Husbands' Knowledge of Obstetric Danger Signs, Attitude, and Involvement in the Maternity Continuum of Care in Rural Central Ethiopia: A Community‐Based Cross‐Sectional Study

ABSTRACT

Background and Aims

Maternal mortality continues to be a critical public health problem in resource‐poor settings, despite the existence of effective interventions. In Ethiopia, the role of husbands in the maternity continuum of care is poorly understood, and challenges evidence‐based decision‐making. This study aims to assess husbands' knowledge, attitudes, and level of involvement in the maternity continuum of care.

Method

A community‐based cross‐sectional study was conducted using a multi‐stage random sampling technique. A total of 838 participants were included through systematic random sampling in rural communities of the Hadiya zone, Ethiopia. Data were collected via the KoBo tool and analyzed using SPSS version 25, with significance set at p < 0.05.

Result

In this study, a 99.4% response rate was reported. Overall, 39.4% of the participants demonstrated good knowledge of obstetric danger signs; 61.2% of respondents had a positive attitude, and 51.5% of the husbands showed good involvement in the maternity continuum of care. Educational status (AOR = 2.345, 95% CI 1.543, 3.563) and media access (AOR = 2.4, 95% CI 1.922, 3.587) were significantly associated with husbands' knowledge. The husband‐reported wife's willingness to be accompanied (AOR = 2.1, CI 1.489, 2.979), and the health professionals' approach (AOR = 1.850, CI 1.354, 2.528) were significantly associated with husbands' attitudes. Having access to media (AOR = 4.077, CI 2.730, 6.089), open communication with a partner (AOR = 2.58, CI 1.303, 3.11), and knowledge of obstetric danger signs (AOR = 2.83, CI 1.958, 3.873) were significantly associated with husband involvement in the maternity continuum of care.

Conclusion

Husbands' knowledge of obstetric danger signs and involvement in the maternity continuum of care in Hadiya zone remain low. Culturally appropriate health education about obstetric danger signs through proper media, and integrating partner communication skills into health education should be promoted to enhance husband involvement.

Abbreviations

ANC

Antenatal care

HI

husband involvement

mCoC

maternity continuum of care

PNC

Post natal care

1. Introduction

Globally, maternal and neonatal mortality remain an unacceptably high public health burden, with a maternal mortality ratio (MMR) of 223; an estimated 260,000 women die annually, and every day over 700 women died from preventable causes related to pregnancy and childbirth [1, 2]. Developing countries, particularly Sub‐Saharan Africa, share a disproportionately huge burden, accounting for 70% of all global maternal deaths and about 40% to 50% of global neonatal deaths [3, 4]. This report indicates that the world remains far apart from the United Nations Sustainable Development Goal of reducing maternal mortality to 70 deaths per 100,000 live births by 2030 [5, 6].

The maternal mortality ratio remains critically high at 267 deaths per 100,000 live births in Ethiopia, with a neonatal mortality rate of 33 deaths per 1,000 live births [7]. In order to overcome these preventable deaths, the World Health Organization (WHO) promotes the maternity continuum of care (continuous utilization of antenatal care, skilled birth attendance, and postnatal care) [8]. However, a woman's ability to use this service is infrequently an independent choice in rural patriarchal societies in low‐income countries like Ethiopia. As the primary heads of household, husbands control the financial resources and transportation arrangements, and they make serious decisions about when and where their wives' access to maternal healthcare occurs [9, 10, 11, 12].

The husband's active involvement in the maternity continuum of care (mCoC) has a tremendous impact on reducing the first two maternal delays, especially when it comes to recognizing obstetric danger signs and accessing health facilities [13, 14]. Husbands are frequently not expected to accompany their wives to maternity clinics in low‐income countries, because these tasks are perceived as belonging to women [15, 16]. In rural communities of Ethiopia, pregnancy is taken as “women's business”; there is stigma around husbands in the labor ward, poor joint decision‐making between couples, and a poor healthcare provider attitude [17, 18, 19].

Despite the crucial importance of husband involvement, a programmatic and methodological gap persists in Ethiopia. Maternal health needs are primarily addressed by maternal and child health programs that involve and educate women about care‐seeking behaviors for themselves and their children that marginalize husbands [20]. The majority of studies are focused on women's viewpoints rather than husbands' perspectives and support. Most conducted studies examined husband involvement by focusing on ANC, skilled delivery, or PNC as a separate entity, rather than examining their involvement as an entire continuum of care [21, 22]. The other gap is the shallow measurement of husband involvement in previous studies, using a single‐item indicator. The concept of husband involvement needs addressing of multidimensional constructs [17, 23].

