Qualitative study design

Given the exploratory nature of this research, the study design followed a qualitative approach. Qualitative study design is an appropriate method in assessing experience, views and perspectives about a phenomenon [25]. Focused group discussions (FGDs) were conducted with women who attended G-ANC and KIIs conducted with the HCPs and health managers. The FGD and KII guides were used in gathering views and perspectives of the respondents on a variety of topics about G-ANC implementations in their settings. Modified interview guides were adopted from elsewhere [5]. The project was implemented from February 2023 to June 2024. However, participant recruitment for the qualitative component commenced in June 2024 to August 2024. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to enhance the rigour and transparency of the study’s reporting (SI).

Selection of participants

Pregnant women or recently delivered women form six facilities were purposefully selected for participation in FGDs. Facilities were categorized as hospital-level, health center-level, and dispensary-level. Two FGDs were conducted with pregnant women and four FGDs with mothers who delivered within the past 6 months from the selected facilities’ catchment areas until we reached saturation in the responses. The snowball sampling method was used to reach women who participated in G-ANC previously. Each FGD consisted of at most 8–12 women. KIIs were conducted with at least one health care provider and the facility leader from each facility. HCPs included doctor/ assistant medical officer, clinical officer, assistant clinical officer, and nurse/midwife. Traditional birth attendants and village health workers were not included in the definition of HCPs. Health Managers included the district/regional maternal health managers or coordinators.

Sample size determination and triangulation

Sampling and sample closure were guided by the principles of purposive sampling, triangulation, and thematic saturation, rather than by a predetermined sample size. Participants were selected to ensure representation of key stakeholder groups involved in the design, delivery, and receipt of G-ANC, namely women receiving care, healthcare providers, and health system managers. Sample closure was reached when thematic saturation was achieved, defined as the point at which additional FGDs or KIIs no longer yielded new concepts, or substantive insights relevant to the study objectives. Saturation was assessed separately within each participant group and then across groups. Sample triangulation was achieved through the inclusion of multiple perspectives across different roles (service users, providers, and managers), facility levels (hospital, health centre, and dispensary), and geographical contexts (urban, peri-urban, and rural settings). This triangulated sampling strategy allowed for comparison and validation of findings across participant categories and service delivery contexts.

Data collection and procedures

Data were collected through FGDs with pregnant and postnatal women who had participated in G-ANC and KIIs with antenatal HCPs and health managers. Semi-structured interview guides were used for both FGDs and KIIs. The core thematic areas explored during FGDs and KIIs included:

1. Perceptions and experiences of G-ANC
2. Practicality within routine health services
3. Overall acceptability of G-ANC among women, healthcare providers, and health managers.
4. Challenges to successful implementation of G-ANC

Examples of guiding (trigger) questions included: “Can you describe your experience attending or providing care through G-ANC?”, “What aspects of G-ANC worked well, and what challenges were encountered?”, and “How does G-ANC fit within routine antenatal care services at this facility?” Probing questions were used flexibly to explore emerging issues in greater depth.

FGDs and KIIs were conducted in Kiswahili by trained qualitative researchers who were not involved in service delivery. All discussions were held in private, quiet locations within or near health facilities to ensure confidentiality and participant comfort. Interviews and discussions were audio-recorded with participant permission, and detailed field notes were taken to capture non-verbal communication and contextual information.

Each FGD was conducted by a trained facilitation team, consisting of a lead facilitator (moderator) and a note-taker (observer). The facilitator guided the discussion, ensured balanced participation, and followed the interview guide, while the note-taker documented key points, group dynamics, and non-verbal cues and managed logistical aspects, including audio recording. In some sessions, an additional research team member provided logistical support. Although a separate co-facilitator role was not formally designated for all FGDs, the note-taker actively supported the facilitator in managing group flow and ensuring all participants had an opportunity to contribute.

