RUNNING HEAD: SELF-MANAGEMENT IN PREGNANCY 1 Improving Self-Management in Pregnancy Cameron Ferrier & Melissa Rossiter Michigan State University College of Nursing 8/28/2022 Running Head: Self-management in Pregnancy 2 Table of Contents Abstract..……………………………………………………………………….………………...4 Introduction.......................................................................................................................5 Background/Significance .................................................................................................5 Problem Statement/Clinical Question ..............................................................................8 Organizational Assessment “Gap” Analysis” of Project Site.............................................8 Purpose of the Project ………………………………………………………….….….............9 Theoretical Framework Evidence Based Practice Model/QI Model..................................9 Review of the Literature..................................................................................................10 Goals..............................................................................................................................16 Methods………………………...…………………………………………….….…….............16 Project Site and Population............................................................................................18 Ethical Considerations/Protection of Human Subjects …………………..………….........19 Setting Facilitators and Barriers......................................................................................20 The Intervention and Data Collection Procedure……………………….….………….......21 Running Head: Self-management in Pregnancy 3 Timeline …………………………………………………………….……….………...............23 Measurement Instrument(s)/ Analysis …………………..……….…………………...........23 Sustainability Plan ..............................….……………………….……….………………....24 Results……………………………………………………………….…………………………24 Discussion/Implications for Nursing ..................................…..……….…………………..25 Cost-Benefit Analysis/Budget .........................…………………..……..…………………..26 Conclusion .....................................................................................................................27 References.....................................................................................................................28 Appendix A SWOT analysis ...........................................................................................31 Appendix B PRISMA .................................................................................................….32 Appendix C Literature Table ..........................................................................................34 Appendix D Pamphlet ....................................................................................................47 Appendix E Organization of Correspondence ...............................................................64 Appendix F Ishikawa Fishbone Diagram .......................................................................65 Appendix G Timeline .....................................................................................................66 Running Head: Self-management in Pregnancy 4 Abstract Prenatal education provides the necessary resources to expecting parents to enhance knowledge and promote understanding of the maternal changes and conditions commonly associated with pregnancy. Improving educational material includes adapting the presentation and dispersion of the material according to the education level of the patient/learner. This patient centered education allows for both improved comprehension and compliance with recommended pregnancy care practices. A literature review was conducted and identified that educational materials provided to patients not only in pregnancy, but other chronic health conditions, can improve their self-management ability. Improved self-management practices in turn helped decrease healthcare utilization costs. Reviewed literature included subjects such as education, healthcare utilization, self-management, and pregnancy. The purpose of this Doctor of Nursing Practice (DNP) project is to implement an evidence-based adaptive educational material for pregnant individuals and promote self-management during pregnancy. Some items that were included within the handout included but was not limited to pregnancy induced symptoms i.e., nausea, reflux, round ligament pain, and sleep disturbances. To do this, Michigan State University (MSU) DNP students developed a gender-neutral evidence based, educational handout for pregnant clients and their partners. The DNP students worked alongside a Certified Nurse Midwife (CNM) whose responsibility was to disperse the handout as well as track the amount of non-emergent calls and/or text messages received pre and post resource implementation to evaluate its effectiveness. Running Head: Self-management in Pregnancy 5 Keywords: Self-management, Prenatal education, Pregnancy, Healthcare Utilization Introduction Healthcare utilization contributes to unnecessary cost and over burdens the health care system. Research done by Nassery et. al. Showed “Overuse is impacted by a perfect storm of factors in the USA and can cause financial, physical, and psychological harm to patients” (Nassery, 2015). This is evident for pregnant individuals having unnecessary healthcare visits and admissions. Research performed in Australia found that proper antenatal education improved the ability for pregnant women to care for themselves at home and utilize hospital services appropriately (Saime, 2022). By facilitating improvements in patient education and comprehension, providers in turn, also facilitate the implementation of condition specific self-management techniques that result in decreased healthcare utilization. Engagement in self-management techniques require adaptations due to the multiple variables and challenges that each patient faces, including health literacy and the availability of and accessibility to healthcare resources (McDonald, 2018). Healthcare information has become widely accessible for patients with the growing number of online resources. These resources have their utility; however, they may present a barrier for providers as not all resources are evidence based. To mitigate the risk of misinformation providers should provide and encourage the use of evidence- based resources for their patients. Providing patient education for all health conditions, including pregnancy is important to ensure best possible outcomes (Demarco, 2011). Running Head: Self-management in Pregnancy 6 Collaboration between providers and patients is required to promote condition specific knowledge and understanding that fosters confidence in the patients’ ability to manage their condition. This includes comprehension of the educational material provided and finding quality information on their own. Research by Purdue University Global concluded that “benefits of being health literate include greater patient safety, less hospitalizations, a greater ability to care for oneself, and a better overall health status” (McDonald, 2018). The purpose of this paper is to evaluate how providing evidence based educational materials and promoting self-management throughout pregnancy will decrease healthcare utilization. Background According to the CDC (Centers for Disease Control and Prevention) (2020) the birth rate in 2020 in the U.S (United States) was 11.0 per 1,000 of the population. The total number of births in the U.S in 2020 was 3,613,647 (Osterman, 2022 p.2). Of these pregnant individuals an estimated 77.7% of them began prenatal care within the first trimester (Osterman, 2022 p.6). Pregnant individuals have the potential for elevated healthcare utilization as well as increased healthcare costs related to the organic changes for which the carrier’s body and fetus undergo during pregnancy. According to the Healthcare Utilization Analysis conducted by the Agency for Healthcare Research and Quality (AHRQ), pregnant individuals utilized the emergency department and were discharged for maternal care other than delivery resulting in an estimated cost of 1.9 billion dollars throughout the United States in 2020 (AHRQ, 2021). Running Head: Self-management in Pregnancy 7 Due to the increased healthcare utilization and cost associated with pregnancy and prenatal care, the development of a means for reducing unnecessary utilization, cost, as well as provider burden, is advantageous. In 2017, the estimated total healthcare costs incurred for those with diabetes in the United States (US) was $327 billion (Whitehouse, 2019). A study by Strawbridge et al. (2017) illustrated the efficacy of EBP educational interventions focused on increasing patient knowledge and providing tools for better self-management of chronic disease. The education focused on topics relating to modifiable risk factors which hold high importance in diabetes management such as blood glucose self-monitoring and foot care. This education was intended for the participants in the Diabetes Self-Management Training (DSMT) (Strawbridge, 2017). Results from the study found that DSMT users achieved a 14% odds reduction of hospitalizations and emergency room visits and is cost effective in development and implementation (Strawbridge, 2017). That same year estimated healthcare costs for those with Chronic Obstructive Pulmonary Disease (COPD) was $32 billion, accounting for nearly 700,000 hospital admissions (Hosseini, 2019). To combat the overuse of healthcare resources Hosseini et al. implemented a disease specific, inpatient education program backed by the GOLD guidelines and taught by Registered Respiratory Therapists (RRTs). Hosseini et al. (2019) found that for those who received the intervention, hospital length of stay as well as associated costs were significantly reduced (Hosseini, 2019). The effectiveness of educational programs used to improve self-management techniques, and decreased utilization of healthcare resources in patients that have chronic conditions and may be generalized for the application of educational Running Head: Self-management in Pregnancy 8 interventions to the pregnant population. This may yield significant benefits to patients, providers, and