Women and Birth 27 (2014) e67–e71
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research – Quantitative
Developing a clinical care pathway for obese pregnant women: A quality improvement project Shanna Fealy a,b,*, Alexis Hure b, Graeme Browne b, Carol Prince a a b
Port Macquarie Base Hospital, Wrights Road, NSW, Australia The University of Newcastle, University Drive, Callaghan, NSW, Australia
A R T I C L E I N F O
Article history: Received 24 June 2014 Received in revised form 22 August 2014 Accepted 1 September 2014 Keywords: Obesity Pregnancy Risks Management Implementation Science
A B S T R A C T
Problem: Obesity in pregnancy is associated with an increased incidence of maternal and foetal morbidity and mortality, from conditions like preeclampsia, gestational diabetes, preterm birth and stillbirth. Between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) 30 kg/m2, defined as obesity in pregnancy. These figures are concerning for midwifery and obstetric staff directly involved in the clinical care of these women and their families. In the absence of national or state clinical practice guidelines for managing the risks for obese pregnant women, a local quality improvement project was conducted. Aim: To plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a BMI 35 kg/m2 at their first antenatal visit. Project setting: The project was undertaken in the antenatal clinic of a rural referral hospital in NSW, Australia. Subjects: Eighty-two women with a BMI 35 kg/m2 were eligible for the alternative care pathway, offered between January and December 2010. Intervention: The alternative care pathway included the following options, in addition to usual care: written information on obesity in pregnancy, referral to a dietitian, early plus repeat screening for gestational diabetes, liver and renal function pathology tests, serial self-weighing, serial foetal growth ultrasounds, and a pre-labour anaesthetic consultation. Findings: Despite being educated on the risk associated with obesity in pregnancy, women did not take up the offers of dietetic support or self-weighing at each antenatal visit. Ultrasounds were well received and most women underwent gestational diabetes screening. Crown Copyright ß 2014 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
1. Background to the problem Midwifery and obstetric staff within a rural tertiary hospital facility regularly engage in clinical reviews of maternity consumer case studies. In 2009, the cases of four obese women who experienced significant adverse birth and post-natal outcomes, including caesarean section wound breakdown and Intensive Care admissions, were discussed. Clinician concerns prompted a review of the clinical management for obese pregnant women. In 2009, no Australian or state clinical practice guidelines addressing risk
* Corresponding author at: 28 Sapphire Drive Port, Macquarie, NSW 2444, Australia. Tel.: +61 0415601169. E-mail addresses: [email protected], [email protected] (S. Fealy).
management for obesity in pregnancy existed. Therefore, this evidence-practice gap became the focus of a year-long quality improvement project, which started by reviewing the available literature. 2. Search strategy A literature search was conducted to understand the extent of the problem of obesity in pregnancy and identify existing guidelines and strategies addressing the antenatal care for obese pregnant women. Keyword search terms were used including ‘obesity’ AND ‘pregnancy*’, AND ‘management’, OR ‘risks’. The initial search was run between January and June 2009, with the search updated after completing the project, in May 2014. Databases searched included OVID, Medline, CINAHL, Embase, Proquest, PubMed, Cochrane
http://dx.doi.org/10.1016/j.wombi.2014.09.001 1871-5192/Crown Copyright ß 2014 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
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S. Fealy et al. / Women and Birth 27 (2014) e67–e71
Collaboration, Science Direct, Nursing Consult and New South Wales Health Clinical Information Access Programme (CIAP). Guidelines, policies, and protocols were sought through additional searches of relevant health information websites including UpToDate, NSW Health Department, and Australian Government health service. 3. Background literature Obesity has become a global epidemic that is linked to many serious health problems including the development of chronic disease such as diabetes, hypertensive disorders, coronary heart disease and stroke.1 In Australia, over 50% of the adult population are overweight or obese.2 In an analysis of the South Australian maternal and perinatal health database, Dodd et al.4 reported that 50% of pregnant women were overweight or obese, with a slightly higher incidence among rural pregnant women (54.4%).3 Cunningham and Teale3 specifically looked at maternal overweight and obesity in rural Victoria, reporting an alarming prevalence of 65% among more than 6000 pregnant women.4 The Australian Longitudinal Study on Women’s Health predicts that approximately 60% of Australian women of childbearing age will be obese by 2050, with young women gaining weight faster than any other age group.2 The Australia’s Mothers and Babies 2011 report indicates that between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) 30 kg/m2, defined as obesity in pregnancy.5 Smith et al.6 explains the pathophysiology of obesity stating that ‘obesity represents a state of altered hormonal and inflammatory activity associated with the function of fatty tissue’. It is thought that this hyper-inflammatory state clinically manifests conditions such as hypertension, glucose intolerance, insulin resistance, elevated cholesterol and triglycerides.6 During the course of normal pregnancy insulin resistance increases up to 60%, facilitating the transfer of nutrition and energy from mother to baby. Hence, any underlying impairment in insulin sensitivity and insulin resistance due to pre-existing metabolic syndrome is likely to be exacerbated during pregnancy.6,7 In a large retrospective study of 287,213 completed singleton pregnancies, Sebire et al.7 found that obese women (BMI 30 kg/ m2) had an increased occurrence of pregnancy and birth complications than women within the healthy weight range, which they defined as a BMI 20–24.9 kg/m2.7 Complications include gestational diabetes (3.6% vs. 0.8%), preeclampsia (1.4% vs. 0.7%), induction of labour (24.6% vs. 15.3%), birth by emergency caesarean section (13.4% vs. 7.8%), postpartum haemorrhage (17.1% vs. 10.4%), wound infection (1.3% vs. 0.4%), infant birth weight above 90th centile (17.5% vs. 9.0%) and stillbirth (0.7% vs. 0.4%).7 More recently, Flenady et al.8 have shown that maternal overweight and obesity (BMI >25 kg/m2) was the highest ranking modifiable risk factor for stillbirths. In their systematic review and meta-analysis Flenady et al.8 calculated population attributable risks of 8–18% across the five countries, contributing around 8000 stillbirths (22 weeks gestation) annually across all highincome countries.8 Many other studies have demonstrated the same association between a high BMI and increased risk of common adverse pregnancy outcomes like gestational diabetes, gestational hypertension and caesarean births.9 One study, on a less frequently reported outcome, was a trial of labour after a previous caesarean section.10 Hibbard et al.10 reported that approximately 40% of morbidly obese (BMI 35 kg/m2) women were unsuccessful in their trial of labour following a previous caesarean section, compared to 15% of normal weight women. Foetal anomalies are also more common with obesity during pregnancy. A systematic review and meta-analysis found that
