Interventions for supporting the initiation and continuation of breastfeeding among women who are overweight or obese

Background Exclusive breastfeeding is recommended for all infants until six months of age due to the many health benefits for both the mother and infant. Evidence suggests that mothers who are overweight (body mass index (BMI) 25.0 to 29.9 kg/m²) or obese (BMI ≥ 30.0 kg/m²)are less likely to initiate breastfeeding and to breastfeed for a shorter duration. Considering the rising prevalence of overweight and obesity globally and the known benefits of breastfeeding particularly in reducing the long-term risks of obesity and diabetes for infants, establishing effective ways to support and promote breastfeeding in women who are overweight or obese is paramount in achieving the goal of healthier communities. Objectives To assess the effectiveness of interventions to support the initiation or continuation of breastfeeding in women who are overweight or obese. Search methods On 23 January 2019 we searched Cochrane Pregnancy and Childbirth’s Trials Register,ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and reference lists of retrieved trials. Selection criteria Randomised controlled trials (RCTs) and quasi-RCTs that compared interventions to support the initiation and continuation of breastfeeding in women who are over weight or obese. Interventions included social support, education, physical support, or any combination of these. Interventions were compared either with each other or against a control group.Data collection and analysis. We assessed all potential trials identified from the search strategy. Two review authors extracted data from each included trial and assessed risk of bias. We resolved discrepancies through discussion with the third review author. We assessed the quality of the evidence using the GRADE approach. Main results We found no trials comparing one type of support versus another. We included seven RCTs (including one cluster-RCT) involving831 women. The number of women in each trial ranged from 36 to 226. The trials were conducted in high-income countries: USA(5 trials); Denmark (1 trial) and Australia (1 trial), between 2006 and 2015. Three trials only included women who were obese prior to pregnancy and four trials included both women who were overweight and women who were obese. We judged risk of bias in the included trials to be mixed; only one trial was judged to be low risk of bias for random sequence generation, allocation concealment and attrition bias. Physical breastfeeding support (manual or electric breast pump) versus usual care (no breast pump)Very low-certainty evidence from one small trial (39 women) looking at a physical support intervention (manual or electric breast pump) versus usual care (no pump) means it is unclear whether physical support improves exclusive breastfeeding at four to six weeks(risk ratio (RR) 0.55, 95% confidence interval (CI) 0.20 to 1.51) or any breastfeeding at four to six weeks (RR 0.65, 95% CI 0.41to 1.03). The trial did not report other important outcomes of interest in this review: non-initiation of breastfeeding, exclusive or any breastfeeding at six months postpartum. Multiple methods of breastfeeding support versus usual care. Six trials (involving 792 women) used multiple methods of support including education and social support through telephone or face-to-face contact. One of these trials also provided physical support through providing a breast pump and a baby sling and one trial provided a small gift to the women at each trial visit. Support in the trials was provided by a professional (four trials) or a peer (two trials). One trial provided group support, with the other five trials supporting women individually. One trial (174 women) did not report on any of our main outcomes of interest. We are unclear about the effects of the intervention because we identified very low-certainty evidence for all of the important outcomes in this review: rate of non-initiation of breastfeeding (average RR 1.03, 95% CI 0.07 to 16.11; 3 trials, 380 women); exclusive breastfeeding at four to six weeks (average RR 1.21, 95% CI 0.83 to 1.77; 4 trials, 445 women); any breastfeeding at four to six weeks(average RR 1.04, 95% CI 0.57 to 1.89; 2 trials, 103 women); r ate of exclusive breastfeeding at six months postpartum (RR 7.23, 95%CI 0.38 to 137.08; 1 trial, 120 women); and any breastfeeding at six months postpartum (average RR 1.42, 95% CI 1.08 to 1.87; 2trials, 223 women).The included trials under the above comparisons al so reported on some of this review’s secondary outcomes but very low-certainty evidence means that we are unclear about the effects of the intervention on those outcomes. Authors’ conclusions There is insufficient evidence to assess the effectiveness of physical interventions, or multiple methods of support (social, educational or physical) for supporting the initiation or continuation of breastfeeding in women who are overweight or obese. We found no RCTs comparing one type of support to another type of support. All of our GRADE assessments resulted in very low-certainty evidence, with downgrading decisions based on limitations in trial design (e.g. risk of attrition bias), imprecision, inconsistency. The available trials were mostly of variable quality with small numbers of participants, confounded by poor adherence within both the intervention and control groups. Well designed, adequately powered research is needed to answer questions about the social, educational, physical support, or any combination of these interventions that could potentially help mothers who are overweight or obese to achieve optimal breastfeeding outcomes. We need trials that examine interventions designed specifically for women who are overweight or obese, delivered by people with training about how to overcome some of the challenges these women face when establishing and maintaining breastfeeding. Particular attention could be given to the assessment of antenatal interventions aimed at improving breastfeeding initiation in women with a raised BMI, and not just focusing on recruiting women who have an intention to breastfeed. Given that the majority of current trials were undertaken in the USA, further trials in a diverse range of countries and settings are required. Future trials need to give consideration to the theoretical basis of the intervention using established frameworks to enable replicability by others and to better determine the components of effective interventions

