The average age of participants was 30.4 ± 4.4 years, this was the first child for 80.8% of the women, average pre-pregnancy BMI was 24.4 kg/m
2 ± 4.0, average GWG was 33.9 ± 18.9 lb., and type of HCP seen most often during pregnancy was: Obstetrician/Gynecologist (58.3%), Family Physician (37.5%), Midwife (4.2%). Age, BMI, GWG and type of HCP of this population are consistent with demographic data gathered from the nationally representative Canadian Maternity Experiences Survey (MES) [
1].
Overall, the topics women discussed and the issues raised were consistent and reached satuation across the five focus groups. Data regarding women’s experiences with weight gain and weight loss, as well as their conversations had with HCPs are organized into three categories: 1) Women are concerned about gestational weight gain, 2) Communication with HCPs about GWG is lacking, and 3) Postpartum weight loss also matters.
Women are concerned about gestational weight gain
Nearly all focus group participants identified that weight gain matters during pregnancy. Women reported that the amount of weight gained during pregnancy had implications for their health, the health of their pregnancy and the health of their baby. Weight gain was seen as a sign that the baby was in good health and that the pregnancy was moving along “on track”. Although weight gain was recognized as being important, it was also a source of concern.
Many women believed there was a "right amount" of weight to gain, specifically between 25 and 35 pounds. Women believed that gaining outside of this range (either more or less) may have negative implications for the health of their baby, which was a “big concern” for them.
“…I was gaining way too much, way too fast and I was concerned about the health risk of that, to me and baby. And, yeah, I’m not so active, so…it coming off afterwards…I worried about that.”
Important to note, almost all women were confused about the range of weight gain (i.e., who it applies to and where this range comes from), and what the weight gain range meant in terms of rate and distribution of weight gain. Despite this, they believed this was the weight gain they should aim for, regardless of their pre-pregnancy BMI. Some women questioned the range. As one woman commented,
“I’m just really curious on where the 25 to 35 pound range came from because there’s very, very few people that I’ve talked to who are anywhere near that 25 to 35 range. So I don’t know… Because I started to freak out about it, and then when everyone I talked to was like, oh no, I gained 50, 60, 70 pounds, I was like, okay, if everyone’s gaining that, then 50 is not too bad then. I’m okay.”
As exemplified by the participant above, some participants’ expectations of pregnancy-related weight gain were based on past experiences and experiences of family and friends. For example, one participant thought she should gain what her mother had gained, which corresponded with what she had read in popular prenatal books so that is what she aimed for,
“I thought I should gain what my mom gained. That’s where I got if from. And, it was right smack in the middle of what the books say, so I had that number in my head.”
When asked about how they were informed of a weight gain range, the majority of women reported accessing various resources, such as the books, What to Expect When you’re Expecting and Healthy Parents, Healthy Children - Pregnancy and Birth (Alberta Health Services); online websites, such as Baby Centre, Fit Pregnancy, and What to Expect; and searching “Dr. Google.” A few women reported this range was calculated by their HCP based on their pre-pregnancy BMI; however, most participants reported they did not receive information about an appropriate weight gain range from a HCP.
Participants reported varying levels of (dis)satisfaction with the amount of weight gained and their perceived ability to manage weight gain during pregnancy. For some women, gaining more weight than was recommended was frustrating and made them feel out of control. Some of these women stated that if they understood the implications exceeding recommendations could have on their baby, they would be more motivated to try to keep within GWG recommendations.
One participant noted that she “hated” the way she looked as she kept getting “thicker, thicker, thicker”. Some women struggled with changes in body shape (e.g., loss of muscle tone, feeling more “jiggly”). Others resigned themselves to the fact that weight gain was an inevitable part of pregnancy; they would try to lose the weight after the baby was born. Some women found it easy to cope with the amount of weight gained; however, for the few women who were satisfied or not concerned with their weight gain, they gained less than 30 pounds or less weight than they anticipated. They also believed they would be able to lose their weight quickly based on pregnancy experiences of family members and/or lifestyle behaviours (e.g. level of physical activity).
