 So Siwet a I'd like to introduce to Cecilia Davies, who is the associate professor at Yale University. She's going to be talking about maybe those who are interviewing. Siwet, that's what I'm going to say. Cecilia has practised my degree and applied that for 30 years and she just recently moved to Metricrit in January and she directs the Mid-degree Education Program at Yale University. This special interest is optimising late day in present day. Cecilia, thank you so much for joining us today at the Metricrit in seven years. And I'd like to pass over the mic to you now. Thank you. Thank you, Sarah. I am so excited about being part of this international day, happy international day of the midwife to all of you. I will admit it's a little daunting to be a speaker late in the day after all of the wonderful presentations that have come from the other midwives who spoke before me. It's four in the afternoon here in Connecticut. It's spring, I think, for a lot of you on the other side of the planet. You're going into winter. And I just have to say it's a beautiful afternoon here. Thank you for those who have stuck with the presentations for so long. Motivational interviewing. Sarah, I'm trying to move my slides along and they're not going. There we go. Thanks. Motivational interviewing is a technique for talking with women and patients. I'm going to talk about some assumptions first because I can't talk about everything in the time we have this afternoon. First of all, I'm making the assumption that you all understand that excessive weight gain causes complications throughout the perinatal period through birth, through postpartum, and even into later life for the mother and the baby. Excessive weight gain causes the same and as many complications as women who have a body mass index of 30 or greater at the start of pregnancy. We also make the assumption that the way we talk with women about their health influences their behavior. During the presentation I will refer to some weight gain recommendations and those come from the United States Institute of Medicine guidelines for weight gain and pregnancy. They're available online. You'll also notice some photos of women in my slides. Those are used with permission. The photos of women come from the Yale Rudd Center for Obesity Prevention and Prevention of Bias Against Obesity. They have a wonderful photo bank that anybody can access as long as they're using the slides for healthcare. Motivational interviewing is a type of counseling style that's patient-centered and it strives to discover patient motivations for change. Patient motivations are used as the base for behavior change. Motivational interviewing was first developed in the 1980s for use with problem drinking. It has been tested and it's particularly been tested with conditions requiring diet modification. It's been tested in diabetes, hyperlipidemia and high blood pressure. I don't see literature specifically testing it in pregnancy but it gives me a little time. Health care is increasingly chronic disease management that requires behavior change. We are with women over the duration of the pregnancy in the postpartum period so motivational interviewing is a good tool for us to use. The first precept of motivational interviewing is that no patient is completely unmotivated. Sometimes we look at women who come to pregnancy with excess weight and think they really don't care about what happens to themselves. In pregnancy we have the added bonus of mothers being motivated to help their babies. Even some of the mothers with the fewest resources will do almost anything to improve the health of their babies. Motivational interviewing is a style that's about guiding, not directing. It's about listening as much as talking and listening can be as much work as spouting health care facts to women. Directing is giving commands. Directing is giving advice with concrete health facts with the expectation that women will follow whatever we say at them. We need to take on a guiding style. So we can think about what words would we avoid if we're guiding. Another way of asking that question is what phrases are directive? What kind of borders on commands? What are those that we could avoid? In motivational interviewing we try to avoid phrases like this, commanding phrases. You have to, you should, you need to, you must. Let me give you some examples of how those sound when we're talking about weight gain in pregnancy. You might hear somebody saying you have to eat five to seven servings of fruits and vegetables a day. You should only gain 25 to 35 pounds during pregnancy. Or you need to reduce your weight gain. Or you must stop bringing sodas in pregnancy. They're just not healthy. Let me give you a little bit more of a contrast between a guiding versus a directing style. In a directing style somebody might say at your pre-pregnant weight you should only gain 15 to 20 pounds during this pregnancy. 