1 Background

The high global prevalence of adverse outcomes of pregnancy and childbirth are important drivers behind the United Nation’s third Sustainable Development Goal (SDG) of achieving universal access to sexual and reproductive health for all by 2030 [1]. SDG3 aims to reduce the global maternal mortality ratio (MMR) to less than 70/100.000 live births. According to the World Health Organization (WHO), antenatal care (ANC) provided by skilled healthcare professionals can reduce maternal and perinatal morbidity and mortality [2]. Core components of effective ANC should include personalised health promotion, identification of obstetric risks and (referral to) adequate management of obstetric complications [2].

A midwife-led model of care that provides quality ANC is group antenatal care (GANC), which involves consultations in group settings at the health facility. During these consultations, women with similar gestational age receive their ANC by a trained midwife and engage in educational discussions about health-related topics [3]. This model aims to be holistic and women-centred, providing quality care while simultaneously increasing health knowledge and creating peer-support networks. Maternal well-being and psychosocial factors such as depression rates and pregnancy-specific distress are positively impacted by GANC [4, 5]. GANC is perceived to be specifically beneficial for pregnant women with sociocultural characteristics that could classify them as vulnerable, such as young maternal age and low educational level [6]. Additionally, several studies in low- and middle-income countries (LMIC) have shown a positive association between GANC and utilisation of ANC services [7, 8]. WHO recommends group care, when provided by qualified healthcare workers, to be offered as an alternative to one-on-one care [2].

Suriname, an upper-middle income country in South America [9], has an estimated MMR of 96/100.000 live births [10]. Approximately 10.000 births take place in Suriname each year [11]. In a study which compared 16 Caribbean countries in the implementation of effective health policies (e.g. programs to reduce maternal mortality), Suriname scored lowest [12]. Reasons for this low performance are associated with low national income, corruption, low population density and high ethnic diversity, creating less social cohesion between different groups and therefore lowering the tendency to invest in public goods such as healthcare [12]. These factors can be linked to the colonial history of Suriname and its political and economic crises after independence in 1975 [13].

Primary care in Suriname’s coastal area (including the capital Paramaribo) is provided by the Regional Health Service (RGD) and independent general practitioners (GP’s). In 2019, midwives and obstetric nurses working at the RGD were trained to provide GANC, based on the principles of the CenteringPregnancy model [14]. Four RGD clinics in the outskirts of Paramaribo were selected as pilot sites. Criteria used to select these locations were the number of pregnant women visiting the clinic, available space to host sessions, and the focus on reaching communities with high numbers of women in vulnerable circumstances [14]. Soon after initiation of GANC implementation in 2020, the COVID-19 pandemic brought it to a halt. When implementation resumed in 2022, only one facility continued to provide GANC. The majority of women attending GANC sessions in this facility have a high socioeconomic status and educational level. As the aim of the implementation pilot was to target women in vulnerable circumstances, it is important to understand why implementation succeeded in one clinic and discontinued in the other three, which have a greater population of women in vulnerable circumstances. Consulting a diverse group of stakeholders on different levels (e.g. RGD midwives working at pilot locations, pregnant women, management, policy makers and other professionals involved in GANC) could provide insight into relevant factors associated with successful implementation of GANC in Suriname.

2 Methods

2.1 Aim

The aim of this research is to provide insight into enablers and barriers that are associated with successful implementation of GANC in primary care in Suriname. This leads to the following research question: Which enablers and barriers are associated with successful implementation of GANC in primary care facilities in Suriname?

2.2 Setting

The current study is part of the ‘Group Care in the first 1000 days: GC_1000’ project [15]. This European Union’s Horizon 2020 Research and Innovation funded project aims to develop strategies that enable the integration of group care into antenatal and postnatal health systems [14]. Demonstration sites are established in four LMIC and three high-income countries to enable sustained service delivery and explore possibilities for scaling up.

2.3 Analytical framework

Five potential moderating factors that influence adherence to an implemented intervention from the model of implementation fidelity by Hasson [16], were used as an analytical framework to evaluate the implementation (Fig. 1). The components of WHO’s framework for Quality Maternal and Newborn Care (QMNC) by Renfrew et al. [17] were used to link the moderating factors to core components of quality maternal care (Fig. 2). The QMNC framework served as a guideline during data collection and analysis.

