[Editor's note: This is the third in a series of seven posts on maternal obesity. If you missed the first two installments, go here to begin reading.]

The CA-PAMR (PAMR) points to disparities in maternal outcomes by ethnicity and in conjunction with weight categorization:

'Obesity among the women who died from pregnancy-related causes was fairly evenly distributed by age and did not differ significantly by insurance type. However, greater proportions of African-American (83%) and U.S.-born Hispanic (80%) women who died were either overweight or obese at the beginning of pregnancy compared to Whites (50%), foreign-born Hispanics (44%), and Asian/Pacific Islanders (20%). African- American women had significantly higher mean BMI (mean=32.6) than foreign-born, Hispanic women (mean=25.5) (p<0.05), but did not significantly differ from the other racial/ethnic groups (range of means=25.9 - 31.0). (2011 CA-PAMR, pg. 32)

The difficult to digest conclusion made in the report is that of the 98 pregnancy-related maternal deaths (2002-2003) analyzed in the PAMR, 60% (n=58) of those women were overweight or obese. Due to confidentiality, specific characteristics linked to each woman who died are not relayed in the report, so we can only postulate on how much of those maternal deaths in women of size were directly correlated to their weight.

Table 3. Cause of death data from THE CALIFORNIA PREGNANCY-ASSOCIATED MORTALITY REVIEW

In the ensuing Recommendations section, the report goes on to advise:

Practice guidelines and best practices for the preconception management of obese women need to be established, as well as for management of gestational weight gain.

National and State education campaigns should target adolescents and women of child-bearing age to promote attainment of a healthy pre-pregnancy weight and appropriate weight gain during pregnancy through better nutrition and increased activity.'

To me, this advice is spot-on, and not just for California's child bearing population, but for the provision of care for women of childbearing age, everywhere. Accepting the status quo of increasing maternal overweight and obesity and patching together practice measures that are less than evidence-based is little more than a Bandaid approach. And not always a very good one, at that. Opting more frequently for labor induction or primary cesarean 'just in case' places a whole heck of a lot of women at increased risk associated with those medical interventions which they may not even be candidates for.

But before going further down the path of preventative measures, I can't leave out the justifiable concerns of maternity care providers: The realities of caring for an obese or extremely obese pregnant woman can be extra-challenging:

• Prenatal sonography in obese women is less accurate
• Instrumentation available to maternity care providers may be inadequate
• Assisting a poorly-mobile (due to epidural anesthesia) obese or morbidly obese woman from gurney to operating table can risk injury to nursing, care provider and other support staff
• Excessive abdominal adipose tissue can make palpating fetal position/lie as a woman's due date approaches difficult
• During the (rare) need for a woman to be placed under general anesthesia (in a super-emergently necessitated c-section) intubation can be more difficult in an extremely obese individual

In her 2010 article, Obesity, risk and the challenges ahead for midwives, published in the British Journal of Midwifery (Vol. 18, Iss. 1, 01 Jan 2010, pp 18 - 23), Research Midwife Jo-Anne Irwin provides a list of equipment that a care provider should consider having on hand, to adequately care for a pregnant woman of size:

• Hoists*
• Heavy duty scales*
• Higher working load
• Extra width, beds, mattresses, [operating] tables and [gurneys]
• Large blood-pressure cuffs
• Extra long spinal needles, extra deep abdominal surgical instruments, extra large gowns
• Large chairs and wheelchairs
• Longer straps for fetal monitors

Once a large, pregnant woman presents for service, a doctor or midwife's call is to care for her with the upmost compassion, knowledge and evidence-based practices possible. Time cannot be reversed and comorbidities present must be dealt with. And yet, Irwin makes the salient point in her article that I would like to finish with:

A good starting point is the provision of preconception care, where dietary advice, weight management and activity levels could be discussed before pregnancy.'

Irwin goes on to reference guidelines recently published by the (British) National Institute of Health and Clinical Excellence (NICE), which offers advice for maternity care providers on weight management before, during and after pregnancy. The emphasis here is on prevention.

The data on comorbidities associated with maternal overweight and obesity are extensive. Obese women who become pregnant do have higher risks of developing certain complications compared to their normal weight counterparts. This doesn't mean that every overweight expectant mother will experience a dangerous or disastrous outcome, just as normal weight women are not 100% immune from pregnancy-related complications. All women deserve compassionate and evidence-based perinatal care'large, small, or somewhere in between. And yet, if we can take the steps to decrease the chances of developing certain risk factors'such as the recommendations for body weight and exercise guidance offered in the SOCG clinical practice guidance'why not put considerable effort toward that goal?

In a perfect, Wallgreens-esque world, here's what I would love to see implemented within our women's healthcare system:

• Referrals to registered dieticians (or successful implementations of wildly popular community classes) for every woman of childbearing age with the goal of teaching teens and young women how to optimize their health, through dietary choices, well before becoming pregnant.
• Referrals to group or individualized exercise programs for women who lack background understanding of healthy exercise options, before their first pregnancy
• Implementation of healthy body weight discussions at every well-woman exam appointment. This might include discussion of individualized genetic risk factors and socioeconomic issues that add a greater degree of challenge to the woman's overall scenario
• Implementation or promotion of community-based nutrition support programs for families that can't afford to buy good, healthy food (and perhaps fall above the income level that dictates inclusion into the WIC program)

To the healthcare provider who responds, 'I barely have enough time to get through the basic well-woman exam, let alone all that patient counseling,' I respond: 'Yeah, I get it.' Fifteen minute appointments that optimize clinic efficiency and income generation don't allow for this type of in-depth patient-provider interaction. In the same token, if we can't rearrange our patient scheduling and make time for preventative care, how can we expect issues, like the world-wide obesity epidemic to get any better? We've got to go back to the drawing board, folks, and start caring for these mamas and their babies well before conception ever takes place.

*On a personal level, I would hope that any maternity care provider and/or facility would do everything in their power to avoid the use of such implements'purely from the perspective of maintenance of dignity. Having heard stories of obese patients taken to a hospital's loading dock for weight measurement on an industrial-sized scale holds the potential to be extremely damaging to a person's self esteem.

[Tomorrow, you will hear from UNC-Charlotte Nursing Professor Kristen Montgomery, regarding dietary education in maternity care, and the sociocultural issues that come into play. Following Kristen's post, look forward to reading thoughts and evidence presented by Kmom, from The Well Rounded Mama.]

"Posted by: Kimmelin Hull, PA, LCCE"

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