Ethiopia has adopted a variety of policies, including maternal waiting homes (MWH), to minimize maternal mortality (1). In MWH, community-based shelters housed by the health center or hospital, pregnant women remain until birth in the last trimester. It is an integral component of a holistic package aimed at overcoming the second delay (2). In recent years, the government of Ethiopia has established a range of health facilities to increase access to health care for people living in rural areas (3). While there is a difference between countries, more than half of the health facilities have MWH (4).

MWHs play an important role in reducing preventable maternal mortality and negative pregnancy outcomes (5, 6). Studies in Ethiopia also found MWH use accounted for 92% (0.04–0.19) reduction in maternal mortality, 83% (0.05–0.58) (9.90–11.4) reduction of stillbirth, and was associated with a lower rate of direct obstetric complications (5, 6). Despite its effectiveness in minimizing maternal mortality and adverse pregnancy effects, the use of MWH in Ethiopia is very limited. In a recent survey, it was found that only 7% of women used MWH (7). Studies also recorded that the shortage of service and transport infrastructure had a negative effect on MWH use (8–12). Many studies have identified individual and community-related influences; such as lack of awareness and limited husband supports in MWH (13, 14).

In a patriarchal society, the position of the husband goes beyond offering financial assistance to the family; they are the ones who determine where to give birth and seek care (15–17). Husbands' involvement in helping women in reproductive health care has been linked with improved maternal health benefits and better birth outcomes (18–20). The participation of husbands in maternal and infant health care has been advocated as a method to increase the use of maternal health services (21). However, studies in Ethiopia (22, 23) and other sub-Saharan African countries such as Ghana (24) Nigeria (17) and Uganda (25) have shown that husbands participate in maternal health care by assisting their wives in the use of maternal health facilities such as facility-based childbirth, but this participation remains limited.

Studies of factors that affect the engagement of husbands in MWHs have identified various factors that range from context to context. For example, studies in Liberia recorded a lack of food and respectful treatment among MWHs (9, 10). On the other hand, a study in Northern Sierra Leone showed that social and cultural traditions, lack of interest, engagement in other events, distance, and the nature of health facilities are obstacles to the participation of men (8).

Similarly, qualitative research with husbands in Zambia recorded that poor MWH conditions (e.g., lack of room, bedding, water, and sanitation facilities) and the lack of anyone to look after children at home were affected by husbands' decisions to let their wives use MWHs (26). The most prominent quotes from this study are as follows: “Empowering mothers, men, and families to recognize maternal health threats during pregnancy and to take responsibility for designing and enforcing effective responses to them” is a key measure implemented by the Ethiopian Federal Ministry of Health to reduce maternal deaths (27).

Husbands are the main decision-makers in a maternity place, with or without the presence of a mother. The wife hardly gives birth at health facilities without the assistance of her husband (15, 28, 29). Help for maternal health care by the husband may take various forms, such as enabling or promoting the use of resources, providing financial and emotional support, accompanying facilities, and joint decision-making on the place of delivery (30). The lack of support or consent for a husband was a cause for home delivery in recent studies in Ethiopia (16, 28, 29). These results underscored the need to examine the reasons behind the husbands' behavioral intention to plan intervention. However, in Ethiopia, no studies have investigated the intention of spouses, predictors of intent, and attitudes relevant to endorsing the use of MWHs, a portal to facility-based childbirth (22, 23).

Understanding the behavioral intention and the underlying causes will inform action aimed at increasing maternal healthcare use through the involvement of the husband (31). According to the Theory of Planned Behavior (TPB), intent (readiness to execute a given behavior) is the key determinant of behavior. Whereas the intention is the role of the behavioral attitude, the subjective norm, and the perceived behavioral influence. Thus, the desire to conduct a safe action is based on a constructive appraisal of the action, a belief that the referents approve of the action, and a sense of the power of the obstacles and the facilitators of the action (31, 32).

TPB assumes that attitude, subjective norm, and perceived behavioral control are determined by silent beliefs. Attitude is determined by behavioral belief and evaluation of outcome. Normative belief and motivation to comply with referents' expectations determine the subjective norm. Similarly, perceived behavioral control determines control beliefs (beliefs about factors that facilitate or hinder action) and the power of these factors to facilitate or impede acting. The theory proposes that these beliefs influence intention through their corresponding construct (32).

TPB enables the identification of predictors of behavioral intention and underlying beliefs that inform interventions to change or modify behavior. Thus, we undertook this study using the theory of planned behavior as a framework to explore predictors of husbands' intention to support wives' use of MWH and to identify underlying beliefs. TPB allows the recognition of behavioral goal predictors and core values that inform action to alter or improve behavior. We have therefore conducted this analysis using the TPB as a basis for examining the predictors of the husband's role in increasing the intention and the uptake of MWHs among pregnant women.

