1
|
Van Damme A, Talrich F, Crone M, Rijnders M, Patil CL, Rising SS, Abanga J, Billings DL, Hindori-Mohangoo AD, Hindori MP, Martens N, Mathews S, Molliqaj V, Orgill M, Slemming W, Beeckman K. Identifying anticipated challenges when implementing group care: Context-analyses across seven countries to develop an anticipated challenges framework. Midwifery 2024; 139:104166. [PMID: 39260126 DOI: 10.1016/j.midw.2024.104166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 08/26/2024] [Accepted: 08/27/2024] [Indexed: 09/13/2024]
Abstract
PROBLEM Despite increasing interest in Group Care worldwide, implementation is challenging. BACKGROUND Group Care is an evidence-based perinatal care model including three core components: health assessment, interactive learning, and community building. It has several advantages for service users and providers compared to individual perinatal care. AIM We aimed to identify anticipated challenges when implementing Group Care, and to develop a supporting tool based on these challenges. METHODS Context analyses through Rapid Qualitative Inquiries were conducted in 26 sites in seven countries to gain insight into the anticipated challenges when implementing Group Care. Data triangulation and investigator triangulation were applied. The context analyses generated 330 semi-structured interviews with service users and other stakeholders, 10 focus group discussions, and 56 review meetings with the research teams. FINDINGS We identified six surface structure anticipated challenges categories (content, materials, facilitators, timing, location, group composition), and five deep structure anticipated challenges categories (health assessment, scheduling Group Care into regular care, enrolment, (possible) partner organisations, financials) occurring in all participating sites, leading to the development of the Anticipated Challenges Framework. CONCLUSION Completing the Anticipated Challenges Framework raises awareness of anticipated challenges if sustainable Group Care implementation is to succeed and encourages the initiation of a concrete action plan to tackle these challenges. Application of the framework may offer important insights to health systems administrators and other key stakeholders before implementing Group Care. In the medium- and long-term, insights gained may lead to greater possibilities for sustainability and to the most cost-effective approaches for implementing Group Care.
Collapse
Affiliation(s)
- Astrid Van Damme
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium; Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium.
| | - Florence Talrich
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium; Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
| | - Mathilde Crone
- Leiden University Medical Center Department of Public Health and Primary Care, the Netherlands; Maastricht University, Department of Health Promotion, the Netherlands
| | - Marlies Rijnders
- Leiden University Medical Center Department of Public Health and Primary Care, the Netherlands; TNO Child Health, Leiden, the Netherlands
| | | | | | - Jedidia Abanga
- Presbyterian Church of Ghana Health Service (PHS), Accra, Ghana
| | - Deborah L Billings
- Group Care Global, Philadelphia, United States; Department of Health Promotion and Behavior and Institute for Families in Society, University of South Carolina, United States
| | | | - Manodj P Hindori
- Foundation for Perinatal Interventions and Research in Suriname (Perisur), Paramaribo, Suriname
| | - Nele Martens
- Leiden University Medical Center Department of Public Health and Primary Care, the Netherlands
| | - Shanaaz Mathews
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | | | - Marsha Orgill
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Wiedaad Slemming
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - Katrien Beeckman
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium; Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
| |
Collapse
|
2
|
Martens N, Haverkate TMI, Hindori-Mohangoo AD, Hindori MP, Aantjes CJ, Beeckman K, Damme AV, Reis R, Rijnders M, Kleij RRVD, Crone MR. Implementing group care in Dutch and Surinamese maternity and child care services: the vital importance of addressing outer context barriers. BMC Pregnancy Childbirth 2024; 24:527. [PMID: 39134970 PMCID: PMC11318268 DOI: 10.1186/s12884-024-06720-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 07/25/2024] [Indexed: 08/16/2024] Open
Abstract
BACKGROUND By addressing physical and psychosocial needs, group care (GC) improves health-related behaviours, peer support, parent-provider interactions and may improve birth outcomes. Hence, global implementation of GC is encouraged. Context analyses prior to implementation are vital to elucidate which local factors may support or hinder implementation. METHODS Contextual analyses conducted in the Netherlands and Suriname were compared to identify the factors relevant to the implementability of GC as perceived by healthcare professionals (HCPs). 32 semi-structured interviews were conducted with Dutch and Surinamese healthcare professionals. Audio recordings were transcribed verbatim and coded using the Framework approach. The Consolidated Framework for Implementation Research guided the development of the interview guide and of the coding tree. RESULTS Outer setting: Concerns regarding funding surfaced in both countries. Due to limited health insurance coverage, additional fees would limit accessibility in Suriname. In the Netherlands, midwives dreaded lower revenue due to reimbursement policies that favour one-on-one care. Inner setting: Appropriate space for GC was absent in one Dutch and three Surinamese facilities. Role division regarding GC implementation was clearer in the Netherlands than in Suriname. INNOVATION HCPs from both countries expected increased social support, health knowledge among women, and continuity of care(r). Individuals/innovation deliverers: Self-efficacy and motivation emerged as intertwined determinants to GC implementation in both countries. Individuals/innovation recipients: Competing demands can potentially lower acceptability of GC in both countries. While Dutch HCPs prioritised an open dialogue with mothers, Surinamese HCPs encouraged the inclusion of partners. PROCESS Campaigns to raise awareness of GC were proposed. Language barriers were a concern for Dutch but not for Surinamese HCPs. CONCLUSIONS While the most striking differences between both countries were found in the outer setting, they trickle down and affect all layers of context. Ultimately, at a later stage, the process evaluation will show if those outer setting barriers we identified prior to implementation actually hindered GC implementation. Changes to the health care systems would ensure sustained implementation in both countries, and this conclusion feeds into a more general discussion: how to proceed when contextual analyses reveal barriers that cannot be addressed with the time and resources available.
Collapse
Affiliation(s)
- Nele Martens
- Leiden University Medical Centre, Leiden, The Netherlands.
