Dorothy Brewin, CNM, PhD and Angela Nannini, PhD, FNP-C, FAANP


ON Falls AND

Fall Prevention DURING PREGNANCY Abstract Background: Falls are the leading cause of unintentional injury in women. During pregnancy, even a minor fall can result in adverse consequences. Evidence to inform effective and developmentally appropriate pregnancy fall prevention programs is lacking. Early research on pregnancy fall prevention suggests that exercise may reduce falls. However, acceptability and effectiveness of pregnancy fall prevention programs are untested. Purpose:To better understand postpartum women’s perspective and preferences on fall prevention strategies during pregnancy to formulate an intervention. Methods:Focus groups and individual interviews were conducted with 31 postpartum women using descriptive qualitative methodology. Discussion of falls during pregnancy and fall prevention strategies was guided by a focus group protocol and enhanced by 1- to 3-minute videos on proposed interventions. Focus groups were audio recorded, transcribed, and analyzed using NVivo 10 software.Results:Emerging themes were environmental circumstances and physical changes of pregnancy leading to a fall, prevention strategies, barriers, safety concerns, and marketing a fall prevention program. Wet surfaces and inappropriate footwear commonly contributed to falls. Women preferred direct provider counseling and programs including yoga and Pilates. Implications:Fall prevention strategies tailored to pregnant women are needed. Perspectives of postpartum women support fall prevention through provider counseling and individual or supervised exercise programs. Key words: Fall prevention; Focus groups; Patient education; Postpartum; Pregnancy; Safety; Unintended injury. 300

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alls are the leading cause of nonfatal unintentional injuries in women of all ages who sought treatment in an emergency room (Centers for Disease Control and Prevention, 2013). During pregnancy, falls have been identified as the most common cause of minor injuries, and only slightly less common than motor vehicle collisions in both severe and minor trauma (El Kady et al., 2004; Fischer, Zarzaur, Fabian, Magnotti, & Croce, 2011; Tinker, Reefhuis, Dellinger, & Jamieson, 2010). Falls during pregnancy and postpartum may have harmful consequences for both mother and fetus (Barraco et al., 2010). Schiff (2008) reported that pregnant women hospitalized after a fall, as compared to a random sample of pregnant women who had not experienced a fall-related hospitalization, had elevated rates of preterm labor (relative risk [RR], 4.4), placental abruption (RR, 8.0), labor induction (RR, 1.9), and cesarean births (RR, 1.3). Significant fetal outcomes for pregnant women who experienced a fall included twice the incidence of fetal “distress” and hypoxia than pregnant women who did not fall. Most concerning, studies suggest that an adverse pregnancy outcome is difficult to predict based on the degree of injury from a fall (Fischer et al., 2011). During pregnancy, 17% to 39% of women seeking emergency department or hospital care for a minor injury report falling (Dunning, LeMasters, & Bhattacharya, 2010). There are many risk factors for falling during pregnancy. Some of them are: women under 18 years of age, as compared to older pregnant women (odds ratio, [OR] = 2.8); having less than a high school education or a low household income; being diagnosed with a seizure disorder; lacking a permanent partner; reporting alcohol use (not binging); and having one or more toddlers (Dunning et al., 2010; Tinker et al., 2010). Pregnant workers in food service, teaching, nursing, and caretaking have the highest risk of falling (Dunning et al., 2003). Other contributing factors to falls are stairs, slippery floors, uneven ground, rushing, poor lighting, clutter, bathing, and intentional or accidental pushing (Dunning et al., 2003). Physiologic changes of pregnancy may contribute to the increased incidence of falling during pregnancy. Changes include a 25- to 30-pound recommended weight gain (Institute of Medicine, 2009), most of which is distributed in the abdominal area; a growing uterus that often results in diastasis of the abdominal muscles; and hormone fluctuations triggering ligamentous laxity in lower extremities and hyperlordosis of the lumbar spine (Borg-Stein, Dugan, & Gruber, 2005). These changes contribute to a shift in a woman’s center of gravity and result in dynamic instability. Other biochemical and physiologic changes, such as low blood sugar and orthostatic hypotension, may result in dizziness and fainting (Ward & Hisley, 2011). Biomechanical adaptations during pregnancy can also lead to an increase in risk of falling. In a prospective casecontrol study to assess postural stability during pregnancy and postpartum, postural stability declined after the 1st trimester of pregnancy and into the postpartum period (6–8 weeks) compared to nonpregnant women (P < 0.05) (Butler, Colón, Druzin, & Rose, 2006). The researchers recommended that fall prevention strategies include

