A realist evaluation of an antenatal programme to change drinking behaviour of pregnant women

Trapped in a maze: A meta-ethnography of women's experiences of alcohol use in pregnancy

INTRODUCTION

Despite the recognized link between prenatal alcohol consumption and various congenital anomalies, the negative consequences for women's own health and family health, as well as the work done in healthcare to prevent alcohol in pregnancy, the acceptance of alcohol use during pregnancy persists in numerous communities around the world. Knowledge about women's alcohol use in pregnancy and how it relates to the social and cultural context they are part of is important to help and support women in abstaining during pregnancy. This meta-ethnography aims to offer a novel interpretation and conceptual understanding of the experiences of women who consume alcohol during pregnancy by synthesizing insights from existing qualitative studies.

METHODS

An interpretative meta-ethnographic design was chosen based on a systematic literature search in seven electronic databases, and manual searches were conducted in 2023. The CASP checklist was used to assess the 18 included articles.

RESULTS

In the synthesis, we use the metaphor of being trapped in a maze to illustrate the complexity of pregnant women's experiences of drinking during pregnancy. Women who drink alcohol during pregnancy are navigating the maze in a whirlwind of conflicting information and knowledge. The findings show how sociocultural norms form rigid pathways within the maze. In relation to their sociocultural context, women use several motives to justify the routes chosen within the maze. The competing information, knowledge and clashing norms within women's sociocultural contexts leave women to navigate alone in the maze.

CONCLUSIONS

Alcohol in pregnancy needs to be conceptualized as an issue positioned at the intersection of social sciences and healthcare and needs to be handled accordingly, both through transdisciplinary research, by early prevention and multimodal interventions in healthcare and the broader society. Such interventions would benefit from drawing on knowledge about women's experiences with alcohol in pregnancy.

Opening Pandora's box: A meta-ethnography about alcohol use in pregnancy from midwives' and other healthcare providers' perspectives

INTRODUCTION

Alcohol consumption has increased in recent years, including among women of childbearing age. A woman's alcohol intake during pregnancy is linked to complications and injuries in the newborn, and the risk of the child being harmed by the mother's alcohol use increases in proportion to the amount of alcohol she consumes. This meta-ethnography aims to explore midwives' and other healthcare providers' experiences of screening pregnant women for alcohol use in pregnancy and counselling them on the subject.

METHODS

A systematic literature search in CINAHL, Maternity & Infant Care, MEDLINE, and Scopus was conducted in August 2021 and updated in January 2023. The CASP checklist was used to assess the included articles and meta-ethnography was used to synthesize the data.

RESULTS

Fourteen qualitative studies were included. In the synthesis, we use the metaphor of Pandora's box to deepen our understanding of the topic. We found that some healthcare providers tiptoe around the box, not wanting to face the consequences and responsibilities of asking women about their alcohol use. Others refuse or are reluctant to open the box because they lack knowledge about screening and counselling. Some eventually open the box, understanding the importance of establishing a trusting relationship to address alcohol use and seeing the need for knowledge and screening tools.

CONCLUSIONS

Healthcare education has the important task of ensuring that healthcare personnel have sufficient evidence-based knowledge about alcohol use in pregnancy. In the future, a health-promoting, tailored approach offering women in pre-pregnancy and early pregnancy sufficient evidence-based information should be implemented.

Accounts of women identified as drinking at 'high risk' during pregnancy: A meta-ethnography of missing voices

BACKGROUND

Drinking alcohol during pregnancy is associated with Foetal Alcohol Spectrum Disorders (FASD), and women who drink at higher levels are more likely to have a baby with FASD. Public health responses focus on population-level approaches to FASD prevention such as promoting abstinence and alcohol brief interventions. Efforts to better understand and respond to 'high risk' drinking during pregnancy have been largely ignored. This meta-ethnography of qualitative research aims to inform this policy and practice agenda.

METHODS

Ten health, social care, and social sciences databases were searched for qualitative studies published since 2000 exploring drinking during pregnancy. Studies that included accounts of women who described themselves, or were diagnosed as, alcohol-dependent during pregnancy, or reported drinking during pregnancy at levels considered by the Word Health Organisation to constitute 'high risk' drinking, were eligible. Noblit and Hare's analytic approach to meta-ethnography was used to synthesise the studies and eMERGe reporting guidance was followed.