| | - Tessa M I Haverkate
- Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Manodj P Hindori
- Foundation for Perinatal Interventions and Research in Suriname (Perisur), Paramaribo, Suriname
| | - Carolien J Aantjes
- Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Health Economics and HIV/AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
| | - Katrien Beeckman
- Vrije Universiteit Brussel (VUB), Universitair ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
- Universiteit Antwerpen, Antwerpen, Belgium
| | - Astrid Van Damme
- Department of Public Health, Vrije Universiteit Brussel (VUB), Brussel, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Brussel, Belgium
| | - Ria Reis
- Leiden University Medical Centre, Leiden, The Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Children's Institute, University of Cape Town, Amsterdam, The Netherlands
| | - Marlies Rijnders
- TNO (Nederlandse organisatie voor toegepast-natuurwetenschappelijk onderzoek), Leiden, The Netherlands
| | | | - Mathilde R Crone
- Leiden University Medical Centre, Leiden, The Netherlands
- University Maastricht, Maastricht, The Netherlands
| |
Collapse
|
3
|
Mkama ME, Koroma MM, Cheng X, Zhang J, Chen D, Kong L, Li B. Factors associated with under-five mortality in Rwanda: An analysis of the Rwanda Demographic and Health Survey 2020. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0003358. [PMID: 38889177 PMCID: PMC11185456 DOI: 10.1371/journal.pgph.0003358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 05/29/2024] [Indexed: 06/20/2024]
Abstract
Despite global and Rwandan progress in reducing under-five mortality, the risk of children dying before their fifth birthday persists, necessitating intensified research on determinants. Thus, this study analyzed the birth history data to shed light on the underlying causes of under-five mortality in Rwanda. The study is a secondary analysis of data sourced from the 2020 Rwanda Demographic and Health Survey (RDHS) cross-sectional design. Using SPSS, the data was cleaned, recoded, and weighted, with descriptive and inferential statistics applied. The dependent variable was the child's living status, while independent variables included socio-demographic, media exposure status of mothers, child, and environmental factors. A total of 10267 under-five children of all interviewed mothers were included in the final analysis, of which 12.3% (1260) died. Maternal age (25-34 years: AOR = 1.514, 95% CI = 1.130-2.029, p = 0.005; 45+: AOR = 13.226, 95% CI = 9.253-18.905, p<0.001), occupational status (agricultural workers and other services), and three or more births within five years (AOR = 1.895, 95% CI = 1.433-2.508, p<0.001) significantly increase the risk of under-five mortality. Conversely, maternal education (primary: AOR = 0.821, p = 0.023; secondary: AOR = 0.533, p<0.001; higher: AOR = 0.365, p = 0.010) and higher wealth indexes (middle: AOR = 0.743, p = 0.001; rich: AOR = 0.612, p<0.001), as well as current breastfeeding (AOR = 0.524, 95% CI = 0.455-0.603, p-value <0.001), are associated with lower under-five mortality. Child sex significantly impacts under-five mortality (AOR = 0.873, 95% CI = 0.770-0.991, p = 0.035), favoring females over males. Conversely, multiple birth type children face higher under-five mortality (AOR = 3.541, 95% CI = 2.727-4.599, p<0.001) compared to singletons. Children in the northern (AOR = 1.478, 95% CI = 1.086-2.011, p = 0.013) and eastern (AOR = 1.470, 95% CI = 1.097-1.971, p = 0.010) regions are more susceptible to mortality compared to those in the central (Kigali) region. Additionally, under-five mortality is higher when using water from tanks and other sources (AOR = 2.240, 95% CI = 1.471-3.411, p<0.001) than piped water. This study identifies crucial factors linked to under-five mortality, underscoring the importance of prioritizing them in interventions to enhance Rwandan under-five survival rates.
Collapse
Affiliation(s)
- Mgole Eliud Mkama
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Mark Momoh Koroma
- Department of Epidemiology, School of Public Health, Southern Medical University (Guangdong Provincial Key Laboratory of Tropical Disease Research), Guangzhou, China
| | - Xiaofen Cheng
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Jindan Zhang
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Duo Chen
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Lushi Kong
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Bei Li
- School of Health Management, Southern Medical University, Guangzhou, China
| |
Collapse
|
4
|
Martens N, Hindori-Mohangoo AD, Hindori MP, Damme AV, Beeckman K, Reis R, Crone MR, van der Kleij RR. Anticipated benefits and challenges of implementing group care in Suriname's maternity and child care sector: a contextual analysis. BMC Pregnancy Childbirth 2023; 23:592. [PMID: 37596532 PMCID: PMC10436662 DOI: 10.1186/s12884-023-05904-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/07/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Suriname is a uppermiddle-income country with a relatively high prevalence of preventable pregnancy complications. Access to and usage of high-quality maternity care services are lacking. The implementation of group care (GC) may yield maternal and child health improvements. However, before introducing a complex intervention it is pivotal to develop an understanding of the local context to inform the implementation process. METHODS A context analysis was conducted to identify local needs toward maternity and postnatal care services, and to assess contextual factor relevant to implementability of GC. During a Rapid Qualitative Inquiry, 63 online and face-to-face semi-structured interviews were held with parents, community members, on-and off-site healthcare professionals, policy makers, and one focus group with parents was conducted. Audio recordings were transcribed in verbatim and analysed using thematic analysis and Framework Method. The Consolidated Framework for Implementation Research served as a base for the coding tree, which was complemented with inductively derived codes. RESULTS Ten themes related to implementability, one theme related to sustainability, and seven themes related to reaching and participation of the target population in GC were identified. Factors related to health care professionals (e.g., workload, compatibility, ownership, role clarity), to GC, to recipients and to planning impact the implementability of GC, while sustainability is in particular hampered by sparse financial and human resources. Reach affects both implementability and sustainability. Yet, outer setting and attitudinal barriers of health professionals will likely affect reach. CONCLUSIONS Multi-layered contextual factors impact not only implementability and sustainability of GC, but also reach of parents. We advise future researchers and implementors of GC to investigate not only determinants for implementability and sustainability, but also those factors that may hamper, or facilitate up-take. Practical, attitudinal and cultural barriers to GC participation need to be examined. Themes identified in this study will inspire the development of adaptations and implementation strategies at a later stage.
Collapse
Affiliation(s)
- Nele Martens
- Leiden University Medical Center, Leiden, the Netherlands.
| | | | - Manodj P Hindori
- Foundation for Perinatal Interventions and Research in Suriname (Perisur), Paramaribo, Suriname
| | - Astrid Van Damme
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
| | - Katrien Beeckman
- Department of Public Health, Vrije Universiteit Brussel (VUB), Jette, Belgium
- Department of Nursing and Midwifery Research Group (NUMID), Universitair Ziekenhuis Brussel (UZ Brussel), Jette, Belgium
- Centre for Research and Innovation in Care, Universiteit Antwerpen, Antwerp, Belgium
| | - Ria Reis
- Leiden University Medical Centre, Leiden, Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, Netherlands
- University of Cape Town, Cape Town, South Africa
| | | | | |
Collapse
|
5
|
Singh K, Murindahabi N, Butrick E, Sayinzoga F, Nzeyimana D, Musange S, Walker D. Utilizing a mixed-methods approach to assess implementation fidelity of a group antenatal care trial in Rwanda. PLoS One 2023; 18:e0288974. [PMID: 37486950 PMCID: PMC10365308 DOI: 10.1371/journal.pone.0288974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND The Preterm Birth Initiative (PTBi)-Rwanda conducted a cluster randomized controlled trial to assess the impact of group antenatal care (group ANC) on preterm birth, using a group ANC approach adapted for the Rwanda setting, and implemented in 18 health centers. Previous research showed high overall fidelity of implementation, but lacked correlation with provider self-assessment and left unanswered questions. This study utilizes a mixed-methods approach to study the fidelity with which the health centers' implementation followed the model specified for group ANC. METHODS Implementation fidelity was measured using two tools, repeated Model Fidelity Assessments (MFAs) and Activity Reports (ARs) completed by Master Trainers, who visited each health center between 7 and 13 times (9 on average) to provide monitoring and training over 18 months between 2017 and 2019. Each center's MFA item and overall scores were regressed (linear regression) on the time elapsed since the center's start of implementation. The Activity Report (AR) is an open-ended template to record comments on implementation. For the qualitative analysis, the ARs from the times of each center's highest and lowest MFA score were analyzed using thematic analysis. Coding was conducted via Dedoose, with two coders independently reviewing and coding transcripts, followed by joint consensus coding. RESULTS A total of 160 MFA reports were included in the analysis. There was a significant positive association between elapsed time since a health center started implementation and greater implementation fidelity (as measured by MFA scores). In the qualitative AR analysis, Master Trainers identified key areas to improve fidelity of implementation, including: group ANC scheduling, preparing the room for group ANC sessions, provider capacity to co-facilitate group ANC, and facilitator knowledge and skills regarding group ANC content and process. These results reveal that monitoring visits are an important part of acquisition and fidelity of the "soft skills" required to effectively implement group ANC and provide an understanding of the elements that may have impacted fidelity as described by Master Trainers. CONCLUSIONS For interventions like Group ANC, where "soft-skills" like group facilitation are important, we recommend continuous monitoring and mentoring throughout program implementation to strengthen these new skills, provide corrective feedback and guard against skills decay. We suggest the use of quantitative tools to provide direct measures of implementation fidelity over time and qualitative tools to gain a more complete understanding of what factors influence implementation fidelity. Identifying areas of implementation requiring additional support and mentoring may ensure effective translation of evidence-based interventions into real-world settings.
