Obesity in pregnancy carries significant risks for both mother and baby, yet we identified limited opportunities for women to access support and advice. We initiated a midwifery-led service which encourages obese, pregnant women to make positive healthy lifestyle changes in the antenatal period, which would be sustainable after the birth.
Aims and objectives
Doncaster has a population with high levels of socio-economic deprivation, which has been clearly linked to maternal obesity (Heslehurst, 2007). Life expectancy, infant deaths, deaths from smoking and people diagnosed with diabetes, are all worse than the England average (The Association of Public Health Observatories, 2009).
In 2009, 20% of women in Doncaster were obese at the beginning of their pregnancy. This carries significant risks both for the mother, for example gestational diabetes, miscarriage, pre-eclampsia, thromboembolism and maternal death, and for the baby: macrasomia, congenital anomaly, fetal death and obesity in later life (Ramacheneran et al, 2008). Our aim was to create a service which encouraged and supported women to make lifestyle and behavioural changes in the antenatal period which would be sustainable after they had given birth. Having ascertained that there were no antenatal services to support pregnant women in our area, regionally or indeed, little evidence of national initiatives from which we could share learning, we planned to create a groundbreaking service. As midwives, we immediately appreciated that our advice and support could not be a single professional response or simple maternity service enhancement offer. To effect the engagement, continual attendance and wellbeing gains we sought to provide and achieve with women, we determined that we needed other professions to work with us i.e. obstetricians, dietitians, counsellors and providers of supported exercise programmes.
Our vision was a service whereby all women with a BMI >=30 at first midwifery contact in their pregnancy would be offered optional additional support from the services of a 'Healthy Lifestyle Midwife'. If they presented with an initial BMI of >=35, they would be given a clinic appointment with us at a specialist midwifery-led clinic at fourteen weeks gestation, which would be part of their antenatal care pathway and additional to their routine antenatal care. Women would be encouraged to return to us for ongoing support throughout their pregnancy.
The purpose of this clinic appointment would be to raise awareness of the potential risks for mothers and babies relating to high BMI, to assess risk, initiate individualised care planning and to offer support in the form of a Dietetic consultation, thus providing a multidisciplinary team intervention. Women (and their supporters) would be educated about the principles of healthy activity and in order to offer appropriate pregnancy exercise opportunities, it would be necessary to link with local leisure services partners, and to make available training for midwives to provide a comprehensive local provision of aquanatal sessions.
Reasons for implementing your project
At the onset of our project in November 2008, our PCT target was to achieve 100% referral rate of all obese pregnant women into our services, with 50% of this cohort engaging in the services. There were no pre-existing services at that time. In Yorkshire and Humber 18.2% of all women who conceive are obese (CMACE, 2010), which is 2.2% higher than the national average.
Data for Doncaster and Bassetlaw hospital communities indicates that the local picture is 20%; i.e. 4% higher than the national average. Obese women spend an average of 4.83 more days in hospital in their maternity pathway and the increased rates of complications in pregnancy with interventions in labour representing a five-fold increase in the cost of their antenatal care (NICE, 2010).
Prior to our initiative, the model for caring for women who were obese in pregnancy was inconsistent and there was poor monitoring of the care pathway being followed, thus leading to inequity of service. Brief intervention advice relating to healthy eating and exercise was universal regardless of BMI, and since no formal training for this advice existed, there were huge variants in the quality and equity of advice given. Women with a BMI >=35 would be referred for consultant care, and an antenatal anaesthetist assessment. Again, there was no consistency of such reviews, and with this consultation being based on advice relating to not gaining excessive weight during pregnancy, such advice was poorly timed since it often occurred in the third trimester. Local guidelines recommended a dietetic referral, but there was very poor uptake of this since the referral pathway was complicated, and many midwives were not aware of the associated risks and complications of obesity for mother and baby.
How did you implement the project
We wanted to achieve a true partnership approach and a seamless service which ensured that all elements were in place for women to move smoothly through the antenatal pathway. It was not possible for our obstetric consultant colleagues to overcome the intensity of their clinical workload, thus we determined a pathway together which would be midwifery led, and feed to and from the specialist pathway for these clinically high risk women.
