Antenatal attendance provides an opportunity to inform and educate pregnant women about pregnancy, childbirth and care of the newborn, and therefore enable pregnant women acquire information on danger signs of pregnancy or childbirth. It is anticipated that from antenatal care, women are assisted to develop a birth plan that ensures birth preparedness and readiness in the eventuality of pregnancy or childbirth complications [3, 4]. Such a birth plan is expected to assist women in making choices that would contribute to good pregnancy outcome. Our study shows that parity, age of spouse, education level, occupation of spouse, presence of pregnancy complications and the anticipated mode of delivery were associated with having a birth plan. Educated women have better pregnancy outcome compared with uneducated women, possibly since they are better informed, are likely to make better choices, are more likely to develop and implement a birth plan, and are more socially or financially empowered to make the necessary decisions in case of obstetric emergencies . Information, education and counseling plays a vital role in prevention of maternal death. This it does by making the pregnant women (and their partners) aware of the sequence of events from late recognition of danger signs, through delays in seeking care to delays in receiving prompt care. An appropriate programme of health literacy or behavior change communication, such as implementing a birth plan, can circumvent this sequence.
Optimal management of pregnancy, labor and childbirth ensures maternal survival by ensuring that pregnant women (as well as women in labor and their newborns) have access to life saving interventions for managing obstetric and newborn complications [9, 10]. In case this care is unavailable at a peripheral facility, mothers are referred to a tertiary facility where care may be obtained. This process inevitably leads to delays in receiving prompt appropriate care. Such delays may result from failure to recognize the need to refer the mother in time, unavailability of transport, failure to meet transport costs, or absence of someone to accompany the referred patient. Once implemented, the birth plan is critical in addressing the first and second of the three delays to receive prompt care in pregnancy and childbirth complications.
Our findings are in agreement with others [11, 12] that many patients are admitted when they already have life threatening complications. This is a reflection of the quality of antenatal care at peripheral units (where such complications may be identified early), the quality of obstetric care at the referring units and the efficiency of the referral system. The delays to access care for referrals may be due to problems of geographical access to the hospital, as the district is hilly and many homesteads are inaccessible with motorized transport. The finding that many of the referrals were in critical condition at admission suggests possible delays in making the decision to refer (possibly due to difficulty in diagnosis), delays in reaching the referral hospital or poor quality of care at the referring health facility. Indeed, diagnostic delays and misdiagnosis are responsible for many of the near-miss mortality and are common among emergency obstetric referrals [13, 14]. Awareness of the danger signs of obstetric complications is the essential first step in accepting appropriate and timely referral to obstetric and newborn care. Studies that have assessed the availability of a birth plan in pregnant women indicate that opportunity for developing and implementing one are often missed. In a study from Nigeria, 61% of the pregnant women studied made adequate preparations for delivery while only 4.8% were ready for emergency/complication , recommending that greater emphasis should be placed on education about emergency/complication readiness during antenatal care. In a study from Kenya , 87.3% of the respondents were aware of their expected date of delivery, 84.3% had set aside funds for transport to hospital during labour while 62.9% had funds for emergencies, 67% knew at least one danger sign in pregnancy, while only 6.9% knew of three or more danger signs.
During antenatal care, only 60 (42.9%) mothers reported having been accompanied by spouses, while for 58 (41.4%) the spouse remained at home while looking after the home and children. Thirty five mothers (25.0%) reported that their spouses helped them with household chores during the antenatal period. During labor, 96 mothers (68.6%) were accompanied by their spouses. Apparently, the women who had a birth plan were more likely to be accompanied by the spouses to health facilities during antenatal care and to the labor ward during labor. They were also more likely to report more support from spouses in looking after children or assistance with household chores during pregnancy. Our findings are similar to those from a study in Northern Uganda  which found that several men were actively involved in birth prepareness and complication readiness when their spouses were pregnant or in labor. In the Northern Uganda study , men who were knowledgeable of ANC services, obtained health information from a health worker and whose spouses utilized skilled delivery at last pregnancy were more likely to accompany their spouses at ANC. This finding suggests that providing information to male partners of pregnant women attending antenatal care might increase their involvement and participation. Prenatal male involvement has been associated with positive outcomes for the mother and baby, which include more antenatal care visits, cessation of smoking and alcohol consumption, participation in high-risk behavior reduction strategies to prevent vertical HIV transmission and more birth preparedness in case of pregnancy complications [7, 8, 18–22]. Unfortunately, in most studies, male partner involvement in maternal and child health is still low in many sub-Saharan African countries.
In our assessment, we acknowledge several limitations: this study was hospital-based among referred patients, such that results are not generalizable to the community. Secondly, the questions about the birth plan were inquired into after delivery, which may create some bias. Ideally, they should be asked before delivery. Thirdly, presence of obstetric complications may influence the acquisition and therefore availability of a birth plan. Indeed, some women may recall or provide information about the birth plan selectively, depending on the delivery experience or pregnancy outcome. Fourthly, information about spouses' role in birth readiness and complication readiness were asked after delivery and after complications had occurred. However, this was the objective of the study, that is, assessing the role played by spouses in birth plan and complication readiness. There is no way one can verify that the responses were not the socially desirable responses, more so considering that the interviews were conducted at the a health facility. The interviews were conducted in absence of spouses to avoid biased responses. Despite the limitations, we believe the study provides relevant information on birth preparedness and complication readiness for women in rural areas, and identify missed opportunities for interventions to improve emergency obstetric care.
Antenatal care represents a window of opportunity for information, education and communication to pregnant women so that they are well make appropriate choices especially when they are in danger. However this opportunity is often missed [23, 24]. This problem is compounded by the inadequate health care system characterized by misplaced priorities, inaccessibility of essential health information to the women most affected, physical as well as economic and geographical distance separating health services from most women, delay to receive adequate and appropriate care . Others are lack of minimal life-saving equipment at the first referral level; the lack of equipment, personnel, and know-how even in referral hospitals. Our findings are in agreement with those in Nigeria  that factors influencing maternal health services utilization operate at various levels - individual, household, community and state, and depending on the indicator of maternal health services, the relevant determinants vary.
Observational studies suggest that including men in reproductive health interventions can enhance positive health outcomes. Where pregnant women and their male partners are given health education together, there is a greater net impact on maternal health behaviors (such as healthcare seeking) compared to educating the women alone . Education and health services provided during the antenatal period have the potential to reduce pregnancy and delivery complications and improve birth outcomes in resource-poor settings [28, 29]. Women's ability to seek health care or implement lessons learned from health education interventions (by developing their own birth plans) is often determined by the household head, who usually is the husband [30, 31]. While the critical role that male partners play in women's reproductive health has been recognized for several years, more attention needs to be focused on involving men in reproductive health education interventions. Men can influence health care utilization during pregnancy and thereby the outcome of an obstetric emergency [32–34] by contributing to development of the birth plan. Indeed, in a study in Northern Uganda , men who were knowledgeable of antenatal services and whose spouses utilized skilled delivery at last pregnancy were more likely to accompany their spouses at antenatal care and possibly for delivery.