Increased BMI during pregnancy: how do midwife

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Aim: To determine the knowledge base of midwife lead maternity carers (LMCs) and explore their adjustments in practice for obese women. Materials & methods: ..... nutrition, exercise and weight gain during pregnancy with women. “It would be ..... food habits, food choices and attitudes will require a consistent public health ...

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Increased BMI during pregnancy: how do midwife lead maternity carers respond?

Aim: To determine the knowledge base of midwife lead maternity carers (LMCs) and explore their adjustments in practice for obese women. Materials & methods: A nationwide cohort study of LMC midwives in New Zealand concerning obesity in pregnancy using an electronic survey. Results: A total of 428 LMCs responded. Most respondents were aware of the risks of obesity during pregnancy. Midwives felt it was important to provide customized care. Various barriers to accessing support for obese women within the health system were identified. Discussing weight and obesity was acknowledged as a sensitive issue for both the woman and the midwife. Conclusion: This study highlights the need to improve access to and availability of supportive maternity services and resources for pregnant women with increased BMI. Keywords: midwives • obesity • pregnancy • primary maternity care

Obesity is a growing problem in New Zealand with almost a third of adults reported as being obese [1] . Maternal overweight and obesity are associated with increased risks of adverse pregnancy outcomes such as increased risk of miscarriage, stillbirth, hypertensive disorders of pregnancy, gestational diabetes, infection (chest, urine, wound), venous thromboembolism and maternal mortality  [2–4] . Increased maternal BMI also carries an increased risk of induction of labor, caesarean birth and anesthetic concerns [2,4] . Maternal obesity is a significant risk factor for fetal macrosomia, adiposity and hyperinsulinemia even after adjustment for maternal glycemia [3] . Babies of obese mothers are more likely to be diagnosed with a congenital anomaly, require resuscitation at birth, require neonatal intensive care input and have increased risk of obesity themselves later in life [2,4] . Primary maternity care in New Zealand differs to many other developed countries [5] . Maternity care is fully funded by the Ministry of Health for all eligible women. During early pregnancy the woman is able to choose a primary maternity care provider

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to be her lead maternity carer (LMC). The LMC provides continuity of care and is responsible for assessment of the woman’s needs and planning care with the woman for pregnancy, labor and birth and up to 6 weeks postpartum  [6] . LMC options available to women are a midwife, a general practitioner or an obstetrician, with the majority choosing a midwife [7] . Women who require obstetric input or have complex issues are referred to obstetric or related medical services using the Ministry of Health’s referral guidelines  [8] . This model of primary maternity care means LMC midwives are able to build a close relationship with a woman during her pregnancy, along with support, preparation and attendance for the labor and birth and transition to parenting. LMCs are required to submit health status information to the Ministry of Health such as the woman’s height and weight and make a comprehensive assessment of the woman’s general health [6] . Class 2 obesity (defined as a BMI of more than 35) is an indicator for referral for consultation with a specialist in the referral guidelines [8] . Within the midwifery scope of practice is the requirement to

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Sze Yin Pan*,1, Lesley Dixon2, Helen Paterson3 & Norma Campbell4 Palmerston North Hospital, Palmerston North, New Zealand 2 Practice Advice & Research Development, New Zealand College of Midwives, 376 Manchester Street, Richmond 8014, New Zealand 3 Dunedin School of Medicine, Otago University, 201 Great King Street, Dunedin 9016, New Zealand 4 New Zealand College of Midwives, 376 Manchester Street, Richmond 8014, New Zealand *Author for correspondence: Tel.: +64 211 258 928 [email protected] yahoo.co.nz 1

