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Two thirds of women report experiencing weight stigma during pregnancy. Newspaper media is powerful in framing health issues. This review synthesized UK newspaper media portrayal of maternal obesity. NexisUni was searched to identify newspaper articles, published January 2010 to May 2021, reporting content on obesity during pregnancy. Framework synthesis integrated quantitative and qualitative analysis of the content of articles. There were 442 articles included (59% tabloids and 41% broadsheets). Three overarching themes with interacting sub-themes were as follows: (1) Women were blamed for their weight, risks, and NHS impact. (2) Women were solely responsible for solving obesity, gendered from school age. (3) Women with obesity were a burden on individuals (e.g., themselves, their children, and health professionals), to society, and the NHS. Catastrophizing language framed the "problem," "scale," and "public health concern" of maternal obesity, emphasizing risk, and danger and was alarmist, aggressive, and violent as to elicit fear or devalue women. Articles platformed 'expert' voices rather than women's lived experiences. This review identified that UK newspaper media negatively frames and oversimplifies the topic of maternal obesity. Exposure to blaming and alarmist messaging could increase women's guilt, stigma, and internalized weight bias. The newspaper media should be harnessed to de-stigmatize maternal obesity and promote maternal well-being.

Maternal obesity increases pregnancy-related risks. Women with a body mass index (BMI) ≥ 30 kg/m2 are considered to be at risk and should receive additional care, although approximately half will have uncomplicated pregnancies. This systematic review aimed to identify early pregnancy measures of adiposity associated with adverse maternal health outcomes. Searches included six databases, reference lists, citations, and contacting authors. Screening and quality assessment were carried out by two authors independently. Random effects meta-analysis and narrative synthesis were conducted. Seventy studies were included with a pooled sample of 89,588 women. Meta-analysis showed significantly increased odds of gestational diabetes mellitus (GDM) with higher waist circumference (WC) categories (1.40, 95% confidence interval [CI] 1.04, 1.88) and per unit increase in WC (1.31, 95% CI 1.03, 1.67). Women with GDM had higher WC than controls (mean difference [MD] 6.18 cm, 95% CI 3.92, 8.44). WC was significantly associated with hypertensive disorders, delivery-related outcomes, metabolic syndrome, and composite pregnancy outcomes. Waist to hip ratio was significantly associated with GDM, hypertensive disorders, and delivery-related outcomes. Fat mass, neck circumference, skinfolds, and visceral fat were significantly associated with adverse outcomes, although limited data were available. Our findings identify the need to explore how useful adiposity measures are at predicting risk in pregnancy, compared with BMI, to direct care to women with the greatest need.

Background Preterm (2) is increasing in women of reproductive age. Maternal obesity has been associated with adverse pregnancy outcomes including preterm and post–term birth. However, the effect sizes vary according to the subgroups of both maternal BMI and gestational age considered. The aim of this retrospective analysis was to determine the association between maternal obesity classes and gestational age at delivery. Methods A secondary data analysis of 13 maternity units in England with information on 479,864 singleton live births between 1990 and 2007. BMI categories were: underweight (2), recommended weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2) and obesity classes I (30.0–34.9 kg/m2), II (35.0–39.9 kg/m2), IIIa (40–49.9 kg/m2) and IIIb (≥50 kg/m2). Gestational age at delivery categories were: Gestational age at delivery (weeks): extreme preterm (20–27), very preterm (28–31), moderately preterm (32–36), early term (37, 38), full term (39–40), late term (41) and post–term (≥42). The adjusted odds of births in each gestational age category (compared to full-term birth), according to maternal BMI categories were estimated using multinomial logistic regression. Missing data were estimated using multiple imputation with chained equations. Results There was a J-shaped association between the absolute risk of extreme, very and moderate preterm birth and BMI category, with the greatest effect size for extreme preterm. The absolute risk of post-term birth increased monotonically as BMI category increased. The largest effect sizes were observed for class IIIb obesity and extreme preterm birth (adjusted OR 2.80, 95% CI 1.31–5.98). Conclusion Women with class IIIb obesity have the greatest risks for inadequate gestational age. Combining obesity classes does not accurately represent risks for many women as it overestimates the risk of all preterm and post-term categories for women with class I obesity, and underestimates the risk for women in all other obesity classes.

The prevalence of overweight/obesity is high among Black women in England, who also face high risks of pregnancy and childbirth complications. This study explored African migrant women’s perceptions of pre- and post-migration influences on their weight-related behaviours and weight management support during pregnancy. Interviews were conducted with women of child-bearing age from Ghana, Nigeria, and Cameroon (n = 23). Data were analysed using thematic analysis. Four themes were identified: changing dietary behaviours after migration, changing physical activity (PA) behaviours after migration, increased discourse on obesity, and weight management advice and support received. Navigating a new food environment, interactions with other populations in England, and the need to socialise influenced changes in dietary behaviours. Participants considered that living in England ‘makes you lazy’ due to its obesogenic environment, while increased discourses on obesity heightened weight awareness. Women struggled to relate to dietary advice from midwives but found PA advice useful. Relatives provided valuable support but could influence unhealthy weight-related practices. There is a need for interventions addressing gaps in weight management support for these women, especially considering their migrant backgrounds and multicultural identities. Further research is needed to understand their unique challenges, and collaborations with relatives could inform the development of effective weight management interventions.

