Pregnancy-induced complications provide an opportunity to facilitate women’s engagement with primary health care services to promote health and reduce the burden of chronic disease in later life [1,2]. However, strategies for preventive interventions are lacking [3,4]. Supporting primary care services to enable this is a vital part of such health promotion endeavors [5,6]. Promoting population health and well-being throughout the life course is a critical global strategic objective, calling for an integrative, multisectoral approach [7]. Interdisciplinary postnatal care is acknowledged to influence short- and long-term health [1,8]. However, although the desirability of integrated health care is widely accepted throughout health policy, effective and sustainable implementation remains challenging [7,9,10].

Previous mixed methods Australian research [4,11-13] identified knowledge gaps of the long-term health risks following hypertensive disorders of pregnancy (HDP) among both women and their health care providers (HCPs). Among HCPs, knowledge gaps were identified in the classification, signs, and symptoms of various HDP and, specifically, the link between all HDP and increased cardiovascular disease and metabolic disorders in women and their children [4,13]. These findings cemented the necessity of addressing these gaps to improve long-term health outcomes for women following HDP [12,13].

The Society of Obstetric Medicine in Australia and New Zealand (SOMANZ) [14] has published recommendations to guide short- and long-term postpartum care after HDP. Addressing identified knowledge gaps and preferences of HCPs following HDP through a collaborative design of a post-HDP education and follow-up package (hereafter referred to as “the package”) may also contribute to improved early intervention for modifiable health risks following HDP. Addressing HCP preferences for content and delivery seeks to enhance clinical integration between tertiary maternity providers and primary health care practitioners, as well as facilitate ongoing counseling and management of health risks after HDP. This study provides a unique opportunity to translate research findings into clinical practice using implementation methodology. This evidence-based approach supports optimal health service design and improved preventive and primary health outcomes. Upon completion of this research, findings will further inform adjustments to existing resources to prepare the package for broader scale-up. This may also include insights for future development of such an approach for all pregnancies, particularly those affected by pregnancy complications with associated long-term health risks.

Through a collaborative design process, using earlier research findings, this protocol describes the design, development, and implementation of a targeted post-HDP education and follow-up package for HCPs. The TIDieR (Template for Intervention Description and Replication) and StaRI (Standards for Reporting Implementation Studies) checklist will be used to support replicability for health service quality improvement [15,16].

Separate complementary research is currently underway focused on addressing the educational preferences and follow-up needs of women after HDP [17]. However, we acknowledge that the women receiving care from participating general practitioners (GPs) and maternity care providers may also, by association, benefit from improved knowledge and follow-up care facilitated throughout the study. While not specifically assessed in this study, increased HCP knowledge has the potential to improve outcomes for women at risk and reduce the distress for a woman, her family, and the community in the event of an adverse cardiovascular event.

This study aims to (1) explore whether a post-HDP education and follow-up service package can be designed, developed, and implemented among targeted GPs and maternity hospitals across Sydney, Australia, and (2) evaluate whether the post-HDP education and follow-up package can address knowledge gaps among health care providers regarding the long-term health risk after HDP and build capacity among GPs to implement evidence-based care.

The objectives of this study are to design, develop, implement, and assess the efficacy, acceptability, and utility for health care providers of an evidence-based post-HDP education and follow-up package for women in the first 12 months following a hypertensive pregnancy (Table 1).

This study will utilize a multisite hybrid type 2 implementation study design [20,21]. A hybrid implementation study design acknowledges a dual focus to research to determine both clinical effectiveness and implementation strategies promoting accelerated research translation. This hybrid type 2 implementation study design aims to determine the effectiveness of an intervention pertaining to improved HCP knowledge and delivery of care after HDP, while also assessing the acceptability and utility of the implementation strategy (“the package”) [20,21]. Evaluation will be undertaken using mixed methods. Mixed methods evaluation is supported as an appropriate method for pragmatic research and implementation science. It facilitates a multidimensional lens to measure the drivers of implementation success and sustainability [22-24].

The study will be conducted in 3 phases: phase 1 (preimplementation), phase 2 (implementation), and phase 3 (postimplementation) (Figure 1).

The planned sample size consists of at least 10 GPs (n=10) employed in participating GP practices where implementation and evaluation of the package will occur. The planned sample size aims to provide sufficient numbers for testing the acceptability and utility of the package, and the potential for scale-up. In keeping with the pilot and implementation science nature of the study, no formal power calculation was done.

Key midwifery and obstetric staff at the linked maternity sites involved in care of women with HDP and/or GP antenatal shared care (ANSC) will also be interviewed (anticipated n=5‐10).

