Perceptions on acceptability of the 2016 WHO ANC model among the pregnant women in Phalombe District, Malawi – a qualitative study using Theoretical Framework of Acceptability

Background: The World Health Organization introduced a new model of care, ‘The 2016 WHO ANC Model’ to overcome challenges encountered during the implementation of the Focused Antenatal Care Approach. For any new intervention to achieve its objective, it must be widely accepted by both the deliverers and recipients. Malawi rolled out the model in 2019 without carrying out acceptability studies. The objective of this study was to explore the perceptions of pregnant women and health care workers on the acceptability of 2016 WHO’s ANC model in Phalombe District, Malawi using the Theoretical Framework of Acceptability. Methodology: We conducted a descriptive qualitative study between May and August 2021. The Theoretical Framework of Acceptability was used to guide the development of study objectives, data collection tools, and data analysis. We purposely conducted 21 in-depth interviews (IDIs) among pregnant women, postnatal mothers, a safe motherhood coordinator, and Antenatal care (ANC) clinic midwives, and two focus group discussions (FGDs) among Disease Control and Surveillance Assistants. All IDIs and FGDs were conducted in Chichewa, digitally recorded, and simultaneously transcribed and translated into English. Data was analysed manually using content analysis. Results: The model is acceptable among most pregnant women and they reckoned that it would help reduce maternal and neonatal deaths. Support from a husband, peers, and health care workers facilitated acceptability of the model while the increased number of ANC contacts which resulted in fatigue and increased transportation cost incurred by the women was a deterrent. Conclusion: This study has shown that most pregnant women have accepted the model despite facing numerous challenges. Therefore, there is a need to strengthen the enabling factors and address the bottlenecks in the implementation of the model. Furthermore, the model should be widely publicised so that both intervention deliverers and recipients of care implement the model as intended. This will in turn help to achieve the model’s aim of improving maternal and neonatal outcomes and creating a positive experience with health care among pregnant women and adolescent girls. This was a descriptive qualitative study design that allowed for the solicitation of participants’ perceptions cognisant that acceptability is a subjective evaluation made by individuals who are experiencing or have experienced the intervention [8]. The study took place at Phalombe Health Centre in Phalombe District, located in the Southern Region of Malawi. The district was chosen because of its rural location, which poses a challenge to the attendance of ANC services [1]. According to the 2015/16 Malawi Demographic Health Survey (2015/16 MDHS) [1], rural districts in Malawi had an attendance of ANC services at 49% compared to 59% of their urban counterparts. The 2015/16 MDHS, further showed that Phalombe District had the highest NMR of 40 neonatal deaths per 1000 live births, which was above the national rate of 27 neonatal deaths per 1000 live births [1], and post-neonatal mortality rates at 28 deaths per 1,000 live births which were among the third highest districts in Malawi [1]. Phalombe District had a population of about 429,450 with 14 out of 15 health facilities offering ANC services. The district rolled out the 2016 WHO ANC Model in August 2019 in all the health facilities. At the time of data collection, that is from May to August 2021, Phalombe Health Centre was the district’s main public health facility as there was no functional district hospital. The district relied on Holy Family Mission Hospital for all in-patient care where admitted patients accessed care for free through Service Level Agreement with the Malawi Government. The staff at Phalombe Health Centre consisted of medical officers, clinical officers, clinical technicians, medical assistants, nursing and midwifery officers, nurse midwife technicians, radiology technicians, dental technicians, environmental health officers, and disease control and surveillance assistants. The health facility offered a wide range of outpatient services such as antiretroviral therapy, adult outpatient care, mental health, orthopaedics, laboratory, radiology, pharmacy, ophthalmic and maternal and child health services. Three midwives who were permanently allocated at the facility’s ANC clinic mainly provided uncomplicated ANC services including ultrasound-scanning services. The researchers chose Phalombe Health Centre because it was the main public referral facility in the area and presented a pool of clients for the researchers to draw from. The researchers believed that the participants drawn from Phalombe Health Centre were a representation of all the women in the district as they had similar socioeconomic and demographic health statuses. We purposely selected and interviewed thirty-three (33) participants based on their age, pregnancy status, parity, expert knowledge and role in the provision of ANC services, and their willingness to participate in the study [9, 10] (see Table S1). The participants included; pregnant women (both at initial and 8th contact), postnatal mothers (both completed and those that did not complete their schedule), and health care providers that included disease control and surveillance assistants (DCSA), ANC clinic midwives, and the safe motherhood coordinator (see Table S1). Women were recruited during their scheduled ANC and postnatal visits. ANC clinic midwives and postnatal ward midwives assisted in the identification of pregnant women and postnatal mothers respectively and briefed them about the study. Those interested were referred to the Principal Investigator (PI) who explained the purpose of the study and obtained written informed consent. The maternity unit in charge facilitated the selection of ANC clinic midwives and a safe motherhood coordinator. Senior DCSA facilitated the selection of eligible DCSAs. Of all the participants approached, two postnatal mothers, particularly the multipara, refused to take part in the study citing time constraints and unwillingness as their reasons. Recruitment continued until there was data saturation [9]. Data were collected from May to August 2021 through face-to-face in-depth interviews (IDIs) and focus group discussions (FGDs). A total of 21 IDIs were conducted with pregnant women, postnatal mothers, safe motherhood coordinators, and