PLOS GLOBAL PUBLIC HEALTH

RESEARCH ARTICLE

Pregnant women’s knowledge of obstetrical

danger signs: A cross-sectional survey in
Kigali, Rwanda
Emmanuel Uwiringiyimana1*, Emery Manirambona ID1, Samuel Byiringiro ID2,
Albert Nsanzimana ID1, Neophyte Uhawenayo1, Pacifique Ufitinema1, Janviere Bayizere ID1,
Patricia J. Moreland3, Pamela Meharry4, Diomede Ntasumbumuyange ID5
1 College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda, 2 School of Nursing,
John Hopkins University, Baltimore, Maryland, United States of America, 3 Nell Hodgson Woodruff School of
a1111111111 Nursing, Emory University, Atlanta, Georgia, United States of America, 4 Human Resource for Health,
a1111111111 University of Illinois, Chicago, Illinois, United States of America, 5 Department of Obstetrics and Gynecology,
a1111111111 University of Rwanda and Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
a1111111111
a1111111111 * [email protected]

Abstract
OPEN ACCESS Maternal mortality remains critically high in low- and middle-income countries (LMIC), partic-
Citation: Uwiringiyimana E, Manirambona E, ularly in sub-Saharan Africa. Rwanda’s leading causes of maternal death include postpar-
Byiringiro S, Nsanzimana A, Uhawenayo N, tum hemorrhage and obstructed labor. Maternal recognition of obstetrical danger signs is
Ufitinema P, et al. (2022) Pregnant women’s
critical for timely access to emergency care to reduce maternal mortality.To assess mater-
knowledge of obstetrical danger signs: A cross-
sectional survey in Kigali, Rwanda. PLOS Glob nal knowledge of obstetrical danger signs among pregnant women attending antenatal care
Public Health 2(11): e0001084. https://doi.org/ services in Kigali, Rwanda. We conducted a cross-sectional study between September and
10.1371/journal.pgph.0001084
December 2018. The outcome of interest was maternal knowledge of ODS during preg-
Editor: Zohra S. Lassi, University of Adelaide, nancy, labor and delivery, and the immediate postpartum period. We recruited pregnant
AUSTRALIA
women at five health centers, one district hospital, and one referral hospital, and we had
Received: September 25, 2021 them complete a structured questionnaire. Reporting three correct ODS was defined as hav-
Accepted: October 17, 2022 ing good knowledge of ODS. A total of 382 pregnant women responded to the survey. Most
women (48.9%) were aged 26–35, and 50.5% had completed secondary or higher educa-
Published: November 14, 2022
tion. The knowledge of ODS was 56%, 9%, and 17% during pregnancy, labor and delivery,
Peer Review History: PLOS recognizes the
and postpartum, respectively. Women aged 26 to 35 had two times (OR: 1.80, 95% CI:
benefits of transparency in the peer review
process; therefore, we enable the publication of 1.05, 3.06) higher odds of ODS knowledge during pregnancy than women aged 16 to 25.
all of the content of peer review and author Attending three antenatal care visits was associated with 2.6 times (OR: 2.59, 95% CI: 1.17,
responses alongside final, published articles. The
5.66) higher odds of ODS knowledge during pregnancy than not attending any visit. Longer
editorial history of this article is available here:
https://doi.org/10.1371/journal.pgph.0001084 distances to the nearby health facility were associated with significantly lower knowledge
during pregnancy, and Muslim women had substantially higher postpartum ODS knowledge
Copyright: © 2022 Uwiringiyimana et al. This is an
open access article distributed under the terms of than any other religion. In conclusion, women’s knowledge of ODS associated with labor
the Creative Commons Attribution License, which and delivery and postpartum was low. Antenatal care must be encouraged and its content
permits unrestricted use, distribution, and revised to ensure it covers potential late pregnancy complications.
reproduction in any medium, provided the original
author and source are credited.

Data Availability Statement: All relevant data are

within the paper and its Supporting Information
files.

