The joy of life

January/February 2017

FocusThe joy of life

Enjoying a healthy pregnancy: GPs’ essential role in health promotion

Volume 46, No.1, January/February 2017 Pages 20-25

Jacqueline Frayne

Yvonne Hauck

Background

For many women, a major pregnancy goal is to achieve an enjoyable, healthy pregnancy. The continuum of care from preconception counselling, management of early pregnancy, referral or continued pregnancy care and management into the postpartum period places general practitioners (GPs) in a unique position to meaningfully contribute on many levels to this realisation.

Objective/s

The aim of this article is to explore the determinants of a healthy and enjoyable pregnancy, and asks how GPs can facilitate an optimum experience for women in pregnancy, regardless of risk.

Discussion

GPs can play a key role with prospective parents in health promotion, directing them to appropriate resources and services; addressing disease prevention by targeting modifiable lifestyle risks; and managing chronic health concerns in the optimisation of pregnancy care.

Pregnancy is a time of change, and the transition to parenthood can be challenging; however, for many parents, it can be an immensely enjoyable experience. The majority of pregnancies are unplanned, with 51% of pregnancies reported as unintended,1 and not all pregnancies are healthy or low risk. Optimum maternal health during preconception and pregnancy is recognised as an essential component to the outcome of the pregnancy and may have a potentially lifelong impact on infant wellbeing.2

Good health is a central determinant of happiness, but it is not the only important factor. Health as it is self-perceived is a relative concept, and is expressed by our world view and our place in it. Poorer self-rated health is associated with poorer physical health and health behaviours (eg smoking, obesity), and greater psychological distress.3 Self-rated health may be a useful screening tool in recognising women who are at potential risk.

In today’s world, we are challenged by time restraints and information overload. Disseminating appropriate health education requires a delicate balance between giving too much or too little information. Managing information can be a major source of anxiety,4 and anxiety in pregnancy is considered to be more prevalent than depression, with estimates of 6.6–21.7%.5 Additionally, the rapid increase in internet use and accessing health information online, and with smartphone applications, (apps) increases the potential for information overload. Health information is cited as a common reason for use of the internet and apps, and some of the information accessed may have reduced evidence-based content.6

General practitioners and health promotion

General practitioners (GPs) are ideally placed to implement effective health promotion, and there is no better time than during discussions around pregnancy to achieve this. Pregnancy can be a perfect time, where women are engaged with health services and may be receptive to changes that can improve health outcomes for their unborn child, especially if the changes are perceived to be normal pregnancy behaviours.7

In order to capitalise on this opportunity for effective health change, we need to reconsider the concept of health promotion. As defined by the World Health Organization (WHO), health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health.8 For many, this means disease prevention or risk reduction, particularly in the area of lifestyle risks, where people assess and consciously choose behaviours on the basis of their relationship to promoting or maintaining health.

Another innovative way of approaching health is based on Antonovsky’s salutogenic theory, which derives its concept from studying the strengths and weaknesses of preventive practices in the complex system that is a human.9 The framework of this theory uses the analogy of a river:

  • curative medicine tries to save people from drowning
  • health prevention attempts to stop people from being pushed into the river
  • health promotion attempts to give people the skills to swim.

This theory could be applied to the concept of preparing and supporting parents to ‘enjoy a healthy pregnancy’. We need to ask what we as GPs can do to help those with chronic health issues to reduce the risks associated with pregnancy, and better prepare women to cope with the issues that can arise in pregnancy. Preconception counselling, reducing lifestyle risks and coping with common minor issues of pregnancy will be discussed in this article. This will include strategies that GPs may consider when translating health promotion into supporting clients to enjoy a healthy pregnancy.

Preconception counselling

Primary care physicians are well placed in the continuum of care for women of reproductive age to initiate preconception counselling around recognised modifiable risk factors. Discussions on reproductive planning, chronic health concerns, medication adjustment, risk reduction for lifestyle factors, and identifying issues around a woman’s health literacy, coping mechanisms and support structures are all relevant topics for a GP to introduce.

