Effectiveness of Interactive Mobile Health Intervention on Contraceptive Adoption and Neonatal Care during Early Postpartum In Northeast Ethiopia: a Cluster Randomized Controlled Trial

Abstract

Background: Despite improvements in family planning services across sub-Saharan Africa, the uptake of modern contraceptive methods during the early postpartum period remains low, contributing to a high unmet need for contraception and increasing the risk of unintended pregnancies and short birth intervals. In Ethiopia, postpartum contraceptive use is particularly low, and existing studies present fragmented and inconsistent findings, with limited exploration of the underlying factors influencing adoption during this critical period. Although global neonatal mortality has declined, progress in Africa, including Ethiopia, has been slower, underscoring the need to strengthen neonatal care practices. Mobile health (mHealth) interventions, enabled by widespread mobile phone access, offer a promising strategy to improve postpartum family planning and neonatal care by enhancing communication between women and health providers. However, evidence on the effectiveness of such interventions in the Ethiopian context remains limited. This study sought to generate evidence on postpartum contraceptive use and neonatal care practices by identifying knowledge gaps, understanding contextual barriers and facilitators, and informing the development of targeted, culturally appropriate, and scalable mHealth interventions. Objectives: This study aimed to evaluate the effectiveness of an interactive mobile health intervention to improve early postpartum modern contraceptive adoption and community-based neonatal care practices, while also identifying the barriers, facilitators, intention levels, associated factors, and existing evidence related to postpartum family planning among women in Northeast Ethiopia. Methods: This study was conducted in Dessie and Kombolcha city zones in the Amhara Regional State, Northeast Ethiopia, using a sequential multi-method approach. A cluster randomized controlled trial served as the primary design to evaluate the effectiveness of an interactive mobile health (mHealth) intervention in improving early postpartum modern contraceptive uptake and neonatal care practices. The intervention package included educational text messages on family planning and neonatal care, automated reminders aligned with critical postpartum milestones, and two-way mobile communication between women and trained health professionals. To ensure the intervention was evidence-based, tailored the needs and realities and contextually appropriate, the cluster randomized controled trial was supported by a scoping review, a qualitative study, and a baseline cross-sectional survey. The scoping review synthesized literature on postpartum contraceptive use in Ethiopia to map evidences, identify information gaps and guide the intervention’s theoretical framework and content. A qualitative study involving 57 purposively selected participants from December 15, 2022 to January 15, 2023, including postpartum women, health care providers, and community members, further explored socio-cultural, individual, and health system-level factors. Data were collected through interviews and focus groups and VII analyzed thematically using Atlas.ti software, ensuring trustworthiness through triangulation and peer review. Insights from this phase guided the cultural and contextual tailoring of the intervention. A baseline cross-sectional survey was conducted from January 2 to 15, 2023, among 780 pregnant women selected using cluster sampling from 20 kebeles in Dessie and Kombolcha. Face to face interviews were administered through Open Data Kit (ODK), and the data were analyzed using STATA version 17. Multivariable logistic regression identified factors influencing intention to use postpartum contraception. The cluster randomized controled trial was implemented from January 15 to June 15, 2023, involving 764 pregnant women at 30 weeks gestation, followed until 45 days postpartum. Kebeles (clusters) were randomized into intervention (n=383) and control (n=381) groups. The intervention group received the mHealth package in addition to standard maternal and newborn care, while the control group received routine care alone. Endline data collection was conducted electronically, and Generalized Estimating Equations (GEE) model was used for analysis to account for clustering of the intervention on early postpartum contraceptive adoption. The main outcomes postpartum contraceptive uptake and neonatal care practices were analyzed using adjusted odds ratios with 95% confidence intervals, with statistical significance set at p<0.05. To investigate how the intervention influenced neonatal care, Structural Equation Modeling (SEM) was performed