The Specialist Weight Management Service (SWMS) Maternity Pathway was launched in January 2012 in Wigan and Leigh. This was as a result of growing public health issues surrounding obesity and the publication of NICE Guidelines for weight management before, during and after pregnancy (PH27).
The service is aimed at obese pregnant women (BMI >35kg/m2) to support them introduce healthy lifestyle changes and safely minimise weight gain during pregnancy. Support is also available for up to 18 months post-partum.
Pregnant women who come to our service are seen in multi-disciplinary clinics by a Dietitian (RD) and Physiotherapist (PT). Staff use a patient-centred behavioural change approach to help service-users implement positive lifestyle changes. Service-users can also access an Occupational Therapist, Medical Consultant and Psychologist if required.
Statistics indicate that the maternity service is constructive in terms of key outcome measures in adherence to NICE guidelines.
Aims and objectives
The main aim of the Maternity Weight Management Service is to support obese ladies to manage their weight through pregnancy, not through advocating weight loss but by providing support to minimise excessive gestational weight gain (GWG). There are still no formal, evidence-based guidelines from the UK government or professional bodies on what constitutes appropriate weight gain during pregnancy, but as per the US Institute of Medicine guidelines (Rasmussen and Yaktine 2009) obese women are expected to gain 5–9 kg (11–20 pounds) in pregnancy.
In comply with NICE Guideline (PH27) clinicians aim to provide patient-centred assessments and care plans to ensure that the following points are addressed:
- Why someone might find it difficult to lose weight
- Support is tailored to individual needs and choices
- Clinicians are sensitive to the service-users weight concerns
- Clinicians help to identify and address barriers to change
As stated in the service slogan, clinicians aim to support service users in having a ‘happy and healthy pregnancy’. The RD works with service-users to optimise their nutritional intake in pregnancy for the wellbeing of both mother and baby. Advice is provided on how to eat healthily and foods which should be avoided in pregnancy to enable women to make more informed decisions about their diet (as per Quality Statement 1 QS98).
The PT promotes safe levels of physical activity during pregnancy and offers practical advice on gradually increasing activity levels in accordance to NICE Guideline 43 QS111. They are also adept at providing first line management of pregnancy related musculoskeletal and incontinence conditions, and signposting onto Women’s Health specialists as appropriate.
The pathway also helps expectant mothers and their wider families access other services including smoking cessation, breastfeeding networks and healthy-start services to name a few (as per Quality Statement 3, 4 + 6 QS98). Support is also available post-partum in the standard weight management service for 18 months. This is to support women to lose weight as advised in Quality Statement 2 QS98 and Quality Statement 8 QS37.
Reasons for implementing your project
Obesity during pregnancy can have significant impacts on both mother and baby according to the Chief Medical Officer’s report in 2015;
- For the mother – increased risk of miscarriage, gestational diabetes and perinatal complications
- For the foetus – increased risk of stillbirth, metabolic and developmental abnormalities
- For the child – increased risk of obesity, diabetes and hypertension
Trends from the Health Survey for England show that the prevalence of obesity among women of childbearing age has increased by 7% from 1993 to 2013 meaning that more women are entering pregnancy at a higher BMI (HSE 2013). The National Maternity and Perinatal Audit 2017 showed that 21.2 % of pregnant women had a BMI> 30kg/m2. According to NHS digital statistics, by July 2018 approximately 25% of women had a BMI> 30kg/m2 at their initial booking appointment at the Wrightington, Wigan and Leigh NHS Trust. This is notably higher than the national average of 18.5% from NHS digital statistics (Health and Social Care Information centre 2019).
The costs associated with maternal obesity and GWG are well documented, including a Welsh study which found an additional healthcare cost of £1,171 for each obese woman (Morgan et al. 2014). As stated above, the expected gain for obese women in pregnancy is 11-20lbs (5 – 9kg). This gain accounts for the unborn child, amniotic fluid, increase in blood and fluid volume and includes increased body fat. False perception of ‘eating for two’ could increase risk of excessive GWG. This excessive GWG is positively correlated with postpartum weight retention, increased healthcare costs and psychological impairments (Brown et al. 2006). Pregnancy however can be an opportune time to alter behaviours around eating and physical activity (Foresight 2007). As per NICE (2010) diets during pregnancy are not recommended due to the potential harm on the unborn child. It is recommend that women with a BMI >30kg/m2 should be offered a referral to a dietitian or appropriately trained health professional for advice around healthy eating and how to be physically action. This project will explore the success of the maternity weight management clinic run by RDs and PTs from Aintree University Hospital NHS trust for promoting healthy lifestyle changes and at preventing excessive rates of GWG.
How did you implement the project
In 2012 the pilot maternity pathway was launched. The referral criteria was decided (pregnant woman with BMI >35kg/m2) and referrals into the service could be made either by the service-user or a healthcare professional. A leaflet was produced to include in the service-user information pack and training was delivered to local midwives about the service. Service-users were to be seen by a consultant physician within 2 weeks of referral, soon to be followed by an assessment with the PT and RD.
