Perceptions of Barriers and Facilitators During Implementation of a Complex Model of Group Prenatal Care in Six Urban Sites

Abstract

Group prenatal care improves perinatal outcomes, but implementing this complex model places substantial demands on settings designed for individual care. To describe perceived barriers and facilitators to implementing and sustaining Centering Pregnancy Plus (CP+) group prenatal care, 24 in-depth interviews were conducted with 22 clinicians, staff, administrators, and study personnel in six of the 14 sites of a randomized trial of the model. All sites served low-income, minority women. Sites for the present evaluation were selected for variation in location, study arm, and initial implementation response. Implementing CP+ was challenging in all sites, requiring substantial adaptations of clinical systems. All sites had barriers to meeting the model’s demands, but how sites responded to these barriers affected whether implementation thrived or struggled. Thriving sites had organizational cultures that supported innovation, champions who advocated for CP+, and staff who viewed logistical demands as manageable hurdles. Struggling sites had bureaucratic organizational structures and lacked buy-in and financial resources, and staff were overwhelmed by the model’s challenges. Findings suggested that implementing and sustaining health care innovation requires new practices and different ways of thinking, and health systems may not fully recognize the magnitude of change required. Consequently, evidence-based practices are modified or discontinued, and outcomes may differ from those in the original controlled studies. Before implementing new models of care, clinical settings should anticipate model demands and assess capacity for adapting to the disruptions of innovation.

A Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies

“…Sustaining a program like Mama Care requires the creation of a culture that values and normalizes the service being offered as well as redundancies in the team providing the service, so it is less vulnerable to staff turnover. These key findings from the implementation and maintenance of the Mama Care program corroborate similar findings from other settings where CenteringPregnancy and other forms of group prenatal care have been implemented both successfully and unsuccessfully …”

“…These key findings from the implementation and maintenance of the Mama Care program corroborate similar findings from other settings where CenteringPregnancy and other forms of group prenatal care have been implemented both successfully and unsuccessfully. [24][25][26][27] A recent study reviewed favorable outcomes using a similar adaptation of CenteringPregnancy in a population of Spanish-speaking women diagnosed with gestational diabetes. 28 The authors described a compressed 4-session schedule of groups with individuals enrolling in the late second or early third trimester of pregnancy, following a diagnosis of gestational diabetes.…”

“…Obstacles to implementation include financial constraints, scheduling difficulties, and insufficient enrollment. When successfully implemented, group prenatal care programs are often dependent on a few key champions and thus vulnerable in the context of staffing changes and turnover . Although a number of articles have described the use of CenteringPregnancy in caring for women with specific risk factors, to date, no publications have described the application of the CenteringPregnancy model to a population of women with pregnancies affected by a fetal anomaly.…”

Key Considerations for Implementing Group Prenatal Care: Lessons from 60 Practices

“…31,32 The findings of this study also concur with prior findings on practice-related barriers, including lack of appropriate meeting space and new scheduling and training needs, prenatal care provider and administrator buy-in, and reluctance to adopt new practices. 22 Addressing these barriers and providing group care requires a willingness to change paradigms and overcome interwoven challenges. Successful programs began with a leader's conviction, systematic approaches to addressing challenges, advocacy among prenatal care providers and consumers, and ongoing training, accompanied by ongoing provider and administrative buy-in.…”

“…Implementation, however, can be challenging as it requires practitioners and other clinic staff to rethink how care is provided and adjust practices accordingly. 21,22 This study investigated implementation of group prenatal care under the Strong Start for Mothers and Newborns Initiative: Enhanced Prenatal Models (Strong Start).…”