Knowledge of Obstetric Danger Signs and Associated Factors among Pregnant Women Attending Antenatal Care at Health Facilities, in Tenta Woreda, South Wollo, Ethiopia 2019, A Facility Based Cross Sectional Study

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Author(s): Mohammed Legas, Roza Teshome and Workinesh Sinashaw Ababe*

Introduction

Maternal mortality refers to deaths with related to complications in pregnancy or childbirth or the death of the mother with in fortytwo days of after delivery. Worldwide, the maternal mortalityratio (MMR) was an estimated of 216 maternal deaths per 100 000 live births in 2015. From those developing regions account for approximately 99% and sub-Saharan Africa alone accounting for 66%, followed by Southern Asia [1].

Even if high MMR is a one of the main concern of health problem of most country in the world, different project and strategies are approved that it is reducible ;even though still the reduction is not reached the excepted level of goal (70 /100 000 live births) [1,2]. Ethiopia is also one of the sub Saharan country which have 412 maternal mortality for every 100,000 live births in 2016 [3]. The Percentage of women aged 15-49 years that were attended at least.

Most of the cause of maternal deaths are preventable and the effect of three delays, from which the major one is delay in seeking care. poor knowledge about obstetric danger sign is a major contributor for this delaines. The percentage of women age 15- 49 years that were attended at least once ANC during pregnancy by skilled health personnel (doctor, nurse, or midwife) in sub Saharan countries were low, this may be related with inadequate knowledge [4].

Every pregnant woman faces the risk of sudden unpredictable complication that could end with death or injury to the mother or baby. Pregnancy related complications couldn’t be reliably predicted if the mother cannot know the risk sign of child birth related [5]. Thus informing women about obstetric danger sign is among the strategies to reduce maternal mortality due to pregnancy complication [6].

Obstetric danger sign (ODS) indicates that maternal health going to wrong in related to child birth; that lead to maternal mortality and morbidity. These danger signs are mainly classified as a major danger signs in the three respective child birthing period (prenatal, childbirth, postnatal). The major danger sign includes vaginal bleeding, swollen hands/face, and blurred vision in the prenatal period, severe vaginal bleeding, prolonged labor (>12 h), convulsions and retained placenta occurred during labor and severe vaginal bleeding, foul-smelling vaginal discharge, and fever are occurring in the postnatal period are expected. Studies in Ethiopia and Tanzania shows that knowledge of women about danger signs during pregnancy, labor and postpartum are low (21.9 and 17.1-25.2%) respectively [7-9]. According to study finding Abeshige only 37.2 % of the participant were knowledgeable on birth preparedness and complication readiness, this study shows that more than 60% of the participant were going to complication due to lake of knowledge on obstetric danger sign [10]. Inadequate knowledge about danger signs of pregnancy is one of the major contributing factors for maternal deaths [11]. Therefor the purpose of this study is to identify the level of knowledge of antenatal mothers and factors about of obstetric danger signs. Increasing maternal knowledge on obstetric danger sign is an important means to reduce maternal mortality and morbidity which enable the mother to seek care before the problem arise.

Conceptual Framework

Studies and reports in different parts of the world reviewed various factors associated with knowledge of obstetric danger signs. Accordingly, for this study the main factors identified are socio demographic factors like age, educational status, occupation and income. This conceptual framework was adapted by the author from the literature. Different literatures suggest that reproductive history could affect negatively and positively the KODS.

Figure 1: Conceptual framework on knowledge of obstetric danger sign and associated factors among pregnant mother

Methods and Materials
Study Design

Institutional based cross-sectional study was conducted

This study was conducted in tenta woreda, governmental health institution from April 20 to May 05, 2019 and the woreda is located Debub wollo zone amhara region of Ethiopia.. Its capital city is Adjibar which is located 524 km north of Addis Ababa, 601 km from Bahirdar, and 128 kilometers from Dessie. Tenta is bordered by legambo in south, by sayint in south west, by magdala in west, by beshilo river in north and kutaber in the east The woreda has also 30 health post, nine health centers and one primary hospital. The study includes nine health center and one primary hospital which have maternity service.

Sample Size, Population And Sampling Technique

Nine health center and one governmental hospitals or all health facilities in Tenta Woreda are included in the study, sample size of the study participant determined using single population proportion with prevalence of 21.9% knowledgeable on obstetric danger signs from Yirga chefe, which will be 293 ANC following mother, the sample size was allocated proportionally to nine health center and one hospital, based the information of ANC attendant of 2018, then systematic sampling was employed to select each study participant [8].

