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University Microfilms International 300 N. ZEEB ROAD. ANN ARBOR. Ml 40100 18 BEDFORD ROW. LONDON WCIR 4EJ, ENGLAND 8009301

K e s s e l , M a r g a r e t W a g n e r

THE NUTRITION COMPON NT OF MATERNITY CARE: ’ OPINIONS AND PRACTICES

The Ohio State University Ph .D. 1979

University Microfilms Internationalm >n.m >rJ. Ann Arbor, M l 48106 18 Bedford Row, London WC1R 4EJ, England

Copyright 1979 by Kessel Margaret Wagner All Rights Reserved THE NUTRITION COMPONENT OF MATERNITY CARE:

PHYSICIANS' OPINIONS AND PRACTICES

DISSERTATION

Presented in Partial Fullfillment of the Requirements for

the Degree Doctor of Philosophy In the Graduate

School of The Ohio State University

By

Margaret Wagner Kessel, B.S., M.S.

M M A

The Ohio State University

1979

Reading Committee: Approved By

Virginia M. Vivian

Franklin R. Banks

Fern E, Hunt

Ted L. Napier /J Adviser Department of and Food Management This dissertation Is dedicated to

John H, Kessel

% In appreciation for his support

patience and encouragement in

completing the Ph.D.

ii ACKNOWLEDGMENTS

1 wish to express my gratitude to the many physicians who participated In this study. Their time* expert knowledge and support waB indispensible in achieving the fundamental goals of this

investigation. 1 also want to express my sincere appreciation to

Dr. Tennyson Williams of the Department of Family and

Dr. Frederick P. Zuspan of the Department of and Gynecology for their support in providing a letter of introduction to their fellow physicians.

The dissertation benefited greatly from the guidance of Ted L.

Napier who focused my attention on numerous critical analytical points.

His suggestions were especially valuable in improving the statistical component of this research.

Special thanks are due to the other members of the reading committee, Fern L. Hunt and Franklin Banks, whose many recommendations improved the quality and style of the dissertation.

I gratefully acknowledge the obligation I owe to my advisor,

Virginia M. Vivian, who helped me arrange the research data in a coherent manner. I appreciate her willingness to work with me over such an extended period of time,

iii VITA

April 25, 1931 ...... Born - Bakersfield, California

1953 ...... B.S., Oregon State University, Corvallis; Oregon

1953-1954...... Dietetic Intern, St. Mary's Hospital, Rochester, Minnesota

1954-1955 ...... Therapeutic Dietitian, St. Luke's Hospital, Hew York, New York

1957 ...... Therapeutic Dietitian, Grant Hospital, Columbus, Ohio

1964 ...... M.S., University of Massachusetts, Amherst, Massachusetts

1965 ...... Therapeutic Dietitian, Virginia Mason Hospital, Seattle, Washington

1966-1967 . . Therapeutic Dietitian, St. Vincent's Hospital, Erie, Pennsylvania

1967-1970 ...... Instructor, Spencer Hospital School of Nursing, Meadvllle, Pennsylvania

1969-1970 ...... Consultant, Conneautville Nursing Home, Conneautlville, Pennsylvania

1970 ...... Instructor, Pennsylvania State University (Behrend Campus), Erie, Pennsylvania

1971-1973 , , ...... Instructor, Capital University, Columbus, Ohio

1973-1976 ...... Teaching Associate, Department of Human Nutrition and Food Management, The Ohio State University, Columbus, Ohio

iv FIELDS OF STUDY

Major Field: Human Nutrition and Food Management

Studies in Human Nutrition, Professor Virginia M, Vivian

Studies in Nutritional Biochemistry, Professor John M. Allred

Studies in Human Physiology. Professor Charles W. Smith

Studies in Food Service Managment. Professor Rachel M, Hubbard

v TABLE OF CONTENTS

Page DEDICATION...... ii

ACKNOWLEDGMENTS ...... Ill

VITA ...... iv

LIST OF TABLES...... ix

Chapter

I. INTRODUCTION ...... 1

Background Information ...... 1 Maternity C a r e ...... 7 Statement of the Problem ...... 9 Significance of the P r o b l e m ...... 10 Scope of Investigation ...... 13 Definition of T e r m s ...... 16

II. LITERATURE R E V I E W ...... 19

Brief History of Nutrition in ...... 19 Current Recommendations for the Nutrition Component of Maternity Ca r e ...... 34 Specific Nutrition-Related Problems Complicating ...... 54 Nutrition and Dietary Component of Maternity Care ...... 59 and Preparation for BreaBt Feeding ...... 61 M y t h s ...... 63 Diffusion of Medical and Nutrition Information . . 65 S u m m a r y ...... 68

vi Page Chapter III. METHODOLOGY...... 71

Introduction ...... 71 Design of the S t u d y ...... 71 Maternal Nutrition Assessment Indexes ...... 93

IV. RESEARCH FINDINGS ...... 110

Introduction ...... 110 Maternal Nutrition Assessment ...... Ill Variation In Maternal Nutrition Assessment .... 134 Nutrition-related Complications of Pregnancy . . . 142 Nutrition-related Problems of Private Patients . . 177 Advice to Patients ...... 178 Physicians' Sources of Nutrition Information . . . 194 Recommendations to Nutritionists ...... 207

V. IMPLICATIONS ...... 214

Patient Education ...... 214 Assessment of Maternal Nutrition ...... 218 Physicians' Management of Maternal Nutrition . . * 219 Nutrition-related Complications of Pregnancy . . » 225 Weight and Weight Gain In Pregnancy...... 231 Physicians' Sources of Medical and Nutrition Information ...... 234 Physicians' Suggestions and Recommendations for Improving the Dissemination of Nutrition Information ...... 238 Recommendations for Further Research ...... 240

VI. SUMMARY AND RECOMMENDATIONS...... 242

Recapltualtion ...... 245 Summary Recommendations...... 248

LIST OF REFERENCES...... 251

APPENDIXES

A. Nutrition Questionnaire for Physicians ...... 265

B. Physicians' Medical Schools . 272

C. Letters to P h y s i c i a n s ...... 275

vii Page

APPENDIXES

D. Consent F o r m ...... 278

E. Maternal Nutrition Assessment ...... 280

F. Composition: Prescribed Hematlnics and Vltamin-Mlneral Supplements ...... 283

viii LIST OF TABLES

Table Page

1. Years Physicians Had Been Licensed to Practice .... 82

2. Distribution of Physicians by Community Size and Specialty...... 82

3. Distribution of Physicians (Percent) by Area Economic Classification ...... 84

4. Levels of Maternal Nutritional Assessment ...... 94

5. Relation of Dietary Assessment Index to Component Items ...... 99

6. Relation of Obstetrical Assessment Index to Component Items ...... 99

7. Relation of Medical Assessment Index to Component Items ...... 100

8. Relation of Family Assessment Index to Component Items ...... 100

9. Relation of Clinical Evaluation Assessment Index to Component I t e m s ...... 101

10. Relation of Laboratory Evaluation Assessment Index to Component ...... 101

11. Relationship Between Indexes ...... 103

12. INDEX VALIDITY: Comparison of Indexes with Physicians* Nutrition Management ...... 103

13. INDEX RELIABILITY: Comparison of Mean Scores of Randomly-Selected Subsamples ...... 105

14. Distribution of Population-Sample by Mean Years ; ...... 107

ix Table Page

15. Distribution of Sampling Fraction by Specialty .... 107

16. Persons Responsible for Taking Medical History .... 112

17. Data Collected by Physicians: Obstetrical History . . 114

18. Data Collected by Physicians: Medical History .... 117

19. Data Collected by Physicians: Family and Social H i s t o r y ...... 119

20. Data Collected by Physicians: Nutrition History . . . 124

21. Clinical Evaluation ...... 128

22. Data Collected by Physicians: Laboratory Evaluation . 132

23. Distributions of Assessment Scores ...... 136

24. Assessment Indexes ...... 140

25. Nutritional Complications of Pregnancy: Identified by All Physicians ...... 144

26. Diagnostic Criteria for Obesity ...... 146

27. Recommended Treatment for Prenatal Obesity ...... 148

28. Diagnostic Criteria for Excessive Weight Gain ...... 151

29. Recommended Treatment for Excessive Weight Gain in P r e g n a n c y ...... 153

30. Recommended Treatment for Insufficient Weight Gain in P r e g n a n c y ...... 159

31. Diagnostic Tests and Criteria for - Deficiency Anemia ...... 162

32. Treatment of Iron-Deflciency Anemia in Pregnant W o m e n ...... 167

33. Diagnostic Criteria for Megaloblastic Anemia ...... 169

34. Treatment of Megaloblastic Anemia ...... 171

35. Diagnostic Criteria for Preeclampsia ... 173

x Table Page

36. Recommended Treatment of Toxemia of Pregnancy ...... 174

37. Desirability of Giving Diet Instructions ...... 179

38. Circumstances Favoring Diet Instructions ...... 180

39. Physicians' Views of Normal Weight Gain In Pregnancy . 183

40. Information Offered on Nutritional Value of Foods . . . 185

41. Information Offered on Nutrition Labels ...... 187

42. Patients Advised to Drink Quart of Milk Dally ...... 188

43. Patients Advised to Attend Prenatal Classes ...... 191

44. Patients Advised How to Apply for Food Stamps ...... 193

45. Patients Advised About Breast Feeding ...... 195

46. PatlentB Advised About Maintaining Lactation ...... 195

47. ANSWERS TO THE QUESTION: "What have you found to be your best source of information about new developments related to your practice of medicine ...... 197

48. ANSWERS TO THE QUESTION: "What have you found to be your best source of information about new developments In nutrition?" ...... 198

49. ANSWERS TO THE QUESTION: "How many journals dc you read regularly?" ...... 200

50. ANSWERS TO THE QUESTION: "What two journals are the best sources of new information about your medical practice?" ...... « 201

51. ANSWERS TO THE QUESTION: "What two journals are the best sources of new Information about your medical practice?" ...... 202

52. Physicians' Ratings of Sources of Medical Information . 205

53. Physicians' Ratings of Sources of Nutrition Information ...... 206

54. ANSWERS TO THE QUESTION: "Is there anything we nutritionists could do to help you with nutrition information?" ...... 209

xl Physicians' Medical Schools ......

Hematlnlcs ......

Composition of Vltamln-Mineral Supplements CHAPTER I

INTRODUCTION

Background Information

During the past six decades physicians and other health

professionals have held diverse opinions about the effects of maternal

nutrition on the course and outcome of pregnancy. Various dietary

regimens have been advocated for maternity patients, all supposedly

designed with the goal of protecting the mother and delivering a

healthy infant. Some regimens have been efficacious, some innocuous

and some possibly harmful. There have been instances when nutrition

information and advice has been omitted from routine prenatal core.

In the mid-1960's government health experts were becoming alarmed

at the incidence of and morbidity among certain

population groups in the United States. Chase (1966, 1969) reported

that this country ranked 5th among six western nations in perinatal mortality, 6th in postnatal mortality and 13th among 40 nations in

infant mortality. By comparing data from several studies of low-birth- weight infants she discovered evidence that linked infant mortality

and morbidity with maternal malnutrition.

1 Other investigators tended to support Chase's conclusions.

Results from numerous animal studies showed a relationship between maternal malnutrition and an assortment of problems such as decreased fertility, fewer and smaller offspring, increased meaternal and fetal mortality and permanent physical damage in the newborn (Runner and Miller, 1956; Winick, 1971; Warkanv, 1958; Roeder and Chow, 1972).

While controlled laboratory conditions allowed investigators an opportunity to manipulate selected nutrients to produce developmental abnormalities and Impaired brain function in offspring, results of such experiments were not necessarily applicable to human reproduction.

Nevertheless, animal experiments alerted physicians and nutritionists to the possible consequences of malnutrition in human reproduction.

Health, vitality and developmental potential of an Infant can be compromised by malnutrition in utero and early life. Evidence to suggest that intellectual development is sensitive to certain nutrition factors is accumulating (Cravioto, 1963; Cravioto et al..

1966; Cravioto et al., 1967; Churchill and Berendes, 1969). Hence, investigators have attempted by means of (1) nutrition surveys,

(2) retrospective examinations of malnourished populations and (3) reappraisals of effects of nutrients supplements on maternal nutrition to collect data that would suggest techniques for improving the quality of maternal diets.

Pregnant women from every society and culture have accepted certain tenets or followed traditional dietary rituals that were thought to aid in the birth of a healthy baby (Seifert, 1961). Often 3 primitive or ancient peoples reserved special foods for their pregnant mothers. However, the more common custom was to restrict or entirely prohibit certain foods, believing that such foods were responsible for long and difficult labor, birth defects or unpleasant personality traits in the offspring. Until the 1920's many ideas about maternal nutrition were baBed on superstition and conjecture rather than scientific fact.

As the new science of nutrition advanced during the decade of the 20's the dietary needs of pregnant women were subject to numerous investigations. Unfortunately, many of the recommendations promulgated as a result of these early studies benefitted neither mother nor fetus. As early as 1861 German physicians routinely weighed their obstetric patients in order to encourage adequate weight gain. Then in the 1920's, American physicians began to champion weight control assuming this would promote good maternal health (Hannah, 1923).

Patients were admonished to restrict food energy Intake in order to

"decrease duration of labor, treat 'inertia uteri', decrease complica­ tions from cardiac and kidney disorders, prevent eclampsia of pregnancy, prevent infections, prevent psychosis, cure apoplexy and hyper­ tension and improve chances for successful breast feeding." Obviously, restricting the energy content of the diet couldn't prevent or cure all these medical conditions.

During this same period, obstetric patients were told to regard animal protein as a hazardous substance. Moore (1923) believed dietary protein overworked the kidneys and precipitated albuminuria, thus neat and eggs were restricted in the diets of pregnant women.

Today, we recognize that low-calorie, low-protein diets are harmful

to nother and fetus (Pitkin, 1977).

In the 1930Ts dietary advice changed; liberal protein intake was

encouraged. Physicians were convinced that complications of pregnancy

such as toxemia and anemia were caused by diets deficient in high

quality protein. Theobald (1935) believed that toxemia of pregnancy was completely preventable if the mother consumed a nutritious diet.

During the 1930's much progress was made in and mineral

research, but Investigators attempting to link various nutrients with

the course and outcome of pregnancy found evidence either contradictory or lacking. Even so, Mellanby (1933) presented convincing data to

support his thesis that good maternal nutrition was an important

factor in successful childbearing. Mcllroy (1934) urged physicians to treat prenatal obesity and excess weight gain with an exercise program. (She was the first to urge overweight patients to limit the Intake of starchy foods such sb bread and potatoes.) Royston (1927) stressed the need for an increase in food energy during pregnancy reasoning that greater food consumption would also increase the protein, vitamin and mineral content of the diet.

He also suggested exercise sb the beBt way to control weight and advocated walking two hours a day. (He had a notion that if the mother exercised the fetus would remain small.) His ideas prevailed

for many years. 5

It was during the 1930*8 that doctors began to worry about

dietary salt. Many physicians assumed that defective

metabolism and excessive weight gain were the major predisposing

factors In toxemia of pregnancy (American Committee on Maternal

Welfare, 1935). Therefore, many patients were advised to limit

sodium Intake during pregnancy.

Controversy developed between the advocates of

and the advocates of dietary supplementation. There were many

physicians who believed that maternal nutrition could be significantly

improved if mothers would supplement their regular diets with liberal

quantities of milk, eggs, fruits and vegetables. Other physicians were just as sure that if ordinary foods were fortified with

and minerals all segments of the populations would benefit, but particularly prenatal patients (Seifert, 1961). Although there was

considerable enthusiasm for nutrition research and Its possible

application to various medical problems, the decade of the 1930's produced very little improvement In maternal and child health.

Depression era mothers lived In poverty and many experienced frank malnutrition, as a consequence reproductive casualties were high.

In the 1940'8 nutrition research expanded to include social,

economic, cultural and psychological factors and their Influence on

the total process of food selection and consumption. It was evident

that some problems In human reproduction were solved by applying this knowledge to dietary management (Seifert, 1961).

During the 1950's considerable skepticism developed about the efficacy of the "solutions" in the 1940's to problems of maternal nutrition. Terris (1966) observed that certain methodological techniques made nutrition studies involving human subjects difficult to Interpret. For example, some research was compromised by investigators who failed to screen subjects for age, reliability of diet history, race, parity or economic statuB. Partial or Incomplete laboratory tests often contributed to weakness in these studies.

After a reappraisal of earlier Investigations into maternal malnutrition and prematurity, the relationship was discounted. Thus, no conclusions or recommendations were forthcoming concerning ways to prevent the birth of small or premature infants. **•

There was a period from the mid-1950's to mid-1960's when the subject of maternal nutrition was largely Ignored by physicians and other health professionals. Then in the late 1960's there was a resurgence of interest in the Importance of diet to human reproduction

(Committee on Maternal Nutrition, 1970). Winlck and Noble (1966) had studied the effects of malnutrition in animals at various stages of development. They discovered a decrease in the number and size of cells in certain organs when the test animals were subjected to nutritional deprivation in utero and early life. The decrease in the number of brain cells was associated with Impaired functioning of the central nervous system. Winlck's studies prompted the obvious question; was it possible that human maternal malnutrition could have long-term effects on the offspring? Could the radical changes in diet and food selection, which had occurred among so many population groups in

America, explain the unfavorable health statistics associated with childbearing (Committee on Maternal Nutrition, 1970)? After reviewing the literature on all aspects of maternal nutrition, a committee of experts suggested some fundamental changes be instituted In the dietary management of obstetric patients (Committee on Maternal Nutrition,

1970). The trend in the 1970's has been to encourage normal weight gain and to avoid strict weight control. Physicians have been urged to prescribe diets high in essential nutrients and forego the tradition of limiting food-energy Intake. No longer Is it acceptable to think or pregnancy as a period when a woman can lose unwanted pounds. The vitamln-mlneral capsule, which has been the foundation of maternal nutrition for the past two generations, should be supplemented with careful nutrition assessment and appropriate dietary counseling.

Maternity Care

Obstetric patients have a number of options available when selecting prenatal care. They may choose a private , an outpatient clinic, a agency or a nurse- service.

Most mothers with adequate incomes will choose a private physician whose

specialty is* obstetrics or family (general) practice. There are some small towns and rural locations where a private physician is not in practice, thus patients will have to travel some distance to obtain services of a medical doctor or accept less than ideal care (Geyman,

1974).

Patients with serious complications of pregnancy will likely receive attention from a qualified specialist. Other patients can expect to receive a portion of routine prenatal care from a nursi, nurse-midwife or nurse-practitloner. However, the ultimate responsi­ bility for medical management, Including nutrition counseling, will belong to the attending physician.

A physician may have to delegate diet instruction to hiB st4ff;

such as the office nurse, receptionist, prenatal class instructor or dietitian. But, the physician has final authority for assuring uhat patients are familiar with the basic principles of nutrition and can

translate this knowledge into sound dietary practices (Pitkin, l!>76).

Guidelines for the nutrition component of maternity care have been developed by organizations such as the National Research Council

(Committee on Maternal Nutrition, 1970) and the Committee on

Nutrition of the American College of Obstetrics and Gynecology

(Pitkin et al.. 1972). The substance of these guidelines have appeared in numerous medical, nutrition and other scientific joutnals,

commercial food and drug publications, newspapers, popular bookB

texts and magazines (Jacobson, 1973; Kinder, 1973; Jauch, 1974 &

1975; Mayer, 1977; Cause, 1977). Nevertheless, critics of conteuporary obstetric care claim that most physicians teach their patients outmoded and sometimes dangerous dietary concepts, or structure their adv:Lce

around superstition, bias or speculation rather than adhering to principles of scientific nutrition (Brewer, 1972).

No current studies are available assessing the attitudes and practices of physicians with regard to . Data are needed by physicians, nutritionists, dietitians and nurses about the kinds of nutrition-related problems common among private maternity patients, and how these problems are diagnosed and treated. Such data would aid In the development of strategies to improve the nutritional quality of diets of prenatal patients and subsequently benefit the health of newborn.

Statement of the Problem

The purpose of this study was to identify the nutrition component of maternity care provided by a selected sample of private physicians, classified according to specialty. A second purpose of this study was

to ascertain the Influence of various channels of medical communication on the dissemination of nutrition information among physicians. A third purpose was to elicit physicians' opinions concerning ways nutritionists could assist them In providing nutrition information.

The following specific objectives were developed for use in this research:

1. To identify Information reflecting nutrition status which physicians routinely obtain from prenatal patients.

2. To compare physicians' diagnostic criteria and treatment for nutrition-related complications for pregnancy with the guidelines developed by the ad hoc Committee on Nutrition of the American College of Obstetrics and Gynecology (Pitkin et al.. 1972) and the Committee on Maternal Nutrition of the National Research Council (Committee on

Maternal Nutrition, 1970). 10

3. To compare and contrast the types of nutrition Instructions obstetric patients receive from four different groups of physicians classified according to specialty: dlplomates of the American College of Obstetrics and Gynecology* non-certified obstetricians, dlplomates of the American College of Family Practice, and general practice physicians.

A. To compare the nutrition component of obstetric care among the four groups of physicians with current standards for dietary management established by the ad hoc Committee on Nutrition of the

American College of Obstetrics and Gynecology (Pitkin et al.. 1972) and the Committee on Maternal Nutrition of the National Research

Council (Committee on Maternal Nutrition, 1970).

5. To identify various sources of nutrition information the physicians considered important to their private practice.

6. To o b t a i n an estimate of the incidence of nutrition- related complications of pregnancy among private patients in central

Ohio.

Significance of the Problem

Knowledge of what opinions physicians hold and what practices they follow concerning the management of maternal nutrition would be of value to health professionals developing guidelines for complete prenatal care. In providing mothers with better prenatal care, reproductive performance can be improved by decreasing the Incidence 11 of perinatal mortality and morbidity and medical complications of pregnancy.

Physicians must know how to provide a nutrition knowledge base from which prenatal patients can choose an adequate diet. Directions for managing prenatal nutrition have been carefully detailed in several medical journals (Pitkin, 1976; Jacobson, 1973; Langer et al..

1973). Furthermore, appropriate dietary guidelines for prenatal patients are available from the federal government, the American

College of Obstetrics and Gynecology, and popular parent-oriented magazines (U.S. Department of Health, Education and Welfare, 1973;

Committee on Nutrition Education, 1976; Cause, 1977). The use of guidelines designed for physicians and for their patients needs to be evaluated and physicians opinions about these guidelines should be ascertained. Are the newer trends in prenatal nutrition accepted by practicing physicians and if not, why?

Physicians continually update their medical knowledge by attending seminars and taking postgraduate courses, reading professional journals and library materials, subscribing to audio tape services, utilizing the radio-television medical network and exchanging information with colleagues. Knowledge about information channels for the dissemination of nutrition facts needs to be appraised. It is also important to obtain data concerning obstacles to distribution of nutrition knowledge among physicians.

It is possible that private practice physicians observe a variety of prenatal nutrition problems which are seldom reported in the medical literature. Numerous clinic studies of nutritional complications of pregnancy have been published and cause concern among physicians and nutritionists. The nutritional status of most American women may be very different from that of the nations poorest mothers.

Women from low-income families experience more pathological complications and have received more attention than patients of better economic status (Committee on Maternal Nutrition, 1970).

Information on the nutrition atatuB of private patients is, therefore, not readily available to nutritionists, dietitians or public health officials and other medical experts responsible for developing programs to remedy or prevent maternal and fetal malnutrition. Empirical data are necessary to establish the incidence of nutrition-related complications of pregnancy and to evaluate physicians' diagnostic criteria and treatment. In order to enhance the quality of maternity care, information is needed on implimentation of scientific nutrition to the management of private practice patients.

This study may prove useful in that it could promote nutrition education for practicing physicians through programs of continuing education, lectures, panel discussions and symposia. Furthermore, physicians could make valuable suggestions to nutritionists, dietitians and other health professionals for ways to improve prenatal care.

Once physicians have an opportunity to identify their needs for nutrition information, this knowledge can be applied to private patient care. Thus nutritionists, dietitians, and nurses can direct 13 their efforts to assisting the physician in solving nutrition-related complications of pregnancy. Precise and accurate information from recognized experts in medicine and nutrition can aid physicians* management of the dietary component of maternity care. It is Important for physicians to Improve their channels of communication with nutrition specialists in order that dietary problems among private patients can receive expert attention.

Scope of Investigation

Source of Data

Data in this descriptive study were collected by personal

Interviews with four groups of physicians practicing in central Ohio.

Physicians were selected from medical specialties that usually offer obstetrical care* The Maternal Nutrition assessment indexes, designed to measure physicians' compliance with recommendations for assessing maternal nutritional status, were adapted from guidelines promulgated by the American Public Health Association (Christakis, 1977).

Information obtained from physicians on kinds of data collected from their maternity patients was compared to the Indexes. Open-ended opinion questions about the nutrition-related complications of pregnancy were developed for use in this study by the investigator.

Questions concerning the dissemination of nutrition and medical information were adapted from an index used by Coleman et al. (1957).

All data were collected by the investigator using the Interview 14 schedule designed especially for this study.

The four groups of physicians were selected to represent two areas of (family and obstetrics) and two levels of (board certification and non-certification). Two groups of physicians: family practice and general practitioners supervise the care of women during pregnancy, labor, delivery, postpartum and presumably the ensuing years. Obstetricians supervise the care of women during pregnancy, labor, delivery and the .

Determination of differences in dietary management with type of practice was of interest because physicians' education may have included different emphases on nutrition.

Half of the physicians were selected on the basis of certification by American Specialty Boards. Two groups of physicians, obstetricians and family practice physicians, had passed their national board examinations and were granted specialty status. It was of interest to determine if physicians with advanced education had more nutrition knowledge than noncertified obstetricians and general practitioners.

Data were collected in a relatively small geographic area of

Ohio, within a radiuB of 100 miles or less from Columbus; thus sweeping generalizations about all physicians in all specialties cannot be made. However., conclusions about the nutritional component of maternity care from physicians in private practice can be drawn from the answers obtained in this sample survey. 15

Collection of Data

A face-to-face personal Interview was chosen as the most practical method for collecting data. This method increases the chances of completing the schedule and decreases the number of "don't know" and "no answer" responses (Babbie, 1973). For open-ended questions, the Interview allows an Investigator an opportunity to probe for answers in greater depth. Furthermore, if questions are not readily understood the interviewer can clarify the subject so that usable responses can be obtained. Overall, this type of interview improves the completeness and accuracy of answers. 16

Definition of Terms

For purposes of this study the following definitions of terms

will apply.

Anemia - A significant reduction in the concentration of hemoglobin

per 100 ml of blood, in the volume of packed red cells per 100 ml of

blood (hematocrit), or in the number of erythrocytes per cubic ml

(Pritchard, 1970).

Basic diet - Descriptive Information on dietary patterns (Christakls,

1977).

Breast-feeding - Human milk feeding of infants.

Deaths - Neonatal: dealth of a live-born Infant prior to the 28th

day of life. Perinatal: combined fetal and neonatal mortality.

Fetal: any termination of pregnancy that does not result in a live

birth (early, lesB than 20 weeks; intermediate, 20 to 27 weeks;

late, greater than 28 weeks) (Hughes, 1972).

Diet instructions - Information concerning foods to eat or avoid, plus data about nutrient and food energy composition of the diet, and

quantities of foods to consume.

Fad diets - Unusual eating patterns or arbitrarily restricted diets

that are believed to prevent and/or cure diseases (Nutr. Rev.

suppl. no. 1, 1974).

Family composition - The number of persons in the family group,

including the age, sex and kinship of the group (Christakls, 1977). Food stamps - Supplemental Income from federal tax revenues,

available to the consumer as stamps to be used for the purchase of

food.

Gravidity - The number of times a woman has been pregnant (Hughes,

1972).

Intercurrent diseases and illnesses - Chronic diseases of a metabolic,

Infectious, or neoplastic nature (Chrlstakis, 1977).

Kilocalorle - The unit of measure for food energy.

Lactation - The process primarily dependent on the physical state of the mammary glands and the physiologic mechanisms which control the development and functional capacity of the glands to produce milk.

Low-blrth-weight babies - All infants with birth weights under 2,500 grams regardless of (Christakls, 1977).

Nutrition label - A listing of the nutritive values in a single serving of a food item, on or attached to the container or package

(The National Nutrition Consortium, Inc., 1975).

Parity - The number of infants b o m to a mother, either premature or full term (Hughes, 1972).

Physicians - Medical doctors who practice a specialty directly related to the care of obstetric patients. Specifically, physicians listed in the American Medical Association Directory (1973) or the Directory of Medical Specialists (1974-1975).

Prlmipara - A woman who has given birth for the first time.

Premature infantB - All infantB b o m prior to 37 weeks gestation

(Christakls, 1977). 18

Prenatal classes ■- Classes sponsored by a hospital clinic or private education association for the pregnant mother, devoted to topics associated with pregnancy, childbirth and the post-partum period.

Small babies - Newborn delivered at birth weights under 2,500 grams

(Siegel and Morris, 1970).

Small-for-date infants - Newborn who are gestatlonally mature but their rate of fetal growth has been retarded (Siegel and Morris, 1970).

Toxemia of pregnancy - Preeclampsia; hypertension with proteinurlp or edema, or both, appearing after the 20th week of pregnancy.

Eclampsia: the occurrence of one or more convulsions in a patient with the criteria for the diagnosis of preeclampsia (Working Group on Nutrition and the Toxemias of Pregnancy, 1970). CHAPTER II

LITERATURE REVIEW

This literature review will focus on investigations concerning » * the relationship between maternal nutrition and the course and outcome of pregnancy. Because the nutritional management of pregnancy from

1930 to 1960 may have profoundly influenced obstetrical care today, nutritional theories will be presented by cyclic periods. Reports and recommendations of the Committee on Maternal Nutrition of the

National Research Council (1970), the ad hoc Committee on Maternal

Nutrition of the American College of Obstetricians and Gynecologists

(Pitkin et al., 1972) and prominent medical and nutrition authorities specializing in nutritional aspects of maternity care will be discussed. Government surveys, conferences and publications related to national nutrition policies for pregnant women will be reviewed.

The moBt current recommendations for the nutritional component of maternity care will be summarized.

Brief History of Nutrition in Human Reproduction

Review of Early Literature

An extensive review of literature related to nutrition and pregnancy for the years 1920-36 was published by Gerry and Stiven

19 20

(1936). The authors evaluated animal and human studies for purposes of discerning maternal dietary needs, but failed to reach any definitive conclusions because early investigators had been unable to distinguish either kinds or amounts of nutrients essential to pregnancy. Gerry and Stlven could only recommend that for pregnant women "a mixed diet of natural foodstuffs gave the best results."

Studies Related to Diet and Maternal Nutrition, 1940’s

In the early 1940's Ebbs and coworkers (1941, 1942a, 1942b) examined the effects of maternal dietary practices on the health and well-being of 285 mothers and offspring who attended a Toronto hospital prenatal clinic. Women were divided into separate groups according to income, food supplements or diet instructions. For all groups there was no correlation between and total maternal dietary intake but mothers with better quality diets had fewer obstetrical complications and the Incidence of spontaneous , prematurity and cogenital debility was low.

Cameron and Graham (1944) documented the importance of prenatal diet instructions. A group of 500 pregnant women in a Glasgow maternity clinic were given Information about selecting an adequate diet and compared with another 500 women who served aB controls. The

Incidence of prematurity and fetal mortality was lower among the group of women who received diet instructions.

In the United Kingdom, Baird (1945) compared family diets for the depression years, 1934-38 with family diets for World War II, 21

1940-44. During the depression period families experienced dietary

deficiencies In every nutrient examined. Throughout the war, diets began to Improve with respect to food energy and protein because of better'health propaganda, food rationing, Increased purchasing power and free or low cost milk. Commencing In 1942 the and neonatal death rates decreased In spite of wartime living.

Improved Infant survival rates reflected a general decline in prematurity, cogenital debility and birth injury. Baird attributed

the improved infant health statistics to better family diets.

Two classic studies involving human reproduction evolved as a result of acute food shortages in Holland and Russia during World War

II. Because of Nazi reprisals against inhabitants of western Holland from September 1944 until May 1945 a severe famine occurred (Smith,

1947a, 1947b, Nur. Rev., 1973). Per capita intake of food energy during the famine was 450-750 kilocalorles and protein consumption was approximately 30-40 grams per day. Mean birth weight of babies born at the end of the famine was 250 grams less than that of other

Dutch infants born in nonfamine areas. Also, babies were shorter than ones born in the same area prior to the famine. The incidence of stillbirth, prematurity and cogenital malformations was not significantly increased. Apparently, the mother's diet had been adequate prior to the famine so nutritional stores were Intact

(Stearns, 1958).

The siege of Leningrad lasted from August 1941 until January

1943. Inhabitants of this city experienced unusually severe 22

starvation. In a study on the status of newborn, Antonov (1947)

reported that by the first half of 1942, the city's birthrate had

declined and the stillbirth rate had doubled. Prematurity Increased

by 41 percent and neonatal deaths accounted for 9 percent of all full-

term Infants and 31 percent of prematures. On the average, a baby b o m during the siege weighted 500 to 600 grams less than a normal

prewar baby.

Stearns (1958) interpreted findings from these two "natural"

experiments in malnutrition to mean that a mother's diet during the

latter part of pregnancy was likely to affect weight and length of

the newborn and chronic maternal malnutrition during an extended period prior to conception and during pregnancy, profoundly affected

the infant's chance of survival. In Leningrad, even full-term infants experienced diminished vitality and poor resistance to infection.

Evidently the mother's nutrient stores were inadequate to sustain the fetus.

In Boston, Burke (1949) and colleagues examined the physical condition of infants at birth and compared these data with similar data obtained from elder siblings. Mother's diet histories were reviewed by the investigators and categorized as "excellent or good",

"fair", "poor" or "very poor." Stillborn infants, neonatal deaths, premature infants, functionally immature infants and most infants with congenital defects were found among groups of babies b o m to mothers with "poor" or "very poor" diets. There was a relationship between ratings for maternal diet and length and weight of offspring 23

at birth. In 53 tnatched pairs of siblings, improved status of the

younger sibling matched improvement of the maternal diet between the

first and second pregnancy. Conversely If the maternal diet declined

in nutritional quality between first and second pregnancy, the status

of the younger sibling was less favorable. In this study no effort

was made to alter dietary patterns so that every mother acted as her

own control.

Jeans et al. (1952, 1955) studied 404 indigent, pregnant women

in Iowa. They reported that diets consumed during pregnancy differed

little from lifetime diets except for an increase in total Intake.

Only 37 women in the study had a dietary Intake with nutrients

exceeding 75 percent of the 1948 Recommended Dietary Allowances (RDA)

and these diets tended to be very high in carbohydrate. Premature

infants were born to women who had been pregnant five or more times in

rapid succession. Six mothers, all under the age of 21, were judged

to have "very poor" diets and delivered prematurely. When diet

histories were analyzed, It was found that poor food selection was a

problem with origins in early childhood. Women with good diets at

time of conception had usually been well-nourished throughout their

lives.

