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Discussing Maternal Obesity

Dr Ruth Bell (Newcastle University)Dr Nicola Heslehurst (Teesside

University)

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Pregnancy and early childhood represent a ‘window of opportunity’ when women and their families:• interact with health services in a planned fashion• have frequent “healthy” contact with healthcare

professionals• may be emotionally and psychologically much

better prepared to change behaviours

“Obesity is arguably the biggest challenge facing maternity services today. It is a challenge not only because of the

magnitude of the problem... but also because of the impact that obesity has on women’s reproductive health and that of

their babies.” (CMACE 2010)

Workshop Aims:• To give a brief overview of maternal obesity• To introduce some of the issues surrounding obesity

communication• To explore how maternal obesity discussions can be improved

for women and practitioners through small group activities

Defining Maternal Obesity

• There is an absence of pregnancy specific BMI categories

• The WHO BMI categories are usually used to define first trimester BMI status

Maternal Obesity Trends: Regional Implications

England: Obese BMI1989: 7.6% (~45,000 women)

2007: 15.6% (~92,500 women)

North East: Obese BMI2007: 18.2%

(Heslehurst et al 2010)

Maternal Obesity and Public Health: Socio-economic Inequalities

Obesity Class Heslehurst et al (2010)(Adjusted Odds Ratios)

CMACE (2010)

Obese (all BMI >30 kg/m2) 2.2 (95% CI 2.1, 2.3) –

Moderately (30–35 kg/m2) 2.0 (95% CI 1.9, 2.0) –

Severely (34–40 kg/m2) 2.7 (95% CI 2.5, 2.9) 11.3% (least deprived) 34.6% (most deprived)

Morbidly (40–50 kg/m2) 3.0 (95% CI 2.7, 3.3) 11.0% (least deprived)33.8% (most deprived)

Extreme (>50 kg/m2) 4.7 (95% CI 3.2, 6.9) 10.2% (least deprived)35.7% (most deprived)

Maternal Obesity and Pregnancy Outcome

Women who start pregnancy with a BMI in the obese range (30+) reported to be at increased risk of:

• Miscarriage, stillbirth and infant death• Congenital anomaly• Gestational diabetes• Pre-eclampsia• Post partum haemorrhage• Caesarean section • Wound infection

Maternal obesity and risk of stillbirth

• Risk of stillbirth is doubled for obese women• Stillbirth is a rare event:• 4 per 1000 in recommended BMI• 8 per 1000 in obese women - less than 1%• So obese women still at low risk - 99.2% will not be

stillborn

Maternal obesity and risk of caesarean section

• Risk of caesarean section is 70% higher for obese women

• Caesarean delivery is common:• 20% for women with recommended BMI• 35% for obese women (‘1 in 3’)• Additional risk for obese women 15% • 15 out of 100 obese women will have a CS due to their

obesity

Can risks be reduced?

Pregnancy in obese women is higher risk, but most are likely to experience normal delivery of a healthy baby

Good antenatal practice should identify and manage the risk, as for any other risk factor• ‘making a good outcome better’

Can risks be reduced?

• No robust evidence yet from RCTs that lifestyle intervention to restrict weight gain or change diet/activity during pregnancy reduces these risks• Published studies too small to show effect on maternal or

baby health outcomes• Several large RCTs underway in UK and internationally

Can risks be reduced?

• Two recent national guidelines on the management of maternal obesity (2010):• CMACE/RCOG guidance focuses on managing the risks

associated with obesity through good practice in antenatal care

• NICE guidance focuses on healthy diet and activity advice during pregnancy

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Obesity Communication

NICE (2010) Guidelines which Involve Obesity/Weight Discussions in Pregnancy

Discuss eating habits and physical activity. Offer practical and tailored information. Dispel myths about what and how much to eat during pregnancy. Advise on physical activity safety and recommendations for pregnancy,

giving specific and practical advice. Measure weight and height, and calculate BMI at the first contact, being

sensitive to any concerns she may have about her weight. Clearly explain why this information is needed and how it will be used to plan her care.

Explain the obesity-related risks to the health of mothers and the unborn child. Explain that they should not try to reduce this risk by dieting while pregnant and that the risk will be managed by the health professionals caring for them during their pregnancy.

Encourage women to lose weight after pregnancy.

CMACE-RCOG (2010) Guidelines which Involve Obesity/Weight Discussions in Pregnancy

• Obese pregnant women should be provided with accurate and accessible information about associated risks and how they may be minimised.

