Abstract
Objective To assess counseling practices for gestational weight gain (GWG) among primary care providers (PCPs) at 2 clinics to identify barriers and potential health interventions for patients from diverse cultural backgrounds.
Design Qualitative interviews with data analyzed for emerging themes using a modified grounded theory method.
Setting Interviews at the South East Toronto Family Health Team and Flemingdon Health Centre in Toronto, Ont, from September 2016 to February 2018.
Participants Family practice obstetric providers and pregnant patients.
Methods Semistructured interviews and focus groups were audiorecorded and transcribed. Analysis used a constant comparative approach to identify themes.
Main findings Patients had a limited understanding of risks associated with excessive GWG and reported infrequent weight counseling by PCPs. Patients at the South East Toronto Family Health Team had high health literacy and were proactive in seeking health information but had difficulty navigating reliable resources. Patients at Flemingdon Health Centre had lower health literacy and more passive interactions with PCPs, relying on family advice and cultural practices to inform health behaviour. Barriers for this group included social isolation and limited funds. Both groups desired increased proactive health counseling and resources. Physicians were knowledgeable about excessive GWG and reported counseling their patients, although patient retention and limited time were barriers.
Conclusion Healthy lifestyle in pregnancy is an important but underemphasized topic in antenatal care owing to barriers faced by patients and physicians, with unique socioeconomic considerations. This gap provides an opportunity to increase education of patients and providers and to develop patient-centred weight management interventions. By contrasting patient groups, our study reflected the importance of addressing social determinants of health in comprehensive care.
Excessive gestational weight gain (GWG) and prepregnancy obesity are becoming increasingly prevalent in North America. Studies quote rates of obesity in Canadian women of childbearing age to be between 11% and 21%; half of women gain more than the recommended amount during pregnancy.1 Most women who gain excessive gestational weight are overweight before becoming pregnant.2,3
Serious maternal and fetal risks are associated with excessive GWG.4 Maternal risk includes increased risk of cesarean section, gestational diabetes, pregnancy-induced hypertension, thromboembolism, postpartum weight retention, and long-term metabolic outcomes.3,5,6 Fetal risk includes higher rates of spontaneous abortion and stillbirth, macrosomia, neonatal metabolic abnormalities (including hypoglycemia and hyperbilirubinemia), as well as downstream obesity and metabolic syndrome.3,6-8 For example, if women had a normal body mass index (BMI) in early pregnancy and subsequent excessive GWG, the odds of their infant’s being overweight at 3 years of age increased 4-fold.8
Pregnancy is often characterized by high motivation, which can be harnessed to influence maternal health and improve the health outcomes of mother and child.9,10 However, barriers exist to achieving healthy weight during pregnancy. Generally, both the provider and patient have gaps in their knowledge of what constitutes healthy nutrition and physical activity during pregnancy, complicated by a lack of appreciation of the harms of excessive GWG.11 Authors cite social influence as a contributor to excessive GWG, suggesting that many women feel encouraged to gain weight during pregnancy.12 Cultural factors must also be considered, as one study showed that White women were more motivated to meet weight guidelines than Black women, who were more concerned with inadequate weight gain.13
Studies have reported that 1 in 3 women did not receive weight counseling from their providers.3 Researchers indicate that physicians sometimes delay counseling owing to fear of offending women and to uncertainty about the effectiveness of counseling.6,10 Further, providers could fail to recognize the direct health consequences of excessive GWG and could feel poorly equipped with relevant knowledge, tools, and services.10,14 Exacerbating the issue, studies show discrepancy between information physicians claim to have delivered and what patients report having discussed, with 40% to 80% of information from health care providers not being absorbed by patients15 and 50% of information remembered incorrectly.16
Guidelines exist on weight gain, nutrition, and exercise in pregnancy. In 2009, the Institute of Medicine published guidelines for weight gain based on prepregnancy BMI,17 recommending a total gain of 7 to 11.5 kg among women who are overweight and 5 to 9 kg for women who are obese. Regarding nutrition, previous Canadian guidelines recommended that women follow Canada’s Food Guide and receive nutritional assessment through a multidisciplinary team when resources permit.2,11 Updated guidelines on physical activity have recently been published, which recommend all women without contraindications be physically active throughout pregnancy, accumulating 150 minutes of moderate- to high-intensity activity weekly.18
While guidelines exist, there is a paucity of data on how primary care providers (PCPs) advise on these topics.10,12,13 Various groups have implemented site-specific interventions to combat excessive GWG, but further evaluation through randomized trials is required to demonstrate efficacy.12,13 Few studies have directly assessed providers’ and patients’ perceptions of barriers to preventing excessive GWG.
