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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 (<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 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.

Diet, physical activity, smoking and alcohol behaviour-change interventions delivered in pregnancy aim to prevent adverse pregnancy outcomes. This review reports a synthesis of evidence from meta-analyses on the effectiveness of interventions at reducing risk of adverse health outcomes. Sixty-five systematic reviews (63 diet and physical activity; 2 smoking) reporting 602 meta-analyses, published since 2011, were identified; no data were identified for alcohol interventions. A wide range of outcomes were reported, including gestational weight gain, hypertensive disorders, gestational diabetes (GDM) and fetal growth. There was consistent evidence from diet and physical activity interventions for a significantly reduced mean gestational weight gain (ranging from -0.21 kg (95% confidence interval -0.34, -0.08) to -5.77 kg (95% CI -9.34, -2.21). There was evidence from larger diet and physical activity meta-analyses for a significant reduction in postnatal weight retention, caesarean delivery, preeclampsia, hypertension, GDM and preterm delivery, and for smoking interventions to significantly increase birth weight. There was no statistically significant evidence of interventions having an effect on low or high birthweight, neonatal intensive care unit admission, Apgar score or mortality outcomes. Priority areas for future research to capitalise on pregnancy as an opportunity to improve the lifelong wellbeing of women and their children are highlighted.

Background: Maternal obesity has severe physical impacts such as increased chances of pre-eclampsia and gestational diabetes. However, mental health impacts are given less attention within antenatal care. Evidence suggests that women with obesity carry increased risk of maternal depression and anxiety, however, this association is not well researched amongst South Asian women in the UK who are vulnerable to both. The aim of this study was to investigate the association between antenatal depression and anxiety and early pregnancy BMI, within and between White British and South Asian women, using data from the Born in Bradford cohort., Methods: Depression and anxiety were assessed using the General Health Questionnaire (GHQ); a GHQ score of > 0 for the depression subscale and > 6 for anxiety. Mother's BMI was stratified into six World Health Organisation BMI categories (underweight, recommended, overweight or obese class 1-3). To determine associations, univariate and multivariate logistic regression models (adjusting for maternal age, education, deprivation and smoking) were used., Results: There were 7824 women included (3514 White British and 4310 South Asian). South Asian women were more likely to have depression than White British (43.3% vs 36.1% p < 0.0001) and less likely to have anxiety (45.3% vs 48.4% p < 0.01). There were no significant associations between BMI and depression or anxiety in South Asian women. White British women with an overweight BMI had higher odds of anxiety compared with women with a recommended BMI (Adjusted Odds Ratio 1.25, 95% Confidence Interval 1.05-1.47). No significant associations were observed for other BMI categories. Smoking was a risk factor for antenatal depression (AOR 1.32, 95% CI 1.12-1.56; AOR 2.08, 95% CI 1.49-2.91) and anxiety (AOR 1.34, 95% CI 1.14-1.57; (AOR 2.87, 95% CI 2.02-4.07) in both White British and South Asian women, respectively., Conclusions: Although South Asian women have a higher prevalence of depression than White women in this cohort, the known associations between maternal obesity and anxiety do not appear to be present. More studies are needed using validated depression tools for South Asian pregnant women. Mental health screening during antenatal care is important for South Asian women, with factors such as smoking considered.

Background: Pregnancy is a teachable moment for behaviour change. Multiple guidelines target pregnant women for behavioural intervention. This systematic review of systematic reviews reports the effectiveness of interventions delivered during pregnancy on changing women's behaviour across multiple behavioural domains., Methods: Fourteen databases were searched for systematic reviews published from 2008, reporting interventions delivered during pregnancy targeting smoking, alcohol, diet or physical activity as outcomes. Data on behaviour change related to these behaviours are reported here. Quality was assessed using the JBI critical appraisal tool for umbrella reviews. Consistency in intervention effectiveness and gaps in the evidence-base are described., Results: Searches identified 24,388 results; 109 were systematic reviews of behaviour change interventions delivered in pregnancy, and 36 reported behavioural outcomes. All smoking and alcohol reviews identified reported maternal behaviours as outcomes (n = 16 and 4 respectively), whereas only 16 out of 89 diet and/or physical activity reviews reported these behaviours. Most reviews were high quality (67%) and interventions were predominantly set in high-income countries. Overall, there was consistent evidence for improving healthy diet behaviours related to increasing fruit and vegetable consumption and decreasing carbohydrate intake, and fairly consistent evidence for increase in some measures of physical activity (METs and VO2 max) and for reductions in fat intake and smoking during pregnancy. There was a lack of consistent evidence across reviews reporting energy, protein, fibre, or micronutrient intakes; smoking cessation, abstinence or relapse; any alcohol behaviours., Conclusions: The most consistent review evidence is for interventions improving dietary behaviours during pregnancy compared with other behaviours, although the majority of diet reviews prioritised reporting health-related outcomes over behavioural outcomes. Heterogeneity between reported behaviour outcomes limits ability to pool data in meta-analysis and more consistent reporting is needed. Limited data are available for alcohol interventions in pregnancy or interventions in low- or middle-income-countries, which are priority areas for future research., Competing Interests: The authors have declared that no competing interests exist.

