Caring for Obese Pregnant Women

A qualitative exploration of the challenges providers experience during peripartum management of patients with a body mass index ≥ 50 kg/m2 and recommendations for improvement

BACKGROUND

The objective of this research was to conduct a qualitative study among a diverse group of providers to identify their clinical needs, barriers, and adverse safety events in the peripartum care of people with a body mass index (BMI) ≥ 50 kg/m2.

METHODS

Obstetricians, anesthesiologists, certified nurse midwives, nurse practitioners, and nurses were invited to participate in focus group discussions if they were employed at the hospital for >6 months. Key concepts in the focus group guide included: (1) Discussion of challenging situations, (2) Current peripartum management approaches, (3) Patient and family knowledge and counseling, (4) Design and implementation of a guideline (e.g., checklist or toolkit) for peripartum care. The audiotaped focus groups were transcribed verbatim, uploaded to a qualitative analysis software program, and analyzed using inductive and constant comparative approaches. Emerging themes were summarized along with representative quotes.

RESULTS

Five focus groups of 27 providers were completed in 2023. The themes included staffing (level of experience, nursing-patient ratios, safety concerns), equipment (limitations of transfer mats, need for larger sizes, location for blood pressure cuff, patient embarrassment), titrating oxytocin (lack of guidelines, range of uses), monitoring fetal heart rate and contractions, patient positioning, and communication (lack of patient feedback, need for bias training, need for interdisciplinary relationships). Providers gave examples of items to include in a "BMI cart" and suggestions for a guideline including designated rooms for patients with a BMI ≥ 50 kg/m2, defining nursing ratios and oxytocin titration plans, postpartum incentive spirometer, and touch points with providers (nursing, physicians) at every shift change.

CONCLUSIONS

Providers discussed a range of challenges and described how current approaches to care may negatively affect the peripartum experience and pose threats to safety for patients with a BMI ≥ 50 kg/m2 and their providers. We gathered information on improving equipment and communication among providers.

Targeting obstetric providers in interventions for obesity and gestational weight gain: A systematic review

Background

Providers need to be comfortable addressing obesity and gestational weight gain so they may give appropriate care; however, health care providers lack guidelines for the most effective educational strategies to assist in providing optimal care.

Objective

To identify studies that involved the obstetric provider in interventions for either the perinatal management of obesity and/or gestational weight gain in a systematic review.

Search strategy

A keyword search of databases was performed up to April 2017.

Selection criteria

Obstetric providers who participated in an intervention with the aim to change a provider’s clinical practice, knowledge, and/or satisfaction with the intervention in relation to the perinatal management of obesity or gestational weight gain were included. Provider intervention could include training or education, changes in systems or organization of care, or resources to support practice. PROSPERO database #42016038921.

Data collection and analysis

Bias was assessed according to the validated Mixed Methods Appraisal Tool. The following variables were synthesized: study location and setting, provider and patient characteristics, intervention features, outcomes and efficacy, and strengths and weakness.

Main results

Of the 6,821 abstracts screened, seven studies (4 quantitative, 3 mixed-methods) with a total of 335 providers met the inclusion criteria; two of which focused on the management of obesity, three focused on gestational weight gain, and two focused on both topics. Interventions that incorporated motivational interviewing skills (n = 2), required additional training for the research study and addressed specific knowledge deficits such as nutrition and exercise (n = 3), and interfaced with the electronic medical record (n = 1) demonstrated the greatest impact on provider outcomes. Provider reported satisfaction scores were generally favorable, but none addressed provider-level efficacy in practice change.

Conclusions

Given the limited number of studies, varying range of provider participation, and lack of provider-level efficacy, further evaluation of provider training and involvement in interventions for perinatal obesity or gestational weight gain is indicated to determine best practices for provider and patient outcomes.

Maternal Overweight Disrupts the Sexual Maturation of the Offspring

The aims of the present work were to study the effect of maternal overweight and obesity on the ovarian reserve, follicular development, and ovulation of the offspring and to assess whether this maternal condition alters oocyte integrity. To this end, female offspring from rats fed standard (OSD) or cafeteria (OCD) diet were used. Body weight, vaginal opening, and estrous cycle were recorded and ovaries were obtained on the day of the second estrus. In addition, ovarian weight, ovulation rate (measured by the number of oocytes within oviducts), follicular development (determined by histology), and oocyte integrity were examined. The OCD were divided into 2 groups: offspring from rats with 17% and 28% of overweight (OCD17 and OCD28, respectively). Both OCD groups showed higher body weight, but OCD28 also exhibited early vaginal opening and higher ovarian weight and glycemia at euthanasia compared with OSD. Both OCD17 and OCD28 had lower number of primordial and primary follicles, and only OCD28 exhibited lower number of antral follicles, all compared with OSD rats. In addition, both OCD17 and OCD28 had higher ovulation rate than controls, and OCD28 had lower number of healthy oocytes, which, in turn, exhibited morphological alterations such as larger perivitelline space and zona pellucida than those of control animals. These results suggest that maternal overweight may severely affect the reproductive ability of the offspring, likely as a result of altering the organogenesis.