Bariatric surgery prior to pregnancy is a significant risk factor for small for gestational age (SGA) babies. This case-control study investigated differences between mothers delivering an SGA baby following bariatric surgery, compared to those delivering an appropriate for gestational age (AGA) baby. Out of 129 babies born to mothers in the AURORA cohort study, 25 were SGA (&lt, 10th percentile) and 97 were AGA (10th–90th percentile). Higher gestational weight gain (GWG) was significantly associated with decreased odds of SGA (aOR per kg 0.92, 95% CI 0.85–0.99). According to the Institute of Medicine GWG guidelines, 44% of SGA mothers had ‘inadequate’ GWG compared to 17% of AGA mothers. Nearly half of the mothers had ‘excessive’ GWG yet still gave birth to an SGA or AGA baby. Mothers of SGA babies lost more weight following bariatric surgery (45.6 ± 14.4 kg vs. 39.0 ± 17.9 kg). Women who reported receiving nutritional advice following bariatric surgery were significantly less likely to have an SGA baby (aOR 0.15, 95% CI 0.0.4–0.55). Women with a history of bariatric surgery should be provided with specialized support before and during pregnancy to encourage adequate nutritional intake and weight gain to support healthy fetal growth.

The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper. ispartof: OBESITY REVIEWS vol:20 issue:11 pages:1507-1522 ispartof: location:England status: published

Maternal diet, physical activity (PA) behaviours, and gestational weight gain (GWG) are important for optimum health of women and their babies. This secondary analysis of the GLOWING pilot cluster trial explored these among women living with obesity in high deprivation. Pregnant women completed food frequency, PA and psychosocial questionnaires. Weights were retrieved from medical records and measured during routine appointments with midwives. Descriptive and regression analyses were stratified by obesity class. A total of 163 women were recruited, 54.0% had class 1 obesity, 25.8% class 2, 20.2% class 3, and 76.1% lived in the two most deprived quintiles. Women had suboptimal dietary intake, particularly for oily fish, fruit and vegetables. PA was predominantly light intensity, from household, care and occupational activities. Most women gained weight outside of Institute of Medicine (IOM) guideline recommendations (87.8%), women in class 3 obesity were most likely to have inadequate GWG below IOM recommendations (58.3%, p &lt, 0.01) and reduced odds of excessive GWG compared with class 1 (AOR 0.13, 95% 0.04–0.45). Deprived women with obesity have a double inequality as both increase pregnancy risks. This population requires support to meet guideline recommendations for diet, PA and GWG. Further research exploring obesity classes would inform policies and care to achieve the best pregnancy outcomes.

Obesity is a well-recognized risk factor for pregnancy complications. Most studies to date are in large cohorts, with results presented in a way that assumes all women living with obesity are at equal risk. This study investigates which women living with obesity are at higher risk of specific pregnancy complications. A systematic search of MEDLINE and Embase identified 7894 prospective or retrospective cohort studies exploring predictors of adverse outcomes among pregnant women living with obesity. Following screening, 61 studies were deemed eligible. Studies were selected if the effects of exposure to any predictor amongst pregnant women living with obesity could be collected. Maternal characteristics assessed for association with adverse outcomes included maternal age, race/ethnicity, maternal height, mode of conception, complement activation factors, and history of various comorbidities/procedures. Gestational diabetes mellitus was the most studied outcome (n = 32), followed by preterm birth (n = 29), preeclampsia (n = 27), low birthweight infants (n = 20), small for gestational age newborns (n = 12), and stillbirth (n = 7). This review identified important characteristics that should be considered during the screening and follow-up sessions of pregnant women living with obesity, including pre-existing type 1 diabetes, maternal age < 20 years or ≥35 years, non-White ethnicity, abdominal adiposity obesity, and history of bariatric surgery.

Eating behaviors and other lifestyle habits have a major role to play in optimizing the health (and obesity control) of women. Wider sociocultural influences of income, gender, employment, ethnicity, marital status, as well as parenting will have lifelong influences on eating behaviors alongside the efforts of the food industry to promote consumption. Individual-level influences, including many psychosocial factors, will impact on immediate health behaviors, and intervention programs need to embrace factors such as access, perceived control, and social support as well as educational initiatives to help women achieve healthy lifestyles.

Background Late access to antenatal care increases risks of adverse outcomes including maternal and perinatal mortality. There is evidence that BMI influences patient engagement with health services, such as cancer screening services and delayed access to treatment; this association has not been fully explored in the context of antenatal care. This study investigated the association between the stage of pregnancy women access antenatal care, BMI, and other socio-demographic factors. Methods Retrospective analysis of routine hospital data from 34 NHS maternity units in England, UK, including 619,502 singleton births between 1989 and 2007. Analyses used logistic regression to investigate the association between maternal BMI categories and stage of pregnancy women accessed antenatal care. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were used to estimate associations, adjusting for maternal age, ethnic group, parity, Index of Multiple Deprivation score and employment status. The primary outcome was late access to antenatal care (>13+6 weeks). Secondary outcomes were trimester of access, and the association between late access and other socio-demographic variables. Results Women with an overweight or obese BMI accessed antenatal care later than women with a recommended BMI (aOR 1.11, 95%CI 1.09–1.12; aOR 1.04, 95%CI 1.02–1.06 respectively), and underweight women accessed care earlier (aOR 0.77, 95%CI 0.74–0.81). Women with obesity were 42% more likely to access care in the third trimester compared with women with a recommended BMI. Additional significant socio-demographic associations with late access included women from minority ethnic groups, teenagers, unemployment and deprivation. The greatest association was observed among Black/Black British women accessing care in the third trimester (aOR 5.07, 95% CI 4.76, 5.40). Conclusions There are significant and complex socio-demographic inequalities associated with the stage of pregnancy women access maternity care, particularly for women with obesity accessing care very late in their pregnancy, and among BME groups, teenagers, deprived and unemployed women. These populations are at increased risk of adverse maternal and fetal outcomes and require support to address inequalities in access to antenatal care. Interventions to facilitate earlier access to care should address the complex and inter-related nature of these inequalities to improve pregnancy outcomes among high-risk groups. Electronic supplementary material The online version of this article (10.1186/s12884-017-1475-5) contains supplementary material, which is available to authorized users.