Figure 2: Schematic representation of sampling procedure for the study on knowledge of obstetric danger signs and associated factors among pregnant mothers in Tenta woreda

Data Collection Instrument

Structured questionnaire was adapted from the result of different previous research on KODS. Then cross cultural consistency was checked by translating English to Amharic then back to translate back to English by expert. The questionnaire has 3 parts the first part socio demographic, the second reproductive history and the third was knowledge based questionnaire about ODS. One nurse and one midwife was selected for data collection and training was given based on the plan. Data collection tool was pre-tested. Then data was collected using interviewing technique after getting individual consent, the completeness of the questioner was checked daily and correction was done Any problem, arise during the data collection process appropriate intervention was made by the principal investigator.

Data Quality Control

Training was provided for data collected based on the objective, individual consent obtained during interviewing, the Data collection tool was pre-tested in 5% of sample size at similar population in akista woreda which was not include in the study and necessary modification was done. The completeness of the collected data was check by the researcher, and necessary correction was made.

Data Analysis

Data was entered by epi data (version 4.2.0.0) and analyzed after checking the completeness using SPSS software (version 25.0). It was coded, and cleaned before analysis. confidence interval of 95% and p- value 0.05 was used. Descriptive statistics was calculating to describe knowledge on obstetric danger signs .if the respondent mention at least three key obstetric danger signs for each of the three periods (pregnancy, delivery and postpartum) their level of knowledge well be Good, if they responded less than three leveled as poor knowledge.

Binary logistic regression done to analyze the relationship between the dependent and independent variables. Multiple logistic regression was used to analyze statistical significance because confounding variables can affect the binary logistic regression. Tables and graphs was used to present the results.

Result
Socio-Demographic Characteristics of Respondents

Out of the total 293 mothers who were planned for the study, 287 (98%)were responds successfully interview. The mean age of the respondents was 25.9 years (range 23 years). Most of the study participants were muslims,173 (60.3%). Majority of the respondents 255(88.9%) were married and 181 (63.1%) of them were housewife. Regarding their education 154(53.7%) of the participants had primary educational level. Partner educational status 128 (44.6 %) of respondents’ husbands did receive primary education, and 152 (53 %) were involved in farmer. About information source obstetric danger signs, 153(53.3%) got information from colloquies. (see Table 1. below)

Regarding to the obstetric characteristic 111(38.7%) respondents had history of 2-4 pregnancies and 19(6.6%) mothers were pregnant for more than four times. The other was first pregnancy. Majority, 262(81.3%) of the respondents had no history of abortion. About 50.5% of mother had health facility contact in their child bearing periods 31.1% of respondent have three and above ANC visit. (Table-2)

Table 1: Sociodemographic characteristics of respondents in tenta woreda health facilities, north Ethiopia,2019

Characteristics	Frequency	Percent
Age of respondents in year( n=287)
<20	45	15.7
21-25	99	34.5
26-30	84	29.1
31-30	24	8.2
>35	35	12.5
Religion( 287)
Muslim	173	60.4
Orthodox	102	35.5
Protestant	11	3.8
Catholic	1	0.3
Marital status(n=287)
Unmarried	17	5.9
Married	255	88.9
Divorce	13	4.5
Widowed	2	0.7
Occupation(n=287)
House wife	181	63
Civil servant	43	15
Farmer	28	9.8
Merchant	16	5.6
Daily labour	19	6.6
Educational level(n=287)
Illiterate	52	18.1
Primary	154	53.7
Secondary	37	12.9
Collage and above	44	15.3
Residency (n=287)
Urban	89	31
Rural	198	69
Paternal education(n=270)
Illiterate	40	14.8
Primary	128	47.4
Secondary	63	23.3
Collage and above	39	14.5
Paternal occupation excluded the unmarried(n=270)
Civil servant	31	11.5
Farmer	152	56.3
Merchant	71	26.3
Daily labour	16	5.9
Monthly income in birr in birr( n=287)
0-600	93	32.4
601-1650	95	33.1
1651-3200	48	16.7
>3201	51	17.8
Distance from home to the nearest HF in minute (n=287)
10-65	176	61.3
66-121	92	32.1
122-180	19	6.6
In case of getting information about ODS for alternative (n=287)
From health personnel	104	36.3
From media	99	34.5
From family	97	33.8
Colloquies	153	53.3
From school	24	8.4

Obstetric Characteristics of the Participants

From the total number of.

