Get Healthy in Pregnancy - Preventive Health€¦ · body mass index according to the IOM...
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1 Get Healthy in Pregnancy Evaluation and Outcomes Report: A cluster randomised trial to evaluate the effectiveness of a telephone based coaching program in reducing excessive gestational weight gain amongst pregnant women NSW Office of Preventive Health June 2016
Transcript of Get Healthy in Pregnancy - Preventive Health€¦ · body mass index according to the IOM...
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Get Healthy in Pregnancy Evaluation and Outcomes Report:
A cluster randomised trial to evaluate the
effectiveness of a telephone based coaching
program in reducing excessive gestational
weight gain amongst pregnant women
NSW Office of Preventive Health
June 2016
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Suggested citation
Get Healthy in Pregnancy Project Team (2016). Get Healthy in Pregnancy - Evaluation and Outcomes
Report: A cluster randomised trial to evaluate the effectiveness of a telephone based coaching program in
reducing excessive gestational weight gain amongst pregnant women. North Sydney: NSW Ministry of
Health. June 2016.
Acknowledgments
We would like to thank the midwives and medical officers at the five study sites for their support in
recruiting women to the trial, the clinic coordinators for the local management of the trial, Healthways staff
for providing the health coaching service and information services and the GHiP Expert Advisory Group for
clinical advice.
Contributors
Chris Rissel, Director, NSW Office of Preventive Health
Jane Raymond, A/Manager, Maternal and Newborn Unit, Office of Kids and Families
Karin Taylor, Trainee Public Health Officer, NSW Ministry of Health
Kit Leung, Trainee Public Health Officer, NSW Ministry of Health
Michelle Maxwell, Centre for Population Health, NSW Ministry of Health
Nageen Ahmed, Get Healthy Service Manager, NSW Office of Preventive Health
Praveena Gunaratnam, Public Health Officer, NSW Ministry of Health
Santosh Khanal, Senior Evaluation Officer, NSW Office of Preventive Health
Vanessa Clements, Clinical Midwifery Consultant, NSW Pregnancy and Newborn Services Network
Vicky Aouad, Trainee Public Health Officer, NSW Ministry of Health
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Definitions
Body Mass Index (BMI) Body mass index is calculated as weight in kilograms divided by height
in meters squared (kg/m2).
Eligible women Women were eligible to participate in the trial if they were:
English speaking
Aged 18 years and over
A singleton pregnancy
Pre-pregnancy BMI ≥18.5 kg/m2
Gestation of 18 weeks or under at enrolment; and
Met the medical clearance requirements outlined at
Appendix C.
Enrolled women Women who had their baseline data collected by a Get Healthy in
Pregnancy health coach.
Excessive gestational weight gain Weight gain above the recommended range according to pre-pregnancy
body mass index according to the IOM guidelines 2009.
Normal weight* A body mass index between 18.5kg/m2 and 24.9kg/m2.
Overweight or Obese (OWO)* An overweight body mass index between 25kg/m2 and 29.9kg/m2 and
an obese body mass index of 30kg/m2 or above.
Referred women Women who were screened by their midwife or doctor and met the
inclusion criteria and agreed to be referred to the Get Healthy in
Pregnancy service.
Screened women Pregnant women who attended an antenatal clinic participating in the
trial and a midwife or doctor completed a Screening and Assessment
Form to determine their eligibility for the trial (at Appendix F).
Study participants Women who enrolled in the Get Healthy in Pregnancy service as well as
women, midwives, medical practitioners and health coaches who were
interviewed as part of the qualitative research.
Underweight* A body mass index of less than 18.5kg/m2.
Withdrawals Women who enrolled in the service but withdrew before completing
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the end-point data collection at 36 weeks gestation.
Women lost to follow up Women who:
1. did not enrol in Get Healthy in Pregnancy service and have their
baseline data collected by a health coach, or
2. enrolled in the service but did not complete the end-point data
collection at 36 weeks gestation.
*Weight category terminology is based on the IOM guidelines 2009.
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Contents
Definitions ..................................................................................................................................................... 3
Executive Summary ....................................................................................................................................... 7
Introduction .................................................................................................................................................. 9
Background ................................................................................................................................................ 9
The NSW Get Healthy in Pregnancy Service (GHiP)................................................................................... 9
Study Aims ..................................................................................................................................................... 9
Methods ...................................................................................................................................................... 10
Data collection ........................................................................................................................................ 12
Data Analysis ........................................................................................................................................... 13
Results ......................................................................................................................................................... 13
Quantitative Findings .............................................................................................................................. 13
Qualitative Findings ................................................................................................................................. 20
Women’s Experience of the Service ........................................................................................................ 20
Midwives and Medical Practitioners’ Experience of Recruiting Women to the Service ......................... 28
Health Coaches ........................................................................................................................................ 32
Discussion ................................................................................................................................................... 37
Limitations ................................................................................................................................................... 38
Recommendations ....................................................................................................................................... 39
Promotion of the Service ......................................................................................................................... 39
Delivery of the Service ............................................................................................................................. 40
Content of the Coaching Calls and Resources ......................................................................................... 40
Coach Training ......................................................................................................................................... 41
Conclusion ................................................................................................................................................... 42
References ................................................................................................................................................... 43
Appendices .................................................................................................................................................. 44
Appendix A – Members of Expert Advisory Panel ....................................................................................... 44
Appendix B: Medical Clearance Form ......................................................................................................... 46
Appendix C – Medical Conditions for Exclusion .......................................................................................... 48
Appendix D – Midwives script ..................................................................................................................... 50
Appendix E: Information flyer for participants ............................................................................................ 52
Appendix F: Screening and Assessment Form ............................................................................................ 56
Appendix G: Coaching Content .................................................................................................................... 58
Appendix H – Interview Guides ................................................................................................................... 62
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Appendix I: Breakdown of results for women requiring medical clearance ............................................... 73
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Executive Summary
Background
Excessive gestational weight gain can result in poor maternal and child health outcomes, which can be
reduced through lifestyle interventions starting in early pregnancy. Get Healthy in Pregnancy (GHiP), a
telephone based lifestyle coaching service, has been developed to support women in NSW to achieve
healthy gestational weight gain. The service utilises existing resources of the Get Healthy Information and
Coaching Service and has two models of delivery; information only and coaching.
Methods/Design
This study aims to compare the effectiveness of a telephone-based health coaching program versus
provision of information only in supporting pregnant women to achieve appropriate gestational weight
gain. A mixed methods approach to the evaluation was taken. For the quantitative aspects, a pragmatic
stratified clustered randomised controlled trial was conducted with women who presented to five hospitals
for their first antenatal appointment during the recruitment period (October 2014 to September 2015), had
a pre-pregnancy body mass index (BMI) ≥ 18.50 (healthy weight or above), were 18 years of age and over,
singleton gestation, English speaking, met the conditions for medical clearance and were 18 weeks or less
gestation. Hospitals were randomised into one of two intervention models: a) information only; or b)
information plus 10 telephone-based health coaching sessions with a university qualified coach. Both
interventions set a weight-gain range target for pregnant women. In-depth qualitative interviews were held
with a selection of participating women, health professionals involved in the trial including midwives and
medical practitioners and the health coaches.
Women recruited to the trial had a number of measures recorded including anthropometrics (self-reported
height and weight), dietary and physical activity scores during and following pregnancy at baseline (prior to
18 weeks gestation) and 36 weeks gestation.
Results
A total of 3,736 women were screened across all the five hospitals. Of the 3,736 women screened, 1,589
(42.5%) were eligible to participate in the study. Attending the antenatal clinic after 18 weeks of gestation
was the most common cause for ineligibility, accounting for almost 70% of ineligible women (n=1489). A
total of 921 pregnant women were referred to the service. Of the 921 women referred to the GHiP service,
33% (n=302) enrolled in the service. Of these, 29% (n=89) completed the end-point data collection at
36 weeks gestation.
For the primary outcome, the proportion of women who gained weight within the target range for their
BMI, the difference between the groups from baseline to 36 weeks gestation was statistically significant in
favour of the intervention arm (there was a 11.0% difference in the proportion of women who gained
weight within the target range between groups, p=0.032). There were significant effects in favour of the
intervention arm for two of the six health behaviour outcomes including reducing daily soft drink intake
and weekly takeaway consumption.
The acceptability of the GHiP service was explored through the experiences of 54 individuals. This group
included 25 women who participated in either the information or coaching arms of the trial, 23 medical
practitioners who recruited women to the trial and six health coaches. Overall, the qualitative analysis
demonstrated that the service was informative, supportive and on the whole, manageable within the daily
routine or work time, for those who took part.
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Women commented that the service filled an important gap in current antenatal care provision, primarily
information in relation to healthy eating and physical activity. Women in the coaching arm were more likely
to gain benefit in terms of support for change than those in the information arm. This benefit was gained
mainly through the regular reminders provided by the calls and the continuity provided by having the same
coach on each call. Change in relation to eating and physical activity habits during pregnancy was reported
by many of the women interviewed.
Midwives and medical practitioners were unanimously positive about the support the service provided,
both to them as a referral service, and to the women. It was noted that involvement in the service had
been a learning opportunity, enabling them to gain confidence to approach the topic and frame it positively
as a ‘routine’ conversation they had with all women, not just those who were overweight or obese.
Practice change for some of these health professionals was evident, although the ability to implement
change varied between midwives. It is clear that ongoing training and leadership is needed to support the
regular intakes of new staff entering the antenatal clinic environment.
The coaches interviewed noted that coaching pregnant women was no different from non-pregnant
participants, although there was more emphasis during the calls on overcoming the minor ‘ailments’ of
pregnancy that arose including constipation, nausea and lethargy. Overall, they reported feeling that they
were able to offer helpful support. In regard to training, the coaches noted that they needed more
information on aspects of early motherhood – such as nutritional support for breastfeeding.
Conclusion
Despite high rates of women lost to follow up in the trial, there is evidence of a positive effect on healthy
gestational weight gain among women completing the Get Healthy in Pregnancy service compared to
receiving information only. Qualitative feedback from participating women, health professionals and
coaches, is largely very positive, and highlights some areas where the delivery of the service can be
improved. With no apparent negative consequences of the Get Healthy in Pregnancy service, there is
reasonable evidence to support the phased roll-out of the Get Healthy in Pregnancy service across NSW
antenatal clinics.
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Introduction
Background
Excessive gestational weight gain is associated with poor short and long term outcomes for both mother
and child. These include gestational diabetes, caesarean section weight retention for women and an
increased risk of childhood obesity for the child1. Studies indicate the prevalence of excessive gestational
weight gain in Australia is between 38 and 67%2,3. The risk of excessive weight gain can be reduced through
healthy eating and physical activity.
A free, telephone based health coaching service, the Get Healthy Information and Coaching Service (GHS),
has been available to all adults over 18 years of age in NSW since 2009. People using GHS can opt for
information only, or enrol in a six-month coaching program through which they receive 10 individually
tailored telephone calls from university qualified health coaches. These calls are aimed at supporting the
individual to make sustainable improvements in healthy eating, physical activity and to achieve or maintain
a healthy weight.
Extensive evidence exists for the effectiveness of telephone based lifestyle programs and the evaluation of
the GHS shows that participants who complete the six-month coaching program lose on average 3.9kgs and
5cms from their waist circumference4. Evaluation of the GHS has demonstrated that it is utilised by people
of low socio-economic status and those in rural, regional and remote areas4.
The NSW Get Healthy in Pregnancy Service (GHiP)
In 2013 the NSW Office of Preventive Health and the Office of Kids and Families (formerly NSW Kids and
Families) collaborated to develop a service enhancement or “module” for the GHS to support pregnant
women to achieve healthy gestational weight gain and to support women to adopt or maintain healthy
lifestyle behaviours post birth.
Development of GHiP was informed by evaluations of other interventions aimed at reducing excessive
gestational weight gain with input from an Expert Advisory Panel consisting of: midwives, dieticians,
diabetes and antenatal educators, obstetricians and clinical advisors. A full list of panel members is at
Appendix A. Reference was also made to relevant state, national and international guidelines5,6, and the
evidence base from Australia and internationally on interventions to address excessive gestational weight
gain7-10.
In order to test the effectiveness and acceptability of GHiP, the NSW Office of Preventive Health and NSW
Office of Kids and Families coordinated a pilot of the service in five antenatal clinics across NSW from
September 2014 to October 2015. The pilot took the form of a randomised controlled trial entitled: A
cluster randomised trial to evaluate the effectiveness of a telephone based coaching program in reducing
excessive gestational weight gain amongst pregnant women. The trial also sought to understand women’s
experience of the service and medical practitioners’ experience of delivering the service.
Study Aims The trial sought to test the effectiveness and acceptability of two different GHS delivery models in
supporting pregnant women to achieve appropriate gestational weight gain, in addition to routine care.
The hypothesis of the trial was that compared with participants who only receive information, pregnant
weight gain above the recommended range according to pre-pregnancy body mass index (BMI)
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women enrolled in the coaching program would be more likely to achieve healthy gestational weight, and
better maintain their weight post pregnancy.
Methods
Study Design
The study was designed as a stratified cluster randomised trial, with stratification by pre-pregnancy BMI
(normal and overweight/obese) and clustering by hospital. Hospitals within geographic classification (rural
or metropolitan) were allocated to either the control or intervention arm, with pregnant women at each
hospital recruited into the trial on their first antenatal visit. To test the effectiveness of the GHiP service,
the proportion of pregnant women who achieved weight gain within the recommended range in the
intervention and control groups were compared.
In order to test the acceptability of GHiP, semi-structured individual interviews were conducted with
participants, health professionals and health coaches to explore the experiences of these groups and to
make recommendations for service improvement.
The study was approved by the Human Research Ethics Committee of South Western Sydney Local Health
District (HREC/14/LPOOL/131) and site specific approvals were obtained for each study site.
Setting
The study was conducted in the antenatal clinics of five NSW hospitals, three rural (Orange Base, Lismore
Base and Dubbo Base) and two metropolitan (Liverpool and Blacktown).The hospitals were selected based
on factors such as number of births per year and ability to provide antenatal care for pregnant women with
high BMIs. These were public hospitals, accounting for approximately 10% of the total births in both public
and private hospitals in NSW, and 16% of all public hospital births in NSW. All of the hospitals offered a
variety of antenatal care options for women including: hospital-based antenatal care, GP shared-care and
midwifery group practice.
