Opportunities to promote healthy maternal weight during and following pregnancy

 This thesis has identified opportunities for provision of support for women to attain a healthy weight and healthy diet and physical activity behaviours during and following pregnancy. A better understanding of strategies to promote optimal support to women during the postpartum period has been achieved.

Optimizing weight gain in pregnancy to prevent obesity in women and children

Pregnancy is now considered to be an important risk factor for new or persistent obesity among women during the childbearing years. High gestational weight gain is the strongest predictor of maternal overweight or obesity following pregnancy. A growing body of evidence also suggests that both high and low gestational weight gains are independently associated with an increased risk of childhood obesity, suggesting that influences occurring very early in life are contributing to obesity onset. In response to these data, the US Institute of Medicine (IOM) revised gestational weight gain guidelines in 2009 for the first time in nearly two decades. However, less than one third of pregnant women achieve guideline-recommended gains, with the majority gaining above IOM recommended levels. To date, interventions to optimize pregnancy weight gains have had mixed success. In this paper, we summarize the evidence from human and animal studies linking over-nutrition and under-nutrition in pregnancy to maternal and child obesity. In addition, we discuss published trials and ongoing interventions to achieve appropriate gestational weight gain as a strategy for obesity prevention in women and their children.

Pregnant women's alcohol consumption : the predictive utility of intention to drink and prepregnancy drinking behaviour

Objective: This study had two aims: (1) to examine pregnant women's alcohol consumption across time from prepregnancy until childbirth and (2) to explore whether prepregnancy drinking and intention to drink predict prenatal alcohol consumption while controlling for relevant demographic variables.

Methods: At 17–21 weeks, 248 pregnant women completed questions about demographics, intention to drink alcohol during the subsequent pregnancy, and retrospective measures of prepregnancy and early pregnancy consumption. After this time, calendars were sent fortnightly assessing daily alcohol consumption until birth.

Results: For women who drank both prepregnancy and postpregnancy confirmation, average fortnight alcohol consumption in the first weeks of pregnancy was lower than during prepregnancy, and consumption continued to decrease between gestational weeks 1 and 8, particularly following pregnancy confirmation, after which it remained relatively stable. When predicting whether women drank in late pregnancy, intention accounted for unique variance after controlling for income and prepregnancy drinking. For women who drank after pregnancy confirmation, prepregnancy drinking quantity significantly predicted intention to drink, which in turn predicted fortnight alcohol consumption in later pregnancy, after controlling for prepregnancy drinking and income.

Conclusions: Findings highlight the need to measure alcohol consumption at multiple time points across pregnancy, the need for educating and supporting women to reduce consumption when planning pregnancies, and the usefulness of intention to drink as a predictor of drinking during pregnancy.

Maternal dietary intake and physical activity habits during the postpartum period: associations with clinician advice in a sample of Australian first time mothers

BACKGROUND: Numerous health benefits are associated with achieving optimal diet and physical activity behaviours during and after pregnancy. Understanding predictors of these behaviours is an important public health consideration, yet little is known regarding associations between clinician advice and diet and physical activity behaviours in postpartum women. The aims of this study were to compare the frequency of dietary and physical activity advice provided by clinicians during and after pregnancy and assess if this advice is associated with postpartum diet and physical activity behaviours.

METHODS: First time mothers (n = 448) enrolled in the Melbourne InFANT Extend trial completed the Cancer Council of Australia's Food Frequency Questionnaire when they were three to four months postpartum, which assessed usual fruit and vegetable intake (serves/day). Total physical activity time, time spent walking and time in both moderate and vigorous activity for the previous week (min/week) were assessed using the Active Australia Survey. Advice received during and following pregnancy were assessed by separate survey items, which asked whether a healthcare practitioner had discussed eating a healthy diet and being physically active. Linear and logistic regression assessed associations of advice with dietary intake and physical activity.

RESULTS: In total, 8.6 % of women met guidelines for combined fruit and vegetable intake. Overall, mean total physical activity time was 350.9 ± 281.1 min/week. Time spent walking (251.97 ± 196.78 min/week), was greater than time spent in moderate (36.68 ± 88.58 min/week) or vigorous activity (61.74 ± 109.96 min/week) and 63.2 % of women were meeting physical activity recommendations. The majority of women reported they received advice regarding healthy eating (87.1 %) and physical activity (82.8 %) during pregnancy. Fewer women reported receiving healthy eating (47.5 %) and physical activity (51.9 %) advice by three months postpartum. There was no significant association found between provision of dietary and/or physical activity advice, and mother's dietary intakes or physical activity levels.

CONCLUSIONS: Healthy diet and physical activity advice was received less after pregnancy than during pregnancy yet no association between receipt of advice and behaviour was observed. More intensive approaches than provision of advice may be required to promote healthy diet and physical activity behaviours in new mothers.

