Dissertations / Theses on the topic 'Obese pregnant women'

Introduction: Obesity during pregnancy is linked to many negative health effects for mothers and offspring. The majority of interventions with obese pregnant women based on physical activity have had limited success suggesting alternative approaches are needed. Sedentary behaviour is defined as waking activities that expend very low energy, 1.5 metabolic equivalents or below, while reclining, lying or sitting. Spending too much time sedentary has been identified as a risk factor for health, regardless of physical activity levels. We hypothesised that targeting sedentary behaviour may be a suitable alternative to reduce health risks during gestation among pregnant women who are morbidly obese (defined as body mass index, BMI > 40 Kg/m²). Aim and objectives: The aim was to explore sedentary behaviour among obese pregnant women and to propose an intervention to reduce the time obese pregnant women spend sedentary, through an active sitting exercise intervention. To conduct a systematic review of the literature to determine the proportion of time spent in sedentary behaviour among pregnant women, and the association of sedentary behaviour with pregnancy outcomes in mothers and offspring. To estimate total energy expenditure, and energy expended in sedentary activities in morbidly obese and lean pregnant women. To assess the feasibility of an active sitting exercise intervention for morbidly obese pregnant women, designed using a patient involvement in research method. Systematic Review: A systematic review of the literature reporting sedentary behaviour during pregnancy and its effects on pregnancy outcomes was conducted. Twenty six publications were included in the systematic review up until October 2015, and a further 18 were identified in the update completed in April 2018. Pregnant women spent at least 50% of their time in sedentary activities. Associations between increased time sedentary and higher risk of macrosomia, higher risk of pre-eclampsia, higher risk of developing gestational diabetes mellitus, and larger new-born abdominal circumference were observed, as the main findings. Most of included studies scored an intermediate quality, only two of the 44 studies scored a good quality. Cross-sectional study. A cross-sectional study was conducted, using the Pregnancy Physical Activity Questionnaire (PPAQ), and the Actical accelerometer, to assess energy expenditure, and energy expended in sedentary behaviour. Based on the PPAQ, women who were morbidly obese expended significantly more energy per day, as total expenditure, than lean pregnant women, which was confirmed by the Actical. During sedentary behaviour lean pregnant women expended significantly less energy than morbidly obese pregnant women, based on the PPAQ. No differences were observed between lean and morbidly obese pregnant women in the proportion of time spent in sedentary activities, nor in time sedentary. Exercise Intervention Design A patient involvement in research approach was used to design an active sitting exercise intervention for morbidly obese pregnant women. Twenty three women took part in the design of the intervention, enabling design of a final protocol including six exercises, to be performed in two sets of 10 repetitions. Active sitting exercise intervention An intervention based on active sitting exercises for morbidly obese pregnant women to reduce sedentary time was conducted to assess the feasibility. Thirty morbidly obese pregnant women were recruited of whom 20% completed the exercise intervention. The main reason not to complete the intervention was lack of time. Conclusion: A better understanding of sedentary behaviour is needed for the design of effective interventions to help to reduce the adverse effects of morbid obesity on pregnancy, especially as prevalence is growing. More time spent in light intensity activities rather than in sedentary behaviour may play a role as contributing to reduce those risks associated with obesity during pregnancy, and to reduce time spent sedentary. Participants have shown real interest in helping to design an effective exercise intervention. Involving and empowering participants in how to take care of themselves as part of the intervention helps to increase their commitment. Giving participants the tools to take care of their own health and their babies' should be considered as part of the intervention with very obese pregnant women. Providing the information in how and why exercise might help, and basing the intervention in giving participants easy and realistic tasks that they could do on their own and around their own environment, will help to increase their commitment. This appears to be a feasible and effective strategy.

Background: Increasing physical activity (PA) may help to reduce the risk of obesity related pregnancy complications. However little is known about the amount, type and intensity of PA obese pregnant women engage in, or the most appropriate measurement method. Previous research suggests that obese pregnant women receive limited advice concerning PA from midwives. Objectives: To investigate the amount of PA carried out by this population and how this changes during pregnancy, to compare measurement methods, and to describe the knowledge, attitudes and practice of midwives surrounding PA. Methods: 1. 130 pregnant women, BMI≥25kg/m2, consented to PA measurement at 2 or 3 time points using the Actigraph accelerometer and Recent Physical Activity Questionnaire. 2. Questionnaires were designed and distributed to midwives within 3 NHS Trusts on Tyneside (n=365) with the aim of identifying barriers to discussing and advising PA with obese pregnant women. The design used the Theoretical Domains Framework approach which uses behavioural determinants to investigate implementation difficulties. Results: 1. At 12-16 weeks gestation over half of the participants achieved 30 minutes of moderate or vigorous PA, decreasing by 36 weeks to 24%. Women who were more active at baseline decreased their PA during pregnancy; those who were less active remained so. Self-reported PA also fell but did not correlate with objectively measured PA. 2. Midwives scored highest on knowledge and social-professional role and lowest on skills, capabilities and environment/context/resources domains. Regression analysis indicated that skills and memory/attention/decision domains had a significant influence on discussing PA. Conclusion: Research is needed to find methods to encourage obese women to increase and maintain PA levels before and during pregnancy, and to find the most appropriate PA measurement methods. Midwives feel knowledgeable and believe giving PA advice to be part of their role, but lack skills, capabilities and resources. Strategies to remove such barriers are needed.

