Results - Online Questionnaire
Characteristics of respondents
Responses were received from 88 people of whom 39 (44.3%) were commissioners, 43 (48.9%) were providers, 1 (1.1%) was a specialist, 1 (1.1%) worked as both a commissioner and provider and four (4.5%) did not answer.
Figure 1 shows the LMS distribution of respondents. A response was received from 23 of the 44 LMS (52.3%) within England. Of the fourteen respondents who did not report which LMS they were from, 11 took no further part in the survey.
Figure 1. Survey responses from the different Local Maternity Systems (LMSs) (n=88)
Service provision for women before, during or after pregnancy
A total of 68 participants answered questions about service availability for all women promoting healthy eating and/or weight management and 44 responded to questions about physical activity. Both types of services were offered most frequently during pregnancy and the time that services were reported to be offered least was prior to pregnancy. Healthy eating and/or weight management services were offered more often than physical activity services at all stages of the childbearing cycle (See Figure 2).
Additional service provision for women with a BMI≥25kg/m² was low at all stages of the childbearing cycle (Figure 2); with very few respondents reporting additional services (only 7 healthy eating and/or weight management services and 3 physical activity services). Similarly to services for all women, most services were provided during pregnancy.
Figure 2. Service availability to all women and women with a raised BMI at different childbearing stages
Geographical distribution of services
Service availability varied between different LMSs, with some LMSs reporting no services during the childbearing cycle, some reporting provision across all stages and some at one or two of the different stages only - prior to pregnancy, during pregnancy or postpartum.
In all LMS where there were multiple respondents it was noted that the services reported varied between respondents. This could be from no service availability to availability across all stages of the childbearing cycle. It was unclear within our survey whether this was due to service availability awareness differing between respondents or whether there were differences in service availability in different NHS Trusts/ clinical commissioning groups within each LMS.
Services provided varied. They could include basic information provision such as the Eat Well Plate (17), safe exercise in pregnancy guidelines or the physical activity in pregnancy infographic (18) given by professionals such as midwives or health visitors. Some areas provided information about bespoke programmes that women could access such as aquanatal classes, Cook it Programmes, leisure centre partnerships or park walks. A few respondents reported the availability of dietician referral or could refer women to specific services such as HENRY (Health, Exercise and Nutrition for the Really Young) (19).
Family approach to the services
A family approach was reported to be taken in 74.4% of healthy eating / weight management services and in 57.7% of physical activity services (Figure 3). Family approaches included other family members being incorporated into the service, whole family activities for example cookery courses or proactive onward referral for family members. Some respondents also felt that changing the mothers' lifestyle would impact the long-term health of all family members.
Evaluation of the services
Only 35.9% of services encouraging healthy eating or weight management and 32.0% promoting physical activity reported to have been evaluated (Figure 3). Evaluation was mainly through service user feedback or internal audit. Only four services had been independently evaluated, either by an independent University or national evaluation of services such as Slimming World. None of the services for women with a raised BMI reported they had been formally evaluated.
Figure 3. Services reporting that they had been evaluated, used a family approach or had involved service users.
Service user involvement in services
Over a third of respondents reported service user involvement (Figure 3). This included co-creation of the service, service development through user feedback or service user involvement on research steering groups.
Results of the survey are also summarised on the infographic in Additional File 1.
Results - Semi-Structured Interviews
Characteristics of participants
Thirteen participants undertook semi-structured individual interviews (n=6) or focus groups (two focus groups with 2 and 5 participants respectively). Participants had a wide geographical distribution within two LMS and varied professional roles including council public health workers (n=7), specialist or consultant midwives whose role included public health (n=4), a health visitor (n=1) and a council-sports partnership worker (n=1)
Service provision description from interview participants' perspectives
Services provided for all women
Services provided for all women were similar to those described within survey responses, including information provision by midwives or health visitors (n=8), HENRY and it’s follow on initiatives (n=5) or other initiatives to promote healthy eating and physical activity (n=2), exercise groups such as aquanatal or buggy fit (n=6) and referral to local leisure centres (n=5). Some interviewees also discussed additional provision not mentioned by survey respondents including links with schools and colleges to provide pre-conception education (n=1), achieving Baby Friendly Initiative (20) accreditation or providing breastfeeding support (n=2), 'Fitmums and Friends' and 'This Girl Can' - campaigns to promote women to exercise (n=1), initiatives targeting healthy food provision options in vending machine (n=2) and the Promotional Guide Tool (21) used by health visitors to promote conversations with women regarding lifestyle (n=1).
