Use of a Facilitated Group Process to Design and Implement a Group Antenatal and Postnatal Care Program in Rwanda

Abstract

IntroductionThe government of Rwanda is exploring strategies that may reduce the incidence of prematurity and low birth weight. Large‐scale implementation of group antenatal care (ANC) and postnatal care (PNC) within the context of the Rwanda national health care system is under consideration. To launch a cluster randomized controlled trial of group ANC and PNC in 5 districts in Rwanda, the implementation team needed a customized group care model for this context and trained health care workers to deliver the program.ProcessAdapting the group ANC and group PNC model for the Rwandan context was accomplished through a group process identical to that which is fundamental to group care. A technical working group composed of 10 Rwandan maternal‐child health stakeholders met 3 times over the course of 3 months, for 4 to 8 hours each time. Their objectives were to consider the evidence on group ANC, agree on the priorities and constraints of their ANC delivery system, and ultimately define the content and structure of a combined group ANC and PNC model for implementation in Rwanda. The same group process was employed to train health care workers to act as group ANC facilitators.OutcomesA customized group ANC and PNC model and guidelines for its introduction were developed in the context of a cluster randomized controlled trial in 36 health centers. Descriptions of this model and the implementation plan are included in this article.DiscussionOur experience suggests that the group process fundamental to successful group ANC and PNC is an effective method to customize and implement this innovative health services delivery model in a new context and is instrumental in achieving local ownership.

Before and after implementation of group antenatal care in Rwanda: a qualitative study of women’s experiences

“…In 2015, the East Africa Preterm Birth Initiative-Rwanda, a partnership among the Rwanda Ministry of Health, the Rwanda Biomedical Center, the University of Rwanda School of Public Health, and the University of California, San Francisco, Institute of Global Health Sciences, decided to implement a cluster randomized controlled trial of group ANC and group PNC powered to assess the impact of this model on gestational age at birth in 5 districts. The design and objectives of this study are described elsewhere [10]. In group ANC, women are organized into groups and attend their ANC visits together over the course of pregnancy.…”

Person Centered Antenatal Care and Associated Factors in Rwanda: A Secondary Analysis of Program Data

“…We conducted a secondary analysis using data from a pair-matched cluster randomized control trial (CRCT) in Rwanda (Sayinzoga et al, 2018). In the parent study, health centers were pair-matched and one facility was randomized to Group Antenatal Care (GANC) and the other randomized to continue delivering the standard models of focused antenatal care (ANC) and postnatal care (PNC).…”

An effectiveness-implementation hybrid type 1 trial assessing the impact of group versus individual antenatal care on maternal and infant outcomes in Malawi

“…However, the WHO was cautious, because premature adoption of a new model can have serious negative consequences, as exemplified by the reversal of the 4visit model [39]. A growing body of literature shows that group antenatal care is feasible and acceptable in many low and middle-income countries across the globe [40][41][42][43][44][45][46][47][48][49][50]. Additional work is underway in Mali, China, Ethiopia, Surinam, and elsewhere [51].…”

“…Additionally, many studies lack adequate power to test for effects on birth outcomes (e.g., prematurity and/or low birthweight). One large cluster randomized trial currently underway in Rwanda is adequately powered to examine preterm birth, but the model deviates on three key practices of the CenteringPregnancy model (e.g., lack of continuity of co-facilitators and group members (women can drop into other groups) and group size can be larger than 12) [42,43]. Our study, taking place in Malawi, fills both the power and fidelity gaps while implementing group antenatal care in the context of a midwife shortage and high rates of prematurity and HIV infection [13,56,57].…”