Stephanie Mattfeld Beaudette M.Ed., RD Project Coordinator Colorado Department of Public Health & Environment Prevention Services Division / Women’s Health Section

Colorado & Low Birth Weight Colorado has one of the highest low birth weight rates in the nation. High Altitude States 2002 LBW rates Colorado 8.9% Oregon 5.8% Washington 5.9% Utah 6.4% Healthy People 2010 Goal is 5%

Inadequate Maternal Weight Gain in Colorado One out of every four Colorado women gains less than the recommended amount of weight during pregnancy In Colorado, more low birth weight babies are born to mothers who do not gain weight adequately than to mothers who smoke Inadequate weight gain is modifiable with intervention! One in five women is underweight at conception This factor is modifiable with counseling. The Prenatal Plus program has had a high degree of success in dealing with this risk and in essence fixing it. (70%) One in 4 women gains inadequately; 1 in 11 women smokes; smoking is a more serious risk but there are far more women who gain inadequately.

Body Mass Index (BMI) Total weight gain Institute of Medicine’s Recommended Ranges for Total Pregnancy Weight Gain Body Mass Index (BMI) Total weight gain Low BMI (<19.8) 28-40 pounds Normal BMI (19.8-26) 25-35 pounds High BMI (26-29) 15-25 pounds Obese BMI (>29) 15 pounds Twins (any BMI) 35-45 pounds *Based on pre-pregnancy weight & height IOM guidelines are based on studies of antepartal weight gain in large groups of women in order to achieve optimal birth outcomes

How did we figure this out? How do we know that inadequate weight gain is so important in Colorado? Isn’t the main problem the high altitude? After altitude, isn’t the main problem smoking? Turn over to Sue.

Sue explains about altitude—does have an impact, but all Colorado births are high altitude—difficult to figure out. If Colorado were flattened to sea level, we’d only be in the middle of the low birth weight ranking for states. WE don’t do very much to improve our rate. We have one of the worst first trimester care rates in the nation. Only 6 states have lower rates than we do. Is NOT modifiable. BECAUSE we are a high altitude state we must address those things that we can change.

Tipping the Scales:Weighing in on Solutions to the Low Birth Weight Problem in Colorado Analyzed all 166,191 births to residents in 1995-1997; results reported in 2000 PAR analysis combines the prevalence of a condition (e.g.. smoking) with the severity of the condition (smoking doubles the risk of LBW) PAR analysis yields a percentage that describes how much of the LBW rate can be “attributed” to a given risk http://www.cdphe.state.co.us/ps/mch/mchadmin/tippingthescales.pdf We did the work.

Top Population Attributable Risks (PAR) Multiple gestation Among singleton births: # 1 Inadequate Weight Gain PAR 12.8% # 2 Maternal Smoking PAR 11.9% # 3 PROM PAR 9.1% # 16 Altitude >10,000 feet PAR 0.8% Inadequate Wt. Gain and/or Smoking PAR 34.4% We got the answers. Multiples contribute 20 percent of all the LBW births. One in LBW babies is a multiple. It used to be 1 in 8. Big change. Addressing the increase in multiples was considered difficult to tackle. Issues of ART. 4 out of 5 LBWs are singletons. Turned our attention to these. 97% of all births are singleton births. IWG was the biggest factor. 12.8 percent does not sound like much, but it is 1 in 8. One out of every eight LBW births is simply because the mother did not gain adequately. Smoking was second. Ten years ago, it would have been first, but we have made big strides. The proportion of women smoking while pregnant has dropped from 18.0 in 1990 to 8.2% in 2002. PROM is a big problem that no one has figured out yet. The March of Dimes has started a 5-year Prematurity Campaign to find out the reasons and educate the public. Very high altitude contributes little to LBW in the state. The combination of inadequate weight gain and smoking is powerful and increases the risk of LBW a great deal. One out of every 3 LBW babies is in the low weight category because of IWG or smoking or both.

Campaign Purpose & Goals To decrease the number of pregnant women in Colorado who gain an inadequate amount of weight during pregnancy.  To decrease the number of low birth weight births in Colorado due to inadequate prenatal weight gain.

Campaign Process Initial consumer and provider Focus groups Advertising agency selected Materials created, tested And revised Campaign promotion & next steps!

Campaign Efforts Provider training and education Campaign materials Combined BMI/gestational wheel Chart-ready weight gain grids BMI wall chart Provider pocket counseling card Patient brochures/posters in English and Spanish Web site coming this Fall! Consumer campaign in 2005

How to implement the campaign in your agency Add prenatal weight gain grid to all new OB charts Include patient education brochure in all new OB education packets Display campaign posters in waiting and exam rooms Post BMI cut-off chart by scale or in exam room

Practice Recommendations Determine woman’s BMI category Advise woman of weight gain recommendations for her BMI category Plot weight gain at each visit on prenatal weight gain grid Monitor weight gain trends Counsel and refer as appropriate

The 5 A’s for Prenatal Weight Gain Counseling ASK: what are her weight gain goals/concerns ASSESS: BMI determination and plotting on grid ADVISE: provide strong, clear, personalized weight gain information based on BMI category ASSIST: problem solve and educate on components of weight gain ARRANGE: referrals as appropriate

Combined BMI calculator / gestational wheel BMI assessment and corresponding weight gain recommendations provided on wheel

Prenatal Weight Gain Grid Graphic depiction of weight gain makes weight gain trends much clearer Grid lines represent minimum weight gain Good education tool to use with women gaining outside IOM guidelines (above or below) Ask about and record patient height and pre-pregnancy weight to determine an appropriate BMI category. Plot first trimester weight on grid and each subsequent visit on the grid. Overall goal is to look for trends! Any significant changes in weight should be evaluated for accuracy. Patient may be receptive to viewing or receiving a copy of the weight gain grid to help facilitate appropriate weight gain. Women gaining inadequately may find comfort in seeing where their weight should be and that it is normal to gain at the recommended rate. Women gaining excessively can also benefit from seeing where they are currently and where they will be if rate of weight gain continues. Current CO weight gain grids only outline MINIMUM weight gain lines. Awaiting BMI specific grids that are likely to be published and adopted by WIC in the next few months. Since women are categorized into 3 weight gain tracks, use of the grid allows for easier identification of inappropriate weight gain compared to assuming all women need to gain X pounds by 20 or 32 weeks. If pre-pregnancy weight is unknown, or women is late entry to care, assess current weight and height, plot according to that BMI category and corresponding line and watch for trends. Most women will not change an entire BMI category (I.e. if they were a high BMI during pregnancy, they were most likely a high BMI pre-pregnancy)

Body Mass Index (BMI) Wall Chart BMI cut off chart: In addition to the gestational/BMI wheel, providers can post this chart by the scale or in the exam room as a quick reference chart.

Patient Education Brochure

For more information contact: Stephanie Beaudette R.D.,M.Ed. at 303-692-2487 or stephanie.beaudette@state.co.us CDPHE-Prevention Services Division Women’s Health Section 4300 Cherry Creek Drive South Denver, CO 80246-1530