The effects of centering pregnancy on maternal and fetal outcomes in northern Nigeria; a prospective cohort analysis

Understanding health education needs of pregnant women in China during public health emergencies: a qualitative study amidst the COVID-19 pandemic

Background

Public health emergencies impose unique challenges on pregnant women, affecting their physiological, psychological, and social wellbeing. This study, focusing on the context of the corona virus disease in 2019 (COVID-19) pandemic in China, aims to comprehensively explore the experiences of pregnant women amidst diverse public health crises. Herein, we investigate the health education needs of pregnant Chinese women in regard to public health emergencies to provide a scientific foundation for the development of targeted health education strategies.

Objective

The study described in this article aims to explore the health education needs of pregnant Chinese women in the context of public health emergencies specifying the types of emergencies of pandemics and to provide a scientific basis for targeted health education interventions.

Methods

Thirteen pregnant women were purposively selected, and the rationale for this sample size lies in the qualitative nature of the study, seeking in-depth insights rather than generalizability. Data collection involved semi-structured interviews, and the Colaizzi, which is a structured qualitative technique used to extract, interpret, and organize significant statements from participant descriptions into themes, providing a comprehensive understanding of their lived experiences.

Results

The analysis yielded six prominent themes encompassing the following areas: I. Personal protection and vaccine safety; II. Knowledge of maternal health; III. Knowledge of fetal health; IV. Knowledge of childbirth; V. Knowledge of postpartum recovery; and VI. Knowledge sources of health education for pregnant women and their expectations of healthcare providers. Theme I was analyzed with two sub-themes (needs for personal protection knowledge, vaccine safety knowledge needs); Theme II was analyzed with three sub-themes (nutrition and diet, exercise and rest, sexual life); Theme III was analyzed with three sub-themes (medications and hazardous substances, pregnancy check-ups, and fetal movement monitoring); Theme IV was analyzed with three sub-themes (family accompaniment, analgesia in childbirth, and choice of mode of delivery); Theme V was analyzed with one sub-theme (knowledge of postnatal recovery); Theme VI was analyzed with one sub-theme (expectations of Healthcare providers). Sub-themes within each main theme were identified, offering a nuanced understanding of the multifaceted challenges faced by pregnant women during public health emergencies. The interrelation between sub-themes and main themes contributes to a holistic portrayal of their experiences.

Conclusion

The study emphasizes the need for healthcare professionals to tailor health education for pregnant women during emergencies, highlighting the role of the Internet in improving information dissemination. It recommends actionable strategies for effective health communication, ensuring these women receive comprehensive support through digital platforms for better health outcomes during public health crises.

Providers' Perspectives of a Culturally Adapted CenteringPregnancy Intervention for Marshallese Women in Arkansas

OBJECTIVE

To explore health care providers' perspectives on the successes, challenges, and suggestions for future directions regarding the implementation of CenteringPregnancy for Marshallese women in Arkansas.

DESIGN

A descriptive qualitative design was used as an exploratory method.

SETTING/LOCAL PROBLEM

This study took place in northwest Arkansas. Arkansas is home to the largest Marshallese Pacific Islander population in the United States. Marshallese Pacific Islanders residing in the United States have disproportionally high rates of poor maternal and infant health outcomes, even compared to other Pacific Islanders.

PARTICIPANTS

Seven CenteringPregnancy providers from the University of Arkansas for Medical Sciences Northwest.

INTERVENTION/MEASUREMENTS

Individual interviews were conducted from February to March of 2023. Data were managed using MAXQDA12 software. Content analysis was used to analyze the data. Initial coding was completed to identify each data segment with short summations of emergent themes. The focused thematic codes that emerged were used to identify and develop the most salient thematic categories of the data, which became the thematic codes.

RESULTS

Three overarching themes emerged: Implementation Successes, Challenges to Implementation, and Future Suggestions to Improve Implementation and Sustainability. Each theme had representative subthemes.

CONCLUSION

Findings provide insight for future implementation of CenteringPregnancy for Marshallese and other Pacific Islander individuals.

Behavioral interventions for vaccination uptake: A systematic review and meta-analysis

BACKGROUND

Human behavior and more specifically behavioral insight-based approaches to vaccine uptake have often been overlooked. While there have been a few narrative reviews indexed in Medline on behavioral interventions to increase vaccine uptake, to our knowledge, none have been systematic reviews and meta-analyses covering not just high but also low-and-middle income countries.

METHODS

We included 613 studies from the Medline database in our systematic review and meta-analysis categorizing different behavioral interventions in 9 domains: education campaigns, on-site vaccination, incentives, free vaccination, institutional recommendation, provider recommendation, reminder and recall, message framing, and vaccine champion. Additionally, considering that there is variability in the acceptance of vaccines among different populations, we assessed studies from both high-income countries (HICs) and low- to middle-income countries (LMICs), separately.