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

Funding: The authors received no specific funding Introduction

for this work.
The complications from pregnancy and childbirth are the leading causes of maternal deaths in
Competing interests: The authors have declared
low- and middle-income countries (LMIC) [1–3]. Half of all maternal deaths result from post-
that no competing interests exist.
partum hemorrhage (27%), hypertensive disorders (14%), and sepsis (11%) [1]. Evidence
Abbreviations: ANC, Antenatal Care; ODS, shows that most maternal complications during pregnancy are preventable via timely recogni-
Obstetrics Danger Signs; DH, District Hospital; HC,
tion of danger signs and effective interventions at health facilities [4]. The danger signs during
Health Center; HEW, Health Expert Worker; MMR,
Maternal Mortality Rate; MDG, Millennium
pregnancy and after delivery are the warnings of imminent or ongoing life-threatening events
Development Goals; PI, Principal Investigator; requiring quick intervention by skilled healthcare providers [5]. The lack of knowledge of
RDHS, Rwanda Demographic and Health Survey; Obstetrical Danger Signs (ODS) coupled with additional factors such as high cost of care and
SPSS, Statistical Package for the Social Sciences; long distance to health facilities lead to hesitation and delay in seeking care, contributing to
UTHK, University Teaching Hospital of Kigali; WHO, higher maternal mortality [6–9]. Any efforts to reduce maternal mortality must include
World Health Organization; CI, Confidence Interval.
improving maternal knowledge of the common complications during pregnancy, labor, and
after delivery to ensure women prioritize seeking care when required.
Several factors predict women’s knowledge of ODS and could guide where to target inter-
ventions. According to a study conducted in Ethiopia, the attendance of Antenatal Care
(ANC) was associated with 26% higher knowledge, and women who delivered at the health
facility were three times more likely to be knowledgeable of ODS [10]. Other factors such as
the level of education among women, urban, and occupation were associated with maternal
knowledge of ODS [10]. Strengthening ANC and multi-sectoral involvement by ensuring ade-
quate education of the ODS may increase early recognition of complications and timely
healthcare-seeking behaviors, thereby significantly decreasing maternal mortality [11,12].
Unfortunately, other factors are unknown in many other SSA countries, which hinders the
interventions towards preventing maternal mortality.
In Rwanda, 203 women die for every 100,000 live births [13]. According to the most recent
Rwanda Demographic Health Survey (2019–2020), the most common maternal mortality
causes are delays in seeking care [11–13]. The value of women’s awareness and early recogni-
tion of ODS cannot be overstated. Evidence shows that women with better knowledge of ODS
have improved healthcare-seeking behaviors than their counterparts with limited knowledge
[3,9,14]. Yet, the maternal knowledge of ODS in Rwanda is unknown, limiting any interven-
tions to decrease maternal mortality. Accordingly, the current study aimed to assess pregnant
women’s knowledge of ODS during pregnancy, labor and delivery, and the postpartum peri-
ods and associated factors.

Objectives
To assess the maternal knowledge of ODS, and associated factors during pregnancy delivery
and post-partum period among pregnant women attending ANC services in Kigali, Rwanda.

Methods
Ethics statement
Approval was granted from the Institutional Review Board of the College of Medicine and
Health Sciences at the University of Rwanda (No317/CMHS/IRB/2018).
And then the approval 2 was granted by Centre Hospitalier Universtaire de Kigali (CHUK)
Research and Ethics Committee (EC/CHUK/640/2018).
Participation in the study was voluntary. Pregnant mothers received an explanation of the
study’s intent and what their participation would entail. Formal written consent was obtained
from pregnant women who agreed to participate before the interview. The collected data was

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

kept confidential on a password-protected laptop only accessible to the research team before
the de-identification.

Study design
We used a cross-sectional study design to assess women’s ODS knowledge. To ensure the full-
ness of the report, we used the STROBE (Strengthening the Reporting of Observational Studies
in Epidemiology) checklist [15].

