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

Abstract

A CorrespondingBackground: Little attention has been paid to understanding the unintended consequences of health policy for midwife-woman partnerships. The measure of Body Mass Index (BMI) is one such policy example which has become established in contemporary midwifery practice as a tool for assessing pregnancy risk. The universal acceptance of BMI creates an unsettling paradox for midwives concerned with promoting woman-centred practice. The increasing focus on BMI is challenging for midwives as they navigate ethical tensions when directed to undertake practices which have potential unwonted consequences for the midwife-woman partnership. Aim:The aim of the study was to explore the use of an indicator, using BMI as an example, to provide an international perspective on obesity prevention policy and maternity care provision.Method: A comparative case study approach was taken, using descriptive cross-national comparative analysis of obesity prevention policy, weight management guidelines and midwifery models of care in New Zealand and Scotland.Discussion: Despite promoting healthy weight gain in pregnancy, New Zealand and Scottish health policies may be missing health promotion opportunities. Focusing on BMI in maternity, per se, should not prohibit other assessment of lifestyle issues or delivery of services based on individual needs, capacities, histories and sociological characteristics. Relying solely on pre-pregnancy BMI as a marker of health in all women has remained relatively unchallenged and, as such, constitutes a policy problem because it occludes the factoring in of other lifestyle issues that may significantly alter individual risk status. Further, such an assessment of risk status is ideally arrived at within a partnership model of maternity care, rather than reliance on an a priori medical test. Conclusion:Decontextualised policies are challenging for midwives where medical and midwifery values are in conflict. Policy which fails to consider the multiple and complex contexts of women's lives is confronting for midwives as they attempt to re-articulate the meaning of woman-centred practice. Furthermore, BMI as a tool may be ineffectual. The current focus on BMI in policy and practice requires re-consideration.

The paradox of contemporary midwifery practice: Promoting an out-of-hospital birth setting

“…More research is needed to understand how midwives embody paradox in practice, how this can be taught or mentored, and how the maternity system might facilitate more midwives to be confident managing it. some women (Knox, Crowther, McAra-Couper, Gilkison, 2018). The "ever narrowing window of normality" (Scamell & Alaszewski, 2012, p. 207) has been attributed to risk categorisation and management where normality could only be defined by midwives in a study, as the absence of imagined unwanted features, despite their low probability.…”

An exploration of midwives’ perspectives on the provision of maternity care to women with an increased BMI during pregnancy and childbirth in NZ

“…Research into obesity in pregnancy often ignores interrelated social factors that impact on women's lives whilst continuing to perpetuate misinformed damaging messages about weight (String & Bacon, 2020;Warbrick et al, 2019). Knox et al (2018) acknowledged the unsettling paradox and ethical tension that midwives in NZ encounter with the use of the medically initiated BMI tool which challenges the midwife partnership by its neglect of holistic lifestyle factors which ignore the complexity of women's lives.…”