Abstract
Increasing numbers of women, particularly in high- and middle-income country settings, have poorer health at pregnancy commencement. This is due to a range of factors including older maternal age at first pregnancy, an increase in the numbers of women who have overweight or obese body mass index (BMI) at pregnancy commencement, and more women who have pre-existing mental and/or physical health problems. The most recent UK confidential enquiry into maternal deaths reported that two-thirds (68%) of the women who died in 2014–16 had pre-existing medical problems and 24% pre-existing mental health problems. More than a third (37%) of the women who died in this triennium had obese BMIs and 20% had overweight BMIs. Risk of maternal death was almost five-fold higher among women from black ethnic minority backgrounds compared with white women (RR 4.93; 95% CI 3.27–7.26).
Maternal pre-existing mental and/or physical problems are associated with a range of adverse birth outcomes for the woman and her infant, including pre-eclampsia, gestational diabetes, preterm delivery, macrosomia, and stillbirth.2 Of concern is that some women may experience severe physical illness, for example sepsis or eclampsia, the signs and symptoms of which could lead clinicians to misdiagnose mental illness or, conversely, to miss severe mental health illness due to only considering a woman’s physical health.
A wide range of mental and physical health problems could potentially lead to an adverse pregnancy outcome, a situation which may be compounded by a woman’s social needs. One condition currently raising concerns due to increased prevalence, risk of adverse pregnancy outcome, and life-long impacts on maternal and child health, is obesity. This chapter specifically considers mental and physical co-morbidity among women who have obese BMIs (BMI ≥30, Box 1) at pregnancy commencement. Some of the issues and practice recommendations described will be relevant for the management of a high-risk pregnancy due to other maternal co-morbidity, although it is important to note that ‘risk’ is a relative term. With tailored, planned multidisciplinary care, pregnant and postnatal women with mental and physical co-morbidity – and their infants – may remain well. Conversely, a woman who is initially well may develop health problems which could lead to poorer outcomes for herself or her infant, highlighting the importance of planned and effective antenatal, intrapartum and postnatal care.