Introduction
Methods
Search strategy
Study selection
Data extraction
Study characteristics
Quality assessment
Meta-ethnographic synthesis
Results
Search outcomes
Study characteristics
Authors | Country | Aims | Data collection method | Recruitment | Number of participants | Age | Pregnancy status | BMI required for participation | Timing of data collection | Method of data analysis | CASP score |
---|---|---|---|---|---|---|---|---|---|---|---|
Denison et al. (2015) [29] | UK | To explore the barriers and facilitators to physical activity and lifestyle interventions in pregnant women with Class III obesity (BMI >40kg/m2) | Semi-structured interviews | Purposive-sampling from a specialist-led clinic providing care to pregnant women with class III obesity. | 13 | 25-34 years | Pregnant | Class III obesity (>40kg/m2) | 17-37 weeks gestation | Framework approach | 17 |
Ferrari et al. (2013) [30] | USA | Elicit from pregnant women their perceptions about provider advice regarding diet and physical activity in pregnancy. | Focus groups | Sample was part of a larger study. Recruited through newspaper ads, posted flyers and prenatal clinics. | 58 | 18-35 years | Pregnant | N/A | 27-30 weeks gestation | Thematic analysis | 16 |
Faucher et al. (2020) [31] | UK | Identify beliefs and attitudes about GWG, exercise, and proposed intervention | Focus groups | Women were recruited with flyers and HCP approaches in their birth centres | 17 | 17-35 | Pregnant | Pre-pregnancy BMI of 30 or greater | <14 to 38 weeks gestation | Content Analysis | 15 |
Flannery et al. (2020) [32] | Ireland | Explore overweight and obese women's experience and perception of dietary behaviours and weight management during pregnancy | Semi-structured interviews | Women with a BMI of 25 or higher were identified and recruited in a maternity hospital | 30 | 20-40+ | Pregnant | Between 20 and 40km/m2 | Across all trimesters but most women between 27 and 40 weeks gestation. | Thematic analysis | 19 |
Flannery et al. (2018) [33] | Ireland | Systematically identify the barriers and enablers to physical activity for women who are overweight and obese in pregnancy using the TDF and COM-B model. | Semi-structured interviews | Purposive-sampling of women with BMI ≥25kg/m2 in the public antenatal clinic of one maternity hospital. | 30 | Pregnant | BMI ≥25kg/m2 | Across all trimesters | Framework approach with inductive thematic analysis | 16 | |
Garnweidner et al. (2013) [34] | Norway | To explore experiences with nutrition related information in routine antenatal care of an ethnically and socially diverse study population. | Semi-structured interviews | Recruited by midwives in eight mother and child health centres in Oslo. | 17 | average 28 years old | Pregnant and postpartum | Pre-pregnancy BMI ≥25kg/m2 | Before the 30th week of pregnancy and two months afterwards | Interpretative phenomenological analysis | 16 |
Groth et al. (2013) [35] | USA | Understand how urban, low income, pregnant African American women view physical activity and how they approach nutrition while pregnant. | Focus groups | Recruited from the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) services and prenatal clinic waiting rooms | 26 | 18-39 years | Pregnant | N/A | Over 60% in their first 20 weeks of pregnancy | Content analysis | 15 |
Holton et al. (2017) [36] | Australia | Describe women's experiences and perspectives of care for weight management during pregnancy in Melbourne, Australia. | Semi-structured interviews | Recruited from Medical Centre using purposive recruitment strategies inc. Flyers and direct approaches from researchers | 17 | 24-43 years (32.6 average) | Pregnant and postnatal | N/A | Late pregnancy (≥28 weeks gestation) and 4-6 weeks after giving birth. | Thematic analysis | 15 |
Keely et al. (2017) [37] | UK | To explore the experiences, attitudes and health-related behaviours of pregnant women with a BMI >40kg/m2 | Semi-structured interviews | Purposeful sampling in a specialist antenatal clinic for women with BMI >40kg/m2. | 11 | 26-40 years | Pregnant and postnatal | Pregnant women with BMI ≥40kg/m2 | 2 interviews during pregnancy and 1 postnatally | Thematic content analysis | 15 |
Kominiarek et al. (2015) [28] | USA | To examine and describe obese racial-ethnic minority women's knowledge, beliefs and attitudes about nutrition, exercise, and healthy lifestyles during pregnancy. | Focus-groups | Recruited at Women’s health clinic via recruitment flyers or recruited by study personnel. | 16 | 21-39 | Pregnant | Prepregnancy BMI ≥30kg/m2 | Across all trimesters | Conventional qualitative data analysis (Thematic analysis) | 17 |
Lee et al. (2018)* [38] | Australia | To assess and compare pregnancy nutrition recommendation knowledge and to explore how nutrition knowledge impacts on food choices in pregnant women and nutrition education practices of antenatal care providers. | Semi-structured interviews | Convenient sample from eligible pool of pregnant women attending the hospital for antenatal care. . | 19 | <30 to 40+ | Pregnant | N/A | Across all trimesters, 45% women last trimester | Thematic analysis | 15 |
