Table 2 Overview of key characteristics of pooled articles

1

Vijay et al. (2015) [24]

2015

OPD of Lata Mangeshkar Hospital, Nagpur, India

Pregnant woman danger sign

100 pregnant women attending ANC

1. 6,38% were having good knowledge

2. 20% have fair knowledge

3. 73% have poor knowledge

1. > 15 Good knowledge (> 75%)

2. 10 – 15 fair knowledge (50–75%)

3. < 10 poor knowledge (< 50%)

During pregnancy danger

1. Bleeding 50%

2. Swollen hands and face 48%

3. Blurred vision 35%

4. Lack of blood 22%

Delivery danger

1. Severe vaginal 50%

2. Retained placenta 23%

3. Labour lasting > 12 h 16%

Postpartum danger

1. Severe bleeding 50%

2. Swollen hand, feet, face 48%

3. Visual disturbances 35%

Weakness 22%

1. A well-planned strategy for danger sign education

1. Health personnel 33%

2. Mass media 67%

2

Belay & Limenih (2020) [32]

2020

Community of Farta Woreda, Northwest Ethiopia

Obstetric danger sign

735 mothers delivered baby at least once in the last 2 years

1. Danger sign during pregnancy

Knowledgeable 71,4%

Not 28,6%

2. Danger sign during childbirth

Knowledgeable 65,3%

Not 34,7%

3. Danger sign during postpartum

Knowledgeable 77%

Not 23%

At least mentioned 3 danger signs considered as knowledgeable

Obstetric danger

1. Vaginal bleeding 48.4%

2. Swollen hands and face 29.1%

Delivery danger

1. Severe vaginal bleeding 61.1%

2. Malpresentation (abnormal position of the fetus) 36.2%

Postpartum danger

1. Vaginal bleeding 72.2%

Severe headache 28.8%

1. Increasing antenatal- care coverage

2. Educating women

3. Increasing institutional delivery

1. Health personnel 62,4%

2. Friends 18,8%

3. Mass Media 7,8%

3

Wassihun et al. (2020) [21]

2020

Community of Shashamane town, Oromia region, Ethiopia

Obstetric danger sign

422 recently delivered mother (< 12 months)

1. 40.5% were having good knowledge

2. 59.5% were having poor knowledge

At least spontaneously mentioned 2 danger signs considered as knowledgeable

Less than that considered as poor

Obstetric danger

1. vaginal bleeding (64.7%)

2. absent or decreased fetal movements (38.6%)

Childbirth danger

1. Bleeding (60%)

2. Absent or decrease fetal movements (28.4%)

Postpartum danger

1. Postnatal bleeding (63.3%)

Postnatal fever (38.9%)

1. Mobilizing communities

2. Encouraging pregnant women to attend antenatal clinics

3. Providing health information dis- semination

4

Mardiyanti et al. (2019) [13]

2019

Community of Surabaya City, Indonesia

Pregnant women danger sign

125 pregnant women

1. 72,4% have good knowledge

2. 26,9% have less knowledge

Not explained

5

Bogale & Markos (2015) [22]

2015

Community of Goba district, Ethiopia

Obstetric Complication danger sign

562 recently delivered mother (< 12 months)

1. Danger sign during pregnancy

Knowledgeable 31,9%

Not 68,1%

2. Danger sign during childbirth

Knowledgeable 27%

Not 73%

3. Danger sign during postpartum

Knowledgeable 22,1%

Not 77,9%

At least spontaneously mentioned 3 danger signs considered as knowledgeable

During pregnancy

1. Severe vaginal bleeding 71,3%

2. Severe headache 53,7%

Childbirth danger

1. Vaginal bleeding 29%

2. Prolonged labour (> 12 h) 27%

3. Retained placenta 23%

Postpartum danger

1. Severe vaginal bleeding 76,5%

Severe headache 39,8%

1. Every woman should be made aware of complications during pregnancy, childbirth/ labour and the postpartum periods

2. Interventions targeting improvement of maternal health need including the quality of information offered to pregnant women during ANC follow up is recommended

6

Tjandraprawira & Ghozali (2019) [1]

