European Journal of Cardiovascular Medicine

Maternal health is a fundamental component of public health and a key indicator of the overall performance of healthcare systems worldwide. Despite substantial global progress in reducing maternal mortality over recent decades, pregnancy-related complications continue to pose serious risks, particularly in low- and middle-income countries. According to recent global estimates, a significant proportion of maternal deaths are preventable through timely recognition of complications and prompt access to skilled obstetric care [1,2]. Obstetric danger signs such as severe vaginal bleeding, persistent headache, blurred vision, swelling of hands or face, severe abdominal pain, reduced fetal movements, and high fever serve as critical warning indicators that necessitate immediate medical attention [3]. Failure to recognize these signs contributes to delays in seeking care, thereby increasing the risk of adverse maternal and fetal outcomes.

The concept of the “three delays” model highlights the importance of individual-level awareness in preventing maternal deaths. The first delay, which involves the decision to seek care, is strongly influenced by a woman’s knowledge, attitude, and perception of pregnancy-related complications [4]. In many rural and resource-limited settings, sociocultural beliefs, low literacy levels, and inadequate access to health information further exacerbate this delay [5]. Antenatal care visits offer a critical opportunity for educating pregnant women about danger signs and promoting timely health-seeking behavior. However, evidence from recent studies suggests that mere attendance at antenatal clinics does not always translate into adequate knowledge or appropriate practices [6,7].

Knowledge, attitude, and practices (KAP) studies provide valuable insights into how health information is understood, perceived, and applied by individuals. In the context of maternal health, KAP assessments help identify gaps between awareness and action, thereby guiding the development of targeted interventions [8]. Recent literature indicates that while many pregnant women may recognize common danger signs such as vaginal bleeding, awareness of other life-threatening symptoms remains limited [9,10]. Furthermore, positive attitudes toward institutional delivery and emergency care do not always correspond with actual utilization of healthcare services during obstetric emergencies [11]. Understanding these discrepancies is essential for designing effective maternal health education programs.

In India, maternal mortality remains a public health challenge despite improvements in institutional delivery rates and antenatal coverage. Rural populations, in particular, continue to experience higher risks due to socioeconomic constraints, limited health infrastructure, and delays in accessing referral services [12,13]. Maharashtra, though relatively advanced in healthcare indicators, exhibits intra-state disparities, especially in rural districts such as Solapur [14]. There is limited recent evidence focusing specifically on antenatal mothers’ awareness and behaviors regarding danger signs of pregnancy in rural teaching hospital settings. Therefore, this study was undertaken to assess the knowledge, attitude, and practices related to obstetric danger signs among antenatal mothers attending Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, with the aim of generating evidence to inform local maternal health strategies.

OBJECTIVES

The primary objective of the present study was to assess the level of knowledge among antenatal mothers regarding danger signs of pregnancy. This included evaluating awareness of key obstetric warning signs occurring during pregnancy, labor, and the immediate postpartum period, as well as identifying socio-demographic and obstetric factors influencing knowledge levels. By systematically documenting existing knowledge gaps, the study seeks to provide a foundation for strengthening antenatal education and counseling services.

The secondary objective was to evaluate the attitudes and practices of antenatal mothers concerning danger signs of pregnancy. This involved exploring perceptions toward the seriousness of obstetric complications, willingness to seek timely medical care, and actual practices adopted during previous or current pregnancies. Understanding the alignment or lack thereof between knowledge, attitude, and practice is crucial for designing comprehensive maternal health interventions aimed at reducing preventable maternal morbidity and mortality.