RESULTS

Nine diverse studies were included. All explored the impact of social norms and relationships, women's knowledge about the risks involved in drinking during pregnancy, the behaviour of women, and the advice they received. Three key themes were identified: drinking is social and relational, knowledge is not enough, and multiple adversities matter. Multiple adversities were interconnected and primarily related to structural inequalities and oppression. The complex needs of women and the wider context in which their drinking occurred were rarely explored or responded to during pregnancy.

CONCLUSION

This meta-ethnography provides a more nuanced understanding of the complex dynamics involved in women's 'high risk' drinking during pregnancy, the contexts in which they drink and their unmet needs. These findings can inform future policy and practice responses to 'high risk' drinking during pregnancy. Further research should explore women's experiences in a UK context and consider how services could meet women's needs.

Fetal alcohol spectrum disorders

Alcohol readily crosses the placenta and may disrupt fetal development. Harm from prenatal alcohol exposure (PAE) is determined by the dose, pattern, timing and duration of exposure, fetal and maternal genetics, maternal nutrition, concurrent substance use, and epigenetic responses. A safe dose of alcohol use during pregnancy has not been established. PAE can cause fetal alcohol spectrum disorders (FASD), which are characterized by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies and poor growth. FASD are a leading preventable cause of birth defects and developmental disability. The prevalence of FASD in 76 countries is >1% and is high in individuals living in out-of-home care or engaged in justice and mental health systems. The social and economic effects of FASD are profound, but the diagnosis is often missed or delayed and receives little public recognition. Future research should be informed by people living with FASD and be guided by cultural context, seek consensus on diagnostic criteria and evidence-based treatments, and describe the pathophysiology and lifelong effects of FASD. Imperatives include reducing stigma, equitable access to services, improved quality of life for people with FASD and FASD prevention in future generations.

"I am busy enough…": Navigating challenges experienced by Medicaid providers serving pregnant people living with substance use disorders in Alabama

PURPOSE

Perinatal substance use is a clinical and public health concern. The purpose of the study was to understand the perspectives and experiences of perinatal healthcare providers serving pregnant people who receive Medicaid and are living with a substance use disorder.

DESIGN AND METHODS

We conducted a secondary data analysis of the responses from perinatal healthcare providers who completed a survey to assess the state of Alabama's capability to effectively identify and treat individuals with substance use disorder. We analyzed short answer responses using consensus coding.

FINDINGS

Nine-hundred and ninety-five Medicaid providers completed the survey, 36 of the respondents identified that they were employed in an obstetric practice. Health insurance limitations, a lack of time and resources, and limited treatment options were the primary barriers indicated in the participants' responses.

CONCLUSIONS

Structural and health system barriers negatively impact the capacity of perinatal healthcare providers in Alabama to serve pregnant people who receive Medicaid and are living with a substance use disorder.

CLINICAL RELEVANCE

Perinatal healthcare providers need educational opportunities, training, and up-to-date resources to provide supportive, comprehensive care programming for perinatal populations with substance use disorders.

Effectiveness of public health education on the uptake of iron and folic acid supplements among pregnant women: a stepped wedge cluster randomised trial

INTRODUCTION

Iron deficiency is the most prevalent micronutrient deficiency in pregnancy globally responsible for nearly 120 000 maternal deaths per year and a fifth of maternal mortality. Over 46% of pregnant women in Africa and 62% of pregnant women in Kenya are anaemic. Anaemia has severe economic and health consequences. Daily iron and folic acid supplementation (IFAS) is an efficacious strategy recommended in pregnancy to reduce the risk of anaemia and improve maternal and neonatal survival. However, most pregnant women do not consume IFAS as recommended. Limited knowledge on IFAS, its benefits and its connection with anaemia, and mitigation of its side effects lead to poor consumption. The main objective of this trial is to determine the effectiveness of public health education on uptake of antenatal IFAS.

METHODS AND ANALYSIS

A stepped wedge cluster randomised trial with antenatal clinics as units of randomisation. Twelve clusters will be randomised to receive the intervention and levels of IFAS uptake compared with preintervention period. The 9-month trial will enrol 1205 pregnant women. The primary outcome will be the proportion of pregnant women effectively taking up IFAS measured through self-reports, residual pill count and inspection of pill reminder cards. Routine clinical data on haemoglobin counts and fetal growth monitoring will also be used. Descriptive and bivariate analysis will be conducted in Stata using Pearson's χ2 test for association, and multivariate logistic regression to identify determinants of uptake. The potential public health benefits will be estimated using the number needed to treat and the preventable fraction.

