The maternal mortality ratio (MMR) is one of the indicators of the public health status of a specific region. Several global authorities devised a long-term plan to reduce global MMR. In 2000, the United Nations (UN) declared the Millennium Development Goals, which included “improving maternal health,” as Millennium Development Goal 5 (MDG-5). The MDG-5 aimed for a 75% reduction in the global MMR. ¹ In 2015, the United Nations Department of Economic and Social Affairs (UNDESA) and all member countries agreed to aim to accomplish the Sustainable Development Goals (SDG) by 2030. The target of SDG Goal 3 is to “ensure healthy lives and promote well-being for all at all ages.” This goal includes “reducing the global MMR to less than 70 per 100,000 births, with no country having a maternal mortality rate of more than twice the global average.” ² Having these goals consistently included in international plans implicitly reflects the global significance of this unresolved situation.

Globally, the MMR is decreasing. ³ The index differs among countries, ranging from 4 deaths per 100,000 live births in the Australia and New Zealand to 442 deaths per 100,000 births in Africa. ^{4 , 5} Thailand’s maternal mortality rate (MMR) was 48.0 deaths per 100,000 live births in 2008. ⁶ It fell to 37.0 deaths per 100,000 live births in 2017. ⁷ Though the low baseline ratio met SDG Goal 3, achieving “equity in MMR for vulnerable populations at the sub-national level” is still the country’s target. ⁸

To decrease preventable maternal mortality, providing health education to all parties involved in healthcare, including patients, families, communities, and medical personnel, is mandatory. Good knowledge will lead to appropriate attitudes and practices, i.e., prompt referral to proper medical services, thus decreasing preventable maternal mortality. Unawareness of obstetric danger signs (ODS) will delay the decision to seek proper care and eventually lead to morbidity and mortality. ⁹

The knowledge of ODS varies among countries and regions. The prevalence of mothers with good knowledge of ODS seems to be lower in some countries or in some rural areas with a higher MMR. ^{10 – 25} Several studies on ODS knowledge have been conducted in developing countries, ^{10 – 30} focusing on urban and rural areas. Most studies found that less than half of the study population had good knowledge of ODS. ^{10 – 12 , 14 , 17 , 18 , 21 , 27 , 29 – 32} In addition, the prevalence of good knowledge or awareness of ODS in rural areas was lower than in urban areas. One study was conducted to examine the prevalence of mothers with good knowledge of ODS and associated factors in a tertiary care university hospital in the capital city of Thailand and found that the prevalence of mothers with good knowledge was around 60%. ³³ Currently, no data is available regarding the prevalence of mothers with good knowledge of ODS and associated factors in rural areas of Thailand, which are the subnational regions at risk for higher MMR. Thus, our study aimed to identify the prevalence of mothers with good knowledge of ODS and associated factors among pregnant women attending an antenatal care clinic at a community hospital in a Northeastern province of Thailand. In addition, we also aimed to identify the variables that could predict the ODS knowledge of pregnant women.

There were 415 eligible pregnant women at the end of the enrolment. Of all these participants, 275 (66.27%) had good knowledge of ODS, 101 (24.34%) had fair knowledge, and 39 (9.40%) had poor knowledge. The most recognized ODS was vaginal bleeding, which accounted for 92.29% of the reported ODS during pregnancy and 80.96% of the reported ODS during labor and delivery. The least recognized ODS during pregnancy was convulsion (68.19%), while the least recognized ODS during labor and delivery was retained placenta (63.61%). The detailed results of the knowledge of ODS among antenatal women are shown in Table 1.

We classified those who knew at least 12 items out of 16 items (75%) as having a good level of ODS knowledge, 6–11 items (50–74%), and 0–5 items (0–49%) as having a fair level and a poor level of ODS knowledge, respectively. Using the Chi-square test, the identified factors that were significantly between the good and the fair/poor knowledge groups included participants’ age, education, occupation, marital status, gravida, and source of the ODS knowledge. After using the multivariate regression analysis to identify which of these characteristics were statistically significant predictors of good ODS knowledge, we found that participants’ age, education, and source of the ODS knowledge were predictors of good ODS knowledge, whereas participants’ occupation, marital status, and gravida were not statistically significant predictors of good ODS knowledge. The detailed results of the demographic characteristics of participants and their association with the level of ODS knowledge are shown in Table 2.

In a community hospital-based antenatal care service in a Northeastern province of Thailand, we found that about two-thirds of the pregnant women had good knowledge regarding ODS. We also found that the factors associated with good ODS knowledge included age, education level, and source of the ODS knowledge that the pregnant women acquired.