Introduction: Obesity is a growing global public health problem and is as prevalent among pregnant women as in the general population. It is well known that obese women have an increased risk for several complications during pregnancy and delivery and this is also true for the neonate. Excessive gestational weight gain among obese women seems to further increase these risks for adverse outcomes. It has not been known up to the time of this study whether a behavioral intervention program designed for obese pregnant women could result in a reduction of gestational weight gain. Aim: The overall aim of the present thesis was to study the effect of an intervention program designed to control weight gain among obese pregnant women during pregnancy and to then observe the outcomes of their pregnancies. In addition we wanted to learn if this behavioral intervention program could result in a weight gain of less than seven kilograms. Material and methods: The intervention group consisted of 155 obese (BMI >30 kg/m2) pregnant women at the antenatal care clinic (ANC) in Linköping; the control group consisted of 193 obese pregnant women in two other cities. The women in the intervention group were offered, in addition to regular care at the ANC, motivational interviewing in weekly visits to support them in making this behavioral change. They were also offered aqua aerobic class once or twice a week. The women in the control group attended the routine antenatal program in their respective ANCs. Outcome measures were: weight in kg, pregnancy-, delivery and neonatal outcomes, prevalence of anxiety- and depressive symptoms and attitudes and experiences of participating in an intervention program. Results: The women in the intervention group had a significantly lower gestational weight gain and also had a lower postnatal weight than the women in the control group. The percentage of women in the intervention group who gained <7 kg was greater than the percentage in the control group. There were no differences between the two groups in pregnancy-, delivery- and neonatal outcomes. In addition, there was no difference in prevalence of symptoms of anxiety and depressions between the intervention- and control group and the gestational weight gain did not have any effect on symptoms of depression or anxiety. The women in the intervention group with gestational weight gain <7 kg, weighed less at the two years follow-up than the women in the control group. Most of the women who participated in the intervention program expressed positive attitudes and were positive towards their experiences with the intervention program and their efforts to manage the gestational weight gain. Conclusion: The intervention program was effective in controlling weight gain during pregnan-cy and did not change the pregnancy, delivery or neonatal outcomes or the prevalence of anxie-ty- and depressive symptoms. The group with a gestational weight gain <7 kg showed the same distribution of complications as the group with a higher weight gain. The intervention program seems to influence the development of weight in a positive direction up to two years after childbirth. The women were also satisfied with their participation in the intervention program.

Maternal obesity is an increasing concern in the obstetric population. It confers increased morbidity and mortality to the mother and offspring during pregnancy and delivery as well as potential long-term increase in risk of ill health to the offspring. There are currently few effective interventions and no pharmacological therapies. Potential mechanisms to account for ill health in obese non-pregnant individuals include excess inflammation, both systemically and within specific tissues such as adipose, as well as alterations in metabolic regulation including hyperglycaemia, reduced sensitivity to insulin and altered adipokine expression. In healthy pregnancy, there are significant adaptations to maternal metabolism, including the development of profound systemic insulin resistance. We hypothesize that there exists an interaction between the metabolic adaptations of pregnancy and those occurring in obesity which could provide a physiologically plausible mechanism which could contribute to the pathogenesis of adverse outcomes associated with obese pregnancies. In this thesis, we sought to understand and define the metabolic adaptations to pregnancy in severely obese women. Anthropometric characteristics are described in a longitudinal case-control study of apparently healthy obese (BMI > 40kg/m2) pregnant women. Systemic adipokine and pro- inflammatory cytokine profiles were measuring using ELISA. Indices of insulin sensitivity were assessed at three time points in pregnancy. In a cohort study of healthy pregnant women in the third trimester, transcript levels of adipokines and inflammatory cytokines in paired subcutaneous and omental adipose tissue biopsies were quantified and correlated these transcript levels with booking body mass index (BMI). Obese pregnant women gained less weight in pregnancy compared to lean women, but had significantly elevated fasting third trimester glucose, as well as elevated blood pressure and fasting insulin resistance throughout pregnancy. Fasting