Pregnancy Risk Perception and Associated Factors Among Pregnant Women Attending Antenatal Care at Health Centers in Jabitehnan District, Amhara, Northwest Ethiopia

Background: Pregnancy risk perception affects a pregnant woman’s decision about health care services use such as prenatal care, place of birth, choices about medical interventions, adherence to medical procedures, and recommendations. Methods: An institutional-based cross-sectional study was conducted among 424 mothers attending ANC at health centers in the Jabitenhan district from April 1 to 30, 2021. Data was collected through a face-to-face interview using a structured questionnaire which was developed according to the health belief model. The logistic regression model was used using adjusted odds ratio with 95% CI and p value <0.05 Result: 424 pregnant women were interviewed of which nearly half of the respondents (48%) had good pregnancy risk perception. Women who had a history of obstetric complication (AOR:95%CI = 3.44:1.73,6.83), those who know at least one pregnancy danger sign (AOR:95%CI =5.22;2.46,11.07), pregnant women who had a bad obstetric history (AOR:95%CI = 2.23:1.13,4.41) and knowing women who died due to pregnancy-related complications (AOR:95%CI =2.85:1.45,5.60) were more likely to have good perception towards pregnancy risk as compared to their counterparts. Conclusion: signs, bad and knowing were found to be signicantly associated with


Introduction
Risk is the probability that a person will be harmed (1). Risk perception means an individual's expectation about the probability, characteristics, and severity of an event. It is an important construct for different health behavior theories such as Health Belief Model, Protection Motivation Theory, and Prospect Theory (2). An individual making judgment about the probability of an event is based on past experience (3) A greater perception of health risk leads to conduct protective action. Therefore understanding people's health risk perception and the accuracy of their perception is important (4). Pregnancy risk perception affects a pregnant woman's decision about health care services use like prenatal care, place of birth, choices about medical interventions, adherence to medical procedures and recommendations, and health behaviors (5)(6)(7).
Pregnancy is a normal physiologic process but some of the common discomforts of pregnancy may make the pregnant woman feels ill. Ranging from mildly irritating to life-threatening conditions(8).
Pregnancy and childbirth are often perceived as normal life events without justi cation in many developing countries including Ethiopia. Obstetric complications are high among normal pregnancies.
The top commonly manifested danger signs during labour and childbirth are severe vaginal bleeding, prolonged labour, convulsion, and retained placenta. Besides, dangerous signs occur during the postnatal period which includes severe vaginal bleeding, unconsciousness, and fever (13,14). Every pregnant woman is at risk of facing pregnancy-related complications that could end in death or injury to both herself or her newborn (15). From pregnancy-related complications, hemorrhage, obstructed labour, pregnancy-induced hypertension, puerperal sepsis, and unsafe abortion are the ve leading causes of maternal death in Ethiopia from 1990 to 2016. Early detection and management of those complications are important to reduce maternal mortality(16).
Pregnancy and childbirth complications are major causes of maternal death. Complications develop during pregnancy accounted 72.5% of maternal death are called direct causes of maternal death.
The maternal mortality ratio in developing countries in 2015 is twenty times higher than in developed countries. The difference in maternal mortality ratio is also present within countries between urban and rural residents, and between high and low-income women (20).
Pregnancy and childbirth-related mortality are unavoidable due to three delays. These are delays in deciding to seek care, delays in accessing and reaching appropriate care, and delay in the recipient of appropriate care once a health facility is reached. The rst delay in uences the probability of the second and third delay. Their poor perception of pregnancy-related risks and complications leads pregnant women to delay decision-making to seek obstetric care (21,22) Therefore, this study is intended to determine pregnancy risk perception and associated factors among pregnant women attending antenatal care at health centers in Jabitehnan district, Amhara, northwest Ethiopia, 2021 2. Material And Methods 2.1. Study Area and Period.
The study was conducted in Jabitehnan District, West Gojjam zone, Amhara region, northwest Ethiopia. Jabitenhnan is bordered on the southwest by Dembech, on the west by Bure, on the northwest by Sekela, on the north by Kuarit, and on the east of Degadamot districts. It is located 387 km from Addis Ababa in the northwest part of Ethiopia. According to the report from the district in 2016, it has 39 kebeles with a total population of 218,447 and 125,323 adults. In the district, there are 11 health centers and 39 health posts. The health centers give different clinical services such as family planning, antenatal care, delivery, testing of HIV, etc. for the nearby community. All health centers provide ANC service for the nearby community The majority of the inhabitants practiced Orthodox Christianity(97.96%) while 2.02% were Muslim (23, 24). This study was conducted from April 01, 2021, to April 30, 2021 2.2. Study Design.
The institutional-based cross-sectional study design was conducted.

