Pregnancy provides an exciting opportunity to influence positive lifestyle changes. The multiple contacts with health care professionals in this period offer a unique opportunity to facilitate behaviour change.
Strategies such as smoking cessation are widespread amongst everyday practice. Despite published evidence relating to the positive impact of physical activity during pregnancy , this lifestyle advice receives less attention.
The maternity pathway endeavoured to change this and there was considerable enthusiasm to integrate physical activity into every patient encounter along their journey.
Maternity Pathway Overview
Interventions were designed and mapped to influence patient care from the initial booking appointment to women who develop gestational diabetes in the third trimester.
The Physical Activity Calculator, a modified version of the exercise vital sign (1, 2), was designed and incorporated into the electronic record system used at the 10-12-week maternity booking appointment. This was felt to be an early opportunity to assess and provide brief advice on physical activity, with the aim of positively impacting on the pregnant woman’s physical activity behaviour during pregnancy and beyond childbirth.
For all women attending this appointment, this system prompt was built into the existing online booking form. It prompted midwives to ask about women’s physical activity levels and give brief advice with our Physical Activity During Pregnancy patient information leaflet. Women, partners and family members are often motivated at this time to make lifestyle changes and there is increasing evidence that being active early in pregnancy is associated with improve pregnancy health (3).
Physical activity levels are assessed and coded into three categories with a brief advice prompt given depending on women physical activity levels. The three categories are:
(1) Green (more than 150 minutes/week)
(2) Amber (30-150 minutes/week)
(3) Red (less than 30 minutes/week).
Brief advice, in the form of a 1 minute conversation, was given depending on physical activity levels.
This tool aimed to ensure physical activity advice was delivered to all women at this early appointment. It identified those women not meeting the aerobic component of the CMO Physical Activity in pregnancy recommendations, so that this can then be flagged and explored again in further appointments.
A supplementary PAC guidance resource was developed to support maternity health care professionals with these new changes, and was circulated at the tools launch. It was made available on the Trust intranet.
Coleman, K.J., et al., Initial validation of an exercise “vital sign” in electronic medical records. Med Sci Sports Exerc, 2012. 44(11): p. 2071-6.
Sallis R, Franklin B, Joy L, et al. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis 2015;57:375–86.
Catov, J.M., et al., Patterns of leisure-time physical activity across pregnancy and adverse pregnancy outcomes. Int J Behav Nutr Phys Act, 2018. 15(1): p. 68.
These resources were designed to encourage pregnant women and provide key messages aimed at starting to change the social culture surrounding physical activity. They provide relevant positive advice regarding the benefits of activity and demonstrate ways to build activity into daily life. They also aim to reduce barriers and develop a positive environment where patients can freely discuss being active and express concerns.
We made a promotional film (see above). The film showcases the benefits of activity and encourages all women to be active throughout their pregnancy. It was shared across the Trust and community teams.
At the OUHFT Women centre, there was a focus on the Level 3 ultrasound department, as these appointments were the most frequently attended. The film is now shown on the waiting room screen. A range of specific Moving Medicine promotional posters are displayed on the department’s notice boards with bespoke patient information leaflets containing the latest evidence and messages available for collection.
Here is one of the posters:
Many healthcare professionals lack the confidence, knowledge and resources to deliver appropriate physical activity advice to women. They feel under-resourced, uncertain regarding safety concerns and inadequately trained(1). Consequently, despite being receptive to physical activity advice, pregnant women receive inconsistent, vague and conflicting guidance(2). As staff have multiple contacts with women during pregnancy, supporting staff educating and training provides an opportunity to positively influence patient care.
A compact Moving Medicine face-to-face training program for Maternity Health care professionals was developed. It is based upon the latest CMO Physical Activity recommendations for Pregnant Women and the use of communication techniques (grounded on motivational interviewing themes) to deliver brief advice. If you would like further information about this please contact us at firstname.lastname@example.org
All staff received a CPD certificate and an ‘active pregnancy’ badge to show they had completed the training. This generated discussions amongst staff and patients helping to change culture and promote activity.
