Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda

Butrick, Elizabeth; Lundeen, Tiffany; Phillips, Beth; Tengera, Olive; Kambogo, Antoinette; Uwera, Yvonne Delphine Nsaba; Musabyimana, Angèle; Sayinzoga, Félix; Nzeyimana, David; Murindahabi, Nathalie Kayiramirwa; Musange, Sabine; Walker, Dilys

doi:10.12688/gatesopenres.13090.1

Cited by 2 publications

(9 citation statements)

References 12 publications

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“…Without additional human resources to manage these challenges, antenatal care providers had to balance their enthusiasm for the group antenatal care model with the burden of additional tasks. We report in a separate publication that the group antenatal care model was delivered at approximately 80% fidelity across more than 2,600 documented visits [ 15 ]. The lowest-rated fidelity outcome was keeping to the intended time frame for each group visit, which was related to antenatal care staff being called to other services, especially labor and birth, when facilities were short-staffed.…”

Section: Discussionmentioning

confidence: 99%

“…This article reports the primary and secondary outcomes of this cluster RCT, including gestational length, mortality among preterm neonates, attendance at four antenatal care visits, attendance at the first antenatal care visit before 14 completed weeks gestation, attendance at a six-week postnatal care visit at a health center, identification of women as at high risk at any antenatal care visit, and caesarean section rates among enrolled women. Results of other outcomes, including women's and providers' experiences of group antenatal care, are reported elsewhere [13][14][15].…”

Section: Objectivesmentioning

confidence: 99%

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Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial

et al. 2021

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Background Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success. Methods We studied the effect of group antenatal care on gestational age at birth among women in Rwanda, hypothesizing that participation would increase mean gestational length. For this unblinded cluster randomized trial, 36 health centers were pair-matched and randomized; half continued individual antenatal care (control), half implemented group antenatal care (intervention). Women who initiated antenatal care between May 2017 and December 2018 were invited to participate, and included in analyses if they presented before 24 weeks gestation, attended at least two visits, and their birth outcome was obtained. We used a generalized estimating equations model for analysis. Findings In total, 4091 women in 18 control clusters and 4752 women in 18 intervention clusters were included in the analysis. On average, women attended three total antenatal care visits. Gestational length was equivalent in the intervention and control groups (39.3 weeks (SD 1.6) and 39.3 weeks (SD 1.5)). There were no significant differences between groups in secondary outcomes except that more women in control sites attended postnatal care visits (40.1% versus 29.7%, p = 0.003) and more women in intervention sites attended at least three total antenatal care visits (80.7% versus 71.7%, p = 0.003). No harms were observed. Interpretation Group antenatal care did not result in a difference in gestational length between groups. This may be due to the low intervention dose. We suggest studies of both the effectiveness and costs of higher doses of group antenatal care among women at higher risk of preterm birth. We observed threats to group care due to facility staff shortages; we recommend studies in which antenatal care providers are exclusively allocated to group antenatal care during visits. Trial registration ClinicalTrials.gov NCT03154177

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Section: Discussionmentioning

confidence: 99%

Section: Objectivesmentioning

confidence: 99%

Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial

et al. 2021

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“…Group ANC implementation fidelity in low and upper middle income countries has only been measured in four other studies, in Malawi and Tanzania, Rwanda, Nepal, and Mexico [10,[25][26][27][28]. At the time of this study, there is an active randomized clinical trial in Malawi measuring the degree of implementation success and associated contextual factors [29].…”

Section: Plos Onementioning

confidence: 99%

“…25% of group care visits were not implemented with fidelity to the intended two hour session, lasting more than two hours [10]. The tool analyzed in the previous study included two distinct open-ended questions for how much time was spent conducting health assessments and on group discussion.…”

Section: Plos Onementioning

confidence: 99%

“…The Preterm Birth Initiative (PTBi)–Rwanda conducted a cluster randomized controlled trial of 36 health centers, using a standardized tool to assess number of providers, ANC volume, suitable space for group care, services, and equipment [ 10 ]. Eighteen health centers were randomized to receive group ANC while 18 health centers continued to provide individual ANC.…”

Section: Introductionmentioning

confidence: 99%

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Utilizing a mixed-methods approach to assess implementation fidelity of a group antenatal care trial in Rwanda

Singh¹,

Murindahabi²,

Butrick³

et al. 2023

PLoS ONE

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Background The Preterm Birth Initiative (PTBi)–Rwanda conducted a cluster randomized controlled trial to assess the impact of group antenatal care (group ANC) on preterm birth, using a group ANC approach adapted for the Rwanda setting, and implemented in 18 health centers. Previous research showed high overall fidelity of implementation, but lacked correlation with provider self-assessment and left unanswered questions. This study utilizes a mixed-methods approach to study the fidelity with which the health centers’ implementation followed the model specified for group ANC. Methods Implementation fidelity was measured using two tools, repeated Model Fidelity Assessments (MFAs) and Activity Reports (ARs) completed by Master Trainers, who visited each health center between 7 and 13 times (9 on average) to provide monitoring and training over 18 months between 2017 and 2019. Each center’s MFA item and overall scores were regressed (linear regression) on the time elapsed since the center’s start of implementation. The Activity Report (AR) is an open-ended template to record comments on implementation. For the qualitative analysis, the ARs from the times of each center’s highest and lowest MFA score were analyzed using thematic analysis. Coding was conducted via Dedoose, with two coders independently reviewing and coding transcripts, followed by joint consensus coding. Results A total of 160 MFA reports were included in the analysis. There was a significant positive association between elapsed time since a health center started implementation and greater implementation fidelity (as measured by MFA scores). In the qualitative AR analysis, Master Trainers identified key areas to improve fidelity of implementation, including: group ANC scheduling, preparing the room for group ANC sessions, provider capacity to co-facilitate group ANC, and facilitator knowledge and skills regarding group ANC content and process. These results reveal that monitoring visits are an important part of acquisition and fidelity of the “soft skills” required to effectively implement group ANC and provide an understanding of the elements that may have impacted fidelity as described by Master Trainers. Conclusions For interventions like Group ANC, where “soft-skills” like group facilitation are important, we recommend continuous monitoring and mentoring throughout program implementation to strengthen these new skills, provide corrective feedback and guard against skills decay. We suggest the use of quantitative tools to provide direct measures of implementation fidelity over time and qualitative tools to gain a more complete understanding of what factors influence implementation fidelity. Identifying areas of implementation requiring additional support and mentoring may ensure effective translation of evidence-based interventions into real-world settings.

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Model fidelity of group antenatal and postnatal care: a process analysis of the first implementation of this innovative service model by the Preterm Birth Initiative-Rwanda

Cited by 2 publications

References 12 publications

Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial

Assessing the impact of group antenatal care on gestational length in Rwanda: A cluster-randomized trial

Utilizing a mixed-methods approach to assess implementation fidelity of a group antenatal care trial in Rwanda

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