ORIGINAL ARTICLE

The Pattern and Level of Knowledge on Obstetric and Newborn Danger

Signs and Birth Preparedness among Pregnant Women in Dodoma
Municipal: a Cross Sectional Study
Theresia John Masoia*, Stephen Mathew Kibusia, Alex Ernest Ibolingab, Athanase G.
Lilungulub
Department of Nursing and midwifery, the University of Dodoma, aDepartment of Public Health, the University of Dodoma, Tanzania, bDepartment of Clinical
a*

Medicine, the University of Dodoma, Tanzania

Correspondence to Theresia John Masoi ([email protected])

ABSTRACT
Background: Unacceptable high maternal mortality rates remain a major challenge in many low-income countries. Early detection
and management of antenatal risk factors and good preparation for birth and emergencies are critical for improved maternal and
infant outcomes. The aim of this study was to understand the pattern and level of knowledge on obstetric and newborn danger signs,
Individual Birth Preparedness and Complication Readiness (IBPACR) among pregnant women in Dodoma Municipal.
Methods: A quantitative cross sectional study was carried out between February and June 2018. A random selection of participants
was employed to achieve a sample size of 450 pregnant women. A standard semi-structure questionnaire was used to collect data
and descriptive analysis was carried out by using SPSS software to see the pattern and level of knowledge on obstetric danger signs
and individual birth preparedness.
Results: The mean age of participants was 25.6 years ranging from 16 to 48 years and majority 326 (72.4%) had 2 to 4 pregnancies.
Only 203(45.1%) of the pregnant women were able to tell 8 and above danger signs with at least 1 from each of the 4 phases, with
the most known obstetric danger signs being vagina bleeding during pregnancy 287(63.8), labour and delivery 234(52.0%), after
delivery 278 (61.8) . 164 (36.4%) of the participants reported fever and difficult in feeding 182 (40.4%) as danger signs in newborn.
Furthermore, only 75(16.7%) of the participants reported to be prepared for birth and complications. The most known component
of birth preparedness was preparing important supply which are needed during birth 283 (62.9%).
Conclusion: Results of this study showed a low level of knowledge on obstetric and newborn danger signs as well as poor individual
birth preparedness and complication readiness. Important predictors of knowledge level and birth preparedness were found to be
age, education level, gestation age at first visit and husband involvement in Antenatal visit and care.

BACKGROUND Mortality Rate in the 2015-2016 Tanzania Demographic and

I dentification and management of antenatal risk factors at Health Survey (TDHS- MIS) report was 556/100000 live births
early stage and good preparation are important for positive which is higher compared to the 2010 TDHS report which was
maternal and newborn.1 454/100000 live births.
Despite of a number of Global and National efforts to improve Dodoma is among the regions with the highest maternal
women’s health, the death of women during pregnancy, mortality rates in Tanzania. According to the 2012 census ,
childbirth and after childbirth remains an unresolved challenge Dodoma ranked the 9th high burdened region with a maternal
in many developing countries, including Tanzania.2 Almost 2 mortality rate of 512/100,000 live births.4
decades since the initiation of the Safe Motherhood Initiative, Maternal Mortality trends in Dodoma Region for the past 5
maternal mortality is still soaring high in many developing years were as follows: − 2012:60 deaths, − 2013:71 deaths,
countries, about 830 women die from pregnancy or childbirth − 2014:69 deaths, − 2015:64 deaths and 2016:49. Trends of
related complications around the world everyday.3 Perinatal death were: - 2012:599 deaths, − 201: 630 deaths, −
The maternal mortality ratio in developing countries in 2015 2014:715 deaths, − 2015:484 deaths, − 2016:517 deaths. The
was 239 per 100 000 live births versus 12 per 100000 live births district with the highest number of maternal and perinatal deaths
in developed countries. There are large disparities between was Dodoma Municipal (Personal communication with the
countries, but also within countries and between women Dodoma Region Reproductive and Child Health Coordinator
with high and low income and women living in rural areas June, 2017)
versus women living in urban areas.3 The estimated Maternal In most developing countries, the underlying cause of maternal

