Background
Maternal obesity, defined as body mass index (BMI) ≥ 30 kg/m
2, during pregnancy is increasing and related to life-threatening and ill-health conditions in both mother and child. It involves risks of morbidity for the mother and for the fetus to develop birth defects, premature birth, perinatal asphyxia and stillbirth [
1]. Furthermore, pregnancy involves a risk for excess weight gain especially for women already overweight or obese [
2]. If limited weight gain during pregnancy can be achieved, health outcomes for the mother can improve with lower risk of obstetric complications without elevated risks for the fetus [
3]. Initiating and maintaining a healthy lifestyle during pregnancy (i.e. keep active and eat healthily) will improve health and decrease risks of long-term illness in mother, child and whole family [
4‐
8]. The goal during pregnancy, according to the American Institute of Medicine (IOM) recommendations, is for the woman to achieve weight control [
9‐
11]. For this purpose, effective and well-designed interventions directed to pregnant women with BMI ≥ 30 kg/m
2 concerning lifestyle change are still needed [
12‐
14].
Pregnant women with BMI ≥ 30 kg/m
2 have described negative experiences of the professional care they have received during pregnancy and childbirth [
15‐
17]. A negative experience of encounters with health care providers, including stigmatisation and a patronising approach can be a barrier for engaging with lifestyle support [
17]. Behavioural change can be difficult to initiate, as deeply rooted lifestyle patterns can be highly resistant to change [
18,
19]. However, pregnancy is in itself a crucial period for potential change to a healthier lifestyle due to maternal concerns for the expected child [
20]. The support and the motivation that will work for each woman with obesity is unique so to find out what is suitable for her it is necessary to start from her personal circumstances and needs [
21,
22].
To date there have been few published accounts of how pregnant women with high BMI experience weight management care pathways and interventions. These have mostly been conducted in the UK [
23‐
25] but also in Sweden [
22]. Collectively this research suggests that women who have chosen to take part in a weight management service view this as a positive experience [
22,
24,
25] and that it has helped them with physical activity and healthy eating behaviour change [
22,
24]. In Gothenburg, Sweden, the project ‘Mighty Mums’ [
26] offering support for pregnant women with BMI ≥ 30 kg/m
2 to adopt a healthy lifestyle was initiated in 2011, including both additional visits to the midwife as well as opportunity to meet a dietician, something previous interventions have lacked [
26]. Compared to matched controls the women in the Mighty Mums intervention group had a significantly lower gestational weight gain and lower weight retention postpartum [
26]. Furthermore, the results from the project show that care could be provided with only a small additional cost and guidelines built on the project have now been implemented as standard care in the region for women with a BMI ≥ 25 kg/m
2 at antenatal health care enrolment. It has not yet been explored whether the programme affects the women in the long term and what the women experience as helping or hindering factors in the pregnancy care to maintain a healthier lifestyle. Therefore, the aim of this study was to explore the experiences of women with BMI ≥ 30 kg/m
2 regarding minimising their gestational weight gain, and to assess how health professionals’ care approaches are reflected in the women’s narratives.
Discussion
The results show in four themes how women with BMI ≥ 30 kg/m
2 experience participation in a lifestyle intervention during pregnancy and how they reflect on how this participation affected them three years later. The main motivation for attendance in the lifestyle intervention was to provide good conditions for the child, both in the womb, and with healthy habits in the family. The women had been living with a high weight before pregnancy and sometimes since childhood. Although they had knowledge of how to eat healthily the expected child became the main motivation for changing lifestyle. The women needed to get personal support from the health care providers and receive help to be able to control the selection and implementation of healthy activities. Extra support during pregnancy helped temporarily but there was still a need of support to maintain a healthy lifestyle in the long run, suggesting pregnancy is not necessarily a ‘window of opportunity’ for long-term, but rather for short-term behaviour change. Pregnancy as a window of opportunity is naturally used for motivation [
28], but can provocatively be seen as an automatic mantra of the health care professionals without long-term meaning. Some, not all, women clearly expressed that they felt abandoned postpartum, although for others this window of opportunity seems to have worked for the long run.
In contrast to previous research [
19,
25] the interviewees in this study had received information and were aware about the risks with the high BMI for themselves and their unborn babies. Due to this knowledge, the women could feel anxious and have feelings of being a danger to the child even though the information and awareness of the risks was a motivating factor. The women wanted clear and factual information and help to adopt a healthier lifestyle for the sake of the baby, corresponding to earlier research where motivation for lifestyle change during pregnancy are described [
23,
29]. Women with BMI ≥ 30 kg/m
2 often report a long struggle with their weight and difficulties to lose extra weight after an earlier pregnancy [
30], which also applies to the women in this study. Living with a high BMI was experienced negatively, similar to descriptions in other studies [
31]. Contrasting with some earlier research [
29] our interviewees considered pregnancy as an opportunity to avoid excessive weight gain. The reason for this fact could be due to the design of the intervention project where the women were informed of health benefits of limited gestational weight gain for own health, lower risk facing the birth and better outcomes for the baby [
26]. This approach is more motivating in a positive sense rather than an intervention where people are simply given risk information to frighten them into change.
The theme of managing weight for the sake of the baby suggests, however, that even if the women are given the information about health benefits to themselves they may not experience this as motivating in the same manner. This is in line with a range of sociological literature that has discussed the moral burden on mothers, in which the need to fulfil the role of a good mother is stronger than the perceived need to protect one’s own health. Social and cultural attitudes towards motherhood, in addition to gender constructs, mean that women perceive a strong need to present themselves as good mothers and experience considerable stigma if they are socially perceived as not fulfilling such a role – such as by having a normal weight or by adopting normative choices in pregnancy, around birth and in their mothering [
32].