Predictors of post-partum weight retention in a prospective longitudinal study

Post-partum weight retention (WR) occurs in 60-80% of women with some retaining ≥10 kg with contributing factors reported as pre-pregnancy body mass index (BMI), gestational weight gain (GWG) and breastfeeding. A longitudinal study of pregnancy, with 12-month post-partum follow-up was conducted to determine factors associated with WR. Pregnant women (n = 152) were recruited from the John Hunter Hospital antenatal clinic in New South Wales, Australia. Pre-pregnancy weight was self-reported; weight was measured four times during pregnancy (for GWG) and in the first 12 months post-partum. Infant feeding data were obtained via questionnaires. Breastfeeding was categorised as exclusive, predominant, complementary or not breastfeeding. Linear mixed models tested the predictors of WR, with and without adjustment for potential confounders. Compared with pre-pregnancy weight, 68% of women retained weight at 12 months, median (interquartile range) [4.5 kg (2.1-8.9)]. After adjustment, GWG was positively associated with WR (P < 0.01), but pre-pregnancy weight did not predict WR. For each additional week of any breastfeeding, 0.04 kg less weight was retained. Compared with women who retained weight, those women who did retain had higher rates of exclusive breastfeeding at three months (P < 0.05), but the number of weeks of exclusive breastfeeding failed to predict WR for all women. WR following childbirth is common and associated with GWG, while the number of weeks of 'any' breastfeeding contributed to post-partum weight loss. Whether these factors are modifiable strategies to optimise the weight status of women at this life stage requires further research.

Reliability and validity of birth certificate prepregnancy weight and height among women enrolled in prenatal WIC program: Florida, 2005

To investigate the reliability and validity of weight, height, and body mass index (BMI) from birth certificates with directly measured values from the Women, Infants, and Children (WIC) Program. Florida birth certificate data were linked and compared with first trimester WIC data for women with a live birth during the last quarter of calendar year 2005 (n = 23,314 women). Mean differences for weight, height, and BMI were calculated by subtracting birth certificate values from WIC values. Reliability was estimated by Pearson's correlation. Validity was measured by sensitivity and specificity using WIC data as the reference. Overall mean differences plus or minus standard error (SE) were 1.93 ± 0.04 kg for weight, -1.03 ± 0.03 cm for height, and 1.07 ± 0.02 kg/m(2) for BMI. Pearson's correlation ranged from 0.83 to 0.95, which indicates a strong positive association. Compared with other categories, women in the second weight group (56.7-65.8 kg), the highest height group (≥167.6 cm), or BMI < 18.5 had the greatest mean differences for weight (2.2 ± 0.08 kg), height (-2.4 ± 0.05 cm), and BMI (1.5 ± 0.06), respectively. Mean differences by maternal characteristics were similar, but statistically significant, likely in part from the large sample size. The sensitivity for birth certificate data was 77.3% (±1.42) for underweight (BMI < 18.5) and 76.4% (±0.51) for obesity (BMI ≥ 30). Specificity was 96.8% (±0.12) for underweight and 97.5% (±0.12) for obesity. Birth certificate data had higher underweight prevalence (6 vs. 4%) and lower obesity prevalence (24 vs. 29%), compared with WIC data. Although birth certificate data overestimated underweight and underestimated obesity prevalence, the difference was minimal and has limited impact on the reliability and validity for population-based surveillance and research purposes related to recall or reporting bias.

Maternal obesity support services: a qualitative study of the perspectives of women and midwives

BACKGROUND

Twenty percent of pregnant women in the UK are obese (BMI ≥ 30 kg/m2), reflecting the growing public health challenge of obesity in the 21st century. Obesity increases the risk of adverse outcomes during pregnancy and birth and has significant cost implications for maternity services. Gestational weight management strategies are a high priority; however the evidence for effective, feasible and acceptable weight control interventions is limited and inconclusive. This qualitative study explored the experiences and perceptions of pregnant women and midwives regarding existing support for weight management in pregnancy and their ideas for service development.

