A qualitative study of the experiences of women who are obese and pregnant in the UK

Pregnancy and weight gain: a scoping review of women's perceptions and experiences with stigma

BACKGROUND

Weight stigma can impact any woman who considers herself as overweight, regardless of BMI. Pregnant women are at risk of experiencing stigma related to weight which harm their physical and mental health. To support and guide on healthy weight gain during pregnancy, it is important to explore women's perceptions and experiences of weight related stigma. This can inform programs and policies to improve maternal and child health outcomes. A scoping review on this issue will provide valuable insights, identify gaps in current research, and establish a foundation for informed interventions.

METHODS

A search syntax was created to retrieve the relevant results from PubMed and Google Scholar. A scoping review was undertaken of published peer reviewed research indexed in these databases, which were written in English, and focused only on primary studies. The methodology for this scoping review was based on the framework proposed by Arksey and O'Malley (2005) and the subsequent recommendations provided by Levac et al. (2010).

RESULTS

From a total of 3109 articles identified using search terms, 85 articles were included for review. There are four themes in this scoping review: pregnant women's perceptions and experience with healthcare givers; pregnant women's experience with family and friends; pregnant women's experience with other members of society; and pregnant women's experience with the media. Weight stigmatization can hinder the communication between healthcare providers and women leading to misunderstanding and compromising the quality of care. This can prevent women from seeking necessary care. Stigmatizing behavior of friends, family and the perpetuation of stigma in the media influences how women perceive their pregnancy weight gain, intensifies feelings of shame, isolation and negatively impacts women's mental well-being and body image during pregnancy.

CONCLUSION

This scoping review examines the perceptions and experiences of weight stigma among pregnant women, focusing on their interactions with healthcare providers, family and friends, other members of society and stigma perpetuated by the media. The review gives an insight into how weight stigma can heighten women's stress and also leads to the avoidance of essential medical care, which affect the health of both the mother and the child. Addressing stigma from various sources is crucial for the general well-being and health of both women and children.

Pre-Pregnancy Diet and/or Physical Activity Interventions for the Prevention of Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

Gestational diabetes mellitus (GDM) is associated with short- and long-term adverse health outcomes for women and their infants. Antenatal diet and/or physical activity interventions have not been effective at preventing GDM, and currently, it is not clear whether intervening similarly prior to pregnancy is beneficial.

AIMS

This review aims to evaluate the impact of pre-pregnancy diet and/or physical activity interventions on rates of GDM and other maternal and infant health outcomes.

METHODS

A systematic literature search of the online databases Embase, Pubmed, Cochrane Central Register of Controlled Trials, Ovid MEDLINE and CINAHL was conducted from inception to 7 February 2023. All randomised controlled trials comparing pre-pregnancy diet and/or physical activity interventions with standard care or control were included. Data were extracted by two reviewers independently, and meta-analysis was performed using random-effects models to calculate summary effect estimates and 95% confidence intervals. The primary outcome was GDM. Five randomised trials assessing pre-pregnancy diet and/or physical activity interventions (n = 1924 women) were included.

RESULTS

Pre-pregnancy diet and/or physical activity interventions were not associated with a significant difference in rates of GDM (2 studies; n = 214; RR 1.19, 95% CI 0.81, 1.75). There were no statistically significant differences for any of the secondary maternal or infant outcomes reported. There was significant heterogeneity between studies with regard to type, duration and intensity of the pre-pregnancy diet and/or physical activity interventions.

CONCLUSIONS

There was no evidence that pre-pregnancy diet and/or physical activity interventions reduced the risk for GDM or other adverse maternal and infant outcomes.

Weight stigma in the preconception, pregnancy, and postpartum periods: A systematic review of women's perspectives

Weight stigma presents a significant challenge for women throughout the preconception, pregnancy, and postpartum (PPP) periods, manifesting in multiple areas of life, including interpersonal relationships, healthcare settings, and broader social contexts. This systematic review investigates weight stigma in women across their reproductive years, examining its impact, and exploring the socioecological factors that contribute to its persistence. We searched Medline, PsycINFO, Embase, Maternity and Infant Care (MIDIRS), and Global Health for peer-reviewed articles published since 2010. Of the 3486 records identified, 38 were included in a narrative synthesis. Inductive thematic analysis was used to explore women's personal experiences of weight stigma. We then applied a socioecological lens to examine the interrelationships between individual, interpersonal, organizational, and societal factors contributing to weight stigma. Five overarching themes were identified: (1) the impact of weight stigma on PPP women; (2) weight stigma experiences across the socioecological contexts; (3) coping strategies; (4) women's voices as a call to action; and (5) interrelationships of weight stigma contexts. Our findings provide critical insights into the multifaceted nature of weight stigma, highlighting the need for future research, and the development of practical strategies that prioritize women's perspectives, and challenge harmful societal norms for positive change.

Young mothers' experiences of maternity care: A synthesis of qualitative research

PROBLEM/BACKGROUND

Maternal health services require robust evidence to inform service provision and improve the health outcomes of mothers and their babies. Young mothers have consistently reported feeling unsupported and facing systematic barriers to accessing maternity care. Our aim was to synthesise the published evidence about how young mothers (aged between 15 and 24 years) living in regional, rural, and remote areas in high income countries experience accessing and receiving maternity health care.

METHODS

This qualitative evidence synthesis used a meta-aggregative approach to systematically synthesize published articles between 1970 and 2022. Electronic databases searches of CINAHL, SCOPUS, ProQuest, EMBASE, PUBMED and Google Scholar identified 4120 articles. Of these 14 were included in this review.

FINDINGS

Three final themes were synthesised: Relationships, Access and use of services and Social context. Limited data exists for regional, rural, and remote contexts.

CONCLUSION

Young mothers face many challenges during their maternity care journey. Identifying the young person's social and cultural care needs and building positive relationships with care providers will improve their experiences. Research is urgently required to design age and context appropriate maternity care for young mothers, who live in regional, rural, and remote areas.

"It's More than Just Exercise": Psychosocial Experiences of Women in the Conscious 9 Months Specifically Designed Prenatal Exercise Programme-A Qualitative Study

Background/Objectives: Physical activity during pregnancy is recognised for its benefits to maternal and foetal health. However, adherence to prenatal exercise programmes is often low due to psychological, physical, and social barriers. This study explored the experiences of women who successfully completed a tailored prenatal exercise programme, "Conscious 9 Months", aiming to identify factors enabling adherence and providing recommendations for future programme development. Methods: A descriptive qualitative research design was employed using semi-structured, in-depth interviews with ten participants who completed the programme between 2017 and 2019. Thematic Analysis was conducted to explore their experiences. Results: Participants emphasised the transformative nature of the programme, which extended far beyond physical exercise. Three interconnected domains emerged: psychosocial, physical, and psychoeducational. The present article focuses on the psychosocial domain, highlighting the significance of exercising in a group of pregnant women as a key source of support. Additionally, the atmosphere played a crucial role in facilitating the participants' regular attendance. Finally, the findings indicate that the programme fostered lasting social connections that extended beyond its formal completion. Conclusions: A holistic approach that integrates physical activity with social and emotional support can foster a sense of community and enhance long-term adherence. The design of future programmes should prioritise small group sizes to facilitate peer support and create a safe and welcoming atmosphere to encourage emotional expression. Additionally, sustained engagement beyond pregnancy through follow-up initiatives, family involvement, and postnatal movement programmes can further reinforce long-term participation and promote lasting health benefits for both mothers and their children.

Co-design and clinician evaluation of resources to address weight stigma in antenatal care

BACKGROUND

Weight stigma is a commonly reported experience in maternity care that negatively impacts the health of mothers and their babies. Knowledge to inform weight stigma reduction efforts in antenatal care is urgently required. This study aimed to co-design weight stigma reduction resources in antenatal care and evaluate clinician perspectives of the resources regarding their relevance to practice, strengths, and areas for improvement.

METHODS

We conducted a five-phase co-design project involving consumers (n = 8) and clinicians (midwives n = 16, obstetrician n = 1), with outputs from each stage informing the next: (1) engaging with key stakeholders; (2) prioritising the voices of lived experience through a consumer stories video; (3) three co-design workshops to inform resource development; (4) resource production; and (5) qualitative evaluation of the resources. The co-developed resources were evaluated via interview where clinicians viewed or listened to the resources and described their engagement and satisfaction with the resources, their relevance to practice, and perspectives on the strengths, areas for improvement, and feasibility for achieving the resources' intended goal. Transcripts were analysed using descriptive thematic analysis.

