Exploring the Acceptability and Impact of Group Antenatal Care: A Qualitative Study Among Women in Selected Health Facilities in Burkina Faso

doi:10.21203/rs.3.rs-5273793/v1

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Exploring the Acceptability and Impact of Group Antenatal Care: A Qualitative Study Among Women in Selected Health Facilities in Burkina Faso

https://doi.org/10.21203/rs.3.rs-5273793/v1

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Antenatal Care (ANC) models have evolved to increase maternal and child health service utilization, especially in low- and middle-income countries. Recently, group antenatal care (G-ANC), where cohorts of pregnant women with similar gestational ages are followed throughout pregnancy, has shown promise in enhancing care utilization, patient satisfaction, and reducing maternal morbidity and mortality. However, the acceptability of G-ANC in Burkina Faso has not been assessed.

This qualitative study aimed to evaluate the acceptability of G-ANC by pregnant women at six pilot sites in Burkina Faso and identify challenges for scaling up. We conducted six Focus Group Discussions (FGDs) with 58 women who attended at least one G-ANC session. Participants were selected through purposive sampling, and discussions were conducted using semi-structured questionnaires. Thematic analysis was performed using N-VIVO software.

Six themes emerged: overall experience, benefits and challenges of G-ANC, relationships with healthcare workers and partners, changes introduced by G-ANC, and suggestions for improvement. Women expressed high satisfaction with G-ANC, citing skill development and improved relationships as key benefits. Challenges included long session durations and inadequate space. A major recommendation was to hold sessions on weekends to allow partner participation.

In conclusion, G-ANC is highly accepted by women in Burkina Faso. This low-cost, high-impact initiative holds potential for broader implementation in similar settings.

Acceptability

Group Antenatal Care

Benefits

challenges

Antenatal care (ANC) is a vital healthcare service for pregnant women, including monitoring the health of both mother and fetus, providing nutrition counseling, micronutrient supplements, vaccinations, and screening for infections such as HIV and STIs. Primarily managed by midwives, ANC plays a crucial role in improving maternal and fetal outcomes, managing complications, and reducing perinatal mortality (Sharma, 2018). The World Health Organization (WHO) recommends at least eight ANC visits, beginning before the 12th week of pregnancy, with specific interventions at each visit to detect and address pregnancy-related risks (WHO, 2016).

Globally, 88% of women attend ANC at least once from a trained provider, but only 66% adhere to the minimum recommended four visits. In many low- and middle-income countries (LMICs), including Burkina Faso, the ANC4 + coverage rate is significantly lower, at just 38%. Factors such as poverty, distance to healthcare facilities, and social barriers often hinder access and lead to late initiation of ANC (Macharia et al., 2020). These challenges underscore the need for innovative strategies to enhance ANC utilization.

Group antenatal care (G-ANC) is an emerging model designed to address some of these barriers. Developed initially in the United States as "Centering Pregnancy," G-ANC has been adapted in several LMICs, including Rwanda, Kenya, and Bangladesh (Grenier et al., 2019). This model integrates health education with peer support, where pregnant women with similar gestational ages attend sessions together, receiving medical care and psychosocial support in a group setting. Research indicates that G-ANC can improve care utilization, patient satisfaction, and adherence to healthy practices, with the potential to reduce maternal morbidity and mortality (Catling et al., 2015).

In July 2022, Burkina Faso launched a pilot G-ANC program in 12 health facilities, funded by USAID and implemented by Jhpiego, a global health organization. The program aimed to address barriers to ANC uptake by creating a supportive environment where pregnant women could learn and share experiences with peers. Facilities were equipped with necessary medical supplies, and midwives were trained to facilitate G-ANC sessions.

Despite its success in other countries, the acceptability of G-ANC in Burkina Faso remains unexplored. Acceptability is crucial for understanding whether this model can be scaled up across the country. Studies in other LMICs, such as Nigeria, have demonstrated the benefits of G-ANC, including increased birth preparedness, higher uptake of preventive treatments, and improved adherence to recommended health practices (Grenier et al., 2019). However, cultural and social dynamics unique to Burkina Faso, such as patriarchal norms and decision-making processes within households, may influence women’s acceptance of G-ANC (Niang, 2015).

