The experience of pregnant women with a body mass index >30 kg/m2of their encounters with healthcare professionals

Factors Influencing Weight Management in Pregnant Women with Overweight or Obesity: A Meta-Synthesis of Qualitative Studies

BACKGROUND

Overweight and obesity have multiple negative consequences for the health of both the mother and the child. Interventions to prevent excessive weight gain during pregnancy have had varying success, and the proportion of pregnant women who exceed national guidelines for weight gain continues to increase.

OBJECTIVE

To investigate the influence of factors on weight management among pregnant women with overweight or obesity.

METHODS

This meta-synthesis of qualitative studies involved searching databases PubMed, Embase, Cochrane, Scopus, and Web of Science. The databases were searched on October 4, 2022, and the search was updated on April 21, 2023. The screening of titles, abstracts, and full texts was conducted utilizing Covidence software. The quality assessment of the articles was performed using the Critical Appraisal Skills Programme checklist. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement was used to enhance transparency in reporting. A meta-aggregation approach was used to guide the data extraction and synthesis.

RESULTS

A total of 46 studies with appropriate Critical Appraisal Skills Programme scores were included for qualitative synthesis. Findings were extracted and integrated into 4 themes: psychological factors (personally driven negative emotions and society-driven negative emotions), social factors (societal attitudes and beliefs and social support resources), factors related to education and counseling (information provision and communication), and factors associated with effective care (provided care components and the method of providing effective care).

CONCLUSIONS

To improve weight management during pregnancy, health care providers should provide tailored and individualized recommendations that take into consideration the factors influencing these women.

Drivers and facilitators of weight stigma among preconception, pregnant, and postpartum women: A systematic review

Women in the preconception, pregnant, or postpartum period are susceptible to weight stigma, particularly due to the risk of excess weight gain during the reproductive life period and the negative effects of stigma on the health of both the mother and the child. Identifying the drivers and facilitators of weight stigma will help guide focused weight stigma prevention interventions. This systematic review aimed to identify the drivers and facilitators of weight stigma among preconception, pregnant, and postpartum women. In May 2022, Medline, Embase, PsycINFO, and the Maternity and Infant Care Database were searched for peer-reviewed articles published since 2010 using search terms weight AND stigma AND preconception, OR pregnant, OR postpartum. Of the 1724 articles identified, 34 fulfilled the inclusion criteria and were included in a narrative synthesis. Women reported facing insensitive language, misconceptions about obesity across all settings, and inappropriate media representation. The unavailability of appropriate equipment at facilities was reported by both women and health professionals. Our findings indicate that a rigorous effort by all stakeholders is necessary to promote regulatory, legal, and educational initiatives designed to reduce weight stigma and discrimination against women in the reproductive period.

Women's perceptions of body mass graphics and their preferences for weight counselling

Health care providers may lack data-driven guidance about best practises for discussing weight. We assessed women's self-perception of body mass index (BMI) and preferences for weight counselling by provider characteristics and the initiating question. A voluntary, anonymous survey was completed by 756 women (age ≥ 19 year) at our tertiary care obstetrics and gynaecology clinics in autumn 2021. The respondents' height and weight were collected before respondents selected graphics from a validated Body Image Scale that they felt best represented their current body size and which graphs should prompt weight loss or gain recommendations. Respondents were asked their preferences about provider characteristics for discussion about weight and to identify which of six initiating questions from a provider was most and least preferred. Blank responses were allowed. In 708 responses, 366 women (52%) selected the most accurate graphic that corresponded to their BMI; the selected graphic represented a lower than actual BMI in 268 women (38%) and higher in 74 women (10%). In 648 responses, 374 women (58%) preferred a female provider, but provider body shape, ethnicity/race and age were not important to most women. The most preferred question to initiate a discussion about weight was "A lot of women have trouble achieving or maintaining a healthy weight; is that something we can discuss?" in 181 of 555 women (33%), and the least preferred question was "Do you feel like you are at an appropriate weight?" in 172 of 554 women (31%). Provider knowledge about patient preferences regarding questions may facilitate the discussion about weight.

Mitigating Weight Bias in the Clinical Setting: A New Approach to Care

Weight bias toward patients in larger bodies is pervasive among health care providers and can negatively influence provider-patient communication, as well as patients' behavior and health outcomes. Weight bias has historical roots that perpetuate thinness and Whiteness as the cultural norm. Although weight bias remains socially acceptable in US culture, contributing factors to an individual's body size are complex and multifactorial. Providers and health care systems also consistently use body mass index (BMI) as an indicator of health status, despite its limitations and harmful effects in the clinical setting. This state of the science review presents 8 evidence-based strategies that demonstrate how to mitigate harm from weight bias and improve quality of care and health outcomes for patients living in larger bodies. Person-centered approaches to care include (1) eliminating clinical recommendations to lose weight; (2) shifting from a focus on weight to health; (3) implementing a size and weight-inclusive approach; (4) engaging in weight bias self-evaluation; (5) creating a welcoming environment for patients of all sizes; (6) seeking permission and learning the patient's story; (7) using weight-inclusive language; and (8) re-evaluating clinical guidelines and policies based on BMI. Midwives and other health care providers may benefit from training that re-imagines the delivery of health care to patients in larger bodies.

The makings of a maternal obesity epidemic: A meta-narrative review

STUDY BACKGROUND

The prevalence and complications of maternal obesity are well reported; with a hegemonic medicalised view leading to women's pregnant bodies being 'managed'. We aimed to address current knowledge gaps by exploring the literature across research traditions and overtime to better understand the experiences of maternity care for women living with obesity, in relation to choice, consent and control.

METHODS

A systematic review using meta-narrative methods. Identification of studies included a scoping phase involving experts, hand searching and database browsing and a systematic searching phase. Seven databases (MEDLINE, MIDIRS, CINAHLComplete, Scopus, SocINDEX, PsycINFO, SPORTDiscuss) were searched with no date or geographical restriction. Non- English language studies were excluded. Two authors appraised quality prior to data extraction and synthesis. Data were tabulated, and women's experiences conceptualised in relation to choice, consent and control, first, by research tradition to reveal the unfolding storyline, secondly emergent narratives were synthesised into meta-themes.