15 to 20 pounds is roughly seven to nine kilograms if I'm doing my math correctly. In a guiding style a midwife would say what target weight gain were you thinking about for this pregnancy? That acknowledges that the woman is in charge of her pregnancy and also that women know something about pregnancy. They come to us with some ideas of what prenatal weight gain will be like. In a directive style a midwife might say pregnant women need to eat five to seven servings of fruits and vegetables per day. In a motivational interviewing guiding style the midwife would say tell me about how you like to eat your fruits and vegetables. They have the vitamins and minerals that the baby needs. So you'll see that from some of these phrases particularly the last one there was an open ended inquiry. Tell me about how you like to eat your fruits and vegetables. Then there was a bit of information and the assumption that everybody eats at least one fruit or vegetable. The second precept of motivational interviewing is that we all have goals and aspirations and that's still true in pregnancy. Think for a minute what are your goals for mothers weight gain when you're talking to them in prenatal care? What do you hope that your patients will do with their nutrition and their weight gain during the pregnancy? Hidden goals are our motivations. They're what make us move. So these might be some midwife's goals. The midwife's goal might be to lower prenatal complications, lower pregnancy complications and birth complications for the mother with an optimal weight gain. A midwife's goal might be for the mother to gain just what's necessary in pregnancy to improve her future health and the future health of the baby to gain just what's needed to reduce future obesity and diabetes. I have to admit I'm going to take a little pause. I'm seeing some of the typing that's going on about the use of language. In addition to being a midwife, I'm a medical anthropologist so you know linguistics is very important to us. My husband is a clinical social worker and I asked him to read these slides as I was putting the presentation together. He said to me, when did you get so good at psychodabble? I said to him, could be four years with you, but it is one of my real interests in the grocery. We've looked at what healthcare workers' goals are often for the mother. We have these implicit goals. If we didn't have them, we wouldn't do this work. How consistent do you think the women that we care for's goals are with ours? Give a little bit of thought about the women that you've cared for over the years. Have you discovered some of their different motivations? Here are some examples from the women that I've worked with on weight gain over the years. If I hadn't been open to listening to them, I wouldn't have discovered this. One young mother was in high school and she was going to have her baby just before the first of the year. Her goal was to keep her weight gain low but healthy. She wanted to fit into a prom dress and an attractive prom dress after the baby was born. Another mother I worked with had had a previous baby that was larger than 4,000 grams and the labor was kind of tough. She knew that her weight gain influenced the birth weight of the baby. She wanted to try to have a smaller baby this time by watching what she ate. Another woman wanted to keep her figure better than the figure of her ex-husband's new wife. The ex-husband's new wife was also pregnant. They lived in a small town. They saw each other all of the time and there was a little competition going on between these two women. Another patient recently said to me that she wanted to keep her weight gain healthy because she wanted to stop her husband nagging her about her weight. And yet another woman said, I want to gain just a little bit now. I was talking to her in early pregnancy. I want to gain a little now. My husband and I are going on a wedding anniversary cruise when I'm about 28 weeks pregnant. And I want to be able to pig out on those cruise ship buffets. So there was a woman who wanted to plan her weight gain and really gave us something to work with. Now, when you think about what these mothers said to me, they don't fit what most midwives would think of as health-related goals for pregnancy. But these were the mother's motivations and they were the goals that would really move them towards some healthy nutrition in pregnancy. Another part of motivational interviewing rests on open-ended questions. I bet most of us somewhere in learning about health care learned about open-ended questions, but it never hurts to do a little bit of a review. Open-ended questions can't be answered with yes or no or single-word answers. So you might take some of the phrases you use often in prenatal care and think about whether they're really open-ended or not. Think about ways of rephrasing them. Open-ended questions start with phrases such as describe to me, tell me about. Can you share with me how would you? What do you think about or let's talk about? For example, you might say to a woman, describe to me the dinners you cook often. Tell me about your favorite foods. That question, tell me about your favorite foods, is one that helps us tailor nutrition in pregnancy so that it's culturally competent and relevant for women. Can you share with me what's most difficult for you in avoiding fatty foods? What do you think about dropping a soda a day? So contrast that with saying to a woman, you must stop drinking sodas. Instead of what do you think about dropping a soda a day? Our work with women needs to be individually relevant to be most effective for them. And if we can discover their motivations, that helps our conversations be relevant. So here's a woman who's had a previous pregnancy. At the first prenatal visit, the midwife asks her, what was your weight being like with your first pregnancy? And the mother has the response of, oh, I gained a lot, 45 pounds. But I lost it all. And you might think that that's the end of the conversation because here's a mother who put on excessive weight. 