Child developmental outcomes in preschool children following antidepressant exposure in pregnancy

To examine child developmental outcomes in preschool-aged children exposed to antidepressant medication in pregnancy and compare their outcomes to children not exposed.

Serotonin discontinuation syndrome following utero exposure to antidepressant medication : prospective controlled study

Objectives: The aim of the present study was to examine neonatal symptoms previously reported to be associated with exposure to antidepressant medication in late pregnancy in a group of infants exposed to antidepressants, using a prospective and controlled design.

Method: A prospective case-control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy. Of the 27 women taking medication, 25 remained on medication in the third trimester and, of these, 23 women had complete data available. In pregnancy and after delivery women were assessed with the Beck Depression Inventory-II and a purpose-designed questionnaire. After delivery mothers were asked a set of nine questions pertaining to symptoms of discontinuation in their newborn and questions about pregnancy and delivery complications.

Results: There was an increased risk of discontinuation symptoms in neonates exposed to antidepressant medication in late pregnancy and an association with higher dose medication. The study group were found to be significantly more likely to display behaviour such as crying, jitteriness, tremor, feeding, reflux and sneezing and sleep for <3 h after a feed. They also had significantly higher rates of jaundice and admissions to the special care nursery.

Conclusions: Exposure to antidepressants in late pregnancy is associated with a range of symptoms in the neonate that are consistent with the effects of exposure to antidepressants in late pregnancy. The clusters of symptoms most highly correlated are the gastrointestinal and central nervous system symptoms. These finding helps to identify the common symptoms associated with a neonatal serotonin discontinuation syndrome.

Neonatal growth outcomes at birth and one month postpartum following in utero exposure to antidepressant medication

Objective: There is evidence of increasing prescription of antidepressant medication in pregnant women. This has arisen from the recognition of the importance of treating maternal depression. This must be balanced, however, with information on outcomes for infants and children exposed to antidepressants in pregnancy. The aim of the present study was to examine whether neonatal outcomes including gestational age at birth, neonatal growth outcomes at birth and then at 1 month postpartum were altered by in utero exposure to antidepressant medication using a prospective and controlled design.

Method: A prospective case–control study recruited 27 pregnant women taking antidepressant medication and 27 matched controls who were not taking antidepressant medication in pregnancy at an obstetric hospital in Melbourne, Australia. Of the 27 women taking medication, 25 remained on medication in the third trimester. A purpose-designed self-report questionnaire and the Beck Depression Inventory-II were completed in pregnancy, after birth and at one month postpartum. In addition information was collected on exposed and non-exposed infants including Apgar scores, birthweight/length/head circumference and gestational age at birth. Weight/length/head circumference was again collected at 1 month of age.

Results: Infants exposed to antidepressants in utero were eightfold more likely to be born at a premature gestational age, had significantly lower birthweight and were smaller in length and head circumference than non-exposed infants. There was no association between birth outcomes and maternal depression. At 1 month, the difference in weight in the exposed group became significantly greater than the control group.

Conclusion: Antidepressant exposure in utero may affect gestational age at birth and neonatal outcomes independently of antenatal maternal depression. Further studies are needed to examine whether these findings vary according to the type of antidepressant prescribed and follow up growth and development in exposed infants beyond 1 month.

Systematic review of lifestyle interventions to limit postpartum weight retention: implications for future opportunities to prevent maternal overweight and obesity following childbirth

Postpartum weight retention can predict future weight gain and long-term obesity. Moreover, failure to lose weight gained during pregnancy can lead to increased body mass index for subsequent pregnancies, increasing the risk of adverse maternal and foetal pregnancy outcomes. This systematic review evaluates the effectiveness of lifestyle interventions aimed at reducing postpartum weight retention. Seven electronic databases were searched for intervention studies and trials enrolling women with singleton pregnancies and published in English from January 1990 to October 2012. Studies were included when postpartum weight was a main outcome and when diet and/or exercise and/or weight monitoring were intervention components. No limitations were placed on age, body mass index or parity. Eleven studies were identified as eligible for inclusion in this review, of which 10 were randomized controlled trials. Seven studies were successful in decreasing postpartum weight retention, six of which included both dietary and physical activity components, incorporated via a range of methods and delivered by a variety of health practitioners. Few studies utilized modern technologies as alternatives to traditional face-to-face support and cost-effectiveness was not assessed in any of the studies. These results suggest that postpartum weight loss is achievable, which may form an important component of obesity prevention in mothers; however, the optimal setting, delivery, intervention length and recruitment approach remains unclear.

Who's responsible for the care of women during and after a pregnancy affected by gestational diabetes?

