Interviews were conducted with 17 women and two midwives. Among the pregnant women, 15 chose to be interviewed by telephone, two in person. All women who participated in a pregnancy interview, except for one who could not be contacted, also completed an interview 4–6 weeks after giving birth. The characteristics of the participants are shown in Tables
1 and
2. Most were aged in their early thirties, born outside Australia, had a postsecondary school qualification, and just over half were overweight or obese. Seven of the women were receiving standard pregnancy care whilst nine attended a speciality pregnancy clinic for women with high BMI (>43 kg/m
2).
Table 1
Women’s sociodemographic characteristics and childbearing experiences
Average age (years) (range) | 32.6 (24–43) | 30.4 |
Country of birth |
Born in Australia | 7 (41.2%) | 67% |
Born overseas | 10 (58.8%) | 33% |
Highest level of education |
Post-secondary school qualification | 15 (88.2%) | |
No post-secondary school qualification | 2 (11.8%) | |
Relationship status |
Partnered | 17 (100%) | |
Not partnered | 0 (0.0%) | |
Healthcare concession card |
Yes | 2 (11.8%) | |
No | 15 (88.2%) | |
Private health insurance |
Yes | 9 (52.9%) | |
No | 8 (47.1%) | |
BMI |
Normal weight (<24.9 kg/m2) | 8 (47.1%) | 54% |
Overweight (25–29.9 kg/m2) | 3 (17.6%) | 26% |
Obese (≥30 kg/m2) | 6 (35.3%) | 20% |
Fertility problems |
Yes | 5 (29.4%) | |
No | 12 (70.6%) | |
Average ideal number of children (range) | 2.6 (2–4) | |
Average number of pregnancies (range) | 2.3 (1–6) | |
Average number of live births (range) | 0.8 (0–2) | |
Average number of unintended pregnancies (range) | 0.2 (0–2) | |
Average age at first birth (years) (range) | 30.0 (19–41) | |
Mode of delivery (index pregnancy) |
Vaginal | 9 (56.3%) | 67% |
Caesarean section | 7 (43.8%) | 33% |
Average baby birth weight (kgs) (range) | 3.3 (2.4–4.1) | 3.335 |
Baby admitted to NICU or SCU |
Yes | 6 (40.0%) | 15% |
No | 9 (60.0%) | |
Infant feeding |
Breastfeeding | 16 (100%) | 96% |
Average weight at end of pregnancy (kgs) (range) | 93.5 (65–150)b
| |
Average weight gain during pregnancy (kgs) (range) | 12.8 (−5.5–23)b
| |
Table 2
Women’s individual weight characteristics
Isla | 21 | Normal |
Ivy | 21 | Normal |
Matilda | 21 | Normal |
Amelia | 22 | Normal |
Chloe | 22 | Normal |
Olivia | 22 | Normal |
Emily | 24 | Normal |
Isabella | 24 | Normal |
Mia | 25 | Overweight |
Zoe | 25 | Overweight |
Charlotte | 27 | Overweight |
Lily | 41 | Obese |
Grace | 43 | Obese |
Ruby | 46 | Obese |
Sophia | 47 | Obese |
Ella | 55 | Obese |
Evie | 58 | Obese |
Two midwives were interviewed, both by telephone. Both were female midwives who practised mostly in the speciality pregnancy care clinic at the MMC for women with a BMI more than 43 kg/m2. Each had practised as a midwife for at least 3 years.
Key themes
Five themes about women’s and midwives’ experiences and perspectives of pregnancy care for pregnant women with high BMI were identified.
Theme 1: Reluctance to and difficulties discussing weight and its implications
The midwives reported that many women with high BMI are reluctant to discuss their weight during pregnancy care appointments. They also commented that it can often be difficult to discuss weight with women and many women become defensive if care providers attempt to discuss their weight. Nevertheless, midwives thought it was important that women were aware of the maternal and fetal implications of high BMI during pregnancy, and tried not to make women feel like they were “attacking” them when providing weight management advice.