leptin was elevated throughout pregnancy in obese compared with lean pregnancy women; however, in the third trimester there was no correlation between adipose tissue leptin mRNA levels and BMI. Transcript levels of IL-6 were positively correlated with BMI in subcutaneous but not omental adipose tissue; no other positive correlations with BMI were shown. Hyperinsulinaemic euglycaemic clamps with concomitant use of stable isotope tracers were carried out in a case-control study of healthy obese pregnant women to characterise in detail whole body insulin sensitivity, endogenous glucose production and rate of lipolysis. In contrast to the original hypothesis, by the third trimester, there were few differences between lean and obese pregnant women in whole body glucose disposal (WGD) and endogenous glucose production. Compared with non-pregnant women, lean pregnant women demonstrated approximately 60% decrement in WGD; in contrast, obese non-pregnant women were already significantly insulin resistant but did not develop further insulin resistance in response to pregnancy. 3-Tesla (3T) Magnetic Resonance Imaging (MRI) and 1H-Magnetic Resonance Spectroscopy (1H-MRS)was used to assess abdominal fat distribution, hepatic and skeletal muscle lipid content in a case-control study of healthy pregnant women in the third trimester. As expected, obese pregnant women have greater adipose accumulation in both subcutaneous and intra-abdominal adipose depots and greater lipid accumulation in skeletal muscle. However, hepatic lipid content was low in both groups and there were no significant differences between lean and obese pregnant women. This was not expected as both groups are profoundly insulin resistant at this at this gestation, and in non-pregnant individuals, insulin resistance at this level would be expected to drive hepatic lipid accumulation, and may point to a pregnancyspecific hepato-protective mechanism. In conclusion, in this thesis, it has been shown that while obese women are insulin resistant with an adverse metabolic profile, that there does not appear to be the expected worsening of this profile in response to pregnancy and that by the end of pregnancy, lean women have a similar phenotype. Instead, while lean women are exposed to this environment only towards the end of pregnancy, obese women and their offspring are exposed throughout gestation, including key periods of fetal development in early pregnancy. This prolonged exposure may account for the excess pathologies in such pregnancies, potentially by exhausting what physiological reserve such women have pre-pregnancy. Potential therapies must therefore be optimally timed to improve the metabolic profile of obese women in early pregnancy, without hindering the required adaptations of the third trimester.

Maternal obesity is associated with adverse pregnancy outcomes, especially the development of gestational diabetes mellitus (GDM), with associated risks for mother and infant. Improved understanding of glucose intolerance in obese women and better prediction and prevention of GDM is key to improving the health of mother and her child. This thesis reports two related projects. The first explored mechanisms of insulin resistance and prediction of GDM in obese pregnant women participating in the pilot study for the UK Pregnancies Better Eating and Activity Trial (UPBEAT), a lifestyle intervention RCT. The second investigated the potential of a dietary intervention to improve glycaemic profiles in this high-risk group. Following an 8 week dietary and physical activity intervention, a panel of biomarkers associated with obesity and insulin resistance were measured in 117 women in the pilot trial. At 27+0-28+6 weeks’ no difference was observed between the intervention and control arms but at 34+0-35+6 weeks’, significant reductions in plasma visfatin, cholesterol and LDL cholesterol were observed. Analysis by GDM status, confirmed greater concentrations of fructosamine, AST and insulin and lower plasma leptin and adiponectin in women who developed GDM. An algorithm based on clinical factors alone (age, parity, ethnicity and blood pressure at 15+0-18+6 weeks’ gestation) showed predictive potential which increased significantly with the addition of plasma adiponectin measured at 15+0-18+6 weeks. In obese pregnant women without GDM (n=16,) the effect of a slow-digesting low glycaemic index (SD-LGI) supplement drink was evaluated at 24+0-28+6 weeks’ gestation. Linear regression analysis with mixed modelling (LMM) showed a significant reduction in glycaemia over the 24 hour period following consumption of the test compared to the control supplement and habitual diet. Fasting and nocturnal glucose concentrations were also significantly improved. In summary biomarkers associated with insulin resistance were identified as potential targets for lifestyle interventions aimed at reducing GDM in obese women. A prediction model for GDM identified those at greatest risk and pending validation in the UPBEAT RCT may have the potential for translation into clinical care. Extending the role of interventions further, multiple improvements in parameters of glycaemic control were demonstrated using a SD-LGI nutritional supplement.

