Open access Original research

Barriers to birth preparedness and

BMJ Open: first published as 10.1136/bmjopen-2022-069565 on 26 April 2023. Downloaded from [Link] on January 12, 2025 by guest. Protected by copyright.
complication readiness among pregnant
women in rural Ethiopia: using a mixed
study design, 2020
Abdi Geda Gedefa ‍ ‍,1 Alazar Ayalew Bekele,2 Keno Melkamu Kitila ‍ ‍,3
Lemi Bacha Eba4

To cite: Gedefa AG, Bekele AA, ABSTRACT

Kitila KM, et al. Barriers Objective To assess birth preparedness and complication STRENGTHS AND LIMITATIONS OF THIS STUDY
to birth preparedness and readiness (BPCR) and associated factors among pregnant ⇒ Collecting primary data for both the quantitative and
complication readiness among qualitative studies are among the strengths of this
women in Bachoo District, Oromia, Ethiopia.
pregnant women in rural study.
Design A mixed cross-­sectional study design was
Ethiopia: using a mixed study
employed to conduct this study. ⇒ Conducting a community-­based mixed study of this
design, 2020. BMJ Open
2023;13:e069565. doi:10.1136/ Setting A community-­based cross-­sectional study was type may generate more representative data.
bmjopen-2022-069565 done in the rural community of Bachoo District of Iluu ⇒ The gestational age of the pregnancy was self-­
Abbaa Boor Zone, Oromia Region, Southwest Ethiopia. reported by the respondents, it was not confirmed
► Prepublication history for by diagnostic test.
Participants A total of 307 pregnant women participated
this paper is available online. ⇒ Some of the study participants may commit recall
in the quantitative study, 51 respondents were involved in
To view these files, please visit
the qualitative part. A simple random sampling technique and social desirability bias.
the journal online ([Link]
org/10.1136/bmjopen-2022-​ was used to select the final respondents. Data were ⇒ Since currently pregnant women have not yet com-
069565). entered into EpiData V.3.1 and analysed using SPSS V.22. pleted their pregnancies, they are unable to report
Binary and multivariable logistic regression analysis was whether they used services they have not yet need-
Received 26 October 2022 done. The level of statistical significance was declared at ed, for example, a skilled provider to assist them
Accepted 13 April 2023 a p<0.05. Three focus group discussions and 21 in-­depth with the birth.
interviews were conducted, and the data were analysed
using thematic analysis and triangulated to support the
findings of the quantitative study. occurred in low-­resource settings, and most
Result The prevalence of BPCR was 30.6%. Being could have been prevented.1 2 Sub-­Saharan
governmental employee ((adjusted OR, AOR=3.22 95% CI Africa (SSA) alone accounted for roughly
(1.49 to 11.79)), educational status of secondary and
two-­thirds (196 000) of maternal deaths.3
above ((AOR=1.9 95% CI (1.15 to 3.84)), multigravidity
Ethiopia is among SSA countries with a
((AOR=5.96, 95% CI (1.18 to 3.68)), having four or above
ANC visits ((AOR=4.25 CI (1.38 to 7.84)), participating in high burden of maternal mortality.4–6 Ethi-
pregnant women conference ((AOR=2.11 95% CI (1.07 to opia fell short of meeting the fifth Millen-
© Author(s) (or their
employer(s)) 2023. Re-­use 3.78)), having good knowledgeable of obstetrics danger nium Development Goal, which was to reduce
permitted under CC BY-­NC. No signs ((AOR=10.4 95% CI (5.57 to 19.60)), hearing the the maternal mortality ratio by three-­quarters
commercial re-­use. See rights term BPCR ((AOR=4.36, 95% CI (1.93 to 9.82)) were between 1990 and 2015, showing only a slow
and permissions. Published by among factors significantly associated with BPCR. decline.7 8
BMJ.
The qualitative study also showed that poor maternal All women need access to high-­quality care
1
College of Health Science, knowledge on birth preparedness and obstetric danger
Public Health Departments,
during pregnancy, and during and after child-
signs, negligence and weak support systems in the birth. It is particularly important to ensure
Mettu University, Mettu, Ethiopia
community were among the main barriers.
2
Bacho District Health Office, that all births are attended by skilled health
Conclusion and recommendation This study
Iluu Abbaa Boor Zonal Health professionals, as it can make the difference
Office, Oromia state, Ethiopia demonstrated that the practice of BPCR in the study
3 area was very low. Therefore, healthcare providers in the between life and death for the mother as well
Department of Public Health,
College of Health Sciences study area should strengthen BPCR knowledge through as for the baby.9–11
Mettu University, Mettu, Ethiopia educating women the community at large. Birth preparedness and complication
4
Psychiatry Department, readiness (BPCR) is a standard set of indi-
College of Health Science Mettu cators (Index) developed by Maternal
University, Mettu, Ethiopia BACKGROUND and Neonatal Health Programme of
Correspondence to Globally, about 295 000 women died during John Hopkins Program for International
Abdi Geda Gedefa; and following pregnancy and childbirth in Education in Gynecology and Obstetrics
​abdiabagada@​gmail.c​ om 2017. The vast majority of these deaths (94%) (JHPIEGO).12 It is described as a process