Randomisation
Randomisation of hospitals, stratified by metropolitan and rural regions, was undertaken using
Microsoft Excel 2010© randomisation generator. Hospitals in each arm were matched on socio-
demographic characteristics as much as was feasible. Two rural hospitals were combined into one unit for
randomisation because they were in the same Local Health District and their aggregated total number of
births in 2012 was similar to the total of the other rural hospital in the study.
Sample Size
A sample size of 710 pregnant women was calculated based on the ability to detect a difference of 3kg in
gestational weight gain between intervention and control groups at 80% power. Attrition rates of 60% in
the coaching arm and 30% in the information only arm was expected. These rates were calculated to
account for up to 15% of women, across both arms, who start the study and go on to develop conditions
during pregnancy that exclude them from further participation and, allows for the perception of participant
burden in the coaching arm. Of the 710 women, it was expected that approximately 177 in total would fall
into the healthy pre-pregnancy BMI category and 523 into the overweight or obese pre-pregnancy BMI
category.
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Participants
Women
Pregnant women attending one of the five trial sites for their first antenatal appointment between
September 2014 and October 2015 and were eligible for GHiP. The inclusion criteria were:
English speaking
aged 18 years and over
a singleton pregnancy
pre-pregnancy BMI ≥18.5 kg/m2, and
gestation of 18 weeks or under at enrolment.
Pregnant women with certain pre-existing medical conditions or obstetric history were deemed ineligible to
participate and were excluded from the trial. Other pre-existing conditions and some complications in
pregnancy required medical clearance (Medical Clearance form can be found at Appendix B) either prior to
or during participation in the GHiP service. Details of criteria for exclusion and medical clearance are at
Appendix C.
Midwives and Medical Practitioners
Midwives and medical practitioners who worked at a trial site between September 2014 and October 2015
were involved in recruiting women to the GHiP service. Face to face training to midwives was provided by
the research team at each site. This covered the importance of gestational weight gain, communication
skills and strategies to assist in broaching the subject with women, the GHiP service, aims and methods of
the study, and protocols for recruitment. Midwives were also provided with resources to facilitate their
conversations with women. These included the GHS information booklet, GHiP factsheets, a midwives’
script (see Appendix D) and a colour coded BMI chart. Medical practitioners were provided with
information on the importance of gestational weight gain, the GHiP service and how to provide medical
clearance for women to participate in the GHiP service.
Health Coaches
Health coaches from the GHS provided the GHiP service during the trial period. Face to face training for
GHS health coaches was provided by the research team on dietary, physical activity and weight gain issues
and recommendations which are specific to pregnancy. GHS coaches also received training in quantitative
data collection. A list of online resources to support pregnant women was also made available to all health
coaches, with the clinical experts available for further consultation as required. As part of the usual quality
assurance process for the GHS, some gestational weight gain coaching calls may have been audited.
Recruitment
Women
Pregnant women who presented at one of the five participating hospitals between September 2014 and
October 2015 received a flyer (Information Flyer can be found at Appendix E) with their initial appointment
letter advising that their midwife would discuss the GHiP service and research trial with them at their first
antenatal appointment. During the recruitment period, midwives screened every woman presenting for
their first antenatal appointment, to determine eligibility to enrol in the study (Screening and Assessment
Form can be found at Appendix F). Women eligible to participate were offered the opportunity to
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participate in the trial and asked for written consent. Women who were unsure were contacted by a
research assistant and reoffered the opportunity to participate.
Women were purposefully selected for interview to be representative of those in each arm of the trial.
Midwives and medical practitioners
The trial coordinator at each site was requested to nominate midwives and medical practitioners who
would be willing to be interviewed to discuss their experiences of the GHiP service trial.
Health coaches
The GHS service provider was requested to nominate health coaches who would be willing to be
interviewed to discuss their experiences of providing the GHiP service.
Study Arms
Intervention – coaching arm
The intervention group or coaching arm comprised up to 10 telephone coaching calls by university qualified
coaches. These calls focused on healthy eating, physical activity and achieving healthy weight gain during
pregnancy. Health coaches also advised women of their recommended gestational weight gain target,
according to the US Institute of Medicine (IOM) weight gain guidelines. The IOM guidelines recommend a
total weight gain of 11.5-16 kg for women who are a normal weight, 7–11.5 kg for overweight women and
5-9 kg for obese women. Calls were based on behaviour change principles designed to help with making
sustainable healthy lifestyle changes including: goal setting, maintaining motivation and overcoming
barriers. Content of the health coaching calls and the IOM weight gain recommendations can be found at
Appendix G. The timing of calls was designed to be flexible based on participant preferences with
approximately eight calls during pregnancy and two calls post birth.
Women in the coaching program were also provided with evidence based materials including pregnancy
specific fact sheets, the Having a Baby Book published by NSW Health and the Get Healthy Service
Information booklet which includes generic advice on healthy eating, physical activity and achieving and
maintaining a healthy weight. All pregnancy specific content was developed based on nationally and
internationally endorsed guidelines such as the Australian Dietary Guidelines and US Institute of Medicine
Weight Gain during Pregnancy guidelines.
Control – information only arm
Women in the control group received the evidence based package of materials provided to the intervention
group and a single health coaching telephone call from a health coach. Health coaches also confirmed the
woman’s recommended gestational weight gain target according to the US Institute of Medicine (IOM)
weight gain guidelines.
Data collection
Quantitative Data
Data for the study was collected at screening (10-18 weeks gestation), baseline (at enrolment into the
service at 10-21 weeks of gestation) and at the end-point (36 weeks of gestation). Screening data was
collected during the first antenatal visit and included measurement by midwife of weight and height and
estimated pre-pregnancy BMI based on consultation with the woman. Baseline and endpoint data were
self-reported by the women and collected over the phone by a health coach or a research assistant.
Coaching participants who discontinued the coaching program without withdrawing from the study were
contacted by a research assistant or an external service provider for their endpoint data collection.
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Qualitative Data
Qualitative data collection during the trial period considered feasibility and acceptability of the GHiP. Semi-
structured individual telephone interviews were conducted with participants and professionals involved in
the trial. Interviews were conducted by three of the study researchers and recorded using a digital recorder
and transcribed by a professional transcription service. Interview guides (at Appendix H) were used to elicit
the study participants’ experiences of the service, usefulness of program resources and suggestions for
service improvement.
Data Analysis
Quantitative Analysis
Differences between the two arms, health-coaching and information only, in mean weight change at
36 weeks gestation was tested using the independent samples t-test. The proportion of pregnant women
who achieve weight gain within the recommended range was analysed using the X2 test, after accounting
for bias due to selective attrition using inverse-probability-of-attrition weighting. Other data was compared
between the health coaching and information only arms.
Qualitative Analysis
Interview data was analysed using the thematic analysis approach. Interview transcripts were analysed in
detail by collating responses under headings and assigning a one-point summary interpretation. The coding
of the transcripts was undertaken and checked by independent coders and themes and subthemes were
extracted from the data.
Results
Quantitative Findings
Sample
A total of 3,736 women were screened across all the five hospitals. Of the 3,736 women screened, 1,589
(42.5%) were eligible to participate in the study. The mean age of screened women was 28.7±5.5 years.
There were no differences in the mean age of women who agreed or declined to participate in the study or
were ineligible. A higher proportion of women screened (65.8%, n=2,173) attended a metropolitan
hospital than those who attended a rural hospital. There were no differences in the pre-pregnancy weight
status of women who were screened or eligible to participate.
More than half of the women screened (57.5%, n=2147) were ineligible to participate in the study.
Attending the antenatal clinic after 18 weeks of gestation was the most common cause for ineligibility,
accounting for almost 70% of ineligible women (n=1489). A larger proportion of women attending rural
hospitals were excluded for this reason. Attending the antenatal clinic after 18 weeks of gestation
accounted for 94% of exclusions in rural hospitals (n=761) compared to 75% of exclusions in metropolitan
hospitals (n=728).
Women attending rural hospitals were more likely to be ineligible than women attending metropolitan
hospitals, with 70.4% of women attending a rural hospital being excluded (n=796) compared to 42.3% of
women who attended a metropolitan hospital (n=919). In rural hospitals, this was mostly due to women
not attending the antenatal clinic before 18 weeks of gestation (95.6%, n=761).
Other reasons for ineligibility were women being non-English speaking (n=188), underweight (n=173),
under 18 years of age (n=60), having pre-existing medical conditions (n=61) or having a multiple pregnancy
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(n=43). BMI status was not available for 201 women and they were also excluded from the study. Figure 1
below shows the proportion of women ineligible for the study by reason and trial arm.
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Table 1 Number of women screened, eligible and referred by pre-pregnancy BMI and trial arm
Control Intervention
Normal
weight
OWO Total Normal
weight
OWO Total
Women screened (n= 3302)* 810 700 1,510 848 944 1,792
Women eligible for GHiP
service (n= 1589)
402 352 754 389 446 835
Women referred to GHiP
(n=921)
240 241 481 187 253 440
*This does not include women who were underweight, had no BMI status or were under 18.
Medical clearance was required for 10% of screened women (n= 370). Around 60% of women who required
medical clearance had a pre-pregnancy BMI of overweight or obese (n=224). The most common conditions
requiring medical clearance were history of mental health conditions (n=72), recurrent miscarriage (n=63)
and moderate asthma (n=54). Only 1.6% of women that were screened were excluded from the study for
medical reasons (n=61). A breakdown of conditions that required medical clearance are at Appendix I.
Figure 1 Reasons women were ineligible by trial arm
Approximately half of eligible women agreed to be referred to the service. The referral rates were lower for
the intervention arm hospitals. There were no differences in the referral rates between the hospitals. The
most common reasons for declining the service was lack of interest in managing weight (n=191) and lack of
time (n=148).
0
100
200
300
400
500
600
700
800
900
Control
Intervention
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Referral and enrolment
A total of 921 pregnant women were referred to the GHiP service. 427 women had a normal pre-pregnancy
BMI while 494 were in the overweight or obese BMI range at pre-pregnancy. A slightly higher proportion of
women referred to the GHiP service were overweight or obese at pre-pregnancy (53.7%). Of the 921
women referred to the GHiP service, 33% (n=302) enrolled in the service and 29% (n=89) completed the
end-point data collection at 36 weeks gestation.
The demographics and pre-pregnancy weight status of women screened, referred and enrolled in the GHiP
service was similar in both the intervention and control arms (Table 2). A higher proportion of women who
were referred to the GHiP service were overweight or obese at pre-pregnancy. 50% of women who were
referred to the GHiP service were overweight or obese at pre-pregnancy, compared to 47% and 41% of
women who were screened. A higher proportion of women in the intervention arm who enrolled in the
GHiP service were overweight or obese compared to control (60% and 50% respectively). Women who
withdrew from the service were more likely to be overweight or obese at pre-pregnancy in both the
intervention and control arms. In the intervention arm, 64% of women who withdrew from the service
were overweight or obese at pre-pregnancy. In the control arm, 55% of women who withdrew from the
service were overweight or obese at pre-pregnancy.
Outcomes
For the primary outcome, the proportion of women who gained weight within the target range for their
BMI, the difference between the groups from baseline to 36 weeks gestation was statistically significant in
favour of the intervention arm. There was a 11.0% difference in the proportion of women who gained
weight within the target range between groups (p=0.032, Table 4).
There were significant effects in favour of the intervention arm for two of the six health behaviour
outcomes including reducing daily soft drink intake and weekly takeaway consumption. The difference in
the mean between the groups favoured the intervention group by 0.1 cups (p<0.005) of soft drink per day.
Mean consumption of soft drink decreased from baseline to 36 weeks gestation by 0.2 cups per day in the
intervention and by 0.1 cups per day in the control.
The mean difference between the groups, from baseline to 36 weeks gestation, favoured the intervention
group by 0.5 serves (p<0.028) of takeaway per week (Table 4). Mean consumption of takeaway decreased
from baseline to 36 weeks gestation by 0.4 serves per week in the intervention and increased by 0.1 serves
per week in the control.
Women in the intervention arm were significantly more confident in doing regular, moderate physical
activity (p<0.000) than those in the control arm. Mean confidence scores increased from baseline to 36
weeks gestation by 1.7 points in the intervention and decreased by 1.6 points in the control. Women in the
intervention arm were also significantly more confident in achieving weight related goals (p<0.000) than
those in the control. Mean confidence scores from baseline to 36 weeks gestation increased by 1.7 points
in the intervention and decreased by 0.3 points in the control.
Women in the intervention arm who received more than five calls achieved less weight gain at 36 weeks
gestation than those who received less than five calls (Figure 2).
