Clinical care team perspectives on universal low‐dose aspirin in pregnancy

Abstract

Objective

To assess clinical care team perceptions of universal low‐dose aspirin (LDA) in a prenatal care clinic serving patients of low socioeconomic status.

Methods

This was a theory‐based rigorous qualitative study of clinical care team members in an urban, tertiary care center prenatal clinic. Participants were recruited between April and July 2023 and participated in focus groups. Focus groups employed a semi‐structured guide using the Consolidated Framework for Implementation Research (CFIR).

Results

A total of 25 care team members met for 19–36 min, of which the majority (n = 10, 40%) were obstetrics and gynecology resident providers. Participants generally responded favorably to the idea of a universal prescription system, though some cited concerns regarding health equity and LDA adherence with a universal protocol. Multiple barriers to both prescribing and taking LDA were identified, including educational deficits, language barriers, and issues with transportation and cost. Consistent communication, optimization of workflow, and iterative educational material development were suggested to improve prescription and adherence of LDA.

Conclusion

Care team members serving prenatal patients of low socioeconomic status are open to universal prescription of LDA in pregnancy, though important barriers to provider and patient knowledge and workflow must be addressed to result in successful quality improvement initiatives.

1. INTRODUCTION

Pregnancy‐induced hypertension is a leading cause of pregnancy‐related morbidity and mortality. Low‐dose aspirin (LDA, e.g., 81 mg) significantly decreases the risk of preeclampsia, particularly when initiated prior to 16 weeks’ gestation [1, 2, 3]. Additional significant but inconsistent findings have shown a decrease in other adverse pregnancy outcomes, including fetal growth restriction and preterm birth [1, 2, 4]. Both the American College of Obstetricians and Gynecologists (ACOG) and the United States Preventive Services Task Force (USPSTF) recommend initiation of LDA between 12‐ and 28‐weeks’ gestation for patients with two moderate or one high‐risk condition [5, 6].

However, the provision of LDA as recommended has proven difficult [7, 8]. The Society for Maternal‐Fetal Medicine (SMFM) identified this “quality gap” in 2023, stating that less than half of patients with high‐risk factors use LDA in pregnancy [9]. Additionally, patients of color and of low socioeconomic status are disproportionately impacted by preeclampsia and are less likely to take aspirin even when prescribed [10, 11]. Given this, both ACOG and USPSTF recommend consideration of LDA use for patients of Black race or low socioeconomic status, as a proxy for discrimination and societal inequities [6, 12].

Implementation of risk factor–based medication recommendations is limited by provider recognition of who is eligible [13]. We sought to mitigate these risks through the implementation of a universal aspirin initiative in a clinic serving patients of low socioeconomic status who would inherently qualify for LDA. During the pre‐implementation phase of this study and using a rigorously developed implementation science framework, we evaluated clinical care team perspectives on universal LDA, as well as perceived barriers and facilitators to LDA use in pregnancy.

2. METHODS

This qualitative study sought to explore care team member perspectives of LDA provision in an urban, tertiary care center prenatal clinic serving patients of low socioeconomic status. Institutional Review Board approval was obtained, and all Standards for Reporting Qualitative Research (SQRQ) guidelines were met in the undertaking of this study [14]. Clinical team members were eligible if they worked in the clinic in any patient‐facing capacity: as a medical assistant, nurse, resident physician, fellow physician, or attending physician. Participants were recruited for participation between April and July 2023. Participants were consented and five focus groups were conducted using video telecommunication. Groups varied in size based on availability, ranging from three to eight participants per group. They were arranged by training level and specialty (e.g., attendings, trainees, nurses), except for one attending who participated in a trainee group due to scheduling conflicts and the clinic medical assistant who participated with the nursing team. Focus groups were moderated by the primary investigator (RR, a maternal‐fetal medicine fellow) and incorporated a semi‐structured focus group guide using the Consolidated Framework for Implementation Research (CFIR), one of the most highly cited determinant frameworks, which utilizes contextual factors to prospectively guide implementation planning and strategies (Table 1) [15]. The primary investigator and moderator, a cisgender white female, was a provider in the clinic and interfaced with most participants during regular clinical duties. Participants were also asked for feedback on educational material that had been crafted after initial patient interviews (see the Supporting Information). Results of the patient‐facing qualitative data have been published previously [16].

TABLE 1.

Semi‐structured focus group content.

