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Let me deal first with women who become obese during pregnancy. This happens—women of normal weight can grow obese during pregnancy, for emotional or feeding reasons, or perhaps because they have given up smoking. No one has mentioned the link between women smoking and keeping their weight down. This is important, particularly to young women. In one of my pregnancies, for no reason that was ever explained to me, I could be described at term only as a gasometer on legs, because I had put on so much weight. Thankfully, a lot of it—though not all—has disappeared since. However, it does happen, and it can be very dangerous for the woman and her baby. I was fortunate: it had no consequences for me or my baby.

Obesity can also cause reduced fertility, and not just because of the physical difficulty of getting pregnant. I have seen many women who get pregnant once they have addressed their diet and begun to lose weight. The noble Baronesses, Lady Rendell and Lady Finlay,

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and the noble Lord, Lord Patel, have described the many complications at birth, including the damage to the baby at delivery. I read in a paper published about two years ago that there is also a higher incidence of foetal abnormalities in women who are obese when they get pregnant. Diabetes is an obvious complication, along with high blood pressure and pre-eclampsia. There are also enormous problems for the midwives and staff who deal with obese patients. This should not be played down: it is very dangerous. If doctors, nurses and midwives find you difficult to handle, you will not have as good an outcome as if you were easier to handle. I think that sometimes people do not realise that. They think that once they get to the National Health Service, all problems will fade away and the doctor will be able to do the right thing and make them better.

The causes are the same as among the general population. Poor education and deprived backgrounds are major factors in obesity. Girls in school are given sex education, and some relationship education if they are lucky. They are taught about the risks of contracting infections. But what about the risks of obesity in pregnancy and the importance of keeping themselves healthy and fit if they want in future to have healthy and fit babies? Do we address that enough when we educate our girls?

I have mentioned in previous debates the confusion over health messages. Yes, people should give up smoking. However, if patients then put on an enormous amount of weight, you have to address that with them as well, because it can be very difficult. Yes, they must give up drinking, but if their only solace is drinking, will they start overeating to replace the drinking? People with addictive personalities often have to do something to stave off their unhappiness, depression or misery. Treatment is often much more complicated than simply telling them to stop doing something.

Breastfeeding has been mentioned. It is terribly important that babies should be breastfed from birth, because that leads to much better health as the baby moves into childhood. Habits formed during babyhood and childhood are terribly important: noble Lords do not have to be reminded of that.

There is sometimes an element of the Government not quite joining up in this area. We hear a lot about joined-up government, but since introducing massive choice in primary schools so that parents could choose where they wanted to send their children, the tendency has been to choose the school far enough away to require using a car rather than the school around the corner. So many children are now driven to school either because it is too far to walk, because their mothers have been encouraged back to work and they are being dropped off on the way, or because mothers are terrified by all the media attention on child abduction and child abuse. Children do not get that natural exercise at the beginning and end of the day which is so important to their development. With my children, being able to walk to school by themselves once they were in primary school was part of their social development and education. They had to be able to do it. So few children have that nowadays, so they are lacking in exercise.



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I know that the Government are trying to address the problem, but the sale of school playing fields and the dumbing down of compulsory sports in the curriculum has resulted in a tendency for both girls and boys to get fatter because not as much exercise is built into the school day. Government departments need to get together and carry out an audit on what effect this will have in terms of people’s health as well as their education.

We hear a lot about the information on food packaging, but sometimes it is difficult to understand, especially if someone has had a poor education. It is hard to work out what all those minute figures mean, even if you can read them. I can never find my specs and I am always in too much of a hurry.

My noble friend Lady Thomas made an important point. We should remember the days when we had community clinics. We had baby clinics, health visitors, free orange juice and the opportunity for mothers to chat and to speak to community nurses. They were meeting points for young mothers to share information about their babies and receive the correct advice. When the noble Lord, Lord Darzi, responds to the debate, I would like him to promise me that if and when his polyclinics are set up—I have to confess that I am a fan of such clinics for some areas—please, please can we have preventive and community health in order to provide sensible advice for mothers, the elderly and people with long-term diseases. That is what we are lacking now. A lot of GPs have tried to provide those services, which used to be available in community clinics, but many do not. They are particularly important in deprived areas. For a long time I worked in Southall in Middlesex where such clinics were essential to the community. I hope that the Minister will address this point and promise that those services will be brought back.

