Development of strategies to enhance holistic antenatal care in Limpopo Province, South Africa: A qualitative method protocol 

Development of strategies to enhance holistic antenatal care in Limpopo Province, South Africa: A qualitative method protocol | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Study protocol Development of strategies to enhance holistic antenatal care in Limpopo Province, South Africa: A qualitative method protocol Violet Manonyana Chewe, Johannah Mabojalwa Mathibe-Neke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4412038/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Holistic antenatal care encompasses a range of services, including mental, physical, social, intellectual, emotional, and spiritual. Antenatal care is regarded as the cornerstone of maternal health. As such, a lack of holistic antenatal care can lead to poor pregnancy outcomes, such as maternal and perinatal mortality. This study aims to develop strategies to enhance holistic antenatal care in Limpopo Province, South Africa. Methods: The population for the study is pregnant women, midwives, and operational managers in selected community health centers in Limpopo Province, South Africa. Non-probability purposive sampling will be used to select the province, districts, municipalities, and community health centers for the study. Convenience sampling will be used to select participants for antenatal card auditing and non-participatory observations of the antenatal care process as offered by midwives. Pregnant women will engage in focus group discussions. Midwives and operational managers will be sampled for in-depth interviews using nonprobability purposive sampling. Non-participatory observation will be conducted using a checklist and an audit tool to audit antenatal cards to support the qualitative data. Data will be analysed manually using Tesch's thematic analysis method for focus groups and in-depth interviews. Quantitative data will be analysed using computerized statistical software for the social sciences (SPSS 28). Ethical considerations will be adhered to throughout the study. Significance of the study: This study aims to enhance midwives' understanding and practice of holistic antenatal care in Limpopo Province. With the data collected, strategies for enhancing holistic antenatal care will be developed, strengthening the standard of antenatal care. Holistic antenatal care has been proven to contribute to the reduction of maternal and perinatal deaths. Antenatal care development enhance holistic strategies Figures Figure 1 Background The World Health Organization (WHO) [ 1 ] acknowledges improving maternal health as a crucial component of the Sustainable Development Goals (SDGs). As a result, the WHO has identified antenatal care (ANC) as one of the goals for attaining SDGs. The World Health Organization [ 1 ] further recommends that all women obtain holistic ANC, which includes physical, psychological, spiritual, and social components of care. According to the World Health Organization (WHO) [ 1 ], holistic care in pregnancy refers to multifaceted care, such as spiritual, emotional, intellectual, physical, social, and mental. During routine visits to the primary health care clinics for basic antenatal care audits, the researcher observed that more effort is being put into the physical aspects of women and the foetal status during antenatal assessments. For instance, psychological, spiritual, and social assessments are often neglected during antenatal assessments. [ 2 ] emphasizes the importance of psychological, spiritual, and social well-being during pregnancy, linked to pregnancy outcomes. According to [ 3 ], poor psychological well-being during ANC is a common cause of postpartum depression. Furthermore, as noted in [ 2 ], this may result in a homeostatic imbalance, weakening the immune system and leading to abortions, preterm deliveries, preterm labour, and preeclampsia. Literature indicates that globally, 287,000 women died while pregnant, giving birth, and postnatally in 2020 [ 17 ] [ 4 ]. As stated in the WHO Maternal Mortality Report, [ 4 ] Sub-Saharan countries contributed 87%, which amounted to 202,000 maternal deaths. According to WHO, as of 2017, the maternal mortality ratio was recorded as 211 worldwide; in Sub-Saharan, 533; in Africa, 525; and in South Africa (SA), 119 per hundred thousand live births, respectively. According to WHO, most deaths were due to poor ANC offered to women, as most factors could have been prevented. Several strategies and models to facilitate quality ANC have been developed so far. For example, the midwife-led continuity of care model was developed in Ethiopia and yielded satisfaction among low-risk pregnant women [ 5 ]. The household-based ANC monitoring model was developed in Indonesia (Palu City) by [ 6 ]. The model provided notable outcomes for quality ANC implementation. However, the strategies and models developed did not include holistic ANC. The researcher observed a gap in the literature for holistic ANC provision worldwide and in SA. What emerged from both the literature gap and the researcher's observation was that pregnant women deserve ANC that equally prioritizes the physical, spiritual, and psychosocial aspects. Hence, strategies to enhance holistic ANC in pregnant women have been developed. Methods Study Aim The study aims to develop strategies to enhance holistic ANC in Limpopo Province. Study Design Qualitative methods will be espoused for this study, and descriptive information from the observation checklist and audit tool will support the qualitative data. Qualitative research investigates and interprets the meaning that participants assign to a phenomenon to make sense of their experiences in the social context [ 7 ]. The qualitative design will assist the researcher in compiling an in-depth overview of participants' perspectives on providing holistic ANC for pregnant women. Phase1 A research design necessitates mapping out each element of the study and figuring out how they relate [ 8 ]. Qualitative approaches will be used, including descriptive information from the observation checklist and audit tool, to complement the qualitative data. The researcher will conduct focus group discussions with pregnant women to explore their experiences regarding the care they receive during antenatal care visits. Each sampled CHC will have a focus group interview, in which a group of women will be interviewed using open-ended questions. The researcher will also conduct in-depth face-to-face interviews to explore midwives' views on rendering holistic ANC and to describe the operational manager's perception of holistic ANC at each CHC. An open-ended question will be posed to both the midwives and operational managers to allow further engagement. The researcher will further audit antenatal cards and observe the midwives using non-participatory methods. The researcher will audit 10% of ANC records at each facility with more than four visits and conduct one non-participatory observation at each facility. Tesch’s eight steps of data analysis and descriptive statistics will be used to analyse qualitative and quantitative data. Phase 2 Development of strategies All data obtained will be interpreted to develop strategies to enhance holistic ANC in Limpopo Province. The strengths, weaknesses, threats, and opportunities of the provided ANC will be determined using situational analysis (BOEM); building strength, overcoming weaknesses, exploring opportunities, and managing dangers are the findings of data gathering. Validation of developed strategies Validation of strategies will be conducted using a quantitative approach. The researcher will employ a non-experimental intervention validation design as it is commonly used in nursing research [ 9 ]. The researcher will use a self-administered questionnaire for the OPMs and the midwives to validate the developed strategies. The participants will be chosen using a systematic and purposeful sampling process. Study Setting The study will be conducted in the Mopani and Capricorn Districts in the South African province of Limpopo. Limpopo is one of the nine provinces in South Africa. It is in the northern region and borders Botswana, Zimbabwe, and Mozambique. Nonprobability purposive sampling was used to choose the province, districts, municipalities, and community health clinics for the study. Capricorn and Mopani were selected out of five districts of Limpopo due to their high rates of maternal mortality, which are 98.7, 195.8, and 93.9 per 10,000 births, respectively [ 10 ]. All eleven CHCs will be selected since they are primary care clinics' sources of referrals: seven from Mopani and four from Capricorn. Figure 1 depicts a map of the province of Limpopo with the locations of each district. Study Population A population is a well-defined collection of comparable characteristics that pique the researcher's attention [ 8 ]. The study population will include all pregnant women, midwives, and operational managers (OPMs) working in Capricorn and Mopani Districts. Consequently, the study's target population will be pregnant women, midwives, and OPMs working in the selected facilities of Capricorn and Mopani Districts. The Capricorn district employs 85 midwives who regularly contribute to providing daily care for pregnant women at the CHCs. Moreover, 163 Mopani midwives are employed to care for pregnant women. In the Capricorn and Mopani districts combined, there are 248 midwives employed. These, therefore, serve as the total population as they will not all participate as purposive sampling will be employed. Study Sample Sampling of pregnant women for focus groups and sampling of midwives and OPMs for in-depth interviews will be done through nonprobability purposive sampling. Purposive sampling, as defined by [ 12 ], is the intentional selection of participants by the researcher based on predetermined criteria indicating which ones will be the most beneficial. Convenience sampling will be used to select participants for ANC card auditing and midwives for observation to support the qualitative data. According to [ 12 ], convenience sampling entails selecting participants who are readily accessible and willing to be involved in the study. Inclusion Criteria The study will include pregnant women over eighteen who have attended ANC more than four times and have granted their written consent to participate, as well as midwives with more than two years of experience who have granted their written consent. Considering there are only 11 CHCs in both Capricorn and Mopani, the study will include all OPMs, provided they voluntarily consent to participate. Exclusion criteria Any potential participants who fail to meet the criteria for inclusion. Sample Size There will be a focus group from each sampled facility, which will make a total of 11 focus groups. The availability and willingness of the participants will determine the number of participants in each focus group per facility. Hence, the minimum number of five to a maximum of ten required for the focus group will be followed [ 13 ]. Data will be collected until saturation is reached. The census method, in which every participant is included in the study, will be used to determine the sample size of the OPMs. All in all, there is one OPM in each CHC, which makes up the total population. Eleven OPMs will, therefore, be included in the sample. Since antenatal card audits and non-participatory observations are only used to supplement qualitative data and not as part of a mixed-method approach, only 10% of cards from women receiving ANC at each institution will be audited. Furthermore, each facility has two or three midwives allocated to ANC daily. For non-participatory observations, a sample size of 11 midwives will be used, one per facility. Recruitment of Participants Ethical clearance was obtained from the University College Research Ethics Committee (46451153_CREC_CHS_2024). Data will be gathered after permission to conduct the study is obtained from the Department of Health in the Limpopo Province, Mopani, and Capricorn districts. To gain access to CHCs, the researcher will visit the assistant managers and explain the purpose of the study. The researcher will further set up a meeting with the OPMs of CHCs to introduce the study and establish appropriate times and dates for data collection. The researcher will brief the pregnant women, midwives, and OPMs in the waiting area about the study before consultations. Before the study commences, individuals interested in taking part will be given a consent form to sign. Data collection tools Data will be collected through focus groups with pregnant women and in-depth interviews with midwives and OPMs utilising an interview guide. Non-participatory observations will be conducted using an observation checklist, and antenatal cards will be audited using an audit tool. Data management and analysis All data will be kept on password-protected computers, and only the investigators can access it. Field data collection will be conducted utilising a logbook. The researcher will use Tesch's eight-step coding procedures to analyse qualitative data [ 14 ]. Data will be transcribed from audio and field notes, noting all captured responses. The co-coder and the researcher will independently agree upon the determined themes. Descriptive statistics will be used to analyse data from the observation checklist and antenatal card audit tool. A computerized statistical package for the social sciences (SPSS version 28) [ 15 ] will be used for such analysis. Graphs and tables will be used to visualize data. Data quality assurance Data quality will be safeguarded during field data collection using predefined protocols, data collector training, monitoring, and feedback. Throughout the study procedure, scheduled random and frequent checking of databases along with methodical feedback will guarantee the quality of the data. Standard procedures, respondent validation, and reflexivity will be used to triangulate qualitative components to preserve the data's reliability. Trustworthiness Trustworthiness, according to [ 16 ], relates to the veracity and accuracy of the results. A range of methodologies to collect and analyse data will be employed to ensure confirmability, reliability, transferability, and credibility. Credibility refers to how authentic a qualitative study is or how accurate and true the outcomes are [ 17 ]. Credibility will be enhanced by forging a bond of trust with the participants. Long periods, estimated at one hour per session, will be spent collecting data while interaction with participants takes place. Transferability is the capacity of an instrument to produce the same outcomes when employed in various contexts [ 16 ]. Transferability will be ensured by using the same instruments with participants