the healthcare system overall. It is reasonable then, to apply this concept of patient self-management education to the pregnant population to decrease healthcare utilization, reduce cost, and promote positive patient outcomes. Problem Statement/Clinical Question In pregnant persons, does promoting knowledge of self-management practices using an evidence based educational pamphlet result in decreased healthcare utilization (non-emergent texts/calls)? Organizational Assessment “Gap” Analysis” of Project Site To better evaluate current strengths and weaknesses of the project site MSU DNP students utilized a SWOT table for organization. This small Nurse Midwife led practice had several areas in which it could improve its current practices. It also had several areas in which there were limitations and threats to its structure. Several areas of strength include the promotion of holistic medicine, acceptance of most insurances, and following of the nursing model. Several main weaknesses were the size, competing healthcare organizations, and availability of misinformation through multimedia resources. Refer to Appendix A to see a complete list and table of strengths, weaknesses, opportunities, and threats. This project is appropriate for this site because there is a need for improved evidence based educational materials to promote self- management and decrease un-needed correspondence between patients and the provider. For a small practice with so many patients, focus needs to be on larger issues in pregnancy rather than questions that can be answered with provided resources. Running Head: Self-management in Pregnancy 9 Purpose of the Project The aim of this project was to improve the ability of pregnant individualizes to self-manage while decreasing healthcare utilization through implementation of an evidence based educational resource. Healthcare utilization was measured by the amount of non-emergent correspondence (emails, phone calls, and text messages) received by the clinic containing topics covered by the educational pamphlet created by the graduate students, in collaboration with the Midwife, and dispersed to pregnant clients during their first office visit (or subsequent visit if already an established patient receiving care). Correspondence received by the Midwife pre, and post dispersion of education was recorded to assess correlation between the evidence based educational tool and the number of correspondences received. Evidence Based Practice Model/QI Model The Iowa Model of evidence-based practice was the foundation being followed for the educational improvement intervention (Iowa, 2017). Identification of the issue within the practice, lack of a brief organized evidence based educational material packet was found. Evaluation of the issue by the current provider and MSU DNP students was deemed important for the population based on case load, and level of low priority correspondence being received. The MSU DNP students then evaluated literature to for importance, and efficacy, of educational materials on self-management and healthcare utilization. After determining there was sufficient evidence, MSU DNP students introduced a brief evidence based educational packet into the practice for dispersion Running Head: Self-management in Pregnancy 10 among all pregnant individuals. The CNM within the office tracked received correspondences from patients for 3 months prior to implementation, during implementation, and after implementation, to see if there is a change in low priority questions frequency. Questions were deemed low priority if they were able to be answered within the handout provided. Evaluation of these results was done by researchers to see if pregnant individuals were better able to self-manage pregnancy by not reaching out to their provider as much after disseminating informational packets. Literature Review To evaluate similar educational interventions and their applicability to similar populations MSU DNP students evaluated articles from two different databases, CINAHL and PubMed. The search terms utilized included: Pregnan* and self- management* and educat*. These search terms yielded a total of 227 articles, 137 from CINAHL and 90 from PubMed. After screening nine articles were found to have relevance to the use of educational materials for self-management in pregnant individuals. A PRISMA diagram was utilized to organize the search and process, see Appendix B. Inclusion criteria included articles between the years 2017-2022, implementation of an education-based intervention, and articles written in English. Exclusion criteria included being written prior to 2017, focused on breast feeding or birthing outcomes, focus on immunizations, focus on self-managed abortions. There was limitations in searching this subject including the lack of studies done within the United States. Many of the applicable studies or reviews were conducted in small populations within Middle Eastern countries. Many of the articles also had a focus Running Head: Self-management in Pregnancy 11 on self-managed abortion practices. To broaden the review other conditions that had educational interventions relating to healthcare utilization results were included. This resulted in a total of nine articles deemed suitable for inclusion within this research. The literature was organized in a literature table located in Appendix C. Meta-analysis/ Utilization Assessment There was one meta-analysis and one utilization management article found during the search. Authors grouped these articles together due to their similarities in findings. The systematic review performed by Sushko et al. identified 30 applicable studies focusing on gestational diabetes management, improved education, and self- management techniques. Unfortunately, many of the studies only provided data on the effects on blood pressure rather than on healthcare utilization. The educational intervention groups within these studies did show significant reductions in blood sugars with the largest coming from a telemedicine education intervention decreasing morning blood sugars from 124 mg/dl to 106 mg/dl (Sushko, 2021 p.6). The other much smaller utilization assessment was designed to evaluate whether a community based educational program decreased healthcare expenditures short term in Camden, New Jersey. This study did not show statistically significant evidence in reducing expenditures related to emergency department visits and inpatient stays with pre and post intervention costs maintaining P values of 0.99 and 0.72 (Burton, 2017 p.97). Even with the lack of studies regarding healthcare utilization there is still evidence of the benefit of education for patients within these studies. The decrease in blood sugars seen in the meta-analysis and the improvement of HgbA1c by 0.9 for participants in the community education is beneficial for patients. Running Head: Self-management in Pregnancy 12 Randomized Control Trials/ Quasi-Experimental Trial There was a total of two randomized control trials (RCT) and one quasi- experimental research study which utilized educational interventions in improving self- management of pregnant individuals. These trials had different educational interventions, but one concluded that education based on Bandura’s SET could have a positive effect on self-efficacy and improve the ability for individuals to practice self- management (Motlagh et al, 2019 p.60). The intervention group improved their self-care behaviors by 18.85±1.95 according to the study (Motlagh et al, 2019 p.59). A quasi- experimental study conducted by. Mohebbi et al. evaluated the Health Belief Model (HBM) based self-management interventional program. The results of utilizing this model showed that after 6-months within the educational program participants self- management increased from 60.31 ± 8.08 to 84.18 ± 8.77 (Mohebbi et al., 2019 p.172). The other RCT showed that educational interventions were effective in promoting health literacy and in improved self-care competencies during pregnancy (Solhi, 2019 p.9). Solhi et. al. (2019) showed that “there was a significant difference in the mean value of the total self-care score before the intervention (62.90±6.29), at 1 month (76.77±4.28) and at 2 months (78±3.98) after the intervention in the intervention group (P<0.001)” (p.8). Overall, each of these research studies showed a significant increase in self- management behaviors post educational intervention. Systematic Review/ Observational Analysis There was one systematic review and one observational analysis and three observational studies that were similar in their educational interventions regarding Running Head: Self-management in Pregnancy 13 patients with different chronic conditions. These studies provided good evidence of improved self-management for patients with osteoarthritis and the other for patients with asthma. The first study conducted by Yildrim et. al. showed that asthma self- management education (ASME) intervention group “made 0.82 ED visits in MI and 0.55 in NY on average in 2010, while in 2011, their average number of ED visits decreased to 0.41 in MI and 0.43 in NY” (Yildrim et al., 2021 p.1642). Three observational studies reviewed reveal a positive correlation between patient self-management education and decreased health care utilization. A claims-based study by Strawbridge et al. (2017) compared a sample of Medicare beneficiaries with a new diagnosis of diabetes that had used diabetes self-management training (DSMT) from 2009-2011 (N=14,860) to a nonuser group. Participants of this study were followed for 1 year, starting 6 months after their diabetes diagnosis as well as a yearlong follow up period. During this time, healthcare utilization (including any hospital and emergency department (ED) services as well as any hospitalization because of diabetes related ambulatory care) and costs between DSMT users and nonusers were compared. Costs included all Medicare Parts A and B expenditures. Results showed that those who received DSMT had a 14.21% predicted probability (roughly 3 fewer per 100) of hospitalization compared to 16.23% for nonusers. Additionally, the hospitalizations and ED visits were decreased by 13% among users than nonusers during the follow-up interval (Strawbridge et al., 2017). Strawbridge et al. (2017) also found that DSMT users account for approximately $830 less in Medicare expenditures (CI 95%, -$1198, -$470) compared to nonusers (Strawbridge et al., 2017). Strengths of this study include that the DSMT trainers were required to get accreditation in evidence-based curriculum and the brevity of the Running Head: Self-management in Pregnancy 14 educational intervention. Limitations of this study include observational design as well as differences between users and nonusers such as health status, patient engagement, and medical care quality. Similarly, findings from a study conducted by Claasen et al. (2018) shows the efficacy of educational programs at reducing healthcare utilization among participating patients with osteoarthritis (OA). There were 146 patients included within the study that were diagnosed with knee or hip OA and had not yet undergone a joint replacement surgery. Included as well were 54 of their partners, all of whom attended a multidisciplinary educational program. After obtaining baseline patient data, including demographic information and pre-intervention healthcare utilization, researchers utilized the following assessment tools. To assess participant’s illness perception related to their OA, several different measurement tools were utilized including the Brief Illness Perception Questionnaire (IPQ). The Dutch General Self-Efficacy Scale (GSES) was also provided and assisted researchers in their evaluation of changes in perceptions of their condition and changes of the patient physically during the study (Classen, 2018). Researchers then tracked changes in healthcare contacts over time utilizing data analysis with the exact McNemar’s test and Wilcoxon Signed-Rank test. Results showed a reduction in the proportion of patients in the intervention group who visited a physiotherapist or exercise therapist, or general practitioner (40% versus 25%) in addition to an increased knowledge of OA and a positive change in patient perceptions of their OA (Classen, 2018). The education included what patients could do for themselves to manage their OA including lifestyle changes like diet, exercise, compliant medication uses and weight loss. It also provided information on when to seek guidance Running Head: Self-management in Pregnancy 15 for treatment and promoted realistic expectations regarding the results of surgical intervention (Claassen, 2018). Limitations of this study included an uncontrolled design, small sample size, and a 25% loss to follow up. In their 2019 retrospective observational study, Hosseini et al. sought to investigate the efficacy of inpatient self-management education provided by Registered Respiratory Therapists (RTs) to patients with chronic obstructive pulmonary disease (COPD). The study was a matched case-control design and the sample included 84 inpatients in which researchers performed a review of medical record data and a retrospective review of administrative data. The patients had a diagnosis of COPD and were admitted in 2016-2017 to an academic hospital. A statistical analysis via the IBM © SPSS © Statistics 25 and Wilcoxon signed-rank test provided data related the difference in hospitalization costs and LOS (length of stay) pre and post intervention (Hosseini et al., 2019). Testing revealed that the median cost of hospitalization, pre- patient education was $10,554 which was much higher than the education cost of 0$ seen in the post-education group. Tests also show that the post-education LOS (0) was significantly lower than the pre-education LOS (5). Strengths of the study include education performed by trained professionals using EBP supported by GOLD guidelines and facilitating improved self-efficacy as well as medication adherence, and exacerbation prevention. Limitations include a relatively small sample size within an academic hospital with confounders such as patient characteristics including smoking history, marital status, gender, socioeconomic status, coping strategies, depression, physical limitations, and number of visits. Therefore, according to Hooseini et al. (2019) patient education for patients with COPD reduces healthcare utilization through Running Head: Self-management in Pregnancy 16 providing patients the confidence to take action in their own health plan and improve self-efficacy. Conclusion Despite an overall lack of research specific to decreasing healthcare utilization with educational materials in pregnancy, there were benefits gleaned from educational interventions on not only patient health but also healthcare utilization in other chronic conditions. Based on the review of literature, educational interventions for pregnant individuals have been deemed beneficial in improving self-management behaviors. Goals, Objectives, and Expected Outcomes The goal of this DNP project was to reduce non-emergent healthcare utilization by pregnant individuals through the implementation of an evidence based educational resource that focuses on prevention and self-management strategies of pregnancy associated conditions. It was expected that during the 3-month intervention period, as client’s knowledge regarding pregnancy and self-management skills improve, healthcare utilization (text messages, emails, phone calls) would be reduced. Methods This evidence-based practice (EBP) quality improvement project used an educational pamphlet to improve self-management and decrease healthcare utilization in pregnant individuals. Expected outcomes for this project include an improved sense of self management in pregnancy and decreased healthcare utilization. The project followed the Plan Do Study Act framework. Running Head: Self-management in Pregnancy 17 Plan The project began with evaluation of the needs of a Certified Nurse Midwife run obstetrics clinic. Once a need (organized evidence based informational packet) was identified, an evidence-based literature review for separate stages, concerns, and homeopathic remedies during pregnancy was pursued. The importance of education within pregnancy as well as other chronic conditions was also researched and found applicable to the needs of the clinic. Organization of this information and the process for implementation was developed prior to dispersion within the clinic. Topics for education include common issues in pregnancy, preventing problems in pregnancy, key vitamins, and minerals during pregnancy, caloric intake during pregnancy, weight gain during pregnancy, recommended online resources, when to contact your provider, preventing problems in pregnancy, and places to write notes during appointments. Do Once the pamphlet was developed and deemed appropriate, dispersion within the office began. MSU graduate students made sure that the brochure was gender neutral and at an 8th grade reading level to better facilitate education. The full pamphlet can be seen in Appendix D. This informational brochure was handed out to all pregnant individuals who were less than nine months pregnant. After having the brochure for three months the provider was to evaluate and organize data related to how often they were contacted by patients with questions that could have been answered within the brochure. Study Running Head: Self-management in Pregnancy 18 The data collection tool utilized for this project was observation. The Nurse Midwife associated with this practice observed the amount of correspondence that they received prior to and throughout the process. Data from the Nurse Midwifes monitoring of correspondence was evaluated to see if implementation of educational handouts decreased healthcare utilization. This was measured by comparing pre-educational handout correspondence numbers to post-implementation correspondence numbers. Data was organized by the CNM in table format listing date, time, format (text, call, or email), and determination of appropriateness of correspondence (See appendix E). Act After evaluation of results, the efficacy and sustainability of the brochure was to be discussed with the nurse midwife. If the project was deemed beneficial to the patients, then long term implementation of the brochure for patients was left to the provider within the office. Training done prior to implementation of the brochures will remain applicable as the office continues to disperse the educational material. Project Site and Population The proposed project took place in an independently owned and operated women’s wellness center in Manistee, Michigan. According to data from the United States Census Bureau (2022), Manistee is a community in Northern Michigan which as of 2021, is home to a population of 6,302 people. The community is predominately white (89.1%), high school educated, married (43.4%), single (33.9%), with no religious affiliation (59.2%), or catholic (20.6%). Healthcare is the predominate industry, employing approximately 13% of the population. 