Coping with obesity: Research and practice realities

Obesity: Overview
The health and economic burdens associated with obesity are given regular (and often sensationalised) coverage in the popular media, supported by statements from high profile bodies like the World Health Organization, which has described this condition as a serious epidemic facing developed countries (WHO, 2000).

In the UK, the government of the day commissioned a review of future trends in terms of obesity. The final report (Foresight, 2007) predicted that if things remain the same, half of adults in the country will be obese by 2050, costing the National Health Service £10 billion per year. Modern lifestyles were identified as a major contributor to the current rise in obesity:

“People in the UK today don’t have less willpower and are not more gluttonous than previous generations. Nor is their biology significantly different to that of their forefathers. Society, however, has radically altered over the past five decades, with major changes in work patterns, transport, food production and food sales. These changes have exposed an underlying biological tendency, possessed by many people, to both put on weight and retain it,” (Foresight, 2007).

Individuals with a Body Mass Index (BMI) = 30 are confronted by psychosocial as well as physical challenges due to their weight, including discrimination and stereotyping (Puhl and Brownell, 2001), being blamed for a perceived lack of personal control, motivation and restraint. Yet research shows the picture is more complicated than this. For example, in England obesity correlates with socioeconomic status and household income among females; it is more likely to affect deprived women (The Health and Social Care Information Centre, 2010) and those from Black African, Black Caribbean and Pakistani groups (Gatineau and Mathrani, 2011).

Given the negative social connotations surrounding obesity, broaching the topic of weight in a healthcare setting can be difficult (Heslehurst et al., 2007; Wadden and Didie, 2003), especially if practitioners feel inadequate in their knowledge, believe that weight management is a difficult clinical outcome to achieve (Brown and Thompson, 2007) or are concerned about a lack of resources to manage such cases.

In this article, we reflect on issues faced by professionals coping with obesity in midwifery care.

The importance of eating fresh fruit and vegetables is even greater for pregnant women.

Pregnancy and obesity: Associated risks
Numbers of women with a raised BMI being seen by midwifery staff are increasing; Heslehurst and colleagues (2010) reported that the prevalence of obesity in English maternity units rose from 7% in 1990 to 16% in 2007. This is despite the fact that obesity has a negative impact on fertility among women (Brewer and Balen, 2010) and augments chances of miscarrying (Lashen et al., 2004). Being obese has also been linked to maternal mortality (Lewis, 2007).

Apart from its association with mortality, obesity heightens the risk of complications such as pre-eclampsia (O’Brien et al., 2003) and gestational diabetes mellitus (Torloni et al., 2009). Women with a raised BMI often have slower labours and more Caesarean births than those of normal weight (Poobalan et al., 2009) and are likely to produce larger babies (Heslehurst et al., 2008). They also tend to have longer postnatal hospital stays (NHS Information Centre, 2010).

Postpartum haemorrhage and wound infections from Caesarean section are increased among this population (Sebire et al., 2001), as is thromboemolism (Jacobsen et al., 2008). A survey by LaCoursiere and colleagues (2006) indicated a potential relationship between pre pregnancy BMI and self-reported symptoms of depression in the postpartum period. In addition, breastfeeding appears lower among women with a raised BMI (Amir and Donath, 2007).

Babies of obese mothers are at risk of developing a congenital abnormality including cleft lip (Stothard et al., 2009) and spina bifida (Ramussen et al., 2008), and are more likely to become obese themselves as they mature (Olson et al., 2009). Neonatal admissions are also increased for such infants (Heslehurst et al., 2008).

Despite the potential problems associated with being pregnant when obese, it is important that practitioners work towards facilitating an experience for the woman and her partner that is acceptable, fulfilling and as normal as possible.

Practice realities: Guidance in how to proceed
Managing the care of a pregnant obese woman is challenging, not only because of the associated risks listed above but also because assessing and monitoring pregnancy and labour are more difficult. To assist midwives and obstetricians, the Centre for Maternal and Child Enquiries (CMACE) and the Royal College of Obstetricians and Gynaecologists (RCOG) published joint guidance on the management of pregnancy among those with a raised BMI (CMACE/RCOG, 2010). Some of its main recommendations are summarised below.

Pregnancy

• To avoid the risk of congenital abnorma- lities, obese pregnant women should be reminded to continue taking daily folic acid (5 milligrams) during the first trimester. Vitamin D (10 micrograms) should also be taken daily during pregnancy and breast feeding by these mothers.
• Assessment is required into the risk of thromboembolism, and prophylactic low molecular weight heparin prescribed, if appropriate.
• The danger of pre-eclampsia means blood pressure recordings should be made with an appropriately sized arm cuff. If women are considered to have additional risk factors for pre-eclampsia, 75 milligrams of aspirin may be prescribed daily, until the birth.
• Gestational diabetes mellitus should be screened by oral glucose tolerance test between 24 – 28 weeks of pregnancy.
• Given the likelihood of operative birth, those with a BMI > 40 should be re viewed by an obstetric anaesthetist to identify any particular difficulties associ ated with regional or general anaesthesia.