Data analysis

Audio recordings were transcribed verbatim and translated from Kiswahili into English by trained bilingual researchers. Transcripts were reviewed against audio files to ensure accuracy. Data were imported into NVivo software for coding and thematic analysis. Analysis followed a hybrid deductive–inductive approach. Coding was conducted iteratively by multiple members of the research team, with regular discussions to compare interpretations, resolve discrepancies, and refine themes.

To enhance credibility and dependability, methodological triangulation was achieved by comparing perspectives across women, healthcare providers, and health managers, as well as across FGDs and KIIs. Data collection continued until thematic saturation was reached. Transferability was supported through detailed description of the study context, participant characteristics, and implementation setting (all facilities).

Ethical considerations

The ethical approval for this project was sought from the National Institute of Medical Research (NIMR) Tanzania, under approval certificate number NIMR/HQ/R.8a/Vol.IX/4194 dated January 23^rd, 2023. The team considered all necessary measures to ensure the recruitment, consenting, data collection, and publication of the materials related to this study are following regulations governing research standards. Key consenting processes were taken to ensure voluntary participation of the study participants, protection of their privacy, confidentiality of the data and their safety.

Informed consent

Verbal consent was obtained from women prior to their engagement in G-ANC services, aligning with the standard procedures commonly followed during conventional antenatal care. Healthcare providers explained the G-ANC, its purpose, and what participation entailed during ANC visits. Women’s verbal consent to participate was recorded in facility ANC registers and cohort tracking tools, consistent with routine service documentation practices. This protocol was reviewed and approved by the Institutional Review Board (IRB).

For participants involved in the qualitative component of the study to explore their perceptions and experiences, written consents were obtained prior to conducting the interviews. The consenting process was administered by trained research staff and conducted in Kiswahili (the national language) to ensure comprehension and cultural appropriateness. Each participant signed two copies of the consent form: one was retained by the participant for their records, and the second was securely stored by the study team. The consent forms included components outlining the purpose of the study, procedures involved, potential risks and benefits, confidentiality measures, voluntary participation, and the right to withdraw at any time without affecting their access to healthcare services. Participants were encouraged to ask questions, and their understanding was verified prior to signing the forms.

Experience of women about Group Antenatal Care (G-ANC)

Women who participated in the qualitative study reported positive experiences, emphasizing the benefits of shared learning, emotional support, and improved access to healthcare services. Group care was recognized as an effective platform for empowering women with essential maternal health knowledge. Women expressed that attending G-ANC sessions helped them gain a deeper understanding of pregnancy-related issues, including nutrition, birth preparedness, and newborn care. One participant shared,

“Before joining the group sessions, I was not aware of the importance of balanced nutrition during pregnancy. Now, I not only eat better but also encourage other women in my community to do the same..” Postnatal woman, Health Centre 2

Pregnant women who were still attending G-ANC similarly described improvements in knowledge and birth preparedness.

“Since joining the group, I have learned many things about how to take care of myself and the baby. I now understand what to prepare before delivery, which I did not know before.”Pregnant woman, Dispensary 1.

The interactive nature of G-ANC also created a sense of community among the women, reducing feelings of isolation during pregnancy. Some women appreciated the opportunity to share experiences and learn from one another.

“It felt reassuring to be in a group with other pregnant women who were going through the same journey as me...We encouraged each other and became like a family.” Postnatal woman, District Hospital 2

Women emphasized how G-ANC fosters a sense of belonging, emotional support, and collective learning, making pregnancy a more positive and informed experience for women. This support system played an important role in alleviating fears and anxieties related to pregnancy and childbirth as noted from some women who said:

“Listening to other women’s experiences made me realize that I was not alone in my struggles. We shared advice, and it helped me feel more confident about my pregnancy.” Postnatal woman, Dispensary 2

“In the group, we laughed, learned, and supported each other. It was not just about medical check-ups; it was a place where we felt heard and understood.” Pregnant woman, Health Centre 2

“I used to feel anxious about childbirth, but hearing stories from other mothers who had gone through it helped ease my fears. Their experiences gave me strength and encouragement.” Postnatal woman, Health Centre 1