Acceptability in health interventions is a multi-dimensional concept that has been inconsistently defined and measured in research. Yardley et al. (2015) describe acceptability as the degree to which an intervention is perceived as credible, comprehensible, and engaging. However, it remains poorly theorized and is often conflated with related constructs like feasibility, satisfaction, and uptake (Sekhon et al., 2018). Some definitions emphasize user satisfaction or pleasure with the intervention, while others focus on whether it is tolerable or endurable. These discrepancies highlight the need for a clearer understanding of acceptability in health interventions.

A common method for assessing acceptability is through participants’ behavior, such as their willingness to engage with an intervention or their adherence levels. However, behavioral measures alone are insufficient, as they fail to account for cognitive and emotional factors that may influence decisions to continue or withdraw from an intervention (Sekhon et al., 2018). Direct participant-reported evaluations, such as interviews exploring experiences and attitudes, provide a more comprehensive understanding of acceptability.

Few systematic reviews have directly measured acceptability using self-report evaluations like satisfaction or attitudes toward interventions (Sekhon et al., 2018). A theoretical framework is needed to assess both the cognitive (beliefs and perceptions) and affective (emotions and attitudes) components of acceptability. Scholars like Pechey et al. (2014) and Yardley et al. (2015) have conceptualized acceptability as either an attitudinal construct or a person-centered approach that considers participants' beliefs, attitudes, and needs.

Studies show that acceptability is often linked to perceived personal benefit, absence of harm, and positive emotional impact (Morrison et al., 2014). For example, cognitive behavioral therapy (CBT) for young people with chronic fatigue syndrome was considered acceptable because participants found the sessions enjoyable (Dennison et al., 2010). In an internet-based health intervention, tailored feedback and perceived benefits were critical factors in determining its acceptability (Morrison et al., 2014).

G-ANC has also been evaluated for its acceptability in terms of women's and providers' satisfaction, adherence to the model, and outcomes for mothers and newborns. Research shows that pregnant women are highly satisfied with G-ANC, appreciating the health knowledge, self-care skills, and peer support gained from the sessions (Jolivet et al., 2017; McKinnon et al., 2020). Other factors contributing to high satisfaction include shorter wait times, respectful treatment by healthcare providers, and the opportunity to interact with peers (Nsaba Uwera, 2019; Grenier et al., 2022).

Healthcare providers facilitating G-ANC also reported high levels of satisfaction, citing improved relationships with patients, the empowerment of women, and more personalized care (Hunter et al., 2018; Lazar et al., 2021). However, some challenges, such as increased workload and organizational difficulties, were noted, particularly in low-resource settings (Lori et al., 2016).

This study aims to assess the acceptability of G-ANC among pregnant women in Burkina Faso, identifying potential challenges and opportunities for scaling up the program. Understanding women’s perspectives on G-ANC is critical to ensuring its effectiveness and sustainability, ultimately contributing to improved maternal and child health outcomes in the region.

Study setting

This study was conducted in Burkina Faso, a West African country with a population of over 20 million and a fertility rate of 4.87 births per woman (World Bank, 2021). Group ANC was introduced in 12 facilities across three regions through a USAID-funded project, implemented by Jhpiego in partnership with the Ministry of Health. The pilot began in July 2022, with 24 healthcare workers trained, and by December 2022, 445 pregnant women had been enrolled across 43 cohorts. The study focused on six randomly selected facilities.

Study design

This study used a descriptive qualitative study design. This design allowed us to accurately describe events, populations, and phenomena being studied. We conducted six Focus Group Discussions with pregnant women who have experienced G-ANC.

Sample

The target population was pregnant and postpartum women attending six G-ANC sessions in pilot sites. Using purposive sampling for maximum variation, 58 women participated in six Focus Group Discussions (FGDs), with 8–10 women per site. This method was chosen to capture diverse perceptions based on age, education level, and distance to the nearest health facility. Factors like parity and marital status were also considered, as pregnant women are not a homogenous group. Six FGDs, following Guest's guidelines, aimed to reflect the perceptions of women in 50% of the pilot sites and to reach theoretical saturation. We included pregnant women who have taken part in as least one of G-ANC sessions and willing to participate. The study excluded who were too sick to participate.

Measures

This study assessed the acceptability of G-ANC in Burkina Faso, focusing on satisfaction, session content, meeting frequency, topic relevance, group attendance and composition, and perceived service quality, including provider friendliness. The evaluation was guided by the Theoretical Framework of Acceptability.