Collapse
Affiliation(s)
- Kalee Singh
- University of California Berkeley School of Public Health, Berkeley, California, United States of America
| | | | - Elizabeth Butrick
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division—Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - David Nzeyimana
- University of Rwanda School of Public Health, Kigali, Rwanda
| | - Sabine Musange
- University of Rwanda School of Public Health, Kigali, Rwanda
| | - Dilys Walker
- Institute of Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
6
|
Gresh A, Abrams ET, Chirwa E, Jere DL, Chodzaza E, Chorwe-Sungani G, Kafulafula U, Kapito E, Patel DR, Jeremiah RD, Klima CS, MacDonald A, Norr KF, Patil CL. Experiential Training Workshops for Group Antenatal Care in Malawi. J Midwifery Womens Health 2022; 67:759-769. [PMID: 36433698 PMCID: PMC10239291 DOI: 10.1111/jmwh.13436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/27/2022]
Abstract
The positive effects of the CenteringPregnancy group antenatal care (ANC) model on perinatal outcomes in the United States has led to its adaptation and implementation in many low- and middle-income countries. Facilitative discussions are a core component of this group ANC model. Facilitator training lays a critical foundation for delivery of this paradigm-shifting model as practitioners learn to adapt their approach to health education from didactive to facilitative. However, there is little rigorous research focused on best practices for training group health care facilitators and none that is guided by a theoretical framework. Kolb's experiential learning theory offers a theoretical framework to guide the development of training workshops that allow trainees to experience, reflect on, and practice the facilitation skills needed to deliver this evidence-based intervention. This article describes an experiential learning-based training workshop that was implemented as part of an ongoing effectiveness-implementation trial of a Centering-based group ANC model in Blantyre District, Malawi. We provide a blueprint for conducting group ANC facilitator trainings that, in addition to imparting knowledge, effectively builds confidence and buy-in to this paradigm-changing approach to ANC delivery. This blueprint can be adapted for use in designing and implementing group health care across settings in the United States and globally.
Collapse
Affiliation(s)
- Ashley Gresh
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Elizabeth T Abrams
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois
| | - Ellen Chirwa
- Department of Midwifery, School of Maternal, Neonatal and Reproductive Health Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Diana L Jere
- School of Maternal, Neonatal and Reproductive Health Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Elizabeth Chodzaza
- Department of Midwifery, School of Maternal, Neonatal and Reproductive Health Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Genesis Chorwe-Sungani
- Institute of Postgraduate Studies and Research, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ursula Kafulafula
- School of Maternal, Neonatal and Reproductive Health Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Esnath Kapito
- School of Maternal, Neonatal and Reproductive Health Sciences, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Dhruvi R Patel
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois
| | - Rohan D Jeremiah
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois
| | - Carrie S Klima
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois
| | - Amy MacDonald
- Group Care Programs, Pomelo Care, Hillsborough, North Carolina
- Group Care Global, Philadelphia, Pennsylvania
| | - Kathleen F Norr
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois
| | - Crystal L Patil
- Department of Human Development Nursing Science, University of Illinois Chicago, College of Nursing, Chicago, Illinois
| |
Collapse
|
7
|
Sserwanja Q, Gatasi G, Musaba MW. Evaluating continuum of maternal and newborn healthcare in Rwanda: evidence from the 2019-2020 Rwanda demographic health survey. BMC Pregnancy Childbirth 2022; 22:781. [PMID: 36261801 PMCID: PMC9583497 DOI: 10.1186/s12884-022-05109-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 09/19/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Access to a complete continuum of maternal and child health care has been recommended globally for better pregnancy outcomes. Hence this study determined the level (pooled prevalence) and predictors of successfully completing continuum of care (CoC) in Rwanda. METHODS We analyzed weighted secondary data from the 2019-2020 Rwanda Demographic and Health Survey (RDHS) that included 6,302 women aged 15 to 49 years who were selected using multistage stratified sampling. We analyzed complete continuum of care as a composite variable of three maternal care services: at least four ANC contacts, SBA, maternal and neonatal post-natal care. We used the SPSS version 25 complex samples package to conduct multivariable logistic regression. RESULTS Of the 6,302 women, 2,131 (33.8%) (95% CI: 32.8-35.1) had complete continuum of care. The odds of having complete continuum of care were higher among women who had exposure to newspapers (adjusted odds ratio (AOR): 1.30, 95% CI: 1.11-1.52), those belonging to the eastern region (AOR): 1.24, 95% CI: 1.01-1.52), southern region (AOR): 1.26, 95% CI: 1.04-1.53), those with health insurance (AOR): 1.55, 95% CI: 1.30-1.85), those who had been visited by a field health worker (AOR: 1.31, 95% CI: 1.15-1.49), those with no big problems with distance to health facility (AOR): 1.25, 95% CI: 1.07-1.46), those who were married (AOR): 1.35, 95% CI: 1.11-1.64), those with tertiary level of education (AOR): 1.61, 95% CI: 1.05-2.49), those belonging to richer households (AOR): 1.33, 95% CI: 1.07-1.65) and those whose parity was less than 2 (AOR): 1.52, 95% CI: 1.18-1.95). CONCLUSION We have identified modifiable factors (exposure to mass media, having been visited by a field health worker, having health insurance, having no big problems with distance to the nearest health facility, belonging to richer households, being married and educated), that can be targeted to improve utilization of the entire continuum of care. Promoting maternity services through mass media, strengthening the community health programmes, increasing access to health insurance and promoting girl child education to tertiary level may improve the level of utilization of maternity services.
Collapse
Affiliation(s)
| | - Ghislaine Gatasi
- Key Laboratory of Environmental Medicine Engineering, School of Public Health, Ministry of Education, Southeast University, 210009, Nanjing, Jiangsu Province, China
| | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Mbale Regional Referral and Teaching Hospital, Mbale, Uganda.,Department of Obstetrics and Gynaecology, Busitema University, Tororo, Uganda
| |
Collapse
|
8
|
Kawuki J, Gatasi G, Sserwanja Q. Women empowerment and health insurance utilisation in Rwanda: a nationwide cross-sectional survey. BMC Womens Health 2022; 22:378. [PMID: 36114507 PMCID: PMC9482274 DOI: 10.1186/s12905-022-01976-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Background Health insurance coverage is one of the several measures being implemented to reduce the inequity in access to quality health services among vulnerable groups. Although women’s empowerment has been viewed as a cost-effective strategy for the reduction of maternal and child morbidity and mortality, as it enables women to tackle the barriers to accessing healthcare, its association with health insurance usage has been barely investigated. Our study aims at examining the prevalence of health insurance utilisation and its association with women empowerment as well as other socio-demographic factors among Rwandan women. Methods We used Rwanda Demographic and Health Survey (RDHS) 2020 data of 14,634 women aged 15–49 years, who were selected using multistage sampling. Health insurance utilisation, the outcome variable was a binary response (yes/no), while women empowerment was assessed by four composite indicators; exposure to mass media, decision making, economic and sexual empowerment. We conducted multivariable logistic regression to explore its association with socio-demographic factors, using SPSS (version 25). Results Out of the 14,634 women, 12,095 (82.6%) (95% CI 82.0–83.2) had health insurance, and the majority (77.2%) were covered by mutual/community organization insurance. Women empowerment indicators had a negative association with health insurance utilisation; low (AOR = 0.85, 95% CI 0.73–0.98) and high (AOR = 0.66, 95% CI 0.52–0.85) exposure to mass media, high decision making (AOR = 0.78, 95% CI 0.68–0.91) and high economic empowerment (AOR = 0.63, 95% CI 0.51–0.78). Other socio-demographic factors found significant include; educational level, wealth index, and household size which had a negative association, but residence and region with a positive association. Conclusions A high proportion of Rwandan women had health insurance, but it was negatively associated with women’s empowerment. Therefore, tailoring mass-media material considering the specific knowledge gaps to addressing misinformation, as well as addressing regional imbalance by improving women’s access to health facilities/services are key in increasing coverage of health insurance among women in Rwanda.
