Journal of Obesity and Metabolism
Open Access

Midwifery; Maternal obesity; Attitudes of health personnel; Health;Practice

Introduction

Over the past ten years, there has been an increase in the prevalence of obesity in Canada, with approximately two thirds of the population now being considered overweight or obese (body mass index (BMI) of 25 or higher or 30 or higher, respectively) [1]. In Ontario, nearly 20% of women who were able to have children in 2019 began their pregnancies obese (BMI 30). Despite the fact that health can exist in a wide range of body types and sizes, there is a link between high BMI during pregnancy and unfavorable maternal and newborn outcomes. The American College of Obstetricians and Gynecologists, (2015), includes macrosomia, neonatal hypoglycemia, gestational diabetes mellitus (GDM), gestational hypertension, premature birth, still birth, caesarean and instrumental birth. Pregnancy obesity is also linked to a higher chance that the foetus would grow up with chronic illnesses. It’s crucial to realise that obesity is a complicated problem and that societal and clinical factors work together to influence these negative effects.

Customers with complex social and clinical contexts, such as those with low socioeconomic status, mental illness, and substance use, benefit from the characteristics of the midwifery model of care in Ontario, Canada, which emphasize choice, continuity, person-centered care, and a trusting, nonjudgmental midwife-client relationship. Due to the potential for highly stigmatised and biased services that could create hurdles to tailored care, these features may put midwives in a strong position to improve care for clients who are obese [2].

Consultation and transfer of care

Little is known about the opinions and practices of midwives in Ontario about caring for clients with an increased BMI, and the effects of the midwifery style of care on outcomes for clients with obesity have not been adequately described. Clients of midwives have reported varying degrees of weight stigma during their pregnancies. While some clients claimed that their midwives believed they would experience negative results like GDM, others claimed that their midwives explained they would receive the same standard care given to all clients. Due to a shortage of proper equipment, such as wheelchairs that were the right size and blood pressure cuffs, patients at some clinics and hospitals also encountered difficulties while receiving care as a result of the physical environment [3].

Research examining the opinions and experiences of midwives outside of Canada has revealed a range of viewpoints and degrees of comprehension on the difficulties in providing care for expectant clients who are obese. Highlighted that choosing when and how to treat obesity with midwives was challenging. The definition of obesity as a high-risk condition presented some midwives with the dilemma of over-medicalizing treatment for this demographic. While others grappled with how to sensitively counsel and encourage individuals to change their eating and activity habits [4]. The midwives admitted they lacked the resources to start conversations on obesity and healthy pregnancy weight gain. However, they reported feeling more at ease when addressing more delicate subjects like nursing and smoking, which they attributed to the training they had received on these subjects. The absence of clinical guidelines addressing obesity, prenatal weight gain, and physical exercise during pregnancy was linked to these knowledge gaps [5].

Midwifery management

In Canada, there is a worry about the absence of recommendations on the best ways to care for patients with high BMIs. In Ontario, the College of Midwives of Ontario, the regulatory body that establishes the standards and scope of the profession, makes no mention of elevated BMI or obesity as a reason for consultation or transfer of care, despite the Association of Ontario Midwives (AOM) developing a clinical practice guideline titled “The Management of Women with High or Low Body Mass Index” that offers recommendations for clinical management (College of Midwives of Ontario, 2014) [6]. Local hospital protocols or obstetrician preferences for when to consult or transfer care may require midwives to follow them locally. Different clinical management practices among communities and care providers may be caused by a lack of regulatory direction as well as the influence of hospital and physician preferences. The goal of this study was to identify the knowledge gaps, facilitators, and barriers that midwives encounter when attempting to care for clients whose pregnancies are affected by obesity. In order to investigate the factors that influenced midwives’ clinical practices and to learn more about their experiences managing pregnancies complicated by obesity[7].

Factors influencing midwives’ clinical behaviors

The survey and interview responses highlighted the factors that influenced clinical behaviours related to caring for clients with obesity. These factors comprise our broad themes and included beliefs and attitudes, knowledge and skills, and system-level influences. From May through October 2018, a survey was conducted online using Survey Monkey, and the results were gathered. All midwives in Ontario who are actively delivering prenatal care (n= 850) were eligible to participate in the survey [8]. Based on survey research literature and earlier studies conducted with this participant group, we projected a response rate of 20% (n= 170). All Ontario-licensed midwives who are registered received an email with the survey link. For three months through the biweekly newsletter of the provincial association.

