 recording. That's great. I shall mute myself and I'll allow you to introduce yourself then since I haven't read your bio recently, being a colleague of mine here in the IBM. Over to you. All right. Thanks so much, Linda. My name's Deborah Davis. I'm Professor of Midwifery at the ACT Health, shared appointment with the government and also the University of Canberra. I've been on the organizing committee for this conference since it first began 10 years ago and I'm just excited every year to see how wide a reach it has and you can see from the chat box there. People are just coming from all parts of the world and of course as the 24 hours progresses some of us will need to go to bed and others will be waking up and joining us for the first time. I'm also really happy to see some names there I recommend from previous years so I know that people have been coming back again and again. Welcome to this session and thank you for bearing with us. Our speakers haven't made it and sometimes that happens. It could be an internet issue. It could be a time conversion issue but for whatever reason they're not able to join us and that's disappointing because we were going to hear a great presentation from Pakistan. So I'm going to fill in. You weren't expecting this but I thought a presentation on obesity might be interesting to you. This is an area that I've been working in now for a few years and it captures my interest because it's something that we can really make a difference in as midwives and it's also an area where I think there's a lot of stigmatism and even in the health sector where we say we give care that's very non-judgmental. I think that's not always the case. I think there's a lot of room for improvement in our maternity service. Obesity is a problem for most countries now. Even those countries that aren't well resourced are struggling with women eating the wrong sorts of foods and becoming more and more obese. So it's something for all of us. You know that in most health services we look, we use the body mass index as a measure of women's obesity. It is a really crude measure. It is our weight in kilograms divided by the square of our height and of course if you're, what it doesn't account for is the weight of different components of our body like bone of course fat but muscle and we know that muscle is quite heavy. So you could be someone who was very muscly and developed and therefore you'd weigh a significant amount and you could have a high BMI and so that doesn't necessarily reflect the amount of fat that you're carrying in your body but it's very difficult to use other sorts of measures in the context of maternity care. There are different ways of determining how much fat we're carrying which include the caliper measurements but they're very time-consuming and require some expertise. So we use this very crude measure and it's just important to appreciate that using the BMI is not completely accurate. It gives us some idea of someone's adiposity. This is one of the classification systems that that's used to identify what's normal BMI under and over. This one comes from the Institute of Medicine which is quite an esteemed organization who's governed by a panel of experts and also a group who've done a lot of research in this area. So underweight is usually defined as a BMI of less than 18.5. Normal is between 18.5 and 24.9 and then you'll see as you become overweight and then into the obese classes they've been subdivided into class 1, 2 and 3. And you can see to the right of that column that the risk of complications emerging by BMI is like a dose effect. So the complications, those risks are higher depending on how much additional weight someone is carrying. So someone may be only just a little bit overweight and they wouldn't have a lot of extra risk that is brought to their pregnancy due to their weight status but it does significantly increase as the BMI increases. So this is an audit that we did in two large area health services in Australia a few years ago and we had over, I think it was more than 10,000 births in this audit and this was just categorizing women by their pre-pregnancy BMI and what category they fell into. So you can see that it was roughly 60% had a normal BMI. We weren't looking at the underweights here, we were just looking at those who were over and then about almost 25%, 24% were overweight and the other quarter were different degrees of obese. So this was a few years ago now and it is an area that's rapidly changing unfortunately with more and more women becoming overweight and obese. So I wouldn't be surprised that if we did this again today that we have a larger group of women in the overweight and a larger group of women in the obese categories but it does demonstrate that we're talking about a large proportion of women in our service. It's always really important that we don't judge any women in our service but particularly around obesity because it is associated with low socioeconomic status. So women that don't have good access to financial resources, to education, to all the resources that go with someone who is in a higher socioeconomic status, they are more likely to have obesity for very complex reasons. Lack of education is highly associated with obesity. There is without a doubt genetic components to obesity so we do inherit some propensity to be obese or to be at risk of obese through our lifetimes. And there's also cultural norms and expectations so it's not, in every country it isn't necessarily