Assessment of Knowledge and Attitude
towards Obstetric Danger Signs During
Pregnancy among Pregnant Mothers Attending Antenatal Care in Mizan Aman Public Health Facilities, Bench Maji Zone, South West Ethiopia
Assessment of Knowledge and Attitude
towards Obstetric Danger Signs During
Pregnancy among Pregnant Mothers Attending Antenatal Care in Mizan Aman Public Health Facilities, Bench Maji Zone, South West Ethiopia
Tilahun Mekonnen*, Bitewlegn Girmaye and Fekadu Taye
Department of Nursing, Mizan Tepi University, Ethiopia
Submission: August 07, 2018; Published: September 06, 201
How to cite this article: Tilahun M, Bitewlegn G, Fekadu T. Assessment of Knowledge and Attitude towards Obstetric Danger Signs During Pregnancy
among Pregnant Mothers Attending Antenatal Care in Mizan Aman Public Health Facilities, Bench Maji Zone, South West Ethiopia. J Gynecol Women’s
Health. 2018: 11(3): 555813. DOI: 10.19080/JGWH.2018.11.555813
Background: Knowledge and positive attitude of the danger signs of obstetric complications is the essential first step in the appropriate and timely referral to obstetric care. hence the study intended to assess knowledge and attitude of obstetric danger signs during pregnancy among pregnant mothers attending Antenatal care in Mizan-Amanpubilic Health facilities in bench maji zone SNNPR Ethiopia 2017.
Methods: Institution based cross-sectional study design was used from April 30/2017 to May 30/ 2017. A total of 223 pregnant mothers was included in the study. The study conducted on pregnant mothers attending Antenatal care in Mizan-Aman public Health Facilities during the time of data collection. Systematic simple rondom sampling technique was used to collect Data using semi structured questionnaire and was analyzed by descriptive analysis method then presented in tables, graphs figures and numerical summery measure.
Result: One handred seventy three (77.5%) of mothers were knowledgeable about danger sign during pregnancy and 157(70.4%) and 161(72.2%) had knowledge about danger sign during labor and postnatal respectively. From the total respondents, 162(72.6%) had positive attitude and 61(27.4%) had negative attitude about danger sign of obstetric.
Conclusion: This study showed level of knowledge and attitude about obstetric danger signs during pregnancy, child birth and postpartum period seems like high among women in Mazan Aman public health facility. The most frequently reported obstetric complication during pregnancy, postpartum and child birth and labor is vaginal bleeding. Health profesionals should continue to increase more about knowledge and attitude toward obstetric complications.
Keywords: Danger sign of pregnancy; MTU; Ethiopia
Abbrevations:ANC: Antenatal Care; CI: Confidence Interval; EDH: Ethiopia Demographic Health Survey; ETB: Ethiopian Birr; HEW: Health Extension Workers; IEC: Information, Education and Communication; JHPIEGO: Johns Hopkins Program for International Education in Gynecology and Obstetrics; KA: Knowledge and Attitude; MDG: Millennium Development Goal; MMR: Maternal Mortality Ratio; MOH: Minter of Health; NGO: None Governmental Organization; SNNPR: Southern Nation’s Nationality People Regional State; UNICEF: United Nations Children’s Fund; UTBA: Untrained Traditional Birth Attendant
Pregnancy is a normal process that results in a series of both physiological and psychological changes in expectant mothers. However, normal pregnancy may be accompanied by some problems and complications which is potentially life threatening to the mother and fetus . Pregnancy is a very important event from both social and medical points of view. Therefore, pregnant women should receive special care and attention from the family, community and from the health care system. Anti natal care is a
care given to a woman during her pregnancy . The objective
of antenatal care (ANC) is to assure that every pregnancy culminates in the delivery of a healthy baby without impairing the health of the mother [3,4].
