Abstract
BackgroundProviders need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; however, health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care.ObjectiveTo identify studies that involved the obstetric provider in interventions for either the perinatal management of obesity and/or gestational weight gain in a systematic review.Search strategyA keyword search of databases was performed up to April 2017.Selection criteriaObstetric providers who participated in an intervention with the aim to change a provider’s clinical practice, knowledge, and/or satisfaction with the intervention in relation to the perinatal management of obesity or gestational weight gain were included. Provider intervention could include training or education, changes in systems or organization of care, or resources to support practice. PROSPERO database #42016038921.Data collection and analysisBias was assessed according to the validated Mixed Methods Appraisal Tool. The following variables were synthesized: study location and setting, provider and patient characteristics, intervention features, outcomes and efficacy, and strengths and weakness.Main resultsOf the 6,821 abstracts screened, seven studies (4 quantitative, 3 mixed-methods) with a total of 335 providers met the inclusion criteria; two of which focused on the management of obesity, three focused on gestational weight gain, and two focused on both topics. Interventions that incorporated motivational interviewing skills (n = 2), required additional training for the research study and addressed specific knowledge deficits such as nutrition and exercise (n = 3), and interfaced with the electronic medical record (n = 1) demonstrated the greatest impact on provider outcomes. Provider reported satisfaction scores were generally favorable, but none addressed provider-level efficacy in practice change.ConclusionsGiven the limited number of studies, varying range of provider participation, and lack of provider-level efficacy, further evaluation of provider training and involvement in interventions for perinatal obesity or gestational weight gain is indicated to determine best practices for provider and patient outcomes.
Highlights
[6] prenatal care providers do not consistently follow these recommendations, especially as it pertains to gestational weight gain counseling. [7,8,9] In one study of 58 providers from a multi-specialty obstetrical practice in Massachusetts, only 26% of providers routinely ordered glucose tolerance testing during the first trimester, 14% referred patients to a nutritionist, and 3% planned for an anesthesia referral for their obese patients
[12] To highlight the role of the provider in gestational weight gain counseling, a systematic review and meta-analysis of health behavior interventions for overweight or obese women found that nutrition and exercise counseling delivered by prenatal care providers had greater reductions in gestational weight gain compared to interventions delivered by other members of the health care team or research staff
The objective of this study was to perform a systematic review of the literature to identify studies that targeted the obstetric provider in interventions that focused either on the perinatal management of obesity and/or gestational weight gain
Summary
The morbidity associated with obesity is magnified in pregnancy, as the risk for pregnancyrelated hypertension and diabetes, cesarean delivery, birth defects, abnormal fetal growth, and stillbirth all increase. [1] Among obese women, a gestational weight gain of 11–20 pounds, as recommended in the 2009 National Academy of Medicine guidelines, can improve short- and long-term maternal and neonatal outcomes; yet, up to 60% of obese women exceed these gestational weight gain guidelines and they are at risk for cesarean deliveries, largefor-gestational-age infants, and postpartum weight retention. [2] women of all body mass index categories encounter excess morbidity including cesarean deliveries and macrosomia when gestational weight gain is excessive. [3, 4]Several national organizations recommend that prenatal care providers counsel obese women about the risks of obesity in pregnancy, and incorporate into their care early screening for gestational diabetes, diet and exercise counseling, and anesthesia consults for women with obstructive sleep apnea. [5] The Association of Women’s Health, Obstetric and Neonatal Nurses recommends to counsel women on the risks of obesity in pregnancy and to provide an interdisciplinary team of experts who promote healthy behaviors during their prenatal care. [6] prenatal care providers do not consistently follow these recommendations, especially as it pertains to gestational weight gain counseling. [7,8,9] In one study of 58 providers from a multi-specialty obstetrical practice in Massachusetts, only 26% of providers routinely ordered glucose tolerance testing during the first trimester, 14% referred patients to a nutritionist, and 3% planned for an anesthesia referral for their obese patients. [10] A crosssectional survey of 900 members of the American College of Obstetricians and Gynecologists revealed that 42% of obstetrician-gynecologists counseled pregnant women about gestational weight gain “most of the time” and only 36% modified their recommendations for gestational weight gain based on a woman’s pre-pregnancy body mass index. [11]providers may inadvertently contribute to inappropriate gestational weight gain when their advice differs from the recommendations. [7] In focus group studies of 52 obstetric providers from the San Francisco Bay Area, a nurse practitioner intentionally told women to Provider interventions obesity weight review gain more than the recommendations so women didn’t feel as though they failed when they had excessive gestational weight gain. [5] The Association of Women’s Health, Obstetric and Neonatal Nurses recommends to counsel women on the risks of obesity in pregnancy and to provide an interdisciplinary team of experts who promote healthy behaviors during their prenatal care. [12] To highlight the role of the provider in gestational weight gain counseling, a systematic review and meta-analysis of health behavior interventions for overweight or obese women found that nutrition and exercise counseling delivered by prenatal care providers (e.g., physicians or midwives) had greater reductions in gestational weight gain compared to interventions delivered by other members of the health care team or research staff. The research questions for this systematic review were: (1) Are there education programs or interventions for obstetric providers that focus on the perinatal management of obesity and/or meeting gestational weight gain goals? Providers need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care
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