doi: 10.1111/hex.12339
Seeing it through their eyes: a qualitative study of the pregnancy experiences of women with a body mass index of 30 or more Tina Lavender PhD MSc RM* and Debbie M. Smith PhD CPsychol MSc BSc (Hons)† *Professor of Midwifery, The School of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre’, The University of Manchester, Manchester and †Lecturer in Health Psychology, The School of Psychological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
Abstract Correspondence Tina Lavender PhD, MSc, RM The School of Nursing, Midwifery and Social Work Manchester Academic Health Science Centre’ The University of Manchester Jean MacFarlane Building Oxford Road Manchester M13 9PL UK E-mail: [email protected]. uk Accepted for publication 18 December 2014 Keywords: maternal obesity, qualitative research, maternal health
Background Maternal obesity [body mass index (BMI) ≥ 30 kg/m2] is associated with numerous complications, but currently, little is known about the pregnancy experiences of these women. Objective To gain insight into the experience of pregnant women with BMI ≥ 30 kg/m2, when accessing maternity services and attending a community lifestyle programme. Design Qualitative methodology, utilizing focus groups and semistructured interviews with post-natal women who had an antenatal BMI ≥ 30 kg/m2. The sample was obtained from a larger study. Results Thirty-four women participated. Three main themes were identified using thematic analysis. Women described disappointment with their pregnancy. In particular, their informational expectations were not met; some health professionals appeared uninterested, insensitive or unconfident. Women described readiness to make a lifestyle change, but this was not encouraged during routine care. Attending the programme began the process of behavioural change. Women’s beliefs that small changes make a big difference led to them being spurred on by success; driven by a desire to improve the health of their family. Discussion and Conclusion Pregnant women who are obese know this is the case and expect to be provided with information to assist them in making lifestyle changes. Health professionals should be aware of women’s readiness for change and view pregnancy as an ideal time to communicate. Pregnant women with a BMI ≥ 30 kg/m2 should contribute to health professional training, to highlight the reality of the maternity system journey; first-hand accounts may improve the way health professionals’ approach these women. Lifestyle interventions should be developed with input from the intended target group.
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ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
Qualitative study of the pregnancy experiences of women, T Lavender and D M Smith
Introduction Rates of maternal obesity (body mass index [BMI] ≥ 30 kg/m2) in England have increased over the last 19 years from 5.6 to 15.6% of women booking their pregnancy.1 The Centre for Maternal And Child Enquiries (CMACE) report outlines the adverse maternal effects associated with maternal obesity.2 Guidance has been devised by the National Institute for Health and Clinical Excellence (NICE) for weight management before, during and after pregnancy. Guidance to address this emerging public health issue highlights the importance of health professionals discussing healthy lifestyle behaviours with women at an early stage in pregnancy.3 However, to date, there is no global agreement on guidance regarding weight management before, during and after pregnancy,4 and no suitable interventions have been proposed, due to a dearth of robust evidence regarding weight management before, during and after pregnancy.5–7 Studies are starting to be published evaluating antenatal interventions for obese women with mixed findings.8–10 However, prior to implementing any such interventions, it is important to understand the views of the key stakeholders, that is pregnant women with a BMI ≥ 30 kg/m2. A meta-synthesis exploring the maternity experiences of women with a BMI ≥ 30 kg/m2 included six papers deemed to be of medium– high quality.11 Women were concluded to be more accepting of their weight during pregnancy and were aware of the benefits of a healthy lifestyle, supporting claims that women are more motivated in pregnancy as it is a time of transition.12 However, although their intentions to manage their weight were conceived in the antenatal period, any action would be deferred until the post-natal period. The meta-synthesis suggested that women received depersonalized, medicalized care, by health professionals who often failed to meet their needs. Women have been found to feel confused about the meaning of gestational weight management13 and low knowledge about maternal obesity,14 highlighting the need for suitable
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
