Amid persistent low coverage and poor quality of antenatal care (ANC) in low- and middle-income countries (LMICs)—and with recent guidelines from the World Health Organization calling for high quality ANC as well as more antenatal contacts—innovative approaches to delivering health care during pregnancy are needed. High quality ANC is not only vital to optimizing health during pregnancy, it also serves as an important touchpoint in the lives of women and families and can promote the use of health services in the future.
Research in high-income countries has shown that compared to the traditional one-on-one model of ANC, group ANC—in which several women, typically of similar gestational age, gather for physical assessment, education, skill-building and peer support—can offer positive health outcomes such as decreases in preterm delivery, increased prenatal knowledge, higher rates of breastfeeding and higher engagement in care. CenteringPregnancy®, the model of group ANC for which the most evidence exists, was established to meet clinical guidelines for ANC in the United States. As such, most of the available evidence on group ANC comes from high-income countries and more research is needed to explore the feasibility, acceptability and effects of group ANC models in LMICs.
A “generic” model of group ANC for low-resource settings
To address this gap in evidence, researchers have begun exploring group ANC models in low-resource settings. A recent systematic review and evidence synthesis by Sharma and colleagues analyzed existing literature on group ANC in LMICs and extracted common attributes of models used to date in such settings. They synthesized descriptive data from group ANC experiences in 16 low and middle-income countries—derived from nine published papers and 10 key informant interviews—to develop a composite “generic” model of group care for LMIC settings. It outlines fundamental components that are consistent across all settings, as well as flexible components that may be adapted based on context. Standard components include providing a physical assessment during the group session, facilitating discussion to cultivate learning and peer support and incorporating self-care activities by women. The “generic” model includes 90-120-minute sessions with a group of 8-12 women of similar gestational age facilitated by the same two leaders (including one health care provider) for the duration of the program. Flexible components, such as the number of sessions and session content, may vary depending on the local guidelines and setting.
As the authors note,
“Several components of the ‘generic’ model aim to empower and support women. For example, engaging in discussion and shared care with other women of similar gestational age helps to normalize the experience of pregnancy and gives women a voice for knowledge sharing and a sense of community for support. The group format also fosters self-efficacy and social support for pregnant woman by creating a forum for participants to build skills and confidence, share experiences and resources and socialize with one another.”
Adapting the model in India: Methods and results
To investigate whether this model would be possible and accepted by community members in an urban low-resource setting, Jolivet and colleagues conducted a feasibility study in Vadodara, a city of around 1.2 million in India, with both providers and beneficiaries. The researchers adapted the model to include four sessions (three antenatal sessions and one postnatal care session) and reflect local clinical care standards. Conducted at three different types of facilities where ANC services are commonly provided—a private maternity hospital, a public health clinic and a community-based mother and child health center—they demonstrated one session of the model to doctors and auxiliary nurse midwives, and to pregnant women and support persons. Focus group discussions, interviews and a survey collected feedback on participants’ perceptions about the group model specifically about the physical assessment, self-assessment (in which women measured their own blood pressure and weight), peer support and education components of the model as well as potential implementation challenges and solutions.
According to the authors,
“Ultimately, both groups of participants saw group ANC as a vehicle for delivering more comprehensive ANC services, improving experiences of care, empowering women to become more active partners and participants in their care, and potentially addressing some current health system challenges.”
Overall, participants reported feeling comfortable with the physical assessment, and providers found the self-assessments to be a “novel idea… [that] helped women pay more attention and develop a feeling of ownership of their health information.” Women were enthusiastic about the model, offering solutions to facilitate its implementation, such as conducting sessions in the afternoons to accommodate women’s schedules and grouping women by common language in addition to gestational age.
Despite some initial skepticism about group participation and engagement, providers found that most women were attentive and more than willing to share information and experiences with the group. Providers also expressed that the group model could meet the goals of high quality ANC while allowing more time for counseling and learning in an interactive format. As one provider reflected, “I could see that they were happy playing games and learning. It is a better way of teaching.”
The findings from these studies can help drive further research testing the effects of group ANC in LMICs. The generic model suggests how researchers and programmers might approach or design group ANC in their own low-resource setting, while the feasibility study is a key step towards making group ANC accessible to women in urban India.
The experiences of group ANC in low-resource settings, while limited, are quite promising. Forthcoming research will provide more insight into the effects of the group care model on coverage of recommended ANC contacts, provision of care, health system efficiency and responsiveness and—notably—women’s experiences of care.
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