Benefits of caseload midwifery to prevent fetal alcohol spectrum disorder: A discussion paper

Implementation barriers and enablers of midwifery group practice for vulnerable women: a qualitative study in a tertiary urban Australian health service

Background

Maternity services have limited formalised guidance on planning new services such as midwifery group practice for vulnerable women, for example women with a history of substance abuse (alcohol, tobacco and other drugs), mental health challenges, complex social issues or other vulnerability. Continuity of care through midwifery group practice is mostly restricted to women with low-risk pregnancies and is not universally available to vulnerable women, despite evidence supporting benefits of this model of care for all women. The perception that midwifery group practice for vulnerable women is a high-risk model of care lacking in evidence may have in the past, thwarted implementation planning studies that seek to improve care for these women. We therefore aimed to identify the barriers and enablers that might impact the implementation of a midwifery group practice for vulnerable women.

Methods

A qualitative context analysis using the Consolidated Framework for Implementation Research was conducted at a single-site tertiary health facility in Queensland, Australia. An interdisciplinary group of stakeholders from a purposeful sample of 31 people participated in semi-structured interviews. Data were analysed using manual and then Leximancer computer assisted methods. Themes were compared and mapped to the Framework.

Results

Themes identified were the woman’s experience, midwifery workforce capabilities, identifying “gold standard care”, the interdisciplinary team and costs. Potential enablers of implementation included perceptions that the model facilitates a relationship of trust with vulnerable women, that clinical benefit outweighs cost and universal stakeholder acceptance. Potential barriers were: potential isolation of the interdisciplinary team, costs and the potential for vicarious trauma for midwives.

Conclusion

There was recognition that the proposed model of care is supported by research and a view that clinical benefits will outweigh costs, however supervision and support is required for midwives to manage and limit vicarious trauma. An interdisciplinary team structure is also an essential component of the service design. Attention to these key themes, barriers and enablers will assist with identification of strategies to aid successful implementation. Australian maternity services can use our results to compare how the perceptions of local stakeholders might be similar or different to the results presented in this paper.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08633-8.

Prevalence and Patterns of Prenatal Alcohol Exposure in Australian Cohort and Cross-Sectional Studies: A Systematic Review of Data Collection Approaches

This study sought to determine data collection approaches in Australian cohort studies and explore the potential impact on reported prenatal alcohol exposure (PAE) prevalence and patterns. Inclusion criteria were that studies related to a general Australian antenatal population where PAE was assessed and reported. Studies were excluded if they were not peer reviewed, examined the prevalence of PAE in pregnancies complicated by alcohol-use disorders, or were published in a language other than English. A systematic search of five electronic databases (PubMed, Embase, CINAHL, Web of Science, and Scopus) was conducted. Risk of bias was assessed using the Effective Public Health Practice Project quality assessment tool. Results were synthesised using MetaXL. Data from 16 separate birth cohorts (n = 78 articles) were included. Included cohorts were either general cohorts that included alcohol as a variable or alcohol-focused cohorts that were designed with a primary focus on PAE. PAE prevalence was estimated as 48% (95% CI: 38 to 57%). When subgroup analysis was performed, estimates of PAE prevalence when self-administered surveys and interviews were used for data collection were 53% (95% CI: 41% to 64%) and 43% (95% CI: 28% to 59%), respectively. Use of trained assessors was an influencing factor of the prevalence estimates when data were collected via interview. Alcohol-focused studies reported higher prevalence of PAE, regardless of method of survey administration. Where interviewer training is not possible, self-administered questionnaires will likely provide the most reliable PAE estimates. No funding sources are relevant to mention. Review was registered with PROSPERO (CRD42020204853).

It takes a village: Influencing policy and practice to prevent alcohol use in pregnancy and promote better outcomes for individuals living with Fetal Alcohol Spectrum Disorder

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by exposure to alcohol in utero. It has pervasive, lifelong impacts and is recognised as a major public health concern in many countries where alcohol is used. The FASD Research Australia Centre of Research Excellence (CRE) was funded by the National Health and Medical Research Council to generate and translate evidence to address prevention, diagnosis, and management of FASD in Australia. The current paper describes the approach to policy and practice impact taken by our CRE, including our stakeholder engagement processes and the key principles that underlie our approach. We provide examples of policy and practice influence in FASD prevention, diagnosis and management that have been achieved over the past five years and discuss challenges that are routinely faced in the translation of our work.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

Introduction

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research.

