How effectively do midwives manage the care of obese pregnant women? A cross-sectional survey of Australian midwives

A mixed methods systematic review of midwives' clinical practices related to prenatal care of women with obesity

OBJECTIVE

Maternal obesity has been related to adverse maternal and infant outcomes. It is a persistent challenge of midwifery care worldwide and can present clinical challenges and complications. This review sought to identify evidence on the practice patterns of midwives related to prenatal care of women with obesity.

METHODS

The databases Academic Search Premier, APA PsycInfo, CINAHL PLUS with Full Text, Health Source: Nursing/Academic Edition, and MEDLINE were searched November 2021. Search terms included weight, obesity, practices, and midwives. Inclusion criteria included quantitative, qualitative, and mixed method studies that addressed practice patterns of midwives related to prenatal care of women with obesity published in peer-reviewed journals, written in English. The recommended Joanna Briggs Institute approach to mixed methods systematic reviews was followed e.g. study selection, critical appraisal, data extraction, and a convergent segregated method of data synthesis and integration.

RESULTS

Seventeen articles from 16 studies were included. The quantitative evidence showed a lack of knowledge, confidence, and support for midwives that would facilitate adequate management of pregnant women with obesity while the qualitative evidence revealed that midwives desire a sensitive approach to discussing obesity and the risks associated with maternal obesity.

DISCUSSION

Quantitative and qualitative literature report consistent individual and system-level barriers to implementing evidence-based practices. Implicit bias training, midwifery curriculum updates, and the use of patient centered care models may help overcome these challenges.

Midwives perceptions of managing pregnancies complicated by obesity: A mixed methods study

OBJECTIVE

The growing prevalence of obesity is a concern for midwives. In Canada, the absence of regulatory standards, varying protocols and consultant preferences shape clinical decision making for the midwife and may lead to inconsistent practice. Our aim was to understand the barriers, enablers, and knowledge gaps that influenced experiences of midwives in Ontario, Canada when providing care to clients impacted by obesity.

METHODS

Mixed methods design using a sequential, explanatory approach. Surveys conducted with midwives were administered using an online platform, followed by semi-structured interviews to understand the perspectives elicited in the survey in greater detail. Interviews were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics, and thematic analysis was used for generating codes, categories and themes from the interview data.

RESULTS

144 midwives completed the survey and 20 participated in an interview. The participants described their clinical management when caring for those with obesity which included considerations regarding additional tests/investigations, consultation and transfer of care, and place of birth. Up to 93% of surveyed midwives believed that clients with obesity were appropriate for midwifery-led care however there was less certainty about suitability as BMI increased to higher ranges such as > 45). The care management was influenced by beliefs and attitudes, knowledge, and system-level factors. Midwives experienced barriers such as inconsistent practices and role confusion, and felt ill equipped to care for pregnancies affected by obesity due to unclear guidelines.

CONCLUSIONS

Overall, midwives believe clients with obesity are suitable for midwifery-led care due to its individualized, non-judgmental approach to care. Additional training for midwives and other obstetric care providers would be beneficial to help overcome barriers in providing effective care to pregnancies affected by obesity.

Midwives knowledge and education/training in complementary and alternative medicine (CAM): A national survey

Despite the proliferation of research exploring complementary and alternative medicine (CAM) use in maternity care and midwifery practice, there is a gap on midwives' level of CAM knowledge and education/training. This national survey investigated Australian midwives' knowledge and education/training in CAM. A total of 571 midwives completed the survey (16%). Over half (54.3%) had some level of CAM education/training (self-learning to diploma) and with multiple CAM modalities. The top four modalities that midwives had received education/training were acupressure (66.5%), aromatherapy (60.3%), massage (45.5%), and reflexology (37.7%). There was a significant correlation between midwives attending a CAM workshop with competency-assessment (p < 0.000) and confidence to discuss CAM options with pregnant women compared with participants who have not. There are no other health-related therapies used by women consumers with such frequency where clinicians are not expected to have baseline knowledge and understanding. Midwifery education programs need to include evidence-based information on CAM modalities.

