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March 2014 • Volume 5 • Number 2

STANDING OUT FROM THE CROWD • LEADERSHIP • ANOREXIA: IT’S NOT JUST ABOUT FOOD

• A DAY IN THE LIFE OF A MIDWIFE VOLUNTEER IN CAMBODIA

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Contents 5

From the editor

MIDIRS Update

Leadership Claire Homeyard Should midwifery leadership development programmes be based on the premise that leadership can be taught?

Not alone

Maternity News

Serendipity

Hyperemesis gravidarum Caitlin Dean A patient experience of hyperemesis gravidarum and how the midwife can support her care.

A day in the life

Anorexia nervosa: it’s not just about food

Resource Reviews

Global Health Media Project Jennie Roe An inspirational organisation working to fill the knowledge gap.

International Women’s Day Michelle Anderson A day when women all across the world come together to celebrate women’s social, economic and political achievements.

For Your Portfolio

Michelle Anderson Standing out or standing in?

Round-up of the latest research and articles from over 400 journals.

Emma Calvert A midwife discusses the benefits of sharing practice errors.

Current news relating to birth and maternity issues.

(Or, look at what we found in the basement!)

Angela Oxley A day in the life of a volunteer midwifery adviser in Cambodia. Michelle Anderson

Essentially MIDIRS Editor provides an overview.

MIDIRS connects you to the world of maternity books and resources.

Or just for fun.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

From the editor: Standing out or standing in? By Michelle Anderson patient/client care. Leadership within the context of midwifery is important to consider as over the years roles have evolved positively, especially with the introduction of consultancy posts. Therefore, it is imperative that midwives understand not just the theoretical concepts of leadership skills, but also the personal qualities required to stand out from the crowd and pioneer excellence in midwifery care.

Standing out from the crowd is the theme for this edition of Essentially MIDIRS as we have a diverse selection of articles that reflect this concept. The first is written by Claire Homeyard who evaluates whether leadership in midwifery can be taught effectively through leadership development programmes. Poor quality leadership has been identified as a contributory factor for serious failings in many areas of the NHS; the Mid Staffordshire inquiry is just one example of this. Implementing programmes that will develop and nurture leadership skills is paramount in the crusade to help improve public and

To consider one aspect of this month’s theme more closely, I will put forward the question of whether it is better to stand together as a crowd or to stand out as an individual. When crowds of people unite their voices, a collective, becomes stronger. The collective stands out from the larger crowd not just as one person, but as many. Søran Kierkegaard (1813-1855), a classical philosopher, disagrees with this view by suggesting that real truth is lost in a crowd because we lose the ability to maintain our own intellectual autonomy (Kierkegaard 1978), in short he is saying we become followers. However, whilst there may be some truth in this, surely one has made an individual decision to join forces with the crowd in the first place, thus ensuring

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

Not alone By Emma Calvert

I have been a qualified midwife for just over two years and still feel that the weight of responsibility a midwife carries is huge. It is a profession that requires so many attributes on both a mental and physical level in order Emma Calvert to provide the best evidence-based care possible to the woman and her family. The first few years as a practising midwife (and maybe even a bit longer after that!) are about learning and gaining experience. Whilst reflecting over the last two years in practice a thought suddenly struck me, that during this time I had assumed I was completely alone in my fears, silly insecurities and little mistakes I have made throughout the course of difficult shifts! I should make it clear at this point, that the mistakes I am referring to have not caused harm or contravened the NMC code of conduct; I feel it is important to distinguish between these and more serious errors that may occur. Serious mistakes should, of course, not be treated lightly and an appropriate course of action should always be taken. Although many of the mistakes I have made were small and easily forgiven, at the time they felt monumental, leading to more than one occasion of rashly announcing to friends and family that I would be leaving the midwifery profession! One ‘mistake’ I will never forget actually happened when I was a student but has lived with me throughout my time as a qualified midwife. It happened during an antenatal clinic as I was about to undertake a vaginal examination. Following two

