Description of the Sample
Between April 2018 and January 2019, 1,652 women were enrolled in group ANC, out of 5,120 new ANC clients recorded in the national health management information system for the study sites. Of the 162 groups formed, 103 were completed at the time of data extraction, with a total of 1,145 women (Table 2). The mean number of women per group was 11.1. We conducted more qualitative interviews with women aged 20–24 who participated in GANC and fewer with adolescents (as they were harder to access) and interviewed more female than male stakeholders.
Overall, demographics were similar between the baseline and endline samples, aside from a shift in the age distribution. At baseline, 44% of the sample was aged 20–24, which declined to 27% at endline, and in the 25–34 age group, these proportions were 40% and 56%, respectively. The overall pattern for lifetime number of births is similar for two births and higher, but the percentage of primigravidae was lower at endline compared to baseline. Other changes in the demographics are consistent with a slightly older sample, including a decrease in the number of primigravidae, an increase in the percentage married, and a larger average household size. The proportion of women reporting delivery at a facility increased from 89% at baseline to 92% at endline. At endline, only 36.1% of the sample had participated in GANC.
[Insert Table 2 here]
Our results were mixed. We saw the greatest change in the proportion of women who could identify three or more danger signs during pregnancy, but no change in reports about knowledge of what a woman could do to improve her and her baby’s health. We also saw changes in sharing of feelings and experiences with other women, a result strongly supported by our quantitative and qualitative findings. In addition, we found improvements in women’s ratings of the knowledge and competence of health workers, respect shown by ANC providers, and overall quality of care, although we did not find changes in their perceptions of other aspects of quality of care. These results were supported by the qualitative results. Quantitatively, we found little evidence of changes in empowerment, in contrast to our qualitative results, which found women participating in GANC reported both feelings of self-efficacy and being able to make a difference for the better. Our survey responses demonstrated improvements between 2.6 and 23.4 percentage points in different aspects of respectful care, although several of these may be explained by sampling error. Improvements were found in ANC retention and women who made two or more birth preparations, with a smaller improvement in women reporting that they prepared items for the baby or delivery, which may be explained by sampling error (see Table 3).
[Insert Table 3 here]
We assessed changes in knowledge from survey data, interviews, and FGDs. The proportion of survey respondents able to identify three or more danger signs of complications during pregnancy more than tripled, from 7.1% at baseline to 26.4% at endline (OR: 4.58; 95% CI: 2.26–10.61) (Table 3). Similarly, the percentage of women who could identify three or more ways to improve their and their baby’s health increased from 30.4% to 37.5% (OR: 1.37); however, the 95% confidence interval suggests that this change may be due to chance (Table 3).
In qualitative interviews and discussions, women reported an overall increase in knowledge as a result of Lea Mimba, in particular gaining practical information on how to care for themselves and their baby. Women reported that they not only learned essential information but also understood better why what they were doing was important for their health and for their baby and that this deeper understanding made them more willing to adopt healthy behaviors.
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
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.
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
Improved experience of care
We found improvements in women’s reports about their experience of care between baseline and endline, particularly in knowledge and competence of health workers (OR: 2.52 95% CI: 1.57–4.02), respect shown by ANC providers (OR: 1.82, 95% CI: 1.16–2.85), and women’s satisfaction with overall quality of care (OR: 1.62, 95% CI: 1.03–2.53) (Table 3). We saw an increase from 58.9% at baseline to 71.7% at endline of women who strongly agreed that they shared their feelings and experiences with other women (OR: 1.73, 95% CI: 1.1–2.7). We did not find any evidence that intent to use the same facility in a subsequent pregnancy changed between baseline and endline or that the proportion of respondents self-described as “very likely” to recommend the facility to other women changed. Similarly, we did not find evidence of changes in disrespect or humiliation.
Through qualitative data, women reported an improved experience of care in GANC as compared to traditional ANC—including improved communication, feelings of respect and dignity, and social and emotional support and solidarity.
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
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.
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
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.
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
Qualitative data also revealed a range of challenges that affected women’s experience of care. In particular, they experienced long wait times, leading to hunger, because other women in their group sometimes arrived late, or the health provider was not available, often with the result that sessions were not held as scheduled. Not all groups seemed to establish camaraderie, with some women noting they did not like the group or the other members.
