Second-phase implementation and sustainability strategies to increase and sustain antenatal care addressing alcohol consumption: a stepped-wedge controlled trial

Although previous trials found that implementation strategies improved antenatal care addressing alcohol consumption in pregnancy, care provision remained sub-optimal and improvements dissipated over time. This study assessed the effectiveness of second phase implementation and sustainability strategies, informed by findings from a previous trial, in: i) increasing the proportion of pregnant people who received evidence-based antenatal care addressing alcohol consumption; and ii) sustaining the rate of care over time. A stepped-wedge controlled trial was conducted within three sectors (one urban, two regional/rural) of a local health district in Australia. All maternity services received second-phase implementation strategies (remind clinicians, facilitation, conduct educational meetings) for two-months to support increased care provision and sustainability strategies (develop a formal implementation blueprint, purposely re-examine the implementation, conduct ongoing training) for an additional month to support sustainment. Primary outcomes were the proportion of people that reported receiving assessment and complete care appropriate to their alcohol risk level during their antenatal appointment. These data were collected for 24 months via surveys of randomly selected pregnant people who had recently attended an early, first comprehensive or subsequent (28- and 36-weeks’ gestation) antenatal visit. Logistic regression models assessed intervention effectiveness. Additional data was collected in the urban sector to explore sustainment of care receipt one-year following the end of implementation support using time series analysis. The implementation strategies were effective in increasing the proportion of pregnant people who reported receiving complete care appropriate to their alcohol risk level at early visits (36.31% vs 47.57%; OR: 1.59; 95% CI: 1.16, 2.18) and being asked about alcohol (36.75% vs 44.30%; OR: 1.29; 95% CI: 1.09, 1.54) and receiving complete care (18.16% vs 24.60%; OR: 1.38; 95% CI: 1.12, 1.70) at subsequent visits. There were no significant increases in complete care at first comprehensive visits. During the sustainment assessment phase, there was no significant changes in the proportion of people reporting receiving any care outcomes. Implementation and sustainability strategies informed by findings from a previous implementation trial can further improve and sustain antenatal care addressing alcohol consumption in pregnancy. Australian and New Zealand Clinical Trials Registry, ACTRN12622000295741 (16/02/2022) https://www.anzctr.org.au/ACTRN12622000295741.aspx