The aim of the session is to give staff more confidence and clarity when discussing physical activity. This package has a pre- and post-session evaluation. There are three training packages available dependent on duration ranging from 20 minutes to 1 hour which include specific role play scenarios.
Staff complete a baseline and two week follow up questionnaire to evaluate the impact of the training. In addition, in order to communicate messages and project developments, a bimonthly newsletter was circulated to all staff. An example of a newsletter can be found here:
To complement this learning and improve its transferability and sustainability, many maternity staff have enrolled in the Moving Medicine Active Conversations course. This mentored learning programme involves 16 hours of supported learning ensuring all staff have the opportunity to learn and develop communication skills to enhance physical activity conversations.
- Brown MJ, S.M., Liddle D, Hill AJ, and M.E. Stockdale J, Motivating pregnant women to eat healthily and engage in physical activity for weight management: an exploration of routine midwife instruction. Evidence Based Midwifery, 2013. 11(4): p. 120-127.
- Weir, Z., et al., Physical activity in pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women. BMC Pregnancy Childbirth, 2010. 10: p. 18.
Controlling blood glucose levels is fundamental to the management of Gestational Diabetes Mellitus (GDM). Regular physical activity has been shown to improve glycaemic control.
A new patient pathway was developed for those with gestational diabetes. Integrated into their usual clinic visit, physical activity has been incorporated into a patient education session and women are also offered a 20 minutes Active Conversation with our specifically trained midwife Physical Activity Champion.
During the conversation, women have an opportunity to consider setting goals to use activity to help manage their blood sugar control. Bespoke resources have been developed including a patient workbook and specific patient leaflets; Physical Activity During Pregnancy and Gestational Diabetes and Physical Activity Leaflet. Women can be linked to our community navigator who holds a catalogue of available activities in their local area.
As with the booking appointment, the Physical Activity Calculator was used to evaluate self-reported aerobic activity levels at baseline and then at a two-week follow up by telephone.
It is planned to transfer this model to other high-risk groups and use a successful grant application to integrate physical activity into a gestational diabetes app.
High level and senior support for development and integration of interventions within the patient journey is important to building change within a hospital outpatient environment.
We liaised closely throughout with senior figures throughout the design, delivery and maintenance phases of this pathway.
We maintained a presence on the maternity departmental governance meetings to ensure full integration of interventions within a robust governance framework.
Assistance and support to staff was provided throughout the educational program and integration of the Physical Activity Calculator within the Electronic patient record booking system.
The Physical Activity Champion was available to support and assist midwives with the changes, a guide to the EPR PAC to support maternity health care professionals with these new changes was provided and a regular Newsletter was circulated to all staff.
A community navigator was appointed to work 1.5 days per week on the Active Hospital pilot across all our clinical pathways. They provided one-to-one consultations with patients as well as providing advice and guidance to staff on where to find support for patients in the community. Their role was critical to ensure continuity of care through hospital admission to discharge to community environment.
A bespoke online maternity specific map was created to assist midwives with signposting patients to support and help in the community to maintain their physical activity.
Our Physical Activity Champion was employed for one day per week to work on the maternity pathway. The clinical champion was critical to the success of the project, and when recruiting we were looking for an enthusiastic, innovative and experienced professional with outstanding leadership and interpersonal skills.
The role included opportunities to develop clinical skills in behavioural change counselling and exercise medicine as well as develop managerial skills such as education, systems review and leadership.
As well as Trust induction, our Physical Activity Champion was given an induction to the Active Hospital project. – we developed an Active Hospitals Staff Induction document to help them with the induction process. They received training in motivational interview techniques from the central active hospital team, as well as completing the online Active Conversations course to consolidate learning further.
In this section you will find some of the outcomes from the pathway.
Are Pregnant Women Meeting the National Physical Activity Recommendations at their Booking Appointment?
