Obesity (body mass index (BMI) ≥ 30 kg/m²) is identified as a major public health challenge of the 21st century across the globe [1]. In the UK, 23% of the population are obese and it is predicted that more than half of the adult population will be obese by 2050 [2]. Obesity is also a growing problem for women of childbearing age [3] and about one fifth of pregnant women in the UK are obese [4].

According to the Confidential Enquiry into Maternal and Child Health [5], obesity is associated with over half of the total maternal deaths from direct and indirect causes. Pre-pregnancy obesity and excessive weight gain during pregnancy are associated with adverse outcomes during pregnancy and birth [6–9], and with obesity in the offspring [10]. Excessive weight gain during pregnancy can increase the likelihood of further development of obesity, perpetuating the cycle of risk [11]. Postpartum body composition may be affected by gestation: increased fat retention has been observed in obese compared to normal weight mothers [12]. Maternal obesity also has psychosocial implications due to stigmatisation [13, 14]. Obesity in pregnancy therefore has considerable implications for health service provision [15]: the cost of obese pregnancy care was estimated to be at least five times greater than that of normal weight mothers [6].

Pregnancy, however, can be seen as a naturally occurring opportunity to alter embedded attitudes and habits and adopt new activities [16–18] and, therefore, to address obesity. Lee & Koren [19] recommend pre-conception counselling to educate women planning pregnancy about the risks of maternal obesity and to encourage healthy lifestyles. Effective gestational weight management strategies are of high priority since they can reduce the likelihood of all the above complications and reduce the risk of further development of obesity in mothers and their offspring. Although behavioural and pharmacological interventions for obesity in the general population are well researched, there is relatively little research into efficacy of weight control interventions in pregnancy [20]. Published studies describe a range of supportive, educational and/or behavioural interventions to manage weight and encourage healthy diet and activity; however results are inconclusive (e.g. [21–23] comp. [24, 25]). Systematic reviews [26, 27] conclude that insufficient evidence exists about the efficacy of dietary and physical activity interventions in pregnancy. Oteng-Ntim et al. [28], who explored service providers' views regarding maternal obesity interventions, recommended that both service providers' and service users' perspectives should be sought when developing new services to ensure they are not only theoretically effective but also acceptable to those who will utilise them. Given the conflicting findings thus far, it is important to continue exploring and evaluating approaches to tackling maternal obesity and consider their acceptability to women and feasibility and cost-effectiveness in practice [28].

Two overarching themes were identified in the data: (1) Explanations for obesity and weight management and (2) Best care for overweight women. These themes and subthemes are explained with illustrative quotations from participants.

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. [36] 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 [37] 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 [38]. Oteng-Ntim et al.'s UK service providers [28], 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 [39]. This is perhaps unsurprising, given the lack of UK guidance regarding appropriate weight gain in pregnancy [40]. 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 [45]. 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 [40].

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 [39]; 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. [46] 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 [47]. 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 [28] 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 [48]. 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 [49]. 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. [28] 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 [49]. 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 [53].

The findings suggest that obese women need unambiguous advice regarding healthy lifestyles, diet and exercise in pregnancy to address a lack of knowledge and a tendency towards unhelpful self-talk messages. Midwives expressed difficulties in communicating with their clients about their weight because of the sensitivity of the issue and concerns about causing distress. Given women's need for clear information and support from professionals, more could be done to educate, prepare and support midwives in their work with obese pregnant women. Motivation and social support were strong explanatory themes for obesity and weight management, suggesting that interventions to promote healthy lifestyles in pregnancy should focus on motivational strategies and social support facilitation.

PF (RN, BA Hons, MSc, PGCHCE, PhD) is a registered nurse, senior lecturer and research fellow in the Faculty of Health and Wellbeing. Her research interests include the psychology of health and illness, health promotion, and education (especially interprofessional) of healthcare students.

KM (BA Hons, MA, PhD) is a research assistant in the Communication and Computing Research Centre at Sheffield Hallam University. Her research interests include language and gender, the discursive construction of social issues, and the management of identity in talk about food and the body.

MA (BSc, PhD, C.Psychol) is a Principal Lecturer in Psychology at Sheffield Hallam University. She is a Health Psychologist and Chartered Psychologist with a particular interest in health behaviour change and women's health.

CG (RGN, RM, BMed Sci Hons) has been a practising midwife for fifteen years and a specialist in maternal obesity since 2008. She has jointly initiated an award winning midwifery-led clinic which supports obese pregnant women, and which has been recognised by the National Institute for Clinical Evidence on both their shared learning database and in their commissioning guide for Public Health Guidance 27.

AD (BSc, MSc, PGCE, PhD) is Professor of Interactive Systems Design at Sheffield Hallam University, UK. His research deals with ways of using interactive computer and communications systems to support social and economic development of communities. He is theme lead on User Centred Healthcare Design part of the NIHR funded Collaboration for Leadership in Applied Health Research and Care in South Yorkshire (CLAHRC-SY). He is co-chair of the International Federation for Information Processing's special interest group 13.1 on Interaction Design and International Development.

HS (PhD, MMedSci, BSc, PgDip, RM) is a Reader and the Lead for Service Delivery and Commissioning theme in the Health and Social Care Research Centre in Sheffield Hallam University, UK. She has been contributing to practice, education and research in midwifery for about 20 years. She is a member of Editorial Boards for maternity related journals, Research Standing Committee (RSC) for the International Confederation of Midwives (ICM) and Yorkshire &Humber Research for Patient Benefit Funding Committee.