{ "abstract": "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", "abstract_shown": true, "affiliations": [ "Department of Health, Behaviour, and Society, Faculty of Public Health, Institutes of Health, Jimma University, Jimma, Ethiopia.", "Oromia Regional State Health Bureau, Jimma Zone Health Office, Department of Maternal, Newborn and Child Health, Jimma, Ethiopia.", "Data Science and Evaluation, African Population and Health Research Center, Nairobi, Kenya.", "Department of Obstetrics and Gynecology, Faculty of Medical Sciences, Institutes of Health, Jimma University, Jimma, Ethiopia." ], "article_type": "Research Article", "arxiv": null, "author_total": 5, "authors": [ { "affs": [ 0, 1 ], "name": "Gebeyehu Bulcha Duguma", "orcid": "0000-0002-5336-679X" }, { "affs": [ 0 ], "name": "Hordofa Gutema" }, { "affs": [ 2 ], "name": "Mulusew Gerbaba" }, { "affs": [ 3 ], "name": "Demisew Amenu" }, { "affs": [ 0 ], "name": "Zewdie Birhanu" } ], "bibtex": "https://research.draconitic.com/paper/0gt9r82d61106.bib", "cited_by": 0, "doi": "10.1371/journal.pone.0360474", "fulltext_url": "https://europepmc.org/articles/PMC13704815", "id": "0gt9r82d61106", "issns": [ "1932-6203" ], "landing_url": "https://doi.org/10.1371/journal.pone.0360474", "language": "eng", "licence": "CC-BY", "licence_label": "CC BY", "licence_source": "article", "licence_url": "https://creativecommons.org/licenses/by/4.0/", "metadata_licence": null, "native_subjects": [ [ "openalex", "3600|Mobile Health and mHealth Applications" ], [ "plos", "/Biology and life sciences/Psychology/Psychological attitudes" ], [ "plos", "/Medicine and health sciences/Health care/Health statistics/Morbidity" ], [ "plos", "/Medicine and health sciences/Health care/Postpartum care/Postnatal care" ], [ "plos", "/Medicine and health sciences/Public and occupational health/Behavioral and social aspects of health" ], [ "plos", "/Medicine and health sciences/Women's health/Maternal health" ], [ "plos", "/Medicine and health sciences/Women's health/Maternal health/Antenatal care" ], [ "plos", "/Medicine and health sciences/Women's health/Maternal health/Birth/Labor and delivery" ], [ "plos", "/Medicine and health sciences/Women's health/Maternal health/Pregnancy" ], [ "plos", "/Medicine and health sciences/Women's health/Obstetrics and gynecology/Birth/Labor and delivery" ], [ "plos", "/Medicine and health sciences/Women's health/Obstetrics and gynecology/Pregnancy" ], [ "plos", "/Social sciences/Psychology/Psychological attitudes" ] ], "openalex": "W7223685539", "pdf_url": "https://europepmc.org/articles/PMC13704815?pdf=render", "pmcid": "PMC13704815", "pmid": "42932269", "published": "2026-10-26", "publisher": "Public Library of Science", "ris": "https://research.draconitic.com/paper/0gt9r82d61106.ris", "sources": [ { "first_seen": "2026-10-30T12:17:17Z", "native_id": "10.1371/journal.pone.0360474", "source": "plos", "url": "https://doi.org/10.1371/journal.pone.0360474" }, { "first_seen": "2026-10-30T12:22:01Z", "native_id": "MED:42932269", "source": "europepmc", "url": "https://europepmc.org/article/MED/42932269" } ], "subjects": [ { "field": "medicine", "origin": "plos:women's health", "subfield": "reproductive-child" } ], "title": "Evaluating gain and loss-framed mobile messaging to improve maternal health service uptake: A cluster randomized controlled trial in Jimma, Ethiopia", "title_text": "Evaluating gain and loss-framed mobile messaging to improve maternal health service uptake: A cluster randomized controlled trial in Jimma, Ethiopia", "type": "peer-reviewed", "updated_at": "2026-10-30T12:22:01Z", "url": "https://research.draconitic.com/paper/0gt9r82d61106", "venue": "PLOS One", "versions": [] }