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of planning for birth and anticipating actions in case METHODS AND MATERIALS
of obstetric emergencies in order to reduce delays in Study area
seeking skilled care.13 This research was carried out in the Bachoo District of
In other words, it is a tool that provides guidance in the Ilu Aba Bora Zone of Oromia Regional State. Bachoo
assessing and monitoring safe motherhood programmes District is 1 of 14 districts in Iluu Abbaa Boor province
that intervene at multiple levels.12–14 In 2005, BPCR was (zone). It is bordered on the south by SNNP (southern
included in the WHO antenatal care (ANC) package.15 nation, nationalities and people) regional state, on the
BP/CR is a relatively common strategy employed southwest by Halu district and on the east by Hurumu
by numerous groups implementing safe motherhood district. The district consists of 17 kebeles with a total
programmes. However, the applications of the concept population of approximately 52 837.
are varied and there is no single agreed on definition.12 13 The district has an estimated 11 692 childbearing
According to the JHPIEGO, BPCR plan contains women and 1833 pregnant women. There are three
the following elements: the desired place of birth; the health centres and sixteen functional health posts in the
preferred birth attendant; the location of the closest district. The Bachoo District health office oversees the
facility for birth and in case of complications; funds for district’s overall healthcare activity.
any expenses related to birth and in case of complications;
supplies and materials necessary to bring to the facility; Study design
an identified labour and birth companion; an identified A community-­based cross-­sectional study design, supple-
support to look after the home and other children while mented by a qualitative study, was conducted from 1
the woman is away; transport to a facility for birth or in November 2020 to 30 December 2020.
the case of a complication and identification of compat-
ible blood donors in case of complications.13
Population
It is a comprehensive matrix that includes shared
Study population
responsibility among the woman and her family, the
The study population was pregnant women who were
community, healthcare providers, facilities that serve
permanently residing in selected kebeles of Bachoo
them and the policies that affect care for the woman and
District, Iluu Abbaa Boor Zone of Oromia State,
the newborn.16 17
Ethiopia.
Hence, (BPCR) is strongly recommended by the WHO
and even included as an essential element of the ANC
package. It is often delivered to the pregnant women by Eligibility criteria
healthcare providers in ANC followed up or through a Inclusion criteria
visit to the home of the pregnant woman by a community All pregnant women whose pregnancy was in the 3rd
health workers.13 18 19 trimester (24 or more gestational age) and resided in the
The three delays (delay in seeking care—delay in sampled kebeles at least for 6 months.
reaching care, and delay in receiving care—highly
contribute to maternal and neonatal death. According to Sample size determination and sampling procedure
Thaddeus and Maine, these delays can be prevented by For the quantitative study
BPCR which allows a pregnant woman and her family to For the quantitative study, sample size was calculated for
plan ahead.20 Previous studies have shown that very low both objectives. For the first objective—proportion of
proportions of pregnant women were prepared for child- pregnant women ready for birth and its complications—
birth and its complications in Ethiopia.21 Furthermore, sample size was calculated using a single population
studies revealed that low socioeconomic status, a lack proportion formula: n = (Zα/2)2 (pq)/d2, with the assump-
of women’s decision-­making power, trust in traditional tions of:
birth attendants, a lack of knowledge and awareness of Z=1.96 at 95% CI.
danger signs during pregnancy, and a fear of travelling d=Margin of error assumed to be 0.05.
to unfamiliar areas were among the identified barriers P—Proportion of BPCR from previous study at north-
preventing pregnant women in Ethiopia from accessing west Ethiopia=24.1%26 with 95% CI.
healthcare services.3 20 22–25 Meanwhile, the authors were q=1−p:
convinced that quantitative study alone is not enough to n = (Zα/2)2 (pq)/d2=1.96×1.96×0.24×(1–0.24)/0.052=280.
understand the underlying problems related to BPCR. Adding 10% non-­respondent rate, the total sample size
Hence, the authors conducted a detailed qualitative study was=310.
to explore the underlying beliefs and problems and to For the second objective (factors associated with
support the findings of the quantitative study. Therefore, BPCR), sample size was calculated using double popula-
this study assessed BPCR and associated factors among tion proportion formula. But since the sample size calcu-
pregnant women and explored the underlying barriers lated for the first objective was larger than the later, the
and beliefs at individual and family level in south-­west larger sample size (of the first objective) was used in this
Ethiopia by using a mixed approach. study.

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Figure 1 Schematic presentation of sampling procedure in Bachoo District (Woreda) of Iluu Abbaa Boor Zone, Oromia,
Ethiopia.

