TITLE:

THE IMPACT OF MATERNAL OBESITY ON OBSTETRIC OUTCOMES IN MATERNITY HOSPITAL PULAU PINANG.

1. CHAPTER 1 : INTRODUCTIONS 1.1 Background of the problem Obesity is one of the hottest topic that being talked lately. There is tons of issue that related to obesity is being published in newspaper and other media to create an awareness among Malaysians. However, we still have significant increment in people who suffered from obesity. According to the statistic and report of Banci Penduduk dan Perumahan Malaysia 2010, Malaysia now having 28.3 million citizen, where is 13.77 million out of them are women. Meaning that from 13.77 million out of them will have the risk or possibility to have maternal obesity or there is significant fraction of them already had this problem. Problem of maternal obesity is also concerned by international government body when Central International Agency (CIA) 2008 also noted the same problem and state that Malaysia is sat on the 28th rank country in the world with people who suffered from obesity. That show the problem of maternal obesity is the risk or problem occur among pregnant mothers.

1.2 Statement of the problem "Problem statement expresses the dilemma or disconcerting situation that needs investigation and incorporate a rationale for a new inquiry ". (Polit& Beck 2010, page 150)

Deputy Ministry of Health Malaysia announce in The Star (Saturday 29 October 2011) that Malaysians are the fattest in Asia. The most important issue here is 43.7% of these people are aged over 18 years old. This is very distressing because they belong to reproductive age, furthermore among them might be woman who is pregnant. Although data from the Mingguan Malaysia (15 Julai 2012: Ruangan Kesihatan) stated that obesity in Penang was ranked 14th out of 15th state in Malaysia which means Penang is sparsely populated state with obesity. However, researchers decided to do research in Maternity Hospital Pulau Pinang because this condition is still not fully resolved yet. Researchers observed there are still many pregnant women with obesity come for followup or delivery. Among them, we still experienced the problems during

pregnancy and at birth even though there is efficient and effective midwifery care together with medical services.

Table 1: Percentage and rank of obesity within state in Malaysia 2011

Researchers strongly believe that maternal obesity is a condition which should be taken into serious consideration and preventive measures should be carry-out to avoid any complications that may occur. Researchers hope with the findings from this research, it would be beneficial the pregnant women and maternity care and services.

1.3 Significant of the research

The important or significant of this research can be divided into several groups namely, the significant interest to pregnant woman, midwife and Ministry of Health (MOH).

1.3.1 Significance to mother The finding from our research will contribute to the principles of risk management theories thus help to improve the health status of maternal obesity at the maximum level and detect any abnormalities so that early treatment can be given to help reduce the morbidity (safe motherhood).

1.3.2 Significance to midwives The benefices from this research can reduce the adverse outcome toward mother and fetus. Adequate midwife especially in Klinik Kesihatan can continue the personal life care programme with more intensive care and effectiveness. Besides that, the proper effective communication or consultation regarding balanced diet can be given. Therefore, the obstetric outcome problem can be reduced efficiently.

1.3.3Significance to Ministry Of Health The significant outcome to our Ministry of Health Malaysia is to prepare a better strategy for health care of pregnant mother during pregnancy. It can help our government to achieve its goals in implementing Millennium Development Goal (MDG) 4 and Millennium Development Goal (MDG) 5.

1.4 Purpose / objective of the research

1.4.1 General objective General objective from this study is to explore the impact of women with high pre-pregnancy body mass index (BMI) and the obstetric outcomes.

1.4.2 Specific objective are: 1) 2) 3) To describe the social demographic status of the study sample. To determine effect of maternal obesity on obstetric outcome. To identified if there is any relationship between demographic data and obstetric outcomes.

1.5 Research questions 1.5.1 What are the social demographic characteristic of the study sample? 1.5.2 What are the complications that happen to mother and neonatal if pregnant women suffering from obesity? 1.5.3 Is there any relationship between demographic data and obstetric outcomes?

Study variables 1. Independent variable is women with obesity. It include age, race, parity and weight at first booking. 2. Dependent variable is obstetric outcome. It`s divided to during pregnancy such as Hypertension, GDM, Risk Coding (Green, yellow and red). During labour it included shoulder dystocia, operative delivery, prolonged labour and perineal tear (1, 2, 3, 4). Neonate is for big baby and Apgar score.

