Integrating postnatal care into the redesign of group care beyond birth

Four workshops and six incubator sessions were conducted with 25 people from 13 countries. Participants included clinicians, researchers, and implementers of group care, outlined in Table 1. We use the FRAME to guide descriptions and reporting of the adaptation process informing the blueprint (Fig. 1). The adaptation process ensured that the three core pillars of the original group care model were retained: health assessment (including self-assessment); interactive learning, and community building. Through the incubator sessions, as participants engaged in free listing, pile sorting, and ranking, participants came to a consensus about what to include in the adapted CenteringParenting^® blueprint of the dyad-focused group care model. We use the FRAME to describe what was included in the final blueprint, which consists of: a session guide for clinical care (see Fig. 1), interactive learning (see Figs. 1 and 3), and community building (see Fig. 1) as well as suggested evaluation metrics for both practice (see Table 2) and research (see Table 3).

Table 1 Participant characteristics

Table 2 Practice monitoring and reporting data – demonstrating the value of group care example template

Table 3 Recommended research and evaluation outcomes and indicators

Table of Contents

FRAME adaptations and modification guide

When was the modification made?

The blueprint was created in the pre-implementation phase to prepare sites to pilot the adapted CenteringParenting^® model.

Were adaptations planned?

The decision to modify CenteringParenting^® was planned and proactive. The main modifications are to increase focus on the maternal and infant/child dyad care, to maximize fit in diverse settings, and to help ensure implementation success before implementation.

Who participated in the decision to modify?

The four workshops held in Kenya had 20 participants from 13 countries. Subsequent synchronous virtual incubator sessions had a range of 5–15 people per session in attendance from 13 countries (see Table 1). All participants had experience with group antenatal care either as a clinician, group care implementer and/or researcher, and some participants had experience with group postnatal and/or well-child care. Participants had a range of experience from program leaders/managers to funders to intervention developers to researchers to practitioners and clinicians.

What is modified?

We modified the content and schedule of integrated care and made contextual modifications to the format and how the intervention is evaluated. The model is designed to be a continuation of group antenatal care so that groups of postnatal people and infant/child dyads and their family members (when appropriate) can continue to receive care together for the first two years after birth. It can also be implemented for new cohorts of families after birth starting at 1–2 weeks after birth depending on country context, health system capacity, and the postnatal person’s preferences. Participants reported that evaluation of the model should include international targets such as immunizations and maternal mental health, local priorities, fidelity measures, satisfaction and experience, and empowerment of families.

At what level of delivery were the modifications made?

The modifications were made at the individual level in terms of adding clinical assessments of the postnatal person which would impact both the individual attending group care and practitioners implementing group care. The modifications also emphasize family-centered care, with a specific focus on providing dyad care to both the postnatal person and their child. These modifications would in turn impact the clinic/organization in terms of selecting providers that can care for both the postnatal person and child as well as ensuring that suggested health assessments and services can be delivered within the group space. Participants hypothesized that this modification would impact the larger network and community with a focus on families and integrated health care services and lead to more efficient health care service delivery and improved outcomes.

Content modification

Elements were added to focus on the integration of care for the postnatal person. The packaging of materials was modified to create a clear emphasis on care of the postnatal person. In addition, participants lengthened exposure to the model, which traditionally starts in some places at six weeks after birth to create a model of group care that can start at one-two weeks after birth and extend through two years after birth. Participants discussed at length the challenges that many countries and contexts may face implementing group care before six weeks after birth when in some cultures and contexts postnatal people do not leave their home for the first six weeks or may not feel comfortable traveling to the clinic. However, participants reached consensus to create an “ideal model” that, when implemented should be adapted to each setting to meet the needs of postnatal people as well as be realistic to implement within each culture and context (e.g., start group care at six weeks after birth instead of 1–2 weeks after birth).

Figure 2 provides the blueprint details with a description of recommended clinical assessments, interactive learning and community building that can be applicable at all sessions but may not be possible to cover entirely in one session. This session guide is a result of the free listing, pile sorting, and ranking process. Participants worked together sharing their experiences from different countries and contexts to make this blueprint globally applicable with a focus on maternal and infant/child dyad care.