For more than 50 years, researchers have recognized complications associated with obesity and pregnancy as a problem for mothers and their unborn children. Despite this recognition, the rates of obesity and mortality in pregnant women have continued to rise. Using the health belief model, the transtheoretical model of behavior change, and the social cognitive theory as the theoretical frameworks, this phenomenological study examined barriers that might hinder the health of obese pregnant women and their unborn children. Semi-structured interviews were conducted with 12 women who had a body mass index of 30 to 50, were between the ages of 18-55, and were at 20 to 30 gestational weeks. The data were coded for emergent inductive themes revealing (a) despite obesity and excessive weight gain, pregnant women believed they were healthy (b) labor and delivery decisions are hindered by uncertainty (c) pregnant women are comfortable when communication is not related to obesity, (d) pregnant obese women share the consumption of similar carbohydrates, (e) public rejection or support is influenced by self-concepts, (f) pregnant obese women believe that providers and the public treat them differently, (g) obesity and excessive weight gain is expected during pregnancy, and (h) stress and life circumstances are related. These findings promote implications for positive social change through the awareness that some pregnant obese women do not believe that they are obese, unhealthy, or prone to disease, and they do not view their weight as a health issue. Although further research is needed, these findings may aid providers and clinicians regarding awareness of factors that might hinder weight loss and the overall health and well-being of obese pregnant women and their children.

Includes bibliographical references.
Background. Obesity is increasing globally and is defined as a Body Mass Index (BMI) over 30 kgms/m². It’s prevalence in the Metro West Maternity service is unknown. Objective .To assess the prevalence of obesity and determine its association with adverse perinatal and maternal outcomes among pregnant women in the Metro West Region, Cape Town, South Africa Study Design. This was a retrospective observational study that compared perinatal outcomes in women with normal pregnancy BMI to outcomes in women with high pregnancy BMI. Setting. Mitchells Plain and Guguletu Midwife Obstetric Units, Mowbray Maternity Hospital and Groote Schuur Hospital, Metro West Region, Cape Town, South Africa Population. A total of 970 pregnant women divided into BMI groups that had their first antenatal booking visit between January and April 2011. Methods. A list of folder numbers was compiled from the antenatal booking registry at the two MOUs. From the list, maternal folders were then traced through the CLINICOM tracking system, MOU delivery registers, antenatal clinic transfer registers and labour ward transfer registers to find place of delivery or outcome of pregnancy. Maternal and perinatal characteristics were then extracted from the folders into the data collection sheet and data was analysed by STATA. Descriptive statistics included proportions with percentages and median with interquartile ranges. Inferential statistics included Chisquared tests, Fisher Exact tests, Kruskal Wallis test, univariate and multivariable logistic regressions. Main outcome measures. Perinatal outcomes (stillbirth, macrosomia, shoulder dystocia, 5 minute Apgar Score less than 7, congenital abnormalities) observed in obese and morbidly obese compared to normal BMI pregnant women.

There has been a global rise in obesity in the last three decades, and at present one in five women are obese at antenatal booking. Maternal obesity is associated with an increased risk of adverse pregnancy outcomes, including increased fetal size and prolonged pregnancy. In the longer-term, offspring of obese are at increased risk of premature death from a cardiovascular event in their adulthood. One mechanism that has been linked to these outcomes is fetal exposure to glucocorticoids in utero. During normal pregnancy, the maternal hypothalamic pituitary adrenal (HPA) axis undergoes major changes, resulting in exponentially increasing levels of the major circulating glucocorticoid cortisol, and other HPA axis hormones, such as corticotrophin releasing hormone (CRH). Cortisol and CRH are vital for normal fetal growth and length of gestation, but in excess they are associated with fetal growth restriction and preterm labour. In non-pregnant obesity, it is thought that the HPA axis is dysregulated, although evidence is inconclusive. Little is known about the effects of maternal obesity in pregnancy on the HPA axis. The work in this Thesis used clinical studies to test the hypothesis that the HPA axis is dysregulated in obese pregnant women with altered release, clearance and placental metabolism of cortisol. Associations with clinical outcomes related to fetal size and length of gestation were also studied. The HPA axis activity during pregnancy was investigated in a prospective case-control study cohort. Fasting serum cortisol levels were measured at 16, 28 and 36 weeks of gestation (obese n=276, lean n=135). In a subset (obese n=20, lean n=20), corticosteroid binding globulin (CBG), CRH, estrogens and progesterone were measured. Salivary cortisol was measured in samples collected at bedtime, waking and 30 minutes after waking at 16 weeks. Urinary glucocorticoid metabolites were measured at 19 weeks and 36 weeks (obese n=6, lean n=5) and non-pregnant (obese n=7, lean n=7) subjects. All circulating hormone levels rose similarly in obese and lean during pregnancy, but were significantly lower in obese women. The diurnal