Saturday, June 11, 2011

Midwives and the battle of the bulge

A new draft National Antenatal Care Guidelines has been released for public consultation. The consultation period ends on 27 June 2011. The guidelines can be found here.

Today's health care world relies heavily on guidelines, and this document is being developed with government funding under the AHMAC priority to "Ensure Australian maternity services provide high-quality, evidence-based maternity care."

If anyone has had an opportunity to read through these draft guidelines, you will find much that is accepted as good practice, presented clearly and referenced. However we need to read with our critical minds switched on: otherwise there's no point in reviewing the draft. Midwives and doctors who provide antenatal care need to ponder the impact on our practices that they might have when they are approved.

Routine weighing at each antenatal visit
Please take note of
Recommendation 4: Routinely weigh women at each antenatal visit. Excessive or inadequate weight gain may have negative effects on the woman and the baby. (p vii)

This recommendation is rated as Grade 'A', which means "Body of evidence can be trusted to guide practice."

I put a question out about this to colleagues, via a midwives' email list. "Do you routinely weigh women at each antenatal visit?" It appears that there is a general consensus in the group that midwives do not currently weigh women at each visit.

It’s clear that obesity in pregnancy is linked to poor outcomes, and the midwife’s duty of care is around promoting health through good diet and weight management. Obesity is the big current focus of health promotion. However it appears to require a great leap of faith to believe that routine weighing in pregnancy will result in better weight management, and better outcomes.

As I remember being pregnant in the ‘70s, when everyone was weighed at every visit, women were harming themselves in an attempt to control weight gain. Some women were restricting their intake to the point were they were nutritionally unbalanced, leading to a lot of fluid retention, and pre-eclampsia. The doctors (bless them) were prescribing a diuretic (Lasix) to get rid of the excess fluid, which did actually give ‘better’ weight gain, but at what cost? The routine weighing potentially led to adverse effects.

The Draft Guidelines Appendix D (p138) gives the UK National Institute for Clinical Excellence (NICE) recommendations, that Weight and height be measured at the first appointment, and BMI calculated. Then this second recommendation:
“Repeated weighing during pregnancy should be confined to circumstances where clinical management is likely to be influenced. [C]”

This second recommendation from NICE has been summarily dropped for the new Draft Australian guidelines, with some review discussion around ‘new evidence’ associated with a high or low pre-pregnancy BMI that has emerged since the NICE (2003).

It would seem wrong to impose routine weight monitoring on all women, when the new evidence, even if it is grade 'A' applies only to those at the ends of the spectrum.

It's good that maternity services seek to "provide high-quality, evidence-based maternity care." BUT, any guideline that claims to be evidence-based, with an A-grade "Body of evidence [that] can be trusted to guide practice." needs to be just that. In this case, there is no evidence that routine weighing of all women will do anything to address obesity and ill health, or under-nourishment for that matter, or improve maternity outcomes.

Comments from readers are welcome. If you refer to something in the Draft Guidelines, please quote the page.

Readers will be interested in the Science and Sensibility blog entries and discussion on maternal obesity.  The writer, Pam Vireday's blog is Well Rounded Mama.


Carolyn Hastie said...

Hello Joy, good that the guidelines are out for review, thanks for sharing that information. I have yet to read them thoroughly, but like you, I'm perplexed that weighing as a routine would be recommended. We stopped doing that decades ago when we realised women were harming themselves to be the ideal weight. I know that recent thinking has been around is the lack of weighing leading to the obesity epidemic. A much more reasonable way to approach the obesity epidemic is to look at the culturally approved media push to sit, watch television and consume an enormous amount of empty calories. Yes, weighing some women, some time may be useful - I'm still flat out trying to work out when, apart from the prepregnancy or early pregnancy weight, that may be useful mind you - but a blanket 'rule'? No, don't agree. Helping women and their partners to discover what nutrition actually means, beyond the TV advertisements, is a real need, as most people get their information from their parents,peers and TV. If what we see in people's supermarket trolleys is an example of those sources of information, our society is in deeper trouble than we may think.

Joy Johnston said...

Thankyou Carolyn for these thoughtful comments. Your advice to focus on nutrition rather than weight is good.

The challenge for me, in being a 'size-friendly' midwife, is to promote health and wellness, while accepting each woman as the unique person she is.

The bottom line is that a pregnant woman who is obese needs confidence and enabling to give birth spontaneously, and avoid the need for surgery. A secondary goal is to improve eating habits for that woman and her family.