Adapting group-based postpartum and well-child care using a human-centered design approach in Malawi

doi:10.21203/rs.3.rs-2223267/v1

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Research Article

Adapting group-based postpartum and well-child care using a human-centered design approach in Malawi

https://doi.org/10.21203/rs.3.rs-2223267/v1

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Journal Publication

published 14 Oct, 2023

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Background. Responsive and resilient strategies to reduce the high rates of maternal and infant mortality and clinician shortages are needed in low- and middle-income countries (LMICs). Malawi has some of highest maternal and infant mortality rates globally. Group-based healthcare is one such strategy to improve maternal and child health outcomes. Group-based care has been applied to the perinatal period, but less attention has been paid its potential benefits in postpartum care. The postpartum period is a period of opportunity for innovative approaches to engage mothers and children in care and contribute to the reduction of maternal and infant mortality and morbidity. We present the adaption of an evidence-based group-based perinatal care model to the postpartum period using human centered design with key stakeholders in Malawi.

Methods. To adapt the perinatal group-based care model for the Malawian context, the team completed four steps of a five-step framework guiding the use of human centered design: 1) define the problem and assemble a team; 2) gather information through evidence and inspiration; 3) synthesize; and 4) intervention design: guiding principles and ideation. Steps 2-4 relied on qualitative methods, in-depth interviews, and incubator sessions with key stakeholders to produce a prototype of the group-based postpartum care model.

Results Once the stakeholders had defined the problem of limited postpartum care in the context and assembled local and global team members, we completed 20 interviews and 6 incubator sessions with stakeholders. All stakeholders reported a desire to participate in and offer group care in the postpartum period in their community. Health promotion priorities identified were hygiene (e.g., perineal care), breastfeeding, family planning, nutrition, and mental health. The recommended group-based care implementation schedule includes 6 sessions that corresponds with the child vaccination schedule over the 12-month postpartum period. A prototype for the curriculum and implementation structure for group postpartum and well-child care was created based on the findings.

Conclusions A human centered design approach to adapt an evidence-based group-based care approach to an LMIC, Malawi is feasible and acceptable to key stakeholders and resulted in a prototype curriculum with practical strategies for implementation in the health care setting.

Maternal child health service

postpartum

infant health

preventive health services

High rates of maternal and infant morbidity and mortality persist in the postpartum period in low- and middle-income countries (LMICs). Globally, sub-Saharan Africa has some of the highest maternal mortality (MMR), severe maternal morbidity, and infant mortality rates (1, 2). Malawi, a country in the Southern Region has an MMR of 439 maternal deaths per 100,000 live births and for every 1,000 births 42 infant die (1). The postpartum period is one of heightened vulnerability that impacts the mental and physical health of a mother as well as how her child develops, learns, and thrives. The first six weeks is a period of physical recovery for the woman after childbirth, but other critical events occur beyond six weeks. The first year after childbirth is a crucial window for identifying and managing health and social challenges including psychosocial adaptations and transitions to a parental role (3). Postpartum stressors increase risk for fatigue and anxiety and decreased self-care, all of which can make women and children vulnerable to poor physical and mental health outcomes (3). Growing data on non-communicable diseases (NCDs) shows that NCDs and maternal health outcomes are inextricably linked, thus contributing to a high proportion of maternal morbidities and mortality (2). Pre-existing conditions and complications in pregnancy can increase the risk of developing long-term chronic health conditions (2). The first year of life for children is equally crucial for their long-term health and development and maternal morbidities have long-term health consequences for children (4–6). When responsive caregiving, attachment, cognitive stimulation, and social support are missing, children are more likely to experience negative behavioral, cognitive, social, and emotional outcomes (5–8). A reimagined form of integrated postpartum and well-child care that sets the stage for long-term health outcomes and well-being for both the mother and her child is needed.

Currently, the World Health Organization (WHO) recommends that every mother and infant have at least four postpartum visits within the first six weeks regardless of birth setting (9). In Malawi, despite current efforts to address high rates of maternal and infant morbidity and mortality, rates remain high. Only 42% of women and 60% of newborns receive a postpartum check in the first 2 days after birth and many are not checked at all (1). And only 48% of women are seen by a skilled health worker in the six weeks after delivery (5). A study examining quality of life in the postpartum period in Malawi found women had lower scores in the domain of physical health than other LMICs (11). Lack of and poor-quality postpartum care amplifies the vulnerabilities that women and infants in low resource settings face (12). Responsive and resilient health system strategies are needed to fill a gap in this non-acute period and address preventable maternal and infant morbidities and deaths.

