Increasing postpartum family planning uptake through group antenatal care: a longitudinal prospective cohort design

Group ANC uses a facilitated discussion methodology to deliver care in small groups with 8–12 women of similar gestational age. While group ANC, where all clinical care and educational content is provided in a group setting with trained facilitators, has been delivered and studied in high-resource settings for over a decade, it has only recently been introduced as an alternative to individual care in sub-Saharan Africa. Two randomized controlled trials of group ANC in the U.S. found women assigned to group care had significantly better antenatal knowledge, greater satisfaction with care, and were less likely to have a preterm birth than those in individual, standard care. In addition, these studies demonstrated more favorable birth, neonatal, and reproductive outcomes in the intervention groups [22, 23]. Although the experimental design of the studies from high-resource countries were scientifically rigorous, findings cannot be generalized to low-resource countries with low literacy rates and high rates of maternal and newborn morbidity and mortality. In the U.S., Australia, and the Netherlands, group ANC has improved outcomes in birth weight, preterm birth rates, satisfaction with care, and breastfeeding initiation [22, 24, 25]. In sub-Saharan Africa, data from two small studies found ANC delivered in groups to be acceptable and feasible to both women and providers in Ghana, Tanzania, and Malawi [26, 27]. Previous findings from this study found significant differences immediately postpartum between women enrolled in group verses individual ANC for birth preparedness and complication readiness, knowledge on preventing problems before delivery, understanding when to access care, and greater understanding of the components of breastfeeding and lactational amenorrhea for birth spacing immediately postpartum [28]. A recent systematic evidence synthesis of group ANC in 16 low- and middle-income countries identified consistent attributes across several different models with recommendations for a composite generic model [29]. Additional group ANC studies are currently underway in several low-income countries with a recommendation from WHO (2016) for increased research into the group ANC [30] model.

This study compares women enrolled in group ANC with women receiving standard, individual focused ANC at a busy urban clinic in Ghana, to: (1) Compare women’s intent to use family planning immediately postpartum, and actual use at one-year postpartum, and (2) Compare exclusive breastfeeding for a minimum for six months.

Our study used an observational, prospective cohort design with intervention and control groups. Women were enrolled in the study at their first ANC visit and followed for one-year postpartum. Details of the study protocol are described elsewhere [26, 28]. Institutional review board approval for the study was obtained from the University of Ghana Noguchi Memorial Institute for Medical Research; the Kwame Nkrumah University of Science and Technology Committee on Human Research, Publications and Ethics; and the University of Michigan’s Institutional Review Board.

The materials developed for the group ANC model have been described elsewhere [26, 28]. Briefly, educational content was delivered through picture cards, role-play, story-telling, and teach-back to small groups of women with similar gestational age. Women remained in the same group throughout their pregnancy developing peer support with the women in the group. Women in both group and individual care were encouraged to attend seven ANC visits. Educational content was similar between both groups with one complete ANC visit dedicated to family planning and exclusive breastfeeding as a lactational amenorrhea method for birth spacing.

A facility-driven convenience sample of 240 women were initially enrolled in the study. We conducted the study at a busy urban district hospital in the Ashanti Region of Ghana outside one of the most populous cities. Women enrolling for their first antenatal visit, over the age of 18 years and less than 14 weeks gestation, were approached by a Ghanaian research assistant (RA). The RA described the purpose of the research, the participant’s ability to refuse to participate without any negative consequences or withdraw from the study at any time, the risks and benefits of participation, and the nature of the research. After informed consent was obtained, every other woman was then assigned to group or individual ANC for her next visit.

The outcomes of interest were use of any family planning at 1 year postpartum, use of a modern method of family planning at one year postpartum and exclusive breastfeeding at 6 months postpartum. Demographic data were collected on all women at the time of enrollment in the study. Data on intended breastfeeding length and intent to use family planning were collected immediately postpartum through face-to-face surveys or via cellphone by a Ghanaian RA using a structured survey. Longitudinal data on postpartum family planning use and length of exclusive breastfeeding for six months were collected one-year postpartum using a 9-question survey. Methods considered to be modern were injectable contraceptives, an intrauterine device, implant, or condoms. Non-modern methods included the lactational amenorrhea method, abstinence, or withdrawal. The surveys at one-year postpartum were conducted via cellphone by a Ghanaian research assistant. Participants were given a canvas carrying bag as a token of appreciation.

We were able to locate 164 women (68.3%) at one-year postpartum (Fig. 1).The majority of participants were Christian, multigravida, had completed at least junior high school, and were between the ages of 17–35 years old (M = 27.5 years old). Attrition analyses indicate women who were lost to follow-up were not statistically different than women who provided follow-up data other than they were more likely to have participated in individual prenatal care (<.001). In women who provided follow-up data there were no statistical differences in demographics between those who participated in group and those who participated in individual prenatal care (Table 1).

Overall, 57.6% of women were using no method of contraception at one-year postpartum, 35.8% were using a modern method, and 6.6% were using a non-modern method. Women who participated in group ANC were more likely to demonstrate intention to use family planning immediately postpartum than those who were in individual care (63.0% vs. 31.6%, X² = 16.49, p < .001), and one year post-delivery were more likely to actually be using a family planning method (59.1% vs 19%, X² = 26.309, p < .001) (Table 2).

Women in both individual and group ANC who reported they intended to use family planning immediately postpartum were more likely to be using a family planning method at one-year postpartum than those with no immediate postpartum intent (52.1% vs. 33.3%; X² = 5.191, p = .023) (Table 3).

Women who participated in group ANC had higher odds of using a modern or non-modern method of contraception at one-year postpartum, controlling for intention, age, gravida, religion, and education (AOR = 6.690, 95% CI: 2.724, 16.420).

Women who stated immediately postpartum that they intended to use contraception had higher odds of using a family planning method (modern or non-modern) one-year postpartum than those with no stated intention (OR = 2.171, 95% CI: 1.109, 4.250). There was no significant difference in family planning use based on age of participant, gravida, religion, or highest level of education. However, when controlling for ANC type, intention to use family planning was no longer a statistically significant variable.

Women who participated in group ANC had higher odds of using a modern family planning method than those in individual care at one year postpartum, controlling for intention, age, gravida, religion, and highest level of education (AOR = 8.063, CI:2.887,22.524). Immediate post-partum intention to use family planning did not have a significant effect on actual use of modern family planning.

A greater portion of women who participated in group ANC reported exclusively breastfeeding for more than 6 months than those in individual care (75.5% vs. 50%, X² = 10.94, p < .001). Women enrolled in group ANC had nearly three-fold odds of exclusive breastfeeding for more than 6 months compared with women in individual care, controlling for covariates (AOR = 2.84, 95% CI: 1.298, 6.216) (Table 4).