45 pounds is about 20 kilograms. But she said she lost it all. It sounds like she's not interested in prenatal weight gain. So the midwife does a bit of informing and says too much weight gain can be risky for you and the baby. What did you do to lose the weight? We want to find out about how this mother was successful. Her response is, I had to like stop eating. It took so long. And now I've gained a lot back. I don't want to do that again. Now the midwife has discovered a hidden motivation for this mother. So she does a little bit of informing. All you and the baby need for a healthy pregnancy is 20 to 25 pounds of gain. What sorts of things do you think you can change to make this pregnancy's weight gain a little lower? So we followed a bit of information with another open-ended question. Once again, recognizing the women are likely to have most of their own answers. We need to validate those answers for them and give them permission to take charge of their solutions. I'm just looking at one of the comments about mothers being harassed about weight gain. I did practice midwifery in the period where in some practices we stopped weighing women entirely. And I realized many of you are providing care to women in places where there's not enough for women to eat. I always feel a little bit apologetic when I'm doing these international presentations. We don't want to harass women. And hopefully use of motivational interviewing is a less threatening, non-harassing way of conversing with women. We do know here in the United States and in most post-industrialized nations that 70% of women gain more weight in pregnancy than they or the baby need. It makes them and the children prone to subsequent obesity, diabetes, and heart disease. So much of my interest in this work is presented of health care that helps women and their families change for a lifetime. Here's another example. This one is from a mother who's a first-time mother. And this is her first prenatal visit. She started the pregnancy with a body mass index of 34. So she's technically obese. And from the prenatal history, we find out that her mother has diabetes. So there's a little bit of information from the midwife saying the risk for diabetes tends to run in families. And then it's followed by an open-ended question. What can you tell me about your mother's diabetes? And the patient says she used to be okay with just cutting out sugar. Now she uses insulin. I don't ever want to use those needles. So now we've discovered a motivation from the young woman. She's afraid of needles and she wants to avoid insulin. So the midwife uses a phrase, some information that's empowering. A healthy weight gain in pregnancy, one that's just what you and the baby need, can lower your future risk of diabetes. Now followed by some open-ended inquiry. Let's talk about your usual meals. And the third example, another mother who's already had one child. That child had a birth weight of 10 pounds three ounces, about 4.6 kilograms. And the birth was a low-transverse Assyrian section. So the midwife wants to know a little bit more about that labor and birth and says, tell me what your first labor was like. The patient describes a long labor with a pitocin augmentation and a three-hour stage two. And she says to the midwife that this time she wants a vaginal birth. She wants to be back. It mirrors her motivation. This is what's most important to her. And the midwife can help her form a plan that can increase her chances of success with a vaginal birth. So the midwife gives some information. The baby's birth weight is proportional to your weight gain and asks for a little more information. Tell me what your weight gain was like in that pregnancy. I'm hoping that you see from my example that motivational interviewing uses a great deal of open-ended inquiry. It's informing not concrete directions. And it tries to be empowering. Can I answer any questions so far? If you type them in, I can see them and answer them. There's a question. Do they allow a three-hour second stage? Yes, and I will say to you that my midwifery experience is all hospital experience. Sometimes I've worked in community hospitals that are very basic. They're more like rural birth centers. I've also worked in tertiary-level hospitals. And particularly in our hospitals, if women have at the girls in place, as long as the mother and the baby look healthy, second stage may continue on beyond an hour or two hours. We will strive for a vaginal birth when we're providing midwifery care. Thank you, Sonia. Sonia is saying that women should not be scolded for gaining weight during pregnancy. Unfortunately, at least here in the United States, that's something we need to teach our midwives and physicians, because many of them are in scolding mode. I think I'm going to move on a bit because I can show you an example of what Verge is on scolding behavior. If you read some authors about motivational interviewing, they talk about four principles that use the acronym RULE. The first part of RULE is to resist the writing reflex. The writing reflex is what happens when we try to jump in and fix everything for women. The writing reflex is rampant in healthcare. We wouldn't be in healthcare if we didn't want to help people. But we have to acknowledge to ourselves that we can't fix everything. The new in RULE is for understanding. We need to explore women's own motivations and accept their motivations. We don't have to be the expert. L in RULE stands for listen, listen with empathy. Good listening is work. E stands for empower, empowering the patient. I'm preaching to the choir when I talk with midwives, particularly those who've been listening to presentations all day about empowering women. And E also stands for encouraging hope and optimism. Motivational interviewing is a glass half full strategy. It's based on being optimistic. Let's talk about Mira as a young woman who started prenatal care at six weeks gestation. She was 24 years old. It was her first pregnancy. And when she came in for her 32 week prenatal visit, she had gained 38 pounds. That's about 17 