FINDINGS

Our results showed that behavioral interventions can considerably improve vaccine uptake in most settings. All domains that we examined improved vaccine uptake with the highest effect size associated with provider recommendation (OR: 3.4 (95%CI: 2.5-4.6); Domain: motivation) and on-site vaccination (OR: 2.9 (95%CI: 2.3-3.7); Domain: practical issues). While the number of studies conducted in LMICs was smaller, the quality of studies was similar with those conducted in HICs. Nevertheless, there were variations in the observed effect sizes.

INTERPRETATION

Our findings indicate that "provider recommendation" and "on-site vaccination" along with other behavioral interventions can be employed to increase vaccination rates globally.

Adapting group care to the postpartum period using a human-centered design approach in Malawi

BACKGROUND

Responsive and resilient strategies to reduce high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of the highest maternal and infant mortality rates globally. Group healthcare is a service delivery model that integrates these strategies. Although primarily implemented during the prenatal period, its potential for improving both maternal and infant health outcomes during the postpartum period has not been realized. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centered design approach with key stakeholders in Malawi.

METHODS

We completed steps of a framework guiding the use of human-centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Qualitative methods were used to complete steps 2-4. In-depth interviews (n = 24), and incubator sessions (n = 6) that employed free listing, pile sorting and ranking were completed with key stakeholders. Data analysis consisted of content analysis of interviews and framework analysis for incubator sessions to produce the integrated group postpartum and well-child care model prototype. The fifth step is detailed in a separate paper.

RESULTS

All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period.

CONCLUSIONS

Using a human-centered design approach to adapt an evidence-based group care model in an LMIC, specifically Malawi, is feasible and acceptable to key stakeholders and resulted in a prototype curriculum and practical strategies for clinic implementation.

Contributions of CenteringPregnancy to women's health behaviours, health literacy, and health care use in the Netherlands

The objective of this study was to assess the effects of CenteringPregnancy (CP) in the Netherlands on different health outcomes. A stepped wedged cluster randomized trial was used, including 2132 women of approximately 12 weeks of gestation, from thirteen primary care midwifery centres in and around Leiden, Netherlands. Data collection was done through self-administered questionnaires. Multilevel intention-to-treat analysis and propensity score matching for the entire group and separately for nulliparous- and multiparous women were employed. The main outcomes were: health behaviour, health literacy, psychological outcomes, health care use, and satisfaction with care. Women's participation in CP is associated with lower alcohol consumption after birth (OR = 0.59, 95 %CI 0.42-0.84), greater consistency with norms for healthy eating and physical activity (β = 0.19, 95 %CI 0.02-0.37), and higher knowledge about pregnancy (β = 0.05, 95 %CI 0.01-0.08). Compared to the control group, nulliparous women who participating in CP reported better compliance to the norm for healthy eating and physical activity (β = 0.28, 95 %CI0.06-0.51)) and multiparous CP participants consumed less alcohol after giving birth (OR = 0.42, 95 %CI 0.23-0.78). Health care use and satisfaction rates were significantly higher among CP participants. A non-significant trend toward lower smoking rates was documented among CP participants. Overall, the results of this study reveal a positive (postpartum) impact on fostering healthy behaviours among participants.

Effects of the online and offline hybrid continuous group care on maternal and infant health: a randomized controlled trial

BACKGROUND

The group care is a well-established maternal care model that has been widely used in many developed countries, but in China, it is confined to prenatal care services. In addition, affected by traditional birth culture, Chinese women tend to focus more on their fetuses and newborns but lack attention to their own intrapartum and postpartum care. The aim of this study was to construct and implement a prenatal, intrapartum, and the postpartum continuous group care model that combines online and offline service in Hainan Province, China, and to evaluate the effect on maternal women and newborns.

METHODS

This study was a randomized controlled trial involving 144 pregnant women in a first-class tertiary general hospital in Hainan Province, China. Women were divided into an intervention group and a control group using the random number table, with 72 women in each group. The control group received routine maternal care services, and the intervention group received the continuous group care based on the routine maternal care services. Count data such as rate of cesarean section and incidence rate of fetal macrosomia were analyzed with the chi-square test or Fisher's exact test, and the General Self-efficacy Scale scores were analyzed by repeated measures ANOVA. P < 0.05 was considered statistically significant, with two-sided probability values.

