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High fertility rates in low and middle-income countries (LMICs), especially in sub-Saharan Africa and Ghana, lead to closely spaced pregnancies and contribute to high maternal and infant morbidity and mortality. Family planning remains critical for reducing rapid repeat and unwanted pregnancies, thus improving the health and survival outcomes. Unfortunately, many women face significant unmet needs due to limited knowledge, misinformation, and limited access to modern family planning methods in particular. Breastfeeding plays a substantial role, and the lactational amenorrhea method (LAM) offers a practical, natural, readily available, and cost-efficient postpartum option when practiced correctly. However, many mothers lack sufficient awareness of LAM and the conditions necessary for its effectiveness. Antenatal care provides a strategic opportunity for targeted education and counselling on contraceptive choices, empowering women with the knowledge to adopt safe, informed, and sustainable practices. Group antenatal care (G-ANC), recommended by WHO for research in LMICs, offers a comprehensive and participatory platform for health education and behavioral change. This study examined G-ANC and its impact on creating awareness and improving knowledge of the lactational amenorrhea method among mothers. A cluster randomized control trial, registered at ClinicalTrials.gov on 25/07/2019 with RCT number NCT04033003, was conducted in Ghana at 14 health facilities with a total of 1761 participants. The study included pregnant women who were at least 15 years old, able to speak English or one of four local languages, and less than 20 weeks of gestation at enrollment. Women classified as high-risk by the midwife were excluded from participation in the study. Facilities were randomized using a matched pair method. Structured interviews were conducted at baseline and subsequent timepoints. The results found that group antenatal care increases maternal awareness and knowledge of the postpartum lactational amenorrhea method of family planning compared to individualized care. Subgroup analysis revealed that a mother’s level of education and parity strongly predict maternal awareness of the lactational amenorrhea method. These findings support group antenatal care as an effective strategy to improve knowledge on the use of lactational amenorrhea as a family planning method.

Background Although the majority of Ghanaian women receive antenatal care (ANC), many exhibit low health literacy by misinterpreting and incorrectly operationalizing ANC messages, leading to poor maternal and newborn health outcomes. Prior research in low-resource settings has found group antenatal care (G-ANC) feasible for women and providers. This study aims to determine the effect of G-ANC on increasing maternal health literacy. We hypothesized that pregnant women randomized into G-ANC would exhibit a greater increase in maternal health literacy than women in routine, individual ANC. Methods A 5-year cluster randomized controlled trial was conducted in 14 rural and peri-urban health facilities in the Eastern Region of Ghana. Facilities were paired based on patient volume and average gestational age at ANC enrollment and then randomized into intervention (G-ANC) vs. control (routine, individual ANC); 1761 pregnant women were recruited. Data collection occurred at baseline (T0) and post-birth (T2) using the Maternal Health Literacy scale, a 12-item composite scale to assess maternal health literacy. Logistic regression compared changes in health literacy from T0 to T2. Results Overall, women in both the intervention and control groups improved their health literacy scores over time ( p  < 0.0001). Women in the intervention group scored significantly higher on 3 individual items and on overall composite scores ( p  < 0.0001) and were more likely to attend 8 or more ANC visits. Conclusion While health literacy scores improved for all women attending ANC, women randomized into G-ANC exhibited greater improvement in overall health literacy post-birth compared to those receiving routine individual care. Life-saving information provided during ANC must be presented in an understandable format to prevent women and newborns from dying of preventable causes. Trial Registry Ethical approval for the study was obtained from the Institutional Review Boards of the University of Michigan (HUM#00161464) and the Ghana Health Service (GHS-ERC: 016/04/19).

The World Health Organization (WHO) recommends exclusive breastfeeding for the first six months after birth to ensure child health and survival. Antenatal care provides an opportunity to educate pregnant women on optimal breastfeeding practices. A cluster-randomized control trial in Ghana examined the impact of group antenatal care on breastfeeding knowledge and practice. The study enrolled 1761 pregnant women from 14 health facilities in Ghana. The intervention group (n = 877) received eight group sessions, while the control group (n = 884) received individual, routine care. Data were collected at baseline and post intervention. Pearson’s chi-square test was performed to examine categorical data, while odds ratios were calculated using separate logistic regression models to examine differences between the intervention and control groups over time. Women enrolled in group antenatal care had higher odds of following WHO recommendations to exclusively breastfeed for the first six months (odds ratio [OR]: 3.6, 95% confidence interval [95% CI]: 2.1, 6.3) and waiting to introduce solid food until six months of age (OR: 3.1, 95% CI: 1.5, 6.9). Our results found that women who participated in group antenatal care were more likely to follow the recommendations for exclusive breastfeeding developed by the WHO.

