“Active Mothers” Bexley is a local community initiative, offering additional support to women who are trying to conceive, pregnant or who are new mums and are overweight or obese and or not very active. Its mission is to give women the tools they need to take control of their own health and become more active in pregnancy and early motherhood.
Obesity is linked to increased health risks in pregnancy for mum and baby and for their health in the future. Active Mothers is midwife-led and utilises the services of other professionals in its approach.
Our aim is to make a sustainable impact by informing women about local services, encouraging peer support, shared learning and discussions based on the recommendations from NICE guideline CG62 which recommends For example recommendations 188.8.131.52 and 184.108.40.206 cite the importance of antenatal information whereby at each contact health professionals should offer consistent information and clear explanations and should provide pregnant women with an opportunity to discuss issues and ask questions.
The Active Mothers group also addresses recommendation 220.127.116.11 whereby the classes are patient led and offer breast feeding support. Active Mothers also meets the recommendations of NICE guideline PH27 which encourages the midwife to discuss eating habits and to distribute healthy start vouchers.
Moreover each week the mothers have the opportunity or undertake guided exercises such as yoga and belly dancing. At Active Mothers, the staff provide healthy drinks and snacks provided free of charge by a local supermarket and discuss ways of eating healthily for all the family. NICE QS98 encourages professionals to improve maternal and child nutrition which Active Mothers does by inviting a local health visitor to discuss weaning and healthy eating for life. Interestingly it has emerged that Active Mothers addresses Perinatal Maternal and Infant Mental Health opportunistically, in that the group is client led and this is a topic which is frequently raised by participants.
Aims and objectives
Obesity in Bexley is 2 percent above the national average 1 in 5 pregnant women in the UK are obese (Rowlands et al, 2010).
At Queen Elizabeth hospital, Woolwich, the number of obese women booked for pregnancy care is higher at twenty three percent (Gordon, 2015). Pregnancy and birth complications are linked to obesity (RCOG, 2011, Zhang et al, 2007, Arrowsmith et al 2011, Swann and Davies, 2012, Centre for maternal and child health enquiries, 2010, Dignoni and Truslove, 2014, Abenhaim et al, 2007).and there is a relationship between both fetal and maternal death with an increased maternal BMI (Knight et al, 2014 and Manktelaw et al 2015). Not only does obesity affect a woman’s current pregnancy now but it can impact on future pregnancies (Soltani and Fraser, 2000, Linne and Rossner, 2003). Maternal obesity affects the baby by increasing the child’s risk of becoming obese (Khazaezadeh, et al 2011) and developing cardiovascular and cerebral-vascular diseases or type II diabetes (Reynolds, and Holmes, 2015).
Obesity is a public health issue, and midwives can play a key role in improving public health (Kennedy, et al, 2010). Midwives can empower women by encouraging them to share decisions about their care, and recognize the contribution they can make to their own health (Nursing and Midwifery Council, 2015). Despite only seeing They can work in collaboration with other health professionals to address factors such as diet; nutrition and exercise, and (Department of Health, 1999) to promote wellbeing and preventing ill health (Nursing and Midwifery Council, 2015).
Due to the health risks, management of obese women has derived from the medical perspective with a focus on illness and risk. With time midwives could balance this approach to care by giving women the information about obesity and pregnancy and explore lifestyle changes with them using a motivational “small steps” approach.
Government reports recognize pregnancy as an opportunity to promote healthy lifestyle, weight management behaviors and breastfeeding and to lessen long term effects of obesity (Lemic, 2013, Department of Health, 2009, Foresight, 2012 and 2007). Comprehensive research and both NICE (2008) and RCOG (2006) show that a moderate course of aerobic and strength conditioning exercise is not associated with adverse outcomes and can be beneficial (RCOG, 2006, Hume, 2014 and Melzer, 2010). NICE (2015) give recommendations on healthy eating and exercise in pregnancy.
Reasons for implementing your project
Five years ago, in response to learning from significant clinical incidents where the Trust see cases that had poor outcomes for women with raised BMI’s and their families, a “Pregnancy Plus” initiative was created by a midwife for women with a BMI >35. This initiative was developed with the idea that support and advise we could reduce the risks to women and their babies.
