How can maternity services be developed to effectively address maternal obesity? A qualitative study

doi:10.1016/j.midw.2010.01.007

Midwifery

Volume 27, Issue 5, October 2011, Pages e170-e177

https://doi.org/10.1016/j.midw.2010.01.007 Get rights and content

Abstract

Objective

to identify developments in maternal obesity services and health-care practitioners’ views on how maternity services need to be further developed to be more effective in the care of obese pregnant women.

Design

follow-up qualitative study using purposive sampling, interviews and focus groups.

Setting

10 maternity units in the North East Government Office Region of England, UK.

Participants

30 maternity unit health-care practitioners with personal experience of maternal obesity services.

Measurements and findings

semi-structured interviews and focus groups were carried out with health-care practitioners representing each National Health Service trust in the region that provides maternity services to identify views on the barriers, facilitators, advantages and disadvantages of developing maternal obesity services, and how maternity services can be more effective in managing maternal obesity. Transcripts were analysed using thematic content analysis. Three dominant themes emerged: questioning maternal obesity service development; psychosocial issues and maternal obesity service development; and the way forward.

Key conclusions

there has been a substantial improvement in the management of the health and safety aspects of maternal obesity over the last three years. However, more work is needed around the psychosocial issues, weight management and public health aspects of maternal obesity.

Implications for practice

to meet the needs of obese pregnant women, maternity services should consider the transition of care between pregnancy and the postnatal period, improve communication between hospital and public health services, and develop services that will engage pregnant women to address their obesity.

Introduction

The increasing international trend of maternal obesity has impacted on maternity services throughout the developed world. The international incidence of maternal obesity is estimated to be between 2% and 25% (Guelinckx et al., 2008), and approximately 16–19% in the UK (Kanagalingam et al., 2005; Heslehurst et al., 2007a). Obesity in pregnancy has significant short- and long-term health implications for pregnant women and their infants (Confidential Enquiry into Maternal and Child Health, 2007; Lewis, 2007). As a result of these increased health risks, there is also demand for additional care and resources from health service providers (Ramsay et al., 2006; Chu et al., 2008; Heslehurst et al., 2008).

There is an absence of research evidence for effective strategies to tackle maternal obesity. Two papers have discussed potential strategies that could tackle maternal obesity (Krishnamoorthy et al., 2006; Bick, 2009). Krishnamoorthy et al. (2006) state that acknowledging obese pregnancies as being high risk would help to make safer pregnancies for women, that an integrated multidisciplinary approach is required, and that there is a strong argument for the development of maternal obesity services within maternity units. Bick (2009) identifies that midwives need to be aware of the impact of obesity on pregnancy in order to offer women appropriate support and advice; that they should be supported to work effectively with women and their families to minimise the potential risks; and that the contact time pregnant women have with midwives presents opportunities for advice, support and encouragement to follow a healthy lifestyle.

A study across all National Health Service (NHS) maternity services in North East (NE) England between 2005 and 2006 showed that the care requirements for obese pregnant women did not match maternity service provision, and there was an absence of maternal obesity services and guidelines (Heslehurst et al., 2007b). The main issues identified were as follows: managing the care of obese women in pregnancy safely, the lack of suitable resources such as delivery beds for obese women, and the costs associated with having fully equipped facilities within maternity units. The need for, and lack of, multidisciplinary care due to coexisting morbidities when the mother is obese was identified, and there were inadequate links between maternity, dietetics and physiotherapy services. The restricted patient choice was raised, particularly choice for method of birth, and how this might have a psychological impact on the mother. Advice given to mothers, particularly dietary advice, tended to be ‘ad hoc’ and was largely dependent on individual health-care practitioners (HCPs) with a lack of consistency both within and between maternity units. However, some HCPs indicated that they wanted to develop services for maternal obesity, or were in the early stages of developing obesity-specific guidelines (Heslehurst et al., 2007b).

At the time of the previous study (Heslehurst et al., 2007b), the only reference to maternal obesity in national guidance was that women with a body mass index (BMI)>35 kg/m² may require care outside the routine National Institute for Health and Clinical Excellence (NICE) antenatal guidance, and are not suitable for midwifery led care (National Institute for Health and Clinical Excellence, 2003), which was supported by Confidential Enquiry into Maternal and Child Health recommendations (2004). However, maternal obesity has been incorporated in UK guidance documents and reports produced in the last three years. NICE has incorporated obesity into their clinical guidelines for antenatal care (National Institute for Health and Clinical Excellence, 2008a), diabetes in pregnancy (National Institute for Health and Clinical Excellence, 2008b) and intrapartum care (National Institute for Health and Clinical Excellence, 2007b). These updated guidelines consider obese women to be among the high-risk groups that require additional screening, intervention or monitoring. The Centre for Maternal and Child Enquiries makes specific recommendations for the management of thromboembolism and anaesthesia, highlighting that obesity presents many challenges which should be addressed by evidence-based clinical guidelines (Lewis, 2007). The Royal College of Obstetricians and Gynaecologists have also produced obesity and reproductive health consensus views (Royal College of Obstetricians and Gynaecologists, 2007). The USA has also recently published evidence-based guidelines for weight gain in pregnancy, which includes differentiation between maternal BMI groups (Institute of Medicine, 2009). However, there is an absence of internationally agreed guidance around weight management.