Study setting
The current study was conducted in the University Teaching Hospital of Kigali (CHUK),
Muhima District Hospital, and five community health centers in Nyarugenge District
(Muhima, Bilyogo, Rugarama, Kabusunzu, and Rwampara).

Recruitment and sampling

The recruitment took place between September and December 2018. Conveniently, we sam-
pled women during their ANC appointments at the study sites. Pregnant women of any gesta-
tional age, 16 years and older, receiving ANC at the study sites during the data collection
period were eligible to participate. The sample size was determined using a single population
proportion formula [16], referring to the prevalence of knowledge of at least three ODS of
45.9%, with a 95% confidence level and a 5% margin of error reported by a study conducted in
Ethiopia [16].

Instrument, pilot testing, and data collection

We adapted the study questionnaire developed and initially tested in Ethiopia [17]. The instru-
ment was a 20 minutes questionnaire consisting of 23 items about maternal demographics,
obstetrical history, time to the health facility, source of ODS information, and knowledge of
ODS separately during pregnancy, labor and delivery, and immediate postpartum periods. All
questions were multiple choice. To ensure adapt the instrument to the local context, we
removed the item regarding ethnicity and modified the question about religion. Two bilingual
speakers of English and Kinyarwanda translated the questionnaire from English to Kinyar-
wanda. We tested the tool on 30 participants at Muhima health center and in Muhima District
Hospital, and there was no need for changes in the instrument. We added the data from the 30
participants of pilot testing to the overall data during analysis.
The investigators (EU, UP, AN, NU) and one trained research assistant (BJ) did the data
collection. Each research participant was interviewed alone, and the data collector read ques-
tions to the mother and wrote responses on her behalf.

Data management and analysis

The outcome of interest was maternal knowledge of ODS during pregnancy, labor and deliv-
ery, and postpartum. In each category, a mother was classified as knowledgeable if she cor-
rectly mentioned at least three ODS from a pool of correct and incorrect danger signs.
Sociodemographic characteristics, including age, level of education, and income, are some
of the powerful predictors of health literacy, according to many empirically tested health liter-
acy frameworks [18]. We included them in our assessment of factors associated with the
knowledge of ODS. We added predictors specific to the knowledge of ODS, namely, the num-
ber of prenatal care visits during the current pregnancy, gravidity, employment status, dura-
tion of travel to the health facility, and religion.

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

We used Stata/BE 17.0 to analyze data. We used descriptive statistical analysis and reported
counts and percentages to describe the sample and the knowledge of ODS. We used multiple
logistic regression models to assess the factors of ODS knowledge and reported odds ratio and
95% Confidence intervals. The multiple logistic regression model in each category of ODS
knowledge was adjusted for all other sociodemographic and pregnancy history factors. The
associations with a p-value equal to or below 0.05 were considered statistically significant.

Results
A total of 382 pregnant women participated in the study. Participants were mostly aged
between 16–35 (88.7%), were married or cohabitant (88.2%), had an equal mix of primary or
lower education (49.5%) and secondary education or higher (50.5%), and mainly were Catho-
lic or Protestants (72.0%) by religion (Table 1). Two hundred twenty-three (58.4%) were
homemakers with no other type of employment. Most women (46.6%) had been pregnant two

Table 1. Demographic characteristics of participants (n = 382).

Variables n (%)
Age (years)
16–25 152 (39.8)
26–35 187 (48.9)
�36 43 (11.3)
Marital status
Married or cohabitant 337 (88.2)
Single, separated, 45 (11.8)
divorced, or widow
Religion
Muslim 48 (10.5)
Catholic 137 (35.9)
Protestant 138 (36.1)
Adventist 44 (11.5)
Others 23 (6.0)
Education
Primary or lower 189 (49.5)
Secondary or higher 193 (50.5)
Number of Prenatal visits
0 76 (20.0)
1 38 (10.0)
2 48 (12.6)
3 220 (57.6)
Gravidity
Gravida 1 130 (34.0)
Gravida 2 178 (46.6)
Gravida 3 74 (19.4)
Employment
Housewife 223 (58.4)
Other types of employment 259 (41.6)
Time to the Health Facility
<30 Min 89 (23.4)
15–30 Min 128 (33.5)
>30 Min 165 (43.2)
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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

