Adapting Group Care to the Postpartum Period Using a Human-Centered Design Approach in Malawi

"Using a human-centered design approach to adapt this model of care for the Malawian context centers co-creation, collaboration, and coordination at the patient, clinician, and health system levels; this sets the stage for a responsive strategy to fill a critical gap in the care continuum and improve maternal and child health outcomes."

Malawi has some of the highest maternal and infant mortality rates globally. Group health care is a service delivery model that involves health care in a group space, interactive learning, and community building. When implemented in the prenatal context, group care models have found to be  acceptable, feasible, and effective in shifting power dynamics, which can lead to increased quality of care and ultimately improve outcomes. The purpose of this study was to adapt and co-design the prototype for an evidence-based group care model for the postpartum period using a human-centred design approach (HCD) with key stakeholders in Malawi.

HCD emphasises the strengths, agency, and priorities of women and healthcare workers to build a model of care that is resilient and responsive to individual and system needs. Previous healthcare research supports the use of this approach, as participating in the co-design process increases self-efficacy for both patients and healthcare workers and leads to sustainable solutions to problems within the health system. The Approach to Human-Centered, Evidence-Driven Adaptive Design (AHEAD) framework provides a practical guide to co-design solutions to healthcare challenges. This paper seeks to showcase how to use HCD with methodological rigor, outlining the 5 steps to adapting and implementing an integrated group postpartum and well-child care model that is context specific and responsive to people's needs and desires.

This formative qualitative study was implemented in three government-run health centres in Blantyre District, Malawi, that have been implementing and sustaining group antenatal care (ANC) since 2019. Experienced group ANC facilitators, midwives and community volunteers, and 12 multiparous patients who completed group ANC and are receiving maternal and child health care were asked to participate.

The researchers followed the 5 AHEAD steps as follows:

1. Define the problem and assemble a team: An integrative review led to the conclusion that a standardised package of postpartum care that can be adapted for specific contexts from birth to one year postpartum is needed to further reduce maternal and infant morbidities and mortality in Malawi. Organisers assembled an interdisciplinary team to guide the adaptation and development of an integrated group postpartum and well-child care model.
2. Gather information through evidence and inspiration: In-depth interviews (n = 24) were completed with key stakeholders. The intent was to encourage participants to talk openly and solicit rich accounts about current postpartum and well-child care practices, patient flow, equipment/supplies, culturally appropriate services, postpartum health concerns, desired health promotion topics, and perspectives on group healthcare.
3. Synthesise qualitative data from step 2: Through this step, organisers identified 5 themes when analysing both the healthcare workers' and mothers' responses: (i) maternal health assessments are not consistently completed; (ii) challenges exist to postpartum and well-child care attendance and delivery of care; (iii) postpartum and well-child health promotion topics are not standardised; (iv) maternal and child health concerns included physical and psychological issues; and (v) there is buy-in for the group healthcare model from both women and healthcare workers.
4. Develop guiding principles and ideate: This step involves creating guiding principles that align with an evidence-based model, and then rounds of brainstorming and prototyping. For example, 6 incubator sessions employed free listing, pile sorting, and ranking to allow for examining intracultural variations of postpartum and well-child care and provide opportunities to build consensus about healthcare services priorities. Prioritised health promotion topics included a range of physical, psychological, social, and behavioural issues. For example, participants prioritised male involvement in care and relationship issues. These issues are important to integrate into the model because it is well established that the social context of patients' lives has implications for maternal and child health outcomes that need to be addressed in clinical practice.
5. Evaluate: This step will be detailed in a separate paper.

All stakeholders reported a desire to participate in and offer group care in the postpartum period. Stakeholders worked collaboratively to co-create the prototype that included a curriculum of health promotion topics and interactive activities and the service delivery structure. Health promotion topic priorities were hygiene, breastfeeding, family planning, nutrition, and mental health. The recommended schedule included 6 sessions corresponding with the child vaccination schedule over the 12-month postpartum period. The preferred interactive learning activities were role plays and discussions. The facilitator's guide was adapted from centring-based group care to: include all priority health promotion content areas desired by women and healthcare workers; be inclusive of activities for low literacy levels; and be translated into Chichewa, the local language. Seven midwives experienced in group care and 2 registered nurses validated the content and structure of the facilitator's guide and implementation plan, which is ready for the final step in the AHEAD framework.

The results of the first 4 steps of the AHEAD framework showed that group care is a promising strategy for improving health outcomes in the postpartum period in Malawi. This adult learning approach is responsive to group needs and provides opportunities to exchange ideas as group members work to better understand and ultimately apply lessons learned to their lives. By transforming the delivery modality of postpartum and well-child care to an integrated group healthcare model, the needs of the mother and the infant can be met at the same time.

The organisers share 3 major lessons learned using the AHEAD framework that they believe are important to consider in undertaking a similar process in other contexts: (i) using this approach is time intensive; (ii) building a strong interdisciplinary team is key to success; and (iii) using multiple methods to engage a range of literacy levels is important. In addition, in clinics where group care has not been implemented, more time would be needed to introduce the concept of group care to stakeholders to then engage in co-creation and adaptation process.

In conclusion, the evidence and inspiration from engaging with women and healthcare workers through the HCD approach lays the foundation for a responsive and resilient adaptation of group care that is co-designed by women, health care workers, and researchers. "The reciprocity and power sharing that is inherent to the co-design process of the AHEAD framework offers a strategy to reduce medical hierarchies and center the voices of patients receiving care and health care workers providing it." This iterative process has the potential to respond to the changing and dynamic needs of patients and healthcare systems in Malawi and perhaps other low- and middle-income countries.