Practice of Birth Preparedness and Complication Readiness and Its Associated Factors:A Health Facility-Based Cross-Sectional Study Design

Abstract

Time of labor or time of emergency is not the time to decide what to do, instead it is time to seek care from skilled health care providers. Birth preparedness and complication readiness is the process of planning for a normal birth and anticipating the action needed in case of an emergency, which helps to minimize obstetric complications. Even though birth preparedness and complication readiness reduce maternal and newborn morbidity and mortality, the practice of birth preparedness and complication readiness is still low in Ethiopia. This study aimed to assess the practice of birth preparedness and complication readiness and its associated factors among pregnant women who attended antenatal care in the public health facilities of Debre Tabor town, northwest, Ethiopia. A health facility-based cross-sectional study was conducted from August 1/2022 to September 15/2022 among 397 pregnant mothers. The study was collected using a systematic random sampling technique and the collected data were entered and analyzed using SPSS version 25.0. Bivariate and multivariate logistic regression analyses were employed to estimate the crude and adjusted odds ratio and considered significant at a confidence interval of 95% and a P-value of less than .05. The proportion of birth preparedness and complication readiness practice was found to be 32.2%. Having formal education, primigravida, starting antenatal care contact in the first trimester of pregnancy, having knowledge of danger signs of labor and delivery, and birth preparedness and complication readiness were significantly associated with the practice of preparedness and complication readiness. In this study area, the practice of birth preparedness and complication readiness was low. Therefore, it is important to strengthen counseling on the advantage of starting antenatal care contact early and creating awareness of birth preparedness and complication readiness.

• What do we already know about this topic?

• Preparing for childbirth and utilizing skilled care during pregnancy, childbirth, and after childbirth are important interventions to reduce maternal and infant morbidity and mortality.

• How does your research contribute to the filed?

• This study finding indicates that the practice of birth preparedness and complication readiness was low, which indicated a need to strengthen counseling of women on the advantage of birth preparedness and complication readiness.

• What are your research implications toward theory, practice, or policy?

• The finding of this study helps to identify the gap and strengthen the action to increase the practice of birth preparedness and complication readiness among pregnant women.

Introduction

Birth preparedness and complication readiness (BPCR) is an intervention included by the World Health Organization as an essential element of the antenatal care package. ¹ The BPCR concept is based on the premise of preparing for birth and being ready for complications. ² The elements of BPCR are deciding the place of delivery, knowing the preferred birth attendant, saving money for birth-related and emergency obstetric expenses, identifying a compatible blood donor and labor companion, choosing a supporting person to look after the home and other children, arranging the necessary supplies and materials for labor and delivery and preparing transportation service. ³

Preparing for childbirth and associated complications reduces the 3 delays of maternal death; delay in recognizing danger signs and the decision to seek care, delay in reaching the health facility, and delay in receiving care at the health facility by encouraging pregnant women, their families, and communities to effectively plan for births and prepare for emergencies.^4,5 Advising pregnant mothers on BPCR during antenatal care contact is vital to keep the course of the pregnancy safer and prepare the women to deliver at health facilities.^6,7 Skilled care during pregnancy, childbirth, and after delivery are important interventions for the survival and well-being of both the mother and the infant. ⁸

However, most pregnant mothers are not aware of how to recognize the danger signs of complications. ⁹ The unprepared family wastes time in getting organized, finding money, recognizing the complications, reaching the appropriate referral facility, and finding transport.^4,10,11 Worldwide, around 15% of pregnancies develop life-threatening complications during pregnancy, delivery, or postpartum period and the majority of maternal mortality occurs during labor and the postpartum period.^12-14 Eight out of the 10 maternal deaths are attributed to pregnancy and its complications, like hemorrhage, preeclampsia, sepsis, unsafe abortion, and obstructed labor, and 2 to 3 are due to indirect causes like anemia, HIV/AIDS, malaria, diabetes mellitus, and cardiac problems.^15-17

