Group Prenatal Care in Mexico: perspectives and experiences of health personnel.

OBJECTIVE: Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS: We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS: The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION: Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.

Evaluating process fidelity during the implementation of Group Antenatal Care in Mexico.

BACKGROUND: CenteringPregnancy (CP) is a group antenatal care (G-ANC) model that has proven beneficial for mothers and their newborns. We conducted a feasibility study beginning in 2016 as part of the Mexican effort to implement G-ANC locally. This study reports on fidelity to the essential elements of CP during its implementation in Mexico. METHODS: We collected prospective data using a standardized checklist at four primary-care centers that implemented our adapted G-ANC model. We performed a descriptive analysis of fidelity to 28 processes per G-ANC session (71 sessions made up of 10 groups and 129 women across 4 health centers). We calculated fidelity to each process as a proportion with 95% confidence intervals. We present overall results and stratified by health center and by facilitation team. RESULTS: Overall fidelity to the G-ANC intervention was 82%, with variability by health center (78-88%). The elements with the highest fidelity were having space for activities such as checking vital signs, conversation in a circle, and medical check-ups (100% each) and the element with the lowest fidelity was using music to enhance privacy (27.3%). Fidelity was not significantly different by center. CONCLUSIONS: Our study suggests good model fidelity during the implementation of G-ANC in Mexico. Our findings also contribute useful information about where to focus efforts in the future to maintain and improve G-ANC model fidelity.

Group Prenatal Care in Mexico: perspectives and experiences of health personnel / Atención Prenatal en Grupo en México: perspectivas y experiencias del personal de salud

ABSTRACT OBJECTIVE: Identify barriers and facilitators to implementing the Group Prenatal Care model in Mexico (GPC) from the health care personnel's perspective. METHODS: We carried out a qualitative descriptive study in four clinics of the Ministry of Health in two states of Mexico (Morelos and Hidalgo) from June 2016 to August 2018. We conducted 11 semi-structured interviews with health care service providers, and we examined their perceptions and experiences during the implementation of the GPC model. We identified the barriers and facilitators for its adoption in two dimensions: a) structural (space, resources, health personnel, patient volume, community) and b) attitudinal (motivation, leadership, acceptability, address problems, work atmosphere and communication). RESULTS: The most relevant barriers reported at the structural level were the availability of physical space in health units and the work overload of health personnel. We identified the difficulty in adopting a less hierarchical relationship during the pregnant women's care at the attitudinal level. The main facilitator at the attitudinal level was the acceptability that providers had of the model. One specific finding for Mexico's implementation context was the resistance to change the doctor-patient relationship; it is difficult to abandon the prevailing hierarchical model and change to a more horizontal relationship with pregnant women. CONCLUSION: Analyzing the GPC model's implementation in Mexico, from the health care personnel's perspective, has revealed barriers and facilitators similar to the experiences in other contexts. Future efforts to adopt the model should focus on timely attention to identified barriers, especially those identified in the attitudinal dimension that can be modified by regular health care personnel training.

RESUMEN OBJETIVO Identificar barreras y facilitadores de la implementación del modelo de Atención Prenatal en Grupo en México (APG), desde la perspectiva del personal de salud. MÉTODOS Estudio cualitativo descriptivo en cuatro clínicas de la Secretaría de Salud en dos estados de México (Morelos e Hidalgo) de junio de 2016 a agosto de 2018. Se realizaron 11 entrevistas semi-estructuradas a prestadores de servicios de salud. Se exploraron sus percepciones y experiencias durante la implementación del modelo de APG. Se identificaron barreras y facilitadores para su adopción en dos dimensiones: a) estructurales (espacio, recursos, personal de salud, volumen de pacientes, comunidad) y b) actitudinales (motivación, liderazgo, aceptabilidad, abordaje de problemas, clima y comunicación). RESULTADOS Las barreras más relevantes reportadas en el nivel estructural fueron la disponibilidad de espacio físico en las unidades y la sobrecarga de trabajo del personal de salud. Se identificó la dificultad para adoptar una relación menos jerárquica durante la atención a las gestantes en el nivel actitudinal. El principal facilitador a nivel actitudinal fue la aceptabilidad que los prestadores tienen del modelo. Un hallazgo específico para el contexto de la implementación en México fue la resistencia al cambio en la relación médico-paciente; resulta difícil abandonar el modelo jerárquico prevaleciente y cambiar a una relación más horizontal con las gestantes. CONCLUSIONES El análisis de la implementación del modelo de APG en México, desde la perspectiva del personal de salud, ha evidenciado barreras y facilitadores similares a las experiencias en otros contextos. Esfuerzos futuros para la adopción del modelo deberán enfocarse en la atención oportuna de las barreras identificadas, sobre todo aquellas señaladas en la dimensión actitudinal que pueden ser modificadas a través de capacitaciones continuas al personal de salud.

Group prenatal care: effectiveness and challenges to implementation.

Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.

Group prenatal care: effectiveness and challenges to implementation / Atención prenatal en grupo: efectividad y retos de su implementación

ABSTRACT Group prenatal care is an alternative model of care during pregnancy, replacing standard individual prenatal care. The model has shown maternal benefits and has been implemented in different contexts. We conducted a narrative review of the literature in relation to its effectiveness, using databases such as PubMed, EBSCO, Science Direct, Wiley Online and Springer for the period 2002 to 2018. In addition, we discussed the challenges and solutions of its implementation based on our experience in Mexico. Group prenatal care may improve prenatal knowledge and use of family planning services in the postpartum period. The model has been implemented in more than 22 countries and there are challenges to its implementation related to both supply and demand. Supply-side challenges include staff, material resources and organizational issues; demand-side challenges include recruitment and retention of participants, adaptation of material, and perceived privacy. We highlight specific solutions that can be applied in diverse health systems.

RESUMEN La atención prenatal en grupo es un modelo alternativo de atención durante el embarazo, que sustituye la atención prenatal individual estándar. El modelo ha mostrado beneficios maternos y se ha implementado en diferentes contextos. Llevamos a cabo una revisión narrativa de la literatura en relación a su efectividad, utilizando bases de datos como PubMed, EBSCO, Science Direct, Wiley Online y la editorial Springer, para el periodo 2002 a 2018. Adicionalmente, discutimos los retos y soluciones de su implementación desde nuestra experiencia en México. La atención prenatal en grupo puede mejorar el conocimiento prenatal y el uso de servicios de planificación familiar en el postparto. El modelo se ha implementado en más de 22 países y existen retos de su implementación desde la oferta y la demanda. Los retos desde la oferta incluyen al personal, recursos materiales y cuestiones organizacionales; desde la demanda, el reclutamiento y retención de participantes, adaptación del material y privacidad percibida. Resaltamos soluciones concretas que pueden aplicar a diversos sistemas de salud.

The Mexican Experience Adapting CenteringPregnancy: Lessons Learned in a Publicly Funded Health Care System Serving Vulnerable Women.

Group antenatal care is an innovative model of health care in which all components of antenatal care-clinical, educational, and supportive-happen in a group context with health care professionals as facilitators. CenteringPregnancy is the most studied model of group antenatal care, now widely implemented in the United States. This model has been shown to be effective in improving health and behavioral outcomes in the United States, but there is less known about the experience adapting group antenatal care in settings outside the US health care system. This article describes the adaptation of the CenteringPregnancy model to a Mexican context. We describe the Mexican health care context and our adaptation process and highlight key factors to consider when adapting the content and modality of the CenteringPregnancy model for diverse populations and health systems. Our findings are relevant to others seeking to implement group antenatal care in settings outside the US health care system.