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The level of knowledge on danger signs and birth preparedness www.eahealth.org

deaths during pregnancy and postpartum are attributed to 3 the Makole Health Center which serves as the main antenatal
crucial delays; These include; ( 1) Identifying life threatening care facility with an inpatient bed capacity of 55 beds and the
event danger signs and making the decision to go to the health Dodoma Regional Referral Hospital which is the highest level
facility (2) Delay in reaching the health facility and (3) Delay in referral hospital in the region with an inpatient bed capacity
receiving appropriate and adequate care at the health facility.5 of 420. In this study, pregnant women attending antenatal care
and delivery services at Makole Health Centre, Chamwino
Low knowledge about danger signs delays obstetric care seeking Dispensary with the capacity of serving 100 pregnant women
behaviours which thus contributes to high maternal mortality per day and 200 under 5 children per day and the Regional
and morbidity worldwide.6 A study assessing determinants and referral hospital were included in the study
awareness of danger signs and symptoms during pregnancy and
complications among women in Jordan showed that 84.8% of
the women interviewed were not aware of danger signs and FIGURE 1. Dodoma Region Map
symptoms of pregnancy complications.7
Another study was conducted in Chamwino District in
Dodoma, Tanzania, the results showed that only 25.2% out
of 428 respondents were knowledgeable about obstetric danger
signs during pregnancy, childbirth and after childbirth.8 Studies
in Tanzania have found that most women are not aware of
danger signs of obstetric complications.2
Birth preparedness is a strategy to promote timely use of skilled
maternal care especially during childbirth, based on the theory
that preparing for childbirth reduces delays in obtaining this
care. The proportion of preparing for birth and its complications
has been found to be low in low-resource settings.9
A study on birth preparedness and complication readiness
among recently delivered women in Chamwino showed that
only 58.2 % of the respondents were considered as prepared for
birth and its complications. The proportion of women prepared Source: Google Map
for birth and its complications was found to be low.10
Pregnant women and their families often ignore early warning Study Population
signs due to lack of adequate knowledge and information The study consisted of pregnant women attending Antenatal
about danger signs during pregnancy and labour and therefore Care (ANC) visits in the health facilities of Dodoma Municipal
delay in seeking health care services.11 Some of the factors
that influence knowledge level and birth preparedness include; Sampling Technique
education level, parity, gravidity and age of a woman. A purposive sampling method was used to get Dodoma Region,
This study aimed at understanding the influencing factors on Dodoma Municipal and the Health care facilities offering ANC
the level of knowledge o n obstetric and newborn danger and delivery care services in Dodoma Municipal. Participants
signs, individual birth preparedness and complication readiness were selected randomly. Participants who met the inclusion
among pregnant women in Dodoma Municipal. criteria and agreed to participate in the study on that particular
day were listed together, where by every 3rd pregnant woman
on that list was selected.
METHODS
Sample Size Calculation
Study Design The sample size was 450 pregnant mothers, which was obtained
Descriptive cross-sectional study was conducted in Dodoma by using the following formula, and by using the Maternal
Municipal from February to June 2018, among pregnant Mortality ratio of Tanzania Demographic and Health Survey of
2015/2016, which was 556/100,000. Then;
women. Dodoma Region is 1 of Tanzania’s 30 administrative n=z2p (1-p)/e2
regions and the location of the capital city of the country. It lies Where n= sample size
centrally in the eastern-central part of the country; it is about z= standard normal deviation of 1.96 corresponding to 95%
300 miles (480 km) off the coast. Dodoma Urban District is 1 of confidence interval
the 7 districts of Dodoma region. It is bordered to the west by the p=proportion of the target population estimated using the
2015/2016 maternal mortality ratio for Tanzania; 556/100,000
Bahi district, and to the east by Chamwino District. According live births.
to the 2012 Tanzania National Census, the population of e=0.05.
Dodoma Urban District was 410,956 covering an area of 2,576 n=(1.96)2 * 0.006 (1- 0.006)/ (0.05)2
square kilometres.12 Dodoma was one of the regions with the n=439.94 minimum sample size, plus 5% Attrition
highest maternal mortality rates in Tanzania in 2012, Dodoma An estimated sample of 450 pregnant women were included in
the study.
ranked the 9th high burdened region with a maternal mortality
rate of 512/100,000 live births.4 Within the municipal, there are Definitions of variables
2 major Public Health facilities;