RESULTS

Compared with the control group, the rate of excessive prenatal weight gain, cesarean section, and 42-day postpartum depression were significantly lower in the intervention group (P < 0.05), and higher General Self-efficacy Scale scores (in the expectant period and 42 days postpartum) and exclusive breastfeeding rate (42 days postpartum) (P < 0.05). The incidence of fetal macrosomia was significantly lower in the intervention group (P < 0.05). But there was no significant difference in birth weight, preterm birth, the incidence of low-birth-weight infants and 1-min Apgar score (P > 0.05).

CONCLUSION

The continuous group care with online and offline service can effectively control the gestational weight gain, reduce the rate of cesarean section, macrosomia, and postpartum depression. It can improve the self-efficacy of women and the rate of exclusive breastfeeding effectively.

TRIAL REGISTRATION

Chinese Clinical Trial Regestry (ChiCTR2200065765, 04/11/2022, Retrospectively registered).

Exploring the feasibility, acceptability, and preliminary effectiveness of a culturally adapted group prenatal program, CenteringPregnancy, to reduce maternal and infant health disparities among Marshallese Pacific Islanders: A study protocol

Background

Marshallese Pacific Islanders residing in the United States have higher rates of adverse perinatal outcomes than the general population and experience numerous barriers to prenatal care. CenteringPregnancy is a group prenatal care model which occurs in the patient's community. CenteringPregnancy, when applied to the Marshallese population, presents a potentially highly successful group-based intervention that can mitigate adverse perinatal outcomes among Marshallese Pacific Islanders.

Methods

This article describes the protocol of a mixed-methods study designed to examine the feasibility, acceptability, and preliminary effectiveness of the implementation of CenteringPregnancy for Marshallese Pacific Islander women. The mixed-methods design collects qualitative and quantitative data at the onset of CenteringPregnancy and during their last session and then augments the data with post-partum data abstraction.

Conclusion

This will be the first study to culturally adapt and implement CenteringPregnancy with Marshallese pregnant women in the United States. This study will be an important first step to exploring the feasibility, acceptability, and preliminary effectiveness of CenteringPregnancy and will better prepare the research team to assess and refine the intervention moving forward.

Trial registration

This study was registered at ClinicalTrials.gov on September 22, 2020 under identifier NCT04558619 and can be accessed at https://clinicaltrials.gov/ct2/show/NCT04558619?term=K%C5%8Dmmour+Prenatal&draw=2&rank=1.

"Taking care of your pregnancy": a mixed-methods study of group antenatal care in Kakamega County, Kenya

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.

A Mobile Education and Social Support Group Intervention for Improving Postpartum Health in Northern India: Development and Usability Study

BACKGROUND

Structural and cultural barriers limit Indian women's access to adequate postnatal care and support despite their importance for maternal and neonatal health. Targeted postnatal education and support through a mobile health intervention may improve postnatal recovery, neonatal care practices, nutritional status, knowledge and care seeking, and mental health.

OBJECTIVE

We sought to understand the feasibility and acceptability of our first pilot phase, a flexible 6-week postnatal mobile health intervention delivered to 3 groups of women in Punjab, India, and adapt our intervention for our next pilot phase, which will formally assess intervention feasibility, acceptability, and preliminary efficacy.

METHODS

Our intervention prototype was designed to deliver culturally tailored educational programming via a provider-moderated, voice- and text-based group approach to connect new mothers with a social support group of other new mothers, increase their health-related communication with providers, and refer them to care needed. We targeted deployment using feature phones to include participants from diverse socioeconomic groups. We held moderated group calls weekly, disseminated educational audios, and created SMS text messaging groups. We varied content delivery, group discussion participation, and chat moderation. Three groups of postpartum women from Punjab were recruited for the pilot through community health workers. Sociodemographic data were collected at baseline. Intervention feasibility and acceptability were assessed through weekly participant check-ins (N=29), weekly moderator reports, structured end-line in-depth interviews among a subgroup of participants (15/29, 52%), and back-end technology data.

RESULTS

The participants were aged 24 to 28 years and 1 to 3 months postpartum. Of the 29 participants, 17 (59%) had their own phones. Half of the participants (14/29, 48%) attended ≥3 of the 6 calls; the main barriers were childcare and household responsibilities and network or phone issues. Most participants were very satisfied with the intervention (16/19, 84%) and found the educational content (20/20, 100%) and group discussions (17/20, 85%) very useful. The participants used the SMS text messaging chat, particularly when facilitator-moderated. Sustaining participation and fostering group interactions was limited by technological and sociocultural challenges.

