Parenting is always an experiment so why not collect the data?
Bigger Births And Breastfeeding

Bigger Births and Breastfeeding: A Q&A with Prof Debra Bick

Professor Debra Bick joined our Big Birthas Parenting Science Gang to discuss the experiences of larger mothers in pregnancy, labour and while breastfeeding.

Hi, and many thanks for inviting me to join your Q & A this evening. My name is Debra Bick and I’m Professor of Midwifery and Maternal Health at King’s College London.

I’ve been involved in research for over 20 years now. Much of my work to date has focused on women’s postnatal health and care for women following birth. I’ve also worked on several large trials of interventions in labour.

This work recently included a large UK trial which compared if women giving birth for the first time who had an epidural were more likely to have normal vaginal birth if they were in an upright or lying down position during second stage of labour. Lying down was better!

My current studies include several relevant to breastfeeding, including support for women who were overweight or obese at pregnancy commencement and for women who have had a caesarean section; a feasibility trial of use of Slimming World groups to support postnatal weight management; and work to explore health and recovery following hypertensive disorders during pregnancy.

PSG A: Wow, the result to do with lying down is surprising to hear!

Debra: I know, it was quite unexpected even by those of us on the trial team!

PSG A: It’s interesting to hear you’re looking at breastfeeding and women with higher BMIs. Please could you tell us a bit more about this?

Debra: We trying to find out how midwives and health visitors can better support women to breastfeed, as we know that women sometimes experience lack of consistency of information, they may feel more uncomfortable feeding in public, and may have experienced interventions such as a C section. There is not a lot of evidence out there to support women, despite many women wanting to breastfeed.

We’re working with women in South London who have higher BMIs to see how best to offer support.

PSG B: Our group is very interested in the experiences of larger pregnant women.

Debra: I would really like to hear from members about some of their experiences.

Experiences of larger women: pregnancy and labour

PSG B: I’m one of the admins, and I had a normal BMI when I fell pregnant (not anymore though – thanks pregnancy!), but from comments in the group, a lot of people felt they were treated as if they were bound to have problems.

PSG F: I ended up starting a website because I was so unimpressed by the way I was treated in my first pregnancy. www.bigbirthas.co.uk

Had a home birth the second time (I had to sign a disclaimer saying that I understood it was against medical advice)
It was fabulous.

PSG I: Thank you for your site I’ve referred to it so many times 🙂

PSG D: It’s a lifeline isn’t it!

PSG F: Thanks for the love! I really need to write more pages!


PSG C: I think though there really are some major flaws in maternity care in general around language used and care pathways not being tailored to the individual. I know a few times I felt like a slab of meat on the table (2 memories that jump out are getting a scan at 36w by a doctor who was showing a student how to do a scan. He didn’t acknowledge me whilst doing it, was explaining about the bits of placenta that had started dying (those were his exact words with no explanation that it was all normal etc) and didn’t take any time to explain the results.

Second time was when I was getting stitched up after my second was born. I’d asked not to be stapled and I remember lying there wondering if my baby was ok (who I’d not yet seen) as he was born not breathing, being exhausted from a long labour and spaced out from the drugs and the sound of the staple gun. The staples were agony and I had lots of problem getting them removed. And in theatre nobody told me what was going on.
I think having high bmi just makes these experiences more likely.

PSG E: Yes! I wanted to say this. As a pregnant person you are treated differently (in my limited experience) to a patient attending other outpatient clinics.


PSG E: When you say larger BMI, what’s your starting range please?

Debra: We’ve been using a BMI of 30 and over in our current work.

PSG E: Great, in that case I can provide experiences as I had BMI of 34 at booking in

PSG H: Same for both my pregnancies

PSG E: I weighed less following birth though.

PSG F: Me too. Both times. Apparently it’s quite common for bigger mums.

“45+” and 44 in mine, respectively.

PSG I: I’m just trying to work out my BMI….

