Improving Maternal Health Service Use Among Underserved Pregnant Women: Evaluation of a Quasi-Experimental Study in Rural Ethiopia

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The World Health Organization recommends that pregnant women attend antenatal care (ANC) regularly throughout pregnancy and deliver in a health facility. While prior interventions have sought to address social barriers to maternal health service utilization, the specific social mechanisms through which these interventions exert influence remain unclear. This study examined changes in key social factors following the intervention and their associations with maternal health service utilization over time in a quasi-experimental study in Ethiopia. Pregnant women facing intersecting vulnerabilities were identified and enrolled in two intervention and two control districts and surveyed at pre- and post-intervention. The intervention included educational audio programs, print materials, and home visits by community health volunteers. Results showed that improvements in injunctive norms, couple communication, and social support were significantly greater among women in the intervention group than in the control group. Overall, women who received the intervention were more likely to use ANC and delivery services at health facilities. Regression analyses showed that improvements in descriptive and injunctive norms, as well as couple communication, predicted ANC use. Improvements in descriptive norms were associated with health facility-based delivery. Institutional delivery appeared less responsive to social influence alone, indicating that structural barriers require concurrent attention. Findings also highlight the central role of social norms in shaping maternal health behaviors, alongside couple communication. Social norms-based strategies, such as using social proof messaging and engaging influential referents, may help catalyze behavioral shifts among pregnant women in low-resource settings.