More than three-fourths of maternal deaths could be averted if all women had access to skilled care, which is considered the cornerstone and key intervention to minimize complications associated with pregnancy and childbirth.^15,18 However, lack of transportation and concern over the cost of services, particularly inadequate preparation for rapid action in the event of obstetric complications are factors contributing to delays in receiving skilled obstetric care.^19,20 Pregnancy-related complications both for the mother and the newborn could be largely alleviated if there is a well-consolidated BPCR plan developed during pregnancy and implemented at the time of delivery.^10,21 The WHO indicates BPCR reduces home delivery with a consequent increase in skilled attendance during labor and childbirth. ¹⁸

Different studies conducted in different countries showed that multiple factors are associated with the practice of BPCR, and some of the factors are knowledge of danger signs of obstetrics, parity, educational and occupational status of the women, maternal age, history of obstetric complications, the timing and the number of ANC contact, residency, history of stillbirth and abortion, attitude toward BPCR practice, distance to the health facility, and wealth quintile.^9,22-27 However, in many societies, cultural beliefs and lack of awareness inhibit preparation in advance for delivery.^28,29 In Ethiopia, a systematic review and meta-analysis showed that the utilization of maternal health care services was low, which is 25.51%, ³⁰ and the BPCR was also low, which is 32%. ⁴ Having a good practice of the BPCR plan increases the utilization of maternal health care services.^10,30

The Sustainable Development Goals (SDG) target is to reduce the global maternal mortality ratio to less than 70, or no country has no more than 140 maternal mortality ratio per 100 000 live births, reducing neonatal and under-five deaths to 12 and 25 per 1000 live births respectively through eliminating preventable maternal, neonatal and child deaths by the year 2030. ³¹ However, the lack of practice of the BPCR plan would be one of the critical factors behind the sluggish progress toward achieving SDG targets and this requires many efforts now and in the future to achieve the SDGs target by 2030. ³² In this study area previously the pregnant women practice level of BPCR was not assessed. Therefore, this study aimed to assess the practice of BPCR and its associated factors.

Methods

Study Design and Period

A health facility-based cross-sectional study was conducted from August 1/2022 to September 15/2022.

Study Setting

Debre Tabor Town is located in South Gonder zone, Amhara regional state; Northwest Ethiopia. The town is situated 98 km to the east of Bahir Dar city, which is the capital city of Amhara regional state, and 668 Km from Addis Ababa, the capital city of Ethiopia. The estimated population of the city for the year 2021/22 is about 119 176 of which 58 010 are females. ³³ The town has 3 health centers (Debre Tabor health center, Hidar 11, and Atse Seyfe Arid health center) and one public hospital (Debre Tabor comprehensive specialized hospital) which provides maternal and other health services to the population of the town and the surrounding area.

Source Population

All pregnant mothers who attended the second and above ANC contact at the public health facilities of Debre Tabor town.

Study Population

All pregnant mothers who attended the second and above ANC contact at the public health facilities of Debre Tabor town during the data collection period.

Study Unit

Systematically selected consenting pregnant mothers who attended the second and above ANC contact at the public health facilities of Debre Tabor town.

Inclusion and Exclusion Criteria

All pregnant mothers who attended the second and above ANC contact at the public health facilities of Debre Tabor town were included, while pregnant mothers who revisited the ANC unit during the data collection period due to their next appointment or the occurrence of danger signs of pregnancy were excluded.

Sample Size Determination

The sample size was calculated using a single population proportion formula by considering the following assumptions: the practice of BPCR was 56.2%, ²⁴ Zα/2 = critical value for normal distribution at 95% confidence level, which is equal to 1.96 (Z value of alpha at = 0.05) or 5% level of significance (α = .05) and a 5% margin of error (d = 0.05).

$$\begin{array}{l}\mathrm{Sample}\mathrm{size}\left(\mathrm{n}\right)=\frac{{\left(\mathrm{z}\alpha /2\right)}^2\mathrm{p}\left(1-\mathrm{p}\right)}{{\mathrm{d}}^2},\\ \frac{{\left(1.96\right)}^{2}0.562\left(1-0.562\right)}{\left(0.05\right)},=378\end{array}$$

The sample size was adjusted by adding a 5% non-response rate and the final sample was 397 pregnant mothers who had the second and above ANC contact.