Pregnancy planning and timing are significantly associated with maternal psychiatric morbidity, psychological distress and poor social support during pregnancy, with the most important predictor being timing of pregnancy.10 The idea of reproductive planning or identifying a woman’s childbearing goals becomes important when trying to optimise her ability to enjoy a healthy pregnancy.

Management of chronic medical conditions is crucial for proper preconception care (Table 1), as is counselling around supplements (Table 2), weight management or reduction, assessing immunisation status, lifestyle risks and mental health.

 

Table 1. Medical conditions in pregnancy

Condition

Prevalence in pregnancy

Risk assessment

Recommendations

Diabetes mellitus

(type 1, type 2, gestational)

7.5%22

Hb1Ac (%)

Risk of congenital abnormalities, miscarriage, perinatal mortality with increased levels

Preconception counselling, including diet and exercise advice

Early assessment endocrinology review 
(type 1, type 2)

Early referral to dietitian

Cardiac disease

0.2–4%23

Risk assessment

Classification of disease

Physical examination/blood pressure

Full blood profile/iron studies

ECG, echocardiogram

Fetal echocardiogram if maternal structural cardiac disease23

Preconception counselling

Early assessment

Cardiology review

Anaemia prevention23

VTE

Thrombophilias

Overall, 2 per 1000 pregnancies24

Previous VTE (24.8%)

Consider risk factors when deciding on prophylaxis

Thrombophilia screen if not already undertaken in high-risk women

Preconception counselling

Thrombophrophylaxis planning (postnatal +/– antenatal; eg low-molecular-weight heparin)

Consider haematology review

Previous bariatric surgery

Increasing trend

Check vitamins D and B12, iron, folate, calcium, and micronutrient status15

Pregnancy is best avoided for 12–24 months to reduce the potential risk of intrauterine growth retardation15

Consider addition supplementation

Dietary review

Thyroid conditions

Overt hypothyroidism: 0.3–0.5%

Subclinical:

2–3%25

Targeted testing of thyroid function tests

Thyroid autoantibodies

Maintain thyroid-stimulating hormone <2.5 mIU/L in first trimester25

May require endocrinology review if difficult to control or hyperthyroidism

No recommendation for routine screening25

Hypertension

0.01%22

Renal function, including eGFR

urinary ACR

Medication review

Switch to medications safe in pregnancy such as labetalol and methyldopa

Hepatitis B and C

Chronic hepatitis B in pregnancy 0.7%26

Liver function tests

Hepatitis status including RNA viral count +/– genome in hepatitis C if not done

Consider hepatology referral, may need prophylactic agent in third trimester for hepatitis B if viral load is >106 log copies/mL (200,000 IU/mL) or higher27

Newer treatments for hepatitis C prior/post pregnancy only

Epilepsy

0.01%22

History of seizure disorder

Medication review

Sodium valproate not recommended in pregnancy

Neurology review

Mental health disorder

Anxiety: 21.7%5

Risk–benefit counselling regarding all psychotropic medication

Consider psychiatric review for severe illness

Consider 5 mg folic acid if on mood stabiliser medication

ECG, electrocardiogram; eGFR, estimated glomerular filtration rate, HBA1c, glycated haemoglobin; ACR, albumin to creatinine ratio; VTE, venous thromboembolism 

 

Table 2. Recommended supplements in pregnancy28

Supplement

Recommendation

Evidence

Folic acid

At least 0.4 mg daily to aid prevention of neural tube defect

High dose 5 mg of folic acid recommended in the below high risk groups:

  • Taking anticonvulsant medication
  • Pre-pregnancy diabetes
  • Previous child or family history of neural tube defect
  • Body mass index >30 kg/m2
  • Risk of malabsorption syndrome
  • Family history of congenital heart disease
  • Hyperhomoscystinaemia (eg MTFHR mutations)
  • Multiple pregnancy

One month before conception and for the first 12 weeks reduces the risk of neural tube defect and possibly congenital heart disease