ETHICS AND DISSEMINATION

Ethical approval was granted by Kenyatta University Ethics Review Committee (PKU/2443/11575). The research permit is obtained from Kenya National Commission for Science, Technology and Innovation (NACOSTI/P/22/16168). Findings will be disseminated through peer-reviewed publications and public health conferences.

TRIAL REGISTRATION NUMBER

PACTR202202775997127.

Screening for Alcohol Use in Pregnancy: a Review of Current Practices and Perspectives

Global trends of increasing alcohol consumption among women of childbearing age, social acceptability of women's alcohol use, as well as recent changes in alcohol use patterns due to the COVID-19 pandemic may put many pregnancies at higher risk for prenatal alcohol exposure (PAE), which can cause fetal alcohol spectrum disorder (FASD). Therefore, screening of pregnant women for alcohol use has become more important than ever and should be a public health priority. This narrative review presents the state of the science on various existing prenatal alcohol use screening strategies, including the clinical utility of validated alcohol use screening instruments. It also discusses barriers for alcohol use screening in pregnancy, such as practitioner constraints, unplanned pregnancies, delayed access to prenatal care, and stigma associated with substance use in pregnancy, providing recommendations to address these barriers. By implementing consistent alcohol use screening, prenatal care providers have the opportunity to facilitate access to counseling and brief interventions and thus, to prevent new cases of FASD and improve maternal and child health.

Guideline No. 405: Screening and Counselling for Alcohol Consumption During Pregnancy

OBJECTIVE

To establish national standards of care for screening and counselling pregnant women and women of child-bearing age about alcohol consumption and possible alcohol use disorder based on current best evidence.

INTENDED USERS

Health care providers who care for pregnant women and women of child-bearing age.

TARGET POPULATION

Pregnant women and women of child-bearing age and their families.

EVIDENCE

Medline, EMBASE, and CENTRAL databases were searched for "alcohol use and pregnancy." The results were filtered for a publication date between 2010 and September 2018. The search terms were developed using Medical Subject Headings terms and keywords, including pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring, and brief intervention. Evidence was included from clinical trials, observational studies, reviews, systematic reviews and meta-analyses, guidelines, and conference consensus.

VALIDATION METHODS

The content and recommendations in this guideline were drafted and agreed upon by the authors. The Board of Directors of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework.

BENEFITS, HARMS, COSTS

Implementation of the recommendations in these guidelines using validated screening tools and brief intervention approaches may increase obstetrical care provider recognition of alcohol consumption and problematic alcohol use among women of child-bearing age and those who are pregnant. It is anticipated that health care providers will become confident and competent in managing and supporting these women so they can achieve optimal health and pregnancy outcomes.

SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)

RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Evidence for the Effectiveness and Acceptability of e-SBI or e-SBIRT in the Management of Alcohol and Illicit Substance Use in Pregnant and Post-partum Women

Alcohol and illicit psychoactive drug use during pregnancy have increased worldwide, putting women and their children's health and development at risk. Multiple drug use, comorbid psychiatric disorders, sexual and physical abuse are common in women who use alcohol and drugs during pregnancy. The effects on the mother include poor reproductive and life-long health, legal, family, and social problems. Additionally, the exposed child is at increased risk of long-term physical health, mental health, and developmental problems. The stigma associated with substance use during pregnancy and some clinicians' reticence to inquire about substance use means many women are not receiving adequate prenatal, substance abuse, and mental health care. Evidence for mHealth apps to provide health care for pregnant and post-partum women reveal the usability and effectiveness of these apps to reduce gestational weight gain, improve nutrition, promote smoking cessation and manage gestational diabetes mellitus, and treat depression and anxiety. Emerging evidence suggests mHealth technology using a public health approach of electronic screening, brief intervention, or referral to treatment (e-SBIRT) for substance use or abuse can overcome the typical barriers preventing women from receiving treatment for alcohol and drug use during pregnancy. This brief intervention delivered through a mobile device may be equally effective as SBIRT delivered by a health care professional in preventing maternal drug use, minimizing the effects to the exposed child, and providing a pathway to therapeutic options for a substance use disorder. However, larger studies in more diverse settings with women who have co-morbid mental illness and a constellation of social risk factors that are frequently associated with substance use disorders are needed.

