Background
Methods
Searching
Screening
Inclusion | Exclusion | |
---|---|---|
Participants | All healthcare providers who have facilitated group antenatal care where group antenatal care is defined as: defined as any antenatal care with a clinical component that includes more than four women meeting in a group | Studies of GANC with no health care provider views and perspectives Studies where it cannot if the participants themselves facilitated the GANC will be excluded |
Phenomenon of interest | The focus will be on the experiences and perspectives of health care providers (physicians, midwives, nurses, allied health professionals) who have been involved with facilitation of group antenatal care (GANC) models | Any studies which describe the experience of women with their health care provider in group antenatal settings will not be included unless it is described from the HCP point of view |
Outcomes | This review will seek to understand the experiences of health care providers as it pertains to the acceptability, feasibility, and sustainability of group models of care in diverse healthcare systems | Outcomes related to women |
Study design | Study must have a qualitative component Mixed method studies that include a relevant qualitative component in the findings | Studies collecting data quantitatively only |
Study focus | Studies should focus on experience of facilitating/participating in group antenatal care | Focus on women |
Setting | All countries | None |
Quality appraisal
Data extraction
Study first author, year | Country | Study aims | Participant, setting | Study design, data collection, and analysis | Quality | Findings | Collaborators |
---|---|---|---|---|---|---|---|
Allen, J., 2015 [51] | Australia | Examine younger women’s experiences of caseload midwifery incorporating gANC | 4 Midwives Caseloading practice for women under 21 Purposive sampling | Qualitative critical ethnography FGD and observations thematic analysis starting with women's data and applied to midwives | H | Women had some benefits, and midwives observed some benefits for participants. The conclusion was that the model interfered with relationship building | Midwives co-facilitate with each other |
Baldwin, K., 2011 [52] | USA | Midwives’ thoughts, feelings, perceptions from pre-implementation through facilitation of five sessions of CP, also focus on sustainability | 6 Midwives 5 clinics in different regions of the United States (Northeast, Midwest, South) recruited at CP training Convenience sampling | Qualitative Design SSI face to face and over telephone at 5 different time periods transtheoretical health education model Colazzis method and thematic analysis | H | Emergence of five themes progression fromcurrent practice is just fine through anxiety about the model to empowerment and looking to the future | Midwives co-facilitate with each other |
Barnes, J., 2016 [53] | UK | Evaluation of the feasibility of the group family nurse partnership (FNP) program | 8 Family nurse partnership nurse midwives 4 community midwives 4 supervisors 4 family support workers Purposive sampling | Mixed Methods FGD and SSI Content Analysis | M | Content and format was positive for participants and FNP facilitators but women struggled to attend regularly and most vulnerable were not recruited and FNP found working with community staff challenging | FNP midwives cofacilitated with community midwives or family support workers |
Craswell, 2016 [54] | Australia | Evaluate a group care model collaboration between an academics, students, and public health service midwives | 5 Midwives 5 midwifery students clinic held on university grounds Purposive sampling | Qualitative design SSI and FGD thematic analysis following donobedians structure process outcome framework | H | Positive opportunity for continuity of care for midwifery students and positive collaboration between university and clinic midwives and positive views from participants | Academic midwives co-facilitate with students and clinic midwives |
Hunter, L., 2018 [67] | UK | Feasibility of implementing gANC in high diversity area by exploring midwife and other maternity care provider views | 16 Stakeholders 9 facilitating midwives 1 student midwife large diverse London NHS trust Purposive sampling | Inductive qualitative approach SSI informal group discussions and workshop post implementation the matic analysis | H | Intervention was supported as a solution to dissatisfaction with standard care, worries about privacy, self-checking and partners were overcome with adequate support and training and experience with the model and midwives enjoyed delivering care this way and felt satisfied with that care | Midwives co-facilitate with each other |
Klima, C., 2009 [63] | USA | Feasibility of implementing CP in a large urban clinic and associated outcomes | 4 Midwives 5 health centre staff Large urban public health clinic Purposive sampling | Mixed methods feasibility FGD thematic analysis | M | Midwives and staff felt women enjoyed their care and improved their attendance and satisfaction midwives and staff experienced challenges with implementation aspects such as scheduling and midwives found facilitation challenging and losing one to one interaction | Midwives co facilitate with project assistant or medical staff (training undefined) |