Fig 1. Overall knowledge of at least three obstetric danger signs.

https://doi.org/10.1371/journal.pgph.0001084.g001

times, and 220 (57.6%) attended three ANC visits during the current pregnancy. Most partici-
pants (43.2%) walked for more than 30 minutes to the nearest maternal health facility.
Overall, the women’s knowledge of ODS during pregnancy, labor and delivery, and post-
partum was 216 (56.6%), 35 (9.2%), and 67 (17.5%), respectively (Fig 1). The most recognized
ODS during pregnancy were vaginal bleeding, 271 (70.9%), and severe abdominal pain, 196
(51.3%) (Table 2). The least recognized ODS during pregnancy were loss of consciousness, 15
(3.9%); high fever, 19 (5.0%); and convulsions, 26 (6.8%).
During labor and delivery, the most recognizable ODS was vaginal bleeding, 136 (35.6%).
Few participants, 45 (11.8%) and 35 (9.2%) recognized that labor lasting longer than 12 hours

Table 2. Knowledge of ODS during pregnancy, labor and delivery, and immediately postpartum (n = 382).
Danger signs Pregnancy n (%) Labor & Delivery n (%) Postpartum n (%)
Vaginal bleeding 271 (70.9) 136 (35.6) 200 (52.4)
Severe headache 80 (20.9) 15 (3.9) 32 (8.4)
Convulsion 26 (6.8) 9 (2.4) 18 (4.7)
High fever 19 (5.0) 19 (5.0) 30 (7.9)
Loss of consciousness 15 (3.9) 12 (3.1) 13 (3.4)
Blurred vision 48 (12.6) n/a 18 (4.7)
Swollen hand/face 53 (13.9) n/a 22 (5.8)
Difficulty in breathing 34 (8.9) n/a 19 (5.0)
Severe weakness 110 (28.8) n/a 52 (13.6)
Severe abdominal pain 196 (51.3) n/a n/a
Fetal movement (rapid or slow) 117 (30.6) n/a n/a
Water breaks without labor 103 (27.0) n/a n/a
Labor lasting >12hr n/a 45 (11.8) n/a
Placenta delay > 30 min n/a 35 (9.2) n/a
Malodorous vaginal discharge n/a n/a 52 (13.6)
�
Immediate postpartum; n/a—not applicable to trimester on the questionnaire.

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

Fig 2. Source of information about obstetric danger signs (n = 327).

https://doi.org/10.1371/journal.pgph.0001084.g002

and a delayed placenta delivery, respectively, are ODS during labor and delivery. For the ODS
knowledge during the postpartum period, half of the respondents– 136 (52.4%) were aware
that vaginal bleeding postpartum is an ODS. The least recognized OD postpartum were those
associated with blurred vision, convulsion, loss of consciousness, and high fever.
Regarding the source of ODS information, 176 (46.1%) got information from nurses and
midwives, 119 (31.2%) from fellow mothers, and 79 (20.7%) from community health workers
(Fig 2).

Factors associated with ODS knowledge during pregnancy, labor and

delivery, and immediate postpartum
The age, marital status, the number of prenatal care visits during the current pregnancy, and
the duration of travel to the nearest health facility were associated with the knowledge of ODS
during pregnancy (Table 3). Women aged 26 to 35 had 80% higher odds (OR: 1.80; 95% CI:
1.05, 3.06) of ODS knowledge than women aged 16 to 25. Married or cohabitant women had
two times higher odds of ODS knowledge than single, separated, divorced, and widows (OR:
0.43; 95% CI: 0.21, 0.89). Attending three ANC visits was associated with 2.6 times higher odds
(OR: 2.60; 95% CI: 1.17, 5.66) of ODS knowledge than not attending any ANC visit. Traveling
15 to 30 minutes to the nearest health facility is associated with two times fewer odds (OR:
0.47; 95% CI:0.29, 0.86) of ODS knowledge than traveling for less than 15 minutes. No partici-
pant’s characteristic was associated with ODS knowledge during labor and delivery.
The knowledge of ODS during the postpartum period was associated with religion, and
Muslim women had significantly higher ODS knowledge than Catholics, Protestants, and
Adventist women. Muslim women had 2.5 times higher odds (OR 2.4, 95% CI: 1.02, 5.88) of
ODS knowledge in immediate postpartum than Catholics.