rhythm of cortisol was maintained. Urinary glucocorticoids increased with gestation in lean, but not in obese, indicating a lesser activation of the HPA axis in obese compared with lean pregnancy. These findings associated with increased birthweight and longer gestation in obese pregnancy, suggesting that decreased HPA axis activity may underlie these obese related adverse pregnancy outcomes. Whether or not lower glucocorticoids in obese pregnancies are maintained at delivery was investigated by measuring active glucocorticoids (cortisol and corticosterone) and their inactive versions (cortisone and 11- dehydrocorticosterone, respectively) from matched maternal and cord plasma samples (n=259, BMI 18 – 55 kg/m2). Active glucocorticoids were significantly higher in maternal than cord blood, and inactive versions were significantly higher in cord than maternal blood. Increased maternal BMI associated with lower maternal cortisol, corticosterone and 11-dehydrocorticosterone. Despite significant correlations between maternal and cord blood glucocorticoid levels, increased maternal BMI did not associate with lower cord blood glucocorticoids. This suggests that conditions at delivery may overcome any potential negative effects of low maternal glucocorticoids on the fetus in the short-term. However, it may not preclude the longer-term effects of fetal exposure to lower glucocorticoid levels during obese pregnancy, and offspring follow-up studies are required. Potential mechanisms leading to altered HPA axis activity in obese pregnancy were explored by studying the pulsatile release and placental metabolism of glucocorticoid hormones. Glucocorticoid pulsatility is thought to be important for transcriptional regulation of glucocorticoid responsive genes, and disruptions to pulsatility have been reported in some disease processes. Glucocorticoids were measured in 10-minute serum sampling between 08.00h-11.00h and 16.00h- 19.00h. Peripheral tissue cortisol was measured from 20-minute sampling of interstitial fluid, over 24-hours, at 16-24 weeks and 30-36 weeks (obese n=7, lean n=8), and non-pregnant controls (obese n=4, lean n=3). Total circulating serum cortisol levels were higher in pregnancy than non-pregnancy in lean and obese, and increased significantly with advancing gestation in lean but not in obese. Pulsatility of cortisol was demonstrated in interstitial fluid in both non-pregnancy and pregnancy. In obese pregnancy, interstitial fluid pulse frequency was lower with advancing gestation. This may be a novel mechanism underlying the observed decreased HPA axis activity in obese pregnancy. Placental cortisol metabolism and transport was studied using an ex vivo placental perfusion model, perfused with a deuterium-labelled cortisol tracer combined with computational modeling. The findings challenge the concept that maternal cortisol diffuses freely across the placenta, but confirmed that 11β- HSD2 acts as major ‘barrier’ to cortisol transfer to the fetus, protecting the fetus from the high maternal circulating cortisol levels. In addition we showed preliminary evidence of local cortisol production within the placenta. The model is able to predict maternal-fetal cortisol transfer and can now be used in future experimental design. In conclusion, in obese pregnancy, lower maternal cortisol and urinary clearance suggested reduced HPA axis activity. Altered glucocorticoid pulsatility may underlie this change. Future studies of placental cortisol metabolism in maternal obesity could be conducted using an ex vivo perfusion model. The lower HPA axis activity in obese pregnancy represents a novel pathway underlying increased fetal growth.

Maternal overweight and obesity are major public health concerns which can have a significant impact on the health of both the woman and her baby. The last twenty years have seen a significant increase in the prevalence of maternal obesity within the UK, with approximately one in five pregnant women being classified as obese. To tackle maternal obesity and reduce complications, guidelines and antenatal weight management programmes have been implemented. In order to inform the planning and development of future effective programmes which may reduce/minimise negative outcomes for the woman and her baby, it is important that programmes are compared with one another. The aim of this study was to advance understanding of the core elements required in the planning, implementation and evaluation processes to maximise the effectiveness of future antenatal weight management programmes. To achieve this, a Comparative Effectiveness Review of antenatal weight management programmes was conducted; a literature review to inform the development of a conceptual framework was undertaken and a mixed-methods study carried out. The main contribution of this study was a current picture of how UK antenatal weight management programmes within maternity services and local councils were planned, implemented and evaluated. This study identified that maternity services were not meeting guidelines for the provision of an antenatal weight management programmes as one-third did not offer a programme (n=25). For those maternity services and local councils that implemented a programme (n=77), only 37.9% adhered to the recommended inclusion threshold (BMI £30 kg/m2). A significant barrier to planning, implementing and evaluating these programmes was the lack of dedicated resources. Finally, the collected data were used to test and subsequently amend the derived conceptual framework which incorporated Realistic Evaluation. This framework and study findings may inform the future effective planning, implementation and evaluation of complex health promotion programmes.

