Discussion
This study determines that tailored social media-based health education guided by health belief model are effective in increasing PNC knowledge score among pregnant women attending DH for antenatal check-up. The mean maternal care attribute knowledge increased by 4.31 scores, newborn care attribute knowledge increased by 3.39 scores, and overall PNC knowledge score increased by 8.07 scores among pregnant women in the intervention compared to the control group. The maternal care attributes knowledge included knowledge of danger signs, place to seek care if experiencing danger signs, frequency of urination in postnatal period, initiation of sex after delivery, PNC diet, delay in menstruation by exclusive breastfeeding, family planning methods, and PNC visit schedule. The newborn care attributes knowledge included knowledge of danger signs of newborns, keeping baby warm, first newborn bathing, cord care, first breastfeeding initiation after birth, breastfeeding frequency in 24 hours, exclusive breastfeeding duration, vaccine and importance of vaccine to newborns. The increased maternal and newborn care attributes knowledge develops confidence among women to take care of themselves and their babies, adapt to new conditions [The total PNC knowledge score increased by 8 points among intervention group compared to control group, which is 23% higher score among intervention group compared to control group. The maternal care attribute score was increased by 4.3 points, which is 18% higher score in intervention group compared to control group; and newborn care attribute score was increased 3.39 points, which is 32% higher in intervention group compared to control group. Women’s engagement in the social media such as Facebook, Instagram, Twitter etc. enhanced the feasibility of disseminating health information to the participants at targeted locations in other settings as well [This mobile-phone based intervention’s positive effect is plausible as the unique characteristics of the mobile phone are ubiquity, mobility, constant availability, and multiple media modalities, among others [The positive direction of effect of intervention found in our study agrees with other experimental studies conducted in similar study settings. In a controlled quasi experimental study conducted among pregnant women attending hospital for antenatal care in Tanzania, interactive alert mobile messaging system of receiving and sending messages reported 29% (48% to 78%) increase in knowledge of danger signs of pregnancy in the intervention group compared to the control group in a sample of 450 women. Urban residence of literate pregnant women with increasing phone ownership were the predictors for increasing knowledge on danger signs of pregnancy [In a randomized controlled trial study conducted in Indonesia, counseling aided with mobile application named Suami Siaga plus found 20% increment in husband’s score in the knowledge of danger signs in the intervention compared to the control group. The possible explanation of increase in the knowledge score suggested methods of health education such as social media had an influence on participants knowledge score. Mobile app-based health education aided with counseling yielded better effect in increasing knowledge score [In contrast to the findings from our study, pseudo randomized controlled trial in India with similar intervention (audio messages included messages on maternal and new born care; and messages were sent twice a week) and conducted among 2016 pregnant women found no significant changes in knowledge of pregnant women in the intervention group. The findings of this study suggested knowledge indicators measured in this study were not directly related to the specific messages or practices. The participants of the study already possessed high level of knowledge on some aspects of maternal care. About two-third of the pregnant women had already given birth to babies making them extremely familiar with the topics covered in the maternal care knowledge [Even through there was about 35.77% attrition rate, the characteristics of the intervention and control participants who were loss to follow up were similar. Assessment in the characteristics of intervention and control group at end-line showed good balance eliminating the chance of potential confounding by attrition. Our study design was open masked leading to the possibility of contamination of information between the intervention and control groups as the participants were taken from the same study site. The contamination of information might have underestimated the result estimates.The findings of the study have important implications in terms of future research. PNC knowledge is associated with increased PNC service utilization [Our study has many strengths. In Nepal, this is one of the few studies with randomized controlled design conducted to assess the effect of social-media based education in increasing the PNC knowledge of pregnant women. As a randomized controlled design study, with strongest empirical evidence it was possible to establish temporal relationship and hence infer causal relationship between intervention and primary outcome, PNC knowledge. The use of standardized knowledge assessment questionnaire and robust measures in analyzing data were the strengths of this study. Use of health belief model for developing social media-based PNC education was another strength of this study. This study provided new evidences that social media-based education program is effective in creating awareness about different issues on post-natal care as compared to conventional antenatal care health education provided in ANC clinic at DH.There are several limitations of the study. First, the short follow -up duration of the study participants which could have overestimated the effect of intervention in increasing PNC knowledge score among pregnant women in the intervention group. Second, inclusion of literate pregnant women owning smartphones with access to internet in the study limits the generalizability of the study. Also, the study was conducted in an urban setting. Therefore, its generalizability to rural settings cannot be confirmed. Third, use of social media for intervention which limited the PNC education and can limit its implications to those who could afford it. Women not having access to internet were deprived from the advantage of social media-based education and hence had to rely on the conventional health education program. Fourth, the assessment of video views by pregnant women was self-reported. However, we tracked the number of views on the YouTube—there were about 701 views on the Youtube videos for 167 intervention participants. And finally, some attrition of participants over the 1-month follow-up period were likely due to the use of telephone calls for follow- up of the participants in the study affecting the precision of the estimates.