Perspectives about and approaches to weight gain in pregnancy: a qualitative study of physicians and nurse midwives

Health System and Individual Barriers to Supporting Healthy Gestational Weight Gain and Nutrition: A Qualitative Study of the Experiences of Midwives and Obstetricians in Publicly Funded Antenatal Care in Tasmania, Australia

Individual and health system barriers can impede clinicians from supporting weight-related behaviour change for pregnant women, particularly in publicly funded antenatal care accessed by women from diverse socioeconomic backgrounds. The aim was to understand clinicians' experiences of supporting healthy gestational weight gain for pregnant women in a publicly funded antenatal setting. The work was undertaken to guide the implementation of systems changes, resource development, and workforce capacity building related to nutrition, physical activity, and gestational weight gain in the service. The qualitative descriptive study used purposive sampling and semi-structured interviews conducted between October 2019 and February 2020. Nine midwives and five obstetricians from a publicly funded hospital antenatal service in Tasmania, Australia participated. Interview transcripts were analysed using inductive thematic analysis. The three dominant themes were prioritising immediate needs, continuity of care support weight-related conversations, and limited service capacity for weight- and nutrition-related support. The subthemes were different practices for women according to weight and the need for appropriately tailored resources. Improving access to continuity of care and clinician training, and providing resources that appropriately consider women's socioeconomic circumstances and health literacy would enhance the ability and opportunities for clinicians to better support all women.

Feasibility of Telehealth and Innovative Technologies to Limit Excessive Gestational Weight Gain

OBJECTIVE

To test the feasibility of using telehealth to deliver nutritional counseling by tracking gestational weight gain remotely using Bluetooth weight scales.

DESIGN

Quasi-experimental feasibility study.

SETTING

One-on-one nutritional counseling was conducted remotely via a telehealth platform using a registered dietitian.

PARTICIPANTS

Twenty-nine pregnant individuals ages 18 years or older, between 12 and 27 weeks' gestation, with a prepregnancy body mass index of ≥30 kg/m2, singleton fetus, and English proficiency were recruited for the study. Among the 29 potential participants, 20 completed the initial survey and met the criteria; 11 completed the study.

METHODS

This study tested the feasibility of using telehealth to deliver nutritional counseling for 30 minutes, once a week, for 6 weeks. Self-weighing was tracked through a preconfigured Bluetooth scale given to study participants that enabled weight data to be automatically uploaded each time the scale was used.

RESULTS

Among the 11 study participants receiving Bluetooth scales, adherence to self-weighing was high (81%). All five participants randomized to nutritional counseling found that telehealth visits with a registered dietitian were easy to use and helpful. Although participants who received nutritional counseling gained 2.5 lb less than those who did not receive nutritional counseling (p = .523), there was no significant difference between the intervention group and historical control individuals (p = .716).

CONCLUSION

Incorporating telehealth for nutrition counseling and accurate remote weight data collection may be part of a comprehensive strategy to address gestational weight gain in high-risk pregnant populations. Further research with larger samples is needed.

Different experiences of weight management and physical activity during pregnancy - a qualitative study of women and healthcare professionals in Australia

OBJECTIVE

Pregnancy is often described as a pivotal life stage for women, where regular contact with health professionals may play an important role in lifestyle awareness. This study explored the knowledge, practices, and beliefs of health professionals and pregnant women regarding physical activity and weight management during the antenatal period.

METHODS

A qualitative study was undertaken in southeastern Australia using individual interviews. Recruitment sought women of gestation >12 weeks, experiencing an uncomplicated pregnancy (n = 6), and antenatal health professionals including midwives (n = 4) and an obstetrician (n = 1). Data were analysed using Interpretive Phenomenological Analysis.

RESULTS

Three major themes emerged: (1) women rely on multiple sources of pregnancy-related healthy lifestyle information; (2) discussions around healthy lifestyle behaviours are low priority and often inconsistent; and (3) lifestyle-related topics perceived as sensitive make some conversations and actions difficult.

CONCLUSIONS

Pregnant women expressed gaps in lifestyle-related knowledge and education being provided by health professionals. In turn, health professionals expressed difficulty discussing sensitive topics such as weight with pregnant women and had limited knowledge of pregnancy-specific physical activity guidelines. The themes generated by this study may form the foundation for further research to inform clinical policy and practice regarding advice in antenatal care.

Assessing Health Care Providers' Knowledge and Practices of Nutrition during Pregnancy in Lebanon: A Cross-Sectional Study

Background and objectives: Health care professionals (HCPs) are well-positioned to discuss healthy behaviors during pregnancy, but the published research of prenatal healthcare providers' knowledge about the significance of nutrition during pregnancy in Lebanon is scarce. The purpose of this study was to explore the knowledge, attitudes, and practices of Lebanese prenatal healthcare providers towards nutrition during pregnancy. Materials and Methods: A cross-sectional study using an online questionnaire was conducted. Health care providers were contacted by phone and email to participate in the online survey. A list of all clinics providing antenatal health services was obtained from the Order of Physicians and the Order of Midwives. A multistage random sample was selected. In the first stage, it was stratified per region (Beirut center or suburbs, and the southern region). In the second phase, it was stratified per clinic type (private, primary healthcare center, or hospital). Gynecologists and midwives who are members of the Order of Physicians and the Order of Midwives (n = 1333), were included. Results: Two-hundred and six responses (55% males) were obtained. Approximately 44% of the HCP were aged 50 and older, and 68.4% had more than 10 years of work experience. HCPs from Beirut represented 41.3% of the respondents. Eighty-eight percent of the HCPs were physicians, and 11% were midwives. The majority of the participants considered nutrition during pregnancy to be very important. Furthermore, half of these participants considered their position in delivering nutrition information as very significant. Most of the respondents reported that they provide nutrition advice to pregnant women, and they also received nutrition education during their profession. However, they perceived their nutrition knowledge as inadequate. Conclusion: Health care providers' attitude towards the importance of maternal nutrition and their confidence in talking about nutrition-related topics with pregnant women were positive despite the lack of knowledge in several areas related to nutrition during pregnancy. Therefore, there is a need for continuing nutrition education for health care providers and the implementation of nutrition education programs to achieve better health outcomes.

Prenatal Nutrition Care in Alberta: The Perspectives of Pregnant Women and Registered Dietitians

Introduction: Optimizing women’s diets in pregnancy improves maternal and child health outcomes; however, the best format for supporting women’s nutrition goals in pregnancy is not clear, and access to dietetic services is not standard in prenatal care in Alberta. This study explored women’s perceptions about access to Registered Dietitians (RDs) throughout pregnancy and RDs experiences providing prenatal nutrition counselling.

Methods: Two studies were conducted. Study A: Pregnant women completed a short survey while attending a prenatal appointment in a large prenatal clinic. The survey assessed women’s perspectives about accessing dietetic services during pregnancy. Survey data were analyzed using descriptive statistics. Study B: RDs participated in either a semi-structured phone interview or a focus group and described their experiences working with pregnant women. Data were analyzed using thematic analysis.

Results: One hundred pregnant women completed the survey. Ninety percent indicated that they had not seen a RD at this time in pregnancy, and 48% reported that they would like to access a RD in pregnancy, if available. Dietitians discussed the diversity of women’s concerns and the challenges to providing prenatal nutrition support.

Conclusions: Women have nutrition-related questions during pregnancy. Dietitians experience challenges providing services in the current care systems.

Strengthening maternal nutrition counselling during routine health services: a gap analysis to guide country programmes

OBJECTIVE

The WHO recommends counselling on healthy eating, weight gain, and physical activity during antenatal care (ANC) and postnatal care (PNC), yet advice and information are often not tailored to women's nutritional needs and contexts. The purpose of the gap analysis was to identify key elements related to the provision of maternal nutrition counselling during routine health contacts and provide programme considerations to strengthen quality service delivery.

DESIGN

A search of PubMed, Cochrane Library, CINAHL Plus and Scopus databases was conducted to retrieve studies from January 2010 to December 2021. Using inclusion criteria, quantitative, qualitative and mixed methods studies were included in the final gap analysis.

SETTING

Low-, middle- and high-income country contexts.