Vitamin B12

Vegetarians and vegans can be at risk of vitamin B12 deficiencies

Recommended daily intake: 2.6 µg/day in pregnancy

Untreated vitamin B12 deficiencies have been reported to cause neurological sequelae in exclusively breastfed infants29

Vitamin D

Women with vitamin D levels >50 nmol/L should take 400 IU daily

Those at risk of deficiency may need to be investigated and treated as appropriate:

  • Reduced sun exposure
  • Veiled women
  • Dark-skinned women
  • Body mass index >30 kg/m2
  • Treatment recommended:

30–50 nmol/L of 1000 IU per day

<30 nmol/L of 2000 IU per day and retest in six weeks

Low maternal vitamin D is associated with low neonatal vitamin D, which can be associated with impaired skeletal development and hypocalcaemic seizures

Calcium

Recommended dietary intake of calcium per day for pregnant women is 1300 mg (aged 14–18 years) and 1000 mg (aged 19–50 years)

Supplement at 1000 mg/day for those with low intake or high risk of preeclampsia

Reduces the incidence of hypertensive disorders and preterm labour

Iron

Routine iron replacement is not recommended for every pregnancy. Haemoglobin should be routinely checked and anaemia investigated in early pregnancy and at 28 weeks

Women with iron deficiency will need replacement with at least 60 mg of iron daily

Iron deficiency anaemia increases the risk of preterm delivery and low-birth weight

Iodine

Recommended iodine supplement of 150 μg each day

Can cause subclinical hypothyroidism and cause cognitive and neurological development in offspring30,31

 

Lifestyle risk reduction

Smoking in pregnancy has decreased in Australia, but still occurs in 12% of women.11 Women in particular risk groups, such as younger women (<20 years of age), those living in regional or remote regions, those from socially and economically disadvantaged backgrounds, Aboriginal and Torres Strait Islander women, and women with an enduring mental health diagnosis, continue to have high rates of smoking.11,12 These groups require special consideration and targeted strategies to effectively reduce smoking rates. Nicotine replacement therapy can be effective and is offered, but women also need to feel supported in their attempts to quit. Women are aware of the health risks of smoking and may feel guilt and shame when they relapse,13 resulting in non-disclosure around continuing to smoke. Resources such as Quit for you/Quit for two, which consists of a free smartphone mobile phone app, can be an engaging and valuable resource (Table 3).

 

Table 3. Australian e-resources28

Area and site

Information/resource

Development

Smoking

www.quitnow.gov.au/internet/quitnow/publishingcp.nsf/content/home

Website

Free smartphone application: Quit for you/quit for two

Brochure

Department of Health and Ageing

Nutrition and weight gain

www.eatforhealth.gov.au

www.eatforhealth.gov.au/sites/default/files/files/the_guidelines/n55h_healthy_eating_during_pregnancy.pdf

Website

Brochure

Australian government

National Health and Medical Research Council

Pregnancy and parenting

http://raisingchildren.net.au/pregnancy/pregnancy_and_birth.html

Website with information on:

  • Pregnancy and birth
  • Week by week
  • Health and wellbeing
  • Dad’s guide
  • Preparing for a baby

Created by a partnership of Australia’s leading early childhood agencies and the Australian government

Pregnancy and parenting

www.pregnancybirthbaby.org.au

Website with information on:

  • Pregnancy
  • Birth
  • Baby
  • Child

healthdirect and Australian government

Parenting

www.whatwerewethinking.org.au

Website

Free smartphone application: What Were We Thinking

Jean Hailes Foundation

Pelvic floor/incontinence issues

www.pelvicfloorfirst.org.au/pages/exercising-during-pregnancy.html

Website with exercise information

Free smartphone application: Pelvic Floor First

Continence Foundation of Australia

Mental Health

www.mindthebump.org.au

www.beyondblue.org.au/the-facts/pregnancy-and-early-parenthood

Free smartphone application: Mind the bump – A mindfulness medication tool for new and expecting mothers/parents

