A woman’s health in the interconception period has an impact on birth outcomes. Pediatric visits offer a unique opportunity to provide interconception care (ICC). Our aim was to screen and provide interconception and safe sleep screening, counseling, and interventions for 50% of caregivers of children <2 years of age in a pediatric medical setting.
Two pediatric clinics implemented the March of Dimes’ Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques (IMPLICIT) toolkit, in addition to standardized safe sleep assessments. A quality improvement learning collaborative was formed with a local “infant mortality champion” leading quality improvement efforts. Monthly webinars with the clinic teams reviewed project successes and challenges. Framework for Reporting Adaptations and Modifications was used to document adaptations.
For each individual IMPLICIT domain, clinics screened and provided needed interventions for ICC and safe sleep in >50% of eligible encounters. Over the course of the quality improvement learning collaborative, the number of caregivers screened for at least 4 of the 5 IMPLICIT domains increased from 0% to 95%.
To successfully implement the IMPLICIT toolkit in pediatrics, adaptations were made to the existing model, which had previously been used in family medicine clinics. Pediatricians should consider providing ICC as an innovative way to impact infant mortality rates in their community. Framework for Reporting Adaptations and Modifications can be used to systematically describe the adaptations needed to improve the fit of IMPLICIT in the pediatric clinic, understand the process of change and potential application to local context.
Interconception care (ICC) is defined as the care of a woman in between pregnancies, from the birth of 1 child to the conception of the next child. Like the preconception period, a woman’s health in the interconception period can have a tremendous impact on subsequent pregnancy and birth outcomes. However, many women do not receive regular medical care from a health care provider (HCP) during the postpartum period.1–3 Furthermore, access to maternal ICC is impacted by racial disparities.4
Pediatric visits offer an opportunity to reach mothers between their pregnancies. The majority of women accompany their child to pediatric visits, and visits occur frequently in the first years of a child’s life.5 Mothers may have risk factors for poor birth outcomes that are amenable to screening by pediatric providers, and a majority of women report that they would accept health advice from their child’s physician.6
The March of Dimes’ Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques (IMPLICIT) ICC model was developed within a network of academic family medicine practices in which ICC screening is completed for mothers during well child visits from birth through 24 months of age. These practices report success in both screening mothers and providing resources, if needed, in 4 domains: maternal depression, birth spacing plans, tobacco use, and folic acid use.6,7
Although some pediatricians advocate for a role in discussing future childbearing planning with mothers in the context of pediatric care,8 providing ICC during pediatric visits has been considered in only a small number of settings.9–11 In the Netherlands, researchers studied acceptability of providing ICC during childhood public health visits. In focus group interviews, pediatric HCPs appreciated the importance of ICC and recognized their role as an access point for women in between pregnancies.10 In a study examining the implementation of birth spacing screening in pediatric visits, researchers found that the screening was easy to perform but presented challenges such as concerns about time constraints, feeling ill prepared to discuss contraception with mothers and shifting the visit focus from child.9
Screening mothers for postpartum mood disorders during well child visits in the first year of life has been well accepted by families and pediatricians.12 Likewise, the American Academy of Pediatrics has endorsed screening all caregivers for tobacco use to decrease tobacco exposure in children, and pediatricians have successfully incorporated parental tobacco screening and treatment into clinical practice.13,14 In a study investigating the acceptability of maternal birth control counseling in the postpartum period, 95% of women reported that they were “very comfortable” discussing birth control at the pediatric visit.15 Although promoting folic acid use among mothers has not been routinely done in pediatric practices, the Centers for Disease Control and Prevention recommend all women of childbearing age consume 400 µg of folic acid daily to prevent birth defects.16
In this study, the IMPLICIT ICC model was implemented in 2 pediatric clinics serving a county with a high infant mortality rate17 through a quality improvement learning collaborative (QILC) adapted from the Institute for Healthcare Improvement’s Breakthrough Series.18 Because of the substantial contribution of sudden unexpected infant death to our region’s infant mortality rate,19 a fifth domain, safe sleep screening, was added in the QILC for infants <12 months of age. The project aim was to screen and provide counseling and needed interventions in at least 50% of eligible encounters as each domain was phased in during pediatric visits for children <24 months. We also aimed to screen and provide counseling and needed interventions for safe sleep at least 50% of the time for families of children <12 months.