The new approach to ANC emphasizes the quality of care rather than the quantity. For normal pregnancies WHO recommends only four antenatal visits. The major goal of focused antenatal care is to help women maintain normal pregnancies through: Health promotion and disease prevention, early detection and treatment of complications and existing diseases Birth preparedness and complication readiness planning.
Focused ANC protocol is designed as a job aid for ANC providers.
It includes revised forms and checklists needed to identify those
women that can follow basic care and those women with special
health conditions or are at risk of developing complications
that needs a special care [3,5]. Pregnancy related complications
are among the greatest killers of women of reproductive age in
developing countries .
Danger signs of pregnancies are a warning signs that women
encounter during pregnancy, child birth and postpartum. It is
important, to know this warning signs for women and health
care providers to rule out serious complications and initiate
treatment immediately . The most common danger signs
during pregnancy that can increase the risk of maternal deaths
are: vaginal bleeding, convulsions, high fever, abdominal pain,
severe headaches, blurred vision, absence of fetal movements,
gush of fluid from vagina, foul smelling vaginal discharge [7,8].
Pregnancy complications are the major health problems among
women in developing countries. Approximately 529,000 women
die from pregnancy related causes annually and almost all (99%)
of these maternal deaths occur in developing countries. The global
maternal mortality is unacceptably high . Although there
was significant progress in all developing regions, the average
annual percentage decline in the global maternal mortality ratio
(MMR) was 3.1%, short of the millennium Development Goals
(MDGs) target of 5.5%. Every day, almost 800 women still die
due to pregnancy or child birth, and for every woman who dies
20 or more experience serious complications. One of the United
Nations‟ MDGs is to reduce MMR by 75% by 2015 .
Developing countries account for 99% (284,000) of the
global maternal deaths, the majority of which are in sub-Saharan
Africa (162,000) and Southern Asia (83,000). These two regions
accounted for 85% of global burden, with sub-Saharan Africa
alone accounting for 56%. The average maternal mortality
ratio in developing countries in 2010 was 240 per 100,000
births versus 16 per 100,000 in developed countries reflecting
inequities in access to health services, and highlighting the
gap between rich and poor. Sub-Saharan Africa had the highest
maternal mortality ratio at 500 maternal deaths per 100,000 live
births. According to a systematic analysis of progress towards
Millennium Development Goal 5 more than 50% of all maternal
deaths in 2008 were in only six countries (India, Nigeria,
Pakistan, Afghanistan, Ethiopia, and the Democratic Republic of
the Congo) .
The situation in Ethiopia is similar to the situation in
many developing countries. In Ethiopia the levels of maternal
mortality and morbidity are among the highest in the world and
the current estimate of MMR is 676 per 100, 000 live births and it
is reported that Maternal deaths accounted for 30% of all deaths
to women age 15-49 .
Maternal mortality is the leading cause of the adult female
deaths in many countries. Women’s death during childbirth often
means death for the newborn, and both death and disabilities
translate into emotional, social, and economic hardships for
women’s older children, their entire families, and even for
communities . Every minute, a woman dies due to causes
related to pregnancy, childbirth and postnatal period .
Maternal deaths are avoidable, if women with complications are
able to identify and seek appropriate emergency obstetric care
which makes a difference between life and death .
Maternal deaths have both direct and indirect causes. Around
80% of maternal deaths worldwide are brought about by direct
obstetric complications. The five major global causes of maternal
death are: severe bleeding (mostly bleeding postpartum),
infections (also mostly soon after delivery), unsafe induced
abortion, hypertensive disorders in pregnancy (eclampsia) and
obstructed labour. Globally, about 80% of maternal deaths are
due to these causes. Hemorrhage alone accounts for one third
of all maternal deaths in Africa, yet many of these deaths are
preventable. Severe bleeding after birth can kill a healthy woman
within two hours if she is unattended. Obstetric fistula resulting
from obstructed labor is a long term complication suffered by as
many as two million women). Indirect causes such as malaria,
diabetes, hepatitis, anemia and other cardiovascular disorders
which are aggravated by pregnancy can also lead to maternal
Awareness of the danger signs of obstetric complications
is the essential first step in accepting appropriate and timely
referral to obstetric and newborn care. Raising awareness
of women on danger signs of pregnancy, childbirth and the
postpartum period improve mother’s attitude to seek medical
care and is crucial for safe motherhood .
