Using the McLeroy et al.’s ecological model [
18], we elucidated the nuances associated with GWG and goal-setting for weight gain. Our qualitative analyses of semi-structured interviews and focus groups in pregnant women showed that factors that might influence GWG include mother’s beliefs concerning diet and exercise and experience during prior pregnancies (individual), conversations with HCPs (interpersonal), interest in clinics utilizing GWG charts (organizational), and influence of information sources (community). Women focused on behaviors that messages were consistent across multiple sources of information, but mainly trusted their HCP. Women highly valued one-to-one conversations with their HCP about GWG, especially if they have weight issues prior or during pregnancy.
Implications for Practice and/or Policy
Indeed, one of the major points that we highlighted in our observations is that pregnant women rank highly clinician advice concerning GWG. Many points throughout the interviews and focus groups supported this conclusion. First, women considered clinicians the most reliable source of information and verified with their provider information found from other sources. This is in line with qualitative studies where women also reported that clinicians were the most credible source of information [
20,
21], and a quantitative study that found that discordant clinician advice was directly associated with excessive GWG [
22]. In addition, clinician input seems to also be an important adjunct to the use of educational tools about GWG. Women in our study reported having received many handouts, but felt that was not sufficient per se and that their providers need to discuss the content with them if the specific matter is an important health issue for the pregnancy. Similarly, pregnant women from a large academic medical center in Wisconsin also reported receiving handouts for nutritional education during pregnancy but underlined the fact that the material was rarely reviewed during the medical encounter [
23]. In our study, when we presented a graphic tool to chart GWG during pregnancy, women stated that the tool would be useful if accompanied by a discussion with their provider, highlighting once again the importance of clinician’s input about GWG in women’s opinion.
We and others have shown that women whose provider recommended weight gains consistent with IOM recommendations were more likely to have a concordant GWG goal compared to women whose providers recommended gains inconsistent with recommendations or no clear GWG recommendations [
17,
24]. Previous interviews found that most clinicians reported discussing appropriate GWG with their patients at the beginning of pregnancy [
25]. Many women reported receiving a GWG goal, but this was not consistent across all participants; unfortunately, many overweight women reported not receiving a specific GWG goal. Similarly, Stengel et al. reported that nine out the 24 overweight/obese women they interviewed were not given a goal, and many were given vague goals or goals outside the IOM recommendations [
21].
In the current analysis, women stated that they would like their providers to open the conversation and give them a goal for GWG early in pregnancy. In our previous qualitative study among obstetric providers, clinicians reported that they felt that weight is a sensitive issue for women and often wait for women to ask questions – or only bring up weight gain as a topic if GWG reaches out of the expected range [
25]. This HCP behavior seems to be fairly common in obstetric providers since the theme also emerged from a systematic review in the UK [
26] and in other US practitioners’ qualitative studies on GWG [
27,
28]. Women in our study and in other reports [
23,
29] felt that GWG should be addressed up front by their provider if this is important and not wait for women to bring up the topic of weight gain to the providers, an approach sometimes called ‘reactive’ counseling [
23,
28]. It is striking that both parties feel like the other one should open the conversation: clinicians believe that weight is sensitive and usually wait until women raised the issue or when GWG was concerning, and women felt as though their provider should and would raise that discussion if that is something that is important for their health.
Providers’ confidence level in their own counseling skills is associated with higher adherence to guidelines for prenatal clinical care of obese pregnant women [
30]. Consequently, the clinicians’ difficulty in opening the discussion might also derive from the fact that providers do not feel adequately prepared and feel uncertain about the impact of their counseling effort, as we and others reported based on interviews with obstetric providers [
25,
27,
28,
31]. This situation is not unique to clinicians in obstetric care, since a few studies have reported that physicians often feel ill-prepared and lack confidence to provide adequate lifestyle counseling, particularly in the fields of physical activity, nutrition, and weight management [
32,
33]. Multidisciplinary approaches and referral to appropriate health professionals are likely part of adequate weight management in obese women during pregnancy, but providers need to have confidence in their knowledge and skills about lifestyle counseling to open the discussions.
Strengths and limitations
Strengths of our study include the use of standardized moderator guides, recording of the group discussions and interviews, and analyzing the transcripts using established qualitative methods. Our study also has limitations. We interviewed women of diverse race/ethnicity in the greater Boston, MA area, and most had college or graduate degrees, so results may not be generalizable to pregnant women living elsewhere or with lower education. In order to build upon this study, future studies will include a quantitative survey on a larger population. GWG goals are based on self-report and may have been over or underreported. Women who participated in the study are likely interested in weight related issues and so our results might overestimate the frequency of GWG goal-setting.