“They turn to you first for everything”: insights into midwives’ perspectives of providing physical activity advice and guidance to pregnant women

It is recognised that the lifestyle choices made by a pregnant woman can have profound effects on the health of both mother and baby and that these can extend beyond gestation and birth [1, 2]. Pregnancy is associated with a decline in physical activity among women [3], and at the same time is viewed as a window of opportunity to address lifestyle issues [4]. It is therefore not surprising that midwives are regarded as being ideally placed to advise on diet and activity changes during pregnancy [5]. However, there is little research relating to the promotion of physical activity by midwives, with the current focus arguably on the management of pregnancy weight gain and maternal obesity [6]. Women with overweight and obesity have access to specialist maternity care pathways [7], there is a lack of pregnancy specific and consistent physical activity guidance in the United Kingdom (UK) for normal uncomplicated pregnancies [8]. Whilst the benefits of an active lifestyle is recognised in various professional documents - such as Statement 4 by the Royal College of Obstetricians and Gynaecologists (RCOG) [9] - at the time of this study there were no national physical activity recommendations for pregnant women. In a topical call for research and guidance, Reid, Smith, Calderwood, and Foster [8] suggest that the views of healthcare professionals in relation to their role in the promotion of physical activity should become a research priority. Therefore, in recognition of midwives’ central role in disseminating information during pregnancy, the primary purpose of this study was to gain insights into midwives’ perspectives of providing physical activity advice and guidance to pregnant women. Three research questions were developed for this purpose:

The purpose of this study was to gain insight into midwives’ perspectives of providing physical activity advice and guidance to pregnant women in the East Kent region of England. Interrelating themes were identified around three research questions. In discussing these findings, midwives’ views are also put in context of Better Births, a report of the National Maternity Review [13] which sets out the vision for maternity services in England. The report set out proposals with the aim of making maternity care safer and giving women greater control and more choices in relation to the care they receive. It is recognised in this report that “each women needs to engage in a relationship with her own midwife and other health professionals, acting on advice where she can make a difference, e.g., by accepting help to give up smoking, having a healthy diet and being physically active” (pp. 84–85). Triangulating the findings of this study with those of the report recently published by the National Maternity Review [13] provides a novel vantage point for the better understanding of midwives’ perspectives that might itself support the development of more effective physical activity policy and practice going forwards.

When considering their role and responsibility in providing physical activity advice and guidance, participants commented that the profession of midwifery had evolved and that the resulting vicissitudes had consequences for their current practice. Specifically, midwives experienced being subjected to increasing demands and expectations associated with an extended scope in practice. These findings echo that of the National Maternity Review [13] “with an increasing administrative burden cited as a particular difficulty. This reduced the amount of time that could be spent with women, increasing the likelihood of mistakes and missed opportunities to spot problems. A perceived litigious culture was partly to blame …” (p. 38). Similarly, midwives participating in this study perceived being exposed to greater risks. The ensuing threat of litigation and the associated costs involved have caused “midwives to practise in a risk-averse way, inhibiting their ability to support some of the choices that women may want to make, contributed to the administrative and data collection burden, and undermined multi-professional working” (p. 39) [13].

Indeed, time constraints were perceived by midwives as one of the most consuming barriers in providing effective physical activity advice and guidance. Of consequence is how pregnant women perceive the resulting lack of information. For example, Olander, Atkinson, Edmunds, and French [15] point out that due to health professionals not having enough time to discuss gestational weight gain, pregnant women interpreted this as being unimportant. A further consequence of time constraints is that information and tasks are then prioritised which infers that the topic of physical activity is often neglected and expectant mums are not being presented with key evidence-based messages allowing them to make informed decisions. The National Maternity Review [13] recognises that changes will need to be made to midwifery staffing allocations so that midwives could “have more time to be able to explain a woman’s choices and personalise the advice she receives” (p. 96).

Resonating the findings of previous research [5, 15‐18], this study found that midwives provided inadequate physical activity advice and guidance. Information was basic and limited to the initial booking appointment. Issues surrounding physical activity or lack thereof was not explored or revisited later in the pregnancy unless it was brought up by the pregnant women themselves. Specifically, women who were regular exercisers at the time of the booking appointment were most likely to initiate further discussion throughout their pregnancy. This implies that inactive pregnant women receive less information than already active women. Similar to the review by Heslehurst et al. [6], the present study indicated variation in midwives’ emphasis of physical activity during pregnancy with participating midwives reporting that information had to be prioritised according to perceived importance and relevance.

