The partner-an underutilized facilitator to support healthy gestational weight gain

Barriers and facilitators to promote recommended gestational weight gain (GWG) are principal considerations in behavioral interventions targeting improvements in health behaviors of women during pregnancy. To date, most prenatal behavioral interventions have targeted the pregnant woman only. While logical, this approach may lessen the impact of behavior change strategies to foster healthy GWG even when considering appropriate individual-level barriers and facilitators.

The Social Ecological Model of Behavior Change [1] posits that individual behaviors have multiple levels of influence, such as intrapersonal (biological, psychological), interpersonal (social, cultural), organizational, community, physical, environmental, and policy. In the context of pregnancy, we hypothesize that promotion of effective behavior changes to support healthy GWG depends on individual-level factors, in addition to support and adoption of health behavior change in partners, and couple-determined changes to the overall household environment (Fig. 1).

We read the study by Escañuela Sánchez and colleagues with great interest [2]. Using a meta-synthesis of qualitative research reporting barriers and facilitators influencing weight management behaviors during pregnancy, the authors concluded that interventions aimed to promote and maintain weight management behaviors during pregnancy should consider all levels of influence in shaping a woman’s behaviors. They suggested input from multiple stakeholders in the pregnancy, including extended family members and the social network. However, the authors also noted that family members can negatively influence a woman’s ability to make behavior change and promote detrimental health behaviors, such as overeating and sedentary behavior.

To our knowledge, and as pointed out by the authors, this is the first meta-synthesis of qualitative data to understand the best means to promote healthful GWG from the viewpoint of the pregnant woman. The body of work summarized up through March 2019 and updated in January 2021 highlights three important observations which underscore the need for future research to understand barriers and facilitators of partners, and that future prenatal interventions should target the pregnant couple collectively.

First, their reported observation that most women had no decision making power over shopping or cooking choices in the family was surprising. While reports often tout the mother as the ‘nutrition gatekeeper’ of the home, this may not be the rule. In many modern households, traditional housekeeping roles are shared among both partners [3] and, in multi-generational households, meals and food considerations may reside in other family members [4]. These factors were not noted in the present meta-synthesis and are a missed opportunity to recognize the influence of the partner and their needed support. A cross-sectional study suggested that increased familial support for a healthy diet predicted greater intake of fruits and vegetables consumed in pregnant women [5].

Second, their statement that partners encouraged pregnant women to overeat and that some women reported their partners as a ‘feeder’ suggests partners have their own view of eating behavior that might change during pregnancy. While there is a social dogma that supports ‘eating for two’ in pregnancy, our work shows that excess GWG is largely the result of excess energy intake [6, 7]. Partners engaged in prenatal interventions have the potential to learn alongside the pregnant woman regarding the value of optimizing nutrition in pregnancy while maintaining minimal increases to overall calorie intake. Further, in couple-based interventions, the duo can work together to set goals and hold each other accountable through healthy meal planning and preparation of shopping lists in the context of the household budgets, needs, and desires.

Third, the authors described that some women reported relying on family and friends for advice on healthful diets and physical activity; yet this advice was sometimes discordant with their own beliefs. While not discussed in the paper, this observation underscores the need to consider the couple as a whole in future pregnancy interventions. Studies suggests that couple concordance in healthy eating habits is most impactful for achieving recommended GWG [8]. Additionally, previous evidence suggests that partners are critical facilitators to physical activity engagement during pregnancy to promote healthy GWG, including couple concordance in physical activity behaviors [9]. Promoting recommended GWG in mothers alone has had little and no effect on partner weight changes to date [10, 11]; but, targeting both the pregnant woman and her partner may have the synergistic effect of optimizing outcomes in both the couple and other family members in the household. Taken together and to advance we field forward; we need to understand the partner’s perceived barriers and facilitators for the pregnant woman to adopt health behavior change and how to actively engage the partner in prenatal interventions to optimize overall health behaviors within the household.