Public Health Wales
Maternal Obesity Report
Maternal Obesity Report
Reproductive and Early Years Pathfinder
Project
Authors (Alphabetical Order):
Dawn Davies
Rebecca Evans
Geinor Jones
Helen Jones
Caroline Nichols
Dr Michael Thomas
Eleri Tyler
Date: 19/02/13
Principal Public Health Specialist, Hywel Dda Local
Public Health Team
Senior Public Health Specialist, Hywel Dda Local Public
Health Team
Senior Public Health Specialist, Hywel Dda Local Public
Health Team
Principal Public Health Specialist, Hywel Dda Local
Public Health Team
Health Promotion Practitioner, Hywel Dda Local Public
Health Team
Consultant in Public Health, Public Health Wales
Clinical Information Analyst, ATTRACT, Public Health
Wales
Version: Final
Publication/ Distribution: Public (internet)
Review Date:
Purpose and Summary of Document:
To provide an overview of the epidemiology of maternal obesity in Wales
and describe approaches that can be taken in primary care and maternity
services to promote a healthy weight.
Work Plan reference:
Public Health Wales
Maternal Obesity Report
Table of Contents
Executive Summary .................................................................................. 4
1. Introduction ......................................................................................... 6
2. Method ............................................................................................... 8
3. Epidemiology ..................................................................................... 10
3.1 Maternal Obesity .............................................................................. 10
3.2 Maternal Risks and Complications ....................................................... 12
3.2.1 Fertility ......................................................................................... 18
3.2.2 Miscarriage ................................................................................... 18
3.2.3 Gestational Diabetes ...................................................................... 19
3.2.4 Pre-eclampsia ................................................................................ 20
3.2.5 Venous Thromboembolism .............................................................. 21
3.2.6 Assisted Delivery ........................................................................... 22
3.2.7 Wound Infection ............................................................................ 24
3.2.8 Postpartum Haemorrhage ............................................................... 25
3.3 Risks and complications – Baby .......................................................... 26
3.3.1 Perinatal Mortality .......................................................................... 26
3.3.2 Congenital Malformations ................................................................ 27
3.3.3 Pre-term Delivery .......................................................................... 28
3.3.4 Neonatal Morbidity ......................................................................... 29
3.3.5 Infant Birth Weight ........................................................................ 30
3.3.6 Breastfeeding ................................................................................ 30
4. Best Practice Guidance ........................................................................ 32
4.1 Before Pregnancy ............................................................................. 32
4.1.1 Weight Loss .................................................................................. 32
4.1.2 Folic Acid Supplements ................................................................... 34
4.2 During Pregnancy ............................................................................. 36
4.2.1 Weight management ...................................................................... 36
4.2.2 Vitamin D ..................................................................................... 39
4.3 After and Between Pregnancy ............................................................. 43
4.3.1 Weight Loss .................................................................................. 43
4.3.2 Breastfeeding ................................................................................ 43
5. Implementing Best Practice Guidance: Issues and Solutions .................... 46
5.1 Perceptions and environment ............................................................. 46
Date: 4th December 2014
Version: v1 final
Page: 2 of 100
Public Health Wales
Maternal Obesity Report
5.1.1 Issues .......................................................................................... 46
5.1.2 Solutions ...................................................................................... 46
5.2 Education and Communication............................................................ 47
5.2.1 Issues .......................................................................................... 47
5.2.2 Solutions ...................................................................................... 48
5.3 Workforce Development .................................................................... 49
5.3.1 Issues .......................................................................................... 49
5.3.2 Solutions ...................................................................................... 49
5.4 Psychosocial/Psychological Support ..................................................... 51
6. Economic Costs .................................................................................. 56
7. Population approach to Obesity ............................................................ 59
8. Conclusion ......................................................................................... 63
9. Recommendations .............................................................................. 64
10. Glossary .......................................................................................... 67
11. References ....................................................................................... 76
10. Appendices ...................................................................................... 91
Appendix 1 ............................................................................................ 91
Appendix 2 ............................................................................................ 92
Appendix 3 ............................................................................................ 95
Appendix 4 ............................................................................................ 97
Date: 4th December 2014
Version: v1 final
Page: 3 of 100
Public Health Wales
Maternal Obesity Report
Executive Summary
In Wales 42% of women of childbearing age (ages 16-44 years) are
overweight or obese1. Wales has the highest overall prevalence of severe
maternal obesity (BMI 35 or over) in the UK at 6.5%, compared with the
other UK Nations4.
Compared to women with a healthy pre-pregnancy weight, pregnant
women with obesity are at increased risk of miscarriage16, gestational
diabetes17, pre-eclampsia18, venous thromboembolism19,20,
induced
21
22
23,24
labour , caesarean section , anaesthetic complications
, and wound
infections15 and they are less likely to initiate or maintain breastfeeding25.
Babies of obese mothers are at increased risk of stillbirth32,52, congenital
anomalies53, prematurity54, macrosomia17,55,56 and neonatal death52,55,57.
Intrauterine exposure to maternal obesity is also associated with an
increased risk of developing obesity and metabolic disorders in
childhood58. The risk associated with maternal obesity, in terms on the
effect on the health of the mother and child, are similar in magnitude to
other antenatal risk factors such as smoking and alcohol14.
Pregnancy is a powerful motivator for change. It is a time when women
and their partners, often for the first time, are more susceptible to new
information92 and make positive lifestyle changes and choices in order to
provide the optimal conditions to ensure the health and wellbeing of their
unborn baby.
The period before, during and after pregnancy provides
opportunities to give women practical, consistent advice to help them to
improve their diet, become more physically active or to help manage their
weight effectively92 avoid associated complications and also impact on the
health and wellbeing of families5.
This report reviews the association between maternal obesity and adverse
pregnancy outcomes, condition management in terms of antenatal care,
delivery and postpartum care as well as some of the long-term health and
social outcomes for mothers and babies. This report also describes the
economic cost of maternal obesity and approaches that can be taken in
primary obstetrical care to promote a healthy weight.
There is UK guidance from NICE on dietary and physical activity
interventions for weight management before, during and after pregnancy;
and from CEMACE about the management of women with obesity in
pregnancy. There is variation between Health Boards in terms of the
extent to which these recommendations have been implemented in
Wales. This report identifies a number of areas that can be addressed by
public health:
•
Provision of training for health professionals to counsel women
about healthy weight gain in pregnancy. This should ideally be
Date: 4th December 2014
Version: v1 final
Page: 4 of 100
Public Health Wales
Maternal Obesity Report
included within a training package for health professionals to
address other behavioural risk factors such as cigarette smoking
and alcohol use during pregnancy.
•
Development of an initiative or campaign to promote pre-conception
advice for pregnant women, including attaining a healthy weight
prior to pregnancy

Evaluation of ongoing interventions that have well defined service
specifications
Date: 4th December 2014
Version: v1 final
Page: 5 of 100
Public Health Wales
Maternal Obesity Report
1. Introduction
Maternal obesity is defined as a pregnant woman with a BMI of 30 or
over.1
This briefing paper, developed as part of the Public Health Wales
Reproductive and Early Years Pathfinder Project, aims to provide an
overview of the epidemiology and evidence base behind the issue of
maternal obesity in Wales, by describing:

The extent of the problem in the Welsh population

The risks for mother and child

What works to support overweight and obese women before, during
and after pregnancy

Best
practice
guidance
for
women
before,
during
and
after
pregnancy, including a whole population approach to attaining and
maintaining a healthy weight

Associated economic costs

The recommendations based on the evidence base
In Wales 42% of women of childbearing age (ages 16-44years) are
overweight or obese1. Wales has the highest overall prevalence of severe
maternal obesity (BMI 35 or over) in the UK at 6.5%. Only 55% of
women with a BMI of 35 or over give birth naturally, with a caesarean
rate 1.5 times higher than the rate in the general maternal population2.
Maternal obesity is associated with increased risks for the mother of
death,
miscarriage16,
stillbirth32,52,
pre-eclampsia18,
gestational
diabetes17, thromboembolism19,20, delivery by caesarean section22 and
postpartum haemorrhage51. The baby is at increased risk of neonatal
death52,55,57,
premature
birth54
and
congenital
anomalies53
and
of
becoming an obese child58. Women who are obese are significantly more
likely to be older in pregnancy to have higher parity and to live in areas of
Date: 4th December 2014
Version: v1 final
Page: 6 of 100
Public Health Wales
Maternal Obesity Report
high deprivation, compared with women who are not obese3. The
increased cost in terms of both health and finance is undisputed.
Maternal obesity is part of a wider public health issue rather than an
isolated maternity one. The reasons for the population being overweight
and obese are complex including environmental, individual and cultural
factors and therefore the support and actions needed to address it are
also multi-faceted.
It is hoped this report will guide future development of services and
support for women before, during and after pregnancy, as part of a whole
population approach, in order to maximise health outcomes for mothers
and babies.
Date: 4th December 2014
Version: v1 final
Page: 7 of 100
Public Health Wales
Maternal Obesity Report
2. Method
The overview of the evidence in this section was identified through
literature searches of high level sources rather than using systematic
review methodology.
The Public Health Wales ATTRACT Team conducted a rapid search of the
literature to identify secondary sources of evidence discussing maternal
obesity using the TRIP database, NHS evidence, PubMed, Google, Public
Health Wales Website and Public Health Wales Observatory. Their search
also included the websites of the National Child and Maternal Health
Observatory (ChiMat), Institute of Medicine (IOM), National Collaborating
Centre for Women and Children’s Health (NCC-WCH), National Perinatal
Epidemiology Unit (NPEU), Royal College of Midwives (RCM), and the
Royal College of Obstetricians and Gynaecologists (RCOG).
In addition, website search engines were scanned by the authors (e.g.
Google and Google Scholar) in the first instance using natural language
free text such as “maternal obesity” in combination with a variety of
maternal risk factors to identify all relevant keywords and synonyms for
use in additional searching of MEDLINE see appendix 1 for table of search
terms relating to the risk factors.
Search terms included:
Maternal or pregnant or pregnancy or postnatal
AND obese or obesity
AND cost-effectiveness or cost or resource or economic
or cost or
resource
AND all other search terms relating to risks and outcomes to answer
the following questions:
1. What is the frequency of complications from obesity in pregnancy?
Date: 4th December 2014
Version: v1 final
Page: 8 of 100
Public Health Wales
Maternal Obesity Report
2. Is there any information on models for the provision of services for
maternal obesity?
In particular who should deliver it and what
should it entail?
3. What are the barriers and facilitators to interventions for maternal
obesity?
4. What is the cost effectiveness of interventions for maternal obesity
during pre—conception, antenatal and postnatal stages?
In addition to the literature review described above there are several key
documents that have informed this evidence review:

CMACE/RCOG Joint Guidelines: The Management of Women with
Obesity in Pregnancy (2010)1

Maternal Obesity in the UK: findings from a national project, Centre
for Maternal and Child Enquiries (2010)4

A
Strategic
Vision
for
Maternity
Services
in
Wales,
Welsh
Government (2011)5

NICE public health guidance (PH27) Dietary interventions and
physical activity interventions for weight management before,
during and after pregnancy.6

BC Perinatal Health Programme (2009). Maternal Overweight,
Obesity and Excess Gestational Weight Gain: Identification of
Maternal and Perinatal Implications and Primary Maternity Care
Providers’
Opportunities
for
Interventions
to
Improve
Health
Outcomes.14
Date: 4th December 2014
Version: v1 final
Page: 9 of 100
Public Health Wales
Maternal Obesity Report
3. Epidemiology
3.1 Maternal Obesity
With the increasing prevalence of obesity in many countries, including
Wales, obesity during pregnancy is becoming a high-risk obstetric
condition
associated
gestational outcomes.
with
a
variety
of
adverse
reproductive
and
There is also research to suggest that the long-
term consequences to the infant may be considerable as there may be an
association with childhood obesity and a greater risk of type-2 diabetes.7
Estimates of obesity prevalence are very much dependent on the
definition and the methods used to measure excess fat and its
distribution. For the purpose of this report body mass index (BMI), which
calculates fat mass using weight (kg)/height squared (m2), has been used
as this standardised approach is most commonly applied in clinical
settings and can be captured from self-reported data.
A number of issues associated with measuring maternal obesity including:

Classifications are independent of age and gender and ethnicity,
therefore, BMI may not be as useful in predicting risk in some
populations for example, teenage mothers.8,9,10

Most research and reports use the prevalence of obesity among
women of childbearing age in the general population as an estimate of
maternal obesity, primarily because this data is readily available,
however estimates may not accurately reflect the actual prevalence
among pregnant women.11