Leiferman et al. (2011) [39] | USA | To elucidate unique barriers and facilitators to antenatal physical activity engagement among women of low socioeconomic status. | Individual and paired interviews | Passive print advertisement Via health care clinics and community organisations | 25 | 18-46 | Yes | N/A | Second and third trimester | Thematic analysis | 15 |
Marquez et al. (2009) [40] | USA | To understand how Latina women perceived, understood, and valued exercise to inform a physical activity intervention designed. | Focus groups | Purposive sampling waiting room at the time of patients pre-natal appointments by bilingual/bicultural interviewers. | 20 | 18 to 40 | Yes | N/A | <28 weeks gestation | Content analysis | 15 |
O'Brien et al. (2017) [41] | Ireland | To explore the various factors within the life course that overweight and obese pregnant women perceive to influence their food choice and physical activity behaviours. | semi-structured in depth interviews | Purposive sampling from patients attending the ODP | 22 | Mean 32.3 | Yes | BMI ranging between 25kg/m2 and 39.9kg/m2 | 34th week of pregnancy | Inductive thematic analysis | 16 |
Padmanabhan et al. (2015) [42] | UK | Examine pregnant women's weight-related attitudes and beliefs (including the weight-related behaviours of diet and physical activity during pregnancy). | Semi-structured face to face interviews | All participants were previously recruited to a prospective quantitative longitudinal study via invitation letters and participation information sheets. | 19 | 19-38 years | Yes | N/A | Third trimester | systematic thematic content analysis | 16 |
Reyes et al. (2013) [43] | USA | Understand the perceptions of low-income, overweight, and obese, African-American mothers about diet quality in pregnancy, specifically focused on what facilitators and barriers exist to eating healthy. | Semi-structured, individual interviews | Waiting room of a single university-affiliated outpatient prenatal care clinic, serving primarily Medicaid-insured patients. | 21 | ≥18 | Yes | Excluded in BMI <25 | All trimesters in pregnancy | Principles of grounded theory | 16 |
Sui et al. (2013)* [44] | Australia | Describe overweight and obese pregnant women's views about making healthy behavioural changes during pregnancy. | Face-to-face interviews | Purposeful sample of women participating in larger study. | 26 | not specified | Yes | Criteria of larger study. | 28 weeks gestation | Framework analytical approach | 16 |
Synthesis
Themes | Categories |
Theme 1: Awareness, beliefs and emotions about weight gain and weight management | 1.1 Knowledge and awareness |
1.2 Risk perception and decision balance | |
1.3 Perceived control over health and weight gain | |
1.4 Personal insecurities and sensitive nature of the topic | |
Theme 2: Antenatal healthcare | 2.1 Interactions with healthcare professionals |
2.2 Antenatal education and sources of information | |
Theme 3: Social and environmental influence | 3.1 Influence of others, support and social norms |
3.2 Social judgement and stigmatization | |
3.3 Environmental and sociodemographic factors |
Theme 1: Awareness and beliefs about weight gain and weight management
Category 1.1: Knowledge and awareness
“I don’t think there is a risk to me and my baby just yet. It’s just, I think, the number . . . I’ve gained 40 [pounds], so it’s not like a lot . . . I mean, even like you said, you gained 70 [pounds] but you were fine. So, the number I feel like is tricky.” [34] [First order construct]
“I mean I don’t know can you do certain exercises so I would be worried that I could pull a muscle so I would be extra cautious I suppose at the gym cause I’m afraid and I wouldn’t really know” [33] [First order construct]“I don’t know what contains iron in food.” [30] [First order construct]
“I’ve been warned by the midwife that I’ve been overweight and it’s so important that I should try to keep healthy.” [44] [First order construct]
"Someone was comparing giving birth to a marathon…the more active you are and the more limber you are, then the easier it is to give birth." [29] [First order construct]"They are both as important… diet because you are directly feeding the baby and you can control weight by eating the rights things. However, exercise…it's not only about weight control, it's about keeping your body moving and all sorts of other pregnancy things…" [29] [First order construct]
Category 1.2: Risk perception and decision balance
