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Effect of the Growth Assessment Protocol on the DEtection of Small for GestatioNal age fetus: process evaluation from the DESiGN cluster randomised trial

Relph, S., Coxon, K., Vieira, M. C. , Copas, A., Healey, A., Alagna, A., Briley, A., Johnson, M., Lawlor, D. A., Lees, C., Marlow, N., McCowan, L., McMicking, J., Page, L., Peebles, D., Shennan, A., Thilaganathan, B., Khalil, A., Pasupathy, D., Sandall, J., Bakalis, S., Rozette, C., Canda, M., Cicero, S., Akinfenwa, O., Cox, P., Giacometti, L., Peregrine, E., Smith, L., Page, S., Janga, D., Essien, S., Hutt, R., Acheampong, Y., Trinder, B., Rimell, L., Cresswell, J., Petty, S., Ajay, B., O’Donnell, H., Wayman, E., Dhanjal, M., Noori, M., Iaschi, E., Napolitano, R., Tsikimi, I., Das, R., Ghalustians, F., Hanks, F., Camarasa, L., Samarage, H., Hiles, S., David, A., Howe, D., Seward, N., Allen, E. & Francis, J. ORCID: 0000-0001-5784-8895 (2022). Effect of the Growth Assessment Protocol on the DEtection of Small for GestatioNal age fetus: process evaluation from the DESiGN cluster randomised trial. Implementation Science, 17, article number 60. doi: 10.1186/s13012-022-01228-1


Reducing the rate of stillbirth is an international priority. At least half of babies stillborn in high-income countries are small for gestational-age (SGA). The Growth Assessment Protocol (GAP), a complex antenatal intervention that aims to increase the rate of antenatal detection of SGA, was evaluated in the DESiGN type 2 hybrid effectiveness-implementation cluster randomised trial (n = 13 clusters). In this paper, we present the trial process evaluation.

A mixed-methods process evaluation was conducted. Clinical leads and frontline healthcare professionals were interviewed to inform understanding of context (implementing and standard care sites) and GAP implementation (implementing sites). Thematic analysis of interview text used the context and implementation of complex interventions framework to understand acceptability, feasibility, and the impact of context. A review of implementing cluster clinical guidelines, training and maternity records was conducted to assess fidelity, dose and reach.

Interviews were conducted with 28 clinical leads and 27 frontline healthcare professionals across 11 sites. Staff at implementing sites generally found GAP to be acceptable but raised issues of feasibility, caused by conflicting demands on resource, and variable beliefs among clinical leaders regarding the intervention value. GAP was implemented with variable fidelity (concordance of local guidelines to GAP was high at two sites, moderate at two and low at one site), all sites achieved the target to train > 75% staff using face-to-face methods, but only one site trained > 75% staff using e-learning methods; a median of 84% (range 78–87%) of women were correctly risk stratified at the five implementing sites. Most sites achieved high scores for reach (median 94%, range 62–98% of women had a customised growth chart), but generally, low scores for dose (median 31%, range 8–53% of low-risk women and median 5%, range 0–17% of high-risk women) were monitored for SGA as recommended.

Implementation of GAP was generally acceptable to staff but with issues of feasibility that are likely to have contributed to variation in implementation strength. Leadership and resourcing are fundamental to effective implementation of clinical service changes, even when such changes are well aligned to policy mandated service-change priorities.

Publication Type: Article
Additional Information: This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Publisher Keywords: Implementation, Small-for-gestational age foetus, Antenatal screening, Process evaluation, Context, Acceptability, Feasibility, Cluster-controlled trial
Subjects: R Medicine > RG Gynecology and obstetrics
Departments: School of Health & Psychological Sciences
SWORD Depositor:
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