PARTICIPANTS

Following application of gap analysis criteria, thirty-seven articles from sixteen countries were included in the analysis.

RESULTS

Gaps in delivery of maternal nutrition counselling include provider capacity building, frequency, content and delivery platforms. Globally, counselling on appropriate weight gain during pregnancy is often not delivered with the desired content nor quality, while targeted counselling to overweight and obese women was provided in several high-income country contexts. Delivery of maternal nutrition counselling through multiple delivery platforms demonstrated improvements in maternal diet and/or weight gain during pregnancy.

CONCLUSIONS

Strengthening the integration of maternal nutrition counselling into pre- and in-service curricula, routine health provider training, supportive supervision and provider mentoring is needed. Future efforts may consider generating global and regional weight gain guidelines and incorporating maternal nutrition counselling indicators as part of quality-of-care ANC/PNC standards and routine health systems.

Clinical Practice Guidelines That Address Physical Activity and Exercise During Pregnancy: A Systematic Review

INTRODUCTION

Physical activity is recommended for healthy pregnant women. Clinical practice guidelines vary with regard to initial time, duration, or type of physical activity that is recommended, which is confusing for health care professionals and pregnant women alike. This study aimed to appraise clinical guidelines relevant to physical activity for pregnant women and summarize consensus and discrepant recommendations.

METHODS

The websites of organizations that develop guidelines including those of obstetricians, gynecologists, midwives, and medical sports associations were searched in addition to 9 literature databases for the period from January 2010 through November 2020. Guidelines were included if they were published in a journal or on a website in English or Chinese; were labeled as a recommendation guideline, position paper, practice parameter, or consensus statement; and addressed physical activity for pregnant women. Two authors independently extracted recommendations. Four reviewers independently assessed guideline quality using the AGREE II instrument.

RESULTS

Thirteen guidelines met the inclusion criteria. The guidelines developed by the World Health Organization and the National Institute for Health and Clinical Excellence were deemed to have the highest methodological quality. The recommendations were consistent with regard to recommended exercise duration, frequency, intensity, and type of physical activity. The main discrepant recommendations included best tools for conducting pre-exercise screening and assessing intensity of exertion. Guidelines also differ on optimal heart rate during exercise, when in pregnancy to initiate an exercise regimen, and duration or frequency of strengthening exercises.

DISCUSSION

Of the 13 guidelines, 2 were found to have good methodological quality. The recommendations that were consistent across the differing guidelines can support health care providers in counseling women about physical activity during pregnancy. The recommendations that are discrepant among these guidelines may contribute to confusion and a reluctance to recommend exercise during pregnancy. Research is needed to clarify discrepant recommendations.

Association Between Maternal Body Mass and Physical Activity Counseling During Pregnancy

Aims: The antenatal period provides an important opportunity for giving advice on healthy lifestyle choices. However, the prevalence of maternal obesity is increasing, and women report that they do not receive counseling. We investigated the information given to pregnant women on gestational weight gain, physical activity, and nutrition during pregnancy in relation with their initial weight status, current gestational weight gain and diagnoses of either pre-pregnancy overweight/obesity or excessive gestational weight gain. Methods: Cross-sectional survey using a questionnaire. Pregnant participants (n = 141) were recruited from a midwife center. They completed a structured questionnaire on the information they received during their pregnancy and we assessed its relationship with their weight. Results: We found that many pregnant women did not receive advice about physical activity, gestational weight gain and nutrition (37.5, 53.2, and 66.2%, respectively). Women with weight problems (pre-pregnancy overweight/obesity and excessive gestational weight gain) were less targeted for counseling, although more than 80% of the women viewed receiving information on these topics as positive. Also, being informed of a weight problem was associated with a greater chance of receiving information about physical activity, gestational weight gain and nutrition (all p < 0.05). However, verbalization of the weight problems was low (14.0% of women with pre-pregnancy overweight were informed of their status). Conclusion: Health professionals should dispense more information, especially on PA and particularly for women with weight problems. Verbalization of the weight problem seems associated with more frequent transmission of information.

Monitoring Physical Activity Intensity During Pregnancy

For apparently healthy pregnant women, regular physical activity is recommended. The American College of Obstetricians and Gynecologists (ACOG) created recommendations for physical activity and exercise during pregnancy in 1985. At that time, pregnant women were advised to not exceed a heart rate of 140 beats per minute with physical activity. The heart rate recommendation was subsequently removed with the recommendations published in 1994, 2002, and 2015. In 2020, the ACOG updated its recommendations on physical activity for pregnant and postpartum women. The recommendation included exercising at a "fairly light to somewhat hard" perceived intensity and at less than 60-80% of age-predicted maximum heart rate, usually not exceeding a heart rate of 140 beats per minute. Women often seek advice from healthcare providers on physical activity during pregnancy, yet providers report concern about giving appropriate physical activity guidance. This paper summarizes the key scientific literature on monitoring absolute and relative exercise intensity in relation to the current ACOG recommendations, providing background on intensity-related concepts used in the recommendation. This paper also provides practical guidance to assist healthcare providers in relaying this information to pregnant women.

Nutrition Practitioner Perceptions of Nutrition Education with Pregnant Clients

OBJECTIVE

Nutrition education during pregnancy is associated with improved maternal and fetal outcomes. This study explored nutrition practitioner perceptions of providing nutrition education to this population and examined gaps in current practices.

METHODS

North Carolina nutrition practitioners (n = 73) working with pregnant women were asked to complete a survey about their provision of nutrition services to pregnant clients. Data were analyzed for descriptive statistics.

RESULTS

Cost (91%) and lack of time to cook (83%) were perceived as the largest barriers for clients to making dietary changes. Topics most requested by clients paralleled those practitioners identified as needs: weight gain (69%), lactation (63%), and general nutrition information (57%). Pamphlets (97%), posters (66%), telehealth (42%), and texting (38%) were accepted education methods.

CONCLUSIONS AND IMPLICATIONS

Evidence-based education on weight, lactation, and general nutrition, using time and cost-efficient approaches, and embracing technology were desired by pregnant clients when receiving nutrition education from nutrition and other health care practitioners and may result in improved maternal and fetal outcomes.

Coping with Stress in Complicated Pregnancy and Gestational Weight Gain

Maternal obesity is one of the leading health problems in the world. Excessive gestational weight gain (GWG) can lead to many complications during pregnancy, especially when it is accompanied by diabetes. Moreover, the risk of excessive GWG in pregnant women is significant, irrespective of prenatal counseling. Studies on this subject concerning coping with stress are lacking in the literature. The present work is aimed at evaluating the styles of coping with stress and their relation to GWG in pregnant women with gestational diabetes (GDM) for whom sudden adaptation to dietary management during this period can be challenging. It was indicated that women with GDM reported high stress related to potential maternal-fetal complications and worries about compliance with dietary management. The overall weight gain of participants in pregnancy was determined in connection to their prepregnancy body mass index (BMI) and classified based on the Institute of Medicine guidelines. A standardized psychological scale was used to assess coping styles. The results showed that almost half of the participants did not meet the Institute of Medicine recommendations for weight gain during pregnancy. There were significant correlations between the styles of coping with stress and the GWG. Additionally, low correlations were indicated between emotional, avoidant, task-oriented coping styles and the age of pregnant women with GDM. Regression analysis showed that the stress-coping style that focused on emotions was the most predictive of overall weight gain. There is a need for a better understanding of psychological barriers in achieving the recommended GWG and potential limitations in providers' interventions, particularly for GDM.

The effect of obesity in pregnancy and gestational weight gain on neonatal outcome in glucose-tolerant mothers

BACKGROUND

Most studies showing association between mothers with obesity in pregnancy or excessive gestational weight gain (GWG) and adverse neonatal outcome were cross-sectional or retrospective. Many included patients are with gestational diabetes mellitus (GDM), which is a strong risk factor for this adverse outcome. There are no prospective studies on this topic in Malaysia. This study aimed to examine prospectively the effects of obesity in pregnancy and GWG, independent of GDM, on neonatal outcome.