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i) Dependent variables: Knowledge of obstetric and newborn Semi-structured questionnaire with both closed and open-
danger signs, individual birth preparedness and complication ended questions was developed to be interviewer-administered.
readiness. This ensured that those unable to read and write could fully
ii) Independent variables: parity, education level, age, participate and also to ensure optimal capturing of all the
gravidity and marital status.
needed information. The questionnaire included questions on
Measurements of variables socio-demographic characteristics, knowledge of key danger
i) Knowledge of the key obstetric danger signs (during signs during pregnancy, childbirth, postpartum and danger signs
pregnancy, childbirth, postpartum and in newborn) was in newborn, individual birth preparedness and complication
scored as follows; readiness.
Those who did not mention any of the danger signs in all the
4 phases were considered to have no knowledge. Participants The questionnaires was first developed in English and then
who mentioned up to 3 danger signs with at least 1 from each translated to Kiswahili which is the National language of
phase were considered to have low knowledge. Women who Tanzania and the language used by the study population. The
mentioned 4 to 7 danger signs with at least 1 from all the 4 questionnaire was adopted from Jhpiego and modified to fit
phases were considered to have moderate knowledge of the Tanzanian context14 also from Tanzania Demographic and
obstetric danger signs and the respondent was considered to be Health Survey 2015/2016 and from Nepal Demographic and
knowledgeable if she mentioned at least 8 danger signs. This Health Survey.15
method of scoring was adopted and modified from the study
done in Southern Tanzania.13 This scoring method was again Data Analysis
grouped into 2 groups of adequate knowledge and inadequate In this study, data was analysed using the Statistical Product for
knowledge in the final analysis. Service Solutions (SPSS) software program version 21. Before
The key danger signs in the 4 phases included: conducting the analysis, error checking (data cleaning) was
performed by using frequency distribution tables to see if all the
Phase 1: Danger signs during pregnancy (vaginal bleeding, data were entered correctly. Each variable was manually cross-
swollen hands/face, severe headache, blurred vision, lower checked to ensure validity and reliability of the findings. Scores
abdominal pain). that were out of range were corrected to avoid distortion of the
Phase 2: Danger signs during labour/childbirth (severe vaginal statistical analysis. Descriptive analysis was used to analyse
participant’s characteristics to determine the frequencies and
bleeding, prolonged labour (>12 hours), convulsions, difficulty percentage of their distributions and also the pattern of level of
in breathing and retained placenta). knowledge and individual birth preparedness.
Phase 3: Danger signs during postpartum (severe vaginal
bleeding, foul-smelling vaginal discharge, and fever). Ethical Considerations
Phase 4: Danger signs in the new-born; pitched cry, difficult Permission to conduct this study was obtained from the
University of Dodoma Research Committee. Ethical research
feeding (unable to suckle), fits (convulsions), loss of clearance and research approval letters were obtained from
consciousness, hot to touch (hyperthermia), difficult breathing, the Graduate Office, University of Dodoma. Authorization to
jaundice, failure to pass urine /stool in the first 24 hours.8 conduct the study in Dodoma Municipal and in the selected
health facilities was obtained from Dodoma Urban District
ii) Individual birth preparedness and complications director and medical officer in charge of Human rights. Privacy,
readiness was scored as follows: and Confidentiality were considered in this study. Research
Participants were asked to name items needed to prepare for objectives, risk, and benefits of the study were well explained
birth and for emergencies. This was aimed at verify whether to the participants. Verbal and written consent were obtained
from the participants and the questionnaires were answered
a participant was aware of the basic steps of Individual voluntarily.
Birth Preparedness and Complication Readiness (IBPACR)
i), Knowing Expected Date of Delivery (EDD) which was RESULTS
confirmed in her Reproductive and Child health 4 (RCH4)
card, ii). Participants were also asked whether they had already Social demographic and obstetric characteristics of the
identified a skilled birth attendant, iii) Identified the mode of participants
transport for delivery and/or for obstetric emergency, iv) Saved A total of 450 pregnant women were included in the analysis,
money, v) Identified at least two blood donors, vi) Prepared with a response rate of 100%. The mean age was 25.6 years
supplies for birth and emergencies, vii) identified someone to (SD=6.1) with a minimum age of 16 years and maximum age
escort them to labour, viii) Identified someone to take care of of 48 years. As shown in Table 1 below, the most prominent age
the family in her absence etc. Participants who scored 4 and group n= 334(74.2%) ranged between 20 and 34 years.
above out of 9 basic steps were classified as having IBPACR On top of that, more than half of the participant, n= 264(58.6%)
while those who scored less than 4 were classified as “not had primary school level of education and few with college/
having IBPACR. This scoring method has been previously used university education n=39(8.7%). Out of 450 respondents
n=353(78.4%) were currently in marital union (married/
in studies which assessed women’s level of birth preparedness cohabiting). This study also explored the Obstetric characteristics
and complications readiness at Chamwino District, Dodoma.10 among the study participants. As indicated below, out of 450
Data Collection participants n=326(72.4%) had 2 to 4 pregnancies .