Dietary supplements administred to low-income pregnant women proved beneficial in reducing perinatal deaths. In England, Balfour

(1944) demonstrated that a milk product and a vitamin-mineral preparation added to the diets of poor mothers significantly reduced

the number of fetal and neonatal deaths. The Improvement was 24 attributed to the vltamin-mineral preparation rather than the milk.

In most studies published prior to 1950, researchers concluded that good maternal nutrition favorably Influenced the course of pregnancy and statue of the newborn. Fetal and neonatal deaths and prematurity were associated with poor quality diets.

Studies in the 1950's

From 1949 to 1958, physicians at Vanderbilt University conducted extensive investigations into the effects of maternal nutrition on the outcome of pregnancy (Darby et al.. 1953a, 1953b; McGanity et al..

1954a, 1954b, 1955; Darby et al.. 1955; McGanity et al., 1958).

McGanity, Darby and coworkers studied 2,338 white, low-lncome mothers from the Nashville area. While they found no frank deficiency diseases they reported that 15 percent of their patients "suffered" from obesity. They concluded that obesity was an unnecessary penalty for childbearing.

McGanity's group found that women with food energy and nutrient intakes greater than one or two standard deviations above the mean or median were not significantly different in obstetrical performance than all other women in the study. Likewise, women with energy and nutrient intakes one or two standard deviations below the mean or, below the RDA for food energy, were not experiencing any complications of pregnancy, nor were there indications that their offspring were in any way adversely affected. Further examination of data related to maternal nutrient intake convinced the investigators that toxemia of pregnancy was not related to either food energy intake or protein content of diet. The conclusion was that the disease process itself caused a voluntary reduction in protein and calories. However, there was one correlation that was significant: obstetrical and fetal complications were associated with a daily intake of less than 1500 kllocalories and less than 50 grams protein during the third trimester of pregnancy. But the group reported that mothers who consumed the greatest amount of food, especially during the second trimester, seemed to gain more weight and also experienced a higher incidence of toxemia.

McGanlty's group also studied the anemias of pregnancy. Many women had hemoglobin values of less than 10 grams per 100 ml, but only four percent of the sample were Iron-deficient. An assumption was made that infants born to anemic mothers would indeed have insufficient iron stores, but with proper feeding could catch up with normal

Infants in about 12 months.

These researchers regarded prenatal vitamln-mineral supplements as extravagant and ineffectual. Should a mother's diet appear deficient in essential nutrients, physicians were advised to provide appropriate diet education. The investigators concluded from this study that "the incidence of most obstetrical complications such as prematurity and fetal mortality were in no way related to nutritional deficiencies." This conclusion was derived from the concept that nutrient intake was unrelated to fetal and neonatal development— a 26 concept prevailing through the 1960's and continuing to Influence physicians1 practices today. Recent research has cast doubt on these

"traditional" approaches to maternity care.

In Detroit, Macy and coworkers (1954, 1958) compared certain biochemical parameters in black and white pregnant women. The range of hemoglobin values in the last months of pregnancy was found to be

0.7 to 1 gram higher for white women than black women. Similar findings were obtained for serum ascorbic acid and ; white women showing conslstantly higher values. All subjects in these studies were healthy and their infants were delivered at full term weighing at least 2,500 grams. Macy concluded that changes in hormonal secretions, a greater retention of nutrients, plus composition and function of the allowed a mother to adjust seccessfully to a variety of dietary practices during pregnancy; adding evidence to the assertion that nutritional influence on pregnancy outcome was minimal,

Thompson (1957) in Scotland reported "the correlations between food intake during pregnancy and the outcome of pregnancy so elusive that it made it far from easy to demonstrate any connection." He studied 3,500 primlgravidas in order to define the characteristics most closely associated with successful childbearing. He concluded that a lifetime of good dietary proctices allowed a woman to grow to her full genetic potential, and good general health meant fewer complications of pregnancy. Females from an Impoverished environment, stunted by poor dietary intake during childhood, tended to have 27

smaller babies and more reproductive failures*

In the United States, Birnberg and Abltbol(1958) summarized the

Important prenatal nutrition considerations prevalent In the 1950*s.

Excessive weight gain was considered the major nutrition-related

complication of pregnancy and thought to cause toxemia, hypertension,

prolonged labor and postpartum hemorrhage. Excessive weight gain was also blamed for large babies and permanent maternal obesity. For weight control, doctors were urged to prescribe a reducing diet and

anorexiants for all except underweight patients. Vitamin-mineral

supplements were considered adequate to meet the nutritional needB of mother and fetus.

Studies in the 1960's

With obvious discrepancies In the results of so many investigations there occurred a decline in interest In the whole subject of maternal nutrition. Nearly a decade (1955-65) elapsed when little emphasis was accorded the dietary component of obstetrical care (Terris, 1966).

Physicians basically limited their diet instructions to weight control and the importance of maintaining a slender figure (Birnberg and

Abltbol, 1958).

In the late 1960's American obstetricians and pediatricians became concerned about perinatal handicaps, birth Injuries and infant deaths. Chase (1967) reported that fetal mortality and mortality during the first 24 hours of life resulted in a relatively high 28

perinatal death rate. This perinatal death rate was associated with

factors which resulted in delivery of low-blrth-weight or preterm

infants.

In the opinion of Siegel and Morris <1970) perinatal mortality

and morbidity were sensitive Indicators of reproductive failure.

They attributed such failure to heredity, Infections, cigarette

smoking and use of certain drugs. They also outline known

relationships between nutrition and pregnancy outcome. Maternal age

clearly Influenced pregnancy outcome. Fetal mortality was highest

among girls under 17 and women over 40; and even higher among young

women with high parity. Prior reproductive lose predisposed a woman

to future losses. Complications such as toxemia and.antepartum

hemorrhage or cesarean section Increased perinatal mortality.

Nutrition and socioeconomic factors were closely Interrelated and

influenced pregnancy outcome. Other factors such as geographic

location, maternity care, race and mother's psychological state were pertinent to pregnancy outcome and subsequent Infant development.

By 1965 babies weighing less than 2,500 grams at birth comprised over 8 percent of all live births within the United States (Chase,

1967). This group of low-blrth-weight infants contributed the bulk of physically and mentally damaged children who required special care (Siegel and Morris, 1970).

The Incidence of reproductive failure created a demand for research to help improve the outcome of pregnancy for both mother and infant. In 1966 the Food and Nutrition Board of the National Research 29

Council organized a Committee on Maternal Nutrition (1970) to:

1) review current knowledge about problems, practices, and research that bear on the relation between nutrition and the course and outcome of pregnancy;

2) provide, through working groups, opportunities for representatives of medicine, the basic sciences, nutritional science, and public health, to confer on problems relating to maternal nutrition;

3) identify areas requiring further research; and

A) make recommendations and point out implications for medicine and public health.

As a result of the committee's examination of the literature on

epidemiology of human reproductive casualties, a recommendation was

made that groups of American women with the best and poorest

reproductive performance be studied on a continuing basis. Information

coming from such studies would help define the most important risk

factors associated with pregnancy. As part of this investigation, nutrition histories and maternal dietary assessment should be obtained

from all mothers. These studies were to be conducted in geographic areas where high and low rates of fetal and neonatal losses occurred so that Information about effects of food, nutrition supplements and nutrition status on pregnancy outcome could be ascertained. In underdeveloped countries, studies of natural experiments in human reproduction could yield data about effects of nutrition education, urbanization, social change and public services, on the health of pregnant mothers and their offspring. Such cross-cultural comparisons could reveal the moBt Important factors in human reproductive efficiency. About the tine the National Research Council's Maternal Nutrition

and the Course of Pregnancy was published, the White House Conference

on Food, Nutrition, and Health (1969) was convened in Washington,

D.C. The purpose of thiB national meeting was to study and evaluate

food and nutrition needB of all segments of American society. A

special panel was assigned to report on nutrition and health care

needs of pregnant and lactating mothers and young Infants. The

conference recommended that existing nutrition programs be expanded

to reach vulnerable population groups,such as the poor, with nutrition

education and better quality food supplies. For families headed by

a pregnant mother with a limited income, supplementary foods and

financial assistance was advocated.

In the final report of the White House Conference, practical

suggestions for improving the nutritional welfare of pregnant mothers,

fetuses and newborn were made (White House Conference on Food

Nutrition and Health, 1970). Recommendations included;

1) Advantages of breaBt feeding should be made known to all mothers.

2) Nutrition labels on packaged foods would aid consumers in selecting foods to meet nutritional needs of the family.

3) Recognize value of nutrition education by granting financial aid to medical schools in order to support and maintain maternal and infant nutrition education programs.

4) Provide pregnant adolescents, who appear to be in greatest need of medical and nutrition services, with appropriate health care, nutrition education and adequate food. In the late 1960's the Department of Health» Education and

Welfare conducted a survey (Ten-State Survey) on the Bcope and

magnitude of malnutrition in selected areas of the United States

(1968-70). Families in this study represented low-average incomes

in ten states and New York City. As part of this survey 600 pregnant

and lactatlng mothers were selected for special study. These womens'

diets were found to be low in energy* protein* iron* vitamin A and

. In areas designated "very-low-income-ratios*" one-fourth

of the pregnant mothers consumed less than 1,000 kllocalories per day.

In "high-income-ratio" areas* only 10 percent of the mothers consumed

less than 1*000 kllocalories per day. An excess of low-birth-weight

infants were b o m to mothers in "low-lncome-ratlo" areas. Thus* the

relationships between weight gain in pregnancy, low food energy intake

and infant's birth weight focused on nutritional adequacy of the

prenatal diet.

Evidence for the importance of adequate nutrition* not only

during pregnancy but throughout the mother's own childhood and

reproductive years* was reported by the authors of the Ten-State

Survey. Limited weight gain during pregnancy* because of dietary deficiency in food energy* significantly reduced infants birth weight and possibly compromised neurological development. The routine use of low-food-energy diets for prenatal patients was challenged. 32

Studies in the 1970's

During the years 1963-71, Higgins (1972) in Montreal Investigated

the dietary Intake of 1,544 pregnant women cared for in two prenatal clinics. Dietary intake vas assessed and Individual patients counseled about ways to improve their nutrient intake. For some patients it was necessary to provide food supplements such as milk, eggs and oranges.

All patients received a standard prenatal vitamln-mineral preparation.

Throughout the period of study, mothers received intensive dietary counseling. This was essential in order to bring about improvements in the maternal diet.

The incidence of prematurity among these clinic patients was 6.7 percent; about the same as private patients, 6.5 percent. However, it was significantly lower than the clinic patient's previous .

Mean birth weight was the same for Infants born to clinic and private patients. Infants born to clinic patients and private patients had higher birth weights than other routine clinic patients not involved in the study.

The birth weight of each infant was related to maternal weight gain and length of time the mother was involved in the study. Birth weight was also correlated with duration of pregnancy and mother's metabolic size. There was only slight correlation between birth weight and maternal intake of energy and protein. For mothers who smoked, their Infant's birth weight was, on an average, 131 grams less than non-smokers. This was s Ib o true for smokers who had a greater 33

Intake of food energy and protein than non-smokers.

During' this decade prenatal nutrition studies have been conducted in countries in South East Asia and Central America. In both these areas infections and malnutrition are common and mothers are often deficient in vitamins, protein, calcium, iron and food energy

(Thanangkul and Amatayakul, 1975; Arroyaye, 1975). For nearly all nutritional parameters, biochemical abnormalities are similar for mothers and offspring. Arroyaye (1975) believes these studies confirm previous Investigations that showed a pregnant woman's nutritional needs to be greater, and her iron and energy deficits to be worse, than a nonpregnant woman.

Lechtlg and coworkers (1975b) found that maternal height and energy supplementation had little effect on incidence of low-birth- welght among Infants born to mothers of high socioeconomic status.

However, maternal height and food supplementation did have a strong, positive effect on birth weight for infants whose mothers were in a low socioeconomic class. Maternal nutrition was the linking factor between socioeconomic status and fetal growth.

Behrman (1975) postulated that malnutrition and infectious diseases directly or indirectly affected the development and function of the umbilical or uterine vascular beds, tissues critical to normal fetal growth and development. Deficiencies in transfer of specific nutrients to the fetus or an abnormal pattern of nutrients may have lesB of an effect. This theory is consistent with observation on fetal growth retardation associated with a wide variety of clinical 34

problems.

Rush (1975) has found very little evidence of the exls Lence of

classic malnutrition among prenatal patients in industrially ed

countries. In one study of poor, urban Americans, he observe d that

infant's birth weight was strongly influenced by the mothers pregravld

weight and her weight gain during pregnancy. He further de terained

that at least half the variance in birth weight was assocla ted with

maternal cigarette smoking. Furthermore, the single nutrle it factor

limiting fetal growth was a deficiency in food energy.

Current Recommendations for the Nutrition Component of Maternity Care

Energy and Weight Gain

Weight gain during pregnancy has been a controversial topic

since the 18th century (Simpson et al., 1975). Excess weight gain

has been Incriminated in fetal Injury, lactation failure, lowered

resistance to Infection, apoplexy, prolonged labor and has been

considered a hazard for women needing or previously experiencing

Caesarian section (Hannah, 1923). The most compelling reason for

limiting weight gain has been the. assumption that it might prevent

toxemia. Evidence has failed to support this assumption.

"Normal" weight gain during pregnancy has been defined many times during the past five decades. The emphasis haB always cent bred on

total gain. In the 1920's, the desirable weight gain was 12 pounds (Hannah, 1923). In the 1930's, It was 14-15 pounds (Simpson et al..

1975). In the 1940's it was 24 pounds (Chesley, 1944). In the 1950's, it was 15-17% pounds (Dickertnan, 1952), and, in the 1960's, 20 pounds

(Birnberg and Abitbol, 1958).

The Committee on Maternal Nutrition (1970) recommended an average gain of 24 pounds, with a range of 20 to 25 pounds. The Committee on Nutrition of the American College of Obstetricians (Pitkin et al..

1972) recommended a range of 22 to 26 pounds. Hytten and Leltch (1971) in the United Kingdom recommended a weight gain of 27,5 pounds based on their study of 746 pregnancies of healthy women who ate to appetite.

They also reported a wide range of weight gains, minus 5 pounds to over 50 pounds, all compatible with normal pregnancy and delivery. In a more recent clinic study where weight control was not heavily emphasized, the mean gain was 28.3 pounds with a SD of 9,2 pounds

(Pomerance et al.. 1974),

Weight gain in pregnancy has been attributed to an expansion in the maternal compartment by 6 kilograms and the fetal compartment by

5 kilograms, at term. The mother adds 2 kilograms in blood volume, almost 2 kilograms to breast and uterus and 2 kilograms in extra­ cellular fluid. Most of the maternal growth occurs during the second trimester. Fetal growth Includes Increases in the fetus itself, plus enlargement of the placenta and amnlotic fluid volume. The fetal compartment growth occurs mostly during the third trimester (Hytten and Thomson, 1970), 36

Pitkin (1977a) thinks the emphasis on total weight gain during pregnancy is wrong; the pattern of accumulation is much more important. He recommends a minimal gain of one to two kilograms during the first trimester of pregnancy, followed by a progressive linear rate of 350 to 400 grams per week after the 19th week of pregnancy. Furthermore, Pitkin believes the best overall reproductive performance is associated with a weight gain of 11 kilograms (about

24 pounds). Thomson and Billewicz (1957) found the lowest overall

Incidence of preeclampsia, prematurity and perinatal mortality at a rate of gain of slightly less than 0.5 kilogram per week during the second half of pregnancy. Maternal weight gain in normal pregnancy follows a course of approximately 0.65 kilograms at 10 weeks; 4,0 kilograms at 20 weeks; 8.5 kilograms at 30 weeks and 12.5 kilograms at term. Either very rapid weight gain or little or no gain signals possible risk (Hytten and Leitch, 1971).

Eastmen and Jackson (1968) reported that mothers who gained lesB than 14 pounds during pregnancy experience net-weight loss and there­ fore had to draw on their own nutrient stores to support pregnancy.

They believe there are serious implications to net-weight loss or underweight at beginning of pregnancy. Any underweight woman who fails to gain at a normal rate during pregnancy should be considered a high- risk patient,

Niswander and Jackson (1974) studied 5,755 white and 6,102 black pregnancies. They discovered that maternal height appeared to have little effect on birth weight but prepregnant weight and weight gain during pregnancy had a significant effect on birth weight. Perinatal death rate diminished as maternal weight gain increased. Simpson et al. (1975) in a study of 24,335 white and 2,133 black pregnancies, found that the incidence of low-birth-weight decreased in relation to an increase in either pregravid weight or weight gain during pregnancy.

Thus, maternal prepregnant weight and gestational weight gain exert

Independent and additive effects on birth weight and Infant survival

(Simpson et al.. 1975). In addition to total food energy, diet supplements of protein, iron and folacln have been identified as positively increasing birth weight, especially when these nutrients were supplied to mothers of low socioeconomic status (Qureshi et al.»

1973).

Pitkin (1976) considers weight gain during pregnancy a crude index of nutritional statuB. However, weight gain per se does not reveal progress of fetal development. He suggests the following guidelines as evidence of deviations from normal weight and weight gain.

Underweight: Prepregnant weight 10 percent or more below ideal weight for height and age.

Overweight: Prepregnant weight 20 percent or more above ideal weight for height and age.

Inadequate gain; Gain of 1 kilogram or less per month in the second or third trimester.

Excessive gain: Gain of 3 kilograms or more per month. 38

Food Energy

The increasing energy costs associated with pregnancy results

from growth and metabolic requirements of the products of conception*

plus adaptive changes in the maternal organism. Additional energy is

required for blood volume expansion* extracellular fluid and the

uterine compartment expansion; and increases in breast and adipose

tissue. Emerson et al. (1972) studied the total extra caloric costs

associated with pregnancy in the resting state. They estimated that

a value of 27*000 i 3*000 kllocalories would meet the metabolic needs

for normal gestation; and that the extra cost of pregnancy was minimal.

The recommended dietary energy allowance (RDA 197A) for the mature

pregnant "reference woman 1b 15 percent above the nonpregnant state*

or 300 kllocalories* which is an average of 2400 kllocalories per day."

However* Pitkin (1977b) takes exception to this allowance as it falls

to reflect unusual physical activity* ambient temperature* additional

growth requirements such as adolescence* or the trimester of pregnancy.

Pregnant women should be encouraged to consume not less than 1800

kllocalories per day. The Incidence of low-birth-weight* approximately

6 percent in highly developed countries*^- could be reduced or

eliminated by a modest food energy supplement (Nutr. Rev,* 1976).

Speroff (1973) warns against food energy restrictions during pregnancy because the primary fetal fuel* glucose* is derived from maternal supplies. In order to meet its growth and metabolic needs*

*In Ohio the rate of low-birth-weight is 7 percent (1976) Annual Report), 39

the £etus "drains" glucose from the mother. In meeting fetal needs,

the mother in turn, is subject to periods of relative hypoglycemia.

Inadequate food energy intake and/or Infrequent eating enhances

hypoglycemia in the mother and ketonemla In the fetus. Speroff

recommends an energy Intake of not less than 2200 kllocalories per

day, divided into several meals*

Stein and Susser (1975) suggest that when maternal energy Intake

dips below 1500 kllocalories per day the placenta may undergo

functional changes. Rather than transmitting nutrients to the fetus,

the placenta utilizes nutrients for its own metabolism.

Pomerance (1972) thinks a woman's appetite may be her beBt guide

to energy needs. Under all circumstances, energy Intake in healthy

women should not be reduced below 36 kllocalories per kilogram of

pregnant body weight, the energy Intake required for adequate

utilization of protein during pregnancy (Food and Nutrition Board,

1974).

Clinical Considerations of Inadequate Energy Intake

The underweight patient enters pregnancy at considerable risk.

There is an increased chance for toxemia and antepartum hemorrhage.

Similarly, a patient with inadequate weight gain during pregnancy is more likely to give birth to an Infant with low weight (Pitkin, 1977).

Birth weight is positively correlated with both physical and mental

development. Mental deficiency is more frequently encountered in

full~term infants with weight below 2,500 gramB than in Infants born AO

prematurely (Bandera and Churchill, 1961). Churchill et al. (1966)

identified children vith mild-to-moderate undifferentiated mental

retardation to be of lower average birth weight than children with higher I.Q.'s. Neither lower I.Q. nor lower birth weight could be attributed to social or cultural factors. In twins, the heavier

infant at birth is favored with a higher I.Q.

Clinical Considerations of Excess Energy Intake

Obesity, the most common nutrition-related disease in the nation, affects over 30 percent of all adult Americans (Stern, 1977).

Obesity at the onset of pregnancy Increases the risk of certain complications such as diabetes mellltus, chronic hypertension and thromboembolic disease (Peckham and Christianson, 1971).

Thromboembolic disease and hemorrhage proved to be the leading causes of death for grossly obese maternity patients (Maeder et al., 1975).

Management of prenatal obesity has changed in the last two decades. In the 1950's physicians recommended strict weight control so that a patient would achieve a net Io b s after delivery. However, severe energy restrictions may have resulted in an Inadequate intake of essential nutrients. Fasting to reduce weight may cause ketonemla in the pregnant mother and ketosls in the fetus. Ketosls is poorly tolerated by the fetus. Churchill and Berendes (1969) found that mothers who produced acetone-positive urine during pregnancy had offspring with significantly lower I.Q. scores by the age of four.

Today, obese patients are encouraged to gain weight at a steady rate 41

and to avoid crash diets or strict dietary controls (Maternal and

Child Health, California Dept, of Health, 1977).

Physicians have often confused excess weight gain with fluid

accumulation.' While extracellular fluid retention Is one of the

classic symptoms of toxemia It Is not necessarily abnormal during the

last few weeks of pregnancy or during hot weather or when only the

feet and ankles are involved (Ayers, 1974). Weight gain through

increased adipose tissue synthesis Is unrelated to preeclampsia. The

only problem associated with excessive tissue accumulation during

pregnancy is its contribution to p.ostnatal obesity.

Protein

It has been exceedingly difficult to establish a precise protein

allowance for the pregnant woman. Together the mother and fetus

accumulate approximately 925 grams of protein during pregnancy

(Hytten and Leitch, 1971), The nitrogen content of blood, uterus,

breast, fetus, placenta and amnlotlc fluid accounts for an addltonal

protein need of 10 grams per day, that Is, in addition to the

recommended allowance and assumes complete protein utilization.

Nitrogen balance studies in pregnant women have made it possible

to estimate the level of protein required to keep subjects in nitrogen

equilibrium. Calloway (1974) has suggested that the efficiency of protein utilization diminishes during pregnancy and protein metabolism

is altered to allow for the increased rate of tissue synthesis. 42

Nitrogen retention during the last half of pregnancy Is approximately

1.1 grams per day. The calculated fetal and maternal gain is

approximately 0.8 grams per day (King, 1975). There are no clear data

to explain this discrepancy. The current RDA for protein Is 76

grams, 30 grams In addition to the 46 grams for the nonpregnant woman.

For the mature woman this amounts to 1.3 grams per kilogram of body weight, 1.5 grams/kg for girls 15 to 18 years, and 1.7 grams/kg for girls under 15 (Pitkin, 1977).

Consequences of insufficient protein Intake during pregnancy have been difficult to establish. There may be a relationship between maternal toxemia and . Often providing supplementary food energy will correct a protein deficiency (Lechtig et al.t 1975).2 Healthy pregnant women who eat to appetite appear to have protein and energy Intakes comparable to the RDA (King, 1975).

Serum protein concentration normally declines by about 1 gram per dl during pregnancy. This physiologic adjustment parallels the

Increase in blood volume and should not be Interpreted as evidence of a deficiency state. Laboratory tests to establish the presence of protein malnutrition during pregnancy have been difficult to develop*

Measuring albumin levels do not reflect protein nutriture to any extent (Hytten and Thomson, 1970). The urinary nitrogen/total nitrogen ratio (UN/TN ratio) may be used to evaluate protein status

^Optimal protein utilization in pregnancy seems to require a minimum of approximately 30 kllocalories/kg/day (Oldham and Sheft, 1951). to

for high risk patients (Aubry et al., 1975),

Iron

A mother's need for iron increases substantially with pregnancy

because of accelerated erythropoieses due to expanded blood volume.

Plasma volume Increases by 50 percent above nonpregnant levels and

erythrocyte volume Increases by 20 to 30 percent. Hemoglobin levels

drop below 12 grams in 72 percent of all women by the end of the

second trimester and 36 percent of all women by term. The "anemia of

pregnancy" results from hemodllution and represents a fundamental

physiologic adjust of human gestation (McFee, 1973). These blood volume changes are responsible for a drop in hemoglobin (and hematocrit) which reaches its nadir by the end of the second trimester.

The increase in plasma volume is closely related to the birth weight of the baby (Hytten and Paintin, 1963).

Pritchard (1970) defines anemia as a "significant reduction in

the concentration of hemoglobin per 100 ml of blood; in the volume of packed red cells per 100 ml (hematocrit) or in the number of erythrocytes per cubic millimeter." During pregnancy, McFee (1973) recommends for practical purposes, true anemia of pregnancy be defined as a "hemoglobin of lean than 11 gm/100 ml or a hematocrit of less than 33 percent." However, serum iron levels more truly reflect bone marrow stores and, as long as a woman possesses iron stores serum iron will remain above 60 jjg percent (McFee, 1973). As iron stores 44

drop Iron binding capacity will rise, the critical value being 300

pg percent. The ratio of serum iron to iron-binding capacity,

saturation of transferrin, is regarded as the most accurate assessment

of iron nutriture in pregnant women (Carr, 1974).3 There are some

differences of opinion as to the critical level for diagnosislng iron

deficiency anemia but values below 15 percent are considered significant.

The fetus acts as a parasite on maternal iron stores regardless

of the mother's capacity to meet her own needs (Strauss, 1933). She

may become severely anemic in the process of delivering a nearly

normal infant. Mild, (maternal) iron deficiency anemia does not appear

to affect Infant's iron stores at birth nor decrease the child's

hemoglobin levels during the first year of life (Pitkin, 1977).

There is some disagreement among various investigators about the

amount of iron required for pregnancy. Studies of single-fetus

pregnancies have provided data indicating that 800 to 1230 mg of iron may be necessary for gestation (McFee, 1973). McFee suggests a

practical value of lOOOmg. American diets provide approximately 10-12 mg elemental iron per day and although iron absorption improves

greatly with pregnancy, only 1.5 to 2.0 mg are actually available to

the mother. It has been estimated that a pregnant mother needs at

least 5 to 6 mg daily (Pitkin, 1977b). Any shortage must be made up

^Transferrin saturation is also a sensitive Indicator of fetal nutrition, Kelly (1974) found that an Infant's birth weight was related to the level of transferrin saturation in the mother at the beginning of the third trimester of pregnancy, A low level of transferrin saturation was indicative of maternal malnutrition and the likllhood that the baby would be small. 45

from maternal body stores or supplements (Scott and Pritchard, 1967).

Scott and Pritchard (1967) estimated that two-thirds of non­ pregnant, nulllgravld, yound women, judged In excellent health, had

Iron stores (In reticuloendothelial bone marrow cells) equal to or

less than 350 mg. One in four women in their study were without

stores. Few of the women possessed Iron stores of 1.0 to 1.5 grams, a value assumed to be normal for adults. This study suggests that

storage iron is I c b s than the amount required to maintain a normal pregnancy.

Ferrous salts of gluconate, sulfate or fumerate taken throughout pregnancy will furnish enough iron to meet the needs of mother and developing fetus (Holly, 1955). The Committee on Maternal Nutrition

(1970) recommends a dally dietary supplement of 30 to 60 mg iron for the latter half of pregnancy.

Even with early and accurate diagnosis, iron-deflciency anemia can persist throughout pregnancy. The ongoing problem may result from a patient's failure to take oral iron compounds, nausea and vomiting of pregnancy, gastrointestinal Intolerance to oral iron, abnormal bleeding, multiple pregnancy, malabsorbtion of iron, poor dietary habits and pica. Pica, consumption of nonfood items such as starch, clay and ice; is considered a symptom of iron-deficiency anemia

(Uhlte, 1975).

If iron deficiency anemia is discovered during the last weeks of pregnancy or, if a patient is unable to tolerate oral iron, parenteral iron preparations may have to be administered (McFee, 1973). 46

The hemoglobin response rate is Identical for oral and Injected

products (Pritchard, 1966). Parenteral iron is appropriate in

emergency situations, not as part of routine care.

Folacln

Folacin needs double during pregnancy because of fetal growth and

accelerated maternal erythropoleses (Kitay, 1969). The RDA for folacin

increases from 400 Mg for the nonpregnant woman to 800 M8 during

pregnancy (Food and Nutrition Board, 1974). Megaloblastic anemia,

caused by an increased demand for , is occasionally encountered

in pregnant women. A diet lacking in meat, especially liver, and

fresh-green vegetables is the primary cause of folate deficiency.

Other causes of megaloblastic anemia include multiple pregnancies,

impaired folate absorption and conditions where abnormally high rates of erythropoleses occur such as chronic hemolytic anemias (Herbert,

1973).

Megaloblastic anemia is distinguished by a sequence of micro­ biological, biochemical and cytomorphological changes that follows a definite pattern (Herbert, 1962), Low serum folate is discernable at 3 weeks, hypersegmentation of neutrophils at 7 weeks, elevated formlmlnoglutamlc acid (FIGLU) excretion at 14 weeks, low red-blood­ cell folate at 18 weeks, megaloblastic marrow at 19 weeks and frank anemia at 20 weeks. Incidence of this type of anemia depends on the diagnostic criteria employed. Perhaps as many as 20 to 23 percent 47

of normal unsupplemented pregnant women exhibit some signs of folate

deficiency by late pregnancy.

Consequences of folate deficiency on pregnancy outcome are not

entirely understood* Several retrospective studies have implicated

hematologic changes with complications such as abruptlo placenta,

spontaneous abortion, fetal malformation and preeclampsia (Streiff

and Little. 1967). Other Btudies have failed to corroborate these

findings (Daniel et al*. 1971),

Treatment of megaloblastic anemia with oral folate produces a

rapid response. Daily supplements of 200 to 400 pgs should be

sufficient to protect most women during pregnancy (Pitkin et al*.

1972),

Calcium

Serum calcium levels decline during pregnancy. This decline is not symptomatic of a deficiency state but rather another physiological adjustment of pregnancy closely associated with the decline In serum albumin (Pitkin. 1975), A woman accumulates approximately 30 grams of calcium during a single pregnancy. Fetal calcification occurs during the third trimester of pregnancy when approximately 300 mg of calcium are utilized dally. There is evidence to suggest that calcium is stored in the maternal skeleton during early pregnancy for late pregnancy needs and use during lactation. 48

Researchers have regarded calcium balance studies with

considerable skepticism, especially those Involving pregnant women

(Pitkin, 1976). The current RDA for calcium In pregnancy Is 1200 mg,

an increase of 400 mg above the RDA for the nonpregnant woman

(Food and Nutrition Board, 1974). Because calcium absorption improves

with pregnancy this increase appears to be adequate (Pitkin, 1975).

The dietary needs of both mother and fetus can be met when the

mother drinks one quart of milk daily, or consumes equivalent amounts

of dairy products. If milk intolerance exists or milk is not consumed,

a calcium supplement would be In order. Some physicians consider

calcium lactate or calcium gluconate acceptable substitutes for the pregnant mother (Duggins et al., 1974).

Intake of calcium below the recomnended level is unlikely to effect the health of either mother or Infant because of large maternal calcium reserves. However, calcium depletion does occur because osteomalacia has been observed both during and after pregnancy

(Hytten and Thomson, 1970).

Vitamins

Vitamin D

The active metabolite of , 1,25 dlhydroxycholecalclferol

(1,25-HCC) is in equilibrium between maternal and fetal tissues, 49

apparently free to cross the placental barrier. Should a toother

experience low serum levels of 1,25-HCC the fetus will likewise maintain diminished levels. Early neonatal hypocalcemia may be caused

by maternal deficiencies In vitamin D or calcium or both. Neonatal

deficiency reaches a peak incidence when late pregnancy coincides with the season of the year having the fewest days of sunshine

(Hlleman and Haddad, 1974).

In England, Turton et al.. (1977) suggests that vitamin D be

included in the list of routine vitamin supplements prescribed for pregnant women, particularly in winter months. The current RDA for pregnancy is 400 IU (Food and Nutrition Board, 1974) the amount contained in one quart of fortified milk. Excessive vitamin D Intake is hazardous and pregnant mothers should be warned against ingesting large amounts (Goodner, 1975).

Other fat-soluble vitamins

There is little evidence linking deficiency states of vitamins

A, E and K with abnormalities of pregnancy. Shortages are unlikely because these vitamins are stored In maternal tissues. The current

RDA for pregnancy for vitamin A is 5,000 IU and for , 15 IU.

Vitamin K deficiency Is rare In adults and no evidence has been forth coming demonstrating any additional needs during pregnancy (Food and

Nutrition Board, 1974).

Overdosages of certain nutrients have been reported in medical literature. Food faddists frequently consume excessive amounts of .50

vitamin A, sometimes 5 to 10 times the recommended dally allowance.

During pregnancy excessive Intake produces hypervitamlnosis A In the

mother and toxicity in the Infant (Frame et al.. 1974; Bernhardt and

Dorseyt 1974; Goodner, 1975).

Water-soluble vitamins

Ascorbic acid. The current RDA for ascorbic acid for the pregnant

woman is 60 mg (Food and Nutrition Board,‘1974). Well-defined scurvy

has disappeared in this country and only among a limited population

of food faddists could one expect to discover individuals with

symptoms of deficiency (JAMA. 1971).

Thiamine. needs increase during the last two months of

pregnancy. The recommended allowance is based on energy intake;

0.5 mg per 1,000 kllocalories for the first and second trimester and

0.6 mg per 1,000 kllocalories for the last trimester. These levels appear to meet the needs of mother and fetus (Food and Nutrition

Board, 1974).

Riboflavin. is retained more efficiently during pregnancy but some evidence supports the concept that a larger intake

is needed to match the increased energy intake by the mother. The

RDA for riboflavin is 1.5 to 1.7 mg daily, an increase of 0.3 rag over the nonpregnant allowance (Food and Nutrition Board, 1974).

Niacin. There has been little research concerning requirements during pregnancy. However, it is known that the tryptophan-nlacln conversion is more efficient during the last 51 trimester of pregnancy. The RDA for niacin, like riboflavin, is related to food energy intake and increases to 15 or 16 mg per day (Food and

Nutrition Board, 1974).

Vitamin Bfi. Numerous Investigations have been conducted into vitamin Bg needs of pregnant women (Contractor and Shane, 1969, 1970;

Lumeng, 1976; and Cleary, 1975). Xanthurenic acid excretion tests following tryptophan loading (the laboratory test forBg deficiency) have been higher and placental pyridoxine levels and pyrodloxal kinase activity lower in preeclamptic women (Splnce et al.. 1951;

Klleger et al.. 1966). While this suggests a vitamin Bg deficiency there is no indication that Bg benefits either mother or fetus, however, in one study patients who delivered low-birth-weight Infants and developed preeclampsia had low or borderline protein, and caloric intakes and low circulating Bg levels (Kaminetzky et al., 1973).

