GESTATIONAL WEIGHT GAIN

Engaging Primary Care Providers to Address Healthy Gestational Weight Gain in

Simcoe Muskoka

Prevent More to Treat Less June 4, 2014

Natalie Riewe (Simcoe MDHU) & Ami Nunn (Barrie Midwives)

DISCLOSURE OF COMMERCIAL SUPPORT

Presenter Disclosure Presenter: Natalie Riewe, Simcoe Muskoka District Health Unit Ami Nunn, Barrie Midwives Relationships with commercial interests: • Grants/Research Support: None • Speakers Bureau/Honoraria: None • Consulting Fees: None • Other: None

CFPC Conflict of Interest

AGENDA

• Public health role • Primary care role • Gestational weight gain background • Food and exercise survey • Interventions with HCP • Grand rounds and webinar • Key message development • Interventions with women

- Social marketing campaign • Outreach visits

OBJECTIVES OF WORKSHOP Objective 1: The session attendees will identify strategies public health practitioners can use to foster positive relationships with local primary care providers that can be applied to their practice.

Objective 2: The session attendees will identify promotion strategies public health professionals and primary care providers can use to support pregnant clients to gain weight within their recommended gestational weight gain range.

Objective 3: The session attendees will analyze and assess the challenges and barriers that were encountered during our work and identify strategies that could be used to support collaboration between public health and primary care in their future practice.

PUBLIC HEALTH Public health focuses on three areas: 1. preventing conditions that may put health at risk,

2. early detection of health problems, and

3. changing peoples and societies attitudes and practices

regarding lifestyle choices.

REPRODUCTIVE HEALTH STANDARDS

Assessment and Surveillance

Requirement #1:

The board of health shall conduct epidemiological analysis of surveillance data, including monitoring of trends over time, emerging trends, and priority populations, in accordance with the Population Health Assessment and Surveillance Protocol, 2008 (or as current) in the areas of : preconception health; healthy pregnancies; reproductive health outcomes; and preparation for parenting.

Health Promotion and Policy Development

Requirement #3:

The board of health shall increase public awareness of preconception health, healthy pregnancies, and preparation for parenting by : a. adapting and/or supplementing national and provincial health communications strategies; and/or b. developing and implementing regional/local communications strategies.

• Situational assessment • Work with community partners (health care providers, local

support programs and agencies) • Advice and information to link people • Link to services that provide consultation, assessment,

referral

MIDWIFERY CARE Woman centred care – the client is seen as an active participant in her care (primary decision maker) Care is personalized – each client receives individualized care based on what her needs are Continuity of care – the client builds a relationship with her care provider(s) that enables trust and reliability Informed choice – the midwife provides education and counselling to support the client in the decision making process (Midwifery Model of Care, CMO, Sept. 25, 2013)

WHY GESTATIONAL WEIGHT GAIN Institute of Medicine (IOM) - 2009 Report

INSTITUTE OF MEDICINE (IOM) - 2009 REPORT The IOM found moderate to strong evidence for associations between gestational weight gain and:

• caesarean section

• pre-term birth

• birth weights

• postpartum weight retention intermediate term (3-36 months)

(Rasmussen, Catalano & Yatkine, 2009)

EXCESS GESTATIONAL WEIGHT GAIN Long Term Health Risks: Infant

• hypertension? (Stuebe, Oken & Gillman, 2009; Fraser et. al, 2010)

• childhood obesity? (Fraser et. al, 2010; IOM, 2011, Lawlor et al., 2011)

• LGA (Nehring et al, 2013; Mamun et al., 2014; Tie et al, 2014)

Maternal

• postpartum weight retention – ↑ BMI over time – ↑ chronic diseases

(IOM, 2009; Nehring et al., 2011; Amorim Adegboye, Linne, Lourenc, 2012)

RISKS ASSOCIATED WITH INADEQUATE GWG • Preterm birth

• Small for gestational age

(Viswanathan et al, 2008)