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Research Article  Pan, Dixon, Paterson & Campbell promote healthy lifestyles [9] which involves the provision of advice about nutrition and exercise. Guidance is available from the Food and Nutrition Guidelines and the Guidelines for promoting physical activity to adults [10,11] . The knowledge base, extent and impact of discussions about maternal health and obesity by midwife LMCs during pregnancy is currently unknown. The aim of this study was to determine the knowledge base of midwife LMCs and explore their adjustments in practice for obese women. A previous paper has explored how these midwives assessed BMI, and what advice was given about nutrition, exercise and gestational weight gain [12] . Key findings were that the majority of midwives established a BMI and altered their pregnancy care discussion based on the woman’s BMI. They generally recommended lower weight gain targets than the updated Institute of Medicine published guidelines [13] , although many were unaware of specific guidelines for gestational weight gain [12] . Materials & methods A nationwide survey of LMC midwives in New Zealand was undertaken using an electronic survey tool. The survey questions were developed from the recommendations within the CMACE/RCOG guideline for Management of Women with Obesity in Pregnancy [14] and piloted with 20 midwives to test the format and structure of the survey and ensure clarity. Questions were designed to explore the knowledge of risks associated with obesity in pregnancy; the impact of a woman’s BMI on usual management and referral to obstetric, anesthetic, dietetic and physiotherapy services. For the majority of questions, the response options were never, usually not, sometimes, almost always and all the time with follow on questions to determine more detail. The survey also included options to provide free text responses. Individual LMCs were invited to participate via an email with the link to the host survey website [15,16] . Each survey was uniquely tied to the email address to ensure that responses were not duplicated. Midwives in New Zealand who provided LMC care and were members of the New Zealand College of Midwives were approached (1067 midwives identified as LMC). All responses were anonymized to the investigators. The data were analyzed using simple descriptive statistics for each question. Due to the wide response rates for questions, the denominator used was the number of participants answering each question. Free text data were analyzed qualitatively using a general inductive approach  [17] . This approach to qualitative analysis assesses the core meaning evident in the text, develops themes or categories and then describes the most important themes. It provides a simple straightforward

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way of analyzing qualitative data which was particularly useful for the free text data provided by the midwives. Ethical approval was obtained from the New Zealand Ministry of Health Multi-Region Ethics Committee (MEC/11/EXP/126). The previous paper discussed survey responses related to nutrition, activity and weight gain and described in detail the method of survey distribution and response rates [12] . Results There were 438 responses giving a response rate of 42.9%. Full demographic and response data are described in a previous paper [12] . Knowledge regarding impact of obesity on pregnancy

The majority of midwives were aware and would routinely counsel the women about the increased pregnancy risks related to obesity for gestational diabetes (83.3%), hypertensive disorders (74.0%), pre-eclampsia (64.3%), fetal macrosomia (65.5%), shoulder dystocia (58.3%) and caesarean section (57.3%) (Table 1) . Fewer respondents were aware of and counseled for the risks of postpartum hemorrhage (48.3%), thromboembolic disease (32.5%) and risk of fetus becoming overweight as a child (40.5%). The increased risk of congenital abnormalities with obesity in pregnancy was less well known, with over half (61.1%) responding that they did not know or were unsure of this fact (Table 1) . Effect of BMI on practice

A woman’s raised BMI would alter most midwives’ management plan for the pregnancy, all the time (22.5%) or almost always, 31.5% (n = 130). A further 38.5% (n = 159) would sometimes change their management plan with a small number indicating that they usually would not (6.5%, n = 27) or would never (1%, n = 4) change their management plan based on BMI alone. The midwives were asked how the woman’s raised BMI changed the plan for pregnancy with a range of options provided. Responses were varied and related to the BMI category with an increase in antenatal visits, higher dose folic acid supplementation and early diabetic screening for those in the higher BMI categories (Table 2) . The response rate for the question related to vitamin D supplementation was very low (n = 38) making these data unreliable. Respondents were asked at what BMI they would consider referring or transferring care to an obstetrician, with 67.6 and 68.8%, respectively, referring for obstetric consultation for women with class 2 obesity (BMI 35–39.9) and class 3 obesity (BMI > 40); 1.5% (n = 6) would not consider obstetric referral at all (Table 3). Sixty six

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Increased BMI during pregnancy: how do midwife lead maternity carers respond? 