Table 2: Obstetric characteristics of respondents in tenta woreda, ethiopia, 2019

Characteristics>Previous obstetric characteristics	Characteristics>Frequency	Characteristics>Percent
Number of pregnancy (n=287)
1	157	54.7
2-4	111	38.7
>=5	19	6.6
Number of follow up in this pregnancy (n=287)
1	131	45.6
2	61	21.3
3	56	19.5
>=4	39	13.6
ANC in previous pregnancy for those history of previous pregnancy(n=130)
yes	84	64.6
No	46	35.4
Previous place of delivery for those history of previous delivery(n=122)
health facility	45	36.9
Home	38	31.1
Health facility and home	39	32
history of abortion(n=287)
Yes	25	8.7
No	262	91.3
previous health facility contact (n=287)
Yes	145	50.5
No	142	49.5

Knowledge on Obstetric Danger Sign during Prenatal Period

This study identifies that 44.6% (128) of the participant were Knowledgeable about obstetric danger signs during prenatal period and 55.4%(159) mothers were found to be not knowledgeable about danger sign during pregnancy. Most of the respondents (71.4%),32.4 % knew that vaginal bleeding and reduce fetal movement are danger sign during pregnancy sequentially. And 11.2%(33) were no listed any perinatal danger signs. (Table three below)

Table 3: The knowledge of respondent’s on danger signs of prenatal period in tenta woreda ethiopia, 2019

Respondent’s knowledge on obstetric danger sign during pregnancy(n=287)
Danger sign	Number of respondents who list pregnancy danger sign	Percent
Vaginal bleeding	205	71.4
Lag and face edema	66	23
Blurring of vision	63	22.4
Severe headache	46	16
Loss of consciousness	35	12.2
Difficult of breathing	39	13.6
Severe weakness	51	17.8
Severe abdominal pain	52	18.1
Reduce fetalmovement	93	32.4
Water break before labour	44	15.3
Malodorous vaginal discharge	36	12.5
Persistent back pain	66	23
Persistent vomiting	94	32.8

Knowledge on Danger Signs during Labor and Childbirth

Out of 287 respondents 140 (48.8%) were have adequate knowledge, but 147(51.2%) of women were found to be not knowledgeable about danger sign during labor. Majority of the respondents (76.0%) 39.4%, 31% knew that Severe vaginal bleeding, retained placenta and cessation of labor are identified danger sign related to child birth period respectively. 22(7.7%) were no listed any danger sign that probably occurs during delivery (see the table below)

Table 4: Participants knowledge on obstetric danger signs
during labor and child birth in Tenta Woreda, Etiopia,2019

Respondent’s knowledge on obstetric danger sign during child birth (n=287)
Danger sign	No. ofrespondentwho list labour danger signs	Percent
Severe vaginal bleeding	218	76
Coming of cord before head	72	25.1
Labour lasting more than 12 hrs.	32	11.1
Convulsion	48	16.7
Water break more than 8hrs	27	9.4
Malpresentation	68	23.7
Retained placenta	113	39.4
Persistent severe abdominal pain	63	22
High fever	45	15.7
Cessation of labour	89	31

Knowledge on Danger Signs during Postpartum Period

From a total of 287 respondents, 132(46.0%) were knowledgeable and 155 (54.0%) study participants were found to be not knowledgeable about danger sign during postpartum period. Most of the respondents (71.8%) knew that severe vaginal bleeding is a danger sign during postpartum period. Severe abdominal pain, face and lag edema and sever weakness are repeatedly listed danger sign during postnatal and 29(10.1%) respondents were no listed any danger sign as shown the table below.

Table 5: Participants knowledge on postnatal danger sign in
tenta woreda, ethiopia, 2019

Respondent’s knowledge on obstetric danger sign during postnatal (n=287)
Danger signs	No. ofrespondent who list postnataldanger sign	Percent
Severe vaginal bleeding	206	71.8
Abdominal pain	96	33.4
Fever	54	18.8
Offensive vaginal discharge	37	12.9
Convulsion	52	18.1
Severe weakness	81	28.2
Blurring of vision	70	24.4
Lag and face edematous	96	33.4
Uterine prolapse	59	20.6
Cessation of labour	89	31

The Over All Knowledge of Respondents. (In the three child
bearing period)

The knowledge of obstetric danger signs in combination of the three priods (prenatal, labor and child birth and postnatal period) as shown the figure below

