Rates of obesity worldwide have doubled in the past 30 years (World Health Organization (WHO), 2013) and obesity in the UK is reaching epidemic levels. The Health and Social Care Information Centre (HSCIC, 2014) reported that over 60% of adults and 30.6% of children in England were classed as overweight or obese in 2012. Rates of maternal obesity in the UK saw an increase from 10% in 1990 to 30% in 2014 (Denison et al, 2014) and obesity-related maternal and infant deaths have mirrored this, with reported obesity-related maternal deaths of 23% in 2007 increasing to 49% in 2011 (Lewis, 2007; 2011). The negative impact of obesity on health, particularly in the childbearing population, should not be underestimated—obesity is now the UK's most prevalent antenatal comorbidity (HSCIC, 2010; 2011).
Rates of maternal obesity in a region of south-east England reflect these increases and present figures above the national average. Data collected from the National Obesity Project (Centre for Maternal and Child Enquiries (CMACE), 2009) indicate that 4.7% of women booking for maternity care locally have a body mass index (BMI) of ≥35 kg/m2 and 3% have a BMI of ≥40 kg/m2, compared to national rates of 3.3% and 1.09% respectively. A major failing of this project was that it ignored data related to women who are overweight and with a BMI of 30–35 kg/m2, despite the fact that these women also present risks if they gain excessive amounts of weight in pregnancy (Lewis, 2007; 2011) (Table 1).
| Classification | Body mass index (general population) |
|---|---|
| Underweight | <18.5 kg/m2 |
| Normal | 18.5–24.9 kg/m2 |
| Overweight | 25–29.9 kg/m2 |
| Obese | ≥30 kg/m2 |
Gaining excessive weight in pregnancy, especially if the woman is already obese, is associated with adverse outcomes for both mother and baby. Complications include higher rates of induction of labour, caesarean section and instrumental deliveries, postpartum haemorrhage, pre-eclampsia, gestational diabetes and thromboembolisms (Catalano, 2007; Heslehurst et al, 2008; Poobalan et al, 2009). Obese women are also less likely to breastfeed their babies (Jevitt, 2010; National Institute for Health and Care Excellence (NICE), 2010). Babies of obese women have increased incidence of congenital abnormalities, macrosomia, birth injury, meconium aspiration and stillbirth and are more likely to require admission to a special care baby unit (Kristensen et al, 2005; Denison et al, 2008; Modder and Fitzsimons, 2010; Scott-Pillai et al, 2013).
Obesity is not isolated to pregnancy; it is a lifelong problem that affects the whole family and impacts on the health of the next generation. Women who gain excessive weight in pregnancy find it difficult to lose it in the postnatal period, predisposing them to long-term obesity-related health complications (Modder and Fitzsimons, 2010). Evidence also suggests that babies of obese women are not only at risk of complications during pregnancy and birth but also long-term health complications such as heart disease, diabetes and metabolic syndrome in childhood and into adolescence, predisposing them to lifelong obesity and its associated health problems (Boney et al, 2005; Modder and Fitzsimons, 2010; Denison and Chiswick, 2011). The complex problems associated with maternal obesity and the rising rates of obesity nationally present the NHS with financial and logistical challenges in providing adequate, safe and appropriate care.
UK recommendations and guidance
Pregnancy is a period in a woman's life when weight-gain is unavoidable and expected. Gaining weight in pregnancy for women with a BMI of 18.5–24.9 kg/m2 may not be problematic, but if the woman is already overweight or obese it can predispose to adverse outcomes for both mother and baby (Modder and Fitzsimons, 2010). Average weight-gain in pregnancy varies from 8 kg to 14 kg (NHS Choices, 2011), but no UK guidance exists regarding what is classed as a ‘healthy’ gestational weight-gain and what is ‘excessive’. This complicates the process of advising women on the risks of excessive weight-gain in pregnancy and also fails to offer guidance regarding the maintenance of a healthy weight-gain in pregnancy.
There have been advances over the past 3 years regarding advice on diet and exercise for obese pregnant women in the UK, with guidance from NICE (2010) and joint guidelines from CMACE and the Royal College of Obstetricians and Gynaecologists (RCOG) (Modder and Fitzsimons, 2010). Although this advice and guidance acknowledges the risks of excessive gestational weight-gain in overweight and obese women, it fails to commit to what is classed as ‘excessive’ weight-gain or endorse weight restriction in pregnancy.
