Introduction

Reducing maternal deaths to less than 70 per 100,000 live births is one of the targets of the Sustainable Development Goal (SDG 3) in 2030 [1]. To achieve this figure, women should clearly understand the direct and indirect ODS that contributed to high maternal death and seek early treatment from health care providers, particularly in developing countries, including Ethiopia [2–4]. These ODS can be broadly divided into three groups. Swollen hands and face, vaginal bleeding, severe headache, blurring of vision, pre-eclampsia, and eclampsia are commonest during pregnancy. Severe vaginal bleeding, labor lasting more than 12 hours, hypertensive disorder, and placenta retention are the main ODS during childbirth. Fever, foul-smelling vaginal discharge, and acute vaginal bleeding are the main ODS during the postpartum period [5]. Besides, direct and indirect ODS are other classifications in terms of the proportion of maternal death contributed. Direct ODS includes infection, hemorrhage, obstructed labor, unsafe abortion, and hypertensive disorders of pregnancy, which account for nearly 80% of maternal death globally, while indirect ODS such as anemia, hepatitis, diabetes, malaria, and cardiovascular conditions that are made worse by pregnancy [6, 7].

The World Health Organization (WHO) 2022 report states that hemorrhage is the primary cause of maternal death worldwide and accounts for around 28% of all deaths, making direct obstetric complications the major cause of maternal death [6, 7]. Additionally, studies showed that the two main causes of maternal death in Africa are eclampsia and hemorrhaging [8, 9]. However, if the women are aware of these ODS and are recognized, treated, and managed appropriately, many of these complications can be avoided [7]. But most women, especially in underdeveloped nations, don’t know much about ODS [6, 10–12].

The three crucial delays model describes the primary cause of maternal mortality throughout the pregnancy, delivery, and postpartum phases in many low-income countries. These include delaying off recognizing life-threatening ODS and making the decision to seek medical attention, delaying off getting to the hospital, and delaying off getting prompt, adequate, and efficient care there [13–16]. Women delay obtaining obstetric medical care due to a lack of understanding about ODS, causing high maternal illness and death in developing nations [17, 18].

Research from Ethiopia likewise revealed that women have poor knowledge of ODS, ranging from 15.5 to 48%. [3, 19, 20], resulting in high maternal illness and death at the country-level in general (412 maternal mortality per 100,000 live births) [21] and the highest death in rural areas (1142 maternal mortality per 100,000 live births) [22].

Several complex and interrelated determinants contributed to poor knowledge of ODS among women and can be categorized as socio-demographic and economic features such as wealth index, age, education, and occupation status of women and her husbands’, and mass media exposure. Reproductive characteristics like age at first marriage and childbirths, gravidity, parity, history of abortion, stillbirths and neonatal deaths, and planned pregnancy. Availability and accessibility of health facilities and health care providers, counseling, and health education during antenatal care, childbirth, and postpartum care are some determinants of ODS knowledge [3, 11, 19, 20, 23, 24].

The Ethiopian government has devised many strategies and programs to boost mothers’ knowledge about ODS, which is very crucial for women’s health and survival [25, 26]. Among these, focused antenatal care (ANC) aims to provide deep counseling to all pregnant women attending ANC clinics, improve early detection of ODS, increase birth preparedness plans, and decrease the delay in seeking care [27]. The national reproductive strategy of Ethiopia aims to empower women, families, and communities to identify pregnancy-related ODS and create a conducive environment to support safe motherhood and decrease maternal mortality [25]. Further, Ethiopia’s growth and transformation plan (GTP) comprises the training and deployment of health extension workers (HEWs) and health care providers (HCPs), particularly midwives, in rural areas to provide community-based maternal and child health services, whereas restructured community engagement using the Women Development Army (WDA) and a pregnant women forum, is vital to teach about ODS and the birth preparedness plan [26].

Mothers’ knowledge of ODS is still low nationwide and extremely poor in rural areas, notwithstanding the Ethiopian government’s measures and programs [3, 19, 20]. Furthermore, there are considerable regional and urban/rural differences in the prevalence of ODS knowledge among women at the national level, implying that more research is needed into the prevalence of ODS knowledge in local settings. Previous research on the frequency of ODS knowledge among pregnant women in Ethiopia, however, focused solely on individual-level determinants, with little consideration given to community and context-specific determinants. Furthermore, no evidence of the proportion and determinants of ODS knowledge has been found in the current study setting. This study’s findings will be highly beneficial in informing implementers, health managers, and decision/policy makers as they build comprehensive intervention methods.

