Keeping baby SAFE in pregnancy: Evaluating the brochure

A systematic review of behaviour change techniques used in the context of stillbirth prevention

BACKGROUND

Stillbirth is one of the most devastating pregnancy outcomes that families can experience. Previous research has associated a wide range of risk factors with stillbirth, including maternal behaviours such as substance use, sleep position and attendance and engagement with antenatal care. Hence, some preventive efforts have been focused on tackling the behavioural risk factors for stillbirth. This study aimed to identify the Behaviour Change Techniques (BCTs) used in behaviour change interventions tacking behavioural risk factors for stillbirth such as substance use, sleep position, unattendance to antenatal care and weight management.

STUDY DESIGN

A systematic review of the literature was conducted in June 2021 and updated in November 2022 in five databases: CINHAL, Psyhinfo, SociIndex, PubMed and Web of Science. Studies published in high-income countries describing interventions designed in the context of stillbirth prevention, reporting stillbirth rates and changes in behaviour were eligible for inclusion. BCTs were identified using the Behaviour Change Technique Taxonomy v1.

RESULTS

Nine interventions were included in this review identified in 16 different publications. Of these, 4 interventions focused on more than one behaviour (smoking, monitoring fetal movements, sleep position, care-seeking behaviours), one focused on smoking, three on monitoring fetal movements and one on sleep position. Twenty-seven BCTs were identified across all interventions. The most commonly used was "Information about health consequences" (n = 7/9) followed by "Adding objects to the environment" (n = 6/9). One of the interventions included in this review has not been assessed for efficacy yet, of the remaining eight, three showed results in the reduction of stillbirth rates. and four interventions produced behaviour change (smoking reductions, increased knowledge, reduced supine sleeping time).

CONCLUSIONS

Our findings suggest that interventions designed to date have limited effects on the rates of stillbirth and utilise a limited number of BCTs which are mostly focused on information provision. Further research is necessary to design evidence base behaviour change interventions with a greater focus to tackle all the other factors influencing behaviour change during pregnancy (e.g.: social influence, environmental barriers).

Interventions to increase patient and family involvement in escalation of care for acute life-threatening illness in community health and hospital settings

BACKGROUND

There is now a rising commitment to acknowledge the role patients and families play in contributing to their safety. This review focuses on one type of involvement in safety - patient and family involvement in escalation of care for serious life-threatening conditions i.e. helping secure a step-up to urgent or emergency care - which has been receiving increasing policy and practice attention. This review was concerned with the negotiation work that patient and family members undertake across the emergency care escalation pathway, once contact has been made with healthcare staff. It includes interventions aiming to improve detection of symptoms, communication of concerns and staff response to these concerns.

OBJECTIVES

To assess the effects of interventions designed to increase patient and family involvement in escalation of care for acute life-threatening illness on patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP) ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform from 1 Jan 2000 to 24 August 2018. The search was updated on 21 October 2019.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and cluster-randomised controlled trials where the intervention focused on patients and families working with healthcare professionals to ensure care received for acute deterioration was timely and appropriate. A key criterion was to include an interactive element of rehearsal, role play, modelling, shared language, group work etc. to the intervention to help patients and families have agency in the process of escalation of care. The interventions included components such as enabling patients and families to detect changes in patients' conditions and to speak up about these changes to staff. We also included studies where the intervention included a component targeted at enabling staff response.

DATA COLLECTION AND ANALYSIS

Seven of the eight authors were involved in screening; two review authors independently extracted data and assessed the risk of bias of included studies, with any disagreements resolved by discussion to reach consensus. Primary outcomes included patient and family outcomes, treatment outcomes, clinical outcomes, patient and family experience and adverse events. Our advisory group (four users and four providers) ensured that the review was of relevance and could inform policy and practice.

MAIN RESULTS

We included nine studies involving 436,684 patients and family members and one ongoing study. The published studies focused on patients with specific conditions such as coronary artery disease, ischaemic stroke, and asthma, as well as pregnant women, inpatients on medical surgical wards, older adults and high-risk patients with a history of poor self-management. While all studies tested interventions versus usual care, for four studies the usual care group also received educational or information strategies. Seven of the interventions involved face-to-face, interactional education/coaching sessions aimed at patients/families while two provided multi-component education programmes which included components targeted at staff as well as patients/families. All of the interventions included: (1) an educational component about the acute condition and preparedness for future events such as stroke or change in fetal movements: (2) an engagement element (self-monitoring, action plans); while two additionally focused on shared language or communication skills. We had concerns about risk of bias for all but one of the included studies in respect of one or more criteria, particularly regarding blinding of participants and personnel. Our confidence in results regarding the effectiveness of interventions was moderate to low. Low-certainty evidence suggests that there may be moderate improvement in patients' knowledge of acute life-threatening conditions, danger signs, appropriate care-seeking responses, and preparedness capacity between interactional patient-facing interventions and multi-component programmes and usual care at 12 months (MD 4.20, 95% CI 2.44 to 5.97, 2 studies, 687 participants). Four studies in total assessed knowledge (3,086 participants) but we were unable to include two other studies in the pooled analysis due to differences in the way outcome measures were reported. One found no improvement in knowledge but higher symptom preparedness at 12 months. The other study found an improvement in patients' knowledge about symptoms and appropriate care-seeking responses in the intervention group at 18 months compared with usual care. Low-certainty evidence from two studies, each using a different measure, meant that we were unable to determine the effects of patient-based interventions on self-efficacy. Self-efficacy was higher in the intervention group in one study but there was no difference in the other compared with usual care. We are uncertain whether interactional patient-facing and multi-component programmes improve time from the start of patient symptoms to treatment due to low-certainty evidence for this outcome. We were unable to combine the data due to differences in outcome measures. Three studies found that arrival times or prehospital delay time was no different between groups. One found that delay time was shorter in the intervention group. Moderate-certainty evidence suggests that multi-component interventions probably have little or no impact on mortality rates. Only one study on a pregnant population was eligible for inclusion in the review, which found no difference between groups in rates of stillbirth. In terms of unintended events, we found that interactional patient-facing interventions to increase patient and family involvement in escalation of care probably have few adverse effects on patient's anxiety levels (moderate-certainty evidence). None of the studies measured or reported patient and family perceptions of involvement in escalation of care or patient and family experience of patient care. Reported outcomes related to healthcare professionals were also not reported in any studies.