Collapse
|
9
|
Somji A, Ramsey K, Dryer S, Makokha F, Ambasa C, Aryeh B, Booth K, Xueref S, Moore S, Mwenesi R, Rashid S. "Taking care of your pregnancy": a mixed-methods study of group antenatal care in Kakamega County, Kenya. BMC Health Serv Res 2022; 22:969. [PMID: 35906642 PMCID: PMC9336107 DOI: 10.1186/s12913-022-08200-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 06/15/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Traditional antenatal care (ANC) models often do not meet women's needs for information, counseling, and support, resulting in gaps in quality and coverage. Group ANC (GANC) provides an alternative, person-centered approach where pregnant women of similar gestational age meet with the same health provider for facilitated discussion. F studies show associations between GANC and various outcomes. METHODS We employed a pre-post quasi-experimental design using mixed methods to assess a GANC model (Lea Mimba Pregnancy Clubs) at six health facilities in Kakamega County, Kenya. Between April 2018 and January 2019, we tracked 1652 women assigned to 162 GANC cohorts. Using an intention-to-treat approach, we conducted baseline (N = 112) and endline surveys (N = 360) with women attending immunization visits to assess outcomes including experience of care, empowerment and self-efficacy, knowledge of healthy practices and danger signs, and practice of healthy behaviors, including ANC retention. At endline, we conducted 29 in-depth interviews (IDIs) and three focus group discussions with women who were currently and previously participating in GANC, and 15 IDIs with stakeholders. RESULTS The proportion of survey respondents with knowledge of three or more danger signs during pregnancy more than tripled, from 7.1% at baseline to 26.4% at endline (OR: 4.58; 95% CI: 2.26-10.61). We also found improvements in women's reports about their experience of care between baseline and endline, particularly in their assessment of knowledge and competence of health workers (OR: 2.52 95% CI: 1.57-4.02), respect shown by ANC providers (OR: 1.82, 95% CI: 1.16-2.85), and women's satisfaction with overall quality of care (OR: 1.62, 95% CI: 1.03-2.53). We saw an increase from 58.9% at baseline to 71.7% at endline of women who strongly agreed that they shared their feelings and experiences with other women (OR: 1.73, 95% CI: 1.1-2.7). The mean number of ANC visits increased by 0.89 visits (95% CI: 0.47-1.42) between baseline (4.21) and endline (5.08). No changes were seen in knowledge of positive behaviors, empowerment, self-efficacy, and several aspects related to women's experience of care and adoption of healthy behavior constructs. Qualitatively, women and stakeholders noted improved interactions between health providers and women, improved counseling, increased feelings of empowerment to ask questions and speak freely and strengthened social networks and enhanced social cohesion among women. CONCLUSIONS GANC offers promise for enhancing women's experience of care by providing improved counseling and social support. Additional research is needed to develop and test measures for empowerment, self-efficacy, and experience of care, and to understand the pathways whereby GANC effects changes in specific outcomes.
Collapse
Affiliation(s)
- Aleefia Somji
- Management Sciences for Health (MSH), Alexandria, USA
| | | | - Sean Dryer
- Globally Minded Foundation, Burgas, Bulgaria
| | | | | | | | - Kathleen Booth
- Columbia University Mailman School of Public Health, New York, USA
| | | | | | | | | |
Collapse
|
10
|
Sserwanja Q, Nuwabaine L, Gatasi G, Wandabwa JN, Musaba MW. Factors associated with utilization of quality antenatal care: a secondary data analysis of Rwandan Demographic Health Survey 2020. BMC Health Serv Res 2022; 22:812. [PMID: 35733151 PMCID: PMC9217119 DOI: 10.1186/s12913-022-08169-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background Over the last decade, progress in reducing maternal mortality in Rwanda has been slow, from 210 deaths per 100,000 live births in 2015 to 203 deaths per 100,000 live births in 2020. Access to quality antenatal care (ANC) can substantially reduce maternal and newborn mortality. Several studies have investigated factors that influence the use of ANC, but information on its quality is limited. Therefore, this study aimed to identify the determinants of quality antenatal care among pregnant women in Rwanda using a nationally representative sample. Methods We analyzed secondary data of 6,302 women aged 15–49 years who had given birth five years prior the survey from the Rwanda Demographic and Health Survey (RDHS) of 2020 data. Multistage sampling was used to select RDHS participants. Good quality was considered as having utilized all the ANC components. Multivariable logistic regression was conducted to explore the associated factors using SPSS version 25. Results Out of the 6,302 women, 825 (13.1%, 95% CI: 12.4–14.1) utilized all the ANC indicators of good quality ANC); 3,696 (60%, 95% CI: 58.6–61.1) initiated ANC within the first trimester, 2,975 (47.2%, 95% CI: 46.1–48.6) had 4 or more ANC contacts, 16 (0.3%, 95% CI: 0.1–0.4) had 8 or more ANC contacts. Exposure to newspapers/magazines at least once a week (aOR 1.48, 95% CI: 1.09–2.02), lower parity (para1: aOR 6.04, 95% CI: 3.82–9.57) and having been visited by a field worker (aOR 1.47, 95% CI: 1.23–1.76) were associated with more odds of receiving all ANC components. In addition, belonging to smaller households (aOR 1.34, 95% CI: 1.10–1.63), initiating ANC in the first trimester (aOR 1.45, 95% CI: 1.18–1.79) and having had 4 or more ANC contacts (aOR 1.52, 95% CI: 1.25–1.85) were associated with more odds of receiving all ANC components. Working women had lower odds of receiving all ANC components (aOR 0.79, 95% CI: 0.66–0.95). Conclusion The utilization of ANC components (13.1%) is low with components such as having at least two tetanus injections (33.6%) and receiving drugs for intestinal parasites (43%) being highly underutilized. Therefore, programs aimed at increasing utilization of ANC components need to prioritize high parity and working women residing in larger households. Promoting use of field health workers, timely initiation and increased frequency of ANC might enhance the quality of care. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08169-x.
Collapse
Affiliation(s)
- Quraish Sserwanja
- Programmes Department, GOAL, Arkaweet Block 65 House No. 227, Khartoum, Sudan.
