Clinical guidelines for the management of weight during pregnancy: a qualitative evidence synthesis of practice recommendations across NHS Trusts in England

We performed a qualitative evidence synthesis of local NHS clinical practice guidelines using the framework analysis approach of Gale et al. (2013) and synthesis method of Thomas and Harden (2008) [14, 15]. Analytical rigour and transparency were ensured through careful documentation of the synthesis process described here.

We approached a purposive sample of NHS Trusts across England. A sample of at least 28 Trusts was selected pragmatically by the principle researcher (LG) aiming to ensure representation of Trusts from the seven NHS regions in order to provide adequate variation of the pre-specified attributes [16]. These attributes were considered to potentially influence the results and included rural/ urban setting, catchment population size, number of births per year and university/ teaching status. Guidelines were downloaded from their website or an application was made through a Freedom of Information process (email or online form) between 1^st April and 1^st June 2021. In the case of non-responders, a Trust within the same region of similar size and university status was contacted. Upon receipt of each guideline, the associated Trust was assigned a unique sequential code to ensure anonymity.

The purpose of this review was not to judge the quality of the existing guidelines but rather sought to present what is currently recommended and examine the content of the guideline. Therefore, no quality appraisal was performed.

Narrative sections of the localised guidelines were extracted and entered verbatim into NVivo for coding (QSR International Pty Ltd. (2020) NVivo (released in March 2020)).

Narrative data were coded into a deductive framework of 18 pre-defined categories, constructed from the recommendations of the NICE Weight management in pregnancy guideline and the RCOG Care of Women with Obesity in Pregnancy guideline by the principle researcher (LG) [12, 13] (Table 1). Descriptive memos for each category supported consistency in coding. Each pre-defined category, and the coded text within it, was extracted and imported into Excel (Microsoft Excel 2016) to generate a matrix, enhancing visualisation for data comparison and interpretation. Cells were tagged with direct quotes or important interpretations, in order to capture nuances and ambiguity between guidelines. This led to collapse and refinement of categories into broad descriptive themes. Reflexivity was practiced throughout the data synthesis, supported by discussions with the full research team. Interpretations were informed by risk discourse and the Birth territory Theory, to synthesise the descriptive themes into three analytical themes that structure the presentation of our synthesis findings [17, 18].

Identification of a theoretical underpinning is vital in midwifery research to tackle and explore complex phenomena, such as weight management, as it ensures findings consider different perspectives; essential to improve care practices and thus, women’s experiences [19]. Birth Territory Theory (BTT), chosen as the theoretical framework here, concerns the balance of power in the birth room and how maternity professionals can support and work in partnership with women [17, 18]. ‘Midwifery guardianship’, the theories key concept, exemplifies integrative power described as when the power between all present during care is equal and the shared, desired outcome is for the woman to feel confident and empowered. In contrast, disintegrative power disables the woman’s confidence in her abilities to achieve a positive pregnancy and birth experience and can induce the woman to become passive in her own care. Disintegrative power, enacted through medical surveillance, draws closely on the concept of risk embedded in maternity services [20, 21].

The Birth Territory theory and the concepts within it, reflect the ambition of UK maternity policy to listen to, understand and work in partnership with each individual woman to ensure a positive pregnancy and birth experience whilst minimising poor outcomes. Thus, the BTT was appropriate to provide an in-depth interpretation of the synthesis findings in the context of current midwifery practice.

Healthcare professionals are advised in national guidance to discuss weight in a sensitive manner and allow opportunities for a woman to raise the concerns she may have about her lifestyle and the ways to address these [12, 13]. The local guidelines reflected this in varying degrees in their weight management recommendations. Ten emphasised the importance of sensitive and respectful conversations around weight where the language used was an important contributor to achieve a good relationship with the woman that laid the foundation for an equalised partnership (Guideline H, I, L, M, S, X, Y, Z, AA, BB). Seven guidelines further emphasised the importance of this to empower women (Guideline S, Z, AA, BB, H, M), to encourage active engagement in care (Guideline AA, BB, H, M, Z), and to promote a positive pregnancy and birth experience (Guidelines L, H). Three guidelines highlighted the sensitive nature of conversations around weight stigma and the lower self-esteem that may be experienced by women of a higher weight (Guideline L, M and I). An awareness of weight stigma and lower self-esteem was not addressed in twenty-five guidelines. A clinical approach was advocated in five guidelines where additional mental health screening was recommended (Guideline J, N, P, X, Z). This reflects RCOG recommendations that as women with a BMI above 30 kg/m² are at an increased risk of mental health problems, they should be screened for these during pregnancy, without necessarily exploring the source of the mental distress [13].

