Does a video module improve patient adherence to recommended gestational weight gain guidelines?

Abstract Objectives We aim to assess if implementation of an educational video module can improve patient adherence to recommended weight gain guidelines. Secondarily, we investigated if patients’ knowledge about gestational weight gain was improved with use of the video, as well as if there was a difference in maternal and neonatal outcomes, and patient satisfaction. Methods This was an IRB-approved, prospective cohort study conducted from February 2019 to October 2019. Patients were recruited from a large academic practice during their first trimester of pregnancy. Patients in the control cohort received routine care. Patients in the video cohort watched a 5-min educational video module about gestational weight gain. Pre-pregnancy weight and baseline demographics were recorded. All patients took a baseline questionnaire assessing gestational weight gain knowledge upon enrollment, and again 4 weeks later. Pre and post score differences were calculated. On admission to the hospital for delivery, all patients’ gestational weight gain was calculated, and the overall gestational weight gain differences between the two groups were calculated. Maternal and neonatal delivery outcomes were also collected. T-tests, Mann-Whitney U tests, and Chi-square analyses were used to compare groups, and a p-value of <.05 was deemed statistically significant. Results During the study period, 155 patients were recruited, with 79 in control cohort and 76 in video cohort, respectively. There was no significant difference in the percentage of patients who gained the appropriate amount of weight between the two groups; 25% (18/74) of patients in the control vs. 25% (17/68) of patients in video cohort (p = .926). There was no difference in the improvement of the pre and post assessment scores when compared between the two cohorts; the average score improvement was 1.72 ± 15.09% for the control, vs. 6.20 ± 12.51% for video cohort (p = .129). There was no difference in maternal or neonatal outcomes between the two groups. Patients were overall satisfied with the video module, with 67.6% (n = 45) reporting the video to be very educational. Conclusions Use of a video module did not improve GWG outcomes or knowledge in our study. Future work can focus on use of a recurring intervention throughout pregnancy, either with app-based technology or multiple videos.


Introduction
Gestational weight gain (GWG) recommendations are an important component of prenatal counseling. The National Academy of Medicine (NAM) has published clear guidelines regarding the recommended GWG for underweight, normal weight, overweight, and obese patients [1,2]. Almost 50% of women exceed these weight gain goals, and approximately 20% of women do not gain adequate weight [3,4]. This is of clinical concern, as both excessive and inadequate weight gain can have adverse maternal and perinatal outcomes such as hypertensive disorders, need for cesarean delivery, postpartum weight retention, childhood obesity, macrosomia, preterm delivery, failure to initiate breastfeeding, and an increased unmonitored fetal heart rates [4][5][6][7][8][9].
Forty percent of pregnant women receive no GWG counseling, receive incorrect information, or are overall unsatisfied regarding their counseling [6,10,11]. The reason for inadequate counseling is likely multifactorial, including lack of time and resources for providers. Newer counseling methods, such as video modules, are being utilized as they can act as an efficient adjunct to a visit, while decreasing time constraints. While the use of video modules has been used across many fields, there is limited research on their use for GWG counseling.
We hypothesize that a video module on GWG will assist in patient counseling and improve weight gain in pregnancy across all weight classes. Therefore, we compare the use of a novel video module to routine prenatal care counseling to determine if this: increases adherence to recommended GWG, improves patient education on GWG, decreases maternal and fetal risks associated with inappropriate GWG, and improves patient satisfaction.

Materials and methods
This was an IRB-approved (Stony Brook University COHRIS #1332546) prospective cohort study comparing the use of a video module to routine provider counseling for GWG counseling.
Participants were recruited from a large academic practice in Eastern Long Island, New York. Participants were approached during their first trimester of pregnancy while at the office for a routine visit or sonogram. The purpose and procedures of the study were explained, and written consent was obtained.
Patients were included if they were 18 years of age and had a confirmed intrauterine singleton pregnancy. Patients were excluded if they were non-English speaking, had a fetus with a known aneuploidy or anomaly, had a fetal demise, or if they had a documented eating disorder. There were no other preexisting medical conditions or BMI classes that precluded participation. The control cohort was recruited first, with women receiving routine GWG counseling by their provider. Once recruitment of the control cohort was completed, the video cohort was then recruited after, which involved women watching a short video module about GWG. Providers were all within the department of obstetrics, however ranged by level of training (residents or attendings) and type of clinicians (certified nurse midwives or physicians). Recruitment took place from February to October 2019. At the time of recruitment, women were asked to complete a maternal demographics form, and a 33-item questionnaire (developed by the investigators) assessing GWG knowledge.