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Table 1. Knowledge regarding pregnancy risks with obesity. Pregnancy risk

Yes, and I counsel about it, n (%)

Yes, n (%)

No, n (%)

Unsure, n (%)

Response count

Congenital malformations

50 (12.5)

146 (36.5)

139 (34.8)

65 (16.3)

400

Gestational diabetes mellitus

333 (83.3)

67 (16.8)

0

0

400

Hypertensive disorders

296 (74.0)

101 (25.3)

3 (0.8)

0

400

Pre-eclampsia toxemia

257 (64.3)

115 (28.8)

17 (4.3)

11 (2.8)

400

Fetal macrosomia

262 (65.5)

119 (29.8)

14 (3.5)

5 (1.3)

400

Shoulder dystocia

233 (58.3)

148 (37.0)

15 (3.8)

4 (1.0)

400

Caesarean section

229 (57.3)

146 (36.5)

16 (4.0)

9 (2.3)

400

Postpartum hemorrhage

193 (48.3)

158 (29.5)

39 (9.8)

10 (2.5)

400

Thromboembolic disease

130 (32.5)

183 (45.8)

60 (15.0)

27 (6.8)

400

Increased risk of the fetus 162 (40.5) becoming overweight as a child

183 (45.8)

32 (8.0)

23 (5.8)

400

percent of LMC midwives (270 of 407 respondents) identified they would recommend transfer of clinical responsibility to an obstetrician if a woman had class 3 obesity but 30.2% (n = 123) would not. The majority would recommend an oral glucose tolerance test rather than a polycose test for women with class 2 and class 3 obesity (67.6 and 74.4%, respectively).

Dietetic services were available to 74.2% of 399 respondents. When considering referral to dietetic services nearly half (185 of 387 respondents) would refer a woman with class 2 obesity all the time and 21% (n = 81) would refer almost always (Table 6) . Physiotherapy services were available to 88% of 399 respondents although no clear association was seen between higher levels of BMI and referral to physiotherapy services (Table 7) .

Referral patterns to other services

The survey asked which services were available for women in the region where respondents practiced. Response options included anesthetic, dietetic and physiotherapy services (Table 4) . Anesthetic services were available to 91.8% of 400 respondents. When asked at which BMI level the midwife would refer to anesthetic services, the majority (79%) would refer women with class 3 obesity all the time, or almost always (Table 5) . For the women with class 2 obesity, 50.7% would refer all the time or almost always.

Qualitative results from free text responses

The survey included text boxes to enable the respondents to clarify their responses. The large volume of text responses was analyzed using a general inductive approach with two themes identified. These were barriers to care provision, and obesity as a sensitive issue. Barriers to care provision

The midwives identified various issues related to care provision for obese women which fell into three subcategories. These were: lack of resources to support the woman,

Table 2. Effect of a woman’s BMI on usual management in pregnancy. Change to usual management in pregnancy 

BMI 25–29.9 (overweight), n (%)

BMI 30–34.9 (class 1 obesity), n (%)

BMI 35–39.9 (class 2 obesity), n (%)

BMI ≥40 (class 3 obesity), n (%) 

Response count

Increased antenatal visits

3 (2.1)

27 (19.1)

74 (52.5)

112 (79.4)

141

Recommend increased folic acid supplementation (5 mg)

12 (10.5)

33 (28.9)

74 (64.9)

87 (76.3)

114

Recommend vitamin D supplementation

12 (31.6)

13 (34.2)

21 (55.3)

27 (71.1)

38

Screening for diabetes in early pregnancy (≤24 weeks)

66 (17.9)

206 (56)

288 (78.3)

285 (77.4)

368

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Research Article  Pan, Dixon, Paterson & Campbell

Table 3. How a woman’s BMI alters usual management in pregnancy. Change to usual management in pregnancy

BMI 25–29.9 BMI 30–34.9 BMI 35–39.9 BMI ≥40 Not at all, (overweight), (class 1 obesity), (class 2 obesity), (class 3 obesity), n (%) n (%) n (%) n (%)  n (%) 

Response count

Consider referring for consultation with an obstetrician

5 (1.2)

68 (16.7)

275 (67.8)

280 (68.8)

6 (1.5)

407

Referral to secondary care (for transfer of clinical responsibility)

2 (0.5)

10 (2.5)

46 (11.3)

270 (66.3)

123 (30.2)

407

190 (46.7)

275 (67.6)

303 (74.4)

27 (6.6)

407

Recommend 24–28-week 61 (15) OGTT (rather than polycose)  OGTT: Oral glucose tolerance test.

lack of services for the woman and inability to transfer clinical responsibility. There was considerable variation nationally with some areas better resourced than others.