interventions. Obesity prevalence rates are associated with lower social classes and with certain minority ethnic groups,15 and it has been argued that we need to be more aware of the social inequalities in obesity.16 As outlined in several recent English Government documents, the involvement of consumers in directing services is essential to ensure adequate care is provided.17 As discussed by others, gaining understanding of the lived experience of those who are obese is integral to ensuring that interventions are successful.18 As part of a programme of work examining the feasibility of a community-based antenatal lifestyle programme for pregnant women with a booking BMI ≥ 30 kg/m2, we explored the views of participating women to gain insight into their pregnancy experience. The overall feasibility study included 227 women who had a BMI ≥ 30 kg/m2 and were 30 kg/m2; a meta-synthesis. British Journal of Obstetrics and Gynaecology, 2011; 118: 779–89. Phelan S. Pregnancy: a “teachable moment” for weight control and obesity prevention. American Journal of Obstetrics & Gynecology, 2010; 202: 135.e1-8. Arden MA, Duxbury AMS, Soltani H. Responses to gestational weight management guidance: a thematic analysis of comments made by women in online parenting forums. BMC Pregnancy and Childbirth, 2014; 14: 216. Shub A, Huning EYS, Campbell KJ, McCarthy EA. Pregnant women’s knowledge of weight, weight gain, complications of obesity and weight management strategies in pregnancy. BMC Research Notes, 2013; 6: 278. Heslehurst N, Sattar N, Rajasinam D, Wilkinson J, Summerbell CD, Rankin J. Existing maternal obesity guidelines may increase inequalities between ethnic groups: a national epidemiological study of 502,474 births in England. BMC Pregnancy and Childbirth, 2013; 12: 156. Sutherland G, Brown S, Yelland J. Applying a social disparities lens to obesity in pregnancy to inform efforts to intervene. Midwifery, 2013; 29: 338–343. NHS England. The NHS Belongs to the People: A Call for Action. Available at: http:// www.england.nhs.uk/wp-content/uploads/2013/07/ nhs_belongs.pdf, accessed 16 August 2013 Heslehurst N, Russell S, Brandon H, Johnston C, Summerbell C, Rankin J. Women’s perspectives are required to inform the development of maternal obesity services: a qualitative study of obese pregnant women’s experiences. Health Expectations, 2013. Epub ahead of print: doi: 10.111/hex.12070. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977. Michie S, Richardson M, Johnston M et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 2013; 46: 81–95. Smith D, Whitworth M, Sibley C, Taylor W, Gething J, Lavender T. The feasibility phase of a community antenatal lifestyle programme (The Lifestyle Course [TLC]) for women with a BMI of 30 kg/m2 or more. Midwifery, 2014. DOI: http:// dx.doi.org/10.1016/j.midw.2014.10.002 Angen MJ. Evaluating interpretive inquiry: reviewing the validity debate and opening the
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
Qualitative study of the pregnancy experiences of women, T Lavender and D M Smith
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dialogue. Qualitative Health Research, 2000; 10: 378–395. Health Profiles. Available at: http://www.apho.org.uk/ default.aspx?QN=P_HEALTH_PROFILES [Accessed 20th October 2014] Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research, 3rd edn. Thousand Oaks, CA: Sage, 2000. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology, 2006; 3: 77–101. Clarke PE, Gross H. Women’s behaviour, beliefs and information sources about physical exercise in pregnancy. Midwifery, 2004; 20: 133–141. Leiferman J, Sinatra E, Huberty J. Pregnant women’s perceptions of patient-provider communication for health behaviour change during pregnancy. Open Journal of Obstetrics and Gynecology, 2014; 4: 672–684. Johnson M, Campbell F, Messina J, Preston L, Buckley Woods H, Goyder E. Weight management during pregnancy: a systematic review of qualitative evidence. Midwifery, 2014; 29: 1287–1296. Wiles R. The views of women of above average weight gain about appropriate weight gain in pregnancy. Midwifery, 1998; 14: 254–260. Lagan BM, Sinclair M, Kernohan WG. Internet use in pregnancy informs women’s decision making: a web-based survey. Birth, 2010; 37: 106–115. Smith DM, Cooke A, Lavender T. Obesity is the new challenge; a qualitative study of health professionals’ views towards an antenatal lifestyle intervention for pregnant women with a Body Mass Index (BMI) ≥30 kg/m2. BMC Pregnancy and Childbirth, 2012; 12: 157. Heslehurst N, Russell S, McCormack S, Sedgewick G, Bell R, Rankin J. Midwives perspectives of their training and education requirements in maternal obesity: a qualitative study. Midwifery, 2013; 29: 736–744. Ley P. Satisfaction, compliance and communication. British Journal of Clinical Psychology, 1982; 21: 241–54. Heselhurst N, Lang R, Rankin J, Wilkinson J, Summerbell C. Obesity in pregnancy: a study of the impact of maternal obesity on NHS maternity services. British Journal of Obstetrics and Gynaecology, 2007; 114: 334–342. Lees D, Haynes C, Garrod D. Exploring Health Promotion Practice within Maternity Services. Stockport NHS Foundation Trust, 2010. Available at: http://www.gmpublichealthpracticeunit.nhs.uk/