Participants took into consideration available evidence related to maternal and infant/child health when making decisions on what to prioritize to include in the model. For example, many participants reviewed literature related to maternal and infant/child morbidities and mortality patterns globally as well as common complaints reported in clinical care/practice to ensure that what is included is well informed based on the latest evidence-based practice. Participants used the WHO recommendations on maternal and newborn care for a positive postnatal experience [30] to guide recommendations for clinical care through the first six weeks after birth and the WHO’s Improving the health and wellbeing of children and adolescents: guidance on scheduled child and adolescent well-care visits [31] to guide recommendations for clinical care for the infant/child as well as families up through the first 1000 days. Participants also discussed how it will be critical for health care workers to also refer to their local guidelines to guide the clinical care they deliver within each context that group care is being implemented. Participants also discussed the specific clinical assessments that could be considered for the postnatal person at specific timepoints that might not occur at every visit and for which there is currently no standard of care globally beyond six weeks after birth. For example, screening for endocrine/metabolic conditions beyond six weeks after birth, HIV testing (context specific), tuberculosis screening (context specific), and oral health were added. Additionally, focusing on transitioning the postpartum person to primary care in the one to two years after birth will ensure that their health care needs are met, to prevent any negative consequences of labor or childbirth from developing into a chronic condition.

Participants discussed how there will be challenges to implementation depending on the health care system context in which it is delivered. Participants also discussed how some of the recommended health assessments may need to be done individually, particularly with an emphasis on the early postnatal visits, and that an individual postnatal intake might be necessary for both the postnatal person and the infant.

Figure 3 summarizes the suggested interactive learning topics by timepoint, noting that what is discussed should be flexible and responsive to meet the needs of the group.

Evaluation modification

Participants discussed two different types of evaluation: one for research purposes and the other for quality improvement in clinical practice. When done in practice, participants felt it was important to reframe evaluation as a process of regularly scheduled reporting that elucidates the value of group care as well as what is working well and what needs to be addressed and improved rather than labeling the process as “evaluation” per se, which can have negative connotations to those providing care.

To demonstrate the value of group care in practice, it is important to take a team-based approach so that the team can assess what is working and what is not and make needed adjustments. A template can be used to collect data that will be beneficial for improving practice over time. Participants discussed how it is important from the beginning to designate who on the clinic team will be collecting, analyzing, and disseminating data so that clear processes are developed. Table 2 is a template for data collection to demonstrate the value of group care in practice. This template can be adapted for local contexts to ensure that data collected aligns with national health care outcome targets and agreed upon indicators for each setting.

Participants recommended not collecting data on all the topics covered in the sessions, other than mandated clinical care data by each health care system. The rationale for this was that the model is meant to be participant-led so that if there are other topics that participants want to discuss, there is flexibility to do so. If one is ticking off the topics on a rigidly defined plan, the valuable free-flowing discussions that should emerge from the group care model will not take place. Participants cautioned to not let data collection take precedence over care, information-sharing, and relationship-building.

Participants discussed how it was important for group care facilitators to be co-designers of the evaluation so that they know if the service they are providing is running efficiently and effectively. Participants suggested using a self-evaluation tool for each visit so that facilitators are not only evaluated by external actors but also take part in reflecting on their fidelity to the model, how facilitative they were, and how involved group members were (see Additional File 1) for example self-reflection template for group care facilitators). Participants also discussed the importance of how postnatal people, and their families should be a part of the evaluation so that their voices are heard as a part of the evaluation and the intervention is responsive to their needs, desires and satisfaction and in addition for prospective families to understand the value of group care and its impact on outcomes.

Participants discussed that evaluation in the context of research will be more detailed and will be collected in partnership with researchers within health systems or academic institutions, and professional associations for the purposes of building the evidence base for this adapted model.

Table 3 outlines suggested research and evaluation outcomes, indicators, data sources, and collection methods. When discussing outcomes and indicators participants discussed the importance of aligning these with research methods. For example, depending on the research question and methodology this will dictate what types of comparisons will be made to determine whether there are improvements in suggested outcomes and indicators (e.g., international, national or facility level comparisons).

Relationship to fidelity

All modifications made throughout this process were fidelity-consistent and preserved the core components of group care for it to be effective. While not the focus of the incubator sessions, participants discussed how training is integral to maintaining model fidelity. Participants discussed how training is necessary to be able to deliver group care effectively and in line with the core components. This is particularly important because group care is a very different approach to traditional health care delivery which often relies on didactive information-giving versus facilitated discussion and interactive learning which is a core pillar of group care.

Goals and rationale for the modifications made

The goals of the adaptation included: to increase the reach and retention of participants in group care beyond birth; improve feasibility so that this blueprint can be used across diverse settings; improve fit with recipients; increase satisfaction with its delivery and address cultural factors; and improve effectiveness and outcomes to improve maternal and child health through group care.

The reasons for adaptation included socio-political factors, to address inequities in health care delivery, and to create a model that addresses the gap in global postnatal care guidelines that focus only up to six weeks after birth; no guidelines exist beyond that. These modifications provide a blueprint for providing care for both the postnatal person and infant/child throughout the entire first two years after birth. In addition, at the provider level, participants discussed how providers can support these modifications to integrate care services and provide family-centred care. And at the recipient level these modifications were made to optimize group care for the dyad to improve maternal and child health outcomes.

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