Objectives

Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified.

Methods

The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each.

Results

A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants.

Conclusion

There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities.

Key Words

Community, priorities, FASD, rapid review, Australia.

Prevention of Alcohol-Exposed Pregnancies and Fetal Alcohol Spectrum Disorder Among Pregnant and Postpartum Women: A Systematic Review

BACKGROUND

Prenatal alcohol exposure can result in a wide range of adverse health outcomes, including in some cases fetal alcohol spectrum disorder (FASD), a lifelong neurodevelopmental disorder. Thus, there is pressing need for effective interventions to prevent alcohol-exposed pregnancies (AEPs).

METHODS

A systematic review was undertaken to provide an up-to-date analysis of the current prevention literature. PubMed, Embase, CINAHL, and PsycINFO were searched for relevant English-language articles published from 1970 onward. Studies were eligible for the current systematic review if the interventions included pregnant and postpartum women and/or their support networks to prevent AEPs and FASD. Outcomes of interest included alcohol consumption, knowledge, contraceptive use, neonatal outcomes, family well-being or functioning, economics, and healthcare utilization outcomes.

RESULTS

Thirty-four peer-reviewed studies met the inclusion criteria. Fifteen studies employed brief intervention (BI) methods, 6 used long-term/intensive strategies, and 5 were educational interventions. A further 3 studies assessed counseling approaches, 2 evaluated multicomponent interventions, and 3 assessed nutritional supplementation interventions.

CONCLUSIONS

The current review identified variable results from available interventions to prevent alcohol use among pregnant and postpartum women. Preliminary evidence demonstrated that BIs may be effective among subgroups of pregnant women with higher initial alcohol consumption, those with partner involvement, and those who used alcohol and other substances concurrently. Some preliminary evidence relating to long-term interventions with pregnant women with polysubstance use emerged, specifically case management that not only focused on reduction in substance use, but also on addressing the complex interplay between health and social well-being of families. Overall, additional research is required to improve the effectiveness of preventative approaches during pregnancy and the postpartum period.

Fetal alcohol spectrum disorder: the importance of assessment, diagnosis and support in the Australian justice context

Fetal alcohol spectrum disorder (FASD) is a neurodevelopmental condition with life-long implications. Individuals with FASD can experience communication, cognitive, behavioural, social and emotional difficulties that impact their functional capacity. Due to these brain-based impairments, previous research suggests that individuals with FASD are over-represented in the justice system. The current article outlines how individuals with FASD may experience inequities within the justice system, why assessment, diagnosis and intervention is important, and the role of health and justice partnerships in promoting more equitable outcomes for justice-involved individuals with FASD. Increased resources and collaborations between health and justice professionals are required to enable the provision of neurodevelopmental assessments for all complex presentations, including FASD.

Contextual Influences Experienced by Queensland Midwives: A Qualitative Study Focusing on Alcohol and Other Substance Use During Pregnancy

PURPOSE

To understand the experiences and contextual factors that influence the ability of midwives to provide appropriate support to women regarding alcohol and other drug (AOD)e use during pregnancy, in the Queensland context.

DESIGN

Using a qualitative approach underpinned by critical realism, we explored the experiences of eleven midwives using semi-structured interviews. Thematic analysis was utilized, which was inductive and deductive, as it aimed to explicate different contextual factors at play, based on the experiences of the current sample of midwives.

MAJOR FINDINGS

Experiences of midwives in the current study were influenced by five overarching contextual factors: (a) patient-level factors (complexities experienced by women and lack of knowledge regarding maternity care options); (b) provider/patient-level factors (importance of midwives building relationships with women and importance of continuity of care); (c) provider-level factors (importance of taking a supportive approach, midwife confidence, engagement in AOD screening, variable attitudes and knowledge); (d) organizational-level factors (lack of support and training, concerns regarding communication, time constraints and organizations that limited midwife involvement); (e) broader system-level factors (lack of effective services and inconsistent messages regarding AOD use during pregnancy).

CONCLUSIONS

The current study has highlighted a range of practice areas and potential implementation strategies across a number of contextual levels that could be beneficial in the Queensland context to improve maternity care provision for women who are experiencing AOD use challenges during pregnancy.