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Table 2: Comparison of the demographics and weight status of women who were referred, enrolled and withdrew by intervention arm
Intervention Control
Screened Referred Enrolled in GHS - pre program data
Withdrawals Screening Referral Enrolled in GHS - pre program data
Withdrawals – pre program data
Average age (yrs±SD) 28.7 (5.7) 29.7 (6.5) 29.5 (4.7) 29.4 (4.3) 28.7 (6.3) 29.0 (5.1) 28.5 (5.2) 27.8 (5.3)
Average pre pregnancy weight (Kg±SD)
61.1 (19.3) 65.0 (19.6) 62.3 (7.0) 71.4 (25.2) 58.8 (18.4) 61.1 (18.5) 58.6 (5.8) 62.1 (17.8)
% OWO 47.4 50.0 60.2 64.0 40.8 50.0 50.3 55.2
% Rural 37.4 31.5 41.7 38.2 33.6 17.4 20.8 23.2
Table 3: Weight and health behaviour characteristics of women in intervention and control arms at baseline and 36 weeks gestation
Intervention Control
Pre N= 180
Post N= 42
Pre N= 146
Post N= 47
Weight and BMI measurements
Participants with normal pre pregnancy BMI (N) 79 23 67 22
Weight (kg ±SD) 60.3 (7.0) 72.6(7.7) 58.1 (5.8) 73.1 (10.7)
BMI (Kg/m2±SD) 22.2 (1.7) 26.4 (2.2) 21.7 (1.7) 27.0 (3.2)
Participants OWO at pre pregnancy (N) 101 19 79 25
Weight (kg±SD) 86.9 (22.0) 96.4 (16.6) 84.8 (18.6) 94.5 (20.0)
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BMI (Kg/m2±SD) 34.0 (9.7) 37.2 (7.9) 33.2 (6.8) 37.6 (7.2)
Health behaviours
No. times walking at least 30mins/week (±SD) 2.9 (2.7) 3.9 (3.0) 3.0 (2.8) 3.7 (2.4)
No. times of moderate to intense PA/week (±SD) 0.4 (1.0) 0.8 (1.4) 0.5 (1.3) 1.0 (1.8)
Veg serves/day (±SD) 2.4 (1.5) 3.3 (1.8) 2.5 (1.7) 2.4 (1.5)
Fruit serves/day (±SD) 2.1 (1.3) 2.3 (0.7) 2.2 (1.4) 2.2 (1.1)
Cups soft drinks/day (±SD) 0.5 (1.0) 0.3 (0.7) 0.4 (1.2) 0.6 (1.2)
Times take away/week (±SD) 1.1 (1.3) 0.6 (0.7) 1.0 (1.4) 1.2 (1.1)
Confidence scores (out of 10)
In doing regular, moderate PA (±SD) 8.0 (2.2) 8.5 (1.8) 8.2 (2.1) 7.0 (2.4)
Eating healthier (±SD) 8.0 (1.9) 8.4 (1.5) 8.1 (2.0) 8.1 (1.6)
Achieving weight related goals (±SD) 8.0 (2.0) 8.6 (1.5) 8.1 (2.1) 8.0 (1.8)
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Table 4: Comparison between intervention and control arms of the changes in health behaviours and outcome measures
Intervention (N=42)
Control (N=47)
P value
Weight gain (Kg±SD) 11.3 (±5.5) 13.6 (±7.7) 0.109
N (%) participants with weight gain within target range
18 (42.9) 15 (31.9) 0.032
Change in health behaviours (post – pre)
No. times walking at least 30mins/week (±SD)
0.8 (±2.6) 1.3 (±3.1) 0.373
No. times of moderate to intense PA/week (±SD)
0.2 (±1.6) 0.4 (±1.6) 0.553
Veg serves/day (±SD) 0.5 (±1.3) 0.2 (±1.7) 0.392
Fruit serves/day (±SD) 0.0 (±1.0) 0.0 (±1.2) 0.972
Cups soft drinks/day (±SD) -0.2 (±0.9) -0.1(±0.9) 0.005
Times take away/week (±SD) -0.4 (±1.0) 0.1 (±1.0) 0.028
Change in confidence scores (post – pre)
In doing regular, moderate PA (±SD)
1.7 (±2.5) -1.6 (±3.3) 0.000
Eating healthier (±SD) 0.5 (±2.2) -0.3 (±2.3) 0.124
Achieving weight related goals (±SD)
1.7(±2.2) -0.3 (±2.5) 0.000
Table 5: Weight gain by BMI category
Intervention Control
Healthy weight N=23
OWO N=19
Healthy weight N=22
OWO N=25
Weight gain (post-pre) (±SD) 12.4 (±4.5) 9.8 (±6.8) 15.4 (±6.0) 9.9 (±8.7)
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Figure 2 Mean weight gain for intervention participants by the number of calls received
Qualitative Findings
Women’s Experience of the Service
A total of 25 interviews were conducted with women across both the information and coaching arms.
Table 6 provides an overview of the women interviewed by pre-pregnancy BMI grouping (healthy or
overweight) and location (rural or metropolitan).
Table 6 – Number of women interviewed by pre-pregnancy BMI grouping, location and trial arm
Rural (n=12) Metro (n=13) Total
Information (A) Coaching (B) Information (C) Coaching (D)
Normal BMI 2 3 2 3 10
OWO BMI 2 5 3 5 15
Total 4 8 5 8 25
Women’s experience of the GHiP service did not appear to differ across rural and metropolitan areas with
women providing similar accounts of their experience. However, the women’s experience was different
depending upon which arm of the trial they were in. This is perhaps to be expected as the specific services
they received were inherently different.
The following discussion of the women’s experience of the service is categorised into the following key
themes: initial engagement, receiving the service and lifestyle change. Throughout this section the women
who were interviewed will be referred to as being either in the information or coaching arm.
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Initial Engagement
There are four sub-themes that describe the woman’s initial engagement with the service: rationale to
participate, conversations about gestational weight gain, making contact and information resources.
Rationale to participate
Women in both the information and coaching arms appear to have been motivated to enrol in the service
due to concern about excessive weight gain in pregnancy. Whilst more overweight than healthy weight
women talked about not wanting to gain too much weight it also appeared to be a concern for many
women of healthy weight.
“just wanted to make sure that I didn’t put on ridiculous amounts of weight that I’d have to then try
to lose once I had bub.” (C2_P)
“staying on track rather than putting on too much weight during my pregnancy.” (C1_P)
“I heard all the horror stories – as soon as you get pregnant say goodbye to that figure… I was most
worried, apart from something happening to the baby, about gaining too much weight.” (B6_P)
Previous struggles with weight were a particular incentive to participate for some women.
”it was something I’ve always battled anyway in life, weight gain and dieting.” (D5_P)
“I wasn’t happy with myself and my image…then when I fell pregnant I knew that I was going to
end up with baby weight.” (C5_P)
Health professionals had a strong influence on women’s decisions to engage with the service. The
recommendation by midwives was a notable motivator for women to enrol in the service as almost every
woman mentioned the midwife as the catalyst for her decision to participate.
“I thought I’ll do it because the midwife spoke to me about it.” (B5_P)
“the midwife said that I was a good candidate for it so I signed up.” (C4_P)
However, it was indicated that other health professionals, who are not well acquainted with the service
were able to influence a woman’s decision to continue, such as dieticians advising against the program in
light of other programs.
“In the end the dietician said don’t worry about continuing with it…but it would have helped keep
me motivated” (D4_P)
Ten of the 16 women in the coaching arm who were interviewed had left the service prior to 36 weeks
gestation. One women developed gestational diabetes and reported that her dietician advised her to
discontinue with the service. However, for the majority of women they did not make a conscious choice to
leave the service but issues around the timing and missing of calls made it inevitable.
“we just kept missing each other …I’m going to the hospital anyway to get checked every week …
it’ll be right.” (C4_P)
”by accident that I missed it.” (D5_P)
A few of the women in the information arm commented that they received little value from the service.
Their comments were related to the information being ‘nothing new’ or their having a limited
understanding of what the service offered.
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“it was information which, for me, I know all that, so there wasn't anything there that was new or
all that informative that helped me in any way.” (A1_P)
“I’m still not really clear what the service offers.” (A3_P)
Conversations about gestational weight gain
Whilst all women in the trial were provided with their target gestational weight gain by their midwife and
or health coach, there did not appear to be good recall or understanding from women in either the
information or coaching arm. Many women were not aware of having been given a target range and for
those who said they had the range quoted for their BMI did not align with the recommendations. For
example an OWO woman in the information arm (B3_P) stated that she had been given the weight gain
range of 13-15kg, similarly a healthy weight woman in the coaching are (D1_P) reported her target range as
11-20kg.
Certainly there was a range of opinions from the women as to the usefulness of this recommended goal.
Some women were dismissive about their target commenting that they thought the weight gain
recommendations were unrealistic, clearly holding their own view about what was acceptable to them.
“Well I wanted to keep it about the same as what I was last time which was 18kg but I didn’t I got
to 22kg” (A4_P)
“I think someone mentioned to me what you should put on in a pregnancy and ... I didn’t take her
seriously because in my previous two pregnancies I’d put on more weight during those two than
what she recommended, so I just ignored her.” (B4_P)
“They put me in the red section (obese) ... it was [gestational weight gain target] up to 9-11kg ...
they wanted me to stay under that. But as it turned out, I was lighter when I was full term than
when I fell pregnant.” (C5_P)
“According to my weight she decided healthy weight gain is 9-12kg ... I gained 10-11kg. (D2_P)
Although the women in the trial may have had differing opinions as to how useful having a target weight
range was, no woman identified that she was unhappy with the subject being raised and many expressed
that they felt it a usual part of antenatal care.
“I didn’t find it [conversation about weight] confronting, it didn’t make me uncomfortable” (D6_P)
“I thought it was a fairly – an important thing” (C8_P)
“I was expecting it [conversation about weight]”. (D4_P)
However there were a couple of women who did not want to engage in the subject.
“I did not believe the midwife when she said I was overweight – I just ignored her.” (B4_P)
Making contact
The women’s first interaction with the GHiP service was at their initial health coaching call following their
recruitment to the trial. For women in the information arm this was their only interaction with a health
coach and was not always positive. One woman reported that her health coach did not seem to understand
the various emotions and health issues pregnant women experience during pregnancy. It is difficult to say if
this experience would have moderated if the woman had been able to have further interactions with her
health coach.
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“I’d had a rough start to the pregnancy and I guess it was about talking about exercise and things
like that. I don’t know, maybe it was the state of mind that I was in at the time but I – yeah, I didn’t
feel like she had any idea what it was like to be pregnant. I think – she had in her head what needed
to be done but when you’re dealing with people who have had different types of illness and things
through pregnancy – my first trimester was very difficult. I think she was just, oh, well, you should
be doing walking and you should be doing this and you should be doing that.” (B4_P)
In spite of these issues many of the women in the information arm commented positively about their
experience and/or perception of the service with a number saying they had, or would, recommend to a
friend.
“It’s a good sort of support, ‘cause I know a little but about the Get Healthy program.” (A4_P)
“I like that you did send out that information pack and that was helpful … I was able to read
through.” (B2_P)
Information resources
The information pack contained the three GHiP factsheets and the GHS information book. Women in both
arms of the trial responded well to the resources and appreciated the depth and validity of the materials.
“you got heaps of information” (A2_P)
“it’s just good … a source of information that you know is – like there’s a lot of information out
there, but not all of it is certified, realistic and accurate” (C7_P)
“There was nowhere else I could get similar information” (D5_P)
Many women commented on the particular aspects they found helpful. For example the serving size, ideas
for healthy snacks and meals and healthy alternatives to things like takeaway foods. Some women
particularly appreciated the pregnancy specific nutritional information. The resources also acted as tools
during and in-between calls.
“General information … serving sizes and stuff like that because it is slightly different when you’re
pregnant” (B2_P)
“how much veggies and things I was meant to eat” (C4_P)
“That was pretty good, because I had something to refer to, if I’m ‘I wonder if it’s healthy’.” (C3_P)
Receiving the service
There are two sub-themes that describe how the GHiP service was able to assist women to maintain
momentum during their pregnancy: support from telephone health coaching and motivators for change.
Support from telephone health coaching
Women in the coaching arm received up to 10 health coaching calls. The telephone based nature of the
service was largely seen as a positive by the participants as it offered them flexibility and a level of
anonymity to discuss their weight. Some women also saw it to be beneficial that the coach was not part of
routine maternity care.
“It suited me at my particular time of the day, when [my other child] was at school or if was
sleeping … I didn’t have to go to an appointment. It was good, I could just do it at home, I could do
it in my pyjamas.” (C2_P)
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“Just being able to talk to someone on the outside, like a positive motivator giving you tips…things
I’d never thought of before.” (D5_P)
“Some days you are feeling fat, you are feeling down and sometimes it is just speaking to someone,
even if it is not about that, it’s just nice to have the reassurance.” (C2_P)
“…face to face in a doctor’s office feeling like you’re getting a little bit judged almost, it seems like
it’s a little bit less confronting.” (D6_P)
The duration and content of the calls was well received and many of the women commented positively
with regards to the regularity and frequency of the calls. However some women responded that they found
it difficult to ‘keep up’ with the number of calls due to the competing demands on their lives such as other
children and work commitments.
“it’s spaced out right. They tend to be long calls, but I do feel you kind of need it. By the end of it
you’ve covered everything that’s needed, so it’s kind of necessary that those calls are long.” (C6_P)
“they called pretty much almost every week which was good … she always called me around the
same time which was awesome.” (D4_P)
However, the timing of coaching calls or the inability to receive calls at preferred times was found to be
frustrating for a number of the women. They cited that it was not always convenient to answer calls from
the service. Some women also highlighted their disappointment that the service did not return calls
immediately after they had left a message.
“I found it difficult to keep up with the phone calls. I also have a three -years -old daughter as well,
and just managing my time, and I was still working and all that, sort of, thing, so it was a bit
difficult. So I just kept missing the phone calls.” (D8_P)
“I’m not going to chase you. Yep. So that’s the downfall to the service.” (C8_P)
When receiving the coaching calls, most women reported that they liked the interactive nature of the
discussions and found the coaches to be polite, kind and motivational. The continuity associated with
speaking to one health coach for the duration of the service was also appreciated as participants were able
to develop a relationship with their coaches. Women also highly valued the reassurances that were offered
by the coaches during the telephone conversations.
“at the hospital you see all these different midwives, they’re all different. Either you don’t get that
relationship going so yeah it’s good to be able to talk to someone that’s the same person.” (D4_P)
“I just found it quite supportive, and she had talked about when would be my most stressful time.
And I talked to her about those, and she made sure that she rang me at those times and supported
me through that, so that was really good.” (C1_P)
The ability of the service to specifically cater for pregnant women and to adapt and change to meet the
women’s individual needs was received enthusiastically by many women.
“It was pretty good; it was targeted particularly for me, so it was nice.” (D1_P)
Where contact with the health coach was successful and regular, this proved to be a great enabler for
women.
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“Just making time for yourself and what you can do for yourself, has been really great … actually
talk about what you and what you think you can achieve.” (C6_P)
“I increased my walks actually. Before I used to walk 10-15 minutes; [the Coach] said ‘just increase
your walk to 30 minutes.’ And I do breathing exercises as well. So it’s really helped me.” (D2_P)
Motivators for change
Pregnancy itself proved to be both a motivational barrier and an enabler. Being pregnant is a distraction, a
change to ‘normal’ routine and as such being healthy for several women took a low priority in amongst
other more pressing considerations.
“Sometimes it’s hard, you forget to try to be healthy especially in pregnancy. You forget to try to
stay fit.” (B3_P)
However, reminders and regular contact via coaching proved to be a motivational factor that was
welcomed by women.
‘’I can’t self-motivate. Just having those calls to check up made me be motivated to do something.”