We did not find evidence of changes in empowerment, as measured through PRES score, between baseline and endline in quantitative data, but women in qualitative interviews and discussions, especially adolescents, described increasing feelings of self-efficacy and confidence to adopt more healthy behaviors. Adolescent women reported that they became more empowered to do things they previously felt they could not do.
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
While this was explicitly expressed only among adolescent age groups, 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:
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
Across facilities, 22.4% of women attended ANC1 ≤12 weeks gestation, compared to data from the Demographic and Health Survey (DHS), which reported 19.7% of women had attended ANC in the first four months (32). These results should be treated with caution, as definitions of early ANC differ between our study and the DHS. Figure 1 shows the retention of women who were enrolled in GANC: 96% of women enrolled during ANC1 attended at least one more ANC (group or individual), 76% attended at least four visits, and 8% attended eight.
[Insert Figure 1 here]
The mean number of ANC visits increased by 0.89 visits (95% CI: 0.47–1.42) between baseline (4.21) and endline (5.08). Among women under 25, the mean number of visits increased by 0.79 (95% CI: 0.27–1.34) between baseline (4.23) and endline (5.11).There was no evidence from client surveys that the reason women attended ANC changed over the course of implementation.
The proportion of women reporting two or more of any of the listed preparations (Table 4) increased from 33.0% at baseline to 48.9% at endline (OR: 1.94; 95% CI 1.24–3.05); however, the improvement of 7.9% in preparing items for the baby or delivery may be due to chance (OR: 1.61; CI: 0.94 – 2.72). In qualitative interviews and discussions, both women and health providers noted improved behaviors in preparing for childbirth. They reported buying items for the baby, saving money for transport once labor began, and packing a bag to take to the facility.
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
… 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
[Inset Table 4 here]
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.
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
Our study also looked at the distribution of family planning methods at baseline and endline. We found no difference between women reporting family planning use at endline when compared to baseline or in women reporting facility-based delivery. We also measured the proportion of women reporting delivery at a health facility, but the difference between baseline and endline may be due to chance (OR: 1.51; CI: 0.70-3.37). In contrast, through interviews and focus groups, women of all ages spoke of the importance of delivery at a facility; health providers and managers also perceived an increase in the use of facility-based delivery at the project sites.
[M]ost of these mothers… are used to being delivered by the traditional birth attendants, but after all these teachings; I can say that we have improved on deliveries. At least they have improved because they come to the hospital for deliveries. They no longer go to the traditional birth attendants. Health provider, health center
While additional qualitative analysis compared health behaviors of women who attended fewer than four and more than four GANC sessions, we found no major difference between the two groups, except that women who attended more than four sessions tended to explain in more detail the behaviors they adopted.
We found a high level of fidelity to the contextualized model. There were, however, site-specific deviations related to women taking their own health measurements, depending on the willingness of the provider and availability of equipment. Participant and provider time diaries from traditional ANC (baseline) and GANC (endline) indicated that systemic and user factors, including human resources, infrastructure, and wait times, affected implementation. Some facilities were short-staffed, sometimes with only one health provider on duty, and other facilities (hospitals) experienced high staff turnover. Adequate space and privacy were not always available, with some facilities holding group sessions in corridors. While the design of the intervention intended to schedule the sessions in the afternoon, when facilities are often empty of regular patients, women reported that they typically arrived in the morning and waited until the provider was free. Health providers had to provide regular clinical services or respond to emergency situations in addition to GANC, often resulting in delays or cancellation of group sessions.
Women attending GANC spent substantially more time at the health facility as compared with their traditional ANC counterparts, not only due to increased time spent in facilitated discussions but also due to increased wait times. On average, at baseline women attending traditional ANC received approximately 6 minutes of individual counseling by health providers compared to 55 minutes of group sessions in GANC. The mean wait time during group ANC was 157 minutes as compared to 67 minutes in traditional ANC. Women would often wait for sessions to begin, attend the group session, and queue again for the individual clinical examination.
The frequency of community group meetings varied widely across project sites, with more difficulty reported for the referral hospital, mainly due to distance and other logistical factors. CHVs reported that women were able to develop savings programs and other types of income-generating activities to save money for delivery and other related costs.