We were joined by Dr Ellinor Olander to talk about the services offered to pregnant woman with a high BMI and how effective they are.
Image by Ryan Franco
Ellinor: Hi everyone, thanks for inviting me to this Q&A.
I work as a lecturer in the Midwifery department at City, University of London. I am not a midwife, but a health psychology researcher. This means that I focus on behaviour, both for women and the healthcare professionals who support them during and after pregnancy. My research for the last 8 years has centred on weight management during and after pregnancy and women’s physical activity and eating behaviour during this time.
I should add – I have the best job, working both with women and with student midwives. 🙂
Q: Are there any structured support programmes for those who are overweight during pregnancy? Are they run by dietitians or midwives?
Ellinor: I think they are run by midwives sometimes, sometimes by dieticians, or exercise professionals.
PSG K: Do we know how successful they are? Is there evidence that they reduce rates of gestational diabetes or macrosomia?
Ellinor: I don’t think local services are being evaluated always. There are some big trials that show little effect on GDM or macrosomia such as the UPBEAT trial.
I would argue that there are so many other benefits of activity and eating that they should be promoted regardless.
Q: We’ve been talking a bit about weight management services in the last few days, and several of our group used them during their pregnancy and found them really useful.
What has your research told you about their effectiveness?
Ellinor: Oh, that’s brilliant, mostly I hear about services that are not well-liked, so great to hear that!
Our research has focused on interviewing women who have taken part in services as well as those who dropped out or declined to participate.
PSG H: What’s the take up rate for using these services?
Ellinor: Great question, I am not sure I know. One that we evaluated a few years ago, had very low uptake. Partly due to the referral route that was not quite working as well as it could. But also because it was during the day when many were working.
PSG B: This would have been a big problem for me as, even though you are entitled to time off for pregnancy related appointments, in reality there are limits to this that are hard to push and also the work you are missing is still waiting for you, causing additional stress!
It would be great if some services could be offered evenings and/or weekends (allowing for the service providers to also have a private life of course) so more people could participate without worrying about work/life balancing
PSG C: Mine was over lunch time. I was not impressed. It should have been an offer, but I was sent… with a BMI at booking of 34
PSG D: That’s one way of controlling your weight!! Remove your dinner hour!
PSG C: The dietician wasn’t best pleased as she thought we’d all been offered and taken it up because we wanted to be there.
“What would you like to achieve?” “I don’t know – I’m here because I was expected to be…”
Not a great group session.
Ellinor: Women who have participated in group services, have loved the group aspect – meeting other mums. This is not for everyone though, and we have also interviewed women in one-to-one services, who likes the personal tailoring they receive.
Q: What do you think of BMI being used as the reason for assigning a woman as high risk and for things like refusal of use of mid-wife led units and the like? Do you feel it would be better to look at each woman as an individual?
Ellinor: Yes, every woman needs to be assessed from her circumstances. BMI is good as it’s quick and easy to do – but this should never be the only assessment used to suggest what care pathway is right.
I am really interested in this – refusal to midwifery led units etc, because I think there is huge variation based on geographical area.
I don’t see why services targeting eating and activity need to be different depending on BMI. Unfortunately when it comes to services they are often for BMI above 30 or 35, as services could not cope otherwise!
PSG E: Unfortunately it seems pretty black and white to a lot of HCPs (health care providers). During my first pregnancy it almost felt as if the doctors were shocked I didn’t develop any complications.
PSG D: Same here. I was shocked I didn’t develop any complications until I read the data for myself!
Ellinor: Yes, I think that is because that is how the maternity and NHS is set up – if you have this BMI you get this, and this BMI you get that. Compare it with things like gestational diabetes – you either have it or you don’t, NHS works in very binary ways. HCPs are sometimes scared to go outside these guidelines.
PSG E: It’s very frustrating. During my first pregnancy I did cross fit until I was 36 weeks then kept active with yoga, aqua aerobics and walking yet I was told I couldn’t use the pool because they worried I’d not be able to get out. One doctor said the baby would probably get stuck any way.
