Identifying pregnant women at risk of poor birth outcomes

The effectiveness of implementation strategies in improving preconception and antenatal preventive care: a systematic review

BACKGROUND

Clinical guideline recommendations for addressing modifiable risk factors are not routinely implemented into preconception and antenatal care. This review assessed the effectiveness of implementation strategies in improving health professional provision of preconception and antenatal care addressing tobacco smoking, weight management and alcohol consumption.

METHODS

A systematic review of randomised and non-randomised studies with a parallel comparison group was conducted. Eligible studies used implementation strategy/ies targeted at health professionals to improve at least one element of preconception and/or antenatal care (smoking: ask, advise, assess, assist, arrange; weight/alcohol: assess, advise, refer) compared to usual practice/control or alternative strategies. Eligible studies were identified via CENTRAL, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL and other sources. Random-effects meta-analyses were conducted where appropriate, with other findings summarised using the direction of effect. The certainty of the pooled evidence was assessed using the GRADE approach.

RESULTS

Fourteen studies were included in the review. Thirteen were in the antenatal period and 12 tested multiple implementation strategies (median: three). Meta-analyses of RCTs found that implementation strategies compared to usual practice/control probably increase asking (OR: 2.52; 95% CI: 1.13, 5.59; 3 studies; moderate-certainty evidence) and advising (OR: 4.32; 95% CI: 3.06, 6.11; 4 studies; moderate-certainty evidence) about smoking and assessing weight gain (OR: 57.56; 95% CI: 41.78, 79.29; 2 studies; moderate-certainty evidence), and may increase assessing (OR: 2.55; 95% CI: 0.24, 27.06; 2 studies; low-certainty evidence), assisting (OR: 6.34; 95% CI: 1.51, 26.63; 3 studies; low-certainty evidence) and arranging support (OR: 3.55; 95% CI: 0.50, 25.34; 2 studies; low-certainty evidence) for smoking. The true effect of implementation strategies in increasing advice about weight gain (OR: 3.37; 95% CI: 2.34, 4.84; 2 non-randomised studies; very low-certainty evidence) and alcohol consumption (OR: 10.36; 95% CI: 2.37, 41.20; 2 non-randomised studies; very low-certainty evidence) is uncertain due to the quality of evidence to date.

CONCLUSIONS

Review findings provide some evidence to support the effectiveness of implementation strategies in improving health professional delivery of antenatal care addressing smoking and weight management. Rigorous research is needed to build certainty in the evidence for improving alcohol and weight gain advice, and in preconception care.

TRIAL REGISTRATION

PROSPERO-CRD42019131691.

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).

Are antenatal interventions effective in improving multiple health behaviours among pregnant women? A systematic review protocol

BACKGROUND

Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women.

METHODS

Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form.

DISCUSSION

The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095315.

Implementation strategies to improve preconception and antenatal care for tobacco smoking, alcohol consumption and weight management: a systematic review protocol

BACKGROUND

Despite existing best practice care recommendations for addressing tobacco smoking, alcohol consumption and weight management in preconception and antenatal care, such recommendations are often not implemented into routine practice. Effective strategies that target known barriers to implementation are key to reducing this evidence to practice gap. The aim of this review is to synthesise the evidence on the effectiveness of implementation strategies in improving the provision of preconception and antenatal care for these modifiable risk factors.

METHODS

Randomised and non-randomised study designs will be eligible for inclusion if they have a parallel control group. We will include studies that either compare an implementation strategy to usual practice or compare two or more strategies. Participants may include any health service providing preconception or antenatal care to women and/or the health professionals working within such a service. The primary outcome will be any measure of the effectiveness of implementation strategies to improve preconception and/or antenatal care for tobacco smoking, alcohol consumption and/or weight management (including care to improve nutrition and/or physical activity). Secondary outcomes will include the effect of the implementation strategy on women's modifiable risk factors, estimates of absolute costs or cost-effectiveness and any reported unintentional consequences. Eligible studies will be identified via searching Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Maternity and Infant Care, CINAHL, ProQuest Dissertations and Theses and other sources (e.g. contacting experts in the field). Study selection, data extraction and risk of bias will be assessed independently by two review authors and differences resolved by a third reviewer. If data permits, we will conduct fixed-effects or random-effects meta-analysis where appropriate. If studies do not report the same outcome or there is significant heterogeneity, results will be summarised narratively.