CANADIAN GWG RECOMMENDATIONS

a Rounded values. b Calculations assume a total of 0.5 - 2 kg (1.1 - 4.4 lbs) weight gain in the first trimester. c A narrower range of weight gain may be advised for women with a pre-pregnancy BMI of 35 or greater. Individualized advice is recommended for these women. (Health Canada, 2009)

(Health Canada, 2009)

Recommended weight gain rates and ranges by pre-pregnancy BMI

Pre-pregnancy BMI category

Mean rate of weight gain in the 2nd and 3rd trimester

Recommended range of total weight gain

kg/week lb/week kg lbs BMI < 18.5 Underweight

0.5 kg 1.0 lb 12.5 - 18 kg 28 - 40 lb

BMI 18.5 - 24.9 Normal weight

0.4 kg 1.0 lb 11.5 - 16 kg 25 - 35 lb

BMI 25.0 - 29.9 Overweight

0.3 kg 0.6 lb 7-11.5 kg 15 - 25 lb

BMI ≥ 30 Obese

0.2 kg 0.5 lb 5 - 9 kg 11 - 20 lb

WHY FOCUS ON GESTATIONAL WEIGHT GAIN? • gestational weight gain (GWG) is modifiable

• pre-pregnancy BMI is not modifiable (once conception occurs, it cannot be changed)

• addressing GWG is part of a comprehensive healthy

weights promotion strategy

PRINCIPLES OF ONTARIO PUBLIC HEALTH STANDARDS

• Need

– Local data and information

• Impact – Evidence of interventions?

• Capacity – Internal capacity

• Partnership and Collaboration – Health sector and others

WHAT IS THE SITUATION?

(PHAC, 2009)

MATERNITY EXPERIENCES SURVEY Who is gaining too much in Ontario?

• normal weight women (pre-pregnancy BMI 18.5-24.9) - 41% gain more than recommended

• overweight women (pre-pregnancy BMI 25-29.9) - 68% gain more than recommended

• obese women (pre-pregnancy BMI ≥ 30) - 60% gain more than recommended

(Personal Communication, Sharon Bartholomew, PHAC, January 17, 2012)

ANOTHER PERSONS SHOES – ACTIVITY 10 MIN 1. Get into pairs and choose role from activity # 1

envelope • Pregnant women or • Health Care Provider

2. Follow scenario cards to roll play 1st prenatal appointment.

3. Report back

THE JOURNEY

2010

Planning 2011

Food and exercise in pregnancy survey

2012

Survey report Grand rounds Webinar Pilot tool Key message development

2013

Finalize tool Outreach Social marketing campaign

2014 Social Marketing Outreach

TITLE (2010)

2010

Planning Need Local Data

BIRTH WEIGHTS IN SIMCOE-MUSKOKA LGA and SGA Rates* among Singleton Live Births

Simcoe Muskoka, 1986-2007

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

Year

% o

f tot

al s

ingl

eton

live

birt

hs

LGA SGA

LGA 8.9% 9.0% 9.2% 9.3% 9.5% 10.4% 11.3% 10.8% 10.1% 10.5% 12.0% 11.4% 12.1% 11.6% 13.9% 13.4% 13.3% 13.1% 12.4% 12.3% 11.6% 12.3%

SGA 13.3% 13.2% 12.1% 12.1% 11.0% 11.4% 10.4% 10.4% 10.8% 11.3% 10.1% 9.6% 9.0% 8.5% 7.5% 8.2% 7.7% 7.3% 6.6% 7.2% 8.1% 7.5%

1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

*Excludes livebirths with unknown gestational age and birthweights, livebirths with gestational age <22 weeks or >43 weeks and multiple births

Source: Livebirth Vital Statistics, intelliHEALTH ONTARIO, MOHLTC, extracted July 28, 2011

ENERGY IN – ENERGY OUT = WEIGHT ? • genetic predisposition, • in utero determinants related to prenatal health, • lack of physical activity, • poor nutrition (namely excessive caloric consumption), • socio-economic drivers, • gender, • lack of sleep, • medication use and/or underlying medical problems that

promote weight gain. (Best start Resource Centre, 2013)

