Interventions and randomization
The project trained selected community members to lead educational sessions on safe motherhood topics with pregnant women. For this reason, we identified two community health workers and 15 women from each kebele cluster to train as research implementers who were literate, permanent residents in the vicinity, willing and able to volunteer, and motivated to teach other about safe motherhood practices. The implementers received two days of training from the project team from November 10–27, 2020. The training covered five sessions on danger signs during pregnancy, labour and postpartum period, birth preparedness, the importance of institutional delivery, MWHs, and timely access to EmOC.The project staff and research implementers conducted two sessions per cluster for pregnant women in intervention clusters in 2020. The training sessions included information presentations and discussions on safe motherhood practices to increase awareness and discourage delays in seeking professional assistance. A total of 10 discussions and promotional activities, storytelling to improve their risk perception during pregnancy and childbirth were conducted with pregnant women in the community.The training materials were developed based on the findings of formative studies as well as the WHO-developed video, "Why Did Mr. X Die, Retold?" (Available at The training approach was based on the activated health education model that engages participants in the intervention process by making them aware of positive and negative behaviours and clarifying their responsibilities [After completing training, each implementer formed a group of 15 to 20 pregnant women who lived in the same village. They held bimonthly meetings to discuss topics related to safe parenthood and provided educational materials, including a birth preparedness card that was prepared specifically for this research. The research implementers were oriented to approach pregnant women based on the local context to help them overcome barriers to using maternal healthcare services, giving birth at health centers, and seeking postnatal care.In addition to the intervention on pregnant women, we provided a four-day training program on clinical skills in basic EmOC using the Safe Delivery application (see The unit for intervention allocation was the kebele (cluster), which refers to the smallest government administrative structure unit in Ethiopia. Since the number of kebeles may have been too small to ensure a balanced allocation between the intervention and control arms, we have matched them by dividing the 10 kebeles into 5 pairs. The pairs were matched on the basis of population, availability of maternity homes, topography and number of available midwives. As there were two kebeles in the pairs next to each other, we included both kebeles in the intervention arm to minimize the spill-over effect of information. Therefore, six kebeles were assigned to the intervention arm, and the remaining four served as the control arm. The impact of interventions on the institutional birth rate and other maternal health indicators was assessed through pre-intervention (baseline) and post-intervention (endline) surveys. Table Characteristics of study areas at their initial assessment in 2019One health post per cluster to serve 3000–5000 population (Six health posts)One health centre (EmOC) to serve up to 25,000 (Three health centres)One health post per cluster to serve 3000–5000 population (4 health posts)One health centre (EmOC) to serve up to 25,000 (two health centers)Two HEWs at a health postTwo nurses, two midwives and one health officer at a health centre