Introduction

Maternal and perinatal mortality remains a significant global health issue, particularly in low- and middle-income countries (LMICs) [1]. According to the World Health Organization (WHO), approximately 287,000 women died from pregnancy-related causes in 2020, with Sub-Saharan Africa (SSA) bearing over 70% of this burden [1]. The region’s high mortality rate is largely due to inadequate access to quality maternal healthcare, including antenatal care (ANC) [2]. ANC is considered a crucial strategy for addressing these challenges, offering preventive services, early complication detection, and vital health education [2]. Studies indicated that women receiving adequate and comprehensive ANC services have a 79% lower risk of adverse maternal and perinatal outcomes compared to those with insufficient care [3].

ANC uptake is a crucial indicator for evaluating progress towards improving maternal outcomes [4]. Comprehensive and women centered ANC interventions, which combine medical care with educational elements, have shown positive effects on maternal and newborn health outcomes [4]. The provision of high-quality, women-centered ANC is especially crucial in low- and middle-income countries (LMICs), where maternal and perinatal outcomes are often disproportionately poor [5–7]. In LMICs, particularly in SSA, the predominant model of individualized, one-on-one care has not significantly improved perinatal outcomes [8]. In contrast, group ANC (G-ANC) has emerged as a viable alternative service delivery model in high-income countries, linked to increased attendance, improved satisfaction, and better health outcomes for pregnant women and newborns [6,9,10]. This model of care also benefits women from marginalized populations who experience maternal and perinatal outcomes comparable to those observed in certain low- and middle-income countries [11,12].

The G-ANC is a transformative service delivery model that provides care to groups of eight to twelve pregnant women who are at similar gestational ages through cascades of scheduled meetings [13]. This model incorporates physical assessments, education, skill development, and peer support and takes a more holistic, woman-centered approach in contrast to traditional ANC [14]. The WHO recommends G-ANC as an alternative to individual ANC, based on rigorous research and its contextual guidance promoting community mobilization through facilitated participatory learning and action cycles [4].

The Global G-ANC Collaborative acknowledges that it is crucial to adapt G-ANC models to the unique local contexts and priorities of LMICs to guarantee ownership, sustainability, and expansion [14]. However, several challenges hinder the implementation of G-ANC in various settings, including recruiting and retaining participants, inadequate training and resources, a lack of focus on individual needs, financial barriers, and poor access to healthcare [15–17]. These challenges can be overcome by developing effective recruitment and retention strategies, utilizing mixed methods to assess fidelity and investigate the potential of G-ANC-facilitated community groups, and implementing cost-effective measures [18–20].

Various studies have demonstrated that, as compared to the individualized care model, G-ANC is associated with increased attendance at ANC visits, improved quality of care, higher rates of facility-based deliveries, enhanced health literacy and client satisfaction, increased uptake of family planning methods, better birth weights, and higher rates of breastfeeding initiation and duration [21–23]. Although the benefits of G-ANC have been demonstrated in developed countries, its feasibility, acceptability, and effectiveness in LMICs, particularly in SSA, have yet to be fully researched. However, individual studies have reported encouraging results regarding the model’s efficacy in these areas, indicating the potential of G-ANC to enhance maternal and neonatal health outcomes in low-income settings [24,25].

Moreover, GANC is not widely implemented in SSA, and there is insufficient evidence regarding its effectiveness in reducing maternal and perinatal mortality in the region. Furthermore, the disparity in maternal mortality rates between developing and developed countries highlights the pressing need for targeted interventions. However, there is a lack of comprehensive meta-analyses and systematic reviews evaluating GANC’s effectiveness across various settings. Current studies show considerable variability, emphasizing the need to consolidate findings from multiple research efforts to provide a clearer understanding of the overall effectiveness of group antenatal interventions. This synthesis will create a robust evidence base to inform policy and practice, ultimately helping to reduce maternal and perinatal mortality in the region.

Thus, performing a thorough review of these studies is crucial to evaluate the quality of the emerging evidence and to synthesize the available knowledge both quantitatively and qualitatively, assisting in the implementation of G-ANC models in sub-Saharan African countries. Specifically, the objective of this review is 1) to assess the effectiveness of G-ANC in increasing ANC retention and attendance, facility-based deliveries, attendance of postnatal care visits, and uptake of postpartum family planning and determine the impact of G-ANC on perinatal outcomes and the utilization of other maternal health services; 2) to synthesize the available evidence on the feasibility of G-ANC service delivery models in low-resource settings; 3) to evaluate its cultural sensitivity and acceptability among pregnant women, healthcare provider and community health workers; quality of care outcomes; and behavioral and social outcomes.

Methods

Search strategy

The search strategy for identifying relevant literature will be developed using a combination of Medical Subject Headings (MeSH) and keyword terms related to both the exposure and outcome of interest. In addition to the MeSH terms, this systematic review and meta-analysis protocol will incorporate the PICO framework (Population, Intervention, Comparator, Outcome). This method is particularly suitable for our research, which focuses on the effect of Group Antenatal Care (G-ANC) on maternal and perinatal outcomes in low-resource settings.

We will apply the PICO framework in our review protocol as follows: Population: This targets expectant mothers, especially those in resource-limited environments or from disadvantaged groups; Intervention: The intervention is G-ANC, defined as the integration of conventional antenatal assessments with group discussions and support. Comparator: We will compare G-ANC with those whose antenatal care was provided by individualized, standard, conventional, or traditional models of care. Outcome: Primary outcomes of interest will include feasibility, perinatal outcomes, and the utilization of maternal health care services/continuum of maternal health care, while other reported outcome events can be considered secondary outcomes.

