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.
Overarching theme 1: Explanations for obesity and weight management
Participants discussed at length factors they believed contributed to obesity and weight management in pregnant women. The four key subthemes were 'Information, knowledge and skills', 'Psychological and lifestyle factors', 'Stigma' and 'Communication'.
Information, knowledge and skills
These women understood that eating and activity were related to weight and health; however they lacked confidence about intake requirements, food safety and appropriate levels and types of exercise in pregnancy. This confusion was exacerbated by what they perceived as ever-changing media messages and a lack of nutritional advice:
The first time I was pregnant was 4 years ago now ... I put on about 4 stone then. I just piled it on because I didn't have the support, and I didn't know what to eat, how much I should be eating or anything like that; if I could exercise still when I was pregnant: I didn't have anything (Sally).
Midwives also felt some of their clients lacked the knowledge and skills to maintain a healthy lifestyle. In particular, they perceived that obese pregnant women 'don't seem to realise the implications of their high BMI' (Becky, MW), did not understand healthy eating and lacked cooking skills. Although the women and midwives in this study identified gaps in women's knowledge and skills, their perspectives differed somewhat: the women here felt the gap was in the information they received, whereas midwives felt that general awareness and skills were lacking. These varying perspectives may help explain why the women in this study felt they weren't getting the information they required. Alternatively the difference may reflect a discrepancy between the women who participated and the larger group of women cared for by the seven participating midwives. When asked how typical their views and experiences were, these women felt they were representative of their peers; however midwives believed that the participants represented the keener, proactive end of the spectrum of women under their care.
Psychological and lifestyle factors
This was a dominant explanation for obesity in pregnancy for both women and midwives. Key issues raised were self-talk, motivation and social support.
Women identified internal dialogues regarding eating in pregnancy, sometimes influenced by social messages. Self-talk messages included using pregnancy as a reason to overeat, overeating once morning sickness had passed 'to make up for' previous eating problems, and assuming weight gain in pregnancy would be quickly lost afterwards, especially when breastfeeding. Postpartum, some women here said they continued to treat pregnancy as an 'excuse' for months or years for obesity:
I think there is only so long that you can get away with, 'yeah, I'm this fat, I've just had a baby' - she's 6 months old now. I think I can't really get away with saying that for much longer, do you know what I mean? Yeah 'I've just had a baby' and soon it will be that she's 4, and it just won't have gone (Lucy).
It seemed these women were not fully convinced by their self-talk messages; underlying the 'excuses' lay an awareness that they were unrealistic and would at some point have to be put aside. This suggests that some input from midwives, health visitors, GPs or obstetricians could help obese women tackle their unhelpful self-talk and provide support to make the necessary changes at an earlier stage.
A linked issue was motivation, raised by women and strongly confirmed by midwives:
I think sometimes it is a motivation issue. Although they would like to lose the weight, they don't want to put the work in to actually do that. They think it's something that's not achievable, or they are just not motivated for it (Sarah, MW).
In keeping with this view, women participants reported struggling to find the motivation to exercise, alter eating habits, and maintain positive efforts over long periods of time, and 'getting carried away' (Jenny) with eating. They shared sympathetic laughter with those who related stories of trying unsuccessfully to resist temptation:
I think you should probably be motivated enough yourself, knowing that you've got to lose weight before your holiday or whatever, but it's just, for me, I've got no willpower. I will just end up with the bar of chocolate in front of the TV, rather than going out (general laughter) (Lucy).
Although aware of individual variation, some midwives believed healthy weight was simply not a priority for many of their obese pregnant clients:
I think many of them are aware of diet and the implications, but I don't actually think they care, in all honesty, a lot of them. I work in an area that has a lowish socioeconomic group, lots of smokers, lots of teenage pregnancies, high BMIs, all the things that go with that, and I don't think it's a priority in their lives, to be truthful (Sarah, MW).
There was general agreement that the focus group women were likely to be 'quite motivated and quite positive' (thus not representative of those referred to by Sarah, above). Some perceived that motivation was inversely related to body weight, with moderately obese clients easier to motivate than those with higher BMIs.
I've found that the women who seem to be most concerned are those with a BMI between 30 and 35. 'I know I'm a bit podgy, I know I'm a bit big, and I don't want to get any bigger'. I wonder whether the larger women have just given up, and think 'I don't think you can help me because I can't help myself'. But I get a lot who are more receptive with a BMI of about 30, 32. They say, 'Oh yeah, I need help, I don't want to get any bigger' (Jackie, MW).