Background There is a global obesity crisis, particularly among women and disadvantaged populations. Early-life intervention to prevent childhood obesity is a priority for public health, global health, and clinical practice. Understanding the association between childhood obesity and maternal pre-pregnancy weight status would inform policy and practice by allowing one to estimate the potential for offspring health gain through channelling resources into intervention. This systematic review and meta-analysis aimed to examine the dose–response association between maternal body mass index (BMI) and childhood obesity in the offspring. Methods and findings Searches in MEDLINE, Child Development & Adolescent Studies, CINAHL, Embase, and PsycInfo were carried out in August 2017 and updated in March 2019. Supplementary searches included hand-searching reference lists, performing citation searching, and contacting authors. Two researchers carried out independent screening, data extraction, and quality assessment. Observational studies published in English and reporting associations between continuous and/or categorical maternal and child BMI or z-score were included. Categorical outcomes were child obesity (≥95th percentile, primary outcome), overweight/obesity (≥85th percentile), and overweight (85th to 95th percentile). Linear and nonlinear dose–response meta-analyses were conducted using random effects models. Studies that could not be included in meta-analyses were summarised narratively. Seventy-nine of 41,301 studies identified met the inclusion criteria (n = 59 cohorts). Meta-analyses of child obesity included 20 studies (n = 88,872); child overweight/obesity, 22 studies (n = 181,800); and overweight, 10 studies (n = 53,238). Associations were nonlinear and there were significantly increased odds of child obesity with maternal obesity (odds ratio [OR] 3.64, 95% CI 2.68–4.95) and maternal overweight (OR 1.89, 95% CI 1.62–2.19). Significantly increased odds were observed for child overweight/obesity (OR 2.69, 95% CI 2.10–3.46) and for child overweight (OR 1.80, 95% CI 1.25, 2.59) with maternal obesity. A limitation of this research is that the included studies did not always report the data in a format that enabled inclusion in this complex meta-analysis. Conclusions This research has identified a 264% increase in the odds of child obesity when mothers have obesity before conception. This study provides substantial evidence for the need to develop interventions that commence prior to conception, to support women of childbearing age with weight management in order to halt intergenerational obesity., Nicola Heslehurst and colleagues highlight the association between childhood obesity and maternal pre-pregnancy weight status., Author summary Why was this study done? Obesity is a leading cause of lifelong poor health globally, and is significantly associated with inequalities. Capitalising on opportunities for early-life prevention of obesity is a priority for public health, global health, and clinical practice. This research aimed to estimate the extent to which mothers’ pre-pregnancy body mass index was associated with the weight status of their children, and hence the extent to which this life course stage may be an opportunity for obesity prevention. What did the researchers do and find? This systematic review included 79 studies from international settings that investigated maternal pre-pregnancy body mass index and childhood weight status. Meta-analysis identified that maternal pre-pregnancy obesity was significantly associated with child obesity (OR 3.64, 95% CI 2.68–4.95; n = 88,872), child overweight/obesity combined (OR 2.69, 956% CI 2.10–3.46; n = 181,800), and child overweight (OR 1.80, 95% CI 1.25–2.59; n = 53,238). Meta-regression found increasing odds of child obesity with increasing child age. What do these findings mean? Our finding of 264% increased odds of child obesity when mothers have pre-pregnancy obesity suggests that commencing obesity prevention interventions prior to conception would be beneficial. This research adds to the substantial evidence base that the causes of obesity involve a complex interplay between in utero and life course exposures, which may unequally affect those with a predisposition to obesity. Little attention has been given to the preconception period among obesity prevention interventions to date; attention to this period may help to address the complex early-life inequalities associated with obesity development.

Aims To describe national implementation of gestational diabetes (GDM) risk-factor based screening guidelines, and barriers to implementation relating to maternal body mass index (BMI). Methods National online survey of NHS Trusts offering maternity services in England. A questionnaire was emailed to clinical staff involved in care of pregnant women assessing compliance with NICE guidelines for risk-factor based screening, BMI thresholds for offering OGTT and barriers to offering OGTT to women with BMI ≥ 30 kg/m 2 . Results Health professionals from 113 (84%) of NHS Trusts in England responded to the survey. Most Trusts (81%) offered OGTT at 26–28 weeks gestation to women with selected risk factors for GDM. However, almost 40% of Trusts were not fully compliant with NICE screening criteria for all risk factors, mainly due to not offering OGTT to women with previous GDM (25% of Trusts), BMI ≥ 30 kg/m 2 or ethnic minority groups (22% of Trusts). The main barriers to compliance with the BMI threshold were lack of capacity, resource and funding given the high prevalence of maternal obesity. Forty one percent of Trusts used diagnostic thresholds for GDM which differed from NICE recommendations. Conclusions Additional resources are required for NHS Trusts to fully implement and sustain risk-factor screening, especially for women with previous GDM, BMI ≥ 30 kg/m 2 and ethnic minority groups.