Okay so mine is 30 but it was never even mentioned. I was weighed at booking and that was it. I freebirthed and told my midwife I would in likelihood do so. I wonder why some people get all the rubbish and sons don’t- I’m quite tall and ‘carry it well’ as I’m often told so maybe there’s a visual bias too


PSG C: Regarding maternity care as soon as I checked in with midwife the second time she told me I would have to go to a further away hospital and I would have to be under consultant care and I would have to have continuous monitoring and I wouldn’t be allowed to use birth pool and I would have to go on the weigh to a healthy pregnancy scheme and get scales fitted in my house to weigh myself on which would send weight back to hospital and I would have to have gtt and extra scans. It was completely this is what our book says and not based on me as an individual. Plus she basically made out I had to do these things and had no choice.

First time I believed I had to do as I was told but second time I just didn’t see her again and saw a fabulous consultant midwife who was amazing. Shame I can’t say the same for the consultants and obs I saw. By the end of it I had a bit of a list of ones I didn’t want to see.

Debra: Thank goodness you saw a midwife who did treat you as an individual.

PSG C: Unfortunately it was only through my own pig headedness and learning about birth options from other mums and HCPs who valued individual care plans.

PSG F: Do you mind if I ask your BMI at booking for that horrendous experience?!

PSG C: 43 or thereabouts? I tried to ignore the number 😂

PSG F: Best advice going 👍

PSG C: I try and pretend I’m a thin dainty lady. To be honest though I do pregnancy really well. Both times I’ve been all bump and had the glow, no swelling, no real issues and full of energy. I had amazing body confidence as well. I wasn’t so good at birth but rock breastfeeding.


PSG E: At the lower end of a high BMI I think I was quite lucky in my experiences regarding my weight and pregnancy. There were raised eyebrows when my glucose tolerance test was fine though.

PSG C: Yeah like how can you not have gestational diabetes! I remember the breastfeeding coordinator coming in to chat to us about breastfeeding when I was in for my glucose tolerance test. She was saying it’s so important for babies of mums with gd to get breast milk. Eh it’s just the test.

PSG H: Same here, in fact, I was a picture of health in both pregnancies, low blood pressure, no swelling, no nothing I honestly felt great yet there seemed to be need on the part of the consultants to find something ‘wrong’ as their risk matrix had indicated I should be seen. That said, having had a textbook homebirth first time round, second time I was automatically classed as ‘normal’ and referred to midwife care.


PSG E: An appointment was made for me to go to a dietician group session. It wasn’t an offer, I was pretty much told I needed to go and I didn’t want to.

Dietician wasn’t best pleased when faced with a room full of women most of whom had no goal in mind because they didn’t want to be there!

PSG D: Ha! Good! But honestly 🤦🏻‍♀️

Debra: Goodness, who made the appointment?

PSG E: Midwife at booking I think. If she had bothered to ask me, I attended a course for staff from the head of nutrition and dietetics at UCLH. Aware of what I need to do….

Debra: Did you find it useful?

PSG E: Nope. Waste of my time. The appointment was also in the middle of the day, right over lunch time. So a room full of pregnant people who need to eat regularly. And anyone at work had to take MORE time off

PSG D: Eyeroll forever. I HATE the assumption the fat women need nutrition advice 🤬

PSG F: Yup. It’s as annoying as the “you need to get more exercise” before asking me how much exercise I’m doing!

PSG D: Yup that too!! 🤦🏻‍♀️


Q: What do you think the average midwife expects larger mums to experience during birth?

Debra: I think most midwives feel that larger mums should be offered same support and choices about labour and birth as other mums. Continuity of care and individualised care are key to this, but we need to know more about women’s experiences as few studies have considered this.

PSG F: Sadly this isn’t what we’re experiencing…


On Waterbirth…

PSG A: Debra: a theme that’s come up a few times in our group is lack of access to water births for mums with high-BMI. Does this sound familiar to you?

Debra: Lack of access to waterbirth is familiar. It’s back to the issue of not treating women individually when discussing birth choices.

PSG A: What do you think is behind this? Is it overworked / under-resourced medical staff not having the time to spend with pregnant women? Or is it a culture of the consultant being very risk averse? Or something else entirely?

Debra: It’s difficult to say that there is a main reason – a colleague from Cardiff – Julia Sanders – is just about to start a very large study to look at safety of waterbirth and I think she would be a great person to talk to about issues of access to waterbirth – and outcomes among women perceived to be at ‘risk’.

PSG B: She sounds a very useful person to talk to!