Figure 3: The Knowledge of Pregnant Mother on Obstetric Danger Sign in Combination of Prenatal,Child Birth and Postnatal in Tenta Wored, Ethiopia, 2019

Factors Affecting Knowledge of Obstetric Danger Signs

Over all knowledge of participants that who list a minimum of three obstetric danger signs from each child bearing period (perinatal, child birth and postnatal) from Crude odd ratio indicates that the age of pregnant mothers had an impact for maternal knowledge on obstetric danger signs, being maternal age 31-35 has seven times knowledgeable than age less than 20 (COR=7.32,95% CI=1.98,27.1) Maternal educational status was significantly associated with knowledge about obstetric danger signs. Respondents who had a secondary education level had almost five times knowledgeable, (AOR=4.7 and 95% CI=1.00,32.01) than illiterate. The study showed that mothers, who worked as civil servant, were about 9.8 times more knowledgeable about danger signs of pregnancy than housewives, (AOR=9.8 and CI=1.53,62.997).

Frequency of Antenatal care (ANC) visit was significantly associated with knowledge respondents about obstetric danger signs. Mothers having four ANC follow-ups were thirteen times knowledgeable about obstetric danger signs than mothers having only one visit. Residence were an effect on the knowledge of mothers about obstetric danger signs, participants who were leave in urban area were three times knowledgeable than participants who leave in rural area AOR=3.1, and 95%CI=1.059, 9.34).

Health facility contact would increase the knowledge of health related problem, respondents who had previous health facility contact related to their health had eleven times knowledgeable than those who had no contact rather than the current pregnancy checkup (AOR=11.3, 95% CI=3.756,34.11) as shown in the table below

Discussion

This study aimed to assess maternal level of knowledge on obstetric danger sign and associated factors Among Pregnant Women Attending Antenatal Care At Health Facilities, In Tenta Woreda, South Wollo, Ethiopia 2019.

Knowledge of Antenatal Mother about Obstetric Danger Signs

In this study of three periods (prenatal period, child birth and postnatal period) repondan were reputedly mention the key danger sign were 78(27.2%). This finding is almost in line with the study finding in Yirgachefe (21.9%) [8]. The similarity is may be due to almost similar, education level, pregnancy history, health facility contact. This finding was also higher than the study finding in errer, Somalia (15.5%), Uganda (18.7) and lower than the study finding in Debaytilatgin (56.8), mamprusi, Ghana (51.1) [12,13,14,15]. The variation is may be the population difference of the study unit in which the study were conducted reproductive age group, the health related strategy difference specially the studies those out of Ethiopia.

Below half of the respondents were, 128 (44.6%) knowledgeable about danger sign during pregnancy. This finding is consistent with the study conducted in Raya kobo, (46.7%), India (49.2) in which respondents mentioned at least three danger signs of pregnancy [16,17]. But higher than the study finding in Goba district, Ethiopia (31.9) [18]. the difference is may be due to the study participant’s education level, the residence of participants, the previous pregnancy difference of participants, the health professional awareness difference.

From the women under the study, 140 (48.8%) were knowledgeable about danger signs during child birth. This finding was higher than the study finding in Raya, (27.8%), Goba district (27%) [17,18]. The difference is may be due to the participant’s education level, the study population, and the reproductive history difference and the health education of professional’s.

Additionally, 132 (46%) were knowledgeable about danger signs during postpartum period which is consistent with similar study in Yirgachefe (44.7%) in which women know at least three danger signs during postpartum period [8]. The finding were not consistent with the study in Uganda (71.6%) [13]. This difference might be due to variation in sociodemographic aspect, particularly education level, the residency of respondents.

In the current study, Vaginal bleeding was the frequently listed obstetric danger sign during prenatal 205 (71.4%), labor 218 (76%), and postpartum period, 206 (71.8%). So it is less likely listed from the finding in Raya kobo,(83.5%) in prenatal, (91.2%) in child birth and (89.2%) in postpartum [17]. This could be an indication of awareness difference for women that bleeding is the main and fastest cause of maternal mortality. Blurring of vision 64(22.3), leg and face edema 66 (23%) and convulsion has listed by16.7 % were the obstetric danger signs mentioned by the study participants. These findings were consistent with the study conducted in chamwino, Tanzania, which had 20.6%, 20.1% and 15.9% in blurred of vision, swallow of leg and face and convulsion respectively( [9]. This similarity was might be due similarity in the study design

Factors associated knowledge of Antenatal mother about
obstetrical danger sign during various child bearing period

Regarding to the factors in which independently associated with knowledge of obstetric danger signs, participants who had secondary education level were 4.7 times knowledgeable about obstetric danger sign than illiterate (AOR=4.7, 95% CI=1.00,22.01). this finding was in line with the study conducted in in Tanzania, AOR=1.96, and Raya kobo, AOR=3.63 [9,17]. This is the fact that education was one instrument to increase the understanding ability of maternal fitness to knowledge. Also, knowledge of obstetric danger signs were ten times higher among civil servant women compared to house wife (AOR = 9.8, 95% CI=1.53,62.997).This finding were consistent with the study finding in Goba district [18].