METHODS

Pregnant mothers in the first trimester, who presented to health clinics in Kuching, were screened. Mothers with existing diabetes mellitus or GDM were excluded using 75-g oral glucose tolerance test during the first and second trimesters. Participants with the first trimester BMI ≥ 23 kg/m2 were recruited as overweight/obese group, whereas those with BMI 18.5-22.9 kg/m2 were taken as the comparison group. At every trimester visit, mothers' weights were recorded. Babies' birth weight and occurrence of adverse neonatal outcome were documented.

RESULTS

There were 123 mothers recruited as overweight/obese group (mean BMI 29.0 kg/m2 ± 4.45) and 102 mothers as comparison group (mean BMI 20.4 kg/m2 ± 1.48). The number of low birth weight was similar between groups: 9.8% in overweight/obese group, 6.9% in the comparison group (p = 0.416). More than half of these babies were born to mothers with inadequate GWG (58.3% in obese group vs. 57.1% in control group, p = 0.077). There was no significant difference in the mean birth weight (3000 g ± 454.5 vs. 3038 g ± 340.8, p = 0.471), preterm delivery (8.13% vs. 3.92%, p = 0.193), and admission rate to neonatal intensive care unit (8.13% vs. 7.85%, p = 0.937) between groups. There was a positive correlation between the total GWG in overweight/obese group on baby's weight (r = 0.222, p = 0.013). Inadequate GWG was not correlated with lower birth weight (p = 0.052).

CONCLUSIONS

Obesity in pregnancy was not associated with poor neonatal outcome in this small sample of women in Malaysia. Total GWG showed a weak correlation with baby's birth weight in overweight/obese group.

Investigating the normalization and normative views of gestational weight gain: Balancing recommendations with the promotion and support of healthy pregnancy diets

OBJECTIVES

Gestational weight gain (GWG) is increasingly monitored in the United States and Canada. While promoting healthy GWG offers benefits, there may be costs with over-surveillance. We aimed to explore these costs/benefits.

METHODS

Quantitative data from 350 pregnant survey respondents and qualitative focus group data from 43 pregnant/post-partum and care-provider participants were collected in the Mothers to Babies (M2B) study in Hamilton, Canada. We report descriptive statistics and discussion themes on GWG trajectories, advice, knowledge, perceptions, and pregnancy diet. Relationships between GWG monitoring/normalization and worry, knowledge, diet quality, and sociodemographics-namely low-income and racialization-were assessed using χ² tests and a linear regression model and contextualized with focus group data.

RESULTS

Most survey respondents reported GWG outside recommended ranges but rejected the mid-20th century cultural norm of "eating for two"; many worried about gaining excessively. Conversely, respondents living in very low-income households were more likely to be gaining less than recommended GWG and to worry about gaining too little. A majority had received advice about GWG, yet half were unable to identify the range recommended for their prepregnancy BMI. This proportion was even lower for racialized respondents. Pregnancy diet quality was associated with household income, but not with receipt or understanding of GWG guidance. Care-providers encouraged normalized GWG, while worrying about the consequences of pathologizing "abnormal" GWG.

CONCLUSIONS

Translation of GWG recommendations should be done with a critical understanding of GWG biological normalcy. Supportive GWG monitoring and counseling should consider clinical, socioeconomic, and community contexts.

Midwives' and obstetricians' perspectives about pregnancy related weight management in Ethiopia: A qualitative study

BACKGROUND

Midwives and obstetricians are key maternity care providers; they are the most trusted source of information regarding nutrition and gestational weight gain. However, their views, practices and perceived barriers to managing pregnancy related weight gain have not been studied in Ethiopia. The aim of this study was to explore midwives' and obstetricians' observations and perspectives about gestational weight gain and postpartum weight management in Ethiopia.

METHODS

We conducted face-to-face interviews with 11 midwives and 10 obstetricians, from January 2019 to March 2019. All interview data were transcribed verbatim. We analysed the data using thematic analysis with an inductive approach.

RESULTS

We identified three themes and associated subthemes. Midwives and obstetricians had limited knowledge of the optimal gestational weight gain. Almost all participants were unaware of the presence of the Institute of Medicine recommendations for optimal weight gain in pregnancy. According to the study participants, women in Ethiopia do not want to gain weight during pregnancy, but do want to gain weight after the birth. Counselling about gestational weight gain and postpartum weight management was not routinely provided for pregnant women. This is mostly because gestational weight gain counselling was not considered to be a priority by maternity care providers in Ethiopia.

CONCLUSIONS

The limited knowledge of and low attention to pregnancy related weight management by midwives and obstetricians in this setting needs appropriate intervention. Adapting a guideline for pregnancy weight management and integrating it into antenatal care is essential.

Methodological quality of clinical practice guidelines for nutrition and weight gain during pregnancy: a systematic review

CONTEXT

Ensuring a healthy pregnancy and achieving optimal gestational weight gain (GWG) are important for maternal and child health. Nevertheless, the nutritional advice provided during pregnancy is often conflicting, suggesting limited adherence to clinical practice guidelines (CPGs).

OBJECTIVE

The aim of this review was to identify all CPGs on maternal nutrition and GWG and to critically appraise their methodological quality.

DATA SOURCES

The MEDLINE/PubMed, Cochrane, Guidelines International Network, and BMJ Best Practice databases, along with gray literature, were searched from inception until February 2019 for CPGs and consensus, position, and practice papers.

STUDY SELECTION

Clinical practice guidelines published in English and containing advice on maternal nutrition or GWG were eligible.

DATA EXTRACTION

Two authors independently extracted data on items pertaining to maternal nutrition or GWG, and CPGs were appraised using the AGREE II instrument.

RESULTS

Twenty-two CPGs were included. All scored adequately in the "scope" domain, but most were considered inadequate with regard to stakeholder involvement, rigor of development, applicability, and editorial independence. Many CPGs lacked patient or dietician involvement, and more than half did not disclose funding sources or conflicts of interest. Guidance on GWG was based mostly on Institute of Medicine thresholds, while nutrition recommendations appeared scattered and heterogeneous.

CONCLUSION

Despite the importance of maternal nutrition and the plethora of advising bodies publishing relevant guidance, there is room for substantial improvement in terms of development standards and content of nutritional recommendations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42019120898.

MAMMA MIA! Norwegian Midwives' Practices and Views About Gestational Weight Gain, Physical Activity, and Nutrition

Objectives

Most studies regarding prevalence of prenatal lifestyle counseling are based on patient report of provider advice. The aim of the present study was to describe midwives' practice and views in promoting three distinct, but importantly related lifestyle factors: gestational weight gain (GWG), regular physical activity (PA), and nutrition.

Design

A cross-sectional study.

Setting

Healthcare clinics in Oslo and Akershus County, Norway.

Participants

Clinics that expressed interest to participate provided an email list of the midwives. Of 107 midwives invited to participate, 65 completed the 15-min electronic survey (SurveyXact), giving a response rate of 60.7%.

Outcome Measures

We developed a new questionnaire based on questions and results from similar studies, as no validated questionnaires existed when we initiated this project in 2014. The final electronic questionnaire included a mix of close-ended questions, semi-close-ended questions, and 11-point Likert scales and covered demographics, personal health behaviors, counseling practice, views, and self-perceived role in lifestyle counseling.

Results

Mean workload in prenatal care was 78%, and mean years practicing was 8.9 (±7.5). Across all three health topics, most (74-95%) reported to give advice on the first meeting, with a mean frequency of 2.2 (±1.4), 2.7 (±1.8), and 2.7 (±2.0) for GWG, PA, and nutrition counseling, respectively. Approximately 40% did not report advice on GWG or give advice discordant with the Institute of Medicine (IOM) recommendations (2009) for at least one prepregnancy body mass index (BMI) category. GWG was rated as more unpleasant to talk about than PA (3.0 ± 2.8 vs. 1.1 ± 2.5, p < 0.001) and nutrition (3.0 ± 2.8 vs. 1.2 ± 2.5, p = 0.002). Also, regarding the importance of giving lifestyle advice, PA (9.6 ± 0.9 vs. 8.3 ± 2.2, p < 0.001) and nutrition (9.9 ± 0.4 vs. 8.3 ± 2.2, p < 0.001) were rated as more important than advice about GWG. Postpartum, nearly 40% gave advice about PA, whereas only two (3.1%) reported to discuss weight/weight retention (p < 0.001).

