Nomonanoto Show

Tuesday, July 9, 2013

Side Goodo
“Human inability to alter the course of wretchedness and misery results in a desire for diversion. But the flaw in diverting our attention via diversion lies in the fact that it keeps us from realizing truth: And yet it is the greatest of our miseries. For it is that above all which prevents us thinking about ourselves and leads us imperceptibly to destruction … diversion passes our time and brings us imperceptibly to our death”. (Pascal, 1995. Trns.)

Based on naturalistic framework taken for granted by scientifically validated common sense, human beings are considered to be a particular sort of evolved animals, homo sapiens. Thus, undeniably, as a particular animal species, human beings have common attributes that distinguish them from other animal species.

However, unlike other animals, human beings have passed through intricate processes of identity development which takes us far beyond the philosophy of human being. Human identity is just that animal identity reflecting the collection of material parts suitable for the support of human existence and continuation of the species. Thus no one with in the home sapiens species can be born with out the common, universal attribute that distinguishes this species from other animal species. Otherwise that particular individual should be classified as a non-human being.

Beyond human identity, we find a distinct personal identity defined on the basis of the functions rather than the underlying nature of that being. This refers to a man as a moral agent or a moral or a rational being. This identity is as distinct as it is an essential attribute of humanity. In the absence of such distinct personal identity the essential attributes of man as a rational being do not exist. Then, the attribute of all animal species including home sapiens can be conveniently compared with the attributes of other animal species where donkeys, cats or dogs belong. However, human individuals posses a morally vital sense of personal identity. Both necessary and sufficient condition for the existence of such morally vital sense of identity is consciousness. A person is not just a moral being but also a moral and a conscious being. Issues such as accountability for ones actions emanate from the very existence of morally conscious being. Thus, it is not the universal attribute of human identity but the attributes of personal identity that are the most important objects of societal concern.

Human evolution bestowed human individuals with verities of identities. On top of the universal human identity and personal identity, we also find racial identity, ethnic identity and political identity. Racial and ethnic identity are critical parts of the overall framework of individual and collective identity. Thus they can not be dubbed as accidents of historical contingencies. Ethnic identity development consists of an individual’s movement towards a highly conscious identification with their own cultural values, behaviours, beliefs and traditions. This is a higher stage of human identity development compared to a rudimentary human identity and a more conscious personal identity. This is because a sense of ethnic identity is developed from shared culture, religion, geography, and language of individuals who are connected by strong loyalty and kinship or genealogy none of which are accidents of historical contingencies.

In advanced western societies with a common race and language, ethnic identity is manifested in mostly unconscious ways through their behaviours, values, beliefs and assumptions. For them ethnicity is usually invisible and unconscious because societal norms have been constructed around their racial, ethnic and cultural frameworks, as well as values and priorities which could be referred to as a culture of a country X. However, in underdeveloped countries such as ours, one can not talk of the “Ethiopian culture” because here societal norms have been constructed around specific ethnic and cultural frameworks as well as values and priorities, unless of course we force the various ethnic groups to submit to a societal norm of one politically dominant ethnic group.

Apart from this, in multiethnic societies an individual naturally integrates ethnicity into his/her self-concept or self-image. This leads to the development of ethnic self-identity. This is a full recognition of ones ethnicity and the subsequent self-identity that flows from the values, and norms of that ethnic group regardless of the opinions and the prejudices of the dominant ethnic group against it. Ethnogenesis is a very complex process. It involves an interaction of contextual and developmental factors. As opposed to racial identity which is defined on the basis of hereditary particles or genes and physical characters and that can disappear from time to time due to geographic and cultural isolation, ethnic identity is a continuous process.

In this context, therefore, ethnic identity is the most important element of human development and can not easily be reduced into an accident of historical contingency.

When the geographic boundaries of an ethnic population and a political state coincide, ethnic identity refers to national identity, i.e. a nation-state. Therefore, in this sense, ethnic identity is the basis of political identity. In this case there will be no conflict between ethnic self-identity and political identity. The problem arises when a political state extends beyond the geographic boundaries of an ethnic population as in the case of the present day Ethiopia.

Under these circumstances conflicts between various ethnic groups for the control of resources with in that geographic boundaries is inevitable. In the absence of clear and agreeable socio-political contracts among these various ethnic groups (which is often the case), the dominant group is bound to oppress and exploit the minorities or the less dominate ones. Anthropologist and historians suggest that such conflicts among ethnic groups should be resolved in one of two ways: first, the legitimacy of modern states must be based on notion of political rights of autonomous individual subjects. According to this view the state should not acknowledge the ethnic, national or racial identity, but instead enforce political and legal equality of all individuals. The second and the most dominant view is that the autonomous individual it self is a cultural construct and hence it is not possible to separate it from ethnic identity. According to this view states must recognise ethnic identity and develop a process through which the particular needs of ethnic groups can be accommodated with in the boundary of the state. If the state fails to address this fundamental problem, it is incumbent upon the ethnic groups to fight for their own separate nation state as we observe in Ethiopia at present. This process can be accentuated by irredentism or grievances with in the state boundary.

Thus the issue of ethnic identity in multiethnic countries like Ethiopia is of paramount importance. First ethnic demands and their legitimacy must be fully recognised. Then the state must clearly indicate which approach it follows to resolve conflicts among the various ethnic groups (most often between the dominant ethnic group and the rest) with in the state. It must be clear whether the state follows the notion of political rights of autonomous individual with no recognition to the ethnic identity or it recognises ethnic identity and agrees to develop a process to accommodate the particular needs of the ethnic group with in the boundary of the state, period.

There is no in-between solution to this fundamental human demand. However, the views of some Ethiopian scholars on this fundamental demand of humanity are inherently flawed. Instead of addressing the issue, the scholars choose to follow what Pascal calls the philosophy of diversion. Instead of addressing a rather straightforward question of ethnic identity, they try to divert the issue by reverting to unnecessary comparisons with universal human attributes that separates us from other animal species which are irrelevant here. They fail to understand and appreciate the value of ethnic self-identity in social development. They try to portray as if ethnic identity contradicts political identity. They try to deny the fact that the foundation of modern nation state is ethnic identity. Our preceding argument clearly indicated that there is no inherent contraction between ethnic identity and political identity. This incoherent attempt of diversion is a reflection of the most disturbing and the most fundamental principle of diversion in Ethiopia, i.e. trying to present Ethiopia as the country of “one people and one language”.