US guidelines
More than 20 years of in-depth research supports the effectiveness of the Institute of Medicine (IOM) recommendations on gestational weight-gain for obese women (IOM, 2009) in substantively reducing the risks of obesity-related complications to both mother and baby in pregnancy, labour and the postnatal period (Cedergren, 2006; Tsukamoto et al, 2007; Claesson et al, 2009; IOM, 2009). The IOM (2009) recommends that women restrict their gestational weight-gain to within a specific range, depending on their BMI at the booking interview (Table 2). Although these recommendations are based on the American population, they are reflective of the similarly diverse British population and have been acknowledged by NICE (2010) as a possible method of addressing the rising rates of maternal obesity in the UK. Further research into their effectiveness in the UK is recommended.
| Classification at booking interview | Total weight gain (kg) | Rate of weight gain in 2nd and 3rd trimester (kg/week)* | |
|---|---|---|---|
| Mean | Range | ||
| Underweight | 12.5–18 | 0.51 | 0.44–0.58 |
| Normal weight | 11.5–16 | 0.42 | 0.35–0.50 |
| Overweight | 7–11.5 | 0.28 | 0.23–0.33 |
| Obese | 5–9 | 0.22 | 0.17–0.27 |
Discussion
Institutional control or individual control?
To achieve success in reducing rates of obesity, a multi-agency approach is required that aims to promote and restore health through education and empowerment (Streubert and Carpenter, 2011; WHO, 2013). Currently, the care of obese pregnant women lies within the remit of obstetricians. Arguably, under an obstetric risk-management framework, the issue of obesity is managed in the short term, with little long-term planning. This risk-management approach uses medical models of care that standardise and restrict women's individual choices in pregnancy and childbirth; this perspective should be challenged.
Risk management is a relative concept and the term ‘risk’ is perceived differently by obstetricians, midwives and pregnant women. A UK qualitative study by Keely et al (2011) suggests that women lack knowledge regarding the risks associated with obesity in pregnancy, childbirth and the postnatal period, and even when they have this information they do not associate poor pregnancy outcomes with their size. This highlights a failure on the part of the maternity service to address this lack of knowledge and understanding effectively, and possibly indicates a gap in professional knowledge and skills when educating obese pregnant women.
The NHS Litigation Authority (NHSLA, 2013) recommends that the care of obese pregnant women is standardised and the risks managed depending on the booking BMI of women. This risk management is based on the recommendations of the Clinical Negligence Scheme for Trusts (CNST) (NHSLA, 2013). Its principles create a care environment that often manages obese pregnant women as a group, with little concern for individuality or choice. Many obese pregnant women report negative encounters with obstetricians and midwives regarding this standardised management of their care and restriction of their choices (Nyman et al, 2008).
Emerging themes
Three main themes emerged from the literature on obesity in pregnancy and individualised care: women's choice in childbirth; models of care and underpinning theory; and how to deliver health education to obese pregnant women.
Choices for women
Ensuring women have choice in childbirth is at the heart of various government policy documents such as Maternity Matters and the four choice guarantees: choice of how to access maternity care, type of antenatal care, place of birth and choice of postnatal care (Department of Health, 2007). However, the Government's attempts to regulate standards of care and safety through CNST (NHSLA, 2013) is a major influencing factor in restricting choices for obese pregnant women. This ‘one size fits all’ approach to care-planning for obese pregnant women leaves no room for individuality. It excludes obese women from normal childbirth by creating policies and procedures that dictate where they will give birth and how, often restricting access to services such as water birth, homebirth or birthing units.
Pre-labour anaesthetic assessments and glucose tolerance tests are standard procedures, presenting the message to obese women that there is a high probability of complications and that they will likely require intervention in pregnancy and childbirth. Arguably, these investigations should be left to the judgement of the lead professional and based on the health and wellbeing of the individual woman as the pregnancy progresses. Such standardised investigations and procedures have a major impact on women's confidence to give birth naturally, and evidence indicates that this may negatively affect birthing outcomes (Richens and Lavender, 2010). While there is a place for standardised tests in pregnancy, women should be given the option of choice. There will always be challenges when providing health care to women perceived as ‘high risk’, particularly in the maternity services, but this should not create inequalities for one group of women, especially with regard to choice in childbirth.
Models of care and underpinning theory
Pregnancy is a prime opportunity to address the issue of obesity from a wider family perspective, formulating long-term strategies that may potentially reduce national rates of obesity in the general population. Failing to maxmise this educational opportunity in favour of the short-term strategic approach achieved through risk management is a false economy. Arguably, to successfully reduce rates of obesity in the long term, a public health approach is required, which prevents disease by promoting and restoring health through education and empowerment (WHO, 2013). Evidence indicates that women are more perceptive to health education during this period of their life (Hui et al, 2012) and are optimally placed in society to make major healthy lifestyle changes for the whole family and the next generation, yet the NHS fails to effectively utilise this opportunity. Midwives and obstetricians are optimally placed to deliver this advice but may lack confidence in their understanding of the causes of obesity and how to positively influence women to reduce these rates (Baker, 2011).
