BACKGROUND:
Scaling up midwifery-led, evidence-based care to improve perinatal outcomes in low- and middle-income countries is a global priority. However, many implementation models are inaccessible to those with little implementation experience. In Blantyre District, Malawi, we adapted a 3-Step Implementation Plan to guide and scale up a midwifery-led Centering-based group antenatal care (ANC) model through an effectiveness-implementation trial (IRB #2018-0845; COMRECP.10/18/2498).

OBJECTIVES:
To describe our Group ANC implementation process and foundations for scale-up.

METHODS:
Our structured approach followed a 3-Step Implementation Plan with key strategies to build capacity for Group ANC. Guided by the RE-AIM and CFIR frameworks, we use multiple data sources (coordinator notes, fidelity, and benchmarks) to describe implementation success and sustaining

RESULTS:
Strategies included the 3-step implementation model, training and mentoring, support for clinical teams and meeting training costs. To prepare, 299 individuals from seven ANC clinics completed facilitator and mentor training workshops. During rollout (June 2019-March 2023), 84 ANC groups were completed with high fidelity. Those in Group ANC reported greater empowerment and satisfaction with ANC, uptake of health-promoting practices and improvements in mental health. During sustain, all seven clinics continued offering groups. The midwife mentors trained 103 more individuals, initiating expansion to six additional clinics. The Malawi Ministry of Health is integrating Group ANC into district-level trainings while exploring nationwide scale-up

CONCLUSIONS:
Midwives and pregnant women are increasingly embracing Group ANC because it meets expectations for a positive pregnancy experience. The 3-Step Implementation Plan was successful, effective, and built capacity to work toward national scale-up

KEY MESSAGE:
This initiative demonstrates that the 3-Step Implementation Plan and associated capacity-building strategies can help diverse clinics overcome challenges and maintain fidelity so that continuity of care, respect, and quality are high. This work provides a replicable framework for scaling similar interventions to advance midwife-led care models Approaches to care