{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T15:10:22Z","timestamp":1778685022120,"version":"3.51.4"},"reference-count":64,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T00:00:00Z","timestamp":1778630400000},"content-version":"unspecified","delay-in-days":42,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["INV-035431"],"award-info":[{"award-number":["INV-035431"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["bmjph"],"accepted":{"date-parts":[[2026,4,1]]},"published-print":{"date-parts":[[2026,4]]},"abstract":"<jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Maternal health services, such as antenatal care (ANC) and institutional delivery, may reduce maternal and child health burdens. However, disparities in service coverage persist across Ethiopia. Pregnant women experiencing intersecting vulnerabilities face particularly significant barriers to accessing care. Understanding how social contexts shape maternal care-seeking behaviours can provide valuable insights into supporting underserved pregnant women, offering guidance for future research and practice. This study examines the influence of social and gender norms, as well as spousal relationship dynamics, on service utilisation among this population.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This study is based on cross-sectional baseline data from a parent quasi-experimental study. Screening tools were developed to identify pregnant women facing vulnerabilities in accessing maternal care. A total of 470 pregnant women participated in the survey, which assessed perceived social norms, gender norms, couple communication, decision-making, social support, ANC visits and institutional delivery experiences. Logistic and linear regression analyses were performed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Our results showed that descriptive norms, injunctive norms, couple communication and joint decision-making were significantly associated with ANC visits. Descriptive and injunctive norms predicted institutional delivery. ANC visit partially mediated the relationship between social norms and institutional delivery and fully mediated the influence of couple communication on institutional delivery. Our findings also revealed interaction effects among social norms, couple communication and gender norms on health service use.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This study revealed that health service use among underserved pregnant women is heavily influenced by social norms\u2014the behaviours, attitudes and beliefs of people in their social networks. Interpersonal communication with husbands also played a significant role in shaping maternal service utilisation. The findings suggest that future programmes should engage and educate male partners, family members and peer pregnant women to foster a supportive social environment that encourages care-seeking behaviours among new mothers facing intersecting barriers.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/bmjph-2025-002778","type":"journal-article","created":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T14:20:20Z","timestamp":1778682020000},"page":"e002778","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Social mechanisms of maternal health service use among pregnant women facing intersecting vulnerabilities in Ethiopia: a cross-sectional study"],"prefix":"10.1136","volume":"4","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1124-2481","authenticated-orcid":false,"given":"Bee-Ah","family":"Kang","sequence":"first","affiliation":[{"name":"Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1413-9305","authenticated-orcid":false,"given":"Rajiv N.","family":"Rimal","sequence":"additional","affiliation":[{"name":"Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Yihunie","family":"Lakew","sequence":"additional","affiliation":[{"name":"Johns Hopkins University Center for Communication Programs, Addis Ababa, Ethiopia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-0167-2920","authenticated-orcid":false,"given":"Daryl","family":"Stephens","sequence":"additional","affiliation":[{"name":"Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Habtamu","family":"Tamene","sequence":"additional","affiliation":[{"name":"Johns Hopkins University Center for Communication Programs, Addis Ababa, Ethiopia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2026,5,13]]},"reference":[{"key":"2026051307201212000_4.2.e002778.1","unstructured":"Central Statistical Agency (CSA) and ICF . Ethiopia demographic and health survey 2016. Addis Ababa, Ethiopia CSA and ICF; 2017."