 So I would like to introduce Dr. Yvonne Greig and Dr. Yvonne Greig is a midwife lecturer at Edinburgh Nepia University. Her areas of research interest are living with obesity during pregnancy and consultation skills. Her doctoral work explored how midwives raised and maintained dialogue around obesity issues. She has practiced clinically for the last 30 years and for the last 10 years has combined academic and clinical practice moving into full academia two years ago. Yvonne is a keen educator and has had the privilege of working in Kenya, Greece, Egypt, where she has supported professionals in both academic clinical practice to improve maternity care and increase safety for mothers and babies. This is Yvonne's first time presenting on VIDM conference and she's delighted to be here. Welcome Yvonne Greig. Thank you very much. Thank you, Eunice. That was really nice and hello everybody and thank you for coming to listen to me today. I apologize now if I get a bit tongue tied. So as Eunice said, my area of interest lies really in obesity and I want to share with you today some of my findings from my doctoral study as well as a bit of background about the risks of living with obesity. Now, Eunice, can you help me? How do I move my slides along? Okay. Okay. Okay. So I'm just going to tell you a bit about a bit of my background really, my clinical background. So I had the privilege of working in the Edinburgh University of Edinburgh Medical School as a research midwife and part of that role was being the lead midwife in a clinic that actually catered for women who had a BMI greater than 40. Now, these women were referred to the clinic by their community midwives but some of these referrals were done without the woman's knowledge or consent and they would just get a letter through the door from me. So once I realized what was happening, I then started to call these women on the Thursday or Friday before their first appointment on the Tuesday and there were so many emotional reactions that I got down the phone. There were tears, they thought they were going to get into trouble when they came to see us and it was really quite upsetting to listen to them. But when I made that call, they were really grateful for it and there was honest and open discussion and most of them came along to the clinic and they were very happy that that happened. Now, when I spoke to the community midwives about any of these discussions or not discussions, they would say to me, oh it's the elephant in the room and I did have a lovely picture of an elephant in the room but the technology I was at takes all the pictures off so I did. The community midwives told me that olive on, it's a really tricky thing to raise that topic, really tricky and that got me thinking why is this so tricky? I was working in a medical school with very skilled obstetricians who were exploring the effects of living with obesity during pregnancy. They were looking at sugar levels, cortisol levels, all things like that but nobody was actually thinking what's going on here? Why aren't we actually talking frankly to women about this? Now this is just a recap and before I go any further I also want to say that if this has any resonance with anyone and you find upsetting, please go if you do find it upsetting but come back to me so that we can have a discussion because I am overweight, my husband is extremely overweight and my children have been overweight so this is not a get at anybody and I'm just going to talk a wee bit about the background about the risks that women are exposed to if they look with obesity and this will not be a surprise to you all, your own midwives. So living with a BMI of 30 or more does carry risk for the women during their pregnancy. She's at risk of miscarriage, fetal abnormality, mainly cardiac and that's got to be because of the high blood sugar level that she will live with. Blood pressure complications including preeclampsia, gestational diabetes again, high blood glucose levels, prolonged pregnancy and therefore the incumbent risks of perhaps the induction of labour. Caesarean section and its incumbent risks such as wind infection, blood clots because of immobility and so on, postpartum hemorrhage and postnatal depression and there is more and more information coming out and evidence coming out now about the psychological effects of living with obesity and anxiety and depression are very much featured there. There are risks to the baby, fetal abnormality as I have already said, feterm birth, shoulder dystocia, childhood obesity, moving into the sort of ongoing risks now. There is now evidence about slower cognitive development for children who are born to obese women rather than those born to women with normal BMI and there's also much more evidence now of these babies going on to develop neuropsychiatric conditions such as autistic spectrum disorders and so on. So we as midwives I believe as a professional we need to be proactive about discussing this issue with women and that was my whole basis for my doctoral work. How midwives go about this it's not really well understood. There is global evidence to suggest that we and when I say we I mean globally as a profession we are fearful of causing offence to the women because we want to always be that supportive professional. So the tensions as I've said they exist for midwives when discussing the topic of obesity because we don't want to cause offence we're a nice bunch of people we want to really look after our women and make sure they feel safe and well cared for. But also the global evidence suggests that we don't feel competent and advice giving when it comes to discussing obesity because of lack of knowledge lack of perceived confidence and competence in our knowledge base. And also there there is now emerging but there was a lack of national and international guidance about what actually to say to women what should we be saying what should we be telling them. So the aim of my study really was to explore what the barriers and facilitators were that influenced the community midwives when raising and maintaining dialogue about living with obesity and in the UK context those of you who are not from the UK we have our midwives are some are based in the hospital to give the inpatient care and then there are teams of midwives in the community and they look after the women close to their own homes in clinics. So I interviewed 13 practising community midwives consent they all gave consent and the interviews lasted 20 to 80 minutes and were all recorded. They were also asked to complete a practice diary of sort of giving me insight into how they had constructed their appointment over the last three times they had spoken to women who had lived with RAs BMI and some did that better than others but nevertheless got some really interesting data. So data from both the interviews and the practice diary were analysed thematically