Factors affecting birth preparedness and complication readiness in Jimma Zone, Southwest Ethiopia: a multilevel analysis

Introduction Birth preparedness and complication readiness have been considered as comprehensive strategy aimed at promoting the timely utilization of skilled maternal health care. However, its status and affecting factors have not been well studied at different levels in the study area. Thus, this study was aimed to fill this gap by conducting community based study. Methods A cross-sectional study was conducted among randomly selected 3612 pregnant women from June-September 2012. The data were collected by interviewer-administered structured questionnaire and analyzed by SPSS V.20.0 and STATA 13. Mixed-effects multilevel logistic regression model was used to identify factors affecting birth preparedness and complication readiness. Results The status of birth preparedness and complication readiness was 23.3% (95% CI: 21.8%, 24.9%). Being in urban residence and having health center within two hours distance were among the higher level factors increasing birth preparedness and complication readiness. Educational status of primary or above, husband's occupation of employed or merchant, third or above wealth quintiles, knowledge of key danger signs during labor, attitude and frequency of antenatal care visits were among the lower level factors found to increase the likelihood of preparation for birth and its complications. Conclusion The status of birth preparedness and complication readiness was low in the study area. Both community level and individual level factors had important program implications. Socio demographic, economic, knowledge of key danger signs, attitude and antenatal care use were identified as associated factors. Improving antenatal care, giving special emphasis to danger signs and community based health education are recommended.


Introduction
Globally, about 287,000 mothers die each year because of problems related to pregnancy and child birth. About 99% of this occurs in developing countries. Sub-Saharan Africa (56%) and Southern Asia (29%) account for 85% of the global burden of maternal death.
With this disparity, the maternal mortality rate in developing countries is more than 15 times higher than in the developed regions [1]. While almost all developed countries have achieved the  [7][8][9]. To address these problems, birth preparedness and complication readiness (BP and CR) has been considered as a comprehensive strategy aimed at promoting timely utilization of skilled maternal health care and addresses the three delays to care-seeking for obstetric emergencies. It promotes active preparation and decision-making for births, including pregnancy and postpartum periods, by shared responsibilities of pregnant women, their families, the community and the service providers [10,11].
The elements of birth preparedness and complication readiness at individual level include: plan for where to give birth, plan for a skilled birth attendant, plan to save money, plan for transportation and identification of compatible blood donors in case of emergency.
These enable the woman and her family for timely use of skilled maternal and neonatal cares based on the theory that preparing for childbirth and being ready for complications reduce delays in obtaining these cares [10]. Though we have limited studies in Ethiopia, the existing evidences show that the status of birth preparedness and complication readiness is low. A cross sectional study conducted in Adgrat town in 2006 revealed that only 22% of the respondents were prepared for birth and its complications [12].
Similarly, a cross-sectional study conducted in Aleta Wondo District, South Ethiopia in 2007 found that only 17% of the respondents were prepared for birth and its complications [13].
Thus, it is timely and very crucial to have up-to-date information on the status of birth preparedness and complication readiness and affecting factors at different levels for policy and program implications. However, studies on this issue are very limited in Ethiopia and non-existent in the study area. Even, the existing studies didn't look at the factors at different levels. Therefore, this study was conducted to fill this gap by identifying the factors affecting birth preparedness and complication readiness at the different levels by applying multilevel analysis of community based study in Jimma zone.

Study design and setting
This is a community based cross-sectional study conducted in Jimma Zone from June-September 2012. Jimma Zone is one of the 17 Zones of the Oromia Regional State of Ethiopia. The capital of the Zone, Jimma Town, is located at 346kms Southwest of Addis Ababa. The Zone has a total of 17 rural districts ("Woredas") and two town administrations. Based on the 2007 national population census conducted by the Central Statistics Agency (CSA) of Ethiopia, the Zone has a total population of 2.6 million, of whom 88.7% are rural inhabitants [14,15].

