Oduro et al. BMC Pregnancy and Childbirth (2023) 23:728 BMC Pregnancy and Childbirth https://doi.org/10.1186/s12884-023-06041-2 RESEARCH Open Access Birth preparedness and complications readiness among women in disadvantaged rural districts of Ghana Abraham Rexford Oduro1,2*, Maria Anyorikeya3, Patrick Ansah3, Samuel Oladokun3, Ernest Maya Tei4, Randy Oduro‑Ayeh2,3, Paul Welaga3 and Seli Deh2,5 Abstract Introduction Essentially all women and babies irrespective of their economic and social status should reach their full potential for health and well‑being. The study assessed the readiness of mothers and their preparedness for birth across three disadvantaged rural districts in Ghana. Methods A multi‑centre quantitative survey from January to December 2018 using a multistage sampling approach was employed. Using a structured questionnaire data from mothers attending antenatal and postnatal clinics in three main ecological zones of Ghana were collected. Women who provided informed consent were consecutively recruited until the sample size was achieved. For categorical data, summary tables, proportions and percentage are presented. Multivariate logistic regression analysis determined the effect of selected characteristics on birth prepared‑ ness. Ethics approval was obtained from the Navrongo Health Research Centre. Results A total of 1058 mothers were enrolled: 33.6%, 33.4% and 33.0% respectively from the Ada west, Upper Den‑ kyira west and Builsa south districts. About 94% of the women had prior knowledge of birth preparedness. Approxi‑ mately 22.6% (95%CI 20.1, 25. 2) of the mothers were assessed to have poor birth preparedness: 8.0% in Builsa south, 27.8% in Ada west and 31.7% in Upper Denkyira west. Prenatal and postnatal data showed no statistically significant difference in poor preparedness (21.9% vs 23.3%; p‑value > 0.05). Maternal age, employment status, religious affili‑ ation and parity were not associated with birth preparedness (p‑value > 0.05). Area of study (P < 0.001), educational level (P < 0.016), marital status (p < 0.001) and antenatal contacts (< 0.001) were significantly associated with birth preparedness. Conclusions As an important safe motherhood strategy woman should plan their pregnancy and birth well to reduce maternal and neonatal mortality. Policy initiatives should take into consideration area of residence, educa‑ tion, marital status and antenatal contacts of women. Keywords Birth preparedness, Complication readiness, Rural districts, No hospitals, Ghana *Correspondence: Abraham Rexford Oduro aroduro@gmail.com Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http://creativecom‑ mons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Oduro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 2 of 12 Introduction since 2008 under the National Health Insurance Scheme Essentially all women and babies irrespective of their [16]. The policy allows pregnant women to have free reg- economic and social status should reach full potential for istration with the scheme to be entitled to free services health and well-being. Although important progress has throughout pregnancy, childbirth and postnatal [16]. The been made in the recent decades, maternal and neonatal policy is one of the Ghana’s strategies for the achievement mortality and morbidity remain unacceptably high espe- of the SDGs in reducing of maternal and child deaths and cially in developing countries. Thus, ending preventable achievement of universal health coverage. adverse maternal and neonatal outcomes remain at the This study documented the practice of birth prepared- top of the global health agenda [1–4]. Simply surviving ness and complication readiness among pregnant women pregnancy and childbirth is not enough marker of suc- in three ecologically distinct settings in Ghana, where cessful maternal health but critical efforts at promoting there are no district hospitals for immediate obstetric their well-being as a global health priority. Addressing emergency referral care. The absence of a district hospi- inequalities in health interventions for mothers and tals often means that in Ghana women may have to travel babies is also fundamental to ensuring equity and high- for long distances before getting to the nearest district quality care for them [1–4]. hospital and therefore if they have not prepared already, Safe motherhood initiatives have played key roles in it