Group antenatal and postnatal care

Group antenatal care is an alternative to traditional, individual antenatal care (ANC) visits. In the group ANC service delivery model, 8–12 women with similar estimated due dates are organized into groups that meet at regular intervals during pregnancy to access all routine ANC services with the assistance of at least one ANC provider. Group ANC replaces individual ANC visits for eligible women, and can be an adjunct opportunity for women who may need some individual visits for high-risk conditions.[1] Because postnatal care is a key component of family-centered care during the childbearing year, group postnatal care (PNC) has also been implemented by some programs; group ANC participants may return for group care at about 6 weeks after birth or in some cases at regular intervals during the child’s first year of life.[2–4]

In addition to the participating beneficiaries, i.e. pregnant women and their partners or parents of the newborn, group ANC visits are led by one or more “facilitators.” Group care programs generally rely on two facilitators to be present at each group visit; one facilitator is a licensed clinician such as a nurse, midwife, or physician, while the second facilitator may be either a clinician, community health worker, or other health specialist (for example, a lactation or nutrition counselor, social worker, or student clinician). The facilitators are responsible for organizing the group visit and accomplish health assessments and group discussion of relevant topics with as much beneficiary participation as possible.

In group ANC and PNC care, education and support are provided in a group. Health assessment takes place in the group space and women participate in their own physical assessment; women who read and write can be coached to measure and record their own weight and blood pressure, using an electronic blood pressure cuff. Group care facilitation promotes participatory learning and sharing of experiences; evidence suggests participants have increased knowledge and are more satisfied.[3,5]

Facilitation is a skill that requires training, practice, and feedback, as it is quite different than a didactic method that providers may use to instruct beneficiaries in antenatal “classes.” The importance of excellent facilitation during group ANC visits has been documented in the literature. A 2013 study examined the associations between fidelity to effective group ANC process (including effective facilitation and group member engagement), fidelity to planned group ANC content, and the health outcomes of group ANC participants at two urban health facilities in the United States.[6] In this study, group ANC participants were, in terms of demographic descriptors, those at the highest risk of poor perinatal outcomes in the United States. Facilitation and engagement during group care visits, or process fidelity, was associated with a significantly decreased risk of preterm birth and decreased newborn admissions to the intensive care unit. Content fidelity was significantly related to decreased newborn intensive care unit admission, but not to preterm birth. Other authors have emphasized that even though providers with some degree of social status facilitate the sessions, the group ANC process must be non-hierarchical so that women can draw on their own strengths and increase their self-efficacy as individuals and as a community of mothers.[7–8]

Published reports of group ANC implementation are available from at least 16 countries. Most of these refer to group ANC’s effects on health outcomes and women’s experience of care. Seven reports of qualitative data from group ANC facilitators are available: one from the United Kingdom,[8] one from Malawi and Tanzania,[9] one from Australia,[10] 2 from Canada,[11–12] and 2 from the United States.[13–14] The United Kingdom study reported that 67% of providers who implemented group ANC (12 midwives in this study) felt that it was an improvement over standard ANC and 33% of providers rated it as somewhat better than standard ANC.[8]

Group ANC/PNC in Rwanda

In 2017, the East Africa Preterm Birth Initiative-Rwanda implemented group antenatal care and postnatal care in 18 health centers in Rwanda, in the context of a cluster randomized controlled trial. The primary outcome of the trial is gestational length and data collection is ongoing. A group of Rwandan stakeholders, including a nurse, a midwife, physicians, officials from the Ministry of Health, and public health researchers, planned for this implementation; their process is described elsewhere.[2] This group of stakeholders made two context-specific decisions. First, they decided that after an initial, one-on-one ANC visit pregnant women would be invited to attend three group ANC visits during pregnancy and one group PNC visit at approximately 6 weeks after birth. Second, the stakeholders decided that the optimal combination of two facilitators at each group visit, within the unique context of the Rwanda public health system, would be one ANC or PNC provider and one community health worker. The Rwanda health care system is a pyramidal structure of 8 national referral hospitals, 4 provincial hospitals, 36 district hospitals in 30 districts, 504 health centers, and 670 health posts, and includes 58,286 community health workers (CHWs) at the village level.[15] Health centers are staffed only by nurses and midwives and must provide a package of primary services. Staff are rotated as needed across services. In addition to other services universally available at the health center level, nurses and midwives provide antenatal, intrapartum, and postnatal services. The 2014–2015 Rwanda Demographic and Health Survey reported that nurses provide 93.7% of antenatal care and midwives provide 0.6% of antenatal care; the remainder is provided by physicians at referral hospitals for complex cases.[16] Some community health workers have special interest and training in maternal and child health surveillance.