Population, sample size and sampling technique
The study population for this study was pregnant women. The sample size was determined by using Epi-Info V.3.5.1 by considering two sample comparison of proportions based on the following assumptions. Among all the factors considered, antenatal care (ANC) was found to give the largest sample size. The prevalence of birth preparedness and complication readiness among mothers who attended ANC is estimated to be 22% (p1=0.22) and among those who didn't attend ANC is to be 13% (p2 = 0.13) [13]; Page number not for citation purposes 3 95% level of confidence and 90% power were considered. The prevalence of ANC in the general population in same study was 45%. As a result, a ratio of 1:1 was used (r = 1). As multistage clustered sampling method was used, a design effect of 2 was considered. Finally, 10% was added for non-responses and the final sample size became 1650. However, this study was part (baseline) of a big longitudinal study to determine the effect of maternal and neonatal health care on neonatal health status, in which 3612 pregnant women have been followed up. As a result, all the 3612 pregnant women were included in the analysis for this study.
Multi-stage clustered sampling technique was used to identify pregnant women for the study. At first stage, the Zone was stratified as rural districts (17 in number) and town administrations (2 in number, Jimma and Agaro). Then, 5 districts were selected by simple random sampling from the 17 districts. At second stage, all the selected 5 districts were clustered by "Kebeles" (A "kebele" is the smallest administrative unit having 5000 population on average) and stratified in to urban and rural "Kebeles". Then, by simple random sampling method, 9 rural "Kebeles" and 2 urban "Kebeles" were selected from each selected district. This number of "kebeles" was determined based on expected number of pregnant women per "Kebele. Jimma town administration and Agaro town administration have 13 and 5 "Kebeles", respectively and all were included. With this, a total of 73 "Kebeles" (clusters) were included in the study.
Then, for all selected "kebeles" pregnant women were enumerated by using house-to-house visit and all obtained were included in the study.

Data collection process
Pre-tested interviewer administered structured questionnaire was adapted from the safe motherhood questionnaire developed by maternal and neonatal health program of JHPIEGO [11]. The indicators for the wealth index were adapted from EDHS [6]. The questionnaire was prepared in English, then translated to local languages "Afan Oromoo" and Amharic and back translated to English by different experts to check its consistency. Females, who had completed 10 th grade or above, were recruited, trained and collected the data. The data collection process was supervised strictly by trained supervisors and principal investigators. To control the quality of data, in addition to training, pretest, supervision and use of local languages, the inter-item consistency of the indicators to measure the composite score of BP and CR was checked by using Chronbach-alpha at 0.7 cut-off point.

Data analysis
The collected data were coded and entered into Epidata V.3.1. and exported to SPSS for windows version 20.0 for cleaning, editing and analysis. Descriptive analysis was done by computing proportions and summary statistics. Wealth quintiles were determined by using Principal Component Analysis (PCA). As Jimma town and Agaro town administrations were both purposefully included, the status of BP and CR was estimated by calculating weighted percentage based on the complex sample survey procedure by considering probability of exclusion at each stage and non responses in order to avoid over estimation. Bivariate analysis was done by using cross tabulation to see associations between the independent and dependent variables.
Then, all variables having P < 0.25 were considered as candidates for the mixed-effects multilevel logistic regression model. Because of the multi-stage clustered sampling procedure, mixed effects multilevel logistic regression model was used by using STATA 13.
This model was preferred in order to avoid the clustering effects as well as ecological fallacy. "Kebeles" was considered as clusters and "kebele" level variables were taken as higher level (level-2).
Mothers were nested within their households and maternal individual variables and household characteristics were taken as lower level (level-1) variables ( Table 1, Table 2). Goodness-of-fit of the multilevel model was tested by the log likelihood ratio (LR) test. To evaluate the existence of sufficient variance at the cluster level to use multilevel analysis, intercept-only model was fitted as Logit (pij) = y00 + u0j and Interclass Correlation Coefficient (ICC) was determined by dividing between group variance (δ 2 μ0) by the total variance variance (between group variance (δ 2 μ0) + within group variance (δ 2 e)). However, within group variance (δ 2 e) is not directly obtained for dichotomous outcome variable; instead, it was estimated by ∏ 2/3 . Then, to identify the determinate factors, the full model was fitted as: Logit (pij)= p00 + y01Zj + y10Xij + u0j + u1jXij. Where: Logit(p ij)=dependent variable at unit i in cluster j, Xij= individual explanatory variable in cluster j, Zj= group level explanatory variable, y 00= fixed intercept, y01 and y10 = fixed slopes and u 0j and u1j= random effects at level-2. Multicollinearity between the independent variables was assessed by using variance inflation factors (VIF > 10 was considered as suggestive of multicollinearity) before interpreting the final output. But, no significant multicollinearity was detected as VIF for all variables were < 5. In Page number not for citation purposes 4 addition cross-level two-way interactions were checked, particularly between place of residence, access to health facilities and ANC visits. However, no significant interaction was detected (P > 0.05 for each).