OPHS – NEED Local Data and Information

- National and provincial data of weight gain

- What were potential local issues

- Determine local weight gain issues

- Determine associated behaviours

FOOD AND EXERCISE IN PREGNANCY SURVEY SMDHU (2011)

2011

Food and exercise in pregnancy survey*

FOOD AND EXERCISE IN PREGNANCY SURVEY SMDHU (2011)

• 361 pregnant women (sample size needed)

• 9 Public Health Nurses

• 329 health care providers

• 248 antenatal care providers

• 119 HCP consents to implement

• 1 week supply of surveys

• 7 weeks for staggered data collection

PUBLIC HEALTH NURSE EXPERIENCE PHN focus group 2011 Helpful in feeling prepared • PHNs requested regular updates and training • Colleague support

CHALLENGES

• Change in scope (processes changes)

• Tight timelines

NEXT TIME…..? Recommendations by PHN’s • Consultation • Decision making • Workload • Enhance MOH involvement

FOOD AND EXERCISE IN PREGNANCY SURVEY– BARRIE MIDWIVES • No way of knowing participation (done anonymously) • No feedback from clients was received by the practice, so

unfortunately we have no way of knowing of our clients participation or experiences with completing the survey.

• Our clients tend to be quite receptive towards surveys and

things of that nature and it is not an inconvenience for us to inform them of options to participate.

• As a practice we would support future surveys and offer our participation.

SURVEY RESULTS

• 50% participation rate for Antenatal Care providers in Simcoe Muskoka

• Women were willing to complete survey - response rate = 85%

• 361 surveys needed (for representative sample) - actual = 479 - usable = 457

SURVEY RESULTS: BMI AND WEIGHT

• 41.5% BMI ≥ 25 pre-pregnancy

• 54% BMI 18.5-24.9 pre-pregnancy

• 58% exceeding recommended weight gain rate - of those who were gaining too quickly, about half were

concerned

• 5% had already exceeded the upper limit of their GWG range in 2nd trimester; 35% in 3rd

• 75% felt fine with the amount of weight they had gained

Contributing Factors:

• important to exercise during this pregnancy (90%)

• physical activity supported by others (80+ %)

• aware of parks, trails, sidewalks (83%)

• HCP advised exercise (52%); HCP explained how (45%)

• too tired (47%) & too busy (32%) were main “barriers”

• income related issues (14%)

SURVEY RESULTS: BMI AND WEIGHT

SURVEY RESULTS: NUTRITION Contributing Factors:

• almost all knew how to cook healthy food (95%)

• most report knowledge of CFG (75%) & Nutrition Facts tables (80%)

- fewer report confidence in following CFG (52%)

• most report cravings (47%), preference for quick foods (51%) and fatigue (29%) as barriers

• 9% reported lack of money to buy healthy food

• 55% told by HCP to follow CFG, 37% explained how

SURVEY: SOURCES OF INFORMATION Information Sources Actual (%) Preferred (%)

One to One Discussion 78 77 Websites 20 41 Book by Health Experts 32 41 Prenatal Class (in person) 29 40 Pamphlets or handouts 64 36 Magazines 22 27 Email Reminders 3 9.5 Online Prenatal Classes 1.5 10 CD or DVD 4 6.5 Social Networking Sites 7 3.5 Blog

7 1.5

Other 0.5

RISK FACTORS THAT MAY AFFECT GWG

• Pre-pregnancy weight

• Age, parity, education, income

• Aboriginal and immigrant status

• Low socioeconomic status

• ‘Health problems’ of the mother

ROLE OF PUBLIC HEALTH AND PRIMARY CARE PROMISING PRACTICES

• Pregnancy is an opportunity for maternal interventions that

are beneficial to maternal health and fetal development • Maternal physical activity and/or nutrition interventions

• improving maternal glycemic control • adherence to gestational weight gain guidelines • limiting the risk of gestational diabetes mellitus • reducing labour complications and optimizing birth weight.