will further worsen the delay in getting to the hospital. birth plan strategies among expectant women and have The study assessed the facteros that determine readiness helped to eliminate some of the delays associated with of mothers and their preparedness for birth across three adverse outcomes [1–4]. There is however the need to disadvantaged rural districts in Ghana. redouble those strategies that improve birth prepared- ness and actions in case of emergency. Since it is impos- Methods sible to predict which pregnancy will have obstetric Study area and setting emergency, it is important for women to be well prepared The study was coordinated in the Navrongo Health for the various scenarios that may arise. It is imperative Research Centre [17] and data collected from three for women to have contingency plans and resources in administrative districts in Ghana namely Ada West, the event of an emergency [3–5]. Upper Denkyira West and Builsa South Districts (Fig. 1). In their birth planning, women are expected to organ- These districts were chosen because they are all rural ize the supplies and logistics they will need for delivery, with no district hospitals for secondary level of care and decide on the location of the closet facility to give birth, their locations represent the three major ecological zones the preferred birth attendant, identify a birth companion of coastal, forest and the savanna of the country (Fig. 1). and funds for any expenses related to birth and in case of Among the three study areas upper Denkyira west complications. They are also to make provision for trans- is tha most economicall active lying in the middle zone port, decide what they will do in an emergency, identify of the country. It is a forest and cocoa growing area and support to look after the home and other children while within the gold mining area including the small scale and she is away. A good birth plan moderates any emergency illegal ones. Builsa area is located in the northern part that may occur during pregnancy and delivery and must of Ghana where poverty is high, and vegetation is arid be supported [6–10]. savanna and the Ada west though is in the south and In Ghana, factors associated with the practice of birth closer to the national is economically less active. preparedness and complication readiness have been The Ada West district lies between Latitudes 5°45’S and documented but limited information exist in hard-to- 6°00’N and Longitude 0°20’W and 0°35’E in the coastal reach communities where there are often no hospitals savannah of Ghana with a land area of about 323.72 for emergency referrals [11–14]. This in addition to other Square km.. The second district, Upper Denkyira west factors contribute to making expectant mothers report lies within latitudes 5º 30’ N and 6º 02’ N of the equator late, unprepared for delivery and hence the associated and longitudes 1º W and 2º W and has a total land area of poor outcomes. The contribution of this to the suste- 579.21 square kilometers within the semi-deciduous for- nance of the high maternal and neonatal mortality, and est zone of Ghana (Fig. 1). The third district Builsa South morbidity cannot be over emphasized. lies between longitudes 1 0 05’ West and 10 35’ West and Though maternal mortality ratio in Ghana have latitudes 100 20’ North and 100 50’ North of the equator declined significantly in recent years. The pace of decline in the guinea savannah parts of Ghana (Fig. 1). Physical has slowed, and this might have led to its inability of access to health care services in the districts are limited Ghana to achieve the Millennium Development Goal by inadequacy of health facilities. Health care in the dis- target [15]. This is against the backdrop of the Ghana’s tricts is delivered at two levels, the community and sub- free maternal health policy that has been implemented district levels as none of the districts has a hospital. In O duro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 3 of 12 Fig. 1 Map of Ghana showing the three administrative sites for the study addition to these facilities, mobile health teams visit sev- approaches was used. The points of data collection eral villages and communities on routine bases to offer included subdistrict antenatal and postnatal clinics. health services in addition to private clinics [18]. The study duration was from January to October 2018. Study population