Therefore, this study aims to determine the level of husband involvement in the mCoC by using a comprehensive and multidimensional measurement tool, knowledge of obstetric danger signs, and attitude in the rural setting of central Ethiopia [24].

2. Method

2.1. Study Setting and Period

This study was conducted in the four randomly selected rural districts (Ameka, Lemo, Gibe, and Soro) of Hadiya Zone, a central Ethiopian region that is situated 230 kilometers from Addis Ababa, the capital city of Ethiopia. In the four districts there are a total of 95 rural kebeles (the lowest administrative units) with a total population of 562, 457 (49.56% males and 50.44% females) and 121, 734 households with an estimated 19, 405 pregnant mothers. There are 2 district hospitals and 18 health centers in the four districts [25].

2.2. Study Design and Period

A community‐based cross‐sectional household survey was employed from November 01 to 20, 2025.

2.3. Study Population

All husbands who have at least one child of less than 1 year in the study area were used as the source population, and randomly selected husbands who have at least one child of less than 1 year in the study area were used as the study population.

2.4. Eligibility Criteria

All husbands who have resided in the study area for at least 6 months, and have at least one child of less than 1 year have been included in the study. Those husbands who are unable to respond to the interview due to any medical reasons were excluded from the study.

2.5. Sample Size Determination and Sampling Techniques

2.5.1. Sample Size Determination

Sample size was determined by using the single population proportion formula based on the husband's involvement in three parameters across the maternity continuum of care.

N = (Z α) ² p (1‐p) d = 5% marginal error (0.05)

d² Zα = 95% CI (1.96) p = proportion of husband involvement

In each parameter, the maximum sample size has been calculated, and finally, from the three parameters, the maximum sample size was taken as follows: 1. By taking 39.3%, the proportion of HI on ANC follow‐up among pregnant women in Ethiopia, 366 sample size was determined [26]. 2. By taking 52.99%, the proportion of HI on skilled delivery service utilization in Ethiopia, 383 sample size for the study was determined [27]. 3. By taking 34.1%, the proportion of HI on PNC in Ethiopia, 345 sample size was determined [28]. The sample size was estimated based on the proportion of HI on delivery service utilization (n = 383) since it gives the maximum sample. Since we used multistage sampling technique that involves multiple phases of selection, there might be lack of the homogeneous grouping and high intra‐class correlation characteristic of traditional cluster sampling. So we used a design effect of 2 from previously published studies in a similar setting [29], and a 10% non‐response rate was added. Finally, 843 husbands were included in the study, which is the largest sample size compared to the sample sizes calculated by taking into account the different proportions of husbands' involvement during the maternity continuum of care.

2.5.2. Sampling Technique

A multi‐stage sampling technique was applied to address the objective of this study. Four districts that represent 30% of the total districts were selected. Lists of every kebele in the designated districts were compiled from the district administrative offices. A representative number of kebeles was selected from each district using a simple random sampling technique. All of the eligible husbands in the selected rural kebeles were listed utilizing the health extension worker (HEW) and community health information system (CHIS) registration logbook.

A systematic sampling technique was used to select study participants by using the “K” interval. The sampling interval (K) was calculated by dividing the total number of eligible households in each kebele by the proportionally allocated sample size for that kebele. From the total sample, the first sample household was selected by simple random sampling (lottery method), and every (Kth) household was selected to collect data until the required sample was obtained in each selected kebele, as detailed in Figure 1.

Figure 1.

Schematic presentation of sampling procedure of husbands in Hadiya Zone, central Ethiopia, November, 2025.

2.6. Data Collection and Procedures

Data was collected by using online data collection software (Kobo Toolbox). Eight BSc nurses and two supervisors (with a master of public health) were hired as data collectors, and their selection was predicated on their proficiency in the community's language and their experience of data collection. To obtain the data, in‐person interviews with participants were conducted at their homes. The surveys were double‐checked by the primary investigator and supervisors to ensure that they were relevant and thorough.

2.7. Study Instrument

Husband involvement in the maternity continuum of care is a multidimensional concept that is affected by different socio‐cultural, traditional, and behavioral factors. We used a global framework to assess husband involvement in the maternity continuum of care that was developed by an international Delphi study [24]. It was used after being adapted and modified to the local context and research objectives. It is a comprehensive tool and has a multidimensional construct with five parameters (communication, joint decision‐making, practical involvement with household chore sharing, physical involvement, and emotional support).