The RDA for vitamin Bg for pregnancy is 2.5 mg, 0,5 mg higher than the nonpregnant allowance but below the level necessary to bring laboratory findings to normal nonpregnant levels (Lumeng et al., 1976). Vitamin

Bg requirements parallel increases in the protein content of the diet

(Food and Nutrition Board, 1974). One current study concludes that the

RDA for pregnancy should be Increased to at least 4 mg per day

(Lumeng et al., 1976).

Vitamin B^j. Vitamin Bj^ allowances have been difficult to estimate. Fetal demand has been estimated at 0.3 /ig per day but definitive recommendations for the mother have not been established

(Ball and Giles, 1964). The RDA for pregnancy is 4 jig (Food and 52

Nutrition Board, 1974).

Trace Elements

Trace elements such as , and are of

considerable interest as more is learned about their role in pregnancy

(Pitkin, 1976). Moreover, as the composition of the typical American

diet changes these relatively little known nutrients may be found to

have an important role in maternal nutrition.

Vltamln-mineral Needs

While there are modest increases In vitamin and mineral allowances during pregnancy, nutrient needs can be met by diet alone, the single exception being Iron. Diet alone may not provide a sufficient quantity of iron; thus every pregnant woman should receive a supplement. Folate needB double with pregnancy and supplementation is regarded as proper and good insurance (Pitkin et al.. 1972). Supplementation of other vitamins and minerals is probably unnecessary and may be a waste of money; but in prescribed amounts, harmless (Langer et al.. 1973).

Kamlnetzky et al. (1973) found that oral mutli-vitamln supplements were effective in raising circulating levels of folate and thiamine but not other vitamins. Obviously, vltamln-mineral supplements taken during pregnancy can't compensate for a lifetime of poor dietary habits (Working Group on Nutrition and Fetal Growth and Development, 53

1970).

«

Sodium

Llndhiemer and Katz (1973) auggest that pregnancy 1b a Balt-

losing state and efforts to restrict dietary sodium are unphyslologic

and inappropriate in normal pregnancy. In studies of pregnant rats,

Pohanka and Pike (1970) discovered a vigorous effort by the maternal

organism to conserve sodium. The effort vas mediated through the

renin-angloten8ln-aldosterone Bystem to compensate for increased

sodium excretion due to accelerated glomerular filtration. When rats

were severly restricted in sodium intake, the zona glomerulosa

became so overworked the tissue ultimately reached physiological

exhaustion. Pike and Yao (1971) contended that normal physiological

adjustments occur during pregnancy and the need for sodium parallels

tissue growth.

In the final months of pregnancy, changes in posture can alter

the glomerular filtration rate, the renal plasma flow and sodium excretion. Sodium retention, weight gain and mild ankle swelling may occur as a result of physical activity, especially during the day when

sodium excretion is maximal, but hypertension and proteinuria are not evident* Llndhelmer et al. (1973) emphasized that physicians should not regard a readily reversible weight gain as a pathological condition.

The Comnittee on Nutrition of the American College of Obstetricians and Gynecologists (Pitkin et al., 1972) regards sodium s b an essential 54

nutrient for normal pregnancy* Severe sodium restriction could lead

to elimination of foods with essential nutrients, either because they

were high in sodium content or because the lack of salt impaired taste.

Specific Nutrition-related Problems Complicating Pregnancy

The Pregnant Adolescent

The Committee on Maternal Nutrition (Working Group on Nutrition and Pregnancy in Adolescence, 1970) emphasized that girls who become pregnant before age 17 "are at great biological and psychological risk." There is an ever-increasing population of pregnant adolescents, this in spite of and abortion. Ballard and Gold (1971) reported that in the two decades between 1950 and 1970 the magnitude of teenage pregnancies Increased by 81 percent. They attributed this phenomenon to two significant trends, increased sexual activity by very young women and society's acceptance of out-of-wedlock pregnancies.

Pregnant teenage girls face two distinct nutrition-related problems. First, added to specific metabolic requirements for normal growth and maturation, there are the additional needs Imposed by pregnancy. Second, previous dietary intake may have been deficient in iron, thiamine, calcium, ascorbic acid, vitamin A and food energy

(Working Group, 1970). Toxemia of prognancy, the major risk factor among teenage girls, often reflects poverty, poor nutrition and nonwhite status (Ballard and Gold, 1971). Dott and Fort (1976) reported that adolescents frequently deliver premature infants. If 55

the mother Is unable to provide the fetus vith nutrients from either

her diet or maternal stores the developmental potential of the child

Is compromised.

Dwyer (1974) studied 510 obstetrical patients* age 12 to 16 and

found the outcome of pregnancy "excellent" provided the mother had good medical care and followed sound nutrition advice. Even with adequate nutrition and medical support* more small and premature

Infants were born to young mothers than to older* physically mature women.

Kaminestzky and colleagues (1973) studied 500 unwed pregnant teenage girls at a Newark Maternal and Infant Care Project. A clinical evaluation assessment was completed each trimester In order to determine the presence or absence of overt malnutrition and a dietary assessment with 24-hour recall was also completed at that time. Diets were rated "excellent*" "good*" "fair*" or "poor".

Laboratory* obstetric and pediatric assessments were also completed.

From the data collected* 24 percent of the girls were judged obese;

5 percent were underweight. About 35 percent had engaged in pica* indicating that a substantial number were deficient In iron* Diets were lacking in milk and milk products* green-leafy vegetables and food sources of ascorbic acid. In spite of Intensive dietary counseling* about half the girls failed to improve the quality of their diet. Kaminestzky suggested that patients whose diets were low

In calories may have made up the energy deficit from protein* thus depleting fetal and maternal supplies* Several recommendations were made by the Working Group of the

Committee on Maternal Nutrition for prenatal care of adolescent

patients. Dietary advice should be adapted to the teenager*s

eating habits and Individually tailored to meet her Income level,

emotional and social needs and nutrient requirements. No attempt should

be made to treat obesity and an adequate intake of food energy should

be encouraged. Pregnant teenagers often present problems best managed

by a community health and social agency in preference to care by a

private physician.

•

Toxemia of Pregnancy

The Committee on Terminology of the American College of

Obstetricians and Gynecologists haB suggested that preeclampsia be defined as hypertension, with proteinuria or edema or both, appearing after the 20th week of pregnancy (Working Group on Nutrition and the

Toxemias of Pregnancy, 1970). Hypertension is further defined as a mean Bystolic pressure of 140 mm of mercury or a diastolic pressure of

90 mm of mercury or both. In the absence of these criteria, a systolic rise of 30 mm or a diastolic rise of IS mm indicates hypertension.

These levels must be observed on two occasions, six or more hourB apart. Proteinuria is defined as a concentration of protein of 1 g/liter or more in a clean specimen of urine confirmed by a standard technique on two or more occasions at least six hours apart. Edema Is considered to be generalized and excessive accumulation of fluid in 57

the tissues. It is often associated with a rapid weight gain of two pounds or more per week, preceding detection of edema. Edema must be generalized and excessive, not a simple fluid accumulation in the legs. Eclampsia is the occurrence of one or more generalized clonic convulsions together with the above criteria for preedampsla.

The Working Group on Nutrition and the Toxemias of Pregnancy

(1970) presented evidence that nearly 75% of all younger pregnant women have blood pressure readings of less than 120/80 and therefore, a more meaningful determination of hypertension, would be a rise in blood pressure of 30 mm mercury, systolic; or 15 mm, diastolic, on two or more occasions, six or more hours apart. Toxemia, although an ill-defined term, usually means preedampsla or eclampsia (as defined), and excludes hypertension if unaccompanied by proteinuria or edema.

There is a clear inverse relationship between the incidence of toxemia and income level. The two states with highest mortality rates from toxemia, Mississippi and South Carolina, also have the lowest per capita income. A dramatic decrease in deaths from toxemia has occurred in the past AO years, but black women in the South have remained above the national average. Economic and environmental factors, not race alone, are the primary causes of toxemia, as women living on low incomes may not always receive early and adequate prenatal care. Associated with poverty is poor nutritional status and a general ignorance of basic principles of hygiene (The Working

Group on Nutrition and the Toxemias of Pregnancy, 1970). In the early 1900*s, Prochownick suggested there existed a relationship between nutrition and toxemia. He treated the symptoms with a high proteini low carbohydrate diet limited in fluids (The

Working Group on Nutrition and the Toxemias of Pregnancy, 1970).

Cramer in 1906, noting the rapid weight gain associated with toxemia, recommended sodium restriction as a means of controlling edema (The

Working Group on Nutrition and the Toxemias of Pregnancy, 1970).

During World War I, prevention and cure of toxemia was believed possible if obstetrical patients would restrict food energy intake.

Thus, dietary treatment was firmly established without previous investigations designed to test the efficacy of these recommendations

(The Working Group on Nutrition and the Toxemias of Pregnancy, 1970).

There is general agreement among physicians and nutritionists that poor maternal nutrition is an important predisposing factor in toxemia

(Brewer, 1972; Osofsky, 1975). Restricted food energy intake does not prevent the disease and a low-calorle diet may result in inadequate protein intake. Furthermore, it has been well established that underweight or malnourished women and adolescents are more likely to develop toxemia than mature, well-nourlBhed women. No evidence exists that accumulation of excessive adipose tissue during pregnancy is a cause of preeclampsia (The Working Group on Nutrition and the Toxemias of Pregnancy, 1970).

Diuretics are of no value In reventlng toxemia and appear a poor treatment because they compound the already diminished plasma volume (Pitkin et al.. 1972), Administration of diuretics during 59 pregnancy has been associated with thrombocytopenia and hyponatremia in the newborn and electrolyte imbalance, hyperglycemia, hyperuricemia and acute pancreatitis in the mother. Sodium restriction and thiazide diuretics in combination is regarded as dangerous therapy for prenatal patients.

Schulte et al. (1971) reported that maturation of the fetal nervous system is adversely affected by maternal toxemia. Apparently intrauterine malnutrition caused by decreased placental blood flow diminishes delivery of oxygen and nutrients. Diuretics,anti- hypertensive drugs and sodium restriction have an adverse effect on placental blood flow (Medical News, 1977).

Nutrition and Dietary Component of Maternity Care

Successful management of any facet of medical care depends on early and adequate evaluation of the patient's status. Aubry, et al.

(1975) identified criteria including clinical and biochemical tests, physical examination, and a nutrition-oriented history; essential to recognizing the patient at risk. Pitkin (1977a) urges physicians to carefully assess the nutritional status of every obstetrical patient and monitor dietary intake and weight gain throughout pregnancy.

The American Public Health Association has established guidelines for evaluating the nutritional status of pregnant women (Christakls,

1977). The association's objective is to have every physician Identify women requiring remedial or rehabilitative nutritional intervention 60

and also Identify those who are likely to become 111 unless additional

health maintenance services are provided. Physicians also need data

about family income, food availability, and previous reproductive

performance including birth weights of older children in the family,

maternal weight gain during previous pregnancies and the incidence of

perinatal mortality. Certain patients are classified as "at risk"

nutritionally if they are adolescents (particularly the unmarried),

or underweight women, or women who experienced inadequate weight gain

during pregnancy. Other women classified as possible high-risk

patients requiring additional nutritional intervention are: grand multiparas, low income mothers with a history of delivering low-birth- weight infants, the grossly obese, the anemic (especially those admitting to frank pica), diabetics, alcoholics, drug addicts, the mentally depressed, the tubercular, and food faddists.

The American Public Health Association (APHA) further recommends that the attending physician obtain a thorough medical, social and dietary history from every patient with special attention afforded those women who experienced delayed onset of menarche. (Average age for menarche is 12.5 years; late onset is a symptom of poor childhood nuturitlon.) If the interconceptional period is less than one year the physician should anticipate the mother may have diminished nutrition reserves. The APHA urges other pertinent data related to the patient's nutrition status be obtained; such as uBe of oral contraceptives, past and current illnesses, smoking history, drug and alcohol use, and any evidence of prior nutritional deficiencies. Nausea and vomiting of 61 ptegnancy persisting for many months may lead to nutritional depletion.

Other nutrition-related problems that require specific evaluation are rigid dieting to achieve veight loss prior to or during pregnancy, food , and bizarre or abnormal eating patterns which would ultimately cause a deficiency in the intake of certain nutrients. The

APHA strongly recommends that every physician follow an established list of priorities in order to evaluate all aspects of maternal nutrition. The association has established a minimal level approach in assessing maternal nutrition. Abnormalities in any one of these factors is sufficient to compromise the outcome of the pregnancy.

Prenatal Care and Preparation for BreaBt Feeding

It is the physician's responsibility to bring to the attention of the pregnant mother Information about the many advantages of breast feeding (Jelliffe, 1975). A breast-fed baby gains many medical benefits over a bottle fed baby; fewer respiratory and gastro­ intestinal infections, emotional satisfaction and a lessened chance to become obese. Neumann (1975) reports that its easy to overfeed with bottled formula, but breast feeding permits the infant to determine appropriate intake.

Adequate nutrient Intake during pregnancy not only assures the fetus the elements essential to normal growth and development, it also prepares the mother for a period of lactation. Approximately

2 to 4 kilograms of body fat are stored during pregnancy to meet the 62

mother's need for energy following delivery. This amount is equal

to an additional 200 to 300 kilocalories per day for 3 months of

(Widdowson, 1977). Energy requirements for lactation

parallel the quantity of milk produced. However, If the food energy

content of the lactatlng mother's diet is deficient, weight loss will occur. Tyson (1977) thinks a period of lactation the Ideal method for combatting maternal and infant obesity. This fact should be brought to the attention of every prenatal patient.

Prenatal care is seldom structured to promote breaBt-feedIng, consequently there has been a continuing decline in the practice for the past 50 years (Jelllffe, 1973). Frequently, hospital routines discourage breast-feeding, but the primary barrier has been the physician's lack of commitment to this aspect of patient education

(Bauer, 1976). Hollen (1976) examined physicians* attitudes toward breast-feeding and reported that 22 percent of the physicians in her study discouraged mothers from breast-feeding. Harfouche (1970) estimated that four of five American primlparas would like to breast feed their newborn but have been discouraged from doing so.

Most physicians are aware of the many advantages of breast­ feeding but only a few make an effort to discuss the subject with their patients because they lack knowledge and are unfamiliar with the lactation process. Only a few physicians have every observed a mother breast feed her child and there is very little information about breast-feeding available to the medical student (Hollen, 1976). 63

Myths

Nutrition fads* fallacies* misconceptions and misinformation

captures the attention of nearly all Americans (Nutr. Rev. Suppl.*

1974), Prenatal patients are no exception. Certain foods have been

endowned with virtues that are supposed to assure successful pregnancy* labor* delivery and lactation. Other foods are condemned for their effect on fetal development and childhood behavior (for example* foods vith artificial colors). Superstition* not science* has established most of these so-called food qualities.

Pregnant woman receive dietary advice and nutrition education from various nonmedical sources such s b well-meaning friends and relatives; popular literature; radio and television* especially the talk shows and from the food market Itself. Physicians have an obligation to protect their patients from false and misleading claims and advertising. This can be achieved by providing authoratatlve dietary instructions and periodic review of nutrition principles and related topics. Patients need to be reminded that there are no miracle foods or nutrients (Alfin-Slater* 1978).

Langer et al. (1973) criticized obstetric care for the following reasons; physicians often tell patients

1. They should not eat for two.

2. Excessive weight gain causes toxemia of pregnancy.

3. Excessive sodium intake causes toxemia,

4. Diuretics should be used to limit weight gain and prevent toxemia. 64

5. Obese patients should lose weight during pregnancy.

6. Limiting weight gain will preserve a slender figure.

7. Prenatal capsules supply the additional nutrients needed during pregnancy.

Some doctors continue to believe that the placenta can extract all nutrients needed for fetal development, regardless of quantity

or quality of the maternal diet (Brewer, 1972).

Many patients resort to crash dieting just prior to a doctor's appointment in order to comply with stringent weight standards;

fasting is one example. By limiting weight gain or losing weight, a patient escapes a scolding by her physician. Too often the physician's nutrition management is limited to a harangue about weight control and "take your vitamin pills" (Pitkin ct al.. 1972).

The opportunity to discuss basic nutritional needs is missed.

Pitkin et al. (1972) also discussed the difficulties physicians experience in providing quality maternity care. Nutrition knowledge is often limited and formal instruction in the science of nutrition is absent from curricula or graduate education. At some time the physician has been taught "traditional" notions about diet and pregnancy. However, many of these concepts have been vigorously challenged. Thus, there is confusion as to what is appropriate advice for prenatal patients. 65

Diffusion of Medical and Nutrition Information

Many excellent studies concerning maternal nutrition and the

course and outcome of pregnancy have been published during the past decade. The essential aspects of these studies have been summarized for the practicing physician by Pitkin and otherB (Pitkin, 1977, and

Pitkin et al.. 1972). Also, articles pamphlets and books for the prenatal patient have been made available to the general public.

Information regarding the nutrition component of maternity care has been designed to be both scientifically accurate and practical by such writers as Cause in American Baby (1977) and Mayer, A Diet for Living

(1977). Thus, the subject of maternal nutrition has had considerable attention by physicians, nutritionists and other health professionals and the maternity patient.

Nutrition education for health professionals-has been promulgated by means of workshops, seminars and courses in continuing education.

The federal government, through the Food and Nutrition Board of the

National Research Council, has established a standing committee on maternal nutrition to provide guidelines for practicing physicians concerning the nutrition component of maternity care (Committee on

Maternal Nutrition, 1970). The American College of Obstetricians and Gynecologists (Pitkin et al.. 1972) has published a review of clinical topicB on the subject of maternal nutrition suitable for all physicians and has also made available for distribution an authoritative booklet concerning nutrition for obstetrical patients 66

(Committee on Nutrition Education* ACOG, 1976).

Until recently there has been little research concerning sources

of practical nutrition information in use by physicians. However,

In 1976 Hollen published a study of physicians' attitudes and practices

about breast-feeding and its management. "Books" and "other individ­

uals" were the most frequently cited sources of information used by

practicing physicians. "Other individuals" were identified as medical

colleagues, personal experience (for female physicians) wife's

experience, nurses and patients. Medical school ranked last as a

source of information with respect to breast-feeding. Only half the

physicians indicated they had attended a lecture or discussion on the

subject of breast-feeding while they were in medical school. Special

seminars were recommended as the best means for imparting medical knowledge about the subject of lactation. Many physicians in this

study indicated they received little practical instruction concerning breast-feeding in medical school and had to rely on less precise

sources of information.

Some years ago Coleman et al. (1957) were interested to discover how medical information was transmitted among physicians. These investigators studied a large group of doctors and how the diffusion of information ultimately led to wide-spread adoption of a new drug.

The time required for physicians to prescribe the new drug was directly related to age (younger ones adopted the drug first), number of journal subscriptions, attachment to medical institutions outside the community and attitudinal characterists. The more profession-oriented 67

doctors adopted the drug first* Integration of doctors among local

colleagues also strongly and positively affected the speed with which

they prescribed the drug. Social contact among physicians was a

crucial determinant in diffusion of medical information. Physicians

Influenced each other more in treatments whose effects were unclear

than in treatments whose effects were established.

How and by whom obstetric patients receive information about

food and nutrition is of practical concern. Nearly all physicians who provide prenatal care are either obstetricians or family physicians, and it has been estimated that over half of all obstetrical deliveries in the United States are performed by general practitioners.

Furthermore, almost half of general practitioners are over 55 years of age (Geyman, 1974). The demand for board-certified obstetricians exceeds the supply and physicians, in general are not always in areas of greatest demand.

Mills (1971) recommends that to maintain competency a physician deliver a minimum of 40 to 50 infants per year. He also urged physicians to delegate routine prenatal care to the nursing staff; including diet and nutrition instructions. Mills says that in a normal pregnancy, much of the prenatal care can be carried out by the family practice nurse, Should abnormalities be detected the family physician can refer the patient to a high risk perinatal unit. 68

Summary

The Importance of adequate nutrition in pregnancy has been well

documented by many researchers but dietary recommendations to

Implement these studies have varied drastically over the past 50

years* Two outstanding examples of the dramatic changes in concepts

are related to maternal weight gain and treatment of iron deficiency

anemia.

Because maternal nutrition represents such an Important influence

on the course and outcome of pregnancy, a physician must give special

attention to nutrition-related factors when managing comprehensive

prenatal care. Every patient's nutrition status should be assessed,

appropriate dietary advice given when necessary and follow-up

evaluations continued throughout pregnancy (Pitkin, 1977a).

In order to gauge maternal nutrition status a physician must

obtain the patient's medical history, previous reproductive performance, diet history, family economic and social status, eating habits, clinical status and laboratory evaluation. By following a

standard assessment routine a physician is most likely to uncover any nutritional complications needing special therapy.

A physician should not attempt to limit weight gain during pregnancy but encourage the patient to gain at a steady rate of 350 to 400 grams per week during the second and third trimesters. Protein intake should be approximately 1,3 gramB per kilogram of mature body weight. A somewhat greater allowance is essential for adolescents. 69

Iron needs cannot be net by diet alone, therefore a dally supplement of 30 to 60 ng is vitally important. Folate needs double during pregnancy so an additonal 200-400 pg of the vitamin taken daily is desirable. In order to meet maternal needs for protein and calcium, a quart of milk or an equivalent amount of dairy products should be consumed every day. Vltamin-mlneral supplements cannot be expected to provide all essential nutrients necessary to sustain pregnancy. A properly selected diet following the Basic 4 Food Pattern will readily provide the mother with adequate nutrition.

Sodium restriction has the potential capacity for impairing maternal physiologic adjustments and when combined with thiazide diuretics, may be highly dangerous to mother and fetus. Sodium should be considered a dietary essential.

The caloric value of the diet should remain above 1500 kilocalorles per day. Long periods of fasting should be discouraged.

Food Intake should be distributed throughout the day.

Weight reduction should not be undertaken by the obese woman during pregnancy. She should follow a normal diet and gain weight at the same rate as the non-obese patient. Breast-feeding should be encouraged as a highly satisfactory method for treating postpartum obesity.

Preparation for lactation begins with pregnancy. The prenatal patient needs both education and encouragement from her doctor in order to breastfeed successfully. 70

Nutrient needs Increase with pregnancy. For a mother to adequately

nourish the fetus and provide for her own increased energy and

nutrient needs the diet must be structured around guidelines like the

RDA. There is no valid reason for limiting maternal nutrient intake.

Lacking sufficient knowledge of nutrition and adequate time for

effective teaching, physicians are often compelled to rely on diet

guides prepared by commerical food and drug companies for patient

education. Prescriptions for vltamin-mlneral supplements become a

substitute for diet instructions and routine supplementation generates

,a false sense of security for patient and physician. Organizations

such as the Lamaze childbirth education association and the Le Leche

League continue to expand their role as distributors of nutrition

Information to maternity patients (Wright, 1966).

Rather than rely on questionable or unreliable sources of

scientific nutrition, the Committee on Maternal Nutrition of the

National Research Council (1970) recommends that physicians learn to

use the skills of nutritionists and dietitians just as they use the

skills of pharmacists, laboratory technicians and roentenologlsts.

It Is especially Important that obstetricians, other specialists

and in fact all doctors who provide maternity learn how to use

experienced and capable professionals for updating their knowledge

of nutrition. CHAPTER III

METHODOLOGY

Introduction

The primary purpose of this study was to determine the nature of nutrition-related problems observed by obstetricians, family practice physicians and general practitioners among their private maternity patients; how these problems were diagnosed and treated; and the

Influence of various communication channels on the dissemination of information concerning contemporary scientific nutrition. There has been very little research involving the physician as a factor in the distribution of nutrition knowledge and the effect attitudes and opinions have on the type of dietary advice given the pregnant woman.

Design of the Study

Lack of knowledge or theory concerning physicians1 instructions to obstetrical patients, a potentially large number of variables and constraints on the data collecting process, made it imperative to obtain descriptive and exploratory data. This study was designed to

Identify areas where physicians1 opinions about maternal nutrition affected prenatal care and how nutritional problems of private patients

71 72

were managed In a practical way.

Several methods of surveying physicians were considered for this

study. Three widely used techniques--the mail questionnaire, the

telephone interview and a face-to-face Interview— were considered by

the face-to-face Interview was chosen because of the advantages the method offers for obtaining complete answers to most questions. Also many open-ended questions can be asked. This type of interview allows for delays and interruptions. Data for this study were collected by means of a face-to-face interview in the physician's office.

The questionnaire was designed to make maximum use of IS minutes of uninterruped time, an interval physicians allot for a single appointment. Because of interruptions it was impossible to calculate an average time for a single interview. The shortest interview was

8 minutes, the longest 2 hours. Although some physicians were functioning under tighter time constraints the quality of the data obtained did not appear to be compromised.

The impact of current recommendations (Chapter2, pages 68-70) on the nutritional management of prenatal patients was the central interest in this study. Given a lack of previous studies about private practice physicians, it appeared more reasonable to ask a wide variety of questions which could aid in developing a description of characteristics of doctors rather than attempting an explanatory survey, ThuB a descriptive survey offered an opportunity to examine certain attributes of the sample and estimate their distribution. In this study there were four modified stratlfeld samples of

particular interest, alone and in comparison with each other.

Physicians represented two types of practice specialty and two levels

of medical education. Because this was a beginning inquiry into a

topic the exploratory or "search" type investigation was appropriate.

Physicians were encouraged to Bpeak freely about their views on any nutrition-related aspect of pregnancy.^

Design of the Questionnaire

Data were obtained by means of a questionnaire. There were 69 closed and open-ended questions designed to provide Information concerning the nutrition component of prenatal care. Part I of the schedule consisted of precoded questions regarding the frequency with which physicians obtained a patient's obstetric, medical, dietary and socioeconomic history (Appendix A, Question 2). This section closely corresponded to recommendations made by the American

Public Health Association (Chrlstakis, 1977) for maternal nutrition assessment. The questions evolved from the "minimum level approach" in evaluating the patient's nutritional status.

^There was very little discussion in the literature how physicians accepted standards for nutritional assessment. The purpose of the study was not to reach judggments about the adequacy of the standards but rather to find out the extent to which physicians followed established protocol for determining presence or absence of nutritional problems. Part II was developed from recommendations made by the Comnittee

on Maternal Nutrition of the National Research Council concerning

nutrition-related problems of pregnancy encountered by the physicians

(Comnittee on Maternal Nutrition, 1970). Most nutrition studies have

been limited to clinic populations and frequently focus on the

pathological aspects of pregnancy. This section of the schedule

consisted of open-ended questions designed to provide information

about kinds of nutrition-related problems observed in private practice

patients. Physicians were requested to estimate the extent to which

these problems existed among their patients, how the problem was

diagnosed and the preferred treatment.

Part II allowed physicians three separate opportunities to express

their opinions about the types of nutrition-related problems observed

in their patients (Appendix A, questions 3, 4, 8, 9 and 10). In order not to solicit specific answers, the questions were designed so the

physician had a chance to reveal attitudes concerning maternal nutrition. Once a topic was BuggeBted by the physician it was possible

to probe for a complete answer. The use of open-ended questions was

to avoid unduly prompting the physician or to appear to "put words in his mouth." This technique worked well because of the considerable intellect and advanced education of the respondents.

Following the first two open-ended questions about nutrition- related problems' of pregnancy, all physicians were asked to discuss three specific problems if they had not already done so. The problems were 1) iron deficiency anemia, 2) megaloblastic anemia and 3) toxemia 75

of pregnancy* As before, physicians were asked for their diagnostic

criteria, the Incidence of the problem and treatment.

All physicians were asked to discuss weight gain in pregnancy,

including problems of excessive and insufficient gain, food energy intake and sodium restriction. These were open-ended questions

(Appendix A, questions 8, 9 and 11).

Part 111 of the schedule (Appendix A, question 12) consisted of questions about physicians' estimates of the value of diet instructions.

The doctors identified or described methods employed to Instruct patients. Whenever possible a sample of the education material was obtained.

Part IV of the schedule (Appendix A, question 13) consisted of questions related to general Instructions on subjects closely related to maternal nutrition. The questions reflected recommendations for the nutritional management of pregnancy described by the American

College of Obstetitlclansand Gynecologists (Pitkin et al., 1972) and the Committee on Maternal Nutrition (1970) of the National Research

Council. Data were obtained on the frequency with which physicians discussed basic nutrition, nutrition labeling, prenatal classes, food stamps and breast-feeding. There was also a question about patient's use of vltamin-mineral supplements and whether they were prescribed during pregnancy. Physicians were asked to identify by trade name the various supplements used.

One goal of this study was to determine how physicians obtain practical information about the subject of nutrition. Part V 76

(Appendix A, questions 15-21) of the schedule consisted of questions

concerning the dissemination of nutrition information and medical

information. Through a series of precoded and open-ended questions,

physicians rated the Importance of various sources of information

related to their medical practice. They answered the same series of

questions but with reference to sources of nutrition information. The

purpose of these questions was to determine if Information diffusion

channels were the same.

Part VI consisted of one optional question which was not

specifically related to the subject of maternal nutrition (Appendix A, question 23). If the physician expressed an interest and had time, he was asked what nutritionists could do to help him with nutrition information. Doctors were encouraged to interpret this question in any way that was relevant to their individual practice of medicine.

Three of four doctors (76 percent) volunteered to give their opinion.

The descriptive sections of the interview schedule Included all questions related to information about maternal nutrition assessment, weight gain, patient instruction, geographic area where physician practices, pluB economic status of the community and several questions on information diffusion.

The exploratory sections concerned physicians' opinions about nutrition-related problems of pregnancy, diet Instructions, sources of nutrition Information and the optional question.

According to Babble (1973) criteria for a successful face-to-face interview are as follows: 77

1. The Interview schedule must be pretested. 2. The topic must be of interest to the respondents. 3. The interview schedule must not be too long. 4. Response errors and biases must be kept to a minimum.

1. Accordingly, this questionnaire was pretested twice. The first time the test was administered to a registered dietitian. The questionnaire was revised and tested again by four physicians representing the four medical specialties. The questionnaire was revised to improve clarity of several questions, to eliminate several irrelevant ones and to improve format for coding purposes.

2. The topic seemed to interest the subjects. Physicians

Indicated they were aware of the Importance of human nutrition, particularly as it Influenced pregnancy. None of the respondents appeared bored during the interview and many gave long, detailed answers supported by anecdotal material.

3. Virtually all questionnaires were completed although many interviews exceeded 15 minutes. Three-fourths of the physicians readily agreed to answer the optional question.

4. Internal validity checks were used on the most critical items. This allowed the investigator to check each interview for consistency and thus alleviate the problem of response error.

Sample Selection and Description

The population for this study consisted of all obstetricians, family physicians and general practitioners in Central Ohio who either 78

practice privately or with a group.of physicians. The 23-county area

selected consists of a large city, Columbus; suburbs; two medium-

sized cities; small towns and rural areas. There are diverse ethnic and cultural groups residing in this part of the state.

Obstetricians and family physicians were selected for the study because, among all groups of physicians, these doctors are most likely to care for obBtetric patients and their offspring. Likewise, these doctors have the greatest opportunity to Influence maternal nutrition. Noncertified family practice physicians, osteopaths and nurse were excluded from the study because they constituted a very small proportion of health-care personnel offering prenatal care.

There were practical considerations Involved in selecting the central Ohio area for this study; the area had to be accessible from the investigator's home in Columbus. A survey restricted to Franklin county (Columbus and suburbs) would yield little variation in the type of private practice surveyed and a statewide study was not feasible for a single investigator. The 23-county area was a compromise; it afforded a good cross-section of private medical practices with patients representing a variety of socioeconomic groups. Patients in this area had access to several different types of medical care.

This sample was not representative of all physicians in Ohio or other areas of the country. However, this study does provide some

Information on a topic which has not been previously Investigated, The names and addresses of 414 physicians were obtained from the

1974-75 Directory of Medical Specialities (American Board of Medical

Specialists, 1974-75), The American Directory of Obstetricians and

Gynecologists (Dew, 1973-74), and the American Medical Association

Directory (1973)* This list was comprised of 79 board-certified

obstetricians, 52 noncertified obstetricians, 50 board-certified

family practice physicians and 233 general practitioners. Fifty

physicians from each of the four groups were initially selected for

interviews. One goal of this study was to obtain a sample consisting

of 50 percent board-certified physicians and 50 percent non-certlfled physicians s b well as 50 percent obstetricians and 50 percent family physicians. The physician's secondary specialty was disregarded in

selection of the sample.

Due to declining numbers of physicians who accepted obstetrical patients and discrepancies in directory listings, many physicians were ineligible for the study. Therefore, it was necessary to select additional names from the original population in order to obtain a sample of 30 physicians from each of the four groups. There were

256 physicians contacted and asked to participate in the study.

Forty-nine percent of all physicians contacted were unavailable for interview for the following reasons.

^Board-certified obstetricians and general practitioners were randomly selected. 80 No. X R e t i r e d ...... 2 (X) D e c e a s e d ...... 2 (1) Other office colleagues already interviewed ...... 2 (1) Not in private practice ...... 1 (<1) No longer licensed to practice ...... 1 (<1) Scheduled interview, then refused at time of i n t e r v i e w ...... 2 (1) Incorrect directory listing 3 (1) Moved from a r e a ...... 12 (5) Did not accept prenatal patients . . . .78 (31) R e f u s e d ...... 23 (9)

Total 126

One-hundred-twenty-eight interviews were completed, of which 44 were with board-certified obstetricians; 22, noncertified obstetricians;

28, board-certified family practice physicians and 34, general

practitioners. This distribution Included changes in physicians'

classification which was revealed at the time of the Interview.

(Every physician was given a copy of his directory listing and asked

if it was accurate and up-to-date.) There were six new board-certified obstetricians, 3 new board-certified family practice physicians.

Nine noncertified obstetricians were actually in general practice.

One physician Identified as a family practice specialist by the office nurse was a general practitioner. The final sample was comprised of 66 (52 percent) obstetricians and 62 (48 percent) family physicians and of these 72 (56 percent) were board-certified physicians and 56 (44 percent) were noncertified. There were only four (3 percent) female physicians in the sample.

The age range was 31 to 73 years; mean age was 49.7 years. The mean age of physicians by specialty was similar: board-certified 81

obstetricians, 49.3 years; non-certified obstetricians, 50.3 years;

board-certified family practice physicians, 48.7 years; and general

practitioners, 50.7 years.

Physicians had been licensed to practice from 3 to 47 years,

mean 21.3 years. The mean years licensed to practice did not differ

by specialty. The range of means vas 20.3 to 21.7 years (Table 1)

Physicians were graduated from 29 American and 10 foreign medical

schools (Appendix B). One-half of the sample (51 percent) graduated

from The Ohio State University College of Medicine.

