The introduction of group antenatal care in northern Nigeria: an implementation research case study on improving quality and uptake

IntroductionWith one of the highest rates of maternal mortality in the world, improving antenatal care for the poorest communities is a high priority in Nigeria. In 2022, Project HOPE partnered with the Nigerian Ministry of Health to implement a group antenatal care project in Niger State. Government managers and Project HOPE aligned policy documents and budgets, and conducted a baseline assessment. Project staff then trained health care workers on group antenatal care. The project also connected women with a national health insurance scheme and strengthened monitoring and supervision systems. MethodsUsing quantitative implementation research, an instrumental case study was developed describing the design and implementation of the project. A final evaluation used both program and national health information system data to examine service utilization and health outcomes. Two tools were created for this purpose--a patient register and a monthly summary derived from that register. ResultsThe project trained 300 health workers and established group antenatal care in 150 health facilities. Over 17,000 women participated in 1,054 antenatal care groups. Multivariate analysis found statistically significant increases in first and fourth antenatal visits and facility births following the intervention. ConclusionDespite challenges, this project demonstrated success in increasing service use. Influencing factors were the use of indigenous master trainers, engaging stakeholders, revitalizing facility monitoring and evaluation, and the inclusion of the group antenatal care model in national antenatal care guidelines. Noted challenges included inadequate skilled birth attendants and lack of antenatal care commodities. O_LIWhat is already known on this topic - Maternal mortality is high in Nigeria. Antenatal care and facility birth are evidence-based practices for reducing maternal mortality. A large-scale group antenatal care project was implemented in 150 primary health centers in Niger State. C_LIO_LIWhat this study adds - We documented project implementation and analyzed changes in service use and health outcomes to share program challenges and impact. Despite funding limitations and a short implementation period, the project increased antenatal care attendance and facility births. C_LIO_LIHow this study might affect research, practice or policy - The results show that group antenatal care implemented using a midwifery care model, and connected to state health insurance schemes and facility mentorship, can increase evidence-based practices that lower maternal mortality. C_LI