Sampling Procedure and Technique

The public health facility of Debre Tabor town stratified in to health center and hospital. The town has 3 health centers, and one public hospital. Then all of the public health facilities found in the town in the study. The average number of pregnant mothers who attended the second and above ANC contact per 2 months at the public health facilities of the town was 1060. On average, at Debre Tabor comprehensive specialized hospital 504, at Debre Tabor health center 252, at Hidar 11 health center 168, and at Atse Seyfe Arid health center, 136 pregnant mothers attended the second and above ANC contact per 2 months. The total sample size was proportionally allocated for each health facility based on the average number of pregnant mothers who attended the second and above ANC visits per 2 months.

The total sample size after proportional allocation was 189, 94, 63, and 51 in Debre Tabor comprehensive specialized hospital, Debre Tabor health center, Hidar 11 health center, and Atse Seyfe Arid health center respectively. Eligible pregnant mothers in each health facility were selected by using systematic random sampling techniques. The sampling interval or the Kth units (1060/393 = 3) was obtained by dividing the average numbers of pregnant mothers who attended second and above ANC visits per 2 months by the sample size. The starting unit was selected by using the lottery method among the first K^th units in each health facility.

Study Variables

Dependent variable

Birth preparedness and complication readiness practice

Independent variables

Socio-demographic characteristics (maternal age, residence, marital status, religion, educational level of the mothers and occupation of the mothers, average monthly income of the family), obstetrics factors (gravidity, parity, history of abortion, history of stillbirth, history of ANC contact in the previous pregnancy, the timing of starting ANC contact in the current pregnancy), knowledge-related factors (knowledge of danger signs of pregnancy, labor and delivery, postnatal period, and BPCR), and health facility and information-related factors (distance to the health facility, source of information).

Term definitions

Birth preparedness: is the process of planning for normal birth and anticipating the actions needed during an emergency. ³⁴

Complication readiness: refers to the process of anticipating the actions needed in case of an emergency. ³⁴

The practice of birth preparedness and complication readiness: refers to the practice of a pregnant mother on BPCR. A total of 10 items were used and for each item, those who respond “yes” scored (+1), and those who respond “no” scored (0). The mother was considered to have good practice of BPCR if she correctly answered greater than or equal to the mean score of the total practice of BPCR assessing questions. ³⁴

Knowledge of danger signs of obstetrics: refers to the knowledge of the mothers about the danger signs of obstetrics (during pregnancy, childbirth, and in the postnatal period). The mother was considered to have good knowledge if she correctly answered greater than or equal to the mean score of the total knowledge assessing questions. ²⁴

Knowledgeable of BPCR: refers to the knowledge of the mothers on the BPCR. The mother was considered to have good knowledge of BPCR if she correctly answered greater than or equal to the mean score of the total knowledge assessing questions. ²⁶

Data Collection Tools and Procedures

A structured interviewer-administered questionnaire was used to collect the data, which was adapted from relevant works of literature,^{2,24,27,35,36} and modified to the local context. The questionnaire was first prepared in the English language and translated into Amharic, then retranslated back into English to check the consistency. The questionnaire consisted of socio-demographic characteristics, obstetrics history, knowledge, health facility, information-related factors, and the practice of BPCR questions. A pre-tested structured checklist was used for data collection purposes. The data were collected by five fourth-year midwifery students

Data Quality Control

The questionnaire was pre-tested before the actual data collection period on 5% of the sample size at Tibebe Ghion Specialized Hospital, to ensure the clarity of the questionnaire, to check the wording, and to confirm the logical sequence of the questions. Necessary modifications and corrections were done based on the result of the pretest. The completeness of the data was checked by the data collectors.

Data Processing, and Analysis

The practice and knowledge-related questions were assessed by +1 for correct answers and 0 for incorrect answers. Then the score for each mother was summed up and categorized. The data were entered into SPSS version 25.0 for analysis. During the analysis, all independent variables which have a significant association in bivariate analysis with a P-value < .20 were entered into a multivariable logistic regression model to get an AOR, and those variables with 95% of CI and a P-value of < .05 in the multivariable analysis were considered as statistically significant with the practice of BPCRP. The multicollinearity between independent variables was checked by the variance inflation factor and was found acceptable (<2). The goodness of fit of a statistical model was checked by using the Hosmer-Lemeshow goodness-of-fit test and its P-value was >.05. Frequency tables, figures, and descriptive summaries were used to describe the study variables.

