Perspectives about and approaches to weight gain in pregnancy: a qualitative study of physicians and nurse midwives

Tammy Chang 0 1 Mikel Llanes 1 Katherine J Gold 1 Michael D Fetters 1 0 University of Michigan, Robert Wood Johnson Clinical Scholars Program, North Campus Research Complex , 2800 Plymouth Road, Building 10 - Room G016, Ann Arbor, MI 48109-2800 , USA 1 Department of Family Medicine, University of Michigan , Ann Arbor, MI , USA Background: Over one third of reproductive age women in the US are obese. Pregnancy is a strong risk factor for obesity, with excess weight gain as the greatest predictor of long term obesity. The majority of pregnant women gain more weight than recommended by the Institute of Medicine guidelines. The objective of this study was to understand prenatal care providers' perspectives on weight gain during pregnancy. Methods: Semi-structured qualitative interviews of 10 prenatal care providers (three family physicians, three obstetricians, and four nurse midwives) at a University Hospital in the Midwest, that included the ranking of important prenatal issues, and open-ended questions addressing: 1) general perceptions; 2) approach with patients; and 3) clinical care challenges. Results: Providers felt that appropriate weight gain during pregnancy was not a high priority. Many providers waited until patients had gained excess weight before addressing the issue, were not familiar with established guidelines, and lacked resources for patients. Providers also believed that their counseling had low impact on patients, avoided counseling due to sensitivity of the topic, and believed that patients were more influenced by other factors, such as their family, habits, and culture. Conclusions: Both providers and patients may benefit from increased awareness of the morbidity of excess weight gain during pregnancy. Practice-level policies that support the monitoring and management of weight gain during pregnancy could also improve care. Research that further investigates the barriers to appropriate weight gain is warranted. - Background Obesity among reproductive age women is a prevalent, debilitating, and expensive public health problem. Obesity is associated with serious physical, psychological and social problems including cardiovascular disease, lower quality of life, and stigma [1-4]. Despite over a decade of focus, overall rates of obesity among reproductive age women in the US remain high, with between a quarter and a third of women age 2044 categorized as obese [5,6]. Pregnancy is a time of expected weight gain. However, the majority of US women gain more than the recommended weight per Institute of Medicine guidelines [7,8]. In fact, pregnancy itself is a strong risk factor for future obesity, with excess weight gain during pregnancy as the greatest predictor of long term obesity [9-11]. Excess weight gain during pregnancy is associated with serious short and long-term consequences for both mothers and their infants. Risks of excess maternal weight gain to infants include low five- minute APGAR score, seizure, hypoglycemia, hyperbilirubinemia, polycythemia, meconium aspiration syndrome, macrosomia, and childhood overweight [12-14]. Perinatal complications such as miscarriage, Caesarean section, development of diabetes mellitus, pregnancy-induced hypertension, as well postpartum weight retention and overweight are among the adverse consequences of excess weight gain during pregnancy for mothers [10,15,16]. In general, weight management during pregnancy has not been emphasized in the prenatal care of patients. One cross-sectional study of Canadian patients of midwives, family physicians, and obstetricians showed very low rates (5.7%-16.3%) of counseling about gestational weight gain by all types of providers [17]. When information is given antenatally regarding weight gain, the advice is typically brief and generally not related to weight management as reported by a recent study in the UK [18]. Interestingly, despite having the highest rates of excessive weight gain nationally, white women were the least likely to receive counseling about nutrition during pregnancy in a cohort study of predominantly lowincome prenatal patients in the US [19]. Studies have examined the patients perspective of weight gain during pregnancy. These studies show that gestational weight gain is associated with overall body image [20], and that the desire to return to prepregnancy weight was a strong motivating factor to control weight gain. In addition, the health and well-being of their unborn baby is often central in womens decisions about appropriate weight gain [21], and womens attitudes about weight gain in pregnancy are embedded in their overall orientation toward pregnancy and their general psychological functioning [22]. Low-income black women in the US had more perceptions encouraging high gestational weight gain than discouraging it [23]. Furthermore, low-income black women did not limit their gestational weight gain, despite knowledge of the risk for weight retention due to their belief that gaining more weight is indicative of a healthy infant [24]. To better understand the complex problem of excess weight gain during pregnancy, it is vital to understand the perspectives of prenatal care providers as well. The objective of this study was to understand the perceptions, approach, and challenges regarding management of weight gain during pregnancy among a sample of family physicians, obstetricians, and certified nurse midwives who provide prenatal care. Participants and recruitment We used maximum variation sampling to obtain a variety of medical specialties and providers with a breadth of background and experience within our sample. Providers were selected based on specialty (FP, OB, CNM) and to represent a broad level of experience (faculty vs resident), and were either contacted by email or face-toface to participate in our study. From this process, we recruited three family physicians (FP), three obstetricians (OB) and four certified nurse midwives (CNM) who practice at community-based sites as part of a university hospital in the Midwest. All eligible providers that were asked to participate consented to be interviewed for the study (n = 10). No incentive was offered for participation. Verbal informed consent was obtained from all study participants, and documented by audio-recording. Data collection Two investigators (TC, ML) conducted face-to-face, indepth, semi-structured interviews using an interview guide developed by the authors after the participants provided their verbal informed consent to participate. The interviews began by participants ranking a list of eleven important prenatal issues occurring during a typical prenatal visit to learn their perceptions about the importance of weight gain relative to other common issues. We then asked semi-structured, open-ended questions addressing their general perceptions about weight gain, their clinical approach to weight gain, and challenges they encounter in the management of weight gain during pregnancy. (...truncated)