METHODS

A purposive sample of 6 women and 7 midwives from Doncaster, UK, participated in two separate focus groups. Transcripts were analysed thematically.

RESULTS

Two overarching themes were identified, 'Explanations for obesity and weight management' and 'Best care for pregnant women'. 'Explanations' included a lack of knowledge about weight, diet and exercise during pregnancy; self-talk messages which excused overeating; difficulties maintaining motivation for a healthy lifestyle; the importance of social support; stigmatisation; and sensitivity surrounding communication about obesity between midwives and their clients. 'Best care' suggested that weight management required care which was consistent and continuous, supportive and non-judgemental, and which created opportunities for interaction and mutual support between obese pregnant women.

CONCLUSIONS

Women need unambiguous advice regarding healthy lifestyles, diet and exercise in pregnancy to address a lack of knowledge and a tendency towards unhelpful self-talk messages. Midwives expressed difficulties in communicating with their clients about their weight, given awareness that obesity is a sensitive and potentially stigmatising issue. This indicates more could be done to educate and support them in their work with obese pregnant women. Motivation and social support were strong explanatory themes for obesity and weight management, suggesting that interventions should focus on motivational strategies and social support facilitation.

'Not waving but drowning': a study of the experiences and concerns of midwives and other health professionals caring for obese childbearing women

OBJECTIVE

to explore the experiences and concerns of health professionals who care for childbearing women who are obese.

BACKGROUND

obesity is increasing nationally and internationally and has been described as an epidemic. A number of studies have highlighted the risks associated with obesity during childbirth, yet few studies have investigated the experiences and concerns of midwives and other health professionals in providing care to these women.

DESIGN

a descriptive qualitative study using focus groups and face-to-face interviews to collect data. Interviews were audio recorded and transcribed verbatim. Data were analysed using thematic analysis.

SETTING

three maternity units in New South Wales, Australia.

PARTICIPANTS

participants included 34 midwives and three other health professionals.

FINDINGS

three major themes emerged from the data analysis: 'a creeping normality', 'feeling in the dark' and 'the runaway train'. The findings highlight a number of tensions or contradictions experienced by health professionals when caring for childbearing women who are obese. These include, on the one hand, an increasing acceptance of obesity ('a creeping normality'), and on the other, the continuing stigma associated with obesity; the challenges of how to communicate effectively with pregnant women about their weight and the lack of resources, equipment and facilities ('feeling in the dark') to adequately care for obese childbearing women. Participants expressed concerns about how quickly the obesity epidemic appears to have impacted on maternity services ('the runaway train') and how services to meet the needs of these women are limited or generally not available.

CONCLUSION AND IMPLICATIONS FOR PRACTICE

it was clear in this study that participants felt that they were 'not waving but drowning'. There was concern over the fact that the issue of obesity had moved faster than the health response to it. There were also concerns about how to communicate with obese women without altering the relationship. Continuity of care, training and skills development for health professionals, and expansion of limited services and facilities for these women are urgently needed.

The state of obesity management for women giving birth in Atlantic Canada

OBJECTIVES

The purpose of this survey was to gain insight into the status of birthing facilities across Atlantic Canada regarding obesity management. Specifically, we were interested in learning about the reported number of obese women entering birthing facilities, if body mass index (BMI) was determined from weight and height, and whether this was used to diagnose maternal obesity or not. Clinical, delivery, or equipment-related challenges and the state of existing or planned policies or guidelines specific to this high-risk population were also sought.

METHODS

An online, cross-sectional survey (audit), distributed via email to key staff members at birthing facilities in Atlantic Canada, including nurse managers, nurse practitioners, registered staff nurses and obstetrician-gynecologists.

RESULTS AND CONCLUSIONS

Twenty-two responses were received from 38 invitees (57% response rate), representing half the birthing facilities in Atlantic Canada. Despite the fact that the majority of facilities recorded maternal height and pre-pregnancy weight upon admission, these measurements were not used to calculate and document maternal BMI, nor to make a diagnosis of maternal obesity. More troubling, no birthing facilities in our survey had guidelines or care plans in place to deal with this high-risk population, and two-thirds of those surveyed had no plans for their creation in the near future. While maternal obesity was considered a problem, a third of respondents reported no direct access to properly sized lifts or transfer devices in their units. This study provides a useful baseline for monitoring improvements in the care of obese women giving birth in Atlantic Canada.