That is the reason why I began my rather short article on ethnic identity with a quote from one of the greatest philosophers, Pascal. We have one and only one choice: use scientific knowledge humanity has accumulated over time to address the problem. Stop diversion. Discover the truth. Avoid an inevitable death to the country.
Side Goodo
1. Introduction

Time and again the Sidama people have rejected the use of the derogatory term “Sidamo”. The term was a deliberate fabrication by the invading Abyssinian soldiers of King Minelik as part of the campaign to humiliate, undermine and subjugate the newly conquered territories in the South of the country.

This article is motivated by the outrageous statements made by Eremias Woldemikael during his email conversations with Kambata Xola of Sidama National Liberation organization (SNLO) regarding the Abyssinian occupation, subjugation and exploitation of the Sidama land. Eremias writes:

“When I was referring to Sidama and Oromo relationship, I was using the term ‘Sidama’ in a historical sense. Historians use the term ‘Sidama’ to refer to peoples that lived South of and including some part of Shewa. The term "Sidamo" is used to one of the ethnic groups of those peoples. As you may know the region was conquered by the Oromo during their expansion in the 16th c. For further information on the distinction between Sidama and Sidamo, see J.S. Trirmingham's Islam in Ethiopia pp. 179-185 and Mordechai Abir's Ethiopia: The Era of the Princes pp.73. By making this distinction, I hope you do not feel like I am trying to lecture you about your culture or ethnicity. I am simply trying to explain the context of my discussion”.

I am shocked to read the above statements in the 21st century. I agree with Eremias, on one point, however. Abyssinians do not know anything and do not want to now anything about non-Abyssinian peoples such as Sidama. They must be taught not only about democracy, respect to human dignity and the rule of law but also the fact that there are other proud nations in Ethiopia who have their own history, who know their history very well and who can articulate these at least as much as the Abyssinians do regarding their peoples. Who is Eremias to tell us who we are and who wrote what rubbish about us? We, the Sidama people very well know where we originated, when and where we first settled in Ethiopia and when and how we came to our present land. Quoting rubbish written on Sidama by foreign transcribers of Abyssinian rulers and telling us that the Oromos conquered us in the 16th century, which they did not, is as outrageous as it is a blatant distortion of our history. Our brief history is presented in the next section in case it may wake Abyssinians like Eremias up in the future. The origin of the misnomer “Sidamo” is elaborated in section 3 of the article. Section 4 presents other evidences of deliberate name changes by Abyssinian rulers in Sidama. Finally, section 5 concludes the article.

2 An overview of the history of Sidama people

The Sidama people live in the southern part of the present day Ethiopia, in the Horn of Africa. They belong to the people of Kushitic origin that occupy the vast area of north eastern and eastern Africa extending from the Sudan throughout the Horn of Africa to Tanzania. The most notable peoples of the Kushitic origin to which the Sidama people belong include, the Saho in Eritrea, Oromo, Hadiya, Afar and Somalis in Ethiopia; the Somalis especially the Degodai tribe both in Somalia and Kenya; the Randle and Sakuye in Kenya and many others in Eastern and central Africa. The Sidama along with Agew and Beja were the first settlers in the northern highlands of the present day Ethiopia before the arrival of Yemeni habeshas (Abyssineans). That was why the present day Ethiopia was called the land of Kush. The Abyssinian historians such as Taddese Tamirat themselves accept this fact.

At present the majority of the Sidama people live in the Southern part of Ethiopia with notable geographical features like lake Awassa in the North and lake Abaya in the South. The population of the Sidama land is about 5 million at present. However, during the course of great popular migration from North and East to the South of Africa, some Sidamas were left behind and were later scattered into different parts of the country and even beyond. One example of such groups of people related to Sidama includes those who live around river Dawa in South Eastern Ethiopia and North Eastern Kenya. The Dawa river was the turning point in the history of the migration of the Sidama people from North to the South. These people now speak Somali language and identify themselves as Digodai, the clans of which include several clans in Sidama. The most notable of these clans is Fardano whose name is maintained both in Sidama and Somali Digodai tribe with out slightest modification. Other people that have even greater affiliation to the Sidama people and its culture and language and that were only separated from the present day Sidama land most recently include Alaba, Tambaro, Qewena and Marako. These groups of the Sidama people live in the western vicinity of the present day Sidama land. This latter group of Sidama people are called western Sidamas. The transcribers of the Abyssinian rulers whom Eremias quotes as his authentic sources on Sidama were misled by the post Minelik Abyssinians writers into believing that there were two different groups of peoples called “Sidamo” and Sidama. That is not only absolutely incorrect but also absolutely outrageous!! I will show why in the next section.

3. The Origin of the Misnomer “Sidamo”


When Baalichcha Worawo, the last king of Sidama, made the Wuchale type treaty with Bashah Aboye, the general of Minelik and the leader of the invading Abyssinian army that first set its foot on the Sidama land in 1891, the latter asked the King of Sidama what the name of this people was called. King Baalichcha Worawo told him that his people were called the Sidama people. However, Beshah never used the name Sidama to refer to this people. This was because it was part of the policy of occupation and subjugation to humiliate the occupied territories by degrading their identity either by selling the peoples as slaves or using other humiliating mechanisms such as calling them with inferior names. Accordingly, Beshah and his soldiers refused to call the people in their real name and started to call them “Sidamo” which implied their inferior status now under occupation. However, because the treaty between Beshah and King Baalichcha failed to work, Beshah’s army was defeated and Beshah retreated back to Shewa. The Sidama land was free once again although it was for a brief period.

When Beshah arrived back in Addis Ababa, he reported to emperor Minelik that he encountered some people called “Sidamo” who repulsed his army. Thus the term “Sidamo’ was first coined by Beshah Aboye and his soldiers in 1891. That was how the term emerged. There have never been any people called “Sidamo” and there never are at present!!

Abyssinians had to change the direction of their attack on Sidama from the north western tip of Sidama near lake Awassa where Beshah was defeated by Baalichcha Worawo to the more remote eastern highland of Hula adjacent to Bale in the present day Oromia region. This time another general of Minelik called Leulseged (probably a Tigre due to his name) launched a massive military attack which was superior in armament and ammunition compared to the ordinary armaments the Sidama people then had to reoccupy the Sidama land. He successfully reoccupied the Sidama land and established his first administrative post in Hula which they later called Hagereselam town in the mid 1890s.