An analysis of behaviour change techniques used in a sample of gestational weight management trials

Introduction: Maternal obesity and excessive gestational weight gain are associated with multiple adverse outcomes. There is a lack of clarity on the specific components of effective interventions to support pregnant women with gestational weight management. Method: All 44 studies within a pre-existing review of lifestyle interventions, with a potential to impact on maternal weight outcomes, were considered for content analysis. Interventions were classified using Behaviour Change Technique (BCT) Taxonomy clusters to explore which categories of BCT were used in interventions and their effectiveness in managing gestational weight gain. Results: The most commonly used BCTs were within the categories of 'feedback and monitoring', 'shaping knowledge', 'goals and planning', 'repetition and substitution','antecedents' and 'comparison of behaviours'. For diet and mixed interventions'feedback and monitoring', 'shaping knowledge' and 'goals and planning' appeared the most successful BCT categories. Conclusions: Poor reporting within studies in defining the BCTs used, in clarifying the differences in processes between intervention and control groups, and in 20 differentiating between the intervention and research processes made BCT classification difficult. Future studies should elaborate more clearly on the behaviour change techniques used and report them accurately to allow a better understanding of the effective ingredients for lifestyle interventions during pregnancy

Migrant women’s experiences of pregnancy, childbirth and maternity care in European countries: A systematic review

Background: Across Europe there are increasing numbers of migrant women who are of childbearing age. Migrant women are at risk of poorer pregnancy outcomes. Models of maternity care need to be designed to meet the needs of all women in society to ensure equitable access to services and to address health inequalities. Objective: To provide up-to-date systematic evidence on migrant women’s experiences of pregnancy, childbirth and maternity care in their destination European country. Search strategy: CINAHL, MEDLINE, PubMed, PsycINFO and Scopus were searched for peer-reviewed articles published between 2007 and 2017. Selection criteria: Qualitative and mixed-methods studies with a relevant qualitative component were considered for inclusion if they explored any aspect of migrant women's experiences of maternity care in Europe. Data collection and analysis: Qualitative data were extracted and analysed using thematic synthesis. Results: The search identified 7472 articles, of which 51 were eligible and included. Studies were conducted in 14 European countries and focused on women described as migrants, refugees or asylum seekers. Four overarching themes emerged: ‘Finding the way—the experience of navigating the system in a new place’, ‘We don't understand each other’, ‘The way you treat me matters’, and ‘My needs go beyond being pregnant’. Conclusions: Migrant women need culturally-competent healthcare providers who provide equitable, high quality and trauma-informed maternity care, undergirded by interdisciplinary and cross-agency team-working and continuity of care. New models of maternity care are needed which go beyond clinical care and address migrant women's unique socioeconomic and psychosocial needs