with similar characteristics in various locations. All districts and CHCs chosen for the study will utilise the same tool to gather data. In-depth descriptions of the research findings will be used to create in-depth narratives of the research environment, participants, and their perspectives on the phenomenon of the study. Dependability , which relates to reliability, assesses the likelihood that another researcher will repeat a study with the same outcomes [ 18 ]. Data will be analysed, and the researcher will decide on codes, categories, and themes in consultation with the co-coder and the supervisor. Confirmability ensures that more researchers will likely find the research study's conclusions accurate [ 18 ]. To avoid revealing the researcher's influences, objectives, or perspectives, the study's conclusions will reflect the participants' emotions, tone, and context of the inquiry. Quotes from participants' comments will be used as evidence in reporting the results. Validity and reliability A pilot study will be conducted to evaluate the audit tool, a non-participatory observation tool, and the audit checklist before data collection occurs. The supervisor and the statisticians will assist with the modification of all the instruments that will be used for data collection. Ethical considerations These well-ordered ethical values concern how closely the study approach complies with the study's acceptable social and professional obligations [ 16 ]. The University of South Africa Research Ethics Committee issued an ethical clearance certificate to the researcher (CREC Reference #: 46451153_CREC_CHS_2024). The researchers will further obtain formal approval to conduct the study from the Limpopo Department of Health, the Mopani Health District, the Capricorn Health District, and the OPMs of the CHCs. The researchers will further abide by the following moral guidelines throughout data collection: The right to Anonymity and confidentiality To ensure anonymity and confidentiality, the researcher will provide the participants with pseudonyms [ 17 ]. The participants' information will not be shared with others except the research assistants, supervisor, statistician, and co-coder. The study participants, research assistants, statisticians, and co-coders will all sign confidentiality agreement forms. Informed consent and voluntary participation [ 17 ] cite that the issue with informed consent concerns the participants ‘right to full information regarding the study and what it entails. Sessions will be held with the participants, who will be provided with information about the purpose of the study. Participants will be allowed to ask questions. This will be followed by a participant information sheet provided with additional information. Participants will be requested to sign an informed consent form before participating to ensure voluntary participation, furthermore, be offered an option of withdrawal at any point of the study. The principle of Beneficence The researcher will guard against physical or psychological harm, discomfort, and unnecessary risk to the participants during data collection [ 17 ]. In case of any anticipated harm, the researcher will disclose such possible risks to the participants. The researcher will inform the participants that there is no direct benefit from participating in monetary or any reward [ 17 ]. As a result, the participants will be informed that the findings will be published and presented at conferences to improve ANC services in the province. The principle of justice Everyone is entitled to fair treatment [ 15 ]. Every participant will have an equal opportunity to participate in the study We will treat each participant equally when gathering data.. DISCUSSION To the researchers’ knowledge, strategies to enhance holistic ANC have not been developed anywhere globally. Antenatal care is one of the Sustainable Development Goals (SDG 3), which includes improving maternal health as the primary priority [ 1 ]. Due to the lack of holistic ANC among pregnant women, important issues such as psychological and social aspects are often neglected as the focus is on routine traditional physiological care. According to [ 19 ], poor psychological well-being during ANC is the cause of postpartum depression, which may weaken the immune system, leading to abortions, preterm births, preterm labor, and preeclampsia [ 2 ]. The current study aims to develop strategies to enhance holistic ANC for pregnant women. The developed strategies are aimed at assisting health professionals, primarily midwives, in improving the quality of care offered to pregnant women. This is corroborated by [ 20 ] stating that the lives of mothers and their unborn babies depend on ANC, which is also a significant contributing factor to the high risk of maternal death. Therefore, obtaining holistic ANC is considered one of the best methods to avoid complications throughout pregnancy. The study findings will be disseminated through workshops, conference presentations, and publications in accredited journals. The study is limited to two districts of Capricorn, which may limit its generalisability to the whole province. However, all the CHCs of the two districts selected will form part of the study. The intended study will increase the understanding of the importance of holistic ANC among pregnant women by midwives and OPMs in South Africa. The results will greatly highlight how well ANC is provided to pregnant women. The developed holistic ANC strategies will be an essential tool to support improving pregnancy outcomes. Abbreviations ANC - antenatal care, CHCs - community health centers, SDGs - sustainable development goals, OPMs- operational managers, SA- South Africa WHO - World Health Organization. Declarations Acknowledgments The University of South Africa, the Department of Health in Limpopo Province, Mopani, and Capricorn District, the pregnant women, midwives, and OPMs) are to be appreciated by the researchers in advance. Authors’ contributions Conceptualization, Methodology, Writing-review, and editing : Violet Manonyana Chewe, Johannah Mabojalwa Mathibe-Neke Investigation, Writing - original draft: Violet Manonyana chewe Supervision and final editing of the manuscript: Johannah Mabojalwa Mathibe-Neke Funding: The study is self-funded. Availability of data and material: The current study did not generate or analyse any datasets. Upon research completion, any relevant data will be made available. Ethics approval and consent to participate: The University of South Africa's Ethics Review Committee (CREC Ref: 46451153_CREC_CHS_2024) awarded ethical approval for this research on March 19, 2024. Every participant will have their informed written consent obtained, and all ethical guidelines will be followed when gathering data. Consent for publication: We will obtain participants' consent before publishing personal information in any format, including photographs, videos, or individual details. We have not yet considered publishing individual data for this study. Competing interests: The authors declare that there are no competing interests. Author Details 1 Faculty of Health Sciences, Department of Advance Nursing Sciences, University of Venda, Thohoyandou, South Africa, 2 College of Human Sciences, Department of Health Studies, University of South Africa, Pretoria, South Africa References World Health Organization. 2019. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division . Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. From: www.googlescholar.com. Accessed 01 June 2023. Traylor, CS, Johnson, JD, Kimmel, MC & Manuck, TA. 2020. Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review. Am Journal of Obstetrics Gynecology MFM. 2020;2(4):100229.doi: 10.1016/j.ajogmf.2020.100229. From: www.googlescholar.com. Accessed 15 May 2023. Guintivano, J, Manuck, T & Meltzer-Brody, S. 2018. Predictors of Postpartum Depression: A Comprehensive Review of the Last Decade of Evidence. Clinical Obstetetric Gynecology. 2018; 61 (3):591–603. From: https://pubmed.ncbi.nlm.nih.gov/29596076/. Accessed 29 April 2023. Word Health Organization. 2023. Maternal Mortality . https://www.who.int/news-room/fact-sheets/detail/maternal-mortality Hailemeskel, S, Alemu, K, Christensson, K, Tesfahun, E & Lindgren, H. 2022. Midwife-led continuity of care increases women’s satisfaction with antenatal, intrapartum, and postpartum care: North Shoa, Amhara regional state, Ethiopia: A quasi-experimental study. Women and Birth 35 (2022) 553-562. From: https://pubmed.ncbi.nlm.nih.gov/34489211/. Accessed 15 May 2023 Suarayasa, K, Syafar, M, Jafar, N, Masni & Mallongi, A. 2017. Household-based Antenatal Care Monitoring Model (An Intervention Study in the Coastal Area of Palu City).2017. Asian Journal of Epidemiology ., 10 (3): 128-137, 2017. https://www.researchgate.net (Accessed 01 September 2022). Hennink, M, Hutter, I & Bailey, A. 2020. Qualitative research methods . 2nd Edition. Los Angeles: SAGE Publications Ltd Walter, M. 2019. Social research methods . 4th Edition. Australia: Oxford University Press. Gray, JR, Grove, SK & Sutherland, S. 2017. Burns and Grove’s the practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence. Elsevier. Massyn, N, Day, C, Ndlovu,N & Padayachee, T. 2020. District health barometer . South Africa: Health Systems Trust. From: https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf. Accessed 09 April 2023. Google.com. From: https://www.google.com/search?q=limpop+map+pictures&rlz. Accessed 10 April 2024 Rabiee, F. 2004. Focus-group interview and data analysis. Proceedings of the Nutrition Society (2004), 63, 655–660. Available at https://pubmed.ncbi.nlm.nih.gov/15831139/. Accessed 15 April 2024 Polit, DF & Beck, CT. 2017. Nursing research: generating and assessing evidence for nursing practice. 10th edition. Philadelphia: JB Lippincott Williams and Wilkins. Creswell, JW & Plano Clark VL. 2018. Designing and Conducting Mixed Methods Research . 3 rd Edition. Thousand Oaks, CA: SAGE. Zagumny, MJ. 2001. The SPSS Book ®, A student guide to the statistical package for the social sciences ®. New York: Writer Club Press. From: www.googlescholar.com. Accessed 05 February 2024. Brink, H. Van der Walt, C, Van Rensburg, G. 2018. Fundamentals of research methodology for healthcare professionals. 4th Edition. Cape Town: Juta. Grove, SK, Gray, JR & Burns, N. 2015. Understanding nursing research. Building on evidence-based practice. 6th Edition. Missouri: Elsevier Saunders Polit, DF & Beck, CT. 2021. Nursing Research. Generating and Assessing Evidence for Practice. 11th Edition. Philadelphia: Wolters Kluwer. Creswell, JW & Creswell, JD. 2018. Research design. Qualitative, quantitative & mixed methods approach . 5 th Edition. UK: Sage. Ermias GT and Laloto AD. 2021. The Impact of Antenatal Care in Maternal and Perinatal Health. Empowering Midwives and Obstetric Nurses. IntechOpen. Available at: http://dx.doi.org/10.5772/intechopen.98668. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4412038","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Study protocol","associatedPublications":[],"authors":[{"id":312027294,"identity":"fb3fc9cb-b56e-4b86-aae5-7482d84da740","order_by":0,"name":"Violet Manonyana Chewe","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIie3PMUvDQBTA8XccpMuVrBcs5iu8o4MUIvkq5+LU4ObUISDEJe7Z/Aqd6nrlIF1C5w6CiuBUoeIS0IIv6iJyWjeH+y/HO+7H8QB8vn8YWmCGzhi7aQMgdiFgQIOa0sCqnYj5ILoj/Pf3VHTOjXlqQR/0SnV/WFwPcHFhoJ1AGuYOchboeUW/jMpmOMyKB4HNUrOyBi6Niwi0ggiustleVlgRVWOEfg4BOEjIibx25Obx6mXUkcs1sm0OIv6JvK+/6s84IxJKgZx+keggAaddymOpps3Jc1QuiYgx2kEtUblIaOe3bZLEuKiPNu2pTYNeo+7WkyTdd5DP5NfRfLvx+Xw+3596A8u2WKkKBMffAAAAAElFTkSuQmCC","orcid":"","institution":"Faculty of Health Science, Department of Advanced Nursing Sciences, University of Venda, Thohoyandou","correspondingAuthor":true,"prefix":"","firstName":"Violet","middleName":"Manonyana","lastName":"Chewe","suffix":""},{"id":312027295,"identity":"6750c38b-119a-491e-a750-5fff4f759f43","order_by":1,"name":"Johannah Mabojalwa Mathibe-Neke","email":"","orcid":"","institution":"College of Human Sciences, Department of Health Studies, University of South Africa, Pretoria,","correspondingAuthor":false,"prefix":"","firstName":"Johannah","middleName":"Mabojalwa","lastName":"Mathibe-Neke","suffix":""}],"badges":[],"createdAt":"2024-05-13 09:06:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4412038/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4412038/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58307571,"identity":"4bfa3035-0b51-4d52-9855-351332c3363a","added_by":"auto","created_at":"2024-06-13 18:43:50","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":252994,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLimpopo Map\u003c/strong\u003e[11]\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4412038/v1/8720ff2878c783fd23dc2467.png"},{"id":92119965,"identity":"b1e71bf7-d87b-4a92-b870-eda52675f03b","added_by":"auto","created_at":"2025-09-24 21:46:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":850846,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4412038/v1/820c4b71-de8a-47bc-859d-ffe663876994.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of strategies to enhance holistic antenatal care in Limpopo Province, South Africa: A qualitative method protocol ","fulltext":[{"header":"Background","content":"\u003cp\u003eThe World Health Organization (WHO) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] acknowledges improving maternal health as a crucial component of the Sustainable Development Goals (SDGs). As a result, the WHO has identified antenatal care (ANC) as one of the goals for attaining SDGs. The World Health Organization [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] further recommends that all women obtain holistic ANC, which includes physical, psychological, spiritual, and social components of care.\u003c/p\u003e \u003cp\u003eAccording to the World Health Organization (WHO) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], holistic care in pregnancy refers to multifaceted care, such as spiritual, emotional, intellectual, physical, social, and mental. During routine visits to the primary health care clinics for basic antenatal care audits, the researcher observed that more effort is being put into the physical aspects of women and the foetal status during antenatal assessments. For instance, psychological, spiritual, and social assessments are often neglected during antenatal assessments. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] emphasizes the importance of psychological, spiritual, and social well-being during pregnancy, linked to pregnancy outcomes. According to [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], poor psychological well-being during ANC is a common cause of postpartum depression. Furthermore, as noted in [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], this may result in a homeostatic imbalance, weakening the immune system and leading to abortions, preterm deliveries, preterm labour, and preeclampsia.