Data collection tools

A semi-structured focus group discussion (FGD) guide was developed to explore women's experiences with G-ANC. Questions covered their treatment by healthcare workers, session duration (1.5 to 2 hours), willingness to participate again, recommendations to others, challenges, and key takeaways. The guide was pre-tested at a non-study site. FGDs were conducted in local languages, with transcripts translated from French to English. The study team verified translations. Tools were refined after pre-testing with a cohort of women who completed G-ANC sessions and delivered their babies before the formal data collection.

Data collection procedures

Data collection occurred from May 24 to June 30, 2023, conducted by two students and six data collectors at six target health facilities. FGDs were held in four local languages: Bissa, Dagara, Dioula, and Mooré. Study objectives and informed consent, guaranteeing anonymity and confidentiality, were explained to participants before each interview. Most FGDs took place at the health centers, recorded with participants' consent. Interviewers ensured focus by actively listening and guiding discussions, while also taking detailed notes on non-verbal cues.

Data collectors

Data was collected by trained social scientists not from the study sites. The two-day training covered ethics, study instruments, FGD techniques in local languages, and data management. Three male and three female data collectors were selected to ensure pregnant women felt comfortable speaking openly during FGDs. Field testing of the tools was also part of the training.

Data management

FGD audio recordings were translated and transcribed in French, then checked by a bilingual reviewer. Transcriptions were professionally translated into English and validated by bilingual study team members. Both audio recordings and transcripts are securely stored on password-protected computers belonging to the investigators.

Data analysis procedure

Initially, data collectors fully transcribed all recordings, allowing researchers to perform repeated readings and both deductive and inductive coding until saturation was reached. This iterative process helped clarify specific terms. A preliminary thematic framework was developed, including themes like Affective Attitude, Burden, and Perceived Effectiveness, and coded using N-VIVO software. Each interview was transcribed and coded, the verbatim transcripts were proofread to enhance confirmability, addressing the subjectivity inherent in qualitative research. Triangulation of data from interviews, literature reviews, and logbook notes increased validity and rigor.

Ethical considerations

This study received ethical approval from the University of Global Health Equity (UGHE-IRB/2023/030) and from the Burkina Faso Ethical Committee for Health Research (IRB No.1969). Written informed consent was obtained from all participants. Anonymity and confidentiality was maintained throughout the study.

Socio-demographic profile of study participants

The sample comprised 58 women, with 56 (96.6%) pregnant and 2 (3.4%) breastfeeding mothers who had attended G-ANC at the study sites. Ages ranged from 18 to 39 years. Marital status included 6 (10.3%) unmarried women living with partners. In terms of education, 7 had secondary education, 11 (19.0%) had primary education, 5 (8.6%) attended madrassa, and 35 (60.3%) had no formal schooling. The gestational age of the pregnant women ranged from 4 to 9 months.

Themes

Six main themes emerged from the data: women's overall experience of G-ANC, its advantages and challenges, social relationships, interactions with husbands/partners, changes due to G-ANC, and suggestions for improvement. These themes were integrated into the seven constructs of the Theoretical Framework of Acceptability (TFA): Affective Attitude, Burden, Ethicality, Intervention Coherence, Opportunity Costs, Perceived Effectiveness, and Self-Efficacy.

1. Affective Attitude

This construct describes how individuals feel about an intervention. We asked the women participating in the G-ANC sessions how they felt about the G-ANC model. Most of the women from the 6 FGDs were contented with the frequency of sessions and felt these were optimal for effective monitoring of the pregnant mother and the fetus. One pregnant woman clearly said, “We love and enjoy G-ANC sessions and are benefiting a lot.” (FGD6, P4). This was believed to contribute significantly to early detection of danger warning signs and early intervention which would ultimately improve maternal and newborn outcomes.

Perceived benefits of G-ANC to pregnant women

Most women expressed positive appreciation for G-ANC as an effective approach to pregnancy monitoring, demonstrating high acceptability within their community. Participants showed eagerness to attend all G-ANC sessions, with even first-time mothers highlighting its advantages. One primigravida noted,

“There are so many benefits... we understand many things in G-ANC that we didn’t in individual ANC, like how to maintain pregnancy until childbirth” (FGD2; P5).