Later in 1890s Leulseged forced Baalichcha Warawo to join him in his campaign to conquer the Konso land, south of Sidama. King Baalichcha had no power to refuse to accompany Leulseged because he was now under occupation. King Baalichcha Worawo was taken to the Konso land wth the pretext of assisting the conquest and was assassinated there by Leulseged. His mule called Laango on which Baalichcha travelled to Konso came back home travelling an amazing distance of over 200 kms by its own. To date the Sidama people lament about Baalichcha’s assassination by saying that: “Warawo Baalichcha, diinu galafati ma manchi shaalicha. Gaangichosi Laango, Baalichchi gorena bae dagu gaango”, roughly translated as “ the enemy brutally murdered the beloved King of Sidama. But his mule escaped and came home alone!!”.

After the Conquest of Sidama, Gedeo, the Guji and Borana Oromos and other smaller Kushitic nations south of Sidama, the entire area of Sidama and south of Sidama including Wolayita and starting from Tikur wuha in Awassa town up to Moyale on the Ethiopian-Kenyan border was named the “Sidamo” province by the successive Amhara rulers until the early 1980s when the military Junta reduced the size of the “Sidamo” province by separating Wolayita and Borana from it. This province was dissolved when TPLF fabricated another pseudoregion called the South Ethiopia Nations and Nationalities and People’s Region in 1993.

The Wolayita people who bordered western Sidama land also resisted the Abyssinian occupation very strongly. After they were defeated, their King Xoona was captured by Minelik’s army and was taken to Addis Ababa and was killed there. Due to their fierce resistances, the Wolayita people were given the name of baria (slaves) and harshly mistreated by the Abyssinians. They were sold as slaves in the country. As a result of their resistance their name was deliberately changed from Wolayita to “Wolamo”. This justifies our previous argument that the name change from Sidama to “Sidamo” and its application as a name of a province that includes, Sidama, Gedeo, Burji, Wolayita, the Guji and Borena Oromos was a deliberate policy of humiliation. This was aimed at degrading the occupied nations and subject them to a psychological torture to tame them for permanent slavery. Until recently, the Wolayita people were called the “Wolamo” which is an out right derogatory and insulting misnomer. While “Wolamo” is less frequently used at present, we the Sidama people are being insulted by Abyssinians like Eremias Woldemikeal being called “Sidamo” in the 21st century. This is an abuse of the right of the Sidama people to be called by their right identity. If people like Eremias will not unconditionally stop from insulting us again by calling us “Sidamo”, we will regard this as a deliberate abuse of our right as a nation and refer the case to the relevant international human rights organizations.

Another outrageous statement by Eremias Woldemikael is the following:“Now, I understand you are concerned only about the Sidamo people who still very specifically use that term for their ethnicity. I have read some about them but I am open to any new information you can contribute to my knowledge of the people and their issues.”

Which people use the term “Sidamo” to refer to their ethnicity? We the Sidama people in Sidama land with the capital city of Awassa never called ourselves “Sidamo” in our entire history. The other Sidama people in Alaba, Qewena, Xambaro or Marakko never call themselves “Sidamo”. The Woalyita, the Gedeo, Burji, the Guji and Borena Oromos to which the name “Sidamo” province referred to never accepted that name and none of them used the term “Sidamo” before or now. So which ethnic group uses the term “Sidamo” at present? Where did Eremias read about this non-existent ethnic group? If Eremias is able to distort the truth at present while the Sidama intellectuals are providing the correct information about Sidama, one can imagine how his uneducated ancestors were able to distort our names and history in 1890s and thereafter. It is amazing how Abyssinians are unwilling to learn from their past mistakes and unwilling to accept the correct account of history other than the ones fabricated by their rulers and written by some foreign opportunistic transcribers who served as chroniclers of the Abyssinians kings.

4. Further Evidences of Deliberate Name Changes in Sidama
The use of the derogatory terms and name changes by invading Abyssinian forces was not limited to the fabrication of the derogatory misnomer “Sidamo” for the Sidama people, “Wolamo” for the Wolayita people and so on.

The settling Abyssinian rulers exercised a policy of deliberate name change on the Sidama people after their attempt to forcefully convert the Sidama people into orthodox Christianity in 1910s and 20s failed. The Sidama people rejected deliberate conversion to orthodox Christianity by lamenting this statement: “Xoomi yihero xoomi. Xoomiro xoomo gowwu doomi. Miniki giddo doogo nooni?” roughly translated as “If they ask you to fast, do it. Let the foolish do it. But is there any road through your house? Why do you even bother about it?”. The ingenious and most democratic Sidama elders used to organise the Sidama resistances through such poems which most of the time were very effective and successful. The Sidama people later accepted Christianity in the 1950s and 60s through protestant missionaries who brought some education and development projects with them.

Deliberate policy of name changes was part of the Abyssinians operation and subjugation. If a child was allowed to join a handful of schools built in Sidama before 1974 he was not allowed to use his Sidama name. In fact, the Abyssinian rulers forced the Sidama youngsters to go to Wolayita for primary school and the Wolayita youngsters to travel to Sidama so that these people will abandon their aim of getting education because of the high transport and living cost involved if they decided to travel to those distant places to get education. Is not this barbaric denial of the right of a child to have access to primary education? And yet Ethiopia used to boast to be part of the League of Nations and United Nations that guarantees the right of a child to have access not only to primary education but to primary education in their mother tongue. For instances, if a child was sent to a school in Sidama he was asked to come with a civilized name, i.e. of course Amhara name. Thus beautiful Sidama names such as Baxisso, Gabisso, Agana were all ridiculed and were replaced with Abebe, Bekele, Ayele so on. In case a child resisted or refused to change his name, then he was either denied school and any other opportunities or his name would be bastardised like “Sidamo”. In this case the Sidama names such as Dangisso were changed to a bastardised name of “Degsew”, Argata to “Argachew” and so on.

However, forced name changes came to an end with the 1974 revolution which abolished barbaric Abyssinian feudalism. But, of course, other forms of subjugations and oppressions continued until today.

5. Conclusion and Call for Immediate Halt in the Use of “Sidamo” Misnomer
There are no people in Ethiopia called “Sidamo”. The misnomer was invented in 1891 by the invading Minelik’s generals and soldiers as part of a psychological war to degrade and dehumanise the newly occupied land of Sidama and other peoples living around the Sidama land. The same dehumanising misnomer was used against the Wolayita people who were called “Wolamo”. Oromos were called with another derogatory name called “Galla” which in fact preceded “Sidamo” and “Wolamo” misnomers.

