Effectiveness of Targeted Social and Behavior Change Communication on Maternal Health Knowledge, Attitudes, and Institutional Childbirth: A Cluster-randomized Trial in Jimma Zone, Ethiopia

"The improvement in the intervention group indicates that the SBCC [social and behaviour change communication] strategy effectively promoted institutional delivery and has the potential for broader use in similar contexts."

Maternal mortality remains a critical global health challenge, with 95% of deaths occurring in low-income countries. In Ethiopia, rural populations continue to face significant barriers to accessing maternal health services, despite initiatives such as the Health Extension Program and the Women's Development Army (WDA). This community-randomised trial evaluated the effectiveness of a social and behaviour change communication (SBCC) intervention to improve maternal health behaviours in rural Ethiopia. SBCC programmes like this one aim to transform community attitudes through targeted messaging and local engagement, which are particularly important in rural areas with limited healthcare access.

Sixteen primary healthcare units across three districts in the Jimma Zone were randomly assigned to either the intervention (SBCC) or control (standard care) group. The intervention reached approximately 511,869 people, including 113,277 women of reproductive age (15-49 years). Key components included:
 

• Training of community health actors (CHAs): 91 health extension workers (HEWs) and 7,363 WDAs, as well as 143 religious leaders, received specialised training using authoritative manuals to promote maternal health.
• Health education sessions: Regular sessions conducted by HEWs engaged the community and provided support to pregnant women.
• Community outreach and education: CHAs conducted proactive door-to-door outreach to emphasise the importance of institutional childbirth and prenatal care and to address cultural misconceptions.
• Ongoing support: Monthly training sessions and updates from HEWs ensured strict adherence to the intervention and promptly addressed challenges.

The control arm received standard care, which included existing community-government collaborations focused on improving healthcare access and delivering regular health education sessions aimed at identifying and supporting pregnant women. This care included monthly follow-ups to monitor community needs and reinforce maternal health messaging.

The study involved 5,057 women. The primary dependent variable was the occurrence of institutional childbirth, coded as 1 for delivery at a healthcare facility and 0 for non-institutional deliveries. Independent variables included antenatal care (ANC) utilization, maternal attitudes, knowledge about maternal health, and socioeconomic and demographic characteristics.

The proportion of childbirths at health institutions showed a slight increase in the control group, with the mean rising from 0.51 (standard deviation (SD) = 0.50) at baseline to 0.53 (SD = 0.50) at endline. In contrast, the intervention group experienced a more substantial increase, with the mean rising from 0.52 (SD = 0.50) at baseline to 0.71 (SD = 0.46) at the endline. This change was statistically significant, with a mean difference of 0.18 (pooled SD = 0.48), a t-value of -9.509 (df = 2530), P < .001, and an effect size of -0.18.

ANC visits showed a minor decrease in the control group, with the mean slightly dropping from 3.26 (SD = 0.86) at baseline to 3.23 (SD = 1.02) at endline. The intervention group demonstrated a notable increase in ANC visits, with the mean rising from 3.27 (SD = 0.87) at baseline to 4.21 (SD = 0.97) at endline. The observed increase in ANC visits within the intervention group may reflect enhanced awareness and motivation driven by targeted SBCC messages that underscored the importance of continuous maternal health care. This improvement was highly significant, with a mean difference of 0.94 (pooled SD = 0.98), a t-value of -24.862 (df = 2530), P < .001, and an effect size of -0.48.

Each additional ANC visit was positively associated with institutional childbirth (B = 0.082, P = .002), increasing the odds by 8.5% (Exp(B) = 1.085, 95% confidence interval (CI) 1.029-1.144). This association underscores the pivotal role of consistent ANC visits in influencing mothers' decisions to deliver at healthcare facilities. Positive attitudes toward institutional childbirth significantly influenced the outcome (B = 0.055, P < .001), resulting in a 5.7% increase in the odds (Exp(B) = 1.057, 95% CI 1.038-1.076).

Attitude scores showed a modest improvement in the control group, increasing from a mean of 37.19 (SD = 4.10) at baseline to 37.86 (SD = 3.34) at endline. In contrast, the intervention group experienced a more substantial rise, with the mean increasing from 37.49 (SD = 3.91) at baseline to 39.73 (SD = 3.26) at the endline. The increase in positive attitudes within the intervention group indicates a favorable shift toward institutional childbirth, likely due to the SBCC’s influence on participants' perceptions and motivation. This change was statistically significant, with a mean difference of 2.24 (pooled SD = 3.60), a t-value of -14.307 (df = 2530), P < .001, and an effect size of -0.28.

Knowledge scores remained stable in the control group, increasing from a mean of 5.68 (SD = 3.10) at baseline to 5.92 (SD = 2.19) at endline. Conversely, the intervention group experienced a significant increase in knowledge, with the mean rising from 5.68 (SD = 2.82) at baseline to 7.70 (SD = 1.82) at the endline. The marked increase in knowledge in the intervention group suggests that the SBCC intervention successfully enhanced participants' understanding of maternal health and institutional childbirth. This resulted in a mean difference of 1.78 (pooled SD = 2.00), a t-value of -22.325 (df = 2530), P < .001, and an effect size of -0.44.

Reflecting on the findings, the researchers note, in part: "Through maternal health-specific SBCC interventions, we cultivated positive attitudes toward healthcare practices, fostering timely health-seeking behaviors critical for advancing maternal and child health in these communities. This aligns with literature suggesting the efficacy of community-driven health education programs across diverse sociocultural contexts and emphasizes the need for continued community engagement to achieve sustainable improvements....The involvement of respected community figures, such as WDAs and HEWs, contributed to improved maternal health outcomes, reinforcing the growing body of evidence supporting the effectiveness of SBCC strategies in low-income settings like rural Ethiopia..."

In conclusion: "This study highlights the effectiveness of community-based SBCC interventions in enhancing maternal health outcomes in rural Ethiopia. The interventions led to increased ANC visits and higher institutional childbirth rates, showcasing the vital roles of CHWs, WDAs, and HEWs. Despite these gains, challenges such as inadequate healthcare infrastructure, supply chain issues, and the need for better workforce training remain. The findings indicate that simply providing knowledge is not enough to drive behavior change; addressing barriers like access to care and cultural alignment is crucial."