ANC clinic midwives, and two FGDs were conducted with DCSAs (see Table S1). Data was collected using semi-structured interview guides that were informed by the Theoretical Framework of Acceptability. The guides were reviewed by ALNM and AKB who have experience in maternal health issues and qualitative research. The tools were pilot-tested at Migowi Health Centre in the same district and the findings helped to modify the data collection tools [11]. The PI conducted all the IDIs and FGDs and two research assistants, experienced in qualitative research, assisted with note-taking during FGDs. All IDIs for pregnant women and postnatal mothers and FGDs were conducted in Chichewa (the predominant local language), while interviews with midwives were conducted in English. All interviews were audio-recorded and lasted for approximately one hour and two hours respectively. The research team ensured the quality of the data was credible, transferable, and reflexible [10, 12, 13]. The credibility of the data was achieved by summarising the key findings at the end of the interviews and discussions as a form of member checking [10]. The detailed description of the research methodology, setting, study findings, and verbatim quotes from individual interviews maximised the applicability of the study to other similar contexts [10, 12]. ALNM and AKB randomly read selected transcripts to identify major categories, so that readers may have a clear picture of the findings, and provided continuous feedback to the data collection team. Reflexivity of this study was achieved through the use of an audit trail [13], where an interpretation matrix was developed, which contained major themes and subthemes supported by quotes, which can be verified if other researchers decide so. The audio recordings were transcribed verbatim directly into English. Each transcription had a unique identification code that was assigned to the participant during the interview. A codebook was developed following a review of three transcripts by the research team (See Table S4). Data was analysed manually where all transcripts were read while applying the codebook and keywords according to the TFA were captured in the margins. Manual data analysis ensued following a directed content analysis technique [14] where data was deductively coded using the seven constructs of the Theoretical Framework of Acceptability (TFA) [8]. Once all transcripts were coded, the researchers examined all the data within a particular code. Data that was under the same code but appeared to contain different ideas was split into subcategories. Whereas data that appeared in different codes but had similar ideas was combined into one subcategory [14, 15]. Finally, the research team developed a matrix of themes, subthemes, and direct quotes from the study participants to the matrix. The College of Medicine Research and Ethics Committee (COMREC) (P.01/21/3240) provided the ethical approval for the study while the Director of Health and Social Services (DHSS) for Phalombe District Council granted the institutional support for the study to be conducted. All study participants signed or thumb printed a copy of the informed consent form before participating in the study. We ensured that all methods were carried out following relevant guidelines and regulations and that we did not deviate from the approved protocol. The demographic characteristics of our study participants showed that most of the women were young mothers aged between 18 and 24 years and started their ANC clinic in their first trimester (see Table S2). The table also shows that there were fewer postnatal mothers as well as the women that attended eight or more contacts as they were not readily available. The table further shows that out of the 18 women that participated in the study, seven were aware of the existence of the new model. The age range for health care providers was between 25 and 49 years with the majority falling between 41 and 49 years of age (Table S3). Unlike the DCSAs, most of the midwives who participated in this study were early career professionals, with less than two years of work experience. All 15 health care providers were aware of the new model of care, but only two had attended formal training on the model. The concept of acceptability of the 2016 WHO ANC Model among pregnant women has been presented under seven constructs of the Theoretical Framework of Acceptability, which are Affective Attitude, Burden, Ethicality, Intervention Coherence, Opportunity Costs, Perceived Effectiveness, and Self-efficacy [8]. Affective attitude describes how an individual feels about an intervention [8]. Upon asking participants how they felt about the 2016 WHO ANC model, the majority of them stated that the number of contacts was adequate for proper monitoring of maternal and foetal wellbeing and early detection and management of problems. A pregnant woman at initial contact narrated: “I am very pleased that we will be seen more frequently. Midwives will have more chances to monitor our wellbeing and that of our unborn babies, identify some problems, and manage them accordingly” (IDI_pregnant woman, 1st contact). The pregnant women’s positive feelings about the new model were influenced by the good attitudes displayed by the health care providers. “Health care workers tried their best not to insult us. Had they been rude to us, we could have lost interest in coming back to this clinic and miss our next date of appointment. But the midwives were friendly.” (IDI_pregnant woman, 8th contact). Despite the majority of the women touting the model as a good one, few pregnant women, both primigravida, and multigravida did not like the increased number of contacts due to the challenges encountered while accessing services. A primigravida at her 8th contact complained: “Although the model entails good services, its schedule is not easy to complete. The previous model was good because of the reduced number of visits considering the distance the women have to endure to access the services. (IDI_pregnant woman, 8th contact). Burden refers to the perceived amount of effort to participate in the intervention [8]. The women and health care providers highlighted long distances, increased transport costs, and fatigue as the major barriers associated with attending such an increased number of contacts. As a result, most of the pregnant women had problems adhering to and completing their ANC clinic schedule. A health worker narrated: “The women that stay far away from the clinic have not accepted the model because for them to attend the monthly