Twenty-seven of the 28 guidelines recommended healthcare professionals discuss the risks associated with obesity during pregnancy with some recommending to explain “the ways in which they [the risks] may be minimised” or management strategies to reduce the risks (Guidelines A, C, D, E, F, L, Q, U, Z). Guidelines mostly provided a list of possible risks for healthcare professionals to discuss, with one guideline (Guideline N) advising a sticky label, listing the risks, be placed in the women’s hand-held notes. 5/28 guidelines provided risk calculations alongside at least one complication (Guidelines M, O, V, X, Y). No guideline offered a risk assessment framework to help healthcare professionals frame risk, or guidance on how risks may be minimised. Guideline H recommended that women should be advised of the risks but be reassured that most women with a raised BMI have straightforward pregnancies and healthy babies. This is unlike the general tone around risk observed in the majority of guidelines but paid attention to how risk information is translated by a woman who may already be feeling vulnerable. Conversely, it could cause confusion in why risk is discussed if most women experience no complications or alternatively, provide false reassurance regarding their potential for poorer outcomes [25].

Advocating a healthy lifestyle and the provision of practical advice on how to improve dietary intake and activity levels are recommended in national guidelines [12, 13]. Informing women of the benefits of adopting health behaviours during pregnancy was recommended in most local guidelines (26/28) but were limited in how they could work with women to achieve this. Seven guidelines offered brief recommendations on what a diet should consist of and recommendations for physical activity but overall information on how to translate this into the reality of women’s lives was not evident (Guideline F, J, K, M, X, Y, Z).

According to national guidance, healthcare professionals should tailor weight management advice to the individual needs of birthing people, enlisting behaviour change knowledge and techniques to provide an individualised approach to care [12]. At a local level, three guidelines mirrored this more collaborative approach (Guideline E, F, G). They recommended healthcare professionals to initiate questions about the woman’s own personal lifestyle, offering a woman an opportunity to frame their experience in a non-judgemental space; exemplifying midwifery guardianship. Three guidelines recommended addressing women’s concerns around physical activity (Guideline F, I, M) or weight (Guideline F, M) but no guidelines made recommendations to address women’s concerns specifically about her diet. Understanding the woman and providing an opportunity to listen to her concerns is central to ensuring equality in care. Guideline G described behavioural techniques such as goal setting to support women to makes changes and expressed that “every contact with women during pregnancy…is an opportunity for tailored health promotion”. Practical steps to identify barriers to behaviour change with women and make plans to overcome them were not clear in any guideline.

Twenty-two guidelines advised midwives to signpost women to reputable sources about healthy lifestyles during pregnancy. As stated in guidance, all women should be provided with accurate and accessible information but only one guideline explicitly identified leaflets that were provided in different languages (Guideline S). It was not evident in other guidelines that there was leaflet provision for those whose first language was not English. If supported with good communication, providing leaflets can be useful in providing women with information and tools to engage in healthy behaviours during pregnancy. However, if it is not reinforced with a conversation and incorporated into the woman’s individual context, it risks being discarded [26].

