Experiences related to health promotion behaviors in overweight pregnant women: a qualitative study

This qualitative study was conducted with the content analysis approach from April to September 2017 in Tabriz-Iran. Iran has different ethnic groups [27]. Tabriz is the fifth largest city in Iran with a population of about one and half million [28] with more than 30,000 births occur annually [29] also the majority of them speak in Turkic languages [28].

The inclusion criteria of the study included single pregnancy with the age range of 18–40 years, having the language skills, pregnancy over 10 weeks, and having information about weight and height preconception in the women’s health records whom are defined as overweight according to their BMI (25–29.9). Having any disease or medical, midwifery risk factor identified on the basis of the family’s health records or, as the pregnant woman claims, also requiring special care or relative or absolute rest for the mother, as well as the withdrawal and non-attendance of the mother were considered as the exclusion criteria. The purposive sampling was used for individual and group interviews with pregnant women referring to health care centers or pregnant women’s care clinics.

All individual and group interviews were conducted by the original author of the paper (A.Fnk) as a faculty member and a Ph.D. student in reproductive health who has a history of participation in the classes of qualitative research methodology and the use of qualitative analysis software also she works as a midwife in prenatal care. All steps for data recording and data analysis were conducted under the supervision of the author (S.H) as a reproductive health faculty member with several years of qualitative study.

After selecting people according to the inclusion criteria of the study through the case of pregnant mothers, at first, in an acquaintance or telephone meeting the purpose and reasons of the study were explained to each of the participants and, according to the willingness of the participants, the time of in-person interviews was determined. Initially, five interviews were conducted in pilot form; these interviews were not included in the analysis. Semi-structured questions were used to conduct interviews. These questions were set by reviewing the texts and based on the experience of the author responsible for qualitative studies. We followed Pender’s Health Promotion Mode and according to prior researches on health promotion, at first, open questions were asked (Table 1: Interview questions). Then interviews focused on behaviors were expressed based on the answer to each question. Participants were also asked to provide more detailed explanation of the issues or to express their purpose more precisely. To record the data, interviews were first recorded and Immediately after each interview, the text was typed. As far as possible, the Note field was used and non-verbal data such as tone of voice and behaviors were recorded, too. Sampling was carried out in pregnant women’s care centers in a quiet room and without someone other than the interviewees. Each participant was given the code and nickname. Interviews lasted from 30 to 60 min. Interviews continued until data saturation, which was achieved in the 14th interview. Nevertheless, two other interviews were conducted to ensure that it was completed. A total of 16 individual interviews and three group interviews (two 5-person interviews and one 6-person interview) were conducted. A total of 32 people participated in the interviews.

Two of the interviews were discontinued because of the participants’ dissatisfaction with the continuation of the interview. In one case, a 19-year-old participant was excluded from the study due to she’s inability to answer the questions, and in the latter case, because of the mother’s dissatisfaction and frustration to continue the interview. One of the interviews was interrupted due to ambient noise and was repeated a few days later.

Data analysis process was performed simultaneously with data collection using MAXQDA software version 10.

Data analysis was performed using content analysis with a conventional approach based on the Graneheim and Lundman method [30]. Identified codes are the result of semantic units from the participants’ descriptions. The codes were categorized into themes and main categories. Subcategories and Sub-subcategories were also extracted based on differences and similarities (Table 2: Examples of content analysis, coding, and categorization).

To validate the results, it was first tried to establish a friendly relationship with the participants. In order to increase the accuracy of the data and for verification of the accuracy of the data, after the registration, the interviews were given to the participants to review and confirm their stated content and, if there were any other content, it has been added to the data. Interviews were frequently read by the corresponding author of the paper; then, the text of the interviews with the extracted codes and categories was shared with the colleagues and their comments were used. External monitoring was also used to increase the reliability. By providing the initial code derived from the analysis and examples of the extraction, as external observers, the concepts were given to four reproductive health researchers who were not related to the study in order to determine whether they also had a similar perception of the data or no.

This theme was classified in two main categories, namely, the modification of the lifestyle and the adoption of new behaviors extracted from five categories and eleven subcategories.

Modification of lifestyle is a major category that reflects the attention of pregnant mothers to various aspects of lifestyle and attempts to change to improve the status quo. This main category was derived from the sub-categories of improving nutritional behaviors, modifying health behaviors and the pattern of sleep and rest.

