Year : 2021 | Volume
: 6 | Issue : 1 | Page : 84--88
Women's experience with group prenatal care in a rural community in Northern Nigeria
Sunday E Adaji, Adenike Jimoh, Umma Bawa, Habiba I Ibrahim, Abiola A Olorikuooba, Hamdalla Adelaiye, Comfort Garba, Anita Lukong, Suleiman Idris, Oladipo S Shittu
|How to cite this article:|
Adaji SE, Jimoh A, Bawa U, Ibrahim HI, Olorikuooba AA, Adelaiye H, Garba C, Lukong A, Idris S, Shittu OS. Women's experience with group prenatal care in a rural community in Northern Nigeria.J Med Womens Assoc Niger 2021;6:84-88
|How to cite this URL:|
Adaji SE, Jimoh A, Bawa U, Ibrahim HI, Olorikuooba AA, Adelaiye H, Garba C, Lukong A, Idris S, Shittu OS. Women's experience with group prenatal care in a rural community in Northern Nigeria. J Med Womens Assoc Niger [serial online] 2021 [cited 2021 Oct 16 ];6:84-88
Available from: http://www.jmwan.org/text.asp?2021/6/1/84/320049
INTRODUCTIONMATERIALS AND METHODSRESULTDISCUSSIONCONCLUSIONLIMITATIONS
In 2016, WHO estimated that 830 women die daily from preventable causes related to pregnancy and childbirth with 99% of them in low income countries1,2. Providing quality care in low income setting is hampered by factors which include availability/management of resources and acceptability/utilization of available care by women in the communities.
A group prenatal care model was piloted, patterned after centering pregnancy, a multifaceted model of group care that integrated three major components of care, health assessment, education and support into a unified program4. In a participatory approach, community women when supported and given a safe space, could take more responsibility to improve outcomes for themselves and their newborn.
Group prenatal care has been gaining attention globally as an alternative to the traditional one to one care. In Sub-Saharan Africa, there have been pilot studies suggesting the feasibility and acceptability of this model10.
The aim of this study was to describe women's experience of community-level group prenatal care with regards to participation, group cohesiveness/support, retention of knowledge of danger signs of pregnancy learned, fidelity to birth preparedness plans developed and enjoyment of the sessions.
Materials and Methods
A prospective observational study was conducted in Tsibri, a village in Northern Nigeria, between the years 2010 and 2011. A baseline survey carried out prior to the study showed that Tsibri had a population of 1490 as shown in [Table 1]. The first cohort was recruited within the PHC in Tsibri Community.
Pregnant women were registered in four groups: those expecting to give birth for the first time, those with one to four previous delivery and those with more than four deliveries.
A separate postnatal group was created subsequently; other interested women were enrolled into the group using this template. Women who were found to have complicated pregnancies at the initial assessment were referred to a nearby hospital.
Ethical approval was obtained from the Institutional Review Board of the Population Council, New York, USA and the Ethical Clearance of the Ahmadu Bello University Zaria, Nigeria. Written permission was granted by the Ministry of Health and verbal permission was given by the community leaders.
Participation in the study was voluntary with written consent, and women were informed that they were free to exit at any point, if they wished without incurring any sanctions. Only registered members of the group attended the group sessions and men were not invited to attend the meetings.
Six female facilitators were trained in community-based participatory research methods, informed consent and the protection of human subject. They were also trained in facilitation skills, providing prenatal and postnatal care in a group setting and health education. A research midwife and a team of traditional birth attendants (TBA) were trained in data collection at the community level.
A handbook was developed to guide the mother's group activities. Key themes included;
Knowing your bodyCommon discomfort of pregnancyHygieneNutrition during pregnancyDanger signs of pregnancy and childbirthPreparation for emergencyBreastfeeding andBaby care
Group sessions took place over a year using an activity schedule developed with the mother's input. Each session was facilitated by two trained female facilitators in a house volunteered by a member of the community, and it lasted for 3 hours. Each session started with an ice breaker followed by private clinical assessment of the individual women. During clinical assessment, the women were asked about their health, their weight, their blood pressure were measured and their abdomen palpitated. Urinalysis was also performed for each woman. Some of the women who had received training helped with weighing care conformed with the local guidelines13.
A group discussion on a specific topic in maternal health which was facilitated by one of the researchers was discussed. Next, the women took turns to demonstrate cooking of a healthy meal of their choosing and a closing activity selected from the handbook ended each session to reinforce key issues discussed for the day.
Knowledge assessment was performed on each woman at the point of entry into the group and 1 week after delivery for knowledge of the danger signs of the pregnancy and what they would do or what they did to prevent pregnancy complications. The women were also interviewed about preparations for labor and delivery and availability of support during labor and childbirth, including circumstances when complications developed. Clinical findings were entered into a predesigned and pretested proforma adapted from the prenatal recording tool of a nearby hospital.
During the group meetings, one facilitator assessed group dynamics using a pretested tool which was designed by the study group. Data on pregnancy outcomes were collected by TBAs during visits to the women's homes using system of color-coded bottles and pebbles that were validated weekly by a research midwife. These outcomes were discussed in another article. SPSS for Windows, Version 24.0(IBM, Armonk, NY, USA) was used to analyze data.