Fig. 1
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Potential moderating factors that influence adherence to an implementation [16]

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Fig. 2
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The framework for quality maternal and newborn care [17]

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2.4 Design

An exploratory, qualitative evaluation study was conducted from February to June 2023, to evaluate the implementation of GANC in primary care facilities in Suriname. The methodological perspective used in this research is phenomenology, operating from the belief that reality is subjective and can only be understood through the perspectives of individuals and the ways in which they have socially and historically constructed their reality [18]. Semi-structured (group-)interviews were used to collect the perspectives of relevant stakeholders. In this type of interviewing, the interviewer uses a topic guide but has the flexibility to add questions or alter their sequence. This allows for a deeper understanding of the answers and subjective concepts brought up by the respondents [19]. A validated topic guide from the GC_1000 consortium was used during the semi-structured interviews to increase consistency and reliability. Questions specifically related to the analytical framework were added to the topic guide. Prior to interviewing, the interviewer (SVK) observed regular ANC and, in the one clinic, GANC sessions. The goal of the observations was to familiarise with the setting and build rapport with midwives [20]. All interviews were conducted in Dutch, the official language of Suriname.

Firstly, a group-interview was conducted with expecting parents who participated in GANC at the only GANC-providing RGD clinic. Parents were recruited through purposive sampling. The interview was held at the Perisur office and focussed on experiences of expecting parents with GANC and the comparison to regular, one-on-one, care. All seven parents had high educational levels and socioeconomic status. Secondly, all midwives from the four pilot sites (n = 10) who were trained to facilitate GANC were invited to participate in an interview. The interviews were held at all four locations and midwives working at the same clinic were interviewed simultaneously. The response rate was 100% and data saturation was reached. During debriefings the findings were pre-analysed and further data collection needs were discussed. In order to have a complete insight into enablers and barriers of implementing group care, two managers and a policy maker (n = 3) who were indirectly involved in the implementation of GANC were interviewed. Additionally, two midwives were interviewed due to their experiences with the implementation of GANC in secondary care (n = 2). These interviews helped to validate the findings from the interviews with primary care midwives and parents, and to gain a deeper understanding about the implementation of GANC from an organisational level. An overview of all participants and their demographics can be found in Fig. 3.

Fig. 3
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Overview of participants and their characteristics

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2.5 Data analysis

All (group-)interviews were audio recorded and anonymously transcribed verbatim. As all interviews were conducted in Dutch, Dutch transcripts were used throughout data analysis. Only quotes which would eventually be used in this article were translated to English and checked by at least two authors to minimise translation errors. Using Atlas.TI (version 23.2.1), an analysis was conducted based on the Grounded Theory as adapted by Strauss and Corbin [33], using three different coding phases: open coding, axial coding and selective coding. During open coding, text fragments were labelled with keywords. Throughout this process, a code guide was developed which contained all keywords [18]. The second phase was axial coding, in which the codes were structured into categories. These categories consisted of the five potential moderating factors from the analytical framework (context, participant responsiveness, recruitment, quality of delivery, and strategies to facilitate implementation), as well as components from the QMNC framework [17]. The final phase, selective coding, consisted of determining core categories in order to refine the findings and find relationships between different data sets. Selective coding resulted in a code tree, which formed the basis of the results section (see Additional file 1).

3 Results

The result section presents the various enablers and barriers associated with successful implementation of GANC. Both enablers and barriers are structured according to the potential moderators from the analytical framework: context, participant responsiveness, recruitment, quality of delivery and strategies to facilitate implementation. The QMNC framework [17] is used throughout the result section to understand the evaluation of GANC in Suriname in the broader sense of quality maternal care.

3.1 Enablers

3.1.1 Context

Within the Surinamese healthcare system, the RGD clinics fulfil the role of primary care providers with clinics located close to people’s homes. Interviewed midwives described how this position enabled them to create a relationship of trust and confidentiality with women from that community. All midwives of the four pilot locations are used to sharing their phone number with pregnant women and provide 24/7 on-call availability. This continuity of care(r) highlights the unique position of RGD compared to hospitals in Suriname, of which both parents and midwives mentioned how they are often overcrowded. The QMNC framework regards continuity of care(r) and the interpersonal relationship with women as important components of quality maternal care.

