The thematic content analysis identified a number of overarching themes and subthemes. Three key themes emerged: 1. GWG being a low priority; 2. midwives concern for the physical and psychological welfare of women and; 3. the central role for midwives in the education process with opportunities for additional support to promote healthy GWG. The Antenatal Clinic Director quotes have not been differentiated from the Midwife quotes due to the possibility of interviewee identification and thus breach of anonymity.
Theme 1: Gestational weight gain is a low priority for midwives
With the many competing interests in antenatal clinics, GWG was perceived by many midwives to be of low priority. A range of factors contributed to this perception, ranging from absence of policies through midwife beliefs regarding GWG, and their support to engage effectively on this topic. Contributing factors included: practices, policies and views limiting the weighing of women and provision of GWG guidelines; perceptions regarding pregnant women’s low levels of interest in weight; limited education of midwives regarding GWG; time limitations for education of pregnant women; and perceptions of limited allied health services, such as Dietetic and Physiotherapy resources.
a. Low incidence ofweight monitoring
In both hospitals midwives often weighed women at the first antenatal visit, and sometimes BMI was calculated, primarily as a risk stratification strategy. Generally, a woman’s weight was not re- measured during her pregnancy unless the woman was defined as “high risk” (BMI
or presenting with a co-morbidity) at the outset. The urban hospital had a formal weighing policy [47
] and GWG guidelines available to staff on the internal intranet. This hospital’s policy and practice at the hospital discouraged weighing women after the first antenatal visit and this was reflected in some midwives’ views. Further, the policy encouraged the provision of the IOM GWG guidelines based on BMI [17
]. Despite the presence of weighing and GWG guidelines policy in the urban hospital and the absence in the rural hospital, there did not appear to be a significant difference in views and practices between both midwife groups. Both groups exhibited diverse views and practices.
"“ (I don’t thinkweighing is) relevant; we’rejust going by clinicalindications.” (Urban midwife 2)"
When midwives were asked about routine weighing practices, two-thirds said they did not consider that routine weighing of pregnant woman was important. The midwives stated there was “no evidence” to support routine weighing and that measurements did not provide useful clinical information. In addition, midwives reported feeling that routine weighing may cause women psychological distress. The acknowledgement of change in pregnant women’s weight was seen to come primarily from the women or midwives’ observation.
"‘… the research supportsthat they don’t reallyneed to be weighedat every appointment. Itdoesn’t really gain muchinformation out of it.” (Urbanmidwife 9)"
"“Too much stigma associatedwith it…It’s embarrassing forthe patient; they seeit as a kindof test, how goodthey’ve been or howbad they’ve been.” (Urban midwife7)"
"“…here we can providecontinuity of care, soI can actually seethe same women forall of her appointmentsapart from one ortwo because she’s seeingher doctor. So Ican actually gauge them(visually), how much they’vebeen putting on.” (Urbanmidwife 9)"
However, the remaining third of midwives supported weighing during pregnancy and felt that weighing women at each antenatal visit allowed them to track GWG, particularly in high risk women such as those of high and low BMIs or those at risk of weight loss. Recording routine weights on women’s care plan was seen as a practice that would normalise weighing and help trigger conversation with women regarding weight and lifestyle behaviours.
"“We were told thatby weighing women, itdoesn’t tell us aboutgood foetal outcomes, sowe stopped…. But weforgot about the processfor women, and whatare the outcomes forwomen if we doweigh them and knowwhat weight they areat the end ofthe pregnancy.” (Urban midwife 6)"
"“(weighing)… instigates a conversationsometimes at each visit,whereas here women don’tget weighed as ageneral rule. …so youdon’t have that conversation,or you don’t havethat prompting.” (Urban midwife 5)"
The challenges associated with the identification of abnormal weight changes were raised by a few urban midwives. They acknowledged that weight changes cannot be identified when women are not weighed routinely.
"“…they’re not identified. Wewould have no ideawhat people put onin pregnancy.” (Urban midwife 5)"
b. Diverse views regardingprovision of pregnancy GWGguidelines
Midwives expressed mixed feelings regarding whether GWG guidelines should be provided to women. Two-thirds of the midwives indicated they did not consider it necessary to provide pregnant women with GWG guidelines unless the woman asked for them. Midwives’ reluctance to discuss weight reflected a perceived lack of evidence regarding GWG, weight not being a priority for the midwives and concerns that women may become fixated on their weight during pregnancy. Consistent with the views regarding routine weighing, high risk women with high BMI and concurrent diseases such as diabetes were seen to be the exception.