Additionally, ads for the study were distributed through social media, institutional department newsletters, and the preceptor email distribution list for the local midwifery education programme in Ontario. This technique is known as convenience sampling. Prior to their voluntarily taking part, all midwives gave their informed consent [9,10]. All poll respondents’ demographic information was gathered. The research team developed survey questions using a five-point Likert scale (1 being “disagree” and 5 being “agree”) to measure midwives’ ideas, beliefs, attitudes, and experiences with managing pregnancies complicated by diabetes, obesity, and hypertension. Because they have been proven to be effective at measuring the attitudes of healthcare providers, Likert scales (also known as Likert attitudinal scales) were used in this study [11]. The survey was split into two sections: the first piece asked about current practice (n= 10); the second section concentrated on care barriers and enablers, as well as decision-making related consultation and transfer of care. Before submitting their final comments, participants had the opportunity to examine their initial responses. Prior to dissemination, the survey was pilot tested with a small group of 10 midwives to make sure the questions were wellwritten. Duplicate IP addresses were checked for in survey replies, and when they were found, they were eliminated (n= 4). It was not necessary to answer every question in order to be considered for analysis. Openended questions were analysed thematically while Likert scale responses were subjected to descriptive analyses (Excel). With SPSS version 15, statistical analysis of the survey results were carried out (IBM Corp, USA). For analyses, Likert scores of 1 and 2 (disagree and somewhat disagree) and 4 and 5 agree and somewhat agree were combined [12].

Midwives who completed the survey were invited to participate in a semi-structured interview to discuss their experience of managing clients with obesity in more depth. The interview guide was developed by our multidisciplinary team of clinician investigators for this study based on literature and the results of the survey data [13]. The questions explored experiences of midwives managing care for women who present with obesity, specifically asking about factors that have enabled or prevented them from effectively managing their care Supplemental File Interviews were conducted by telephone or in person, by a trained research assistant. Following consent, the interviews were audio recorded and lasted approximately 30 minutes in length. Recruitment continued until saturation was reached, whereby no new information or perspectives were coming forward [14].

Suitability of Midwifery Care

In several communities, there were discussions among midwives and other care providers about the suitability of obese clients for midwifery-led care: Especially for something like BMI where there’s not so many clear-cut guidelines; what one experienced midwife does is very different than the next, some, of course, are more medicalized than others, and it can be challenging to navigate that when there’s discrepancy between people.

Interviews were professionally transcribed verbatim, and analyzed using into NVivo application (QSR International, Australia). We applied inductive thematic analysis according to Braun and Clarke’s method. The first step in data analysis was initial coding, which involved summarizing each sentence or statement. Next, relevant codes were grouped while themes were looked for and reviewed [15]. The emergent concepts that characterized midwives’ experiences, attitudes, and behaviors were finally clustered together and described as bigger themes. One trained research assistant conducted every interview in order to maintain uniformity throughout the data collection process. To guarantee consistency, the initial coding of three transcripts was carried out by two researchers. To reduce the influence of individual researcher bias, emerging codes and themes were also discussed, reviewed, and validated by the study team. Care planning and wise decision-making the midwives also brought up the topic of birthplace conversations as something they handled more carefully with clients who had high BMIs. Although the majority of midwives (79%) felt that a client with a BMI more than 35 was suitable for a home birth, some midwives indicated that their capacity to provide home birth to obese clients was constrained because hospital procedures demanded a transfer to higher level care [16].

Discussion

Our findings indicate that midwives in Ontario believe clients who are obese are suitable for midwifery-led care, but feel they have gaps in knowledge about the clinical implications of obesity and approaches to management. The lack of consistent guidelines and policies focused on obesity in pregnancy has led to considerable variation among midwives and other care providers which has contributed to challenges for interprofessional collaboration. The participants articulated a desire to achieve a ‘healthy at every size,’ individualized, and non-judgmental approach underpinned by consistent clinical practice guidelines to inform clinical management.

Conclusion

The midwives explained that practice guidelines and local norms, consultant preferences, client preferences, comorbidities, and the availability of specialist hospital equipment all influenced decisions regarding consultations and transfers of care. Despite the lack of legislative requirements in this area, 56% of midwives said that a BMI of 40 or higher required consultation based on their clinical opinion. Likewise, 53 percent (data not shown) concurred that a BMI >50 indicated a need for a shift of care. For obstetrical consultations, midwives described using BMI cut-points of 35, 35 with comorbidities, or 40 depending on the community where they practiced; nevertheless, this rarely led to a transfer of care.

Acknowledgement

I would like to acknowledge Department of Obstetrics and Gynecology, McMaster Midwifery Research Centre, McMaster University, Hamilton, Ontario, Canada for providing an opportunity to do research.

Conflict of Interest

No potential conflicts of interest relevant to this article were reported.

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