When mothers do not recognize the danger signs in
pregnancy, adverse effects can occur to the mother, the unborn
baby, or the pregnancy itself. Adverse effects include: Illness
or death of the mother, for instance, severe bleeding can lead
to anemia or death of the mother, infection to the unborn baby
through prematurely ruptured membranes, when amniotic fluid
leaks from the vagina. If not attended to, this can lead to fetal
or neonatal morbidity and mortality, termination of a pregnancy
before term in vaginal bleeding. Maternal hypertension or fever,
can lead to increased numbers of neonatal deaths or prematurely
born babies who may eventually die due to inadequate facilities
to care for them .
According to the Ethiopian Federal Ministry of Health,
only10% of the deliveries are attended by health professionals.
In one nation where the maternal mortality ratio is 676 per
100,000 live and IMR 59/1000 and NMR 37/1000 live births
which are the highest in the world. In Ethiopia, there is little
information about the knowledge and attitude of obstetric
danger signs during pregnancy since the introduction of Health
Extension Workers (HEWs), despite the national Reproductive
strategy aim to raise the awareness to 80% in the area in which
HEW are deployed .
Studies conducted in Aleta Wondo district, indicated that
the knowledge level of pregnant women about obstetric danger
signs (during pregnancy, childbirth and postpartum period) was
low and affected by residential area. Therefore, the identified
deficiencies in awareness should be addressed through maternal
and child health services by designing an appropriate strategies
including provision of targeted information, education and
communication. In spite of great potential of knowledge and
attitude of obstetric danger a sign in reducing the maternal and
newborn deaths its status is not well known in most of Sub-
Saharan Africa including Ethiopia . This study therefore
aims to fill this gap by assessing the current status of knowledge
and attitude of danger signs among pregnant mothers attending
antenatal care in Mizan Aman public health facilities in Bench
Maji Zone SNNPR, Ethiopia.
This study was conducted at Mizan-Aman town, health
facility from march 1-30 2017. The area is located at 565km in
South west direction from Addis Ababa. There are four wards
in the hospital such as Medical, surgical, Gyny, obstetric and
pediatrics. There are also one emergency and 3OPD. It has 1
gynecologist, 1 general surgeon, 22GP, 11Bsc nurse, 92 diploma
nurses, 14 diploma midwifery, 5Bsc midwifery, and 63 other
staff. In health center also 22 diploma nurses, 4 midwifery, 1Bsc
nurse, 3pharmacies, 2 public health and 24 others. The hospital
providing service to south west Ethiopia and Gambella region for
around 8, 50, 538 peoples [18-20].
An institutional based cross sectional study design was
carried out to assess Knowledge and Attitude of Obstetric Danger
Signs During Pregnancy Among Pregnant Mothers Attending
Antenatal Care in Mizan Aman Public Health Facilities, Bench
Maji Zone, SNNPR, South West Ethiopia .
The sample size was determined using a single population
proportion formula by considering 95% confidence interval,
Margin of sampling error 5 and, Prevalence level of Knowledge of
obstetric danger signs during pregnancy 24.1% . After 10%
non-response rate added, thetotal sample size become 223.
Both public health facilities that had been giving ANC service
in Mizan-Aman town (MTUTH and Mizan health Center (HC)
were included. The sample size was distributed in proportion
to average monthly load of previous year of pregnant women
who made ANC follow up at each health facility. The total
sum of average monthly load previous year ANC of two health
facilities is (N=713). The total sample size (n=223) was allocated
proportionally to the two (MTUTH and Mizan health Center (HC)
care giving public health facilities of Mizan-Aman town according
to the number of pregnant women attending antenatal service in
the respective health facilities. Then the study participants were
systematically selected from each health facilities and pregnant
women who were eligible to the study were include in the study
by using the “k” value interval (k=713/223=3), thus every 4th
pregnant women who attended ANC follow up was recruited as
study units in each health facilities until the total sample size for
this study is obtained. The first pregnant woman was selected
based on lottery method.