My last word is this. Please can we get it across to people that the National Health Service is there to help us when we are sick. It is not there to allow us to abuse our bodies and do what we like, just so that the health service can pick up the tab and make us better, whether ourselves or our children. I look forward to the Minister’s reply.

8.21 pm

Earl Howe: My Lords, the topic of obesity is by no means a new one in your Lordships’ House, but the noble Baroness, Lady Rendell, has turned our minds to an extremely important aspect of it. It is also one on which government pronouncements have been comparatively few. I congratulate the noble Baroness on tabling her Question and for the compelling way in which she spoke to it.

When we look at the statistics for maternal deaths in this country, I think it is important that we do not overplay the scale of the problem. The UK has one of the lowest rates of maternal deaths in the world, but the death rate is beginning to rise. It is about 40 per cent higher than it was 20 years ago, and for the first time deaths from cardiac causes, which are often linked to obesity, are the commonest type of death among women in pregnancy and childbirth. If a woman is obese when she is pregnant, she dramatically increases her risk of death or serious complications in childbirth. The CEMACH report of last December described obesity as,



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That is surely a wake-up call.

The threats are not only the ones directly associated with obesity, like sepsis and blood clots. They also lie in the fact that women from less affluent backgrounds are more likely to be in poor overall health and less likely to have regular contact with maternity services. The evidence of risk is quite clear, and we have heard about it from all noble Lords. An obese woman is three times more likely to miscarry, two or three times more likely to suffer from pre-eclampsia and twice as likely to need a caesarean section. She runs a fourfold risk of having gestational diabetes.

When we look at the health of the child, there is an equally worrying picture. Obesity in the mother is associated with an increased risk of her baby being born unusually large, which in turn makes it more likely that the child will suffer injury or need intensive care. As the noble Baroness, Lady Finlay, said, obese mothers are less likely to breastfeed, which often leads to babies gaining weight more rapidly than they otherwise would. The risk of spina bifida is multiplied threefold. In the longer term, there is evidence that children of obese mothers may be pre-programmed for increased obesity and impaired cardiovascular health when they are older, which tends to suggest that the problem, as the noble Lord, Lord Patel, pointed out, could, in this sense, be self-perpetuating.

The trouble is that, as so often with health matters, the messages for women are not completely straightforward. Obesity may be harmful, but having a lower than normal body mass index is equally bad. Underweight women are subject to pregnancy-related complications such as giving birth prematurely and having a child of low birth weight. So it is important to be balanced in pitching any public health messages in this area.

However, even this is far from easy because it is not simply a case of saying to women that before they think of becoming pregnant they should aim for an optimum weight. It has been found that, for women who have already had a child, putting on or taking off weight between pregnancies carries its own quite considerable health risks. Increases in the body mass index of only one or two units were associated with significantly increased rates of pre-eclampsia, gestational diabetes and hypertension, and also led to babies who were excessively large. An increase of more than three body mass index units significantly increased the rate of stillbirth and perinatal complications, quite independently of whether the woman was overweight or not. Equally, women who lost five or more body mass index units between pregnancies were found to have a higher risk of giving birth prematurely than women whose weight remained stable or who gained weight. So gaining or losing a lot of weight between pregnancies poses its own serious risks to a mother's health and to that of her baby. That means that getting to, and keeping to, a normal weight before, during and after pregnancy is, ideally, what women should aim for.

What we know about the increased risk factors for women in pregnancy does, I think, have some serious implications for IVF services. It has been recognised

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for many years that obesity reduces the chances of successfully achieving conception. But if obesity also adds to risk, then it is questionable whether public funds should be spent in cases where the risk factors are very obviously present. Currently, NICE advises that patients should ideally have a BMI of between 19 and 30 when seeking IVF. However, about 18 months ago, doctors in the British Fertility Society recommended that women with a BMI of 36 or more should be disqualified from treatment altogether, and women with a BMI of between 30 and 36 should be accepted only if they engage in a regime of diet and exercise. I should be glad if the Minister would comment on that.

At the moment, there are no national eligibility criteria: it is up to individual PCTs to set their own limits and restrictions. The result really is, I am afraid, reminiscent of a lottery, and at the very least there must be a case for basing the criteria on the clinical evidence and, at the same time, making them much more transparent. In New Zealand, where strict eligibility limits have been applied based on a woman's BMI index, the results have, I understand, been encouraging, because women are made to take control of their own health.

