Twenty-one women participated in this study between November 2009 and December 2010. Twenty-one women participated in an interview at 6 months postpartum and 18 of these participated in a second interview at 12 months postpartum. All but one of the interviews was conducted in the women’s own homes. The interviews at 6 months postpartum lasted between 30 and 80 minutes. The interviews at 12 months postpartum lasted between 25 and 70 minutes.
The women ranged in age from 23 to 41 with a mean age of 32 years. All of the women were Caucasian and four of the women were born outside of Ireland (one was German, one was Ukrainian and two were English). The mean BMI of the sample at their 'booking’ visit in their second pregnancy was 26.3, which is overweight. Nine of the mothers were normal weight, eight were overweight and four were obese. Most were in paid employment (19 women) and approximately two-fifths (eight women) had graduate degrees. We compared the interview sample with the ROLO study sample and found that it was representative of the larger study across a range of demographic characteristics including age, educational attainment and smoking status.
The participants’ names and any other identifying information were changed to protect the participants’ anonymity.
An exceptional time for lifestyle practices
The first theme consists of two subthemes: 1) following bodily calls and 2) the risks or rewards of physical activity in pregnancy. The mothers viewed pregnancy as an exceptional time for lifestyle practices, when the baby’s needs have to take prominence over their own needs.
Following bodily calls
The women generally described an increased awareness of healthy eating habits during pregnancy and recalled making an effort to eat more healthy foods, except if they perceived their diet to be very healthy already. All of the women believed in following their bodily 'calls’ or cravings during pregnancy, as this was seen as the best way of meeting their baby’s nutritional needs. Most of the women were also aware that you are not supposed to follow the traditional adage of 'eating for two’ during pregnancy, but in spite of this knowledge, some recalled using pregnancy as an 'excuse to indulge’ , especially in their first pregnancy. This often involved eating large amounts of treats, such as chocolate and biscuits, which they would only have consumed in small amounts before pregnancy. Some described their eating during their pregnancies as uncontrollable and excessive, as they ate everything they wanted, or craved:
I didn’t particularly watch what I ate during my [second] pregnancy, I kind of just ate what I wanted, when I wanted, you know, and I suppose naively you feel it’s a chance to or a time to indulge yourself, rightly or wrongly. (Cliona)
I think like the first time around I was like, 'well I can’t help it, you know, I’m pregnant, this is what my body wants’. (Silvia)
Over-indulgence during pregnancy often led to feelings of guilt, as suggested by descriptions of foods eaten as 'bad’ or 'bold’. This guilt appeared to arise because the women wanted to fulfil all of their food cravings or wants and thus meet their baby’s needs, but this contradicted their knowledge about the importance of healthy eating and not 'eating for two’ during pregnancy:
I did try. I was eating healthy [in the second pregnancy], but then eating bold stuff as well. (Lisa)
I kind of think it is nearly an excuse in a way - 'you can eat whatever you want really’. Well you can’t, but you do - I did. Lots of people don’t. I used to when I was pregnant with Liza [first child], I used to buy chocolate all the time – it was an excuse to gorge on chocolate and ice-cream and all those things. (Clare)
Pre-pregnancy lifestyle habits were often perceived to influence food cravings during pregnancy. A number of women perceived that, as they had to give up a lot of things during pregnancy, such as smoking and drinking, they compensated with food. In particular, smoking cessation was perceived to lead to increased cravings for 'junk’ foods:
So, I gave up smoking when I was pregnant with her [first child] and maybe that was why I didn’t eat as much chocolate before…I just craved chocolate more I guess. (Clare)
Some participants also perceived that women who restricted their eating before pregnancy often ate excessive amounts during pregnancy:
But like I said a lot of people who would maybe not eat enough when they’re not pregnant go all hell for leather when they are. (Susan)
In contrast, some of mothers perceived that they did not 'eat for two’ during their pregnancies, but instead followed their wants and cravings in moderation. Many of these mothers emphasised the importance of listening to your body and continuity in healthy eating, before and throughout pregnancy:
You see, some women, they, they are worried about the baby; the baby has to grow…so some people try to eat more…which I think is not necessary. You eat just as you ate before, just a little bit more - some extras that you want. (Caroline)
Many of the mothers who described following their bodily calls in moderation mentioned eating treat foods as well as healthy foods during pregnancy, but this was not a source of guilt for the mothers and was instead depicted as a normal, balanced diet. In the following excerpt, a participant described balancing healthy foods with treat foods in both of her pregnancies:
I don’t think that you have to double your intake or anything like that. Like I was saying, I would always allow myself little treats and I would be conscious of maybe upping my calories by 200/300 a day or something you know, but just eating lots of healthy stuff and as I normally would. (Linda)
The risks or rewards of physical activity in pregnancy
