Plain English summary
Background
Utilization of antenatal care and postnatal care in Rwanda
Methods
Study design and setting
Participant recruitment and data collection methods
Round one
Round 2
Analysis and interpretation
Ethical consideration
Results
Timepoint | Themes | Sub-themes | Details |
---|---|---|---|
Before implementation | Group ANC may offer advantages for pregnant women | Social cohesion | Friendship; Shared accountability for perinatal outcomes in the community |
Shared knowledge | Overcome the fear of asking questions or disclosing concerns | ||
Some women may be too afraid to share personal information in a group | Test results and measurements should be confidential | ||
After implementation | Group ANC is better than individual ANC | Problem-solving and increased health literacy as a group | Increased participant knowledge about ANC interventions, nutrition, danger signs, planning for facility birth |
New and meaningful relationships form | Among pregnant women and between providers and pregnant women | ||
The group model of care cannot overcome all barriers to ANC and PNC attendance | Financial barriers are significant | Co-payments required at the time of care; lost wages; important work at home unattended while woman attends ANC | |
Distance between home and facility | Primary means of transportation is walking; other transportation is expensive | ||
Women forget appointment dates/times | An improved appointment reminder method is needed | ||
Shortage of staff at health centers results in long wait times in both models of care | Some group visits were abandoned by the provider who was called out to attend to a woman in labor | ||
Women, family members, and communities do not value PNC | Women expect a reward for “completing” the program |
Before implementation of group ANC and PNC
Group ANC may offer advantages for pregnant women
You can have a problem and then you try to resolve it but you don’t get the solution. But as we will be in group, you can share that problem with your group members who may advise you. Especially when you come for ANC, you have so many questions to ask; and when you want to ask to the healthcare provider, they don’t have enough time to answer. (Burera district, YW P7)
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)
Fear of sharing personal information
All people don’t have the same understanding. When you are alone with the healthcare provider, you tell them many things so that they may help you but when you are with many people, you hide some of the things relative to your disease and how you feel. (Bugesera district, W P6)
The woman can tell everyone your weight and comment on you [all the focus group participants laugh]. (Bugesera district, YW P1)
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)
After group care implementation
Group ANC is better than individual ANC
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)
The consultation in group care improves the relationships among people. For example, I didn’t know this woman before. Today I cannot pass by her without greeting her; she may even help me when I’ve got a problem and fail to remember what I can do about it; in that case I can feel free to ask her." (Nyamasheke district, HC1, P3)
Some mothers who were not yet in the group care . . . were surprised at seeing the nurse come and sit near me, and then ask me about my health and my child’s health. They eagerly inquired why she was much interested in me only to learn that we got to know each other when she was training us in the group care. Therefore, I found that there is a difference, and this led me to like the program much more and attend it. (Burera district, HC1, P7)
The group model of care cannot overcome all barriers to ANC and/or PNC attendance
[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)
It sometimes happens to a person to lack that amount of money of 200 Rwandan Francs we pay for the form which is filled for a woman who has come for consultation. This may also be a reason for some people to fail to attend! . . . When you don’t have this money, you can go to a friend and borrow. You may even stop buying salt provided that you bring [the money]. It is an obstacle [to ANC attendance]. (Nyamasheke district, HC1, P4)
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)
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. Some of their suggestions were related to solving problems that might impede attendance, and others noted that the logistics of starting and ending a group visit “on time” were complicated. A common response was that a better system is needed to remind women of the appointments, especially among those women who cannot read.All of us [in the same group] didn’t arrive here at the same time because of different distances we have to walk. A long distance can also discourage a person from coming here for consultation or tests. (Nyamasheke district, HC3, P2)
I can suggest that this topic [group ANC and PNC] should be made part of discussions we have during the parents’ evening [regular community meetings] where we may be together with our husbands. There, they may hear about it; or, as it was said, it can be made an obligation and be published to people as they publish other public meetings of local government. (Bugesera district, HC1, P6)
The postnatal component of the group care model in Rwanda was conceived as a way to introduce the 6-week postnatal visit to providers and mothers in a system that did not yet have a mature postnatal care package. When women were asked about their perceptions of group postnatal care, they reported a mix of confusion about the purpose of the visit, disappointment that they didn’t receive a gift for having completed the series of visits, and contentment when providers reassured them that their children were growing well.There is something which needs correction for both of 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 . . . the nurse also would fail to attend the group because of other clients she had to help. So, I would suggest that they may increase the number of nurses to help the other mothers so that the [provider] may be available on time. Group care members also should learn to keep time. (Burera district, HC1, P9)