Therefore, this study aimed to describe the levels of knowledge of ODS and identify determinants of ODS knowledge among women in the northern zone of the Sidama region, Ethiopia. The current study’s research question is: What are the individual and community-level determinants of obstetric danger sign knowledge among women in the northern zone of the Sidama region, Ethiopia?

Methods

Sampling technique

A multi-stage sampling method was utilized to select study participants. The first, second, and third stages were a selection of districts, kebeles, and households, respectively, from the zone using a simple random sampling procedure. The sampling frame was prepared by conducting a house-to-house census through HEWs. The calculated sample size was allocated to each kebele based on their population size. Lastly, eligible women were selected from households using a simple random sampling procedure. If two or more women were present in the selected household, one woman was selected by using a lottery method. Three consecutive visits were done before declaring women as non-respondents for this study during data collection (Fig 1).

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Fig 1. Schematic presentation of the sampling procedure of the study in Northern Zone of the Sidama region, Ethiopia, 2022.

https://doi.org/10.1371/journal.pone.0314916.g001

Result

Determinants of obstetric danger signs knowledge

The women who were government employees had 37% higher likelihoods of knowledge of obstetrics danger signs than housewives (AIR = 1.37; 95% CI: 1.20–1.56). Women’s mass media use increased the likelihoods of ODS knowledge by 1.16 times compared to women who did not use mass media (AIR = 1.16; 95% CI: 1.08–1.25). Women who had received model family training had a 34% higher likelihood of knowledge of ODS than their counterparts (AIR = 1.34; 95% CI: 1.25, 1.46). The likelihoods of ODS knowledge had increased by 15% for autonomous women as compared to non-autonomous (AIR = 1.15; 95% CI: 1.04, 1.25). Women who had faced health problems during pregnancy had a higher prevalence of obstetrics danger sign knowledge than their counterparts (AIR = 1.21; 95% CI: 1.11, 1.32), while urban residence increased the likelihood of ODS knowledge (AIR = 1.22; 95% CI: 1.09, 1.62) as compared to rural residence (Table 1).

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Table 1. Determinants of obstetric danger signs knowledge among women of reproductive age in the Northern zone of Sidama region, Ethiopia, 2022 (N = 1,130).

https://doi.org/10.1371/journal.pone.0314916.t001

Discussion

This study determined the level of ODS knowledge and identified determinants of knowledge of ODS among women who gave birth in the past year. The overall proportion of knowledge of ODS among women was 22.3%. Government employee occupation, access to mass media, receiving model family training, women autonomy, facing health problems during pregnancy, and urban residence were determinants of knowledge of ODS.

The overall proportion of knowledge of ODS among women was 22.3% in this study. This finding is lower than the study’s findings from Shashamane town, Ethiopia (40.5%) [11], Hosanna town, southern Ethiopia (63.2%) [24], and the national average of ODS knowledge (32%) [19]. However, our finding is higher than studies conducted in Wolaita Sodo town, South Ethiopia (16.8%) [20], Bahir Dar city administration, Ethiopia (18.5%) [10], and rural Uganda (19%) [12]. The disparity in the levels of knowledge of ODS among women in different parts of Ethiopia and other nations could be attributed to differences in socio-demographic factors, degree of economic development, study area, level of health service availability and accessibility, study periods, and sample size. Our study was focused on rural women and community-based, whereas the other studies were focused on urban areas and institution-based.

Government-employed women were more likely to mention a greater number of contents of obstetrics danger signs than farmers. This finding is similar to the findings of various studies [38–40]. Studies conducted elsewhere revealed employment was significantly associated with knowledge of obstetric danger signs. Women’s employment usually improves household income and satisfies the financial needs of women; hence, they can have access to health services, from which they obtain health-related information, including knowledge of ODS [41, 42]. Besides, in contrast to unemployed women, women who are government-employed may be more independent in their pursuit of better health care. Furthermore, this discrepancy might be explained by the exposure of educated women to health information that they could learn in school and health facilities. Compared to their uneducated counterparts, educated women typically have less trouble comprehending the information they get from counseling during ANC visits [23]. Additionally, women with higher levels of education are able to read and comprehend health messages from written materials as well as other communication channels [43].

