According to the Centre for Maternal and Child Enquiries (CMACE, 2010: xiii), ‘obesity is arguably the biggest challenge facing maternity services today’. Obesity is defined as having a body mass index (BMI) of ≥ 30 kg/m², and 13% of the global adult population falls into this category (World Health Organization (WHO), 2014). In the UK, 1/1000 childbearing women are classed as super morbidly obese, with a BMI ≥ 50 kg/m² or weighing over 140 kg (Knight et al, 2009). UK prevalence of maternal obesity has risen from 7.6% to 15.6% since 1989, presenting major issues for maternity services owing to associated serious health consequences for mother and infant (Heslehurst et al, 2010). These include direct and indirect causes of maternal death and the risk of congenital abnormality, miscarriage, stillbirth and neonatal death (Knight et al, 2014). Both maternal and neonatal risk of serious complications positively correlate with rising maternal BMI, predisposing offspring to non-communicable diseases (Liat et al, 2015). Consequently, the Clinical Negligence Scheme for Trusts categorises maternal obesity as a high-risk condition (NHS Litigation Authority, 2013).
Obesity is classified in the 10th edition of the International Classification of Diseases (WHO, 2015) under ‘endocrine, nutritional and metabolic diseases.’ At an elementary level, weight gain results from more calories being consumed than expended (National Obesity Observatory (NOO), 2015). Therefore, the management of maternal obesity predominantly focuses on healthy diet and exercise (Dodd et al, 2010; Ronnberg and Nilsson, 2010). However, these interventions appear relatively ineffective (Johnson et al, 2013), perhaps as they fail to address other relevant complex issues, including social environment, media influence and psychological traits (Mulrooney, 2012). Collins and Bentz (2009: 124) assert that obesity is as much a psychological problem as a physical one:
‘Psychological issues cannot only foreshadow the development of obesity, but they can also follow ongoing struggles to control weight.’
Correia and Ravasco (2014) and Pan et al (2012) identify bidirectionality between depression and obesity; both sets of authors emphasise that further investigation is essential to understand this link, which is pivotal to successful treatment of both conditions. The NOO (2011) highlights a bidirectional relationship between obesity and psychological issues, which is more prevalent in women, suggesting that some individuals' weight management may be affected by their emotional state; conversely, others may develop psychological issues as a result of their weight issues. Joint maternal weight management guidelines from CMACE and the Royal College of Obstetricians and Gynaecologists (RCOG) omit consideration of these factors (Fitzsimons and Modder, 2010). Conversely, the National Institute for Health and Care Excellence (NICE, 2010) acknowledges that psychological needs should be taken into account on the recommendation of fieldwork evaluators, who suggested the exclusion of such issues may present a major barrier to weight management (Smith et al, 2010). However, NICE did not include recommendations suggesting the bidirectionality of this association and referral to professional counselling services for women who are affected (Smith et al, 2010). As the ‘single point of contact for wide-ranging authoritative information related to weight status and its determinants’ for public health professionals, the NOO is a key resource for midwives. However, although the NOO (2011) recognises the comorbidity between maternal weight and mental health as ‘an important public health issue,’ no guidance specific to the perinatal period is provided. This may suggest a potential shortcoming, particularly as maternal obesity not only predisposes offspring to obesity but—alongside maternal mental wellbeing—is a predisposing factor for short-and long-term emotional and mental health problems in children, indicating an intergenerational perpetuation of these conditions (Robinson, 2013).
Arguably, these guidelines fail to consider emotional wellbeing when tackling maternal obesity, owing to a paucity of evidence specifically investigating a comorbid relationship in the maternal population (Molyneaux et al, 2014). Reflection on the author's practical experience confirms that some midwives are uninformed of this association, while others are aware of it but feel they lack the knowledge and skills to effectively support affected women. As the Nursing and Midwifery Council (NMC, 2012; 2015) requires midwives to prioritise safe, high-quality care, these discrepancies in relevant knowledge and guidance—along with the potential serious consequences of overlooking this issue—provide the rationale for this reflective literature review.