13.7% of the population live at or Running Head: Self-management in Pregnancy 19 below the poverty line and 26,593 people receive social assistance. (U.S. Census Bureau, 2022). The community is home to one hospital, a county medical care facility, assisted living facilities, primary care offices, dental offices, and ophthalmology offices. There are tribal services run by the Little River Band of Indians as well as a casino. There is no OB/GYN provider within the county and the nearest labor and delivery unit is 35 miles away. The nearest PICU is approximately 50 miles away from the clinic. Manistee has both public and private elementary and high schools. There is also a public bus service that provides affordable and safe transportation throughout Manistee County. The participants of the project were the CNM, pregnant clients, and Michigan State University (MSU) graduate students. The midwife and her staff provided eligible candidates with the EBP pamphlet and tracked correspondence. Inclusion criteria was pregnant clients of the wellness center, less than nine months gestation, and correspondence with the CNM related to frequently asked questions or problems covered by the EBP pamphlet. Exclusion criteria was pregnant persons greater than nine months gestation and non-pregnant clients. Ethical Considerations/Protection of Human Subjects Michigan State University Internal Review Board (IRB) approval was obtained prior to initiating the DNP project. All data was HIPPA compliant, and the project did not include any personal identifiers from participants. All information included within the handouts was evidence based to ensure the highest standards of care were being provided to all willing participants. There was minimal to no risk of providing improved Running Head: Self-management in Pregnancy 20 educational material to patients. Benefits included better self-management and fewer correspondence between provider and patient. Setting Facilitators and Barriers The clinic was staffed by a Certified Nurse Midwife (CNM) with more than thirty years of combined experience as a labor and delivery nurse and midwifery care. She also partnered with two professional midwifes and employed several birth assistants and doulas. She has personally trained first responders in infant resuscitation as the nearest labor and delivery unit is approximately 35 minutes away. This partnership with the community is mutually beneficial, as she also performs home deliveries, which can increase travel time to these units as well as emergency departments. Because of her commitment to safety, properly trained first responders can assist if emergent services are needed. This preparation provides peace of mind to the CNM as well as the patient and their loved ones that there is competent help in the event of an emergency. The office has 3 birthing suites and birthing tubs. Office visits take place in the parlor located in front of the building, in a comfortable, private, and intimate setting. Appointments are scheduled hourly. Physical exams and lab draws take place in the exam room that is separate from the front to promote privacy, but to also promote comfort and foster a trusting connection between the midwife, patient, and their family. Other services provided at the office are sonography, tocodynamometer, glucose intolerance testing, pelvic exams, as well as holistic and homeopathic adjunctive therapies for labor. The mission of the clinic is to provide a patient centered, safe, and welcoming environment for pregnant persons to deliver their children, whether at the clinic or in the home. Some Running Head: Self-management in Pregnancy 21 of these facilitators and barriers have been organized into an Ishikawa Fishbone Diagram which can be seen in Appendix F. The MSU graduate students did not have any direct patient contact. There was a briefing between the MSU graduate students and the CNM prior to the distribution of the EBP pamphlets to discuss the project and review the process of data collection prior to implementation. The MSU library and EBP guidelines for maternal care and midwifery were resources that were used to develop the educational pamphlet. Constraints of the project was a relatively short period of implementation, as well as a generally small population of eligible participants, and varying levels of self-management, confidence, and participant backgrounds. Facilitators of project implementation included a clinical staff that was committed to providing individualized, holistic prenatal care, and promoting positive outcomes for their clients. There were no anticipated barriers to the implementation of the project. The Intervention and Data Collection Procedure Intervention Process Review of literature has shown that improved education within pregnancy and other chronic conditions can improve self-management and decrease healthcare utilization. With the importance of education being highlighted, MSU graduate students developed an evidence based educational pamphlet for dispersion. To assess the effectiveness of the educational handout researchers, and the CNM, measured inappropriate calls. The CNM and MSU graduate students determined that inappropriate calls were to be determined by whether the answers to the questions Running Head: Self-management in Pregnancy 22 being called about can be found within the brochure or if the correspondence is truly something that needs to have provider notification, also listed in the brochure. Discussion of time frames as well as expectations with the CNM was important to formalize the process and ensure data was not lost due to process errors. As the CNM was the only one providing the pamphlets, there was no need to educate other staff members on the utilization of the pamphlet. A total of three people, not including patients, were involved in the process of implementation. After evaluating patients for eligibility, the CNM dispersed the educational packet to all pregnant patients who are 6 months or less gestational age. The patient was expected to review the information initially with the provider and bring it with them to appointments. During this time frame the CNM was to be tracking how many texts, emails, and phone calls she had received from patients. After a three-month time frame the CNM was to turn over total correspondence prior to the educational packet and after dispersion of the packet. Once all data had been submitted MSU grad students were to organize and evaluate the data to see if there was any correlation between the education and the amount of correspondence the CNM received. At this stage the CNM was not needed for involvement as they have provided all necessary information. The data was to be communicated with the provider to provide them with the value of the intervention. The data was then going to be compared using percentage change in correspondence over the interventional period. Timeline Running Head: Self-management in Pregnancy 23 The timeline of this project began with the approval of the Institutional review board (IRB) which was obtained during the month of September 2022. Soon after, during September, the educational packet was reviewed with the provider and the process was discussed. To obtain a larger population, this took place over 3 months, ending in December. Evaluation of results from this survey as well as the amount of correspondence that the CNM had been tracking was to be performed. Results were then going to be evaluated and organized for presentation. Full timeline can be seen in Appendix G. Measurement Instruments/Analysis To evaluate if the educational packet could reduce the number of correspondences received after business hours this DNP project reviewed, phone calls, text messages, and emails received by the CNM. These correspondences were deemed inappropriate if they included questions which could be answered by the educational material. Pre-intervention correspondence was to be logged by the CNM and was going to be compared with post material dispersion correspondence to evaluate if the material made a significant difference in patients’ ability to self-manage and decrease healthcare utilization. Individuals included in this analysis included the CNM, MSU graduate students, and patients. The goal of this data was to show a significant difference in the amount of after-hours correspondence received by a CNM. Due to the practice being so small results would be difficult to generalize for larger populations. Appropriate statistical analysis would be analyzed using percentage change in number of correspondences Running Head: Self-management in Pregnancy 24 received. If this data showed a decrease in un-needed correspondence, then providers should consider implementing similar educational interventions for their patients. The decreased off hours workload and ability to focus on more critical patient care aspects could prove beneficial not only to obstetric providers but also providers who care for patients with other chronic conditions. Sustainability Plan The sustainability of this project will depend on the applicability over time and available resources. Primary resources being utilized for this project was paper, printer, printer ink, and staples. If the office can financially sustain these products the informational packet should continue to exist. Evaluation of up-to-date evidence regarding pregnancy will also need to be evaluated at intervals deemed appropriate by the provider to ensure that the packet does not provide misinformation after a period. Results Prior to project implementation, the CNM reviewed her texts and clinic phone calls and messages and reported at least 279 unnecessary correspondences over a 3- month period. Based on findings garnered during the literature review process, the positive correlation between educational interventions and self-management across multiple healthcare domains, the assumption of the DNP students was that the results of this project would reflect a similar outcome. However, the effectiveness of the educational pamphlet on reducing unnecessary call volumes and workload for the CNM will remain unknown as the clinic doors abruptly closed in late September 2022. The MSU DNP students were led to believe that the intervention and data collection was still Running Head: Self-management in Pregnancy 25 underway at the clinic until December 2022 when correspondence ceased. January 2023 the CNM reached out to explain the hardships of the clinic and then ceased all future correspondence with the DNP students henceforth rendering data collection a total loss. The intention of the MSU DNP students was to compare pre-implementation correspondence and cross examine it to post-implementation correspondence. Unfortunately, the CNM did not report any data to the DNP students for analysis even though it was requested and agreed upon. Due to this no official statement can be made based on the student’s data other than the assumption that it would have had a positive correlation. Discussion/Implications for Nursing The results of this QI may affect how to organize and disseminate educational materials for pregnant individuals. Patient education is important within all domains and phases of healthcare and condition management. Evaluation of how this educational material is delivered and perceptions of knowledge and its effects of self-management may promote the adaptation of improved evidence based educational material. Due to a lack of data on the effect of education’s link to self-management in pregnancy specifically, this project was hopeful to find a correlation with EBP