},{"key":"2026051307201212000_4.2.e002778.2","unstructured":"Ethiopian Public Health Institute - EPHI, Federal Ministry of Health - FMoH, ICF . Ethiopia mini demographic and health survey 2019. 2019."},{"key":"2026051307201212000_4.2.e002778.3","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2023-011911","article-title":"Learning from Ethiopia\u2019s success in reducing maternal and neonatal mortality through a health systems lens","volume":"9","author":"Melesse","year":"2024","journal-title":"BMJ Glob Health"},{"key":"2026051307201212000_4.2.e002778.4","unstructured":"Central Statistical Authority\/Ethiopia,ORC Macro . Ethiopia demographic and health survey 2000. Addis Ababa, Ethiopia, 2001."},{"key":"2026051307201212000_4.2.e002778.5","unstructured":"Central Statistical Agency\/Ethiopia, ICF International . Ethiopia demographic and health survey 2011. Ethiopia Addis Ababa; 2012."},{"key":"2026051307201212000_4.2.e002778.6","unstructured":"Central Statistical Agency (CSA) and ICF . Ethiopia demographic and health survey 2024\u201325: key indicators. Addis Ababa and Rockville, Maryland, USA,"},{"key":"2026051307201212000_4.2.e002778.7","doi-asserted-by":"crossref","DOI":"10.1186\/s12992-019-0470-1","article-title":"Community health extension program of Ethiopia, 2003-2018: successes and challenges toward universal coverage for primary healthcare services","volume":"15","author":"Assefa","year":"2019","journal-title":"Global Health"},{"key":"2026051307201212000_4.2.e002778.8","doi-asserted-by":"publisher","DOI":"10.1590\/S1555-79602011000300011"},{"key":"2026051307201212000_4.2.e002778.9","unstructured":"World Health Organization . Trends in maternal mortality 2000 to 2020: estimates by who, unicef, unfpa, world bank group and undesa\/population division. Geneva, 2023."},{"key":"2026051307201212000_4.2.e002778.10","doi-asserted-by":"crossref","first-page":"1775","DOI":"10.1016\/S0140-6736(16)31470-2","article-title":"Global, regional, and national levels of maternal mortality, 1990\u20132015: a systematic analysis for the Global Burden of Disease Study 2015","volume":"388","author":"Kassebaum","year":"2016","journal-title":"The Lancet"},{"key":"2026051307201212000_4.2.e002778.11","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.socscimed.2014.10.042","article-title":"Inequalities in institutional delivery uptake and maternal mortality reduction in the context of cash incentive program, Janani Suraksha Yojana: Results from nine states in India","volume":"123","author":"Randive","year":"2014","journal-title":"Soc Sci Med"},{"key":"2026051307201212000_4.2.e002778.12","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2458-14-1"},{"key":"2026051307201212000_4.2.e002778.13","unstructured":"Graham WJ , Bell JS , Bullough CH . Can skilled attendance at delivery reduce maternal mortality in developing countries? safe motherhood strategies: a review of the evidence. 2001."},{"key":"2026051307201212000_4.2.e002778.14","doi-asserted-by":"crossref","first-page":"977","DOI":"10.1016\/S0140-6736(05)71088-6","article-title":"Evidence-based, cost-effective interventions: how many newborn babies can we save?","volume":"365","author":"Darmstadt","year":"2005","journal-title":"The Lancet"},{"key":"2026051307201212000_4.2.e002778.15","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-020-05096-7","article-title":"Factors associated with institutional delivery in Ethiopia: a cross sectional study","volume":"20","author":"Ketemaw","year":"2020","journal-title":"BMC Health Serv Res"},{"key":"2026051307201212000_4.2.e002778.16","first-page":"343","article-title":"Socio-cultural Beliefs and Practices Influencing Institutional Delivery Service Utilization in Three Communities of Ethiopia: A Qualitative Study","volume":"29","author":"Ababor","year":"2019","journal-title":"Ethiop J Health Sci"},{"key":"2026051307201212000_4.2.e002778.17","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2393-9-1"},{"key":"2026051307201212000_4.2.e002778.18","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0284592","article-title":"Social