The Healthy Pregnancy Service to Optimise Excess Gestational Weight Gain for Women with Obesity: A Qualitative Study of Health Professionals' Perspectives

Maternal obesity is associated with health risks for women and their babies, exacerbated by excess gestational weight gain. We describe health professionals’ perspectives in the provision of a Healthy Pregnancy service designed to optimise healthy lifestyle and support recommended gestational weight gain for women with obesity. Semi-structured interviews were conducted with health professionals. Questions were based on the Theoretical Domains Framework (TDF) and deductive thematic analysis was performed. A total of 14 multidisciplinary staff were interviewed. Six themes were identified: 1. health professionals view themselves as part of a team; 2. health professionals reported having necessary skills; 3. experience generated confidence in discussing gestational weight gain; 4. gestational weight gain is considered of variable importance; 5. health professionals want women to be comfortable; 6. the environmental context and resources presented some barriers. Staff were supportive of the Healthy Pregnancy service and valued developing teamwork with staff and rapport with women. Most felt relatively comfortable discussing weight gain with women. Barriers included ability to navigate sensitive topics with women, limited awareness of the intervention among new staff, communication between teams, and waiting time for women. Barriers and enablers to the delivery of an integrated model of maternity care were identified. These findings should inform and improve implementation of service models integrating healthy lifestyle in the antenatal care of women with obesity.

Midwives' and obstetricians' level of knowledge of appropriate gestational weight gain recommendations for pregnancy: A systematic review

BACKGROUND

Excessive gestational weight gain (GWG) is a modifiable risk factor associated with maternal and infant health, and pregnancy outcomes. However, several factors influence the provision of health promotion advice including professional knowledge. This review aims to summarize published evidence relating to midwives' and obstetricians' knowledge of GWG guidelines.

METHODS

Electronic database searches were carried out using EMBASE, CINAHL, PubMed, Web of Science, and Cochrane Database. English-language studies and quantitative results were included. Identified studies were screened by two authors independently. Disagreements were discussed with a third reviewer. A review protocol was submitted for registration with PROSPERO in May 2019.

RESULTS

From 10 960 records identified in preliminary searches, 12 studies reporting on 2652 midwives and obstetricians collectively were included. All studies were conducted in high-income countries. Synthesis of data was difficult as guidelines and methods for assessing knowledge varied. Midwives were mainly reported as the leading participant, with limited data available on obstetrician knowledge. Both groups demonstrated insufficient knowledge of GWG guidelines. Self-reported knowledge was significantly higher than those assessed by direct knowledge.

CONCLUSIONS

This review highlights a substantial gap in health care professionals' knowledge of GWG guideline content which needs to be addressed. Differences between professionals' direct knowledge and self-reported knowledge are important for clinical practice as it may inhibit the provision of evidence-based advice. It is important to accurately assess knowledge in this area to develop further training for midwives and obstetricians to improve health promotion during pregnancy.

Communication practices of healthcare professionals when caring for overweight/obese pregnant women: A scoping review

OBJECTIVE

To synthesize existing research on communication practices between healthcare professionals and overweight and obese pregnant women.

METHODS

Following PRISMA guidance on conducting scoping reviews, we included original research addressing communication/counseling practices of healthcare professionals with overweight and/or obese pregnant women, published between 2008-2018, and available in English. Fourteen articles are included in this review.

RESULTS

Study findings were organized into three themes: (a) topics addressed during encounters, (b) providers' comfort/confidence, knowledge and methods in communicating with overweight/obese pregnant women, and (c) overweight/obese pregnant women's experiences in communicating with healthcare providers. The most prevalent topics addressed were gestational weight gain, physical activity, and nutrition. Healthcare professionals experience discomfort and are reluctant to address weight status with overweight/obese pregnant patients, use vague statements about weight gain and weight-related obstetric risks, and report low confidence when counseling obese pregnant women. Overweight/obese pregnant women perceive weight stigma when interacting with providers.

CONCLUSION

Weight-related counseling in obstetric care is suboptimal. Providers may benefit from training to more confidently and effectively counsel overweight and obese pregnant women about gestational weight gain, physical activity, and nutrition.

PRACTICE IMPLICATIONS

Patients perceive weight stigma in the obstetric setting, which may be prevented by effective, patient-centered communication.

Co-designing preconception and pregnancy care for healthy maternal lifestyles and obesity prevention

PROBLEM

A recognised gap exists between current and recommended practices in the provision of lifestyle advice and weight management support for women across preconception and pregnancy care.

BACKGROUND

Preconception and pregnancy are critical stages for promoting healthy maternal lifestyles and obesity prevention. Co-design is a novel approach with the potential to strengthen existing models of care to facilitate the implementation of clinical practice guidelines promoting preconception and pregnancy health, especially in relation to preconception weight management and preventing excessive gestational weight gain.

AIM AND METHODS

The aims of this discussion paper are to (i) define co-design in the context of preconception and pregnancy care, (ii) outline key considerations when planning co-design initiatives and (iii) describe co-design opportunities in preconception and pregnancy care for promoting women's health and obesity prevention.