RESULTS

Twenty-four studies were included, from six research traditions. Of these, twenty-one were qualitative, two were quantitative, and one study utilised a mixed method design. Studies spanned twenty-six years from 1994 to 2020. Across research traditions, four themes were evident, 'women's beliefs and experiences of weight', 'social determinants', 'being risked-managed' and 'attitudes of caregivers'. Over time, management of maternal obesity has moved from a focus on weight gain and diet as a woman's issue, to weight being pathological resulting in increased medicalisation, to a renewed focus on lifestyle through the public health arena. It suggests that lack of choice over care can reduce women's perception of control over their pregnancy and birth experience.

CONCLUSION

Increased medicalisation of maternal obesity, which includes defining and managing weight as pathological can limit women's choice and control over their maternity care. There is a need for national and local policy development which includes women in the process. It is important that women's views are heard, understood and acted upon so that a balance can be achieved, avoiding over medicalisation, yet ensuring mortality and morbidity risks are minimised.

Weight stigma experienced by patients with obesity in healthcare settings: A qualitative evidence synthesis

Weight stigma research is largely focused on quantifiable outcomes with inadequate representation of the perspectives of those that are affected by it. This study offers a comprehensive systematic review and synthesis of weight stigma experienced in healthcare settings, from the perspective of patients living with obesity. A total of 1340 studies was screened, of which 32 were included in the final synthesis. Thematic synthesis generated three overarching analytical themes: (1) verbal and non-verbal communication of stigma, (2) weight stigma impacts the provision of care, and (3) weight stigma and systemic barriers to healthcare. The first theme relates to the communication of weight stigma perceived by patients within patient-provider interactions. The second theme describes the patients' perceptions of how weight stigma impacts upon care provision. The third theme highlighted the perceived systemic barriers faced by patients when negotiating the healthcare system. Patient suggestions to reduce weight stigma in healthcare settings are also presented. Weight stigma experienced within interpersonal interactions migrates to the provision of care, mediates gaining equitable access to services, and perpetuates a poor systemic infrastructure to support the needs of patients with obesity. A non-collaborative approach to practice and treatment renders patients feeling they have no control over their own healthcare requirements.

Pregorexia: a systematic review and meta-analysis on the constructs of body image dissatisfaction and eating disturbances by gestational age in the peripartum

PURPOSE

Pregorexia is a phenomenon posited to occur in the peripartum, characterized by an attempt to counter pregnancy's physiological changes in body shape through reduced calorie intake or increased physical activity.

METHODS

In this pre-registered systematic review and meta-analysis, body image dissatisfaction and eating psychopathology in the peripartum according to gestational age were formally assessed. PubMed was searched up to May 2023. Selection criteria were represented by studies on body image concerns or eating psychopathology in the peripartum (up to 1 year after delivery). The population needed to include women from the general population or among patients with a history of (or current) eating disorder. For the meta-analysis, 17 studies were included: 10 for body image dissatisfaction (2625 individuals overall), 7 for eating behaviors (2551 individuals overall). The interplay between body image and the following themes was examined in depth: the adoption of breastfeeding, peripartum depression, sociocultural influences on body image, sexual disturbances, experiencing or reporting an altered food intake.

RESULTS

Progressive dissatisfaction with body image during pregnancy by gestational age was observed, stably elevated for at least 12 months postpartum. Eating psychopathology was observed as elevated only at 12 months in the postpartum, but not during pregnancy.

DISCUSSION

The current work offers normative values of body image satisfaction and eating psychopathology in the peripartum by gestational age. The relevance of current results was discussed, in order to inform both current clinical practice and future public policies.

LEVEL OF EVIDENCE

Level I-Evidence obtained from: systematic reviews and meta-analyses.

Midwives perceptions of managing pregnancies complicated by obesity: A mixed methods study

OBJECTIVE

The growing prevalence of obesity is a concern for midwives. In Canada, the absence of regulatory standards, varying protocols and consultant preferences shape clinical decision making for the midwife and may lead to inconsistent practice. Our aim was to understand the barriers, enablers, and knowledge gaps that influenced experiences of midwives in Ontario, Canada when providing care to clients impacted by obesity.

METHODS

Mixed methods design using a sequential, explanatory approach. Surveys conducted with midwives were administered using an online platform, followed by semi-structured interviews to understand the perspectives elicited in the survey in greater detail. Interviews were audio recorded and transcribed verbatim. Survey data were analyzed using descriptive statistics, and thematic analysis was used for generating codes, categories and themes from the interview data.

RESULTS

144 midwives completed the survey and 20 participated in an interview. The participants described their clinical management when caring for those with obesity which included considerations regarding additional tests/investigations, consultation and transfer of care, and place of birth. Up to 93% of surveyed midwives believed that clients with obesity were appropriate for midwifery-led care however there was less certainty about suitability as BMI increased to higher ranges such as > 45). The care management was influenced by beliefs and attitudes, knowledge, and system-level factors. Midwives experienced barriers such as inconsistent practices and role confusion, and felt ill equipped to care for pregnancies affected by obesity due to unclear guidelines.

CONCLUSIONS

Overall, midwives believe clients with obesity are suitable for midwifery-led care due to its individualized, non-judgmental approach to care. Additional training for midwives and other obstetric care providers would be beneficial to help overcome barriers in providing effective care to pregnancies affected by obesity.