Pregnancy Plus offered:
- Three appointments at around 16, 28 and 36 weeks of pregnancy with a pregnancy plus midwife
- Additional screening test for gestational diabetes (Glucose Tolerance Test)
- Additional growth ultrasound scans (At 34 weeks and more if needed)
- Weight monitoring
- Risk assessments and birth planning
- Referral to slimming world postnatally
The pregnancy plus appointments are at least 30 minutes long in order to allow time for in depth discussion about current lifestyle and diet and activity levels. Women are encouraged to identify areas in which the she feels she can realistically make changes to suit her personal circumstances.
As a community midwife I was concerned about the impact of obesity. This was heightened when a client put on weight rapidly during the antenatal period (gaining 25 kg in 15 weeks). She began her pregnancy with a BMI of 30 otherwise healthy. She was informed about the foods to avoid in pregnancy and advised about eating healthily. She wanted to have her baby in the birth centre which was an acceptable plan of care at the time.
However, if women gain an excessive amount, it is not recommended that they deliver at the birth centre – because of the additional health risks. Unfortunately because of the weight gain she had to deliver in the obstetric unit. She also suffered back and pelvic pain which caused mobility problems and she developed pre-eclampsia which has known links to obesity. An audit was undertaken in March 2016 by the Pregnancy Plus Midwives and the Community Matron from LGT which clearly demonstrated that women with a raised BMI of 35 or over had significantly more complications in pregnancy and also more adverse outcomes during labour such as PPH.
All women with a BMI of 35 or over are offered an appointment with a Pregnancy Plus midwife at around 16 weeks, 28 weeks and 36 weeks to have a 30 minute appointment to address their specific health needs including discussions around healthy eating, exercising for a healthy lifestyle, and prevention of excessive weight gain.
As a generic community midwife seeing women in a “traditional community midwife clinic” I reflected on my practice and wanted to prevent this happening again.
NICE and the Department of Health give midwives evidence based guidance of what midwives should include in our antenatal appointments. However these appointments are only 15 to 20 minutes long, there are only 7 to 10 of them and the majority are at the end of pregnancy.
This makes it difficult for community midwives to incorporate all the recommendations in the appointments. For that reason, I chose to develop the NICE guidance into a new innovative dynamic programme for Mothers to be, offering group sessions to incorporate best practice in a fun but informative way. The classes are offered to all women whatever their weight and BMI but mothers are directly referred from the Pregnancy Plus midwives.
How did you implement the project
In developing a service, a literature search was conducted which found three qualitative studies were (Khazaezadeh et al, 2011, Weir et al, 2010 and Furness et al, 2011).
Common themes emerged in all three studies; women wanted honest, non-conflicting information, they wanted social support, access and availability to local services, and behavioural change needed to be addressed. Such issues cannot be managed as part of the routine antenatal appointment due to time restraints.
I realised from the literature review that I needed to gather the key stakeholders and members of the multidisciplinary team both within LGT but also from the wider community, to share my vision and to gain support and sharing of skills and resources. At a strategic level the Head of Midwifery and Matron for Community Services have lobbied commissioners and the relevant Borough Councils for sustainable funding as well as their support. This is the biggest barrier to success – classes evaluate well and are well attended but securing sustainable funding in the current economic climate is challenging. However many involved professionals skill swap.
A pilot was held in a local sports centre for 16 weeks wherein the women had to pay but it was extremely well evaluated. Alongside this a successful small grant bid was submitted to the Florence Nightingale Trust (a charitable organisation) to enable the classes to be run for one year free of charge to participants. In essence it costs £5000 a year to run the class 48 weeks a year for two hours a week. The funding will cover until early October 2016 but further charitable bids have been submitted to other organisations to enable the project to continue. The CCGs are also being approached to adopt this work as core business.
We worked with a local sports centre to combine exercise classes with midwife-led health promotion and parent education classes. A charge of £3.15 a week was made for attendance at the classes. This charge covered the cost of the accommodation and instructor.