DISCUSSION

This review will identify which implementation strategies are effective in improving the routine provision of preconception and antenatal care for tobacco smoking, alcohol consumption and weight management. Such a review will be of interest to service providers, policy makers and implementation researchers seeking to improve women's modifiable risk factors in preconception and antenatal care settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019131691.

Application of space-time disease clustering by administrative databases in Italy: Adverse Reproductive Outcomes (AROs) and residential exposure

BACKGROUND

The aims of this study were to estimate the existence of clusters of AROs in the municipalities of the Marches Region (Central Italy) after complaints from residents living near an abandoned landfill site.

METHODS

Cases of AROs (i.e., congenital malformation, chromosomal abnormalities, and low birth weight) were retrieved from hospital discharge data. SaTScan and GeoDa were used to check for the presence of clusters at a regional and a small area level. Moreover, at a small area/neighborhood level, smoothed rates were calculated, and a case-control approach was used to assess the residence in proximity to the abandoned landfill as an independent risk factor for AROs.

RESULTS

AROs were associated with the price per square meter of the accommodations in the area of residence (OR 2.53, 95 % CI 2.06-3.10). On the other hand, residence within one kilometer of the landfill (OR 0.04, 95 % CI 0.01-0.23) and maternal age greater than 35 years (OR 0.96, 95 % CI 0.92-0.99) were protective.

CONCLUSIONS

Residency in proximity to the abandoned landfill was not a risk factor for the occurrence of AROs. The results show that basic information, such as the price of accommodations in different neighborhoods, could be of interest in order to target training programs for women living in difficult conditions and highlights the potential role of the building environment in perinatal health. However, we note that aside from the data provided by Geographic Information Systems in public health, collection of the patient's residential address was unreliable for selected conditions. Future efforts should emphasize the patient's residential address as information important for evaluating the health of individuals instead of being merely administrative data.

Which modifiable health risk behaviours are related? A systematic review of the clustering of Smoking, Nutrition, Alcohol and Physical activity ('SNAP') health risk factors

OBJECTIVE

There is a growing body of literature examining the clustering of health risk behaviours, but little consensus about which risk factors can be expected to cluster for which sub groups of people. This systematic review aimed to examine the international literature on the clustering of smoking, poor nutrition, excess alcohol and physical inactivity (SNAP) health behaviours among adults, including associated socio-demographic variables.

METHOD

A literature search was conducted in May 2014. Studies examining at least two SNAP risk factors, and using a cluster or factor analysis technique, or comparing observed to expected prevalence of risk factor combinations, were included.

RESULTS

Fifty-six relevant studies were identified. A majority of studies (81%) reported a 'healthy' cluster characterised by the absence of any SNAP risk factors. More than half of the studies reported a clustering of alcohol with smoking, and half reported clustering of all four SNAP risk factors. The methodological quality of included studies was generally weak to moderate. Males and those with greater social disadvantage showed riskier patterns of behaviours; younger age was less clearly associated with riskier behaviours.

CONCLUSION

Clustering patterns reported here reinforce the need for health promotion interventions to target multiple behaviours, and for such efforts to be specifically designed and accessible for males and those who are socially disadvantaged.

Revisiting the association between maternal smoking during pregnancy and ADHD

OBJECTIVE

Studies examining the relationship between maternal smoking during pregnancy and the development of Attention Deficit Hyperactivity Disorder (ADHD) among offspring have yielded mixed results, with some studies suggesting a strong association and others finding no association. These studies have varied in quality of design and measures. The purpose of this study was to evaluate the association between maternal smoking during pregnancy and offspring ADHD, using detailed prospective smoking data and subsequent follow-up data from the Collaborative Perinatal Project (CPP).

METHOD

Maternal smoking status was collected throughout pregnancy during the original CPP study. Offspring were followed-up in early adulthood and questioned about ADHD symptoms and diagnosis. Logistic regression was used to model the association between maternal smoking during pregnancy and ADHD. Linear and logistic regression were used to examine clinical characteristics and remission rates associated with ADHD in relation to maternal smoking.

RESULTS

No association was found between maternal smoking during pregnancy and offspring ADHD. Further, no differences in age of onset, number of symptoms, or likelihood of remission were found among ADHD subjects with and without a history of maternal smoking during pregnancy.

CONCLUSIONS

These findings do not support the hypothesis that maternal smoking during pregnancy is causally related to ADHD. Ongoing research should continue to strive to identify those environmental or genetic factors that may enhance the impact of maternal smoking on ADHD or that may be associated more clearly with the development and potential prevention of ADHD.