Qualitative data (acceptability of the ANC package)
’ affective attitude
To understand whether the adapted ANC packages are acceptable to and create value for women and health workers as well as their experience of care, we will collect and analyse qualitative data. Qualitative components will entail in-depth interviews (IDIs) and focus group discussions (FGDs) with purposively identified participants from stakeholder groups. Questions for the FGDs and the IDIs have been developed on the basis of the theoretical framework of acceptability to gauge women’s and health workers’ affective attitude and perceived effectiveness towards the adapted ANC package as well as their understanding (intervention coherence) of it and the sense of self-efficacy when delivering the package [Country teams will conduct facility assessments at all the study sites using a standard process evaluation form for monitoring. The evaluation form will include items for measuring the readiness of study facilities in terms of supplies and equipment, in addition to training and supervision needs. The implementation of the updated adapted ANC package will be further documented to understand to what extent the co-interventions were performed as intended and factors that inhibited or promoted effectiveness, allowing for iteration where necessary, using the adapted version of WHO Programme Reporting Standards [Costing data will also be gathered during the cohort study exit interviews with pregnant women. The cost per contact will be estimated through exit interviews with beneficiaries as part of the main evaluation. Direct costs are anticipated to include all out-of-pocket costs incurred in seeking ANC, including consultation fees, transportation costs, medicine and other supply costs. Indirect costs will additionally be assessed, including wages lost and childcare costs as a result of time spent seeking ANC. Additionally, economic costs incurred by implementing partners will be tracked prospectively.To determine the full spectrum of costs to the health system, a range of methods will be employed, including (1) tracking marginal commodity costs (through implementation research partners and WHO program records); (2) understanding infrastructure costs, including buildings and capital equipment; and, in Burkina Faso and India only, (3) assessing health worker's time.To support the measurement of health worker time, teams will conduct observations of health worker's efforts during ANC service delivery, followed by IDIs with the health workers observed. Observations and interviews will be done at two time points in the same geography: (1) prior to guideline introduction (baseline) and (2) once the revised guidelines have been introduced and the program stabilized. Data collection will be carried out by implementation research staff using (a) structured observation sheet per type of ANC patient observed and (b) an IDI guide. The latter will be implemented as part of IDIs with health workers, who were observed and seek to understand their perceptions of time allocation on the basis of different ANC contacts and patient risk profiles. A total of 480 observations will be conducted during the baseline period and 480 observations during the intervention period across both states. All pregnant women receiving ANC services on the day of observations will be eligible to be observed. For the observations, verbal consent will be obtained from the health worker and pregnant women.