The quantity and quality of food consumed were considered more in adopting a proper nutritional pattern; so that most participants mentioned increasing consumption of natural and beneficial foods and prefer the consumption of milk and dairy, fruits and vegetables, and avoid consumption of prepared foods, sugars, and fats and salts, and strive for balanced consumption of food groups and attention to religious teachings related to food intake and timely meals. For example, concerning the quantity, quality, and eating habits of participants, they said:

“I did not eat vegetables much (laughing), for example, I ate them once a week, but now that I’m pregnant, I eat vegetables every day at lunch and dinner without exception. I pay much attention to my nutrition, for example, I used to eat a lot of salt before. I do not get too much salt now. Pizza, sausages, I liked and ate fried foods a lot, but now I rarely consume them.”(p.1).

“When I’m eating, I’m caring for chewing food too much and eating food slower. In addition, I also pay attention to my nutrition. For example, I’ll not start the day without breakfast; while previously, I could not eat anything from morning to noon, but now I’m sure to have breakfast.” (p.2).

“Before pregnancy, I do not care how much calcium was in my body, I’m now taking calcium supplements, and even now, I’m sure I’ll take the iron tablet on time and every day.”(p.4).

Another aspect of lifestyle modification was the effort to improve health behaviors extracted from the subcategories of attention to individual factors and environmental hazards. Increasing the accuracy of the model of behavior and increasing the observance of health issues was the focus of most participants. For example, two of the participants said:

“In order not to allow microbe to enter my body, I wash my hands after doing all the work. In the meantime, I might have changed my clothes for two days, but now I change my underwear every day.”(p.3).

“I’m trying to take my monthly care in a timely manner, I could not have been careful about controlling my health previously.”(p.4).

Regarding environmental hazards, the participants referred to environmental health, the use of protective equipment and efforts to ensure environmental safety. In this regard, two of them said:

“I arrange the furniture and tools of the house from now in a way that we will be healthy, and also the child who will be born does not encounter them, so that he/she will not hurt.”(p.5).

“Now that the air is polluted, it’s worrying, so I’ll use mask from the beginning of pregnancy.”(p.6).

Apart from the changes mentioned in the daily life, participants pointed to the change in their sleep and rest pattern extracted from the subcategories of attention to sleep hygiene and the need for further rest. In this regard, the participants stated:

“I prefer to sleep on my left side, if it is not possible on the right side and not usually on my back” AND “Now (in pregnancy), I’m careful about the time of my sleeping, my sleep and my rest are regular now, according to the plan”(p.7).

“Everything I do, I’m resting. Pregnancy is not like normal situations. The energy is finished too early. I try to rest”. (p.6).

Adopting new behaviors was a main category extracted from sub-category of conducting behaviors adapted to new needs and preventive behaviors. Pregnant mothers adopt new behaviors to adapt to physical and emotional changes in pregnancy. According to pregnant women, pay more attention to their behaviors to prevent disease during pregnancy increases and most participants try to use supplements and medications, to avoid harmful effects during pregnancy, and to take measures to control weight gain in order to improve and promote their health. For example, some of them mentioned:

“Now I’m not alone. If I was just myself, if I have a headache I’ll take sedative, but I cannot do it now. We must be careful not to get sick because the medicine cannot be consumed.”(p.6).

“I studied the Internet and books, and I made a diet for myself so that my weight will not be increased.”(p.2).

“Since my weight was already high, I’m now trying not to use high-fat foods; instead, I use vegetables and fruits.”(p.15).

Avoiding harmful acts on health is another effort by pregnant women to promote their health; and a kind of physical self-care in pregnancy that was distance from the Internet and cell phones because of their radio waves as well as the lack of using cosmetics because of harmful substances were mentioned. For example, two subjects said that:

“I eliminate WI-FI in pregnancy because of its damages.” (p.7).

“I do not use cosmetics and health products at all, because they can be absorbed to the body and may be harmful to the baby.”(p.8).

Among other behavioral changes, attention was drawn to sexual behaviors that most pregnant women referred to decreased sexual activity and unwillingness to have sex and changing their sexual activity. For example, one of the participants said that:

“Sexual intercourse has become lower, limited and more cautious, although stress is becoming more prominent in the sexual intercourse (laughs).” (p.9).