educational materials and efficacious self-management. If the educational materials were found beneficial then it is reasonable for Nurse Midwives to implement similar educational programs to improve their patient’s self-management during pregnancy. While there are no findings to report due to the fall out of the CNM from the project as mentioned. Retrospectively, the authors of this paper submit that perhaps the Running Head: Self-management in Pregnancy 26 project implementation was an intervention that came too late. It is possible that the additional workload of tracking correspondence (while discussed at great length and mutually agreed to by the DNP students and CNM), was too taxing for the CNM. Perhaps, if the DNP students could have been able to meet on a more regular basis with the CNM, they could have tracked the data rather than the CNM (this was offered but declined per the CNM) which could have at least produced tangible data for analysis. The regular presence of the DNP students might have also facilitated more of an interpersonal relationship with the CNM, making it more likely for her to continue with the project or at least provide notice that the clinic would be closing. However, regardless of the method used to track and analyze data, the project would have still been confounded by the closure of the clinic by reducing the time of implementation as well as further reducing population size. It is the belief of the DNP students that had the clinic not closed, the results would positively correlate patient education with reduced call volumes and workload. Cost-Benefit Analysis/Budget Costs to implementing the evidence based informational packet included things such as paper, printer ink, and staples. These are items that are already currently in most offices, extra will be used, to print and put together these packets. The most expensive item required for the project was Lexmark printer ink at $87.99. Paper for the printer was $8.49. Staples costed $2.99. These up-front costs would be mitigated as these items are currently in the office for other uses. The benefit of this project is that having less correspondence and greater independence of patients will outweigh the minimal costs of printing and stapling the packets together. The costs would be taken Running Head: Self-management in Pregnancy 27 on by the office, but like previously stated these items were already within the office being used. Conclusion The lack of consistent simplified educational material has led to decreased self- management practices in pregnancy. Improving, and providing, these educational materials should improve patients’ self-management and decrease healthcare utilization. Research has shown that educational interventions in chronic conditions as well as pregnancy can improve self-management and decrease healthcare utilization. Ensuring an appropriate literacy level for patients and using up to date evidence-based recommendations will provide patients with the best possible chances to allow them to manage common symptoms during pregnancy. Running Head: Self-management in Pregnancy 28 References Agency for Healthcare Research and Quality (2021) Emergency Department and Inpatient Utilization and Cost for Pregnant Women: Variation by Expected Primary Payer and State of Residence, 2019. Healthcare Cost and Utilization Project. ONLINE. December 14, 2021. www.hcup- us.ahrq.gov/reports/ataglance/findingsataglance.jsp. Beaudin, J., Chouinard, M.C., Girard, A., Houle, J., Ellefsen, E, & Hudon, C. (2022). Integrated self-management support provided by primary care nurses to persons with chronic diseases and common mental disorders: a scoping review. BMC Nursing, 21(1), 1-19. https://doi.org/10.1186./s12912-022-01-000-2 Brown, C. G. (2014). The Iowa Model of Evidence-Based Practice to Promote Quality Care: An Illustrated Example in Oncology Nursing. Clinical Journal of Oncology Nursing, 18(2), 157-159. Doi: 10.1188/14.CJON.157-159 DeMarco, J., Nystrom, M., & Salvatore, K. (2011). The importance of patient education throughout the continuum of health care. Journal of Consumer Health on the Internet, 15(1), 22–31. https://doi.org/10.1080/15398285.2011.547069 Hosseini, H., Pai, D., Ofak, D. (2019). COPD: Does inpatient education impact hospital costs and length of stay? Hospital Topics, 97(4), 165-175. https://doi.org/10.1080/00185868.2019.1677540 Running Head: Self-management in Pregnancy 29 Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. doi:10.1111/wvn.12223 McDonald, M., & Shenkman, L. (2018). Health Literacy and Health Outcomes of Adults in the United States: Implications for Providers. Internet Journal of Allied Health Sciences and Practice, 16(4). https://doi.org/10.46743/1540-580x/2018.1689 Osterman, M. J. K., Hamilton, B. E., Martin, J. A., Driscoll, A. K., & Valenzuela, C. P. (2022). Births: Final Data for 2020 Figure 1. Live births and general fertility rates: United States. National Vital Statistics Reports, 70(17). https://www.cdc.gov/nchs/products/index.htm. Ross, D.L. & Hvizdash, S. (2002). Integrating religious practices in home health care: A case study of collaborative between the health care system and the Orthodox Jew. Home Health Care Management & Practice, 14(6), 457-460. 10.1177/108482202236699 Saime, S. H., Abdul-Mumin, K. H., & Hashim, S. (2022). Admission to delivery suites: The importance of antenatal education. British Journal of Midwifery, 30(4), 215– 221. https://doi.org/10.12968/bjom.2022.30.4.215 Schiraldi, G. R. (2003). The post-traumatic stress disorder sourcebook: A guide to healing. (Adobe Digital Edition version). Doi: 10.1036/10071393722 Running Head: Self-management in Pregnancy 30 U.S. Census Bureau. (2022). Quick Facts: Manistee City Mi; United States. https://www.census.gov/quickfacts/fact/table/manisteecitymichigan,US/PST0452 21 Whitehouse, C., Haydon-Greatting, S., Brady, V., Bzowyckyj, A., Smith, T., Srivastava, S.B., Kauwetuitama, A.,I., Blanchette, J., Cedrone, M., Litchman, M.L. (2021). Economic impact and health care utilization outcomes of diabetes self- management education and support interventions for persons with diabetes: a systematic review protocol. JBI Evidence Synthesis, 20(1), 238-248. Doi: 10:11124/JBIES-20-00550 Zuraida, E. ,Irwan, A., Sjattar, E.L. (2021). Self-management education programs for patients with heart failure: A literature review. Central European Journal of Nursing and Midwifery, 12(1), 279-294. Doi:10.15452/CEJN.2020.11.0025 Running Head: Self-management in Pregnancy 31 Appendix A SWOT Analysis Strengths Weaknesses  Patient centered  Limited resources  Nursing Model  Over accessibility  Holistic Approach  Safety (Emergent birthing situations  Insurance Acceptance i.e.. Shoulder dystocia, hemorrhage, infant resuscitation) Opportunities Threats  Growth- additional providers/patients  Large hospital systems  Community Partners (Fire Dept.)  Misinformation available through  Free educational classes for public internet  Preconceived misconceptions of nurse midwifery  Roe V Wade Running Head: Self-management in Pregnancy 32 Appendix B PRISMA Diagram for “Pregnan* and self-management* and educat*” search. Identification of studies via databases and registers Identification Records removed before Records identified from: screening: Databases CINAHL, PubMed Duplicate records removed (n = 2) (n = 27) Records screened Records excluded (n = 137) (n = 30) Screening Reports assessed for eligibility Reports excluded: (n = 80) Relevance (n = 62) Time frame (n = 12) Intervention (n =6) Other (n = 5) Studies included in review (n =6) Included Running Head: Self-management in Pregnancy 33 PRISMA Diagram for “educat* and self-management* and healthcare utilizat*” search. Identification of studies via databases and registers Identification Records removed before Records identified from: screening: Databases CINAHL, PubMed Duplicate records removed (n = 2) (n = 50) Records screened Records excluded (n = 90) (n = 80) Screening Reports assessed for eligibility Reports excluded: (n = 10) Relevance (n = 2) Intervention (n =5) Included Studies included in review (n =3) Running Head: Self-management in Pregnancy 34 Appendix C Literature Table Running Head: Self-management in Pregnancy 35 Citation Design/Level Sample Intervention Measurement: Findings Strengths/Limitati of Evidence/ Variables and ons/ Purpose Instruments Implications Motlagh, A. E., Babazadeh, Design: Sample: Intervention Variables: The intervention Strengths: No R., Akhlaghi, F., & Randomized 100 group: Age, Sex, group obtained conflicts of Esmaily, H. (2019). Control Trial pregnant educational Gravida, Para, higher scores interest, RCT Effect of an educational women, 2 training based perceptions of regarding self- intervention program Level of randomized on the pregnancy, care behaviors, Limitations: Small based on Bandura’s self- evidence: groups. All constructs of ability to care and a sense of population size, efficacy theory on self- Level II have Bandura’s for self, ability self-efficacy non-generalizable care, self-efficacy, and prediabetes SET. Control to attend compared to the blood sugar levels in Purpose: This Group was education, control group. Implications: mothers with pre- study aimed at provided educational Their blood Education based diabetes during investigating standard care materials sugars were also on Bandura’s SET pregnancy. Evidence the effect of an significantly could increase Based Care Journal, educational Measurement lower. sense of self 9(2), 53–64. intervention tools: 5-point- efficacy and https://doi.org/10.22038/ program based Likert- Type improve self-care ebcj.2019.37173.1959 on Bandura’s Rating system behaviors. Self-Efficacy Questionnaire Theory (SET) on self-care, Mann-Whitney self-efficacy, U test and blood sugar levels in mothers with pre-diabetes during pregnancy. Running Head: Self-management in Pregnancy 36 Mohebbi, B., Tol, A., Design: Sample: The self- Variables: theory- based Strengths: Sadeghi, R., Mohtarami, Quasi- 110 management Age, Sex, educational Randomized S. F., & Shamshiri, A. experimental Women education Gravida, Para, intervention quasi- (2019). Self- Study between program was perceptions of focusing on experimental management 17-41 presented in pregnancy, diabetes risk in