Part of the problem with conveying the necessary public health messages about obesity is that even today, after several years of media coverage of the problem, the public are still generally ignorant of the health implications of being obese and why they are so serious. At the same time, social etiquette dictates that we never tell a person to their face that he or she is too fat, because nowadays that is considered offensive. As a result, in many cases, obesity is given every encouragement to continue unchecked. The CEMACH report was quite unequivocal in saying that women who are obese, and especially those who also have a pre-existing medical condition such as diabetes or epilepsy, should have proper counselling and support.

In my view, the case for the hazards associated with obesity to form a key part of a new national service framework on the care of women before and during pregnancy is compelling. All relevant professionals should be made to appreciate the importance of advice and counselling on obesity in this context; and we should try to look at new ways of bringing home to women contemplating pregnancy that if they are obese or severely overweight they are playing Russian roulette with their lives and the lives of their future children. I hope the Minister will be able to tell us that these matters are receiving a serious degree of thought in his department and that the messages from this debate will be closely heeded.

8.28 pm

The Parliamentary Under-Secretary of State, Department of Health (Lord Darzi of Denham): My Lords, I am grateful to my noble friend Lady Rendell for raising this very important subject. Saving Mothers’ Lives, the recent report of the Confidential Enquiry into Maternal and Child Health, raises some very serious issues about the impact of obesity on the health of pregnant women and their children, issues

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which we are determined to address. I am also grateful to noble Lords who have contributed so knowledgeably to today’s debate. In the short time available to me I want to summarise the current understanding of the issues and set out what actions the Government are taking. I shall also seek to respond to as many points as I can.

As noble Lords will be aware, Britain is in the grip of an obesity epidemic. Almost two-thirds of adults and a third of children are either overweight or obese. This has very significant health implications in terms of increased rates of cancer, coronary heart disease and diabetes, to name but a few examples. In addition, as eloquently described by the noble Lord, Lord Patel, obesity poses a risk for any form of intervention, whether that happens to be a delivery or even surgery.

The CEMACH report, Saving Mothers Lives, published in December 2007, looked in detail at the causes of maternal death for the period 2003-05. Overall, the number of women who died of obvious pregnancy-related causes has remained at seven per 100,000 maternities. The report highlighted that maternal obesity is emerging as a major and growing risk factor. Currently, around 20 per cent of all pregnant women have a body mass index of more than 30 and are therefore classified as obese. However, more than half of the mothers who died in the UK between 2003 and 2005, the period covered by this report, were overweight or obese, with 27 per cent of the mothers recorded as obese and more than 15 per cent as morbidly obese.

The report’s findings reinforce research studies which have produced overwhelming evidence that obesity in pregnancy contributes to increased morbidity and mortality for both the mother and the baby, as eloquently described by the noble Earl, Lord Howe. The evidence is clear on adverse outcomes not just for the mother but also for the baby. For example, CEMACH’s 2005 report into perinatal mortality found that approximately 30 per cent of mothers who had a stillbirth or a neonatal death were also obese.

How, then, do we tackle these growing problems? Maternity services are already responding by developing local protocols and guidelines. There are a number of national initiatives under way and some further lessons from the research evidence which I would like to highlight. I will also highlight the further work that we will do with experts outside the department to help us collectively address these issues.

Many noble Lords in this debate raised the issue of prevention.Prevention is the best way to tackle this and we should be encouraging weight loss before pregnancy as much as possible as part of our overall strategy to tackle obesity. As Saving Mothers Lives says, it is vital that we lose no opportunity to explain clearly but sensitively to women of childbearing age who are overweight or obese about the benefits of achieving a good body weight and adopting a healthy lifestyle before conception.

There is also a clinical consensus that women with a BMI of over 30 should be cared for by a multidisciplinary maternity team so that their individual needs and risks can be managed. This is the safest form of care for them and their baby. In the case of very obese women, as for any other patient, this will include risk analysis

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decisions about the facilities and resources required to support the birth. To do this effectively, services need to ensure that all pregnant women, and particularly women in relatively high-risk groups, including obese women, have access to maternity care early in their pregnancy so that they receive the right advice and get access to the right services from the outset. This is the cornerstone of our maternity policy as set out in Maternity Matters. We will be working with primary care trusts to increase the percentage of women who access services for a full assessment of their needs, risks and choices by the twelfth completed week of pregnancy.

