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Strong Study (Strong Together Raising Our Next Generation) (American Samoa)

In American Samoa, 86% of women enter pregnancy overweight or obese compared to 42% of the general US population. Pre-pregnancy overweight and obesity and excessive gestational weight gain are linked with a number of poor pregnancy outcomes for mother and infant - cesarean delivery, gestational diabetes, and excessive birth weight – as well as longer term chronic diseases such as hypertension, or heart disease.
Efficacious and sustainable interventions are critically needed to (a) change non-communicable disease (NCD) trajectories for women who are already overweight/obese upon entering pregnancy, and (b) prevent maternal obesity-related NCD in their infants. This study will incorporate a lifestyle intervention to prevent NCD into a widely validated, insurance supported group prenatal care model.

In the STRONG (Strong Together Raising Our Next Generation) study we will use an outcome assessment blinded randomized controlled trial design to compare the effectiveness of group prenatal care versus standard one-on-one care for the following outcomes: gestational weight gain, gestational diabetes screening, and breastfeeding at six weeks postpartum.

The study will take place at the Lyndon B Johnson Tropical Medical Center, Pago Pago, American Samoa

Timeline: This study will be actively recruiting participants between August 2017 and February 2018 in American Samoa

Investigators: Nicola Hawley, Bethel Muasau-Howard [Lyndon B Johnson Tropical Medical Center], Rochelle Rosen [Brown University], Elizabeth Triche & Alysa Pomer [both Yale University]

Funding Source: National Institutes of Health, National Institute for Nursing Research 1R21NR016352-01A1

Relevant Publications:

If you can not access any of the full publications, please reach out to Nicola Hawley

1. Gestational weight gain among Samoan women and its impact on delivery and infant outcomes.

Hawley, N.L., Johnson, W.O., Hart, C.N., Triche, E.W., Muasau-Howard, B., & McGarvey, S.T. (2015). BMC Pregnancy and Childbirth 15: 10-17.

This paper described gestational weight gain (GWG) among American Samoan women and examines the association between GWG and four adverse pregnancy and infant outcomes: cesarean delivery, small- and large-for-gestational age (SGA/LGA), and infant overweight/obesity. The findings show 86% of women studied were overweight or obese in early pregnancy and greater GWG in the 2nd trimester and early pregnancy weight were independently associated with increased odds of a c-section. This paper recommend that physicians in American Samoa encourage women into prenatal care early and begin education about appropriate GWG and the potential risks of excess weight gain for both the mother and baby.

2. Mothers’ attitudes and beliefs about infant feeding highlight barriers to exclusive breastfeeding in American Samoa.

Hawley, N.L., Rosen, R.K., Strait, E.A., Ruffuci, G., Holmdahl, I., Freeman, J.R., Muasau-Howard, B.T., & McGarvey, S.T. (2015) Women and Birth 28 (3): e80-86.

This study examined American Samoan mothers' feeding experiences, attitudes, and beliefs about infant feeding and to identify potential barriers to exclusive breastfeeding. Through 18 semi-structured interviews with American Samoan mothers several weeks postpartum, we found that intention to breastfeed did not predict practice. The identified barriers to exclusive breastfeeding included: the convenience of formula, perceptions among mothers that they were not producing enough breast milk, and pain while breastfeeding. The study highlights barriers to exclusive breastfeeding can be immediately addressed by providers of breastfeeding support services.

3. An evaluation of gestational diabetes mellitus screening practices in American Samoa.

Freeman, J., Thompson, K., Muasau-Howard, B., McGarvey, S.T. & Hawley, N.L. (2015) Pacific Journal of Reproductive Health 1 (2): 68-73

The study evaluated the adequacy of gestational diabetes screening among pregnant women in American Samoa through the review of 622 clinical records to determine: whether or not the patient was screened, the week of gestation in which the screening occurred, and the type of screening the patient received. According to the findings, only 16.2% of women received adequate gestational diabetes screening. This study highlights the critical need for improved screening in this high risk population and urges that the causes of inadequate screening be identified and that interventions be targeted at both patients and clinicians.

4. Conceptions of pregnancy health and motivations for healthful behavior change among women in American Samoa.

Kocher, E., Sternberg-Lamb, J., McGarvey, S.T., Faiai, M., Muasau-Howard, B.T. & Hawley, N.L. (2017) Women and Birth 31: e32-e41.

This study aimed to understand American Samoan women's conceptions of health during pregnancy, their motivations for pregnancy behavior change, and the role of their family in both enabling and preventing these changes. Using eighteen postpartum women’s semi-structured interviews, we found participants expressed a Westernized conception of health during pregnancy that focused on eating a balanced diet and exercising regularly and described external motivations for adopting healthy behaviors, most notably the perceived benefit to their baby. These findings show pregnancy is an opportune moment for health behavior intervention and suggest future efforts should capitalize on external motivations for behavior change and encourage the development of internal motivators.