Healthy weight - local health systems support for pregnant women and young children: research

2. Prevention

This chapter provides a detailed look at how the key stages of local systems from pre-birth to Primary 1 operate in practice. It first covers support for women before they conceive, then goes on to discuss support on infant feeding, weaning, and the remainder of the early years and Primary 1.

In summary:

• Significant challenges of undertaking prevention work in relation to a woman's weight, both pre-conception and during pregnancy, were identified.
• Professionals felt confident, on the whole, supporting pregnant women and new parents around infant feeding, the introduction of complementary foods and healthy lifestyles during toddler and pre-school years.
• School nurses felt they were less involved in preventative work relating to child healthy weight since their role had changed.

Preconception prevention for women

The WHO recognises that targeting women's weight preconception plays a role in efforts to reduce childhood obesity^[36]. However, the significant challenges of doing this type of preventative work were acknowledged by participants in this research. They noted that there is little or no opportunity for contact with the target audience until they are pregnant – they are essentially the 'general public'.

While this was recognised as a challenge, it did not appear to be something that health boards were actively addressing as a priority. One health professional did, however, mention services accessible to adults more widely, whereby primary care professionals could refer people onto physical activity programmes. It may be that these more general services are available across other health boards, but were not mentioned as part of the research.

There was a view that there needed to be more of a drive on the role of healthy weight in fertility and pregnancy, at a national level. It was suggested this could include covering it as part of sexual health education in secondary schools.

As things stand currently, the first time at which health boards are able to intervene before women become pregnant is when they are referred to services due to fertility problems. This type of intervention could take the form of dietician referral (to qualify for IVF); goal setting and motivational sessions; or a twelve week NHS weight management programme.

The other opportunity identified for undertaking preventative work pre-pregnancy was engagement with postnatal women who may be planning future pregnancies. Indeed, one midwife described a particular need for postnatal intervention, having seen a pattern of pregnant women presenting with higher BMIs in subsequent pregnancies.

Another area I think we fail with is recurrent pregnancies. A woman comes with her first pregnancy, BMI is 27, a year later, her BMI is suddenly 33, then her third pregnancy 38 – and that support for – not pushing women to get back to their pre-pregnancy size, but how do you support that.

Midwife

Again, this type of intervention tended to be discussed as something under consideration rather than services currently in place. However, one midwife did report that she would always speak to postnatal women about looking to improve future pregnancies, while another board was offering a postnatal programme to women who have had gestational diabetes, aiming to prevent the development of type 2 diabetes. Their evaluation had shown positive results, with the education received via the programme helping to motivate women to make changes that reduced their need for medication.

Pregnancy

In relation to a woman's weight in pregnancy, the primary focus was not on prevention but instead on identifying that there is a high BMI, managing any associated risks in pregnancy and minimising weight gain. This is discussed fully in Chapters 3 and 4. However, it should be noted that some of the approaches and interventions described in these later chapters were also considered to have a preventative element – for example, gestational diabetes interventions, given the links with type 2 diabetes and childhood obesity. Midwives also felt that the information and support on healthy lifestyles they provided universally to pregnant women had a preventative element, both for the women and for the child in the future.

Area for consideration (local health board level):

Increased focus on prevention at the preconception stage – and on prevention among pregnant women more generally

Infant feeding

The provision of information on feeding babies in the early weeks and months and, in particular, support and encouragement to breastfeed was seen as a key preventative strand both during pregnancy and postnatally. Benefits for both the child's future weight and the mother's weight were highlighted. Provision was often discussed in the context of the UNICEF Baby Friendly Accreditation^[37], including standards, training for health professionals and assessment of progress, about which participants were very positive.

Increasing breastfeeding rates remained a priority. However, there had also been a move towards widening out the information and support on infant feeding to incorporate advice on responsive feeding, regardless of how babies are fed. This approach is also part of the UNICEF Baby Friendly Initiative and is described below.

Midwives played a key role in the provision of information to inform women's feeding choices during pregnancy while health visitors were the main group supporting them postnatally, as part of the UHVP. This core provision is discussed first, before going on to discuss additional support.

