Effectiveness of Engaging Religious Leaders in Maternal Health Education for Improving Maternal Health Service Utilization in Ethiopia: Cluster Randomized Controlled Trial

"In this study, the intervention had a notable impact on the utilization of maternal health services, indicating that the involvement of religious leaders in maternal health education can enhance the utilization of such services."

Involving families, religious leaders, and traditional authorities in maternal health initiatives can be a powerful strategy. Religious organisations can be leveraged to raise awareness and educate communities about available services. Communities need to be given the power to take part in and manage their own matters. A religious leader, as a trusted member of the community, is in a position to inspire others to modify their behaviour. This cluster-randomised trial (cRCT) was conducted to assess how the involvement of trained religious leaders in maternal health education impacts the utilisation of maternal health services in Ethiopia, where there are high rates of maternal deaths and poor health outcomes for women.

The research study took place from February 2023 to September 2023 in two rural districts within the Hadiya Zone: Lemo and Ameka. A cRCT single-blind parallel-group, two-arm trial with a 1:1 allocation ratio was conducted among pregnant mothers. Non-adjacent clusters were chosen to avoid the risk of information contamination. An equal number of clusters were selected from each district for both the intervention and control groups to ensure balance and mitigate variations. 

The intervention was designed based on findings from the baseline formative phase, which encompassed qualitative and quantitative studies. Therefore, this behavioural intervention was based on a context-specific intended population. In short, religious leaders with training in maternal health provided four months of training to the pregnant mothers in the intervention group. Specifically, the intervention comprised three distinct parts:

 

• Part 1: recruiting and training of religious leaders - Sixteen religious leaders were selected to receive a four-day training designed to equip these leaders with the knowledge, attitude, and communication skills needed to effectively support and encourage pregnant women to utilise recommended healthcare services. The training combined theoretical sessions and practical demonstrations, ensuring alignment with the intervention protocol and community acceptance. Religious leaders were equipped with the necessary skills and resources to deliver culturally appropriate training sessions in the local language, using facilitator manuals and posters to enhance understanding and engagement. The trained religious leaders were tasked with conducting four sessions on maternal health topics for their congregations, with the aim of enhancing the use of maternal health services among their members.
• Part 2: training of pregnant mothers - Over a 4-month period, in collaboration with health extension workers, kebeles' leaders and religious leaders, researchers, and field workers, appropriate training places were arranged in the intervention groups to educate pregnant women about maternal health. The trained religious leaders conducted four group training sessions for pregnant mothers, adhering to the same training procedures they had received during their own training. Following the training sessions, participants received visual materials (posters) summarising key ideas for encouraging behaviours that promote maternal health. The training sessions employed direct, interactive, and participatory learner and activity-oriented instructional strategies.
• Part 3: home visits - Religious leaders made four home visits to each pregnant mother. During these home visits, religious leaders provided personalised counseling and support on maternal health, adhering to a structured counseling protocol. These home visits served as a reinforcement mechanism, helping pregnant mothers translate the knowledge and skills gained from group training sessions into positive maternal health behaviours.

While pregnant women in the control group did not receive this maternal health training intervention, they did receive maternal health education during routine services and any community-based interventions by health extension workers. 

Data on end points were gathered from 593 pregnant mothers, comprising 292 and 301 individuals in the intervention and control groups, respectively. Following the trial's implementation, the proportion of optimal antenatal care (ANC) - four ANC visits - in the intervention arm increased by 21.4% from the baseline (50.90 vs. 72.3, p ≤ 0.001), and the proportion of institutional delivery in the intervention group increased by 20% from the baseline (46.1% vs. 66.1%, p ≤ 0.001). Pregnant mothers in the intervention group significantly showed an increase of proportion of postnatal care (PNC) by 22.3% from baseline (26% vs. 48.3%, p ≤ 0.001).

Put another way, pregnant women in the intervention group were 2.09 times more inclined to receive optimal ANC compared to their counterparts in the control group (adjusted odds ratio (AOR) = 2.09, 95% confidence interval (CI): 1.69, 2.57). Similarly, the intervention group showed a 2.36-fold increase in institutional delivery rates compared to the control group (AOR = 2.36, 95% CI: 1.94, 2.87). Furthermore, the intervention group demonstrated a 2.26 times higher likelihood of utilising postnatal care services compared to the control group (AOR = 2.26, 95% CI: 1.79, 2.85).

In this study, it was noted that engaging religious leaders in health promotion activities in rural areas posed challenges. Some noted they require fuel and vehicles to enable them reach community gatherings; however, in most cases, they do not have the means. Also, some community members complained that religious leaders were talking about family planning inappropriately and that they were straying from their mission of preaching the word of God. Because religious leaders are sought by their communities for advice on almost every aspect of daily life, including reproductive health issues, they need scientific and updated information, which prepares them to correct misconceptions, dispel rumours, and provide useful advice.

Based on the findings, the researchers indicate that: "Given the importance of religion in Ethiopia's sociocultural fabric and the position of influence, authority, and respect occupied by various religious leaders (i.e., pastors, evangelists, priests, imams, and sheiks), one way of achieving a rapid increase in Ethiopia's use of maternal health services may be continuously engaging religious leaders at all levels in advocacy efforts." They conclude that "the engagement of religious leaders in maternal health education, when executed effectively alongside other reproductive health activities, could yield meaningful outcomes not only in Ethiopia but also in other Sub-Saharan African countries facing similar challenges."