Sampling procedure *The WDA is a form of volunteer community health

For the quantitative study workers who are selected from the community to support
Bachoo District has 17 kebeles, 11 of which were chosen the health extension programme by encouraging families
through simple random sampling. The updated lists of to take responsibility for their own health.27 28
pregnant women in the respective (selected) kebeles
were obtained and cross-­checked from multiple sources Data collection instrument and procedure
(health posts/health extension workers, health centres, For quantitative study
district health office). Following that, a list of all preg- Data were gathered using a questionnaire developed
nant women in the selected kebeles was created based by JHPIEGO (Maternal, Neonatal Health Programme),
on the eligibility criteria. The total sample size was allo- an affiliate of Johns Hopkins University’s Bloomberg
cated to the selected kebeles based on the total number School of Public Health.12 Then it was translated into
of pregnant women in the kebeles using a proportional Afaan Oromoo by a language expert and translated back
allocation technique (see figure 1). Then, using the to English by another language expert to ensure consis-
newly created list of pregnant women as sampling frame, tency. Then the tool was pretested on 5% of the sample
systematic random sampling method was employed to size at a place different from the study area.
reach the final respondents. The interview took place in A face-­to-­face interviewer administered data collection
the selected kebeles at the home of sampled participants method was used to gather information from pregnant
(figure 1). All the sampled individuals agreed to partici- women. Those who met the inclusion criteria in the
pate in the interview except three individuals. chosen group were interviewed. Seven midwifes were
recruited for data collection, and two [Link]. nurses were
For the qualitative study assigned as supervisors with the principal investigators.
A total of 30 participants were purposively selected and For qualitative: Open-­ ended questionnaire for this
divided into 3 focus group discussions (FGDs). interview was taken from the JHPIEGO’s individual
Furthermore, since the nature of FGDs may prevent level BPCR index12 and modified to meet local context.
some participants from freely expressing their opinions, A total of three sessions of FGDs consisting: pregnant
the authors conducted in-­depth interviews (IDIs) with 21 women, males (married men who had pregnant wife) and
key informants including Women’s development army elderly women. But pregnant women and her husband
(WDA)* who were not involved in the quantitative inter- did not participate on the same FGD session. Each
view or FGD to mitigate this limitation. group consisted of 10 members. Then discussion was

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undertaken to explore the community’s views and expe- into themes. Then manual thematic analysis was done to
rience regarding birth preparedness and complication explore main barriers identified during FGDs and IDIs.
redness. Twenty-­ one IDIs were also conducted among Finally, the themes that stemmed from both FGD and IDI
pregnant women and WDA who were not participants in were triangulated with quantitative findings.
quantitative interview and FGD.
Main points addressed during the discussion are: Measurements
knowledge of danger signs during pregnancy, labour, In this study, birth preparedness score was computed
postpartum and, in newborn, plan to attend at least four from the following key elements of BPCR; arrangement
ANC visits with a skilled provider; plan to give birth with a for transportation, saving money for delivery, identified
skilled provider; plan to save money for a childbirth; plan skilled attendants to assist at birth, identifying a health
to identify a mode of transport to the place of delivery; facility for emergency, identifying blood donor in case of
preparing important materials necessary to bring to the emergency and identified who would accompany them
facility; any identified labour and birth companion; iden- during emergency.12
tified person/support to look after the home and other The participants who fulfilled at least four of the
children while the woman is away; and identification of above-­ mentioned BPCR practices were considered as
compatible blood donors in case of complications. ‘prepared’.14 29
During the entire FDG and IDI, notes were taken and Data collectors were trained on how to handle confi-
their voices were also recorded using a tape recorder. The dentiality and privacy of the participants. Then consent
discussions were held in the quite room of health posts of was obtained from the study participants. Confidenti-
each kebele. ality was assured by excluding participants’ names from
the data collection tools. The study purpose, procedure
Data analysis procedure and duration, of the study were clearly explained to study
Data were checked for completeness and consistency. participants. Study participants were informed that they
The collected data were entered into a computer using can skip any question they do not want to respond to and
EpiData software V.3.1 and exported to SPSS V.22 for can quit the interview at any time if they want to do so.
cleaning, recoding and analysis. Descriptive results like
percentage and frequency distributions of all variables Patient and public involvement
were presented using tables and charts. First, univariable No patient and public involvement.
logistic regression analysis was run to identify variables
candidates for the multivariable logistic regression anal-
ysis. Accordingly, variables with p<0.25 on the univariable RESULT
logistic regression analysis were considered as candidates Sociodemographic characteristics of the participants
for the multivariable logistic regression analysis. The A total of 307 pregnant women participated in this
goodness of the fit of the final model was checked using study, making the response rate 99.7%. The mean age of
the Hosmer-­Lemeshow test, considering a good fit at a respondents was 28.1±5.18 SD. Most of the participants
p>0.05 (0.463). Then multivariable logistic regression (268, or 87.3%) were Muslim. The majority of the partici-
model was fitted and variables with p<0.05 at 95% CI were pants, 190 (61.9%) were housewives and 140 (45.6%) had
declared to be significant and adjusted odds ratio (AOR) primary education, while 111 (36.2%) were not able to
were used to measure the strength of association. read and write. Two hundred and eighty-­six (93.2%) were
Variables: The main predictor variables identified married. One hundred and forty (45.6%) of the study
during univariable logistic analysis were: gravidity, parity, participants’ husbands had completed primary school,
maternal occupation, maternal education, access to while 111 (36.2%) of the women’s husbands could not
mass media and frequency of ANC visit, decision-­making read or write, and more than three-­quarters of them (243,
on obstetrics care seeking, participation in pregnant or 79.2%) were farmers (table 1).
women’s conferences, knowledge about obstetrics danger
signs and hearing the term BPCR Findings from the qualitative study
The main themes that emerged from the FGD and IDI
Qualitative analysis were: the participants’ perception of the importance
Prior to analysing the data, all audio records from qualita- of emergency maternal and newborn services utilisa-
tive interviews were transcribed and translated to English. tion; importance of early recognising danger signs and
The authors transcribed each discussion verbatim and taking actions; the importance of saving money for
carefully checked each transcript for accuracy by simulta- emergency; the impact of distance from health facility
neously listening to the audio recording and reading the on using routine and emergency maternal healthcare
transcript. Notes taken during the interviews were incor- services; the impact of household responsibility on the
porated in the final transcripts. Preliminary coding of tran- BPCR and maternal service utilisation; being dissatisfied
scripts was done using a hybrid approach (combination with ANC care and its impact on the BPCR. The findings
of deductive and inductive approach). Then consistent summarised under these themes are triangulated with the
codes were condensed into categories and subsequently quantitative findings.