Background Weight management in pregnancy guidelines exist, although dissemination alone is an ineffective means of implementation. Midwives identify the need for support to overcome complex barriers to practice. An evaluation of an intervention to support midwives’ guideline implementation would require a large-scale cluster randomised controlled trial. A pilot study is necessary to explore the feasibility of delivery and evaluation prior to a definitive trial. The GestationaL Obesity Weight management: Implementation of National Guidelines (GLOWING) trial aims to test whether it is feasible and acceptable to deliver a behaviour change intervention to support midwives’ implementation of weight management guidelines. Methods GLOWING is a multi-centre parallel group pilot cluster randomised controlled trial comparing the delivery of a behaviour change intervention for midwives versus usual practice. Four NHS Trusts (clusters) will be randomised to intervention and control arms, stratified by size of maternity services. The intervention uses social cognitive theory and consists of face-to-face midwifery training plus information resources for routine practice. The main outcomes are whether the intervention and trial procedures are feasible and acceptable to participants and the feasibility of recruitment and data collection for a definitive trial. Target recruitment involves all eligible midwives in the intervention arm recruited to receive the intervention, 30 midwives and pregnant women per arm for baseline and outcome questionnaire data collection and 20 midwives and women to provide qualitative data. All quantitative and qualitative analyses will be descriptive with the purpose of informing the development of the definitive trial. Discussion This pilot study has been developed to support community midwives’ implementation of guidelines. Community midwives have been selected as they usually carry out the booking appointment which includes measuring and discussing maternal body mass index. A cluster design is the gold standard in implementation research as there would be a high risk of contamination if randomisation was at individual midwife level: community midwives usually work in locality-based teams, interact on a daily basis, and share care of pregnant women. The results of the pilot trial will be used to further develop and refine GLOWING prior to a definitive trial to evaluate effectiveness and cost-effectiveness. Trial registration ISRCTN46869894; retrospectively registered 25th May 2016. Electronic supplementary material The online version of this article (10.1186/s40814-018-0241-4) contains supplementary material, which is available to authorized users.

Background Maternal obesity is a challenge for clinical practice due to high prevalence and adverse outcomes for women and offspring. Health professionals have to manage the clinical risks while simultaneously promoting public health recommendations for healthy behaviors and weight management. Methods Part 1 reviews the evidence-base on maternal obesity and gestational weight gain (GWG), including definitions, population trends, inequalities, guidelines, and the potential mechanisms for adverse outcomes of pregnancy. Part 2 provides a reflective account of the challenges of caring for pregnant women with obesity based on an obstetrician’s experience of working in North East England, within a deprived area with a high obesity prevalence. Results Part 1: Between 10%–30% of pregnant women are reported to be obese internationally. Prevalence is highest among deprived and minority ethnic populations. Risks include maternal and perinatal mortality, gestational diabetes, preeclampsia, congenital anomalies, and offspring obesity. There are potential mechanical and hormonal causes of adverse outcomes, and a lack of clarity on appropriate GWG. Part 2: Clinical challenges arise from preconception to postnatal periods. There are challenges engaging women with preconception care to lose weight before pregnancy. Health services need to prepare for future increases in maternal obesity to manage the challenges and provide the best care for women and their babies. Conclusions Maternal obesity poses significant risks to women and offspring, and the challenges to practice are not uncommon. Prevention and management is both a public health and clinical priority due to associated inequalities and the impact on the health of women and offspring.

A woman who is healthy at the time of conception is more likely to have a successful pregnancy and a healthy child. We reviewed published evidence and present new data from low-income, middle-income, and high-income countries on the timing and importance of preconception health for subsequent maternal and child health. We describe the extent to which pregnancy is planned, and whether planning is linked to preconception health behaviours. Observational studies show strong links between health before pregnancy and maternal and child health outcomes, with consequences that can extend across generations, but awareness of these links is not widespread. Poor nutrition and obesity are rife among women of reproductive age, and differences between high-income and low-income countries have become less distinct, with typical diets falling far short of nutritional recommendations in both settings and especially among adolescents. Several studies show that micronutrient supplementation starting in pregnancy can correct important maternal nutrient deficiencies, but effects on child health outcomes are disappointing. Other interventions to improve diet during pregnancy have had little effect on maternal and newborn health outcomes. Comparatively few interventions have been made for preconception diet and lifestyle. Improvements in the measurement of pregnancy planning have quantified the degree of pregnancy planning and suggest that it is more common than previously recognised. Planning for pregnancy is associated with a mixed pattern of health behaviours before conception. We propose novel definitions of the preconception period relating to embryo development and actions at individual or population level. A sharper focus on intervention before conception is needed to improve maternal and child health and reduce the growing burden of non-communicable diseases. Alongside continued efforts to reduce smoking, alcohol consumption, and obesity in the population, we call for heightened awareness of preconception health, particularly regarding diet and nutrition. Importantly, health professionals should be alerted to ways of identifying women who are planning a pregnancy. This is the first in a Series of three papers about preconception health.

Objective to understand the lived experiences and views of being referred to an antenatal dietetic service from the perspective of pregnant women with obesity. Design a qualitative, interpretive approach using one-to-one in-depth interviews to explore the lived experience of pregnant women with obesity following referral to an antenatal dietetics service. Thematic content analysis was carried out by two researchers independently to develop data-driven themes. Setting one NHS Trust maternity and dietetic services, North East England, UK. Participants fifteen pregnant women with a booking body mass index ≥30kg/m 2 attending an obesity-specific antenatal dietetic service. All women were White, parity between 0 and 2, and BMI range 30–51kg/m 2 . Findings four themes were identified. (1) Women's overall experience of the service: experiences were predominately positive with only two negative cases identified. (2) Process of referral: women placed importance on informative and in-person communication about the service, with health professionals, at the point of referral. (3) Delivery of the service: dietitians were considered to be the experts and women wanted more frequent contact. (4) Content of the service: tailored advice enabled behaviour change, and women desired increased physical activity support and weight monitoring. Key conclusions women reported an overall positive experience and thought that dietitians were the expert health professionals to support them. Women in this study felt that tailoring advice specific to their personal circumstances helped them implement changes, and had a strong interest in the nutritional benefits for fetal development. Women considered weight monitoring to be a positive element of the service; however, further research is required given the limited and conflicting evidence-base. Implications for practice it is important to incorporate women's experiences in the development and delivery of antenatal weight management services to facilitate person-centred care. Communication by health professionals at the point of referral is particularly important to provide accurate expectations of services and to reduce anxieties. Dietitians are considered to be appropriate experts to deliver these services, although they may need additional support to address women's physical activity needs in pregnancy.