\u003c/p\u003e \u003cp\u003eLiterature indicates that globally, 287,000 women died while pregnant, giving birth, and postnatally in 2020 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. As stated in the WHO Maternal Mortality Report, [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Sub-Saharan countries contributed 87%, which amounted to 202,000 maternal deaths. According to WHO, as of 2017, the maternal mortality ratio was recorded as 211 worldwide; in Sub-Saharan, 533; in Africa, 525; and in South Africa (SA), 119 per hundred thousand live births, respectively. According to WHO, most deaths were due to poor ANC offered to women, as most factors could have been prevented.\u003c/p\u003e \u003cp\u003eSeveral strategies and models to facilitate quality ANC have been developed so far. For example, the midwife-led continuity of care model was developed in Ethiopia and yielded satisfaction among low-risk pregnant women [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The household-based ANC monitoring model was developed in Indonesia (Palu City) by [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The model provided notable outcomes for quality ANC implementation. However, the strategies and models developed did not include holistic ANC.\u003c/p\u003e \u003cp\u003eThe researcher observed a gap in the literature for holistic ANC provision worldwide and in SA. What emerged from both the literature gap and the researcher's observation was that pregnant women deserve ANC that equally prioritizes the physical, spiritual, and psychosocial aspects. Hence, strategies to enhance holistic ANC in pregnant women have been developed.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Aim\u003c/h2\u003e \u003cp\u003eThe study aims to develop strategies to enhance holistic ANC in Limpopo Province.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eQualitative methods will be espoused for this study, and descriptive information from the observation checklist and audit tool will support the qualitative data. Qualitative research investigates and interprets the meaning that participants assign to a phenomenon to make sense of their experiences in the social context [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The qualitative design will assist the researcher in compiling an in-depth overview of participants' perspectives on providing holistic ANC for pregnant women.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003ePhase1\u003c/h2\u003e \u003cp\u003eA research design necessitates mapping out each element of the study and figuring out how they relate [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Qualitative approaches will be used, including descriptive information from the observation checklist and audit tool, to complement the qualitative data. The researcher will conduct focus group discussions with pregnant women to explore their experiences regarding the care they receive during antenatal care visits. Each sampled CHC will have a focus group interview, in which a group of women will be interviewed using open-ended questions. The researcher will also conduct in-depth face-to-face interviews to explore midwives' views on rendering holistic ANC and to describe the operational manager's perception of holistic ANC at each CHC. An open-ended question will be posed to both the midwives and operational managers to allow further engagement. The researcher will further audit antenatal cards and observe the midwives using non-participatory methods. The researcher will audit 10% of ANC records at each facility with more than four visits and conduct one non-participatory observation at each facility. Tesch\u0026rsquo;s eight steps of data analysis and descriptive statistics will be used to analyse qualitative and quantitative data.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003ePhase 2\u003c/h2\u003e \u003cp\u003eDevelopment of strategies\u003c/p\u003e \u003cp\u003eAll data obtained will be interpreted to develop strategies to enhance holistic ANC in Limpopo Province. The strengths, weaknesses, threats, and opportunities of the provided ANC will be determined using situational analysis (BOEM); building strength, overcoming weaknesses, exploring opportunities, and managing dangers are the findings of data gathering.\u003c/p\u003e \u003cp\u003eValidation of developed strategies\u003c/p\u003e \u003cp\u003eValidation of strategies will be conducted using a quantitative approach. The researcher will employ a non-experimental intervention validation design as it is commonly used in nursing research [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The researcher will use a self-administered questionnaire for the OPMs and the midwives to validate the developed strategies. The participants will be chosen using a systematic and purposeful sampling process.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStudy Setting\u003c/h2\u003e \u003cp\u003eThe study will be conducted in the Mopani and Capricorn Districts in the South African province of Limpopo. Limpopo is one of the nine provinces in South Africa. It is in the northern region and borders Botswana, Zimbabwe, and Mozambique. Nonprobability purposive sampling was used to choose the province, districts, municipalities, and community health clinics for the study. Capricorn and Mopani were selected out of five districts of Limpopo due to their high rates of maternal mortality, which are 98.7, 195.8, and 93.9 per 10,000 births, respectively [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. All eleven CHCs will be selected since they are primary care clinics' sources of referrals: seven from Mopani and four from Capricorn. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e depicts a map of the province of Limpopo with the locations of each district.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eA population is a well-defined collection of comparable characteristics that pique the researcher's attention [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The study population will include all pregnant women, midwives, and operational managers (OPMs) working in Capricorn and Mopani Districts. Consequently, the study's target population will be pregnant women, midwives, and OPMs working in the selected facilities of Capricorn and Mopani Districts. The Capricorn district employs 85 midwives who regularly contribute to providing daily care for pregnant women at the CHCs. Moreover, 163 Mopani midwives are employed to care for pregnant women. In the Capricorn and Mopani districts combined, there are 248 midwives employed. These, therefore, serve as the total population as they will not all participate as purposive sampling will be employed.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eStudy Sample\u003c/h2\u003e \u003cp\u003eSampling of pregnant women for focus groups and sampling of midwives and OPMs for in-depth interviews will be done through nonprobability purposive sampling. Purposive sampling, as defined by [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], is the intentional selection of participants by the researcher based on predetermined criteria indicating which ones will be the most beneficial.