Conclusion

While most midwives gave advice on GWG, PA, and nutrition at the first meeting and rated lifestyle counseling as an important topic, the advice on GWG was often discordant with IOM recommendations, and the topic was viewed as more unpleasant to talk about than PA and nutrition.

Gestational weight gain counselling practices among different antenatal health care providers: a qualitative grounded theory study

BACKGROUND

Inappropriate gestational weight gain in pregnancy may negatively impact health outcomes for mothers and babies. While optimal gestational weight gain is often not acheived, effective counselling by antenatal health care providers is recommended. It is not known if gestational weight gain counselling practices differ by type of antenatal health care provider, namely, family physicians, midwives and obstetricians, and what barriers impede the delivery of such counselling. The objective of this study was to understand the counselling of family physicians, midwives and obstetricians in Ontario and what factors act as barriers and enablers to the provision of counselling about GWG.

METHODS

Semi-structured interviews were conducted with seven family physicians, six midwives and five obstetricians in Ontario, Canada, where pregnancy care is universally covered. Convenience and purposive sampling techniques were employed. A grounded theory approach was used for data analysis. Codes, categories and themes were generated using NVIVO software.

RESULTS

Providers reported that they offered gestational weight gain counselling to all patients early in pregnancy. Counselling topics included gestational weight gain targets, nutrition & exercise, gestational diabetes prevention, while dispelling misconceptions about gestational weight gain. Most do not routinely address the adverse outcomes linked to gestational weight gain, or daily caloric intake goals for pregnancy. The health care providers all faced similar barriers to counselling including patient attitudes, social and cultural issues, and accessibility of resources. Patient enthusiasm and access to a dietician motivated health care providers to provide more in-depth gestational weight gain counselling.

CONCLUSION

Reported gestational weight gain counselling practices were similar between midwives, obstetricians and family physicians. Antenatal knowledge translation tools for patients and health care providers are needed, and would seem to be suitable for use across all three types of health care provider specialties.

Review of Recent Physical Activity Guidelines During Pregnancy to Facilitate Advice by Health Care Providers

Importance

Physical activity during pregnancy can offer many maternal and fetal health benefits.

Objective

The aim was to summarize American, Canadian, and international recommendations published recently on physical activity during pregnancy to aid health care providers in their delivery of advice on the topic.

Evidence Acquisition

A descriptive review of 3 national guidelines and 1 international guideline on physical activity during pregnancy was conducted. The guidelines included the 2019 Canadian recommendations, the 2018 United States' Physical Activity Guidelines for Americans (second edition), the 2015 (reaffirmed in 2017) American College of Obstetrics and Gynecology guideline, and the 2016-2018 International Olympic Committee recommendations for recreational and elite athletes.

Results

For apparently healthy women, under the guidance of their health care provider, moderate-intensity physical activity using both aerobic and muscle conditioning activities is recommended. The guidelines recommended at least 150 min/wk spread throughout the week (Canada, United States) or at least 20 to 30 min/d (American College of Obstetrics and Gynecology).

Conclusions and Relevance

This summary of 4 recent guidelines can facilitate use of updated recommendations by health care providers regarding physical activity during pregnancy. More detailed evidence-based guidelines on physical activity during postpartum are needed.

Patient Attitudes toward Gestational Weight Gain and Exercise during Pregnancy

Body mass index (BMI) and gestational weight gain (GWG) are important factors for neonatal and maternal health. Exercise helps women moderate their BMI and GWG, and provides health benefits to mother and child. This survey study assessed patients' perceptions of counseling they received during pregnancy, their sources of information about GWG, and their attitudes toward exercise during pregnancy. We distributed an anonymous survey to 200 pregnant women over the age of 18 at a tertiary care center in Danville, Pennsylvania. Survey questions included demographics, discussions with medical providers regarding GWG and exercise, and their exercise habits before and during pregnancy. 182 women (91%) responded. Most reported their provider discussed weight and diet (78.8%), expected GWG (81.6%), and exercise during pregnancy (79.8%); however, 28% of obese women and 25% of women who did not plan to exercise during pregnancy reported not receiving exercise counseling. Approximately 20% of women did not plan to exercise during pregnancy. Women decreased the number of days per week they exercised (40.6% with 3 or more days prepregnancy versus 30.7% during pregnancy, P = 0.002). Some patients who did not exercise prior to pregnancy (12%) expressed interest in a personal training session. Among women in the eight month or later, 42.4% were above GWG recommendations. Our study found barriers to adequate activity during pregnancy; 20% of pregnant women not receiving/remembering counseling regarding exercise. Interest in personal training from patients that did not exercise suggests they would benefit from increased efforts to encourage physical activity. Exercise and GWG counseling based in medical science as well as patient psychological needs will help efforts to reduce GWG and improve pregnancy outcomes.

What the Health? Information Sources and Maternal Lifestyle Behaviors

Background

Regular physical activity (PA), adequate gestational weight gain (GWG), and healthy eating are important for the long-term health of both mother and baby. Hence, it is important that women receive current and updated advice on these topics and are encouraged to adopt a healthy lifestyle during pregnancy.

Objective

The aim of this study was to investigate the main information sources among pregnant women regarding PA, GWG, and nutrition as well as to evaluate how these information sources may affect their health behaviors.

Methods

A cross-sectional study design, comprising an electronic questionnaire, was distributed to 2 antenatal clinics, as well as pregnancy-related online chat forums and social media. The inclusion criteria were ≥18 years, ≥20 weeks gestation, and able to read and write Norwegian. In total, 150 pregnant women answered the questionnaire, which was a mix of 11-point Likert scales, close-ended questions, and semi–close-ended questions with the option to elaborate. The relationship between information sources and selected variables, including health behaviors and descriptive variables, were assessed by logistic regression, linear regression, or chi-square as appropriate (P<.05).

Results

Mean age (years), gestation week, and prepregnancy body mass index (kg/m²) were 31.1 (SD 4.3), 30.6 (SD 5.9), and 24.2 (SD 4.2), respectively. More than eight out of 10 had received or retrieved information about nutrition (88.7%, 133/150) and PA (80.7%, 121/150), whereas 54.0% (81/150) reported information on GWG. When combining all 3 lifestyle factors, 38.5% had retrieved information from blogs and online forums and 26.6%, from their midwife or family physician. Women who reported the internet and media as their primary source of information on weight gain had increased odds of gaining weight below the Institute of Medicine (IOM) guidelines compared with gaining within the guidelines (odds ratio [OR] 15.5, 95% CI 1.4-167.4; P=.02). Higher compliance with nutritional guidelines was seen among those who cited the internet and media as their main source of information on nutrition (beta=.7, 95% CI 0.07-1.3; P=.03). On the other side, receiving advice from friends and family on weight gain was significantly associated with gaining weight above the IOM guidelines compared with gaining within the guidelines (OR 12.0, 95% CI 1.3-111.7; P=.03). No other associations were found between information sources and health behaviors.

Conclusions

The small number of health professionals giving information and the extensive use of internet- and media-based sources emphasize the need to address the quality of internet advice and guide women toward trustworthy sources of information during pregnancy. The association between information sources and PA, GWG, and nutrition requires further research.

Patient and obstetric provider communication regarding weight gain management among socioeconomically disadvantaged African American women who are overweight/obese

To examine the communication between obstetric providers and their socioeconomically disadvantaged, African American patients who are overweight and obese during pregnancy, and whether this communication relates to outcomes. Pregnant patients and their obstetric providers were surveyed between October 2012 and March 2016 at Washington University School of Medicine in St. Louis, MO. Percent agreement between patients' and obstetric providers' survey responses was analyzed and measured (κ coefficient). Descriptive and multilevel logistic regression analyses aimed at identifying the relation of perceived communication between providers and patients to gestational weight gain, diet, and exercise during pregnancy. A total of 99 pregnant women and 18 obstetric providers participated in the study. Significant lack of agreement was observed between patients and obstetric providers regarding communication about weight gain recommendations, risk factors associated with excessive weight gain, what constitutes adequate exercise per week, exercise recommendations, dietary recommendations, and risk factors associated with a poor diet. Our findings suggest patients were not receiving intended messages from their obstetric providers. Thus, more effective patient-obstetric provider communication is needed regarding gestational weight gain, exercise and dietary recommendations among overweight/obese, socioeconomically disadvantaged, African American women.