1.6 Operational definition / definition of term

1.6.1 Impact ~ A powerful effect that something, especially something new, has on a situation or person. (Cambridge, International Dictionary of English)

1.6.2 Maternal ~ Pertaining to the mother, especially during pregnancy or shortly after childbirth. (Bailliere`s Midwives Dictionary, 2008)

1.6.3 Obesity ~ Excessive development of fat throughout the body, increase in weight beyond that considered desirable with regard to age, height and bones structures obesity can affect physical and mental health. (Bailliere`s Midwives Dictionary, 2008)

Obesity is defined by the excessive accumulation of fat which can be measured using the body mass index (BMI) with a BMI above 27.5 kg/m2. (Ministry of Health Malaysia)

1.6.4 Maternal obesity ~ Maternal obesity (defined as obesity during pregnancy) increases health risks for both the mother and child during and after pregnancy. (World Health Organization 2009)

~ Maternal obesity is defined when mother with BMI more than 23.0 kg/m2. (Ministry of Health Malaysia)

1.6.5Obstetrics ~ The branch of medicine that concern management of women during pregnancy, childbirth, and the puerperium. (Bailliere`s Midwives Dictionary, 2008)

1.6.6 Outcome ~ The condition of a patient at the end of therapy or a disease process, including the degree of wellness and the need for continuing care, medication, support, counselling, or education. The result of an action. (Cambridge, International Dictionary of English)

1.7 Limitations of the study

According to our research in Maternity Hospital Pulau Pinang, there are several disadvantages regarding information such as weight measurements of pregnant women. This happened because of the Maternity Hospital Pulau Pinang not take the mother's body weight measurements during admissions.

This flaw will make our research cannot identified the rates of obesity that occured among pregnant women in Maternity Hospital Pulau Pinang. However, we are determined to continue this study by taking the relevant data that we were already mentioned in problem statement.

2 CHAPTER 2: REVIEW OF THE LITERATURE

2.1 Introductions High pre-pregnancy BMI is associated with adverse obstetric outcome. Maternal complications include pregnancy induced hypertension, gestational diabetes, increased risk of interventions like operative delivery. Perinatal complications included macrosomia. (Satpathy et al 2008).

2.2 Theoretical groundwork related to research topic The weight gain for a normal BMI of pregnant woman should be 12.5 kg throughout the pregnancy. This normal weight gained during pregnancy is due to the physiology changing and fetus development in the uterus. Besides that, the weight gained from the mother also affected by the increasing amount of amniotic fluid, the weight of placenta and oedema at the end of pregnancy. However this is not the main cause that triggered maternal obesity.

In Myles Textbook of Midwifery (Fraser & Cooper, 2009), the raise in weight for the 20 first weeks should be in 0.5 kg in every month and from the 20 weeks onward the weight gain should be 0.5 kg every week.

According to Ismail Mohammad Nor et.al (2002) found in their research that the terrible diet pattern and lifestyle which is unhealthy is the factor that influencing the weight gains. This is frequently happen when unbalanced diet such as fast food like KFC, McDonalds, carbonated drinks and many more taken incautiously. Furthermore, they also fell within the group who dont practise exercise regularly which later on will embrace obesity.

According to Jolly et.al (2003) maternal obesity is independent risk factor of fetal macrosomia. It is a common adverse infant outcome related to Gestational Diabetes Mellitus, especially if unrecognized and untreated of Gestational Diabetes Mellitus. Macrosomia increases the risks of shoulder dystocia, clavicle fractures, and brachial plexus injury and is also associated with depressed 5-min Apgar scores and increased rates of admission to neonatal intensive care unit. Furthermore according to Dixit et.al (2008) maternal obesity also increase the risk of Hypertension during pregnancy due to increased risk of caesarean delivery.

Due to the study that was conducted in Penang, our group researcher will use the BMI calculation as proposed by the Malaysia Ministry of Health where the reading for the obesity proposed was a BMI which overweight and obesity. The comparison can be seen on the table 1 and 2 in page 10.