Methods
Context
The quality improvement (QI) leadership team included a pediatrician (project leader) and a QI coach with support from a senior pediatric health services investigator and program manager. Two pediatric clinics within the target county were enrolled in the QILC: a small county public health department clinic and a general pediatrics clinic focused on infant growth and development (IGD). (See Table 1 for additional clinic information.)
Description of Participating Clinics
| Public Health Department Clinic | General Pediatrics IGD Clinic | |
|---|---|---|
| Primary clinic focus area | Preventive and sick care for children and adults <27 y of age | Infant growth and feeding clinic |
| Clinic medical team | 1 pediatrician, 1 family medicine physician, 1 nurse practitioner, 2 nurses, 2 medical assistants | 2 pediatricians, 1 nurse, 1 medical assistant, 1 speech therapist, 1 registered dietician, 1 social worker |
| Payment structure | $20 payment for all visits | Patients billed through insurance |
| Annual visits | 5677 | 415 |
| Insurance | 12% Private insurance | 31% Private insurance |
| 23% Medicaid | 68% Medicaid | |
| 65% Self-paya | 1% Self-pay | |
| Race and ethnicity | 14% White | 59% White |
| 72% African American | 18% African American | |
| 14% Hispanic/Latino | 10% Hispanic/Latino | |
| — | 8% Asian American | |
| — | 5% Unreported |
| Public Health Department Clinic | General Pediatrics IGD Clinic | |
|---|---|---|
| Primary clinic focus area | Preventive and sick care for children and adults <27 y of age | Infant growth and feeding clinic |
| Clinic medical team | 1 pediatrician, 1 family medicine physician, 1 nurse practitioner, 2 nurses, 2 medical assistants | 2 pediatricians, 1 nurse, 1 medical assistant, 1 speech therapist, 1 registered dietician, 1 social worker |
| Payment structure | $20 payment for all visits | Patients billed through insurance |
| Annual visits | 5677 | 415 |
| Insurance | 12% Private insurance | 31% Private insurance |
| 23% Medicaid | 68% Medicaid | |
| 65% Self-paya | 1% Self-pay | |
| Race and ethnicity | 14% White | 59% White |
| 72% African American | 18% African American | |
| 14% Hispanic/Latino | 10% Hispanic/Latino | |
| — | 8% Asian American | |
| — | 5% Unreported |
Description of demographics of the 2 clinics enrolled in the IMPLICIT ICC and safe sleep QILC. —, not applicable.
May have not reported insurance status given clinic payment model.
Intervention
The QI leadership team initially reviewed the IMPLICIT ICC toolkit,20 collated local resources, and developed a key driver diagram for the project (Fig 1). A 9-month QILC was formed and led by the QI leadership team. Each clinic established their own multidisciplinary team to work on implementation locally. At each site, an “infant mortality champion” (IMC) (a registered nurse or medical assistant) was selected to champion IMPLICIT. A $5000 stipend was provided to protect the time of the IMC. The IMC was expected to dedicate 4 hours per week to the project. As an additional incentive, physicians were eligible for maintenance of certification credit.
Key driver diagram. Key driver diagram for the implementation of IMPLICIT ICC and safe sleep screening and interventions in the pediatric setting.
Key driver diagram. Key driver diagram for the implementation of IMPLICIT ICC and safe sleep screening and interventions in the pediatric setting.
In January 2019, an in-person program kick-off meeting was held with the IMC and providers from clinic sites. During this 3-hour meeting, attendees learned about the local problem of infant mortality and how ICC can impact birth outcomes. The IMPLICIT ICC model was introduced in the context of QI methods. At the end of this meeting, the clinic teams created a process map for visits at their site.
IMPLICIT screening was put into practice through phased implementation. Through weekly site visits with the IMC, QI coach, and project leader, each clinic identified the domain of the IMPLICIT model that they wanted to implement first and began their small tests of change. The clinic team was given autonomy to choose the order of implementation, with the only guidance given to consider starting with “low-hanging fruit.” The IMC sought input from the multidisciplinary clinic team to determine ways to incorporate screening or interventions into the clinic workflow. Plan-do-study-act (PDSA) cycles were performed weekly, guided by data and feedback from clinic staff. Once 1 domain of the project was smoothly incorporated into the workflow and met the goal of >50% of eligible visits screened and intervened, the next domain was added.