We ask all the Abyssinians living in Ethiopia and globally to stop using the derogatory term “Sidamo” which was coined by their invading ancestors. The continued use of this term only validates our arguments that Abyssinians are not the people to live with and the Sidama people be better off as an independent nation in east Africa. Do not add insult to injury by reminding us all the time what your ancestors did to us by using this humiliating term “Sidamo” .

The term “Sidamo” must be declared illegal both in Ethiopia and internationally and must be removed from all websites, other electronic and hard copy documents.

We also plead to the international community to stop using the misnomer “Sidamo” from today on and put pressure on the Ethiopian government to declare the term “Sidamo” illegal as it is illegal to use the term “Galla” and “Wolamo” any more. No people and individuals know better the history of the Sidama people than the Sidamas themselves. We are Sidama not “Sidamo” and no one else is “Sidamo” either.
በሲዳማ ዞን አርቤጎና ውስጥ በአገር ሽማግሌዎች የተከወነ የፍትሃዊ ምርጫ ሂደት ተመክሮ እንካችሁ…
ምርጫው ሊካሄድ ሁሉም ነገር ተዘጋጅቷል… አስመራጮች… ታዛቢዎች… ጸጥታ አስከባሪዎች… ሽማግሌዎችና ሌሎች የሚመለከታቸው አካላት ሁሉ ቦታ ቦታቸውን ይዘዋል…. መራጩ ህዝብም የምርጫ ካርዱን እንደያዘ ተሰልፎ ይጠባበቃል… ምርጫው ይጭበረበራል፣ ኮሮጆው ሊቀየር ይችላል ብለው የሰጉት የአገር ሽማግሌዎች የራሳቸውን የፍትሃዊ ምርጫ መላ ዘይደዋል… ሁሉም ነገር መጠናቀቁን ሲያረጋግጡም ተነሱ…
ለጸጥታ አስከባሪዎችም አሏቸው: ”ቴኔ ኮሮጆ ሃዺ !” … በደምሳሳው ሲተረጎም ”ይህን ኮሮጆ ወዲያ አንሱት!”… ”ኮሮጆውን ውሰዱት!” እንደማለት ሊሆን ይችላል…
በመቀጠልም የለበሷቸውን ረጃጅም ቡሉኮዎች (ጋቢዎች) ለሁሉም ግልጽ በሆነ መሃል ቦታ ላይ አነጠፏቸው… ለፍትህና ለሃቅ ቆሙ… ለመራጩ ህዝብም አሉት…
”ኮኤ ፉሺ !…”
”ሃኮ ፉሺ !…”
በግርድፉ ሲተረጎምም :
” እዚህ አድርግ! … እዚችው ጣል !” 
” እዚህ አስቀምጥ! … እዚችው ቁጭ አድርግ !” … እንደማለት ሊሆን ይችላል …
ሕዝቡ በሽማግሌዎቹ እምነት አለውና አላንገራገረም!… የፓርቲዎች አርማ ያለበትን ወረቀት ወስዶ… ሚስጥራዊ ክፍሏ ውስጥ ገብቶ… የሚመርጠው ምልክት ላይ የ X ምልክቱን አኑሮ… ወረቀቱን እያጣጠፈ ወደ ውጭ ይወጣል… ወደ ተዘረጋው ቡልኮ ላይ ሁሉም እያዩት ወርውሮ ይሄዳል… ሽማግሌዎቹም በንቃት ይጠባበቃሉ… ድንገት የሚያንገራግር… ከሂደቱ የሚያፈነግጥ ሲገኝም ሽማግሌዎቹ ይገስጹታል…
”ኮኤ ፉሺ !…”
”ሃኮ ፉሺ !…” … ይሉታል… ”እዚህ አድርግ! … እዚችው ጣል!” … ወይ ፍንክች!… እያሉ ይመልሱታል…
እንዲሁ ቀኑን ሙሉ ”ኮኤ ፉሺ !… ”ሃኮ ፉሺ !…” እንዳሉ ይውሉና ምርጫው ይጠናቀቃል… የድምጽ ቆጠራውም በሽማግሌዎቹ ዳኝነት ይከወናል… ኮሮጆ የሚባል ነገር ለምርጫው ቅንጣት አስተዋጽኦ ሳያደርግ ይውላል… ለማጭበርበር የተዘጋጁ ኮሮጆዎች ከነበሩም ውሃ በላቸው… በውጤቱም ባለ ዶሮ ምልክቱ የተቃዋሚ ፓርቲ ሲአን (ሲዳማ አርነት ንቅናቄ) አሸነፈ… ባለ ንብ ምልክቱ ተፎካካሪም ሽንፈቱን አምኖ ተቀበለ… ምንም መፈናፈኛ የለማ!…
መራጩ ሕዝብም አለ:
”ቢኒቾ ኢሽ !…”
”ሉኪቾ ሊሽ !…”
ሲተረጎምም…
”ንቧን ወደዚያ !…
ዶሮዋን ወደዚህ !…
እንደማለት ይሆናል… ንብ በሲዳምኛ ቢኒቾ ሲሆን ዶሮ ደግሞ ሉኪቾ ነው… ቋንቋውን በደንብ የምታውቁ ትርጓሜውን ብታርሙኝ ደስታዬ ነው …
”ኮኤ ፉሺ !…”
”ሃኮ ፉሺ !…” የሚሉ ሃቀኛ ዳኞች አያሳጣን አቦ!…
ሽማግሌዎቻችንን እድሜያቸውን ያርዝምልን !!!
”ቢኒቾ ኢሽ !…”
”ሉኪቾ ሊሽ !…”
በሰላም የተሞላ የሳምንት መጨረሻ ይሁንላችሁ!
አብዲ ሰዒድ
“Most of these women trek for as long as eight hours from their villages to the waiting house just because they know MSF is here and they will get quality medical care"
EVA DOMINGUEZMSF NURSE AND MIDWIFE, ARORESSA
Aroressa is a beautiful, green mountainous area, with small coffee plantations irrigated by natural waterfalls and streams that meander down the steep slopes of the valleys, with cliffs falling 300 metres and more. At the bottom, cattle graze alongside the streams and children play outside onion shaped huts, typical of the Sidama zone, southern Ethiopia.
Two Médecins Sans Frontières/Doctors Without Borders (MSF) programmes are located in these highlands, separated by dusty mountain roads of more than 80 kilometres. The beauty of the area can deceive the visitor regarding the very serious health problems faced by the population.

