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Women and Birth xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Women and Birth

journal homepage: www.elsevier.com/locate/wombi

ORIGINAL RESEARCH – QUALITATIVE

The perspectives of obese women receiving antenatal care:

A qualitative study of women’s experiences
Catherine R. Knight-Agarwal a,*, Lauren T. Williams b, Deborah Davis c, Rachel Davey d,
Rebecca Shepherd a, Alice Downing a, Kathryn Lawson a
a
Discipline of Nutrition and Dietetics, School of Public Health and Nutrition, Faculty of Health, The University of Canberra, University Drive, Bruce, ACT 2617,
Australia
b
Discipline of Nutrition and Dietetics, School of Allied Health Sciences, Griffith University, Gold Coast Campus, Parklands Drive, Southport, QLD 4215,
Australia
c
Discipline of Nursing and Midwifery, Faculty of Health, The University of Canberra, University Drive, Bruce, ACT 2617, Australia
d
Centre for Action and Research in Public Health, Faculty of Health, The University of Canberra, University Drive, Bruce, ACT 2617, Australia

A R T I C L E I N F O A B S T R A C T

Article history: Background: The prevalence of overweight and obesity is increasing amongst women of child bearing
Received 6 May 2015 age. Maternal obesity has implications for both mother and baby including increased health risks from
Received in revised form 9 October 2015 gestational hypertensive disorders, caesarean section and stillbirth. Despite the increasing prevalence of
Accepted 17 October 2015
maternal obesity little is known of the experiences of these women within the health care system. The
aim of this research was to investigate the perspectives of pregnant women with a body mass index
Keywords: (BMI) of 30 kg/m2 receiving antenatal care.
High BMI
Methods: A qualitative study using individual interviews was undertaken. Sixteen pregnant women
Pregnancy
Women’s health
with a BMI 30 kg/m2 participated. Interviews were audio recorded, transcribed, cross checked for
Qualitative study consistency and then entered into a word processing document for analysis. Data was analysed using
Phenomenology Interpretative Phenomenological Analysis. In any phenomenological study the researcher’s objective is
to elicit the participant’s views on their lived experiences.
Findings: Four major themes emerged: (1) obese during pregnancy as part of a long history of obesity; (2)
lack of knowledge of the key complications of obesity for both mother and child; (3) communication
about weight and gestational weight gain can be conflicting, confusing and judgmental; (4) most women
are motivated to eat well during pregnancy and want help to do so.
Conclusion: Specialist lifestyle interventions for obese women should be a priority in antenatal care.
Extra support is required to assist obese women in pregnancy achieve recommended nutritional and
weight goals. Health professionals should approach the issue of maternal obesity in an informative but
non-judgmental way.
ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf
of Australian College of Midwives.

1. Introduction young women with the Australian Health Survey reporting

Worldwide, obesity is identified as a major public health
problem. In Australia, the prevalence of overweight and obesity
has been steadily increasing for the past three decades. In 2011–
12, approximately 60% of Australian adults were classified as
overweight or obese, and more than 25% of these fell into the
obese category.1 There is an increasing incidence of obesity in
* Corresponding author at: Locked Bag 1, University of Canberra, ACT 2601,
Australia. Tel.: +61 0407806663.
E-mail address: Cathy.Knight-Agarwal@canberra.edu.au (C.R. Knight-Agarwal).
42.4% of women in the peak child bearing years of 25–34 to be
overweight or obese.2 Maternal obesity and excess weight gain
during pregnancy are associated with increased incidence of
gestational diabetes, caesarean sections and increased stillbirth
and neonatal death.3–6 Along with the personal consequences,
obesity significantly burdens the current health care system.
A US study estimated that maternal obesity is associated with
an increased direct cost of $US2387 per pregnancy.7 Occupa-
tional health and safety issues can be encountered by staff
caring for obese pregnant women including difficulty lifting
patients and obtaining access to bariatric beds and operating
tables.8,9

http://dx.doi.org/10.1016/j.wombi.2015.10.008
1871-5192/ß 2015 Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd) on behalf of Australian College of Midwives.