Background: Preterm (< 37 weeks gestation) and post-term birth (≥42 weeks gestation) are associated with increased morbidity and mortality for mother and infant. Obesity (body mass index (BMI) ≥30 kg/m 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 (< 18.5 kg/m 2 ), recommended weight (18.5-24.9 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ) and obesity classes I (30.0-34.9 kg/m 2 ), II (35.0-39.9 kg/m 2 ), IIIa (40-49.9 kg/m 2 ) and IIIb (≥50 kg/m 2 ). 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 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., (© 2019 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Background: Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension. However, bariatric surgery, particularly malabsorptive procedures, can make patients susceptible to deficiencies in nutrients that are essential for healthy fetal development. The objective of this systematic review and meta-analysis is to investigate the association between pregnancy after bariatric surgery and adverse perinatal outcomes., Methods and Findings: Searches were conducted in Medline, Embase, PsycINFO, CINAHL, Scopus, and Google Scholar from inception to June 2019, supplemented by hand-searching reference lists, citations, and journals. Observational studies comparing perinatal outcomes post-bariatric surgery to pregnancies without prior bariatric surgery were included. Outcomes of interest were perinatal mortality, congenital anomalies, preterm birth, postterm birth, small and large for gestational age (SGA/LGA), and neonatal intensive care unit (NICU) admission. Pooled effect sizes were calculated using random-effects meta-analysis. Where data were available, results were subgrouped by type of bariatric surgery. We included 33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls. Odds ratios (ORs) were increased after bariatric surgery (all types combined) for perinatal mortality (1.38, 95% confidence interval [CI] 1.03-1.85, p = 0.031), congenital anomalies (1.29, 95% CI 1.04-1.59, p = 0.019), preterm birth (1.57, 95% CI 1.38-1.79, p < 0.001), and NICU admission (1.41, 95% CI 1.25-1.59, p < 0.001). Postterm birth decreased after bariatric surgery (OR 0.46, 95% CI 0.35-0.60, p < 0.001). ORs for SGA increased (2.72, 95% CI 2.32-3.20, p < 0.001) and LGA decreased (0.24, 95% CI 0.14-0.41, p < 0.001) after gastric bypass but not after gastric banding. Babies born after bariatric surgery (all types combined) weighed over 200 g less than those born to mothers without prior bariatric surgery (weighted mean difference -242.42 g, 95% CI -307.43 to -177.40 g, p < 0.001). There was low heterogeneity for all outcomes (I2 < 40%) except LGA. Limitations of our study are that as a meta-analysis of existing studies, the results are limited by the quality of the included studies and available data, unmeasured confounders, and the small number of studies for some outcomes., Conclusions: In our systematic review of observational studies, we found that bariatric surgery, especially gastric bypass, prior to pregnancy was associated with increased risk of some adverse perinatal outcomes. This suggests that women who have undergone bariatric surgery may benefit from specific preconception and pregnancy nutritional support and increased monitoring of fetal growth and development. Future studies should explore whether restrictive surgery results in better perinatal outcomes, compared to malabsorptive surgery, without compromising maternal outcomes. If so, these may be the preferred surgery for women of reproductive age., Trial Registration: PROSPERO CRD42017051537., Competing Interests: The authors have declared that no competing interests exist.

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., Competing Interests: The authors have declared that no competing interests exist.