Consolidated framework for implementation research themes	Example topics
Intervention characteristics	Current prescribing practice, existing evidence for universal aspirin
Inner setting	Practice culture, necessary changes to clinic processes and space
Outer setting	Perceived barriers to aspirin adherence, perceptions of other care team members
Characteristics of individuals	Current aspirin prescription practice, beliefs on universal policy
Process	Policy change champions, necessary materials and resources, communication plan

Focus groups were manually transcribed by the primary author (RR) and coded by the primary author and research assistants (JL and MW) using Dedoose (www.dedoose.com), a secure data management and qualitative analysis software. Themes and subthemes were framed within the CFIR; a priori, we performed a deductive thematic analysis and supplemented our analysis with inductive coding as new themes emerged to reflect the richness and nuances of the data [17]. Content was analyzed using the constant comparative method, whereby researchers iteratively review individual transcripts, then compare transcripts and revisit them until salient themes emerge [17, 18, 19]. Focus groups were conducted until a subjective assessment of thematic saturation was achieved. A codebook was developed with the primary author and two research assistants. The first two focus groups were coded individually, and then as a team. Using this codebook, the next three focus groups were coded independently, and then iteratively as a research assistant group. Finally, the primary author reviewed each focus group's results and provided arbitration as needed. Iterative coding continued until thematic saturation was achieved.

3. RESULTS

A total of 25 clinical team members met in focus groups for 19–36 min, of which the majority (n = 10, 40%) were obstetrics and gynecology resident providers (Table 2). Other providers included attending maternal‐fetal medicine providers, obstetrics and gynecology generalist attendings, and maternal‐fetal medicine fellows. All clinic nurses and the only clinic medical assistant participated. Most (n = 16, 64%) had worked in the clinic between 1 and 5 years, with nearly one‐fourth of participants having been at the clinic for over a decade. Themes and subthemes across all CFIR domains were elucidated (Figure 1). Frequent themes, subthemes, and representative quotations are shown in Table 3. Many themes emerged from pre‐existing CFIR constructs, which were integrated into the questions.

TABLE 2.

Characteristics of clinical care team participants.

Characteristics of clinical care team participants (n = 25)
	Overall no. (%)
Job Category
MFM Attending Physician	6 (24)
Ob/Gyn Generalist Physician	3 (12)
MFM Fellow Physician	2 (8)
Ob/Gyn Resident Physician	10 (40)
Clinic Nurse	3 (12)
Clinic Medical Assistant	1 (4)
Years in Clinic
<1	1 (4)
1–5	16 (64)
5–10	2 (8)
10+	6 (24)

FIGURE 1.

Using Consolidated Framework for Implementation Research constructs to map care team perspectives.

TABLE 3.

Provider perspectives on universal aspirin with selected quotations.