Very severe maternal obesity (BMI > 40kg/m2) increases significantly the risks of poor pregnancy outcomes for both mothers and babies. In light of the limited success of behavioural interventions to date in improving outcomes in very severely obese women, this study sought to gain an understanding of women's beliefs and experiences regarding weight, health and pregnancy, within the context of their everyday lives. Qualitative serial interviews were conducted with eleven very severely obese women during pregnancy and the postnatal period. Seven partners of the women took part in one semi-structured interview during the woman's pregnancy. Analysis took place in several stages using a thematic approach. Themes were identified within and between individual women's accounts, as well as within and between the accounts of members of couples. Participants' narratives demonstrated the ways in which they navigated the experience of high-risk pregnancy, and stigma emerged as a key theme. This research contributes new knowledge about the complex ways in which women experience ‘very severe obese' pregnant embodiment, relating to both formal and informal discourses around weight and health in pregnancy. Most undertook ‘moral accounting' in response to stigma, and several accounts resonated with Monaghan's (2006) categorisations of excuses, justifications, contrition and repudiation, in both accounting for their weight and in demonstrating their ‘fitness' for pregnancy and motherhood. Following birth, high levels of motivation to enact behaviour change were expressed, in some cases alongside repudiatory accounting regarding the associated risks and the medicalisation of very severe obesity. Participants experienced a lack of formal healthcare support in the postnatal period. Future approaches to policy and practice should consider ways in which to engage women and partners during pregnancy, exploring ways which in which stigma can be acknowledged and neutralised, in order to provide support and advice during and after pregnancy and birth, and into parenthood.

Normal birth, defined as birth without induction of labour, anaesthetic, instruments or caesarean section conveys significant maternal and neonatal benefits. Currently one-fifth of women in the United Kingdom are obese. There is increasing evidence of the detrimental effects obesity has on intrapartum outcomes. There is a lack of research on how to minimise the associated risks of obesity through non-medicalised interventions and how to support obese women to maximise their opportunity for normal birth. This thesis aims to provide evidence to address this gap and develop an evidence-based intervention to promote normal birth. Using a methodological approach aligned with pragmatism, this research was conducted in four parts and underpinned by the Medical Research Council framework for the development of complex interventions. Part one was a national survey involving 24 maternity units. Part two was a qualitative study of the experiences of 24 health professionals and part three involved 8 obese women. The final part was a multi-disciplinary workshop that used consensus decision-making to design the intervention. Collectively, the findings suggest that intrapartum care of obese women is medicalised. Health professionals face challenges when caring for obese women but many strive to optimise the potential for normal birth by challenging practice and utilising ‘interventions’ to promote normality. The findings also demonstrate that obese women have an intrinsic fear of pregnancy and birth, have a desire for normal birth and ‘obese pregnancy’ presents a window of opportunity for change. The intervention consists of three component parts; an educational aspect (e-learning package), a clinical aspect (intrapartum care pathway) and a leadership aspect (ward champions). Whilst acknowledging the importance of safety, increasing intervention during labour for obese women may further increase the risk of complications, with detrimental effects. Addressing intrapartum management of obese women through non-medicalised interventions is of paramount importance in order to promote normality, maximise the opportunity for normal birth and reduce the associated morbidities.

BAKGRUND: Obesitas är ett globalt, växande folkhälsoproblem. Att vara både gravid ochobese utgör en stor hälsorisk både för modern och barnet, vilket kräver specialiseradomvårdnad. Ett dilemma uppstår när sjukvårdspersonal ska ge god omvårdnad till denna patientgrupp då det saknas riktlinjer för hur de ska gå tillväga utan att kränka den gravida överviktiga kvinnan. SYFTE: Syftet var att belysa obesa gravida kvinnors upplevelser av omvårdnaden från sjukvårdspersonal. METOD: En litteraturstudie av kvalitativa och kvantitativa artiklar kring aktuellt forskningsområde. RESULTAT: Gravida kvinnor med obesitas har negativa upplevelser av omvårdnaden frånsjukvårdspersonal. Vidare identifierades upplevelserna i att vara obese och gravid i fyra olikateman:Upplevelser av behandlingen, Stigmat kring obesitas, Bristande information och Bristande delaktighet. SLUTSATS: Gravida överviktiga kvinnors upplevelser av att vara både obese och gravidpåverkas av bemötandet från sjukvårdspersonalen. Det generella stigmat kring obesitasgenererar fördomar och negativa attityder hos vårdgivare och tar sig i uttryck i derasförhållningssätt gentemot patienterna. Den bristande omvårdnaden skapar en sämre vårdupplevelse för patientgruppen. FÖRSLAG PÅ VIDARE FORSKNING: Ett behov av mer forskning som berör effektiva strategier för att minska förekomsten av obesitas under graviditeten är önskvärt. Likaså forskning som undersöker patienternas upplevelse av omvårdnaden som obese och gravid. Internationella och nationella riktlinjer för sjukvårdspersonal att följa beträffande omvårdnaden av gravida obesa kvinnor efterfrågas av vårdpersonal, vilket därför vidare forskning kring ämnet och problemet skulle vara välkommet.