“Oh, I think it feels like it gives you a free pass… I just think, ‘Well, I’m gonna.’…this is likely to be my last baby, I can lose the weight once I’m done” [37] [First order construct]“I eat quite a lot of salad but I also eat quite a lot of chips and I know that chips are not healthy but I like them (laughs), in my mum’s house we eat a lot of veg and fruits, so I thought that was just enough really” [42] [First order construct]“If she's moving, then it's like, ‘okay, well maybe she wants something’. When she moves, it's like, ‘maybe I'm hungrier than I feel. Maybe she needs something special.” [43] [First order construct]“I know I don't really exercise but, like I said, getting the kids ready and walking to the car—I feel like that's sufficient enough for me to exercise." [28] [First order construct]
‘I've seen pregnant people there and they're on the treadmill and I think ‘cool yourself'…you've got your baby bouncing up and down and then you've got your fat on top of the baby and it's just, you know, you could give them brain damage'." [29] [First order construct]
“Now because I only have a short time to go, I look at the scales and it’s a big achievement, and that’s brilliant, as what I have gained has been sufficient for the baby, but not to put on myself if you like, so I’m actually quite proud of myself" [42] [First order construct]“Now I'm not eating a lot of greasy foods… (Before pregnancy) I wouldn't say I didn't care, but I got another life growing in me, so I don't want to jeopardize my life and the baby's life.” [43] [First order construct]
Category 1.3: Perceived control over health and weight gain
“You can't control it, cuz that baby controlling it for you.” [28] [First order construct].“According to our participants, biology and environment can conspire to make managing dietary intake feel beyond their control.” [31] [Second order construct]
"I must admit a few weeks ago I tried [exercise] and I ended up in big trouble, I felt so sick, my head was swimming and my pelvis was killing and the baby wasn't happy and I thought no I've pushed, you know, when you've pushed it too far" [29] [First order construct]“I think I gained weight due to severe morning sickness. The only thing I could eat was bread which helped to stop the nausea and heartburn. I ate bread even when I wasn’t hungry as it alleviated the alkaline taste on my tongue.” [36] [First order construct]
“ […] Like, I can’t do anything about it. I mean, I know all this… I mean I’ve studied this so much… like… I could be a dietitian probably! I just can’t implement it, for whatever reason, like… know what I mean?” [37] [First order construct]“If I’ve already got an exercise routine, then stick with it… and just, if you are eating healthy, keep up with that.” [44] [First order construct]
“I think it’s more because of my diet and everything and the way I am eating and I can actually see that you know it is working, not eating too much […] so I think that helps you know, that you can physically see that I am in control” [42] [First order construct]
Theme 2: Antenatal healthcare
Category 2.1: Interactions with healthcare professionals
"I had a very bad experience during my first pregnancy. I was 29 weeks and I went in to see my consultant and asked him if I could find out the sex of the baby but he just pinched my stomach … I felt very upset. I think they turn off when you are a little bit overweight. And they think oh she's after letting herself go.” [32] [First order construct]"…what I found different was when they know that you have children already they kind of thinking that you know everything which is not true…you may forget […] but they seem to assume because you have had other children you know already what to do" [33] [First order construct]
"I was very frustrated my first pregnancy because my midwife was very keen on nutrition and, “Don’t gain too much weight,” and “We don’t want to have a really big baby.” And I wasn’t gaining any weight at all. And, so the fact that she was harping on it to me made me very angry […] It made me almost want to neglect the nutrition aspect, because I felt like she wasn’t listening to me personally." [31] [First order construct]“I don't feel like I'm the typical obese person, you know. They say I'm obese, and I'm like, well, I don't know how you figure I'm obese. How do you classify obesity? I don't like that word because I don't feel—I know I'm big, but I'm not as big as most.” [28] [First order construct]
"I feel very insecure about my weight … [the midwives] really tried not to mention it or make me feel uncomfortable." [35, 48] [First order construct]"They reported that although it “hurt” when providers discussed their weight, they knew they were being truthful and ultimately it helped them." [37] [Second order construct]
Category 2.2: Antenatal education and sources of information
“They don’t tend to offer any advice good or bad in terms of weight management and activity and stuff like that. It’s more the blood pressure, checking the baby and stuff like that” [33] [First order construct]“It was about the food I couldn’t eat. Like some types of raw fish and pasteurized milk and cheese, as I recall it?” [34] [First order construct]“Nobody told me nothing [about physical activity]. They gave me some brochures [chuckling] and that's it.” [30] [First order construct]