• Women should be given the opportunity to discuss this information.

Obese Women/Patients Experiences of Obesity Discussions

• Negative experiences include:• Obese pregnant women feel risks are not adequately explained (Keely et al 2011)

• A lack of information from health professionals about risks leads women to think that maternal obesity was acceptable and they’re not at increased risk (Smith & Lavender 2011)

• Risk communication can be received negatively and evoke feelings of guilt (Smith & Lavender 2011)

• Women do not like to be categorised as obese (Heslehurst et al, unpublished)

• Obese patients have described HCPs as ambivalent, insulting, demeaning, discriminating, judgemental, blame-inducing, highly insensitive, patronising and derogatory (Wadden & Diddie 2003, Keenan & Stapleton 2010, Brown & Thompson 2006, Merrill & Grassley 2008)

• Avoid seeking healthcare due to negative experiences (Brown & Thompson 2006, Merrill & Grassley 2008)

• Avoid confrontation about humiliating treatment due to fears of the impact on antenatal care (Nyman et al 2010)

Obese Women's Experiences of Obesity DiscussionsShe’d told me that she was finding it hard to find the baby’s heartbeat because I was overweight. I come out and I was in floods of tears. You think that you’re doing the baby some wrong. (Furber &McGowan 2011)

So she [caregiver] thinks that she can talk to me which ever way she wants and I feel that she damn well can’t. Because if she is a ‘fat-hater’, as I call it, she has to keep that to herself. (Nyman et al 2010)

‘When I was delivering my son . . . I think I weighed 215 pounds when he was born and I just felt huge . . . I can remember in the delivery room the doctor saying something to me . . . during the birthing process. He said, “Just relax and just envision yourself on a beach like a big ole whale beached” . . . That hurt me so much because already I felt big’. (Nyman et al 2010)

It was kind of weird actually. It hadn’t been raised at all until I got a phone call from the midwife saying, ‘I’ve got two scans and an appointment with a consultant for you’. I was like, ‘What’s wrong, like?’ And then she said ‘No, no, it’s just because you’re obviously … a BMI over 40 (Keely et al 2011)

Healthcare Professionals Experiences of Obesity Discussions

• Barriers to discussion:• Sensitivity of obesity discussions act as a barrier to broaching the topic

(Heslehurst et al 2010, Heslehurst et al 2011, Oteng-Ntim et al 2010)• Past history of complaints acts as a barrier to discussion (Heslehurst et

al 2007, Schmied et al 2010)• Wanting to develop a supportive midwife-woman relationship

(Heslehurst et al 2011)• Time constraints in practice (Heslehurst et al 2011)• Fear of increasing social stigma if discussing without support

mechanisms in place (Heslehurst et al 2010)• Conscious of own body weight when talking to pregnant women

about their weight (Schmied et al 2010)

“Like I’m overweight. You know, how can I sit there and tell this lady about her weight when I’m overweight?” (Midwife)“I’ve always found it’s a little bit easier to address it when you are overweight than if you’re this gorgeous skinny looking thing saying well you’re a bit chubby there” (Schmied et

al 2010)

Healthcare Professionals Experiences of Obesity Discussions: Building a Relationship/Own Weight

Often when you meet somebody you’ve just met them for the first time, most of us want to be nice to that person... you don’t wanna come across as though you’re sitting there Miss Perfect criticising when you’re trying to start this good relationship with them, you’re going to be looking after them for the next nine months. (Midwife) (Heslehurst et al 2011)

You’re kind of torn... you’ve got to be there as a support for them, at the same time you’re the one that’s giving them the bad news “as a medical professional we’re saying that you are now high risk because of this”...you’re trying to be as sympathetic and empathetic as you can but yet you’re still the one that’s going to stop them from having what they want [birth choice]. I just think that’s quite hard sometimes. (Midwife) (Heslehurst et al 2011)

Because I think that’s the hardest thing, most of us just ignore it when... they say “I’m a fat lass” are they wanting you to say “right... how are we gonna tackle it?” but most of us don’t, most of us just go [embarrassed gesture] “yeah I know” and just ignore it because we don’t know what to answer to that. What do you say to somebody who’s making fun of themselves? (Midwife) (Heslehurst et al 2011)

Every time she comes in she is completely totally embarrassed that I have to look and feel her tummy, and totally embarrassed you can see her almost like, fear factor that I’m gonna mention something, and I find then that situation much harder because I don’t wanna hurt her. (Midwife) (Heslehurst et al 2011)