An essential component to improving maternal and newborn outcomes is antenatal care. A trial of group antenatal care was implemented in Ghana where 7 health care facilities were randomized to be intervention sites and 7 control sites continued traditional antenatal care. Group antenatal care, where 10-14 women with similar due dates meet together for visits, includes traditional components such as risk assessment with increased opportunity for education and peer support. The study aim was to assess and report the process evaluation of the implementation of a group antenatal care intervention. Process evaluation data were collected alongside intervention data and included both quantitative and qualitative data sources. Midwives at the health facilities which were randomized as intervention sites completed tracking logs to measure feasibility of the intervention. Research team members traveled to intervention sites where they conducted structured observations and completed fidelity and learning methods checklists to determine adherence to the model of group antenatal care delivery. In addition, midwives facilitating group antenatal care meetings were interviewed and focus groups were conducted with women participating in group antenatal care. In the majority of cases, midwives facilitating group antenatal care completed all components of the meetings with fidelity, following best practices such as sitting with the group rather than standing. Across 7 intervention sites, 7 groups (622 pregnant women) were documented in the tracking logs and of these participants, the majority (74%) attended more than half of the meetings, with 32% attending all 8 group meetings. Three themes were identified in both the midwife interviews and focus groups with pregnant women: 1) information sharing, 2) sense of community, and 3) time management challenges. An additional theme emerged from the focus groups with the women: women who had already given birth noticed a disconnect between what they learned and treatment received during labor and birth. This process evaluation determined that group antenatal care can be implemented with fidelity in low and middle-income countries. Time management was the biggest challenge, however both midwives and pregnant women found the model of care not only acceptable, but preferable to traditional care. The knowledge shared and sense of community built during the meetings was a valuable addition to the individual model of antenatal care.

Background: While group antenatal care (ANC) has been delivered and studied in high-income countries for over a decade, it has only recently been introduced as an alternative to individual care in sub-Saharan Africa. Although the experimental design of the studies from high-resource countries have been scientifically rigorous, findings cannot be generalized to low-resource countries with low literacy rates and high rates of maternal and newborn morbidity and mortality. The Group Antenatal Care Delivery Project (GRAND) is a collaboration between the University of Michigan in the United States and the Dodowa Health Research Centre in Ghana. GRAND is a 5-year, cluster randomized controlled trial (RCT). Our intervention—group ANC—consists of grouping women by similar gestational ages of pregnancy into small groups at the first ANC visit. They then meet with the same group and the same midwife at the recommended intervals for care. Objective: This study aims to improve health literacy, increase birth preparedness and complication readiness, and optimize maternal and newborn outcomes among women attending ANC at seven rural health facilities in the Eastern Region of Ghana. Methods: Quantitative data will be collected at four time points using a secure web application for data collection and a database management tool. Data will be analyzed on an intention-to-treat basis to test the differences between the two arms: women randomized to group-based ANC and women randomized to routine individual ANC. We will conduct a process evaluation concurrently to identify and document patient, provider, and system barriers and facilitators to program implementation. Results: The study was funded in September 2018. Recruitment and enrollment of participants and data collection started in July 2019. In November 2021, we completed participant enrollment in the study (n=1761), and we completed data collection at the third trimester in May 2022 (n=1284). Data collection at the additional three time points is ongoing: 6 weeks postpartum, 6 months postpartum, and 1 year postpartum. Conclusions: This study is significant and timely because it is among the first RCTs to be conducted to examine the effects of group ANC among low-literacy and nonliterate participants. Our findings have the potential to impact how clinical care is delivered to low-literacy populations, both globally and domestically, to improve maternal and newborn outcomes. Trial Registration: ClinicalTrials.gov NCT04033003; https://clinicaltrials.gov/ct2/show/NCT04033003 International Registered Report Identifier (IRRID): DERR1-10.2196/40828

