The thematic content analysis identified a number of overarching themes and subthemes. Three key themes emerged: 1. GWG being a low priority; 2. midwives concern for the physical and psychological welfare of women and; 3. the central role for midwives in the education process with opportunities for additional support to promote healthy GWG. The Antenatal Clinic Director quotes have not been differentiated from the Midwife quotes due to the possibility of interviewee identification and thus breach of anonymity.
Theme 1: Gestational weight gain is a low priority for midwives
With the many competing interests in antenatal clinics, GWG was perceived by many midwives to be of low priority. A range of factors contributed to this perception, ranging from absence of policies through midwife beliefs regarding GWG, and their support to engage effectively on this topic. Contributing factors included: practices, policies and views limiting the weighing of women and provision of GWG guidelines; perceptions regarding pregnant women’s low levels of interest in weight; limited education of midwives regarding GWG; time limitations for education of pregnant women; and perceptions of limited allied health services, such as Dietetic and Physiotherapy resources.
a. Low incidence of
weight monitoring
In both hospitals midwives often weighed women at the first antenatal visit, and sometimes BMI was calculated, primarily as a risk stratification strategy. Generally, a woman’s weight was not re- measured during her pregnancy unless the woman was defined as “high risk” (BMI > 35 kg/m
2 or presenting with a co-morbidity) at the outset. The urban hospital had a formal weighing policy [
47] and GWG guidelines available to staff on the internal intranet. This hospital’s policy and practice at the hospital discouraged weighing women after the first antenatal visit and this was reflected in some midwives’ views. Further, the policy encouraged the provision of the IOM GWG guidelines based on BMI [
17]. Despite the presence of weighing and GWG guidelines policy in the urban hospital and the absence in the rural hospital, there did not appear to be a significant difference in views and practices between both midwife groups. Both groups exhibited diverse views and practices.
"
“ (I don’t think
weighing is) relevant; we’re
just going by clinical
indications.” (Urban midwife 2)
"
When midwives were asked about routine weighing practices, two-thirds said they did not consider that routine weighing of pregnant woman was important. The midwives stated there was “no evidence” to support routine weighing and that measurements did not provide useful clinical information. In addition, midwives reported feeling that routine weighing may cause women psychological distress. The acknowledgement of change in pregnant women’s weight was seen to come primarily from the women or midwives’ observation.
"
‘… the research supports
that they don’t really
need to be weighed
at every appointment. It
doesn’t really gain much
information out of it.” (Urban
midwife 9)
"
"
“Too much stigma associated
with it…It’s embarrassing for
the patient; they see
it as a kind
of test, how good
they’ve been or how
bad they’ve been.” (Urban midwife
7)
"
"
“…here we can provide
continuity of care, so
I can actually see
the same women for
all of her appointments
apart from one or
two because she’s seeing
her doctor. So I
can actually gauge them
(visually), how much they’ve
been putting on.” (Urban
midwife 9)
"
However, the remaining third of midwives supported weighing during pregnancy and felt that weighing women at each antenatal visit allowed them to track GWG, particularly in high risk women such as those of high and low BMIs or those at risk of weight loss. Recording routine weights on women’s care plan was seen as a practice that would normalise weighing and help trigger conversation with women regarding weight and lifestyle behaviours.
"
“We were told that
by weighing women, it
doesn’t tell us about
good foetal outcomes, so
we stopped…. But we
forgot about the process
for women, and what
are the outcomes for
women if we do
weigh them and know
what weight they are
at the end of
the pregnancy.” (Urban midwife 6)
"
"
“(weighing)… instigates a conversation
sometimes at each visit,
whereas here women don’t
get weighed as a
general rule. …so you
don’t have that conversation,
or you don’t have
that prompting.” (Urban midwife 5)
"
The challenges associated with the identification of abnormal weight changes were raised by a few urban midwives. They acknowledged that weight changes cannot be identified when women are not weighed routinely.
"
“…they’re not identified. We
would have no idea
what people put on
in pregnancy.” (Urban midwife 5)
"
b. Diverse views regarding
provision of pregnancy GWG
guidelines
Midwives expressed mixed feelings regarding whether GWG guidelines should be provided to women. Two-thirds of the midwives indicated they did not consider it necessary to provide pregnant women with GWG guidelines unless the woman asked for them. Midwives’ reluctance to discuss weight reflected a perceived lack of evidence regarding GWG, weight not being a priority for the midwives and concerns that women may become fixated on their weight during pregnancy. Consistent with the views regarding routine weighing, high risk women with high BMI and concurrent diseases such as diabetes were seen to be the exception.