Group healthcare is a health system innovation that can fill this void. Group antenatal (ANC) care has large body of rigorous evidence supporting its effectiveness and the feasibility of bringing it to scale. CenteringParenting is an emerging model of group postpartum/well-child care that shows promise in advancing guidelines for quality postpartum and well-child services, addressing gaps in care as indicated by a growing evidence base (13–26). The core components of this model are healthcare in a group space, interactive learning, and community building (27). In this model, the same group of 6–8 women and their similarly aged infants attend care together for up to two years (13). Each group visit is 120 minutes with the first 30–45 minutes consisting of self-care (measuring their own infant’s weight and length) and standard health assessments of the infant and mother by a clinician in a separate section of the room. Parent and/or infant referrals are made if needed. This is followed by 75–90 minutes of interactive health promotion, skills building, and support activities. Group-based care with longer visits provides time and resources to support and address maternal and infant health such as breastfeeding, family planning, depression, nutrition, child development and infection prevention, and by doing this improves quality of care and has the potential to reduce maternal and infant morbidity and mortality (13, 18, 28, 29). Not only do patients experience positive outcomes, studies show that clinicians also prefer delivering prenatal and postpartum care in a group, due to feelings of increased freedom of expression, and a dissolution of hierarchies (15, 21). This shift in power dynamics leads to increased quality of care, which can ultimately improve outcomes (15, 21).

Even though Centering-based group models of care have not been widely implemented in the postpartum period in LMICs, the model has been successfully adapted for antenatal care in Malawi and other countries in Africa such as Ghana, Nigeria, Kenya, and Tanzania (30). Group models are acceptable, feasible, and have improved outcomes including health literacy, prenatal and postpartum attendance, the number of health facility births, and breastfeeding practices (31–35). Expanding group healthcare into the postpartum period offers a promising strategy to reduce gaps in the care continuum. An integrated Centering-based group postpartum/well-child care model that is attentive to the multiple and interrelated individual, family, and economic barriers is pragmatic and innovative.

Human-centered design (HCD) offers an approach to co-design and safely, efficiently, and effectively adapt evidence-based interventions such as Centering-based group healthcare to new contexts. HCD emphasizes the strengths, agency, and priorities of women and health care workers to build a model of care that is resilient and responsive to individual, and system needs. This approach reframes a research question or behavior change from “what matters” to “what matters most,” allowing for solutions that are human centered and context specific (36, 37). Previous healthcare research supports the use of this approach, as participating in the co-design process increases self-efficacy for both patients and health care workers and leads to sustainable solutions to problems within the health system (38–45). While HCD is an increasingly used approach to finding healthcare solutions, recent systematic reviews of HCD in healthcare have found discrepancies in the quality and methodological rigor of the studies (46, 47). Human-Centered, Evidence-Driven Adaptive Design (AHEAD)(37) framework provides a practical guide to co-design solutions to healthcare challenges (37). The five steps of AHEAD framework (Fig. 1) include: 1) define the problem and assemble a team; 2) review evidence and seek inspiration; 3) synthesize; 4) develop guiding principles and ideate; 5) evaluate (37). The purpose of this study was to use existing evidence and the AHEAD framework to develop an integrated group-based postpartum and well-child care model in Malawi.

Study design and setting

This formative study was implemented in three primary care government clinics in Blantyre District, Malawi. These three clinics participated in a trial, “Group Antenatal Care: Effectiveness for Maternal/Infant and HIV Prevention Outcomes and Contextual Factors Linked to Implementation Success in Malawi,” (ANC Trial, UIC IRB #00403255), and have been implementing and sustaining group ANC since 2019 (48). Key stakeholders from these clinics included health workers and patients familiar with group healthcare are poised to provide in-depth perspectives on the benefits and challenges of group-based care. Experienced group ANC facilitators, midwives and community volunteers, and multiparous patients who completed group ANC and are receiving maternal and child health care were asked to participate. Each stakeholder is an in ideal position to inform the design of the integrated postpartum and well-child care group care prototype.

Sample and recruitment

Patients

Purposive sampling was used to recruit women for this study. Eligibility included participation in the group ANC trial and having two or more biological children. The rationale for multiparous women was to allow for comparisons across multiple pregnancies and experiences with postpartum and well-child care services.