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Table 1 Sociodemographic characteristics of the Table 2 Obstetrics and service utilisation characteristics of
participants, Bachoo District November 2020 (n=307) study participants in the selected kebeles of Bachoo District,
Characteristics Frequency % Iluu Abbaa Boor Zone November 2020 (n=307)
Characteristics Categories Frequency %
Age
No of pregnancy 1–2 203 66.1
112 36.4
≥3 104 33.9
 15–19 111 36.2
No of children 0 77 25.1
 20–24 54 17.6
1–2 223 66.1
 25–34 30 9.8
≥3 27 8.8
Religion History of stillbirth Yes 15 4.9
 Muslim 268 87.3 No 292 95.1
 Others 39 12.7 History of abortion Yes 25 8
Ethnicity No 282 92
 Oromo 246 80 Previous ANC visit other Yes 181 59
than this pregnancy
 Others 61 20 No 126 41

Occupation/women Current ANC visit Yes 234 76.2

No 73 23.8
 Housewife 190 61.9
Gestational age at 1st <12 weeks 16 6.8
 Others 117 38.1 ANC visit
12–24 weeks 173 74
Marital status
>24 weeks 45 19.2
 Married 286 93.2
Place of ANC visit Health centre 196 83.7
 Others 21 6.8
Health post 23 9.8
Women’s education Both 15 6.5
 Has no formal education 99 32.2 Frequency of ANC Visit 1 31 13.3
 Primary school 109 35.5 2 92 39.4
 Others 99 32 3 86 36.7
Husband education n=294 ≥4 25 10.6
 Has no formal education 111 37.7 Health professional Nurse 3 1.3
contacted
 Read and write 140 47.6 Midwife 205 87.6

 Primary school 43 14.7 Health extension 26 11.1

worker
Mass media Future plan of ANC 1–2 time 57 18.6
 Radio 102 33.2 3–4 times and above 213 69.4
 Television (TV) 35 11.4 Not planned yet 37 12
 Both TV and radio 49 16 Decision for obstetric Herself only 32 10.4
healthcare seeking
 Do not have any 121 39.4 Husband only 125 40.7
Distance from health centre/by foot Herself and husband 150 48.9

 Less than 15 min 62 20.2 Participation in pregnant Yes 133 43.3

women conference
No 174 56.7
 15–45 min 90 29.3
 Greater than 45 min 155 50.5 Knowledge about and source of information on key danger signs during
pregnancy, labour and delivery and the postpartum period among
respondents Bachoo District, Iluu Abbaa Boor Zone, November–December
2020 (n=307)
ANC, antenatal care.

Obstetric and service utilisation characteristics of

respondents token, only 16 (6.8%) had their first ANC before the end
Out of 307 respondents, 210 (68.4%) were multigravida of the first trimester. More than two-­thirds (212, 69.2%)
(pregnant for the second time or more). Twenty-­ five of them decide jointly with their husbands for obstetric
(8.14%) of the participants had a history of abortion. healthcare seeking (table 2).
Nineteen (6.2%) of the participants had a history of still- The majority of participants in the FDG and IDI
birth. Among the multiparas 141 (60%) and 234 (76.2%) reported that the majority of pregnant women usually
of the mothers had an ANC visit during their previous start ANC visits at nearby health facilities when their preg-
and current pregnancy, respectively. However, only 25 nancy is past 16 weeks or when they start feeling fetal
(10.6%) of them had 4 or more ANC visits. In the same movement.

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The discussants of the FGD raised the importance and after her ANC visit and tells me that both she and the
benefits of having ANC for the well-­being of the mother baby (fetus) are healthy, I feel happy and hopeful.
and fetus as follows. But if she doesn’t go to a health facility and some-
thing bad happens to her and the baby (fetus), while
… Yes, it is important to go to the health center for
she could avoid the problem through ANC services,
ANC visits. When I went to the health center, the pro-
there is no one to blame for the consequences in the
fessional did some checkups for me and told me that
my pregnancy was 6 months, the baby was in good end said A husband of pregnant women.
condition, and advised me to eat well. They also sent The majority of respondents believe that unexpected
me to the laboratory and took some blood for inves- health problems could occur to a mother during preg-
tigation. They told me that I was healthy and advised nancy, labour and delivery, and post partum, and 146
me to come back if any unusual signs or symptoms (47.6%) believe that those problems could endanger
occurred. However, in our village, there are many both the mother and the fetus. Only 76 (24.7%) of
pregnant women who say “Let God do whatever he respondents had good knowledge about danger signs.
likes; I am not going to the health center The most common danger signs of pregnancy identified
…Personally, I believe having ANC follow up is im- by the respondents were vaginal bleeding, 152 (49.5%)
portant. You know why? When my wife comes home (table 3).