Women reported feeling empowered through G-ANC, gaining skills they previously lacked. One participant remarked, “I now know many things that I did not know” (FGD1; P1).

The program also enhanced their practical abilities; another participant shared,

“The midwives helped us a lot... now we can take blood pressure, temperature, and weight. Some in the group didn’t know how to write, but thanks to G-ANC, they managed to note their weight” (FGD3; P2).

This new found knowledge and skill set contributed significantly to their confidence and understanding of maternal health, reinforcing the positive impact of G-ANC on their pregnancy experiences.

Perceived Benefits for the family and community

Focus group discussions revealed that women participating in G-ANC not only benefited personally but also became better communicators about maternal care with family members, helping to combat harmful traditional practices, such as force-feeding infants with herbal tea. Participants noted that they shared important information about pregnancy danger signs, enabling them to educate their families effectively. One participant recalled,

“The midwife told me to stop force-feeding my babies and to only breastfeed until they were 6 months old. My husband said no to force-feeding when my mother-in-law suggested it because I had shared this advice” (FGD6; P9).

Another participant emphasized the overall health benefits of following midwifery advice:

“The advantages are good health and uncomplicated childbirth...it was beneficial for us” (FGD4; P3).

G-ANC also reduced the long waiting times typically associated with antenatal care at health centers, allowing women to address concerns collectively and spend more time on household chores. G-ANC serves as a vital learning space covering various aspects of maternal and child well-being, such as saving for childbirth, preparing a layette, and family planning. One participant noted, “In a group, you get clarification on how to manage your pregnancy right up to the birth, without any problems” (FGD2; P1).

While women acknowledged these numerous benefits, they also shared challenges and difficulties encountered during their ANC experience.

2. Burden

The burden reflects the perceived effort required to participate in G-ANC (Sekhon et al., 2018), with women highlighting various challenges they face.

One significant difficulty is the session duration, as noted by a participant:

“The difficulty is in the time taken. Not all pregnant women come at the same time, which means the meetings extend. When one pregnant woman arrives late, it can be exhausting” (FGD5; P7).

Additionally, women reported inadequate physical spaces for G-ANC sessions, contributing to long wait times for services, which can be burdensome due to their numerous household responsibilities. Some participants who lived further from health centers cited transportation costs and fatigue from increased ANC visits. One participant shared,

“We love G-ANC sessions, but our husbands complain that we’re using health visits to avoid fieldwork” (FGD6; P4).

Time constraints emerged as another challenge, with delays during consultations leading to extended session times. For example, one woman recounted,

“We were told to be there at 8 a.m., but one came at 8:30 a.m., and we had to tell her to leave” (FGD1; P2).

Such delays create frustration among midwives and other participants, often resulting in misunderstandings at home due to unmet daily household duties.

3. Ethicality

This construct assesses how well an intervention aligns with individual values (Sekhon et al., 2018), focusing on cultural values and norms. In this study, both pregnant and postnatal mothers found that the G-ANC model aligns with their cultural expectations. Participants across all six focus group discussions (FGDs) expressed satisfaction with how G-ANC promotes equality, welcomes women's perspectives, and fosters participation, including inviting in-laws and husbands. One participant highlighted the support of her husband, who insisted on exclusive breastfeeding after learning about its benefits from G-ANC sessions (FGD2, P3).

Women's Empowerment and Social Cohesion

G-ANC fosters trust and cohesion among women, which is crucial for achieving widespread health service coverage. Unlike traditional prenatal consultations, G-ANC emphasizes communication and shared experiences. As one respondent noted,

“Before we start, they tell us it’s a family we need to form, and everyone has to know each other's names” (FGD3, P7).

The women reported strong relationships within their groups, even continuing to support each other outside the sessions. They have exchanged contact information, enabling ongoing support and reminders about G-ANC.

“Because we’re a family, if we see each other at the market or naming ceremonies, we can sit down to discuss anything,” shared a participant (FGD1, P5). This participatory environment enhanced their sense of equality and satisfaction with ANC services.

Relationship Between Women and Midwives

The G-ANC model has also facilitated a closer relationship between beneficiaries and midwives. Women appreciated the open communication, feeling comfortable asking questions and seeking advice from midwives they affectionately called “tantie” (Auntie).

“We have become like family,” one woman expressed, noting that they can now approach midwives easily” (FGD6, P8). This familiarity encourages attendance at ANC consultations and promotes ongoing dialogue, including sharing information via phone.

