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Group Antenatal Care in Rwanda: Examining Successes and Challenges in Implementation


Increasing access to quality maternal health services for women in low and middle income countries (LMICs) is crucial in improving maternal and child health outcomes. Antenatal care (ANC) serves as an opportunity to provide clinical care and may be associated with an increased odds of delivering in a health institution.1–3 To address the utilization and quality of ANC, in 2016 the World Health Organization (WHO) provided updated recommendations for health systems interventions. Group antenatal care (group ANC) provided by qualified health-care professionals was highlighted as a promising intervention warranting implementation in the context of research.4 Traditional ANC models are centered around one-on-one visits between a pregnant woman and her health care provider. The visit focuses on the woman’s physical health, with the provider communicating clinical information and self-care recommendations. In contrast, group ANC uses an integrated approach, combining a physical assessment with group education and support.

The Preterm Birth Initiative (PTBi) – Rwanda conducted a cluster randomized controlled trial of group ANC to assess the impact of this care model on preterm birth. This dissertation assesses Community Health Workers’ (CHWs) experiences in piloting group ANC, the impact of introducing ultrasound in the context of individual ANC, and successes and challenges in implementing the program with fidelity to the program design.

Using focus group data, paper 1 explores the successes and challenges CHWs experienced in implementing the group ANC pilot program. Successes included effective training, collaboration between nurses and CHWs and perceived complementarity of group ANC with CHW’s existing community based responsibilities. Challenges included a need for additional training on various clinical topics, financial barriers to CHW engagement and problems in scheduling.

There is limited research on how the introduction of a technological intervention, such as ultrasound, can affect the delivery of other critical services when working in low resource settings. Paper 2 utilizes patient data from 8,910 women from 18 health centers to measure the association between the provision of ultrasound and the number of ANC screening factors assessed. There was no significant association between the provision of ultrasound and number of ANC risk factors assessed. Given the several limitations in conducting this study, we recommend further studies to assess the impact of ultrasound on ANC services.

Through the analysis of qualitative Activity Reports and quantitative Model Fidelity Assessments, paper 3 examines whether the program was implemented with fidelity. Results found implementing group ANC with model fidelity required: group ANC scheduling, preparing the room for group ANC sessions, provider capacity to co-facilitate group ANC, and facilitator knowledge and skills regarding group ANC content and process. Duration of program implementation was associated with improvements in implementation fidelity. Results illustrate the importance of monitoring implementation fidelity through the use of quantitative and qualitative tools and providing consistent training and mentorship throughout program implementation.

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