Antenatal care (ANC) provided by a skilled health professional is a key opportunity to address maternal and perinatal mortality/morbidity through the delivery of crucial health services during pregnancy. In Rwanda, as with many other settings, standard ANC involves one-on-one provider-to-client interactions, often with long wait times and short visits with providers. Despite low satisfaction and calls to reform care for women during pregnancy, traditional one-on-one ANC remains the standard model worldwide. Low satisfaction may contribute to the fact that only 64% of pregnant women between 2007–2014 globally attended the four ANC visits recommended by the WHO. Group care is an innovative model for providing antenatal care (ANC) delivery that has resulted in health improvements across diverse settings and is associated with a reduction in preterm birth rates among high-risk women in the United States. Inspired by these results and motivated by the aim of improving the experience and quality of ANC to bolster attendance and prevent preterm birth, neonatal mortality, and maternal mortality, the Preterm Birth Initiative – Rwanda (PTBi Rwanda) sought to assess the health outcomes of a group ANC and postnatal care (PNC) model implemented as the standard of care for all pregnant women at select primary health centers in Rwanda.
This study relied on the partnership and collaboration of investigators at the University of Rwanda and the University of California, San Francisco and national health system implementers at the Rwanda Biomedical Centre and the Rwanda Ministry of Health. In addition to these partners, national and local stakeholders and leaders were included in, and contributed to, every step of the development, implementation, and evaluation process. Researchers implemented a cluster-randomized trial in 36 primary health centres across Rwanda between May 2017 and May 2019, examining outcomes of 8,843 women. The researcher’s primary aim was to understand the effects of group ANC, compared to the standard individual ANC model, on prematurity, measured in the study by gestational age (GA) at birth. PTBi-Rwanda partners also studied how community-based urine pregnancy testing by community health workers (CHWs) and basic obstetric ultrasound performed by nurses and midwives at the intake visit, impacted the timing of presentation for ANC and the number of ANC visits attended by each woman. Rwanda’s national health system provided an excellent opportunity to test this service delivery model due to its community capacity, cultural foundations in community-based decision-making and cooperation, and extant, longitudinal ANC registers.
In this context, group ANC delivered at an average dose of 3 group visits does not prevent preterm birth when compared to standard individual ANC. Birth outcomes data for 8,843 mother-baby dyads (4,752 intervention; 4,091 control) revealed that the average GA at birth was 39.3 weeks among women in both the standard and group ANC groups.
- Group care did not lead to statistically significant changes in cesarean section rates, completion of four ANC visits, or ANC initiation before 14 weeks.
- The group model resulted in a statistically significant lower rate of postnatal visit attendance at approximately 6 weeks after birth
- The implementation of community-based urine pregnancy testing and basic obstetric ultrasound had no significant effect on GA at the first ANC visit or attendance of 4 ANC visits Group ANC improved the experience of care and was the preferred form of ANC delivery for both providers and patients in Rwanda Health center providers reported increased satisfaction with their work and strengthened relationships with their patients, CHWs described an increased interest in providing health services and improved relationships with providers, and women expressed positive reactions to sharing with a group of peers, a newfound comfort in communicating with their providers and increases in health-related knowledge.
Group ANC improved the experience of care and was the preferred form of ANC delivery for both providers and patients in Rwanda
Health centre providers reported increased satisfaction with their work, and strengthened relationships with their patients, CHWs described an increased interest in providing health services and improved relationships with providers, and women expressed positive reactions to sharing with a group of peers, a newfound comfort in communicating with their providers and increases in health-related knowledge.
The group ANC model used in this trial was developed by a Rwandan Technical Working Group based on Rwanda’s four-visit Focused ANC model, and included an initial individual visit, followed by three groups ANC visits and one group postnatal visit. During the development of the Rwanda-specific group ANC model, the Technical Working Group met as a circle of peers and employed group-facilitated discussions in a similar process to the group ANC model implemented. Once the model was developed, a group of Master Trainers was trained in group ANC; this group then trained three ANC providers (nurses and midwives) at each health center randomized to ANC and 12 community health workers (CHWs) specializing in maternity care in each of these health centers’ catchment areas. During the trial, research activities were undertaken by field research coordinators placed at each site, while all clinical work was performed by existing health care staff and/or assisted by CHWs.
In the group care model, 8–12 women of the similar gestational stages in pregnancy attended their last three ANC visits as a group. Visits were scheduled about 8 weeks apart, lasted for 1-2 hours, and were co-facilitated by a maternity care provider and a community health worker who was trained in group care. During the first half of the visit, the women took turns meeting with the health care provider individually and privately, while the rest of the group socialized and performed other health assessment activities on each other (such as measuring blood pressure and weight), with guidance from the CHW. The second half of the group sessions was devoted to a discussion about various pregnancy and parenting health topics amongst the expectant mothers, facilitated by the ANC provider and/or CHW. Group ANC and PNC were integrated into the existing structure of health services delivery, without the addition of any clinical staff.
Researchers learned that there are four crucial considerations that need to be made when studying or implementing group ANC models, particularly in low-resource settings:
- Relationships matter: Experience of care is improved through interconnectedness: The keys to our success were facilitative leadership, group consistency, and the integration of CHWs in group ANC facilitation.
- Group ANC magnified pre-existing structural barriers to ANC delivery: The most significant barriers uncovered in the study were affordability, transportation, support from family and community, scheduling/rigidity, and workforce shortage/organizational structures. We must understand and mitigate these barriers for the optimal success of ANC, specifically group ANC.
- Women may need a higher dose of group ANC: Group ANC benefits may increase with more contacts. A flexible model or mixture of individual and group ANC and PNC visits during the childbearing year may increase attendance and be beneficial to both women and the health system. With WHOs more recent recommendation for 8 ANC contacts, there are many combinations that may be effective and acceptable for women and providers that deserve further exploration.
- Improved measurement is needed to assess the impact of group ANC: A high-quality first-trimester GA assessment is needed to optimally assess outcomes of any intervention on preterm birth rates. Also, strengthening routine measurement for a wide range of ANC-related outcomes will allow for the detection of all benefits of group ANC. The effects of group ANC on populations of women in which a higher-than-average rate of preterm birth is documented should also be studied.
The lack of impact of group ANC on prematurity in the study does not mean that the group ANC model is ineffective. Based on the feedback from providers and patients, group care is a way to prioritize the experience and quality of ANC. Further research on the alternative benefits of group ANC is necessary--especially with respect to maternal mental health, impact on future pregnancies, and cost-effectiveness. It is also important to remove structural barriers that impact both group and individual ANC uptake and delivery, including workforce shortages, transportation difficulties and out-of-pocket costs to access services. Overall, group ANC can improve the experience and quality of care, but further work is needed for it to reach its full potential.
“The group care program has brought the nurses closer to their clients. Before one could see a nurse as someone who is in a very high level, but today we can talk and laugh together in groups. We find that we have freedom; even when a woman has a problem she comes again and asks you. In fact, it is like a friendly relationship between the woman and the nurse. She considers you as a sister rather than a health centre employee.” --Group ANC Provider
“Some mothers who were not yet in the group care...were surprised at seeing the nurse come and sit near me, and then ask me about my health and my child’s health. They eagerly inquired why she was much interested in me only to learn that we got to know each other when she was training us in the group care. Therefore, I found that there is a difference, and this led me to like the program much more and attend it.” --Group ANC participant/client