Testing the feasibility of a mobile technology intervention promoting healthy gestational weight gain in pregnant women (txt4two) - study protocol for a randomised controlled trial.

BACKGROUND: Overweight, obesity and excess gestational weight gain (GWG) are associated with negative health outcomes for mother and child in pregnancy and across the life course. Interventions promoting GWG within guidelines report mixed results. Most are time and cost intensive, which limits scalability. Mobile technologies (mHealth) offer low cost, ready access and individually-tailored support. We aim to test the feasibility of an mHealth intervention promoting healthy nutrition, physical activity and GWG in women who begin pregnancy overweight or obese. METHODS/DESIGN: txt4two is a parallel randomised control trial pilot recruiting women with a singleton, live gestation between 10(+0) and 17(+6) weeks at the first hospital antenatal clinic visit. Inclusion criteria are pre-pregnancy BMI > 25 kg/m(2) and mobile phone ownership. One hundred consenting women will be randomised to intervention or control groups at a 1:1 ratio. All participants will receive standard antenatal care. In addition, the txt4two intervention will be delivered from baseline to 36 weeks gestation and consists of a tailored suite of theoretically-grounded, evidence-based intervention strategies focusing on healthy nutrition, physical activity and GWG. This includes: mobile phone interactive text messages promoting positive health behaviours, goal setting and self-monitoring; video messages; an information website; and a private moderated Facebook® chat forum. The primary outcome is the feasibility of the intervention. Secondary outcomes include GWG and participants' knowledge and behaviour regarding diet and physical activity during pregnancy. DISCUSSION: Findings will inform the development of larger-scale mHealth programmes to improve the delivery of healthy pregnancy nutrition, physical activity and GWG, that could be widely translated and disseminated. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRNU111111544397 . Date of registration: 19 March 2014.

Psychosocial factors and excessive gestational weight gain: the effect of parity in an Australian cohort

OBJECTIVES: psychosocial variables can be protective or risk factors for excessive gestational weight gain (GWG). Parity has also been associated with GWG; however, its effect on psychosocial risk factors for GWG is yet to be determined. The aim of this study was to investigate if, and how, psychosocial factors vary in their impact on the GWG of primiparous and multiparous women. DESIGN/PARTICIPANTS: pregnant women were recruited in 2011 via study advertisements placed in hospitals, online, in parenting magazines, and at baby and children's markets, resulting in a sample of 256 women (113 primiparous, 143 multiparous). Participants completed questionnaires at 16-18 weeks' gestation and their pregravid BMI was recorded. Final weight before delivery was measured and used to calculate GWG. FINDINGS: the findings revealed that primiparous women had significantly higher feelings of attractiveness (a facet of body attitude; p=0.01) than multiparous women. Hierarchical regressions revealed that in the overall sample, increased GWG was associated significantly with lower pre-pregnancy BMI (standardised coefficient β=-0.39, p<0.001), higher anxiety symptoms (β=0.25, p=0.004), and reduced self-efficacy to eat a healthy diet (β=-0.20, p=0.02). Although higher GWG was predicted significantly by decreased feelings of strength and fitness for primiparous women (β=-0.25, p=0.04) and higher anxiety was related significantly to greater GWG for multiparous women (β=0.43, p<0.001), statistical comparison of the model across the two groups suggested the magnitude of these effects did not differ across groups (p>0.05). CONCLUSIONS/IMPLICATIONS FOR PRACTICE: the findings suggest that psychosocial screening and interventions by healthcare professionals may help to identify women who are at risk of excessive GWG, and there may be specific psychosocial factors that are more relevant for each parity group.

