Perspectives on risk and obesity: Towards a ‘tolerable risk’ approach?

Abstract

NHS trusts are required to demonstrate the actions they are taking to reduce the risks for obese pregnant women. To this end, health professionals often use the body mass index to identify women at risk. While the aim of risk management is to increase safety, taking an ‘absolute risk’ approach of considering risk in terms of what can go wrong is arguably narrow and does not take into consideration individual factors. This article considers an alternative approach to risk management in maternity services—‘tolerable risk’ management in which midwives can help to successfully address the issue of maternal obesity through a partnership approach based on women's individual needs.

“Everything is revolved around me being heavy … it’s always, always spoken about.” Qualitative experiences of weight management during pregnancy in women with a BMI of 40kg/m2 or above

“…Health services' focus on risk management, rather than taking individual factors into account, coincides with an increasingly prevalent medical model of care for these women. This model views pregnant women with obesity as needing to be 'managed' by obstetricians [43,44], as professionals becoming progressively interventionist in an attempt to protect themselves from litigation should an adverse outcome occur [45]. However, this focus on risk is at odds with women's own focus, as clinical outcomes only cover a subset of the factors they consider to be important during pregnancy [46].…”

“…A systematic review of patient reported outcomes has shown that women with obesity viewed adequate healthcare provider support and an emphasis on their emotional wellbeing as key elements of care [46]. A move towards a social model of maternity care is argued for which integrates women's physiological, psychological and spiritual wellbeing; with women and professionals working in partnership to support women to focus on health promoting activities [44]. The social model views the three most significant factors for women during pregnancy and childbirth to be choice, continuity of care and control [47], with maternal satisfaction an important outcome of pregnancy, not just a live, healthy mother and infant [48].…”

Health policy and its unintended consequences for midwife-woman partnerships: Is normal pregnancy at risk when the BMI measure is used?

“…A salient feature to emerge from obesity-targeted policies is an explosion of weight-focused discourses leading to increasing surveillance and focus on risk in contemporary maternity care. McGlone and Davies (2012) maintain that the BMI calculation was never intended for individual diagnosis, yet the pre-pregnant BMI has emerged as the standard measure to label women with a high BMI as "at risk" (McGlone & Davies, 2012) and as a singular tool in "helping midwives to help obese pregnant women towards a healthier pregnancy" (Poston, 2017). The use of a standard BMI measurement fails to factor in women's complex histories, capacities and sociological characteristics.…”

An exploratory Interpretative Phenomenological Analysis (IPA) of childbearing women's perceptions of risk associated with having a high Body Mass Index (BMI)

“…The NHS Litigation Authority Clinical Negligence Scheme stipulates that NHS Health Boards/Trusts must demonstrate actions taken to reduce risks for obese women (McGlone and Davies, 2012) , which are based upon joint CMACE/RCOG Management of Women with Obesity in Pregnancy guidelines (Modder and Fitzsimons, 2010) . This document provides guidance about how to manage these women throughout their pregnancy journey, with an accompanying recommendation that women with a BMI (>35kg/m 2 ) give birth in a 'consultant led unit.'…”