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

Table 3. Factors associated with the knowledge of at least three ODS during pregnancy, labor and delivery, and postpartum.
Pregnancy Labor and delivery Postpartum
Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI)
Age category
16–25 Ref Ref
�
26–35 1.80 (1.05, 3.06) 2.19 (0.75, 6.37) 0.96 (0.48, 1.92)
�36 1.75 (0.74, 4.1) 3.63 (0.91, 14.58) 0.91 (0.25, 2.65)
Marital status
Married or cohabitant Ref. Ref
Single, separated, 0.43 (0.21, 0.9) � 0.88 (0.24, 3.22) 0.70 (0.25, 2.01)
divorced, or widow
Education
Primary or lower Ref. Ref
Secondary or higher 1.17 (0.74, 1.84) 1.82 (0.82, 4.02)) 1.21 (0.67, 2.17)
Number of Prenatal visits
0 Ref.
1 2.22 (0.92, 5.31) 0.29 (0.30, 2.95) 0.40 (0.71, 2.26)
2 2.20 (0.91, 5.32) 1.01 (0.21, 4.97) 1.46 (0.40, 5.32)
3 2.59 (1.17, 5.66) � 0.95 (0.21, 4.20) 2.38 (0.76, 7.45)
Gravidity
Gravida 1 Ref. Ref
Gravida 2 0.92 (0.47, 1.81) 0.91 (0.25, 3.36) 1.48 (0.59, 3.70)
Gravida 3 0.51 (0.22, 1.19) 1.82 (0.43, 7.73) 0.78 (0.24, 2.48)
Employment
Housewife Ref. Ref
Other types of employment 0.80 (0.59, 1.26) 1.15 (0.54, 2.47) 1.27 (0.71, 2.27)
Time to the Health Facility (minutes)
<15 Ref. Ref
15–30 0.47 (0.26, 0.86) � 0.78 (0.28, 2.17) 0.74 (0.33, 1.67)
>30 0.84 (0.47, 1.50) 1.0 (0.39, 2.59) 1.24 (0.59, 2.65)
Religion
Catholic 0.96 (0.45, 2.06) 0.47 (0.14, 1.55) 0.41 (0.17, 0.98) �
Protestant 1.04 (0.48, 2.22) 0.61 (0.19, 1.90) 0.43 (0.18, 1.02)
Adventist 0.67 (0.27, 1.70) 0.38 (0.08, 1.85) 0.28 (0.08, 0.92) �
Others 0.97 (0.32, 2.98) 0.95 (0.18, 4.89) 1.34 (0.39, 4.61)
�
p<0.05.

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Discussion
The current study explored maternal knowledge of ODS and associated factors during preg-
nancy, labor and delivery, and the immediate postpartum periods. Our results indicate that
56.6%, 9.2%, and 17.5% were knowledgeable of ODS during pregnancy, labor and delivery,
and immediate postpartum, respectively. The age, marital status, the number of prenatal care
visits during the current pregnancy, travel duration to the nearest health facility, and religion
were associated with maternal knowledge of ODS.
Our study reported low maternal knowledge of ODS in general, and these findings are con-
sistent with prior similar studies in other settings of SSA. Studies conducted in Ethiopia,
Uganda, and South Africa reported that maternal knowledge of at least three ODS was 46.7%,
19%, and 5.2%, respectively [6,8,19]. Bleeding was the most recognizable ODS, consistent with

