Proposal Summary Globally, pregnant people from sub-Saharan Africa, including Malawi experience some of the highest rates of maternal and infant mortality (439 maternal deaths per 100,000 live births and 46 infant deaths per 1,000 live births) as well as high rates of psychological distress. For the health system to effectively reduce these poor outcomes, it is imperative that quality of care improves during the perinatal period. CenteringPregnancy, an innovative group antenatal care model recommended by the World Health Organization, addresses gaps in prenatal care and there is a growing evidence base of positive results. Community building is a core component of CenteringPregnancy, where women experience a dynamic process of connecting to their peers and their providers, through consistent group meetings throughout their pregnancy. However, this core component of the model is not well-defined. Therefore, the purpose of this mixed methods study is to understand community building in group antenatal care in Malawi. This study will use the research infrastructure and momentum of the ongoing NINR-funded (R01 NR018115) effectiveness trial for group based antenatal care in Blantyre district, Malawi, to complete a secondary data analysis of the parent study data as well as primary qualitative data collection. The specific aims are: Aim 1: Examine the differences in community building as measured by peer connectedness, provider connectedness, and partner communication, between the intervention and control group. Aim 2: Determine the difference in outcomes including psychological distress and birth outcomes, by community building between intervention and control groups. Aim 3: Explore how women perceive community building within group antenatal care and what changes, if any, they have experienced in related to community building, specifically in connectedness, communication and decision making within their relationship with providers, partner, family, and larger community. This study aligns with the National Institute of Nursing Research’s strategic goal of improving systems and models of care to advance women’s physical and mental health during pregnancy and postpartum. This training plan will begin a program of research focused on the promotion of the health and well-being of pregnant and postpartum women living in low-income settings. This study will inform the expansion of the effective intervention of group antenatal care both in the US and globally.