Background
During pregnancy and delivery, a healthy and nutritionally balanced diet can minimize health risks for the expecting mother and her child and can have significant effects on the child’s future growth and development [
1]. Many women of reproductive age only come into contact with health care during pregnancy; therefore, midwives in antenatal care have a unique role in promoting healthy behaviour and diet among pregnant women as a part of regular antenatal check-ups [
2]. Pregnant women are also frequently seen as receptive to directly or electronically delivered health messages [
3,
4]. They use the Internet for interactions, such as communication for getting and giving support to other pregnant women; something that has the potential to empower them with respect to lifestyle changes [
5]. However, a Swedish study reported that pregnant women rarely discussed information retrieved from the Internet with their midwives [
6]. In a British study pregnant women requested healthy eating information early in the pregnancy, and they also wanted dietary support from women who had themselves struggled with their diet while pregnant [
7].
Health literacy among pregnant women varies between countries with women in western and northern Europe reportedly having the highest literacy [
8]. Health literacy has been described at three levels: functional, interactive and judgmental literacy. Functional literacy concerns knowledge of health risks and compliance with prescriptions. Interactive literacy concerns skills to extract information from different sources. Judgmental literacy concerns the analysis of information to control life events and situations [
9]. Schulz & Nakamoto [
10] have advocated supporting both health literacy and empowerment to enable people to take an active role in decision-making regarding their own health. This corresponds well with the concept of person-centred care, which implies taking the patient’s preferences, values, needs, and priorities into account when planning, performing, and evaluating care.
Person-centred care is described as a paradigm shift in nursing and health care and something that should be supported and implemented in all aspects of health care [
11]. It implies a mutual partnership where the health professional’s medical expertise and the patient’s expertise in self-management activities in their everyday life are exchanged on an equal basis. Person-centred care is interchangeable with woman-centred care, which is a more appropriate concept for this article and will be used throughout the rest of this manuscript [
12,
13]. The International Confederation of Midwives (ICM) advocates that midwifery care be based on woman-centred care where midwives, in partnership with the women, empower the pregnant women to assume responsibility for both their own health and the health of their families [
14].
Difficulties for health care professionals to deliver individualized dietary counselling and self-management support are reported to be a prominent barrier to changing dietary habits among pregnant women [
15]. Although there is a paucity of research in the area of the role of midwives in health promotion practices such as dietary counselling, a study from the UK, reports from an interview study that even if midwives acknowledged their role in supporting health, their practice predominantly consisted of health information. Barriers were inadequate training and concerns about the midwife-woman relationship [
16]. An integrative literature review of 33 research reports aimed at answering the question “What makes a good midwife” reports that good communication skills, a caring approach and individual treatment of women are essential [
17].
Dietary counselling is particularly complex. Recommendations have changed over time and are sometimes controversial and scientific “facts” about risks vary between countries [
18,
19]. Examples are the varying recommendations about fish and cheese intake, as well as alcohol.
Pregnant women are reported to struggle with their diet [
20], and midwives seem to struggle with how best to provide them with dietary information [
21]. There is little evidence in the literature for how best to assist pregnant women in reducing diet-related risks while simultaneously not increasing guilt and worry about causing harm to themselves and their unborn child cf. [
22]. The qualitative study in the present work was conducted in order to show how midwives perceive their potential to influence the dietary habits of pregnant women. The aim of the study was therefore to describe how midwives perceive their role and their significance in dietary counselling of pregnant women.
Discussion
Our results showed that the midwives felt that they were being listened to, but were uncertain what impact their counselling had on the pregnant women’s behaviour. Their authority, therefore, was both ambiguous and questioned. The midwives viewed the pregnant women as eager information seekers who scoured the Internet for dietary information. However, the women were in need of guidance because they were considered to be too emotional and worried about interpreting the information and managing their diet on their own. The midwives were doubtful about the use of information sources on the Internet because they could not control or evaluate the information.
