A total of 928 studies were identified through electronic database searching with an additional study identified through hand searching of citations. After duplicates were removed and screening was completed (see Fig. 1), 19 papers from 17 studies were included. Five papers were from LMICs and the remaining studies were from high-income countries. Two papers were personal reflections of midwives conducting group care; 10 papers were pure qualitative research; and the remaining papers were mixed methods analysis that included a qualitative component. In Rwanda, Nepal and one of the U.S. studies, the qualitative analysis was conducted alongside a cluster randomized control trial. Eleven papers were assessed as being high quality, one as medium–high quality, six as medium quality and one as low quality. The low-quality paper was a personal reflection of an Australian midwife’s direct experience of facilitating GANC and thus, although lacking methodological rigour, was clearly relevant to the research question. The vast majority of the facilitating providers were midwives (n = 133); in the Rwandan study, both midwives and nurses (n = 59) were facilitating and no distinction was made between them in the focus group discussions. The other providers facilitating included three family practice physicians, five perinatal educators and four family support workers. Two papers mentioned ancillary medical staff (qualifications not specified) and obstetricians. In some cases, it is unclear from the papers what facilitative role, if any, the medical staff and obstetricians had [49, 50]. In seven studies midwives co-facilitated with other midwives [51,52,53,54,55,56,57], sometimes from academic backgrounds or different disciplines, and in one case with the aid of a support nurse. In one study physicians facilitated with perinatal educators [58, 59]. In two studies midwives or nurses worked with community health workers [60, 61]. In two papers midwifery students were involved in the facilitation process [54, 62]. The remaining studies had either no co-facilitator or did not describe a co-facilitator. Some mentioned ancillary medical staff or programme staff but didn’t specify their training or participation in the facilitation process [49, 50, 63,64,65] (see Table 2.)
Three overarching themes emerged from the analysis of provider experiences with facilitation of GANC. Firstly, the experience of providing the elements of care they know women want; secondly, the experience of skill building and role change; and thirdly, the theme entitled Value Proposition of GANC’ addressing provider investment and workload (see Fig. 2).
Giving women what providers feel they want and need: the satisfying experience of giving women personalized, supportive, high-quality care
In a GANC model, providers experience the opportunity to offer women many of the attributes of care that influence their uptake and satisfaction with antenatal care.
Now due to this program pregnant women are also enjoying it a lot. Now pregnant women come and ask us, ‘When are we coming for our next checkup? When are we going next?’ They ask this and then when they get to sit in a group … Now they don’t have the ‘aa, why do we need to go for checkup?’ kind of mentality.—Community Health Worker in Nepal [61, p 10]
Providers uniformly related that women who participated in group care were happier and seemed to want to come for prenatal care. They stated that women also appreciated not having to wait for their visits, a common issue in this crowded clinic.—Clinicians in the US [63, p 30]
The following subthemes describe providers’ experiences of providing care that women want through the richer use of time, more depth in the time allotted, more personalized care, more supportive care and continuity of care.
Richer use of time
An adequate quantity and quality of time in antenatal care has repeatedly been identified as a key component of what women want, and what providers themselves often feel they lack. In this review, providers repeatedly commented on the ways in which the time was spent in GANC was more productive . The richer use of time was facilitated by decreased repetition and the ability to achieve more educational and personal depth of care in the time allotted in group care as compared to standard antenatal care [55, 57, 58, 64]. The restructuring of provider hours with group models afforded providers more time to deliver higher quality care.
In our regular clinic…sometimes we’re kind of rushed and moving pretty quickly and so [I like] to just feel like we can sit down and get in depth with people. … I like that. … I’d rather have a thick novel than a one paragraph of a magazine article.—Physician in Canada [58, p 4]
More personalized care
Providers appreciated that the extra time spent in discussion in GANC models allowed them to assess women’s knowledge and better meet their needs, in some ways offering care that is more personalized than in standard care.
…facilitating midwives felt that GANC enabled them to be truly ‘with woman’, building up trust and rapport over multiple encounters and addressing social, emotional, and clinical needs: It’s not one-to-one but honestly, I can remember all of the women’s names and you can’t really say that for when you are in an antenatal clinic and all the women come in and out, you don’t remember them.—Midwife in the U.K. [67, p 61]
In addition to getting to know women better, GANC allowed providers more possibility to tailor their care and listen and respond to feedback from numerous women and other providers. The additional opportunities to ask and answer questions invested the time spent with richer education and support around pregnancy and parenting [58, 60, 63].