It would appear that more resources are required financially for obese rural women and the current leaflets require updating and translating to make them more culturally supportive.

A lack of resources to support the woman

The midwives commented on the difficulties women have accessing services when they lived rurally. Often there were also issues with financial resource and lack of transport for hospital consultations. “I work in a rural area with women who often have very limited resources and sometimes don’t attend for routine antenatal visits because of transport and money issues. I have to cater the care and referrals taking all this into consideration. I have developed good counsel and information that I give women and sometimes don’t always follow the same referral pathway for every woman because their wider needs differ. Services are approximately an hour from my practice and clientele is often unable to afford the travel into base hospital to attend appointments.” Some midwives discussed leaflets they currently use but others suggested there was need for specific, modern resources that would support them to discuss nutrition, exercise and weight gain during pregnancy with women. “It would be good to have hand-outs that list these things and information for the women so that they can take it away.” “We need an updated booklet with pictures and few words for non-English speakers and illiterate immigrants.”

A lack of services for the woman

Many midwives explained the lack of service or slow response from dieticians and physiotherapist services. “Dietician is unavailable other than for diabetes, physiotherapy referrals not accepted from midwife.” “It is difficult to tease out making a referral based on the BMI as most often there are other comorbidities which necessitate a referral too and high BMI just adds to the complexity. The turnaround time for physio referrals is very slow in the area where I work which suggests that they are overworked. I have tried referring to the dietician service at the hospital on a couple of occasions and got told that they are to go to their GPs (family doctor) for assistance.” The survey questions established that dietetic and physiotherapy services were available within the health services (Table 4) but the qualitative data have demonstrated that these services were difficult to access and not prioritized for obese pregnant women. An inability to transfer clinical responsibility

Many of the midwives agreed they would refer to the hospital obstetric service when they encountered a woman with a raised BMI, however whether there was a transfer of clinical responsibility to an obstetrician depended on the hospital services and the woman’s health.

Table 4. Availability of anesthetic, dietician and physiotherapy services.

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Services available

Yes, n (%)

No, n (%)

Sometimes, n (%) Unsure, n (%)

Response count

Anesthetic

367 (91.8)

30 (7.5)

3 (0.8)

0

400

Dietician

296 (74.2)

35 (8.8)

50 (12.5)

18 (4.5)

399

Physiotherapy

351 (88)

17 (4.3)

23 (5.8)

8 (2.0)

399

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Increased BMI during pregnancy: how do midwife lead maternity carers respond? 

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Table 5. Anesthetic referral. BMI range

Never, n (%)

Usually not, n (%)

Sometimes, n (%)

Almost always, n (%)

All the time, n (%)

Response count

BMI 25–29.9 (overweight)

123 (34.6)

194 (54.6)

31 (8.7)

3 (0.8)

4 (1.1)

355

BMI 30–34.9 (class 1 obesity) 

73 (20.3)

151 (41.9)

88 (24.4)

31 (8.6)

17 (4.7)

360

BMI 35–39.9 (class 2 obesity)

30 (7.9)

59 (15.5)

98 (25.8)

96 (25.3)

97 (25.5)

380

BMI ≥40 (class 3 obesity)

21 (5.4)

24 (6.1)

39 (10.0)

73 (18.7)

234 (59.8)

391

“Referral is done for BMI of 35 or above but there is no transfer of clinical responsibility unless other conditions appear due to high BMI.” “Transfer of care would only occur after a discussion with the Obstetric team. If the women has a BMI over 40 but has no other significant health problems I would continue care with consultation from the obstetric team.” “In our area, the obstetric team would be unlikely to accept a referral for BMI alone unless weight over 150 kg.” Hospital services responded differently to referrals for high BMIs despite the maternity services referral guidelines which were agreed to by multidisciplinary representatives and the District Health Boards [18,19] . Some services did have streamlined referral processes but the majority limited transfers and referrals to those at the higher end of the BMI scale. Some of the text responses discussed the lack of cohesive response and support for the obese woman. “The referral to consultant will result in either them accepting transfer to secondary care or them referring back to me - I leave that decision up to them, I just do the initial referral if women consent to this.” “The obstetric clinics are overflowing with increased BMI women so we no longer transfer care but work with the Obstetricians on how to manage in pregnancy/labor.”