study, associated intervention program Level of newly four sessions ability to care GDM women, significance of based on the health evidence: diagnosed lasting 35-40 for self, ability improving data post belief model (Hbm) Level III with minutes for to attend perceived self- intervention among women with gestational each during a education, efficacy to adopt gestational diabetes Purpose: diabetes month. The educational healthy Limitations: Small mellitus: A quazi- determine the content of materials behaviors, sample size, no experimental study. effect of educational identifying educational Archives of Iranian theory-based programs Instruments/ common barriers requirements for Medicine, 22(4), 168– educational included basic Measurements: to healthy subjects 173. intervention information baseline lifestyle program regarding HgbA1C, behaviors should Implications: among women GDM facts, Scoring of be provided to Running with figures and Health both patients intervention gestational self- behavior programs using diabetes management model educational and mellitus based on HBM regarding self- consulting management, strategies can lead associated P to better self- values. management and health improvement Running Head: Self-management in Pregnancy 37 Solhi, M., Abbasi, K., Azar, Design: Sample: A Self-care and Variables: Educational Strengths: RCT, F. E. F., & Hosseini, A. Randomized sample size health literacy Age, Sex, interventions to no conflicts of (2019). Effect of health Controlled of 300 questionnaires Gravida, Para, promote health interest, findings literacy education on Trial pregnant were filled out. perceptions of literacy in of significant self-care in pregnant women The pregnancy, pregnant women change with women: A randomized Level of was intervention ability to care of Pakdasht was intervention group controlled clinical trial. Evidence: reduced to group followed for self, ability effective in International Journal of Level II 80 total four sessions to attend improving their Limitations: small Community Based pregnant of the education, self-care status sample size, non- Nursing and Midwifery, Purpose: The women. 40 educational educational during generalizable, 7(1), 2–12. study aimed to in the program: materials pregnancy. self-reporting of determine the control covering topics participants effect of health group, and on health Instruments/ literacy 40 in the literacy and Measurements: Implications: It is education on interventio self-care two dedicated recommended that self-care in n group. during questionnaires intervention for pregnant These were pregnancy and on self-care the promotion of women then split its impact on (21 questions) physical and between 2 self-care in and on health mental self-care different pregnant literacy (24 during pregnancy centers so women. Each questions) should emphasize that session lasted Results were on increasing individuals 45 minutes based on a 4- women’s health could point Likert literacy in the exchange Scale, areas of information Kolmogorov- computational Smirnov comprehension, testing for reading distribution comprehension, Reliability and and behavior. maintainability analysis Running Head: Self-management in Pregnancy 38 Sushko, K., Menezes, H. T., Design: Sample: Interventions: Variables: Findings: This Strengths: Large Strachan, P., Butt, M., & Scoping 511 Identification Age, Sex, review found scoping review of Sherifali, D. (2021). review/ meta- identified of key Gravida, Para, that prenatal evidence, review Self-management analysis citations, characteristics perceptions of education for of evidence over education among women 30 studies of prenatal pregnancy, women with type last 4 years. No with pre-existing Level of were education and ability to care 1 and type 2 external funding diabetes in pregnancy: A Evidence: included in support for self, ability diabetes consists or competing scoping review. Level I the final interventions to attend of frequent interests. International Journal of review. for women education, outpatient Nursing Studies, 117, Purpose: Approxima with type 1 and educational sessions focused Limitations: Lack 103883. synthesize the tely 44% of type 2 materials, on diabetes self- of methods and https://doi.org/10.1016/j. evidence the pooled diabetes, methods of the management, is adequate articles ijnurstu.2021.103883 regarding sample finding that studies, provided by found, lack of prenatal were multidisciplina availability of multidisciplinary research for type 2 diabetes women ry healthcare research healthcare teams, diabetes education and with type 1 teams provide and is support for diabetes, frequent Instruments/ supplemented Implications: women with 46% had outpatient self- Measurements: with self- Lack of sources type 1 and type gestational management Searches management within the last 4 2 diabetes diabetes education, utilizing support. years for mellitus, supplemented EMBASE, However, these educational based and 10% with self- Cinahl, and studies were interventions for had type 2 management Medline, limited in the management diabetes support Medical methods and of gestational Research there was a lack diabetes Council of research Framework focused on type evaluation of 2 diabetes. randomization, Running Head: Self-management in Pregnancy 39 Yildirim, M., Griffin, P., Design: Sample: Interventions: Variables: ED Findings: All the Strengths: Large Keskinocak, P., Systematic Children Asthma self- (Emergency interventions descriptive study, O’Connor, J. C., & Review aged 0-17 management Department) reduced both all interventions Swann, J. L. (2021). with education (AS- utilization utilization and decreased Estimating the impact of Level of asthma Me), focused indicator, IP asthma expenditures self-management Evidence: from New on influenza (International medication costs. education, influenza Level V York and vaccinations, Program) Asthma self- Limitations: latest utilization vaccines, nebulizers, and Michigan nebulizer and management available data was indicator, spacers on health Purpose: enrolled in spacer education, from 2010 and utilization utilization and Quantification the education, expenditures, nebulizer, and 2011, many expenditures for of the effect of Medicaid National and asthma spacer unobservable Medicaid-enrolled a set of Program. Asthma medication interventions factors affecting children with asthma. interventions Education and expenditures reduced the interventions, Journal of Asthma, including Prevention per person per prob- ability of 58(12), 1637–1647. asthma self- Program year. emergency Implications: This https://doi.org/10.1080/0 management (NAEPP) department analysis provides 2770903.2020.1821056 education, (20.8–1.5%, evidence to influenza 95%CI 19.7– policymakers vaccination, Instruments/M 21.9% vs. 0.5– about the benefits spacers, and easurements: 2.5%, of the nebulizers on Difference-in- respectively) and interventions of healthcare difference inpatient (3.5– influenza utilization and (DiD) 0.8%, 95%CI vaccines, spacers, expenditures regression 2.1–4.9% vs. AS-ME, and for Medicaid- model 0.4–1.2%, nebulizers on enrolled respectively) health outcomes children with utilizations of pediatric asthma in New asthma patients. York and Michigan. Running Head: Self-management in Pregnancy 40 Claassen, A. A. O. M., Design: Sample: 3 Interventions: Variables: Findings: short- Strengths: no Schers, H. J., Koëter, S., Observational districts in The organized Age, sex, term preliminary competing Van Der Laan, W. H., Study the knee and hip perceptions of effects of a interests, Kremers-Van De Hei, K. Nijmegan OA illness multidisciplinary evaluation of a C. A. L. C., Botman, J., Level of area of the educational educational pro- multidisciplinary Busch, V. J. J. F., evidence: Netherland program Instruments/M gram may result approach Rijnen, W. H. C., & Van Level III s, 18 years consisted of easurements: in decreased Den Ende, C. H. M. or older two 1.5-h Western HCU. However, Limitations: (2018). Preliminary Purpose: The and had a meetings. The Ontario a controlled trial Uncontrolled effects of a regional objective of the clinical program was University with long-term design, small approached present study diagnosis led by a Index of follow-up is sample size multidisciplinary was to of OA in physiotherapist osteoarthritis needed to further educational program on determine the knee or and a GP, (WOMAC), explore effects Implications: healthcare utilization in preliminary hip Brief illness on HCU Results show that patients with hip or knee effects of this (diagnosed perception behavior in a osteoarthritis: An OA by a questionnaire patients with hip multidisciplinary observational study. educational general (IPQ), Patient or knee OA. educational BMC Family Practice, program on practitioner Activation program may 19(1), 1–9. healthcare (GP) or Measure result in a https://doi.org/10.1186/s utilization medical (PAM-13), decrease in 12875-018-0769-7 (HCU) and specialist), Short healthcare clinical 146 total Questionnaire utilization and has outcomes. patients to Assess a positive effect physical on illness activity perceptions and (SQUASH) knowledge on OA due to clear and consistent information on OA and its treatment options Running Head: Self-management in Pregnancy 41 Burton, J., Eggleston, B., Design: Sample: Interventions: Variables: Findings: no Strengths: Did Brenner, J., Truchil, A., Utilization Participatio Attendance to Socioeconomic bend in the cost show a decrease Zulkiewicz, B. A., & analysis n and the coalitions status, race, curve for those in A1c by almost Lewis, M. A. (2017). demograph Diabetes Self- clinical participating in one full point in Community-Based Level of ic management variables, the DSME participants of the Health Education Evidence: III information Education progression of programs as had program Programs Designed to for Program disease, been previously Improve Clinical Purpose: The approximat (DSME), 8 genetics, found for some Limitations: Many Measures Are Unlikely purpose of this ely 125 class diabetes adherence to care medical needs not to Reduce Short-Term study is to test participants and education medical management associated with Costs or Utilization whether the as well as and nutrition regimen interventions for