Level of Awareness on Danger Signs During Pregnancy and Associated Factors among Pregnant Mothers Attending Daynile General Hospital Mogadishu, Somalia: A Facility-Based Cross-Sectional Study

Technical Summary: Level of Awareness on Danger Signs During Pregnancy in Mogadishu, Somalia

Problem Statement
Maternal mortality remains a critical public health challenge in low-resource settings, with Somalia reporting a maternal mortality ratio of 396 deaths per 100,000 live births (2020). A primary driver of preventable maternal deaths is the delayed recognition of obstetric danger signs, which contributes to the "first delay" in the three-delays model: the delay in deciding to seek care. While global and regional data indicate unacceptably low awareness levels in Sub-Saharan Africa, evidence specific to Mogadishu, particularly within the Daynile district, is scarce. This lack of localized data hinders the development of targeted public health interventions necessary to improve emergency care-seeking behaviors and reduce maternal mortality in the capital.

Methodology
The study employed a facility-based cross-sectional design conducted at Daynile General Hospital in Mogadishu between April 28 and June 20, 2026.

• Population and Sampling: The study targeted pregnant women attending antenatal care (ANC). From a total of 1,034 assessed women, 422 were enrolled using systematic random sampling (sampling interval $k \approx 2$). Inclusion criteria required women to be currently pregnant and attending ANC; exclusion criteria included serious illness, inability to communicate, or refusal to provide informed consent.
• Data Collection: Data were gathered using a structured, interviewer-administered questionnaire adapted from previous studies. The instrument covered sociodemographic characteristics, obstetric history, ANC utilization, and specific knowledge of danger signs (e.g., vaginal bleeding, blurred vision, severe headache).
• Operational Definitions: "Good awareness" was defined as correctly identifying four or more obstetric danger signs. "Poor awareness" was defined as identifying fewer than four or none.
• Statistical Analysis: Data were analyzed using Stata version 14. Bivariate and multivariate logistic regression analyses were performed to identify associated factors. Variables with a $p$-value <0.25 in bivariate analysis were entered into the multivariate model. Statistical significance was set at $p < 0.05$. Multicollinearity was assessed via Variance Inflation Factor (VIF), and model fit was evaluated using the Hosmer–Lemeshow test.

Key Results

• Level of Awareness: Overall awareness was critically low. Only 112 participants (26.54%) demonstrated good awareness of danger signs. A significant majority (264 participants, 62.56%) could not identify any danger sign.
• Specific Knowledge Gaps: The most frequently recognized signs were vaginal bleeding (18.01%) and blurred vision (15.17%). Conversely, 89.81% of participants reported never having been informed about obstetric danger signs during their current pregnancy, and only 20.14% reported receiving health talks during ANC.
• Associated Factors (Multivariate Analysis):
  • Negative Associations: Mothers aged ≥30 years (AOR = 0.32), those with ≤2 ANC visits (AOR = 0.47), and those with intended pregnancies (AOR = 0.31) were significantly less likely to have good awareness.
  • Positive Associations: Participants who experienced a danger sign during the current pregnancy (AOR = 2.56), those who received health talks during ANC (AOR = 2.80), and those with hemoglobin levels ≥10 g/dL (AOR = 2.05) were significantly more likely to have good awareness.
• Demographics: The study population was predominantly illiterate (84.12% unable to read/write), housewives (87.44%), and had low monthly household incomes (70.85% earning ≤100 USD).

Key Contributions
This study provides the first facility-based evidence regarding the level of awareness of obstetric danger signs among pregnant women in the Daynile district of Mogadishu. It quantifies the severity of the knowledge gap in a specific urban Somali context, identifying that nearly two-thirds of pregnant women cannot recognize even a single danger sign. Furthermore, it isolates specific, actionable predictors—particularly the receipt of health talks and the frequency of ANC visits—that are statistically associated with awareness levels, offering a basis for refining local maternal health education strategies.

Significance and Claims
The authors conclude that the current level of awareness is "critically low" and constitutes a fundamental barrier to reducing maternal mortality in the region. The study claims that:

1. Health Education is the Primary Intervention Point: The strong positive association between receiving health talks and good awareness underscores that routine ANC is the most effective venue for disseminating life-saving information.
2. Current Strategies are Insufficient: The finding that only 10.19% of women were informed about danger signs suggests that existing hospital-based education is failing to reach the majority of patients.
3. Targeted Interventions are Needed: The identification of older mothers and those with fewer ANC visits as high-risk groups for poor awareness suggests that standard protocols may need to be adapted to ensure these specific demographics receive adequate counseling.

The paper asserts that strengthening routine health education during ANC and promoting early, regular attendance are essential steps to facilitate timely recognition of complications and improve maternal survival outcomes in Somalia.