Explaining the impact of mHealth on maternal and child health care in low- and middle-income countries: a realist synthesis

Background

Despite the growing global application of mobile health (mHealth) technology in maternal and child health, contextual factors, and mechanisms by which interventional outcomes are generated, have not been subjected to a systematic examination. In this study, we sought to uncover context, mechanisms, and outcome elements of various mHealth interventions based on implementation and evaluation studies to formulate theories or models explicating how mHealth interventions work (or not) both for health care providers and for pregnant women and mothers.

Method

We undertook a realist synthesis. An electronic search of five online databases (PubMed/Medline, Google Scholar, Scopus, Academic Search Premier and Health Systems Evidence) was performed. Using appropriate Boolean phrases terms and selection procedures, 32 articles were identified. A theory-driven approach, narrative synthesis, was applied to synthesize the data. Thematic content analysis was used to delineate elements of the intervention, including its context, actors, mechanisms, and outcomes. Abduction and retroduction were applied using a realist evaluation heuristic tool to formulate generative theories.

Results

We formulated two configurational models illustrating how and why mHealth impacts implementation and uptake of maternal and child health care. Implementation-related mechanisms include buy-in from health care providers, perceived support of health care providers’ motivation and perceived ease of use and usefulness. These mechanisms are influenced by adaptive health system conditions including organization, resource availability, policy implementation dynamics, experience with technology, network infrastructure and connectivity. For pregnant women and mothers, mechanisms that trigger mHealth use and consequently uptake of maternal and child health care include perceived satisfaction, motivation and positive psychological support. Information overload was identified as a potential negative mechanism impacting the uptake of maternal and child health care. These mechanisms are influenced by health system conditions, socio-cultural characteristics, socio-economic and demographics characteristics, network infrastructure and connectivity and awareness.

Conclusion

Models developed in this study provide a detailed understanding of implementation and uptake of mHealth interventions and how and why they impact maternal and child health care in low- and middle-income countries. These models provide a foundation for the ‘white box’ of theory-driven evaluation of mHealth interventions and can improve rollout and implementation where required.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03684-x.

Directive clinique no 405 : Dépistage et conseils en matière de consommation d'alcool pendant la grossesse

OBJECTIF

Établir des normes pancanadiennes fondées sur les meilleures données probantes actuelles sur le dépistage et les conseils en matière de consommation d'alcool et de troubles de consommation d'alcool chez les femmes enceintes ou en âge de procréer. PROFESSIONNELS CONCERNéS: Les fournisseurs de soins qui prodiguent des soins aux femmes enceintes et aux femmes en âge procréer.

POPULATION CIBLE

Les femmes enceintes, les femmes en âge de procréer et leurs familles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, Embase et CENTRAL avec le thème « alcohol use and pregnancy ». Les résultats ont été filtrés de façon à obtenir des publications parues entre 2010 et septembre 2018. Les termes de recherche ont été mis au point à partir des termes du thésaurus de référence biomédicale MeSH et de mots clés, dont les suivants : pre-pregnancy, pregnant, breastfeeding, lactation, female, women, preconception care, prenatal care, fetal alcohol spectrum disorder, prenatal alcohol exposure, drinking behavior, alcohol abstinence, alcohol drinking, binge drinking, alcohol-related disorders, alcoholism, alcohol consumption, alcohol abuse, benzodiazepines, disulfiram, naltrexane, acamprosate, ondansetron, topiramate, cyanamide, calcium carbimide, alcohol deterrents, disease management, detoxification, Alcoholics Anonymous, alcohol counselling, harm reduction, pre-pregnancy care, prenatal care, incidence, prevalence, epidemiological monitoring et brief intervention. Les données probantes retenues proviennent d'essais cliniques, d'études observationnelles, de revues de la littérature, d'analyses systématiques et méta-analyses, de lignes directrices et de conférences de consensus. MéTHODES DE VALIDATION: Les auteurs ont rédigé et accepté le contenu et les recommandations de la présente directive. Le conseil d'administration de la Société des obstétriciens et gynécologues du Canada a approuvé la version définitive aux fins de publication. La qualité des données probantes a été évaluée au moyen des critères de l'approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation) (consulter les tableaux A1 et A2 de l'annexe en ligne). BéNéFICES, RISQUES, COûTS: La mise en œuvre des recommandations de la présente directive à l'aide d'outils de dépistage validés et de stratégies d'intervention brève peut améliorer la capacité des fournisseurs de soins obstétricaux à reconnaître la consommation d'alcool et la consommation problématique d'alcool chez les femmes enceintes ou en âge de procréer. Il est attendu des fournisseurs de soins de santé qu'ils deviennent confiants et compétents en matière de prise en charge et de soutien de ces femmes afin qu'elles puissent avoir la meilleure santé possible et une issue de grossesse optimale. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).