attractive to have a normal body weight. Some cultures prefer women that are around and heavier or there might be cultural practices or norms around the ability to exercise or around certain food groups that just make it more difficult for women in some cultural groups to maintain a normal body mass index. The health risks are pretty well documented and you'd be able to find these within a lot of guidelines from professional groups. This one comes from a Queensland government which is in Australia, a guideline and it's very well put together so it's one that I could recommend to you. They do reference all these conditions and the research that informs them but just the simplicity of presenting them without their references. But I'm sure as midwives many of you know that the health risks in relation to pregnancy really span every part of the pregnancy, labour and birth and postpartum period even stretching from preconception. So it is more difficult for women of high BMIs to become pregnant in the first place and then once they do become pregnant they're a range of potential complexities. But as I said we have to remember that these are dose dependent so not everybody is going to experience any of these complications but the heavier they are the more likely they are to experience one or more and I'm sure you've read what some of those were there. We've gone from pre-pregnancy, we've gone through the anti-partum period, now into the intrapartum period there are a range of additional potential complications, the postpartum period and the neonatal and some of those complications arise just because of the mechanics of having additional weight so the interstitial tissues are more crowded with fat so really the birth canal and the pathway for the baby is much more crowded when there's fat in those interstitial periods so you've got a baby sometimes a bigger baby trying to get out of a smaller space so there are mechanical issues. There are also physiological issues right down to the way that the cells are functioning for example in the uterus so the contractability might not be there and that's why there's often slow progress there's a higher risk of PPH for example and then into the breast tissue so when there's additional fat tissue in the breast the circulation to the ducts and lactogenesis might not be as efficient so there are issues with breastfeeding as well and then of course there is research now suggesting that the intrauterine environment of the fetus can have an impact on the baby through its lifetime so potentially that environment can increase the risk of that baby to obesity through its lifetime beyond just the the nurture in relation to the culture of the family and eating and exercise habits but something happening potentially epigenetically to the fetus in that sort of environment so this is just back to the audit that I mentioned that we did on this hospital database we looked at women in those different BMI categories the normal, the overweight and the three classes of obesity and we just looked at some of the clinical outcomes as I said these were in New South Wales Australia but that you could go to any many many pieces of research that really demonstrating the same thing there's there's an enormous amount of research out there on this topic relating clinical outcomes to women's weight and you can see you can see the dose effect here this was an antenatal admission so it wasn't care episodes when these women might be seen by a midwife or other maternity health provider but actually being admitted to hospital it's not telling us what they were admitted for but you can see there's the proportions are increasing as the BMI is increasing and in that highest category 30% of those women had an admission to hospital during their pregnancy and usually we don't admit women to hospital unless it's a pretty significant condition these are just narrowing down looking at women who have hypertension or diabetes in their pregnancy so if you were just comparing the normal weight women with the obese class 3 women you could see there's quite a disparity there a lot more women with that heavier BMI being diagnosed with problems with hypertension or diabetes and they're some of the most common conditions related to BMI. Caesarean section at the rate at this time for women who had a normal BMI was 24% and then we can see that dose relationship going right up to 50% for obese class 3 and we know that they're there women who are really at high risk from the Caesarean section so you're exposing this group to hemorrhage to DVTs to anesthetic problems to wound infections there's a whole additional consequence of a woman with a very high BMI having a Caesarean section but 50% of this group had Caesarean sections this was looking at macrosomic babies or babies that were over 4000 grams four kilos not such a neat stepped up pattern here but still twice the proportion in the obese class 3 as the as the normal weight women and then this is very small proportions if you look at the percentages on the top of each one but this is apgas with zero at five minutes so these these are babies that probably didn't survive if they had an apgar of zero at five minutes definitely like I said it's just it's very small percentages not point so a third of one percent for the normal category but it's almost up to one percent for the women who are in obese class 3 so that's almost one in a hundred which is a really very very tragic outcome admitted to nicker I'll just fly through these