To assist this process, we designed a care planning tool, which enables early identification of a woman's individual needs, and addresses issues such as equipment and manual handling requirements. Clear care planning is documented and easily shared by all health care providers, resulting in better communication and improved patient care. Our dietetic partners put forward a successful business case to provide 3 hours presence in the clinic per week. A provision existed for the local population with specific needs to access reduced rate gym-based activities. We negotiated obesity in pregnancy to be included in their entry criteria of to offer our clients a more comprehensive experience.
Since our Community Midwifery colleagues are the primary referrers into the service, it was imperative that we ensured that the process did not significantly increase their current workload, and that we gained their cooperation and trust in the service. We responded to their concerns about raising this sensitive subject with women by carefully designing literature, training and education to assist them. Our local Maternity Service Liaison Committee members gave feedback about the use of inappropriate language which influenced our choice of naming the initiative 'The Monday Clinic', avoiding difficult titles and unnecessary stigmatism. The annual tariff for our intervention is £53,115 (midwifery and dietetic salaries, resources and marketing, and exercise provision).
At the end of year one, attendance rate to the 'Monday Clinic' was 81% with 20% of attendees returning throughout their pregnancy for ongoing support. To date, we can demonstrate a 1% reduction in LSCS rate of attendees to our intervention compared to national data. This 1% reduction equates to a cost saving of approximately £93,000 per annum at the Doncaster site. Women who are obese at the beginning of their pregnancy will have fewer complications if they manage gains at around 7kg (Cedergren, 2006).
Average weight gain of attendees to our clinic is 7.65kg, with 74% not developing any new conditions i.e. co-morbidities during pregnancy, thereby impacting positively on maternity care costs. In 2010, national publications from RCOG, CMACE and NICE gave detailed insight into the complexity of maternal obesity, and a survey of 6,252 Netmums members revealed that 64% of mums wanted to talk about healthy eating and weight loss with their midwife after the baby was born.
With this, and an acknowledgement of the national strategy in mind, we recently launched 'Yummy Tummies'; a postnatal peer support group for weight loss. The aim of this project is for women to support each other, with the agenda and tools to achieve postnatal weight loss being set and owned by the group. Midwifery input allows for specialist knowledge to be accessed if required. Reducing the number of women who are obese during pregnancy will result in fewer high risk women entering specialist maternity care pathways, and will thus affect women's long term health and life expectancy.
We have linked maternal obesity support needs into our congruent and robust healthy pregnancy care pathway to provide a seamless approach to the delivery of information and support before, during and after pregnancy. Women's needs are viewed in context and as part of wider family structures, aligning their needs with those of their existing children and partners.
Key learning points
In the first instance, we implemented an eight week pilot programme for our initiative, which incorporated a total of 40 events. The programme involved dietetic and midwifery education and support sessions, land and water based exercise opportunities and counselling sessions for women who felt that their eating patterns were symptoms of other underlying issues. Despite an encouraging referral number of 76 women, with 73 giving positive response to the telephone invitation to the events, not one woman attended any of these planned sessions. Upon reflection, we concluded that we had not engaged women with a telephone conversation as we had anticipated and we would need a face-to-face contact to establish any future rapport and trust upon which to build this service offer.
It was also apparent that offering a voluntary 'opt in' service would lead to inequity of provision, thus embedding an additional appointment into the maternity care pathway ensures that our current service offer is for all women who fit the criteria. We have shared our learning within the region by initiating a forum of specialist midwives with a key role in the obesity agenda.
Our learning over the past two years has heightened our awareness that our regional midwifery colleagues lack the capacities to initiate a similar maternal obesity service in their units due to their responsibility for multiple public health agendas. They therefore do not have the ability to dedicate the time required to start a learning journey such as we have undertaken. In response to this, we are hosting our first project management and training programme in March; a two day course which will enable delegates to acquire the skills and resources required to develop a maternal obesity service which fits local purpose. Monies generated from this training initiative will be used to further develop our primary service.