Best Start Resource Centre. (2013)..

PRIMARY CARE Health Services:

• advice of primary care providers re: weight gain in pregnancy impacts the amount of weight women gain, however…. 63% reported receiving incorrect advice or no advice

(Cogswell et al., 1999)

ASSOCIATION ONTARIO MIDWIVES - CPG

The Management of Women With a High or Low Body Mass Index (March 2010)

(Press E, Bennett S. The management of women with high or low body mass index. Association of Ontario Midwives CPG 2010;(12))

• Objective – “to provide a critical review of the research

literature on the management of uncomplicated pregnancy in women who have a pre-pregnancy body mass index (bmi) less than 18.5 or greater than or equal to 30.”

• Method – Searched the Medline database and

Cochrane library from 1994-2009. Key words: pregnancy, bmi, weight gain, birth weight, postpartum weight, maternal health, preterm delivery, obesity, overweight.

ASSOCIATION ONTARIO MIDWIVES - CPG

Consider: • Care may start after conception • BMI is one piece of the entire medical picture • Care should remain individualized • Information is key – Informed choice

Recommendations…

(Press E, Bennett S. The management of women with high or low body mass index. Association of Ontario Midwives CPG 2010;(12))

SMALL GROUPS ACTIVITY – 10 MIN 1. Use paper on table – small group discussion

2. What practices enhance collaboration between primary

care and public health?

3. What barriers exist for collaboration?

4. Report back - Generate large group list

PUBLIC HEALTH TO PRIMARY CARE

• To work collaboratively Public Health must carefully design and position primary care -based interventions.

• Increase the use of primary care outreach strategies that are more effective including “Educational Outreach Visits” and “Continuing education (presentations) that contain both informative and interactive components.

• Develop an internal primary care outreach strategy within the Public Health Unit that supports the shift towards more effective physician communication strategies.

- (Peel Public Health, 2010)

PRIMARY CARE TO PUBLIC HEALTH

• To work in collaboration with Public Health ensuring that clients are well informed and enabled to prevent possible future health concerns, and to treat current concerns.

• Working together to help clients gain access to resources in the community that will continue to educate, support, and counsel the individual.

• Continuous communication to ensure that the information provided by both parties is the most current, evidenced based research and that it supports best practice standards.

ACTIVITY - 5 MIN A new primary care provider practice has developed in your area (midwife, physician practice NP practice).

or You are a new health care provider in a area wondering what resources are available for your clients. What are your engagement strategies?

Resources

Presentations Outreach visits

MULTIPLE STRATEGIES

INTERVENTION STRATEGY Health Care Sector:

Support local primary care providers to:

• inform pregnant women early in pregnancy about their GWG range and rate

• screen for nutrition, PA and mental health

• discuss nutrition and PA recommendations

• plot GWG using interactive tools

• refer to resources and follow-up counseling

SURVEY DISSEMINATION

2012

Survey report Grand rounds Webinar Pilot tool Key message development

CHALLENGES FOR PRACTICE • Counseling confidence and skill

• Not to focus on this too much (outcome caloric restriction)

• Sensitive topic to discuss

• Personal weight experience

GRAND ROUNDS & WEBINAR Two events at two local hospitals • June 14, 2012 Barrie (31 attendees) • June 18 2012 Orillia (34 attendees) • 23 attendees antenatal providers (248) • Promoted to HCP who participated in survey through thank

you letter, and postcards in vaccine pick up bags and by hospitals

• Webinar • Presentations delivered by MOH • Local reach 4 primary care organizations including CHC,

FHT, FNIM community health nurse

GRAND ROUNDS HEALTH CARE PROVIDER SURVEY (2012)

Of the antenatal care providers that attended, survey results indicated:

• There is inconsistent practice in determining pre-pregnancy BMI and informing women of her recommended weight gain rate and range