obese women were at significantly higher risk of pregnancies affected by: neural tube defects (OR 1.9, 95% CI 1.6, 2.2), including spina bifida (OR 2.2, 95% CI 1.9, 2.7); cardiovascular anomalies (OR 1.3, 95% CI 1.1, 1.5); septal anomalies (OR 1.2, 95% CI 1.1, 1.3); cleft lip and palate (OR 1.2, 95% CI 1.0, 1.4); anorectal atresia (OR 1.5, 95% CI 1.1, 2.0); hydrocephaly (OR 1.7, 95% CI 1.2, 2.4); and limb reduction anomalies (OR 1.3, 95% CI 1.0, 1.7).11 Hall and Neubert12 explain that the reason neural tube defects may be more prominent in obese women, is due to poor absorption and decreased serum folic acid levels as a result of impaired metabolic functioning, with lower levels of folic acid reaching the developing embryo. Detection of foetal anomalies by ultrasound is less reliable in obese pregnant women with obese women at twice the risk of having suboptimal visualisation of detailed foetal anatomy than normal weight women.13 A similar study reported that detecting foetal anomalies decreased with an increasing BMI.14 In light of these increased risks for obese pregnant women and their babies, many recommendations have been suggested throughout the literature. These recommendations include: assessment of weight and BMI at the first antenatal visit; stringent weighing of women at each antenatal visit; early glucose tolerance testing and universal testing at 26–28 weeks gestation; counselling about miscarriage, stillbirth, hypertension, diabetes, and nutrition; referral to a dietitian; detailed growth and anomaly ultrasound scans; anaesthetic consultation; and early evaluation of maternal kidney, cardiac and liver function due to the high incidence of hypertension and preeclampsia.15–21 The aim of our project was to plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a body mass index (BMI) 35 kg/m2 at their first antenatal visit. Given that women with the highest BMI have the highest risks reported throughout the literature, it was considered reasonable to focus our limited resources on women with a BMI 35 kg/m2. It was anticipated that by providing these women with education and clinical care about managing the risks associated with being obese that we would detect complications earlier and reduce their impact. Implementation science, the study of methods that facilitate the uptake of research findings and evidence-based practices into routine health care, forms the foundations for this study.22,23 This body of research recognises that bridging the gap between theory and clinical practice can be difficult and requires an understanding of the uniqueness of the health systems in which changes are to be implemented.24 As a result, the NSW quality improvement methodology was adopted to guide the project team. 4. Site and participants The project was conducted within a rural maternity unit comprising of a 19-bed maternity ward, 3-bed birthing unit, level two special-care nursery and publicly funded antenatal clinic. In 2009, a total of 796 babies were born at the hospital. All women attending antenatal clinic for their first trimester antenatal clinic visit had their height and weight measured, and BMI calculated. Eighty-two women with a BMI 35 kg/m2 were identified between January 2010 and December 2010. A project team including a clinical midwifery consultant, a clinical midwifery specialist, four consultant obstetricians and one dietitian was formed. The chief investigators responsible for overall project planning, design, implementation and evaluation were the clinical midwifery consultant and clinical midwifery specialist. 5. Methods This study utilised a NSW public health service quality project methodology.3 This design uses a five-step process including.
S. Fealy et al. / Women and Birth 27 (2014) e67–e71
1. The Planning Phase, that identifies the problem and who will be involved3; 2. The Diagnostic Phase, that assists researchers to clarify the extent of the problem through gathering evidence and identifying strategies to address the problem3; 3. The Intervention and Testing Phase, where the identified strategies are implemented following a Plan, Do, Study, Act cycle3; 4. The Impact and Implementation Phase, where strategies are implemented and review of the effects of the strategies are recorded; and 5. The Evaluation and Sustainability Phase, which involves the continued monitoring of changes and sustaining of improvements.3
5.1. The Planning Phase This phase involved data collection by clinical review of case studies and literature review. The findings were presented to clinicians at the monthly maternity clinical risk meeting in July 2009. The information contained in the review evaluated the extent of the problem and quantified the increases in morbidity and mortality amongst obese pregnant woman. A survey of antenatal women exploring their knowledge of risks associated with obesity and exploring their views on the appropriateness of addressing obesity in pregnancy was also considered. Based on the data presented from the clinical audit, literature review and surveys, the project team recommended that a clinical practice improvement project be undertaken. 5.2. The Diagnostic Phase The project team considered that the most appropriate way to address risks associated with obesity in pregnancy was by devising an alternative antenatal care pathway for pregnant women with a BMI 35 kg/m2. These women were seen in the literature to be at greatest risk for pregnancy complications. 5.3. The Intervention and Testing Phase Following the Plan, Do, Study, Act process, a draft pathway was developed.3 The pathway was presented at a planning meeting for the project team to discuss and make comment. Following this meeting the additional care strategies were endorsed as an alternative pathway for pregnant women with a BMI 35 kg/m2 (Table 1).
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identified as eligible for participation in the pathway. These women had their medical record number, gravida, parity, due date, and BMI recorded in a spreadsheet. Participation in each of the individual components of the alternate clinical care pathway was recorded progressively by the project’s clinical midwifery consultant. Birth data was accessed from the Obstetrix database. 5.5. Ethical considerations Permission to initiate this project was sought from the hospital’s quality improvement department and approval was granted by the Director of Nursing and the Midwifery Unit Manager in December 2009. Health service ethics approval was not required. Women were provided with information, then invited to voluntary participate in the additional care components; however, the decision to participate was left with the individual. Data were stored securely and analysed using descriptive statistics in Microsoft Excel (2010). 6. Results Eighty-two women who presented to the antenatal clinic were identified with a BMI 35 kg/m2 at their first antenatal clinic visit, representing 10.3% of all women attending the antenatal clinic. This figure is based on the total number of births being 796 for the previous year (2009). Data on BMI category and parity for participants are presented in Table 2. All women had a discussion with a consultant obstetrician, obstetric registrar, or clinical midwifery consultant on the risks associated with obesity at their first antenatal visit, where they were offered the alternate clinical care pathway outlined in Table 1. The participation rates for each component of the alternative care pathway (Table 3) varied from no woman engaging in serial self-weighing at each antenatal clinic visit to almost all women undergoing some screening for gestational diabetes. The appointment with the anaesthetist was offered to all women from at least 30 weeks gestation. Women were called when an appointment was available and were invited to accept or decline. At birth, 79 women remained engaged in the project giving a participation rate of 96.3% from initial recruitment to birth: 1 had a miscarriage, 1 had a termination and 1 had relocated to another area. Sixty-two percent of women experiencing their first pregnancy (nulliparous) birthed by caesarean section, compared to the national average of 33% for first-time mothers (Table 4). 7. Discussion 7.1. The Evaluation and Sustainability Phase
5.4. The Impact and Implementation Phase All women presenting to the antenatal clinic had their height, weight and BMI calculated. Women with a BMI 35 kg/m2 were
The literature is clear: obesity is associated with higher maternal and foetal risks during pregnancy and at birth. This quality improvement project identified 82 pregnant women with a
Table 1 Alternative clinical care pathway for obese pregnant women (BMI 35 kg/m2).
