Birth Preparedness and Complication Readiness among Pregnant Women in Southern Ethiopia Mesay Hailu1,2, Abebe Gebremariam2, Fissehaye Alemseged3, Kebede Deribe4* 1 Sidam Zone Health Office, Hwassa, Ethiopia, 2 Population and Family Health Department, College of Public Health and Medical Science, Jimma, Ethiopia, 3 Department of Epidemiology and Biostatistics, College of Public Health and Medical Science, Jimma University, Jimma, Ethiopia, 4 College of Public Health and Medical Science, Jimma University, Jimma, Ethiopia Abstract Background: Birth preparedness and complication preparedness (BPACR) is a key component of globally accepted safe motherhood programs, which helps ensure women to reach professional delivery care when labor begins and to reduce delays that occur when mothers in labor experience obstetric complications. Objective: This study was conducted to assess practice and factors associated with BPACR among pregnant women in Aleta Wondo district in Sidama Zone, South Ethiopia. Methods: A community based cross sectional study was conducted in 2007, on a sample of 812 pregnant women. Data were collected using pre-tested and structured questionnaire. The collected data were analyzed by SPSS for windows version 12.0.1. The women were asked whether they followed the desired five steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, identified blood donor and saved money for emergency. Taking at least two steps was considered being well-prepared. Results: Among 743 pregnant women only a quarter (20.5%) of pregnant women identified skilled provider. Only 8.1% identified health facility for delivery and/or for obstetric emergencies. Preparedness for transportation was found to be very low (7.7%). Considerable (34.5%) number of families saved money for incurred costs of delivery and emergency if needed. Only few (2.3%) identified potential blood donor in case of emergency. Majority (87.9%) of the respondents reported that they intended to deliver at home, and only 60(8%) planned to deliver at health facilities. Overall only 17% of pregnant women were well prepared. The adjusted multivariate model showed that significant predictors for being well-prepared were maternal availing of antenatal services (OR = 1.91 95% CI 1.21���3.01) and being pregnant for the first time (OR = 6.82, 95% CI 1.27���36.55). Conclusion: BPACR practice in the study area was found to be low. Effort to increase BPACR should focus on availing antenatal care services. Citation: Hailu M, Gebremariam A, Alemseged F, Deribe K (2011) Birth Preparedness and Complication Readiness among Pregnant Women in Southern Ethiopia. PLoS ONE 6(6): e21432. doi:10.1371/journal.pone.0021432 Editor: Fernando Althabe, Institute for Clinical Effectiveness and Health Policy (IECS), Argentina Received February 16, 2011 Accepted May 30, 2011 Published June 22, 2011 Copyright: �� 2011 Hailu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: This study was financially supported by Jimma University. The funder had no role in study design, data collection and analysis, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. * E-mail: kebededeka@yahoo.com Introduction Childbirth is a universally celebrated event yet for many thousands of women each day, child bearing is experienced not as the joyful event as it should be [1]. Globally 40% or more of pregnant women may experience acute obstetric problems. The WHO estimates that 300 million women in the developing world suffer from short-term or long-term illness brought about by pregnancy and childbirth. Most of maternal deaths occur in the developing world [2���6]. For example from 342,900 maternal deaths in 2008, 52% occurred in sub Saharan Africa [7]. This is because of several reasons one of which is inadequacy or lack of birth and emergency preparedness, which is a key component of globally accepted safe motherhood programs. Birth preparedness helps ensure that women can reach professional delivery care when labor begins and reduces the delays that occur when women experience obstetric complications [8���11]. Birth Preparedness and Complication Readiness (BPACR) is the process of planning for normal birth and anticipating the actions needed in case of an emergency [12,13]. Birth prepared- ness is a strategy to promote the timely use of skilled maternal care, especially during childbirth, based on the theory that preparing for childbirth reduces delays in obtaining this care. A birth plan/ emergency preparedness plan includes identification of the following elements: identifying a skilled birth attendant identifying the location of the closest appropriate care facility funds for birth- related and emergency expenses transport to a health facility for the birth and obstetric emergency and identification of compatible blood donors in case of emergency. The role of BPACR improving the use and effectiveness of key maternal and neonatal services is PLoS ONE | www.plosone.org 1 June 2011 | Volume 6 | Issue 6 | e21432

through reducing delays in deciding to seek care in two ways. First, it motivates people to plan to have a skilled provider at every birth. If women and families make the decision to seek care before the onset of labor, and they successfully follow through with this plan, the woman will reach care before developing any potential complications during childbirth, thus avoiding the first two delays completely. Second, complication readiness raises awareness of danger signs thereby improving problem recognition and reducing the delay in deciding to seek care [14,15]. Making arrangements for blood donors is also important because women giving birth may need blood transfusions in the event of hemorrhage or cesarean section. Blood donor systems at the community level can help overcome problems related with access to blood [13,15]. There are evidences from Nepal, Burkina Faso and India [16��� 18] that promoting BPACR improves preventive behaviors, improves knowledge of mothers about danger- signs, and leads to improvement in care-seeking during obstetric emergency. However there are no evidences which clearly indicate the reduction