Provider perspectives on universal aspirin
CFIR domain	Theme	Subtheme	Exemplary quotations
Intervention characteristics	Educational Needs	Patient education	“I think honestly developing materials that are iterative through an iterative process using patients to understand their own barriers and what messages they need to hear in order to make these decisions otherwise we're just guessing”
		Provider education	"I as a as a nurse need to be educated first just so I can present what I know and if I can say confidently ‘research shows that this is beneficial to all women who are pregnant’"
	Relative advantage	Addresses ineffective screening	“I think that increases the chance that patients aren't going to get missed aspirin prescribing, they're going to be more likely to take it because every single patient is getting it.”
		Most qualify regardless	“I think it ends up being a lot of patients in general because the list of risk factors that it can help with I know has just gotten lengthier over the past couple of years”
		Non‐judgmental	“They're going to be more likely to take it because every single patient is getting it. This isn't like ‘this is a stigma of me being high risk, of me being obese, of me having hypertension’ this is just like something everyone gets.”
		Universal is “better”	“I think that from a quality perspective whenever we do something universally, we do it better. It just changes culture and everyone … from both patients and providers we tend to be more consistent and not miss people and it's something that people start to accept as something we do”
	Relative disadvantage	Concern for non‐adherence	“I think the absolute number of people would increase since we would be prescribing it to everyone, but I don't know if necessarily the like proportion of patients would increase.”
Inner Setting	Barriers to prescribing	Competing priorities	“Some of our low risk …patients are coming from outside clinics and are transferring care. And at the beginning, like 12 to 16 weeks or so, when you are in clinic trying to accumulate records and organize your thought process…it can be hard to think about the low dose aspirin”
	Leveraging key stakeholders	Communication challenges	“I don't see any practice updates come through from like my Outlook or anywhere and when I proctor it's based on my own understanding of evidence‐based medicine”
		Need for “buy‐in”	“I think having buy‐in from our nurses is going to be really important to too since they do kind of most consistently spend time in the clinic. And know our patients kind of on a long more longitudinal basis”
		Readiness for change	“I think that a lot of us are still trying to figure out our practice styles and we can take some of the you know new things that are implemented and either take those to different sites or take those to our future practice. So, I think it's a great place for us to learn about new, you know, evidence and new policies and procedures”
		Resource availability	“I think small, just like anything, small changes in policy that don't require personnel to change their schedules, don't require structural change– I think it's easier than say adding‐ I don't know—an NST for a diabetic. I mean I think that when we have to make changes that really impact schedules and impact the actual operation of the clinic it's much more difficult.”
	Optimizing existing resources	Medication list	“As part of the intake we are always asking their current medications. If they have aspirin prescribed and they're not taking it, we usually bring it to the attention of the doctors”
		Multiple safety checkpoints	“The patients are seen again at the 20‐week ultrasound in addition to whatever other prenatal visits may happen, so I think there's lots of opportunities too for someone to think about giving aspirin and if it was missed on first go round there are – there's sort of a safety net in place for those participants in the clinic.”
		Problem list	“Problem lists are set up, where I feel like they've done –over time, a good set up to help in an environment where multiple different, yeah, providers are going to be caring for a patient ”
Outer Setting	Barriers to obtaining medication	Insurance/cost	“I don't know if aspirin is covered by insurance or not. But if it's over the counter then cost, although it's not that expensive, but cost for our patients in the clinic may be a barrier as well"
		Language barriers	“English may not be their first language, because aspirin is an over the counter medicine we have patients that may have family members that are taking full dose aspirin, or different doses of aspirin”
		Pharmacy barriers	“I've definitely heard stories of people getting it from the pharmacy and the pharmacist says ‘oh you shouldn't take aspirin when you're pregnant’ and then they get nervous about that.”
		Transportation barriers	“Sometimes the patients in the clinic will have transportation assistance to the clinic but they don't always have assistance when going from the clinic to the pharmacy or somewhere to get their prescriptions.”
	Barriers to adherence	Daily burden	“Taking a medication every day is burdensome, which I've found a lot of my patients say. Like it's just sometimes, some days I forget it and you know, I'm so busy and maybe that happens for five days straight, you know… Because it is difficult to remember to take a medication every single day.”
		Poor health literacy	“Some patients who just didn't understand why they were prescribed and they weren't taking it. And often I find those patients in like the third trimester and no one like just no one had asked them if they understood why it was important or why it was prescribed.”
Characteristics of Individuals	Patient perspectives	Safety concerns	“There's this thought that goes frequently that you know medications in pregnancy are not safe, always check with your doctor”
		Acceptability	“I think they'd be more likely to accept it if it's given in that way. Uh as that this is our standard”
		Trust	“I think it's nurses have been more schooled to make sure people feel comfortable in our environment and you know we're talking about relaxing while they do their blood pressure, we're asking them how they are, we're kind of getting a warm up conversation going so that by the time we get to medications um, you know, if they, if they say no I'm not taking that aspirin because whatever you know that's a good alert for us.”
		Value	“People have a lot of other things on their To Do List, and if they're not clear why that's important sometimes it just doesn't get activated”
	Acceptability	Official guidelines	“I am always a little uncomfortable with making recommendations that are either outside of um evidence from like a randomized control trial or outside of an ACOG or SMFM guideline”
		Openness to change	“My personal opinion is that it's a very low risk medication with potentially high benefit.”
Process	Communication plan	United messaging	“The bigger issue is trying to disseminate that information to everyone and get everyone on the same page since it's not a true continuity clinic where you see the same patients over and over again. Typically, the way that that information is distributed is via e‐mail.”
	Patient driven education	Early introduction	“Maybe even including information on it in their initial prenatal visit paperwork, so they're primed beforehand that this is something that will come up in discussion later on and that they may be prescribed.”
		Readability	“You can use on Word… the reading level and then keep making adjustments until you get down to I would suggest a 6th grade reading level.”
	Workflow optimization	Assessing adherence	“I think we should mention it if it's been prescribed, and they've already initiated we can do the follow up checking on ‘are you taking it’ and ‘do you have any more questions about that?’”
		Electronic medical record	“This could be incorporated into the problem list, the preexisting HROB problem list so it's already there. I think putting it there is pretty um helpful because it's like it's a premade thing you're gonna look at it all the time and see it.”