Results

Socio-Demographic Characteristics

A total of 397 pregnant mothers participated with a response rate of 100%. The mean age of the mothers was 28.27 years with + 6.09 standard deviation. Of the mothers, 213 (53.7%) were found in the age group of 25 to 34 years and 382 (96.2) were married. More than three-fourths (77.6%) live in urban, and 358 (90.2%) were followers of Orthodox Christianity religion. Half of the mothers (50.6%) are housewife, and 304 (76.6%) has at least a primary educational level (Table 1).

Table 1.

Socio-Demographic Characteristics of Pregnant Mothers at the Public Health Facilities of Debre Tabor Town, Northwest, Ethiopia, (n = 397).

Variables	Frequency (%)
Maternal age in years
15-24	97 (24.4)
25-34	213 (53.7)
>35	87 (21.9)
Residence
Urban	308 (77.6)
Rural	89 (22.4)
Marital status
Married	382 (96.2)
Others*	15 (3.8)
Religion
Orthodox	358 (90.2)
Muslim	28 (7.1)
Protestant	11 (2.7)
Occupation
Housewife	201(50.6)
Farmer	87 (21.9)
Merchant	51 (12.9)
Government employee	33 (8.3)
Private employee	19 (4.8)
Student	6 (1.5)
Educational level
Had no formal education	93 (23.4)
Had formal education	304 (76.6)
Average monthly income in Ethiopian birr**
<1999	191 (48.1)
2000-3999	150 (37.8)
>4000	56 (14.1)

Note. *Widowed, divorced, and single. **US$1 = 50 Ethiopian birr ETB at the time of data the collection.

Obstetric Characteristics

In this study, 211 (53.2) and 177 (44.6%) of the mothers were multigravida and multipara respectively. Of the mothers, 21 (5.3%) have a history of stillbirth, and among mothers who have a history of previous pregnancy 306 (95.9) have a history of ANC contact. In their current pregnancy 169 (42.6%) started ANC contact within the first trimester of pregnancy, and 305 (76.8%) reach the nearest health facility within 60 min (Table 2).

Table 2.

Obstetric Characteristics of the Pregnant Mothers at the Public Health Facilities of Debre Tabor Town, Northwest, Ethiopia (n = 397).

Variables	Frequency (%)
Gravity
Primigravida	78 (19.6)
Multigravida	211 (53.2)
Grand multigravida	108 (27.2)
Parity
Nullipara	83 (20.9)
Primipara	96 (24.2)
Multipara	177 (44.6)
Grand multipara	41 (10.3)
History of abortion
Yes	13 (3.3)
No	334 (96.7)
History of stillbirth
Yes	21 (5.3)
No	376 (94.7)
History of ANC contact in the previous pregnancy (n = 319)
Yes	306 (95.9)
No	13 (4.1)
Timing of first ANC contact in the current pregnancy
Within the first trimester	169 (42.6)
After the first trimester	228 (57.4)
Distance from home to health facility by walking (one way in minutes)
<60 min	305 (76.8)
>60 min	92 (23.2)

Knowledge of the Mothers on Obstetric Danger Signs

Based on the predetermined criteria, 225 (56.7%) of the mothers had good knowledge of the danger signs of pregnancy. Of the mothers, 381 (96.0%), 312 (78.6%), 259 (65.2%), 253 (63.7%), 242 (60.9%), and 233 (58.7%) of the mothers responded vaginal bleeding, severe headache, lower abdominal pain, reduced fetal movement, a gush of fluid and premature onset of labor as the major danger signs of pregnancy respectively. About 229 (57.7%) of the mothers had good knowledge of danger signs of labor and delivery and 384 (96.7%), 338 (85.1%), 321 (80.8%), 298 (75.1%) identified heavy vaginal bleeding, prolonged labor, severe headache, retained placenta as the major danger signs of labor and delivery respectively. In this study, 151 (38.0%) of the mothers had good knowledge of the danger signs of the postpartum period, and 359 (90.4%) mentioned heavy vaginal bleeding as a major danger sign of the postpartum period (Table 3)

Table 3.