Most women we see with high BMI [in the pregnancy clinic] don’t want to discuss the weight issue. (Midwife #1)
Midwives don’t want to ‘lecture’ women about their weight, they just want to talk about the implications of high weight for pregnancy and the baby. (Midwife #1)
We talk to every women in the booking appointment about their BMI and optimal weight for pregnancy so I take that as an opportunity to determine how receptive they would be to a discussion about diet but I make sure I include it in every appointment [not just for women with high BMI] … and make sure women are aware that we are not telling them they need to go on a crazy diet but it is about making small changes … I try not to make them feel like I am attacking them … and that any changes they make will benefit them and their baby … and acknowledge any changes that they make. (Midwife #2)
Although it can be frustrating caring for women with high BMI, I don’t want to belittle them in any way … I want to make sure they are supported. (Midwife #2)
Although most women reported positive pregnancy care experiences, were satisfied with the care they received, and perceived that the response from care providers about their weight was appropriate, they felt that care providers should not “criticise” pregnant women who have a high BMI.
I think women may be hesitant to bring up the issue of weight with the midwives and doctors so they need to be approachable and provide advice. (Zoe, BMI 25-29.9 kg/m
2
)
I think that the midwives and doctors at [the hospital] don’t make a huge deal about weight … they don’t emphasise your weight but they do tell you the risks. (Ruby, BMI ≥ 30 kg/m
2
)
I feel very insecure about my weight … [the midwives] really tried not to mention it or make me feel uncomfortable. (Evie, BMI ≥ 30 kg/m
2
)
Most women had received some dietary advice and information from their care provider but this was mainly about foods that should be avoided during pregnancy such as those that may contain harmful bacteria such as Listeria. However, women, both with and without a high BMI, also wanted their care provider to give them advice and information about managing weight and appropriate weight gain during pregnancy, and have opportunities to discuss these with them.
I asked my doctor for advice about my weight … I have put on 15kgs and would like to know if this is normal and get some tips about what I should eat. (Ivy, BMI < 24.9 kg/m
2
)
The two midwives stated that they were often guided by women’s individual level of interest in weight management when determining how much information to provide but felt they needed to be “blunt” with women who were at high risk of maternal and foetal complications such as women with a BMI > 40 kg/m2. They also thought it was important to manage the expectations of women with a high BMI about the most appropriate settings for labour and delivery. For example, that home or water births are not usually recommended for women with a high BMI. Midwives also tried to focus on discussing establishing better health habits such as regular exercise and healthy eating but reported becoming frustrated if women did not follow their advice.
It is frustrating to give women advice and information during pregnancy about healthy eating and then see them in the postnatal ward eating McDonald’s … it feels like you are wasting your time. (Midwife #1)
The midwives felt that women “normalised” obesity and this was especially true for women attending the speciality pregnancy care clinic for women with high BMI.
Theme 2: Barriers to providing appropriate pregnancy care for women with high BMI
Several barriers were identified to providing appropriate pregnancy care for women with a high BMI by the midwives, including a lack of suitable equipment, few resources to assist women manage their weight, and limited formal training for midwives about caring for pregnant women with high BMI.
The midwives reported difficulties sourcing suitable equipment and facilities for women with high BMI given the hospital’s limited supply including wide wheelchairs, large blood pressure cuffs, bariatric beds, and wards with appropriate toilet facilities, and felt this affected their ability to provide effective care. Despite midwives’ concerns about sourcing appropriate equipment, most women reported that the equipment used during pregnancy care, labour and birth was suitable for their needs.