Please cite this article in press as: Knight-Agarwal CR, et al. The perspectives of obese women receiving antenatal care: A qualitative
study of women’s experiences. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.10.008
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At the same time, there has been less emphasis on weighing
pregnant women in Australian antenatal clinics despite both
national and international recommendations.10 While acknowl-
edging the limitations of body mass index (BMI), it is considered to
be reliable at a population level.11 The Australian Government
released clinical practice guidelines for antenatal care in
2013 which recommend gestational weight gain advice to women
in relation to their BMI at conception.10 The Royal Australian and
New Zealand College of Obstetricians and Gynaecologists advocate
for women to have their BMI documented at their first antenatal
appointment. They also recommend those in high BMI categories
be offered referral to allied health services such as dietetics.12 The
US Institute of Medicine recommends health professionals record
women’s weight, height, and BMI as part of routine antenatal and
post-natal care.13 Likewise, the UK National Institute for Health
and Care Excellence encourages maternity care providers to
monitor and assess weight management before, during and after
pregnancy.14
Perhaps as a result of weighing no longer being a significant part
of antenatal practice, there appears to be a lack of knowledge
amongst pregnant women about the effects of obesity on maternal
and child health.9 In a prospective cohort study, Sui and colleagues
reported that obese pregnant women were significantly
(p < 0.001) less likely to correctly identify their BMI and more
likely to experience higher gestational weight gain than women of
normal BMI.15 These results are supported by Shub and
colleague’s16 who interviewed 364 pregnant women regarding
their knowledge of weight, gestational weight gain and complica-
tions of obesity. They found that women had little knowledge of
the risks associated with excess gestational weight gain and
maternal obesity. Conversely, another Australian survey of
412 pregnant women carried out by Nitert et al.17 found that
the majority of women in their cohort identified that overweight
and obesity increases the overall risk of complications for
pregnancy and childbirth. The researchers concluded that level
of maternal education status was a main determinant of the extent
of knowledge.
Many women with obesity receiving antenatal care perceive it
in a negative light. In a UK study, pregnant women with a BMI of
30 kg/m2 felt stigmatised and that strong lines of communication
between themselves and their maternity care providers were often
lacking.18 These findings were replicated in one phenomenological
Danish study where obese pregnant women felt they were treated
with a lack of respect compared to normal weight women. They
expressed dissatisfaction that information provided by healthcare
professionals, including gestational weight gain advice, was vague
and often inconsistent.19 In a series of semi-structured interviews,
Stengel and colleagues20 found that many obese women desire and
value gestational weight gain advice from their health care
provider. Our previous qualitative research has shown that health
professionals themselves acknowledge that the advice offered to
pregnant women, particularly in regards to gestational weight
gain, was inconsistent.9 A sense of frustration was expressed by
obstetricians and midwives, that clear Australian evidence based
guidelines for gestational weight gain are lacking and that
international recommendations are out-dated.9 The initiation of
a conversation about weight with applicable women was viewed
as a sensitive issue by health professionals and we note the voices
of those providing antenatal care is as important as the voices of
those receiving it.9 The aim of this study was to add the voices of
the women who are obese, pregnant and receiving antenatal care.
In choosing Interpretative Phenomenological Analysis as the
methodological approach we committed to exploring and inter-
preting the means by which obese pregnant women make sense of
their lived experiences.21 Incorporating such perspectives into the
development and implementation of maternity services may
Please cite this article in press as: Knight-Agarwal CR, et al. The perspectives of obese women receiving antenatal care: A qualitative
study of women’s experiences. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.10.008
encourage women’s positive engagement with them. This research
is not trying to create a representative study but rather to
understand the manner in which obesity impacts the lives of those
pregnant women interviewed.
2. Methods
2.1. Design
Methodological experts recommend employing a qualitative
approach when the research aim is to answer complex questions
such as those relating to lifestyle related behaviours.22 The
analytical process in Interpretative Phenomenological Analysis is
often described in terms of a double hermeneutic as firstly, the
participants make meaning of their world and, secondly, the
researcher tries to translate that meaning to make sense of the
participants’ meaning making.21 The result is a method which is
descriptive (concerned with how things appear) and interpretative
(recognises there is no such thing as an un-interpreted phenome-
non). At the same time Interpretative Phenomenological Analysis
is inherently idiographic23 and qualitative researchers who use
this approach explore every single case transcript by asking critical
questions such as Do I have a sense of something going on here that
maybe the participants themselves are less aware of?23 Smith
emphasises that conclusions need to be firmly rooted in what the
participants have actually said with wide application of direct
quotes to substantiate findings.21 Smith et al.24 have welcomed
and encouraged health professionals without formal training in
psychology, such as midwives and dietitians, to use Interpretative
Phenomenological Analysis to explore subjective questions of
importance to their discipline. Therefore, the objective is not to test
a predetermined hypothesis rather to explore, flexibly and in
detail, an area of concern.
2.2. Setting
The health facility chosen as the site for the research is the
largest public hospital in the region, supporting a population of
over 500,000 people with approximately 3700 deliveries per
annum (Knight, personal communication).25
2.3. Participants
Researchers attended the waiting room of the antenatal clinic
during hours of operation and approached all women about the
study. Those who expressed interest (and provided permission)
were asked some basic questions such as What is your height?,
What is your weight?, What is your date of birth and How many weeks
pregnant are you? Researchers then calculated BMI and determined
the woman’s eligibility to participate. Eligibility criteria included a
BMI of 30 kg/m2, aged 18 years or older, of at least 12 weeks
gestation and who were accessing care through the local area
health service. Women who were eligible and agreed to be
interviewed provided signed consent and were given unique
identifying numbers to ensure anonymity.
2.4. Procedure
The questions for the semi-structured interview protocol were
based upon a discussion between the primary researchers and a
review of the published literature.12–16,26,27 Demographic data
were also collected. Grades of obesity were categorised using self-
reported height and weight to calculate BMI and the classification
system of the World Health Organisation.28 Interviews were
conducted between September 2012 and November 2013. Parti-
cipants were asked to choose a time for the interview that suited
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them and all elected to be interviewed on the spot. As weight can be a
sensitive topic to discuss, women were given the choice to be
interviewed in either a quiet area of the antenatal clinic or in a
private room. The majority of questions were kept deliberately open
providing cues for participants to talk with a minimum of
interruption and without judgement. Each interview was audio
recorded and transcribed verbatim by the principle investigator and
research assistants independently, cross checked for consistency
and then entered into a word processing document for analysis.
2.5. Ethics
Ethical approval to conduct this research was received from the
relevant university and Health Sector Human Research Ethics
Committee’s (No: ETH.6.11.124).
gestation and parity as shown in Table 1. They came from different
geographical areas situated within and around the study hospital.
Fifteen women had a singleton pregnancy and one woman was
carrying twins. The majority of women fell into the obese class III
category (BMI >40 kg/m2).28 Following the sixteenth interview no
new or relevant information had emerged indicating data
saturation had been reached.
An emergent finding was the high frequency of miscarriage and
still birth reported by the women as a result of asking about
number of previous pregnancies (see Table 1). Another disturbing
finding was the self-reported prevalence of Gestational Diabetes
Mellitus which is also reported in the table.
Four super-ordinate themes relating to maternal obesity were
identified and results are described under these themes with
quotes to illustrate the findings (see Table 2).