After the first in-person meeting, monthly virtual webinars were held in which the IMC and providers from both clinics shared their current PDSA cycles, successes, and opportunities for improvement. Run charts from both clinics were displayed to enrich the discussion. During these webinars, the project leader shared QI concepts, in addition to any new research and resources pertaining to ICC and safe sleep. Clinics shared best practices and learned from each other’s experiences. Periodically, local celebrations were held to acknowledge each clinic’s hard work and dedication to reducing infant mortality.
The implementation period was to occur for 9 months in both clinics but was extended for 2 months in the pediatric IGD clinic given structural and organizational changes in the clinic, including relocation of the clinical site and changes in personnel. Two additional months of QI support was provided to ensure that the clinic had adequate time to implement the IMPLICIT model.
Study of the Intervention
Six weeks of retrospective baseline data collection were obtained through review of electronic medical records. Subsequently, data were collected weekly on a paper collection form and then entered by either the IMC or QI coach into the secure, web-based application Research Electronic Data Capture, which provides an interface for secure, validated data entry.21
Measures
Data were collected for process measures on the number of eligible visits, the number of visits with each domain of IMPLICIT screening performed, the number of screens requiring a resource, and the number of needed resources provided. A screen was defined as needing a resource if the screening question was “positive” in a specific domain. For example, a maternal tobacco screen was positive if a mother reported that she was using a tobacco product.
To determine the success of implementation of the IMPLICIT model as a whole, data were collected on the total number of screens performed at each eligible visit over the course of the project. We tracked all domains over time; however, we use 4 out of 5 domains as our outcome measure because caregivers of children >12 months of age were not eligible for safe sleep screening because of the child’s age.
Qualitative data were collected within each domain’s PDSA cycles to track decision-making, lessons learned, and adaptations to the original toolkit. We use the Framework for Reporting Adaptations and Modifications (FRAME), which allows for systematic reporting of changes made to the model.22 FRAME addresses the timing, planning, and level of modifications and adaptations, in addition to the reason, drivers, context, and nature of the change. FRAME also addresses whether modifications and adaptations are consistent with the fidelity of the model.
Analysis
Data were reported back to the clinics during site visits and QILC webinars. Percentages of eligible visits with screening performed were aggregated monthly by site and reported through line graphs created with Microsoft Excel. Data on the percentage of visits needing a resource and the percentage of needed resources provided were presented cumulatively to clinics in bar graphs. The percentage of caregivers with 4 or more screens performed were reported through a run chart at the conclusion of the project.
Ethical Considerations
The project was reviewed and designated an exempt QI project by the institutional review board that covered the university and both clinical sites.
Results
Throughout the course of data collection, our clinics reached a combined total of 429 mother/infant dyads. As each new domain was phased in, both clinics were able to implement and exceed the aim of screening >50% of encounters eligible for the added domain. Neither clinic was routinely screening for any of the domains of the IMPLICIT model before the QILC. Providers implemented each IMPLICIT domain in ∼4 to 8 weeks, from scripting screening questions to connecting with community based resources for interventions. Clinics were able to sustain high screening rates as further domains were added. An example of phased implementation of IMPLICIT and safe sleep screening in 1 clinical site is displayed in Fig 2. Over the course of the QILC, we increased the number of caregivers screened for at least 4 IMPLICIT domains from 0% to 95% (Fig 3). Furthermore, our data reveal that clinic providers were able to sustain screening in at least 4 IMPLICIT domains in 85% or more eligible visits over the last 4 months of the project.
Portion of eligible visits receiving screening in IMPLICIT domains, phased implementation with baseline and intervention data, in the public health clinic. Line graph displaying the phased implementation of interconception and safe sleep screening in the public health clinic. Number of eligible patients noted each month in parentheses.
Portion of eligible visits receiving screening in IMPLICIT domains, phased implementation with baseline and intervention data, in the public health clinic. Line graph displaying the phased implementation of interconception and safe sleep screening in the public health clinic. Number of eligible patients noted each month in parentheses.
Percentage of eligible visits receiving screening in 4 or 5 IMPLICIT domains, combined clinic sites. Run chart displaying the percentage of eligible patient encounters with 4 or 5 IMPLICIT screens performed by month. Aggregate data from both clinical sites are displayed.
Percentage of eligible visits receiving screening in 4 or 5 IMPLICIT domains, combined clinic sites. Run chart displaying the percentage of eligible patient encounters with 4 or 5 IMPLICIT screens performed by month. Aggregate data from both clinical sites are displayed.