Remote health centres

Health centres are scarce; as are qualified medical personnel, and maternal and child mortality rates are high. The mountainous terrain makes it difficult for pregnant women to trek to their nearest health centre, which could be 20 or more kilometres away.
MSF teams have met many stranded people ferrying sick people or pregnant women to a nearby health centre while driving or horse riding from one health centre to the other. Many lives have been lost on these wearisome journeys.
In a bid to reduce maternal and child mortality rates, MSF has established two mothers’ waiting houses, in the divisions of Chire and Mejo. These houses shelter heavily pregnant women who come from distant villages and cannot access medical assistance quickly, who are experiencing or have experienced complications during their pregnancy, or who have conditions requiring regular medical attention.
These women come to the waiting house, are examined by MSF’s medical staff and kept under regular observation so that in case urgent treatment is needed, immediate action can be taken.
“I came to the waiting house because I had pains and bleeding during my pregnancy and knew that MSF is offering help to expectant women,” says Birtu Kawato, a 25-year-old woman from Baya Faficho Kebele (division), staying at the MSF waiting house.
Uncomplicated births are assisted by an MSF midwife in the health centres, while women with complications are referred to nearby hospitals. Presently, each waiting house has a carrying capacity of 20 beds.

Successful deliveries

Since the establishment of the waiting house in Mejo in the final quarter of last year, 251 women have delivered successfully. Their satisfaction drives them to pass the message to other women in their communities.
“Most of these women trek for as long as eight hours from their villages to the waiting house just because they know MSF is here and they will get quality medical care,” states Eva Dominguez confidently, a nurse and midwife with MSF in Aroressa.
The waiting house is a way of encouraging women to seek medical assistance during delivery and to reduce maternal and child mortality in the area. It mostly targets women of child bearing age in the zone, which is presently estimated at 50,556.
In both health centres, MSF, in cooperation with the Ethiopian Ministry of Health provides antenatal and postnatal services, family planning and medical and psychological assistance to victims of sexual violence.
Find out more about MSF's work in Ethiopia
Photo by http://www.msf.org.uk/country-region/ethiopia
Hawassa – In Sidama Zone these days it
is not uncommon to see health supervisors
on motorbikes traveling quickly throughout
each of the 19 districts, transporting
information and education as well as test
samples. These are people who have
become bridges between their own rural
communities and far-off healthcare facilities.
They are part of a project which has newly
energized effort to control tuberculosis (TB)
in Ethiopia.

Read more:http://www.stoptb.org/assets/documents/global/awards/tbreach/TBREACH_Flyer%20Lille%20LSTM%20and%20GF%20Ethiopia.pdf

Abstract

Background

Birth preparedness and complication preparedness (BPACR) is a key component of globally accepted safe motherhood programs, which helps ensure women to reach professional delivery care when labor begins and to reduce delays that occur when mothers in labor experience obstetric complications.

Objective

This study was conducted to assess practice and factors associated with BPACR among pregnant women in Aleta Wondo district in Sidama Zone, South Ethiopia.

Methods

A community based cross sectional study was conducted in 2007, on a sample of 812 pregnant women. Data were collected using pre-tested and structured questionnaire. The collected data were analyzed by SPSS for windows version 12.0.1. The women were asked whether they followed the desired five steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, identified blood donor and saved money for emergency. Taking at least two steps was considered being well-prepared.

Results

Among 743 pregnant women only a quarter (20.5%) of pregnant women identified skilled provider. Only 8.1% identified health facility for delivery and/or for obstetric emergencies. Preparedness for transportation was found to be very low (7.7%). Considerable (34.5%) number of families saved money for incurred costs of delivery and emergency if needed. Only few (2.3%) identified potential blood donor in case of emergency. Majority (87.9%) of the respondents reported that they intended to deliver at home, and only 60(8%) planned to deliver at health facilities. Overall only 17% of pregnant women were well prepared. The adjusted multivariate model showed that significant predictors for being well-prepared were maternal availing of antenatal services (OR = 1.91 95% CI; 1.21–3.01) and being pregnant for the first time (OR = 6.82, 95% CI; 1.27–36.55).

Conclusion

BPACR practice in the study area was found to be low. Effort to increase BPACR should focus on availing antenatal care services.

Introduction

Childbirth is a universally celebrated event yet for many thousands of women each day, child bearing is experienced not as the joyful event as it should be [1]. Globally 40% or more of pregnant women may experience acute obstetric problems. The WHO estimates that 300 million women in the developing world suffer from short-term or long-term illness brought about by pregnancy and childbirth. Most of maternal deaths occur in the developing world [2][6]. For example from 342,900 maternal deaths in 2008, 52% occurred in sub Saharan Africa [7]. This is because of several reasons one of which is inadequacy or lack of birth and emergency preparedness, which is a key component of globally accepted safe motherhood programs. Birth preparedness helps ensure that women can reach professional delivery care when labor begins and reduces the delays that occur when women experience obstetric complications [8][11].
Birth Preparedness and Complication Readiness (BPACR) is the process of planning for normal birth and anticipating the actions needed in case of an emergency [12][13]. Birth preparedness is a strategy to promote the timely use of skilled maternal care, especially during childbirth, based on the theory that preparing for childbirth reduces delays in obtaining this care. A birth plan/emergency preparedness plan includes identification of the following elements: identifying a skilled birth attendant; identifying the location of the closest appropriate care facility; funds for birth-related and emergency expenses; transport to a health facility for the birth and obstetric emergency; and identification of compatible blood donors in case of emergency. The role of BPACR improving the use and effectiveness of key maternal and neonatal services is through reducing delays in deciding to seek care in two ways. First, it motivates people to plan to have a skilled provider at every birth. If women and families make the decision to seek care before the onset of labor, and they successfully follow through with this plan, the woman will reach care before developing any potential complications during childbirth, thus avoiding the first two delays completely. Second, complication readiness raises awareness of danger signs thereby improving problem recognition and reducing the delay in deciding to seek care [14][15]. Making arrangements for blood donors is also important because women giving birth may need blood transfusions in the event of hemorrhage or cesarean section. Blood donor systems at the community level can help overcome problems related with access to blood [13][15].
There are evidences from Nepal, Burkina Faso and India [16][18] that promoting BPACR improves preventive behaviors, improves knowledge of mothers about danger- signs, and leads to improvement in care-seeking during obstetric emergency. However there are no evidences which clearly indicate the reduction of neither maternal nor neonatal mortality. In Ethiopia, the levels of maternal mortality and morbidity are among the highest in the world and the current estimate of Maternal Mortality Rates is 580 per 100, 000 live births [7] and it is reported that Maternal deaths accounted for 21 percent of all deaths to women age 15–49 [19]. In Millennium Development Goal 5, countries have committed to reducing the maternal mortality ratio by three quarters between 1990 and 2015. Following the commitment with the goal, Ethiopia is expected to reduce maternal mortality in 2015 to 267 maternal deaths per 100,000 live births[20].
Despite the fact that birth preparedness and complication readiness is essential for further improvement of maternal and child health little is known about the current magnitude and influencing factors in Ethiopia. This study therefore aims to fill this gap by assessing the current status and factors associated with birth preparedness and complication readiness among pregnant women in Aleta Wondo Woreda Sidama zone, Ethiopia, through a community based cross sectional study. It is hoped that the results of the study will provide valuable information for design of possible programs and interventions to improve maternal and neonatal health. And also serve as baseline information for further study.