now so we've got increasing rates there and the other thing about this is that women do tend to gain weight with each pregnancy and I know there's another presentation or it might already have been today on this tendency to carry additional weight with each baby so what happens you know the first pregnancy a woman might be a normal weight she might gain a little bit too much in pregnancy and then after she's had that baby she's got a couple of extra kilos that she's not been able to shift so she comes into the next pregnancy a little bit heavier and then the next one a bit heavier again so that that can be moving women from a normal weight into an overweight and sometimes into obese we also know that more and more women are coming even to their first pregnancy already overweight or already obese so that problem is just being compounded with each successive baby so this was the BMI by parity that really demonstrates this the women who were nullaparous went coming in to us to have their first baby their BMI was still in the normal range the average BMI of all these women and then by the time they were having their fifth babies their BMI's were quite high on average 28.8 so that's almost obese as an average but we do have to remember as well that women are getting older over this period of time so it's not only the fact of having these babies but the fact of aging so as we move through the childbearing years typically women are gaining weight gaining a few kilos regardless of whether or not they're having babies so just a little bit now that's the statistics and of course behind every statistic there's a woman who's having a pregnancy and a baby and needs our maternity care so a really important part of this is what are women's experiences of having maternity care and this literature here comes from a literature review on women's experiences so this wasn't our own research I've got some references for you at the end but we had a really careful look at how women are finding care the thing about obesity or overweight is it's a very visible condition it's not like diabetes or hypertension where you can go through the world and people wouldn't be looking at you going oh my goodness she's got diabetes so it's something people can see and of course there's a lot of social pressure in our world to be slim and to be beautiful so there's a lot of stigma attached to being overweight and it is associated with moral qualities like lack of self-control like greed like laziness like selfishness so people do see an obesity or overweight body and attach these moral qualities to it which is pretty unhelpful really because as we we know there's a range of reasons why people could be overweight or obese so it's also a very public body the pregnant body is quite a public body and you'll know this if you've ever been pregnant and subject to people touching your body or padding your belly in any way so this is just a quotation from someone and for her she's an overweight woman who is pregnant but she feels more confident in her body but people do feel increased scrutiny from the public when they're pregnant so we see this in other areas for example women who smoke people would be looking at them sideways if they're pregnant and they're smoking drinking alcohol same with obesity and pregnancy some women feel like they're being looked at and judged some women have a very positive image of their their body in pregnancy and and sometimes it's negative so we can't necessarily determine how women might be feeling about their bodies when they're pregnant and overweight and obese some some will like their bodies and some won't so I guess that's just like all of us isn't it so it's interesting isn't it what's socially sanctioned so some women have said that's a great excuse you're allowed to put on weight when you're pregnant so you know I feel like it's a good it's a good excuse and people won't judge me so much this was really interesting so women who feel quite relaxed about their their body size sometimes they think well you know I'm just I have the pregnancy and we'll worry about this later on but I think a future slide might show that that does tend to be the primary for us women because women who've had babies before might have experienced how difficult it is to shed those extra few kilos so they tend to be the group for a little bit more careful in pregnancy where the primary for us women could tend to be a little bit more relaxed thinking it's going to come off pretty easily after I've had my baby yeah so there's an example of one woman who had an experience with the previous pregnancy of finding a little bit hard to get that weight off and something that is pretty clear in the literature across a variety of different countries actually is that women get very mixed messages about weight gain in pregnancy from their health carers so some health carers don't address it at all and women interpret that as it's not important as you can see from that quote so the my midwife or my health carer they raise things with me that are important so if that wasn't raised it mustn't be important and I think there's a there's a lot of reasons for this ambiguity one is that health carers find it's such a sensitive issue that they don't know how to broach it with women they don't want to risk the relationship they don't want to offend them or some don't know what to recommend they don't know what the recommended weight gain is in pregnancy or they don't feel like they've got the skills to