“I saw a dietician at the pre-pregnancy clinic [due to diabetes]. She gave me useful information about food groups and healthy eating during pregnancy. I think other women would benefit from similar information.” [36] [First order construct]“You know, it doesn’t say that much to me. It’s very, very much information you have to absorb during few consultations. I honestly have to admit that not all information is processed.” [34] [First order construct]
Theme 3: Social and environmental influence
Category 3.1: Influence of others, support and social norms
“The food that my mother buy [gets in the way of me reaching my GWG goal]. She don't buy healthy food, she, cuz my brother, and they all like fried chicken... She don't buy plain chicken.” [28] [First order construct]“My family says eat as much as I want. And just keep eating, ‘Cause it’s good for the baby.” [43] [First order construct]“I don't know what to follow. I don't know whether to obey what the nurse says about lying down or her [my husband's aunt].” [30] [First order construct]
“Lot of people have constantly said to me throughout my pregnancy, you need to rest, you need to rest, you need to rest. I don't really understand why I need to rest. If my body's not telling me that I need to rest you know, then why do I need to rest? … so it's been quite difficult.” [29] [First order construct]“Well, just my husband and both my brothers, they all work out together, and me and my cousin work out, so everybody around me works out, so that kind of helped me.” [39] [First order construct]
"You know, that’s really weird, because in Norway you are told to eat eggs and fish, however in Pakistan you should stay away from it in the first three months of pregnancy." [34] [First order construct]"You are in trouble when the elders say something and the midwife says something else. Especially your mother in law. She has much influence, especially during the first pregnancy. It is really difficult sometimes to decide what I should eat." [34] [First order construct]
Category 3.2: Social judgement and stigmatization
“I beat myself up for it [weight gain]. I'm like, oh, I'm just so depressed, and I don't wanna eat no more.” [28] [First order construct]“It’s going in like a swimming costume, it's definitely… Yeah, that's what puts me off 100%. It's nothing else… I'm like ‘oh my God,’ the thought of going swimming and people seeing me.’ [29] [First order construct]
“When I was in the [hospital] waiting room, people looked at me differently … people think that you don’t look after yourself or take care of yourself when you are overweight.” [36] [First order construct]“I think the thing as well…they think you’re just sitting here stuffing pints of Ben & Jerry's, like… that's not what my life is like…” [tearful]. [37] [First order construct]
Category 3.4: Environmental and sociodemographic factors
“I don't drive. So, when I get to the store, I have to go shopping for the entire month, because getting on the bus to go get groceries, it's too much.” [43] [First order construct]"I think city life is probably not good for me... Takeaways and stuff, everything is delivered, you find stuff to do that's not even that active, like go to the cinema... it's just too easy to be bold" [41] [First order construct]"It used to be expensive for Cornflakes and so cheap for porridge and it was always if you had less money you made you already made better choices... Now I don't know how they are doing chocolate and doughnuts so cheap... The people eating free--range eggs and wholegrain bread are middle class... They are educated people" [41] [First order construct]
“If you live in a bad neighborhood… it's not safe to exercise…You don't do that…” [40].“I was looking for swimming baths…that I could afford [as unemployed]…I do like going to the gym. I have had to give up my gym membership because I'm not working and I can't afford it.” [29] [First order construct]
“We tend to eat a lot of convenience food because I’m working full time and more things like fish fingers, chicken nuggets […] its always just whatever is in the freezer type of things” [42] [First order construct]“I do find it, I would find it difficult to go out and do a proper exercise routine, because I just physically don’t have the time I don’t get in much until 6pm and I leave the house at 6am” [42] [First order construct]
"I suppose just as the years progress, you know, you have to think for the future, because what you do right now will definitely benefit you for the future. And that's the way I look on it, you know. I think in your early twenties, you're out and what not and you know, your whole perspective on life completely changes" [41] [First order construct]
“I probably would be less active if they (trails, parks) weren’t there. I do walk up and down the neighbourhoods […] when I am really motivated I do the trail because the trail is long. But, yeah, I do think I would be less active if I didn’t have that (trail).” [39] [First order construct]