1. 2. 3. 4. 5. 6. 7. 8. 9. a b
Alternative care component
When it was provided
Discuss the risks of obesity in pregnancy and describe the alternate care pathway Provide written information: Obesity in Pregnancy: a guide for womena Provide a referral to a dietitian Offer liver and renal function pathology tests Offer self-weighing and discuss weight gain Offer an early 75 g glucose tolerance test Offer repeat 75 g glucose tolerance test Offer serial growth ultrasounds Offer a pre-labour anaesthetic consultation
First antenatal visit 12–14 weeks gestation First antenatal visit 12–14 weeks gestation First antenatal visit 12–14 weeks gestation First antenatal visit 12–14 weeks gestation Every visit 16–20 weeks gestation 26–28 weeks gestationb 28, 32 and 36 weeks gestation 30 weeks gestation
Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2008. Screening for gestational diabetes at 26–28 weeks gestation is part of routine antenatal care.
S. Fealy et al. / Women and Birth 27 (2014) e67–e71
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Table 2 Body mass index categories by parity for women participating in an alternative clinical care pathway during pregnancy. Weight classa
Body mass index
Nulliparous
Multiparous
Total
Obese class 2 Obese class 3 Total
35.0–39.9 kg/m2 40.0 kg/m2 35 kg/m2
14 14 28
34 20 54
48 34 82
At 12–14 weeks gestation. a World Health Organisation.
BMI 35 kg/m2 through a rural maternity service over a 12-month period. The women accounted for over 10% of the population accessing the local antenatal care service. An important component in the evaluation of studies founded on implementation science is to measure participant responsiveness, explained as the degree to which participants engage with activities.24 Meyers et al.24 describe this as an important factor, stating that the delivery of an innovation alone does not evaluate behaviour change but that it is also affected by the participant’s uptake of the innovation. Participants were provided with education about the risks associated with being obese and pregnant, and were offered supplementary clinical care options in an effort to manage some of the risks associated with obesity in pregnancy. The most well received components of the alternative care pathway were the foetal growth ultrasound scans and pre-labour anaesthetic consultation, according to participation rates. The alternative care components that had the poorest rates of uptake were the recommended serial self-weighing (no woman completed this component) and a consultation with the dietitian (13% participation). Despite the additional clinical care that was offered, the participants still had a very high rate of birth by caesarean section. A low-risk pregnant woman who goes to term will generally have at least 12 appointments associated with her antenatal care. Hence, adding in further antenatal care options may not be appealing, especially if women are working, already have young children, do not drive or have access to a private vehicle and/or having other important demands on their time. One of the reasons more women participated in the anaesthetics consultation may have been because they were called with an available booking, compared to the dietetic consultation which required them to book their own appointment. They may also have perceived greater potential benefits in finding out about pain management options. The self-weighing component of the alternative care pathway could perhaps have been improved by providing women with a weight diary and/or having a dedicated room where women could weigh themselves in private. Wadden and Foster25 suggest that Table 3 Additional clinical care options for obese pregnant women participating in a quality improvement project. Alternative care component
Offered (n)
Received (n)
% Received
Education on obesity in pregnancy Dietetic consultation covered by Medicare Screening for gestational diabetesa 16–18 weeks gestation 26–28 weeks gestation Renal and liver function tests Self-weighing Serial ultrasounds 28 weeks gestation 32 weeks gestation 36 weeks gestation 28, 32, and 36 week scans Anaesthetic consultation
82 82
82 13
100 16
80 77 82 82
39 73 60 0
49 95 73 0
79 79 79 79 79
62 69 63 43 66
78 87 80 54 84
a 75 g oral glucose tolerance test. Two women had pre-existing diabetes at their first antenatal visit and did not undergo further screening.
Table 4 Mode of birth for obese pregnant women participating in a quality improvement project. Mode of Birth
Normal vaginal Instrumental Emergency caesarean Elective caesarean
Nulliparous (n = 26)
Multiparous (n = 53)
Combined (N = 79)
n
n
n
4 6 13
15% 23% 50%
35 1 4
66% 2% 7%
39 7 17
49% 9% 22%
3
12%
13
24%
16
20%
National Referencea
56% 12% 32% combined
a
Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011. Perinatal statistics series no. 28. Cat. no. PER 59. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013.