Data on actual maternal BMI should reflect weight status prior to any
significant weight gain during pregnancy, however, these data may
not be routinely collected and do not therefore reflect the current
trend towards excessive levels of weight gain during pregnancy.6,12,13
In Wales 42% of women of childbearing age (ages 16-44 years) are
overweight or obese1. Wales has the highest overall prevalence of severe
Date: 4th December 2014
Version: v1 final
Page: 10 of 100
Public Health Wales
Maternal Obesity Report
maternal obesity (BMI 35 or over) in the UK at 6.5%, compared with the
other UK Nations4.
Figure 1 below provides an overview of maternal
obesity in the UK by BMI and clearly illustrates that in all BMI categories
from obese to super-morbidly obese Wales has the highest prevalence.
Figure 1. Maternal Obesity in the UK4
7.0
6.0
5.0
4.0
BMI 35-39.99
%
BMI 40-49.99
3.0
BMI >= 50
2.0
1.0
0.0
England
N. Ireland
Scotland
Wales
The demographic and economic characteristics of women who are obese
during pregnancy are similar to those of obese women in the general
population as they are significantly more likely to be older, to have a
higher parity and are more than twice as likely to live in areas of high
deprivation when compared with women who are not obese.1 The United
Kingdom Obstetric Surveillance System (UKOSS) study for extreme
obesity found that pregnant women with a BMI of at least 50kg/m2 were
likely to be older than average, white, multiparous, and from manual or
unemployed social groups.15
Date: 4th December 2014
Version: v1 final
Page: 11 of 100
Public Health Wales
Maternal Obesity Report
The economic and social costs of maternal obesity are also important both
in terms of the direct costs relating to additional medical interventions
and management.
A recent projection based on data from the US
National Health and Nutrition Examination Survey estimated that by the
the year 2030, costs related to overweight and obesity will account for
16-18% of total US healthcare costs. Estimates of the economic costs of
maternal obesity are limited, however, the evidence presented here does
suggest they are and will continue to be considerable.
3.2 Maternal Risks and Complications
Compared to women with a healthy pre-pregnancy weight, pregnant
women with obesity are at increased risk of miscarriage16, gestational
diabetes17, pre-eclampsia18, venous thromboembolism19,20,
induced
21
22
23,24
labour , caesarean section , anaesthetic complications
, and
15
wound infections
and they are less likely to initiate or maintain
25
breastfeeding .
While maternal deaths are extremely rare in the United Kingdom
(14/100,000 maternities for the period 2003-05) the maternal mortality
rate for those mothers’ deaths that could only be due to pregnancy e.g.
haemorrhage or pre-eclampsia, have shown a slight increase for this
period.
Many possible factors lie behind the lack of decline in the
maternal mortality rate and include rising numbers of older or obese
mothers, women whose lifestyles put them at risk of poorer health and a
growing proportion of women with medically complex pregnancies.
More
than half of all the women who died from all causes, and for whom data
were available, were either overweight or obese and more than 15% of all
women who died from all causes were morbidly or super morbidly obese
171.
Date: 4th December 2014
Version: v1 final
Page: 12 of 100
Public Health Wales
Maternal Obesity Report
Table 1, below summarises the risks associated with maternal obesity.
Data are presented by citation and risk is expressed as either an odds
ratio (OR) with 95% confidence intervals (CI) or percentages.
Date: 4th December 2014
Version: v1 final
Page: 13 of 100
Public Health Wales
Maternal Obesity Report
Table 1. Maternal/Gestational Complications Attributed to Obesity (OR with 95% CI or Percentages)
Obese Class/(BMI)
Obesity Related Complications and Citation
Normal
Overweight
1
II
(18.5-24.9)
(25.0-29.9)
(30.0-34.9)
(35.0-39.9)
III
25.9%
10.5%
( 40.0)
Fertility
Lim et al. (2007)26
Miscarriage
O’Dwyer et al. (2012)31
2.7%
3.7%
11.3%
Boots et al. (2011)29
1.3 (1.18-1.46)
Lashen et al. (2004)16
1.2 (1.01-1.46)
Gestational Diabetes Mellitus
Kim et al. (2010)
0.7%
2.3%
4.8%
5.5%
9.7%
21.1%
3.56 (3.05-4.21)
8.56(5.07-16.04)
Huxley (2009)9
Chu et al (2007)32
2.14(1.82-2.53)
Sebire et al. (2001)17
1.68(1.53-1.84)
3.6 (3.25-3.98)
Bhattacharya et al. (2007)36
2.4 (2.2-2.7)
Pre-eclampsia
Bhattacharya et al. (2007)36
1.6 (1.2-1.8)
Callaway et al. (2006)54
2.4%
5.6%
Cedergren et al. (2004)55
3.3 (2.7-3.9)
7.2 (4.7-11.2)
9.1%
2.62(2.49-2.76)
Sebire et al. (2001)17
1.44(1.28-1.62)
Robinson et al. (2005)44
Version: v1 final
3.9(3.54-4.3)
4.82(4.04-5.74)
2.14 (1.85-2.47)
2.38(2.24-2.52)
Date: 4th December 2014
14.5%
Page: 14 of 100
3.0 (2.49-3.62)
Public Health Wales
Maternal Obesity Report
Obese Class/(BMI)
Obesity Related Complications and Citation
Normal
Overweight
(18.5-24.9)
(25.0-29.9)
1
(30.0-34.9)
III
II
(35.0-39.9)
( 40.0)
0.5%
0.6%
Venous Thromboembolism
CMACE (2010)2
UKOSS (2008)41
21%
James et al. (2006)38
4.4 (3.4-5.7)
Complications of Labour
CMACE (2010)2
Spontaneous
49.7%
40.6%
Induced
32.0%
35.7%
No Labour
18.4%
23.7%
Usha et al. (2005)21
25.5%
36.0%
Bhattacharya et al. (2007)36
27.2%
33.4%
Sebire et al. (2001)17
15.3%
19.2%
Arrowsmith et al. (2011)46
26.2%
30.5%
42.8%
49.0%
24.6%
34.4%
40.0%
43.6%
Dysfunctional Labour
Sheiner et al. (2004)81
3.1 (2.5-3.8)
Caesarean Section
CMACE (2010)2
24.6%
34.7%
Knight et al. (2010)15
43.1
50.0%
Bhattacharya et al. (2007)36
16.4%
Usha et al. (2005)21
24.1%
30.8%
18.0%
Date: 4th December 2014
Version: v1 final
27.0%
Page: 15 of 100
Public Health Wales
Maternal Obesity Report
Obese Class/(BMI)
Obesity Related Complications and Citation
Normal
Overweight
1
II
(18.5-24.9)
(25.0-29.9)
(30.0-34.9)
(35.0-39.9)
III
( 40.0)
Infection
Sabire et al. (2001)17
Wound Infection
1.3(1.1-1.5)
2.2 (1.9-2.6)
Urinary Tract Infection
1.2 (1.04-1.3)
1.4 (1.2-1.6)
Genital tract Infection
1.24 (1.09-1.41)
1.30 (1.07-1.56)
Postpartum Haemorrhage
Bloomberg et al. (2011)
Normal delivery
4.4%
5.2%
Instrumental delivery
8.8%
13.6%
Fetal Anomalies
Stothard et al. (2009)
Neural Tube Defects
1.87(1.62-2.15)
Spina Bifida
2.24(1.86-2.15)
Cardiovascular Anomalies
1.30(1.03-1.47)
Septal Anomalies
1.20 (1.09-1.31)
Cleft palate
1.23 (1.03-1.47)
Cleft lip & palate
1.20 (1.03-1.40)
Anorectal atresia
1.48 (1.12-1.97)
Hydrocephaly
1.68 (1.19-2.36)
Limb reduction anomalies
1.34 (1.03-1.73
Perinatal Mortality
Raatikainen et al. (2006)59
1.5 (1.0-2.4)
Date: 4th December 2014
Version: v1 final
2.2 (1.3-3.6)
Page: 16 of 100
Public Health Wales
Maternal Obesity Report
Obese Class/(BMI)
Obesity Related Complications and Citation
Normal
Overweight
1
II
(18.5-24.9)
(25.0-29.9)
(30.0-34.9)
(35.0-39.9)
Chu et al. (2007)11
1.5(1.1-1.9)
III
( 40.0)
2.1(1.6-2.7)
Sebire et al. (2001)17
2.7(1.2-6.1)
Pre-term Delivery
Smith et al. (2007)63
Elective
1.2 (1.03-1.3)
1.5 (1.3-1.8)
2.1 (1.8-2.6)
Spontaneous
0.9 (0.8-0.98)
0.9 (0.7-0.99)
0.8 (0.6-1.03)
Neonatal Mortality
Abenhaim et al.
(2007)77
APGAR 3
1.7 (1.3-2.7)
3.2 (2.1-4.8)
6.0 (2.7-13.4)
NICU Admissions
1.2 (1.1-1.4)
1.6 (1.4-1.9)
2.9 (1.9-4.4)
Doherty et al. (2006)48
Neonatal Resuscitation
1.3 (1.0-1.7)
1.8 (1.3-2.4)
Hypoglycaemia
1.9 (1.2-3.1)
Infant Birth Weight
Olmos et al. (2012)
Sebire et al. (2001)35
Baeten et al. (2001)75
Jensen et al. (2003)76
Abenhaim et al (2007)77
Macrosomic (+GDM)
Macrosomic
14.9%
26.4%
1.3-2.1
1.9-3.5
Deprivation
Heslehurst et al. (2010)14
2.44 (1.98-3.02)
Sellstrom et al. (2009)
2.25 (1.91-2.66)
Date: 4th December 2014
Version: v1 final
Page: 17 of 100
Public Health Wales
Maternal Obesity Report
3.2.1 Fertility
Women who are obese are at increased risk for infertility and other
reproductive problems. The research demonstrates that women who are
obese (BMI  30) are more likely to have ovulation problems that result in
irregular or infrequent menstrual cycles and infertility. In the treatment of
infertility
using
in-vitro
fertilisation
(IVF),
obese
women
are
less
successful which may be due, in part, to the fact that obese women do
not respond to fertility medications as well and have a higher percentage
of immature eggs.
168
There are lower conception rates in women with a BMI  25 when
compared to those with a BMI  25, 10.5% and 25.9% respectively26.
Research also shows that the relationship between obesity and polycystic
ovary syndrome contributes to infertility rates as insulin resistance makes
achieving a pregnancy difficult27.
3.2.2 Miscarriage
Women who are overweight or obese have an increased risk of
miscarriage,
following
reproduction28,29,30,31.
either
natural
conception
or
assisted
The rate of miscarriage in the general pregnant
population is estimated to be 12%28. A 2011 systematic review29
investigating whether obesity increased the risk of miscarriage in
spontaneous conception identified six studies forming a cohort of 28,538
women. The authors report that pooled analysis revealed a higher
miscarriage rate of 13.6% in 3800 obese women versus 10.7% in 17,146
normal-BMI women.
In addition, a meta-analysis of 12 observational
studies showed that women who were overweight or obese (vs. women of
normal weight) were also more likely to miscarry in the first trimester
following in vitro fertilization (IVF)32.
Date: 4th December 2014
Version: v1 final
Page: 18 of 100
Public Health Wales
Maternal Obesity Report
A 2012 study31 investigating late miscarriage in primigravidas, in 3000
pregnancies where a foetal heart rate had been identified in the first
trimester, noted an overall miscarriage rate of 3.9% (n=117). However,
the rate for those with a BMI  39.4 kg/m2 was 11.8% (n=8) compared
with 2.7% (n = 24) in the normal BMI category and 3.7% (n = 5) in the
class 1 obese category (not significant). In multigravidas, there was no
increased rate of miscarriage among class II-III obese women compared
with multigravidas in the normal BMI category31.
3.2.3 Gestational Diabetes
Gestational diabetes mellitus (GDM) is defined as any degree of glucose
intolerance resulting from the onset of pregnancy. The definition applies
regardless of whether insulin or diet modifications are used for treatment
and it does not exclude the possibility that undiagnosed glucose
intolerance may have preceded the pregnancy or begun as a result of the
pregnancy4.
Maternal obesity is associated with a threefold increase in
the risk of GDM; CMACE reported that 8% of women with a BMI  35 had
GDM compared with a rate of 2.5% for the general maternity population
of England in 201033.
A meta-analysis of 20 cohort studies34 published in 2007 aimed to identify
the risk of GDM associated with maternal obesity. Eleven of the cohort
studies had sample sizes greater than 10,000 participants and these were
conducted in the US, UK, Australia, Finland and Canada. In these large
studies the prevalence of GDM ranged from 1.3 % (UK population data
1989-97) to 4.9% (US data).
The
largest
cohort
study
included
in
this
meta-analysis
was
a
retrospective analysis35 of a validated maternity database in London
including 287,213 pregnancies from 1989-97. This yielded percentages of
women with GDM in three BMI categories according to measurements
Date: 4th December 2014
Version: v1 final
Page: 19 of 100
Public Health Wales
Maternal Obesity Report
taken at booking. The rates of gestational diabetes increased with BMI:
BMI 20-25 exhibited a rate of 0.75%, BMI 25-30 exhibited a rate of 1.7%
and BMI>30 exhibited a rate of 3.5%. These are slightly lower risk
estimates than the 2007 meta-analysis, which may reflect that the metaanalysis included cohort studies in minority ethnic populations with a
higher risk of metabolic disorders and high prevalence of GDM which may
skew the data upwards.
3.2.4 Pre-eclampsia
Gestational hypertension and pre-eclampsia occur at a higher rate in
women with obesity when compared to women within a normal weight
range.
The CMACE report4 gives a figure of 1.9% as the rate of pre-
eclampsia across the general maternity population in England, however,
in their cohort study of women in London with a BMI ≥35, the rate is
5.5% for women with a BMI of between 35 and 39.9, 7.0% for those with
a BMI of 40.0 – 49.9 and 12.7% for women with a BMI  50. This finding
is supported in earlier studies in the UK and Europe35,36,37.
Data from a cohort of 24,241 nulliparous women delivering singleton
babies in Aberdeen between 1976 and 200536 found the overall rate of
pre-eclampsia to be higher in this population than in the London data.
These authors reported numbers of women in each BMI grouping
exhibiting
pre-eclampsia;
these
numbers
correspond
to
2.9%
of
underweight women, 4.1% of normal weight women, 5.9% of overweight
women, 9.7% of obese women and 18.5% of morbidly obese women.
A systematic review of studies published in 2003 examining maternal
obesity and the risk of pre-eclampsia included 13 cohort studies and
1,390,226 women18. These authors estimated the degree of change in the
risk of preeclampsia according to increasing BMI and note that the risk of
preeclampsia doubles for each 5 to 7 Kg/m2 increase in BMI. These
Date: 4th December 2014
Version: v1 final
Page: 20 of 100
Public Health Wales
Maternal Obesity Report
authors note that their linear models suggest that pre-pregnancy weight
reduction might produce an approximately 0.54% decrease in the rate of
preeclampsia per 1 Kg/m2 decline in BMI.
3.2.5 Venous Thromboembolism
The
CMACE
report
does
not
give
a
figure
for
deep
venous
thrombosis/pulmonary embolism across the general maternity population
in England but gives a rate of 0.5%, 0.7% and 0.5% in the categories
BMI 35.0-39.99, BMI 40.0-49.99 and BMI≥50 respectively4.
The Nationwide inpatient sample from the Healthcare Cost and Utilization
Project of the Agency for Healthcare Research and Quality for the years
2000 to 2001 was analyses for pregnancy related discharges and
diagnosis of venous thromboembolism38. This analysis did not yield data
on rate of thromboembolism in obese women but did provide an OR of 4.4
(95% CI 3.4-5.7) though actual BMI categorization was not defined in the
paper, however, other case-control studies have reported elevated Odds
Ratios for women with high BMI39,40,41,42 and a higher risk of pulmonary
embolism rather than deep venous thrombosis during pregnancy and the
puerperium period.
Knight’s
39
case-control
study
using
data
from
the
UK’s
Obstetric
Surveillance System (UKOSS) reports adjusted ORs of 2.50 (95% CI1.02-6.19) for women with BMI 25-29.9 and an OR of 2.65 (1.09- 6.45)
for antenatal pulmonary embolism40. These authors report that assuming
causality population proportional attributable risks indicated that 21% of
antenatal pulmonary emboli were attributable to BMI of 30 Kg/m2 or
over.40
Jacobsen41 also noted increased odds ratios both antenatally and
postnatally and particularly with immobilization in women with BMI ≥ 25.
Simpson42
has
reported
Date: 4th December 2014
elevated
Odds
Version: v1 final
Ratios
for
venous
Page: 21 of 100
Public Health Wales
Maternal Obesity Report
thromboembolism postnatally in those with a BMI ≥ 25, but not
antenatally.
One large Birth Registry cohort from Denmark43 and another from the
UK35 failed to find an association of significance between thrombosis and
obesity whereas a similar Canadian study44 denoting moderate obesity as
women weighting 90-120 kg and severe obesity as >120 kg found that
moderately obese women had an increased risk of antepartum venous
thromboembolism, whereas severely obese women had an increased risk
of antepartum venous thromboembolism.
3.2.6 Assisted Delivery
Maternal obesity can present many technical challenges including larger
cuffs to monitor blood pressure, problems associated with external fetal
monitoring
during
labour
and
an
increased
risk
of
intrapartum
complications such as failure to progress, shoulder dystocia, induction of
labour and caesarean section.
Ultrasonography of obese patients is
difficult due to the effect adipose tissue can have on the intensity of the
signal, therefore, affecting accurate dating and the detection of fetal
anomalies. A study of routine ultrasound screening in pregnant women
with diabetes found that major congenital anomalies were nearly sixtimes more common in these women when compared to the controls and
the detection rate was lower (30% vs 73%) due to a higher incidence of
obesity.30
Induced labour
The CMACE cohort study reports an induction rate of 33% in women with
a BMI ≥35; these authors report the induction rate in the general
population as 20%4. These authors also note that for women with a BMI
≥35 who laboured prior to delivery each unit increase in BMI was
Date: 4th December 2014
Version: v1 final
Page: 22 of 100
Public Health Wales
Maternal Obesity Report
associated with a 3% increased risk in induction of labour. The CMACE
report also gives figures for induction of labour across the three BMI
categories studied as shown in Table 1.
An earlier study examining data from the Cardiff Births Survey (n=8350)
compared induction rates in women with a BMI 20-30 with those in
women with a BMI 3021. These authors report the induction rate in the
lower BMI group as 25.5% whereas that in those with a BMI 30 is
reported as 36%. The retrospective cohort study from Aberdeen45 data
gives rates for induction of labour across BMI categories of underweight
(BMI<20), normal (BMI 20-24.9), overweight (BMI 25-29.9), obese (BMI
30.0-34.9) and morbidly obese (BMI>35) as 24.0%, 27.2%, 33.4%,
42.8% and 49% respectively. The London data17 showed lower induction
rates of 15.26%, 19.24% and 24.65% for BMI 20-25, BMI 25-30 and BMI
30 respectively. One other retrospective cohort study of singleton
pregnancies (n=22,294) born between 2004 and 2008 in Liverpool was
found46. The overall induction rate in this cohort was 29.1% with rates
ranging through 24.1%, 26.2%, 30.5%, 34.4%, 40.0%, 43.6% for
underweight (BMI≤19.9), normal (BMI 20-24.9), overweight (BMI 2529.9), obese (BMI 30-34.9), very obese (BMI 35-39.9) and morbidly
obese (BMI 40) women.
Dysfunctional labour
Failed labour induction is more common in obese women47. In a study of
126,080 deliveries, after excluding women with diabetes or hypertensive
disorders, obesity was associated with more failure to progress in the first
stage relative to women with normal BMI (OR 3.1; 95% CI 2.5-3.8)81.
Labour duration is not affected by maternal weight48.
Date: 4th December 2014
Version: v1 final
Page: 23 of 100
Public Health Wales
Maternal Obesity Report
Anaesthetic
Anaesthetic risks among women who are overweight or obese are
significant49.
The
need
for
emergency
anaesthesia
is
particularly
hazardous. Women with class II/III obesity have the highest rate of
complications, which include poor peripheral access, difficult placement of
epidural
or
spinal
anaesthesia,
difficult
intubation,
more
frequent
pulmonary aspiration during anaesthesia, and more frequent sleep
apnoea post partum49.
Caesarean Section
The CMACE cohort study reports an overall rate for caesarean section of
37% for all singleton deliveries in women with a BMI ≥35; that for the
general maternity population in England is given as 24.6%4.
The Cardiff Births Survey cohort (n=8350)21 compared caesarean section
rates in women with a BMI 20-30 with those in women with a BMI 30
reporting rates of 18% versus 27% respectively for these BMI groups.
The cohort from Aberdeen36 reported caesarean section rates of 11.3% in
underweight (BMI 20) women, 16.4% in normal weight (BMI 20-24.9)
women, 24.1% in those who were overweight (BMI 25-29.9), 30.8% in
obese women (BMI 30.0-34.9) and 42.7% in morbidly obese (BMI 35)
women.
A study50 using data from UKOSS examining complications in women with
BMI ≥50 noted that 50% of extremely obese women had caesarean
deliveries compared with 22% of women in the comparison group.
3.2.7 Wound Infection
Operative vaginal deliveries, third and fourth degree lacerations and
shoulder dystocia are more common with increasing maternal BMI47.
Date: 4th December 2014
Version: v1 final
Page: 24 of 100
Public Health Wales
Maternal Obesity Report
Overweight and obese women are more prone to infections such as
endometritis, urinary tract infections, wound infections and post operative
pneumonia17. In one of the largest observational studies addressing
pregnancy complications17, the risk of wound infection was increased
among women who were overweight (OR 1.3; 95% CI 1.1-1.5) or obese
(OR 2.2; 95% CI 1.9-2.6), compared with women of normal prepregnancy BMI. Similar figures were seen for urinary tract infection for
overweight (OR 1.2, 95% CI 1.04-1.3) and obese women (OR 1.4, 95%
CI 1.2-1.6), and genital tract infection among overweight (OR 1.24; 95%
CI 1.09-1.41) and obese (OR 1.30; 95% CI 1.07-1.56) women.
3.2.8 Postpartum Haemorrhage
A population-based cohort study including 1,114,071 women with
singleton pregnancies who gave birth in Sweden from January 1, 1997
through December 31, 2008, found evidence of increased risk of post
partum haemorrhage with increased BMI51. Obese women (class I-III)
were compared with normal weight women concerning the risk for
postpartum haemorrhage after suitable adjustments. The use of heparinlike drugs over the BMI strata was analyzed in a subgroup.
There was an increased prevalence of postpartum haemorrhage over the
study
period
associated
primarily
with
changes
in
maternal
characteristics. The risk of atonic uterine haemorrhage increased rapidly
with increasing BMI. There was a twofold increased risk in obesity class
III (1.8%). No association was found between postpartum haemorrhage
with retained placenta and maternal obesity. There was an increased risk
for postpartum haemorrhage for women with a BMI of 40 or higher
(5.2%) after normal delivery compared with normal-weight women
(4.4%) and even more pronounced (13.6%) after instrumental delivery
compared with normal-weight women (8.8%). Maternal obesity also
Date: 4th December 2014
Version: v1 final
Page: 25 of 100
Public Health Wales
Maternal Obesity Report
increases the likelihood of needing heparin type drugs (OR 2.86, 95% CI
2.22 – 3.68).51
3.3 Risks and complications – Baby
Babies of obese mothers are at increased risk of stillbirth32,52,
congenital anomalies53, prematurity54, macrosomia17,55,56 and neonatal
death52,55,57.
Intrauterine exposure to maternal obesity is also
associated with an increased risk of developing obesity and metabolic
disorders in childhood58.
3.3.1 Perinatal Mortality
Although
between-study
comparisons
are
hampered
by
different
definitions of perinatal mortality, there appears to be an association
between increasing maternal BMI and higher perinatal mortality rates. For
example, a Finnish study59 involving 25,601 singleton pregnancies
demonstrated that perinatal mortality was higher among overweight (OR
1.5, 95% CI 1.0-2.4) or obese women (OR 2.2, 95% CI 1.3-3.6)
compared with those of normal BMI. The association is strongest for
stillbirth.
Stillbirth is more common among women who are overweight (OR 1.5,
95% CI 1.1-1.9) or obese (OR 2.1, 95% CI 1.6-2.7), compared with
women with normal BMI (meta-analysis of 9 observational studies of
primarily nulliparous women)32. Although risk estimates were unadjusted,
several
cohort
studies
have
demonstrated
a
significant
positive
association between maternal obesity and stillbirth after adjusting for
factors such as maternal age, parity, diabetes, hypertensive disorders,
smoking, alcohol, and chronic disease59,60,61,62.
Neonatal death is more common among the infants of obese women. In a
Danish cohort study involving 24,505 women with singleton pregnancies,
obesity (vs. normal BMI) was associated with more neonatal death
Date: 4th December 2014
Version: v1 final
Page: 26 of 100
Public Health Wales
Maternal Obesity Report
(adjusted OR 2.7; 95% CI 1.2-6.1)35; similar rates were seen in a second
study involving women with class II/III obesity63. In neither study was
maternal overweight associated with neonatal death.
Maternal obesity is a risk factor for spontaneous abortion (for both
spontaneous conceptions and conceptions achieved through assisted
reproductive technology), as well as for unexplained stillbirth (intrauterine
fetal demise). A recent meta-analysis of 9 studies revealed that obese
pregnant women have an estimated risk of stillbirth that is twice that of
normal weight pregnant women32. Several mechanisms have been
proposed
for
this
relationship,
including
the
increased
risks
of
hypertensive disorders and gestational diabetes that are associated with
maternal obesity during pregnancy.
3.3.2 Congenital Malformations
There is a strong positive association between pre-pregnancy BMI and
birth defects, particularly those involving the neural tube64,65,66,67,68,69. A
case-control study using data from the Atlanta Birth Defects Risk Factor
Surveillance Study64 demonstrated a 7% increase in the risk of fetal
anomaly for each 1-unit incremental increase in BMI above a value of 25
kg/m2 (i.e. any degree of overweight or obesity).
The National Birth Defects Prevention Study (NBDPS), demonstrated an
association between pre-pregnancy BMI and 16 categories of structural
birth defects70. Excluded from analyses were mothers with important
confounders (e.g., pre-gestational diabetes) and adjustment was made
for pre-conceptual folic acid consumption.
This study found maternal
obesity to be most strongly associated with spina bifida (OR 2.1, 95% CI
1.6-2.7), as well as more severe forms of neural tube defect (i.e.
anencephaly and hydrocephaly)65,67,69,71,72. These data are consistent with
older studies65,66,67,69,71,73,74.
Date: 4th December 2014
Version: v1 final
Page: 27 of 100
Public Health Wales
Maternal Obesity Report
In the NBDPS study, maternal obesity was also positively associated with
heart defects (OR 1.4, 95% CI 1.2-1.6), omphalocoeles (OR 1.5, 95% CI
1.-4-2.2), hypospadias (OR 1.3, 95% CI 1.01-1.5), diaphragmatic hernia
(OR 1.4, 95% CI 1.03-2.0), and inversely associated with gastroschisis
(adjusted OR 0.2; 95% CI 0.1-0.3).
The reasons for an association between maternal obesity and a spectrum
of structural birth defects of different pathogenesis are unknown. For
example, maternal overweight is associated with a higher risk of
omphalocoeles (which result from a failure of reduction of mid-gut
herniation),
whereas
obesity
is
associated
with
reduced
risk
of
gastroschisis (which results from a vascular event). It must also be
recognized that some associations have reached only borderline statistical
significance and may be spurious. Regardless, undiagnosed maternal
diabetes has been suggested in the pathogenesis of maternal weightrelated fetal anomalies30,70. Also, although folic acid supplementation was
adjusted for in the aforementioned studies, there is some evidence that
obese women do not experience the typical reduction in neural tube
defect
risk
associated
with
folic
acid
supplementation
at
the
recommended 400 mcg/day66.
3.3.3 Pre-term Delivery
The association between maternal BMI and pre-term delivery remains
controversial with some studies showing an increased risk75,76,77,78,79,63,62
and others demonstrating a reduced risk or no change49,80,81. When
subtypes of pre-term birth are examined, however, infants of women who
are overweight or obese have a higher risk of iatrogenic preterm delivery
because of maternal complications, such as pre-eclampsia. The risk of
preterm delivery due to spontaneous preterm labour appears to be
reduced.
Date: 4th December 2014
Version: v1 final
Page: 28 of 100
Public Health Wales
Maternal Obesity Report
This was demonstrated in a recent study which reported an increase in
elective pre-term deliveries for women who were overweight (OR 1.2,
95% CI 1.03-1.3), obese (OR 1.5, 95% CI 1.3-1.8) or who had class II or
III obesity (OR 2.1, 95% CI 1.8-2.6), but a lower risk for spontaneous
preterm labour for women who were overweight (OR 0.9, 95% CI 0.80.98), class I obese (OR 0.9, 95% CI 0.7-0.99), and class II/III obese
(OR 0.8, 95% CI 0.6-1.03)63. A large Danish study reported similar
findings but in addition, noted a higher risk of preterm birth due to preterm, premature rupture of membranes (PPROM) which has been
associated with infections in the urogenital region62.
3.3.4 Neonatal Morbidity
Infants of women who are obese are more likely to have low APGAR
scores, hypoglycaemia, require resuscitation, and to be admitted to a
neonatal intensive care unit. In a retrospective cohort study, after
adjusting for maternal age, smoking, parity and pre-existing diabetes, the
risk of an APGAR score ≤3 at five minutes was significantly higher for
women who were overweight (OR 1.7; 95% CI 1.3-2.7), class I/II obese
(OR 3.2; 95% CI 2.1-4.8), or class III obese (OR 6.0; 95% CI 2.7-13.4),
compared with women of normal BMI77.
An Australian study reported that neonatal resuscitation was more
common among women who were overweight (OR 1.3, 95% CI 1.0-1.7)
or obese (OR 1.8; 95% CI 1.3-2.4), compared with infants born to
women of normal weight48. In addition, women who were obese were
twice as likely to deliver an infant with neonatal hypoglycaemia (OR 1.9;
95% CI 1.2-3.1)48.
In a Canadian cohort study involving 18,643 women, the risk of a
neonatal intensive care (NICU) admission was higher among infants born
to women who were overweight (OR 1.2; 95% CI 1.1-1.4), class I/II
Date: 4th December 2014
Version: v1 final
Page: 29 of 100
Public Health Wales
Maternal Obesity Report
obese (OR 1.6; 95% CI 1.4-1.9), or class III obese (OR 2.9; 95% CI 1.94.4)77.
3.3.5 Infant Birth Weight
Maternal BMI has an important independent influence on infant birth
weight. Several studies have demonstrated a protective effect of maternal
overweight on delivery of small for gestational age (SGA) infants80,78,59.
Macrosomia or a large for gestational age (LGA) infant are also more
common among women who are overweight (OR 1.3- 2.1) or obese; this
effect
persists
after
adjustment
for
maternal
diabetes
(OR
1.9-
3.5)35,75,76,77,82,78,79.
Macrosomia is a powerful predictor of shoulder dystocia and through this,
third and fourth degree perineal lacerations, blood loss, and neurological
injury to the infant81,83. Macrosomic infants also face an increased risk of
obesity later in life84.
3.3.6 Breastfeeding
Maternal obesity is associated with reduced breastfeeding rates, both in
terms of breastfeeding initiation and duration25,85. This is likely to be
multifactorial in origin, including women’s perception of breastfeeding,
difficulty with correct positioning of the baby, and the possibility of an
impaired prolactin response to suckling86.
Several epidemiological studies have found an inverse association
between maternal overweight and obesity and breastfeeding87,88,89,90,91. In
a large retrospective study, the likelihood of breastfeeding at discharge
was significantly lower among mothers who were overweight or obese
compared to those with normal BMIs35.
Date: 4th December 2014
Version: v1 final
Page: 30 of 100
Public Health Wales
Maternal Obesity Report
A systematic review of 22 observational studies found that after adjusting
for confounders, women who were overweight or obese planned to
breastfeed for a shorter period, were less likely to initiate breastfeeding,
had delayed lactogenesis, and breastfed for shorter durations compared
with women with normal BMIs25.
Date: 4th December 2014
Version: v1 final
Page: 31 of 100
Public Health Wales
Maternal Obesity Report
4. Best Practice Guidance
Pregnancy is a powerful motivator for change. It is a time when women
and their partners, often for the first time, are more susceptible to new
information92 and make positive lifestyle changes and choices in order to
provide the optimal conditions to ensure the health and wellbeing of their
unborn baby.
Therefore the period before, during and after pregnancy
provides opportunities to give women practical, consistent advice to help
them to improve their diet, become more physically active or to help
manage their weight effectively92 avoid associated complications and also
impact on the health and wellbeing of families5.
4.1 Before Pregnancy
Pre-pregnancy BMI is a greater determinant of health outcomes than any
weight they may gain during pregnancy93.
4.1.1 Weight Loss
The CMACE/RCOG Joint Guideline: ‘Management of Women with Obesity
in Pregnancy’ recommends that primary care services should ensure that
all women of childbearing age have the opportunity to optimize their
weight prior to pregnancy. Advice on weight and lifestyle should be given
during family planning consultations, and weight, body mass index and
waist circumference should be regularly monitored 1.
The
American
College
of
Obstetricians
and
Gynecologists
(ACOG)
recommends preconception counselling about potential complications of
maternal overweight and obesity, and participation in weight loss
programmes pre-pregnancy94.
Date: 4th December 2014
Version: v1 final
Page: 32 of 100
Public Health Wales
Maternal Obesity Report
Weight loss may improve fertility. A loss of 5-10% of body weight may
restore ovulation within six months for more than half of obese women
with polycystic ovarian syndrome (PCOS)95,96,97,98. If conception is not yet
desired,
contraception
should
be
advised,
even
for
women
with
demonstrated sub-fertility. Several studies have shown that following
bariatric surgery, fertility is improved99.
It is assumed that weight
reduction before pregnancy will improve future pregnancy outcomes, but
there are no randomized controlled trials that have established that this
assumption is correct.
A cohort study involving 150,000 Swedish women with two births
examined changes in BMI between pregnancies in relation to perinatal
morbidity. Women with a BMI decrease of more than one unit had
significantly lower rates of pre eclampsia and LGA infants in their second
pregnancy. However, as only 5.4% of women in this study were obese
and 19% were overweight, it is unclear whether such modest weight loss
in overweight or obese women would result in similar benefits100.
Several studies have shown that following bariatric surgery, adverse
maternal
(e.g.
pre-eclampsia,
GDM)
and
fetal
outcomes
(e.g.
macrosomia) are reduced in a subsequent pregnancy99. If a woman has
undergone
bariatric
surgery
prior
to
conception,
she
may
need
supplementation with vitamin B12, iron, calcium, and folic acid101,102,103.
Regardless of proven benefit on subsequent pregnancy outcomes, there
are recognized health benefits for women for moderate weight reduction
(on glycaemic control, BP, lipids, and the risk of stroke, coronary artery
disease and death) that make a convincing argument for advocating for
taking steps towards the achievement of a healthy weight outside of
pregnancy.
Date: 4th December 2014
Version: v1 final
Page: 33 of 100
Public Health Wales
Maternal Obesity Report
Outside of pregnancy, best practice for achievement of a healthy weight
involves
lifestyle
interventions
including
calorie
reduction,
physical
activity, and behavioural therapy. Pharmacotherapy and bariatric surgery
may also have a role. Canadian clinical practice guidelines recommend
consideration of pharmacotherapy for individuals with BMI≥ 27 in the
presence of cardiovascular risk factors or BMI ≥ 30 if 3-6 months of
lifestyle modification has been unsuccessful. Bariatric surgery could be
considered for individuals with BMI ≥ 35 and cardiovascular risk factors,
or BMI≥ 40 if other weight loss strategies have failed52.
4.1.2 Folic Acid Supplements
In the general maternity population, maternal folate deficiency is
associated with fetal congenital malformations104, and periconceptional
use of folic acid supplementation reduces the risk of the first occurrence,
as well as the recurrence, of Neural Tube Defects (NTD)105.
In women at high risk of fetal NTD (due to previous pregnancy with NTD),
a randomised double-blind prevention trial has shown that a higher dose
of folic acid supplementation (4mg/day) reduces the risk of a subsequent
NTD-affected pregnancy by 72% (RR 0.28, 95% CI 0.12–0.71).3087.
Women with a raised BMI are at increased risk of NTD, with a metaanalysis of 12 observational cohort studies reporting an odds ratio (OR) of
1.22 (95% CI 0.99–1.49), 1.70 (95% CI 1.34–2.15) and 3.11 (95% CI
1.75–5.46) for women defined as overweight, obese and severely obese,
respectively, compared with healthy-weight women53. There is evidence
from cross-sectional data that, compared to women with a BMI 27,
women with a BMI 27 are less likely to use nutritional supplements and
less likely to receive folate through their diet. However, compared to
women with a BMI 27, women with a BMI 27 have lower serum folate
levels even after controlling for folate intake157.
Date: 4th December 2014
Version: v1 final
Page: 34 of 100
Public Health Wales
Maternal Obesity Report
Women with a BMI  30 may need higher doses of folic acid to achieve
the same folate levels as women with a BMI 20 kg/m2106.
The findings from the studies above suggest that obese women should
receive higher doses of folate supplementation in order to minimise the
increased risk of fetal NTDs.
4.1.3 Best Practice Guidance for weight management
Table 2 below provides an overview of NICE6 and CMACE2 good practice
guidelines and clinical care recommendations for weight management
before and between pregnancies.
Table 2. Best Practice Guidance: Before or Between Pregnancies
Before and between pregnancies
All Women

