Evaluating gain and loss-framed mobile messaging to improve maternal health service uptake: A cluster randomized controlled trial in Jimma, Ethiopia

BACKGROUND: Maternal mortality has declined in Ethiopia, yet rural areas still struggle with access to care. Mobile phone-based gain or loss-framed messaging-hold promise for improving maternal health outcomes. Evidence on the comparative impact of these framing strategies in low-resource rural settings remains limited. This study evaluated the effectiveness of gain- versus loss-framed SMS messages in improving maternal health service utilization in Jimma Zone, Ethiopia. METHODS: A three-arm cluster-randomized controlled trial was conducted across 21 clusters, with clusters allocated to gain-framed messaging, loss-framed messaging, or control (usual care). A total of 588 pregnant women (16-20 GA) were recruited in March 2023 and followed from May to December 2023, with endline assessment in February 2024. Participants received 39 messages over a 6-8 month period, aligned with gestational age and postnatal timeline. Primary outcomes were at least one ANC, SBA, and PNC within 7 days. Secondary outcomes included knowledge, attitudes, self-efficacy, and self-reported morbidity. Analyses used generalized and linear mixed models with cluster-level adjustments. RESULT: Both framing strategies improved service utilization compared to control. Gain-framed messages increased odds of ANC attendance (OR 5.40, 97.5% CI 1.95-14.94), SBA (OR 7.53, 97.5% CI 2.20-25.79), and PNC (OR 4.83, 97.5% CI 1.71-13.67). Loss-framed messages also improved ANC attendance (OR 7.14, 97.5% CI 2.40-21.26), Skilled Birth Attendance (SBA) (OR 7.31, 97.5% CI 2.13-25.09), and PNC (OR 4.07, 97.5% CI 1.46-11.39). Knowledge improved in both arms, attitudes improved only in the gain-framed arm, and self-efficacy showed no significant change. Self-reported maternal morbidity decreased in both intervention arms. CONCLUSION: Both gain- and loss-framed mobile messages led to increased maternal health service utilization. Loss-framed messages were more effective for ANC attendance, knowledge, and morbidity reduction, while gain-framed messages showed greater impact on SBA, PNC, and attitudes. TRIAL REGISTRATION: Pan African Clinical Trials Registry (PACTR), PACTR202201753436676, registered on January 4, 2022; https://tinyurl.com/ykhnpc49.