previous successful examinations I had started to gain confidence with my technique and therefore felt a little more positive when my mentor asked me to attempt a cervical sweep; I took my new found assurance and went ahead. Unfortunately this confidence led me to not fully look when commencing the examination. This, coupled with the fact that my mentor had encouraged the woman to tilt her pelvis using her fists, meant I very nearly attempted to insert my fingers into, to put it bluntly, the wrong hole! Cue both the woman and my mentor abruptly (and quite rightly) stopping the examination. I turned bright red, apologised profusely, and promptly decided I would never perform a vaginal examination again without looking very carefully on where to begin! Something I should have thought about more carefully from the onset! The issue of mistakes surrounding vaginal examinations is one which I am sure we have all experienced. The level of subjectivity involved in such examinations can lead to small discrepancies in assessing dilatation, discrepancies which often make no difference to the pathway of a woman’s care, although may sometimes change the management if two professionals differ in their findings at the crucial point between early labour and established labour. However, on more than one occasion such an error can lead you to waking in the middle of the night for weeks afterwards, wondering how you could have got it so wrong. The most glaring example of this for me occurred within the first week of work as a newly qualified midwife. I was caring for a woman, who was a gravida 6 para 5 and feeling strong urges to push. In view of her parity I encouraged her to push without first performing an examination. I observed that there was nothing visible after a few contractions, so I gained consent to perform a vaginal examination and found there to be an

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

“I realise that as a midwife I am in an incredibly privileged position; being granted the opportunity to care for, and support women and their families through one of the most exceptional times in their life is amazing” anterior lip with membranes still intact. After pushing involuntarily for around 20 minutes the woman requested me to rupture her membranes; she informed me that she had needed this intervention to progress during all her previous labours. I proceeded to attempt to rupture her membranes but struggled as, having trained in a different hospital, the amnihook was very unlike the one I had used as a student. Having tried and failed to perform the artificial rupture of membranes (ARM) I ventured outside of my room to inform the coordinator. A very nice registrar overheard me discussing my predicament and offered to break the waters for me. After examining, the registrar explained to both the woman and me that she was in fact 4cm dilated and not an anterior lip as I had first thought. I felt absolutely mortified and apologised profusely to the woman. I, once again, found myself considering leaving the midwifery profession. Following this disastrous mistake, the registrar who had so kindly come to perform the ARM, told me a story in which an obstetric consultant had rushed a woman to labour ward having found her to be fully dilated, only to be informed after she was reexamined that she was in fact only 1cm dilated, with a very posterior cervix! The knowledge that a consultant with years of experience could make a similar mistake gave me comfort, and has continued to do so ever since. During a break on an unusually quiet night shift I had the chance to speak tentatively to some of my colleagues about a few of my recent errors. I revealed these mistakes with trepidation and with concern, wondering if I would be mocked or judged. However this concern quickly vanished when one by one my colleagues disclosed their own stories, including delivering babies without gloves on because they had been caught off guard, or rushing women from triage to labour ward believing they were pushing, only to find they simply had a urinary tract infection (UTI). These conversations made me realise I was not alone in the accidental errors I have made.

Emma Calvert

Following that night I have always been very honest with my colleagues and students when mistakes are being discussed, and the look of surprise that has often crossed their faces when they realise they are not the only one to have made the occasional misjudgement is priceless. More recently I have attempted to undertake twin monitoring, only to discover after having difficulty picking up the second twin that the woman was in fact only having one baby; I shall blame this on a long run of tiring night shifts. Luckily this gave the woman and her partner a good laugh, and a good story to tell their baby when he or she grows up. I’m happy to say that as of yet I have never followed through with my threats to quit midwifery. One of the reasons behind this has been the incredible support I have received from my colleagues, my family and my friends. It has also been the very generous response from the women I care for, often reacting to small mistakes with humour, understanding and kindness that have reassured me I can continue in this profession. I realise that as a midwife I am in an incredibly privileged position; being granted the opportunity to care for, and support women and their families through one of the most exceptional times in their life is amazing. So through talking with my colleagues and not being afraid to discuss my worries, whilst reflecting on my practice, I will hopefully continue to progress throughout my midwifery career, learning from, and making fewer mistakes along the way. Making errors and small mistakes are part of being human. When writing this article I have had the opportunity to reflect further on the implications of making mistakes in practice. When advising others, I feel the most important wisdom I can impart is never to be afraid of asking questions or asking for help. Also, do not feel afraid of confiding in your peers as I’m sure you will find as I did, that however silly your mistake may seem, you are not alone in making it.