help them if the even if the women want to try and have a healthier weight gain in pregnancy so they don't say anything about it and then there are and these are hard to read as a health carer there there are a lot of women who have very bad experiences in our maternity services so those the things that women are worried about is actually being weighed and particularly if they're going to be weighed somewhere that might be a bit public they might have been avoiding their weight and what they weigh for some time so they don't want to know for themselves and they just don't want that embarrassment and I've heard of people some women not even going to antenatal care because this is such a concern for them then not only exposing their weight but exposing their bodies so they they know that they might be exposed at least on the abdomen when they're having palpations or you know when they're having their babies parts of their bodies will be exposed and even with their intimate partners some women didn't feel comfortable being naked so I think that's something that's really important for us to remember every woman obese or not obese or overweight or not overweight will have their own issues around their body and their own comfort zones in relation to their their naked bodies even with intimate partners so we can't make any presumptions about what they're comfortable or not comfortable with and then there's there's a whole area that women are reporting about their bodies being difficult bodies because the the the body habitus is is large perhaps it's making the ultrasound difficult because there's body fat that has to be navigated on the ultrasound we as midwives can find it more difficult to palpate the baby the position of the baby the size of the baby sometimes if they're having procedures done you know sometimes if we're lifting a woman's leg that their leg can be heavy so they do perceive their body as being a difficult body and a body that's getting in the way and and they feel guilty about this because they know perhaps their baby can't be visualized so the position of the baby can't be found so easily so you know we have to be really careful if we are having these sorts of problems to be enormously tactful because women are going to feel embarrassed and potentially guilty about that and then of course there's this whole area of risk you know they've got a risky body and that seems to be the only thing everybody concentrates on so you know i did start the presentation with the litany of potential problems and complexities and risks that face this group of women but we do have to always remember that they're you know they're having a baby first and foremost which is such a life affirming experience and and they don't want to hear every single time they come to the service about the risks so particularly when they're seeing someone different every time and if everybody's going to hound them about the risk we end up just alienating these women and making them feel worse which isn't helpful and really taking the shine off a pregnancy that by and large they should be able to enjoy so yeah we can sit there and go okay well all this is terrible and we don't want women to have be having these terrible experiences so what can we do what are more positive encounters that this group of women can have and i think they from the literature women say they really like affirming encounters and for that what they mean by that is that women health care is our frank with them and upfront with them so they don't want us to be secretive or keep things from them so being upfront and also yes they're not planning care behind their back but also dealing with things with humour so diffusing embarrassing situations with laughter together and but i think you know there can be a fine line can't there with humour sometimes they really liked it when caregivers were interested in the woman so i like this woman said you know there's a baby and then there's me and you know she said well i'm not really an oven just an incubator for a baby you know she wants someone to know about her and how she's feeling and having an interest in her so i think that's something that's pretty easy that we could all do participating in their own care so you know potentially weighing themselves we don't necessarily have to weigh them we're going to ask them to take their weight or or bring their weight with them if they're weighing them we don't have to do it and we don't have to do it in a public place certainly and caregivers who are encouraging and supportive especially when they're achieving personal goals and one of my students told me a story recently of one of the women she was providing care to as a student midwife who who went to the hospital service to book in and she'd already lost 10 kilos in an attempt to get healthy for her pregnancy and she'd gotten pregnant and then she was still leading a really healthy lifestyle but she was still overweight even though she'd lost some weight and without asking or you know about this woman's situation the healthcare has just launched into a pretty punitive attack on her and her weight and the risks making the woman feel terrible when she'd actually already done so much to get herself in a great position for pregnancy so you know finding out where women are at finding out what they've done so far it it's a great opportunity in pregnancy because most women really do want to focus on their health at this time so you know I think we could be encouraging we