Implementing immediate postpartum contraception: a comparative case study at 11 hospitals

Abstract

Background Immediate postpartum long-acting reversible contraception (LARC) is an evidence-based practice, but hospitals face significant barriers to its adoption. Our objective was to examine how organizational context (e.g., size, employee attitudes toward the clinical practice) and implementation strategies (i.e., the actions taken to routinize a clinical practice) drive successful implementation of immediate postpartum LARC services, with a goal of informing the design of future implementation interventions. Methods We conducted a comparative case study of the implementation of inpatient postpartum contraceptive care at 11 US maternity hospitals. In 2017–2018, we conducted site visits that included semi-structured key informant interviews informed by the Consolidated Framework for Implementation Research. Qualitative measures of implementation success included stakeholder satisfaction, routinization, and sustainability of immediate postpartum LARC services. Qualitative content analysis and cross-case synthesis explored relationships among organizational context, implementation strategies, and implementation success. Results We completed semi-structured interviews with 78 clinicians, nurses, residents, pharmacy and revenue cycle staff, and hospital administrators. Successful implementation required three essential conditions: effective implementation champions, an enabling financial environment, and hospital administrator engagement. Six other contextual conditions were influential: trust and effective communication, alignment with stakeholders’ professional values, perception of meeting patients’ needs, robust learning climate, compatibility with workflow, and positive attitudes and adequate knowledge about the clinical practice. On average, sites used 18 (range 11-22) strategies. Strategies to optimize the financial environment and train clinicians and staff were commonly used. Strategies to plan and evaluate implementation and to engage patients emerged as promising to address barriers to practice change, yet were often underused. Conclusions Implementation efforts in maternity settings may be more successful if they select strategies to optimize local conditions for success. Our findings elucidate key contextual conditions to target and provide a menu of promising implementation strategies for incorporating recommended contraceptive services into routine maternity practice. Additional prospective research should evaluate whether these strategies effectively optimize local conditions for successful implementation in a variety of settings.

Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services

“…11,18,21,22,50e53 ajog.org GYNECOLOGY Original Research programs found that sites utilized, on average, 18 distinct implementation strategies (range, 11e22). 18 Another study of 5 sites found that immediate postpartum LARC implementation efforts cost, on average, $14,433.94 (range, $9955.61e$23,690.49), with higher costs at sites with more barriers to implementation. 50 An implementation toolkit may help increase the efficiency and effectiveness of implementation efforts.…”

“…We previously conducted a qualitative multiple case study of immediate postpartum LARC implementation at 11 US early adopter hospitals, 18 ajog.org…”

“…Opinion leaders supportive of the initiative can strongly influence colleagues' perceptions and motivation to participate. Content based on findings in Moniz et al18 ; b All tools are publicly adapted from Michigan Contraceptive Access Project 10 ; c Adapted from University of California, San Francisco 47. Moniz et al Toolkit-based implementation of postpartum contraception care.…”

From Research to Practice in OBGYN: How to Critically Interpret Studies in Implementation

“…Example: Prior studies of the implementation of immediate postpartum longacting reversible contraception programs have utilized the CFIR, allowing researchers to identify key determinants of implementation success and explain variation in outcomes across sites. 24,25…”

“…For example, CFIR aids in systematically identifying factors that influence implementation including intervention characteristics, features of the implementing organization, and the external context under which the organization lives 21. When studies incorporate these frameworks, theories, or models into their work, there can be a more organized approach to implementation, and evaluation of the implementation effort can create generalizable knowledge to inform other sites undertaking similar efforts. Example : Prior studies of the implementation of immediate postpartum long-acting reversible contraception programs have utilized the CFIR, allowing researchers to identify key determinants of implementation success and explain variation in outcomes across sites 24,25 …”