This study has demonstrated the implementation of the LWdP program increased the referral of women eligible for pregnancy weight management support from one in thirty-three to one in one in eight, with demonstrated improvements in eating and activity behaviours in those who attended. However, despite a facilitated and deliberate implementation effort to integrate the service into antenatal care, the findings indicate further work is needed to ensure more women are provided with early intervention, particularly women with a high BMI at high risk of adverse pregnancy outcomes.
Despite women not commencing the program until mid-way through their pregnancy, the implementation of LWdP resulted in a 10% increase in eligible women being referred for support during pregnancy and a three-fold increase in women receiving care. However, women’s uptake of the program and retention of women was still poor. A similar evaluation of a telephone coaching lifestyle and weight management service during pregnancy, delivered external to the antenatal care health facility, observed less than one in ten women completing the program . Based on previous research  the LWdP program was deliberately integrated into women’s antenatal care where the dietitian health coach could see medical notes from other health care providers between appointments and document in medical records to allow other care providers to monitor progress. This alteration in referral and delivery approach resulted in a fourfold difference in completion compared with an external delivery strategy  with four in ten women completing the LWdP program.
While health professionals, predominantly midwives, were the primary source of referrals, a simple implementation strategy of a text message to all women registering for care at the facility resulted in a seven-fold increase in self referrals to the program. A consistent barrier reported by health professionals, particularly midwives is a lack of confidence and shame in discussing weight with women [35, 36], and the negative association women have with being referred to a dietitian [36, 37]. This means many women who may benefit from intervention are never aware services exist to support them. Text message reminders have been commonly used to successfully increase attendance at health care appointments and adherence to behaviour change advice . The LWdP program is one of the first to report the effectiveness of a text message prompt to encourage women to initiate their enrolment in a routine service, thus overcoming a key barrier to accessing support and increasing the reach of the program.
While the LWdP program delivered via telecoaching demonstrated equivalent GWG outcomes as achieved in the face-to-face care model of care, the proportion of women gaining more weight than recommended was high. This excess GWG may have been due to the relatively late recruitment of women to the program. Prior to commencing LWdP, one in three women had met or exceeded their recommended GWG for the entire pregnancy. First trimester GWG is recommended at around 1-2 kg regardless of ppBMI, with excess in early pregnancy being most closely associated with adverse outcomes including GDM , pre-eclampsia  and high birthweight . Interestingly, women who commenced LWdP prior to 16-weeks gestation experienced lower GWG and a lower proportion of women who had a ppBMI in the obese range exceeded GWG recommendations. Furthermore, no additional benefits were noted towards achieving appropriate GWG for women attending per-protocol (4 or more appointments). These findings emphasise the importance of engaging women early in their pregnancy to support appropriate GWG, but to achieve this, barriers must be overcome. ‘Late’ entry to birthing facilities (usually ~ 16 to 18 weeks) often results in a challenging situation of addressing this early excess GWG through lifestyle intervention when the rate of recommended GWG is greater . Potential strategies to address these issues include aligning services with primary care settings to support early pregnancy lifestyle support  and providing tailored, individualised schedules of care to appropriately meet women’s needs .
The improvements in dietary intake observed in women who participated in the LWdP program are consistent with previous interventions to support health behaviour change in pregnancy that impact on GWG [44, 45]. Significant improvements in dietary quality were observed, driven by a reduction in discretionary food and an increase in fruit and vegetables. While there was no observed effect on GWG, high diet quality in pregnancy has been associated with a reduction in GDM, hypertension and pre-term birth . Furthermore, if sustained, these improvements may contribute to a lowering of long-term diabetes and cardiovascular disease risk in women . Somewhat unique to the LWdP was a focus on intuitive eating. The process of how women eat is likely to be as important, if not more so than, what women eat if long term behaviour change is sustained. Intuitive eating is considered an adaptive form of eating where there is a connection with internal hunger and satiety cues rather than emotions or cognitions driving food consumption [30, 48]. Developing a healthy relationship with food where there is not a pre-occupation with dieting or the labelling of food as good or bad is needed before healthy eating can be pursued . For many women experiencing a high body weight, breaking a long-held dieting cycle is likely to be important to sustaining behaviour change consistent with healthy eating and weight management. The improvements in intuitive eating observed within the program if sustained may assist women’s eating behaviours well beyond the current pregnancy, having a long- term positive influence. This requires further investigation.
Positive changes in physical activity based on interventions during pregnancy have been mixed and vary according to the provision of supervised and structured activity . The reduction in sedentary time and increase in overall duration of physical activity observed with the LWdP program based on counselling and behaviour change techniques, demonstrates that improved behaviour can be achieved independent of women needing to be provided with additional classes through birthing facilities.
There is limited guidance on the optimal duration, intensity, delivery method for the interventions to support behaviour change and healthy weight gain . This may be because of the complex and individualised nature of lifestyle behaviour change and GWG. The LWdP program was specifically designed with continuity of health care to facilitate rapport and person-centred care, with call fidelity reducing as the call number progressed. Comments indicated women wanted to address topics relevant to them earlier than scheduled. Furthermore, a key factor in women withdrawing or not taking up LWdP was time and appointment burden. This is a common reason for not adopting weight management interventions in pregnancy,  and while remote delivery removes travel time, it does not address the need for another appointment. Collectively, the lack of evidence for what constitutes optimal care, and in practice the limited ability to meet women’s needs by imposing a rigid schedule, point to the need for flexibility in services and modalities to deliver person centred care. Offering a suite of evidence-based options for remote delivery behaviour change support that can be individualised to each woman’s circumstance may provide solutions engagement challenges, particularly to those women with a high body weight that may have more comorbidities requiring high risk pregnancy care.
Strengths and limitations
The findings of this study need to be considered in the context of several strengths and limitations. The completion of behavioural questionnaires by women was low and limited to those more likely to complete the program. The behavioural improvements observed are likely to reflect those women most motivated for change, it is possible that different approaches may be needed for women experiencing greater barriers to change or who are less motivated. Furthermore, the detailed program workbook and telephone delivery may have been a deterrent for women with a lower level of literacy. Future work needs to explore support options for those with lower education. The historical comparison group received face to face dietetic intervention, limiting the ability to determine the effectiveness of the LWdP program compared to no intervention. It is likely the differences observed in this evaluation would be more profound if compared to no intervention. However, in the context of overwhelming evidence and clinical guidelines recommending dietetic care for weight management support for women, this team deemed it unethical to withhold appropriate treatment. The dissemination methods of the staff survey meant we were unable to identify the total number approached to determine completion rate. A strength of this study was the strong theoretically driven approach, and the applied implementation within routine care demonstrated that a change in model of care is feasible within a large health service and results in favourable behaviour change for women who engage, with high participant satisfaction.