Facilitating GANC in RGD facilities was perceived as beneficial by several interviewees, due to the clinics being quieter than hospitals, clinics being close to people’s homes, and the higher volume of women with low socioeconomic status visiting RGD clinics compared to hospitals. Additionally, the potential smooth transition from GANC to (group) postnatal care at the same facility was mentioned. Such integrated services are regarded as quality components in maternal care according to the QMNC framework.

3.1.2 Participant responsiveness

Motivating factors for the midwives and RGD management to implement GANC were the belief that this model of care could improve (long-term) pregnancy and birth outcomes, has the potential to increase pregnant women’s self-confidence, and provides women with more information compared to one-on-one care. This corresponds with the value component of the QMNC framework, which emphasises strengthening women’s capabilities. One midwife mentioned how GANC could be beneficial for her, as she would not have to explain the same topic to each individual woman. GANC was also mentioned as a way to attract more pregnant women to RGD clinics which might in time result in more women choosing to deliver in RGD facilities.

GANC participants emphasised their desire to gain knowledge about reproductive health: “I did not know anything. […] It was a big eye-opener for me that I could receive so much more information.” (Parent 3, 20–30 year old female). Learning together with other pregnant couples helped them to gain knowledge as you might not realise what you do not know until someone else asks a question about it. One midwife emphasised how health education can mean the difference between life and death for women and children in Suriname, as women often have low levels of health literacy.

Interviewees mentioned relationships to be an important aspect of their responsiveness to GANC. Relationships between health care providers and pregnant couples might strengthen through GANC: “Because you see them more often and longer in the group, compared to one-on-one. One-on-one is short: they come to listen to the baby’s heartbeat, some questions, and they are gone.” (Midwife 6, 50–60 year old female). Parents mentioned the relationship of trust and confidentiality with other parents as beneficial. In addition, the involvement of partners was highly valued by both parents and facilitators:

“For me it was also the involvement in the pregnancy as a father. There are topics which you usually would not discuss at home. But in group care, it lets you participate as a couple and makes you think: how can we handle that?” (Parent 5, 30–40 year old male)

These factors contribute to the psychological and social components within the philosophy of the QMNC framework.

3.1.3 Recruitment

Two midwives who were experienced in facilitating GANC in secondary care, emphasised on advertising and promoting the program as important factors for successful implementation of GANC:

“I was so enthusiastic about this model that anywhere I saw a pregnant woman, I would go to her and say: ‘Do you know this type of care? Come! We facilitate it, it is for free, you have to come.’ [...] This is how we were able to recruit women.” (Midwife 11, 40–50 year old female)

Other interviewees agreed that increased promotion and advertisements could help to make women aware of the existence of the program. They highlighted the uniqueness of this model of care within the Surinamese healthcare system as a great benefit which could be used for promotion. One interviewee pointed out the importance of easily understandable promotion material, tailored to the needs and knowledge of the target population.

3.1.4 Quality of delivery

In GANC sessions, participants are supposed to learn in an interactive way about health-related topics. All midwives of the four pilot locations were trained to facilitate sessions this way. Although most midwives felt confident after the training to start GANC, midwives who actually started facilitating GANC explained a learning curve in which their sessions became more interactive over time. Providing adequate health education and promotion is part of QMNC’s effective practices.

3.1.5 Strategies to facilitate implementation

Receiving support from direct colleagues as well as management appeared to be an important enabler for successful implementation. Interviewed midwives who have facilitated GANC emphasised the importance of one of them taking a leading-role and thereby motivating other professionals to participate. Additionally, midwives facilitating GANC mentioned how they had been unable to facilitate sessions at a convenient time due to inflexible working hours. After reporting this, support and approval from their management provided them with a more flexible schedule.

3.2 Barriers

3.2.1 Context

All midwives who were interviewed emphasised how the current healthcare system undermined their position as autonomous and educated care providers for low-risk pregnant women, whereas they do perceive themselves as designated care providers for this group. Several midwives suggested that the source of this lies in their midwifery education, as this study is not accredited and does not provide graduates with an official, (internationally) recognised BSc diploma. Both healthcare professionals and parents explained how the general assumption in Suriname seems to be that obstetric care provided by an obstetrician is the best care.