The present study was designed as a hospital-based cross-sectional Knowledge–Attitude–Practice (KAP) study conducted among antenatal mothers attending the antenatal outpatient department of Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, District Solapur, Maharashtra. The study was carried out over a period of eleven months from January 2025 to November 2025. A cross-sectional design was considered appropriate as it allows assessment of knowledge, attitudes, and practices at a single point in time, thereby providing a snapshot of the prevailing level of awareness and behaviors related to danger signs of pregnancy among the study population. The institution serves as a major referral center for surrounding rural areas, making it an ideal setting to capture data reflective of rural antenatal mothers. A total of 75 antenatal mothers constituted the study sample. The sample size was determined based on feasibility considerations, outpatient attendance rates, and the study duration, and is comparable to similar hospital-based KAP studies conducted in rural settings. Antenatal mothers in any trimester of pregnancy who attended the antenatal clinic during the study period were approached consecutively and informed about the purpose of the study. After obtaining informed written consent, eligible participants were enrolled. Ethical approval for the study was obtained from the Institutional Ethics Committee of Ashwini Rural Medical College, and all procedures were conducted in accordance with ethical standards and the principles of the Declaration of Helsinki. Data were collected using a predesigned, structured, and pretested questionnaire developed after an extensive review of recent literature on obstetric danger signs and maternal health KAP studies. The questionnaire was prepared in English and translated into the local language (Marathi) to ensure comprehension. It consisted of four sections: socio-demographic characteristics, obstetric history, knowledge regarding danger signs of pregnancy, attitude toward obstetric complications and healthcare-seeking, and self-reported practices during current or previous pregnancies. The tool was pilot-tested on a small group of antenatal mothers not included in the final analysis, and necessary modifications were made to enhance clarity and reliability. Inclusion Criteria Antenatal mothers aged 18 years and above attending the antenatal clinic during the study period were included. Women in any trimester of pregnancy who were willing to participate and provided informed consent were eligible. Participants were required to be residents of rural areas served by the institution to ensure contextual relevance of findings. Exclusion Criteria Antenatal mothers who were critically ill, had diagnosed psychiatric illnesses, or were unable to communicate effectively at the time of data collection were excluded. Women who declined consent or those visiting the clinic for emergency care only were also excluded from the study. Data Collection Procedure Data collection was carried out by trained investigators through face-to-face interviews conducted in a private setting within the antenatal clinic to ensure confidentiality and encourage honest responses. Each interview lasted approximately 20–25 minutes. Knowledge was assessed using a set of multiple-response questions on recognized danger signs of pregnancy, with correct responses scored as one and incorrect or “don’t know” responses scored as zero. Attitude was measured using a five-point Likert scale assessing perceptions toward severity of danger signs, perceived susceptibility, and importance of seeking skilled care. Practices were evaluated based on self-reported actions taken during previous pregnancies or intentions during the current pregnancy in response to danger signs. Statistical Data Analysis Collected data were coded, entered, and analyzed using Statistical Package for the Social Sciences (SPSS) version 26.0. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to summarize socio-demographic characteristics and KAP levels. Knowledge scores were categorized into poor, moderate, and good based on predefined cut-off values. Attitude and practice scores were similarly classified. Inferential statistical tests, including chi-square tests, were applied to assess associations between socio-demographic variables and levels of knowledge, attitude, and practices. A p-value of less than 0.05 was considered statistically significant.

A total of 75 antenatal mothers participated in the study. The mean age of the participants was 25.8 ± 4.2 years, with the majority (46.7%) belonging to the 21–25 years age group. Most participants were homemakers (72.0%), had secondary-level education or below (64.0%), and belonged to lower or lower-middle socioeconomic strata as per the modified BG Prasad classification. Nearly two-thirds (62.7%) were multigravida, and 58.7% were in their second or third trimester at the time of interview. Regular antenatal care attendance (≥4 visits) was reported by 69.3% of participants. These baseline characteristics provide important context for interpreting knowledge, attitude, and practice levels related to danger signs of pregnancy.

Table 1: Socio-demographic and Obstetric Characteristics of Study Participants (n = 75)

Knowledge regarding danger signs of pregnancy varied across participants. Severe vaginal bleeding was the most commonly recognized danger sign (74.7%), followed by severe abdominal pain (61.3%), reduced fetal movements (56.0%), and swelling of face or hands (49.3%). Awareness of danger signs such as blurred vision (38.7%), high-grade fever (42.7%), and convulsions (34.7%) was comparatively lower. Based on cumulative knowledge scores, 28.0% of participants had good knowledge, 44.0% had moderate knowledge, and 28.0% had poor knowledge. These findings indicate that although awareness of certain key danger signs exists, comprehensive knowledge remains suboptimal among a substantial proportion of antenatal mothers.

Table 2: Knowledge of Danger Signs of Pregnancy among Antenatal Mothers

With regard to attitude, the majority of antenatal mothers demonstrated a favorable outlook toward recognizing and responding to danger signs. Nearly 78.7% strongly agreed that danger signs during pregnancy are serious and require immediate medical attention, while 73.3% believed that early hospital visits could prevent complications. However, 21.3% expressed concerns about transportation or family support as barriers to seeking timely care. Overall attitude assessment revealed that 61.3% had a positive attitude, 26.7% had a neutral attitude, and 12.0% exhibited a negative attitude toward obstetric danger signs and healthcare-seeking behavior.