Background As utilization of individual antenatal care (I-ANC) has increased throughout sub-Saharan Africa, questions have arisen about whether individual versus group-based care might yield better outcomes. We implemented a trial of group-based antenatal care (G-ANC) to determine its impact on birth preparedness and complication readiness (BPCR) among pregnant women in Ghana. Methods We conducted a cluster randomized controlled trial comparing G-ANC to routine antenatal care in 14 health facilities in the Eastern Region of Ghana. We recruited women in their first trimester to participate in eight two-hour interactive group sessions throughout their pregnancies. Meetings were facilitated by midwives trained in G-ANC methods, and clinical assessments were conducted in addition to group discussions and activities. Data were collected at five timepoints, and results are presented comparing baseline (T0) to 34 weeks’ gestation to 3 weeks post-delivery (T1) for danger sign recognition, an 11-point additive scale of BPCR, as well as individual items comprising the scale. Results 1285 participants completed T0 and T1 assessments ( N  = 668 I-ANC, N  = 617, G-ANC). At T1, G-ANC participants were able to identify significantly more pregnancy danger signs than I-ANC participants (mean increase from 1.8 to 3.4 in G-ANC vs. 1.7 to 2.2 in I-ANC, p  < 0.0001). Overall BPCR scores were significantly greater in the G-ANC group than the I-ANC group. The elements of BPCR that showed the greatest increases included arranging for emergency transport (I-ANC increased from 1.5 to 11.5% vs. G-ANC increasing from 2 to 41% ( p  < 0.0001)) and saving money for transportation (19–32% in the I-ANC group vs. 19–73% in the G-ANC group ( p  < 0.0001)). Identifying someone to accompany the woman to the facility rose from 1 to 3% in the I-ANC group vs. 2–20% in the G-ANC group ( p  < 0.001). Conclusions G-ANC significantly increased BPCR among women in rural Eastern Region of Ghana when compared to routine antenatal care. Given the success of this intervention, future efforts that prioritize the implementation of G-ANC are warranted. Trial registration ClinicalTrials.gov Identifier: NCT04033003 (25/07/2019). Protocol available Protocol Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9508671/ .

Background Maternal recognition of neonatal danger signs following birth is a strong predictor of care-seeking for newborn illness, which increases the odds of newborn survival. However, research suggests that maternal knowledge of newborn danger signs is low. Similarly, maternal knowledge of optimal newborn care practices has also been shown to be low. Since both issues are typically addressed during antenatal care, this study sought to determine whether group antenatal care (G-ANC) could lead to improvements in maternal recognition of danger signs and knowledge of healthy newborn practices, as well as boosting postnatal care utilization. Methods This cluster randomized controlled trial of G-ANC compared to routine individual antenatal care (I-ANC) was conducted at 14 health facilities in Ghana, West Africa, from July 2019 to July 2023. Facilities were randomized to intervention or control, and pregnant participants at each facility were recruited into groups and followed for the duration of their pregnancies. 1761 participants were recruited: 877 into G-ANC; 884 into I-ANC. Data collection occurred at enrollment (T0), 34 weeks’ gestation to 3 weeks postdelivery (T1) and 6–12 weeks postpartum (T2). Comparisons were made across groups and over time using logistic regression adjusted for clustering. Results Overall, knowledge of newborn danger signs was significantly higher for women in G-ANC, both in aggregate (13-point scale) and for many of the individual items over time. Likewise, knowledge of what is needed to keep a newborn healthy was higher among women in G-ANC compared to I-ANC over time for the aggregate (7-point scale) and for many of the individual items. Women in G-ANC were less likely to report postnatal visits for themselves and their babies within 2 days of delivery than women in I-ANC, and there was no difference between groups regarding postnatal visits at one week or 6 weeks after birth. Conclusion This study illustrates that group ANC significantly improves knowledge of newborn danger signs and healthy newborn practices when compared to routine care, suggesting that the impact of G-ANC extends beyond impacts on maternal health. Further research elucidating care pathways for ill newborns and maternal behaviors around healthy newborn practices is warranted. Trial registration : ClinicalTrials.gov Identifier: NCT04033003, Registered: July 25, 2019 Protocol Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9508671/ .

The use of family planning (FP) methods significantly contributes to improved outcomes for mothers and their offspring. However, the use of FP remains low, particularly in low- and middle-income countries. A cluster randomized controlled clinical trial was implemented in Ghana, comparing group antenatal care (ANC) with routine care. The group ANC intervention included eight meetings where the seventh group meeting incorporated information and discussion regarding methods of FP. Data collection occurred at five time points: baseline (T0), 34 weeks’ gestation (T1), 6–12 weeks post birth (T2), 5–8 months post birth, and 11–14 months post birth (T4). At T1, there was a significantly greater increase in the knowledge of FP methods as well as the intention to use FP after the birth among the intervention group. The uptake of FP was significantly higher in the intervention group for all post-birth timepoints except for T4 where the control group had significantly higher rates. The reasons for the diminishing effect are unclear. An increasing uptake of FP methods requires a multifaceted approach that includes increasing accessibility, knowledge, and acceptability as well as addressing societal and cultural norms.