Recommendation

Group antenatal care provided by qualified health-care professionals may be offered as an alternative to individual antenatal care for pregnant women in the context of rigorous research, depending on a woman’s preferences and provided that the infrastructure and resources for delivery of group antenatal care are available

(Context-specific recommendation)(research)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

 

Remarks

• With the group ANC model, the first visit for all pregnant women is an individual visit. Then at subsequent visits, the usual individual pregnancy health assessment, held in a private examination area, is integrated into a group ANC session, with facilitated educational activities and peer support.
• Health-care facilities need to be seeing sufficient numbers of pregnant women, as allocation to groups is ideally performed according to gestational age.
• Health-care providers need to have appropriate facilities to deal with group sessions, including access to large, well ventilated rooms or sheltered spaces with adequate seating. A private space should be available for examinations, and opportunities should be given for private conversations.
• Group ANC may take longer than individual ANC, and this may pose practical problems for some women in terms of work and childcare. Health-care providers should be able to offer a variety of time slots for group sessions (morning, afternoon, evening) and should consider making individual care available as well.
• The GDG noted that group ANC may have acceptability and feasibility issues in settings where perceived differences keep people apart, e.g. women from different castes in India may not wish to be in a group together.
• Group ANC studies are under way in Nepal, Uganda and five other low-income countries, and the GDG was informed by a GDG member that some of these studies are due to report soon. Core outcomes of studies of group ANC should include maternal and perinatal health outcomes, coverage, and women's and providers' experiences.

 

Background

ANC conventionally takes the form of a one-on-one consultation between a pregnant woman and her health-care provider. However, group ANC integrates the usual individual pregnancy health assessment with tailored group educational activities and peer support, with the aim of motivating behaviour change among pregnant women, improving pregnancy outcomes, and increasing women’s satisfaction (1). The intervention typically involves self-assessment activities (e.g. blood pressure measurement), group education with facilitated discussion, and to socialize. Group ANC needs to be delivered in a space large enough to accommodate a group of women, with a private area for examinations.

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (2). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (3) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (4) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (5) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

• Should group ANC be recommended as an alternative to standard ANC care to improve quality of care?

 

Evidence summary

The evidence on the effects of group ANC was derived from a Cochrane review that included four trials involving 2350 women (1). Two trials from the USA used a group ANC model known as CenteringPregnancy®, in which group ANC was conducted in circles of 8–12 women of similar gestational age, meeting for 8–10 sessions during pregnancy, with each session lasting 90–120 minutes. Sessions included self-assessment activities (blood pressure measurement), facilitated educational discussions and time to socialize, with individual examinations performed in a private/screened off area. One trial conducted in Sweden used a group model similar to the USA model but mainly assessed provider outcomes and contributed little data to the review. The fourth trial, conducted in the Islamic Republic of Iran, was a cluster-RCT in which group ANC was described as being similar to the CenteringPregnancy® approach.

Maternal outcomes

Moderate-certainty evidence indicates that group ANC probably does not have an important effect on vaginal birth rates compared with individual ANC (1 trial, 322 women; RR: 0.96, 95% CI: 0.80–1.15). But low-certainty evidence suggests that it may lead to higher women’s satisfaction scores (1 trial, 993 women; MD: 4.9, 95% CI: 3.10–6.70).

Fetal and neonatal outcomes

Moderate-certainty evidence indicates that group ANC probably has little or no effect on low birth weight (3 trials, 1935 neonates; RR: 0.92, 95% CI: 0.68–1.23) and low-certainty evidence suggests that it may have little or no effect on perinatal mortality (3 trials, 1943 neonates; RR: 0.63, 95% CI: 0.32–1.25). However, low-certainty evidence also suggests that group ANC may reduce preterm birth (3 trials, 1888 women; RR: 0.75, 95% CI: 0.57–1.00); this evidence includes the possibility of no effect. Evidence on the risk of having an SGA neonate is of a very low certainty.

 

Additional considerations

There is little evidence on the effects of group ANC from LMICs. However, a feasibility study conducted in Ghana suggests that group ANC might improve women’s pregnancy experiences, and providers’ experiences, and potentially improve health outcomes in low-income settings, due to improved health literacy and better engagement of pregnant women with ANC (6). It is plausible that group ANC may have an impact on other outcomes outside the scope of the ANC guideline, such as breastfeeding initiation and postnatal contraception, by improving communication and social support related to these healthy behaviours; but the evidence on these potential effects is limited (7). 

Resources

It has been suggested that group ANC may be associated with lower health-care provider costs due to increased staff productivity and efficiency; e.g. health-care providers do not need to repeat advice to each woman individually, and they may be less likely to feel overwhelmed by long queues of women waiting to be seen (8,9). However, training and supervising health-care providers to conduct group-based counselling and participatory discussions is also associated with cost. Group ANC visits take longer than individual visits, therefore, from a user perspective, there may be additional costs associated with the time each pregnant woman needs to take off work. However, in many settings, long waiting times are the norm, so group ANC with a scheduled appointment could represent a reduced visit time.