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improving postural stability. Jang, Hsiao, & HsiaoWecksler (2008), measuring postural sway, perceived sense of balance, preferred stance and width, and history of falling, reported a perceived and actual decline in standing balance related to anterior–posterior postural sway. To compensate for this change, lateral stability was maintained by increasing stance width during pregnancy. McCrory, Chambers, Daftary, and Redfern (2010) measured postural reaction time and Center of Pressure during pregnancy, defined as the point at which the pressure of the body over the soles of the feet is concentrated when standing in one spot (Butler et al., 2006). They found that women who did not exercise during pregnancy were more likely to fall than women who exercised (P < 0.005) and hypothesized that increased muscle strength related to exercise might reduce falls during pregnancy. More recently, researchers using the same sample as the prior study created mathematical models to measure biomechanical differences between fallers and nonfallers (Ersal, McCrory, & Sienko, 2014). They concluded that higher ankle stiffness in the nonfallers, as compared to the fallers and the controls, contributed to the increased stability in the nonfallers, and suggested that strengthening ankle stiffness may reduce falls during pregnancy. Evidence to inform fall prevention strategies during pregnancy and postpartum is lacking. Also, consumer preferences for specific fall prevention strategies may differ. The purpose of this research is to better understand the perspectives of postpartum women on fall prevention strategies during pregnancy to formulate a fall prevention intervention.

Study Design and Methods This study used a descriptive qualitative methodology (Sandelowski, 2010). Individual and focus group interviews (FGIs) were conducted with postpartum women. Data from FGIs provide rich and detailed information from participants because they stimulate shared discussions based on pooled perceptions of the group rather than individual perceptions. During the FGIs, the research team engaged the participants in a conversation to elicit their experiences with falls and fall prevention during pregnancy, as well as exploring prevention strategies. The FGIs took place in a variety of settings, such as library media rooms, a parenting center, and individual homes. If setting allowed, refreshments were provided. A gift card was offered as an incentive and reimbursement for childcare was provided, as needed. A convenience sample of postpartum women was recruited through flyers posted at health centers, libraries, pediatric and obstetrical offices, an electronic posting on Craig’s List, outreach to parenting education classes and professional organizations, and snowballing techniques. The women were within 1-year postpartum and older than 18 years of age. Consent forms were developed for all participants, including permission to record the session. Participants signed the consent before the start of the group or interview. They could withdraw from the study at any time. Prior to implementing this research, the study was approved by the university Institutional Review Board (IRB). MCN

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A FGI guide, consisting of open-ended questions with probes, was developed based on findings from the literature and the clinical experience of the researchers (Table 1). A physical therapist and obstetrical providers validated the interview guide prior to the focus groups.

Table 1. Postpartum Fall Prevention FGI Questions and Videos Think back to when you were pregnant, were you aware that you could fall? Did anyone talk with you about the possibility of falling during pregnancy? Who was that? Can you remember what they said about falling during pregnancy? Did you receive information about fall prevention during your prenatal care or during prenatal classes? Did you fall during your pregnancies or postpartum? If you fell, what events happened next? Did other people come to your assistance? Did you call your provider? Did you have further assessment at either your provider’s office/health center or hospital? Do you think your fall could have been prevented? During pregnancy, what type of information about falls would you like to know? Did you have problems with your balance during pregnancy? Please describe. We are now going to show you several short videos about prenatal exercises, which might be helpful in preventing falls. After each video, we will have a brief discussion about your thoughts on those exercises. You Tube Videos: Central2Bumps. (2009, Oct 9). Small group ball exercise group demo. Retrieved from Garcia, L. (2010, Sep 20 ). 10 minute prenatal Pilates, part 1. Retrieved from; Hogerzeil, T.(2010, Oct 30). Yoga during Pregnancy without prior yoga experience. Retrieved from Mak, L. (2011, Sep 12). Third Trimester Training with Laura Mak, MS. Retrieved from Russ, J. (2011, Mar 27).Yang styleTai Chi, section 1. Retrieved from; Wendland-Colb, C. (2008, Nov 14). Pregnancy Exercise - Warm Up. Retrieved from Now we will look at the Fall Prevention handout. Do you think that you would read a flyer on fall prevention? Would you follow these suggestions?


