Background
Methods
Study setting
Intervention design
Study sample
Data collection and analysis
Outcome | Quantitative Methods | Qualitative Methods |
---|---|---|
Knowledge | Cross-sectional surveys at baseline and endline included an open-ended question for clients to identify: • danger signs/complications • how to improve own and baby’s health Data collectors compared the client’s response to a list of expected responses based on the educational content offered in ANC. Data was analyzed using logistic regression. | IDIs with women currently in GANC IDIs with women who completed at least 4 GANC visits IDIs with women who did not attend at least 4 GANC visits FGDs with women who completed GANC FGDs with women who did not complete 4 group ANC sessions IDIs with health providers, facility managers, CHVs, and county health team Questions focusing on: What learning has made a difference in your life, if any Likes and dislikes about participating in or implementing pregnancy club |
ANC experience of care (based on WHO framework: effective communication, respect and dignity, and emotional support) | Cross-sectional surveys at baseline and endline included a question on the below topics for the client to rate using a Likert scale. • Sharing feelings and experiences with other women (social support) • Knowledge and competence of health workers • Respect shown to respondent by ANC providers • Trust in ANC providers • Language ANC providers used toward respondent • Information and counseling provided about pregnancy, delivery, and postnatal care • Overall quality of care Responses were transformed into a binary response for the purpose of hypothesis testing, as the data did not meet the proportional odds assumption of ordinal regression. For “sharing feelings and experiences with other women,” we compared women who responded they “strongly agree” to those who did not due to the heavily skewed results. For all other measures, we compared women who rated the characteristic of experience as “excellent” or “very good” to those who did not. Data was analyzed using logistic regression. | IDIs with women currently in GANC IDIs with women who completed at least 4 GANC visits IDIs with women who did not attend at least 4 GANC visits FGDs with women who completed GANC FGDs with women who did not complete 4 group ANC sessions IDIs with health providers, facility managers, CHVs, and county health team Questions focusing on: Likes and dislikes about participating or implementing pregnancy club Describe relationships between women and with health providers Benefit of participating in pregnancy clubs |
Empowerment | Cross-sectional surveys at baseline and endline included a series of questions related to pregnancy-related empowerment, defined by Patil et al. as “the quality of communication and connectedness pregnant women feel with their care providers and peers, their participation in decision-making, and their capacity to recognize and engage in pregnancy-related healthy behaviors.” Each individual question was collected using a Likert scale, with a point-value attached to each response. The sum of these point-values was used to calculate an overall PRES score for each client. Data was analyzed using logistic regression. | IDIs with women currently in GANC IDIs with women who completed at least 4 GANC visits IDIs with women who did not attend at least 4 GANC visits FGDs with women who completed GANC FGDs with women who did not complete 4 group ANC sessions IDIs with health providers, facility managers, CHVs, and county health team Questions focusing on: Benefit of participating in pregnancy clubs Likes/dislikes about pregnancy club – open-ended question that revealed knowledge improvements |
Adoption of healthy behaviors | Cross-sectional surveys at baseline and endline included a question on the following topics. • Birth preparations: open-ended question for clients to identify preparations they had made, and project technical staff compared the client’s response to a list of expected preparations based on the educational content offered in ANC The following information was extracted from health facility registers: • Retention: number of ANC visits by an ANC client Data was analyzed using logistic regression, except for retention, which was analyzed using linear regression. | IDIs with women currently in GANC IDIs with women who completed at least 4 GANC visits IDIs with women who did not attend at least 4 GANC visits FGDs with women who completed GANC FGDs with women who did not complete 4 group ANC sessions IDIs with health providers, facility managers, CHVs, and county health team Questions focusing on: Benefit of participating in or implementing pregnancy clubs Likes/dislikes about pregnancy clubs |