Source and Study Population.
Source population of this study was all pregnant women coming to antenatal care service in Jabitehnan district health centers and the study population was all pregnant women attending to antenatal care service in Jabitehnan district health centers during the data collection period 2.4. Sample Size Determination.
The sample size was calculated using the single population proportions formula by considering 50% of the population has good pregnancy risk perception. The size of the sample was calculated as follows: Then by adding a 10% non-response rate, the total sample size was 424 2.5. Sampling Technique and Procedure.
There are eleven health centers in the Jabitehnan district. All health centers were included in the study and a systematic sampling technique was used to collect data. The total number of pregnant women attending ANC per month for the previous three consecutive months in each health center was taken from the ANC tally record book. The average number of pregnant women attending ANC per month was calculated. Based on the total number of pregnant women attending antenatal care in Jabitehnan district health center the total sample was divided to each health center proportionally. P=n/N then P times by total antenatal care attendant per month in each health center (Fig 1) The tool has four parts. These are socio-demographic characteristics, obstetric characteristics, Knowledge of pregnancy danger signs, and pregnancy risk perception using the two constructs of health belief model. These tools were rst prepared in English and later translated into Amharic (local language) and back to English again to maintain its consistency. The socio-demographic variables, obstetric characteristics, and knowledge of pregnancy danger sign was assessed as a factor for pregnancy risk perception using two constructs of health belief model. The client's knowledge of pregnancy danger signs was assessed as a factor for their perception of pregnancy risk. Knowledge about pregnancy danger signs (yes or no options for being familiar with each pregnancy danger sign). This tool consists of 11 questions, which focus on general knowledge of pregnancy danger signs.
The client's pregnancy risk perception using health belief model constructs was assessed. Clients are asked question of two constructs of health belief model that ranges from ve to twenty-ve score for perceived susceptibility and seven to thirty-ve score for perceived severity. The total scores were calculated from the combined questions ranges from twelve to sixty. The questions has ve options ( 1=strongly disagree,2=disagree, 3=neutral, 4=agree, 5=strongly agree)(25).

Data Collection Procedure.
Eleven trained midwives collected the data through a face-to-face interview. The data collectors and supervisors had taken training on the objective of the study, methods of data collection procedures, and tool of data collection for one day by the researcher 2.10. Data Quality Control.
To ensure the data quality training was given to data collectors and supervisors by the principal investigator on how to conduct client interviews. A pre-test was conducted in 5 % of the sample on March 2021 Finote Selam health center. Cronbach's alphas (0.89 up to 0.90) were calculated to check the internal consistency and reliability of the item. The necessary modi cation was made for any ambiguity, confusion, and di cult words based on pre-test data analysis. Each data collector and supervisor checked before and immediately after collection for the completeness and consistency of the questionnaire.
2.11. Data processing and Analysis.
The data was cleaned, coded and entered, and analyzed using Statistical Package for social sciences (SPSS) version 20. Descriptive statistics such as frequency, percentage, standard deviation, and mean were used to characterize the participants in terms of socio-demographic variables, obstetric variables, and knowledge of pregnancy danger signs. A logistic regression model was tted to assess the association between dependent and independent variables with a P-value of 0.25 or less in the bivariable analysis will be included in the multivariable analysis. The adjusted odds ratio together with 95% con dence intervals was computed and, results with P-value <0.05 were considered to declare a result as signi cantly associated.

