Catherine McParlin

Physical activity in pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women

BackgroundWhilst there has been increasing research interest in interventions which promote physical activity during pregnancy few studies have yielded detailed insights into the views and experiences of overweight and obese pregnant women themselves. The qualitative study described in this paper aimed to: (i) explore the views and experiences of overweight and obese pregnant women; and (ii) inform interventions which could promote the adoption of physical activity during pregnancy.MethodsThe study was framed by a combined Subtle Realism and Theory of Planned Behaviour (TPB) approach. This enabled us to examine the hypothetical pathway between beliefs and physical activity intentions within the context of day to day life. The study sample for the qualitative study was chosen by stratified, purposive sampling from a previous study of physical activity measurements in pregnancy. Research participants for the current study were recruited on the basis of Body Mass Index (BMI) at booking and parity. Semi-structured, in-depth interviews were conducted with 14 overweight and obese pregnant women. Data analysis was undertaken using a Framework Approach and was informed by TPB.ResultsHealthy eating was often viewed as being of greater importance for the health of mother and baby than participation in physical activity. A commonly cited motivator for maintaining physical activity during pregnancy is an aid to reducing pregnancy-related weight gain. However, participants often described how they would wait until the postnatal period to try and lose weight. A wide range of barriers to physical activity during pregnancy were highlighted including both internal (physical and psychological) and external (work, family, time and environmental). The study participants also lacked access to consistent information, advice and support on the benefits of physical activity during pregnancy.ConclusionsInterventions to encourage recommended levels of physical activity in pregnancy should be accompanied by accessible and consistent information about the positive effects for mother and baby. More research is required to examine how to overcome barriers to physical activity and to understand which interventions could be most effective for overweight/obese pregnant women. Midwives should be encouraged to do more to promote activity in pregnancy.

Objectively measured physical activity during pregnancy: a study in obese and overweight women.

BackgroundObese and overweight women may benefit from increased physical activity (PA) during pregnancy. There is limited published data describing objectively measured PA in such women.MethodsA longitudinal observational study of PA intensity, type and duration using objective and subjective measurement methods. Fifty five pregnant women with booking body mass index (BMI) ≥ 25 kg/m2 were recruited from a hospital ultrasound clinic in North East England. 26 (47%) were nulliparous and 22 (40%) were obese (BMI ≥ 30 kg/m2). PA was measured by accelerometry and self report questionnaire at 13 weeks, 26 weeks and/or 36 weeks gestation. Outcome measures were daily duration of light, moderate or vigorous activity assessed by accelerometry; calculated overall PA energy expenditure, (PAEE), and PAEE within four domains of activity based on self report.ResultsAt median 13 weeks gestation, women recorded a median 125 mins/day light activity and 35 mins/day moderate or vigorous activity (MVPA). 65% achieved the minimum recommended 30 mins/day MVPA. This proportion was maintained at 26 weeks (62%) and 36 weeks (71%). Women achieving more than 30 mins/day MVPA in the first trimester showed a significant reduction in duration of MVPA by the third trimester (11 mins/day, p = 0.003). Walking, swimming and floor exercises were the most commonly reported recreational activities but their contribution to estimated energy expenditure was small.ConclusionOverweight and obese pregnant women can achieve and maintain recommended levels of PA throughout pregnancy. Interventions to promote PA should target changes in habitual activities at work and at home, and in particular walking.

Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review

Importance Nausea and vomiting affects approximately 85% of pregnant women. The most severe form, hyperemesis gravidarum, affects up to 3% of women and can have significant adverse physical and psychological sequelae. Objective To summarize current evidence on effective treatments for nausea and vomiting in pregnancy and hyperemesis gravidarum. Evidence Review Databases were searched to June 8, 2016. Relevant websites and bibliographies were also searched. Titles and abstracts were assessed independently by 2 reviewers. Results were narratively synthesized; planned meta-analysis was not possible because of heterogeneity and incomplete reporting of findings. Findings Seventy-eight studies (n  = 8930 participants) were included: 67 randomized clinical trials (RCTs) and 11 nonrandomized studies. Evidence from 35 RCTs at low risk of bias indicated that ginger, vitamin B6, antihistamines, metoclopramide (for mild symptoms), pyridoxine-doxylamine, and ondansetron (for moderate symptoms) were associated with improved symptoms compared with placebo. One RCT (n = 86) reported greater improvements in moderate symptoms following psychotherapy (change in Rhodes score [range, 0 {no symptoms} to 40 {worst possible symptoms}], 18.76 [SD, 5.48] to 7.06 [SD, 5.79] for intervention vs 19.18 [SD, 5.63] to 12.81 [SD, 6.88] for comparator [P < .001]). For moderate-severe symptoms, 1 RCT (n = 60) suggested that pyridoxine-doxylamine combination taken preemptively reduced risk of recurrence of moderate-severe symptoms compared with treatment once symptoms begin (15.4% vs 39.1% [P < .04]). One RCT (n = 83) found that ondansetron was associated with lower nausea scores on day 4 than metoclopramide (mean visual analog scale [VAS] score, 4.1 [SD, 2.9] for ondansetron vs 5.7 [SD, 2.3] for metoclopramide [P = .023]) but not episodes of emesis (5.0 [SD, 3.1] vs 3.3 [SD, 3], respectively [P = .013]). Although there was no difference in trend in nausea scores over the 14-day study period, trend in vomiting scores was better in the ondansetron group (P = .042). One RCT (n = 159) found no difference between metoclopramide and promethazine after 24 hours (episodes of vomiting, 1 [IQR, 0-5] for metoclopramide vs 2 [IQR, 0-3] for promethazine [P = .81], VAS [0-10 scale] for nausea, 2 [IQR, 1-5] vs 2 [IQR, 1-4], respectively [P = .99]). Three RCTs compared corticosteroids with placebo or promethazine or metoclopramide in women with severe symptoms. Improvements were seen in all corticosteroid groups, but only a significant difference between corticosteroids vs metoclopramide was reported (emesis reduction, 40.9% vs 16.5% at day 2; 71.6% vs 51.2% at day 3; 95.8% vs 76.6% at day 7 [n = 40, P < .001]). For other interventions, evidence was limited. Conclusions and Relevance For mild symptoms of nausea and emesis of pregnancy, ginger, pyridoxine, antihistamines, and metoclopramide were associated with greater benefit than placebo. For moderate symptoms, pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo. Ondansetron was associated with improvement for a range of symptom severity. Corticosteroids may be associated with benefit in severe cases. Overall the quality of evidence was low.

Hyperemesis in Pregnancy Study: a pilot randomised controlled trial of midwife-led outpatient care

OBJECTIVE To assess the feasibility of implementing a complex intervention involving rapid intravenous rehydration and ongoing midwifery support as compared to routine in-patient care for women suffering from severe nausea and vomiting in pregnancy, (NVP)/hyperemesis gravidarum (HG). STUDY DESIGN 53 pregnant women attending the Maternity Assessment Unit (MAU), Newcastle upon Tyne NHS Foundation Trust, Newcastle, UK with moderate-severe NVP, (as determined by a Pregnancy Unique Quantification of Emesis and Vomiting [PUQE] score ≥nine), consented to participate in this pilot randomised controlled trial (RCT). Subsequently 27 were randomised to the intervention group, 26 to the control group. Women in the intervention group received rapid rehydration (three litres Hartmans solution over 6h) and symptom relief on the MAU followed by ongoing midwifery telephone support. The control group were admitted to the antenatal ward for routine in-patient care. Quality of life (QoL) determined by SF36.V2 score and PUQE score were measured 7 days following randomisation. Completion rates, readmission rate, length of hospital stay and pregnancy outcomes data were collected. RESULTS Groups were comparable at baseline. Questionnaire two return rate was disappointing, only 18 women in the control group (69%) and 13 women in the intervention groups (44%). Nonetheless there were no differences between groups on Day 7 in terms of QoL, mean PUQE score, satisfaction with care, obstetric and neonatal outcomes or readmission rates. However, total combined admission time was higher in the control group (94h versus 27h, p=0.001). CONCLUSIONS This study suggests that day-case management plus ongoing midwifery support may be an effective alternative for treating women with severe NVP/HG. A larger trial is needed to determine if this intervention affects womens QoL.

Objective measurement of physical activity in overweight and obese pregnant women

Introduction Promoting increased physical activity (PA) during pregnancy could decrease the risk of obesity related pregnancy complications. At least 30 min of moderate or vigorous activity (MVPA) or 8000 steps/day are recommended. There is little information on PA levels in pregnant women. Self-report measurement methods tend to overestimate PA. This study assessed PA in overweight and obese pregnant women objectively using accelerometers and pedometers. Methods 65 pregnant women, body mass index (BMI) >25 kg/m2, consented and had their PA measured for at least three valid days, using both measurement tools. Their mean age was 31.3 years (SD=5.6), mean BMI 31.2 kg/m2 (SD=5.5) and median gestation 13 weeks (IQR=12–20), 60% were overweight, 40% obese and 46% nulliparous. Results 46% of women recorded ≥30 min/day MVPA via accelerometry while 30% recorded ≥8000 steps via pedometry. The mean step counts by accelerometry and pedometry were 6007 (SD=2039) and 5933 (SD=2777). Despite the small mean difference there was substantial intrapersonal disagreement, (limits of agreement= −3389 to 3357 steps/day). There were no differences in any of the PA variables between overweight and obese women. Multiparous women recorded more time in light PA, (3 h 31 min, SD=47 min), than nulliparous women, (2 h 41 min, SD=45 min, p<0.001), while nulliparous women recorded more sedentary time, (10 h 15 min, SD=1 h 9 min, compared to 9 h 25 min, SD=1 h 44 min, p=0.031). There were no parity differences in the proportion of participants achieving recommended PA guidelines. Conclusion Only 46% of participants achieved the recommended 30 min of MVPA/day, fewer achieved recommended step counts. Interventions to improve PA levels should target moderate intensity activities such as brisk walking.

GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING): A pilot cluster randomised controlled trial of a guideline implementation intervention for the management of maternal obesity by midwives

BackgroundWeight management in pregnancy guidelines exist, although dissemination alone is an ineffective means of implementation. Midwives identify the need for support to overcome complex barriers to practice. An evaluation of an intervention to support midwives’ guideline implementation would require a large-scale cluster randomised controlled trial. A pilot study is necessary to explore the feasibility of delivery and evaluation prior to a definitive trial. The GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING) trial aims to test whether it is feasible and acceptable to deliver a behaviour change intervention to support midwives’ implementation of weight management guidelines.MethodsGLOWING is a multi-centre parallel group pilot cluster randomised controlled trial comparing the delivery of a behaviour change intervention for midwives versus usual practice. Four NHS Trusts (clusters) will be randomised to intervention and control arms, stratified by size of maternity services. The intervention uses social cognitive theory and consists of face-to-face midwifery training plus information resources for routine practice. The main outcomes are whether the intervention and trial procedures are feasible and acceptable to participants and the feasibility of recruitment and data collection for a definitive trial. Target recruitment involves all eligible midwives in the intervention arm recruited to receive the intervention, 30 midwives and pregnant women per arm for baseline and outcome questionnaire data collection and 20 midwives and women to provide qualitative data. All quantitative and qualitative analyses will be descriptive with the purpose of informing the development of the definitive trial.DiscussionThis pilot study has been developed to support community midwives’ implementation of guidelines. Community midwives have been selected as they usually carry out the booking appointment which includes measuring and discussing maternal body mass index. A cluster design is the gold standard in implementation research as there would be a high risk of contamination if randomisation was at individual midwife level: community midwives usually work in locality-based teams, interact on a daily basis, and share care of pregnant women. The results of the pilot trial will be used to further develop and refine GLOWING prior to a definitive trial to evaluate effectiveness and cost-effectiveness.Trial registrationISRCTN46869894; retrospectively registered 25th May 2016.

Views, experience and adherence among pregnant women with gestational diabetes participating in a weight loss study (WELLBABE).

To investigate the views and experience of pregnant women newly diagnosed with gestational diabetes mellitus participating in a 1200 kcal/day diet to achieve moderate weight loss (the WELLBABE study), and to explore barriers to and facilitators of adherence.

PD.06 Implementation barriers experienced by midwives when advising obese pregnant woman about physical activity: A cross-sectional survey

Introduction Increasing levels of physical activity (PA) may help to reduce the risk of some obesity related pregnancy complications and NICE guidelines advise at least 30 minutes of moderate PA per day. However, women receive limited advice concerning PA from midwives. This study investigated perceived implementation difficulties for midwives advising obese pregnant women regarding PA. Methods A self-completion, anonymous questionnaire was distributed to all midwives employed by three Trusts in Tyne and Wear (n = 365; response rate 52.6%). It was designed to identify barriers to midwives ‘discussing PA with obese pregnant women and advising them in accordance with national guidelines’. The design used the Theoretical Domain Framework approach proposed by Michie (2005), which describes 11 domains of behavioural determinants used to investigate perceived implementation difficulties. Results Midwives scored highest on knowledge, social-professional role and beliefs about consequences and lowest on skills, beliefs about capabilities and environment/context/resources domains. There were no differences in mean domain scores between hospital Trusts but midwives providing antenatal care scored higher than ward midwives, indicating they perceived fewer barriers to the behaviour. Regression analysis indicated that skills and memory/attention/decision domains had a significant influence on discussing /advising on PA. Conclusions Midwives feel knowledgeable about PA advice for obese women and believe it is part of their role, but perceive they lack necessary skills, capabilities and resources. Designing interventions that improve skills, promote routine enquiry regarding PA and provide resources (eg. Information, referral pathways) may help improve midwives’ PA advice. Reference Michie S, et al. Quality and Safely in Health Care 2005;14:36–35