Individual- and Community-Level Predictors of Birth Preparedness and Complication Readiness: Multilevel Evidence from Southern Ethiopia

<b>Background/Objectives</b>: Birth preparedness and complication readiness (BPCR) is a cornerstone of maternal health strategies designed to minimize the "three delays" in seeking, reaching, and receiving skilled care. In Ethiopia, uptake of BPCR remains insufficient, and little evidence exists on how individual- and community-level factors interact to shape preparedness. This study assessed the determinants of BPCR among women of reproductive age in Hawela Lida district, Sidama Region. <b>Methods</b>: A community-based cross-sectional study was conducted among 3540 women using a multistage sampling technique. Data were analyzed with multilevel mixed-effect negative binomial regression to account for clustering at the community level. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were reported to identify determinants of BPCR. Model fitness was assessed using Akaike's Information Criterion (AIC), the Bayesian Information Criterion (BIC), and log-likelihood statistics. <b>Results</b>: At the individual level, women employed in government positions had over three times higher expected BPCR scores compared with farmers (AIRR = 3.11; 95% CI: 1.89-5.77). Women with planned pregnancies demonstrated higher BPCR preparedness (AIRR = 1.66; 95% CI: 1.15-3.22), as did those who participated in model family training (AIRR = 2.53; 95% CI: 1.76-4.99) and women exercising decision-making autonomy (AIRR = 2.34; 95% CI: 1.97-5.93). At the community level, residing in urban areas (AIRR = 2.78; 95% CI: 1.81-4.77) and in communities with higher women's literacy (AIRR = 4.92; 95% CI: 2.32-8.48) was associated with higher expected BPCR scores. These findings indicate that both personal empowerment and supportive community contexts play pivotal roles in enhancing maternal birth preparedness and readiness for potential complications. Random-effects analysis showed that 19.4% of the variance in BPCR was attributable to kebele-level clustering (ICC = 0.194). The final multilevel model demonstrated superior fit (AIC = 2915.15, BIC = 3003.33, log-likelihood = -1402.44). <b>Conclusions</b>: Both individual- and community-level factors strongly influence BPCR practice in southern Ethiopia. Interventions should prioritize women's empowerment and pregnancy planning, scale-up of model family training, and address structural barriers such as rural access and community literacy gaps. Targeted, multilevel strategies are essential to accelerate progress toward improving maternal preparedness and reducing maternal morbidity and mortality.