Improving health literacy through group antenatal care: A prospective cohort study

Background: To examine whether exposure to group antenatal care increased women’s health literacy by improving their ability to interpret and utilize health messages compared to women who received standard, individual antenatal care in Ghana. Methods: We used a prospective cohort design. The setting was a busy urban district hospital in Kumasi, the second most populous city in Ghana. Pregnant women (N = 240) presenting for their first antenatal visit between 11 and 14 weeks gestation were offered participation in the study. A 27% drop-out rate was experienced due to miscarriage, transfer or failure to return for follow-up visits, leaving 184 women in the final sample. Data were collected using an individual structured survey and medical record review. Summary statistics as well as two sample t-tests or chi-square were performed to evaluate the group effect. Results: Significant group differences were found. Women participating in group care demonstrated improved health literacy by exhibiting a greater understanding of how to operationalize health education messages. There was a significant difference between women enrolled in group antenatal care verses individual antenatal care for preventing problems before delivery, understanding when to access care, birth preparedness and complication readiness, intent to use a modern method of family planning postpartum, greater understanding of the components of breastfeeding and lactational amenorrhea for birth spacing, and intent for postpartum follow-up. Conclusion: Group antenatal care as compared to individual care offers an opportunity to increase quality of care and improve maternal and newborn outcomes. Group antenatal care holds the potential to increase healthy behaviors, promote respectful maternity care, and generate demand for services. Group ANC improves women’s health literacy on how to prevent and recognize problems, prepare for delivery, and care for their newborn. The group ANC model used for this study was modified from a curriculum initially developed by the American College of Nurse-Midwives to mobilize communities in low-resource countries for early problem identification of pregnancy related problems and referral [29]. Using the WHO Standards for Maternal and Neonatal Care [30] the group ANC model was developed and tested for acceptability and feasibility for the first time in a clinical setting in Ghana [14]. A Facilitator’s Guide provides step-by-step details on how to conduct each of the 7 group ANC visits. Seven modules were developed covering the essential elements of ANC [31–35] (Table ​(Table1).1). The Facilitator’s Guide also includes chapters on preparing for and implementing group care, becoming a facilitator, enhancing adult learning, respectful maternity care, and monitoring for program quality, performance, and fidelity. The model uses a collaborative approach between providers and pregnant women with respect for all types of knowing. Group Antenatal Care Modules Following the initial ANC visit, pregnant women are grouped into small groups with 12 women of similar gestational age. Prior to the start of each group, blood pressure, weight, and a urinalysis are measured on each woman. She then receives an individual assessment with the provider to measure fundal height, listen to fetal heart tones, and answer any questions she prefers not to raise in the group. Pregnant women and providers then sit in circle facing one another for a 60-min facilitated discussion. The teaching component uses strategies such as story-telling, peer support, demonstration and teach-back – capturing and sharing experiences among the pregnant women to enhance its effectiveness. Improving health literacy is incorporated as an integral part of clinical practice within the model. Evidence-based information is presented in a non-hierarchical, patient centered, participatory manner. Because the model was developed for use in low-resource settings and with women who often have not had the opportunity to attend formal school, picture cards are used as visual images to enhance communication and learning in the group setting [14, 21]. They provide a mechanism to envision new concepts and ideas. The picture cards provide a valuable group discussion and learning aid to stimulate thinking and reflection, dialogue, and learning among participants. Content is repeated multiple times in multiple ways to enhance retention including: 1) auditory by listening to stories and signs of problems; 2) visual through use of demonstration and picture cards; 3) kinesthetically by practicing actions and “handling” picture cards; and 4) reminder pictures for home use. Ghana is a low income country in sub-Saharan West Africa with a maternal mortality ratio of 319 per 100,000 [2], a perinatal mortality rate of 38 per 1000 live births, and an infant mortality rate of 41 deaths per 1000 live births [36]. While 87.3% of women in Ghana surveyed had attended the minimum standard of 4 ANC visits, 27% gave birth alone or with a non-skilled attendant [36]. Only 22.8% of newborns in Ghana received the recommended postnatal check-up within the first 2 days of life between 2012 and 2014 [36]. Since 