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
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wp-content/uploads/2010/04/Health-Promotionin-Maternity-Final-Report-July-2010.pdf, accessed 14 February 2011. Basu A, Kennedy L, Tocque K, Jones S. Eating for 1, Healthy and Active for 2; feasibility of delivering novel, compact training for midwives to build knowledge and confidence in giving nutrition, physical activity and weight management advice during pregnancy. BMC Pregnancy and Childbirth, 2014; 14: 218. Department of Health. World Class Commissioning: Vision, 2007. Available at: www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_080952.pdf, accessed 1 October 2010. Lacoursiere DY, Baksh L, Bloebaum L, Varner MW. Maternal body mass index and self-reported postpartum depressive symptoms. Maternal & Child Health Journal, 2006; 10: 385–90. Giroux I, Lander S, Charlesworth S, Mottola MF. Weight history of overweight pregnant women. Canadian Journal of Dietetic Practice & Research, 2009; 70: 127–34. Olander E, Fletcher H, Williams S, Atkinson L, Turner A, French DP. What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis. International Journal of Behavioural Nutrition and Physical Activity, 2013; 10: 29. Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity, 2014; 22: 2485–2488. Berkman LF, Sye SL. Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. American Journal of Epidemiology, 1979; 109: 186–204. Lambert L, Raidi M, Safaii S, Conner C, Geary EJ, Ault S. Perceived benefits and barriers related to postpartum weight loss of overweight/obese postpartum WIV participants. Topics in Clinical Nutrition, 2005; 20: 16–27. Weir Z, Bush J, Robson SC, McParlin C, Rankin J, Bell R. Physical activity in pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women. BMC Pregnancy and Childbirth, 2010; 10: 18. Morgan KL, Rahman MA, Macey S et al. Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS. BMJ Open, 2014; 4: e003983.
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Seeing it through their eyes: a qualitative study of the pregnancy experiences of women with a body mass index of 30 or more Tina Lavender PhD MSc RM* and Debbie M. Smith PhD CPsychol MSc BSc (Hons)† *Professor of Midwifery, The School of Nursing, Midwifery and Social Work, Manchester Academic Health Science Centre’, The University of Manchester, Manchester and †Lecturer in Health Psychology, The School of Psychological Sciences, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK
Abstract Correspondence Tina Lavender PhD, MSc, RM The School of Nursing, Midwifery and Social Work Manchester Academic Health Science Centre’ The University of Manchester Jean MacFarlane Building Oxford Road Manchester M13 9PL UK E-mail: [email protected]. uk Accepted for publication 18 December 2014 Keywords: maternal obesity, qualitative research, maternal health
Background Maternal obesity [body mass index (BMI) ≥ 30 kg/m2] is associated with numerous complications, but currently, little is known about the pregnancy experiences of these women. Objective To gain insight into the experience of pregnant women with BMI ≥ 30 kg/m2, when accessing maternity services and attending a community lifestyle programme. Design Qualitative methodology, utilizing focus groups and semistructured interviews with post-natal women who had an antenatal BMI ≥ 30 kg/m2. The sample was obtained from a larger study. Results Thirty-four women participated. Three main themes were identified using thematic analysis. Women described disappointment with their pregnancy. In particular, their informational expectations were not met; some health professionals appeared uninterested, insensitive or unconfident. Women described readiness to make a lifestyle change, but this was not encouraged during routine care. Attending the programme began the process of behavioural change. Women’s beliefs that small changes make a big difference led to them being spurred on by success; driven by a desire to improve the health of their family. Discussion and Conclusion Pregnant women who are obese know this is the case and expect to be provided with information to assist them in making lifestyle changes. Health professionals should be aware of women’s readiness for change and view pregnancy as an ideal time to communicate. Pregnant women with a BMI ≥ 30 kg/m2 should contribute to health professional training, to highlight the reality of the maternity system journey; first-hand accounts may improve the way health professionals’ approach these women. Lifestyle interventions should be developed with input from the intended target group.