Aim
This literature review aimed to identify whether midwives should consider associated psychological factors when caring for obese women.
Methods
A comprehensive literature search of Quest, Medline, CINAHL, Science Direct and Cochrane databases was undertaken, using the following keywords:
The search was limited to academic print journals from a university library catalogue, in addition to academic e-journals, dissertations, theses and professional magazines. Publication dates were restricted to between 2005 and 2015. Unpublished works and those in languages other than English were excluded. A total of 529 articles were returned. Through a process of discounting duplicates and skim-reading abstracts, 73 full-text articles were chosen to be skim-read, to identify those specifically relevant to an association between psychological factors and maternal obesity. Subsequently, 18 articles were read thoroughly, of which 15 appeared relevant and were re-read. A 16th article—a systematic review and meta-analysis—was received directly from the researcher, which was thoroughly read and deemed important. Hence, studies included in that paper were discounted from selection, resulting in 10 articles for review (Table 1).
| Author and year | Aim and hypothesis | Sample and outcome measures | Methodology | Results | Author's interpretation | Country |
|---|---|---|---|---|---|---|
| Schrauwers and Dekker (2009) | Overview of perinatal physical and psychological outcomes | Women with raised BMI, singleton pregnancies delivered Jan–Jun 2006 (n = 370). Psychological outcome measures included | Retrospective review | Mental health issues more common in groups with raised BMI. Group I OR 3.16, Group II OR 3.53, Group III OR 4.17 (all 95% CIs). Group I: 25.1–30 kg/m2; Group II: 30.1–40 kg/m2; Group III: > 40 kg/m2 | Obesity presents major risk for adverse outcomes and a major challenge for health care providers. Multidisciplinary approach required to care for women with associated mental health issues | Australia |
| Furber and McGowan (2011) | Explore women's experiences related to obesity in pregnancy | 19 pregnant women with BMI > 35 kg/m2 | Semi-structured interviews and field notes; framework analysis | Feelings of humiliation and stigma associated with being obese and pregnant | Obese pregnant women are sensitive about their size, and interactions with health professionals cause distress | Northern England |
| Khazaezadeh et al (2011) | Identify healthcare needs of obese service users | Six obese pregnant women and three trying to conceive. Feasibility study | Semi-structured interviews and focus group interview; framework analysis | Lack of awareness of complex factors associated with maternal obesity | Need for psychological support highlighted. Deep-rooted issues acknowledged | London, UK |
| Furness et al (2011) | Explore women's and midwives' experience of weight management of obese women in pregnancy | Purposive sample; six women and seven midwives | Focus groups | Two overarching themes: ‘Explanations for obesity and weight management’ and ‘Best care for pregnant women’. Psychological and lifestyle are key factors in obesity in pregnancy | Women need midwives' support to combat their negative self-talk messages. Midwives' awareness of psychological impact of obesity and provide appropriate support | Northern England |
| Schmied et al (2011) | Explore experiences of health professionals when caring for obese pregnant women | n = 37 (34 midwives and three other maternity professionals). Focus groups/face-to face interviews | Thematic analysis | Three major themes: 1) A creeping normality; 2) Feeling in the dark; 3) The runaway train | ‘Not waving but drowning’. Problem moving faster than response. Training, communication, rapport, continuity of care to address related psychological issues | Australia |
| Walfisch et al (2012) | Relationship between weight and depressive symptoms in high-risk maternal population | All women attending Motherisk Clinic between Oct 2007 and April 2010 (n = 352); 43.7% were pregnant, 56.3% pre-conceptual | Self-report Edinburgh Postnatal Depression Scale (EPDS) | 27% diagnosed with depression had statistically significant higher body weight compared to non-depressed (P = 0.016), also significant in pregnancy subgroup (P = 0.036). EPDS score positively correlated with body weight for whole group (P = 0.027) | Strong association between maternal weight and depressive symptoms regardless of diagnosis. As both may adversely affect pregnancy outcomes, addressing both is essential | Canada |