The notion of not feeling heard or seen was also apparent regarding the employer/employee relationship between midwives and the higher-level management: “I mean.. Is the light off with us, that they can’t see us? You know how some people have cameras at home and a screen that shows all places? Well, at the midwives it’s off, it’s dark. You can’t see anything there.” (Midwife 9, 40–50 year old female). The organisational structure of RGD consists of various hierarchical levels with decision-making authority centralised at the top. In general, midwives do not feel involved in decision-making that relates to their clinic. This was also felt in regard to the implementation process of GANC and the selection of pilot locations:

“They never spoke with us, before the training, like: ‘You know, sister, what do you think. We want to start this, are you okay with your clinic being selected, how big is the group,’ etcetera. No. We just received an invitation: there will be a training. And that was it.” (Midwife 8, 30–40 year old female)

Different stakeholders indicated how the current difficult economic situation in Suriname affects healthcare in general and the implementation of GANC in particular. They highlighted how the economic situation has worsened between the start of GANC implementation in primary care in 2019 until the moment of evaluation in 2023: “Now some have part time jobs, everything is expensive. So people are more likely to choose to earn something extra than to come sit here for two hours. Right?” (Midwife 9, 40–50 year old female). In contrast to this, one midwife mentioned how the economic situation actually motivated her to start GANC: “The situation is not getting better, but I think people are happy to belong somewhere, to tell their story.” (Midwife 5, 40–50 year old female).

3.2.2 Participant responsiveness

An important barrier in the enthusiasm to provide GANC for all midwives who are trained but not facilitating GANC was the absence of a financial incentive:

“And now we have to do it for free at RGD, because we always say yes. We have to do it, because we’ve had the assignment. But everyone knows it’s a project and money is being made. [...] Why can’t we also earn a little extra money?” (Midwife 1, 50–60 year old female)

Non-facilitating midwives perceived the implementation of GANC as additional to their regular tasks, forcing them to invest extra time in finding and motivating women and setting up and emptying a space before and after the sessions. Higher-level managers stressed that these tasks could be carried out within the regular working-hours and were therefore not regarded as valid reasons for financial compensation. They indicated how individual compensation could undermine the sustainable implementation of GANC: “Imagine you give people compensation. When it stops after one or five years, people will no longer be motivated to continue.” (Manager 2, female).

3.2.3 Recruitment

In addition to the barrier of financial compensation, interviewed midwives pointed out practical barriers that refrained them from implementing GANC. A frequently mentioned barrier was the availability of a room which is big enough to host 10–15 people, as well as the difficulty of setting up and emptying this space before and after each session. Additionally, other women might come in for regular ANC or delivery during GANC (therefore disturbing the session). Other barriers mentioned by parents and midwives were related to time: finding an adequate time for the sessions that suits both working- and stay-at-home mothers, not having enough time to attend a session due to other (household) obligations, and difficulty finding a babysitter for other children. Regarding the more vulnerable women such as pregnant teens, midwives added how they try to limit time spent at the clinic in order for the adolescent to attend school. Hence, a two-hour session would impede this. Additionally, most women are not used to having fixed dates for regular ANC appointments. Therefore, being in the clinic at a specific time for the session might be problematic as women often rely on unpredictable (public) transport.

Most midwives who have not started implementing GANC, mentioned how they perceived their population as not being willing to talk in a group setting. Reasons for not being willing to talk were the commonality of several women sharing the same partner, and the fact that many people within the community know each other and might therefore be too shy to talk about personal issues in a group-setting: “I will say it in Sranan Tongo: […] Mi no wani sma sabi mi tori (I do not want anyone to know my story).” (Midwife 9, 40–50 year old female). The perceived lack of confidentiality during GANC sessions contradicted the midwives’ values of community knowledge and respect (QMNC framework). Interestingly, midwives who do have experience in facilitating GANC did not express themselves as worried about the aspect of confidentiality. They mentioned how women were often surprisingly more open to other women than expected and highlighted the importance of strict rules about confidentiality: “You are not obliged to share your personal things, experiences. […] If you feel like doing it the first time or only at the tenth session: okay. The only obligation we have is the confidentiality document.” (Midwife 12, 40–50 year old female).