Through IMPLICIT screening, many women were identified with interconception risk factors. When data from both sites are combined, 9% of women used tobacco products and 14% had a positive depression screen (Fig 4). Even more prevalent (55%) were women of childbearing age not taking folic acid supplementation. Sixty-nine percent of women who did not desire a pregnancy in the next 12 months were not using a long-acting reversible contraceptive. In addition, 16% of families with infants <12 months of age reported that they were not always placing their infant to sleep safely.
Percentage of positive caregiver screenings, combined clinic sites. Bar chart displaying the percentage of caregiver screenings with a positive result that required an intervention (counseling, resource or referral). Data combined for both clinic sites.
Percentage of positive caregiver screenings, combined clinic sites. Bar chart displaying the percentage of caregiver screenings with a positive result that required an intervention (counseling, resource or referral). Data combined for both clinic sites.
The pediatric clinics were able to successfully offer resources and referrals for interconception risk factors and safe sleep needs. Clinics were more successful at providing needed interventions in domains traditionally included in pediatric scope of practice (safe sleep and maternal depression) providing needed counseling, referrals, and resources in 90% of positive screens (Fig 5). Interventions were provided at a lower rate to mothers who needed an intervention for tobacco use (77%), folic acid use (74%), and birth spacing (67%). See Table 2 for a list of interventions used for each IMPLICIT domain.
Percentage of positive screenings that received an appropriate intervention, combined clinic sites. Bar chart displaying the percentage of positive screenings with provision of an appropriate intervention (counseling, resource or referral) for combined clinic sites.
Percentage of positive screenings that received an appropriate intervention, combined clinic sites. Bar chart displaying the percentage of positive screenings with provision of an appropriate intervention (counseling, resource or referral) for combined clinic sites.
Potential Clinic-Level Interventions provided for Positive IMPLICIT and Safe Sleep Screen by Domain Description of Potential Interventions Provided for Positive Interconception and Safe Sleep Screens in Participating Clinics
| IMPLICIT Screening Domain | Interventions Provided for Positive Screen |
|---|---|
| Safe sleep | Safe sleep counseling |
| Referral to crib distribution site | |
| Portable crib distributed at clinic | |
| Tobacco | Counseled about tobacco cessation |
| Referral to tobacco QuitLine | |
| Maternal depression | Referral to clinic social worker |
| Referral to postpartum mood disorder support group | |
| Referral to Postpartum Support International | |
| Recommended mother call her primary care provider | |
| Folic acid | Recommended folic acid use to mother |
| Birth spacing | Counseled mother about interpregnancy intervals |
| Recommended appointment with obstetrician or primary care physician to discuss contraception |
| IMPLICIT Screening Domain | Interventions Provided for Positive Screen |
|---|---|
| Safe sleep | Safe sleep counseling |
| Referral to crib distribution site | |
| Portable crib distributed at clinic | |
| Tobacco | Counseled about tobacco cessation |
| Referral to tobacco QuitLine | |
| Maternal depression | Referral to clinic social worker |
| Referral to postpartum mood disorder support group | |
| Referral to Postpartum Support International | |
| Recommended mother call her primary care provider | |
| Folic acid | Recommended folic acid use to mother |
| Birth spacing | Counseled mother about interpregnancy intervals |
| Recommended appointment with obstetrician or primary care physician to discuss contraception |
We used FRAME to document modifications made to the IMPLICIT model. In Table 3 we summarize adaptations and in the following paragraphs detail the 6 primary changes to the original model using standardized FRAME reporting.