All women of childbearing age should have the opportunity to
optimise their weight before pregnancy

Women with a BMI 30 should be encouraged to achieve a 5-10%
weight loss prior to conception.

Advice on weight and lifestyle should be given, including the need
to take daily folic acid supplements
Women with a BMI of 30 and above

Give information and advice about risks of obesity and pregnancy

Advise, encourage and support women to lose weight e.g. offer a
weight loss programme including diet and physical activity

Commence 5mg folic acid daily at least 1 month prior to conception

Health professionals should encourage women to check their weight
and waist management periodically or as a simple alternative, check
the fit of their clothes

Explain the increased risks that being obese poses to them and, if
they become pregnant again, their unborn child
Date: 4th December 2014
Version: v1 final
Page: 35 of 100
Public Health Wales
Maternal Obesity Report
4.2 During Pregnancy
4.2.1 Weight management
It is important that women are aware of the increased risk of maternal
and fetal complications associated with obesity, and they should be
advised about the possible strategies to minimise them prior to
conception. It is also important to give clear and consistent messages to
pregnant women about weight gain in conjunction with advice about
healthy eating during pregnancy, without advocating weight loss during
pregnancy. NICE guidance states that dieting during pregnancy is not
recommended as it may harm the health of the unborn child 6.
Many pregnant women ask health professionals for advice on what
constitutes appropriate weight gain during pregnancy. However, there are
no evidence-based UK guidelines on recommended weight-gain ranges
during pregnancy, due to the natural variations in the amount of weight a
woman may gain in pregnancy. Only some of the weight gain is due to
increased body fat – the unborn child, placenta, amniotic fluid and
increases in maternal blood and fluid volume also all contribute 6.
Pre-pregnancy BMI is used as a basis for recommended weight gain
during pregnancy in the Institute of Medicine (IOM) Pregnancy Weight
Guidelines, first published in 1990 and subsequently reviewed in 2009 by
a committee of the IOM with the National Research Council of the National
Academies107.
Table 3, below provides an overview of the IOM
recommendations for total and rate of Weight Gain during Pregnancy.
Date: 4th December 2014
Version: v1 final
Page: 36 of 100
Public Health Wales
Maternal Obesity Report
Table 3. IOM Recommendations for total and rate of weight gain
during pregnancy, by pre-pregnancy BMI (2009).
Pre pregnancy BMI
Total Weight
Gain
Range Range
in kg
in lbs
Rates of weight gain*
2nd and 3rd Trimester
Mean (range)
Mean
in kg/week
(range) in
lbs/week
Underweight (18.5)
12.5-18
28 - 40
0.51
(0.44 - 0.58)
1
(1 – 1.3)
Normal weight (18.5–24.9)
11.5- 16
25 - 35
0.42
(0.35 – 0.50)
1
(0.8 – 1)
7–11.5
15 – 25
0.28
(0.23 – 0.33)
0.6
(0.5 – 0.7)
5-9
11 - 20
0.22
(0.17 – 0.27)
0.5
(0.4 – 0.6)
Overweight (25.0–29.9)
Obese (29.9)
* Calculations assume a 0.5 – 2kg (1.1 – 4.4 lbs) weight gain in the first
trimester 108,109,110
The IOM committee considered whether any special populations warrant
separate guidelines, and examined evidence on women of short stature,
adolescents, women with multiple fetuses, racial or ethnic group, obesity
classes II and III, parity, and smokers. Of these, evidence suggests that
only women with multiple fetuses warrant modified guidelines, although
there is insufficient data with which to establish how much more weight
should be gained by women carrying multiple fetuses
107.
After the publication of the IOM report107, the World Health Organization
(WHO) held a consultation that developed a categorization of BMI values
for adults based on different cut-off points108. The WHO cut-off points
were subsequently endorsed by the National Institutes
of Health
(NHLBI)111. These categories have been widely adopted in the United
States and internationally and, if used in formulating recommendations
for gestational weight gain, would provide opportunities for a consistent
message to women and health care providers about weight status for all
groups of adults, including women of childbearing age. For these reasons,
the committee adopted the WHO BMI categories for its recommendations.
Evidence from the scientific literature is remarkably clear that preDate: 4th December 2014
Version: v1 final
Page: 37 of 100
Public Health Wales
Maternal Obesity Report
pregnant BMI is an independent predictor of many adverse outcomes of
pregnancy. These data provide ample justification for the choice made in
the IOM report to construct weight-gain guidelines according to prepregnant BMI107. That approach has been retained in the current
document.
Many approaches have been and are currently being used for making
recommendations for how much weight women should gain during
pregnancy. At one extreme is the advice from the National Centre for
Clinical Excellence in the United Kingdom that women should not be
weighed at all during pregnancy, “as it may produce unnecessary anxiety
with no added benefit” with the exception being “pregnant women in
whom nutrition is of concern112”. At the other extreme is the single target
approach. For example, in the United States, the 1970 report Maternal
Nutrition and the Course of Pregnancy113 recommended a single target:
an average gain of 10.9 kg (24 pounds), with a range of 9.1-11.3 kg (2025 pounds). This target was based on the amount of weight that healthy
women gain when meeting the physiologic needs of pregnancy (e.g., the
products of conception, expansion of plasma volume, red cell mass, and
maternal fat stores).
Still another approach has been used in Chile. Since 1987, maternal
weight gain recommendations have been based on a single target,
although instead of an absolute amount of weight, a proportion (120
percent) of the woman’s “standard weight” for her height is used114,115.
Consequently, the recommendation is for a higher gain in underweight
women and a lower gain in heavier women, with an upper limit of 7 kg for
women with pre-pregnant weights over 120 percent of the standard. The
objective of this recommendation is to increase birth weight among
underweight women, and it is considered successful in having done so115.
Similar
to
the
Chilean
recommendations,
the
IOM
report107
also
recommended higher gains for underweight women and lower gains (but
at least 6.8 kg) for heavier women. The desired outcome was expressed
Date: 4th December 2014
Version: v1 final
Page: 38 of 100
Public Health Wales
Maternal Obesity Report
as specific target ranges for each of three pre-pregnant body mass index
(BMI) groups. The rationale for this approach was to achieve the birth
weight (i.e., 3-4 kg) associated with “a favourable pregnancy outcome” in
all pre-pregnant BMI groups while avoiding the birth of infants with
weight  4 kg because of “the possible risks to the mother and infant of
complicated labour and delivery107”.
In constructing their recommendations, the IOM committee explicitly
recognized the trade-off between raising the birth weight of infants born
to underweight women and increasing the risk of high birth weight in
some infants as well as obesity and other undesirable outcomes in their
mothers107.
In fact, the IOM committee recommended that a formal
decision analysis be undertaken “in which probabilities and utilities
(values) are assigned to each potential outcome” to assist in balancing
the risks and benefits of any recommendation107
4.2.2 Vitamin D
Pre-pregnancy BMI is inversely associated with serum vitamin D
concentrations among pregnant women, and women with obesity (BMI
30) are at increased risk of vitamin D deficiency compared to women
with a healthy weight (BMI 25)62. Cord serum Vitamin D levels in babies
of obese women have also been found to be lower than babies born to
non-obese women62.
The main source of vitamin D is synthesis on exposure of the skin to
sunlight. However, in the UK there is limited sunlight of the appropriate
wavelength, particularly during winter. A recent survey in Britain showed
that about a quarter of British women aged 19–24 and a sixth of those
aged 25–34 are at risk of vitamin D deficiency116.
Maternal skin exposure alone may not always be enough to achieve the
optimal vitamin D status needed for pregnancy and the recommended
Date: 4th December 2014
Version: v1 final
Page: 39 of 100
Public Health Wales
Maternal Obesity Report
oral intake of 10 micrograms Vitamin D daily for all pregnant and
breastfeeding women cannot usually be met from diet alone.
Table 4. Best Practice Guidance: During Pregnancy
2,6
During Pregnancy
All Women

Measure weight and height at the first contact with the pregnant
woman, being sensitive to any concerns she may have about her
weight. Clearly explain why this information is needed and how it
will be used to plan her care. Use BMI percentile charts for pregnant
women under 18 years.