The GANC program in Suriname is based on the CenteringPregnancy model. Some midwives explained how the ‘rigidity’ of this format, consisting of nine GANC sessions with a desired group size of 8–12 women around the same gestational age, formed a barrier for successful implementation. Women often present themselves relatively late in pregnancy and, according to local guidelines, need to be referred to a hospital at 30 weeks of gestation. This provides only a small window for nine GANC sessions. Two midwives mentioned how the high number of sessions and participants daunted them to recruit pregnant women for the program.

3.2.4 Quality of delivery

The CenteringPregnancy model of care aims to replace individual, one-on-one care for pregnant women. Within the RGD, this appears to be difficult. Women often have another ANC-provider such as a gynaecologist or independent GP and perceive GANC as additional: “We also indicated that we do not want to miss the gynaecologist appointments. You see it as additional, not as a replacement.” (Parent 1, 20–30 year old female). Midwives also noticed how women preferred to come back for one-on-one consultations after GANC.

3.2.5 Strategies to facilitate implementation

A lack of clear communication between different stakeholders was mentioned by most interviewees as a barrier throughout the implementation process, especially regarding the financial incentive for midwives: “We did not hear anything. We thought maybe they were angry with us, because we asked for compensation. […] Nobody communicates.” (Midwife 2, 30–40 year old female). Interviewed midwives stressed the need for clear communication since they are the ones who need to execute the project: “You should not only be giving orders. Come, sit with me, let’s talk. Listen to me.” (Midwife 4, 40–50 year old female). One member of the management acknowledged the interconnectedness between communication problems and the hierarchical structure of the organisation, as concerns in lower hierarchical layers often do not reach higher layers.

4 Discussion

This study provided insight into the enablers and barriers associated with successful implementation of GANC in primary care facilities in Suriname. Perspectives of relevant stakeholders were collected through semi-structured (group-)interviews, guided by the moderating factors from the analytical framework. Enablers mentioned were the role of primary care facilities and continuous midwifery care. Health care professionals were enthusiastic to provide the service as it could strengthen women’s capabilities. Parents mentioned eagerness to gain knowledge, relationships, and partner involvement as motivating factors to participate. Support from management and colleagues appeared to be an indispensable enabling factor. The most important barriers were the position of the midwife and the current economic situation in Suriname; practical barriers experienced by midwives and parents; a lack of financial compensation for midwives; and inadequate communication between different stakeholders. An overview of all enablers and barriers can be found in Fig. 4.

Fig. 4
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Overview of enablers and barriers associated with successful implementation of GANC

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4.1 Motivated midwives and financial compensation

This study observed a relationship between successful implementation in clinics where an intrinsically motivated midwife was present, compared to clinics where the midwives seemed to be less enthusiastic. Midwives who were convinced of the benefits of GANC, appeared to be able to motivate others and were persistent in continuing the project, even when (practical) difficulties arose. Midwives less convinced of the added value of GANC, mentioned the absence of a financial compensation for perceived extra work as the highest barrier preventing them from implementing GANC. In a literature review on GANC, Lazar et al. [21] confirm these perceived additional tasks, as ‘learning a new model of care increased the work needed in preparation, particularly at the start of programme implementation’. A financial incentive to cover this extra work might increase motivation among midwives [22,23,24]. However, if coming from a project budget, financial compensation will stop as soon as the project ends and would therefore not be sustainable. Project budgets often do allow for compensation of hours spent in training, implementation, and scientific contribution such as data collection or evaluations. Financially reimbursing midwives for their share in these (scientific) efforts, acknowledges the extra work during implementation and related research, while an unsustainable incentive linked to the facilitation of GANC sessions is being prevented. Nonetheless, midwives who are intrinsically motivated to provide GANC without need for financial compensation should be seen and treated as key stakeholders in the process of implementing GANC.