Health care workers

Health care workers included midwives, community volunteers, and health surveillance assistants (HSAs). HSAs are a type of community health care worker paid by the government to serve as a link between communities and the health care sector, they have secondary school education, and receive 12 weeks of training and provide many of the under-five health care services, such as vaccinations and growth monitoring were approached to participate (49). Convenience sampling was used to recruit health care workers since there are a limited number of health care workers with group healthcare experience and that are working in postpartum and well-child care at each of the three clinics. Eligibility criteria for health care workers included the ability to read/speak Chichewa and/or English at a grade 8 level and that they had been working in postpartum or well-child care for at least one year. Exclusion criteria for the study included marked cognitive impairment that would prevent providing informed consent and if they did not speak and understand Chichewa (the national language).

Ethics

This study was approved by the Institutional Review Boards at Johns Hopkins University School of Nursing (IRB #00245018), Kamuzu University of Health Sciences (IRB #P.06/21/3341), and the University of Illinois Chicago (IRB #2022 − 0327).

Procedures

The five steps of the AHEAD framework are summarized in Fig. 1. Given the iterative nature of HCD, we detail the procedures for each AHEAD step along with the analysis and results since each step informs the next.

[Insert Fig. 1 AHEAD Framework for rigorous human centered design to produce the group postpartum/well child prototype]

Step 1: Define the problem and assemble a team

To define the problem, we completed an integrative review (50) to describe and evaluate current postpartum care content and service-delivery models used throughout the African continent. Guided by the WHO’s Maternal Morbidity Working Group’s conceptual framework for healthcare interventions to address maternal morbidity, we also identified multiple gaps in care. We showed that NCDs, intimate partner violence (IPV) screening, mental health, and a rights-based approach to care are rarely included (50). Group care and integrated maternal and child health services models were identified as ways to improve maternal and child health outcomes (50). We concluded that a standardized package of postpartum care that can be adapted for specific contexts from birth to one year postpartum is needed to further reduce maternal and infant morbidities and mortality (50).

The results of this review supported moving to Step 2. We leveraged existing partnerships, research infrastructure, expertise, and momentum from the ANC trial to assemble a team to guide the adaption and development of an integrated group postpartum and well-child care model.

Step 2: Gather Information through Evidence and Inspiration

In-depth interviews (51) were conducted with key stakeholders to inform the design of group postpartum and well-child care, identify priority health promotion topics to include in the prototype, and explore perspectives on extending group care into the postpartum period. Interview guides were first translated from English to Chichewa by a committee consisting of researchers, a bilingual midwife, and two lay people (52). The interview guides were piloted and refined to ensure appropriate framing and sequencing. Following an informed consent process, written consent was obtained, and interviews were conducted in Chichewa by a trained research assistant who is also a midwife in a private room reserved at the clinic and lasted approximately 45 minutes. The intent of the format and interview questions was to encourage participants to talk openly and solicit rich accounts about current postpartum and well-child care practices, patient flow, equipment/supplies, culturally appropriate services, postpartum health concerns, desired health promotion topics, and perspectives on group healthcare. For example, women were asked, what were your health needs during the postpartum period? Health care workers were asked, what topics do you think are important to cover in creating content for postpartum visits? We achieved thematic saturation after completing twenty-four audio-recorded interviews with 12 women, 4 midwives, 4 community volunteers, and 4 HSAs across the three clinics. Audio-recordings were transcribed and translated by the research assistant who conducted the interviews. To ensure translation accuracy, translations were reviewed by a team consisting of researchers, a bilingual midwife and two lay people so that English transcripts would be ready for the Step 3 analysis. To promote rigor and trustworthiness, the procedures adhered to recommended qualitative research guidelines and the consolidated criteria for reporting qualitative research (COREQ) (53, 54).

Step 3: Synthesis of Qualitative Data from Step 2

Transcribed interviews were stored, managed, and analyzed using Dedoose software. A content analysis approach was used to analyze interviews, and a category system was created based on the health promotion topics covered in the original Centering-based group care model for coding themes using the interviews as the unit of analysis (55). New codes were added as needed. Two team members coded each transcript separately and then met to compare and finalize the codebook. Although the analysis was largely deductive, we allowed for the inclusion of emergent codes, as we know that all health promotion topics and content areas of the original model may not be comprehensive of experiences in Malawi.

Women ranged in age from 19 to 41 years and had between 2 and 4 children. Health care workers were 35 to 58 years old and their years of experience in their current role ranged from 1 to 21 years. The information and insights gained through this analysis provided an empathetic view of what is currently offered as part of postpartum and well-child care in the Malawian context and allowed the women and health care workers to express what mattered most to them as they identified postpartum and well-child care service and health promotion priorities.