RESULTS

We produced a set of evidence-based resources co-designed by consumers and clinicians including a consumer video designed to elicit empathy about lived experiences of weight stigma in maternity care, images representing women with diverse body sizes for use in clinic waiting rooms, a short podcast to raise awareness of weight stigma in maternity care, and signposts for the antenatal clinic to prompt clinicians to consider weight stigma in everyday clinical interactions. Clinicians who saw the resources reported that they were valuable and relevant to practice and were important and helpful introductory materials to the issue of weight stigma. Pragmatic examples of reducing weight stigma in clinical interactions were requested.

CONCLUSIONS

Maternity care clinicians have an appetite to improve their learning opportunities to tackle weight stigma in practice. Further refinement of the resources, evaluation of the effectiveness at changing clinician behaviour, and implementation into health services are logical next steps. Reducing women's experiences of weight stigma should lead to better care and better pregnancy outcomes for larger bodied women.

CLINICAL TRIAL NUMBER

Not applicable.

Experiencing weight stigma during childbirth increases the odds of cesarean birth

BACKGROUND

Weight-biased clinical practices and institutional characteristics can have a wide impact on the quality of care provided to women with obesity. This may substantially increase their risks for poor birth outcomes. The current study assessed experienced weight stigma by women during childbirth in maternity care settings in Switzerland. We aimed to identify frequencies, sources, and manifestations of weight-related stigmatization, hypothesizing that such stigma impacts birth outcomes, specifically cesarean birth (CB).

METHODS

Data from a nationwide cross-sectional online survey was used to investigate the frequencies, sources, and manifestations of experienced weight stigma during childbirth. Binomial logistic regression was applied to predict CB from experienced weight stigma. Mediation analysis assessed the role of experienced weight stigma in the association between body mass index (BMI) and CB.

RESULTS

In a total of 1352 women who gave birth in the last five years, women with obesity (BMI ≥ 30 kg/m2) experienced weight stigma more often than their peers with healthy weight (BMI 18.5-24.9 kg/m2). Obstetricians were identified as a major source of weight stigma, accounting for 77.8% of stigmatization experienced by women, compared to stigmatization perceived from nurses (21.7%) and midwives (23.8%). Overall, weight stigma was mostly experienced in the form of dismissive or critical comments towards a woman's figure or weight. Significantly more women with obesity indicated being blamed for weight-related risks during childbirth than their healthy-weighted peers (χ²(2) = 22.2, P < 0.001). An increase in the frequency of experienced weight stigma was related to higher odds of intrapartum CB ([aOR], 1.08; 95% CI, 1.02,1.15; P < 0.05), and it partially mediated the relationship between increased pre-pregnancy BMI and CB (b = 0.07, SE = 0.029; P < 0.05).

CONCLUSION

Women with obesity reported the highest proportion of weight stigmatization during childbirth, experiencing stigma more frequently than women without obesity. This increased frequency of weight stigma was associated with higher odds of CB. Raising awareness among healthcare providers and reducing potential biases and stigmatization may improve care quality and health outcomes for women with obesity.

Where is communication breaking down? Narrative tensions in obesity-in-pregnancy clinical encounters

There are numerous biomedical and psychosocial challenges associated with obesity in pregnancy that impede communication between healthcare providers (HCPs) and patients. We conducted a narrative study informed by stigma theory to understand specific areas of communication breakdown in obesity-in-pregnancy clinical encounters. Sixteen patients and 19 HCPs participated in in-depth, semi-structured interviews. We explored how participants positioned obesity-in-pregnancy clinical encounters within their broader narratives. Employing narrative analysis, we identified five narrative tensions contributing to communication challenges: 1) obesity as a detriment to health versus an acceptable biologic variation; 2) obesity as the result of personal choice versus the result of uncontrollable circumstances; 3) a regular pregnancy versus a high-risk diagnosis; 4) a typical and problem-free clinical encounter versus a tremendously difficult clinical encounter; and 5) talking openly about Body Mass Index (BMI) and related co-morbidities versus sidestepping the topic. How participants positioned themselves relative to prevailing societal discourses regarding obesity in general influenced these tensions. These narrative tensions revealed specific areas where communication is vulnerable to breaking down during the obesity-in-pregnancy clinical encounter. Participants' (both HCPs and patients) past experiences of clinical encounters-and the meanings they ascribe to them-shape subsequent encounters, and our analysis illuminates the complexities of this interactive space. This research has implications for improving clinical practice and education.

Weight Stigma in Gynecological Care Among Cisgender Women

Objective

Healthcare is one of the primary contexts in which people experience weight stigma (social devaluation due to body weight), especially in gynecological care, where people's bodies are exposed. Thus, people may feel especially vulnerable to negative evaluations from healthcare providers due to their weight, given the physical exposure which accompanies a breast exam, abdominal palpitations, and a pap-smear or cervical exam. The existing literature examining weight stigma in obstetrics and gynecology has focused almost exclusively on pregnant or postpartum women. The only research on weight stigma during routine gynecological care is based on qualitative studies with small samples.

Methods

Participants (N = 1087; cisgender women) were sampled on Qualtrics, and quotas were set to reflect the most recent US census. The women reported their experiences with gynecological care and then were asked to qualitatively describe what they most recently encountered.

Results

Overall, 14% of the women in this sample had experienced weight stigma in reproductive or gynecological care at least once, and about 5% of this sample reported that this occurred frequently. Participants with higher body weights (≥ 30 kg/m2) were more likely to report frequent weight stigma in gynecological care. A few participants reported more serious experiences, such as misdiagnosis, environmental or systemic weight stigma, and provider reluctance to perform a pelvic exam.

Conclusions

Women experience weight stigma in routine gynecological care, and future research should continue investigating the effects of these experiences.

Being pregnant and obese: A qualitative study of the experiences of pregnancy and birth of women who are obese

OBJECTIVES

This study explored the views and experiences of maternity care of postnatal women identified as being obese.

DESIGN

A qualitative methodology was adopted using individual semi-structured interviews. Data was analysed using a framework approach.

SETTING

Two National Health Service Hospitals- a large tertiary unit in England, and a district general hospital in Scotland.

PARTICIPANTS

8 women with a body mass index of greater than 35 who had recently had a baby.

FINDINGS

The overall interpretation 'Being pregnant and obese; Obese women's experiences of pregnancy and birth' was underpinned by three key emergent themes: embodiment of obesity; being pregnant and overweight, and resource intensive maternity care. These findings are encapsulated in a conceptual framework that was formed to demonstrate the trajectory from the embodiment of obesity to becoming pregnant as an obese woman, experiencing the maternity regime that is currently in place for the care of obese women and then finally returning to being an obese woman.

KEY CONCLUSIONS

Women who are obese have an intrinsic fear of pregnancy and birth, have a desire for normal birth and 'obese pregnancy' presents a window of opportunity for both short and long-term lifestyle change.

IMPLICATIONS FOR PRACTICE

Currently one-fifth of women in the UK are obese. There is increasing evidence of the detrimental effects obesity has on intrapartum outcomes and a lack of research on how to minimise the associated risks of obesity through non-medicalised interventions and how to support women who are obese to maximise their experience of birth. Addressing the intrapartum management through non-medicalised interventions is of paramount importance to maximise the experience of birth and reduce the associated morbidities.

How experiences of weight stigma impact higher-weight women during their maternity care: A meta-ethnography

AIM

The aim of this review was to explore the experiences of pregnant women and birthing people with higher weight bodies, to understand the extent to which weight stigma impacted their maternity care.

METHODS

We performed a systematic search of seven databases (CINAHL plus, Medline, Social Sciences Full Text [SSFT], International Bibliography of Social Sciences [IBSS], PsychINFO, Maternity and Infant Care [MIC], NIHR Journals Library, EThOS) using the Setting, Perspective, Intervention, Comparison, Evaluation (SPICE) framework search strategy and pre-defined inclusion and exclusion criteria. Included studies underwent a critical appraisal and data richness assessment. We undertook thematic analysis after coding first- and second-order constructs and developed a synthesis from the themes.

FINDINGS

Thirty-eight papers, including six doctoral theses and one book chapter, met the inclusion criteria. Five themes were identified through thematic analysis, and the synthesis demonstrated that women of a higher weight experience shame, harmful attitudes and preconceptions from healthcare professionals regularly and repeatedly while receiving maternity care. This can be alleviated by individualised supportive care from a healthcare professional.