The community in which the physician- practices was divided

into five categories by sire (Table 2). In this sample, obstetricians

were concentrated in the cities (Columbus, Mansfield, Springfield)

and family physicians were located in Columbus, small cities and

rural areas.

Areas in the sample were divided into five separate categories

according to a calculated economic status. This index was constructed

from 1973 census data and based on mean incomes and deviations above

and below the mean. The middle category included those counties

whose own mean incomes were within one standard deviation of the grand mean ($3668). The high and low categories Included those counties whose mean incomes were between one and two standard deviations above or below the mean income for all counties. The very high and very low

categories included those counties whose mean Incomes were at least

two standard deviations above or below the mean income for all counties.

The income data for Columbus were gathered by the R. L. Polk Company 82

TABLE I

Years Physicians Had Been Licensed to Practice

Years Percentage

0 - 1 0 ...... 13 1 1 - 2 0 ...... 37 2 1 - 3 0 ...... 30 31-40 ...... 15 over 40 5

TABLE 2

Distribution of Physicians by Community Size and Specialty

Physicians by Specialty and Certification Family All Community Obstetricians Physicians_____Physicians Category Board Not Board Not ______Cert. Cert. Cert. Cert.______

Columbus 48% 41% 18% 24% 34%

Columbus suburb 7 — 4 — 3

Other large cities (over 50,000) 14 4 — 5

Medium sized cities (5,000-49,000) 32 50 39 29 36

Small town/rural -- 4 39 47 22

N 44 22 28 34 128 83

for the Columbus Department of Development. The smaller areas within

Columbus have been placed In the five categorics-very high. high,

average, low and very low-according to analogous consideration. The

average category included those areas with index scores closest to

the mean and deviations from this score were placed In appropriate

categories. The distribution of physicians by economic area

classification Is summarised in Table 3. The family and general practice physicians were clustered In areas of lower mean income while obstetricians were located In areas of higher mean income.

The question concerning "number of babies delivered" (Appendix

A. question 22) by the physician was limited to the year immediately preceding the Interview. Usually, the physician's staff provided this data. The average number of deliveries for board-certified obstetricians was 224. range 55-480; for noncertified obstetricians the average was 216. range 0-380; for board-certified family practice physicians the average was 47. range 0-150; and for general practitioners the average was 63, range 0-200. Physicians who had no deliveries the previous year explained that their practice was oriented toward gynecology or that they had to send their obstetric patients to a regional hospital for delivery. In the latter case they did provide prenatal and postnatal care. 84

TABLE 3

Distribution of Physicians (Percent)

by Area Economic Classification

Physicians by Specialty and Certification Mean Family All Income Category Board Non Board Non Cert. Cert. Cert. Cert.

Very Low 7% 231 29% 21% 18%

Low 14 14 26 15

Mean 39 54 39 29 39

High 29 18 7 15 19

Very high 11 4 11 9 9

N 44 22 28 34 128 85

Contacting the Physicians

A letter explaining the purpose of the research, together with

another letter of Introduction from the chairman of the Department of

Obstetrics and Gynecology and the Department of at

The Ohio State University College of Medicine was mailed to physicians

during the months of August, September, October and December 1975

and January and February 1976 (Appendix C) to the group of 256

physicians. Within seventy-two hours after the letters were mailed

the investigator telephoned each physician's office and requested an appointment for an interview. Except for those physicians who

immediately indicated they did not accept prenatal patients, scheduling an appointment usually required two or more telephone calls (1-7) because there were multiple staff members who managed the office.

Usually, the receptionist had to talk to the physician before she could give an answer. In offices where numerous phone calls were needed to make an appointment, failure in lntraofflce communication was the cause.

The Interview

Every physician was given a consent form to read and Blgn before the interview occurred (Appendix D). This action provided every physician with assurance that information given during the course of the interview would be strictly confidential and all answers to open- ended questions would be used for analytical purposes only. No exact 86 quotations were included in the dissertation and none of the physicians was Identified except by practice.

Interviews were recorded on tape when permission was granted by the physician. (Permission was denied in 5 Instances.) Only the interviewer had access to the tapes. While it is true that recording the conversation could have a biasing effect on the quality of the interview, the general Impression was that physicians were at ease and gave honest answers. There appeared to be no difference in the type of responses obtained from individuals recorded and those not recorded.

It was the prerogative of every physician to decline to answer any question. Several physicians exercised this option.

Physicians were informed when fifteen minutes had expired and the interview could be terminated at that point or continued to completion. No one elected to end the interview but two physicians were unable to complete the schedule. In both Instances the physicians were called away for an emergency. In one case the answers to several questions were supplied by another colleague on the staff. In the second situation, several questions at the end of the interview were incomplete. In some interviews, part of the information was supplied by the physician's office nurse or nurse practitioner. Physicians indicated that this was an expeditious arrangement. (At not time was information obtained from any other office staff member or any other source.) 87

Coding the Questions

A code book was assembled by the Investigator. Numerical values were assigned to all responses for open and precoded questions. The optional question was not included In data processing because of difficulty in coding. There was a total of 97 codable questions.

Missing data were excluded from construction and analysis of indexes. So few doctors failed to respond to questions concerning medical history and clinical and laboratory evaluation of patients that no special procedures were necessary.

Statistical Analysis

The coded responses were put into a SPSS (Statistical Package for the Social Sciences) data file (Nie et al.. 1975). SPSS was sleeted because of Its capacity for univariate, bivarlate and multi­ variate analyses appropriate to a descriptive study and because simple

Indexes could be calculated by the program Itself, thus eliminating the further possibility of key punch error

All computer runs were made at the Instructional and Research

Computer Center of The Ohio State University.

In this analysis, a subfile structure was created with separate subfiles for the board-certified obstetricians, the noncertified obstetricians, the board-certified family practice physicians and the general practitioners. The subfile structure takeB advantage of 88

an SPSS option allowing the entire data set, or any combination of

subfiles, to be processed.

For the univariate analysis, the FREQUENCIES program was used.

This provided output for the descriptive sections of the study. For

example, data concerning frequency with which nutrition assessment

was secured and the incidence of various nutrition-related problems

was available for each of the four groups of physicians and for the

total smaple.

The CROSSTABS program was used for blvarlate analysis. This

program yields output showing the crosstabulation of any selected variables. In addition, summary statistics are provided which allow

the investigator to determine whether nominal or ordinal variables are significantly associated with each other.

The NONPAR CORK (nonparametric correlation) program was used to determine which possible Independent variables were in fact, signifi­

cantly related to the dependent variable of interest. Specifically,

Kendall’s Tau was used to determine significant association. Tau was selected because its properties were appropriate to the measures of association being investigated. Also, it was the only measure of rank order correlation appearing in both NONPAR CORR and CROSSTABS programs, both of which had to be used In the analysis, Tau b was used when number of rows and number of columns were even) tau c, when uneven, Tau b is sensitive to the location of cases on the main diagonal and is also sensitive to existence of ties in the marginal distribution. These properties made Tau a good measure to use, but 89

the fundamental reason for Its selection was the need to measure

association for ordered variables. When either of the variables was

not ordered, chi square was UBed. (As one example of ordinal levels,

physicians were asked how frequently they obtained information from

the patient about cigarette smoking, and they indicated they "always", 4 "usually", "occasionally" or "never" obtained this information. As

another example, physicians rated professional meetings as either

"very", "somewhat", or "not too" important as sources of new

information concerning their medical practice.)

Once it was determined by the NONPAR CORR program that a

significant relationship existed at the probability level of .05

. between a pair of variables, the CROSSTABS program was used to array

the variables against one another. No further analysis was conducted

on pairs of variables not significantly correlated with each other.

Variables

• #< • The variables collected included age of phyBlcian, years licensed

to practice, location of practice, journal reading, medical school

attended, specialty, board-certification, community economic status

and number of deliveries during the previous year. Age and years

licensed to practice were directly related to the period when physicians

attended medical school. Because concepts associated with prenatal

nutrition management have changed over the decades, data were analyzed

to assess the effects medical education exercised on physicians' 90 opinions and practices concerning diet and prenatal care.

Although there is evidence that physicians' social Interaction with colleagues strongly Influences adoption of new medical techniques, there have been very few studies about the dissemination of nutrition information among physicians. One might expect doctors located in urban areas to adopt the new concepts of maternal nutrition faster than rural physicians because of their regular contacts with other metropolitan area physicians. In contrast, doctors practicing in rural areas may be isolated from discussion of recent advances in nutrition.

Reading of professional journals has been acknowledged as an effective means for physicians to keep up to date with new developments in medicine. In this study the impact of medical journals on the dissemination of nutrition information was examined.

Medical school curricula are quite similar throughout the United

States. However, there are five medical schools recognized as leading institutions: Harvard, Yale, John HopkinB, Duke and Stanford

Universities (Margulus and Blau, 1973). Also, many physicians in practice (both foreign born and American) are graduates of medical schools outside the United States. A question was included as to who had the better knowledge of nutrition fundamentals— graduates of the top five universities, other American medical schools or foreign- trained physicians.

Two medical specialties, obstetrics and general practice, were represented by the physicians in this study. The investigation was 91

designed to examine the overall Impact of two different approaches

to maternity care. Would dietary advice vary with specialty and would

the nutrition component of maternity care reflect the physician's medical experience? There was also the question of board-

certification— could the implied additional education by the board- certified obstetricians and family physicians offer patients any advantages, particularly in nutritional support?

Part of the strategy in this study was to obtain and analyze data supplied by the physicians about economic factors associated with the nutritional problems of prenatal patients. Would the average regional income influence nutrition status? Would there be a relationship between areas of low income and prevalence of underweight mothers? Would a predominantly black clientele experience a high incidence of iron-deflciency anemia? Would patients with toxemia of pregnancy come from poor, rural areas? Would patients from the affuent suburbs be obese? Clarification of these relationships was sought in the study.

The extent of a physician's prenatal practice might influence the kind of nutrition advice given to patients. The more involved he/she was in obstetric care, the more incentive a physician would have to keep up to date with current management practices.

The variables that were the central focus of this study were physicians' management of the nutrition component of maternity care and dissemination of nutrition information. 92

In summary, this study was expected to reveal which groups of physicians included nutritional status as part of overall routine prenatal assessment, and how this Information was related to their diet Instructions. Physicians identified existing nutrition-related problems of pregnancy, estimated the frequency with which they observed

the problems and the subsequent treatment. Data processed by the SPSS program revealed the relationship between this information and the recommendations made by the American College of Obstetricians and

Gynecologists (Pitkin et al.. 1972) and the Committee on Maternal

Nutrition of the National Research Council (1970) on the nutrition component of obstetrical care.

One aspect of the study that was of special Interest was the doctors' opinions about weight gain during pregnancy. Did such variables as age, specialty, location of practice and attitudes concerning breast-feeding influence the physicians' concept of optimal weight gain?

Finally, physicians were asked to determine the value of various sources of information about recent developments in medicine and to rate these sources according to the influence they exercised on their private practice. Results of this portion of the study were used to identify the Information network operating to keep physicians Informed about recent advances in their medical specialty. A matching series of questions about nutrition information was used to ascertain if diffusion channels were similar to medical Information. 93

Maternal Nutrition Assessment Indexes

9

Individual physicians were rated on the frequency with which

they obtained Information about their patients' nutrition status.

Data were compared to the "Minimal Level of Approach" as outlined by

the American Public Health Association (Chrlstakis, 1977). The

ratings were determined from Information physicians were expected to obtain concerning dietary history, medical and socioeconomic history,

clinical evaluation and laboratory studies. Each component of data

collected was assigned a numerical value. The physician's performance was compared against the standard. One Index was created for each of

the six categories (dietary, obstetrical, medical, family/social, clinical and laboratory). Two composite indexes were created; the first was based on all six indexes and the second was based on dietary, family and clinical indexes, the three that showed the greatest variation.

Calculating the indexes involved selecting answers from the questionnaire on the appropriate topic. Physicians were asked if they "always", "usually", "occasionally" or "never" obtained infor­ mation or discussed with their patients, topics associated with maternal nutrition. By assigning numerical values of 3, 2, 1 or 0 for always, usually, occasionally or never, respectively, it was possible to obtain an overall score of the physician's performance in assessing maternal nutrition. Each of the 18 individual responses was weighted equally because each factor was deemed essential in 94

TABLE 4

Levels of Maternal Nutritional Assessment

Level of History Approach Dietary Medical & Clinical Laboratory Socioeconomic Evaluation Evaluation

Present basic Obstetrical: 1 Hemoglobin: diet: meal Age; parity; < hematocrit patterns; fad interval ' or abnormal between ] diets; pregnancies; < supplements previous ob- i stetrlcal history Medical: Incurrent diseases and illnesses; drug use; smoking history Family and Social Size of family; "wanted" pregnancy; socioeconomic status

Source: Nutritional Assessment in Health Programs, George Chrlstakis, editor. American Public Health Association, Inc. Washington, D.C. 95

influencing the outcome of pregnancy. No assumption could be made

that any one factor was more important than any other. The dietary, medical, clinical, laboratory, obstetrical and family Indexes were calculated according to the following formula:

Sum of scores on each variable Assessment Index - Number of variables

The obstetric assessment index was created from data concerning physicians' knowledge of their patient's obstetric history (questions

2a, 2b, 2c, 2d, 2e, Appendix A). Answers provided information about the frequency with which physicians obtained facts about parity, interval between pregnancies, prematurity, perinatal mortality and low-birth-welght. A score of "3" on the index indicated physicians answered "always" to all, or nearly all questions.

The medical assessment index was calculated from patients' medical history as obtained by physicians (questions 2f, 2g, and 2h,

Appendix A). These data concerned Information about patients' intercurrent diseases and illnesses; medication and drug use and smoking history. The scoring w s b the same as for the obstetrical index.

The family assessment index was calculated from data physicians obtained about their patients' family and socioeconomic status

(questions 2k, 21, 2m, Appendix A). The answers provided information about the size of the family, whether pregnancy was desired and the patients' financial statuB, The scoring was the same as for the other indexes. 96

The dietary assessment Index was created from data concerning

physicians' knowledge of patients' eating habits (questions .21, 2j,

13h and 13i, Appendix A). The Information concerned the patients'

basic diet and fad dieting and a review of the use of vitamin and

mineral supplements. Scoring was the same as for other Indexes.

The clinical assessment Index was created from data related to

predictors of Infant's birth weight: mothers pre-pregnancy weight

and weight gain or loss pattern during pregnancy (questions 8 and

9, Appendix A). Scores were 2, 1 or 0 depending on whether both, one,

or neither clinical parameters were used In evaluating the nutritional

status of the patient.

The laboratory assessment index was calculated from data obtained

from answers to questions 5 and 6 (Appendix A). If physicians

Indicated they routinely determined a patient's hemoglobin, hematocrit,

serum iron, transferrin saturation or iron-binding capacity, the score

assigned was one. Failure to have at least one of these tests

routinely performed resulted in a zero score.

Reliability and Validity of the Indexes

Index Validation

Item analysis

There was no variation among three of the indexes— obstetrical, medical and laboratory— due to the fact that physicians always obtained 97

information about previous pregnancies. Guidelines for prenatal care

have been established by the American Medical Association and the

American College of Obstetricians and Gynecologists (1974) and were

reflected in the high scores on these Indexes.

There are limits to statements that can be made about the validity

and reliability of the indexes In this study. Since there are no

other studies of this population of physicians nor reports of the

frequency with which any population of physicians follows guidelines

for maternal nutrition assessment, there are no parameters against which the sample estimates can be compared to so as to determine validity. Furthermore, there was only a single interview with each

doctor, so there were no measures obtained at several points in time

that allowed for a direct test of reliability. Internal tests of the

study itself, can be done.

Validity

The Indexes are relatively simple, Bingle purpose tools. They reflect the recommendations for obstetric care made by the American

Public Health Association, The American College of Obstetricians and Gynecologists Committee on Maternal Nutrition, The Committee on

Maternal Nutrition of the National Research Council and Roy M. Pitkin,

M.D., ACOG. In every case a physician was given a score according to the frequency with which he said he obtained certain information or had certain tests performed. Each physician's index score is a linear function of the sum of the recommendations followed in the area 98 concerned, such as dietary evaluation or'obstetric history, adjusted so that each index would be similarly scored.

In view of the manner in which the indexes were constructed, each index should be related to the separate items that compose it.

However, some of the information was always obtained (for example, the number of pregnancies) and some information was obtained by only a certain group of physicians (for example, cigarette smoking) so that indexes are valid indicators of those component items in which there is variation over the sample population, but not for component items where there is little or no variation. This is clearly shown in'the Dietary Assessment Index (Table 5). There w s b considerable variation among physicians as to whether they assessed a patient's basic diet pattern or attempted to discover if the patient had followed some fad or abnormal diet. There was a strong relationship between the index and both of these items. Thus the index may be taken as a valid indicator of the physician's assessment of patient's eating habits. However, almost every physician asked his patients about the use of vitamin-mlneral supplements, so this Index score was not a valid indicator of the use of supplements.

Tables 6 through 10 present similar information for the remaining indexes. When there is virtually no variation among components of the index (as evident with items in Tables 5, 6 and 7) Kendall's Tau is highly sensitive to a very few cases that do vary. The very high or very low scores depend on the location of a very few cases* 99

TABLE 5

Relation of Dietary Assessment Index to Component Items0

Dietary Assessment Score Kendall's Tau between Index and 12 3 Item

Present Basic Diet 2.3% 27.6% 100% .77

Fad Diet 0 20.7 100 . 74

Vitamin-Mineral Supplement 97.7 100.0 100 .03

aCell entries are percentage of respondents who "usually" of "always" obtained the Information mentioned.

TABLE 6

Relation of Obstetrical Assessment Index to Component Items

Obstetrical Kendall's Assessment Tau between Score Index and 2 3 Item

Number of pregnancies 100.0% 100.0% .03

Interval between pregnancies 100.0 99.2 .06

Number of perinatal deaths 100.0 100.0 .03

Number of premature infants 100.0 100.0 .06

Number of low-birth-veight infants 100.0 99.1 .06 100

TABLE 7

Relation of Medical Assessment Index to Component Items

Medical Kendall's Assessment Tau between Score Index and 2 3 Item

Diseases and Illnesses 97.6% 100*0% .06

Use of drugs and medications 97.6 100.0 .09

Smoking history 7.3 100.0 .83

TABLE 8

Relation of Family Assessment Index to Component Items

Family Kendall's Assessment Tau between Score Index and Item 1 2 3

Size of Family 0 % 54.5% 100% .61

Pregnancy wanted 50.0 63.6 100 .59

Socioeconomic status 33.3 81.6 100 .45 101

TABLE 9

Relation of Clinical Evaluation Assessment Index

to Component Items

Clinical Kendall's Assessment Tau between Score Index and Item

Weight Gain Pattern During Pregnancy 0 66.7% 100.0% .81

Pre-pregnancy weight 0 33.3 100.0 .63

TABLE 10a

Relation of Laboratory Evaluation Assessment Index

to Component Items

Laboratory Kendall's Assessment Tau between Scores Index and 0 1 Item

Hemoglobin or hematocrit 0 9.5% 100% .85

aCell entries are percentage of respondents who "mentioned" or did "not mention" information. 102

The relationship between these six Indexes falls Into three

separate classes. First, the obstetrical assessment Index was not

related to anything else because almost every physician had the

highest possible score on It. Second, the clinical and laboratory

Indexes were not related to any other indexes or to each other.

Third, the dietary, medical and family Indexes were all significantly

related to each other. Should a physician make the effort to assess

a patient's dietary practices, It is likely he will also obtain

information about medical status and family life.

Almost all the variables that were found to be related to the

indexes are discussed in the chapter on "Findings" later in the

dissertation. These findings add to the face validity of the indexes

in that they predict response to related topics in the questionnaire

(Table 12). It is not surprising that physicians who took time to

acertain family structure also discussed breast-feeding with the mother. Also, physicians who were thorough in the medical assessment

aspects of maternal nutrition also were most likely to provide diet

instructions.

Reliability

Many of the normal tests of reliability are inappropriate to

this study because each physician was interviewed just once and there can be no demonstration of consistency over time. Further, all the interviewing, coding and index construction was performed by the investigator and there was no possibility of testing for inter-coder 103

TABLE 11

Relationship Between Indexes

Obstetrical Medical Family Clinical Laboratory

Dietary -.11 .26 .20 .05 0

Obstetrical -.09 -.02 .003 .02

Medical .32 -.07 -.05

Family -.10 -.04

Clinical -.03

TABLE 12

INDEX VALIDITY:

Comparison of Indexes with Physicians' Nutrition Management

Index Frequency of dietary advice Kendall's Tau between Index and Item

Dietary How to enroll in prenatal classes *16

How to apply for food stamps .22

Family How to breast feed .21

Lactation information .19

Medical General diet Instructions .12

Laboratory Basic nutrition information .19 104

reliability.

However, there is one test available that suggests that the

Index scores are quite stable. One option in the SPSS package makes

it possible to draw a random sample from the data set, thus one can

compare the stability of the index scores across random subsamples of

the full data set. According to the SPSS manual (Nie et al.. 1975)

"probability of selecting any particular case in the file is equal

to the factor specified on the SAMPLE card. However, since each case is considered for selection independently of all other cases, the resulting set of sampled cases will generally not be exactly the size specified." Four random subsamples were selected at the .3 level.

This resulted in subsamples of 32, 36, 44 and 43 cases. Because each case was selected or rejected independently for each subsample, the extent of overlap between subsamples is unknown. It is probable that overlap between subsamples is not too great as 155 cases were included in all four subsamples and there were 128 cases in the full sample.

Mean score and standard deviation for each index and the full sample are shown in Table 13. The mean scores for each of the four subsamples, also given, reveal some differences from the full sample.

When the mean scores for the four subsamples were considered in relation to variation expected from the standard deviations and the much smaller number of cases in the subsamples, the estimates appear to be quite stable. 105

TABLE 13

INDEX RELIABILITY:

Comparison of Mean Scores of Randomly- Selected SubBamplea

Index Maximum Full Score Sample SubSamples 1 2 3 4 / x / o x 32 N 36 N 44 N 43

Dietary 3 1.81 .70 1.70 1.86 1.95 1.83

Obstetrical 3 2.98 .13 3.0 2.97 2.97 3.0

Medical 3 2.67 .47 2.67 2.68 2.77 2.57

Family 3 2.50 .63 2.60 2.63 2.53 2.54

Clinical 2 .62 .71 .61 .71 .51 .76

Laboratory 2 1.28 .59 1.38 1.33 1.32 1.23

Composite 3 2.88 .42 2.93 2.86 2.89 2.89

Abbreviated 3 2.31 .72 2.30 2.35 2.24 2.50 106

Sample Validity

In a descriptive study a certain amount of error is to be

expected. For example, sources of error are in sampling and measure­ ment. One limitation in this study was the small size of the sample

(noncertified obstetricians and board-certified family, physicians).

The sample was more skewed toward board-certified physicians (56 percent) than noncertified physicians. Another limitation was stratification necessary to obtain a relatively large number of physicians who accepted obstetrical patients. Thus, the sample was more representative of obstetricians than family physicians.

The mean age of physicians in the sample was 49.7 years while the age of the total population of physicians in the area eligible for this study was 52.4 years (American Medical Directory, 1973).

Age distribution by specialty is shown in Table 14.

Approximately 52 percent of the total population had graduated from The Ohio State University College of Medicine whereas 51 percent of the sample had graduated from this medical school. In the total population, 8 percent were graduates of foreign medical schools compared to 9 percent of the sample. One percent of the total population graduated from the top five medical schools, Harvard, Yale,

Duke, Johns Hopkins, and Stanford whereas two percent of the sample graduated from one of these schools (American Medical Directory, 1973).

The mean years licensed to practice for the total population was

23.8 and 21.3 years for the sample (American Medical Directory, 1973). 107

TABLE 14

Distribution of Population and Sample by Mean Years

Specialty Population Sample

Board-certified Obstetricians 50.9 49.3

Non-certified Obstetricians 47.3 50.3

Board-certified Family Physicians 47.9 48.7

General Practitioners 54.7 50.8

TABLE 15

Distribution of Sampling Fraction by Specialty

Sampling Specialty Population Sample Fraction N N

Board-certified Obstetricians 79 44 55.7X

Non-certlfled Obstetricians 52 22 42.3

Board-certified Family Physicians 50 28 56.0

General Practitioners 233 34 14.5 108

The most general question concerns the representativeness of the

specialties In the sample compared to the same specialties In the

total population of physicians. The sampling fractions for each of

the specialties Is shown in Table 15. The sampling fractions are

highest (and almost identical) for the two groups of board-certified doctors. The sampling fraction is lowest for the general practitioners, but it should be remembered that the population N is that for all general practitioners whereas those of concern to this study were

the physicians whose practices Included obstetric care. The population of general practitioners engaged In obstetrics was undoubtedly lower than 233 (and hence the 'true' sampling fraction is better than 14.52), but since there was no way of knowing the size of this population with accuracy, the N for all general practitioners was reported in

Table 15.

In view of these sampling fractions, estimates for the full sample will be biased toward the board-certified physicians and away from the general practitioners. Similarly the estimates for the two groups of board-certified physicians will be the most reliable, and those for the general practitioners will be least reliable.

Physicians' Estimates

The data elicited from physicians concerning nutritional complications of pregnancy were estimates based on criteria established by the individual physicians* This study did not include an examina­ tion of physicians' office records, therefore there is no way of 109 knowing how the physicians' verbal statements corresponded to their office records. CHAPTER IV

RESEARCH FINDINGS

Introduction

The data in this chapter are organized in five major sections.

The first section is an analysis of the frequency with which physicians

collect information reflecting the nutritional status of their

obstetric patients. The second deals with the physicians' opinions

regarding the incidence of nutrition-related complications of pregnancy, diagnostic criteria employed, and methods of treatment.

The third contains information about routine nutritional and dietary advice which the physicians provided their obstetric patients. The fourth section is a comparison of sources of nutrition-related information available to physicians with their sources of medical information. The doctors appraisal of the value of these sources of information also is included in this section. In the final section suggestions made by physicians about ways in which nutritionists could be of greater assistance to them are reviewed.

Most of the data are presented in tabular form. In all but a single Instance, the univariate distributions for all respondents appear in the margins with the data for each of the specialty- certification types in separate columns. This permits easy

110 Ill

comparison between the speclalty-certiflcatlon types and the overall

distribution.

Maternal Nutrition Assessment

Patient's History

Physicians were Initially asked "who takes the patient's medical

history?" Over 80 percent of all doctors assumed the responsibility

themselves or shared part of the assignment with the office staff

(Table 16). Eighteen percent of the physicians delegated the task to

their office nurses and two physicians indicated the history was

obtained by receptionists. Family physicians were more likely than

obstetricians to personally take the medical history.

Information Obtained from Patients

Physicians answered a total of seventeen questions associated

with their patients' obstetrical, medical. family/social, and

nutrition histories; and clinical and laboratory evaluations. The

frequency with which this information was obtained was reported by

the physicians as "always", "usually", "occasionally," or "never".

Obstetric History

Physicians virtually "always" obtained their patients' obstetric histories (Table 17). Over 95 percent of the physicians collected 112

TABLE 16

Persons Responsible for Taking Medical History

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Person(s) Board Not Board Not Responsible Certi­ Certi­ Certi­ Certl fied fied fied fled

Physician only 36% 27* 46% 59% A 3%

Physician & Staff 34 55 43 28 38

Nurse only 25 18 11 13 17

Receptionist only 5 0 0 0

N 44 22 28 32 126

Tau b ■ -.11; p m .08

Physicians by Specialty

All Obstetricians All Family Physicians

Physician only 33% 53% 43%

Physician & Staff 41 35 38

Nurse only 23 12 17

Receptionist only

N 66 60 126

Tau c ■ -.16; p ■ ,05 113

TABLE 16 cont.

Person(s) All Responsible Physicians by Certification Physicians

All Board Certified All Non-Certlfled

Physician only 40% 46% 43%

Physician & Staff 38 39 38

Nurse only 19 15 17

Receptionist only 3 0

N 72 54 126

Tau c » -,03; p - ,36 114

TABLE 17

Data Collected By Physicians: Obstetrical History

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi­ Certi- Certi­ Certi­ fied fied fled fied

PARITY

Always 100% 100% 96% 100% 99%

Usually **** PIH 4 m m <1

Occasionally — — — — —

Never — -- — —

N 44 22 28 34 128

INTERVAL BETWEEN PREGNANCIES

Always 100% 100% 86% 100% 97%

Usually — — 11 2

— Occasionally — 4 — <1

Never ——— —

N 22 28 31 125

* PERINATAL DEATHS

Always 100% 100% 96% 100% 99%

— Usually — 4 <1

— w m m Occasionally — — —

— Never — — —

N 44 22 28 34 128 115

TABLE 17 cont,

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi­ Certi- Certi­ Certi­ fied fied fled fied

PREMATURE BIRTHS

Always 100% 100% 89% 97% 97%

Usually — — — 3 3

Occasionally — ——— —

Never — —

N 44 22 28 34 128

• INCIDENCE OF LOW-BIRTH-WEIGHT INFANTS

Always 1001 95% 89% 94% 95%

Usually 5 7 6 4

Occasionally ~ — 4 — <1

Never — — —

N 44 22 28 34 128 116

data concerning parity, intervals between pregnancies, perinatal mortality, prematurity and Incidence of low-blrth-weights. There was not a single case in which a doctor said he "never" obtained this

Information.

Medical History

As part of evaluating overall medical status, physicians nearly

"always" asked their patients about use of drugs and medications and about past and current diseases and illnesses. However, only 54 percent of the doctors questioned patients about their smoking habits

(Table 18). Board-certified obstetricians were somewhat more likely than the other physicians to obtain data on cigarette use.

Family/Social History

Information concerning patients' family, social and economic histories were obtained by nearly three-fourths of the physicians

(Table 19). Almost 90 percent of the physicians estimated patients' incomes. Family size and composition were more frequently ascertained by family physicians than obstetricians. Information aB to whether the pregnancy was desired waB known to 62 percent of the physicians.

Most doctors indicated they could tell if the baby was wanted by the mother'a attitude when pregnancy was confirmed. A few physicians declined to answer the question: "pregnancy wanted". 117

TABLE 18

Data Collected by Physicians: Medical History

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi­ Certi­ Certi­ Certi­ fied fied fied fied

INTERCURRENT DISEASES AND ILLNESSES

Always 100% 95% 96% 97% 98%

Usually — — 4 3 2

Occasionally —— — — . —

Never — 5 WM — 1

N 44 22 28 31 125

USE OF DRUGS AND MEDICATIONS

Always 98% 100% 93% 91% 95%

Usually 2 «. 7 6 4

Occasionally — — WM

Never — — 3 1

N 44 22 28 34 128

CIGARETTE SMOKING

Always 65Z 48% 54% 45% 54%

Usually 12 14 21 13 15

Occasionally 7 34 21 35 20

Never 16 14 4 6 10

N 43 21 28 31 123

Tau b - --.09: p « .11 118

TABLE 18 cont.

Cigarette Smoking (Physicians by Specialty)

All All All Obstetricians Family Physicians Physicians

Always 59% 49% 54%

Usually 12 17 15

Occasionally 12 29 20

Never 16 5 10

N 64 59 123

Tau c ■ -,06; p ■ .27

(Physicians by Certification) All All All Board Certified Non-Certlfled Physicians

Always 61% 46% 54%

Usually 15 13 15

Occasionally 13 31 20

Never 11 10 10

N 71 52 123

Tau c * -.14; p ■ .06 119

TABLE 19

Data Collected by Physicians] Family and Social History

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi­ Certi­ Certi­ Certi­ fied fied fied fied

FAMILY SIZE AND COMPOSITION

Always 58Z 65/E 65% 71% 64/E

Usually 7 5 23 19 13

Occasionally 7 9 4 — 5

Never 28 23 8 10 18

N 42 22 26 31 122

Tau b ■ ,14; p. * ,04

(Physicians by Specialty) All All All Obstetricians Family Physicians Fhyslciani

Always 60% 68% 64%

Usually 6 21 13

Occasionally 8 2 5

Never 26 9 18

N 65 57 122

Tau c ■ .15; p ■ .05 120

TABLE 19 cont.

* (Physicians by Certification) All All All Board-certified Non-certlfled Physicians

Always 61* 68* 66*

Usually 13 13 13

Occasionally 6 6 5

Never 20 15 18

N 69 53 122

Tau c ■ .08 ; p • .19

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Certi- Certi­ Certi- Certi­ fied fled fied fled

Always 66* 68* 52* 76* 62*

Usually 20 29 30 10 21

Occasionally 7 19 11 13 12

Never 7 5 7 3 6

N 61 21 27 31 120

Tau b m .03; p - .36

(Physicians by Specialty) Obstetricians Familt^hyaicians Physicians Always 60* 66* 62*

Usually 23 19 21 Occasionally 11 12 12 Never 6 5 6

N 62 58 120 Tau c ■ .03; p ■ .36 121

TABLE 19 cont,

(Physicians by Certification) All All All Board Certified Non-Certifled Physicians

Always 60% 63% 62%

Usually 24 17 21

Occasionally 9 15 12

Never 7 4 6

N 68 52 120

Tau c ■ ,02; p ■ ,40

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi- Certi- Certi­ Certi­ fied fled fled fied

SOCIOECONOMIC STATUS

Always 93% 86% 73% 88% 87%

Usually 2 — 8 6 4

Occasionally 5 5 15 6

Never — 9 4 4

N 44 22 26 34 126

Tau b » -,08; p - ,13 122

TABLE 19 cont.

(Physicians by Specialty)

All All All Obstetricians Family Physicians Physiclant

Always 91% 82% 87%

Usually 2 7 4

Occasionally 5 7 6

Never 3 5 4

N 66 60 126

Tau c » — *08; p ■ .07

(Physicians by Certification)

All All All Board-Certified Non-Certifled Physiclanc

Always 86% 88% 87%

Usually 4 4 4

Occasionally 9 2 6

Never 1 7 4

N 70 56 126

Tau c ■ .01; p - .42 123

Nutrition History

Physicians frequently omitted' the task of taking patients' nutrition histories (Table 20). About one in three physicians "never" obtained information about the patients' eating habits or adherence to fad diets. However, obstetricians were more likely than others to ask about fad dieting. Ninety-eight percent "always" asked patients about their use of vitamin-mineral supplements. This finding confirms opinions expressed by Pitkin et al. (1972) and Langer et al. (1973) that doctors too often rely on vitamin-mineral supplements as a substitute for thorough dietary evaluation. The few physicians who did not "always" discuss vitamin-mineral supplements with their patients' did so "usually" or "occasionally."