Knowledge of the Pregnant Mothers on Key Danger Signs of Obstetrics at the Public Health Facilities of Debre Tabor Town, Northwest, Ethiopia (n = 397).

Variables	Frequency (%)
Danger signs of pregnancy
Vaginal bleeding	381 (96.0)
Severe headache	312 (78.6)
Lower abdominal pain	259 (65.2)
Reduced fetal movement	253 (63.7)
Gush of fluids	242 (60.9)
Premature onset of labor	233 (58.7)
Blurring of vision	227 (57.2)
High-grade fever	198 (49.9)
Excessive vomiting	169 (42.6)
Swelling of hands and face	156 (39.3)
Convulsion	139 (35.0)
Epigastria pain	134 (33.8)
Knowledge of danger signs of pregnancy
Good knowledge	225 (56.7)
Poor knowledge	172 (43.3)
Danger signs of labor and delivery
Heavy vaginal bleeding	384 (96.7)
Prolonged labor	338 (85.1)
Severe headache	321 (80.8)
Retained placenta	298 (75.1)
High-grade fever	167 (42.1)
Convulsion	129 (34.5)
Epigastria pain	108 (27.2)
Swelling of hands and face	87 (21.9)
Knowledge of danger signs of labor and delivery
Good knowledge	229 (57.7)
Poor knowledge	168 (42.3)
Danger signs of the postpartum period
Heavy vaginal bleeding	359 (90.4)
Foul-smelling vaginal discharge	207 (52.1)
Severe headache	194 (48.9)
High-grade fever	119 (30.0)
Blurring of vision	98 (25.7)
Convulsion	85 (21.4)
Epigastria pain	79 (19.9)
Swelling of hands and face	67 (16.9)
Knowledge of danger signs of the postpartum period
Good knowledge	151 (38.0)
Poor knowledge	246 (62.0)

Knowledge of the Mothers on Birth Preparedness and Complication Readiness

Regarding awareness of BPCR 183 (46.1%) of the mothers had good knowledge of BCRP. Of the mothers, 375 (94.5%), 260 (65.5%), and 258 (65.0%) mentioned identifying the place of delivery, nearest health facility, and skilled birth attendant as the major components of BPCR respectively (Figure 1).

Figure 1.

Knowledge of pregnant mothers on birth preparedness and complication readiness at the public health facilities of Debre Tabor town, Northwest, Ethiopia, (n = 397).

Source of Information About Birth Preparedness and Complication Readiness

More than three-fourths (77.6%) of the mothers were informed about BPCR and two third (67.9%) of the mothers obtained the information from health professionals. The others obtained information about BPCR from community health extension workers 135 (34.0%), social media 54 (13.6%), and from family and relatives 29 (7.3%).

Practice of Birth Preparedness and Complication Readiness

Based on the predetermined criteria 128 (32.2%) with 95% CI (23.2-41.2%) of the mothers had good practice of BPCR. About, 195 (49.1%), 190 (47.8%), 185 (46.6%), 164 (41.3%), and 162 (40.8%) of the pregnant mothers identified place of delivery, the nearest health facility, place of delivery, skilled birth attendant, saved money and identifying obstetric danger signs respectively (Figure 2).

Figure 2.

Practice of pregnant mothers on birth preparedness and complication readiness at the public health facilities of Decree Tabor town, Northwest, Ethiopia (n = 397).

Factors Associated With Practice of Birth Preparedness and Complication Readiness

In the bivariate analysis: maternal age, educational status, residency, gravidity, history of stillbirth, the timing of starting ANC contact, distance to the nearest health facility by walking, knowledge of danger signs of pregnancy, labor and delivery, and knowledge of BPCR was significantly associated with the practice of BPCR at a P-value of less than <.20.