Materials and Methods

Study area

Sidama zone is one of the 13 zones found in the Southern Nations, Nationalities and People Regional Government (SNNPRG) with the total population estimate for 2007 was 2,855,386[21]. Of this 2,610,439 (91%) are rural and 244947 (9%) are urban dwellers [21]. In the zone there are 19 woredas (equals district in other countries) and 2 town administrations. By ethnic group majority are Sidama and the major religious groups are protestant Christians.The potential health service coverage of the zone in 2005 was 38% [22][23]. During the survey period the number of pregnant women was 119837 (4.26%) and the antenatal care coverage was 69.3%, [23][24]. According to demographic health survey 2005 only 6% deliveries in Ethiopia occurred in health facilities assisted by skilled health providers [25].
The study was conducted in Aleta Wondo Woreda in Sidama zone, which is located 333 kilometers southeast of Addis Ababa. Administratively, the woreda is subdivided in to 27 rural and 4 urban kebeles (lowest administrative unit). The Woreda, is one of 19 woredas in Sidama zone, and has a total population of 212,459. Among these 184,015 are rural and 28,444 urban dwellers. In the Woreda there are 1 health center, 2 upgrading health centers, 2 medium private clinics and two NGO clinics. The potential health coverage of the Woreda is 29% according to regional health bureau report of 2004/2005.

Study design

In March 2007 a community based cross sectional study was conducted using both quantitative methods. The study was conducted among all pregnant women who were residing in Aleta Wondo district during the study period. The inclusion criteria were Women, with at least 3 months of current pregnancy, permanent resident of the study area, volunteer to participate and respond to the questionnaire were included. Women who were mentally disabled and severely ill were excluded.

Sample size and sampling technique

Sample size calculation was made based on the following assumptions pregnant women in the woreda were estimated to be about 4.26% of 212459 = 9050 pregnant women. Proportion of women who know danger signs of pregnancy & childbirth assumed to be 50% because there was no study conducted locally. The margin of error and confidence interval were taken to be 5% and 95% respectively. Based on the above assumption, this gives a sample size of 369. Considering the design effect of 2 and 10% non-response rate, the total sample size became 812.
Multistage sampling procedure was used to select study subjects. First, all the kebeles in the woreda were stratified in to urban and rural. Then 2 urban and 8 rural kebeles were randomly selected for the study. The calculated sample size was proportionally allocated to urban and rural according to their population. Then a census was conducted to register all pregnant women and their gestational age. Based on the above information a sampling list, which enlists all eligible study subjects, was prepared. From the list, pregnant women with gestational age of 3 months and above were included in the survey. As the sample list did not allow simple random sampling, all eligible pregnant women in the selected kebeles were included in the study.

Measurement

A pre tested Structured interview questionnaire was used for data collection. It was taken from the safe mother hood questionnaire developed by maternal and neonatal health program of JHPIEGO the affiliate of Johns Hopkins University [11][12], and adapted according to local context and the objectives of the study. Using a pre tested questionnaire the following information were collected. Socio demographic characteristics including: age, marital status, family size, residence (urban versus rural), ethnicity, religion, education, occupation and average monthly family income. The questionnaire included questions gestational age, number of pregnancies, history of still birth and health problems during previous pregnancies. Danger signs during pregnancy, delivery and newborn which require referral and whether the mother follows the following four basic BPACR were asked i) identified a trained birth attendant or ii) health facility for emergency; iii) identified mode of transport for delivery and/or for obstetric emergency; iv) saved money and v) identified blood donor. The women were asked about antenatal care services and number of visits, who attended the ANC, preferred place of delivery.
Data collection process.
Fifteen community health workers (CHA) who can speak local language were recruited and trained on mapping and conducting households' census with pregnant women conducted a census. Ten-health extension workers from other kebeles interviewed the eligible pregnant women after thorough training on the objective of the study and the questionnaire. Two nurses supervised the data collectors. Data collectors were trained for 4 days by using training manual prepared for this purpose.
Data analysis.
The collected data were coded, entered, and cleaned, and analyzed by SPSS for windows version 12.0.1. First, simple frequency distribution was calculated. Then those mothers who followed at least two of the five BPACR were considered “well prepared”. The remaining pregnant women were considered “less prepared”. Logistic regression analysis was done to identify factors associated with BPACR.
Data quality control.
To maintain the validity of the measurement standard questionnaire of safe motherhood was taken and modified based on study interest. The instrument was pre tested on 5% of sample size in Aleta Wondo district that was not included in study and analysis. Modifications were made after pretest. The questions were translated to local language (Sidama language and Amharic) and back translated to English to maintain consistency. The translators were from Woreda education and health department experts on both languages. Training was given to data collectors, supervisors and data entry personnel. Observation and supervision was done throughout the fieldwork, training and data collection process. In addition meeting with each member of the team on a daily basis to discuss performance and give out future work assignments was performed.
Ethical considerations: Ethical approval was obtained from Ethical Review Committee of Jimma University. Letter of support was obtained from the zonal and Woreda health offices before undertaking the study and verbal informed consent was obtained from the respondents before the interview. To document verbal consent, the household ID given during data collection was recorded along with the questionnaire. Due to the large number of individuals that were surveyed and high illiteracy, it was considered impractical to obtain written consent from each study participant, and the institutional review boards approved this procedure. For Privacy and confidentiality, all interviews were conducted in private and all cautions were taken to ensure confidentiality. The right of the respondents to refuse to participate in the study was respected. Respondents were provided information on importance of antenatal care and BPACR.