Core provision

During pregnancy, the provision of information and support on infant feeding tended to be provided through both routine midwife appointments and antenatal parent education classes. Midwives started discussing feeding options at an early stage, with one describing breastfeeding as something she would 'drop into conversations' whenever she could. Midwives talked about their role in terms of helping women make an informed choice about feeding and normalising breastfeeding. They felt confident in this area of their work and did not identify any specific training needs. Public health professionals spoke positively about the additional training available to midwives as part of the UNICEF Baby Friendly initiative.

Health visitors described supporting new mothers with feeding choices from their early visits. They were clear on the benefits of breastfeeding and would encourage and support women who were doing so to continue. They also described discussing feeding in relation to weight and height centiles from the outset, showing parents where their baby was and the curve they would expect them to follow. As well as helping parents to understand their babies' growth and be reassured they were getting enough milk, they felt these early discussions made it easier to raise any future concerns about weight.

Responsive feeding advice was a move away from the idea of having a feeding routine and, instead, feeding on demand. Health visitors described: explaining to parents that their babies' tummies can be stretched by overfeeding; helping them to tune into their babies' hunger cues, encouraging feeding little and often (and explaining that this may include during the night); advising them to feed their baby upright and to allow them to pause during feeds; and explaining that babies don't need to finish their bottles. They would also advise parents against using 'hungry baby' milks^[38]. The extent to which parents were receptive to this approach varied and is discussed below.

We have discussions around appropriate types of milk to use, quite a lot of parents can be keen to move on to hungry baby milk quite early because they want them to sleep longer and things like that and we kind of discourage that.

Health visitor

As part of the FNP^[39], family nurses provided support to their clients on breastfeeding and responsive feeding both during pregnancy and during the early stages after their baby was born. Due to the nature of the programme, they were able to provide more intensive support than midwives and health visitors. They described linking their discussion on feeding to attachment theory, explaining that, due to their bond with their baby, they (rather than grandparents, for example) would be best able to recognise their babies' hunger cues.

Yes, I will say that our clients are really interested in information on responsive feeding, where it can be more difficult is where the voice of their parent or grandparent or supportive adult, who hasn't really been brought up that way, they kind of maybe struggle with that a wee bit more. Alongside that is their work within attachment. So, actually, if we can support our client to be the main caregiver and support that early attachment then they are responding much better to the baby cues. So, they gain in confidence, so actually their ability to read their baby and they feel confident then they are not reliant on their own parent.

Family nurse supervisor

Additional support for breastfeeding

Across health boards, there were a number of other ways in which breastfeeding was supported. These included:

• breastfeeding champions within midwifery teams who provided support to their colleagues and kept teams up to date on new information/guidance
• support for new mums on post-natal wards
• support provided by third sector organisations
• peer support
• (mentioned in one health board) work with other parts of the system including commitments from local authorities to have breastfeeding friendly cafes and restaurants, workplaces and schools (by teaching it at that stage)

• (mentioned in one health board) a breastfeeding programme specifically for women with gestational diabetes involving hospital midwives contacting women before their baby is born to show them how to hand express.

While participants spoke positively about the additional support mentioned, they were generally unable to reference evaluations of any impacts on breastfeeding rates^[40].

Challenges

Although practitioners were generally positive about their own knowledge and skills, as well as individual sources of infant feeding support available in their boards, they acknowledged there remained a number of barriers to increasing breastfeeding rates and receptiveness to responsive feeding approaches. They felt that there should be a continued focus on increasing breastfeeding rates as a priority.

Barriers reported included:

• Cultural barriers (both to breastfeeding and responsive feeding), including the influence of grandparents
• A lack of time and funding for greater breastfeeding support
• The COVID-19 pandemic making it more difficult to provide in-person support (although an opposing view was that new mums having fewer visitors and being home more in the early days may actually have helped them to breastfeed)
• Women who want to breastfeed not always being prepared for the fact that it can be difficult
• (for responsive feeding for formula fed babies specifically) Packaging on formula feeding stating the maximum amount per feed, which parents interpret as what their baby should be having. This was compounded by the fact that bottle preparation machines (which many parents owned) only make large bottles, resulting in waste if babies don't drink the full bottle.