While women’s perceptions and experiences regarding weight gain varied, focus group discussions frequently centred on ways women tried to stay healthy and achieve healthy weights during pregnancy. Many women discussed monitoring and tracking their weight outside of doctors’ appointments on a frequent basis and almost all participants described modifications to their diet and/or amounts or types of physical activity. Modifications to diet included eliminating or reducing unhealthy foods, such as sweets, sodas and desserts, and increasing amounts of healthy foods, such as fresh fruits and vegetables. Conversely, some women noted that they “stopped being so strict” with their diet and would occasionally eat fast food because “now is the time to give in to your cravings”.
Changes to physical activity included both frequency and type of activity. The majority of women reported that they tried to walk more frequently and for longer periods of time. Others noted reducing the amount of physical activity due to high risk pregnancies (e.g., multiples, in vitro fertilization, extreme nausea), complications (e.g. sciatica, swelling), feeling tired or ill (mainly due to morning sickness), engaging in physical activities that were deemed not safe during pregnancy (e.g., heavy weight lifting), or due to family or social circumstances.
“I didn’t want to screw anything up so I stopped running.”
Evident throughout the focus group discussions was stress, both good and bad, that pregnancy can place on a woman. Women talked about feeling stressed because they were “worried” they might do something wrong that could put the baby and pregnancy at risk. Women repeatedly reported experiencing feelings of guilt when they could not fully comply with GWG recommendations; make positive lifestyle changes; or when changes to their normal routine resulted in reducing healthy behaviours, such as exercising less or eating fewer healthy foods. Although women were motivated and aware of the importance of healthy lifestyle behaviours during pregnancy, this was not always simple or possible.
“…it’s like, maybe earlier on I wasn’t eating the right things and I screwed this up and that’s why she’s not, you know, growing as much now. So, of course, you know, it kind of sets the wheels spinning… I’m trying to do the best I can here and…I don’t want to think I screwed this up…”
Communication with HCPs about GWG is lacking
Women in all focus groups stated that communication with HCPs about GWG was lacking. An example of this was participants’ experiences of being weighed during prenatal appointments. Women described that they were weighed by nurses at nearly every prenatal appointment and that their weight was recorded in their chart but typically not disclosed or discussed with them. This lack of communication about weight gain was confusing, leading some participants to question if GWG was important to their HCPs.
“I thought that maybe the obstetrician didn't really care about the weight I'm gaining because she didn't tell me too much…Every time, just go to the scale, she would look and tell me, ‘That's right’, every time. I don't know what's good or not.”
“I got weighed at every appointment but no one ever – like, we never discussed whether I was, you know, gaining too much, too little, anything. Like, it was just never really brought up.”
Women who reported that conversations about GWG did occur explained that these conversations were neither timely nor positive. Several women commented that weight gain was discussed by HCPs only after they had gained too much weight or were “out of range”. One woman described that her weight was discussed by her physician, “only when I had done something bad” (i.e., gained too much weight in one month). This same participant expressed that she was “glad that they brought it [weight gain] up because that means they’re not ignoring it” but suggested that her doctor could have discussed concerns about weight in a “gentle way…to explore what could be happening”. Similarly, another woman recalled that her obstetrician “had this thing about weight gain; she made me feel kind of bad about it, that I had been gaining so much”.
Women that reported gaining too much total weight or gained weight too quickly felt that, often, HCPs made assumptions about their lifestyle behaviours resulting in feelings of frustration, humiliation, or distress. One woman, who had been running her entire pregnancy, commented that she was told by her doctor to “jump on the treadmill once in a while” because she had gained 40 pounds by approximately 30 weeks gestation and felt the physician never took the time to inquire about her level of physical activity.