Thermal territories of the abdomen after Caesarean Section birth : infrared thermography and analysis

Objective: To develop and refine qualitative mapping and quantitative analysis techniques to define 'thermal territories' of the post-partum abdomen, the caesarean section site and the infected surgical wound. In addition, to explore women's perspectives on thermal imaging and acceptability as a method for infection screening. Method: Prospective feasibility study undertaken at a large University teaching hospital, Sheffield UK. Infrared thermal imaging of the abdomen was undertaken at the bedside on the first two days after elective caesarean section. Target recruitment: six women in each of three body mass index (BMI) categories (normal, 18.5 to 24.9kg/m²; overweight 25 to <30kg/m²; obese ≥30kg/m²). Additionally, women presenting to the ward with wound infection were eligible for inclusion in the study. Perspectives on the use of thermal imaging and its practicality were also explored via semi-structured interviews and analysed using thematic content analysis. Results: Twenty women were recruited. All had undergone caesarean section. From the booking BMI, eight women were obese (including two women with infected wounds), six women were overweight and six women had a normal BMI. Temperature (oC) profiling and pixel clustering segmentation (Hierarchical Clustering Segmentation, HCS) revealed characteristic features of thermal territories between scar and adjacent regions. Differences in scar thermal intensity profiles exist between healthy scar and infected wounds; features that have potential for wound surveillance. Maximum temperature differences (deltaT) between healthy skin reference and wound site, exceed 2oC in women with established wound infection. At day 2, two women had a scar thermogram with features observed in the ‘’infected’’ wound thermogram. Thermal imaging at early and later times after caesarean birth is feasible and acceptable. Women reported potential benefits of the technique for future wound infection screening. Conclusion: Thermal intensity profiling and HCS for pixel cluster dissimilarity between scar and adjacent healthy skin has potential as a method for the development of techniques targeted to early infection surveillance in women after caesarean section. Key words: Thermal imaging, infrared thermography, abdomen, surgical site infection, Caesarean section, infection surveillance

Evaluation of gestational weight management interventions for women with obesity

Background: The prevalence of extreme obesity (body mass index (BMI) ≥40kg/m²) is increasingly common during pregnancy. Women with obesity and their infants are at increased risk of adverse outcomes including excessive gestational weight gain (GWG) and increased risk of childhood obesity. Aim: The primary aim of this thesis was to explore GWG management among women with a BMI ≥40kg/m². Methods: An overview of systematic reviews on the effectiveness of lifestyle interventions to reduce GWG in women with overweight or obesity was undertaken followed by a sequential explanatory mixed methods study. This included: 1. A dominant quantitative component collecting retrospective data to explore the impact of an antenatal healthy lifestyle service for women with a BMI≥40kg/m² on GWG, pregnancy and birth outcomes and childhood obesity up to age 5. 2. A supplementary qualitative component undertaking semi-structured interviews with thirteen women with a BMI≥40kg/m² to explore their experiences of gestational weight management. Key findings: Findings across the research programme were integrated narratively. The findings indicated a lack of impact of most antenatal healthy lifestyle services. Within the overview of systematic reviews current lifestyle interventions among women with overweight or obesity reduced average GWG by 0.3 to 2.4kg but had minimal impact on clinical outcomes. Similarly, the antenatal healthy lifestyle service made no difference to mean GWG. There were no beneficial clinical effects from the antenatal healthy lifestyle service (3 visits) except for a higher rate of breastfeeding at discharge compared to women in the comparison cohort. Nor was there any association between lifestyle service attendance and childhood overweight or obesity up to 5 years. Socio-demographic context and parity were noted to be important. Those from more deprived backgrounds were less likely to attend the service and more likely to have a child with overweight or obesity by school age. The antenatal healthy lifestyle service appeared to be effective among multiparous women, as those offered three visits had a lower rate of weight gain and fewer small for gestational age infants. Within the qualitative interviews women highlighted the stigma they experienced, especially when healthcare providers placed excessive focus on the risks of obesity during pregnancy without providing practical advice and support. The final integrated finding suggested the need to refine interventions in terms of their content, timing and format. Conclusion: Lifestyle based interventions may cause a small reduction in GWG, however their impact on clinical outcomes was minimal. More holistic approaches to weight management during pregnancy are required for women with obesity, with future interventions focussing on environmental and social factors, not just changing individual behaviour. Original contribution: This work makes an original contribution by evaluating experiences and outcomes of antenatal weight management in women with a BMI≥40kg/m², a subgroup frequently lacking in previous research. Additionally, it explored the long-term association between antenatal weight management service attendance and childhood obesity, which has seldomly been undertaken previously