• Clinical Evaluation

According to Christakis (1977) the single most important physical finding associated with adequate prenatal nutrition is weight. A low prepregnant weight with Inadequate weight gain during pregnancy

Is a sign of poor nutrition. Gross obesity among poor women is most frequently associated with Insufficient nutrient intake. In this study,

AO percent of the doctors regarded extremes of overweight and under­ weight as warning signs of nutritional problems (Table 21). Only 37 percent of the physicians monitored weight gain as a means of assessing adequacy of the maternal diet. The other two-thirds of the physicians established weight gain limits for their patients. 124

TABLE 20

Data Collected by Physicians: Nutrition History

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi- Certi­ Certi- Certi­ fied fled fied fled

CURRENT BASIC DIET

Always 23% 32% 21% 29% 26%

Usually 9 — 6 5

Occasionally 32 36 43 26 34

Never 26 32 36 38 36

N 44 22 28 34 128

Tau b • .00 ; p - .50

(Physicians by Specialty)

All All All Obstetricians Family Physicians Physicians

Always 26% 26% 26%

Usually 6 3 5

Occasionally 33 34 34

Never 35 37 36

N 66 62 128

Tau c » -.02; p « .39 125

TABLE 20 cont.

(Physicians by Certification)

Frequency All All All Obtained Board-Certified Non-CertIfled Physicians

Always 222 302 262

Usually 5 4 5

Occasionally 36 30 34

Never 26 36 36

N 72 56 128

Tau c * ,05) p - ,30

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Certi­ Certi­ Certi­ Certi­ fied fied fied fied

FAD DIETS

Always 242 272 72 132 182

Usually 10 5 14 3 8

Occasionally 38 46 54 42 44

Never 29 23 25 42 30

N 42 22 28 31 123

Tau b - 14) p » ,04 126

TABLE 20 cont.

(Physicians by Specialty)

Frequency All All All Obtained Obstetricians Fatally Physicians Physicians

Always 25% 10% 18%

Usually 8 8 8

Occasionally 41 47 44

Never 25 34 30

N 64 59 123

Tau c « ,17; p » .05

(Physicians by Certification)

All All All Board Certified Non-Certified Physicians

Always 17% 19% 18%

Usually 11 4 8

Occasionally 44 43 44

Never 27 34 30

N 70 53 123

Tau'c ■ -,08; p ■ ,21 127

TABLE 20 cont.

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Obtained Certi- Certi- Certi­ Certi­ fied fled fled fied

VITAMIN-MINERAL SUPPLEMENTS

Always 95% 100% 100% 97% 98%

Usually 2 — — 3 1

Occasionally 2 —— — — 1

Never

N 43 22 27 33 125 128

TABLE 21

Clinical Evaluation

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Certi- Certi- Certi- Certi­ fied fled fled fled

PREPREGNANT WEIGHT

Assessed 58% 36% 32% 26% 40%

Not assessed 42 64 68 74 60

N 43 22 25 34 124

Tau b - -.34; p ■ .00001

(Physicians by Specialty)

All All All Obstetricians Family Physicians Physlciam

Assessed 51% 29% 40%

Not assessed 49 71 60

N 65 59 124

Tau b » -,32; p « .00001 129

TABLE 21 cont.

(Physicians by Certification)

All All All Board-Certified Non-Certifled Physicians

Assessed 49% 30% 40%

Not assessed 51 70 60

N 68 56 124

Tau b ■ -.18; p - .02

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Certi- Certi- Certi- Certi­ fied fled fled fled

WEIGHT GAIN IN PREGNANCY

Pattern monitored 50% 41% 27% 26% 37%

Weight limit established 50 59 73 74 63

N 44 22 26 126

Tau c ■ -.23; p ■ ,009 130

TABLE 21 cont.

(Physicians by Specialty)

All All All Obstetricians Family Physicians Physicians

Pattern monitored 47% 27% 37%

Weight limit established 53 73 63

N 66 60 126

¥ Tau b - -.20; p - ,01

(Physicians by Certification)

All All All Board-Certified Non-Certlfled Physicians

Pattern monitored 41% 32% 37%

Weight limit established 49 68 63

N 70 56 126

Tau b » -,10; p - .14 131

It has been observed that underweight mothers (low prepregnant weight and/or Inadequate prenatal weight gain) give birth to Infants of Insufficient weight. Such Infants often suffered from diminished brain size because of fetal growth retardation or unfavorable post­ natal nutrition.

The majority of physicians in thlB study did not obtain Information about prepregnant weight or emphasize the pattern of weight gain during pregnancy. Board-certified obstetricians were the group most concerned about evaluating weight gain status among their patients.

Laboratory evaluation

An Integral part of prenatal care Is routine testing for anemia.

Only three physicians in this study failed to obtain any kind of laboratory analysis of Iron status (Table 22). Values for hemoglobin and hematocrit were routinely obtained but Interpretation of data was subject of considerable variation.

Importance of nutrition assessment

Because some pregnant women may be at risk from nutritional deficiencies, all pregnant women should receive thorough nutrition assessment by their own physician. Specifically, a history of frequent conceptions might indicate the mother has depleted nutrition reserves.

Perinatal deaths and infants with low birth weight, either full term or premature, reflect inadequate maternal nutrition. Physicians who participated in this study "always" obtained data about previous 132

TABLE 22

Data Collected by Physicians: Laboratory Evaluatlona

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Diagnostic Board Non Board Non Tests Certi­ Certi­ Certi­ Certi fied fied fied fled

DETERMINATION OF ANEMIA

Hemoglobin 88% 77% 96% 76% 85%

Hematocrit 40 41 29 32 35

Other tests 49 32 39 38 41

No lab tests — 4 — 6 2

N 43 22 28 34 127

aMany physicians used more than one laboratory test in evaluating nutritional anemia, 133 obstetric performance.

Diseases that adversely affect nutrition status: chronic

Infections, diabetes and neoplastic conditions, usually affect the outcome of pregnancy. Smoking during pregnancy results in a greater incidence of low-birth weight. Certain drugs, alcohol and medications

Interfere with absorption and utilization of nutrients. Except for smoking habits, physicians were thorough in obtaining patients' medical histories.

Limited economic resources may force a mother to purchase inexpensive foods, perhaps some deficient in protein and other essential nutrients. Finances may shrink further if the family is large and various age groups must be catered to. An unwelcome pregnancy may dampen incentive to seek adequate prenatal care or consume a nutritious diet. Although physicians in this study had access to information about family income; some were reluctant to go further and investigate family structure and desire for the new baby.

Several physicians stated that family composition, income and accept­ ance of the pregnancy were none of their business.

Fast and present dietary patterns were generally overlooked by physicians in this study. However, the subject of vitamin-mineral supplements was always discussed with patients.

In assessing the clinical status of patients, about two-thirds of the physicians ignored pregravid or prenatal weight gain. The prevailing tendancy was to establish a weight gain limit for all patientB regardless of existing weight status. 134

The nose common nutrition-related complication of pregnancy and

the pregravld period is anemia. Hematologic analysis of blood was

virtually always performed.

To summarize the flndlngB on maternal nutrition assessment,

physicians did an excellent Job in obtaining obstetrical histories,

obtaining laboratory evaluations and (except for a failure to obtain

smoking history) collecting data about medical histories. Physicians

did very well in obtaining family/social histories, were adequate in

their reliance on clinical evaluations, but did poorly in obtaining

nutrition histories. These findings are important, not because they

reflect the subjective opinion of the investigator, but because they

reveal behavior with respect to standards for maternal nutrition

assessment set forth by the American Public Health Association (1977).

Variation in Maternal Nutrition Assessment

Zn order to summarize adherence to the standards of the American

Public Health Association, a series of indexes was constructed.

Details of index computation were given in the preceding chapter, but essentially a low score on the index indicated a physician was failing to acquire Information in the area concerned and a high score meant relevent Information was obtained. Six indexes were devised: one for each of the sections in the preceding pages. There were obstetrical, medical, family/social, dietary, clinical and laboratory

Indexes, 135

The distributions of scores on the six assessment indexes appear

in Table 23» High scores on obstetrical and laboratory evaluation

indexes confirm the judgment and physicians were doing very well in

these areas of overall maternal nutritional assessment. Almost all

"2" scores on the medical index were due to a failure to obtain a

smoking history. The number of low scores on the famlly/social,

clinical and nutrition indexes suggests that collecting these data

did not have first priority.

These Indexes were next associated with a series of potential

Independent variables such as physician's specialty and certification

(already discussed), and a series of additional variables Including physicians habits of reading journals and attendance at professional meetings. When a significant association was found between an independent variable and one of the indexes, the variable was considered correlated with adherence to standards promulgated by the

American Public Health Association.

A report of the variables associated with high scoreB on each of the indexes will follow. As before, the sequence will be obstetrical, medical, family/social, dietary, clinical, and laboratory indexes.

Since complete data on some of the independent variables are presented later in the chapter, only bivarlate measures of association and significance levels will be presented.

There was a significant relationship between the number of deliveries per year and the obstetrical assessment index (tau c - .04, p ■ .04), 136

TABLE 23

Distributions of Assessment Scores

Scores 0 1 2 3

Obstetrical Assessment Indes 0 0 2% 98% (Max. score 3) (2) (123)

Medical Assessment Index 0 0 33% 67% (Max. score 3) (41) (82)

Family/Social Assessment Index 1% 5% 37% 57% (Max. score 3) (1) (6) (44) (67)

Dietary Assessment Index 35% 48% 17% (Max. score 3) (43) (58) (20)

Clinical Assessment Index 51% 36% 13% (Max. score 2) (64) (45) (16)

Laboratory Assessment Index 3% 97% (Max. score 1) (4) (119) 137

There was a significant relationship between medical specialty and the medical assessment index. Board-certified obstetricians were more likely than other physicians to obtain patients’ medical histories (tau c - .16, p - .04). Board-certified family physicians likewise scored higher than noncertified obstetricians and general practitioners on the medical assessment index. Board-certification itself, was an important factor (tau b ■ .19, p " .01) as it was significantly related to the medical index. Thus, obstetrical and family practice diplomateB were obtaining more medical information associated with maternal nutrition than noncertified physicians.

Journal reading by physicians was positively associated with the medical assessment index (tau c ■ .24, p - .006). The more journals a physician read the more likely he obtained the patient's medical history.

One finding was completely unexpected. There was an association between higher scores on the medical index and physicians volunteering during the interview that they observed many nutrition-related problems among their pregnant adolescent patients (tau b » .18, p ■ .02).

While the medical index was not significantly associated with number of babies delivered per year, there was a weak relationship

(tau c » .12, p ■ .09).

There was a significant relationship between family/social index and number of journals read (tau c ** ,13, p * .04). 138

There was a significant negative relationship (tau b « -.20, p ■ .03) between the dietary assessment index and number of professional meetings attended by physicians. Data for number of professional meetings attended came from obstetricians and a few general practitioners. The more professional meetings a physician attended the lower his score on the assessment index.

The relationship between hours of continuing education and dietary assessment index was not significant. Data for hours of continuing education were obtained from family and general practice physicians who are required to complete 150 hours every three years to maintain membership in their professional organizations. These physicians appeared to be neither positively or negatively influenced by their professional meetings in relation to dietary assessment.

There was a significant relationship between the dietary assessment index and number of journals read by physicians (tau b -

.25, p ■ .003), Physicians who kept up to date with medical develop­ ments by reading journals were more likely to assess patients' dietary status. Furthermore, twice as many physicians rated journals as very

Important sources of nutrition information as compared to professional meetings,

The clinical assessment index was significantly associated with specialty and medical school status. Board-certified obstetricians, more than other specialties, assessed patients' clinical status.

Certification was significantly associated with clinical assessment

(tau c ■ .17, p ■ .03) but obstetrical orientation had an extremely 139

strong relationship (tau c ■ .37, p " .001).

Graduation from a foreign medical school was positively

associated with the clinical assessment Index (tau b «• .16, p ■ .03).

The clinical assessment index was also associated with the number of

journals read (tau b * .17, p * .02).

Because so many physicians Included laboratory studies

(hemoglobin, hematocrit etc.) as part of routine obstetrical care,

there were no significant relationships between the laboratory

index and all other variables.

Composite Indexes

In order to provide more complete information about adequacy of maternal nutrition assessment, two composite Indexes were constructed

from the six individual indexes. In the first, each of the six

indexes were Included and each was weighted equally. As with the

specific indexes, a high score meant the physician was obtaining essential Information; a low score indicated little information.

Scores on this index were skewed to the high side (Table 24) because

all physicians had high scores on the obstetrical, medical and labora­

tory indexes. This reflected the generally high quality of maternal nutrition assessment but because there was a lack of variation, the

index was not very useful as a dependent variable. Therefore, an abbreviated index was constructed using only family/social clinical and dietary indexes. These three indexes Included almost all variation 140

TABLE 24

Assessment Indexes

Score Composite Index Abbreviated Index No. Percentage No. Percentage

0 0 0

1 0 11 10

2 17 15 61 55

3 90 82 34 30

4 4 3 5 5 141

In the composite index and served as a reflection of the composite

index but with more variation (Table 24)* The abbreviated index was

a better device for detecting covariation and, thus, association with

independent variables. The abbreviated index will be used in the

following analysis.

The first variable significantly associated with the abbreviated

index, the one chosen for special emphasis in the research design,

was physicians' speciality. There was a significant relationship

between specialty and the index (tau b ■ .18, p ■ .01). However,

speciality combines two properties, board-certiflcation and a

restriction of practice to obstetrics. The relationship between

board-certlficatlon and the index scores turned out to be not

significant but the relationship between obstetrical or family

orientation and this index is significant (tau c ■ .20, p ■ .02).

This the restriction of physicians' practice to obstetrics is more

important in this case than board-certiflcation.

Physician's age was the third variable significantly associated

wit the abbreviated assessment index. When age was measured directly

it was associated with the abbreviated assessment index (tau b « -.12,

p - .04). Older physicians were more likely to have lower scores while

younger physicians were more likely to have higher scores.

When years licensed to practice was measured against the abbreviated index, the relationship was stronger. For most doctors, age and years to practice are equivalent. However, years licensed

to practice is a better measure than age as it allows for the 142

possibility that a physician may have been older vhen enrolled In

medical school or was In military service for a period of time

* (tau c ■ -.14, p - .04). Journal reading was also associated with the

abbreviated index (Tau b - .18, p « .02).

Thus, in the abbreviated composite Index the strength of two

factors— specialty and obstetrical orientation— were observed. Two

other factors, age and years licensed to practice, were noted to be

almost identical, an observation not seen when the individual index

components were analyzed. Some factors that were related to a

particular component did not turn out to be significantly related to overall assessment. This included board certification, lack of attendance at professional meetings, and graduation from a foreign medical school.

Two variables were not correlated with any of the Indexes.

There were community size and area economic status.&

Nutrition-related Complications of Pregnancy

Obesity, identified as most serious

Fifty-one percent of the physicians in this study, said obesity was either the first or second-most serious nutritional complication

®In order to determine whether the decision not to weight any of the variables included in the indexes affected the results, parallel sets of indexes using a subjective weighting scheme were constructed. The distributions and patterns of association of the weighted indexes were essentially the same as those of the unweighted indexes. 143 of pregnancy. Seventeen percent of the physicians identified excessive weight gain s b a most serious problem; thus, seven out of ten doctors

said overeating prior to or during pregnancy constituted a health risk

(Table 25). Only 10 percent of the physicians regarded underweight or inadequate weight gain as a serious problem. This contrasts with several clinic studies where Insufficient weight gain seriously complicated pregnancy; especially among adolescents and poor women (Rush, 1975;

Kaminestzky, 1971; Chrlstakls, 1977).

PiaRnostic criteria

Diagnostic criteria for obesity (Table 26) could be Interpreted as evidence that physicians did not distinguish between obesity and overweight. Those doctors who indicated they used weight-for-helght charts said they compared patients' pregregavld weights with the standards. Approximately one-fifth of physicians diagnosed obesity by appearance only. Just six percent (4 doctors) adopted Pitkin's

(1976) standard for overweight: "20 percent or more above ideal weight." About half (44 percent) fhe doctors based their diagnosis on questionable criteria.

Incidence

According to these doctors, 32 percent of their private patients were obese* In the United States, about one in three adults is considered obese (Stearn, 1977). 144

TABLE 25

NUTRITIONAL COMPLICATIONS OF PREGNANCY:

Identified by All Physicians

Most Second Other Total serious most Percentage Complication serious

Obesity 47% 4% " 512

Excessive weight gain 16 1 — 17

Underweight 4 — 4

Inadequate weight gain 1 5 5

Nausea/vomiting 1 3 1% 5

Toxemia of pregnancy — 1 — 1

Iron-deflciency anemia 14 25 — 39

Pica — — 2 2

Megaloblastic anemia — 1 1 2

Inadequate dietary protein 5 1 1 7

Inadequate dietary calcium — 1 3 4

Vitamin deficiencies — 1 1 2

Poor-quality protein 4 6 6 16

Milk-free diet — 2 — 2

Fad dieting 1 1 1 2

"Crash" dieting — — 1 1

Chronic malnutrition 1 mmwm 1 2 145

TABLE 25 cont.

Most Second Other Total serious most Percentage Complication serious

Infrequent meals 1% 2% 12 5%

Constipation 3 3

Diabetes 2 4

Alcoholism/drug addiction 3

Smoking 1

"Poverty" diet 3

Cultural food practices 2

Adolescent food choices 6

Dental problems 1 2

Excessive sodium intake 3 5

Food additives, water quality 1

Diuretics 1

Inappropriate answer

N 119 87 58 146

TABLE 26

Diagnostic Criteria for Obesity®

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Criterion Certi­ Certi­ Certi­ Certi­ fied fied fied fied

Standard height- weight charts 29% 62% 33% 65% 45%

Physicians* own rule-of-thumb 18 13 6 12 12

20% above ideal weight — — 11 5

10% above ideal weight — — 17 5

25% above ideal weight 6 2

15 pounds above ideal weight 18 — 6

30 pounds above ideal weight -- — -- 6 2

Visual 23 13 22 12 18

Skin-fold thickness -- 13 6 2

« Inappropriate answer 6 — 6 3

N 17 8 18 17 60

^Answers were compiled from only those physicians who identified obesity as the most serious nutrition-related complication of pregnancy. 147

Treatment

Nearly all obese patients were advised to follow some dietary modifications throughout pregnancy. There were 45 distinct recommendations for treating obesity. These recommendations have been summarized, Table 27. About three-fourths of the doctors said it was essential to patients' health and well-being that food energy

Intake be restricted. JuBt one physician recommended exercise as the most appropriate treatment for prenatal obesity. No physician followed

Pitkin's (1977b) recommendation that "obese pregnant women should be managed In accordance with the same general nutrition principles as the non obese...energy intake should be adequate to support the usual and customary pattern of weight gain." However, 8 percent of the doctors In this study opposed rigid dietary restrictions, even for the most obese women.

Excessive weight gain

All physicians in this study were asked a series of questions concerning excessive weight gain. This included the 17 percent who identified the problem as "most serious".

Diagnostic criteria

For those physicians who thought excessive weight gain was most serious, a total average weight gain greater than 26.6 pounds was 1A8

TABLE 27

Recommended Treatment for Prenatal Obesity®

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Certi­ Certi­ Certi­ Certi­ fied fied fied fied

Restrict food energy intake 12% 37% 28% 29% 25%

Hold weight constant throughout pregnancy 22 18 12

General nutrition advice 6 13 28 12

No dietary re­ strictions during pregnancy 12 12

Establish total weight gain limit 12 12 8

Low carbohydrate diet 23

Carbohydrate-free diet 12 13 5

"ADA" diabetic diet 5 12 5

Low carbohydrate, low fat diet 5 6 3

Low carbohydrate, low fat, low sodium diet 12 149

TABLE 27 cont.

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Cert- Cert- Cert- Cert- fied fied fled fled

Low food energy low sodium diet 26% 3%

Refer for special diet Instructions 12%

Encourage weight loss throughout pregnancy 13

Reduce sodium & fluid Intake 6%

Reduce quantity of food to reduce food energy

N 17 8 18 17 60

aAnBwers were compiled from only those physicians who Identified obesity as the most serious nutrition-related complication of pregnancy. 150

excessive (Table 28). For all the other physicians, greater than 29.2

pounds was excessive. Thirty-seven percent of all physicians defined

a weight gain of 25 pounds or less as excessive; a criterion well

within the limits designated "normal" by the American College of

Obstetricians and Gynecologists (Pitkin et al.. 1972). Only two

physicians used a criterion similar to Pitkin's: a weight gain of

3 kilograms (6.6 pounds) or more per month.

Eleven of the 21 physicians (who said excess weight gain was a

serious problem) made a positive diagnosis on total gain within the

accepted "normal" range.

Indicence

According to all physicians, approximately one in four patients

(24 percent) were exceeding their prenatal weight gain limit. Using more realistic criterion, the incidence was probably less.

The obstetrical practice of limiting prenatal weight gain was evident among the four groups of physicians. There was great concern expressed that serious complications of pregnancy were caused by rapid weight gain (or obesity).

Treatment

There were almost as many answers as there were respondents to the question about treatment of excessive weight gain (Table 29). The majority of physicians recommended some kind of food energy restriction. Only a few physicians recognized that pregnancy was an 151

TABLE 28

Diagnostic Criteria for Excessive Weight Gaina

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Criterion Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. No. No. No. No.

Over 20 pounds 2X 2% 19X

> 20 pounds over ideal weight 2 9

Over 25 pounds 1 3% IX 2A

Over 30 pounds 2 19

Over 35 poundB 5

Over AO pounds 5

> 6 pounds/mo. 5

> A-5 pounds per month 5

> 8 pounds/mo. 5

Depends on somatotype, edema

N 21

aAnswers were compiled from only physicians who identified excessive weight gain as the most serious nutritional complication of pregnancy. 152

TABLE 28 cont.

Diagnostic Criteria for Excessive Weight Gain8

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Criterion Certi­ Certi­ Certi­ Certi­ fied fied fied fied

Over 24 pounds 3% 2% 4% 1% 102

Over 25 pounds 3 3 7 9 22

Over 30 pounds 15 5 6 10 36

Over 35 pounds 4 — 1 5

Over 40 pounds 1 4 0 4 9

Pounds above ideal weight 3 3

Pounds/week, month or TM 3 3 3 4 13

No criterion- any weight gain is acceptable 2 1 3

Separate criterion for obese patients 1 1 2 2 6

N 34 19 24 28 107

aAnsvers compiled from physicians not rating excess weight gain among serious nutritional complications of pregnancy. 153

TABLE 29

* Recommended Treatment for Excessive Weight Gain In Pregnancy3

Physicians by Specilty and Certification

Obstetricians Family Physicians AH Physicians Board Non Board Non Treatment Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. No. No. No.

General diet instructions 2% 1% — IX 4%

No food energy restrictions during pregnancy 1 1

Restrict food energy Intake 1 2 2X 4 9

Refer to RN for diet 1 — —— 1

Low fat, low carb. diet 1 ——— 1

Low carb. diet 1 — 1 — 2

Establish wt. gain limit 1 — 1

Patient to follow any diet that works 1 1

N 21

aAnswers compiled from only those physicians who Identified excessive weight gain as the most serious nutritional complication of pregnancy. 154

TABLE 29 cont.

Recomnended Treatment for Excessive Weight Gain in Pregnancy8

Physicians by Specialty and Certification

Family PhysiciansObstetricians All Physicians Board . Non Board Non Treatment Certi­ Certi­ Certi­ Certi­ fied fied fied fied

Restrict food energy Intake 9% 7% 8% 111 35%

Low carbohydrate diet 7 3 1 3 14

Intimidation 6 6 1 13

General Nutrition advice 10

Low fat, low carbohydrate diet 7

Establish wt. gain limit 3

No food energy restriction during pregnancy

Carbohydrate- free diet

Eliminate sweets, desserts

Low Na diet, restrict fluids 155

TABLE 29 cont.

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Certl- Certl- Certi- Certi­ fied fled fled fled

Hospitalization 1% 1%

Exercise 1 IX 2

No treatment, except diabetics 1% 2

"ADA" diabetic diets 3

Reduce portion size to re­ strict food energy Intake

Inappropriate answer 1%

N 35 18 25 28 106

aAnswers compiled from physicians who did not identify excessive weight gain as a serious nutritional complication of pregnancy. 156

inappropriate tine to attempt weight lose.

Summary: Treatment of obesity and excess weight gain

Almost all physicians recommended some dietary restrictions for

treating obesity and excess weight gain. Such restrictions Included:

a decrease in total food consumption, reduced carbohydrate Intake,

reduced food energy Intake and elimination of food high in dietary

sodium. Fewer than five percent of the physicians recommended exercise

as the best method for controlling weight. As for treatment there

were no Important differences between the 21 physicians who identified

excessive weight gain as a serious problem of pregnancy and the other

107 physicians in the study. (Opinions and objectives were freely

expressed to the investigator.)

Eighteen percent of the obstetricians and 24 percent of the family

physicians provided their obese and overweight patients with diets

designed to provide 1800 kilocalories (or less) per day. Many nutritionists consider that severely limiting food energy Intake may

also limit the intake of essential nutrients. Thirteen percent of all physicians encouraged obese patients to restrict weight gain

throughout pregnancy so a significant weight loss would be achieved after delivery.

Fewer than 10 percent of all physicians Instructed their over­ weight or obese patients in the general principles of prenatal nutrition; nor did physicians caution agalnBt attempts to lose weight during pregnancy. "Intimidation" was employed by several physicians 157 to get patients to limit weight gain. For examplef patients were told about the dire effects of unlimited weight gain on the course of labor and delivery. No reported research evidence supports such claims.

Underweight Patients and Patients who Fail to Gain Weight During Pregnancy

t

Physicians are sometimes confronted with prenatal patients who can't or won't gain weight. Only one physician identified inadequate gain as the most serious nutritional complication of pregnancy.

Diagnostic criteria

This single physician said a weight gain of less than 18 pounds was inadequate.

Incidence

Sixty-four percent of all physicians in this study estimated that approximately 6 percent of their patients experienced inadequate weight gain. Twenty percent of the physicians insisted they "never" observed this condition and another 16 percent declined to discuss the subject.

Treatment

According to AO percent of all physicians in the study, dietary intervention to correct inadequate weight gain was unnecessary 158

(Table 30). Other physicians suggested patients try eating multiple,'

small meals; Increase dietary protein or Increase food energy Intake.

Twelve percent of the physicians emphasized the Importance of prenatal nutrition counseling.

Underweight

Fregravid underweight was not considered a serious nutritional problem and only A percent of the physicians said it complicated pregnancy, It was not identified as a "most serious" problem

(Table 25).

Summary

A substantial number of physicians in this study appeared to disagree with the conclusion of Christakis (1977) that "prepregnant underweight and inadequate prenatal weight gain are significant risk factors to the infant and the mother," Or, they do not presume their patients have these problems.

Iron-deficlency Anemia

More than one-third (39 percent) of the physicians in this study identified iron-deficiency anemia as a serious nutritional complication of pregnancy (Table 25). 159

TABLE 30

Recommended Treatment for Insufficient Weight Gain in Pregnancy8

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Certl- Certl- Certl- Certi­ fied fled fled fled

No dietary Intervention 30% 41% 44% 507. 40%

Multiple, small meals 12 4 4 7

Increase food energy Intake 5 9 4 3

Increase dietary protein 37 32 16 13 25

Increase dietary carbohydrate 7 9 4

Restrict dietary carbohydrate 2 4 4 3

Restrict dietary fat — 4

General diet instructions 12 4 20 13 12

Increase vitamin mineral supplements 2 — 4 6 3

Food supplements 5 4 — 9 5

Appetite stlmulent 6 2 160

TABLE 30 cont.

Phy'slclans by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Certi­ Certi­ Certi­ Certi­ fied fied fied fied

Diet history, appropriate diet therapy 9% 92 12% 6% 9%

Patients warned not to diet . during pregnancy

Patients told "think of the baby" 12 16 11

Avoid snacks, spoil appetite 2 2

Eat everything 7 2

Eat more 2 2

Force feeding 2 2

Public assistance for poor women 2 1

Hospitalization 2 1

Search for medical cause 3

Limit weight gain 2

Stop smoking 2

Correct emotional problems N 43 22 25 32 122

percentages exceed 100 as physicians gave more than one answer. 161

Diagnostic criteria

Fourteen percent of the physicians said anemia was the moat

serious nutritional problem and their diagnostic criteria can be

found In Table 31. Over one-third or these physicians defined anemia as a hemoglobin level below 12.5 g/dl. McFee (1973) says "by the end of the second trimester of pregnancy, about 72 percent of all pregnant women show a hemoglobin value of 12 g/dl or less".

Those physicians who did not designate anemia as the moat serious nutritional problem of pregnancy were also asked to comment on this deficiency disease. Almost one In three physicians in this group also defined anemia as a hemoglobin level of less than 12.5 g/dl.

However, this group of physicians utilized many other laboratory tests in making a diagnosis.

Although physicians identified 51 different definitions or criteria for diagnosing iron deficiency anemia, hemoglobin determi­ nations were by far the most frequently used test. This variety of criteria is indicative of the confusion resulting from so many tests used to measure iron nutrlture. Only 12 percent of all physicians used diagnostic tests considered more precise than hemoglobin and hematocrit determinations: serum iron, iron binding capacity and transferrin saturation.

Hemoglobin and' hematocrit determinations and basic laboratory studies, are necessary to assess maternal nutrition status. If hemoglobin levels are less than 11.0 g/dl or hematocrit below 33 162

TABLE 31

Diagnostic Tests and Criteria for Iron-Deficiency Anemia3 ***

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Criteria Cert- Cert- Cert- Cert- fied fled fied fled No. No. No. No. No. 2

Hemoglobin Lebel <10% g/dl — — 1 ™ 1 6 <11*5 g/dl 2 3 — 1 6 33 <12% g/dl 2 — 4 1 7 39

Hematocrit level (1) Lri <30% 1 1 2 11 <332 1 — -- — 1 6 <372 — 1 — — 1 6 <382 — 1 — — 1 6

Red cell indices 1 1 — — 2 11

Total iron binding capacity — — 1 2 3 17

Serum iron 2 — 1 2 5 27

Iron-responsive anemia — 1 — ™ 1 6

Erythrocyte smear —— —— 1 6

Bone marrow exam (if necessary) 1 —— — 1 6

N 5 4 5 4 18 aPhy8icians gave more than one answer to the question, bData compiled from physicians who identified anemia as the most serious nutritional complication of pregnancy. 163

TABLE 31 cont.

Diagnostic Tests and Criteria for Iron-Deficiency Anemia3 *b

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Criteria Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. No. No. No. No. %

Hemoglobin level (1) (1) (1)

<10*5 g/dl 6 7 6 A 23 21% <11*5 g/dl 13 3 6 7 29 26 <12*s g/dl 10 3 10 9 32 29

Hematocrit level (8) (1) (2) (5)

<30% A A — 8 7 <33 1 — 3 1 5 A <35 2 1 2 2 7 6

<37 1 — 1 2 AA

Erythrocyte smear A 2 1 1 8 7

Complete blood ct 10 2 5 A 21 19

Red cell indices 1 — 2 2 5 A

Mean corpuscular volume 1 1 1 3

Mean corpuscular hemoglobin concentration

Mean corpuscular humoblogin 1 1 TABLE 31 cont.

Physicians by Specialty and Certification

Family PhysiciansObstetricians All Physicians Board Non Board Non Criteria Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. No. No. No. No. X

Serum iron 3 1 1 2 7 6%

Total iron binding capacity 3 1 —— 1 5 A • Percent satura­ tion of trans ferrln 1 1 — — 2 2

No criterion — — — 5 5 A

Unclassified 2 3 — — 5 A

N 39 18 23 30 110

aPhyslclans gave more than one answer to the question, t>Data compiled from physicians who did not identify anemia as the "most serious" nutritional complication of pregnancy. 165 percent* some abnoramllty exists (Chrlstakis, 1977). Examination of erythrocyte smears may provide information about the cause of anemia.

Sixty-six percent of the physicians in this study made appropriate preliminary evaluations necessary in establishing the exlstance of anemia.

Mean corpuscular volume and mean corpuscular hemoglobin concentration are two laboratory calculations used to determine micro- or macrocytosis and hypochromla. Mean corpuscular humoglobln is used to Indicate hypchromla. Red cell indices (MCV* MCHC and MCH) permit evaluation of the size and hemoglobin content of red corpuscles

(Chrlstakis* 1977). Only 7 physicians used these Indices for hematological evaluation. Percent saturation of transferrin, the test considered most reliable for diagnosing anemia in pregnant women* was used by just two physicians.

Incidence

Those physicians who identified iron deficiency anemia as the most serious nutritional complication of pregnancy* estimated that approximately 28 percent of their patients met their criteria for the disease. All the other physicians in the study estimated that about

15 percent of their patients were anemic.

Neither group of physicians indicated they routinely went beyond basic laboratory studies. 166

Treatment

There was considerable variation among physicians in their treatment of iron-deficiency anemia (Table 32). Nearly every physician prescribed oral iron (ferrous sulfatet ferrous fumerate or ferrous gluconate) In addition to standard vltamln-mineral supplements.

About 10 percent of the physicians Indicated they were satisfied with response to the prenatal vitamln-mlneral supplement alone. Trade names and composition of all the prescribed hematlnlcs are listed in the appendix (Appendix F).

Approximately 17 percent of the physicians administered parenteral iron to patients with severe anemia, or to patients who were unable to tolerate oral iron, or failed to respond to oral iron therapy early in pregnancy, or to patients who refused to take oral iron.

All supplements and special prenatal hematlnlcs contained elemental iron in excess of 18 mg: the RDA for pregnancy. The

Committee on Maternal Nutrition (1970) recommended that dally dietary supplements contain 30 to 60 mg iron and be administered throughout the latter half of pregnancy. Only three supplements provided less than 30 mg elemental iron. There was evidence that physicians provided abundent nutrition therapy for patients with iron deficiency anemia. 167

TABLE 32

Treatment of Iron-Deficiency Anemia in Pregnant Women8

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Recommended Certi­ Certi­ Certi­ Certi­ Supplements fied fied fied fied No. No. No. No. No. X

Vitamln-mineral supplement 42 20 26 33 122 962

Oral iron 27 15 22 31 94 75

Injectable iron 11 2 3 6 22 17

Iron in different form (from supple­ ment) 7 2 3 4 16 13

Double iron Intake 1 0 0 2 3 2

Water soluble vitamins 1 0 1 0 2 2

Folate 1 2 2 7 5

Ascorbic acid 7 2 3 2 14 11 Vitamin B^2 1 0 2 1 4 3 Vitamin Bj2 (by Injection) 1 0 0 1 1 Vitamin E 1 0 1 0 3 2 B-complex vitamins 1 0 0 0 1 1 Intrinsic factor 1 0 2 1 4 3 Vitamin Bx 0 0 1 0 1 1

Double Intake of vitamln-mineral supplements 1 1 0 1 3 2 Diet counseling 4 0 4 1 9 7

N 43 21 28 34 126

&Many physicians recommended two or more nutrient supplements to their patients. 168

Megaloblastic anemia

McFee (1973) reported that "in the United States about 20 to 25

percent of normal, unsupplemented parturients will show early evidence

of folic acid deficiency in late pregnancy." His judgment applied to

affluent as well as indigent women.

