Randomized controlled pilot of a group antenatal care model and the sociodemographic factors associated with pregnancy-related empowerment in sub-Saharan Africa

Background: The links between empowerment and a number of health-related outcomes in sub-Saharan Africa have been documented, but empowerment related to pregnancy is under-investigated. Antenatal care (ANC) is the entry point into the healthcare system for most women, so it is important to understand how ANC affects aspects of women’s sense of control over their pregnancy. We compare pregnancy-related empowerment for women randomly assigned to the standard of care versus CenteringPregnancy-based group ANC (intervention) in two sub-Saharan countries, Malawi and Tanzania. Methods: Pregnant women in Malawi (n = 112) and Tanzania (n = 110) were recruited into a pilot study and randomized to individual ANC or group ANC. Retention at late pregnancy was 81% in Malawi and 95% in Tanzania. In both countries, individual ANC, termed focused antenatal care (FANC), is the standard of care. FANC recommends four ANC visits plus a 6-week post-birth visit and is implemented following the country’s standard of care. In group ANC, each contact included self- and midwife-assessments in group space and 90 minutes of interactive health promotion. The number of contacts was the same for both study conditions. We measured pregnancy-related empowerment in late pregnancy using the Pregnancy-Related Empowerment Scale (PRES). Independent samples t-tests and multiple linear regressions were employed to assess whether group ANC led to higher PRES scores than individual ANC and to investigate other sociodemographic factors related to pregnancy-related empowerment. Results: In Malawi, women in group ANC had higher PRES scores than those in individual ANC. Type of care was a significant predictor of PRES and explained 67% of the variation. This was not so in Tanzania; PRES scores were similar for both types of care. Predictive models including sociodemographic variables showed religion as a potential moderator of treatment effect in Tanzania. Muslim women in group ANC had a higher mean PRES score than those in individual ANC; a difference not observed among Christian women. Conclusions: Group ANC empowers pregnant women in some contexts. More research is needed to identify the ways that models of ANC can affect pregnancy-related empowerment in addition to perinatal outcomes globally.