is a midwife working at The Hillingdon Hospitals NHS Foundation Trust. She qualified at the University of the West of England in 2011.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

A day in the life

of a volunteer midwifery adviser in Cambodia Angela Oxley Ever since qualifying as a midwife more than 30 years ago I have wanted to work in a developing country, to experience first-hand the challenges and rewards of working in some of the world’s poorest communities. Prior to volunteering, I was dissatisfied in an NHS management position, yet still passionate about midwifery and providing the best possible care for women. I wanted to return to my passion, and so I decided to volunteer with VSO (Voluntary Service Overseas) — an international development charity that works through volunteers, placing their professional expertise where it will have a lasting impact.

rate is 19 per 1000 births (UNICEF 2011). Roughly 50% of births in Stung Treng take place in the presence of a trained health professional, but the remainder are at home with either a traditional birth attendant or just a relative. On top of the problems they have simply getting to the health centres, women lack confidence in the often junior midwives and worry about how they will be treated. It was my job to help change that by improving procedures and training staff across a range of core areas, including clinical skills and practice, resuscitation, hygiene and infection control.

Health centre entrance by Mekong River With training, advice and support from VSO, I was sent to Cambodia for two years to work in the small provincial town of Stung Treng. The project aimed to improve the standard of midwifery care in the province’s one hospital and eight health centres. The current maternal death rate for the country is 290 per 100,000 live births (UNFPA 2011) and the neonatal death

A typical day in Stung Treng province, Cambodia 0800 I attend the daily meeting in the hospital with all doctors and ward chiefs. The director informs us that only two units of blood remain in the blood bank — both group A; the wages will be two weeks late as no money has yet arrived from the health department; we have run out of magnesium sulphate and normal saline; and the paediatric ward is without any electricity.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

1000 I support a student midwife in delivering a baby. The hands-off technique is alien to midwives in Cambodia. My assurances that it will make no difference to the woman’s perineum are viewed with incredulity, reminding me of British midwives ten years ago. However, skin-to-skin contact immediately after the birth is regular practice and the hospital actually has the UNICEF Baby Friendly award. 1030 Following the birth, a midwife asks if I will watch her suturing using the method I have been encouraging them to use. With encouragement she uses lignocaine — the midwives are reluctant to use this as they believe it may cause heart failure, which is a very rare side effect when larger doses of lignocaine are given accidently IV.

Teaching in Siem Pang health centre

0815 I arrive on the labour ward. A newly qualified midwife is anxious to show me the premature twins that were born the previous night. She has persuaded the dad to fasten the smaller one to his chest while the young mum breastfeeds the other one and, helped by grandma, expresses drops of colostrum onto a spoon for the small twin. I am delighted that this midwife has put into practice the kangaroo mother care I taught in the previous week. 0830 A man and his wife arrive on an old motorbike — he carries her into the labour ward where she has her sixth child ten minutes later. Oxytocin is given for the third stage but after 30 minutes the midwife gently inserts her hand into the uterus and does a manual removal without anaesthetic. While this is common practice here, I stand back as it is not standard practice for midwives in the UK. I just encourage sterile gloves, prophylactic IVi and antibiotics, along with an explanation for the woman. 0930 A young doctor who has been sent from Phnom Penh to work for the next five years in remote Stung Treng arrives to review and discharge postnatal women. So far my attempts to have midwives discharge the women have failed due to bureaucratic constraints. Consequently, today we have 22 patients for just 16 beds. Six women sleep on mats on the floor with their babies.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

