asked Her Majesty’s Government how they propose to combat the increasing threat to women’s health of obesity during pregnancy and childbirth.

The noble Baroness said: My Lords, scarcely a day passes without warnings about obesity appearing in the media: how, in its various manifestations—obese, morbidly obese and super-morbidly obese—it endangers the nation's health and is on the increase. Obesity in pregnant women is seldom referred to, although it has been called the biggest threat to women during pregnancy. In the Government’s large, tripartite obesity document, Foresight, I was unable to find any specific reference to obesity and pregnancy.

The problems are serious. Midwives and obstetricians have been aware of them and have been dealing with them for several years. Recently, things have changed. Due to the current obesity epidemic, if such it can be called, an increasing number of extremely overweight women are becoming pregnant. The rate of that increase is alarming. In 1980, no more than 8 per cent of women in England were classified as obese and the word itself was seldom used. If we heard it, a good many of us would not have known what it meant. That would be laughable today, for the prevalence of obesity had nearly trebled to 21 per cent of women by 1998 and current figures suggest that it may have reached 25 per cent. It is estimated that that figure will have increased to 50 per cent by 2050. It is clear that obesity is one of the greatest public health challenges facing healthcare professionals and that this trend must be reversed.

Body mass index is measured by dividing an individual's weight in kilos by height in metres and then dividing the result by height in metres again. An ideal weight for women is between 18 and 25. The Confidential Enquiry into Maternal Deaths of 2004 reported that 35 per cent of women who died were identified as clinically obese, with a body mass index of 30 or more, while a body mass index of more than 40 indicates morbid obesity. The latest Confidential Enquiry, that of 2007, shows that out of the 295 women who died 119 were overweight and 64 of those were morbidly or super-morbidly obese. In 30 per cent of women who experienced a stillbirth or perinatal death, the maternal BMI was recorded at more than 30.

Maternal obesity during pregnancy is associated with increased complications for both mother and baby. The risks to mother include miscarriage, gestational diabetes, pre-eclampsia, hypertension, thromboembolism, post-caesarean wound infection, prolonged labour, postpartum haemorrhage and many others. The risks to the baby may be child adiposity, early neonatal death, intrauterine death and hypoglycaemia. In adults, obesity increases the likelihood of type 2 gestational diabetes dramatically—by up to 80 times that of the non-obese. Although this will disappear after pregnancy, it may be a precursor of developing diabetes in later life, which can be a cause of high blood pressure and coronary heart disease. Obesity is also associated with less serious but debilitating conditions such as shortness of breath, back pain and reduced mobility. In some cases, midwives find taking specimens from and conducting examinations of obese women complicated if not impossible due to their excess weight.

Pre-eclampsia has increased nearly fivefold in morbidly obese women compared with normal-weight women. The risk of caesarean section has increased threefold and instrumental deliveries have increased by 34 per cent. In comparison with normal-weight women, there is evidence that maternal obesity is also associated with foetal abnormalities, particularly spina bifida and heart defects. It appears that women who were obese prior to pregnancy are more likely to have a baby large for gestational age. Generally speaking, obese parents have obese children. The odds of an obese one to two year-old child being obese as an adult is one in three.

A survey carried out in 2005 identified that maternal obesity resulted in, among other defects, a twofold increase in stillbirths and neonatal death compared to birth outcomes in women of normal body weight. Excessive weight gain in pregnancy is an independent risk factor for caesarean birth; it has been estimated that a significant number of caesarean sections could be avoided each year if women's weight did not exceed the level recommended by the Institute of Medicine.

Morbidly obese women—those with a body mass index of 40-plus—have risks for complications that are significantly greater. It has been found that those women are at risk of prolonged labour, gestational diabetes, pre-eclampsia, placental abruption, surgical birth, postpartum endometritus and prolonged postpartum stays in hospital. Also, larger women often have restricted mobility and may not be able to get into a position ideal for a safe delivery.

We also have to consider, although it may be a secondary consideration, the added costs to the NHS associated with the safe management of obese women in pregnancy and the resources needed to achieve that, as specialist equipment may be required. For instance, serial scans may be required to assess foetal growth, foetal monitoring by an external transducer may be needed and a foetal scalp electrode may be applied if the foetal heart is impossible to record. Delivery may have to take place in a consultant unit or, if an emergency caesarean must be carried out, two obstetricians are required to be present.

