Abstract
Background: Unsafe home delivery remains a major contributor to preventable maternal and neonatal morbidity in Pakistan, particularly where births occur without skilled attendance and referral is delayed. Community-based education may reduce home birth by improving danger-sign recognition, birth preparedness, and antenatal care (ANC) uptake.
Objective: To evaluate whether targeted community education decreases unsafe home deliveries. Outcomes include knowledge improvement, ANC attendance, and skilled-birth rates.
Methods: A parallel, two-arm cluster randomized trial was conducted in the catchment area of a tertiary hospital in Pakistan. Geographically distinct clusters were randomized 1:1 to intervention or routine care. Pregnant women residing in participating clusters were enrolled and followed to six weeks postpartum. The intervention combined (1) interactive group education sessions, (2) structured home counseling, (3) engagement of key family decision-makers, and (4) facility linkage support (birth planning and referral pathway information). The primary outcome was unsafe home delivery (home birth without a skilled birth attendant). Secondary outcomes included ANC attendance (≥1 and ≥4 visits), skilled birth attendance (any setting), facility delivery, and maternal knowledge score (0–22). Analyses followed intention-to-treat principles with cluster-level correlation accounted for.
Results: Twenty-four clusters (12 per arm) were randomized. A total of 960 women were enrolled (480 per arm); 920 completed follow-up (intervention: 462; control: 458). Unsafe home delivery was lower in intervention clusters 24.2% (112/462) versus controls 37.3% (171/458) (RR 0.65; 95% CI 0.53–0.79). ANC uptake increased (≥1 visit: 90.9% vs 80.8%, RR 1.13; 95% CI 1.07–1.19; ≥4 visits: 62.8% vs 44.8%, RR 1.40; 95% CI 1.24–1.59). Skilled birth attendance was higher in the intervention arm 79.7% vs 64.6% (RR 1.23; 95% CI 1.14–1.34). Mean knowledge scores improved more in intervention clusters (endline 16.8 vs 13.4; mean difference 3.4).
Conclusion: A targeted community-based health education package delivered in a tertiary hospital catchment area was associated with reduced unsafe home delivery and improved knowledge, ANC attendance, and skilled birth attendance. Integrating structured community education with referral linkage support may be an effective strategy to accelerate safer childbirth practices in Pakistan.