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1 Discussing Maternal Obesity Dr Ruth Bell (Newcastle University) Dr Nicola Heslehurst (Teesside University)

2 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

3 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 womens 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

4 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

5 Maternal Obesity Trends: Regional Implications England: Obese BMI 1989: 7.6% (~45,000 women) 2007: 15.6% (~92,500 women) North East: Obese BMI 2007: 18.2% (Heslehurst et al 2010)

6 Maternal Obesity and Public Health: Socio-economic Inequalities Obesity ClassHeslehurst et al (2010) (Adjusted Odds Ratios) CMACE (2010) Obese (all BMI >30 kg/m 2 )2.2 (95% CI 2.1, 2.3)– Moderately (30–35 kg/m 2 )2.0 (95% CI 1.9, 2.0)– Severely (34–40 kg/m 2 )2.7 (95% CI 2.5, 2.9)11.3% (least deprived) 34.6% (most deprived) Morbidly (40–50 kg/m 2 )3.0 (95% CI 2.7, 3.3)11.0% (least deprived) 33.8% (most deprived) Extreme (>50 kg/m 2 )4.7 (95% CI 3.2, 6.9)10.2% (least deprived) 35.7% (most deprived)

7 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

8 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 % will not be stillborn

9 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

10 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

11 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

12 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

13 Obesity Communication

14 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.

15 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.

16 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 theyre 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)

17 Obese Women's Experiences of Obesity Discussions Shed told me that she was finding it hard to find the babys heartbeat because I was overweight. I come out and I was in floods of tears. You think that youre 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 cant. 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 hadnt been raised at all until I got a phone call from the midwife saying, Ive got two scans and an appointment with a consultant for you. I was like, Whats wrong, like? And then she said No, no, its just because youre obviously … a BMI over 40 (Keely et al 2011)

18 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)

19 Like Im overweight. You know, how can I sit there and tell this lady about her weight when Im overweight? (Midwife) Ive always found its a little bit easier to address it when you are overweight than if youre this gorgeous skinny looking thing saying well youre a bit chubby there (Schmied et al 2010) Healthcare Professionals Experiences of Obesity Discussions: Building a Relationship/Own Weight Often when you meet somebody youve just met them for the first time, most of us want to be nice to that person... you dont wanna come across as though youre sitting there Miss Perfect criticising when youre trying to start this good relationship with them, youre going to be looking after them for the next nine months. (Midwife) (Heslehurst et al 2011) Youre kind of torn... youve got to be there as a support for them, at the same time youre the one thats giving them the bad news as a medical professional were saying that you are now high risk because of this...youre trying to be as sympathetic and empathetic as you can but yet youre still the one thats going to stop them from having what they want [birth choice]. I just think thats quite hard sometimes. (Midwife) (Heslehurst et al 2011)

20 Because I think thats the hardest thing, most of us just ignore it when... they say Im a fat lass are they wanting you to say right... how are we gonna tackle it? but most of us dont, most of us just go [embarrassed gesture] yeah I know and just ignore it because we dont know what to answer to that. What do you say to somebody whos 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 Im gonna mention something, and I find then that situation much harder because I dont wanna hurt her. (Midwife) (Heslehurst et al 2011) Healthcare Professionals Experiences of Obesity Discussions: Womens Reactions/Reacting to Women

21 References 1.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, 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: /j.midw 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-e 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 Births, International Journal of Obesity, 34, 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: Womens understanding of risks. British Journal of Midwifery, 19(6), Keenan, J., & Stapleton, H. (2010). Bonny Babies? Motherhood and Nurturing in the Age of Obesity. Health, Risk & Society, 12(4), Merrill, E., & Grassley, J. (2008). Women's Stories of their Experiences as Overweight Patients. Journal of Advanced Nursing, 64(2), 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), 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), 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: /j.midw 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: /j x. 16.Wadden, T. A., & Didie, E. (2003). What's in a Name? Patients' Preferred Terms for Describing Obesity. Obesity Research, 11(9),

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

23 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

24 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.

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