KEY CONCLUSIONS

Negative interactions with maternity care professionals are central to the experience of weight stigma, leading to a sense of 'shame', with pervasive feelings of humiliation, judgement and blame. Current guidance does not acknowledge the stigmatising effects of weight related conversations, additional interventions and restrictions on women's birthplace choices. Adopting a shame-sensitive lens within a culturally safe approach to maternity care could transform support for women.

Anxiety, depression, and perceived wellbeing in antenatal women at risk of preterm birth: a retrospective cohort study

Introduction

Women identified at risk for preterm may be vulnerable to developing mental health difficulties due to the increased likelihood of poor pregnancy outcome and uncertainty surrounding their delivery. Formal assessment of mental wellbeing in specialist preterm birth clinics is not routinely offered, but may offer the opportunity for early intervention.

Methods

We aimed to investigate if demographic characteristics and obstetric risk factors were associated with psychological wellbeing in women at risk of preterm birth. We explored associations between mental wellbeing and risk factors for preterm birth using hierarchical regression analyses.

Results

When demographic variables were considered alone, high body mass index (BMI) was significantly associated with anxiety (p = .026), however became non-significant when obstetric risk factors were also considered. Previous late miscarriage was associated with high anxiety (p = .049). Lower maternal age at estimated date of delivery (p = .019) and non-European ethnic heritage (p = .029) were significantly associated with depression. High maternal BMI (p < .001), being of any other non-European ethnic heritage (p = .043), currently smoking (p = .002), and previous spontaneous preterm birth (p = .017) were associated with lower perceived wellbeing.

Discussion

The results of this study highlight the importance of routinely monitoring mental health in women with relevant risk factors, particularly if they are already at risk of preterm birth.

SWIPE: a conceptual, multi-perspective model for understanding and informing interventions for weight stigma in preconception, pregnancy, and postpartum

Weight stigma is salient across the preconception, pregnancy, and postpartum (PPP) periods because of prevailing prescriptive norms and expectations about weight and weight gain during the reproductive period. Weight stigma is associated with negative physical and psychological health outcomes for mother and child. A clearly defined, multi-level conceptual model for interventions, research, and policy is critical to mitigating the adverse effects of weight stigma in PPP populations. Conceptual models of weight stigma towards PPP women have advanced our understanding of this issue and guided evidence accumulation but there remains a gap in informing the translation of evidence into action. Guided by evidence-based paradigms for conceptual model development, this paper has two primary objectives. First, we review and summarise theories, frameworks, and models from the PPP population and general literature to inform our understanding of the development and perpetuation of weight stigma for PPP women. Second, we propose a novel comprehensive intervention-guiding conceptual model that draws from and synthesises across multiple disciplines - the SWIPE (Stigma of Weight In the PPP Experience) model. This conceptual model will help to plan coordinated, multi-layered, and effective strategies to reduce and ultimately eliminate weight stigma for PPP women.

Shared Decision-Making and Body Mass Index in Australian Antenatal Care: An Exploratory OPTION12 Evaluation

BACKGROUND

Shared decision-making is recommended as a person-centred approach to decision-making in antenatal care. Little is known about the implementation of shared decision-making in antenatal care.

OBJECTIVE

An exploratory study to understand how shared decision-making is implemented in antenatal clinics and whether body mass index influences maternity clinicians' use of shared decision-making when providing antenatal care for women.

METHODS

Twenty-six antenatal clinic consultations were audio-recorded with maternity clinicians and women with body mass index ≥ 35 kg/m2, and a comparison group of women with body mass index 18.5-24.9 kg/m2. Data were analysed quantitatively using the OPTION12 scale. Narrative case studies are presented to compare shared decision-making behaviour related to induction of labour.

RESULTS

Twelve clinicians and 26 pregnant women were recruited to the study. The total scores ranged from 0 to 24, with a mean score of 9 and a median of 9.5 indicating low implementation of shared decision-making by clinicians and limited involvement of women in decision-making. No difference was observed in OPTION12 scores in decision-making for women by body mass index.

CONCLUSION

This study suggests that shared decision-making is limited in the antenatal clinic setting for all women, regardless of body mass index. Further research is required to confirm the findings of this exploratory study.

PATIENT OR PUBLIC CONTRIBUTION

The perspectives of women with body mass index ≥ 35 kg/m2 informed many aspects of this study including the language/terminology adopted by researchers. A consumer group reviewed the language used in the study materials, to ensure readability and avoidance of stigmatising terminology.

Development of a habit-based intervention to support healthy eating and physical activity behaviours for pregnant women with overweight or obesity: Healthy Habits in Pregnancy and Beyond (HHIPBe)

BACKGROUND

The number of women entering pregnancy with overweight or obesity is increasing. This can increase the risk for excessive gestational weight gain (GWG) which is associated with health complications for mother and baby. There are limited evidence-based interventions within antenatal care settings to encourage healthy eating and physical activity behaviours and support women with managing GWG.

METHODS

A previous habit-based intervention 'Ten Top Tips for a Healthy Weight' (10TT) was adapted and made suitable for pregnancy in line with the Medical Research Council's (MRC) complex intervention development guidelines. It involved three key activities: (1) identifying the evidence base; (2) identifying appropriate theory; and, (3) modelling processes. A core element was integrating lived experience via personal and public involvement (PPI).

RESULTS

The original 10TTs were adapted with PPI in line with current advice on nutrition and physical activity in pregnancy. New intervention materials were devised, including a leaflet and a logbook and app for self-monitoring to be delivered alongside a brief 1:1 conversation. Behaviour change techniques (BCTs) included in the new materials were coded using a number of behavioural taxonomies. An E-learning resource was created to help standardise the approach to delivery of the intervention and avoid stigmatising conversations.

CONCLUSION

Following MRC guidance for the development of complex interventions alongside significant PPI allowed for the adaption of 10TT habit-based weight management intervention into the 'Healthy Habits in Pregnancy and Beyond' (HHIPBe) intervention. The feasibility and acceptability of implementing this intervention in the antenatal setting will be explored in a feasibility randomised controlled trial.

TRIAL REGISTRATION

This study was registered on Clinical Trials as 'Healthy Habits in Pregnancy and Beyond (HHIPBe)' ClinicalTrials.gov Identifier: NCT04336878. The study was registered on 07/04/2020.

"In an ideal world": A qualitative exploration of shared decision-making and weight stigma in antenatal care

BACKGROUND

Shared decision-making supports women's autonomy in antenatal care, but several barriers to shared decision-making have been identified in practice. Women with high body mass index experience a higher rate of interventions, which could provide more opportunities for shared decision-making in antenatal care. However, weight stigma may exist as a barrier to shared decision-making, limiting access to collaborative care.

AIM

To explore how shared decision-making is implemented and whether body mass index influences maternity clinicians' use of shared decision-making when providing antenatal care for women.

METHODS

Maternity clinicians were recruited via purposive sampling from two sites in metropolitan Melbourne, Australia. Semi-structured interviews were audio recorded, transcribed, and analysed using reflexive thematic analysis.

FINDINGS

Twelve maternity clinicians consented to participate. Three themes and ten sub-themes were identified. The themes were: 1) Whose choice is it anyway? 2) Pregnancy as risky 3) Excess weight as a diseased state.

DISCUSSION

Maternity clinicians in this study view pregnancy through a risk management lens that complicates women's involvement in decision-making, demonstrating inherent beliefs that may further limit options for women with high body mass index.

CONCLUSION

Shared decision-making is difficult to implement in the current antenatal clinic setting and requires significant structural consideration to become a reality for women. Clinicians may inadvertently limit meaningful opportunities to engage in shared decision-making with women with high body mass index due to preconceived perceptions of risk and stigmatising beliefs about women with high body mass index.

"Ask for my ideas first": Experiences of antenatal care and shared decision-making for women with high body mass index

BACKGROUND

Shared decision-making supports women's choices in pregnancy. Women with high body mass index (≥35 kg/m2) experience a high rate of interventions in pregnancy, labour, and birth, providing an opportunity for clinicians to implement shared decision-making in practice. However, weight stigma may limit women's opportunities for shared decision-making.

AIM

To understand how pregnant women with high body mass index perceive their involvement in antenatal decision-making, including whether weight stigma influences their experience.