Weight, height and BMI should be recorded in notes, the woman’s
hand held record and the patient information system. If hand-held
record is not available, use local protocols to record this information

Discuss eating habits and physical activity. Find out any concerns
and try to address.

Advise that a healthy diet and being physically active will benefit
both woman and unborn child during pregnancy and will also help to
achieve a healthy weight after giving birth

Offer practical and tailored information e.g. advice on how to use
Healthy Start vouchers

Dispel any myths about what and how much to eat during
pregnancy e.g. there is no need to ‘eat for two’

Advise that moderate-intensity physical activity will not harm the
woman or unborn child. At least 30 minutes per day of moderate
intensity activity is recommended

Give specific and practical advice about being physically active
during pregnancy:
-
Recommend recreational exercise such as swimming or brisk
walking and strength conditioning exercise is safe beneficial
-
the aim of recreational exercise is to stay fit, rather than to reach
peak fitness
-
if women have not exercised routinely they should begin with no
more than 15 minutes of continuous exercise, three times per week,
increasing gradually to daily 30-minute sessions
-
if women exercised regularly before pregnancy they should be able
to continue with no adverse effect

Explain to those who would find this level of physical activity
difficult that it is important not to be sedentary, as far as possible.
Date: 4th December 2014
Version: v1 final
Page: 40 of 100
Public Health Wales
Maternal Obesity Report
Encourage them to start walking and to build physical activity into
daily life, for example, by taking the stairs instead of the lift.
Women with a BMI of 30 and above
Booking visit:

Measure weight and height, calculate and document BMI in hand
held record and patient information system

Give information about risk of obesity and pregnancy and how to
minimise them

Offer women a referral to a dietician or an appropriately trained
health professional for assessment and personalised advice on
healthy eating and how to be physically active

Use appropriate size BP cuff

Continue 5 mg folic acid daily up to 12 weeks

Commence 10 mcg Vitamin D daily throughout pregnancy

Assess thromboembolism risk

Thromboprophylaxis if indicated

Book for glucose tolerance test at 24-28 weeks

Refer to consultant obstetrician to discuss delivery plan

BMI ≥35 as above plus:

Refer to specialist care if one or more additional risk factors for preeclampsia

BMI ≥40 as above plus:

Arrange antenatal anaesthesia review
Throughout Pregnancy:

Assess thromboembolism risk

Thromboprophylaxis if indicated

Use appropriate size BP cuff

BMI ≥35 as above plus:

Monitor for pre-eclampsia 3 weekly between 24-32 weeks and 2
weekly from 32 weeks to delivery
Date: 4th December 2014
Version: v1 final
Page: 41 of 100
Public Health Wales
Maternal Obesity Report
Third Trimester:

75g oral glucose tolerance test at 24-28 weeks

Give advice and support regarding
maintenance of breastfeeding

BMI ≥ 40 as above plus:

Re-measure maternal weight

Risk assessment for manual handling requirements
benefits,
initiation
and
Labour and Delivery

Individual risk assessment to decide planned place of birth

Recommend active management of third stage of labour

Ensure single dose of prophylactic antibiotics given at caesarean
section

Suture subcutaneous tissue space at caesarean section if more than
2 cm subcutaneous fat

BMI ≥ 35 as above plus:

Advise birth in consultant-led obstetric unit

Alert theatre staff if
intervention in theatre

BMI ≥40 as above plus:

Continuous midwifery care

Inform duty anaesthetist if delivery or operative intervention
anticipated

Establish early venous access

Consider early epidural in labour

Inform obstetrician and anaesthetist

Senior obstetrician and anaesthetist to review on ward rounds and
attend operative vaginal or abdominal delivery
Date: 4th December 2014
weight
>120kg
Version: v1 final
and
needs
operative
Page: 42 of 100
Public Health Wales
Maternal Obesity Report
4.3 After and Between Pregnancy
4.3.1 Weight Loss
Use the 6-8 week postnatal check to offer weight loss support2,6.
A study showed that 12% of women retained at least 11lbs one year
postpartum - these women were more likely to have gained excessive
weight during pregnancy and to be younger, heavier prior to pregnancy,
non-white, unmarried, primiparous, and of lower socioeconomic status117.
For multiparous women, weight retention from previous pregnancies and
the quality of health care received between pregnancies appear to be
important determinants of subsequent pre-pregnancy weight117. A large
epidemiologic study in Sweden demonstrated that an increase in interpregnancy BMI (by at least 3 kg/m2) was associated with a higher risk of
adverse pregnancy outcomes100.
4.3.2 Breastfeeding
Evidence derived from randomised controlled trials in the general
maternity population shows that breastfeeding education and support is
associated with higher breastfeeding initiation rates and, in some
instances, longer durations of breastfeeding118,119.
Women with obesity should have an opportunity during the antenatal
period to discuss the benefits of breastfeeding and the support that will be
available to them, so that they can make an informed decision regarding
feeding choices. Dedicated breastfeeding support during the postnatal
period is also needed to overcome any potential difficulties with feeding.
Date: 4th December 2014
Version: v1 final
Page: 43 of 100
Public Health Wales
Maternal Obesity Report
Table 5. Best Practice Guidance: After Pregnancy2,6
After Pregnancy
All Women

During the 6-8 week postnatal check, or during the follow-up
appointment within the next 6 months, provide clear, tailored,
consistent, up-to-date and timely advice about how to lose weight
safely after childbirth. Advice on healthy eating and physical activity
should be tailored to her circumstances.

Health professionals should advise women, their partners and family
to seek information and advice from a reputable source.

Health professionals should give advice on recreational exercise
from the Royal College of Obstetricians and Gynaecologists. In
summary, this states that:

If pregnancy and delivery are uncomplicated, a mild exercise
programme consisting of walking, pelvic floor exercises and
stretching may begin immediately. But women should not resume
high-impact activity too soon after giving birth.

After complicated deliveries, or lower segment caesareans, a
medical care-giver should be consulted before resuming prepregnancy levels of physical activity, usually after the first check-up
at 6-8 weeks after giving birth.

Health professionals should emphasise the importance of
participating in physical activities, such as walking, which can be
built into daily life.

Use the 6-8 week postnatal check as an opportunity to discuss the
woman’s weight. Ask those who are overweight, obese or who have
concerns about their weight if they would like any further advice
and support now – or later. If they say they would like help later,
they should be asked whether they would like to make an
appointment within the next 6 months for advice and support.

Women who want support to lose weight should be given details of
appropriate community-based services.

Midwives and other health professionals should encourage women
to breastfeed. They should reassure them that a healthy diet and
regular, moderate-intensity physical activity and gradual weight loss
will not adversely affect the ability to breastfeed or the quantity or
quality of breast milk.
Date: 4th December 2014
Version: v1 final
Page: 44 of 100
Public Health Wales
Maternal Obesity Report
Women with a BMI of 30 and above

Encourage to mobilise as early as practicable

Commence postnatal Thromboprophylaxis for 7 days if one or more
additional risk factors for thromboembolism

Provide compression stockings if > 2 additional risk factors for
thromboembolism

Give advice and support regarding
maintenance of breastfeeding

Offer a structured weight loss programme or refer for ongoing
dietetic and lifestyle advice

Explain the increased risks that being obese poses to them and, if
they become pregnant again, their unborn child

If gestational diabetes:

Test of glucose tolerance 6 weekly postnatally

Offer lifestyle and weight management advice

Refer to GP for annual screening for type 2 diabetes and cardio
metabolic risk factors
benefits,
initiation
and
BMI ≥40 - as above plus:

Commence postnatal thromboprophylaxis for 7 days regardless of
delivery mode
Date: 4th December 2014
Version: v1 final
Page: 45 of 100
Public Health Wales
Maternal Obesity Report
5. Implementing Best Practice Guidance: Issues and
Solutions
5.1 Perceptions and environment
5.1.1 Issues
Pregnancy can be a time when women express ambivalence towards
eating behaviour; justifying over eating during pregnancy.
Some
welcome the freedom they perceive that pregnancy gives them to eat
without limitations, with excess eating being perceived to be positive for
the baby – ‘eating for two’.
A general decline in physical activity can also occur during pregnancy: a
range of factors contributing including; anxiety about risks to the unborn
baby, general physical discomfort, discouragement to undertake physical
tasks by people around them, poor access to exercise facilities and a
sense that pregnancy was a time to take it easy and opt out of certain
tasks. Also feelings of fullness, nausea or hunger, physical discomfort in
later pregnancy all contribute to changing a woman’s normal patterns of
behaviour120. Pregnant women may also not be aware of the importance
of weight gain restriction nor the benefits of eating healthily or exercising
during pregnancy121,122.
The technological revolution of the 20 th century has left in its wake an
‘obesogenic
environment’92
an
environment
in
which
influences,
surrounding opportunities or conditions of life combine to promote weight
gain in individuals or populations123, this includes access to safe spaces to
be active and to an affordable, healthy diet124.
5.1.2 Solutions
When working with potential, pregnant and new mothers’ health
professionals should follow the usual principles of person centred care124.
Date: 4th December 2014
Version: v1 final
Page: 46 of 100
Public Health Wales
Maternal Obesity Report
Good communication between health professional and patient is essential,
it should be supported by evidence based written information, such as the
NICE recommendations provided in Appendix 2.
5.2 Education and Communication
5.2.1 Issues
The
provision
and
communication
of
information
is
not
always
straightforward as studies have found the absence of information or the
contradictory nature of information available to women regarding weight
management during their pregnancy.
Where advice was given it
addressed healthy eating rather than weight management issues and
information when given was contradictory and confusing120,122,126,127.
Women report that information and advice comes from three main
sources during their pregnancy: family and friends, the media and health
professionals. Advice about healthy dietary patterns and physical activity
behaviours in pregnancy appeared to be strongly influenced by the views
of the peer support structures around women during pregnancy.
This
exerts a powerful influence and may serve to undermine the messages of
health professionals126.
A study in 2011 found that women understood that eating and activity
were related to weight and health; however they lacked confidence about
intake requirements, food safety and appropriate levels and types of
exercise in pregnancy. This confusion was exacerbated by what they
perceived as ever-changing media messages and a lack of nutritional
advice.
In contrast midwives felt some of their clients lacked the
knowledge and skills to maintain a healthy lifestyle128.
There are potential barriers to achieving weight loss among women who
are overweight or obese and planning a pregnancy. First, 50% of
Date: 4th December 2014
Version: v1 final
Page: 47 of 100
Public Health Wales
Maternal Obesity Report
pregnancies are unplanned. Second, as the most successfully maintained
weight loss involves lifestyle change resulting in slow progressive weight
loss, it is possible that women who are planning pregnancy may not be
willing to wait for such a long time prior to conceiving. In the setting of
advanced maternal age, it may even be inappropriate to suggest that
conception be delayed to achieve weight loss. There appears to be a
consensus, however, that pregnancy should be delayed for two years
following bariatric surgery, during which time one sees the majority of the
weight loss and postoperative complications.14
5.2.2 Solutions
Women, their partners and their families should always be treated with
kindness, respect and dignity. The views, beliefs and values of the
woman, her partner and her family in relation to her care and that of her
baby should be sought and respected at all times. Women should have
the opportunity to make informed decisions about their care and every
opportunity should be taken to provide the woman and her partner or
other relevant family members with the information and support they
need125.
Good communication between healthcare professionals and women is
essential. It should be supported by evidence-based, written information
tailored to the woman's needs. Care and information should be culturally
appropriate. All information should also be accessible to women with
additional needs such as physical, sensory or learning disabilities, and to
women who do not speak or read English125.
Date: 4th December 2014
Version: v1 final
Page: 48 of 100
Public Health Wales
Maternal Obesity Report
5.3 Workforce Development
5.3.1 Issues
Health professionals are often too embarrassed to initiate a discussion
around weight management due
overweight or obese women125.
to
the
perceived sensitivities
of
Some studies found that none of the
trained professionals involved in delivering antenatal care had the skills to
address issues of healthy dietary and physical activity behaviours in
pregnancy instead they relied on nutritionists, dieticians or fitness
instructors to deliver the interventions, the health messages therefore
may not be consistent125.
Too often health professionals ignore the obvious signs or symptoms of
obesity or simply instruct the individual to go on a diet and lose significant
weight. It is therefore not surprising that most healthcare interventions
only happen when medical complications and morbidity are apparent. This
oversight by healthcare professionals reflects a poor understanding and
lack of recognition of the social and environmental determinants of
obesity, the complexity of nutritional issues, barriers to physical activity,
and lack of understanding of the factors that impact behavioural
change126.
There is limited information provided in both undergraduate
postgraduate
training
programmes
and
minimal
focus
on
and
weight
management in specialist medical training. Health professionals either
lack appreciation of the health and medical consequences of obesity or
lack confidence and the ability to help122.
5.3.2 Solutions
A whole health approach should also be discussed including how
maternity services should look at a wellness model in a positive way and
Date: 4th December 2014
Version: v1 final
Page: 49 of 100
Public Health Wales
Maternal Obesity Report
think outside the box beyond what is core provision.
Effective services to
address maternal obesity need to think beyond pregnancy and should
include more continuity and a better transition between pre conception,
antenatal, labour, postnatal and long term services129.
NICE recommends that any healthcare professional involved in the
delivery of interventions for weight management should have relevant
competencies and have undergone specific training.
Training for health
professionals should include130:

The health benefits and the potential effectiveness of interventions
to prevent obesity, increase activity levels and improve diet (and
reduce energy intake)

The best practice approaches in delivering such interventions,
including tailoring support to met people’s needs over the long term