of neither maternal nor neonatal mortality. In Ethiopia, the levels of maternal mortality and morbidity are among the highest in the world and the current estimate of Maternal Mortality Rates is 580 per 100, 000 live births [7] and it is reported that Maternal deaths accounted for 21 percent of all deaths to women age 15���49 [19]. In Millennium Development Goal 5, countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. Following the commitment with the goal, Ethiopia is expected to reduce maternal mortality in 2015 to 267 maternal deaths per 100,000 live births [20]. Despite the fact that birth preparedness and complication readiness is essential for further improvement of maternal and child health little is known about the current magnitude and influencing factors in Ethiopia. This study therefore aims to fill this gap by assessing the current status and factors associated with birth preparedness and complication readiness among pregnant women in Aleta Wondo Woreda Sidama zone, Ethiopia, through a community based cross sectional study. It is hoped that the results of the study will provide valuable information for design of possible programs and interventions to improve maternal and neonatal health. And also serve as baseline information for further study. Materials and Methods Study area Sidama zone is one of the 13 zones found in the Southern Nations, Nationalities and People Regional Government (SNNPRG) with the total population estimate for 2007 was 2,855,386 [21]. Of this 2,610,439 (91%) are rural and 244947 (9%) are urban dwellers [21]. In the zone there are 19 woredas (equals district in other countries) and 2 town administrations. By ethnic group majority are Sidama and the major religious groups are protestant Christians.The potential health service coverage of the zone in 2005 was 38% [22,23]. During the survey period the number of pregnant women was 119837 (4.26%) and the antenatal care coverage was 69.3%, [23,24]. According to demographic health survey 2005 only 6% deliveries in Ethiopia occurred in health facilities assisted by skilled health providers [25]. The study was conducted in Aleta Wondo Woreda in Sidama zone, which is located 333 kilometers southeast of Addis Ababa. Administratively, the woreda is subdivided in to 27 rural and 4 urban kebeles (lowest administrative unit). The Woreda, is one of 19 woredas in Sidama zone, and has a total population of 212,459. Among these 184,015 are rural and 28,444 urban dwellers. In the Woreda there are 1 health center, 2 upgrading health centers, 2 medium private clinics and two NGO clinics. The potential health coverage of the Woreda is 29% according to regional health bureau report of 2004/2005. Study design In March 2007 a community based cross sectional study was conducted using both quantitative methods. The study was conducted among all pregnant women who were residing in Aleta Wondo district during the study period. The inclusion criteria were Women, with at least 3 months of current pregnancy, permanent resident of the study area, volunteer to participate and respond to the questionnaire were included. Women who were mentally disabled and severely ill were excluded. Sample size and sampling technique Sample size calculation was made based on the following assumptions pregnant women in the woreda were estimated to be about 4.26% of 212459 = 9050 pregnant women. Proportion of women who know danger signs of pregnancy & childbirth assumed to be 50% because there was no study conducted locally. The margin of error and confidence interval were taken to be 5% and 95% respectively. Based on the above assumption, this gives a sample size of 369. Considering the design effect of 2 and 10% non-response rate, the total sample size became 812. Multistage sampling procedure was used to select study subjects. First, all the kebeles in the woreda were stratified in to urban and rural. Then 2 urban and 8 rural kebeles were randomly selected for the study. The calculated sample size was proportionally allocated to urban and rural according to their population. Then a census was conducted to register all pregnant women and their gestational age. Based on the above information a sampling list, which enlists all eligible study subjects, was prepared. From the list, pregnant women with gestational age of 3 months and above were included in the survey. As the sample list did not allow simple random sampling, all eligible pregnant women in the selected kebeles were included in the study. Measurement A pre tested Structured interview questionnaire was used for data collection. It was taken from the safe mother hood questionnaire developed by maternal and neonatal health program of JHPIEGO the affiliate of Johns Hopkins University [11,12], and adapted according to local context and the objectives of the study. Using a pre tested questionnaire the following information were collected. Socio demographic characteristics including: age, marital status, family size, residence (urban versus rural), ethnicity, religion, education, occupation and average monthly family income. The questionnaire included questions gestational age, number of pregnancies, history of still birth and health problems during previous pregnancies. Danger signs during pregnancy, delivery and newborn which require referral and whether the mother follows the following four basic BPACR were asked i) identified a trained birth attendant or ii) health facility for emergency iii) identified mode of transport for delivery and/or for obstetric emergency iv) saved money and v) identified blood donor. The women were asked about antenatal care services and number of visits, who attended the ANC, preferred place of delivery. Data collection process. Fifteen community health workers (CHA) who can speak local language were recruited and trained on mapping and conducting households��� census with pregnant women conducted a census. Ten-health extension workers from other kebeles interviewed the eligible pregnant women after Birth and Complication Readiness in Ethiopia PLoS ONE | www.plosone.org 2 June 2011 | Volume 6 | Issue 6 | e21432