Service provision for women with a raised body mass index
Similarly to the survey, there were few services specifically for women with a raised BMI. Some had consciously move away from targeted services to avoid stigmatisation, while others had experienced decommissioning of services due to funding issues (n=3).
Thematic representation of the interview findings
The themes and subthemes identified from qualitative data are presented in Figure 4 and discussed in detail below.
Equity and variation in service provision
In line with survey results, geographical variation in service provision was noted both between areas and within areas. In one area women within the same NHS Trust for maternity care could have access to different services dependent on where they lived, due to councils which commissioned services having different boundaries to NHS Trusts.
"I see women on a Wednesday morning and I can only say you can go to Slimming World if you want but you’ll have to pay for it yourself and then I see ladies on a Thursday morning and I say this is the lovely XXXX [who runs the free local maternity programme for women with a raised BMI]. It’s just unequal" Participant 2
Figure 4 Thematic representation of key stakeholders’ views on maternal weight management service provision
Need for rigorous evaluation
Evaluation of services was universally poor. The exception was the national HENRY programme which had been independently evaluated (22). Any local evaluation described was by monitoring attendance or asking women for feedback, with changes incorporated into the service in response to any issues raised.
Respondents felt limited specific guidance on acceptable weight gain during pregnancy as standards to measure services against hindered evaluation. One service however used the Centre for Maternal and Child Enquires maternal obesity report (7) as a UK baseline for outcomes such as Caesarean delivery, induction of labour and preterm birth, with which to compare their service outcomes.
“I think it’s very difficult in pregnancy to evaluate it properly because we don’t have a true reference range for what is a healthy weight gain.” Participant 7
Facilitators for weight management service provision and access
Suggestions made by interviewees to encourage better access or more effective service provision, included prioritisation, a change in focus and co-design of services.
Prioritisation of the first 1000 days by one council had allowed additional funding to be attained for high priority areas, to commission additional services. The high-level initiative Healthy Weight Declaration was also seen to support local government to develop and implement policies around healthy weight for example changing food provision at community cafes or parenting groups (23).
“So there's things like the healthy weight declaration … that’s something that we’re trying to take on board here and it's very much about changing the culture around food, activity and the environment essentially. So you know the food that’s provided in hospital vending machines or gym vending machines, so that's been challenged so that healthier food is provided” Participant 1
A change in focus
There was a shift from focussing exclusively on weight onto healthy eating and activity. The importance of establishing the individual's current understanding of weight management and encouraging women to identify their own goals was also considered to be important, rather than imposing the provider’s ideas.
“on a general level I think the focus needs to move away from weight and more onto health of eating well and moving more and shifting the culture in that way” Participant 1
Co-design of services with women
Clear communication with service users to ensure appropriate services are commissioned was considered key to ensure access. Providing free services, in places with good transport links, on-site childcare, high visibility through good marketing and de-centralised services to reduce the distances women have to travel were all considered vital to improve service accessibility.
"being commissioned appropriately with discussion with services and with women ... because sometimes I think when services are being commissioned they don’t think about the people who’re actually using them, so it's so important asking the right women" Participant 5
Providing services for all women was felt to increase service uptake, by preventing mothers with a raised BMI feeling stigmatised. This also made sense to providers given the increasing population levels of overweight and poor diet and the lower cost associated with embedding a universal service into existing provision, rather than paying for an additional service.
"Regardless of people’s weight, we know that people have poor diets. I think whenever we talk about targeted interventions, we always just come back to we might as well do it universally" Participant 13
Barriers to weight management service provision and access
Numerous barriers that inhibited provision, promotion and access to healthy lifestyle services were identified.
Financial and time obstacles
Lack of money was the biggest obstacle reported. It prevented services being commissioned, prevented investment in services and inhibited service delivery. Rural areas were especially hard hit as running services in areas where pregnant women were very dispersed was not cost effective. Money restrictions also equated to time restrictions within appointments, meaning discussions around healthy eating or referral to available services were always a low priority for midwives needing to address many other topics. The proper evaluation of services was also impeded by lack of money.
“It’s a difficult one because the council don’t have the budget anymore.” Participant 4
The constant cycle of commissioning, decommissioning, revamping and re-commissioning of services as funding was available made it difficult for practitioners to stay informed with service availability.
