The World Health Organization ([WHO], 2013) has identified that obesity (body mass index ([BMI] ≥30 kg/m2) is the most challenging health epidemic in this century, stating that the incidence has more than doubled in the past 25 years. They postulate that a significant shift in dietary and physical activity cultures that has led to this increase. Table 1 presents the WHO (2020) BMI categories.
Table 1. Body mass index (BMI) categories
| BMI | Nutritional status |
|---|---|
| Below 18.5 | Underweight |
| 18.5–24.9 | Normal weight |
| 25.0–29.9 | Pre-obesity |
| 30.0–34.9 | Obesity class I |
| 35.0–39.9 | Obesity class II |
| Above 40 | Obesity class III |
Recent figures demonstrate that 29% of the population in England is obese (NHS Digital, 2019). Obesity is responsible for an increased risk of cardiovascular disease, and a generalised increase in morbidity and mortality, and subsequent additional costs to the health and social care system (WHO, 2020). These costs not only include the actual care provision to screen for, monitor and treat the conditions linked to obesity but also the rising costs of additional bariatric equipment required to provide such care (Heslehurst et al, 2007; Heslehurst, 2011; Morgan et al, 2014).
The rise in obesity is particularly evident in the female population with 30% having a BMI of ≥30 kg/m2 and within childbearing years (16-44 years) the figure is over 25% (Public Health England, 2019). The Centre for Maternal and Child Enquiries ([CEMACE], 2010) indicated that 4.99% of maternity patients had a BMI of ≥35 kg/m2 in 2009 and this was predicted to continue to rise. Further statistics from more recent UK audits show that the figure is approaching 10% on average and is higher still in areas with significant deprivation (National Maternity and Perinatal Audit, 2017).
The subsequent increased risks posed by a raised BMI in pregnancy can affect both the mother and infant. The most common risks are pregnancy induced hypertension, gestational diabetes and postpartum haemorrhage (CEMACE, 2010; Simmons, 2011; Whitworth, 2012), risks to the infant include morbidity or mortality that arises from complications, such as shoulder dystocia, large for gestational age and poorly detected intrauterine growth restriction (Heiskanen and Heinonen, 2006; Raatikainen et al, 2006; Kither and Whitworth, 2012). Maternal obesity can have detrimental effects on many, if not all, aspects of reproductive health, midwifery, obstetrics, anaesthetics and neonatal health (ArrowSmith et al, 2011; Kither and Whitworth, 2012; Foster and Hirst, 2014). Maternal death rates have remained relatively static in recent years and can often be attributed to a combination of complex factors (Knight et al, 2018). Furthermore, records show that while the largest disparity in maternal mortality and morbidity rates are for women of black and minority ethnic origin and for those with advanced maternal age, there also remains a significant disparity in relation to BMI. It can be noted that over 50% of the maternal deaths notified through the confidential enquiry MBRRACE were either in women that were overweight or obese (Knight et al, 2018). Given the potential risks and the additional cost involved, it is clear why health services and researchers are beginning to invest in ways to tackle this growing problem. Researchers have postulated that a reduction in gestational weight gain and inter-pregnancy weight gain could lead to a reduction in risks for both mothers and babies (Cedergren, 2006; Teulings et al, 2016). Therefore, many studies have focused on reducing gestational weight gain or investigated measures to prevent the mother's BMI increasing between pregnancies.
Previous qualitative studies found that midwives face huge challenges in caring for the obese parturient, from monitoring the safety of the fetus and mother to the promotion of normality for this seemingly high-risk group of patients (Heslehurst, 2011; Smith et al, 2012; Singleton and Furber, 2014). More than one study identified that further research is needed regarding the nature of the challenges faced by staff when delivering care, suggesting multidisciplinary working, improved education for women of childbearing age regarding obesity in pregnancy and continuity of care for these women (Schmied, 2010; Smith et al, 2012; Singleton and Furber, 2014). The available evidence in this area is sparse. National guidance exists covering care prior to, during and post pregnancy and on managing and mitigating the associated risks during labour (National Institute for Health and Care Excellence [NICE], 2010) but does not cover the practical care required. Their suggestion for professional skill development makes no mention of the specific skills that may be required during the intrapartum period and how this care may be affected by BMI (NICE, 2010). This highlights the need for further work in this area.