The table below shows the difference between BMI is recommended by the Health Ministry of Malaysia 2010 and BMI from the World Health Organization 2009.

Classification Underweight

BMI ( kg / m2 ) < 18.5

Classification Underweight

BMI ( kg / m2 ) < 18.5

Normal Range

18.5 - 24.9 Normal Range 18.5 22.9

Overweight

> 25 Overweight 23.0 27.4

Pre Obesity

25.0 - 29.9 Obesity >27.5

Obesity

30.0 - 34.9 Table 2 : BMI Health Ministry Of Malaysia

Obesity 11

35.0 - 39.0

Obesity 111

> 40

Table 1 : BMI World Health Organization 2009

2.3 Review of previous research

Hypertension is defined as high blood pressure (i.e., repeatedly elevated blood pressure exceeding 140 over 90 mmHg a systolic pressure above 140 with a diastolic pressure above 90). There were 40 % increased risks of pre-existing chronic hypertension in pregnant, obese women compared to normal weight or lean pregnant women. The risk of PIH or gestational hypertension is significantly greater if the pregnant woman is overweight or obese (Yogev & Catalano, 2009).

Diabetes mellitus is a group of metabolic diseases characterized by high blood sugar (glucose) levels that result from defects in insulin secretion, or insulin action, or both. There are three 45 % increased risk of pre-gestational diabetes in pregnant, obese women compared to normal-weight or lean pregnant women (Dietl, 2005). Furthermore, women who are overweight or obese pre-pregnancy are more likely to develop gestational diabetes mellitus (GDM) during pregnancy (Reece, 2008).

According to (Guelinckx et al, 2008) the most common effect of maternal obesity on the mother during labour is an increased risk for caesarean section with rate for obese pregnant woman was 35.2% as compared to 22.3% of normal weight.

According to (Arendas et al 2008) infants born to obese women are significantly more likely to weight at 4000 g or more than 4500 gm. Also a high prevalence of obesity results from a complex interaction between changes in the populations lifestyle, involving a higher energy and fat consumption and an increasingly sedentary existence, the effects of these changes being particularly severed if the population has an inherited metabolic predisposition to fatness. (Lewis et al, 2010).

3 CHAPTERS 3: METHODOLOGY 3.1 Study setting The study was carried out at the Department of Obstetrics and Gynaecology, Hospital Pulau Pinang. It is because many obstetric problematic cases referred to Maternity Hospital such as maternal obesity. are

3.2 Study design The study designs that is carried out in this study were in form of quantitative which is non-experimental by observational and cross sectional studies.

3.3 Populations and sample 3.3.1 Population Populations are pregnant women with BMI 23.0 who received treatment and delivered in Maternity Hospital Pulau Pinang especially pregnant women whos treated at third class ward.

3.3.2 Sample and sampling method A sample of 30 obese women with BMI more than 23.0 were selected using convenient sampling method. All obese mothers whom delivered at MHPP especially in third class ward is selected as our sampling.

3.4 The research instrument Our research group design a data collection sheet as our research tools. It divides into 2 sections. In section 1 that is demographic data which consist of 4 items. Section 2 is about obstetric outcome and divides into 2 categories which include of maternal and obstetric outcome. Researchers have 2 section in maternal outcome it include 3 item during antenatal, 4 item during labour and 2 item in neonatal outcome section. The data is taken from Delivery Register . 3.5 Ethical consideration We had permission letter from the Head of Department of Obstetrics and Gynaecology and consent for samples. Approval is obtained from National Medical Research Register (NMRR) and CDC. All samples were informed that data emerging from the study is kept confidential, anonymity is assured, and that they could withdraw from the study without prejudice. All samples gave their informed consent.

3.6 Procedure for data collections The 13 items in 2 sections which is written is used as well as data from the Register Entry of Hospital /Institution PER-PD 101 (Pin.2/2009). Antenatal card KIK /1(a) / (96), Labour summary which is related to the demographic data and obstetric outcome during pregnancy and during labour. The data is collected by our group member. The study is already done in last period of April to June 2013.