using data from 743 participants (376 in the intervention group and 367 in the control group). Structural equation modeling assessed both direct and indirect pathways through which the intervention affected neonatal care. Confirmatory Factor Analysis (CFA) validated the constructs, and model fit was assessed using indices such as the chi-square to degrees of freedom ratio (3), Root Mean Square Error of Approximation (RMSEA) (0.03), and Standardized Root Mean Square Residual (SRMR) (0.06). The results showed acceptable model fit and statistically significant pathways, supporting the theoretical model that guided the design of the mHealth intervention. Results: From an initial pool of 1,607 records identified through database searches and reference list screening, duplicates and ineligible studies were excluded, leaving 28 full-text articles for detailed review. The scoping review revealed a notable absence of controlled trials or longitudinal research targeting early postpartum contraceptive use. Instead, the majority of existing studies broadly addressed postpartum family planning without emphasizing the critical early postpartum period and its unique challenges. The barriers to early postpartum contraceptive uptake identified through the review were multifaceted. Knowledge barriers were prominent, with many women unaware of the timing and necessity for contraception soon after childbirth. Negative attitudes both among women and healthcare providers also posed challenges, often stemming from fears that contraceptive use could reduce breast milk production or misconceptions about the risk of pregnancy during the postpartum period. Health system barriers such as VIII insufficient follow-up care, inconsistent availability of family planning services, long waiting times, and sometimes unfavorable provider attitudes further limited uptake. Moreover, community and cultural influences played significant roles in discouraging early postpartum contraceptive use. Regarding intention to use contraception in the early postpartum period, the study found that approximately three-quarters (75.8%, 95% CI: 73%–79%) of pregnant women intended to adopt modern contraceptive methods soon after childbirth. After adjusting for confounding variables, several factors were significantly associated with this intention. Older maternal age (AOR = 6.2; 95% CI: 2.6–14.6). A longer preceding birth interval (AOR = 2.5; 95% CI: 1.6–3.7), employment status (AOR = 1.9; 95% CI: 1.3–2.8), closer proximity to health facilities (AOR = 2.6; 95% CI: 1.5–4.4), Public facility delivery in the last birth (AOR = 2.4; 95% CI: 1.1–5.7), better knowledge of contraception (AOR = 1.5; 95% CI: 1.1–2.1), and attendance at antenatal care (AOR = 1.9; 95% CI: 1.2–3.3) were significaltly associated factors to had intention. An interactive mobile health intervention demonstrated a significantly higher rate of early postpartum contraceptive uptake in the intervention group (51.6%) compared to the control group (38.0%). Women who received the intervention were 1.6 times more likely to use modern contraceptive methods early postpartum than those who did not (AOR: 1.6; 95% CI: 1.249–2.123). The mobile health intervention had also a significant direct positive effect on neonatal care practices (β = 0.393, p = 0.007). Improved knowledge of neonatal care, also fostered by the intervention, independently contributed to better neonatal care practices (β = 0.347, p = 0.012). No significant indirect effects were found, indicating that both the intervention and enhanced knowledge acted as key, direct predictors of improved neonatal care behaviors. The total effects of the intervention and increased knowledge on neonatal care practices were statistically significant, with β = 0.382 (p = 0.009) and β = 0.347 (p = 0.012), respectively. Conclussion: This study provides compelling evidence that digital health interventions (mHealth) can play a transformative role in improving early postpartum contraceptive uptake and neonatal care. However, the study also identified several barriers to the adoption of modern contraceptive methods, including individual factors, method-related concerns, misconceptions, facility-level limitations, and broader sociocultural influences. Despite these challenges, approximately three out of four pregnant women expressed an intention to use contraceptives postpartum, even if intention had no significant association in this study. Overall, integrating mobile health solutions into maternal and neonatal care programs offers a promising pathway to overcoming persistent barriers and improving reproductive health outcomes in resource-limited settings. Trial Registration: Protocol Registration and Results System (PRS) Clinical Trial Registry, www.ClinicalTrials.gov, ClinicalTrials.gov ID: NCT05666050. Registered on December 23, 2022.