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

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7 Session 4: Collaborating for Action LEADING IMPLEMENTATION OF THE GUIDELINES: ACTION STEPS Rafael Pérez-Escamilla, professor of epidemiology and director of the Office of Public Health Practice at the Yale University School of Public Health and a member of the Committee to Reexamine IOM Pregnancy Weight Guidelines and the Committee on Implementation of the IOM Pregnancy Weight Gain Guidelines, introduced Session 4. This session was conducted as a facilitated conversation aimed at distilling the ideas and thoughts expressed throughout the day into actions for disseminating and implementing the guidelines. To set the context for this discussion, Pérez-Escamilla noted several key points and questions from the day:  It does not make sense to have pregnancy weight gain guidelines if the target audience cannot carry them out.  What we are doing now with respect to helping women gain within the guidelines is too little, too late. A radical change is needed in the care of women of childbearing age if the Institute of Medicine (IOM) gestational weight gain guidelines are to be successfully implemented.  The health care system plays a central role. Greater coordination and multidisciplinary teamwork are needed, and this is a com- plex task. 57 

58 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES  How can we change communities and the environments in which women live to help them gain greater access to healthy food, physical activity, and prenatal care?  How can we reach women before they become pregnant? Pérez-Escamilla then introduced the panel facilitator and panelists: Facilitator:  Sarah Brown, co-founder and chief executive officer of the National Campaign to Prevent Teen and Unplanned Pregnancy. Panelists:  Regina Davis Moss, associate executive director of public health policy and practice for the American Public Health Association (APHA).  Patricia Fontaine, representing the American Academy of Family Physicians (AAFP). Fontaine is also a senior clinical research investigator at Health Partners Research Foundation and an associate professor at the University of Minnesota in the Department of Family Medicine. FACILITATED CONVERSATION Brown opened the discussion by noting that the pregnancy weight gain guidelines dissemination committee has good ideas on the important issue of gestational weight gain. However, the committee faces a critical question: What can or should the committee do to get women, col- leagues, and others in positions of authority to pay more focused at- tention to this issue than to other issues? It is a competitive marketplace. Why focus on this set of materials, pamphlets, posters, and recom- mendations more than others? The committee’s job is to make its ideas come to life in order to gain the attention of leaders in relevant organizations and fields. Brown asked Davis Moss and Fontaine to describe how they make decisions about the issues on which their organizations will focus and how they respond to issues pressed by advocacy groups. Davis Moss stated that APHA is one of the oldest and largest public health associations in the world and is an umbrella organization for 

SESSION 4 59 public health professionals representing every sector of society. As a result, APHA advocates for a broad array of issues addressing the health and safety needs of the public and focuses on issues that will allow it to have an immediate impact. Every year APHA spends time identifying legislative priorities in three overarching areas: achieving health equity, rebuilding the public health infrastructure, and the right to health and health care. APHA has not taken action specifically on gestational weight gain, but it does advocate for related issues, such as Health Resources and Services Administration programs on education for health care providers or efforts to increase health care services, including contraceptive coverage. Davis Moss suggested several strategies that may help gain the attention of APHA leadership:  Be passionate about the issue of appropriate gestational weight gain and improving maternal health care.  Network within APHA sections. Six or 7 of the association’s 29 sections would be relevant, including the public health nursing, maternal and child health, and food and nutrition sections.  Explore ways to have IOM recommendations cited in APHA policy statements and other APHA publications, such as its Nation’s Health newspaper.  Reach lay audiences through a variety of means, including social media.  Consider nontraditional approaches, such as including information on gestational weight gain in pregnancy tests, or when women purchase prenatal vitamins or are given a prescription for prenatal vitamins. This information also could be disseminated in stores through tear sheets or coupon-like dispensers next to items such as pregnancy tests, condoms, and lubricants. These methods can capitalize on the fact that pregnancy is a time of intense self-initiated health-seeking behavior. Women are motivated to try to improve and maximize the health outcomes for their infants. Fontaine noted that AAFP has more than 100,000 members. Family medicine residents in training provide prenatal care, deliver babies in the hospital, and care for babies afterwards. Although only a minority of residents end up doing obstetrics as part of their practice, this minority is sizable. Eighteen percent of rural family doctors are still providing 

60 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES doctors provide such care in urban areas. Fontaine then provided several suggestions for disseminating the guidelines:  Encourage the incorporation of maternity care into the patient- centered medical home. Encourage a focus on team care in which all the disciplines in the office can contribute so that the physician’s time is used effectively. The primary physician’s efforts can be substantially augmented by other staff, such as social workers, dietitians, nurse coordinators, or health educators.  Explore ways to help patients develop their own goals. Merely telling a patient how much she ought to gain will not help her remember it. Asking her how much she thinks she ought to gain in pregnancy, how much she thinks she ought to be exercising, or how much she is planning to exercise can help clinicians learn much more and help set achievable, incremental goals.  Incorporate the guidelines into training courses, such as AAFP’s Maternity Care and Infant Safety program. One of the products of that program is the Advanced Life Support in Obstetrics (ALSO) curriculum. Although ALSO emphasizes labor and delivery room emergencies, it also covers prenatal risk assessment. AAFP was able to get information about the risks of obesity and the new weight gain guidelines into a standardized lecture that is delivered to thousands of maternity care providers annually. In addition, recertification for family physicians includes a specific module on obstetric care that is in the process of being updated. Brown then opened the floor to discussion and asked workshop participants to identify the important ideas that had come up during the day. The first issue raised in the discussion concerned the practice of back-loading prenatal visits and whether the Patient Protection and Affordable Care Act (ACA) provides any opportunities for rethinking that structure. This issue is somewhat controversial, with diverse opinions about the optimal structure and number of visits. Several participants responded, with general agreement, that the actual number of visits was not as important as making sure that the number was appropriate for a particular patient. However, for the purposes of weight management, data suggest that more visits early in pregnancy are needed. A participant added that everyone—obstetricians, midwives, family practitioners, and other people who take care of pregnant women— 