CONCLUSIONS

The intervention was considered generally feasible and acceptable, and protocol adjustments were identified to improve intervention delivery and engagement. To address technological issues, we engaged a cloud-based service provider for group calls and an interactive voice response service provider for educational recordings and developed a smartphone app for the participants. We seek to overcome sociocultural challenges through new strategies for increasing group engagement, including targeting midlevel female community health care providers as moderators. Our second pilot will assess intervention feasibility, acceptability, and preliminary effectiveness at 6 months. Ultimately, we seek to support the health and well-being of postpartum women and their infants in South Asia and beyond through the development of efficient, acceptable, and effective intervention strategies.

Transforming women’s and providers’ experience of care for improved outcomes: A theory of change for group antenatal care in Kenya and Nigeria

Background

Group antenatal care (G-ANC) is a promising model for improving quality of maternal care and outcomes in low- and middle-income countries (LMICs) but little has been published examining the mechanisms by which it may contribute to those improvements. Substantial interplay can be expected between pregnant women and providers’ respective experiences of care, but most studies report findings separately. This study explores the experience and effects of G-ANC on both women and providers to inform an integrated theory of change for G-ANC in LMICs.

Methods

This paper reports on multiple secondary outcomes from a pragmatic cluster randomized controlled trial of group antenatal care in Kenya and Nigeria conducted from October 2016—November 2018 including 20 clusters per country. We collected qualitative data from providers and women providing or receiving group antenatal care via focus group discussions (19 with women; 4 with providers) and semi-structured interviews (42 with women; 4 with providers). Quantitative data were collected via surveys administered to 1) providers in the intervention arm at enrollment and after facilitating 4 cohorts and 2) women in both study arms at enrollment; 3–6 weeks postpartum; and 1 year postpartum. Through an iterative approach with framework analysis, we explored the interactions of voiced experience and perceived effects of care and placed them relationally within a theory of change. Selected variables from baseline and final surveys were analyzed to examine applicability of the theory to all study participants.

Results

Findings support seven inter-related themes. Three themes relate to the shared experience of care of women and providers: forming supportive relationships and open communication; becoming empowered partners in learning and care; and providing and receiving meaningful clinical services and information. Four themes relate to effects of that experience, which are not universally shared: self-reinforcing cycles of more and better care; linked improvements in health knowledge, confidence, and healthy behaviors; improved communication, support, and care beyond G-ANC meetings; and motivation to continue providing G-ANC. Together these themes map to a theory of change which centers the shared experience of care for women and providers among multiple pathways to improved outcomes.

Discussion

The reported experience and effects of G-ANC on women and providers are consistent with other studies in LMICs. This study is novel because it uses the themes to present a theory of change for G-ANC in low-resource settings. It is useful for G-ANC implementation to inform model development, test adaptations, and continue exploring mechanisms of action in future research.

Risk of Adverse Birth Outcomes in Two Cohorts of Pregnant Women With HIV in Zambia

BACKGROUND

A trial of progesterone to prevent preterm birth among HIV-infected Zambian women [Improving Pregnancy Outcomes with Progesterone (IPOP)] found no treatment effect, but the risk of the primary outcome was among the lowest ever documented in women with HIV. In this secondary analysis, we compare the risks of preterm birth (<37 weeks), stillbirth, and a composite primary outcome comprising the two in IPOP versus an observational pregnancy cohort [Zambian Preterm Birth Prevention Study (ZAPPS)] in Zambia, to evaluate reasons for the low risk in IPOP.

METHODS

Both studies enrolled women before 24 gestational weeks, during August 2015-September 2017 (ZAPPS) and February 2018-January 2020 (IPOP). We used linear probability and log-binomial regression to estimate risk differences and risk ratios (RR), before and after restriction and standardization with inverse probability weights.

RESULTS

The unadjusted risk of composite outcome was 18% in ZAPPS (N = 1450) and 9% in IPOP (N = 791) (RR = 2.0; 95% CI = 1.6, 2.6). After restricting and standardizing the ZAPPS cohort to the distribution of IPOP baseline characteristics, the risk remained higher in ZAPPS (RR = 1.6; 95% CI = 1.0, 2.4). The lower risk of preterm/stillbirth in IPOP was only partially explained by measured risk factors.

CONCLUSIONS

Possible benefits in IPOP of additional monetary reimbursement, more frequent visits, and group-based care warrant further investigation.

Scoping review of maternal and newborn health interventions and programmes in Nigeria

OBJECTIVE

To systematically scope and map research regarding interventions, programmes or strategies to improve maternal and newborn health (MNH) in Nigeria.

DESIGN

Scoping review.

DATA SOURCES AND ELIGIBILITY CRITERIA

Systematic searches were conducted from 1 June to 22 July 2020 in PubMed, Embase, Scopus, together with a search of the grey literature. Publications presenting interventions and programmes to improve maternal or newborn health or both in Nigeria were included.