Aim
The aim of this study was to explore and better understand the experiences of staff who provide care for obese women in labour.
Previous qualitative research has addressed issues such as the financial effect on the NHS (Heslehurst et al, 2007), women's views on their encounters with healthcare providers (Nyman at al, 2008), the personal risk perception of obese women (Keely et al, 2011) and gestational weight gain (Stengel et al, 2012; Nikolopoulos et al, 2017). A fuller understanding from the point of view of the staff and appreciating their perspective can lead to a greater understanding of these challenges and could lead to improved service provision (Schmied, 2010; Heslehurst, 2011; Smith et al, 2012). Staff education has been highlighted as an area for improvement (Heslehurst, 2011a) and it is hoped that any educational deficits that are identified, both at undergraduate and postgraduate level and could be in some way addressed by this and future research.
Method
A qualitative methodology was adopted for this research. This paradigm seeks the personal expression of the research participants in order to fully appreciate the phenomenon (Braun and Clarke, 2013). This study was carried out in a single NHS Trust maternity unit in the North East of England in May 2015. Ethical approval was obtained from the local university research ethics committee (Ref – 218/14) and the Trust Research and Development Department (Ref – MED-361-2015). Purposive sampling was utilised to seek participants who had the required experience therefore all midwives and obstetricians working within one site within the Trust were invited (by email) to respond. It was deemed unethical for the researcher to undertake the research in the same hospital site where she was employed and so the research was undertaken in a different site.
It is noted that despite the ethical considerations of peer interviewing, in this case, the researcher anticipates that the homogenous nature of the interviewer-interviewee relationship would encourage a good rapport, and create an affinity with the participants (Braun and Clarke, 2013). Exclusion criteria included those who had not had recent experience (in the previous 12 months) of providing care for labouring women with a BMI≥40 kg/m2. This ‘cut-off’ of obesity level was considered by the researcher as the point where the risks increased more significantly and so of more clinical interest. Information was given about the study and those interested were invited to participate. A total of five midwives responded and were invited to participate, unfortunately, no obstetricians responded, despite a second invitation to all staff, and this remains unexplained. Due to the time restrictions upon the researcher, it was not possible to attempt to further recruit participants. However, it can be noted that small qualitative studies of this nature can be sufficient to provide a rich narrative of the topic under scrutiny (Cleary et al, 2004). Written information and informed consent was obtained prior to interview.
Data collection
Semi-structured interviews were conducted at a time to suit participants (some during a clinical shift and some following their shift), in a quiet room away from the clinical area in order to create a relaxed and uninterrupted atmosphere conducive to open discussions (Braun and Clarke, 2013; Gagnon et al, 2015). An interview guide (see Appendix 1) was used to achieve some equality between interviews and to ensure no aspect of the required discussion was missed (Brod et al, 2009; Doody and Noonan, 2013). Broad questions were used to encourage the participant to describe their experiences and talk about their feelings on the topic. The interviews were recorded and then transcribed verbatim. Anonymity was ensured by giving each participant a number M (midwife) 1–5.
Data analysis
Deductive thematic analysis of the interview transcripts was undertaken with the aim of producing a rich descriptive narrative, exploring and endeavouring to clarify the phenomenon (Braun and Clarke, 2006; Vaismoradi et al, 2013).
Following the initial analysis, ‘mind maps’ were utilised to further the process. This involved the repeated rereading of the text until ‘meaning units’ were noted (Lindseth and Norberg, 2004). A series of these maps were drawn as the analysis of the data progressed, with a focus on the emerging ‘meaning units’. Thus enabling a progressively more focused analysis to occur and facilitating the development of crucial themes (Lindseth and Norberg, 2004). The data was colour coded and condensed down into smaller units using the maps (Lindseth and Norberg, 2004). A final mind map was produced that describes the seven themes (see Figure 1).