After an in-depth orientation to the trial objectives and methods, directors of the 18 health centers randomized to group care for this trial each selected 3 providers to be trained and act as group care facilitators. These selected provider-participants were either nurses or midwives, were frequently assigned to ANC or PNC services at their respective health centers, and were required to fulfil this new group care facilitator role as part of their regular job duties. Ministry of Health officials preferred that health center directors choose which providers to include, relying on their facility-specific staffing knowledge. A distinct community leader, the Supervisor of Community Health Workers (CHWs) associated with each of the 18 group care study sites, selected 12 CHWs to be trained and act as group care co-facilitators. A team of 6 Rwandan group care Master Trainers prepared those 72 providers and 216 community health workers to act as co-facilitators during group visits, training them in small mixed groups. Master Trainers focused on building facilitation skills during a three-day orientation to group care, and then reinforced these skills during supportive visits made to each health center every other month for 12 months. A group ANC/PNC manual, created by the Rwandan stakeholder group, was given to each health center, and providers were encouraged to study it and use it as a reference during every group visit. Study staff invited trained providers to reach out at any time with questions or concerns about group care implementation.

The parent study conducted by the East Africa Preterm Birth Intiative-Rwanda includes the analysis of multiple outcomes, including gestational length, ANC coverage and women’s experiences in group ANC/PNC; those results will not be reported in this article. This nested study seeks to understand the experiences of Rwandan nurses and midwives one year after the implementation of group ANC and PNC in 18 health centers in order to inform policy makers as they consider the feasibility of scaling up this alternative model of care.

Study setting

Five of 30 Rwandan districts were selected for this trial in collaboration with the Rwanda Ministry of Health. Within those 5 districts, 55 health centers were assessed with a standardized tool for number of providers, ANC volume, suitable space for group care, services, and equipment. Health centers that reported, in this facility assessment, that they allocate at least 2 providers to ANC services on any day that ANC is offered were selected for this trial, for a total of 36 health centers. These 36 health centers were pair-matched and then randomized to either continue individual ANC and PNC or switch to group ANC and PNC. The 18 health centers randomized to implement group ANC and PNC are located in rural, peri-urban, and urban locations.

Participant recruitment and data collection: Questionnaires

Providers trained to be group ANC/PNC facilitators at the 18 health centers randomized to group care were invited to participate in a longitudinal survey, with a questionnaire administered at baseline (training), and at approximately 9 months after implementation. At each of the 18 health centers randomized to continue traditional, one-on-one ANC/PNC visits (control), the providers most frequently allocated to ANC/PNC were invited to participate in the same longitudinal survey (average 3 providers); these were also selected by facility directors based on facility-specific staffing patterns. Questionnaires were also administered to control providers at similar time points. Providers did not receive any incentive to participate in this study.

The survey instruments include questions about education, license/title, and years of work experience in order to describe the cohort and look for associations with model preference over time. To assess job satisfaction, we asked, “Thinking specifically about your work in ANC and/or PNC services, how would you rate your current job satisfaction on a scale from 1–5, with 1 representing extremely dissatisfied and 5 representing extremely satisfied?” We used the Perceived Stress Scale to measure stress.[17] Questions and answers appeared in the survey in both English and French; provider training at secondary and post-secondary schools is in one of these languages, and the written form of Kinyarwanda is not standardized. These questionnaires appear in S1 Doc.

Questionnaires were self-administered by providers entering data on a tablet that syncs to an electronic data capture system.[18] If the tablet was not available, providers completed the questionnaires on paper and a data collector entered the data to the electronic data capture system. Questionnaires did not collect name or other personal identifiers; each provider participant was assigned a unique study identification code and this was used on all questionnaires, both at baseline and follow-up.

Participant recruitment and data collection: Focus groups

Twelve months after implementation, we convened three focus groups for group ANC/PNC providers. Health center directors at the 18 intervention sites selected for these focus groups the providers who had been most actively involved in group care provision over the past year. The selected providers were granted “time off” by their supervisors to attend the focus group discussions, which were held in a geographically central location.

