Tailoring Site-Specific Implementation Strategy Plans for a Cesarean Risk Calculator Trial: A Mixed-Methods Approach

Document Type

Conference Proceeding

Publication Date

5-20-2026

Publication Title

Implement Sci

Keywords

Health Care Sciences & Services

Abstract

Background: Our prior single-site study demonstrated that patient and clinician awareness of individualized patient cesarean risk, facilitated by a novel calculator, was associated with reductions in maternal morbidity and cesarean rates. To prepare for a 14-site stepped-wedge type I hybrid effectiveness-implementation trial of this calculator, we developed a multi-phase mixed-methods approach to create context-specific implementation strategy plans that center the opinions of front-line clinicians. Methods: Guided by CFIR 2.0 and the Implementation Research Logic Model, our embedded sequential mixed-methods study (QUAN- > QUAL; 8/2023–9/2024) systematically identified implementation determinants at 14 diverse labor and delivery sites to inform selection of ERIC strategies most likely to achieve successful local implementation. Strategies were categorized as “set” (required across sites), “optional” (potentially beneficial based on preliminary qualitative data), or “emergent” (responsive to newly identified site-specific barriers). First, we established site-based leadership teams (3–15 obstetricians, midwives, nurses, doulas, and patient/community partners). Next, pre-implementation clinician surveys across sites assessed barriers/facilitators, and perceived benefit/feasibility of four “optional” strategies: (1) preparing patients as active consumers (outpatient calculator discussion), (2) enhancing patient uptake (preliminary risk score outpatient), (3) electronic health record integration, and (4) visual aids for counseling. QUAN data were presented to site-based leadership teams to generate preliminary plans. These plans were refined, including the selection of emergent strategies, and finalized through clinician focus groups at each site. Findings: Frontline clinicians participated meaningfully across the survey (QUAN, n = 437) and focus groups (QUAL, 21 groups, n = 92). Cross-cutting barriers reported by clinicians included time constraints, buy-in, and competing priorities. Site-specific barriers also emerged, e.g. minimal physician/midwife presence on nurse-driven labor units for risk counseling. Perceived benefit/feasibility of the “optional” strategies varied across sites; leadership teams’ preliminary plans combined these ratings with personal judgement. Focus groups were crucial for finalizing plans and identifying “emergent” strategies, such as development of a direct-to-patient educational video for use at nurse-driven sites. Implications for D&I Research: This innovative methodology allowed development of 14 context-specific implementation strategy plans that center frontline perspectives prior to a national trial. Ongoing work will evaluate how these tailored plans impact calculator penetration and outcomes after trial completion, offering a scalable model for future multi-site implementation research.

Volume

21

Issue

SUPPL2

First Page

2

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