1100 Most of the midwives go home or on to a second job, which many have because the wages for midwives are so low. The nine midwives who run the unit have a variety of extra jobs, including baker, market trader and private clinic nurse. Two midwives remain on duty for the next 24 hours: they cover births and emergencies only. The other postnatal women are cared for by relatives, who also bring in food since none is provided by the hospital. 1130 With Thol, my interpreter, I try to explain to postnatal women that they shouldn’t try to heat up their bodies using alcohol drinks, woollen hats and fires, which they do in the belief that it will prevent infection and bleeding. Wearing a woollen hat after giving birth is even common practice amongst the midwives who have had children themselves. The fires and alcohol are still very common in the villages, yet the average temperature in Cambodia is between 25 and 35 degrees. 1200 A woman is carried in by her father. I ask her questions in my basic Khmer — Are you bleeding? No. Are you in pain? No. Do you have a problem? Yes, second baby stuck, first baby born at home six hours ago. After discussion with the young doctor we give a touch of oxytocin and deliver the baby breech in good condition. He weighs 1.9kg and breastfeeds immediately. The outcome could have been so different, but this time the mum and baby were lucky. The first twin, another boy, is thought to be larger but he is 40km away, being cared for by the woman’s sister.

1330 With my interpreter and a rucksack containing teaching equipment, we leave by motorbike to travel 25km on a muddy road with streams running over it to Chamka Leu Health Centre. The temperature is 36 degrees, but I heed VSO’s advice to wear a full helmet as accidents on the rough, unmade roads are frequent. 1430 Covered in mud and dust we arrive at the health centre, a small hut in the middle of the forest where midwives and nurses provide care for the local people, who are extremely poor. The three young midwives are delighted to see us even though two of them were up in the night with a woman who gave birth in the health centre. We discuss this case and they show me the correctly completed partogram, which is a relatively new improvement to care in labour.

feeding well and appear healthy. They will not be routinely checked by a midwife until tomorrow. 1900 I call at the local market on my way home and buy fresh eggs, peppers, onions and courgettes for a tasty egg fried rice. I only buy meat when I can reach the market before 8am as the freshly killed animals sit on a wood plank in the hot market all day with no refrigeration. 2000 I call my 88 year-old mother and my son for a short chat. The internet dongles we purchased work on a top-up basis and make a huge difference to keeping in touch with family. 2100 I go to bed listening to the sound of crickets, geckos and frogs accompanied by drumming from the nearby pagoda.

1500 I demonstrate breech birth and the midwives run through the skill drill. They tell me about a case they had where a baby’s legs came out first and became stuck, leading to the baby’s death. During their one year of training they had learnt about the theory of breech, but had never done skill drills. They are fascinated by the techniques for delivering a breech which becomes stuck. They ask if we can come again to teach them about eclampsia and suturing. 1600 We set off back to Stung Treng town. 1700 I arrive back at the labour ward to hear that a woman has been admitted with an intrauterine death at eight months. The stillborn baby was delivered rapidly and is now in a black plastic bag being given to the father. He hands the bag back to a midwife with a bit of money so that she can dispose of it. I don’t think the mother saw the baby at all. Again I wonder at the cultural differences between Britain and Cambodia. I talk to the midwives about how British midwives would care for the woman and her family in the case of a stillborn baby. They think this would be very strange and not a good approach for Cambodian families. 1800 As I leave for home, the labour ward is quiet. The two midwives are both asleep on a bed in the labour ward office. They have been on duty since 8am and will stay on duty for births and emergencies until the following morning. The women and babies continue to be cared for by their families. Luckily the three premature small babies are all

Teaching suturing at Kbal Romeas health centre

A lasting legacy A big part of VSO’s philosophy is about ensuring that the benefits are long term and sustainable. This is much harder than just teaching and walking away. For example, during my visits to one of the rural health centres in the province, I instructed the centre’s only two midwives in continuous subcuticular suturing technique. We used kitchen sponges tied inside pelvic models and VSO funding enabled the purchase of suturing instruments, needles and training equipment. At my last visit, six months after the teaching, the two young midwives reported having sutured about eight women. They had