TPB can be utilized to change the husband's behavior and increase support for the utilization of MWHs. The TPB posits that behavioral intentions are influenced by three key factors: attitude toward the behavior, subjective norms, and perceived behavioral control. In this case, changing the husband's behavior to support the utilization of MWH would involve evaluating attitude toward this behavior, the influence of subjective norms, and perceived control over engaging in this supportive behavior.

This study examined psychological factors influencing the intention to support the wife in using MWH among husbands. The findings revealed that subjective norms and perceived behavior control were significantly associated with the intention to support the wife in using MWH. Forty-two percent of respondents reported that they intend to support their wives using MWH for their current pregnancy. In this study, we did not measure behavior, but the intention is assumed to be the immediate predictor of behavior (32, 33); thus, the low involvement of the husband in maternal health care reported in previous studies (22, 23) could be explained by low motivation. Given the high preventable maternal and child mortality in the country, improving husbands' intentions is crucial to reducing maternal mortality by increasing access to and utilization of maternal health services (19, 20).

In line with previous studies (7, 9), the respondents listed “medical attention” and “institutional delivery” when asked about the benefits of MWH. With regards to the time to visit the MWH, 12.8% of respondents did not know the right time. To avoid delays in utilizing MWHs, healthcare professionals must focus on raising awareness about the appropriate time to visit MWHs. This is crucial because an insufficient understanding of the ideal timing for seeking care can result in missed opportunities for receiving MWH services.

The bivariate analyses revealed that attitude towards supporting a partner to use maternal waiting services showed statistically significant associations with intention. However, when controlled for other variables, the association becomes non-significant. The essence of the behavior and study participants may be explained as follows: Traditional gender roles delineate pregnancy and childbirth-related issues for women (17, 34, 35). The tie of target behavior with social values and the collectivist nature of participants' culture may subdue personal feelings (36, 37).

In our study, subjective norms were positively associated with the intention to support the use of MWH by women. This has demonstrated that supporting the wife to use MWH was influenced by perceptions about what the others do and referents' approval of supporting the wife to use MWH. Previous studies also showed that social pressure is one factor that influences male involvement (35, 38). This finding highlights the importance of targeting social norms to improve husbands' intentions and practices related to supporting wives to use MWH. An intervention needs to address beliefs about the approval and practice of referents with factors in a broader social context to change social norms and increase intentions and related behavior (39).

Perception of control was another predictor of intention to support a wife using MWH among husbands. In an analysis aimed at identifying the beliefs that discriminate between intenders and non-intenders, only three control beliefs were found to have significant influence or discriminate between two groups: having someone who takes care of children at home, having a person who cares for a wife in MWH, and quality service at MWH.

Husbands are income earners in the family (35) and they may be busy with activities to support the family economically (25). This could lead them to perceive the absence or presence of a person who looks after children at home and a wife in MWH as a barrier or facilitator. Moreover, belief about the quality of services provided at MWH was mentioned as one factor. This finding is consistent with previous studies that reported a lack of space for men, the absence of health workers, and the lack of amenities as barriers (9, 11).

MWHs have become an important intervention in Ethiopia to improve maternal health outcomes. In addition to the expansion of MWHs, there are ongoing community-level promotions to create demand and engage the community. However, those who have used the services reported several limitations (7). This suggests the government and stakeholders need to improve the quality of services provided in the MWHs, as poor quality of service negatively affects maternal health service utilization (40, 41).

This study has the strength to note: (1) This study is the first to analyze the role of husbands in increasing MWH uptake; (2) the qualitative salient beliefs were explored and integrated into the beliefs dimensions for the quantitative study; and (3) a standard pretested structured questionnaire was used. However, this study has some potential shortcomings that should be noted: (1) First, only husbands whose wives were pregnant were included in the study. Thus, the results may not be inferred from the general population of male partners; (2) this study used data obtained from self-report that might be subjected to social desirability bias. We tried to minimize these issues by recruiting experienced interviewers, providing a brief overview of the study, and ensuring that their responses were not linked to them in any way. (3) The associations reported in this study were so correlational that we cannot make a causal link. Finally, we did not measure actual behavior and incorporated variables that predict intention, such as past behavior. Therefore, future research may extend this by measuring actual behavior.

The present research used TPB to determine psychological factors impacting the intention of husbands to support their wives in the utilization of MWH. The findings of the study indicated that the subjective norm and perceived behavioral control were associated with the intention to support MWH utilization.

In a study aimed at defining particular beliefs, all the normative beliefs and three control beliefs, such as having a person who looks after children in the home and a wife at MWH, and the quality of services provided at MWH, were separated between intenders and non-intenders. Ajzen suggests interventions aim to promote change in practice through intention and the need to target underlying beliefs (31, 32). Therefore, to increase the utilization of MWHs, interventions should focus on targeting both normative and control beliefs, particularly through the support of husbands. By addressing societal norms surrounding maternity care that may prevent women from utilizing the services, interventions have a higher likelihood of success in promoting MWH utilization. By involving husbands in the decision-making process and support, women may feel more empowered to access MWHs and ultimately improve their maternal health outcomes.