We used the Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) standardized questionnaires to measure husbands' knowledge of obstetric danger signs that have been developed for maternal and neonatal health studies, and they were adapted and modified to align with the local context and research objectives [30]. To measure the attitude of the husbands toward the maternity continuum of care, there are 14 items from previously published studies that were measured by using a five‐point Likert scale, where respondents were supposed to strongly agree, agree, neutral, disagree, and strongly disagree [31]. The sociodemographic, obstetric, and health facility‐related factors were also the sections of the survey. ( S1 : Survey questioner tool)

2.8. Variable Measurement

To measure knowledge, attitude, and involvement, modified Bloom's cut‐off points for KAP were used. In this study, a modified Bloom's cut‐off value of 75% was used to categorize participants' Knowledge, Attitude, and Practice (in this study, Involvement) into two levels: Poor/Negative/Low and Good/Positive/High [32, 33]. This cut‐off value was also based on previously published KAP studies. A knowledge score from 0 to 11 indicated ‘poor’ knowledge, whereas a knowledge score from 12 to 16 indicated ‘good’ knowledge. The overall attitude score was calculated by adding the items after reverse scoring for negatively phrased sentences. An attitude score below 53 (< 75%) indicated a ‘negative’ attitude, whereas an attitude score from 53 to 70 (≥ 75%) indicated a ‘positive’ attitude. To measure husband involvement, the 21‐item involvement scale was first analyzed within its five sub‐dimensions (communication, decision‐making, practical involvement, physical involvement, and emotional support). Then 75% threshold was used to classify husband involvement for each dimension independently. To evaluate a multidimensional involvement, over all involvement was dichotomized. Husbands who score ≥ 75% in three and more of the five dimensions were categorized as ‘high involvement’ while those husbands who score > 75% in two and fewer dimensions were as having ‘low involvement’ [34, 35, 36].

2.9. Operational Definition

2.9.1. Definition of Statistical Term

Husband Involvement in the Maternity Continuum of Care: In this study, husband involvement is operationalized as a multidimensional construct that has five parameters: active communication, shared decision‐making, physical support, practical assistance, and emotional support throughout a wife's pregnancy, childbirth, and the postpartum period [24].

Health Developmental Army (HDA): is a network of female community volunteers in Ethiopia. It is established to support the country's Health Extension Program and organizes local women into grassroots groups of 30 households each to promote healthy behaviors, prevent disease, and reduce maternal and child mortality [37].

2.10. Quality Control

To ensure data quality, data collectors and supervisors received comprehensive training by the principal investigator for 3 days. The training focused on the objective of the study, research ethics during the survey, interviewing skills, and their roles and responsibilities. The data collectors also practiced how to interview properly and use a mobile‐based application, Kobo Collect, prior to starting actual data collection. Translating the original English version into the local language (Hadiyyisa) is one of the vital steps to assure the validity of the measurement tool [38]. The English version of the questionnaire was translated into the local language (Hadiyyisa) by professional fluent translators and then translated back into English to check for correspondence. Public health professionals who are experts in the field reviewed the translated version to ensure the tool's validity. Then, a pre‐test was conducted with 42 husbands who were not part of the actual study. After the final evaluation of the tools for clarity, lucidity, logical order, and appropriateness, subject experts evaluated the content, reconciliation was reached, and the necessary modifications were made. The tools' internal consistency (reliability) was tested by using Cronbach's alpha, and the value was 0.793 for knowledge, 0.924 for attitude. Cronbach's alpha per scale/sub‐domain was conducted for the five involvement parameters and the values were in the acceptable ranges from 7.65 to 8.92. We used the Strengthening the Reporting of Observational Studies in Epidemiology cross‐sectional checklist for our report. ( S2 : STROBE checklist)

2.11. Data Management

Regular supervision, check‐up, and follow‐up of the data were done on a daily basis by supervisors and the principal investigator. Every day, collected data by KoBo Collect (the mobile application) was checked for completeness and consistency before being sent to the server (KoBo Toolbox). The supervisor and principal investigator considered the length of time to finish each survey, the collection of Global Positioning System points, and their random distribution. The anonymous record and coding of personal data were not disclosed to any third party to ensure strict secrecy. Data was stored on a password‐protected data server (KoBo Toolbox) and only accessible by the research team.