DISCUSSION

While several definitions of co-design exist, one critical element is the meaningful involvement of all key stakeholders. In this discussion, we specifically identified the involvement of women and expanding the role of practice nurses in primary care may assist to overcome barriers to the provision of healthy lifestyle advice and support for women during preconception. Co-designing pregnancy care will involve input from women, nurses, midwives, obstetricians, allied health and administration and management staff. Additional attention is required to co-design care for women considered most at-risk.

CONCLUSION

There is potential to enhance current provision of preconception and pregnancy care using co-design. Nursing and midwifery professions are active across both preconception and pregnancy and therefore, they have an important role to play.

'Weighty issues' in GP-led antenatal care: a qualitative study

Background

Approximately 50% of women gain weight in excess of gestational weight gain (GWG) recommendations during pregnancy leading to adverse maternal and foetal outcomes and the perpetuation of the cycle of obesity. Antenatal care provided by a general practitioner (GP) in the primary care setting is an important model of care, particularly for women in regional areas where rates of overweight and obesity are highest. The aim of this study is to explore GPs’ perceptions and experiences of implementing GWG recommendations in GP-led antenatal care.

Methods

A qualitative exploratory approach recorded GPs’ experiences and insights regarding the application of GWG recommendations in practice. Data were collected via semi-structured interviews informed by the revised Theoretical Domains Framework (TDF). Deductive thematic analysis grouped coded text into TDF domains from which main themes were generated.

Results

Twenty GPs (13 female, 7 male) from metropolitan and regional Victoria, Australia participated. Codes related to at least one of 11 TDF domains. Five main themes were apparent: 1) Despite low awareness of guidelines, GWG advice is provided; 2) ‘I should do this more’; 3) Lack of everyday resources; 4) Working ‘against the odds’ at times; and 5) Optimism and reality. GPs were aware of the importance of optimal GWG however, other pregnancy-related issues are given precedence during consultations. Enablers for the implementation of GWG guidelines were practitioner-based and included GPs’ strong sense of their professional role to provide advice, and ongoing and trusting relationships with women throughout pregnancy. Barriers were mostly health system-based with limited time, remuneration, and restrictive referral pathways being limiting factors.

Conclusions

There is a need to support GPs to provide GWG advice in accordance with current national guidelines. Solutions potentially lie in strategies that promote the effective dissemination and uptake of guidelines, and changes to policy and funding within the health-system so that longer GP-led antenatal care consultations are remunerated and referrals to allied health are accessible to women who require additional support to optimise GWG.

Exploring obstetricians', midwives' and general practitioners' approach to weight management in pregnant women with a BMI ≥25 kg/m2: a qualitative study

OBJECTIVE

The aim of this study was to explore healthcare professionals' (HCPs) beliefs and attitudes towards weight management for pregnant women with a body mass index (BMI) ≥25 kg/m².

DESIGN

Qualitative study.

SETTING

A public antenatal clinic in a large academic maternity hospital in Cork, Ireland, and general practice clinics in the same region.

PARTICIPANTS

HCPs such as hospital-based midwives and consultant obstetricians and general practitioners (GPs).

METHOD

Semistructured interviews were conducted with a purposive sample of hospital-based HCPs and a sample of GPs working in the same region. Interviews were recorded, transcribed and thematically analysed using NVivo software.

RESULTS

Seventeen HCPs were interviewed (hospital based=10; GPs=7). Four themes identified the complexity of weight management in pregnancy and the challenges HCPs faced when trying to balance the medical and psychosocial needs of the women. HCPs acknowledged weight as a sensitive conversation topic, leading to a 'softly-softly approach' to weight management. HCPs tried to strike a balance between being woman centred and empathetic and medicalising the conversation. HCPs described 'doing what you can with what you have' and shifting the focus to managing obstetric complications. Furthermore, there were unclear roles and responsibilities in terms of weight management.

CONCLUSION

HCPs need to have standardised approaches and evidence-based guidelines that support the consistent monitoring and management of weight during pregnancy.

Evaluating Online Continuing Professional Development Regarding Weight Management for Pregnancy Using the New World Kirkpatrick Model

INTRODUCTION

Clinical practice guidelines advocate the importance of continuing professional development (CPD) that supports health professionals (HPs) to discuss the sensitive topic of maternal weight management with women. However, there is a lack of accredited CPD related to this important area of preconception and antenatal care. Therefore, aims were to evaluate HPs' reactions to accredited online CPD regarding weight management for pregnancy and their knowledge, attitudes, confidence, and commitment to provide women with advice after completing the course.

