Background
The presence of modifiable risk factors prior to conception and during pregnancy can have significant implications for pregnant women and their babies [
1]. Three of the most prevalent modifiable risk factors that can adversely impact pregnancy and offspring outcomes are tobacco smoking, alcohol consumption and gestational weight gain outside of recommended ranges (including inadequate nutrition and physical activity) [
1]. Internationally, it is estimated that during pregnancy: 10% of women smoke tobacco [
2‐
4], 10% consume alcohol [
5] and 68% gain weight outside of recommended ranges [
1,
6‐
8]. However, these rates vary considerably and reported prevalence in some countries and population groups is much higher [
1]. Each of these modifiable risk factors is associated with an increased risk of pregnancy complications and poor obstetric outcomes, including spontaneous abortion, small or large for gestational age, preterm birth and need for neonatal intensive care [
6,
9‐
12]. Further negative impacts of these risk factors include poor infant and child outcomes, such as developmental delay and obesity, which can have long term consequences and increase the risk of chronic diseases in adulthood [
6,
9,
13‐
15]. Clustering of these modifiable risk factors prior to and during pregnancy is also well established, which can increase such risks through cumulative effects [
16‐
18].
Timely access to health care prior to pregnancy (preconception care) and during pregnancy (antenatal or prenatal care) contributes to better maternal and child health outcomes and fewer clinical interventions [
1,
19]. Clinical guidelines provide best practice care recommendations for health professionals who see women prior to and during pregnancy [
1,
20‐
23]. Such guidelines recommend that as part of routine preconception and antenatal care, all women are universally assessed for tobacco smoking, alcohol consumption and weight; provided advice; and offered targeted support (e.g. counselling, brief intervention or pharmaceutical support) if required [
1,
20‐
23]. As part of weight management care, it is further recommended that women receive advice and appropriate support for nutrition and physical activity [
1,
20‐
23].
Such guidelines are supported by systematic review evidence that indicates interventions are effective in reducing these risk factors prior to and during pregnancy. For example, psychosocial interventions are effective in increasing smoking cessation during pregnancy [
24]; psychological, educational and brief interventions are effective in reducing alcohol consumption and increasing alcohol abstinence during pregnancy [
25,
26]; and educational and behavioural interventions targeting nutrition and/or physical activity are effective in preventing excessive gestational weight gain [
27,
28]. Preconception care may also be effective in improving risk factors prior to pregnancy [
8], including lowering rates of risky alcohol consumption [
29].
Despite the existence of clinical guideline recommendations and evidence for interventions addressing modifiable risk factors in preconception and antenatal settings, many women do not routinely receive such best practice care [
30]. For example, a study of 1173 women in the UK reported low levels of receipt of preconception advice from general practitioners on tobacco smoking (13%), alcohol consumption (13%) and healthy weight (10%) [
31]. An Australian study of 223 pregnant women found that the majority of women reported being asked about smoking (97%) and alcohol (92%) during their antenatal care, but less than half (48%) reported having their weight gain assessed [
32]. Of those women who reported requiring further support to manage their risks, 62% were offered assistance for smoking, 10% for alcohol consumption and 36% for weight management [
32]. With these varying levels of care provision, clinical guideline recommendations designed to improve pregnancy outcomes are unlikely to achieve their intended benefits and, as such, strategies are needed to reduce the current evidence to practice gap in guideline care.
Implementation frameworks recommend that system and individual level barriers to care provision need to be identified so that appropriate behaviour change techniques are applied when selecting strategies to improve practice [
33]. Numerous barriers have previously been reported to impede health professional’s provision of care for tobacco smoking, alcohol consumption and weight management in preconception and antenatal care settings, including lack of supporting systems, resources and time within the consult [
34‐
43]; lack of knowledge of the risk factors and care procedures [
38,
43]; lack of skills and confidence in delivering care to women and limited training opportunities to address this [
35,
36,
39,
41,
43,
44]; and a reluctance to ask women about their health risks due to a perception that it will have a negative effect on the client-clinician relationship [
43]. Such barriers present a considerable challenge for health professionals and managers seeking to improve guideline implementation in these settings [
33].
A number of systematic reviews have reported on the effectiveness of implementation strategies in improving care when similar barriers are present in health care settings more broadly, including prompts and system reminders [
45], educational meetings and materials [
46,
47], educational outreach visits [
48,
49], local opinion leaders [
50‐
52] and audit and feedback [
53]. Specific to the antenatal setting, one previous review has reported on the effectiveness of strategies in increasing smoking cessation care [
54] and another has reported on health provider focussed interventions to support obese pregnant women [
55], with the latter review identifying no eligible studies. Despite tobacco smoking, alcohol consumption and weight gain outside of recommended ranges often co-occurring in pregnant women, and preconception and antenatal guideline recommendations and reported barriers to care provision being similar across these modifiable risk factors, no reviews to date have synthesised the evidence for the effectiveness of implementation strategies in increasing preconception and antenatal care across these modifiable risk factors.
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