Leveraging Action to Support Dissemination of the Pregnancy Weight Gain Guidelines: Workshop Summary (2013)

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4 Session 2: Panel Discussion: What Are We Doing to Support Behavior Change? Esa Davis, a member of the Committee on Implementation of the IOM Pregnancy Weight Gain Guidelines, and assistant professor of medicine at the University of Pittsburgh, introduced Session 2, which focused on what front-line providers are doing to support behavior change related to weight gain for women during the perinatal period. The three panelists for Session 2 were  Dotun Ogunyemi, an obstetrician-gynecologist and specialist in maternal–fetal medicine representing the Society of Maternal– Fetal Medicine and the National Medical Association. Ogunyemi also is a clinical service professor at the David Geffen School of Medicine at the University of California, Los Angeles (UCLA).  Josephine Cialone, head of the Nutrition Services Branch of the North Carolina Division of Public Health, Women’s and Children’s Health Section.  Christina Johnson, director of professional practice and health policy at the American College of Nurse-Midwives. PANEL DISCUSSION Davis asked each of the panelists to discuss three topics as they relate to their own practices: the populations served and their needs, a 31 

32 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES typical day of patient care, and how best to incorporate the guidelines into educational materials and tools. Populations Served and Their Needs Ogunyemi works in three different capacities with three different patient populations. In one practice he serves as a maternal–fetal medicine subspecialist. Patients who come to this practice have various complications of pregnancy, and more than half of them are obese. He also works as a supervisor of residents in an obstetrical practice that includes practicing midwives. The patients in this practice are also usually high risk. Many are migrant farm workers and have low incomes. About 60 percent are obese. Finally, Ogunyemi works as a maternal-fetal medicine specialist for a global health group that meets once a month. The group includes institutions from Ghana, Nigeria, Rwanda, Switzerland, Uganda, and the United States. At each meeting a member presents a clinical case with maternal mortality or major morbidity, and the group helps the presenter review various processes for community action that could improve care. In addition, in his work at UCLA Ogunyemi teaches residents, medical students, and fellows. An important issue in working with this group is to increase their awareness of nutrition during pregnancy. Cialone noted that the Special Supplemental Food Program for Women, Infants, and Children (WIC) is administered in North Carolina through the state’s local public health departments. The WIC program serves clients receiving such services as prenatal or family planning at the health department as well as clients working with private-sector providers; many of these clients also participate in Medicaid. The WIC program serves low-income women who often work in low-wage jobs. Their needs are great and go well beyond the issue of weight gain. Clients are juggling many stresses, such as food insecurity, concerns about paying rent, and concerns about whether their children can participate in the same activities that other children in school settings and child care do. Johnson said that she and her fellow members of the American College of Nurse-Midwives (ACNM) perform about 12 percent of the vaginal births in the United States; of the births that midwives perform in the United States, 95 percent take place in hospitals. Midwives traditionally serve women in vulnerable populations, and they regularly deal with a variety of cultural issues, because their clients come from many countries and cultures. Many of the patients struggle with difficult 

SESSION 2 33 issues in their daily lives: how to get to an appointment with three small children and a bus system that is not working right, or how to feed a family a healthy diet when the community does not have sources of good, fresh food. A key priority for midwives is to establish personal relationships with their patients during the prenatal course of care so that they can substantively engage in these issues with them. Establishing such relationships allows midwives to use motivational interviewing techniques that help elicit the reasons why a patient is not able to change her behavior or what elements need to be put into place to enable behavior change. It is difficult to tell patients to exercise when their neighborhood is not safe, there is no mall nearby, or they cannot get their children to the park easily. Furthermore, the patients’ traditional favorite foods are often not conducive to weight loss, but it is difficult to get patients to act in ways that are contrary to their cultural norms. Trying to find effective solutions takes one-on-one, time-intensive therapy, which is difficult to do in the current structure of the U.S. prenatal health care system. Additional frameworks are needed within the system to permit this more effective approach. A Typical Day of Patient Care Ogunyemi’s practice includes a maternal–fetal medicine practice and a high-risk obstetrical practice. First, the maternal–fetal medicine practice is located in downtown Los Angeles and sees 80 or more patients daily. All are high-risk obstetrical patients referred by other clinicians. The office has 3 maternal–fetal medicine specialists and about 10 medical assistants. When a patient comes in, she is first weighed and then classified into a weight status category. A classification of morbid obesity is treated as an indication for referral to the practice, and her management is based on that indication. The next priority is to assess the patient’s weight gain up to that point during the pregnancy and to ask the patient to recall everything she ate during the previous 24 hours. Based on the answers provided on that 24-hour recall, the patient is given nutritional instruction and counseling that has been individualized with an electronic medical-based approach, and then she is asked to return in a week for a follow-up visit. At that follow-up session, a physician reviews the dietary changes that the patient has been making and makes further suggestions. The patient is also informed about the importance of exercise. Ultrasound is used to detect excessive fetal growth, whose presence will lead to further adjustments in the patient’s dietary and exercise recommendations. Many of patients in the practice have diabetes, 

