- Title
- A practice change intervention to increase the provision of antenatal care addressing alcohol consumption during pregnancy
- Creator
- Doherty, Emma
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2023
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- The consumption of alcohol during pregnancy impacts the development of the fetus and is associated with a range of harms for the exposed child that are evident throughout different life stages. Despite international and national guidelines consistently recommending pregnant women to not consume alcohol, the prevalence of consumption remains high in a number of countries, including Australia. Antenatal clinical guidelines recommend that all pregnant women have alcohol consumption addressed at initial and subsequent antenatal visits using an evidence-based model of care consisting of three key elements: assessment, advice and referral. Relatively little is known about the extent and consistency of recommended care provision in public maternity services; pregnant women’s acceptability of receiving such care; and antenatal care provider and maternity manager barriers to guideline implementation. There is also a lack of evidence regarding implementation strategies that may be effective in supporting providers deliver recommended antenatal care addressing preventable modifiable risk factors, including alcohol consumption. Such gaps were addressed through a series of studies undertaken within all public maternity services in three geographically and administratively defined sectors of a single local health district in New South Wales, Australia. The studies included: a cross-sectional prevalence of care survey with pregnant women attending public maternity services; a cross-sectional survey of antenatal clinicians and maternity managers based on the Theoretical Domains Framework assessing barriers to care provision; and a randomised stepped-wedge controlled trial testing the implementation of a theoretically, empirically and end-user informed multi-strategy practice change support package. The trial was evaluated through weekly cross-sectional surveys of pregnant women who had recently attended participating maternity services over a period of 35 months. In addition, a systematic review of controlled studies that have tested the effect of implementation strategies in supporting health professionals provide pregnancy focused care addressing tobacco smoking, weight management and/or alcohol consumption was undertaken. The work encompassed in this thesis has contributed to advancing research and practice in a number of ways. Firstly, this thesis reported that public maternity services do not routinely provide the recommended care elements (assess, advise, refer) for addressing alcohol consumption during pregnancy, with particularly low levels found at later antenatal visits. Care was also found to be inconsistently provided, with characteristics of pregnant women (older age, not a first pregnancy, higher education, residing in an advantaged area, non-Aboriginal origin) and maternity services (urban located) associated with decreased odds of care receipt. Despite sub-optimal care, pregnant women reported high acceptability for receipt of all recommended care elements in antenatal visits. A number of barriers were reported by antenatal clinicians as impeding their delivery of such care, including absence of supporting resources, lack of expectation from others that alcohol will be addressed and low confidence in providing each of the recommended care elements. The main barriers reported by maternity managers included stress and complexities in managing clinical practice change. The systematic review concluded that implementation strategies probably increase elements of antenatal care related to tobacco smoking and weight management. The ability to draw a stronger conclusion of the effect of such strategies on the provision of guideline recommended care addressing alcohol consumption was constrained by the absence of randomised controlled studies, lack of reported outcomes regarding assessment and referral, and very-low-certainty in the evidence for advice outcomes. The multi-strategy practice change intervention tested in the randomised stepped-wedge controlled trial was developed using theory and empirical evidence, and strategy content and delivery informed by end-users and Aboriginal partners. The intervention was found to be effective in improving all elements of guideline recommended care both overall, and at initial and subsequent antenatal visits. The intervention resulted in similar effects between subgroups of women and types and location of maternity services, with the exception of non-Aboriginal women and women who had not consumed alcohol in pregnancy, for whom the intervention was more effective in increasing assessment of alcohol consumption at subsequent antenatal visits. The thesis identified two key issues to be further explored in order to advance research and practice in this area: a need to further increase the proportion of women who receive guideline-recommended antenatal care addressing alcohol consumption during pregnancy through the testing of iterative improvement approaches; and a need to sustain care provision after the withdrawal of active implementation support.
- Subject
- implementation; guideline improvement; antenatal; maternity services; alcohol; prevention; public health; randomised controlled trial; stepped-wedge; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1473217
- Identifier
- uon:48980
- Rights
- Copyright 2023 Emma Doherty
- Language
- eng
- Full Text
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 35 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 491 KB | Adobe Acrobat PDF | View Details Download |