2019

Patient of maternity ward, Majalengka General District Hospital, Indonesia

Pregnancy danger sign

127 recently delivered postpartum women treated in the maternity ward

1. 61,4% have good knowledge

2. 38,6% have less knowledge

Scored above average score (25.41 (± 3.44)) considered as knowledgeable

During pregnancy

1. Swellings of the hands, feet and face 78%

2.‘Water break’ or premature rupture of membrane (PROM) 85%

3. Bleeding early in pregnancy 93.7%

4. Prolonged coughing 94%

5. Episode of palpitations during pregnancy 76%

6. Repeated episodes of diarrhea needed an urgent referral to a physician 93%

During Childbirth

7. Bleeding during labor 83.5%

8. Seizure 90%

Postpartum

9. Prolonged anxiety required a consultation with a physician 95%

10. Prolonged sadness after delivery (postpartum depression) is normal 29%

11. Women knew that only fevers more than 2 days during the postpartum/puerperium period required referrals to the nearest health facility 29%

12. Patients had known that foul-smelling vaginal discharge during puerperium was an ominous sign 79.5%

1. MCH (Mother and Child Health) book

7

Vallely et al. (2019) [16]

2019

Community of Hiri District (Central Province), Karkar Madang Province), and Asaro (Eastern Highlands Province), Papua New Guinea

Pregnancy danger sign

482 recently delivered women (1 – 2 years prior) attending ANC clinic

1. Any Danger sign during pregnancy (183/459)

Knowledgeable 39,9%

Not 60%

2. ≥ 3 danger signs during pregnancy (39/183)

Knowledgeable 21,3%

Not

1. Mentioned any danger sign

2. Mentioned ≥ 3 danger signs

1. Fever 47.5%

2. Bleeding in pregnancy 39.3%

3. Swelling of the legs/ arms 36.6%

4. Headaches and dizziness 27.9%

1. Health care worker harness the opportunity of the antenatal clinic to provide women with information on the importance of recognising danger signs during pregnancy

2. The importance to seek professional, skilled care promptly should problems arise

1. Health personnel 53.6%

8

Woldeamanuel et al. (2019) [25]

2019

Community of Angolela Tera District, Northern Ethiopia

Obstetric Complication danger sign

563 pregnant women

1. Danger sign during pregnancy

Knowledgeable 56,1%

Not

2. Danger sign during childbirth

Knowledgeable 58,8%

Not

3. Danger sign during postpartum

Knowledgeable 34,5%

Not

At least spontaneously mentioned 3 danger signs considered as knowledgeable

1. Excessive vaginal bleeding 72,6%

2. Swollen hands 12,8%

3. Convulsion 9,8%

4. Reduced fetal movement 54%

5. High fever 43,9%

1. Health care workers 60%

2. Neighbors 34.3%

3. Media 5.7%

9

Bililign & Mulatu (2017) [20]

2017

Community of Raya Kobo district of Ethiopia

Obstetric danger signs

493 recently delivered mother (< 12 months)

1. Danger sign during pregnancy

Knowledgeable 46,7%

Not 53,3%

2. Danger sign during childbirth

Knowledgeable 27,8%

Not 72,2%

3. Danger sign during postpartum

Knowledgeable 26,4%

Not 73,6%

At least spontaneously mentioned 3 danger signs considered as knowledgeable

Obstetric danger

1. Vaginal bleeding 83,5%

2. Accelerated/ decreased fetal movement 38,1%

Childbirth danger

1. Vaginal bleeding 91,2%

2. Retained placenta 58,7%

Postpartum danger

1. Vaginal bleeding 89,2%

2. Offensive vaginal discharge 23,3%

Severe headache 23,1%

1. Empowering women

2. Improving the quality of health information about danger signs during ANC follow up

3. Promoting institutional delivery are the recommended interventions

10

Amenu et al. (2016) [7]

2016

Patient of Mechekel District Health Centers, East Gojjam Zone, Northwest Ethiopia

