We conducted a descriptive qualitative study using focus group methodology. Focus groups typically comprise five to eight people who are like one another (e.g., in the same profession). Researchers use predetermined questions to collect a range of opinions in the form of qualitative data such as discussion recordings and transcripts (Krueger & Casey, 2015). Richard Krueger’s systematic analysis process guided our methods for conducting and analyzing the data from the focus groups (Krueger, n.d.). We collaborated with staff from the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), a professional society for nurses who care for women, newborns, and their families. Our team held two in-person focus groups at the June 2023 AWHONN annual convention in New Orleans, LA. We did not apply a theoretical framework to this exploratory set of focus groups given the formative evaluation design used to assess the primary perceptions of the unique target audience. The CDC reviewed this activity, and it was conducted consistent with applicable federal law and CDC policy 45 C.F.R. (Informed Consent, 1991)part 46 (Protection of Human Subjects, 2024), 21 C.F.R. part 56 (Informed Consent, 1991), 42 U.S.C. §241(d) (The Public Health Service Act, 2003), 5 U.S.C. §552a (The Privacy Act of 1974, 2020), and 44 U.S.C. §3501 (Paperwork Reduction Act, 2001).

AWHONN staff recruited participants through a cloud-based form builder. They posted a call for participants with a link to the builder on AWHONN’s Facebook, LinkedIn, and X (formally Twitter) accounts and to an internal member communication platform. The call was posted for a duration of 3 weeks. Requirements to sign up for the focus groups included the following: being a current AWHONN member, being registered for the 2023 convention, currently working in a labor and delivery setting, and having direct contact with patients during childbirth. Based on these requirements and low response rate, we did not exclude any registrants from the focus groups. Participation was voluntary, and we did not provide incentives.

AWHONN members answered a series of screening demographic questions, and we registered them in one of two focus groups based on preferred time. Both focus groups lasted approximately 45 minutes. A trained behavioral scientist (the third author, R.C.), who has served as the CDC lead for qualitative research for the National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) for more than 20 years, moderated the focus groups using a pool of nine prompts to conduct each session. The specific prompts varied by focus group based on the flow of discussion and were used to ascertain participants’ understanding of when and how to implement infection prevention and control practices, clarity and consistency of current recommendations, current training and resources available, and barriers they experienced while providing care. Participants provided verbal consent to be recorded before the start of the focus groups. Per determination by the CDC’s NCEZID Human Subjects Advisor, this qualitative assessment did not meet the definition of research under 45 C.F.R. 46.102(l) (Protection of Human Subjects, 2024), and institutional review board review was not required. The determination of the NCEZID also indicated that the project did not require submission to the CDC’s Human Research Protection Office because granting authority was delegated to the CDC Centers, Institutes, and Offices under internal CDC Policies SSA-2010–01 and SSA-2010–02.

We used Richard Krueger’s (n.d.) systematic analysis process for focus groups to structure our analytic approach, which involves iterative rounds of reflecting on the data. We began by listening for common topics during the focus groups, coded the data by each prompt, and then analyzed for convergent themes across all prompts (Krueger, n.d.). During the focus groups, our moderator (third author, R.C.) and assistant moderator (second author, K.W.) took notes on topics of potential interest that arose during the conversations, and the team discussed the notes in a debriefing after each focus group. We assessed topics of interest in real time based on the intensity of the participants, such as their tone of voice and specific words they used, which our labor and delivery subject matter expert (fourth author, K.P.) identified as possible priorities (Krueger, n.d.).

A team of three trained coders (first author, L.A., second author, K.W., and third author, R.C.) analyzed the data to ensure intercoder reliability and consistent application of codes. Each of the coders are master’s-trained public health practitioners with backgrounds in mixed-methods research and infection prevention and control with more than 40 combined years of experience. The first author (L.A.) manually transcribed the focus group recordings, deidentified all responses, and assigned each participant a unique identifier to track the number of participants coded under each theme. We used the qualitative software NVivo 13 (version 2020 R1) to perform our analysis. Our team began a first iteration of coding, in which we collectively read the responses organized by prompts and discussed potential codes until we achieved agreement. We developed a preliminary report of codes, and the labor and delivery subject matter expert (fourth author, K.P.) reviewed them to confirm contextual relevance. Once patterns of codes began to emerge from each prompt, we then coded again across all responses to isolate the most prominent themes that arose from all participants. We looked for convergence and divergence across these emerging themes. We used topic frequency and the extensiveness of the discussion (i.e., how many participants discussed a particular topic; Krueger, n.d.) to identify notable themes. We then reassessed the codes under additional context and insights gained through the data and organized them into five overarching themes.

Twenty-seven AWHONN convention attendees registered to participate, and 16 were present at the time of the focus groups (nine in Group A and seven in Group B). Most (94%) participants were registered nurses, and one (6%) was an advanced practice registered nurse. Participants had an average of 24 years of experience (SD = 11 years). Ten (63%) participants spent 50% to 100% of their time providing direct care to patients during labor and birth (e.g., labor management, vaginal birth, cesarean birth, immediate recovery after birth). Six (38%) participants spent 0% to 25% of their time providing direct care to patients during labor and birth. Several had leadership or infection prevention roles in labor and delivery. Eleven (69%) participants worked in teaching hospitals, two (13%) worked in public hospitals, two (13%) worked in private hospitals, and one (6%) worked in a nonteaching hospital. All participants practiced in the United States: 44% in the Northeast, 31% in the South, and 25% in the Midwest.

We identified five convergent themes and ordered them from greatest to least frequency based on the number of participants who expressed the thematic construct.

Our ability to generalize these findings to perinatal nurses and facilities across the United States is limited because of the small sample size and the use of a convenience sample. Furthermore, all responses were self-reported and subject to recall bias. Although participants were among their peers, responses may have been affected by group biases, such as social desirability.

In our previous focus groups, we collected first-hand accounts from physicians regarding their perceptions of barriers to the implementation of infection prevention and control practices. Our current report adds to the knowledge base regarding these barriers from a nurse perspective and provides a more comprehensive picture of clinical perspectives in this setting. Our nurse focus groups were limited to registered nurses, and including nurse-midwives and nursing assistants in future explorations could add additional insight. Garnering nonclinical perspectives (e.g., infection preventionists, medical epidemiologists, hospital administration, and environmental services) would also identify additional gaps and potential ways to address them.

Obstetric nurses can benefit from interventions that address the barriers we identified so that they can successfully implement infection prevention and control practices in routine and emergent childbirth care. Such interventions may include increased hands-on infection prevention and control training, education that reinforces fundamental concepts, and face-to-face in-services provided by the hospital infection prevention program. Additional interventions can involve improved relationships between the labor and delivery unit and the hospital infection prevention program, cultures in which nurses are comfortable asking questions about the rationale behind infection prevention and control practices, and advocacy to improve infection prevention and control resources for labor and delivery.

Identifying a nurse champion in the unit, who can build relationships with the hospital infection prevention program and act as a local resource for colleagues, may also help to better integrate infection prevention and control into the labor and delivery culture and workflow. Nurse champions can help guide specific unit goals so that appropriate practices are also included in trainings for other types of emergency obstetric care (e.g., ensuring education on appropriate personal protective equipment use when managing a postpartum hemorrhage and ensuring quick and ready access to personal protective equipment for precipitous vaginal birth). Unit leaders or nurse champions should also be empowered to educate hospital administration about the unique aspects of care provided in the labor and delivery setting and the need for infection prevention resources to be tailored and readily available for this area of the hospital. Obstetric nurses can play a critical role in shifting the culture of labor and delivery to make infection prevention and control a key part of providing quality obstetric care.