PSG D: Yup. Me too. Had a great birth and an “against medical advice” home birth second time around in order to use the pool, which was VERY beneficial!
PSG B: I had the same. I did 2 zumba classes a week to 8 months pregnant and then aqua zumba until 4 days before I gave birth and was walking 3 miles to work every day as well. But because I was obese I was assumed to be unfit and incapable of making my own choices!
PSG D: I was also told to ‘do more exercise and eat less junk food’ without first being asked what my activity levels were or my diet was like!
PSG E: My midwife was similar. I told her I was doing CrossFit. She asked what it was and I explained it saying I’d dropped my weights right down to no more than 40kg. She then gave me a lecture that I should just walk a bit more (I was lifting in the 100kg range prior to this so it was a significant drop and I felt ok with it) so I couldn’t win.
Q: Have you found in your research that different NHS trusts offer wildly different services? I would have loved to have some additional support, group or otherwise, during my pregnancy but this doesn’t seem to be available in my area (or if it is it was not offered to me!)
Ellinor: Yes!! Huge variation unfortunately, and also services seems to be there one day and gone the next! It takes time to embed services into care pathways etc, but they are not given this time. Hugely frustrating.
Q: Weight management services were never mentioned to me in either of my pregnancies. How effective are they in supporting pregnant and new mums to control their weight?
Ellinor: I’m asking myself that same question. I think it varies hugely. But also – focusing on weight gain is problematic. How much weight are you meant to gain as a pregnant woman?
PSG G: Exactly! My midwife kept complaining that my BMI was going up in my pregnancy the first time round. I was a little hesitant to say ‘but I’m growing a little person inside me for crying out loud!’ Second time round I just refused to be weighed. Maybe it’s an area so hard to pin down boundaries so it’s difficult to make recommendations for these services.
Ellinor: Well, the UK does not have guidelines for weight gain in pregnancy. So difficult for women to tell you how much to gain. This is about to change though, watch this space: https://tinyurl.com/yaggqx4r The NICE guidelines are being updated!
Q: Are weight management services focused purely on diet/ healthy eating or is there an exercise element as well? I’ve been talking to midwives about high BMI women using a birth pool, and their major concern seems to be the woman’s ability to get in or out of the pool. I wondered if a gentle exercise programme in pregnancy would help alleviate such concerns.
Ellinor: Keeping active throughout pregnancy is really important, I know it’s not easy, but can really help with labour and recovery after birth. Plus it improves mood. I think all services need to include both.
PSG D: I’d imagine that assessing a woman’s ability to get in/out of the pool might alleviate those concerns, rather than assuming she’ll struggle because of her BMI and excluding their use solely on that basis!
PSG H: That’s one thing midwives often do, but I wonder how much supervised exercise could help to increase strength and flexibility for women who may otherwise struggle at first with that assessment.
Ellinor: I think this (supervised exercise) would be hugely beneficial (I’m saying this as someone who has read the literature, not just my opinion 🙂 )
PSG H: It also occurred to me that this could be linked to pregnancy and baby walking groups which all women could be encouraged to attend.
Ellinor: Services need to focus on physical activity, and healthy eating, not on weight.
PSG A: Do you have any thoughts on how much mothers’ motivation for using these services is based on their own long-term health and how much is in order to “qualify” for a relaxed interactions with their health care professionals during pregnancy?
Ellinor: Again, good question. I think this varies – I think sometimes the conversation can be uncomfortable, so women simply say ‘yes, I’ll go’ and never do.
Other women feel motivated to be healthy, they see pregnancy as the reason they have been waiting for, and thus are very keen to attend services.
And yes, I think some women may be worried about how they will be treated by hcp’s due to their weight, often because they have been treated badly by other HCPs outside maternity services.
Q: Is there any psychological support on these programmes? Things like NLP (neuro-linguistic programming) or CBT (cognitive behaviour therapy)?
Ellinor: Not that I know of. The HCPs we have worked with have identified the need for this, but rather than include them, the service has referred to other services.