Semistructured interviewing in primary care research: a balance of relationship and rigour

Semistructured in-depth interviews are commonly used in qualitative research and are the most frequent qualitative data source in health services research. This method typically consists of a dialogue between researcher and participant, guided by a flexible interview protocol and supplemented by follow-up questions, probes and comments. The method allows the researcher to collect open-ended data, to explore participant thoughts, feelings and beliefs about a particular topic and to delve deeply into personal and sometimes sensitive issues. The purpose of this article was to identify and describe the essential skills to designing and conducting semistructured interviews in family medicine and primary care research settings. We reviewed the literature on semistructured interviewing to identify key skills and components for using this method in family medicine and primary care research settings. Overall, semistructured interviewing requires both a relational focus and practice in the skills of facilitation. Skills include: (1) determining the purpose and scope of the study; (2) identifying participants; (3) considering ethical issues; (4) planning logistical aspects; (5) developing the interview guide; (6) establishing trust and rapport; (7) conducting the interview; (8) memoing and reflection; (9) analysing the data; (10) demonstrating the trustworthiness of the research; and (11) presenting findings in a paper or report. Semistructured interviews provide an effective and feasible research method for family physicians to conduct in primary care research settings. Researchers using semistructured interviews for data collection should take on a relational focus and consider the skills of interviewing to ensure quality. Semistructured interviewing can be a powerful tool for family physicians, primary care providers and other health services researchers to use to understand the thoughts, beliefs and experiences of individuals. Despite the utility, semistructured interviews can be intimidating and challenging for researchers not familiar with qualitative approaches. In order to elucidate this method, we provide practical guidance for researchers, including novice researchers and those with few resources, to use semistructured interviewing as a data collection strategy. We provide recommendations for the essential steps to follow in order to best implement semistructured interviews in family medicine and primary care research settings.

An investigation of Australian midwifery curricula for obesity management and health behaviour change training

INTRODUCTION

Fifty percent of Australian women enter pregnancy overweight or obese. Unfortunately, few women receive weight management advice from health professionals during pregnancy. The aim of this study was to investigate current midwifery curricula from Australian universities to identify strengths and deficits in the teaching of preconception and antenatal weight management.

METHODS

Midwifery courses from 20 universities were identified. Of the 568 units taught at these universities, 252 course outlines were obtained. Data were coded using the qualitative analysis technique of Framework Analysis for the following main themes: 1) the effect of weight, diet and physical activity on health outcomes for women who are pregnant or planning a pregnancy; 2) weight management advice in any population; and 3) health behaviour change techniques in any context.

RESULTS

Analysis revealed a variety of teaching methods and skills training that emphasised the importance of clinical judgement and autonomous clinical practice, in conjunction with critical enquiry and sourcing reputable evidence. There was little evidence, however, that weight management advice was taught explicitly to midwifery students in the curricula.

DISCUSSION

A greater emphasis on skilling midwifery students to address weight gain during pregnancy, and behavioural techniques to achieve this, is required.

Exploring obstetricians', midwives' and general practitioners' approach to weight management in pregnant women with a BMI ≥25 kg/m2: a qualitative study

OBJECTIVE

The aim of this study was to explore healthcare professionals' (HCPs) beliefs and attitudes towards weight management for pregnant women with a body mass index (BMI) ≥25 kg/m².

DESIGN

Qualitative study.

SETTING

A public antenatal clinic in a large academic maternity hospital in Cork, Ireland, and general practice clinics in the same region.

PARTICIPANTS

HCPs such as hospital-based midwives and consultant obstetricians and general practitioners (GPs).

METHOD

Semistructured interviews were conducted with a purposive sample of hospital-based HCPs and a sample of GPs working in the same region. Interviews were recorded, transcribed and thematically analysed using NVivo software.

RESULTS

Seventeen HCPs were interviewed (hospital based=10; GPs=7). Four themes identified the complexity of weight management in pregnancy and the challenges HCPs faced when trying to balance the medical and psychosocial needs of the women. HCPs acknowledged weight as a sensitive conversation topic, leading to a 'softly-softly approach' to weight management. HCPs tried to strike a balance between being woman centred and empathetic and medicalising the conversation. HCPs described 'doing what you can with what you have' and shifting the focus to managing obstetric complications. Furthermore, there were unclear roles and responsibilities in terms of weight management.

CONCLUSION

HCPs need to have standardised approaches and evidence-based guidelines that support the consistent monitoring and management of weight during pregnancy.

Excessive Gestational Weight Gain

Excessive gestational weight gain (GWG) is associated with an increasing incidence of maternal and neonatal complications, including hypertensive disorders of pregnancy, fetal macrosomia, and increased cesarean birth rates. In the United States, it is recommended that health care providers use an individualized approach to counsel a woman about pregnancy weight gain goals that is based on the woman's initial body mass index (BMI) and to track GWG throughout the pregnancy by evaluating maternal weight at each visit. Studies have shown that women entering pregnancy with a higher BMI are at increased risk for excessive GWG and postpartum weight retention. Research also demonstrates an increased risk of childhood obesity in children born to women with excessive GWG. Specific counseling about exercise and diet, as well as technology and motivational interviewing, are some tools prenatal care providers can use that have been shown to be effective in reducing excessive GWG. This article reviews the current research regarding maternal and neonatal risks associated with excessive GWG, as well as the interventions that have demonstrated promise for addressing this problem.

Inconsistent Weight Communication Among Prenatal Healthcare Providers and Patients: A Narrative Review

Importance

Gestational weight gain (GWG) is an independent and modifiable factor for a healthy pregnancy. Gestational weight gain above or below the Institute of Medicine Guidelines has been shown to impact both maternal and fetal health (eg, gestational diabetes, hypertension, downstream obesity). Healthcare providers (HCPs) have the potential to be reliable sources of evidence-based weight information and advice during pregnancy.

Objective

The aim of this study was to summarize the literature assessing GWG discussions between patients and their HCPs in a clinical setting to better understand the knowledge that is currently being exchanged.

Evidence Acquisition

A literature review was conducted by searching Ovid Medline, CINAHL, and Embase databases. All relevant primary research articles in English that assessed GWG discussions were included, whereas intervention studies were excluded.

Results

A total of 54 articles were included in this review. Although the overall prevalence and content of GWG counseling varied between studies, counseling was often infrequent and inaccurate. Healthcare providers tended to focus more on women experiencing obesity and excessive GWG, as opposed to the other body mass index categories or inadequate GWG. Women of higher socioeconomic status, older age, nulliparous, history of dieting, low physical activity, and those categorized as overweight/obese were more likely to receive GWG advice. Patients also reported receiving conflicting facts between different HCP disciplines.

Conclusions

The evidence regarding GWG counseling in prenatal care remains variable, with discrepancies between geographic regions, patient populations, and HCP disciplines.

Relevance

Healthcare providers should counsel their pregnant patients on GWG with advice that is concordant with the Institute of Medicine Guidelines.

