A Cluster Randomized Controlled Intervention to Improve Institutional Birth Rate in a Rural District of Ethiopia
Condition: Maternal Health Services
Study type: Interventional

Summary: 
      Despite the efforts from the government, maternal healthcare services utilization is far
      below the recommended level in Ethiopia with a high urban-rural disparity. Currently,
      two-thirds of pregnant women do not receive the recommended number of antenatal care, more
      than 50% of births are not attended by skilled birth attendants, and two-thirds of postpartum
      women do not receive postnatal checks, according to the 2019 EDHS report. There is also
      evidence that the rate of continuity of maternity care completion is low, implying that
      pregnant women are not getting the most out of the existing healthcare services. In Ethiopia,
      the rural communities are scattered over a wide geographic area some with difficult mountains
      and valleys. Hence, geographic barriers and limited information sources are likely to
      influence women's access to skilled birth attendance. As part of improving access and
      overcoming physical or geographical inaccessibility in rural areas, maternity waiting homes;
      residential lodgings built near healthcare facilities where expectant women near or at term
      would stay till the onset of labor is one of the measures taken by the Ethiopian government.
      The majority of the rural populations commonly have a lower perception of health services in
      general, and many traditional practices support behaviors that are inconsistent with
      effective health interventions. Thus, there is a challenge concerning behavior (social norms,
      beliefs, and culture) from the demand side related to utilizing maternity services on top of
      non/partial functionality of existing waiting homes. Therefore, this research project aimed
      at promoting access to and utilization of maternal healthcare services utilization in
      southern Ethiopia.
    

Detailed description: 
      Health centers and kebeles (villages) in the study setting were randomly assigned to
      intervention or comparison. We recruited all eligible pregnant women who reside in the
      respective selected health centres' catchment areas. In the intervention areas, community
      health workers (unpaid and volunteer women) were identified in consultation with the head of
      the villages/local leaders/. They received training on safe motherhood, the benefit and
      importance of maternity homes, identification of local beliefs, traditions and taboos that
      are barriers to birth preparation, stay in maternity homes and the use of maternal health
      services. The main functions of these trained community health worker in the intervention
      clusters include facilitating training sessions for pregnant women, assisting pregnant women
      in the preparation of birth preparedness plan, supporting pregnant women in starting and
      sustaining maternity care (prenatal care, skilled delivery and postnatal care). Pregnant
      women were also trained in the intervention clusters (12 sessions/4 sessions per cluster).

      The training of both community health workers and pregnant women was based on a video story
      titled "Why Did Mr. X Die, Retold?" and a manual on working with individuals, families and
      communities to improve maternal and neonatal health from the World Health Organization.

      After getting permission from the World Health Organization to use the video, we translated
      it into the local language and used it as an introduction during training. The training was
      designed based on the findings of preliminary studies and was intended to educate pregnant
      women about danger signs during pregnancy, labour and the postpartum period, about the birth
      preparation plan, the benefits and importance of waiting homes. In addition, it also covered
      how to develop a birth plan that included waiting home with the help of community health
      workers, as well as correcting misconceptions (belief-related barriers). The intervention was
      based on principles from the theory of planned behavior and the health belief model. These
      models were considered to offer direction for what types of variables and processes may be
      important in shaping maternal health behaviors and thus needed to be addressed in the
      intervention. The theory of planned behavior is used to explain and predict behavior based on
      attitudes, norms, and intentions and stipulates that an individual intention to act
      (behavior) is essentially a function of that individual's attitude toward that behavior and
      perceptions of social subjective norms. The health belief model which describes how health
      beliefs interact with modifying factors (e.g., perceived seriousness of problem) to determine
      health behaviors was also considered in developing the intervention.

      The comparison group continued to receive maternal health information and services that are
      provided as part of the routine healthcare system. Both the baseline and end-line data were
      managed by trained interviewers using a mobile application supporting Open Data Kit. Data
      were analyzed through descriptive and inferential statistics (Chi-square test, McNemar tests
      and multi-level mixed-effects logistic regression analysis). For all analyses, a p-value of
      <0.05 was considered the level of significance.
    

Intervention name(s): Safe motherhood Promotion
Intervention type(s): Behavioral
Intervention description(s): Interventions included the training of community members, who subsequently led participatory educational sessions on safe motherhood topics with pregnant females. The project staff identified 2 community health workers and 15 female volunteers from each kebele cluster and trained them as research implementers. The implementers received 2 days of training led by the project team. The project staff and research implementers conducted safe-motherhood training comprising 2 h of information presentations and discussions with pregnant females in the intervention clusters. In addition to the pregnant-female intervention strategy, we also conducted a four-day training programme on clinical skills for local maternal and child healthcare providers in the study area. MWH intervention was also implemented in the intervention group, including upgrades to existing MWH services per national guidelines to standardize services and create a homelike environment for pregnant females.
Other intervention name(s): improving maternity waiting homes
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: A total of 727 pregnant women were recruited and followed up to six months after delivery in this quasi-experimental, two-arm, controlled study. In the intervention group, eligible pregnant women received training to promote safe motherhood, supported by the story "Why Did Mr. X Die, Retold?" and a booklet on working with individuals, families and communities to promote maternal and neonatal health. Pregnant women received counselling (12 sessions/4 sessions per cluster) and biweekly check-ins were performed by community health workers. Pregnant women are encouraged to stay in maternity waiting homes, which have been upgraded to accommodate pregnant women while they wait for their baby to arrive. The control group received standard maternal health information and services as part of the standard health care system.
Masking: None (Open Label)
Primary purpose: Health Services Research
Keywords: Antenatal care; Births attended by skilled health providers; Birth Preparedness Plan; Postnatal care