involved all pregnant women in their third trimester seeking antenatal care services and Study design women who had delivered in the last six weeks in the A cross-sectional survey with multistage sampling three districts during the period of study. All those who approach was conducted in the three study districts. met the selection criteria were recruited. Participants A mixture of convenient and probability sampling were enrolled consecutively until the sample size was Oduro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 4 of 12 achieved. Each person participated and provided infor- professionals in the respective study districts who also mation only once during the study period. liaised with colleague staff in participating health facili- ties to facilitate and supervised data collection pro- Data collection cess. Supervisors and data collectors were all stationed A structured questionnaire on birth preparedness was in the study area throughout the data collection pro- developed and used to obtain study information. The cess. Research assistants who were first degree hold- structured questionnaire was based on previous similar ers employed at the Navrongo Health Research Centre studies [9–14]. The questionnaire was prepared first in (NHRC) double checked completed forms and notified English and translated by fluent speakers into the local the project coordinator for completeness or otherwise. languages during interview. The questionnaire was pre- Sampling strategy and frame (Fig. 2). In each study dis- tested and piloted before deplored. After piloting, all sug- trict, three subdistricts were randomly selected and the gested revisions were made before being administered in largest antenatal clinic in each subdistrict chosen for the the actual study. The study variables involved were soci- recruitment of participants. The total sample size for odemographic, reproductive history, obstetric factors, the district was shared among three subdistrict facilities questions on birth preparedness and complication readi- by proportionate to size using the previous two months ness. Data was collected through face-to-face interviews. average client flow. For each subdistrict half of the par- Data collectors were recruited and paid to implement the ticipants were recruited from the mothers attending study. Data collected were checked and reviewed on daily antenatal clinic and the other half from those attend- basis by supervisors before data entry. ing postnatal clinic. Again, for each clinic, half of the Data collectors were university graduates from each women were enrolled from those having their first preg- district who spoke their local languages and were super- nancy and the half from those having their second or vised by research supervisors who were senior health more pregnancy. For women who have just delivered in Fig. 2 Sample frame showing each stage of the study sampling process O duro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 5 of 12 the last six weeks, half were women who have just deliv- depict the data. Bivariate analyses using Chi square test ered their first baby and the other half were women who and logistic regression were undertaken to determine have delivered their second or more baby. For cost and association of effect of selected characteristics on birth other reasons an estimated 1200 women for the study preparedness. Those found significant (p-value ≤ 0.05) was determined and therefore 400 women per district. In were entered in the multivariable logistic regression anal- each district, 200 pregnant women and 200 women who ysis. The results are presented in frequency tables, odds have delivered in the last six weeks were interviewed. ratio and 95% confidence interval. P-value < 0.05) denote Participants were consecutively recruited. Figure 2 shows statistical significance. the stages of the study sampling process. Study results Sample size estimation Background characteristics The sample size was calculated using a formula for esti- A total of 1058 mothers consented and enrolled into the mation of single population proportion. An earlier study study. Approximately 33.6% were from the Ada west dis- reported a level of birth preparedness to be 17%. A trict, 33.4% from the Upper Denkyira west district and minimum sample size was obtained from each district 33.0% from the Builsa south district of Ghana. About using sample size calculation formula as shown below. 