| Smith et al (2012) | Explore health professionals' experiences of caring for pregnant women with a BMI > 30 kg/m2 and opinion of proposed lifestyle programme | 30 maternity professionals (midwives, sonographers, anaesthetists, obstetricians) | Semistructured interviews; thematic analysis | Three main themes: 1) Obesity is a communication challenge; 2) Maternity issue, grave impact, intervention needed; 3) How to break obesity cycle? | Support for antenatal lifestyle programme and need for further exploration of impact of interventions on maternal obesity. Little knowledge of psychological issues related to obesity | North West England |
| Lindhardt et al (2013) | Examine experiences of women with pre-pregnant BMI > 30 kg/m2 and their encounters with health professionals | 16 pregnant women | Qualitative in-depth interviews, face-to-face in women's homes; Giorgi's (2009) phenomenological analysis | Two main themes identified: 1) Accusatorial response from health professionals; 2) A lack of helpful advice on how being obese and pregnant might affect woman's and infant's health | Obese pregnant women felt judged and treated disrespectfully. Communication skills during training should be improved. Health professionals need awareness of psychological factors associated with obesity and its relationship to mental health | Denmark |
| Heslehurst et al (2013) | Explore midwives' perceptions of education and training relevant to maternal obesity | 46 community and hospitalbased midwives from all NHS Trusts in North East England | 11 focus groups; thematic analysis | Three main themes identified: 1) Discussing obesity; 2) Weight management; 3) Practicalities of training | Systematic approach to training endorsed by midwives to achieve the required specialist level, particularly to deal with psychological and emotional aspects related to maternal obesity. Focus on communication and interpersonal skills | North East England |
| Molyneaux et al (2014) | Evaluation of the prevalence and risk of antenatal and postnatal mental disorders in overweight and obese women | Seven databases, citation tracking, handsearching, expert recommendation. 62 studies, 540 373 women | Systematic review and metaanalysis | Elevated depressive symptoms during pregnancy: (obese OR 1.43, 95% CI 1.27–1.61, overweight OR 1.19, CI 95% 1.09–1.31, median prevalence: obese 33%, overweight 28.6%, normal weight 22.6%). Postpartum: (obese OR 1.30, 95% CI 1.20–1.42, overweight OR 1.09, 95% CI 1.05–1.13, median prevalence: obese 13%, overweight 11.8%, normal weight 9.9%). Increased antenatal anxiety in obese women: OR 1.41, 95% CI 1.10–1.80 | Health-care providers should be aware that obese women who have associated maternal obesity and mental health issues present a particularly high-risk category | Conducted in UK, included studies from developed and developing nations |
BMI–body mass index
Discussion of findings
Evidence of associations between maternal obesity and mental health
Maternal depression
Schrauwers and Dekker (2009), Walfisch et al (2012) and Molyneaux et al (2014) concur that there is a strong association between maternal depression and maternal obesity throughout the entire perinatal period, although prevalence during pregnancy appears to be greater than postnatally (Furber and McGowan, 2011). However, 80% of women who experience depression during pregnancy will also experience postnatal depression (Boots Family Trust Alliance, 2013). Molyneaux et al (2014) report a dose-response relationship with increasing BMI, which may explain why midwives find women in higher BMI categories more difficult to motivate in relation to weight management (Furness et al, 2011).
Walfisch et al (2012) identify that maternal obesity is related to psychological disorder, regardless of whether or not depression has been officially diagnosed, asserting that this is not a rare occurrence. Molyneaux et al (2014) corroborate this, stating that one third of obese women suffer perinatal depressive symptoms. Many such women remain undetected, which can have serious consequences (Alder et al, 2011); the majority of late maternal deaths in 2009–12 were associated with perinatal mental health conditions (Knight et al, 2014). Furthermore, maternal depression can adversely affect mother–infant attachment, resulting in impaired infant social, emotional and cognitive development (McPhail et al, 2012). Molyneaux et al (2014: 9) agree that even subclinical symptoms can result in detrimental perinatal outcomes, identifying the need for further research to establish the impact of maternal depression on ‘health behaviour and behavioural change’ within the obese maternal population.