National guidance recommends that an accurate height and weight should be obtained at the first antenatal contact and a further weight in the third trimester should be considered to plan for appropriate equipment and personnel for birth [12, 13]. Additional weight measurements should only be taken when “clinical management can be influenced or if nutrition is of concern”. All 28 guidelines recommended a baseline BMI to be calculated at the booking (27/28) or first scan (1/28) appointment. An initial weight measurement is part of the risk assessment to determine the appropriate clinical pathway for the woman and her pregnancy as women with a higher BMI have poorer outcomes and therefore should have increased surveillance [13]. The majority of guidelines (24/28) recommended further weight measurements with 13 aligning with national guidance to re-weigh for risk assessment purposes or if nutrition was a concern (Guidelines E, F, G, J, M, N, O, Q, V, W, Z, AA, BB). Eleven recommended healthcare professionals to monitor weight throughout pregnancy (Guideline K, R, H, I, L, P, S, T, U, X, Y). The purpose of re-weighing was clear in only two guidelines to support weight management (Guideline K and R). Women need clear and consistent messaging to feel encouraged and supported. Re-weighing with no given rationale can take away a woman’s sense of control especially as the guidance on how to act on a weight measurement was not clear in any guideline. Monitoring weight throughout pregnancy strongly speaks to the idea that pregnancy is an opportunity for increased surveillance to bring the body back to the “norm” and to identify when further surveillance or intervention is needed in order to guarantee safety as defined by the medical system. Weighing women for the purpose of clinical management, such as for drug calculations, is an example of this and has an important role in ensuring the woman receives appropriate and safe care. However, weighing women with no rationale or no subsequent guidance could be interpreted as controlling the pregnancy but to no clear advantage to the woman or the healthcare professional. For some women, weighing can induce feelings of shame and guilt and this needs considering within the recommendation when there is no clear pathway following a measurement.

National guidance does not provide weight gain thresholds for pregnancy because it concludes that there is no evidence or a lack of consensus on optimal gestational weight gain [12, 13]. Whilst 15 guidelines acknowledged this, eight guidelines recommended weight gain thresholds (Guideline I, M, Q, AA, J, R, X, Y). These were based either on the Institute of Medicine guidelines or on recommendations of which the source was unclear [27]. Current maternity care in the UK sits within a discourse of risk that perhaps explains the advocacy or attempts to adopt weight gain thresholds but we do not have the evidence in which to determine what a healthy gain looks like. This non-conclusive evidence results in recommendations lacking information about what to do should a woman fall above or below thresholds. This challenges the healthcare professional’s ability to support the woman effectively, thus, putting at risk the trusting relationship.

National guidance recommends a referral should be offered to women with a BMI of 30 kg/m² or above at booking and then again in the postnatal period [12, 13]. A dietician or appropriately trained healthcare professional can then perform an assessment and provide personalised advice on a healthy lifestyle. Referrals for additional weight management support were suggested (21/28) but clear eligibility criteria and how to initiate the referral were frequently missing or unclear. Table 3 displays a breakdown of the suggested places for referral. Referrals were sometimes at the healthcare professional’s discretion to consider whether it was necessary and was dependent on resources or availability of services in the area. Referral pathways could have an important role in offering women an opportunity for more specialised or individualised care regarding her weight that may not be possible in routine appointments. Only Guideline R had a clear referral process where attendance at a specific workshop was requested via the midwife as early as possible. An additional referral was offered to women with a BMI above 25 to funded weight management services that included either one-to-one telephone support with a specialist midwife or support from a dietician via an App, depending on the area.

National guidance recommends that healthy lifestyle messages should be reinforced in the postnatal period and women should be advised to seek further support to manage weight or dietetic advice [12, 13]. This was recommended in 23 guidelines. Pregnancy is a life event for the woman and her family that continues beyond the remit of maternity service provision. The transition in services after birth is a tentative period as intervention, advice and information is often suspended or orientated toward the baby meaning women can feel a sudden loss of support and advice. Guideline I recommended that healthcare professionals write to the GP to consider measures to help with weight reduction. This transfer and sharing of information with the woman’s GP could provide a useful support link when women no longer fall within the scope of maternity services. Clear referral pathways after birth are essential in upholding the important health messaging established during pregnancy that are fundamental in determining the potential course of subsequent pregnancies. Breastfeeding was advocated, specifically in relation to supporting weight management, in four guidelines. (Guideline A, D, G, R).

While local recommendations were largely reflective of national guidance, our synthesis has exposed a disconnect between the partnership approach emphasised in national maternity policy, and the risk dominated discourse of local practice recommendations for weight management during pregnancy. The most consistent recommendations were to obtain a weight measurement at booking, inform women of the benefits of a healthy lifestyle and of the risks associated with being obese during pregnancy. Specific, practical advice about how to achieve a healthy lifestyle was lacking, there was variation in the adoption of routine weighing practices and referral pathways were ambiguous.

The Birth Territory Theory challenges the focus on surveillance and risk observed in the majority of guideline recommendations. In contrast but in alignment with the BTT, few guidelines promoted or facilitated an individualised or partnership approach; a characteristic of midwifery guardianship that displays an awareness of the sensitive and emotive nature of weight management conversations.