Figure 1. Thematic mind map
Results
A total of five midwives agreed to participate and took part in semi-structured interviews, in May 2015, lasting between 18-45 minutes. They varied in age and experience (10-20 years), were all female and all worked in a moderate-size, consultant-led unit that also provided care for low-risk women.
This research described an overarching theme of the midwives' frustration at the many challenges to normal practice that maternal obesity caused. The seven main overlapping and intertwined sub-themes identified were:
- Monitoring the fetal heart and mobilisation
- Assessing the labour progression
- Different to caring for a labourer with a lower BMI
- Emotional issues
- Opinions regarding women's risk perception
- Problems addressing the issue of obesity
- Equipment and training.
Monitoring the fetal heart and mobilisation
Of the midwives, four of the five found that caring for a woman who has obesity posed a challenge to their normal practices in labour. The most common difficulty was concerning the challenges of monitoring of the fetal heart. Using routine equipment, position of the woman in labour were all affected. Using telemetry (wireless fetal heart rate monitoring) and a fetal scalp electrode was utilised by many midwives to encourage mobility in labour while still monitoring the wellbeing of the baby.
‘So difficult for some women…it's impossible! But we managed it between us, her husband helped a lot by holding it (the sensor).’
–M1
‘Monitoring the fetal heart was very difficult until she reached a stage where we could actually apply a fetal scalp electrode, to then be better able to monitor the fetal heart.’
–M3
Assessing the labour progression
Interviewees described difficulties in using usual midwifery skills to determine progress in labour, such as abdominal palpation and vaginal examinations.
‘I find it really difficult to care for someone when I only have half the picture, when you do your palpation but you can't actually work out which way the baby is lying … I find that you feel that you're doing your job with only half the information…’
–M1
‘I always find caring for these women challenging from a physical point of view because I have a bad back … I tend to use lithotomy (leg supports) to do my VE's (vaginal examinations) when they are larger women…’
–M1
Another participant drew attention to the concerns she had about the intensity of the care episode and how the midwives could benefit from additional support.
‘…with a (lady with a) BMI of over 40, they need to be just really one-to-one and they need support. Support from a healthcare support worker or a maternity support worker, or plenty of relief as it is quite intensive.’
–M5
Different to caring for a labourer with a lower BMI
The midwives all discussed that the choices offered to these women are limited for safety reasons, and that options like the birthing pool were not offered, in line with their local and national policies.
‘I would have encouraged the pool, definitely, for a lower BMI woman … I'm more concerned about the physical difficulties of getting them out of the pool if anything goes wrong.’
–M1
The high-risk nature of labour in an obese patient requires additional invasive, clinical procedures. A noticeable problem highlighted by one of the interviewees was the difficulty in acquiring venous access in these patients.
‘It was purely because of her BMI that we were struggling, so we had to get the consultant anaesthetist to come and cannulate her.’
–M3
Another midwife explained the challenges that had to be overcome in order to assess and repair a patients' perineal trauma, as well as the difficulties in achieving analgesia effectively and safely.
‘…the whole procedure took a very long time; they were down there (theatre) for a long time as it was very difficult to get the spinal (anaesthetic) in.’
–M4
Emotional issues
Interviewees described a multitude of emotions; frustration and embarrassment to concern and fear, and from this experience, it was acknowledged that the woman was acutely aware of the problems her size created.
‘…because she knew, she said it first, nobody had to say anything to her. She was obviously embarrassed about it, but you know, when they do that thing, laughing-about-it thing, but still embarrassed. So, we didn't have to address it, she knew why.’
–M4
Sensing embarrassment from the women was a common finding during the interviews. Whether it was in relation to reduced mobility or their desire to maintain privacy and dignity. One midwife commented that having more ‘assistants’ in the room compromised privacy.
‘…it can be like that you have to have lots more people in the room and yes, privacy and dignity can be an issue.’
–M3
She also brought attention to the fact that hospital gowns can be problematic.
‘…even things like nightgowns that we use in theatre, finding them big enough or that do actually cover.’
–M3
Caring for these women uncovered further emotions in the midwives, including fear and worry associated in caring for complex high-risk cases.
‘There are lots of things that you worry about more than if it was someone with a normal BMI … then you are worrying about the delivery itself so I think for a midwife it is more stressful looking after them.’