50.6% of the mothers were recruited in the antenatal clin- Thus n = Z2 (p*q)/e2 n = 1.962 (0.17*0.83)/0.052 where: ics and 49.4% in the postnatal clinics. The average mater- n = sample size, Z = percentile for 95% significance level nal age was 26.7 (Range; 14–49) years. The average age for normal distribution (1.96) P = Prevalence of birth pre- in years for Ada west was 26.9 (95% CI 26,4, 27.2), Upper paredness (17% = 0.17) p = 1-P e = margin of allowable Denkyira west was 26.9 (95% CI 26.6, 27.1) and Builsa error (0.05). With an alpha of 0.05 and a statistical power south was 26.6 (95% CI 26.2, 29.9). The average age was of 80%, 217 clients were targeted as minimum sample 27.2 (95%CI 26.7, 27.5) and 26.4 (95%CI 26.0, 26.7) years size  per group. This sample size was adjusted to 250 to for the antennal and postnatal mothers respectively. In all compensate for contingencies such as non-response, 10.8% of the mothers were under 20 years, 64.6% between recording errors and to allow for generalization of results. 20 to 30 years and 24.6 above thirty years. The proportion of mothers under 20 years was lowest in Upper Denkyira Quality assurance west 2.9% (95%CI 1.3, 5.1) compared to 13.3% (95%CI Training was given to the supervisors, research assistants 9.9,17.2) in Ada west and 16.4% (95% CI 12.7, 20.8) in and data collectors at the districts on how to administer Builsa south (Table 1). Some background characteristics the questionnaire and translate technical terms into local showed some differences among the three study sites. language for the understanding of participants. Data col- About 24.3% of the participants had no formal educa- lectors were taught on how to ensure that the dignity and tion, 62.1% had basic education and 13.6% had second- rights of participants were respected and on how to seek ary education and above. Approximately 77.5% of the consent from all participants before questionnaires were participants were married, 12.7% were single and 9.8% administered. They ensured completeness and consist- either divorced, separated or widowed. Single mother- ency of information during data collection. The question- hood was least among the Builsa south participants 1.7% naire was pretested in one clinic and the study piloted (95% CI 0.6, 3.7) compared to 9.9% (95%CI 7.0, 13.5) in before the main activities were made to commence. This Upper Denkyira west and 26.2% (95%CI (21.6, 31.0) in ensured that all misunderstandings, ambiguities and Ada west districts. On employment status, about 30.8% inconsistencies were corrected. The research supervisor of the women indicated they were unemployed, about checked filled questionnaires from each data collector 62% reported self-employment and only 7.2% had formal and meetings held during the data collection process for employment. Participants from the Builsa district had improvement. the highest unemployment rate 49.6% (95%CI 44.2, 54.9) compared to those from Upper Denkyira west 14.8% Data management and analysis (95% CI 11.2,18.9) and Ada west 28.3% (95%CI 23.6, The collected data was reviewed, coded and double 33.2). Majority of the participants were Christians 88.8% entered. Data obtained was initially entered into Epi- and Moslems were 8.1% and other faiths accounted for data, verified and cleaned. This was then exported into 3.1%. STATA for analysis. All data where necessary were coded In terms of pregnancy, 20.6% of the women were grav- using numeric values. For continuous variables, summary ida one, 19.2% were gravida two and 60.2% reported had tables of means, standard deviations and ranges are pre- gravida three or more. For women who had more than sented. For categorical data, summary tables, proportions two pregnancies, those from Upper Denkyira west dis- and percentage are presented. Bar chart was also used to trict had the highest 85.6% (95%CI 81.4, 89.0) compared Oduro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 6 of 12 Table 1 Socio‑demographic characteristics of the study participants by district Characteristics Categories Study District, n (%) Ada West Denkyira West Builsa South Total Maternal Status Prenatal 185 (52.0) 176 (49.9) 174 (49.9) 535 (50.6) Postnatal 171 (48.0) 177 (50.1) 175 (50.1) 523 (49.4) Maternal Age < 20 47 (13.3) 10 (2.9) 57 (16.5) 114 (10.9) 20–30 215 (60.7) 266 (76.0) 197 (56.9) 678 (64.6) > 30 92 (26.0) 74 (21.1) 92 (26.6) 258 (24.6) Education Level None 78 (22.0) 71 (20.2) 106 (30.7) 255(24.3) Primary 223 (62.8) 229 (65.3) 201 (58.3) 653 (62.1) Secondary 54 (15.2) 51 (14.5) 38 (11.0) 143 (13.6) Marital status Single 93 (26.2) 35 (9.9) 6 (1.7) 134 (12.7) Married 248 (69.9) 230 (65.4) 34 0 (97.7) 818 (77.5) Others 14 (3.9) 87 (24.7) 2 (0.6) 103 (9.8) Employment status None 100 (28.3) 52 (14.8) 173 (49.6) 325 (30.8) Employed 39 (11.0) 21 (6.0) 16 (4.6) 76 (7.2) Self employed 215 (60.7) 278 (79.2) 160 (45.8) 653 (62.0) Religious affiliations Christianity 328(94.0) 298(85.9) 299(86.4) 925 (88.8) Islam 15(4.3) 40(11.5) 29(8.4) 84 (8.1) Others 6(1.7) 9(2.6) 18(5.2) 33 (3.2) Number of previous Pregnancies One 97(27.5) 14(3.9) 106(30.4) 217 (20.6) Two 89(25.2) 37(10.5) 77(22.0) 203 (19.2) > two 167(47.3) 302(85.6) 166(47.6) 635 (60.2) ANC attendance Once 33(9.3) 3(0.9) 2(0.7) 38 (3.6) Twice 45(12.6) 13(3.7) 18(5.2) 76 (7.2) Three times 63(17.7) 22(6.2) 34(9.7) 119 (11.2) Four times 77(21.6) 72(20.4) 55(15.7) 204 (19.3) Four + 138(38.8) 243(68.8) 240(68.7) 621 (58.7) to those in Ada west 47.3% (95%CI 42.0, 52.9) and Builsa On the question of making provision for transport dur- south 47.6% (95%CI 42.2, 52,6). In all about 41.3% had ing the day of labour, 61.0% answered in affirmation; a four or less contacts and 58.7% had more than four ante- relatively higher percentage in the Builsa 83.6% (95%CI natal contacts (Table 1). 79.0,87.1) and in Ada 68.6% (95%CI 63.5,73.4) compared to Denkyira 30.9% (95%CI 26.0, 35.0). Similar estimate (59.0%) was found for night transportation (Table  2). Knowledge of birth preparedness About 75% of the women reported saving money for hos- Table  2 presents participants responses in relation to pital expenses during their pregnancy. More in women in their birth preparedness by district. Overall, 94% indi- the Builsa area (80.8%) compared to those in the Upper cated having heard about birth preparedness before; Denkyira west (70.7%) and Ada west (73.3%). Builsa south district had 99.4%; Ada west 89.9% and Overall fewer women (12.8%) made provision for refer- Upper Denkyira west 92.6%. In all only about 39% of ral to another hospital should it arises. This ranged from respondents were aware of their expected date of deliv- 21.9% (95%CI 17.6,26.6) in Ada west to 4.0% (95%CI ery. This varied from Upper Denkyira west (56%) and 2.2, 6.6) in the Builsa south district and 12.5% (95% CI Ada west (52.3%) compared to the 9% (95%CI 6.3,12.8) in 9.2,16.4 in the Upper Denkyira west. Overall, 60.8% of Builsa south. the women reported that they lacked financial support A total of 68.5% (721) of respondent were aware that during their pregnancy. This ranged from Builsa south labor may start before due date. Only 40.5% (95%CI 35.3, district (95%) and Upper Denkyira west (67%) compared 45.9) respondent in the Builsa area knew their labour to 20% in the Ada west (Table  2). Approximately 98.7% may start before the due date compared to 93% (95%CI of the women indicated they have registered with the 89.7,95.4) in the Denkyira and 72% (66.6, 76.2) in Ada national health insurance scheme and 85.1% had renewed districts. their insurance at the time of the study with those Builsa O duro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 7 of 12 Table 2 Participants responses to their birth preparedness across the three districts Questions to participants on birth preparedness % (95% CI) Ada West Denkyira West Builsa South Total Heard about birth preparedness before 89.9 (86.3, 92.8) 92.6 (89.4, 95.1) 99.4 (97.9, 99.9) 94.0 (92.3,95.3) Know the expected date of delivery 52.3(46.9, 57.5) 56.0 (50.6, 61.2) 9.2(6.3,12.8) 39.3(36.3,42.4) Aware labor may start before the due date 71.6(66.6,76.2) 92.9(89.7, 95.4) 40.5(35.3, 45.9) 68.5(65.5,71.3) Made provision during day of labor for transport 68.6(63.5, 73.4) 30.9(26.0, 36.0) 83.6(79.0, 87.1) 61.0(57.9,63.9) Made provision for transport for night labor 66.0(60.7, 71.0) 27.9(23.3,32.9) 83.4(79.0, 87.1) 59.0(55.9, 62.0) Had saved money for hospital expenses 73.3(68.3, 77.8) 70.8(65.6,75.5) 80.8(76.2, 84.8) 75.0(72.2, 77.5) Made provision for referral to another hospital 21.9(17.6, 26.6) 12.5(9.2,16.4) 4.0(2.2, 6.6) 12.8(10.8, 15.0) Indicated she lacked financial support 20.3(16.2,24.9) 67.1(62.0,72.0) 95.4(92.7, 97.4) 60.8 (57.7, 63.7) Have national health insurance 98.0(93.4, 97.8) 100.0 (0, 0) 100.0 (0, 0) 98.7(97.7,99.3) Health insurance renewed