Healthcare provider advice on gestational weight gain: uncovering a need for more effective weight counselling

Limited research has examined the factors related to knowledge of gestational weight gain (GWG) recommendations and the receipt of advice from healthcare providers regarding GWG recommendations among women with pre-pregnancy overweight/obesity. Women with pre-pregnancy overweight/obesity (N = 191) reported the amount of gestational weight they believed they should gain and that healthcare providers advised them to gain. Only 24% (n = 46) of women had a correct knowledge of GWG recommendations. Women were less likely to have a correct knowledge of GWG recommendations if they had pre-pregnancy obesity, were of a minority race, or were socioeconomically disadvantaged. Meanwhile, only 17% (n = 32) of women reported being correctly advised about GWG recommendations by healthcare providers. There were no differences between women who did and did not report being correctly advised about GWG recommendations from healthcare providers. These findings indicate that women with pre-pregnancy overweight/obesity lack knowledge of GWG recommendations and report being incorrectly advised about GWG recommendations from healthcare providers. Impact statement What is already known on this subject? Extant literature indicates that women's knowledge of gestational weight gain (GWG) recommendations and women's receipt of information from their healthcare providers regarding GWG recommendations are predictive of meeting the Institute of Medicine guidelines for GWG. What do the results of this study add? Findings from the present study indicate that the majority of women with pre-pregnancy overweight/obesity lack knowledge of GWG recommendations and report that education on GWG recommendations from healthcare providers is an aspect of their prenatal care that is largely insufficient. Although there were no differences between women who did and did not report being correctly advised about GWG recommendations by healthcare providers, women were less likely to have a correct knowledge of GWG recommendations if they had pre-pregnancy obesity, were of a minority race, or were socioeconomically disadvantaged. What are the implications of these findings for clinical practise and/or further research? These findings highlight a need for more effective tailoring of prenatal care to ensure that women receive accurate advice from healthcare providers regarding GWG recommendations.

Healthcare providers' gestational weight gain counselling practises and the influence of knowledge and attitudes: a cross-sectional mixed methods study

OBJECTIVE

To understand current gestational weight gain (GWG) counselling practices of healthcare providers, and the relationships between practices, knowledge and attitudes.

DESIGN

Concurrent mixed methods with data integration: cross-sectional survey and semistructured interviews.

PARTICIPANTS

Prenatal healthcare providers in Canada: general practitioners, obstetricians, midwives, nurse practitioners and registered nurses in primary care settings.

RESULTS

Typically, GWG information was provided early in pregnancy, but not discussed again unless there was a concern. Few routinely provided women with individualised GWG advice (21%), rate of GWG (16%) or discussed the risks of inappropriate GWG to mother and baby (20% and 19%). More routinely discussed physical activity (46%) and food requirements (28%); midwives did these two activities more frequently than all other disciplines (P<0.001). Midwives interviewed noted a focus on overall wellness instead of weight, and had longer appointment times which allowed them to provide more in-depth counselling. Regression results identified that the higher priority level that healthcare providers place on GWG, the more likely they were to report providing GWG advice and discussing risks of GWG outside recommendations (β=0.71, P<0.001) and discussing physical activity and food requirements (β=0.341, P<0.001). Interview data linked the priority level of GWG to length of appointments, financial compensation methods for healthcare providers and the midwifery versus medical model of care.

CONCLUSIONS

Interventions for healthcare providers to enhance GWG counselling practices should consider the range of factors that influence the priority level healthcare providers place on GWG counselling.

Clinician self-efficacy in initiating discussions about gestational weight gain

OBJECTIVE

To compare prenatal care providers' perceived self-efficacy in starting discussions about gestational weight gain with pregnant women under a variety of conditions of gradated difficulty, when weight gain has been in excess of current guidelines.

DESIGN

A 42-item online questionnaire related to the known barriers to and facilitators of having discussions about gestational weight gain.

SETTING

Canada.

PARTICIPANTS

Prenatal care providers were contacted through the Family Medicine Maternity Care list server of the College of Family Physicians of Canada.

MAIN OUTCOME MEASURES

The 42 items were clustered into categories representing patient factors, interpersonal factors, and system factors. Participants scored their self-efficacy on a scale from 0 ("cannot do at all") to 5 ("moderately certain can do") to 10 ("highly certain can do"). The significance level was set at α = .05.

RESULTS

Overall, clinicians rated their self-efficacy to be high, ranging from a low mean (SD) score of 5.14 (3.24) if the clinic was running late, to a high mean score of 8.97 (1.34) if the clinician could externalize the reason for undertaking the discussion. There were significant differences in self-efficacy scores within categories depending on the degree of difficulty proposed by the items in those categories.

CONCLUSION

The results were inconsistent with previous studies that have demonstrated that prenatal care providers do not frequently raise the subject of excess gestational weight gain. On the one hand providers rate their self-efficacy in having these discussions to be high, but on the other hand they do not undertake the behaviour, at least according to their patients. Future research should explore this discrepancy with a view to informing interventions to help providers and patients in their efforts to address excess gestational weight gain, which is increasingly an important contributor to the obesity epidemic.

Obstetrician/Gynecologists' Knowledge, Attitudes, and Practices Regarding Weight Gain During Pregnancy

Objective: Assess obstetrician–gynecologists' knowledge and counseling practices regarding gestational weight gain (GWG).

Materials and Methods: Questionnaire studies were conducted in 2012 and 2014 sent to practicing obstetrician–gynecologists.

Results: Response rates were 111/236 (47%) and 206/474 (43.5%). The majority of respondents agreed (50.0%) or strongly agreed (26.6%) that excessive GWG is a major health concern, often or always calculate the body mass index (BMI) of their patients (79.1%), and use BMI to modify their weight gain recommendations (78.5%). The physicians reported that, on average, 7.8% of pregnant patients gained too little weight, 47.3% gained an appropriate amount, and 45.1% gained too much. A greater proportion of patients with private insurance was associated with physician perception of fewer gaining excessive weight (r = −0.205, n = 198, p = 0.004), whereas high proportions with Medicaid or uninsured were positively correlated with a perception of excessive GWG (r = 0.206 and 0.187, n = 198, p = 0.004 and 0.008, respectively). A majority of physicians (55.1%) were not confident in their ability to affect their patients' prenatal weight gain. Confident physicians exhibited more appropriate practice efforts (e.g., use prepregnancy BMI; 83.6% vs. 74.8%, p = 0.009) and were more likely to inform their patients about the increased risk of pregnancy complications (90.8% vs. 69.7%, p = 0.001) and possible harms to their baby (76.9% vs. 61.0%, p = 0.001) from excessive GWG.

Conclusions: Study participants perceived excessive GWG to be a significant problem, but had low confidence in their ability to address it.

Characteristics of women age 15-24 at risk for excess weight gain during pregnancy

PURPOSE

Excess weight gain during pregnancy is a serious health concern among young pregnant women in the US. This study aimed to characterize young women at highest risk for gaining over the recommended amount of weight during pregnancy.

METHODS

Using a database that is representative of births in large U.S. cities, The Fragile Families and Child Wellbeing Study, we identified mothers of singleton term-infants age 15-24 years at the time of delivery. Institute of Medicine guidelines were used to categorize each mother's weight gain as less than, within, or more than recommended during pregnancy. Multinomial logistic regression models for weight gain category were performed, controlling for age, race/ethnicity, federal poverty level (FPL), health status, and prepregnancy BMI.

RESULTS

Among the weighted sample (n = 1,034, N = 181,375), the mean (SD) age was 21 (3) years, 32% were black, 39% were Hispanic, 44% reported income under the Federal Poverty Level, 45% were overweight or obese before pregnancy, and 55% gained more weight than recommended during pregnancy. Women who were overweight or obese before pregnancy were at increased risk for gaining more pregnancy weight than recommended, compared to normal-weight women (adjusted Relative Risk Ratio (RRR) = 3.82, p = 0.01; RRR = 3.27, p = 0.03, respectively). Hispanics were less likely than non-Hispanics to gain more weight than recommended (RRR = 0.39, p = 0.03).

CONCLUSIONS

The majority of mothers ages 15-24 gained excess weight during pregnancy, a strong risk factor for later obesity. Prepregnancy overweight or obesity and non-Hispanic ethnicity predicted excess pregnancy weight gain. Interventions and policies should target these high-risk young women to prevent excess weight gain.

Advice given by community members to pregnant women: a mixed methods study

Background

Smoking and excess weight gain during pregnancy have been shown to have serious health consequences for both mothers and their infants. Advice from friends and family on these topics influences pregnant women’s behaviors. The purpose of our study was to compare the advice that community members give pregnant women about smoking versus the advice they give about pregnancy weight gain.

Methods

A survey was sent via text messaging to adults in a diverse, low-income primary care clinic in 2015. Respondents were asked what advice (if any) they have given pregnant women about smoking or gestational weight gain and their comfort-level discussing the topics. Descriptive statistics were used to characterize the sample population and to determine response rates. Open-ended responses were analyzed qualitatively using grounded theory analysis with an overall convergent parallel mixed methods design.