2.12. Data Processing and Analysis

The data was exported to SPSS window version 25 for analysis from the online server (KoBo Toolbox). Before entering multivariate analysis, potential variables were screened with bivariate analysis. Those factors with a p‐value less than 0.25 in the bivariate logistic regression analysis were considered for the multivariable logistic regression analysis. A p < 0.05 (two‐sided) was considered statistically significant in bivariate analyses. Since the outcome variables (knowledge, attitude, and involvement) are dichotomous, binary logistic regression was used for multivariate analysis for each separately. This approach estimates the probability of the outcome variables while simultaneously adjusting for multiple predictors and produces odds ratios (ORs) with 95% confidence intervals (CIs) as interpretable effect sizes. Missing data was handled by imputing the missing value with a mean of non‐missing values for that variable. To test for multicollinearity, a variance inflation factor (VIF) analysis was conducted for three outcome variables separately. The result for knowledge indicates that all independent variables had VIF value ranges from 1.014 to 1.021, and tolerance values were above 0.20. Multicollinearity test result for attitude indicates, all independent variables had VIF value ranges from 1.003 to 1.039 with tolerance values were above 0.20, and for involvement VIF values well below the threshold (ranging from 1.078 to 1.965), and tolerance values were above 0.20. Therefore, multicollinearity was not a concern in this model. The model's fitness was checked using Hosmer and Lemeshow for the three outcome variables and was found fit (knowledge p‐value = 0.214, attitude p‐value = 0.715, and involvement p‐value = 0.616). An a priori significance level of α = 0.05 (two‐sided) was set for the multivariate analysis.

2.13. Ethical Approval

This study has been thoroughly reviewed and ethically approved by Wolaita Sodo University's institutional review board (IRB‐WSU) committee with a protocol number WSU‐41/49/283 dated October 02, 2025. All participants were informed about the objectives of the study, and written informed consent was attained.

3. Result

3.1. Socio‐Demographic Characteristics

In this study, 838 husbands participated, with a response rate of 99.4%; the majority of them (45.5%) were in the age group of 35–49, with a mean age of 41.2, and a standard deviation of 8.01. The majority (43.3%) of the participants were from grades 1 to 8; more than half (57.2%) of the husbands and around two‐thirds (67.9%) of the wives were farmers and housewives by their occupation, respectively. From the respondents. 28.8% have open communication with their partners on sexual and reproductive health, and 55.1% were exposed to media about reproductive health issues, as detailed in Table 1.

Table 1.

Socio‐demographic characteristics of husbands in Hadiya Zone, central Ethiopia, November, 2025 (n = 838).

Variable	Category	Number (%)
Age	20–34	235 (28%)
	35–49	381 (45.5%)
	≥ 50	222 (26.5%)
Religion	1. Protestant	410 (49)
	2. Orthodox	316 (37.7)
	3. Muslim	85 (10.1)
	4. Catholic	27 (3.2)
Husband's highest an educational status	1. No formal education	138 (16.5)
	2. Grade 1–8	363 (43.3)
	3. Grade 9–12	198 (23.6)
	4. College and above	139 (16.6)
Wife's highest educational status	1. No formal education	290 (34.6)
	2. Grade 1–8	403 (48.1)
	3. Grade 9–12	108 (12.9)
	4. College and above	37 (4.4)
Husband occupation	1. Farmer	479 (57.2)
	2. Merchant	189 (22.6)
	3. Government employer	109 (13.0)
	4. Daily laborer	61 (7.3)
Wife's occupation	1. House wife	569 (67.9)
	2. Merchant	112 (13.4)
	3. Government employer	70 (8.4)
	4. Daily laborer	50 (6)
	5. Others	37 (4.4)
Family size	1. 1–2 persons	89 (10.6)
	2. 3–4 persons	345 (41.2)
	3. ≥ 5 persons	404 (48.2)
Open communication with partner on sexual and reproductive health	1. Yes	244 (28.8)
	2. No	594 (71.2)
Access to media information	1. Yes	462 (55.1)
	2. No	376 (44.9)

3.2. Obstetric and Health Facility‐Related Factors

From the participants, 21% had previous obstetric complications, 79.4% of the wives used ANC in the most recent pregnancy, and 62.6% of the wives participated in the health developmental army program. From the total respondents, 71.4% reported that their wives want to be accompanied to the health facility. More than half (53.3%) of the respondents report that health professionals encourage them to accompany their wives to health institutions, whereas 52.6% of the husbands reported that there is a good approach of health professionals in health institutions as shown in Table 2.