I didn’t have to worry about my weight … [the hospital] had all the equipment I needed and it was appropriate for me … everything was organised before my appointments so I wasn’t inconvenienced. This was much better than other hospitals I have gone to which were not prepared for caring for someone [of my weight]. … I didn’t have to apologise for being overweight. (Evie, BMI ≥ 30 kg/m
2
)
Midwives commented that although they attempted to “treat all women the same” regardless of their weight, some women required or would benefit from additional support particularly from other care providers such as dieticians. However, opportunities for additional support were limited and midwives expressed frustration in not being able to refer women easily, especially those who expressed concern about their weight and wanted to take action for individual appointments or group sessions with dieticians.
Although the midwives felt confident about and well-supported in providing pregnancy care for women with a high BMI, they commented that they had received little or no formal training about the care and management of such women and that they had mostly “learnt on the job”.
Theme 3: Inconsistent weight management/weighing practices
Many women had expected to be weighed at every visit especially those who had pregnancy-related conditions such as gestational diabetes. However, both midwives and women described inconsistent weighing practices. Women reported not being weighed at all, weighed only at their first pregnancy care appointment, weighed inconsistently during pregnancy, or weighed at every pregnancy care appointment.
I have never been weighed in the pregnancy clinic (Olivia, BMI < 24.9 kg/m
2
).
I have only been weighed at the pre-pregnancy clinic for women with diabetes. I haven’t been weighed at any of my routine hospital visits. (Zoe, BMI 25-29.9 kg/m
2
)
I have been weighed by the midwife at every visit. I’ve also been weighed by my diabetes educator at the hospital. (Sophia, BMI ≥ 30 kg/m
2
)
Several women commented that whether or not they were weighed appeared to be inconsistent and when they sought clarification from their care provider about whether they should weigh themselves were told it was not necessary.
I have been weighed twice by the midwives. First when I was diagnosed with diabetes and then at another midwife visit but it seems a bit random. I thought I would be weighed at every visit given that I have gestational diabetes. (Emily, BMI < 24.9 kg/m
2
)
I was only weighed at my first clinic visit. I asked the doctor if I should weigh myself and was told not to bother. (Lily, BMI ≥ 30 kg/m
2
)
Some women who were not weighed regularly by their care providers weighed themselves.
I haven’t been weighed at any of my pregnancy clinic visits … but I weigh myself at home. (Mia, BMI 25-29.9 kg/m
2
)
Midwives stated reasons for not weighing women including not always having time (especially if the woman was late to her appointment) as they had to prioritise other care activities, and trying to avoid women feeling that they were focused on their weight.
Theme 4: Beliefs about the causes of obesity
Midwives and women expressed consistent views about the causes of obesity, and identified time, cost, and psychological and cultural barriers to women being able to manage their weight effectively during pregnancy. Women reported that fast food, soft drinks, and sedentary lifestyles or a lack of exercise were the main reasons people were overweight. Midwives believed that women with high BMI often ate too much food and the “wrong” types of food, lacked nutritional knowledge and motivation to effectively manage their weight, and were time poor. Women had similar beliefs, as well as suggesting that hormones caused weight gain during pregnancy. Several women also commented that some women “use pregnancy as an excuse to eat” and gained weight during pregnancy due to misperceptions such as “eating for two”.
Although few women reported personal experiences of stigma or discrimination due to their weight, both midwives and women identified negative societal stereotypes about people who are obese. Women felt that “everyone has an opinion on pregnant women’s weight” (Charlotte, BMI 25–29.9 kg/m2) and pregnant women who have a high BMI often receive negative comments from a range of people including strangers and care providers. Concerns for the health of the baby were often the main focus of such comments with women told that their weight would have detrimental effects for their baby. Women also thought that because women with a high BMI may not look pregnant, especially at the beginning of pregnancy, they were often treated differently to other women who are pregnant.
People question whether women who are overweight during pregnancy are really pregnant … no-one gives up their seat on the train for them … and people stare. (Lily, BMI ≥ 30 kg/m
2
)
When I was in the [hospital] waiting room, people looked at me differently … people think that you don’t look after yourself or take care of yourself when you are overweight. (Evie, BMI ≥ 30 kg/m
2
)
Women also felt that negative societal perceptions and comments about pregnant women who have a high BMI may result in women becoming distressed and eating for emotion regulation or self-soothing. Midwives also believed that women who had a high BMI often lacked self-esteem and self-confidence.