Husbands' Participation and Perceptions

Husbands have been invited to join G-ANC sessions, and their participation has been met with mixed reactions. Some men found the sessions beneficial, saying,

“Our husbands came, participated, and found it interesting” (FGD2, P8).

These experiences have altered their views on antenatal consultations. However, other husbands remain indifferent, adhering to cultural norms that consider pregnancy discussions as strictly a women's domain. One woman noted,

“Our parents said if a pregnant woman calls her husband to the hospital, he shouldn't go, because it’s a women's meeting” (FGD2, P6).

Such beliefs reflect socio-cultural prejudices that may hinder participation.

Exchanges Between Women and Their Husbands

Women whose husbands participated in G-ANC reported continued discussions at home, enriching their communication about pregnancy-related topics.

“He learned a lot and said it was very interesting,” one participant stated (FGD3, P7).

Husbands’ participation helps normalize discussions about sensitive issues like pregnancy, sex, and family planning. Conversely, those who did not attend often hold onto misconceptions. For instance, one respondent noted,

“Some believe that birth control pills will prevent pregnancy or alter their blood” (FGD4, P1).

Despite some resistance, even husbands who do not participate in G-ANC remain open to conversations about reproductive health. One woman shared that her husband, although he didn’t attend, appreciates their discussions, recognizing the value in what they learn through G-ANC.

In summary, G-ANC has positively influenced relationships among women, between women and midwives, and has initiated discussions with husbands, though cultural barriers still pose challenges to full engagement.

4. Intervention coherence

Intervention coherence relates to participants’ understanding of an intervention and its functioning. In this study, women generally demonstrated a strong grasp of the G-ANC model’s purpose and its benefits for improving health outcomes for pregnant and postnatal mothers. While there was some variation in the depth of knowledge, all participants in the focus group discussions articulated the advantages of G-ANC.

One participant shared her experience, noting,

“I am 36 and this is my third pregnancy. Previous ANC visits lacked peer support and were less effective due to individual attention from nurses. I appreciate this new approach, which brings women together to support and learn from each other about managing pregnancy and caring for newborns” (FGD6, P3).

Women described G-ANC as more practice-oriented than conceptual. They engaged in self-consultations by monitoring their health, such as checking blood pressure and weight. This empowerment method significantly differed from traditional prenatal consultations. As another participant expressed,

“Group care has been interesting; we are well taken care of, sit together, and learn what to do and what not to do” (FGD6, P5).

5. Opportunity cost

Opportunity cost refers to the benefits or values sacrificed to participate in an intervention. In this study, pregnant and postnatal mothers identified competing needs they must forgo to attend G-ANC sessions. They often conduct a cost-benefit analysis, weighing the time spent on G-ANC against their various responsibilities, especially since sessions continue until delivery. Participants noted that the short duration of G-ANC sessions encourages their attendance.

Competing needs included caring for older children, farming activities, and household chores. Socio-economic pressures, such as the necessity to sell produce to support their families, were also highlighted. One participant shared her experience:

“I am 25 and the breadwinner for my family. My husband is jobless and often spends time drinking. I plan my day carefully, but attending G-ANC means I cannot sell my farm products on those days. However, the knowledge I gain that protects my life and my unborn child makes this sacrifice worthwhile” (FGD2, P7).

Additionally, myths, cultural beliefs, and traditional practices contribute to missed opportunities for fully benefiting from G-ANC. Some influential in-laws devalue modern medicine and pressure their daughters-in-law to seek traditional midwives, further complicating access to necessary care. These cultural beliefs can delay attendance at important G-ANC sessions.

6. Perceived Effectiveness

Perceived effectiveness refers to the belief that an intervention can achieve its intended purpose (Sekhon et al., 2018). The participants unanimously agreed that the G-ANC model effectively reduces maternal and child morbidity and mortality by enhancing knowledge of early warning signs and risk factors. They noted that G-ANC sessions build social capital, improving relationships and communication with healthcare providers, which fosters trust.

Women expressed that G-ANC allows them to form meaningful relationships with healthcare workers beyond clinical interactions. One participant remarked,

"In individual ANC, we are examined but not considered, whereas in G-ANC, we are engaged, and new knowledge is shared. The warm welcome encourages us to ask questions, and we receive clear answers, which I never experienced during previous visits." (FGD4, P4).