| | - Lilian Nuwabaine
- School of Nursing and Midwifery, Aga Khan University, Kampala, Uganda
| | - Ghislaine Gatasi
- Key Laboratory of Environmental Medicine Engineering, School of Public Health, Southeast University, Nanjing, 210009, Jiangsu Province, China
| | - Julius N Wandabwa
- Department of Obstetrics and Gynaecology, Busitema University/ Mbale Regional Referral and Teaching Hospital, Mbale, Uganda
| | - Milton W Musaba
- Department of Obstetrics and Gynaecology, Busitema University/ Mbale Regional Referral and Teaching Hospital, Mbale, Uganda
| |
Collapse
|
11
|
Nwankwo HC, Habtu M, Rutayisire E, Kalisa R. Prevalence and factors associated with preterm birth in a rural district hospital, Rwanda. Pan Afr Med J 2022; 43:173. [PMID: 36879632 PMCID: PMC9984828 DOI: 10.11604/pamj.2022.43.173.34113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/02/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction globally, the leading cause of neonatal mortality is preterm birth which may hinder the achievement of Sustainable Development Goal 3.2 target. We aimed to determine the prevalence and factors associated with preterm delivery at Kabutare hospital, Rwanda. Methods a cross-sectional study was conducted between August and September 2020. Mothers were interviewed using a standard pretested semi-structured questionnaire and additional data were extracted from medical records of obstetric files. Gestational age was assessed using the Ballard score. Adjusted Odds Ratios and their 95% confidence intervals were calculated for multivariable logistic regression analysis to take care of all potential confounders. Results the prevalence of preterm birth was 17.5% (95% CI: 12.9% - 22.9%). The independent factors associated with preterm birth after considering multiple logistic regression were husband being a smoker (adjusted Odds Ratio (aOR) = 5.9; 95% CI; 1.9-18; p= 0.002), antenatal care (ANC) attendance ≤ 3 visits (aOR=3.9; 95% CI; 1.1-13.8; p=0.04) and low mother's Mid Upper Arm Circumference (MUAC) < 23cm (aOR=5.6, 95% CI; 1.8-18.9; p=0.004). Conclusion: preterm delivery was high in Huye district. Thus, we recommend ANC sessions to emphasize on maternal nutritional education which is of good quality and quantity, discourage maternal alcohol consumption as well as passive smoking.
Collapse
Affiliation(s)
- Hellen Chinwe Nwankwo
- Mount Kenya University, School of Health Sciences, Department of Public Health, Kigali Campus, Rwanda
| | - Michael Habtu
- Mount Kenya University, School of Health Sciences, Department of Public Health, Kigali Campus, Rwanda
| | - Erigene Rutayisire
- Mount Kenya University, School of Health Sciences, Department of Public Health, Kigali Campus, Rwanda
| | - Richard Kalisa
- School of Public Health, University of Rwanda, Kigali, Rwanda
| |
Collapse
|
12
|
Jeremiah RD, Patel DR, Chirwa E, Kapito E, Mei X, McCreary LL, Norr KF, Liu L, Patil CL. A randomized group antenatal care pilot showed increased partner communication and partner HIV testing during pregnancy in Malawi and Tanzania. BMC Pregnancy Childbirth 2021; 21:790. [PMID: 34819018 PMCID: PMC8611988 DOI: 10.1186/s12884-021-04267-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 11/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV testing at antenatal care (ANC) is critical to achieving zero new infections in sub-Saharan Africa. Although most women are tested at ANC, they remain at risk for HIV exposure and transmission to their infant when their partners are not tested. This study evaluates how an HIV-enhanced and Centering-based group ANC model-Group ANC+ that uses interactive learning to practice partner communication is associated with improvements in partner HIV testing during pregnancy. METHODS A randomized pilot study conducted in Malawi and Tanzania found multiple positive outcomes for pregnant women (n = 218) assigned to Group ANC+ versus individual ANC. This analysis adds previously unpublished results for two late pregnancy outcomes: communication with partner about three reproductive health topics (safer sex, HIV testing, and family planning) and partner HIV testing since the first antenatal care visit. Multivariate logistic regression models were used to assess the effect of type of ANC on partner communication and partner testing. We also conducted a mediation analysis to assess whether partner communication mediated the effect of type of care on partner HIV testing. RESULTS Nearly 70% of women in Group ANC+ reported communicating about reproductive health with their partner, compared to 45% of women in individual ANC. After controlling for significant covariates, women in group ANC were twice as likely as those in individual ANC to report that their partner got an HIV test (OR 1.99; 95% CI: 1.08, 3.66). The positive effect of the Group ANC + model on partner HIV testing was fully mediated by increased partner communication. CONCLUSIONS HIV prevention was included in group ANC health promotion without compromising services and coverage of standard ANC topics, demonstrating that local high-priority health promotion needs can be integrated into ANC using a Group ANC+. These findings provide evidence that greater partner communication can promote healthy reproductive behaviors, including HIV prevention. Additional research is needed to understand the processes by which group ANC allowed women to discuss sensitive topics with partners and how these communications led to partner HIV testing.
Collapse
Affiliation(s)
- Rohan D Jeremiah
- College of Nursing, University of Illinois Chicago, Chicago, USA.
| | - Dhruvi R Patel
- College of Nursing, University of Illinois Chicago, Chicago, USA
| | - Ellen Chirwa
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Esnath Kapito
- Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Xiaohan Mei
- School of Public Health, University of Illinois Chicago, Chicago, USA
| | - Linda L McCreary
- College of Nursing, University of Illinois Chicago, Chicago, USA
| | - Kathleen F Norr
- College of Nursing, University of Illinois Chicago, Chicago, USA
| | - Li Liu
- School of Public Health, University of Illinois Chicago, Chicago, USA
| | - Crystal L Patil
- College of Nursing, University of Illinois Chicago, Chicago, USA
| |
Collapse
|
13
|
Miller P, Afulani PA, Musange S, Sayingoza F, Walker D. Person-centered antenatal care and associated factors in Rwanda: a secondary analysis of program data. BMC Pregnancy Childbirth 2021; 21:290. [PMID: 33838658 PMCID: PMC8037834 DOI: 10.1186/s12884-021-03747-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 03/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Research suggests that women's experience of antenatal care is an important component of high-quality antenatal care. Person-centered antenatal care (PCANC) reflects care that is both respectful of, and responsive to, the preferences, needs, and values of pregnant women. Little is known in Rwanda about either the extent to which PCANC is practiced or the factors that might determine its use. This is the first study to quantitatively examine the extent of and the factors associated with PCANC in Rwanda. METHODS We used quantitative data from a randomized control trial in Rwanda. A total of 2150 surveys were collected and analyzed from 36 health centers across five districts. We excluded women who were less than 16 years old, were referred to higher levels of antenatal care or had incomplete survey responses. Both bivariate and multivariate logistic regression analyses were used to test the hypothesis that certain participant characteristics would predict high PCANC. RESULTS PCANC level was found to be sub-optimal with one third of women leaving antenatal care (ANC) with questions or confused and one fourth feeling disrespected. In bivariate analysis, social support, greater parity, being in the traditional care (control group), and being from Burera district significantly predict high PCANC. Additionally, in the multivariate analysis, being in the traditional care group and the district in which women received care were significantly associated with PCANC. CONCLUSIONS This quantitative analysis indicates sub-optimal levels of PCANC amongst our study population in Rwanda. We find lower levels of PCANC to be regional and defined by the patient characteristics parity and social support. Given the benefits of PCANC, improvements in PCANC through provider training in Rwanda might promote an institutional culture shift towards a more person-centered model of care.