A meta-review of systematic reviews of lifestyle interventions for reducing gestational weight gain in women with overweight or obesity.

Women with overweight or obesity are twice as likely to gain excessive gestational weight than women of normal weight. Identifying effective interventions to support this group achieve healthy gestational weight gain is important. An overview of systematic reviews regarding the effectiveness of lifestyle interventions on gestational weight gain in women with overweight or obesity was undertaken, including searching eight electronic databases. Quality of included reviews was assessed by two independent researchers. A narrative data synthesis was undertaken, with subgroup and sensitivity analyses by type of intervention and quality of the included reviews. A total of 15 systematic reviews were included within this meta-review. A small reduction in gestational weight gain of between 0.3 and 2.4 kg was noted with lifestyle interventions compared with standard care. There was some evidence that dietary only or physical activity only interventions may reduce the odds of gestational diabetes. No differences were noted in the odds of other maternal or infant health outcomes. Although lifestyle interventions appeared to decrease gestational weight gain, current evidence does not show a clear benefit on maternal and infant outcomes from the small nature of the reduction in gestational weight gain produced by lifestyle interventions in women with overweight or obesity

A retrospective comparative study of antenatal healthy lifestyle service interventions for women with a raised body mass index.

BACKGROUND: Women with obesity are more likely to gain excessive gestational weight; with both obesity and excessive weight gain linked to adverse outcomes for mothers and their infant. Provision of antenatal healthy lifestyle services is currently variable, with uncertainty over the most effective gestational healthy lifestyle interventions. AIM: To compare pregnancy and birth outcomes among women who experienced an antenatal health lifestyle service with a cohort who did not receive this service. METHODS: A retrospective comparative cohort study was undertaken in women with a BMI ≥ 40 kg/m² attending maternity care in two NHS Trusts. One Trust provided an antenatal healthy lifestyle service, while the comparison Trust provided routine maternity care. Data was collected from medical records. FINDINGS: No differences were observed between the antenatal healthy lifestyle service and comparison cohorts for average gestational weight gain [adjusted mean difference (aMD) - 0.70 kg (95%CI -2.33, 0.93)], rate of weight gain [aMD - 0.02 kg/week (95%CI -0.08, 0.04)] or weight gain in accordance with recommendations. The proportion of women breastfeeding at discharge was higher for the antenatal healthy lifestyle service than the comparison cohort (42.4% vs 29.8%). No other clinical outcomes were enhanced with the antenatal healthy lifestyle service. CONCLUSION: Internal audit had suggested the antenatal healthy lifestyle service was successful at managing gestational weight gain in women with a BMI ≥ 40 kg/m². However, no benefit on gestational weight gain was evident once the service was evaluated against a comparison cohort with adequate adjustment for confounders. It is essential that future services are evaluated against a relevant comparison group

Differing intensities of a midwife-led antenatal healthy lifestyle service on maternal and neonatal outcomes: A retrospective cohort study.