Table 3 Participants knowledge and source of information about danger sign during pregnancy, labour and delivery and
postpartum period among respondents (N=307)
Danger sign/variables Frequency %
Respondents knowledge of key danger signs during pregnancy (multiple responses)
 Vaginal bleeding 152 49.5
 Blurred vision 24 7.8
 Swollen hand/face 33 10.7
Respondents knowledge of key danger signs during labour and delivery (multiple responses)
 Vaginal bleeding (severe/excessive) 191 62.2
 Retained placenta 50 16.2
 Prolonged labour >12 hours 88 28.66
 Convulsions 11 3.5
Respondents knowledge of key danger signs during the postpartum period (multiple responses)
 Vaginal bleeding (severe/excessive) 113 36.8
 Vaginal discharge (foul smelling) 8 2.6
 High-­grade fever 33 10.7
 Others 10 3.25
Respondents aggregated knowledge of danger sign during pregnancy, labour and delivery and the postpartum period
 Had good knowledge 76 24.8
 Poor knowledge 231 75.2
Practice on BPCR components
Heard the term BPCR Yes 88 (28.7)
No 219 (71.3)
Source of information about BPCR Health professional 51 (57.9) 57.9
Family/friend/relatives 37 42.1
Practice of components of BPCR Saved money 138(45) 169(55)
Identified place of delivery 122 (39.7) 185 (60.3)
Identified means of transportation 106 (34.5) 201 (65.5)
Identified skilled provider 31 (10.1) 278 (89.9)
Arranged blood donor 8 (2.6) 299 (97.4)
Identified who accompany 80 (26.1) 277 (73.9)
BPCR, birth preparedness and complication readiness.

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During the qualitative study, the majority of the respon- Unfortunately, they couldn’t get an ambulance. They
dents mentioned the following problems as danger signs: paid one thousand birr from the cash I gave to her
vaginal bleeding, prolonged labour, retained placenta, and took her to the health center, where she gave
and blurred vision, back pain, nutritional problems, and birth. If I hadn’t given her that money, bad things
vomiting. could have happened to her and the baby. Next to
During an FGD, one of the pregnant women shared her God, saving money saves your life when such things
experience of how she went through during her second happen
pregnancy as follows:
…I remember it was last year (during coffee collect- Factors associated with BPCR
ing season) when suddenly I got a head ache and I Variables that were identified as candidates for multivari-
noticed that I was bleeding and no one was there for able logistic regression in the binary logistic regression
me in the house. My husband was in the farm col- model (p<0.25) were: gravidity, parity, maternal occu-
lecting coffee. Then I called my elder brother and pation, maternal education, access to mass media and
he took me to the health center by motor cycle. The frequency of ANC visit, decision-­making on obstetrics care
health professionals admitted me and checked me seeking, participation in pregnant women’s conferences,
and referred me to the hospital. I gave birth by cesar- knowledge about obstetrics danger signs and hearing the
ean section in hospital. If I didn’t realize the danger- term BPCR. In multivariable logistic regression, maternal
ousness of the problem and go to the health center occupation, maternal education, gravidity, frequency of
by the time my baby would die ANC visit, participation in pregnant women’s confer-
ences, knowledge of danger signs during pregnancy,
Another pregnant woman shared her thoughts on the
labour and delivery, and post partum, and hearing the
danger signs she was aware of, as shown below:
term BPCR were found to be significantly associated with
…health problems could arise during pregnancy, BPCR.
such as vaginal bleeding and back pain, and the pla- Pregnant women who were government employees
centa may not be delivered during birth; if this oc- were 3.2 times ((AOR=3.22 95% CI (1.49 to 11.79)) more
curs, the woman should go to a health center for likely to be prepared for birth and its complications than
assistance; the other is that when a woman is preg- those who were housewives. The odds of BPCR among
nant, she may experience vomiting and loss of appe- pregnant women with secondary education and above
tite, and she must eat food; however, only God knows were 1.9 ((AOR=1.9 95% CI (1.15 to 3.68)) times higher
what will happen than those pregnant women with no formal education.
Multigravida women with two pregnancies were 2.1 times
Among the study participants, 88 (28.7%) heard the more likely to be prepared for birth and its complications
terms ‘birth preparedness’ and ‘complications readiness’. (AOR=2.1, 95% CI (1.2 to 4.4)) than the primigravida.
Among the respondents, 80 (26.1%) of them had iden- Similarity, multigravida women with 3 or more pregnan-
tified a place of delivery for emergency occasions, 138 cies were 6.0 times more likely to be prepared for birth
(45%) saved money to pay for costs related to childbirth and its complication ((AOR=6.0, 95% CI (1.18 to 7.68))
and emergency occasions, 106 (34.5%) had identified a than the primigravida.
mode of transportation to a nearby health facility in case A pregnant woman who participated in the qualitative
of emergency, 80 (26.1%) identified who would accom- study described how being a housewife hampered BPCR
pany them and only 8 (2.6%) had identified a potential and what she went through as follows:
blood donor. The overall prevalence of BPCR in this study
was 30.6%. A lower proportion of pregnant women spon- …all of the household work is on me; making food,
taneously mentioned components of BPCR. See table 3 cleaning the house, feeding my children, and there
for more information. are days when I don’t go to the health center as per
The qualitative study also found that most of the inter- my plan, because the time goes by while I am doing
viewees and discussants reported that they believe in the housework, since there is no one to manage the
the importance of preparation for childbirth since they house for me. It takes me two and a half hours to
obviously observed that labour is not predictable. A male reach the health center on foot. Last time I went
discussant from FDG described what his wife passed there, the health professionals were out for lunch,
through as the following: and I stayed all day without doing anything until they
got back
… last time when my wife was pregnant for the first
time, I was living in the village far away from her, leav- Pregnant women who had four or more ANC visit
ing her with her family, which is near to the health were 4.3 ((AOR=4.25, 95% CI (1.38 to 7.84)) times more
center. One day, I went to her place, gave her mon- likely to be prepared for birth and its complication than
ey, and turned back to the village. As a chance, the those pregnant women who do not had ANC visits. Those
night her labor started, heavy rain was falling. Her pregnant mothers who participated in pregnant women
brothers tried a phone call to get an ambulance. conference were 2.1 ((AOR=2.11, 95% CI (1.07 to 3.78))