PSG G: I do think there needs to be psychological input. Otherwise it’s likely to be a service that struggles to be effective, like a lot of weight management services.
PSG E: Exactly as an overweight person I know what I should be doing. But it’s a lot more complex than just eating less!!
PSG D: I agree. Trouble is, I guess it makes the service considerably more expensive. But then if it works, wouldn’t that be money well spent?
Ellinor: Yes I agree, what we eat and whether we are active or not is very related to our mood isn’t it? And how we feel about ourselves. This needs to be included in services. I guess I was more thinking about severe depression and anxiety, for that I think there are better services.
PSG E: It’s related a lot more than too our mood. Our belief system, how we see ourselves consciously and unconsciously. You should have a look at neuro linguistic programming. Amazing stuff.
PSG B: I think there is a definite link in some cases to obesity/weight management and more severe emotional health issues.
I suffered from antenatal depression and anxiety that was directly linked to the way I was treated in interactions with HCPs during my pregnancy, and specifically the way I was treated and spoken to as an obese woman (like an idiot despite my PhD!) I was referred for counselling but for me it came way too late in the pregnancy to be of much help.
I do wonder if I had had a bit more support in both the weight management and emotional side of things from the early weeks if things may have been different? I don’t think it would have made it any worse!
Q: It seems that even when there’s lots of evidence on topics affecting mothers with high BMI (possibly mothers in general!), it doesn’t always relate to changes in practice “on the ground” to reflect that evidence.
What do you think is going on here? Is there an issue with disseminating information? Or is there resistance to change? Or does it simply come down to funding? Or is there some other reason?)
Ellinor: I love all these questions! Wish I was a faster typer! I think it’s all of the above.
There is definitely an issue of implementation of guidelines. Firstly because change is difficult and takes time, but also because there are so many changes all the time (this should make it easier theoretically, but I don’t think it does).
I don’t think there is resistance to change, all HCPs want what is best for women – but it’s difficult to change and remembering what services are where and when and for whom.
Q: On the flipside, how much support is there for women who go into pregnancy underweight or suffering from an eating disorder where their BMI is ‘too low’ or falls ‘too low’ during the pregnancy?
Ellinor: I went to a training event about this yesterday! Not much. Some new resources have just been launched – http://www.eatingdisordersandpregnancy.co.uk
There are just fewer of these women (prevalence 2-7% in pregnancy) so they are not prioritised as much as obesity (approx 20-25%).
PSG G: The numbers are interesting, I wasn’t sure how they would compare. I just find that eating disorders are treated with psychology have a greater prevalence in treatment than obesity is. I (wrongly) presumed there would be more help for these women during pregnancy.
Ellinor: Not sure what you mean? Help for women with raised BMI?
PSG G: Sorry that was so jumbled (in bed with a cluster feeding baby!!)
I meant that eating disorders are often treated with psychological help. Obesity sufferers are told just to eat less and the physical symptoms are the only ones treated. I wondered if that was the same with women in pregnancy.
PSG D: I also wonder if underweight women are targeted with messages about how they’re increasing the risks to their baby through their ‘unhealthy lifestyle’ etc (as bigger mothers regularly are) and expected for that to be the motivation they need to change…
Q: Do you think there has been any change in HCPs approach to weight management of pregnant women since the national Midwives professional body started partnering with Slimming World? To my mind that’s when it suddenly seemed to be on every midwife’s agenda…
Ellinor: Great question, I don’t know. I think having somewhere to refer women to has helped midwives hugely, but I know not everyone thinks Slimming World is appropriate. The name doesn’t help in this situation.
I think we have to remember that the way it often works in maternity is that women refer to other services. For example with smoking, it is a straight referral usually. If midwives have somewhere to refer, they may be more likely to discuss weight as they can do something about that. If there is nowhere to refer, that conversation becomes a lot more difficult!
PSG D: I agree that the name is very unhelpful when the message is supposed to be ‘maintain, don’t lose’. And the fact that pregnant women are expected to attend a Slimming World group with non-pregnant people who are all there focused on losing weight. Makes me exceedingly uncomfortable.