The use of motivational interviewing and counselling techniques
Training also needs to address barriers that health professionals may
experience in providing support and advice130.
Regardless of the particular discipline of the health professional, or the
setting in which he/she works the message that needs to be heard, is that
‘managing overweight and obesity is everybody’s business’.
The causes
of obesity are complex and the solutions for individuals are equally so.
Healthcare professionals need to understand the complexities connected
with people being obese.
They need to understand the fundamentals of
nutritional science, physical activity and the social, psychological and
environmental factors that underpin obesity and be able to apply these to
their clinical practice on an everyday basis131.
The Royal College of Physicians recommends that to meet the increased
demand, every health professional will need to be trained to identify those
at risk from increasing body weight, and be skilled in the initial
management of the condition.
Date: 4th December 2014
Many health professionals are taught to
Version: v1 final
Page: 50 of 100
Public Health Wales
Maternal Obesity Report
take a ‘social history’, or enquire about ‘risk factors’ as part of their
assessment.
This
includes
questions
about
occupation,
alcohol
consumption and smoking. In future health professionals should be
encouraged to include a brief assessment of regular diet and physical
activity within this part of their assessment131.
5.4 Psychosocial/Psychological Support
5.4.1 Issues
Maternal obesity also has implications in stigmatisation and possible social
exclusion132,133,134,135. There is a fear that raising the issue of obesity with
the mother without the necessary support mechanisms in place could
potentially increase feelings of stigma and victimisation132,136,137 this has
been supported by Wiles138 who found that comments and advice by the
medical profession about weight were perceived by women as being
insulting or derogatory138. There was also the fear of women withdrawing
from antenatal care as a consequence120.
The stigma of obesity can have different meanings for women and
midwives. The study by Furness et al (2011) found that midwives
discussed how attitudes towards weight had changed over time, there
was a greater acceptance of obesity and the relative ease today of finding
fashionable clothing in larger sizes. They felt these social changes meant
larger women were still able make positive social comparisons and were
less motivated to heed midwives' advice to alter health behaviours and
manage weight.
Women in the study had different views, although
aware of changing attitudes, they felt stigmatised due to their weight and
vulnerable to negative attitudes and judgements nonetheless.
Women
reported embarrassment about their weight during and after pregnancy
and feeling conspicuous in social situations128,129.
Date: 4th December 2014
Version: v1 final
Page: 51 of 100
Public Health Wales
Maternal Obesity Report
This difference in attitudes suggests that midwives may inadvertently
make
assumptions
about
women's
response
to
their
size
and
underestimate the pressures upon them. This could limit their ability to
understand and respond to the psychosocial consequences of obesity for
women.
Women can also experience a more passive role where food is provided
by women’s mothers and women are encouraged to rest. Some describe
weight gain as an inevitable and desirable and not something over which
they could exert much control.
For overweight and obese women
pregnancy can be a time where they feel more comfortable with their
body image.
Pregnancy is seen as a time when being large is socially
acceptable and therefore conferred a sense of confidence that had been
lacking in their non-pregnant state130,139.
Very few studies have looked at the relationship between maternal
obesity and mental health but more have focused on general obesity and
mental health. Results from the most recent systematic review of
longitudinal studies point towards bidirectional associations between
depression and obesity. Luppino et al (2010) conclude that: ‘Obese
persons had a 55% increased risk of developing depression over time,
whereas depressed persons had a 58% increased risk of becoming
obese’140. Another recent systematic review and meta-analysis found a
weak but positive association between obesity and anxiety disorders141.
There are various theories as to why obesity could lead to poor mental
health in adults. These emphasise the increased medical problems and
mobility restrictions associated with obesity which can have a direct
impact on psychological well-being, and can lead to depression, eating
disorders, distorted body image and low self-esteem142.
There is less research on the mechanisms that may cause adults with
common mental health disorders to become obese. It has been suggested
that poor mental health can lead to unhealthy lifestyle choices and
Date: 4th December 2014
Version: v1 final
Page: 52 of 100
Public Health Wales
Maternal Obesity Report
increased appetite. A combination of the biological affect of increased
stress alongside poor adherence to weight loss programmes, binge
eating, negative thoughts and reduced social support, may make it
difficult for a depressed person to avoid weight gain143. There is also
evidence that people with chronic or repeated episodes of depression are
at particular risk of subsequent obesity144.
A recent review found that weight stigma increases vulnerability to
depression, low self esteem, poor body image, maladaptive eating
behaviours
and
exercise
avoidance.
These
negative
consequences
challenge the idea that stigma may serve a positive function on
motivating healthy eating behaviours145.
5.4.2 Solutions
Social support is considered one of the key influences upon and
motivators for physical activity and healthy lifestyle changes, especially
for women146,147,148. This indicates the importance of taking a holistic
approach to midwifery care, considering the woman's social support
network and influences and including family members in consultations
where appropriate and consented.
Midwives and health professionals may underestimate the considerable
social stigma of obesity for the pregnant and postpartum woman. As well
as encouraging healthy lifestyle choices, they should be aware of the
psychosocial impact of obesity, be prepared to offer psychological support
to
avoid
women
feeling
isolated,
and
take
a
constructive,
non-
judgemental approach to care. Midwives have reported struggling to talk
to women openly about their weight, which suggests educators and
experienced practitioners may need to consider how best to prepare and
support staff caring for this client group.128
Date: 4th December 2014
Version: v1 final
Page: 53 of 100
Public Health Wales
Maternal Obesity Report
The influence of the social environment and, in particular, the views of
peers and ‘significant others’ is a common theme as people tend to
engage in behaviour which is practiced by, and valued by their peers.
Self-efficacy can also be a key determinant of eating and physical activity
behaviour. Researchers have recommended that motivational education
techniques may be useful in influencing personal belief and therefore
support
sustained
behaviour
change149.
A
review
that
looked
at
randomised, controlled psychological interventions for overweight or
obese adults supports theories of behaviour change and advocates an
approach to weight management that focuses on using cognitive
therapies to change behaviour combined with healthy eating education
and exercise components150.
At each postnatal contact, women should be asked about their emotional
well-being, what family and social support they have and their usual
coping strategies for dealing with day-to-day matters. Women and their
families/partners
should
be
encouraged
to
tell
their
healthcare
professional about any changes in mood, emotional state and behaviour
that are outside of the woman’s normal pattern151.
Should this not be
encouraged at ante natal appointments also?
All healthcare professionals should be aware of signs and symptoms of
maternal mental health problems that may be experienced in the weeks
and months after the birth.
Women should be encouraged to help look
after their mental health by looking after themselves. This includes taking
gentle exercise, taking time to rest, getting help with caring for the baby,
talking to someone about their feelings and ensuring they can access
social support networks151.
Health professionals also need sufficient knowledge and skills to support
patients and families in changing behaviours to prevent weight gain and
to initiate and maintain weight loss.
These behaviours are difficult to
change and may not always be understood by practitioners who may
Date: 4th December 2014
Version: v1 final
Page: 54 of 100
Public Health Wales
Maternal Obesity Report
themselves have a different set of embedded behaviours. Building
capacity and capability of practitioners to deliver behaviour change at
individual and population level is key to achieving weight management
targets152.
Training should therefore focus on how to raise weight management
issues with patients and parents, assess their views, build rapport and
facilitate discussion about the barriers and challenges of change92. In
addition, health professionals need to be skilled in helping a patient or
parent identify appropriate behaviour change targets and supporting them
in the change process.
Date: 4th December 2014
Version: v1 final
Page: 55 of 100
Public Health Wales
Maternal Obesity Report
6. Economic Costs
Rowlands et al (2009) published a general review article on the
economics of obesity in pregnancy.154 These authors noted that the
economic implications of maternal obesity had gained relatively little
research attention despite the fact there was evidence of higher rates of
caesarean deliveries, greater usage of antibiotics and intravenous
infusions due to wound infections with consequent longer lengths of stay
in those obese mothers.
In addition, the incidence of post-partum
haemorrhage is also higher in obese mothers which can lead to longer
hospitalisation, increased drug costs, transfusion, theatre and possibly
intensive care treatment. Both growth restriction of the fetus and large
for gestational age babies have a knock- on effect on the number of scans
and
tests
required
antenatally
as
a
higher-than-normal
BMI
was
associated with significantly more prenatal foetal tests, obstetrical
ultrasound
examinations
with
greater
difficulty
conducting
such
monitoring in obese women.
“Almost all of the increase in use of services was related to the increased
rates of caesarean delivery, gestational diabetes mellitus, pre-existing
diabetes mellitus, and hypertensive disorders among obese pregnant
women.”
154
A UK study (n=651, data collection 2007/8) attempted to capture the
increased costs associated with the minor complications found to be
associated with increasing BMI during pregnancy namely symphysis pubis
dysfunction, heartburn, carpal tunnel syndrome and chest infection155.
These authors report the mean incremental (additional) NHS costs per
woman for treating these were £15.45, £17.64 and £48.66 pounds per
woman for BMI 25 kg/m2, BMI 25 to 30 kg/m2 and BMI 30 kg/m2
respectively. The authors note that in their study women with a BMI of
≥30 Kg/m2 accounted for 39%, 57%, 31% and 27% of the additional
Date: 4th December 2014
Version: v1 final
Page: 56 of 100
Public Health Wales
Maternal Obesity Report
NHS costs for symphysis pubis dysfunction, chest infection, heartburn and
carpal tunnel syndrome respectively.
NICE156 have developed a costing report in association with PH27
guidance6 on weight management before during and after pregnancy.
Although not giving an outline cost of the economic impact of maternal
obesity in the UK it does detail associated costs of some high risk
conditions. However, as women who are obese when they become
pregnant face an increased risk of complications during pregnancy and
childbirth, it is reasonable to assume that a reduction in obesity has the
potential to result in savings.
Benefits and savings
Implementing the NICE public health guidance 27 may bring the following
benefits6:
• A decrease in the number of women experiencing complications during
pregnancy.
For example, additional costs are incurred when women develop
conditions such as gestational diabetes and pre-eclampsia. These
cost an additional £1139158 and £8628159 per person respectively,
compared to an uncomplicated pregnancy.
• A decrease in the number of women experiencing complications during
delivery.
For example, obese women are more likely to need a caesarean
section, which costs an additional £1987 compared to a vaginal
delivery (payment by result tariff 2010–11).
Obese women who are pregnant are likely to spend longer in hospital
than those with a healthy weight because of morbidity during
pregnancy and labour related to their weight160.
• A decrease in the number of women who remain obese after childbirth.
Date: 4th December 2014
Version: v1 final
Page: 57 of 100
Public Health Wales
Maternal Obesity Report
The National Obesity Observatory report3 that maternal obesity can
lead to the need for additional healthcare due to complications
associated with the pregnancy. Resource implications relating to
maternal obesity have been identified as161-167:

increases in caesarean and operative deliveries

admission to hospital for complications

length of hospital stay

requirements for neonatal intensive care

a need for appropriate equipment to manage safely the
care of obese mothers
There are also technical issues to consider during pregnancy including
difficulties in performing ultrasound examinations, the size of blood
pressure cuffs required, issues concerning foetal monitoring, women
having reduced awareness of foetal movements, problems encountered
with surgical deliveries and equipment, and implications for regional and
general anaesthesia163.
There is a lack of data on the cost of maternal obesity in the UK. The
impact of maternal overweight and obesity on healthcare costs has been
studied in France, where the cost of prenatal care was higher in women
with a BMI of more than 25kg/m2 compared with women with a BMI of 18
to 24.9 kg/m2165,166. When both pre and postnatal care were considered,
the costs were even higher in women with a BMI of more than 29kg/m2
due to longer hospital admissions166.
Date: 4th December 2014
Version: v1 final
Page: 58 of 100
Public Health Wales
7.
Maternal Obesity Report
Population approach to Obesity
“There is also a much wider and long term public health message here.
There is a real need to reduce obesity in the population as a whole,
tackling the issue before women get pregnant”153
The UK Governments Foresight Report92 and NICE Guidance130 provide a
comprehensive overview of the challenges presented by obesity. Many of
the evidence based recommendations presented in these documents not
only
focus
on
individual
strategies
for
change
but
also
present
interventions to address the obesity epidemic at multiple levels to include
the family and community as well as the wider physical and social
environment that may, through design, limit opportunities to be active or
eat a healthy diet.
In Wales, a number of policy documents reinforce the need to tackle the
root causes of obesity. For example, Our Healthy Future169 not only aims
to improve quality and length of life but also focuses on equity and
reducing inequalities with two of its ten priorities (healthy eating and
physical activity) having a direct impact on obesity. The Wales Obesity
Pathway170 provides a tool for Local Health Boards, Local Authorities and
other key stakeholders to not only map local policies and services to
address obesity but also ensure local measure to tackle obesity are
incorporated into Health, Social Care and Wellbeing Plans, Children and
Young Peoples Single Plans, Community Plans and Local Development
Plans. Appendix 3 provides an overview of interventions, by Local Health
Board (LHB) area in Wales, to address maternal obesity.
NICE has made the following recommendations (Table 6, below) for the
prevention, assessment and management of overweight and obesity in
adults and children.
The recommendations emphasis the need for joint
working across a statutory, voluntary and private sectors to ensure the
Date: 4th December 2014
Version: v1 final
Page: 59 of 100
Public Health Wales
Maternal Obesity Report
opportunity to reduce obesity and achieve a healthy weight are promoted.
130
Table 6. Recommendations for the prevention, identification,
assessment and management of overweight and obesity in adults
and children
Target
Suggested Action
RECOMMENDATIONS FOR LOCAL AUTHORITIES AND THIRD SECTOR
PARTNERS
Prevent and
manage obesity in
local authority
workplaces
All relevant workplaces policies should support the local
obesity strategy:
- onsite catering should promote healthy food and drink
choices
- physical activity should be promoted through active
travel plans, encouraging staff to use stairs, and
providing showers and secure bike parking
Policy and
planning

Encourage active
travel in the
community

Provide facilities and information such as:
- tailored active travel plans for motivated people
- cycle lanes and cycle parking
- walking routes, including area maps and pedestrian
crossings
- traffic calming measures
- improved street lighting
Promote and
support physical
activity

Ensure building designs encourage the use of stairs and
walkways
Provide safe play areas
Support local physical activity schemes
Work with the local community to identify environmental
barriers to eating healthily and being physically active
through :
- an audit, involving “LHBs”, residents, businesses and
institutions
- assessing (ideally by health impact assessments) the
impact of policies on people’s ability to eat healthily and
be physically active, and considering subgroups such as
people of different ages, from different socioeconomic
and ethnic groups, and people with disabilities
 Address concerns about safety, crime and inclusion
 Consider particularly people who need tailored information
and support, especially inactive, vulnerable groups
 Facilitate links between health professionals and others to
ensure local policies improve access to healthy food and
opportunities for physical activity


Date: 4th December 2014
Version: v1 final
Page: 60 of 100
Public Health Wales
Maternal Obesity Report
Target
Suggested Action
Promote healthy
foods

Encourage local shops and caterers to promote healthy
food and drink choices via signs, posters and pricing
Community
programmes to
prevent obesity
and improve diet
and physical
activity levels

Address people’s concerns about the availability of
services, costs of making changes, the taste of healthy
foods, dangers of walking and cycling, and mixed
messages in the media about weight, diet and activity
Include awareness-raising promotional activities, but as
part of a longer-term, multicomponent interventions, not
on their own

RECOMMENDATIONS FOR WORKPLACES
Policies and
working practices

Ensure policies encourage activity and healthy eating; for
example, travel expenses should encourage walking and
cycling to work and between work sites
Building design

Provide showers and secure cycle parking to encourage
active travel
Improve stairwells to encourage use of stairs

Physical activity

Support out-of-hours activities such as lunchtime walks
and the use of local leisure facilities
Workplace food
provision

Actively promote healthy choices in restaurants,
hospitality, vending machines and shops for staff and
clients, in line with “FSA advice”
For example, using signs, posters, pricing and positioning
of products to encourage healthy choices

Education and
promotion
Any incentive schemes should be sustained and part of a wider
programme to encourage healthy eating, weight management
and physical activity. Examples of schemes include:
- travel expenses policies
- policies on pricing food and drink
- contributions to gym membership
Public sector and large commercial organisations:
- offer tailored education and promotion programmes to
support any action to improve food and drink in the workplaces (including restaurants, hospitality and
vending machines). To be effective, schemes need:
- commitment from senior management
- an enthusiastic catering department
- a strong occupational health lead
- supportive pricing policies and heavy promotion
Date: 4th December 2014
Version: v1 final
Page: 61 of 100
Public Health Wales
Maternal Obesity Report
Target
Suggested Action
Health checks
Public sector and large commercial organisations: if
employee health checks are offered, they should address
weight, diet and activity, and provide ongoing support
RECOMMENDATIONS FOR THE PUBLIC
General advice
Healthy
balanced diet
Physical activity
Check your weight or waist measurement every now and then,
or keep track of the ‘fit’ of your clothes, to make sure you are
not gaining weight
Discuss any concerns about your (or your family’s) diet,
activity levels or weight with a GP or practice nurse, health
visitor, school nurse or pharmacist
See Appendix 2 for Guidelines
Children and young people should have regular meals in a
pleasant, sociable environment with no distractions (such as
television); parents and carers should join them as often as
possible
See Appendix 4 for Guidelines
Make activities you enjoy such as walking, cycling, swimming,
aerobics or gardening – part of your everyday life. Small
everyday changes can make a difference
At work, take the stairs instead of the lift, or go for a walk at
lunchtime
Avoid sitting too long in front of the television, computer or
playing video games
For children:
 gradually reduce the time they are sitting in front of a
screen
 encourage games that involve running around, such as
skipping, dancing or ball games
 be more active as a family, by walking or cycling to
school, going to the park, or swimming
 encourage children to take part in sport inside and
outside school
Date: 4th December 2014
Version: v1 final
Page: 62 of 100
Public Health Wales
Maternal Obesity Report
8. Conclusion
This review provides a clear indication that obesity has substantial
implications for maternal, fetal and neonatal health and presents a
significant problem to those services delivering obstetric and neonatal
care. While the ideal scenario would be to ensure all pregnant women are
given an opportunity to achieve a healthy weight prior to conception, the
reality in terms of pregnancy planning and the current trend towards
higher rates of obesity in the general population will mean that obesespecific management strategies will have to be developed to improve
pregnancy outcomes for obese women.
In planning maternity care, risk assessment is essential as the evidence
presented here clearly illustrates there is an association between BMI and
antenatal, intrapartum and postpartum complications as well as perinatal
outcomes.2 Therefore, interventions that manage physiological and
metabolic dysfunction should be developed, including, strategies to
monitor weight gain throughout pregnancy and support postnatally to
ensure opportunities for weight loss.
This report not only emphasises the importance of capturing information
on BMI and other lifestyle risk factors at booking but also the need for
preconception care to reduce the level of obesity prior to conception.
Date: 4th December 2014
Version: v1 final
Page: 63 of 100
Public Health Wales
Maternal Obesity Report
9. Recommendations
Preconception:

All women of childbearing age should have the opportunity to
optimise their weight before pregnancy.
Women with a BMI 30
should also receive information on the potential complications.

Encourage 5-10% weight loss for women with BMI of 30 or above
prior
to
conception
using
evidence-based
behaviour
change
techniques6.

Advice on weight and lifestyle should be given, including the need
to take daily folic acid supplements (5 mg/day) at least one month
prior to conception and continued daily for 12 weeks post
conception.

All women should have their height and weight measured and their
body
mass
index
calculated
at
the
antenatal
booking
visit.
Measurements should be recorded in the handheld notes and/or
electronic patient information system.
During Pregnancy:

Guidelines for recommended weigh gain during pregnancy based
upon pre-pregnancy BMI should be implemented.

Pregnant women with a booking BMI 30 should commence 10 mg
Vitamin D supplementation daily throughout pregnancy.

Pregnant women with a booking BMI ≥40 should have an antenatal
consultation with an obstetric anaesthetist, so that potential
difficulties with venous access, regional or general anaesthesia can
be identified. In addition an anaesthetic management plan for
Date: 4th December 2014
Version: v1 final
Page: 64 of 100
Public Health Wales
Maternal Obesity Report
labour and delivery should be discussed and documented in the
medical record.

Women with a booking BMI ≥30 should be assessed at their first
antenatal visit and throughout pregnancy for all risk factors in
accordance
with
recommendations
outlined
in
the
risk
of
thromboembolism.

Women with a booking BMI ≥35 have an increased risk of preeclampsia and should have surveillance during pregnancy in
accordance with the Pre-eclampsia Community Guideline (PRECOG),
2004.34.

Women
with
a
booking
BMI
≥30
requiring
pharmacological
thromboprophylaxis should be prescribed doses appropriate for
maternal weight, in accordance with the RCOG Clinical Green-top
Guideline No. 37.13.

All pregnant women with a booking BMI ≥30 should be screened for
gestational
diabetes,
as
recommended
by
the
NICE
Clinical
Guideline No. 63 (Diabetes in Pregnancy, July 2008).35.

Antenatal
considered
and
in
post
delivery
accordance
with
thromboprophylaxis
the
RCOG
Clinical
should
be
Green-top
Guideline No. 37.13.
Care During Childbirth:

Adopt recommendations outlined in CMACE/ROCG (2010) report on
the management of women with obesity in pregnancy. Section 7,
page 78.2
Date: 4th December 2014
Version: v1 final
Page: 65 of 100
Public Health Wales
Maternal Obesity Report
Postnatal Care:

Women with a booking BMI ≥30 should receive appropriate
specialist advice and support antenatally and postnatally regarding
the benefits, initiation and maintenance of breastfeeding.

Women with a booking BMI ≥30 should continue to receive
nutritional advice following childbirth from an appropriately trained
professional, with a view to weight reduction.2

All women with a booking BMI ≥30 who have been diagnosed with
gestational diabetes should have a test of glucose tolerance
approximately 6 weeks after giving birth.
Service Development:

Interventions needed to train health professionals to counsel
women about healthy weight gain in pregnancy.
• Develop interventions to promote attaining a healthy weight prior to
pregnancy.
• Develop interventions to reduce the number of women who remain
obese after childbirth.
• Ensure Obesity Pathway development includes strategies to reduce
maternal obesity.

