Transforming women’s and providers’ experience of care for improved outcomes: A theory of change for group antenatal care in Kenya and Nigeria

Abstract

Background Group antenatal care (G-ANC) is a promising model for improving quality of maternal care and outcomes in low- and middle-income countries (LMICs) but little has been published examining the mechanisms by which it may contribute to those improvements. Substantial interplay can be expected between pregnant women and providers’ respective experiences of care, but most studies report findings separately. This study explores the experience and effects of G-ANC on both women and providers to inform an integrated theory of change for G-ANC in LMICs. Methods This paper reports on multiple secondary outcomes from a pragmatic cluster randomized controlled trial of group antenatal care in Kenya and Nigeria conducted from October 2016—November 2018 including 20 clusters per country. We collected qualitative data from providers and women providing or receiving group antenatal care via focus group discussions (19 with women; 4 with providers) and semi-structured interviews (42 with women; 4 with providers). Quantitative data were collected via surveys administered to 1) providers in the intervention arm at enrollment and after facilitating 4 cohorts and 2) women in both study arms at enrollment; 3–6 weeks postpartum; and 1 year postpartum. Through an iterative approach with framework analysis, we explored the interactions of voiced experience and perceived effects of care and placed them relationally within a theory of change. Selected variables from baseline and final surveys were analyzed to examine applicability of the theory to all study participants. Results Findings support seven inter-related themes. Three themes relate to the shared experience of care of women and providers: forming supportive relationships and open communication; becoming empowered partners in learning and care; and providing and receiving meaningful clinical services and information. Four themes relate to effects of that experience, which are not universally shared: self-reinforcing cycles of more and better care; linked improvements in health knowledge, confidence, and healthy behaviors; improved communication, support, and care beyond G-ANC meetings; and motivation to continue providing G-ANC. Together these themes map to a theory of change which centers the shared experience of care for women and providers among multiple pathways to improved outcomes. Discussion The reported experience and effects of G-ANC on women and providers are consistent with other studies in LMICs. This study is novel because it uses the themes to present a theory of change for G-ANC in low-resource settings. It is useful for G-ANC implementation to inform model development, test adaptations, and continue exploring mechanisms of action in future research.

Development of pregnancy class with husband’s assistance on the outcome of teenage pregnancy

“…The impact of this transformation ultimately reaches not only service providers and women but also their families and communities, thereby improving pregnancy outcomes. 34 The study also shows that antenatal care improves pregnancy outcomes among teenage girls. Understanding adolescent views and experiences about pregnancy and motherhood is important to ensure that antenatal care meets needs.…”

Maternal satisfaction with group care: a systematic review

“…Finally, 18 articles, encompassing data from 20 studies, were included in evidence synthesis. 6 , 7 , 9 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51

Figure 1 Study selection process

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“… 1 In many countries, this model is known as group antenatal care (G-ANC). 2 , 3 , 4 , 5 , 6 There are similar models that share a similar philosophy and derived from the original model, including Connecting Pregnancy, implemented in Canada, 7 Expect With Me, implemented in the United States, 8 Group Based Antenatal Care, implemented in Denmark and Sweden, 9 and Pregnancy Circles implemented in the United Kingdom. 10 …”

Group Care in the first 1000 days: implementation and process evaluation of contextually adapted antenatal and postnatal group care targeting diverse vulnerable populations in high-, middle- and low-resource settings

“…Other important benefits of CBGC, described in qualitative research, include an improved woman-provider experience, enhanced self-care, empowerment, enhanced learning about health behaviours, enriched networks of relationships and increased social support [23]. CBGC has also been shown to raise clinicians' motivation [24][25][26][27] and may provide savings to the health care system [28,29]. Moreover, antenatal CBGC has been shown in some settings to increase women's attendance at antenatal and postnatal visits significantly.…”