We identified five themes: 1) maternal health assessments are not consistently completed; 2) challenges exist to postpartum and well-child care attendance and delivery of care; 3) postpartum and well-child health promotion topics are not standardized; 4) maternal and child health concerns included physical and psychological issues; and 5) there is buy-in for the group healthcare model from both women and health care workers. See Table 1 for illustrative quotes by theme.

Table 1

Themes from interviews with participants and illustrative quotations
Theme	Illustrative Quotations
Maternal health assessments are not consistently completed
1-week visit	• At the first week, we are assessing if the baby is breastfeeding well; we ask them if they have experienced any problems. So, if they say there is no problem then we do an assessment of the baby. Midwife 2, Clinic B
1-week visit	• They weighed the baby, then she was 2.5 kgs but his birth weight was 2.9 kgs. And then they said that I should go and get vaccine for the baby; they gave the baby an injection on the arm and then also some on the tongue…they did not ask me how I am doing…They checked the baby on the cord, and they also gave me iron tablets. Mother, Clinic C
6-week visit	• At 6 weeks they [women] don’t meet us; they go for vaccines. Midwife, Clinic A
	• [At 6 weeks] I reported here…they checked the baby on the cord and then they told me to go for immunization. Mother, Clinic C
	• [At 6 weeks] they report at the under-five clinic but if they have problems, they come back to the maternity. But those who are ok don’t come back unless if the woman wants family planning methods. Midwife 2, Clinic A
Challenges exist to postpartum and well-child care attendance and delivery of care
Responsibility of health care workers and their attitude	• I think the gaps are many, but I think for most of the gaps, we are the ones that create them; may be because sometimes we have work overload, and we tend to skip most of the things that are supposed to be done with the woman. But we have everything that we need to tell the women…So it all starts with us; we need to teach them. At one week they come but at 6 weeks to be honest they don’t come to be reviewed by the nurse, they just come for a vaccine, if they come here, it’s because they have a problem. Midwife 2, Clinic A
Responsibility of health care workers and their attitude	• …If the health workers’ attitude is good, women come to the under-five clinic, but if the attitude of the health worker is not right, women stop coming to the clinic. They seek care from another place. HSA 2, Clinic B
	• We know the baby is supposed to get vitamins every 6 months. But you find that 6 months have elapsed, and the baby is not given the vitamins. So sometimes we just look, we can’t ask because we are afraid. Mother, Clinic B
Lack of resources (e.g., staff shortage, lack of equipment)	• But sometimes we are busy, when the woman just says that she is fine, you just continue without paying attention to the woman, not knowing that she has other issues. But because she didn’t say, you don’t know and because you didn’t inquire, then the woman is not properly assisted. Midwife 2, Clinic B
Lack of resources (e.g., staff shortage, lack of equipment)	• We need to also be checking vital signs but at this facility we don’t have equipment. Midwife 1, Clinic A
Perceived lack of knowledge	• We can also say it is a lack of understanding on the importance of postnatal care. So, to them, it’s enough if the baby got the initial vaccine. The rest is not important to them; I also think it’s because of lack of knowledge. So, we just need to sit down with them and explain in detail, so they understand. Midwife 1, Clinic C
Environmental	• …there are some who are very far, but we fail to reach out to them because of floods. You find that a place which is close by, become inaccessible during rainy season… HSA 1, Clinic C • The issue of distance in this area, being a hilly area, and also rivers during rainy season, make women not come to the clinic if it’s raining…The distances are very long and it’s difficult for a woman to travel with a small baby. Midwife 2 Clinic B
Maternal and child health concerns included physical and psychological issues
Physical	• Then another problem is nutrition; when they tell you that they baby is not having enough breastmilk, you can see that the nutrition of the mother is very poor. And you can see that the way the woman is looking she is poor. Midwife 1, Clinic C
	• Malnutrition is about 10–12% of all the children that we see at the under-five clinic. HSA 2, Clinic C
	• But most of the women when they come, we find that their BPs are very high, so we give them medication. Midwife 1, Clinic A
	• Most of the times the women don’t say, but sometimes they would tell you that the baby had diarrhea. For the first 6 months we have common problems like diarrhea and also malaria…But we emphasize a lot on the growth monitoring and if we see that the weight has dropped a lot, we refer women to the nutrition unit. HSA 1, Clinic C
Mental health	• They also told me that when a woman has just delivered, sometimes you may have psychological problems so when I feel like that, I should rush to the hospital because it shows that something is happening in the body. Mother 3, Clinic B
Mental health	• On the psychological, we check so many things; like here, most of the women have children with men that left them, and they don’t have any support for the child; some women are staying with someone who abuses them, and this affects how they are breastfeeding the baby. Midwife 2, Clinic A
Health promotion topics discussed in both postpartum and well-child visits are not standardized
	• See Table 3 for list of health topics currently being discussed at health visits
There is buy-in for the group healthcare model from both women and health care workers
	• I think that [extending group care into the postpartum period] would be a very good thing because if like the way we were doing when we were pregnant, we were sharing ideas so that we should not be in the dark, so I think that if we do the same thing now that we have delivered, it can still help us; we can still share ideas. For example, if someone has a problem and she shares it on the group, we can help each other. For example, the way I was struggling with my baby when she was having fevers, there could be some women who had also experienced that, and they know exactly what to do They could have assisted me. Maybe it’s at night, I can’t come to the hospital right away, those advice help. So, to me, I think the group care approach is the best; it is very helpful. Mother 1, Clinic B
	• I would have loved if these groups continued. Sometimes things happen in the village; emergencies and the doctor is not readily available you can assist someone and save a life because at least you know some things. Mother 2, Clinic B
	• I believe that the group postnatal care could assist a lot because there are so many things that the women don’t know; and when they are in groups and they receive counseling, I feel this can help to improve their well-being, both the mother and the baby. Because I strongly feel that these women can take very good care of their babies, they only need enough time to get enough counseling. But I feel that if you can adopt that model, it will be very helpful. HSA 1, Clinic C
	• That can work very well, and it can be very good. Because as for us we just see the babies once, but that can assist us to be following up on the babies to some point and be monitoring them, so it can be very good because it will bring change. It can also improve the way we do our work because then the babies can also be seen at 6 weeks. So, it is very good so many things can change. Midwife 1, Clinic A

