The clinical foundation of the effort is Mothers and Babies, a cognitive-behavioral intervention with a strong evidence base for reducing perinatal depressive symptoms. Cognitive-behavioral approaches teach people to recognize and reframe patterns of thinking that contribute to low mood, and Mothers and Babies packages these skills in a format that can be delivered by home visitors rather than licensed therapists. That design matters because home visiting programs — in which trained staff make regular visits to pregnant women and new parents in their homes — are one of the most widely available service platforms in the United States, particularly for families with low incomes. The programs reach families where they live, build relationships over months or years, and are trusted in communities where clinical settings can feel intimidating or inaccessible.

Yet despite this reach, uptake of evidence-based perinatal mental health services across the heterogeneous landscape of home visiting programs remains limited. The stakes are high: perinatal mental health conditions are associated with maternal mortality and with persistent health disparities, particularly among Black, Indigenous, and People of Color, often abbreviated BIPOC. The research team argues that the problem is not a lack of effective interventions but a lack of effective implementation — the contextual, structural, and workforce-related barriers that prevent proven programs from being adopted, delivered consistently, and sustained across organizations that differ enormously in size, staffing, funding, and client population.

To understand those barriers, the researchers conducted a multi-component formative evaluation, the first phase of a larger hybrid implementation-effectiveness-context cluster randomized controlled trial registered at ClinicalTrials.gov as NCT06575894. Formative evaluation is a structured diagnostic process conducted before a major rollout: rather than assuming a strategy will work everywhere, investigators gather evidence about local conditions and adapt accordingly. The team used implementation mapping, a participatory framework that walks planners through identifying who needs to do what differently, why they are not doing it yet, and what change objectives and methods could close the gap. The framework draws on established implementation science models, including the Consolidated Framework for Implementation Research and the Integrated Promoting Action on Research Implementation in Health Services framework, which together organize the many factors — from individual motivation to organizational culture to external policy — that shape whether innovations take hold.

The evidence gathering was deliberately multi-method. The researchers conducted semi-structured interviews with nine BIPOC birthing people, asking directly about experiences with perinatal mental health services and what would make support feel trustworthy and usable. They carried out a landscape analysis that identified 509 home visiting programs across Iowa and Indiana, mapping the terrain of organizations that any scaled strategy would need to accommodate. They then surveyed 72 of those programs to characterize their current practices, capacities, and needs. This combination of qualitative and quantitative data allowed the team to triangulate — to check whether what programs said they needed matched what mothers described and what the structural landscape implied.

Community engagement was not an afterthought but a core design element. The team convened two in-person Community Coalition meetings that brought together home visitors, supervisors, program directors, mental health providers, and representatives from the Indiana Department of Health and the Iowa Department of Health and Human Services. Separately, they held three virtual meetings with an Iowa home visiting Parent Expert Panel, including one conducted entirely in Spanish, ensuring that the perspectives of Spanish-speaking families were captured in their own language rather than through translation after the fact. This layered structure meant that the people who would actually deliver the intervention, the people who would receive it, and the state agencies that oversee the programs all had a voice in shaping the implementation strategy.

To turn conversation into structured data, the researchers used the Nominal Group Technique, a method designed to elicit and prioritize ideas from groups while limiting the influence of the loudest voices. Participants generated candidate determinants — the factors that would help or hinder implementation — and then voted to rank them. The results revealed a shared core of concerns but also striking state-level differences. Participants across both states identified determinants spanning workforce capacity, system integration, training needs, and client trust. In Indiana, participants emphasized overcoming logistical barriers such as workload and the procedural integration of a new intervention into already demanding visit schedules. In Iowa, participants prioritized leveraging existing training infrastructure, communication systems, and mental health consultation arrangements. The lesson for implementation science is clear: even neighboring states with superficially similar programs may require meaningfully different support strategies.

The Parent Expert Panels added a dimension that provider-focused analyses often miss. Mothers highlighted trust, stigma reduction, flexible scheduling, and personalized support as decisive factors in whether they would engage with mental health services. Stigma around depression and anxiety during pregnancy and the postpartum period remains a powerful deterrent, and a mother’s willingness to disclose distress often depends on the relationship she has with her home visitor and the sense that disclosure will lead to help rather than judgment. These findings underscore that implementation is not only an organizational problem; it is also a relational one, in which the perceived safety of the encounter determines whether evidence-based care ever has a chance to work.

Triangulating across the interviews, surveys, coalition meetings, and parent panels, the team produced a matrix of change organized around four performance outcomes: Professional Development and Staff Growth; Integration into Current System of Implementation; Staff Understand the Importance of Mental Health; and Building Client Trust and Rapport. Each outcome is linked to specific performance objectives and change strategies, creating a practical bridge between abstract determinants and concrete tools. This matrix directly informed the IMPACT Implementation Support Package — named for Implementing Mental Health Programs Across Communities in Iowa and Indiana — which adapts implementation facilitation, a strategy in which trained facilitators provide ongoing, tailored support to help organizations adopt new practices, to the specific conditions identified in each state.

The broader significance of the study lies in its demonstration that a community- and partner-engaged, multi-method formative evaluation can identify context-specific implementation determinants and translate them into actionable tools for scaling evidence-based mental health services within existing health systems. Rather than treating home visiting programs as passive recipients of a packaged intervention, the approach treats them as expert partners whose local knowledge is essential to successful adoption. For service planners and researchers working across heterogeneous community health settings, the study offers a structured, replicable pathway: map the landscape, listen to providers and clients alike, prioritize determinants systematically, and build support packages that respect local differences. As maternal mental health continues to drive preventable harm and deepen disparities, the Iowa-Indiana collaboration suggests that the fastest route to scale may run not through new inventions, but through listening carefully to the communities where care actually happens.

Subject of Research: Scaling evidence-based perinatal mental health services in home visiting programs through adapted implementation facilitation

Article Title: Adapting implementation facilitation to scale evidence-based perinatal mental health services in home visiting programs: a community and partner-engaged formative evaluation across Iowa and Indiana

Article References: Faro, E. Z., Hamil, J. L., Adeagbo, M. J., Jones, D. D., Peters, M., Iyangar, A. S., Shelton, E., Van Tiem, J., Chasco, E. E., Ramirez, X., Sarria, I., Hanselman, E., Tandon, S. D., Tabb, K. M., & Ryckman, K. K. (2026). Adapting implementation facilitation to scale evidence-based perinatal mental health services in home visiting programs: a community and partner-engaged formative evaluation across Iowa and Indiana. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15768-5

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15768-5

Keywords: perinatal mental health, home visiting programs, implementation science, Mothers and Babies, community engagement, health disparities, maternal health, implementation facilitation, Iowa, Indiana, cognitive-behavioral intervention, formative evaluation