Prenatal Parenting Intervention Modules for High Risk Pregnant Women

Project Category: Amplifying the Impact of Community Early Care Providers 

Kimberly D’Anna Hernandez, Ph.D.
Assistant Professor, Department of Psychology
California State University, San Marcos

Introduction: Obesity during pregnancy is a public health concern with consequences for mother and child. Over half of women begin pregnancy overweight or obese [1]. Obese pregnant women are at risk for multiple disorders including hypertension, preeclampsia and gestational diabetes, all of which are associated with adverse perinatal outcomes (high or low birth weight, preterm birth) [2, 3]. Thus, monitoring of these conditions is vital, particularly amongst minority women whom are at higher risk for obesity-related outcomes. However, compliance to the demanding prenatal care regimen is low. In-clinic interventions are needed to decrease prenatal weight gain. This project partners with a federally qualified health clinic that serves a low-income majority Latino population to develop a group prenatal visit intervention for women at risk for obesity-related complications. Group prenatal visits consist of women simultaneously attending a medical visit and are used successfully in prenatal care [4], however their role for women at-risk for obesity-related complications is unknown. The goals were to 1) understand from patients and clinic staff the important factors in a prenatal intervention, 2) design educational modules for a group prenatal intervention.

Methods: Two groups of participants participated in six focus groups. The first three groups consisted of clinic staff (3 health educators, 3 medical assistants, 2 providers) and the last three were 9 pregnant patients. Interviews focused on patient interactions (positive and challenges), compliance with prescribed treatments (exercise, food, medications), clinic improvements and group prenatal visits as an intervention. Patients also filled out a survey on demographics and interest in psychoeducational topics.

Results: Clinic Staff Interview Themes. Three major themes were found including patient-provider interactions, barriers to care and support interventions. Themes from health educators and providers focused on empowering patients while medical assistants focused on patient responsibility.

Patient Demographics and Interview Themes. Women reported interest in the psychoeducational topics of effects of excessive weight gain and gestational diabetes on the developing child, as well as synchrony between mothers/children and fetal brain development. The three major interview themes found were continuity of care, wait times and communication with providers/staff. The need for empowerment over ones’ own healthcare experience and social support were also highlighted.

Proposed Pilot Intervention (and themes it will address): The intervention will be piloted Spring 2017. The intervention will be bi-monthly for 10 weeks. Group visits (medical and psychoeducational) will be conducted in adjacent rooms. Participants will have a half hour for arrival and vitals and labs taken (minimize wait and allows for late arrivals). The psychoeducational portion will be 90 minutes during which women will be pulled out to meet with the provider. One doctor will see women for the entire 10 weeks (continuity of care, minimize wait times, interactions with providers). There will be structured activities and discussions with health educators, CSUSM staff and participants (patient engagement, cultural barriers, and social support). All visits will begin with a mindfulness activity (decrease stress) and include a check of eating diaries and sugar readings (social support, compliance, patient engagement) and a healthy snack/meal demonstration (patient engagement). The primary outcome is to decrease gestational weight gain.

Discussion: Within the current study, gestational diabetes was identified as an important health consequence amongst obese women. Patients and clinic staff indicated a desire for greater patient engagement and empowerment and the need for improved communication. Given that our community clinic serves a primarily low income, mainly Latino population, culturally competent interventions are needed to improve maternal/child outcomes. Group prenatal visits were identified as an ideal intervention. Group prenatal visits have been associated attendance to as well as satisfaction with prenatal care in immigrants [4]. Different from other models, proposed psychoeducational modules focus on the neuroscience of fetal brain development and the role of maternal environment. These modules are based off of the providers desire to empower patients and the patients desire to learn about ideal health behaviors for the developing baby.  Results will be used to design an intervention, however, there are limitations. There were a limited number of individuals and findings represent what these individuals chose to disclose. Nevertheless, insight was gained to design the intervention.