Our objective is to investigate the current landscape of counseling and perceptions around weight gain, nutrition, and exercise among family practice obstetrics patients and providers at South East Toronto Family Health Team (SETFHT) and Flemingdon Health Centre (FHC) in Toronto, Ont. Our goal is to highlight barriers to healthy weight management in pregnancy and identify potential provider-driven interventions to better serve our patients from diverse socioeconomic and cultural backgrounds.
METHODS
The study was conducted at 2 clinics in the Toronto East Health Network, FHC and SETFHT, from September 2016 to February 2018. The FHC is a community health centre. By definition, its patient population is largely composed of immigrants and refugees from within a specified catchment area. This clinic serves 5368 clients, of whom 53% are English speaking and 78% were born outside Canada. In contrast, of the 20 000 patients at SETFHT, only 7% are immigrants and most (83%) come from a middle- to high-income family, according to Statistics Canada’s 2016 census.19 According to Statistics Canada, low income is defined as below $22 133 annually for a 1-person household, $31 301 for a 2-person household, and $44 266 for a 4-person household.19
Approval was obtained from the Research Ethics Board of the Toronto Academic Health Sciences Network. Recruitment was performed via purposeful and convenience sampling. All of the 9 family practice obstetrics providers at the Toronto East Health Network were recruited for participation from a quarterly physicians’ meeting. Of the 9 providers, 8 attended the meeting and agreed to participate in the focus group. Patient recruitment strategies were clinic-dependent. For SETFHT, the study was advertised in clinic with flyers, and patients were cold-called from a list of potential attendees at an upcoming physician-patient meet-and-greet. Patients then consented to remain on-site for the focus groups after the meet-and-greet. At FHC, participants were recruited on-site for individual interviews by their PCP after prenatal visits, from a single provider. Patient inclusion criteria included women who were pregnant and receiving care at SETFHT or FHC. Any patients who had received clinical care from either of 2 of the researchers (S.G., A.D.) were excluded. Theoretical sampling was used, and participant recruitment ended when focus groups and interviews generated no new concepts and theoretical saturation was achieved.
All participants consented to audiorecorded sessions. Interviews and focus groups were conducted by 2 of the authors (S.G., A.D.) and lasted on average 15 minutes for individual interviews and 60 minutes for focus groups. A semistructured interview guide consisting of open-ended questions was developed to explore patients’ and providers’ perspectives on GWG (the guide is available on request). Recordings were transcribed verbatim for analysis, and each interview was rendered anonymous during the transcription process. Each transcript was compared for accuracy with the original recording. Interviewers made field notes after each interview, enhancing confirmability.20
Data were analyzed for emerging themes using a modified constructivist, or Charmaz, grounded theory method.21 We used this method because few studies elucidate patients’ and providers’ perceptions of excessive GWG, and grounded theory allows elucidation of new related theories. We used concurrent data collection and analysis, an iterative analytic approach, and constant comparative techniques.22 Authors S.G. and A.D. independently reviewed transcripts iteratively for key words and emerging themes, first through line-by-line coding. Memoing was used to explore links between initial codes, and focused coding allowed organization of initial codes into higher-order concepts, categories, and themes. At each stage this was done independently by each of the 2 authors and then in unison so that concepts could be clarified, enhancing confirmability.20
The interview guide was adjusted as needed to allow further insight in subsequent sessions. Analyses were compared and consistency of coding was checked. Discrepancies were resolved through referral to examples from the data. The final stage of analysis involved examining all interviews with NVivo 11, version 7, which served to condense the data and identify relevant quotations to illustrate findings.
