Study: Group antenatal care positively transforms the care experience: Results of an effectiveness trial in Malawi (DOI: 10.1371/journal.pone.0317171)
Women who attend prenatal care visits in groups are more likely to continue with their care and have better health outcomes at birth and beyond, according to a University of Michigan study.
The study examined women's prenatal care experience in Malawi through an individually randomized trial in which half of the women received prenatal care as a group and the other half received traditional one-on-one care. It found that women in group prenatal care reported better outcomes than those in individual care, and most preferred group care for future pregnancies.
"Many pregnant women, particularly in low-resource settings, are facing challenges. Mental well-being is often overlooked, and accessible health care information is problematic. However, bringing women together for group prenatal care allows them to form meaningful connections with peers and their midwife," said lead study author Crystal Patil, U-M professor of nursing. "They don't just come to care and get a lecture about having a healthier pregnancy-instead, they collaboratively problem-solve."
The results from this work, published in the journal PLOS One, provide a framework and practical insights for U.S. health providers and systems striving to deliver more effective, equitable and sustainable perinatal care.
The study, supported by the National Institute of Nursing Research, randomly divided 1,887 women into those who received standard, individualized care and those who received care in groups of about eight to 12 women, across seven clinics in Malawi. The groups were led by a midwife and an experienced woman from the community, a community volunteer.
Women in group prenatal care reported greater connection with peers, higher pregnancy-related empowerment, recalled receiving more services and discussing more health topics. They also reported less wait time and were more satisfied with their care.
The benefits remained beyond the pregnancy. Women in group care reported being better prepared for birth, communicated more with their partners, and were more likely to use condoms consistently, indicating an increased commitment to HIV prevention and safer sexual practices. They also reported less mental distress in late pregnancy.
"Midwifery-led models that are respectful and encourage the sharing of experiences and ideas, help get women into care, and then they stay in care," Patil said. "Attending more visits gives midwives more opportunities to address health issues like high blood pressure. While most women do know what supports a healthy pregnancy, group visits help them turn that knowledge into action-by sharing strategies, building confidence, and finding practical ways to eat well and prepare for childbirth."
Group prenatal care, developed by a U.S. midwife, Sharon Rising, aims to address quality-of-care issues in standard one-on-one care, including long wait times and limited time for patient-provider interactions. Group care is more flexible, so this creates opportunities to comprehensively cover health education.
Patients in the group prenatal care attend an initial one-on-one visit, and then attend subsequent visits throughout their pregnancies with the same group of pregnant people at similar gestational ages. They complete an initial health assessment with a midwife in the group, and then perform self-assessments such as measuring their own blood pressure and weight in the following meetings. Then, the group talks about health-promoting behaviors.
Patil thinks the key is the "self-reinforcing cycle of more and better care." The idea is that when a person feels more empowered during pregnancy and is connected to peers, then the services and the health promotion that is covered during their visits becomes more meaningful to them; so perinatal health outcomes can improve.
"We reported that women had more diverse diets and were more prepared for their birth. They know what to do and what to bring when they come to the health center, which means that they're more aware and can act on things they should be concerned about, such as bleeding and HIV prevention," Patil said.
This team adapted and tested a three-step implementation plan that supported sustainability, allowing the clinics to continue offering group care after the study concluded. Patil says that in addition to the seven clinics in the trial, group prenatal care is being offered at six new clinics in Blantyre District. With support from the Ministry of Health, group prenatal care has also expanded to at least three other districts in the country.
Other countries in Africa, including Ghana, Kenya, Nigeria, Rwanda, Tanzania and Zanzibar, are implementing group health care.
"There is a shift in the power hierarchy that comes with group care. Compared to a one-on-one visit, group care is more relaxed and encourages belonging through the sharing of experiences," Patil said. "Having the right information and being able to translate that into solutions and apply them to your daily life-that's what happens when you get a group of women together."
The research team also included Malawi investigators Ellen Chirwa, Esnath Kapito, Genesis Chorwe, Ursula Kafulafula and Elizabeth Chodzaza. Patil's fellow researchers included Kathleen Norr, Kylea Liese and Rohan Jeremiah of the University of Illinois, Chicago.
This research was supported by the National Institute of Nursing Research (R01NR018115).
