Introduction

Maternal Mortality Rate (MMR) is one indicator of women's health of Goals 3 Sustainable Development Goals [1, 2]. It is estimated that low- and middle-income countries contributed to the 56% - 99% of total global MMR (Mother Mortality Rate) [3, 4]. In order to design an effective intervention for to reduce MMR in developing country, obstetric danger sign awareness level is a necessary factor to address [5]. Mother's awareness of obstetric danger signs in developing country is relatively low regardless many local and national program attempt [1, 6,7,8]. It is crucial to increase pregnant women knowledge of obstetric danger signs through education and awareness-raising efforts [9,10,11,12]. Inseparable with efforts to increase knowledge, it is necessary to understand how different community utilize the of health care facility according to the awareness level [4]. Low ANC visit in the health care facility affected the level of awareness to obstetric danger sign which then add the number of MMR [1, 13,14,15].

Mother's awareness of obstetric danger signs is integral of knowledge, which refers to the extent a pregnant woman is able to utilize her knowledge of the signs and symptoms of potential complications during pregnancy, childbirth, and the postpartum period [4, 5, 16, 17]. With this information, she is better equipped to anticipate possible issues and seek timely medical attention, which can reduce the risk of maternal and neonatal morbidity and mortality 14,18. Recent studies highlight the importance of maternal awareness of obstetric danger signs in which the more aware women act differently to unaware women. Aware woman in Nigeria were more likely to seek skilled birth attendance [18]. Similarly, aware woman in Cameroon would more likely to seek antenatal care, give birth in a health facility, and had better maternal health outcomes [19]. Another study in Ethiopia found that these women were keen to seek postnatal care within the recommendation time [4, 7, 8, 19,20,21,22,23].

Mother and family should immediately seek medical help if the obstetric danger sign is present [21, 24, 25]. There is significant variation in the statistics of mother seeking help for obstetric danger signs by utilizing ANC visit (Antenatal Care) a minimum of four visit during the pregnancy period [1]. Some developing countries reported as follows: Indian women were 72% [5], Tanzanian women were 64.7% [3], Indonesian women were 96,9% [1], Ethiopian ranged from around 29.1% [4] to around 39.08% [26]. This variation of statistics highlights the need to improve maternal education effectiveness and healthcare access in developing countries [5]. Because women who aware about the obstetric danger sign are 3,47 times more likely to utilize the ANC care and reduce maternal and neonatal mortality rates [17].

The lack of knowledge about sign and symptoms leads to low awareness, then mismanagement of the complications in pregnancy, childbirth, postpartum [24]. Additionally, some mother in developing country reports the needs to consult with family to access the health care facility. Coupled with the lack of drugs and equipment, the unavailability, and the long queue of health service [27]. The combination of lack of quality, resources and access to health services coupled with mother’s low awareness and family factors become the barrier for maternal wellbeing [28, 29]. The purpose of this study was to collect current empirical studies to describe the pregnant women awareness about the obstetric danger sign in developing country.

Method

This review employed the PRISMA-ScR checklist. This review sought to answer these questions:

  1. 1)

    What is the current empirical data of pregnant mother awareness about the obstetric danger sign in developing country?

  2. 2)

    What are the determinant of awareness?

  3. 3)

    What is the effective strategy to improve awareness for developing country?

This review designed to pool all relevant literature which emphasizes the topic of woman knowledge of pregnancy danger sign. Broad keywords used to find as many relevant results as possible.

The research explored must contain the following inclusion criteria: a) research involving pregnant women of all ages and parity, b) conducted in developing countries, c) quantitative research methods, d) cross sectional research design, and e) employed more than 100 respondents.

The found research was directly excluded if a) Published 2017 - 2022, b) research in languages other than English and Bahasa, c) research that discusses these factors but from the results of the intervention, d) community service reports that provide treatment for the factors, and e) research conducted in the developed country (based on the World Bank Country and Lending Groups).

Electronic databases used were Scopus, Science Direct, CINAHL, and Google Scholar. Articles known by the researcher and not collected during the search process on the database added manually. The article search conducted in June 2022. The search term based on the PICO framework which is Patient: (Mother OR Woman), Interest: (Knowledge) AND (Awareness), AND (danger signs of pregnancy OR danger signs during pregnancy), there were no Comparison and Outcome necessary to highlighted. The details of search strategy shown in the (Table 1). To increase the search accuracy, the bibliography of related articles screened as well.

Table 1 PICO Systematic Review Keywords
Full size table

Three authors responsible to evaluate the pooled literature. First, they removed the duplicates, then continue to the screening phase. Second, they used the filter and exclusion criteria by reading the title and the abstract. Third, read all the full texts and apply the inclusion criteria. Lastly the articles that pass until this stage appraised critically using the CASP checklist [30]. The articles that judged to be of high quality included in the review for systematic qualitative analysis.

Data extraction included the design, sample, variable, instrument, analysis, and result. The narrative literature review built thematically. The most common theme that emerge in all articles collected and reported in a way that will rhyme with the topic and the review questions.

