Understanding enablers and barriers to implementing the Safer Baby Bundle: a mixed-methods study with site leads

The Australian Safer Baby Bundle (SBB) consists of five elements (smoking cessation, fetal growth restriction, decreased fetal movements, maternal side sleeping and decision making around timing of birth) which aim to reduce stillbirth and improve antenatal care. Queensland (QLD), New South Wales (NSW), and Victoria (VIC) were the first states to implement the SBB, laying the foundation for its national rollout. This study explores site leads’ experiences integrating the SBB into routine care. A mixed-methods study was conducted using surveys and interviews with site leads following SBB implementation across maternity services in QLD, NSW and VIC. Quantitative data were analysed descriptively, qualitative data underwent inductive and deductive thematic analysis, guided by Normalisation Process Theory (NPT) to identify implementation barriers and enablers. In 2022, 45 site leads completed surveys, and 20 were interviewed. From surveys, most reported strong endorsement of the SBB from hospital leadership (81%) and opinion leaders (73%). However, only 32% felt their service was adequately resourced, and just 17% believed teams had enough time for Quality Improvement (QI) activities. Only two of five SBB elements, decreased fetal movements (93%) and maternal side sleeping (82%), were reliably implemented across sites. Other elements showed moderate uptake, with smoking cessation (47%) achieving the lowest fidelity. From interviews, five themes were identified as barriers and enablers to implementing and sustaining the SBB in routine practice: (1) nationally consistent resources and training; (2) navigating QI readiness and capacity; (3) collaborative change; (4) service capacity to make recommendations operational; and (5) capability to access data and track progress. Mapping to the four NPT constructs revealed key drivers of SBB implementation: coherence (understanding the approach), cognitive participation (engagement), collective action (operationalising change through relationships) and reflexive monitoring (assessing and adapting). SBB implementation was supported by strong leadership endorsement but challenged by limited resources, time for QI, and the exacerbating effects of the COVID-19 pandemic. Reliable integration of key elements varied across sites, shaped by consistent training, service capacity, collaborative approaches, and access to data. These findings underscore the need for tailored support and resilient infrastructure to embed and sustain evidence-based antenatal care practices at scale. The Safer Baby Bundle Study was retrospectively registered on the Australian New Zealand Clinical Trials Registry database, ACTRN12619001777189, date assigned 16/12/2019.