–M5
‘…it's a shame really, because I think it really spoils their experience because you're stressed, but they're stressed, so there is some of that happiness around the birth is taken away through anxiety.’
–M5
Opinions regarding women's risk perception
One very experienced midwife indicated that appreciating how women receive and understand information about risks was an area that needed further focus.
‘They do get information at booking … but no, I don't think women really realise the impact their BMI can have on their pregnancy.’
–M3
Another participant postulated that there may be an impression that modern healthcare could overcome all the risks.
‘People's perception of modern-day obstetrics is that, “yeah, I am high risk but I'll be fine because they can look after me because they have the technology”. Instead of understanding the number of women who die … who are overweight as appose to normal weights.’
–M5
Another suggested that some women do not like to hear about the risks.
‘I think they just don't want to (understand the risks). I'm sure they do get them explained to them, well you do, when you go through things with them.’
–M2
Problems addressing the issue of obesity
Many of the midwives highlighted concerns and the dilemmas faced when addressing the issue of obesity with women. They were troubled over the language used; the timing of such discussions and that maybe the issues should be addressed much earlier in pregnancy.
‘…it's still really difficult to tackle the fact that you've got to say, “you're obese” and it's the way to word it without sounding like you're preaching or criticising.’
–M4
‘…not everyone knows what BMI is, do they? It's not something that people use every day, is it?’
–M2
They described considering their language carefully but admit that they did not always know which terms to use without causing offence.
‘…there are ways and means, and I wouldn't be really blunt, but they have got to know all the facts, ‘coz if something happens and they could say, “well, you didn't tell me that”’
–M2
She went on to equate the issue of obesity to that of smoking in pregnancy and how it could be tackled in a similar fashion.
Some of the midwives admitted to having empathy for the women as they had their own experiences of being overweight. One commented:
‘I know it's very hard, I'm trying to lose weight, I'm only trying to lose half a stone and I find that hard, but if someone is trying to lose a few stone!’
–M2
There were comments made from each of the participants around the developing issue of obesity within maternity services. They recognised that practice has altered following the noticeable increase in maternal obesity rates in recent years.
‘…I've seen the momentum pick up and suddenly we have realised … this is a big issue! These women are getting sick, they are getting ill, they are dying.’
–M5
Equipment and training
The midwives commented that overall, they feel their clinical areas are now well-equipped to manage the care of the obese maternity patient. One midwife however, commented that sometimes what you need is more staff to assist in the care of the women.
‘I don't think equipment would have helped … but really we needed more hands.’
–M4
On the issue of training/education for the staff, all the midwives felt this would be helpful. One midwife suggested that we involve the women themselves in this process. One midwife suggested better planning for the delivery of these women so that all necessary equipment is ready for them. She went on to further suggest a ‘lead’ midwife in obesity who can have all the specialist knowledge and liaise with the maternity staff with regards to training, education, equipment and safe use of it, and more practical issues.
Discussion
The midwives described the many ways in which the ‘usual’ care they provide in labour is profoundly affected by obesity. Monitoring the fetal heart caused the most concern for these midwives and this has been highlighted in joint guidelines produced by the CMACE and the Royal College of Obstetricians and Gynaecologists (2018).
Many of the midwives highlighted the challenges the additional habitus made to their practice including clinical procedures which was made more complicated by obesity. The midwives recognised the physical challenges and practical difficulties obesity posed and the need for assistance from other staff thus potentially impacting on dignity and privacy.
The midwives highlighted a number of differences involved when caring for a labouring woman with a raised compared to a woman with a lower BMI. Even without pre-existing co-morbidities, the excess weight alone increases the risk of a multitude of complications. Due to this fact, the recommendations for the women is to not to use the pool, and to be closely monitored in labour and to achieve this often mobility is compromised. This increases the chances of intervention which further reduces the likelihood of a normal labour and delivery (NICE, 2010).