Classification tree analysis of postal questionnaire data to identify risk of excessive gestational weight gain

OBJECTIVE: overweight/obese weight status during pregnancy increases risk of a range of adverse health outcomes for mother and child. Whereas identification of those who are overweight/obese pre-pregnancy and in early pregnancy is straightforward, prediction of who will experience excessive gestational weight gain (EGWG), and thus be at greater risk of becoming overweight or obese during pregnancy is more challenging. The present study sought to better identify those at risk of EGWG by exploring pre-pregnancy BMI as well as a range of psychosocial risk factors identified as risk factors in prior research. METHODS: 225 pregnant women completed self-reported via postal survey measures of height, weight, and psychosocial variables at 16-18 weeks gestation, and reported their weight again at 32-34 weeks to calculate GWG. Classification and regression tree analysis (CART) was used to find subgroups in the data with increased risk of EGWG based on their pre-pregnancy BMI and psychosocial risk factor scores at Time 1. FINDINGS: CART confirmed that self-reported BMI status was a strong predictor of EGWG risk for women who were overweight/obese pre-pregnancy. Normal weight women with low motivation to maintain a healthy diet and who reported lower levels of partner support were also at considerable risk of EGWG. IMPLICATIONS FOR PRACTICE: present findings offer support for inclusion of psychosocial measures (in addition to BMI) in early antenatal visits to detect risk of EGWG. However, these findings also underscore the need for further consideration of effect modifiers that place women at increased or decreased risk of EGWG. Proposed additional constructs are discussed to direct further theory-driven research.

The challenges and future considerations regarding pregnancy-related outcomes in women with pre-existing diabetes

Ineffective management of blood glucose levels during preconception and pregnancy has been associated with severe maternal and fetal complications in women with pre-existing diabetes. Studies have demonstrated that preconception counseling and pre-pregnancy care can dramatically reduce these risks. However, pregnancy-related outcomes in women with diabetes continue to be less than ideal.

This review highlights and discusses a variety of patient, provider, and organizational factors that can contribute to these suboptimal outcomes. Based on the findings of studies reviewed and authors’ clinical and research experiences, recommendations have been proposed focusing on various aspects of care provided, including improved accessibility to effective preconception and pregnancy-related care and better organized clinic consultations that are sensitive to women’s diabetes and pregnancy needs.

How well do women adapt to changes in their body size and shape across the course of pregnancy

This study examined body image across pregnancy. Pregnant women ( N = 158) completed measures of general attractiveness, feeling fat, fitness and strength, salience of weight and shape, and ideal and current body size at pre-pregnancy (retrospective), and in early, middle and late pregnancy. Body image was found to be fairly stable across pregnancy such that women who started with greater body concerns maintained them over time. Although women were least satisfied with their stomach size at late pregnancy, women's ideal body shape increased in parallel with increases in body size. Women with the most body concerns reported more depressive symptoms, tendency towards dieting, and smoking during pregnancy suggesting they were at greater risk in terms of health and well-being during pregnancy.

A review of the relationship between socioeconomic position and the early-life predictors of obesity

A range of important early-life predictors of later obesity have been identified. Children of lower socioeconomic position (SEP) have a steeper weight gain trajectory from birth with a strong socioeconomic gradient in child and adult obesity prevalence. An assessment of the association between SEP and the early-life predictors of obesity has been lacking. The review involved a two-stage process: Part 1, using previously published systematic reviews, we developed a list of the potentially modifiable determinants of obesity observable in the pre-natal, peri-natal or post-natal (pre-school) periods; and part 2, conducting a literature review of evidence for socioeconomic patterning in the determinants identified in part 1. Strong evidence was found for an inverse relationship between SEP and (1) pre-natal risk factors (pre-pregnancy maternal body mass index (BMI), diabetes and pre-pregnancy diet), (2) antenatal/peri natal risk factors (smoking during pregnancy and low birth weight) and (3) early-life nutrition (including breastfeeding initiation and duration, early introduction of solids, maternal and infant diet quality, and some aspects of the home food environment), and television viewing in young children. Less strong evidence (because of a lack of studies for some factors) was found for paternal BMI, maternal weight gain during pregnancy, child sleep duration, high birth weight and lack of physical activity in young children. A strong socioeconomic gradient exists for the majority of the early-life predictors of obesity suggesting that the die is cast very early in life (even pre-conception). Lifestyle interventions targeting disadvantaged women at or before child-bearing age may therefore be particularly important in reducing inequality. Given the likely challenges of reaching this target population, it may be that during pregnancy and their child's early years are more feasible windows for engagement.