\u003c/p\u003e \u003cp\u003eConvenience sampling will be used to select participants for ANC card auditing and midwives for observation to support the qualitative data. According to [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], convenience sampling entails selecting participants who are readily accessible and willing to be involved in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eInclusion Criteria\u003c/h2\u003e \u003cp\u003eThe study will include pregnant women over eighteen who have attended ANC more than four times and have granted their written consent to participate, as well as midwives with more than two years of experience who have granted their written consent. Considering there are only 11 CHCs in both Capricorn and Mopani, the study will include all OPMs, provided they voluntarily consent to participate.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eExclusion criteria\u003c/h2\u003e \u003cp\u003eAny potential participants who fail to meet the criteria for inclusion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSample Size\u003c/h2\u003e \u003cp\u003eThere will be a focus group from each sampled facility, which will make a total of 11 focus groups. The availability and willingness of the participants will determine the number of participants in each focus group per facility. Hence, the minimum number of five to a maximum of ten required for the focus group will be followed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Data will be collected until saturation is reached. The census method, in which every participant is included in the study, will be used to determine the sample size of the OPMs. All in all, there is one OPM in each CHC, which makes up the total population. Eleven OPMs will, therefore, be included in the sample.\u003c/p\u003e \u003cp\u003eSince antenatal card audits and non-participatory observations are only used to supplement qualitative data and not as part of a mixed-method approach, only 10% of cards from women receiving ANC at each institution will be audited. Furthermore, each facility has two or three midwives allocated to ANC daily. For non-participatory observations, a sample size of 11 midwives will be used, one per facility.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRecruitment of Participants\u003c/h2\u003e \u003cp\u003eEthical clearance was obtained from the University College Research Ethics Committee (46451153_CREC_CHS_2024). Data will be gathered after permission to conduct the study is obtained from the Department of Health in the Limpopo Province, Mopani, and Capricorn districts. To gain access to CHCs, the researcher will visit the assistant managers and explain the purpose of the study. The researcher will further set up a meeting with the OPMs of CHCs to introduce the study and establish appropriate times and dates for data collection. The researcher will brief the pregnant women, midwives, and OPMs in the waiting area about the study before consultations. Before the study commences, individuals interested in taking part will be given a consent form to sign.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eData collection tools\u003c/h2\u003e \u003cp\u003eData will be collected through focus groups with pregnant women and in-depth interviews with midwives and OPMs utilising an interview guide. Non-participatory observations will be conducted using an observation checklist, and antenatal cards will be audited using an audit tool.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eData management and analysis\u003c/h2\u003e \u003cp\u003eAll data will be kept on password-protected computers, and only the investigators can access it. Field data collection will be conducted utilising a logbook. The researcher will use Tesch's eight-step coding procedures to analyse qualitative data [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Data will be transcribed from audio and field notes, noting all captured responses. The co-coder and the researcher will independently agree upon the determined themes. Descriptive statistics will be used to analyse data from the observation checklist and antenatal card audit tool. A computerized statistical package for the social sciences (SPSS version 28) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] will be used for such analysis. Graphs and tables will be used to visualize data.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eData quality assurance\u003c/h2\u003e \u003cp\u003eData quality will be safeguarded during field data collection using predefined protocols, data collector training, monitoring, and feedback. Throughout the study procedure, scheduled random and frequent checking of databases along with methodical feedback will guarantee the quality of the data. Standard procedures, respondent validation, and reflexivity will be used to triangulate qualitative components to preserve the data's reliability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eTrustworthiness\u003c/h2\u003e \u003cp\u003eTrustworthiness, according to [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], relates to the veracity and accuracy of the results. A range of methodologies to collect and analyse data will be employed to ensure confirmability, reliability, transferability, and credibility.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCredibility\u003c/b\u003e refers to how authentic a qualitative study is or how accurate and true the outcomes are [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Credibility will be enhanced by forging a bond of trust with the participants. Long periods, estimated at one hour per session, will be spent collecting data while interaction with participants takes place.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTransferability\u003c/b\u003e is the capacity of an instrument to produce the same outcomes when employed in various contexts [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Transferability will be ensured by using the same instruments with participants with similar characteristics in various locations. All districts and CHCs chosen for the study will utilise the same tool to gather data. In-depth descriptions of the research findings will be used to create in-depth narratives of the research environment, participants, and their perspectives on the phenomenon of the study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDependability\u003c/b\u003e, which relates to reliability, assesses the likelihood that another researcher will repeat a study with the same outcomes [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Data will be analysed, and the researcher will decide on codes, categories, and themes in consultation with the co-coder and the supervisor.