SESSION 4 61 should be taught the importance of the first few weeks of pregnancy in determining the course of pregnancy. Women also need to understand this. If the women do not know this period is important, if the physicians who are taking care of them do not know it is important, and if the reimbursement companies do not think it is important and do not want to cooperate, then little can be accomplished. Another participant continued the conversation by suggesting that there is a difference between public health and medical care perspectives on prenatal care. From a medical care perspective, a healthy woman coming in for prenatal care does not have complications and thus needs less care; on the other hand, an unhealthy woman may develop complications and would therefore need more intensive monitoring, especially toward the end of pregnancy. In contrast, a public health model would put the emphasis on helping women come in to prenatal care in the healthiest possible state. The United States does not necessarily have the institutional support for women to be in the healthiest possible condition to ensure the future of the next generation. This may be where policy action is necessary. A participant noted that primary care is beginning to move away from a relative value unit–based payment system, in which a physician delivers the care one on one and then gets reimbursed for the services provided, toward an approach in which the physician, along with an expert team that may include a nutritionist, social worker, or nurse practitioner, is responsible for a panel of patients. In this approach, all the non-physician providers have expertise in certain areas, which frees up the physician to deal with more complicated concerns. To apply this framework to prenatal care, the team would take an inventory of a woman on her first visit in order to define her level of risk for that pregnancy based on how she presents. The team would then create a care plan for her in the first prenatal visit, which would set out what each of her visits would look like and who would be responsible for each element of the visit. The payment structure would then follow that framework, with the team being paid for taking care of a panel of patients. The University of Pittsburgh is currently conducting a pilot study of this team care approach in a primary care setting (not the maternal care setting). One useful next step would be to test these systems and put the models into the literature because evidence-based support will be critical to changing the payment system. Another participant agreed that these changes are worth exploring but reminded workshop participants of the complexity of the coordinating system that would need to be in place to make all of these 

62 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES ideas work. He then suggested that many previous successes have had a champion at the very top. For example, Surgeon General C. Everett Koop and his antismoking report had an enormous impact. More recently, Surgeon General Regina Benjamin’s call to action for supporting breastfeeding has already had an impact, even though that report was only released in 2010. First Lady Michelle Obama also has had a huge impact on the success of the Let’s Move campaign. Brown agreed and noted that popular media is another efficient and potentially effective way to raise awareness and increase understanding about issues. Over the past 15 to 20 years, the rates of teen pregnancy and childbearing have gone down between 40 and 50 percent, depending on the measurement. One factor that may have accelerated the decline in the past several years was the MTV shows 16 and Pregnant and Teen Mom. Some limited research suggests that adolescent girls respond to those programs and that they influence what the girls think and do. A participant echoed the challenge of bringing gestational weight gain to people’s attention when it must compete with so many other issues. She noted that girls who have a negative pregnancy test are likely to get pregnant within the next 6 months. A woman visiting a doctor’s office for a pregnancy test presents an opportunity for counseling and education, but now that many women use home pregnancy tests, that opportunity arises much less often and other channels are necessary for reaching women. One possible course of action might be to put messages in home pregnancy test boxes to help women develop a reproductive life plan. These messages could cover topics such as contraception to prevent unplanned pregnancy, the importance of preparing for pregnancy by being at a healthy weight and engaging in healthy lifestyle behaviors, and the importance of early and regular prenatal care. One participant expressed concern about the influence of mass media, noting the current attention that is paid to celebrities’ appearance during pregnancy and the way in which some consumers interpret that appearance as an encouragement to gain less weight than recommended. Other participants suggested ways that the media could be a positive force in educating women about appropriate weight gain during pregnancy, such as the involvement of a credible celebrity who could be a role model or spokeswoman for healthy weight and pregnancy, a reality show about healthy behaviors leading to healthy weight gain, education from well-known media health authorities, shows on the Food Network, and efforts to increase awareness of HBO’s documentary series The Weight of the Nation. Other suggestions for educating consumers included apps that provide nutrition information when a product’s UPC 

SESSION 4 63 code is scanned and a “seal of approval” logo from a trusted organization such as the March of Dimes. Brown noted that analyses of declines in highway fatality research have indicated that a combination of multiple factors (e.g., air bags, driver’s education, seatbelts, exit ramp redesign, speed limits) is responsible, not any single factor. A multi-faceted approach may be applicable in this case as well. One participant suggested that improved monitoring and surveillance data systems would be of great value in determining the effects of policies and programs aimed at helping pregnant women gain weight within the guidelines. Other ideas offered by participants included talking with mothers of young women at their own well-woman visits to encourage the support system that is critical to helping young women develop and maintain healthy behaviors, and ensuring that the science textbooks used in high schools appropriately cover issues related to the effects of nutrition during pregnancy on the health of the fetus and mother. Brown thanked the panelists and workshop participants for a stimulating discussion and concluded the session.