Additionally, women noted that G-ANC improved their confidence in communicating with healthcare providers. This increased engagement contributed to better adherence to recommended antenatal care practices. They felt more comfortable asking questions and seeking clarification about their health. One participant explained,

“In the past, I was afraid to ask the nurse questions, but in the group, we openly discuss everything, and I feel more prepared for delivery.” Postnatal woman, District Hospital 1

“Because of the group sessions, I am no longer afraid to speak to the nurse. I ask questions when I don’t understand, and this has helped me follow the advice given during my clinic visits.”(Pregnant woman, Health Centre)

Perception and experience of healthcare providers on G-ANC

Healthcare providers who implemented and facilitated G-ANC reported their positive experiences, highlighting its effectiveness in improving maternal health outcomes, improving patient engagement, and fostering a supportive environment for both providers and pregnant women. HCPs acknowledged that G-ANC allowed them to deliver health education more efficiently, reaching multiple women at once instead of repeating the same information individually. One midwife shared,

“With G-ANC, we can educate many women at the same time, ensuring they receive consistent and accurate information. It saves time and improves understanding.” Health Care Provider, District Hospital 2

Another key benefit recognized by HCPs was the improved rapport and trust between providers and pregnant women. In conventional ANC, women often hesitate to ask questions due to time constraints or fear of being judged. Improved communication helped providers address misconceptions and ensured women were better prepared for childbirth. However, G-ANC created an open and interactive space where women felt comfortable discussing their concerns. A nurse explained,

“In one-on-one visits, many women remain silent, but in a group setting, they are more open to asking questions and sharing their concerns. It makes our work easier and more impactful.” Health Care Provider, Dispensary 2

HCWs also observed that G-ANC strengthened peer support among pregnant women and promoted positive behavioral changes. Women, inspired by their peers, became more proactive in adhering to recommended antenatal care practices, such as taking iron supplements, Intermittent Preventive Treatment in pregnancy (IPTp) uptake, and preparing for institutional delivery. One health provider noted,

“Women who were initially reluctant to follow ANC recommendations became more motivated after seeing others share their positive experiences. The group setting created a sense of accountability and encouragement.” Healthcare Provider, District Hospital 2

“The effect on maternal health is evident. Women are more informed, confident, and engaged. We need to invest more in scaling up this intervention,” Facility In -charge Health Centre 1

Health managers’ perception and experience with G-ANC

Health managers overseeing the implementation of services in Chato and Geita districts expressed strong support for the ANC approach, recognizing its transformative effect on maternal health care services. They highlighted improvements in service delivery, increased ANC attendance, and better engagement between healthcare providers and pregnant women. Some managers noted that G-ANC has led to more efficient use of resources and improved health outcomes. One district SRH coordinator explained,

“G-ANC helped our facilities to increase ANC attendance indicator. Women enjoy coming to the sessions because they receive care and learn from each other in a supportive environment.” Health Coordinator District 1

They acknowledged that unlike the conventional ANC, which often resulted in brief interactions between providers and clients, G-ANC enhanced a more interactive and trusting environment.,

“At Nzera hospital we have seen a shift in how women perceive ANC services. They are more engaged, ask more questions, and actively participate in discussions, which was not the case before...This change was attributed to the group-based approach, which encouraged collective learning and reduced fear or hesitation among pregnant women”. Health Coordinator, District 2

Health managers also appreciated the efficiency of G-ANC in optimizing healthcare workers’ time and reducing workload pressures. Instead of repeating the same health education topics individually, providers could deliver key messages to multiple women simultaneously. They also strongly supported scaling up G-ANC, recognizing its potential to improve maternal health outcomes.