DATA EXTRACTION AND ANALYSIS

The data extracted included source and year of publication, geographical setting, study design, target population(s), type of intervention/programme, reported outcomes and any reported facilitators or barriers. Data analysis involved descriptive numerical summaries and qualitative content analysis. We summarised the evidence using a framework combining WHO recommendations for MNH, the continuum of care and the social determinants of health frameworks to identify gaps where further research and action may be needed.

RESULTS

A total of 80 publications were included in this review. Most interventions (71%) were aligned with WHO recommendations, and half (n=40) targeted the pregnancy and childbirth stages of the continuum of care. Most of the programmes (n=74) examined the intermediate social determinants of maternal health related to health system factors within health facilities, with only a few interventions aimed at structural social determinants. An integrated approach to implementation and funding constraints were among factors reported as facilitators and barriers, respectively.

CONCLUSION

Using an integrated framework, we found most MNH interventions in Nigeria were aligned with the WHO recommendations and focused on the intermediate social determinants of health within health facilities. We determined a paucity of research on interventions targeting the structural social determinants and community-based approaches, and limited attention to pre-pregnancy interventions. To accelerate progress towards the sustainable development goal MNH targets, greater focus on implementing interventions and measuring context-specific challenges beyond the health facility is required.

Adolescents' experiences with group antenatal care: Insights from a mixed-methods study in Senegal

OBJECTIVES

Group antenatal care (G-ANC) is an innovative model in which antenatal care is delivered to a group of 8-12 women of similar gestational age. Evidence from high-income countries suggests G-ANC is particularly effective for women from marginalised populations, including adolescents. The objective of this study was to examine the experiences of Senegalese adolescents engaged in group antenatal care.

METHODS

This convergent parallel mixed-methods study is derived from a larger effectiveness-implementation hybrid pilot study conducted in Kaolack district, Senegal. Quantitative data for adolescent participants were collected through baseline and postnatal surveys and descriptively analysed. One-on-one interviews and focus-group discussions were conducted with adolescent participants, and qualitative data were analysed using qualitative descriptive analysis.

RESULTS

Forty-five adolescents aged 15-19 participated in G-ANC, with a median age of 18 years. The majority (93.3%) were married, and 64.4% were nulliparous. Findings indicated similar levels of G-ANC participation for adolescent and adult women. The majority (93.1%) of participants who had previously attended individual ANC indicated they would prefer G-ANC to individual care for a future pregnancy. Qualitative findings indicated key facets of consideration relevant to G-ANC for adolescents include social connectedness, the influence of social norms and the opportunity for engagement in healthcare.

CONCLUSIONS

This study suggests that G-ANC has the potential to be an adolescent-responsive and culturally appropriate method of delivering antenatal care in Senegal.

Weekly 17 alpha-hydroxyprogesterone caproate to prevent preterm birth among women living with HIV: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Women with HIV face an increased risk of preterm birth. 17 alpha-hydroxyprogesterone caproate (17P) has been shown in some trials to reduce early delivery among women with a history of spontaneous preterm birth. We investigated whether 17P would reduce this risk among women with HIV.

METHODS

We did a randomised, double-blind, placebo-controlled trial in pregnant women with HIV at the University Teaching Hospital and Kamwala District Health Centre in Lusaka, Zambia. Eligible patients were women aged 18 years or older with confirmed HIV-1 infection, viable intrauterine singleton pregnancy at less than 24 weeks of gestation, and were receiving or intending to commence antiretroviral therapy during pregnancy. Exclusion criteria were major uterine or fetal anomaly; planned or in situ cervical cerclage; evidence of threatened miscarriage, preterm labour, or ruptured membranes at screening; medical contraindication to 17P; previous participation in the trial; or history of spontaneous preterm birth. Eligible participants provided written informed consent and were randomly assigned (1:1) to receive 250 mg intramuscular 17P or placebo once per week, starting between 16 and 24 weeks of gestation until delivery, stillbirth, or reaching term (37 weeks). Participants and study staff were masked to assignment, except for pharmacy staff who did random assignment and prepared injections but did not interact with participants. The primary outcome was a composite of delivery before 37 weeks or stillbirth at any gestational age. Patients attended weekly visits for study drug injections and antenatal care. We estimated the absolute and relative difference in risk of the primary outcome and safety events between treatment groups by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03297216, and is complete.

