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Maternal obesity during pregnancy is associated with increased complications for both mother and baby. The risks to mother include miscarriage, gestational diabetes, pre-eclampsia, hypertension, thromboembolism, post-caesarean wound infection, prolonged labour, postpartum haemorrhage and many others. The risks to the baby may be child adiposity, early neonatal death, intrauterine death and hypoglycaemia. In adults, obesity increases the likelihood of type 2 gestational diabetes dramatically—by up to 80 times that of the non-obese. Although this will disappear after pregnancy, it may be a precursor of developing diabetes in later life, which can be a cause of high blood pressure and coronary heart disease. Obesity is also associated with less serious but debilitating conditions such as shortness of breath, back pain and reduced mobility. In some cases, midwives find taking specimens from and conducting examinations of obese women complicated if not impossible due to their excess weight.
Pre-eclampsia has increased nearly fivefold in morbidly obese women compared with normal-weight women. The risk of caesarean section has increased threefold and instrumental deliveries have increased by 34 per cent. In comparison with normal-weight women, there is evidence that maternal obesity is also associated with foetal abnormalities, particularly spina bifida and heart defects. It appears that women who were obese prior to pregnancy are more likely to have a
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A survey carried out in 2005 identified that maternal obesity resulted in, among other defects, a twofold increase in stillbirths and neonatal death compared to birth outcomes in women of normal body weight. Excessive weight gain in pregnancy is an independent risk factor for caesarean birth; it has been estimated that a significant number of caesarean sections could be avoided each year if women's weight did not exceed the level recommended by the Institute of Medicine.
Morbidly obese women—those with a body mass index of 40-plus—have risks for complications that are significantly greater. It has been found that those women are at risk of prolonged labour, gestational diabetes, pre-eclampsia, placental abruption, surgical birth, postpartum endometritus and prolonged postpartum stays in hospital. Also, larger women often have restricted mobility and may not be able to get into a position ideal for a safe delivery.
We also have to consider, although it may be a secondary consideration, the added costs to the NHS associated with the safe management of obese women in pregnancy and the resources needed to achieve that, as specialist equipment may be required. For instance, serial scans may be required to assess foetal growth, foetal monitoring by an external transducer may be needed and a foetal scalp electrode may be applied if the foetal heart is impossible to record. Delivery may have to take place in a consultant unit or, if an emergency caesarean must be carried out, two obstetricians are required to be present.
It has been suggested that pregnancy is not a time to lose weight. However, antenatal booking may be the ideal time to discuss diet with women who have been identified as obese or morbidly obese, as well as the conditions in pregnancy that may result from obesity. Midwives say that the myth that the weight should not be lost during pregnancy should be dispelled. However, this is not the place to go into causes of obesity or weight-loss regimens. The media instruct women in these procedures almost every day and it is hard to believe that anyone who has a problem can be unaware of them. A recent proposal, which should meet with derision, is that of paying people to lose weight, which has been the subject of television programmes shown in the past two weeks. Contrary to popular belief among the thin, overweight and obese women are well aware of their obesity and many, far from being complacent in the well known image of the jolly fat person, are made miserable by their condition.
Unfortunately there is a growing trend to accept overweight verging on obesity as the norm—the condition of what the media call real women—while leanness must be attributed to excessive dieting, if not anorexia. This attitude may be seen as encouraging obesity in pregnancy where eating for two as a principle, if old-fashioned, is still a current belief. The fact remains that the Confidential Enquiry into Maternal and Child Health in 2007 estimated that at least 360 existing children and 160 live newborns lost their mother. One hundred and nineteen of the women who died were
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However, although gestational obesity is a growing problem and presents severe risks to both mother and baby, currently there is no national guidance for midwives on how to care for this increasing number of women. Women are repeatedly told not to drink alcohol while pregnant, or to drink it in very small quantities. It is now taken for granted that they should not smoke while pregnant, but obesity is not subject to similar condemnation, nor is a woman warned that she may be carrying too much weight for a safe pregnancy and satisfactory delivery. Something on the French model might be considered, where women’s health and weight are monitored throughout the pregnancy. Does the Minister believe that the Government should give guidance to midwives nationally and that attention should be focused by health professionals on young women who are obese prior to their becoming pregnant?