Pregnancy and motherhood were considered as theoretically good opportunities to support women with BMI ≥ 30 kg/m2 in behaviour change due to potential triggers such as struggling to carry a baby upstairs, keep up with their children, and fears about school bullying. Nonetheless midwives reported feeling at a loss regarding how to motivate obese women and described admitting defeat in certain cases:
It's almost like they've given up on themselves, and you can hear yourself, that you've given up on them. But then, what more can we do, we can't, it's absolutely true, but isn't it sad, we've given up on them too (Jackie, MW).
The women here reported feeling lonely and isolated at times. Unhealthy eating and inactivity seemed more likely when they were alone, but others' support helped motivate them to eat well and become more active:
I used to be so tired after work and think I can't be bothered to go [to Aquanatal] ... And that sort of motivated me to get up and go, knowing that everyone was gonna be there, and everyone else was gonna be the same as me (Lucy).
The stigma of obesity had different meanings for women and midwives. Midwives, for example, discussed how attitudes towards weight had changed over time, the greater acceptance of obesity, and the relative ease today of finding fashionable clothing in larger sizes. They felt these social changes meant larger women were still able make positive social comparisons and were less motivated to heed midwives' advice to alter health behaviours and manage weight.
I think that our idea of what's big has changed, and so it's more acceptable to be bigger because there are more people... They can buy clothes easier. It's not so difficult for them to buy clothes and be accepted as what it was. So I think that when they come to clinic at first ... They know we're going to mention it, and then they just quickly want to get it over with, they nod their head when we talk about being referred [to Monday clinic], but 'let's move on and talk about the baby (Jackie, MW).
Women in this study had a different view. Although aware of changing attitudes, they felt stigmatised due to their weight and vulnerable to negative attitudes and judgements nonetheless:
I think the stigma is that if you're over a certain BMI that you don't exercise isn't it? (General agreement) That's what people think. I mean if you're slim and you've got a low BMI then they automatically think that you exercise, if you're not then they think you don't (Kate).
Women here reported embarrassment about their weight during and after pregnancy and feeling conspicuous in social situations:
I think you just feel like, because you are pregnant, you're fat anyway, and being big before, you feel like everybody is looking at you. You don't want to go anywhere; I got to a stage where I didn't want to go out of the house (Rachel).
Some women attending a general weight loss class postpartum had felt obliged to explain to others that they had been pregnant in order to justify their present size and weight. They preferred weight-management activities alongside other mothers because 'everyone's in the same boat' (Lucy), believing other people did not understand how they felt.
This difference in attitudes suggests that midwives may inadvertently make assumptions about women's response to their size and underestimate the pressures upon them. This could limit their ability to understand and respond to the psychosocial consequences of obesity for women, such as those discussed above.
The stigma of obesity seemed to create problems for communication between midwives and pregnant women. As one midwife commented, 'It's quite acceptable now to talk to women about smoking, but it's still not quite acceptable to say to a woman, 'your weight may kill your baby'' (Anna, MW). Jackie (MW) observed 'you're not allowed to use the F word, are you, the fat word?' As a result of sensitivity surrounding language and anxiety about creating offence, it was perceived that women's obesity may be 'skirted around', not acknowledged properly during midwife consultations, and that messages were given in a vague, indirect manner to 'protect' both parties (Anna, MW):
I have a disk that I work out people's BMIs on, and it says 'obese' there, and I can't say it; I say to them 'well this is where your BMI is, look.' And I've said it, but she can't say 'she called me obese', but I say 'look, look, you're there look, that's what it says you are'. So I'm anxious, but I'm also protecting myself, y'know, and we don't use the language that we should be using sometimes, do we? (Jackie, MW).
Despite midwives' reluctance to communicate openly, the women in this study were aware that their obesity was a cause of concern and resulted in extra tests and referrals. Midwives' concerns appeared justified by the attitude of at least one of the women in the focus group, however, who did not want her pregnancy care dominated by her weight:
I felt again like I was being penalised because I was fat. I used to say, 'oh, I've got to do the fat girls' test again, have I?' All the time, I felt like they were picking on you because you were fat ... But that's obviously because I knew I was fat, and I was just 'I don't need somebody to tell me that I'm fat, thank you very much!' (Alice).
According to these findings, messages about obesity and weight management in pregnancy at present may be blurred by unspoken anxieties and resentments. These comments suggest more work needs to be done to overcome social barriers which affect midwives' confidence in raising the issue of weight and discussing its implications with women in their care.