appointments means more cost to them. So, some women skip their appointments to avert the long distance and the increased transport cost” (IDI_ male DCSA). A pregnant woman amplified the notion of fatigue that was associated with attending more contacts: “When they began scheduling me frequently, I felt like I was being overburdened. Considering the long distance, I felt like I should not come particularly when I reached the 9th month when the appointment dates were so close to each other. I felt like I needed to rest” (IDI_ pregnant woman, 8th contact). Ethicality refers to the extent to which an intervention has a good fit with an individual’s value system [8]. The majority of pregnant women and postnatal mothers explained that the care they received met their expectations and that they accepted the new model. The women affirmed this as they had their problems identified and managed. A postnatal mother who completed eight contacts and had lost a baby in the preceding pregnancy narrated: “I feel pleased and have accepted this new model. All the problems I experienced during pregnancy were identified and managed during the encounter with the health care providers. The care I received helped me deliver a live baby without problems.” (IDI_ postnatal mother, completed 8 contacts). In agreement, midwives felt the routine provision of the USS service would increase pregnant women’s attendance at ANC services. “Provision of routine scanning services has the potential to improve acceptability because women like to be scanned to check the condition of the foetus inside the womb but also to check other problems that might be there other than those of the foetus. The women who have been scanned will develop high expectations and have a happy experience. In addition, these pregnant women who had pregnancy-related problems identified through abdominal USS and were managed promptly would motivate other reluctant women with similar problems to come and attend ANC clinics with the hope that they too would be scanned for their problems and be timely managed.” (IDI_midwife). Intervention coherence encompasses participants’ understanding of an intervention and how it works [8]. The study participants expressed variations in their awareness of the existence of the new model. While few women reported having been informed about the existence of the new model, the majority denied their awareness of the model. A pregnant woman who completed her new schedule without knowing the existence of it narrated as follows: “You mean there is a new model? I am not aware of this. What exactly has changed? Or maybe HIV testing because we are now being tested twice, or that we are attending more visits?” (IDI_ pregnant woman, 8th contact). Healthcare providers mentioned a lack of adequate knowledge of the model as most of them did not attend formal training and that there were no guidelines to guide their practice. Staff that were trained on the new model were rotated to other departments leaving out one midwife to train on the job the incoming new staff. “I feel like I have little knowledge about this model because we were just told briefly about the services we have to offer to pregnant women. In addition, there are no guidelines here to guide our practice. So it is difficult for us to explain to the women for them to understand this model clearly.” (IDI_midwife). Opportunity cost refers to the extent to which benefits, profits, or values must be given up to engage in an intervention. [8]. In assessing opportunity costs, participants were asked to explain the competing interests that hinder pregnant women from accessing ANC services. The participants reported that being engaged in socio-economic activities, seeking traditional medicine, and fear of losing foetuses to witches were some of the factors that hinder pregnant women from starting ANC clinics early or completing ANC schedules. Furthermore, other women who develop minor disorders of pregnancy rely on traditional medicine to stabilise their pregnancy and delay initiating care once they get better. “Some pregnant women who complain of abdominal discomfort seek relief from traditional healers or birth attendants where they are given concoctions to stabilise the pregnancy. Once they are cured, they do not see the importance of starting an ANC clinic or start the clinic very late while their pregnancies have advanced thereby minimising their chances of completing the new schedule.” (IDI_pregnant woman, 8th contact). Perceived effectiveness refers to the extent to which the intervention is perceived as likely to achieve its purpose [8]. Most of the participants felt that the model has the potential to reduce maternal and neonatal mortality rates. “I think the new model has a great impact in reducing maternal and neonatal mortality rates. This is because in every visit, we assess the woman and it’s very easy for us to note if something is wrong with the woman hence correcting any problems that may arise. In addition, the USS assists in the identification of some of the problems which we could have missed if using the old model. Furthermore, we provide these women with more doses of Fansidar SP hence protecting them from malaria.” (IDI_ Safe motherhood coordinator). This refers to participants’ confidence that they can perform the behaviour required to participate in the intervention [8]. The study found that some women completed their schedules. These women cited, apart from the positive attitudes of the health care providers, the presence of social support from their husbands and peers who adhered to and completed their ANC schedule as some of the factors that enabled them to complete the schedule. On husbands’ support, the women cited that their husbands wanted improved health status, good pregnancy outcomes, and pregnancy confirmation as some of the reasons for the husbands’ involvement in ANC services. “Although I stay a bit far away from this health facility, my husband would provide transport for me to attend the clinic. He also reminded me about the appointment dates. My husband would not allow me to miss any clinic appointment date. He wanted to know the progress of our baby” (IDI_pregnant woman, 8th contact). On the other hand, women who failed to complete the schedule mentioned a lack of awareness of the model as the main reason for their failure. “I was not aware that women were supposed to come to the clinic eight times so I just felt the three visits were enough. Now that I am aware of the new arrangement, I am ready to comply in the next pregnancy” (IDI_postnatal mother, attempted 3 contacts).