• Plotting weight gain on a graph was not usual practice

• ParMed-X for pregnancy was not used regularly

• Dietitian referrals were used by over half of respondents

• Nutrition and physical activity resources were provided by over half

• Pre-pregnancy BMI may influence practice

HEALTH CARE PROVIDER – TOOL

Front Back

DRAFT TOOL

• Feedback received from primary care providers “where can they refer women at risk of gaining outside recommendations”

• Created tool with clinical supports and patient resources

• Grand rounds introduction

• Feedback from Midwives OB and family physicians

• Modified tool

HEALTH CARE PROVIDER TOOL

• Regarding the usefulness of the Assessment/Referral Tool, 21/21 respondents indicated the tool would be helpful to their practice and 16/21 would prefer using it electronically.

• Based on survey all identified interest in using many preferred electronically.

EDUCATIONAL EVENTS Health Care Provider Perspective • Ensures consistency of information among HCP’s

• Enables HCP’s to re-evaluate their current clinical practices based on new research and recommendations they may or may not have been aware of

• Allows HCP’s to learn from one another and share their experiences

• Provides a setting for education, discussion, and collaboration among HCP’s from different backgrounds, but who are working with a common goal

GRAND ROUNDS 2012 How has the event impacted my practice? • Interesting but difficult to change motivating factors for

obese women. Good reminders for HCP.

• Importance of establishing pre-pregnancy BMI and tracking gestational weight gain to improve overall outcomes for mom and baby.

• This has provided me with increased knowledge in providing education to gestational diabetics in pregnancy.

• Enhance knowledge when seeing gestational diabetes.

General comments: • I have lapsed in addressing weight gain - good reminder to

be more vigilant.

KEY MESSAGE DEVELOPMENT Dietitian staff worked with other Dietitians from: Barrie Community Health Centre CPNP Barrie Community Family Health Team Royal Victoria Hospital Chigamik Community Health Centre

KEY MESSAGES Gaining a healthy amount of weight is good for you and baby. Talk to a health care provider about your healthy weight gain.

NUTRITION Follow Eating Well with Canada’s Food Guide recommendations for pregnancy.

PHYSICAL ACTIVITY Being active during pregnancy has many benefits for you, like more energy, improved mood, better sleep and healthy weight gain. Your baby benefits too!

MENTAL HEALTH Emotional and physical changes are part of a normal pregnancy. If you find that your mood is low, talk to your primary health care provider.

TITLE

2013 & 2014

Finalize tool Plan and implement outreach visits HCP Social marketing campaign Additional rounds by local HCP

SOCIAL MARKETING CAMPAIGN

OUTREACH VISITS Educational Outreach Visits had small-to-moderate effect on professional practice – particularly on prescribing behavior Peel public health 2010

OUTREACH VISITS 2014

• Continue to connect with antenatal care providers in Simcoe Muskoka

• Evaluation (Midwives and Nurse Practitioners) 2013- 2014 (still working on results)

• Outreach 2014

SUCCESSES • Developed new and ongoing relationships between

primary care and public health in Simcoe Muskoka

• The importance of addressing gestational weight gain is being discussed by various community partners.

• Other health units are reviewing the information, process

and resources produced.

RECAP Need • Food and Exercise in Pregnancy Survey

Impact • Promising practices dietary and exercise counselling

Capacity • Internal capacity (PHN & MOH time, $ resources) • External capacity (Primary care)

Partnership and Collaboration

• Outreach visits

• Social marketing

• Local champion

• Survey

• Tool pilot

• Rounds/webinar

DISCUSSION - 10 MINUTES 1. How did we do?

2. Successes

3. Challenges

4. What does this mean for your work? Need, Impact, Capacity, Collaboration.

THANK YOU

Questions or comments?

Natalie Riewe, RN, BScN, BA natalie.riewe@smdhu.org

Ami Nunn, RM ami@barriemidwives.com

www.simcoemuskokahealth.org

www.barriemidwives.com