FINDINGS
Participant demographic characteristics
Participants in our focus groups and interviews included 8 physicians (interviewed in a single focus group: 3 from FHC and 5 from SETFHT), 6 pregnant women from SETFHT (interviewed in 2 focus groups of 2 and 4 participants each), and 4 women from FHC (interviewed individually). We intended to interview FHC patients as a focus group, but converted to interviews for patients’ convenience.
Patient demographic characteristics in Table 123 illustrate the differing cultural backgrounds of FHC versus SETFHT patients.
Patient demographic characteristics
At the time of interview, patients’ initial height and weight were self-reported and compared with third-trimester weights. At SETFHT, 4 of 6 patients gained weight within the Health Canada guidelines.17 One gained excess weight, and another gained less than the recommended amount, although her starting BMI was in the obese range. At FHC, 3 of 4 patients gained weight within the Health Canada guidelines.23 One did not gain enough, and her starting weight was normal.
Themes from patients’ and physicians’ focus group and interviews follow with illustrative quotations. Participants are identified by an interview number and location: SETFHT (S) or FHC (F) whether patient or physician.
Patient findings
Patient findings are summarized in Table 2.
Findings from patient interviews and focus groups
Approach to health in pregnancy. When asked about their approach to a healthy lifestyle, women from SETFHT identified weight management, nutrition, and exercise as priorities. A woman from SETFHT reported specific knowledge of guidelines, commenting, “The normal weight gain is 25 to 35 pounds. They recommend a balanced diet and light exercises” (S4). Many women from SETFHT were active before pregnancy and adapted their routines to pregnancy, citing walking, yoga, and weight training. They had a general sense of physical activity guidelines, saying, “[I]f you haven’t run, you shouldn’t just start running when you’re pregnant, or … don’t do exercises on your stomach and nothing too strenuous” (S3). They were unaware of specific recommendations, such as heart rate targets.
In contrast, women from FHC focused on physical symptoms as a measure of health. One woman said, “Being healthy in pregnancy means having a healthy diet and having no indigestion” (F2). Women from FHC followed nutrition advice from family members, “In Pakistan they tell you to eat for two; … my mom used to tell me the same” (F4). They were generally unaware of guidelines for exercise during pregnancy, and their main form of activity was housework and walking for errands. “In my country we mostly do housework. We wash clothes [by] hand. We clean the garage and wipe the floor; it’s hard work” (F1).
Knowledge of GWG risks. Most patients at SETFHT and FHC had a general but limited knowledge of immediate risks associated with excessive GWG, including gestational diabetes and cesarean section. However, neither group appreciated the lifelong health effects on mother and baby. One woman from FHC commented, “I don’t think the weight is bad for baby. God made everything for baby” (F1).
Sources of knowledge and counseling. Women from SETFHT actively sought resources on nutrition and exercise in pregnancy. A few accessed dietitians, and all relied on published material in books or online, as well as smartphone apps. One patient from SETFHT said, “The dietitian was very good; … he helped me learn about servings and what has a lot of sugar. [Books] helped us to figure out how to read the food labels, sugars, and sodium” (S2). Women from SETFHT reported infrequent counseling on diet and exercise by their providers unless they themselves broached the topic. One SETFHT patient said, “I wish I had more information at the start of pregnancy on proper nutrition and exercise. It’s hard to know all the questions to ask” (S3).
In contrast, FHC patients relied heavily on advice from friends and family as well as on cultural practices when determining lifestyle choices. One woman from FHC observed,
No one has given me advice. In my country [Pakistan] we use herb waters like ginger. I think those work. My mom told me … if you balance your weight in pregnancy, it will be helpful if you want vaginal [delivery].… I mostly talk to my mother for advice (F2).