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Pattern and Level of Knowledge on Obstetric and Newborn

TABLE 1: Social Demographic and Obstetric Danger Signs within Different Categories
Characteristics of the Participants N=450 Pattern and level of knowledge differed within individual
categories. Participants in the age group of 20 to 34 years were
Variable n(%) more knowledgeable on obstetric and newborn danger signs
compared to other age groups. Also participants with college
Age (years) < 20 71(15.8) and university level of education scored higher than the lower
20-34 334(74.2) levels of education. Other results are as shown in Table 3.
≥ 35 45(10%)
Practices on Individual Birth Preparedness and Complication
Education status Primary school 264(58.7) Readiness
Secondary school 147(32.7) Study participants were asked to tell how they have prepared
College/University 39(8.6) themselves for birth and complications. It was found that
only n=75 (16.7%) of the participants were able to tell at
Occupational status Non-employed 144(32.0) least 4 or more of the basic components of individual birth
Self-employed 298(66.2) preparedness and complication readiness where as n=375
Employed 8(1.8) (83.3%) could not tell. On IBPACR score, participants who
scored a total of 4 or more out of the 8 basic steps of IBPACR
Marital status Not married 97(21.6) were classified as being prepared for birth.
Married 353(78.4)
Knowledge of the Basic Components of IBPACR among the
Gravidity 1 97(21.6) Study Participants
2-4 326 (72.4) Participants were asked to tell the components of IBPACR ;
≥5 27(6.0) the most known components by the study participants were
saving money n= 277 (61.6%), Also most of the participants
Parity 1 121(26.9) n=283 (62.9) said preparing important supply such as clothes
2-4 309(68.7) as shown in Table 4.
≥5 20(4.4)
Pattern and Practice of IBPACR within Different Categories
Gestation age at first visit in weeks As shown in Table 5; Results showed that Pattern and practice
1-12 weeks 2(42.7) of individual birth preparedness was more observed among
13-20 weeks 258(57.3) pregnant women who started their first ANC visit within the
first 3 months of pregnancy, n=44 (19.5%) as compared to
Age at first pregnancy in years those who started late. On top of that, pregnant women who
<20yrs 214(47.4) were accompanied by their husband to ANC clinics were more
20-34yrs 234(52.0) prepared compared to those who were not accompanied.
≥35 yrs 2(0.6)
DISCUSSION
The minimum age of the respondent being pregnant at first Evaluating level of birth preparedness and complication
was 14 years and maximum was 38 years with their mean age readiness among pregnant women can also be measured by
and standard deviation being 20 years(3.4).Other results are as assessing knowledge of obstetrics danger signs.14 Having
knowledge on obstetrics danger signs is an essential step in
shown in Table 1. recognition of complications and enables one take appropriate
action to access emergency care.8 Knowledge about danger
Level of Knowledge on Obstetric and Newborn Danger signs among pregnant women is the key factors which influence
Signs timely access to care. The findings from this study showed a
Study participants were asked to mention obstetric and newborn low level of obstetric and newborn danger signs but was higher
danger signs which they know. It was found that overall score compared to the study which was done in Ethiopia.16 The
of the participants with adequate knowledge on obstetric low knowledge on obstetric and newborn danger signs might
and newborn danger signs was n=203 (45.1%) whereas 247 be due to high proportion of pregnant women who had only
(54.9%) had inadequate knowledge. On knowledge level, primary level of education in this study. The most mentioned
individual scoring 8t and above with at least 1 from each of danger signs were vaginal bleeding during pregnancy, labour
the 4 phases was regarded as having adequate knowledge and and delivery, severe vaginal bleeding after delivery and foul-
scored less termed as having inadequate knowledge. smelling vaginal discharge, fever and convulsions as danger
signs in newborn.
Level of Knowledge on Specific Key Obstetric and Newborn
Danger Signs Education level and the number of pregnancies (gravidity) were
The most known obstetric danger signs was vagina bleeding good predictors of knowledge on danger signs. Participants with
during pregnancy 287(63.8), labour and delivery 234(52.0%), college/University level of education were more knowledgeable
after delivery 278 (61.8) and 164 (36.4%) of the study on key danger signs compared to those with lower education
participants reported fever and difficult in feeding 182 (40.4%) levels, these findings mirrors the findings of the study in Uganda
as danger signs in newborn; other results are as shown in Table on Obstetric danger signs and birth preparedness practices who
2 also find education level to be an important factor.17 On top of
that, participants with 2 to 4 number of pregnancies were also