When women and health care workers explained that current one- and six-week postnatal visits often focused on the infant health assessment. Most women did not get a physical assessment although midwives did describe discussing danger signs at the postnatal visits. Women were instructed by health care workers to bypass 6-week postnatal check and go straight to the under-five clinic. A woman noted that she was too afraid to ask questions or ask for services because of the negative attitudes of health care workers. While the health care workers recognized the need for thorough physical examinations of the woman and infant and wanted to complete them, they often cited staff shortages and lack of equipment as reasons for incomplete exams. In addition to describing the clinic-level challenges, some midwives took personal responsibility for the lack of postnatal care. Health workers also explained that the rainy season, difficult terrain, and long travel distances made getting to the clinic a challenge for their clients. Others cited poverty and relationship conflicts as additional access barriers for women. Participants identified individual, structural, economic, and environmental factors related to attendance and delivery of services (see Table 1 for illustrative quotes describing these challenges).

When asked to identify which health promotion topics were currently discussed at clinic, responses varied and were inconsistent (see Fig. 2, topics in the blue circle). Some mothers expressed that they did not receive any health education. When asked what common maternal health concerns they experienced responses included: difficulty breastfeeding, poor nutrition, IPV, sexually transmitted infections, mental health, high blood pressure, malaria, complications post c-section, late in seeking care for health issues, and sepsis. When asked about common child health concerns they described: cord infections, malnutrition, poor growth, eye infections, jaundice, skin problems, diarrhea, pneumonia, and coughs and fevers.

All participants reported a desire to participate in or offer group care during the postpartum period. Mothers felt that the group care model was supportive and helped them translate knowledge into practice and better address health concerns. Health care workers expressed that group care could improve overall quality of care.

[Insert Table 1 Themes from interviews with participants and illustrative quotations]

Step 4: Intervention Design: Developing the Guiding Principles and Ideation for Content and Structure of the Integrated Group Postpartum and Well-Child Care Prototype

Building on the Step 3 synthesis, we carried out incubator sessions with key stakeholders. A total of six incubator sessions, two at each clinic, were completed with one to three women and two health care workers, a midwife, community volunteer, or HSA. Incubator sessions are like focus groups, but the emphasis was on developing the health promotion content, interactive learning activities, and structure of the group postpartum/well-child through brainstorming, co-creation, and finding solutions. Multiple qualitative methods supported this process including free listing, pile sorting and ranking (56, 57). Free listing, successfully used in public health research (56), is a method for rapidly gathering information on a topic by listing as many ideas as possible related postpartum and well-child care. This approach allows for examining intracultural variations of postpartum and well-child care and provides opportunities to build consensus about healthcare services priorities (50).