Objective The aim of this study was to identify trends in maternal obesity incidence over time and to identify those women most at risk and potential-associated health inequalities. Design Longitudinal database study. Setting James Cook University Hospital maternity unit, Middlesbrough, UK. Sample A total of 36 821 women from 1 January 1990 to 31 December 2004. Methods Trends in maternal obesity incidence over time were analysed using chi-square test for trend. Demographic predictor variables were analysed using multivariate logistic regression, adjusting for confounding factors after testing for multicollinearity. National census data were used to place the regional data into the context of the general population. Main outcome measure Trends in maternal obesity incidence. Demographic predictor variables included ethnic group, age, parity, marital status, employment and socio-economic disadvantage. Results The proportion of obese women at the start of pregnancy has increased significantly over time from 9.9 to 16.0% (P < 0.01). This is best described by a quadratic model (P < 0.01) showing that the rate is accelerating; by 2010, the rate will have increased to 22% of this population if the trend continues. There is also a significant relationship with maternal obesity and mothers' residing in areas of most deprivation (odds ratio [OR] = 2.44, 95% CI = 1.98, 3.02, P < 0.01), with increasing age (OR = 1.04, 95% CI = 1.04, 1.05, P < 0.01), and parity (OR = 1.17, 95% CI = 1.12, 1.21, P < 0.01). Conclusions The incidence of maternal obesity at the start of pregnancy is increasing and accelerating. Predictors of maternal obesity are associated with health inequalities, particularly socio-economic disadvantage.

Objective: To gain a detailed understanding of healthcare professionals' perceptions of the impact that caring for obese pregnant women has on maternity services. Design: Qualitative interview study using purposeful sampling and face-to-face interviews. Setting: Sixteen maternity units in NHS Trusts in the North East Government Office Region of England, UK. Sample: Thirty-three maternity and obstetric healthcare professionals with personal experience of managing the care of obese pregnant women. Methods: Semi-structured interviews with healthcare professionals representing each maternity unit in the region. Transcripts were analysed using systematic content analysis. Main outcome measures: Views on the impact maternal obesity has on maternity services, the facilities required to care for obese mothers in pregnancy, and existing services directed towards maternal obesity. Results: Five dominant themes relating to service delivery emerged; booking appointments, equipment, care requirements, complications and restrictions, and current and future management of care. Many of the issues identified were associated with managing the care of obese women in pregnancy safely, resources and cost issues to be able to do this, multidisciplinary care requirements because of coexisting morbidities when the mother is obese, and restricted care options and patient choice. Conclusions: Healthcare professionals in the North East of England feel that maternal obesity has a major impact on services and resource, on the health of both the mother and child, and on the psychological wellbeing of the mother

BACKGROUND: Increasing maternal obesity trends and accompanying risks have led to the development of guidelines internationally. However, the evidence-base is poor for effective intervention, and there is a lack of representation from the perspective of obese pregnant women in guidelines. Women's engagement with weight management support services is low. OBJECTIVE: To explore obese pregnant women's experiences to better understand factors which need to be considered when developing services that women will find acceptable and utilize. POPULATION: Obese women referred to an antenatal dietetic service in the Northeast of England, UK. METHODS: Low-structured depth-interviews allowed women to freely discuss their own experiences. Discussion prompts were included; however, issues that women raised were explored thoroughly. Women summarized what they considered most important to ensure the analyses placed appropriate emphasis on factors women perceived as important. Thematic analysis identified common themes. Saturation was confirmed after 15 interviews. RESULTS: Key issues included: women's weight; families; experience of negativity; and priorities and desired outcomes. These combined represented women's perspectives of issues which they considered important and integral to their lived experience of being obese and pregnant. The theme incorporates women's pregnancy-related experiences, as well as life experiences which contributed to how they felt about their weight during pregnancy. CONCLUSIONS: There are strong associations with women's lived experiences and engagement with antenatal weight management services. Incorporating women's perspectives in the development of these services could encourage engagement by focussing on women's priorities and motivations, while taking into consideration their socially related experiences in addition to their clinical health needs.

Background There has been a rapid increase in the publication of guidelines for managing obesity and weight gain during pregnancy over the past five years. Healthcare professionals have identified multiple barriers to this area of practice, including the need to improve their communication skills, beliefs that pregnant women will have negative reactions to weight-related discussions, and a lack of weight management knowledge. This systematic review aimed to identify: the effectiveness of interventions in changing healthcare professionals’ practice relating to maternal obesity or weight management during pregnancy; and which behaviour change techniques and modes of intervention delivery have been used in interventions to date. Findings The search strategy included searching electronic databases, trial registers, and citation searching. Inclusion criteria were intervention studies targeted towards changing healthcare professionals’ practice in relation to maternal obesity or weight management. The searches identified 3,608 studies. However, no eligible completed studies were identified. One registered Canadian randomised controlled trial was identified. The trial includes a training intervention for family physicians with the aim of supporting adherence to gestational weight gain guidelines. The trial had not yet commenced therefore no effectiveness data were available. Conclusions The current focus of maternal obesity and weight management research is targeted towards changing pregnant women’s behaviours. These interventions do not address the multiple healthcare professionals’ barriers to maternal obesity and weight management practice. Further research is required to identify the most effective approaches to support healthcare professionals to implement maternal obesity and weight management guidelines into practice. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0097-9) contains supplementary material, which is available to authorized users.