Other midwives commented on the need for women to continue to have continuity of care. “I would not be ‘handing responsibility over’ as I work remote rurally and our obstetricians are 2 hours by road away, however they would be referred to and have regular on-going consults through the pregnancy and birth planned to occur in the secondary unit. These women still need midwifery input closely. Obesity is only a part of her health and maternity care.” Midwives recognized the need for obese women to have additional input into their pregnancy care but due to the constraints of the DHB services, they often continued as the main care provider alongside these services and without handover of clinical responsibility. Obesity as a sensitive issue

Discussing weight and obesity was acknowledged by many participants as a sensitive issue for both the woman and the midwife. The midwives discussed the need for sensitivity when raising the issue and the difficulty of the conversation itself. “Some women do react very negatively to discussing weight because they say it is ‘normal’ in their culture or they feel intimidated because you have mentioned their weight.” “It is hard to talk about obesity with our clients. They take it very personally; they are offended by these comments and talks. They know that they are

Table 6. Dietician referral.  BMI range

Never, n (%)

Usually not, n (%)

Sometimes, n (%)

Almost always, n (%)

All the time, n (%)

Response count

BMI 25–29.9 (overweight)

103 (28.3)

179 (49.2)

65 (17.9)

6 (1.6)

11 (3.0)

364

BMI 30–34.9 (class 1 obesity) 

65 (17.3)

115 (30.7)

124 (33.1)

48 (12.8)

23 (6.1)

375

BMI 35–39.9 (class 2 obesity)

39 (10.2)

49 (12.8)

107 (27.9)

98 (25.6)

90 (23.5)

383

BMI ≥40 (class 3 obesity)

32 (8.3%)

31 (8.0)

58 (15.0)

81 (20.9)

185 (47.8)

387

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Research Article  Pan, Dixon, Paterson & Campbell

Table 7. Physiotherapy referral. BMI range

Never, n (%)

Usually not, n (%)

Sometimes, n (%)

Almost always, n (%)

All the time, n (%)

Response count

BMI 25–29.9 (overweight)

117 (30.8)

173 (45.5)

75 (19.7)

7 (1.8)

8 (2.1)

380

BMI 30–34.9 (class 1 obesity) 

97 (25.4)

150 (39.3)

111 (29.1)

12 (3.1)

12 (3.1)

382

BMI 35–39.9 (class 2 obesity)

86 (22.4)

125 (32.6)

115 (29.9)

32 (8.3)

26 (6.8)

384

BMI ≥40 (class 3 obesity)

81 (21.4)

112 (29.6)

114 (30.1)

27 (7.1)

45 (11.9)

379

obese, but they do not want to listen to lectures and constant reminding about risks and complications, as they want to have positive and supporting words.” Midwives discussed the difficulty of finding the balance between informing women of the risks and concerns of obesity while developing a positive therapeutic relationship. “I am struggling to find a balance between informing women of the risks of obesity and making them feel good about their body while they are pregnant.” “This is a difficult issue to tackle in an empathetic manner, however I discuss it at many points throughout the pregnancy. I tend to work on the NICE guidelines, and the ‘healthy plate’ portion sizes, and 30 min a day push play, as these are easy to use health messages. The majority of women are aware of the health risk of being overweight themselves but do not understand the implications for their baby.” Despite this difficulty the midwives considered that a sensitive approach that acknowledged the woman’s culture and what was important to her worked well. Ongoing discussion was supported by the maternity model of continuity of care along with the partnership approach which is the foundation of the midwifery profession in New Zealand [20] . “For those women with a high BMI that I have provided midwifery care have needed a sensible but very sensitive approach with regards their weight. It is visually obvious on the first meeting that obesity is in question and the approach needs to be sensitive but honest. For appointments some will need their partner or family support while others prefer the privacy of attending on their own to be able to express their feelings and be honest. This aim can be achieved in the midwifery partnership with a client.” Discussion The combination of quantitative and qualitative responses was a strength of this study and provided insight into LMC midwife’s practice specific to obese pregnant women. An understanding of the midwifery