After women in the control cohort completed these questionnaires, they had a routine visit with their provider. As mentioned, participants came from a variety of provider backgrounds, and at this visit the GWG counseling they received was at the discretion of their provider. Providers were not blinded to the study participants' groups, however they were also not explicitly made aware of their patients' enrollment in the study. This decision was made to avoid providers adjusting their usual counseling practices that may impact any potential difference that the video may have.
Approximately 4 weeks later, participants in the control cohort were contacted either via telephone or approached at their next office visit to complete a 24item post-questionnaire developed by the investigators, again assessing GWG knowledge.
After recruitment was completed for the control cohort, new patients were then enrolled in the video cohort. In the video cohort, women were similarly approached in the first trimester. They completed the intake questionnaire and baseline knowledge assessment, and then watched a 5-min educational video about GWG. The investigators created the video, with all information obtained from the American College of Obstetricians and Gynecologists and the March of Dimes. The video was limited to 5 min to include the most pertinent information about GWG.
Four videos were created: one for each BMI classification, as defined by the NAM as underweight (BMI <18.5 kg/m 2 ), normal weight (BMI 18.5-24.9 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ), or obese (BMI >30.0 kg/m 2 ). Patients were given the video that applied to their pre-pregnancy BMI. This allowed for an individualized explanation of the appropriate GWG. The video emphasized the dangers of gaining outside of the recommended guidelines, discussing possible adverse maternal and fetal outcomes. It also provided advice about how to stay within these guidelines, speaking about diet and exercise during pregnancy. The video was 5 min long and was viewed on tablets owned by the Department of Obstetrics, Gynecology, and Reproductive Medicine Research Division. After watching the video, participants had their visit with their provider. At this visit, they may or may not have had additional GWG counseling, depending on the practice of their provider.
Approximately 4 weeks later, participants in the video cohort were contacted either via telephone or approached at their office visit to complete a 27-item post-questionnaire, again assessing their GWG knowledge. This was the same assessment that the control cohort had, with the exception of three additional questions asking about patient satisfaction with the video.
The primary outcome was the percentage of participants who gained within the recommended guidelines for their pre-pregnancy BMI class. To calculate each participant's GWG, we subtracted her delivery admission weight (kg) from her reported pre-pregnancy weight (kg). After delivery, women were classified as having adequate GWG, inadequate GWG, or excessive GWG. Our definition of adequate GWG for underweight (12.7-18.1 kg), normal (11.3-15.9 kg), overweight (6.8-11.3), and obese (5.0-9.1 kg) women were the same as those published in 2009 by the NAM [12]. Women who gained above these ranges were classified as having excessive GWG. Women who gained below these ranges or lost weight were classified as having inadequate GWG. We then dichotomized GWG to those who either had inappropriate GWG or appropriate weight gain, including all of those who had excessive or inadequate GWG in the inappropriate GWG category.
Our first secondary outcome was to assess if the video improved patient GWG knowledge. This was done by calculating the score difference between the pre-and post-questionnaires for all of the subjects and comparing the average score difference between the two cohorts.
Other secondary outcomes included assessing if adverse maternal and neonatal outcomes were different between the control and video cohorts. Prespecified antepartum, intrapartum, and neonatal birth outcomes were collected from the electronic medical record and compared between the two groups. These included development of hypertensive disorders of pregnancy (preeclampsia with and without severe features, and gestational hypertension), gestational or pre-gestational diabetes, intrapartum intraamniotic infection (defined as maternal temperature 39.0, or from 38.0 to 38.9 with fetal tachycardia), placental abruption, postpartum hemorrhage (defined as blood loss 1000 mL for both vaginal and cesarean deliveries), shoulder dystocia, length of hospital admission for delivery, gestational age at delivery, and mode of delivery. Neonatal outcomes investigated included birth weight, Apgar scores, neonatal intensive care unit (NICU) admission, hypoglycemia (identified by pediatricians' documentation), respiratory distress, infection, and fetal distress during labor. For those who attended a postpartum visit, the maternal weight at 6 weeks postpartum was also obtained and compared to their self-reported pre-pregnancy weight.
Lastly, patient satisfaction of their counseling was also assessed. Three questions on the intervention group's survey asked about the helpfulness and educational value of the video, as well as their likelihood to watch their weight. Participants in both arms were asked if they had received any counseling from providers during their pregnancy, and what their satisfaction was with this counseling.
All data was de-identified, given a case number, and entered into REDCap, a secure web platform for online databases hosted at Stony Brook University [13]. Paper surveys were then stored in a locked file cabinet in a locked, private office in the research Division.
The primary outcome of this study was the percentage of women in each arm who gained within the recommended range of weight for their pre-pregnancy BMI class. Given the reported rate that 70% of patients gain outside of the recommended guidelines, we sought to decrease this by half (35%) [3,4]. Using a significance level of 0.05 and a statistical power of 0.8, a power analysis was performed which demonstrated a sample of 62 patients was needed in each arm to show an improvement in compliance.