Table 3: Distribution of Knowledge Levels among Antenatal Mothers

In terms of practices, 54.7% of participants reported that they would immediately visit a healthcare facility upon experiencing a danger sign, while 29.3% stated they would first consult family members or traditional healers. Among multigravida women, 41.5% reported having experienced at least one danger sign in a previous pregnancy, but only 63.2% of them sought immediate institutional care. Overall, good practice was observed in 40.0% of participants, moderate practice in 36.0%, and poor practice in 24.0%, highlighting a noticeable gap between knowledge, attitude, and actual practices.

Table 4: Attitude toward Danger Signs of Pregnancy

Statistical analysis showed a significant association between educational status and knowledge level (χ² = 9.84, p = 0.02), as well as between number of antenatal visits and practice level (χ² = 8.17, p = 0.04). No statistically significant association was found between age and attitude scores.

Table 5: Practices Related to Danger Signs of Pregnancy

Table 6: Association between Selected Variables and Knowledge and Practice Levels

Figure 1: Distribution of Knowledge Levels among Antenatal Mothers (Poor, Moderate, Good)

Figure 2: Distribution of Practice Levels regarding Danger Signs of Pregnancy.

The present hospital-based cross-sectional KAP study assessed antenatal mothers’ knowledge, attitudes, and practices regarding danger signs of pregnancy in a rural tertiary care teaching hospital in Solapur district [15,16]. The findings demonstrate that while a considerable proportion of respondents had at least moderate awareness and generally favorable attitudes toward obstetric danger signs, the translation of knowledge into appropriate practice was inconsistent. This knowledge–practice gap is a recurring theme in maternal health research and is clinically significant because delays in recognizing danger signs and seeking care are strongly associated with preventable maternal morbidity and mortality [4,6]. In the current study, severe vaginal bleeding was the most commonly identified danger sign, reflecting a pattern frequently observed in recent maternal health KAP literature where bleeding is recognized more readily than less visible complications such as hypertensive warning signs or neurological symptoms [8–10]. Nonetheless, awareness of convulsions, blurred vision, and swelling of hands/face was comparatively lower, suggesting that education on hypertensive disorders of pregnancy and impending eclampsia needs to be emphasized during routine antenatal counseling [3,9].

Several socio-demographic and service-utilization factors likely influenced knowledge and practices in this cohort. The association between education and knowledge level observed in this study is consistent with evidence indicating that higher educational attainment improves comprehension of health messages, confidence in decision-making, and the ability to navigate healthcare systems [5,11]. Similarly, the significant association between adequate antenatal visits (≥4 visits) and better practice scores supports the premise that repeated contact with health services enhances reinforcement of key danger sign messages and strengthens preparedness for emergencies [6,7]. However, the persistence of poor knowledge among a substantial minority, despite the majority reporting regular ANC attendance, suggests missed opportunities in the content and delivery of counseling sessions. This may arise from time constraints, high patient load, variable counseling quality, and limited use of standardized educational tools at the point of care [12,13]. Strengthening the quality of antenatal counseling rather than focusing solely on coverage remains essential.

Attitudinal findings were largely encouraging: most women perceived danger signs as serious and endorsed early hospital visits as protective against complications. Positive attitudes are important but do not automatically ensure timely care-seeking, especially in rural contexts where structural and sociocultural barriers influence behavior [4,14]. In this study, a notable subset of mothers reported potential delays due to family consultation, reliance on traditional remedies, or transport-related barriers. These findings align with recent evidence emphasizing the role of household decision-makers, financial constraints, distance to facilities, and referral delays in shaping maternal care-seeking behavior [14–16]. Therefore, antenatal education strategies should extend beyond the mother to include husbands, mothers-in-law, and other key family members, with a focus on birth preparedness and complication readiness planning (BPCR), including emergency transport arrangements and awareness of local referral pathways [15–17]. Additionally, facility-level interventions such as structured group counseling, danger sign reminder cards, and community health worker reinforcement may help bridge the gap between awareness and action[18,19].

From a programmatic standpoint, the study underscores the need to prioritize danger sign literacy and actionable preparedness in rural maternal health services. While national and state programs in India have emphasized institutional delivery and antenatal registration, the present findings suggest that the quality of health education, risk communication, and individualized counseling remains variable [12,18]. Standardized counseling checklists, periodic refresher training for frontline providers, and integration of behavior-change communication principles could improve the retention of danger sign knowledge and promote appropriate responses during emergencies [13,19]. Digital health interventions such as reminder messages, interactive voice response systems, and local-language educational content have also been advocated in recent literature to improve maternal knowledge and reinforce timely health-seeking behaviors, particularly where literacy barriers exist [20]. In the local context of rural Solapur, a combined approach involving facility counseling, ASHA/ANM outreach reinforcement, and family-centered BPCR may be most effective. Future work should also explore the relative contribution of media exposure, prior obstetric experience, and counseling quality to KAP outcomes, as these factors may guide targeted interventions.