34 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES and the preventive approach and emphasis on diet and exercise that they learn while pregnant has helped many of them lose weight, maintain their diet, and get off diabetic medications. Second, Ogunyemi’s obstetrical care practice, which is also in downtown Los Angeles, is staffed by residents and five or six midwives, who are critical providers of the care to these high-risk patients. The patients in this practice have a very high incidence of obesity and gestational diabetes. One of the models used is a “centering” approach in which similar patients are grouped together in their first trimester. They meet with a midwife at each visit to discuss diet and exercise, they bring their meals and are taught to cook together, and they are followed as a group throughout the pregnancy. This approach helps the patients become more motivated as a result of working with others in their group. They obtain ideas and receive support from other women in the group After the women deliver, they are invited to stay in interconception care in which they are followed regularly for 2 years or until they become pregnant again. Through such care, Ogunyemi has been able to help patients maintain or reduce their weight so that they are in a better place if they become pregnant again. The program also provides contraceptive care to patients, which has been especially helpful for women with gestational diabetes. In his role as an educator, Ogunyemi encourages medical students, residents, and fellows to meet with nutrition service providers. This approach fosters the creation of multidisciplinary teams in which fellows, residents, and medical students can confer with nutritionists and nutrition counselors about patients’ weight gain, and it helps both the clinicians and the nutrition professionals provide consistent, reinforcing messages to patients. In response to a question about whether it was difficult to get either of the practices he works with to implement these new approaches to patient care, Ogunyemi said that one reason the changes were successful was that the practices were somewhat freestanding. The maternal–fetal medicine practice is a private practice run by a physician who is supported by a hospital. The maternal–fetal medicine staff feel strongly that many of the problems of pregnancy are related to weight gain and therefore emphasize pregnancy weight gain in the program. The other practice has been successful because of the leadership of the midwives, who realized that much of the morbidity in the patient population was related to obesity. The midwives met with the physicians as well as with the administrators of the clinic and made a successful case for their proposed approach. 

SESSION 2 35 Cialone, the second panelist, said that the North Carolina health department has addressed pregnancy weight gain in two ways. One was to change policies for prenatal visits as well as policies within the WIC program to support the Institute of Medicine (IOM) recommendations. The health department integrated information from the IOM guidelines into new client materials and tools developed for clinicians to use with prenatal and preconception clients. Second, the health department has supported providers and local health departments, primarily nurses and dietitians, with training to help them understand why helping clients meet the guidelines is so important to the long-term outcomes of the women and their children. The health department puts considerable emphasis on weight gain during pregnancy, but places even more emphasis on preconception care to help clients achieve a healthy weight between or after their pregnancies. This effort has been carried out primarily through WIC because the program has the opportunity of seeing the children in a family throughout their first 5 years. WIC has tried to use a family approach to counseling around weight and to moving families to a healthy weight. North Carolina has built on a state-level obesity prevention initiative of the Centers for Disease Control and Prevention called NC Eat Smart, Move More to conduct a program called Families Eating Smart, Moving More (http://www.eatsmartmovemorenc.com/FamiliesESMM/Families ESMM.html). The program has an array of tools and materials for providers that focus on moving families toward a healthy weight. One barrier that North Carolina has experienced is that private providers have not used the health department’s tools and trainings extensively; this may be because private providers look to their national associations rather than to the health department for guidance in their clinical practice. Another barrier is that providers within health depart- ments need enhanced skills in motivating behavior change. Accordingly, the health department has put considerable effort into helping providers learn how to counsel and to examine the barriers that are preventing women and families from achieving their goals as well as into helping providers learn how to set appropriate, attainable goals with families. In response to a question about the interactions between WIC programs and the health care system, Cialone said that the health department attempts to have good interactions with private providers and the WIC program, which is housed primarily in local health departments. The health department suggests to WIC program staff that they encourage their clients to discuss their concerns about barriers to care with their private providers and to share the WIC staff’s recom- 

36 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES mendations. However, time constraints and the challenges of providing care to many patients each day can make it difficult to maintain ongoing communication with the clients. Johnson said that one of the hallmarks of midwifery care is that it is grounded in health promotion and disease prevention, and this emphasis is a major focus of midwifery education programs. Midwives are very concerned about education, interpersonal communication skills, and developing one-on-one relationships as patient advocates. The systems barriers described by the others panelists are very familiar to midwives as well. One potential solution is to educate members more thoroughly and to provide more specific guidance about interviewing techniques so that providers can be more successful in conversations about weight, nutrition, and exercise. Johnson also noted that changing the paradigm of prenatal care to focus more on prevention may be advantageous because pregnancy is usually a time of wellness for women. In addition, women may be more amenable to behavior change during pregnancy because they are motivated to do the best for their babies. Traditionally, midwives have used a variety of innovative care models and techniques, such as the centering pregnancy model or diet recalls at every prenatal visit. If a woman has trouble writing, recalling, or describing her diet, then she can take pictures with her smart phone and bring them to the next visit. It is very simple, and the photos allow the clinician to estimate portion sizes. A third option is to incorporate diet and nutrition into home visits. Nurses do considerable home visiting for vulnerable populations. Integrated care models with a maternity care home focus, in which one care provider does the coordination and can follow up with referral sites, show great promise. Incorporating the Guidelines into Educational Materials and Tools Many professional associations have been using their conferences and meetings to teach clinicians about the guidelines, and the Society of Maternal–Fetal Medicine, for example, has even created a link on its website for people who have questions about the guidelines. At the clinic level, individual doctors can also play a role. Ogunyemi has made sure that copies of the guidelines are available in his practice and that doctors and other providers are familiar with the guidelines and the specific weight gain recommendations. He noted the poster (see Figure 3-3) also is very useful in helping providers remember the specifics of the guidelines. 