Presence of condition that increases the chances of pregnant
woman and/ or her unborn child dying or having poor health.
Most common Danger signs are vaginal bleeding, convulsions,
high fever, abdominal pain, severe headaches, blurred vision,
absence of fetal movements, gush of fluid from vagina, foul
smelling vaginal discharge [24,25].
Knowledge of obstetric danger signs means the basic
information that the mothers have regarding obstetric danger
Knowledgeable on key danger signs during pregnancy:
If she can mention at least three key danger signs of pregnancy
(vaginal bleeding, swollen hands/face, fever, blurred vision,
Abdominal pain and Sever head ache) unless not.
Knowledgeable on key danger signs of Labor/child birth:
- If she can mention at least three key danger signs for labor/
child birth (sever vaginal bleeding, prolonged labor, convulsions
and retained placenta) unless not knowledgeable.
Knowledgeable on key danger signs of post-partum: If
she can mention at least Two key danger signs for post-partum
(Severe vaginal bleeding, Foul lochia and High fever) unless not
Attitude: It is an opinion of study participants towards
obstetric danger signs.
Positive attitude: refers to those participants who respond
correctly to attitude questions score above mean value.
Negative attitude: refers to those participants who respond
correctly to attitude questions score less than mean value.
Informal education: Mothers who were illiterate and can
read and write only.
Formal education: Mothers who were primary and
High level education: Mothers whose educational status
were diploma and above.
Data was collected using structured questionnaire. The
questionnaire was first prepared in English then translated to
Amharic language and retranslated back to the original one to
evaluate its consistency. The data was collected by the principal
investigators. Before the data collection pre testing was done on
5% of population from non-sampled individuals .
From the beginning the data collection tool was prepared
in order to answer the necessary variables, it was discussed,
re-evaluated. Data collectors and the supervisor was trained
for the necessary approaches, questioners will be checked
for completeness, supervisors was taken a role to assure the
reliability of the data collected by data collectors, the collected
data will be coded appropriately. The data was analyzed
After checking for completeness of data, the data was coded
and tallied and calculated by scientific calculated. Descriptive
analysis was done. Result was presented in tables, graphs figures
and numerical summery measure .
Permission letter was obtained from Mizan-Tepi university
college of Health sciences, department of nursing. Communication
with different town administrators will be made through formal
letter obtained from the college. After the purpose and objective
of the study have been informed, Verbal and written consent will
be obtained from each participant to ensure their voluntariness
to participate in the study and they will be told that all have
a right to withdraw at any time if they are not comfortable to
participate in the study or to put an end for single question,
segment of questions or refuse to participate at all. In order
to keep confidentiality of any information provided by study
subjects, the data collection procedure will be maintained by
excluding their names as identification in the questionnaire and
by keeping their privacy during the interview by interviewing
them alone .
The finding of the study was presented to the Mizan- Tepi
university college of Health science department of nursing,
Mizan-Tepi university teaching hospital, and also result send to
Mizan Aman public health facilities .
A total of 223 mothers were enrolled in the study giving
a response rate of 100%. Majority 203 (91%) of participant
were married and most 133 (59.6%) of the respondents were
housewives. About n= 90 (40.3%) of the respondents were
Protestant while n=69 (30.90%) were Orthodox followed
by Muslim 41 (21.5%) and Catholic 23 (10.3%). Out of total
respondent 47.50% were uneducated whereas only 21% of
participant had completed Secondary education and above
(Table 1) .