FINDINGS

Between Feb 7, 2018 and Jan 13, 2020, we assessed 1042 women for inclusion into the study. 242 women were excluded after additional assessments, and 800 eligible patients were enrolled and randomly assigned to receive intramuscular 17P (n=399) or placebo (n=401). Baseline characteristics were similar between groups. Adherence to study drug injections was 98% in both groups, no patients were lost to follow-up, and the final post-partum visit was on Aug 6, 2020. 36 (9%) of 399 participants assigned to 17P had preterm birth or stillbirth, compared with 36 (9%) of 401 patients assigned to placebo (risk difference 0·1, 95% CI -3·9 to 4·0; relative risk 1·0, 95% CI 0·6 to 1·6; p=0·98). Intervention-related adverse events were reported by 140 (18%) of 800 participants and occurred in similar proportions in both randomisation groups. No serious adverse events were reported.

INTERPRETATION

Although 17P seems to be safe and acceptable to participants, available data do not support the use of the drug to prevent preterm birth among women whose risk derives solely from HIV infection. The low risk of preterm birth in both randomisation groups warrants further investigation.

FUNDING

US National Institutes of Health and the Bill and Melinda Gates Foundation.

A systematic review of providers' experiences of facilitating group antenatal care

Background

Group antenatal care is a rapidly expanding alternative antenatal care delivery model. Research has shown it to be a safe and effective care model for women, but less is known about the perspectives of the providers leading this care. This systematic review examined published literature that considered health care professionals’ experiences of facilitating group antenatal care.

Methods

Systematic searches were conducted in seven databases (Cinahl, Medline, Psychinfo, Embase, Ovid Emcare, Global Health and MIDRS) in April 2020. Qualitative or mixed methods studies with a significant qualitative component were eligible for inclusion if they included a focus on the experiences of health care providers who had facilitated group antenatal care. Prisma screening guidelines were followed and study quality was critically appraised by three independent reviewers. The findings were synthesised thematically.

Results

Nineteen papers from nine countries were included. Three main themes emerged within provider experiences of group antenatal care. The first theme, ‘Giving women the care providers feel they want and need’, addresses richer use of time, more personal care, more support, and continuity of care. The second theme, ‘Building skills and relationships’, highlights autonomy, role development and hierarchy dissolution. The final theme, ‘Value proposition of group antenatal care’, discusses provider investment and workload.

Conclusions

Health care providers’ experience of delivering group antenatal care was positive overall. Opportunities to deliver high-quality care that benefits women and allows providers to develop their professional role were appreciated. Questions about the providers’ perspectives on workload, task shifting, and the structural changes needed to support the sustainability of group antenatal care warrant further exploration.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01200-0.

Receiving antenatal care in a group setting has been found to be safe and satisfying for women and is supported by international public health guidelines. However, questions remain about the experience of health care professionals tasked with providing this model, such as whether they like working in this model and whether they support its expansion. To answer these questions, the team searched for studies about the experiences of health care providers with group antenatal care, and only included those studies where providers themselves spoke about their own experiences of providing this kind of care. Our review demonstrated that midwives, doctors, nurses and community health workers mostly enjoyed facilitating group antenatal care. They particularly appreciated the ability to give women the kind of care they felt women want and need. Health care providers also experienced some changes in their professional roles, in relation to both the women they serve and their colleagues and organizations. In order to determine if group antenatal care models are a satisfying and sustainable option for health care professionals in the long term, more research is needed.

Postpartum care content and delivery throughout the African continent: An integrative review

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.

Associations between Prenatal Education, Breastfeeding and Autistic-Like Behaviors in Pre-Schoolers

This study aimed to investigate the association between prenatal education and autistic-like behaviors of preschoolers as well as the mediating role of breastfeeding in their associations. A cross-sectional study via a structured questionnaire was conducted with 67,578 preschool children and parents from Longhua District of Shenzhen, China. Hierarchical logistic regression models were performed to explore the associations between maternal participation in prenatal education and autistic-like behaviors in preschoolers, as well as the mediating effect of breastfeeding in the associations. After controlling for potential confounders, logistic regression analysis indicated that maternal participation in prenatal education could significantly increase the prevalence of breastfeeding, and the strength of the association was enhanced with the increase frequency of prenatal education visits (ORs ranging from 1.191 to 1.899). While both maternal participation in prenatal education (ORs ranging from 0.732 to 0.798) and breastfeeding (OR = 0.773) were significantly associated with the lower presence of autistic-like behaviors in preschoolers. The crossover analysis indicated that children with both maternal prenatal education and breastfeeding had the lower risk of presence of autistics-like behaviors (OR = 0.569). Furthermore, mediation analysis illustrated that breastfeeding mediated the association between maternal participation in prenatal education and the presence of autistic-like behaviors in preschoolers, with a mediating effect of approximately 14.3%. Our findings suggest that maternal participation in prenatal education is significantly associated with a decreased risk of autistic-like behaviors in preschool children through increased breastfeeding in the mothers who attended prenatal education.