SESSION 2 37 Cialone reiterated that North Carolina has developed an array of materials and tools for providers. As part of this effort, the health department disseminated posters to every waiting room and exam room. The bottom of the poster lists a few key questions designed to encourage patients to talk to their providers about their body mass index. North Carolina also has worked on “conversation starter” tools. In clinic settings, the health department has moved away from doing diet recalls, focusing instead on a few key trigger questions, such as “Tell me a little bit about what you usually drink with your meals,” “Tell me a little bit about how many times you eat out,” “Is this something you’re concerned about?” and “Is this something you would like to work on?” The health department has developed materials on a variety of topics that help guide providers in their counseling and also can be given to clients to take home. Increasingly, the clients that these providers serve are less inclined to prepare meals at home. Messages about eating at home and how it can be done more easily are therefore integrated into these materials. The North Carolina health department also has done much to focus on breastfeeding through peer support. Increasing the prevalence of breastfeeding is a major key to helping women move toward a healthy weight. Johnson said that the ACNM has disseminated the guidelines to its members through its weekly e-newsletters, articles in its quarterly newsletter, and a small campaign on ACNM’s Facebook site that asked members how they talk to their patients about weight. The ACNM has also published a number of articles on the guidelines in its peer-reviewed Journal of Midwifery & Women’s Health and has disseminated relevant information on its e-mail lists. The ACNM also has developed a series of patient handouts called “Share with Women,” which providers can use in their offices and are geared to the reading level of the average patient population. The ACNM is also engaging women directly through a new consumer campaign called Moment of Truth, the mission of which is to increase awareness about women’s health and maternity care. The association surveyed more than 1,200 women who had given birth recently or were pregnant, and the survey’s results showed a major gap between what women say they want in their prenatal care and what they are actually getting. Eighty percent of the women who responded to this survey said that they value a partner in their care, and they want someone who listens to them. However, 50 percent of women had not had any conversations on any of the typical prenatal care topics that were listed in the survey, including nutritional and wellness topics. The ACNM be- 

38 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES lieves this is where it needs to focus its efforts because women need to know what questions to ask so that they can prompt their clinicians to engage in these important conversations. QUESTION-AND-ANSWER SESSION Davis opened the floor to questions from workshop participants, but first noted that creating a maternal-centered medical home using a multidisciplinary team-based approach, an idea expressed in different ways by each of the panelists, could be a valuable opportunity for bringing together obstetricians/gynecologists (OB-GYNs), family phy- sicians, pediatricians, nutritionists, and outside organizations such as WIC, La Leche League, and other maternal health community groups. The electronic health record could act as a linchpin in this approach by linking all the participants and providing a forum for ongoing communication. One participant said that, from a life-course perspective, helping young pregnant women achieve and maintain a healthy weight can be seen as a way to capitalize on a window of opportunity in which the woman might be saying, “I want to make something of myself because I realize I want to be a good parent.” One suggestion was to put the guidelines on a sticker that goes on the bathroom scale so that the guidelines are literally at a woman’s feet. Ogunyemi and Cialone both agreed strongly that the life-course perspective provides a useful way of thinking about the issue and that pregnancy presents an opportunity to set a women on a healthy path. Cialone noted that the North Carolina health department has formed a group to look at how women’s and children’s health programs can focus on the life course. For example, when an adolescent comes into the clinic for well care, staff can start to have a conversation, not only about the specific purpose of the visit (an adolescent visit, school health visit, or permission to participate in athletics), but also more broadly about the young woman’s goals and what staff can do for her and with her to get her on a healthy life course. Johnson noted the gap that currently exists between pediatric care and prenatal care. Many women come into prenatal care not having been seen by a clinician since they were children. Despite the fact that it is important to reach women before they become pregnant, the reality that providers face is that they miss that preconception period for a large percentage of their patients. Johnson expressed the hope for greater linkages between pediatricians and clinicians involved in women’s reproductive health care, which could encourage discussions on how best 

SESSION 2 39 to educate and prepare girls and young women about a range of topics, such as the nature of a well-woman visit. Davis thanked the panelists and workshop participants and ended the session on supporting behavior change.