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

become confident in the technique and the local women knew they could carry out this procedure effectively, which in turn had increased confidence in the health centre. When midwives from the other health centres heard about the teaching, they also requested it; now most of the midwives in Stung Treng province have adopted the technique. Prior to this, women with perineal tears were usually sent home in the hope that the wound would heal itself. It was an honour and a privilege to contribute to the work of these midwives and exactly the reason why I went to volunteer in Cambodia. Yet there is still so much to be done: Cambodian midwives, supported by VSO volunteer, British midwife Kath Hinchcliffe, continue to strive for registration and formal regulation. Since my time in Cambodia I have returned to clinical midwifery and am once again enjoying work as a practising midwife here in the UK. While we may experience frustrations and challenges, working in Cambodia has enabled me to fully appreciate the education, standards and status of midwives here in the UK. I will always look back on my time as a VSO volunteer — working with dedicated midwives doing their best for women under difficult circumstances — as a humbling and inspiring experience. For more information about volunteering with VSO or to make a donation, visit www.vso.org.uk.

About VSO: International development charity VSO provides health professionals of all backgrounds with the opportunity to volunteer and improve the quality of health care in some of the world’s poorest countries. Volunteering internationally gives health professionals the opportunity to develop new skills, respond to a broad range of challenges, and learn to do more with less. Volunteers don’t just save lives; they pass these life-saving skills on so that long after they return home, health workers in developing countries are able to make a large scale difference to people’s lives. VSO is currently recruiting for midwives, doctors, nurses and health managers to help tackle urgent challenges in maternal health care in various countries across Africa and Asia, including Malawi, Ethiopia and Sierra Leone. Generally volunteers will need two to six years of relevant professional experience, a professional qualification and some experience of supervising, mentoring or project management. VSO further supports volunteers by providing them with comprehensive training and covering the costs of flights, accommodation and a basic living allowance. To find out more about the wide range of roles in various specialities across more than 30 developing countries and how to volunteer, visit www.vso.org.uk

References UNFPA (2011). Cambodia. http://tinyurl.com/nnwjwnk [Accessed 27 January 2014]. UNICEF (2011). Cambodia. http://tinyurl.com/arr9k5 [Accessed 27 January 2014].

Angela Oxley is a qualified nurse and midwife with more than 30 years’ experience. In 2011 she volunteered with VSO for two years as a midwifery adviser in Cambodia. Since then she has since returned to clinical midwifery with a special interest in promoting normality in a busy consultant unit. Angela has worked as a community midwife and a specialist midwife, helping to lead the change from a small GP / consultant unit to a standalone midwifery-led unit. In 2007 she became head of midwifery before moving into obstetrics and gynaecology management. She holds a masters in midwifery and has presented on MLU and water birth research to national units and at the ICM.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

Anorexia nervosa:

it’s not just about food Michelle Anderson, Editor, Essentially MIDIRS

norexia nervosa is a common eating disorder in young women with a mean yearly incidence of 20 per 100,000 females (Morris & Twaddle 2007). The condition is most likely to develop during adolescence with an average age onset of 15 years (Morris & Twaddle 2007). The age range of this disorder can vary between 12-35 years, thus predominantly affecting women who are at the peak of their reproductive cycle (Lowes et al 2012). Symptoms of anorexia cause the individual to have a morbid fear of fatness and an intrinsic belief that self worth is solely related to weight, shape and physical appearance (Micali 2008). Body dysmorphia is a common trait of anorexia with individuals constantly over evaluating their weight, which leads to extreme self imposed weight loss (Morris & Twaddle 2007). Due to the common nature of anorexia nervosa it is not unreasonable to assume that, at some point during their career, midwives will care for women suffering from this condition; therefore, it is important to have a basic understanding of this illness.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

Anorexia nervosa: it’s not just about food

“Unplanned pregnancies can be distressing enough for women who are not suffering from a psychiatric disorder; however for a woman with anorexia the consequences may be extremely harsh”