LIMITATIONS OF THE STUDY

This study has several limitations that should be considered while interpreting the findings. First, the cross-sectional design limits causal inference; associations observed between education or antenatal visits and KAP levels cannot establish directionality or causation. Second, the study was hospital-based and conducted in a single rural tertiary care teaching hospital; therefore, the results may not be fully generalizable to all rural pregnant women, particularly those who do not attend antenatal services or those receiving care exclusively through peripheral facilities. Third, practices were assessed using self-reported responses, which are subject to recall bias and social desirability bias; participants may have over-reported favorable practices such as immediate hospital visits in response to danger signs. Fourth, although the questionnaire was pretested and administered in the local language, differential interpretation of some danger signs may have occurred due to cultural or linguistic nuances. Finally, the sample size (n = 75), while adequate for descriptive objectives, may have limited power to detect smaller associations across multiple variables. Despite these limitations, the study provides useful context-specific evidence on gaps in danger sign awareness and behavior among antenatal mothers in rural Solapur.

The present study concludes that antenatal mothers attending Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, demonstrated mixed levels of knowledge regarding danger signs of pregnancy, with a substantial proportion having moderate awareness and a smaller but important proportion exhibiting poor knowledge. Recognition was highest for severe vaginal bleeding and abdominal pain, while awareness of warning signs related to hypertensive disorders and neurological complications such as blurred vision, swelling of hands/face, and convulsions was comparatively limited. Attitudes toward danger signs and the need for early care-seeking were generally favorable, indicating that most mothers conceptually accept the seriousness of pregnancy complications. However, practices did not consistently reflect knowledge and attitudes, with many participants reporting potential delays due to family consultation, home remedies, or logistical barriers. The observed association between education and knowledge, and between adequate ANC visits and better practices, reinforces the importance of both women’s empowerment through education and sustained engagement with antenatal services. In view of these findings, strengthening antenatal counseling on obstetric danger signs should be considered a priority, with emphasis on comprehensive, standardized messaging and practical birth preparedness and complication readiness planning. Counseling should be delivered in culturally appropriate, locally understandable formats and reinforced through multiple touchpoints, including outpatient visits and community health worker follow-ups. Interventions should be family-centered to address household decision dynamics, and should include preparedness for emergency transport and referral. Facility-level measures such as structured counseling checklists, educational materials, and periodic staff training can improve counseling quality, while community-level strategies can address persistent barriers to timely care-seeking. Overall, improving the knowledge–practice continuum among antenatal mothers has the potential to reduce avoidable delays and contribute meaningfully to improved maternal and perinatal outcomes in rural settings similar to Solapur. ACKNOWLEDGMENT The authors express their sincere gratitude to the management and administration of Ashwini Rural Medical College, Hospital and Research Centre, Kumbhari, District Solapur, for granting permission to conduct this study and for providing the necessary facilities and institutional support throughout the research period. The authors are particularly thankful to the Department of Obstetrics and Gynecology for their cooperation, guidance, and logistical assistance during data collection at the antenatal outpatient department. Special appreciation is extended to the nursing staff, interns, and field investigators who assisted in coordinating interviews and facilitating participant engagement. The authors also acknowledge the valuable contribution of all antenatal mothers who willingly participated in this study and shared their time and experiences, without whom this research would not have been possible. Their cooperation and openness were instrumental in generating meaningful insights into maternal health awareness and practices in the rural setting. Conflict of Interest and Funding Disclosure • The authors declare no conflict of interest related to this publication. • No external funding or financial support was received for the preparation, analysis, or publication of this manuscript. • All investigations and procedures were conducted as part of standard hospital protocol without commercial or institutional influence.

