This study explored the views of women and midwives about services and support for obese pregnant women in Doncaster, UK, a relatively deprived area with high levels of obesity in pregnancy. Results raised a number of issues, including a range of explanations for obesity and aspects relating to effectiveness of care for obese pregnant women.
Women reported a lack of confidence about what foods they should eat, how much and what types of exercise are safe, and how much weight gain is acceptable. The women felt they did not always receive clear guidance and that social messages, especially about eating, placed conflicting pressures upon them. These findings are mirrored in the UK and elsewhere. For example, Curzik et al.  comment that, although women are socialised to 'eat for two' there is a strong social pressure, reinforced by media images, to remain thin during pregnancy. A US survey  found that perceptions of acceptable weight gain in pregnancy vary greatly, with thinner women typically underestimating, and heavier women overestimating, recommended levels. Many women received no or inappropriate advice about weight gain, and half of overweight women were advised to gain more than recommended, despite established US guidelines . Oteng-Ntim et al.'s UK service providers , like the women here, considered verbal advice offered to women on these topics was often inconsistent and unsupported by written information, a finding repeated elsewhere . This is perhaps unsurprising, given the lack of UK guidance regarding appropriate weight gain in pregnancy . There is also a widely held belief that breastfeeding protects against weight retention after pregnancy [39, 41], which is not consistently supported by research evidence [42–44], possibly through early discontinuation of or overeating during breastfeeding . This common misconception formed part of these women's self-talk which acted to limit their self-control of eating and activity during pregnancy. This suggests midwives need to provide clear advice to women early in pregnancy, backed up by written information and regular reinforcement, about healthy lifestyle in pregnancy, and that breastfeeding is unlikely to contribute to weight loss after pregnancy unless the woman is also active and eating healthily. The potential for UK midwives to offer specific advice about weight gain is currently limited by the absence of clear national guidelines .
Another finding from this study was that women's and midwives' perceptions about the psychosocial consequences of obesity differed. The women here were very aware of and often embarrassed by their weight. This contrasts with Olander et al.'s participants, who expressed little concern about weight gain ; however those women were not recruited on the basis of weight, hence obesity may not have been the pressing issue it was for the women in the present study. Smith et al.  note that body image is a concern for women both during and after pregnancy, especially postpartum with the social expectation that pregnancy weight will be lost, and women feel vulnerable to negative judgements . Midwives believed that stigma surrounding obesity had reduced and, with it, the pressure to strive for a healthy weight. Alongside this, however, midwives' difficulties raising the issue of obesity with their clients, and awkwardness and anxiety around use of obesity-related language demonstrated that the stigma was still very much alive. Service providers elsewhere  raised very similar issues. Whereas these midwives erred on the side of caution, some women had clearly encountered practitioners whose critical and offensive approach had caused considerable distress. Findings here indicate that practitioners involved in pregnancy care may find it difficult to find ways to talk openly and honestly about obesity without causing offence to their clients. Concerns about the sensitivity of this issue are raised in other studies . This suggests more could be done to raise awareness among student and practising midwives of the importance of obesity among women as both a physical and a psychological health issue, and to enhance their communication skills and confidence in discussing it effectively with service users. Those women who had attended the 'Monday clinic' appreciated and benefited from the clear, non-judgemental approach: specialist midwives could perhaps do more to disseminate their experience and expertise to their colleagues, and support them in this challenging aspect of their care. This small explorative study suggests that supportive, multidisciplinary innovations like Doncaster's 'Monday clinic' could be a valuable addition to maternity services elsewhere.
Factors considered by these women and midwives to influence eating and activity levels in pregnancy included motivation, and social support. A survey of 1535 pregnant US women found that barriers to exercise were most commonly intrapersonal, particularly motivation, procrastination, and a lack of time . To date, intervention studies focusing upon dietary advice and exercise activities have shown inconsistent or limited effectiveness, especially with overweight women (e.g. [23, 50]), which suggests that advice and provision of activities alone are not sufficient to address the problem in the long term. Oteng-Ntim et al.  identified client motivation and readiness to change as barriers to the effectiveness of service providers' efforts to promote healthy lifestyles for pregnant women. Motivation to act was a strong theme in the explanatory models of both midwives and women in these focus groups, which suggest more should be done to motivate obese pregnant women to make healthy lifestyle changes. This would clearly require additional investment in order to train and resource maternity service teams with the time and skills to deliver these services.