Socio-demographic characteristics.
Four hundred twenty-one pregnant women have completed the questionnaire making the response rate of the study 99.3%. The mean age of respondents was 26.99±6.22 and nearly one-third 33.3% of respondents were age between 25 and 29 years. All respondents were Amhara in ethnicity and 93.8% were orthodox in religion. All most all the respondents 99.8% were married and more than half 58.7% of the respondents were housewives. Of the total study participants, 57% respondents were living in rural. Concerning educational status, slightly more than one third 42.7% of respondents were no formal schooling. Of 421 respondents 47.5% were primigravida and 48% were nulliparous. Of multigravida women, 52% had experienced obstetric complications in the previous pregnancy or labour or postpartum period and the majority 64.3% of respondents had no history of bad obstetric history (Table 2).

Pregnancy risk perception.
In this study out of the total respondent's majority of women (51.7%) did not perceive they were extremely susceptible to pregnancy-related complications but above half of the respondents (60.1%) were perceived that they are susceptible to complications related to delivery and the postpartum period, and di cult pregnancy period. Each item means score pregnancy risk perception of pregnant women showed that they are not perceived for developing pregnancy-related complications. They are dichotomized to good perception (agree, strongly agree) and Poor perception (disagree, neutral, and strongly disagree) Concerning the perceived severity of pregnancy-related complications, 57.9% perceived that pregnancy and delivery problems would last a long time while 55.9% of respondents perceived that Pregnancy complications would not threaten the relationship with my partner. The majority of the respondents 74.3% perceived that my baby will be born prematurely. 32.8% of respondents strongly agree that my baby would not survive the pressure that comes with labour and delivery (Table 4).

Factors affecting pregnancy risk perception.
In bivariable analysis, residence, own income, knowing a woman who died due to pregnancy-related complications, past obstetric complications, current pregnancy danger signs, the number of ANC visits, bad obstetric history, and awareness of pregnancy danger signs showed P-value less than 0.25 making them eligible for multivariable analysis.
In multivariable analysis awareness of pregnancy danger signs, bad obstetric history, past obstetric complications, and knowing a woman who died due to pregnancy-related complications were associated with pregnancy risk perception