In the past, pregnant women used to come and listen to a brief talk from the nurse. But today, they come and sit together with the nurse and share. They ask questions and get answers to them. In the past, the nurse could fail to get time to answer to their questions; so they could go back home without answers. Today, they are free to ask whatever they want; they feel at ease with the nurse; they behave like friends.—Nurse/Midwife in Rwanda [60, p 8]
Midwives also commented that the increased feedback and communication made their jobs faster and easier .
More supportive care
Providers facilitating GANC appreciated the peer component as a vital element that engendered a supportive environment, normalized the pregnancy experience and enabled health behaviour changes.
They witnessed the creation of a community, and saw transformative support for young or vulnerable members and bonding between women with the exchange of personal details and valuable information that filled important knowledge and support gaps [55, 56, 58].
…sometimes there’s sort of synchrony in the life issues that the women are having in terms of relationships, particularly with their partners. They teach each other and they teach me about ways in which they are able to cope, and demonstrate some strength in their lives, no matter how chaotic sometimes it appears or how crazy it is.—Midwife in the U.S. [66, p 598]
Additionally, normalization of pregnancy as a healthy state in the presence of peers was identified as an important reassurance for women and a validation of provider beliefs [56, 67]. Maternity care providers identify the group setting as being an advantageous way for women to transition knowledge into healthy behaviours, where sharing experiences among peer experiences in the presence of a clinical facilitator was a motivator for health-seeking behaviour and health-promoting behaviours [58,59,60,61, 64, 65]. Providing care that supported knowledge acquisition and behaviour change was satisfying for providers,
As for me, this group care program has pleased us very much; you can even learn of this fact through much excitement of the group members. For us who lead group care, we can see it. You can see that mothers are thirsty for knowing all those new things. When you discuss with them and when you are making conclusions together with them, you find the members happy, and most of them wish never to miss out.—Nurse/Midwife in Rwanda [60, p 6]
Continuity of care
Continuity of care has been identified as a driver of improved outcomes for women and as an important element in women’s satisfaction with their care. For providers facilitating GANC, the continuity of care delivery was an important benefit for women , but also for students and the providers themselves.
It contributes because they [students] won’t see it in a hospital setting, they won’t see a same group coming at the same time, on set dates…[the women] growing as a group and shifting in their pregnancies’ how comfortable they are and sharing, hearing more than one person. So I think it contributes in changing their perception of what a pregnancy journey is…—Midwife in Australia [54, p 419]
In another study, providers identified this continuity as contributing to patient safety and ease of follow-up as well as a sense of autonomy in managing their workload .
Building skills and relationships
The second theme to emerge from the data was that of experiences around skill-building and changes in the roles of providers and participants. Fourteen papers contributed to this theme, which is further explored in three subthemes: independence/autonomy, provider role development and hierarchy shifts.
Providers repeatedly commented on the increased independence/autonomy of the women in GANC.
Notably, in the study of Rwandan nurses’ and midwives’ experiences facilitating GANC, the focus group participants described ways in which a key element of GANC, the self-checking component, improved care quality by shifting health surveillance tasks to women and allowing them to take more ownership of their care.
Some providers admitted that the structure of group care visits resulted in an increase in routine assessments, especially blood pressure: “We didn’t use to test blood pressure, and the effect resulting thereof could take the lives of many women. This test is very important. [In the past] it was very possible [we did not check blood pressure] even until she gives birth. They [group care participants] can test that blood pressure themselves because they already know how to do it. When they have tested one another and found out that there is one who has a problem, they inform the nurse, and the nurse can verify and provide due assistance to the woman having the problem before the situation becomes worse. Things have become very easy.”—Nurse/Midwife in Rwanda [60, p 10]
Physicians in Canada also commented on the ways in which women became more confident and knowledgeable through checking their own blood pressure and urine . In one study from the U.S., this independence was viewed differently:
Some staff complained that group prenatal care was ‘spoiling’ women for individual care because they had ‘become used to coming in, doing whatever they have to do for themselves and getting everything done instead of just sitting and waiting.’—Clinician in the U.S. [50, p 469]
In addition to restructuring the task of health surveillance, providers identified the ways in which they found that GANC restructured health education and communication with women and between women.
Seeing women so comfortable with themselves and me as a health professional was a new experience. … Compared with women experiencing normal midwifery practice in Thailand, the women in my antenatal groups were more independent and talkative. Women in Thailand are usually submissive and they generally do not have the confidence to take responsibility for their own health.—Midwife in Thailand [65, p 633–4]
Other midwives were moved by ways that participating women found coming to the group made them better mothers, and the ways that shifted the focus from the midwife to the group, or the ways GANC rebuilt trust between providers and women in communities where these relationships were strained [56, 66].
