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
Back to the beginning – the aims of this day/why we have brought together a range of public health issues relating to pregnancy and early childhood rather than focussing on issues such as alcohol, smoking, obesity, teenage pregnancy etc separately.

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 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
This workshop is focussing on maternal obesity communication, but workshop activities aim to get you to think across public health issues, similarities, and reflect on what you can learn from your experiences relating to this topic.

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 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)
Not sure if this is needed?

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 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)

17. Obese Women's Experiences of Obesity Discussions
She’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)

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. 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)
“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)

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

21. References
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.
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.
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-e177.
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.
Keely, A., Gunning, M., & Denison, F. (2011). Maternal obesity in pregnancy: Women’s 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.
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.
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