Patients at FHC also used nonclinical online search engines (Yahoo, Google) to self-search. Women from FHC infrequently addressed concerns with their providers. “No one gave me advice on healthy eating. [My PCP] doesn’t tell me about my weight, and I don’t ask questions” (F4).
Barriers to healthy nutrition and exercise. Barriers to nutrition and exercise cited by both patient groups included physical symptoms and lack of time to prepare healthy foods and to exercise. “When you’re sick … it’s stressful to figure out what to eat” (S2). Another patient said, “Back home in my first pregnancy, my family was there to help me.… Now during my second pregnancy, I’m alone and it’s really hard. I’m a student and I have another child” (F3). Barriers mentioned specifically by SETFHT patients included poor understanding of pregnancy-safe healthy foods. “At the beginning of our pregnancy, we should be told what to eat and what not to eat.… We are searching this on our own, but sometimes I didn’t know what was a trustworthy source of information” (S5). Patients at FHC reported lack of child care and transportation as a barrier: “I have not attended prenatal classes. It depends on my husband’s schedule and the weather. I am not reading books about pregnancy because I spend time with my first baby” (F2).
Desired interventions. Most women from SETFHT were interested in receiving counseling and resources from their provider at the outset of pregnancy. “There’s so much out there; it’s hard to know what to follow. Like, if there was a book or something for recipes, and the nutrition it’s giving your baby, that would be great at the beginning of the pregnancy” (S5). Most SETFHT patients were interested in seeing a dietitian. Many women from FHC wanted language-specific resources, and a few women desired assistance in transportation and child care, allowing more access to prenatal classes and appointments. Another, reflecting on the need for culturally sensitive prenatal classes, said, “I think there are [many] ladies from different countries with different cultures and languages, so to inform the ladies, there must be some kind of class in the first trimester, to gain information during pregnancy” (F4).
Physician findings
Physician findings are summarized in Table 3.
Findings from the physician focus group
Existing knowledge. Physicians were knowledgeable about risks of excessive GWG. They correctly reported risks including difficult labour, difficult epidural, difficult anesthesia, difficulty tracing fetal heart rate, dystocia, macrosomia, increased risk of obesity in the child, and increased risk of diabetes in the mother after pregnancy. They also noted that often excessive GWG is propagated to subsequent pregnancies.
Provider counseling practices. Providers differed in their counseling approach, which was largely dependent on the health literacy of their patient population. They reiterated that patients with lower education usually didn’t bring up questions related to weight gain, receiving most of their pregnancy advice from family members. One physician observed, “I run into a lot of patients at FHC … who think that the more weight you can gain the better, so education around that is important” (F1). As a result, providers at FHC reported counseling more thoroughly on diet and exercise advice, using educational handouts. In contrast, providers agreed that patients at SETFHT, who generally have a higher level of education, get much of their pregnancy advice from books or the Internet. Their approach to counseling was more patient-led. “I think that’s how my approach does vary; … patients here are so well educated and they will bring questions up, so I don’t discuss it in so much detail with them or bring it up in a formal way” (F2). Providers said that, no matter the patient’s education level or background, they tried to emphasize guidelines if the patient was gaining excessive weight.
Perceived patient barriers to healthy nutrition and exercise. Providers reported that, although pregnancy is a time when patients are motivated to make health-conscious choices, it is still difficult to instill behaviour changes. One physician commented, “Even outside of pregnancy, we know that trying to motivate your patients by telling them what to eat and how to exercise often doesn’t work, so I think that we need another approach” (S2). Physicians speculated that the lack of lifestyle change during pregnancy was due to patients’ time constraints and physical symptoms. “I think for new immigrants, there’s not a lot of family support. So often it’s just the mom and her husband, and this makes it really hard” (F2). Financial barriers preventing the purchase of nutritious food and gym memberships were also cited. Providers reported that cultural differences could affect patient compliance, with refugee patients sometimes having a general distrust of the health care system and varied beliefs concerning pregnancy. “A lot of [FHC patients] don’t want to go out on their own, and so to go do exercises can be difficult” (F1). Given that this patient group often receives information from their friends and family, physicians speculated that peer counseling might be a more effective mode of counseling.