During the study, 54 group sessions were held out of 72 planned sessions (75%), with a total of 161 participating mothers. The mother's age ranged from age 13 to 40 with a median age of 22 while their parity ranged from 0 to 12, with a median of 3 [Table 2].
Out of 161 women enrolled into the program, 105 continued and had a cumulative attendance of 392. The 56 mothers, who dropped out remained in the register but were excluded from further analysis beyond enrollment. The attendance per mother ranged from a minimum of 1 to a maximum of 11, with a median of 3. The total of 290 out of 392 attendances (74%) were associated with full participation in the day's activities and judged to be “complete” visits.
The mothers interacted with each other, learned from each other and functioned as a group [Table 3]. They demonstrated significant retention of knowledge of the key danger signs of pregnancy and childbirth acquired during group sessions [Table 4]. The mothers were also asked about what they would do in preparation for childbirth and/or a pregnancy complication at the time of enrollment. Their responses were compared with what they actually did afterwards in preparation for childbirth [Table 5].
The study actually showed that group prenatal care was feasible even in a rural community. The women demonstrated their enthusiasm by their active participation with good group interaction and cohesion. The group sessions helped them to learn and retain knowledge of key danger signs of pregnancy and enhanced their fidelity to their birth preparedness plans. They also utilized the opportunity to develop a new social and support network. The women's acceptance of the model of care and their enthusiasm for participation echoes the findings by previous author14.
During group sessions, the mother's learned from each other and showed support, connection and understanding with each other, corroborating the findings of McNeil et al,14 with a minimum of disruption and disrespect.
However, while the findings of these previous authors were based on qualitative interviews conducted after delivery, the present study findings were based on real time observations carried out while the group sessions were going on and so they were less likely to be affected by recall bias. In terms of group processes, the sessions were observed to be peer-group like in most cases with little or no didactic, classroom-like behavior. This conversation from didacticism to interaction and discussion within a group space was one of the key strengths of group prenatal care when compared to conventional prenatal care15.
Furthermore, during sessions the majority of the mothers were observed to easily connect with each other, sharing their experiences with others and forming new relationships. The evolution of such social networks are also considered a core benefit of group prenatal care, with some studies showing association with improvement in psychosocial function16. This benefit is of special significance in the setting of the present study where ''purdah” the cultural study of social confinement of women is still rife and a major contributor to unsupervised home births17.
Mothers were able to retain knowledge of danger signs of pregnancy to a significant extent. A comparison of knowledge before and after birth showed that the scores has increased, as well as the proportion of women who knew about the individual danger signs.
One systemic review demonstrated that group prenatal care mothers have better prenatal care knowledge compared to mothers who attended the conventional prevention care.18 The finding that the proportion of women who implemented birth preparedness plan was significantly higher than those who indicated that they had plans initially. It may be that the group process and new social network, developed, galvanized some of the mothers to take more responsibility of their own health. Some authors have reported better birth preparedness plan and improved commitments to such plans among participants of group prenatal care.
The majority of mother's in this study enjoyed being in the company of other women, made new friends and planned to keep in touch, They even shared the lessons they learned with female friends and spouses. This suggested an impact of the prenatal sessions beyond the meeting room to family and community which could engender more social support for women. Interestingly Chae et al,20 have shown that group prenatal care confers higher perception of family and friends support, compared to traditional prenatal care. It is difficult to forecast if such eagerness by mothers to disseminate their acquired knowledge would have any bearing on the future of group prenatal care in the study community.
Although the model of group prenatal care used in the present study was patterned after the “Centering Pregnancy” model, it was implemented within a rural community setting outside of a healthcare facility. Reports of group prenatal care outside of healthcare facility settings are rare in the English-language literature.
A key strength of the model was the removal of the physical barrier between health facilities and the community, which could be a factor in under-utilization of maternal services.21 This factor was of specializing significance in the setting of the present study, where the uptake of conventional prenatal care was a mere 51% (Population and Reproductive Health Initiative (PRHI), Ahmadu Bello University Zaria, Nigeria, unpublished report).
Group prenatal care, more so at the community level, was new in the part of world represented by the set up. Setup required a huge mobilization effort at the community level. Such strategies have been shown to work well for maternal health care provision in Sub- Saharan African Countries22 and should be an essential component in the design of community-based models such as in the current study, especially in conservative communities.
The study engaged doctors in contrast to trained midwives used in other Centering Pregnancy Programs. The chief reason for this was the death of midwives with the level of community orientation required for the study design, It would seem logical to train midwives to the level of facilitative proficiency required for group prenatal care, a case already made by some authors.23
In conclusion, the experience of women in the study suggested that there could be a place for group prenatal care in resource constrained settings.Careful planning, as well as tapping into existing skills and resources could help to develop a more realistic and cost-effective model that, if scaled up, could contribute to improvement in maternal and newborn outcomes.
A key limitation to the present study was its non-comparative design. However, Kennedy et a.l24 demonstrated that group prenatal care is associated with mother's increased satisfaction of care as well as adequacy of prenatal care when compared with individual care. Hopefully, the present study findings will stimulate such comparative study in the future.The occurrence of communal unrest in neighboring communities which led to cancellation was also a limitation. Future researchers need to consider this important factor before approaching such a community.
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