Overall, the women perceived their relationships with healthcare providers as warm and friendly, believing that G-ANC provided access to quality care compared to individual ANC, where attention was rushed due to high demand.

7. Self-efficacy

Self-efficacy refers to participants' confidence in their ability to perform recommended behaviors. This study assessed self-efficacy by evaluating women's completion of scheduled activities in G-ANC sessions, their willingness to attend future sessions, and their interactions with peers.

Most women demonstrated high self-efficacy, showing enthusiasm for practical activities like checking vital signs and using a fetoscope. G-ANC sessions fostered social cohesion by allowing women to share experiences and strengthen relationships. One participant noted,

“I’m not Bissa, so it wasn't easy at first, but with G-ANC, I made friends and learned the language. Now I don't feel like a stranger in my husband's family" (FGD6, P3).

Participants emphasized the positive relationships built during group meetings, enhancing their confidence and self-esteem. Ground rules for G-ANC encouraged equality and active participation, further boosting self-efficacy. Overall, these interactions significantly improved women's perceived ability to engage in group activities and reinforced their sense of community.

Participants' recommendations to improve G-ANC

Participants frequently raised concerns about the inadequate space for G-ANC sessions. One participant expressed discomfort, stating,

“What I don't like is when the other patients pass by and watch us measuring weight or blood pressure; it would be better if it were inside, but the room is small” (FGD2, P10).

Women also suggested enhancements for G-ANC, including improved communication via WhatsApp and increased partner involvement. One participant mentioned,

“If we could make the group with our midwife on WhatsApp, it would allow us to stay in touch and contact her quickly if there is a problem” (FGD6, P9).

Additionally, participants proposed adjusting the scheduling of G-ANC sessions to include weekends, enabling more partners to attend. As one participant noted,

"Can we do it on Saturday night? That way they can come and listen too and help us with the mother-in-law [laughs]" (FGD4, P1).

Overall, the women emphasized the need for innovative strategies to encourage greater male participation in G-ANC activities.

Studies have consistently shown that women are satisfied with G-ANC (Nsaba, 2019; Anderson, 2013; Hunter, 2019). One participant expressed, “We love and enjoy G-ANC sessions and are benefiting a lot” (FGD6, P4). Reasons for their satisfaction include the empowerment gained from conducting their own ANC checks, such as measuring weight and blood pressure (Hunter, 2019), and improved communication with healthcare providers (Patil et al., 2013). High retention rates among participants also indicate satisfaction, as noted by Cunningham (2017), who found that increased attendance correlates with greater satisfaction.

Participation in G-ANC requires women to spend 60 to 90 minutes per visit, attending six to seven sessions instead of four. Some women voiced concerns about inadequate space for group meetings and long waiting times, despite improvements compared to individual ANC sessions. Musabyimana et al. (2019) highlighted the need for better time management from both participants and service providers. Recommendations include developing a reminder system for scheduling appointments and offering G-ANC services at community outreach events to alleviate time management issues.

In Burkina Faso, where traditions significantly influence women's lives, the introduction of G-ANC has faced little resistance from pregnant women or community gatekeepers. Women at pilot sites have embraced G-ANC, appreciated the support and learning opportunities it provides. One participant expressed gratitude for the program, noting its value in fostering peer support. Similarly, Nyumwa (2023) found that the WHO eight-contact model of ANC aligns well with women's values in Botswana. While the study did not raise concerns about culturally appropriate educational materials for G-ANC, this consideration should be addressed as the program expands.

Women in this study expressed high satisfaction with G-ANC due to the new knowledge and skills they acquired. This reflects their understanding of G-ANC's content and functioning. Research indicates that G-ANC enhances knowledge levels, promotes healthy behaviors, and increases self-efficacy. For example, one quantitative study found that knowledge of danger signs during pregnancy tripled from 7.1–26.4% after G-ANC sessions, while the percentage of women identifying ways to improve health rose from 30.4–37.5% (Somji et al., 2022). Similarly, participants in Rwanda noted significant improvements in health-related knowledge and self-care, attributing this to more time spent with midwives and learning from experienced mothers. Additionally, Lori (2017) reported that G-ANC attendees developed better health literacy and a greater understanding of health education messages taught during sessions.