3.1. Intervention characteristics

Intervention characteristics are essential aspects that influence the adoption of a clinical change [20]. Three salient themes emerged through the focus groups: relative advantage, relative disadvantage, and educational needs.

Relative advantage was the perception of the benefit of initiating universal LDA versus the current risk‐based system. Advantages of a universal screening program centered on improving screening and decreasing judgment. In terms of improving screening quality, clinical team members focused on a universal protocol's ability to address ineffective screening among patients who would likely qualify regardless under the risk‐based method. One participant stated: “I think sometimes especially in more complex patients … sometimes I know I've missed asking about compliance with aspirin…so, if it's something that's more universal for everybody I think it may be more readily like on our checklist of things to kind of keep track of.” Other care team members commented that a universal program would not only improve effectiveness, but also decrease stigma around having a high‐risk issue. One stated that this could lead to improved adherence as well: “They're going to be more likely to take it because every single patient is getting it. This isn't like ‘this is a stigma of me being high risk, of me being obese, of me having hypertension’ this is just like something everyone gets.”

In terms of relative disadvantage, there was a concern for non‐adherence and, paradoxically, increasing disparities with a universal system. The concern for non‐adherence centered on the idea that although the absolute number of patients prescribed LDA would increase, the proportion taking the medication would not. This was echoed in concerns that universal LDA would deemphasize physician counseling: “I feel like we might be increasing the disparity between those who are a little bit more health literate than those who are not and then the ones who actually might need it or the ones that are a little bit more high risk still might not be taking the aspirin.”

Clinical team members had common suggestions for how to optimize LDA use through educational needs for both providers and patients. This included ideas such as patient‐facing materials and provider‐directed information tailored to different kinds of clinicians. Regarding patient education, an emphasis on patient‐led materials emerged. One participant suggested: “I think honestly developing materials that are iterative through an iterative process using patients to understand their own barriers and what messages they need to hear in order to make these decisions – otherwise we're just guessing.”

3.2. Inner setting

The inner setting is the physical and cultural place where the intervention occurs [15]. Three themes emerged in the inner setting: barriers to prescribing, leveraging key stakeholders, and optimizing existing resources. For the universal LDA program, this involved understanding the current practice culture and issues that might arise, which would preclude the successful implementation of this change.

Barriers to prescribing centered on issues of competing priorities, or the notion that in trying to contend with the multitude of complex aspects of pregnancy care, LDA might not be a top priority. This appeared to be moderated by training level (i.e., a participant endorsing that a first‐year resident might be more likely to experience this when compared to trainees later in residency or fellowship) and care transitions (e.g., a patient transfers from an outside clinic), as the latter requires incorporation of outside medical records and building patient rapport, which may increase the complexity of patient care. One participant stated: “Some of our low risk … patients are coming from outside clinics and are transferring care. And at the beginning, like 12 to 16 weeks or so, when you are in clinic trying to accumulate records and organize your thought process…it can be hard to think about the low‐dose aspirin.”

Focus groups elucidated thoughts on how the clinic culture would optimize the rollout of a universal aspirin program. A major theme that emerged through these discussions was the importance of leveraging key stakeholders. This centered on engaging trainees who often lead clinical management in this clinic. One trainee stated this as an advantage: “The attendings we work with are always very open to actually learn from us too on like newest evidence‐based practices, so I don't think there would be push back.” Additionally, participants emphasized the importance of staff buy‐in, particularly around nurse clinicians, who have the most consistent relationship with the patients, as the medical trainees rotate in and out of the clinic. Participants cautioned on implementing any changes without having clear communication with relevant providers as well as an emphasis on changes that could be accomplished without requiring significantly increased use of clinic or staff resources.

Finally, an emphasis on optimizing existing resources to meet the needs of the intervention was elucidated. These often centered on features of the electronic medical record system, including medication list management and “problem list” use for communication between multiple providers. Additionally, clinical team members encouraged multiple opportunities for “check‐ins” to capture those patients who may have been missed, stating: “I think there's lots of opportunities to for someone to think about giving aspirin and if it was missed on first go round there are – there's sort of a safety net in place for those participants in the clinic.”