Evaluation of ongoing interventions that have well defined service
specifications.
Date: 4th December 2014
Version: v1 final
Page: 66 of 100
Public Health Wales
Maternal Obesity Report
10. Glossary
Term
Definition
A
C
Antenatally
Before birth
Ante partum
Of or occurring in the period before
childbirth
APGAR
An acronym for: Appearance, Pulse,
Grimace, Activity, and Respiration.
The agar score is the very first test given
to a newborn in the delivery or birthing
room. The test is designed to quickly
evaluate a newborn's physical condition
and to determine any immediate need for
extra medical or emergency care.
Atonic uterine
haemorrhage
Massive bleeding during puerperium (the
period from the end of the last stage of
labour and the return of the uterus to its
normal size after delivery: about 3-6
weeks in duration) and happens because
of uterine contraction failure immediately
after the placenta is delivered. It rarely
occurs a day later.
Caesarean section
Surgical incision into the abdominal and
uterine wall to achieve delivery of the
baby.
Cohort studies
An observational study that takes a group
(cohort) of individuals and observes their
progress over time in order to measure
outcomes, such as disease or mortality
rates, and make comparisons according to
different
exposures,
treatments
or
outcomes.
Confounders
In statistics, a confounding variable (also
confounding factor, hidden variable,
lurking
variable,
a
confound,
or
confounder) is an extraneous variable in a
statistical model that correlates (positively
Date: 4th December 2014
Version: v1 final
Page: 67 of 100
Public Health Wales
Maternal Obesity Report
or negatively) with both the dependent
variable and the independent variable.
Congenital
anomalies
A
congenital
anomaly
(congenital
abnormality, congenital malformation,
birth defect) is a condition which is
present at the time of birth which varies
from the standard presentation.
Anomalies can occur in the limbs, heart,
nervous system and gastrointestinal
system.
D
Diaphragmatic
hernia
A diaphragmatic hernia is a birth defect in
which there is an abnormal opening in the
diaphragm, the muscle that helps you
breathe.
Double blind
prevention trial
A procedure of blind assignment to study
and control groups and blind assessment
of outcome, designed to ensure that
ascertainment of outcome is not biased by
knowledge of the group to which an
individual was assigned.
Endometritis
Endometritis is an inflammation or
irritation of the lining of the uterus (the
endometrium).
Epidemiology
The study of the distribution and
determinants of health-related states or
events in specified populations, and the
application of this study to control of
health problems.
Evidence Base
The process of systematically finding,
E
Date: 4th December 2014
Version: v1 final
Page: 68 of 100
Public Health Wales
Maternal Obesity Report
appraising and using research findings as
the basis for clinical decisions.
G
Gastroschisis
Gastroschisis is a birth defect in which an
infant's intestines stick out of the body
through a defect on one side of the
umbilical cord.
Gestational diabetes
mellitus
Any degree of glucose intolerance with its
onset
(or
first
diagnosis)
during
pregnancy and usually resolving shortly
after delivery.
Gestational
hypertension
A generic term used to define a significant
rise in blood pressure during pregnancy,
occurring after 20 weeks’ gestation.
Hypospadias
Hypospadias is a birth (congenital) defect
in which the opening of the urethra is on
the underside, rather than at the end, of
the penis.
Iatrogenic pre term
delivery
Dr induced birth of a baby of less than 37
weeks gestational age.
Infertility
Infertility refers to an inability to conceive
after having regular unprotected sex.
Infertility can also refer to the biological
inability of an individual to contribute to
conception, or to a female who cannot
carry a pregnancy to full term.
Insulin resistance
Insulin resistance (IR) is a physiological
condition where the natural hormone
insulin becomes less effective at lowering
blood sugars.
Intrauterine
Takes place in the uterus.
H
I
Date: 4th December 2014
Version: v1 final
Page: 69 of 100
Public Health Wales
Maternal Obesity Report
In vitro fertilisation
(IVF)
A process by which an egg is fertilised by
sperm outside the body: in vitro.
Lactogenesis
The process through which the mammary
gland develops the capacity to secrete
milk (lactogenesis).
Large for
gestational age
(LGA)
A baby that has a birth weight more than
the 10th percentile of all babies with the
same gestational age.
Longitudinal studies
A longitudinal study is a correlational
research study that involves repeated
observations of the same variables over
long periods of time — often many
decades.
Meta-analysis
Meta-analysis is a statistical technique for
combining the findings from independent
studies.
Macrosomia
A newborn with an excessive birth weight.
Methodology
A system of broad principles or rules from
which specific methods or procedures may
be derived to interpret or solve different
problems within the scope of a particular
discipline.
Miscarriage
The loss of a pregnancy that occurs
during the first 23+6 weeks.
Multigravidas
A woman who has been pregnant more
than one time.
Multiparous
A woman who has given birth two or more
times.
L
M
Date: 4th December 2014
Version: v1 final
Page: 70 of 100
Public Health Wales
Maternal Obesity Report
N
Neonatal death
Deaths at under seven days of life.
Neonatal
hypoglycaemia
Low blood sugar levels in newborn babies.
It refers to low blood sugar (glucose) in
the first few days after birth.
Neonatal morbidity
A diseased condition or state during first
28 days of life.
Neural tube defect
Neural tube defects are birth defects of
the brain and spinal cord. The two most
common neural tube defects are spina
bifida and anencephaly.
Nulliparous
A woman who has never completed a
pregnancy beyond 20 weeks.
Obesity
Body mass index (BMI) ≥30
O
Class I BMI 30.0 – 34.9
Class II (Severe obesity) BMI 35.0 – 39.9
Class III (Morbid obesity) BMI ≥40.0
Super-morbid obesity BMI ≥50.0
Observational study
An epidemiological study that does not
involve any intervention, experimental or
otherwise.
Odds ratio (OR)
Odds ratio (OR) – Odds are a way of
representing probability. They provide an
estimate (usually with a confidence
interval) for the effect of a treatment.
Odds are used to convey the idea of ‘risk’
and an odds ratio of 1 between two
treatment groups would imply that the
risks of an adverse outcome were the
same in each group. For rare events the
odds ratio and the relative risk (which
uses actual risks and not odds) will be
very similar.
Date: 4th December 2014
Version: v1 final
Page: 71 of 100
Public Health Wales
Omphalocoeles
Maternal Obesity Report
An omphalocele is a birth defect in which
the infant's intestine or other abdominal
organs stick out of the belly button
(navel). In babies with an omphalocele,
the intestines are covered only by a thin
layer of tissue and can be easily seen.
An omphalocele is a type of hernia. Hernia
means "rupture.”
P
Pathogenesis
The mechanism by which the disease is
caused.
Periconceptual
Relating to, or done during the period
from
before
conception
to
early
pregnancy.
Perinatal morbidity
A disorder in the neonate, child or family
which occurs as a result of adverse
influences or treatments acting either on
the fetus during pregnancy and/or the
infant during the first four weeks of life.
Perinatal mortality
The death of a fetus or neonate.
Pharmacotherapy
Treatment of disease through the use of
drugs.
Physiologic
Of or consistent with
normal functioning.
Pneumonia
Pneumonia is an inflammation of the lung,
usually caused by an infection.
Polycystic ovary
syndrome
Polycystic
ovary
syndrome
(PCOS)
happens when a woman's ovaries or
adrenal glands produce more male
hormones than normal.
Postnatally
Of or occurring after birth, especially in
the period immediately after birth.
Date: 4th December 2014
Version: v1 final
an
organism's
Page: 72 of 100
Public Health Wales
Maternal Obesity Report
Post partum
After childbirth.
Post partum
haemorrhage
Blood loss of 500ml or more from the
genital tract up to 6 weeks after labour.
Pre – eclampsia
Pregnancy-induced
hypertension
in
association with proteinuria (> 0.3 g in 24
hours) ± oedema.
Prematurity
Infants born before 37 weeks gestation.
Pre term delivery
The birth of a baby of less than 37 weeks
gestational age.
Primigravidas
A woman in her first pregnancy.
Prolactin
A hormone secreted by the pituitary gland
that
stimulates
lactation
(milk
production).
Pulmonary
aspiration
When
your
ability
to
swallow
is
compromised enough to cause you to
breathe liquids into your lungs.
Pulmonary
embolism
A blockage of one of the arteries in the
lung by a blood clot.
Randomised
controlled trials
An epidemiologic experiment in which
subjects in a population are randomly
allocated into groups, usually called study
and control groups, to receive or not to
receive an experimental preventative or
therapeutic procedure, manoeuvre, or
intervention.
Retrospective
analysis
A study in which a search is made for a
relationship between one (usually current)
phenomenon or condition and another
that occurred in the past.
Shoulder dystocia
Shoulder dystocia occurs when a baby's
head is delivered through the vagina, but
R
S
Date: 4th December 2014
Version: v1 final
Page: 73 of 100
Public Health Wales
Maternal Obesity Report
his shoulders get stuck inside the
mother's body. This creates risks for both
mother and baby. Dystocia means "slow
or difficult labour or delivery."
Singleton babies
A fetus alone in the womb – one baby.
Sleep Apnoea
Obstructive sleep apnoea is a condition in
which the flow of air pauses or decreases
during breathing while you are asleep
because the airway has become narrowed
blocked, or floppy.
Small for
gestational age
(SGA)
A baby that has a birth weight less than
the 10th percentile of all babies with the
same gestational age.
Spina bifida
It is a type of neural tube defect, which is
a problem with the spinal cord or its
coverings. It happens if the fetal spinal
column doesn't close completely during
the first month of pregnancy. There is
usually nerve damage that causes at least
some paralysis of the legs.
Spontaneous
abortion
Any pregnancy that is not viable (the
fetus cannot survive) or in which the
foetus is born before the 20th week of
pregnancy. Also known as miscarriage.
Stillbirth
A baby delivered without signs of life after
23+6 weeks of pregnancy.
Sub fertility
A
less
than
reproduction.
Systematic review
A systematic review is a critical
assessment and evaluation of all research
studies that address a particular clinical
issue.
Thromboembolism
A condition in which a blood clot that has
formed inside a blood vessel or inside the
normal
capacity
for
T
Date: 4th December 2014
Version: v1 final
Page: 74 of 100
Public Health Wales
Maternal Obesity Report
heart subsequently breaks off and travels
inside the bloodstream to plug another
blood vessel, causing organ damage.
Thromboprophylaxis
Prevention of thromboembolic disease.
Trimester
A period or term of three months.
Type 2 diabetes
A common form of diabetes that usually
develops in adulthood and most often in
obese individuals. It is characterised by
hyperglycaemia resulting from impaired
insulin utilisation coupled with the body’s
inability to compensate with increased
insulin production.
Urogenital
Of, relating to, or involving both the
urinary
and
genital
structures
or
functions.
Venous
thromboembolism
A condition in which a blood clot
(thrombus) forms in a vein, which in
some cases then breaks free and enters
the circulation as an embolus, finally
lodging in and completely obstructing a
blood vessel, e.g., in lungs causing a
pulmonary embolism (PE). The term
encompasses both DVT and PE.
U
V
Date: 4th December 2014
Version: v1 final
Page: 75 of 100
Public Health Wales
Maternal Obesity Report
11. References
1.
Welsh Government. (2010). Welsh Health Survey. Cardiff: Stastical
Publication Unit.
2.
Centre for Maternal and Child Enquiries (CMACE) and Royal College
of Obstetricians and Gynaecologists (RCOG). (2010). The
Management of Women with Obesity in Pregnancy. Joint Guidelines.
London: CMACE/ROCG.
3.
National Obesity Observatory. Maternal Obesity. National Obesity
Observatory.
[Online]
2010.
http://www.noo.org.uk/NOO_about_obesity/maternal _obesity.
4.
Centre for Maternal and Child Enquiries (CMACE). (2010). Maternal
obesity in the UK: Findings from a national project. London: CMACE.
5.
Welsh Government. (2011). A Strategic Vision for Maternity Services
in Wales. Cardiff: Welsh Government
6.
NICE. (2010). Nice Public Health Guidance 27 – Dietary Interventions
and Physical activity interventions for weight management before,
during and after pregnancy. London: NICE
7.
Catalano, P.M. (2003). Obesity and pregnancy – the propagation of a
viscous cycle? Journal of Clinical Endocrinology and Metabolism.
88:3505-6
8.
WHO (1998) Technical Report Series 854
9.
Huxley R, Jamie WPT, Barzi, F. (2009). Ethnic comparisons of the
cross-sectional relationships between measures of body sixe with
diabetes and hypertension. Obesity Review 9(suppl. 1):53-61
10. Chu SY, Abe K, Hall L (2009). Gestational Diabetes Mellitus in the
United States: all Asians are not alike.
49:265-8.
Preventative Medicine
11. Chu, S (2011). The Epidemiology of Obesity in Pregnancy. In:
Pregnancy in the Obese Woman Ed: Conway, D, Blackwell Publishing
Ltd.
12. Henderson, MM., Weiss NS., Sacks DA. (2006). Pregnancy weight
gain and the risk of neonatal
Gynaecology 108:1153-61.
complications.
Obstetrics
and
13. Nohr EA, Vaeth M, Baker, JL (2008). Combined associations of
prepregnancy body mass index and gestational weight gain with the
Date: 4th December 2014
Version: v1 final
Page: 76 of 100
Public Health Wales
outcome of
87:1750-9
Maternal Obesity Report
pregnancy.
American
Journal
of
Clinical
Nutrition
14. Heslehurst N (2007). Obesity in Pregnancy: A study of the impact of
maternal obesity on NHS maternity services.
Gynaecology. 114:334-342
British Journal of
15. Knight, M et al. (2009) United Kingdom Obstetric Surveillance
System (UKOSS)
Epidemiology Unit.
annual
report.
Oxford:
National
Perinatal
16. Lashen H, Fear K, Sturdee DW. Obesity is associated with increased
risk of first trimester and recurrent miscarriage: matched casecontrol study. Human Reproduction 2004;19(7):1644-6.
17. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, et al.
Maternal obesity and pregnancy outcome: a study of 287,213
pregnancies in London. International Journal of Obesity & Related
Metabolic Disorders: Journal of the International Association for the
Study of Obesity 2001;25(8):1175-82.
18. O'Brien TE, Ray JG, Chan W-S. (2003) Maternal body mass index and
the risk of preeclampsia: a systematicoverview. Epidemiology;
14(3):368-74.
19. Jacobsen
AF, Skjeldestad FE, Sandset PM. (2008) Ante- and
postnatal risk factors of venous thrombosis: a hospitalbasedcase
control study. Journal of Thrombosis and Haemostasis; 6(6):905912.
20. Larsen TB, Sorensen HT, Gislum M, Johnsen SP. (2007) Maternal
smoking, obesity, and risk of venous thromboembolism during
pregnancy and the puerperium: a population-based nested casecontrol study. Thrombosis Research; 120(4):505-9.
21. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. (2005) Outcome of
pregnancy in a woman with an increased body mass index. BJOG: An
International Journal of Obstetrics and Gynaecology; 112(6):768772.
22. Chu SY, Kim SY, Schmid CH, Dietz PM, Callaghan WM, Lau J, et al.
(2007) Maternal obesity and risk of caesarean delivery: a metaanalysis. Obesity Reviews; 8(5):385-94.
23. Dresner M, Brocklesby J, Bamber J. (2006) Audit of the influence of
body mass index on the performance of epidural analgesia in labour
and the subsequent mode of delivery. BJOG: An International Journal
of Obstetrics and Gynaecology;113(10):1178-81.
Date: 4th December 2014
Version: v1 final
Page: 77 of 100
Public Health Wales
Maternal Obesity Report
24. Saravanakumar K, Rao SG, Cooper GM. (2006) The challenges of
obesity and obstetric anaesthesia. CurrentOpinion in Obstetrics &
Gynecology;18(6):631-5.
25. Amir LH, Donath S. (2007) A systematic review of maternal obesity
and breastfeeding intention, initiation and duration. MC Pregnancy
and Childbirth;
26. Lim SS, Noakes M and Norman R (2007). Dietary effects on fertility
treatment and pregnancy outcome.
Current
Endocrinology, Diabetes and Obesity. 14(6), 465-69.
Opinion
in
27. Jungheim E, Lanzendorf S, Odem R, Moley K, Chang A and Ratts V
(2009). Morbid obesity is associated with lower clinical pregnancy
rates after in vitro fertilisation in women with polycystic ovary
syndrome. Fertility and Sterility 92(1)256-61
28. http://prodigy.clarity.co.uk/miscarriage/view_whole_topic#
29. Boots C, Stephenson MD, (2011) Does obesity increase the risk of
miscarriage in spontaneous conception: a systematic review. Semin
Reprod Med. Nov; 29(6):507-13.
30. Lashen H, Fear K, Sturdee DW. (2004) Obesity is associated with
increased risk of first trimester and recurrent miscarriage: matched
case-control study. Hum Reprod. Jul; 19(7):1644-6.
31. O'Dwyer V, Monaghan B, Fattah C, Farah N, Kennelly MM, Turner MJ,
Miscarriage after sonographic confirmation of an ongoing pregnancy
in women with moderate and severe obesity.Obes Facts.
2012;5(3):393-8. Epub 2012 Jun 22.
32. Chu SY et al. Maternal obesity and risk of stillbirth: a metaanalysis.
American Journal of Obstetrics & Gynecology. 2007 Sep;197(3):2238.
33. The NHS Information Centre. HES Online- Maternity data: Health and
Social Care Information Centre 2010.
34. Chu SY, Callaghan WM, Kim SY, Schmid CH, Lau J, England LJ, Dietz
PM. (2007) Maternal obesity and risk of gestational diabetes mellitus.
Diabetes Care: Aug;30(8):2070-6.
35. Sebire NJ, Jolly M, Harris JP, Wadsworth J, Joffe M, Beard RW, et al.
(2001) Maternal obesity and pregnancy outcome: a study of 287,213
pregnancies in London. International Journal of Obesity & Related
Metabolic Disorders: Journal of the International Association for the
Study of Obesity: 25 (8):1175-82.
Date: 4th December 2014
Version: v1 final
Page: 78 of 100
Public Health Wales
Maternal Obesity Report
36. Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. (2007)
Effect of Body Mass Index on pregnancy outcomes in nulliparous
women delivering singleton babies. BMC Public Health 2007;7:168.
37. Sohlberg S, Stephansson O, Cnattingius S, Wikström AK.Maternal
body mass index, height, and risks of preeclampsia. (2012) Am J
Hypertens: Jan;25(1):120-5.
38. James AH, Jamison MG, Brancazio LR, Myers ER. (2006) Venous
thromboembolism during pregnancy and the postpartum period:
incidence, risk factors, and mortality. Am J Obstet Gynecol. May;
194(5):1311-5.
39. Larsen TB, Sorensen HT, Gislum M, Johnsen SP. (2007) Maternal
smoking, obesity, and risk of venous thromboembolism during
pregnancy and the puerperium: a population-based nested casecontrol study. Thrombosis Research 2007;120(4):505-9.
40. Knight, M. and UKOSS (2008), Antenatal pulmonary embolism: risk
factors, management and outcomes. BJOG: An International Journal
of Obstetrics & Gynaecology, 115: 453–461. doi: 10.1111/j.14710528.2007.01622.x
41. Jacobsen EF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk
factors of venous thrombosis: a hospital-based case control study.
Journal of Thrombosis and Haemostasis 2008; 6 (6): 905-912.
42. Simpson, E.L., Lawrenson, R.A., Nightingale, A.L. and Farmer, R.D.T.
(2001), Venous thromboembolism in pregnancy and the puerperium:
incidence and additional risk factors from a London perinatal
database. BJOG: An International Journal of Obstetrics &
Gynaecology, 108: 56–60.
43. Ovesen P, Rasmussen S, Kesmodel U.(2011) Effect of prepregnancy
maternal overweight and obesity on pregnancy outcome. Obstet
Gynecol.:Aug;118
44. Robinson HE, O'Connell CM, Joseph KS, McLeod NL.(2005) Maternal
outcomes in pregnancies complicated by obesity. Obstet Gynecol.:
Dec;106(6):1357-64.
45. Kongulbol A and Phupong V. (2011). Pregnancy Obesity and the Risk
of Gestational Diabetes Mellitus. BMC Pregnancy and Childbirth
11(59)
46. Arrowsmith, S., Wray, S. and Quenby, S. (2011), Maternal obesity
and labour complications following induction of labour in prolonged
pregnancy. BJOG: An International Journal of Obstetrics &
Gynaecology, 118: 578–588.
Date: 4th December 2014
Version: v1 final
Page: 79 of 100
Public Health Wales
Maternal Obesity Report
47. Kabiru W, Raynor BD. (2004) Obstetric outcomes associated with
increase in BMI category during pregnancy. American Journal of
Obstetrics & Gynecology. Sep;191(3):928-32.
48. Doherty DA, Magann EF, Francis J, Morrison JC, Newnham JP. (2006)
Pre-pregnancy body mass index and pregnancy outcomes.
International Journal of Gynaecology & Obstetrics: Dec;95(3):242-7.
49. Robinson HE, O'Connell CM, Joseph KS, McLeod NL. (2005) Maternal
outcomes in pregnancies complicated by obesity. Obstetrics &
Gynecology: Dec;106(6):1357-64.
50. Knight M, Kurinczuk JJ, Spark P, Brocklehurst P; (2010) UK Obstetric
Surveillance System. Extreme obesity in pregnancy in the United
Kingdom. Obstet Gynecol. May;115(5):989-97.
51. Blomberg M. (2011) Maternal obesity and risk of
postpartum
hemorrhage. Obstetrics & Gynecology. 118(3):561-8, Sep.
52. Kristensen J, Vestergaard M, Wisborg K, Kesmodel U, Secher
NJ.(2005) Pre-pregnancy weight and the risk of stillbirth and
neonatal death. BJOG: An International Journal of Obstetrics and
Gynaecology: 112(4):403-408.
53. Rasmussen SA, Chu SY, Kim SY, Schmid CH, Lau J. (2008) Maternal
obesity and risk of neural tube defects: a metaanalysis. American
Journal of Obstetrics and Gynecology: 198(6):611-619.
54. Callaway
LK, Prins JB, Chang AM, McIntyre HD. (2006) The
prevalence and impact of overweight and obesity in an Australian
obstetric population. Medical Journal of Australia: 184(2):56-9.
55. Cedergren MI. (2004). Maternal morbid obesity and the risk of
adverse
pregnancy
103(2):219-24.
outcome.
Obstetrics
and
Gynaecology:
56. Usha Kiran TS, Hemmadi S, Bethel J, Evans J. (2005) Outcome of
pregnancy in a woman with an increased body mass index. BJOG: An
International Journal of Obstetrics and Gynaecology: 112(6):768772.
57. Shah A, Sands J, Kenny L. (2006) Maternal obesity and the risk of
still birth and neonatal death. Journal of Obstetrics and Gynaecology:
26(Supplement 1):S19.
58. Boney CM, Verma A, Tucker R, Vohr BR. (2005) Metabolic Syndrome
in Childhood: Association With Birth Weight, Maternal Obesity, and
Gestational Diabetes Mellitus. Pediatrics: 115(3):e290-296.
Date: 4th December 2014
Version: v1 final
Page: 80 of 100
Public Health Wales
Maternal Obesity Report
59. Raatikainen K, Heiskanen N, Heinonen S. (2006) Transition from
overweight to obesity worsens pregnancy outcome in a BMIdependent manner. Obesity: Jan;14(1):165-71.
60. Stephansson O, Dickman PW, Johansson A, Cnattingius S. (2001)
Maternal weight, pregnancy weight gain, and the risk of antepartum
stillbirth.
American
Journal
of
Obstetrics
&
Gynecology:
Feb;184(3):463-9.
61. Kristensen J, Vestergaard M, Wisborg K, Kesmodel U, Secher NJ.
(2005) Pre-pregnancy weight and the risk of stillbirth and neonatal
death. BJOG: Apr;112(4):403-8.
62. Nohr EA, Bech BH, Davies MJ, Frydenberg M, Henriksen TB, Olsen J.
(2005) Prepregnancy obesity and fetal death: a study within the
Danish
National
Birth
Cohort.
Obstetrics
&
Gynecology:
Aug;106(2):250-9.
63. Smith GCS, Shah I, Pell JP, Crossley JA, Dobbie R.(2007) Maternal
obesity in early pregnancy and risk of spontaneous and elective
preterm deliveries: a retrospective cohort study. American Journal of
Public Health:Jan;97(1):157-62.
64. Watkins ML, Rasmussen SA, Honein MA, Botto LD, Moore CA. (2003)
Maternal obesity and risk for birth defects. Pediatrics:May;111(5 Part
2):1152-8.
65. Waller DK et al. (1994) Are obese women at higher risk for producing
malformed offspring? American Journal of Obstetrics & Gynecology:
Feb;170(2):541-8.