Healthcare professionals face significant personal and contextual barriers to having conversations about weight during pregnancy [28‐30]. Barriers include a lack of knowledge, skill, confidence and a fear of stigmatising women who enter pregnancy with obesity. The focus on risk, absence of clear instruction on providing behaviour change advice, unclear pathways and omission of practical lifestyle advice on how to work with women to manage weight that was observed in the local guidelines offers explanation to why such barriers may exist. Weight management advice is often sought by women but insensitive counselling around weight and in particular, risk, and the medicalisation of these pregnancies can result in depersonalisation of care and feelings of shame and guilt [6, 8, 31]. Creating a non-judgemental space, where a woman feels safe to discuss her concerns with the healthcare professional is fundamental within conversations about weight that do not induce weight stigma. However, local guidelines appear to fail healthcare professionals in advocating midwifery guardianship.

Local clinical guidelines derive from a medical perspective in which healthcare professionals dictate the course of clinical management, intervention and treatment based on the best available evidence. However, weight management is complex and incorporates biological, psychological, environmental and social factors, and the guidelines examined often overlooked these factors and were orientated around risk and surveillance. Focus on risk disempowers women and elevates anxiety [26]. During risk conversations, women can feel judged for their weight that can affect her decisions during pregnancy and if complications arise, made to feel they are to blame [25]. Pregnant women understand risk in a context specific way dependent on their previous experiences and socio-cultural factors emphasising the importance of individual assessment and framing of risk around the woman’s cultural and social context to support her sense making [32]. Women want constructive advice to follow new information about her risk and the omission of this detail creates challenges for healthcare professionals to ameliorate the anxieties created by risk counselling [33]. Clinical guidelines can support the complex interplay between scientific evidence, healthcare provider’s expertise and the woman’s preferences by considering how each recommendation and the evaluated outcome may support, or inhibit, personalised and sensitive conversations that would instigate a partnership approach to care [34].

Reconceptualising weight management care to align with the partnership approach that enacts midwifery guardianship is warranted. Whilst we work in a medical system that utilises clinical guidelines to inform healthcare professionals, recommendations must consider how a woman’s social, environmental and psychological context can be considered in order to reduce weight stigmatisation, increase her choice and empower her. To achieve the partnership approach that maternity care policy advocates, the manner in which weight conversations in pregnancy are had, the subsequent communication of practical, individualised advice as well as the dominant risk-focus of the guidelines must be re-examined.

Implementing evidence-based recommendations must be complemented by equipping healthcare professionals with specific training to increase skills, knowledge and confidence, frequently identified as barriers to providing supportive weight management care. This includes offering professionals support in communicating risk about weight in a way that the woman can make sense of considering her values, beliefs and preferences to dissipate feelings of anxiety or guilt. Co-designing clinical guidelines with women who have experienced pregnancy with obesity or excessive gestational weight gain could be fundamental in the design of tools we use to deliver weight management care.

To our knowledge, this is the first study to use a theoretical framework to understand weight management guidelines that are used across different NHS Trusts in England. Adding to existing evidence surrounding weight management care provision during pregnancy, this study helpfully adds a new perspective that challenges current practices by highlighting the disconnect between the ambition of maternity policy and guideline recommendations. It has also provided some context for the barriers faced by healthcare professionals as well as the experiences of pregnant women; providing momentum for ongoing inspection of national and local clinical guidelines that may hinder progression towards supportive, collaborative weight management care that empowers women.

A purposive sample generated a well-represented national picture of guidelines from all seven NHS regions in England. Maternity units in Scotland, Wales and Northern Ireland were not included due to the differences in NHS or non-NHS healthcare structures, which would have made comparability with NICE and RCOG guidelines difficult. Therefore, a study comparing local guidelines beyond England may be warranted.

Using the NICE and RCOG guidelines as a deductive analysis framework was useful to ensure we explored all aspects of weight management care. However, we did not include associated guidelines in our framework such as ‘Maternal and child nutrition’ [PH11], ‘Antenatal care’ [NG201] or ‘Postnatal care’ [NG194] guidelines [35‐37]. It is important to acknowledge that they may provide additional detail on the care women receive. However, the focus of this synthesis was weight management and therefore, to ensure the study had a clear focus on this, other guidelines were not used in the framework for analysis.