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Programs to tackle pregnancy & weight

Australians are putting on the kilos and this causes problems for pregnant women. But health workers and patients are working on it. Amie Larter reports

The prevalence of obesity around the nation has more than doubled in the past 20 years.
According to the results from the 2011-2012 health survey released by the Australian Bureau of Statistics in 2011-12, some 63.4 per cent of people aged 18 years and over were overweight or obese.

This percentage was made up of 35 per cent being overweight and 28.3 per cent obese.

Percentage wise, Australian women are less likely to be overweight or obese then Australian men, however, they have seen the biggest rise over the past decade. Since 1995, the average Australian woman has put on 4.1 kilograms, growing from 67kg to now weighing 71.1kg.

As the childbearing gender, these statistics have caused an increase concern regarding the prevalence of adiposity in our obstetric population.

Adverse pregnancy outcomes due to being overweight or obese are well recognised. Published in The Medical Journal of Australia, the paper Overweight and obesity in Australia mothers: epidemic or endemic? confirms that adverse effects can include hypertension in pregnancy, gestational diabetes, caesarean delivery, perinatal mortality, and baby and neonatal morbidities including jaundice and respiratory distress.

Hannah Dahlen, Professor of Midwifery at the University of Western Sydney's school of nursing and midwifery, says that due to the health risks that develop for both mother and baby, pregnant women with a higher body mass index have a higher rate of intervention at childbirth.

"They are more likely to end up with inductions or caesarean sections due to increased risk factors," Dahlen said. "We know if they end up having a caesarean that the risks are definitely increased. They are more likely to have anaesthetic issues, wound breakdown and infections as well."

Rural focus

Recent results from a six-year study in Victoria's Goulburn Valley show that there is an exceptionally high incidence of obesity in this rural area - with more than two-thirds of the 6000 women studied either overweight or obese throughout their pregnancy.

Co-author of the study and clinical services director with Victoria's Western Health, Associate Professor Glyn Teale, says obesity has commonly been more associated with non-metropolitan areas.

Teale says the underlying reasons for this are "very complex social issues".

The paper, A profile of body mass in a large rural Victorian obstetric cohort, highlights the extraordinary levels of obesity in a pregnant rural population.

"The complications of overweight and obesity [in pregnancy] are such that you will often need to have specialist care," Teale said.

"Lots of rural areas in particular do not have specialist care. Smaller hospitals that may deliver 50-500 women is not going to attract a specialist to such a position ... as a specialist is probably not going to be able to function in a hospital like that because of the deskilling nature of the low birth rate."

This leads to the consideration of further training the current workforce to better manage the complications. GPs, obstetricians and midwives could be imparted with specialist knowledge, however, as confirmed by Teale, this still means women are lacking specialist care.

He suggests that instead we need to ensure the rural workforce in particular is aware of the increased risks associated with obesity.

"One of the things various guidelines are advocating is that there is increased surveillance for [these] women."

Increased surveillance could entail a change in expectations for health professionals. Instead of seeing an overweight woman and expecting that she will present with a low risk profile and only seeing her every fortnight throughout later stages of the pregnancy, Teale suggests that she be seen weekly or sometimes even more frequently than that.

"Be aware that a chance of her developing a problem is much greater. Have your antenna out for detecting a problem and pick up any complications as early as possible so they can be properly managed."

What women want

Jane Raymond, (previously) the project midwife, Sutherland and St George Weight Intervention Group (SSWInG), South Eastern Sydney Local Health District, believes Australian health professionals are well equipped to handle the medical complications, but it is the guidelines and tools to manage the emotional and psychological care that a woman needs that is lacking.

Raymond says there are several studies that have asked obese women what they are looking for in terms of support and care throughout their pregnancy and their responses were much the same as any women, they wanted to feel valued, respected and cared about.

"These [women] wanted a chance to develop a relationship with one maternity care provider who they trusted, and to be seen as a person and not an obstacle, to be involved with decisions about their care, not to feel humiliated or made to feel like a disaster waiting to happened," said Raymond.

"They talked about ambiguous messages where different maternity care providers gave inconsistent advice about eating or exercise, or never mentioned their weight at all so they got the impression it wasn't important."

Dahlen agrees, stating that from her experience, women don't want health professionals tiptoeing around the issue.

"The women said 'we don't want people tiptoeing around it, we want you to tell it as it is, we need to hear the hard facts but then get alongside us and support us."

Women around Australia with a BMI greater than 35 (sometimes more than 40) are referred to a tertiary centre for pregnancy and birth because of the increased risk of gestational diabetes, high blood pressure and surgical care.

Raymond suggests that in these centres "women receive care in a 'high risk' antenatal clinic where their care is often fragmented and they will be seen by a large number of different medical staff".

In these environments, sometimes the emphasis seems to be on managing the medical complications that focus on preventative care.

There are an increasing number of policies being introduced that recommend women above a certain BMI should be transferred to a hospital with specialist care facilities. Regardless of area, what everyone seems to agree on is that models of care need to change in order to successfully care for the needs of this group of women.

Case study: SSWInG

Raymond was involved in the development and implementation of the innovative St George and Sutherland Weight Intervention Group (SSWInG) in the Sydney South East Local Health District.

SSWInG is an integrated model of group antenatal care that provides women who are obese with a one-stop-shop for care throughout their pregnancy - with a particular focus on limiting their weight gain in pregnancy.

"[The program] provides pregnancy care, birth preparation, activity and healthy eating information and social interaction all at the same time," said Raymond.

"Women of the same gestation meet as a group (10-12 women) throughout their pregnancy with the same two midwives. There are eight sessions for each group and each last two hours. An optional drop-in session each week provides an opportunity for extra weigh-ins or chat with the midwives. A new group of women starts every six weeks."

To help normalise the experience, groups are held in community venues, which also helps participants make weight management feel as though it is part of everyday life rather than something that requires medical assistance.

The women do not go on a diet, rather they are encouraged to incorporate more fruit and vegetables into their diet while limiting unhealthy foods to once or twice a week.

The model uses the American Institute of Medicine Guidelines for weight gain in pregnancy, for obese women this is only 5-9kg.

SSWInG has had some difficulties getting people to attend, with only about three in every 10 accepting to join the group. However, for those involved Raymond reports they have really enjoyed it and they virtually never see any drop out.

Upon evaluation, women have said that the group is often the first time a health professional has talked to them about their weight and the strength drawn from sharing experiences and feelings with other women in the same situation.

"In the first two years of the program over 50 per cent of the women had gained weight within the guidelines, some more and some less," said Raymond.

"Every woman said she was 'satisfied' with her weight gain - in many cases it was much less than she had gained with a previous pregnancy. A major focus of the groups is to increase the normal birth rate (to reduce the major complications of surgical birth), and the normal birth rate in the groups has seen a steady rise. We've been running the groups for three years and are starting to see women coming back with another pregnancy determined to limit their weight gain."

Feedback from midwives involved suggest that although they had always realised that overweight and obesity were important topics, talking to women about their weight was challenging - worrying about the perceived impact on their relationship with women.

"Midwives need support and training to talk to women about weight, we provided training in motivational interviewing to the midwives in SSWInG and those recruiting through the antenatal clinics, and they also need the back up of official guidelines," said Raymond. "No guidelines exist in NSW for gestational weight gain.

"However, research from Queensland suggests that even where there are guidelines, and midwives see it as important, women do not necessary receive accurate weight-gain information. This requires further research."

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