3.7 Data analysis and interpretations The data collected is analysed using statistical software which is Trial SPSS version16. For first objective we use frequency test by measures of central tendency of demographic data. Then for second objective we use frequency test by measures of central tendency to measured outcomes. For third objective we use Chi-square to identify relationship between demographic data and the obstetric outcomes. The data is analysed and the results of the study is obtained.

CONCLUSION Obesity caused significant complications during pregnancy for the mother and fetus. Interventions promoting pre-pregnancy weight loss and the prevention of excessive weight gain during pregnancy must begin in the pre-conception period. Health care workers need to counsel their obese patient about the risk and complications by obesity and the importance of weight loss before pregnancy. Women need to be informed about both maternal and fetus complications.

4. RESEARCH PLANNING
Research activities No 1 Preparation of research proposal 2 3 Rectify research proposal Present proposal research and research Nov Dec Jan Feb Mac April May Jun July

application letter 4 Approval committees 5 6 7 8 9 10 11 Pilot study Review instrument Data collection Data analysis Write research report Hand in research report Research presentations 12 Research presentations poster oral by ethics

Table 1: GANTT Chart for completion of research report Advanced Diploma In Midwifery 2/2012

Appendix 1

Informed consent form (Versi bahasa) (Code No. :) 1. Kami pelajar kebidanan di Kolej Kejururawatan Pulau Pinang dan sedang menjalankan kajian penyelidikan sebagai sebahagian daripada keperluan untuk kursus kami, Diploma Lanjutan Perbidanan. Kumpulan penyelidikan kami terdiri daripada 6 orang; a) b) c) d) e) f) Azmuhaini Binti Musa (Leader) Murni Binti Marodzakhi Nur Izzatul Afizainizam Binti Che Sidek Siti Noraini Binti Mustafa Rohana Binti kamis Zurina Binti Abu Bakar

2. Tujuan kajian dijalankan, untuk mengetahui dengan lebih mendalam mengenai kesan wanita obesity semasa hamil dan obstetric outcome di Hospital Bersalin Pulau Pinang. Kita mahu untuk mencari cara yang lebih baik untuk mengurangkan komplikasi daripada wanita obesity semasa hamil. 3. Anda perlu mengetahui bahawa penyertaan anda di dalam kajian ini adalah dengan cara sukarela. Sekiranya anda ingin menarik diri sebelum atau semasa kajian ini dijalankan adalah dibenarkan. 4. Segala maklumat yang kami perolehi daripada pihak puan akan dirahsiakan. Sebarang maklumat mengenai anda hanyalah mempunyai nombor diatasnya dan bukannya nama anda. 5. Jika anda mempunyai sebarang soalan, anda boleh bertanya penyelidik kami sekarang atau kemudian dan selepas kajian telah bermula. Cadangan ini telah disemak dan diluluskan oleh Ketua Jabatan Obstetrik dan Ginekologi. 6. Saya telah membaca maklumat di atas dan saya bersetuju secara sukarela untuk menyertai sebagai peserta dalam kajian ini. 7. Sekian, terima kasih. Tandatangan peserta Tandatangan penyelidik Tarikh : _____________ : _____________ : _____________

Appendix 1

Informed consent form (versi bahasa ) (Code No. :) 1. Kami pelajar kebidanan di Kolej Kejururawatan Pulau Pinang sedang menjalankan kajian penyelidikan sebagai sebahagian daripada keperluan untuk kursus kami, Diploma Lanjutan Perbidanan. Kumpulan penyelidikan kami terdiri daripada 6 orang; g) h) i) j) k) l) Azmuhaini Binti Musa (Leader) Murni Binti Marodzakhi Nur Izzatul Afizainizam Binti Che Sidek Siti Noraini Binti Mustafa Rohana Binti kamis Zurina Binti Abu Bakar