Background:\ud Asians are at increased risk of morbidity at a lower body mass index (BMI) than European Whites, particularly relating to metabolic risk. UK maternal obesity guidelines use general population BMI criteria to define obesity, which do not represent the risk of morbidity among Asian populations. This study compares incidence of first trimester obesity using Asian-specific and general population BMI criteria.\ud \ud Method:\ud A retrospective epidemiological study of 502,474 births between 1995 and 2007, from 34 maternity units across England. Data analyses included a comparison of trends over time between ethnic groups using Asian-specific and general population BMI criteria. Logistic regression estimated odds ratios for first trimester obesity among ethnic groups following adjustment for population demographics.\ud \ud Results:\ud Black and South Asian women have a higher incidence of first trimester obesity compared with White women. This is most pronounced for Pakistani women following adjustment for population structure (OR 2.19, 95% C.I. 2.08, 2.31). There is a twofold increase in the proportion of South Asian women classified as obese when using the Asian-specific BMI criteria rather than general population BMI criteria. The incidence of obesity among Black women is increasing at the most rapid rate over time (p=0.01).\ud \ud Conclusion:\ud The twofold increase in maternal obesity among South Asians when using Asian-specific BMI criteria highlights inequalities among pregnant women. A large proportion of South Asian women are potentially being wrongly assigned to low risk care using current UK guidelines to classify obesity and determine care requirements. Further research is required to identify if there is any improvement in pregnancy outcomes if Asian-specific BMI criteria are utilised in the clinical management of maternal obesity to ensure the best quality of care is provided for women irrespective of ethnicity.

Background Post-term births and preterm births (PTBs) are associated with increased risks for both mother and baby, and have resource implications for NHS maternity services. Increased body mass index (BMI) is associated with both PTB and post-term birth. Extremely obese women (BMI ≥ 50 kg/m 2 ) and their babies have the greatest obesity-related risks in pregnancy. However, there is a lack of research in this population on gestational age at delivery. The aim of this study was to investigate the association between maternal extreme obesity and PTB and post-term birth. Methods We included women who delivered singleton live births in 16 UK maternity units between 1990–2007. We categorised gestational age at delivery as extreme PTB (20–27 weeks), very PTB (28–31 weeks), moderately PTB (32–36 weeks), early-term birth (37–38 weeks), full-term birth (39–40 weeks), late-term birth (41 weeks) and post-term birth (≥42 weeks). Women with missing gestational age at delivery (n = 53,514, 10.1%) were excluded. Maternal BMI was categorised as underweight ( 2 ), recommended weight (18.5–24.9 kg/m 2 ), overweight (25–29.9 kg/m 2 ), moderately obese (30–34.9 kg/m 2 ), severely obese (35–39.9 kg/m 2 ), morbidly obese (40–49.9 kg/m 2 ) and extremely obese). The risk of birth occurring in each gestational age category (compared to full-term birth), according to maternal BMI was estimated using Multinomial logistic regression. Models were adjusted for parity, gestational age at booking, maternal socioeconomic status, employment, ethnicity and maternal age. Missing data was imputed using multiple imputation. Results Of 477,777 women with data on gestational age at delivery, 2.7% were underweight, 46.0% were recommended weight, 21.5% were overweight, 8.1% were moderately obese, 2.9% were severely obese, 1.2% were morbidly obese and 0.1% were extremely obese. The odds of extreme PTB, very PTB, moderately PTB and post-term birth were increased in all categories of obesity, but the effect sizes were consistently highest in extremely obese women. For example, compared to recommended weight women, extremely obese women were at 2.7 times the odds of extreme PTB (95% confidence interval (CI): 1.2–6.2; p = 0.002), 1.7 times the odds of very PTB (95% CI: 0.7–4.1; p = 0.246), 2.2 times the odds of moderately PTB (95% CI: 1.6–3.0; p Conclusion While all obese women were at increased risk of PTB and post-term birth, extremely obese women were at the greatest risk, almost three times more likely to have an extreme PTB, which poses the greatest risk to the baby.

Objective to explore midwives' perceptions of their training and education requirements in relation to maternal obesity. Design an interpretive constructionist approach used focus groups and broad discussion topics to allow midwives to identify their own personal and professional needs. Data analysis incorporated researcher and data triangulation (transcripts, debrief notes, and observers' notes), using a thematic content analysis approach. Setting and participants participants included 46 community and hospital-based midwives from all NHS Trusts providing maternity services in Northeast England, UK. Eleven focus groups took place in midwives' place of work. Sampling was determined by data saturation. Findings three main themes were identified: discussing obesity, weight management, and practicalities of training. Midwives' justification for the need for training was centrally connected to all themes, and there were strong views on the need for training and education, and the potential benefits to their practice. Issues relating to obesity communication were most prominent. Midwives' uncertainty about effective obesity communication and management, and concerns of a negative impact on the midwife–woman relationship, are key barriers to their practice. Key conclusions and implications for practice the provision of a systematic approach to training and education is endorsed by midwives, and would provide the required level of knowledge and skills to deliver the recommended standard of care appropriate to their practice. It is clear that midwives require both training and education, although there are challenges to midwives' engagement with effective continuous professional development largely outside their control. Realistic models of training and education are required to address midwives' needs, and these should be thoroughly evaluated for impact on midwifery practice, and on obese women's health and well-being.