A complex condition Multiple theories have been put forward in an attempt to gain a greater understanding of what might trigger the onset of anorexia. Media influences are thought to play a major contributing factor towards the development of this condition (Hoggard 2005); this is predominantly due to how western societies use media to portray cultural expectations of beauty and success. Psychological approaches may help explain this further by using theoretical concepts. Sociocultural theory asserts that a thinner body image ideal is propagated throughout western societies, consequently encouraging women to view their own body shape negatively (Morrison et al 2004), whilst social comparison theory suggests that individuals are motivated to evaluate their own opinions and abilities, which may lead them to engage in social comparison with others (Festinger 1954). There are various studies that have shown support for these theories. Levine (1996) found that 47% of girls attending school in the USA reported wanting to lose weight due to comparisons with magazine images, whilst an additional 69% of girls reported magazine pictures influenced their idea of the perfect body shape. An interesting article in The Observer (Hoggard 2005) refers to the effect of media in societies detached from western ideals; it quotes the author Susie Orbach who refers to a study

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

that describes how television was first introduced to the island of Fiji in 1995 with many programmes being imported from the USA and reflecting western ideals of beauty. Three years after this event, 11.9% of teenage girls were diagnosed as suffering from some type of eating disorder, whereas, previously, disorders of this kind were practically unheard of (Becker 2004). Although we cannot say for sure that televised images portraying western ideals of attractiveness was the sole reason for the increase in prevalence of eating disorders in Fiji, a positive correlation between these two variables can be observed. Other theories suggest that anorexia may be triggered by family conflicts, academic pressures and developmental challenges (Morris & Twaddle 2007). The condition has also been associated with low self esteem, depression, anxiety, self-harm and obsessive compulsive disorder (Sullivan et al 1998). It is more commonly found in families with obsessive, perfectionist and competitive traits (Morris & Twaddle 2007). Obsessive, ritual behaviour patterns may result in repeated weighing, measuring and mirror gazing in order to reassure the individual that they are not gaining weight (Morris & Twaddle 2007). There is some suggestion that anorexia may be associated with autistic spectrum traits (Odent 2008). Wentz et al (2005) found that 23% of female patients with severe eating disorders had symptoms similar to those of autistic traits. Southgate et al (2008)

Anorexia nervosa: it’s not just about food

support this notion, postulating that ‘people with anorexia find it difficult to change self-set rules; they see the world in close-up detail’. This is typical of individuals with autism who find it difficult to change habitual patterns of behaviour. Some researchers propose that risk factors for anorexia occur in the perinatal period. One Italian retrospective study found that the risk of developing anorexia nervosa increased with the total number of obstetric complications (Favaro et al 2006), whilst a large Swedish study found the most significant risk was cephalohematoma at birth, along with the use of forceps or ventouse (Cnattingius et al 1999). However, it is suggested that further large scale longitudinal studies are needed in this area to fully validate these findings. Anorexia has the highest rate of mortality compared to any other psychiatric condition (Morris & Twaddle 2007). In the USA, 1000 women die from this illness annually, with the most common immediate cause of death being suicide (Lowes et al 2012).

Risk factors for anorexia nervosa

• Familial/genetic Perinatal

• Prematurity • Small for gestational age • Birth trauma • Pre-eclampsia • Placental infarction • Neonatal cardiac problems • Hyporeactivity Psychosocial

• Low self-esteem • Childhood sexual abuse and neglect • Family dysfunction • Alcohol and substance misuse (Lowes et al 2012)

Classiﬁcation of anorexia nervosa

to maintain bodyweight at or above 85% of the ideal body weight • Refusal for age and height • Intense fear of gaining weight or becoming fat, even though underweight Disturbed perception of body weight or shape with undue influence of • body shape in self-evaluation, or denial of the seriousness of the low body weight

postmenarchal females, amenorrhea for at least three consecutive • Inmenstrual cycles, in the absence of other courses (American Psychiatric Association 1994)