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Each focus group had between 2 and 12 participants and lasted about 45 to 50 minutes. One- to three-minute videos obtained from YouTube augmented the discussion of fall prevention strategies. The videos demonstrated visibly pregnant women performing exercises associated with improved balance, such as yoga, Tai Chi, Pilates, balancing balls and group, and individual muscle toning exercises (Table 1). After each video, the researchers asked pertinent questions regarding the video. Women shared their opinions about whether or not they would perform the exercises shown, freely remarking on the risks and benefits of different exercises. The timing of fall education was also discussed. Individuals not able to attend the focus groups were interviewed using the same process. After each focus group, the team met to debrief and discuss the group process. The focus groups and individual interviews were audio recorded and transcribed verbatim. To insure the trustworthiness of the data, graduate student research assistants attended the focus groups and took notes on the group process. Later, they listened to the taped interviews, comparing the typed transcript to the taped group interviews. Corrections to the transcripts were made as needed. Data were later analyzed using NVivo 10 software. During the initial data analysis, both the researchers and the graduate students met collectively to identify early themes and to clarify the coding process. In the next phase, team members individually coded the focus groups. Finally, with all group members present, all the focus group transcripts were reviewed, completing the final coding and theme identification. The focus group transcriptions were not shared with individual group members for validation, because individual contact information was not collected and the IRB did not approve the sharing of group information with individual participants. Four focus groups were conducted between March and November 2012 in order to reach saturation of themes. In addition, there were four individual consumer interviews. The final sample consisted of 31 women.

Results The vast majority of the women (81%) were White, nonHispanic, with a mean age of 33 years. Other selected characteristics of the women are summarized in Table 2. In this sample, 35.5% of the women reported falling during pregnancy and 3% fell postpartum. Of those who reported a fall, only 36% either called their provider or sought medical attention. Only 7% of women reported receiving any fall prevention education.

Major Themes During data analysis, major and subthemes emerged. Circumstances of the fall, contributory physical changes of pregnancy, prevention strategies, barriers, safety concerns, and marketing a fall prevention program were major themes. The subthemes were footwear and weather and general and specific use of exercises methods to prevent falls. Circumstances of the Fall

When discussing fall prevention during pregnancy, many women shared details about their own fall. Participants told stories of falling when not being mindful, rushing, September/October 2014

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carrying children or bundles, or tripping over objects, animals, or children in their path. One woman reported, “I almost fell twice and they were both when I was running.”Another shared,“My friend fell down the stairs holding her son when he was a baby. She really hurt herself but the baby was fine because she instinctively protected him.” Highlighting the fall risk of working pregnant women, a consumer said, “I’m a teacher and I was walking into the office in the morning. I think my shoes were wet from outside. I just I slipped but I caught myself on the counter and my knee just touched down, but then I called my doctor, my midwife… she said as long as the baby is moving it’s alright.” Footwear and Weather

All groups were asked about risk factors for falling. The women participated in a lively discussion of the role of weather, footwear, and other external factors that contribute to pregnancy and postpartum falls. Some consumer comments include:“It was 22 weeks and it was late at night. I had slippers on and I just went sliding”; “I almost fell when I was like 9 months pregnant. It had rained a couple of hours before – I was in flip-flops”; “My boss told me not wear high heels to work anymore….”; “I was like going into one of the trains and it was kind of just like a slushy day …. I just kind of slipped and fell on my butt about the second step down.” Contributory Physical Changes of Pregnancy

Many of the women focused on the physical changes of pregnancy that placed them at an increased risk of falling. A consumer shared,“I remember something about the whole center of gravity thing changing but I don’t know if that was from my midwife or I read it.” “It just, um, I didn’t notice a step, so I just lunged forward. It was probably my 8th month of pregnancy.” Prevention Strategies