for the year 87.8(83.9, 91.0) 97.5(95.2, 98.8) 69.9(64.8, 74.7) 85.1(82.8, 87.2) Identified a place of delivery 90.1(86.4, 93.0) 89.0(86.1, 93.0) 99.7(98.4, 100) 93.2(91.4,95.6) Identified birth companion during delivery 94.4(91.4, 96.5) 94.3(91.3, 96.5) 98.9(97.0, 99.7) 95.8(94.4,97.0) Have identified a possible blood donor 35.1(30.1, 40.4) 10.7(7.6,14.4) 91.1(87.6,93.9) 45.6(42.5,48.7) south (70%) less likely to renew their insurance compared 30 years (21.2%) and those above 30 years of age (23.6%), to those from Ada west (88%) and Upper Denkyira west Table  3. From the results of the study, the higher the (97%). maternal level of education the lower the proportion of From the results 93.2% of the women had identified a poor preparedness. Mothers who had not been to school place of delivery while 95.8% had identified a companion had 29.4% poor preparedness compared to those with to the hospital during labour. On whether they had iden- basic education (21.6%) and secondary or more educa- tified blood donor in the event blood is needed a total tion (16.1%) p-value < 0.005). Further, single mothers of 45.6% indicated in affirmation and this varied widely (37.3%) were less prepared for birth compared to mar- from 91.1% from the Builsa south district to 35.1% in the ried mothers (17.7%) and this was very statistically sig- Ada west district and the Upper Denkyira west district nificant (p < 0.001). The employment status of the women recording a very low (10.7%) Table 2. interviewed influenced their level of poor prepared- ness. Whereas 10.5% of the mothers who had formal Determinants of birth preparedness employment had poor birth preparedness, those with no Using the thirteen questions for the study questionnaire employment and self-employment had 21.5% and 24.5% (Table 2), we estimated the proportion of the participants poor preparedness respectively Table 3. who had less than average (poor) birth preparedness. Overall, the results indicate that the number pregnan- This applied to all the participants who had less than cies a woman has had and her religious affiliations did average score among the study participants. In all 22.6% not determine her level of poor preparedness Table  3. (239/1058) of the women deemed to have poor birth pre- Though Christian mothers (22.2%) had the lowest poor paredness compared with 77.4% (819/1058) deemed to preparedness compared to Moslem mothers (26.2%) have good preparedness to. Among those with poor pre- and other Faiths (24.2%), this did not reach statistical paredness, the Builsa south district had the lowest value significance. Surprisingly mothers who reported more 8.0% (95%CI 4.8, 12.1) and this was significantly lower than two previous pregnancies (24.4%) were the highest than Ada west 27.8% and Upper Denkyira west 31.7% unprepared compared to those with two (20.7%) and one Fig. 3. (19.4%) pregnancy respectively, Table 3. There was no statistical significance (p-value > 0.05) The results showed a negative correlation between the between the poor birth preparedness of mothers attend- number of antennal contacts and the level of birth unpre- ing prenatal clinics (21.9%) and mothers attending post- paredness of the women Fig. 4. natal clinics (23.3%). Using logistic regression and adjusting for the back- Maternal age was not associated with poor prepared- ground characteristics, the area of study (P < 0.001), ness (p-value = 0.3). However, mothers below twenty educational level (P < 0.016), marital status (p < 0.00) and years had the highest poor preparedness (27.2%), this antenatal attendance (< 0.001) were the factors associated was not statistically different from those between 20 to with birth preparedness (Table 4). Oduro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 8 of 12 Fig. 3 Proportion of women with poor birth preparedness in the three study districts Discussion danger signs and adverse birth outcomes. Such educated As a component of focused antenatal care, birth pre- women are more inclined to utilize essential health ser- paredness is an important safe motherhood strategy vices, access skilled delivery attendance and prepare well intended to help women and families plan for safe preg- to avert delays during labour [19–22]. In a study among nancy and childbirth to help reduce maternal and neo- expectant mothers in northern Ghana, it was observed natal mortality. This study determined the level