Summary of Modifications Made to IMPLICIT ICC Model Using FRAME
| When Was the Modification Made? | Was the Modification Proactive or Reactive? | Who Determined the Modification Should be Made? | What was Modified? | At What Level of Delivery Was the Modification Made? | Nature of Content-Level Modifications | Is the Modification Fidelity Consistent? | Reason for Modification | |
|---|---|---|---|---|---|---|---|---|
| Change in context from family medicine clinic to pediatric clinic | Preimplementation | Proactive | QI team | Context | Cohort | — | Consistent | Increase reach |
| Addition of safe sleep screening to IMPLICIT model | Preimplementation | Proactive | QI team | Context | Cohort | Addition | Consistent | Improve fit with mission to address local infant mortality risk factors |
| Phased implementation of IMPLICIT model | Preimplementation | Proactive | QI team/clinic team | Context | Cohort | — | Consistent | Improve feasibility |
| Addition of IMPLICIT screening at all pediatric visits ≤24 mo | Implementation | Reactive | Clinic team | Context | Cohort | — | Consistent | Increase reach |
| Modification of tobacco screening question | Implementation | Proactive (result of PDSA cycle) | Clinic team | Content | Unit level (individual clinic) | Tailoring/ tweaking/ refining (minor) | Consistent | Improve fit with recipients |
| Addition of requesting maternal permission before birth spacing question | Implementation | Reactive | Clinic team | Content | Unit level (individual clinic) | Tailoring/ tweaking/ refining (minor) | Inconsistent | Provider level factors: provider preferences, experience. Recipient level factors: recipient comfort level, acceptance |
| When Was the Modification Made? | Was the Modification Proactive or Reactive? | Who Determined the Modification Should be Made? | What was Modified? | At What Level of Delivery Was the Modification Made? | Nature of Content-Level Modifications | Is the Modification Fidelity Consistent? | Reason for Modification | |
|---|---|---|---|---|---|---|---|---|
| Change in context from family medicine clinic to pediatric clinic | Preimplementation | Proactive | QI team | Context | Cohort | — | Consistent | Increase reach |
| Addition of safe sleep screening to IMPLICIT model | Preimplementation | Proactive | QI team | Context | Cohort | Addition | Consistent | Improve fit with mission to address local infant mortality risk factors |
| Phased implementation of IMPLICIT model | Preimplementation | Proactive | QI team/clinic team | Context | Cohort | — | Consistent | Improve feasibility |
| Addition of IMPLICIT screening at all pediatric visits ≤24 mo | Implementation | Reactive | Clinic team | Context | Cohort | — | Consistent | Increase reach |
| Modification of tobacco screening question | Implementation | Proactive (result of PDSA cycle) | Clinic team | Content | Unit level (individual clinic) | Tailoring/ tweaking/ refining (minor) | Consistent | Improve fit with recipients |
| Addition of requesting maternal permission before birth spacing question | Implementation | Reactive | Clinic team | Content | Unit level (individual clinic) | Tailoring/ tweaking/ refining (minor) | Inconsistent | Provider level factors: provider preferences, experience. Recipient level factors: recipient comfort level, acceptance |
Description of the modifications made to the March of Dimes’ IMPLICIT ICC toolkit to facilitation implementation in the pediatric setting by using the FRAME reporting tool. —, not applicable.
First, the preimplementation adaptation was a change in scope from family medicine to pediatric clinics. This adaptation was made proactively to determine if the IMPLICIT model could be implemented in pediatric practice settings. Because family medicine physicians provide care to adult patients, they may be more able and willing to screen for and address ICC concerns.
Second, the core domains of IMPLICIT were maintained with a proactive addition of safe sleep screening during the preimplementation phase. This addition was a fidelity-consistent modification that expanded the scope, because sudden unexpected infant death accounts for 1 out of every 6 infant deaths in the geographic area where the IMPLICIT ICC model was implemented.17
Third, implementing screening and referral of all 5 domains of our adapted model simultaneously could have overwhelmed the clinic staff. To improve the feasibility of implementation, clinics began by choosing 1 screening domain to start. Further domains were added once the previous domain had been implemented and met the 50% aim. This phased implementation was a modification to the process that was proactively planned in early, preimplementation meetings with the leadership team and IMC. This was a fidelity-consistent modification.
Fourth, within weeks of implementation, the clinic team recommended that IMPLICIT screening be expanded to all pediatric visits for children <24 months of age, rather than just well child visits. This was done to capture more mothers and infants during sick or problem-focused visits and to streamline and simplify the workflow for clinic staff. This was a reactive, unplanned change to the model with the purpose of increasing reach and improving feasibility. The modification preserved the IMPLICIT ICC toolkit content and was considered fidelity consistent.
Fifth, after tobacco screening was added into the workflow, clinic providers at the public health clinic noted that mothers were not identifying as “smokers.” Recognizing that this was inconsistent with local rates of tobacco use, the screening question was modified to be more comprehensive to all forms of tobacco use, including vaping and electronic cigarette use. This modification in screening was the result of a PDSA cycle in the clinic. Modifications driven by PDSA cycles are considered planned changes according to the FRAME model. This refinement occurred at the individual clinic level and maintained the fidelity of IMPLICIT.