Website

Smiling mind and beyondblue

Dad’s and pregnancy

www.sms4dads.com

Free message service that sends text messages with tips, information and links to other services for new dads: sms4dads

The Family Action Centre at the University of Newcastle

 

Obesity is a challenge in modern obstetrics, with >19% of pregnant women being obese (ie with a body mass index [BMI] >30 kg/m2 measured at the first antenatal visit).11 Many women are unaware of the recommended weight gain during pregnancy and this has consequences not only for the current pregnancy but also for any future pregnancies. For a woman with a normal BMI, the recommended weight gain during pregnancy is 11.5–16kg in total or 0.42 kg/week in the second and third trimester.14 The adverse impact of obesity occurs prior to conception, persists throughout the pregnancy and into the postpartum period, and has a stepwise association with BMI classification.15 Early referral to an appropriate allied health practitioner, such as a dietitian or exercise physiologist, should be considered.

While tackling this issue, it is important to explore concepts of body image with the patient. Simple questioning that addresses their self-perceived satisfaction with body weight or shape could help identify women at risk of experiencing poor body image.16 Obesity can contribute to a less healthy pregnancy, and negatively influence self-esteem and body image during the physical changes of pregnancy, which contribute to increased weight gain.16 Women who are obese have a 32% increased risk of depression. A recent study has shown that for women with high pre-pregnancy BMI, weight gain can increase their depressive symptoms significantly.17 Even in women with normal BMI status, positive body image is highly protective of depressive symptoms.17

Coping with common minor pregnancy issues

Common minor issues can decrease the enjoyment of pregnancy. The most common include musculoskeletal aches and pains, with >50% being lumbar or pelvic girdle pain, with or without pain in the pubic symphysis, ranging from mild to severe.18 These issues may cause significant physical and psychological distress. Evidence-based treatment options to address this issue include physiotherapy, pelvic belts, transcutaneous electrical nerve stimulation, exercise programs to minimise activities that exacerbate pain, simple analgesia (eg paracetamol), acupuncture and yoga.18

Other issues such as nausea, gastro-oesophageal reflux, carpel tunnel syndrome, constipation, haemorrhoids and lack of sleep may affect a pregnant woman’s sense of wellbeing. GPs are well equipped to deal with these physical issues. However, how can we build on the woman’s strengths to contribute to her resilience? Although there is no universal definition of resilience, themes reflecting this concept within a health promotion framework include rising above, adaptation and adjustment.19

In Antonovsky’s salutogenic theory, a sense of coherence is an important contributor to overall health,20 and aligns with the principles of ‘Act, Belong and Commit’, a successful campaign promoted in Western Australian. This campaign encouraged action, belonging to a group or community, and committing to a task to improve personal mental health and wellbeing.21 Encouraging women to engage in the pregnancy, being active in managing their own health and belonging to groups can be beneficial in building resilience and developing positivity, which enhance a person’s ability to manage adverse situations while providing meaning or purpose. An example of this is that GPs can guide expectant parents to credible websites that distribute knowledge in a timely way, and apps that integrate knowledge delivery, allow for social interaction and provide immediate feedback. Furthermore, GPs can link parents to pregnancy groups for support and mental health promotion, and arrange referrals to appropriate exercise regimes and perinatal education.

Conclusions

GPs can play a key role in health promotion with prospective parents, a role that can extend beyond treating chronic health conditions and giving lifestyle or dietary advice. Being able to direct patients to credible resources that offer accurate and engaging information, and connecting them to appropriate support services, may offer the opportunity to develop important skills to cope with challenges they may face across the perinatal period and into early parenting and facilitate enjoyment of pregnancy.

Key points

  • Self-rated health in pregnancy is an important factor.
  • Unintended pregnancy and poor timing of pregnancy may contribute to psychological distress.
  • Preconception counselling should be encouraged to foster optimal pregnancy care.
  • Lifestyle risk reduction is important, but awareness of risks around guilt and shame must be mitigated.
  • Body image and self-esteem are contributors to psychological wellbeing.
  • Coping mechanisms for adjustment to common minor issues in pregnancy may be enhanced through engagement with credible sources (eg interactive media, education, support services).

