Feet on scale [credit: Mater Mothers’ Hospitals]

Why focus on healthy weight gain in pregnancy?

Gestational weight gain (GWG) outside of guidelines is linked with negative health consequences for both the mother and her baby. Pregnant women who gain weight in accordance with the US Institute of Medicine (IOM) guidelines, also adopted for use in Australia (where we did our study), have the lowest risk of pregnancy and birth-related complications. Women who gain more are more likely to experience high blood pressure and diabetes in pregnancy, longer hospital stays after birth, and Cesarean sections. They are also more likely to have trouble losing weight after the baby is born and to have difficulty breastfeeding. Women who do not gain enough weight are more likely to deliver their baby early.

Less than a third of pregnant women gain the right amount.

In a recent systematic review and meta-analysis of over 1 million pregnant women, linked above, 47% had GWG greater than and 23% had GWG less than IOM recommendations. With the service changes made in our hospital’s antenatal care processes, we have been able to document significant reduction in excess GWG (decreasing from 57.3% to 32.6%).

How can we support women’s healthy weight gain?

If you build it (properly), they will come.

Gut instinct says that if you tell people what to do they will do it – disseminate guidelines, deliver training, display posters – but evidence shows otherwise. Just as telling someone they need to exercise regularly for good health rarely results in a long-term change in routine, similarly, a more nuanced and tailored approach is required to facilitate sustainable changes in healthcare delivery.

Enter Implementation Science – the field of scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine care. The approach we took in our large tertiary maternity service follows the recommended steps to develop effective health care interventions. In this case, we wanted behaviors of health professionals, teams, and the organization to change.

We asked:

1. Who needs to do what, differently?
2. What barriers and enablers need to be addressed?
3. Which intervention components (behavior change techniques and modes of delivery) could help?
4. How can behavior change be measured and understood?

Through a body of work that synthesized data from the literature, clinical observations, and staff surveys (i.e. theory, evidence, and practical issues), we followed this four-step approach to select the most appropriate components of our implementation intervention.

Elements of a system-wide intervention to improve GWG guideline adherence.

Early steps in our work resulted in a number of service and system changes, informed by our use of the theoretical domains framework (TDF). This allowed us to sort and categorize the barriers we faced to achieving best GWG practice. The domains from the TDF relevant to our maternity service included: Knowledge, Skills, Social and professional role/identity, Beliefs about capabilities, and Environmental context and resources. This led to us increasing dietitian time in clinic (including a dietitian-led early antenatal workshop), development of GWG resources for maternity staff to use (including a Weight tracker), and staff training around GWG. Our changes were small but targeted – made within service capacity and with reorientation of existing resources.

We showed better compliance with individual guideline elements but overall adherence did not improve. The focus of this research related to the same identified gaps, and strategies were implemented in stages including:

• staff in-services training outlining and incorporating the evidence into practice via voiceover PowerPoint presentation (2014),
• obtaining scales for each antenatal clinic room (2014), and
• removal of a default ‘skip’ option from the e-health record where weight is recorded, to promote mandatory entries (September 2016).

What is more effective for ensuring weight recording in pregnancy?

This study assessed the cumulative influence of these interventions on staff’s compliance to recording of antenatal weights. Using routinely collected data across the same periods of our interventions allowed us to easily compare staff’s documentation of women’s weights at antenatal visits to measure how each intervention affected practice.

Across three 15-month cohorts (from April 2014 to December 2017), there were approximately 39,000 pregnancies. The proportion of women who had a weight recorded at each visit per cohort differed significantly between cohorts, from 4.2% (baseline) to 18.9% (scales and in-services) to 61.8% (medical record prompts) (p <0.001). Improvements were observed across the entire service, in all models of care and with all professional groups.

Think global, act local.

Reliance on memory to follow recommended practices from guidelines less-consistently elicits behavior change compared to routine structural changes to facilitate their implementation. Our interventions showed greater improvements than previously documented for reminder systems (usually only ~4%), perhaps through being uniquely tailored to the local barriers. Simple system changes appear to be most effective for sustainable outcomes in this instance of antenatal weight recording. This reflects findings from a recent eHealth review that highlighted substantial improvements in accuracy and completeness of clinical information as well as guideline adherence when electronic medical records are integrated into workflow processes (used at the point of care). Future guideline implementation projects should look beyond education sessions to harnessing systems and technology which will support their desired changes.