Table 2.

Obstetric and health facility‐related factors of husbands in Hadiya Zone, central Ethiopia, November, 2025 (n = 838).

Variable	Category	Number (%)
Previous obstetric complication	1. Yes	176 (21)
	2. No	662 (79)
Wife used ANC in the most recent pregnancy	1. Yes	665 (79.4)
	2. No	173 (20.6)
If she did not attend antenatal care reason for not attending	1. No health problem encountered	111 (64.2)
	2. No knowledge	62 (35.8)
Wife ever participated in health developmental army	1. Yes	525 (62.6)
	2. No	313 (37.4)
Number of births	1. < 3 times	145 (17.3)
	2. 3–5 times	298 (35.6)
	3. > 5	395 (47.1)
Number of children	1. > 5	135 (16.1)
	2. 3–5	312 (37.2)
	3. < 3	391 (46.7)
Husband‐reported wife's willingness to be accompanied	1. Yes	598 (71.4)
	2. No	240 (28.6)
Get encouragement from health professionals to go health facility	1. Yes	447 (53.3)
	2. No	391 (46.7)
Health professionals' approach	1. Good	441 (52.6)
	2. Poor	397 (47.4)
Average time it takes to reach a health institution	1. < 1 h	427 (51.0)
	2. ≥ 1 h	411 (49.0)
History of going to a health facility with your wife	1. Yes	371 (44.3)
	2. No	467 (55.7)
Opening hour of the health facility	1. Too early	231 (27.6)
	2. Appropriate	470 (56.1)
	3. Late	137 (16.3)
	4. Appropriate	470 (56.1)
	5. Late	137 (16.3)

3.3. Knowledge of Husbands on Obstetric Danger Signs

Only 330 (39.4%), 95% CI (35.8, 42.5), of respondents had good knowledge of obstetric danger signs in all categories (pregnancy, childbirth, and postpartum period). Vaginal bleeding (67%) is the most recognized obstetric danger sign, and convulsion (43%) is the least recognized obstetric danger sign. The multivariable logistic regression result showed that those with an educational status of college and above were two times (AOR = 2.35, 95% CI 1.54–3.56) more likely to be knowledgeable when compared to those with no formal education, and those husbands with access to media information were 2.4 times (AOR = 2.4, 95% CI 1.92–3.59) more likely to be knowledgeable than their counterparts, as detailed in Table 3.

Table 3.

Factors associated with knowledge of obstetric danger signs among husbands' in Hadiya Zone, central Ethiopia, November, 2025 (n = 838).

Variable		Knowledge		Crude OR (95% CI)	p value	AOR (95% CI)
		Good	Poor
Educational status	College and above	76	63	1.52 (1.14, 3.75)	0.001	2.35 (1.54, 3.56)a
	9–12	71	127	0.71 (0.31, 1.47)	0.367	1.19 (0.71, 1.99)
	1–8	122	241	0.64 (0.42, 1.46)	0.187	1.01 (0.73, 1.41)
	No formal education	61	77	1		1
Open communication with the partner	Yes	115	129	1.57 (1.08, 1.98)	0.092	1.26 (0.91, 2.14)
	No	215	379	1		1
Access to media information	Yes	228	234	2.62 (2.07, 3.75)	0.001	2.43 (1.92, 3.59)a
	No	102	274	1		1
Wife participated in HAD	Yes	223	302	1.42 (1.13, 1.82)	0.576	1.26 (0.91, 1.74)
	No	107	206	1		1
History of going to health facility with your wife	Yes	166	205	1.50 (1.12,1.98)	0.412	1.49 (0.88, 2.01)
	No	164	303	1		1

^aFor statistically significant (p < 0.05).

3.4. Attitude of Husbands Towards Their Involvement in the Maternity Continuum of Care

More than half of the study participants, 513 (61.2%), 95% CI (57, 63.7), had a positive attitude toward their involvement in the maternity continuum of care, as indicated in Table 4.

Table 4.

Attitude of husbands toward their involvement in the maternity continuum of care in Hadiya Zone, Central Ethiopia, November, 2025 (n = 838).