capital and its role to improve maternal and child health services in Northwest Ethiopia: A qualitative study","volume":"18","author":"Mengesha","year":"2023","journal-title":"PLoS ONE"},{"key":"2026051307201212000_4.2.e002778.19","doi-asserted-by":"publisher","DOI":"10.1037\/\/0022-3514.58.6.1015"},{"key":"2026051307201212000_4.2.e002778.20","doi-asserted-by":"crossref","DOI":"10.1186\/1471-2393-12-113","article-title":"Making pragmatic choices: women\u2019s experiences of delivery care in Northern Ethiopia","volume":"12","author":"Gebrehiwot","year":"2012","journal-title":"BMC Pregnancy Childbirth"},{"key":"2026051307201212000_4.2.e002778.21","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2393-13-1"},{"key":"2026051307201212000_4.2.e002778.22","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/S0065-2601(08)60330-5","article-title":"A focus theory of normative conduct: A theoretical refinement and reevaluation of the role of norms in human behavior","volume":"24","author":"Cialdini","year":"1991","journal-title":"Adv Exp Soc Psychol"},{"key":"2026051307201212000_4.2.e002778.23","doi-asserted-by":"publisher","DOI":"10.1177\/0093650205275385"},{"key":"2026051307201212000_4.2.e002778.24","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1111\/comt.12080","article-title":"A Re-Explication of Social Norms, Ten Years Later","volume":"25","author":"Rimal","year":"2015","journal-title":"Commun Theor"},{"key":"2026051307201212000_4.2.e002778.25","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0249917","article-title":"The association between male involvement in institutional delivery and women\u2019s use of institutional delivery in Debre Tabor town, North West Ethiopia: Community based survey","volume":"16","author":"Tessema","year":"2021","journal-title":"PLoS ONE"},{"key":"2026051307201212000_4.2.e002778.26","first-page":"403","article-title":"Utilization of Institutional Delivery Service in a Predominantly Pastoralist Community of Northeast Ethiopia","volume":"28","author":"Ahmed","year":"2018","journal-title":"Ethiop J Health Sci"},{"key":"2026051307201212000_4.2.e002778.27","doi-asserted-by":"crossref","first-page":"407","DOI":"10.1111\/1467-9566.13008","article-title":"Gender norms and social norms: differences, similarities and why they matter in prevention science","volume":"42","author":"Cislaghi","year":"2020","journal-title":"Sociology Health &Amp; Illness"},{"key":"2026051307201212000_4.2.e002778.28","doi-asserted-by":"crossref","first-page":"350","DOI":"10.1007\/s11199-022-01319-9","article-title":"The G-NORM Scale: Development and Validation of a Theory-Based Gender Norms Scale","volume":"87","author":"Sedlander","year":"2022","journal-title":"Sex Roles"},{"key":"2026051307201212000_4.2.e002778.29","doi-asserted-by":"publisher","DOI":"10.1086\/233851"},{"key":"2026051307201212000_4.2.e002778.30","doi-asserted-by":"crossref","unstructured":"Nussbaum MC . Women and Human Development: The Capabilities Approach. Cambridge university press, 2000.","DOI":"10.1017\/CBO9780511841286"},{"key":"2026051307201212000_4.2.e002778.31","doi-asserted-by":"publisher","DOI":"10.1111\/j.1728-4465.2002.00185.x"},{"key":"2026051307201212000_4.2.e002778.32","doi-asserted-by":"crossref","first-page":"112","DOI":"10.4103\/0970-0218.51232","article-title":"Spousal communication, changes in partner attitude, and contraceptive use among the yorubas of southwest Nigeria","volume":"34","author":"Ogunjuyigbe","year":"2009","journal-title":"Indian J Community Med"},{"key":"2026051307201212000_4.2.e002778.33","unstructured":"Parsons J , Sebany M . A Conceptual Framework for Reproductive Intentions: Empowering Individuals and Couples to Improve Their Health. International Center for Research on Women, 2018."