B Terms of reference 10.8Expert Advisory Committee

Managing conflict of interest

No financial conflicts of interest arose for the EAC or working groups. The only conflicts of interest identified involved members being authors of opinion pieces or of studies included in the evidence base for a recommendation. When this was the case, it was noted and the member did not participate in deliberating or decision-making on relevant text in the Guidelines or grading of the evidence. In particular, two members of the EAC (Prof Jeremy Oats and Philippa Middleton) took no part in the discussion and development of the diabetes section and did not participate in the development and finalising of the recommendations and consensus-based recommendations in that section.

Specific declared conflicts of interest, or the potential for a perceived conflict of interest, are shown below.

Name	Conflict of interest
Prof Caroline Homer	Co-authored a report for NSW Health and published papers on Group B streptococcus. She has published in the areas of models of maternity care and pre-eclampsia.
Prof Jeremy Oats	Member of HAPO Study Steering Committee and writing group of IADPSG that developed and published recommendations for classification and testing for gestational diabetes. Also published papers that countered articles that argued the case for either not changing previously used criteria or proposing other criteria. No other relevant conflicts of interest to declare.
Dr Steve Adair	Nil
Ann Catchlove	Nil
Dr Marilyn Clarke	Nil
Prof Warwick Giles	Has published on Group B Streptococcus and participated in and published with the Hyperglycemia and Adverse Pregnancy Outcomes study group.
Dr Jenny Hunt	Nil
Professor Sue McDonald	Nil
Dr Henry Murray	Nil
Assoc Prof Ruth Stewart	Nil
Dr Anne Sved Williams	Nil
Methodological Consultant
Philippa Middleton	Was an ex-officio member of the New Zealand Guideline Group who have recently developed diabetes in pregnancy guidelines. She has also published in several areas relevant to the antenatal care guidelines.
Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care
Dr Jenny Hunt	Nil
Dr Marilyn Clarke	Nil
Ms Simone Andy	Nil
Dr Lynore Geia	Nil
Ms Sue Hendy	Nil
Prof Sue Kildea	Nil
Ms Leshay Maidment	Nil
Assoc Prof Katie Panaretto	Nil
Ms Arimaya Yates	Nil
Working Group for Migrant and Refugee Women’s Antenatal Care
Assoc Prof Ruth Stewart	Nil
Dr Daniela Costa	Nil
Ms Andrea Creado	Nil
Dr Adele Murdolo	Nil
Ms Natalija Nesvadba	Nil
Ms Assina Ntawumenya	Nil
Ms Jan Williams	Nil

Process

The ADAPTE framework was used to identify and appraise relevant international and national guidelines. Following appraisal of identified guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument, the NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman was selected as a reference guideline. Following review of the evidence (see Appendix D), the grading of evidence and recommendations followed the NHMRC Levels of Evidence and Grades for Recommendations for Developers of Guidelines (NHMRC 2009). Consensus by the EAC on the grading of the systematic literature review evidence was achieved for all items and recorded in detailed summary sheets used to form the basis of the EAC’s decisions about which recommendations were appropriate to develop, and the subsequent grading of these recommendations.

Consensus-based recommendations were developed where insufficient evidence was identified to support a recommendation.

Practice points (PPs) were developed to cover areas that were beyond the scope of the systematic literature reviews but where practical advice is needed.

The process of the systematic literature reviews is discussed in more detail in Appendix D.

Public consultation

The guideline consultation was open publically; therefore all interested stakeholders had the opportunity to make submissions. An online portal was used, providing a means by which stakeholders could choose to comment on one or all sections. The consultation period was extended until 14 July and 40 submissions were received. Authors of submissions included organisations, individual health professionals and consumers.

Key themes raised in submission and changes made to incorporate these are listed below.

Migrant and refugee women — Additional practice points included to highlight the importance of using accredited interpreters and involving multicultural health workers.

Mental health — Additional practice points included to highlight the importance of continuity of care and the need for ongoing assessment for emotional/mental health problems throughout the pregnancy.

Partner involvement — Involvement of women’s partners in antenatal education and other aspects of care further emphasised.

Parenting education — Some submissions suggested including a recommendation on antenatal couple education programs. The evidence was reviewed and was not considered strong enough to support a recommendation.

Fetal growth assessment — The section was revised to include more detail on the technique of measuring symphysis-fundal height and information on the use of customised fetal growth charts. A practice point on further investigation when intrauterine growth restriction is suspected was included.

Prolonged pregnancy — The section was reviewed by a sub-group of EAC members and the text amended to better reflect the available evidence.

Diabetes — A section on screening for diabetes was included in the Guidelines following requests for guidance in public consultation submissions from the initial consultation in May 2013. Public consultation on this new section was undertaken from 25 January to 24 February 2014. The EAC received and reviewed 26 submissions and changes were made to incorporate suggestions from submissions. The main themes raised through the submissions were:

the need for greater distinction between pre-existing diabetes (including Types 1 and 2) and gestational diabetes — the background section was revised to clarify that the scope of the Guidelines is the antenatal care of pregnant women without identified pre-existing conditions and that the focus of the chapter is identifying pre-existing diabetes during pregnancy and identifying gestational diabetes;

the inclusion of polycystic ovarian syndrome and use of corticosteroids or antipsychotics as risk factors for gestational diabetes — additional evidence was included on polycystic ovarian syndrome and it was included in the recommendation on risk factors; no high-level evidence on an association between corticosteroid or antipsychotic use and increased risk of gestational diabetes was identified;

the inclusion of different testing recommendations based on level of risk — the EAC considered that in the context of the Guidelines it was appropriate to outline a process of identifying risk, without stratifying levels of risk; and

conflicting views on whether specific guidance on testing procedures and diagnostic thresholds be included — the majority of submissions that commented on this issue requested specific guidance on which tests to use and which thresholds to apply so the EAC agreed to give advice in this area, while acknowledging that other approaches remain in use and the resource implications of introducing lower thresholds. Two consensus-based recommendations were developed to provide guidance on the screening process.