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Review Question/objective: The objective of this umbrella review is to determine the characteristics of dietary interventions delivered any time before, during or after pregnancy for women living in developed countries, identified in quantitative systematic reviews as effective for improving mother and infant health outcomes and feasible for translation into practice.Specifically, the review will address the following questions:For the purpose of this overview, dietary interventions encompass the broad scope of dietary manipulations, including the direct provision of food and/or nutrients to participants, nutrition education, nutrition counseling, nutrition care teams, or any combination of these four intervention types.Both a narrative and quantitative summary on the effect of maternal dietary interventions on maternal and infant health outcomes as compared with usual care will be provided. The quantitative summary of the maternal and infant outcomes will be supported by an appraisal of the certainty of evidence of the effects and the strength of the recommendations using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework.

Dietary and physical activity behaviours during preconception and in pregnancy are important determinants of maternal and child health. This review synthesised the available evidence on dietary and physical activity behaviours in pregnant women and women of childbearing age women who have migrated from African countries to live in high income countries. Searches were conducted on Medline, Embase, PsycInfo, Pubmed, CINAHL, Scopus, Proquest, Web of Science, and the Cochrane library. Searches were restricted to studies conducted in high income countries and published in English. Data extraction and quality assessment were carried out in duplicate. Findings were synthesised using a framework approach, which included both a priori and emergent themes. Fourteen studies were identified; ten quantitative and four qualitative. Four studies included pregnant women. Data on nutrient intakes included macro- and micro-nutrients; and were suggestive of inadequacies in iron, folate, and calcium; and excessive sodium intakes. Dietary patterns were bicultural, including both Westernised and African dietary practices. Findings on physical activity behaviours were conflicting. Dietary and physical activity behaviours were influenced by post-migration environments, culture, religion, and food or physical activity-related beliefs and perceptions. Further studies are required to understand the influence of sociodemographic and other migration-related factors on behaviour changes after migration., Competing Interests: The authors declare no conflicts of interest.

Background: Global migration is at an all-time high with implications for perinatal health. Migrant women, especially asylum seekers and refugees, represent a particularly vulnerable group. Understanding the impact on the perinatal health of women and offspring is an important prerequisite to improving care and outcomes. The aim of this systematic review was to summarise the current evidence base on perinatal health outcomes and care among women with asylum seeker or refugee status., Methods: Twelve electronic database, reference list and citation searches (1 January 2007-July 2017) were carried out between June and July 2017. Quantitative and qualitative systematic reviews, published in the English language, were included if they reported perinatal health outcomes or care and clearly stated that they included asylum seekers or refugees. Screening for eligibility, data extraction, quality appraisal and evidence synthesis were carried out in duplicate. The results were summarised narratively., Results: Among 3415 records screened, 29 systematic reviews met the inclusion criteria. Only one exclusively focussed on asylum seekers; the remaining reviews grouped asylum seekers and refugees with wider migrant populations. Perinatal outcomes were predominantly worse among migrant women, particularly mental health, maternal mortality, preterm birth and congenital anomalies. Access and use of care was obstructed by structural, organisational, social, personal and cultural barriers. Migrant women's experiences of care included negative communication, discrimination, poor relationships with health professionals, cultural clashes and negative experiences of clinical intervention. Additional data for asylum seekers and refugees demonstrated complex obstetric issues, sexual assault, offspring mortality, unwanted pregnancy, poverty, social isolation and experiences of racism, prejudice and stereotyping within perinatal healthcare., Conclusions: This review identified adverse pregnancy outcomes among asylum seeker and refugee women, representing a double burden of inequality for one of the most globally vulnerable groups of women. Improvements in the provision of perinatal healthcare could reduce inequalities in adverse outcomes and improve women's experiences of care. Strategies to overcome barriers to accessing care require immediate attention. The systematic review evidence base is limited by combining heterogeneous migrant, asylum seeker and refugee populations, inconsistent use of definitions and limited data on some perinatal outcomes and risk factors. Future research needs to overcome these limitations to improve data quality and address inequalities., Systematic Registration: Systematic review registration number: PROSPERO CRD42017073315 .