Discussion
A major nding of this study was that above half of pregnant women had signi cantly poor risk perception. Out of the total study subjects, 48%( 43.2%, 52.7%) had a good pregnancy risk perception. The independent variables that affect pregnancy risk perception were history of obstetric complications, knowing women who died due to pregnancy-related complications, bad obstetric history, and awareness of pregnancy danger sign.
In this study, 48% of pregnant women had a good pregnancy risk perception. Studies conducted at Health and Medical centers of Hamadan city in the west of Iran, 2 tertiary-care hospitals in Winnipeg, Manitoba, two major teaching hospitals of a city in Western Canada, and urban tertiary care hospital in western Canada showed that their mean score perception of pregnancy risk was below the midpoint of scales. It means that 100% of their study participants perceived that their susceptibility to pregnancy-related complications was mild. This difference might be due to that all the research conducted using a visual analog scale tool measurement which is only administered for literate people, data collection tool difference, sociocultural difference, sample size difference, and time gap of the study (26)(27)(28)(29).
This study showed that 48.9%( 43.9%, 53.7%) of study subjects perceived that they were susceptible to pregnancy-related complications. This nding was higher than studies conducted in Mandera County, Kenya 14.5%. This difference might be due to socio-cultural differences of study participants, study population, and time gap of the study (25).
This research showed that 29.7% (25.7%, 34.4%) of pregnant women were perceived they are susceptible to bad pregnancy outcomes, 58.2%( 53.7%, 62.9%) were perceived that they are susceptible to di cult pregnancy periods. This nding was consistent with the study conducted in Mandera County, Kenya 28.2% (25).
In this study, 74.3%( 70.5%, 78.4%) of pregnant women perceived that their baby will be born prematurely. This result was consistent with studies conducted in Mandera County, Kenya 75%. But studies conducted at Hamadan city Iran and Winnipeg, Manitoba showed that mean score perceptions were below the midpoint of scales that indicate mild risk perception. This difference might be due to the difference of measurement scale, socio-cultural difference, and time gap of the study (25,26,28).
This study revealed that 45.1% (40.1%, 49.9%) of pregnant women were perceived that the occurrence of pregnancy complications would not threaten their relationship with their partners, which is lower than a study conducted in Mandera County, Kenya 51%. This difference might be due to the socio-cultural difference of study participants and the time gap of the study. Besides, it may be because Ethiopian women's were honest with their husband to keep their promise during the marriage (25) In this study, mean score perception pregnancy risk in pregnant women showed that they didn't perceive that they are at risk for dying due to pregnancy-related complications. Studies conducted in Winnipeg, Manitoba, Western Canada, and the west of Iran had mild risk perception. This difference may be due to difference in measurement scale, data collection tool, socio-cultural difference, and educational status of respondents (26)(27)(28)(29) Approximately seventy percent of women perceived that their babies will be dying during labour and delivery. This result was inconsistent with studies conducted in western Canada and Hamadan city in the west of Iran. This difference may be due to difference in measurement scale, socio-cultural difference, and educational status of respondents (26, 27) The study also revealed that women having a history of obstetric complications were more likely to have positive pregnancy risk perception. This may be because these women had information about pregnancyrelated complications from their experience of obstetric complications and understand their risk of susceptibility.
Pregnant women who had awareness of pregnancy danger signs were more likely to have positive pregnancy risk perception than their counterparts. This may be due to knowledge about pregnancy danger sign clears rumor about pregnancy-related complication and increase their awareness about pregnancy-related complications.
According to this study, pregnant women with bad obstetric history were more likely to have positive pregnancy risk perception. This may be due to pregnant women familiarized with the bad obstetric outcome and learned their susceptibility towards pregnancy-related complications.
In this research one of the factors that affecting positively, pregnancy risk perception was knowing a woman who died due to pregnancy-related complications. This may be because these women learned the probability of developing pregnancy-related complications as well as the consequences of pregnancyrelated complications from women's died due to pregnancy-related complications.
Generally, pregnant women with a bad obstetric history, past obstetric complication and knew a woman who died due to pregnancy-related complications was associated with pregnancy risk perception. This result was similar to the concept of availability of the Heuristic approach which means that an individual makes a judgment about likely hood of an event based on past experience or information from others(3).
In this study past experience and information from others are pregnant women with bad obstetric history and past obstetric complications, and knew a woman who died due to pregnancy-related complications respectively.
In this study age of pregnant women is not signi cantly associated with pregnancy risk perception. But women aged < 18 years had a statistically signi cantly associated to pregnancy risk perception than women aged 18 to 35 in studies conducted at Health and Medical centers of Hamadan city in the west of Iran(26). This difference might be due sample size difference (421 pregnant women versus 240 pregnant women), age category difference (15-43 years versus <35 years), study participant difference (both nulliparous and multiparous versus only nulliparous) and measurement scale differences (Likert scale versus visual analog scale) and the difference in data collection tools.

Conclusion
These studies showed that pregnant women perceive that they were risky in developing pregnancy-related complications and their consequences were low. Only forty-eight percent of pregnant women had good pregnancy risk perception. This is likely to have implications for medical care and pregnancy outcomes.
History of obstetric complication and bad obstetric history was associated with a higher degree of actual risk perception in pregnancy whilst women who knew the death of pregnant women due to pregnancy complication and knowing at least one pregnancy danger signs were more likely to be concerned about risk.

Declarations
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Not applicable
Availability of data and materials: The original data for this study are available from the corresponding author on reasonable request.
Competing interest: Figure 1 Please See image above for gure legend.