Nonetheless, most midwives agreed that they were ideally placed to provide physical activity advice and guidance but that it was ultimately up to pregnant women to take responsibility for their own health and wellbeing. Whilst being in control of their care is also the desire of pregnant women, Baroness Cumberland points out that “with this control comes a responsibility which mothers must accept and professionals must support – that personal health and fitness are integral to safe and fulfilling childbearing” (p. 4) [13]. However, in acknowledging the increasing evidence that regular physical activity during pregnancy improves health outcomes for both mother and baby [2], we believe the onus is on midwives to disseminate information that will allow pregnant women to make informed choices regarding their physical activity behaviours or indeed the consequences of a sedentary lifestyle.

Midwives, however, felt that they were not equipped in providing effective physical activity advice and guidance to pregnant women. The identified lack in training, knowledge, and confidence resulted in midwives not being able to address the issues surrounding physical activity exhaustively and having to rely on common sense and their own experience to advise and guide pregnant women. Given midwives’ central positioning in the care pregnant women receive and the role they have in disseminating information, they must be provided with the opportunity to improve their knowledge and confidence [15]. This requirement appears to not be confined to a UK context, for example, Lindqvist and colleagues identified a need for additional physical activity training provision within Swedish midwifery education [18]. Although the need for greater investment in education and training is also highlighted in the National Maternity Review [13], training around physical activity and public health is not mentioned specifically. Importantly, not any of the midwives participating in this study were aware of relevant training opportunities, however, they appeared willing to improve their knowledge and proposed that training or upskilling should be facilitated on study days or as online CPD opportunities.

The National Maternity Review report [13] identifies that pregnant women have “expressed frustration over receiving conflicting advice from different healthcare professionals throughout their care” and “wanted information to be evidence-based” (p. 33). In a recent qualitative study, Evans, Walters, Liechty, and LeFevour [19] found that a lack of knowledge or receiving misinformation or unclear advice contributed to pregnant women experiencing uncertainty about the physical activities they could engage with. This uncertainty quite often resulted in the participating pregnant women having to rely on informal sources, such as the internet, as opposed to that of a health professional. However, midwives are themselves subjected to the same level of information as the general public and are unaware of additional professional resources to draw upon. Consequently, they felt unable to address the topic from a position of authority. It is thus not surprising that participating midwives also expressed the desire to be able to provide reliable and current information as part of evidence-based practice. This evidence base is becoming increasingly relevant with a current focus in literature on the positive birth and health outcomes for both mother and baby [2]. For example, meta-analytic evidence shows that regular exercise is associated with a reduced risk of gestational diabetes, a lower prevalence of excessive maternal weight gain [20], and an increased probability of a normal delivery in healthy pregnant women [21]. Similar evidence should be used to inform practice, challenge exercise related misconceptions and elaborate on potential benefits.

Midwives showed awareness of the potential social benefit of group activities aimed specifically at pregnant women and were keen to support these. However, there was a general lack of awareness and confidence in whether suitable and credible exercise opportunities existed in the local community. This implied that they were less likely to promote specific activities, such as aqua natal, but promoted general activities, such as swimming, instead. Similarly, Heslehurst and colleagues’ [6] review suggest that healthcare professionals perceived a lack in supporting physical activity services being available to pregnant women. Pregnant women have, however, expressed a desire for “locally relevant information about the services available, and for there to be time to discuss the information with a healthcare professional” (p. 33) [13].

Participating midwives recognised that engaging pregnant women’s partner could be beneficial in terms of the support and motivation they can provide. This sentiment is highlighted in the report by the National Maternity Review [13] where expecting women stated that they “relied on their partner to support them in pregnancy and with the care of the baby and the NHS needed to recognise this and help their partners to help them” (p. 33). This finding is particularly interesting in the context of De Vivo, Hulbert, Mills, and Uphill’s [22] meta-analysis showing that subjective norm, or the perceived social pressure to conform to how significant others think an individual should behave, is an important concept influencing the physical activity intentions of pregnant women.

