The effectiveness of a practice change intervention to increase the provision of recommended care for addressing maternal alcohol consumption during pregnancy.

A seven month multi-component clinical practice change intervention will be implemented across three health sectors, which will include a one month wash-in period introducing the practice change and a six month intensive practice change intervention. Practice changes implemented will include the routine provision to all pregnant women of recommended care for addressing alcohol use in pregnancy including: 1) alcohol screening with a validated instrument (i.e. AUDIT-C), 2) provision of brief advice in-line with national guidelines for alcohol consumption in pregnancy, and 3) offer of referral to specialist services for ongoing care if screened to be consuming alcohol at medium or high risk levels. To facilitate these practice changes the following intervention strategies will be implemented: Leadership and consensus support: Existing clinical networks and antenatal clinical leaders will be engaged prior to and during the intervention to facilitate ongoing leadership support for the initiative. A clinical expert group will provide clinical guidance across all components of the intervention. To increase intervention adherence, consensus for the model of care will be sought from clinical stakeholders and formalised through the development of service level guidelines and procedures. Aboriginal health staff will provide oversight regarding cultural appropriateness of the intervention, and specific cultural task groups will be formed. At the service level, antenatal clinicians and service managers will be consulted prior to the intervention to identify potential barriers to clinical practice change and resources required to support practice change. Educational outreach visits and academic detailing: Clinical Midwife Educators (CMEs) will be allocated to the three health sectors for each of the seven month intervention phases to facilitate the implementation of practice change strategies and clinician provision of recommended care for addressing alcohol use in pregnancy. CMEs will advise, train, monitor and provide feedback to antenatal clinicians and service managers, and support local care improvement initiatives. Services will be supported to set practice change goals, monitor progress and develop action plans in response to such feedback. Enabling systems and procedures: Modifications will be made to medical record systems used by antenatal clinicians to prompt standardised point of care assessment of alcohol use using the validated AUDIT-C alcohol screening tool, tailored brief advice based on the AUDIT-C risk score, and referral (if required) for clients requiring further support for alcohol use. Clinician training and resources: Multi-mode training will be provided to clinicians in service with the support of a CME in each of the health sectors. Face-to-face training sessions will be rostered into the health sectors’ routine educational sessions. These sessions vary per sector due to size, geographical dispersion of services within the sectors, and standard training procedures per sector for implementing changes to routine practice. Therefore, the number, frequency and duration of sessions will be tailored to the different sectors to fit within standard procedures for implementing practice change within maternity services. Based on partnership agreements for this project, three hours per clinician has been dedicated through in-kind support from Hunter New England Local Health District Clinical Services Nursing and Midwifery. At least one face-to-face 30-60 minute presentation to introduce the practice change to a number of clinicians (e.g. midwives, staff specialists) will occur within each sector. Additional introductory sessions will be scheduled as needed in health sectors with a larger number of staff or dispersed services. These introductory sessions will be delivered jointly by both senior health promotion staff and a Clinical Midwife Educator. One off expert presentations by an investigator specialising in Fetal Alcohol Spectrum Disorder, and an expert specialising in addressing alcohol and drug use with pregnant clients will be scheduled for each health sector. Face-to-face training will then be delivered to each service within each sector by a CME who is a registered senior midwife with training in antenatal staff education and professional development. Each service has an individual training procedure, of which this training will be incorporated into (e.g. half hour morning briefing). Training will be scheduled in consultation with maternity service managers to mitigate burden on their services. The CME will also provide individual support and feedback to clinicians as they provide antenatal care. The training will relate to the practicalities of providing the new model of care for addressing alcohol use in pregnancy (i.e. assess alcohol use with the AUDIT-C, provide brief advice and refer to specialist services for support if required) at three time points in antenatal care (ie. Booking in visit, 28 week visit, 36 week visit). Clinicians will also complete a 20 minute online learning module delivered via the local health district clinician online learning platform. Training content will be adapted from the nationally accredited ‘Women Want to Know’ course developed by the Foundation for Alcohol Research and Education in partnership with the Australian Government Department of Health. Training will improve clinician knowledge and skills in addressing alcohol use in pregnancy, and will cover content including: * Recommendations for alcohol consumption in pregnancy based on The National Health and Medical Research Council Alcohol Guidelines. *Recommended care for addressing alcohol use in pregnancy based on the Australian Antenatal Care Clinical Practice Guidelines and New South Wales Guidelines for the Management of Substance Use During Pregnancy, Birth and the Postnatal Period. *Effects of alcohol consumption in pregnancy and associated adverse health outcomes for the fetus and child. *Providing recommended care for addressing alcohol use in pregnancy in-line with clinical practice guidelines including 1) alcohol use assessment, 2) brief advice and 3) referral for ongoing care. Monitoring and feedback: Antenatal service managers will be supported to build capacity in accessing, interpreting and monitoring performance measures for clinician provision of recommended care for addressing alcohol use in pregnancy. Performance measures will be built into antenatal services’ existing monitoring and accountability frameworks including Operational Plans, formal performance measures, Sector Performance Report, 90 day action plans, and Monthly Accountability Meetings.