HIV-Adapted Group Prenatal Care: Assessing Viral Suppression and Postpartum Retention in Care

Viral suppression and postpartum retention in care have far-reaching health implications for pregnant women living with HIV and their children, yet remain public health challenges. Prenatal care presents a unique opportunity to engage pregnant women in care. The purpose of this study is to evaluate whether group prenatal care is effective in impacting these outcomes for pregnant women living with HIV. A retrospective cohort study was performed of all women living with HIV who obtained prenatal care from a community-based health center between 2013 and 2019. Women who spoke English or Spanish, remained within the system, and had not participated in group prenatal care previously were included. Women self-selected a prenatal care model: 85 selected group care and 109 elected individual care. Group prenatal care followed a standard Centering Pregnancy^® curriculum with the addition of HIV-related topics. The primary outcomes of the study were viral suppression (viral load <20 copies/mL) and postpartum retention in care (attending at least one or two visits with HIV primary care within 12 months postpartum). After adjusting for potential confounding factors, women who participated in group prenatal care were significantly more likely to have at least one HIV primary care visit postpartum {adjusted odds ratio (aOR) = 2.71 [95% confidence interval (CI 1.14-6.46)]; p = 0.024}, and had a trend for achieving viral suppression by the time of delivery [aOR = 2.29 (95% CI 0.94-5.55); p = 0.068]. We have demonstrated that group prenatal care for pregnant women living with HIV is feasible and effective, with positive impacts on retention in care and viral suppression, factors that affect long-term outcomes from patients living with HIV.

Impact of group prenatal care on key prenatal services and educational topics in Malawi and Tanzania

OBJECTIVE

To examine whether group prenatal care (PNC) increased key services and educational topics women reported receiving, compared with individual PNC in Malawi and Tanzania.

METHODS

Data come from a previously published randomized trial (n=218) and were collected using self-report surveys. Late pregnancy surveys asked whether women received all seven services and all 13 topics during PNC. Controlling for sociodemographics, country, and PNC attendance, multivariate logistic regression used forward selection to produce a final model showing predictors of receipt of all key services and topics.

RESULTS

In multivariate logistic regression, women in group PNC were 2.49 times more likely to receive all seven services than those in individual care (95% confidence interval [CI] 1.78-3.48) and 5.25 times more likely to have received all 13 topics (95% CI 2.62-10.52).

CONCLUSION

This study provides strong evidence that group PNC meets the clinical standard of care for providing basic clinical services and perinatal education for pregnant women in sub-Saharan Africa. The greater number of basic PNC services and educational topics may provide one explanatory mechanism for how group PNC achieves its impact on maternal and neonatal outcomes. ClinicalTrials.gov: NCT03673709, NCT02999334.

An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi

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.

Impact of group antenatal care (G-ANC) versus individual antenatal care (ANC) on quality of care, ANC attendance and facility-based delivery: A pragmatic cluster-randomized controlled trial in Kenya and Nigeria

Background

Low quality and frequency of antenatal care (ANC) are associated with lower uptake of facility-based deliveries—a key intervention to reduce maternal and neonatal mortality. We implemented group ANC (G-ANC), an alternative service delivery model, in Kenya and Nigeria, to assess its impact on quality and attendance at ANC and uptake of facility-based delivery.

Methods

From October 2016‒January 2018, we conducted a facility-based, pragmatic, cluster-randomized controlled trial with 20 clusters per country. We recruited women <24 weeks gestation during their first ANC visit and enrolled women at intervention facilities who agreed to attend G-ANC in lieu of routine individual ANC. The G-ANC model consisted of five monthly 2-hour meetings with clinical assessments alongside structured gestationally specific group discussions and activities. Quality of care was defined as receipt of eight specific ANC interventions. Data were obtained through facility records and self-report during a home-based postpartum survey. Analysis was by intention to treat.

Findings

All women who completed follow up are included in the analysis (Nigeria: 1018/1075 enrolled women [94.7%], Kenya: 826/1013 [81.5%]). In Nigeria women in the intervention arm were more likely to have a facility-based delivery compared to those in the control arm (Nigeria: 76.7% [391/510] versus 54.1% [275/508]; aOR 2.30, CI 1.51–3.49). In both countries women in the intervention arm were more likely than those in the control arm to receive quality ANC (Nigeria: aOR 5.8, CI 1.98–17.21, p<0.001; Kenya: aOR 5.08, CI 2.31–11.16, p<0.001) and to attend at least four ANC visits (Nigeria: aOR 13.30, CI 7.69–22.99, p<0.001; Kenya: aOR 7.12, CI 3.91–12.97, p<0.001).