},{"key":"2026051307201212000_4.2.e002778.34","doi-asserted-by":"crossref","first-page":"2403","DOI":"10.1016\/j.socscimed.2012.09.017","article-title":"Couples\u2019 reports of household decision-making and the utilization of maternal health services in Bangladesh","volume":"75","author":"Story","year":"2012","journal-title":"Soc Sci Med"},{"key":"2026051307201212000_4.2.e002778.35","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0209985","article-title":"Women\u2019s reproductive health decision-making: A multi-country analysis of demographic and health surveys in sub-Saharan Africa","volume":"14","author":"Darteh","year":"2019","journal-title":"PLoS ONE"},{"key":"2026051307201212000_4.2.e002778.36","doi-asserted-by":"publisher","DOI":"10.1136\/jech-2014-204784"},{"key":"2026051307201212000_4.2.e002778.37","doi-asserted-by":"crossref","first-page":"2474","DOI":"10.23937\/2474-1353\/1510054","article-title":"Women\u2019s Healthcare Decision-Making Autonomy by Wealth Quintile from Demographic and Health Surveys (DHS) in Sub-Saharan African Countries","volume":"3","author":"Rose","year":"2017","journal-title":"Int J Womens Health Wellness"},{"key":"2026051307201212000_4.2.e002778.38","doi-asserted-by":"crossref","DOI":"10.3390\/nu10111687","article-title":"Demand and Supply Side Barriers that Limit the Uptake of Nutrition Services among Pregnant Women from Rural Ethiopia: An Exploratory Qualitative Study","volume":"10","author":"Bezabih","year":"2018","journal-title":"Nutrients"},{"key":"2026051307201212000_4.2.e002778.39","doi-asserted-by":"crossref","DOI":"10.1186\/1742-4755-11-71","article-title":"Facilitators and barriers to facility-based delivery in low- and middle-income countries: a qualitative evidence synthesis","volume":"11","author":"Bohren","year":"2014","journal-title":"Reprod Health"},{"key":"2026051307201212000_4.2.e002778.40","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1093\/oso\/9780195083316.003.0007","article-title":"Social integration, social networks, social support, and health","volume":"1","author":"Berkman","year":"2000","journal-title":"Social Epidemiology"},{"key":"2026051307201212000_4.2.e002778.41","doi-asserted-by":"crossref","DOI":"10.1186\/s12939-014-0110-6","article-title":"Exploring inequities in skilled care at birth among migrant population in a metropolitan city Addis Ababa, Ethiopia; a qualitative study","volume":"13","author":"Mirkuzie","year":"2014","journal-title":"Int J Equity Health"},{"key":"2026051307201212000_4.2.e002778.42","doi-asserted-by":"publisher","DOI":"10.1186\/1471-2393-13-1"},{"key":"2026051307201212000_4.2.e002778.43","unstructured":"JHUCCP . Ethiopia baseline report: Communication for Health Johns Hopkins Center for Communication Programs (CCP). 2020."},{"key":"2026051307201212000_4.2.e002778.44","unstructured":"Tigabie A , Tefera B , Kasa Y , et al . n.d. Rural women\u2019s role in agriculture and household workloads: the case of North Shewa Amhara Region, Ethiopia. The Official Journal of the Amhara Agricultural Research Institute (ARARI) 2022:86."},{"key":"2026051307201212000_4.2.e002778.45","doi-asserted-by":"crossref","unstructured":"Getahun C . Resources, Time and Gender: Determinants of Women\u2019s Housework in Bahir Dar and nearby Rural Villages, Northwest Ethiopia. Eth J Soc Sci Hum 2018;14. doi:10.4314\/ejossah.v14i2.1","DOI":"10.4314\/ejossah.v14i2.1"},{"key":"2026051307201212000_4.2.e002778.46","doi-asserted-by":"crossref","DOI":"10.1038\/s41598-023-28044-x","article-title":"Utilization of optimal antenatal care, institutional delivery, and associated factors in Northwest Ethiopia","volume":"13","author":"Hailemariam","year":"2023","journal-title":"Sci Rep"},{"key":"2026051307201212000_4.2.e002778.47","doi-asserted-by":"crossref","DOI":"10.1186\/s12913-018-3370-9","article-title":"The effect of antenatal care on use of institutional delivery service and postnatal care in Ethiopia: a systematic review and meta-analysis","volume":"18","author":"Fekadu","year":"2018","journal-title":"BMC Health Serv Res"},{"key":"2026051307201212000_4.2.e002778.48","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2024-018811","article-title":"Introducing and testing the maternal vulnerability segmentation tool (MVST) for essential health services use: demonstrating its use in Oromia, Ethiopia","volume":"11","author":"Lakew","year":"2026","journal-title":"BMJ Glob Health"},{"key":"2026051307201212000_4.2.e002778.49","unstructured":"WHO . Definition of skilled health personnel providing care during childbirth: the 2018 joint statement by who, unfpa, unicef, icm, icn, figo and ipa. 2018."},{"key":"2026051307201212000_4.2.e002778.50","unstructured":"HMIS . Indicators reference guide. 2022."