Results

Socio-demographic and obstetric characteristics

Out of 812 pregnant women to be interviewed, 743 were interviewed making a response rate of 92%. The rest were not found for an interview after three repeated visits. The mean±Standard Deviation age of respondents was 25±4 years. Of the respondents 715(96.2%) were currently in marital union and 3.2% were single. Large Majority 644(86.7%) were rural dwellers. By ethnicity 91.8% were Sidamas and 6.1% were Amhara. The major predominant religions include protestant 645(86.8%) and Orthodox Christians 44(5.9%). Educationally 371(49.9%) respondents can't read & write and the rest 50.1% can read and write. Occupationally 710(95.6%) were housewives followed by government employees 12(1.6%). Out of the studied subjects only 568(76.7%) volunteered to tell their income. Regarding pregnancy status majority 62.0% of the respondents had already given birth for two to four children; 20.9% had delivered one child, 17.1% had delivered five and more and the remainders 135(18.2%) were primigravidae. The highest parity was nine. Most (50.6%) of the respondents were in the 3rd, 41.5% on 2nd, and 7.8% on 1st trimester of pregnancy respectively (Table 1).
Table 1. Socio-demographic and obstetric characteristics of pregnant women, Aleta Wondo Woreda, March, 2007.
doi:10.1371/journal.pone.0021432.t001

Antenatal care and preferences during current pregnancy

About 332(44.7%) of respondents attended antenatal care in their current pregnancy. The mean antenatal attendance was 2.4+1.2. Among those pregnant women who attended ANC more than half (61.1%) have had 1–2 visits, 104(31.6%) 3–4 visits and 24(7.3%) more than five visits. The respondents' median gestational age at first antenatal visit was 4.0 month (interquartile range (IQR): 3–5 months).
Majority 228(68.3%) of respondents reported a Health care provider had given health advice during their ANC visit. More than half 184 (55.4%) of respondents were given advice where to go if health problems happen; 138(41.4%) were given where to deliver, 121(36.4%) were advised for arrangement of health care professional to assist in child birth and only 66(20%) were given advice for arrangement for transportation to reach health facility during labor (Table 2).
Table 2. Birth preparedness and complication readiness among pregnant women in Aleta Wondo worda March, 2007.
doi:10.1371/journal.pone.0021432.t002

Birth preparedness practices

Only a quarter (20.5%) of pregnant women identified skilled provider. Only 8.1% identified health facility for delivery and/or for obstetric emergencies. Of which 79.7% identified government health facility. Preparedness for transportation was found to be very low (7.7%). Considerable (34.5%) number of families saved money for incurred costs of delivery and emergency if needed (Table 3). Only few (2.3%) identified potential blood donor in case of emergency. Majority of 653(87.9%) of respondents reported that they intended to deliver at home, and only 60(8%) planned to deliver at health facilities. Seventeen (2.3%) of the respondents didn't decide where to give birth (Fig. 1).
Figure 1. Expected place of delivery among pregnant women in Aleta Wendo Woreda, March 2007.
doi:10.1371/journal.pone.0021432.g001
Table 3. Antenatal care services and preference of birth attendant among pregnant women in Aleta Wondo Woreda, March 20, 2007.
doi:10.1371/journal.pone.0021432.t003
The birth preparedness score was computed from key elements of birth preparedness such as; arrangement for transportation, saving money for delivery, identified skilled attendant to assist at birth, identifying a health facility for emergency and identifying blood donor in case of emergency. Taking at least two steps was considered being well prepared. Accordingly 17% of pregnant women on this study were considered as well prepared for birth and complications.
Compared to the less-prepared pregnant women, the well prepared pregnant women tended to be literate, live in urban area and availed of antenatal services during the current pregnancy. The adjusted multivariate model showed that significant predictors for being well-prepared were maternal availing of antenatal services (OR = 1.91 95% CI; 1.21–3.01) and the current pregnancy was the first for the woman (OR = 6.82, 95% CI; 1.27–36.55) (Table 4).
Table 4. Selected characteristics of mothers who were well-prepared* versus those who were less-prepared (n = 743).
doi:10.1371/journal.pone.0021432.t004

Discussion

In this study several important findings were observed. Less than a quarter of pregnant women were well prepared for delivery and emergency obstetric care; availing antenatal care and being pregnant for the first time were predictors of birth preparedness and complication readiness. The finding of this study is consistent with previous study [26] and reinforce efforts to increase BPACR should focus on availing antenatal care services.
Studies have indicated the relation between BPACR and skilled birth attendant. The findings showed that BPACR increases skilled birth attendants [15][26]. In this study however only 17% of the pregnant women were well prepared, implying the importance of interventions to increase BPACR in the setup. Similar to other study conducted in India [26] in this study those women who attended antenatal care service were well prepared than those who did not attend. This signifies that antenatal care services visits are an opportunity to inform pregnant women and help to plan for the important components of BPACR. Our finding indicated that women were not informed well all the components of BPACR utterly. This implies the importance of training for health providers on how to advise pregnant women on components of BPACR.
In our study women with first pregnancy were more prepared than their counterparts. This could be due to high risk perception of such women than those who had experience. This shows that increasing risk perception might help in improving BPACR.
In our study only few (7.7%) pregnant women made adequate arrangements for transportation to a health facility in case of an obstetric emergency. This is far less than findings from Burkina Faso's (35%) [15] and India (29.5%) [26].This could be differences in the local contexts. In our setup the community uses traditional ways such as donkey cart and local stretchers to carry patients to facilities. Unavailability of roads in some of the rural setups plays role. Therefore messages on BPACR should be tailor to the local contexts and doe able messages.
In this study a large proportion 87.9% of women reported that they intended to give birth in their home, and only 8% planned to deliver in health facilities. Furthermore only 20.1% of pregnant women in this study planned to deliver by assistance of skilled provider. While increasing knowledge to prepare for birth and emergencies is important, efforts are required to identify barriers for use of health facilities and skilled attendants at birth. Since most of pregnant women relay on TBAs it is important to make TBAs allies of the health system. They can be used as referral linkage by escorting pregnant women to health facilities.
The strength of the study includes it is a community based; census was conducted before data collection to identify currently pregnant women and also large sample size was used. The limitations of the study are: since the participants have not completed their pregnancies, they may not yet have had the opportunity or need to make arrangements related to BPACR. Pregnant women may not able to report whether they used services that they have not yet needed. There could be social desirability bias; to reduce this we used health extension workers from other areas. Finally previous study [16] has indicated that pregnant women were more likely to report planning to give birth with the assistance of a skilled provider, which might not reflect the true result.
This study revealed that only few of pregnant women were well prepared for delivery and obstetric complication, a large majority of pregnant women planned to deliver at home where the presence of skilled attendants is uncertain. Few pregnant women planned to have assisted by skilled attendant. In addition only small percentage of pregnant women arranged financial preparations and identified transportation to reach health facility to deliver. The present study shows availing antenatal care services and being pregnant for the first time affected BPACR.
Therefore the MOH, regional health bureau, zonal health department, Woreda health office as well as other partner organizations that are working in areas of maternal health should come up with strategies to improve birth preparedness at individual and community level. Effort to increase BPACR should focus on availing antenatal care.