Pregnancy has traditionally been considered in midwifery as a normal life event. Nowadays, an increasing focus in midwifery care has been placed on risks and disease prevention instead of health promotion [
26]. In a Swedish observational study, the midwives in antenatal care emphasized pregnancy as being a healthy condition, but at the same time they used the antenatal visits to check the pregnancies for deviations and complications [
27]. Moreover, the midwives in our study seemed to medicalize dietary issues and prohibited intake of food items that might risk containing toxins or contaminants. They expected the pregnant women to follow their advice and to take responsibility for their diet while at the same time remaining relaxed and not too rigorous in relation to dietary issues. This is not an easy balancing act. Pregnant women receive advice and restrictions in the name of safety and risk-reduction, and they should certainly avoid an array of foods, but they should also avoid many other risky behaviours such as changing the cat litter and should take other precautions in their daily lives “just in case” [
22]. Medicine in Western society plays an increasingly important role in shaping the ways we think about and treat our bodies. Thus medical advice influences many women to be more careful, but it can also lead to worry cf. [
28]; and worrying about being a bad mother is reported to be a significant problem among many pregnant women [
20].
The midwives in our study viewed themselves as experts who should provide important knowledge about risks because the pregnant mothers were seen as lacking the ability to interpret the information they found on their own. Pregnant women were even seen as enfeebled during pregnancy and, therefore, to be in need of some degree of governance for the sake of their own and their unborn child’s health. Rather than counselling, the activity could be labelled as a transfer of information about dietary change. Unfortunately, the transfer of knowledge and information did not solve the difficulties of reaching women who were described as uninterested or non-adherent, i.e., women who were obese, underweight, or living in socioeconomic or cultural circumstances that they could not easily influence. In a previous study, we reported that when dictating and governing strategies did not work, the last step was resigning responsibility and leaving the pregnant women on their own [
21]. Increasing weight-gain, overweight and obesity in pregnancy is a growing health problem among pregnant women: The midwives described such counselling situations as delicate and they requested more training and education. Midwives in the UK as well as in Australia have reported a similar lack of training and education, particularly in dietary counselling of obese women. Building a trusting and supporting relationship between midwives and obese pregnant women has in previous studies been reported essential for effective care. An important issue is to identify and address possible underlying causes of unhealthy diet if they should be solved, but simultaneously avoiding communication styles that negatively impact the midwife-women relationship [
29,
30].
Despite that pregnant women in Europe are reported to have high health literacy [
8] the midwives in our study described pregnant women as being in need of hands-on guidance to interpret health information, since they did not fully trust the women’s ability to make good judgments. Sometimes they even tried to stop them from seeking information on their own. Despite their own awareness of not having sufficient dietary knowledge, they defended their choices of prioritizing their own expertise over that of their patients and of the one-way flow of written as well as verbal information that included permissions and prohibitions based on the recommendations of the NFA. Midwives in the UK were also reported to predominately provide information instead of counselling pregnant women [
16]. We have interpreted that, by holding on to one source of information and excluding or disqualifying others that they were not familiar with, the midwives in our study could more easily maintain their authority cf. [
31]. Midwives in another Swedish study [
32] perceived that more enquiring and knowledgeable parents undermined their professional expertise and competency as well as their control.
A traditional, authoritarian counselling style might possibly be a way to increase
functional health literacy among pregnant women, but their
procedural and
judgmental health literacy will be less supported. There is the risk with such a method that there will be little opportunity for the women to develop the skills to extract information from different sources. Furthermore it could negatively impact pregnant women’s ability to critically analyze and use information to control life events and various situations that are related to dietary choices [
10].
