Structured observations
A sample of group ANC meetings were observed for each midwife facilitator to monitor fidelity to the model. Beginning with the initial groups in fall 2019, and continuing at intervals throughout the study period, members of the Ghana research team who had also participated as champion trainers traveled to the intervention site health facilities to observe the facilitation of group ANC meetings. Observations occurred during one of the later (5, 6 or 7) group ANC meetings. Observations included whether content was delivered as intended, whether women were encouraged to actively participate in group discussions and activities, whether picture cards were used as written in the Facilitators Guide, and whether feedback was provided to participants during demonstrations. During these observations the research team members completed both the Fidelity Checklist Scale and the Learning Methods Checklist (