"
“….I think the trend
is not worry so
much how much weight
gain you have right
through unless there’s other
medical issues involved such
as hypertension and smoking
and all that side
issues.” (Rural midwife 2)
"
"
“I guess it’s that
thing where you know
the woman is going
to put on weight
and they do eat
more so generally I
guess I wouldn’t feel
that I would need
to.” (Rural midwife 3)
"
"
“(Providing guidelines). should be
always research based, but
I don’t think it
is.” (Urban midwife 6)
"
The third of midwives who provided GWG guidelines to women cited foetal and maternal outcomes as their main reason for doing so, along with the habit of providing weight guidelines to women.
"
“I feel that they
all should be given
so that they have
a rough idea of
what is normal and
not normal, so they’re
having a proper diet
and exercise.” (Urban midwife
2)
"
"
“So I think we
…… need some guidelines
” (Rural midwife 2)
"
The GWG guidelines provided to women during antenatal care by all midwives, either voluntarily or if asked, varied greatly. A few urban midwives provided women with individual guidelines related to pre-pregnancy BMI, such as the IOM guidelines [
17], but the majority provided highly varied ranges for example 10-20 kg or 10–14 kg. Not providing GWG information to women was in contrast to the policy supporting the provision of GWG guidelines at the urban hospital [
47].
Half the midwives said that women sought weight gain advice during antenatal care and half noting that weight was rarely raised in consultations. Some midwives felt that healthy weight women were more likely to ask about GWG guidelines. A few midwives shared their personal strategies on discussing GWG and normalising the healthy GWG. The most common strategies involved focusing on the benefits of healthy GWG for the foetus and differentiating the pregnancy weight gain from weight gained through a positive energy balance.
"
“I tell them that
gaining weight in pregnancy
is completely different to
gaining weight when you
eat too much cake.” (Urban
midwife 7)
"
c. Excess GWG not
seen to be common
or problematic by many
Most midwives considered excess GWG to be uncommon with the exception of women deemed at “high risk”. In addition, many communicated that they did not see excessive GWG as a significant health issue for women. However, it was also highlighted by some that GWG was impossible to detect since weighing pregnant women was uncommon.
"
“(Excess GWG) is unusual
from my experience…” (Urban midwife
1)
"
"
“…your baby’s an appropriate
size then no-one’s going
to be too concerned
if there’s a 20
kilo weight gain.” (Urban midwife
5)
"
"
“…they’re not identified. We
would have no idea
what people put on
in pregnancy.” (Urban midwife
5)
"
In contrast, the midwives who considered excessive GWG problematic were concerned about maternal and foetal outcomes. There was a sense that the emphasis on GWG had been inappropriately played down over recent years. In addition, concern was expressed that excess GWG compounded associated problems for those already overweight or obese.
"
“But I think we
sort of ignore the
fact that a lot
of the girls have
started heavier. We are
a fatter population so
we still have the
problem of really big
women being pregnant, and
getting to the end
of the pregnancy they
have other problems as
well they get too
big.” (Rural midwife 2)
"
When midwives were prompted to identify important implications of excess GWG, the most common responses related to gestational diabetes, preeclampsia, inability to palpate the foetus and complicated deliveries. Two midwives mentioned foetal health implications, including macrosomia.
d. Limited resources to
address GWG and lifestyle
behaviours
The midwives identified a lack of time and resources, such as dietetic services, as key limitations enabling them to address healthy GWG and lifestyle issues with the women. Midwives are required to address a large number of issues during antenatal consultations including assessment of medical, family, pregnancy and psychological history as well as provision of pregnancy information, antenatal tests, procedures and bookings. Midwives considered they had limited time available for discussions about GWG and healthy lifestyle. The late timing of the first antenatal visits (often occurring after the first trimester) was sometimes seen to preclude education when it would have been most appropriate. In addition, a reluctance to bombard women with excess information influenced midwives’ decisions about what topics to discuss during visits.
