Group Antenatal Care in Rwanda: A Master Trainer’s Perspective

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By: Tiffany Lundeen, University of California, San Francisco, East Africa Preterm Birth Initiative ; Yvonne Delphine Nsaba Uwera, University of California, San Francisco, East Africa Preterm Birth Initiative

In 2017, the East Africa Preterm Birth Initiative (PTBi-EA) in Rwanda—a partnership among the University of California, San Francisco, the University of Rwanda, the Ministry of Health and the Rwanda Biomedical Center—launched the largest cluster randomized controlled trial ever conducted on group antenatal care. Results are expected in 2019.

Women discussing nutrition at a group antenatal care session in Kigali, Rwanda. Photo credit: Nicholas Berger, Pinecone Pictures, 2016In group antenatal care, women attend their pregnancy visits at a health facility at regular intervals with the same group of about 10 pregnant peers. The antenatal care provider, usually a nurse or midwife, performs brief but thorough exams behind a privacy screen while the women socialize and help one another check their vital signs. Then, the provider facilitates an hour-long discussion of important pregnancy education topics. Research suggests this model, which offers education and support as well as recommended clinical care, has the potential to improve perinatal outcomes in some populations. For example, African-American women who participate in group antenatal care in the United States demonstrate a significantly reduced risk of preterm birth. Among pregnant adolescents, group care participation has been associated with a decrease in depressive symptoms and increases in breastfeeding and uptake of long-acting reversible contraception in the postnatal period. Other studies of the effects of group antenatal care report improvements in blood sugar control among pregnant women with diabetes, smoking cessation and decreases in rapid repeat pregnancy. The Rwanda-specific group care model includes an individual first antenatal visit, three subsequent group antenatal visits and one group postnatal visit about six weeks after delivery.

In the following interview, Tiffany Lundeen, a midwife on the Preterm Birth Initiative-Rwanda team based at the University of California, San Francisco who led the group care model development process, speaks with Yvonne Delphine Nsaba Uwera, a Rwandan midwife who serves as a master trainer of group care facilitators, about her observations of group care.

T: How did you get involved with group antenatal care in Rwanda?

Y: I was involved with the technical working group that designed the model for Rwanda. Then I went to San Francisco with other midwives for training to become a master trainer. Soon after, our group of six Rwandan master trainers transferred the knowledge of group care to nurses, midwives and community health workers who began providing group care at 18 health centers. Then I began making supportive field visits to observe and mentor the facilitators as they implemented group antenatal and postnatal care.

T: Through this process, how have your ideas about group antenatal care evolved?

Y: When I saw how group care was working in the United States, I wanted to try it in Rwanda. But my question was: Will it work with our culture? We are so private. Are women going to open up and speak and talk to each other and say the truth?  I discovered that even women in the remote villages of Rwanda love the group model and are so comfortable to talk to and advise each other. As a facilitator, you are just there to guide them to give the right information.

T: When you visit the health centers, what do you hear the women saying about group antenatal care?

Y: At the first visit, they are shy, but soon they are like sisters. They often ask why the next appointment can’t be sooner: “Why can’t you put it next month so we can meet again and discuss?” Women love it because it helps them to open up, express themselves and support each other. In one group I observed, the women donated clothes to a group member in need. Another member proposed that the group put in some money every month in case one of them had financial issues after the baby is born. And they made plans to bring food to members who didn’t have family nearby.

T: Do you think women will attend more antenatal care visits because they are enrolled in a group?

Y: Based on seeing women really loving being in group care and asking to come earlier than their next appointment—or women not enrolled asking to join a group – I feel women will come more often because they are feeling really supported by each other. Also, they have fun in the group. They forget [their problems] when they are with the others.

T: Do you think group care providers are able to provide higher quality clinical care than in the traditional antenatal care model?

Y: Yes. In the traditional model, providers see more than 20 women individually per day, and so they have to check the women quickly. But with the group, 8-12 women can get all the valuable information at the same time and then there is still time to examine each woman.

T: After the trial is complete in 2019, what do you hope for the future of group care in Rwanda?

Y: I wish it could be implemented in all the health centers for the benefit of women in Rwanda.

T: What do you think the challenges are to scaling the model in Rwanda?

Y: The challenge will be having enough health care providers, especially in rural areas, and then training them in group care.

T: Is there anything else that you want readers to know about your experience with group care?

Y: Yes, I keep insisting on attention to maternal mental health. Group care helps women feel more confident and comfortable expressing themselves. It empowers women to speak up and talk about their problems and seek help. The group is like a village of women that empowers them during a very vulnerable time, both mentally and physically.

To learn more about PTBi-EA’s group antenatal care trial, view our video.

Photo credit: Women discussing nutrition at a group antenatal care session in Kigali, Rwanda © 2016 Nicholas Berger, Pinecone Pictures

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