Effect of a Culturally Adapted Birth Preparedness and Complication Readiness Training Intervention on Knowledge Attitudes and Practices among Hehe Pregnant Women in Rural Iringa Tanzania a Controlled Pretest Posttest Quasi Experimental Study

<title>Abstract</title> <p> <bold>Background</bold> Birth preparedness and complication readiness (BPCR) is a key strategy for improving maternal and neonatal outcomes; however, educational materials developed through direct translation may not adequately reflect local cultural and linguistic contexts. This study evaluated the effectiveness of a culturally adapted BPCR education programme developed using the Cultural Equivalence Model of Translation among pregnant women attending antenatal care clinics in rural Tanzania. <bold>Methods</bold> A controlled pretest–posttest quasi-experimental study was conducted among 176 pregnant women (88 intervention; 88 control) attending ANC clinics in two rural districts of Iringa Region, Tanzania. Participants in the intervention group received culturally adapted BPCR education, whereas the control group received the standard translated BPCR manual. BPCR knowledge, attitudes, and practices were assessed before and after the intervention using structured questionnaires. Independent-samples and paired t-tests compared between- and within-group differences. Difference-in-Differences regression and multiple linear regression analyses were performed to estimate intervention effects while adjusting for baseline characteristics and potential confounders. <bold>Results</bold> Baseline knowledge and practice scores were comparable between groups, although the intervention group had significantly lower attitude scores (p &lt; 0.001). Following the intervention, the intervention group achieved significantly higher knowledge (38.49 ± 7.54 vs. 32.70 ± 5.61; mean difference = 5.79, p &lt; 0.001) and practice scores (9.60 ± 1.40 vs. 9.03 ± 1.58; mean difference = 0.57, p = 0.012) than the control group, while post-intervention attitude scores did not differ significantly (p = 0.482). Within-group analyses demonstrated significant improvements in knowledge, attitudes, and practices in the intervention group (all p &lt; 0.001). DID analysis confirm significantly greater improvements attributable to the intervention for knowledge (β = 7.18, p &lt; 0.001), attitudes (β = 2.55, p = 0.006), and practices (β = 0.99, p = 0.010). After adjustment for baseline measures and sociodemographic characteristics, intervention exposure remained the only independent predictor of higher post-intervention knowledge (β = 5.88, 95% CI: 3.84–7.92; p &lt; 0.001) and, together with baseline practice, significantly predicted post-intervention practice scores (β = 0.66, 95% CI: 0.20–1.11; p = 0.005). <bold>Conclusions</bold> Culturally adapted BPCR education was more effective than the standard translated educational manual in improving pregnant women's BPCR knowledge, attitudes, and practices. Integrating culturally and linguistically adapted educational materials into routine ANC services may enhance maternal health communication and strengthen birth preparedness in rural settings. Further research should evaluate the long-term effectiveness, scalability, and cost-effectiveness of culturally adapted maternal health education interventions. <bold>Trial registration</bold> Pan African Clinical Trials Registry: Current Controlled Trials PACTR202607626025411, registered retrospectively on 09 July 2026 https://pactr.samrc.ac.za Retrospectively registered. </p>