General Exercise Most of the women reported that they participated in a variety of physical activities with walking, swimming, and exercising while watching a video being the most common. A few women were not open to exercising during their pregnancies because of work and family demands. “I would have liked to exercise but with work and just the schedule of things, it didn’t match with my schedule.” To improve exercise participation, several participants suggested joining a group activity with an instructor, “I think with the visual thing, like a hand-out, is OK, but you can kind of need to have an auditory and a visual kind of combo.” “They do a lot of classes here that are education-based, and maybe this is crazy – it just seems like there’s no reason why you couldn’t be exercising during those classes.” “You go to the prenatal class and you just sit there. It would be cool, … you know, to multi-task and do a little bit of exercising.” Specific Exercise Methods All participants viewed the exercise videos. Most of the women expressed a preference for yoga and Pilates. One consumer sharing about yoga, said,“I think it September/October 2014

Table 2. Characteristics of Postpartum Women Participating in the Focus Groups (N = 31) Characteristics

N (%)

Age < 30 30–34 35–39

8(26) 14(45) 9(29)

Education < High School High School Some college College or more

1(3) 1(3) 3(10) 26(84)

Pregnancy Fall No Yes

20(64.5) 11(35.5)

Post Partum Fall Yes No

1(3) 30(97)

Medical attention after fall No Yes

7(64) 4(36)

Received Fall Prevention Education No Yes

29(93) 2(7)

helps make you more aware of your body…” Another consumer voted for Pilates, “When I work out I like to sweat. Yoga is more calming. I prefer Pilates.” The women expressed that Tai Chi was not a top choice.“Personally, I’d be turned off by even the thought of taking Tai-Chi classes.” The ball and muscle toning exercise methods also received varied reviews. Some women developed their own exercise programs reporting, “I did it with my first. I didn’t do as much but with my son but I worked out until I couldn’t fit between the machine.” A limitation of selfdesigned programs was that those women did not receive additional coaching or peer support. “I feel if there was a group or in a group setting, you know, personal instruction. I took classes here. I really loved them.”Another consumer shared, “Especially for first time moms, I’ve been looking for other women going through a similar experience.” Barriers to Prevention Strategies Some of the women expressed concerns about the exercises in the videos reporting, “I’m getting tired just looking at the videos and worrying about sitting on a ball or sitting on the floor doing a yoga pose but a whole class of standing while you’re really pregnant; it just sounds a little exhausting.” Another said, “Someone gave me a prenatal DVD, and I just couldn’t get into it at home.” and“I’m watching it but thinking, you sort of have to know what MCN

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Limitations of the Study Although we believe this study is the first to provide consumer insight on fall prevention strategies, given the sample characteristics and small size, these results may not be generalizable to all pregnant and postpartum women. For example, those who are at greater risk of falling during pregnancy, such as adolescent women and those with less than high school education, were not represented. In addition, exercise strategies, such as quadriceps strengthening, were not presented as a specific technique, but grouped together in a muscle toning video. Also, the increased fall risk after alcohol consumption was not explored. A final limitation is that the participants did not verify the transcripts, leaving open the possibility that the researchers may have misinterpreted their sharing.

Clinical Implications Women cited wet surfaces and footwear as common contributors to falls.

you’re doing beforehand. It doesn’t seem, that now I’m pregnant, that I’m going to start if I’ve never done it before.” A consumer focusing on barriers said, “I’ve tried a couple of random classes over the years. I’m the opposite, where I just didn’t find it fun.” Safety Women expressed safety concerns about exercises, “I think I fell off a ball when I was not pregnant, so I can’t even imagine doing that.”Others expressed, that a folding chair, used by the instructor in the muscle toning video, was a fall risk.

Marketing Fall Prevention An important aim of the FGIs was to explore strategies for promoting fall prevention to this young and healthy group. Although most women did not receive any fall prevention advice, one consumer shared “My midwife handed out a packet, a little folder that had a ton of information. I read all of it.” A second consumer expressed an interest in mixing exercise techniques, “I think if it was combined somehow, maybe with a little bit of yoga or with the ball exercising or just a pregnancy exercise and stretch class where the elements of different things are included.” Another consumer summed up her reality, “I need specific information, so ….it says wear low-heeled shoes with a non-slip bottom. Well clearly, my judgment about what was a non slip bottom was way off base because I slipped in flip flops.” and a final consumer comment focused on the importance of group instruction “I just couldn’t get into it at all. I feel if there was a group or in a group setting or in person instruction, it would help.” 304