I guess dedicated weight-maintenance/healthy eating groups specifically for high BMI pregnant women are a luxury the NHS can’t afford when there are a plethora of Slimming World groups all over the place at all sorts of times already running which are almost good enough…
Q: Do you think there would be value in giving information about available antenatal weight management services at booking in appointments with the ability for women to self-refer within a certain time frame (perhaps within the first x weeks of pregnancy) if they fit the apparently requisite BMI category? That would perhaps make those conversations a little easier on both sides and result in a better uptake of the services?
Ellinor: Yes absolutely, I think the key is to have services to refer to. Whether women self-refer or are referred. I think these should be more focused on activity and eating though, weight management may not be what women want to do in pregnancy. Just opportunities to meet other women really.
PSG B: Absolutely! I would have loved this to be available for both the social aspect and the availability of a relevant HCP if I did have questions or concerns or wanted to seek guidance on dietary modifications.
Q: Have you seen fatphobia in HCPs?
Ellinor: Very rarely personally, but I am aware that the research literature has identified this. For example in Nicola Heslehurst’s work.
It’s something I am very aware of when teaching my midwifery students about obesity and pregnancy.
In no way do I think HCPs in maternity services have more fat phobia than other HCPs though. Not sure if research has looked at this, just my take on the literature.
PSG D: Actually, you might well have a very good point here – it’s even possible that maternity HCPs are less fat phobic than the rest!
Q: I was lucky enough to have access to free aquanatal classes during my pregnancy through the NHS trust I worked for (not the NHS Trust area I live in, I hasten to add) – and these were for all pregnant women, not just the ones with high BMI. Is there any evidence to suggest attendance is better/women prefer to be in groups which reflect their BMI, or do they prefer to be mixed with other exercising mums?
Anecdotally, I found that I was concerned I wouldn’t be able to ‘keep up’ with everyone else. When I discovered that fear was unfounded and that I was fitter than many of the thinner mums, that boosted my confidence no end…
Ellinor: Oh, I am so glad to hear that, glad you had that opportunity.
I think it’s important that services are for pregnant women, that comes out from our interviews all the time. Ideally that ‘women look like me’.
Interestingly I am also working with postnatal services, and there women say ‘Is it led by a mum?’ so that’s important. So I would say should always be highlighted in information.
PSG D: Interesting. I hadn’t thought of that, but it was led by a colleague… I particularly found the language used by the instructor ‘pull your tummy button in towards baby…’ reminded me when I was there and helped maintain motivation.
Sadly it was only available for 12 months postnatally. And my fitness levels have dropped massively since. Is this something that’s been observed universally? Those women who do lose/maintain weight during pregnancy then fall back ‘off the wagon’ so to speak after they’ve given birth and the gains do not continue – particularly when the service they’re used to has been withdrawn?
I was interviewed by the course instructor (a fitness professional who looks nothing like me and wasn’t a mum!!) as part of a review. One of the questions was something like ‘why is this better for you as exercise than other forms?”
She was quite surprised at my answer – that being mostly submerged in water hides all the wobbly bits and I don’t need to feel embarrassed in any way as no-one can really see what I’m doing, except the instructor. She’d never even considered that, and what that might mean to a participant.
Q: You mentioned previously that you thought that we’d reached saturation on research projects that examined women’s experiences of pregnancy while obese, and of midwives experiences in supporting these women.
What do you think needs to happen next? What should future research do?
PSG C: I’m concerned this means that the research isn’t being acted on.
PSG H: This would be a good issue to talk to Maternity Voices Partnerships and MSLCs about.
Ellinor: To clarify, I think we now know that women feel badly treated by hcps due to their weight in pregnancy. We also know that midwives find discussing weight, diet etc very difficult.
I share your concerns, it may just become an assumption without us doing something about it
PSG C: So what needs to happen in order to effect change in a safe way?
Ellinor: I think it may be a problem with academics not making their research available to mums.
I am very keen for us to look at pregnancy separately from the postnatal period. It is problematic that services are set up this way, because it is all about preparing for parenthood.