with the aid of the in vivo software. I don't know if any of you have heard of that or used it before but if any of you come to research in the future I'm sure you will and it's really an elaborate way of copying and pasting many of the quotes into particular categories. So I used going into the philosophy that underpin this social constructionism if you consider that we construct everything that we do and the antenatal appointments are a construction and the philosopher Gergen very much drew on his theories about this construct and how we as teams within our various social and professional context how we develop behaviours and language and habits that's specific to particular groups and my particular group was the community midwives. So what did I find then? So what I found was that construction relationships with women was really important to the midwives they really valued this relationship and they didn't want to do anything to jeopardise it so obviously you want to build up a good kind of mutual relationship and that really put it in a nutshell and the midwives they seem to believe that developing this relationship affirmed their role as the women's advocate you know one way you can they can trust you they're happy to tell you anything and they can ask you anything that's worrying them yet you know just that you're there to support them and you can get them through this pregnancy safely so that was really important this this issue of this relationship and getting them through this this life event safely. We also felt that relationship building was really important and this was where the one of the tensions arose because they felt that to discuss obesity in the context of relation building a relationship really could be damaging so there was a sense that although building the relationships was a key part of the midwives role that tension existed because they really wanted to avoid at all costs raising sensitive topics at that initial meeting you're trying to build up that relationship and the last thing you want to do is annoy and I don't want to cause harm or cause them to be upset because they're anxious and it's their first appointment and they're excited fair enough. Information exchange between the midwives and the women was also really important so the participants acknowledged that they had learned their communication informally and on the job and this for me was the real crux of my research because I knew a lot about living with obesity and the risks and all of that but when I really analyzed this data what I found was that the midwives had learned their communication on the job and as a student and during many years of practice rather than as a result of receiving formal education and I think that's really important and it can be seen in this quote you know I think as a student you've got such a fantastic position you're in such a fantastic position because you get to work with different midwives and see how they do things and I was forever oh I like the way she said that oh I like the way she did that you know so you pick up a lot of positive ways of saying thing through watching other people and then I think when you qualify you just have to learn what your style is but it takes time to do that you know and that's quite a long quote but I think there's quite a lot in that and it's quite informative. Now in this part of the world we use a very structured institutional questionnaire to ask women questions it's very ordered one size fits all and it was the institutional questionnaires that were used to record the information of eternity notes that appeared not only to provide permission for the midwives to raise the topic of obesity but also to devolve the responsibility for doing so to the institution and that can be seen in this next quote when they're talking about calculating BMI so I say the computers just worked out your BMI where you're aware of your BMI do you know what BMI is and just you know explore it with them and they just go well I know I'm a wee bit heavier or sometimes if it's a second time mum they'll go well I'm definitely a wee bit heavier than I was in my first pregnancy now that's just a quote out of a really big transcript but actually what I found was the conversation didn't go anywhere else after that the BMI was recorded and that was that was end of the story and again yes you follow the booking appointment so this is the questionnaire that I'm talking about so the midwives followed this this questionnaire you follow that yep you weigh them and you put the weight down but I never discuss weight and I have never been told that weight is something we should discuss now I find that quote quite alarming because as autonomous practitioners as we are in the UK we don't need to be told and we don't need permission we have a professional right to discuss these things it's evidence-based and it clearly says in our code of practice that we should be giving women evidence-based information now another thing that the professionals did was they used the medical protocols or the clinical protocols I could say so the institutional questionnaires used to record the information and the maternity notes appeared not just to give permission to raise the topic but also devolve that responsibility for doing so to the institution so again they were saying it's not really my responsibility to discuss this but I'm told I have to do it you know so again that is the same quote then about BMI but actually there is another quote I only just noticed this before I came on so I must apologize there's another quote where the midwife says because your BMI is over 30 I have to do a glucose tolerance test and I have to refer you to the anesthetic clinic and actually it's about informed consent and discussion with the woman and asking what she wants to do and does she understand these things so midwives appear to really value this midwife-woman relationship they prioritize over discussing other sensitive other sensitive issues of which obesity is one so the other things are things like smoking cessation now in this part of the world there are places that are organizations that the woman can be referred to to support them in giving up smoking there are organizations to support them if they are suffering from domestic or intimate partner violence but when it comes to obesity and weight management there is nothing this is supposed to be you know holistic care but there really is nothing else other than if a woman has a BMI over 40 they get referred to the specialist clinic and they have a bit of additional surveillance in terms of growth scans and being seen by the dietitian and so on but if somebody's BMI is between 30 and 40 there is nothing else for them and same with the other sensitive issues if there is somewhere for the midwives to sign post-women too they'll discuss it because they've got permission on these questionnaires but