Maternal anxiety
Molyneaux et al (2014) report that obese women are significantly more inclined to experience perinatal anxiety than their normal-weight peers. Midwives allude to anxiety in obese pregnant women being provoked by weight-monitoring, suggesting that routine weighing of all women may reduce stigma, as obese women would not feel ‘singled out’ (Heslehurst et al, 2013). However, historically, weight-monitoring was discontinued because of the anxiety it provoked (Warriner, 2000). Consequently, reintroduction could incur increased scrutiny, which may already encroach on women's ability to enjoy their pregnancy (Lindhardt et al, 2013), and may create greater anxiety among those at higher risk of psychological distress (Molyneaux et al, 2014). Such evidence suggests an association between maternal anxiety and maternal obesity is mediated by women's experiences of weight-focused maternity care (Lindhardt et al, 2013); this may exacerbate the anxiety and impaired self-esteem many women already experience, owing to deleterious media attention that negatively influences societal perception of obesity (Mulrooney, 2012). Hayes (2010) cautions that maternal anxiety can precede depression, with both negatively affecting the mother–infant bond. Molyneaux et al (2014) recommend that further high-quality inves tigation into the association between maternal anxiety and obesity is required for more definitive conclusions to be drawn.
Binge eating disorder
With the exception of Molyneaux et al (2014), none of the studies identify binge eating disorder (BED) as a psychological issue associated with maternal obesity. However, in one study a woman explains how having to lose weight to receive fertility treatment caused her to self-loathe, which led to ‘increased consumption of food as comfort and consolation’ (Khazaezadeh et al, 2011: 53). Obese women who self-loathe have extremely low self-esteem, and are more likely to experience depression and engage in disordered eating (Edman et al, 2011). BED is a serious psychiatric disorder, which does not involve compensatory purging, hence can lead to obesity (Harris, 2010). Vandenberg and Baker-Townsend (2012) assert that BED linked to maternal obesity can begin during pregnancy owing to hormonal changes leading to feelings of despair. This appears to indicate that there may be a bidirectional relationship between maternal obesity and BED. Two large-scale prospective studies, with more than 100 000 perinatal participants, provide evidence of the prevalence of BED related to psychological and weight-related factors in the maternal population (Knoph Berg et al, 2011; Knoph et al, 2013).
The American Psychiatric Association (2000) suggests that subclinical binge eating behaviours, not meeting full diagnostic criteria, are likely in 15% of young females (aged 12–29 years), indicating that these may be present in a substantial proportion of the maternal population. Chizawsky and Newton (2006) specify that such tendencies should be explored by midwives at booking appointments and, if identified, involve a specialist multidisciplinary approach to care. However, Vandenberg and Baker-Townsend (2012) allege that midwives may lack the knowledge and competence to screen for psychological issues; this was unanimously confirmed in all studies exploring midwives' experiences (Furness et al, 2011; Schmied et al, 2011; Smith et al, 2012; Heslehurst et al, 2013).
NICE (2010) advocates that midwives discuss eating habits with women, yet none of the midwives or health professionals in any of the qualitative studies allude to this directly (Furness et al, 2011; Schmied et al, 2011; Smith et al, 2012; Heslehurst et al, 2013). Furber and McGowan (2011) report on women's eating behaviour in terms of women feeling stereotyped, believing that maternity professionals presume that they eat excessively or lack control. Women express experiencing antagonistic self-talk messages, providing them with excuses to eat (Furness et al, 2011). Bourne (2010) explains that such inner dialogue perpetuates maladaptive behaviours and psychological distress. One woman admits being more likely to eat ‘unhealthily’ when alone; however, what this specifically means is not expanded on (Furness et al, 2011: 4).