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responses was gained from the rich qualitative data. The midwives reported a good knowledge base about specific aspects of risk for obese women with the exception of congenital malformation and to a lesser extent thromboembolic disease. However, not all the midwives counseled women about all of the increased pregnancy risks suggesting a discrepancy between practice and knowledge. Although this issue was not explored further within the study, we hypothesize that the reason may be related to the potential to increase anxiety and distress for the pregnant woman at a time that should be positive and affirming. Listing all the risks when there is a limited ability to change/alter them may not be the optimum approach to support lifestyle changes. Heslehurst et al. in their focus group interviews with midwives in the UK found they considered that discussing obesity was ‘negative’ with concerns related to not upsetting, stigmatizing, blaming or scaring the pregnant woman [21] . The need for sensitivity when discussing obesity was identified by the LMC midwives in this current study with obesity considered an emotive issue and one that can potentially cause great upset if handled poorly. Overweight women may feel marginalized or have low self-esteem, they may also absorb messages in a different way to that intended all of which increases the potential to upset rather than inform and support women  [22] . This raises the question as to who is the most appropriate person to provide advice to obese pregnant women and when is the most appropriate time to address weight management issues. Johnson et al. found in their systematic review that health professionals face barriers to providing information which may be due to a lack of specialist nutritional knowledge and the sensitivity of the issue [23] . Additionally, the woman may be limited in her ability to absorb information due to the volume of information being provided especially during the first trimester. They suggest that midwives should focus on healthy lifestyle advice and that prepregnancy and the postpartum are the optimal times to support weight management and discuss risks.

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Increased BMI during pregnancy: how do midwife lead maternity carers respond? 

Interpregnancy weight gain is associated with adverse pregnancy outcomes [24,25] . Although this issue was not addressed in this study it would be useful in future research to determine what advice and support midwives and other health providers provide to women about optimal weight loss following pregnancy. Continuity of care enhances the ability to build a relationship and provide information over time during the pregnancy. The LMC midwives described the value of knowing the woman and being able to adapt their care and advice to what was identified as important by the woman. They identified a need for more resources such as updated and culturally appropriate pamphlets to help provide key information. The LMC midwives considered that providing information and advice was important and continued during pregnancy and adapted their care accordingly. Changes to their usual pregnancy care plan involved increased frequency of antenatal visits, higher dose folic acid supplementation and earlier screening for diabetes. The response rate regarding vitamin D supplementation was very low (8%). We hypothesize that New Zealand practitioners may be less aware of the impact of obesity on vitamin D levels. Additionally other factors such as expensive testing and lack of subsidized vitamin D supplementation available for use in pregnancy may also have affected this response [26] . The referral guidelines recommend referral for pregnant women with class 2 obesity and a transfer or care for those with class 3 obesity yet the survey respondents indicated that these guidelines were not always followed. The qualitative data provided a more detailed and in-depth response to this issue indicating the lack of referral was often due to limited resources with a lack of availability and accessibility to hospital obstetric services. The decision related to transfer of care was determined by the obstetric team of the hospital being referred to, with the midwives explaining that services were limited due to the volumes of women with increased BMI and therefore prioritized to those with higher levels of obesity. Referral for anesthetic review was common but dietetic and physiotherapy services were limited due to the difficulty of connecting women to these services. The qualitative data suggested that the ability to engage with these services for obese pregnant women was low because the services were generally prioritized for women with complex issues (such as gestational diabetes). The LMC midwives in this survey considered that their involvement and ability to provide continuity of care was an important source of support for the obese pregnant woman. Secondary maternity services were considered problematic due to the lack of a cohesive

