Table 1 Implementing countries and their rationale for inclusion

Suriname

Suriname has high rates of maternal deaths (MMR of 120 per 100,000 live births) and perinatal deaths (25 per 1000 births) and adverse birth outcomes. Adverse pregnancy and birth outcomes have been associated with socio-demographics and environmental factors, such as lack of social support, insufficient knowledge, poor living conditions and substandard care. Antenatal GC was introduced in Suriname in 2014 as the SamenZwanger-health care model and its expansion can help to improve maternal and child health in Suriname. As such, the GC model has to be adapted for vulnerable women and it will be implemented in deprived communities.

The Netherlands

In the Netherlands, the number of adverse perinatal outcomes is higher in non-Western women and in Western women living in disadvantaged areas. Adverse outcomes are associated with lifestyle but also with system failure. It has been argued that specific care and attention should be given to so-called marginalized groups and recently the government funded the programme ‘A promising Start’ aimed at addressing health inequalities during the first 1000 days of child’s life. Although group ANC has been successfully implemented, it needs to be expanded to mother-infant care and adapted to better reach under-served, marginalized and migrant women.

England

A government recommendation in 2010 highlighted the priority to early infant years including maternal and infant health to achieve a long-term sustainable reduction in health inequalities. English policy for maternity services in 2015, Better Births, recommended a greater focus on continuity of carer, personalized care and attention to perinatal mental health. Currently, a model of group antenatal, Pregnancy Circles, tailored to a local community and services in an inner-city area of high socio-economic, cultural, ethnic and linguistic diversity is being researched. The model will be further researched and expanded to postnatal care.

Ghana

Access to quality of health services is still challenging for rural communities in Northern Ghana. For instance, while it takes an average 30 min to reach a health facility in urban Ghana, in some parts of rural Northern Ghana accessing a health facility can take as much 3 h. There is a lack of adequate testing materials for ANC in most rural facilities. Psycho-social care, birth preparedness plans and parenting information are not adequately covered during antenatal and postnatal visits. It is anticipated that antenatal GC services tailored to women’s needs will be delivered to rural and poor communicates in Ghana.

Kosovo

The infant mortality rate in Kosovo is the highest in Europe. One of the major challenges is to improve parenting skills as a lack of knowledge about adequate home care management, child physical and cognitive development and reproductive health prevails. Further, the immunization rate remains low amongst Roma, Ashkali and Egyptian communities and inappropriate breastfeeding and infant feeding patterns raise major concerns. Most women do not receive any preventative educational services; hence, system change towards Group antenatal and mother-infant care in Kosovo can strengthen the provision of women-centred care that is informative, supportive and empowering especially for the underserved Roma population.

Belgium

Large cities in Belgium are characterized by high levels of poverty. In Brussels, 33% of the children are born in poverty. Inequities in health care have been identified as evidenced by an increased perinatal mortality rate amongst children of mothers with low educational level, who are single parents and not active in the labour market. Most of these women have mixed foreign ethnic origins. It is anticipated that GC can make a difference for these women, yet the current health care model hinders its implementation. The results of the GC_1000 project will be used for advocacy activities targeting policy-makers and health care managers to ensure sustainability of the model.

South Africa

South Africa is of the most unequal countries in the world, reporting a per-capita expenditure Gini coefficient of 0.65 in 2015. Despite free primary health care, including ANC, stark inequities persist between rural and urban areas as well as the private and public health care sectors. Pregnancy is a critical time for diagnosis, maternal treatment and prevention of HIV transmission to children. HIV prevalence rates are as high as 30% amongst pregnant women. In addition, there are clear evidence-based links between alcohol use and health issues, HIV/AIDs and gender-based violence, as well as crime, road accidents and interpersonal violence. Non-, late and infrequent attendance at ANC is amongst the top five avoidable factors in perinatal deaths and amongst the most common underlying causes of patient-related maternal mortality. It is expected that antenatal GC can contribute significantly to tackle these issues.