METHODS

A mixed-methods evaluation was based on the New World Kirkpatrick Model (NWKM). Accredited online CPD was developed by experts in maternal nutrition and weight management. Participants completed a questionnaire before (n = 136) and after (n = 65) the weight management components of the course. McNemar and Wilcoxon signed-rank tests were used to evaluate paired data (n = 36) (p < .05). Deductive content analyses explored free-text responses (n = 65).

RESULTS

Participants' reactions to the online CPD were encouraging, facilitating increases in perceptions of the importance of weight management for pregnancy and confidence to provide advice. Quantitative measures assessed no change in participants' knowledge; however, qualitative analyses revealed an increase in participants' knowledge of communication strategies that they intend to apply in practice.

DISCUSSION

The NWKM facilitated an evaluation of HPs' encouraging reactions to online CPD and the affective constructs of education including attitudes, confidence, and commitment to provide advice. Online CPD should be developed with collaboration between universities/professional associations and health care providers, so that evaluation of organizational change and clinical outcomes is possible.

Antepartum Care of Women Who Are Obese During Pregnancy: Systematic Review of the Current Evidence

INTRODUCTION

Nearly 40% of US women of childbearing age are obese. Obesity during pregnancy is associated with multiple risks for both the woman and fetus, yet clinicians often feel unprepared to provide optimal antepartum care for this group of women. We collected and reviewed current evidence concerning antepartum care of women who are obese during pregnancy.

METHODS

We conducted a systematic review using PRISMA guidelines. Current evidence relating to the pregnancy care of women with a prepregnancy body mass index of 30kg/m2 or higher was identified using MEDLINE databases via PubMed, Embase, and Web of Science Core Collection between January 2012 and February 2018.

RESULTS

A total of 354 records were located after database searches, of which 63 met inclusion criteria. Topic areas for of included studies were: pregnancy risk and outcomes related to obesity, communication between women and health care providers, gestational weight gain and activity/diet, diabetic disorders, hypertensive disorders, obstructive sleep apnea, mental health, pregnancy imaging and measurement, late antepartum care, and preparation for labor and birth.

DISCUSSION

Midwives and other health care providers can provide better antepartum care to women who are obese during pregnancy by incorporating evidence from the most current clinical investigations.

Weight management during pregnancy: a qualitative study of women's and care providers' experiences and perspectives

Background

Obesity during pregnancy is a serious health problem for women and their children. Despite the high prevalence of high body mass index (BMI) among women of reproductive age in high-income countries, there is insufficient evidence to inform practice and policy about weight management for women with high BMI who are pregnant. The aim of this project was to describe women’s and midwives’ experiences and perspectives of care for weight management during pregnancy in Melbourne, Australia.

Methods

A qualitative study. Semi-structured interviews were conducted with pregnant women and midwives. Transcripts were analysed thematically.

Results

A total of 17 women and 2 midwives were interviewed. Five themes were identified: 1. Reluctance to and difficulties discussing weight and its implications; 2. Barriers to providing appropriate pregnancy care for women with high BMI; 3. Inconsistent weighing practices; 4. Beliefs about the causes of obesity; and 5. Opportunities to assist women to manage their weight. Although most women were satisfied with the pregnancy care they had received, both women and midwives expressed concerns about effective weight management during pregnancy. These included constraints on discussing weight, difficulties accessing appropriate resources and additional support from other health care providers, and inconsistent weighing practices.

Conclusions

The findings suggest that women with high BMI would benefit from additional information and support about weight management prior to conception, during pregnancy, and postnatally.

Self-Reported Nutrition Education Received by Australian Midwives before and after Registration

Educating midwives to provide nutrition advice is essential. Limited research focuses on midwives' nutrition education. This paper explores self-reported nutrition education received by Australian midwives before and after registration. It draws on quantitative and qualitative data from a larger online survey conducted with the members of the Australian College of Midwives (response rate = 6.9%, n = 329). Descriptive and content analyses were used. Of the midwives, 79.3% (n = 261) reported receiving some nutrition education during, before, and/or after registration. However, some described this coverage as limited. It lacked sufficient focus on topics such as weight management, nutrition assessment, and nutrition for vulnerable groups. Continuing education often occurred through personal initiatives, such as the midwife enrolling in external courses or exploring issues on the Internet and with colleagues. The majority of participants indicated a need for increased nutrition education (94.2%, n = 310) and guidelines tailored for them to provide nutrition advice (87.8%, n = 289). Australian midwives may not be receiving adequate nutrition education to provide nutrition advice. Inclusion of evidence-based nutrition components in midwifery education and regular updates for practising midwives focusing on challenging nutrition issues is required to ensure that they are supported in this important role.