What works, for whom and under what circumstances? Using realist methodology to evaluate complex interventions in nursing: A scoping review

BACKGROUND

The Medical Research Council's (MRC) framework recommends basing every evaluation of a complex intervention on a theory that explains WHY an intervention works instead of focusing exclusively on the identification IF an intervention works. Theory-based evaluation approaches such as realist evaluations are promising in this respect. The aim of this scoping review is to examine current scientific literature with regard to the use of realist methodology in studies that evaluate complex nursing interventions. We also seek to answer the question whether realist evaluation studies of complex nursing interventions are embedded in the Medical Research Council's framework.

METHODS

A systematic database search in MEDLINE and CINAHL supplemented with snowballing techniques and a hand search in relevant nursing journals were performed between January and February 2018 and updated in July 2019. Both authors independently screened the title / abstract of studies that were initially identified and appraised the full texts if inclusion criteria were fulfilled. Inclusion criteria were the explicit use of realist methodology and a focus on the development or evaluation of complex nursing interventions. Results were summarized narratively.

RESULTS

A total of 28 articles from 22 studies, published between 2010 and 2019, were included. The majority of the studies included originate in the UK. Realist methodology was used by a variety of nursing disciplines, including midwifery, community / public health, critical care, palliative care, gerontological nursing, psychiatric nursing / mental health, and infection control. Study designs included case studies and realist reviews; two studies were conducted alongside a randomized controlled trial. All studies included used more than one method to develop their results; the majority of methods were qualitative by nature. Thirteen of the studies included aimed to develop a theory about what works, for whom and under what circumstances regarding the investigated complex nursing intervention. One study was clearly embedded in the Medical Research Council's framework.

CONCLUSION

Realist evaluation broadens the methodologies that have traditionally been used in nursing. Conceptual clarity on its principal tenets is still needed, as well as the methods used to assess them. Nursing scientists should be more critical when using novel methodology and contribute to academic debates about limitations. Embedding realist evaluations into the Medical Research Council's framework is in its infancy in nursing and needs more contributions in order to develop a common academic position within the profession. Tweetable abstract Realist methodology in nursing - review of the use, methods, limitations and embedding into the Medical Research Council's framework.

Uptake of a primary care atrial fibrillation screening program (AF-SMART): a realist evaluation of implementation in metropolitan and rural general practice

Background

Screening for atrial fibrillation (AF) in people aged ≥65 years is recommended by international guidelines. The Atrial Fibrillation Screen, Management And guideline-Recommended Therapy (AF-SMART) studies of opportunistic AF screening in 16 metropolitan and rural general practices were conducted from November 2016–June 2019. These studies trialled custom-designed eHealth tools to support all stages of AF screening in general practice.

Methods

A realist evaluation of the AF-SMART studies, which aimed to explain the circumstances in which the program worked (or not) to increase the proportion of people screened for AF. The initial program theory was based on our previous research, policy documents and screening studies. To test this, we conducted 45 semi-structured interviews with general practitioners (GPs), nurses and practice managers across all participating practices, and collected observational and quantitative screening data. These data were analysed and interpreted to refine the program theory.

Results

GPs/nurses liked the eHealth tools, although technical problems sometimes disrupted screening. Time was the main barrier to screening for GPs/nurses, so systems need to be very efficient. Practices with leadership from a senior GP ‘screening champion’ had broader uptake, especially from the nursing team. Providing regular feedback on screening data was beneficial for quality improvement and motivation. Clear protocols for follow-up of abnormal results were required for successful nurse-led screening in a hierarchical system. Participation in the program had broader benefits of improving AF knowledge and raising the profile of cardiovascular health in the practice. Screening for a shorter, more intense period (eg during influenza vaccination) worked well for practices where sufficient staff time was allocated.