These 3 focus groups were convened at a hotel, one group per day for 3 consecutive days, with an average of 10 provider participants in each group. They received reimbursement for their travel expenses but did not receive an additional incentive. Each focus group discussion (FGD) lasted 60 minutes, was conducted in Kinyarwanda, and was facilitated by one of the group ANC/PNC Master Trainers. The focus group facilitator followed a guide with 4 open-ended questions, to allow the nurses and midwives to freely verbalize their ideas and concerns about group ANC/PNC (S2 Doc). Focus group discussions were audio recorded and each participant was assigned a number; facilitators referred to these numbers when calling on participants during the discussion. Also present during the FGDs was the Principal Investigator [SM] and the group ANC/PNC technical advisor [TL], who asked the providers to speak freely because their inputs are vital to improving the program, reassured them about confidentiality, and emphasized that there is no personal or professional hierarchy among providers and researchers.

Analysis and interpretation

Quantitative data from the questionnaires were analyzed using simple descriptive statistics. We used the five steps of the Framework Method to analyze 3 FGDs: familiarization, identify a thematic framework, indexing, charting, and mapping and interpretation.[19] Audio recordings of FGDs were transcribed verbatim and translated from Kinyarwanda to English; this translation was reviewed by one of the authors, who is fluent in Kinyarwanda, for accuracy (SM). Transcripts were not returned to the participants for comment or correction. Next, one author coded one full FGD transcript, assigning 1–3 codes to every phrase, sentence, and/or paragraph (TL). Two authors then met to discuss the codes, group them, and organize them into a working analytical framework (EB and TL). Sixty-three codes were grouped into 12 new codes, in 6 main categories, plus an “other” category. The codes for this analytical framework were then applied to the two remaining FGD transcripts and the data was charted into a framework matrix. The authors generated themes by reviewing this matrix, keeping in mind our original research objectives while simultaneously looking for unexpected results. These codes and themes were reviewed independently by a third author (SM).

Ethical considerations

Ethical approval for the survey and the focus group activities was granted by the Rwanda National Ethics Committee (No.0034/RNE/2017) and University of California, San Francisco Institutional Review Board (16–21177). Written informed consent was obtained from each participating provider prior to administering the baseline questionnaire. A separate written informed consent was obtained from providers participating in a FGD. Only participants who agreed to participate and signed the consent form were invited to complete the questionnaires or join the FGDs. Moderators obtained permission from FGD participants to record the conversation. Voluntary participation was ensured throughout the study. All information was kept confidential and personal identifiers were not recorded on audio and written files.

Quantitative results

Fifty-nine providers at intervention sites and 46 providers at control sites completed questionnaires at both baseline and a follow-up time point ranging from 3 to 12 months after baseline. Over time, there was attrition among provider participants at both group ANC and traditional ANC study sites for various personal or professional reasons. For this reason, not all 72 providers originally trained in group care are represented in this sample. While 29 providers trained in group ANC/PNC participated in the 3 focus groups, only 26 of those completed both a baseline and follow-up questionnaire. The basic characteristics of group care providers, control site providers, and focus group participants were similar and are presented in Table 1. The average job satisfaction and Perceived Stress Scale scores at both time points were similar among all groups. Group care providers were asked in the follow-up questionnaire, “How do you prefer to provide antenatal and/or postnatal care—individual visits, group visits, or no preference?” Eighty-six percent preferred to provide group ANC and PNC instead of individual ANC and PNC, while 9% reported no preference and 5% preferred to deliver individual ANC and PNC. Because such a large majority preferred group ANC/PNC to individual ANC/PNC and the sample size is small, there were no clear associations between model preference and title, education, service preference, age, or years of ANC/PNC experience. Providers of group ANC/PNC reported that they had, on average, facilitated 26 group visits in the previous 9–12 months (minimum number of visits was 5, maximum number of visits was 130).

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Table 1. Responses of provider participants who completed both baseline and follow-up questionnaires.

https://doi.org/10.1371/journal.pone.0219471.t001

Qualitative results

Themes and sub-themes that emerged from the FGDs are summarized in Table 2. The two over-arching themes are that 1) group ANC and PNC offer advantages to both mothers and providers compared to individual ANC and PNC, and 2) implementation challenges can be addressed by following best practices shared by provider-peers during these focus group discussions.

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Table 2. Themes, sub-themes, and details of focus group discussions among Rwandan providers of group ANC and PNC.

https://doi.org/10.1371/journal.pone.0219471.t002

Limitations

We did not include all providers trained in GANC in the 3 FGDs. Some important provider perspectives may be absent from our data set, particularly those of providers who “opted out” of GANC/GPNC participation by avoiding engagement with the program and shifting responsibility of its provision to the FGD participants represented here.