"“….I think the trendis not worry somuch how much weightgain you have rightthrough unless there’s othermedical issues involved suchas hypertension and smokingand all that sideissues.” (Rural midwife 2)"
"“I guess it’s thatthing where you knowthe woman is goingto put on weightand they do eatmore so generally Iguess I wouldn’t feelthat I would needto.” (Rural midwife 3)"
"“(Providing guidelines). should bealways research based, butI don’t think itis.” (Urban midwife 6)"
The third of midwives who provided GWG guidelines to women cited foetal and maternal outcomes as their main reason for doing so, along with the habit of providing weight guidelines to women.
"“I feel that theyall should be givenso that they havea rough idea ofwhat is normal andnot normal, so they’rehaving a proper dietand exercise.” (Urban midwife2)"
"“So I think we…… need some guidelines” (Rural midwife 2)"
The GWG guidelines provided to women during antenatal care by all midwives, either voluntarily or if asked, varied greatly. A few urban midwives provided women with individual guidelines related to pre-pregnancy BMI, such as the IOM guidelines [17
], but the majority provided highly varied ranges for example 10-20 kg or 10–14 kg. Not providing GWG information to women was in contrast to the policy supporting the provision of GWG guidelines at the urban hospital [47
Half the midwives said that women sought weight gain advice during antenatal care and half noting that weight was rarely raised in consultations. Some midwives felt that healthy weight women were more likely to ask about GWG guidelines. A few midwives shared their personal strategies on discussing GWG and normalising the healthy GWG. The most common strategies involved focusing on the benefits of healthy GWG for the foetus and differentiating the pregnancy weight gain from weight gained through a positive energy balance.
"“I tell them thatgaining weight in pregnancyis completely different togaining weight when youeat too much cake.” (Urbanmidwife 7)"
c. Excess GWG notseen to be commonor problematic by many
Most midwives considered excess GWG to be uncommon with the exception of women deemed at “high risk”. In addition, many communicated that they did not see excessive GWG as a significant health issue for women. However, it was also highlighted by some that GWG was impossible to detect since weighing pregnant women was uncommon.
"“(Excess GWG) is unusualfrom my experience…” (Urban midwife1)"
"“…your baby’s an appropriatesize then no-one’s goingto be too concernedif there’s a 20kilo weight gain.” (Urban midwife5)"
"“…they’re not identified. Wewould have no ideawhat people put onin pregnancy.” (Urban midwife5)"
In contrast, the midwives who considered excessive GWG problematic were concerned about maternal and foetal outcomes. There was a sense that the emphasis on GWG had been inappropriately played down over recent years. In addition, concern was expressed that excess GWG compounded associated problems for those already overweight or obese.
"“But I think wesort of ignore thefact that a lotof the girls havestarted heavier. We area fatter population sowe still have theproblem of really bigwomen being pregnant, andgetting to the endof the pregnancy theyhave other problems aswell they get toobig.” (Rural midwife 2)"
When midwives were prompted to identify important implications of excess GWG, the most common responses related to gestational diabetes, preeclampsia, inability to palpate the foetus and complicated deliveries. Two midwives mentioned foetal health implications, including macrosomia.
d. Limited resources toaddress GWG and lifestylebehaviours
The midwives identified a lack of time and resources, such as dietetic services, as key limitations enabling them to address healthy GWG and lifestyle issues with the women. Midwives are required to address a large number of issues during antenatal consultations including assessment of medical, family, pregnancy and psychological history as well as provision of pregnancy information, antenatal tests, procedures and bookings. Midwives considered they had limited time available for discussions about GWG and healthy lifestyle. The late timing of the first antenatal visits (often occurring after the first trimester) was sometimes seen to preclude education when it would have been most appropriate. In addition, a reluctance to bombard women with excess information influenced midwives’ decisions about what topics to discuss during visits.