For somewhere like [FHC], peer groups would probably be more effective.… I have a lot of patients that come in and say, “my friend says I’m not gaining enough weight,” so it’s interesting how much clout that one friend has; … sometimes you’re not really sure who is getting more credibility, you or the family (F1).
Provider barriers to effective counseling. Physicians cited time constraints during appointments as the main barrier to health counseling. They reflected that so many other items are prioritized during a prenatal visit that physical activity and nutrition fall to the bottom of the agenda. One FHC physician declared,
Sometimes it’s the other risks in their pregnancy.… I’m going to spend more time on getting them to stop smoking and using drugs than [minimizing] weight gain in pregnancy” (F2).
With time restraints and language barriers, you may not have time, even to engage in motivational interviewing; … timing is tricky when you have so much more to go over with them (F2).
Sourcing resources in patients’ native language was an additional barrier.
I find that the first visit is just a lot of information, and so a lot of the time, I refer them to websites. Sometimes, Toronto Public Health has resources, like nutrition resources, that are translated, so sometimes I use that (F2).
DISCUSSION
Healthy lifestyle and weight gain in pregnancy are important but underemphasized areas of focus in antenatal care, and our study identifies culturally specific differences between patient groups and potential areas for intervention. Patients had a general but limited sense of risks associated with excessive GWG, with little appreciation of long-term effects. In general, patients reported limited counseling on these matters by their PCPs, unless they brought up the topic themselves. However, our study revealed physicians were very knowledgeable about risks of excessive GWG and reported counseling by means of discussion in early pregnancy and referral to online material, although approaches varied greatly. This variation highlights previously documented discrepancies in information delivered to and retained by patients,15 with patients perceiving lack of counseling despite physicians’ efforts.24 This failure to recognize counseling was especially prominent among FHC participants. Generally, physicians acknowledged barriers to healthy lifestyle mentioned by patients but were unsure how to address them.
In our study, patients from SETFHT generally had high health literacy and were proactive in their interactions with health care providers. Barriers to healthy nutrition and exercise during pregnancy included physical symptoms and difficulty navigating the abundance of online resources, with patients describing a sense of resource overload. They expressed a desire for physicians to provide trusted resources early in pregnancy. Physicians’ barriers to counseling this population were time constraints and superseding priorities during prenatal appointments, results echoed by a qualitative study by Piccinini-Vallis.24 The discrepancy between physicians’ counseling on weight management and patient compliance is an important area in need of ongoing research.24 A possible solution for this group is to provide patients with comprehensive resources and counseling early in pregnancy, with periodic assessments of compliance to facilitate opportunities to offer guidance. As other studies indicate,11 these information-seeking patients might benefit from referral to other health care professionals, such as dietitians.
In contrast, patients from FHC had lower health literacy, had more passive interactions with PCPs, and were less likely to raise lifestyle concerns. These women relied more on their family and friends for advice, emphasizing the importance of targeting a population at large in shaping weight management perspectives.12 Common patient barriers to achieving healthy lifestyle in pregnancy included time constraints, low funds, and physical symptoms. Advocating for regular patient education in this population is essential to improve health literacy. Possible solutions include provision of translated pregnancy resources as well as prenatal classes for women from similar cultures incorporating a walking or exercise component, allowing women to connect to their community while participating in accessible physical activity.