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times more likely to be prepared for birth and its compli- Pregnant women who were government employees
cation than who did not participate on it. were more likely to be prepared for birth and its compli-
Pregnant women who had good knowledge about cation than those who were housewives. This finding is
danger signs of pregnancy were 10.4 ((AOR=10.4, 95% CI in line with the study conducted in Gambella region of
(5.57 to 19.6)) times more likely to be prepared for birth Ethiopia.34 This might be due to the fact that women
and its complication than those women who had poor who are government employees are more educated, have
knowledge about danger signs of pregnancy (table 4). more financial autonomy (could earn more money), and
The qualitative study also revealed that having poor hence are in a better position to save money, have better
knowledge about obstetric danger sign was among the decision-­making capacity, and understand the need for
barriers of BPCR: prioritisation of health service matters when compared
with housewives, who depend mostly on their husbands
…In my opinion, a pregnant woman who has prob-
for money.
lems like vaginal bleeding and headache has to go to
Educational status was the other predictor of BPCR.
the health center so that she may get help and give
Those pregnant women with secondary or more educa-
birth peacefully
tional levels were more likely to be well prepared for birth
Pregnant women who heard the term BPCR were 4.4 and its complication than those who had no formal educa-
times ((AOR=4.36, 95% CI (1.93 to 9.82)) more likely to tion. This finding is in line with a previous cross-­sectional
be prepared for birth and its complications than those study conducted in Adigrat town, north Ethiopia,24 in
who did not hear about it, and those who heard about Kofale District of South East Ethiopia,29 in south Wollo,
it from health professional were 2.0 time (AOR=2.04 northwest Ethiopia26 and Adama town.35 This is due to
95% CI (1.08 to 5.47)) more likely to be prepared for the fact that, as mentioned above, education empowers
birth and its complication than those who heard about it women by increasing their knowledge about the impor-
from other persons (table 4). tance of healthcare, paves the way for economic indepen-
The qualitative study in general identified that lack of dence and ensures their decision-­making autonomy.
knowledge on BPCR components, poor knowledge of Those pregnant women who had access to radio and
obstetrics danger sign, negligence and weak community television were more likely to be prepared for birth and
support system were barriers of BPCR. its complications. This can be attributed to the fact that,
in the Ethiopian context, pregnant women who have
access to television are more likely to be town dwellers,
DISCUSSION where there is better access to facilities, including access
Findings of this study revealed that a very low proportions to electricity and other very important infrastructure that
(30.6%) of pregnant women were prepared for birth and enables them to get health information directly from
its complication. This finding is consistent with systematic health experts through television, which in turn helps her
review study conducted in Ethiopia (32.0%),22 but less to be well prepared for delivery.
than studies done in Kofale district, South East Ethiopia Even though there is no report which supports this
of 41.3%29 and Tehulederie district 43.4%.30 Difference finding, those mothers who had more than two preg-
in the study settings, sociodemographic and sociocultural nancies were more likely to be prepared for birth and its
differences, might have contributed for the observed complication when compared with primigravid mothers,
difference. The finding was higher than the finding this shows the fact that multigravid mothers are more
from north Ethiopia (24.1%),26 Duguma Fango district, experienced on birth and related issues than the primi-
Wolayta zone 18.3%,31 in Southern Ethiopia 17%32 and gravid mothers and prepare more. Pregnant women with
Adigrat 22.1%.33 This could be due to better expansion of four and more antenatal visits were more likely to be well
the Health Extension Programme than those study areas prepared for birth and its complications than those who
which might have improved the number of ANC atten- had no ANC visits. This is consistent with the finding from
dants in the health facilities which probably increased Arba Minch Zuria district southern Ethiopia36 and in
awareness of obstetric danger signs which improved Tehulederie district, Northeast Ethiopia.30 This is due to
preparedness for birth and its complication of pregnant the fact that pregnant women who duly attend ANC service
women. Another possible justification for the observed obtain comprehensive information including about the
disparity with studies conducted in Adigrat and Aleta importance of birth preparedness directly from the reli-
Wondo is that these studies were conducted long time able source (health professionals). Pregnant women who
(2007) immediately after counselling on BPCR as one were participants in a pregnant women’s conference were
package of FANC (Focused Anti Natal Care) started in more likely to be prepared for birth and its complications
Ethiopia. when compared with those mothers who did not partici-
Moreover, occupation, parity, gravidity, having ANC pate. This finding is supported by the study from north-
visit, participation in pregnant women conference, west Ethiopia26 and Dale district southern Ethiopia.37 This
knowledge about danger signs of pregnancy, hearing the is due to the fact that the importance of ANC follow-­up,
term BPCR and access to media were among significantly BPCR, instructional delivery, early recognition of danger
associated variables. signs of pregnancy and the actions to be taken, and the

