Description and implementation of the intervention
The intervention had three components: group health education, individual home visits and provision of print health messages. The intervention was provided at three contact points for couples in the intervention group. The first contact was the group health education at baseline whereas the second, and third contacts were home visits. The couples in the control groups continue receiving the usual care.The intervention was provided by the health extension workers who are trained village health workers. Group health education, provision of leaflets, and home visits were conducted. Health education was provided once in the first month whereas the home visits were performed 2 times at 2 months intervals (i.e., at 3rd and 5th months). Leaflets were provided 3 times (i.e., at first contact during group health education and at each of the two home visits). The health education session was provided in a group for 90–120 min. All participants (couples) in the intervention group within a cluster were gathered at one common place and received health education. Health extension workers in collaboration with Kebeles leaders selected the place of health education and invited the participants. Both women and their male partners were invited to receive the health education. This was done in all eight intervention clusters, and as a result, eight health education sessions were performed at baseline.Health education addressed the importance of antenatal care, importance and kinds of paternal support, purpose and benefits of staying in MWHs, and advantages of skilled birth. The purpose and benefits of MWHs and paternal support were emphasized in health education. The services available at MWHs, the benefits of staying at MWHs, the right time to visit MWHs, and the importance of paternal support were discussed. Types of paternal support during pregnancy and MWH stay, such as allowing a spouse to stay at MWH, accompanying her to MWH, providing financial support during MWH stays, providing food and other necessary materials, looking after the home, and caring for the remaining children at home, were emphasized. Health messages in leaflets focused on paternal support and the purpose and advantages of MWHs. The health messages in the leaflets were picture based as most of the participants were not educated. In addition, he health extension workers provided the health education based on the contents in leaflets before they gave them to the participants. Next, the schedule of home visits was proposed through discussions with participants, with an emphasis that couples would be contacted at their residence.The first home visit was conducted 2 months after the health education intervention (i.e., in the 3rd month of the intervention). During this visit, couples received advice regarding antenatal care, paternal support, and MWHs. Male partners were advised on how to support their wives and encourage them to use antenatal care, stay at MWHs, and deliver at a health facility. The couples were asked to discuss their perceptions of antenatal care, MWH use, and health facility delivery. They were advised based on their perceptions and actual observed practices. Leaflets with the same health messages at baseline health education were provided. Repeated visits were made if couples were absent.The second home visit was conducted 2 months after the first home visit (i.e., in the 5th month of the intervention). During this visit, paternal support, birth preparedness plans, and intention to use MWHs were assessed. Leaflets containing messages regarding possible risks of home delivery and advantages of staying at MWHs and institutional delivery were provided. Any misunderstandings regarding MWHs were clarified through discussion. Male partners were advised to continue supporting their wives. The expected delivery date was estimated and a possible appointment to arrive at the MWH was made. To make the couples remember the appointment, a written invitation letter was provided. The study findings were reported using Consolidated Standards of Reporting Trials (CONSORT) for cluster randomized trials criteria