Diagnostic criteria

Only one physician in this study used the formimlnoglutamic

acid (FIGLU) excretion test and obtained bone marrow biopsy data to

diagnose megaloblastic anemia. This private practice physician

provided medical care for many poor patients. One other physician

routinely examined serum folate levels. Otherwise, physicians relied

on peripheral blood smears, complete blood counts, or patient's

failure to respond to iron therapy as techniques for diagnosing

megaloblastic anemia. (It should be noted that 16 percent of the

physicians were not screening for megaloblastic anemia.) Another 15

percent of the physicians depended on their laboratory technicians

to alert them to the existence of this prenatal deficiency disease.

Almost one in five physicians declined to answer the question

concerning diagnostic criteria (Table 33).

Incidence

Only three physicians said they frequently diagnosed megaloblastic anemia. Eighty-five percent of the physicians had not seen a*single 169

TABLE 33

Diagnostic Criteria for Megaloblastic Anemia

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Determinations Certi- Certi- Certi­ Certi­ fied fled fled fied No, No. No. No. No.

Peripheral blood smear 14 13%

Complete blood count 12 26 25

Red cell macro-cytosls

Hemoglobin/ hematocrit 4 4

Severe anemia 1 1

Failure to respond to Iron therapy 3 3 18 17

Laboratory alert 5 5 4 16 15

Serum folate 1 1 1

Urinary FICLU, serum folate, serum B^2

No routine testing

Unclassified

N 36 18 22 28 104 170

case in the preceding year. The overall estimated incidence was less

than one-half of one percent.

Treatment

Physicians treated megaloblastic anemia with prenatal vitamln- mineral supplements, alone, or with additional folate. Doctors

indicated their patients responded favorably to vitamin therapy.

About one in three physicians declined to discuss treatment (Table 34).

The very low incidence of megaloblastic anemia among pregnant women was due to satisfactory diets and routine supplementation with folate. However, no physician mentioned the importance of routine laboratory studies for those prenatal patients suspected of carrying twins or of high parity.

Other Nutrition-related Complications of Pregnancy— Toxemia of Pregnancy

Only two physicians reported toxemia of pregnancy was a common nutritional problem among their private patients. One physician was a board-certified obstetrician; the other a general practitioner and both had a substantial number of Indigent patients. It was evident from comments made by all physicians that eclampsia was almost unknown.

Diagnostic criteria

All physicians in this study were asked a series of questions related to toxemia specifically preeclampsia. There were 47 different 171

TABLE 36

Treatment of Megaloblastic Anemia

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Management Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. No. No. No. No. X

Prenatal Vitamln- Mlneral supp. 9 A 6 19 23

plus folate 8 7 8 5 28 3A

plus folate & vita Bj2 2 — 1 3 6 7

plus Iron & vit, B12 — — — 1 1 1

Double dose of vitamin supplement 1 1 1

Refer patient to hematologist 10 A 3 3 20 2A

Diet counseling 2 — 1 3 A

Refer patient to dietitian 1 — — 1 1

Inappropriate answer 1 1 — 1 3 A

N 33 16 12 21 82 172

answers in response to the question about diagnostic criteria.

Answers have been classified either by terminology used to describe preeclampsia: from the American College of Obstetrics and Gynecology

(1973) (hypertension, proteinuria, and edema associated with rapid weight gain) or other criteria employed by the physicians (Table 35).

Nearly every physician made a diagnosis based on the classical

triad: hypertension, proteinuria and edema with rapid weight gain.

Approximately one~thlrd of the physicians designated rapid weight gain as an Independent criterion. Only 5 doctors mentioned the "two pounds per week" (Pitkin's (1977) definition) as a positive sign for preeclampsia.

Incidence

Using their own criteria for preeclampsia, doctors estimated that toxemia was evident in four percent of their private patients. No estimate of the incidence of toxemia among American women was found in the literature, but Molina et al. (1974) reported that the frequency of preeclampsia was four percent among middle class women in the city of Maracaibo, Venezuela.

Treatment

Recommended treatment of preeclampsia was varied and inconsistent

(Table 36), Very few physicians had adopted the current recommended approach: a highly nutritious diet with hospitalization or bed rest.

Most physicians suggested restricting dietary sodium, and prescribed TABLE 35

Diagnostic Criteria for Preeclampsia®

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicist Board Non Board Non ACOG Certi- Certi­ Certi­ Certi­ Criteria fied • fled fied fied No. X No. % No. % No.. % No. X

Hypertension 40 93 20 100 24 100 29 91 113 95

Proteinuria 36 84 19 95 21 87 26 81 102 86

Edema 32 74 13 65 18 75 21 66 84 71

Rapid weight gain 16 37 7 35 8 33 9 28 40 34

Other Criteria No, No. No. No. No X

Obesity 1 1 — — 2 2 Headaches, blurred vision 2 3 1 6 5 Positive roll­ over test 2 __ — — 2 2 Creatinine clearance rate __— 1 1 1 Abnormal reflexes 1 __ —— 1 1 Decreased urinary output 1 ——— 1 1 Albumln-globulln ratio — __— 1 1

Diet history 2 — ——

Laboratory Alert — — 1 1 1 Cerebral edema — — 1 — 1 1 No criteria 1 —— 1 1

N 43 20 24 32 119

^Percentages exceed 100 as physicians gave more than one answer. 174

TABLE 36

Recommended Treatment of Toxemia of Pregnancya

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. No. No. No. No.

DIET RELATED

General diet instructions 3 3 2

Restrict sodium Intake 30 16 18 23 87 73

Increase sodium intake 1 1

High protein diet 12 10 25 21

Low protein diet

Restrict milk Intake

Restrict food energy Intake 7 5 2 16 13

Low fat diet 1 1 1 3 2

Low carb. diet 1 1 3 2

Low cholesterol diet

Limit weight gain 1 2

Lose weight 1 3 175

TABLE 36 cont.

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Treatment Certi- Certl- Certi- Certi- fled fled fled fled No. No. No. No. No. %

Increase fluid Intake 5 1 1 1 8 7

Restrict fluid intake — — 1 — 1 1

Drink distilled water — 1 —— 1 1

Avoid foods made with white sugar & white flour 1 mm MM MM 1 1

Bland diet — m 1 ’ ~ - 1 1

Increase intake of vitamln-mineral supplements 1 ••m 1 1 3 2

NOT DIET RELATED

Diuretics 8 6 7 14 35 29

Other medications — 6 2 1 9 8

Referred to another MD 1 — 1 1 3 2

Hospitalisation 13 5 2 4 24 20

Bed rest 11 6 4 6 27 23

Induce labor 4 — — 1 5 4

No dietary management— 1 4 — 5 4

N 43 21 26 30 120 apercentagea exceed 100 as physicians gave more than one answer. 176

natriuretic drugs— a combined approach considered harmful to the fetus

(Medical News, 1977).

Twenty-one percent of the physicians reported they Instructed

preeclamptic patients to Include plenty of high-quality protein in

their diet, but almost as many (18 percent) urged patients to restrict

food energy Intake to control weight. Restricting food energy Intake

appears to have no beneficial effect in either preventing or treating

toxemia of pregnancy (Brewer, 1974; Ayers, 1974).

Protein Malnutrition

Approximately nine percent of the physicians, all obstetricians, identified inadequate protein intake or poor quality protein as "the most serious nutritional complication of pregnancy." One physician used the albumln-globulin ratio to diagnose protein malnutrition, a test considered unreliable for obstetric patients. The other physicians relied on subjective evaluations of patients' diet histories. Three physicians said that excessive weight gain and gross obesity were

Bymptoms of protein deficiency. Physicians were unable to estimate the extent to which protein malnutrition existed among their private obstetric patients.

Treatment of protein malnutrition by the board-certified obstetricians consisted of advice to consume more meat, milk, eggs, cheese and seafood. Two of these physicians recommended that their patients increase the use of prenatal vitamln-mineral supplements. 177

Noncertified obstetricians gave less precise dietary advice.

Other Nutrition-related Problems

Chrlstakls (1977) listed a number of conditions requiring careful

management during pregnancy. He considered a pregnant woman at

nutritional risk if she were: an adolescent, diabetic, drug addict)

alcoholic, tubercular or mentally depressed. Adolescence, was the

only problem mentioned with any frequency by physicians in this study.

While only six physicians considered adolescent eating habits

Important enough to mention as one of the three most serious

complications of pregnancy, one-fourth of the doctors during the course of the Interview made some reference to teenager nutrition. The physicians were troubled about obstetric complications caused by poor quality diets and reported little success in attempts to improve the nutrient intake of these young mothers.

Nutrition-related Problems of Private Patients

Obesity, excessive weight gain and lron-deflclency anemia were the most frequently mentioned problems of a dietary origin prevalent among private obstetric patients. These problems are hardly unique in any segment of American society. Thus, there did not seem to be any unusual nutritional problems among private obstetric patients. 178

Advice to Patients

Prenatal nutrition was recognized as an Important factor In

maternal and Infant health. Nearly every physician in this study

acknowledged that obstetrical care should Include guidance in food

selection and advice about weight gain. All physicians, except one,

instructed patients to take vitamln-mineral supplements throughout

pregnancy. Asked if diet instructions should be part of routine prenatal care, three-fourths (73 percent) of the physicians said

"always.1* No physician said "never" to diet Instructions (Table 37).

Situations requiring diet Instructions are summarized In Table 38.

Although all doctors Indicated that maternal nutrition was Important to obstetric patients, only 15 percent said diet Instructions were essential to help the patient understand the special needs of pregnancy. Approximately one in four physicians said they provided dietary advice to correct problems of overweight or underweight. Only nine percent of the physicians mentioned the nutrient requirements of the fetus or newborn as justification for diet Instructions.

In answer to the question "who gives diet instructions?" approximately 65 percent of the physicians said they personally accepted responsibility. Xnother group of physicians (24 percent) shared the task with an office nurse or receptionist. Eight percent of the physicians relied entirely on the office staff, nurses or receptionists, to provide diet instructions* Only three physicians routinely used the services of a dietitian for general instructions, 179

TABLE 37

Desirability of Giving Diet Instructions

PhysiclanB by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non of Diet Certi­ Certi­ Certi­ Certi­ Instruction fied fied fied fied

Always 67% 67% 86% 74% 73%

Usually 19 6 7 10 12

Occasionally 14 24 7 16 15

Never MW MM MM

N 42 21 28 31 122

Tau c ■ .06; p * .16 180

TABLE 38

Circumstances Favoring Diet Instructions®

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Circumstances Board Non Board Non Favoring Certi­ Certi­ Certi­ Certi­ Diet Instructions ' fied fied fied fied No. No. No. No. No. %

Adolescence 4 1 0 2 7 6 Underweight, not gaining weight, or lost weight in previous pregnancies 5 2 1 4 12 10 Low socioeconomic status 3 0 2 3 8 6 Disease that Influences maternal nutrition 0 0 2 o’ 2 2 Previous obstetrical complications 0 0 0 2 2 2 Fad dieting 4 0 0 2 6 5 Overweight or gaining excessively 14 6 11 9 40 32 Prevent toxemia and other complications of pregnancy 5 4 0 1 10 8 Mothers who need basic nutrition education 13 3 5 10 31 25 Misunderstandings concerning maternal nutrition 2 0 1 2 5 4 181

TABLE 38 cont.

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Circumstances Board Non Board Non Favoring Certi­ Certi­ Certi­ Certi­ Diet Instructions fied fied fied fied No. No. No. No. No. Z

Signs and symptoms of nutritional deficiencies 0 0 1 3 4 3 Family history of nutritional problems 0 0 1 0 1 1 Special nutritional needs of pregnancy 5 3 7 4 19 15 Special nutritional needs of fetus 2 3 2 4 11 9 Physicians' responsibility 3 1 2 4 10 8 Prenatal patients' needing diet after pregnancy 0 0 0 1 1 1 Unusual meal patterns 1 0 0 0 1 1 Miscellaneous 3 5 1 1 10 8 No answer 0 2 0 1 3

N 44 22 28 34 128

‘Percentage exceeds 100 because physicians gave store than one answer. 182

but many doctors said they would refer patients with diabetes or

cardio-vascular disease for expert diet counseling. One physician considered diet instructions a responsibility of the hospital maternity unit, specifically the prenatal class instructor.

There were two different types of diet instructions. Eighty-

three percent of the physicians relied on printed materials. These materials were usually supplied by commercial food or drug companies.

All physicians who used printed materials provided the investigator with copies of their handouts. Sixteen percent of the physicians gave verbal instructions only. Two physicians augmented their printed materials with cassette movie tapes which could be played over a television set in the physician's office.

Routine Diet Instructions for Prenatal Patients

Weight gain in pregnancy

Physicians were asked to discuss their concept of "normal weight gain in pregnancy." Their mean recommended gain was 22 pounds; mode,

20 pounds and range, 0 to 36 pounds (Table 39). In discussing prenatal weight gain, 37 percent of the physicians said the pattern established by individual mothers was a better criterion of nutrition status than any rigid standard established to limit total gain.

Some physicians indicated a separate criterion of "normal" weight gain for obese and underweight patients. Fourteen percent of the 183

TABLE 39

Physicians' Views of Normal Weight Gain In Pregnancy

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Range Certi­ Certi­ Certi­ Certi­ fied fied fied fied

Less than 20 pounds 9% 182 252 152 162

20-24 pounds 64 50 50 56 56

25-30 pounds 20 23 25 24 23

More than 30 pounds

No established range

N 44 22 28 34 128

Mean 22 21.5 21.3 22.5 (In pounds) 18A

physicians stated that "normal" weight gain for obese patients was

5 pounds; mode, 0 pounds; and range 0 to 20 pounds. Nineteen percent

of the physicians Indicated that "normal" weight gain for thin

patients was 25 pounds. There were two distinct ranges for the thin woman: 15 to 18 pounds, and 25 to $5 pounds. When those recommending

the 15 to 18 pound range were asked why they restricted weight gain

in already underweight women, the most frequent response was "it was unwise to push them too hard." The physicians who recommended weight

gain over 25 pounds hoped it would aid the patient in achieving normal weight after delivery.

The American College of Obstetricians and Gynecologists (Pitkin,

1972) recommends a weight gain of 22 to 26 pounds, the Committee on

Maternal Nutrition of the National Research Council (1970) recommends

20 to 25 pounds and Hytten and Leltch (1970) recommends 27.5 pounds.

A substantial number of physicians in this study were in agreement with these recommendations. However, almost two-thirds of the physicians had not adopted Pitkin's (1976) criterion for normal weight gain: a steady increase throughout the second and third trimesters of pregnancy. Fewer than 10 percent of the physicians urged their obese patients to gain at a normal rate (350 to A00 grams weekly) after the tenth week of pregnancy. Neither underweight nor thin patients were encouraged to gain at a steady rate.

Nutritional value of foods

Information concerning the nutritional value of foods was "always" reviewed by 32 percent of the physicians (Table A0). Nearly half the 185

TABLE AO

Information Offered on Nutritional Value of Foods

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Information Certi­ Certi­ Certi­ Certi­ Given fied fied fied fied

Always A7% 25% 30% 30% 32%

Usually 8 20 22 18 16

Occasionally 18 AO 37 32 30

Never 27 15 11 29 22

N AO 20 27 3A 121

Tau b ■ -,12j p * .06 186 board-certified obstetricians Instructed patients In basic principal of nutrition. The other three groups of physicians were less likely

to discuss food composition. It was evident from doctors' comments

that the phrase "nutritional value of foods" was not completely understood.

Nutrition labels

Physicians were asked If they explained or Interpreted the nutri­ tion labels on food packages for the benefit of their patients. Only three physicians responded "always." Sixty-seven percent responded

"never," Several physicians admitted they were unaware of the existence of these labels. Apparently, many physicians did not realize this nutrition Information would benefit their prenatal patients (Table 41),

Milk and dairy products

Physicians were asked If they instructed their patients to drink one quart of milk daily or eat cheese, Ice cream or other dairy products to provide the equivalent amount of nutrients. About 22 percent responded "never" (Table 42), and twelve percent of the physicians expreBBed the opinion that milk was not an essential food.

These physicians assumed an adequate supply of calcium could be obtained from prescription vitamln-mineral supplements, Examination of the nutrient content of various supplements revealed that none provided calcium at a level equivalent to the RDA for pregnancy 187

TABLE 41

Information Offered on Nutrition Labels

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Information Certi­ Certi­ Certi­ Certi­ Given fied fied fied fied

Always 5% 5% — — IX

Usually — 8% 2

Occasionally 13 19 50 38% 29

Never 83 76 42 62 67

N 40 21 26 34 121 188

TABLE 42

Patients Advised to Drink Quart of Milk Dally

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Advice Certl- Certi­ Certl- Certl* Given fied fled fled fled

Always 48% 29% 36% 26% 36%

Usually — 5 18 8 7

Occasionally 12 14 14 18 14

Never 40 52 32 47 42

N 42 21 28 34 125

Tau b (for entire table » -,07; p » ,17 Tau c (for certification) * -,17; p •* ,04 Tau c (for specialty) *• -.02; p *» ,41 189

(Appendix F). Other reasons given for limiting milk consumption were:

"overrated as a food" or "too high in calories." Only 36 percent of

the physicians "always" instructed their patients to drink a quart of

milk daily. Twice as many board-certified obstetricians as the other

three groups of physicians urged patients to drink one quart of milk

every day.

Board-certified physicians were most likely to recommend mllk-

drinking to their patients (tau c ■ -.17, p ■ .04).

Vltamin-mlneral supplements

Almost all physicians (98 percent) routinely prescribed vitamin-

mineral capsules so moBt doctors apparently considered supplements

"nutrition insurance.'-' However, several supplements failed to meet

the standards for iron and folic acid established by the Committee on

Maternal Nutrition of the National Research Council (1970) and the

American College of Obstetrics and Gynecology (Pitkin et al.. 1972)

(Appendix F).

Approximately 31 percent of the physicians prescribed "Natallns"

(Mead Johnson), a supplement designed to meet the vitamin and mineral needs of pregnant women. Hematlnlcs were routinely proscribed by many physicians to increase the patient's Intake of iron. This iron was In addition to the amount supplied by the vitamin-mineral supplement. 190

Sodium

Physicians were asked "under what circumstances do you advise a

patient to limit sodium intake?" Eighty-seven percent recommended a

decrease in sodium Intake to: (1) prevent toxemlai (2) prevent edema

(3) control weight gain and (4) treat kidney, cardiac and hyper­

tensive disorders. Only 7 percent Indicated they "never" routinely

adviBed a patient to limit sodium Intake unless there was some

specific disease requiring dietary restriction. Many doctors Baid

they usually recommended a "mild" sodlum-restrlcted-diet to all patients for the purpose of preventing edema and rapid weight gain.

Prenatal Classes

Sixty-three percent of the physicians in this study said they

"always" urged their patients to attend prenatal classes sponsored by hospital or childbirth education associations (Lamaze) or community health centers. These classes almost always provide diet counseling and nutrition education. Doctors seemed unconcerned that information presented in these classes might conflict with their specific diet instructions. Many physicians said they were most anxious for prlmiparas to attend prenatal classes (Table 43). 191

TABLE 43

Patients Advised to Attend Prenatal Classes

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Advice Certi­ Certi­ Certi­ Certi­ Given fied fied fied fied

Always 71% 57% 57% 61% 63%

Usually 7 5 17 19 12

Occasionally 12 29 22 10 16

Never 10 9 4 10 9

N 42 21 23 31 117

Tau b ** -.50; p ■ ,27 192

Food Stamps

Physicians were asked If they explained the advantages of the

federal food stamp program to patients who would benefit by

additional food. Thirty-nine percent said they could not respond to

the question because they had no experience with the program, or they didn't consider their patients economically disadvantaged. Fifteen percent of the physicians said they "always" provided assistance to their indigent patients in obtaining food stamps (Table 44).

Physicians' Assessment of Diet Instructions

Each physician was asked to evaluate personal effectiveness in managing the nutrition component of obstetric care. Specifically, physicians were asked to estimate patients' adherence to diet instructions. Over one-third of the physicians (38 percent) indicated they were convinced that patients understood the diet instructions and followed their advice. However, the degree of cooperation depended on such factors as patient's motivation, education, age and economic status. One-fourth of the physicians reported they had been unsuccessful in getting patients to follow their dietary advice. They attributed part of their failure to the patient's lack of education, lower social class, or poverty. Thirty-six percent of the physicians avoided answering the question* Eleven percent of the doctors indicated they had no way of evaluating their success or 193

TABLE 44

Patients Advised How to Apply for Food Stamps

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Advice Certi­ Certi­ Certi­ Certi­ Given fied fied fied fied

Always 19% 20% 21% 4% 15%

Usually

Occasionally 5 7 16 13 10

Never 76 73 63 83 74

N 21 15 19 23 78

Tau c " -.05} p ■ ,28 194 failure In communicating dietary Information.

Attitudes Toward Breast-Feeding

Physicians In this study were asked if they provided their prenatal patients with Instructions about breast-feeding; 64 percent said "always." However, many stated that they would never attempt to persuade a mother to breast feed if she were reluctant in any way.

Three physicians Indicated they discouraged breast-feeding (Table 45).

Attitudes Toward Lactation

Sixty-one percent of the doctors said they "always" explained the lactation process to every prenatal patient (Table 46). Several physicians who did not discuss breast-feeding or lactation with their patients said the hospital nursing staff or the pediatrician should be responsible for this portion of patient education. The La Leche

League was frequently mentioned as an important organization for dispensing breast-feeding information.

Physicians' Sources of Nutrition Information

Dissemination of Information

Physicians answered parallel sets of questions about their favorite sources of medical and nutrition information. They also evaluated 195

TABLE 45

Patients Advised About Breast Feeding

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Advice Certi­ Certi­ Certi­ Certi­ Given fied fied fied fied

Always 68% 67% 69% 53% 64%

Usually 7 10 8 18 11

Occasionally 10 10 12 12 11

Never 15 14 12 18 15

N 41 21 26 34 122

Tau b » -.08; p - .15

TABLE 46

Patients Advised About Maintaining Lactation

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Frequency Board Non Board Non Advice Certi­ Certi­ Certi­ Certi­ Given fied fied fied fied

Always 63% 67% 71% 48% 61%

Usually 3 10 13 16 9

Occasionally 10 10 4 6 8

Never 25 14 13 29 22

N 40 21 24 31 116

T b - -.05; p ■ .25 196

medical journals, professional meetings, colleagues and their own

practice in providing continuing education. The purpose of these

questions was to ascertain and evaluate methods by which physicians

keep up to date with scientific developments.

Best source of information. One-third of physicians in this study

rated medical journals as the single best source of information about

new developments In medicine. Approximately half of the physicians

Identified *a single "best" source of Information, AO percent mentioned

two sources and 9 percent mentioned three or more sources. Medical

journals, professional meetings, casette tape services or advanced

courses were the most frequently mentioned sources of medical

education (Table A7).

The distribution of answers was quite different when physicians

rated their "best" source of nutrition information (Table AS). Only

3A percent of the physicians rated journals as a "best" source of

nutrition Information compared to 73 percent for medical Information.

Twenty-nine percent of the physicians failed to Identify a "best"

source. Popular publications such as newspapers and magazines were

rated as "best" sources of nutrition information by A percent of the

physicians.

Professional meetings. To the question: "how many professional meetings were you able to attend this past year" physicians used various criteria or definitions of a meeting. Some obstetricians and

general practitioners counted local hospital meetings and conferences 197

TABLE 47

ANSWERS TO THE QUESTION:

"What have you found to he your best source of Information about new developments related to your practice of medicine?"6

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Information Certi­ Certi­ Certi­ Certi­ Sources fied fied fied fied No. %

Medical journals 77% 77% 68% 59% 90 73

Cassette tapes 30 32 18 18 31 25

Professional meetings 20 14 32 24 29 24

Advanced courses 9 14 29 21 22 18

Colleagues 7 5 11 15 12 10

Drug company representatives — — 4 6 3 2

Textbooks and other professional publications 7 9 18 12 14 11

Other sources 9 9 4 — 7 6

No best source 2 5 4 6 5

N 44 22 28 34 128

“Total percentage exceeds 100 because of multiple responses. 198

TABLE 48

ANSWERS TO THE QUESTION;

"What have you found to be your best source of Information about new developments in nutritlon?"a

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicians Board Non Board Non Information Certi­ Certi­ Certi­ Certi­ Sources fied fied fied fied No. %

Journals 48% 50% 14% 21% 43 34

Cassette tapes 9 9 7 38 9 7

Professional meetings 7 — * ■ 4 9 7 6

Advanced courses 9 — — — 4 3

Colleagues 5 — — 2 2

Drug company representatives 2 14 7 6 8 7

Textbooks and other professional publications 16 14 43 12 26 21

Popular literature 2 — 11 3 5 4

Dietitian 5 11 12 8 7

Other Bources «*** — 7 9 5 4

None 32 23 18 35 36 29

No best source 2 5 4 — 3

N 44 22 28 34 128

aTotal percentage exceeds 100 because of multiple responses, 199 while others answered In terms of large national or regional meetings.

Physicians estimated they attended none to fifty-two meetings a year.

Data obtained about meetings were difficult to assess.

Continuing education is a condition of membership for Family

Practice specialists; 150 hours of continuing education must be completed every three years. The Academy of General Practice also requires attendance at professional education meetings and credit is accepted in six medical education categories (Crowley, 1975). Only two physicians belonging to either The Academy of General Practice or The American College of Family Physicians had less than 50 hours of continuing education the preceding year. The reported range of hours for continuing education was 25 to 300, mean 75.

Journals. Physicians regularly read from 0 to 23 journals, mean ■

3 1/3 (Table 49). Only nine percent of the physicians slad they had no time to read professional journals. Obstetricians and family physicians read journals published for their own speciality (Tables

50, 51), The obstetricians first choice was Obstetrics and Gynecology, preferred about two-to-one by the board-certified specialists. The

American Journal of ObBtetrics and Gynecology was second choice for both certified and noncertified obstetricians. Family Practice was first choice by both board-certified family physicians and general practitioners. There was a lack of agreement about second choice.

The family-oriented physicians had a longer list of choices than the obstetricians due to the more deverse nature of their practice. 200

TABLE 49

ANSWERS TO THE QUESTIONS;

"How many journals do you read regularly?"

Physicians by Specialty and Certification

Obstetricians Family Physicians All Physicist Board Non Board Non Certl- Certi­ Certl- Certi­ Number fied fled fied fled No. %

None 7% 5% 14% 9% 11 9

1-5 73 81 61 61 84 68

6-10 10 10 21 6 14 11

15-20 4 3 2 2

>20 — -- — 3 1 1

"Some" 10 5 — 18 11 9

N 41 21 28 33 123 201

TABLE 50

ANSWERS TO THE QUESTION: "What two journals are the best sources of new Information about your medical practice?"

Obstetricians Board-certified Non-certlfied 1st 2nd 1st 2nd Journals Choice Choice Choice Choice No. % No. % No. Z No. %

Obstetrics and Gynecology 25 60 10 24 8 38 3 14 American Journal of Obstet­ rics and Gynecology 6 15 13 32 3 14 6 29 Obstetrics and Gynecology Survey 4 10 3 7 2 10 4 19 Contemporary Obstetrlcs- Gynecology 2 5 3 7 2 10 0 — Obstetrics and Gynecology News 2 5 1 2 2 10 1 5 Obstetrics and Gynecology Annual 0 0 2 10 0 International Journal of Gynecology and Obstetrics (Corre spondance) 1 2 0 0 0 Family Practice 0 — 0 -- 1 5 0 — Clinical Obstetrics and Gynecology 0 — 1 2 0 —- 1 5 Fertility and Sterility 0 — 1 2 0 — 0 — Journal of 0 «. 1 2 0 __ 0 __ Journal of the American Medical Association 0 __ 0 «... 0 1 5 Private Practice 0 — 0 — 0 — 1 5 Medical Economics 0 — 1 2 0 — 0 — No favorite 1 2 7 17 1. 5 4 19

N 41 41 21 21 202

TABLE 51

ANSWERS TO THE QUESTION: "What two journals are the best sources of new information about your medical practice?"

Family Physicians Board-certified Non-certlfied 1st 2nd 1st 2nd Journals Choice Choice Choice Choice No. Z No. Z No. Z No. Z

Family Practice 10 37 4 15 5 15 2 6 American Family Physician/ GP 5 19 3 11 3 9 0 — Journal of the American Medical Association 3 11 2 7 3 9 4 12 Post Graduate Medicine 2 7 1 4 2 6 2 6 Patient Care 1 4 4 15 2 6 2 6 Medical Economics 0 — 1 4 1 3 0 — Emergency 0 — 1 4 0 — 3 9 Obstetrics and Gynecology 5 15 2 6 New England Journal' of Medicine 1 4 4 15 Medical Letter on Drugs and Theraputlcs 2 7 British Journal of 1 4 Family Practice Clinics 1 4 Consultant 2 6 Obstetrics and Gynecology Observer 1 3 Modern Medicine 1 3 Medical Digest 1 3 Diagnostics 1 3 1 3 Continuing Education for the Family Physician 1 4 1 3 203

TABLE 51 cont.

Board-certified Non-certlfied 1st 2nd 1st 2nd Journals Choice Choice Choice Choice No. % No. % No. % No. %

Current Therapy 1 3 Cutis 1 A Prism 1 A American Journal of Diseases of Children 1 A Archleves of Environmental Health 1 A Family Medicine 1 3 Medical Clinics of North America 1 3 Medical Tribune 1 3 Medical World News 1 3 1 3 Archieves of 1 3 Hospital Practice 1 3 "All" 1 3 None 1 A 2 7 2 6 10 30

N 27 27 33 33 204

Racing Sources of Information

Physicians rated the importance of Information obtained from

colleagues, professional meetings, journals and their own practice as

sources of continuing medical education (Table 52). Professional

meetings were rated "most important" followed by journals and obser­

vations in their own practice, and conversations with colleagues. All

of these sources were considered "very Important" by over half the

physicians.

The Importance of these four sources in providing continuing nutrition education was considerably less than for medical education.

Observations in the course of the physician's own practice was rated as the most important source of nutrition information by 47 percent of the physicians (Table 53). Conversations with colleagues, professional meetings, journals and observations in the course of physicians practice were all rated more important for medical information than nutrition Information. These data tend to confirm comments made by individual physicians that nutrition-related topics were seldom discussed by doctors and information associated with recent developments in nutrition rarely Included in continuing medical education programs.

An examination of responses from the four different groups of physicians revealed some differences in choices of medical information.

Blghty-three percent of the board-certified obstetricians and 79 percent of the board-certified family practice physicians selected 205

TABLE 52

Physicians' Ratings of Sources of Medical Information

All Obstetricians Family Physicians Physicians Board Non Board Non Sources Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. % Conversation with Colleagues

Very important 515! 40% 61% 76% 71 58% Somewhat important 41 60 28 18 43 35 Not very important 7 — 11 6 8 7

N 41 20 28 33 122

Tau c (for entire table) ■ .16; P - .02 Tau c (for certification) - .08; P - .17 Tau c (for specialty) - .18; P - .02

Professional Meetings

Very important 83% 61% 79% 82% 94 78 Somewhat important 12 39 21 15 23 19 Not very important 5 ■ M 3 3 3

N 41 18 28 33 120 Tau c ■ .00; p ■ .46

Journals

Very important 63% 74% 64% 50% 74 62 Somewhat important 34 21 29 34 37 31 Not very important 2 5 7 16 9 8

N 41 19 28 32 120 Tau c « -.10; p ■ .07

Observation in own Practice Very important 66% 65% 50% 64% 75 62 Somewhat important 29 30 32 27 36 30 Not very important 5 5 18 9 11 9

N 41 20 28 33 122

Tau c ■ -.05; p * .25 206

TABLE 53

Physicians' Ratings of Sources of Nutrition Information

Obstetricians Family Physicians All Board Non Board Non Physicians Sources Certi­ Certi­ Certi­ Certi­ fied fied fied fied No. % Conversation with Colleagues

Very Important 7% — 7% 13% 9 8 Somewhat important 17 32 18 22 25 21 Not very important 76 68 75 66 86 72 N 41 19 28 32 120 Tau c ■ ,06; p ■ .19

Professional Meetings Very Important 15% 11% 22% 31% 24 21 Somewhat Important 38 67 44 44 53 45 Not very Important 48 22 33 25 40 34 N 40 18 27 32 117 Tau c (for entire table - .18; P - .01 Tau c (for certification) * .18; P - .04 Tau c (for specialty) ■ .17; P ■ .04

Journals Very important 37% 47% 48% 34% 48 40 Somewhat Important 51 37 48 38 53 45 Not very important 12 16 4 28 18 15 N 41 19 27 32 119 2 0 Observations in own Practice Very Important 44% 60% 39% 50% 57 47 Somewhat important 29 25 29 25 33 27 Not very important 27 15 9 25 31 25 N 41 20 28 32 121 207

professional meetings as "very Important" among the four types of

continuing medical education. Seventy-four percent of the noncertified

obstetricians rated journals "very important" vhile 76 percent of

general practitioners rated colleagues as "very important." Fewer

than 10 percent of all physicians rated any of the four sources of

information as "not very Important."

As to sources of nutrition information, observation in the

course of their own practice was considered "very important" by 60 percent of the noncertified obstetricians, 50 percent of the general practitioners and 44 percent of board-certified obstetricians*

Forty-eight percent of the board-certified family physicians selected journals as "very important." Thus, three out of four physicians depended on professional meetings to provide them with medical knowledge and about one-half relied on their personal observations

(in practice) for nutrition Information. Almost three-fourths of the physicians thought other doctors were not very knowledgable about nutrition and nutrition-related subjects.

Recommendations to Nutritionists

The final question on the schedule was optional: only physicians who had time and expressed an Interestin nutrition Information were asked for their opinions on the topic "Is there anything we nutritionists could do to help you (the physician) with nutrition

Information?" Physicians were encouraged to interpret the question in 2C8

any way applicable to their practice or to the special needs of their patients.

Seventy-six percent (97) of the physicians responded to the

question. Several other physicians talked about nutrltlon*-related

topics but made no suggestions.

Answers have been divided into three general categories: suggestions that would primarily benefit patients, suggestions that would be of help to physicians and specific recommendations for nutritionists and dietitians. 209

TABLE 54

ANSWERS TO THE QUESTION; "Is there anything ve nutritionists could do to help you with nutrition information?"

Obstetricians Family Physicians Board Non Board Non Suggestions Certi- Certl* Certi­ Certi­ fled fled fied fied No. No. No. No. Patient Orientation (Nutrition education) Teach use of nutrition labels Improve labeling of foods Consumer education 1 Meal management instruction for poor families 1 Nutrition education for general public 9 Nutrition education for clinic patients 3 Nutrition education for slow learners 1

(Public Schools) Become actively involved in school lunch program Educate elementary school teachers in nutrition

(Patient Counseling) Provide nutritionists for private practice HD’s 3 Improve access to hospital dietitian for general nutrition information 1 Establish dietetic referral service for all patients 4 1 1 1 210

TABLE 54 cont.

