Maternal and Newborn Health Unit, Jhpiego, Baltimore, Maryland, United States of America.
Global Programs, Jhpiego, Nairobi, Kenya.
PLoS One. 2022 May 3;17(5):e0265174. doi: 10.1371/journal.pone.0265174. eCollection 2022.
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.
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.
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.
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.
群体产前护理（G-ANC）是改善中低收入国家（LMICs）产妇护理质量和结果的有前途的模式，但很少有研究探讨其可能有助于改善的机制。可以预期孕妇和提供者在各自的护理体验之间会有大量的相互作用，但大多数研究分别报告研究结果。本研究通过探索 G-ANC 对妇女和提供者的经验和影响，为 LMICs 的 G-ANC 综合变革理论提供信息。
本文报告了 2016 年 10 月至 2018 年 11 月在肯尼亚和尼日利亚进行的群体产前护理的实用群组随机对照试验的多项次要结果，每个国家包括 20 个群组。我们通过焦点小组讨论（19 名妇女；4 名提供者）和半结构化访谈（42 名妇女；4 名提供者）从提供或接受群体产前护理的提供者和妇女那里收集定性数据。通过对干预组中的提供者进行的调查收集定量数据，这些提供者在进行了 4 个队列后在入组时和入组后进行了调查；2 项研究臂中的妇女在入组时；产后 3-6 周；和产后 1 年。通过框架分析的迭代方法，我们探讨了护理体验和感知效果的相互作用，并将它们在变革理论中相关地定位。对基线和最终调查的选定变量进行了分析，以检查该理论对所有研究参与者的适用性。
研究结果支持七个相互关联的主题。三个主题与妇女和提供者共同的护理体验有关：形成支持性的关系和开放的沟通；成为学习和护理的赋权伙伴；提供有意义的临床服务和信息。四个主题与该体验的效果有关，这些效果并非普遍存在：更多更好的护理的自我强化循环；健康知识、信心和健康行为的关联改善；超越 G-ANC 会议的沟通、支持和护理改善；以及继续提供 G-ANC 的动力。这些主题共同构成了一个以妇女和提供者的共同护理体验为中心的变革理论，其中包含了改善结果的多种途径。
报告的 G-ANC 对妇女和提供者的经验和效果与其他在 LMICs 中的研究一致。本研究是新颖的，因为它使用这些主题为资源匮乏的环境中的 G-ANC 提出了变革理论。它对 G-ANC 的实施有用，可以为模型开发提供信息，测试适应性，并继续在未来的研究中探索作用机制。