Women who had media exposure had higher rates of spontaneously mentioned contents of knowledge of obstetrics danger signs. This finding is in line with studies from Ethiopia and other developing countries [38, 44–46]. The reason might be that women who frequently read newspapers or magazines, listen to the radio, and watch television have a higher likelihood of ODS knowledge due to the fact that those women could be more educated, autonomous, economically independent, and reside in urban areas as compared to their counterparts [46]. Also, the WHO report argued that women who had a high living and income could have better exposure to mass media that increased awareness and knowledge of ODS and antenatal care utilization [47]. This argument is supported by results from studies employed in low-income countries [48, 49].

Women who had model family training had more likelihoods of telling more contents of ODS than their counterparts. This finding is consistent with previous studies [41, 45, 50]. The probable reason might be that discussing health issues with health professionals is indispensable for getting clear and updated information regarding obstetric danger signs, and HEWs have frequent contacts with women, which could help to acquire knowledge on obstetric danger signs. Likewise, the potential justification may be explained as follows: women who receive model family training from HEWs typically have positive attitudes, health-seeking behavior, good knowledge of ODS, and information about the advantages of maternal health services. This result briefs the requirement to reinforce the existing model family training by HEWs to enhance knowledge of ODS among women, reduce maternal mortality, and achieve third SDG target 1.

Autonomous women were more likely to have higher likelihoods of mentioning contents of obstetrics danger signs than their counterparts. This is consistent with the previous studies [39, 51, 52]. This is because autonomy empowers mothers to take any action anytime on health-related matters. It is clear that mothers who have full autonomy to decide to seek care from reproductive and maternal health services are more likely to have enough information and knowledge on issues including the danger signs of pregnancy, labor and delivery, and the postnatal period [53]. The researchers contended that because of cultural norms and economic reliance, mothers who are denied autonomy may have little knowledge of ODS and be unable to choose to seek medical care without their spouses’ consent [54].

Women who faced health problems during pregnancy were more likely to have knowledge on danger signs than their counterparts. The most plausible explanation could be that experiencing complications makes women and their families more anxious about experiencing more issues. Additionally, mothers who have seen severe warning signs are more likely to have unfavorable perceptions of their vulnerability and the severity of the risks, which directly contributes to their increased understanding of ODS. Another explanation would be that women’s awareness of ODS grew as a result of mothers’ understanding of the condition being influenced by their suspicions of recurrence.

Urban resident was more likely to expose women to knowledge of obstetrics danger signs than their counterparts. This finding is similar with previous studies [3, 55, 56]. Mothers who live in urban areas are more likely to be educated, have better access to information and the media, be more independent, have better employment prospects, be financially independent, and live closer to medical facilities, which might increase their knowledge of ODS. Furthermore, insufficient knowledge of ODS in rural areas may result from a lack of awareness, poor infrastructure, unavailability, inaccessibility of service, lack of road access and transportation, and other factors.

Conclusion

Only one in five women has good knowledge of ODS among women in the study area. This indicated that much work remains to be done to improve women’s knowledge of ODS in the study setting. Government employees, mass media exposure, receiving model family training from HEWs, autonomy in decision-making, facing health problems during pregnancy, and urban residence were determinants that positively increased the incidence of knowledge of obstetrics danger signs. Any policy should consider inter-sectorial collaboration to address determinants of ODS knowledge at the individual and community level. The specific intervention programs should strengthen model family training via HEWs and local mass media exposure. Any ODS knowledge promotion approach must consider empowering women to increase their capacity to make decisions about health care issues. Future researchers should conduct further research, particularly focusing on husbands’ knowledge of ODS, the level of pregnant women’s forum implementation status, and the engagement of women’s development teams and HEWs using a longitudinal cohort study or randomized controlled trial to establish causality between exposure variables and knowledge of ODS.

Supporting information

Acknowledgments

We thank Netsanet Kibru and Hawassa University School of Public Health staff for their technical support. We are also very grateful to the study subjects, data collectors, supervisors, district health offices, and administrators of Kebeles for their contribution to the success of this study.