(C2_P)
“the way that she talked to me … it’s really motivated me to do exercise and take a healthy diet”
(D2_P)
“[The Coach] kept me motivated and it was pretty hard some days.” (D4_P)
“It was not new information – but it was just more motivating to hear it” (D5_P)
Women within the coaching arm did not express concern about their weight and behaviours being
monitored and many saw this as an integral aspect in supporting them to achieve a healthy weight gain.
“It’d been really good, just, I suppose, keeping me in check and making sure that I remembered
eating the right things for myself and for bub, and get the right nutrition.” (C2_P)
“Always the weight was checked, how I was going with my exercise that was talked about. What
can be improved, because I was not able to do that much of exercise, what was the right way to do
it, healthy eating, and also all those things were pretty well explained, that was really good.” (D1_P)
Many of the women talked about being enrolled in the service as creating a feeling of accountability where
the knowledge that the health coach would be calling acting as a reminder to maintain healthy lifestyle
choices. This was expressed by women as a means of keeping them on track or in-check. Goal setting added
another level of accountability for some women.
“Having that coach reminding me of what was best for me, and what I see the greater results of,
was good. Just having someone call and check in, and making sure that you’re still on track and
everything like that, that gets me motivated, because knowing that I was going to a phone call to
see what my weight is doing and whether I was eating right.” (C2_P)
“not going to let [the coach] down or let yourself down.” (D1_P)
“Just knowing that there was someone going to call me about it, probably made me think twice
about picking up the extra chocolate bar.” (D8_P)
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The concept of accountability was also present in the interviews with women from the information arm
with many expressing that they would have liked access to more coaching calls. The rationale for this
contact appears to be around having a ‘reminder’ or ‘check’ to promote and support the woman’s
behaviour changes.
“If I had to talk to someone about my lifestyle on a weekly basis, maybe [I] would have changed …
maybe weekly calls just to keep people motivated and talk about their food choices … just to keep
the thinking about doing the right thing.” (A1_P)
“the good thing is it reminds mums to be wary and to try to be healthy during pregnancy, but if
we’re not being – if there’s no regular contact, they we kind of forget it.” (B3_P)
Lifestyle change
The GHiP service aimed to support pregnant women to achieve appropriate gestation weight gain and for
many women this involved enacting lifestyle changes. Inevitably, the GHiP participants were making
lifestyle changes whilst managing a range of other physical, emotional, and at times psychological changes,
as their pregnancies progressed. Women in the service noted that pregnancy is a dynamic state (all about
change) so what may work for women one week may be more difficult to accomplish next. Some women
found it difficult to manage lifestyle change along with pregnancy change especially when change was
uncertain. Tiredness and nausea was mentioned by many of the women as being a barrier to their making a
change:
“second trimester we had the whole exhaustion and nausea thing happening.” (A4_P)
As the pregnancy progressed, women commented that exercise became more challenging.
“I could have done something ... I just couldn’t think of anything worse than going for a walk in the
heat during summer.” (A1_P)
“Now I go for walks, slow jogs when I was smaller but now I'm getting a bit cumbersome so I don’t
really do that anymore.” (B6_P)
“I’m unable to do as much exercise as I used to do ... So [the Coach] advised what other things could
be done, how I can change a little bit ... I was checking with [the Coach] like how many steps should
be counted in a day and all those things ... like how many kilometres that I can walk in a day.”
(D1_P)
Many women reported that they were more emotional and anxious during pregnancy, which may have had
an impact on their response to dietary change, such as comfort eating. Craving for certain foods also
appeared to have played a part in this emotional response.
“Anything that helps with that self-control would be good, ‘cause when you are looking at that bar
of chocolate, and you’re feeling exhausted or emotional or whatever, it is pretty hard to walk away
from it.” (A1_P)
“I continued to eat fairly much the same sort of diet but my cravings took over at times.” (C8_P)
“sometimes during pregnancy you don't want to eat the vegetables … just the mood swings.”
(D2_P)
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In the interviews women were asked if they made any changes to their eating or exercise habits as a result
of information received from the Service. Three of the nine of the women interviewed in the information
arm reported that they had made changes to either their eating or exercise habits whereas 12 of the 16
women interviewed in the coaching arm said that they had made positive changes.
Changes to exercise
When surveyed about their exercise habits, women in the coaching arm who received part or all of the
coaching calls cited that their exercise habits improved; they exercised more frequently or for longer.
Women reported generally taking up additional regular moderate exercise in the form of walking (30
minutes), swimming, yoga or creating opportunities for incidental exercise as a result of the coaching
service:
“like exercise just like parking my car away from the shops further just to get that bit more rather
than closest part possible.” (C3_P)
“I tried to be more active ... as in going for walks.” (D8_P)
In contrast, women in the information arm reported little change to their exercise habits. The following
comment suggests that without the regular reminder from a coach the women were less likely to make
changes:
“...Exercise was difficult ... It [would be] easy for me to do it, I just chose not to.” (A3_P)
However, even where the service did assist women in improving their exercise habits, the service was not
always appreciated.
“Maybe [the coach was] the help that I need, the reminder that I need that I can go out and do
some swimming... but it felt like I was shamed into doing it ...[but] there you go, I went and started
swimming.” (B4_P)
Changes to eating
The most common improvements in diet noted by the women interviewed in the coaching arm related to
reducing soft drinks and drinking more water, adjusting vegetable and fruit intake to achieve the
recommended intake, and overall being more conscious about what foods and quantities were healthy. No
women in the coaching arm reported that they adopted poorer eating and drinking habits during
pregnancy.
“[The coach said] ‘well instead of having a can of Coke for energy, do you think you could have a
banana or something like that.’ I was drinking fizzy drink and stuff like that, and they were giving
me healthier options in replacements of that, and I took that on board. (C5_P)
“Based on the GHS information booklet ... Like I eat so much fruit in general, I can eat six pieces of
fruit a day and the recommendation in that book is two pieces of fruit, so I’ve been working on
cutting down that” (C6_P)
“So I was trying to drink a lot more water instead of going for soft drink” (D5_P)
Advice received both through coaching together with the books and factsheets provided information which
led to more conscious eating such as: healthy food choices, home cooking, making meal plans and portion
control.
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“Instead of having fizzy drink or takeaway as an easy option, I was tending to, [due to] the calls,
doing meal preparation plans ... based on what was suggested to me” (C5_P)
“We end up having take-out here and there, but generally, I was able to cook. At least being more
aware, portion size and things like that.” (D4_P)
“I’ve been trying to each better, eating less junk and more good food rather than bad, sugary food.
I’ve just been making sure I don’t over-indulge.” (D6_P)
Fewer women in the information arm reported improvements in their eating and drinking habits.
“Maybe [eating habits improved] slightly, not a lot because I was trying to eat healthy prior to
falling pregnant ... I tried to reduce my sugar intake a little bit. (B2_P)
“Knowing the right number of servings because I wasn’t getting in enough servings before I spoke to
someone ... Eating [improved] by [having] more of the fruit and veg intake, not having too many
sweets. (B3_P)
For one woman improvement was motivated following a diagnosis of gestational diabetes:
“I just drank more water and got some fruit in me ... I learnt how I could live with diabetes ... I know
how to manage portions.” (B5_P)
There were a number of women in the information arm however, who noted that their habits worsened.
“I tried, but throughout my pregnancy I was probably doing what I’d normally do anyway, but in
time of extreme fatigue, I would go for the chocolate.” (A1_P)
“I just chose to eat the wrong things.” (A3_P)
“I have been so restricted in the past; I just ate what I wanted to eat this pregnancy.” (A4_P)
Midwives and Doctor’s Experience of Recruiting Women to the Service
A total of 18 interviews were conducted with midwives and 5 doctors across the five trial sites. Table 7
provides an overview of the health professionals who were interviewed at each site.
Table 7 Number and type of health professionals interviewed by location and trial arm
Rural Metro Total
Information Coaching Information Coaching
Midwife 4 6 4 4 18
Doctor 2 1 2 0 5
Total 6 7 6 4 23
The participants were asked to comment on their experience of the trial in terms of staff preparation,
recruitment and referral process, resources and promotional opportunities. Many of the participants
referred to the challenges of offering the service within the trial conditions. Comments particularly related
to a number of factors that inhibited their ability to refer women to the service including: the maximum
29
gestation at enrolment (20 weeks), exclusion criteria and clearance for particular medical conditions. As the
purpose of this report is to provide recommendations for the future development and state-wide roll-out,
comments solely related to the trial conditions have not been included.
Three key themes were identified: organisational readiness, selling the service, and practice change.
Recommendations that were made for the future of the service are provided at the end of this section.
Organisational Readiness
The need to be ‘ready’ to participate in the trial, prior to the ‘Go Live’ date when recruitment commenced
was mentioned by health professionals at all of the five sites. ‘Being ready’ involved the preparation of
staff, the refining of local processes, and the introduction of operational procedures to ensure recruitment
of women to the trial was as smooth as possible.
At each site the research team attended face-to-face meetings with the managers and the medical team,
and provided training to the midwives and doctors on the recruitment paperwork. One midwife
commented on the initial difficulties of introducing a new service.
“Once everyone was on board it got easier, we had the usual resistance initially.” (X6_M)
The midwives were also provided with additional training in motivational interviewing skills, as their role
was to broach the subject of the woman’s weight, provide a gestational weight gain target and offer the
service. The training was generally well received and perceived to be very helpful. However, suggestions
were made for improvements or additions to the training.
“Training should involve more detail about the Get Healthy Service – just an outline of what each
call involves so we can give the women more insight.” (Y7_C)
“Have a consumer there to tell us what they need to know and what was really good about the
service.” (Y1_M)
Organisational readiness was noted to be a key factor in both achieving and maintaining efficient and
successful recruitment; in busy antenatal clinics a smooth and efficient process to support recruitment of
women was vital. Some of the midwives’ comments revealed how the process could be easily disrupted
even after months of smooth operation.
“We got a new shelf and then no-one knew where to put anything.” (Y13_G)
Many of the midwives commented that they needed a leader, or champion, to help to promote the service
to new staff and to assist with problem solving as issues cropped up.
“this would be someone who knows what they are talking about and thinks it’s a great idea,
that would be the leader we would follow – life a champion sort of...” (Y1_M)
Staff turnover created the need to constantly support new staff and those who work irregularly in the clinic
environment in new skills and practices.
“it’s a matter of training the new staff as they come in – we are getting new rotations of staff all the
time.” (Y2_E)
Unfortunately there were times where it appears that new staff were not always fully prepared for change
and it was a case of ‘sink or swim’. One of the midwives commented.
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“I came into the clinic one day and they said “we’re doing this now [recruitment to Get Healthy in
Pregnancy] you just need to get on with it” and so I was a bit lost for a while.” (Y4_C)
The doctors did not actively recruit women to the trial, but provided medical ‘clearance’ for those who
wished to participate. A number of new medical staff were allocated to the clinics during the trial period
causing some delay in referrals as they familiarised themselves with the requirements of the trial. One
doctor commented.
“It took me a little while to figure out exactly what it is was all about...” (X10_DR)
Midwives were challenged with time constraints: the booking-in visit is comprehensive and time
consuming. Midwives felt that they already had a lot to cover in this visit and little time in which to do it.
“Working within our time constraints was really difficult. We only have an hour for each woman
and to add another 10 minute discussion in was really difficult at first.” (Y3_C)
The process became easier for most midwives with time and practice as they became more experienced.
This is explained in more detail under the next theme ‘Selling the Service’.
Selling the service
“Selling the service” was a phrase used by several midwives to describe the process of recruitment. They
explained how they became adept at linking weight gain with the women’s individual needs or
circumstances in order to make the service appealing.
“you have to sell it to them [the women]. You can run your ‘sell’ around their stories of friends or
family, or themselves, putting on a lot of weight in a pregnancy.” (X3_C)
They also noted that this was more difficult with some women than others.
“some women just take a little bit more selling .. you know, to get them keen.” (X4_C)
During their interviews midwives remarked that recruiting women to the service became easier with time
and practice.
“it’s just knowing the right words to use…” (X8_R))
“The more they [the midwives] did it the more confident they became.” (X1_M)
The experience of recruiting women to the service was different for junior and senior staff. It was noted
that junior staff found it harder to recruit women when they had so many other competing priorities to
recall during the appointment, but the more experienced midwives were able to absorb this new
requirement into their work more easily.
“it’s harder for more junior staff - just juggling all the things they need to do.” (Y2_E)
“The more experienced midwives certainly have better success because they’re very familiar with
the booking-in process.” (Y1_M).
The evaluation was undertaken some months after the start of the trial, but it was noted that some staff
were still finding having conversations with women about weight and weight gain challenging.
“some staff are still really uncomfortable, speaking or talking about weight gain in pregnancy with
women.” (Y6_M)
31
Experiences in relation to recruitment varied considerably between individual midwives. The midwives
were aware that weight was a sensitive topic for many women and that some may already be ‘feeling bad
about themselves’, and they did not want to make things worse. As a result some midwives were hesitant
to offer the service. One midwife commented she had only recruited three women in ‘months and months
of doing it’ (X8_R). Conversely, several others reported recruitment was easy.
“I’ve only had one who was eligible who turned it down. Women are very engaged in the idea, and
usually quite excited…learnt from their mistakes in their first pregnancy.” (X3_C).
On occasion, difficulties with recruitment were attributed to attitudes of women who were overweight.
‘”t’s [recruitment] either easy or really hard – if they [the women] are happy being overweight then
they won’t want to do anything about it.” (Y7_C)
“There are some women who are completely against healthy eating; they don’t care. They don’t
see themselves as being overweight and they don’t want to hear anything. The young ones are
particularly hard. They think it all comes off afterwards, but of course it doesn’t.” (Y13_G)
One of the doctors commented that the disinterest shown from women in her local area was
demographically-related.
“I think the demographics that we work in …the care factor is not there from them [the women]
anyway.” (X5_DR).
There were also organisational issues that often made recruitment difficult for the midwives. If the woman
was not going to see the same midwife again, because of the way care was organised locally, midwives
perceived it more unlikely that the woman would take their advice to enrol in the service. The midwives
also commented that this lack of continuity made it difficult for them to follow up on the issues.