This two-arm randomized controlled pilot study compared PRES scores for those assigned to individual ANC or CP-based group ANC (group ANC) at sites in rural Malawi and urban Tanzania. Malawi and Tanzania are both low-income countries with high rates of maternal and infant mortality, but Malawi is substantially poorer and a larger proportion of its population is rural [42–44]. The study site located in central Malawi offered group ANC at two clinics, one located at a rural hospital and the other a rural health centre. The Tanzanian site included one clinic located in the city center of Dar es Salaam. Between August and November of 2014, pregnant women who were 20–24 weeks pregnant, over age 16 and capable of completing study procedures were recruited and assessed for eligibility to participate. ANC midwives informed pregnant women that a research project was being conducted and, if the women were interested, the midwife escorted them to a private space in the clinic where research staff provided further information about the study. A total of 223 pregnant women were assessed for eligibility and 218 women provided consent. Baseline surveys, translated to Chichewa (Malawi) and Swahili (Tanzania), were administered to women using a touch screen computer and customized Computer-Assisted Personal Interview software developed at Tufts University [45]. After completing the baseline survey, a research assistant brought a basket filled with envelopes with equal numbers of assignments (1:1 ratio) to each study condition into the room. Women chose and opened one sealed envelope. Study condition assignment was concealed to research staff and women until the envelope was opened and the enclosed card was read aloud. Women enrolled in individual ANC received FANC, the standard of practice in both countries. Women arriving to the antenatal clinic are served on a first come, first served basis. At some point in the day as women wait for services, they are assembled in the waiting area so that a midwife can deliver a health lecture on a predetermined topic. Where available, women complete laboratory tests and are encouraged to get an HIV test. Women have a one-on-one physical assessment and discussion with a midwife in a private room. The midwife (or an assistant) weighs her and takes and records her vitals. The expected number of ANC contacts is four and she may or may not see the same midwife over the course of the four contacts. For women enrolled in group ANC, the same midwife and co-facilitator provide 2 hours of care, education, and support for 12 women at each of the scheduled group ANC contacts. In Tanzania, women first go to the lab for services and then go to the group space. In Malawi, women do not routinely receive lab services, so they go directly to the group space upon arrival. In addition to socializing with group members, women participate in self-care activities by measuring and recording their own weight and vital signs. Each woman then has a 3- to 5-minute private meeting with the midwife in a corner of the group space. They discuss her health data and personal problems and the midwife conducts a physical assessment. If further examination is needed it is usually provided after the session ends. If a woman expresses a general concern or problem, the midwife will suggest that this be shared and discussed with the entire group either by the woman or by the midwife. After individual assessments are complete, the midwife and co-facilitator join the circle of women and facilitate interactive discussions using pre-arranged activities. Each session is appropriate for gestational age, but the discussion is fluid; women can bring up additional topics and the time allotted can change by degree of engagement. The PRES is a 16-item Likert-type scale used to assess women’s sense of control over their pregnancy-related health and healthcare. Responses for each item ranged from 1 (strongly disagree) to 4 (strongly agree); the scale has a maximum score of 64. Scale development and content validity, as well as reliability for a sample of pregnant women in the USA, are described by Klima et al. [37]. Type of care (individual ANC or group ANC), was the primary independent variable for this study. Both Malawi and Tanzania administer ANC following FANC guidelines. Based on established associations with pregnancy experiences and outcomes, we examined several sociodemographic factors. Age was divided into three groups (<20, 20–34, 35+) since adolescents and older mothers have different risks [46, 47]. Other variables included gravidity (primigravida or multigravida), religion (Muslim or Christian), and four indicators of socioeconomic status. Education was categorized into three categories (less than primary school, primary school completion, and more than primary school). We also looked at whether the woman said she was a subsistence farmer, indicative of a more rural lifestyle. We assessed extreme poverty using a single question regarding food insecurity – whether the woman had experienced lack of food or money to buy food in the past four weeks. To obtain some sense of the other end of the economic spectrum in terms of disposable income, we constructed an 10-item assets index that reflected how many of these items were owned [48]. Prior to data collection we received approvals from three institutional review boards – the University of Illinois at Chicago, the College of Medicine Research and Ethics Committee in Malawi, and the National Institute for Medical Research in Tanzania. We also received approval from the Ministries of Health and administrators at participating sites. We recruited participants, obtained informed consent and conducted the baseline survey. Women either attended individual ANC or group ANC throughout their pregnancy. The late pregnancy interview and PRES tool were scheduled to take place after the woman’s fourth ANC contact (between 32 and 38 weeks). When possible, the project manager made reminder phone calls. This strategy worked well in Tanzania, where over 95% of women had access to a cell phone, but was less successful in Malawi, where only 34% had access to a phone. Another strategy was meeting women at the clinic. For women in group ANC, the country project managers knew when the last group contact was scheduled, and thus made arrangements for the interviewers to be present at the clinic on those days. All interviews were conducted using the same in-person interview procedures for both individual and group participants. Extensive training of interviewers and use of the Computer-Assisted Personal Interview minimized potential interviewer bias. Analyses were conducted separately for Malawi and Tanzania because baseline characteristics were significantly different for the two countries. We examined baseline sociodemographic factors of the study participants by study condition. Independent samples t-tests and Wilcoxon rank sums tests were employed to assess if mean PRES scores differed by study condition. In addition, we investigated sociodemographic factors to identify additional characteristics associated with pregnancy-related empowerment using model selection that maximized adjusted R-squared considering all subsets of predictors. Among the models selected, we tested moderation of treatment effect by the other variables in the models using two-way interaction terms. In our primary analyses, participants with missing data were excluded through list-wise deletion. However, since differential retention occurred in Malawi, we compared our primary results to models estimated using the full information maximum likelihood approach to handling missing data. This approach is known to produce less biased estimates than complete case analyses [49, 50]. Using Mplus version 7 [51], we incorporated access to a cell phone, which was related to missingness, as an auxiliary variable in these inclusive, full information maximum likelihood models. All regression analyses, t-tests, χ2 tests, and correlations were conducted using version SAS 9.4. Level of significance was set at P < 0.05 throughout; because of the small sample size, we also discussed trends (P < 0.10).

• patil, crystal l.
• klima, carrie s.
• leshabari, sebalda
• steffen, alana d.
• pauls, heather
• mcgown, molly
• norr, kathleen f.