Antenatal screening practices in the WHO European Region: a mixed methods study

Background Literature suggests an increasing trend towards more screening tests, while awareness of potential harms of screenings has been reported to be sub-optimal. This paper aimed to characterize ANC screening practices within the 53 countries of the WHO Europe Region and compare these to evidenced-based recommendations from WHO and from other key reference sources. Methods From January 2019 to July 2019 we conducted a survey among key informants (KIs) in the 53 countries of the WHO European Region and a systematic review of literature. KIs were invited to answer an online structured questionnaire, available both in English and Russian. Published and unpublished guidelines, policies or cross-sectional studies on ANC screening practices were searched for in four electronic databases (MEDLINE, Global Health Library, Web of Science, Google) and also sent by KIs. Data obtained from both methods were analysed and triangulated by two independent authors. Results Overall 42 countries participated in the survey. Among these, 36 (86%) reported national guidelines on ANC screening, but only 26 (61.9%) reported up-to-date and comprehensive guidelines. All countries reported supplemental use other guidelines, with 19 (45.2%) using more than three. When looking at current evidence-based recommendations, only one (ultrasound before 24 weeks) was reported to be implemented in all countries. Overall, 35 (83.3%) countries reported using at least five not-recommended ANC screening practices, with 21 (50%) implementing ≥10 not-recommended ANC screening practices. The systematic review resulted in 11871 records, with 111 (90 guidelines, 4 policies, 17 cross-sectional studies) matching inclusion criteria. Findings from the systematic review were largely consistent with those of the online survey: among the most comprehensive national guidelines identified, only six (24%) had a concordance ≥75% with the reference recommendations, independently from their publication date, while the few existing cross-sectional studies highlighted large heterogeneity in the implementation of ANC practices among countries. Conclusions Guidance on and implementation of evidenced-based recommendations on ANC screening is suboptimal in the WHO European Region. It is necessary to increase the availability of evidence-based high-quality national guidelines and their concrete use in routine practice.

Methods Qualitative approach and research paradigm -Qualitative approach (e.g., ethnography, grounded theory, case study, phenomenology, narrative research) and guiding theory if appropriate; identifying the research paradigm (e.g., postpositivist, constructivist/ interpretivist) is also recommended; rationale** 9-10 Researcher characteristics and reflexivity -Researchers' characteristics that may influence the research, including personal attributes, qualifications/experience, relationship with participants, assumptions, and/or presuppositions; potential or actual interaction between researchers' characteristics and the research questions, approach, methods, results, and/or transferability NA Context -Setting/site and salient contextual factors; rationale** 9 Sampling strategy -How and why research participants, documents, or events were selected; criteria for deciding when no further sampling was necessary (e.g., sampling saturation); rationale** 9-10 Ethical issues pertaining to human subjects -Documentation of approval by an appropriate ethics review board and participant consent, or explanation for lack thereof; other confidentiality and data security issues 14 Data collection methods -Types of data collected; details of data collection procedures including (as appropriate) start and stop dates of data collection and 9-11 analysis, iterative process, triangulation of sources/methods, and modification of procedures in response to evolving study findings; rationale** Data collection instruments and technologies -Description of instruments (e.g., interview guides, questionnaires) and devices (e.g., audio recorders) used for data collection; if/how the instrument(s) changed over the course of the study 9,10; S3 Appendix Units of study -Number and relevant characteristics of participants, documents, or events included in the study; level of participation (could be reported in results) 9-10; S4 Appendix Data processing -Methods for processing data prior to and during analysis, including transcription, data entry, data management and security, verification of data integrity, data coding, and anonymization/de-identification of excerpts 10 Data analysis -Process by which inferences, themes, etc., were identified and developed, including the researchers involved in data analysis; usually references a specific paradigm or approach; rationale** 10 Techniques to enhance trustworthiness -Techniques to enhance trustworthiness and credibility of data analysis (e.g., member checking, audit trail, triangulation); rationale** 10-11 Results/findings Synthesis and interpretation -Main findings (e.g., interpretations, inferences, and themes); might include development of a theory or model, or integration with prior research or theory [15][16][17] Links to empirical data -Evidence (e.g., quotes, field notes, text excerpts, NA Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

11-12
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched.

11-12
Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated.

S5
Appendix Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

11-13
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

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Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made. You have been identified as an expert in this field. We kindly ask you to answer the 20 questions of the survey.
Time needed is less than 10-12 minutes.
Please note that the questions aim at identifying antenatal screening practices in your country/institution (which may differ from what you do at your personal level).

WHY TO PARTECIPATE
Your help is very much appreciated; results will aid improving practices within the Region! Survey findings will be published as a technical report and a scientific paper. We will acknowledge survey respondents in these publications. (tw:(antenatal screening)) OR ((tw:(maternal OR pregnancy OR prenatal)) AND (tw:(screening OR testing OR diagnosis OR examination OR investigation OR test))) AND (instance:"ghl") AND ( mj:("Pregnancy" OR "Prenatal Diagnosis") AND clinical_aspect:("diagnosis") AND la:("en")) weeks 0 days and 20 weeks 6 days.

Recommended
Recommended 9 Adapted and integrated from the WHO publication Systematic screening for active tuberculosis: principles and recommendations (2013). 10 SFH measurement is routinely practiced in many ANC settings. Due to a lack of clear evidence of accuracy or superiority of either SFH measurement or clinical palpation to assess fetal growth, the GDG does not recommend a change of practice.
• The GDG agreed that there is a lack of evidence on SFH, rather than a lack of effectiveness, particularly in LMIC settings.
• Apart from false reassurance, which might occur with both SFH measurement and clinical palpation, there is no evidence of harm with SFH measurement.
• Research is needed to determine the role of SFH measurement in detecting abnormal fetal growth and other risk factors for perinatal morbidity (e.g. multiple pregnancy, polyhydramnios) in settings where antenatal ultrasound is not available.
11 Stakeholders should consider offering a late ultrasound scan to pregnant women who have not had an early ultrasound scan, for the purposes of identifying the number of fetuses, presentation and placental location.   No data available 1 ANC screening practices "recommended" and "not recommended" by reference guidelines