“Lack of continuity makes it much harder to convince the woman.” (Y2_E)
“If you haven’t seen the woman before, you don’t know what she has been told.” (X8_R)
Support to sell the service
Visual tools, designed by the Get Healthy Service program team to support midwives in their conversations
with women were reported to be helpful.
“I like the BMI chart because you can show them [the women] and they can actually see, rather
than me just telling them.” (Y3_C)
As part of their role, midwives do not usually provide specific advice on nutrition for pregnancy, but focus
on advising women to exclude certain foods from their diet (e.g. liver) and avoid viral and bacterial
infection through hygienic food handling. During the interviews suggestions were made by midwives for
additional resources that would help develop their knowledge and confidence in relation to weight gain.
“some fact sheets – like healthy snack options would be really good’ and ‘an exercise program for
pregnancy.” (Y12_R)
The doctors described how they generally encouraged women during the pregnancy not to gain too much
weight and one doctor suggested a visual resource would help to support this conversation.
32
“a graph of something, to see how much weight they should put on …to cover the three trimesters.”
(X5_DR)
In addition, a poster was suggested, to be positioned near the scales encouraging women to check their
weight gain on arrival and record it for discussion with their midwife or doctor.
Practice Change
Until recently, health professionals in NSW have not routinely discussed weight gain during pregnancy with
women. The trial of the Get Healthy in Pregnancy Service required health professionals to introduce and
sustain practice change in relation to discussion around gestational weight gain. Midwives and doctors
described how recruiting women to the trial had almost given them permission to discuss the topic of
weight without feeling bad for the women.
“it’s made me more aware to discuss BMI and the weight gain, before I probably wasn’t doing it. I
think it has just made me as a doctor a bit more confident to discuss it.” (Y10_DR)
“I don’t feel guilty anymore talking to women [about weight and weight gain] when they’ve got a
service now that can support them.” (Y12_R)
“it’s been helpful because it [the service] gives another way of communicating with the patients
and approaching them with their weight gain – it gives more support for what we are talking about
in the clinic’.”(X6_DR)
Several midwives and doctors described how the knowledge and experience they had gained through their
involvement had translated to practice change in their clinical role.
“That’s how I was taught – never to weigh. But now, since Get Healthy in Pregnancy I weigh
women at booking in ……and trying to recruit women to the service is making me ask those
questions more routinely. It’s a habit now and I think I will continue.” (X9_G)
“it’s about everybody…it’s just what we do now.” (Y2_E)
Midwives were generally very positive about the tangible support that the service presented for them and
for women.
“It’s been a really positive thing to support the staff. In the past you’d refer to dietitians and you’d
be lucky if they [the women] saw one [dietitian] by the end of their pregnancy.” (Y6_M)
“I can say ‘we’ve actually got the services for you, and that’s why I’m asking these things’…I’m not
just pushing something on someone where there’s no solution.” (X9_G)
Health Coaches
Four key themes were identified: experience delivering the service, barriers to coaching pregnant women
to manage gestational weight gain, enablers to coaching pregnant women to manage gestational weight
gain, and perception of change in the audience.
Theme 1 – Experience delivering the service
Health coaches reported having an overall positive experience of the program and believed that provision
of health coaching to pregnant women was beneficial. Health coaches indicated that whilst they were
aware of specialised dietetic services for pregnant women (such as for gestational diabetes), they had little
to no knowledge of any other one-on-one services provided for pregnant women relating to gestational
weight gain or focused on broad healthy lifestyle changes.
33
“I don’t know any other programs that really work with a pregnant women around
anything, their weight ... during pregnancy, on such a one-on-one basis.” (HC-1M)
“Sometimes there’s not so much support that might be available around for [pregnant
women], so I really like the idea behind [the program].” (HC_6)
“I think it’s really great to have that reach ... Pregnant women who have limited time and
access, if they’re at risk of gestational diabetes and things, it’s about getting them
information on how they can improve their risk. I know that they don’t get time to go out
and see their dietician, so we’re sort of that in between service for them.” (HC_4)
“The service has helped [pregnant women] think about their weight throughout their
pregnancy journey, which is something novel.” (HC_2M)
The health coaches compared coaching pregnant women to their work within the general telephone
coaching service, where both female and male participants are coached using behavioural interviewing and
goal setting techniques. Methods for goal setting were cited as being the same. In this sense, the health
coaches expressed that they were able to coach pregnant women to break down goals into smaller
achievable goals, reflect on short term benefits (e.g. reduced back pain), and think about long term goals
(e.g. ease of delivery or getting back to pre-pregnancy weight).
“It’s the same kind of process of helping find an alternative or breaking [a goal] down into
more achievable goals to achieve that long term success. So it was really then about taking
it in small gradual steps, doing little things more regularly rather than trying to do a bit
thing.” (HC_6)
“Similar to the [other programs] we progress with the week reviewing the benefits they’re
seeing. What we try to do is find motivation for why they’re doing it in the first place, and
keep reflecting on what benefit they personally see in the short term. And then what they
feel that’s going to do for them in the long term.” (HC_4)
The key difference for the health coaches between coaching pregnant participants and those in their
standard programs was in managing the initial lack of self-engagement, and the women’s mistaken
expectation of what the service would entail. Due to being referred to the service rather than opting in by
choice, the health coaches found many of the women to be not as self-motivated as their usual clients.
Some women also expected a face-to-face service, and/or different specific advice about what to eat and
do, rather than motivational coaching. Half of the health coaches reported needing to explain and promote
the program to these women.
“Some women didn’t understand what the program was about.” (HC_1M)
“[Some women] were looking to be told what to do to manage their blood sugar levels or
they were looking to have their blood results read regularly.” (HC_6)
“Some expected face-to-face contact.” (HC_2M)
“Their expectation of the Service was that they were going to meet a dietician, not an
exercise physiologist.” (HC_3)
34
Theme 2 – Barriers to coaching pregnant women to manage gestational weight gain
The trial conditions, such as eligibility criteria and gestational age at enrolment were cited as being
significant barriers to the provision of coaching. Trial conditions stipulated it was necessary to screen and
enrol women prior to 21 weeks gestation. Where there was a delay in contacting women after referral to
the service the coaches found some women to be disconnected or have lost motivation to participate. For
women over 21 weeks gestation they were not eligible to be enrolled. The need to seek medical clearance
for pre-existing or newly developed medical conditions led to further delays or gaps in service provision
which made it difficult to begin or maintain continuity of coaching.
“The timeframes we found were really narrow ... we need to successfully contact these
ladies and enrol them into the program before they reach 21 weeks gestation ...
sometimes we only receive the referral when they’re about 18, 19 weeks [gestation].”
(HC_1M)“Whenever there’s a medical issue that requires medical clearance, we have to
send them back [to their doctor]. It takes two to three weeks, sometimes a whole month,
before their next appointment so then they miss coaching.” (HC_3)
Many of the health coaches specified that it was often difficult to get in touch with pregnant women for
their coaching session even at the participants preferred time. The coaches identified this was a result of
the fast-changing needs and priorities of the women. A centralised contact number also meant that
rescheduling calls or facilitating a call back was difficult.
“We did have a few dropping out. Mostly the calls weren’t convenient for them ... We try
them at their referred time and they didn’t answer.” (HC_1M)
All health coaches said that pregnancy and pregnancy related symptoms, such as tiredness, nausea,
aversions to particular foods were a barrier for them in being able to provide useful and consistent
coaching relating to healthy eating and exercise or lifestyle change. They found that women’s changing
priorities whilst managing existing commitments such as work and other children, added an additional level
of complexity to their usual health coach practice.
“Being tired, lack of energy were the biggest challenges that everyone had. Most of [the
pregnant women] would say, ‘I’m too tired to exercise, I don’t have the energy, I don’t
have the time.’” (HC_5)
Theme 3 - Enablers to coaching pregnant women to manage gestational weight gain
Training and training packages, as well as pre-existing experience (e.g. in dietetics), were useful to coaches
in building confidence to coach pregnant women. In addition opportunities to discuss and share their
experiences of coaching pregnant women were valued and increased the coaches’ confidence by providing
tangible approaches to managing their interactions with pregnant women.
“Diet and exercise training was really effective. Many coaches say they feel a lot more
confident.” (HC_2M)
“Mainly because of my background, the training probably just refreshed my memory ...
from my previous background as a dietician, [I have had the] experience to work with
pregnant women before.” (HC_3)
“We did have quite a lot of group sessions where we were looking at what everybody’s
finding, what are you saying, what resources are you using.” (HC_6)
35
The coaches found the written resources, such as books and flyers useful to refer to, and commented that
they often used these resources in their calls with participants. Similarly, to support advice provided within
coaching sessions, health coaches found it useful to provide women with links to online resources.
However, it was noted that additional information and resources on breastfeeding and the postnatal period
would be beneficial to support coaches in the future.
“They look at the information [sheets] when we’re speaking with them. Having the
summary sheets makes it easy.” (HC_4)
“The information sheets that were given out to participants were very well appreciated by
almost all of the participants. They really liked having something in front of them while we
provided coaching.” (HC_2M)
'Maybe more information. I've had a few, the two that have reached the graduation
around post-stuff and breastfeeding and recommendations for that. So any information
that we can refer back for them in preparation for that call.” (HC_5)
Having the opportunity to provide multiple coaching sessions to participating women was considered
beneficial by the coaches. Continuity was identified as an enabler by the coaches as they were able to
further engage with women, providing the opportunity to ask questions and a structure for ongoing goal
setting. It also provided the opportunity to regularly refresh or reiterate concepts already raised, and to
assist women to monitor their gestational weight gain.
“The ongoing coaching aspect seems to be quite effective. We can talk about making a
plan, to make it gradual, we’ll say start with one or two sessions of exercises and we build
up over the next week.” (HC_4)
Theme 4 - Perception of change in the audience
Coaches observed that the greatest motivation for behavioural or lifestyle change amongst pregnant
women was the perceived benefit to their unborn child’s health. Conversely applying the benefits of
lifestyle changes for the woman’s own health was not often seen as a great priority.
“I think a lot of [the women] felt they needed to be a part of the Service though because it
was [for] the child.” (HC_5)
“Quite often when [the women] don’t want to make a change for themselves, and you say,
‘Okay, well if you're making this change, it’s going to help the baby,’ and then they’re like
‘yeah, I will do anything.’ When you talk about their kids or their baby, they will to do
anything.” (HC_5)
“They’re generally quite motivated in pregnancy to gain the right amount so their baby’s
safe, so that they’re safe.” (HC_4)
One coach noted that women with higher pre-pregnancy BMIs appeared less sure of the program
due to weight gain restrictions that felt unachievable for these participants.
“Women that in the high BMI, I find they’re most discouraged by the weight gain
guidelines.” (HC_4)
Coaches found that their support, along with written resources provided to the women, was helpful in
extending women’s thinking beyond pregnancy. Coaches also found that participants engaged in coaching
36
appreciated support over the telephone with participants perceiving coaching in this forum to be less
judgemental and more convenient.
“They get a booklet and three information sheets, so them knowing that they can compare
what they’re meant to do outside pregnancy compared to when in pregnancy... gets them
thinking about the fact that this is long term.” (HC_4)
“Participants have particularly appreciated the extra bit of support they get from someone
over the phone. Because the judgement factor is not there, they can just speak to people
over the phone and get expert advice from qualified people.” (HC_2M)
“Telephone support they find more useful than having to attend appointments.” (HC_3)
Many of the coaches cited that on entering the GHiP service many women had little knowledge of what
was safe to eat and what exercises, if any, were safe to undertake. Much of this confusion appeared to
arise from women’s cultural or family views which were sometimes contradictory to the healthy guidelines
that the coaches were promoting. In these instances health coaches reported that they encouraged
women to seek further guidance and reassurance from their GP if they continued to have concerns about
over exertion or food restrictions.
“Their family member advised that exercise at all wasn’t a good idea. It’s just finding
strategies to work through that, assuring them in terms of what’s going to be safe, what
the benefits are, and if they’ve got any concerns, who they can speak to about it.” (HC_4)
“Sometimes there’s not a lot of information on culturally specific food, vegetarian, vegan
or Asian food ... staying active, ‘What can I safely do, I don’t want to hurt my baby’ quite
commonly they say that.” (HC_3)
Overall, coaches reported their perception that the health literacy of pregnant women improved following
coaching. In particular for those women who may not have known of the healthy guidelines and also those
who may have initially entered the program believing they were ‘doing well’ in regards to healthy lifestyle
choices. Coaches reported that for those pregnant women who did receive coaching, they made changes to
food and exercise habits and usually met their recommended weight gain targets.
“Most women feel that they’re doing really well. When we have a talk to them and we
found out that they’re not...” (HC_5)
“The comments that [women]’ve said to the health coaches have been ‘Oh, I didn’t realise
that you weren’t supposed to put on 30kg, I’m going to keep an eye on it now.’” (HC_6)
“They made changes to food and exercise and in turn [I] had a few [pregnant women] that
stayed within the weight gain that was recommended, which is really good.” (HC_5)
37
Discussion Quantitative
The aim of the study was to test the effectiveness of two different service delivery models to support
pregnant women to achieve appropriate gestational weight gain. Positive results in favour of the
intervention were found for weight gain within the target range. A higher proportion of women in the
intervention arm achieved weight gain within the target range, compared to the control. Women in the
intervention arm gained less weight than women in the control arm. These findings suggest that the GHiP
service has the potential to reduce excessive weight gain during pregnancy and support the hypothesis that
the intervention is more effective in helping women achieve appropriate gestation weight gain than the
control.
Positive results in favour of the intervention group were also found for two key health behaviours. Women
in the intervention reduced the amount of sugar sweetened drinks they consumed daily and the amount of
takeaway meals consumed per week. These changes were significant compared to the control and are
consistent with findings from the GHS. While changes in physical activity levels were not significantly
different between the intervention and control, women’s confidence scores for doing regular, moderate
physical activity improved in the intervention arm. Women’s confidence scores for achieving weight related
goals also increased in the intervention arm. Both these confidence scores decreased in the control arm.
The study has a number of strengths including the cluster randomised controlled trial design. The number
of pregnant women screened between September 2014 and October 2015 also represents a substantial
proportion of births in NSW over this period. While over half of the women screened were ineligible to
participate, this was mainly due to the study conditions including the gestational age being over 18 weeks.