‘getting weighed is among the most unpleasant experience for obese patients in the medical setting’. Nyman et al.26 in a qualitative study of 10 obese pregnant women with a BMI between 34 kg/m2 and 50 kg/m2 also reported negative experiences when accessing maternity care services, wishing that their weight was not the focus for caregivers. This was also reported in a similar study by Helehurst et al.27 where negative experiences from health care service personnel led to negative feelings such as low self-esteem and embarrassment. It is possible that women did not engage in regular weight measurements for fear of being embarrassed and to avoid further compounding negative feelings associated with being obese and accessing health care services. Unfortunately, it is not possible to decipher from this project whether better birth outcomes were obtained by those who engaged in a greater number of the alternative care components that were offered. There are further opportunities to assess these risk management strategies with birth outcomes for obesity in pregnancy in future studies. Since completing this quality improvement project, Queensland Health released a guideline for the management of obesity in pregnancy in 2010.28 Following this in 2012 the Australian Government released the First National Evidence-Based Antenatal Care Guidelines – Module One.29 The Queensland guidelines based on consensus from the guideline development programme members, suggest clinical management for obese pregnant women during antenatal care should include; documentation of BMI at initial antenatal visit; discuss weight gain and consider weighing obese women at each antenatal visit; increase surveillance of obese pregnant women particularly assessing for gestational diabetes at the first antenatal visit and ascertain baseline blood tests including renal and liver function.28 First and second trimester screening for congenital anomalies; detailed morphology ultrasounds and where detailed assessment cannot be made recommending serial ultrasounds.28 Anaesthetic consultation is recommended specifically for women in the 35 kg/m2 BMI category and nutritional referral is to be considered and offered for all obese women.28 The recommendations within these guidelines being similar to those developed for this project. In contrast, the Antenatal clinical practice guidelines – Module 1 (2012) make no specific recommendations or pathway for obese pregnant women.29 Recommendations are given for a woman’s height weight and BMI to be calculated at the first antenatal visit, noting that women who are obese or underweight may need additional care.29 It is also recommended that women should be given advice of appropriate gestational weight gain in relation to their BMI.29 Routine weighing is suggested to only be employed in circumstances where clinical management might be influenced.29 The difference in recommendations from both guidelines demonstrates a need for studies into the effectiveness of management strategies for these women and their babies to be conducted.29
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It is possible that obese women who present for antenatal care do not want to be identified as being ‘different’ to any other pregnant woman. As clinicians, we must be careful managing higher obstetric risks, without the stigmatisation and judgement that obese women feel throughout society.30 A qualitative project identifying the barriers to engaging in additional care perceived by obese women would provide important insight into how we can improve antenatal service delivery. 8. Conclusion This quality improvement project was planned, designed and implemented before the release of the Queensland Health and national antenatal care guidelines. The findings demonstrate that educating women about the risks associated with obesity in pregnancy does not lead to participation in health promoting strategies, including dietitian support, and weight measurement at antenatal visits. Most women took up some additional antenatal screening and an anaesthetics consultation. These results warrant further investigation using qualitative and quantitative methods. References 1. NSW Health Department. Easy Guide to Clinical Practice Improvement. Sydney: NSW Health Department; 2002. 2. Australian Government Department of Health and Ageing. Trends in women’s health: Results from the ALSWH – priority conditions, risk factors and health behaviours. Canberra: Australian Government Department of Health and Ageing; 2006. 3. Cunningham C, Teale G. A profile of body mass index in a large rural Victorian obstetric cohort. Med J Aust 2013;198(1):39–42. 4. Dodd J, Grivell R, Nguyen A, Chan A, Robinson J. Maternal and perinatal health outcomes by body mass index category. Australian & New Zealand Journal of Obstetrics & Gynaecology 2011;51:136–40. 5. Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011 perinatal statistics series. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013. 6. Smith S, Hulsey T, Goodnight W. Effects of obesity on pregnancy. J Obstet Gynaecol Neonatal Nurs 2008;37:176–84. 7. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, et al. Maternal obesity and pregnancy outcome: a study of 287 213 pregnancies in London. Int J Obes 2001:1175–82. 8. Flenady V, Koopmans L, Middleton P, Froen JF, Smith GC. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011;377:1331–40. 9. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and caesarean delivery rate – a population based screening study. Am J Obstet Gynaecol 2004;190:1091–7.
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10. Hibbard J, Gilbert S, Landon M, Hauth J, Leveno K, Spong C, et al. Trial of labour or repeat caesarean delivery in women with morbid obesity and previous caesarean delivery. Am Coll Obstet Gynaecol 2006;108(1):125–33. 11. Stothard K, Tennant P, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies. a systematic review and meta-analysis. J Am Med Assoc 2009;301(6):636–50. 12. Hall LF, Neubert AG. Obesity and pregnancy. Obstet Gynaecol Surv 2005; 60(4). 13. Khoury FR, Ehrenberg HM, Mercer BM. The impact of maternal obesity on satisfactory detailed anatomic ultrasound image acquisition. J Maternal Fetal Med 2009;22:337–41. 14. Dashe J, McIntire D, Twickler D. Effect of maternal obesity on the ultrasound detection of anomalous fetus. Am Coll Obstet Gynaecol 2009:1001–7. 15. Birdsall K, Vyas S, Khazaezadeh N, Oteng-Ntim E. Maternal obesity a review of interventions. Int J Clin Pract 2009;63(3):494–507. 16. Cesario S. Obesity in pregnancy. What nurses need to know? Association Women’s Health Obstet Neonatal Nurs (AWHONN) Lifelines 2003;7(2):118–25. 17. Shirazian T, Raghavan S. Obesity and pregnancy: implications and management strategies for providers. Mt Sinai J Med 2009;76:539–45. 18. Catalano PM. Management of obesity in pregnancy. Am Coll Obstet Gynaecol 2007;109(2). 19. Catalano PM, Ehrenberg HM. The sort and long term implications of maternal obesity on the mother and her offspring. Br J Obstet Gynaecol 2006;113: 1126–33. 20. Massiah N, Kumar G. Obesity and pregnancy: a care plan for management. Internet J Gynaecol Obstet 2008;9(2). 21. Royal College of Obstetricians. Gynaecologists 53rd Study Group. Obesity and reproductive health – study group statement. 2009. 22. Eccles M, Mittman B. Welcome to implementation science. Implement Sci 2006;1(1):1–3. 23. Newhouse R, Bobay K, Dykes P, Stevens K, Titler M. Methodology issues in implementation science. Med Care 2013;51(4):s32–40. 24. Meyers D, Katz J, Chein V, Wandersman A, Scaccia J, Wright A. Practical implementation science: developing and piloting the quality implementation tool. Am J Commun Psychol 2012;50:481–96. 25. Wadden T, Foster G. Behavioural treatment of obesity. Med Clin North Am 2000;84(2):1–15. 26. Nyman NMK, Prebensen AK, Flensne GEM. Obese women’s experience of encounters with midwives and physicians during pregnancy and childbirth. Midwifery 2010;26:424–9. 27. Heslehurst N, Russell S, Brandon H, Johnso C, Summerbell C, Rankin J. Women’s perspectives are required to inform the development of maternal obesity services: a qualitative study of obese pregnant women’s experiences. Health Expect 2013:1–13. 28. Queensland Maternity. Neonatal Clinical Guidelines Program. Queensland maternity and neonatal guideline: obesity. Brisbane: Queensland Health; 2010: 1–20. 29. Australian Health Ministers Advisory Council. Clinical practice guidelines: antenatal care – module 1. Canberra: Australian Government Department of Health & Ageing; 2012. 30. Lewis S, Thomas SL, Hyde J, Castle D, Blood RW, Komesaroff PA. ‘‘I don’t eat a hamburger and large chips every day!’’ A qualitative study of the impact of public health messages about obesity on obese adults. BMC Public Health 2010;4(10).