It has been suggested that pregnancy is not a time to lose weight. However, antenatal booking may be the ideal time to discuss diet with women who have been identified as obese or morbidly obese, as well as the conditions in pregnancy that may result from obesity. Midwives say that the myth that the weight should not be lost during pregnancy should be dispelled. However, this is not the place to go into causes of obesity or weight-loss regimens. The media instruct women in these procedures almost every day and it is hard to believe that anyone who has a problem can be unaware of them. A recent proposal, which should meet with derision, is that of paying people to lose weight, which has been the subject of television programmes shown in the past two weeks. Contrary to popular belief among the thin, overweight and obese women are well aware of their obesity and many, far from being complacent in the well known image of the jolly fat person, are made miserable by their condition.

Unfortunately there is a growing trend to accept overweight verging on obesity as the norm—the condition of what the media call real women—while leanness must be attributed to excessive dieting, if not anorexia. This attitude may be seen as encouraging obesity in pregnancy where eating for two as a principle, if old-fashioned, is still a current belief. The fact remains that the Confidential Enquiry into Maternal and Child Health in 2007 estimated that at least 360 existing children and 160 live newborns lost their mother. One hundred and nineteen of the women who died were classified as obese. It is deeply distressing to contemplate these orphaned children who were deprived of that unique figure in everyone’s life, not through disease in its usual sense but through a failure to be given dietary and exercise help before and during pregnancy.

However, although gestational obesity is a growing problem and presents severe risks to both mother and baby, currently there is no national guidance for midwives on how to care for this increasing number of women. Women are repeatedly told not to drink alcohol while pregnant, or to drink it in very small quantities. It is now taken for granted that they should not smoke while pregnant, but obesity is not subject to similar condemnation, nor is a woman warned that she may be carrying too much weight for a safe pregnancy and satisfactory delivery. Something on the French model might be considered, where women’s health and weight are monitored throughout the pregnancy. Does the Minister believe that the Government should give guidance to midwives nationally and that attention should be focused by health professionals on young women who are obese prior to their becoming pregnant?

My Lords, it is always stimulating to listen to the speeches of the noble Baroness, Lady Rendell, whose dedication to the physical well-being of women is well known and highly respected in this House.

The subject of today’s debate is of real relevance at a time when there is wide general concern at the growing number of people who are overweight and growing evidence of the dangers of obesity to both mothers and their babies during confinement in particular. Interestingly, an article was published in G2 today about the growing number of large babies in general and the problems that they can suffer during the birth itself. However, that is probably beyond the bounds of today’s debate, because although recent research indicates that obesity in pregnancy is linked with the high birth weight of the baby, it seems likely that other factors affect birth weight, such as the height of parents, which are rather beyond today’s subject.

The report to which the noble Baroness, Lady Rendell, referred clearly indicates a link between a mother’s high body weight and a number of serious problems, which the noble Baroness has rehearsed for us already. One of the effects has been increased costs to the NHS in the number of days in hospital during pregnancy, in a fivefold increase in the costs of neonatal care and in the increased likelihood of the child being admitted into a neonatal intensive care unit. Worryingly, no single clinical guideline is available in the UK on the best way of dealing with these problems, although work is being done and evidence collected on the best way to handle the problem medically. I join the noble Baroness in asking the Minister whether such a guideline is currently being prepared.

Overweight, or a high body mass index, is caused by factors well beyond the power of doctors alone to deal with. Home Office figures published this year show a strong relationship between obesity and social class. I suspect that that is really a relationship between being better off and being less well off. In 2006, about a fifth of the richest quintile of women was obese compared with a third of the poorest quintile. Furthermore, four times as many of the poorest women are morbidly obese compared with their richer sisters. These differences seem to be associated with a low-activity lifestyle and a less healthy diet among poorer women when compared with the wealthy. These trends begin in childhood, with lower levels of physical activity among girls than boys, particularly after the age of nine, and fewer children of poorer families getting the desired five portions of fruit and vegetables daily.

Given the costs to the individual woman and to the NHS of excess weight, what can the Government or individual women do about it? Perhaps better advice to women about the risks to themselves and their babies from overweight would be useful. I had my babies when free orange juice was still available from baby clinics; I certainly listened to what the nurses had to say and tried to follow their advice. The fact that my three children weighed 9 pounds 10 ounces, 8 pounds and 8 ounces and 8 pounds respectively might suggest to some that I did not listen hard enough, although they all grew up perfectly normal.

In an age when mothers of children at school can encourage them to refuse healthy school lunches and push burgers and fries through the schoolyard fence to keep them from starving, we need to do more. Clearly, educating children about health and exercise and healthy eating from their earliest years would be a start. As anyone knows who has frequently visited five and six year-olds in their classrooms, one can teach a child almost anything at that age, always provided that the teaching matches the child’s understanding. Doing some of this on days or at times when parents can be present would be even better.