Table 6:The binary and multivariate regression of participants knowledge on obstetric danger sign in tenta woreda, Ethiopia,2019

Independentvariable	GoodknowledgeN(%)	Poor knowledge N(%)	COR (95% CI)overall knowledge on ODS	P-value	AOR (95% CI)overall knowledge on ODS	p-value
Age
>20	4(8.9)	41(91.1)	1		1
21-25	24(24.2)	75(75.8)	3.28(1.06,10.1)	0.038	3(.941,9.85)	0.063
26-30	32(38.1)	52(61.9)	6.3(2.06,19.277)	0.001	1.448(0.391,5.34)	0.579
31-35	10(41.7)	14(58.3)	7.32(1.98,27.1)	0.003	0.625(0.10,3.85)	0.602
>36	8(22.9)	27(70.1)	3.03(0.83,11.02	0.093	0.439(0.077,2.51)	0.356
Religion
Muslim	37(21.4)	136(78.6)	1		1
Orthodox	36(35.3)	66(64.7)	2(0.20,3.42)	0.12	1.4(0.638,3.13)	0.394
Protestant	4(36.4)	7(63.6)	2.1(0.58,7.56)	0.256	0.47(0.043,5.16	0.538
Catholic	1	0	Xx		Xx
Occupation
House wife	25(13.8)	156(86.2)	1		1
Civil servant	36(83.7)	7(16.3)	32(12.8,79.97)	0.000	9.8(1.53,62.997)	0.016
Farmer	5(18.9)	23(81.1)	0.57(0.47,3.89)	1.357	0.879(0.246,3.14)	0.843
Merchant	12(75)	4(25)	18(5.59,62.639)	0.000	2.46(0.265,22.8)	0.429
Daily labor	0	19	0.124(0.016,0.95)	0.16	0.115(0.009,1.4)	0.09
Educational status
Illiterate	5(9.6)	47(90.4)	1		1
Primary	16(10.4)	138(89.6)	1.09(0.38,3.137)	0.87	6.38(1.78,22.9)	0.005
Secondary	23(62.2)	14(37.8)	15(4.95,48.110)	0.000	4.7(1.00,22.01)	0.049
Collage and	34(77.3)	10(22.7)	31.9(10.02,102.5)	0.000	3.28(0.39,27.774)	0.277
Collage andabove	34(77.3)	10(22.7)	31.9(10.02,102.5)	0.000	3.28(0.39,27.774)	0.277
Marital status
Unmarried	2(11.8)	15(88.2)	1		1
Married	73(28.6)	182(71.4)	3(0.67,13.48	0.15	0.18(0.026,1.25)	0.083
Divorce	2(15.4)	11(84.6)	1.36(0.166,11.233	0.773	0.007(0.00 , 0.192)	0.003
Widowed	1	1	Xx	xx	xx	Xx
Monthly income in birr
0-600	7(7.5)	86(92.5)	1		1
601-1650	18(18.9)	77(81.1)	2.87(1.138,7.247)	0.025	1.5(0.610,3.75)	0.37
1651-3200	18(37.5)	30(62.5)	7.37(2.8,19.38)	0.000	4(1.34,12.17)	0.013
>=3201	35(68.6)	16(31.4)	26.9(10.18,70.98)	0.000	6.3(1.3,30.55)	0.021
Residence
Rural	20(10.1)	178(89.9)	1		1
Urban	58(65.2)	31(34.8)	16.6(8.8,31.44)	0.001	3.1(1.059,9.34)	0.039
No. of follow up
First	14(10.7)	117(89.3)	1		1
Second	4(6.6)	57(93.4)	0.56(0.185,1.89)	0.365	3.8(1.535,9.55)	0.004
Third	36(64.3)	20(35.7)	15(6.90,32.76)	0.000	8.7(2.09,36.319)	0.003
>=fourth	24(40)	36(60)	13.4(5.71,31.3)	0.002	12.8(1.28,128.39)	0.03
Gravidity
I	34(21.7)	123(78.3)	1		1
II-IV	38(34.2)	73(65.8)	1.88(1.09,3.25)	0.023	0.847(0.32,2.22)	0.736
>=V	6(31.6)	13(68.4)	1.67(0.59,4.72)	.334	5.2(0.89,30.3)	0.067
Gate information from health personnel
Yes	72(49.7)	73(50.3)	22(9.27,53.9)	0.000	11.3(3.756,34.11)	0
No	6(4.2)	136(95.8)	1		1
From Media
Yes	71(68.3)	33(31.7)	54(22.87,127.9)	0.000	1.7(1.705,19.22)	0.032
No	7(4.8)	176(95.2)	1
From Media
Yes	66(66.7)	33(33.3)	29(14.29,60.19)	0.000	2.12(7.80,12.3200	0.004
No	12(6.4)	176(93.6)