Result

Pooled articles and the characteristics

One thousand five hundred fifteen articles collected on the first literature search and 6 articles added from manual search. 220 articles removed due to duplication. 727 articles excluded according to the filters. 499 articles removed due to irrelevant title and abstract. Seventy-five full paper articles read and applied the eligibility criteria which resulted on 20 articles included in the review (Fig. 1 for PRISMA flow diagram). The references of all the included articles reviewed to find additional sources, yet the team found no eligible article.

Fig. 1
figure 1

PRISMA Diagram

Full size image

The overview of key characteristics found in the 20 included articles described in the Table 2. All studies conducted in the developing countries, mostly from Africa, namely Cameroon, Ethiopia, Madagascar, Nigeria, Republic of Congo, and, Tanzania, the rest was from Asia, which are Bhutan, India, Indonesia, and Papua New Guinea. All the study was a cross sectional study in which some of them was community based and the rest was clinic or hospital based. All the study were measuring the level of knowledge of mother about obstetric danger sign in which consist of pregnancy, childbirth, and postpartum danger sign. Only one study includes additional newborn danger sign [31].

Table 2 Overview of key characteristics of pooled articles
Full size table

The sum of respondents from all articles were around 13,443 women. The respondents characteristics were pregnant woman [4, 5, 13, 14, 18, 24, 25] mother delivered in the last 1 - 2 years [16, 32], recently delivered mother (<12 months) [1, 6,7,8, 19,20,21,22,23, 31], and one study did not clearly state the time period from the last labour [33]. Meanwhile, the place of respondents recruited were in the community or in health facilities. Some of the respondents in health facilities currently hospitalized after giving birth, some visited ANC and the last one was looking for immunizations for their children.

Operation definition of the knowledge level

Details of the level of knowledge report can be seen in the Table 3. Eight articles report the three knowledge levels of obstetric danger sign [4, 7, 18, 20, 22, 23, 25, 31, 32], while the rest reported two or had summarized the three categories. The method used to measure the level of knowledge was by ask the respondents to mention obstetric danger sign. If they can mention a certain number of danger sign above the benchmark, then those respondents rated as knowledgeable or have good knowledge. While the benchmark values used are slightly different. The majority of studies use the number of danger signs, namely ≥ 4 dangers [33], ≥ 3 obstetric danger signs [5, 16, 20, 22, 25, 32], ≥ 2 danger sign [4, 8, 18, 21, 23], dan ≥ 1 danger sign [31]. Three other studies used different measurement methods, two studies used the mean as the limit of assessment [1, 6, 7, 19], and two study used a percentage of more than 75% [14, 24].

Table 3 Operation definition of level of knowledge
Full size table

The mother level of awareness according to the knowledge level

Because the categories used by each study to describe the level of knowledge are different, the authors will report based on the operational definitions used. Studies using the understand 4 danger signs measure have a good knowledge level of 31% and the remaining 69% have low or no knowledge at all [33]. Next, using the 3 danger sign measure, the highest percentage of the good knowledge category is 71.4% regarding the danger sign during pregnancy [32] and the lowest is 22.1% [22] about the danger sign during postpartum. Additionally 100% knowledgeable found in the overall danger sign [5].

In this measurement category there are many reported knowledge level values, for more details see Table 4. The next measurement is 2 danger signs, the highest value is during childbirth at 45.5% while the lowest is 19.1% during postpartum [4]. The measurement of 1 danger signs tends to be high at 80.9% during pregnancy and the lowest is 50.8% during postpartum [31]. For other categories, the highest level of knowledgeable is around 50-60% [1, 7, 24]. The other one studies which did not mention the operational definition of level of knowledge are reported as it is [19].

Table 4 Mother level of knowledge of obstetric danger sign
Full size table

Most known obstetric danger sign

There were five danger signs of pregnancy that often occur, namely vaginal bleeding, swelling of the feet and hands, infection, premature rupture of membranes, and reduced fetal movement [1, 5,6,7,8, 13, 14, 16, 18,19,20,21,22,23,24,25, 31,32,33] (Fig. 2).

Fig. 2
figure 2

The chart of the most known obstetric danger sign

Full size image

Determinant of awareness

Factors related to the level of awareness of pregnant women about the danger signs of pregnancy (see Table 5), namely the first is Educational Status. Mothers with formal education have higher knowledge of the danger signs of pregnancy compared to illiterate mothers [24, 25, 31, 32]. This was in line with research conducted by Wassihun et al. [21] which said that respondents who have formal education are 6.01 times more likely to have good knowledge about the danger signs of pregnancy.

Table 5 Determinant of awareness
Full size table

The second is pregnant experience, the results of research conducted by Mwilike et al. [27, 33] showed that there was a strong relationship between pregnant experience and knowledge of the danger signs of pregnancy. This was because women who have more pregnant experience have often received information, thus increasing their knowledge.