Among the entire participant 163 (73%) had visited ANC more
than once while the rest 60 (27%) of the respondent had visited
ANC once. Furthermore, out of total number of respondents 153
(68.7%) had history of 2 and above pregnancies and 70 (31.1%)
mothers had pregnancy once. Regarding first pregnancy age
148 (66.4%) mothers got their first pregnancy at >18 years
while 75 (33.60%) had pregnancy at < 18. About 121 (54.2%)
respondents had 1 and 2 live children whereas 67 (30.10%) who
have 3 and above live children. Out of respondents had birth 1-2
and 3 & above, about 29 (13%) and 6 (2.7 %) were born dead
respectively (Table 2) .
About 174 (78%), mothers have information about obstetric
danger signs and 116 (52%) heard about danger sign from
health personnel followed by media 56 (25%). From those who
had the information,167(74. 80%) identified severe vaginal
bleeding at any time during pregnancy as danger sign. Swelling
of the body 65 (29.1%), persistent headache 121 (54.20%),
Abdominal pain 97(43.4%) blurred vision 88 (39.4%), and High
fever 73 (32.7%) were also indicated by the study subjects as
danger sign. Severe vaginal bleeding was the most frequently
mentioned complication by women during pregnancy by 167
(74.80%), labor by 139 (61%) and postpartum period by 61
(27.3%) respectively (Table 3) .
Generally,173 (77.5%) of mothers were knowledgeable
about danger sign during pregnancy and 157(70.4%) and
161(72.2%) had knowledge about danger sign during labor and
postnatal respectively (Figure 1).
In this study, mother’s level of Knowledge about danger signs
of obstetric complications during pregnancy, labor and postnatal
was 77.5%, 70.4% and 72.2%. This finding is higher than the
study done in Goba district that shows 31.9%, 27% and 22.1%
of study participants knew at least three key danger signs during
pregnancy, delivery and postpartum period, respectively .
The variation of result is due to difference in study period and
difference in study area. As compared to the studies done in past,
it seems increased because of the current health policy being
applied is increasing the awereness about obstetric complication
to prevent maternal and child death. Vaginal bleeding was the
most recognized obstetric danger sign all, during pregnancy,
74.8%, labor, 61% and postpartum period 27.3%. This is in line
with the studies conducted in different countries .
In this study, 72.6% of mothers had positive attitude on
prevention of obstetric danger sign during pregnancy. This is
almost compatible with the study conducted in Debre Birhan
city that stated 88% the study participants agreed that knowing
obstetric danger signs is important to seek medical care on time,
57% of the respondents were agreed on prevention of obstetric
danger signs and 71.2% disagree on the idea that mothers who
develop obstetric danger signs should seek help from traditional
birth attendants. The possible reason for this variation was
due difference in study area and due to this study was done on
facility this may contribute to the diffirence. This also shows
attitude of the women being increased dou to different activities
being implemented in health facilities changed the attitude of
women. As any cross sectional study this study has strength
and weakness. The strength is that the study was done at risky
population group while the limitation is, since this study is
facility based it may not indicate the finding in community.
This study shows even though the level of knowledge and
attitude of women about danger signs of obstetric complication
among pregnant women attending ANC follow up in Mizan
Aman health facility seems high as compared to past studies, it
is not sufficient to prevent the burden related to complication
during pregnancy, labor and postnatal. The most frequently cited
obstetric complication during pregnancy, postpartum and child
birth and labor was vaginal bleeding.
This study was not involved in any experiment on human
subjects. The written consent was taken from the respondents
just before data collection. Ethical approval was obtained from
Mizan Tepi University Collage of Health Sciences, Institutional
Review Board to communicate with hospital administrative
body. Permission letter was obtained from administrative body
of Mizan Tepi University teaching hospital.
The authors’ responsibilities were as follows: All authors
designed, supervised the study, ensured quality of the data
and assisted in the analysis and interpretation of the data. All
authors critically reviewed the manuscript. The corresponding
authors did the analysis & drafted the manuscript and had the
responsibility to submit the manuscript for publication.