This theme was classified into three main categories, including Stress management strategies, tendency to social interactions, and seeking support, which consists of six categories and fifteen subcategories.

One of the measures stated by pregnant mothers was to drive disturbing thoughts and efforts to reduce stress, distracting, and trying to forget about problems was to fill leisure times and entertain. For example, two of the participants said that:

“When some people bother me, especially my husband’s family (laughs), I do not pay attention to their words that hurt me, I turn around as if I did not hear.” (p.10).

“I like to go outside and go to the market with my sister, talk or walk. It is very influential in my spirit.”(p.3).

Another aspect of stress coping strategies was the use of problem solving behaviors. Most participants talked about stress control factors and coping strategies, focusing on solving the problem, need for psychological counseling, avoiding confronting stressful people and environments, tolerating and confronting problems, and trying to control anger. For example, a pregnant woman said that:

“I try to cut off the relationship with people who have a lot of anxiety and limit my relationship with such people.”(p.9).

Other behaviors of women related to improving mental health included having positive thoughts, going towards spirituality and feeling of evolutionism. In this regard, the participants pointed out:

“When I talk to my husband about our child, our hopes and motives for the future increase. I also believe in normal delivery. I’m ready to tolerate any pain to see my child.”(p.2).

“In the first pregnancy, I did not understand anything, but later I felt that we would become a big family, and felt maternal feeling.”(p.11).

In terms of spirituality, most pregnant women tried to achieve mental relaxation and proximity to God through religious practices, enduring hardship, and correcting past moral defects; they also talked about having different feelings, such as being steady in life and subjecting God’s particular attention which suggests a sense of evolution. For example, two people said:

“It is good to have communication with God during pregnancy and it can make God love you somehow. Very important, for example, the Qur’an will make you feel such a calmness as you no longer think about your matters.”(p.5).

“I try to participate in many religious ceremonies during my pregnancy.”(p.12).

The tendency towards social interactions is a main category including the subcategory of the tendency toward group membership. What mothers emphasized and loved was being alongside pregnant women and interacting with each other. Two of the participants said:

“Participating in pregnancy classes is very good because they all are like you. I like that all are pregnant. I feel happy and convenient that everything can be said, we learn things from each other and it is good for our spirit.”(p.8).

“One should try to interact with colleagues and friends. Let’s go together to talk about a place. It has a lot of psychological effects. For example, let’s go to walking collectively. All these things have health effects.” (p13).

Seeking for support is a main category, extracted from subcategories of psycho-emotional support, instrumental and information support. Pregnant mothers try to establish close relationships with family members and relatives, improve their relationship with their spouse and receive support for improving their health. It was also considered important to receive the financial and non-financial support for those around them. In this regard, the participants mentioned that:

“Finally, I have another child. My husband can care him, so I can rest much. When I return from work, this is a kind of attention and help. I now love to be supported psychologically by hugging (laughing) with kissing.” “I’m trying to go to the house of my relatives. I visit them more and more. It’s good for the mood.”(p.14).

On the other hand, gaining support from health care providers is important for pregnant mothers and they want to receive emotional support from care providers. For example, one of the mothers said:

“I expect them to provide a good time to control my situation and explain me well.”(p.12).

Regarding the instrumental support, one of pregnant women said that:

“I would love that someone gives me present, for example, my sister, my friend, my husband, especially the books I need to read now.” (p.5).

Another important aspect pregnant women seek to achieve in order to improve their health includes.

receiving information support from health care providers and supporting lawmakers /policymakers. For example, two subjects said that:

“I ask my doctor step by step what I’m allowed to do this month, for example; traveling or exercise.”(p.10).

“Pregnant lady is not always pregnant. She is pregnant once for a certain time, it’s better to give pregnant women better facilities and the government helps her with costs.”(p.15).

This theme has two main categories of controlling the threat and perception the threat extracted from four subcategories and eight subcategories, respectively.

This is the first study in Iran that examines the experiences of overweight pregnant women in relation to health promotion behaviors. However, like other qualitative studies, caution must be considered for generalizability; especially since most participants had high education level and were Primigravida.