A programme of age-related teaching financed by the Government might be cost-effective, given the high costs to the NHS of obesity in women, to say nothing of the costs to the women themselves. A greater emphasis on PE and games would clearly be beneficial, as the gap between the activity levels starts early and is widest in the children of the poorest families. There seems to be a real difficulty in that girls in general seem to be turned off team games from quite an early age, but the Government are making a good deal of effort, in the context of the Olympic Games, to encourage more participation in sport of all kinds. Perhaps less concentration on team games and more encouragement of swimming—very good for the figure—and gymnastics, dance or aerobics in all-girl contexts would be more attractive to girls than having to exercise in the school playground or on the hockey pitch with the boys looking on and jeering.

Of course, I understand that there are forces working against such ambitions, not least the increasingly early sexualisation of young girls as a result of high-pressure sales techniques. We also need to be concerned about the understanding of women who are now in their childbearing years of the malign effects of being seriously overweight on their efforts to carry and give birth to a healthy baby. Do the Government ever consider getting this sort of message across in women’s magazines, without anyone ever realising that it is a government message of course? The medium really can be the message if handled tactfully.

I do not have anything more to contribute to the debate in any medical sense, which is why I have concentrated on what one might call the social aspects of some of this. It is extraordinary that, in an education system that began by teaching children how to look after their babies, we have got so far away from practical education of that kind and from an interest in teaching children how to look after themselves physically as well as mentally, and that we are suffering from a ridiculous and dangerous epidemic of obesity that is causing harm both to mothers and to their children.

My Lords, I thank the noble Baroness, Lady Rendell, for securing this debate. For a minute, I thought that she was going to ask us all to declare our BMI before we speak. I would not like to admit that mine is approaching that crucial number. I hope that I will be able to keep it under control.

We all know that obesity in our country is of epidemic proportions—more so than in any other western European country. What is worse is the fact that childhood and adolescent obesity is on the increase, with nearly 30 per cent of children and adolescents classified as obese. In the longer term, that will have its effect in all areas of healthcare, not just in pregnancy. What is now happening in terms of maternal perinatal mortality and morbidity will have its effect in the longer term.

The proverb, “You are what you eat”—and maybe even drink—is familiar to all of us. What is less well known is that it is also true that you are what your parents, and even your grandparents, ate, which is based on the established science of development biology. As we understand more about the genes we inherit and the environment in which we live, and the increased understanding of foetal health and its relation to parental diet, we are beginning to see the link between a predisposition to certain adulthood diseases, such as cardiovascular disease, cancer, diabetes and obesity, as well as to foetal development and maternal obesity. The roots of these diseases are laid down before birth. There is a strong co-relation between maternal insulin sensitivity in late pregnancy, and birth weight and fat-free mass in the body.

So what does all that mean? There is a strong link between obesity in pregnancy and weight at birth, and subsequent obesity in children. In mothers with a BMI of more than 30 kilograms per square metre in the first three months of pregnancy, the prevalence of childhood obesity—that is, a more than 95th percentile weight at the ages of two, three and four—in one study was 15, 20 and 24 per cent. The rise in babies born large for gestational age—with a birth weight of more than four and a half kilos—in the most part is related to maternal obesity and diet, which will then lead to a rise in adulthood diseases.

These are the long-term effects of maternal obesity. The immediate effect is an increased maternal and perinatal mortality, which the noble Baroness, Lady Rendell, has already mentioned. That may well be associated with higher maternal mortality in the United Kingdom than in other western European countries. Let us admit that we now have a rising maternal mortality rate. Fifty per cent of deaths reported in the confidential report on maternal deaths and nearly 30 per cent of perinatal deaths are associated with obesity in the mother. Add to this the fact that the prevalence of obesity is higher in lower socio-economic groups, which is already a significant factor in maternal and perinatal deaths, and we have the reason for this increase in numbers. Complications such as pulmonary embolus, pre-eclamptic toxaemia, pre-term labour, small-for-gestational age babies—that is, small babies—are also higher in obese mothers.

Care of obese mothers requires personalised care from experienced staff and the interpretation of tests, both antenatally and intrapartum, is problematic. The incidence of surgical intervention, such as caesarean sections, is high and fraught with difficulties. I still remember the case of a very large lady on whom I was called to do an emergency caesarean section because of foetal distress. The foetus was not being oxygenated well. The consultant has to deal with the problem. After six hours of surgery, which normally takes 40 minutes, and 25 pints of blood, I was exhausted and my hair turned the colour it is now. In obese women, any surgery is fraught with difficulties. The Minister may be able to use his laparoscope or his robot, but I cannot use those for a caesarean section.