"I know staff find it so frustrating when things are coming and going because they say you know it's fantastic this and the next minute you're putting a message saying actually the services have stopped." Participant 5
Commissioners reported difficulties in evaluating services as they were unable to assess the quality of frontline staff conversations. They also reported frustration at not receiving information such as attendance when it was requested from providers, so did not know whether further promotion of services was required.
"They [midwives] tend to record that a discussion has to take place, but the quality of the discussion could vary so I could say, well you know you are pregnant, now you must eat well and exercise and then tick my box, or ... it could be a bit more of an open discussion with a bit more quality to it" Participant 11
Lack of clear strategic national guidance
Limited evidence on interventions that positively impact on pregnancy or neonatal outcomes, coupled with no national guidelines on weight gain in pregnancy and National Institute of Health and Care Excellence (NICE) guidance that was seen to be out-of-date, made it difficult for providers to know what services to commission and how to effectively evaluate current services.
“Our NICE guidelines for weight monitoring, if you want the truth they are so woolly you could never evaluate it, because it doesn’t specifically say who to do what ... It is not a proactive guide in my opinion.” Participant 4
“It would help if current NICE guidelines were appropriate … we were so looking forward to them coming out and … when they did they were very meek and all they were talking about was about myth-busting … These guidelines are totally out of date … they need updating and they need more teeth as well.” Participant 7
One respondent felt it also led to NHS trusts all developing their own thing, when a lot of time and effort could be saved with national level input.
An uphill struggle
Participants felt the public viewed being overweight as 'normal', due to increasing population prevalence. The media propagated image of healthy eating and physical activity being middle-class and too expensive for women from deprived communities also needs addressing to reduce inequitable access.
“there is a perception I think that healthy eating and being physically active is quite a middle-class thing and I think that’s a real issue ... and that’s not helped by the media ... I know from experience when I've delivered sessions and it was about sugar and our children having sugar and she [a mother] was like I don't want my child to be an effing snob by not having sugar.” Participant 1
Work commitments and employers not facilitating access to healthy lifestyle appointments also made it difficult for women to benefit from services. Finally, women wanting to lose weight often undertake it themselves rather than going to a healthcare professional for support to achieve their goal. Group interventions were especially felt to inhibit access for some women.
Need for additional support
There was a call for more pre-conception education, either through schools or a national campaign highlighting the risks to mother and child of being overweight at conception, to reduce the number of women with a raised BMI prior to pregnancy. Incorporating aspects such as weight maintenance and cooking skills into antenatal classes was also suggested.
“ideally you don’t want them to go into pregnancy overweight … I think you start at school because they are potentially your mothers of the future.” Participant 4
“ideally with women who are overweight it would be nice if they lost some weight before they got pregnant, which some of them do, but not all of them because some of them are oblivious!” Participant 2
Training all healthcare professionals prior to registration was felt to be essential, so healthy eating is an integral part of the job from the start.
"Ideally we should be starting with the student midwives in university and then the newly qualified midwives, so that actually, that message is from the start of their midwifery training. ... No, it’s not an extra, it’s not something that they learn afterwards, it’s part of their training." Participant 4
Healthcare professionals who themselves were obese or struggled with their weight were seen to lack confidence to raise the topic with women. Training staff to understand behaviour change theory, personal motivators and to initiate conversations, including those who traditionally don't have a public health role, was seen as crucial to achieve the ethos of Make Every Contact Count.
“We’re looking at things like workforce development and … trying to train up parts of the workforce that perhaps wouldn’t have traditionally been … and sometimes people from different services have better relationships with families, we know that a lot of our housing officers for example, have good relationships with families.” Participant 13
Furthermore, service availability for pregnant women could be improved by training providers on the needs of pregnant women and how to incorporate them into existing adult services.
Maternity service changes
Many respondents wanted further maternal obesity services, either bespoke or the commissioning of programmes such as Slimming World for all pregnant women. Continuity of carer during pregnancy was also desired to assist with conversations and follow-up regarding healthy lifestyle. A desire for personalised trajectories for monitoring weight during pregnancy was also voiced, however this would require services in place for onward referral if women’s weight gain exceeded expectations. Better liaison between midwives and health visitors for women with a raised BMI to prevent weight gain between pregnancies was also called for.
“I think, if we had a secure evidence base that enabled us to say, ‘this is a good trajectory for you’, … similar to ... customised growth charts for plotting a foetus, ... we could follow them ... But, also we’d need to know what to say if somebody’s growth exceeds; what to do, what to offer, where to refer them, how to help them” Participant 7