This study explored antenatal care provider practices and barriers to providing GWG care and examined differences by professional disciple and years of experience. The findings show that the majority of antenatal care providers, regardless of their professional discipline and experience, did not provide care consistent with the past (14) or current (35) Australian Clinical Practice Guidelines for Pregnancy Care. There were particularly low levels of routine care for all women (<10% of antenatal care providers) for the recommended practices of weighing at follow-up visits and providing advice on GWG, healthy eating and physical activity. Skills, belief about capabilities, beliefs about consequences and environmental context and resources were identified as key barriers to providing GWG care, including in providing culturally appropriate care for Aboriginal women. Medical professionals had higher odds of agreeing that they had been adequately trained (domain: skills) and felt competent in conversing (domain: belief about capabilities) with pregnant women about GWG than midwives. Midwives had higher odds of agreeing that there are support services that they can refer pregnant women to for further GWG care (domain: environmental context and resources).
Most antenatal care providers in the study reported that they did not routinely (i.e., ‘almost always; > 90%) provide all elements of GWG assessment at the first or follow-up antenatal visits. The findings on infrequent weighing at follow-up antenatal visits may be influenced by the preceding Australian Clinical Practice Guidelines for Antenatal Care (2012) that recommended that repeat weighing ‘be confined to circumstances that are likely to influence clinical management’ (14). In February 2018, the month after this study, the Australian Clinical Practice Guidelines changed to recommend routine weighing of all women at all appointments (35). The revised Clinical Practice Guidelines were distributed via a web-based approach (35). Systematic review evidence has shown that such passive dissemination methods are usually ineffective in supporting adherence to clinical guideline practices (36). This is likely to have contributed to low and slow uptake of the new recommended practice of routining weighing at all visits. Governments, policy makers, clinical practice guideline developers, and health services need to employ evidenced based implementation strategies to support health care providers to uptake new care practices with changing clinical guidelines if intended population health gains are to be achieved.
Few antenatal care providers reported routinely providing all recommended advice elements of care (7%) to women, including discussing a GWG recommended range, healthy eating or physical activity at the first antenatal visit, which were recommended in both the 2012 (14) and 2018 Clinical Practice Guidelines (35). The findings are consistent with low levels of advice found in previous research, with 22% of Australian obstetricians and midwives advising women of specific weight targets (19), compared with 15% of UK midwives (37) and 21% of Canadian prenatal healthcare providers (20). Our study found no association between health profession characteristics and the provision of advice. This suggests that all antenatal care providers, regardless of their professional discipline or experience, encounter barriers to discussing GWG and eating and physical activity behaviours with pregnant women and require support to change their practices.
The findings show that antenatal care providers know there is a strong rationale to provide GWG care, however, they face individual and organisational barriers in doing so. Key barriers include inadequate skills and belief in their capabilities to address GWG, particularly with pregnant Aboriginal women; a belief that the consequence of providing care will make some pregnant women feel uncomfortable or judged; and environmental context and resourcing challenges with a lack of known culturally appropriate referral pathways. Such barriers are consistent with existing evidence (15, 21, 23, 24), including previous research using the Theoretical Domains Framework (TDF) (24), which showed a reluctance by antenatal care providers to discuss GWG due to a perceived lack of knowledge and skills, a belief that care may have negative consequences on their patient relationships, and an unsupportive environment and lack of resources (24). Midwives were more likely to report inadequate training and lower competence in their communication skills as barriers than medical professionals. While a need for training to address weight management is consistent with past research (19, 24, 38-41), the difference in perceived competence in communication skills between midwives and medical professionals is a novel finding. The general training and role of communication skills in medical curriculum may result in a higher perceived ability among medical professionals to have such conversations (42). Medical professionals reported a lack of appropriate referral options as a greater barrier than midwives, which may relate to a lack of knowledge of local community referral pathways. The findings indicate that the type and prioritisation of practice-change implementation strategies need to be tailored to address the common and differential barriers faced by professional groups (43), including to provide culturally appropriate care and referral options with Australian Aboriginal pregnant women and their families.
This evidence informs the selection of implementation strategies to improve GWG care. The Behaviour Change Wheel (44) can be used to map the barriers to the COM-B, intervention functions and behaviour change techniques. Training, education, persuasion, modelling, environmental restructuring, and enablement are evidenced-based implementation strategies (44) that address key barriers reported by antenatal care providers in this study. Systematic review evidence has shown that use of multiple implementation strategies result in increases in guideline adherence of up to 60% (36). Individually, the use of interactive education strategies can result in improvements of 1-39% (36). Face-to-face and/or online interactive training and education for antenatal care providers with instruction, demonstration and practice of recommended GWG care and behaviour change communication skills may be delivered by a local champion (i.e., clinical midwife educator) to address skill deficits, model recommended practices and provide social support (44). Local data and testimonials on women’s acceptability of receiving GWG care could provide information on the positive social and emotional consequences of providing care (44). Embedding training within antenatal services’ existing professional learning systems could aid sustainability as high staff turnover is a major barrier in maintaining practice implementation in clinical settings (45). Clinical reminder and decision support systems can result in improvements in guideline adherence of 8-71.8% (36). Restructuring the physical environment by modifying electronic medical record systems may enable recommended GWG care through clear instruction on how to assess, advise and refer within the context of each maternity service and the local culturally appropriate referral services available (44). It may also remind antenatal care providers to deliver each care element and track GWG at the point-of-care (44).
Several limitations need to be considered when interpreting the findings of this study. While the study achieved a high participation rate, antenatal care providers were recruited from three maternity service so the findings may not be generalizable to other maternity services in Australia and internationally. Further, few Aboriginal health workers or student health professionals completed the survey, therefore the findings should be interpreted with such consideration. These limitations could be addressed in future research by conducting surveys across a range of maternity settings, professions, and regions to ensure appropriate representation of all services and health care providers of antenatal care. The use of self-reported data is inherently subject to limitations such as recall bias and social desirability bias (46). While the survey items to assess barriers and facilitators to recommended GWG care were based on a validated TDF instrument (33), for the practical reason of having limited time (5-10 minutes) in meetings for antenatal service providers to complete the survey, we adapted the full survey to use only a selection of items and these were not re-validated. Further qualitative research would provide more in-depth and contextual information to complement these quantitative survey measures to support co-design of the implementation strategies.