Women who live in urban area were three times more likely to mention at least three obstetric danger signs as compared with rural counterparts (AOR=3.1, and 95%CI=1.059,9.34). This variable was also found to have a significant association with other study conducted in Goba district, yirgachefe and erere, Somalia [8,18,15]. This could be due to the fact that urban residents have better access to health information and maternal health services as compared with rural counterparts. Multivariate regression indicates that increase the number of Antenatal care follow up also increase the maternal knowledge on obstetric danger signs, participants who had four or more visited were 13 times knowledgeable on obstetric danger sign than one visitor, (AOR=12.8, 95%CI=1.28,128.39) this finding was in line with the study finding in Debaytilatgin, AOR=3.46 [12]. In the binary logistic regression, analysis revealed that, adequate ANC follow up, women education, occupation, parity, income, and number of ANC, age, residence were found to be an independently significant association with knowledge of obstetric danger signs. This finding was congruent with the study finding in Debaytilatgin [12]. This similarity may be due to all most similar sociodemographic aspect, health issue related policy [19-25].

Limitations of the Study

The limitations of this study could be the small sample size which may make estimates unstable and associations between dependent and independent variables undetectable. The method cross sectional was another limitation, in which able to detect cause and effect

Conclusion

In current study a significant proportion of mothers were not knowledgeable about the danger signs of pregnancy, labor and childbirth and postnatal. This indicates that many women not likely to seek health care during antenatal labor and postnatal period. Sever Vaginal bleeding was the most common spontaneously mentioned danger signs among the three periods. According to the result of this study, age, level of education, occupation, residence, health facility contact, antenatal care follows up were the predictors association factor for knowledge of mothers about obstetric danger signs during pregnancy, labor and post-partum period. Therefore, intervention programs aiming to improve women’s knowledge about obstetric danger signs in the area of health facility, Federal ministry of health and research area.

Declaration

By my signature below, I declare and affirm that this thesis is my own work. I have followed all ethical principles of scholarship in the preparation, data collection, data analysis and completion of this thesis.

Ethics Approval and Consent to Participate

Ethical clearance was received from AAU college of Health science, school of nursing and Midwifery research team prior to data collection. A formal letter was written by the department of nursing to the concerned office. Permission were asked from the responsible body of the unit. Each study participant was adequately informed about the purpose, methods, and anticipated benefits of the study by the data collectors. Respondents who were volunteer and was available at the time of data collection were interviewed without writing their names to ensure confidentiality. Used reference materials for the study was coated and cited with their proper Authors, funding organization, the study subject, the institution, advisors and people supporting in searching literature (digital Liberian,) data collector, supervisors and all peoples contribute genuine suggestion and advise was duly acknowledged.

Consent for Publication

not necessary

Availability of Data and Materials

All the information or data incorporated in the manuscript can be accessed primary author and other co-author with the email address of mohalegas86@gmail.com

Competing Interests

No competing interest since the author declare

Funding

This study funded by Addis Ababa university student grant of post graduate office, which is small to cover the wholly process the study activity

Authors' Contributions

Legas Mohamed develop the proposal, search literatures, select and train the data collector, analysis and wrote the finding and discussion

Teshom R, and Abebe WS advising on starting from the development of proposal and to defending time about methodological,reviewing ,writing result and analysis issue

Acknowledgements

We are indebted to addis ababa university college of health scince school of nursing and midwifery in giving both financial and technical support, we also our great thank to Tenta woreda health bureau helping for the entire process of the research is successful. Our special thank goth to the participant and technical assistant in the data collection process.

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