Anaesthesia and post-operative care are also problematic, as is neonatal resuscitation. Babies born to gestationally diabetic mothers, which obese mothers often are, mostly consist of fat and water, and have difficulties in the neonatal period.

What do we need to do? What should the Government’s policy be? First, there should be a better, continuous strategy for the prevention of obesity in children and adolescents, particularly young girls, which is rising. Secondly, with the incidence of obese pregnant women attending clinics in some maternity units as high as 22 per cent, there should be better resourced maternity units. They need equipment, such as bigger blood pressure cuffs, which noble Lords may think are easy to get; stronger operating theatres; and, importantly, skilled, experienced staff, particularly midwives. The Government’s proposal to increase the number of midwives by 4,000 is good, but what steps are being taken to make that happen? We need more midwives to enter not just education but also to practise.

The increasing incidence of obesity in pregnancy will be a sign of a failed strategy for reducing childhood and adolescent obesity, and will lead to greater demands on healthcare in the future. Under-resourced maternity care will lead to an increase in maternal and perinatal deaths and disability. Maternal obesity is a serious problem. Prevention is key in the long term. In the short term, we need better resourced maternity units.

Baroness Finlay of Llandaff: My Lords, I am sure that we are all most grateful to the noble Baroness, Lady Rendell of Babergh, for having secured this debate. It is very timely as we see obesity and morbid obesity increasingly account for maternal and child mortality, and morbidity in pregnancy and childbirth, as has already been outlined. In preparing for this debate, my literature search identified a series of papers, 14 of which were very high-quality studies, and the consistency of their findings rang out loud and clear. The complications for mother and baby are worse the fatter the woman is. Even when you exclude women with diabetes and high blood pressure, the risk from obesity itself is evident, stark and statistically significant in all the studies.

The 2000-02 report, Why Mothers Die, found that 35 per cent of all women who died were obese—a figure that has already been alluded to by the noble Baroness, Lady Rendell. The problems can be considered under various phases of the pregnancy and birth. Pre-existing obesity risks adverse outcomes in pregnancy. In early pregnancy, there is an increased risk of spontaneous miscarriage and congenital abnormalities. These include cardiac problems in the baby; omphalocoele, which is when the abdominal wall does not close and the baby’s guts are exposed; and spina bifida.

As pregnancy progresses, the risks to the baby are of oversized organs, which can lead later to obstructed labour, and of premature labour and of stillbirth, which is sometimes because the placenta comes away with potentially massive haemorrhage. These mothers are at risk of high blood pressure, pre-eclampsia and diabetes in pregnancy, all of which put the placenta at risk. In the morbidly obese women, the babies are at risk of being dangerously small through placental insufficiency, but for most obese women, the babies are dangerously large, which applies right across the board.

Some women are so obese that they have sleep apnoea. They literally cannot breathe properly when they are asleep. The mother is more likely to go into labour at the wrong time, either prematurely or post-term. When in labour, if the head is delivered, the shoulders are at risk of getting stuck and in the process of delivery the baby’s collar bone is at risk of fracturing. The fragments can go through the brachial plexus, which is the main nerve trunk to the arm, and the baby has a paralysed arm. The baby is much more likely to be severely distressed in labour in obese women and after delivery may need resuscitation, which is hard because of the metabolic disturbances that the baby has had.

Caesarean sections certainly are not the answer. Anaesthesia is so hard in these women that they may not ever have adequate sedation because the fat just soaks up the anaesthetic agents. They are extremely difficult to intubate and then they are very hard work to ventilate adequately to maintain oxygen levels to the brain. It is hard to put in an epidural because none of the landmarks are there to guide safe insertion and surgery is complicated by this apron of fat, as has already been alluded to. The wound is then more likely to break down. The women are at risk of genital tract and urinary tract infection and of post-partum haemorrhage. Tragically, the main cause of death in women is thromboembolism when a deep vein thrombosis breaks off as a pulmonary embolus and blocks the blood supply to the lungs, and the woman dies.

The other problem for the baby is that these women are less likely to breastfeed, so there are ongoing nutritional problems in the infant. Should the women have a catastrophic event, resuscitation is harder because of the obesity. Indeed, midwives have said that even finding beds strong enough to hold some of these women is very difficult. Monitoring the foetus during labour is extremely difficult, because normal pieces of equipment to monitor the foetal heart cannot be attached easily. There is also the problem of back injuries and strain if these women have to be moved or lifted.

In going through the literature, I also found an interesting study from work done on animals. Maternal junk food diets during pregnancy and lactation play a role in predisposing the offspring to obesity. This food alters the metabolism of the offspring. Giving the mother junk food has a subsequent lifelong damaging effect on the offspring.