Following an informed consent process, written consent was obtained, and incubator sessions were conducted in Chichewa by a trained research assistant. In-person incubator sessions lasted 1–2 hours and took place in a private room reserved at each clinic. Participants were asked to free list what they wanted to be addressed in postpartum and well-child care and their responses were recorded on a flip chart.

The research assistant then presented and described each health promotion topic generated from Steps 2 and 3 (see Fig. 2, blue and purple circles) and health promotion topics and activities included in Centering-based group care model to participants. Participants were instructed to confirm or reject each of these. We retained all topics that had a majority vote among participants. Then each item was written on a card which the research assistant read aloud to participants during a group pile sorting and ranking activity (57). Participants worked collaboratively to rank the topics and generate a prioritized list for the final prototype. Participants were then asked to identify which type of group ANC interactive activities (e.g., games and role plays), should be retained in the final prototype.

Participants were asked to explore the ideal visit length and structure and provide feedback on how to implement group postpartum/well-child care feasibly and sustainably at their clinic. Other implementation factors were asked about including resource availability, scheduling, follow-up care, and ways to integrate this service delivery model within the existing infrastructure.

Incubator session data analysis was iterative and included continuous data integration and consultation with key stakeholders. The set of codes were analyzed using a framework method for qualitative analysis (58) because the defining feature of this method is a matrix output of summarized data. The framework method includes seven analytical stages: 1) transcription and translation of transcripts; 2) familiarization with the interviews/focus groups; 3) coding (An initial set of codes was developed based on the health promotion topics and activities included in the Centering-based group care model; 4) developing a working analytical framework using a few transcripts after initial coding (codes are grouped together based on sessions and content areas); 5) applying the analytical framework to remaining transcripts using existing categories and codes (new codes were added as they emerged); 6) charting data into the framework matrix (in an Excel spreadsheet to manage and summarize data); and 7) interpreting the data (58).

The iterative process of data collection and analysis from Steps 2–4 were used to produce the group postpartum and well-child care prototype which included the health promotion topics and structure of implementation.

Health promotion topics

At incubator sessions when the Step 2 current and recommended health promotion topics were presented to participants, they confirmed that all the presented health promotion topics should be included in the group postpartum/well-child care prototype. See Fig. 2 for a comparison of what was described in current practice during the interviews (Step 2), what was recommended during interviews (Step 2), and what health promotion topics were prioritized in Step 4.

[Figure 2 Health promotion topics described as current practice, recommendations, and/or priorities]

During the free listing activity, seven additional health promotion topics were added such as how to care for babies with abnormalities and male involvement. Women and health care workers often provided explanations for why they thought each one was important that reflected their prior experiences. As part of the prioritization process, participants also linked topics that should be introduced together (e.g., family planning and return to sexual activity; Table 2).

Table 2

Number of incubator sessions (n = 6) that prioritized each health promotion topic
Number of Session						Health Promotion Topic
1	2	3	4	5	6
▪	▪	▪	▪	▪	▪	Hygiene
▪	▪	▪	▪	▪	▪	Exclusive breastfeeding
▪	▪	▪	▪	▪	▪	Family planning (combined with return to sexual activity)
▪	▪		▪	▪	▪	Nutrition
▪	▪		▪	▪		Depression screening/mental health
	▪		▪	▪	▪	Growth monitoring
		▪	▪	▪	▪	HIV Prevention of Mother-to-Child transmission
▪	▪		▪			Immunizations
	▪	▪	▪			Danger signs for mother and baby
		▪		▪	▪	Intimate partner violence
			▪	▪	▪	Sexually transmitted infections
▪		▪				Anemia/Iron supplements
	▪			▪		Developmental milestones
▪					▪	Illness management
		▪			▪	Disease prevention
		▪		▪		COVID-19
	▪	▪				Kangaroo care
		▪			▪	Harmful cultural practices
▪						Male involvement
▪						Relationship issues
	▪					Childcare
		▪				Hypertension
					▪	Bonding/attachment

The final list of health promotion topics included in the prototype were: hygiene, exclusive breastfeeding, family planning (combined with return to sexual activity), nutrition (for both mother and infant), depression screening/mental health, growth monitoring and developmental milestones, sexual health (including STIs and HIV), immunizations, danger signs for mother and baby, IPV and relationship issues, mother’s physical health (including anemia, hypertension, and cervical cancer screening), disease prevention and management (including COVID-19 and common maternal and child health concerns), and male involvement. The preferred interactive learning activities were role plays and discussions.