Despite midwives’ strong professional identity [
32] it seems to be prime time for a professional role change from a guidance-cooperation model to a woman-centred care model cf. [
10,
12]. Such care derives from a mutual participation model and implies that both parts trust each other and are respectful of the other’s expectations and values cf. [
33]. In a woman-centred care model, risk communication is a two-way process. In this process, the pregnant woman who actively seeks information on risks from many different sources is one important part [
20,
34]. The other part is the midwife, who should be skilled in counselling methods but also knowledgeable in questions about risks and risk magnitude. Alaszewski [
34] problematizes the communication of risk knowledge and states that even in an area where there is scientific consensus, such as abstinence from alcohol and caffeine consumption during pregnancy, there are often alternative views. Alaszewski argues that epidemiological knowledge of the probability of harmful events occurring within populations does not address individual patients’ needs for information about their own personal risks, and it is not possible to talk about one single truth. Midwives in the UK have reported that they predominantly focus on risk assessment and health information instead of supporting women to change behaviour [
16]. Also in our interviews, the pregnant women’s exposure to risks was described as a common issue in dietary counselling. However, the magnitudes of the risks were never discussed in terms of how risky a particular behaviour might be, such as eating smoked fish twice a week. Lyerly et al. [
22] state that the boundaries between “dangerous” and “safe” and between “reckless” and “responsible” in pregnancy are constructed in a rigid, yet often arbitrary, manner.
Trust is a central component in risk communication and lifestyle counselling during pregnancy. It is expected that a trusting relationship will allow the midwife to be seen as a credible source of information where the midwife with whom the pregnant woman has hopefully developed a relationship cf. [
34]. However, the midwives in our study seemed to question the credibility of their own advice and its impact. The medicalization of pregnancy implies an increased power of the health care professionals through monitoring and medical procedures along with excessive emphasis on medical outcomes and risk prevention [
35,
36]. While midwives are a part of this monitoring, risk reducing, and controlling care, at the same time they are expected to build trust and support pregnant women in developing health literacy and empowerment so that these women become more responsible for their own health choices. From interviews with Swedish midwives, Larsson et al. [
32] report two existing midwifery cultures that clash and lead to decreased confidence in the professional group. On the one hand, there exists a culture of making judgements by themselves without always thinking ‘to be on the safe side’ and on the other hand they are controlled by safety and the use of medical technology and measurements. Midwives have to combine a risk-focused approach with a woman-centred approach in their counselling. If not reflected on, these conflicting priorities could become very difficult to handle and will most certainly lead to role ambiguities [
37-
40] or risks for burn out symptoms [
32].
In the organization of antenatal care, the midwives have an intermediate role where they are expected to autonomously counsel women and monitor pregnancies, while at the same time they are closely controlled by health care organizations and government authorities through registrations, statistics, and time restrictions cf. [
16]. Lack of training, insufficient knowledge, and limited time have previously been described by midwives as barriers to efficient health counselling cf. [
16]. In order to fulfil governmental and institutional expectations, many of the interviewed midwives informed all pregnant women about dietary issues even if they were not in need of such information or were not interested in it. In many situations, the midwives felt insufficient and on their own in the organization and as just being solely workers, burdened and without support, only doing what they were expected to do. According to Street & Epstein [
33], health service is organized in a quite fragmented manner, and thereby midwives are likely to withdraw from building relationships and instead focus solely on task completion as a result of role ambiguities [
32].
Methodological discussion
We observed when we conducted the secondary analysis of the initially collected data that the two qualitative data collection methods, labelled a mixed-/mono-method where the new, additional interviews had a slightly different focus, complemented the aim well [
41].
The use of different interview techniques has also been questioned [
42,
43], but mixed data could be seen as a useful strategy by providing more opportunities to get answers to the research questions [
42]. We did not find any significant differences when comparing telephone and face-to-face-interviews, but the four additional interviews contributed with further examples and variations. One might think that face-to-face interviews will give richer and more personal data but that was not our experience. In this study we found that the telephone interviews sometimes gave richer and also more in-depth material than the face-to-face interviews. We suggest that the telephone interviews facilitated a sort of soliloquizing by the midwives and that the “distance” allowed for more honest descriptions.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ALW, ÅH and KH designed the study. ALW recruited and interviewed the participants. ALW analyzed the data under supervision of ÅH and KH. ALW drafted the manuscript. All authors reviewed the manuscript and approved the final version.