Many of the women believed that pregnancy was a time for rest. Many of the women also described cutting back heavily on physical activity during pregnancy due to fears for the baby - especially in their first pregnancy:
I used to go to the gym two or three times a week before I had Anna [first child] and then when I had Anna I didn’t want to run, I didn’t want to use the weights, I didn’t want to do anything that I’d done before, because I just didn’t want to hurt her. (Celia)
Some of these women perceived that their sedentary lifestyle during pregnancy contributed to high weight gains, especially if they had a big drop in physical activity from pre-pregnancy levels:
It [exercise] went out the window [in the second pregnancy]. I suppose I thought because I was kind of so toned and so I had lost about a stone before I got married. I kind of said, I can be a bit more…give myself a bit more leeway, but I think I gave it too much. (Lisa)
In contrast, some of the women perceived that physical activity during pregnancy was healthy for the baby and strived to do as much as they could physically manage:
Yes, more movement is much, much better. Some women think it is better to stay at home, sit on the chair, watch TV - that is good for the baby. It is not, I think movement is healthier. (Caroline)
Many of the participants perceived that they 'listened’ to their body or used 'common sense’ to guide their physical activity habits during pregnancy. Engaging in gentle exercise, such as walking or pregnancy yoga was generally perceived as enough during pregnancy. All of the women who were physically active in their leisure time before pregnancy therefore halted or curtailed their strenuous physical activities during pregnancy. Some of these women swopped vigorous physical activities such as jogging for gentler exercises which they perceived as safer, such as swimming.
Managing the home and work environment
The mothers perceived that they had much greater demands on their time in their second pregnancy, as they had to balance childcare and work responsibilities. This demanding lifestyle was perceived by the women to reduce their control over eating and physical activity habits and thus their weight. Tiredness from a long day at work and from looking after their child when they got home was perceived by some mothers to contribute to unhealthy eating habits and a sedentary lifestyle during their second pregnancy. Some of the women described using energy dense, convenience foods as a means of overcoming the tiredness which resulted from an extremely busy lifestyle:
Yeah, towards the end [of the second pregnancy] I kind of just wanted to eat a lot basically – chocolate and whatever so…I mean I worked up until 2 weeks before he was due and I think that was a bad idea anyway…I was very, very tired at that stage. Working full-time and then having to spend time with her [first child] in the evening. The weekend was the only time I got to spend full days with her – it’s actually very stressful working full time and being pregnant and trying to care for another child – it was a bit of a nightmare. (Clare)
Many of the women also noted that it was easier to do physical activity in their first pregnancy, as they didn’t have a child to mind:
I walked a lot during my first pregnancy, I didn’t walk quite as much during my second because of my little girl – I think it was easier during the first pregnancy because I could just go walking whenever, whereas I would have to wait until she was in bed you know. (Lorraine)
A supportive home environment was perceived to enable healthy prenatal lifestyle practices. A woman who developed gestational diabetes during her second pregnancy perceived that support from her partner and sister helped her to stick to her prescribed diet:
So my sister and my partner they would be the people that I spend most of my time with and so if I needed to eat they would feed the baby, or if I was eating and the child needed to be fed they would take over and they would do it, so it was quite good like that. (Sonia)
Another woman perceived that a lack of family support nearby to provide childcare was a barrier to physical activity during her second pregnancy:
To go out and exercise…that’s a big issue I think, you know, if you have children already and if you don’t have…family support, if you don’t have people that can come in for an hour or two or three to look after children you’re just not free, you know. (Cliona)
Bodily changes
Physical conditions and physical discomforts during pregnancy were often perceived to limit women’s control over lifestyle practices and therefore weight gain. These bodily changes included nausea, heartburn, fatigue, backache, a growing body and pelvic problems. Particularly in early pregnancy, nausea led some mothers to eat less and others to eat more regularly in an effort to counteract the symptoms. In addition, many of the women found that their ability to exercise during pregnancy was constrained due to physical conditions or the physical discomforts of a growing body:
I did walk up until I was about 5 months’ [gestation in the second pregnancy]…but my hips started getting sore and my bump was getting bigger and I was just uncomfortable and I was out of breath, so I couldn’t do much. (Emma)
Furthermore, some women were advised by health professionals to stop exercising during pregnancy, because of their pregnancy complications. Finally, pregnancy conditions such as Symphysis Pubis Dysfunction (SPD) impaired some women’s mobility which adversely affected their lifestyle practices:
My circumstances during my first pregnancy, they were fine really up until about 22 or 24 weeks when I developed Pubis Symphysis disorder and I couldn’t move. That affected my eating because Patrick [husband] was working full-time, so it ended up being an awful lot of takeaways. Throughout my second pregnancy, from the very start I had the same thing and dinners were left and it ended up being takeaways. (Laura)