Dr Nicola Heslehurst from Teeside University and Dr Ruth Bell and Professor Judith Rankin from Newcastle University look at how pregnancy could be an opportune time to incite behavioural change to help prevent obesity development in women and children The increase in obesity in the UK population has significant implications for women of childbearing age and has recently been described as the biggest challenge for maternity services today.1 There are no pregnancy-specific BMI criteria to define maternal obesity. The BMI criteria for the general population2 are used to define obesity in early pregnancy as there is usually minimal weight gain in the first trimester. In addition to the World Health Organization (WHO) BMI categories of moderate (BMI 30-34.9 kg/m^sup 2^); severe (BMI 35-39.9 kg/m^sup 2^); and morbid (BMI ≥40 kg/m^sup 2^) obesity,2 there is an additional category used in the UK for pregnancy. A BMI ≥50 kg/m^sup 2^ in early pregnancy has been described as 'extreme obesity' or 'super morbid obesity'. This equates to approximately 92,500 pregnant women per year.3 The rest of the UK shows similar trends.1 A major public health concern is the association with health inequalities, as obese mothers are more likely to live in areas of high deprivation, be of black ethnic origin, unemployed and older than women with an ideal BMI.1,3 Most of these associations become stronger with increasing maternal BMI. For example, there is a twofold increase in moderately obese women living in areas of high deprivation compared with those residing in areas of low deprivation; this increases to an almost fivefold for extreme obesity.3 The increased risks associated with a raised BMI include stillbirth, maternal and infant mortality,4,5 and congenital anomalies that are a major contributor to childhood morbidity.6,7 Obese women are also more likely to require caesarean sections and to experience serious obstetric complications.8,9 Gestational diabetes is also more prevalent among obese women, which has long-term health implications due to an increased risk of developing type 2 diabetes for women and their children.10 Furthermore, it has been suggested that foetal exposure to maternal obesity during pregnancy may influence the development of obesity in the infant (via 'foetal programming'), although current evidence is inconclusive.11 Pregnancy also contributes towards the development of obesity through excessive gestational weight gain and postnatal weight retention. The antenatal period is an opportune time to engage women with behaviour change interventions as the health of the baby provides a powerful motivator. However, there is limited evidence on the effectiveness of interventions to change pregnant women's weight-related behaviours, as well as a lack of UK evidence-based guidelines for appropriate gestational weight gain. It is paramount that pregnant women are not encouraged to lose weight during pregnancy due to the potential related risks to the foetus, such as growth restriction and the development of congenital anomalies. Obese pregnant women should instead be advised to follow a healthy diet and be physically active.12 Further evidence from randomized controlled trials is needed to determine the safety and effectiveness of interventions to limit gestational weight gain. Discussing the implications of obesity with pregnant women is also a challenging area, with healthcare professionals feeling apprehensive about doing so. Midwives are very aware of the stigma associated with obesity and the sensitive and emotive nature makes it an uncomfortable discussion to initiate without jeopardizing their relationship with the expectant mother.13,14 The psychosocial relationship with weight for many women makes the message that 'obesity may increase pregnancy risks' a largely unwelcome one. How this issue is approached and managed by healthcare professionals is critical. Communication should be sensitively delivered to encourage continued engagement with antenatal services and to promote engagement with the appropriate public health services. …

Obesity is a public health concern worldwide, arising from multifaceted and complex causes that relate to individual choice and lifestyle, and the influences of wider society. In addition to a long-standing focus on both childhood and adult obesity, there has been more recent concern relating to maternal obesity. This review explores the published evidence relating to maternal obesity incidence and associated inequalities, the impact of obesity on maternity services, and associated guidelines. Epidemiological data comprising three national maternal obesity datasets within the UK have identified a significant increase in maternal obesity in recent years, and reflect broad socio-demographic inequalities particularly deprivation, ethnicity and unemployment. Obese pregnancies present increased risk of complications that require more resource intensive antenatal and perinatal care, such as caesarean deliveries, gestational diabetes, haemorrhage, infections and congenital anomalies. Healthcare professionals also face difficulties when managing the care of women in pregnancy as obesity is an emotive and stigmatising topic. There is a lack of good-quality evidence for effective interventions to tackle maternal obesity. Recently published national guidelines for the clinical management and weight management of maternal obesity offer advice for professionals, but acknowledge the limitations of the evidence base. The consequence of these difficulties is an absence of support services available for women. Further evaluative research is thus required to assess the effectiveness of interventions with women before, during and after pregnancy. Qualitative work with women will also be needed to help inform the development of more sensitive risk communication and women-centred services.

Obesity in pregnancy is rising and is associated with severe health consequences for both the mother and the child. There is an increasing international focus on guidelines to manage the clinical risks of maternal obesity, and for pregnancy weight management. However, passive dissemination of guidelines is not effective and more active strategies are required for effective guideline implementation into practice. Implementation of guidelines is a form of healthcare professional behaviour change, and therefore implementation strategies should be based on appropriate behaviour change theory. This systematic review aimed to identify the determinants of healthcare professionals' behaviours in relation to maternal obesity and weight management. Twenty-five studies were included. Data synthesis of the existing international qualitative and quantitative evidence base used the Theoretical Domains Framework to identify the barriers and facilitators to healthcare professionals' maternal obesity and weight management practice. The domains most frequently identified included 'knowledge', 'beliefs about consequences' and 'environmental context and resources'. Healthcare professionals' weight management practice had the most barriers compared with any other area of maternal obesity practice. The results of this review will be used to inform the development of an intervention to support healthcare professional behaviour change.

Summary Objectives This study was conducted to develop a better understanding of community-based initiatives relating to maternal obesity, and to gain community service providers’ views on maternal obesity services and their perceived role in the management and prevention of maternal obesity. Study design An interpretive constructionist approach using semi-structured interviews and focus groups. Methods Semi-structured interviews and focus groups were carried out with community service providers in the North East of England, UK. Data were analysed using thematic content analysis. Results Five dominant themes emerged: community-based obesity services, understanding maternal obesity services, participation in maternal obesity services, challenges in the development of community maternal obesity services, and factors contributing to successful maternal obesity services. Community service providers identified their role in tackling maternal obesity alongside maternity services. Participants identified a lack of community maternal obesity services, distinct training requirements, and felt that a multi-agency approach was likely to be required. Conclusions Increasing rates of maternal obesity and the relationship between maternal obesity and childhood obesity mean that the preconception, pregnancy and postnatal periods are important and timely stages in the life course for public health intervention. However, current public health and community service provision lacks structured maternal obesity objectives.

