Abstract
Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success. 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. 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. 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. ClinicalTrials.gov NCT03154177.
Highlights
In 2016, the World Health Organization recommendations on antenatal care for a positive pregnancy experience prioritized research on the individual outcomes and health systems effects of group antenatal care implementation [1]
When the authors performed a sub-group analysis by race/ethnicity limited to the two highest-quality studies, the preterm birth rate was significantly lower among African-American women who participated in group antenatal care (8.0%) compared to African-American women who participated in individual antenatal care (11.1%)
Intrigued by lower rates of preterm birth among high-risk American women who participated in group antenatal care, the Preterm Birth Initiative-Rwanda aimed to test the primary hypothesis that Rwandan women receiving antenatal care at health centers that offer group antenatal care would experience increased gestational length compared to women receiving antenatal care at health centers that provide the standard, individual model of care
Summary
In 2016, the World Health Organization recommendations on antenatal care for a positive pregnancy experience prioritized research on the individual outcomes and health systems effects of group antenatal care implementation [1]. Group antenatal care is hypothesized to positively impact preterm birth rates and other outcomes among women at elevated psychosocial risk due to three main features of the model: 1) greater social support between women who are linked via the group; 2) more total antenatal care-associated time spent in educational activities in facilitated group discussions; and 3) attention to key elements of person-centered care, including respect and safety, empowerment, and participation [5,6,7]. These elements create a more positive pregnancy care experience which may encourage antenatal care attendance and create additional opportunity for risk assessment by providers. Research on group antenatal care in low- and middle-income contexts suggests high acceptability and preliminary implementation success
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