Obstetric danger signs

411 Postnatal mothers / recently delivered / postpartum women treated in the health centre

1. Danger sign during pregnancy

Knowledgeable 52,1%

Not

2. Danger sign during childbirth

Knowledgeable 53,3%

Not

3. Danger sign during postpartum

Knowledgeable 46,4%

Not

If scored above the calculated mean is considered knowledgeable

During pregnancy danger

1. Vaginal bleeding 53,8%

2. Severe headache 52,3%

3. Increased/ decreased fetal movement 43,5%

Childbirth danger

1. Vaginal bleeding 56,8%

2. Prolonged labour (> 12 h) 46,9%

3. Retained placenta 44,4%

Postpartum danger

1. Vaginal bleeding 60,2%

2. Foul smell of vaginal discharge 38,5%

High fever with or without abdominal pain 36,8%

1. Health service providers 76.3%

2. Mass media 20.5%

3. Friends 24.0%

4. Community 10.9%

11

Maseresha et al. (2016) [4]

2016

Community of Erer district, Somali region, Ethiopia

Obstetric danger sign

666 pregnant women

1. Danger sign during pregnancy

Knowledgeable 25,5%

Not

2. Danger sign during childbirth

Knowledgeable 31,8%

Not

3. Danger sign during postpartum

Knowledgeable 19,1%

Not

At least spontaneously mentioned 2 danger signs considered as knowledgeable

During pregnancy danger

1. Vaginal bleeding 25%

Childbirth danger

1. Prolonged labour 26%

2. Excessive bleeding 15%

Postpartum danger

1. Excessive vaginal bleeding 20%

2. Abdominal pain 10%

Fever 8%

1. Increasing ANC service utilization would improve pregnant women’s knowledge about obstetric danger signs and symptoms

12

Salem et al. (2018) [31]

2018

Community of Ambanja, Madagascar

Obstetric complications danger sign and newborn danger sign

372 recently delivered mother (< 12 months)

1. Danger sign during pregnancy

Knowledgeable 80,9%

Not

2. Danger sign during childbirth

Knowledgeable 51,9%

Not

3. Danger sign during postpartum

Knowledgeable 50,8%

Not

4. Danger sign of newborn

Knowledgeable 53,2%

Not

At least spontaneously mentioned 1 danger signs considered as knowledgeable

During pregnancy danger

1. Fever 41,1%

2. Headache 32,0%

3. Swollen hands and body 28.8%

4. Vaginal bleeding 26.9%

Childbirth danger

Postpartum danger

1. Mobile health (mHealth) as the remote ANC solution

13

Nigussie et al. (2019) [8]

2019

Community of Bahir Dar city administration, North West, Ethiopia

Obstetric danger sign

701 recently delivered mother (< 12 months)

1. 37,9% have good knowledge

2. have less knowledge

At least mentioned 2 danger signs considered knowledgeable

During pregnancy danger

1. Severe vaginal bleeding 81,6%

2. Loss of consciousness 34,1%

3. Increase/ decrease of fetal movement 32,7%

4. Difficulty in breathing 30,5%

Childbirth danger

1. Severe vaginal bleeding 82,2%

2. Retained placenta 59,6%

3. Prolonged labour 51,6%

4. Loss of consciousness 32,7%

Postpartum danger

1. Severe vaginal bleeding 85,3%

2. Loss of consciousness 32,7%

Swelling of face/ hands 28,5%

1. Provision of information on ODSs during the ANC period to facilitate the recognition on ODSs

2. Improve access to skilled attendance services

14

Dangura (2020) [23]

2020

Community of Dale district, Southern Ethiopia

Obstetric danger sign

782 recently delivered mother (< 12 months)

1. Danger sign during childbirth

Knowledgeable 45,5%

Not

2. Danger sign during postpartum

Knowledgeable 29,1%

Not

At least mentioned 2 danger signs considered knowledgeable

Childbirth danger

1. Severe vaginal bleeding 68.4%

2. Severe headache 29.4%

3. Convulsion 27.5%

4. High fever 24.6%

5. Loss of consciousness 19.7%

6. Labor lasting greater than 12 h 17.0%

7. Placenta not delivered 30 min after delivery 18.7%

Postpartum danger

1. Severe vaginal bleeding 16%

2. Severe headache 8.6%

3. Convulsion 7%

4. Swollen hand or face 5.3%

5. High fever 6.8%

6. Loss of consciousness 6.2%

7. Difficult of breathing 6.6%

8. Severe weakness 7%

9. Malodorous vaginal discharge 8.9%

15

Mwilike, Nalwadda, et al. (2018) [33]