The availability of support from health professionals and close family members was perceived as crucial for managing and recovering from physical conditions during and after pregnancy. A mother who had SPD in both pregnancies described the importance of timely support from health professionals in her recovery:
Damien [first child] was only 9 months when I got pregnant again so I really think my body didn’t have enough time to recover properly from it. So, when I got pregnant, just right from the very start, from 8 weeks I felt my hips move. I got much better care the second time. The first time I told them from about 16 weeks that I wasn’t feeling right. I was feeling very difficult and stiff and everything when I got up to the physiotherapist. They just didn’t listen to me. When I got pregnant with Fergal [second child] I said it to them from the very start and because I had it with Damien; so because of the care I wasn’t as bad with him as I was with Damien. (Laura)
Weight consciousness
Many of the mothers described feeling more relaxed about their weight during pregnancy than at other times. Many felt that you shouldn’t worry about your weight during pregnancy, because it is a natural part of pregnancy over which you have little control – as everybody gains weight differently. A number of women also expressed that weight gain should only be a concern if a woman’s diet is unhealthy:
I know that you need to have a good weight gain. But every woman is different to start off with. Every baby has a different weight gain. So I wouldn’t put myself under pressure or I wouldn’t want any woman to put themselves under pressure that they have to have a certain weight gain. If they are too heavy that they start dieting during pregnancy, that wouldn’t be good either. So just really have your good three meals a day and healthy snacks and even if you feel like eating out of normal, eat out of normal, but healthily of course. (Jane)
I think that if you’re eating healthily you shouldn’t worry too much about how much you gain, because everybody is different. (Laura)
Although not asked directly about their attitude towards having a high birth weight infant in their first pregnancy, it was apparent from the dialogues that most perceived big babies as healthy. Some of the women eschewed exercising normal levels of dietary restraint during pregnancy, as they perceived that high food intake and weight gain are beneficial for fetal development. In addition, any excess weight can be lost afterwards:
The best part about being pregnant [laughter] is just eating what you like and not worrying about the weight. (Sonia)
Postpartum weight retention was generally the only negative outcome of high gestational weight gain that was perceived by the women. Therefore, some of the women observed that they prioritised the health of their unborn baby over their own weight or physical appearance:
I just think people should be allowed to put on what they want when they’re pregnant and not have to worry about it too much. As long as their baby is healthy and once they are healthy…if they want to lose it after they have the baby, then they should just worry about it and do something about it if they want. (Sinéad)
It was evident from the dialogues that the experience of having a prior macrosomic delivery did not alter most women’s perspectives on weight gain and lifestyle practices in their second pregnancy. In contrast, one mother, who found her first childbirth experience very stressful as she had an episiotomy and had to use a crutch afterwards while it healed, decided to modify her eating habits in her second pregnancy in an effort to have a smaller baby:
I felt like I just didn’t, I didn’t want to have a big, you know a bigger baby and a lot of people had said to me oh if…your first baby is big, your second baby will be bigger and I just kind of panicked then, I thought oh Jesus I don’t want to have a bigger baby than that, so I just really watched [my eating habits] and spoke to the Consultant in Holles Street [the hospital] and she just told me things like, because I love pasta, so she said try and cut down on pasta because it’s full of sugar and little things like that. (Sarah)
Two mothers who had a lower weight gain and a smaller baby in their second pregnancy discerned health benefits of this, although neither had made deliberate attempts to avoid the recurrence of macrosomia (Caroline largely attributed her lower weight gain to staying active by working throughout her second pregnancy compared to finishing up 3 months early in her first pregnancy, whilst Miriam attributed it to heartburn which affected her eating habits):
This time I’d say I ate less, I moved more and I had the baby one week earlier and the baby was smaller, so I’d say it is more movement, less food, smaller baby and less weight…That was an easier pregnancy as well, because the belly was smaller and I didn’t put on much weight. (Caroline)
I had Symphysis Pubis Dysfunction…But it wasn’t actually so bad after the second time because I think because he [second baby] was that bit lighter. (Miriam)
The interviewees reported that the bodily changes of pregnancy diminished their ability to monitor their weight gain. One woman recalled having little awareness of how much weight she had gained during her first pregnancy, as she could no longer 'see’ her body, as it was blocked by the bump. Furthermore, some women reported that they normally used their clothes as an indicator of weight gain, rather than a weighing scale, but this indicator no longer worked during pregnancy.