Quantitative research
Qualitative research
Ethical approval
Results
Description of the sample
GANC Facility Registry
| |||
Age |
N = 1650 (%) | ||
10–14 | 1 (0.06%) | ||
15–19 | 287 (17.4%) | ||
20–24 | 593 (35.9%) | ||
25–34 | 656 (39.8%) | ||
35+ | 113 (6.8%) | ||
Facility |
N = 1652 (%) | GANC cohorts completed (103) | |
Level 3 | 388 (23.5%) | 19 | |
Level 3 | 218 (13.2%) | 13 | |
Level 3 | 254 (15.4%) | 19 | |
Level 3 | 230 (13.9%) | 16 | |
Level 4 | 350 (21.2%) | 23 | |
Level 5 | 212 (12.8%) | 13 | |
Survey Respondents
| |||
Baseline (N = 112) | Endline (N = 360) | ||
Age | |||
15–19 | 13 (11.6%) | 39 (10.8%) | |
20–24 | 49 (43.6%) | 97 (26.9%) | |
25–34 | 45 (40.2%) | 201 (55.8%) | |
35+ | 5 (4.5%) | 23 (6.4%) | |
Number of lifetime births | |||
1 birth | 44 (39.3%) | 93 (25.8%) | |
2 births | 30 (26.8%) | 106 (29.4%) | |
3 births | 20 (17.9%) | 79 (21.9%) | |
4 births | 11 (9.8%) | 43 (11.9%) | |
5 births | 2 (1.8%) | 22 (6.1%) | |
6+ births | 5 (4.5%) | 17 (4.8%) | |
Marital status | |||
Never married | 18 (16.1%) | 60 (16.7%) | |
Currently married | 81 (72.3%) | 286 (79.4%) | |
Separated | 4 (3.5%) | 3 (0.8%) | |
Divorced | 0 (0.0%) | 4 (1.1%) | |
Widowed | 0 (0.0%) | 2 (0.6%) | |
Partnered— living together | 6 (5.4%) | 1 (0.3%) | |
Partnered— not living together | 3 (2.7%) | 3 (0.8%) | |
N/A | 0 (0.0%) | 1 (0.3%) | |
Highest level of education | |||
None | 3 (2.7%) | 8 (2.2%) | |
Before Primary | 9 (8.0%) | 3 (0.8%) | |
Primary | 38 (33.9%) | 139 (38.6%) | |
Vocational | 4 (3.6%) | 3 (0.8%) | |
Secondary | 40 (35.7%) | 160 (44.4%) | |
Training Post-Secondary | 7 (6.3%) | 28 (7.8%) | |
University | 11 (9.8%) | 19 (5.3%) | |
Years of living in village or town | |||
< 1 year | 1 (.9%) | 25 (6.9%) | |
1–2 years | 47 (42.0%) | 90 (25.0%) | |
3–5 years | 25 (22.3%) | 111 (30.8%) | |
6–10 years | 16 (14.3%) | 72 (20.0%) | |
11–20 years | 17 (15.2%) | 45 (12.5%) | |
21–30 years | 5 (4.5%) | 15 (4.2%) | |
> 30 years | 1 (0.9%) | 2 (0.6%) | |
Religion | |||
Muslim | 2 (1.8%) | 5 (1.4%) | |
Christian | 97 (86.6%) | 353 (98.1%) | |
Traditional | 12 (10.7%) | 2 (0.6%) | |
None | 1 (0.9%) | 0 (0.0%) | |
Number of household members | |||
< 3 | 4 (3.6%) | 10 (2.8%) | |
3–4 | 54 (48.2%) | 147 (40.8%) | |
5–6 | 30 (26.8%) | 131 (36.4%) | |
7–8 | 18 (16.1%) | 49 (13.6%) | |
> 8 | 6 (5.4%) | 23 (6.4%) | |
Head of household by gender | |||
Man | 98 (87.5%) | 323 (89.7%) | |
Woman | 10 (8.9%) | 35 (9.7%) | |
Do not know | 4 (3.6%) | 2 (0.6%) | |
Qualitative Respondents | |||
In-depth interviews (N = 29) | |||
Age | Women who have delivered and competed at least 4 group ANC visits (N = 20) | Women who have delivered but did not complete 4 visits (N = 6) | Women who are currently in group ANC and have completed 4 group visits (N = 3) |
< 20 | 8 | 2 | 1 |
20–24 | 8 | 2 | 2 |
25+ | 4 | 2 | – |
Facility level | |||
Level 3 | 10 | 6 | 2 |
Level 4 | 5 | – | – |
Level 5 | 5 | – | 1 |
Focus Group Discussion (N = 19) | |||
Group | Number of Participants | ||
Young women (age 20–25) | 8 | ||
Adolescents (15–19) | 6 | ||
Older women (26+) | 5 | ||
Stakeholder IDI (N = 15) | |||
Position | |||
Health facility manager | 4 (male = 1; female = 3) | ||
Health care provider | 4 (male = 1; female = 3) | ||
CHVs | 4 (male = 1; female = 3) | ||
County health official | 3 (male = 1; female = 2) |
Outcomes
Percentage | Odds Ratio (95% CI) | ||
---|---|---|---|
Baseline (N = 112) | Endline (N = 360) | ||
Knowledge
| |||
Women who could identify 3 or more danger signs of complications during pregnancy | 7.1% | 26.4% |
4.58 (2.26–10.61)
|
Women who could identify 3 or more things a woman can do during pregnancy to improve her and her baby’s health | 30.4% | 37.5% | 1.37 (0.87–2.19) |
Qualitative themes: Knowing the why and not only the what; practical tips and information; mutual learning for women and health providers | |||