Most women were able to identify a number of strategies to assist with weight management during pregnancy even if they did not implement or practice these themselves. These included eating healthy foods, reducing portion sizes, and regular exercise.
Although most women reported being satisfied with their body weight and shape during pregnancy, several had concerns about the amount of weight they had gained and felt “miserable” or that they had gained too much weight. Some women expressed concern about their ability to manage their weight given their pregnancy, especially in the first trimester if they had morning sickness and struggled to find suitable food to eat.
I think I gained weight due to severe morning sickness. The only thing I could eat was bread which helped to stop the nausea and heartburn. I ate bread even when I wasn’t hungry as it alleviated the alkaline taste on my tongue. (Ivy, BMI < 24.9 kg/m
2
)
I have found it difficult to feel full whilst I have been pregnant so have eaten a lot more than I usually would. (Isabella, BMI < 24.9 kg/m
2
)
Theme 5: Opportunities to assist women manage their weight during pregnancy and postnatally
Women expressed concern about managing their weight during pregnancy and losing excess weight after the birth. Women and midwives identified several possible interventions to assist women manage their weight. They recommended that women with high BMI be offered specialised services and support similar to that which pregnant women with other conditions such as gestational diabetes or women having multiple pregnancies/births currently receive. For example, group information sessions about weight management offered as part of routine pregnancy care supported with printed or web-based information and individualised appointments with allied health care providers as is done with women with gestational diabetes. It was suggested that midwife-led, non-judgemental group sessions would provide a safe place for women to talk and receive information about weight management.
I saw a dietician at the pre-pregnancy clinic [due to diabetes]. She gave me useful information about food groups and healthy eating during pregnancy. I think other women would benefit from similar information. (Zoe, BMI 25-29.9 kg/m
2
)
When we have women who are diagnosed with gestational diabetes they have an education session, I think something like that is needed for women with a high BMI … a group session. (Midwife #1)
I think the midwives could offer a group information session like what the twin clinic does for women having twins … they could talk about nutrition and engage women with a high BMI in a group … it could be a safe place … where women could ask questions … and where we could also address all the risks of high BMI in labour. (Midwife #2)
I think midwives should give women information about managing their weight during pregnancy and this could include pamphlets or free seminars or groups sessions like mothers’ groups. (Emily, BMI < 24.9 kg/m
2
)
I think midwives should speak to women at antenatal classes and at individual appointments about managing their weight, particularly if the midwife has concerns about a woman’s weight or weight gain. (Isla, BMI < 24.9 kg/m
2
)
Women reported positive experiences with online pregnancy support groups, smartphone apps, and web-based tools in seeking and obtaining weight management information. Midwives were identified as the most appropriate people to talk to about managing their pregnancy weight. Women thought that care providers should discuss weight management with women and suggested that women should be given information about healthy eating, a diet plan, and recommendations about appropriate exercise. Women also thought it would be useful for care providers to regularly check women’s weight and that women could also use smartphone apps to track their weight during pregnancy. As well as web-based resources women also identified written information such as pamphlets as useful and thought any information provided should focus on why it is important to manage weight during pregnancy and how to do this, and be framed positively.
During the postnatal interviews participants reported that primary or routine care is mostly focused on the baby not the mother, and it would be useful for care during the postnatal period to include information on the best ways to lose weight. Maternal child and health care nurses who see women regularly after birth in Australia were also perceived as having a role in providing women with information about weight management and losing weight after pregnancy.
Midwives felt that weight management programs or interventions should not just be focused on pregnancy but also on making lifelong changes. Midwives believed that women with high BMI often lacked motivation about making changes during pregnancy so it would be beneficial for programs to be targeted at women prior to pregnancy and given that this may not always be possible then during the postnatal period before future pregnancies.