3.3. Outer setting

The outer setting is a macro‐level look at the environment surrounding the clinic (i.e., larger hospital system, community, state) and its influence on the intervention [15]. Conversations on the outer setting emerged centrally around two themes—barriers to obtaining LDA and barriers to adherence.

Regarding barriers to obtaining medication, participants often cited patient experiences based on concerns that had been raised in clinic. Among these were systemic barriers influenced by a patient's socioeconomic and educational status, including issues with transportation, insurance, cost, and language barriers. One participant astutely recognized that the “over the counter” availability of LDA might limit patients’ ability to obtain it, despite its relatively low cost. Further, the designation of LDA as something that doesn't necessarily require a prescription can be problematic. One team member stated, for example, that “Sometimes it's not prescription…they say just go get it over the counter and that, I think, is also a barrier that patients may feel a little intimidated – they can't remember what they're supposed to be asking for, they have to go get it and make that happen.” Language barriers were perceived to contribute to the inability to obtain the correct medication and the correct dose. One participant stated: “English may not be their first language, because aspirin is an over‐the‐counter medicine we have patients that may have family members that are taking full dose aspirin, or different doses of aspirin.”

The other theme that emerged in discussions of the patient's lived experiences outside of clinic was barriers to adherence. This often centered on poor health literacy and the cumulative burden of other health or social issues that may impact adherence. One participant stated: “Taking a medication every day is burdensome, which I've found a lot of my patients say. Like it's just sometimes, some days I forget it and you know, I'm so busy and maybe that happens for five days straight, you know… Because it is difficult to remember to take a medication every single day.”

3.4. Characteristics of individuals

Characteristics of individuals included discussions that centered on who this intervention will impact and how their attitudes toward universal LDA would influence its success. The two major themes within this domain were patient perspectives and acceptability.

Participants noted that distinct patient perspectives served as barriers and facilitators to aspirin adherence. Facilitators included acceptability of LDA prescription as the standard of care and feeling a sense of trust in providers. Barriers on the patient side included concerns with safety and a lack of perceived value in LDA use. For example, one participant stated: “they're worried that maybe they've been told don't take medications in pregnancy [and that taking] medications in pregnancy is dangerous.” Value judgments were noted to be essential in an individual's decision of whether to engage in taking the medication regularly. One participant stated simply: “People have a lot of other things on their to do list, and if they're not clear why that's important sometimes it just doesn't get activated.”

The other theme noted was acceptability, which emerged as a key concept of whether individual team members would be willing to incorporate universal aspirin into their practice. This hinged on two major subthemes of being open to change and fears of going against guidelines. Most participants indicated that they would be open to the idea of universal LDA. One stated, “if there's sound reasoning behind the change, I feel like everybody is very on board.” However, some team members felt cautious about changing from a risk‐based to a universal protocol. One maternal‐fetal medicine provider stated: “I am always a little uncomfortable with making recommendations that are either outside of, um, evidence from like a randomized control trial or outside of an ACOG or SMFM guideline.”

3.5. Process

The final CFIR domain that was explored was the implementation process, or how a universal aspirin program would get operationalized for success. Three themes emerged in this domain, including the importance of developing a communication plan, optimizing workflow, and creating patient‐driven materials.

The first theme of crafting a communication plan emerged among many participants as essential to an effective implementation. Components of a communication plan included highlighting “project champions” to motivate programmatic fulfillment, as well as united messaging and iterative feedback throughout the intervention cycle. Most clinical team members noted that trainees and nurses are most consistent in the clinic and would be ideal project champions, although some noted that attending participation would be essential for setting expectations.

Workflow optimization centered on ways to assess LDA prescription and adherence without creating notably increased workload, and ways to optimize the electronic medical record through checklists and standardized phrases to facilitate reminders and incorporate universal LDA into the clinic. Specifically, participants mentioned the importance of medication reconciliation and updating the problem list to ensure multiple opportunities to address prescription and adherence at each appointment, as well as to provide education.

Finally, the last theme of patient‐driven education centered on the notion of introducing the benefits of LDA early on in pregnancy and supporting educational efforts with the development of concise, patient‐driven content. One participant stated: “I think talking about it earlier than twelve weeks, they have time to think about it and take it home and come back with questions. And so, it's not the first time you're bringing it up when you're prescribing it.” Additionally, emphasis was on clear, concise educational material at a 6th‐grade or lower reading level, with opportunities to link provided materials to further information on the internet.

