Partnering faith leaders with community health workers increases utilization of antenatal care and facility delivery services in Ethiopia: A cluster randomized trial

BACKGROUND: Ethiopia and other countries continue to experience high rates of maternal mortality and neonatal deaths. Interventions are needed to increase utilization of antenatal care (ANC) and facility delivery services to improve outcomes. METHODS: A cluster-randomized trial was conducted in the Amhara Region of Ethiopia, with 6 communities randomly assigned to receive the intervention and 12 communities monitored as controls. Intervention teams provided outreach to pregnant women and their families. Registry data were used to measure utilization of services provided at health centers in intervention and control communities.The intervention consisted of trained pairs of community health workers and Ethiopian Orthodox priests who worked together to promote health messages around safe delivery. The pairs visited pregnant women and their families in their homes to provide counseling, discuss concerns, and answer questions about ANC and facility deliveries. Intervention impact was measured using facility-level data on monthly number of ANC visits and facility deliveries at the health centers that served the intervention and control communities. Intervention effect was measured using difference-in-difference analyses estimated by generalized estimating equation models. RESULTS: During the 12-month intervention period, intervention facilities (n = 6) recorded 14% more ANC1 visits (relative risk RR = 1.14; 95% confidence interval (CI) = 1.09-1.19; P < 0.001) and 26% more ANC4 visits (RR = 1.26; 95%CI = 1.18, 1.34; P < 0.001) compared to control health centers (n = 12). The intervention health centers experienced a 10% increase in facility deliveries over what would have been expected had the intervention not occurred (RR = 1.10; 95% CI = 1.05-1.16; P < 0.001). CONCLUSIONS: Promotion of safe delivery through home visits by community health workers paired with Ethiopian Orthodox priests increased utilization of ANC and facility delivery services. This approach could leverage the influential role of faith leaders and increase the impact of community health workers in Ethiopia. TRIAL REGISTRATION: NCT04039932.