Women in this study felt at times isolated and expressed the need for more support from peers and professionals. Among interpersonal barriers identified by Evenson et al., lack of social support (informational, emotional and tangible) was most important . Social support is considered one of the key influences upon and motivators for physical activity and healthy lifestyle changes, especially for women [51, 52]. This indicates the importance of taking a holistic approach to midwifery care, considering the woman's social support network and influences and including family members in consultations where appropriate and consented. Given the importance, raised here and in other studies, of social support in motivating and supporting obese pregnant women in healthy lifestyle choices, interventions should consider how to harness this factor. Women here enjoyed meeting other pregnant women through existing services such as Aquanatal, but identified other possibilities such as organised walks, regular support days, and dedicated websites and chat rooms. This topic will be raised in another paper; however there is evidence from the general population that mobile technologies can be used very effectively to support healthy behaviour change and weight loss .
This was a small-scale, localised study with a qualitative methodology. Participants' perceptions and experiences may not reflect those of midwives and service users elsewhere, although similar findings have recently been made in another UK study . Generalisability is rarely a priority within qualitative research; however, evidence from previous research suggests these are not isolated findings.
Results are limited by the participation of midwives alone from the health care team. Obstetricians did not respond to efforts to engage them, possibly due to workload and time constraints. It should also be acknowledged that a range of practitioners, including dietitians, are involved in the care of obese pregnant women. Failure to engage medical practitioners in research with a multi-professional focus is not unusual. A recent practice-based interprofessional learning project involving one of the authors had similar problems in some clinical areas [54, 55]. In that case, it seemed that a lack of time and a tendency to prioritise projects with immediate relevance to their medical/surgical practice were the issues. It is not yet clear whether obstetricians we tried to include in this study had similar concerns.
Women interviewed here may not have been representative of other pregnant women in this locality; however midwives' perspectives were based on a more mixed client group and presenting the two alongside one another raises a number of issues for discussion. Women identified shortcomings and excellence in their care experiences and suggested ideas for improved service provision. More research is required to develop and trial these approaches to assess their feasibility, acceptability and effectiveness in practice. Furthermore, if successful in obese women, application of such services for women in other BMI groups (including overweight or normal weight) may also merit investigation. The decision was made to focus this study upon obese (rather than overweight women of BMI 25-30 kg/m2) because of the clear link in the literature between obesity and complications during pregnancy and birth. However it is arguable that issues raised by women and midwives in this study have relevance to women with lower BMIs and that future work should take a more inclusive approach.
Midwives and health professionals may underestimate the considerable social stigma of obesity for the pregnant and postpartum woman. As well as encouraging healthy lifestyle choices, they should be aware of the psychosocial impact of obesity, be prepared to offer psychological support to avoid women feeling isolated, and take a constructive, non-judgemental approach to care. Midwives here reported struggling to talk to women openly about their weight, which suggests educators and experienced practitioners may need to consider how best to prepare and support staff caring for this client group.
Literature suggests more research is required to identify effective interventions for weight management among obese pregnant women. The midwives and women here independently identified that, among others, knowledge, motivation and social support are key factors in both causing and managing obesity in pregnant women. These perceptions are supported by findings elsewhere. This suggests that any intervention aimed at addressing maternal obesity should take account of these factors. Midwives and other health professionals caring for obese pregnant women should ensure messages about eating and exercise in pregnancy are consistent and unclouded by social misconceptions. Information alone may be insufficient to change long-standing behaviours and so interventions will need to address how to instigate and maintain motivation for health behaviour change in obese women. Health professionals and researchers should also consider how to harness natural social interaction opportunities and encourage social support for and between these women to help keep them engaged and motivated with healthy living plans.