Group antenatal care positively transforms the care experience: Results of an effectiveness trial in Malawi
Authors: Patil Crystal L. , Norr Kathleen F. , Kapito Esnath , Liu Li C. , Mei Xiaohan , Abrams Elizabeth T. , Chodzaza Elizabeth , Chorwe-Sungani Genesis , Kafulafula Ursula , Desloge Allissa , Gresh Ashley , Jeremiah Rohan D. , Patel Dhruvi R. , Batchelder Anne , Wang Heidy , Faydenko Jocelyn , Rising Sharon S. , Chirwa Ellen 
Published: December 2024

Background

We developed and tested a Centering-based group antenatal (ANC) model in Malawi, integrating health promotion for HIV prevention and mental health. We present effectiveness data and examine congruence with the only Group ANC theory of change model, which identifies key processes as supportive relationships, empowered partners in learning and care, and meaningful services, leading to better ANC experiences and outcomes.

Methods

We conducted a hybrid effectiveness-implementation trial at seven clinics in Blantyre District, Malawi, comparing outcomes for 1887 pregnant women randomly assigned to Group ANC or Individual ANC. Group effects on outcomes were summarized and evaluated using t-tests, Mann-Whitney, or Chi-squared tests, and multivariable linear or logistic regression models adjusted for baseline outcomes, seven individual and two clinic-level covariates. All statistical tests were two-sided, controlling for a Type I error probability of 0.01 due to multiple testing.

Findings

Women in Group ANC had higher peer connectedness and pregnancy-related empowerment, recalled receiving more services, and discussed more health promotion topics. They experienced less wait time, greater satisfaction with care (Estimate = 1.21, 99% CI = 0.07, 2.35), had a higher mean number of ANC contacts (Estimate = 0.74, 99% CI = 0.50, 0.98), and were more likely to complete at least four or eight contacts. Most women preferred Group ANC for a future pregnancy (81% in Individual ANC; 95% in Group ANC). Women in Group ANC had more diverse diets (Estimate = 0.35, 99% CI = 0.17, 0.53), were better prepared for birth (Estimate 0.32, 99% CI = 0.16, 0.48), more likely to use condoms consistently (OR= 1.07, 99% CI = 1.00, 1.14) and communicated more with partners. They reported less mental distress in late pregnancy (Estimate = -0.61, 99% CI = -1.20, -0.02). Exclusive breastfeeding, partner HIV testing and disclosure, facility-based delivery, postnatal care attendance, postpartum family planning, and low birth weight did not differ by ANC type.

Conclusions

This effectiveness study of Malawi Group ANC, the first trial with individual randomization in a low-income country, maps outcomes to the theory of change, enhancing our understanding of Group ANC’s diverse positive impacts. The integration of typically neglected health promotion topics highlights group care’s flexibility to address local and global needs. Based on study results, the Malawi Ministry of Health is introducing Group ANC at district-level trainings and exploring the logistics for nationwide adoption. With momentum and political will, we are poised to bring better care and a positive healthcare experience to women, infants, and families throughout Malawi and globally.