The third is ANC visit, the number of ANC visit can significantly affect knowledge about the danger signs of pregnancy. Respondents who had antenatal care visits were 1.26 times more likely to have good knowledge of the danger signs of pregnancy [21, 31, 32]. This was in line with a study conducted by Vallely et al [16] which stated that women who received information during ANC visit were almost eight times more likely to know the danger signs of pregnancy compared to women who did not.

The last is place of delivery, mother who gave birth in health services were 5.7 times more likely to have knowledge of the danger signs of pregnancy than respondents who gave birth at home [21]. This was in line with research conducted by Belay & Limenih [32] stated that mothers who the latest child delivery was in a health care facility were more likely to know three or more obstetric danger signs.

Furthermore, awareness of the obstetric danger signs was an important alarm to receive appropriate and timely referrals for care during pregnancy, childbirth, and postpartum [22]. Most maternal deaths can be avoided, if the mother and family are aware of the obstetric danger signs. Dangura [23] stated that increasing maternal awareness about the danger signs of pregnancy can increase early detection of problems and reduce delays in deciding to seek care.

Discussion

The majority of studies do not report the awareness using direct measurement, but many studies that aim to examine awareness use knowledge as the criteria [1, 4, 7, 8, 14, 16,17,18,19,20,21,22,23,24,25, 31,32,33]. Surprisingly the pregnant women’s low awareness of obstetric danger sing in the developing country is partly incorrect. The studies in developing countries shown mother to have good level of awareness, proven by the ability to recall the knowledge of obstetric danger sign [1, 7, 19, 25, 31, 32].

Many developing countries have addressed the gap of low level of obstetric danger sign awareness by increase ANC facilities, and improve the quality, but the evidence about the adequate resources in the facility is a question that beyond the scope of this review. The problem that increased the MMR in developing countries is not lay in the process of ANC [34,35,36]. Somehow, this review found that the barriers for women to seek medical care promptly when the obstetric danger sign is present could be the culprit for the high number of MMR [4, 5, 14, 19, 21]. The barriers such as the family issue on taking action for the aware mother when the danger sign is appeared, practically the most neglected factors during the ANC visit [14, 37, 38]. The ANC visit focusing in the pregnancy health, improve the knowledge, and administer medicine or vitamin to improve the pregnancy health [31].

Surprisingly education and economic status does not play any major role in the mother awareness [8, 18]. Despite, some research state that the better the education and the economic status would make mother retain information better [5, 14, 16]. However, the case in obstetric danger sign awareness is different. It is not about the internal characteristics of the mother, but more of a social support and the health education that the mother may obtain during ANC visit [14, 37, 38]. Programs for pregnant and giving birth women including their services are provided free of charge by many developing countries from national or international support [1, 14, 18, 22].

The recommendation for clinical practice to improve mother awareness about the obstetric danger sign is to improve the effectiveness of the health education during the ANC [15, 19, 20, 31]. Mother who is more experienced in pregnancy have better knowledge about obstetric danger sign and the more she would visit the ANC [6, 19, 23]. There should be a clear strategy to transfer all the obstetric danger sign information, especially to the mother with high risk factors [1, 19, 20].

An MCH handbook (Maternal and Child Health) is a good media to for information transfer [1, 14]. This book is an integral of medical record. A medical record only available for the health care, yet the MCH handbook is available for both parties, mother and the health care. Even the family could have access to the book. This could inform what is found during the ANC to the family. This would improve the mother’s knowledge of danger sign, including the family [1, 14, 27]. Mother in developing country reported that awareness begins from their household. In the form of partner or family support of their pregnancy [17, 18, 39]. The MCH handbook would facilitate the information transfer to the family and especially the father, the head of the family, or the dominant elders. This can support the mother to seek medical care for dangerous signs and symptoms appear [1, 14, 27]. Furthermore, an application to support ANC such as the mhealth (mobile health) in Madagascar could be an alternative. So that information related to the health of pregnant women can be more extensive and increase the involvement of younger pregnant women [5, 31].

The ANC is the perfect place to deliver health education, but the efficiency of the ANC might be hindered by the barriers on mother seeking medical help [6, 7, 19, 20]. The assessment about the barrier of health seeking should be part of the ANC program. Mother needs to be encouraged to express the barrier of health seeking [19, 23]. The nurse or other health care staff should help the mother to find the solutions for particular barrier. Nurse care plan includes family intervention. Nurse need to treat the family problem related to the health seeking of pregnant mother [33, 40]. This review suggests developing country should start to include assessment of barrier of health seeking and use an MCH handbook into the ANC program.

Conclusion

The empirical data of pregnant mother awareness about the obstetric danger sign in developing country is low to medium. Only a handful of developing country have fair awareness, in which related to determinant of awareness. It is better educational status, more pregnant experience, more ANC visit, place of delivery in the health care facility. The recommended effective strategy to reinforce women awareness is by waive the barrier of health seeking, especially in the household level. The assessment of barrier of health seeking should be part of ANC program. The barrier of health seeking is unique in the developing country. Mostly it is related to the family support, i.e. the husband and the elderly. Additionally, use MCH handbook or mobile application to record the ANC visit is also beneficial to communicate with the family.