Study setting

This qualitative study is nested within a project that implemented GPC in Bangladesh. The project was conducted in a government-run Maternal and Child Welfare Centre (MCWC) situated in the municipal area of Chandpur District. The municipality has a population of 95,000, of which approximately 50% are female. Among the total number of pregnant women listed in this municipality, approximately 7% received at least four ANC sessions from qualified health care providers. Recruitment was conducted in this single centre to compare both intervention and control groups, as it serves a population with similar socio-demographic characteristics.

Study population

Pregnant women within 20 months of gestational age who sought prenatal care in the study site were recruited in the study as per the study protocol [7]. Women assigned to the GPC were considered the “intervention group”, while those that received the standard existing care were considered the “control group”. A total of 697 pregnant women with specific inclusion criterion were recruited and randomised for placement into either the intervention or control group. A total of 300 pregnant women participated in at least one GPC session. Each group consisted of 6–10 pregnant women who met together 4–6 times throughout their pregnancy period for general physical assessments and attending group sessions [7]. A total of 125 sessions were organised throughout the intervention period of the project. The sessions were conducted in a separate room involving the standard prenatal assessment followed by group discussions. After physical assessments were performed, GPC began with an educational discussion session for approximately 30–40 minutes, where health education related to the prenatal period, delivery, and postnatal care was mainly emphasised. The sessions were initially facilitated by study nurses, while experienced mothers later discussed their health issues, thus ensuring peer education. The control group received the current standard pregnancy care. The details of this intervention procedure have been described elsewhere [7].

Sampling procedure and sample size

Among the GPC participants, the study aimed to include those who attended at least four GPC sessions along with other characteristics (age, birth outcome, and education). The rationale of this selection process was to identify women who could best provide rich and in-depth information on their experiences with the services provided through GPC. As such, a total of 107 pregnant women who joined at least four sessions were purposively selected; among them, 21 were selected for the in-depth interviews. The final sample size was determined by informational deliberation i.e. data saturation while no new information was generated by the respondents [17,19]. As a result, a total of 21 interviews were conducted for the present study.

Data collection

Considering the convenience and availability of the participants, we decided to conduct in-depth interviews. Potential study participants were first contacted via telephone and the purpose of the study was then briefly described to them. An interview date was fixed for the candidates who agreed to participate in the in-depth interview. The interviewers deployed to conduct the in-depth interviews (IDIs) were well trained on the guidelines and had significant experience in using qualitative data collection tools. Data were collected from February to April 2016. The time of the data collection was arranged considering the convenience of the participants, and each interview lasted for approximately 45–60 minutes. Interviews were conducted in Bangla, and each of the discussions between the participant and interviewer was recorded using an audio recorder with the permission of the respondents. Data were collected using a specific interview guideline. This interview guideline was adopted from published qualitative literature based on GPC and then finalised by the researchers involved in the study, considering both cultural and socio-demographic aspect. Both written and verbal informed consent were obtained from all participants prior to the data collection. Participants were first asked to provide written informed consent to participate, and then verbal consent was recorded at the beginning of the interviews. Questions were initially broad, according to the guidelines, and later probing was applied to achieve more detailed responses.

Data analysis

Thematic analysis was conducted to ensure the methodological accuracy and transparency of the analysis of qualitative data [20]. To perform the thematic analysis, several phases were followed according to the methodology adopted by Braun and Clarke [21], which included becoming familiar with the data, generating initial codes, defining and reviewing themes, and drawing overall interpretations.

Transcriptions were made from each of the recorded interviews by the interviewers in native language (Bangla), and the reading of transcripts with field notes was performed for an overall understanding. All transcripts were then translated into English by a bilingual translator who was directly involved in the study. All transcriptions and translations were checked twice by the other investigators. Data were manually coded according to meaningful statements (issues, highlights, concerns, and accomplishments) in relation to GPC experience, and then categorised by team investigators. Contents were compared across codes, and key concepts were recognised from where core themes were identified. The lead and senior authors cross-checked the themes for common agreement and refined the identified themes. The investigators finally listed some specific themes based on the guidelines and code categories that included participants’ own perceptions, personal beliefs, and understanding. Throughout the intervention period, investigators visited several times, observed the session’s activities and took notes. While generating themes, these notes were also considered. Finally, an evaluation of the themes with a re-reading of the interviews was performed to ensure that the insistence, meaning, and perception of the participants were precisely captured.

Ethical approval

The protocol of the present study was approved by the Research Review Committee (RRC) and the Ethical Review Committee (ERC) of icddr,b (PR-14119). All study participants provided both written and verbal consent prior to the interview. Detailed study objectives and the contents of consent forms for voluntary participation were explained to each participant prior obtaining their consent.