The prevalence of good ODS knowledge in our study is higher than in previous studies. One study in a Thai university hospital in an urban area reported a prevalence of 59.8% ³³ and another study in a teaching and referral hospital in Malaysia reported a prevalence of 48.3%. ³¹ The finding that the prevalence of good ODS knowledge in Thai pregnant women was slightly higher than that of the Malaysian study might be due to the different score cut-off levels of good knowledge of ODS, that is, 80% (16 out of 20 items) in the Malaysian study whereas 75% (12 out of 16 items) in our study and the other Thai study. Several studies reported the knowledge of ODS among pregnant women in many countries, including India, ^{34 , 35} Nepal, ^{26 , 27} Malaysia, ³¹ Ethiopia, ^{10 – 22} Nigeria, ²³ Tanzania, ²⁸ Egypt, ²⁹ Jordan, ³⁰ Congo, ³⁶ and Uganda. ³⁷ The prevalence of mothers with good knowledge of ODS differed among studies could be because of the difference in participants’ demographic characteristics and the definition of good knowledge of ODS in each study. Overall, the prevalence of mothers with good knowledge of ODS was the lowest in Africa, ^{10 – 25} especially in the remote area where most participants received lower education.

For the knowledge of each ODS among the study population, we found that vaginal bleeding is the most mentioned ODS during pregnancy and during labor/delivery among participants. Less than 70% of the participants reported epigastric pain, blurred vision, and convulsion during pregnancy as an ODS. A similar proportion mentioned convulsion and retained placenta during labor/delivery as ODS. These findings were congruent with the previous study in Thailand. ³³ Since vaginal bleeding is a visible, genital organ–related sign, it is easily recognized as an ODS among pregnant women. In contrast, since epigastric pain, blurred vision, and convulsion are symptoms of other organ systems, it was more complicated to educate pregnant women that these symptoms must also be perceived as ODS.

For the study’s secondary objective, the predictive factors of good knowledge of ODS, we found that higher maternal education of at least a Bachelor’s degree, compared to high school or lower education, is one of the significant predictors. This finding is similar to the study from the Thai university hospital. ³³ Studies in other Asian countries, including Malaysia ³¹ and Jordan, ³⁰ also found that higher maternal education was a significant predictive factor of good knowledge of ODS. Several studies from the African region, ^{23 , 32} especially Ethiopia, ^{14 , 15 , 18 – 20 , 22 , 38} where women received lower education, emphasized the predictive value of women’s education on the level of ODS knowledge. The level of education could be the source of the quality of ODS knowledge. Women with a lower education level could have more difficulty in understanding healthcare information about the importance of ODS given by others. The lower level of education might reflect lower opportunities for women since they might share poor attitudes and misinformation with peers at the same level of education. A study in Africa reported that ODS was perceived as a natural process of pregnancy or related to witchcraft. ³⁹ This attitude was a significant barrier, preventing the women facing ODS from seeking proper help.

Maternal age was another predictive factor of the better knowledge of ODS in our study. Age was a good predictive factor in studies from Malaysia, ³¹ Ethiopia, ^{14 , 15 , 18 , 21 , 22 , 38} Tanzania, ²⁸ Nigeria, ²³ South Africa, ²⁴ and Zambia. ³² Women with more advanced ages had better knowledge of ODS. This may be attributed to several hypotheses. Having better ODS knowledge is an essential indicator of pregnancy preparedness. Teenage pregnancy is more unprepared than pregnancy in adulthood. ⁴⁰ Being an adult also means having more mature neurological development, awareness, and experience than being a teenager. Having more experience in older pregnant women leads to gaining both personal experience and information from the experience of other people during their pregnancies. This hypothesis could explain our finding that women with multigravida tended to have better ODS knowledge than those with primigravida. Also, higher gravidity was reported a significant predictor in some previous studies. ^{21 , 36}

Our study also found that pregnant women who had medical personnel as a source of ODS knowledge tended to have better ODS knowledge than those who obtained information from women’s friends or other media. Medical personnel are a good source of information for expecting mothers. A lower gestational age could partially reflect this at the first antenatal care (ANC) visit and the higher number of ANC visits since these women had more time spent in the clinic, and thus had more opportunities to obtain important information from medical personnel. Although our study cannot demonstrate that these two variables were predictors of better ODS knowledge, many other studies showed the association, e.g., studies in Thailand, ³³ Congo, ³⁶ Saudi Arabia, ⁴¹ and Ethiopia. ^{10 – 14 , 17 , 38}

The strengths of our study include a large sample size and only one well-trained research assistant collecting the data to minimize the inter-observer variation. Furthermore, data collection setting and process were similar for all participants. They were considerably optimal since it took place in a private room during the waiting time in the antenatal care clinic. In addition, our study design was similar to other studies in the same region, allowing data comparison between countries with similar contexts.

Nevertheless, our study has some limitations. The study was cross-sectional, so we cannot establish a causal relationship between variables. We did not evaluate some variables, i.e., the number of family members and the region of residence, reported as significant predictors in previous studies. ^{12 , 29} Some variables might also affect the knowledge, such as the interval between pregnancy, birth preparedness, accessibility to healthcare services, and medical expense subsidies. Further study focusing on the relationship between a pregnant woman’s knowledge and her intimate partner’s knowledge should be conducted.

Our study demonstrates the fair prevalence of mothers with good knowledge of ODS in Thailand’s rural areas. We found that participants’ age of at least 20 years, higher education, and reporting medical personnel as the source of ODS knowledge were predictors of good ODS knowledge. Identifying those at risk for fair and poor ODS knowledge and prompt management for the vulnerable subgroups might help decrease maternal mortality in this region. Further research and educational programs are needed to raise the knowledge of ODS, aiming to reduce maternal mortality.