Date of Award


Document Type

Open Access Dissertation


Health Promotion, Education and Behavior


The Norman J. Arnold School of Public Health

First Advisor

Edward A. Frongillo, Jr.


Background: Poor birth outcomes and racial disparities in birth outcomes in South Carolina are widely recognized problems. To improve maternal and child health outcomes, especially among vulnerable groups, universal access to timely, appropriate, and effective care should remain a priority through increased availability and accessibility. An interagency collaborative in South Carolina expanded CenteringPregnancy (CP) from two to five medical practices throughout the state. CenteringPregnancy is associated with improved birth outcomes and reduced rates of racial disparities in preterm birth throughout the United States. Important questions in the literature remain about strategies and determinants of scaling up sexual and reproductive health interventions and how scale up is managed over time. Methods: The aims of this mixed-methods process evaluation were to: 1) identify and describe the multi-level contextual elements that influence statewide scale-up of a health model; 2) identify the degree of completeness and fidelity that sites achieved during GPNC implementation; and 3) identify the system-level essential (core) strategies, settings, policies, and structures that facilitate or challenge formal scale-up of GPNC to the state level. The process evaluation involved the following data collection procedures: twenty-nine individual and group interviews with key stakeholders; three site observations of six to nine group prenatal care sessions with women; two surveys of group facilitators across sites; review of policies, meeting notes, and conference proceedings; and a media analysis of national and local CP coverage in newspapers, blogs, news websites, and press releases published from January 2013 – November 2014. Data analysis of qualitative data involved ongoing and inductive systematic coding and quantitative data involved calculating average scores. Results: Windows of opportunity emerged and were created at state and site levels throughout the scale-up process. Key decisions and actions at state and local levels occurred in ways that were consistent with stakeholder values. At the state level, strategic use of research demonstrating that CP improved birth outcomes as well as reduced racial disparities in outcomes, leveraged financial and political commitment to expanding statewide access to group prenatal care, especially among women enrolled in Medicaid. All five sites had high levels of fidelity, dose delivered, and dose received. Reach was low. Discussion: This was the first evaluation of how CP can be implemented within existing healthcare systems, and how to successfully move CP to scale. Motives, decisions, and actions of stakeholders were reflections of their values. Creation and use of opportunity windows that allowed stakeholders to pursue actions consistent with values was important to the early phases of intervention implementation and scale-up. Advancing these processes across complex health systems required strong political advocacy and support, interdisciplinary collaborations, and funding. Despite contextual challenges, successful GPNC implementation occurred at these five sites through state-level support and training, strong organizational advocacy, and site-level leadership and staff capacity. Successful CP expansion within existing complex health systems was possible when political will, financial support, and community engagement were created and utilized. Findings of this study lay the groundwork for future decisionmakers who are interested in expanding a new model of healthcare into diverse health systems to the state level in the US.


© 2015, Kristin M. Van De Griend