Pearlstein (2002) alleges that maladaptive eating behaviours are difficult to detect in the perinatal population, as women are unlikely to disclose their symptoms. Harris (2010) affirms that pregnant women are clandestine about such behaviour, as a result of feeling ashamed. However, the gravity of the apparent problem and the detrimental consequences of both maternal mental health issues and obesity on perinatal outcomes (Knight et al, 2014) suggest that midwives urgently require adequate education and training to successfully identify and appropriately care for women at risk.
Severe mental disorder
Evidence of an increased risk of severe mental illness (e.g. bipolar disorder, schizophrenia, diverse psychotic conditions) in obese women throughout the perinatal period is exclusively reported by Molyneaux et al (2014). However, midwives express knowledge of a link between women's weight issues and serious physical or sexual trauma they have experienced (Schmied et al, 2011; Heslehurst et al, 2013). Women with a history of serious mental health problems are at increased risk of experiencing perinatal mental disorders, which may be partially attributable to discontinuation of medication (Cantwell et al, 2011). They often have little support and endure societal stigma, causing them psychological distress which can adversely affect the mother–infant bond (Mowbray et al, 1995). The NSPCC (2013) reports that 50% of infanticides are committed by mothers, 90% of whom are suffering from mental health disorders.
Knight et al (2014) identify both maternal obesity and mental illness as increasing the risk of maternal mortality; however, data demonstrating a possible correlation are not provided. Taylor (2012) reports a bidirectional association between obesity and severe psychiatric illness, which is dose-dependent i.e. as BMI increases, so does the probability of receiving a psychiatric diagnosis. Moreover, the association between obesity and serious psychiatric conditions is significant enough to lead to consideration of its categorisation in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Marcus and Wildes, 2012). Midwives need to understand that the association between maternal obesity and serious mental disorders places women in a very high-risk category (Molyneaux et al, 2014), requiring both specialist multidisciplinary support and additional midwifery care (NICE, 2010).
Psychological barriers to weight management
Motivation
Health professionals may presume that weight management interventions during pregnancy have a higher probability of success, as women's motivation is likely to increase (Smith et al, 2012). However, women do not appear to corroborate this, feeling that their heightened emotion during pregnancy is inappropriate for weight management (Khazaezadeh et al, 2011). A large US survey identified lack of motivation as a major factor preventing pregnant women from exercising (Evenson et al, 2009). In the study by Furness et al (2011), women and midwives cited lack of motivation as a barrier to healthy lifestyle change, indicating that psychological explanations of motivation on health behaviour should be explored (Dixon, 2008).
Motivation and self-efficacy
Motivation is linked to self-efficacy (Dixon, 2008)—the belief that one can achieve something (Bandura, 1977). The association between the two is vital to behavioural change, as the former is required to initiate intention and the latter to continue action while coping with potential obstacles (Dixon, 2008). Obese women require perinatal support to develop self-efficacy, in order to successfully manage their weight issues. Appropriately, Smith et al (2012) underpin their ‘TLC programme’ with health psychology theories, as these provide insight into how psychological factors are involved in reinforcing behaviour, in terms of changing attitude and promoting self-efficacy (Smith et al, 2015).
Self-efficacy and self-esteem are interlinked (Jomeen and Martin, 2005). Low self-esteem is significantly correlated with BED in pregnant women (Knoph Berg at al, 2011); it has an impact on self-confidence, and Dixon (2008) suggests individuals may have low levels of confidence due to a depressed or anxious emotional state. Cameron et al (1996) identified that higher body weight negatively correlates with self-esteem and that both are associated with depressive symp toms during late pregnancy. One woman interviewed by Khazaezadeh et al (2011) attributed her low self-esteem to her raised BMI. Obesity has an impact on self-esteem owing to stigmatisation exacerbated by the media, diminishing the ability of those affected to lose weight (Heslehurst et al, 2011). O'Connor et al (2008) confirm that the psychological distress experienced leads to overindulging in sweet and fatty foods, again indicating a bidirectional link with maternal obesity (NOO, 2011). Maternal obesity entails multiple psychological factors, one of which is low self-esteem, which may inhibit establishing the respectful woman–midwife relationship of trust that is vital to providing safe, womancentred care (Kirkup, 2015). Consequently, this has a negative impact on the effectiveness of weight management in pregnancy (Schmied et al, 2011).