Specific criteria will be applied to the literature search, including restrictions on date, language, and publication location. Table 1 displays the pilot search strategies for PubMed and MEDLINE. The search will be further refined to focus on articles published in SSA. Additionally, the search will be updated toward the end of the review after validation to ensure that the PubMed/MEDLINE strategy retrieves a high proportion of eligible studies.

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Table 1. Pilot search in the PubMed/MEDLINE database, June 30, 2024.

https://doi.org/10.1371/journal.pone.0311473.t001

Selection process

Three reviewers (MG, ZHG, and HEA) will conduct abstract and full-text screening based on the eligibility criteria using Covidence. Any discrepancies among the three reviewers will be resolved with the help of other reviewers (MBM). A separate section will be created in Excel specifically for relevant studies identified during full-text screening, including reference lists of included studies and systematic reviews within the same domain. Rationales for exclusion will be carefully recorded throughout the full-text screening process. A final determination regarding the inclusion of studies will be made by considering the outcomes from both Covidence and the spreadsheet. The presentation of study selection results will utilize PRISMA flow diagrams (PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources, reproduced from Page et al. [27] (Fig 1).

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Fig 1. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources, reproduced from page et al [27].

https://doi.org/10.1371/journal.pone.0311473.g001

Risk of bias assessment

The Joanna Briggs Institute (JBI) Critical Appraisal Tools, specifically designed for JBI Systematic Reviews of both quantitative and qualitative studies, will be used to evaluate the methodological quality of the included studies [28,29]. To assess the quality of articles for cohort, non-randomized, quasi-experimental, and randomized controlled trial (RCT) studies, the JBI Critical Appraisal Tools, which include specific checklists for each study design, will be utilized. Three assessors (TTC, AHA, and EWT) will evaluate the quality of each research study, and any discrepancies will be resolved through discussion. To address limitations when using the Joanna Briggs Institute (JBI) critical appraisal tools, the following techniques will ensure quality and reliability: Comprehensive training will be provided to reviewers to effectively use the tools. Standardized guidelines or protocols will maintain consistency across reviewers for each study design. Pilot appraisals on a small set of studies will help identify potential challenges. More than three independent reviewers will evaluate studies and compare results to minimize bias. Clear documentation of decisions will enhance transparency and reproducibility.

Data synthesis

The characteristics of pregnant women (number of groups, group size, number of women grouped, number of leaders in the group, who leads the group, the total number of group sessions (number of ANC), follow-up periods for the outcome and setups for G-ANC) will be assessed. Statistical heterogeneity will be assessed using the Higgins test, where the I² statistics will be determined and reported. If the studies included in the analysis are homogeneous, a meta-analysis will be conducted to calculate the overall effect of G-ANC on the continuum of care and perinatal outcomes compared to conventional individualized care.

This analysis will utilize R version 4.4.2 software, applying random effects to determine the weights for the meta-analysis, if necessary, after thoroughly investigating the presence and nature of heterogeneity. A qualitative synthesis will be performed if there is significant heterogeneity (I² ≥ 50% or P < 0.1) or in situations where the data are incomplete or unsuitable for meta-analysis. Moreover, when appropriate, additional analytical strategies will be evaluated to strengthen the robustness and depth of the analysis, such as subgroup analysis, sensitivity analysis, or meta-regression. Furthermore, to minimize the risk of bias and ensure the reliability of the findings, studies with certain designs (e.g., high risk of bias or methodological limitations) will be excluded from the analysis.

If various types of effect measures are utilized in the original studies, such as odds ratios, risk ratios, and hazard ratios, the meta-analysis will be conducted for each type of effect measures. The study results will be reported sequentially, commencing with primary outcomes, followed by secondary outcomes and important subgroup analysis based on design, setup, country/region context, and methods of group classification. These methods will be conducted to investigate the possible causes of variability between studies and to explore the strength of the meta-analysis.

Given that the effectiveness of G-ANC can be greatly affected by the country’s context, policy, and resources, stratification will be made based on the country’s context or region (Eastern Africa, Western Africa, South Africa, and Central Africa). Additionally, study results will be stratified based on the setup where the G-ANC was conducted (facility-based vs. community-based intervention). Furthermore, study results will be stratified based on study design to assess whether the study design influences the association between exposure and outcomes. The number of women in a group and how they are grouped may impact the effectiveness of G-ANC.

For qualitative synthesis, we will present summary and narrative statements and quotes from the experiences of pregnant women, group leaders, and health workers regarding the feasibility and acceptability of G-ANC.

Meta-bias (es)

Outcome reporting biases will be assessed by comparing outcomes documented in research protocols with those reported in the actual study reports. Additionally, sensitivity analysis using STATA will evaluate the impact of selective reporting on the results of meta-analyses, if deemed necessary. Funnel plots will also be employed to investigate potential publication bias.

Confidence in cumulative evidence

The Grading of Recommendations, Assessment, Development, and Evaluation working group methodology will be used to assess the quality of evidence for all outcomes. The assessment will consider the domains of risk of bias, consistency, directness, precision, and publication bias. Due to the mixed nature of the studies comprising this review, including both observational and experimental research, the evidence will initially be assessed as moderate. However, if a substantial effect size is present, a dose-response relationship is established, or all potential biases are minimal, the strength of the evidence may be potentially upgraded [30].

Supporting information