Medical clearance was generally required this for minor conditions and only 1.6% of women screened were
excluded due to medical conditions. Broadening the entry requirements, recruiting women earlier through
other services or promotion and simplifying the medical clearance process could increase the ease at which
women can access the service. This will be explored further as part of the phased state-wide roll out.
Qualitative
The acceptability of the GHiP service was explored through the experiences of 54 individuals. This group
included 25 women who participated in either the information or coaching arms of the trial, 23 medical
practitioners who recruited women to the trial and six health coaches. Overall, the qualitative analysis
demonstrated that the service was enjoyable, supportive and on the whole, manageable within the daily
routine or work time, for those who took part.
Women commented that the service filled an important gap in current antenatal care provision, primarily
information in relation to healthy eating and exercise. Not surprisingly, women in the coaching arm were
more likely to gain benefit in terms of support for change than those in the information arm. This benefit
was gained mainly through the regular reminders provided by the calls and the continuity provided by
having the same coach on each call. Change in relation to eating and exercise habits during pregnancy was
reported by many of the women interviewed. It was noted however, that the majority of women did not
recall correctly the ‘target’ weight gain provided to them at the beginning of their pregnancy. Whether this
was not reiterated by their maternity care provider or health coach, or whether the women did not feel the
target applied to their circumstances, is unknown.
Midwives and medical practitioners were unanimously positive about the support the service provided,
both to them as a referral service, and to the women. It was noted that involvement in the service had
38
been a learning opportunity, enabling them to gain confidence to broach the topic and frame it positively
as a ‘routine’ conversation they had with all women, not just those who were overweight or obese.
Practice change for some of these medical practitioners was evident. It is clear however, that ability varied
between midwives, and that ongoing training and leadership is needed to support the regular intakes of
new staff entering the antenatal clinic environment. The frustrations noted by the medical practitioners in
relation to the trial conditions for eligibility have not been explored in this report, as they are no longer
relevant.
The coaches interviewed noted that coaching pregnant women was no different from non-pregnant
participants, although there was more emphasis during the calls on overcoming the minor ‘ailments’ of
pregnancy that arose including constipation, nausea and lethargy. Overall, they reported feeling that they
were able to offer helpful support. In regard to training, the coaches noted that they needed more
information of aspects of early motherhood – such as nutritional support for breastfeeding.
Pregnancy is a time of immense change, both physical and psychological, and introducing lifestyle change
simultaneously presents challenges for both women and those who support them. Comfort eating,
tiredness and cravings can de-rail good intentions. Each woman’s response to pregnancy is different and for
some women, particularly those who are overweight, medical complications will arise during pregnancy,
inevitably providing a de-motivating distraction from achieving personal or lifestyle goals. These realities
go some way to explaining why some women evidently chose not to enrol or left the service prior to
graduation as their pregnancies advanced. The GHiP service must therefore be designed to be sufficiently
flexible to respond appropriately to these needs, providing women with individually planned call schedules
throughout pregnancy. A phased state-wide implementation will explore these issues further.
Limitations A limitation of the study is the large proportion of women who were lost to follow up throughout the study,
including prior to enrolment. Women lost to follow up include those who were unable to be contacted and
those who passively or actively withdrew from the service. The large loss of women to follow up highlights
the challenges of trialling a program in real life settings through a service delivery provider. However,
undertaking a trial under these conditions also provides valuable insights into the challenges of
implementing a program in real life settings with learnings for state-wide implementation. Better managing
the flow of women through the program including from midwife referral to enrolment in the GHiP service
will be explored as part of the phased state-wide roll out. The referral of women to the GHiP service from
antenatal clinics or a clinical setting also provides opportunities and challenges for enrolment. Encouraging
women to enrol in the coaching program and to complete the program is recommended given the positive
results.
39
Recommendations
Promotion of the Service
In relation to the promotion of the service, it was suggested to improve advertising and information sharing to facilitate higher uptake. It was recommended that the service consider:
1. Displaying posters for GHiP :
a. In antenatal and General Practitioners’ (GP) waiting rooms
b. In bathroom cubicles – on the back of the door
c. In childcare centres
d. In family planning centres
e. Ultrasound and pathology departments.
2. Distributing and/or providing brochures:
a. In antenatal clinics
b. In GP waiting rooms
c. In information bags
d. By midwives/clinicians
e. In childcare centres
f. In family planning centres
g. In early childhood health centres.
3. Advertising:
a. On pregnancy related websites and forum websites
b. On social media e.g. Facebook
c. In parenting magazines
d. On television
e. On existing smartphone and computer applications (Apps)
f. By ensuring GHiP is a Google/Search Engine advertisement search result when pregnancy
and gestational weight is the subject of an internet search
g. Via influencers or ambassadors
4. Promotion of GHiP and referral to the service by clinicians:
a. By educating and encouraging GPs to discuss gestational weight gain and refer women to
GHiP pre-conceptually and during the early stages of pregnancy
40
b. By educating and encouraging midwives to discuss gestational weight gain and refer
women to GHiP at antenatal appointments
c. By educating and encouraging obstetricians and junior medical officers to discuss
gestational weight gain and refer women to GHiP at antenatal appointments
5. Utilising and undertaking mail drops to provide written information directly to potentially
interested participants.
Delivery of the service
With regard to service delivery, feedback suggested changes to the way the service is delivered, structured, or supported. To address attrition and increase enrolment in the GHiP service, it is recommended that the service consider:
1. The development of a smart phone/computer App for GHiP or optimising program materials for
mobiles and tablets
2. Sending resources to all referred women including those who do not receive a call from GHiP
3. Introducing group sessions or forums to allow women to interact with other women whilst
engaging with the health coach including online forums or webinars
4. Developing and distributing additional resources as part of GHiP such as an exercise plan, videos,
meal plans and healthy recipes including ideas for healthy snacks
5. Implementing flexible methods of coaching, such as through text, chat or email, choosing the
distribution of the coaching calls during the 6-9 month coaching period, or being able to call the
service when needed
6. Development and integration of better call back, email, SMS interaction to reinforce content, or to
confirm appointments
Content of the Coaching Calls and Resources
Participant feedback suggested changes to the content and resources or sensitivity of the coaching service. To assist in reducing attrition and to encourage enrolment, it is recommended the service consider:
1. Tailoring coaching to suit individual limitations/circumstances
2. Development of tools to assist women stay on track
a. Weekly weight gain calculator
b. Handouts and additional fact sheets
c. Information on local areas to exercise
3. Information about nutrients that are important in pregnancy
4. Bilingual resources
5. Postnatal and breast feeding advice for later, postnatal calls
6. Recipes and meal plans on website.
41
Coach Training
Coaches raised the need for additional and regular training. It is recommended the service consider training for:
1. Management of stressful and emotional scenarios such as miscarriage
2. Management of pregnancy related symptoms to be able to provide sympathy and more specific
advice around cravings
3. Specific advice around cravings, nausea, constipation, and fatigue
4. Postnatal advice including breastfeeding.
42
Conclusion Despite high rates of women lost to follow up in the trial, there is evidence of a positive effect on healthy
gestational weight gain among women completing the Get Healthy in Pregnancy coaching service
compared to receiving information only. Qualitative feedback from participating women, health
professionals and coaches, is largely very positive, and highlights some areas where the delivery of the
service can be improved. With no apparent negative consequences of the Get Healthy in Pregnancy
coaching service, there is reasonable evidence to support the phased roll-out of referral processes to the
Get Healthy in Pregnancy coaching service across NSW antenatal clinics.
43
References
1. Hector D HL. Prevention of excessive gestational weight gain: an evidence update to inform policy
and practice. Sydney: Physical Activity Nutrition & Obesity Research Group;2013. 2. de Jersey SJ, Nicholson JM, Callaway LK, Daniels LA. A prospective study of pregnancy weight gain in
Australian women. The Australian & New Zealand journal of obstetrics & gynaecology. Dec 2012;52(6):545-551.
3. Chung JG, Taylor RS, Thompson JM, et al. Gestational weight gain and adverse pregnancy outcomes in a nulliparous cohort. Eur J Obstet Gynecol Reprod Biol. Apr 2013;167(2):149-153.
4. O'Hara BJ, Phongsavan P, Venugopal K, et al. Effectiveness of Australia's Get Healthy Information and Coaching Service(R): translational research with population wide impact. Preventive medicine. Oct 2012;55(4):292-298.
5. (US) IoMUaNRC. Committee to Reexamine IOM Pregnancy Weight Guidelines. In: Rasmussen KM YA, ed. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington DC2009.
6. Australian Health Ministers’ Advisory Council. Clinical Practice Guidelines: Antenatal Care – Module 1. Canberra: ustralian Government Department of Health and Ageing; 2012.
7. Cogswell ME, Scanlon KS, Fein SB, Schieve LA. Medically advised, mother's personal target, and actual weight gain during pregnancy. Obstetrics and gynecology. Oct 1999;94(4):616-622.
8. Jeffries K, Shub A, Walker SP, Hiscock R, Permezel M. Reducing excessive weight gain in pregnancy: a randomised controlled trial. The Medical journal of Australia. Oct 19 2009;191(8):429-433.
9. Phelan S, Jankovitz K, Hagobian T, Abrams B. Reducing excessive gestational weight gain: lessons from the weight control literature and avenues for future research. Women's health. Nov 2011;7(6):641-661.
10. Dodd JM, Turnbull D, McPhee AJ, et al. Antenatal lifestyle advice for women who are overweight or obese: LIMIT randomised trial. Bmj. 2014;348:g1285.
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Appendices
Appendix A – Members of Expert Advisory Panel
Name Title
Chris Rissel (Chair) Director, Office of Preventive Health
Louise Farrell Manager, Strategy and Operations, Office of Preventive Health
Michelle Maxwell Manager, NSW Get Healthy Service
Jane Raymond A/Manager, Maternal and Newborn Unit, Office of Kids and Families
Elisabeth Murphy Senior Clinical Advisor, Office of Kids and Families
Michael Nichol Senior Clinical Advisor Obstetrics, Office of Kids and Families
Stephen Colagiuri Professor of Metabolic Health, Boden Institute of Obesity, Nutrition, Exercise &
Eating Disorders, University of Sydney
Janice McLay Head of Government and Business Partnerships, Australian Diabetes Council
Jan Fizzell Medical Advisor to the Chief Health Officer, NSW Ministry of Health
Simon Willcox Acting Manager, Healthy Workers Initiative, Office of Preventive Health
Vanessa Clements Clinical Midwifery Consultant, NSW Pregnancy and newborn Services Network
Amanda Reilly Antenatal Clinical Midwifery Educator, St George Hospital
Natasha Leader Accredited Practising Dietician, Royal Hospital for Women
Linda Bootle Clinical Midwifery Consultant, Aboriginal Maternal and Infant Health Strategy,
Western NSW Local Health District
Peter Todaro Director, Multicultural Health Communication Service
Andrew Zuschmann Obstetrician
45
46
Appendix B: Medical Clearance Form
MEDICAL CLEARANCE FORM
For participants wishing to enrol in the Evaluation of a telephone based information and coaching program to
reduce excessive gestational weight gain amongst pregnant women
Please return to referring antenatal clinic once completed
Dear Doctor,
Your patient ________________________________________________ is interested in participating in a randomised control trial evaluating a telephone based information and coaching program to reduce excessive gestational weight gain amongst pregnant women. The NSW Office of Preventive Health and NSW Kids and Families have developed this program to support women to increase healthy eating and physical activity behaviours and achieve healthy weight gain during pregnancy. Women will receive either information only or enrol in a 6-8 month coaching program delivered by university qualified coaches. All content is based on established guidelines, including the Australian Dietary Guidelines (NHMRC 2013) and the
College Statement released in September 2013 by the Royal Australian and New Zealand College of Obstetricians and
Gynaecologists on the management of obesity in pregnancy. Development of the module has also been informed the
input of an Expert Advisory Panel including midwives, obstetricians, dieticians and antenatal educators.
This is hospital is one of four hospitals involved in the trial state-wide. Each hospital has been randomised to either the
information only or coaching arm of the trial.
The gestational weight gain program or “module” is part of the NSW Get Healthy Information and Coaching Service, a
free telephone based coaching service available to all adults 18 years and over in NSW. If results from this trial are
positive, the module will be made available to all pregnant women aged 18 years and over in NSW from 2015 onwards.
A screening and assessment questionnaire has been undertaken with your patient and it has been deemed necessary to
seek medical clearance prior to them enrolling in the trial. A copy of their screening and assessment questionnaire is
attached for your information.
It would be appreciated if you could review your patients’ records and make a determination as to their suitability to
participate in the trial. If you agree they are suitable, please sign the consent below and return to the referring antenatal
clinic. You may also be requested to provide further clearance if your patient enrols in the trial but develops
complications during pregnancy which might require her to discontinue participation.
Please do not hesitate to contact Michelle Maxwell (email [email protected] or phone 02 8738
6503, Chief Investigator for the trial, if you have further questions.
Consent
47
I agree that __________________________________________ is suitable to participate in the evaluation of the gestational weight gain module of the NSW GHS
OR
__________________________________________ is suitable to participate in the evaluation of the gestational weight gain module of the NSW GHS, provided the following issues are considered (list any nutrition or physical activity requirements or prescriptions) ____________________________________________________________________________________________
____________________________________________________________________________________________
________________________________________________________________________
OR
I do not agree that __________________________________________ is suitable to be involved in the evaluation of the gestational weight gain module of the NSW GHS
Medical Professional Signature_______________________________________ Date_____________
Medical Professional Details
Name:
Title
Hospital
Phone Number
Fax:
Email:
48
Appendix C – Medical Conditions for Exclusion Table 1 – Medical conditions for exclusion
Pre-existing conditions (exclude at first antenatal visit)
Conditions that develop during pregnancy (exclude when condition is diagnosed)
4.