Introducing complementary food (weaning)

Weaning is the next key prevention stage. The provision of information and support on weaning was largely undertaken by health visitors (or nursery nurses in one health board) via one-to-one appointments, as part of the UHVP, and appeared to be broadly consistent across Scotland.

Common themes in weaning support included:

• advice to wait until their baby is six months before weaning

• discussing/providing resources at three/four month appointments and then again at eight month appointment (there were health visitors who felt this gap was too long and made an additional contact at six months)
• talking about weaning in relation to family meals rather than foods specifically for babies such as baby rice and porridge
• discussing portion sizes
• advising on healthy eating habits/building health habits for life – and how what they do now is linked to health and weight later in life
• advising on how much milk babies should have during weaning

Resources provided to parents included both national materials (Ready Steady Baby, Fun First Foods, and signposting First Steps Nutrition website) and those developed locally (for example, in one local authority a recipe resource reflecting the foods available in local shops had been developed). Another health board was in the process of developing a child healthy weight app, which would incorporate weaning. Health visitors also had their own crib sheets and resources such as healthy food plates, a visual desk stand on portion sizes, an eat well guide and physical activity guides to use in discussions with parents. Again, both national and locally developed resources were mentioned.

It was noted that, since the introduction of the UHVP, weaning support had moved from being group based to one-to-one. In some cases, group based weaning support still existed, particularly in more deprived areas (e.g. in early years centres), but tended to be delivered by others such as community food workers. In line with this, there were health promotion professionals who were delivering training on weaning/healthy lifestyles to those in other sectors, for example those working in family/Surestart centres and in early years settings, to enhance the support they can provide.

The Family Nurse Practitioner interviewed talked about the intensive support on weaning provided as part of the programme. While they covered the same themes as health visitors, they were able to provide additional support. This included teaching their clients how to make healthy meals such as soup and going food shopping with them to show them nutritious options and ways to buy reduced fruit and vegetables. This was considered particularly important given the financial barriers they generally faced.

On the whole, health visitors were confident in the current information and support they were providing on weaning and felt they had the necessary training and resources to do so. In addition to the training received as part of their health visiting qualification, some health visitors had received other training, such as capacity building or motivational interviewing training, which they were able to draw on. There were some slight exceptions to this. For example, one health visitor felt the information she was providing was more focused on safety and routine rather than approaches such as baby led weaning and another would have liked more information about what further support is available for parents.

Health visitors noted that the extent to which parents were receptive to advice on weaning varied. There were parents who health visitors found very difficult to engage. Pressure from peers and grandparents to wean before six months was perceived to be one of the main barriers, although there was some suggestion that this was improving. The fact that packaging on baby foods often states it is suitable from four months also hindered getting across the message that they should wait until six months. As with all the work they delivered with families, health visitors also acknowledged that families were often facing challenges, for example living in poverty, that affected their ability to take on board and implement advice.

On the other hand, health visitors described this as a time when parents could be particularly motivated to make changes, wanting to do the best for their young baby, and that they were particularly receptive to advice. Family nurses also noted that their clients were generally receptive to their advice on weaning.

A lot of them are very grateful, yes, and a lot of our clients will actually say to their mum, you know, this is my baby, and this is what I'm going to do, because my family nurse has suggested this, so it can be something that they become quite passionate about.

Family nurse supervisor

Health visitors and health promotion professionals identified the following as being particularly important to continue or start in order to engage parents with weaning:

• Ensuring that support is positive and achievable, leaving parents feeling empowered to make changes. As an example, this might involve focusing on small changes such as suggesting adding some frozen vegetables to their current meals rather than making very different meals.
• Providing more focused advice rather than generic 'eat healthy' messages. It was hoped that the planned introduction of training in the HENRY programme^[41] would help with this.

There was also some enthusiasm for the continuation/re-introduction of group weaning sessions as they were felt to stimulate discussion more than one-to-one health visitor appointments.