Eﬀects of anorexia nervosa on pregnancy Antenatal Severe weight loss may result in changes to the menstrual cycle, such as irregular periods or amenorrhea. Women who suffer from anorexia may associate amenorrhea with not needing to use contraception (Lowes et al 2012); this may lead to unplanned pregnancies. Unplanned pregnancies can be distressing enough for women who are not suffering from a psychiatric disorder; however for a woman with anorexia the consequences may be extremely harsh. Hoffman et al (2011) posit that unplanned pregnancies may impact on the opportunities these women have to establish critical nutrition and emotional support to help them manage the psychological and physical demands of childbearing. Another factor to consider is that women who have irregular menstrual cycles may not be aware they are pregnant, consequently leading to late booking; this may impede the amount of care and support received by the woman during the antenatal period, with the increased possibility of leading to adverse perinatal outcomes (Lowes et al 2012). Many women try to conceal their eating disorder and may not freely disclose their condition to midwives at booking (Stewart et al 1990); therefore it is important to ensure that, if an eating disorder is suspected, the appropriate screening is undertaken.

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

Anorexia nervosa: it’s not just about food

“In the USA,

1000 women

die from this illness annually”

Screening

Nutrition

NICE recommends screening and antenatal booking for eating disorders among high risk women (NICE 2004), deﬁned as those with:

There are suggestions that women with anorexia improve their eating habits during pregnancy (Shaffer et al 2008). Blais et al (2000) reported that women with either anorexia or bulimia improve during pregnancy by demonstrating less restrictive behaviour and less binging or purging. Another study found that 44-75% of women did take nutritional supplements during pregnancy, possibly suggesting they were keen for their baby to receive adequate nutrition (Allen 2005).

• Low body mass index • Concern about body weight or image, although not overweight

• Gastrointestinal symptoms (more than morning sickness) • Physical signs of starvations, more than repeated vomiting • Psychological problems Suggested screening questions

• Do you think you have eating problems? • Do you worry excessively about your weight? The SCOFF questionnaire is also a useful screening tool to help health care professional detect eating disorders (Luck et al 2002, Shaffer et al 2008, Lowes et al 2012). SCOFF Questionnaire

• Do you make yourself Sick because you feel uncomfortably full?

• Do you worry you have lost Control over how much you eat?

• Have you recently lost more than One stone in a 3-month period?

• Do you believe yourself to be Fat when others say you are too thin?

• Would you say that Food dominates your life? 44

Essentially MIDIRS • March 2014 • Volume 5 • Number 2

It has been suggested by some theorists that pregnancy is the motivation for women to change their eating patterns (Lowes et al 2012), therefore working closely with multidisciplinary teams and ensuring good communication and detailed care plans to achieve this are paramount. This is especially important to consider as one piece of qualitative research found that some women had a constant mental battle to prevent themselves from losing control with eating behaviours (Shaffer et al 2008), suggesting that although women with eating disorders may aim to modify their eating patterns during pregnancy, it is not an easy thing to preserve. In order to maintain a form of control over their changing body without using food to do so, some women may undertake high levels of exercise during pregnancy; this is defined as more than one hour of vigorous physical activity per day (Hoffman 2011). There is no risk with moderate exercise during pregnancy, providing the woman is maintaining healthy eating patterns and does not over exert herself.

Anorexia nervosa: it’s not just about food

Intrpartum Pregnancy outcomes Lowes et al (2012) posits that as labour is a rigorous, energy-consuming process good hydration should be adhered to by the woman and if necessary fluids should be administered if dehydration becomes apparent. Encouraging the woman to consume a light diet of carbohydrates and high energy drinks will help maintain the energy needed to progress through labour; however, this does depend on how adequate the woman’s nutritional intake was antenatally. It is suggested that women with a lower body weight are more at risk of adverse obstetric outcomes (Micali 2008). Lowes et al (2012) suggest that current literature reveals a higher incidence of caesarean section among women with anorexia; however, it is recommended that a caesarean section should only be performed for maternal and fetal indications, and that a vaginal delivery should be the aim (Lowes et al 2012). There has also been interest in how anorexia may affect the neonate. Franko et al (2001) found that women with anorexia had infants who were more likely to be small for gestational age and lower in birth weight. A more recent large scale study (n=35,929) carried out in Sweden shared similar findings, and also observed a higher incidence in prematurity and microcephaly (Bulik et al 2009).