Variables	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
Women should plan ahead where they will give birth	114 (13.6)	397 (47.4)	242 (28.9)	85 (10.1)	NA
A woman should plan‐ahead how she will get to the place where she will give birth	129 (15.4)	316 (37.7)	236 (28.2)	121 (14.4)	36 (4.3)
Woman needs rest/special nutrition during pregnancy	128 (15.3)	295 (35.2)	264 (31.5)	151 (18.0)	NA
Pregnancy/childbirth related issues are women's matter that should not involve husbands	67 (8)	170 (20.3)	187 (22.3)	172 (20.5)	242 (28.9)
Educating husbands in maternal health will enhance their involvement	326 (38.9)	117 (14.0)	266 (31.7)	129 (15.4)	NA
Cultural belief restraints husbands from getting involved in maternal care.	162 (19.3)	367 (43.8)	152 (18.2)	98 (11.7)	59 (7.0)
Husbands should provide finances for antenatal care and delivery	324 (38.7)	236 (28.2)	114 (13.6)	114 (13.6)	50 (5.9)
Husbands should give care for the children	343 (40.9)	223 (26.7)	110 (13.2)	137(16.3)	25 (2.9)
Pregnant women and husbands should discuss issues concerning pregnancy and child birth regularly	283 (33.8)	318 (37.9)	101 (12.1)	88 (10.5)	48 (5.7)
It is not necessary for husbands to accompany pregnant women to antenatal care	19 (2.3)	101 (12)	155 (18.5)	394 (47.0)	169 (20.2)
It is necessary for husbands to accompany pregnant women to a health institution to give birth	345 (41.2)	200 (23.9)	172 (20.5)	103 (12.3)	18 (2.1)
Husbands should be present in the labor room	204 (24.4)	336 (40.1)	119 (14.2)	90 (10.7)	89 (10.6)
It is necessary that a husbands should encourage his wife to get postnatal care services	393 (46.9)	238 (28.4)	86 (10.3)	94 (11.2)	27 (3.2)
Composite attitudes	Positive attitude			513	61.2%
	Negative attitude			325	38.8%

In the multivariate logistic regression analysis, those husbands who respond as their wives had willingness to be accompanied were 2 times (AOR = 2.1, CI 1.49–2.98) more likely to develop a positive attitude than those husbands whose wives did not show willingness to be accompanied, and those participants who responded that health professionals' approach is good were 1.8 times (AOR = 1.85, CI 1.35–2.53) more likely to develop a positive attitude towards their involvement in the maternity continuum of care when compared to those who responded that health professionals' approach is poor, as detailed in Table 5.

Table 5.

Factors associated with attitude of respondents towards their involvement in the maternity continuum of care, in Hadiya Zone, central Ethiopia, November, 2025 (n = 838).

Variable		Husband's attitude		COR(95% CI)	p value	AOR (95% CI)
		Positive	Negative
Open communication with partner	Yes	142	102	0.84 (0.17, 0.98)	0.263	1.11 (0.79, 1.57)
	No	371	223	1		1
Husband‐reported wife's willingness to be accompanied	Yes	380	218	1.40 (1.13, 2.06)	0.001	2.11 (1.49, 2.98)a
	No	133	107	1		1
Wife used ANC in the most recent pregnancy	Yes	399	266	0.78 (0.48, 0.99)	0.106	1.07 (0.74, 1.59)
	No	114	59	1		1
Wife participated in HAD	Yes	311	214	0.80 (0.35, 0.93)	0.827	1.05 (0.77, 1.44)
	No	202	111	1		1
Health professionals' approach	Good	294	153	1.51 (1.07, 2.10)	0.030	1.85 (1.35, 2.53)a
	Poor	219	172	1		1

^aFor statistically significant (p < 0.05).

3.5. Prevalence of Husband's Involvement in the Maternity Continuum of Care

From the total of 838 participants, 432 (51.5%), 95% CI (48.1, 55.9), of the husbands were involved in the maternity continuum of care. In the multivariable analysis, those husbands with access to media information regarding MCH issues were 4 times (AOR = 4.08, CI 2.73–6.09) more likely to be involved in the maternity continuum of care than those who didn't get access to media information; those participants who have open communication with the partner on sexual and reproductive health were 2.5 times (AOR = 2.58, CI 1.30–3.11) more likely to be involved than their counterparts, and those husbands with good knowledge on obstetric danger signs were 2.8 times (AOR = 2.83, CI 1.96–3.87) more likely to be involved in the maternity continuum of care when compared to those with poor knowledge, as indicated in Table 6.

Table 6.

