This was a cross-sectional study undertaken in Rufiji district, between November and December 2006. Rufiji district is one of the six districts of Coastal Region in Tanzania. The district covers an area of about 14,500 km2. It has an estimated population of 203,000 with approximately 52% females, according to the 2002 Census . The majority of the population are peasants, with 38% living below the national basic needs poverty line . Geographically, the Rufiji district consists of flood plain, coastal-delta, and plateau zones. Most road networks in the district are difficult to pass especially during the rainy season. The district has five divisions divided into 19 wards: eight wards in the flood plain, four in the coastal-delta, and seven in the plateau zone. The total number of villages is 128, each with an average population of 1600.
The district has two hospitals, both providing comprehensive emergency obstetric care, four rural health centers and 48 dispensaries. Health workers provide maternal care in all health institutions.
Sampling was with a two-stage cluster. In the first stage, two wards were randomly selected in each zone, and in the second stage, two villages were randomly selected from each of the six wards (n = 12). In each of the 12 villages, all women who had been pregnant during the previous two years were selected for interview using structured questionnaires. Women who were pregnant for the first time at the time of the data collection were excluded.
The crude birth rate in Tanzania is approximately 4%  which means 8% of the population is expected to have been pregnant or delivered in the past two years: this made 16,000 women eligible for the study. Assuming that 25% of the women were aware of obstetric danger signs, with a desired precision of 5% (95% confidence interval), a design effect of two and a non-participation rate of 10%, a total of 974 women were required for the study. The number of women selected for the study was 1 151 and of these, 33 (2.8%) were absent at the first and second visit and were regarded as non-respondents; thus, 1 118 women were interviewed.
The questionnaire, translated and back translated, Swahili to English to Swahili, to ensure relevance and accuracy. The questionnaire was then piloted in a similar district (Mkuranga) in the same region. The interviews were evaluated by the researchers and necessary changes made.
The questionnaire included socio-demographic characteristics including age, marital status, education level and occupation; pregnancy characteristics including number of deliveries, number of pregnancies and whether the women were pregnant or not at the time of the interview; experiences during their last pregnancy including whether they attended antenatal care, month of pregnancy booked for care, the number of visits made and if were informed of any risk or complication during antenatal care and danger signs of obstetric complications.
The antenatal cards used in their last pregnancy were available for 636 women and were reviewed for more information on the advice given to deliver in a hospital. Information on awareness of danger signs was collected by asking women if they knew any danger signs that may occur during pregnancy, delivery and after delivery separately in the same interview and those who knew danger signs were asked to mention them. Probing was used to elicit further responses.
The village leaders were informed of the research activities before data collection. House-to-house visits were made on the day of data collection. All women who had been pregnant in the past two years were identified and interviewed by pre-trained research assistants (nurse midwives).
Based on the recommendations of the national antenatal care guideline and the Safe Motherhood Initiative, a list of medically recognized life threatening obstetric signs were obtained from the women's responses. The list included vaginal bleeding during pregnancy and delivery, severe vaginal bleeding after delivery, anemia, swelling of lower limbs, fits of pregnancy, severe headache, high grade fever, child does not move, severe abdominal pain, awareness of fast heart beats, high blood pressure, prolonged labor, loss of consciousness and retained placenta.
After data collection, responses for open-ended questions were reviewed, categorized, and coded for computerization. Data were entered with Epi Info and subsequently analyzed with SPSS. Awareness of danger signs of obstetric complication in this study was defined as the ability to mention at least one recognized danger sign during pregnancy, delivery or after delivery. Chi-square test was used to determine associations between categorical variables. The differences were deemed significant when p < 0.05. Bivariate logistic regression analysis was used to identify factors associated with awareness of obstetric danger signs. Variables significant in the bivariate analysis were then entered into a multivariate logistic regression analysis. The associations between awareness and each independent variable were estimated by odds ratio (OR) and 95% confidence interval (CI). A CI was considered statistically significant when the interval between the upper and lower values did not include one.
The Muhimbili University of Health and Allied Sciences (MUHAS) research and publication committee gave ethical clearance to conduct the study. Permission to conduct the study was obtained from Rufiji district and village authorities. The purpose of study, benefits, right to refuse participation, and liberty to refuse or leave the study at any time was explained to each participant before the interview. Verbal consent was regarded as sufficient to be included in the study. To ensure confidentiality, women's names were not written on the questionnaires.