Background: There is an absence of national statistics for maternal obesity in the UK. This study is the first to describe a nationally representative maternal obesity research data set in England. Design: Retrospective epidemiological study of first trimester obesity. Methods: Data from 34 maternity units were analysed, including 619 323 births between 1989 and 2007. Data analysis included trends in first trimester maternal body bass index status over time, and geographical distribution of maternal obesity. Population demographics including maternal age, parity, ethnic group, deprivation and employment were analysed to identify any maternal obesity-associated health inequalities. All demographics were tested for multicollinearity. Logistic regression analyses were adjusted for all demographics as confounders. Results: First trimester maternal obesity is significantly increasing over time, having more than doubled from 7.6% to 15.6% over 19 years (P

Objective to identify developments in maternal obesity services and health-care practitioners' views on how maternity services need to be further developed to be more effective in the care of obese pregnant women. Design follow-up qualitative study using purposive sampling, interviews and focus groups. Setting 10 maternity units in the North East Government Office Region of England, UK. Participants 30 maternity unit health-care practitioners with personal experience of maternal obesity services. Measurements and findings semi-structured interviews and focus groups were carried out with health-care practitioners representing each National Health Service trust in the region that provides maternity services to identify views on the barriers, facilitators, advantages and disadvantages of developing maternal obesity services, and how maternity services can be more effective in managing maternal obesity. Transcripts were analysed using thematic content analysis. Three dominant themes emerged: questioning maternal obesity service development; psychosocial issues and maternal obesity service development; and the way forward. Key conclusions there has been a substantial improvement in the management of the health and safety aspects of maternal obesity over the last three years. However, more work is needed around the psychosocial issues, weight management and public health aspects of maternal obesity. Implications for practice to meet the needs of obese pregnant women, maternity services should consider the transition of care between pregnancy and the postnatal period, improve communication between hospital and public health services, and develop services that will engage pregnant women to address their obesity.

Obesity is rising in the obstetric population, yet there is an absence of services and guidance for the management of maternal obesity. This systematic review aimed to investigate relationships between obesity and impact on obstetric care. Literature was systematically searched for cohort studies of pregnant women with anthropometric measurements recorded within 16-weeks gestation, followed up for the term of the pregnancy, with at least one obese and one comparison group. Two researchers independently data-extracted and quality-assessed each included study. Outcome measures were those that directly or indirectly impacted on maternity resources. Primary outcomes included instrumental delivery, caesarean delivery, duration of hospital stay, neonatal intensive care, neonatal trauma, haemorrhage, infection and 3rd/4th degree tears. Meta-analysis shows a significant relationship between obesity and increased odds of caesarean and instrumental deliveries, haemorrhage, infection, longer duration of hospital stay and increased neonatal intensive care requirement. Maternal obesity significantly contributes to a poorer prognosis for mother and baby during delivery and in the immediate post-partum period. National clinical guidelines for management of obese pregnant women, and public health interventions to help safeguard the health of mothers and their babies are urgently required.

ObjectivesMaternal obesity has multiple associated risks and requires substantial intervention. This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives.Study designA simultaneous mixed methods model with data integration was used. Three component studies were given equal priority. 1: Semi-structured qualitative interviews explored obese pregnant women's experiences of being on the pathways. 2: A quantitative and qualitative postal survey explored healthcare professionals' experiences of delivering the pathways. 3: A case note audit quantitatively assessed pathway compliance. Data were integrated using following a thread and convergence coding matrix methods to search for agreement and disagreement between studies.ResultsStudy 1: Four themes were identified: women's overall (positive and negative) views of the pathways; knowledge and understanding of the pathways; views on clinical and weight management advice and support; and views on the information leaflet. Key results included positive views of receiving additional clinical care, negative experiences of risk communication, and weight management support was considered a priority. Study 2: Healthcare professionals felt the pathways were worthwhile, facilitated good practice, and increased confidence. Training was consistently identified as being required. Healthcare professionals predominantly focussed on women's response to sensitive obesity communication. Study 3: There was good compliance with antenatal clinical interventions. However, there was poor compliance with public health and postnatal interventions. There were some strong areas of agreement between component studies which can inform future development of the pathways. However, disagreement between studies included a lack of shared priorities between healthcare professionals and women, different perspectives on communication issues, and different perspectives on women's prioritisation of weight management.ConclusionThe differences between healthcare professionals' and women's priorities and perspectives are important factors to consider when developing care pathways. Shared perspectives could help facilitate more effective implementation of the pathway interventions that have poor compliance.

Introduction International evidence shows that Asians have increased diabetes risk at a lower body mass index (BMI) than European Whites.1 UK guidance for routine gestational diabetes screening does not consider this BMI difference in risk. A proportion of high risk Asian women are therefore unscreened for diabetes in pregnancy, and potentially wrongly assigned to low risk care leading to inequalities. This study describes trends in first trimester obesity using the WHO BMI criteria for Asians. Methods Retrospective epidemiological study using data from 34 maternity units in England between 1995 and 2007. Obesity classification was BMI >27.5 kg/m 2 for Asians, and >30 kg/m 2 for all other ethnic groups. χ 2 analyses were used for trends over time. Logistic regression for odds of first trimester obesity among ethnic groups adjusted for maternal age, parity, deprivation and employment. Results Black and South Asian women have a significantly higher incidence of first trimester obesity compared with White women, and this is increasing at a more rapid rate over time in Black women. The proportion of South Asian women classified as obese doubled from 10.6% to 20.5% when using the WHO criteria for Asians compared with the general population BMI. Following adjustment for population demographics, Pakistani women had the highest odds of first trimester obesity (OR 2.19, 95% CI 2.08 to 2.31). Conclusion Current gestational diabetes screening in the UK excludes half of the South Asian population at high risk. There should be further consideration of ethnic groups when defining the BMI categories to be used when developing clinical guidelines and services.

Maternal obesity has serious implications to the health of both mothers and infants, including maternal and neonatal death, stillbirth, congenital anomalies, poor breastfeeding rates, and obesity in the offspring. There are also additional complications during antenatal, intrapartum, and postnatal periods which impact on maternity services. However, there is an absence of national statistics for maternal obesity in the UK. This study is the first to describe a nationally representative …