if that doesn't exist they avoid it and that can be quite catastrophic catastrophic for some women what I found really interesting was that the midwives prided themselves on being good communicators but I don't know what they were measuring this good against was it social or professional communication because communication is what I'm doing to you now is what Eunice did when she introduced the session professional communication is quite different and I'm not sure how much formal education individuals were given around their professional communication so I find that quite worrying that they're just assessing themselves particularly if they have not had any formal communication and if that's the case then what exactly are the students seeing as I said to you earlier the clinical protocols were viewed as giving permission given the professionals permission to raise some topics with the terms I have to often being raised with respect to these additional investigations and the midwives don't have to do anything it's a professional responsibility to discuss these additional investigations such as the glucose tolerance test screen for gestational diabetes such as referring these women to an anesthetic clinic so that they can be assessed by the anesthetists shoot where the time comes they need any anesthetic input but it's not the midwife doesn't really have to do anything so what I think my interpretation of all my data was that by using these questionnaires and the protocols what the midwives were really doing was conflating the woman's pregnancy journey just to a list of problems rather than making sure it was a tailor-made woman-centered approach where decisions were made in conjunction with the woman now doing that I believe risks emitting some of the topics that are very relevant to someone and whatever they may be whether that might be you know somebody who's really tocopobic and concerned about pain relief in labour or concerned about will the baby be well it doesn't really matter but using these proformas and focusing on the clinical protocols I think does risk us forgetting that the woman should be at the centre of her own care and her own decision making and the other thing that I think is really of concern is the midwives learner communication skills informally and on the job and that suggests a weakness in professional practice and non-adherence to the code I'm talking about the UK nursing and midwifery council code of 2018 which really clearly says that we should be giving women evidence based and up-to-date advice so evidence based and up-to-date advice about living with obesity does tell us that these women are at risk of various complications so we really have a professional responsibility to discuss it with the woman and indeed to discuss how they can optimise their lifestyle choices so that was my findings now that any of you who work in research will know that completing a research study doesn't really answer questions it always creates more and that's exactly what's happened here and so in order to minimise the risks I believe that our midwives and our student midwives need target or it might optimise their practice if they receive targeted education that encompasses evidence-based consultation models because I think we don't really as midwives have a consultation model the consultation models that are out there are medically based and that's where somebody goes along to a medical person a GP or a surgeon or whoever and says I have a problem will you fix me in this context is the women who are coming to us probably not thinking they've got any problems whatsoever and we're saying well actually your risk your health may be at risk here so can we discuss how to for how I can support you to optimise that and that's the difference between a medical consultation and a midwifery consultation so I think midwives need to be made aware of that and I think we need to really develop our own consultation model and I think that our practice could be strengthened and midwives empowered to confidently raise and maintain dialogue regarding these sensitive topics now the reason I say that is in not so much in my research but there is evidence globally that some midwives are really reticent about raising the topic because they are afraid that complaints are raised against them for being offensive and that is why we need a consultation model that will facilitate our practice and so if somebody goes to a manager and says soon so talk to me about said I was fat well actually if we do it in a professional way they really can't argue there were a lot of limitations to my study and it was very small it was limited to one geographical area that was Edinburgh in the east of Scotland right in the fringes of Europe it just focused on midwifery practice and the views of the women were not sought and that's one of the the next things I want to do and the findings may have been strengthened by looking at the length of experience and approach to communication education that each midwife had had but I didn't do that because my findings came along when I analysed the data but again that's one of my future things so what am I doing now well I have developed a an e-learning module and I have just piloted that with some of our students at Edinburgh Nathan University and I'm currently analysing the data it does look like though that the view has shifted on the post exposure questionnaire that our student advice now are much more women-centred and how they might approach this topic and I'm also carrying out a literature review to explore what educational interventions are being delivered for nurses and midwives with respect to consultation education and I really want to carry out more interview research to really explore what the women expect from a midwifery consultation and what the midwives themselves want and need or feel they need in terms of education so my take home messages for you today sorry I'm going on a bit we need to view and remember that living with obesity is a serious risk for pregnant women and pregnant people and develop our practice to approach it meaningfully so that we don't actually damage this trusting relationship that is so important to us as midwives we want the women to trust us so we have to really view this as a serious health issue and if any of your educators out there I think we really need to consider adding this as a topic in its own right to curricula rather than threading it through the programs and saying oh obesity is a risk for preeclampsia it's a risk for diabetes or whatever because it is a very big subject in its own right the risk of psychiatric illness all these things are really important for us to acknowledge and attention needs to be given to equipping midwives of the ability to construct these meaningful consultation episodes as I've said to you so that's where I am I'm really in the middle of what seems like a