7.52 pm
Baroness Thomas of Walliswood: My Lords, it is always stimulating to listen to the speeches of the noble Baroness, Lady Rendell, whose dedication to the physical well-being of women is well known and highly respected in this House.
The subject of today’s debate is of real relevance at a time when there is wide general concern at the growing number of people who are overweight and growing evidence of the dangers of obesity to both mothers and their babies during confinement in particular. Interestingly, an article was published in G2 today about the growing number of large babies in general and the problems that they can suffer during the birth itself. However, that is probably beyond the bounds of today’s debate, because although recent research indicates that obesity in pregnancy is linked with the high birth weight of the baby, it seems likely that other factors affect birth weight, such as the height of parents, which are rather beyond today’s subject.
The report to which the noble Baroness, Lady Rendell, referred clearly indicates a link between a mother’s high body weight and a number of serious problems, which the noble Baroness has rehearsed for us already. One of the effects has been increased costs to the NHS in the number of days in hospital during pregnancy, in a fivefold increase in the costs of neonatal care and in the increased likelihood of the child being admitted into a neonatal intensive care unit. Worryingly, no single clinical guideline is available in the UK on the best way of dealing with these problems, although work is being done and evidence collected on the best way to handle the problem medically. I join the noble Baroness in asking the Minister whether such a guideline is currently being prepared.
Overweight, or a high body mass index, is caused by factors well beyond the power of doctors alone to deal with. Home Office figures published this year show a strong relationship between obesity and social class. I suspect that that is really a relationship between being better off and being less well off. In 2006, about a fifth of the richest quintile of women was obese
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Given the costs to the individual woman and to the NHS of excess weight, what can the Government or individual women do about it? Perhaps better advice to women about the risks to themselves and their babies from overweight would be useful. I had my babies when free orange juice was still available from baby clinics; I certainly listened to what the nurses had to say and tried to follow their advice. The fact that my three children weighed 9 pounds 10 ounces, 8 pounds and 8 ounces and 8 pounds respectively might suggest to some that I did not listen hard enough, although they all grew up perfectly normal.
In an age when mothers of children at school can encourage them to refuse healthy school lunches and push burgers and fries through the schoolyard fence to keep them from starving, we need to do more. Clearly, educating children about health and exercise and healthy eating from their earliest years would be a start. As anyone knows who has frequently visited five and six year-olds in their classrooms, one can teach a child almost anything at that age, always provided that the teaching matches the child’s understanding. Doing some of this on days or at times when parents can be present would be even better.
A programme of age-related teaching financed by the Government might be cost-effective, given the high costs to the NHS of obesity in women, to say nothing of the costs to the women themselves. A greater emphasis on PE and games would clearly be beneficial, as the gap between the activity levels starts early and is widest in the children of the poorest families. There seems to be a real difficulty in that girls in general seem to be turned off team games from quite an early age, but the Government are making a good deal of effort, in the context of the Olympic Games, to encourage more participation in sport of all kinds. Perhaps less concentration on team games and more encouragement of swimming—very good for the figure—and gymnastics, dance or aerobics in all-girl contexts would be more attractive to girls than having to exercise in the school playground or on the hockey pitch with the boys looking on and jeering.
Of course, I understand that there are forces working against such ambitions, not least the increasingly early sexualisation of young girls as a result of high-pressure sales techniques. We also need to be concerned about the understanding of women who are now in their childbearing years of the malign effects of being seriously overweight on their efforts to carry and give birth to a healthy baby. Do the Government ever consider getting this sort of message across in women’s magazines, without anyone ever realising that it is a government message of course? The medium really can be the message if handled tactfully.
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I do not have anything more to contribute to the debate in any medical sense, which is why I have concentrated on what one might call the social aspects of some of this. It is extraordinary that, in an education system that began by teaching children how to look after their babies, we have got so far away from practical education of that kind and from an interest in teaching children how to look after themselves physically as well as mentally, and that we are suffering from a ridiculous and dangerous epidemic of obesity that is causing harm both to mothers and to their children.