Contents lists available at ScienceDirect
Women and Birth journal homepage: www.elsevier.com/locate/wombi
Original Research – Quantitative
Developing a clinical care pathway for obese pregnant women: A quality improvement project Shanna Fealy a,b,*, Alexis Hure b, Graeme Browne b, Carol Prince a a b
Port Macquarie Base Hospital, Wrights Road, NSW, Australia The University of Newcastle, University Drive, Callaghan, NSW, Australia
A R T I C L E I N F O
Article history: Received 24 June 2014 Received in revised form 22 August 2014 Accepted 1 September 2014 Keywords: Obesity Pregnancy Risks Management Implementation Science
A B S T R A C T
Problem: Obesity in pregnancy is associated with an increased incidence of maternal and foetal morbidity and mortality, from conditions like preeclampsia, gestational diabetes, preterm birth and stillbirth. Between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) 30 kg/m2, defined as obesity in pregnancy. These figures are concerning for midwifery and obstetric staff directly involved in the clinical care of these women and their families. In the absence of national or state clinical practice guidelines for managing the risks for obese pregnant women, a local quality improvement project was conducted. Aim: To plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a BMI 35 kg/m2 at their first antenatal visit. Project setting: The project was undertaken in the antenatal clinic of a rural referral hospital in NSW, Australia. Subjects: Eighty-two women with a BMI 35 kg/m2 were eligible for the alternative care pathway, offered between January and December 2010. Intervention: The alternative care pathway included the following options, in addition to usual care: written information on obesity in pregnancy, referral to a dietitian, early plus repeat screening for gestational diabetes, liver and renal function pathology tests, serial self-weighing, serial foetal growth ultrasounds, and a pre-labour anaesthetic consultation. Findings: Despite being educated on the risk associated with obesity in pregnancy, women did not take up the offers of dietetic support or self-weighing at each antenatal visit. Ultrasounds were well received and most women underwent gestational diabetes screening. Crown Copyright ß 2014 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
1. Background to the problem Midwifery and obstetric staff within a rural tertiary hospital facility regularly engage in clinical reviews of maternity consumer case studies. In 2009, the cases of four obese women who experienced significant adverse birth and post-natal outcomes, including caesarean section wound breakdown and Intensive Care admissions, were discussed. Clinician concerns prompted a review of the clinical management for obese pregnant women. In 2009, no Australian or state clinical practice guidelines addressing risk
* Corresponding author at: 28 Sapphire Drive Port, Macquarie, NSW 2444, Australia. Tel.: +61 0415601169. E-mail addresses: [email protected], [email protected] (S. Fealy).
management for obesity in pregnancy existed. Therefore, this evidence-practice gap became the focus of a year-long quality improvement project, which started by reviewing the available literature. 2. Search strategy A literature search was conducted to understand the extent of the problem of obesity in pregnancy and identify existing guidelines and strategies addressing the antenatal care for obese pregnant women. Keyword search terms were used including ‘obesity’ AND ‘pregnancy*’, AND ‘management’, OR ‘risks’. The initial search was run between January and June 2009, with the search updated after completing the project, in May 2014. Databases searched included OVID, Medline, CINAHL, Embase, Proquest, PubMed, Cochrane
http://dx.doi.org/10.1016/j.wombi.2014.09.001 1871-5192/Crown Copyright ß 2014 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives. All rights reserved.
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S. Fealy et al. / Women and Birth 27 (2014) e67–e71
Collaboration, Science Direct, Nursing Consult and New South Wales Health Clinical Information Access Programme (CIAP). Guidelines, policies, and protocols were sought through additional searches of relevant health information websites including UpToDate, NSW Health Department, and Australian Government health service. 3. Background literature Obesity has become a global epidemic that is linked to many serious health problems including the development of chronic disease such as diabetes, hypertensive disorders, coronary heart disease and stroke.1 In Australia, over 50% of the adult population are overweight or obese.2 In an analysis of the South Australian maternal and perinatal health database, Dodd et al.4 reported that 50% of pregnant women were overweight or obese, with a slightly higher incidence among rural pregnant women (54.4%).3 Cunningham and Teale3 specifically looked at maternal overweight and obesity in rural Victoria, reporting an alarming prevalence of 65% among more than 6000 pregnant women.4 The Australian Longitudinal Study on Women’s Health predicts that approximately 60% of Australian women of childbearing age will be obese by 2050, with young women gaining weight faster than any other age group.2 The Australia’s Mothers and Babies 2011 report indicates that between 20% and 25% of pregnant women in Australia are presenting to their first antenatal appointment with a body mass index (BMI) 30 kg/m2, defined as obesity in pregnancy.5 Smith et al.6 explains the pathophysiology of obesity stating that ‘obesity represents a state of altered hormonal and inflammatory activity associated with the function of fatty tissue’. It is thought that this hyper-inflammatory state clinically manifests conditions such as hypertension, glucose intolerance, insulin resistance, elevated cholesterol and triglycerides.6 During the course of normal pregnancy insulin resistance increases up to 60%, facilitating the transfer of nutrition and energy from mother to baby. Hence, any underlying impairment in insulin sensitivity and insulin resistance due to pre-existing metabolic syndrome is likely to be exacerbated during pregnancy.6,7 In a large retrospective study of 287,213 completed singleton pregnancies, Sebire et al.7 found that obese women (BMI 30 kg/ m2) had an increased occurrence of pregnancy and birth complications than women within the healthy weight range, which they defined as a BMI 20–24.9 kg/m2.7 Complications include gestational diabetes (3.6% vs. 0.8%), preeclampsia (1.4% vs. 0.7%), induction of labour (24.6% vs. 15.3%), birth by emergency caesarean section (13.4% vs. 7.8%), postpartum haemorrhage (17.1% vs. 10.4%), wound infection (1.3% vs. 0.4%), infant birth weight above 90th centile (17.5% vs. 9.0%) and stillbirth (0.7% vs. 0.4%).7 More recently, Flenady et al.8 have shown that maternal overweight and obesity (BMI >25 kg/m2) was the highest ranking modifiable risk factor for stillbirths. In their systematic review and meta-analysis Flenady et al.8 calculated population attributable risks of 8–18% across the five countries, contributing around 8000 stillbirths (22 weeks gestation) annually across all highincome countries.8 Many other studies have demonstrated the same association between a high BMI and increased risk of common adverse pregnancy outcomes like gestational diabetes, gestational hypertension and caesarean births.9 One study, on a less frequently reported outcome, was a trial of labour after a previous caesarean section.10 Hibbard et al.10 reported that approximately 40% of morbidly obese (BMI 35 kg/m2) women were unsuccessful in their trial of labour following a previous caesarean section, compared to 15% of normal weight women. Foetal anomalies are also more common with obesity during pregnancy. A systematic review and meta-analysis found that