In the multivariable analysis mothers who had formal education [AOR = 3.49, 95% CI = 1.72-7.07], primigravida mothers [AOR = 3.52, 95% CI = 1.97-6.30], mothers who started ANC contact in the first trimester of pregnancy [AOR = 2.48, 95% CI-1.32-4.65], good knowledge of the danger signs of labor and delivery [AOR = 2.29, 95% CI = 1.24-4.23], good knowledge of BPCR [AOR = 1.90, 95% CI = 1.02-3.55] were significantly associated with the practice of BPCR at a P-value of less than .05 (Table 4).

Table 4.

Logistics Regression Analysis on Factors Associated with the Practice of Birth Preparedness and Complication Readiness among Pregnant Mothers at Public Health Facilities of Debre Tabor Town, Northwest, Ethiopia (n = 397).

Variables	Category	Practice of BPCR		COR (95% CI)	AOR (95% CI)	P-value
		Yes	No
Maternal age in years	>25	83	217	1	1
	15-24	45	52	2.63 (1.41-3.63)	0.70 (0.33-1.46)	0.343
Residence	Rural	19	70	1	1
	Urban	109	199	2.02 (1.15-3.53)	0.77 (0.31-1.91)	0.577
Educational level	Had no formal education	28	65	1	1
	Had formal education	100	204	1.14 (0.69-1.88)	3.49 (1.72-7.07)	0.001*
Gravidity	Multigravida	87	232	1	1
	Primigravida	41	37	2.95 (1.78-4.91)	3.52 (1.97-6.30)	0.001*
History of stillbirth	No	13	8	1	1
	Yes	115	261	3.69 (1.49-9.14)	2.26 (0.76-6.72)	0.141
Timing of starting ANC contact	After first t trimester	53	175	1	1
	At first trimester	75	94	2.63 (1.71-4.06)	2.48 (1.32-4.65)	0.005*
Distance to the nearest health facility by walking	>60 min	28	64	1	1
	Less 60 min	100	205	1.15 (0.67-1.85)	1.27 (0.61-2.64)	0.524
Knowledge of danger signs of pregnancy	Poor knowledge	33	139	1	1
	Good knowledge	95	130	3.08 (1.94-4.89)	0.47 (0.16-1.37)	0.167
Knowledge of danger signs of labor/delivery	Poor knowledge	28	140	1	1
	Good knowledge	100	129	3.88 (2.39-6.28)	2.29 (1.24-4.23)	0.008*
Knowledge of BPCR	Poor knowledge	42	172	1	1
	Good knowledge	86	97	3.63 (2.33-5.67)	1.90 (1.02-3.55)	0.044*

Note. *Significant at a P-value of less than <.05. The bold has been used to highlight significantly associated factors during analysis with the outcome variable. AOR = adjusted odds ratio. COR = crude odds ratio, CI = confidence interval.

Discussion

Birth preparedness and complication readiness help ensure that women can reach professional delivery care when labor begins. The practice of BPCR intervention is recommended to increase the use of skilled care at birth and to increase the timely use of facility care for obstetric and newborn complications. ³⁷ This study showed that the practice of BPCR was 32.2% with a 95% CI (23.2-41.2%). The finding of this study is nearly in line with studies done in the South Gondar zone Farta district (34%), ²⁶ Goba woreda (29.9%), ³⁸ and Gurage Zone Abeshige district (37%). ¹⁹ It is also consistent with a study conducted in Southwestern Uganda (35%). ³⁹ The finding of this study is lower than other studies conducted in Debre Berhan town public health facilities (56.2%), ²⁴ Yirgalem general hospital (48.6%), ⁴⁰ Sodo town (48.5%), ³⁵ Bule Hora town (46.3%), ⁴¹ and Kofale District (41.3%). ²² The finding of this study is also lower than studies done in North Ghana (64.42%), ⁴² and South West Nigeria (40.3%). ⁴³ This could be due to the differences in socio-demographic status and study area.