Despite its increasing incidence and high conferred risk to women and their children, gestational diabetes mellitus (GDM) is managed inconsistently during and after pregnancy due to an absence of a systemic approach to managing these women. New guidelines for GDM testing and diagnosis are based on stronger evidence, but raise concerns about increased workloads and confusion in a landscape of multiple, conflicting guidelines. Postnatal care and long-term preventive measures are particularly fragmented, with no professional group taking responsibility for this crucial role. Clearer guidelines and assistance from existing frameworks, such as the National Gestational Diabetes Register, could enable general practitioners to take ownership of the management of women at risk of type 2 diabetes following GDM, applying the principles of chronic disease management long term.

Supporting working parents: findings from the AHRC’s national inquiry into the prevalence of pregnancy and return to work discrimination in the workplace

In July 2014 the Australian Human Rights Commission (AHRC) released the findings of its national review into pregnancy and return to work discrimination in the workplace1 which it conducted following a request from the Commonwealth Attorney-General’s Department.2 The review comes 15 years after the commission’s first inquiry into pregnancy discrimination in the workplace.3Federal law has prohibited pregnancy discrimination in the workplace since the Sex Discrimination Act 1984 (Cth) (SDA) came into force.4 It is now unlawful in every state and territory.5 Discrimination on the basis of breastfeeding and family or carer’s responsibilities is also prohibited.6 Since 2009 the Fair Work Act 2009 (Cth) (FW Act) has prohibited workplace discrimination based on pregnancy and family or carer’s responsibilities7 and the Act gives employees additional entitlements relating to their parental and caring responsibilities. Male and female employees who are the primary caregiver for a child are entitled to 12 months unpaid parental leave upon the birth or adoption of the child and can request an additional 12 months leave.8 Upon returning to work, they can request flexible working conditions9 and they are protected from adverse action, such as dismissal, for exercising these rights.10 Yet despite these legal protections, the findings of the national review show that employees continue to experience discrimination during pregnancy, when taking parental leave and upon re-entering the workforce. This note presents the main findings from the surveys and consultations that were held with employers and employees as part of the review and the review’s recommendations for addressing the prevalence of what it terms ‘pregnancy/return to work discrimination’.

A prospective cohort study of antipsychotic medications in pregnancy: the first 147 pregnancies and 100 one year old babies

BACKGROUND: Many women diagnosed with varying psychiatric disorders take antipsychotic medications during pregnancy. The safety of antipsychotic medications in pregnancy is largely unknown.

METHODS: We established the National Register of Antipsychotic Medications in Pregnancy in 2005. Women who are pregnant and taking an antipsychotic medication are interviewed every 6 weeks during pregnancy and then followed until their babies are one year old. The baby's progress is closely followed for the first year of life.

FINDINGS: As of April 18 2012, 147 pregnancies had been followed through to completion. There were 142 live births and data is available for 100 one year old babies. 18% of babies were born preterm, with a higher dose of antipsychotic medication correlating to an increased likelihood of premature delivery; 43% of babies required special care nursery or intensive care after birth; 37% had any degree of respiratory distress and 15% of babies developed withdrawal symptoms. Congenital anomalies were seen in eight babies. Most pregnancies resulted in the birth of live, healthy babies. The use of mood stabilisers or higher doses of antipsychotics during pregnancy increased the likelihood of babies experiencing respiratory distress or admission to Special Care Nursery or Neonatal Intensive Care Units.

CONCLUSION: There is a great need for safety and efficacy information about the use of antipsychotic medications in pregnancy. Live, healthy babies are the most common outcome following the use of antipsychotic medication in pregnancy, but clinicians should be particularly mindful of neonatal problems such as respiratory distress.

"If you can have one glass of wine now and then, why are you denying that to a woman with no evidence": Knowledge and practices of health professionals concerning alcohol consumption during pregnancy.

BACKGROUND: Alcohol consumption during pregnancy has the potential to cause significant harm to the foetus and the current Australian guidelines state that it is safest not to drink alcohol while pregnant. However, conflicting messages often appear in the media and it is unclear if the message to avoid alcohol is being effectively conveyed to pregnant women. AIMS: This research aims to explore the advice that health professionals provide to pregnant women about alcohol consumption; the knowledge of health professionals regarding the effects of alcohol consumption; and their consistency with following the Australian guidelines. METHODS: Ten semi-structured face to face interviews were conducted with health professionals who regularly provide antenatal care. These include midwives, obstetricians, and shared care general practitioners. A six-stage thematic analysis framework was used to analyse the interview data in a systematic way to ensure rigour and transparency. The analysis involved coding data extracts, followed by identifying the major themes. FINDINGS: Health professionals displayed adequate knowledge that alcohol can cause physical and mental difficulties that are lifelong; however, knowledge of the term FASD and the broad spectrum of difficulties associated with alcohol consumption during pregnancy was limited. Although health professionals were willing to discuss alcohol with pregnant women, many did not make this a routine part of practice, and several concerning judgements were noted. CONCLUSION: Communication between health professionals and pregnant women needs to be improved to ensure that accurate information about alcohol use in pregnancy is being provided. Further, it is important to ensure that the national guidelines are being supported by health professionals.