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Table 4 Predictors of BPCR in the selected kebeles of Bachoo District, Iluu Abbaa Boor Zone from December to November
2020 (N=307)
BPCR
Characteristics Yes N (%) No N (%) COR (95% CI) AOR (95% CI) P value
Occupation/women
 Housewife 50 (26.3) 140 (73.6) 1
 Government employee 15 (68.2) 7 (31.8) 6 (2.31 to 15.56)* 3.22 (1.49 to 11.79)* 0.001
 Farmer 19 (35.2) 35 (64.8) 1.5 (0.79 to 2.89) 0.41 (0.28 to 1.93) 0.88
 Merchant 10 (24.4) 31 (75.6) 0.27 (0.07 to 0.92)* 0.14 (0.12 to 1.13) 0.63
Women education
 Not educated 28 (28.2) 71 (71.8) 1
 Read and write 4 (36.3) 7 (63.4) 1.45 (0.39 to 5.33) 0.48 (0.21 to 3.08) 0.47
 Primary school 20 (18.3) 89 (81.7) 0.57 (0.29 to 1.09) 0.16 (0.10 to 1.01) 0.76
 Secondary and above 42 (47.7) 46 (52.3) 2.30 (1.25 to 4.25)* 1.9 (1.15 to 3.84)* 0.004
Mass media access
 Radio 24 (23.5) 78 (76.5) 0.69 (0.38 to 1.27) 0.31 (0.16 to 1.02) 0.13
 Television (TV) 6 (17.1) 29 (82.9) 0.46 (0.17 to 1.22) 0.26 (0.07 to 1.10) 0.43
 Both TV and radio 27 (55.1) 22 (44.9) 2.78 (1.40 to 5.5)* 2.35 (1.22 to 5.15)* 0.001
 No source of information 37 (30.6) 84 (69.4) 1
No of pregnancy/gravidity
 1 78 (37.1) 132 (62.9 1
 2 14 (19.4) 58 (80.6) 2.44 (1.28 to 4.67)* 2.11 (1.16 to 4.38)* 0.002
 ≥3 2 (8) 23(92) 6.75 (1.79 to 43.52) 5.96 (1.18 to 7.68)* <0.001
No of children/parity
 1 34 (37.8) 56 (62.2) 1
 2 41 (36.3) 72 (63.7) 0.93 (0.52 to 1.89) 0.86 (0.43 to 1.72) 0.55
 ≥3 19 (18.3) 85 (81.7) 0.36 (0.19 to 0.70) 0.23 (0.11 to 1.52) 0.67
Frequency of ANC Visit
 1 15(60) 10(40) 4.02 (1.67 to 9.66)* 2.58 (1.01 to 6.61)* 0.001
 2 16 (51.6) 15 (48.4) 1.73 (0.84 to 3.55) 0.4 (0.23 to 1.04) 0.47
 3 23 (31.5) 50 (68.5) 1.66 (0.80 to 3.45) 0.46 (0.21 to 1.04) 0.14
 ≥4 22 (23.9) 70 (76.1) 5.66 (2.18 to 14.7)* 4.25 (1.38 to 7.84)* <0.001
 Not attended 18 (20.9) 68 (76.1) 1
Decision for obstetric healthcare seeking
 Herself 23 (71.9) 9 (28.1) 1
 Husband only 25(20) 100(80) 0.09 (0.04 to 0.24)* 0.91 (0.33 to 1.22) 0.74
 Herself and husband 46 (30.7) 104 (69.3) 0.17 (0.07 to 0.40)* 0.67 (0.25 to 1.30) 0.89
Participation in pregnant women conference
 Yes 56 (42.1) 77 (57.9) 2.60 (1.58 to 4.28)* 2.11 (1.07 to 3.78)* <0.001
 No 38 (21.8) 136 (78.2) 1
Knowing danger sign during pregnancy, labour and delivery and postpartum period
 Favourable knowledge 54 (71.1) 22 (28.9) 11.72 (6.42 to 21.39) 10.4 (5.57 to 19.60)* <0.001
 Unfavourable knowledge 40 (17.3) 191 (82.7) 1
Heard the term BPCR
 Yes 41 (46.6) 47 (53.4) 2.73 (1.62 to 4.59) 4.36 (1.93 to 9.82)* <0.001
 No 53 (31.7) 166 (75.8) 1
Source of information of BPCR
 Health professional 31 (60.8) 20 (39.2) 4.185 (1.67 to 10.7) 2.04 (1.08 to 5.47) <0.001
 Family/friends 10(27) 27(73) 1

Continued

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Table 4 Continued
BPCR
Characteristics Yes N (%) No N (%) COR (95% CI) AOR (95% CI) P value
* strongly significant
ANC, antenatal care; BPCR, birth preparedness and complication readiness.