“With limited staff, G-ANC helps us reach more women effectively. Providers can dedicate more time to meaningful discussions rather than rushing through individual consultations. The effect is clear…women are more informed, confident, and proactive about their health. We need to invest in infrastructure and training to sustain and expand this approach,” Health Coordinator, District 2

Experience on practicality of Group Antenatal Care

G-ANC required careful planning to ensure that health facilities had the necessary resources to run group sessions effectively. Key resources included trained healthcare workers, sufficient space for group meetings, and the provision of essential materials such as educational tools (maternal booklets) and proper health records. Healthcare workers reported that organizing and facilitating G-ANC sessions required more initial time and effort compared to individual visits. One midwife noted,

“At first, it was challenging to organize the group sessions because we had to coordinate schedules in the G-ANC Cohort tracker or ANC registers and ensure that we had enough space. But now that we have the process in place, we are trying our best.” Healthcare Provider, Dispensary 1

Training healthcare workers to facilitate G-ANC was important to its success. HCWs noted the importance of equipping them with the skills needed to manage group dynamics and address the diverse needs of pregnant women in a group setting. A nurse explained,

“The training we received in Katoro made a huge difference in how we conduct the sessions. It’s not just about providing information…it’s about managing the group and facilitating discussion.” Healthcare Provider, Health Centre 2

Integrating G-ANC into routine maternal health services was seen as a practical and beneficial approach to improve service delivery efficiency. It allowed healthcare workers to educate multiple women simultaneously while still providing individualized care and counselling when necessary. This was particularly important in areas with high patient volumes, where conventional one-on-one consultations could lead to long waiting times and overcrowding. One facility in-charge said,

“G-ANC allows us to manage our time better. It reduces waiting times for women and ensures that we can reach more women with the same resources, especially in facilities with many clients like Bwanga and Katoro I think...” Facility In-charge, Dispensary 2

The integration of G-ANC with other maternal, child health, and community services was a key feature of its implementation. Through leveraging existing health systems and services, G-ANC promoted a holistic approach to care. The integration was achieved through strategic collaboration between healthcare workers from different units such as labour ward and the laboratory. Another area of integration is family planning services. During G-ANC sessions, healthcare workers introduced a full session discussion about postpartum family planning, which allowed women to make informed decisions about their reproductive health before delivery. A healthcare worker explained,

“We ensure that women understand their options for family planning after childbirth. We encourage them to choose the methods before birth, and this is a full session discussion”. Healthcare Provider, District Hospital 1

Women, in turn, appreciated the opportunity to receive detailed family planning counselling during their group care sessions. Unlike conventional ANC women receive partial counselling of family planning issues. A participant shared,

“It’s helpful to learn about family planning while I am still pregnant. I feel more prepared for after delivery.” Pregnant woman, Dispensary 1

Acceptability of Group Antenatal Care among women

For women, G-ANC was accepted as a valuable alternative to conventional antenatal care. Many women appreciated the opportunity to engage with other pregnant women, which fostered a sense of community and emotional support. A pregnant woman mentioned

“I feel less alone now because we talk about our pregnancies together, and I can learn from others’ experiences. It makes me more confident about my pregnancy.” Pregnant woman, Dispensary 2

The shared learning environment allowed women to feel more empowered in managing their pregnancies, and the group format was often described as both informative and reassuring. One woman commented,

“I used to feel anxious going to individual appointments, but in a group, we share our worries and talk openly. It feels like we’re all in it together.” Postnatal woman, Health Centre 1

While most women were positive about G-ANC, there were some who expressed concerns about group dynamics. One participant mentioned feeling shy or uncomfortable discussing personal health issues in front of others, especially in larger groups. However, the majority of women acknowledged that the benefits of being in a group far outweighed these concerns. This participant noted,

“Sometimes, I feel uncomfortable asking certain questions in front of so many people. It would be better if we had smaller groups.” Postnatal woman, Health Centre 2

Acceptability of G-ANC among healthcare providers

Generally, healthcare providers who were involved in this study perceived G-ANC as an appropriate approach for delivering antenatal care services. They recognized the advantages of the group care in terms of time management and increased efficiency. Also, they appreciated the opportunity to provide more interactive, participatory sessions. A midwife expressed,

“G-ANC has allowed us to engage with many women at once, which helps reduce the pressure on our time. It’s a more organized way to deliver care, women feel more involved in their care, and it’s much easier to address common questions in a group than one by one.” Healthcare Provider, District Hospital 2