Theme 1: Comprehensiveness of pregnancy care services

GPC service participants were abounded with all of the required information and services they needed during their pregnancy. They were able to learn common things during pregnancy in different and meaningful ways, which make them more conscious about their reproductive health. These points were reflected through the following sub-themes.

“Getting all of the necessary services at the right time”

The majority of participants mentioned that they received nearly all of the required services simultaneously from GPC. Most participants reported that, along with the regular physical assessment, detailed explanation and discussion on various topics (i.e., general discomforts, complications and danger signs during pregnancy, dietary suggestions, regular physical activities, safe daily activities, and newborn child care) were delivered in the session, which had made the discussion session livelier and self-contained. The content of each session was designed so that each group consisted of mothers of the same gestational age, thus enabling them to learn about all possible issues according to their respective gestational period. To describe the services and contents of the GPC sessions, a 20-year-old mother stated that, “In GPC, we talked with nurse. They did physical check-ups, measured blood pressure, and observed the movement and position of the baby and sent us to doctor’s room in case of any difficulties, and the doctor prescribed medicine(s) if needed.” She also emphasised the support that she received from GPC even after childbirth. She said; “One of the good things about GPC is that they followed up the newborn’s condition for two months and took information on the weight of the baby, advised about vaccination time and its importance, and so on. If I did not participate in the GPC sessions, then I would not know about these important things that need to be taken care. But now, GPC has made me free from these anxieties.”

Another mother who attended all of the recommended GPC sessions said that, “We have come to know almost all pregnancy-related health issues from GPC. They informed us on how to maintain a nutritious diet, as well as what to do and what not to do—all of the things we needed to know. They also said to make a phone call (mobile) to them if we face any problem(s).”

“Learning things in different ways”

Pregnant mothers perceived that they had learnt topics in a different way from the general antenatal care visits. They participated in discussions with nurses and could also learn many topics visually, as the moderators used video footage and pictures to make them better understand the danger signs of pregnancy and other relevant health issues.

One of the mothers (aged 22 years) explained the different ways of learning through the following statement, “One more thing is that the moderator also showed many things through videos. What to do, what to eat, what are the danger signs in pregnancy, and where to go for safe delivery; all of these were shown in pictures. In the session, all of these were discussed along with the pictures.”

As pregnant women sat together during GPC sessions, they could learn many things by discussing topics with peers who had a previous history of delivery. A first-time mother (aged 21) stated; “In these sessions, I learnt so many things from other experienced mothers, such as the possibility of excessive bleeding, convulsion, and other issues that could occur during the time of pregnancy.”

Few mothers reported that they acquired all of the required information and received services at the exact time they were required.

Theme 2: Prescheduled appointments, reminders and reduction of waiting time

Prescheduled appointments and mobile communication reminders helped mothers to participate in each GPC session with scheduled ANC visits. Minimal waiting time reduced additional suffering for participating mothers.

“Reduced waiting time and minimised suffering”

“I may have had to wait for a long time or had to return back home without a check-up. Right after reaching at the facility, the nurse allowed us to sit in a room, received our cards [recruited as participant], and made arrangements for a general physical assessment by the doctor. This was a benefit of this programme. In a word, I never had to return without a check-up”. This statement, made by a 24-year-old mother, expanded the importance of group care to reduced waiting time. In contrast to standard care, participants reported minimal waiting time as they had definite appointments in advance. GPC assigned participants to a particular group with the specific time slots for the session, which allowed them to receive regular check-ups with minimal waiting times, thus satisfying the pregnant women.

One-third of the participants noticed some differences in regular check-ups in GPC compared to those of standard care. One mother, aged 29 years, stated that, “There are surely some differences from other ways/places for physical check-ups. We have to wait in a long queue to visit a doctor in other places, but through GPC, we gathered in a room and discussed many things.”

Another first-time mother also emphasised this theme: “Furthermore, after submitting our cards [GPC group], we participated in the discussion in a room and learnt many things while other mothers were waiting in the queue for the check-up.”

“Almost impossible to forget the check-up date”

The majority of women in GPC overwhelmingly liked two things most; one was sitting with other mothers in the same place, while the other was getting reminder calls via telephone prior to the check-up date. They were delighted by this and felt the importance of antenatal care by receiving phone calls to remind them about their scheduled check-up date. One respondent, aged 20 years, explained her opinion by saying, “Every month I received two phone calls from them to remind me of the check-up dates; the first call was 10 or 12 days before and the other call was 1 day prior to my check-up date. Viewing the number on my phone screen, I could remember my scheduled check-up date. I was careful about this.” Another mother (aged 30 years) stated, “Before our check-up date, we got phone calls from the team. I went for a check-up when they called me. I might have forgotten my date if they had not called me”

Theme 3: Social gathering to reduce stresses and solitudes

Participating mothers believed that sitting together and participating in group discussions helped to relieve them of stress and tension. They also reported that GPC allowed them to obtain answers to many unresolved questions. All of these points emerge in the following sub-themes.