"
“. when you’re on
a time efficiency….you can’t
really think of every
topic, because every topic
in pregnancy has become
the most important, because
there’s always a smoking
process going on. There’s
the alcohol intervention process,
so everything becomes the
most important thing in
pregnancy.” (Urban midwife 5)
"
"
“.they are blown away
by how much we
give them in the
early visits.” (Urban midwife 1)
"
As noted, the limited resources for dietetic and physiotherapy services were seen to constrain interventions for healthy GWG and lifestyle issues, reducing the ability for antenatal services to intervene even if a need was identified.
"
“.our Dietetics have an
appointment system .(and). those
appointments are hard to
get because they take
a long time and
by the time you
get there you could
be half way through
the pregnancy. ” (Urban
midwife 10)
"
One midwife felt that the limited dietetic and physiotherapy resources available to them in the public health system has resulted in a redefinition of “at risk” or “healthy” pregnancy weight because only those women with BMIs > 35/kg/m2 were chosen for interventions and education. Therefore women with BMIs 25 kg/m2 to 35 kg/m2 were redefined as “normal”.
"
“.there’s a lot of
issues for women around
…being fat and weight
gain and pregnancy which
we normalise” (Rural midwife
1)
"
Theme 2Concern for physical and psychological health of pregnant women
Midwives articulated a concern for the physical and psychological health of pregnant women in general. However, their greatest concern was for possible psychological ramifications of weight related discussions and interventions.
a. Concern for the
psychological impacts of weight
discussions and women’s inappropriate
views on weight gain
It was a common view among the midwives that many women were inappropriately concerned about putting on too much weight during pregnancy. This concern was mirrored in the antenatal weighing policy of one hospital [
47]. At this urban hospital the midwives felt that women were controlling their GWG through inappropriate strategies, such as restricted eating, but did not cite evidence to support the supposition. Hence, with a desire to “do no harm” some midwives were concerned about perceived psychological ramifications if weight and GWG were discussed and monitored at routine antenatal visits. Further, there was concern that women would become anxious about their weight, or actively lose weight which would have adverse effects on the mother and foetus. This was expressed as the prime reason for not discussing GWG.
"
“I think it stresses
a lot of pregnant
women out. I find
a lot of women
are fixated on weight
and how much they
should be gaining.” (Urban
midwife 3)
"
"
“Women were getting very
anxious and they were
getting obsessed about (weight
gain) and I think
that added extra anxiety,
they’re already anxious with
their pregnancy.” (Urban midwife
2)
"
Other midwives recognised the co-morbidities associated with excessive GWG, such as poor delivery and foetal outcomes, caused by not informing and/or supporting women to achieve these goals and the need for good health outcomes.
"
“You know, we can
be nice about it
all, but at the
end of the day,
we want good foetal,
good maternal outcomes.” (Urban midwife
6)
"
b. Concern for the
physical health of women
The majority of midwives expressed deep concern about the physical health of their patients. In particular, a few expressed concerns about the increasing incidence in overweight and obesity in the community and their desire for an intervention to reduce women’s weight pre-pregnancy.
"
“I consider it (pre-pregnancy
overweight and obesity) a
really big (issue), probably
across my midwifery time
one of the biggest
issues that’s out there
at the moment.” (Urban midwife
7)
"
Theme 3Midwives are central to healthy lifestyle education process and opportunities exist for support to promote healthy GWG
All midwives viewed themselves as part of a team of antenatal colleagues who were responsible for the promotion of healthy lifestyle behaviours, including healthy GWG. When asked about how midwives could be best supported to deliver healthy weight and lifestyle behaviour education, a number of models were suggested.
a. Key providers of
lifestyle behaviour education
Despite some midwives expressing concerns about healthy GWG and their role in its promotion, the midwives unanimously saw themselves as having responsibility for education and interventions around GWG and lifestyle issues. This was seen to be a responsibility shared with obstetricians, general practitioners and other health providers that pregnant women consulted. The need for consistent messages and education along with multidisciplinary care was also mentioned.
"
“So it’s all our
jobs and the idea
would be to work
together and with our
most difficult clients using
support such as Dietetics
and whatever it is
the woman needs.” (Urban
midwife 7)
"
Most midwives discussed some lifestyle behaviours during pregnancy, however, they considered that Listeria infection and vitamin and mineral intake and supplementation to be the most important. This was followed by advice regarding “general healthy nutrition”, avoidance of alcohol and smoking and the importance of physical activity.
b. Lack of confidence
in addressing weight and
GWG
The majority of midwives thought that conversations with women regarding their weight were difficult, reflecting a negative social construction around weight. It was therefore often easier to avoid raising weight as a concern during antenatal consultations.