PSG F: Oooh definitely! Debra: we were thinking of trying to research this, but don’t want to do something if its already being done!

Do you know if she’s including women with high BMI? Most waterbirth studies exclude us…


Experiences of larger women: breastfeeding

PSG C: I think support is the key regardless of BMI or mode of delivery. As a mum who had 2 emergency sections and is overweight I didn’t feel I needed different advice to another mum. The only different advice would be about rolling a Muslin under my boob but that could apply to a large breasted woman who doesn’t have high bmi

PSG D: Quite!

PSG A: Having huge boobs made me feel a bit self conscious about BFing in public, I suspect it could have been easier if I could have been a bit less conspicuous. But I got over that, partly by spending time with other BFing mums. So, pointing me to support groups could have helped I guess, but that’s good for all BFing mums, right?

PSG D: I don’t actually feel there was anything difficult about being fat and breastfeeding. But then I’ve never been thin and breastfed so 🤷🏻‍♀️

Debra: I totally agree but we’ve had some mums who felt very upset at how unsupported they felt when they wanted to breastfeed, and that staff seemed to give up on them.

PSG C: My major issues were the consistency of breastfeeding advice. My first boy was born by emcs after 36 hours of labour. I fed him straight after in recovery and he was checked by paediatrician on the 3rd day who asked about his feeding. When I told her he’d fed all night she told me I had to top up with formula as she didn’t want to see him in special nursery on a drip with dehydration. He showed no signs of dehydration, she had not asked about nappy output and after that had been written in my notes I got so much pressure from hospital and community midwives to top up.

They weighed him daily and caused me so much stress and in hindsight I’m pretty sure he had any tongue tie which nobody diagnosed as he caused a lot of nipple damage. Some of the midwives were awful with one actually telling me I was starving my baby. It was such a stressful time.

Second time I tried for a VBAC but ended up with emcs again due to fetal distress. Again he was very tough night 2 (which I expected this time) but I still had a mw try and get me to give him formula as she felt he was starving. Luckily I’d 2.5y breastfeeding experience as well as having done a ton of research on the topic on my side but even then I still nearly wobbled. Imagine a vulnerable new mum getting that advice. Neither boy had a drop of formula which was down to my sheer stubbornness and getting my own support Network in place.

Debra: Your experiences are exactly what we’re trying to address. I’ve been holding some groups with women who had a CS birth and their experiences are sadly very similar. I was shocked when I heard what women had been told/not told and some of the poor quality support and advice they were offered.

PSG B: One of our other groups is about breastfeeding advice from HCPs, and sadly this sounds like quite a common experience, for mums of all sizes.

PSG C: It’s dreadful. I was very clear I wanted to exclusively breastfeed and all I got was pressure to top up

PSG E: I was told I had big nipples and also to be careful I didn’t smother my newborn.

My nipples are not large. My breasts are large. Baby also had a bad posterior tie which wasn’t diagnosed

Debra: Did you manage to breastfeed for as long as you’d hoped to? I get very concerned about the lack of good support following discharge from the postnatal ward

PSG E: Debra: yes, to 34 months when he started losing his latch 🙂 there was a good (think there still is) support in my area

Midwives and health visitors gave poor advice though

Debra: How do you think we could improve care for breastfeeding mums?

PSG G: Access to help. I found the NHS support for breastfeeding so patchy it contradicted itself. In the hospital I was let down lots but when I was released I found the LLL and oddly I found the passion of volunteers made me feel like I trusted their judgement and help more. Plus the fact that within 5 minutes I was breastfeeding without pain which was the first time. NHS staff told me just to grit my teeth and it would get better, despite the open wounds on my nipples.

PSG E: Sidecar cots so you’re sleeping with baby, but midwives don’t worry about bed sharing which I think most units won’t allow.

Specialist training for midwives and health visitors. Tongue tie clinics available in all hospitals. Mandatory funding of an adequate level for breastfeeding support services.

Community midwife told me it was normal to have grazed nipples. There was no effective milk transfer.

A HV told me I needed to “let my son know what it felt like to be hungry”. He was 8+ weeks and feeding like a newborn. He WAS hungry. I had just told her we were on the waitlist for a TT clinic! Luckily I sought further assistance.