“We sit together; we learn together”

Over time, mothers felt comfortable in the group as relationships grew up among peers, discussion topics evolved, and they learnt by discussing with each other. Moreover, being a member of a group reduced their anxiety and feeling of being alone during the pregnancy period. They received friendly assistance, even from peers, to direct them to the doctor’s room. One 20-year-old mother stated, “It was beneficial to come across all the mothers together. I might not have understood many things or felt lonely, or I might not have reached the office on time or been able to find the doctor. Now, through GPC, they helped us find the doctor”.

A few mothers reported that they enjoyed sharing their pregnancy experiences with others who had similar experiences and concerns. Emphasising on that topic, one 30-year-old mother, “I benefitted by getting in touch with all the mothers. Other pregnant women in my group asked different questions. Those topics were unknown to me and I learnt by hearing the solutions”

“Getting answers to questions without asking them”

Women’s active participation in discussions and their GPC experience varied widely. Some participants rarely spoke during sessions; however, they were attentive to the discussions and acquired knowledge. One mother stated, “In the group discussion when I talked about a problem of mine, some of the others knew about it and experienced the same. Similarly, I also learnt about many things by hearing about problems faced by other peers” (mother, aged 24 years).

Another mother, aged 33 years, also stated that, “It was helpful to have all the mothers in one place at one time. We could know about any issue by hearing from others. Similarly, other mothers could also learn something by hearing from us.”

The opportunity to learn from other members through group discussions was a noticeable benefit of GPC. The pregnant women believed that they benefitted from the experienced mothers in their group. A first-time mother (19 years old) said; “Getting together in GPC, we learnt many things from others. I was experiencing first-time pregnancy and there were other pregnant women who experienced it four or more times. They discussed and shared their experiences and we learnt many things from them.” She also believes that by attending the group discussions, she received many answers for questions she did not even ask; “Sometimes, in the group sessions, there was a time limitation to ask individual questions. By asking a common question for any mother, we all got the answer.”

One session participant (aged 20 years) believed that every single moment she spent on GPC was effective, even though the moderator was not present after the completion of the session. In her words, “When the moderator was not present, mothers continued to discuss various informative matters, and we learnt from them.”

From GPC sessions, mothers learnt many things about their regular physical activities, food intake, and recommendations for taking rest. Mothers commented that they were more alert about eating well and exercising because of GPC. One mother (aged 30) stated that the group sessions helped her to be healthier through maintaining the recommended behaviours. In her voice: “In the meeting, lots of things were discussed, like what to eat, not to lift heavy weight, consuming sufficient food and water, and so on”

Theme 4: Coping with common discomforts during pregnancy

It was difficult for many of the mothers—particularly those experiencing first-time pregnancy—to differentiate pregnancy-related problems and whether to consider or ignore them due to lack of proper knowledge. In GPC sessions, all of these problems were discussed to make mothers aware of common discomforts and danger signs.

“Received effective information on common pregnancy-related discomfort”

Mothers reported that the opportunity to connect and share their pregnancy experiences, common discomforts, and other general knowledge about pregnancy were a very important part of GPC. They believe that this information would help them in the future as well. A first-time mother, aged 24, explained, “In the sessions, the information they provided on pregnancy care was so effective that I believe I will not face any problems in the future.”

Another mother (aged 35 years) said, “If they spread the information that was taught in the GPC to all pregnant mothers rather than just the GPC sessions, then it will be very beneficial for all.”

“Conscious about symptoms: Whether to ignore or consider”

Sometimes, due to a lack of awareness regarding the common symptoms of pregnancy, many mothers suffered greatly, especially those who were experiencing first-time pregnancy. To reduce this suffering, GPC clearly taught pregnant women about common discomfort, complications, and danger signs requiring medical treatment. One 20-year-old mother explained, “Some of the problems, previously, I ignored as minor difficulties and considered that no treatment will be required and that I will be fine anyway; such as if I had problems with water retention or leg swelling. Now, after attending GPC sessions, I came to know that this is not a negligible issue as it may head towards danger signs.”

Later in the interview, she also acknowledged; “Conversely, we sometimes go to consult the doctor with some common problems, like intermittent abdominal pain. But in the session, we learnt that it is not a problem and rather a usual occurrence during pregnancy.”

Theme 5: Upturns of provider-patient and family relationships through GPC

Due to an insufficient number of health professionals with high workload, doctors may not be able to devote a sufficient amount of time to patients in some cases. Moreover, reproductive health remains a taboo in some people, who may feel shy to explain their problems to doctors and family members. To some extent, GPC mitigated these barriers, which were mentioned by the mothers.