AUTHORS' CONCLUSIONS

Our review identified that interactional patient-facing interventions and multi-component programmes (including staff) to increase patient and family involvement in escalation of care for acute life-threatening illness may improve patient and family knowledge about danger signs and care-seeking responses, and probably have few adverse effects on patient's anxiety levels when compared to usual care. Multi-component interventions probably have little impact on mortality rates. Further high-quality trials are required using multi-component interventions and a focus on relational elements of care. Cognitive and behavioural outcomes should be included at patient and staff level.

Embedding supportive parenting resources into maternity and early years care pathways: a mixed methods evaluation

BACKGROUND

During pregnancy and postnatally, women seek information from a variety of sources. The potential to incorporate educational pregnancy and parenting resources into conventional health services is underexplored. In 2014-2016, UK-based charity Best Beginnings used an embedding model to embed three of their resources - the Baby Buddy app, Baby Express magazine, and 'From Bump to Breastfeeding' DVD - into maternity and early years care pathways at three sites in the north of England. A mixed-methods evaluation comprising an impact evaluation and a process evaluation was undertaken. Here we report findings from the process evaluation that aimed to understand the embedding process, explore maternity and early years' professionals' views and use of the resources, explore women's engagement with and views of the resources, and identify barriers and facilitators to the embedding process.

METHODS

We carried out semi-structured interviews with stakeholders (professionals involved in embedding) and observations of embedding activities to understand how embedding worked. Surveys of postnatal women were conducted over a two-month period both prior to, and after, the resources had been embedded, to ascertain engagement with and views of the resources. A survey of professionals was carried out post-embedding to understand how, where and when the resources were used in practice, and professionals' views. Descriptive and thematic analyses were undertaken.

RESULTS

Thirty stakeholders took part in interviews. Surveys were completed by 146 professionals, and by 161 and 192 women in the pre and post-embedding phases respectively. Themes derived from analysis of qualitative data were 'Implementation of the embedding model', 'Promotion and distribution of, and engagement with, the resources', 'Fit with care pathways', and 'Perceptions of the resources'. While survey responses indicated that embedding of the resources into practice was not yet complete, those who had used the resources believed that they had helped increase knowledge, build confidence and support relationship-building.

CONCLUSIONS

Incorporating supportive parenting resources into maternity and early years' care pathways requires a planned embedding approach, committed champions, and senior management support. Findings indicate largely positive views of women and professionals, and suggest the resources can be a beneficial aid for families.

Identification of populations at risk: Stillbirth toolkit for health care providers

BACKGROUND

Maternity care and women's health are measured, in part, by the stillbirth rate of a country. The purposes of this pilot project were to: a) establish a baseline of health care provider knowledge regarding stillbirth risk factors based on geographic distribution (urban/rural) and provider licensure (MD, APRN, PA, CNM) and b) evaluate the utility of a Stillbirth Risk Factor Toolkit and its effects on provider knowledge.

METHODS

Evaluative research using a retrospective pre-posttest survey design was completed. The study setting included primary care clinics (urban [n=25] and rural [n=25]) in Nebraska. Health care providers from N=50 clinics were surveyed about their knowledge of stillbirth risk factors (modifiable and non-modifiable) before and after reading the Toolkit.

RESULTS

Providers were least knowledgeable regarding the definition of stillbirth and the number of weeks' gestation that constitute a stillbirth. Overall, there was no significant difference in baseline knowledge between rural and urban providers. Nearly half (43.8%) found the Toolkit to be very helpful and applicable to their patient population, and 34.8% said they would be very likely to utilize it with their patients. There was a statistically significant increase in knowledge of stillbirth risk factors among all health care providers after reviewing the Toolkit (p<0.001).

CONCLUSIONS

Health providers had varied baseline knowledge about stillbirth. The Toolkit improved provider knowledge, but further research is needed to assess its impact on clinical practice.