Results

Respondents (n = 370) were 77 % female, 40 % black, and 25 % reported education of high school or less. More respondents had spoken to pregnant women about smoking (40 %, n = 147) than weight gain (20 %, n = 73). Among individuals who had not discussed either topic (n = 181), more reported discomfort in talking about weight gain (65 %) compared to smoking (34 %; p < 0.0001). Advice about smoking during pregnancy (n = 148) was frequently negative, recommending abstinence and identifying smoking as harmful for baby and/or mother. Advice about weight gain in pregnancy (n = 74) revealed a breadth of messages, from reassurance about all weight gain (“Eat away” or “It’s ok if you are gaining weight”), to specific warnings against excess weight gain (“Too much was dangerous for her and the baby.”).

Conclusions

Many community members give advice to pregnant women. Their advice reveals varied perspectives on the effects of pregnancy weight gain. Compared to a nearly ubiquitous understanding of the harms of smoking during pregnancy, community members demonstrated less awareness of and willingness to discuss the harms of excessive weight gain. Beyond educating pregnant women, community-level interventions may also be important to ensure that the information pregnant women receive supports healthy behaviors and promotes the long-term health of both moms and babies.

A qualitative study of gestational weight gain goal setting

Background

Gestational weight gain (GWG) is an important predictor of short and long-term pregnancy outcomes for both mother and child, and women who set a GWG goal are more likely to gain within recommended ranges. Little information is available regarding potentially modifiable factors that underlie a woman’s GWG goals. Our aims were to explore women’s perceptions regarding factors that affect GWG, their understanding of appropriate GWG, their goal-setting experiences including patient-health care provider (HCP) conversations, and supportive interventions they would most like to help them achieve the recommended GWG.

Methods

We conducted nine in-depth interviews and seven focus groups with a total of 33 Boston, Massachusetts (MA) area women who were pregnant and had delivered within the prior 6 months. We recorded and transcribed all interviews. Two investigators independently coded resulting transcripts. We managed data using MAXQDA2 and conducted a content analysis.

Results

Perceived factors that contributed to GWG goal-setting included the mother’s weight control behaviors concerning exercise and diet—including a “new way of eating for two” and “semblance of control”, experiences during prior pregnancies, conversations with HCPs, and influence from various information sources. Women focused on behaviors with consistent messaging across multiple sources of information, but mainly trusted their HCP, valued one-to-one conversations with them about GWG, preferred that the HCP initiate the conversation about GWG goals, and would be open to have the conversation started based on visual aid based on their own GWG progression.

Conclusions

Pregnant women highly value discussions with their HCP to set GWG goals. Pregnant women view their clinicians as the most reliable source of information and believe that clinicians should open weight-related discussions throughout pregnancy.

Crowdsourcing and the Accuracy of Online Information Regarding Weight Gain in Pregnancy: A Descriptive Study

Background

Excess weight gain affects nearly half of all pregnancies in the United States and is a strong risk factor for adverse maternal and fetal outcomes, including long-term obesity. The Internet is a prominent source of information during pregnancy; however, the accuracy of this online information is unknown.

Objective

To identify, characterize, and assess the accuracy of frequently accessed webpages containing information about weight gain during pregnancy.

Methods

A descriptive study was used to identify and search frequently used phrases related to weight gain during pregnancy on the Google search engine. The first 10 webpages of each query were characterized by type and then assessed for accuracy and completeness, as compared to Institute of Medicine guidelines, using crowdsourcing.

Results

A total of 114 queries were searched, yielding 305 unique webpages. Of these webpages, 181 (59.3%) included information regarding weight gain during pregnancy. Out of 181 webpages, 62 (34.3%) contained no specific recommendations, 48 (26.5%) contained accurate but incomplete recommendations, 41 (22.7%) contained complete and accurate recommendations, and 22 (12.2%) were inaccurate. Webpages were most commonly from for-profit websites (112/181, 61.9%), followed by government (19/181, 10.5%), medical organizations or associations (13/181, 7.2%), and news sites (12/181, 6.6%). The largest proportion of for-profit sites contained no specific recommendations (44/112, 39.3%). Among pages that provided inaccurate information (22/181, 12.2%), 68% (15/22) were from for-profit sites.

Conclusions

For-profit websites dominate the online space with regard to weight gain during pregnancy and largely contain incomplete, inaccurate, or no specific recommendations. This represents a significant information gap regarding an important risk factor for obesity among mothers and infants. Our findings suggest that greater clinical and public health efforts to disseminate accurate information regarding healthy weight gain during pregnancy may help prevent significant morbidity and may support healthier pregnancies among at-risk women and children.

Improving gestational weight gain counseling through meaningful use of an electronic medical record

The purpose of this study was to test the effectiveness of an intervention to improve the consistency and accuracy of antenatal gestational weight gain counseling through introduction of a "best practice alert" into an electronic medical record (EMR) system. A best practice alert was designed and implemented in the EMR. Based on each patient's pre-gravid body mass index (BMI), fetal number, and 2009 Institute of Medicine (IOM) guidelines, the alert provides an individualized total gestational weight gain goal, the weight gain goal per week of gestation, a template for scripted provider counseling and documentation, and a patient handout containing personalized gestational weight gain information. Retrospective chart reviews of 388 pre-intervention patients and 345 post-intervention patients were used to evaluate effectiveness. Introduction of a gestational weight gain best practice alert into the EMR improved the rate of antenatal gestational weight gain counseling that was consistent with current IOM guidelines (p < 0.001). Improvement in IOM-consistent gestational weight gain counseling was seen across all provider types, including obstetricians, family practice physicians, and certified nurse midwives. The intervention also resulted in significant improvement in documentation of pre-gravid weights and BMIs within the EMR. The EMR is an effective tool for improving the consistency and accuracy of antenatal gestational weight gain counseling in accord with 2009 IOM guidelines.

Patient and Provider Perceptions of Weight Gain, Physical Activity, and Nutrition Counseling during Pregnancy: A Qualitative Study

OBJECTIVE

This study investigated patient and provider perceptions of weight gain, physical activity, and nutrition counseling during prenatal care visits.

METHODS

Individual qualitative interviews were conducted with 30 pregnant women between 20 and 30 weeks gestation (15 African American, 15 White) and 11 prenatal care providers (5 attending physicians, 5 residents, 1 nurse practitioner) in 2014.

RESULTS

The majority of patients and providers reported receiving or giving advice on weight gain (87% and 100%, respectively), physical activity (87% and 91%), and nutrition (100% and 91%) during a prenatal visit. Discussion of counseling content was largely consistent between patients and providers. However, counseling was limited and not fully consistent with current weight gain, physical activity, or dietary guidelines during pregnancy. Most patients viewed provider advice positively, but some wanted more detailed information. Providers discussed many barriers to lifestyle counseling, including lack of time, inadequate training, concern about the sensitivity of the topic, lower education or income level of the patient, cultural differences, and lack of patient interest.

CONCLUSIONS

Providers discussed weight gain, physical activity, and nutrition during prenatal care visits and patients accurately recalled this advice. However, counseling was limited and not fully consistent with guidelines. Future studies are needed to develop and evaluate the efficacy of interventions to help providers overcome perceived barriers and more effectively counsel women on weight and healthy lifestyles during pregnancy.

Factors associated with knowledge of personal gestational weight gain recommendations

Objectives

Excess adiposity (obesity and excess gestational weight gain, GWG) during pregnancy (EADP) increases risk for gestational diabetes, preeclampsia, and child and maternal obesity. Personal GWG goals predict total GWG. Some estimates suggest only 30% of pregnant women have personal GWG goals that are congruent with Institute of Medicine GWG recommendations. The primary purpose of this study was to determine the extent to which perceived pre-pregnancy weight status, healthcare provider advice, knowledge of EADP risks, and value for healthy GWG predicted knowledge of GWG recommendations. The secondary purpose was to determine sources of GWG information among pregnant women.

Methods

Pregnant women with a confirmed singleton pregnancy completed a one-time survey in obstetric clinic waiting rooms. Logistic regression analysis was used.