Introduction Maternal obesity and excessive gestational weight gain are associated with adverse maternal and neonatal outcomes. There is uncertainty over the most effective antenatal healthy lifestyle service, with little research determining the impact of different lifestyle intervention intensities on pregnancy outcomes. Method This retrospective cohort study compared pregnancy and birth outcomes in women with a body mass index of 40 or above who were offered a low intensity midwife-led antenatal healthy lifestyle service (one visit) with women who were offered an enhanced service (three visits). The primary outcome was gestational weight gain. Results There were no differences between the two healthy lifestyle service intensities (N=682) in the primary outcome of mean gestational weight gain [adjusted mean difference (aMD) -1.1kg (95% CI -2.3 to 0.1)]. Women offered the enhanced service had lower odds of gaining weight in excess of Institute of Medicine recommendations [adjusted odds ratio (aOR) 0.63 (95% CI 0.40-0.98)] with this reduction mainly evident in multiparous women. Multiparous women also gained less weight per week [aMD -0.06kg/week (95% CI -0.11 to -0.01)]. No overall beneficial effects were seen in maternal or neonatal outcomes measured such as birth weight [aMD 25g (95% CI -71 to 121)], vaginal birth [aOR 0.87 (95% CI 0.64-1.19)] or gestational diabetes mellitus [aOR 1.42 (95% CI 0.93-2.17)]. However, multiparous women receiving the enhanced service had reduced odds of small for gestational age [aOR 0.52 (95% CI 0.31-0.87)]. This study was however underpowered to detect differences in some outcomes with low incidences. Discussion Uncertainty remains over the best management of women with severe obesity regarding effective interventions in terms of intensity. It is suggested that further research needs to consider the different classes of obesity separately and have a particular focus on the needs of nulliparous women given the lack of effectiveness of this service among these women

Reduction in global maternal mortality rate 1990–2012 : Iran as a case example

Out of a total of eight Millennium Development Goals (MDG) set by the United Nations, MDG5 aimed to improve maternal health worldwide. This was specifically aimed at reducing childbirth-related deaths for mothers by three quarters between 1990 and 2015. The total number of maternal deaths globally has declined by 45% from 523,000 in 1990 to 289,000 in 2013 (WHO 2014). This reduction, as an indicator of improving maternal health globally, is a remarkable achievement. There has however been wide variation in this improvement (WHO 2014) which needs thorough evaluation, individually and as a cross comparison, in order to extract constructive lessons to enhance the health of mothers, families and communities subsequently. This commentary focuses on issues related to maternal mortality ratio (MMR) reduction and contributing factors in Iran; identified as one of the leading countries achieving the highest percentage MMR reduction since 1990 (WHO, 2014)

Association of child weight with attendance at a healthy lifestyle service among women with obesity during pregnancy

Women with obesity during pregnancy are at increased risk of excessive gestational weight gain (GWG) and other maternal and infant adverse outcomes, which all potentially increase childhood obesity. This study explored infant weight outcomes for women with a body mass index (BMI) ≥ 35 kg/m² who were offered an antenatal healthy lifestyle service. A retrospective cohort study, including linking data from two separate health care Trusts, was undertaken. Data were collected from maternity records for women with a BMI ≥ 35 kg/m2 referred to an antenatal healthy lifestyle service from 2009 to 2015. The respective child's weight outcome data was additionally collected from health and National Child Measurement Programme records. Univariate logistic regression determined the odds of childhood overweight, obesity and severe obesity according to attendance at the antenatal healthy lifestyle service, GWG and sociodemographic characteristics. Factors significant (p < 0.05) within the univariate analysis were entered into multiple logistic regression models. Among women with a BMI ≥ 35 kg/m², 30.4% of their children were obese at school entry and 13.3% severely obese. Healthy lifestyle service attendance was not associated with childhood overweight or obesity at any point within the univariate analysis. At school age multiple regression analysis showed the odds of overweight and obesity increased with excessive GWG and the odds of obesity decreased with a parent in a professional occupation, additionally having a mother who smoked in pregnancy increased severe obesity. Women should be supported to optimise their BMI before pregnancy. Additionally, rather than exclusively focusing on changing an individual's behaviour, future interventions should consider external influences such as the woman's family, friends and sociodemographic background