The WOMBS Framework: A review and new theoretical model for investigating pregnancy-related weight stigma and its intergenerational implications

As the growing weight stigma literature has developed, one critically relevant and vulnerable population has received little consideration-pregnant and postpartum women. Because weight fluctuations are inherent to this life phase, and rates of prepregnancy overweight and obesity are already high, this gap is problematic. More recently, however, there has been a rising interest in pregnancy-related weight stigma and its consequences. This paper therefore sought to (a) review the emerging research on pregnancy-related weight stigma phenomenology and (b) integrate this existing evidence to present a novel theoretical framework for studying pregnancy-related weight stigma. The Weight gain, Obesity, Maternal-child Biobehavioral pathways, and Stigma (WOMBS) Framework proposes psychophysiological mechanisms linking pregnancy-related weight stigmatization to increased risk of weight gain and, in turn, downstream childhood obesity risk. This WOMBS Framework highlights pregnant and postpartum women as a theoretically unique at-risk population for whom this social stigma engages maternal physiology and transfers obesity risk to the child via social and physiological mechanisms. The WOMBS Framework provides a novel and useful tool to guide the emerging pregnancy-related weight stigma research and, ultimately, support stigma-reduction efforts in this critical context.

A qualitative exploration of obesity bias and stigma in Irish healthcare; the patients' voice

BACKGROUND

Current data indicates 70% of adults with obesity report experiencing bias and stigmatisation when engaging with healthcare. Most studies to date, have focused on weight bias from a healthcare professional's perspective. Few have explored weight bias from the perspective of the individual living with obesity and no study has conducted this research in the Irish context.

AIMS

This study explored, the lived-in experience of individuals afflicted with obesity, when interacting with the Irish healthcare system. It examined whether participants encountered weight bias and stigma, if so, how it may have impacted them and gathered their suggestions on how it could be best addressed.

METHODS

Employing a phenomenological approach, purposive sampling and semi-structured interviews were conducted with 15 individuals living with class II (BMI 35.0-39.9) or III obesity (BMI ≥40kg/m2) who reported regular and consistent engagement with the Irish healthcare system. Predominant emergent themes were categorised using the interview domains; (1) experiences of obesity bias and stigma, (2) impact of this bias and stigma and (3) suggested avenues to reduce bias and stigma.

FINDINGS

Participants reported experiencing high levels of weight bias and stigmatisation. Relating to experiences, three themes were identified; interpersonal communication, focus of care and physical environment. In terms of its impact, there were two emergent themes; negativity towards future healthcare and escalation of unhealthy behaviours. Suggested avenues to eliminate bias and stigma included the introduction of a timely and clear clinical pathway for obesity management and a focus on HCPs education in relation to obesity causes and complexity.

CONCLUSIONS

Outside of specialist obesity tertiary care, weight bias and stigmatisation is commonly reported in the Irish healthcare system. It is a significant issue for those living with obesity, detrimental to their physiological and psychological health. A concerted effort by HCPs across clinical, research and educational levels is required to alleviate its harmful effects.

Being overweight or obese during pregnancy: a qualitative study

OBJECTIVE

The objectice of this study was to reveal difficulties, coping and expectations of overweight/obese women during pregnancy.

METHODS

A descriptive, phenomenological approach was used. Fourteen pregnant women having a body mass index of 25 or over 25.

RESULTS

The findings were presented under three themes: difficulties experienced, coping and expectations. The women had physical difficulties and their daily life was affected negatively. They experienced stigmatization, humiliation and uncertainty about how much they had to eat during pregnancy. Therefore, they were upset and unhappy. Some women denied that they were overweight and some women considered being overweight as normal due to pregnancy. Social support plays an important part in coping with difficulties; however, some women could not get sufficient social support. The women also expected to be treated tolerantly.

CONCLUSION

Overweight/obese women try to overcome many physical and psychological problems due to their weight during pregnancy, but they do not receive adequate support.

The Influence of Four Constructs of Social Support on Pregnancy Experiences in Group Prenatal Care

Objective: This study aimed to identify the influence of the four constructs of social support on positive pregnancy experiences in CenteringPregnancy, a group prenatal care (GPNC) model. Methods: Using a qualitative descriptive design, semi-structured interviews were conducted with 11 women who had participated in at least 6 of 10 GPNC sessions at a family practice medicine residency. Participants were asked to describe their experiences in GPNC. Results: Using a standard content analysis, four constructs of social support (emotional, informational, instrumental, and appraisal) were identified through three major themes: (1) informational support, offered by peers in GPNC settings, promotes learning and prepares women for motherhood; (2) emotional and appraisal support, offered by peers in GPNC, improves emotional well-being and helps women build lasting, supportive connections with peers, and (3) emotional, informational, instrumental, and appraisal support work in tandem to create positive relationships between women and health care providers. Conclusion: Social support provided a means to a positive prenatal health care experience that facilitated the attainment of new knowledge and the formation of positive relationships with health care providers and peers. The findings of this study can provide health care providers with a framework to examine and enhance their practice and care of women in the perinatal period.

The Relationship Between Internalized Weight Stigma During Pregnancy and Breastfeeding: A Prospective Longitudinal Study

OBJECTIVE

This study aimed to examine the relationship between internalized weight stigma during pregnancy and breastfeeding outcomes at 1 month post partum among individuals with prepregnancy overweight or obesity. Secondarily, the study explored the temporal stability of internalized weight stigma from the third trimester to 1 month post partum via the Weight Bias Internalization Scale (WBIS).

METHODS

A total of 103 pregnant individuals with overweight or obesity were recruited for this study. Participants completed the WBIS during the third trimester and self-reported breastfeeding initiation, continuation, and exclusivity outcomes at 1 month post partum. A paired t test and binomial logistic regression were conducted with covariates hierarchically added to the model.

RESULTS

The average prepregnancy BMI was 33.53 (SD 7.17) kg/m² (range = 25.4-62), and average prenatal WBIS scores were 25.95 (SD 11.83). No difference was found in mean prenatal and postpartum scores (25.95 [SD 11.83]; 26.86 [SD 13.03], respectively; t₉₄ = -0.83, P = 0.41), evidencing temporal stability in WBIS scores from pre to post partum. Prenatal WBIS scores did not predict breastfeeding initiation, continuation, or exclusivity at 1 month post partum in either unadjusted or adjusted models.