So I would like to see services that women can attend when pregnant and then come back to with their babies.
The HAPPY (Healthy and Active Parenting Programme for early Years) intervention is a great example: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-016-2861-z
Going back to qualitative work – I would love to see research focusing on positive experiences, such as the free aqua natal or women who have attended services and found them useful.
We need examples of good practice. I would love to share good practice with my midwifery students!
PSG A: What are the barriers (apart from money!), to this happening?
Ellinor: Don’t underestimate the barrier of money with health visitors being funded differently from midwives! Also we need better partnership working between midwives and health visitors, so that health visitor knows that woman has stated she is keen to be active after she has her baby.
This partnership working is something we are working on at City currently; The Collaborating in Pregnancy and Early Years (COPE) Project https://blogs.city.ac.uk/cope/
Q: Question for everyone: what sort of a) support/ intervention and b) outcomes would you like to see from a research project working with pregnant women with a high BMI?
Ellinor: I love this – it would be so helpful to know what you want us researchers to focus on.
In some cases I think it may be that some of the research has been done, but not very well disseminated to mums. It’s something us researchers need to work on. Any advice how to do this would be greatly appreciated – the Parenting Science Gang is such a fantastic initiative
PSG D: I’d like to see more free activity sessions. I’d like the outcomes to anticipate lower BMIs, but for this NOT to be the focus of the project in any way, just an ancillary measured benefit – I’d like the stated outcomes to be increased activity levels, maternal well-being, companionship, support, preparation for labour and motherhood etc.
Ellinor: I think this is really important.
PSG C: Evidence based practice!! 😉 So less variation
Ellinor: Yes I think services can learn more from each other than what they currently do.
PSG G: Opportunities for pregnant women / new mums who have high BMI to come together. Sometimes a support network can lead to interesting places. Like breastfeeding cafes/groups.
Ellinor: How important do you think that this needs to be face-to-face or can online support be helpful?
PSG G: Online support is very useful. We have a wonderful La Leche League Facebook group locally and it makes a massive difference to women’s confidence in breastfeeding in an area where breastfeeding rates are the lowest in the country.
PSG A: I’d like to see fewer guidelines that start “If the mother has a BMI of over x” and more complex conversations with HCPs that take into account a wide range of markers.
PSG K: I would like pregnant women (regardless of BMI) to have access to HE advice with the aim of keeping weight gain within recommended weight gain for that BMI. I think we should be looking at whether that improves outcomes for gestational diabetes and macrosomia.
Ellinor: NICE will update guidelines regarding weight gain, so more research will be needed on this.
PSG K: Could breastfeeding be tied in too? Good for baby but also weight loss after pregnancy…
Ellinor: Agree but beware, breastfeeding does not always help with weight loss, depends on how much you breasted and how much you eat and activity you do.
PSG C: And a sensible take on increased risks and what that actually means. Otherwise there’s no informed choice for pregnant women – just scare tactics
Ellinor: Yes!! How do we best explain risks associated with raised BMI. So much work to be done.
Ellinor: They have done some great work on place of birth and risk, maybe something similar for BMI?
PSG G: Yes, totally although many women still find it very surprising it’s so safe to give birth at home. There’s the general acceptance that a medical environment is better but this is ingrained across society in lots of areas.
Ellinor: Yes, change will take a while, but it’s a good start.
PSG A: Thanks so much Ellinor -this has been a really interesting evening and you’ve give us quite a bit to discuss. Thanks so much for your time.
Ellinor: Again thank you for inviting me. Happy to help in any way I can, we are all working towards the same goal!
Inspired? Want to get involved in doing some research that could help support women with a high BMI during their pregnancy? Why not join the Big Birthas Parenting Science Gang? Just visit our Facebook page and join up.
And if you want to hear more about what experts have told us, why not check out some of our other Q&A sessions? We talked about:
- Pregnancy with a high BMI with Clare Murphy
- How breastfeeding is supported in the UK with Ruth Stirton
- Extreme picky eating with Jenny McGlothlin.
All our sessions can be found on our Q&A webpage.