We have before us the Health and Social Care Bill, which features the grant in pregnancy. It is a unique opportunity to engage women in education on health issues, on issues around breastfeeding and on parenting. There is another aspect that we must not ignore. Quite a few morbidly obese women who present are like that because they are desperately unhappy and have been abused. We should use this opportunity to screen for abuse women and other members of their family. There is also the potential problem of substance abuse—particularly of alcohol, but of other substances as well.

Severe obesity is not a reason to chastise a woman, because it may be a pointer to there being a great deal of dysfunction in many aspects of her life. I hope that the Government will use the Health and Social Care Bill to take forward positive health education for these women. When you are giving them a grant, you have a captive audience.

My Lords, I, too, congratulate the noble Baroness on bringing this matter to the attention of the House. I suspect a lot of things that need to be said have been said. However, I have a few things to add. Of 12.95 maternal deaths per 100,000 births in this country, nearly half—six—are due to obesity in some form. That is disgraceful in a civilised society, with a National Health Service that gives treatment free at the point of need.

Let me deal first with women who become obese during pregnancy. This happens—women of normal weight can grow obese during pregnancy, for emotional or feeding reasons, or perhaps because they have given up smoking. No one has mentioned the link between women smoking and keeping their weight down. This is important, particularly to young women. In one of my pregnancies, for no reason that was ever explained to me, I could be described at term only as a gasometer on legs, because I had put on so much weight. Thankfully, a lot of it—though not all—has disappeared since. However, it does happen, and it can be very dangerous for the woman and her baby. I was fortunate: it had no consequences for me or my baby.

Obesity can also cause reduced fertility, and not just because of the physical difficulty of getting pregnant. I have seen many women who get pregnant once they have addressed their diet and begun to lose weight. The noble Baronesses, Lady Rendell and Lady Finlay, and the noble Lord, Lord Patel, have described the many complications at birth, including the damage to the baby at delivery. I read in a paper published about two years ago that there is also a higher incidence of foetal abnormalities in women who are obese when they get pregnant. Diabetes is an obvious complication, along with high blood pressure and pre-eclampsia. There are also enormous problems for the midwives and staff who deal with obese patients. This should not be played down: it is very dangerous. If doctors, nurses and midwives find you difficult to handle, you will not have as good an outcome as if you were easier to handle. I think that sometimes people do not realise that. They think that once they get to the National Health Service, all problems will fade away and the doctor will be able to do the right thing and make them better.

The causes are the same as among the general population. Poor education and deprived backgrounds are major factors in obesity. Girls in school are given sex education, and some relationship education if they are lucky. They are taught about the risks of contracting infections. But what about the risks of obesity in pregnancy and the importance of keeping themselves healthy and fit if they want in future to have healthy and fit babies? Do we address that enough when we educate our girls?

I have mentioned in previous debates the confusion over health messages. Yes, people should give up smoking. However, if patients then put on an enormous amount of weight, you have to address that with them as well, because it can be very difficult. Yes, they must give up drinking, but if their only solace is drinking, will they start overeating to replace the drinking? People with addictive personalities often have to do something to stave off their unhappiness, depression or misery. Treatment is often much more complicated than simply telling them to stop doing something.

Breastfeeding has been mentioned. It is terribly important that babies should be breastfed from birth, because that leads to much better health as the baby moves into childhood. Habits formed during babyhood and childhood are terribly important: noble Lords do not have to be reminded of that.

There is sometimes an element of the Government not quite joining up in this area. We hear a lot about joined-up government, but since introducing massive choice in primary schools so that parents could choose where they wanted to send their children, the tendency has been to choose the school far enough away to require using a car rather than the school around the corner. So many children are now driven to school either because it is too far to walk, because their mothers have been encouraged back to work and they are being dropped off on the way, or because mothers are terrified by all the media attention on child abduction and child abuse. Children do not get that natural exercise at the beginning and end of the day which is so important to their development. With my children, being able to walk to school by themselves once they were in primary school was part of their social development and education. They had to be able to do it. So few children have that nowadays, so they are lacking in exercise.

I know that the Government are trying to address the problem, but the sale of school playing fields and the dumbing down of compulsory sports in the curriculum has resulted in a tendency for both girls and boys to get fatter because not as much exercise is built into the school day. Government departments need to get together and carry out an audit on what effect this will have in terms of people’s health as well as their education.

We hear a lot about the information on food packaging, but sometimes it is difficult to understand, especially if someone has had a poor education. It is hard to work out what all those minute figures mean, even if you can read them. I can never find my specs and I am always in too much of a hurry.

