Introduction
deaths
COMPLICATION
Maternal and infant health have long been at the forefront of global health initiatives. Through concerted efforts to improve maternal and newborn health, some progress has been made. In 1990, newborn deaths worldwide were 5 million and by 2019 that had decreased to 2.4 million [Antenatal care (ANC) defined by the World Health Organization as “care provided by skilled health-care professionals to pregnant women and adolescent girls to ensure the best health conditions for both mother and baby during pregnancy” [A National Institute of Health funded study (Clinical Trial # NCT04033003) entitled “Group antenatal care to promote a healthy pregnancy and optimize maternal and newborn outcomes: A cluster randomized controlled trial” (GRAND) has been implemented in Ghana to determine the effectiveness of the group ANC model of care. This report focuses on the process evaluation of the implementation of the intervention (group ANC). The overarching goal of the GRAND study is to determine whether group ANC facilitated by trained midwives, utilizing a fixed group model of 10–14 pregnant women by gestational age for the duration of the pregnancy, improves outcomes when compared with participants in routine, individual antenatal care. The randomization occurred at the facility level whereby 7 facilities were randomized to routine ANC and 7 were randomized to offer group ANC to pregnant women seeking ANC at the facility. Primary outcomes include birth preparedness, complication readiness, increased care-seeking behavior, and improved maternal and newborn outcomes. Enrollment in the study and participating in group ANC was voluntary. The project used a Health Literacy Skills Framework and details of the framework and project protocol have been described elsewhere [While program outcomes measure the success of an intervention, a process evaluation is important to understand why an intervention is, or is not, successful and to ensure that the outcomes seen are a result of the intervention, particularly when implementation occurs in different cultures and contexts [