Provider role development through facilitation and collaboration
The growth in independence and confidence in the women coincided with a shift in the role of the provider. The facilitative role was easier for some providers than others as it required providers to cede some control over what information was given and how. This was experienced by providers in the GANC model as a process of stepping back and experiencing a sense of release from some of the pressures maternity care providers experience in the delivery of antenatal care.
It was mind-blowing just how much I could just sit back and allow the group to run itself and there was no pressure, it was just easy to facilitate this group…—Midwife in Australia [57, p e35]
The relational shift that occurred in a facilitative environment was described, as above, as a sensation of relaxation and, for many, it contributed to increased feelings of job satisfaction and provider well-being.
Most times you are chatting, you have a laugh, you are doing the work, you are accomplishing what you would do antenatal [sic] but there is a different sort of atmosphere. I find it is very relaxed.—Midwife in the U.K. [67, p 61]
It takes a little bit of the pressure off of us as well to be kind of all things to everybody. To be their midwife and their best friend and their mother…it maybe defines our clinical role a little more clearly in some respects and takes away from some of that social role.—Midwife in Canada [56, p 7]
Stepping back and giving control to the group are core distinctions between didactic and facilitative interaction. This letting go and trusting the group process was not an automatic experience for providers, as demonstrated in studies that examined the experiences of providers over the course of implementing the intervention [52, 57, 64]. The fear of failing to deliver all the necessary information or being held solely accountable in a model that shares out responsibility was anxiety producing for some participants .
It was hard at first because…that lack of control makes you feel like, I don’t know if they’re getting the right amount of information and then I started to realize…who am I to decide what kind of information they really need?—Perinatal educator in Canada [59, p 129]
The following quote illustrates the experience of the challenges of facilitation for maternity care providers who have been trained to deliver prescribed antenatal care content. If that content is up for discussion, providers can feel that they lose control of the narrative.
It is impossible in a group to give what we give to people one-to-one because of the constraints of them [the participants] wanting to discuss it.—Family Nurse Partnership Midwife in the U.K. [53, p 178]
Providers repeatedly acknowledged anxiety about the facilitation component of GANC. They highlighted fears of being unprepared in the event the women in the group remained silent [57, 64].
As confidence in facilitation skills grew, providers experienced their groups with satisfaction. They learned how to create a comfortable environment, and use silence, encouragement, humour and guidance to create an optimal experience for participants where everyone felt equal and heard and the groups were able to create bonds and feel safe [52, 59, 65, 67]. The result was that facilitation skills made providers feel more effective.
I was able to see the group bond and work together as my skills grew.—Midwife in the U.S. [52, p 215]
Another aspect of facilitating GANC that brought about new experiences was collaborating with other professionals. This inter-provider collaboration echoed some of the peer support benefits of group care for women and worked well in instances where providers were able to play off one another’s strengths.
I learn from her [health service midwife] about the updates in clinical practice …she realises that we’re from that evidence based [approach] and so she asks for that input. She says, ‘Oh what’s the latest thinking on this? And how do you think I could do that better?’ It’s more of a discussion.—Midwife in Australia [54, p 420]
However, inter-provider collaboration could be challenging for some.
…but I have to wear the hat of the hospital midwife not the community midwife. … there has been those moments … I haven’t necessarily resonated with what the [other] midwife has said.—Midwife in Australia [54, p 419]
Inter-provider collaboration also allowed for a shift in professional hierarchies, which was the final subtheme to emerge under provider role changes.
GANC appeared to alter established hierarchies in antenatal care, those between pregnant women and health care providers and those between different ranks of health care professionals, such as physicians and perinatal educators or junior and senior midwives .
At the beginning I was ‘absolutely petrified’. Now I feel so much more confident as a midwife. I have learnt so much. It didn’t matter how junior I was to the rest of my colleagues who were also a part of it. You’ve created a relationship with them and we had fun you know, we laughed.—Midwife in Australia [57, p e35]
This hierarchy flattening was also experienced positively by providers in their relationship with the women in their groups. They found themselves more approachable and sensed the women as more open and more confident in the value they contributed to groups, and more likely to access services they might need [50, 55, 58, 64].
I am very much satisfied [with group ANC/PNC]. I would say that the success results from freedom. When we have come together, we sit and talk freely with those mothers whom we serve.—Nurse/Midwife in Rwanda [60, p 8]
The freedom in communication observed among midwives and women in the Rwandan study also occurred between midwives and managers.