METHODS

Women with high body mass index were recruited via purposive sampling from two sites in Melbourne, Australia. Semi-structured interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis.

FINDINGS

Ten pregnant women consented to participate. Three themes and six sub-themes were identified. These were: 1) Trusting the system, 2) Who takes the lead?, and 3) Defying disease.

DISCUSSION

Shared decision-making is limited for women with high body mass index in antenatal care, and weight stigma is experienced by women. Clinical practice recommendations relating to excess weight have the potential to further limit women's involvement in decision-making if adequate support is not provided to ensure women's understanding and involvement in care.

CONCLUSION

Women's involvement in care is a central component of shared decision-making and it is currently limited for women with high body mass index. Transparency regarding the rationale for recommendations is required, and further work must be done to address the influence and impact of weight stigma on the care of women with high body mass index.

Factors Influencing Weight Management in Pregnant Women with Overweight or Obesity: A Meta-Synthesis of Qualitative Studies

BACKGROUND

Overweight and obesity have multiple negative consequences for the health of both the mother and the child. Interventions to prevent excessive weight gain during pregnancy have had varying success, and the proportion of pregnant women who exceed national guidelines for weight gain continues to increase.

OBJECTIVE

To investigate the influence of factors on weight management among pregnant women with overweight or obesity.

METHODS

This meta-synthesis of qualitative studies involved searching databases PubMed, Embase, Cochrane, Scopus, and Web of Science. The databases were searched on October 4, 2022, and the search was updated on April 21, 2023. The screening of titles, abstracts, and full texts was conducted utilizing Covidence software. The quality assessment of the articles was performed using the Critical Appraisal Skills Programme checklist. The Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement was used to enhance transparency in reporting. A meta-aggregation approach was used to guide the data extraction and synthesis.

RESULTS

A total of 46 studies with appropriate Critical Appraisal Skills Programme scores were included for qualitative synthesis. Findings were extracted and integrated into 4 themes: psychological factors (personally driven negative emotions and society-driven negative emotions), social factors (societal attitudes and beliefs and social support resources), factors related to education and counseling (information provision and communication), and factors associated with effective care (provided care components and the method of providing effective care).

CONCLUSIONS

To improve weight management during pregnancy, health care providers should provide tailored and individualized recommendations that take into consideration the factors influencing these women.

Drivers and facilitators of weight stigma among preconception, pregnant, and postpartum women: A systematic review

Women in the preconception, pregnant, or postpartum period are susceptible to weight stigma, particularly due to the risk of excess weight gain during the reproductive life period and the negative effects of stigma on the health of both the mother and the child. Identifying the drivers and facilitators of weight stigma will help guide focused weight stigma prevention interventions. This systematic review aimed to identify the drivers and facilitators of weight stigma among preconception, pregnant, and postpartum women. In May 2022, Medline, Embase, PsycINFO, and the Maternity and Infant Care Database were searched for peer-reviewed articles published since 2010 using search terms weight AND stigma AND preconception, OR pregnant, OR postpartum. Of the 1724 articles identified, 34 fulfilled the inclusion criteria and were included in a narrative synthesis. Women reported facing insensitive language, misconceptions about obesity across all settings, and inappropriate media representation. The unavailability of appropriate equipment at facilities was reported by both women and health professionals. Our findings indicate that a rigorous effort by all stakeholders is necessary to promote regulatory, legal, and educational initiatives designed to reduce weight stigma and discrimination against women in the reproductive period.

A prospective observational evaluation of an online health care professional training program to promote healthy pregnancy weight gain

ISSUE ADDRESSED

A lack of programs to develop clinician knowledge and confidence to address weight gain within pregnancy is a barrier to the provision of evidence-based care.

AIM

To examine the reach and effectiveness of the Healthy Pregnancy Healthy Baby online health professional training program.

METHODS

A prospective observational evaluation applied the reach and effectiveness elements of the RE-AIM framework. Health professionals from a range of disciplines and locations were invited to complete questionnaires before and after program completion assessing objective knowledge and perceived confidence around aspects of supporting healthy pregnancy weight gain, and process measures.

RESULTS

There were 7577 views across all pages over a year period, accessed by participants across 22 Queensland locations. Pre- and post- training questionnaires were completed 217 and 135 times, respectively. The proportion of participants with scores over 85% and of 100% for objective knowledge was higher post training (P ≤ .001). Perceived confidence improved across all areas for 88%-96% of those who completed the post- training questionnaire. All respondents would recommend the training to others.

CONCLUSIONS

Clinicians from a range of disciplines, experience and locations accessed and valued the training, and knowledge of, and confidence in delivering care to support healthy pregnancy weight gain improved after completion. SO WHAT?: This effective program to build the capacity of clinicians to support healthy pregnancy weight gain offers a model for online, flexible training highly valued by clinicians. Its adoption and promotion could standardise the support provided to women to encourage healthy weight gain during pregnancy.

The makings of a maternal obesity epidemic: A meta-narrative review

STUDY BACKGROUND

The prevalence and complications of maternal obesity are well reported; with a hegemonic medicalised view leading to women's pregnant bodies being 'managed'. We aimed to address current knowledge gaps by exploring the literature across research traditions and overtime to better understand the experiences of maternity care for women living with obesity, in relation to choice, consent and control.

METHODS

A systematic review using meta-narrative methods. Identification of studies included a scoping phase involving experts, hand searching and database browsing and a systematic searching phase. Seven databases (MEDLINE, MIDIRS, CINAHLComplete, Scopus, SocINDEX, PsycINFO, SPORTDiscuss) were searched with no date or geographical restriction. Non- English language studies were excluded. Two authors appraised quality prior to data extraction and synthesis. Data were tabulated, and women's experiences conceptualised in relation to choice, consent and control, first, by research tradition to reveal the unfolding storyline, secondly emergent narratives were synthesised into meta-themes.

RESULTS

Twenty-four studies were included, from six research traditions. Of these, twenty-one were qualitative, two were quantitative, and one study utilised a mixed method design. Studies spanned twenty-six years from 1994 to 2020. Across research traditions, four themes were evident, 'women's beliefs and experiences of weight', 'social determinants', 'being risked-managed' and 'attitudes of caregivers'. Over time, management of maternal obesity has moved from a focus on weight gain and diet as a woman's issue, to weight being pathological resulting in increased medicalisation, to a renewed focus on lifestyle through the public health arena. It suggests that lack of choice over care can reduce women's perception of control over their pregnancy and birth experience.

CONCLUSION

Increased medicalisation of maternal obesity, which includes defining and managing weight as pathological can limit women's choice and control over their maternity care. There is a need for national and local policy development which includes women in the process. It is important that women's views are heard, understood and acted upon so that a balance can be achieved, avoiding over medicalisation, yet ensuring mortality and morbidity risks are minimised.

Clinical guidelines for the management of weight during pregnancy: a qualitative evidence synthesis of practice recommendations across NHS Trusts in England

BACKGROUND

Women who enter pregnancy with a Body Mass Index above 30 kg/m² face an increased risk of complications during pregnancy and birth. National and local practice recommendations in the UK exist to guide healthcare professionals in supporting women to manage their weight. Despite this, women report inconsistent and confusing advice and healthcare professionals report a lack of confidence and skill in providing evidence-based guidance. A qualitative evidence synthesis was conducted to examine how local clinical guidelines interpret national recommendations to deliver weight management care to people who are pregnant or in the postnatal period.

METHODS

A qualitative evidence synthesis of local NHS clinical practice guidelines in England was conducted. National Institute for Health and Care Excellence and Royal College of Obstetricians and Gynaecologists guidelines for weight management during pregnancy constructed the framework used for thematic synthesis. Data was interpreted within the embedded discourse of risk and the synthesis was informed by the Birth Territory Theory of Fahy and Parrat.

RESULTS

A representative sample of twenty-eight NHS Trusts provided guidelines that included weight management care recommendations. Local recommendations were largely reflective of national guidance. Consistent recommendations included obtaining a weight at booking and informing women of the risks associated with being obese during pregnancy. There was variation in the adoption of routine weighing practices and referral pathways were ambiguous. Three interpretive themes were constructed, exposing a disconnect between the risk dominated discourse evident in the local guidelines and the individualised, partnership approach emphasised in national level maternity policy.