Collapse
Affiliation(s)
- Phoebe Miller
- University of California San Francisco, San Francisco, USA.
| | | | - Sabine Musange
- University of Rwanda School of Public Health, Kigali, Rwanda
| | | | - Dilys Walker
- University of California San Francisco, San Francisco, USA
| |
Collapse
|
14
|
Gresh A, Cohen M, Anderson J, Glass N. Postpartum care content and delivery throughout the African continent: An integrative review. Midwifery 2021; 97:102976. [PMID: 33740519 DOI: 10.1016/j.midw.2021.102976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of this review was to describe and evaluate the content of postpartum care and models of delivery throughout the African continent. DESIGN Integrative review was used to allow for the combination of studies using diverse research methodologies. DATA SOURCES A comprehensive search strategy using the phrases 'postpartum period', 'healthcare delivery', and 'Africa,' including all spelling variants and countries within the continent, was used in the following databases: PubMed, Cumulative Index of Nursing and Allied Health Literature Plus, and Embase for studies published through September 2019. REVIEW METHOD The integrative review process included five stages: problem identification, literature search, data evaluation, data analysis and presentation. Twelve studies from eight African countries were identified in the search and met the inclusion criteria for the review. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies included in the review. The theoretical framework developed by the World Health Organization Maternal Morbidity Working Group for healthcare interventions to address maternal morbidity was used for data analysis and to synthesize the results for presentation. RESULTS Definitions of the postpartum period varied among studies with service delivery ranging from six weeks to one year postpartum. There was no standard package of postpartum care across studies. Based on the World Health Organization theoretical framework, five primary topics were covered in postpartum care interventions: preventive care and counseling, health systems innovation, a life course approach, family planning, and health literacy and education. In contrast, five gaps in content of postpartum care services and service delivery included: integration of screening and treatment of noncommunicable diseases with maternal healthcare, intimate partner violence screening, social protection, a rights-based approach, and social vulnerability. No study addressed all aspects of the World Health Organization framework to address maternal morbidity. CONCLUSIONS The results from this review indicate the need to address gaps in postpartum care services throughout the African continent in order to reduce maternal morbidity. Re- conceptualizing the paradigm of maternal health to take a life course approach and focusing future research on developing and building interventions to target postpartum care and healthcare delivery of postpartum care are necessary and important in efforts to reduce maternal morbidity and improve health outcomes for mother and child.
Collapse
Affiliation(s)
- Ashley Gresh
- Johns Hopkins University School of Nursing, 525 North Wolfe Street, Baltimore, MD, 21205, USA.
| | - Megan Cohen
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21287, USA.
| | - Jean Anderson
- Johns Hopkins University School of Medicine, 600 North Wolfe Street, Baltimore, MD, 21287, USA.
| | - Nancy Glass
- Johns Hopkins University School of Nursing, 525 North Wolfe Street, Baltimore, MD, 21205, USA.
| |
Collapse
|
15
|
Sayinzoga F, Lundeen T, Musange SF, Butrick E, Nzeyimana D, Murindahabi N, Azman-Firdaus H, Sloan NL, Benitez A, Phillips B, Ghosh R, Walker D. Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial. PLoS One 2021; 16:e0246442. [PMID: 33529256 PMCID: PMC7853466 DOI: 10.1371/journal.pone.0246442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 01/16/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success. METHODS We studied the effect of group antenatal care on gestational age at birth among women in Rwanda, hypothesizing that participation would increase mean gestational length. For this unblinded cluster randomized trial, 36 health centers were pair-matched and randomized; half continued individual antenatal care (control), half implemented group antenatal care (intervention). Women who initiated antenatal care between May 2017 and December 2018 were invited to participate, and included in analyses if they presented before 24 weeks gestation, attended at least two visits, and their birth outcome was obtained. We used a generalized estimating equations model for analysis. FINDINGS In total, 4091 women in 18 control clusters and 4752 women in 18 intervention clusters were included in the analysis. On average, women attended three total antenatal care visits. Gestational length was equivalent in the intervention and control groups (39.3 weeks (SD 1.6) and 39.3 weeks (SD 1.5)). There were no significant differences between groups in secondary outcomes except that more women in control sites attended postnatal care visits (40.1% versus 29.7%, p = 0.003) and more women in intervention sites attended at least three total antenatal care visits (80.7% versus 71.7%, p = 0.003). No harms were observed. INTERPRETATION Group antenatal care did not result in a difference in gestational length between groups. This may be due to the low intervention dose. We suggest studies of both the effectiveness and costs of higher doses of group antenatal care among women at higher risk of preterm birth. We observed threats to group care due to facility staff shortages; we recommend studies in which antenatal care providers are exclusively allocated to group antenatal care during visits. TRIAL REGISTRATION ClinicalTrials.gov NCT03154177.
Collapse
Affiliation(s)
- Felix Sayinzoga
- Maternal, Child, and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
| | | | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - David Nzeyimana
- School of Public Health, University of Rwanda, Kigali, Rwanda
| | | | - Hana Azman-Firdaus
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Nancy L. Sloan
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Alejandra Benitez
- Department of Biostatistics, University of California Berkeley, Berkeley, California, United States of America
| | - Beth Phillips
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Rakesh Ghosh
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California, United States of America
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, San Francisco, California, United States of America
| |
Collapse
|
16
|
Penney D. Ethical Considerations for Short-Term Global Health Projects. J Midwifery Womens Health 2020; 65:767-776. [PMID: 33247528 DOI: 10.1111/jmwh.13162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/18/2020] [Accepted: 06/28/2020] [Indexed: 01/21/2023]
Abstract
Various types of health professional volunteers from high-income nations are increasingly engaged in short-term global health projects in low- and middle-income countries. The goal of global health projects is to improve health for all people and address health inequities. Short-term projects lasting days to months can create challenges for volunteers and hosts. Despite attempting to do good, volunteer efforts may unwittingly cause harm to host organizations by planning projects without consideration for the local infrastructure, the community, and the health care staff. Although well-intentioned and often beneficial, volunteer efforts can fail to provide adequate follow-up or may disrupt or override local health efforts. In some low-resource settings, dire health needs and lack of supervision may result in volunteers practicing beyond their professional scope. Recently published guidelines, competencies, and position statements have addressed ethical behaviors for short-term global health experiences. Partnerships that are founded on principles of justice and autonomy provide an avenue for mutual collaboration. Short-term global health projects that focus on host needs are likely to strengthen local capacity to improve health outcomes. This article reviews guidelines for short-term global health experiences and addresses the ethical principles for planning effective projects.
Collapse
Affiliation(s)
- Debra Penney
- University of Utah College of Nursing, Salt Lake City, Utah
| |
Collapse
|
17
|
Grenier L, Lori JR, Darney BG, Noguchi LM, Maru S, Klima C, Lundeen T, Walker D, Patil CL, Suhowatsky S, Musange S. Building a Global Evidence Base to Guide Policy and Implementation for Group Antenatal Care in Low- and Middle-Income Countries: Key Principles and Research Framework Recommendations from the Global Group Antenatal Care Collaborative. J Midwifery Womens Health 2020; 65:694-699. [PMID: 33010115 PMCID: PMC9022023 DOI: 10.1111/jmwh.13143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 02/13/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
Evidence from high‐income countries suggests that group antenatal care, an alternative service delivery model, may be an effective strategy for improving both the provision and experience of care. Until recently, published research about group antenatal care did not represent findings from low‐ and middle‐income countries, which have health priorities, system challenges, and opportunities that are different than those in high‐income countries. Because high‐quality evidence is limited, the World Health Organization recommends group antenatal care be implemented only in the context of rigorous research. In 2016 the Global Group Antenatal Care Collaborative was formed as a platform for group antenatal care researchers working in low‐ and middle‐income countries to share experiences and shape future research to accelerate development of a robust global evidence base reflecting implementation and outcomes specific to low‐ and middle‐income countries. This article presents a brief history of the Collaborative's work to date, proposes a common definition and key principles for group antenatal care, and recommends an evaluation and reporting framework for group antenatal care research.
