Key elements of the birth plan package include recognition of danger signs. Although there are some
studies on birth preparedness and complication readiness in Ethiopia; most of them studied women
attending antenatal care. Moreover, there is no data on the eastern part of the country where the culture
is more liberal and cash crop is the mainstay of the livelihood. This study explored the association
between knowledge of obstetric danger signs and birth preparedness among pregnant women in rural
communities. A cross sectional community based study was conducted in Dere Teyara District
(Woreda) of Rural Harari Region in the Eastern Ethiopia from March to May, 2013. The sample size was
determined using formula for estimation of single population proportion. A total of 436 pregnant women
were selected using simple random sampling technique. A pre tested interviewer administered
structured questionnaire was used to collect relevant data. The data were coded and entered into and
analyzed using SPSS for windows version 20. Multivariable logistic regression analyses were used to
isolated independent predictors of good birth preparedness. Out of 423 respondents, 42.8% (181/423) of
the pregnant women had good birth preparedness. A total of 28.6, 28.6 and 40.9% had good knowledge
on obstetrical danger sign during pregnancy, delivery and post-partum period, respectively. The main
danger signs during pregnancy mentioned were vaginal bleeding (75.5%) and severe headache (68.8%),
while severe vaginal bleeding (81.1%) and prolonged labor (39.2%) were mentioned to be danger signs
during delivery. Severe vaginal bleeding (68.3%) and swollen hands/face during the postpartum period
(44.7%) were stated to be danger signs in the post partum period. On multivariable logistic regression
model, women who had literate husbands were 2.8 times more likely to have good preparedness
(adjusted odds ratio (AOR)=2.83; 95% confidence interval (CI)=1.423, 5.655). Literate mothers were 2.46
times more likely to be birth prepared (AOR=2.46; 95% CI= 1.09, 5.57). Likewise, women who started the
first antenatal visit before four months of pregnancy were 15.5 times more likely to have good birth
preparedness (AOR=15.50; 95% CI=3.713, 64.67). It was also observed that, women who had two or
more ANC visits were nearly twice as likely to have good birth preparedness (AOR=1.96; 95% CI=1.13,
3.41). Women with good knowledge on obstetric danger signs during pregnancy (AOR=2.517; 95%
CI=1.39, 4.55) and postnatal period (AOR=2.245; 95% CI=1.26, 3.97) were also more likely to be birth
prepared than those without this knowledge. Antenatal care attendance, knowledge about obstetric
danger signs and literacy status of the woman and her husband were strong predictors of birth
preparedness practices. The findings imply the need for behavior change communication on obstetric
danger signs and the importance early initiation of ANC follow up, especially to illiterate women to
reduce maternal mortality.