Overarching theme 2: Best care for overweight women
The women participants had varying experiences of midwife and obstetric care. The discussed what they perceived as more or less helpful about that care and its implications for weight management. Here subthemes comprised: 'Consistency and Continuity', 'Support not judgement', and 'Opportunities for interaction'.
Consistency and continuity
Continuity of care meant seeing the same midwives repeatedly, so that a rapport could be developed, as well as hearing clear messages about pregnancy and weight. Most of these women had seen many different midwives in pregnancy so hadn't enjoyed the type of relationship in which discussions about weight management could develop:
I used to see a different midwife every week, so I was gaining a lot of weight and not really talking to anybody about it. I think if I'd have seen the same midwife all the way through and talked to someone about healthy eating and stuff like that, it would have been easier, because I gained about 4 stones in total (Jenny).
Women also noted that the messages they received about weight gain in pregnancy were inconsistent. Several reported trying to get advice about their weight from the midwives they saw; however they felt midwives' responses were vague and did not reinforce the importance of weight or women's efforts to manage it:
I had mentioned it a few times and they were like 'oh, well, you're pregnant; you are going to put weight on' (Jenny).
I used to ask to get weighed because I was really worried about putting weight on, and the midwives told me, 'oh, we won't weigh you every time you come, you don't need to get weighed' (Lucy).
I was forever asking the midwives [about exercise activities] but I got swapped between a few midwives ... so I kind of found out there wasn't much information out there (Rachel).
Clearly the women in this study felt they were receiving mixed messages and needed unambiguous advice in order to feel fully informed and supported in their weight management efforts. The midwives themselves believed they were giving clear, consistent information to women about being healthy, eating well and being active; however it appeared from speaking with the pregnant women that these messages were not getting across effectively.
Support not judgement
Some women reported unfortunate experiences of care in earlier pregnancies:
There was one consultant that I used to go to, and he was a brilliant consultant but he had no bedside manner at all, and he was horrible. He used to have me in tears - every time I'd go and see him, he'd tell me I was putting on too much weight, and he would literally shout at me. I don't smoke, I've never drunk throughout; it was the only thing that I was doing wrong, and he used to have me in tears (Sally).
Sally felt judged, stigmatised and unsupported by this obstetrician. In contrast, those women, including Sally on her most recent pregnancy, who attended the 'Monday clinic', were delighted with midwives' constructive, non-judgemental attitude, the provision of dietary advice and physical activity programs. Women were able to meet the same midwives each time, which promoted relationship-building and trust. This, in combination with the practical strategies and support helped motivate the women, and the resulting successes gave them a real sense of achievement:
They were brilliant, and I put on just over a stone this time, which I lost within a day of having my son! So it was completely different, and I saw a dietitian, and I saw [instructor at local gym], and she set me out a program, so I could still go to the gym throughout it. It was just brilliant, and it was so different this time 'round, I can't explain how good it was! I'd get pregnant again just 'cause it was so good, whereas I was dreading it after the first time! It was brilliant (Sally).
A positive feature of the 'Monday clinic', according to those who had attended, was its clear focus: 'I have noticed this time around that they are more about the weight, do you know what I mean? Everything is about the weight, compared to other pregnancies' (Kate). This was positive, however, because it wasn't 'like I was going to be the worst mum ever because I was overweight': instead 'they just want to help you, and they've been nice about it' (Sally). Thus, although women were in no doubt as to why they were there, they appreciated the consistent care, clear advice and non-judgemental support.
Opportunity for interaction
In keeping with the importance of social support in motivating women and reducing the sense of isolation mentioned above, participants here believed they benefited most from interaction with midwives and other pregnant women. Some who had had their babies recently were now attending a postnatal exercise group or had been to Aquanatal during their pregnancies. Specifically designed sessions provided an opportunity for mutual support and healthier lifestyle in a non-judgemental, non-threatening environment: 'we all get to see each other every week, and you get to talk about how much you've lost or what you've done. That is nice, to be able to talk to other people in the same boat as you' (Sally).
When asked to imagine ideal maternity care, these women wanted more opportunities to meet and support one another with healthy lifestyles, online and in person: 'Something with loads of other new mums, or going- to- be new mums, to bond for a day. To have a day of fun exercise-type activities, with like a bit of dieting' (Rachel). When one suggested regular midwife-led walks for pregnant women, the others enthusiastically agreed. Some midwives were cautious about this idea, identifying barriers such as lack of midwife time and funding, and mobility or motivational variation in the service user group. Others, however, were keen, discussing similar previous initiatives which 'had worked really well ... because everyone was on board locally we got great numbers' (Kathy). Jackie also noted that they had given midwives excellent opportunities for 'health promotion and advice'.