Authors

Jacqueline Frayne MBBS, DRANZCOG, FRACGP, MMed (Women’s Health), GCIM, GP Obstetrician, Department of Obstetrics and Gynaecology, King Edward Memorial Hospital, Subiaco, WA; Senior Lecturer/PhD candidate, School of Primary, Aboriginal and Rural Health Care, University of Western Australia, WA. Jacqueline.frayne@health.wa.gov.au

Yvonne Hauck BScN, MSc, PhD, Professor of Midwifery, Department of Nursing and Midwifery Education, King Edward Memorial Hospital, Subiaco, WA; School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, WA

Competing interests: None.

Provenance and peer review: Commissioned, externally peer reviewed.

References

  1. Finer LB, Zolna MR. Shifts in intended and unintended pregnancies in the United States, 2001–2008. Am J Public Health 2014;104 Suppl 1:S43–48.
  2. Bird AL, Grant CC, Bandara DK, et al. Maternal health in pregnancy and associations with adverse birth outcomes: Evidence from growing up in New Zealand. Aust N Z J Obstet Gynaecol 2016. [Epub ahead of print].
  3. Christian LM, Iams J, Porter K, Leblebicioglu B. Self-rated health among pregnant women: Associations with objective health indicators, psychological functioning, and serum inflammatory markers. Ann Behav Med 2013;46(3):295–309.
  4. Salanova M, Llorens S, Cifre E. The dark side of technologies: Technostress among users of information and communication technologies. Int J Psychol 2013;48(3):422–36.
  5. Somerville S, Dedman K, Hagan R, et al. The perinatal anxiety screening scale: Development and preliminary validation. Arch Womens Ment Health 2014;17(5):443–54.
  6. Taki S, Campbell KJ, Russell CG, Elliott R, Laws R, Denney-Wilson E. Infant feeding websites and apps: A systematic assessment of quality and content. Interact J Med Res 2015;4(3):e18.
  7. Atkinson L, Shaw R L, Fench DL. Is pregnancy a teachable moment for diet and physical activity behavioural change? An interpretive phenomenological analysis of the experiences of women during their first pregnancy. Br J Health Psychol 2016;21(4):842–58.
  8. World Health Organization. First International Conference on Health Promotion, Ottawa, 21 November 1986. Geneva: WHO, 1986. Available at www.who.int/healthpromotion/conferences/previous/ottawa/en [Accessed 9 August 2016].
  9. Antonovsky A. The salutogenic model as a theory to guide health promotion. Health Promot Int 1996;11(1):11–18.
  10. Gariepy AM, Lundsberg LS, Miller D, Stanwood NL, Yonkers KA. Are pregnancy planning and pregnancy timing associated with maternal psychiatric illness, psychological distress and support during pregnancy? J Affect Disord 2016;205:87–94.
  11. Australian Institute of Health and Welfare. Australia’s mothers and babies 2013 – In brief. Canberra: AIHW, 2015.
  12. Nguyen TN, Faulkner D, Frayne JS, et al. Obstetric and neonatal outcomes of pregnant women with severe mental illness at a specialist antenatal clinic. Med J Aust 2013;199(3 Suppl):S26–29.
  13. Constantine NA, Slater JK, Carroll JA, Antin TM. Smoking cessation, maintenance, and relapse experiences among pregnant and postpartum adolescents: A qualitative analysis. J Adolesc Health 2014;55(2):216–21.
  14. Ball L, Wilkinson S. Nutrition care by general practitioners: Enhancing women’s health during and after pregnancy. Aust Fam Physician 2016;45(8):542–46.
  15. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Management of obesity in pregnancy. East Melbourne, Vic: RANZCOG, 2013. Available at www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/C-Obs_49_Management-of-Obesity-in-Pregnancy-Review-Sep-2013.pdf?ext=.pdf [Accessed 7 November 2016].