CONCLUSIONS

Local NHS weight management guidelines are rooted in a medical model rather than the model advocated in national maternity policy that promotes a partnership approach to care. This synthesis exposes the challenges faced by healthcare professionals and the experiences of pregnant women who are in receipt of weight management care. Future research should target the tools utilised by maternity care providers to achieve weight management care that harnesses a partnership approach empowering pregnant and postnatal people in their journey through motherhood.

The design, delivery and evaluation of 'Human Perspectives VR': An immersive educational programme designed to raise awareness of contributory factors for a traumatic childbirth experience and PTSD

BACKGROUND

A traumatic childbirth experience affects ~30% of women each year, with negative impacts on maternal, infant, and family wellbeing. Women classified as vulnerable or marginalised are those more likely to experience a psychologically traumatising birth. A key contributory factor for a traumatic childbirth experience is women's relationships with maternity care providers.

AIMS

To develop, design and evaluate an immersive educational programme for maternity care providers to raise awareness of traumatic childbirth experiences amongst vulnerable groups, and ultimately to improve women's experiences of childbirth.

METHODS

A critical pedagogical approach that utilised virtual reality (VR) underpinned the design and development of the educational programme. This involved: a) collecting vulnerable/disadvantaged women's experiences of birth via interviews; b) analysing data collected to identify key hotspots for traumatic experiences within interpersonal patient-provider relationships to develop a script; c) filming the script with professional actors creating a first person perspective via VR technology; d) using existing literature to inform the theoretical and reflective aspects of the programme; e) conducting an evaluation of the education programme using pre-and post-evaluation questionnaires and a follow-up focus group.

FINDINGS

Human Perspective VR was very well received. Participants considered the content to have enhanced their reflective practice and increased their knowledge base regarding contributory factors associated with a traumatic childbirth experience. A need for further work to implement learning into practice was highlighted.

CONCLUSION

While further research is needed to evaluate the impact of the programme, Human Perspective VR programme offers an innovative approach to reflective education and to enhance participants' care practices.

A Pragmatic Guide to Qualitative Analysis for Pediatric Researchers

OBJECTIVE

To describe four approaches to qualitative analysis in order to provide a pragmatic, application-oriented guide to their use in research focused on children and their families.

METHODS

Four commonly used approaches to qualitative analysis-framework analysis, rapid qualitative analysis, content analysis, and reflexive thematic analysis-are described and compared, including their analytic strategies, tips for use, terminology, and application to a hypothetical example.

RESULTS

A pragmatic guide to each method is provided as well as examples of how each analytic approach could be utilized to analyze the same dataset.

CONCLUSIONS

A variety of approaches to qualitative analysis are available to both novice and experienced qualitative researchers. The approach selected from the options presented in this article will depend on numerous factors, such as the clinical problem being explored, research context, aims, objectives, research questions, and resources available such as time and funds, and the qualitative expertise of the team.

Overweight, obesity and excessive weight gain in pregnancy as risk factors for adverse pregnancy outcomes: a narrative review

The global prevalence of overweight and obesity in pregnancy is rising and this represents a significant challenge for the management of pregnancy and delivery. Women who have a pre‐pregnancy body mass index greater than 25 kg m^–2 are more likely than those with a body mass index in the ideal range (20–24.99 kg m^–2) to have problems conceiving a child and are at greater risk of miscarriage and stillbirth. All pregnancy complications are more likely with overweight, obesity and excessive gestational weight gain, including those that pose a significant threat to the lives of mothers and babies. Labour complications arise more often when pregnancies are complicated by overweight and obesity. Pregnancy is a stage of life when women have greater openness to messages about their lifestyle and health. It is also a time when they come into greater contact with health professionals. Currently management of pregnancy weight gain and the impact of overweight tends to be poor, although a number of research studies have demonstrated that appropriate interventions based around dietary change can be effective in controlling weight gain and reducing the risk of pregnancy complications. The development of individualised and flexible plans for avoiding adverse outcomes of obesity in pregnancy will require investment in training of health professionals and better integration into normal antenatal care.

Overweight and obesity before pregnancy and excessive gestational weight gain are major determinants of risk for pregnancy loss, gestational diabetes, hypertensive conditions, labour complications and maternal death.

Pregnancy is regarded as a teachable moment when women are at their most receptive to messages about their health. However, unclear guidance on diet and physical activity, weight stigma from health professionals, inexperience and reluctance among professionals about raising issues about weight, and stretched resources put the health of women and babies at risk.

Excessive weight gain in pregnancy and post‐partum weight retention compromise future fertility and increase risk for future pregnancies.

Large randomised controlled trials have had little success in addressing excessive gestational weight gain or antenatal complications. Individualised, culturally sensitive and responsive interventions appear to have greater success.

The WOMBS Framework: A review and new theoretical model for investigating pregnancy-related weight stigma and its intergenerational implications

As the growing weight stigma literature has developed, one critically relevant and vulnerable population has received little consideration-pregnant and postpartum women. Because weight fluctuations are inherent to this life phase, and rates of prepregnancy overweight and obesity are already high, this gap is problematic. More recently, however, there has been a rising interest in pregnancy-related weight stigma and its consequences. This paper therefore sought to (a) review the emerging research on pregnancy-related weight stigma phenomenology and (b) integrate this existing evidence to present a novel theoretical framework for studying pregnancy-related weight stigma. The Weight gain, Obesity, Maternal-child Biobehavioral pathways, and Stigma (WOMBS) Framework proposes psychophysiological mechanisms linking pregnancy-related weight stigmatization to increased risk of weight gain and, in turn, downstream childhood obesity risk. This WOMBS Framework highlights pregnant and postpartum women as a theoretically unique at-risk population for whom this social stigma engages maternal physiology and transfers obesity risk to the child via social and physiological mechanisms. The WOMBS Framework provides a novel and useful tool to guide the emerging pregnancy-related weight stigma research and, ultimately, support stigma-reduction efforts in this critical context.

Can Weight Watchers (WW) Help Address Maternal Obesity? An Audit of Weight Change in Women of Childbearing Age and Mothers-To-Be, Referred into a Commercial Slimming Programme

Objectives

The scale of overweight and obesity amongst women of childbearing age or mothers to be, living in Wales, places a considerable burden on the NHS and public health. High BMI (over 30) during pregnancy increases the health risks for mother and baby. Policy advice recommends weight management services are available to help women lose weight before and whilst planning pregnancy. In parts of Wales, NHS partnerships with commercial companies provide weight management services for women considering or planning pregnancy. This study evaluates whether an established referral Weight Watchers (WW) programme, known to be effective in adults in England, can help mothers-to-be living in North Wales lose weight.

Methods

Analysis used routine data from 82 referrals to WW between June 2013 and January 2015. Participants received a referral letter inviting them to attend face-to-face group workshops combined with a digital experience. The programme encompassed healthy eating, physical activity and positive mind-set. Trained WW staff measured bodyweight before, during and at 12 weeks. On entry to the course, participants had a median age of 31.4 years (interquartile range (IQR) 28–34) with a median BMI of 36.8 kg/m² (IQR 33.3–43.7).

Results

Women completing the course (n = 34) had a median weight loss of 5.65 kg (IQR 0.45–10.85), equating to 5.7% (SD 3.46) of initial body weight. Intention-to-treat analysis (last observation carried forward), which included lapsed courses n = 66, showed a median weight loss of 3.6 kg (IQR − 2.53 to 9.73), equating to 3.7% (SD 3.62) of initial body weight. Overall, there was significant weight loss during the WW programme (Wilcoxon signed rank test Z = − 6.16; p < 0.001). Weight loss was significantly correlated with the number of workshops attended (Spearman correlation coefficient 0.61 p < 0.001). The proportion of all 82 participants (intention to treat, baseline observation carried forward) that achieved a weight loss of ≥ 5% initial weight was 30.5%.

Conclusions for Practice

Referral of obese mothers-to-be into WW can successfully achieve short-term weight loss, at or above 5%, in approximately one third of participants. The dose–response effect supports a causal inference. Successful weight loss at this critical life stage may provide women with the necessary motivation to initiate weight loss for healthy pregnancy, however further research is required.

Women's experiences of living with obesity during pregnancy, birthing, and postpartum: a qualitative systematic review protocol

OBJECTIVE

The objective of this review is to explore and understand women's experiences of living with obesity during the perinatal period to support evidence-informed approaches to care.