Following the integration of the Physical Activity Calculator into the booking appointment system physical activity levels are being discussed and recorded at every maternity booking appointment across this Trust.
6,356 women have been assessed (up to June 2019). Mean Age 30.8y (14-54y), mean Booking Weight 73.6kg (32.9-160kg), mean BMI 25.9kg/m2 (11.5-60.89kg/m2).
There is a significant association between increased BMI & lower levels of physical activity. Women with BMI ≥30kg/m2 were associated with lower self-reported physical activity levels. There was no significant association between physical activity & age less than or more than 30 years old.
Less than 2/3 women met the recommended physical activity levels – 1 in 8 women were very inactive.
This information helps identity those who may benefit from conversations about physical activity during their multiple antenatal contacts with healthcare professionals.
Does a compact training package delivered to maternity staff build knowledge and confidence when providing brief physical activity advice to pregnant women?
The training package was based upon the latest Chief Medical Officers PA recommendations for pregnant women. It focused on the use of communication techniques (based on motivational interviewing themes).
69% of delegates were Midwives, with the majority (82%) having not previously received any formal physical activity training. Immediate feedback from the session found that delegates felt the session was relevant, met learning needs and would impact on their clinical practice. The training results can be seen in the table below.
Key message: Delivering a compact physical activity training package improves MHCPs self reported confidence to discuss PA and increases PA discussions.
Integrating Motivational Interviewing into Clinical Care to Increase Physical Activity Levels in Women with Gestational Diabetes
As an adjunct to their normal care, women with a diagnosis of GDM were invited to engage in a 20 minute individual MI session on PA, delivered by a trained midwife, during their first outpatient appointment. This included goal setting and activity planning. A modified version of the exercise vital sign (1) was used to record self-reported PA levels (moderate intensity or greater) at baseline, and at 2-week telephone follow-up.
62 women were assessed, mean age 31.7y (21-43y); mean gestation 27+5/40 weeks (9-36+4/40); mean BMI 29.9kg/m2 (18.3-48.2kg/m2). There was a significant increase in physical activity after motivational interview (p<0.001), reflecting an increase in the average physical activity of the post-MI cohort to meet national guidance. 30.6% of women were very inactive at baseline, compared to 4.8% after the motivational interview.
Since incorporation into routine clinical care for women with GDM, this motivational interviewing intervention has been associated with a significant increase in self-reported PA at 2-week follow-up. Further work is now required to examine the impact on glycaemic control, maternal & fetal outcomes, and maintenance of PA levels.
‘I found goal setting supportive and the 2-week telephone call gave me drive to be active’
‘I used activity to help on blood sugar control level and haven’t need to go onto medication’
Click on the numbers below for some tips from our Active Hospital team
Seek the support of a senior Consultant working within the department and attend the local governance meetings. Support of the pathway from the department is vital for service development. Attending governance meetings helps to share and discuss information with departmental leads. We found our public health midwifes a great source of support.
Think about how you will evaluate/assess every intervention you put in place. It is key to be able show the changes your intervention has made and can help to prove the value of the service.
Most healthcare professionals believe it is within their role to deliver physical activity related messages and that it plays a key part of patient care. They need support to develop the knowledge and skills to utilise resources which will help them to approach and communicate effectively with pregnant women.
The introduction of the Physical Activity Calculator at the 10-12 week booking appointment (system prompt) generated a increase in contacts and brief advice. Once it had been set up, this model is sustainable. However, designers must be aware of the possible delays in Trust IT systems and the necessity to work closely with your department lead.
If you are proposing any significant system changes, this will require support and education with additional resources. The changes need to be communicated effectively. This worked well in this pathway as the education programme complements these changes and was made relevant to daily practice. There was a delay where some staff had not received the full teaching prior to new system changes. This caused some anxiety amongst staff. Advertising and communicating change is important to ensure staff understand why they are discussing physical activity.