Midwives in this study articulated their frustration with the fact that the responsibility of providing physical activity advice and guidance is often a case of passing the buck between health and exercise professionals. However, as midwives are central to the care of pregnant women and given the fact that they “must have the ability to communicate effectively with all members of the maternity team, other professionals, women receiving care and their family members” (p. 7) [23], it is therefore not unreasonable to suggest that communication and referral pathways should also include exercise professionals. Inter-professional communication, and indeed collaboration implies that knowledge and responsibility with regards to physical activity advice, guidance, and motivation will be shared in such a manner that it meets the specific needs of a pregnant woman [24]. The notion of a collaboration between healthcare and exercise professionals was also identified as an opportunity to alleviate some of the time constraints of current practise. Participating midwives explained that they had access to additional care pathways and services for various health issues (e.g. obesity, diet, smoking, alcohol, etc.), however, for exercise there was nothing in place. Some midwives suggested that they could do the initial consultation and then refer suitable pregnant women to a separate service for further advice and guidance. Other midwives were, however, more sceptical about uptake of such services and suggested that pregnant women would give it “lip service” during the appointment and then not attend. Although such a referral pathway does not currently exist, the viability and cost-effectiveness of including pregnant women in the existing exercise referral scheme [25] or a similar service should be explored. Future research should also investigate the challenges and effectiveness of inter-professional collaboration between healthcare and exercise professionals in the context of antenatal care.

It was, however, the view of some midwives in this study that pregnancy was too late to bring about change in pregnant women’s lifestyle behaviours and that health issues should be addressed in preconception clinics. This rationale is in some way reflective of current thinking involving a life-course approach to women’s health which aims to maximise every contact opportunity to improve women’s lifestyle and general health [26]. Indeed, the “women’s health network” concept advocates that “preconception care can improve maternal and newborn health by providing the foundation for a good pregnancy and birth experience”, whilst also promoting pregnancy as the “optimum time to help promote a healthy lifestyle and introduce preventative measures for reducing ill health in the mother and baby” (p. 1) [26]. Pregnancy presents multiple opportunities to influence the health and wellbeing of mothers and their children and may also be the first time that a woman and her family have continued contact with health services [13]. Whilst the proposed women’s health network is yet to materialise, maternity services are well established with opportunities to improve women’s and children health being missed far too often. Midwives’ role in securing better outcomes for mothers and babies in the broader context of population health needs to be made more explicit [27].

Communicating about health behaviours have, however, also brought to light perceived issues of vulnerability. Midwives disclosed a fear of not giving the right information, disappointing, upsetting, or potentially offending pregnant women. Similarly, Schmied, Duff, Dahlen, Mills, and Kolt [28], reported that when discussing the issue of obesity, midwives who were overweight or obese themselves had described feeling either comfortable stating that they were not good role models or uncomfortable that their body image portrayed them as not being good role models. However, midwives who were normal or underweight also felt uncomfortable broaching the subject. Likewise, Foster and Hirst [29] reported that midwives expressed concern about upsetting pregnant women as they risk spoiling the pregnancy and the relationship between them breaking down. Issues of authenticity and vulnerability are thus barriers to midwives being able to communicate effectively regarding health behaviours or as Foster and Hirst [29] reported, absolving themselves from addressing these issues entirely.

Despite facing several challenges, midwives identified eight feasible opportunities in changing pregnant women’s physical activity behaviour, which included: (1) recognising and addressing barriers in the uptake and maintenance of exercise participation during pregnancy, (2) professional development, (3) inter-professional collaboration, (4) communicating effectively through simple, reliable resources, (5) improved access, availability and awareness of suitable activities in the local community, (6) encouraging a support network, (7) “selling” physical activity by challenging misconceptions and focusing on benefits, and (8) providing suitable motivation, incentives and reward. These suggestions and the issues raised by midwives should continue to be explored in both practice and future research endeavours.

Midwives feel strained by the increasing demands of their profession and pregnant women’s expectation for them to be the “fount of all knowledge” to who they turn first for all information. This perception includes their role and responsibility in securing better health outcomes for mothers and babies through the promotion of physical activity. However, several barriers exist which prevent effective physical activity advice and guidance from being delivered with authority. Whilst hypothetically midwives are “ideally placed” to advise regarding physical activity, this is not always feasible. Instead, they may be better placed as agents in a wider network of facilitators that share a consistent and confident message regarding physical activity during pregnancy. This notion has far reaching implications for practice, policy, research thereby facilitating the normalisation of active pregnancies in the wider population.