I have learnt also to play a role in boldly speaking to the manager in favor of group care when elaborating the timetable. We shall inform them about how the group care activities are scheduled throughout the week so that they will provide room for the people trained to handle group care and do that very job without having much work in other services.—Nurse/Midwife in Rwanda [60, p 12]
This quote illustrates both need and desire among providers to advocate for institutional time, space, staffing and support for GANC. It speaks to the third theme that emerged from this review, which can be expressed in the unasked question of whether this model of care is worth the work, and for whom.
Value proposition of GANC
The third theme raised in the included studies encompassed the workload and commitment invested by providers implementing GANC, the effects of organizational support on that investment, and the value return experienced by the facilitating providers.
Providers expressed their commitment to and enthusiasm for the model in the varied ways that they advocated for the programme, often exceeding expectations to make GANC succeed.
They [clinicians] facilitated groups, solved logistical problems, did ‘everything’ that needed to be done, aggressively recruited women, advocated and ‘tapped into every resource.’—Unidentified Clinician Facilitators in the U.S. [50, p 470]
Providers differed in their opinions of whether GANC reduced workload or increased it. While, as identified above, they found that the repetition was decreased and they had more time to dedicate to support, relationship building and in-depth education, learning a new model of care increased the work needed in preparation, particularly at the start of programme implementation [54, 57, 67].
In the beginning, it [GANC] created more work and the atmosphere was chaotic and stressful.—Midwife in the U.S. [52, p 214]
The work described fell into two categories, one involving the mental challenge of facilitation and the other being the logistical effort put into the structural functioning of GANC within a health care organization.
The workload was perceived as more onerous in the presence of organizational barriers (raised in 11 included studies), such as in cases where staffing shortages didn’t allow for a co-facilitator or a provider had to cover intrapartum and antepartum services simultaneously, or there was inadequate administrative buy-in.
Sometimes I felt, like, helter-skelter trying to do everything by doing this by myself, it’s more work than one-on-one care.—Midwife in the U.S. [49, p 695]
In spite of their flexibility, enthusiasm and commitment, some providers experienced real challenges in this model of care. Most of the barriers were organizational: issues around scheduling, staffing, charting and following up labs, lack of support or recognition from colleagues or management, or generalized system dysfunction [54, 61, 63, 67].
So we need one person who coordinates it from [hospital] side. Because there’s so many things to follow-up, to prepare, we need a permanent staff member to continue to organise all of the groups, all of the charts to be prepared, all of the follow up bloods, ultrasound . . . —Midwife in Australia [68, p 419]
These barriers led some providers to make untenable compromises or to abandon the model altogether . One clinician stated, “…the joy of doing groups is gone.” [49, p 695].
With proper institutional support, most providers found the benefits outweighed the challenges, and several providers felt that GANC reduced their workload or made it easier by increasing confidence in women and reducing unnecessary pages or clinic visits [55, 56, 61, 67]. Findings from Rwanda and the reflection of an Australian midwife indicate that the workload is more manageable when providers have more autonomy over their scheduling in GANC, as with case-loading models [60, 62].
[Group care] adds to our workload as others have said, but I am lucky because it is me who plans the work to be done. Therefore I allot enough time to it;—Nurse/Midwife in Rwanda [60, p 11]
Adequate training in the model and facilitation skills was routinely appreciated by providers facilitating GANC [52, 53, 57, 61].
Providers noted an improvement in participation and acceptance of group ANC over time. They expressed that conducting group ANC was easy (n = 4) and stressed the importance of using guides and having ongoing training.—Midwives and CHW in Nepal [61, p 10].
Value return for providers
The overall experience of providers with GANC as reported in the literature was a positive one across a wide variety of contexts and countries, from busy urban clinics to rural low-risk practices. A majority of included providers stated the benefits associated with the programme generally outweighed any additional associated workload. Midwives, physicians, nurses and educators all reported enjoying this type of care delivery model. Speaking specifically about the experience of facilitating GANC, the words ‘joy”, “fun”, “meaningful” were used repeatedly [50, 52, 67].
Group care was for me, a rewarding, enjoyable and far more effective way in engaging with women and families and to meet their educational support needs. I miss ‘my’ women and students greatly.—Midwife in Australia [62, p 89]
This Ibaruke Neza [group ANC/PNC] program which is carried out in the groups made me like my job. Why is that? Clients have lovely and friendly interactions with nurses, they feel at ease when talking with them.—Nurse/Midwife in Rwanda [60, p 10]