Structure of Implementation

There was consensus across all three clinics to create a 6-visit model with recruitment occurring at the 1-week postpartum visit and the first group visit beginning with the 6-week postpartum visit. They suggested that the schedule correspond with the child vaccination schedule (6, 10, and 14-weeks and 6, 9, and 12-months) with each group 1–2-hour visit being co-facilitated by a midwife and an HSA. Some hypothesized that this schedule would increase vaccine uptake since vaccines would be administered at the end of each visit. Responses varied for the ideal group size ranging from 8–15 mother/infant dyads.

Participants outlined a set of resources and materials needed to successfully provide high quality care in a group format that included: training, an adult and baby weight scale, blood pressure equipment, thermometer, tape measure, an examination bed, mattress protectors, a mat to sit on, privacy screen for in the room, physical assessment guidelines, hand sanitizer, laminated pictures of danger signs to show women, flip charts, toys for babies, and a storage basket. Many health care workers stated they did not have access to guidelines to perform standardized physical assessments. So, they recommended inclusion of written clinical maternal and infant assessment guidelines for each visit to standardize and improve the quality of these health assessments.

The Prototype

As part of Step 4, a curriculum and implementation structure prototype for group postpartum/well-child care was produced. The prototype consisted of a facilitator’s guide outlining each of the six visits with a detailed plan for each visit that included the associated clinical guidelines for physical assessments and objectives and directions for each interactive learning activity reflecting the prioritized health promotion topics (Table 2), as well as an implementation plan. For example, for the six-week visit, interactive learning activities focus on danger signs for mom and baby, physical and emotional adjustments after having a baby, breastfeeding, and family planning/resuming sexual activity. Each visit outlines all activities necessary to maintain model fidelity to Centering-based group healthcare’s core components of healthcare in a group space, interactive learning, and community building.

Seven midwives experienced in group care (5 from Malawi including the principal investigator of the Group ANC Study, and 2 in charge of clinics participating in this study) and 2 registered nurses (1 specializing in pediatric care) validated the content and structure of the facilitator’s guide and implementation plan. Based on their input content was added or refined and irrelevant content was removed. The clinical guidelines for assessments for women and infants and developmental milestones infants are expected to achieve at each visit in the facilitator’s guide were reviewed to ensure that these adhered to the guidelines and recommendations of the American Academy of Pediatrics Bright Futures (59), WHO (9), and Malawian Ministry of Health. The finalized facilitator’s guide has been translated into Chichewa and is ready for the final step in the AHEAD framework which includes a pilot test and evaluation.

Our prototype of group postpartum and well-child care produced using an HCD approach guided by the AHEAD framework is ready for rigorous evaluation (37). The results of the first four steps of the AHEAD framework showed that group care is a promising strategy for improving health outcomes in the postpartum period (50). The evidence and inspiration from engaging with women and health care workers reinforced findings from other studies that there are gaps in the availability and provision of postpartum care to mothers in Sub-Saharan Africa (60). The HCD approach lays the foundation for a responsive and resilient adaptation of group care that is co-designed by women, health care workers, and researchers. As with other studies using HCD approaches this leads to sustainable solutions to health care issues (45, 46, 61, 62). The reciprocity and power sharing that is inherent to the co-design process of the AHEAD framework offers a strategy to reduce medical hierarchies and center the voices of patients receiving care and health care workers providing it (63). This iterative process laid the foundation for a flexible model that can respond to the changing and dynamic needs of patients and health care systems.

Prioritized health promotion topics included a range of physical, psychological, social, and behavioral issues. Consistent with current literature, there were noticeable differences in topics desired and prioritized compared to current practice, particularly related to mental and sexual health (64, 65). The acknowledgement of the high prevalence of perinatal mental health disorders is growing globally and there is a call for models of care that integrate mental health into primary care to improve outcomes for women, which is particularly critical in the postpartum period (66). Interestingly, malaria was not prioritized or recommended through this work which might signal that people feel they have adequate knowledge and understanding of prevention and treatment strategies. Participants noted several social factors and prioritized male involvement in care and relationship issues. These are important to integrate into the model because it is well-established that the social context of patients’ lives has implication for maternal and child health outcomes that need to be addressed clinical practice (67). The priority placed on both maternal and child nutrition, malnutrition, and anemia in women highlights the many forms of undernutrition persisting among women and children in many LMICs (68). Group care during the first 1,000 days offers a promising strategy to identify and manage health issues such as undernutrition that is likely to have the highest gains and improve the nutritional status of women and children during this critical period in the life course (68).