\u003c/p\u003e \u003cp\u003e \u003cb\u003eConfirmability\u003c/b\u003e ensures that more researchers will likely find the research study's conclusions accurate [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. To avoid revealing the researcher's influences, objectives, or perspectives, the study's conclusions will reflect the participants' emotions, tone, and context of the inquiry. Quotes from participants' comments will be used as evidence in reporting the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eValidity and reliability\u003c/h2\u003e \u003cp\u003eA pilot study will be conducted to evaluate the audit tool, a non-participatory observation tool, and the audit checklist before data collection occurs. The supervisor and the statisticians will assist with the modification of all the instruments that will be used for data collection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003eThese well-ordered ethical values concern how closely the study approach complies with the study's acceptable social and professional obligations [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The University of South Africa Research Ethics Committee issued an ethical clearance certificate to the researcher (CREC Reference #: 46451153_CREC_CHS_2024). The researchers will further obtain formal approval to conduct the study from the Limpopo Department of Health, the Mopani Health District, the Capricorn Health District, and the OPMs of the CHCs. The researchers will further abide by the following moral guidelines throughout data collection:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe right to Anonymity and confidentiality\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eTo ensure anonymity and confidentiality, the researcher will provide the participants with pseudonyms [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The participants' information will not be shared with others except the research assistants, supervisor, statistician, and co-coder. The study participants, research assistants, statisticians, and co-coders will all sign confidentiality agreement forms.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cstrong\u003eInformed consent and voluntary participation\u003c/strong\u003e\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e\u003cp\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] cite that the issue with informed consent concerns the participants \u0026lsquo;right to full information regarding the study and what it entails. Sessions will be held with the participants, who will be provided with information about the purpose of the study. Participants will be allowed to ask questions. This will be followed by a participant information sheet provided with additional information. Participants will be requested to sign an informed consent form before participating to ensure voluntary participation, furthermore, be offered an option of withdrawal at any point of the study. The principle of Beneficence\u003c/p\u003e \u003cp\u003eThe researcher will guard against physical or psychological harm, discomfort, and unnecessary risk to the participants during data collection [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In case of any anticipated harm, the researcher will disclose such possible risks to the participants. The researcher will inform the participants that there is no direct benefit from participating in monetary or any reward [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As a result, the participants will be informed that the findings will be published and presented at conferences to improve ANC services in the province.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eThe principle of justice\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEveryone is entitled to fair treatment [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Every participant will have an equal opportunity to participate in the study We will treat each participant equally when gathering data..\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eTo the researchers\u0026rsquo; knowledge, strategies to enhance holistic ANC have not been developed anywhere globally. Antenatal care is one of the Sustainable Development Goals (SDG 3), which includes improving maternal health as the primary priority [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to the lack of holistic ANC among pregnant women, important issues such as psychological and social aspects are often neglected as the focus is on routine traditional physiological care. According to [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], poor psychological well-being during ANC is the cause of postpartum depression, which may weaken the immune system, leading to abortions, preterm births, preterm labor, and preeclampsia [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current study aims to develop strategies to enhance holistic ANC for pregnant women. The developed strategies are aimed at assisting health professionals, primarily midwives, in improving the quality of care offered to pregnant women. This is corroborated by [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] stating that the lives of mothers and their unborn babies depend on ANC, which is also a significant contributing factor to the high risk of maternal death. Therefore, obtaining holistic ANC is considered one of the best methods to avoid complications throughout pregnancy. The study findings will be disseminated through workshops, conference presentations, and publications in accredited journals.\u003c/p\u003e \u003cp\u003eThe study is limited to two districts of Capricorn, which may limit its generalisability to the whole province. However, all the CHCs of the two districts selected will form part of the study.\u003c/p\u003e \u003cp\u003eThe intended study will increase the understanding of the importance of holistic ANC among pregnant women by midwives and OPMs in South Africa. The results will greatly highlight how well ANC is provided to pregnant women. The developed holistic ANC strategies will be an essential tool to support improving pregnancy outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eANC - antenatal care, CHCs - community health centers, SDGs - sustainable development goals, OPMs- operational managers, SA- South Africa WHO - World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe University of South Africa, the Department of Health in Limpopo Province, Mopani, and Capricorn District, the pregnant women, midwives, and OPMs) are to be appreciated by the researchers in advance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConceptualization, Methodology, Writing-review, and editing\u003c/strong\u003e: Violet Manonyana Chewe, Johannah Mabojalwa Mathibe-Neke\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInvestigation, Writing - original draft:\u003c/strong\u003e Violet Manonyana chewe\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupervision and final editing of the manuscript:\u003c/strong\u003e Johannah Mabojalwa Mathibe-Neke\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The study is self-funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material:\u003c/strong\u003e The current study did not generate or analyse any datasets. Upon research completion, any relevant data will be made available.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e The University of South Africa\u0026apos;s Ethics Review Committee (CREC Ref: 46451153_CREC_CHS_2024)\u0026nbsp;awarded ethical approval for this research on March 19, 2024. Every participant will have their informed written consent obtained, and all ethical guidelines will be followed when gathering data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e We will obtain participants\u0026apos; consent before publishing personal information in any format, including photographs, videos, or individual details.\u0026nbsp;\u003cbr\u003e\u0026nbsp;We have not yet considered publishing individual data for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that there are no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e Faculty of Health Sciences, Department of Advance Nursing Sciences, University of Venda, Thohoyandou, South Africa, \u003cstrong\u003e2\u003c/strong\u003e College of Human Sciences, Department of Health Studies, University of South Africa, Pretoria, South Africa\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. 