Stigma and iatrogenic causes of psychological distress
Furness et al (2011: 3) identify stigma and psychological factors as subordinate themes of ‘explanations of obesity and weight management’, as women report that the pre-pregnancy stigma they felt increased during pregnancy. Conversely, others feel less stigmatised when around other pregnant women, which may explain why Carter et al (2000) suggest maternal obesity is unlikely to be associated with depression. Molyneaux et al (2014) refute this claim, providing evidence of the existence of weight-stigma throughout the perinatal period, which has an impact on the mental wellbeing of women affected. These findings support Kulie et al (2011), who suggest stigmatisation may account for a link between obesity and depression in females, which Campos et al (2006) deem is intensified during pregnancy by the current over-emphasis on the detrimental effects of maternal obesity on the woman and fetus.
Women can feel humiliated and stigmatised by being made to feel that their weight dominates their pregnancy (Furber and McGowan, 2011). Such stigma may have a negative effect on their body image, exacerbating the distress they may already feel about their size (Furber and McGowan, 2011; Lindhardt et al, 2013). One woman reported that her midwife's comments during auscultation increased her self-loathing (Furber and McGowan, 2011: 439):
‘“Which way's she lying? I think this way, but I have to dig a bit deeper with you.” She just makes me feel awful for being big. It just makes you think you don't want to be pregnant.’
In practice, this author has observed similar scenarios, which were non-malicious but were seemingly an attempt to cover midwives' embarrassment of feeling inept in the situation. Nonetheless, this contravenes the midwife's professional duty to demonstrate respect and dignity at all times (NMC, 2015), which has been highlighted by Kirkup (2015) as an essential component of safe care.
Many women reported that feelings of embarrassment dominated their maternity experience (Furber and McGowan, 2011; Furness et al, 2011; Lindhardt et al, 2013); two women revealed that having their raised BMI determined at booking felt like receiving an official confirmation of being fat (Khazaezadeh et al, 2011). During ultrasound examinations, some women reported feeling ostracised, leaving them unable to cope and turning a potentially pleasurable experience into one in which they felt vulnerable (Lindhardt et al, 2013). The realisation that specialist equipment is required for their care may further perturb women; their distress increases when this equipment is not available (Furber and McGowan, 2011). Large blood pressure cuffs frequently have to be sought and cardiotocography straps are generally only available in one size, so are often inadequate for women with higher BMI; this may cause them physical discomfort and emotional distress.
The detrimental impact on women's body image may impede their preparation for motherhood. Some women describe their devastation on being informed that their weight may adversely affect breastfeeding (Lindhardt et al, 2013). None of the studies exploring midwives' views acknowledge this impact on women (Furness et al, 2011; Schmied et al, 2011; Smith et al, 2012; Heslehurst et al, 2013), which may be attributable to women hiding their weight-related anxieties (Furber and McGowan, 2011). Breastfeeding was only considered in terms of difficulties that have an impact on time and the related expense of providing extra care (Schmied et al, 2011). This discrepancy between women's and midwives' experiences demonstrates a necessity to address the psychological impact of weight-focused treatment on women, particularly as some professionals feel the physical impact of maternal obesity is their domain and self-admittedly know ‘little about the possible effects of obesity on psychological wellbeing’ so are unable to provide appropriate support (Smith et al, 2012: 5). As highlighted by Francis' (2013) recommendations, midwives are required to provide consistent compassionate care (NMC, 2015), utilising reflection in and on practice to straddle the theory/practice gap, enhancing their competency, and improving the care they provide (Jasper, 2003). Interprofessional and multidisciplinary team working, as advocated by Kirkup (2015)—in this case, with mental health practitioners—may increase midwives' understanding of the psychological complexities involved.