CONCLUSIONS

Collectively, this sample displayed low weight bias internalization, which was not predictive of breastfeeding initiation, continuation, or exclusivity at 1 month post partum. Future research is needed to develop a pregnancy-specific weight stigma measure.

She "didn't see my weight; she saw me, a mom who needed help breastfeeding": Perceptions of perinatal weight stigma and its relationship with breastfeeding experiences

Weight stigmatization is related to emotional and psychological distress including low self-esteem, body image dissatisfaction, depression, and anxiety; all linked with suboptimal breastfeeding outcomes. This qualitative descriptive study explored postpartum individuals' recalled experiences of weight stigma during interactions with perinatal healthcare professionals and its perceived influence on their breastfeeding experiences. Semi-structured phone interviews were conducted with (n= 18) participants. Three themes emerged: (1) "Size Doesn't Matter: They Looked Beyond the Scale," (2) "My Self-Confidence and Desire to Breastfeed is More Important than Weight," and (3) "I Was on My Own"-Limited Social Support not Weight Stigma Influenced Breastfeeding.

"Talk to me, not at me": obese women's experiences of birth and their encounter with birth attendants-a qualitative study

Purpose: To explore the birth experiences of obese women in regard to their encounter with birth attendants.

Methods: Qualitative, in-depth interviews with 10 women were conducted in February 2020. Data were analysed using a descriptive phenomenological method.

Results: Four interrelated constituents were identified: The preconception and prejudice of being unhealthy and less able; Being unique among all the other unique women; “Talk to me, not at me”—the importance of information and communication, and; Feeling secure enough to be in the 'birthing bubble'.

Conclusion: For the women in our study, being obese meant experiencing challenges as well as opportunities during childbirth and in their encounter with birth attendants. Experiences of preconceptions, alienation, a focus on risk and a loss of autonomy in encounters with birth attendants were found to negatively impact the birthing process. The women desired affirmative and inclusive encounters; these kinds of encounters may improve the birth experiences of obese women.

What are the experiences of women with obesity receiving antenatal maternity care? A scoping review of qualitative evidence

PROBLEM

Obesity is a major public health problem and is rising in prevalence in child-bearing women. The complications of pregnancy in women with obesity are well documented. Pregnant women with obesity require different maternity care considerations to normal weight women. How women respond to the care of health professionals, determines how likely they will be to engage with it, and thus research into the current care experiences of women with obesity is valuable.

OBJECTIVE

The purpose of this scoping review was to examine the evidence of the antenatal maternity care experiences of women with obesity (BMI≥30kg/m²).

METHOD

A systematic literature search was conducted for English language publications 2008-2018 using Medline, Scopus, PsycINFO and CINAHL. Following critical appraisal, and a search of the reference lists of primary articles, 17 articles resulted for this review. A thematic synthesis process was used to collate the findings.

FINDINGS

Four major themes were identified: 1) inconsistent or absent information regarding weight management, 2) the stigma and stereotyping associated with their obesity, 3) medicalisation and depersonalisation of pregnant women with obesity, and 4) a desire for information and need for change.

CONCLUSION

The findings suggested that based on women's experiences there is a need for improved education and communication for health care professionals when caring for pregnant women with obesity. Some conflicting information from women in the studies highlight the need for further research in the area, and the implementation of individualised care and continuity of care for pregnant women with obesity.

Communication practices of healthcare professionals when caring for overweight/obese pregnant women: A scoping review

OBJECTIVE

To synthesize existing research on communication practices between healthcare professionals and overweight and obese pregnant women.

METHODS

Following PRISMA guidance on conducting scoping reviews, we included original research addressing communication/counseling practices of healthcare professionals with overweight and/or obese pregnant women, published between 2008-2018, and available in English. Fourteen articles are included in this review.

RESULTS

Study findings were organized into three themes: (a) topics addressed during encounters, (b) providers' comfort/confidence, knowledge and methods in communicating with overweight/obese pregnant women, and (c) overweight/obese pregnant women's experiences in communicating with healthcare providers. The most prevalent topics addressed were gestational weight gain, physical activity, and nutrition. Healthcare professionals experience discomfort and are reluctant to address weight status with overweight/obese pregnant patients, use vague statements about weight gain and weight-related obstetric risks, and report low confidence when counseling obese pregnant women. Overweight/obese pregnant women perceive weight stigma when interacting with providers.

CONCLUSION

Weight-related counseling in obstetric care is suboptimal. Providers may benefit from training to more confidently and effectively counsel overweight and obese pregnant women about gestational weight gain, physical activity, and nutrition.

PRACTICE IMPLICATIONS

Patients perceive weight stigma in the obstetric setting, which may be prevented by effective, patient-centered communication.

Competing priorities: a qualitative study of how women make and enact decisions about weight gain in pregnancy

Background

Despite ample clinical evidence that gaining excess weight in pregnancy results in negative health outcomes for women and infants, more than half of women in Western industrialized nations gain in excess of national guidelines. The influence of socio-demographic factors and weight gain is well-established but not causal; the influence of psychological factors may explain some of this variation.

Methods

This is the qualitative portion of an explanatory sequential mixed-methods study designed to identify predictive psychological factors of excess gestational weight gain (QUAN) and then explain the relevance of those factors (qual). For this portion of the study, we used a qualitative descriptive approach to elicit 39 pregnant women’s perspectives of gestational weight gain, specifically inquiring about factors determined as relevant to excess gestational weight gain by our previous predictive study. Women were interviewed in the latter half of their third trimester. Data were analyzed using a combination of unconstrained deductive content analysis to describe the findings relevant to the predictive factors and a staged inductive content analytic approach to examine the data without a focus on the predictive factors.

Results

Very few participants consistently made deliberate choices relevant to weight gain; most behaviour relevant to weight gain happened with in-the-moment decisions. These in-the-moment decisions were influenced by priorities, hunger, a consideration of the consequence of the decision, and accommodation of pregnancy-related discomfort. They were informed by the foundational information a woman had available to her, including previous experience and interactions with health care providers. The foundational information women used to make these decisions was often incomplete. While women were aware of the guidelines related to gestational weight gain, they consistently mis-applied them due to incorrect understanding of their own BMI. Only one woman was aware that weight gain was linked to maternal and infant health outcomes.