In 2009, the National Institute for Clinical Excellence will be publishing a tool kit to enable each pregnant woman to have her own risks and needs identified so that she receives the best possible help and support during her pregnancy from the most appropriate professionals. Local protocols have also been developed covering, for example, appropriate scan and screening to enable referral to specialists to manage risks such as diabetes, hypertension and thromboembolism; assessment to identify appropriate facilities and equipment for labour and delivery, including increased diagnostics such as ultrasound, suitable surgical instruments, listening devices and beds; and assessment and management of any complications following the birth.

Once their individualised care plans have been established, these women will be closely monitored and supported by their midwife, obstetrician and other members of the maternity team, including nutritionists. Women for whom obesity may pose a significant problem at birth will require an antenatal assessment to discuss the least risky method of birth for both themselves and their babies and an antenatal anaesthetic assessment to discuss analgesia and anaesthesia should caesarean section be necessary.

Although Maternity Matters gives us the policy framework, there is much more to do to address the problems highlighted in the Saving mothers lives report. We are working with outside experts in two areas: improved advice on prevention of excessive weight gain in pregnancy and the scope to develop evidence-based UK guidelines on the optimum management of obese women in pregnancy.

First, on prevention, we have asked the National Institute for Health and Clinical Excellence to develop guidance on prevention of excessive weight gain in pregnancy. This will add to a suite of guidance on pregnancy and childbirth which already includes guidance for improving nutrition for pregnant and breastfeeding mothers. We will also be looking to improve information available to clinicians on the care for this group. We have asked the Royal College of Obstetricians and Gynaecologists to consider developing a national clinical guideline for the management of obese pregnant women, both using the numerous local guidelines already in existence and in light of the results of the current CEMACH and National Perinatal Epidemiology Unit research programmes. The need for such a guideline was a key recommendation in the Saving mothers’ lives report. We will work closely with the royal colleges on this.



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On some of the specific issues raised in the debate, I am grateful for the acknowledgment by the noble Baroness, Lady Tonge, of the polyclinics. I should probably restrain myself from talking about that subject today. However, I could not agree more that we wish to see an NHS in the future not for sickness but for well-being.

Children and their parents have access to children’s centres, supported by two departments: the Department of Health and the DCSF. These centres bring together services for education and health, and have an important role to play in preventive care. They also provide opportunities for mothers to meet and gain experience and support from these different resources.

The noble Earl, Lord Howe, mentioned the current guidelines for IVF and the BMI rates. Most PCTs currently have a policy that, before receiving fertility treatment, women should aim to have a BMI of 19 to 30. The NICE fertility guidelines on the assessment and treatment for people with fertility problems say that women with a BMI of more than 29 should be informed that they take longer to conceive and that losing weight is likely to increase the likelihood of conception. They also refer to men; men with a BMI of more than 29 are likely to have reduced fertility.

The noble Baroness, Lady Finlay, raised the important point of the role of the Health and Social Care Bill. The Bill includes the provision to inform parents of their child’s weight, height and BMI when measured at school at the entry age of 5 and at age 10 to 11. This will alert parents to their child’s weight and, it is hoped, promote them to take action.

The noble Baronesses, Lady Finlay and Lady Tonge, asked what the Government are doing on breastfeeding. Our main challenge is to focus on interventions that will promote breastfeeding. We know that health professionals such as midwives and health visitors can play a vital role in encouraging more mothers to initiate and sustain breastfeeding beyond the early weeks.

The noble Lord, Lord Patel, mentioned the Government recruiting an additional 4,000 midwives. Many of these midwives will be new to the profession but there are also former midwives whose expertise could be brought back into the NHS. The department, along with the Royal College of Midwives, will therefore launch a return-to-practice campaign this summer, with incentives including free training support with childcare and travel costs.

I am running short of time so I will conclude, but I will be more than happy to address some of the other issues raised today. The Government take very seriously the need to address this country’s obesity epidemic and the health implication which stems from it. I hope I have demonstrated that we take equally seriously the need to support high-risk groups, such as obese women who are, or may become, pregnant, recognising the health impacts for them and their babies, so ably described by noble Lords. I thank the noble Baroness once again for bringing this subject forward and also all the noble Lords who have contributed to today’s important debate.


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