Lori, J., 2016 [55] | Ghana | Does gANC improve providers perceptions of communication and engagement-does facilitative gANC improve health information delivery-is a health literacy skills framework suitable for maternal health literacy development | 6 Midwives (4 participated in FGD) 1 nurse who co-facilitated groups busy clinic Ashanti region Convenience sampling | Mixed methods survey and FGD constant comparative analysis | H | No significant difference in survey of communication and engagement focus group identified themes of improved understanding of patient concerns, enhanced information and sharing with facilitated discussion, and improved communication with picture cards | Midwives co-facilitated with each other and a support nurse |
Lundeen, T., 2019 [60] | Rwanda | Understand the experience and job satisfaction and perceived stress of gANC providers as compared to standard ANC providers | 59 Nurses and midwives completed questionnaire 29 participated in FGD 18 health centres in Rwanda Cluster randomized sampling | Mixed methods nested study survey 3 FGD thematic analysis | H | Survey showed no change in job satisfaction or perceived stress however 86% midwives said they preferred gANC and FGD showed benefits for women and midwives and opportunities for problem solving implementation challenges with peer nurses and midwives | Midwives and nurses co-facilitate with CHWs whose experiences were not reported in this article |
Maier, B., 2013 [62] | Australia | Reflection piece | 1 Midwife caseloading Large urban hospital | Personal reflection | L | Author found this a very satisfying way to deliver antenatal care and thus extended it to postnatal groups and included students | Doesn't mention a co-facilitator but did have midwifery students in group |
McDonald, S., 2014 [56] | Canada | Experiences of low-risk women and their care providers with gANC | 5 Midwives Midwifery clinic in Ontario Purposive sampling | Qualitative descriptive study FGD thematic analysis | H | Women felt they received more information and support but less one on one time with midwifemidwives saw systems level challenges but saw professional benefits such as reduced workload and more autonomy for women | Midwives co-facilitate with each other |
McNeil, 2013 [58] Vekved, 2017 [59] | Canada | Understand the central meaning of centering pregnancy to family physician facilitators and perinatal educator facilitators | 3 Family physicians providing CP care in Calgary 5 perinatal educators providing CP care Low-risk group practice in Calgary Purposive sampling | Phenomenological approach IDI meaning units/thematic analysis confirmation fgd and interviews and re-analysis | M/H | Core meaning for physicians of "providing richer care" examined across six themes around more time and more satisfaction and seeing women create relationships with each other and physicianperinatal educators found a core meaning of "invested in success" covered by six themes including bridging the gap and getting to knowing and stepping back | Physicians co-facilitate with perinatal educators |
Novick, 2013 [49] Novick, 2012[66] | USA | What are perceived as the challenges to implementing centering and how is centering model adapted to meet these challenges? | 2 Nurse midwife group leaders 3 support staff included in participant observations 2 urban clinics in north-eastern US Purposive sampling | Longitudinal qualitative study interpretive description (Thorne, 2008) SSI with group leaders participant observation of centering sessions thematic analysis and situational mapping | M/M | Leaders were committed to gANC but hampered by resource constraints which resulted in modifications to the model that further impacted successgroup leaders felt strongly benefits to vulnerable women of participating in this model of care and women participating in this group found some respite from their stressors | One midwife had a staff member co-facilitator (not identified) the other had no co-facilitator |
Novick, G., 2015 [50] | USA | Identify barriers and facilitators to implementing CP in 6 urban sites | 14 Clinical site staff ( 2 administrators, 4 obstetricians, 3 nurse midwives, 1 registered nurse, 3 social workers, and 1 dietician) of whom 6 facilitated care Urban women’s health care clinics in 6 large hospitals Purposive sampling | Qualitative research conducted alongside a cluster RCT IDI and SSI A priori coding and implementation frameworks ATLAS software | H | Thriving sites had organizational cultures that supported innovation and committed staff and provider champions | Some had co-facilitators but they are not specified |
Patil, C., 2013 [64] | Malawi/ Tanzania | Determine if CP is an acceptable model in African antenatal care contextdevelop CP curriculum that maintains national guidelines and essential CP elementssmall pilot trial in Malawi | 1 Administrator 6 midwives 4 HSAs (community health workers) | Feasibility study with small pilot in advance of RCT ethnographic rapid assessment (action research model) observations and field notes by researchers of groups FGD with semi structured guide | H | Centering Pregnancy Africa was feasible and acceptable in the Malawian context and midwives adapted to and enjoyed the facilitation and greater information sharing | Co-facilitation format not specified |
Teate, 2013 [57] | Australia | Explore midwives’ experiences as they moved from one-to-one care to Centering Pregnancy care | 8 Midwives 2 public maternity services in Sydney (3 antenatal clinics, 2 community health centres) Purposive sampling | Qualitative descriptive and iterative action research designpre- and post-surveys, checklists, FGD, observations of facilitation meetings thematic content analysis | H | Midwives progressed throughout the action research from initial anxiety through to appreciating the benefits of CP for women and for their own relationship with women and for the support and training they received | Midwives co-facilitated with each other |