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and consistent response despite guidance from the maternity services referral guidelines [19] . The LMC midwives highlighted the importance of continuing to be involved in the care of obese women but also the need to have the support of secondary specialist services when providing this care. Limitations of this study are the low response rate and inherent selection bias of surveys meaning that these results cannot be generalized and may not be representative of the population surveyed. The strengths are that by utilizing both qualitative and quantitative data a fuller picture of practice and knowledge has emerged. Conclusion The majority of LMC midwives are aware of the increased risks for pregnant obese women and their offspring and adjusted their practice accordingly. They provided information and counseled about obesity but describe the conversation as difficult and requiring a sensitive caring approach. The LMC midwives reported referring according to the referral guidelines but were hampered by limited access and availability of hospital secondary services. The continuity of care inherent within the New Zealand primary maternity model of care enhanced the midwife’s ability to customize her care for the woman. The ability to continue to provide care during the secondary services interface was considered to be an important means of support for the obese pregnant woman. Future perspective Obesity is becoming an increasing problem worldwide. This creates increased demand and strain on existing healthcare services. There is a need to reduce the incidence of obesity within the general population as this will then lead to reduced obesity levels within the maternity population. Greater awareness regarding the dangers of obesity and how these can be avoided through promoting healthy lifestyle and eating choices may help. Emerging evidence is linking the fetal environment with a lifelong health impact although it would also appear that this could be mitigated by improving nutrition in the baby’s first years of life [27–29]. Midwives and obstetricians may be able to influence individual women by explaining their risks and promoting healthy nutrition, exercise and breastfeeding during childbirth [22,23] . However at a population level political leadership will be necessary along with some consideration of additional strategies to tackle the underlying issues that have led to the obesity epidemic. Changing food habits, food choices and attitudes will require a consistent public health

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Research Article  Pan, Dixon, Paterson & Campbell approach and a range of strategies which will need to be evaluated. Discussion of nutrition, activity and healthy lifestyles are required in the community by other primary healthcare providers so that there is an integrated systematic approach. Additionally, the establishment of more fully funded community based services that are designed to support and motivate families to improve their nutrition and exercise levels may help to increase and sustain a change in attitude and knowledge at the population level. Specifically to New Zealand maternity care, a review committee has been appointed to write and implement a national guideline to help guide maternity healthcare providers in navigating this sensitive issue. In time, there will be a streamlined healthcare process for obese pregnant women, starting with preconception counseling and improving access to bariatric surgery.

Financial & competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.

Ethical conduct of research The authors state that they have obtained appropriate institutional review board approval or have followed the principles outlined in the Declaration of Helsinki for all human or animal experimental investigations. In addition, for investigations involving human subjects, informed consent has been obtained from the participants involved.

Executive summary • Obesity is a difficult and sensitive topic to discuss with pregnant women who are obese. • Midwives in New Zealand are aware of the risks of obesity in pregnancy to the woman but less aware of the impact on child health. • The lead maternity carers changed their pregnancy management plan dependent on the level of the woman’s BMI. • Midwives believe that care should be customized to the needs of the individual woman. • More resources are needed for women such as increased access and availability of community dietetic services, written information for women and support for midwives providing care for women who are obese. • There needs to be a consistent approach from hospital secondary services to manage obesity in the pregnant population that reflects the referral guidelines and also supports continuity of care for the woman

References 1

2

3

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Health, Wellington, New Zealand (2011).  www.health.govt.nz 

Ministry of Health. New Zealand health survey: annual update of key findings 2012/13. Ministry of Health, Wellington, New Zealand (2013).

9

Catalano PM, Ehrenberg HM. The short- and long-term implications of maternal obesity on the mother and her offspring. BJOG 113, 1126–1133 (2006).

New Zealand College of Midwives. Midwives Handbook for Practice. New Zealand College of Midwives, Christchurch, New Zealand (2008).

