Enhancing Maternal Health in Rural Ethiopia: A Cluster-Randomized Social and Behavior Change Communication Interventions Trial to Overcome Barriers to Institutional Childbirth

Abstract

Maternal mortality continues to be one of the most urgent global health challenges, particularly in low-income countries, which bear 95% of the global burden. While some progress was made in reducing maternal deaths between 2000 and 2015, recent trends show stagnation or even setbacks in certain regions, especially sub-Saharan Africa. Ethiopia, with its alarmingly high maternal mortality rate, is far from achieving the Sustainable Development Goal (SDG) target of reducing maternal deaths to 70 per 100,000 live births by 2030. This PhD dissertation offers a comprehensive evaluation of interventions aimed at reducing maternal mortality, focusing on improving institutional childbirth practices in rural Ethiopia. The dissertation is based on three complementary studies, each addressing different aspects of maternal health interventions in the Jimma Zone of Oromia, Ethiopia. The first study explores the barriers to institutional childbirth by gathering qualitative insights from various stakeholders, including women, religious leaders, health extension workers, and healthcare providers. The second study investigates the role of religious leaders in promoting maternal health practices, particularly their influence on encouraging institutional childbirth. The third study assesses the effectiveness of a targeted social and behavior change communication (SBCC) intervention, which aimed to improve maternal health knowledge, attitudes, and behaviors, with a particular focus on antenatal care (ANC) attendance and institutional childbirth. Study 1: Identifying Barriers to Institutional Childbirth The first study utilized an exploratory qualitative case study design to identify barriers to institutional childbirth in rural Ethiopia. In 2019, 16 focus group discussions and 18 in-depth interviews were conducted with key stakeholders, including women of reproductive age, religious leaders, health extension workers, midwifery nurses, primary healthcare unit directors, and members of women’s development armies. Purposive sampling was employed to ensure a diverse range of perspectives. The interviews and discussions were transcribed, translated into English, and analyzed using thematic analysis. Five key themes emerged: (1) knowledge gaps regarding maternal health, (2) cultural beliefs and practices surrounding pregnancy and childbirth, (3) poor access to healthcare services, particularly in remote areas, (4) lack of essential resources such as medical supplies and skilled health personnel, and (5) limited community involvement in promoting institutional childbirth.