The group postpartum and well-child care prototype and model offers a strategy to reduce maternal and child morbidity and mortality by integrating maternal and child health care and placing a focus on health promotion and prevention activities addressing NCDs, health-related social needs, and factors that affect morbidity beyond the immediate postpartum period within each visit which aligns the WHO’s Maternal Morbidity Working Group’s conceptual framework for healthcare interventions to address maternal morbidity (69). A shift to a group healthcare model is an innovative strategy for strengthening health systems because a model, informed by the steps of the AHEAD framework has flexibility to be responsive and resilient to changing contexts and provides a strategy to adapt the group postpartum and well-child care model to meet changing needs in the future and to diverse contexts (69). The interactive learning component of this model increases the total amount of time that each mother receives health promotion in the first year of life. This adult learning approach is responsive to group needs and provides opportunities to exchange ideas as group members work to better understand and ultimately apply lessons learned to their lives. By transforming the delivery modality of postpartum and well-child care to an integrated group healthcare model, the needs of the mother and the infant are met efficiently at the same time. This model seeks to identify and address the underlying causes of maternal and child morbidities and places importance on the health system’s role in influencing health outcomes.

The implementation plan created reflects one that is responsive to the desires of women and the realities of the health care system based on shared decision making during the incubator sessions in dialogue with both patients and health care workers. The next step in the AHEAD framework will be to pilot all 6 sessions included in the prototype with women and their infants in the postpartum period and assess its feasibility, acceptability and appropriateness among women and health care workers.

Using a human-centered design approach to adapt this model of care for the Malawian context centers co-creation, collaboration, and coordination at the patient, clinician, and health system level setting the stage for a responsive strategy to fill a critical gap in the care continuum and improve maternal and child health outcomes. This integrated maternal health and well-child group-based model of care may serve as a transformative approach to filling a neglected area of the care continuum that meets the needs of the dyad in the first year postpartum.

LMIC Low- and middle-income country

MMR Maternal mortality rate

NCD Non-communicable disease

ANC Antenatal care

HCD Human-centered design

AHEAD Human-Centered, Evidence-Driven Adaptive Design

WHO World Health Organization

HSA Health surveillance assistant

IPV Intimate partner violence

COREQ Consolidated Criteria for Reporting Qualitative Research

HIV Human Immunodeficiency Virus

STI Sexually Transmitted Infection

COVID-19 Coronavirus disease

Ethics approval and consent to participate. This study was approved by the Institutional Review Boards at Johns Hopkins University School of Nursing (IRB #00245018), Kamuzu University of Health Sciences (IRB #P.06/21/3341), and an exemption from the University of Illinois Chicago (IRB #2022-0327). Following an informed consent process, we obtained written informed consent from all participants.

Consent for publication. Not applicable.

Availability of data and materials. The datasets generated and/or analyzed during the current study are not publicly available to maintain confidentiality of participants but are available from the corresponding author on reasonable request.

Competing interests. The authors declare that they have no competing interests.

Funding. Ashley Gresh was supported by the National Institute of Nursing Research of the National Institutes of Health under Award Number F31NR019205. The funders played no role in research design, data collection, data analysis, manuscript write-up, or decision to publish. Any opinions, findings, conclusions, or recommendations expressed in this article are those of the authors alone and do not necessarily reflect the views of the National Institutes of Health. This study also received IRSP support from the UIC College of Nursing Dean’s Fund.

Authors' contributions. AG conceived and designed the study, analyzed, and interpreted the data, and drafted and revised the manuscript. AB contributed to the analysis, interpretation of data and revised the manuscript. JM contributed to the design of the work, NN contributed to the design of the work, EK contributed to the design of the work, interpretation of data, and revisions, CP contributed to the interpretation of data and revisions, AM contributed to the design of the work and revisions, EC contributed to the design of the work, NG contributed to the design of the work, and substantial revisions, CLP contributed to the design of the work, analysis and interpretation of data, and substantial revisions. All authors have approved the submitted version.

Acknowledgements. Not applicable.

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Adapting group-based postpartum and well-child care using a human-centered design approach in Malawi

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Background

Methods

Study design and setting

Sample and recruitment

Ethics

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Step 1: Define the problem and assemble a team

Step 2: Gather Information through Evidence and Inspiration

Step 3: Synthesis of Qualitative Data from Step 2

Results

Health promotion topics

Structure of Implementation

The Prototype

Discussion

Conclusions

Abbreviations

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