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

prior literature. Studies in Uganda, Tanzania, and Ethiopia reported that high women’s aware-
ness of vaginal bleeding as an ODS is due to blood-red being symbolized as a danger in African
cultures [6–9,11,20–25]. This aspect of the findings is encouraging, given that 27% of all mater-
nal deaths are caused by postpartum hemorrhage [1].
Although infections and hypertensive disorders are among the significant causes of preg-
nancy-related maternal mortality, the ODS associated with them were the least recognized by
women. In Kenya, fever was the third most common ODS mentioned [26] and in Tanzania,
headaches during pregnancy were recognized as an ODS by 44% of women [9]. These findings
highlight the need to strengthen the women’s education of ODS about sepsis and hypertensive
disorders during ANC.
The older age was favorable to maternal knowledge of obstetrical danger signs during preg-
nancy. Usually, older age correlates with a higher number of pregnancies hence higher
encounter with the health systems or other opportunities to learn about pregnancy and deliv-
ery, such as caregiving to pregnant relatives and friends. Therefore, age is expected to be asso-
ciated with higher maternal knowledge of ODS. Studies in Ethiopia, Tanzania, and Nigeria
reported similar findings of higher age and better knowledge of ODS [27–31]. These findings
point to the potential value of structured peer-to-peer learning among pregnant women at the
ANC sessions or in the community. This strategy helps older, likely knowledgeable mothers to
exchange knowledge and experience with younger and inexperienced women. Peer education
is influential in mothers’ change or the adoption of certain health behaviors [32] and increased
maternal knowledge of ODS effective in Tanzania [33].
Marital status was significantly associated with ODS knowledge, where married or cohabi-
tant mothers are twice as likely to be knowledgeable. A study in Ethiopia reported similar find-
ings [34]. The mechanism by which marital status contributes to maternal knowledge of ODS
is not well understood. In the Rwandan culture, becoming pregnant while not married or not
living with a partner comes with criticism, stigma, and sometimes rejection by the family,
while the pregnancy of married couples is often seen as a blessing. Such cultural dynamics
affect women’s access to family support and utilization of health services. A study conducted
in rural Rwanda reported that single women had three times higher risk for poor utilization of
ANC services. Additional studies are needed to explore the association between marital status
and women’s health literacy on ODS.
In the current study, the higher attendance to ANC was associated with better knowledge of
ODS during pregnancy but not during labor and delivery and postpartum. These findings are
expected. In Kenya, the ANC attendance was significantly associated with the knowledge of
ODS [26]. Similar results have been reported in Ethiopia, Tanzania, and Ethiopia [27–31]. The
lack of significant association between ANC attendance and ODS knowledge during labor and
delivery and the postpartum period could be a factor in the type of content covered during
ANC visits. These findings point to the need for strategies that promote early and sustained
attendance to ANC. There is additionally the need to ensure that the content covered during
ANC visits includes the maternal understanding of the labor and birth procedure and postpar-
tum expectations, as well as possible complications during these periods.
The accessibility of health services is an essential factor in health literacy and health out-
comes [35]. Our study found that longer travel to the nearest maternal health facility was sig-
nificantly associated with less knowledge of ODS during pregnancy. Even when health services
are available, their utilization remains contingent on their accessibility by geographical loca-
tion and cost of care [36]. Traveling longer distances is often associated with extreme physical
exhaustion through walking or high travel costs, and the loss of time. The accessibility of health
services partly explains why rural residents are likely to be less health literate than their urban
counterparts [35]. These findings highlight the value of decentralizing health services closer to

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

the community and universal health coverage to alleviate health geographical and cost barriers
to health services’ accessibility.
We additionally found significant disparities in ODS knowledge by religion during postpar-
tum but not pregnancy and labor and delivery periods. In our study, religion relates to the type
of church where people worship. Muslims were significantly different from the rest of the
study participants, yet, there is no known explanation for this finding. The science behind reli-
gious beliefs and health literacy is still in its infancy. In a study conducted in the United States
of America, higher religious beliefs scores were associated with lower health literacy about
colorectal cancer [37]. Furthermore, there is a need to understand why this type of association
existed only during the postpartum period. Additional studies exploring the role of religion on
ODS knowledge are needed.
Despite our call for additional studies on ODS knowledge, the current literature lacks con-
sistency in defining this concept. Some studies define maternal knowledge as the recognition
of three ODS, while others raise the threshold to the knowledge of a higher number of ODS.
The variability in reporting renders the comparability of findings ambiguous, which calls for a
universal instrument for assessing maternal knowledge of ODS.