Student t-tests, paired t-tests, Chi-square, and logistic regression analyses were used with a p-value of less than .05 indicating statistical significance. SPSS was used to analyze data. An intention to treat analysis was performed.

Results
One hundred and fifty-five pregnant persons were recruited, with 79 in the control cohort, and 76 in the video cohort. Five participants in the control cohort and eight participants in the video cohort were lost to follow up after enrollment, leaving 74 and 68 participants in the control and video cohorts, respectively, for final analysis of the primary outcome, adherence to GWG recommendations ( Figure 1). For analysis of one of our secondary outcomes, GWG knowledge, we included patients who were lost to follow up who had completed both the pre and post-questionnaires, however, there were also participants in the control and video cohorts who were followed to delivery, but did not complete both questionnaires. This was due to either patient refusal or inability for research personnel to contact the patient in the appropriate time frame. After taking into account both scenarios, there were 72 participants in the control cohort and 66 participants in the video cohort who completed both the pre and post-questionnaires and were able to be included in the analysis of GWG knowledge.
In regard to baseline demographics, the level of education in the two groups was significantly different, with more participants in the video cohort earning higher levels of education. 79.4% (54/68) in the video cohort and 51.3% (38/74) in the control cohort completed college or graduate school (p ¼ .005). In addition, the provider type differed between the two groups, with more resident providers in the control group (18.7%, 14/74) than in the video cohort (4.4%, 3/68) (p ¼ .03); also, half of the patients in the video cohort were seen by certified nurse midwives (50.0%, 34/68) versus only 37.3% (28/74) in the control cohort (p ¼ .03). There were no differences in the remaining baseline demographics between the groups, including pre-pregnancy weight and BMI class (see Table 1).
Regarding the primary outcome, there was no difference in the percentage of participants who gained the recommended amount of weight, with 24% (18/74) and 25% (17/68) gaining appropriately in the control and video cohorts, respectively (p ¼ .926).
Of the remaining participants in both cohorts who did not gain appropriately, there was no statistically significant difference in the amount of participants who gained too little or too much weight during pregnancy (p ¼ .745) (see Table 2). GWG was then stratified by pre-pregnancy BMI and provider type. In the control group, fewer overweight participants (8.3%, 1/12) gained the appropriate amount of weight compared to underweight (0%, 0/7), normal weight (46.4%, 13/28), and obese women (16%, 4/25) (p ¼ .007) (see Table 3). Although more overweight women in the video group gained appropriate weight compared to controls, this relationship was not statistically significant (p ¼ .216) (see Table 4). The providers who participants saw during their pregnancy also did not impact GWG. Only 35.2% (6/17), 17.6% (6/34), 23.3% (7/30), and 25.8% (16/62) gained the recommended amount of weight among patients who sought care from Residents, General Obstetricians, Maternal-Fetal Medicine providers, and Certified Nurse Midwives, respectively (p ¼ .570).
In regard to one of the secondary outcomes, the baseline knowledge score was higher in the video cohort than in the control cohort (68.6% in the control cohort vs. 75.9% in the video cohort), although this was not significant (p ¼ .31). A total of 72 participants (72/79, 91.1%) in the control cohort and 66 participants (66/76, 86.8%) in the video cohort completed  There was no significant difference in any maternal outcomes between the control and video cohorts, including postpartum weight retention. However, only 50.3% of participants (78/155) had data available for a 6-week postpartum weight. 8.4% (12/143) of all participants delivered preterm, with 75% (9/12) of these being in the late preterm period after 34 weeks. Although GWG was not adjusted for the gestational age at delivery, the gestational age at delivery was similar between the two cohorts and therefore unlikely to impact any potential difference in GWG between the two cohorts. There were also no significant differences in any neonatal outcomes between the two groups.
Lastly, for all subjects enrolled in the study, only 30.3% (47/155) reported having a provider speak with them about GWG during their prenatal visits. Of these, 30.8% reported they were dissatisfied with the discussion they had. Furthermore, when asked if a provider reviewed their weight at each visit, only 16.7% (26/155) of patients replied yes. In the video cohort, 68.2% (45/66) of participants felt that the video was very educational, 31.8% (21/66) of participants felt that the video was somewhat educational, and no participants felt the video was not educational at all. 75.8% (50/66) of participants who watched the video said they were more likely to watch their weight after seeing the video.

Discussion
In our study, when compared to routine prenatal counseling, the use of an educational video module did not improve the percentage of patients who had appropriate gestational weight gain in pregnancy, nor the total weight gain in pregnancy. After further stratification, neither patient BMI category, nor provider type improved GWG. With regard to secondary outcomes, the use of the video module did not improve GWG knowledge amongst the patients. Maternal and neonatal outcomes, including postpartum weight retention did not differ among the groups. Lastly, only one third of patients reported receiving any counseling by a provider, but the majority of the patients were not satisfied with this counseling, and the video module was well received by those who viewed it.