  16. Sui Z, Turnbull D, Dodd J. Effect of body image on gestational weight gain in overweight and obese women. Women Birth 2013;26(4):267–72.
  17. Han SY, Brewis AA, Wutich A. Body image mediates the depressive effects of weight gain in new mothers, particularly for women already obese: Evidence from the Norwegian Mother and Child Cohort Study. BMC Public Health 2016;16:664.
  18. Bhardwaj A, Nagandla K. Musculoskeletal symptoms and orthopaedic complications in pregnancy: Pathophysiology, diagnostic approaches and modern management. Postgrad Med J 2014;90(1066):450–60.
  19. Aburn G, Gott M, Hoare K. What is resilience? An integrative review of the empirical literature. J Adv Nurs 2016;72(5):980–1000.
  20. Eriksson M, Lindstrom B. Antonovsky’s sense of coherence scale and the relation with health: A systematic review. J Epidemiol Community Health 2006;60(5):376–81.
  21. Donovan R, Jalleh G, Robinson K, Lin C. Impact of a population-wide mental health promotion campaign on people with a diagnosed mental illness or recent mental health problem. Aust N Z J Public Health 2016;40(3):274–75.
  22. Hilder L, Zhichao Z, Parker M, Jahan S, Chambers GM. Australia’s mothers and babies 2012. Canberra: AIHW, 2014.
  23. Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011;32(24):3147–97.
  24. McLintock C, Brighton T, Chunilal S, et al. Recommendations for the prevention of pregnancy-associated venous thromboembolism. Aust N Z J Obstet Gynaecol 2012;52(1):3–13.
  25. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Testing for hypothyroidism during pregnancy with TSH. East Melbourne, Vic: RANZCOG, 2015. Available at www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Testing-for-hypothyroidism-during-pregnancy-with-serum-TSH-(C-Obs-46)-Review-July-2015.pdf?ext=.pdf [Accessed 7 November 2016].
  26. Turnour C, Cretikos M, Conaty SJ. Prevalence of chronic hepatitis B in South Western Sydney: Evaluation of the country of birth method using maternal seroprevalence data. Aust N Z J Public Health 2011;35(1):22–26.
  27. Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver disease and pregnancy. Am J Gastroenterol 2016;111(2):176–94.
  28. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Vitamin and mineral supplementation and pregnancy. East Melbourne, Vic: RANZCOG, 2015. Available at www.ranzcog.edu.au/RANZCOG_SITE/media/RANZCOG-MEDIA/Women%27s%20Health/Statement%20and%20guidelines/Clinical-Obstetrics/Vitamin-and-mineral-supplementation-in-pregnancy-(C-Obs-25)-Review-Nov-2014,-Amended-May-2015.pdf?ext=.pdf [Accessed 7 November 2016].
  29. Van Noolan L, Nguyen-Morel MA, Faure P, Corne C. Don’t forget methylmalonic acid quantification in symptomatic exclusively breast-fed infants. Eur J Clin Nutr 2014;68(8):941–42.
  30. Hynes KL, Otahal P, Hay I, Burgess JR. Mild iodine deficiency during pregnancy is associated with reduced educational outcomes in the offspring: 9-year follow-up of the gestational iodine cohort. J Clin Endocrinol Metab 2013;98(5):1954–62.
  31. Bath SC, Steer CD, Golding J, Emmett P, Rayman MP. Effect of inadequate iodine status in UK pregnant women on cognitive outcomes in their children: Results from the Avon Longitudinal Study of Parents and Children (ALSPAC). Lancet 2013;382(9889):331–37.

Correspondence afp@racgp.org.au

Yes     No

Declaration of competing interests *

Yes No

Additional Author (remove)

Yes No

    

 

 

 

 

Competing Interests: 

Your comment is being submitted, please wait

 

Download citation in RIS format (EndNote, Zotero, RefMan, RefWorks)

Download citation in BIBTEX format (RefMan)

Download citation in REFER format (EndNote, Zotero, RefMan, RefWorks)

For more information see Wikipedia: Comparison of reference management software