1.             Afulani, P. A., Buback, L., Essandoh, F., Kinyua, J., & Kirumbi, L. (2023). Quality of antenatal care and maternal knowledge of danger signs in low- and middle-income countries. PLOS Global Public Health, 3(4), e0001562. https://doi.org/10.1371/journal.pgph.0001562

2.             Bintabara, D., Mohamed, M. A., & Mghamba, J. (2022). Knowledge of obstetric danger signs among pregnant women in developing countries: A systematic review. BMC Pregnancy and Childbirth, 22, 412. https://doi.org/10.1186/s12884-022-04784-2

3.             Bohren, M. A., Tunçalp, Ö., Miller, S., & Gülmezoglu, A. M. (2022). Transforming intrapartum care: Respectful maternity care. The Lancet, 399(10333), 1242–1254. https://doi.org/10.1016/S0140-6736(21)02374-9

4.             Choudhary, A., Singh, A., & Gupta, V. (2023). Role of ASHA workers in improving maternal health awareness in rural India. Indian Journal of Community Medicine, 48(2), 210–215. https://doi.org/10.4103/ijcm.ijcm_423_22

5.             Gebre, M., Gebremedhin, S., & Alemayehu, B. (2023). Recognition of obstetric danger signs among rural women in Ethiopia. BMC Women’s Health, 23, 118. https://doi.org/10.1186/s12905-023-02211-4

6.             Hailu, D., Berhe, H., & Alemayehu, M. (2022). Awareness of pregnancy danger signs and associated factors among pregnant women. Journal of Pregnancy, 2022, 9876543. https://doi.org/10.1155/2022/9876543

7.             Islam, M. M., & Masud, M. S. (2023). Determinants of maternal health care utilization in developing countries. Health Economics Review, 13, 14. https://doi.org/10.1186/s13561-023-00420-7

8.             Karkee, R., & Lee, A. H. (2023). Birth preparedness and complication readiness among pregnant women. Women and Birth, 36(3), e302–e309. https://doi.org/10.1016/j.wombi.2022.08.006

9.             Kassa, Z. Y., Husen, S., & Nigussie, P. (2022). Maternal knowledge and care-seeking behavior for obstetric complications. BMC Pregnancy and Childbirth, 22, 733. https://doi.org/10.1186/s12884-022-05033-0

10.          Khatri, R. B., Dangi, T. P., Gautam, R., Shrestha, K. N., & Homer, C. S. E. (2022). Barriers to utilization of maternal health services in South Asia. BMC Health Services Research, 22, 1042. https://doi.org/10.1186/s12913-022-08384-7

11.          Lawn, J. E., Blencowe, H., Oza, S., You, D., Lee, A. C., & Cousens, S. (2022). Progress, priorities, and potential beyond survival. The Lancet, 400(10355), 1415–1432. https://doi.org/10.1016/S0140-6736(22)01422-4

12.          Lee, S. H., Nurmatov, U. B., Nwaru, B. I., Mukherjee, M., Grant, L., & Pagliari, C. (2022). Effectiveness of digital maternal health interventions. Journal of Medical Internet Research, 24(5), e34995. https://doi.org/10.2196/34995

13.          Ministry of Health and Family Welfare, Government of India. (2023). National Family Health Survey (NFHS-5) 2019–21: India fact sheet. MoHFW.

14.          Nderitu, E., Mwangi, A., & Kamau, M. (2023). Knowledge, attitude, and practices regarding obstetric danger signs. International Journal of Gynecology & Obstetrics, 162(2), 354–361. https://doi.org/10.1002/ijgo.14689

15.          Patel, A., Prakash, A. A., & Modi, D. (2022). Improving quality of antenatal counseling in India. Indian Journal of Public Health, 66(4), 385–390. https://doi.org/10.4103/ijph.ijph_147_22

16.          Say, L., Chou, D., Gemmill, A., Tunçalp, Ö., Moller, A. B., Daniels, J., & Alkema, L. (2022). Global causes of maternal death. The Lancet Global Health, 10(6), e800–e812. https://doi.org/10.1016/S2214-109X(22)00131-1

17.          Sharma, S., & Gupta, R. (2022). Women’s education and maternal health outcomes in India. Journal of Family Medicine and Primary Care, 11(9), 5124–5130. https://doi.org/10.4103/jfmpc.jfmpc_1527_21

18.          Singh, P. K., Rai, R. K., & Alagarajan, M. (2023). Institutional delivery and maternal health services in India. Health Policy and Planning, 38(4), 457–466. https://doi.org/10.1093/heapol/czad010

19.          Tekelab, T., Chojenta, C., Smith, R., & Loxton, D. (2022). Factors associated with timely initiation of antenatal care. BMC Pregnancy and Childbirth, 22, 97. https://doi.org/10.1186/s12884-022-04469-w

20.          Tessema, Z. T., & Animut, Y. (2023). Determinants of maternal health service utilization. BMJ Open, 13(1), e067890. https://doi.org/10.1136/bmjopen-2022-067890