Factors associated with husband's involvement in the maternity continuum of care in Hadiya Zone, central Ethiopia, November, 2025 (n = 838).

Characteristics and categories		Husband involvement		COR (95% CI)	p value	AOR (95% CI)
		High	Low
Educational status	College and above	82	57	0.98 (0.73, 1.91)	0.183	0.61 (0.31, 1.62)
	9–12	81	117	0.98 (0.57, 1.83)	0.347	0.36 (0.19, 1.28)
	1–8	186	177	0.72 (0.46, 1.59)	0.726	0.38 (0. 18, 1.31)
	No formal	82	56	1		1
History of going to health facility	Yes	213	158	1.53 (1.23, 2.14)	0.070	1.34 (0.90, 1.99)
	No	219	248	1		1
Access to media information	Yes	296	166	3.15 (2.50, 4.65)	< 0.001	4.078 (2.73, 6.09)a
	No	136	240	1		1
Wife participated in HAD	Yes	256	269	0.74 (0.43, 0.94)	0.176	1.18 (0.77, 1.82)
	No	176	137	1		1
Open communication with partner	Yes	156	88	2.04 (1.58, 3.18)	0.001	2.58 (1.30, 3.11)a
	No	276	318	1		1
Wife used ANC in the most recent pregnancy	Yes	325	320	0.82 (0.49, 0.97)	0.343	1.27 (0.78, 2.07)
	No	107	86	1		1
Previous history of obstetric complication	Yes	110	70	1.64 (1.31, 2.04	0.089	0.62 (0.37, 1.11)
	No	322	336	1		1
Number of births	> 5 times	194	201	0.88 (0.42, 1.44)	0.634	0.61 (0.38, 1.35)
	3–5 times	162	136	1.08 (0.85, 1.53)	0.167	0.77 (0.43, 1.77)
	< 3 times	76	69	1		1
Knowledge	Good	195	135	1.65 (1.21, 2.24)	0.007	2.8 (1.96, 3.87)a
	Poor	237	271	1		1

^aFor statistically significant (p < 0.05).

4. Discussion

This study assessed the knowledge of husbands on obstetric danger signs, the attitude and involvement in the maternity continuum of care, and associated factors in rural communities of the Hadiya Zone. Accordingly, educational status and getting access to media were significantly associated with husbands' knowledge of obstetric danger signs; husband‐reported wife's willingness to be accompanied and health professionals' approach were significantly associated with husbands' attitude, whereas access to media information, having open communication with a partner, and knowledge of obstetric danger signs were significantly associated with husband involvement in the maternity continuum of care.

In the current study, 39.4% (35.8, 42.5) of the study participants had good knowledge of obstetric danger signs. This finding is lower than studies conducted in different study areas in Ethiopia [31, 39, 40] and Kenya [41], but it is consistent with the pooled prevalence of knowledge on obstetric danger (37.29%) [42] in Ethiopia. Husbands with a college and above educational status were more likely to be knowledgeable than those with no formal education. This result is consistent with other study findings that have been done in Southern Ethiopia [40], and Indonesia [43], where husbands with a higher educational level were more likely involved in maternity care. The possible reason might be when husbands get educated, there is a higher probability of getting awareness of maternal and child health issues. In the current study, those husbands who have access to media information were two times more likely to be knowledgeable than those who were not exposed to media. This finding is supported by the studies conducted in the Southern Ethiopian [40] and Bangladesh [44]. This could be getting media access might have a significant linkage with the knowledge and promoting husbands' involvement in the maternity continuum of care.

This result reveals that 61.2% (57, 63.7) of the husbands had a positive attitude towards their involvement in the maternity continuum of care. This is lower than research from Nigerian community [45], where (76.6%) husbands had a positive attitude about their role. The difference might be due to the utilization of different measurement tools; participants' socio‐cultural characters and the variable attitude by itself can be influenced by multifaceted individual factors. Those husbands who report as their wives want to be accompanied to the health facility by their husbands were 2 times more likely to have a positive attitude than those who did not want to be accompanied. This result implies that a husband's attitude and real participation in maternal healthcare may be linked to spousal communication and a wife's clear desire for her partner's attendance. Those husbands who respond as health professionals' approach is good were more likely to have a positive attitude than those with a poor approach. This finding is concurrent with the study conducted in Anomabo, Ghana [46], and a Nigerian community [45]. The possible reason might be when husbands perceive health providers' attitude towards their involvement as friendly, they are more likely to participate in maternal health services [47].