Thapa, P., 2019 [61] | Nepal | # of ANC visitinstitutional birth rate experience of the model and mechanism of impact from a variety of perspectives | 2 CHW and 2 government care providers Rural Nepal Purposive sampling (one interview with gov't care provider excluded) | Mixed methods cluster-controlled trial FGD with participants KII with providers directed content analysis approach theory of change codes and moving on to open coding [p. 4 Qualitative data were only gathered from those with direct experience of the intervention supervisory and Nyaya program staff had insights-where to include] | M/H | Women appreciated groups for learning and support providers appreciated relationship with community health workers and birth planning was a challenge for women and facilitators | Government midwife co-facilitated with Nyaya health chw |
Wisanskoonwong, P., 2011 [65] | Thailand | Develop a culturally appropriate model of group antenatal care for Thai women | 1 Midwife Meeting room near antenatal clinic of large hospital in Bangkok | Feminist Action researchpersonal reflection and evaluation | M | Reflection on decision to not wear her uniform for group care resulted in her perception of more equalized relationships in group care and giving up role of expert allowing more open discussion | Doesn’t mention co-facilitator in reflection |
Data analysis and synthesis
Results
Included studies
Qualitative themes
Giving women what providers feel they want and need: the satisfying experience of giving women personalized, supportive, high-quality care
Now due to this program pregnant women are also enjoying it a lot. Now pregnant women come and ask us, ‘When are we coming for our next checkup? When are we going next?’ They ask this and then when they get to sit in a group … Now they don’t have the ‘aa, why do we need to go for checkup?’ kind of mentality.—Community Health Worker in Nepal [61, p 10]Providers uniformly related that women who participated in group care were happier and seemed to want to come for prenatal care. They stated that women also appreciated not having to wait for their visits, a common issue in this crowded clinic.—Clinicians in the US [63, p 30]
Richer use of time
In our regular clinic…sometimes we’re kind of rushed and moving pretty quickly and so [I like] to just feel like we can sit down and get in depth with people. … I like that. … I’d rather have a thick novel than a one paragraph of a magazine article.—Physician in Canada [58, p 4]
More personalized care
…facilitating midwives felt that GANC enabled them to be truly ‘with woman’, building up trust and rapport over multiple encounters and addressing social, emotional, and clinical needs: It’s not one-to-one but honestly, I can remember all of the women’s names and you can’t really say that for when you are in an antenatal clinic and all the women come in and out, you don’t remember them.—Midwife in the U.K. [67, p 61]
In the past, pregnant women used to come and listen to a brief talk from the nurse. But today, they come and sit together with the nurse and share. They ask questions and get answers to them. In the past, the nurse could fail to get time to answer to their questions; so they could go back home without answers. Today, they are free to ask whatever they want; they feel at ease with the nurse; they behave like friends.—Nurse/Midwife in Rwanda [60, p 8]
More supportive care
…sometimes there’s sort of synchrony in the life issues that the women are having in terms of relationships, particularly with their partners. They teach each other and they teach me about ways in which they are able to cope, and demonstrate some strength in their lives, no matter how chaotic sometimes it appears or how crazy it is.—Midwife in the U.S. [66, p 598]
As for me, this group care program has pleased us very much; you can even learn of this fact through much excitement of the group members. For us who lead group care, we can see it. You can see that mothers are thirsty for knowing all those new things. When you discuss with them and when you are making conclusions together with them, you find the members happy, and most of them wish never to miss out.—Nurse/Midwife in Rwanda [60, p 6]
Continuity of care
It contributes because they [students] won’t see it in a hospital setting, they won’t see a same group coming at the same time, on set dates…[the women] growing as a group and shifting in their pregnancies’ how comfortable they are and sharing, hearing more than one person. So I think it contributes in changing their perception of what a pregnancy journey is…—Midwife in Australia [54, p 419]
Building skills and relationships
Independence/autonomy
Some providers admitted that the structure of group care visits resulted in an increase in routine assessments, especially blood pressure: “We didn’t use to test blood pressure, and the effect resulting thereof could take the lives of many women. This test is very important. [In the past] it was very possible [we did not check blood pressure] even until she gives birth. They [group care participants] can test that blood pressure themselves because they already know how to do it. When they have tested one another and found out that there is one who has a problem, they inform the nurse, and the nurse can verify and provide due assistance to the woman having the problem before the situation becomes worse. Things have become very easy.”—Nurse/Midwife in Rwanda [60, p 10]