diabetes may lead Without Additional strategies clinical curriculum 50 high health care to hospital stays Features Targeting These implemented measures minutes each. Instruments/M utilizers.9 and ER visits. Outcomes. Population in Camden for a subset easurements: DSME deployed Those were not Health Management, through the of those Multivariate at the taken into 20(2), 93–98. Coalition’s participants regression community accordance. Small https://doi.org/10.1089/p Diabetes Self- . Camden models with level. time frame with a op.2015.0185 Management New Jersey generalized limited number of Education estimating participants. Only (DSME) equations 48 people program (GEEs), completed the reduced logistic gamma education hospital hurdle models program. utilization and costs. Implications: Although there wasn’t a decrease in utilization costs there were benefits for the patient Running Head: Self-management in Pregnancy 42 Hosseini, H., Pai, D., & Ofak, Design: Sample: Interventions: Variables: Findings: Strengths: D. (2019). COPD: Does Retrospective Retrospecti Self- Age, gender, Statistical Consistent, inpatient education observational ve management marital status, analyses guideline directed impact hospital costs and study with administrat interventions number of revealed that patient education length of stay? Hospital matched case ive & provided to visits, smoking COPD education provided to Topics 97 (4), 165-175. control. medical patients at the status, and received during inpatients in all https://doi.org/10.1080/0 record data bedside by length of stay inpatient stay areas of care. 0185868.2019.1677540 Level of from 84 trained RT’s (LOS). appears to Retrospective, Evidence: VI patients during reduce observational data admitted admission to Instruments/M hospitalization obtained through Purpose: To with COPD acute care, easurements: costs and length medical records assess the as a progressive & Statistical of stay. provides unbiased effectiveness diagnosis intermediate analysis with Post hoc information/result of COPD admitted care units. IBM SPSS regression s. Results are inpatient between Statistics 25. analyses reveal inclusive of any education 2016-2017. Effectiveness Post hoc that age, gender, disease severity. using of inpatient regression marital status Few studies respiratory education was analyses was significantly examine actual therapy staff in compared associated with hospital cost and an academic before and LOS. Whereas LOS based on health system. after the smoking, LOS, response to COPD interventions. and number of inpatient Hospital LOS visits were education. and significantly hospitalization associated with Limitations: Small costs are hospitalization sample size of 84 primary costs. at an academic outcomes. hospital. Length of study was only 7 months to account for lag in administrative billing. Running Head: Self-management in Pregnancy 43 Lack of diversity among sample population. Confounders such as health literacy, socio-economic status, coping techniques, physical limitations, and depression. Implications: COPD patient education may be an effective strategy at reducing hospital costs and healthcare utilization. Empowering patients to take responsibility for their health outcomes by improving self- efficacy has proven valuable. Running Head: Self-management in Pregnancy 44 Strawbridge, L., Lloyd, J., Design: Sample: Interventions: Variables: Findings: Strengths: Results Meadow, A., Riley, G., Claims-based Twenty Diabetes Self- Pretreatment Multivariate support literature Howell, B. (2017). One-year observational percent Management value of the regression results showing the outcomes of diabetes self- study with 1- random Training outcome. found that health benefits of management training among year follow-up sample of (DSMT) Medicare FFS DSMT users had diabetes self- Medicare beneficiaries newly beginning 6 Medicare population. 14% reduced management diagnosed with diabetes. months after beneficiarie Glycemic odds of programs. Aligns Medical Care. 55(4). 391-396. diagnosed with s newly control, hospitalization, with other studies Wolters Kluwer Health, Inc. diabetes diagnosed weight, lower numbers that find lower with medication of hospital health care Level of diabetes use, and admissions, and utilization and Evidence: III during cardiovascular ED visits (3 costs among 2009-2011 risk factors. fewer per 100 for individuals using Purpose: who used each), and $830 preventive Short-term DSMT lower Medicare services and those benefits of (N=14,680) Instruments/M expenditures (CI who adhere to diabetes self- matched to easurements: 95%, -$1195, - disease management a nonuser health service $470) compared management training comparison utilization and to non-users. The strategies. DSMT (DSMT) are group. costs between odds of any finding are established; DSMT users hospitalization important given however, and non-users due to diabetes- predicted longer-term were related increases in impacts among compared. ambulatory care diabetes and Medicare Health service sensitive Medicare beneficiaries utilization conditions and beneficiaries. are not known. included any any ED visit utilization of were lower for Limitations: the hospital or DSMT users Observational emergency compared with design. department and nonusers, but the Although any reductions were confounders were hospitalization controlled through Running Head: Self-management in Pregnancy 45 s due to not statistically a doubly robust diabetes- significant. methodology, related there may be ambulatory unobservable care sensitive characteristics that conditions as differ between the well as the groups. number of hospitalization Implications: s and ED visit Study results with the show a beneficial follow-up year. impact of DSMT Costs included on health care Medicare A & utilization and B cost outcomes in expenditures. the year following the intervention. Beneficiaries who used any DSMT services had significantly lower odds of any hospitalization, fewer admissions and ED visits, and lower Medicare expenditures in the follow-up year than nonusers. These finding highlight opportunities to reduce the burden Running Head: Self-management in Pregnancy 46 of diabetes on both Medicare beneficiaries and the health care system. Running Head: Self-management in Pregnancy 47 Appendix D Pamphlet Running Head: Self-management in Pregnancy 48 What to Expect During Pregnancy Running Head: Self-management in Pregnancy 49 Promoting Healthy Babies Eating a well-balanced diet and making healthy lifestyle choices play a key role in the growth and development of your baby. See the recommendations below for ways to improve your health and the health of your growing baby. Folic Acid: Folic acid is a vitamin B that can help prevent major birth defects. Take a vitamin with at least 400 micrograms (mcg) of folic acid every day, during pregnancy. You should be able to buy this from any pharmacy or stores like Wal-Mart, Meijer, or Walgreens. Prenatal Vitamins: Prenatal vitamins provide your growing baby with nutrients that support healthy development, and are available in pill, gummy, and smoothie form. These can be taken with food or at bedtime to minimize nausea or GI upset. These are also available over the counter and should be taken daily. Smoking: The best time to quit smoking is before you get pregnant but quitting at any time during pregnancy can help your baby get a better start on life. Learn more about the dangers of smoking and find help to quit. Running Head: Self-management in Pregnancy 50 Alcohol: A baby can be exposed to the same level of alcohol as the mother during pregnancy. There is no known safe amount of alcohol used during pregnancy. Marijuana Use: Marijuana use during pregnancy can be harmful to your baby’s health. The chemicals in marijuana (in particular, tetrahydrocannabinol or THC) pass through your system to your baby and can harm your baby’s development. Vaccinations: Did you know a baby gets disease immunity (protection) from mom during pregnancy? This immunity can protect a baby from some diseases during the first few months of life, but immunity decreases over time. Key Vitamins and Minerals During Pregnancy Nutrients (Daily Recommended Why You and Your Fetus Need It Best Sources Amount) Calcium (1,300 milligrams for ages 14 Milk, cheese, yogurt, sardines, dark to 18; 1,000 milligrams for ages 19 to Builds strong bones and teeth green leafy vegetables 50) Lean red meat, poultry, fish, dried Helps red blood cells deliver oxygen Iron (27 milligrams) beans and peas, iron-fortified cereals, to your fetus prune juice Essential for healthy brain Iodized table salt, dairy products, Iodine (220 micrograms) development seafood, meat, some breads, eggs Important for development of your Milk, beef liver, eggs, peanuts, soy Choline (450 milligrams) fetus’s brain and spinal cord products Vitamin A (750 micrograms for ages Forms healthy skin and eyesight Carrots, green leafy vegetables, 14 to 18; 770 micrograms for ages 19 Helps with bone growth sweet potatoes to 50) Builds your fetus’s bones and teeth. Sunlight, fortified milk, fatty fish such Vitamin D (600 international units) Helps promote healthy eyesight and as salmon and sardines skin Running Head: Self-management in Pregnancy 51 Helps form red blood cells. Beef, liver, pork, ham, whole-grain Vitamin B6 (1.9 milligrams) Helps the body use protein, fat, and cereals, bananas carbohydrates Maintains nervous system. Meat, fish, poultry, milk (vegetarians Vitamin B12 (2.6 micrograms) Helps form red blood cells should take a supplement) Helps prevent birth defects of the Fortified cereal, enriched bread and brain and spine. pasta, peanuts, dark green leafy Folic acid (600 micrograms) Supports the general growth and vegetables, orange juice, beans. Also, development of the fetus and take a daily prenatal vitamin with 400 placenta micrograms of folic acid. Prenatal Vitamins. (ACOG, 2022). How much should I eat during pregnancy? If you are pregnant with one fetus, you need an extra 340 calories per day starting in the second trimester (and a bit more in the third trimester). That is approximately the calorie count of a glass of skim milk and half a sandwich. Women carrying twins should consume about 600 extra calories a day, and women