To find effective long-term solutions that reduce rates of maternal obesity, a comprehensive understanding of the complexities of the issue is required (Downe, 2001). Evidence suggests that critical theory is an appropriate theory that promotes understanding of the underlying causes of obesity for both obese women and the midwives caring for them (Streubert and Carpenter, 2011). It also incorporates the principles of a health education model, important in understanding the most effective method of delivering information to women. This theory aims to promote self-management of obesity by empowering women with the knowledge to change their lifestyle for themselves. It clearly identifies health education as the solution to rising rates of maternal obesity. Finding the most appropriate and effective method of delivering this information is central to reducing rates of obesity in the long term. Care should be taken, however, not to adopt a paternalistic approach to health education; to achieve favourable outcomes, it is necessary to have the maximum cooperation and participation of the women receiving the information (CMACE, 2009; Berg, 2010; Kirkham, 2010).
Finding the most effective model of care is the next step. This model should realistically offer women choice but also keep mother and baby safe. To achieve this, the model must incorporate the individual physiological, social, economic and political needs of the obese pregnant woman, yet also address the medical aspects of her care. The Royal College of Midwives (RCM) endorses the use of the salutogenic model of care (Antonovsky, 1996) as a method of achieving a normal birthing experience (Day-Stirk and Palmer, 2003). This model can holistically address the issue of obesity in pregnancy (Downe, 2001). It acknowledges obesity and considers it in terms of planning care, but ensures that the individual needs and choices of the woman are supported. It achieves a balance between the normality of pregnancy and risks associated with obesity in pregnancy, and opposes the pathogenic principles that underpin medical models of care commonly utilised to plan the care of obese pregnant women. Medical models of care arguably ignore the needs of the individual, adopting a method of standardisation (Berg, 2010) and failing to acknowledge that obesity does not change the individuality of the woman and the uniqueness of each pregnancy.
Healthy lifestyle programme
The next emerging theme is finding a method of delivering obesity-related health education to obese pregnant women. There is a growing body of evidence that suggests that the use of a multi-intervention healthy lifestyle programme, containing information around healthy eating, exercise and health education regarding obesity and its possible risks, can be a successful method of restricting gestational weight-gain to within the IOM (2009) recommendations and therefore reducing obesity-related risks to both mother and baby (Claesson et al, 2009; Baker, 2011; Nascimento et al, 2011; Vinter et al, 2011). The principles of such a programme reflect the necessary components for successfully reducing rates of maternal obesity as previously discussed: empowerment with knowledge that encourages self-identification and management of potential obesity-related complications.
Pregnancy Plus
One strategy aimed at addressing the long-term issue of obesity is the Pregnancy Plus programme. The programme was set up in 2009 to address higher-than-national rates of maternal obesity in a region of south-east England and was the winner of the RCM Public Health Award in 2015. It targets pregnant women, identified at the booking interview, with a BMI of ≥30 kg/m2. It incorporates the gestational weight-gain recommendations of the IOM (2009) and the principles of critical theory to present an 8-week healthy lifestyle and weight maintenance programme aimed at empowering women and placing them in control of their care. This salutogenic approach to health education and care-planning ensures that obesity is not the primary focus of the information given. For example, there are sessions that focus on yoga and relaxation, hypnobirthing, breastfeeding and baby massage. The underlying aims of these sessions are to improve women's body image and enhance their self-confidence, factors often lacking in obese pregnant women that can predispose to depression and poor birth outcomes (Richens and Lavender, 2010). Pregnancy Plus involves women in decision-making about their care through constant evaluation and consultation, promoting partnership-working with the women attending, a factor that is crucial to achieving successful outcomes such as spontaneous vaginal delivery and improved breastfeeding rates in high-risk women (CMACE, 2009; Kirkham, 2010).
Pregnancy Plus encourages women to maintain their gestational weight-gain to within the IOM (2009) recommendations by eating a healthy diet and exercising regularly, and incorporates weekly aqua-natal and yoga sessions. Evidence indicates that healthy lifestyle programmes such as Pregnancy Plus have demonstrated improved outcomes in obese women who attended, such as higher rates of vaginal delivery and breastfeeding, lower incidences of gestational diabetes and improved diet and lifestyle in the long term for the whole family (Lindholm et al, 2010; Baker, 2011). Pregnancy Plus also offers obese pregnant women the opportunity to share experiences and support each other through the programme, a factor that enhances the success of maintaining a healthy gestational weight-gain (Baker, 2011).