PSG J: I’m a larger mum (think BMI was 42 at full term), had a section and breastfeed my lg. Though we haven’t really had any issues (apart from a few hand expressed feeds as my nipples were bigger than her head!!) but I didn’t feed in public until she was much bigger (around 6 months) because I had to get my full boob out and hold my boob off her face. I was laughed at by a hospital midwife for wanting a pool if we had to transfer in (planned homebirth), though she soon changed her face when I made sure the head midwife on the labour ward knew her attitude towards me 😁😁

PSG D: I live in Bristol and have encountered no issues with breastfeeding which I think is in large part down to the immensely positive attitude about bf here in this area; there is SO much support available i.e. breastfeeding support groups every day of the week and an amazingly active bf Facebook group scene. There has been zero prejudice about my weight and massive baps 😛 Wish the same could be said for the antenatal care here…. but I did complain and the trust responded very robustly and implemented changes.

PSG E: Great to hear 🙂 it was the same in Harrow for me.

Debra: It does seem to very much depend on where you live. I see so few women out in public breastfeeding in Lambeth and Southwark, yet we know uptake rates are very high. Great to have pro-active NHS units that want to positively support all women.

PSG D: I’m not sure it’s the NHS here, it’s just the culture in the south west. Groups are run by breastfeeding counsellors and volunteers but it means people do it for a lot longer I think.

PSG E: Here there is a breastfeeding lead, and that post is funded by local authority and provided by NHS. But yes, mostly volunteers and bfc

PSG C: I’m in Northern Ireland and rates are shocking here

PSG F: I’m in Birmingham. The NHS paid for me and others to do a 12 week La Leche League peer supporter course… Then when I offered my services as a volunteer while on maternity leave with my next baby I was told I couldn’t bring my exclusively breastfed on demand 8 week old with me due to ‘infection risk’ and I’d have to leave him with someone… 👿👿👿

PSG D: ???

PSG F: Guess what I chose to do with that.

PSG E: Ridiculous. I bet if you asked the Trust infection lead you would get a different response. However – politics.

PSG F: I was so frustrated! Surely an actively breastfeeding mum with bub on board in a sling is exactly what peer support is all about!?

PSG D: PSG F: it’s PRECISELY what it’s all about. Hmmm 🤔


Q: What methods are you using in your study on how midwives and health visitors can better support women to breastfeed?

PSG A: e.g. are you analysing interviews from women?

Debra: Yes, we’ve interviewed local midwives and health visitors but now want to interview mums at around 6 months. We then want to use an approach called co-design, so that the health professionals, mums and family members work together to consider how care/advice etc can be improved.


Q: Where could we have the most impact?

PSG A: Some themes that have come up in our group include:

  • waterbirth for women with a high BMI
  • pregnancy choices (or lack of!) for women with high BMI
  • barriers to successful breastfeeding (social or biological) for women with obesity

We’re going to create our own study, quite possibly around one of these themes.

Please could I ask, are there any particular gaps in research for these topics? Where do you think we could have the most impact?

As well as the people here tonight, we’re a group of 130 citizen-scientists mothers, so lots of people to help design and get involved in a study.

Debra: I would say that there are gaps in all of these topics, and research is needed. I think pregnancy choices is an important one, as so many women I speak to – and evident in some of the issues raised this evening – is that women with a high BMI are placed on pathways determined from ‘risk’ as assessed at their booking visit. This can then limit whatever choices they may be able to make…..

I think you could do some really important work around the issue of choice as it’s at the core of so much current maternity policy.

PSG F: My trouble with just illustrating that big mums don’t get the full array of birth choices is that I don’t feel that people creating policies care – so long as a baby is born safely and they’re not getting sued, our preferences and birth experience aren’t high priority.
If we could show that the reduction in choice actually causes detrimental outcomes (as other studies have shown) with an associated cost increase, then we might get the right people listening…

A doctor once explained it to me with the of “you don’t necessarily want an episiotomy, but how many unnecessary episiotomies are acceptable to prevent one neonatal death? ”

Can’t help but feel there’s a middle ground to be had…

PSG D: Amen.


Q: What kind of evidence (if any?) is most likely to change HCPs’ practice?