In this research, the overall proportion of husband involvement in the mCoC was 51.5% (48.1, 55.9). This finding is higher than a study conducted in Addis Ababa, Ethiopia, 34.8% [23], and Bangladesh (40%) [44], and lower than the study finding reported in southern Ethiopia, which found that 57% [21] of husbands were involved. The difference might be due to socio‐cultural norms and gender role variances, different measurement tools and study participants, and health system factors. In this study, husbands who have access to media information were 4 times more likely to be involved in the mCoC, and this finding is supported by the research from the Southern Ethiopia [40] and Malawi [48]. This highlights that mass media access might be a tool for public health promotion and could encourage husband involvement to improve maternal and neonatal health outcomes by [49].

Husbands who had an open communication with their partners on sexual and reproductive health were 2.5 times more likely to be involved in the mCoC than their counterparts. This is in line with the study conducted in Mozambique [50]. This suggests that communication between couples might encourage husband involvement in practical ways, such as going to clinics with his spouse, offering logistical and financial support, and taking part in shared decision‐making. Additionally, communication between couples might be associated with more equitable power dynamics and shared decision‐making, which empowers women's health‐seeking behavior [51].

Husbands having good knowledge of obstetric danger signs were more likely to be involved in the mCoC than those with poor knowledge. This finding is parallel with the research conducted in Southern Ethiopia [40), and Southeast Nigeria [52]. The possible explanation could be that informed husbands are able to identify danger signs, which helps them make timely decisions to seek care and overcome delays in doing so, resulting in faster referrals and get service utilization. The “first delay” in identifying problems is caused by lack of knowledge, but those husbands and families who get awareness night take rapid measures to prevent bad consequences [53].

5. Strengths and Limitations of the Study

This study comprises a lot of strengths, as it was analyzed with a large sample size. Husband involvement in the maternity continuum of care was measured through a comprehensive approach. Utilizing a cross‐sectional design, this study inherently possesses limitations in establishing definitive causal relationships. Recall bias might be introduced since this study includes those husbands who have had children under 1 years. The reliance on self‐reported data from husbands might lead to social desirability bias. This study exclusively depends on the husbands' data, and this might lead to sole‐informant bias, since verifying the actual extent of husband involvement in the household requires wives' parallel responses. Selection bias might also be introduced, because the study recruited only through health extension registers, and husbands with no contact with the formal health system were excluded.

6. Conclusion and Recommendations

Educational status and access to media information were significantly associated with husbands' knowledge of obstetric danger signs. Husband‐reported wife's willingness to be accompanied and good health professionals' approaches were associated variables with the husbands' attitudes. Husbands' access to media information, having open communication with their partners, and knowledge of obstetric danger signs were significantly associated with husband involvement in the maternity continuum of care.

To enhance husbands' knowledge of obstetric danger signs and their involvement in the maternity continuum of care, it is recommended to deliver culturally appropriate health education about obstetric danger signs through proper media coverage and integrated partner communication skills should be promoted. Health professionals should have to encourage husbands to accompany their wives to the health facility, and health system should have to facilitate a supportive and attractive health service environment for husbands.

Author Contributions

Lonsako Abute Woiloro: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, formal analysis, data curation, resources, software. Takele Tadesse Adafrie: funding acquisition, writing – original draft, investigation, methodology, validation, visualization, writing – review and editing, software, project administration, supervision, conceptualization. Amene Abebe Kerbo: conceptualization, investigation, funding acquisition, writing – original draft, validation, visualization, supervision, software, writing – review and editing. Mengistu Meskele: conceptualization, investigation, funding acquisition, writing – original draft, methodology, validation, visualization, writing – review and editing, software, formal analysis, project administration, data curation, resources.

Ethics Statement

This study has been thoroughly reviewed and ethically approved by Wolaita Sodo University's institutional review board (IRB‐WSU) committee with a Protocol Number: WSU‐41/49/283 dated October 02, 2025. The study has been evaluated for its adherence to the ethical principles and guidelines set forth by Wolaita Sodo University. All participants were informed about the objectives of the study, and written informed consent was attained. Respondents' confidentiality was ensured throughout the research process, and they were informed that their identity and the information they provided were kept private.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author, Lonsako Abute Woiloro (bt.lnsk@gmail.com), affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Supporting File 1

Supporting File 2

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. Requests for data access should be directed to the corresponding author, Lonsako Abute Woiloro (bt.lnsk@gmail.com).