222
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
Qualitative study of the pregnancy experiences of women, T Lavender and D M Smith
Introduction Rates of maternal obesity (body mass index [BMI] ≥ 30 kg/m2) in England have increased over the last 19 years from 5.6 to 15.6% of women booking their pregnancy.1 The Centre for Maternal And Child Enquiries (CMACE) report outlines the adverse maternal effects associated with maternal obesity.2 Guidance has been devised by the National Institute for Health and Clinical Excellence (NICE) for weight management before, during and after pregnancy. Guidance to address this emerging public health issue highlights the importance of health professionals discussing healthy lifestyle behaviours with women at an early stage in pregnancy.3 However, to date, there is no global agreement on guidance regarding weight management before, during and after pregnancy,4 and no suitable interventions have been proposed, due to a dearth of robust evidence regarding weight management before, during and after pregnancy.5–7 Studies are starting to be published evaluating antenatal interventions for obese women with mixed findings.8–10 However, prior to implementing any such interventions, it is important to understand the views of the key stakeholders, that is pregnant women with a BMI ≥ 30 kg/m2. A meta-synthesis exploring the maternity experiences of women with a BMI ≥ 30 kg/m2 included six papers deemed to be of medium– high quality.11 Women were concluded to be more accepting of their weight during pregnancy and were aware of the benefits of a healthy lifestyle, supporting claims that women are more motivated in pregnancy as it is a time of transition.12 However, although their intentions to manage their weight were conceived in the antenatal period, any action would be deferred until the post-natal period. The meta-synthesis suggested that women received depersonalized, medicalized care, by health professionals who often failed to meet their needs. Women have been found to feel confused about the meaning of gestational weight management13 and low knowledge about maternal obesity,14 highlighting the need for suitable
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
interventions. Obesity prevalence rates are associated with lower social classes and with certain minority ethnic groups,15 and it has been argued that we need to be more aware of the social inequalities in obesity.16 As outlined in several recent English Government documents, the involvement of consumers in directing services is essential to ensure adequate care is provided.17 As discussed by others, gaining understanding of the lived experience of those who are obese is integral to ensuring that interventions are successful.18 As part of a programme of work examining the feasibility of a community-based antenatal lifestyle programme for pregnant women with a booking BMI ≥ 30 kg/m2, we explored the views of participating women to gain insight into their pregnancy experience. The overall feasibility study included 227 women who had a BMI ≥ 30 kg/m2 and were 30 kg/m2; a meta-synthesis. British Journal of Obstetrics and Gynaecology, 2011; 118: 779–89. Phelan S. Pregnancy: a “teachable moment” for weight control and obesity prevention. American Journal of Obstetrics & Gynecology, 2010; 202: 135.e1-8. Arden MA, Duxbury AMS, Soltani H. Responses to gestational weight management guidance: a thematic analysis of comments made by women in online parenting forums. BMC Pregnancy and Childbirth, 2014; 14: 216. Shub A, Huning EYS, Campbell KJ, McCarthy EA. Pregnant women’s knowledge of weight, weight gain, complications of obesity and weight management strategies in pregnancy. BMC Research Notes, 2013; 6: 278. Heslehurst N, Sattar N, Rajasinam D, Wilkinson J, Summerbell CD, Rankin J. Existing maternal obesity guidelines may increase inequalities between ethnic groups: a national epidemiological study of 502,474 births in England. BMC Pregnancy and Childbirth, 2013; 12: 156. Sutherland G, Brown S, Yelland J. Applying a social disparities lens to obesity in pregnancy to inform efforts to intervene. Midwifery, 2013; 29: 338–343. NHS England. The NHS Belongs to the People: A Call for Action. Available at: http:// www.england.nhs.uk/wp-content/uploads/2013/07/ nhs_belongs.pdf, accessed 16 August 2013 Heslehurst N, Russell S, Brandon H, Johnston C, Summerbell C, Rankin J. Women’s perspectives are required to inform the development of maternal obesity services: a qualitative study of obese pregnant women’s experiences. Health Expectations, 2013. Epub ahead of print: doi: 10.111/hex.12070. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall, 1977. Michie S, Richardson M, Johnston M et al. The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Annals of Behavioral Medicine, 2013; 46: 81–95. Smith D, Whitworth M, Sibley C, Taylor W, Gething J, Lavender T. The feasibility phase of a community antenatal lifestyle programme (The Lifestyle Course [TLC]) for women with a BMI of 30 kg/m2 or more. Midwifery, 2014. DOI: http:// dx.doi.org/10.1016/j.midw.2014.10.002 Angen MJ. Evaluating interpretive inquiry: reviewing the validity debate and opening the