Nearly all of the women were not particularly conscious or concerned about weight gain during their first pregnancy, whilst there was an increased consciousness for some women during their second pregnancy. Some of the mothers who had difficulties losing weight after their first pregnancy described being more watchful of their eating and weight gain during their second pregnancy:
I suppose I was a bit more concerned about gaining weight last time, because I think naively when I was pregnant with Liza [first child] I kind of thought the weight would just fall off me after I gave birth and it really didn’t. (Clare)
Likewise, many of those who had difficulties losing weight after their second pregnancy expressed that they would be more conscious of not gaining excessively, if they were pregnant again. This increased weight consciousness was often due to a realisation that the weight did not just 'fall off’ after having a baby.
In contrast to the rest of the women who were not particularly concerned about weight gain during pregnancy, one mother was 'horrified’ by her weight gain. She described overeating and cutting back heavily on physical activity during her second pregnancy, which contrasted with the strict weight control techniques she employed before becoming pregnant. She also hated being weighed in the hospital. When asked about her views on weight gain during pregnancy, she replied:
Dreadful, horrified, I hated going in and getting weighed in the hospital. (Lisa)
Most of the women reported not receiving any advice from health professionals about healthy eating during pregnancy, beyond which foods they should avoid. In addition, the majority of the women did not recall receiving any advice about weight gain during antenatal care. A small number of women were advised during pregnancy that their weight gain was too high. These women recounted feeling surprised, stressed, or annoyed by the comments:
The first time I was probably quite stressed because the consultant…I felt like I was going to Weight Watchers every week. (Silvia)
Furthermore, the participants were asked how they would feel if women were given a recommended weight gain range for pregnancy based on their pre-pregnancy BMI, which is standard practice in the US. This question provoked a mixed response from the mothers. Some of the women had a positive attitude towards it, as it would increase awareness about overeating during pregnancy:
Yeah, yeah, I think it is good because…I think if you knew yourself what it was, I think you might be more conscious as well. I think some people think because they’re pregnant, 'ah sure, I can eat what I want’ , and I did think like that when I was pregnant with Annette [second child] and I was kind of like, 'I’ll worry about it after’. (Lisa)
More of the mothers had a negative attitude towards it, as it would be too restrictive or stressful for women, especially overweight women:
I think that’s added pressure they don’t need during pregnancy. (Celia)
You know, people just might find it a bit irritating if it was, you know, said to you every time you went for a check-up, I don’t know larger people might not bother going for a check if they felt they were going to get a dressing down or be given out to. (Cliona)
Many of the women felt that weight gain is a personal, sensitive issue and that weight gain guidelines would be too 'clinical’. Some women felt that guidelines would need to be tailored to each individual’s circumstances, as every pregnancy is different. Some women also noted that the provision of weight gain guidelines would have to be very carefully managed to avoid putting pregnant women under undue stress. One participant, who worked as a nurse, commented:
The whole weight thing has to be carefully managed because it’s a balance between the mental health of the patient and, you know, striking a balance between that and the weight gain. (Emma)