Central in the women’s stories was the need to get personal attention and support on their own terms. They wished that the issue of weight was discussed in a straightforward and non-judgmental way by health professionals because it is a sensitive issue [
16,
24,
33,
34]. The women preferred professionals to refer to BMI when discussing weight [
23] and the interviewees also requested training of health care providers in how to approach the subject and counsel them, which is consistent with previous qualitative studies showing that health care staff face difficulties in communication about weight and weight management during pregnancy with women with high BMI [
14]. Furthermore, our results underpin earlier findings of the stigmatisation of obesity where attitudes among health care providers, guidelines, written information and how weight discussions are initiated and performed need scrutinising not to include hidden stigma messages [
35].
Some of the interviewed women reported that the health care providers lacked interest in their personal well-being. Instead they could feel being reduced to a weight issue with the purpose of getting good results at the antenatal care clinic. This approach is opposite to the one described by Ekman et al. as person-centred care (PCC) [
36] where PCC reduces the risk of depersonalisation. Instead, the core elements in person-centred care include listening to the person’s narrative, working in partnership and safeguarding the partnership through documentation [
36]. Our results confirm earlier studies showing that women with a high BMI may feel badly treated in health care [
31] and support previous arguments for PCC in antenatal care of women with BMI ≥ 30 kg/m
2 [
21,
37]. The current study finding that the women wanted to be listened to and be met with respect in a personal relationship with the midwife corresponds to initiating the partnership in person-centred care [
36]. Furthermore, focusing solely on the importance of weight in itself could pose a risk for people who have obesity to neglect health exams or screenings due to the stigmatisation [
17]. For health care it is therefore important to emphasise increased health, instead of merely weight management, to provide good help and support to suit the individual woman [
25,
31]. In addition, this may help to improve the focus on the women’s positive health gains, given that the theme of motivation for the sake of the unborn child may not encourage
long-term weight management and health benefits for the women.
Help and support to be able to choose healthy activities was described as important. An approach that suited the women well was when in discussions with the midwife, she suggested options, and the woman decided which to aim for. This compares well with the routine of working the partnership in PCC [
36]. This partnership is described in these interviews as discussing together what is desirable and at the same time realistic and in collaboration making a plan that takes into account the woman’s own situation. Working in partnership then means that the women receive knowledge and help to manage information to be able to make informed decisions and find activities that promote health and that suit their own situation. This gives the woman the tools to manage her situation of her own accord and being less subjected to conflicting advice and general prescriptions about pregnancy [
14,
18,
21,
37].
Our results indicate that follow-up appointments are needed to maintain healthy routines over time. This is consistent with previous research that has shown that the effect decreases when the intervention ends [
23,
25]. Continued health care support for the woman after pregnancy can give positive health effects for her and her family. Lifestyle interventions during pregnancy is most often targeting the pregnant woman only and not her partner or family who have a great influence over her habits [
14,
29]. To be truly meaningful the help and support to the woman should give her the tools to self-manage her situation and also involve her partner and family. In the lifestyle intervention described here the women completed food diaries and the midwife made notes about the lifestyle activities in a logbook [
26]. Our interviewees did not talk specifically about documentation but about the importance of follow-up meetings. Therefore, safeguarding the partnership according to PCC [
36] can be understood as providing continued support to maintain a healthy lifestyle after childbirth in the care of women with BMI ≥ 30 kg/m
2.
The woman and her family are living in a context that cannot be separated from the individual, with opportunities to consume food and beverages at convenience and inexpensively. In the modern society it is easy to obtain a lot of energy with little of nutritional value [
38] and therefore approaches that simply target individual behaviour without recognising the social context may not be as effective as they optimally could have been. There are also barriers to physical activity, and some of them reported by women are scarcity of time and lack of energy [
38]. Furthermore, a longer distance to open green space areas, which is often the case in a city, will render it more difficult taking walks [
39]. The driving force for the increasing prevalence of overweight and obesity is the obesogenic environment, and it is important to have this in mind when dealing with individuals with difficulties to keep their weight within healthy limits [
40]. It would be of advantage for the woman and her family if the society was more oriented towards health, and more helpful when it comes to making healthy everyday choices, e.g. marketing of healthy/unhealthy food and supporting healthy alternatives, decreasing servings and package sizes, facilitating safe walking in green areas close to home, promoting architecture that makes it easier to take the stairs, and similar measures. A clear stance for health on the whole life span is of uttermost importance, and women need to universally be reached by the same health message – in health care, school, work, media and public places.
Strengths and limitations
Women who declined to participate in the lifestyle intervention are not accounted for, which is a limitation since interviewing pregnant women about why they chose to decline weight management support can help improve said intervention [
41,
42]. Another limitation of this study is that the small sample size (17 women) may limit the applicability of these results. Two approached women declined to participate and may have had other views. Professional background of researchers may influence data interpretation. This risk of bias was reduced by a mixture of professions in the group, with experience both within and outside the health care system. The interviewees were encouraged to speak freely in a place of their own choice and the interviewers were not involved in delivering the intervention. This together with the length of the interviews was considered to reduce the risk of social desirability. Almost all of the contacted women agreed to be interviewed (17/19). Likewise, the first author had no experience of the intervention and therefore less risk of influencing the results. Strengths also include that the interviews were performed three years after the intervention and the women could reflect upon how their day-to-day behaviour was affected after these years. The purposive sampling of participants allowed a mix of primi- and multiparous women of different age and countries of birth and therefore the results may be representative for Swedish women.
Acknowledgement
We would like to express our gratitude to all women who participated in the interviews and shared their experiences.