Conclusions

There is an important role for prenatal providers to provide the foundational information to positively influence in-the-moment decisions. Understanding how weight gain guidelines apply to one’s own pre-pregnancy BMI and comprehending the well-established link between gestational weight gain and health outcomes may help women prioritize healthy weight gain amongst many competing factors.

Weight Stigma Related to Pregnancy: A Concept Analysis

The aims of this article are to (1) present a shared definition of weight stigma related to pregnancy and (2) develop a definition to inform valid and reliable nursing research addressing weight stigma in the obstetric setting. Weight stigma is increasingly prevalent in society, especially among women with prepregnancy overweight or obesity. However, a universally accepted definition of weight stigma related to pregnancy has yet to be identified. We followed Walker and Avant's concept analysis methodology using an iterative approach to ensure a robust and conceptually sound definition of weight stigma related to pregnancy.

Obesity in Pregnancy - Patient-Reported Outcomes in Qualitative Research: A Systematic Review

The purpose of this study was to determine the clinical and non-clinical outcomes that pregnant women with obesity value as pertaining to their health and that of their babies. In this systematic review of the qualitative literature, a search of four databases was conducted for studies using qualitative methods in pregnant women with obesity. From the included studies, the review synthesized relevant themes representing the voiced concerns and perceived benefits of and barriers to the uptake of interventions, to yield patient-reported outcomes (PROs). PROs were categorized into domains according to the published taxonomy of outcomes in medical research. Of the 89 identified studies, 27 were included, none of which were primarily intended to elicit PROs. A total of 256 PROs and 7 distinct themes were identified. Only 13% of PROs represented physiological or clinical outcomes, whereas 21% represented the core area of emotional functioning or well-being, and 15% represented the area of delivery of care. The most frequently voiced concern was inadequate health care provider support (60%), and women considered intervention-specific challenges to be the greatest barriers to the uptake of interventions (34%). This study synthesized the qualitative evidence of concerns that pregnant women with obesity have regarding their pregnancy and postpartum care, as well as specific barriers they perceive to the uptake of interventions. In addition, this study revealed that clinical outcomes, which are most often reported in clinical trials, comprise only a minority of outcomes considered important by these women. A core outcome set that adequately incorporates PROs is required to inform the conduct of future trials in pregnant women with obesity.

Perceptions of risk and influences of choice in pregnant women with obesity. An evidence synthesis of qualitative research

Background

Between 7–35% of the maternity population are obese in high income countries and 1–40% in lower or middle-income countries. Women with obesity are traditionally limited by the choices available to them during pregnancy and birth because of the higher risk of complications. This evidence synthesis set out to summarise how women with obesity’s perceptions of pregnancy and birth risk influence the care choices that they make.

Methods

A search of medical and health databases for qualitative studies written in the English language, published Jan 1993—April 2019 and reporting on pregnant women with obesity’s perception of risk and influence of pregnancy and birth choices. Data was extracted by two reviewers onto a questions framework and then analysed using a thematic synthesis technique. Confidence in the qualitative findings was assessed using GRADE-CERQual.

Results

23 full texts were included. The common themes on perception of risk were: ‘Self-blame arising from others’ stereotyped beliefs ‘, ‘Normalisation’, ‘Lack of preparation’, ‘Fearful acceptance and inevitability’ and ‘Baby prioritised over mother’. For influence of choices, the themes were: ‘External influences from personal stresses’, ‘Restrictive guidelines’, ‘Relationship with healthcare professional’ and ‘Perception of Risk’.

Conclusions

Evidence on what influences women with obesity’s pregnancy choices is limited. Further research is needed on the best methods to discuss the risks of pregnancy and birth for women with obesity in a sensitive and acceptable manner and to identify the key influences when women with obesity make choices antenatally and for birth planning.

The nutrition-related information seeking behaviours and attitudes of pregnant women with a high BMI: A qualitative study

BACKGROUND

The prevalence of high body mass index is increasing amongst women of child bearing age. High maternal body mass index has ramifications for both mother and baby including increased health risks from gestational diabetes mellitus, caesarean section and stillbirth. Despite the increasing prevalence of high maternal body mass index little is known of the experiences of these women regarding nutrition information access and use during the antenatal period.

METHODS

A qualitative study using individual interviews was undertaken at a tertiary hospital in south-eastern Australia. Twenty-Eight women with a body mass index ≥30kg/m² participated. Interviews were audio recorded, transcribed, cross-checked for consistency and entered into a word processing document for further scrutiny. Data was analysed using interpretative phenomenological analysis (IPA). In any phenomenological study the researcher's objective is to elicit the participant's views on their lived experiences.

FINDINGS

Three major themes emerged: (1) Nutrition-related information attainment; (2) Nutrition-related information management; (3) Nutrition-related information needs and wants.

CONCLUSION

The findings from this study may assist the future development and dissemination of nutrition-related information for pregnant women with a high body mass index. Women want more individualised support regarding nutritional requirements during pregnancy.

Hospital breastfeeding support and exclusive breastfeeding by maternal prepregnancy body mass index

Overweight and obese mothers in the United States have disproportionately lower rates of exclusive breastfeeding than mothers of normal weight. The Ten Steps to Successful Breastfeeding (Ten Steps), a series of evidence-based practices designed to support breastfeeding initiation, duration, and exclusivity, demonstrate effectiveness at the population level. It is unknown, however, whether they are consistently provided to women across all maternal body mass index (BMI) categories. We sought to determine whether pre-pregnancy BMI is associated with the implementation and effectiveness of the Ten Steps. We used data from Listening to Mothers III, a cross-sectional survey administered to a sample of mothers who delivered in U.S. hospitals between July 2011 and June 2012. Measures of the Ten Steps were based on maternal self-report on Listening to Mothers III. Our analytic sample was limited to mothers of term infants intending to breastfeed (N = 1,506, weighted). We conducted chi-square testing and constructed weighted multivariable logistic regression models to account for potential confounders. Results suggest that two practices (i.e., holding their babies skin-to-skin for the first time and being encouraged to breastfeed on demand) were more strongly associated with exclusive breastfeeding among mothers with obesity than other mothers. Additionally, mothers with obesity reported holding babies skin-to-skin significantly less often than other mothers. Thus, interventions aimed at helping mothers with obesity to hold their babies skin-to-skin in the first hour and teaching them to breastfeed on demand have the potential to decrease the breastfeeding disparities in this population.