Obstetricians Family Physicians

Board Non Board Non Certi- Certi­ Certi- Certi­ Suggestions fied fied fied fled No. No. No. No. Sponsor continuing education in nutrition for MD*8 and their office staff 1 Develop nutrition pretest for office patients 1

(Prenatal nutrition counseling) Sponsor nutrition education for pregnant teenagers Design nutrition instruction pamphlets: grade school through graduate school levels Supervise nutrition component of prenatal classes

(Reference material) Prepare nutrition and diet handbooks for patients 2 Prepare brochure on food- velfare recipients 1

(The Media) Combat advertising that promotes "junk" foods 2 Campaign against "dietetic" foods 1 Use TV, radio, press for public service announcements about nutrition Get factual nutrition information published in popular magazines 211

TABLE 54 cont.

Obstetricians Family Physicians

Board Hon Board Non Suggestions Certi- Certi- Certi- Certi­ fied fled fled fled No. No. No. No.

Physician Orientation .

(Medical education) Provide medical meetings with speakers to discuss Nutrition and Pregnancy 11 3 Prepare nutrition- related programs for medical meetings 1 Publish nutrition studieB in medical literature 5 1 3 1 Publish a digest or news­ letter on recent deve­ lopments in nutrition (practical, pertinent, concise, accurate) 2 2 1 Provide practicing physi­ cians with factual nutrition information 1 Help establish basic nutri­ tion course for medical school 3 1 Develop basic nutrition course at residency level 4 Nutrition education course for practicing physician 5 1 1 Provide nutrition informa­ tion through Ohio Medical Network 1 Record nutrition news and developments for cassette tape service 9 212

TABLE- 54 cont.

Obstetricians Family Physicians

Board Non Board Non Suggestions Certi­ Certi­ Certi­ Certi fied fied fied fled No. No. No. No.

(Reference Material) Develop nutrition reference handbook 3 2 3 1 Provide physicians with nutrition information suitable for patient Instruction

(For pediatricians) Work with psychologists in preventing and treating childhood obesity Provide completet accu­ rate information on pediatric nutrition

(Nutrition research) More studies on problems of private practice patients Investigate adolescent diet practices Work with medical inves­ tigators to develop new research strategies Investigate relationship between nutrition and sports medicine

Nutritionist-Dietltian Orientation Take active role in exposing dangers of food faddlsm 213

TABLE 54 cont

Obstetricians Family Physicians

Board Non Board Non Suggestions Certi- Certi Certi­ Certi fied fied fied fied No. No. No. No.

Improve teaching skills 2 Inform physicians as to activities 1 Inform physicians as to where-abouts 1 Present nutrition infor­ mation and research In an interesting manner 1 Take a more practical approach to nutrition education 1 Show more concern for patients* welfare and satisfaction 1 Combat food stamp abuses 1 Allay resentments of working poor against fooB stamp recipients 1 Aid rural areas in obtain­ ing a registered dietitian 1

NOTHING 1 1

N 33 19 21 24 CHAPTER V

IMPLICATIONS

To facilitate discussion of the findings, this chapter has been divided into six principal sections. The first sections concerns physicians' attitudes about maternal nutrition and their views on the

Importance of diet counseling for prenatal patients. The second is a discussion of nutrition education and dietary advice given by physi­ cians. Third is a consideration of nutrition-related complications of pregnancy focusing on incidence, diagnosis and treatment. The fourth section contains a discussion of prenatal weight gain. Fifth comes an analysis of physicians' sources of medical and nutritional

Information. The last section concerns suggestions made by physicians about ways nutritionists and dietitians could Improve nutrition education. Suggestions for further research and a brief recapitualtion of the major findings in the study are also included.

Patient Education

Four groups of Ohio physicians representing two medical specialties and two levels of professional education were interviewed on the subject of maternal nutrition. These physicians believed that

214 215

the course and outcome of pregnancy was influenced by maternal dietary

practices; good nutrition was essential to the health and well-being

of both mother and fetus. Physicians indicated that some form of

diet counseling should be Included in routine prenatal care, and most

provided food and nutrition information to their patients, at least

the prlmlgravidas. No physician consciously ignored a patient's diet

if convinced the diet was deficient in essential nutrients.

Although physicians were generally aware of the Importance of

nutrition in overall obstetric performance, many seemed uncertain in

applying the basic principles of nutrition to routine prenatal care.

Guidelines popular 15 to 20 years ago were still being followed by

some doctors, even though these guidelines are now considered incompat­

ible with good maternal health. For example, about 63 percent of the

physicians imposed weight gain limits on some or all patients, 83 percent advocated sodium restriction-even in the absence of pathologic

conditions— and 23 percent routinely prescribed diuretics. Many physicians were unaware or unconvinced that attempts to lose weight during pregnancy were deleterious to fetal development, that sodium- restricted diets were unpalatable and Inconvenient to prepare or that

the safety of diuretics had been challenged.

Printed materials and prenatal classes were the two sources of nutrition information physicians relied on for their obstetric patients.

Eight-three percent of the doctors distributed some printed diet or nutrition Information. Examination of these printed materials showed that nearly all were prepared and distributed by food, drug or medical 216

supply companies. These handouts tended to emphasize the manufac­

turer's own products. Physicians urged patients to obtain more

information about pregnancy and childbirth (including nutrition) by

attending prenatal classes. These classes were usually sponsored by

hospitals or childbirth education associations. It was impossible to

gain any impression about the quality of nutrition education obtained

through these classes, but whatever Information the patients received

it was beyond the control of the physicians.

Good Instructional materials providing nutrition information are needed. These materials should be designed for patients with varying economic and educational backgrounds. The patient with limited financial resources has a special need to know how good nutrition can be .provided from low-cost foods. The undereducated patient needs simple instructions and the college graduate would profit by more complete explanations.

In general, physicians did not utilize services of dietitians and nutritionists to instruct their prenatal patients in the basic concepts of nutrition* Only when patients experienced complications of pregnancy believed to require expert dietary counseling (such as diabetes and heart disease) were nutritionists and dietitians consulted. Over half the physicians relied on their office staff to provide prenatal patients with nutrition information and dietary advice. There was no evidence to suggest that these staff members conferred with dietitians or nutritionists about the special needs of obstetric patients. 217

Physicians In this study did not make use of nutrition labels

as teaching aids. These labels were instituted to educate and inform

the general population about the nutrient content of many different

foods. In fact, only a few doctors in this study recognized the term

"nutrition label" and even they failed to associate this information

with the special nutrition requirements of pregnancy.

Physicians and office nurses need to acquire authoritative

nutrition information in order that they may provide comprehensive

maternity care. Furthermore, there should be Intercommunication

between physicians, office nurees, prenatal class instructors and

nutritionists or dietitians about the kinds of questions patients

ask, so that complete and accurate answers can be provided. Efforts

should be made to prevent teaching materials from becoming vehicles

for food and drug advertising. Reliable guidelines about prenatal

nutrition can be obtained from the American College of Obstetrics and

Gynecology, Federal and State Health departments and professional

nutrition and dietetic organizations.

Physicians should use the services of nutritionists and

dietitians when treating patients with nutrition-related complications

of pregnancy. Sixteen percent of the physicians in this study referred

patients with megaloblastic anemia to hematologists for evaluation and treatment, whereas only one physician routinely had such patients go to a dietitian for expert diet counseling. Patients with toxemia of pregnancy, who definitely need to improve the quality of their diet, were not referred to a dietitian or nutritionist. 218

Physicians need to alter their role perception in obstetric care

concerning diet counseling* Almost every physician regarded patient

education, Including diet instructions, as the physician's

professional responsibility. Patient instruction was considered a

routine office procedure augmented by prenatal classes. No other professional expertise was regarded as essential. Thus, the primary

source of nutrition information for private obstetric patients was

the physician or his staff and only one in three physicians discussed

"food selection to meet the special needs of pregnancy" with their individual patients.

Assessment of Maternal Nutrition

Physicians have a responsibility to evaluate the nutritional status of every obstetric patient. The significance of maternal nutrition assessment was explained by Beal (1971): "if a woman has been well-nourished throughout her life, her intake during pregnancy will probably be similar. The course of pregnancy should be favorable and the health and size of the Infant satisfactory. If however, the mother has been poorly nourished and she enters pregnancy without nutrient reserves, her diet during pregnancy becomes crucial."

Physicians can obtain information about a patient's nutrition status by taking a diet history, obtaining data from specific laboratory examinations, evaluating clinical findings and reviewing previous obstetric performance. This Information together with a medical 219 history and estimation of the family's socioeconomic status provides the kinds of Information physicians can use to obtain a patient's nutrition profile. If this evaluation is made early in pregnancy,

the physician can initiate appropriate diet therapy.

Physicians in this study did not accord dietary evaluation the same Importance as other types of evaluations. Patient's obstetric history and laboratory studies were always obtained. Socioeconomic status was almost always ascertained. But, one in three physicians

"never" asked about food intake or adherence to dietary fads. Failure to assess patient's nutritional statuB made it difficult to provide appropriate dietary counseling. This probably contributed to some of the physicians' acknowledged frustrations in managing the nutrition component of maternity care.

Maternal obesity, a factor that apparently does not adversely affect newborn health, always concerned physicians. Maternal underweight, a factor that does affect newborn health, was usually

Ignored. Physicians need a protocol for identifying maternal malnutrition.

Physicians' Management of Maternal Nutrition

Approximately one in four physicians expressed dissatisfaction with their ability to change patients' eating habits. Less than half the physicians were convinced their patients followed their diet

Instructions, Physicians seldom inquired about patient's food 220

preferences prior Co diet counseling. They indicated that it was

easier to "just tell the patient what to eat" rather than constructing

a diet to fit the patient's usual eating habits. This may be one

reason why physicians failed to influence food choices.

Most physicians equated effectiveness in diet counseling with

their patients' success in controlling weight gain. A doctor often considered his diet counseling effective when the patient maintained pregravid weight or limited weight gain to predetermined number pounds at term. However, when a patient limited weight gain, the nutritional content of the diet may have been Inadequate to meet fetal needs. In this study, physicians recommendations on weight control were not In accord with guidelines established by American College of

Obstetrics and Gynecology or the Committee on Maternal Nutrition of the National Research Council. If physicians are to provide effective prenatal care they must be aware of current concepts of maternal nutrition.

Vitamln-mineral Supplements

Every physician in this study prescribed vitamin-mlneral supplements to their prenatal patients. The attitude of doctors appeared to be that supplements were a form of nutrition insurance.

Some patients may have assumed that s b long as they took their prenatal capsule regularly, their dietary Intake could be Ignored, 221

A prenatal vltamln-mlneral supplement does, in fact, furnish

sufficient nutrients to meet a pregnant mother's needs for every

dietary essential except food energy, essential fatty acids, protein

and calcium (Appendix F). Of particular value to the mother is the

fact that supplements contained iron and folate, thus the practice

of supplementation in Itself is justified.

However, the practices of a few physicians In treating nutrition-

related complications of pregnancy (real or suspected) may lead to

undesirable therapy. For example, instructions to double or triple

the intake of vitamin-mineral supplements could be harmful, expensive, and would not teach patients to obtain nutrients from foods. The practice may lead to other complications such as an increased need for

a particular nutrient which has been Induced in the fetus.

Protein

Every doctor in this study recognized the Importance of adequate dietary protein to match the increase rate of maternal tissue synthesis.

However, a few doctors prescribed diets so limited in food energy the protein content would be utilized for energy needs.

On the other hand, many physicians prescribed hlgh-protein diets for a variety of medical problems, real or potential. Some of these diets were described as high in protein but limited or "free" in carbohydrate. Such regimens were based on physicians' perception of

'good and bad' foods. "Good" foods were high in protein and thought to 222

be non-fattening, while "bad" foods were carbohydrate-containing foods

believed to contribute excess food energy to the diet.

One of the most widely distributed books given by 18 percent of

the physicians was A Doctor Discusses Pregnancy (Birch, 1976). In

this reference, low carbohydrate diets were discussed in detail. Many

recommendations were without scientific validity and not in agreement with principles of good obstetric nutrition. Such misconceptions about

energy and food composition emphasize the need for medical students,

Interns, residents and practicing physicians to obtain basic nutrition

education.

Almost half of the physicians interviewed failed to encourage

their patients to consume a quart of milk daily. Some believed the nutritional value of milk was overrated; others thought it was too high In food energy. Still other physicians assumed that the calcium needs of the mother and fetus were being met by the prenatal vltamin- mlneral supplement; none of the prescribed supplements contained more than half the RDA for calcium (Appendix F). Physicians who routinely recommended their patients limit milk intake were unaware they were limiting the supply of high quality protein, calcium, vitamins and minerals. A patient on a limited milk Intake would have difficulty eating sufficient meat, poultry, seafood, eggs and vegetables to meet the current RDA for protein.

Protein malnutrition was not a common complication of pregnancy among private patients. Only 8 percent of the physicians in this study had patients whom they believed to be deficient in dietary 223

protein. It was by no means clear whether or not these physicians

used valid diagnostic criteria to determine protein malnutrition.

No physician used the UN/TN ratio for "at risk" patients, nor were

there any other suitable tests or procedures employed.

A minimum dally Intake of 1800 kilocalorles has been estimated

as sufficient food energy to protect the protein content of the

maternal diet (Lachtig et al.t 1975a). In this sudy, approximately

30 percent of all physicians prescribed diets providing 1800 kilo-

calories or less to some or all their patients. Other physicians who

said they encouraged a liberal protein Intake may have Inadvertantly

restricted protein utilization by prescribing the popular low-calorie

or low-carbohydrate diets.

Food Stamps

Some physicians provided maternity care to patients who were

classified as "clinic" population. There were several reasons why

low-lncome patients selected a private physician: lack of clinic

facilities, complications of pregnancy requiring special medical skills and availability of physicians accepting any maternity patient.

Doctors who practiced in small towns and rural areas were most likely to care for patients with limited incomes.

Only 12 physicians in this study "always" provided low~income patients with information about the federal food stamp program. About half the physicians were unable to respond to the question since they 224

lacked experience with this type of federal aid. A few physicians

said they were skeptical about the value of government "handouts."

Other physicians Indicated it had been their experience that needy

patients were already receiving food stamps and required no further

assistance from them.

No physician said handicapped infants were more common among

low-lncome families than other families nor did they regard these mothers at greater nutritional risk. There waB no report as to differences in morbidity or mortality rates among low-lncome patients.

However, physicians did express the opinion that social class and economic status Influenced food selection.

Private practice physicians appeared to need more information about income supplementation for families with too little money.

Specifically, they needed facts about food stamps; federal, state and local assistance programs for family health; and means to refer private patients to community agencies for financial assistance.

Attitudes about Breast-Feeding

Almost every physician In this study discussed breast-feeding with prenatal patients and only three said they actually discouraged breast-feeding. Approximately two-thirds of the physicians routinely provided patients with Information concerning breast-feeding and lactation; the other physicians preferred to delegate or share teaching responsibility with obstetrical nurses, pediatricians or members of 225 the LaLeche League.

The relationship between physicians' attitudes about breast­ feeding as measured by frequency of Instruction; and obesity as measured by physicians' opinions concerning welght-gain-characteristlcs was examined. Discussion of breast-feeding and lactation with patients was not related to physicians' opinions about prenatal weight gain.

Apparently, doctors did not consider breast-feeding a practical method for controlling postpartum obesity.

Nutrition-related Complications of Pregnancy

Diagnosis and Treatment

The publication of Maternal Nutrition and the Course of Pregnancy

(Committee on Maternal Nutrition, 1970) prompted nutritionists and physicians to examine more carefully the unfavorable medical statistics of American newborn. The high incidence of infant and neonatal mortality and morbidity, particularly among poor families, led to a federal investigation of conditions associated with satisfactory and unsatisfactory reproduction. Physicians and nutritionists assigned to survey the scientific literature for relevant data reported that nearly every important study of maternal nutrition was limited to clinic patientB, Very few investigations concerned private patients, a group that presumable enjoyed satisfactory incomes, good health and adequate nutrition. 226

In this study, 119 of 128 physicians identified at least one or

more nutrition-related complications of pregnancy requiring dietary

or medical management (Table 25). The most frequently mentioned

problems of private patients were obesity and iron-deflclency anemia,

diet-related disorders common to all segments of the American

population. Physicians estimated that one in three prenatal patients

were obese, an estimate of the same proportion as the general

population (Stern, 1977). The most common deficiency disease among

women of childbearing age, lron-deficlency anemia, was estimated at

approximately 16 percent. This estimate is substantially higher than

the 5 percent level observed in the general population.

Although nutrition-related complications of pregnancy were

common among private patients, there was no general agreement as to

appropriate diagnostic criteria for identifying these problems.

Many physicians lacked precise methods to evaluate nutrition status.

There seemed to be no uniform procedures to determine which patients

needed nutritional rehabilitation and the extent to which dietary

management was imperative. Diagnosis data obscured the actual findings.

Diet-related complications of pregnancy such as toxemia, megaloblastic anemia and Insufficient weight gain have been reported

as prevalent among clinic patients (Working Group on Nutrition and

Toxemias of Pregnancy, 1970; Daniel et al.. 1971; Lechtlg, 1975).

In this study, only two physicians said they "frequently” cared for private patients with txoemia of pregnancy. The incidence of megaloblastic anemia was extremely low, probably due to routine 227

supplementation vlth folate.

However, 64 percent of the physicians reported they observed

patients with less-than-recommended weight gain but only 5 percent

thought this problem effected the health and well-being of the fetus

and mother. Ho physician identified low-blrth-weight or prematurity

as evidence of past or existing maternal malnutrition.

Some physicians, by prescribing low-calorle diets, may have

contributed to insufficient weight gain. Only a few physicians

acknowledged that insufficient weight gain might interfere with normal

fetal development. What was identified as a problem for low-lncome

(clinic) patients was regarded as desirable or beneficial for adequate-

lncome (private) patients.

Physicians estimated the incidence of toxemia among their

private patients at approximately 4 percent. Information regarding

the actual incidence of toxemia in the United States is unavailable.

Diagnostic criteria employed by physicians in this study were highly

subjective and often varied from patient to patient. Such procedures as the "roll-over" test (Medical News, 1977) for routine screening of preeclampsia were seldom mentioned. Early and accurate diagnosis of the disease would permit initiation of appropriate dietary measures.

All physicians considered preeclampBla a dangerous, but prevent­ able stage, of toxemia. They routinely prescribed weight control, sodium restriction and diuretics to prevent or cure preeclampsia. Such a combined approach has been recognized as potentially harmful to the fetus (Medical News, 1977j Pitkin et al.. 1972). Only a few 228

physicians considered Improved maternal nutrition as the most effective

preventive therapy. In fact, not many physicians associated toxemia

with patient's past or existing nutritional status. Doctors need

more information about nutrition and toxemia of pregnancy.

Teenage Pregnancies

Questions about were not included in the

interview schedule. However, in response to open-ended questions one

in four physicians identified the adolescent as a patient at consid­ erable risk because of many dietary inadequacies. The girls were described as unmarried, in their early teens and consuming diets deficient in one or more essential nutrients. Physicians thought that pregnant teenagers needed nutrition education, medical care and psychological support.

Private practice physicians seemed to need more information about teenage nutrition. There have been many excellent investigations of teenage clinic patients but very few studies of teenage patients attended by fee-for-service physicians,

Alcoholism

There were no specific questions about alcohol abuBe and apparently it was not a problem for private prenatal patients. Only four physicians indicated they cared for mothers who drank excessively. 229

It's possible that physicians in this study were unaware of evidence linking excessive alcohol Intake during pregnancy with physical and mental abnormalities In offspring. Also, some physicians may have considered alcohol a drug rather than a food, thus disassociating it from the subject of nutrition.

Miscellaneous Problems

Common obstetric complaints such as morning sickness, heartburn, constipation and food cravings were not mentioned by physicians as serious or significant nutrition-related complications of pregnancy.

Only one physician in this study considered hyperemesis graviderum

(morning sickness) as a seriouB health problem. The other complaints were regarded as minor aggravations of pregnancy. Problems that often persuade a woman to seek medical help are seldom serious enough to threaten the nutritional status of either mother or fetus. According to most physicians, only a few patients ever experienced severe hyperemesis gravaderum. In such cases the mothers were often hospitalized for treatment.

Diabetes

The Incidence of dlabeteB in pregnancy has been Increasing in this past decade, but only 5 physicians indicated they treated a significant number of diabetic patients. These physicians referred 230

the patients to qualified dietitians for diet counseling*

Iron-deficiency Anemia

Physicians identified iron-deficiency anemia as the second most

common nutrition-related complication of pregnancy, A generation ago,

doctors at Vanderbilt University reported the presence of anemia in

11.3 percent of their clinic patients (Darby et al.. 1953b) according

to diagnostic criteria in use at that time. In more recent studies vlth Improved laboratory procedures, the incidence of anemia has

been identified ln2,5to 4 percent of private patients (Carr, 1974).

Physicians in this study estimated the incidence of iron- deflclency anemia among their private patients at 16-28 percent.

This hlgher-than-antlcipated occurrence could be explained by the diagnostic criteria used by Borne physicians. Nearly one-third of the doctors believed anemia was present if a patient's hemoglobin was 12.5 grams percent (or less), This probably included many pregnant women with "normal" physiologic anemia. For those few physicians who used transferrin saturation or Iron binding capacity as teBts, the incidence of anemia was estimated at 15 to 20 percent, Due to the variety of laboratory techniques employed the estimate could be in error. Only by actually examining patients' diagnostic data would

Iron-deficiency anemia be accurately determined.

This study did not provide Information to explain why so many prenatal patients were apparently anemic. Perhaps there was an 231

Inadequate Intake of foods with sufficient iron density due to the

trend by votnen of childbearing age to consume low calorie diets. If

this were the case, inadequate iron stores in pregravid women would lead to anemia during pregnancy.

Physicians successfully treated anemia with ferrous sulfate, ferrous gluconate or ferrous fumerate. These Iron supplements often contained other nutrients such as vitamins E, Bg, B12» ascorbic acid, folacin, thiamin, niacin, riboflavin, intrinsic factor and stomach concentrate. Some physicians Indicated a standard prenatal vitamin- mineral supplement provided sufficient Iron to correct anemia without additional Iron preparations.

Pica, a manifestation of Iron-deficiency anemia was not a significant nutrition problem of private patients. Only three physicians said they occasionally treated a patient who consumed non­ food items,

Weight and Weight Gain in Pregnancy

One significant modification in prenatal nutrition management has occurred this past decade; Btrict weight control is no longer encouraged, emphasis has shifted to adequate weight gain. A smooth, steady increase throughout the second and third trimesters of pregnancy encourages normal fetal development (Pitkin, 1976). Maternal weight gain during pregnancy has been significantly related to newborn birthwelght, birth length and head circumference (Springer et al., 232

1977). Rigid weight control or weight loss daring pregnancy is potentially damaging to mother and fetus. Regardless of pregravid weight, weight reduction should not be undertaken during pregnancy.

Physicians in this study were asked about their concept of ideal weight gain. Answers varied from 0 to 36 pounds, mean 22 pounds.

Twenty-two pounds corresponds closely with the 20 to 25 pounds recommended by the Committee on Maternal Nutrition (1972). Approxi­ mately 16 percent of the physicians established a weight gain limit for their patients of less than 20 pounds, the weight guideline popular among physicians in the 1950's. These physicians were of the opinion that strict limits on weight gain would prevent toxemia and other complications of pregnancy. Physicians who adopted the older standards had been in practice an average of 25 years, range 9 to

43 years.

Among the four groups of physicians, board-certified obstetricians were most informed about maternal growth requirements and recommended the most liberal weight gain. Their attitudes and practices presumably reflected advice in the obstetrics journals, their principle source of nutrition information. Numerous research and summary articles about maternal nutrition are published in The American Journal of Obstetrics and Gynecology and Obstetrics and Gynecology— the two favorite journals of obstetricians. However, it is important to note that 4 board-certified obstetricians took issue with the liberal trend toward weight gain; they feared unrestricted food energy intake would ultimately result in postpartum obesity. Only two of the 128 physicians prescribed exercise as the most appropriate method for 233

controlling obesity and excessive weight gain. In summary! all groups

of physicians were more concerned about prenatal and postnatal

obesity than the nutritional content of the maternal diet. Preoccu­

pation with weight: pregravid, prenatal and postnatal, may have

influenced physicians to disregard currently accepted weight gain

concepts.

Many obstetricians and family physicians ignored the underweight

patient, that is, the patient with low pregravid weight or weight loss

or poor weight gain during pregnancy. Often the underweight mother

was described as "lucky". Medical or emotional complications of

pregnancy were most often blamed for the problem. Diet and activity

levels were not considered primary causes of weight deficiency.

Virtually every physician in this study could provide the investigator

with a copy of a low calorie diet but only two physicians had diets

designed for the underweight patient.

According to Higgins (1972), underweight patients need both

intensive dietary counseling and supplementary feeding in order to

gain sufficient weight during pregnancy. Twelve percent of the physicians in this study provided dietary instructions to underweight patients in what might be described as basic nutrition. Seven percent urged their patients to add extra meals every day. One physician seemed to sum up the feelings of most of his colleagues when he said

"there is no such thing as inadequate or insufficient weight gain in pregnancy," 234

The lack of attention to prenatal undernutrltlon has Important

implicartlona for the fetus as veil as the mother. When problems of

underweight, Inadequate weight gain or weight loss are Ignored,

the fetus may suffer from Impaired growth. Prematurity and low-birth-

welght are consequences of pregravid and prenatal malnutrition. In

summary, medical students, interns, residents and practicing physicians

need Information about the role of food energy in normal fetal and

maternal growth and development.

Physicians' Sources of Medical and Nutrition Information

Information Diffusion

Physicians in this study frankly admitted that they seldom

discussed nutrition related topics with their medical colleagues.

Furthermore, they did not consider doctors to be generally well-

informed on the subject of food and nutrition. Doctors reported they

seldom consulted dietitians for information and advice about the nutrition problems of their patients.

Coleman et al. (1957) analyzed Information diffusion among physicians and suggested that doctors could be classified as either

"profession oriented" or "patient oriented" according to certain

Individual traits. Profession-oriented physicians, those favorably recognized by local colleagues, were first to adopt new procedures, techniques, medications or attitudes about patient care, and 235

positively influenced the speed with which medical innovations spread

to other doctors. Communication was by way of discussion and advice.

Highly Integrated doctors learned from each other. Patient-oriented physicians, those respected by patients and, community, had fewer contacts with other doctors. They were also less receptive to new developments in medicine.

Because physicians in this study Beldom discussed nutrition topics with their colleagues one primary channel of communication was blocked. One qualified source of nutrition information, nutritionists and dietitians, were not part of the network of professional friendships essential in communicating ideas. Thus, another route of Information diffusion was blocked.

In comparing physicians' attitudes and practices concerning maternal nutrition, board-certified obstetricians were first to adopt current concepts In dietary instruction and management of pregnant women. Why other physicians were not influenced by these specialists can be explained from the research findings of Coleman et al. (1957).

Evidence was provided that a doctor is Influenced more by his colleagues in situations that are uncertain than in ones that are clearcut.

In addition, doctors influenced each other more in treatments whose effects were unclear than in those that were obvious.

The majority of physicians in this study identified obesity and excess weight gain as the most serious nutritional complications of pregnancy. Their treatment consisted of various low calorie diets.

It patients lost weight, the efficacy of their treatment was 236

demonstrated. Results were measurable and there was nothing uncertain

about the way they managed the problem. This sequence of events may

have imlnimized the motive for discussing weight control with

colleagues.

The age of the physician and amount of journal reading were

related to acceptance of new trends in maternal nutrition. Educational

meetings, seminars and advanced courses were not related to the kinds

of dietary management offered prenatal patients* One physician

suggested that nutrition education for practicing physicians should be

managed by physician experts in nutrition because physicians have the

"ear of the doctor-students."

Interesting contrasts existed between the physicians' sources of

medical and nutrition information. One in three physicians failed to

identify a single "best" source of nutrition information, but virtually

all physicians identified a "best" source of medical information.

Publications such as newspapers, magazines and throw-aways were rated

"best" sources of nutrition information by 4 percent of the physicians

but never mentioned as a "best" source of medical information.

The importance of four different sources of medical and nutrition

information: (1) professional journals, (2) colleagues, (3) profes­ sional meetings and (4) observations in the course of their own practice were rated on a three-part Beale. Doctors indicated whether

the source was "very", "somewhat" or "not too" important as a source of new medical and nutrition information. Doctors were also asked for the same information in two open-ended questions about best sources of 237

medical and nutrition information. All sources were considered more

Important for medical than nutrition information, regardless of how

the question was asked.

To obtain some measure of the value of each source relative to other sources "difference scores" were calculated. The difference was between the percentage saying an information source (Journals, meetings, etc.) was "very important" and those saying "not too important." For medical information, the difference scores were: professional meetings, +75; journals, +54; observations in practice,

+53; conversations with colleagues, +51. A slightly different ranking was obtained in response to the open-ended question about the "best" source of medical Information. Journals were most frequently mentioned, followed by cassette tapes (rather similar sources in that physicians determined when they were to be used), professional meetings and advanced courses, and conversations with colleagues.^

The relative Importance of sources of nutrition information was determined by similarly calculated difference scores. The scores

?In a study of "allocation of time to various modes of instruction" (Story et al., 1968) physicians (general practitioners, surgeons, and internists) estimated half of their time was devoted to reading subscription journals, unsolicited medical*literature (throw aways) and library material. Learning by doing (similar to observations) was rarely mentioned except by surgeons. Educational programs provided by professional organisations and medical schools were important to surgeons but not to general practitioners. Contacts with colleagues were less Important than journal reading or professional meetings for all physicians but much more important than cassette tape recordings. Ratings were similar, but not identical to responses to open-ended questions in this study. 238 were: journals* +22; observation In practice* +22; professional meetings* **13; conversations with colleagues, -64. In response to

the open-ended question concerning the "best" source of nutrition

Information* journals were the most frequently mentioned* followed by "other publications."

Thus* professional journals were favorably regarded as reliable communication channels for medical and nutrition information* regardless of the measure used. "Observations in the course of their own practice" was evaluated as very important when asked about directly but not volunteered in response to the open-ended question about the best source of information.

Many physicians expressed satisfaction with the educational services provided them by organizations such as Weight Watcher, Lamazc

Childbirth Education Association and the LaLeche League. On the other hand* only two physicians indicated that important professional education was provided by dietitians.

4 Physicians1 Suggestions and Recommendations for Improving the Dissemination of Nutrition Information

Physicians' recommendations and suggestions to nutritionists were grouped Into three categories: patient education, physician education and specific procedures designed to improve the image of nutritionists and dietitians. Physicians indicated they could be helped most if private patients and the general public had access to 239 nutrition education•

Board-certified obstetricians urged nutritionists to take a more active role in teaching basic principles of nutrition to various groups, with special attention directed toward the economically disadvantaged and public school children. One in three board- certified obstetricians said nutritionists could make an important contribution to obstetrics by developing techniques for counseling private obstetric patients. One in four of these same physicians wanted a nutrition referral service providing private patients with instructions in normal and therapeutic nutrition.

All doctors wanted educational materials for patients with diverse backgrounds. Among the suggestions were educational pamphlets for patients with grade school, middle school and high school education, college education and for those who had attended graduate or profes­ sional schools. All four groups of physicians wanted nutritionists and dietitians to provide authoritative reference materials for the public and make better use of the media; expecially television.

For the personal use of physicians, several suggested a nutrition reference handbook similar to the Physicians Desk Reference. Such a book would provide information about food, diet and nutrition.

PhysiclanB also asked for a monthly or quarterly publication devoted to nutrition and related topics; one published by a unverslty or professional nutrition society, not a commercial organisation, A few physicians asked for more nutrition-oriented articles in their professional journals. 240

Another group of physicians said they would welcome "nutrition"

programs at their professional meetings and seminars, especially ones

tailored to meet the needs of practicing physicians. Physicians from

all four groups wanted help in providing nutrition education to all

private patients.

A few suggestions were directed specifically at the dietetics

and nutrition professions. These comments Involved interrelationships

of physicians and dietitians and appeared to reflect physicians'

desire that these health professionals provide more expert knowledge

to the medical profession.

In summary, physicians wanted nutritionists and dietitians to

become Involved in patient care by providing doctors with up to date,

interesting, educational materials for distribution to private

patients; to combat food misinformation and quackery; and to operate

in a more visible manner. Among the four groups of physicians the

board-certified specialists were most cognizant of their needs for

nutrition facts and, asked for specific reference materials and

special programs to help their patients.

Recommendations for Further Research

1. Specific data should be collected from patients; office

records to determine the actual incidence of iron deficiency anemia, megaloblastic anemia, toxemia of pregnancy, obesity, exceBB prenatal weight gain, underweight, inadequate prenatal weight gain, protein 241 deficiency and other examples of malnutrition. Uniform diagnostic criteria and procedures must be employed in order to accurately evaluate the extent of these complications of pregnancy.

2. In addition to the four groups of physicians represented in this study other classes of medical personnel such as noncertified family practice physicians, osteopaths and nurse midwives should be surveyed. Osteopaths and nurse midwives may have a very different view of maternal nutrition.

3. The data base should be enlarged to obtain information for the entire state and eventually a representative nation-wide sample.

A more heterogenous population might reveal different approaches to prenatal care.

4. Nutrition assessment parameters should be expanded to Include information on the following topics:

a. Meal patterns and food allergies b. Alcohol and drug abuse c. Hyperemesls gravidarum d. Age of menarche

These factors too, affect pregnancy outcome.

3. Information should be obtained on incidence of adolescent pregnancies in private practice and specific dietary problems of these patients. Also it would be Important to learn about types of community services and public health agencies utilised by private physicians in meeting the medical, education and emotional needs of these unique patients. CHAPTER VI

SUMMARY AND RECOMMENDATIONS

This study was conducted to obtain information from four separate

groups of private practice physicians concerning the nutritional aspects of routine prenatal care. A questionnaire was developed specifically for a personal Interview with the physicians in their private offices.

Physicians were selected for the study if they practiced in one of the 23 counties in central Ohio, were identified in general or obstetrical practice and provided care to obstetric patients. If physicians provided prenatal care they were considered eligible for the study. There were two groups of obstetricians: board-certified and noncertified and two groups of family physicians: board-certified and noncertified.

All data were recorded on the interview schedule by the investigator and nearly all interviews were tape recorded, In several

Instances the physician suggested that some information was available from an office nurse or secretary. There were a total of 128 physicians participating in the study and slightly more than half were obstetri­ cians.

Physicians were asked to provide information about their routine assessment of patients; Including the data obtained to determine

242 243 nutritional status. Specifically, physicians vere asked how frequently

they obtained a patient's obstetrical, medical, socioeconomic and diet history and whether they evaluated the patient's clinical and laboratory (blood tests) status in order to discover existing nutritional problems.

Physicians estimated the Incidence of nutrition-related complications of pregnancy observed among their obstetrical patients.