Ethical clearance
Ethical approval was obtained from the Institutional Review Board (IRB) of College of Health Sciences of Addis Ababa University.
Formal permission letters were secured from all respective local administrators. Written informed consent was obtained from each respondent before actual data collection and confidentiality of the data were strictly maintained.  Table 3).

Past obstetric history
Gravida, number of pregnancies ever had, ranged from 1 to 9 among the respondents with a mean (±SD) of 3.3±1.9. Similarly, number of live births ever had ranged from 1-8 with a mean (±SD) of 2.8±1.6. Among those who ever had two or more pregnancies, 156 (5.5%) and 203 (7.2%) had life time history of abortion and stillbirth, respectively. Nearly four-fifth, 2236 (79.1%) had the last inter-pregnancy interval of 2-4 years with a mean of 3±1.3 years.
Among those who had at least one delivery in the past, 1690 (59.8%) had at least one ANC visit and only 406 (14.5%) gave birth attended by skilled providers.

Knowledge of key danger signs
The three key danger signs during pregnancy: severe vaginal bleeding, swollen hands/face and blurred vision were spontaneously mentioned by 964 (26.7%), 530 (14.7%) and 1078 (29.8%), respectively. However, only 227 (6.3%) were able to spontaneously mention all the three key danger signs. The four key danger signs during labor and delivery: severe vaginal bleeding, convulsions,

Attitude towards BP and CR
Attitude of the respondents was measured by using a composite variable of 8 items in a Likert-scale and those achieved above or equal to the mean score were rated as having favorable attitude.
Based on this, 2202 (61.0%) were found to have favorable attitude towards birth preparedness and complication readiness.

BP and CR practice
Among the five key elements of BP and CR practice, 2656 (73.5%) planned to save money, 2174 (60.2%) planned to arrange transport, 719 (19.9%) planned to prepare blood donor, 1169 (32.4%) planned to give birth in health facility and 791 (21.9%) planned to be attended by skilled attendant for their current pregnancy. By considering 3 or more steps of the five parameters, 1245 (34.5%) were found to fulfill the criteria and rated as well prepared for birth and its complications. However, after weighted analysis to avoid over estimation, the final status of BP and CR was found to be 23.3% (95% CI: 21.8%, 24.9%) ( Table 4).