Being targeted as a "severely overweight pregnant woman" -A qualitative interview study

Background

Pregnant women with a body mass index (BMI) ≥ 30 kg/m² have been targeted in health‐care systems in many western countries as a high‐risk group. However, we have limited knowledge of the long‐term significance of this prenatal care policy.

Objective

To investigate accounts women give of their experiences of being targeted as severely overweight during pregnancy when they look back at the intervention 4‐5 years later.

Design

Interpretive analysis based on 21 semi‐structured interviews conducted 4‐5 years after the pregnancy with Danish mothers categorized as having a pre‐pregnancy BMI ≥ 30.

Findings

In the women's retrospective accounts three phases were identified and separated: (i) Being identified as a “severely overweight pregnant woman.” The women differed over whether they accepted this categorization, but all believed that an approach based on weight was acceptable. (ii) Encounters with health‐care professionals. The women differed here: some reported no negative experiences; others reported experiences of prejudice and silence. (iii) Reflections on long‐term outcomes. Most women reported that the interventions during their pregnancies did not lead to any lasting lifestyle change. The women disagreed over whether, in principle, pregnancy was a suitable time to be targeted.

Discussion and conclusion

Our study illustrates the importance of critically considering whether pregnancy is a suitable window of opportunity for obesity prevention, and shows that women's experiences should be examined in relation to each phase of intervention. More interdisciplinary studies are needed to map potential benefits and other consequences over the short‐ and long‐term.

Pregnant women's perceptions of gestational weight gain: A systematic review and meta-synthesis of qualitative research

Excess gestational weight gain has numerous negative health outcomes for women and children, including high blood pressure, diabetes, and cesarean section (maternal) and high birth weight, trauma at birth, and asphyxia (infants). Excess weight gain in pregnancy is associated with a higher risk of long-term obesity in both mothers and children. Despite a concerted public health effort, the proportion of pregnant women gaining weight in excess of national guidelines continues to increase. To understand this phenomenon and offer suggestions for improving interventions, we conducted a systematic review of qualitative research on pregnant women's perceptions and experiences of weight gain in pregnancy. We used the methodology of qualitative meta-synthesis to analyze 42 empirical qualitative research studies conducted in high-income countries and published between 2005 and 2015. With this synthesis, we provide an account of the underlying factors and circumstances (barriers, facilitators, and motivators) that pregnant women identify as important for appropriate weight gain. We also offer a description of the strategies identified by pregnant women as acceptable and appropriate ways to promote healthy weight gain. Through our integrative analysis, we identify women's common perception on the struggle to enact health behaviors and physical, social, and environmental factors outside of their control. Effective and sensitive interventions to encourage healthy weight gain in pregnancy must consider the social environment in which decisions about weight take place.

Women with a BMI ≥ 30kg/m² and their experience of maternity care: A meta ethnographic synthesis

OBJECTIVE

this paper is a report of a systematic review and meta-ethnography of the experiences of women with body mass index (BMI) ≥ 30kg/m² and their experience of maternity care.

METHOD

systematic review methods identified 12 qualitative studies about women's experiences of maternity care when their BMI ≥ 30kg/m². Findings from the identified studies were synthesised into themes, using metaethnography. SYNTHESIS AND FINDINGS: the meta-ethnography produced four key concepts; Initial encounters, Negotiating risk, Missing out and The positive intervention, which represent the experiences of maternity care for women with BMI ≥ 30kg/m² KEY CONCLUSION: many women with BMI ≥ 30kg/m² appear to be dissatisfied with the approaches taken to discuss weight status during maternity encounters. When weight is not addressed during these encounters women appear to be equally dissatisfied. The absence of open and honest discussions about weight, the feeling of being denied of a normal experience, and an over emphasis on the risks imposed upon pregnancy and childbirth by obesity, leave women feeling dissatisfied and disenfranchised. Sensitive care and practical advice about diet and exercise can help women move towards feeling more in control of their weight management.

Providing prenatal care to pregnant women with overweight or obesity: Differences in provider communication and ratings of the patient-provider relationship by patient body weight

OBJECTIVE

To examine the association of women's body weight with provider communication during prenatal care.

METHODS

We coded audio recordings of prenatal visits between 22 providers and 117 of their patients using the Roter Interaction Analysis System. Multivariate, multilevel Poisson models were used to examine the relationship between patient pre-pregnancy body mass index and provider communication.

RESULTS

Compared to women with normal weight, providers asked fewer lifestyle questions (IRR 0.66, 95% CI 0.44-0.99, p=0.04) and gave less lifestyle information (IRR 0.51, 95% CI 0.32-0.82, p=0.01) to women with overweight and obesity, respectively. Providers used fewer approval (IRR 0.68, 95% CI 0.51-0.91, p=0.01) and concern statements (IRR 0.68, 95% CI 0.53-0.86, p=0.002) when caring for women with overweight and fewer self-disclosure statements caring for women with obesity (IRR 0.40, 95% CI 0.19-0.84 p=0.02).

CONCLUSION

Less lifestyle and rapport building communication for women with obesity may weaken patient-provider relationship during routine prenatal care.

PRACTICE IMPLICATIONS

Interventions to increase use of patient-centered communication - especially for women with overweight and obesity - may improve prenatal care quality.