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TABLE 2: Scores of Knowledge on Specific Key Obstetric and Newborn Danger Signs

Key danger signs during pregnancy n (% )

Yes No

Vaginal bleeding 287 (63.8) 163 (36.2)

Swollen hands/face, ankle 131 (29.1) 319 (70.9)
Severe headache and blurred vision 56 (12.4) 394 (87.6)
Severe lower abdominal 152 (33.8) 298 (66.2)
Decreased or absent fetal Movements 52 (11.6) 398 (88.4)
Contractions/Labor pain before completed 37 weeks 31 (6.9) 419 (93.1)
Key danger signs during labor/delivery

Severe vaginal bleeding 234 (52.0) 216 (48.0)

Prolonged labor (>12 hours) 56 (12.4) 394 (87.6)
Fits/Convulsions 38 (8.4) 412 (91.6)
Difficult breathing 39 (8.7) 411 (91.3)
Early rupture of membrane 35 (7.8) 415 (92.2)

Key danger signs after childbirth

Severe vaginal bleeding 278 (61.8) 172 (38.2)

Foul-smelling vaginal discharge 148 (32.9) 302 (67.1)
Fever and convulsion 55 (12.2) 395 (87.8)
Placenta not delivered within one hour after delivery 38 (8.4) 412 (91.6)
Breast or nipple pain and fail to breastfeed 26 (5.8) 423 (94.0)
Severe headache and blurred vision 42 (9.3) 408 (90.7)

Key danger signs in the newborn

High Pitched cry 179 (39.8) 271 (60.2)

Difficult feeding (unable to suckle) 182 (40.4) 268 (59.6)
Fits (convulsions) or loss of consciousness 73 (16.2) 377 (83.8)
Fever 164 (36.4) 286 (63.6)
Difficult breathing 39 (8.7) 411 (91.3)
Unable to pass urine and stool or both within 24 hours after delivery 19 (4.2) 431 (95.8)
Bleeding from the umbilical cord 54 (12.0) 395 (87.8)
Failure to cry immediately after birth 60 (13.3) 390 (86.7)
Jaundice/yellowish coloration 53 (11.8) 397 (88.2)

more knowledgeable compared to other categories. CONCLUSION

Birth preparedness and complication readiness knowledge is The study findings showed a low level of obstetric and newborn
derived from a combination of knowledge about obstetric and danger signs as well as individual birth preparedness among
newborn danger signs. In this study, the prevalence of birth pregnant women in Dodoma Municipal. Level of knowledge
preparedness and complication readiness was estimated to be differed among different age group, parity and gravidity.
only 16.7%. This prevalence was found to be very low, similar These findings reveal a need for innovative community-based
to that of a study which was done in Mpwapwa district in educational strategies to increase the levels of knowledge about
Tanzania.18 Factors, such as education level and gestation age birth preparedness and complication readiness among pregnant
at first visit also played a greater role on birth preparation and women, which may help in minimizing and stop preventable
complication readiness. Participants with college or university maternal and newborn deaths. Also early booking for Antenatal
education level and those who start their initial ANC visit care should be promoted at the community level, which may
within the first 12 weeks of pregnancy were more prepared help in early identification and diagnosis of diseases and their
compared to other categories. These findings are similar with related complication during pregnancy, labour and after delivery.
the study in Ethiopia on birth preparedness 19
Strength of the Study
All these factors could also be explaining the reasons for the The finding of this study showed a low level of knowledge on
high maternal mortality prevailing in Tanzania, because most of key danger signs and birth preparedness which provides an alert
the women seem not to be prepared for birth and for emergencies to the Government and other stakeholder on health related issue
and they are not much aware of the key obstetric and newborn on where we are and where should we improve, as we still have
danger signs that make them delay in making the decisions once high number of maternal death in Tanzania and specifically in
problem arises. Dodoma

