Guest Blog – weight and healthy eating in pregnancy – by PhD student Helen Parsons

This month we have a guest blog by Helen Parsons. I remember discussing this research some months (maybe even years!) back, so I’m delighted to hear now about Helen’s results. You might remember her recruitment ad on here last year! Many of us have discussions around weight and healthy eating in pregnancy, so I’m so glad some of you shared your views.

Over to you, Helen!

Headshot of Helen Parsons who is white, with shoulder length sandy coloured hair

Hi I’m Helen. First and foremost, I am a mum of two and a Doula passionate about all things pregnancy and birth related. I am undertaking a PhD in Psychology at Birmingham City University, researching eating behaviours, body image and self-compassion during pregnancy and early motherhood.

I have now concluded my research and would love to share some of the findings with you.

A bit more about me

I have two teenage boys and have had a difficult relationship with food since I was a teenager. My weight has yo-yo’ed throughout my life. I am passionate about supporting women, especially during pregnancy, and I understand the challenges pregnancy can bring whilst navigating maternity services, especially with a raised BMI.

About my PhD

As a Doula, I know how the approaches and language used by maternity services providers can impact on pregnant women. My work has drawn me to investigating this area for my PhD. During my PhD I have interviewed new mothers as well as NHS midwives; from students and newly qualified midwives to those with over 25 years’ experience. I have also interviewed women and midwives from across England including women from Black and South Asian communities, who may already face greater challenges navigating healthcare and maternity systems.

Colourful image of various fruits, vegetables and nuts

Summary of my research

Background: Pregnancy has been described as a particularly powerful teachable moment to change health behaviours. This is because women may be especially motivated to improve their health, and they have more contact with Healthcare Professionals. Midwives provide maternity services to pregnant women during the antenatal period and may have the opportunity to discuss healthy eating.

The proposed study explored the experiences of women who had recently given birth, and midwives’ experiences of supporting women in relation to being healthy in pregnancy.

Methods: Interviews with 24 women who had recently given birth and with 13 NHS midwives with a range of experience from across England.

Results: I identified three key findings. First, most women want healthy eating information from their midwife. However, midwives may be reluctant or feel uncomfortable to engage in discussing weight and healthy eating with pregnant women in their care.

Second, midwives do not receive adequate training, guidance or resources to support them in these discussions. Midwives therefore resort to referring to their own self-taught knowledge, or their own pregnancy experiences, to provide advice and information around healthy eating.

Finally, BMI is the main factor used to determine any signposting or need for further support. BMI appears to be synonymous with weight and health when considering being healthy in pregnancy. However, irrespective of BMI, most women interviewed discussed experiencing difficulties with their weight, body image or eating habit before pregnancy. These women may benefit from additional support around healthy eating, but would miss out if BMI is the only factor considered.

Recommendations: The study gained a deeper understanding of the potential barriers and enablers to discussions with pregnant women about prenatal weight gain. This included eating behaviours, body image acceptance, and how to maintain a healthy pregnancy. The findings of this study will inform the development of a toolkit to enable discussions between pregnant women and midwives. The toolkit will take a holistic approach to health and wellbeing in pregnancy that prevents weight stigma.

What was I investigating in this research?

During the interviews with new mothers I was exploring their pregnancy experiences in relation to being healthy. I wanted to know what that meant and looked like to them. This included asking about their eating and exercise habits during pregnancy and how these changed during early motherhood. I asked about how they felt about their body as it changed during pregnancy, and how this impacted their eating habits. I also asked about their interactions with their NHS midwife, and the information they had been given about healthy eating.

During the interviews with NHS midwives, I was interested in their experiences of interacting with pregnant women. I also wanted to know about their discussions around healthy lifestyle and healthy eating. I wanted to better understand the midwife’s perspective of these topics including how much training and guidance midwives receive. Furthermore, I wanted to know how their work interacts with additional healthy lifestyle services that may be available to some pregnant women.

Illustration of a pregnant woman torn between 'healthy' and 'unhealthy' food choices

Why did I undertake this research?

Previous research informed the background and rationale for this research:

  • Pregnancy alone may not be sufficient to drive behaviour change (Fair and Soltani, 2021)
  • Pregnancy is especially complex due to the quantity and involvedness of behaviour change required of pregnant women (Olander et al., 2018) and it is unclear what changes women may make without intervention (Hillier et al., 2017).
  • Midwives in England are tasked with engaging in discussions about having a healthy pregnancy or may refer pregnant women to specialised services such as healthy lifestyle interventions.
  • Some midwives may avoid any discussion relating to weight or healthy lifestyles due to the fear of enacting weight stigma or creating feelings of shame or guilt (Atkinson et al, 2017).
  • Interventions for women with a raised BMI may decrease gestational weight gain but there is no clear evidence of improving pregnancy or birth outcomes.
  • It is also not clear which interventions are most effective (Fair and Soltani, 2021)
  • Interventions that show success in clinical settings, fail when translated into community-based services (Walker et al., 2018)
  • As a result, a better understanding of both women’s pregnancy experiences and midwives’ perspectives of discussing healthy lifestyle with all pregnant women in their care might offer a different viewpoint and may enlighten future approaches to the services offered to pregnant women.