Labour

• Key personnel such as the anaesthetist, obstetrician and operating theatre staff should be notified when women with BMI > 40 are in established labour.
• Because of the risk of operative birth, ve- nous access should be established early in the labour of those with BMI > 40; epidural analgesia may be advised be- cause of anaesthetic complications if a Caesarean birth is needed.
• In the second stage of labour, midwives and obstetricians attending the birth should be alert for shoulder dystocia and skilled in procedures to deliver the baby if this event occurs.
• Active management of the third stage of labour is recommended because of the risk of haemorrhage.

Postnatally

• For those women who have a Caesarean birth, prophylactic antibiotics should be prescribed to minimise infections.
• If mobility is restricted, obese mothers should be supported in caring for their baby and encouraged to mobilise as much as they can.
• Prophylactic thromboembolic therapy may be continued during the postnatal period.
• If the labour has been long and/or trau- matic for the mother, it is important that staff take time to answer any questions posed by the woman and her partner.
• Breastfeeding should be supported and after transfer home, midwives should en- sure that mothers have contacts for appropriate help, such as feeding counsellors, baby cafes and support groups.

The remainder of this paper will pick up on and expand some of the points listed above, by discussing important aspects of care to be considered by midwives and obstetricians when working with an obese woman.

Language and information: Discomfort and deficits
A UK-wide audit has suggested pregnant women are generally not made aware of the risks associated with being obese by their midwifery team (CMACE, 2010) and may be surprised at the levels of attention afforded to them. Additional assessments in cases of obesity contribute to a more medicalised approach to pregnancy (Furber and McGowan, 2010), with a greater use of technology potentially forming a ‘barrier’ between the woman and practitioner (Schmied et al., 2010).

Pregnancy can be a worrying time, so it is important practitioners explain why assessments are required and that informed consent is obtained for all procedures. Clear and effective communication that is sensitive to the situation and fosters participation in decision making will help mothers and their partners to feel in control. Conversely, poor information provision increases anxiety and dissatisfaction among obese women, who may be shocked at reading remarks practitioners make in their notes, as the following quote from Furber and McGowan’s (2009) qualitative research illustrates:

“Every time I go to the hospital it says on the scans that they weren’t as good due to the raised BMI. Nobody actually speaks about it. It’s virtually on every page of my notes. Nobody’s actually sat down and asked if I’m aware I’m overweight. I’m not over the moon about it, but when you’re trying really hard, that’s more than soul destroying.”

Obesity is a sensitive topic to discuss due to associated social stigma (Brown and Thompson, 2007), coupled with practitioners’ wish to maintain a good relationship with service users (Tailor and Ogden, 2009). Raising this topic may be particularly awkward when first meeting someone, especially if the reason for presenting to a service is not for weight management. Techniques used by nurses in primary care to discuss weight with obese patients include motivational interviewing, avoiding stereotypes and being cognisant of psychosocial contributors to the condition (Brown and Thompson, 2007). These are approaches that staff in midwifery services should likewise follow.

Research by Tailor and Ogden (2009) suggested practitioners may avoid the term obese, replacing it with something they perceive to be more palatable, such as ‘your weight may be damaging to your health’. Yet this study also found that the term ‘obese’ made lay people feel the situation was serious, prompting them to consider changing behaviour, whereas a euphemistic phrase caused confusion and was perceived to downplay the need to act. That said, it should be noted that obese pregnant women dislike constant references to their size during appointments (Furber and McGowan, 2010; Nyman et al., 2010).

Pregnancy and weight management: A time to intervene
The apprehension some practitioners experience when broaching size in a clinical setting is unfortunate because pregnancy offers an optimal opportunity to initiate discussion of weight management. Such discussion could start at the booking visit. Some practitioners may feel happier waiting to do so until a rapport has been developed with the woman, but this can be difficult if continuity in midwife is lacking.

Women and practitioners may be frustrated by a paucity of guidance relating to optimal weight gain during pregnancy if obese; there is currently no research sufficiently rigorous in this area, although weight loss during pregnancy is not advised because it can be harmful to the unborn child (NICE, 2010). That said, the US Institute of Medicine has published guidance based on observational studies recommending obese women aim to gain between 5 and 9.1 kilograms during pregnancy (Rasmussen et al., 2009).

It is argued that midwives are ideally placed to advise obese pregnant women about lifestyle changes (Schmied et al., 2010), although dietetic input may be a more appropriate (if under-resourced) service for these mothers (CMACE, 2010). Stressing the benefits of a good diet for the fetus may motivate individuals to alter their habits, if done in a way that does not make them feel judged. Breastfeeding should also be promoted and the benefits explained, underlining the fact that breastfed babies appear less likely to be obese when they grow up (Dewey, 2003).

Women’s nutritional understanding and self-confidence in being able to change their weight-related behaviours are likely to vary. For some, it will be necessary to start from a low level in terms of knowledge and skills, and setting realistic, progressive goals may be required to build self-efficacy. Whilst providing such support, practitioners need to consider socioeconomic factors that play a role in obesity; for example, highlighting how frozen fruit and vegetables are a suitable alternative to fresh and giving suggestions for inexpensive physical activities. It should be made clear that exercise is safe during pregnancy and that women should try to incorporate at least 30 minutes of physical activity into daily life (NICE, 2010; RCOG, 2006); this will need to be introduced gradually if someone is unaccustomed to regular exercise.