“At first, we were unsure about how to manage the group dynamics and ensure every woman got the individual attention they needed. With more experience, we’ve found ways to balance the group discussions with one-on-one support.” District Hospital 1

Acceptability of G-ANC among the health managers

District health managers were generally supportive of G-ANC, as they experienced the G-ANC approach as a means to promote service delivery coverage and improve pregnant outcomes. A district health coordinator noted,

“G-ANC has increased the number of women attending antenatal care regularly which is a big win for our Geita region. It also reduces the workload on individual healthcare appointments.” Health Coordinator, District 1

It was recognized that G-ANC could potentially reduce maternal and neonatal health risks by increasing the number of women attending regular check-ups and receiving timely care. However, one health manager expressed concerns about the initial costs of implementing G-ANC, particularly after the Mlinde Mama project closeout.

“While we support the idea, the costs involved in setting up the program is a bit challenging especially if PHIT leave the project. But we saw the value it brought in terms of both health outcomes and service efficiency, but we don’t have money to print maternal booklets and to replace rechargeable batteries for BP machines.” Health Coordinator, District 2

Barriers to successful implementation of G-ANC

Several barriers were identified that could limit effective implementation of G-ANC and its acceptability. Privacy and confidentiality concerns were frequently raised by women, particularly regarding the sharing of sensitive personal information in a group setting. Some women expressed fear that details disclosed during sessions could be discussed outside the group, leading to social discomfort or stigma within their communities.

“When you are in a group, you are not sure who will keep your secrets. Some issues are very personal, like problems in the pregnancy or things happening at home, and if they spread, it can affect your relationship with your husband or even how neighbours treat you. That fear sometimes makes you keep quiet, even when you need help.” Pregnant woman, Dispensary 1

Others noted that this concern made them hesitant to fully participate or ask questions related to complications or personal challenges:

“There are things you want to ask the nurse, but you keep quiet because you don’t want everyone to know your problem, especially when it is something very personal. “Postnatal woman, Health Center 2

Economic barriers also influenced participation in G-ANC. Women reported that lack of money for transport, food, or childcare reduced their ability to attend sessions consistently. One postnatal woman noted:

“Even if the service is good, you still need money to reach there. Sometimes I had to choose between attending the group and buying food for my children.” (Postnatal woman, District Hospital 2)

In addition, male partner support played a role in enabling or constraining participation. Providers and managers also acknowledged that limited male engagement could negatively affect women’s attendance and continuity in care. Several women described situations where partners were unsupportive or questioned the value of group-based care, limiting women’s autonomy to attend sessions.

“My husband asked why I should go many times for the same check-up. When he refuses to support me, I miss some meetings.” (Pregnant woman, Health Center 1)

“Sometimes my partner would say the group meetings are a waste of time and that one visit is enough. For me, when my husband was not involved or informed, I missed some sessions because I did not want to cause conflict at home.” Postnatal woman, District Hospital 2

Geographical distance and transport challenges were particularly pronounced in two rural facilities. Women living far from facilities or community meeting points reported difficulty attending sessions, especially in later stages of pregnancy or during the rainy season.

“The road is bad, and when it rains, it is impossible to reach the health centre. That made me miss some group meetings.” Pregnant woman, Dispensary 1

“During the rainy season, even if you want to attend the group, it becomes very difficult. The paths are flooded, boda boda (motorcycles) refuse to come,… how can you attend the clinic”. Postnatal woman, Dispensary 2

From the healthcare providers’ perspective, organizational challenges within facilities were highlighted. Providers emphasized the importance of protected time for G-ANC sessions and noted that frequent interruptions undermined the quality of group discussions.

“If we are called to attend emergencies or other clinics during the group session, we cannot concentrate. Women notice this and feel the session is not taken seriously.” Healthcare provider, District Hospital 2

Health managers echoed this concern, noting that staff shortages and competing service demands made it difficult to consistently allocate uninterrupted time for group care.

“We support G-ANC, but with few staff, it is not always easy to free one provider for the whole session without interruptions.” Health Coordinator, District 1