My noble friend Lady Thomas made an important point. We should remember the days when we had community clinics. We had baby clinics, health visitors, free orange juice and the opportunity for mothers to chat and to speak to community nurses. They were meeting points for young mothers to share information about their babies and receive the correct advice. When the noble Lord, Lord Darzi, responds to the debate, I would like him to promise me that if and when his polyclinics are set up—I have to confess that I am a fan of such clinics for some areas—please, please can we have preventive and community health in order to provide sensible advice for mothers, the elderly and people with long-term diseases. That is what we are lacking now. A lot of GPs have tried to provide those services, which used to be available in community clinics, but many do not. They are particularly important in deprived areas. For a long time I worked in Southall in Middlesex where such clinics were essential to the community. I hope that the Minister will address this point and promise that those services will be brought back.

My last word is this. Please can we get it across to people that the National Health Service is there to help us when we are sick. It is not there to allow us to abuse our bodies and do what we like, just so that the health service can pick up the tab and make us better, whether ourselves or our children. I look forward to the Minister’s reply.

My Lords, the topic of obesity is by no means a new one in your Lordships’ House, but the noble Baroness, Lady Rendell, has turned our minds to an extremely important aspect of it. It is also one on which government pronouncements have been comparatively few. I congratulate the noble Baroness on tabling her Question and for the compelling way in which she spoke to it.

When we look at the statistics for maternal deaths in this country, I think it is important that we do not overplay the scale of the problem. The UK has one of the lowest rates of maternal deaths in the world, but the death rate is beginning to rise. It is about 40 per cent higher than it was 20 years ago, and for the first time deaths from cardiac causes, which are often linked to obesity, are the commonest type of death among women in pregnancy and childbirth. If a woman is obese when she is pregnant, she dramatically increases her risk of death or serious complications in childbirth. The CEMACH report of last December described obesity as,

“one of the greatest and growing overall threats to the childbearing population of the UK”.

That is surely a wake-up call.

The threats are not only the ones directly associated with obesity, like sepsis and blood clots. They also lie in the fact that women from less affluent backgrounds are more likely to be in poor overall health and less likely to have regular contact with maternity services. The evidence of risk is quite clear, and we have heard about it from all noble Lords. An obese woman is three times more likely to miscarry, two or three times more likely to suffer from pre-eclampsia and twice as likely to need a caesarean section. She runs a fourfold risk of having gestational diabetes.

When we look at the health of the child, there is an equally worrying picture. Obesity in the mother is associated with an increased risk of her baby being born unusually large, which in turn makes it more likely that the child will suffer injury or need intensive care. As the noble Baroness, Lady Finlay, said, obese mothers are less likely to breastfeed, which often leads to babies gaining weight more rapidly than they otherwise would. The risk of spina bifida is multiplied threefold. In the longer term, there is evidence that children of obese mothers may be pre-programmed for increased obesity and impaired cardiovascular health when they are older, which tends to suggest that the problem, as the noble Lord, Lord Patel, pointed out, could, in this sense, be self-perpetuating.

The trouble is that, as so often with health matters, the messages for women are not completely straightforward. Obesity may be harmful, but having a lower than normal body mass index is equally bad. Underweight women are subject to pregnancy-related complications such as giving birth prematurely and having a child of low birth weight. So it is important to be balanced in pitching any public health messages in this area.

However, even this is far from easy because it is not simply a case of saying to women that before they think of becoming pregnant they should aim for an optimum weight. It has been found that, for women who have already had a child, putting on or taking off weight between pregnancies carries its own quite considerable health risks. Increases in the body mass index of only one or two units were associated with significantly increased rates of pre-eclampsia, gestational diabetes and hypertension, and also led to babies who were excessively large. An increase of more than three body mass index units significantly increased the rate of stillbirth and perinatal complications, quite independently of whether the woman was overweight or not. Equally, women who lost five or more body mass index units between pregnancies were found to have a higher risk of giving birth prematurely than women whose weight remained stable or who gained weight. So gaining or losing a lot of weight between pregnancies poses its own serious risks to a mother's health and to that of her baby. That means that getting to, and keeping to, a normal weight before, during and after pregnancy is, ideally, what women should aim for.

What we know about the increased risk factors for women in pregnancy does, I think, have some serious implications for IVF services. It has been recognised for many years that obesity reduces the chances of successfully achieving conception. But if obesity also adds to risk, then it is questionable whether public funds should be spent in cases where the risk factors are very obviously present. Currently, NICE advises that patients should ideally have a BMI of between 19 and 30 when seeking IVF. However, about 18 months ago, doctors in the British Fertility Society recommended that women with a BMI of 36 or more should be disqualified from treatment altogether, and women with a BMI of between 30 and 36 should be accepted only if they engage in a regime of diet and exercise. I should be glad if the Minister would comment on that.