7.59 pm
Lord Patel: My Lords, I thank the noble Baroness, Lady Rendell, for securing this debate. For a minute, I thought that she was going to ask us all to declare our BMI before we speak. I would not like to admit that mine is approaching that crucial number. I hope that I will be able to keep it under control.
We all know that obesity in our country is of epidemic proportions—more so than in any other western European country. What is worse is the fact that childhood and adolescent obesity is on the increase, with nearly 30 per cent of children and adolescents classified as obese. In the longer term, that will have its effect in all areas of healthcare, not just in pregnancy. What is now happening in terms of maternal perinatal mortality and morbidity will have its effect in the longer term.
The proverb, “You are what you eat”—and maybe even drink—is familiar to all of us. What is less well known is that it is also true that you are what your parents, and even your grandparents, ate, which is based on the established science of development biology. As we understand more about the genes we inherit and the environment in which we live, and the increased understanding of foetal health and its relation to parental diet, we are beginning to see the link between a predisposition to certain adulthood diseases, such as cardiovascular disease, cancer, diabetes and obesity, as well as to foetal development and maternal obesity. The roots of these diseases are laid down before birth. There is a strong co-relation between maternal insulin sensitivity in late pregnancy, and birth weight and fat-free mass in the body.
So what does all that mean? There is a strong link between obesity in pregnancy and weight at birth, and subsequent obesity in children. In mothers with a BMI of more than 30 kilograms per square metre in the first three months of pregnancy, the prevalence of childhood obesity—that is, a more than 95th percentile weight at the ages of two, three and four—in one study was 15, 20 and 24 per cent. The rise in babies born large for gestational age—with a birth weight of more than four and a half kilos—in the most part is related to maternal obesity and diet, which will then lead to a rise in adulthood diseases.
These are the long-term effects of maternal obesity. The immediate effect is an increased maternal and perinatal mortality, which the noble Baroness, Lady Rendell, has already mentioned. That may well be associated with higher maternal mortality in the United Kingdom than in other western European countries. Let us admit that we now have a rising maternal
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Care of obese mothers requires personalised care from experienced staff and the interpretation of tests, both antenatally and intrapartum, is problematic. The incidence of surgical intervention, such as caesarean sections, is high and fraught with difficulties. I still remember the case of a very large lady on whom I was called to do an emergency caesarean section because of foetal distress. The foetus was not being oxygenated well. The consultant has to deal with the problem. After six hours of surgery, which normally takes 40 minutes, and 25 pints of blood, I was exhausted and my hair turned the colour it is now. In obese women, any surgery is fraught with difficulties. The Minister may be able to use his laparoscope or his robot, but I cannot use those for a caesarean section.
Anaesthesia and post-operative care are also problematic, as is neonatal resuscitation. Babies born to gestationally diabetic mothers, which obese mothers often are, mostly consist of fat and water, and have difficulties in the neonatal period.
What do we need to do? What should the Government’s policy be? First, there should be a better, continuous strategy for the prevention of obesity in children and adolescents, particularly young girls, which is rising. Secondly, with the incidence of obese pregnant women attending clinics in some maternity units as high as 22 per cent, there should be better resourced maternity units. They need equipment, such as bigger blood pressure cuffs, which noble Lords may think are easy to get; stronger operating theatres; and, importantly, skilled, experienced staff, particularly midwives. The Government’s proposal to increase the number of midwives by 4,000 is good, but what steps are being taken to make that happen? We need more midwives to enter not just education but also to practise.
The increasing incidence of obesity in pregnancy will be a sign of a failed strategy for reducing childhood and adolescent obesity, and will lead to greater demands on healthcare in the future. Under-resourced maternity care will lead to an increase in maternal and perinatal deaths and disability. Maternal obesity is a serious problem. Prevention is key in the long term. In the short term, we need better resourced maternity units.