Outcomes such as higher breastfeeding rates and positive diet and lifestyle changes have been observed and reported by women attending Pregnancy Plus and preliminary (as yet unpublished) findings and evaluations have been positive. This is a notable success in terms of combining a method of reducing short-term risk and addressing rates of obesity in the long term, therefore it may be a viable solution to the overall problem.
There is conflicting evidence regarding the effects on infant birth weight when antenatal weight-gain is restricted in obese pregnant women (Dodd et al, 2008). However, there is a large body of evidence that reports no adverse outcomes when weight-gain is restricted to within the IOM (2009) recommendations (Guelinckx et al, 2010; Baker, 2011). In addition, a recent substantial meta-analysis of 39 randomised controlled trials concluded that restricting gestational weight in obese pregnant women has no adverse effect on infant birth weight (Quinlivan et al, 2011). Claesson et al (2009) support these findings, adding that weight-gain restriction in obese pregnant women contributes to reduced incidences of pre-eclampsia, pre-labour rupture of membranes, caesarean section and instrumental deliveries.
Conclusions and recommendations
The process of risk management, when applied to obesity in pregnancy, is a ‘one size fits all’ strategy that restricts choices and creates inequalities in care for obese pregnant women. Although current risk-management strategies may be appropriate in the short term, long-term strategies need to be developed. The financial benefits associated with apparently managing risks may appear positive. However, compared to the long-term cost of obesity-related health and social care complications, it is an expensive and inefficient solution to reducing national rates of obesity. Dealing with obesity and its underlying causes, rather than just managing the associated risks, is the only realistic method of reducing rates of obesity and costs to the NHS in the long term.
CNST and the NHSLA not only identify the risks of obesity-related complications in pregnancy but also acknowledge the need to address obese pregnant women's expectations for birth. These principles should be applied to aspects of addressing obesity through healthy lifestyle programmes that will work in partnership with the risk-management process to facilitate the individual needs of obese pregnant women. One possible solution that would ensure the sustainability of programmes such as Pregnancy Plus is the endorsement of healthy lifestyle strategies by CNST, as a recognised quality standard of reducing the risks of obesity in pregnancy and childbirth. This would securely embed them in NHS culture and ensure equal access for obese pregnant women to such programmes.
Lack of insight, understanding, empathy and knowledge are major professional limitations when caring for obese pregnant women (Berg, 2010). Negative attitudes of midwives and obstetricians have a major impact on women's uptake of information and also their actual weight-gain, therefore these issues need to be addressed. It is crucial that midwives and obstetricians have sound knowledge and understanding of the underlying causes and predisposing factors associated with obesity, as this will ensure that they can explore possible solutions. Understanding how obese women view and make sense of the world around them is also essential and can be achieved by utilising a social theory such as critical theory (Holloway and Wheeler, 2010; Streubert and Carpenter, 2011). This will identify what information to give women and how to deliver it. There is an identified need to train midwives and obstetricians in broaching the subject of obesity and offering advice and support to women who are obese.
To successfully reduce rates of maternal obesity there is a need for midwives and obstetricians to work together, contributing their expertise to the individual needs of the woman. Utilising a mixed model of care such as the salutogenic model (Antonovsky, 1996) or Berg's (2010) ideal model of midwifery care will facilitate this and ensure that obese women are cared for on an individual basis and have equal access to services. Not all obese women will have complicated pregnancies and births, and it makes financial sense to intervene only when necessary. This will allow obese women to be treated as ‘normal’ unless complications occur. Government or NHS incentives linked to normalising birth for high-risk women—such as financial incentives or rewards to maternity units for reducing caesarean section rates and increasing normal birth outcomes in obese women—may be beneficial to this process.
The IOM (2009) guidelines on restricting gestational weight-gain should be embraced. With 20 years of proven success in reducing risks to mother and baby and vast amounts of evidence that suggest that restricting weight-gain in pregnancy presents no adverse effects for either mother or baby, outcomes are likely to be positive. There is, however, a lack of evidence supporting the use of these guidelines in the UK. This can easily be rectified. There appears to be a failure to commit on behalf of professional bodies such as NICE, the NHS, CMACE and RCOG, where utilising the guidelines is concerned; there is also no commitment to UK guidance. While the professional bodies contemplate these issues, rates of obesity in the UK are rising annually.
In 2014, MBRRACE-UK published its latest triennial report on maternal deaths in the UK (Knight et al, 2014). The findings indicate that rates of obesity-related maternal death have dropped to 27.1%, the first decrease since 2003. This implies that methods of dealing with the risks of obesity in pregnancy have been successful in terms of reducing obesity-related maternal deaths. However, it is debatable whether this outcome is due solely to risk management, or whether health education and public awareness of the associated risks of obesity have been contributory factors. Further research is required to answer this question.