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Strengthening the evidence base for maternal and child health programs

New: MCH Best strategies database for sample ESMs

Evidence Tools
MCH Best. NPM 2: Low-Risk Cesarean Delivery

MCH Best Logo pregnant woman reviewing a chart with a doctor

Strategy. Nutrition Education for Expectant Mothers

Approach. Provide educational materials or trainings that increase awareness and identify risk factors for nutrition-related indicators that have been shown to increase cesarean deliveries.

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Overview. Women who enter pregnancy at a healthy body mass index (BMI); maintain healthy pregnancy weight and experience appropriate weight gain during pregnancy; and are screened and treated for gestational diabetes mellitius (GDM), hypertension, and pre-existing diabetes are shown to experience low-risk first births through non-cesarean, vaginal delivery.1

Evidence. Emerging. Multiple studies have shown that weight and associated health issues affect the decision for cesarean delivery: increasing BMI;2 pregnancy weight and weight gain, independent of birth weight;3,4 gestational diabetes mellitus (GDM);5 hypertension;6 and pre-existing diabetes7 have all been associated with increased risk for cesarean delivery. (Read more about understanding evidence ratings). Preconception education interventions, including nutrition interventions, have been identified by Robert Wood Johnson Foundation's What Works For Health as having some evidence for improved outcomes.

Target Audience. Patients.

Outcome. Reduction of primary cesarean delivery rates among nulliparous women. For detailed outcomes related to each study supporting this strategy, click on the peer-reviewed evidence link in the references and read the "Intervention Results" for each study.

Examples from the Field. There are currently no ESMs across all states/jurisdictions that use this strategy directly; however several states use intervention components that align with this strategy. Access descriptions of these ESMs through the MCH Digital Library. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Using the approach “Provide educational materials or trainings that increase awareness and identify risk factors for nutrition-related indicators that have been shown to increase cesarean deliveries,” here are sample ESMs you can use as a model for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies):

Quadrant 1:
Measuring Quantity of Effort
("What/how much did we do?")

  • Number of women receiving educational nutrition-related materials during pregnancy.

Quadrant 2:
Measuring Quality of Effort
("How well did we do it?")

  • Percentage of women receiving educational nutrition-related materials during pregnancy who indicated that they were incorporating content into their health routine.

Quadrant 3:
Measuring Quantity of Effect
("Is anyone better off?")

  • Number of women receiving educational nutrition-related materials during pregnancy who eventually delivered vaginally.

Quadrant 4:
Measuring Quality of Effect
("How are they better off?")

  • Percentage of women receiving educational nutrition-related materials during pregnancy who eventually delivered vaginally.

Note. ESMs become stronger as they move from measuring quantity to measuring quality (moving from Quadrants 1 and 3, respectively, to Quadrants 2 and 4) and from measuring effort to measuring effect (moving from Quadrants 1 and 2, respectively, to Quadrants 3 and 4):

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.


Reference:

1 Association of State Public Health Nutritionists. (2016). Incorporating Nutrition into the Title V MCH Services Block Grant National Performance Measures. [Health Resources and Services Administration, Maternal and Child Health Bureau Funded Issue Brief].

2 Berendzen JA, Howard BC. Association between cesarean delivery rate and body mass indexTenn Med. 2013;106(1):35-42.

3 Witter FR, Caulfield LE, Stoltzfus RJ. Influence of maternal anthropometric status and birth weight on the risk of cesarean deliveryObstet Gynecol. 1995;85(6):947-951. doi:10.1016/0029-7844(95)00082-3

4 Graham LE, Brunner Huber LR, Thompson ME, Ersek JL. Does amount of weight gain during pregnancy modify the association between obesity and cesarean section delivery?Birth. 2014;41(1):93-99. doi:10.1111/birt.12095

5 Moyer VA; U.S. Preventive Services Task Force. Screening for gestational diabetes mellitus: U.S. Preventive Services Task Force recommendation statementAnn Intern Med. 2014;160(6):414-420. doi:10.7326/M13-2905

6 Bramham K, Parnell B, Nelson-Piercy C, Seed PT, Poston L. Chronic hypertension and pregnancy outcomes: systematic review and meta-analysis. BMJ 2014; 348.

7 Kitzmiller JL, Block JM, Brown FM, et al. Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for careDiabetes Care. 2008;31(5):1060-1079. doi:10.2337/dc08-9020

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.