kilograms. The midwife had been working very carefully with Mira about her weight gain. And the midwife was really frustrated with how much weight had been gained. She told Mira at the first prenatal visit that based on her body mass index, her prenatal weight gain should be about 15 to 20 pounds. That's about seven to nine kilograms. That's probably a much lower target weight gain than many of you are used to in pregnancy. But that's our newer recommendations for women who already have excess weight as the pregnancy starts. So the midwife was so frustrated. She had given Mira meal plans at the previous prenatal visit. She wanted us to say to Mira, cut your intake in half and join prenatal weight watchers. But using motivational interviewing, she resisted the writing reflex. That would be the quick fix. That would be to say, keep trying those meal plans. And she started to explore Mira's motivations. So she said, we talked about some meal plans at your last visit. How did it go using them these last two weeks? And then she did some listening with empathy. The meal plans weren't really easy for Mira. She found out that they were more time consuming to assemble than she thought they would be. When it came to packing a lunch and taking it to work, it turned out that the food she was packing at home was more expensive. Than buying a hamburger and fries that were on sale just around the corner. And when Mira packed lunch for work, she couldn't keep it cold at work. Work didn't have a refrigerator. And the food wasn't cold at lunchtime, so it was unappetizing for her. Here's a question. What weight gain guidelines am I referring to? I'm referring to the United States Institute of Medicine guidelines. They're available over the internet. Google or search Institute of Medicine guidelines. I'll come back to them when I'm done with this presentation. It looks like I'm going to have time. So finding out basically what Mira's obstacles were, the midwives can investigate them a little bit more closely. So for Mira, the meals took too long to assemble. So we want to encourage Mira and say, that's great that you tried the meals we talked about. You found some drawbacks like the meals took too long to assemble. Now we're going to empower Mira again. Can you think of some ways you might get around that? We've given permission for a strategy not to work. Sometimes our best plans don't work out and that's okay. We continue to say that she gets home from work and she gets too hungry while she's preparing dinner after work. There is more active listening going on. So a little bit of informing from the midwife. She says to Mira, what do you think about having a small snack, a little appetizer while you're preparing dinner? Maybe half an apple and a glass of water. Mira's something forming that gives Mira something else to try. The midwife asks Mira how she usually prepares her food. As it turns out, Mira thinks that dinners have to be cooked and the way she learned to cook was on a stove top and it takes her a long time. So the midwife thinks about some other strategies. Could Mira microwave some of the food? Could she cook double portions that might be eaten the next night or later in the week and they would only need reheating instead of cooking from scratch? Could an extra portion be frozen for heating up later on? Some of this may seem very basic, but if we don't talk about eating in pregnancy with women, it's business as usual. They carry on with their usual nutrition patterns. If we can find motivators, the pros in their lives, we can help move them toward change. If we dictate to women, they move towards the con. They become defensive and they push themselves away from change. So if the midwife spouts health care and nutrition victims and doesn't take the woman into consideration, the woman becomes self-protected. She gets defensive and she reacts with cons. Here's an example of what might have happened with Mira. The midwife might have said, we talked about some planned meals to help keep your weight gain down at the last visit. Did you use them? You know this weight gain is risky for you and the baby. That would push Mira to say something like, they're too hard. I don't have the time to do them when I get home from work. It's 6.30 and I'm starving. Then I have to wait for the rice to cook? No. It's easier to get a burger and fries and eat it on the bus home. I don't want you to think that motivational interviewing is the perfect cure-all for everything. After I sent these slides to Sarah to post, I had an experience in the clinic where motivational interviewing failed. I want to give you that example. I was in the clinic this week and I had a student midwife with me. We were seeing a woman together. She had two previous uncomplicated pregnancies. It was about 3 o'clock in the afternoon. This woman was about 30 weeks pregnant and she had gained 34 pounds, about 15 kilograms. The student started a conversation that was related to weight. She said to the woman, are you eating seven fruits and vegetables a day? The woman said, no. The student said, what vegetables do you like to eat? The woman replied, none. I decided it was my time to step in. Here's an example of the writing reflex. I feel like this conversation needs to be redirected. I had a responsibility to the student and I thought I might be able to model a little bit different conversation for her. I said to the mother, tell us about what you've eaten today. She said, nothing. I said, nothing. It's late. Do you have a schedule where you sleep later in the day and are up at night? Many of the women we care for are up at night, sometimes working, sometimes waiting for their partners to come home from work. They