obese women were at significantly higher risk of pregnancies affected by: neural tube defects (OR 1.9, 95% CI 1.6, 2.2), including spina bifida (OR 2.2, 95% CI 1.9, 2.7); cardiovascular anomalies (OR 1.3, 95% CI 1.1, 1.5); septal anomalies (OR 1.2, 95% CI 1.1, 1.3); cleft lip and palate (OR 1.2, 95% CI 1.0, 1.4); anorectal atresia (OR 1.5, 95% CI 1.1, 2.0); hydrocephaly (OR 1.7, 95% CI 1.2, 2.4); and limb reduction anomalies (OR 1.3, 95% CI 1.0, 1.7).11 Hall and Neubert12 explain that the reason neural tube defects may be more prominent in obese women, is due to poor absorption and decreased serum folic acid levels as a result of impaired metabolic functioning, with lower levels of folic acid reaching the developing embryo. Detection of foetal anomalies by ultrasound is less reliable in obese pregnant women with obese women at twice the risk of having suboptimal visualisation of detailed foetal anatomy than normal weight women.13 A similar study reported that detecting foetal anomalies decreased with an increasing BMI.14 In light of these increased risks for obese pregnant women and their babies, many recommendations have been suggested throughout the literature. These recommendations include: assessment of weight and BMI at the first antenatal visit; stringent weighing of women at each antenatal visit; early glucose tolerance testing and universal testing at 26–28 weeks gestation; counselling about miscarriage, stillbirth, hypertension, diabetes, and nutrition; referral to a dietitian; detailed growth and anomaly ultrasound scans; anaesthetic consultation; and early evaluation of maternal kidney, cardiac and liver function due to the high incidence of hypertension and preeclampsia.15–21 The aim of our project was to plan, implement, and evaluate the impact of an alternative clinical care pathway for pregnant women with a body mass index (BMI) 35 kg/m2 at their first antenatal visit. Given that women with the highest BMI have the highest risks reported throughout the literature, it was considered reasonable to focus our limited resources on women with a BMI 35 kg/m2. It was anticipated that by providing these women with education and clinical care about managing the risks associated with being obese that we would detect complications earlier and reduce their impact. Implementation science, the study of methods that facilitate the uptake of research findings and evidence-based practices into routine health care, forms the foundations for this study.22,23 This body of research recognises that bridging the gap between theory and clinical practice can be difficult and requires an understanding of the uniqueness of the health systems in which changes are to be implemented.24 As a result, the NSW quality improvement methodology was adopted to guide the project team. 4. Site and participants The project was conducted within a rural maternity unit comprising of a 19-bed maternity ward, 3-bed birthing unit, level two special-care nursery and publicly funded antenatal clinic. In 2009, a total of 796 babies were born at the hospital. All women attending antenatal clinic for their first trimester antenatal clinic visit had their height and weight measured, and BMI calculated. Eighty-two women with a BMI 35 kg/m2 were identified between January 2010 and December 2010. A project team including a clinical midwifery consultant, a clinical midwifery specialist, four consultant obstetricians and one dietitian was formed. The chief investigators responsible for overall project planning, design, implementation and evaluation were the clinical midwifery consultant and clinical midwifery specialist. 5. Methods This study utilised a NSW public health service quality project methodology.3 This design uses a five-step process including.
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1. The Planning Phase, that identifies the problem and who will be involved3; 2. The Diagnostic Phase, that assists researchers to clarify the extent of the problem through gathering evidence and identifying strategies to address the problem3; 3. The Intervention and Testing Phase, where the identified strategies are implemented following a Plan, Do, Study, Act cycle3; 4. The Impact and Implementation Phase, where strategies are implemented and review of the effects of the strategies are recorded; and 5. The Evaluation and Sustainability Phase, which involves the continued monitoring of changes and sustaining of improvements.3
5.1. The Planning Phase This phase involved data collection by clinical review of case studies and literature review. The findings were presented to clinicians at the monthly maternity clinical risk meeting in July 2009. The information contained in the review evaluated the extent of the problem and quantified the increases in morbidity and mortality amongst obese pregnant woman. A survey of antenatal women exploring their knowledge of risks associated with obesity and exploring their views on the appropriateness of addressing obesity in pregnancy was also considered. Based on the data presented from the clinical audit, literature review and surveys, the project team recommended that a clinical practice improvement project be undertaken. 5.2. The Diagnostic Phase The project team considered that the most appropriate way to address risks associated with obesity in pregnancy was by devising an alternative antenatal care pathway for pregnant women with a BMI 35 kg/m2. These women were seen in the literature to be at greatest risk for pregnancy complications. 5.3. The Intervention and Testing Phase Following the Plan, Do, Study, Act process, a draft pathway was developed.3 The pathway was presented at a planning meeting for the project team to discuss and make comment. Following this meeting the additional care strategies were endorsed as an alternative pathway for pregnant women with a BMI 35 kg/m2 (Table 1).
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identified as eligible for participation in the pathway. These women had their medical record number, gravida, parity, due date, and BMI recorded in a spreadsheet. Participation in each of the individual components of the alternate clinical care pathway was recorded progressively by the project’s clinical midwifery consultant. Birth data was accessed from the Obstetrix database. 5.5. Ethical considerations Permission to initiate this project was sought from the hospital’s quality improvement department and approval was granted by the Director of Nursing and the Midwifery Unit Manager in December 2009. Health service ethics approval was not required. Women were provided with information, then invited to voluntary participate in the additional care components; however, the decision to participate was left with the individual. Data were stored securely and analysed using descriptive statistics in Microsoft Excel (2010). 6. Results Eighty-two women who presented to the antenatal clinic were identified with a BMI 35 kg/m2 at their first antenatal clinic visit, representing 10.3% of all women attending the antenatal clinic. This figure is based on the total number of births being 796 for the previous year (2009). Data on BMI category and parity for participants are presented in Table 2. All women had a discussion with a consultant obstetrician, obstetric registrar, or clinical midwifery consultant on the risks associated with obesity at their first antenatal visit, where they were offered the alternate clinical care pathway outlined in Table 1. The participation rates for each component of the alternative care pathway (Table 3) varied from no woman engaging in serial self-weighing at each antenatal clinic visit to almost all women undergoing some screening for gestational diabetes. The appointment with the anaesthetist was offered to all women from at least 30 weeks gestation. Women were called when an appointment was available and were invited to accept or decline. At birth, 79 women remained engaged in the project giving a participation rate of 96.3% from initial recruitment to birth: 1 had a miscarriage, 1 had a termination and 1 had relocated to another area. Sixty-two percent of women experiencing their first pregnancy (nulliparous) birthed by caesarean section, compared to the national average of 33% for first-time mothers (Table 4). 7. Discussion 7.1. The Evaluation and Sustainability Phase
5.4. The Impact and Implementation Phase All women presenting to the antenatal clinic had their height, weight and BMI calculated. Women with a BMI 35 kg/m2 were
The literature is clear: obesity is associated with higher maternal and foetal risks during pregnancy and at birth. This quality improvement project identified 82 pregnant women with a
Table 1 Alternative clinical care pathway for obese pregnant women (BMI 35 kg/m2).