carrying triplets should take in 900 extra calories a day (ACOG, 2022). Running Head: Self-management in Pregnancy 52 Weight Gain During Pregnancy Rate of Weight Gain in Recommended Total Recommended Total Body Mass Index (BMI) the Second and Third Weight Gain with a Weight Gain with Twins Before Pregnancy Trimesters* (Pounds Single Fetus (in (in Pounds) Per Week) Pounds) Less than 18.5 1.0 to 1.3 28 to 40 Not known (underweight) 18.5 to 24.9 (normal 0.8 to 1.0 25 to 35 37 to 54 weight) 25.0 to 29.9 (overweight) 0.5 to 0.7 15 to 25 31 to 50 30.0 and above (obese) 0.4 to 0.6 11 to 20 25 to 42 Weight gain chart. (ACOG, 2022). Running Head: Self-management in Pregnancy 53 Ways to Manage Common Issues During Pregnancy The body undergoes many changes during pregnancy and these changes may result in some uncomfortable symptoms. Most of these discomforts will resolve once the baby is delivered. Below is a list of commonly occurring symptoms of pregnancy. Swollen Feet/ Ankles: Elevate your feet frequently, exercise, wear loose clothing and shoes, wear compression stockings, drink plenty of water and avoid salt. Leg Cramps: Increase Calcium in your diet (foods high in calcium- milk, yogurt, cheese, green leafy vegetables), elevate legs, stretch frequently, use heat or massage, make sure you have been taking in enough salt. Hemorrhoids: Elevate feet and pelvis when having a bowel movement, drink plenty of fluids, eat plenty of whole grains, fruits, and vegetables, apply cold compresses with witch hazel. Backache: Pregnancy hormones cause joints to stretch. Try standing tall to improve your posture, rest with weight off your back, wear supportive shoes, sleep on a firm mattress, exercise, stretch, and avoid standing or sitting for extended periods of time. Use ice or moist heat to painful areas or soak in a warm bath. Sleep on your side with back supported and pillow between knees to support hips. Shortness of Breath: Because of increased blood volume and the increasing size of your fetus, it is not unusual to experience shortness of breath, especially with exertion. Use good Posture, sit upright with your chest pointed up, take frequent rest breaks. Running Head: Self-management in Pregnancy 54 When to contact your provider Ways to Manage Common Issues During Pregnancy Heartburn: Eat small frequent meals instead of 3 large meals, sit up straight after meals, sleep with upper body propped up, sip milk or hot tea. Avoid acidic and spicy foods. Varicose Veins: Twisted or enlarged veins. Elevate legs when laying or sitting, use support stockings, and walk daily. Try to avoid crossing your legs. Constipation: Eat more green leafy vegetables and whole grains, increase water intake, walk daily, eat prunes, and fiber (including supplements like Metamucil) raise feet on a stool when having a bowel movement. Nausea/ Morning Sickness: Increase intake of Vitamin B6, eat small frequent meals every 2-3 hours, drink lesser amounts of fluid often throughout the day, try bland foods like dry toast or crackers, potatoes, and noodles. Avoid greasy, fried, spicy, or hot foods. Ginger root tea, ginger gum, ginger ale, and capsules can help minimize nausea. Acupressure bands to pressure points on the wrists may also help. If your nausea and vomiting continue after trying lifestyle changes and OTC meds, you may need a prescription. Contact your provider during business hours to develop a plan. Insomnia (Inability to sleep): Take a hot bath, set a bedtime routine, avoid TV or cellphones while in bed, try herbal teas like chamomile, avoid caffeinated beverages especially towards bedtime. Running Head: Self-management in Pregnancy 55 Ways to Manage Common Issues During Pregnancy Mild Headaches: Use neck roll exercises, relaxation techniques, soothing herbal teas, alternate hot and cold showers, neck massage, and Tylenol. Make sure you are drinking at least 6-8 large glasses of water daily. Magnesium is an element that can help prevent headaches, leg cramps, promotes sleep, and can calm nausea and morning sickness. Talk to your provider about magnesium supplementation as every pregnancy is different. Bladder infection: Drink lots of water and increase acidic foods and beverages like cranberry juice, increase vitamin C, pay strict attention to hygiene, wear cotton underwear, urinate after intercourse, and do not hold your bladder. Yeast Infections: An itchy, clumpy white vaginal discharge that can be prevented by using plain yogurt or acidophilus capsules in the vagina. Wear cotton or breathable underwear. Avoid tight clothing, highly fragranced soaps, or cleansers. Round Ligament Pain: A sharp or jabbing pain on one or both sides of the abdomen, usually during the 2nd trimester. You can wear elastic belly bands, do prenatal yoga, or rest frequently to alleviate symptoms. Intercourse: You can have sex while you are pregnant, however, make sure that your vagina is well lubricated (you might need to try a water- based product), and you may need to try various positions (side-lying, on top, standing, or on your hands/knees) to be comfortable. Talk to your partner about what feels good and what does not. Avoid sex if you are leaking amniotic fluid, bleeding heavier than spotting, in pre-term labor, or have been diagnosed with placenta previa. Oral sex is okay if there are no active herpes lesions. Running Head: Self-management in Pregnancy 56 Recommended Online Resources http://www.kellymom.com http://www.cdc.gov/pregnancy.html https://evidencebasedbirth.com https://www.llli.org https://www.acog.org/womens-health/pregnancy/during-pregnancy When to contact your provider Below are some of the more serious conditions that pregnant individuals may experience. Should these symptoms go untreated, you and your unborn child are at risk. It is important to be open and honest with your provider to ensure the best outcome for you and your baby. Absence of Fetal movement- Babies begin moving usually between 16 and 24 weeks. If at 24 weeks, you haven’t felt the baby move, notify the provider. If the baby has been moving but doesn’t seem to be moving as much over a 24-hour period. Notify the provider. Nausea/ Vomiting that will not go away or you can’t keep food or fluids down over a 24-hour period. Running Head: Self-management in Pregnancy 57 When to contact your provider Vaginal bleeding or drainage (not mucous). Severe, continuous headache that won’t go away with rest, herbal teas, or medications. Painful urination- Burning, stinging, difficult to start and stop peeing. Pain in the lower back area. Severe stomach pain- May feel like stabbing or shooting pains that do not go away with rest. You do not gain weight or have weight loss in between visits. Fever higher than 100.1 and unrelieved with Tylenol or tepid baths. New onset of blurred or double vision. Fainting spells or dizziness. You do not urinate as often as usual, and your urine is dark. Swollen face or hands that won’t go away. Feelings of depression or hopelessness, thoughts of self-harm. Running Head: Self-management in Pregnancy 58 Be engaged during appointments It is important that you take an active role during your appointments. You should try and take notes on things that are discussed with your provider during your appointments. You should also try and produce several questions prior to each appointment to ask during your appointment and write them down in the sections provided. At the appointment write down the answers to your questions. This will help you learn more about your pregnancy while also getting some of your concerns answered while meeting with the provider. Some frequent questions asked may include: Can I exercise while I am pregnant? What foods should I avoid while pregnant? What pregnancy books would you suggest I read? It is encouraged that you produce some of your own as well! ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 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______________________________________________________________________________________________________________ _____________________________________________ Running Head: Self-management in Pregnancy 62 References American College of Nurse-Midwives. (2017). Sex during pregnancy. Journal of Midwifery & Women’s Health, 62(5), https://doi.org/10.1111/jmwh.12677 American College of Nurse-Midwives. (2016). Nausea and vomiting during pregnancy. Journal of Midwifery & Women’s Health,61(2), https://doi.org/10.1111/jmwh.12451 American College of Nurse-Midwives. (2015). Alcohol and Pregnancy. Journal of Midwifery & Women’s Health, 60(1), https://doi.org/10.1111/jmwh.12286 American College of Nurse-Midwives. (2016). Folic acid in pregnancy. Journal of Midwifery & Women’s Health, 61(6), https://doi.org/10.1111/jmwh.12584 American College of Nurse-Midwives. (2017). Back pain during pregnancy. Journal of Midwifery & Women’s Health, 62(1), https://doi.org/10.1111/jmwh.12597 American College of Nurse-Midwives. (2009). Taking good care of yourself while you are pregnant. Journal of Midwifery & Women’s Health, 54(6). https://doi.org/10.1016/j.jmwh.2009.08.019 American College of Obstetrics and Gynecology. (2022). Nutrition during Pregnancy. https://www.acog.org/womens-health/faqs/nutrition-during- pregnancy Centers for Disease Control and Prevention (CDC). (2021). During Pregnancy. https://www.cdc.gov/pregnancy/during.html Running Head: Self-management in Pregnancy 63 Makrides, M., Crosby, D., Bain, E., Crowther, C. (2014). Magnesium supplementation during pregnancy. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD000937.pub2 Pregnancy & When to Call During the First Trimester. (2018, January 1). Cleveland Clinic. https://my.clevelandclinic.org/health/articles/9699-when-to- call-your-healthcare-provider-during-your-first-trimester-of-pregnancy Running Head: Self-management in Pregnancy 64 Appendix E Organization of Correspondence Date Time Format Appropriateness Running Head: Self-management in Pregnancy 65 Appendix F Ishikawa Fishbone Diagram Running Head: Self-management in Pregnancy 66 Appendix G Timeline Task August September October November December January February March April IRB approval X Development X of Evidence based handout Dispersion of X X X handout Evaluation of X X Results Running Head: Self-management in Pregnancy 67