Group Antenatal Care: A Paradigm Shift to Explore for Positive Impacts in Resource-poor Settings

Qualitative evaluation of a package of implementation strategies codesigned to support the introduction of multiple micronutrient supplementation (MMS) for pregnant women in Bamako, Mali

Mali national policy recommends that women take iron and folic acid supplements (IFA) from the time of the first antenatal care (ANC) visit, throughout pregnancy and during the first 3 months after delivery. In 2020, the World Health Organization (WHO) updated their ANC guidelines to recommend the United Nations International Multiple Micronutrient Antenatal Preparation (UNIMMAP) formulation of multiple micronutrient supplements (MMS) in the context of rigorous research, including implementation research. In Bamako, Mali, a codesign process was used to tailor antenatal care MMS packaging and counselling materials aimed at optimizing delivery and uptake of and adherence to MMS. This paper presents the codesign process along with the results of a post-intervention qualitative assessment to evaluate the behaviour change intervention. At the conclusion of the intervention, we conducted semistructured qualitative interviews with 24 women who had received the intervention and six pharmacy managers from the six health centres participating in the study. We conducted two focus groups with midwives who had delivered the intervention and two group discussions with family members of women who had received the intervention. Respondent perspectives reveal an easy experience transitioning from previously used IFA. Women and providers concur that the intervention counselling materials and visual aids were instrumental in influencing the perceived benefit and uptake of MMS. Family members play an influential role in pregnant women's decision-making regarding MMS uptake. MMS and the associated implementation strategies developed through the codesign process were found to be a highly acceptable intervention.

Effect of group antenatal care versus individualized antenatal care on birth preparedness and complication readiness: a cluster randomized controlled study among pregnant women in Eastern Region of Ghana

BACKGROUND

As utilization of individual antenatal care (I-ANC) has increased throughout sub-Saharan Africa, questions have arisen about whether individual versus group-based care might yield better outcomes. We implemented a trial of group-based antenatal care (G-ANC) to determine its impact on birth preparedness and complication readiness (BPCR) among pregnant women in Ghana.

METHODS

We conducted a cluster randomized controlled trial comparing G-ANC to routine antenatal care in 14 health facilities in the Eastern Region of Ghana. We recruited women in their first trimester to participate in eight two-hour interactive group sessions throughout their pregnancies. Meetings were facilitated by midwives trained in G-ANC methods, and clinical assessments were conducted in addition to group discussions and activities. Data were collected at five timepoints, and results are presented comparing baseline (T0) to 34 weeks' gestation to 3 weeks post-delivery (T1) for danger sign recognition, an 11-point additive scale of BPCR, as well as individual items comprising the scale.

RESULTS

1285 participants completed T0 and T1 assessments (N = 668 I-ANC, N = 617, G-ANC). At T1, G-ANC participants were able to identify significantly more pregnancy danger signs than I-ANC participants (mean increase from 1.8 to 3.4 in G-ANC vs. 1.7 to 2.2 in I-ANC, p < 0.0001). Overall BPCR scores were significantly greater in the G-ANC group than the I-ANC group. The elements of BPCR that showed the greatest increases included arranging for emergency transport (I-ANC increased from 1.5 to 11.5% vs. G-ANC increasing from 2 to 41% (p < 0.0001)) and saving money for transportation (19-32% in the I-ANC group vs. 19-73% in the G-ANC group (p < 0.0001)). Identifying someone to accompany the woman to the facility rose from 1 to 3% in the I-ANC group vs. 2-20% in the G-ANC group (p < 0.001).

CONCLUSIONS

G-ANC significantly increased BPCR among women in rural Eastern Region of Ghana when compared to routine antenatal care. Given the success of this intervention, future efforts that prioritize the implementation of G-ANC are warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04033003 (25/07/2019).

PROTOCOL AVAILABLE

Protocol Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9508671/ .

WHO antenatal care policy and prevention of malaria in pregnancy in sub-Saharan Africa

BACKGROUND

The WHO 2016 antenatal care (ANC) policy recommends at least eight antenatal contacts during pregnancy. This study assessed ANC8 uptake following policy implementation and explored the relationship between ANC attendance and intermittent preventive treatment in pregnancy (IPTp) coverage in sub-Saharan Africa following the rollout of the World Health Organization (WHO) 2016 ANC policy, specifically, to assess differences in IPTp uptake between women attending eight versus four ANC contacts.

METHODS

A secondary analysis of data from 20 sub-Saharan African countries with available Demographic Health and Malaria Indicator surveys from 2018 to 2023 was performed. The key variables were the number of ANC contacts and IPTp doses received during a participant's last completed pregnancy in the past two years. Pooled crude and multivariable logistic regression models were used to explore factors associated with attendance of at least four or eight ANC contacts as well as receipt of at least three doses of IPTp during pregnancy.

RESULTS

Overall, only a small proportion of women (median = 3.9%) completed eight or more ANC contacts (ANC8 +). Factors significantly associated with increased odds of ANC8 + included early ANC attendance (AOR: 4.61: 95% CI 4.30-4.95), literacy (AOR: 1.20; 95% CI 1.11-1.29), and higher wealth quintile (AOR: 3.03; 95% CI 2.67-3.44). The pooled estimate across all countries showed a very slight increase in the odds of IPTp3 + among women with eight (AOR: 1.06; 95% CI 1.00-1.12) compared to those with four contacts. In all but two countries, having eight instead of four ANC contacts did not confer significantly greater odds of receiving three or more doses of IPTp (IPTp3 +), except in Ghana (AOR: 1.67; 95% CI 1.38-2.04) and Liberia (AOR: 1.43; 95% CI 1.18-1.72).

CONCLUSION

Eight years after the WHO ANC policy recommendation, all countries still had sub-optimal ANC8 + coverage rates. This paper is a call to action to actualize the vision of the WHO and the global malaria community of a malaria free world. Policies to improve ANC and IPTp coverage should be operationalized with clear actionable guidance and local ownership. Study findings can be used to inform multi-level policy, programmatic, and research recommendations to optimize ANC attendance and malaria in pregnancy prevention, thus improving maternal and child health outcomes, including the reduction of malaria in pregnancy.

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Improving health literacy through group antenatal care: results from a cluster randomized controlled trial in Ghana

BACKGROUND

Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC.

METHODS

A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2.

RESULTS

Overall, women in both the intervention and control groups improved their health literacy scores over time (p < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores (p < 0.0001) and were more likely to attend 8 or more ANC visits.

CONCLUSION

While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes.

TRIAL REGISTRY

Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

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.