66. Werler MM, Louik C, Shapiro S, Mitchell AA. (1996) Prepregnant
weight in relation to risk of neural tube defects. JAMA: Apr
10;275(14):1089-92.
67. Watkins ML, Scanlon KS, Mulinare J, Khoury MJ. (1996) Is maternal
obesity a risk factor for anencephaly and spina bifida? Epidemiology:
Sep;7(5):507-12.
68. Shaw GM, Todoroff K, Schaffer DM, Selvin S. (2000) Maternal height
and prepregnancy body mass index as risk factors for selected
congenital anomalies. Paediatric and Perinatal Epidemiology:
Jul;14(3):234-9.
69. Shaw GM, Velie EM, Schaffer D. (1996) Risk of neural tube defect-
affected
pregnancies
10;275(14):1093-6.
Date: 4th December 2014
among
obese
Version: v1 final
women.
JAMA:
Page: 81 of 100
Apr
Public Health Wales
Maternal Obesity Report
70. Waller DK et al. (2007) Prepregnancy obesity as a risk factor for
structural birth defects. Archives of Pediatrics & Adolescent Medicine:
Aug;161(8):745-50.
71. Anderson JL, Waller DK, Canfield MA, Shaw GM, Watkins ML, Werler
MM. (2005) Maternal obesity, gestational diabetes, and central
nervous system birth defects. Epidemiology: Jan;16(1):87-92.
72. Moore LL, Singer MR, Bradlee ML, Rothman KJ, Milunsky A. (2000) A
prospective study of the risk of congenital defects associated with
maternal
obesity
and
diabetes
mellitus.
Epidemiology:
Nov;11(6):689-94.
73. Shaw GM, Todoroff K, Finnell RH, Lammer EJ. (2000) Spina bifida
phenotypes
in
infants
or
mothers.Teratology:May;61(5):376.
fetuses
of
obese
74. Hendricks KA, Nuno OM, Suarez L, Larsen R. (2001) Effects of
hyperinsulinemia and obesity on risk of neural tube defects among
Mexican Americans. Epidemiology: Nov;12(6):630-5.
75. Baeten JM, Bukusi EA, Lambe M. (2001) Pregnancy complications
and outcomes among overweight and obese nulliparous women.
American Journal of Public Health: Mar;91(3):436-40.
76. Jensen DM et al. (2003) Pregnancy outcome and prepregnancy body
mass index in 2459 glucose-tolerant Danish women. American
Journal of Obstetrics & Gynecology: Jul;189(1):239-44.
77. Abenhaim H, Kinch R, Morin L, Benjamin A, Usher R. (2007) Effect of
prepregnancy body mass index categories
neonatal
outcomes.
Archives
of
Obstetrics:275(1):39-43.
on obstetrical
Gynecology
and
and
78. Cnattingius S, Lambe M. (2002) Trends in smoking and overweight
during pregnancy: prevalence, risks of pregnancy complications, and
adverse
pregnancy
outcomes.
Seminars
in
Perinatology:
Aug;26(4):286-95.
79. Bhattacharya S, Campbell DM, Liston WA, Bhattacharya S. (2007)
Effect of Body Mass Index on pregnancy outcomes in nulliparous
women delivering singleton babies. BMC Public Health: 7:168-75.
80. Cnattingius
S, Bergstrom R, Lipworth L, Kramer MS. (1998)
Prepregnancy weight and the risk of adverse pregnancy outcomes.
New England Journal of Medicine: Jan 15;338(3):147-52.
Date: 4th December 2014
Version: v1 final
Page: 82 of 100
Public Health Wales
Maternal Obesity Report
81. Sheiner E, Levy A, Menes TS, Silverberg D, Katz M, Mazor M. (2004)
Maternal obesity as an independent risk factor for caesarean
delivery. Paediatric and Perinatal Epidemiology: May;18(3):196-201.
82. Rode L, Nilas L, Wojdemann K, Tabor A. (2005) Obesity-related
complications in Danish single cephalic term pregnancies. Obstetrics
& Gynecology: Mar;105(3):537-42.
83. Dandolu V, Jain NJ, Hernandez E, Kruse L. (2006) Shoulder dystocia
at non-instrumental vaginal delivery.
Perinatology: Oct;23(7):439-44.
American
Journal
of
84. Hediger ML, Overpeck MD, Maurer KR, Kuczmarski RJ, McGlynn A,
Davis WW. (1998) Growth infants and young children born small or
large for gestational age: findings from the Third National Health and
Nutrition Examination Survey. Archives of Pediatrics & Adolescent
Medicine: Dec; 152(12):1225-31.
85. Mok E, Multon C, Piguel L, Barroso E, Goua V, Christin P, et al.
(2008) Decreased Full Breastfeeding, Altered Practices, Perceptions,
and Infant Weight Change of Prepregnant Obese Women: A Need for
Extra Support. Pediatrics: 121(5):e1319-1324.
86. Rasmussen KM, Kjolhede CL. (2004) Prepregnant overweight and
obesity diminish the prolactin response to suckling in the first week
postpartum. Pediatrics: 113(5):e465-71.
87. Oddy WH, Li J, Landsborough L, Kendall GE, Henderson S, Downie J.
(2006) The association of maternal overweight and obesity with
breastfeeding duration. Journal of Pediatrics: Aug;149(2):185-91.
88. Hilson JA, Rasmussen KM, Kjolhede CL. (2006) Excessive weight gain
during pregnancy is associated with earlier termination of breastfeeding among White women. Journal of Nutrition: Jan;136(1):1406.
89. Donath SM, Amir LH. (2000) Does maternal obesity adversely affect
breastfeeding initiation
Nov;8(3):29-33.
and
duration?
Breastfeeding
Review:
90. Hilson JA, Rasmussen KM, Kjolhede CL. (1997) Maternal obesity and
breast-feeding successin a rural population of white
American Journal of Clinical Nutrition: Dec;66(6):1371-8.
women.
91. Li R, Jewell S, Grummer-Strawn L. (2003) Maternal obesity and
breast-feeding practices. American Journal of Clinical Nutrition:
Apr;77(4):931-6.
Date: 4th December 2014
Version: v1 final
Page: 83 of 100
Public Health Wales
Maternal Obesity Report
92. Foresight (2007). Tackling Obesities: Future Choices – Project Report
2nd ed. Government Office for Science.
93. Office for National Statistics. (2004). The national diet and nutrition
survey: adults aged 19 to 64 years: nutritional status
(anthropometry and blood analytes), blood pressure and physical
activity London: The Stationery Office.
94. American College of Obstetricians and Gynecologists. Obesity in
pregnancy, opinion no. 315. Obstet Gynecol.
95. Pasquali R et al. Clinical and hormonal characteristics of obese
amenorrheic hyperandrogenic women before and after weight loss.
Journal of Clinical Endocrinology & Metabolism. 1989 Jan;68(1):1739.
96. Kiddy DS et al. (1992) Improvement in endocrine and ovarian
function during dietarytreatment of obese women with polycystic
ovary syndrome. Clinical Endocrinology. Jan;36(1):105-11.
97. Crosignani PG, Colombo M, Vegetti W, Somigliana E, Gessati A, Ragni
G. (2003) Overweight and obese anovulatory patients with polycystic
ovaries: parallel improvements in anthropometric indices, ovarian
physiology and fertility rate induced by diet. Human Reproduction:
Sep;18(9):1928-32.
98. Clark AM et al. (1995) Weight loss results in significant improvement
in pregnancy and ovulation rates in anovulatory obese women.
Human Reproduction: Oct;10(10):2705-12.
99. Patel
JA, Colella JJ, Esaka E, Patel NA, Thomas RL. (2007)
Improvement in infertility and pregnancy outcomes after weight loss
surgery. Medical Clinics of North America. May;91(3):515-28.
100. Villamor E, Cnattingius S. (2006) Interpregnancy weight change and
risk of adverse pregnancy outcomes: a population-based study.
Lancet: Sep 30;368(9542):1164-70.
101. Woodard CB.(2004) Pregnancy following bariatric surgery. Journal of
Perinatal & Neonatal Nursing: Oct-Dec;18(4):329-40.
102. Malinowski SS. (2006) Nutritional and metabolic complications of
bariatric surgery. American
[Review]. pr;331(4):219-25.
Journal
of
the
Medical
Sciences.
103. Alvarez-Leite JI. (2004) Nutrient deficiencies secondary to bariatric
surgery. Current Opinion in Clinical Nutrition & Metabolic Care.
Sep;7(5):569-75.
Date: 4th December 2014
Version: v1 final
Page: 84 of 100
Public Health Wales
Maternal Obesity Report
104. Scholl TO, Johnson WG. (2000) Folic acid: influence on the outcome
of pregnancy. American Journal of Clinical Nutrition: 71(5):1295S1303.
105. Lumley J, Watson L, Watson M, Bower C. (2001) Periconceptional
supplementation with folate and/or multivitamins for preventing
neural tube defects. Cochrane Database of Systematic Reviews.
106. Wilson
RD et al. (2007) Preconceptional vitamin / folic acid
supplementation 2007: the use of folic acid in combination with a
multivitamin supplement for the prevention of neural tube defects
and other congenital anomalies. Journal of Obstetrics & Gynaecology
Canada: Dec; 29(12):1003-26.
107. IOM (Institute of Medicine). 1990. Nutrition During Pregnancy.
Washington, DC: National Academy Press
108. Siega-Riz A. M., L. S. Adair and C. J. Hobel. (1994). Institute of
Medicine maternal weight gain recommendations and pregnancy
outcome in a predominantly Hispanic population. Obstetrics and
Gynecology 84(4): 565-573.
109. Abrams B., S. Carmichael and S. Selvin. (1995). Factors associated
with the pattern of maternal weight gain
Obstetrics and Gynecology 86(2): 170-176.
during
pregnancy.
110. Carmichael S., B. Abrams and S. Selvin. (1997). The pattern of
maternal weight gain in women with good pregnancy outcomes.
American Journal of Public Health 87(12): 1984-1988.
111. NHLBI (National Heart, Lung, and Blood Institute). (1998). Clinical
Guidelines on the Identification,Evaluation, and Treatment of
Overweight and Obesity in Adults. National Institutes of Health
Publication 98-4083. Washington, DC: National Institutes of Health.
112. National Collaborating Centre for Women’s and Children’s Health.
(2008). Antenatal care:Routine care for the healthy pregnancy
woman. London: Royal College of Obstetricians and Gynaecologists.
113. NRC (National Research Council). (1970). Maternal Nutrition and the
Course of Pregnancy.Washington, DC: National Academy Press.
114. Rosso P. (1985). A new chart to monitor weight gain during
pregnancy. American Journal of Clinical Nutrition 41(3): 644-652.
115. Mardones F. and P. Rosso. (2005). A weight gain chart for pregnant
women designed in Chile. Maternal and Child Nutrition 1(2): 77-90.
Date: 4th December 2014
Version: v1 final
Page: 85 of 100
Public Health Wales
Maternal Obesity Report
116. Office for National Statistics. (2004) The national diet and nutrition
survey: adults aged 19 to 64 years: nutritional status
(anthropometry and blood analytes), blood pressure and physical
activity London: The StationeryOffice.
117. Oken E, Taveras EM, Popoola FA, et al. (2007) Television,walking,
and diet: associations with
PreventMed:32:305-311.
postpartum
weight
retention.
Am
118. Dyson
L, McCormick F, Renfrew MJ. (2005) Interventions for
promoting the initiation of breastfeeding. Cochrane Database of
Systematic Reviews 2005(2):CD001688.
119. 73. Fairbank L, O'Meara S, Renfrew MJ, Woolridge M, Sowden AJ,
Lister-Sharp D. (2000) A systematic review to evaluate the
effectiveness of interventions to promote the initiation of
breastfeeding. Health Technology Assessment: 4(25).
120. University of Sheffield (2010). HEDS discussion paper on Behavioural
interventions for weight management in pregnancy: A systematic
review of quantitative and qualitative data. (Fiona Campbell, Maxine
Johnson, Josie Messina, Louise Guillaume, Liddy Goyder).
121. Symons Downs D, Hausenblas HA (2004) Women’s exercise beliefs
and behaviors during their pregnancy and postpartum. J Midwifery
Womens Health 49(2): 138–144.
122. Oland er EK, Atkinson L, Edmunds JK, French DP (2010) The views of
pre-and post-natal women and health professionals regarding
gestational weight gain: An exploratory study. Sex Reprod Healthc.
2(1): 43–8.
123. Treating adult obesity through lifestyle change interventions – A
briefing paper for commissioners March 2010 – National Obesity
Observatory
124. NICE clinical guideline 43 2006 Obesity: guidance on the prevention,
identification, assessment and management of overweight and
obesity in adults and children
125. NICE March 2008 Antenatal care Routine care for the healthy
pregnant woman. This guideline partially updates and replaces NICE
clinical guideline 62.
126. Gross, H, Bee PE. Perceptions of effective advice in pregnancy – The
case of activity. Clinical Effectiveness in Nursing 2004; 8:161-169.
127. Oteng-Ntim E, Pheasant H, Khazaezadeh N, Mohidden A, Bewley S,
Wong J, Oke B. Developing a community-based maternal obesity
Date: 4th December 2014
Version: v1 final
Page: 86 of 100
Public Health Wales
Maternal Obesity Report
intervention: a qualitative study of service providers' views. BJOG.
2010;117:1651–1655.
128. Penny J Furness, Kerry McSeveny, Madelynne A Arden, Carolyn
Garland, Andy M Dearden and Hora Soltani – Maternal obesity
support services: a qualitative study of the perspectives of women
and midwives. BMC Pregnancy and Childbirth 2011, 11:69
129. How can maternity services be developed to effectively address
maternal obesity? A qualitative study. Heslehusrt, N, Morre H,
Rankin J, Ells LJ, Wilkinson JR, Summerbell CD, Midwifery 27 (2011)
e170-e177.
130. National Institute for Health and Clinical Excellence.(2006). Clinical
Guideline 43. Obesity: Guidance on the prevention, identification,
assessment and management of overweight and obesity in adults
and children. London: NICE.
131. The training of health professionals for the prevention and treatment
of overweight and obesity Report prepared for Foresight by the Royal
College of Physicians March 2010
132. Brown et al 2006. Obesity stigma and quality of life. International
Journal of Interdisciplinary Social Science 1, 169-178.
133. Wiles, R 1998. The views of women above average weight about
appropriate weight gain in pregnancy. Midwifery 14, 254-260.
134. Roehling, M.V., 1999. Weight based discrimination in employment:
psychosocial and legal aspects. Personnel Psychology 52, 969-1017.
135. Thomas et al 2008. Being ‘fat’ in today’s world: a qualitative study of
the lived experiences of people with obesity in Australia. Health
Expectations 11, 321-330.
136. Oteng-Ntim E, Pheasant H, Khazaezadeh N, Mohidden A, Bewley S,
Wong J, Oke B. Developing a community-based maternal obesity
intervention: a qualitative study of service providers' views. BJOG.
2010;117:1651–1655.
137. Stotland NE, Gilbert P, Bogetz A, Harper CC, Abrams B, Gerbert B.
Preventing excessive weight gain in pregnancy: How do prenatal care
providers approach counselling? J Women Health. 2010;19(4):807–
814.
138. Wiles, R 1994. I’m not fat, I’m pregnant. In: Wilkinson, S., Kitzinger,
C. (eds), Women and Health: Feminist Perspectives. Taylor & Francis,
London.
Date: 4th December 2014
Version: v1 final
Page: 87 of 100
Public Health Wales
Maternal Obesity Report
139. Warriner S. Women’s views on being weighed during pregnancy. BR J
Midwifery 2000; 8(10): 620-623.)
140. Luppino FS, de Wit LM, Bouvy PF, Stijnen T, Cuijpers P, Penninx
BWJH, et al. Overweight, obesity, and depression: a systematic
review and meta-analysis of longitudinal studies. Archives of General
Psychiatry 2010;67(3):220-9.
141. Gariepy G, Nitka D, Schmitz N. The association between obesity and
anxiety disorders in the population: a systematic review and metaanalysis. International Journal of Obesity 2010;34:407-19.
142. Mental Health and chronic physical illnesses: The need for continued
and integrated care. World Federation for Mental Health, 2010.
143. Markowitz S, Friedman MA, Arent SM. Understanding the relation
between obesity and depression: Causal mechanisms and
implications for treatment. Clinical Psychology: Science and Practice
2008;15(1):1-20.
144. Kivimaki M, Lawlor DA, Singh-Manoux A, Batty G, Ferrie JE, Shipley
MJ, et al. Common mental disorder and obesity: Insight from four
repeat measures over 19 years: Prospective Whitehall II cohort
study. BMJ: British Medical Journal 2009;339(7726):No Pagination
Specified.
145. Puhl RM, Heuer CA. The Stigma of Obesity: A Review and Update.
Obesity 2009;17(5):941-64.
146. Evenson KR, Moos M-K, Carrier K, Siega-Riz AM. Perceived barriers
to physical activity among pregnant women. Maternal Child Health J.
2009;13:364–375.
147. Eyler AA, Baker E, Cromer L, King AC, Brownson RC, Donatelle RJ.
Physical activity and minority women: A qualitative study. Health
Educ Behav. 1998;25:640–652.
148. Keller C, Allan J, Tinkle MB. Stages of change, processes of change,
and social support for exercise and weight gain in postpartum
women. JOGNN.
149. Burg J. Determinants of Healthy Eating: Motivation, Abilities and
Environmental Opportunities, Family Practice, 2008, 25 (Supplement
1) i50-i55.
150. Shaw
KA, O’Rourke P, Del Mar C, Kenardy J. Psychological
Interventions for Overweight or Obesity, Cochrane Database of
Systematic Reviews, 2005, Issue
Date: 4th December 2014
Version: v1 final
Page: 88 of 100
Public Health Wales
Maternal Obesity Report
151. NICE (2006) Routine postnatal care of women and their babies
GuidlineGC37. London: NICE
152. K Powell and M Thurston. Commissioning training for behaviour
change interventions: evidence and best practice in delivery. Centre
for Public Health Research, University of Chester, 2008.
153. Warwick, C. (2010) CMACE report news release statement 2010
(CMACE release: National enquiry into maternal obesity- Implications
for
women,
babies
and
the
NHS)
http://www.rcog.org.uk/news/cmace-release-national-enquirymaternal-obesity-%E2%80%93-implications-women-babies-and-nhs
154. Rowlands I, Graves N, de Jersey S, McIntyre HD, Callaway L. Obesity
in pregnancy: outcomes and economics. Semin Fetal Neonatal Med.
2010 Apr;15(2):94-9.
155. Denison, F., Norrie, G., Graham, B., Lynch, J., Harper, N. and
Reynolds, R. (2009), Increased maternal BMI is associated with an
increased risk of minor complications during pregnancy with
consequent cost implications. BJOG: An International Journal of
Obstetrics & Gynaecology, 116: 1467–1472.
156. Weight management before during and after pregnancy: costing
report
(2010)
http://www.nice.org.uk/nicemedia/live/13056/49954/49954.pdf
157. MRC Vitamin Study Research Group. (1991) Prevention of neural
tube defects: results of the Medical Research Council Vitamin Study.
MRC
Vitamin
Study
Research
Group.
The
Lancet
1991;338(8760):131-7.
158. Kitzmiller JL, Elixhauser A, arr S et al. (1998) Assessment of costs
and benefits of management of gestational diabetes mellitus.
Diabetes Care (21) Suppl 2: 123–30
159. Simon J, Gray A, Duley L et al. (2006) Cost-effectiveness of
prophylactic magnesium sulphate for 9996 women with preeclampsia from 33 countries: economic evaluation of the magpie
trial. BJOG: An International Journal of Obstetrics & Gynaecology 113
(2):144–51
160. Chu SY, Bachman DJ, Callaghan WM et al. (2008) Association
between obesity during pregnancy and increased use of health care.
New England Journal of Medicine 358:1444–53
161. Heslehurst, N. et al. Obesity in pregnancy: a study of the impact of
maternal obesity on NHS maternity services. BJOG: an International
Journal of Obstetrics & Gynaecology 2007; 114: pp.334-342.
Date: 4th December 2014
Version: v1 final
Page: 89 of 100
Public Health Wales
Maternal Obesity Report
162. Heslehurst, N. et al. The impact of maternal BMI status on pregnancy
outcomes with immediate short-term obstetric resource implications:
a meta-analysis. Obesity Reviews 2008; 9(6): pp.635-683.
163. Ramsay, J.E., Greer, I. and Sattar, N. Obesity and reproduction.
British Medical Journal 2006; 333: pp.1159-1162.
164. Chu, S.Y. et al. Association between obesity during pregnancy and
increased use of health care. The New England Journal of Medicine
2008; 358(14): p.1444.
165. Galtier-Dereure, F., Boegner, C. and Bringer, J. Weight excess before
pregnancy: complications and cost. International Journal of Obesity
and Related Metabolic Disorders 1995; 19(7): pp.443-448.
166. Galtier-Dereure,
F., Boegner, C. and Bringer, J. Obesity and
pregnancy: complications and cost. American Journal of Clinical
Nutrition 2000; 71(5(s)): pp.1242-1248s.
167. Chu, S.Y., Kim, S.Y., Schmid, C.H. et al. Maternal obesity and risk of
caesarean delivery: a meta-analysis. Obesity Reviews 2007; 8:
pp.385-394.
168. Pandey S. Maheshwari A. And Bhattacharya S. (2010). The impact of
female obesity on the outcome of fertility treatment.
Human Reproductive Science, 3(2) 63-67
Journal of
169. Welsh Government (2009). Our Healthy Future; Technical Working
Paper.
http://www.wales.gov.uk/docs/phhs/publications/100527technicalen.
pdf
170. Welsh
Government (2010).
All Wales Obesity Pathway.
http://www.wales.gov.uk/docs/phhs/publications/100824obesityen.d
oc
Lewis, G (ed) (2007). The Confidential Enquiry into Maternal and
Child. Health (CEMACH). Saving Mothers' Lives: reviewing maternal
deaths to make motherhood safer 2003-2005. The Seventh report on
Confidential Enquiries into Maternal Deaths in the United Kingdom.
London: CEMACH.
171.
Date: 4th December 2014
Version: v1 final
Page: 90 of 100
Public Health Wales
Maternal Obesity Report
10. Appendices
Appendix 1. Search Terms for each Risk Factor
CONDITIONS AND RISK
FACTORS
SEARCH TERMS
Maternal Obesity
Maternal Obesity or Maternal BMI or
Maternal Body Mass Index or Maternal
Weight or Maternal Weight Gain
(Key words and Synonyms)
AND
Pregnancy or Pre-natal or anti-natal or postnatal or post-partum or perinatal
AND
Fertility
Fertility or Infertility or Polycystic Ovar* or
Polycystic Ovary Syndrome or Menstrual
Disorder*
Miscarriage
Miscarriage or Spontaneous Abortion or
Early Pregnancy Loss
Gestational Diabetes
Gestational Diabetes or Gestational Diabetes
Mellitus or Impaired glucose tolerance or
hypoglycaemia
Pre-eclampsia
Pre-eclampsia or High Blood Pressure or
Hypertension or Hypertensive Disorder*
Thromboembolism
Venous-Thromboembolism or Deep Vein
Thrombosis or DVT
Delivery
Labour or Birth or Induction or Induced
Labour or Induced Birth or Induced Delivery
or Assisted Labour or Assisted Delivery or
Dysfunctional Labour or Caesarean Section
or C-section
Anaesthetic complications or Emergency
Anaesthe* or Spinal Anaesthe* or Epidural
or Pain Relief or Pain Management
Post-partum Haemorrhage or Wound
Infection or Wound Healing
Pain Management
Haemorrhage
Fetal Outcomes
Perinatal
Morbidity/Mortality
Date: 4th December 2014
Macrosomia or LGW or shoulder dystocia or
fetal anomalies or congenital anomalies
Perinatal Mortality or Neonatal mortality or
Maternal Mortality or Fetal Mortality or
Stillbirth* or fetal distress
Version: v1 final
Page: 91 of 100
Public Health Wales
Maternal Obesity Report
Appendix 2
The NICE public health guidance 27: Weight management before,
during and after pregnancy (2010) recommendations for effective
interventions are based on strategies and weight-loss programmes that
are proven to be effective for the whole population. The criteria for
effective programmes are listed below. Programmes that do not meet
these criteria are unlikely to help women to maintain a healthy weight in
the long term.
Criteria 1 - Achieving and maintaining a healthy weight – ADVICE
Women will be more likely to achieve and maintain a healthy weight pre, ante
and post natal if they are provided with the following healthy eating guidance
(6):
• base meals on starchy foods such as potatoes, bread, rice and
pasta, choosing wholegrain where possible
• eat fibre-rich foods such as oats, beans, peas, lentils, grains, seeds,
fruit and vegetables, as well as wholegrain bread and brown rice
and pasta
• eat at least five portions of a variety of fruit and vegetables each
day, in place of foods higher in fat and calories
• eat a low-fat diet and avoid increasing their fat and/or calorie intake
• eat as little as possible of fried food; drinks and confectionery high
in added sugars (such as cakes, pastries and fizzy drinks); and
other food high in fat and sugar (such as some take-away and fast
foods)
• eat breakfast
• watch the portion size of meals and snacks, and how often they are
eating
• make activities such as walking, cycling, swimming, aerobics and
gardening part of everyday life and build activity into daily life – for
example, by taking the stairs instead of the lift or taking a walk at
lunchtime
• minimise sedentary activities, such as sitting for long periods
watching television, at a computer or playing video games
• walk, cycle or use another mode of transport involving physical
activity (7)
Weight loss programmes are effective pre and post natal but should not
be recommended during antenatal as they may harm the health of the
unborn child. Effective weight-loss programmes should include the
following characteristics:
Date: 4th December 2014
Version: v1 final
Page: 92 of 100
Public Health Wales
Maternal Obesity Report

