Sheela Maru | October 2015
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Presentation at the Global Maternal Newborn Health Conference, October 21, 2015

Background: Drawing from programs that have improved maternal and neonatal outcomes, we designed a group antenatal care (ANC) program that creates social support and incorporates participatory action to engage women in rural Nepal in overcoming barriers to healthcare access. Women receive ANC in 2-hour group sessions co-facilitated by government midwives and community health workers (CHWs). Our program aims to increase institutional birth via improving health knowledge, self-efficacy, social support, and birth planning.

Methodology: We ran 22 ANC groups in 6 village clusters from August-March 2014-15. We conducted routine observation, informal interviews with participants and CHWs, a focus group with midwives, and government meetings. We will study the program as a prospective non-randomized-controlled trial in 14 clusters from April-September 2015 using birth outcomes data, pre/post participant surveys, and qualitative methods.

Results: We found generally positive attitudes toward the program among all, but limited understanding of participatory action goals. Participants emphasized the groups’ fun, supportive aspects, and enjoyed more time with providers. CHWs enjoyed facilitating but some found collaboration with midwives difficult. Midwives appreciated the time-saving nature of groups, but found schedules conflicted with other responsibilities. Implementation challenges included scheduling logistics, poor documentation, variable facilitator performance, equivocal government support, and inadequate referral systems for high-risk patients. To improve the program prior to the trial, we: simplified scheduling, resulting in more fluidity in group composition; focused participatory action on birth planning; and increased supervision and coaching of facilitators.

Conclusion: Group ANC is acceptable and preferred by women in our area of rural Nepal, and may improve birth planning through stronger patient-provider and patient-patient relationships. However, implementation is challenging and requires significant practice shifts for under-supported providers. The program also revealed health system weaknesses, particularly around documentation, high-risk patient management and referrals. We acknowledge that group ANC will require integrated ANC-strengthening efforts to succeed.