This clinical study aims to find out if a redesigned health education program-one that respects local cultural beliefs and is based on well-known behavior change theories-can help improve how well mothers care for their newborns and how often they use postnatal care services. The main hypothesis is that culturally tailored health education provided by trained midwives will lead to: 1. Increased use of postnatal care services by mothers after childbirth, and 2. Improved knowledge among mothers about how to care for their newborns.
In the study, midwives will first be trained in how to provide this culturally appropriate health education. Then, the trained midwives will deliver four health education sessions-once a month-to pregnant women during their regular antenatal (before birth) visits at health facilities.
A catchment population size of at least 5,000 people
An average of more than 50 antenatal care (ANC) visits per month
Location in a peri-urban area to facilitate participant follow-up
Gestational age between 20 and 24 weeks at the time of enrollment
Mothers who plan to relocate from the selected cluster area before or shortly after delivery
Mothers who do not speak either Afan Oromo or Amharic, as these are the languages used for delivering the intervention.
Mothers who have already completed all recommended postnatal care visits during their most recent previous birth
Parallel
Health Education
BehavioralThe intervention-a culturally tailored and redesigned health education-will be guided by established behavioral theories, namely the Theory of Planned Behavior (TPB) and Social Cognitive Theory (SCT) and implemented in a culturally sensitive manner. The TPB focuses on attitudes toward utilizing PNC services, the influence of subjective norms such as cultural norm, and their perceived behavioral control including transportation (34), while SCT emphasizes self-efficacy, social modeling, and reinforcement(35). Both TPB and SCT have been extensively validated in various health behavior studies, supporting their relevance and applicability in this context(36, 37). Our intervention will consist of a structured training foe health extension worker and mentorship program. The intervention package, including the training curriculum and implementation manual, will be developed in accordance with guidelines from the World Health Organization (WHO) and the Federal Ministry
Postnatal care use
PNC utilization will be assessed based on the World Health Organization (WHO) recommendations, which define adequate postnatal care as having four scheduled contacts: within 24 hours of birth, on Day 3 (48-72 hours), between Days 7-14, and at six weeks postpartum. Data will be collected using a structured maternal postnatal care follow-up questionnaire administered during endline interviews. This questionnaire includes items capturing self-reported timing and number of PNC visits, supplemented by verification from clinic records where available. For the primary analysis, PNC utilization will be coded as a binary variable: 1 (Yes) - if the mother attended at least two postnatal care visits and 0 (No) - if the mother attended fewer than two visits. This threshold reflects a more feasible level of access in the study setting. For the secondary analysis, attendance of all four WHO-recommended visits will be assessed as an indicator of higher adherence to WHO standards.
Newborn care knowledge
Maternal knowledge of newborn care will be assessed using a structured questionnaire titled the "Maternal Knowledge of Newborn Care Questionnaire", developed based on World Health Organization (WHO) guidelines and existing validated tools. The consists of 16 items grouped into key dimensions of essential newborn care, including breastfeeding, recognition of neonatal danger signs, vaccination, hygiene practices, cord and eye care, and sunlight exposure. Each correct response will be scored as 1, and incorrect or "don't know" responses as 0. The questionnaire has a total score ranging from 0 to 22, where 22 indicates the highest level of knowledge and 0 represents no correct knowledge. Mothers will be categorized as follows: Good knowledge - correctly answering at least 50% of the items and Poor knowledge - correctly answering less than 50% of the items. This binary classification will serve as the primary metric for evaluating newborn care knowledge in the analysis.
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