"
“.weight is a difficult
one. It’s easier to
bring it up if
your blood pressure’s high,
or you’ve got protein
in you urine. But
when you’ve got to
say to someone “You’re
a little bit overweight
for midwives to look
after.” .it’s not a
nice thing to say,
but I think…they understand
if you discuss it
in a clinical risk
manner.” (Urban midwife 6)
"
"
“I know myself I
am so euphemistic about
the conversation.” (Urban midwife 2)
"
Midwives felt that it was important for them to develop the communication skills needed to establish rapport with women that would enable them to have conversations around weight so that discussions were positive, non-judgemental and did not infer blame.
"
“ I hear young
grads say all the
time “oh I don’t
know how to talk
to women cos their
BMI is high” and
I think to myself
have you never learnt
about putting your judgement
to one side and
giving facts and letting
people see you mean
what you say, that
you’re not there judging” (Urban
midwife 7)
"
c. Support for midwives
to promote healthy GWG
A model for education and support for midwives to increase their knowledge, skills and opportunity was the most commonly suggested way to help midwives promote and encourage healthy GWGs. Some participants recommended additional education and training for midwives around GWG and others saw greater opportunity for intervention which could occur during longer antenatal consultations.
"
“Probably for midwives to
have a lot more
education on what we
should be saying to
women and what we
should be doing, because
we are at the
forefront of seeing these
women.” (Urban midwife 9)
"
The need for longer and individualised antenatal consultations was underpinned by the midwives’ perception that women wanted individual consultations with midwives, continuity of care and relationship and trust building.
Another model to support midwives was the implementation of healthy GWG detection and management policies that would flow down to practice changes, where there was an expectation that GWG would be discussed.
"
“I know that’s what
I’d like to see,
these triggers that come
up. Because I know
for the smoking, there’s
the trigger point where
you must ask the
questions, and it’s part
of what you do
at every visit.” (Urban midwife
6)
"
Models targeting women to promote healthy GWG were suggested. These models would ideally utilise multidisciplinary antenatal group sessions employing midwives, dietitians and physiotherapists. Drop in services for ‘high risk’ groups such as refugees and young mothers were suggested by others.
When the midwives were prompted to consider whether some of the new technologies such as the internet, telephone counselling and short message service (SMS) interventions could be used in this context, the midwives favoured the internet and SMS interventions. However, some expressed concern over quality of information and the ability for some women to access the technologies. Others felt that the introduction of these interventions may augment services, increase consistency of information and provide improved access to ‘at risk’ groups.
"
“People are hooked into
the internet these days.
That’s where they are
seeking a lot of
information. ” (Urban midwife
3)
"
"
“…doesn’t matter what economic
class people come from,
they’ve always got a
mobile. But if it’s
coming to their phone,
they’re always going to
read a message, which
is a really good
way to get to
these people……….” (Urban midwife
9)
"
d. Features and content
of an optimal intervention
to promote healthy GWG
Continuity of care was considered an optimal feature to promote healthy GWG with women seeing the same midwives or health professionals at each visit.
"
“I sometimes think it’s
better to have that
personal input from someone
you’ve actually built up
a rapport with.” (Urban
midwife 1)
"
Interventions connected and branded to the antenatal clinic and consistency of messages were seen to be central features in a contiguous approach.
"
“……even hospital (nutrition based)
internet sites would be
good.” (Urban midwife 3)
"
Healthy eating, followed by physical activity and the provision of individual GWG parameters, were the topics perceived to be the most important for inclusion in an intervention. Furthermore, supporting women to learn from health providers and other women was seen to be crucial to intervention success.
"
“… the food group
eating isn’t enough, it
isn’t enough to tell
someone who doesn’t understand
about nutrition that this
is the way you’re
supposed to eat. Having
someone sit down to
teach them about what’s
on the back of
packaging and how to
read the packaging and
what is a good
food and giving them
examples of what a
meal is much more
beneficial” (Urban midwife 10)
"
"
“Eat from a wide
food group. Exercise as
a balance in your
life. And, I’m trying
to think of the
right way of putting
it, don’t go to
extremes.” (Urban midwife 7)
"