BACKGROUND: Obesity is a global, growing public health problem. Being both pregnant and obese constitutes a major health risk for both the mother and the child, requiring specialized care. A dilemma arises when medical staff is to provide good care for this patient since there are no recommendations for how to approach the subject without humiliating the pregnant obese woman. AIM: The aim was to highlight Obese pregnant women's experiences of care from healthcare professionals. METHOD: A literature study of qualitative and quantitative articles on the current research area. FINDINGS: Pregnant women with obesity have negative experiences of the care provided by health care professionals. Furthermore, identified experiences of being obese and pregnant were described in four different themes: Experience of treatment, Thestigma of obesity, Lack of information and Lack of participation. CONCLUSION: Pregnant obese women's experiences of being both obese and pregnant were determined by the response from the health care professionals. The general stigma of obesity generates prejudices and negative attitudes from health care providers and expresses in their approach. The lack of quality of care creates negative experiences for the patient group. SUGGESTIONS FOR FURTHER RESEARCH: A need for more research on effective strategies to reduce the prevalence of obesity in pregnancy is desired. Similarly, research that examines patients' experience of care as obese and pregnant. International and national guidelines for medical staff to follow regarding the care of pregnant obese women are demanded by health professionals, which therefore further research on the topic and the issue is welcome.

Orientadores: Egberto Ribeiro Turato, Fernanda Garanhani de Castro Surita
Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas
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Resumo: Objetivo: Compreender as vivências emocionais relatadas por gestantes obesas que tiveram variação adequada de peso durante o acompanhamento pré-natal no Ambulatório de Pré-Natal Especializado do CAISM/UNICAMP. Métodos: Para contextualização e compreensão do objeto de estudo, realizou-se uma revisão sistemática de literatura em bases de dados. Foram acessadas bases de dados e contempladas publicações entre janeiro/2003 até junho/2013, que abordavam diretamente aspectos psicológicos na intervenção ou vivência da gestante obesa. Foram incluídos 08 artigos nessa revisão, 03 de metodologia qualitativa e 05 de metodologia quantitativa. Para a pesquisa de campo foi utilizado o desenho clínico-qualitativo. A amostra de sujeitos foi intencional e concluída pelo critério de saturação de informações com 13 mulheres Utilizou-se a técnica de entrevista semidirigida de questões abertas. A técnica de tratamento de dados incluiu: transcrição na íntegra das entrevistas, releituras flutuantes para desvelar núcleos de sentidos das falas das entrevistadas, categorização em tópicos para discussão e análise qualitativa de conteúdo. Cuidados éticos foram tomados seguindo as normas preconizadas pelo Conselho Nacional de Saúde. Resultados: A revisão sistemática indica que aspectos emocionais como depressão, ansiedade e stress estão associados ao IMC na gestação; sendo que quanto maior o IMC, maiores os índices dos aspectos psicológicos referidos. Os estudos qualitativos revisados indicam que a experiência da mulher obesa quando gestante envolve sentimentos em relação ao estigma da obesidade, o julgamento, sentimentos de humilhação e críticas aos profissionais de saúde quanto aos preconceitos e falta de suporte à mulher nessa situação. Da análise dos dados qualitativos emergiram quatro categorias. Sendo que três delas mostram um caminho de cuidado com o corpo que as mulheres obesas percorreram durante a gestação: 1) O corpo começa a ser pensado; 2) O desafio da dieta; 3) A relação com a equipe de saúde pré-natal. E a quarta categoria que revela uma origem da motivação para a mudança: 4) O potencializador das mudanças. Conclusão: A revisão sistemática de literatura indica que há um numero relativamente pequeno de estudos que consideram os aspectos psicológicos na gestação de uma mulher obesa. Existe uma demanda psicológica destas de que a equipe de cuidado pré-natal as vejam para além dos estigmas da obesidade e das questões gestacionais. A pesquisa de campo aponta que a gestação é um momento oportuno para a mulher entrar em maior contato consigo mesma e notar seus conflitos emocionais. Através das transformações no corpo, a mulher pode iniciar um processo mais refinado de autocuidado e vivência da unidade corpo-mente. O medo da própria morte ou do bebê, ocasionados pelos riscos que a obesidade oferece, demonstrou ser um grande potencializador de mudanças. A relação com os profissionais da equipe de saúde exerce um papel importante no suporte motivacional à gestante obesa