of birth that as the educational level of these mothers increased, preparedness in three disadvantaged rural districts of there was a corresponding increase in the level of birth Ghana and examined the associated factors. The results preparedness, with women having at least primary edu- showed that fewer women were unprepared for delivery. cation twice more likely to deliver at facility compared to Only one out of every four mothers had less than average their counterparts with no formal education [12]. Fur- preparation, of which four factors; area of study, educa- thermore, as women climbs up the educational ladder, tional level, marital status and the frequency of antenatal they are likely to become financially more empowered contacts were found to be significantly associated with with much disposable income that enables them to either them. own their personal means of transport or make arrange- ment in order to access skill delivery at farther distances from their place of residence [19–22] [24]. Other studies Educational attainment have also found the lack of association of maternal level The results show that level of maternal educational of education as these women may have ignored their own attainment was significantly associated with birth pre- knowledge of reproductive health and relied mainly on paredness. Women with primary or secondary educa- the advice of their partners in decision making, a practice tion were twice likely to be prepared for their delivery very common in patriarchal African society, [13, 19–22]. compared to those without education. However, there was no significant difference between those with pri- Antenatal contacts mary and secondary education. The positive relationship The study showed a significant positive correlation between maternal education and birth preparedness in between the number of antennal contacts a woman has this study is consistent with others documented in Ghana during her pregnancy and the level of birth prepared- and in other sub-Saharan countries [19–22]. This positive ness. Antenatal contact is a preventive health care that effect may be explained by the fact that women who have provides women the opportunity for early facility-based higher education are more knowledgeable about obstetric assessment. Its importance is dependent on the adequacy O duro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 9 of 12 Table 3 Level of birth preparedness and complication readiness by baseline characteristics Characteristics Categories Frequency Poor Preparedness Statistics n (N) % (95CI) p-value Districts Ada west 99 (356) 27.8 (22.0, 33.8) < 0.001* Denkyira west 112 (353) 31.7 (25.9, 38.1) Builsa South 28 (349) 8.0 (4.8, 12.1) Maternal Status Prenatal 117 (535) 21.9 (16.7, 27.5) 0.571 Postnatal 122 (523) 23.3 (18.2, 29.3) Maternal Age < 20 31 (114) 27.2 (21.5, 33.3) 0.324 20–30 144 (678) 21.2 (16.1, 27.0) > 30 61 (258) 23.6 (18.4, 29.7) Education Level None 75 (255) 29.4 (23.5. 35.5) 0.005* Primary 141 (653) 21.6 (16.7, 27.5) Secondary + 23(143) 16.1 (11.5, 21.2) Marital status Single 50 (134) 37.3 (31.2, 43.9) < 0.001* Married 146 (818) 17.9 (13.0, 23.1) Others 42 (103) 40.8 (34.4, 47.3) Employment status None 70 (325) 21.5 (16.3, 27.2) 0.019* Employed 8 (76) 10.5 (6.9, 15.1) Self employed 160 (653) 24.5 (19.0, 30.3) Religious affiliations Christianity 205 (925) 22.2 (16.9, 28.0) 0.680 Islam 22 (84) 26.2 (20.8, 32.5) Others 8 (33) 24.2 (18.9, 30.3) Pregnancies One 42 (217) 19.4 (14.4, 24.8) 0.233 Two 42 (203) 20.7 (15.5, 26.2) > two 155 (635) 24.4 (18.9, 30.2) ANC attendance Once 25 (38) 65.8 (59.3, 71.7) < 0.001* Twice 31 (76) 40.8 (34.3, 47.1) Thrice 32 (119) 26.9 (21.2, 32.9) Four times 56 (204) 27.5 (22.0 33.8) Four + 95 (621) 15.3 (11.1 20.7) Fig. 4 Relationship between antenatal clinic contacts and poor birth preparedness Oduro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 10 of 12 Table 4 Determinants of birth preparedness in three rural women who attend ANC early while other evidence districts of Ghana suggest women who initiate ANC at late gestational age Factors Unadjusted Adjusted are more likely to be birthprepared. On the frequency of ANC visits, four or more visits have reportedly been OR (95% CI) p-value OR (95% CI) p-value linked with increased awareness of danger signs. Recent Districts evidence from WHO recommend frequent antenatal Ada west 1 < 0.001 1 < 0.001 contacts of eight or more