Factors affecting birth preparedness and complication
readiness Before running the full model, ICC (ρ) was calculated in the empty model and it was found to be 0.554 indicating that 55.4% of the variation is contributed by between cluster variation.
The test of the preference of log likelihood versus logistic regression was also strongly significant (P < 0.0001). Then, the full model was run by including both the cluster level and individual level variables and the ICC (ρ) was reduced to 0.302. This again indicated that 30.2% of the variation is attributed to cluster level variables suggesting the preference of multilevel analysis. The preference of log likelihood versus logistic regression was again strongly significant (P < 0.0001).
After adjusting for confounders in the two-levels mixed-effects

Discussion
As the occurrences of complications during the process of child birth are unpredictable, every woman needs to be aware of the key danger signs of obstetric complications during pregnancy, delivery and the postpartum period. This knowledge will ultimately empower them and their families to make prompt decisions to seek care from skilled birth attendants [11]. However, the knowledge of key danger signs in this study was found to be very low. The three key danger signs during pregnancy, the four key danger signs during labor and delivery, the three key danger signs during postpartum period and the four key danger signs of neonates were spontaneously mentioned by 6.3%, 3.7%, 2.4% and 2.1% ,respectively which were very low. Similar problems were reported in other prior studies in Ethiopia and other African countries [12,[16][17][18]. In this study, 73.5% of respondents planned to save money and 60.2% planned to arrange transport which were relatively better.
However, only 19.9% planned to arrange blood donor, 32.4% identified skilled attendant at delivery [12]. Similarly, in the study conducted in Sidama Zone, South Ethiopia in 2007, 34.5% planed to Page number not for citation purposes 6 save money, 7.7% planed to arrange transport, 2.3% planed to arrange blood donor and 8.1% planed to deliver in health facilities [13]. This may be explained by the low socio-economic status, low level of knowledge and low education among women as well as the general population. As birth preparedness and complication readiness is relatively a recent strategy, service providers and program planers might not have given special attention.
Particularly, the preparation of health facility delivery and skilled delivery attendant, were lower than some other countries' study like Tanzania [18], Nigeria [19] and Burkina Faso [20]. This difference may be explained by the difference in socio-economic status, availability and accessibility of services or any other interventions in the countries. The overall status of birth preparedness and complication readiness in this study was 23.3%. This is consistent with other priori studies in the country. In a study done in Adgrat town, North Ethiopia in 2006 and Sidama Zone, South Ethiopia in 2007, the status of birth preparedness and complication readiness were 22% and 17%, respectively [12,13]. This suggests that in spite of many efforts by the government, the progress is slow. In Among the higher level factors, being in urban residence was found to increase the likelihood of preparation for birth and its complication by about six times in this study. Having health centers within 2 hours distance on foot in average was also found to increase the likelihood of preparation by about three times. These findings are consistent with other previous studies [12,18]. This may be explained by the fact that women in urban areas have access to health information through different media and relatively low barriers due to distance and lack of transportations as compared to the rural women. Similarly, having nearby health facility increases access to health information and also reduces distance barriers. Among socio-demographic and economic related factors, education, husband's occupation and wealth quintiles were the detrminats of BP and CR in this study. Attending primary (grades 1-8), secondary (grades 9-12) and tertiary (12+) schools were found to increase the likelihood of preparation by about 1.5, 3 and 8 times, respectively. Similarly, having partner who is employed or merchant increased the likelihood of preparation for birth and its complication as compared to those whose partners were farmers.
Besides, wealth quintiles were found to be the other determinant factor. Being in the wealth quintile category of third and above were associated with increased preparation for birth and its complications. This is in line with the findings of other study conducted in the country as well as other countries; where education, occupation and income were among the factors affecting birth preparedness and complication readiness [12,18]. The reasons could be, having high education, being employed and merchant are directly related with high access to information and income which enable them to be prepared for birth and its complications.
Most importantly, Knowledge of key danger signs during labor and delivery, women's attitude towards BP and CR and ANC visit were found to be the determinant factors in this study. However, knowledge of key danger signs during pregnancy, post partum period and neonates were not found to have significant associations. This is in line with other studies in the country and abroad in which ANC visit and knowledge of danger signs were among the strong predictors of BP and CR practice [12,13,18].

Competing interests
The authors declared no competing interest.  Tables   Table 1:        The wealth status was categorized into five groups and ranked from poorest to wealthiest quintile.

Authors' contributions
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