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
Qualitative study of the pregnancy experiences of women, T Lavender and D M Smith
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dialogue. Qualitative Health Research, 2000; 10: 378–395. Health Profiles. Available at: http://www.apho.org.uk/ default.aspx?QN=P_HEALTH_PROFILES [Accessed 20th October 2014] Krueger RA, Casey MA. Focus Groups: A Practical Guide for Applied Research, 3rd edn. Thousand Oaks, CA: Sage, 2000. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology, 2006; 3: 77–101. Clarke PE, Gross H. Women’s behaviour, beliefs and information sources about physical exercise in pregnancy. Midwifery, 2004; 20: 133–141. Leiferman J, Sinatra E, Huberty J. Pregnant women’s perceptions of patient-provider communication for health behaviour change during pregnancy. Open Journal of Obstetrics and Gynecology, 2014; 4: 672–684. Johnson M, Campbell F, Messina J, Preston L, Buckley Woods H, Goyder E. Weight management during pregnancy: a systematic review of qualitative evidence. Midwifery, 2014; 29: 1287–1296. Wiles R. The views of women of above average weight gain about appropriate weight gain in pregnancy. Midwifery, 1998; 14: 254–260. Lagan BM, Sinclair M, Kernohan WG. Internet use in pregnancy informs women’s decision making: a web-based survey. Birth, 2010; 37: 106–115. Smith DM, Cooke A, Lavender T. Obesity is the new challenge; a qualitative study of health professionals’ views towards an antenatal lifestyle intervention for pregnant women with a Body Mass Index (BMI) ≥30 kg/m2. BMC Pregnancy and Childbirth, 2012; 12: 157. Heslehurst N, Russell S, McCormack S, Sedgewick G, Bell R, Rankin J. Midwives perspectives of their training and education requirements in maternal obesity: a qualitative study. Midwifery, 2013; 29: 736–744. Ley P. Satisfaction, compliance and communication. British Journal of Clinical Psychology, 1982; 21: 241–54. Heselhurst N, Lang R, Rankin J, Wilkinson J, Summerbell C. Obesity in pregnancy: a study of the impact of maternal obesity on NHS maternity services. British Journal of Obstetrics and Gynaecology, 2007; 114: 334–342. Lees D, Haynes C, Garrod D. Exploring Health Promotion Practice within Maternity Services. Stockport NHS Foundation Trust, 2010. Available at: http://www.gmpublichealthpracticeunit.nhs.uk/
ª 2015 John Wiley & Sons Ltd Health Expectations, 19, pp.222–233
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wp-content/uploads/2010/04/Health-Promotionin-Maternity-Final-Report-July-2010.pdf, accessed 14 February 2011. Basu A, Kennedy L, Tocque K, Jones S. Eating for 1, Healthy and Active for 2; feasibility of delivering novel, compact training for midwives to build knowledge and confidence in giving nutrition, physical activity and weight management advice during pregnancy. BMC Pregnancy and Childbirth, 2014; 14: 218. Department of Health. World Class Commissioning: Vision, 2007. Available at: www.dh.gov.uk/ prod_consum_dh/groups/dh_digitalassets/ documents/digitalasset/dh_080952.pdf, accessed 1 October 2010. Lacoursiere DY, Baksh L, Bloebaum L, Varner MW. Maternal body mass index and self-reported postpartum depressive symptoms. Maternal & Child Health Journal, 2006; 10: 385–90. Giroux I, Lander S, Charlesworth S, Mottola MF. Weight history of overweight pregnant women. Canadian Journal of Dietetic Practice & Research, 2009; 70: 127–34. Olander E, Fletcher H, Williams S, Atkinson L, Turner A, French DP. What are the most effective techniques in changing obese individuals’ physical activity self-efficacy and behaviour: a systematic review and meta-analysis. International Journal of Behavioural Nutrition and Physical Activity, 2013; 10: 29. Jackson SE, Beeken RJ, Wardle J. Perceived weight discrimination and changes in weight, waist circumference, and weight status. Obesity, 2014; 22: 2485–2488. Berkman LF, Sye SL. Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. American Journal of Epidemiology, 1979; 109: 186–204. Lambert L, Raidi M, Safaii S, Conner C, Geary EJ, Ault S. Perceived benefits and barriers related to postpartum weight loss of overweight/obese postpartum WIV participants. Topics in Clinical Nutrition, 2005; 20: 16–27. Weir Z, Bush J, Robson SC, McParlin C, Rankin J, Bell R. Physical activity in pregnancy: a qualitative study of the beliefs of overweight and obese pregnant women. BMC Pregnancy and Childbirth, 2010; 10: 18. Morgan KL, Rahman MA, Macey S et al. Obesity in pregnancy: a retrospective prevalence-based study on health service utilisation and costs on the NHS. BMJ Open, 2014; 4: e003983.
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