The opportunity cost of group antenatal care (G-ANC) has been rarely examined. This study was conducted in contexts where women balance farming and household activities, which may compete with G-ANC attendance (Nyumwa, 2023). While time spent in G-ANC affects these activities, women view the trade-off positively. One participant stated, “I always find it worthwhile to make this sacrifice” for the knowledge gained. Husbands sometimes voice concerns about G-ANC conflicting with farming duties, suggesting it allows women to avoid work. Additionally, Stringer et al. (2005) noted that women in the USA prioritize postnatal care despite personal costs. More research on the opportunity cost of G-ANC is needed.

A key theme from the focus group discussions (FGDs) is the effectiveness of group antenatal care (G-ANC) in providing a positive learning experience for mothers. One participant noted, "There are many benefits...many things that we did not understand in individual ANC that we understand in G-ANC." Research indicates that G-ANC enhances the pregnancy experience (Hunter et al., 2019) and aligns with WHO guidelines (2016). It has improved knowledge of danger signs during pregnancy (Thapa et al., 2019) and fostered social support (Sharma et al., 2018). Participants in this study not only socialized but also established a tontine, enhancing their sense of security regarding pregnancy outcomes (Nyumwa, 2023). One participant stated, “The advantages are good health and uncomplicated childbirth because we followed the advice...and gave birth without worries.” Despite low literacy levels, G-ANC improves health literacy, with women learning to track their weight in notebooks (Lori et al., 2024).

Self-efficacy and empowerment

Exploring self-efficacy, McKinnon et al. (2020) demonstrated that group antenatal care (G-ANC) improves maternal self-efficacy. Patil et al. (2017b) found that G-ANC empowers pregnant women in Malawi compared to traditional ANC. In Senegal, G-ANC has enabled pregnant women to gain a voice and engage in ANC tasks like measuring blood pressure and weight. Jeremiah et al. (2021) reported enhanced partner communication in Malawi and Tanzania, with one participant noting G-ANC empowered her to discuss sensitive health issues and negotiate the abandonment of harmful childcare practices.

Throughout the sessions, consistent group leadership facilitated open discussions about challenges, promoting a woman-centered and interactive environment (Arnold et al., 2014). G-ANC strengthens relationships between midwives and pregnant women, fostering social cohesion and satisfaction among participants (Adaji et al., 2019). Women value the friendships formed during G-ANC, which often extend beyond pregnancy, creating robust social networks. One participant shared that her cohort formed a tontine due to the trust developed during their interactions. These findings underscore the community-oriented nature of G-ANC and its role in enhancing relationships among pregnant women and health workers, contributing to improved pregnancy outcomes.

However, challenges exist for both pregnant women and service providers. Participants reported inadequate physical spaces for G-ANC sessions, echoing concerns from studies in Canada (Donald et al., 2014) and Mexico (Ibañez-Cuevas et al., 2020), which raised issues of privacy. Long waiting times for services, as noted by Novick (2009), were also mentioned by women in Burkina Faso. Although participants acknowledged improved waiting durations compared to individual ANC, discomfort with session lengths persisted. Musabyimana et al. (2019) suggested improvements in time management and the development of a reminder system for scheduling appointments. Providing G-ANC services at community outreach events was also recommended to alleviate time management issues. Conversely, Gaur et al. (2021) found that waiting times decreased in G-ANC compared to separate appointments.

A study in Bangladesh suggested using WhatsApp groups to improve communication and shorten waiting times for antenatal care (Saltana et al., 2019). However, Burkinabe women’s suggestions for digital tools may not directly transfer due to contextual differences. Misago et al. (2023) reported high participation rates in a digital intervention in Burundi, with positive perceptions of automated reminders. Nonetheless, half of the mothers indicated the program impacted their time management significantly, highlighting variability in acceptability based on mobile phone access.

The COVID-19 pandemic prompted a UK study testing virtual G-ANC, which allowed women to engage and connect, reducing feelings of isolation (Wiseman et al., 2022). While online G-ANC presents opportunities, challenges remain regarding access, leadership, and confidentiality. Currently, G-ANC sessions are conducted only on weekdays. Women in Burkina Faso suggested expanding this schedule to include weekends, allowing male partners to attend and engage in discussions. This aligns with findings from South Africa, where work-related challenges hindered male participation.

