be differences in the sociocultural backgrounds that characterize each of these regions.

In this study, obstetric danger signs were categorized into three parts: pregnancy, labor/childbirth, and the postpartum period. The danger signs that were most frequently discussed during pregnancy were weakness 173 (25.9%), vaginal bleeding 145 (21.7%), and reduced fetal movement 105 (15.7%), which is contradictory to a study reported in the Eastern Democratic Republic of the Congo, which found that severe abdominal pain was the best-known danger sign.²⁵ This result was in line with other research findings published in Ethiopia and Africa and revealed that severe vaginal bleeding was the frequently mentioned obstetric danger sign during pregnancy and postpartum period.^{13,20,25,28,29} Labor of more than 12 hours and abnormal fetal position were the most common danger signs mentioned by study participants during labor and childbirth. This finding was consistent with the finding reported in Wolayita Sodo Town, Southern Ethiopia.²⁶

In this study, the age of pregnant mothers, maternal education, and parity were determinants of knowledge of obstetric danger signs. Pregnant mothers aged 25–34 years were more likely than other age groups to be knowledgeable of obstetric danger indicators. This result is consistent with results from other studies that have been done in Arbaminch, Wolayita Sodo, and Yirgacheffe Towns, South Ethiopia, and South Eastern Nigeria. Women in this age category are believed to be physically and psychologically ready to accept information about obstetric danger signs. This result contradicts a study conducted in the Eastern Democratic Republic of the Congo that found women aged 30–39 years were more likely than other age groups to be knowledgeable of obstetric danger indicators.^16,20,25,26

In this study, maternal age, education, and parity were determinants of knowledge of obstetric danger signs. Pregnant mothers aged 25–34 years were more likely than other age groups to be knowledgeable of obstetric danger indicators. This result is consistent with results from other studies that have been done in Arbaminch, Wolayita Sodo, and Yirgacheffe Towns, South Ethiopia, and South Eastern Nigeria. Women in this age category are believed to be physically and psychologically ready to accept information about obstetric danger signs. This result contradicts a study conducted in the Eastern Democratic Republic of the Congo that found women aged 30–39 years were more likely than other age groups to be knowledgeable of obstetric danger indicators.^{16,20,26,28,30} The multivariate logistic regression revealed that the knowledge of obstetric danger signs among pregnant women was associated with parity. The probability of knowing obstetric danger signs decreased by 53% among primipara mothers compared to nullipara mothers. This finding contradicts the finding reported in Eastern Democratic Republic of the Congo.²⁵ However, it is consistent with the results reported in other studies.^26,29,31

In this study, the mean score of attitude towards skilled delivery service utilization was 30.4. More than half of the study participants 337 (50.4) had a positive attitude towards skilled delivery service utilization. This finding was lower than the finding reported in Oromia Region, Ethiopia (61.2%).³² Our finding is higher than the result reported in Northwest Ethiopia (28.3%).³³ A possible explanation could be differences in study setting and health program implementation. This study revealed that pregnant mothers with a high perception of pregnancy risk were more likely to have a positive attitude toward skilled delivery service utilization than pregnant mothers with a low pregnancy risk perception. This is because having risk perception could develop a positive attitude towards health service utilization. The utilization behavior of individuals is driven by their perception to develop a positive attitude and take over the action.³⁴ It was also observed that pregnant mothers who were multiparous were more likely to have a positive attitude towards skilled delivery service utilization than nulliparous pregnant mothers. This may be because pregnant mothers who experienced previous births were more likely to benefit from maternal health services and learn from their experiences.

The results of this study have important policy implications. Determining the level of the pregnancy risk perception, knowledge of obstetric danger signs and attitude of pregnant women towards skilled delivery service utilization can predict their preventive practice, and identifying variables is crucial for developing appropriate risk communication methods and measures.

Limitations

Regarding limitations of this study, bias might be provoked in prompting the participants to mention the danger signs, though the authors tried their best to avoid it. In addition, reports of the pregnant mothers may under/overestimate the result because the data was collected by self-report.

Conclusion

In this study, pregnancy risk perception, attitude towards skilled delivery service utilization, and level of pregnant women’s knowledge of obstetric danger indicators in Lemo and Ameka Districts of Hadiya Zone were low. Maternal age, maternal education, and parity of the respondents were determinants of knowledge of obstetric danger signs. It was also observed that perception of pregnancy risk and parity were significantly associated with attitude towards skilled delivery service utilization. Based on the findings of this study, we recommend that stakeholders of the health sector develop a strategic plan to increase pregnancy risk perception, pregnant women’s knowledge of obstetric danger indicators and develop a positive attitude towards skilled delivery service utilization to reduce maternal death through the provision of health education and health promotion.