Experiences of group antenatal care in the context of the NHS in England: what are the mechanisms by which it functions in this context?

Christine McCourt^1,2*Anita Mehay¹Octavia Wiseman¹Jalana Lazar¹Ruth Ajayi³Thomas Hamborg⁴Vivian Holmes¹Rachael Hunter⁵Ekaterina Mishareva¹Pearl Safo Sobre⁶Meg Wiggins⁵Angela Harden¹Cathy Salisbury¹Bethan Hatherall¹

• ¹Centre for Maternal and Child Health Research, School of Health Sciences, City, University of London, London, United Kingdom
• ²City St George's, University of London, London, United Kingdom
• ³PPIE co-investigator, London, United Kingdom
• ⁴Queen Mary, University of London, London, United Kingdom
• ⁵University College London, London, United Kingdom
• ⁶Barts Health NHS Trust, London, United Kingdom

Introduction: Group antenatal care is a model where care is provided in groups of around 6-12 women/birthing people integrating healthcare with information and learning in a participatory approach. There is international evidence of improved experiences and outcomes, but the approach (here called Pregnancy Circles) had not been trialled in the UK, in the context of a universal health system with midwife-led care. We aimed to understand the experience of care and any mechanisms by which group care functions for the diJerent people involved. Method: A qualitative process evaluation nested within a randomised controlled trial. Mixed qualitative methods included observations of care, interviews with participants, survey open-text responses, written feedback and review of relevant documents. Inductive thematic analysis was synthesised using a framework of theorised mechanisms based on a realist review. Clinical and psychosocial outcomes and lessons for implementation are reported elsewhere. Results: we found a high-level of concordance with the mechanisms derived from the literature. Key mechanisms were: social support and community building, a critical pedagogy (combining peer learning, an interactive and participatory approach and health education), satisfaction and engagement with care and health professional satisfaction and development. Empowerment of participants and midwives formed an overarching mechanism which built on these. Relational continuity and time for care formed key underpinning components. Discussion: Pregnancy Circles address key deficits in contemporary maternity care including lack of time and relational or informational continuity of care, lack of informed choice and loss of opportunities to enhance empowerment through health knowledge, social support and confidence in caring for one's own health, in decision-making and in seeking support. Importantly, midwives felt that facilitating group care enhanced their professional satisfaction and development and collaboration across boundaries, features associated with service safety and resilience. Fidelity in terms of midwives' skills and confidence in using a facilitative approach was important and was underpinned by continuity. Midwives' and women's empowerment were found to be mutually supportive rather than in tension. Scaling up Pregnancy Circles as a standard care option in the NHS may support positive care experiences, further research is needed to monitor longer-term impact, service and public health implications