Physical and mental health

The CEMACH Maternal Death Enquiry for the period 2000-2002 found that 78 (30%) of the 261 maternal deaths(A) in the UK were in obese women (BMI of at least 30kg/m2); of those women, 20 were morbidly obese (BMI of at least 40kg/m2) [7]. The CEMACH Maternal Death Enquiry for the period 2003-2005 revealed that 64 (22%) of the 295 maternal deaths involved women who were obese; of those women, 19 were morbidly obese [8]. BMI status was not recorded for 15% of maternal deaths in 2000 to 2002, and 22% of maternal deaths in 2003 to 2005.

During the period 2003-2005, as in previous years, thromboembolism was the most common direct cause of death(B), and heart disease (‘cardiac’) was the most common indirect cause of death(C). Of the 41 deaths from thromboembolism, 20 (49%) involved women who were overweight or obese; of the 48 deaths from heart disease, 29 (60%) involved women who were overweight or obese [8].

Obesity increases the health risks to the mother during the antenatal, intrapartum, and postnatal periods. The CEMACH report (2003-2005) summarises the risks related to obesity during pregnancy for the mother as [8]:

• maternal death or severe morbidity
• cardiac disease
• spontaneous first trimester and recurrent miscarriage
• pre-eclampsia
• gestational diabetes
• thromboembolism
• post-caesarean wound infection
• infection from other causes
• postpartum haemorrhage
• low breastfeeding rates

The psychological impact of obesity during pregnancy is relatively unexplored. Issues raised in qualitative research include [9-15]:

• a sense of greater social acceptance of increased body size during pregnancy
• difficulties experienced in adjusting to post-pregnancy body shape
• anxieties experienced by both women and healthcare professionals about raising the topic of obesity during pregnancy
• a lack of awareness of the risks associated with obesity during pregnancy amongst some women
• the potential for a negative impact on the psychological wellbeing of mothers by drawing attention to their weight

Implications for healthcare services

Maternal obesity can lead to the need for additional healthcare due to complications associated with the pregnancy. Resource implications relating to maternal obesity have been identified as [14, 16, 17-21]:

• increases in caesarean and operative deliveries
• admission to hospital for complications
• length of hospital stay
• requirements for neonatal intensive care
• a need for appropriate equipment to manage safely the care of obese mothers

There are also technical issues to consider during pregnancy including difficulties in performing ultrasound examinations, the size of blood pressure cuffs required, issues concerning foetal monitoring, women having reduced awareness of foetal movements, problems encountered with surgical deliveries and equipment, and implications for regional and general anaesthesia [17].

There is a lack of data on the cost of maternal obesity in the UK. The impact of maternal overweight and obesity on healthcare costs has been studied in France, where the cost of prenatal care was higher in women with a BMI of more than 25kg/m2 compared with women with a BMI of 18 to 24.9 kg/m2 [19, 20]. When both pre- and postnatal care were considered, the costs were even higher in women with a BMI of more than 29kg/m2 due to longer hospital admissions [20].

The CMACE audit of obesity during pregnancy aims to provide an overview of current healthcare services available to obese women in pregnancy, and to identify any gaps in service provision. This should lead to a set of recommendations for healthcare providers, commissioners and policymakers on ways to improve the management of pregnant women with obesity, so improving the outcomes for these women and their babies.

A. The death of a woman while pregnant or within 42 days of the end of the pregnancy from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
B. Death resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium) from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.
C. Death resulting from previous existing disease, or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by the physiologic effects of pregnancy.