Consumer issues in navigating health care services for type I diabetes

• Despite increasing interest in consumer awareness and participation in health care service delivery, there has been little exploration of consumer views in relation to services for people with type I diabetes. • The purpose of this qualitative exploratory study was to identify strategies people with type I diabetes used to access health services and the barriers they perceived in accessing the services they needed. • Data gathered in semi-structured interviews revealed that consumers experience significant barriers when navigating the health care system. • Three dominant themes were identified. They relate to access to specialist medical skill, to the transition from teenager to young adult and to pre-pregnancy and obstetric care. • Directions for change in service delivery and policy development are discussed.

Low birth weight in South Asian babies in Britain: time to reduce the inequalities

Babies born in Britain to women of South Asian ethnic origin are lighter on average than the offspring of women of European origin. The causes have been incompletely elucidated but nutritional factors, low socioeconomic status and maternal pre-pregnancy weight have been implicated. This health inequality has received little policy prioritization in Britain. As further research clarifies reasons for this differential, appropriately targeted preventive strategies need to be implemented.

Birthweight and childhood cancer : preliminary findings from the International Childhood Cancer Cohort Consortium (I4C)

BACKGROUND: Evidence relating childhood cancer to high birthweight is derived primarily from registry and case-control studies. We aimed to investigate this association, exploring the potential modifying roles of age at diagnosis and maternal anthropometrics, using prospectively collected data from the International Childhood Cancer Cohort Consortium.

METHODS: We pooled data on infant and parental characteristics and cancer incidence from six geographically and temporally diverse member cohorts [the Avon Longitudinal Study of Parents and Children (UK), the Collaborative Perinatal Project (USA), the Danish National Birth Cohort (Denmark), the Jerusalem Perinatal Study (Israel), the Norwegian Mother and Child Cohort Study (Norway), and the Tasmanian Infant Health Survey (Australia)]. Birthweight metrics included a continuous measure, deciles, and categories (≥4.0 vs. <4.0 kilogram). Childhood cancer (377 cases diagnosed prior to age 15 years) risk was analysed by type (all sites, leukaemia, acute lymphoblastic leukaemia, and non-leukaemia) and age at diagnosis. We estimated hazard ratios (HR) and 95% confidence intervals (CI) from Cox proportional hazards models stratified by cohort.

RESULTS: A linear relationship was noted for each kilogram increment in birthweight adjusted for gender and gestational age for all cancers [HR = 1.26; 95% CI 1.02, 1.54]. Similar trends were observed for leukaemia. There were no significant interactions with maternal pre-pregnancy overweight or pregnancy weight gain. Birthweight ≥4.0 kg was associated with non-leukaemia cancer among children diagnosed at age ≥3 years [HR = 1.62; 95% CI 1.06, 2.46], but not at younger ages [HR = 0.7; 95% CI 0.45, 1.24, P for difference = 0.02].

CONCLUSION: Childhood cancer incidence rises with increasing birthweight. In older children, cancers other than leukaemia are particularly related to high birthweight. Maternal adiposity, currently widespread, was not demonstrated to substantially modify these associations. Common factors underlying foetal growth and carcinogenesis need to be further explored.

A path model of psychosocial and health behaviour change predictors of excessive gestational weight gain

This study aimed to evaluate a conceptual model of psychosocial, behaviour change, and behavioural predictors of excessive gestational weight gain (GWG). Background: Excessive GWG can place women and their babies at risk of poor health outcomes, including obesity. Models of psychosocial and behaviour change predictors of excessive GWG have not been extensively explored; understanding the mechanisms leading to excess GWG will provide crucial evidence towards the development of effective interventions. Method: Two hundred and eighty-eight pregnant women (≤18 weeks gestation) were recruited to a prospective study. Demographic, psychosocial, health behaviour change, and behavioural factors were assessed at 17 (Time 1, T1) and 33 weeks (Time 2, T2) gestation. Pre-pregnancy and final pregnancy weight were obtained and women were classified with/without excessive GWG. Logistic regressions refined the list of predictors of excessive GWG; variables with p < .1 were included in a path analysis. Results: Age, family income, T2 depression, T2 pregnancy-specific coping, T1 buttocks dissatisfaction, T2 GWG-specific self-efficacy, T1 dietary readiness, T1 dietary importance, and T1 vegetable intake predicted excessive GWG in the logistic regressions and were included in the path model. The baseline path model demonstrated poor fit. Once statistically and theoretically plausible paths were added, adequate model fit was achieved (χ² = 21.61(9), p < .05; RMSEA = .07; CFI = .93); this revised model explained 19.5% of the variance in excessive GWG. Women with high T1 buttocks dissatisfaction were more likely to exhibit low levels of dietary readiness. Women with low dietary readiness were more likely to have a lower vegetable intake, which predicted excessive GWG. Women with higher T2 depressive symptoms were more likely to report lower GWG self-efficacy and gain excessively. Conclusion: Future behavioural GWG trials should consider combining psychosocial and health behaviour change factors to optimise GWG.

