Improving the diet of pregnant women: a mixed methods study

1. Background
There are about 800,000 babies born in the UK each year. Diet is an important factor for every pregnancy in determining the health and development of the baby. The NHS provides online guidance on avoiding or limiting intakes of fish and game/gamebirds to minimise intakes of mercury and lead, respectively (guidance on rice products to minimise arsenic intakes is currently only for children). The evidence base for this information is poor, and there has not been any evaluation of the effect of the ways that the guidance is publicised, or how closely women follow the advice at different stages of pregnancy. We also know very little about the effects of these foods on the amounts of the metals in their bodies. This information is essential to ensure that the guidance gives the right messages, and is publicised for maximum impact.
2. Aim
My aim is to find out about the effectiveness of NHS guidance on which foods to avoid or limit during pregnancy to avoid pollutants, specifically toxic metals. I'd like to find out how much pregnant women know about the advice on the foods that contain small amounts of these toxic metals - fish, game/gamebirds and rice/rice products - and where they get their information from. I'd also like to know whether the guidance affects how much of these foods women actually eat and how that affects the amount of the metals in their bodies. I want to enable women to make informed choices, based on scientific evidence about these foods, with confidence so that their unborn baby can develop fully to its potential.
3. Design and methods used
I'll recruit 400 women who are having their first baby. At the first antenatal clinic visit (about 10 weeks), I'll ask the midwife to take some extra blood (about half a teaspoon) to measure the levels of mercury and lead. I'll ask the women to fill in an electronic or paper questionnaire at home asking about their about how often they eat particular foods. I'll also ask about what they know about the advice on foods to limit or avoid and where they got their information from. I'll repeat all this to coincide with a later clinic visit (about 28 weeks), with an additional urine sample to measure arsenic. In addition, three groups of six other pregnant women will be invited to take part in a focus group meeting to talk about what they know about the guidance and where they get their information from in more detail. I'll also be recruiting 100 midwives to complete an electronic questionnaire on their knowledge of the guidance and how they inform women about it. I'll invite two groups of six midwives to tell us about this in greater detail.
4. Patient/Public involvement
I will consult patient/public advisory groups regularly during the whole project (every 2 to 3 months) to ensure that our questionnaires are feasible and acceptable while still answering the questions that we are interested in. The groups will also be used to help us to maximise the number of women who take part in the study and complete it. An online forum will be used to ask about issues that need a quicker response.
5. Dissemination
I'll be working with the government advisors who develop the details of the guidance for pregnant women to make sure the advice is based on good evidence, and is accurate, clear, and easy to follow. I'll also work with midwives, health-carers, and MumsNet and other online sites to make sure the guidance is easy to access and given at the best time for women to able to absorb and follow the information.

There are two UK dietary guidelines for pregnant women that aim to minimise ingestion of toxic metals, which flow freely through the placenta to the fetus with adverse effects on neurodevelopment. The guidance is not informed by up-to-date data on dietary intakes and exposure levels, nor has there been any evaluation of the effectiveness of current guidance.
A mixed methods observational cohort study of 400 healthy primigravid women will: (1) evaluate understanding of the UK guidance on fish and game/gamebird consumption in pregnant women and midwives; (2) compare dietary intakes with the guidance; (3) measure blood lead and mercury and urine arsenic concentrations; (4) estimate the contribution of diet to the biomarker concentrations. This will be achieved by quantitative assessment of dietary intakes with food-frequency questionnaires at 10- and 28-weeks' gestation and opportunistic blood and urine sampling at the same times through community antenatal clinics. Qualitative interview group studies with pregnant women will enable evaluation of knowledge and impact of the guidance. A questionnaire will be used to establish knowledge of the guidance by midwives, and how and when they disseminate information, with further in-depth data collection through qualitative interview groups.
The research will provide an evidence-base for clarification and effective dissemination of dietary guidance related to toxic metals to enable women to make informed choices about their diet with optimisation of the health and development of the baby.

1. Women, children and their families: The primary beneficiaries are children born to women who are enabled to make informed choices about what they eat during pregnancy. The health and development of children will be maximised, so that they are able to reach their cognitive, physical and economic potential.
2. Environmental and health policy-makers: The study will also be of interest to environmental and health policy-makers at local and national levels. It is expected that the project will continue to raise interest in the health effects of toxic metals in the UK and internationally. Policy-makers at a local level and nationally will have an improved evidence-base from which to develop policy changes in relation to toxic metals, the environment and health. It is expected that the project will continue to raise interest in the health effects of toxic metals in the UK and internationally.
3. Health professionals: This research study will have an impact on a varied group of health-related stakeholders, including a wide circle of health providers and care-givers. Clinical interests include a range of medical and allied specialities such as obstetricians, midwives, health visitors, dietitians and general practitioners. Healthcare providers will be able to access clear evidence-based information on what advice they should be offering to pregnant women and be able to deliver it with clarity and confidence, timed for maximum impact.
4. Economic, educational and societal benefits: Children who reach their developmental potential are able to make the best possible contribution to the national economy and minimise their need for resources from educational services, the NHS, educational supports services, social services, etc., while improving their quality of life. The economic rewards of public health policy in minimising exposures are quantifiable.
5. Public sector and third sector: Charities that engage with pregnant women such as the NCT, Tommy's, Maternity Action, First Steps Nutrition and Baby Lifeline will have access to evidence-based information presented in an accessible format, that can be used to amend and update their information for pregnant women. Work with these charities that engage with pregnant women and their families will be essential in promoting information about the outcomes of the study. Professional-facing charities such as the British Nutrition Foundation and Nutrition Society will be enabled to update their information on diet in pregnancy.
6. Catering and food services: Food-related businesses will be able to provide suitable meals and menu-information for women who are pregnant. Hospital catering services will be able to provide meals for obstetric wards based on clear and accessible information.
7. Academia and knowledge acquisition: The project will provide results including information that has not been updated (or has been absent) in the UK for many years against a rapidly changing environmental background. It will therefore make an importance contribution to knowledge that will be of great value nationally and internationally.
8. Collaborators/inter-disciplinary research: The project will bring together collaborators with a variety of interests, expertise and backgrounds. The applicant will work closely with each collaborator involved with a specific aim. Knowledge and exchange of ideas will be enhanced by forming these new relationships and successful long-term scientific partnerships will be forged.
9. Staff development: The PI, research staff and collaborators will all be beneficiaries of increased knowledge, experience and skills. The development of staff is of benefit to other projects that they may go on to design, run and work on, maximising the value of the outputs for the benefit of individuals and society.