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

ABSTRACT

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.