Results

246 predominantly African American, low income, overweight/obese women completed surveys. Average age was 25 (SD 5.3) and gestation age ranged from 7 to 40 weeks. Knowledge of pre-pregnancy weight status was the only unique predictor of GWG recommendation knowledge (B = .642, p = .03). The top three sources of GWG information were physicians, internet, and books. The least frequently reported sources of GWG information were other healthcare providers, community programs, and television.

Conclusion

In low income diverse overweight/obese pregnant women, accurate pre-pregnancy weight status perception was the only significant unique predictor of knowledge of GWG recommendations. Physicians were the preferred source of GWG information. Clinicians should have frequent, ongoing conversations about weight status with women before, during, and after pregnancy.

Knowledge translation tool to improve pregnant women's awareness of gestational weight gain goals and risks of gaining outside recommendations: a non-randomized intervention study

Background

There is an urgent need to prevent excessive pregnancy weight gain, a contributor to both maternal and child obesity. However, the majority of women had reported not being counseled to gain an appropriate amount of gestational weight by their health care providers. We developed a knowledge translation (KT) tool designed to facilitate the clinical interaction between pregnant women and their health care providers (HCPs). We piloted the tool on the impact on women’s knowledge of gestational weight gain (GWG) goals, and evaluated its potential in promoting appropriate knowledge about GWG within the 2009 Institute of Medicine guidelines.

Methods

We conducted a prospective cohort study, comparing women’s knowledge about GWG after the KT tool to women from the same clinics and care providers the year prior. Our primary outcome was the proportion of women who reported receiving an appropriate GWG recommendation from their care provider. We evaluated knowledge on a survey conducted at enrollment in the cohort at ≤ 20 weeks gestation and evaluated participant satisfaction with the KT tool in the third trimester. We performed univariate and multivariable logistic regression analyses for differences in outcomes with historical controls from the same clinics. Our a priori sample size calculation required 130 participants to demonstrate a 15% increase in reported counseling about gestational weight gain.

Results

One hundred and forty-six women were recruited and 131 (90%) completed the enrollment survey. Women who received the KT tool were more likely to report receiving a specific GWG recommendation from their HCP (adjusted odds ratio [AOR] 3.45, 95% confidence interval [CI] 2.22-5.37) and discussing GWG topics with their HCP (AOR 7.96, 95% CI 4.41-14.37), and believing that there were risks to their infants with inadequate GWG (AOR 2.48, 95% CI 1.14-5.37). Half of women (49.5%) indicated that they would recommend the tool to a friend.

Conclusions

Women who received the KT tool reported receiving more counseling on GWG from their HCPs and were more aware of the risks of gaining outside appropriate GWG recommendations. The association between GWG education and GWG requires further research.

"An on-going individual adjustment": a qualitative study of midwives' experiences counselling pregnant women on physical activity in Sweden

Background

In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide.

Methods

Eight focus group discussions (FGD) were conducted with 41 midwives working in antenatal care clinics in different parts of Sweden between September 2013 and January 2014. Purposive sampling was applied to ensure a variation in age, work experience, and geographical location. The FGD were digitally recorded, transcribed verbatim, and analyzed using manifest and latent content analysis.

Results

The main theme– “An on-going individual adjustment” was built on three categories: “Counselling as a challenge”; “Counselling as walking the thin ice” and “Counselling as an opportunity” reflecting the midwives on-going need to adjust their counselling depending on each woman’s specific situation. Furthermore, counselling pregnant women on physical activity was experienced as complex and ambiguous, presenting challenges as well as opportunities. When midwives challenged barriers to physical activity, they risked being rejected by the pregnant women. Despite risking rejection, the midwives tried to promote increased physical activity based on their assessment of individual needs of the pregnant woman. Some participants felt that their own lifestyle and body shape might negatively influence the counselling; however, the majority of participants did not agree with this perspective.

Conclusions

Counselling on physical activity during pregnancy may be a challenging task for midwives, characterized by on-going adjustments based on a pregnant woman’s individual needs. Midwives strive to find individual solutions to encourage physical activity. However, to improve their counselling, midwives may benefit from further training, also organizational and financial barriers need to be addressed. Such efforts might result in improved opportunities to further support pregnant women’s motivation for performance of physical activity.

Healthy eating and lifestyle in pregnancy (HELP): a protocol for a cluster randomised trial to evaluate the effectiveness of a weight management intervention in pregnancy

Background

Approximately 1 in 5 pregnant women in the United Kingdom are obese. In addition to being associated generally with poor health, obesity is known to be a contributing factor to pregnancy and birth complications and the retention of gestational weight can lead to long term obesity.

This paper describes the protocol for a cluster randomised trial to evaluate whether a weight management intervention for obese pregnant women is effective in reducing women’s Body Mass Index at 12 months following birth.

Methods/design

The study is a cluster randomised controlled trial involving 20 maternity units across England and Wales. The units will be randomised, 10 to the intervention group and 10 to the control group. 570 pregnant women aged 18 years or over, with a Body Mass Index of +/=30 (kg/m²) and between 12 and 20 weeks gestation will be recruited. Women allocated to the control group will receive usual care and two leaflets giving advice on diet and physical activity. In addition to their usual care and the leaflets, women allocated to the intervention group will be offered to attend a weekly 1.5 hour weight management group, which combines expertise from Slimming World with clinical advice and supervision from National Health Service midwives, until 6 weeks postpartum.

Participants will be followed up at 36 weeks gestation and at 6 weeks, 6 months and 12 months postpartum. Body Mass Index at 12 months postpartum is the primary outcome. Secondary outcomes include pregnancy weight gain, quality of life, mental health, waist-hip ratio, child weight centile, admission to neonatal unit, diet, physical activity levels, pregnancy and birth complications, social support, self-regulation and self-efficacy. A cost effectiveness analysis and process evaluation will also be conducted.

Discussion

This study will evaluate the effectiveness of a theory-based intervention developed for obese pregnant women. If successful the intervention will equip women with the necessary knowledge and skills to enable them to make healthier choices for themselves and their unborn child.

Trial registration

Current Controlled Trials: ISRCTN25260464

Date of registration: 16^th April 2010.

Patient-provider communication about gestational weight gain among nulliparous women: a qualitative study of the views of obstetricians and first-time pregnant women

BACKGROUND

In 2009 the Institute of Medicine updated its guidelines for weight gain during pregnancy, in part because women of childbearing age now weigh more pre-pregnancy and tend to gain more weight during pregnancy than women did when the previous set of guidelines were released in 1990. Women who begin pregnancy overweight or obese and women who gain weight outside IOM recommendations are at risk for poor maternal and fetal health outcomes. With these concerns in mind, we examined what obstetricians communicate about gestational weight gain to their pregnant patients and how nulliparous patients perceive weight-related counseling from their obstetricians.

METHODS

We conducted one-on-one, semi-structured interviews with 19 nulliparous women and 7 obstetricians recruited from a single clinic at a large academic medical center in the United States. Interviews were transcribed verbatim and analyzed inductively using thematic analysis.

RESULTS

We identified 4 major themes: 1) Discussions about the amount and pace of gestational weight gain: obstetricians reported variation in the frequency and timing of weight-related discussions with patients while most patients said that weight was not emphasized by their obstetricians; 2) The content of communication about nutrition and physical activity: obstetricians said they discuss nutrition and activity with all patients while most patients reported that their obstetrician either discussed these topics in general terms or not at all; 3) Communication about postpartum weight loss: obstetricians said that they do not typically address postpartum weight loss with patients during prenatal visits while patients had concerns about postpartum weight; and 4) Patient feelings about obstetrician advice: most patients said that their obstetrician does not tend to offer "unsolicited advice", instead offering information in response to patient questions or concerns. Women were divided about whether they desired more advice from their obstetrician on weight gain, nutrition, and activity.

CONCLUSIONS

Our analysis revealed discrepancies between obstetricians' and patients' perceptions of their weight-related clinical interactions. Our findings suggest that there is a missed opportunity to use prenatal visits as opportunities to discuss healthy eating and exercise during pregnancy, the postpartum period, and beyond. Additional research on the design, implementation, and testing of interventions to address prenatal nutrition and physical activity is warranted.