2. Tujuan kajian dijalankan, untuk mengetahui dengan lebih mendalam mengenai kesan wanita obesity semasa hamil dan obstetric outcome di Hospital Bersalin Pulau Pinang. Kami mahu mencari cara yang lebih baik untuk mengurangkan komplikasi daripada wanita obesity semasa hamil. 3. Anda perlu mengetahui bahawa penyertaan anda di dalam kajian ini adalah dengan cara sukarela. Sekiranya anda ingin menarik diri sebelum atau semasa kajian ini dijalankan adalah dibenarkan. 4. Segala maklumat yang kami perolehi daripada pihak puan akan dirahsiakan. Sebarang maklumat mengenai anda hanyalah mempunyai nombor diatasnya dan bukannya nama anda. 5. Jika anda mempunyai sebarang soalan, anda boleh bertanya penyelidik kami sekarang atau kemudian dan selepas kajian telah bermula. Cadangan ini telah disemak dan diluluskan oleh Ketua Jabatan Obstetrik dan Ginekologi. 6. Saya telah membaca maklumat di atas dan saya bersetuju secara sukarela untuk menyertai sebagai peserta dalam kajian ini. 7. Sekian, terima kasih. Tandatangan peserta Tandatangan penyelidik Tarikh : _____________ : _____________ : _____________

Appendix 2

(Versi Bahasa)

(Kod No:____)

ADVANCED DIPLOMA IN MIDWIFERY PENGUMPULAN DATA THE IMPACT OF MATERNAL OBESITY ON

OBSTETRIC OUTCOME IN MHPP Kepada para pelanggan yang dihormati, diharap Puan dapat meluangkan sedikit masa untuk menjawab soalan-soalan di dalam borang ini. Seksyen 1: Demografic Data :1. Umur ( Sila isikan ) 2. Bangsa ( Sila tandakan di kotak yang berkenaan )

Melayu Cina India Lain-lain

3. Bilangan anak

Anak 1 Anak 2 Anak 3 dan seterusnya semasa lawatan pertama ke klinik? 4. Berapakah berat badan

45 kg ke bawah 46 62 kg 63 79 kg 80 kg ke atas

Seksyen 2 :Kesan daripada masalah kegemukan semasa hamil 1. Maternal During pregnancy YES NO

a) Hypertension b) Gestational Diabetic Mellitus c) Risk coding Green Yellow Red

During labour

YES

NO

Shoulder Dystocia Operative labour Prolonged Labour Perineal Intact

1 tear 2 tear 3 tear 4 tear

2. Neonate

YES

NO

Baby weight > 4kg Apgar score 7 10 64 30

APPENDIX 3

THE STAR 29 OKTOBER 2011

APPENDIX 4

THE STAR 29 OKTOBER 2011

APPENDIX 5

MINGGUAN MALAYSIA 15/7/2012 RUANGAN KESIHATAN

APPENDIX 6

UTUSAN MALAYSIA 15/11/2010 RUANGAN KESIHATAN

ARKIB : 15/11/2010

60 peratusrakyat Malaysia gemuk - Menteri

15/11/2010 5:26pm

KUALA LUMPUR 15 Nov. - Tigapuluhperatuspenduduk di negarainimempunyaiberatbadanberlebihanmanakala 30 peratuslagiobes, kata MenteriKesihatanDatuk Seri LiowTiong Lai. Beliauberkata, iamerangkumisemuaperingkatumur, manakalajumlahkanak-kanak yang mengalamimasalahkegemukan pula menunjukkanpeningkatan yang membimbangkansejakakhir-akhirini. "Kita perlulihatkesihatanbadantusebagaisesuatu yang pentingkeranaiaadalahpintumasukkepadasegalajenispenyakit yang berpuncadaripadacarapemakanandangayahidup yang kurangsihat. "Fenomenainimembimbangkankeranaiasecaralangsungberkaitandenganpeningkatan risikopenyakitseperti diabetes, sakitjantung, buahpinggang, darahtinggi, barahdansebagainya, katanyakepadapemberitaselepasmerasmikanPersidanganAhliLembagaPelawat Hospital 2010 di sinihariini. Sehubunganitu, Tiong Lai menggesarakyatsupayamengamalkanpemakanan yang seimbangselainmengamalkangayahidupsihatdenganmelakukanaktivitifizikaltermasuk bersenam, berjogingdanbersukan. - Bernama

