The Mexican Experience Adapting CenteringPregnancy: Lessons Learned in a Publicly Funded Health Care System Serving Vulnerable Women

Couples' perceptions and experience of smartphone-assisted CenteringPregnancy model in southeast of China: a dyadic analysis of qualitative study

OBJECTIVES

The objectives of this study are to describe couples' experiences and perceived barriers to participation in the CenteringPregnancy model in southeast of China and to understand whether smartphones could play a potential role in this model.

DESIGN

This study employed a descriptive phenomenological qualitative study using semistructured dyadic interviews with women and their partners. The interviews were audiotaped, transcribed verbatim and subjected to thematic analysis.

SETTING

This study was conducted in two pilot prenatal clinics in southern China.

PARTICIPANTS

A purposive sample of 13 couples who underwent smartphone-assisted CenteringPregnancy were recruited. Data were collected until saturation through semistructured dyadic interviews between December 2022 and March 2023.

RESULTS

The study yielded four primary themes: (1) motivation for participation, (2) acceptance of CenteringPregnancy, (3) barriers and suggestions and (4) support for smartphone use of CenteringPregnancy.

CONCLUSIONS

CenteringPregnancy was well received by couples. Couples can access additional medical care and engage in intensive social interactions assisted by smartphones. However, certain objective challenges need to be acknowledged, including inadequate activity space, high demand for knowledge by couples and inflexible time for employed partners. Moreover, the risk that smartphones can lead to false expectations among couples needs to be noted.

"With group antenatal care, pregnant women know they are not alone": The process evaluation of a group antenatal care intervention in Ghana

BACKGROUND

An essential component to improving maternal and newborn outcomes is antenatal care. A trial of group antenatal care was implemented in Ghana where 7 health care facilities were randomized to be intervention sites and 7 control sites continued traditional antenatal care. Group antenatal care, where 10-14 women with similar due dates meet together for visits, includes traditional components such as risk assessment with increased opportunity for education and peer support. The study aim was to assess and report the process evaluation of the implementation of a group antenatal care intervention.

METHODS

Process evaluation data were collected alongside intervention data and included both quantitative and qualitative data sources. Midwives at the health facilities which were randomized as intervention sites completed tracking logs to measure feasibility of the intervention. Research team members traveled to intervention sites where they conducted structured observations and completed fidelity and learning methods checklists to determine adherence to the model of group antenatal care delivery. In addition, midwives facilitating group antenatal care meetings were interviewed and focus groups were conducted with women participating in group antenatal care.

RESULTS

In the majority of cases, midwives facilitating group antenatal care completed all components of the meetings with fidelity, following best practices such as sitting with the group rather than standing. Across 7 intervention sites, 7 groups (622 pregnant women) were documented in the tracking logs and of these participants, the majority (74%) attended more than half of the meetings, with 32% attending all 8 group meetings. Three themes were identified in both the midwife interviews and focus groups with pregnant women: 1) information sharing, 2) sense of community, and 3) time management challenges. An additional theme emerged from the focus groups with the women: women who had already given birth noticed a disconnect between what they learned and treatment received during labor and birth.

CONCLUSION

This process evaluation determined that group antenatal care can be implemented with fidelity in low and middle-income countries. Time management was the biggest challenge, however both midwives and pregnant women found the model of care not only acceptable, but preferable to traditional care. The knowledge shared and sense of community built during the meetings was a valuable addition to the individual model of antenatal care.

Utilizing a mixed-methods approach to assess implementation fidelity of a group antenatal care trial in Rwanda

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.

Group Prenatal Care in Mexico: perspectives and experiences of health personnel

OBJECTIVE

Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective.

METHODS

We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication).

RESULTS

The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women.

CONCLUSION

Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.

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

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.

Evaluating process fidelity during the implementation of Group Antenatal Care in Mexico

BACKGROUND

CenteringPregnancy (CP) is a group antenatal care (G-ANC) model that has proven beneficial for mothers and their newborns. We conducted a feasibility study beginning in 2016 as part of the Mexican effort to implement G-ANC locally. This study reports on fidelity to the essential elements of CP during its implementation in Mexico.

METHODS

We collected prospective data using a standardized checklist at four primary-care centers that implemented our adapted G-ANC model. We performed a descriptive analysis of fidelity to 28 processes per G-ANC session (71 sessions made up of 10 groups and 129 women across 4 health centers). We calculated fidelity to each process as a proportion with 95% confidence intervals. We present overall results and stratified by health center and by facilitation team.

RESULTS

Overall fidelity to the G-ANC intervention was 82%, with variability by health center (78-88%). The elements with the highest fidelity were having space for activities such as checking vital signs, conversation in a circle, and medical check-ups (100% each) and the element with the lowest fidelity was using music to enhance privacy (27.3%). Fidelity was not significantly different by center.

CONCLUSIONS

Our study suggests good model fidelity during the implementation of G-ANC in Mexico. Our findings also contribute useful information about where to focus efforts in the future to maintain and improve G-ANC model fidelity.

Group prenatal care: effectiveness and challenges to implementation

Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.