Some staff complained that group prenatal care was ‘spoiling’ women for individual care because they had ‘become used to coming in, doing whatever they have to do for themselves and getting everything done instead of just sitting and waiting.’—Clinician in the U.S. [50, p 469]
Seeing women so comfortable with themselves and me as a health professional was a new experience. … Compared with women experiencing normal midwifery practice in Thailand, the women in my antenatal groups were more independent and talkative. Women in Thailand are usually submissive and they generally do not have the confidence to take responsibility for their own health.—Midwife in Thailand [65, p 633–4]
Provider role development through facilitation and collaboration
It was mind-blowing just how much I could just sit back and allow the group to run itself and there was no pressure, it was just easy to facilitate this group…—Midwife in Australia [57, p e35]
Most times you are chatting, you have a laugh, you are doing the work, you are accomplishing what you would do antenatal [sic] but there is a different sort of atmosphere. I find it is very relaxed.—Midwife in the U.K. [67, p 61]It takes a little bit of the pressure off of us as well to be kind of all things to everybody. To be their midwife and their best friend and their mother…it maybe defines our clinical role a little more clearly in some respects and takes away from some of that social role.—Midwife in Canada [56, p 7]
It was hard at first because…that lack of control makes you feel like, I don’t know if they’re getting the right amount of information and then I started to realize…who am I to decide what kind of information they really need?—Perinatal educator in Canada [59, p 129]
It is impossible in a group to give what we give to people one-to-one because of the constraints of them [the participants] wanting to discuss it.—Family Nurse Partnership Midwife in the U.K. [53, p 178]
I was able to see the group bond and work together as my skills grew.—Midwife in the U.S. [52, p 215]
I learn from her [health service midwife] about the updates in clinical practice …she realises that we’re from that evidence based [approach] and so she asks for that input. She says, ‘Oh what’s the latest thinking on this? And how do you think I could do that better?’ It’s more of a discussion.—Midwife in Australia [54, p 420]
…but I have to wear the hat of the hospital midwife not the community midwife. … there has been those moments … I haven’t necessarily resonated with what the [other] midwife has said.—Midwife in Australia [54, p 419]
Hierarchy dissolutions
At the beginning I was ‘absolutely petrified’. Now I feel so much more confident as a midwife. I have learnt so much. It didn’t matter how junior I was to the rest of my colleagues who were also a part of it. You’ve created a relationship with them and we had fun you know, we laughed.—Midwife in Australia [57, p e35]
I am very much satisfied [with group ANC/PNC]. I would say that the success results from freedom. When we have come together, we sit and talk freely with those mothers whom we serve.—Nurse/Midwife in Rwanda [60, p 8]
I have learnt also to play a role in boldly speaking to the manager in favor of group care when elaborating the timetable. We shall inform them about how the group care activities are scheduled throughout the week so that they will provide room for the people trained to handle group care and do that very job without having much work in other services.—Nurse/Midwife in Rwanda [60, p 12]
Value proposition of GANC
Provider investment
They [clinicians] facilitated groups, solved logistical problems, did ‘everything’ that needed to be done, aggressively recruited women, advocated and ‘tapped into every resource.’—Unidentified Clinician Facilitators in the U.S. [50, p 470]
In the beginning, it [GANC] created more work and the atmosphere was chaotic and stressful.—Midwife in the U.S. [52, p 214]
Organisational impact
Sometimes I felt, like, helter-skelter trying to do everything by doing this by myself, it’s more work than one-on-one care.—Midwife in the U.S. [49, p 695]
So we need one person who coordinates it from [hospital] side. Because there’s so many things to follow-up, to prepare, we need a permanent staff member to continue to organise all of the groups, all of the charts to be prepared, all of the follow up bloods, ultrasound . . . —Midwife in Australia [68, p 419]
[Group care] adds to our workload as others have said, but I am lucky because it is me who plans the work to be done. Therefore I allot enough time to it;—Nurse/Midwife in Rwanda [60, p 11]
Providers noted an improvement in participation and acceptance of group ANC over time. They expressed that conducting group ANC was easy (n = 4) and stressed the importance of using guides and having ongoing training.—Midwives and CHW in Nepal [61, p 10].
Value return for providers
Group care was for me, a rewarding, enjoyable and far more effective way in engaging with women and families and to meet their educational support needs. I miss ‘my’ women and students greatly.—Midwife in Australia [62, p 89]This Ibaruke Neza [group ANC/PNC] program which is carried out in the groups made me like my job. Why is that? Clients have lovely and friendly interactions with nurses, they feel at ease when talking with them.—Nurse/Midwife in Rwanda [60, p 10]