1. 2. 3. 4. 5. 6. 7. 8. 9. a b
Alternative care component
When it was provided
Discuss the risks of obesity in pregnancy and describe the alternate care pathway Provide written information: Obesity in Pregnancy: a guide for womena Provide a referral to a dietitian Offer liver and renal function pathology tests Offer self-weighing and discuss weight gain Offer an early 75 g glucose tolerance test Offer repeat 75 g glucose tolerance test Offer serial growth ultrasounds Offer a pre-labour anaesthetic consultation
First antenatal visit 12–14 weeks gestation First antenatal visit 12–14 weeks gestation First antenatal visit 12–14 weeks gestation First antenatal visit 12–14 weeks gestation Every visit 16–20 weeks gestation 26–28 weeks gestationb 28, 32 and 36 weeks gestation 30 weeks gestation
Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2008. Screening for gestational diabetes at 26–28 weeks gestation is part of routine antenatal care.
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Table 2 Body mass index categories by parity for women participating in an alternative clinical care pathway during pregnancy. Weight classa
Body mass index
Nulliparous
Multiparous
Total
Obese class 2 Obese class 3 Total
35.0–39.9 kg/m2 40.0 kg/m2 35 kg/m2
14 14 28
34 20 54
48 34 82
At 12–14 weeks gestation. a World Health Organisation.
BMI 35 kg/m2 through a rural maternity service over a 12-month period. The women accounted for over 10% of the population accessing the local antenatal care service. An important component in the evaluation of studies founded on implementation science is to measure participant responsiveness, explained as the degree to which participants engage with activities.24 Meyers et al.24 describe this as an important factor, stating that the delivery of an innovation alone does not evaluate behaviour change but that it is also affected by the participant’s uptake of the innovation. Participants were provided with education about the risks associated with being obese and pregnant, and were offered supplementary clinical care options in an effort to manage some of the risks associated with obesity in pregnancy. The most well received components of the alternative care pathway were the foetal growth ultrasound scans and pre-labour anaesthetic consultation, according to participation rates. The alternative care components that had the poorest rates of uptake were the recommended serial self-weighing (no woman completed this component) and a consultation with the dietitian (13% participation). Despite the additional clinical care that was offered, the participants still had a very high rate of birth by caesarean section. A low-risk pregnant woman who goes to term will generally have at least 12 appointments associated with her antenatal care. Hence, adding in further antenatal care options may not be appealing, especially if women are working, already have young children, do not drive or have access to a private vehicle and/or having other important demands on their time. One of the reasons more women participated in the anaesthetics consultation may have been because they were called with an available booking, compared to the dietetic consultation which required them to book their own appointment. They may also have perceived greater potential benefits in finding out about pain management options. The self-weighing component of the alternative care pathway could perhaps have been improved by providing women with a weight diary and/or having a dedicated room where women could weigh themselves in private. Wadden and Foster25 suggest that Table 3 Additional clinical care options for obese pregnant women participating in a quality improvement project. Alternative care component
Offered (n)
Received (n)
% Received
Education on obesity in pregnancy Dietetic consultation covered by Medicare Screening for gestational diabetesa 16–18 weeks gestation 26–28 weeks gestation Renal and liver function tests Self-weighing Serial ultrasounds 28 weeks gestation 32 weeks gestation 36 weeks gestation 28, 32, and 36 week scans Anaesthetic consultation
82 82
82 13
100 16
80 77 82 82
39 73 60 0
49 95 73 0
79 79 79 79 79
62 69 63 43 66
78 87 80 54 84
a 75 g oral glucose tolerance test. Two women had pre-existing diabetes at their first antenatal visit and did not undergo further screening.
Table 4 Mode of birth for obese pregnant women participating in a quality improvement project. Mode of Birth
Normal vaginal Instrumental Emergency caesarean Elective caesarean
Nulliparous (n = 26)
Multiparous (n = 53)
Combined (N = 79)
n
n
n
4 6 13
15% 23% 50%
35 1 4
66% 2% 7%
39 7 17
49% 9% 22%
3
12%
13
24%
16
20%
National Referencea
56% 12% 32% combined
a
Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011. Perinatal statistics series no. 28. Cat. no. PER 59. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013.