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., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

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., Competing Interests: This pilot study has received ethical approval from the Proportionate Review Sub-committee of the Yorkshire & The Humber—South Yorkshire Research Ethics Committee, 16/12/2015, ref.: 15/YH/0565. The protocol described here is based on the full protocol submitted to the ethics committee (V1.0, 23/11/2015). Research and development (R&D) approval has also been granted from the four pilot NHS Trusts (clusters). All midwives and pregnant women will need to provide informed consent before participating in this research. Separate consent will be sought for the different levels of involvement in the research: midwives will be required to consent to provide the questionnaire baseline and outcome data, to participate in the intervention sessions and to participate in the focus groups; pregnant women will be required to consent to provide the questionnaire baseline data and outcome data and to participate in the interviews. Copies of the information sheets and consent forms for each stage of the research are provided in Additional file 4. Any amendments to the protocol will be discussed with the ethics committee to determine if a minor amendment or substantial amendment is required before any changes to trial procedures are actioned. All amendments will be reported to the R&D departments at each participating NHS Trust and will be reported in the publication of the pilot study results. The trial sponsor is Newcastle upon Tyne Hospitals NHS Foundation Trust, Ms. Amanda Tortice, Research Operations Manager, amanda.tortice@ncl.ac.ukThis is not applicable to this pilot study as individuals will not be identified from any study report. It is planned to publish the results of this study in peer review journals and to present data at national and international meetings. Results of the study will also be reported to the sponsor and funder and will be available on their website. Midwives and pregnant women will be offered the option of receiving information about their contribution to the study at the end of the study, including a lay summary of the results. The results of this study will inform the development of a grant application for a definitive trial. Any arising publications will follow the International Committee of Medical Journal Editors requirements for authorship. No restrictions are placed on publication of the trial results.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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.

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., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Review Objective/question: The objective of this umbrella review is to examine the effectiveness of different types of weight management, smoking cessation and alcohol reduction interventions in producing explicitly measured behavior change or proxy measures of behavior change in pregnant women.Specifically the review question is: are weight management, smoking cessation and alcohol reduction interventions effective in producing behavior change in pregnant women?

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., (© 2013 John Wiley & Sons Ltd.)

Objectives: Maternal obesity has multiple associated risks and requires substantial intervention. This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives., Study Design: A 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., Results: Study 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., Conclusion: The 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.

Background: There is little information on the individual cognitive, perceptual and psychosocial factors that influence the lifestyle behaviours of pregnant women. This study explored pregnant women's weight-related attitudes and beliefs during pregnancy., Methods: Nineteen pregnant women with different pre-pregnancy BMIs and in their third trimester were purposefully sampled for face-to-face interviews. Topics covered included lifestyles, sources of information, feelings about their bodies, and level of control over themselves and their bodies. Systematic thematic content analysis was used to identify recurrent themes., Results: Women perceived their bodies as fragmented into 'my pregnancy' (the bump) and 'me' (rest of my body). This fragmentation was the key driver of their weight-related attitudes and beliefs and influenced their dietary and physical activity behaviours. Consuming healthy foods was necessary for 'my pregnancy' to provide the ideal gestational environment. Simultaneously, pregnancy was perceived as a time to relax previously set rigid rules around diet and physical activity, allowing women to consume unhealthy foods and lead sedentary lifestyles. Women faced emotional conflicts between limiting weight gain for 'me', and being perceived as acting morally by gaining enough weight for 'baby'. Although 'bump' related weight gain was acceptable, weight gain in other parts of their body was viewed negatively and implied lack of self-control. Conflict was often alleviated, and weight-related behaviours validated, by seeking practical and reputable information for weight management. Women felt that their midwives provided detailed information on what they should not do during pregnancy, but were rarely given information about what they should do in relation to diet and physical activity for weight management. Consequently, women often used information from a variety of sources which they filtered using 'common sense'., Conclusions: This study has identified that a central concept to pregnant women's diet and physical activity beliefs during pregnancy is the fragmentation of self into 'me' and 'my pregnancy'. This fragmentation influenced beliefs about diet and physical activity, and control and acceptability of gestation weight gain on different parts of the body. Future interventions and antenatal care should take this fragmentation into consideration when providing pregnant women with advice, information and support relating to their diet and physical activity behaviours.

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.

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., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Implications for practice and research: Behavioural interventions can reduce maternal, fetal and neonatal obstetric and weight-related risks. Good-quality research is required to inform the development of behavioural interventions to determine effectiveness and cost-effectiveness for short-term and long-term health outcomes.

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.

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., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

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.

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.