Healthcare Professionals Experiences of Obesity Discussions: Women’s Reactions/Reacting to Women

References1. Brown, I., Thompson, J., Tod, A. M., & Jones, G. (2006). Primary Care Support for Tackling Obesity: A Qualitative Study of the Perceptions of

Obese Patients. British Journal of General Practice, 56, 666-672.2. Centre for Maternal and Child Enquiries (CMACE). (2010). Maternal obesity in the UK: Findings from a national project. London: CMACE.3. CMACE-RCOG. (2010). Management of Women with Obesity in Pregnancy: Jointly published by the Centre for Maternal and Child Enquiries

and the Royal College of Obstetricians and Gynaecologists.4. Furber, C. M., & McGowan, L. (2010). A qualitative study of the experiences of women who are obese and pregnant in the UK. Midwifery,

doi:10.1016/j.midw.2010.04.001.5. Heslehurst, N., Moore, H., Rankin, J., Ells, L. J., Wilkinson, J. R., & Summerbell, C. D. (2011). How can maternity services be developed to

effectively address maternal obesity? A qualitative study. Midwifery, 27(5), e170-e177.6. Heslehurst, N., Rankin, J., Wilkinson, J. R., & Summerbell, C. D. (2010). A Nationally Representative Study of Maternal Obesity in England,

UK: Trends in Incidence and Demographic Inequalities in 619 323 Births, 1989-2007. International Journal of Obesity, 34, 420-428.7. Heslehurst, N., & Russell, S. L. (January 2011). Research Report: A Qualitative Study Exploring Womens' Experiences of Dietetic Referrals for

a Raised BMI in Pregnancy.8. Keely, A., Gunning, M., & Denison, F. (2011). Maternal obesity in pregnancy: Women’s understanding of risks. British Journal of Midwifery,

19(6), 364-369.9. Keenan, J., & Stapleton, H. (2010). Bonny Babies? Motherhood and Nurturing in the Age of Obesity. Health, Risk & Society, 12(4), 369-383.10. Merrill, E., & Grassley, J. (2008). Women's Stories of their Experiences as Overweight Patients. Journal of Advanced Nursing, 64(2), 139-146.11. National Institute for Health and Clinical Excellence. (2010). Weight Management Before, During and After Pregnancy: Department of

Health.12. Nyman, V. M. K., Prebensen, A. K., & Flensner, G. E. M. (2010). Obese women's experiences of encounters with midwives and physicians

during pregnancy and childbirth. Midwifery, 26(4), 424-429.13. Oteng-Ntim, E., Pheasant, H., Khazaezadeh, N., Mohidden, A., Bewley, S., Wong, J., et al. (2010). Developing a community-based maternal

obesity intervention: a qualitative study of service providers’ views. BJOG: an International Journal of Obstetrics & Gynaecology, 117(13), 1651-1655.

14. Schmied, V. A., Duff, M., Dahlen, H. G., Mills, A. E., & Kolt, G. S. (2010). 'Not Waving but Drowning': A Study of the Experiences and Concerns of Midwives and Other Health Professionals Caring for Obese Childbearing Women. Midwifery, doi:10.1016/j.midw.2010.02.010.

15. Smith, D. E., & Lavender, T. (2011). The maternity experience for women with a body mass index >30 kg/m2: a meta-synthesis. BJOG: an International Journal of Obstetrics & Gynaecology, DOI: 10.1111/j.1471-0528.2011.02924.x.

16. Wadden, T. A., & Didie, E. (2003). What's in a Name? Patients' Preferred Terms for Describing Obesity. Obesity Research, 11(9), 1140-1146.

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Workshop Activities

Ruth Bell (Newcastle University)Nicola Heslehurst (Teesside University)Gill Sedgewick (South Tees NHS Trust)Sarah-Louise Russell (Teesside University)

Small Group Activities

• Workbooks with small group activities based on reflection• Professional experiences of obesity discussions (or

other sensitive topics)• Personal experiences of obesity discussions• What can we learn from our experiences about how to

improve communication in this area?

• Small group feedback to the workshop

Acknowledgements

The work was undertaken by Fuse, a UKCRC Public Health Research: Centre of Excellence. Funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research council, Medical Research Council, and the National Institute for Health Research, under the auspices of the UK Clinical Research Collaboration, is greatly acknowledged.

Opinions expressed in this presentation do not necessarily represent those of the funders.