Collapse
Affiliation(s)
| | - Jody R Lori
- Department of Health Behavior and Biological Science, School of Nursing, University of Michigan, Ann Arbor, Michigan
| | - Blair G Darney
- Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon.,National Institute of Public Health, Center for Population Health Research, Cuernavaca, Mexico
| | | | - Sheela Maru
- Department of Health Systems Design and Global Health, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carrie Klima
- Department of Women, Children, and Family Health Sciences, College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, California.,Department of Obstetrics, Gynecology, and Reproductive Health Sciences and Institute for Global Health Sciences, University of California San Francisco, San Francisco, California
| | - Crystal L Patil
- Department of Women, Children, and Family Health Sciences, College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | | | - Sabine Musange
- University of Rwanda, School of Public Health, Kigali, Rwanda
| |
Collapse
|
18
|
McKinnon B, Sall M, Vandermorris A, Traoré M, Lamesse-Diedhiou F, McLaughlin K, Bassani D. Feasibility and preliminary effectiveness of group antenatal care in Senegalese health posts: a pilot implementation trial. Health Policy Plan 2020; 35:587-599. [PMID: 32155254 DOI: 10.1093/heapol/czz178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2019] [Indexed: 11/14/2022] Open
Abstract
Almost all pregnant women in Senegal receive some antenatal care (ANC), yet only around half receive four or more visits and provision of education and counselling during ANC is often inadequate and, in some cases, non-existent. This results in missed opportunities to provide support and to counsel women regarding appropriate care-seeking practices and health behaviours during pregnancy and across the continuum of care. This pilot effectiveness-implementation randomized controlled trial explored whether group ANC (G-ANC), a model that integrates standard individual pregnancy care with facilitated participatory group education activities and peer support, could potentially address some of these challenges. The G-ANC model adapted for Senegal builds on local healthcare delivery systems and aligns with World Health Organization recommendations for a shift towards women-centred models of maternity services. It was implemented at the health post level, and a total of 330 pregnant women participated in the study, of whom 85% were followed up at 6-10 weeks post-delivery. We assessed implementation outcomes (e.g. acceptability, cost) to establish the feasibility of the model in Senegal and explored effectiveness outcomes related to maternal and infant health for the planning of a large-scale trial. Results indicate that women and ANC providers were overwhelmingly enthusiastic about the G-ANC model, and exploratory analyses suggested improvements in exclusive breastfeeding, intention to use family planning, birth preparations and knowledge around maternal and newborn danger signs. This article provides timely and relevant evidence on the feasibility of G-ANC as an alternative model of care during pregnancy and a solid basis for recommending the conduct of a large-scale implementation study of G-ANC in Senegal.
Collapse
Affiliation(s)
- Britt McKinnon
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada
| | - Mohamadou Sall
- Institut de Recherche et Formation en Population, Développement et Santé de la Reproduction, Université Cheik Anta Diop, P.O. Box 45 550 Dakar Fann, Dakar, Senegal
| | - Ashley Vandermorris
- Division of Adolescent Medicine, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Department of Pediatrics, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada
| | - Mahamadou Traoré
- Institut de Recherche et Formation en Population, Développement et Santé de la Reproduction, Université Cheik Anta Diop, P.O. Box 45 550 Dakar Fann, Dakar, Senegal
| | - Fatma Lamesse-Diedhiou
- Institut de Recherche et Formation en Population, Développement et Santé de la Reproduction, Université Cheik Anta Diop, P.O. Box 45 550 Dakar Fann, Dakar, Senegal
| | - Katie McLaughlin
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada
| | - Diego Bassani
- Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, ON M5G 0A4, Canada.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, ON M5T 3M7, Canada.,Department of Pediatrics, University of Toronto, 555 University Ave, Toronto, ON M5G 1X8, Canada
| |
Collapse
|
19
|
Chirwa E, Kapito E, Jere DL, Kafulafula U, Chodzaza E, Chorwe-Sungani G, Gresh A, Liu L, Abrams ET, Klima CS, McCreary LL, Norr KF, Patil CL. An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi. BMC Public Health 2020; 20:205. [PMID: 32039721 PMCID: PMC7008527 DOI: 10.1186/s12889-020-8276-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 01/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sub-Saharan Africa has the world's highest rates of maternal and perinatal mortality and accounts for two-thirds of new HIV infections and 25% of preterm births. Antenatal care, as the entry point into the health system for many women, offers an opportunity to provide life-saving monitoring, health promotion, and health system linkages. Change is urgently needed, because potential benefits of antenatal care are not realized when pregnant women experience long wait times and short visits with inconsistent provisioning of essential services and minimal health promotion, especially for HIV prevention. This study answers WHO's call for the rigorous study of group antenatal care as a transformative model that provides a positive pregnancy experience and improves outcomes. METHODS Using a hybrid type 1 effectiveness-implementation design, we test the effectiveness of group antenatal care by comparing it to individual care across 6 clinics in Blantyre District, Malawi. Our first aim is to evaluate the effectiveness of group antenatal care through 6 months postpartum. We hypothesize that women in group care and their infants will have less morbidity and mortality and more positive HIV prevention outcomes. We will test hypotheses using multi-level hierarchical models using data from repeated surveys (four time points) and health records. Guided by the consolidated framework for implementation research, our second aim is to identify contextual factors related to clinic-level degree of implementation success. Analyses use within and across-case matrices. DISCUSSION This high-impact study addresses three global health priorities, including maternal and infant mortality, HIV prevention, and improved quality of antenatal care. Results will provide rigorous evidence documenting the effectiveness and scalability of group antenatal care. If results are negative, governments will avoid spending on less effective care. If our study shows positive health impacts in Malawi, the results will provide strong evidence and valuable lessons learned for widespread scale-up in other low-resource settings. Positive maternal, neonatal, and HIV-related outcomes will save lives, impact the quality of antenatal care, and influence health policy as governments make decisions about whether to adopt this innovative healthcare model. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT03673709. Registered on September 17, 2018.
Collapse
Affiliation(s)
- Ellen Chirwa
- University of Malawi, Kamuzu College of Nursing, PO Box 415, Blantyre, Malawi
| | - Esnath Kapito
- University of Malawi, Kamuzu College of Nursing, PO Box 415, Blantyre, Malawi
| | - Diana L Jere
- University of Malawi, Kamuzu College of Nursing, PO Box 415, Blantyre, Malawi
| | - Ursula Kafulafula
- University of Malawi, Kamuzu College of Nursing, PO Box 415, Blantyre, Malawi
| | - Elizabeth Chodzaza
- University of Malawi, Kamuzu College of Nursing, PO Box 415, Blantyre, Malawi
| | | | - Ashley Gresh
- Johns Hopkins University, School of Nursing, 525 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Li Liu
- University of Illinois at Chicago, School of Public Health, 1603 W. Taylor Street (M/C 932), Chicago, IL, 60612, USA
| | - Elizabeth T Abrams
- University of Illinois at Chicago, College of Nursing, 845 S. Damen Avenue (M/C 806), Chicago, IL, 60612, USA
| | - Carrie S Klima
- University of Illinois at Chicago, College of Nursing, 845 S. Damen Avenue (M/C 806), Chicago, IL, 60612, USA
| | - Linda L McCreary
- University of Illinois at Chicago, College of Nursing, 845 S. Damen Avenue (M/C 806), Chicago, IL, 60612, USA
| | - Kathleen F Norr
- University of Illinois at Chicago, College of Nursing, 845 S. Damen Avenue (M/C 806), Chicago, IL, 60612, USA
| | - Crystal L Patil
- University of Illinois at Chicago, College of Nursing, 845 S. Damen Avenue (M/C 806), Chicago, IL, 60612, USA.
| |
Collapse
|
20
|
Butrick E, Lundeen T, Phillips BS, Tengera O, Kambogo A, Uwera YDN, Musabyimana A, Sayinzoga F, Nzeyimana D, Murindahabi N, Musange S, Walker D. Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda. Gates Open Res 2020; 4:7. [PMID: 32363328 PMCID: PMC7177154 DOI: 10.12688/gatesopenres.13090.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2019] [Indexed: 11/24/2022] Open
Abstract
Background: For a large trial of the effect of group antenatal care on perinatal outcomes in Rwanda, a Technical Working Group customized the group care model for implementation in this context. This process analysis aimed to understand the degree of fidelity with which the group antenatal care model was implemented during the trial period. Methods: We used two discreet questionnaires to collect data from two groups about the fidelity with which the group antenatal care model was implemented during this trial period. Group care facilitators recorded descriptive data about each visit and self-assessed process fidelity with a series of yes/no checkboxes. Master Trainers assessed process fidelity with an 11-item tool using a 5-point scale of 0 (worst) to 4 (best). Results: We analyzed 2763 questionnaires completed by group care facilitators that documented discreet group visits among pregnant and postnatal women and 140 questionnaires completed by Master Trainers during supervision visits. Data recorded by both groups was available for 84 group care visits, and we compared these assessments by visit. Approximately 80% of all group visits were provided as intended, with respect to both objective measures (e.g. group size) and process fidelity. We did not find reliable correlations between conceptually-related items scored by Master Trainers and self-assessment data reported by group visit facilitators. Conclusions: We recommend both the continued participation of expert observers at new and existing group care sites and ongoing self-assessment by group care facilitators. Finally, we present two abbreviated assessment tools developed by a Rwanda-specific Technical Working Group that reviewed these research results.
