The Centre for Food, Physical Activity, and Obesity Research Maternal Obesity

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The Centre for Food, Physical Activity, and
Obesity ResearchMaternal Obesity
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Maternal Obesity Collaborators

• University of Teesside (UoT)
• Prof. Carolyn Summerbell, Professor of Human
  Nutrition, Assistant Dean for Research
• Dr. Louisa Ells, Lecturer in Research
• Ms. Nicola Heslehurst, Research Assistant
• Mrs. Judith Porch, Principal Lecturer in Women's
  Health
• North East Public Health Observatory (NEPHO)
• Prof. John Wilkinson, Director of NEPHO
• Regional Maternity Survey Office (RMSO)
• Dr. Judith Rankin, Principal Research Associate,
  University of Newcastle
• Dr Ruth Bell, Clinical Senior Lecturer in Public
  Health, University of Newcastle
• James Cook University Hospital (JCUH)
• Dr. Helen Simpson, Consultant Obstetrician and
  Gynaecologist
• Local Supervising Authority (LSA)
• Kath Mannion, LSA Midwifery Officer

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Regional Obesity Prevalence

• Health Survey for England 2002 Adults with BMI
  gt30 kg/m2
• 21.4 England
• 27.3 County Durham and Tees Valley

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Maternal Mortality

• CEMACH 2004 Report
• 35 deaths mothers were obese (BMIgt30 kg/m2)
• Direct causes
• Thromboembolism
• Haemorrhage
• Anaesthesia
• Social disadvantage, poor communities, minority
  groups

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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1. North East Scoping Study

• Regional study involving all north east England
  Maternity units (n16)
• Part 1 Audit of routine data collection practice
  
• Part 2 Clinical impact of maternal obesity on
  service delivery
• NEPHO Occasional Paper 22 www.nepho.org.uk
• Heslehurst, N., Lang, R., Rankin, J., Wilkinson,
  J.R., Summerbell, C.D. (2007) Obesity in
  pregnancy a study of the impact of maternal
  obesity on NHS maternity services. Online Early.

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Part 2 Clinical Issues

• Semi-Structured Interviews
• Impact on service
• Facilities to cope with the potential additional
  demand
• Existing services directed towards maternal
  obesity
• Data Analysis
• Systematic, thematic content analysis (Burnard
  1991)
• Burnard, P., A method of analysing interview
  transcripts in qualitative research. Nurse
  Education Today, 1991. 11 p. 461-46.

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Themes Identified

• Booking appointments
• Equipment
• Care requirements
• Complications and restrictions
• Current and future management of care

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Theme 1 Booking Appointments

• Determine whether height and weight is measured
  or self reported
• May influence responses to booking questions
• If the booking appointment is in the home then
  there may be external influence due to other
  people being around at the time, whereas in a
  hospital booking there is more of an opportunity
  for one-to-one discussion and this may influence
  the data. For example if there is something that
  the mother doesn't want to say in front of others
  then often this is updated/addressed at follow up
  hospital appointments.

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Theme 2 Equipment

• Numerous issues mainly related to availability,
  and additional equipment requirements
• Equipment mainly couches, chairs Wheelchairs
  for excess of 300kg are available in the hospital
  but not in maternity unit although if required
  can be obtained from elsewhere. Chairs in the
  waiting room in the maternity unit are not
  changed yet but they are in the process. There
  are theatre tables that hold an excess of 300kg
  but the unit wants a permanent one so they are
  not being moved around all the time. There are
  issues around the trolleys used to transport
  women to theatre - they take the weight but not
  the girth.

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Theme 3 Care Requirements

• High dependency care
• Resources to cope with number of obese mothers?
• The lack of an operating table large enough for
  elective caesareans means that these women are
  booked in on the gynae theatre list which
  disrupts the list and has implications on the
  waiting times for the women who need surgery for
  gynae problems, this happens approximately twice
  a month. The gynae theatre table is also needed
  when an emergency caesarean is required which
  disrupts the theatre list and impacts on the
  waiting times as well.

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Theme 4 Complications Restrictions

• Restricted options for care
• Patient dignity and psychological health
• It is embarrassing having to find extra large
  theatre P.J's for the fathers who are often obese
  when the mothers are obese as well, and how to
  word / approach the issues as a member of staff,
  how to handle the situation without making the
  mother feel uncomfortable - it's difficult to get
  a balance. Some women in the past have chosen to
  deliver elsewhere as this unit has tried to
  broach the subject and other units have not the
  women felt victimised.

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Theme 5 Current and Future Management of Care

• Guidelines specific to maternal obesity
• Addressing the matter
• There needs to be a balance when making women
  aware of the issues for example not being blunt
  and trying to be kind - but by doing this were
  perhaps not giving enough information - difficult
  to get the balance.

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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2. Hospital Episodes Statistics (HES) Exploration

• An exploration of Hospital Episode Statistics
  from 1996-2006 to investigate the relationship
  between recorded complications of labour
  delivery and maternal obesity.