4.2 ‘Sit with me, talk to me’

Various interviewees mentioned a lack of communication as a barrier in the implementation of GANC. The notion of ‘not feeling heard or seen’ was also present on an organisational level, and reflected how midwives perceived their position within the wider structure of healthcare on a national level. Support from colleagues and management was valued as an important enabling factor. In previous research on GANC in Suriname, midwives have indicated that they need a sense of ownership and autonomy over the project in order to adapt their working method to a new care model [24]. In order to sustainably innovate and even transform health practices, continuous reflection with all stakeholders involved is indispensable and should not be limited to those with decision-making abilities in higher hierarchical layers [21, 25]. Organisational structures based on subordination and hierarchy are common within the Surinamese societal and political system and could be seen as inheritance from colonisation [26]. When aiming to innovate, one needs to realise that involving all stakeholders in decision-making is not the default for strong hierarchical organisations and therefore this will require extra effort.

4.3 Format of the model

Some participants explained how the format of nine antenatal sessions with 8–12 pregnant women, as prescribed by the CenteringPregnancy model, might be unsuitable within the Surinamese context. Previous research suggests that the higher the number of GANC sessions a woman attends, the higher her satisfaction with the care she receives [27]. This might be related to stronger peer-support and greater group cohesion over the course of the sessions [4]. However, other formats in LMIC, for example a model of four two-hour sessions in Nepal [28], also indicate higher care satisfaction among women who participated in GANC, compared to one-on-one care. In other words, trust and group cohesion might increase with each visit but are not merely dependent on the strict nine sessions of the CenteringPregnancy model. Reducing the number of GANC sessions might create an opportunity for more sustainable implementation of GANC and simplified recruitment of women [2, 3]. Additionally, future research could study the possibility of transitional group care: providing a program in which a group continues from antenatal to postnatal group care at the same RGD facility. When provided this way, group cohesion and care satisfaction could increase over a longer period of time.

4.4 Prioritising preventative care

Contextual factors regarding the organisation of care in Suriname appeared to be of high impact on successful or unsuccessful implementation of GANC. The continuity of care(r) the RGD offers, as well as clinics being close to people’s homes, were identified as enablers. Despite this structure being well-suited for GANC [3], up until now GANC at RGD is additional for most women, instead of replacing one-on-one care. According to the QMNC framework, the division of tasks in maternal care should be based on ‘need, competencies, and resources’ [17]. Numerous studies provide evidence for a midwife-led model of care as the safest and most beneficial option for low-risk populations of pregnant women [29]. Providing GANC in addition to other, often more expensive, one-on-one care, could be seen as a waste of (sparse) resources [17]. In 2019, the Surinamese government published a strategic plan to transform the healthcare structure, focusing on preventative measures and primary care while letting go of the emphasis on curative, disease-centred, care [30]. GANC, like regular ANC, is pre-eminently a program that focuses on preventive care [2, 3]. Including GANC in primary care facilities in a national strategic plan could strengthen primary care organisations like RGD to (re)start the implementation.

4.5 Transferability of results

Although data collected in this study has a specific context (LMIC in economic distress, primary care), the results can be used to better understand enablers and barriers in the implementation of GANC in general [31]. For example, an understanding of barriers related to the position of the midwife and the added value of GANC compared to one-on-one care could be valuable for other medically-led contexts with limited autonomy for midwives. In addition, contexts with healthcare financing structures similar to Suriname could use insights from this study on the barriers related to financial compensation for midwives.

4.6 Strengths and limitations

The variety of participants and a member check with participants during a reflective session after data collection increased the credibility of this study [31]. Paired-interviews were used for midwives working at the same clinic. This was an advantage, as midwives had strong relationships with each other which contributed to a sense of trust and confidentiality during the interview [32]. A limitation of this study is that the target population of the project, i.e., women in vulnerable circumstances, were not interviewed as they did not participate in GANC at the time of this study. Future research could focus on evaluating the experiences of women from this target group, thereby providing insights into the actual reasons why they would (not) want to participate in GANC.

5 Conclusion

This qualitative study evaluated the enablers and barriers related to successful implementation of GANC in primary care facilities in Suriname. Enablers found in this study were the role of primary care facilities within the healthcare system, motivated midwives, adequate support from colleagues and higher-level management, and promotional activities. Barriers that emerged were the lack of financial compensation for midwives; practical barriers mainly related to space, time, and format; and contextual factors such as the current economic situation in Suriname, and the position of midwives within the organisation and on national level. Further research could be aimed at identifying why pregnant women in vulnerable circumstances would (not) participate in GANC, as well as studying the possibility of a combined ante- and postnatal group care program in Suriname.