Acknowledgments

We would like to thank Aleta Wondo woreda health office and town administration for their cooperation throughout household census and data collection period. We would also like to thank Sidama zone health department, SNNP Regional health bureau for provision of regional health information.

Author Contributions

Conceived and designed the experiments: MH KD. Performed the experiments: MH AG FA. Analyzed the data: MH AG FA KD. Contributed reagents/materials/analysis tools: MH AG FA. Wrote the paper: MH AG FA KD.

References

  1. 1.World Health Organization (1989) Preventing Maternal Deaths. Geneva: World Health Organization.
  2. 2.World Health Organization (1994) Mother-Baby Package: Implementing Safe Motherhood in Countries. Geneva: World Health Organization.
  3. 3.World Health Organization (1998) Pregnancy is special let's make it safe. World Health Day,Safe Motherhood. Geneva: World Health Organization.
  4. 4.World health organization (2005) World health day making every mother and child count. Geneva: World Health Organization.
  5. 5.United Nations Children's Fund (1996) The Progress of Nations. New York: United Nations Children's Fund. Available: http://www.unicef.org/pon96/woestima.htmAccessed on 2006 Sep.
  6. 6.John Snow Inc (2000) Issues in programming for safe Mother Care. Arlington, , VA: John Snow Inc.
  7. 7.Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, et al. (2010) Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 375: 1609–23. doi: 10.1016/S0140-6736(10)60518-1.
  8. 8.JHPIEGO (2004) Maternal and Neonatal Health Programme Birth Preparedness and Complication Readiness: A Matrix of Shared Responsibilities (Original BP/CR Matrix Poster Published in 2001.English Introductory Text Revised in 2004). Baltimore, , MD: JHPIEGO.
  9. 9.Stanton CK (2004) Methodological issues in the measurement of birth preparedness in support of safe motherhood. Eval Rev 28-3: 179–200. doi: 10.1177/0193841X03262577.
  10. 10.Moore KM (2000) Safer Motherhood 2000: Toward a framework for behavior change to reduce maternal deaths.
  11. 11.JHPIEGO (2004) Monitoring birth preparedness and complication readiness: tools and indicators for maternal and newborn health.Baltimore, MD: JHPIEGO. 1–19.
  12. 12.Banza Baya, Gabriel Sangli, Abdoulaye Maiga (2004) Measuring the effects of behavior change interventions in Burkina Faso with population-based survey results.Baltimore, Maryland, USA: JHPIEGO. 18–45.
  13. 13.JHPIEGO (2001) Maternal and Neonatal Health Programme. Birth Preparedness and Complication Readiness: A Matrix of Shared Responsibilities. Baltimore, , MD: JHPIEGO. 12 p.
  14. 14.Thaddeus S, Maine D (1994) Too far to walk: Maternal mortality in context. Social Science and Medicine 38: 1091. doi: 10.1016/0277-9536(94)90226-7.
  15. 15.The White Ribbon Alliance for Safe Motherhood (2002) Saving Mothers' Lives; what works Field Guide for Implementing Best Practices in Safe Motherhood/India Best Practices Sub-committee.
  16. 16.Moran AC, Sangli G, Dineed R, Rawlins B, Yameogo M, et al. (2006) Birth-preparedness for maternal health: findings from Koupela district, Burkina Faso. J Health Pop Nutr; 24: 489–97.
  17. 17.McPherson RA, Khadka N, Moore JM, Sharma M (2006) Are birth-preparedness programmes effective? Results from a field trial in Siraha district, Nepal. J Health Popul Nutr; 24: 479–88.
  18. 18.Fullerton JT, Killian R, Gass PM (2005) Outcomes of a community- and home-based intervention for safe motherhood and newborn care. Health Care Women Int 26: 561–76. doi: 10.1080/07399330591004881.
  19. 19.Central Statistical Agency and ORC Macro (2006) Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA.
  20. 20.Ministry of Finance and economic development (2008) Ethiopia: progress towards achieving the millennium goals. Success, challenges and prospects. Addis Ababa: Ministry of Finance and economic development.
  21. 21.Federal Democratic Republic of Ethiopia (2006) Central Statistical Agency. Addis Ababa: Statistical Abstract 2005.
  22. 22.Sidama zone Finance and Economic Development Coordination Department (2005) Sidama administrative zone socioeconomic & demographic profile. Awassa: Sidama zone Finance and Economic Development Coordination Department.
  23. 23.SNNPR health bureau (2004) Health related indicators. Planning, engineering and information service. Awassa: SNNPR health bureau.
  24. 24.Sidama Zone Health Department (2006) annual report. Awassa: Sidama Zone Health Department.
  25. 25.Central Statistical Agency and ORC Macro (2006) Ethiopia, Demographic and Health Survey, 2005. Addis Ababa, Ethiopia and Calverton, Maryland, USA.
  26. 26.Agarwal S, Sethi V, Srivastava K, Jha PK, Baqui AH (2010) Birth Preparedness and Complication Readiness among Slum Women in Indore City, India. J Health Popul Nutr 28(4): 383–391. doi: 10.3329/jhpn.v28i4.6045.