Abstract: Objective: To understand the emotional experiences reported by obese pregnant women that had adequate variation in weight during the pre-natal follow-up at the PreNatal Care Outpatiet Clinic of the CAISM/UNICAMP. Methods: For understanding and contextualization of the object of study, a systematic review of the current literature was firstly done on databases about the subject obesity in pregnancy in its psychological aspects. For the systematic review in literature, databases and covered publications between January/2003 to June/2013 were accessed, which approached directly psychological aspects in the intervention or experiences of obese pregnant women. Eight articles were included in this review, 03 regarding qualitative methodology and 05 quantitative methodology. For the field survey, the Clinical Qualitative Method was used. The sample of subjects was intentional and completed by the criterion of information saturation with 13 women, the technique of interview with open questions was used. The interviews were conducted individually in the Prenatal Care outpatient clinic of the CAISM/Unicamp. The technique of data included: full transcript of the interviews, floating rereading to unveil cores of meanings from interviewees' discourse, categorization in topics for discussion and qualitative analysis of content. Ethical Care was taken following the standards recommended by the National Health Council. Results: The systematic review indicates that emotional aspects such as depression, anxiety and stress are associated with body mass index in pregnancy; being that the higher the BMI, the higher the rates of referred psychological aspects. The qualitative studies reviewed indicate that the experience of obese women when pregnant involves feelings in relation to the stigma of obesity, judgement, feelings of humiliation and criticism to the health professionals as to the prejudices and lack of support for women in this situation. The analysis of the qualitative data in this research emerged from four categories. Three of them show a path of caution with the body that obese women have taken during the pregnancy: 1) The body begins to be heavy; 2) The challenge of the diet; 3) The relationship with the prenatal health team; and the fourth category that reveals a source of motivation for changing: 4) Changes enhancer. Conclusion: The pregnancy is an opportune moment for women to come into greater contact with themselves and to notice their emotional conflicts. Through the changes in the body, the woman can start a more refined process of self-care and the experience of body-mind unit. The fear of death itself or the baby's, caused by risks that obesity offers, proved to be a great enhancer effect of changes. The relationship with the professional health team plays an important role in motivational support to pregnant obese women
Mestrado
Saúde Materna e Perinatal
Mestra em Ciências da Saúde

Overweight and obese women who lose weight prior to pregnancy have fewer pregnancy complications than those who do not (Forsum, Brantsaeter, Olafsdottir, Olsen, & Thorsdottir, 2013; Schummers, Hutcheon, Bodnar, Lieverman, & Himes, 2015). Research findings suggest there are missed opportunities to provide diet and physical activity counseling during preventive care visits. Providers cite a lack of time and resources as barriers (Morgan et al., 2006; Yamamoto et al., 2014). This was a two-group, randomized, pilot-study of 19 overweight or obese women in Central Georgia. Participants completed surveys related to their perception of risk for obesity-related pregnancy complications, readiness to change nutrition and physical activity behaviors, nutrition and physical activity self-efficacy, actual physical activity, and dietary history at baseline, after completion of the study, and at follow-up. Those in the intervention group participated in one face-to-face meeting, reviewed eight online education modules, and received weekly booster messages. The control group participated in a similar protocol; however, information was limited to general women’s health topics. Nineteen women (intervention = 11, control = 8) completed all instruments related to primary outcomes—perception of risk, readiness to change, and self-efficacy. The average age of participants was 28.7 years (SD = 6.35). The average body mass index was 36.54 kg/m2 (SD = 5.52). Women were predominately Caucasian (68.4%) and married (52.6%) with children (57.9%). Most had a college degree (42.1%) or higher (15.8%), and a yearly income between $25,000 and $75,000 (42.1%). Evaluation of completion data, resources, and intervention management indicated that the intervention may be feasible during preventative care visits. Participant responses to exit interview questions demonstrated the intervention may be acceptable for women of childbearing age. Effect sizes ranged from small (ƞp2= .00, p = .88) to large (ƞp2= .27, p = .08) indicating the intervention may be effective in an adequately powered sample. Future research should focus on the further development and implementation of programs that assist with pre-conception weight loss. Providing women with information regarding the complications associated with being overweight and obese, as well as the information or tools necessary to reduce weight prior to pregnancy, may be instrumental for improving short and long-term pregnancy outcomes for both mothers and their offspring.