Conclusions

Introducing an AF screening program is likely to be successful in contexts where there is a senior GP ‘screening champion’, a clear protocol exists for abnormal results, and there is regular data reporting to staff. These contexts link to mechanisms around motivation, leadership, empowerment of nurses, and efficient screening systems. The contexts and mechanisms contribute to the longer-term outcomes of increasing the proportion of people screened and treated for AF, which is recommended by guidelines as a key strategy for the prevention of AF-related stroke.

Trial registrations

AF SMART (metropolitan): ACTRN12616000850471 (Australia New Zealand Clinical Trials Registry).

AF SMART II (rural): ACTRN12618000004268 (Australia New Zealand Clinical Trials Registry).

Antenatal care for alcohol consumption during pregnancy: pregnant women's reported receipt of care and associated characteristics

Background

Antenatal clinical guidelines recommend that during initial and subsequent antenatal visits all pregnant women: have their alcohol consumption assessed; be advised that it is safest not to consume alcohol during pregnancy and of the potential risks of consumption; and be offered referrals for further support if required. However, the extent to which pregnant women attending public antenatal services receive guideline recommended care at these visits, and the characteristics associated with its receipt, is unknown. The purpose of this study was to examine: 1) pregnant women’s reported receipt of guideline recommended care addressing alcohol consumption during pregnancy; 2) characteristics associated with the receipt of care; and 3) pregnant women’s acceptability of care.

Methods

From July 2017 – February 2018 a survey (telephone or online) was undertaken with 1363 pregnant women who had recently visited a public antenatal service in one health district in Australia. Receipt and acceptability of recommended care were assessed via descriptive statistics and associations via logistic regression analyses.

Results

At the initial antenatal visit, less than two thirds (64.3%) of pregnant women reported that they received an assessment of their alcohol consumption and just over one third (34.9%) received advice and referral appropriate to their self-reported level of alcohol consumption since pregnancy recognition. Less than 10% of women received such care at subsequent antenatal visits. Characteristics that significantly increased the odds of receiving all guideline elements at the initial antenatal visit included: less than university attainment (OR = 1.93; 95% CI:1.12, 3.34), not residing in an advantaged area (OR = 2.11; 95% CI:1.17, 3.79), first pregnancy (OR = 1.91; 95% CI:1.22, 2.99) and regional/rural service location (OR = 2.38; 95% CI:1.26, 4.48); and at subsequent visits: younger age (OR = 0.91; 95% CI:0.84, 0.99) and Aboriginal origin (OR = 3.17; 95% CI:1.22, 8.24). Each of the recommended care elements were highly acceptable to pregnant women (88.3–99.4%).

Conclusions

Although care for alcohol consumption is both recommended by clinical guidelines and highly acceptable to pregnant women, its receipt in public antenatal services is suboptimal. There is a need and an opportunity for interventions to support antenatal care providers to routinely and consistently provide such care to all pregnant women.

Women's experiences of messages relating to alcohol consumption, received during their first antenatal care visit: An interpretative phenomenological analysis

BACKGROUND

Despite greater awareness of fetal alcohol spectrum disorder, there has not been similar attention paid to research regarding effective strategies for prevention.

AIMS

To explore and interpret the messages women receive during their first antenatal care visit, relating to alcohol consumption.

METHODS

Participants were 12 females who had attended an initial antenatal care visit within the previous two years. They participated in semi-structured interviews about their experiences of the health messages they recalled receiving during their first antenatal care visit, with emphasis on messages relating to alcohol consumption.

FINDINGS

Data were analysed using Interpretative Phenomenological Analysis which identified two superordinate themes: (1) Messages Received About Alcohol Consumption, and (2) Ways of Interpreting Messages Relating to Alcohol Consumption. Messages received by participants about alcohol consumption were generally consistent with national guidelines, stating that there is no safe level during pregnancy. Women interpreted these messages, however, within a broader, personal and socio-cultural context. This leads to women's choices about alcohol consumption being informed by their individual understanding of risk. To facilitate open discussions about sensitive topics such as alcohol consumption, participants expressed a preference for antenatal support that is tailored to their individual needs.