could be helping women to set some small achievable goals and we could be helping them work towards those and having a healthy weight gain in their pregnancy at the very least I think if women don't want to do anything about it if we put it to them and ask them if they want to focus on their their weight gaining pregnancy if they don't want to then I don't think we should go there thanks Linda I think we should let it go but some people are going to want to focus on it so what should we do as health carers you know in this ideal world women would have a normal BMI before they got to pregnancy we would all love that but look they don't do they and they're not going to and we're still going to have a lot of women coming to our service already heavier than they need to be so we do really need to work with them to defend their dignity and their privacy and promote their comfort in pregnancy we do have to provide appropriate care for that group in pregnancy and sometimes that does mean additional monitoring sometimes that does mean extra services and things doing things differently than you would to other people um we can try and help them achieve prevent excessive weight gain in this pregnancy because that will benefit them long term and it will benefit them when they come in if they have future babies with us and we can potentially introduce some lifestyle changes some small changes that might help them avoid excessive weight gain between pregnancies so there's so there's a lot we can do with this health promotion focus of midwifery in helping to make these women make some changes but also to giving them a better experience of our service so the recommended weight gain these are in kilos if you if you're used to working in pounds you'll find this in pounds on the internet again it comes from the Institute of Medicine um so they do recommend uh smaller weight gains for women who have high bmi so the least somebody should gain is five to nine kilos throughout their pregnancy and that's for a woman with a bmi of greater than 30 it's definitely not recommended that women have weight loss or no weight gain in pregnancy that's found to be associated with a range of unhealthy outcomes including premature birth and growth retarded babies so they should be able to gain at least five kilos um and that probably does represent a bit of a weight loss when when the baby and all the pregnancy weight is taken into consideration don't worry about that don't worry about that so uh i won't go through these but there are a range of things that we might need to do additionally for women who are overweight or obese and i'll just click through them so if you wanted to review them um on the video we could and again as i said it really is going to depend on what women's weight is if they're a little bit overweight there are not going to be additional risks uh this is a photo of harmony and jasper and um harmonies photo i found on flicker and i asked her if she'd be happy if we could use it um because she just looks so uh gorgeous yeah so happy to take any questions thank you are you there linda hi um sheryl i'm not i'm not aware of um any what the recommendations might be for weight gain who've had bariatric surgery but i know that um there is a lot of work looking at the um nutritional condition i guess of um women who've had bariatric surgery because that might not be optimal they they certainly um might need some supplementation it depends on how many um you know what their diet is like because some women after bariatric surgery i know um can be really struggling to to get the nutrients that they need um so i'm not sure what the weight gain recommendations would be i'd be surprised um um if it was very different from that the bmi categories i'm trying to think of how could be different if any of you want to ask a question directly to uh professor depot gravies uh i will now give you the option of using your uh micro do you have anyone to want to ask any questions i think uh yeah someone said that it's often not prioritized in our settings i mean that's right and and sometimes actually some policies are quite punitive against women that um have high bmi's for example water birth um might be um not uh promoted for women who have high bmi's um you know they might need continuous monitoring in in some services and uh you know i think water immersion is actually a great thing for someone who's got a high bmi because it can just take the pressure off the knees um of the woman or the joints and they can change position much more easily so i think we do have to think carefully about what how can we make uh the experience of this group of women better in our health health service can obesity cause a syncletic presentation yes i'm i'm not really sure i think um it maybe it probably depends a bit on what the fat deposition is like in in the woman in in the abdomen and in those interstitial tissues i haven't um thought about that specifically thank you yep we can finish thank you um i just want to say i see the speakers from pakistan did turn up in the end and i'm so sorry we just couldn't wait any longer um but i i hope that you'll have another opportunity to present your great work and thank you to the audience for um accepting this very different topic at the last minute yes i agree hilma i absolutely agree okay okay over to you annette okay we the this session is coming to to a closing now thank you very much said debora for for standing in in a very short notice for the presentation