Sixth, in the IGD clinic, providers expressed unease screening mothers for birth spacing plans. Pediatricians and nursing staff were concerned about offending mothers by asking about their future childbearing plans, particularly if the mother had struggled with infertility, premature birth, or poor birth outcome in the past. Ultimately, before inquiring about birth spacing plans, the clinic staff sought maternal permission to discuss family planning. This adaptation helped the clinic staff address a potentially sensitive topic. This tailoring of the screening question was a reactive change made at an individual clinic level. This modification is inconsistent with the IMPLICIT model, which is predicated on screening all mothers in the ICC domains.
Discussion
Implementing the IMPLICIT model into pediatric clinics allowed touchpoints with mothers to improve their health and the health of their next infant. We were also able to implement comprehensive screening and interventions for safe sleep practices. Success was enhanced by modifications made to the existing IMPLICT ICC toolkit.20 Decisions to adapt or modify an existing toolkit are complex and multifactorial,23 yet standardized formats to report such changes are rarely used. Reporting of adaptations using FRAME within the pediatric population has been done in the psychology literature,24–26 but we could find no examples within pediatric specific journals of the use of FRAME. The use of SQUIRE guidelines for developing and reporting QI projects can be further enhanced by a standardized framework of reporting adaptive changes when spreading QI efforts.
There were several “lessons learned.” Through this project, the QI team learned the importance of high fidelity adaptations with clinic and systems changes. The importance of having the whole team champion the work was highlighted because of staff turnover in the IGD clinic. It was important for everyone in the clinic to believe in the importance of the IMPLICIT model so that the project moved forward. The QI team also identified the need to have robust resources available for the clinics to use. By identifying resources and referral partners early, the clinic was able to confidently move forward with ICC screening. This addressed an initial barrier identified by the clinic of not having the time or resources available to intervene with a positive screening test. By creating a streamlined workflow for positive screens, mothers were able to receive needed support without disrupting clinic flow.
This implementation project has several limitations. We did not assess continuation of ICC and safe sleep screening after completion of the QILC. Therefore, we are unable to comment on program sustainment after QI support ceased. In addition, we did not have a priori specified balancing measures. Initially, the clinic teams expressed concerns that the project might interrupt patient flow. Throughout the implementation process, we checked informally with the teams and received feedback that staged implementation was efficient and did not inhibit clinic productivity. Finally, the goal of the IMPLICIT model is to improve birth outcomes through the reduction of preterm and low birth weight deliveries. Although our study reveals the feasibility of implementing interconception and safe sleep screening in the pediatric setting, we did not look at changes in future birth outcomes or infant mortality rate in families reached through IMPLICIT screening.
Conclusions
Pediatricians are a trusted resource for families and provide an important touchpoint for new mothers. This QILC reveals that it is feasible for pediatric offices to successfully provide ICC and safe sleep screening through the IMPLICIT model. Highlighting and implementing ICC screening by HCPs who do not traditionally care for mothers may have potential to decrease the risk for premature and low birth weight deliveries of their future patients and improve the health of the family unit as a whole.
We have demonstrated successful expansion of the IMPLICIT ICC model from family medicine to pediatric clinics. The specific adaptations were reported in a standardized format by using FRAME. In the future, the model may be expanded to settings outside of the medical home, including subspecialty clinics and inpatient units such as the NICU. In addition, future research could tie patient-level outcomes and infant mortality rates to provision of IMPLICIT screening.
FUNDING: Funded by March of Dimes, Indiana and Riley Children’s Foundation, Inc.
Dr Scott conceptualized and designed the study, coordinated and supervised data collection, conducted the initial analyses, and drafted the initial manuscript; Ms Casavan designed the study and coordinated and supervised data collection; Dr Swigonski conceptualized and designed the study; and all authors reviewed and revised the manuscript and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
- FRAME
Framework for Reporting Adaptations and Modifications
- HCP
health care provider
- ICC
interconception care
- IGD
infant growth and development
- IMC
infant mortality champion
- IMPLICIT
Interventions to Minimize Preterm and Low Birth Weight Infants Through Continuous Improvement Techniques
- QI
quality improvement
- QILC
quality improvement learning collaborative
- PDSA
plan-do-study-act
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