Some women express feeling sadness and worry at being ‘singled out’ because of their weight (Lindhardt et al, 2013: 1104). The assumption that obese women are abnormally restricted in their movement makes them feel stereotyped (Furber and McGowan, 2011) and fails to provide individualised woman-centred care (Royal College of Midwives (RCM), 2016). In this author's experience, some women express that they look forward to using the birthing pool, only to hear that their BMI prevents them from doing so. Depriving women of choice violates both the NMC (2015)Code and maternity policy (DH, 1993; Chief Nursing Officers of England, Northern Ireland, Wales and Scotland, 2010). Given that obese women experience greater levels of ‘emotional and traumatic stress during pregnancy’ (Lacoursiere et al, 2006: 385), they may actually benefit from the water's relaxing effect.
‘Stereotyping, labelling, separation, status loss and discrimination’ are all aspects of stigma that obese women mention (Furber and McGowan, 2011: 442), asserting that they feel alienated from other pregnant women. In the study by Heslehurst et al (2013), women affirmed that they felt isolated and unsupported. Weight-stigma is associated with increased maternal depression and BED, and can lead to social isolation (Mulherin et al, 2013), increasing the risk of maternal mortality (Cantwell et al, 2011). Furber and McGowan (2011: 442) purport that labelling women as obese sanctions the medicalisation of their pregnancies and depersonalises their care, as their individual ‘needs, expectations and anxieties’ are lost. Confirmation of this notion is given by women who feel that their weight, unexpectedly, overshadows their pregnancy, causing them psychological distress (Lindhardt et al, 2013).
Stigma and communication
Many midwives report feeling uncertain about how best to communicate with women without causing distress (Schmied et al, 2011; Heslehurst et al, 2013). One woman described being brought to tears by an obstetrician who constantly referred to her weight, making her feel responsible for potential pregnancy risks (Furber and McGowan, 2011). Conversely, some midwives appear to understand the sensitivity and emotion surrounding mat ernal obesity, empathising that they do not want women to experience stigma, worry or guilt (Heslehurst et al, 2013). Accordingly, they give women a choice—for example, of whether to be weighed—which they feel encourages women to engage (Heslehurst et al, 2013).
Some midwives comment that women's choices are limited on being categorised as obese, which has a negative impact on the emotional wellbeing of both parties (Heslehurst et al, 2013). Health professionals express difficulty addressing weight issues but feel the need to overcome these, as the serious implications of maternal obesity necessitate discussion (Smith et al, 2012). Many mid wives realise that, in some cases, causes of obesity may be deep-rooted in psychological trauma experienced in childhood (Schmied et al, 2011). Knoph Berg et al (2011) verify that lifetime physical and sexual abuse significantly correlate with BED in pregnant women. Collins and Bentz (2009: 3) suggest that obese women who have experienced abuse may use their size as a ‘protective barrier’, and post-traumatic symptoms may re-emerge if they lose weight. A common theme is that midwives feel that such sensitive issues obstruct them from broaching the subject of weight without putting their relationship with the woman at risk (Furness et al, 2011; Schmied et al, 2011). There is general consensus among health professionals that an urgent need exists for communication and interpersonal skills training to provide appropriate care for women with obesity, without causing additional distress (Furness et al, 2011; Schmied et al, 2011; Smith et al, 2012; Heslehurst et al, 2013). In consideration of NHS Constitution (DH, 2015) specifications to prioritise patients by providing collaborative care, demonstrating respect and dignity at all times—along with the NMC (2015) requirement to provide individualised woman-centred care, promoting autonomy and respecting diversity—the apparent lack of confidence in their interpersonal skills suggests that practitioners require specialist training in person-centred counselling, as is currently being piloted to address fear of childbirth (Reed et al, 2014). Underpinned by humanistic ideology, this approach advocates the use of reflection to enhance self-awareness to provide congruent, non-judgemental care, communicating empathic understanding (Rogers, 1957). Without appropriate application of these values, true woman-centred care as advocated by the NMC (2015) and DH (2015) cannot be provided.