Collapse
Affiliation(s)
- Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| | - Beth S Phillips
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| | - Olive Tengera
- School of Nursing and Midwifery, National University of Rwanda, Kigali, Rwanda
| | | | | | | | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - David Nzeyimana
- School of Public Health, National University of Rwanda, Kigali, Rwanda
| | | | - Sabine Musange
- School of Public Health, National University of Rwanda, Kigali, Rwanda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California San Francisco, San Franciso, CA, 94158, USA
| |
Collapse
|
21
|
Musange SF, Butrick E, Lundeen T, Santos N, Azman Firdaus H, Benitez A, Nzeyimana D, Kayiramirwa Murindahabi N, Nyiraneza L, Sayinzoga F, Ndahindwa V, Ngabo F, Condo J, Walker D. Group antenatal care versus standard antenatal care and effect on mean gestational age at birth in Rwanda: protocol for a cluster randomized controlled trial. Gates Open Res 2019; 3:1548. [PMID: 31656954 PMCID: PMC6792348 DOI: 10.12688/gatesopenres.13053.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Group antenatal care has demonstrated promise as a service delivery model that may result in improved outcomes compared to standard antenatal care in socio-demographic populations at disparately high risk for poor perinatal outcomes. Intrigued by results from the United States showing lower preterm birth rates among high-risk women who participate in group antenatal care, partners working together as the Preterm Birth Initiative - Rwanda designed a trial to assess the impact of group antenatal care on gestational age at birth. Methods: This study is a pair-matched cluster randomized controlled trial with four arms. Pairs randomized to group or standard care were further matched with other pairs into quadruples, within which one pair was assigned to implement basic obstetric ultrasound at the health center and early pregnancy testing at the community. At facilities randomized to group care, this will follow the opt-out model of service delivery and individual visits will always be available for those who need or prefer them. The primary outcome of interest is mean gestational age at birth among women who presented for antenatal care before 24 completed weeks of pregnancy and attended more than one antenatal care visit. Secondary outcomes of interest include attendance at antenatal and postnatal care, preterm birth rates, satisfaction of mothers and providers, and feasibility. A convenience sample of women will be recruited to participate in a longitudinal survey in which they will report such indicators as self-reported health-related behaviors and depressive symptoms. Providers will be surveyed about satisfaction and stress. Discussion: This is the largest cluster randomized controlled trial of group antenatal and postnatal care ever conducted, and the first in a low- or middle-income country to examine the effect of this model on gestational age at birth. Trial registration: This study is registered on ClinicalTrials.gov as NCT03154177 May 16, 2017.
Collapse
Affiliation(s)
- Sabine Furere Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Nicole Santos
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Hana Azman Firdaus
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
| | - Alejandra Benitez
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
- University of California, Berkeley, Berkeley, USA
| | - David Nzeyimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Lauriane Nyiraneza
- Maternal, Child and Community Health Division - Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division - Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | - Vedaste Ndahindwa
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Fidele Ngabo
- Maternal, Child and Community Health Division - Institute of HIV/AIDs, Disease Prevention and Control, Rwanda Biomedical Center, Kigali, Rwanda
| | | | - Dylis Walker
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, USA
- Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, USA
| |
Collapse
|
22
|
Lundeen T, Musange S, Azman H, Nzeyimana D, Murindahabi N, Butrick E, Walker D. Nurses' and midwives' experiences of providing group antenatal and postnatal care at 18 health centers in Rwanda: A mixed methods study. PLoS One 2019; 14:e0219471. [PMID: 31295335 PMCID: PMC6622527 DOI: 10.1371/journal.pone.0219471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/24/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The East Africa Preterm Birth Initiative-Rwanda began a cluster randomized controlled trial of group antenatal care (ANC) and postnatal care (PNC) in Rwanda in 2017. That trial will report its primary outcome, gestational length at birth, after data collection concludes in 2019. This nested study includes providers of ANC and/or PNC at the 18 health centers randomized to provide the group model of ANC/PNC and the 18 health centers randomized to continue providing ANC/PNC in the traditional, individual visit model. The objective of this study is to understand the experiences of providers of group ANC/PNC and compare their job satisfaction and perceived stress with individual ANC/PNC providers. METHODS We collected both quantitative and qualitative data from providers (nurses and midwives) who were recruited by health center directors to participate as group ANC and PNC facilitators at intervention sites and from a similar number of providers of standard ANC and PNC at control sites. Quantitative data was collected with questionnaires administered at baseline and approximately 9 months later (follow up). Qualitative data was collected in 3 focus groups of group ANC/PNC providers conducted one year after group care began. RESULTS Eighty-six percent of nurses and midwives surveyed who implemented group ANC and PNC reported that they prefer group care to the traditional individual model of ANC and PNC. Perceived stress levels and job satisfaction results were similar between groups. Mixed focus group discussions among both nurses and midwives experienced in group ANC and PNC suggest that the group model of care has advantages for both service beneficiaries and providers. When providers described implementation challenges, their peers in the focus groups offered them suggestions to cope and improve service delivery. DISCUSSION These results are consistent with studies of providers of group ANC and PNC in other LMIC contexts with respect to the perceived benefits of group care. This study adds new insights into the ways peer providers can help one another solve implementation problems. When given the opportunity to meet as a group, these study participants offered one another peer support and shared knowledge about best practices for successful implementation of group ANC/PNC. This trial is registered at clinicaltrials.gov as NCT03154177.
Collapse
Affiliation(s)
- Tiffany Lundeen
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
| | - Sabine Musange
- University of Rwanda School of Public Health, Kigali, Rwanda
| | - Hana Azman
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
| | - David Nzeyimana
- University of Rwanda School of Public Health, Kigali, Rwanda
| | | | - Elizabeth Butrick
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
| | - Dilys Walker
- University of California San Francisco, Institute of Global Health Sciences, San Francisco, California, United States of America
- University of California San Francisco, Department of Obstetrics, Gynecology, and Reproductive Sciences, San Francisco, California, United States of America
| |
Collapse
|
23
|
Musabyimana A, Lundeen T, Butrick E, Sayinzoga F, Rwabufigiri BN, Walker D, Musange SF. Before and after implementation of group antenatal care in Rwanda: a qualitative study of women's experiences. Reprod Health 2019; 16:90. [PMID: 31248425 PMCID: PMC6595554 DOI: 10.1186/s12978-019-0750-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 06/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. Methods We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. Results Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. Discussion These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care. Conclusion Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. Trial registration This trial is registered at clinicaltrials.gov as NCT03154177. Electronic supplementary material The online version of this article (10.1186/s12978-019-0750-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Angele Musabyimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA.
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Ngabo Rwabufigiri
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Sabine F Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| |
Collapse
|