“I tipped the 40 pound scale, and that’s when she [the obstetrician] was like, ‘Whoa, whoa’, like, we hadn’t discussed it [GWG] at all up until that point [30 weeks] and then it was, okay, too much weight. But her recommendation was – and as far as I was… ’You should jump on the treadmill once in a while.’ And I ran until I was seven months pregnant, outside, because I like to run outside. And then I just – the weather wasn’t safe anymore. And so when she said, ‘Jump on a treadmill’, I was like, seriously? I was running the whole time.”
Again, another woman recalled gaining nine pounds in one month and the doctor “got a little cross with me”, telling her “you can’t be eating junk food”. This approach resulted in some participants experiencing negative emotions, such as guilt, blame, irresponsibility, and feeling out of control as more weight than was recommended was gained. These interactions with HCPs made women feel increasingly frustrated, commenting that the physicians’ approach to weight gain was “extreme” and “not helpful”, resulting in a lack of trust. As this participant described,
“She [the obstetrician] should have asked me how I felt about my weight gain, not just told me how she felt about it.”
While HCPs communicated when too much weight was gained, many did not offer strategies to help or support women create plans to achieve recommendations, discuss with them how to adjust their expectations when things did not go as planned, or what to do for the remainder of their pregnancy once recommendations were exceeded.
Women wanted to be given the option to talk about weight gain and suggested that discussions about GWG should be done as early on in pregnancy as possible and as part of standard care. To do this, women recommended that HCPs could ease into conversations about weight by simply asking women if it is okay to talk about their weight. One woman stated that,
“Not everyone likes to talk about their weight gain, so I guess they could ask if you like to talk about it.”
Women believe it is the responsibility of HCPs to broach the topic of weight gain and to provide accurate and timely information to women. Women want to discuss weight before exceeding recommendations, to be made aware of recommendations for total and rate of weight gain, their progress at every appointment; and they want regular feedback from their HCPs to assess if they are “on track”.
Postpartum weight loss also matters
All women emphasized that it was important to return to their pre-pregnancy weight, with one woman stating “as fast as humanly possible”. Women commented that, after delivery, they felt that the focus of postpartum visits by public health nurses and physicians was on the baby; however, moms still matter and women want continued support and education from their HCPs. One woman stated that after the baby is born, “That’s the end of it. You’re sort of on your own now to deal with whatever”. Another woman reflected that HCPs do not discuss weight loss because they are more concerned about postpartum mental health. Another woman mentioned that women’s mental wellbeing and weight after pregnancy are often linked and, for that reason alone, physicians should be discussing postpartum weight loss.
Women could not recall ever discussing weight loss with their HCPs before or after giving birth, except for one participant whose midwife talked with her about, “losing the baby weight” while she was still pregnant. While the timing of this conversation was stressful at first, after her baby was born, she found it helpful to remember the midwife’s advice to focus on proper eating and not be overly focused about weight loss specifically. This participant wished she could continue discussions about weight loss at all of her postpartum visits; however, since seeing a family doctor, the issue had not been discussed.
The majority of women thought it would be best to have a weight loss discussion during the six week postnatal check-up; alternatively, some women thought it would be helpful to begin these discussions during pregnancy to have the opportunity to start thinking about it early on. Whether weight loss is discussed during or after pregnancy, all women agreed that they want to be given the option to have this discussion and that it should be a part of standard care.
“No matter what size you are, I think every woman should have that [discussing postpartum weight loss] option. …if your healthcare provider sits there and says, here’s your options, it’s not like they’re telling you you’re heavy and you need to lose weight. They’re just saying that if you’re willing to or if you want to, here you go. And if they’re doing it to every woman, then every woman’s not going to feel cornered and saying, oh my gosh, you’re heavy. If it’s like, oh yeah, well, my healthcare provider asked me too, then they’re [women] going to be like, oh, okay, well maybe everybody’s getting asked. It’s not just me. It’s a woman thing. It’s every woman.”