INTRODUCTION

The rising incidence of maternal obesity is a serious global health problem. Qualitative studies exploring the viewpoints of pregnant women living with obesity have shown that some women report negative experiences associated with pregnancy, with some instances of current care management practices being perceived as confronting, judgmental, and generally unhelpful. Synthesizing qualitative findings about the experiences of pregnant and postpartum women who live with obesity can provide important insights into the general needs of this population and current gaps in health care practice.

INCLUSION CRITERIA

All settings in which women who live with obesity during their pregnancies and receive health care for pregnancy, birthing, and postpartum care will be considered. Studies published from 1995 onward will be included. The review will consider all studies that present qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research, and feminist research.

METHODS

The following databases will be searched for this review: CINAHL (EBSCO), Embase (Elsevier), PsycINFO (EBSCO), MEDLINE (Ovid), and Sociological Abstracts (ProQuest). ProQuest Dissertations and Theses will be searched for unpublished studies. Each study will be assessed by two independent reviewers. Any disagreements will be resolved through discussion. Data extraction will be conducted by two independent reviewers. The JBI resources for meta-aggregation will be used to create categories and synthesized findings.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020214762.

What are the experiences of women with obesity receiving antenatal maternity care? A scoping review of qualitative evidence

PROBLEM

Obesity is a major public health problem and is rising in prevalence in child-bearing women. The complications of pregnancy in women with obesity are well documented. Pregnant women with obesity require different maternity care considerations to normal weight women. How women respond to the care of health professionals, determines how likely they will be to engage with it, and thus research into the current care experiences of women with obesity is valuable.

OBJECTIVE

The purpose of this scoping review was to examine the evidence of the antenatal maternity care experiences of women with obesity (BMI≥30kg/m2).

METHOD

A systematic literature search was conducted for English language publications 2008-2018 using Medline, Scopus, PsycINFO and CINAHL. Following critical appraisal, and a search of the reference lists of primary articles, 17 articles resulted for this review. A thematic synthesis process was used to collate the findings.

FINDINGS

Four major themes were identified: 1) inconsistent or absent information regarding weight management, 2) the stigma and stereotyping associated with their obesity, 3) medicalisation and depersonalisation of pregnant women with obesity, and 4) a desire for information and need for change.

CONCLUSION

The findings suggested that based on women's experiences there is a need for improved education and communication for health care professionals when caring for pregnant women with obesity. Some conflicting information from women in the studies highlight the need for further research in the area, and the implementation of individualised care and continuity of care for pregnant women with obesity.

Facilitators and barriers to behaviour change within a lifestyle program for women with obesity to prevent excess gestational weight gain: a mixed methods evaluation

Background

Maternal obesity is associated with health risks for women and their babies and is exacerbated by excess gestational weight gain. The aim of this study was to describe women’s experiences and perspectives in attending a Healthy Pregnancy Service designed to optimise healthy lifestyle and support recommended gestational weight gain for women with obesity.

Methods

An explanatory sequential mixed methods study design utilised two questionnaires (completed in early and late pregnancy) to quantify feelings, motivation and satisfaction with the service, followed by semi-structured interviews that explored barriers and enablers of behaviour change. Data were analysed separately and then interpreted together.

Results

Overall, 49 women attending the service completed either questionnaire 1, 2 or both and were included in the analysis. Fourteen women were interviewed. Prior to pregnancy, many women had gained weight and attempted to lose weight independently, and reported they were highly motivated to achieve a healthy lifestyle. During pregnancy, diet changes were reported as easier to make and sustain than exercise changes. Satisfaction with the service was high. Key factors identified in qualitative analysis were: service support enabled change; motivation to change behaviour, social support, barriers to making change (intrinsic, extrinsic and clinic-related), post-partum lifestyle and needs. On integration of data, qualitative and quantitative findings aligned.

Conclusions

The Healthy Pregnancy service was valued by women. Barriers and enablers to the delivery of an integrated model of maternity care that supported healthy lifestyle and recommended gestational weight gain were identified. These findings have informed and improved implementation and further scale up of this successful service model, integrating healthy lifestyle into routine antenatal care of women with obesity.

Trial registration

This trial is registered with the Australian New Zealand Clinical Trials Registry (no.12620000985987). Registration date 30/09/2020, retrospectively registered. http://www.anzctr.org.au/

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04034-7.

'I know my place'; a meta-ethnographic synthesis of disadvantaged and vulnerable women's negative experiences of maternity care in high-income countries

OBJECTIVE

During pregnancy and childbirth, vulnerable and disadvantaged women have poorer outcomes, have less opportunities,face barriers in accessing care,and are at a greater risk of experiencing a traumatic birth. A recent synthesis of women's negative experiences of maternity care gathered data from predominantly low-income countries. However, these studies did not focus on vulnerable groups, and are not easily transferable into high-income settings due to differences in maternity care provision. The aim of this study was to synthesise existing qualitative literature focused on disadvantaged and vulnerable women's experience of maternity care in high-income countries.

METHODS

A systematic literature search and meta-ethnographic methods were used. Search methods included searches on four databases, author run, and backward and forward chaining. Searches were conducted in March 2016 and updated in May 2020.

FINDINGS

A total of 13,330 articles were identified and following checks against inclusion / exclusion criteria and quality appraisal 20 studies were included. Meta-ethnographic translation analytical methods were used to identify reciprocal and refutational findings, and to undertake a line of argument synthesis. Three third order reciprocal constructs were identified, 'Prejudiced and deindividualized care', 'Interpersonal relationships and interactions' and 'Creating and enhancing insecurities.' A line of argument synthesis entitled 'I know my place' encapsulates the experiences of disadvantaged and vulnerable women across the studies, acknowledging differential care practices, stigma and judgmental attitudes. A refutational translation was conceptualised as 'Being seen, being heard' acknowledging positive aspects of maternity care reported by women.

CONCLUSION

Insights highlight how women's vulnerability was compounded by complex life factors, judgmental and stigmatizing attitudes by health professionals, and differential care provision. Further research is needed to identify suitable care pathways for disadvantaged and vulnerable women and the development of suitable training to highlight negative attitudes towards these women in maternity care settings.

Being overweight or obese during pregnancy: a qualitative study

OBJECTIVE

The objectice of this study was to reveal difficulties, coping and expectations of overweight/obese women during pregnancy.

METHODS

A descriptive, phenomenological approach was used. Fourteen pregnant women having a body mass index of 25 or over 25.

RESULTS

The findings were presented under three themes: difficulties experienced, coping and expectations. The women had physical difficulties and their daily life was affected negatively. They experienced stigmatization, humiliation and uncertainty about how much they had to eat during pregnancy. Therefore, they were upset and unhappy. Some women denied that they were overweight and some women considered being overweight as normal due to pregnancy. Social support plays an important part in coping with difficulties; however, some women could not get sufficient social support. The women also expected to be treated tolerantly.

CONCLUSION

Overweight/obese women try to overcome many physical and psychological problems due to their weight during pregnancy, but they do not receive adequate support.

Experiences of Pregnant Women With Obesity

OBJECTIVE

To explore how pregnant women with obesity feel about their bodies before and during pregnancy.

DESIGN

Qualitative descriptive design.

SETTING

Obstetric and gynecologic offices in a rural setting in Maryland that employed physicians and midwives as prenatal care providers.

PARTICIPANTS

A purposive sampling technique was used to recruit a sample of 20 women. Inclusion criteria were pregnant women ages 18 to 35 years with a prepregnancy body mass index of greater than 30 kg/m², in the third trimester of the pregnancy (28-40 weeks gestation), and receiving regular prenatal care from a licensed provider.

INTERVENTION/MEASUREMENT

A typology analysis chart was used to group participants' responses from their interviews in the areas of positive or negative feelings regarding their prepregnancy body and weight, and positive or negative feelings regarding their pregnant body.

RESULTS

Data were analyzed using a four-square matrix by identifying those participants who felt positive regarding their prepregnancy body/weight and pregnant body (n = 6), felt negative regarding their prepregnancy body/weight and pregnant body (n = 3), felt negative regarding their prepregnant body but positive regarding their pregnant body (n = 8), and felt positive regarding their prepregnant body but negative about their pregnant body (n = 3).

CONCLUSION

Pregnancy had allowed many of the women to gain a sense of achievement, where the growth of the fetus and subsequent weight gain were seen as positive attributes, and they embraced the functionality of their bodies.