Conclusions

G-ANC was associated with higher facility-based delivery rates in Nigeria, where those rates associated with individual ANC were low. In both Kenya and Nigeria it was associated with a higher proportion of women receiving quality ANC and higher frequency of ANC visits.

Group versus individual antenatal and first year postpartum care: Study protocol for a multi-country cluster randomized controlled trial in Kenya and Nigeria

Background: Antenatal care (ANC) in many low- and middle-income countries is under-utilized and of sub-optimal quality. Group ANC (G-ANC) is an intervention designed to improve the experience and provision of ANC for groups of women (cohorts) at similar stages of pregnancy. Methods: A two-arm, two-phase, cluster randomized controlled trial (cRCT) (non-blinded) is being conducted in Kenya and Nigeria. Public health facilities were matched and randomized to either standard individual ANC (control) or G-ANC (intervention) prior to enrollment. Participants include pregnant women attending first ANC at gestational age <24 weeks, health care providers, and sub-national health managers. Enrollment ended in June 2017 for both countries. In the intervention arm, pregnant women are assigned to cohorts at first ANC visit and receive subsequent care together during five meetings facilitated by a health care provider (Phase 1). After birth, the same cohorts meet four times over 12 months with their babies (Phase 2). Data collection was performed through surveys, clinical data extraction, focus group discussions, and in-depth interviews. Phase 1 data collection ended in January 2018 and Phase 2 concludes in November 2018. Intention-to-treat analysis will be used to evaluate primary outcomes for Phases 1 and 2: health facility delivery and use of a modern method of family planning at 12 months postpartum, respectively. Data analysis and reporting of results will be consistent with norms for cRCTs. General estimating equation models that account for clustering will be employed for primary outcome analyzes. Results: Overall 1,075 and 1,013 pregnant women were enrolled in Nigeria and Kenya, respectively. Final study results will be available in February 2019. Conclusions: This is the first cRCT on G-ANC in Africa. It is among the first to examine the effects of continuing group care through the first year postpartum. Registration: Pan African Clinical Trials Registry PACTR201706002254227 May 02, 2017.

Group versus individual antenatal and first year postpartum care: Study protocol for a multi-country cluster randomized controlled trial in Kenya and Nigeria

Background: Antenatal care (ANC) in many low- and middle-income countries is under-utilized and of sub-optimal quality. Group ANC (G-ANC) is an intervention designed to improve the experience and provision of ANC for groups of women (cohorts) at similar stages of pregnancy. Methods: A two-arm, two-phase, cluster randomized controlled trial (cRCT) (non-blinded) is being conducted in Kenya and Nigeria. Public health facilities were matched and randomized to either standard individual ANC (control) or G-ANC (intervention) prior to enrollment. Participants include pregnant women attending first ANC at gestational age <24 weeks, health care providers, and sub-national health managers. Enrollment ended in June 2017 for both countries. In the intervention arm, pregnant women are assigned to cohorts at first ANC visit and receive subsequent care together during five meetings facilitated by a health care provider (Phase 1). After birth, the same cohorts meet four times over 12 months with their babies (Phase 2). Data collection was performed through surveys, clinical data extraction, focus group discussions, and in-depth interviews. Phase 1 data collection ended in January 2018 and Phase 2 concludes in November 2018. Intention-to-treat analysis will be used to evaluate primary outcomes for Phases 1 and 2: health facility delivery and use of a modern method of family planning at 12 months postpartum, respectively. Data analysis and reporting of results will be consistent with norms for cRCTs. General estimating equation models that account for clustering will be employed for primary outcome analyzes. Results: Overall 1,075 and 1,013 pregnant women were enrolled in Nigeria and Kenya, respectively. Final study results will be available in February 2019. Conclusions: This is the first cRCT on G-ANC in Africa. It is among the first to examine the effects of continuing group care through the first year postpartum. Registration: Pan African Clinical Trials Registry PACTR201706002254227 May 02, 2017.

Mental health and worries of pregnant women living through disaster recovery

The health and well-being of pregnant women during and after natural disasters remains an international concern. In this mixed methods study we described pregnant women's mental health, psychosocial concerns and sources of stress living in New Orleans during long term recovery from Hurricane Katrina. Our survey of 402 pregnant women indicated poor social support was associated with higher levels of depression symptomology, post-traumatic stress disorder, anxiety, and stress. Women were interviewed and described seven common areas of worry. We concluded that pregnant women living in post-disaster communities have stressful lives years after the event, needing innovative models of care to build resilience.