Obese Mothers have Lower Odds of Experiencing Pro-breastfeeding Hospital Practices than Mothers of Normal Weight: CDC Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2008

OBJECTIVES

This study examines the extent to which a mother's pre-pregnancy body mass index (BMI) category is associated with her exposure to pro-breastfeeding hospital practices.

METHODS

Data from the 2004-2008 CDC PRAMS were analyzed for three states (Illinois, Maine, and Vermont) that had administered an optional survey question about hospital pro-breastfeeding practices.

RESULTS

Of 19,145 mothers surveyed, 19 % were obese (pre-pregnancy BMI ≥ 30). Obese mothers had lower odds than mothers of normal weight of initiating breastfeeding [70 vs. 79 % (unweighted), p < 0.0001]. Compared with women of normal weight, obese mothers had lower odds of being exposed to pro-breastfeeding hospital practices during the birth hospitalization. Specifically, obese mothers had higher odds of using a pacifier in the hospital [odds ratio (OR) 1.31, 95 % confidence interval (CI) (1.17-1.48), p < 0.0001] and lower odds of: a staff member providing them with information about breastfeeding [OR 0.71, 95 % CI (0.57-0.89), p = 0.002], a staff member helping them breastfeed [OR 0.69, 95 % CI (0.61-0.78), p < 0.0001], breastfeeding in the first hour after delivery [OR 0.55, 95 % CI (0.49-0.62), p < 0.0001], being given a telephone number for breastfeeding help [OR 0.65, 95 % CI (0.57-0.74), p < 0.0001], rooming in [OR 0.84, 95 % CI (0.73-0.97), p = 0.02], and being instructed to breastfeed on demand [OR 0.66, 95 % CI (0.58-0.75), p < 0.0001]. Adjusting for multiple covariates, all associations except rooming in remained significant.

CONCLUSIONS

Obesity stigma may be a determinant of breastfeeding outcomes for obese mothers. Breastfeeding support should be improved for this at-risk population.

Lifestyle intervention to prevent obesity during pregnancy: Implications and recommendations for research and implementation

Maternal obesity and excessive gestational weight gain (GWG) are significant contributors to the global obesity epidemic. However, isolated lifestyle interventions to address this in pregnancy appear to have only modest benefit and responses can be variable. This paper aims to address the question of why the success of lifestyle interventions to prevent excessive GWG is suboptimal and variable. We suggest that there are inherent barriers to lifestyle change within pregnancy as a life stage, including the short window available for habit formation; the choice for women not to prioritise their weight; competing demands including physiological, financial, relationship, and social situations; and lack of self-efficacy among healthcare professionals on this topic. In order to address this problem, we propose that just like all successful public health approaches seeking to change behaviour, individual lifestyle interventions must be provided in the context of a supportive environment that enables, incentivises and rewards healthy changes. Future research should focus on a systems approach that integrates the needs of individuals with the context within which they exist. Borrowing from the social marketing principle of 'audience segmentation', we also need to truly understand the needs of individuals to design appropriately tailored interventions. This approach should also be applied to the preconception period for comprehensive prevention approaches. Additionally, relevant policy needs to reflect the changing evidence-based climate. Interventions in the clinical setting need to be integrally linked to multipronged obesity prevention efforts in the community, so that healthy weight goals are reinforced throughout the system.

Maternal obesity in Europe: where do we stand and how to move forward?: A scientific paper commissioned by the European Board and College of Obstetrics and Gynaecology (EBCOG)

Paralleling the global epidemic of obesity figures in the general population, the incidence of maternal obesity (BMI>30kg/m(2) at the start of pregnancy) has been rising over the last world. While most European countries do not systematically report obesity figures in their pregnant population, the prevalence of maternal obesity varies from 7 to 25% and seems strongly related to social and educational inequalities. Obesity during pregnancy represents an important preventable risk factor for adverse pregnancy outcomes and is associated with negative long-term health outcomes for both mothers and offspring. These effects are often aggravated by the high incidence of abnormal glucose tolerance and excessive gestational weight gain found in this group. The main controversies around the management of the obese pregnant women are related to (1) the value of repeated weighing during pregnancy, (2) the optimal gestational weight gain to advise and the lifestyle messages to deliver in order to achieve this, (3) the optimal strategy and timing of screening for gestational diabetes (GDM) and (4) the optimal timing and mode of delivery. These controversies are reviewed in this review, with the exception of screening for gestational diabetes that is discussed extensively elsewhere in this issue (Benhalima et al.). An agenda for research is proposed with the hope that it will catch the attention of policy-makers and funders and ultimately lead to the development of European-wide evidence-based guidelines for clinicians.

Beliefs, Barriers, and Preferences of European Overweight Women to Adopt a Healthier Lifestyle in Pregnancy to Minimize Risk of Developing Gestational Diabetes Mellitus: An Explorative Study

Introduction. We explored beliefs, perceived barriers, and preferences regarding lifestyle changes among overweight European pregnant women to help inform the development of future lifestyle interventions in the prevention of gestational diabetes mellitus. Methods. An explorative mixed methods, two-staged study was conducted to gather information from pregnant European women (BMI ≥ 25 kg/m²). In three European countries 21 interviews were conducted, followed by 71 questionnaires in six other European countries. Content analysis and descriptive and chi-square statistics were applied (p < 0.05). Results. Women preferred to obtain detailed information about their personal risk. The health of their baby was a major motivating factor. Perceived barriers for physical activity included pregnancy-specific issues such as tiredness and experiencing physical complaints. Insufficient time was a barrier more frequently reported by women with children. Abstaining from snacking was identified as a challenge for the majority of women, especially for those without children. Women preferred to obtain support from their partner, as well as health professionals and valued flexible lifestyle programs. Conclusions. Healthcare professionals need to inform overweight pregnant women about their personal risk, discuss lifestyle modification, and assist in weight management. Lifestyle programs should be tailored to the individual, taking into account barriers experienced by overweight first-time mothers and multipara women.