2018

Patient of two health centers in Kinondoni Municipality, Dar es Salaam, Tanzania

Obstetric danger sign

384 postpartum women who were seeking immunization services for their children

Danger sign during pregnancy

1. Knowledgeable (≥ 4) 31%

2. Low knowledge (1–3) 57,8%

3. Not (none) 2,7%

Mentioned ≥ 4 danger signs is having sufficient knowledge

1. Vaginal bleeding 81.2%

2. Edema 46.3%

3. Headache 43.6%

1. RCHC (Reproductive and Child Health Clinic) 81.8%

2. Social gatherings 17.4%

3. Radio 0.8%

16

Nkamba et al. (2021) [6]

2021

Woman visited health facility for ANC

Democratic Republic of Congo

Obstetric danger sign

4512 recently delivered women attending ANC clinic

Obstetric danger sign

1. 23% Good knowledge

2. 76% Poor knowledge

Mentioned more than median (> 2)

During pregnancy danger

1. Vaginal bleeding 18%

2. Headache or blurred vision 2%

3. Swollen face or hands 18%

4. Reduced or no fetal movement 18%

5. Tiredness or breathlessness 8%

6. Cough or difficulty breathing 5%

7. Fever 18%

8. Convulsion (Not Mentioned)

17

Emeh et al. (2021) [19]

2021

Woman delivered in the Buea Regional Hospital

Cameroon

Obstetric danger sign

532 woman 24 h postpartum

Obstetric danger sign

73,3% knowledgeable / aware

During pregnancy

1. Severe vaginal bleeding 71,4%

2. Convulsion/ loss of consciousness 35,7%

3. Severe headache or blurred vision 41,7%

4. Reduced fetal movement 60,9%

5. Swollen face or hands 18%

During Labor

6.Prolonged labor (> 12 h) 18,7%

7. Retained placenta 17,3%

8. Fast or difficulty in breathing 39,8%

During Postpartum

9. Fever 62%

10. Severe vaginal bleeding

11. Foul-smelling vaginal discharge

18

Shamanewadi et al. (2020) [5]

2020

Pregnant women (18 – 32 y.o) attended ANC in the Primary Health Centre, Nandagudi, Bengaluru rural

India

Obstetric danger sign

210 women attending the ANC clinic

1.1.55% high school

2.2.9% illiterate

3.3.6% higher education

Obstetric danger sign

100% knowledgeable

Mentioned at least 3 danger signs

1. Fever 37.1%

2. Bleeding PV 100%

3. Reduced fetal movements 0.95%

4. Leaking PV 1.90%

5. Blurred vision 3.33%

6. Abdomen pain 100%

7. Loss of consciousness 0.95%

8. Convulsions 100%

Screening for high risk conditions – a free managerial tool during the ANC

1. ANC clinic in PHC

2. Health care staff

19

Oguntunde et al. (2021) [18]

2021

Nigeria

Obstetric danger sign

1624 < 25 years old women, join the The Nigeria Maternal Newborn and Child Health Programme (MNCH2), a UK Aid funded 5-year (2014–2019)

1. Danger sign during pregnancy

Knowledgeable 50%

2. Danger sign during childbirth

Knowledgeable 58%

3. Danger sign during postpartum

Knowledgeable 41,45%

Mentioned at least 2 danger sign

Solution on the need of always ask Husband permission before seeking care although danger sign appear

20

Tamang et al. (2021) [14]

2021

Pregnant women aged ≥ 18 years and attending the ANC clinic at Gyaltsuen Jetsun Pema Mother and Child Hospital

Bhutan

Obstetric danger sign

422 women attending the ANC clinic

Obstetric danger sign

1. 4.7% good knowledge

2. 58.1% satisfactory knowledge

3. 37.2% poor knowledge

Good = Scored ≥ 80%

Satisfactory = Scored 60 – 79%

Poor =  < 60%

1. Pulmonary embolism 1,70%

2. Preterm labour 7,70%

3. Reduced Foetal movement 14,90%

4. Fever 23,80%

5. Preeclampsia 24,80%

6. Hyperemesis 34,30%

7. Vaginal bleeding 67,70%

Use the MCH handbook

1. Nurse & Midwife 77,00%

2. Family & relatives 58,50%

3. Media 54,30%

4. MCH Handbook 49,20%

5. Doctor 19,40%

6. Others 17,30%