In the first year only 31 referrals were received and although this exceeded the key performance indicator KPI of 24, it was estimated that of the over-weight pregnant women in the borough only 11% had accessed the service. No referrals had been made by midwives. All were self or GP referrals, or current SWMS service-users that had become pregnant. Due to the first contact being with the consultant, patients often waited over a month before initial assessment.
Consequently, clinicians collaboratively worked across two NHS trusts to obtain a midwife to join the maternity weight management. Midwives started to refer directly into the service instead of just signposting. Those with a BMI >40kg/m2 were also automatically referred by midwifes. Most service-users didn’t require the input of a consultant physician and so the pathway changed to have the initial assessment carried out by an AHCP; meaning quicker access to the RD and PT. At initial assessment with the PT and RD service-users are given a PT and RD outcome measure tool to complete produced by Aintree Trust. This is reassessed at their final ante-natal appointment. We have collated the results, as is reported below. Service-users are seen monthly throughout their pregnancy by the PT and RD to address any key concerns and their weight is monitored. We communicate their progress back to their midwives via their written care plan.
Over the past 6 years the pathway has continued to develop and progress. In order to reduce the amount of patients that fail to attend their initial assessment DNA, a telephone triage process was introduced in June 2017. An opt-in system was also introduced in July 2018 to further reduce these rates. We continue to liaise with other weight management services in the borough such as ‘Healthy Routes’ to improve service user engagement.
27 sets of Aintree Dietetic Outcome Measure Tools have been completed from May 2015 to July 2018. The mean GWG was 4.39kg/9.6lb which is within the IMO’s recommendations. One women who had gained 5 stone in her previous pregnancies managed to maintain her weight throughout. Most women reported being highly motivated to change their diet at their first appointment (mean score 8.2 out of 10). At their final appointment 67% of service-users had increased in confidence in making dietary changes (mean score 8.8 out of 10).
We looked at improving dietary outcomes such as meal pattern and nutritional status. Overall, 15% of women improved their meal regularity and 37% reduced the number of high calorie snacks eaten per week. Service-users provided positive feedback about the service including; ‘The staff are lovely and make you feel comfortable; I never felt judged, just supported; I’ve now got a better understanding of beneficial foods during pregnancy’.
We aimed to address eating behaviours that can affect weight gain. 78% of women reported eating while distracted, 52% reported boredom eating and 70% reported to get take-away on a regular basis. These numbers reduced to 63%, 26% and 67% respectively at final reviews.
Overall 30% noticed an increase in the frequency of which they had F&V and 41% noticed an increase in portions per day. Women who met the recommended daily fluid requirements increased from 30% to 59%. At final review 78% had reduced portion sizes and 67% were planning more meals. Overall the frequency of dairy intake increased for more than 63% of women.
Public Health England (2017) indicates that a higher maternal BMI is associated with a lower breastfeeding rate and a higher caesarean section rate. Of the 27 patients, 48% had normal vaginal deliveries and 66% initiated breastfeeding. The Health Profile for Wigan indicates that 55.1% of service-users initiated breast feeding within 48 hours of delivery in 2014/15. This is significantly lower than the national average (74%), so it is pleasing that 66% of patients within this project initiated breastfeeding.
64 sets of Physiotherapy Outcome Measure Tools have been completed since January 2012 – July 2018. At initial assessment 87% of service-users were achieving the national recommendations for physical activity levels. By their last antenatal appointment this figure had increased to 89%, despite service-users being 34-38 weeks gestation. Pelvic floor exercise compliance also increased by 26%.
Key learning points
There is a current need to establish GWG targets within the UK. NICE (2010) recommend researching if the American guidelines can be applied in the UK. With this project, having these as guidelines did give patients targets to aim towards which improved outcomes. Perhaps more research is needed to demonstrate this further.
This service is available to women with a BMI >35kg/m2. According to the Chief Medical Officer’s report in 2015 and recent research in Hong Kong, the effects of excessive GWG are seen independent of starting BMI, particularly in effects to the unborn child with regards to increased body size, increased risk of hypertension and insulin resistance (Tam et al. 2018). This has posed the question; should specialist weight management advice should be open to all women in pregnancy regardless of starting BMI? According NHS digital statistics 22% of maternity patients were classed as overweight and are at risk of excess GWG and moving into the obese category. These statistics are experimental and are open to limitations. Granting all women access to the service may allow them to control their GWG and prevent them from entering future pregnancies at a higher BMI or becoming obese. Public Health England’s maternity obesity report suggests that commissioners may want to consider opening up weight management interventions to all women of childbearing age to achieve a healthy BMI prior to pregnancy (Public Healthy England 2017). This is also supported by The International Weight Management in Pregnancy Collaborative Group in their 2017 study which concluded that weight management interventions reduced GWG and lowered the odds of caesarean sections and that the effects did not differ across BMI subgroups. They recommend that it is likely that all women, regardless of BMI could benefit from weight management interventions prior to and during pregnancy to reduce GWG and improve outcomes.