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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3. JCUH Maternal Dataset

• Phase 1 Pilot study -15 years of data collected
  electronically
• Incidence and trends of maternal obesity
• N Heslehurst, N., Ells, L.J., Simpson, H.,
  Batterham, A., Wilkinson, J., Summerbell, C.D.
  (2007) Trends in maternal obesity incidence
  rates, demographic predictors, and health
  inequalities in 36 821 women over a 15-year
  period. BJOG 114 (2) 187-194
• Phase 2 Follow up study looking at pregnancy
  outcomes and cost factors

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Phase 1 Aims and Methods

• To look at the trends in incidence rates of
  maternal obesity between 1990-2004
• Maternal Obesity Body Mass Index (BMI) gt30
  kg/m2 within 16 weeks gestation
• To identify any demographic predictors of
  maternal obesity
• At risk groups
• Inform future public health interventions

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Statistical Analysis - Incidence

• Women grouped based on BMI into
• Lean (lt18.5 kg/m2)
• Ideal (18.5 24.9 kg/m2)
• Overweight (25.0 29.9 kg/m2)
• Obese (gt30 kg/m2)
• CHI squared test for trend
• Health Survey for England (HSE) data for women of
  childbearing age

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Statistical Analysis Demographic Predictors

• Maternal Age Parity continuous
• Deprivation Quintiles 1most 5least deprived
• Ethnic Group - Caucasian, Mixed Race, Asian /
  Asian British, Black / Black British, Chinese /
  Other Ethnic Group
• Employment Status - Paid Employment, No Paid
  Employment, Education / Training
• Marital Status - Married, Single, Separated /
  Divorced / Widowed
• CHI Squared, Multicollinearity, Logistic
  Regression

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Results - At Risk Groups
Variables Adjusted Deprivation, Age, Ethnic
Group, Parity, Employment, Marital Status
plt0.01, plt0.05
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Excluded Population

• Statistically significant differences between
  included and excluded groups
• Age mean difference 0.86 years (plt0.001)
• Proportionally more Caucasians included (60.5),
  while more Black (63.5) and Asian (53.0)
  subjects excluded due to gestational age at
  booking gt16weeks
• Access to services
• House of Commons Health Committee. Inequalities
  in Access to Maternity Services. London The
  Stationary Office, 2003

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Conclusions

• Maternal obesity at the start of pregnancy is
  increasing and accelerating
• Health inequalities strongly related to
  deprivation
• Increasing age and parity are associated with
  maternal obesity
• Access to maternity services

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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4. Systematic Review

• Systematic review of the impact of maternal
  obesity on obstetric care
• Quantifiable factors with direct or indirect
  resource implications to the NHS
• Onset of labour
• Mode of delivery
• Shoulder dystocia
• Apgar score
• Neonatal intensive care requirements
• Length of stay
• Birth weight and gestational age
• Wounds and infections
• Haemorrhage
• Fetal distress

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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5. National Maternal Obesity Data Collection

• National study on incidence and trends of obesity
  in pregnancy
• Pilot study Phase 1 of JCUH data analysis
• Obesity in pregnancy questionnaire to identify
  electronic data collection sent to all NHS
  maternity units in England
• 151 consultant led
• 33 combined consultant and midwife led
• 54 midwife led
• 5 GP led

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5. National Maternal Obesity Data Collection

• 243 maternity units contacted
• 217 responders (89.3)
• 26 non responders (10.7)
• 217 responders
• 135 collect anthropometric data electronically
• 31 collect data electronically but not
  anthropometric data
• 51 dont have a database

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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6. Postnatal Intervention

• Middlesbrough PCT Initiated by Community
  Midwifery and Health Promotion Service
• Setting Sure Start Children's Centre
• Holistic approach centred around health
  education, physical activity and healthy eating
• Pilot recruitment in progress

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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7. Maternal obesity and congenital anomalies

• Dr Judith Rankin
• Dr Ruth Bell
• Prof. Carolyn Summerbell

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Maternal obesity and congenital anomalies

• Increase in prevalence of about one third in
  overweight and obese mothers
• Mainly accounted for by neural tube defects
  (NTDs)
• Cardiovascular and other anomalies may also be
  increased

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Why might obesity lead to congenital anomalies?

• Four potential mechanisms
• Undiagnosed diabetes

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Why might obesity lead to congenital anomalies?

• Four potential mechanisms
• Undiagnosed diabetes
• Folate status

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Why might obesity lead to congenital anomalies?

• Four potential mechanisms
• Undiagnosed diabetes
• Folate status
• Nutritional deficiencies

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Why might obesity lead to congenital anomalies?

• Four potential mechanisms
• Undiagnosed diabetes
• Folate status
• Nutritional deficiencies
• Difficulties with antenatal detection

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Regional cohort study of maternal obesity and
congenital anomalies

• First UK study funded by BDF/Newlife
• Includes nearly 40,000 births from five hospitals
  in the North East
• Congenital anomaly data from NorCAS
• Includes antenatally diagnosed anomalies
• Will investigate rates of anomaly in obese,
  overweight and normal weight women, and effects
  of deprivation

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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8. NICE and RCOG

• NICE Guidance
• 'Obesity the prevention, identification,
  assessment and management of overweight and
  obesity in adults and children'
• Published December 2006
• RCOG Green Top Guidelines

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Previous and Ongoing Research

• 1. North east scoping study audit of data
  collection practice, and a qualitative study on
  the impact of maternal obesity on services
• Hospital Episodes Statistics (HES) exploration
• James Cook University Hospital (JCUH) maternal
  dataset analysis (2 phases incidence of maternal
  obesity, and pregnancy outcome)
• Systematic review service impact of maternal
  obesity
• National maternal obesity data collection
• Postnatal Intervention
• Obesity and congenital anomalies
• NICE and RCOG
• ASO Conference

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9. ASO Conference

• Association for the Study of Obesity.
• Conference Women and Obesity
• 19th June 2007. Warwick
• www.aso.org.uk

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Summary menu for debate

• Maternal obesity has an impact on services
• measurement of height weight
• equipment
• care requirements
• Complications and restrictions
• Prevalence of maternal obesity is increasing
  related to health inequalities, age and parity
• Maternal obesity increases risk of some
  short-term pregnancy outcomes in mother and baby
• Obesity related to certain congenital anomalies
• Need for national guidance on weight gain during
  pregnancy