4. DISCUSSION

Through theory‐informed and rigorous qualitative research design, we elucidated major themes and subthemes surrounding clinical care team member perspectives of risk‐based versus universal LDA approaches, as well as perceived barriers and facilitators to LDA prescription and use.

Universal screening in pregnancy has gained traction in recent years to help reduce barriers to provider identification of risk factors and improve perinatal outcomes [21, 22]. Participants in our study similarly express optimism in a universal prescription system, whereby providers can focus on providing LDA rather than considering who qualifies. While universal prescription of aspirin has been advocated for by some experts, given safety and cost‐effectiveness in large modeling studies, counterarguments warning against it cite concerns for decreased adherence and increased bleeding [13, 23, 24, 25]. This discourse similarly mirrors our participants, who mostly felt comfortable and positive about a universal prescription, but had similar hesitations regarding adherence and health disparities. While certain universal screening efforts have undoubtedly improved equality in obstetric care (e.g., group B streptococcus [GBS] screening in the third trimester), other efforts, such as universal hepatitis C screening in pregnancy, have seen overall rates improve, though stark disparities exist based on markers of socioeconomic inequity [22, 26]. In the pediatric literature, for example, a program of universal neonatal bilirubin screening has demonstrated increased rates of testing when compared to selective screening; however, a significant disparity was noted in follow‐up of elevated bilirubin by socioeconomic status [27]. This suggests that universal efforts that require multiple steps may be less impactful than those with simple treatments (e.g., use of antibiotics in labor for GBS‐positive patients). Further research after the implementation of universal prescription of LDA will aid in gaining a greater understanding of whether clinical team member concerns are borne out in a real‐life setting.

Our findings also provided opportunities to better understand barriers and facilitators to LDA prescription, and to use these findings to optimize a quality improvement initiative. Care team perceptions of individual facilitators and barriers including acceptability as a standard of care and medication safety concerns have been supported in our own patient‐facing research as well as other studies on LDA use in pregnancy [16, 28, 29]. Need for educational materials, both for care team members and patients, on the indications for and benefits of LDA use emerged throughout all levels of the CFIR framework, from understanding the value of LDA, to knowing indications, and combatting poor health literacy due to societal inequities. Other research has highlighted the importance of educating patients and providers on LDA to improve prescription and adherence [29, 30]. One study found that most missed LDA prescriptions were among those with less obvious moderate‐risk factors, including nulliparity, Black race, and low socioeconomic status [7].

Finally, our study demonstrated a need for explicit and understandable communication and optimization of existing electronic medical record resources to increase aspirin prescription and to monitor adherence. Use of clear, consistent communication has similarly been advocated for in other work surrounding LDA adherence in pregnancy [31]. Future efforts may go further by exploring the use of clinical decision tools built into the electronic medical record, which has been successful in improving LDA prescription in the past [32].

This study is limited in that it only included care team members from one geographic location serving in the same clinical environment, which may not represent how others (i.e., at Federally Qualified Health Centers, non‐urban clinics) feel about LDA in pregnancy and particularly about a universal aspirin program. While our study had a large range of participant training and years of experience, all members of the clinical care team are involved in working with medical trainees, which may also influence results. Additionally, the study skewed toward trainee and attending perspectives, and key members of the care team (i.e., clinical support staff) may not have had adequate representation. Strengths of this study include using a validated implementation science framework, which allowed for a greater understanding of how a universal LDA initiative could be optimally designed [15]. Qualitative research is valued in implementation science research, as it is essential to understanding the context in which clinical changes are made [33]. Virtual focus groups allowed for greater flexibility and participation of clinically busy and geographically distant participants. Focus groups also carry the advantage of allowing for social context and participants’ answers not only to the moderator's questions, but to each other, allowing for richer data [34].

In using an implementation science–based, qualitative approach, we were able to gain a deeper contextual understanding of clinical care team member perspectives surrounding LDA in pregnancy and specifically in relation to the method of aspirin prescription. Findings from this work, in addition to patient‐level perspectives gained in other pre‐intervention data collection, will help inform initiatives geared toward improving aspirin prescription and adherence, moving closer to closing the critical quality gap that exists, especially for our most vulnerable patients.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Supporting Information

Supporting Information