Sleep quality and depression during pregnancy: a prospective study

For the first time, the relationship between depressive symptoms and sleep quality was explored prospectively during pregnancy. Participants (n = 273) completed the Pittsburgh Sleep Quality Index and Beck Depression Inventory at three 8-week intervals, starting from 15–23 weeks gestation. In addition to sleep quality and depression remaining relatively stable during pregnancy, findings revealed that sleep quality earlier in pregnancy predicted higher levels of depressive symptoms at later stage in pregnancy (after controlling for prior depression levels). In contrast, there was no evidence to suggest that depressive symptoms earlier in pregnancy impacted on sleep quality later on. Given that depressive symptomatology can lead to major depression and given the prevalence of pre- and postnatal depression, our findings suggest that screening for sleep problems during pregnancy may be of clinical significance.

Women's views and outcomes of an educational intervention designed to enhance psychosocial support for women during pregnancy

Background: Identification of psychosocial issues in pregnant women by screening is difficult because of the lack of accuracy of screening tools, women's reluctance to disclose sensitive issues, and health care practitioner's reluctance to ask. This paper evaluates if a health professional education program, a new (ANEW) approach, improves pregnant women's ratings of care and practitioner's listening skills and comfort to disclose psychosocial issues.

Methods: Midwives and doctors from Mercy Hospital for Women, Melbourne, Australia, were trained from August to December 2002. English-speaking women (< 20 wks' gestation) were recruited at their first visit and mailed a survey at 30 weeks (early 2002) before and after (2003) the ANEW educational intervention. Follow-up was by postal reminder at 2 weeks and telephone reminder 2 weeks later.

Results: Twenty-one midwives and 5 doctors were trained. Of the eligible women, 78.2 percent (584/747) participated in a pre-ANEW survey and 73.3 percent (481/657) in a post-ANEW survey. After ANEW, women were more likely to report that midwives asked questions that helped them to talk about psychosocial problems (OR 1.45, CI 1.09–1.98) and that they would feel comfortable to discuss a range of psychosocial issues if they were experiencing them (coping after birth for midwives [OR 1.51, CI 1.10–2.08] and feeling depressed [OR 1.49, 1.16–1.93]; and concerns relating to sex [OR 1.35, CI 1.03–1.77] or their relationships [OR 1.36, CI 1.00–1.85] for doctors).

Conclusions: The ANEW program evaluation suggests trends of better communication by health professionals for pregnant women and should be evaluated using rigorous methods in other settings.

Adolescent and pre-conception risk factors for perinatal depression

Women who experienced psychiatric disorder during adolescence reported a 5̃-fold increased risk for depressive symptoms during pregnancy and during the postnatal period. A number of other adolescent and pre-conception risk factors, such as persistent stress and hormonal volatility, were also found to be implicated in the development of perinatal depression. Four case studies of children with profound and pervasive attachment-related disturbances are presented in the portfolio in order to highlight the shortcomings of the current diagnostic criteria for reactive attachment disorder in infancy or early childhood.

Pre- and post-natal development of the diaphragm

Animal models were used to examine properies of the diaphragm (the main respiratory muscle) before and after birth. The study revealed an insufficient blood supply to the fetus can result in structural and functional damage to the diaphragm. Damage was prevented when the mother was supplemented with creatine during pregnancy.