At the moment, there are no national eligibility criteria: it is up to individual PCTs to set their own limits and restrictions. The result really is, I am afraid, reminiscent of a lottery, and at the very least there must be a case for basing the criteria on the clinical evidence and, at the same time, making them much more transparent. In New Zealand, where strict eligibility limits have been applied based on a woman's BMI index, the results have, I understand, been encouraging, because women are made to take control of their own health.

Part of the problem with conveying the necessary public health messages about obesity is that even today, after several years of media coverage of the problem, the public are still generally ignorant of the health implications of being obese and why they are so serious. At the same time, social etiquette dictates that we never tell a person to their face that he or she is too fat, because nowadays that is considered offensive. As a result, in many cases, obesity is given every encouragement to continue unchecked. The CEMACH report was quite unequivocal in saying that women who are obese, and especially those who also have a pre-existing medical condition such as diabetes or epilepsy, should have proper counselling and support.

In my view, the case for the hazards associated with obesity to form a key part of a new national service framework on the care of women before and during pregnancy is compelling. All relevant professionals should be made to appreciate the importance of advice and counselling on obesity in this context; and we should try to look at new ways of bringing home to women contemplating pregnancy that if they are obese or severely overweight they are playing Russian roulette with their lives and the lives of their future children. I hope the Minister will be able to tell us that these matters are receiving a serious degree of thought in his department and that the messages from this debate will be closely heeded.

My Lords, I am grateful to my noble friend Lady Rendell for raising this very important subject. Saving Mothers’ Lives, the recent report of the Confidential Enquiry into Maternal and Child Health, raises some very serious issues about the impact of obesity on the health of pregnant women and their children, issues which we are determined to address. I am also grateful to noble Lords who have contributed so knowledgeably to today’s debate. In the short time available to me I want to summarise the current understanding of the issues and set out what actions the Government are taking. I shall also seek to respond to as many points as I can.

As noble Lords will be aware, Britain is in the grip of an obesity epidemic. Almost two-thirds of adults and a third of children are either overweight or obese. This has very significant health implications in terms of increased rates of cancer, coronary heart disease and diabetes, to name but a few examples. In addition, as eloquently described by the noble Lord, Lord Patel, obesity poses a risk for any form of intervention, whether that happens to be a delivery or even surgery.

The CEMACH report, Saving Mothers’ Lives, published in December 2007, looked in detail at the causes of maternal death for the period 2003-05. Overall, the number of women who died of obvious pregnancy-related causes has remained at seven per 100,000 maternities. The report highlighted that maternal obesity is emerging as a major and growing risk factor. Currently, around 20 per cent of all pregnant women have a body mass index of more than 30 and are therefore classified as obese. However, more than half of the mothers who died in the UK between 2003 and 2005, the period covered by this report, were overweight or obese, with 27 per cent of the mothers recorded as obese and more than 15 per cent as morbidly obese.

The report’s findings reinforce research studies which have produced overwhelming evidence that obesity in pregnancy contributes to increased morbidity and mortality for both the mother and the baby, as eloquently described by the noble Earl, Lord Howe. The evidence is clear on adverse outcomes not just for the mother but also for the baby. For example, CEMACH’s 2005 report into perinatal mortality found that approximately 30 per cent of mothers who had a stillbirth or a neonatal death were also obese.

How, then, do we tackle these growing problems? Maternity services are already responding by developing local protocols and guidelines. There are a number of national initiatives under way and some further lessons from the research evidence which I would like to highlight. I will also highlight the further work that we will do with experts outside the department to help us collectively address these issues.

Many noble Lords in this debate raised the issue of prevention. Prevention is the best way to tackle this and we should be encouraging weight loss before pregnancy as much as possible as part of our overall strategy to tackle obesity. As Saving Mothers’ Lives says, it is vital that we lose no opportunity to explain clearly but sensitively to women of childbearing age who are overweight or obese about the benefits of achieving a good body weight and adopting a healthy lifestyle before conception.

There is also a clinical consensus that women with a BMI of over 30 should be cared for by a multidisciplinary maternity team so that their individual needs and risks can be managed. This is the safest form of care for them and their baby. In the case of very obese women, as for any other patient, this will include risk analysis decisions about the facilities and resources required to support the birth. To do this effectively, services need to ensure that all pregnant women, and particularly women in relatively high-risk groups, including obese women, have access to maternity care early in their pregnancy so that they receive the right advice and get access to the right services from the outset. This is the cornerstone of our maternity policy as set out in Maternity Matters. We will be working with primary care trusts to increase the percentage of women who access services for a full assessment of their needs, risks and choices by the twelfth completed week of pregnancy.