consequence of not taking the recommended actions are reflects both the impact of programmatic interventions
among the main contents of the messages communicated and non-­programmatic factors such as economic, polit-
during the conference, which increases the likelihood of ical and social influences, among others.
getting prepared for panned delivery. In general, BPCR is a very important tool to iden-
Pregnant women, who had good (at least three or more) tify policy-­related and non-­ policy factors, monitor
knowledge of danger signs of pregnancy, were more likely programme implementations, and improve the effective
to be prepared for birth and its complication than those use of key maternal and neonatal services, thus saving the
who had poor knowledge of danger signs of pregnancy. lives of women and newborn babies.
This finding was supported by the study from Gambela, Ethiopia, on the other hand, is currently facing an
Agnuak zone, Ethiopia34 and Kofale District, South East extreme lack of financial resources (extreme poverty),
Ethiopia.29 The odds of being prepared for birth its which is compounded by an overwhelming domestic price
complication among pregnant women who heard the increase, a devastating drought, COVID-­ 19 pandemic
term BPCR were 4.4 times more than women who did and a political crisis, posing a greater threat to healthcare
not hear the term BPCR. Pregnant women who heard the access. This urges decision-­makers (the Ethiopian govern-
term BPCR from health professional was more likely to be ment and its allies) to exert more effort in the midst of the
prepared for birth and its complication as compared with crisis to ensure that more people have access to primary
those who did not hear it. This finding similar with the healthcare services, especially for the most vulnerable
literature from Abeshige district, Guraghe zone, SNNPR, groups like women and children.
Ethiopia.38 In general, Even though PBCR can be measured at six
A qualitative study found that pregnant women, their levels (individual woman, partner/family of the woman,
families and community members had limited knowledge community, facility, etc), in Ethiopia, often times, studies
of the following topics: the importance of BPCR, preg- carried out on BPCR are highly concentrated at the first
nancy danger signs (the most common being vaginal level.
bleeding and headache) and ANC visits. The qualitative In a patriarchal society like Ethiopia, where all
study also showed that socioeconomic conditions like resources and decisions are concentrated in the hands of
types of pregnant women’s jobs (being housewives), and men, BPCR assessment is not an issue that is left to and
lack of means of transportation are among the barriers measured among pregnant women alone.
that are preventing pregnant women from accessing Using primary data and conducting a community-­based
healthcare. study using a mixed approach are among the strengths of
In general, the above findings have very important prac- this study.
tical implications for policy-­makers and those who imple- However, this study is not without limitations. This study
ment it at different levels. Very low level of BPCR indicates was conducted among pregnant women. Even though
that there are multiple behavioural and resources pregnant women represent the primary target popula-
(including human power and material resources) related tion for BP/CR initiatives, there are also disadvantages
obstacles halting access to healthcare services. Ethiopia, as to interviewing currently pregnant women. Since they
a member state of UN, is working to achieve Sustainable have not completed their pregnancies, they may not yet
Development Goals particularity goal 3 target 8 which have had the opportunity or need to make arrangements
states ‘Achieve universal health coverage, including financial related to BP/CR.
risk protection, access to quality essential health-­care services for Furthermore, the gestational age of the pregnancy was
all” and goal 5 target 6 “Ensure universal access to sexual and self-­reported by the respondents, it was not confirmed
reproductive health and reproductive rights …’.39 by diagnostic test. The authors employed interviewer-­
The working Ethiopian national reproductive health administered data collection method this may induce
strategy (2021–2025) also dictates that ‘…priority will be recall and social desirability bias among some of the study
given to scaling-­up of community-­based reproductive, maternal participants.
and newborn health interventions … the main objective is to Therefore, to overcome the limitations encoun-
achieve universal health coverage with community-­based promo- tered in this study, the authors recommend that future
tive, preventive and curative interventions…’ researchers go further in assessing the roles of the family
Therefore, promoting BP/CR can reduce delays in and the community in BPCR by following a different
receiving (or providing) appropriate care at the health approach and using other study designs like follow-­up
facility. Furthermore, BP/CR status in a given community studies.

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CONCLUSION Funding The authors have not declared a specific grant for this research from any
This study showed that BPCR in the study area was very funding agency in the public, commercial or not-­for-­profit sectors.
low (30.6%). Women’s occupation, educational status, Competing interests None declared.
frequency of ANC visits, gravidity, knowledge of obstetrics Patient and public involvement Patients and/or the public were not involved in
danger signs, participation in pregnant women confer- the design, or conduct, or reporting, or dissemination plans of this research.
ence, hearing the term BPCR and source of information Patient consent for publication Not applicable.
on BPCR were found factors associated with BPCR. The Ethics approval This study involves human participants and this study was
FGD and IDI showed that lack of awareness on BPCR and done according to the Declaration of Helsinki. The Research Ethical Committee of
Mettu University granted ethical approval for this study, with reference number
poor community resources were among the determinants
RPG/04/2012, and informed consent was obtained from the participants after the
that negatively impacted BPCR. necessary explanation was given on the purpose and benefits of the study, as well
as their right to decide whether or not to participate in the study. All the interviews
Recommendations with respondents were conducted under strict privacy. Participants gave informed
consent to participate in the study before taking part.
For healthcare providers
Providing health education on the importance BPCR, Provenance and peer review Not commissioned; externally peer reviewed.
ANC, danger signs of pregnancy, strengthening preg- Data availability statement All data relevant to the study are included in the
article or uploaded as online supplemental information. All data generated or
nant women’s conference, with more emphasis (strict
analysed during this study are included in this published article.
follow-­up) on those who have no formal education, are
Open access This is an open access article distributed in accordance with the
house wives, nulligravida. Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
For healthcare system managers (local, regional and federal levels) and license their derivative works on different terms, provided the original work is
Healthcare system managers at each level should work properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: [Link]
to alleviate the material and economic constraints that
hinders the access to healthcare services. ORCID iDs
Abdi Geda Gedefa [Link]
Keno Melkamu Kitila [Link]
For further researchers
More strong/interventional research design such as
cluster randomised clinical trial might be need to estab-
lish cause-­and-­effect relationships.
Furthermore, the authors recommend that future REFERENCES
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