Equity

Less-educated women are more likely to have poor maternal health literacy than more-educated women (6). Therefore, interventions such as group ANC that aim to improve women’s ability to access, understand and use educational materials could have a positive impact on reducing health inequalities by improving maternal health literacy among disadvantaged women. In addition, social support is often lacking for disadvantaged women and group ANC may help to reduce inequalities by facilitating the development of peer support networks. However, in certain settings, where group ANC sessions take longer than standard ANC visits, there may be greater cost implications for disadvantaged women. In addition, in settings with poor transport systems or variable weather, the appointment system with group ANC may not be suitable and may have a negative impact on equity for women living in remote areas. Furthermore, some disadvantaged women might find it harder to disclose personal information in a group setting and might prefer a more private approach to ANC.

Acceptability

Qualitative evidence from several HICs suggests that women enjoy the group format and use the opportunity to build socially supportive relationships with other pregnant women and health-care professionals (high confidence in the evidence) (10). The flexibility of the format allows women to exchange valuable information with each other and discuss pregnancy-related concerns in a relaxed and informal manner (high confidence in the evidence). Most women appreciate the additional time inherent in the group approach (high confidence in the evidence), although some women do not attend group sessions because of the additional time commitments (moderate confidence in the evidence). Some women have reservations about the lack of privacy during the group sessions, particularly during physical examinations (low confidence in the evidence) and the desire to have partners/ husbands included varies (moderate confidence in the evidence). Evidence from providers in HICs suggests they find group sessions to be enjoyable and satisfying and a more efficient use of their time (moderate confidence in the evidence) (11). Providers also identified the group approach as a way of providing continuity of care (moderate confidence in the evidence).

Feasibility

Qualitative evidence from high-resource settings suggests that health-care professionals view the facilitative components of group ANC as a skill requiring additional investment in terms of training and provider commitment (moderate confidence in the evidence) (11). Some providers also feel that clinics need to be better equipped to deliver group sessions, i.e. clinics need to have large enough rooms with adequate seating (moderate confidence in the evidence). The feasibility of group ANC in low-resource settings needs further research; however, pilot studies in Ghana, Malawi and the United Republic of Tanzania suggest that group ANC is feasible in these settings (8). It has been suggested that group ANC may be a feasible way of improving ANC quality in settings where relatively few providers attend to relatively large numbers of women in a limited time and, as such, effective communication can be challenging (9). Others have suggested that the group approach may be a sustainable way of providing continuity of care (8).

 

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement- eng.pdf?ua=1

 

Implementation considerations

• The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
• The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
• An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
• Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
• Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified these priority questions related to this recommendation

• Can a group ANC model be developed for LMICs, to provide guidance on the optimal group size, frequency and content of group ANC contacts?
• Is group ANC acceptable (data should include the views of women who decline to participate), feasible and cost-effective in LMIC settings?
• Are mixed models (group and individual ANC) feasible and acceptable, and are there benefits to mixed models?
• What are the effects of group ANC on maternal and perinatal health outcomes, coverage outcomes (ANC contacts and facility-based births), and women’s and providers’ experiences?
• Should women with complicated pregnancies also be offered group ANC, for the communication and social support aspects, in addition to receiving specialist care?

 

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

References

1. Catling CJ, Medley N, Foureur M, Ryan C, Leap N, Teate A, Homer CSE. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2015;(2):CD007622.
2. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
3. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
4. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
5. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
6. Lori JR, Munro ML, Chuey MR. Use of a facilitated discussion model for antenatal care to improve communication. Internat J Nurs Stud. 2016;54:84–94. doi:10.1016/j. ijnurstu.2015.03.018.
7. Ruiz-Merazo E, Lopez-Yarto M, McDonald SD. Group prenatal care versus individual prenatal care: a systematic review and meta-analysis. J Obstet Gynaecol Can. 2012;34(3):223–9.
8. Patil CL, Abrams ET, Klima C, Kaponda CP, Leshabari SC, Vonderheid SC et al. CenteringPregnancy-Africa: a pilot of group antenatal care to address Millennium Development Goals. Midwifery. 2013;29(10): 1190–8. doi:10.1016/j.midw.2013.05.008.
9. Jafari F, Eftekhar H, Fotouhi A, Mohammad K, Hantoushzadeh S. Comparison of maternal and neonatal outcomes of group versus individual prenatal care: a new experience in Iran. Health Care for Women Int. 2010;31(7):571–84.
10. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
11. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on group antenatal care. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.