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APPENDIX 7

UTUSAN MALAYSIA 6/11/2008 RUANGAN KESIHATAN ARKIB : 06/11/2008

Ibugemukrisikobayibesar
Susunan ROSMAWATI MION WANITA perlumengawalberatbadansemasahamil.Sebabnya, jikaberatbadanmerekabertambahsebanyak 18 kilogram (kg) hanyaketikamerekahamil, merekaberhadapandengandua kali gandarisikomelahirkanbayibesarberbandingwanitahamil yang lain. Menurutkajian yang dilakukanparapenyelidik AS keataslebih 40,000 wanitanegaraitudanbayimerekamenunjukkan, satudaripada lima wanita yang bertambahberatbadansecaraberlebihankalahamilmempunyaipeluanglebihbesaruntuk melahirkanbayiseberat 4 kg keatas. Malah, kajianitujugamendapatiwanita yang bertambahberatbadansebanyak 18 kg semasamengandunglebihcenderungmempunyaibayibesarwalaupunmerekatidakmen ghidapdiabetisgestasiiaitudiabetisjangkapendek yang berkaitdengankehamilandandiketahuimampumenambahkanrisikomelahirkanbayibes ar. Disebabkanterlalubanyakwanita yang bertambahberatbadanlebih 18 kg semasahamil, makaamatpentingkesedarankesihatandiberikankepadagolonganwanitadalamusaham engelakkanberlakunyapertambahanberat yang berlebihanitu, kata Dr. Teresa Hillier daripadaPusat Kaiser Permanente untukPenyelidikanKesihatan di Portland, Oregon. Kajian yang dilakukan Teresa danbeberaparakansekerjanyaitutelahditerbitkandalamjurnalObstetrikdanGinekologi. Teresa berkata, pertambahanberatbadanberlebihanbukanhanyameningkatkanrisikountukmendapatka nbayibesar, malahbayibayimerekaitujugaakanmenghadapimasalahmempunyaiberatbadanberlebihanatauob esdalamhidupnya. Menurutpakar-pakarObstetrikdanGinekologi di American College, bayi-bayi yang mempunyaiberatmelebih 4 kg semasadilahirkandianggapbesar. Bayi yang besarakanberhadapanrisikosukardilahirkan, meningkatkanpeluang vagina ibukoyak, pendarahan, ibuterpaksamenjalanipembedahancaesariandanbayijugamempunyairisikobahunyater sekatdantulangselangkapatahkaladilahirkan.

Teresa danrakansekerjanyatelahmengkajirekodperubatan 41,540 wanita yang bersalin di Washington, Oregon danHawaidaritahun 1995 hingga 2003. Semuawanitatersebuttelahmenjalaniujiandiabetisgestasidan 5.4 peratusdaripadamerekadirawatkeranamempunyaimasalahtersebutdenganmelakukan program diet, senamandansuntikan insulin jikaperluuntukmengawalkandunganguladalamdarahmerekasepanjangkehamilan. Secarakeseluruhannya, kajiantersebutmendapati 20 peratusdaripadawanitaberkenaan yang bertambahberatbadansebanyak 18 kg, iaitu had terakhirpertambahanberatbadanketikahamil yang disarankan di AS telahmelahirkanbayibesar. Jelas Teresa, kurangdaripada 12 peratuswanita yang mempunyaiberatbadan normal didapatijugamelahirkanbayi yang besar. Kumpulan berisikotinggiadalahmereka yang bertambahberatbadanlebihdaripada 18 kg danmempunyaidiabetisgestasi.Hampir 30 peratusdaripadawanitainimelahirkanbayibesarberbanding 13.5 peratuswanitadengandiabetisgestasi yang beratbadan normal semasahamil. Kajianitujugamencadangkansemuawanitaperlumengelakkanberatbadanberlebihanke tikahamil.Dan, wanita yang dirawatuntukdiabetisgestasijugaperluberusahamemastikanberatbadanmerekabertam bah di bawah 18 kg. Andatidakbolehmerawatglukosdanmengambilsambillewamasalahpertambahanberat badan, katanya. Pertambahanberatbadansemasahamiltelahmeningkatsejakduadekadkebelakanganin idansesetengahpenyelidikmengesyakiiamungkinakanmenyebabkanberlakunyagejala obesiti di kalangankanak-kanak. - Reuters

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