The study will specifically seek to include ANSC GPs from practices within the Central Eastern Sydney Primary Health Network (CESPHN) and their affiliated maternity care providers. With a reported 19,356 births within CESPHN in 2021, CESPHN covers a large and diverse population, providing services across approximately 590 km² [25]. The inclusion of ANSC GPs will promote a cohort engaged with women’s health throughout the perinatal period with already established relationships with maternity care providers. Furthermore, the diversity of the population combined with the locality of tertiary level maternity services within CESPHN is appropriate in the context of providing complex maternity care such as HDP.

The following eligibility criteria will be used for this study:

Expression of Interest process for CESPHN GP practices, including recruitment of GP representatives for the package co-design and study Steering Committee.

Recruitment of affiliated hospitals via targeted emails and meetings with relevant maternity service providers.

Ethical approval has been obtained from the appropriate Human Research Ethics Committees across 3 hospital sites in Sydney (2023/ETH00812 | X23-0281 & 2023/STE01377 | 2023/STE01378 | 2023/STE01379). Ethical ratification was also granted by the University of Technology Sydney (ETH23-8511) and University of New South Wales.

The study will be conducted as outlined throughout the approved study protocols associated with ethical approval. Written informed consent for all aspects of the study will be obtained from GP participants and from hospital providers for their participation in interviews. Women being cared for will not provide informed consent as post-HDP follow-up is recommended standard of care [14].

Extensive consultation will occur across each participating site (GPs and maternity hospitals) to ensure development of a context-appropriate intervention within the constraints of local operating procedures.

This flexible approach, adopting context-specific design, aligns with a realist approach to implementation science to promote sustainable and effective implementation [22]. This further aligns with the prior research undertaken by Roth et al [4] exploring health care provider preferences regarding education on long-term health after HDP.

The researcher (JG), along with site “champions” (nominated by site-specific representatives and principal investigators), will facilitate implementation support, including the development of educational resources and quick reference guide dissemination, in-service education, and face-to-face training with staff tasked with implementing the post-HDP package.

Sustained support will continue throughout the study period. This may include, but is not limited to, adapting implementation strategies, which will be documented according to the hybrid implementation study design.

Given the strong association between HDP and increased risk of chronic disease [30,36-39], the care provided throughout the perinatal period is vital for optimizing harm minimization through targeted education and primary health promotive strategies [30,39-41]. As highlighted previously, complementary research is currently underway focused on addressing educational preferences and follow-up needs of women after HDP [17]. To our knowledge, this is the first implementation of a co-designed targeted post-HDP education and follow-up package in Australia aimed at addressing knowledge gaps and enhancing capacity among HCPs to support care after HDP.

A recent publication by Slater et al [42] provides evidence to support our multidisciplinary co-design approach for targeted interventions to improve the uptake of evidence-based care after HDP. It also demonstrates demand for this research in the context of improving primary care management post HDP more broadly. Additionally, although not HDP-specific, MacKay et al [43] developed a complex health system intervention for improving systems of care in the context of hyperglycemia. MacKay et al [43] used implementation frameworks to support sustainable implementation in the Northern Territory and Far North Queensland. This research further supports our methodological approach to implementing a multifaceted post-HDP education and follow-up package in Australia’s complex health system.

Current Australian postnatal transitions of care following pregnancy are inadequate, highlighting the lack of appropriate handover between services as a barrier to the uptake of recommended follow-up care [18]. This research is therefore timely in the context of the integrated care landscape in Australia.

The research aims to bridge an identified practice gap by enhancing knowledge and improving health care systems to promote uptake of contemporary evidence-based care guidelines. Adopting a collaborative and evidence-informed approach in consultation with health care providers (the end-users) is a key strength of the study. Although the focus on metropolitan Sydney may limit the generalizability, the multisite design will provide valuable context-specific insights for future scale-up.

The planned sample size of GPs (n=10) and HCPs (n=5‐10) is appropriate for the pilot study design. However, the small sample size limits statistical power and generalizability. Furthermore, the targeted recruitment of ANSC GPs likely favors early adopters. However, the complexities of health system design provide challenges for implementing meaningful system change. Therefore, meaningful and sustained engagement is essential for providing insight to inform evidence-based strategies for future scale-up.

Furthermore, the study period may limit the ability to influence permanent digital health solutions (follow-up intervention) due to lengthy approval processes. However, the use of evidence-based methodological implementation and reporting frameworks will promote replicable and robust results to influence policy and practice.

This pilot implementation study will determine whether a post-HDP education and follow-up service package can be designed, developed, and implemented among GPs and maternity hospitals across Sydney. The findings of this research will provide an opportunity to influence contemporary development of effective post-HDP communication strategies, thereby improving the transition of care between tertiary and primary care services, and informing future implementation at scale.