The midwifery perspective on maternal obesity

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The midwifery perspective on maternal obesity

• Hannah Dahlen Post Doctoral Research Fellow RHW
  and UTS
• Sally Tracy Professor of Womens Health Nursing
  and Midwifery, RHW and UTS

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The dilemma

• How do you find a lion that has swallowed you?
• (Carl Jung)

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We can understand this
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Swim fat boy swim, Underbelly, The biggest
Looser
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The media distorts the issue
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The role of the media

• 22 days of web based news reports on obesity
• 213 stories
• Most about childhood obesity
• Mothers most often blamed as cause
• Messages are conflicting
• High level and low level evidence given same
  media exposure

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Women in headlines
Obese mothers-to-be 'burden NHS'

• A lot of weight related reporting seems to be
  about women. The headlines too mostly appear to
  draw upon data related to women, even if the
  article discusses both men and women.

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Good mothers and bad mothers

• To be told you're partly responsible for the
  death of your child is absolutely devastating
  (Maria Thornton, whose son was stillborn-
• BBC News March 7th 2007)

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Between a rock and a fat place
Obesity may worsen impact of asthma
Gut microflora and obesity Nestle expands the
possibilities
FAT CHANCE FOR GROUP OF TODDLERS WITH OBESITY
PROBLEMS
Caution Over Anti-Obesity Drugs for Kids
Podiatrist walks to fight obesity
housebound inertia
Obesity hampers fertility
no known long term effective strategies
Breaking the diet mentality
Obesity Drug-Discovery
New Study Links Erectile Dysfunction With Obesity
UK schools to be judged on obesity
Invention of the microwave unleashed global
obesity ripple effect
Neighborhood's food options affect obesity rates
To sleep right, perchance to stay slim
Metabolic Syndrome Triggered by Overeating, Not
Obesity
Can surgery reverse obesitys damage?
Large waist may raise death risk for women
Obesity no risk factor for caries in kids
Obesity crusade propelling Brit kids towards
anorexia
Obesity can increase dementia risk by up to 80
per cent
Cancer Survivors No More Active or Less Obese
than General Population
Cancer 'sloths' risk it again
Super-sizing the maternity ward
'Turn Off' Week Targets Obesity
Working mums obese kids
pharmacists to tackle obesity
Fathers obesity linked to childs liver disease
Obesity and Low Birth Weight Harm Kids' Health
New Study Correlates Preschoolers' Screen Time
With Obesity
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What did we tell the mothers of todays mothers?

• Sampselle (1999) little documentation about
  exercise in American textbooks
• Bennet and Brown (1989)no sit ups or leg cycling
  in the air
• Maggie Myles (1981) dont lift weights causes
  miscarriage

• spend two hours a day in fresh air,...preferably
  walking or sitting in the garden or park. Noted
  that women need to be ...reminded that baby
  needs a daily airing before birth as well as
  after,... (Myles, 1981, p.149).

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Problem

• We know we have a problem
• We know the problem is getting worse
• We know we should do something about it
• We dont quite know how to best approach it

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What do midwives worry about?

• Dont pathologise yet another group of women
• Women get labeled not individualised
• The service is fragmented and stretched
• Everyone is doing something different
• Weight is a psychological issue as well as a
  physical one
• Even the equipment cant keep up with expanding
  waist lines
• Our approach is not long term or a primary health
  care approach, so can it be effective

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How do we confront the issue?
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How do we talk to women about obesity?
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Worshiping at the feet of the BMI God!

• BMI can be misleading
• Overweight and exercising is healthier than
  underweight or normal weigh and not exercising
• Is BMI applicable to all races (Chinese, Indian,
  Malaysian) ages (children and adults) and body
  types (body builders)
• When do we take a BMI?

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What do we need to do?

• How do women who are obese think we can help?
• How do women change activity patterns in
  pregnancy?
• How can we get women to motivate each other?
• Take a wholistic, primary care approach
• Continuity or carer/care will help address
  fragmentation and psychological issues
• We need a truly multidisciplinary approach
• We need guidelines not rules and regulations

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How best to approach the drowning
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Introducing WOW Watch Our Weight Midwifery
Group Practice

• A reorganisation of existing resources rather
  than the development of an expensive specialised
  expert team.
• The Watch Our Weight (WOW) program - is the first
  attempt to reorganise an existing service (public
  hospital antenatal, birth and postnatal care)
  into an integrated care program for obese women
  co-ordinating and redirecting resources at a
  community level aimed at prevention.

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GOAL

• To promote healthy eating and breastfeeding,
  active living and positive self esteem rather
  than the achievement of ideal body weight.

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AIM

• To identify women at risk during pregnancy to
  initiate a prevention program that has a life
  course approach focussed through a strong level
  of continuity of care, education and support.
• (Midwives currently have little opportunity to
  provide this continuum of care to a known group
  of women in a continuity of care model.)

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Potential Benefits

• Addressing the problem of obesity at such a
  critical period of growth and development of both
  the mother and the infant has the potential to
  effect changes in the management of weight
  related problems where parents are viewed as the
  central agents of change

Golan et al (2006)
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Prevention

• The program concentrates on prevention as a
  critical element of health services. An emphasis
  on primary health care prevention through simple
  information and skill-building to change
  behaviour, taking a life-course approach.

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Proposed Program for the WOW Midwifery Group
Practice (6 FTE midwives)

• One WOW midwife is nominated as the primary
  caregiver for approximately 35-40 obese women per
  year.
• As the primary caregiver they co-ordinate other
  members of an interdisciplinary team (eg
  dieticians, physiotherapists) to initiate and
  sustain intervention programs
• Walking (pedometers 10,000 step program)
• healthy eating programs ( CSIRO Total Wellbeing
  Diet in audio)
• breastfeeding support
• for at least twenty weeks covering the pregnancy,
  birth and the first six to eight weeks of
  postnatal care when infant feeding practices are
  establishing.
• The benefit of providing a system of continuity
  of care recognises the potential and
  philosophical importance of continuity where the
  caregiver and patient enter into a complex
  interpersonal relationship characterised by trust
  and a sense of responsibility

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Conceptual Framework

• A toolkit developed by the Faculty of Public
  Health and National Heart Forum in the UK.
• Lightening the load tackling overweight and
  obesity. A toolkit for developing local
  strategies to tackle overweight and obesity in
  children and adults.
• It was designed to assist in operationalising the
  UK National Institute for Health and Clinical
  Excellence 2006 Guideline on Obesity

Lightening the load tackling overweight and
obesity. DOH London, UK
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The Three Es Program (Maryon-Davis, 2003.)

• encouragement
• empowerment
• environment

Lightening the load tackling overweight and
obesity 2005
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The Three Es Program (Maryon-Davis, 2003.)
ENVIRONMENT
EMPOWERMENT
ENCOURAGEMENT
Maryon-Davis, 2003
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The triple-tier pathway for weight management.
(From Maryon-Davis, 2004.)
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What can midwives do ..

• Golden Opportunity Women are motivated during
  pregnancy
• Stigma
• Opportunity to build networks and encourage group
  interactions antenatally/postnatally for support
  and friendship
• Discuss and seek treatment for sleep apnoeas etc
• Food
• Opportunity to educate and try foods modification
• Shopping lists/how much TV/school lunches
• Exercise
• Walking with pedometers - doesnt take a gym
  subscription
• Help organise walking buses

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Differentiating the WOW and Routine Care
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Evaluation of the Program

• A randomised controlled trial of a new initiative
  in public hospital pregnancy support for obese
  childbearing women the Watch Our Weight (WOW)
  program