Barriers and enablers to the implementation of a perinatal care bundle: the Perinatal Excellence to Reduce Injury in Premature Birth project.

Background: Preterm birth is one of the most significant causes of child mortality and morbidity internationally. Although we have seen an overall reduction in neonatal mortality since 1990 there remains significant variation across the world. PERIPrem, is a care bundle that brings together 11 low-cost best-practice interventions for mothers and preterm babies. Through a structured and supportive implementation approach, using primarily Quality Improvement (QI) methodology, implementation of these evidence-based interventions has increased but remains varied across participating sites. Methods: This was a qualitative exploration of the barriers and enablers to implementation, and the behavior change techniques used to encourage adherence to the bundle, using semi-structured interviews. The COM-B model for behavior change was used as a framework for the interviews and the Theoretical Domains Framework and Behavior Change Techniques Taxonomy to guide the analysis. Results: Across two timepoints, 47 interviews were conducted with 29 staff from maternity, obstetrics and neonatology. The data revealed that capability, opportunity, and motivation functioned as both barriers and enablers to the implementation of the bundle. The qualitative interviews revealed that implementation was achieved through improvements in perinatal team culture, improving knowledge and skills, having strong leadership and access to the right resources. At its core, implementation depended upon having a care bundle that was evidence-based and a supportive and credible team. Implementation did not come without its challenges; notwithstanding the COVID-19 pandemic and the effects this had on staff, challenges included the complexity and size of the bundle, limited dedicated time and resources to enhance implementation, and the impact of hierarchical perinatal structures. These findings have provided insights that will advance our understanding about the processes that underpin successful implementation of a complex perinatal regional care bundle. Discussion: Several factors interacted to enhance as well as hinder the implementation of this complex perinatal care bundle. Over time, adherence to the PERIPrem bundle was enabled by the application of theoretically informed behavior change techniques. To improve future delivery of complex care bundles, like PERIPrem, the processes and support provided to aid implementation should reflect on how these barriers can be overcome and the enablers enhanced.