ANC experience of care: Percentage rating “excellent” or “very good” based on 5-point Likert scale
| |||
Women who strongly agreed that they shared their feelings and experiences with other women | 58.9% | 71.7% |
1.73 (1.1–2.7)
|
Knowledge and competence of health workers | 57.2% | 78.6% |
2.52 (1.57–4.02)
|
Respect shown to respondent by ANC providers | 59.8% | 73.3% |
1.82 (1.16–2.85)
|
Experienced disrespect and humiliation | 7.1% | 9.7% | 1.40 (0.66–3.33) |
Trust in ANC providers | 58.1% | 65.0% | 1.23 (0.78–1.91) |
Language ANC providers used toward respondent | 57.2% | 65.6% | 1.39 (0.88–2.16) |
Level of privacy and confidentiality observed during ANC | 55.3% | 62.0% | 1.29 (0.79–2.22) |
Intent to use same facility in a subsequent pregnancy | 88.8% | 93.2% | 1.87 (0.39–9.47) |
Very likely to recommend facility to other women | 75% | 90.8% | 2.82 (0.39–9.47) |
Overall quality of care | 56.3% | 68.3% |
1.62 (1.03–2.53)
|
Qualitative themes: Sharing experiences to solve problems, giving each other strength and encouragement to cope, feeling that nurses create an open and safe space | |||
Empowerment and self-efficacy: Percentage who “strongly agree” based on a 5-point Likert scale
| |||
You could ask your ANC provider about your pregnancy. | 67.0% | 63.1% | 0.86 (0.54–1.36) |
Since you began antenatal care, you have been making more decisions about your health. | 74.1% | 74.7% | 1.02 (0.61–1.66) |
You felt you had a right to ask questions when you don’t understand something about your pregnancy. | 83.0% | 76.4% | 0.67 (0.37–1.16) |
You were able to change things in your life that are not healthy for you or the baby. | 75.0% | 78.3% | 1.21 (0.73–1.99) |
You did what you could do to have a healthy baby. | 92.9% | 87.5% | 0.54 (0.23–1.12) |
You could talk to your partner about your pregnancy and planning for delivery. | 85.6% | 76.9% | 0.56 (0.21–1.23) |
Qualitative themes: Feelings of self-efficacy | |||
Adoption of healthy behaviors
| |||
Number of ANC visits | 4.21 | 5.08 |
95% CI of difference: 0.47–1.42 visits
|
Number of ANC visits among under 25 years of age | 4.23 | 5.11 |
95% CI of difference: 0.27–1.34 visits
|
Birth preparations
| |||
Women reporting that they made 2 or more of any of the listed preparations | 33.0% | 48.9% |
1.94 (1.24–3.05)
|
Women reporting that they prepared items for the baby or delivery | 64.3% | 71.9% | 1.61 (0.94–2.72) |
Qualitative themes: Making a difference for the better |
Knowledge
Women described learning not only from health providers but also from peers. Providers also described a mutual learning environment where they gained insights into cultural practices and beliefs, which helped them understand women’s situations. As a result, they were able to provide better counseling and communication.Even that part of taking drugs... we never knew the importance of taking these drugs … we would say the drugs are bad, they make someone nauseated when you take them. We were taught the importance of the drug that makes the baby grow well in the uterus … . Nowadays I can’t miss taking it. Adolescent, county hospital
To me personally it has opened my eyes, the interaction with these mothers has taught me a lot, we teach each other actually, because there are some things they know that we never knew; some things are taboo actually, so you try to know misconceptions so you try to rectify [them] and they take it positively. Health provider, county hospital
Experience of care
GANC participants described the social support, trust, and solidarity they gained by sharing experiences and giving each other strength and encouragement to cope. They described receiving support that was both practical, such as sharing transport, as well as emotional, such as dealing with the stress of a pregnancy complication. Most women described forming bonds with at least some of the women in their group and with the health provider. Discussions with their peers enabled them to solve problems together.Our service provider was very good. She was very free and open and in any case you had any problem and you are pregnant, you could still approach her and she would teach you. Young woman, county hospital