2019. \u003cem\u003eTrends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division\u003c/em\u003e. Geneva: World Health Organization; 2019. Licence: CC BY-NC-SA 3.0 IGO. From: www.googlescholar.com. Accessed 01 June 2023. \u003c/li\u003e\n\u003cli\u003eTraylor, CS, Johnson, JD, Kimmel, MC \u0026amp; Manuck, TA. 2020. Effects of psychological stress on adverse pregnancy outcomes and nonpharmacologic approaches for reduction: an expert review. \u003cem\u003eAm Journal of Obstetrics Gynecology MFM. \u003c/em\u003e2020;2(4):100229.doi: 10.1016/j.ajogmf.2020.100229. From: www.googlescholar.com. Accessed 15 May 2023. \u003c/li\u003e\n\u003cli\u003eGuintivano, J, Manuck, T \u0026amp; Meltzer-Brody, S. 2018. Predictors of Postpartum Depression: A Comprehensive Review of the Last Decade of Evidence. \u003cem\u003eClinical Obstetetric Gynecology. \u003c/em\u003e2018;\u003cstrong\u003e61\u003c/strong\u003e(3):591\u0026ndash;603. From: https://pubmed.ncbi.nlm.nih.gov/29596076/. Accessed 29 April 2023. \u003c/li\u003e\n\u003cli\u003eWord Health Organization. 2023. \u003cem\u003eMaternal Mortality\u003c/em\u003e. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality\u003cu\u003e \u003c/u\u003e\u003c/li\u003e\n\u003cli\u003eHailemeskel, S, Alemu, K, Christensson, K, Tesfahun, E \u0026amp; Lindgren, H. 2022. Midwife-led continuity of care increases women\u0026rsquo;s satisfaction with antenatal, intrapartum, and postpartum care: North Shoa, Amhara regional state, Ethiopia: A quasi-experimental study. \u003cem\u003eWomen and Birth\u003c/em\u003e 35 (2022) 553-562. From: https://pubmed.ncbi.nlm.nih.gov/34489211/. Accessed 15 May 2023 \u003c/li\u003e\n\u003cli\u003eSuarayasa, K, Syafar, M, Jafar, N, Masni \u0026amp; Mallongi, A. 2017. Household-based Antenatal Care Monitoring Model (An Intervention Study in the Coastal Area of Palu City).2017. \u003cem\u003eAsian Journal of Epidemiology\u003c/em\u003e., 10 (3): 128-137, 2017. https://www.researchgate.net (Accessed 01 September 2022). \u003c/li\u003e\n\u003cli\u003eHennink, M, Hutter, I \u0026amp; Bailey, A. 2020. \u003cem\u003eQualitative research methods\u003c/em\u003e. 2nd Edition. Los Angeles: SAGE Publications Ltd \u003c/li\u003e\n\u003cli\u003eWalter, M. 2019. \u003cem\u003eSocial research methods\u003c/em\u003e. 4th Edition. Australia: Oxford University Press. \u003c/li\u003e\n\u003cli\u003eGray, JR, Grove, SK \u0026amp; Sutherland, S. 2017. \u003cem\u003eBurns and Grove\u0026rsquo;s the practice of Nursing Research: Appraisal, Synthesis, and Generation of Evidence.\u003c/em\u003e Elsevier. \u003c/li\u003e\n\u003cli\u003eMassyn, N, Day, C, Ndlovu,N \u0026amp; Padayachee, T. 2020. \u003cem\u003eDistrict health barometer\u003c/em\u003e. South Africa: Health Systems Trust. From: https://www.hst.org.za/publications/District%20Health%20Barometers/DHB%202019-20%20Complete%20Book.pdf. Accessed 09 April 2023. \u003c/li\u003e\n\u003cli\u003eGoogle.com. From: https://www.google.com/search?q=limpop+map+pictures\u0026amp;rlz. Accessed 10 April 2024\u003c/li\u003e\n\u003cli\u003eRabiee, F. 2004. Focus-group interview and data analysis. \u003cem\u003eProceedings of the Nutrition Society\u003c/em\u003e (2004), 63, 655\u0026ndash;660. Available at https://pubmed.ncbi.nlm.nih.gov/15831139/. Accessed 15 April 2024\u003c/li\u003e\n\u003cli\u003ePolit, DF \u0026amp; Beck, CT. 2017. \u003cem\u003eNursing research: generating and assessing evidence for nursing practice.\u003c/em\u003e 10th edition. 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Missouri: Elsevier Saunders \u003c/li\u003e\n\u003cli\u003ePolit, DF \u0026amp; Beck, CT. 2021. \u003cem\u003eNursing Research. Generating and Assessing Evidence for Practice.\u003c/em\u003e11th Edition. Philadelphia: Wolters Kluwer. \u003c/li\u003e\n\u003cli\u003eCreswell, JW \u0026amp; Creswell, JD. 2018. \u003cem\u003eResearch design. Qualitative, quantitative \u0026amp; mixed methods approach\u003c/em\u003e. 5\u003csup\u003eth\u003c/sup\u003e Edition. UK: Sage. \u003c/li\u003e\n\u003cli\u003eErmias GT and Laloto AD. 2021. The Impact of Antenatal Care in Maternal and Perinatal Health. Empowering Midwives and Obstetric Nurses. IntechOpen. Available at: http://dx.doi.org/10.5772/intechopen.98668. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Antenatal care, development, enhance, holistic, strategies","lastPublishedDoi":"10.21203/rs.3.rs-4412038/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4412038/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Holistic antenatal care encompasses a range of services, including mental, physical, social, intellectual, emotional, and spiritual. Antenatal care is regarded as the cornerstone of maternal health. As such, a lack of holistic antenatal care can lead to poor pregnancy outcomes, such as maternal and perinatal mortality. This study aims to develop strategies to enhance holistic antenatal care in Limpopo Province, South Africa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The population for the study is pregnant women, midwives, and operational managers in selected community health centers in Limpopo Province, South Africa. Non-probability purposive sampling will be used to select the province, districts, municipalities, and community health centers for the study. Convenience sampling will be used to select participants for antenatal card auditing and non-participatory observations of the antenatal care process as offered by midwives. Pregnant women will engage in focus group discussions. Midwives and operational managers will be sampled for in-depth interviews using nonprobability purposive sampling. Non-participatory observation will be conducted using a checklist and an audit tool to audit antenatal cards to support the qualitative data. Data will be analysed manually using Tesch's thematic analysis method for focus groups and in-depth interviews. Quantitative data will be analysed using computerized statistical software for the social sciences (SPSS 28). \u0026nbsp;Ethical considerations will be adhered to throughout the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSignificance of the study:\u003c/strong\u003e This study aims to enhance midwives' understanding and practice of holistic antenatal care in Limpopo Province. With the data collected, strategies for enhancing holistic antenatal care will be developed, strengthening the standard of antenatal care. Holistic antenatal care has been proven to contribute to the reduction of maternal and perinatal deaths.\u003c/p\u003e","manuscriptTitle":"Development of strategies to enhance holistic antenatal care in Limpopo Province, South Africa: A qualitative method protocol ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-13 18:43:43","doi":"10.21203/rs.3.rs-4412038/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"947f73ae-4655-482a-a0e9-ea0dc123e4bc","owner":[],"postedDate":"June 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-24T21:38:17+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-13 18:43:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4412038","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4412038","identity":"rs-4412038","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}