Pulmonary hypotension
Arrhythmia/palpitations; murmurs: recurrent, persistent or associated with other symptoms
Cardiac valve disease
Cardiac valve replacement
Cardiomyopathy
Congenital cardiac disease
Ischaemic heart disease 6.1.6
Pre-existing Type 1 diabetes
Cystic fibrosis
Phenylketonuria (PKU) 6.1.16
Sarcoidosis
Severe lung disorder
6.1.6 Pre-existing Type 2 diabetes (that move to oral
hypoglycaemics or insulin) 7.1.7
Foetal death in utero 7.1.8
Small for dates (<10th centile) 7.1.18
Multiple pregnancy 7.1.21
Placental abruption
Placenta accrete
Placenta preavia
Vasa Praevia 7.1.23
Preterm birth (<36 weeks) 7.1.24
Rupture of membranes (<36 weeks)
Taken from the ACM National Midwifery Guidelines for Consultation and Referral – 3rd Edition, 2013
Table 2 – List of criteria for medical clearance prior to enrolment in GHS – Early Pregnancy
Potential issues from an exercise standpoint Potential issues from a diet standpoint
6.1.4 Cardiovascular disease
Arrhythmia/palpitations; murmurs: recurrent, persistent or associated with other symptoms
Cardiac valve disease
Cardiac valve replacement
Cardiomyopathy
Congenital cardiac disease
Hypertension
Ischaemic heart disease
Pulmonary hypotension 6.1.16
Asthma Moderate
Sarcoidosis
Severe lung disorder 6.1.17
Skeletal problems 6.3.18
Previous pre-term birth 6.3.22
Recurrent miscarriage
6.1.6 Pre-existing Type 1 diabetes
Cystic fibrosis
Coeliac Disease
Phenylketonuria (PKU)
Taken from the ACM National Midwifery Guidelines for Consultation and Referral – 3rd Edition, 2013
49
Table 3 – List of criteria for medical clearance prior to enrolment in GHS – During Pregnancy
Potential issues from an exercise standpoint Potential issues from a diet standpoint
7.1.12 Slipped disc
7.1.15 Hypertension
Chronic
Eclampsia
Gestational
Pre-eclampsia 7.1.18
Multiple pregnancy 7.1.21
Placental indications
Placental abruption
Placenta accrete
Placenta preavia
Vasa Praevia 7.1.29
Sympysis pubis dysfunction
7.1.5 Gestational diabetes – diet
Gestational diabetes – insulin 7.1.7
Fetal death in utero 7.1.8
Small for dates 7.1.11
Anaemia (Hb <90) 7.1.18
Multiple pregnancy
Taken from the ACM National Midwifery Guidelines for Consultation and Referral – 3rd Edition, 2013
50
Appendix D – Midwives script
MIDWIVES SCRIPT
Evaluation of a telephone based information and coaching program to reduce excessive gestational weight gain
amongst pregnant women
Step 1 Introduction
In this hospital we are teaming up with the NSW Get Healthy Information and Coaching service to find out how helpful it is for women to receive additional information (and support) about achieving a healthy weight gain during pregnancy. Did you receive a leaflet in the post about this? Midwife will need additional leaflets to provide if the woman has not received
activity Midwife needs to review the exclusions on screening questionnaire to establish whether the woman is eligible at this point (no point in talking about it is she is not eligible)
Step 2 Eligibility
For women who are not eligible – see words on the screening questionnaire. For women who are eligible - I’d like to spend little time explaining more about the trial we are doing – is that OK?
Step 3 Explanation
Eating healthily and being active during pregnancy has a positive effect on the healthy development and growth of your baby. Experts are also beginning to understand how important weight gain is during pregnancy. Gaining too little may mean your baby is born smaller than usual, but gaining too much can mean your baby is born bigger than usual with complications such as low blood sugar. Gaining too much weight can put you at an increased risk of developing diabetes or high blood pressure during pregnancy, and can increase your risk of a caesarean section.
Step 4 Calculating the women’s BMI for weight gain recommendation
Your recommended weight gain will depend on how much you weighed just before you became pregnant. Let’s have a look at the chart together and see what this means for you.....
activity Shares the coloured BMI chart and weight gain recommendations with the woman.
Step 5 Raising importance
As you can see, your weight is in the healthy/overweight range. Healthy range: it’s great that your weight is in the healthy range. However, research shows that pregnancy is a time when some women do put on a lot of weight, which they may find difficult to lose after the baby is born. So it is important for you and your baby that you manage your gain during pregnancy Overweight/obese range: Research shows that pregnancy is a time when some women put on a lot of weight, which they may find difficult to lose after the baby is born. As your weight is already in the overweight category, it is especially important for you and your baby that you eat healthily and are more active so you can more easily manage your weight gain during pregnancy.
51
Step 6 Offering the trial
The new Get Healthy service for pregnancy has designed especially to help all women to achieve a healthy weight gain through healthy eating and activity, by providing helpful tips for action. The service is free of charge to all women. The trial is designed to look at whether just giving women basic information about a healthy weight gain is as effective as telephone ‘coaching’ or encouragement at regular intervals during pregnancy. There are several hospitals in NSW participating in this trial and each hospital has been allocated to either the information or coaching group. In this hospital women who consent to be part of the trial will receive: add appropriate words here from the participant info sheet (section 4)
Step 7 Gauging interest
Would you be interested in participating in the trial? Note on form as to why not interested
Step 7 Assessing requirement for medical clearance
If interested review medical clearance and note on form.
Step 7 Gaining consent
Midwife provides information sheet and consent form
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Appendix E: Information flyer for participants
Evaluation of a telephone based information and coaching program to reduce
excessive gestational weight gain amongst pregnant women
Flyer
Weight Matters!
Eating healthily and being active during pregnancy has a positive effect on the healthy development and
growth of your baby. Experts are also beginning to understand how important weight gain is during
pregnancy. Gaining too little may mean your baby is born smaller than usual, but gaining too much can
mean your baby is born bigger than usual with complications such as low blood sugar. Gaining too much
weight can put you at an increased risk of developing diabetes or high blood pressure during pregnancy,
and can increase your risk of a caesarean section.
Gaining the right amount of weight increases your likelihood of a normal birth and may reduce your risk of
high blood pressure and diabetes during pregnancy. It may also prevent your baby from being overweight
and having complications later in life.
Are you interested in participating in a trial of the new Get Healthy Service to help
pregnant women manage their weight gain during pregnancy?
The Get Healthy Information and Coaching Service is trialling a new service designed especially to help
women to learn more about healthy eating and physical activity and support them to manage their weight
gain during pregnancy. The service is free of charge to all women.
Your hospital is participating in a trial during 2014/15 to see what works best for women in terms of
support – either telephone coaching or simply giving women information.
We are recruiting women now for the trial and are looking for participants. Ask your midwife for more
information.
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MASTER PARTICIPANT INFORMATION SHEET (Pregnant Women)
Evaluation of a telephone based information and coaching program to reduce excessive gestational weight gain
amongst pregnant women
INVITATION
You are invited to take part in a study about program to support healthy weight gain during pregnancy. This study is
being conducted by Ms Michelle Maxwell, Ms Praveena Gunaratnam, and Dr Santosh Khanal from the Office of
Preventive Health, and by Ms Vanessa Clements, Dr Michael Nicholl and Ms Jane Raymond from NSW Kids and
Families.
Before you decide if you would like to take part, it is important you to understand why the research is being done and
what it will involve. Please read the following information carefully and discuss with others if you wish.
1. Why are you doing this study? The NSW Office of Preventive Health and NSW Kids and Families have developed a program to support women to
achieve healthy weight gain during pregnancy. As part of this program, women will either to receive information only
or enrol in a 6-8 month coaching program. We would like to see which is more effective in supporting healthy eating,
physical activity and healthy weight gain during pregnancy and post birth.
The program is part of the NSW Get Healthy Information and Coaching Service, a free telephone based coaching
service available to all adults 18 years and over in NSW. If results from this study are positive, the program will be
made available to all pregnant women aged 18 years and over in NSW from 2015 onwards.
2. Why have I been invited to take part in this study? You have been invited to take part as a pregnant woman aged 18 years or over; with a gestation of 18 weeks or
under; being English speaking; having a singleton pregnancy; and attending one of the four public hospitals who
have agreed to participate in this study. Each hospital has been allocated either to the information or coaching
group. If you agree to participate, the group you are allocated to will depend on the hospital you attend.
During your first booking visit, your midwife will discuss the trial further with you and ask if you would like to
participate.
Insert relevant LHD logo here
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3. What if I don’t want to take part in this study, or if I want to stop taking part later? Participation in this study is voluntary. It is completely up to you whether or not you participate. If you decide not to
participate, it will not affect the services you receive now or in the future from your midwife or any other health
professional. Whatever your decision, it will not affect your relationship with the staff caring for you. If you wish to
withdraw from the study once it has started, you can do so at any time without having to give a reason.
4. What does this study involve? The study will take place over the next two years. If you are interested in participating, before seeking consent, your
midwife will assess your eligibility to be included in the study based on age, English language ability, how many
weeks pregnant you are and other pregnancy and health related criteria. If you have certain pre-existing conditions
you may either be ineligible to participate or require further medical clearance before you can enrol in the study.
Once you consent and enrol in the study, you will be contacted by a coach from the NSW Get Healthy Service and
receive either:
Information only – a package of materials and one off information and advice session from a Get Healthy Service coach on healthy eating, physical activity and importance of healthy weight gain during pregnancy; OR
Coaching – package of materials and up to 10 individually tailored calls from your Get Healthy Service coach designed to support to you to achieve your goals around healthy eating, physical activity and healthy weight gain during pregnancy. Eight calls will be during pregnancy and two calls post-birth, with duration of approximately 15 minutes per call and timing based on your preferences.
Depending on which group you are in are, either your coach or a trained research assistant you will ask you over
the phone, at three time points, questions about your weight and behaviours (for example how much fruit and
vegetables you are eating and the amount of physical activity you are doing). The first time will be upon enrolment
into the study. The second time will be when you are 36 weeks pregnant. The third time will be 12 months after you
give birth. Each call should take no longer than 20 minutes. You will be asked to report your weight using scales at
home or in your antenatal clinic.
In addition to the above, you may be asked to take part in a half hour interview in early 2015 with one of researchers
on your experiences with the NSW Get Healthy Service and any suggestions for improvement. This feedback will
help us adjust the information and coaching program to ensure it is acceptable and appropriate for pregnant woman.
5. How is this study being paid for? The study involves minimal cost and these costs are being met by the NSW Office of Preventive Health.
6. Are there risks to me in taking part in this study? All information and advice you will be given during the trial is based on guidelines which have been established as
safe for pregnant women.
However, during pregnancy, you may experience complications which mean it is either no longer appropriate to
participate in the study or that you require further medical clearance before continuing. If you consent to take part in
the study, your midwife or coach will discuss these possible complications and monitor if any concerns arise. You
are also urged to raise any changes in your health status with your midwife and/or coach as soon as possible.
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7. Will I benefit from this study? Through participating in this study, you will have access to resources and support for healthy eating, physical
activity and healthy weight gain during and after pregnancy.
8. Will taking part in this study cost me anything? No.
9. Who will be able to see the information I give in interviews? Of the people involved in this research, only those named above, your midwife and potentially hospital doctors, the
Get Healthy Service coach or research assistant who contacts you will know whether or not you are participating in
this study. Any identifiable information that is collected about you in connection with this study will remain
confidential and will be disclosed only with your permission, or except as required by law. Only the researchers
named above will have access to your details that will be held securely at the NSW Office of Preventive Service.
10. What happens with the results? If you give us your permission by signing the consent document, we plan to discuss/publish the results with the
ethics committee for monitoring purposes and as a report to the NSW Office of Preventive Health, NSW Kids and
Families and participating hospitals. The report may also be submitted for publication in a journal depending on
findings.
In any publication, information will be provided in such a way that you cannot be identified. Results of the study will
be provided to you, if you wish.
11. What should I do if I want to discuss this study further before I decide? When you have read this information, the Chief Investigator Michelle Maxwell can discuss it with you and any
queries you may have. If you would like to know more at any stage, please do not hesitate to contact her on 8738
6503 or email [email protected].
12. Who should I contact if I have concerns about the study? This study has been approved by the South Western Sydney Local Health District Human Research Ethics Committee.
Any person with concerns or complaints about the conduct of this study should contact the Ethics and Research Office,
SWSLHD Locked Bag 7017, LIVERPOOL BC, NSW, 1871 on phone 02 8738 8304 or email
[email protected] and quote HREC project number 14/070.
Thank you for taking the time to consider this study.
If you wish to take part in it, your midwife will ask you to sign a consent form.
56
Appendix F: Screening and Assessment Form
SCREENING AND ASSESSMENT QUESTIONNAIRE
Evaluation of a telephone based information and coaching program to reduce excessive gestational
weight gain amongst pregnant women
Please complete for every booking Name of participating hospital:____________________________
1. Woman’s Age <18 Exclude
18+ Go to Q2
2. Gestation >18 weeks Exclude
18 or under Go to Q3
3. Interpreter required No Go to Q4
Yes Exclude
4. Singleton pregnancy No Exclude
Yes Go to Q5a
5a. Estimated pre-pregnancy weight kg
5b. Height cm
5c. Calculate estimated pre-pregnancy BMI
<18.5 kg/m2
Exclude
18.5 kg/m2
or over Go to Q6
6. Does the woman have any of the following pre-existing conditions? Pulmonary hypotension Arrhythmia/palpitations;
murmurs: recurrent, persistent or associated with other symptoms
Cardiac valve disease Cardiac valve replacement Cardiomyopathy Congenital cardiac disease Ischaemic heart disease Pre-existing Type 1 diabetes Cystic fibrosis Phenylketonuria (PKU) Sarcoidosis
Yes (circle relevant) Exclude
No Go to Q7
Patient Sticker with contact
details
57
Severe lung disorder
7. Does the woman have any of the following pre-existing conditions? Hypertension Asthma Moderate (women
requiring daily bronchodilators and steroid inhalers)
Musculo-skeletal problems Previous pre-term birth Recurrent miscarriage History of mental health conditions
(e.g. eating disorders) Coeliac Disease Type 2 diabetes (diet controlled)
Yes (circle relevant) Medical clearance required prior to enrolling in trial (if woman consents)
No Go to Q8
8. Is the woman interested in entering the trial?
Yes No Maybe but will think about it
Yes Go to Q9
9. If the woman is not interested in entering the trial please note her reason
Time Not interested in managing
weight gain Not interested in finding out
more about healthy eating/activity
Other
_________________________________
_______________________________
If excluded because of answers to Q1-4, 5c or 6:
Thank you for your interest, unfortunately we are unable to include in the trial because:
Under the age of 18 years - the GHS has been established for adults and no guidelines for weight gain in pregnant women under 18 years exist;
Pre-pregnancy BMI < 18.5 kg/m2 – we are concerned with weight gain which is over the recommended limits, which is primarily an issue for women who are normal or overweight ;
58
Gestation over 18 weeks– we need to allow adequate time during pregnancy for any effects of the intervention on weight gain to be realised;
Non English speaking – we would like to trial the program with English speakers first, before adapting for non-English speakers;
Multiple pregnancy – weight gain guidelines differ for women with multiple compared to singleton pregnancies; or
Women with pre-existing conditions – participation in the trial may not be safe for you.