Smartphone-based lifestyle coaching modifies behaviours in women with subfertility or recurrent miscarriage: a randomized controlled trial

RESEARCH QUESTION

Is an online lifestyle coaching platform more effective at modifying periconceptional behaviours than standard advice offered by the UK National Health Service (NHS)?

DESIGN

Women with subfertility or recurrent miscarriage were recruited to a two-centre randomized controlled trial. They were randomized to either the online lifestyle coaching platform Smarter Pregnancy (intervention) or periconceptional advice provided by NHS websites (control). Participants completed a lifestyle questionnaire at baseline, 6, 12, 18 and 24 weeks, and the results were used to tailor lifestyle coaching in the intervention group. At baseline, 12 and 24 weeks, composite risk scores (CRS) were calculated. A lower CRS corresponds to a healthier lifestyle.

RESULTS

Of the 400 women recruited, 262 women were randomized (131 in each arm). At 12 weeks, a reduction in CRS (includes risk score for intake of folic acid, vegetables and fruits, smoking and alcohol) was observed in the intervention versus control arms. After correcting for baseline, the difference in the CRS between intervention and control was -0.47 (95% CI -0.97 to 0.02) at 12 weeks and -0.32 (95% CI -0.82 to 0.15) at 24 weeks. A statistically significant reduction in lifestyle risk scores was found in women with a body mass index (BMI) of 25 kg/m² or above compared with those with a BMI below 25kg/m². The odds of being pregnant at 24 weeks was increased in the intervention versus control (OR 2.83, 95% CI 0.35 to 57.76).

CONCLUSIONS

The Smarter Pregnancy coaching platform is more effective in delivering lifestyle advice and modulating behaviours to support women with a history of subfertility or recurrent miscarriage than standard online NHS advice.

Women's Suggestions for How To Reduce Weight Stigma in Prenatal Clinical Settings

OBJECTIVE

To describe the experiences of weight stigma in prenatal clinical settings among high-risk pregnant women living with obesity and to obtain women's perspectives regarding changes to prenatal health care practices that may reduce weight stigma.

DESIGN

Qualitative descriptive study.

SETTING/LOCAL PROBLEM

High-risk obstetrics clinic. Weight stigma experienced in prenatal clinical settings can negatively influence maternal health and well-being as well as communication with health care providers.

PARTICIPANTS

Nine pregnant women with obesity who were receiving specialized prenatal care in their third trimester.

INTERVENTION/MEASUREMENTS

Women participated in semistructured telephone interviews. Data were inductively analyzed using a content analysis, whereby coded data were organized to represent experiences of or suggestions provided by pregnant women to reduce weight stigma in prenatal clinical settings.

RESULTS

Experiences of weight stigma included poor communication, generalizations made about health and lifestyle behaviors, and focusing only on excess body weight during clinical appointments as the cause of negative health outcomes. To reduce weight stigma, women suggested that health care providers practice sensitive communication, offer individualized care for weight management, and reduce the focus on body weight by also independently addressing comorbidities or other health indicators.

CONCLUSION

Women interviewed for this study provided suggestions that can be implemented in prenatal clinical settings to reduce weight stigma and improve the delivery of equitable health care.

Weight Stigma across the Preconception, Pregnancy, and Postpartum Periods: A Narrative Review and Conceptual Model

Weight stigma is a pervasive issue promoting significant adverse health and psychosocial consequences. Preconception, pregnant, and postpartum women are particularly vulnerable to weight stigma, which can directly impact their health and that of the next generation. Of note, weight stigma affects women living with obesity who are already at risk for developing gestational diabetes and experiencing associated stigmas. This narrative review aimed to examine the literature on weight stigma across the preconception, pregnancy, and postpartum periods, specifically to (1) synthesize the evidence using a socioecological lens; (2) develop a conceptual model of weight stigma tailored to women across this life phase; and (3) provide recommendations for future research. To date, weight stigma research across the preconception, pregnancy, and postpartum periods has focused predominately on pregnancy and antenatal care. The drivers and facilitators of this stigma are pervasive, occurring across various contexts and settings. Manifestations of weight stigma include decreased reproductive healthcare quality, mental health symptoms, poorer health behaviors, and adverse pregnancy outcomes. Future research should further investigate the experiences of women preconception and postpartum, and health/social impacts beyond healthcare. The model herein will guide such research to ultimately identify opportunities for stigma reduction and improve multigenerational health and well-being outcomes.

The impact of pre-pregnancy BMI on maternal depressive and anxiety symptoms during pregnancy and the postpartum period: A systematic review and meta-analysis

BACKGROUND

Studies have reported conflicting results on the association between maternal pre-pregnancy weight and adverse mental health outcomes during pregnancy and the postpartum period. This systematic review and meta-analysis aim to provide the current state of evidence concerning the association between maternal pre-pregnancy BMI and the risk of antenatal and postnatal depressive and anxiety symptoms.

METHODS

PubMed, EMBASE, Web of Science and Scopus databases were searched from their inception through August 31, 2020. Observational studies assessing the association between maternal pre-pregnancy BMI and risk of depression and/anxiety during pregnancy and the postpartum period were included. We used random-and quality-effects meta-analyses to estimate risks. Subgroup, sensitivity and meta-regression analyses were performed.

RESULTS

Pre-pregnancy obesity was associated with a 33% increased risk of antenatal depressive symptoms (pooled OR = 1.33 [95% CI; 1.20-1.48]). The pooled ORs for the association between underweight, overweight and obesity and postnatal depressive symptoms were 1.71 [95% CI; 1.27 - 2.31], 1.14 [95% CI; 1.0 - 1.30] and 1.39 [95% CI; 1.23 - 1.57], respectively. Low to moderate level of between-study heterogeneity was noted. The association between pre-pregnancy BMI and perinatal anxiety symptoms remain uncertain.

CONCLUSIONS

Pre-pregnancy obesity was associated with an increased risk of maternal depressive symptoms both in pregnancy and the postpartum period. The findings suggest that women with both high and low pre-pregnancy weight may benefit from receiving mental health screening and interventions during prenatal care.

"Talk to me, not at me": obese women's experiences of birth and their encounter with birth attendants-a qualitative study

Purpose: To explore the birth experiences of obese women in regard to their encounter with birth attendants.

Methods: Qualitative, in-depth interviews with 10 women were conducted in February 2020. Data were analysed using a descriptive phenomenological method.

Results: Four interrelated constituents were identified: The preconception and prejudice of being unhealthy and less able; Being unique among all the other unique women; “Talk to me, not at me”—the importance of information and communication, and; Feeling secure enough to be in the 'birthing bubble'.

Conclusion: For the women in our study, being obese meant experiencing challenges as well as opportunities during childbirth and in their encounter with birth attendants. Experiences of preconceptions, alienation, a focus on risk and a loss of autonomy in encounters with birth attendants were found to negatively impact the birthing process. The women desired affirmative and inclusive encounters; these kinds of encounters may improve the birth experiences of obese women.

Summarizing recommendations to eliminate weight stigma in prenatal health care settings: A scoping review

OBJECTIVE

As the prevalence of obesity increases, more women are at risk of potentially experiencing weight stigma in prenatal health care settings. The objective of this scoping review was to summarize the primary literature assessing potential causes of weight stigma in prenatal health care settings and synthesize recommendations for health care providers to improve clinical practice.

METHODS

A search strategy was developed combining the terms pregnancy, weight stigma, obesity, and prenatal care. A systematic search was completed in the following databases: Medline, EMBASE, PsycInfo, CINAHL, Opengrey, and Proquest.

RESULTS

Eighteen resources were included in this review, of which 17 were qualitative, and one was a mixed-methods study design. Weight stigma occurred in prenatal health care settings when providers: avoided weight-related discussions, assumed lifestyle behaviors, and had poor communication when discussing risks associated with obesity. Recommendations to prevent weight stigma included: offering sensitivity training to discuss obesity during pregnancy, implementing a patient-centred approach, including evaluating individual health behaviors, and providing educational resources to patients explaining potential risks and referrals.

CONCLUSION

This review summarizes recommendations to eliminate weight stigma in prenatal health care settings.

PRACTICE IMPLICATIONS

These recommendations can be implemented in clinical practice and can improve the delivery of prenatal care.

