An evaluation of the quality, suitability and impact on equity of clinical practice guidelines relevant to preterm birth for use in Aotearoa New Zealand.

BACKGROUND: Preterm birth is a leading cause of perinatal morbidity and mortality and a defining event for pregnant people, infants, and whanau (extended families). Recommendations have been made for a national preterm birth prevention initiative focusing on equity in Aotearoa New Zealand, including the development of a national best practice guide. An understanding of the number and quality of guidelines, and consideration of their suitability and impact on equity is required. METHODS: Guidelines were identified through a systematic literature search, search of professional bodies websites, and invitation to regional health services in Aotearoa New Zealand. Obstetric and midwifery clinical directors were invited to report on guideline use. Identified guidelines were appraised by a 23-member trans-disciplinary Review Panel; quantitatively using the AGREE-II instrument and qualitatively using modified ADAPTE questions. The quality of guidelines available but not in use was compared against those in current use, and by health services by level of maternity and neonatal care. Major themes affecting implementation and impact on equity were identified using Braun and Clarke methodology. RESULTS: A total of 235 guidelines were included for appraisal. Guidelines available but not in use by regional health services scored higher in quality than guidelines in current use (median domain score Rigour and Development 47.5 versus 18.8, p < 0.001, median domain score Overall Assessment 62.5 versus 44.4, p < 0.001). Guidelines in use by regional health services with tertiary maternity and neonatal services had higher median AGREE II scores in several domains, than those with secondary level services (median domain score Overall Assessment 50.0 versus 37.5, p < 0.001). Groups identified by the Review Panel as experiencing the greatest constraints and limitations to guideline implementation were rural, provincial, low socioeconomic, Maori, and Pacific populations. Identified themes to improve equity included a targeted approach to groups experiencing the least advantage; a culturally considered approach; nationally consistent guidance; and improved funding to support implementation of guideline recommendations. CONCLUSIONS: We have systematically identified and assessed guidelines on preterm birth. High-quality guidelines will inform a national best practice guide for use in Taonga Tuku Iho, a knowledge translation project for equity in preterm birth care and outcomes in Aotearoa.

Detection of small for gestational age babies and perinatal outcomes following implementation of the Growth Assessment Protocol at a New Zealand tertiary facility: An observational intervention study.

BACKGROUND: Timely detection of small for gestational age (SGA) fetuses is important for reducing severe perinatal morbidity and mortality, and better tools are needed to detect SGA in maternity care. AIM: We evaluated the effect of the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) in the Counties Manukau Health region, South Auckland, New Zealand, on antenatal detection of SGA and maternal and perinatal outcomes. MATERIALS AND METHODS: Uncontrolled before and after study in women booked under hospital community midwife care with a singleton, non-anomalous pregnancy. Antenatal detection of SGA (birthweight <10th customised centile) was compared pre-GAP (2012, N = 1105) and post-GAP (2017, N = 1082). Composite adverse neonatal outcome was defined as neonatal unit admission >48 h, five-minute Apgar score <7, and/or any ventilation. Analyses were adjusted for maternal age, body mass index, deprivation, smoking and ethnicity. RESULTS: SGA rates were similar across epochs (13.8% vs 12.9%) but antenatal detection of SGA increased from 22.9% (35/153) to 57.9% (81/140) post-GAP (adjusted odds ratio (aOR) = 4.8, 95% CI 2.82-8.18). Rates of induction of labour and caesarean section increased between epochs but were similar in SGA, non-SGA, and detected and non-detected SGA subgroups. Among SGA babies, there was some evidence that antenatal detection of SGA may be associated with lower composite adverse neonatal outcome (detected SGA: aOR 0.44 95% CI 0.17-1.15; non-detected SGA: aOR = 1.81 95% CI 0.73-4.48; interaction P = 0.03). Pre-term birth did not appear to be influenced by GAP. CONCLUSION: Implementation of GAP was associated with a nearly five-fold increase in SGA detection without increasing obstetric intervention for SGA.

Enablers and barriers for women with gestational diabetes mellitus to achieve optimal glycaemic control - a qualitative study using the theoretical domains framework.

BACKGROUND: Glycaemic target recommendations vary widely between international professional organisations for women with gestational diabetes mellitus (GDM). Some studies have reported women's experiences of having GDM, but little is known how this relates to their glycaemic targets. The aim of this study was to identify enablers and barriers for women with GDM to achieve optimal glycaemic control. METHODS: Women with GDM were recruited from two large, geographically different, hospitals in New Zealand to participate in a semi-structured interview to explore their views and experiences focusing on enablers and barriers to achieving optimal glycaemic control. Final thematic analysis was performed using the Theoretical Domains Framework. RESULTS: Sixty women participated in the study. Women reported a shift from their initial negative response to accepting their diagnosis but disliked the constant focus on numbers. Enablers and barriers were categorised into ten domains across the three study questions. Enablers included: the ability to attend group teaching sessions with family and hear from women who have had GDM; easy access to a diabetes dietitian with diet recommendations tailored to a woman's context including ethnic food and financial considerations; free capillary blood glucose (CBG) monitoring equipment, health shuttles to take women to appointments; child care when attending clinic appointments; and being taught CBG testing by a community pharmacist. Barriers included: lack of health information, teaching sessions, consultations, and food diaries in a woman's first language; long waiting times at clinic appointments; seeing a different health professional every clinic visit; inconsistent advice; no tailored physical activities assessments; not knowing where to access appropriate information on the internet; unsupportive partners, families, and workplaces; and unavailability of social media or support groups for women with GDM. Perceived judgement by others led some women only to share their GDM diagnosis with their partners. This created social isolation. CONCLUSION: Women with GDM report multiple enablers and barriers to achieving optimal glycaemic control. The findings of this study may assist health professionals and diabetes in pregnancy services to improve their care for women with GDM and support them to achieve optimal glycaemic control.