address the reasons why someone might find it difficult to lose
weight

are tailored to individual needs and choices

are sensitive to the person’s weight concerns (6)

are based on a balanced, healthy diet (6)

encourage regular physical activity (6)

expect people to lose no more than 0.5–1 kg (1–2 lb) a week (6)

identify and address barriers to change
Criteria 2 - Sources of information
Reputable sources of information and advice about diet and physical
activity for women pre, ante and post natal include: ‘The pregnancy book’
(8) ‘Birth to five’ (9) and the ‘Eat well’ website (10). The Eat Well website
is no longer in existence evidence based consistent information can now
be sought on www.nhs.uk/livewell/healthy-eating
Programmes should also be aligned with government messages such as ‘5
A DAY’, the new CMO’s recommendations for physical activity, and social
marketing campaigns such as Change4Life (11).
Criteria 3 - Changing behaviour
Behaviour plays an important role in people’s health, particularly so in
achieving healthy weight and its maintenance.
The evidence shows that different patterns of behaviour are deeply
embedded in people’s social and material circumstances, and their
cultural context. Social and economic conditions can prevent people from
changing their behaviour to improve their health, and can also reinforce
behaviours that damage it.
Social circumstances can be difficult to change, by comparison people’s
behaviour – as individuals and collectively – may be easier to change.
These factors all affect people’s ability to withstand the stressors –
biological, social, psychological and economic – that can trigger ill health.
They also affect the capacity to change behaviour (12).
Date: 4th December 2014
Version: v1 final
Page: 93 of 100
Public Health Wales
Maternal Obesity Report
People’s health behaviours can also change, depending on their stage of
life and other factors such as place of birth, parental income, education
and employment opportunities, or the impact of prejudice and
discrimination. They can have both direct and indirect effects on health,
and on people’s ability to change, leading to a cumulative effect over the
life course (13, 14).
People choose whether or not to change their lifestyle. Assessing their
readiness to make changes affects decisions on when or how to offer any
intervention. Evidence-based behaviour change advice includes:

understanding the short, medium and longer-term consequences of
women’s health-related behaviour

helping women to feel positive about the benefits of healthenhancing behaviours and changing their behaviours

recognising how women’s social contexts and relationships may
affect their behaviour

helping plan women’s changes in terms of easy steps over time
identifying and planning situations that might undermine the changes
women are trying to make and plan explicit ‘if–then’ coping strategies to
prevent relapse (12)
Date: 4th December 2014
Version: v1 final
Page: 94 of 100
Public Health Wales
Maternal Obesity Report
Appendix 3
Mapping of Maternal Obesity Activity in Health Boards across
Wales
Health Boards
(HB)
Maternal Obesity Activity
-
-
Betsi Cadwaladr
University Health
Board
-
-
Cardiff and Vale
University Health
Board
Abertawe Bro
Morgannwg
University Health
Board
-
Aneurin Bevan
Health Board
Cwm Taf Health
Board
-
Task & finish group established to develop obesity
in pregnancy clinical pathway (pathway under
development – includes all recommendations from
latest CMACE report)
Lead midwife identified
Pregnancy pathway linked to wider HB work on WG
obesity pathway
Data quality variable
Research project underway in Wrexham – arm of
Cardiff University/Slimming World study
Maternal Obesity has been identified as a public
health priority in North Wales with an inter agency
group established to monitor the plan and report to
the North Wales Obesity Alliance
A two year North Wales Healthy and Safe Weight
for Pregnancy action plan has been ratified
Actions identified include the extension of the
Maternal Obesity pathway to include preconception
Pregnancy pathway linked to wider health board
work on national obesity pathway
Data quality issues to be addressed
Lead midwife identified
Pregnancy pathway linked to wider UHB work on
WG obesity pathway
Obesity work in maternity services including RCT
research project with Slimming World
Obesity Strategic Implementation Group set up
ABHB Dietetics, Lead Midwife Obesity and PHW,
have developed a pilot intervention/project “Eating
for 1, Healthy for 2”, and have completed two
phases of the project. New models and approaches
are now being reviewed, due to low
uptake/attendance
Lead Public Health Midwife identified for obesity
Work starting on this via obesity pathway working
group: information paper and recommendations
Date: 4th December 2014
Version: v1 final
Page: 95 of 100
Public Health Wales
Health Boards
(HB)
Maternal Obesity Report
Maternal Obesity Activity
prepared
-
-
Hywel Dda Health Board
-
Powys Health
Board
-
Prince Charles hospital control site for Slimming
World pilot
Analysis of MITS database to commence re obesity
levels and geographical distribution
Maternal and child obesity workshop held with
partners to develop an Obesity Strategy and Action
Plan
Pregnancy and early years health improvement
research project – set up to look into obesity in
pregnancy and children up to two years of age, also
linked to the Health Improvement Advisory group
which will aim to provide advice and
recommendations on how to tackle obesity
Implementation of All Wales Obesity Pathway
PHW dietitian working directly with midwives on
how to advise pregnant women on obesity
Family Challenge (Pembs)
Hywel Dda Pregnancy and early years health
improvement advisory group (PEYHIAG) have got
findings from ORS study and are going to link with
Pathfinder
Plan for practice development midwife, still at preimplementation phase
Date: 4th December 2014
Version: v1 final
Page: 96 of 100
Public Health Wales
Maternal Obesity Report
Appendix 4
Physical Activity Guidelines’
Age Range
Physical Activity Guideline
Early Years (under 5s) – for infants
who are not yet walking.
Physical
activity
should
be
encouraged from birth, particularly
through floor-based play and waterbased
activities
in
safe
environments.
All under 5s should minimise the
amount
of
time
spent
being
sedentary (being restrained or
sitting) for extended periods (except
time spent sleeping).
Individual physical and mental
capabilities should be considered
when interpreting the guidelines.
Early Years (under 5s) – for
children who are capable of
walking.
Children of pre-school age who are
capable of walking unaided should
be physically active daily for at least
180 minutes (3 hours), spread
throughout the day. *
All under 5s should minimise the
amount
of
time
spent
being
sedentary (being restrained or
sitting) for extended periods (except
time spent sleeping).
* Most UK pre-school children
currently spend 120–150 minutes a
day in physical activity, so achieving
this guideline would mean adding
another 30–60 minutes per day.
Individual physical and mental
capabilities should be considered
when interpreting the guidelines.
Date: 4th December 2014
Version: v1 final
Page: 97 of 100
Public Health Wales
Maternal Obesity Report
Age Range
Physical Activity Guideline
Children and Young People (5-18
years)
All children and young people should
engage in moderate to vigorous
intensity physical activity for at least
60 minutes and up to several hours
every day.
Vigorous intensity activities,
including those that strengthen
muscle and bone, should be
incorporated at least three days a
week.
All children and young people should
minimise the amount of time spent
being
sedentary
(sitting)
for
extended periods.
Individual physical and mental
capabilities should be considered
when interpreting the guidelines.
Date: 4th December 2014
Version: v1 final
Page: 98 of 100
Public Health Wales
Age Range
Adults (19-64)
Maternal Obesity Report
Physical Activity Guideline
Adults should aim to be active daily.
Over a week, activity should add up
to at least 150 minutes (2½ hours)
of moderate intensity activity in
bouts of 10 minutes or more – one
way to approach this is to do 30
minutes on at least 5 days a week.
Alternatively, comparable benefits
can be achieved through 75 minutes
of vigorous intensity activity spread
across the week or combinations of
moderate and vigorous intensity
activity.
Adults
should
also
undertake
physical activity to improve muscle
strength on at least two days a
week.
All adults should
amount
of
time
sedentary (sitting)
periods.
minimise the
spent
being
for extended
Individual physical and mental
capabilities should be considered
when interpreting the guidelines.
Older Adults (65+ years)
Older adults who participate in any
amount of physical activity gain
some health benefits, including
maintenance of good physical and
cognitive function. Some physical
activity is better than none, and
more physical activity provides
greater health benefits.
Older adults should aim to be active
daily. Over a week, activity should
add up to at least 150 minutes (2½
hours) of moderate intensity activity
in bouts of 10 minutes or more –
one way to approach this is to do 30
minutes on at least 5 days a week.
Date: 4th December 2014
Version: v1 final
Page: 99 of 100
Public Health Wales
Age Range
Maternal Obesity Report
Physical Activity Guideline
For those who are already regularly
active
at
moderate
intensity,
comparable
benefits
can
be
achieved through 75 minutes of
vigorous intensity activity spread
across the week or a combination of
moderate and vigorous activity.
Older adults should also undertake
physical activity to improve muscle
strength on at least two days a
week.
Older adults at risk of falls should
incorporate physical activity to
improve balance and co-ordination
on at least two days a week.
All older adults should minimise the
amount
of
time
spent
being
sedentary (sitting) for extended
periods.
Individual physical and mental
capabilities should be considered
when interpreting the guidelines.
For further information: Start Active, Stay Active: A report on physical
activity for health from the four home countries’ Chief medical Officers
(2011).
Date: 4th December 2014
Version: v1 final
Page: 100 of 100