The perspectives of obese women receiving antenatal care: A qualitative study of women's experiences

BACKGROUND

The prevalence of overweight and obesity is increasing amongst women of child bearing age. Maternal obesity has implications for both mother and baby including increased health risks from gestational hypertensive disorders, caesarean section and stillbirth. Despite the increasing prevalence of maternal obesity little is known of the experiences of these women within the health care system. The aim of this research was to investigate the perspectives of pregnant women with a body mass index (BMI) of ≥30kg/m(2) receiving antenatal care.

METHODS

A qualitative study using individual interviews was undertaken. Sixteen pregnant women with a BMI ≥30kg/m(2) participated. Interviews were audio recorded, transcribed, cross checked for consistency and then entered into a word processing document for analysis. Data was analysed using Interpretative Phenomenological Analysis. In any phenomenological study the researcher's objective is to elicit the participant's views on their lived experiences.

FINDINGS

Four major themes emerged: (1) obese during pregnancy as part of a long history of obesity; (2) lack of knowledge of the key complications of obesity for both mother and child; (3) communication about weight and gestational weight gain can be conflicting, confusing and judgmental; (4) most women are motivated to eat well during pregnancy and want help to do so.

CONCLUSION

Specialist lifestyle interventions for obese women should be a priority in antenatal care. Extra support is required to assist obese women in pregnancy achieve recommended nutritional and weight goals. Health professionals should approach the issue of maternal obesity in an informative but non-judgmental way.

Healthcare professionals experience with motivational interviewing in their encounter with obese pregnant women

OBJECTIVE

to explore and describe how healthcare professionals in the Southern Region of Denmark experienced motivational interviewing as a communication method when working with pregnant women with obesity.

DESIGN

a qualitative, descriptive study based on face-to-face interviews with 11 obstetric healthcare professionals working in a perinatal setting.

METHODS

a thematic descriptive method was applied to semi-structured interviews. The healthcare professional's experiences were recorded verbatim during individual semi-structured qualitative interviews, transcribed, and analysed using a descriptive analysis methodology.

FINDINGS

motivational interviewing was found to be a useful method when communicating with obese pregnant women. The method made the healthcare professionals more aware of their own communication style both when encountering pregnant women and in their interaction with colleagues. However, most of the healthcare professionals emphasised that time was crucial and they had to be dedicated to the motivational interviewing method. The healthcare professionals further stated that it enabled them to become more professional in their daily work and made some of them feel less 'burned out', 'powerless' and 'stressed' as they felt they had a communication method in handling difficult workloads.

CONCLUSION

healthcare professionals experienced motivational interviewing to be a useful method when working perinatally. The motivational interviewing method permitted heightened awareness of the healthcare professionals communication method with the patients and increased their ability to handle a difficult workload. Overall, lack of time restricted the use of the motivational interviewing method on a daily basis.

Person-centred care in interventions to limit weight gain in pregnant women with obesity - a systematic review

Background

Person-centred care, asserting that individuals are partners in their care, has been associated with care satisfaction but the value of using it to support women with obesity during pregnancy is unknown. Excessive gestational weight gain is associated with increased risks for both mother and baby and weight gain therefore is an important intervention target. The aims of this review was to 1) explore to what extent and in what manner interventions assessing weight in pregnant women with obesity use person-centred care and 2) assess if interventions including aspects of person-centred care are more effective at limiting weight gain than interventions not employing person-centred care.

Methods

Ten databases were systematically searched in January 2014. Studies had to report an intervention offered to pregnant women with obesity and measure gestational weight gain to be included. All included studies were independently double coded to identify to what extent they included three defined aspects of person-centred care: 1) “initiate a partnership” including identifying the person’s circumstances and motivation; 2) “working the partnership” through sharing the decision-making regarding the planned action and 3) “safeguarding the partnership through documentation” of care preferences. Information on gestational weight gain, study quality and characteristics were also extracted.

Results

Ten studies were included in the review, of which five were randomised controlled trials (RCT), and the remaining observational studies. Four interventions included aspects of person-centred care; two observational studies included both “initiating the partnership”, and “working the partnership”. One observational study included “initiating the partnership” and one RCT included “working the partnership”. No interventions included “safeguarding the partnership through documentation”. Whilst all studies with person-centred care aspects showed promising findings regarding limiting gestational weight gain, so did the interventions not including person-centred care aspects.

Conclusions

The use of an identified person-centred care approach is presently limited in interventions targeting gestational weight gain in pregnant women with obesity. Hence to what extent person-centred care may improve health outcomes and care satisfaction in this population is currently unknown and more research is needed. That said, our findings suggest that use of routines incorporating person-centredness are feasible to include within these interventions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0463-x) contains supplementary material, which is available to authorized users.

'Ultrasound is an invaluable third eye, but it can't see everything': a qualitative study with obstetricians in Australia

Background

Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians’ experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents’ experiences.

Methods

A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis.

Results

An overall theme emerged during the analyses, ‘Obstetric ultrasound - a third eye’, reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:‘Everyday-tool’ for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians’ and expectant parents’ differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents.

Conclusions

This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.

Training in motivational interviewing in obstetrics: a quantitative analytical tool

OBJECTIVE

To examine whether a 3-day training course in motivational interviewing, which is an approach to helping people to change, could improve the communication skills of obstetric healthcare professionals in their interaction with obese pregnant women.

DESIGN

Intervention study.

SETTING

The Region of Southern Denmark.

METHODS

Eleven obstetric healthcare professionals working with obese pregnant women underwent a 3-day course in motivational interviewing techniques and were assessed before and after training to measure the impact on their overall performance as well as the effect on specific behavioral techniques observed during interviews.

FINDINGS

With a few exceptions, the participants changed their behavior appropriate to the motivational interviewing technique. The participants made more interventions towards the principles of motivational interviewing (adherent and nonadherent interventions). Furthermore, the participants asked fewer closed and more open questions before training in motivational interview. In the assessment of proficiency and competency, most of the participants scored higher after the training in motivational interviewing.

CONCLUSIONS

Training in motivational interviewing improves healthcare professionals' proficiency and competency when communicating with obese pregnant women, albeit that the effect was not universal.