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TABLE 3: Pattern and Level of Obstetric and Newborn Danger Signs within Different Categories N=450

Variable Key danger signs

Inadequate Adequate
knowledge n(%) knowledge n(%)

Age (years) < 20 45(63.4%) 26 (36.6)

20-34 180(53.4%) 154(46.1%)
≥ 35 22(48.9%) 23(51.1%)

Education status Primary school 154 (58.3%) 110 (41.7%)

Secondary school 73 (51.3%) 74 (48.7%)
College/University 20 (49.7%) 19 (50.3)

Accompanied by husband Yes 88(53.3%) 77(46.7%)

No 159(55.8%) 126(44.2%)

Gravidity 1 101 (58.4%) 72 (41.6%)
2-4 126(51.0%) 121 (49.0%)
≥5 20 (66.7%) 10 (33.3%)

Parity 1 110(57.6%) 81 (42.4%)

2-4 126 (52.5%) 114 (47.5%)
≥5 11(57.9%) 8 (42.1%)

Gestation age at first visit in weeks

1-12 weeks 123 (54.4%) 103(45.6%)
13-20 weeks 124 (55.4%) 100(44.6%)

Age at first pregnancy in years

<20yrs 109 (58.3%) 78 (41.7%)
20-34yrs 138(52.9%) 123(47.1%)
≥35 yrs 0 (0.0%) 2 (100.0%)

TABLE 4: Knowledge on individual component of IBPACR

Basic IBPACR components n (% )

Yes No

know the expected date of delivery 169(37.6) 281(62.4)

Identify a skilled birth attendant 21(4.7) 281(62.4)
Identify the health facility which can be used in case of emergency or 33(7.3) 417(92.7)
for childbirth
Identify 2 potential blood donors who would donate blood in 32(7.1) 418(92.9)
case of Emergency
Preparing important supplies such as clothes needed for child birth 283(62.9) 167(37.1)
Identify a person who will escort to the health facility during an 49 (10.9) 401(89.1)
emergency
Identify and arrange for transportation 143 (31.8) 307(68.2)
Saving money for delivery or for emergency 277 (61.6) 173(38.4)

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TABLE 5: Pattern and practice of IBPACR within different categories N=450

Variable IBPACR categories

IBPACR not prepared n(%) IBPACR prepared n(%)

Age (years) <20 54(86.7%) 17(13.3%)

20-34 282(84.4%) 52(15.6%)
≥ 35 39(76.1%) 6(23.9%)

Education status Primary school 227(86.0%) 37(14.0%)

Secondary school 121(82.3%) 26(17.7%)
College/University 27(69.2%) 12(30.8% )

Accompanied by husband Yes 134(81.2%) 31(18.8%)

No 241(84.65%) 44(15.4%)

Gravidity 1 138(90.0%) 35(10.0%)
2-4 210(85.0%) 37(15.0%)
≥5 27(79.8%) 3(20.2%)
Gestation age at first visit in week
1-12 weeks 182 (80.5%) 44(19.5%)
13-20 weeks 193 (86.2%) 31 (13.8%)

Study Limitations Acknowledgements: Heartfelt thanks to the University of

The findings of the study could have been affected by the Dodoma, local leaders of Dodoma Municipal and study
study setting, Dodoma Urban where the infrastructure are participants for their willingness to participate and
more improved compared to infrastructure in rural areas. Also, contribute to this study and the health facilities who agreed
women in urban areas are more educated compared to those to host research teams during research activities.
in rural areas, so these findings should not be generalised but
instead more studies need to be done in these areas to come up
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