In 2009, the National Institute for Clinical Excellence will be publishing a tool kit to enable each pregnant woman to have her own risks and needs identified so that she receives the best possible help and support during her pregnancy from the most appropriate professionals. Local protocols have also been developed covering, for example, appropriate scan and screening to enable referral to specialists to manage risks such as diabetes, hypertension and thromboembolism; assessment to identify appropriate facilities and equipment for labour and delivery, including increased diagnostics such as ultrasound, suitable surgical instruments, listening devices and beds; and assessment and management of any complications following the birth.

Once their individualised care plans have been established, these women will be closely monitored and supported by their midwife, obstetrician and other members of the maternity team, including nutritionists. Women for whom obesity may pose a significant problem at birth will require an antenatal assessment to discuss the least risky method of birth for both themselves and their babies and an antenatal anaesthetic assessment to discuss analgesia and anaesthesia should caesarean section be necessary.

Although Maternity Matters gives us the policy framework, there is much more to do to address the problems highlighted in the Saving mothers’ lives report. We are working with outside experts in two areas: improved advice on prevention of excessive weight gain in pregnancy and the scope to develop evidence-based UK guidelines on the optimum management of obese women in pregnancy.

First, on prevention, we have asked the National Institute for Health and Clinical Excellence to develop guidance on prevention of excessive weight gain in pregnancy. This will add to a suite of guidance on pregnancy and childbirth which already includes guidance for improving nutrition for pregnant and breastfeeding mothers. We will also be looking to improve information available to clinicians on the care for this group. We have asked the Royal College of Obstetricians and Gynaecologists to consider developing a national clinical guideline for the management of obese pregnant women, both using the numerous local guidelines already in existence and in light of the results of the current CEMACH and National Perinatal Epidemiology Unit research programmes. The need for such a guideline was a key recommendation in the Saving mothers’ lives report. We will work closely with the royal colleges on this.

On some of the specific issues raised in the debate, I am grateful for the acknowledgment by the noble Baroness, Lady Tonge, of the polyclinics. I should probably restrain myself from talking about that subject today. However, I could not agree more that we wish to see an NHS in the future not for sickness but for well-being.

Children and their parents have access to children’s centres, supported by two departments: the Department of Health and the DCSF. These centres bring together services for education and health, and have an important role to play in preventive care. They also provide opportunities for mothers to meet and gain experience and support from these different resources.

The noble Earl, Lord Howe, mentioned the current guidelines for IVF and the BMI rates. Most PCTs currently have a policy that, before receiving fertility treatment, women should aim to have a BMI of 19 to 30. The NICE fertility guidelines on the assessment and treatment for people with fertility problems say that women with a BMI of more than 29 should be informed that they take longer to conceive and that losing weight is likely to increase the likelihood of conception. They also refer to men; men with a BMI of more than 29 are likely to have reduced fertility.

The noble Baroness, Lady Finlay, raised the important point of the role of the Health and Social Care Bill. The Bill includes the provision to inform parents of their child’s weight, height and BMI when measured at school at the entry age of 5 and at age 10 to 11. This will alert parents to their child’s weight and, it is hoped, promote them to take action.

The noble Baronesses, Lady Finlay and Lady Tonge, asked what the Government are doing on breastfeeding. Our main challenge is to focus on interventions that will promote breastfeeding. We know that health professionals such as midwives and health visitors can play a vital role in encouraging more mothers to initiate and sustain breastfeeding beyond the early weeks.

The noble Lord, Lord Patel, mentioned the Government recruiting an additional 4,000 midwives. Many of these midwives will be new to the profession but there are also former midwives whose expertise could be brought back into the NHS. The department, along with the Royal College of Midwives, will therefore launch a return-to-practice campaign this summer, with incentives including free training support with childcare and travel costs.

I am running short of time so I will conclude, but I will be more than happy to address some of the other issues raised today. The Government take very seriously the need to address this country’s obesity epidemic and the health implication which stems from it. I hope I have demonstrated that we take equally seriously the need to support high-risk groups, such as obese women who are, or may become, pregnant, recognising the health impacts for them and their babies, so ably described by noble Lords. I thank the noble Baroness once again for bringing this subject forward and also all the noble Lords who have contributed to today’s important debate.

My Lords, I beg to move that the House do now adjourn for two minutes.

Moved accordingly, and, on Question, Motion agreed to.

[The Sitting was suspended from 8.40 to 8.42 pm.]