What influences the implementation of group antenatal care in English NHS maternity settings? Findings from a qualitative process evaluation integrated within a randomised controlled trial of Pregnancy Circles

Background: Despite universal and generally positive antenatal care in England, some poor experiences and outcomes are reported, especially by minoritised groups. The Pregnancy Circles trial set out to test whether group antenatal care could improve outcomes and experiences compared to traditional one-to-one care in ethnically and socio-economically diverse areas. This integrated process evaluation explored factors influencing implementation at system, organisational and individual levels. Methods: We explored the context and process of implementing Pregnancy Circles in 14 NHS Trusts using a case study design. Qualitative methods included: participant interviews in both arms focusing on those living with complexities (n = 36); interviews with midwives (n = 23) and stakeholders (n = 14); observations of group (n = 14) and traditional (n = 7) antenatal appointments. Data were coded thematically and mapped to the Consolidated Framework for Implementation Research to synthesize influences on implementation at different levels and explore the impact of innovation design and implementation processes. Fidelity was assessed in relation to Pregnancy Circles core values: relational, interactive, personalised, safe. Results: Pregnancy Circles were seen as a radical approach to improving relational care, health education and community support. The majority of participants and midwives preferred Circles to traditional care, including many with complex care pathways. Pregnancy Circles addressed unconscious bias by diversifying sources of information for participants and challenging midwives’ assumptions. Despite concordance with midwifery values and maternity policy, implementation was challenging, requiring leadership and change at organisational and individual level. Systemic and cultural factors in the outer and inner domains were more significant barriers than individual factors. The Covid-19 pandemic and local challenges (accessing venues; over-stretched services; unconscious bias) resulted in many participants not receiving a full ‘therapeutic dose’ of the intervention. Midwives’ initial anxiety about facilitating groups dissipated with training, continuity and experience. Conclusions: Pregnancy Circles’ alignment with midwifery values and maternity policy was both facilitative and challenging in the context of a medicalised maternity system. Participants preferred Pregnancy Circles to traditional care. Midwives require training, experience and support to adapt their practice. Planning and additional resources are required to address structural and cultural barriers. Further research is needed into long-term impact, scaling-up and sustainability.