This follow-up study was conducted to assess the impact of the increased national focus on maternal obesity on local maternity service development to answer the research question: how can maternity services be developed to effectively address maternal obesity?

Section snippets

Methods

An interpretive constructionist approach was used to elicit interviewees' experiences and views relating to maternal obesity service development within their workplace. HCP perceptions of the benefits and disadvantages of maternal-obesity-specific services, and any barriers encountered or successes in developing such services were explored. Purposive sampling was used to gain representation from the whole of the NE region. Information packs were sent to heads of midwifery and clinical

Findings

Service development since the previous study was discussed. All maternity units were implementing antenatal or postnatal obesity guidelines. The majority were better equipped with investment in delivery beds and theatre tables suitable for obese women. An improvement in multidisciplinary care was noted, with most units having established referral pathways for dietetics services and anaesthetics, although some units’ links were still inadequate. Existing working groups were also being utilised

Theme 1: questioning maternal obesity service development

This relates to confusion around how obesity services should be developed, what services should be trying to achieve, and conflicting arguments both between and within maternity units.

The majority of HCPs felt that the safety of the mother and infant was the priority for maternity services, and the greatest benefit that could result from developing obesity services. There was questioning among HCPs of what exactly maternal obesity services were expecting to achieve other than looking after the

Theme 2: psychosocial considerations in maternal obesity service development

This theme relates to the psychosocial relationship with obesity, the impacts on the development of maternal obesity services, and difficulties in conveying obesity risk to pregnant women.

The difficulty in discussing obesity with pregnant women was raised by the majority of HCPs; however, it was accepted that there was a responsibility to inform women of their increased risk of complications:

…a lot of women say ‘it’s great to be pregnant and then you just tell us about all of these horrendous

Theme 3: the way forward

HCPs acknowledged that there was a lot of work still to be done to address maternal obesity effectively, particularly in the community setting. There were some suggestions on what else was required to address maternal obesity effectively (Box 5). Training requirements were discussed, and these related to the use of appropriate language, and feeling uncomfortable raising the issue. Suggestions for training that HCPs would find useful included working with dietitians for behavioural change

Discussion

The previous study identified a lack of clinical guidelines, policy, multidisciplinary care, links with dietetics services, and equipment to manage the care of women safely (Heslehurst et al., 2007b). This study has identified that the majority of maternity units now have local guidance and services in place for the obstetric requirements of maternal obesity. The safe management of obese pregnant women has also improved, particularly relating to equipment required such as birth beds. One NHS

Disclosure of interest

No conflicts of interest declared from any authors or the funders.

Funding

The funding for this study was provided by Public Health North East. JR is funded by Personal Award Scheme Career Scientist Award from the UK National Institute of Health Research.

Acknowledgements

The authors would like to acknowledge Katie Dykes and the staff in the maternity units who gave up their time to participate in the study.

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women reported an overall positive experience and thought that dietitians were the expert health professionals to support them. Women in this study felt that tailoring advice specific to their personal circumstances helped them implement changes, and had a strong interest in the nutritional benefits for fetal development. Women considered weight monitoring to be a positive element of the service; however, further research is required given the limited and conflicting evidence-base.
it is important to incorporate women's experiences in the development and delivery of antenatal weight management services to facilitate person-centred care. Communication by health professionals at the point of referral is particularly important to provide accurate expectations of services and to reduce anxieties. Dietitians are considered to be appropriate experts to deliver these services, although they may need additional support to address women's physical activity needs in pregnancy.

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How can maternity services be developed to effectively address maternal obesity? A qualitative study

Abstract

Objective

Design

Setting

Participants

Measurements and findings

Key conclusions

Implications for practice

Introduction

Section snippets

Methods

Findings

Theme 1: questioning maternal obesity service development

Theme 2: psychosocial considerations in maternal obesity service development

Theme 3: the way forward

Discussion

Disclosure of interest

Funding

Acknowledgements

Midwifery

Midwifery

Obesity stigma and quality of life

International Journal of Interdisciplinary Social Science

A method of analysing interview transcripts in qualitative research

Nurse Education Today

Analysing and presenting qualitative data

British Dental Journal

Association between obesity during pregnancy and increased use of health care

New England Journal of Medicine

Why Mothers Die 2000–2002

Perinatal Mortality 2005

Maternal obesity: pregnancy complications, gestational weight gain and nutrition

Obesity Reviews

Trends in maternal obesity incidence rates, demographic predictors, and health inequalities in 36 821 women over a 15-year period

BJOG: an International Journal of Obstetrics and Gynaecology

Obesity in pregnancy: a study of the impact of maternal obesity on NHS maternity services

BJOG: an International Journal of Obstetrics and Gynaecology

The impact of maternal BMI status on pregnancy outcomes with immediate short-term obstetric resource implications: a meta-analysis

Obesity Reviews

Weight Gain During Pregnancy: Reexamining the Guidelines.

National Academic Press