Background: Group antenatal care has demonstrated promise as a service delivery model that may result in improved outcomes compared to standard antenatal care in socio-demographic populations at disparately high risk for poor perinatal outcomes. Intrigued by results from the United States showing lower preterm birth rates among high-risk women who participate in group antenatal care, partners working together as the Preterm Birth Initiative - Rwanda designed a trial to assess the impact of group antenatal care on gestational age at birth. Methods: This study is a pair-matched cluster randomized controlled trial with four arms. Pairs randomized to group or standard care were further matched with other pairs into quadruples, within which one pair was assigned to implement basic obstetric ultrasound at the health center and early pregnancy testing at the community. At facilities randomized to group care, this will follow the opt-out model of service delivery and individual visits will always be available for those who need or prefer them. The primary outcome of interest is mean gestational age at birth among women who presented for antenatal care before 24 completed weeks of pregnancy and attended more than one antenatal care visit. Secondary outcomes of interest include attendance at antenatal and postnatal care, preterm birth rates, satisfaction of mothers and providers, and feasibility. A convenience sample of women will be recruited to participate in a longitudinal survey in which they will report such indicators as self-reported health-related behaviors and depressive symptoms. Providers will be surveyed about satisfaction and stress. Discussion: This is the largest cluster randomized controlled trial of group antenatal and postnatal care ever conducted, and the first in a low- or middle-income country to examine the effect of this model on gestational age at birth. Trial registration: This study is registered on ClinicalTrials.gov as NCT03154177 May 16, 2017.

Childhood stunting can have negative health, social, and economic outcomes. In 2015, 37.9% of children under the age of five were stunted in Rwanda. This study aimed to understand the risk factors associated with stunting specific to Rwanda in order to inform effective interventions.The analysis found higher odds of stunting among the children of mothers who had no education compared to those with secondary education (OR: 2.1, 95% CI: 1.34-3.36), who did not take sufficient quantities of food during the pregnancy (OR: 1.3, 95% CI: 1.07-1.65) or did not consume a diverse diet during pregnancy (OR: 1.3, 95% CI: 1.12-1.73). Children living in households with two or more children under two years of age (OR: 2.4, 95% CI: 1.35-2.50), born with low birth weight (OR: 2.8, 95 CI: 1.67-4.27), born preterm (OR: 4.1, 95 CI: 1.96-8.70), not consuming animal proteins (OR: 1.7 CI: 1.49-2.02) and not drinking treated water (OR: 1.6, CI: 1.07-2.23) all have higher odds of developing stunting. Children living in households with low dietary diversity also had higher odds of stunting (OR: 2.2 CI: 1.23-3.88).The results of the analysis suggested that women should be educated to modify their feeding behavior. Educating women can potentially influence their decision-making related to antenatal care (ANC) service attendance and to their own as well as their children’s nutrition needs. Appropriate birth spacing should be encouraged. Providing nutritional supplements to mothers at ANC appointments, increasing access to diverse food groups, and providing nutritional care for babies with low birth weight are potential interventions to address the issue of childhood stunting in Rwanda.