CONCLUSION

Strategies to prevent fetal alcohol spectrum disorder need to include messages encouraging women to abstain during pregnancy, whilst at the same time, providing the type of individualised antenatal care that best enables this to be accomplished.

Barriers to screening pregnant women for alcohol or other drugs: A narrative synthesis

BACKGROUND

Maternal alcohol or other drug use during pregnancy is associated with a range of adverse health outcomes for mothers and their unborn child. The antenatal period presents an opportunity for health professionals to offer routine screening for alcohol or other drugs, to then provide intervention and referral for treatment and/or specialised support services. However, literature indicates that limited screening practices currently exist in maternity care settings.

AIM

To identify barriers to screening pregnant women for alcohol or other drugs in maternity care settings, from the perspectives of healthcare professionals.

METHODS

A comprehensive literature search was conducted in October 2017 to identify relevant studies. Seven databases that index health and social sciences literature, and google scholar, were searched. Eligible articles were subjected to critical appraisal. Extracted data from the eligible studies were synthesised using narrative synthesis.

FINDINGS

Nine studies were eligible for this review. The review identified seven key barriers to screening for alcohol or other drugs in pregnancy, namely competing priorities and time constraint; lack of adequate screening skills and clear protocol; relationship between healthcare providers and pregnant women; healthcare providers' perceptions; under-reporting or none/false disclosure; inconclusive evidence regarding the risk of alcohol or other drug use in pregnancy; and concerns about guilt and anxiety.

CONCLUSIONS

The narrative review revealed a range of barriers to screening for alcohol or other drugs in pregnancy. Further research in minimising the barriers is required to establish women-centred, evidence-base screening practices.

The effect of an educational intervention in early pregnancy with spouse's participation on optimal gestational weight gain in pregnancy: a randomized controlled trial

Gaining weight above the Institute of Medicine recommended range contributes to the development of obesity, which increases risk for diseases. We evaluated the effectiveness of an educational program with the spouse's participation on the optimal gestational weight gain (GWG) in pregnancy. We conducted a randomized controlled trial on 128 nulliparous women attending Najmieh Hospital-Antenatal Clinic based in Tehran-Iran. Participants randomly allocated into two groups of interventions and one control group. In group A, the women received education with their spouse's participation. In group B, the women received education without the participation of the spouses. In the control group, women received only routine prenatal care. Data were analysed by the ANOVA and Chi-square coefficient. The mean of the total GWG in the groups A and B was significantly lower than the control group (13.50 ± 3.85, 13.55 ± 3.20 and 15.53 ± 4.20 kg, respectively, P > 0.05). The rate of optimal GWG in groups A and B was 1.97 and 1.77 times of the control group, respectively (P < 0.05). The percentage of non-optimal GWG significantly decreased (P < 0.05). Groups A and B were not significantly different indicating no effect of spousal presence.

Realist evaluation of an enhanced health visiting programme

Background

The health visitors’ role in many countries is changing. In Scotland, the role has undergone substantial changes through the introduction of an enhanced health visiting programme, which includes increased, structured home visits. This evaluation was conducted within NHS Ayrshire and Arran, one of the 14 Scottish Health Boards. Our aim was to understand and explain how, and why, the programme could contribute to improving health and wellbeing outcomes for children and families.

Methods

We used a realist evaluation approach, conducted in three phases. In phase one, eight managerial staff involved in developing and implementing the programme provided data, which were used to develop initial programme theories. In phase two, the programme theories were tested using qualitative data from 25 health visitors and 22 parents. The programme theories were refined through analyses and interpretation of data in phase three.

Results

The home visiting context provided by the programme interacted with the mechanisms of the programme and produced outcomes such as early identification of health and wellbeing issues amongst families who needed more support, leading to referral and engagement with sources of additional help. The home visits facilitated development of parent-health visitor relationships, and parents considered health visitors as their first point of contact on children’s wellbeing and developmental-related issues. Moreover, the programme provided more clarity to health visitors’ role, which in turn enhanced partnership working. However, there were aspects of the programme that may require further development. For instance, both parents and health visitors were concerned about the wide gaps between some home visits.

Conclusions

The enhanced health visiting programme increased opportunities for monitoring and early identification of health and wellbeing concerns. It created structures for a more efficient partnership working and ensured that the needs of children and families were supported. These benefits need to be evaluated further in an effectiveness study.