10

Ministry of Health. Food and Nutrition Guidelines for Healthy Pregnant and Breastfeeding Women: A Background Paper. Ministry of Health, Wellington, New Zealand (2006).  www.health.govt.nz 

11

Ministry of Health. Movement = Health, Guidelines for promoting physical activity to adults. A Resource for Health Professionals. SPARC (2005). www.health.govt.nz

12

Pan S, Dixon L, Paterson H, Campbell N. New Zealand LMC midwives’ approaches to discussing nutrition, activity and weight gain during pregnancy. New Zealand College of Midwives Journal 50, 24–29 (2014).

13

Institute of Medicine. Weight gain during pregnancy: re-examining the guidelines. The National Academics Press, Washington DC, USA (2009).

14

CMACE/RCOG Joint Guideline. Management of women with obesity in pregnancy (2010). www.rcog.org.uk

HAPO Study Cooperative Research Group. Hyperglycaemia and Adverse Pregnancy Outcome (HAPO) Study: associations with maternal body mass index. BJOG 117, 575–584 (2010).

4

Dodd JM, Grivell RM, Nguyem AM, Chan A, Robinson JS. Maternal and perinatal health outcomes by body mass index category. Aust. NZ J. Obstet. Gynaecol. 51, 136–140 (2011).

5

Rowland T, McLeod D, Forese-Burns N. Comparative Study of Maternity Systems. Ministry of Health, Wellington, New Zealand (2012).

6

Section 88 Primary Maternity Services Notice 2007 (2007). www.health.govt.nz

7

Ministry of Health Report on Maternity (2010). www.health.govt.nz/publication/report-maternity-2010

8

Ministry of Health. Guidelines for Consultation with Obsetric and Related Medical Services (Referral Guidelines). Ministry of

Womens Health (Epub ahead of print)

future science group

Increased BMI during pregnancy: how do midwife lead maternity carers respond? 

15

The Survey System – Survey Design Software  www.surveysystem.com/sdesign.htm 16

Survey Monkey  www.surveymonkey.com 

17

Thomas DR. A general inductive approach for analyzing qualitative evaluation data. Am. J. Eval. 27, 237–246 (2006).

18

Ministry of Health. Maternity services – secondary and tertiary maternity services and facilities tier level two service specification. In: Nationwide Service Framework Library. District Health Boards, Ministry of Health, New Zealand (2011).

19

Ministry of Health. Primary Maternity Services Notice. Ministry of Health, Wellington, New Zealand (2007).

23

Johnson M, Campbell F, Messina J, Preston L, Buckley H, Goyder E. Weight management during pregnancy: a systematic review of qualitative evidence. Midwifery 29, 1287–96 (2013).

24

Villamor E, Cnattingius S. Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. Lancet 368, 1164–1170 (2006).

25

Bogaerts A, Van den Bergh BR, Ameye L et al. Interpregnancy weight change and risk for adverse perinatal outcome. Obstet. Gynecol. 122(5), 999–1009 (2013).

26

New Zealand Pharmaceutical Schedule. www.pharmac.govt.nz

27

Reynolds R, Allan K, Raja E et al. Maternal obesity during pregnancy and premature mortality from cardiovascular event in adult offspring: follow-up of 1 323 275 person years. BMJ 347, 1–10 (2013).

20

Guilliand K, Pairman S. The Midwifery Partnership – A Model for Practice (2nd Edition). New Zealand College of Midwives, Christchurch, New Zealand (2010).

21

Heslehurst N, Lang R, Rankin R, Wilkinson J, Summerbell C. Obesity in pregnancy: a study of the impact of maternal obesity on NHS maternity services. BJOG 114, 334–342 (2007).

28

Yamakawa M, Yorifuji T, Inoue S, Kato T, Doi H. Breastfeeding and obesity among schoolchildren: a nationwide longitudinal survey in Japan. JAMA Pediatr. 167(10), 919–925 (2013).

22

Heslehurst N, Russell S, McCormack S, Sedgewick G, Bell R, Rankin J. Midwives perspectives of their training and education requirements in maternal obesity: a qualitative study. Midwifery 29, 736–44 (2013).

29

Monasta L, Batty GD, Cattaneo A et al. Early-life determinants of overweight and obesity: a review of systematic reviews. Obes. Rev. 11, 695–708 (2010).

future science group

Research Article

10.2217/WHE.15.8