Women valued these aspects of GANC and talked about how they maintained the relationships even outside the group sessions. A number of women talked about how the relationships would likely continue after the pregnancy. A few expressed disappointment when the health provider who was facilitating their sessions changed and was replaced by another, which may indicate that the women had developed a bond with the provider. Health providers also seemed to gain some satisfaction from developing closer relationships with women and found it helped them provide better quality of care. In particular, women noted improved respectfulness from the health provider and a reduction in perceived discrimination. Adolescents in particular reported being treated more respectfully and felt at ease, free from discrimination and judgement.They are friends. When one tells her experience and another also talks about her experience, they help to sort out the problem... When one woman does not come, her friend will remind her of the next meeting, and she will make an effort of looking for her and asking her why she has not seen you. CHV, health center
Lea Mimba really encouraged mothers; when we used to attend, most of the nurses were friendly. In normal ANC clinics, you will find some nurses don't attend to you well, but in the Lea Mimba club, the nurses did not discriminate against anyone. When you go to other clinics you are told you are dirty, here you are attended to the way you are. Adolescent, county hospital
Empowerment and self-efficacy
For the groups in general, health providers described how women were more active in taking a role in their ANC experience, such as asking for services or tests, as expressed by this provider:Yes, for me I never imagined I could take care of my pregnancy, I never saw myself taking care of a child and using family planning, I thought it was a lot of work. But after the Lea Mimba lessons, I can do all these things. Adolescent, referral hospital
They really liked it [group ANC] and if you had not taken their pressure, they are the ones who would remind you that sister you have not taken my pressure, teacher you have not weighed me. We used to teach them how to do some of these things … unlike the normal ANC where a mother walks in and you are the one who does everything for her, but now they are the ones doing these things for themselves. Health provider, health center
Adoption of healthy behaviors
At least nowadays they come when they are prepared, they carry clothes for the baby, and she has a towel to wrap the baby, so I think that it has improved [behaviors]. Health facility manager, health center
In addition, women across all age groups and district and health facility staff described how participating in Lea Mimba helped women adopt positive behaviors for a healthy pregnancy and newborn baby. In particular, young and adolescent women indicated that the advice and information helped them make improvements and had a positive effect on their lives.my first pregnancy... I did not save money to buy clothes for the baby and transport costs before the baby was delivered. But for this one, I was taught and I prepared myself early. I bought the baby’s clothes early and saved some cash for delivery costs. Older woman, county hospital
These sessions really helped me, because I was opting to abort but after the sessions I did not abort. Then I did not know anything like taking care of my pregnancy, but through attending the sessions I survived with the pregnancy. Adolescent, health center
And then you should not bathe the baby but just wipe, just wipe until the umbilical cord drops off. Let it heal, that is when you can start bathing her in much water. I did that but for those other ones I used to bathe them immediately and it used to take time for the umbilical cord to heal, so it was different for this other one. Those lessons really helped me. Older woman, health center
Response | Baseline (N = 112) | Endline (N = 360) |
---|---|---|
Saved money | 56 (50%) | 201 (55.8%) |
Selected facility | 4 (3.6%) | 24 (6.7%) |
Arranged transport | 5 (4.5%) | 50 (13.9%) |
Prepared items for the baby/delivery | 72 (64.3%) | 259 (71.9%) |
None | 19 (17%) | 44 (12.2%) |
Do not know | 1 (0.9%) | 0 (0%) |
Other | 0 (0%) | 6 (1.7%) |
Not applicable | 1 (0.9%) | 1 (0.3%) |