Diagnostic criteria and recommended treatment for these complications were also explained by the physicians. These data were compared to findings in contemporary medical and nutrition literature.

Several questions were related to the types and frequency of general dietary advice given to all prenatal patients by the physicians.

Doctors also rated their success in managing the nutritional component of maternity care.

In a series of questions, precoded and open-ended, data were obtained on physicians opinions about the best sources of medical and nutrition information. This information was related to their practice and to check the accuracy of the answers, questions were asked in several different ways.

One optional question Invited physicians to suggest ways nutritionists and dietitians could assist them in obtaining nutrition

Information, Physicians were encouraged to interpret this question in any way applicable to their private practice.

One-hundred and twenty eight physicians participated in the study;

44 were board-certified obstetricians, 22 noncertified obstetricians, 244

28 board-certified family practice physicians and 34 general

practitioners. The data they provided were analyzed by (1) frequency

distribution (univariate analysis) and (2) crosstabulation as a

related measure of association (bivarlate analysis). The frequency

distribution provided data for the descriptive aspects of the study while the blvariate analysis provided Information on variables

associated with nutrition assessment.

The purpose of this study was to identify the nutrition component of maternity care provided by a selected sample of private physicians classified according to specialty and board certification. A second purpose of this study was to ascertain the Influence of various channels of medical communication on the dissemination nutrition and medical information among the physicians. A third purpose was to elicit physicians1 opinions concerning ways nutritionists could assist them in providing nutrition information.

The following specific objectives were developed for use in this research:

1. To identify information reflecting nutrition status which physicians routinely obtained from prenatal patients.

2, To compare physicians' diagnostic criteria and treatment for nutrition-related complications of pregnancy with guidelines developed by the ad hoc Committee on Nutrition of the American College of Obstetrics and Gynecology (Pitkin et al.. 1972) and the Committee on Maternal Nutrition of the National Research Council (Committee on

Maternal Nutrition, 1970), 245

3. To compare and contrast the types of nutrition instructions

obstetric patients receive from the four different groups of physicians

classified according to specialty and board certification.

4. To compare the nutrition component of obstetric care among

the four groups of physicians with current standards established by

recognized authorities in the field of maternal nutrition.

5. To Identify various sources of nutrition Information physicians consldred Important to their private practice.

6. To obtain an estimate of the incidence of nutrition-related

complications of pregnancy among private patients in central Ohio.

Recapitualtion

According to all physicians in this study* the successful outcome of pregnancy depended to some extent on satisfactory maternal nutrition.

(Probably no practicing physician could disagree with this premise.)

However, In examining the specific reasons for emphasizing good prenatal nutrition, less than one in four physicians mentioned the special needs of mother or fetus as a motive for providing diet Instructions, Most physicians expressed concern for the obese woman and her special diet needs, as they perceived them. Board-certified obstetricians seemed to have more facts regarding the nutritional needs of pregnant women than the other three groups of physicians,

Physicians lacked reliable sources of nutrition information. They seldom discussed nutrition topics with their colleagues nor did they 246

have a high regard for physicians vhen it cane to the subject of

nutrition. Articles in medical journals were the most frequently

cited sources of nutrition Information but only one in three physicians

read regularly about the subject. Physicians urged nutritionists to

take a more active role in educating doctors and the general public

in basic principles of nutrition.

Nutrition Status of Prenatal Patients

Physicians always obtained a patient's obstetric history, always

had essential laboratory tests performed and always obtained a medical

history except for data related to cigarette smoking. Physicians did

not always obtain information about patient's family and social

statuB, certain clinical parameters and were negligent about taking

a diet history. Nutrition assessment of obstetrical patients needs

more attention from private practice physicians.

Diagnostic Criteria and Treatment of Nutrition-related Complications of Pregnancy

Iron deficiency anemia

Doctors failed to employ reliable laboratory tests for diagnosing

anemia and criteria for this deficiency disease was highly subjective.

However, most physicians prescribed ferrous salts for real or suspected

cases of anemia with satisfactory results. 247

Toxemia of pregnancy

Doctors did not utilize any simple test to Identify patients who

were in a high risk category. Diagnostic criteria were subject to

Individual interpretation and dietary treatment was almost uniformly

Inappropriate.

Megaloblastic anemia

4 This was not a significant nutritional* problem for private

obstetric patients. Many physicians did not bother to screen patients

for this type of anemia.

Underweight and inadequate weight gain

These nutritional problems associated with pregnancy were either

Ignored or considered a "blessing”. Treatment for these problems were

not in line with recommendations of nutritionists, the National

Research Council or the American College of Obstetrics and Gynecology.

Nutrition Instructions to Private Patients

Eight of ten physicians provided their obstetric patients with

printed nutrition information but only one in three physicians actually

instructed their patients in the principles of baBlc nutrition.

Board-certified obstetricians were more likely to discuBS nutrition-

related subjects with their patients than the other three groups of physicians. These board-certified obstetricians were also more 248

knowledgeable about prenatal nutrition needs.

Nutrition Guidelines

The major change in maternal nutrition management occurring this decade has been associated with food energy intake and weight gain.

Physicians have been instructed to make sure their patients gain weight at a steady rate throughout the second and third trimesters of pregnancy and all patients should gain a minimum of twenty-one pounds. Many physicians in this study rejected these recommendations.

Most doctors firmly believed that complications of pregnancy could be averted if patients would limit weight gain to some predetermined amount. Although the "quality of maternal diet" was frequently mentioned by physicians, prescriptions for vltamin-mineral supplements continued to be the most frequently employed form of nutrition management.

Summary Recommendations

Based on findings in this study there is a need to improve the nutrition component of maternity care. My recommendations are directed toward two groups of health professionals: physicians and nutritionists (or dietitians). For Physicians Standard helght-weight charts should be consulted in order to diagnose prenatal underweight and obesity.

Limiting sodium intake during pregnancy should be restricted to those patients with cardio-vascular disease, hypertension or kidney disorders.

If a weight control program is absolutely essential, the patient should be advised to Increase physicial activity. Reducing the fat or sugar content of the diet is preferable to any of the low- carbohydrate or no-carbohydrate diets.

Patients should be provided with a daily food guide to assist in selecting a diet adequate in all essential nutrients. Special emphasis should be focused on milk consumption.

The underweight patient and the patient who falls to achieve a normal weight gain during pregnancy should receive intensive dietary counseling.

Monitoring the pattern of weight gain is more important to the patient's well-being than establishing a specific weight gain limit.

Iron nutrlture can be accurately diagnosed by measuring the percent saturation of transferrin, TIBC or serum iron. These tests are appropriate for the prenatal patient. Hemoglobin or hematocrit evaluations are important in routine screening.

More nutrition-related topics should be Included in continuing education programs for obstetricians and family physicians.

A diet history should be obtained from every prenatal patient.

Dietitians and nutritionists should be employed to assist physicians in providing expert nutrition counseling.

The office staff: nurses, aids and receptionists should participate in continuing education programs emphasising the Important aspects of maternal nutrition. 250

For Nutritionists and Dietitians

1. The American Dietetic Association or some other professional nutrition society should publish a reference handbook about food, nutrition and diet therapy for the practicing physician.

2* Patients need an authoratlve guide on the subject of nutrition and pregnancy. Such a guide (or booklet) should be written by experts in maternal nutrition and made available to the patient by her physician. These guides should be printed in several languages for several education levels and especially for low-lncome families.

3* Dietitians need to improve their image as experts in subject of maternal nutrition and provide prenatal counseling for private patients.

4. State and local dietetic associations should be more aggressive in combatting food faddlsm and quackery,

5. Nutritionists need to publish moreresearch in medical journals,

6, Nutritionists and dietitians should assume responsibility for providing nutrition education to leaders in the Lamaze Childbirth Education Association, the LaLeche League and hospital prenatal classes.

7, Nutritionists and dietitians as professionals and expertB in the area of food science and nutrition should endeavor to educate physicians about all aspects of maternal nutrition. LIST OF REFERENCES

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Nie, C. H., J, G. Jenkins, K. Stelnbrenner and D, H, Bent. 1975. Statistical Package for the Social Sciences. 2nd. McGraw-Hill. New York.

Niswander, K. and E. C. Jackson. 1974. Physical characteristics of the gravida and their association with birth weight and perinatal death. Am, J. Obstet. Gynecol. 119(3):306-313,

Nutrition Foundation. 1973. Effects of famine on later mental performance, Nutr. Rev. 31(5):140-143.

______. 1974. Nutrition Misinformation and Food Faddism. Nutr. Rev. Suppl. no. 1, 32:53-56. 260

______. 1976. The Influence of maternal food supplements on birthweight in Guatemala. Nutr. Rev. 34(6):169-172.

Oldham, H. and B. B. Sheft. 1951. Effect of caloric intake on nitrogen utilization during pregnancy. J. Am. Diet. Assoc. 27(10):847-854.

Osofsky, H. J. 1975. Relationship between prenatal medical and nutritional measures, pregnancy outcome, and early Infant development in an urban poverty setting. I. Role of nutritional Intake. Am. J. Obstet. Gynecol. 123(7):682-690.

Peckham, C. H. and R. E. Christianson. 1971. The relationship between pre-pregnancy weight and certain obstetric factors. Am. J. Obstet. Gynecol. 111(1):1-7.

Petry, J. A. 1956. Obesity with pregnancy. Obstet. Gynecol. 7(3):299-303.

Pike, R. L. and C. Yao, 1971. Increased sodium chloride appetite during pregnancy in the rat. J. Nutr. 101(2):169-175.

Pitkin, R. M., H. A. Kaminetzky, M. Newton and J. A. Pritchard, 1972. Maternal nutrition: A selective review of clinical topics. Obstet. Gynecol. 40(6):773-785.

Pitkin, R. M. 1975. Calcium metabolism in pregnancy: A review. Am. J. Obstet. Gynecol. 121(5):724-737.

. 1976. Nutritional support in obstetric and gynecology. Clin. Obstet. Gynecol, 19(3):489-513.

. 1977a. Nutrition during pregnancy: the clinical approach. In: Nutritional Disorders of American Women. Myron Winlck ed. John Wiley and Sons, New York, pp. 27-36,

. 1977b. Nutritional influences furing pregnancy, Med. Clinics of North America. 61(1):3-15.

Fohanka, D. G, and R. 1. Pike, 1970. Effects of dietary sodium restriction during pregnancy on the histochemistry of the rat zona glomerulosa. Proc, Soc. Exp. Biol. Med. 133Cl):246-251,

Pomerance, J, 1972. Weight gain in pregnancy, how much is enough? Clin. Ped. 11(10):554-556.

Pomerance, J. J,, L. Gluck and V, A, Lynch. 1974. Physical fitness in pregnancy. Its effect on pregnancy outcome. Am. J, Obstet. Gynecol. 119(7):867-875. 261

Pritchard, J. A. 1970. Anemias complicating pregnancy and the puerperium. In: Maternal Nutrition and the Course of Pregnancy. Committee on Maternal Nutrition Food and Nutrition Board National Research Council, Washington, D.C., pp. 74-109.

Qureshi, S., N. P. Rao, V. Madhavi, Y. C. Mathur, and Y. R. Reddl. 1973. Effect of maternal nutrition, supplementation on the birth weight of the newborn. Indian Pediatrics. 10(9):541-543.

Roeder, L. M. and B. F. Chow. 1972. Maternal undernutrition and its long term effects on the offspring. Am. J. Clin. Nutr, 25(8):812-821.

Report of Vital Statistics for Ohio. 1976. State of Ohio Department of Health.

Royston, G. D. 1927. Diet and pregnancy. J, Am. Diet. Assoc. 3:223-ff.

Runner, M, N. and J. R. Miller. 1956. Congenital deformity in the mouse as a consequence of fasting. Anat. Record, 124:437-438.

Rush, D. 1975. Maternal nutrition during pregnancy in industrialized societies. Am. J. Dis. Child. 129(4):430-433.

Schulte, F. J., G. Schrempf and G. Hlnze. 1971. Maternal toxemia, fetal malnutrition and motor behavior of the newborn. Pediatrics 48(6):871-881.

Springer, N. S., A. M. Byrne and W. D. Block. 1977, Nutritional indexes of clients in a maternity and infant care project. Ill Relationship between developmental, medical, and nutritional variables. J. Am. Diet, Assn, 71(6):621-623.

Scott, D. E. and J. A. Pritchard. 1967. Iron deficiency in healthy young college women, J. Am. Med. Assn. 199(12):897-900,

Seifert, E. 1961, Changes in beliefs in food practices and pregnancy. J. Am. Diet, Assn. 39(4):455-466,

Siegel, E. and N. Morris, 1970. The epidemiology of human reproductive casualties, with emphasis on the role of nutrition. In: Maternal Nutrition and the Course of Pregnancy. Committee on Maternal Nutrition/Food and Nutrition Board National Research Council, Washington, D.C,

Simpson, J. W., R. W. Lawless and A. C. Mitchell. 1975, Responsibility of the obstetrician to the fetus, 2, Influence of prepregnancy weight and pregnancy weight gain on birthweight, Obstet, Gynecol, 45(5):481-487, 262

Smith, C. A. 1947a. Effect of vartime starvation in Holland upon pregnancy and its products. Am. J. Obstet, Gynecol, 53(4): 599-608.

Smith, C. A. 1947b. Effects of maternal undernutrition upon newborn infants in Holland (1944-45). J. Pediat. 30:299-343.

Speroff, L. 1973. Toxemia of pregnancy, mechanism and therapeutic management. A. J. Cardiol. 32:582-591.

Spince, H., R. S, Lowry, C, E. Folsome and J, S, Behrman, 1951. Studies on the urinary excretion of xanthurenic acid during normal and abnormal pregnancy: A survey of the excretion of xanthurenic acid in normal nonpregnant, normal pregnant, preeclamptic and eclamptic women. Am. J. Obstet. Gynecol. 62(1);84-92.

Steam, J. S. Dietary management of obesity: Focus on portion sire. Nutr. & the M.D. 3(8):1.

Stearns, G. 1958. The nutritional state of the mother prior to conception. In: Nutrition in Pregnancy, Symposium 4. Council on Foods and Nutrition, American Medical Association. Chicago, pp. 7-19.

Stein, A. and M, Susser. 1975. The Dutch famine, 1944-1945 and the reproductive process. II. Interrelationships of caloric rations and six indices at birth. Pediat. Res. 9(2):76-83.

Story, P. 3., J. W. Williamson and C. H. Castle. 1968, Continuing medical education, a new emphasis. Division of Scientific Activities. American Medical Association. Chicago,

StrauBs, M, B. 1933. Anemia of infancy from maternal iron deficiency in pregnancy, J. Clin. Invest. 12:345-353.

Streiff, R. R. and A. B, Little. 1967. Folic acid deficiency in pregnancy. N, Engl. J. Med, 276(14);776—779-

Ten—State Nutrition Survey. 1968-70. U, S. Department of Health, Education and Welfare. Center for Disease Control. Atlanta, Ga. DHEW Publication no. (HSM) 72-8134. pp. 233-234,

Terris, M. 1966. The epidemlolgy of prematurity: Studies of specific etiologic factors. In: Research Methodology and Needs In Pernatal Studies, Charles C. Thomas, Springfield, 111, 207-242,

Thanangkul, 0. and K, Amatayakul, 1975. Nutrition of pregnant women in a developing country-Thailand. Am. J. Dis. Child. 129(4):426-427. 263

Theobald* G, W. 1935. The dietetic deficiency hypothes of the toxaemias of pregnancy. Froc. Roy. Soc. Med. 28:1388-1398.

Thomson* A. M. and W. Z, Billewicz, 1957. Clinical significance of weight trends during pregnancy. Brit. Med. J. 5013:243-347.

Thomson* A. M. 1957. Technique and perspective in clinical and dietary studies of human pregnancy. Proc. Nutr. Soc. 16:45-51.

Turton* C. W. G.* T, C. B. Stamp, P. Stanley* and J. D, Maxwell. 1977. Altered vitamln-D metabolism in pregnancy. Lancet. 1(8005):222-225.

Tyson* J. E, 1977. Mechanisms of puerperal lactation. Med. Clin. N. Amer. 61(1):153-163.

U. S. Department of Health, Education, and Welfare. 1973. Prenatal Care (DHEW Publication no, (OCD) 75-17). Children's Bureau Publication No, 4.

Warkany* J. 1958. Production of congenital malformations by dietary measures. (Experiments in mammals). In: Nutrition and Pregnancy, Symposium IV. Council on Foods and Nutrition American Medical Association, Chicago, pp. 31-41.

White* H. S. 1975. Dietary iron and anemia. Nutr. & the M.D, 2(1):1.

White House Conference on Food* Nutrition and Health. November 1969. Panel Recommendations.

White House Conference on Food* Nutrition and Health* 1970. Survellliance and Evaluation on the State of Nutrition of the American People. Final Report. U. S. Government Printing Office. Washington* D.C.

Wlddowson* E. M. 1977. Nutrition and lactation. In: Nutritional Disorders of American Women. Ed. Myron Wlnlck, John Wiley & Sons* New York. pp. 67-75.

Winick* M. and A. Noble, 1966. Cellular response in rata during malnutrition at various ages. J. Nutr. 89(16);300-306,

Wlnlck* M. 1971. Cellular growth during early malnutrition, Pediatrica. 47(6):969-978. 264

Working Group. Relation of Nutrition to the Toxemias of pregnancy. 1970. Maternal Nutrition and the Course of Pregnancy. Committee on Maternal Nutrition, National Research Council, National Academy of Sciences, Washington, D.C. pp. 163-187.

Working Group. Relation of Nutrition to pregnancy in adolescence. 1970. Maternal Nutrition and the Course of Pregnancy. Committee on Maternal Nutrition, National Research Council, National Academy of Sciences, Washington, D.C. pp. 139-162.

Wroklng Group. Relation of nutrition to fetal growth and development. 1970. Maternal Nutrition and the Course of Pregnancy. Committee on Maternal Nutrition, National Research Council, National Academy of Science, Washington, D.C. pp. 110-138.

Wright, E. 1966. The New Childbirth. Hart Publishing Co., New York. pp. 49-52. APPENDIX A

NUTRITION QUESTIONNAIRE FOR PHYSICIANS

265 266

Identification Humber — ______

Nutrition Questionnaire for Physicians

Introduction: Who I am; why I am doing this study; can be completed in under 15 minutes, but willing to talk longer if doctor desires.

"I would like to begin with a few questions about the information you obtain from each obstetrical patient when she first comes to see you."

1. "Who takes the patient's medical history? Do you do this, or a member of your staff?"

Physician Nurse Receptionist Other DK/NA (or Combination)

2. "Listed on this card are a number of items of information you might ask about or expect the patient to volunteer herself." (HAND DOCTOR CARD A) "For each of these items'— would you say you always obtain the information, usually obtain the information, occasionally obtain the information, or never obtain the information?"

Always Usually Occasionally Never DK/NA

a. Number of pregnancies ______b. Interval between pregnancies ______c. Number of perinatal deaths ______d. Number of premature Infants______e. Number of low-birth- welght Infants ______(RECORD ONLY-O.B. HISTORY) ____ *______f. Intercurrent diseases & illnesses ______g. Medications currently being used ______h. Smoking history ______i. Present basic diet______J. Fad diet ______k. Size of family ______1. Pregnancy wanted? ______m. Socioeconomic statuB 267

(RECORD HERE FROM SUBSEQUENT QUESTIONS)

Mentioned Not Mentioned NA

a. Weight gain pattern ______b. Pre-Pregnancy weight ______c. Hemoglobin______d. Hematocrit .__

"Now, I would like to turn to nutritional problems of pregnancy you may encounter,"

3a. "What would you say is the most serious nutritional problem you observe in your obstetrical patients?"

b. "Of the patients you have seen in the last year, about what proportion have this problem?" (IF NEEDED:) "For example, would you say 1 in 3, 1 in 10, 1 in 30, 1 in 100, or just what?"

c. "What diagnostic criteria do you use?"

d. "What do you recommend for treatment?"

A. "Briefly, what is the next most serious nutritional problem you encounter?"

"I'd like to ask you about some other nutritional problems encountered in pregnancy. In each case, I'd like you to tell me what proportion of your patients have these problems, how you diagnose them, and how you treat them. The first is:

5a. Iron deficiency anemia. b. Of the patients you have seen in the last year, about what proportion have this problem?" (IF NEEDED:) "For instance, would you say 1 in 3, 1 in 10, 1 in 30, 1 in 100, or just what?"

c. "What diagnostic criteria do you use?"

d. "What do you recommend for treatment?"

6a. "Megaloblastic anemia, b. Of the patientB you have seen in the last year, about what proportion have this problem?" (IF NEEDED:) "For example, would you say 1 in 3, 1 in 10, 1 in 30, 1 in 100, or just what?"

c. "What diagnostic criteria do you use?"

d. "What do you recommend for treatment?" 268

7a. "Toxemia of pregnancy," b. Of the patients you have seen in the last year* about what proportion have this problem?" (IF NEEDED:) "For example* would you say 1 in 3* 1 In 10* 1 in 30* 1 in 100* or just what?"

c. "What diagnostic criteria do you use?"

d. "What do you recommend for treatment?"

8a. "What do you consider a normal weight gain in pregnancy?" (IF NECESSARY:) "In pounds?"

b. "Of the patients you have seen in the last year* about what proportion have a less-than-normal weight gain in pregnancy?" (IF NEEDED:) "For example* would you say 1 in 3* 1 in 10* 1 in 30* 1 in 100, or just what?"

c. "How do you suggest these patients manage this problem?"

9a. "What do you consider excessive weight gain for a pregnancy?" (IF NECESSARY:) "In pounds?"

b. "Of the patients you have seen in the last year* about what proportion experience excessive weight gain?" (REPEAT CUE FROM QUESTION 8b IF NEEDED.)

c. "How do you suggest these patients manage this problem?"

10a. "Are there any other important nutritional problems we have no discussed?" (IF NO, SKIP TO Q. 11: IF YES;) "What?"

b. "About what proportion of the patients you have seen in the last year have this problem?" (IF NEEDED;) "For example* would you say 1 in 3* 1 in 10* 1 in 30* 1 in 100, or just what?"

c. "How do you diagnose this problem?"

d. "What do you recommend for treatment?"

11. "Under what circumstances do you advise a patient to limit sodium intake?" 269

"I'd like to turn now to the subject of diet instructions,"

12. "Do you think diet instructions should always be given, usually be given, occasionally be given, or never be given7"

Always Usually Occasionally Never DK/NA

(IF ALWAYS OR NEVER) "Why do think this is (necessary/unnecessary)?" (IF USUALLY OR OCCASIONALLY) "Under what circumstances do you think a diet instruction is necessary?"

"Do you give the instruction yourself, or does a member of your staff, or do you refer the patient to a dietitian?"

Yourself Staff Dietitian DK/NA

(IF STAFF) "May I interview this person?"

"Do you rely on printed material?" Yes No NA

(IF YES) "May I have a sample?"

"How closely do you think patients follow your dietary advice?"

13. "Listed on this card are various types of advice that might be given a pregnant woman. (HAND RESPONDENT CARD B.) For each item, could you tell me If you always review this information with your patients, usually do so, occasionally do so, or never do so?"

Always Usually Occasionally Never DK/NA a. Information on nutritional value of foods ______b. Interpretation of nutritional labels on food packages ______c. Drink 1 quart of milk per day ______d. How to enroll in a prenatal class ______e. How to apply for food stamps If 270

Always Usually Occasionally Never DK/NA

f* Instructions on breast feeding ______g. How to maintain lactation______h. Use of vitamin supplements ______, _ it Use of mineral supplements ______

14. "Could you tell me what vitamin (and/or mineral) supplements you recommend?

Vitamin Mineral Specific Specific

Various Various DK/NA ”d k /n a

"Now I have a few more questions about your sources of information."

15. "What have you found to be your best source of information about new developments related to your practice of medicine?"

16. "What have you found to be your best source of information about new developments in nutrition?"

17. "About how many professional meetings were you able to attend during the past year?"

18. "How many journals do you read regularly?"

19. "What two journals are the best sources of new information about your medical practice?"

20. "Now thinking about several sources of information: Conversations with colleagues, Professional meetings, Journals, and Observations in the course of your own practice, would you say that each is very important, somewhat important, or not too important, as a source of new medical information?" (HAND PHYSICIAN CARD C.) 9 271

Very Somewhat Hot too Important Important Important DK/NA

a. Conversations with colleagues ______b. Professional meetings ______c. Journals ______d. Observations in own practice ______

21. "And how important is each of these as a source of nutrition information?"

Very Somewhat Not too Important Important Important DK/NA

a. Conversations with colleagues______b. Professional meetings ______c. Journals ______d. Observations in own practice ______

22. (ASK IF TIME PERMITS, OTHERWISE OBTAIN INFORMATION FROM ASST.) "About how many babies did you deliver during this past year?"

23. (ASK IF TIME PERMITS) "Is there anything we nutritionists could do to help you with nutritional information?"

24. "Is the information about you in the Medical Directory accurate and up to date?" (NOTE CORRECTIONS)

Conclusion: Thanks; Do you want summary? APPENDIX B

PHYSICIANS' MEDICAL SCHOOLS

272 273

TABLE 55

PHYSICIANS' MEDICAL SCHOOLS

Number of Physicians Institution Graduated from Medical School

The Ohio State University College of Medicine, Columbus 65 University of Cincinnati College of Medicine, Cincinnati 9 Indiana University School of Medicine, Indianapolis 5 Case Western Reserve University School of Medicine Cleveland 4 Jefferson Medical College of Thomas Jefferson University, Philadelphia 4 Loyola University Strltch School of Medicine, Maywood 4 University of Illinois College of Medicine, Chicago 2 University of Louisville School of Medicine, Louisville 2 Howard University College of Medicine, Washington, D.C. 2 St. Louis University School of Medicine, St. Louis 2 John Hopkins University School of Medicine, Baltimore Northwestern University Medical School, Chicago University of Tennessee College of Medicine, Memphis Loma Linda University School of Medicine, Loma Linda-Loe Angeles Washington University School of Medicine, St. Louis University of Pittsburg School of Medicine, Pittsburgh Chicago Medical School University of Health Sciences, Chicago University of Pennsylvania School of Medicine, Philadelphia University of Maryland School of Medicine, Baltimore Tufts University School of Medicine, Boston University of Colorado School of Medicine, Denver New York Medical College, New York 274

TABLE 55 cont.

Number of Physicians Institution Gradua ed From Medlca School

Wayne State University School of Medicine, Detroit Duke University School of Medicine, Durham Temple University School of Medicine, Philadelphia George Washington University School of Medicine, Washington, D.C. Columbia University College of Physicians and Surgeons, New York University of Miami School of Medicine, Miami Georgetown University School of Medicine, Washington University of the Fhllliplnes University Seville Tipfakultesi Ankara Universitlsi Faculty of Medicine, Kyushu University, Fukuoka National University of Ireland Faculty of Medicine, University of Santo Tomas, Manila College of Medicine, National University of Taiwan, Taipei College of Medicine, Seoul National University, Seoul Faculty of Medicine, National University of Colombia, Bogota Faculty of Medicine Guadalajara, Jalisco APPENDIX C

LETTERS TO PHYSICIANS

275 276

THE OHIO STATE UNIVERSITY

Within the next few days I shell be telephoning your office in order to eehedule an interflow with you as part of m j research on the nutritional counseling of pregnant patients* As you know* there is little inforaatlon available on physicians' assessment of the nutritional status of pregnant patients. Information you can give would help oorreot this situation. The data to be gathered will be of value for all ■embers of the health oare team* but particularly so for aedloal educators, medical students, and those oonoemed with obstetrlos. The findings will be mads available for planning oontlnuing education programs for physleians. X shall be analysing the data under the direction of Virginia II. Vivian. Ph.D.. of the Department of Human Nutrition and Food Management, who is directing up research. Because of their Interest In researoh on the nutritional oare of patients X have also sought the counsel of Tennyson Williams, M.D., Chairman of the Department of Family Medicine, and Frederick Zuspan, M.D., Chairman of the Department of Obstetrics and Qyneoology. The interview will last fifteen minutes. Your answers will, of oourae, be treated confidentially. I shall be happy to mall you a sunaary of my findings when the study is eompleted. Thank you so much for your consideration.

Yours sincerely.

Margaret W. Kesael.

I C*tap.lA*w*w'M4M«MtoMmc« .■ inTNctUmw: friwkM .Otw*)}l|< n«(

272 THE OHIO STATE UNIVERSITY HOSPITALS

D M IO HAUL M U H* HALL MtCAMAKUHALL (TAAUMC LOVING HALL ^LfwtvDtArrr m o w t t a i u w w w i r r m o m t a u o n e UHHAM HAIL V M M AH HALL «I0 WEST 10TM AVENUE OOLUMtUS, OHIO 411)0

W* hop* that you will b* willing to eooperat* in th* research being eonduoted by Merger*t Keaael, e Ph.D. oendldet* at Ohio Stet* University. We have dlaousaed Mra. Keaael*a raaeeroh with h*r and believe It to b* auTflcl*ntly important to aak for your help. Thank you ao much.

Slnoerely,

r ~ 7 V < U w . Frederiok P. Zuapen, TLd T) Chelman and Profa^spr — Department of ObateCrloa fc Oyneoology

T*n^ao

CONSENT FORM

278 THE OHIO STATE UNIVERSITY

I oonsent to bo o portlolponfc In tho investigation titled* Fhyalolanat Oplnlono and Praotlooo In tho nutritional Component of Maternity Caro, Mr*. Keaael has explained tho intended use of tho lnfomatlon provided by tho participants, I understand participation involves answering a questionnaire, I also understand the information I provide will be used solely for research purposes and will bo treated confidentially.

(Signature)

TCaSeT C K 5 e T “

TUfcfc—IWHMtr»w ln I AfriHkwtMtHMM&MMika I IflflM U w M t f Ctfaak«.Ofc,«U» / rkm ttlljC M H I APPENDIX E

MATERNAL NUTRITION ASSESSMENT

280 281

MATERNAL NUTRITION ASSESSMENT (Minimal Level Approach)

* The American Public Health Association has established an

assessment guide (Chrlstakls, 1977). This assessment guide Is

designed to Identify women requiring remedial or rehabilitative

intervention by the physician; including dietary, medical and

socioeconomic history plus clinical and laboratory evaluation.

Following is an outline of the minimal level of approach:

Dietary History

1. Present basic diet: The goal of a diet history is to establish the quantity and quality of nutrient intake. For routine clinical use the 24-hour recall technique is relatively easy to assess or a 7-day food list can be taken with the patient's cooperation. At the same time, meal patterns can be discerned.

2. Fad or abnormal diets: Food faddists and constant dieters run the risk of depleting nutritional reserves. Large weight losseB to achieve "normal" weight during pregnancy may adversely effect fetal development.

3. Vitamin-mlneral supplement: Dietary supplements of iron and folic acid plus other vitamins and minerals are usually prescribed during pregnancy. The use of supplements should be considered in any nutritional assessment.

Obstetrical History

4. Parity: High parity is frequently linked with deminished nutritional reserves.

5. Interconceptual period: Repeated pregnancies and lactation at intervals of less than one year deplete undernourished mothers. Nutritional reserves may not be restored,

6. Perinatal deaths; Perinatal mortality (and morbidity) reflects poor maternal nutrition.

7. Prematurity: The major contributing cause of perinatal mortality is prematurity. 282

8* Low-birth-weight: Full tern, low-birth-weight Infant suggests maternal malnutrition prior to and during pregnancy.

Medical History « 9. Incurrent diseases and illnesses: Chronic Illness such as diabetes, chronic infections, drug abuse or addiction, alcoholism, malabsorption syndromes and severe emotional disorders affect pregnancy and its outcome.

10. Medications: Women on oral contraceptives have special nutritional needs for ascorbic a d d and folic acid. Other medications may interfere with the absorption or metabolism of certain nutrients.

11. Smoking: Women who smoke during pregnancy experience a high incidence of low-birth-weight infants and somewhat higher incidence of perinatal mortality.

Family and Social History

12. Size of family: Very large families may be at an economic disadvantage, especially among minority groups,

13. "Wanted" pregnancy: An unwanted baby may mean inadequate health care and indifferent attitude toward maternal nutrition.

14. Socioeconomic status: Family income and the amount available for food purchases should be determined. Accessibility and utilization of food stamps when necessary should be ascertained. Occupation and physical activity of mother should be evaluated.

Clinical Evaluation

15. Prepregnancy weight; A mother with low prepregnant weight risks delivering a low-birth-weight infant. Underweight mothers have a significantly greater chance of developing toxemia and experiencing antepartum hemorrhage,

16. Weight gain pattern during pregnancy: The pattern of weight gain is a rough estimate of maternal physiologic adjustments being made throughout gestation.

Laboratory Evaluation

17. Hemoglobin and hematocrit levels are the first basic studies in assessing maternal nutrition. Criteria of deficiency- for pregnant women are hemoglobin < llg/lOOdl; hematocrit < 33%,

Adapted from "Nutritional Assessment in Health Programs" George Chrlstakls, M.D,, Editor,

« APPENDIX F

COMPOSITION: PRESCRIBED HEMAXINICS AND VITAMIN-MINERAL SUPPLEMENTS

283 TABLE 56

Hematlnlcs

Product ______Composition

Iron B2 Nlac. Bg B^2 Fol. Pant. C E Copper

Feosol spanst 50mg Feosol tabt 65 (Smith Kline)

Ferancee* 67 150mg Ferancee HP* 110 110 (Stuart)

Fergon0 50 (Breon)

Fer-in-sol* 60 (Mead Johnson)

Fero-Follc500t 105 800ucg 500 Fero-Grad500t 105 500 (Abbott)

Ferro-Sequals**- 50 (Lederle)

Fumarsore (Marlon)

Iberett 105 6mg 6og 30mg 5mg 25ucg lOrag Iberet 500+ 105 6 6 30 5 25 10 500 284 (Abbott) TABLE 56 cont.

Product Composition

Iron Bj B2 Niac. Bg B12 Fol. Pant. C E Copper

Imferon (Lakeside)2

Lextron 30tng lmg .25mg lmcg (Lilly)^

Livatrlnsic* 33 3 3 lOmg 3mg 5 2mg lOOmg .66mg (Beecham)^

Mol-Iront 78 (Schering)

Peratlnic* 100 7.5 7.5 30 7.5 50 . 05mg 15 200 (Lederle)l

Pronemla

Tri-Hemic600* 115 25 1.00 600 301.U, (Lederle)^*!

Trlnsacon* 110 7.5 .50 75 (Dista)^

Vitron-C* 66 125 (Fisons)

Is J Jectofer-314^ 00 TABLE 56 cont.

1. Contains dioctyl sodium sulfosuccinate, a stool softener. 2. Iron dextran by Injection. 3. Llver-stomach concentrate, 455mg A. Dessicated liver, 150mg. and intrinsic factor 5. Intrinsic factor added to product at concentration of 240mg 6. Iron sorbltex by injection

* Ferrous fumerate t ferrous sulfate o ferrous gluconate 286 T U U 57

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