Debra: This is an interesting question. Often it’s personal experience or hearing feedback directly from someone you’ve cared for, rather than the published findings of a large study.

PSG B: That is really interesting. So a peer-reviewed scientific paper isn’t necessarily the way to have the biggest impact? We have been wondering about this in the bf advice group – as so much advice people get is NOT evidence-based. Is creating another paper that busy GPs won’t read actually going to make a difference?

PSG A: How do HCPs hear about new evidence in general?

Debra: From numerous sources- probably more and more from social media, Twitter or from what colleagues in practice discuss with them. I think summaries of evidence (which NIHR or NHS Choices often produce) are invaluable, but getting busy NHS clinicians to read and critique latest research papers is probably not best approach.

I’ve found that even when we ask about colleagues awareness of a peer reviewed scientific paper, only the ‘headline’ story is taken on board.

PSG A: Debra: do you think HCPs would find well-written lists – or infographics – of what pregnant mothers find helpful (based on evidence and produced by mothers themselves) useful and interesting enough to actually read?


Q: Is it really better to lie down in second stage labour?!

PSG I: Debra: can you tell us more about that epidural/second stage position please? I’ve got two friends likely to birth within month who had epidurals the first time

Regarding policy, how recent are the suggestions, the gtt etc etc

Debra: The paper is published in the British Medical Journal and it was the BUMPES epidural trial.

If your friends are having second babies, findings wouldn’t apply as we were only looking at first time births. We now need to do a similar study of position among first time mums who did not have an epidural.

PSG D: Interesting stuff though, thanks!

 


Q: What advice would you give a larger pregnant woman about preparing for interactions with HCPs?

PSG B: How can people avoid being problematised and get the birth they want?

Debra: I think you ask that you have continuity of care from the same midwife/team of midwives, that you ask to be involved in all decisions about your care, challenge care that you don’t agree with, and if you’re not happy with your care, do ask to see someone else. Local consultant midwives are often very useful to ask to meet to discuss ongoing care.


Alternatives to BMI?

PSG D: Debra – do you really feel and believe the BMI is a good measure of health and of a woman’s quality of pregnancy, labour and birth? And postnatal experiences (ie breastfeeding)?

Debra: No I don’t believe it’s a good measure of health, as there are so many factors to consider alongside a BMI measure.

PSG H: If BMI at booking isn’t the best indicator of potential issues what is/are? And how could that be linked to birth choices?

PSG E: I think the key here is ‘potential ‘?

Risks may be higher, but by how much? Double of not very much is still not very much! If the risks are overstated then how can informed consent be given?

PSG D: Increased risk can simply mean 2 in a 1000 instead of 1. And yet we are made to feel it’s 999/1000 chance 😡

PSG F: Yup. ☝️That.

PSG H: Totally this – although I think this applies to most women making informed decisions about their pregnancy if those decisions do not follow the standard routes
ETA by which I mean ‘do as they’re told’ by their consultant!

PSG E: Yep

What I found quite frustrating was that BMI at booking in is used regardless of whether weight stays the same for a period of pregnancy as that means BMI has reduced?

Debra: Exactly! It also means we’re not picking up the women who had a normal BMI at booking but gained more weight than they needed to in pregnancy. We’re also failing to work with women with low BMIs

PSG E: I do feel like obesity has been slightly ‘demonised’ for want of a better word. It’s quite rightly an important topic, and very important to Public Health, but the focus seems too much

PSG K: So, what would be a better indicator of potential issues?

Debra: It would have to be informed by how well you were during the pregnancy, for example your blood pressure measurements, how well baby was growing etc, previous health and outcomes of previous pregnancy. I could say lots on this! Perhaps next time!!

PSG D: That’s useful. We need to steer our down midwives this route and attempt to abandon BMI pathways.


 

Inspired? Want to help do some research to add to the body of knowledge about pregnancy and childbirth for women with a high BMI? Why not join our Big Birthas Parenting Science Gang on Facebook? We’re going to be doing own study and you can help us decide exactly what we do!

And check out some of our other Q&A session related to women with a high BMI:

You can read all the other Q&As on lots of subject relating to parenting at: www.parentingsciencegang.org.uk/live-chats-with-the-experts/

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