“Feeling free to discuss with health workers and other peers”

Women became knowledgeable, developed greater awareness regarding their own health, and learnt how to care themselves and their upcoming newborns. The social connections and support from providers were identified as beneficial to the women. While discussing the services and attitude of the service providers, a mother (aged 20 years) said, “People from the GPC treated us great. They all talked in a very polite manner. Actually, patients’ suffering from illness goes away if doctors behave well with them. All the people of the GPC were well-mannered.”

Another first-time mother (aged 24 years) added to this point by saying, “They discussed many health issues about pregnancy. I asked about my problems and they tried to give me solutions. Basically, they talked about the solutions in more detail, which helped me to understand clearly.”

“Getting supports from family members”

Though husbands and other guardians such as parents and in-laws were not included in the GPC discussions, mothers reported that they shared the GPC session discussions with their husbands, which changed their husbands’ perceptions about prenatal care. They also reported that they received extra care from their partners since they became more conscious about their pregnancy health issues. One mother (aged 30 years) said, “Participation in the GPC sessions was beneficial, as we did not get such services before. During the time of my pregnancy, my husband took care of me after hearing about the various aspects of the GPC session discussions from me.”

Few participants reported that their mothers-in-law, who were previously reluctant about regular check-ups, became more conscious about pregnancy care after observing the GPC procedure. According to the statement of a first-time mother, “It was good that my mother-in-law—who did not allow me to go for check-ups earlier—became motivated after taking her to the facility, and she did not restrict me from going for further check-ups. This is how I benefitted.”

Theme 6: Birth preparedness and confidence to tackle situations

GPC sessions also emphasised birth preparedness for timely access to skilled delivery care services. In GPC sessions, mothers were taught to be psychologically and financially prepared, while arranging for suitable vehicles to reach to the nearest delivery centres. Participants’ perceptions on this issue are collated in this theme.

“Feeling prepared for labour and delivery”

Participants reported that they took preparation prior to delivery, which made them confident about their labour and the postpartum period. They mentioned that this happened as a result of participating in GPC sessions, as they would not have otherwise considered birth preparedness. They also believed that their partners also felt the same, as a 29 years’ mother stated: “In GPC sessions, various danger signs were discussed with pictures, and suggestions were provided on when to consult a doctor. They were also advised to deliver with the presence of a skilled birth attendant or nurse, and suggested that someone with a matching blood group be present prior to delivery, as blood transfusion may be required during/after delivery.”

“Arranging vehicles and money for delivery care”

Participants were suggested to arrange suitable mode of transportation and sufficient money on hand for the delivery. To mention this topic a mother (aged 30 years) commented, “They advised us to visit health centre in case of excessive bleeding or coming hands or legs instead of head during delivery. For managing this situation, early preparation, arranging transportation and depositing money is very important those also were taught in the sessions.”

Moreover, to explain the effectiveness of the information that they got received the GPC, one mother (aged 20 years) stated that, “We learnt a lots of things from the GPC session, such as a minimum of four check-ups, the importance of blood grouping, saving some money for delivery purposes, and managing transportation in case of emergency. If the delivery centre is far away, confirming transportation is very much important.”

Theme 7: Recommendations for prospective mothers

There were also some recommendations made by participants regarding the improvement of GPC services. Some points were elicited by them that require improvement. Broader discussions about family planning methods, including diagnostic and delivery services, were recommended by GPC participants. All of these recommendations are explained under the sub-themes.

“GPC is helpful for pregnant women and would be more beneficial with some moderation”

Overall, the women were satisfied with their GPC experience, which is reflected through this statement made by a first-time mother (aged 20 years), “I wish GPC would always continue so that many mothers would benefit like me.”

When they were asked about any aspects of the model they would like to change, they had made a few suggestions for improvement of the content and process. One mother (aged 24) suggested: “Many mothers were sent to other healthcare centres for diagnostic tests. If this facility were available within the GPC centre, then mothers would not have to go outside, and it would reduce the suffering of mothers.” Another suggestion from the same mother was, “It would be great if there was a doctor assigned for treating us.”

A few mothers recommended adding more information on birth control methods. One mother (aged 29) said, “Discussions about family planning would have been more effective. We have just delivered, and which contraceptive method would be more effective should be included in GPC. They did not discuss this matter much.”

Participants also suggested to include delivery facility within the GPC programme. A mother (age, 20 years) suggested that, “It would be more beneficial for mothers if the delivery services were also included in GPC as they checked all the mothers, knew their problems and consulted them for nine months.”

Suggestions about extending staff were also made by the mothers. They felt the necessity of a gynaecologist in the session. One mother (age 21) suggested, “GPC service would have been more beneficial with availability of specialist doctor (gynaecologist) for the pregnant mother and if all the services- check-up, consulting a doctor and diagnostic take place in one centre.” Another suggestion in this regard by another mother (age 20 years) was, “A special doctor only for pregnant mothers’ care should be available in GPC.”