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Healthcare providers need to address fall prevention strategies throughout pregnancy and after childbirth, because the evidence suggests that pregnant and postpartum women are at increased risk of falling and the study participants reinforced those findings. Currently, research to support evidence-based fall prevention strategies for pregnant women is not available. Most of the women expressed a desire for educational materials about the risk of and advice on avoiding a fall. Maternal exercise was also identified as a potential fall prevention tactic. Most women were open to using some form of exercise, modified for pregnancy and individual level of fitness, as a fall prevention strategy. The majority expressed an exercise preference for yoga and Pilates. In planning a pregnancy fall reduction program, counseling on fall risk can be readily incorporated into preconception counseling and standard prenatal anticipatory guidance. The women suggested that fall prevention should be introduced early in pregnancy and repeated at least once a trimester, highlighting physiologic changes throughout pregnancy. They stressed that a combination of written and verbal information was the most helpful. Because there is limited consumer information on fall prevention during pregnancy, nurses and others can develop consumer friendly educational materials focusing on fall avoidance strategies. Education identified as the most helpful to the women was emphasizing wearing proper footwear, body/environment mindfulness, the physiologic and biomechanical changes of pregnancy, and adaptive coping skills, such as the importance of hydration and avoiding hot showers to reduce falls from orthostatic hypotension, and planning alternative activities during changing seasonal weather conditions. Other important teaching points are avoiding rushing, using handrails when going up and downstairs, and extra care when carrying bundles or children. In reaching out to women, educational materials need to be tailored to their developmental and health literacy level. For some women, social media is another effective tool to share fall prevention tips. The majority women felt that a mixed method of exercise activities, combined with social and educational components, enhanced adoption of fall prevention activities. Early research suggests that vulnerable women, such September/October 2014

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as teens, women with lower education attainment, and those who report alcohol consumption during pregnancy, have a higher incidence of injury during pregnancy (Tinker et al., 2010). Kvigne et al. (2008) found that screening for alcohol use at the time of a pregnancy injury identified at-risk women. Nurses can use alcohol screening, intervening, and referral for treatment when caring for pregnant women who report that alcohol contributed to a fall (Keough & Jennrich, 2009). The importance of avoiding alcohol and illegal substances can be reinforced in a fall prevention intervention. Common barriers to acceptance of fall prevention as a routine component of prenatal care were safety concerns and time constraints. Many women expressed a preference for supervised exercise programs. Others were not open to adding another activity to their already very busy schedule, filled with work and family demands. Some women honestly shared that they would not read additional printed educational materials. One suggestion was that prenatal providers hold an orientation session with a community physical therapist to discuss strategies to improve core stability and balance throughout pregnancy. Another woman suggested that a poster and/or a flyer could be placed in waiting areas and bathrooms where women receive their healthcare. One more way to motivate women to participate in exercise activities is to highlight other benefits of maternal physical activity, such as improved cardiovascular health and glucose metabolism, and a normalization of pregnancy weight gain (Wadsworth, 2007). An additional safety concern is that two third of those who experienced a fall reported that they did not call their provider. Nurses and other providers need to counsel all pregnant women to call their healthcare provider after a fall, especially if they note any pain, bleeding, or decreased fetal movement. Outpatient and inpatient units should have protocols for evaluating the woman and her fetus after a fall, including culturally sensitive screening for intimate partner violence, discharge counseling, and follow-up (Amanze, 2008; Furniss, McCaffrey, Parnell, Rovi, 2007). This study explored postpartum women’s preferences for fall prevention strategies. The findings highlight the need for consumer education and the development of fall prevention programs, as 35% of the women reported falling during pregnancy, with only 7% reporting they received fall prevention counseling. Next steps include recruiting a larger, more diverse population to test specific fall prevention interventions during pregnancy. ✜ Dorothy Brewin is an Assistant Professor, University of Massachusetts Lowell, Lowell, MA. She can be reached via e-mail at [email protected] Angela Nannini is an Associate Professor, University of Massachusetts Lowell, Lowell, MA. She can be reached via e-mail at [email protected] The authors have no conflicts of interests. An Internal University Seed Grant funded this research. DOI:10.1097/NMC.0000000000000064 September/October 2014

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Women's perspectives on falls and fall prevention during pregnancy.

Falls are the leading cause of unintentional injury in women. During pregnancy, even a minor fall can result in adverse consequences. Evidence to info...
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