8.05 pm
My Lords, I am sure that we are all most grateful to the noble Baroness, Lady Rendell of Babergh, for having secured this debate. It is very timely as we see obesity and morbid obesity increasingly account for maternal and child mortality, and morbidity in pregnancy and childbirth, as has already been outlined. In preparing for this debate, my literature search identified a series of
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The 2000-02 report, Why Mothers Die, found that 35 per cent of all women who died were obese—a figure that has already been alluded to by the noble Baroness, Lady Rendell. The problems can be considered under various phases of the pregnancy and birth. Pre-existing obesity risks adverse outcomes in pregnancy. In early pregnancy, there is an increased risk of spontaneous miscarriage and congenital abnormalities. These include cardiac problems in the baby; omphalocoele, which is when the abdominal wall does not close and the baby’s guts are exposed; and spina bifida.
As pregnancy progresses, the risks to the baby are of oversized organs, which can lead later to obstructed labour, and of premature labour and of stillbirth, which is sometimes because the placenta comes away with potentially massive haemorrhage. These mothers are at risk of high blood pressure, pre-eclampsia and diabetes in pregnancy, all of which put the placenta at risk. In the morbidly obese women, the babies are at risk of being dangerously small through placental insufficiency, but for most obese women, the babies are dangerously large, which applies right across the board.
Some women are so obese that they have sleep apnoea. They literally cannot breathe properly when they are asleep. The mother is more likely to go into labour at the wrong time, either prematurely or post-term. When in labour, if the head is delivered, the shoulders are at risk of getting stuck and in the process of delivery the baby’s collar bone is at risk of fracturing. The fragments can go through the brachial plexus, which is the main nerve trunk to the arm, and the baby has a paralysed arm. The baby is much more likely to be severely distressed in labour in obese women and after delivery may need resuscitation, which is hard because of the metabolic disturbances that the baby has had.
Caesarean sections certainly are not the answer. Anaesthesia is so hard in these women that they may not ever have adequate sedation because the fat just soaks up the anaesthetic agents. They are extremely difficult to intubate and then they are very hard work to ventilate adequately to maintain oxygen levels to the brain. It is hard to put in an epidural because none of the landmarks are there to guide safe insertion and surgery is complicated by this apron of fat, as has already been alluded to. The wound is then more likely to break down. The women are at risk of genital tract and urinary tract infection and of post-partum haemorrhage. Tragically, the main cause of death in women is thromboembolism when a deep vein thrombosis breaks off as a pulmonary embolus and blocks the blood supply to the lungs, and the woman dies.
The other problem for the baby is that these women are less likely to breastfeed, so there are ongoing nutritional problems in the infant. Should the women have a catastrophic event, resuscitation is harder because
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In going through the literature, I also found an interesting study from work done on animals. Maternal junk food diets during pregnancy and lactation play a role in predisposing the offspring to obesity. This food alters the metabolism of the offspring. Giving the mother junk food has a subsequent lifelong damaging effect on the offspring.
We have before us the Health and Social Care Bill, which features the grant in pregnancy. It is a unique opportunity to engage women in education on health issues, on issues around breastfeeding and on parenting. There is another aspect that we must not ignore. Quite a few morbidly obese women who present are like that because they are desperately unhappy and have been abused. We should use this opportunity to screen for abuse women and other members of their family. There is also the potential problem of substance abuse—particularly of alcohol, but of other substances as well.
Severe obesity is not a reason to chastise a woman, because it may be a pointer to there being a great deal of dysfunction in many aspects of her life. I hope that the Government will use the Health and Social Care Bill to take forward positive health education for these women. When you are giving them a grant, you have a captive audience.
8.11 pm
Baroness Tonge: My Lords, I, too, congratulate the noble Baroness on bringing this matter to the attention of the House. I suspect a lot of things that need to be said have been said. However, I have a few things to add. Of 12.95 maternal deaths per 100,000 births in this country, nearly half—six—are due to obesity in some form. That is disgraceful in a civilised society, with a National Health Service that gives treatment free at the point of need.
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