Limitations
This study used a cross-sectional design; hence we cannot learn the trend in maternal knowl-
edge of ODS across the trajectory of pregnancy, labor and delivery, and postpartum. Since the
study participants were mainly the residents of Kigali–the capital city of Rwanda, the findings
may not be generalizable to other regions, especially the rural population. It was an observa-
tional study; therefore, we cannot make causal inferences between explanatory variables and
ODS knowledge. The comparably low knowledge of ODS during labor and delivery and post-
partum than during pregnancy could be explained by the fact that the study participants were
pregnant, so familiarity with ODS in the other perinatal periods may have been less critical at
the time of data collection.

Conclusion
This study assessed pregnant women’s knowledge of obstetrical danger signs during preg-
nancy, labor and delivery, and immediate postpartum. Maternal knowledge was found to be
low, especially the knowledge of ODS during labor and delivery and the immediate postpar-
tum period. Early in pregnancy, women need to be introduced to what to expect during labor
and delivery as well as the postpartum period. This understanding could help them know
potential complications and recognize them early and seek support if they occur. Other media,
including public service announcements on TV and radios, could be leveraged to sensitize the
general knowledge about pregnancy, labor and delivery, and the postpartum period.
Young mothers, women without partners (single and widow), and those traveling long dis-
tances to health facilities are at increased risk for low ODS knowledge, and particular interven-
tions, including peer-to-peer support and decentralization of maternal services, are needed.
Additional studies are also needed to understand the association between ODS knowledge and
marital status and religion.

Supporting information
S1 Data. Danger signs.
(CSV)

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PLOS GLOBAL PUBLIC HEALTH Pregnant women’s knowledge of obstetrical danger signs

Acknowledgments
We would like to thank the midwives and health administrators at the health facilities for their
cooperation with the data collection, Daniel Bogale, the Assistant professor who gave us the
structured questionnaire, and Becky White, who helped in structuring the title of this research
project.

Author Contributions
Conceptualization: Emmanuel Uwiringiyimana, Albert Nsanzimana, Neophyte Uhawenayo,
Pacifique Ufitinema, Patricia J. Moreland.
Data curation: Emmanuel Uwiringiyimana, Samuel Byiringiro, Janviere Bayizere.
Formal analysis: Emmanuel Uwiringiyimana, Samuel Byiringiro.
Investigation: Emmanuel Uwiringiyimana.
Methodology: Emmanuel Uwiringiyimana, Emery Manirambona, Samuel Byiringiro, Patricia
J. Moreland, Pamela Meharry.
Project administration: Emmanuel Uwiringiyimana, Albert Nsanzimana, Neophyte
Uhawenayo.
Resources: Emmanuel Uwiringiyimana.
Software: Emmanuel Uwiringiyimana, Janviere Bayizere.
Supervision: Emmanuel Uwiringiyimana, Samuel Byiringiro, Patricia J. Moreland, Diomede
Ntasumbumuyange.
Validation: Emmanuel Uwiringiyimana.
Visualization: Emmanuel Uwiringiyimana, Janviere Bayizere.
Writing – original draft: Emmanuel Uwiringiyimana, Samuel Byiringiro, Albert Nsanzimana,
Neophyte Uhawenayo, Pacifique Ufitinema, Pamela Meharry.
Writing – review & editing: Emmanuel Uwiringiyimana, Emery Manirambona, Samuel Byir-
ingiro, Pacifique Ufitinema, Patricia J. Moreland, Pamela Meharry, Diomede
Ntasumbumuyange.

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