Although Macdonald et al. (2014) noted the value of male partners' presence in G-ANC, women expressed concerns that men might inhibit discussions on sensitive topics. It was recommended to designate women-only sessions for sensitive discussions while inviting men on scheduled days for less sensitive topics. These considerations highlight the importance of balancing male involvement with creating a supportive environment for women.

Limitations of the study

This study assessed the acceptability of group antenatal care (G-ANC) during its pilot implementation, focusing solely on the opinions of pregnant women. This approach had limitations, as it did not include the perspectives of care providers and spouses, who are crucial in pregnancy management. To effectively advocate for scaling up G-ANC, it is essential to evaluate its impact on health outcomes and costs. Further research in this area could provide evidence supporting G-ANC as an efficient method for monitoring pregnancies, promoting women's health, and reducing maternal mortality in Burkina Faso.

Strengths of the study

Despite its limitations, the study boasts significant strengths, including a wealth of qualitative data gathered from six focus group discussions. This analysis captures the perspectives of women from six health facilities across three regions, reflecting diverse social and demographic realities in Burkina Faso.

Recommendations

For Jhpiego, ensure adequate space for G-ANC meetings and the availability of ANC commodities like sulfadoxine-pyrimethamine and IFA. A thorough assessment of the pilot phase should evaluate health outcomes before scaling up. Additionally, consider introducing group postnatal care after discussions with the Ministry of Health.For the Ministry of Health of Burkina Faso, collaborate with Jhpiego to study G-ANC implementation costs and develop a scale-up plan that includes G-ANC in national maternal and newborn health guidelines and pre-service education.Future research should assess healthcare workers' and partners' perspectives on G-ANC and investigate its health outcomes and implementation costs.

In conclusion, this pilot study indicates that G-ANC is a promising model for enhancing women's experiences during antenatal care in Burkina Faso, aligning with WHO guidelines. Utilizing the seven constructs of the Theoretical Framework of Acceptability—Affective Attitude, Burden, Ethicality, Intervention Coherence, Opportunity Costs, Perceived Effectiveness, and Self-efficacy—results demonstrate that G-ANC is largely acceptable to pregnant and postnatal women. Focus group discussions supported each dimension of the framework. Establishing the acceptability of G-ANC is crucial for scaling up this approach, alongside assessing implementation costs. Further studies are needed to evaluate its impact on pregnancy outcomes.

ANC Antenatal care

BMI Body Mass Index

FBC Full Blood Count

G-ANC Group antenatal care

HBLSS Home-based Life Saving Skills

HCW Healthcare Workers

IPTp Intermittent Prophylactic Treatment

IFA Iron and Folic Acid

LMICs Low to Middle-Income Countries

MoH Ministry of Health

UGHE University of Global Health Equity

SMA Shared Medical Appointments

SRH Sexual and Reproductive Health

STI Sexually Transmitted Infections

TFA Theoretical Framework of Acceptability

WHO World Health Organization

WPAG Women’s Participatory Action Groups

Authors’ contributions

BD & YO conceptualized the study, implementation and drafting the manuscript; MM reviewed the study and did the analysis; supported with interpretation and write-up; AK; field supervision and manuscript drafting

Funding

This study had no external funding.

Availability of data and materials

Data supporting results in the paper is filed and safely kept under lock and key by the first author (Blami Dao). The corresponding author is ready to avail the said data on reasonable request.

Consent for publication

Not applicable.

Competing interests

None

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No competing interests reported.

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Exploring the Acceptability and Impact of Group Antenatal Care: A Qualitative Study Among Women in Selected Health Facilities in Burkina Faso

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Version 1

Abstract

Introduction

Methods

Study setting

Study design

Sample

Measures

Data collection tools

Data collection procedures

Data collectors

Data management

Data analysis procedure

Ethical considerations

Results

Socio-demographic profile of study participants

Themes

1. Affective Attitude

Perceived benefits of G-ANC to pregnant women

Perceived Benefits for the family and community

2. Burden

3. Ethicality

Women's Empowerment and Social Cohesion

Relationship Between Women and Midwives

Husbands' Participation and Perceptions

Exchanges Between Women and Their Husbands

4. Intervention coherence

5. Opportunity cost

6. Perceived Effectiveness

7. Self-efficacy

Participants' recommendations to improve G-ANC

Discussion

Self-efficacy and empowerment

Limitations of the study

Strengths of the study

Recommendations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1