If medical clearance required:
Based on these answers, we would like your hospital doctor make sure that participation in the trial is appropriate for you. We would also like to ensure your antenatal clinic receives regular reports from the Service to keep them informed of your progress.
Appendix G: Coaching Content Content of the coaching calls delivered as part of GHiP has two components – generic and gestation
specific.
Key topics which will be covered for all coaching participants irrespective of stage of pregnancy include:
Screening and assessment to determine if further clearance is required before enrolling In GHS
Take biometric data including (e.g. estimate of pre-pregnancy BMI) and assess current behaviours
and beliefs around healthy eating and physical activity – at beginning, mid-point and end of
coaching program
Provide information about GHS and gestational weight gain module
Explore readiness to change, barriers and risk of relapse
Explain what healthy gestational weight gain is
o Effects for mother and child of excessive or inadequate weight gain
o How to reduce risk through healthy eating and physical activity
Establish individual risk factors for excessive or inadequate gestational weight gain
Establish goals and action plan
Provision of a recommended gestational weight gain target in line with US Institute of Medicine
(IoM) weight gain guidelines
Provide advice and support around healthy eating and physical activity during pregnancy
Assess other lifestyle related risk factors (e.g. smoking and alcohol consumption) and make
referrals as appropriate
Monitor progress (e.g. ask woman to weigh herself regularly at home or clinic, and report back to
coach on changes), particularly at the start of the coaching program, prior to birth and after birth.
Nutritional content is based on recommendations in Eat for Health: Australian Dietary Guidelines. More
specifically, topics include the five food groups, serve sizes and quantities, important nutrients for
pregnancy, foods to avoid, food labels, and healthy snacks.
59
Physical activity content similarly is based on existing guidelines and resources, and adapted to the
individual based factors such as pre-pregnancy fitness and BMI; and contraindications to exercise.
Particular topics include the benefits of increasing activity, precautions or flags to cease exercise, and the
type, frequency and duration of physical activity suited to the individual.
Coaching calls are otherwise tailored to the woman’s stage of pregnancy when she enters GHiP. Different
stages have different implications in terms of challenges the woman may be facing around healthy
behaviours and what these behaviours mean for the development of the foetus.
Standards and content of the gestational weight gain module have been developed with reference to state,
national and international guidelines and resources. These include, but are not limited to:
National Health and Medical Research Council and Australian Department of Health and Ageing. Eat for Health: Australian Dietary Guidelines. February 2013
Institute of Medicine. Weight gain during pregnancy: re-examining the guidelines. 2009
Families NSW and NSW Health. Having a Baby. September 2012
Australian Health Ministers’ Advisory Council. Clinical Practice Guidelines: Antenatal Care – Module 1.2012
Australian College of Midwives. National Midwifery Guidelines for Consultation and Referral. 3rd Edition 2013
Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Management of Obesity in Pregnancy. September 2013
Table 1 – Outline for Coaching Scripts
Call Number Topics to be covered
1 Introduce self to client
Confirm the identity of the client
Advise the client of the potential for call monitoring
Collects medical history and determine if further clearance is required before enrolling In GHS
Take measurements (e.g. estimate of pre-pregnancy BMI) and assess current behaviours and beliefs around healthy eating and physical activity – at beginning, mid-point and end of coaching program
Provide information about GHS and gestational weight gain module o Explain what healthy gestational weight gain is o Effects for mother and child of excessive or inadequate weight gain
How to reduce risk through healthy eating and physical activity
Explore readiness to change, barriers and risk of relapse
Establish individual risk factors for excessive or inadequate gestational weight gain
Emphasise importance of continual monitoring of health status to ensure participation in GHS gestational weight gain module is appropriate
o Explain contraindications to physical activity and diet recommendations
2 Establish goals and action plan. These can be in line with US Institute of Medicine weight gain guidelines if acceptable to participant
Explore importance of goal to client
Explore how the clients rates their confidence in being able to do their action plan
Provide advice and support around healthy eating and physical activity
Assess other lifestyle related risk factors (e.g. smoking and alcohol consumption) and make referrals as appropriate
60
3-8 Monitor changes in health status
Monitor progress
Motivate and advise in line with stage of pregnancy
9-10 Referral to other health services if appropriate
Check how coping and barriers to maintenance of healthy eating behaviours
Referral into standard GHS if appropriate
Table 2 – Target Weight Gain
Pre-pregnancy weight
category
Body Mass Index Rate of gain 2nd
and 3rd
trimester (kg/week)
Recommended total gain range (kg)
Underweight Less than 18.5 0.45 12.5 to 18
Normal weight 18.5-24.9 0.45 11.5 to 16
Overweight 25.0-29.9 0.28 7 to 11.5
Obese (all classes) 30 or more 0.22 5 to 9
Source: US Institute of Medicine Table 3 – Healthy eating recommendations for pregnant women
Food Group How Many Serves a Day?
Bread, cereals, rice, pasta, noodles 8.5
Vegetables, legumes 5
Fruit 2
Milk, yoghurt, cheese and dairy alternatives 2.5
Lean meat, fish, poultry, eggs and legumes 3.5
Unsaturated spreads and oils 2
Table 4 – Gestation-specific guide for coaching content
Call No /
Stage of
Pregnancy
Content
1-6 (1st
and 2
nd
trimester)
Common problems of pregnancy, why they occur and what might help
Common discomforts and what to do to relieve them (e.g. for nausea, have a snack and avoid greasy/spicy foods)
Healthy Eating: Australian Guide to Healthy Eating (5 food groups), snack ideas, myths (e.g. “eating for two”) and recommended weight gain during pregnancy important nutrients during pregnancy and lactation (e.g. folate, iodine, iron), foods to avoid
Physical Activity: benefits of exercise, tips and precautions, stretching exercises, type, intensity, frequency and duration, importance of variety, incidental daily activity
61
7-8 (3rd
trimester)
Feeding your baby and benefits of breastfeeding
Healthy eating: portion sizes and serves, healthy plate, keeping motivated, food labels
Physical activity: posture, back care and symptom cycle, pelvic floor exercises, physical activity towards the end of pregnancy
9-10 (Post Natal)
Healthy eating: eating out, tips for busy lives and easy meals
Physical activity: relaxation
Behaviour maintenance
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Appendix H – Interview Guides
SCHEDULED INTERVIEWS WITH SELECT COACHING PARTICIPANTS
LENGTH OF AUDIO: ________________________________________________________ ADDITIONAL NOTES BY TRANSCRIBER_____________________________________________________________
# Interviewer Participant
1 [“Thinking back to early on in your pregnancy…”] Can
you tell me why you signed up for the Get Healthy in
Pregnancy Service?
2 How would you describe your experience using the Service?
3 How could we make the Service more useful to you?
4 Did you make any changes to your eating or exercise habits as a result of information that you received from the Service?
5 Would you tell me what was your target weight gain
for this pregnancy?
……………..….
No target mentioned
6 On a scale of 1-10, with 10 being “very easy” and 1
being “very difficult”, how would you rate your
experience of staying within your target weight
gain range for this pregnancy?
Score:
7 How did you feel when the midwife raised the topic
of weight gain during pregnancy at your first
booking?
63
# Interviewer Participant
8 You heard about this Service through your midwife at your first booking appointment. How else can we best inform other pregnant women, like yourself, about the Service?
9 [NOT ALL PARTICIPANTS WILL BE ASKED THIS]
If you withdrew from the coaching program prior to
completion, what were the reasons for this?
10 Would you recommend the Service to a friend? If yes, what would you tell them about the service?
64
SCHEDULED INTERVIEWS WITH SELECT INFORMATION ONLY PARTICIPANTS
LENGTH OF AUDIO: ________________________________________________________ ADDITIONAL NOTES BY TRANSCRIBER_____________________________________________________________
# Interviewer Participant
1 [“Thinking back to early on in your pregnancy…”] Can
you tell me why you signed up for the Get Healthy in
Pregnancy Service?
2 How would you describe your experience using the Service?
3 How could we make the Service more useful to you?
4 Did you make any changes to your eating or exercise habits as a result of information that you received from the Service?
5 Would you tell me what was your target weight gain
for this pregnancy?
……………..….
No target mentioned
6 On a scale of 1-10, with 10 being “very easy” and 1
being “very difficult”, how would you rate your
experience of staying within your target weight
gain range for this pregnancy?
Score:
7 How did you feel when the midwife raised the topic
of weight gain during pregnancy at your first
booking?
65
# Interviewer Participant
8 You heard about this Service through your midwife at your first booking appointment. How else can we best inform other pregnant women, like yourself, about the Service?
9 [NOT ALL PARTICIPANTS WILL BE ASKED THIS]
You did not complete your one-off information call,
what were the reasons for this?
10 Would you recommend the Service to a friend? If yes, what would you tell them about the service?
66
SCHEDULED INTERVIEWS WITH SELECT HEALTH CARE PROFESSIONALS: MIDWIVES
LENGTH OF AUDIO: ________________________________________________________ ADDITIONAL NOTES BY TRANSCRIBER_____________________________________________________________
# Interviewer Participant
1 Would you tell me about your experience with the Get
Healthy in Pregnancy Service in your clinic?
2 Were you involved in any training or meetings about the
trial, either during the trial or before it began?
3 On a scale of 1-10, with 10 being “very easy” and 1 being
“very difficult”, how would you rate your experience in
recruiting women to the Get Healthy in Pregnancy
Service?
Score:
4 Do you think that the Service inclusion and exclusion
criteria (Screening and Assessment Form criteria and
Medical Re-clearance Form) are appropriate?
5 On a scale of 1-10, with 10 being “very easy” and 1 being
“very difficult”, how would you rate your experience of
getting medical clearance and re-clearance for women
who required it?
Score:
67
# Interviewer Participant
6 How would you describe your experience of talking to
pregnant women about weight gain?
7 What did you think of the Get Healthy in Pregnancy
factsheets?
8 Can you think of any additional resources or training
that would assist you when talking to women about
healthy weight gain during pregnancy?
9 How has being involved in the Get Healthy in Pregnancy
Service changed or impacted on your practice?
10 How can we best promote the Get Healthy in Pregnancy
Service among healthcare professionals?
11 Do you have any other comments or suggestions about
the Service?
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# Interviewer Participant
69
SCHEDULED INTERVIEWS WITH SELECT HEALTH CARE PROFESSIONALS: MEDICAL OFFICERS
LENGTH OF AUDIO: ________________________________________________________ ADDITIONAL NOTES BY TRANSCRIBER_____________________________________________________________
# Interviewer Participant
1 Would you tell me about your experience with the Get
Healthy in Pregnancy Service in your Hospital?
2 Were you involved in any training or meetings about the
trial, either during the trial or before it began?
3 Do you think that the Service inclusion and exclusion
criteria (Screening and Assessment Form criteria and
Medical Re-clearance Form) are appropriate?
4 On a scale of 1-10, with 10 being “very easy” and 1 being
“very difficult”, how would you rate your experience of
providing medical clearance and re-clearance for women
who required it?
Score:
5 How would you describe your experience of talking to
pregnant women about weight gain?
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# Interviewer Participant
6 Can you think of any additional resources or training
that would assist you when talking to women about
healthy weight gain during pregnancy?
7 Has being involved in the Get Healthy in Pregnancy
Service changed or impacted on your practice?
Or
In your view how do medical officers view the Get
Healthy in pregnancy service, where referrals are
effectively made to health coaches?
9 How can we best promote the Get Healthy in Pregnancy
Service among healthcare professionals?
10 Do you have any other comments or suggestions about
the Service?
71
SCHEDULED INTERVIEWS WITH SELECT HEALTH CARE PROFESSIONALS: HEALTH COACHES
LENGTH OF AUDIO: ________________________________________________________ ADDITIONAL NOTES BY TRANSCRIBER_____________________________________________________________
# Interviewer Participant
1 Would you tell me about your experience providing the
Get Healthy in Pregnancy Service?
2 [NOT ALL PARTICIPANTS WILL BE ASKED THIS]
Did women report any challenges in relation to:
a. Eating healthily during pregnancy
b. Staying active during pregnancy
a. Eating healthily during pregnancy
b. Staying active during pregnancy
3 What particular strategies in health coaching worked well
with pregnant women in overcoming their challenges
(refer to the ones raised in Q2)?
4 How can the Service be improved to better serve the
needs of pregnant women?
5A Are you aware of any participants who chose to drop out
of the Service?
5B In your opinion, what were the main reasons for women
dropping out of the Service?
72
# Interviewer Participant
6 On a scale of 1-10 (1 being not at all prepared, 10 being
fully prepared), how prepared did you feel to work with
pregnant women?
7 What additional resources or training, if any, would assist
you to support women during and after pregnancy to
achieve healthy weight gain?
7 Other comments/suggestions:
73
Appendix I: Breakdown of results for women requiring medical clearance
Table 1 Reasons women required medical clearance by BMI status
Normal
weight
OWO Total
History of mental health conditions 32 40 72
Recurrent miscarriage 27 36 63
Asthma Moderate 24 30 54
Previous pre-term birth 17 36 53
Musculo-skeletal problems 11 22 33
Hypertension 8 33 41
Epilepsy 7 11 18
Vaginal blood loss at or after 12 weeks 10 6 16
Type 2 diabetes 5 8 13
Coeliac Disease 5 2 7
Total 146 224 370
Table 2 Reasons women were excluded due to pre existing medical conditions
Number
Arrhythmia/palpitations; murmurs 28
Pre-existing Type 1 diabetes 12
Congenital cardiac disease 7
Pulmonary hypertension 7
Cardiomyopathy 4
Cardiac valve disease 3
Total 61
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