"“. when you’re ona time efficiency….you can’treally think of everytopic, because every topicin pregnancy has becomethe most important, becausethere’s always a smokingprocess going on. There’sthe alcohol intervention process,so everything becomes themost important thing inpregnancy.” (Urban midwife 5)"
"“.they are blown awayby how much wegive them in theearly visits.” (Urban midwife 1)"
As noted, the limited resources for dietetic and physiotherapy services were seen to constrain interventions for healthy GWG and lifestyle issues, reducing the ability for antenatal services to intervene even if a need was identified.
"“.our Dietetics have anappointment system .(and). thoseappointments are hard toget because they takea long time andby the time youget there you couldbe half way throughthe pregnancy. ” (Urbanmidwife 10)"
One midwife felt that the limited dietetic and physiotherapy resources available to them in the public health system has resulted in a redefinition of “at risk” or “healthy” pregnancy weight because only those women with BMIs
were chosen for interventions and education. Therefore women with BMIs 25 kg/m2
to 35 kg/m2
were redefined as “normal”.
"“.there’s a lot ofissues for women around…being fat and weightgain and pregnancy whichwe normalise” (Rural midwife1)"
Theme 2 Concern for physical and psychological health of pregnant women
Midwives articulated a concern for the physical and psychological health of pregnant women in general. However, their greatest concern was for possible psychological ramifications of weight related discussions and interventions.
a. Concern for thepsychological impacts of weightdiscussions and women’s inappropriateviews on weight gain
It was a common view among the midwives that many women were inappropriately concerned about putting on too much weight during pregnancy. This concern was mirrored in the antenatal weighing policy of one hospital [47
]. At this urban hospital the midwives felt that women were controlling their GWG through inappropriate strategies, such as restricted eating, but did not cite evidence to support the supposition. Hence, with a desire to “do no harm” some midwives were concerned about perceived psychological ramifications if weight and GWG were discussed and monitored at routine antenatal visits. Further, there was concern that women would become anxious about their weight, or actively lose weight which would have adverse effects on the mother and foetus. This was expressed as the prime reason for not discussing GWG.
"“I think it stressesa lot of pregnantwomen out. I finda lot of womenare fixated on weightand how much theyshould be gaining.” (Urbanmidwife 3)"
"“Women were getting veryanxious and they weregetting obsessed about (weightgain) and I thinkthat added extra anxiety,they’re already anxious withtheir pregnancy.” (Urban midwife2)"
Other midwives recognised the co-morbidities associated with excessive GWG, such as poor delivery and foetal outcomes, caused by not informing and/or supporting women to achieve these goals and the need for good health outcomes.
"“You know, we canbe nice about itall, but at theend of the day,we want good foetal,good maternal outcomes.” (Urban midwife6)"
b. Concern for thephysical health of women
The majority of midwives expressed deep concern about the physical health of their patients. In particular, a few expressed concerns about the increasing incidence in overweight and obesity in the community and their desire for an intervention to reduce women’s weight pre-pregnancy.
"“I consider it (pre-pregnancyoverweight and obesity) areally big (issue), probablyacross my midwifery timeone of the biggestissues that’s out thereat the moment.” (Urban midwife7)"
Theme 3 Midwives are central to healthy lifestyle education process and opportunities exist for support to promote healthy GWG
All midwives viewed themselves as part of a team of antenatal colleagues who were responsible for the promotion of healthy lifestyle behaviours, including healthy GWG. When asked about how midwives could be best supported to deliver healthy weight and lifestyle behaviour education, a number of models were suggested.
a. Key providers oflifestyle behaviour education
Despite some midwives expressing concerns about healthy GWG and their role in its promotion, the midwives unanimously saw themselves as having responsibility for education and interventions around GWG and lifestyle issues. This was seen to be a responsibility shared with obstetricians, general practitioners and other health providers that pregnant women consulted. The need for consistent messages and education along with multidisciplinary care was also mentioned.
"“So it’s all ourjobs and the ideawould be to worktogether and with ourmost difficult clients usingsupport such as Dieteticsand whatever it isthe woman needs.” (Urbanmidwife 7)"
Most midwives discussed some lifestyle behaviours during pregnancy, however, they considered that Listeria infection and vitamin and mineral intake and supplementation to be the most important. This was followed by advice regarding “general healthy nutrition”, avoidance of alcohol and smoking and the importance of physical activity.
b. Lack of confidencein addressing weight andGWG
The majority of midwives thought that conversations with women regarding their weight were difficult, reflecting a negative social construction around weight. It was therefore often easier to avoid raising weight as a concern during antenatal consultations.