‘getting weighed is among the most unpleasant experience for obese patients in the medical setting’. Nyman et al.26 in a qualitative study of 10 obese pregnant women with a BMI between 34 kg/m2 and 50 kg/m2 also reported negative experiences when accessing maternity care services, wishing that their weight was not the focus for caregivers. This was also reported in a similar study by Helehurst et al.27 where negative experiences from health care service personnel led to negative feelings such as low self-esteem and embarrassment. It is possible that women did not engage in regular weight measurements for fear of being embarrassed and to avoid further compounding negative feelings associated with being obese and accessing health care services. Unfortunately, it is not possible to decipher from this project whether better birth outcomes were obtained by those who engaged in a greater number of the alternative care components that were offered. There are further opportunities to assess these risk management strategies with birth outcomes for obesity in pregnancy in future studies. Since completing this quality improvement project, Queensland Health released a guideline for the management of obesity in pregnancy in 2010.28 Following this in 2012 the Australian Government released the First National Evidence-Based Antenatal Care Guidelines – Module One.29 The Queensland guidelines based on consensus from the guideline development programme members, suggest clinical management for obese pregnant women during antenatal care should include; documentation of BMI at initial antenatal visit; discuss weight gain and consider weighing obese women at each antenatal visit; increase surveillance of obese pregnant women particularly assessing for gestational diabetes at the first antenatal visit and ascertain baseline blood tests including renal and liver function.28 First and second trimester screening for congenital anomalies; detailed morphology ultrasounds and where detailed assessment cannot be made recommending serial ultrasounds.28 Anaesthetic consultation is recommended specifically for women in the 35 kg/m2 BMI category and nutritional referral is to be considered and offered for all obese women.28 The recommendations within these guidelines being similar to those developed for this project. In contrast, the Antenatal clinical practice guidelines – Module 1 (2012) make no specific recommendations or pathway for obese pregnant women.29 Recommendations are given for a woman’s height weight and BMI to be calculated at the first antenatal visit, noting that women who are obese or underweight may need additional care.29 It is also recommended that women should be given advice of appropriate gestational weight gain in relation to their BMI.29 Routine weighing is suggested to only be employed in circumstances where clinical management might be influenced.29 The difference in recommendations from both guidelines demonstrates a need for studies into the effectiveness of management strategies for these women and their babies to be conducted.29
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It is possible that obese women who present for antenatal care do not want to be identified as being ‘different’ to any other pregnant woman. As clinicians, we must be careful managing higher obstetric risks, without the stigmatisation and judgement that obese women feel throughout society.30 A qualitative project identifying the barriers to engaging in additional care perceived by obese women would provide important insight into how we can improve antenatal service delivery. 8. Conclusion This quality improvement project was planned, designed and implemented before the release of the Queensland Health and national antenatal care guidelines. The findings demonstrate that educating women about the risks associated with obesity in pregnancy does not lead to participation in health promoting strategies, including dietitian support, and weight measurement at antenatal visits. Most women took up some additional antenatal screening and an anaesthetics consultation. These results warrant further investigation using qualitative and quantitative methods. References 1. NSW Health Department. Easy Guide to Clinical Practice Improvement. Sydney: NSW Health Department; 2002. 2. Australian Government Department of Health and Ageing. Trends in women’s health: Results from the ALSWH – priority conditions, risk factors and health behaviours. Canberra: Australian Government Department of Health and Ageing; 2006. 3. Cunningham C, Teale G. A profile of body mass index in a large rural Victorian obstetric cohort. Med J Aust 2013;198(1):39–42. 4. Dodd J, Grivell R, Nguyen A, Chan A, Robinson J. Maternal and perinatal health outcomes by body mass index category. Australian & New Zealand Journal of Obstetrics & Gynaecology 2011;51:136–40. 5. Li Z, Zeki R, Hilder L, Sullivan EA. Australia’s mothers and babies 2011 perinatal statistics series. Canberra: AIHW National Perinatal Epidemiology and Statistics Unit; 2013. 6. Smith S, Hulsey T, Goodnight W. Effects of obesity on pregnancy. J Obstet Gynaecol Neonatal Nurs 2008;37:176–84. 7. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, et al. Maternal obesity and pregnancy outcome: a study of 287 213 pregnancies in London. Int J Obes 2001:1175–82. 8. Flenady V, Koopmans L, Middleton P, Froen JF, Smith GC. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet 2011;377:1331–40. 9. Weiss JL, Malone FD, Emig D, Ball RH, Nyberg DA, Comstock CH, et al. Obesity, obstetric complications and caesarean delivery rate – a population based screening study. Am J Obstet Gynaecol 2004;190:1091–7.
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10. Hibbard J, Gilbert S, Landon M, Hauth J, Leveno K, Spong C, et al. Trial of labour or repeat caesarean delivery in women with morbid obesity and previous caesarean delivery. Am Coll Obstet Gynaecol 2006;108(1):125–33. 11. Stothard K, Tennant P, Bell R, Rankin J. Maternal overweight and obesity and the risk of congenital anomalies. a systematic review and meta-analysis. J Am Med Assoc 2009;301(6):636–50. 12. Hall LF, Neubert AG. Obesity and pregnancy. Obstet Gynaecol Surv 2005; 60(4). 13. Khoury FR, Ehrenberg HM, Mercer BM. The impact of maternal obesity on satisfactory detailed anatomic ultrasound image acquisition. J Maternal Fetal Med 2009;22:337–41. 14. Dashe J, McIntire D, Twickler D. Effect of maternal obesity on the ultrasound detection of anomalous fetus. Am Coll Obstet Gynaecol 2009:1001–7. 15. Birdsall K, Vyas S, Khazaezadeh N, Oteng-Ntim E. Maternal obesity a review of interventions. Int J Clin Pract 2009;63(3):494–507. 16. Cesario S. Obesity in pregnancy. What nurses need to know? Association Women’s Health Obstet Neonatal Nurs (AWHONN) Lifelines 2003;7(2):118–25. 17. Shirazian T, Raghavan S. Obesity and pregnancy: implications and management strategies for providers. Mt Sinai J Med 2009;76:539–45. 18. Catalano PM. Management of obesity in pregnancy. Am Coll Obstet Gynaecol 2007;109(2). 19. Catalano PM, Ehrenberg HM. The sort and long term implications of maternal obesity on the mother and her offspring. Br J Obstet Gynaecol 2006;113: 1126–33. 20. Massiah N, Kumar G. Obesity and pregnancy: a care plan for management. Internet J Gynaecol Obstet 2008;9(2). 21. Royal College of Obstetricians. Gynaecologists 53rd Study Group. Obesity and reproductive health – study group statement. 2009. 22. Eccles M, Mittman B. Welcome to implementation science. Implement Sci 2006;1(1):1–3. 23. Newhouse R, Bobay K, Dykes P, Stevens K, Titler M. Methodology issues in implementation science. Med Care 2013;51(4):s32–40. 24. Meyers D, Katz J, Chein V, Wandersman A, Scaccia J, Wright A. Practical implementation science: developing and piloting the quality implementation tool. Am J Commun Psychol 2012;50:481–96. 25. Wadden T, Foster G. Behavioural treatment of obesity. Med Clin North Am 2000;84(2):1–15. 26. Nyman NMK, Prebensen AK, Flensne GEM. Obese women’s experience of encounters with midwives and physicians during pregnancy and childbirth. Midwifery 2010;26:424–9. 27. Heslehurst N, Russell S, Brandon H, Johnso C, Summerbell C, Rankin J. Women’s perspectives are required to inform the development of maternal obesity services: a qualitative study of obese pregnant women’s experiences. Health Expect 2013:1–13. 28. Queensland Maternity. Neonatal Clinical Guidelines Program. Queensland maternity and neonatal guideline: obesity. Brisbane: Queensland Health; 2010: 1–20. 29. Australian Health Ministers Advisory Council. Clinical practice guidelines: antenatal care – module 1. Canberra: Australian Government Department of Health & Ageing; 2012. 30. Lewis S, Thomas SL, Hyde J, Castle D, Blood RW, Komesaroff PA. ‘‘I don’t eat a hamburger and large chips every day!’’ A qualitative study of the impact of public health messages about obesity on obese adults. BMC Public Health 2010;4(10).