In order to develop the content for the classes, we utilized the services of a physiotherapist, yoga instructor, hypnobirthing teacher, health visitor, health trainers and breastfeeding lead for the Trust
A steering group was set up and additional training was undertaken to ensure that my knowledge base was evidence based and current. There was liaison by myself with community midwives to ensure that they were engaged and enthusiastic about this new service, thereby able to refer appropriately.
A local supermarket donated food on a weekly basis and with the help of the trust dietitian we were able to give women examples of a 200 calorie snack.
An 8 week rolling programme was drawn up to offer different themes for discussion each week:
- Introduction to a healthy lifestyle/ exercise in pregnancy – belly dancing
- Back care and pelvic girdle pain/ exercise in pregnancy – aerobics low intensity
- Yoga and relaxation/ birth preparation discussion
- Small steps…big changes … looking at behaviour change and what the barriers are to change/ circuit training
- Labour discussion/ hypnobirthing/ belly dancing
- Active families discussion – Change for Life
- Infant feeding information/ circuit training
- Beyond pregnancy/ health visitor visit and discussion about weaning baby – aerobics – low intensity
Women were encouraged to attend as often as they wanted. We have a library of books which women donate and borrow from. We are constantly reviewing our approach and try to accommodate cultural needs. For a while we offered a prayer break to reflect the cultural and diversity requirements of those attending the classes, however this is very flexible to meet the needs of participants.
We won the Royal College of Midwives public health award this year. Winning the award has helped raise the profile of the initiative and subsequent to this there has been interest in adoption shown by the 3 local Clinical Commissioning Groups.
The pilot study and future audits identified the classes were acceptable to 100% women attending and demonstrated that the sessions did encourage women to explore a healthier lifestyle. It was evident that women attending were forming supportive relationships within the group. In the near future it is intended that an audit will be undertaken determining the outcomes in labour of the women who regularly attended Active Mothers. This is to identify whether there is a direct correlation between increased understanding of how to reduce their risks in pregnancy and therefore healthier lifestyles in pregnancy leading to improved outcomes in labour. A comparison could be made with the outcomes identified in a recent LGT Pregnancy Plus Audit and Service User Evaluation.
The importance of having a midwife available for advice and support on a weekly basis was highlighted as invaluable for pregnant women and very reassuring.
The women who attended the classes began to seek out other local activities so that they could continue being active after the birth. We worked with the local children’s centres to encourage uptake of further activities.. Initially the uptake of classes was slow. The number of women attending on a weekly basis was initially 2 it rose to 11. We found that this was a suitable number of women to engage in constructive discussion.
The pilot study showed that for 73 percent of the women attending the classes, it was their first time in a sports centre.
The results demonstrated 100 percent of the women included in the initial evaluation began breastfeeding. This may be because an entire class is devoted to the concept of exploring infant feeding in a non-threatening, unrushed way with plenty of peer support from each other.
Key learning points
During our evaluation, we found that 30% of the women who didn’t attend the classes were unable to due to work commitments. Few employers accepted an appointment letter. In future we would explore the possibility of offering more classes at different times of the day to overcome this.
Women were asked to complete a health screening questionnaire before starting the classes. These helped us cater for the needs of the women attending the classes. The majority of the women attending were aged 26 to 35. We would want to explore ways to make the classes more attractive to all women. 45 percent of women had back or pelvic girdle pain which highlighted the importance of physiotherapy input and the core exercises.
Women found it difficult to attend when children were on school holidays. So we invited the children along as well. We would explore ways of exercising with children and the department of health recommendations as well as preparation for baby classes. We also had sessions from St Johns Ambulance by peer educators to teach children how to put their mums into the recovery position and how to call 999 and when not to.
Women shared their stories with us - emotional and mental health issues were often identified and explored. We have seen women go on journeys from initially not being able to leave their home unless it was a health appointment to feeling confident to take her 18 month old to the park for the first time, another women who had suffered antenatal and postnatal depression in her previous three pregnancies felt more positive with the one she went through with us.
We conclude that to incorporate the recommendations from NICE guidance into practice, schemes like ‘Active Mothers’ can help.