It could be postulated that these midwives experienced a contradictory role while caring for these women. On the one hand, acceptance of their patients' high-risk status and all the many interventions and procedures that may be necessary, and on the other, trying to provide, safe and sensitive labour care so that the women and her family feel their birthing experience is special. This apparent clash of roles is not unique to caring for obese women but has been noted in other situations where the clinical scenario is somewhat at odds with the caring and supportive role of the midwife, such as in the care for pregnant women with diabetes or pre-eclampsia (Berg, 2005). The studies' Berg refers to investigated the relationship between midwife and women in high-risk pregnancies, and one theme was the delicate balance of supporting normalcy in spite of the high risk situation.
The lack of preparation midwives receive regarding how to care for these women could be a possible cause for the stress they experience. There are many antenatal pathways to guide the obstetric care for obese women but few that cover midwifery care (Richens, 2008; NICE, 2010; Khazaezadeh et al, 2011). Heslehurst et al (2007) attempts to fill that research gap by their uniquely qualitative research on the effects of maternal obesity on maternity services. They included various professionals, including midwives, in their study and highlighted some similar issues such as the psychological effects of obesity for both the women but also for the staff caring for them. They also indicate the need for further research into this area.
Previous studies involving the experiences of obese women in labour have given voice to their concerns regarding emotional issues (Nyman et al, 2008). Feelings of shame and embarrassment were noted in this study but it is through the voices of the staff that the emotions of the women are described, and this leads to the possibility of misinterpretation. Therefore, any findings relating to the personal feelings of the women must be viewed in this context. It highlights further, however, the need for staff to be well-educated and to be sensitive when caring for this particular group of women, and suggests that staff are fully aware of their own preconceptions and prejudices (Nyman et al, 2008). Further work by Heslehurst (2011) also highlights the importance of staff education as their findings indicated that staff noted it difficult to find the most suitable words and phrases to use to describe obesity with fears of upsetting the women in their care.
In this study, the midwives commented on how they felt women were unaware of the risks that obesity in pregnancy posed. This correlates with findings from previous studies which demonstrated that obese women generally viewed themselves as healthy, and that they were aware of the risks but did not connect them with themselves and their pregnancy (Keely et al, 2011). Evidence suggests that women are more receptive to health professionals' advice on weight-related issues during pregnancy and this should be utilised in order to provide women with appropriate information that may have an impact on their health and that of their unborn child (Phelan, 2010; Keating, 2011). It is to be noted that some research has highlighted women's dissatisfaction with a lack of discussion around their weight and the associated risks (Jones and Jomeen, 2017).
The research, as discussed, can demonstrate how difficult it can be to adequately discuss issues around obesity at any time during pregnancy but even more so at the physically and emotionally challenging time around birth. Evidence suggests that some women can perceive staff to be rude and abrupt (Keely et al, 2011) and this study, as well as previous studies, showed that staff found it challenging to use appropriate terms (Wadden and Didie, 2003; Stotland et al, 2010). As suggested by one of the participants, it may be that in seeking the opinions of the women themselves that answers may be found. This is not a new concept and others have undertaken such work in relation to maternal obesity and found that further education is needed and guidance on how best to provide sensitive and appropriate information (Khazaezadeh et al, 2011; Nikolopoulos et al, 2017).
Much research has concluding that an increase in the education of staff would aid progress to be made in how health professionals deal with the complexities of this phenomenon (Nyman et al, 2008; Furness et al 2011; Stengel et al, 2012).
Another common conclusion that was also echoed in this study was the merit given to seeking the views of this group of women on the improvement of maternity services (Furness et al, 2011). This may lead to an improvement in the satisfaction of those using the services and adding this to the improved education of the maternity staff may lead to a possible improvement in risk management (Wilcox et al, 2012; Chang, 2013). Singleton and Furber (2013) undertook similar research, utilising differing methodology; and concluded that educational improvement and more effective multidisciplinary team working would likely improve women's experiences. In this study, the researcher sought to go one step further than Singleton and Furber by being inclusive of other staff members who also provide care for this group of women, a point overlooked in their study. Inclusion of the obstetricians was hoped to provide an insightful addition to the previous research in this area, this was unfortunately not achieved.