about being overweight and what other people would think of them. Some women reported a return or worsening of their eating disorder symptoms (Shaffer et al 2008). Lowe (2012) posits that rapid hormonal changes, lack of sleep and the stress of coping with motherhood can compound the risk of symptoms returning. It is important that midwives remain vigilant in providing seamless care for the mother and baby during the postpartum period. Extra support should be given to encourage bonding and breastfeeding (Lowes 2012). The importance of good nutritional intake for breastfeeding should be stipulated as this may encourage the mother to maintain healthy eating patterns. It is also imperative that the midwife ensures a multidisciplinary team is fully in place before discharging from midwifery care to ensure the woman remains fully supported. This should include good communication with the health visitor and mental health team.

Becker AE (2004). Television, disordered eating, and young women in Fiji: negotiating body image and identity during rapid social change. Culture, Medicine and Psychiatry 28(4):533-59. Bulik CM, Von-Holle A, Siega-Riz AM et al (2009). Birth outcomes in women with eating disorders and the Norwegian Mother and Child Cohort Study. International Journal of Eating Disorders 42(1):9-18. Cnattingius S, Huttman CM, Dahl M et al (1999). Very preterm birth, birth trauma, and the risk of anorexia nervosa among girls. Archives of General Psychiatry 56(7):634-8. Favaro A, Tenconi E, Santonastaso P (2006). Perinatal factors and the risk of developing anorexia nervosa and bulimia nervosa. Archives of General Psychiatry 63(1):82-8. Festinger L (1954). A theory of social comparison processes. Human relations 7:117-40. Franko DL, Blais MA, Becker AE (2001). Pregnancy complications and neonatal outcomes in women with eating disorders. American Journal of Psychiatry 158(9):1461-6. Hoffman ER, Zerwas SC, Bulik CM, (2011). Reproductive issues in anorexia nervosa. Expert Review of Obstetrics and Gynaecology. 6(4):403-14. Hoggard L (2005). Why we’re all beautiful now. The Observer, 9 Jan. http://tinyurl.com/pdu9zfu [Accessed 30 Jan 2014]. Levine MP, Smolak L, Schermer F (1996). Media analysis and resistance by elementary school children in the primary prevention of eating problems. Eating Disorders 4(4):310–22. Lowes H, Kopeika J, Micali N et al (2012). Anorexia nervosa in pregnancy. The Obstetrician and Gynaecologist 14(3):179-87. Luck AJ, Morgan JF, Reid F et al (2002). The SCOFF questionnaire and critical interview for eating disorders in general practice: comparative study. BMJ 325(7367):755-6. Micali N. (2008). Eating disorders and pregnancy. Journal of Paediatrics, Obstetrics and Gynaecology 34(5):201-4. Morris J, Twaddle S (2007). Anorexia nervosa. BMJ 334(7599):894-8.

Conclusion To conclude, by discussing just some of the theoretical concepts that attempt to understand anorexia nervosa and offering a brief overview of how this debilitating illness can affect pregnancy, it is hoped that midwives will identify ways of supporting and caring for women who suffer from this condition.

Morrison TG, Kalin R, Morrison MA (2004). Body-image evaluation and body-image investment among adolescents: a test of sociocultural and social comparison theories. Adolescence 39(155):571-92. NICE (2004). Eating disorders: core interventions in the treatment and management of anorexia nervosa, bulimia nervosa and related eating disorders. London: NICE. Odent M (2008). Autism and anorexia nervosa: two facets of the same disease? Primal Health Research 16(1):1-8. Shaffer SE, Hunter LP, Anderson G (2008). The experience of pregnancy for women with a history of anorexia or bulimia nervosa. Canadian Journal of Midwifery Research and Practice 7(1):17-30.

Postpartum

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Essentially MIDIRS • March 2014 • Volume 5 • Number 2