is associated with a reduced Denkyira west 1.20(0.87 1.65) 1.80(1.15 2.82) likelihood of adverse birth outcomes due to increased Builsa south 0.23(0.14 0.36) 0.33(0.20 0.57) opportunities to detect and manage potential complica- Maternal Age tions [2, 12, 19–22]. < 20 1 1 20–30 0.72(0.46 1.13) 0.326 0.55(0.28 1.07) 0.080 Marital status > 30 0.83(0.50 1.37) 0.74(0.34 1.63) Married women and those with other status were found Education Level to be significantly associated birth preparedness. This None 1 1 significant determinant of birth preparedness in this Primary 0.66(0.47 0.92) 0.005 0.57(0.38 0.84) 0.016 study is similar to findings from studies elsewhere [19– Secondary 0.46(0.27 0.77) 0.54(0.29 1.02) 22]. This finding has been explained to be attributable to Marital status the social and economic support that married women Single 1 1 enjoyed. Sometimes pregnancies outside of a union of Married 0.37(0.25 0.54) < 0.001 0.63(0.38 1.05) 0.001 marriage is culturally frown upon in our setting and Others 1.16(0.68 1.96) 1.56(0.83 2.95) as such unmarried women tend to shy away from pub- Employment status lic view and less amenable to discuss issues of maternal None 1 1 health [19–22]. Moreover, married women are likely to Employed 0.43(0.20 0.93) 0.024 0.41(0.16 1.04) 0.162 be better placed financially to pay for the cost of facility Self employed 1.18(0.86 1.63) 0.92(0.59 1.43) delivery even at distant places and therefore likely to seek Religious affiliations skill delivery and also likely to enjoy spousal and related Christianity 1 1 support [19–22]. Islam 1.25(0.75 2.07) 0.6808 1.19(0.67 2.11) 0.836 Others 1.12(0.78 0.50) 1.09(0.41 2.92) Study area Pregnancies On the association of area of study to birth prepared- One 1 1 ness among women, of the three areas of the study, par- Two 1.08(0.67 1.75) 0.234 1.17(0.62 2.21) 0.8393 ticipating women from the Builsa south district were the > two 1.35(0.92 1.97) 1.20(0.64 2.27) most prepared for birth. Several findings from the study ANC attendance might have accounted for this outcome. The proportion Once 1 1 of mothers under 20  years of age was highest in Builsa Twice 0.36(0.16 0.81) < 0.001 0.33(0.13 0.82) < 0.001 South district compared to the other two districts whilst Three times 0.19(0.09 0.42) 0.18(0.08 0.44) single motherhood was least among the Builsa south par- Four times 0.20(0.09 0.41) 0.17(0.07 0.39) ticipants even though about half of the participants from Five + 0.09(0.05 0.19) 0.09(0.04 0.20) the Builsa district were unemployed compared to the other participants. This could have contributed for this finding. Our findings already showed that mothers with of the content, timing, frequency and quality of health fewer pregnancy who are likely to be young have higher education during ANC sessions. Our result is consist- preparedness. And also, being likely to be married means ent with an earlier finding in Ghana and thus affirms the that they also enjoy spousal support. While this finding importance of ANC as a predictor of birth preparedness, was to do with study area other studies have however in Ghana [14]. This thus underscores the need for contin- found important association between birth preparedness uous adherence to antenatal care protocols in Ghana and and area of residence. Women who reside in urban areas elsewhere to ensure that women are adequately educated have been documented to be more prepared for birth for a positive pregnancy experience. There is variability than those in rural areas. The availability and proximity of evidence on the effectiveness of timing of ANC visits to health facility affect utilization of health care includ- on birth preparedness [2, 12, 19–22]. Some studies sug- ing maternal health services. It is expected that pregnant gest increased likelihood of birth preparedness among women are more likely to access antenatal services and improve on their knowledge of birth preparedness when O duro et al. BMC Pregnancy and Childbirth (2023) 23:728 Page 11 of 12 they are at close proximity to a health facility and staff Consent for publication [19–22]. No applicable. Limitations of the study; this study is limited to only Competing interests three rural districts in Ghana and looks only at areas The authors declare no competing interests. without district hospital which may limit its representa- Author details tiveness. 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