Group Antenatal Care: Effectiveness for Maternal/Infant and HIV Prevention Outcomes and Contextual Factors Linked to Implementation Success in Malawi

撒哈拉以南非洲的孕产妇和围产儿死亡率是世界上最高的，占世界人口的三分之二 新的艾滋病毒感染和1/4的早产。产前护理是进入卫生系统的切入点。 对于许多妇女来说，这是一个独特的机会，可以提供拯救生命的监测。但是，提供商 短缺、护理质量低以及未能参加所有建议的就诊意味着 没有实现产前护理。迫切需要测试新的干预措施，以降低 母亲和孩子。集体产前护理是一种提供积极妊娠的变革性护理模式 经验，有效地利用提供者的时间，改善围产期和艾滋病毒相关的结局。团体中的女性 在8-12名处于类似阶段的妇女中，产前护理人员与同一提供者进行2小时的访问 怀孕了。女性进行自我评估，简要咨询助产士，并与助产士会面80-90分钟 通过游戏和角色扮演来活跃互动的健康促进。女性与助产士建立关系，并 彼此之间。在一项美国随机临床试验(RCT)中，团体护理改善了早产儿发生率，产前护理 出勤率、对护理的满意度、母乳喂养做法、安全性行为和接受计划生育。 我们在马拉维和坦桑尼亚的随机试验取得了有希望的结果。参加团体护理的女性多于参加团体护理的女性 常规护理完成了≥4产前检查(94%对58%)。他们的伴侣更有可能接受艾滋病毒检测 怀孕期间(51%对27%)。我们确定，集体产前护理可以在严格的随机对照试验中提供 尽管供应商短缺，但仍保持高保真。下一步是进行动力充足的有效性试验。 马拉维是一个特别合适的地方，因为它有世界上最高的早产率(18%)和高艾滋病毒 患病率(全国为10%，研究地点为16%)。我们使用混合设计来同时进行 采用个人水平随机抽样的有效性随机对照试验，并在#年的6个诊所检查实施过程 马拉维布兰太尔区。目的1是通过6个月评价团体产前护理的效果。 产后。我们假设，与常规护理相比，团体护理中的妇女及其婴儿将有更少的 发病率和死亡率以及更积极的艾滋病毒预防成果。我们测试目标1假设使用多个- 使用来自重复调查和健康记录的数据来分级分层模型。目标2是确定临床水平 每个诊所和整个诊所的实施成功程度和与成功相关的背景因素 诊所。分析使用案例内和案例间的矩阵。这项影响很大的研究涉及三个全球健康问题 影响马拉维所有育龄妇女的优先事项--孕产妇和婴儿死亡率以及艾滋病毒预防。 卫生部强烈支持这一项目；结果将帮助他们决定是否扩大这一项目 创新团体照护模式。负面结果将避免花费在无效的医疗保健上。积极的结果将 提供在全国和其他低资源国家采用集体产前护理所需的证据。

Sub-Saharan Africa has the world's highest rates of maternal and perinatal mortality and accounts for 2/3 of new HIV infections and 1/4 of preterm births. Antenatal (prenatal) care is the entry point into the health system for many women and offers a unique opportunity to provide life-saving monitoring. However, provider shortages, low quality of care and failure to attend all recommended visits mean that the potential benefits of antenatal care are not realized. There is an urgent need to test novel interventions to reduce health risks for mother and child. Group antenatal care is a transformative model of care that provides a positive pregnancy experience, uses provider time efficiently, and improves perinatal and HIV-related outcomes. Women in group antenatal care have 2-hour visits with the same provider in a group of 8-12 women at a similar stage of pregnancy. Women conduct self-assessments, briefly consult the midwife, and meet for 80-90 minutes of interactive health promotion enlivened by games and role-plays. Women form relationships with midwives and each other. In a US randomized clinical trial (RCT), group care improved prematurity rates, antenatal care attendance, satisfaction with care, breastfeeding practices, safer sex behaviors, and uptake of family planning. Our randomized pilot in Malawi and Tanzania had promising outcomes. More women in group care than in usual care completed ≥4 antenatal visits (94% vs 58%). Their partners were more likely to be tested for HIV during pregnancy (51% vs. 27%). We established that group antenatal care can be offered in a rigorous RCT with high fidelity despite provider shortages. The next step is an adequately powered effectiveness trial. Malawi is an especially appropriate site because it has the world's highest prematurity rate (18%) and high HIV prevalence (10% nationally, 16% at the study site). We use a hybrid design to simultaneously conduct an effectiveness RCT with individual-level randomization and examine implementation processes at 6 clinics in Blantyre District, Malawi. Aim 1 is to evaluate the effectiveness of group antenatal care through 6 months postpartum. We hypothesize that compared to usual care, women in group care and their infants will have less morbidity and mortality and more positive HIV prevention outcomes. We test Aim 1 hypotheses using multi- level hierarchical models using data from repeated surveys and health records. Aim 2 is to identify clinic-level degree of implementation success and contextual factors associated with success for each clinic and across clinics. Analyses use within and across-case matrices. This high-impact study addresses three global health priorities, maternal and infant mortality and HIV prevention, that affect all women of childbearing age in Malawi. The Ministry of Health strongly supports this project; results will help them decide whether to scale-up this innovative model of group care. Negative results will avoid spending on ineffective care. Positive results will provide evidence needed to adopt group antenatal care nationally and in other low-resource countries.