Strengths and limitations of this study
One limitation, as discussed above, was that no medical staff were successfully recruited. Further studies focusing on or including, the views and experiences of these professionals may give a unique insight and possibly a conflicting or complementary approach to those voiced by the midwives, as they may have differing experiences and concerns. It may be more appropriate to have further research dedicated to giving a voice to the other professionals who care for women who are obese in labour, such an anaesthetists. This segregation may potentially result in a different set of themes to emerge from the interviews.
A reflection on the findings indicates confirmation of the researchers' own professional experiences in this area, and of the anecdotal experiences of fellow clinical midwives, namely that providing care for this groups of women poses specific challenges. It is recognised that the purpose of qualitative work is to not achieve generalisation this but rather to seek the personal expression of the research participants in order to fully appreciate the phenomenon under scrutiny (Davies and Dodds, 2002; Hale and Kitas, 2007). Individual interviews give a voice to subjective notions and experiences, and can be very personal but the researcher noted that many of the findings echoed those reported in other related similar studies. It could be suggested that this may indicate that many clinical midwives may have similar experiences as those participants interviewed for this study.
Conclusions
This study set out to explore the lived experience of staff caring for women with a BMI greater than 40 while in labour, and in the process has revealed interesting details about the process and nature of the care provided. There is undeniably an increasing number of obese women within maternity services, and while the technologies that ensure their safely are advancing and the services needed to manage their risks are being developed, it seems that the staff caring for them are not so advantaged. Additional education and training may address this deficit. Education could additionally delve in to the more psychological aspects of care and this may lead to a more satisfied patient experience if care provided for them could be more informative, sensitive, safe and caring. Provision of adequate, honest and realistic information to women early in pregnancy and even in the preconception stage should be improved so that confusion can be avoided in labour.
The findings of this study suggest that midwives found providing care for obese women in labour challenging, and practical issues featured heavily in the narrative. Recognition of this by senior staff and provision of support to the staff may alleviate the situation to some extent and prevent health concerns that could potentially lead to sickness episodes.
Implications for practice
Utilising the findings from this research and other research in this area could be a way to try to promote normality for these women. To encourage a movement within obstetrics and midwifery to accept the risks obesity poses but to foster an environment of normality also. This should include additional training for staff—many of the staff expressed a need for specialised education, not only covering the complexities of obesity and its effects on pregnancy and labour but also on the practical difficulties of delivering safe labour care and appropriate communication skills.
The interviews demonstrated that staff often felt the strain of providing care for this group of women and recognition of this and provision of support would be beneficial.
It was noted that not all staff felt their clinical area was adequately equipped to provide appropriate care for the obese parturient, and how this had a negative effect on the provision of care. It would be prudent to ensure that all clinical areas be cognisant of their clientele and their BMI, and ensure appropriate equipment is available to provide safe, effective and sensitive care.
Implications for future research
Given the small-scale size of this work, further, larger qualitative research in this area would be useful to confirm the findings. As mentioned previously, the aim of this research was to also include the experiences of obstetricians who provide care for these women. This was not achieved however, the researcher still feels these additional viewpoints would provide an interesting and useful insights. There should therefore be future research in this area.
It would also prove interesting to directly gain the perspectives of the women, who are obese, while in labour. This would allow for a more rounded, multi-faceted view of the phenomenon of the experiences of these women.
It may prove beneficial to those providing care for these women, to identify if there are differences in experiences for women of differing BMI categories. Research in this area, sub-categorising the women may inform and potentially improve practice.
Key points
- Findings from this study showed that providing care for women who are obese in labour is challenging
- These challenges include the impact obesity has on the nature of the care given and how that can differ from providing care for those with a lower body mass index
- The issues that have been highlighted, include the emotional impact this care provision has on the staff and how it can affect the staff/patient relationship, as obesity is deemed a difficult subject to discuss sensitively
- A need for additional staff education and more appropriate bariatric equipment was identified
CPD reflective questions
- In your practice, do you feel you have had adequate training on this topic?
- Consider how you may approach a discussion on body mass index while providing labour care
- Consider how your discussions with women in labour may facilitate or hinder their perception of risk
- If you had participated in this research, what issues would you have raised from your own professional experience?