However, the finding of this study is higher than studies done in the Wolayta zone (18.3%), ⁴⁴ Agnuak zone, Gambella region (23.4%) (25.8% in urban and 18.5% in rural women, ²⁷ South Wollo (24.1%), ²³ Mizan-Aman Town (22.2%), ⁴⁵ and Jimma Zone, Southwest Ethiopia (23.3%). ⁴⁶ This could be due to the differences in study design, the majority of these studies are community-based, while our study was institutional-based. The other possible reason for this discrepancy might be the year of study. As we have seen over time, the awareness of pregnant women on obstetric danger signs and preparation for it increases due to the implementation of health extension workers. ⁴⁷ There is a supporting report from a study done in Gurage Zone Abeshige district that indicated the practice of BPCR was higher among women who obtained information from health extension workers. ¹⁹ Our study finding is also higher than a study done in Cameron (18.8%). ²⁵ The difference might be attributed to the awareness of the term BPCR, in our study more than three-fourths (77.6%) of the mothers were informed about BPCR, while a study done in Cameron indicated that 46.1% of them were heard of the term BPCR. ²⁵ This is also supported by another study, which indicates that women who were informed of the term were more likely to practice BPCR. ⁴⁵

This study shows the maternal socio-demographic, obstetric, and knowledge-related factors associated with the practice of BPCR. Mothers who had formal education were 3.49 times more likely to have good practice of BPCR relative to pregnant mothers who had no formal education. This finding agrees with other studies finding.^{22 -26,35,38-41,46} This may also related to their wealth quintile level, since educated women can have a high chance of having their own income, lives in urban area, and can have a decision making power this may make them to have a practice of BPCR. There is supporting evidence from studies done in different countries that showed the practice of BPCR was higher among women who are employed, have income, and live in urban areas.^26,42,43

The odds of having good practice of BPCR were 3.52 times higher among primigravida mothers than multigravida mothers. This finding is consistent with another study. ⁴⁴ In our study majority of the primigravida mothers are in the young age group. The higher practice of BPCR in primigravida mothers may be attributed to their age, as our study indicates the proportion of practice of BPCR was 46.4%versus 27.7% among the pregnant women age group of 15 to 24 and >25 years respectively. There is supporting evidence from studies conducted in different countries that showed that the practice of BPCR was higher in women who are in the young age group.^{22,27,35,39,41} This might be attributed to the gravidity, most of the time in primigravida mother the male partner is more likely to accompany his wife to the ANC unit and get counseling together with his wife. This supported by studies done in Ethiopia indicates that having a male partner in ANC contact counseling increases the practice of BPCR.^23,35

Starting the ANC contact in the first trimester of pregnancy increased the practice of BPCR by 2.48 times relative to starting ANC contact after the first trimester of pregnancy. This finding is congruent with another study’s finding. ²⁷ Pregnant women who started ANC contact early where have the chance of optimal ANC contact and this in turn increases their chance of having a good practice of BPCR. This is supported by other studies done in different countries.^25,27,41,42

Mothers who had good knowledge of the danger signs of labor and delivery were 2.29 times more likely to practice BPCR relative to mothers who had poor knowledge of the danger signs of labor and delivery. Studies conducted in different countries indicate that knowing obstetric danger signs increase the practice of BPCR.^{19,22,24-27,38,39,41,44-46} This may be attributed that knowledge is an important factor that affects the attitude, intention, and behavior of a person. Knowledgeable women could have a high perception of pregnancy risk, which in turn increases the preparation for emergencies and the use of obstetric health services. ⁴⁸ The likelihood of having good practice of BPCR was 1.90 times higher among mothers who had good knowledge of BPCR than mothers who had poor knowledge of BPCR. This finding is in line with another study. ²⁶ This indicates that women who know BPCR are well prepared for an emergency and give childbirth at a health facility with the help of skilled health care providers. ⁴⁹

Strength and Limitations

This study included all of the public health facilities found in the town. However, it has certain limitations. We have not included the husband’s involvement in their wife’s practice of BPCR. Additionally, this study was health facility-based, which included only pregnant women who have ANC contact.

Conclusions

In this study area, the practice of BPCR among pregnant women was low compared to other studies. Maternal educational level, gravidity, the timing of starting ANC contact, knowledge of labor and delivery, and knowledge of BPCR were significantly associated with the practice of BPCR. Therefore, health care providers should have to provide health education and counseling on the obstetric danger signs and its complications and the advantage of BPCR. The health extension workers should encourage pregnant mothers to start the ANC contacts early. Therefore, further study is needed by including husbands, and private health facilities. Triangulating with a qualitative study can also make the study finding stronger.