sleep in and they might not before they come in to see us. The woman just gave me a blank look and shrugged. I said, okay, let's talk about yesterday. What did you eat yesterday? The children wake up and you give them some breakfast. And she said, no. At that point, I just gave her a questioning look. I thought talking about starting the children's breakfast would be a way into the conversation. I didn't say anything. I gave her time. I was listening and she said, I don't have custody of my children. So then I needed to acknowledge that that was hard and I said to her, I'm sorry, that's hard. And I paused a minute and she said, I spend a lot of my day with lawyers and in court. Clearly we didn't have this in the prenatal record anywhere and nutrition and weight gain in pregnancy wasn't a priority for this mother. So I said to her, there are several social workers and counselors here. Would you like us to help you arrange a visit? And we moved off in another direction. Motivational interviewing isn't the perfect cure-all for everything. Time is short. Motivational interviewing takes time. Now remember that I come from a whole country, 50 states, where healthcare is for profit. So time is money. We can use some pacing phrases when we need to shorten the visit. I'm sure you all have worked with women. Talking with them is like turning on a faucet. You start the conversation and you are hard pressed to do anything but agree with them. So here are some pacing phrases. You might say to a mother, we've talked about several things. Let me see if I'm remembering them correctly. And then the midwife briefly summarizes issues. Or you can say to a mother, let's write down the things you want to try before the next visit. They could be written down in the paper record, in the electronic record, or you could write them down for the mother to take home as a reminder. We can acknowledge that sharing information can be difficult. So we can say to mothers, thank you for sharing that information with me, particularly when the information involves a mystical or something that was difficult for them. Motivational interviewing doesn't have to stop after the pregnancy. We can summarize women's successes and do some anticipatory guidance with them about what weight gain will be like after the pregnancy. We know from weight management therapy, outside of pregnancy, that most people regress to old eating behaviors after about six months' time. Maybe in the system that you're working in, referrals can be made for mothers to primary care so that if they need continued health with weight management, that support is there for them. Motivational interviewing can be woman-centered and directed, but not directive. It's individualized, it's culturally competent, it can be empowering, and it's great midwifery care. I'm willing to take any questions that you all have about motivational interviewing in our time left. I really regret that I haven't been able to keep up with all of the typing that's going on. You're giving each other some excellent information. Cecilia, thank you so much for that. If you're interested, I can always go and do transcripts with that. If you're interested, I can do that after the conference. What a fabulous session. I don't know about anyone else, but I feel a bit obliged for more reason I'm never going to admit this, but you certainly give me some things to think about. I love having that framework to hook my questioning on to, but it's been a fantastic session. We've got just a couple of minutes left, I'm afraid. Is there anyone who's got a particular question you'd like to ask Cecilia? Anybody who wants to put the mic and make a quick comment or ask a question at all? Have we evaluated the guidance with clients? We're striving to be very evidence-based here in the United States, and that's why I put in, in the beginning of the presentation, that motivational interviewing has been tested with a variety of weight management healthcare scenarios. I haven't tested it with my own patients. I'm new to Yale, and this is work I'm hoping to do in the future. Which would involve randomising women to other people's practice and midwives who are using motivational interviewing? I'll go to a quick question. I don't know if this can be yet, but I'm going to ask it anyway. Can this be used in the same language with my team? It can be. There is some literature about using motivational interviewing and smoking. There's also a smoking abatement technique called the 5Rs. I'm going to be talking about that at the annual meeting of the College of Nurse-Midwives. If I can get some time away from teaching and practice, there are two manuscripts sitting on my desk about the 5Rs that were used in smoking cessation and applying it to healthy weight gain in pregnancy. It's kind of a generalisation, but techniques that work for smoking cessation are usually helpful with weight management. Thank you very much indeed, Cecilia. I really appreciate your support of this conference and being with us for so many hours today. I'm afraid we've run out of time as much as I know what we could talk about this further. We're just getting the point to get rid of our absolute last lesson and to build a conference for them. Cecilia, once again, a huge thank you to you. So, we've got about 10 minutes to prepare for our absolute last lesson. It's a winter glorial of May, and she's going to be talking about it completely, so maybe we can see a lot of interest in this lesson. So, you've got 10 minutes for a quick get-up and a wander around to pick your legs and do that place-to-store, rub your bum, place-to-store management, and then we'll be heading off to our final lesson. Thank you all.