},{"key":"2026051307201212000_4.2.e002778.51","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2005.04.006"},{"key":"2026051307201212000_4.2.e002778.52","doi-asserted-by":"crossref","DOI":"10.1186\/s12884-020-02984-y","article-title":"Do male engagement and couples\u2019 communication influence maternal health care-seeking? Findings from a household survey in Mozambique","volume":"20","author":"Sitefane","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"key":"2026051307201212000_4.2.e002778.53","doi-asserted-by":"publisher","DOI":"10.1037\/0022-3514.51.6.1173"},{"key":"2026051307201212000_4.2.e002778.54","doi-asserted-by":"crossref","first-page":"773","DOI":"10.2471\/BLT.20.278820","article-title":"Iron and folic acid consumption and changing social norms: cluster randomized field trial, Odisha, India","volume":"99","author":"Rimal","year":"2021","journal-title":"Bull World Health Organ"},{"key":"2026051307201212000_4.2.e002778.55","doi-asserted-by":"crossref","first-page":"2034","DOI":"10.1093\/jn\/nxz167","article-title":"Information Diffusion and Social Norms Are Associated with Infant and Young Child Feeding Practices in Bangladesh","volume":"149","author":"Nguyen","year":"2019","journal-title":"J Nutr"},{"key":"2026051307201212000_4.2.e002778.56","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0254085","article-title":"Perceived norms, personal agency, and postpartum family planning intentions among first-time mothers age 15-24 years in Kinshasa: A cross-sectional analysis","volume":"16","author":"Gage","year":"2021","journal-title":"PLoS ONE"},{"key":"2026051307201212000_4.2.e002778.57","doi-asserted-by":"crossref","unstructured":"Kang B-A , Rimal RN , Bingenheimer J , et al . n.d. Promoting iron folic acid consumption using social norms as a mechanism of change in the Reduction in Anemia through Normative Innovations (RANI) project: a randomized controlled trial. BMC Nutr 11. doi:10.1186\/s40795-025-01053-x","DOI":"10.1186\/s40795-025-01053-x"},{"key":"2026051307201212000_4.2.e002778.58","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0191620","article-title":"Involving men to improve maternal and newborn health: A systematic review of the effectiveness of interventions","volume":"13","author":"Tokhi","year":"2018","journal-title":"PLoS ONE"},{"key":"2026051307201212000_4.2.e002778.59","doi-asserted-by":"crossref","DOI":"10.1186\/s13690-021-00569-5","article-title":"Childbirth at home and associated factors in Ethiopia: a systematic review and meta-analysis","volume":"79","author":"Ayenew","year":"2021","journal-title":"Arch Public Health"},{"key":"2026051307201212000_4.2.e002778.60","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1016\/j.midw.2015.02.004","article-title":"Barriers and facilitators to accessing skilled birth attendants in Afar region, Ethiopia","volume":"31","author":"King","year":"2015","journal-title":"Midwifery"},{"key":"2026051307201212000_4.2.e002778.61","doi-asserted-by":"crossref","DOI":"10.1186\/s12884-017-1442-1","article-title":"Midwives\u2019 and patients\u2019 perspectives on disrespect and abuse during labor and delivery care in Ethiopia: a qualitative study","volume":"17","author":"Burrowes","year":"2017","journal-title":"BMC Pregnancy Childbirth"},{"key":"2026051307201212000_4.2.e002778.62","doi-asserted-by":"publisher","DOI":"10.1080\/17441692.2013.835434"},{"key":"2026051307201212000_4.2.e002778.63","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-020-09125-2","article-title":"Determinants of institutional delivery service utilization in Ethiopia: a population based cross sectional study","volume":"20","author":"Berelie","year":"2020","journal-title":"BMC Public Health"},{"key":"2026051307201212000_4.2.e002778.64","doi-asserted-by":"publisher","DOI":"10.1186\/1472-6963-13-1"}],"container-title":["BMJ Public Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjph-2025-002778","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T14:20:48Z","timestamp":1778682048000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjpublichealth.bmj.com\/lookup\/doi\/10.1136\/bmjph-2025-002778"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4]]},"references-count":64,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,5,13]]},"published-print":{"date-parts":[[2026,4]]}},"alternative-id":["10.1136\/bmjph-2025-002778"],"URL":"https:\/\/doi.org\/10.1136\/bmjph-2025-002778","relation":{},"ISSN":["2753-4294"],"issn-type":[{"value":"2753-4294","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4]]}}}