"“.weight is a difficultone. It’s easier tobring it up ifyour blood pressure’s high,or you’ve got proteinin you urine. Butwhen you’ve got tosay to someone “You’rea little bit overweightfor midwives to lookafter.” .it’s not anice thing to say,but I think…they understandif you discuss itin a clinical riskmanner.” (Urban midwife 6)"
"“I know myself Iam so euphemistic aboutthe conversation.” (Urban midwife 2)"
Midwives felt that it was important for them to develop the communication skills needed to establish rapport with women that would enable them to have conversations around weight so that discussions were positive, non-judgemental and did not infer blame.
"“ I hear younggrads say all thetime “oh I don’tknow how to talkto women cos theirBMI is high” andI think to myselfhave you never learntabout putting your judgementto one side andgiving facts and lettingpeople see you meanwhat you say, thatyou’re not there judging” (Urbanmidwife 7)"
c. Support for midwivesto promote healthy GWG
A model for education and support for midwives to increase their knowledge, skills and opportunity was the most commonly suggested way to help midwives promote and encourage healthy GWGs. Some participants recommended additional education and training for midwives around GWG and others saw greater opportunity for intervention which could occur during longer antenatal consultations.
"“Probably for midwives tohave a lot moreeducation on what weshould be saying towomen and what weshould be doing, becausewe are at theforefront of seeing thesewomen.” (Urban midwife 9)"
The need for longer and individualised antenatal consultations was underpinned by the midwives’ perception that women wanted individual consultations with midwives, continuity of care and relationship and trust building.
Another model to support midwives was the implementation of healthy GWG detection and management policies that would flow down to practice changes, where there was an expectation that GWG would be discussed.
"“I know that’s whatI’d like to see,these triggers that comeup. Because I knowfor the smoking, there’sthe trigger point whereyou must ask thequestions, and it’s partof what you doat every visit.” (Urban midwife6)"
Models targeting women to promote healthy GWG were suggested. These models would ideally utilise multidisciplinary antenatal group sessions employing midwives, dietitians and physiotherapists. Drop in services for ‘high risk’ groups such as refugees and young mothers were suggested by others.
When the midwives were prompted to consider whether some of the new technologies such as the internet, telephone counselling and short message service (SMS) interventions could be used in this context, the midwives favoured the internet and SMS interventions. However, some expressed concern over quality of information and the ability for some women to access the technologies. Others felt that the introduction of these interventions may augment services, increase consistency of information and provide improved access to ‘at risk’ groups.
"“People are hooked intothe internet these days.That’s where they areseeking a lot ofinformation. ” (Urban midwife3)"
"“…doesn’t matter what economicclass people come from,they’ve always got amobile. But if it’scoming to their phone,they’re always going toread a message, whichis a really goodway to get tothese people……….” (Urban midwife9)"
d. Features and contentof an optimal interventionto promote healthy GWG
Continuity of care was considered an optimal feature to promote healthy GWG with women seeing the same midwives or health professionals at each visit.
"“I sometimes think it’sbetter to have thatpersonal input from someoneyou’ve actually built upa rapport with.” (Urbanmidwife 1)"
Interventions connected and branded to the antenatal clinic and consistency of messages were seen to be central features in a contiguous approach.
"“……even hospital (nutrition based)internet sites would begood.” (Urban midwife 3)"
Healthy eating, followed by physical activity and the provision of individual GWG parameters, were the topics perceived to be the most important for inclusion in an intervention. Furthermore, supporting women to learn from health providers and other women was seen to be crucial to intervention success.
"“… the food groupeating isn’t enough, itisn’t enough to tellsomeone who doesn’t understandabout nutrition that thisis the way you’resupposed to eat. Havingsomeone sit down toteach them about what’son the back ofpackaging and how toread the packaging andwhat is a goodfood and giving themexamples of what ameal is much morebeneficial” (Urban midwife 10)"
"“Eat from a widefood group. Exercise asa balance in yourlife. And, I’m tryingto think of theright way of puttingit, don’t go toextremes.” (Urban midwife 7)"