Although our study results did not show benefit of the video module, this may be multifactorial. For the Table 2. Breakdown of GWG in both the control and video cohorts. Categorical data is presented as n (%). Table 3. GWG stratified by BMI class, for both the control and video cohorts.  past 15-20 years, studies have shown that almost one third of pregnant women receive no counseling regarding GWG at their prenatal visits [10,11]. Our practice unfortunately aligned with these reported rates. The etiology for this is unclear, but likely to be multifactorial, including time constraints for visits, weight gain being a sensitive topic of discussion, prioritizing other counseling topics, and a lack of provider knowledge. With such good patient satisfaction with our counseling model, it is unfortunate that we did not see an improvement in GWG. This begs the question, then, of how we can improve video module counseling to translate patient satisfaction into improved patient outcomes.
In prior literature there have also been mixed results to support the optimal way to give GWG counseling. Our findings are consistent with preexisting literature regarding use of technology to improve GWG. A similar study in 2010 used a "Video Doctor" to counsel patients using an interactive module with a virtual doctor [14]. In this randomized controlled trial, participants either underwent routine counseling by their provider, or were counseled by the video doctor. The module focused heavily on diet and exercise, rather than on potential harms of inappropriate GWG as our video did. They found that the module improved reported adherence to diet and regular exercise but did not show improvement in GWG.
Previous attempts have largely focused on intensive, one-on-one, in person counseling, often requiring additional visits for patients and providers, with printed resources as an adjunct. This has shown mixed results. One such trial only showed improvement in GWG for normal weight women, however not for overweight women [15]. Another had poor generalizability by including only healthy women without a history of conditions such as hypertension, diabetes, or thyroid disease [16]. In more recent years, a few studies have explored the use of modern technology to aid with GWG counseling. These have mostly focused on text message-based or live-online chatting interventions, again with variable results [17,18]. There remains no good consensus for the optimal mode of counseling for GWG.
One of the most successful GWG interventions reported in the literature is a pilot randomized-control trial of socioeconomically disadvantaged African American women in Philadelphia, where they received daily automated text messages about GWG; several texts per week that the participants could respond to, discussing their diet; regular phone calls; and enrollment in an online support group [19]. Although intensive, this regular contact with participants may be responsible for the significant success reported. In the future, using our video as part of a series of videos throughout pregnancy, or converting it into App-based technology for regular use, may have more of an impact.
Our study had several strengths. First, it addresses an important and relevant topic via a unique approach. The video focused not only on diet and exercise, but also attempted to explain to patients why GWG is important, reviewing the risks of what can occur if patients do not gain the appropriate amount of weight. Our patient population was diverse and had few exclusion criteria, allowing it to be generalizable.
There were several limitations. Our patient population was too small to detect potentially significant differences in subgroup analyses and secondary outcomes. Given the trend toward improved adherence to GWG guidelines seen in the overweight participants in the video cohort compared to the control cohort, it is possible that with a large sample that this may have been significant. Our patient populations also differed between the two cohorts, with those in the video cohort having a higher level of education and being more likely to see certified nurse midwives rather than resident physicians. A larger sample size would have allowed for multivariate analyses to control for these differences. Lastly, the video was not repeated during gestation and therefore retention of the material may have been limited.
These difference in patient populations between the two cohorts is an important potential confounder to address. The different education levels of the two cohorts may have affected the differences in the baseline knowledge level in our two groups, making it difficult to truly assess if the video could improve knowledge. While all participants were recruited from the same practice, there are two different geographic sites for the practice which may have inherent demographic differences. If recruitment from the two sites was not similar in each cohort, this may explain the group differences.
The video was also unfortunately only available in English, therefore excluding many individuals who may have benefited from this intervention. Lastly, the video was only a one-time intervention, completed early in pregnancy. It is possible that a more continuous or recurrent intervention throughout pregnancy may have made more of an impact. Our video was also not previously validated.
Converting our video into App-based technology may also allow for greater involvement of a patient's family, as they would have access to this at home.
Many of the challenges surrounding significant lifestyle changes such as diet and exercise involve the flexibility of the patient's social system to also adapt or support their change. Future interventions involving family may also help improve outcomes. Additionally, in the future, designing a randomized trial would remove several of the limitations above.
The optimal mode of GWG counseling to improve maternal and neonatal outcomes remains unknown. Our study demonstrated that a video module is a well-received, efficient form of counseling, however certain aspects of the optimal way to deliver such an intervention require further investigation.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Funding
The author(s) reported there is no funding associated with the work featured in this article.