Duplication between modules — There was comment in some submissions about repetition between Module I and II. Following the release of Module I, the section on migrant and refugee women was revised to include input from a newly formed Working Group for Migrant and Refugee Women’s Antenatal Care. The sections on women with mental health disorders and the content of the first antenatal visit were also revised following further input from members of the EAC. For this reason, these sections have been repeated in Module II. Versions from Module II will be included in any future combined volume.

Independent review

The appraisal from both reviewers was generally positive, with combined domain scores as follows.

Note that although the domain scores are useful for comparing guidelines and will inform whether a guideline should be recommended for use, the AGREE Consortium has not set minimum domain scores or patterns of scores across domains to differentiate between high quality and poor quality guidelines. These decisions should be made by the user and guided by the context in which AGREE II is being used.

Both reviewers recommended the use of the Guidelines, with some modifications. In response to the independent reviews, the Guidelines were revised in the following ways:

further information was included about selection of committee members, the health professions represented on the committee and consumer involvement;

the process of formulating and achieving consensus on recommendation wording was further clarified and quorum defined;

this description of the independent review process was included;

a statement on the process for updating the Guidelines was included;

discussion of the resource implications of implementing the recommendations and barriers/facilitators to implementation was included in Appendix D (and cross-reference made to the Technical Report, which provides more detail on these);

the section on monitoring uptake of the Guidelines was revised.

the list of competing interests for committee members was completed and a statement on editorial independence from the funding body included.

Peer review and methodological review

The Guidelines underwent peer and methodological review and were amended accordingly. The main changes resulting from the methodological review were:

clarifying that the Guidelines were fully funded by AHMAC;

including a timeframe for review of the Guidelines;

describing the process of recruiting members to the working groups;

providing additional detail on how relevant stakeholders and consumer groups were included in the consultation process;

including additional terms in the glossary;

adding discussion of the selection of the reference guideline and further detail on exclusion criteria to the technical report; and

amending the dissemination plan.

No major amendments resulted from the peer review.

Implementation

The following multidisciplinary team will aim to increase the uptake of the Guidelines through liaison with their professional groups and promotion of the recommendations:

Prof Sue McDonald (Chair) (Professor of Midwifery La Trobe University/ Mercy Hospital for Women);

Dr Steve Adair (Director, The Canberra Hospital Obstetric Department);

Ms Ann Catchlove (consumer representative);

Ms Sue Hendy (Director of Women’s, Children’s and Youth Health, Nepean Blue Mountains and Western Sydney Local Health Networks);

Ms Philippa Middleton (methodological adviser); and

Assoc Prof Ruth Stewart (Director Parallel Rural Community Curriculum, School of Medicine Deakin University, Australian College of Rural & Remote Medicine Representative).

Professor Jeremy Oats (Chair Victorian Consultative Council on Obstetric and Paediatric Mortality and Morbidity, Medical Co-Director, Northern Territory Integrated Maternity Services) and Professor Caroline Homer (Professor of Midwifery, Child and Family Health University of Technology, Sydney) will act as ex officio members.

Members of the Working Group for Aboriginal and Torres Strait Islander Women’s Antenatal Care and the Working Group for Migrant and Refugee Women’s Antenatal Care will contribute to the implementation plan for the Guidelines, because of the need to specifically consider and develop strategies for implementation in the full range of specific settings and contexts where Aboriginal and Torres Strait Islander and migrant and refugee women receive care.

The EAC includes a number of members in positions of influence within various organisations and government departments. Similarly, the Maternity Services Inter-jurisdictional Committee is well-placed to effect change in clinical and regulatory environments.

Key messages for dissemination and implementation

Central to the dissemination and implementation plan is the identification of key messages resulting from the Guidelines, which will be prioritised for communication and implementation. High priority will be given to recommendations that have:

strong evidence underpinning the recommendation;

an identified gap or need for a change to current practice;

an identified burden of care including the number of women and babies likely to be affected by implementation of the recommendation; or

cost implications.

Key priorities for the Australian context will be based on identified gaps in current practice and where wide variations in clinical practice currently exist.

Dissemination

There will be a web-based approach to dissemination whereby the Guidelines are published on the Department of Health website.

Implementation strategies: facilitating uptake of the disseminated Guidelines

A range of strategies, harnessing the multidisciplinary team of opinion leaders involved in the development of the Guidelines, will be employed, informed in some cases by an assessment of the likely barriers to uptake of the prioritised recommendations. Potential implementation strategies include:

education through meetings, conferences and presentations;

outreach education; and

opinion leaders — EAC endorsement.

Key messages from the Guidelines may also be implemented through a number of existing initiatives.

Monitoring uptake of the Guidelines

While recognising the guidelines are not mandated, the extent to which the Guidelines have influenced practice and policy may be monitored in a number of ways.

The Headline Indicators for Children's Health, Development and Wellbeing provide measurements suitable for defining the current situation. Indicators related to antenatal care are: smoking in pregnancy; alcohol use in pregnancy; low birth weight; and infant mortality (noting that this indicator measures the number of deaths of live-born infants less that 1 year of age).

The National Core Maternity Indicators provide information on smoking in pregnancy and antenatal care in the first trimester.

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