much bigger project as a result of all of that so thank you for your attention it's just a quick overview really of my work and I hope there's a lot more to come I do have some sources if anybody wants a copy of this I'm sure it'll be recorded but you can get in touch with me I can hand send it on to you as well these references so I'm going to thank you hand back to you now I thank you so much Yvonne for that nice presentation I don't know do you still have other comments no I'm happy I see quite a lot of people have put some comments that's what I can't read them all at the same time but I'm very happy to take questions if anybody wants to ask me anything um there's a comment by Ella Kane um we is asking about that quote about students picking up skills in practice is interesting students in UK spend 50% of their course in theory where they learn about health promotion and models of health promotion they learn about behavioral change model and motivational interviewing which might fit in discussing smoking or other public health issues then they go into practice and are not facilitated to apply the theory to practice because they don't see promotion techniques in practice used by medias so I don't know whether that is something well you want to yeah thanks Eunice yeah you're right um we do talk about health promotion and health protection and all these things in our theoretical programs but it would appear that our midwives excuse me who are out there don't actually translate that into their practice and the proformas that I was talking about certainly in this part of the world they're electronic I think most places do have electronic notes now certainly in Europe um so it's you know do you have a healthy diet so and so and so says oh yes yes I have a very healthy diet but our BMI is 38 tick and that's it so that that's why I think we need to move away from using not from using the electronic proformas they're there for a reason we have to gather that information it's a risk assessment I don't mean that but what we need to approach our consultations I think in in more of a way if you if you watch medical staff consulting for example they won't write anything down at all until they've had the conversation with that individual and I think we need to to just redress that a bit thank you yeah um I'm just liking these questions because it's quite interesting actually having been a midwife for quite a while I've never thought about really now talking to women pregnant about obesity I tend to wait until after pregnancy then I start speaking about obesity so I think this is quite an interesting research so they may not Elena is asking here they may not have consultation model but in UK education they do study health promotion model so I don't know whether that is quite related to consultation model well I suppose it is I mean they go out there knowing of the theories about behavior change health promotion but that's what I'm saying they don't then translate that into the appointment or at least that was my findings I mean other other parts of parts of the UK and the world that might not be the case but these were my findings when I did my data collection and that was about four years ago now and from what the students are telling me and this is just anecdotal it's not exactly um research but the students tell me that nothing very much has changed and in my little um hub site that I developed around education because it was very targeted on education the data from the pre-exposure the students who filled in the questionnaire pre-exposure it's all very talking from the textbooks learning by role have a healthy diet blah blah blah but the post-exposure data suggests that they have really switched their thinking and it's become much more much more awareness of being women-centred and understanding and promoting what actually is a healthy diet because in my hub site I've put quite a big section in about nutritional science that's something I can't speak for other parts of the world but it's something that we you know we say this phrase have a healthy balanced diet now the Scottish diet is one of the worst in Europe you know the amount of sugar in the Scottish diet is unbelievable I stood in a supermarket the other day and just watched the the amount of obesogenic food was unbelievable and other parts of the world it may be different so the students were much more aware of how to promote a good lifestyle changes and there's also recommendations in the both the Scottish and UK governments about how much exercise we should be advising women to have now that's not easy because you know the social determinants of health not everybody can afford to go swimming go to the gym or whatever but they can walk that's free of charge so there are things that we can promote and discuss with women and we can't make anybody do anything but we can discuss that with them and say you know is this possible so the students on the post-exposure data are it seems to be much more aware of the tangible things that they can suggest for women and they seem to be much more aware of the nutritional advice that I put in my my hub site and I worked at well myself as a learning technologist to help me into workbooks so it could really reflect as they went along so it seems to be quite useful thank you very much for those comments Yvonne there's another comment by Karen Johnson thank you for this information Cecilia Jevitt what wonderful resources you have made available then Cecilia Jevitt's eager to see more of Yvonne's work so I think it's Cecilia Jevitt has a comment Yvonne and listening friends I have a website full of educational material for you and other educators free of charge please go to advantage midwifery.org the materials include curricula and approaches for talking with clients there are also materials for clinicians and patients thank you and then there's also a comment by Stephanie yes we label ourselves as good communication communicators far too often how can we find a module you are developing I think that's a question you may need to handle sorry what was that question they are interested in finding the module that you are developing well it's it's it's invited access only at the moment and it's part of Edinburgh University's Edinburgh University's Moodle community site however I have just signed a contract to write a book and it's it is based on what I have written in that module so there will be a book being published next year on all of this and you know I'll let you know when that is published I I'm not sure how I proceed really with my module I'm going to get this published or hopefully present at ICM next year about my my website the data from it and then hopefully I can give people access to it after that okay thank you very much other comments are about Karen Johnson thank you Yvonne for these important work and thank you for an excellent presentation