Supporting obese women with comorbid psychological issues
Midwives suggest that continuity of care would provide better support to women with underlying psychological issues. They recognise the requirement for training and skills development to achieve optimal outcomes (Schmied et al, 2011), owing to the ‘deep-rooted’ issues some women have (Heslehurst et al, 2013: 740). Lindhardt et al (2013) assert that training should focus on empathic techniques of enhancing women's self-efficacy and motivation, which could involve motivational interviewing. This technique may also be useful to address women's negative self-talk (Miller and Rollnick, 1991). Khazaezadeh et al (2011) concur that weight issues cannot be successfully addressed with dietary and exercise interventions alone, as they need to have a psychological impact. Consequently, bespoke weight management interventions must be developed for women with related mental health problems (Molyneaux et al, 2014). Walfisch et al (2012) recommend optimising safe pregnancy outcomes by screening obese women for comorbid occurrence of depression, which could involve adapting Whooley et al (1997) style questioning for the purpose of identifying specific weight-related issues (Smith et al, 2012). Molyneaux et al (2014) stipulate that women affected by comorbid conditions are likely to be a particularly high-risk group. Given the potential increased risks, a specialist multidisciplinary approach to care is advocated (Schrauwers and Dekker, 2009; Heslehurst et al, 2013; Molyneaux et al, 2014), as corroborated by Kirkup (2015).
Conclusions and recommendations
An association between maternal obesity and psychological problems has been identified, the causality of which may be bidirectional. Both women with diagnosable psychological disorders and those experiencing subclinical symptoms are at risk, and many may not disclose these concerns. The disrespectful or tactless treatment some women receive in maternity services can exacerbate their psychological distress, which may make them feel unsupported and lead them to comfort-eat. The blame, guilt and stigma women experience through medicalised weight-focused care can increase their psychological turmoil, depriving them of pregnancy enjoyment and leaving them feeling incapable of motherhood. These combined issues may have a negative impact on weight management in the perinatal period; greater consideration of this may be given if maternity professionals are educated in empirically corroborated related psychological conditions, resulting in robust evidence-based practice in line with NMC (2015) requirements.
Interprofessional and multidisciplinary working with mental health professionals may enhance understanding of the psychological complexities involved and increase midwives' competence in providing appropriately sensitive care when performing clinical duties. In view of the distress it appears to cause, weighing should be limited to a required minimum (Lindhardt et al, 2013).
Overall, midwives appear to empathise and understand that there may be deep-rooted psychological issues underlying women's weight problems, yet they feel ill-equipped to provide appropriate care for fear of intensifying women's distress. A common theme is that interpersonal skills training, using personcentred counselling techniques underpinned by humanistic principles, is required—not least as it promotes reflection in and on practice, which enhances practitioners' self-awareness, facilitating non-discriminatory, woman-centred care (Freshwater, 2003). Additionally, this deeper understanding of interpersonal communication may assist identification of women presenting a higher level of associated risk, who require specialist psychological or psychiatric referral and would fulfil midwives' professional duty to provide individualised care within a multidisciplinary team (Kirkup, 2015; NMC, 2015).
Current maternal weight management guidance (Modder and Fitzsimons, 2010; NICE, 2010), on which local policy is based, appears largely ineffective (Johnson et al, 2013). This is partially due to neglecting issues surrounding an association between psychological factors and maternal obesity. Consequently, the apparent magnitude of the problem, including a potential intergenerational cycle of obesity and mental health in relation to these issues, suggests that policy revision may be necessary to highlight this matter so that appropriate improvements can be made. This will serve to enhance the maternity experience of obese women, improve maternity outcomes and, possibly, have a positive impact on associated public health trajectories.