One health visitor discussed the role and influence that budget supermarkets can have in the form of offering their own, more affordable, brands of additive-free baby food pouches and in making popular weaning books more accessible to those who wouldn't normally buy them, by stocking them as part of baby events.

The influence of social media was also acknowledged, with a public health professional suggesting her health board could make more use of platforms such as Facebook to get their messages out.

Beyond weaning

Health visitors described continuing to discuss healthy diets and lifestyles at subsequent UHVP appointments. Specifically, this tended to include: the family's diet; portion sizes; foods that may contain hidden sugars; physical activity and screen time. There were also health visitors and public health professionals who talked about the specific role of milk overconsumption, post-weaning, in obesity. They noted the importance of covering this in the 12-15 month appointment.

Thirteen months, we would be actively encouraging exercise and talk a bit about screen time, and also go over milk requirements as well, because quite often some babies are still having quite a lot of milk as well as three meals a day.

Health visitor

Similar to their experiences of supporting parents with the weaning stage, health visitors generally felt confident about the advice they were providing at this stage. One raised the point of wanting to ensure that health visitors were using the same terminology (consistency is discussed in Chapter 5) while another noted that parents of fussy eaters tended to want advice and she would like more information on what is available to them.

Outwith the support provided by the health system, partner organisations (local authorities, childcare providers and third sector organisations) were also involved in supporting healthy lifestyles for toddlers and pre-schoolers. It appeared that physical activity programmes for this age group were not, however, currently commonplace across Scotland. One board had a particular focus on prevention which had started in the school setting and been more recently introduced for pre-school children. Their tier 1, universal programme, offered six weeks of sessions, designed around behaviour change theory and incorporating both physical activity for the child and the provision of advice on healthy habits for the parents. It was delivered via other services such as local authority leisure facilities and nursery settings but had been on hold since the COVID-19 pandemic. Another board was considering extending the prevention programme currently run in schools to include pre-schoolers, while others had active play sessions delivered via nurseries or third sector organisations.

Prevention in Primary 1

School nurses did not feel their role allowed them to undertake a great deal of preventative work. The main point at which they had contact with Primary 1s in this capacity was the Primary 1 health review^[42] (described in more detail in Chapters 3 and 4), although in some boards these were undertaken by healthcare assistants. When they visited schools to undertake these, they tended to include a talk with the class about healthy eating behaviours, dental health and physical activity.

Although the measurements were undertaken in Primary 1, there was little distinction made between Primary 1 and other year groups when school nurses and health promotion professionals spoke about prevention work in schools. Given the other demands on their time, prevention work in relation to healthy weight was not generally high priority. They spoke about a change in role^[43] over recent years meaning that, on the whole, they no longer visited schools (other than the short talk as part of the Primary 1 measurements) to speak to pupils about healthy eating. A school nurse in a case study board which appeared to be particularly focused on prevention did, however, still make visits to schools to talk to pupils about healthy diets, physical activity and sleep. School nurses in other boards could see the benefit in being more involved in health promotion, including work with both pupils and parents and support for teachers, but did not feel their current job description and caseload allowed for this.

School nurses could do things like coffee mornings at schools where they can offer parents advice on topics like sleeping, eating and anxiety but doing that is dependent on how busy you are. Some school nurses just have too much else.

School nurse

Area for consideration (national level):

Consider whether there is merit in increasing the remit of school nurses in relation to child healthy weight (currently very minimal)

There were examples of preventative work being delivered in schools by other parts of the system, with input from those working within health promotion. These included:

• links with leisure service to provide afterschool clubs offering physical activity as well as family food skills
• development of approaches, resources and training for teachers to deliver preventative work
• introduction of elements of the HENRY programme.

Another board had plans to change their approach to the Primary 1 weight and height measurements to a less targeted programme, due to their current method of engagement not being felt to work well. Rather than sending letters to only those parents whose children were identified as having a high BMI, they planned to send letters to all parents offering them the chance to take part in a family programme focusing on healthy eating and physical activity. The intention was that this more universal approach would reduce any stigma parents felt from being referred. An initial screener would still be used to determine whether families were likely to benefit from the intervention.