2008, there has been only a marginal decline (3%) in neonatal mortality within Ghana [36]. A prospective cohort design was used for this study. The comparison group received the standard individualized focused ANC by the same group of providers. The teaching component for women in individual care consisted of the midwife providing information in a lecture format to all women who presented for care that day on standard ANC educational content (i.e. danger signs, breastfeeding, birth preparedness and complication readiness, etc.) prior to their individual appointment with the midwife. The same educational content was presented as a facilitated discussion in the intervention group. Other than group vs. individual care, the two groups received identical antenatal treatment following the clinic guidelines [10]. Women enrolled in the study were encouraged to attend 7 ANC visits following the initial enrollment visit every 4 weeks until 36 weeks gestation and then every 2 weeks until 40 weeks gestation. Women were followed longitudinally from the time of entry into ANC through the postpartum period. Institutional review board approval for the study was obtained from the University of Ghana Noguchi Memorial Institute for Medical Research; the Kwame Nkrumah University of Science and Technology Committee on Human Research, Publications and Ethics; and the University of Michigan’s Institutional Review Board. A facility-driven convenience sample of 240 Ghanaian women presenting for their first ANC visit between 11 and 14 weeks gestation, at a busy urban district hospital were recruited for the study. Any woman over the age of 18 years, who spoke English or Twi, was currently between 11 and 14 weeks gestation, and enrolling for ANC at the identified district hospital clinic was offered participation in the study. The research assistant met with each woman in a private area of the clinic to explain the study, answer questions, and obtain informed consent. A written informed consent was used. If women were unable to read, the research assistant read the document to them. All women provided written consent through a signature or mark entered onto the informed consent document. Every other woman presenting for her first visit, who agreed to participate in the study, was alternately enrolled into either group or individual care. Women meeting inclusion criteira were recruited consecutively until 10 groups consisting of 12 participants and 120 participants for individual care were reached. No individual refused participation. Sample size was set by power calculations for a two group continuity corrected chi-square test with a 0.05 two-sided significance level and 80% power to detect a difference in knowledge acquisition between the two groups. The calculations were performed to detect a medium size effect of 0.5 as defined by Cohen [37]. Power analysis was conducted with nQuery Advisor 7.0 software [38]. From these calculations, a sample size of 73 was required per group. Anticipating the potential for a high attrition rate during the course of the study because of the known mobility patterns and potential loss to follow up in this peri-urban community, we employed an over sampling strategy. Demographic data were collected on all pregnant women at the beginning of the study. The study utilized individual survey questions and chart review for data collection. Survey questions were adapted from the Home Based Life Saving Skills evaluation toolkit [29]. The survey was assessed for both face and content validity by US and Ghanaian researchers familiar with antenatal care research in Ghana in particular, and sub-Saharan Africa in general. Questions were refined to assure comprehension of the concepts in the Ghanaian context. The survey included 37 questions to capture the knowledge gained by pregnant women during their experiences with antenatal care; 4 short answer, 18 dichotomous (yes/no) questions, and 15 recall questions to assess self-care knowledge, birth preparedness, complication readiness, breastfeeding knowledge, and postpartum danger signs. Measurement tools are available, Additional files 1, 2, and 3. The individual survey took approximately 20–30 min to complete. Women were informed they could refuse to answer any question or stop the survey at any time. Data were collected by the research assistant following birth using a face-to-face individual structured survey. Due to low literacy, the survey was administered verbally by the research assistant. Women were given an incentive of baby items worth approximately 8 US dollars upon completion of the survey. A medical record review was also conducted to obtain information on birth weight, number of ANC visits, mode of delivery, and maternal and perinatal morbidities and mortalities. All data were first entered into an excel spreadsheet and transferred to SAS 9.4 (SAS Institute Inc., Cary, NC, USA) for analyses. Summary statistics based on mean, standard deviation, or frequency were carried out for the exploratory analysis. Two sample t-tests or chi-square tests were performed to evaluate the group effect for demographic, individual surveys, and chart view items depending on the type of variables (continuous or categorical). Significance was determined at p < .05.