One means of tackling the problems associated with obesity in pregnancy is by providing preconception advice. This is recommended for all obese women of childbearing age, but does not appear to be provided by many maternity units in the UK (CMACE, 2010). In the case of women who have already given birth, if the individual is likely to have further children, advice on preconceptional care for future pregnancies could be provided by professionals in the postnatal period. This may involve support for weight loss and advice about the importance of folic acid supplements taken before conceiving. Those who have had bariatric surgery in particular are at risk of micronutrient deficiency such as iron, vitamins A, B, K, folate and calcium (Richens and Fiennes, 2010). It is therefore essential to ensure these women understand the importance of taking prescribed supplements prior to and during pregnancy.

Maternity services: An unwelcoming environment
Facilities and equipment in maternity units may be inadequate for women with a raised BMI (e.g. chairs, beds and blood pressure cuffs) (CMACE, 2010). In addition, they can experience greater physical manipulation during pregnancy.

Women with a BMI > 40 need an assessment to identify manual handling requirements so that appropriate plans can be made for the birth and postnatal period. Any such assessment should be sympathetic to an individual’s abilities as some obese mothers have limited mobility because of joint pain (Furber and McGowan, 2010). This links to the risk of injury to midwifery staff that has been noted when managing obese women (e.g. from assisting with mobility) (Furber and McGowan, 2010; Schmied et al., 2010). Sonogrophers have also reported increased incidence of repetitive strain injury in their wrist due to sustained pressure required positioning the transducer to image an obese abdomen satisfactorily (Pandya and Hogg, 2010).

Excess weight hinders abdominal examination among obese women, especially in the third trimester of pregnancy. As a consequence, ultrasounds are used more frequently (Richens and Lavender, 2010), although they can also be problematic because increased abdominal tissue makes it difficult to visualise an obese woman’s abdomen (Dashe et al., 2009; Pandya and Hogg, 2010). Increased abdominal tissue can likewise make external cardiotocography difficult, meaning that artificial rupture of the membranes and application of a fetal scalp electrode may be required for monitoring purposes (Rajasingam and Swamy, 2010).

Labour is often slow in obese women and may be uncomfortable and more painful because of difficulties carrying out vaginal examinations (Furber and McGowan, 2009). To enable labour to be as normal as possible, midwives should help women to be as mobile as they can by facilitating positions that aid fetal descent, rotation and maternal breathing (Rajasingam and Swamy, 2010).

Arousing negative reactions: Professionals’ responses
Pregnant women with a raised BMI come to midwifery services with previous healthcare encounters, which are not necessarily positive (Merrill and Grassley, 2008). These mothers may feel a loss of status because of their weight and associated stereotypes, lacking confidence to question care provided in maternity units as a consequence (Furber and McGowan, 2010). This may be compounded by some healthcare workers who have been reported to hold judgemental views towards those with a raised BMI (Brown, 2006), although other practitioners express an awareness of the multifaceted difficulties individuals face and are sympathetic towards these service users (Petrich, 2000). It is the latter response that needs to be cultivated within midwifery units.

Obese pregnant women have stated they feel ashamed and embarrassed if staff show their frustration when dealing with the challenges that arise during their care and assessment (Nyman et al., 2010). If women feel judged by professionals because of their weight, and if constantly reminded of this problem, it may impair their experience of pregnancy.

That is not to ignore the fact that working with these mothers may arouse feelings of anxiety and frustration among healthcare professionals because as a group obese women’s needs are not always suitably resourced or addressed by healthcare policy and planning (Schmied et al., 2010). Hence, practitioners who are trying to do their best may feel overwhelmed by the prospect. But this should not translate into a shifting of the blame onto women, with their label as obese defining how they are treated (Schmied et al., 2010).

Conclusion
Maternity services in the developed world are likely to see a greater number of women with a raised BMI because of an overall increase in obesity. The association of obesity with maternal and fetal health means it is important for practitioners to be able to provide appropriate advice and support, whilst treating each woman as an individual. People who are obese tend to be stigmatised as solely responsible for their condition and simply lacking motivation and self-restraint. Such attitudes have been shown among some practitioners, which can leave service users feeling objectified as they come to be marked out because of their weight.

They may then receive a less positive service as a consequence. The sensitivity associated with obesity may make practitioners ill-at-ease when broaching the topic of weight in a clinical setting. In maternity units, such discomfort can be heightened by inadequate support and resources for staff working with obese women, with the additional time and lack of equipment required meaning these mothers are labelled as a problem.

Practitioners need to be sensitive and non-judgmental in their interactions with obese pregnant women, but should ensure they are fully aware of the risks associated with having a raised BMI so they can make an informed choice in relation to whether or not to change their behaviours. It is important for future investigations to explore the views of midwifery staff about managing pregnant obese women because limited research has focused on this topic. Such work would help to identify training needs and structural changes to improve services and mothers’ experiences of pregnancy.

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