Women with a BMI ≥ 30kg/m² and their experience of maternity care: A meta ethnographic synthesis

OBJECTIVE

this paper is a report of a systematic review and meta-ethnography of the experiences of women with body mass index (BMI) ≥ 30kg/m² and their experience of maternity care.

METHOD

systematic review methods identified 12 qualitative studies about women's experiences of maternity care when their BMI ≥ 30kg/m². Findings from the identified studies were synthesised into themes, using metaethnography. SYNTHESIS AND FINDINGS: the meta-ethnography produced four key concepts; Initial encounters, Negotiating risk, Missing out and The positive intervention, which represent the experiences of maternity care for women with BMI ≥ 30kg/m² KEY CONCLUSION: many women with BMI ≥ 30kg/m² appear to be dissatisfied with the approaches taken to discuss weight status during maternity encounters. When weight is not addressed during these encounters women appear to be equally dissatisfied. The absence of open and honest discussions about weight, the feeling of being denied of a normal experience, and an over emphasis on the risks imposed upon pregnancy and childbirth by obesity, leave women feeling dissatisfied and disenfranchised. Sensitive care and practical advice about diet and exercise can help women move towards feeling more in control of their weight management.

The use of midwife-led primary antenatal care by obese women in The Netherlands: An explorative cohort study

OBJECTIVE

to study the effect of body mass index (BMI) on the use of antenatal care by women in midwife-led care.

DESIGN

an explorative cohort study.

SETTING

11 Dutch midwife-led practices.

PARTICIPANTS

a cohort of 4421 women, registered in the Midwifery Case Registration System (VeCaS), who received antenatal care in midwife-led practices in the Netherlands and gave birth between October 2012 and October 2014.

FINDINGS

the mean start of initiation of care was at 9.3 (SD 4.6) weeks of pregnancy. Multiple linear regression showed that with an increasing BMI initiation of care was significantly earlier but BMI only predicted 0.2% (R²) of the variance in initiation of care. The mean number of face-to- face antenatal visits in midwife-led care was 11.8 (SD 3.8) and linear regression showed that with increasing BMI the number of antenatal visits increased. BMI predicted 0.1% of the variance in number of antenatal visits. The mean number of antenatal contacts by phone was 2.2 (SD 2.6). Multiple linear regression showed an increased number of contacts by phone for BMI categories 'underweight' and 'obese class I'. BMI categories predicted 1% of the variance in number of contacts by phone.

KEY CONCLUSIONS

BMI was not a relevant predictor of variance in initiation of care and number of antenatal visits. Obese pregnant women in midwife-led practices do not delay or avoid antenatal care.

IMPLICATIONS FOR PRACTICE

Taking care of pregnant women with a high BMI does not significantly add to the workload of primary care midwives. Further research is needed to more fully understand the primary maternal health services given to obese women.

Patient report of guideline-congruent gestational weight gain advice from prenatal care providers: differences by prepregnancy BMI

BACKGROUND

Prenatal care provider weight gain advice consistent with the Institute of Medicine recommendations is related to guideline-adherent gestational weight gain (GWG), yet many women may not receive guideline-congruent advice. We examined pregnant women's recall of prenatal care provider GWG advice in relation to prepregnancy body mass index (BMI).

METHODS

We conducted a prospective cohort study of women (n = 149) receiving prenatal care for a singleton pregnancy at a large academic medical center in 2010. Data were collected via a survey during late pregnancy and medical record abstraction.

RESULTS

Thirty-three percent of women did not recall receiving the provider GWG advice; 33 percent recalled advice consistent with 2009 Institute of Medicine recommendations. Recalled advice differed by prepregnancy BMI; 29 percent of normal weight, 26 percent of overweight, and 45 percent of obese women reported not receiving advice, and 6, 37, and 39 percent, respectively, recalled advice exceeding Institute of Medicine recommendations. Among the 62 percent who recalled that their provider had labeled their prepregnancy BMI, 100 percent of normal weight, 32 percent of overweight, and 23 percent of obese women recalled the labels "normal weight," "overweight," and "obese," respectively.

CONCLUSIONS

Helping providers give their patients memorable and guideline-consistent GWG advice is an actionable step toward preventing excessive GWG and associated maternal and child health consequences.