1. “In the group, there was something extraordinary”:
Women’s perceptions of group antenatal and postnatal care in Rwanda.
I do not have any financial interest in any product or service related to my presentation; and my participation at this conference has been supported by the East Africa Preterm Birth Initiative, which is funded by the Bill and Melinda Gates Foundation.
Dr. Sabine F. Musange

2. PRESENTATION OUTLINE
Overview of East Africa Preterm Birth Initiative- Rwanda
Methodology
Results
Key messages

3. OVERVIEW OF EAST AFRICA PRETERM BIRTH INITIATIVE
Decrease overall burden of preterm birth with a focus on neonatal mortality among preterm infants
Decrease morbidity and mortality by strengthening:
measurement & data systems
antenatal and postnatal care in Rwanda
intrapartum/immediate postnatal care in Kenya and Uganda
PTB Initiative or PTBi aims at decreasing the overall burden of preterm birth in East Africa. Currently PTBi is working in Kenya, UG and RWA. In RWA the focus is on decreasing mortality and morbidity among preterm infants by strengthening measurement and data systems and implementing a new ANC and PNC model of delivery.

4. PRETERM BIRTH INITIATIVE- RWANDA
Cluster Randomised Controlled Trial (CRCT) of group antenatal and postnatal care
Started June 2017, planned to end data collection in May 2019
18 health centers implemented group care, 18 continued with standard care
Enrolled more than 20,000 women
Primary outcome of interest: gestational length

5. WHAT IS GROUP ANTENATAL & POSTNATAL CARE?
Group of 8-12 women of similar gestational age
4 ANC visits (1 initial & 3 group visits)
+ 1 group PNC visit
Women attend their subsequent ANC and
PNC visits in group
Facilitative environment to empower
participants: seating arrangement,
health assessments conducted in the same
room, facilitation NOT instruction
Each visit has a basic plan but the discussion is
flexible based on participants’ interests
Adapting the group care model to the Rwandan context was accomplished by a technical team of MCH stakeholders.
Each group is made of 8-12 women with similar GA. The number of ANC visits remained unchanged, women attend their initial visit individually and attend the subsequent ANC visits and PNC in a group.
The seating arrangement, the facilitation are promoting participants’ empowerment.
We have a basic plan for each visit.

6. This article published last year in the journal of Midwifery and Women’s Health, describes the development process of the Rwandan Group care model

7. METHODOLOGY: Women Experience Data
Qualitative: 2 rounds of data collection, before and at mid-implementation
Before implementation:
FGDs with women (18-21 years old, over 21 years) with child <12 months of age Experiences with ANC service delivery, perceptions of benefits and limitations with current ANC services and perceptions of the feasibility of group care.
After implementation:
FGD with women who had been invited and agreed to participate in group care
Purposively sampled low and high attendance sites
Reasons women chose to attend or not group ANC/ PNC, suggestions to strengthen the program.
Round 2 sought to capture the context of experiences with ANC service delivery, perceptions of benefits and limitations with current ANC services, and perception of the feasibility of group care
Round 2 qualitative work sought to capture reasons women chose to attend or not attend group ANC and PNC visits, as well as soliciting suggestions to strengthen the program
Questionnaires did not collect name or other personal identifiers; each provider participant was assigned a unique study identification code.
Ethics approvals obtained from RNEC and UCSF IRB.

8. RESULTS: BEFORE IMPLEMENTATION
Enthusiasm for group model: peer support and education, friendship, motivation
As a benefit, I see that being in a group creates friendship among mothers so that you plan to visit each other in order to know how your sister is with her pregnancy. Being in the same group motivates mutual visits during pregnancy.” (Nyarugenge district, W P10)
“The advantage of the groups is that sometimes women who go for ANC for the first time are afraid to tell everything to the healthcare provider due to ignorance but when she is with other women in groups, she tells them her problems and they advise her.” (Burera district, W P12)
Women anticipated multiple potential benefits of participation of this alternative model of care, such as increased social cohesion.
The advantage of hearing the personal stories of other pregnant women and learning about pregnancy-specific topics from trusted peers was acknowledged by participants.
Women emphasized that group sharing could help all members “open up” about questions and concerns so they could benefit more from the time spent engaged in ANC.
Women imagined that through group discussion they could motivate their peers to engage in healthy behaviors:

9. RESULTS: BEFORE IMPLEMENTATION
Concern about privacy:
“There are some people who don’t like to talk in groups, or fearing the group they will not be able to express themselves.” (Burera district, YW P10)
Mixed feelings:
“Sometimes you may be HIV infected and when you share your secret you will start thinking that everyone will know about it. Yet it is also good when you dare share it, it releases you from that load, and if they are informed, they may know how to behave towards you.” (Burera district, W P10)
Women anticipated multiple potential benefits of participation of this alternative model of care, such as increased social cohesion.
The advantage of hearing the personal stories of other pregnant women and learning about pregnancy-specific topics from trusted peers was acknowledged by participants.
Women emphasized that group sharing could help all members “open up” about questions and concerns so they could benefit more from the time spent engaged in ANC.
Women imagined that through group discussion they could motivate their peers to engage in healthy behaviors:

10. RESULTS: AFTER IMPLEMENTATION
Benefits: Relationships and increased knowledge
“With the old way of consultation, the nurse would only do her job, and when she is done, you would go home. But in the group, there was something extraordinary— that of sitting and asking the nurse what she was doing, and she would take time to explain to you. You would also ask more experienced mothers in your group whether they may have gone through such or such other experience. They would also relate to you what they saw and how they solved any complicated situation.” (Nyamasheke district, HC1, P6)
Many women described a significant increase in health-related and self-care knowledge related to group care participation.
Women reported forming meaningful relationships with their pregnant peers and their providers:.

11. RESULTS: AFTER IMPLEMENTATION
Challenges: barriers to attendance
Need to work instead of attending ANC due to lack of financial resources.
“[One may decide to stay] at home because a person may use that time to go and make a thousand Rwandan Francs to sustain her family.”
(Burera district, HC1, P6)
Some women report husbands do not support attendance
“Your husband may feel annoyed by the number of times you go to the health center; and when he has compared them to what he may see other women do—like weeding their crops— he may order you not to go there once again.” (Bugesera district, HC1, P3)
None of the women who participated in the focus groups convened after implementation mentioned that concerns about privacy impeded their group care participation. The barrier to group care participation most commonly cited was lack of the financial resources required to attend, husbands' support

12. RESULTS: AFTER IMPLEMENTATION
Suggestions:
More community outreach to raise awareness among male partners and community members in general:
“I can suggest that this topic [purpose and value of ANC, PNC] should be made part of discussion we have during the parents’ evenings [regular community meetings] where we may be together with our husbands. There, they may hear about it……….” (Bugesera district, Nzangwa HC, P6)
Participants must be accustomed to a new way of organizing their time
When asked for suggestions to improve women’s experience of group ANC and group PNC, women did not make any recommendations related to the fundamental components of the model (such as health assessments shared in the group space or facilitated group discussion activities or topics).
A common message was that more community outreach is needed to help male partners, female next-of-kin, older women in the community, and pregnant and postnatal mothers understand the purpose and value of ANC and postnatal care in general, and group care in particular.
Participants were well aware of the challenges of introducing scheduled appointments at a specific date and hour in a system that has not previously used to allocate both provider and client time

13. RESULTS: AFTER IMPLEMENTATION
Difficult for providers to remain for the entire group visit because they are concurrently assigned to multiple services (e.g. ANC, maternity, family planning)
“There is something that needs correction for both us beneficiaries and trainers. We did not keep time when we would come to the Health Center for group care. On our side, some of us would come on time and be bound to wait for the latecomers; this then inconvenienced those who would have come on time. On another occasion, the nurse also would fail to attend the group because of other clients she had to attend to. So I would suggest that they may increase the number of nurses to help the other mothers so that the nurse may be available on time. Group care members also should learn to keep time.” (Burera district, HC1, P9)
More staff needed and/or better organization of available staff on group care days.

14. KEY MESSAGES
Women in this sample reported that group care results in stronger relationships among pregnant participants and providers and increases knowledge about self-care and newborn care in the antenatal and postnatal periods
According to participants, financial stress and partners support are barriers to attendance.
Women noted that there were two main problems with the group care structure: women did not arrive at the appointed time and providers had to leave the group visit when called to provide care in other service areas. These resulted in problematic delays for participants

15. Ibaruke Neza Mubeyi: May every woman have a healthy birth