Barriers and Enablers to the Implementation of a Perinatal Care Bundle: The Perinatal Excellence to Reduce Injury in Premature Birth (PERIPrem) Project

Background: Preterm birth is the biggest cause of child mortality and morbidity in the UK and although we have seen an overall reduction in stillbirth and neonatal mortality in recent years there is still significant variation across the UK. PERIPrem, is a care bundle that brings together 11 best-practice interventions for mothers and preterm babies. A structured and supportive implementation approach using primarily Quality Improvement methodology has been found to significantly increase adherence to the whole bundle and its individual interventions. Methods: This was a qualitative exploration of the barriers and enablers to implementation and the behaviour change techniques used to encourage adherence to the bundle, using semi-structured interviews. The COM-B model for behaviour change was used as a framework for the interviews and the Theoretical Domains Framework and Behaviour 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 acted as both barriers and enablers to the implementation of the bundle. The qualitative interviews revealed that this was achieved through improvements in perinatal team culture, increasing knowledge and skills, having strong leadership and access to the right resources. But above all else 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 global pandemic and the effects this had on staff, challenges included the complexity and size of the bundle, limited dedicated time and resource, 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 care bundle. Conclusions: 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 behaviour 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.