Low-cost and affordable group prenatal care that can reduce premature births

José Maria Lopes

Fernandes Figueira Institute (IFF), Rio de Janeiro
Project: Forty Weeks: an innovative intervention in prenatal care to reduce prematurity

Adequate prenatal care is essential for reducing the risk of premature births and maternal mortality. Although this coverage is considered practically universal in Brazil, the service is not always of high quality. According to Pesquisa Nascer no Brasil, a survey of 23,894 women, 60 percent of pregnant women still begin prenatal care late, after 12 weeks of gestation. In addition, a quarter of them undergo fewer than six consultations, the minimum number recommended by the Ministry of Health.

To increase the number of women with access to quality prenatal care, researchers José Maria Lopes and Maria Elisabeth Moreira, both from Instituto Fernandes Figueira (IFF), decided to test an innovative solution in Brazil for the first time: prenatal care in group. Adapted from the United States and Europe, the intervention included 86 pregnant Brazilian women — another 248 received traditional individualized prenatal care as part of the control group. “Our objective was to evaluate the effects of the technique on the incidence of prematurity and on the behavioral psychological and biological health of pregnant women,” says Lopes.

Divided into groups of ten, the pregnant women who participated in the study met once a month for eight months at family clinics in Rio de Janeiro. At the start of the sessions, they received an illustrated, easy to understand manual with instructions and suggestions for activities. The manual was also intended for their partners. “The idea is that the women themselves would conduct and lead the sessions with the support of health professionals,” explains Moreira. Each meeting had a specific theme and a healthy snack of tea and fruit was provided.

The guide provided a script to follow: assisted by an obstetrical nurse and a general practitioner, they weighed themselves, measured their blood pressure and focused on weight control. If they had any questions or complaints, they were referred to an obstetrician set up in the same location. They also performed ultrasounds and collected urine for testing. “At the end of the meetings, we realized that the participants had developed a strong bond, exchanged information and experiences, and helped each other, including bringing cakes and other food for the group.”

Pregnant women exchange information about diet and weight control during group prenatal care

In addition to fielding three questionnaires with hundreds of questions about women’s health conditions during pregnancy and after childbirth – including questions about depression and knowledge about pregnancy – the study used the Live Birth Information System (SINASC) to obtain data about the type of delivery and the gestational age of the babies. The rate of prematurity among babies whose mothers received the intervention was eight percent, as compared to 11 percent — the same rate as the city of Rio de Janeiro — among those who had conventional prenatal care. “Although we did not reach the ideal sample size of 800 women that we had originally planned for, we can say that the intervention generated a tendency to reduce prematurity,” says Lopes. According to the researchers, violence was one of the main factors that hindered recruitment because it limited the operations of family clinics and the movement of pregnant women to them. Another important factor was the discontinuity of municipal health policies. “We attribute the reduced rates of prematurity to greater self-care and reduced stress provided through participation in the group,” say the researchers in charge. “The risks of premature birth, such as high blood pressure, were also more easily identified and controlled.”

Group prenatal care also has advantages for health management: using the same professionals, it is possible to expand access to a much larger number of pregnant women. To implement the program in a family clinic or Basic Health Unit (UBS), it is necessary to train professionals in the method — 20 were trained for this project — and designate, at minimum, a location for the meetings to take place. A team consisting of a nurse and an obstetrician or midwife is required, in addition to scales, blood pressure measurement equipment and snacks.

Although they have not conducted cost-effectiveness analyzes, the researchers estimate that with R$8,000 a month it would be possible to keep this basic structure running for four meetings of two hours per month, or one per week. “The project has attracted the attention of Rio’s municipal health secretary and other managers,” explains Lopes, who held six meetings with them. “Our goal now is to expand it to other cities.”