Future work will test interventions in pregnant women at risk for obesity-related complications. Minority populations are at increased risk for obesity-related outcomes and interventions should target such populations. Such an intervention should promote communication between patients and clinic staff, empower patients with information to promote healthy prenatal behavior, and provide women a safe space to express their concerns and triumphs related to prenatal health behaviors. Improving health behavior in vulnerable populations will promote healthy maternal/child outcomes.

Contact:
Kimberly D’Anna-Hernandez
333 S. Twin Oaks Valley Rd
San Marcos, CA 92078
kdanna@csusm.edu

References

Dudenhausen J, Gruenbaum A, Kirschner W. Prepregnancy body weight and gestational weight gain—recommendations and reality in the USA and in Germany. American Journal of Obstetrics and Gynecology. 2015; 213:591-592.

Nohr EA, Vaeth M, Baker JL, Sørensen TI, Olsen J, Rasmussen KM. Combined associations of prepregnancy body mass index and gestational weight gain with the outcome of pregnancy. The American Journal of Clinical Nutrition. 2008; 87:1750-1759.

Baeten JM, Bukusi EA, Lambe M. Pregnancy complications and outcomes among overweight and obese nulliparous women. American Journal of Public Health. 2001; 91:436- 440.

Cunningham SD, Grilo S, Lewis JB, Novick G, Rising SS, Tobin JN, et al. Group prenatal care attendance: Determinants and relationship with care satisfaction. Maternal and Child Health Journal. 2016:1-7.

Cameron KA. Advancing equity in clinical preventative services: The role of health communication. Journal of Communication. 2013; 63:31-50.

Willard-Grace R, Chen EH, Hessler D, DeVore D, Prado C, Bodenheimer T, et al. Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: A randomized controlled trial. The Annals of Family Medicine. 2015; 13:130-138.

Van Walraven C, Oake N, Jennings A, Forster AJ. The association between continuity of care and outcomes: a systematic and critical review. Journal of Evaluation in Clinical Practice. 2010; 16:947-956.

Carman KL, Dardess P, Maurer M, Sofaer S, Adams K, Bechtel C, et al. Patient and family engagement: A framework for understanding the elements and developing interventions And policies. Health Affairs. 2013; 32:223-231.

Coulter A: Engaging patients in healthcare. New York, New York: McGraw-Hill, 2011.

Johnson MH. Functional brain development in humans. Nat Rev Neurosci. 2001; 2:475- 
483.

Matsuzawa J, Matsui M, Konishi T, Noguchi K, Gur RC, Bilker W, et al. Age-related volumetric changes of brain gray and white matter in healthy infants and children. Cerebral Cortex. 2001; 11:335-342.

Paus T, Collins D, Evans A, Leonard G, Pike B, Zijdenbos A. Maturation of white matter in the human brain: A review of magenetic resonance studies. Brain Research Bulletin. 2001; 54:255-256.

Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, et al. Group prenatal care and perinatal outcomes: A randomized controlled trial. Obstetrics and Gynecology. 2007; 110:330-339.

Ickovics JR, Earnshaw V, Lewis JB, Kershaw TS, Magriples U, Stasko E, et al. Cluster randomized controlled trial of group prenatal care: Perinatal outcomes among adolescents in New York City Health Centers. American Journal of Public Health. 2015; 106:359-365.

Lathrop B. A Systematic review comparing group prenatal care to traditional prenatal care. Nursing for Women’s Health. 2013; 17:118-130.

Mazzoni SE, Hill PK, Webster KW, Heinrichs GA, Hoffman MC. Group prenatal care for women with gestational diabetes. The Journal of Maternal-Fetal & Neonatal Medicine. 2016; 29:2852-2856.

Betancourt JR, Carrillo JE, Green AR, Maina A. Barriers to health promotion and disease prevention in the Latino population. Clinical Cornerstone. 2004; 6:16-29.