Dietary behaviours and weight management: A thematic analysis of pregnant women's perceptions

Maternal obesity is associated with increased risk of gestational diabetes and other complications. Although antenatal interventions to help prevent these complications are ongoing, an understanding of overweight and obese pregnant women's opinions and attitudes is lacking. Therefore, this study aims to explore these women's experiences and perceptions of dietary behaviours and weight management during pregnancy. Secondary analysis of qualitative data originally collected to examine lifestyle behaviours in pregnant women was conducted. The data were from a purposive sample of overweight and obese pregnant women attending a public antenatal clinic in Cork, Ireland. The data were explored using thematic analysis. Interviews with 30 overweight and obese pregnant women were analysed. Three themes were developed relating to overweight and obese women's dietary behaviours and weight management perceptions including 'pregnancy's influence on dietary behaviours', 'external influences on dietary behaviours' and 'perception of and preferences for weight related advice and resources'. Together these themes reveal women's experiences of diet and how pregnancy factors (physiological changes) and external factors (family and friends) can influence dietary behaviours. Furthermore, perceptions of weight management advice and lack thereof were highlighted with women drawing attention to potential resources for future use during pregnancy. This study provides important insights into overweight and obese pregnant women's dietary behaviours and perceptions of weight management. According to these findings, there is a need for clear and unambiguous information about weight management, acceptable weight gain, food safety and how to achieve a balanced diet.

Pregnant and postpartum women's experiences of weight stigma in healthcare

BACKGROUND

Weight stigma is a societal phenomenon that is very prevalent in healthcare, precipitating poor patient-provider relationships, discontinuity of care, and delayed cancer screening. Little research, though, has investigated weight stigma in prenatal and postpartum healthcare. To address this gap, this study examined the prevalence and frequency of weight-stigmatizing experiences in prenatal and postpartum healthcare.

METHODS

501 pregnant and postpartum women responded to an online survey where they reported whether they had experienced weight stigma in prenatal or postpartum healthcare and, if so, how frequently. Participants also responded to questions about how providers had treated them regarding their weight and their reactions to these experiences. A subset of participants (n = 80) also provided examples of their experiences, and these were subjected to a thematic analysis and coded for overarching themes.

RESULTS

Nearly 1 in 5 women (n = 92) reported experiencing weight stigma in healthcare settings. Percentages differed by BMI, with 28.4% of participants with pre-pregnancy obesity endorsing healthcare providers as a source of weight stigma. Experiences occurred between "less than once a month" and "a few times a month." Obstetricians were the most commonly-reported source (33.8%), followed by nurses (11.3%). Participants reported feeling judged, shamed, and guilty because of their weight during healthcare visits. Additionally, 37 participants (7.7%) reported having changed providers because of treatment regarding their weight. Many also reported that they expected to feel or had felt uncomfortable seeking help with breastfeeding from a healthcare professional. Finally, thematic analysis of the open-ended examples identified four key themes: (1) negative attitudes and unkind or disrespectful treatment from providers; (2) evaluative comments about their weight; (3) healthcare providers focusing on their high-risk status and potential negative consequences (often when birth outcomes were ultimately healthy); and (4) inappropriate or demeaning comments.

CONCLUSIONS

Weight stigma may be a common experience in pregnancy and postpartum healthcare. Providers need additional training to avoid stigmatizing their patients and inadvertently undermining patient-provider relationships, quality of care, and health outcomes.

Supportive strategies for men who perform a care role: an occupational perspective

Background/aims

Health and social care practitioners often work alongside caregivers. This study aimed to consider commonality in the experience of male caregiving using secondary analysis of research related to fathers of an adult child with intellectual disability and to older widowers.

Methods

Secondary analysis of findings arising from two qualitative studies of men who have experience of a caregiving role (fathers of an adult child with intellectual disability and older widowers) was applied using a triangulation approach to illuminate, develop and enrich inter-study findings.

Results

Overarching themes across the two studies included ‘aspects of a care role’ and ‘supportive mechanisms’. The findings demonstrate that men from these specific groups are actively involved in care and that there are varied aspects to a care role. Factors that support men include the provision of appropriate and timely information, time spent pursuing leisure activities and support from family, friends and individualised services.

Conclusions

There are multiple aspects involved in a care role and the provision of care has positive and negative impacts on men. If service providers are aware of support strategies that are useful to male carers, this may support the health and wellbeing of both the carer and the person they support.

Obesity in Pregnancy - Patient-Reported Outcomes in Qualitative Research: A Systematic Review

The purpose of this study was to determine the clinical and non-clinical outcomes that pregnant women with obesity value as pertaining to their health and that of their babies. In this systematic review of the qualitative literature, a search of four databases was conducted for studies using qualitative methods in pregnant women with obesity. From the included studies, the review synthesized relevant themes representing the voiced concerns and perceived benefits of and barriers to the uptake of interventions, to yield patient-reported outcomes (PROs). PROs were categorized into domains according to the published taxonomy of outcomes in medical research. Of the 89 identified studies, 27 were included, none of which were primarily intended to elicit PROs. A total of 256 PROs and 7 distinct themes were identified. Only 13% of PROs represented physiological or clinical outcomes, whereas 21% represented the core area of emotional functioning or well-being, and 15% represented the area of delivery of care. The most frequently voiced concern was inadequate health care provider support (60%), and women considered intervention-specific challenges to be the greatest barriers to the uptake of interventions (34%). This study synthesized the qualitative evidence of concerns that pregnant women with obesity have regarding their pregnancy and postpartum care, as well as specific barriers they perceive to the uptake of interventions. In addition, this study revealed that clinical outcomes, which are most often reported in clinical trials, comprise only a minority of outcomes considered important by these women. A core outcome set that adequately incorporates PROs is required to inform the conduct of future trials in pregnant women with obesity.

Perceptions of risk and influences of choice in pregnant women with obesity. An evidence synthesis of qualitative research

Background

Between 7–35% of the maternity population are obese in high income countries and 1–40% in lower or middle-income countries. Women with obesity are traditionally limited by the choices available to them during pregnancy and birth because of the higher risk of complications. This evidence synthesis set out to summarise how women with obesity’s perceptions of pregnancy and birth risk influence the care choices that they make.

Methods

A search of medical and health databases for qualitative studies written in the English language, published Jan 1993—April 2019 and reporting on pregnant women with obesity’s perception of risk and influence of pregnancy and birth choices. Data was extracted by two reviewers onto a questions framework and then analysed using a thematic synthesis technique. Confidence in the qualitative findings was assessed using GRADE-CERQual.

Results

23 full texts were included. The common themes on perception of risk were: ‘Self-blame arising from others’ stereotyped beliefs ‘, ‘Normalisation’, ‘Lack of preparation’, ‘Fearful acceptance and inevitability’ and ‘Baby prioritised over mother’. For influence of choices, the themes were: ‘External influences from personal stresses’, ‘Restrictive guidelines’, ‘Relationship with healthcare professional’ and ‘Perception of Risk’.

Conclusions

Evidence on what influences women with obesity’s pregnancy choices is limited. Further research is needed on the best methods to discuss the risks of pregnancy and birth for women with obesity in a sensitive and acceptable manner and to identify the key influences when women with obesity make choices antenatally and for birth planning.

Co-designing preconception and pregnancy care for healthy maternal lifestyles and obesity prevention

PROBLEM

A recognised gap exists between current and recommended practices in the provision of lifestyle advice and weight management support for women across preconception and pregnancy care.

BACKGROUND

Preconception and pregnancy are critical stages for promoting healthy maternal lifestyles and obesity prevention. Co-design is a novel approach with the potential to strengthen existing models of care to facilitate the implementation of clinical practice guidelines promoting preconception and pregnancy health, especially in relation to preconception weight management and preventing excessive gestational weight gain.

AIM AND METHODS

The aims of this discussion paper are to (i) define co-design in the context of preconception and pregnancy care, (ii) outline key considerations when planning co-design initiatives and (iii) describe co-design opportunities in preconception and pregnancy care for promoting women's health and obesity prevention.

DISCUSSION

While several definitions of co-design exist, one critical element is the meaningful involvement of all key stakeholders. In this discussion, we specifically identified the involvement of women and expanding the role of practice nurses in primary care may assist to overcome barriers to the provision of healthy lifestyle advice and support for women during preconception. Co-designing pregnancy care will involve input from women, nurses, midwives, obstetricians, allied health and administration and management staff. Additional attention is required to co-design care for women considered most at-risk.

CONCLUSION

There is potential to enhance current provision of preconception and pregnancy care using co-design. Nursing and midwifery professions are active across both preconception and pregnancy and therefore, they have an important role to play.