So, what did I do?

Illustration showing a maternity appointment, where the woman's heavily pregnant stomach is being measured

I conducted two separate studies.

In study one I interviewed 24 women who had given birth recently (within 12 months of the interview). Some of these interviews were conducted online, others took place at community centres in the West Midlands to reach a more diverse population.

In study two I interviewed 13 NHS midwives who practise in England, including a student midwife close to qualification. All these interviews were conducted online to reach midwives from across England.

What did I find?

Both studies were consistent in finding that the level of discussion about healthy eating at antenatal appointments, outside of any specific healthy lifestyle intervention, was minimal, if it happened at all. Despite the discomfort midwives expressed about discussing weight and healthy eating, and their concern that some pregnant women may not wish to discuss eating or weight, most women did in fact want this information, and they wanted and expected to receive it from their midwife.

Midwives also recognised that this was important information and that women, therefore, needed to be given good quality information. Some midwives knew it was their duty to provide such information. However, they did not always feel adequately trained or equipped to engage effectively in the discussion, or to provide accurate and evidence-based information.

The information that midwives did provide, and the knowledge they had to draw upon for these discussions, was often based on their own self-directed learning and experiences, including from their own pregnancies. There was
little or no formal training for midwives around healthy eating. Outside of any additional intervention, the topics of healthy eating and pregnancy weight gain did not form part of any study days or mandatory training provision. Midwives across the board recognised that further training was needed. All those that were interviewed said they would welcome it.

BMI dominates

Another key finding of this research was the entire discussion with midwives around weight in pregnancy focussed on BMI. Any signposting to further services or additional discussions around healthy eating was ‘triggered’ by BMI. This was set at either 30 or 35, though there were midwives who said some services set it higher still. A raised BMI was also a trigger for more clinical and medicalised approaches. These included glucose tolerance testing, additional fetal scans and obstetric-led birth planning. This finding was also supported by women’s
experiences expressed in study one.

For women below the BMI threshold set, they received almost no information about healthy eating at all. Some midwives expressed that they knew there was poor evidence of using BMI for more medical/clinical referrals. Several midwives acknowledged that BMI is not a good indicator of health. Some felt that all women should be provided with good information about healthy eating. Midwives also said that they wondered what the impact might be if all women were provided with the same high-quality evidence-based information, irrespective of BMI.

This observation is relevant and interesting because in study One, the majority of new mothers, irrespective of pre-pregnancy BMI, said that they had experienced difficulties in the past with their weight, body image or eating habits. This may mean they are at a greater risk of developing issues in pregnancy. In addition, even though women had been healthy during their pregnancy, most women described that their eating habits got worse during early motherhood. This made losing any additional weight gained during pregnancy even more difficult.

Many of these women did not have a BMI above 30. Therefore they would have been entirely missed for receiving additional information and support. Support which may have helped them during pregnancy and beyond. Moreover, BMI and weight are often used to denote a healthy or unhealthy person, and as an indicator or proxy measure of healthy or unhealthy eating. This focus on BMI over any other considerations may also contribute to weight stigma.

How does this research contribute?

Many previous studies examining weight gain during pregnancy have focused on women with a raised BMI. They have only considered the services that these women are provided. This study finds that many women, irrespective of BMI, find managing their weight more difficult either in pregnancy or afterwards. Therefore they could also benefit from additional support during pregnancy. Instead of singling out women with a raised BMI, providing good quality healthy eating information to all pregnant women, irrespective of BMI, may also destigmatise weight during pregnancy.

In order to provide all pregnant women with consistent high-quality evidence-based information around healthy eating, midwives may benefit from receiving additional training, guidance and resources to add to their knowledge in this area.

Want more information about my research?

Please email me at helenelizabeth.parsons@mail.bcu.ac.uk.

An illustration of a colourful bookshelf

References
Atkinson, L. et al. (2017) ‘Midwives’ experiences of referring obese women to either
a community or home-based antenatal weight management service: Implications for
service providers and midwifery practice’, Midwifery, 49, pp. 102–109

Fair, F. and Soltani, H. (2021) ‘A meta-review of systematic reviews of lifestyle
interventions for reducing gestational weight gain in women with overweight or
obesity’, Obesity Reviews, 22(5), p. e1
3199

Hillier, S.E. and Olander, E.K. (2017) ‘Women’s dietary changes before and during
pregnancy: A systematic review’, Midwifery,
49, pp. 19–31


Olander, E.K., Smith, D.M. and Darwin, Z. (2018) ‘Health behaviour and pregnancy:
a time for change’, Journal of Reproductive and Infant Psychology, 36(1), pp. 1–
3


Walker, R., Bennett, C., Blumfield, M., Gwini, S., Ma, J., Wang, F., Wan, Y., & Truby,
H. (2018). Attenuating pregnancy weight gain—what works and why: A systematic
review and meta-analysis. Nutrients, 10(7), 944-

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