Discussion with providers highlighted their understanding of excessive GWG, but also exposed their uncertainty about effectively counseling patients, noted in other studies.24 This is an important consequence of a knowledge gap, as people who have weight gain discussions with their clinicians are more likely to comply with recommendations.6 The Society of Obstetricians and Gynaecologists of Canada recommends using periodic health visits before pregnancy as an ideal opportunity to address weight,2 with a focus on overweight and obese people. Specific published guidelines to use for this purpose are plentiful and include the Institute of Medicine weight guidelines,17 prenatal nutrition advice,11,25 and antenatal and postpartum exercise guidelines.14,18
In general, authors have noted success if patients set small goals for behaviour change, using the health of the developing fetus as motivation,10 a driver reflected by our patients. One group suggests using the “5As” of healthy gestational weight gain6 as a framework for counseling on weight gain, ideally starting before pregnancy: ask permission, assess the root causes of inappropriate weight gain, advise on pregnancy weight gain risks and management options, agree on a realistic plan, and assist in identifying barriers and arranging education, referrals, and follow-up.6
In addition to proactive counseling, it would be synergistic for GWG interventions to be put into place. Despite the reality of construed social norms, most GWG interventions have engaged women on an individual basis, ignoring their social networks.12 Our study demonstrates the importance of considering the social determinants of health when counseling about lifestyle. Our findings starkly contrast 2 populations of women from differing socioeconomic backgrounds, highlighting their unique approaches to health, and, in turn, the need for physicians to tailor interventions accordingly. Future directions for research include investigating patient- and culture-centred interventions.
Limitations
This study has a few important limitations. One limitation is that the interview guide was independently developed without a formal validation process; however, the guide was adjusted throughout the study according to grounded theory methods, and participants were encouraged to raise discussion points other than our questions. We had 8 physician and 10 patient participants, which is a small but reasonable number for qualitative studies. Our SETFHT focus groups were small, but some participants might not feel comfortable sharing information in a focus group; consequently private interviews could have provided richer information. However, focus groups were conducted out of convenience, as participants were recruited after a group meet-and-greet event, and previous studies attempting interviews at this clinic have resulted in low buy-in. Having only 1 physician focus group raises the possibility that saturation of data was not reached in this group. However, the group is representative of our provider population. Patients recruited for interviews from FHC were all under the care of the same provider providing prenatal care on the day of interviews, introducing selection bias. We were unable to determine whether previous pregnancies had had excessive GWG; because we know this condition can propagate in further pregnancies, this lack of knowledge is a limitation of the study. We were unable to compare weight trends among nulliparous versus multiparous women, given small sample sizes; however, nulliparous weight gain was not a focus of our qualitative study.
Conclusion
Healthy lifestyle in pregnancy is an important but underemphasized topic in antenatal care owing to myriad barriers faced by patients and providers. This gap provides an opportunity to increase patient and provider education and develop patient-centred weight management interventions. By contrasting patient barriers from two socioeconomic backgrounds, our study reflected the importance of addressing social determinants of health in developing GWG interventions.
Notes
Editor’s key points
▸ Excessive gestational weight gain is increasingly prevalent in North America and poses risks to mother and baby. Gestational weight management is an important yet underemphasized aspect of antenatal care. Physicians know about the risks of gestational weight gain but face barriers to counseling patients.
▸ Patients are unaware of the long-term consequences of excessive gestational weight gain and carry culturally driven misconceptions about what constitutes health in pregnancy.
▸ Several sociocultural factors should be considered in implementing weight-related interventions, including social influences and traditional food choices.
Points de repère du rédacteur
▸ Le gain pondéral excessif durant la grossesse est de plus en plus fréquent en Amérique du Nord, et il pose des risques pour la mère et l’enfant. La prise en charge du poids gestationnel est importante, mais il s’agit pourtant d’un aspect sur lequel on insiste peu dans les soins prénataux. Les médecins sont au courant des risques posés par le gain pondéral élevé durant la grossesse, mais ils rencontrent des obstacles dans leur counseling aux patientes.
▸ Les patientes ne sont pas au fait des conséquences à long terme d’un gain de poids gestationnel excessif, et elles ont des idées erronées d’origine culturelle sur ce qu’est la santé durant la grossesse.
▸ Divers facteurs socioculturels devraient être pris en compte dans la mise en œuvre d’interventions liées au poids, y compris les influences sociales et les choix alimentaires traditionnels.
Footnotes
Contributors
Drs Di Stefano and Godard came up with the research concept, conducted qualitative interviews, and synthesized data. Dr Bellaire assisted with research design, participant recruitment, and manuscript editing.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © the College of Family Physicians of Canada
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