2.6. Data analysis 3.1. Obese during pregnancy as part of a long history of obesity

The Interpretative Phenomenological Analysis protocol de-
scribed by Smith and Osborn21 was applied to the data. The first
step in the analysis involved repeated reading of all the transcribed
interviews. Each line within each transcript was numbered to enable
the researchers to locate specific information during all stages of the
analysis. Attention was paid to the type of language used by the
women and preliminary codes that summarised content and initial
interpretations were written on each transcript. These codes were
then clustered into preliminary themes, with care being taken to
ensure that these were consistent with the data. When this process
had been repeated with each transcript the resulting set of
preliminary themes were examined to identify recurrent patterns
across all sixteen transcripts. A final set of superordinate themes
emerged and corresponding quotes were assigned to each of these
themes.21 Quotes were given a unique identifier comprising
characters to first identify the participant and second to indicate
the line(s) from which the extract in question was taken. Thus, P1/
L45 indicates that the quote was taken from participant 1 and begins
on line 45 of the transcript. Any discrepancies in coding between the
researchers were discussed by presenting arguments for their
interpretation. Agreement was always reached following this
process. The final themes were then compared and reviewed with
three senior researchers as a means of triangulation.23
3. Results
Sixteen women, all with a self-reported pre-pregnancy BMI of
30 kg/m2, took part in the study. Participants were of varying
Many participants reported having issues with their body size
and have ‘‘struggled [their] whole life with weight’’ (P7, L61).
Nevertheless, these women recognised that being overweight can
contribute to maternal pregnancy complications such as an
increased risk of caesarean section as one woman commented:
‘‘I really want to go natural but because of my weight I might not be
able to go natural. . . it might be too much of a health risk’’ (P15, L40).
Women acknowledged that excess weight gain can be viewed
negatively by the broader community and that this way of thinking
now even extends into pregnancy as one woman commented:
‘‘Um, well weight gain. . . . . . is not a particularly nice thing. . . . . .
there’s a perception out there that weight gain isn’t good [even in
pregnancy]’’ (I6, L43). Some others emphasised the psychological
burden that some overweight women may feel as a result of being
constantly represented in a negative light by the media and society
in general.
For women who had experienced previous pregnancies there
was a real concern about losing excess body weight in the post-
natal period as one participant expressed:
‘‘I think for me the time that I struggled the most was actually
after the birth. . . . . . I think I [initially] lost maybe eight or ten
kilos or around that sort of thing but I think I then had a bit of
postnatal depression and it was just such a stressful time that I
just didn’t know how to organise myself, to get meals and things
like that ready. . . . . . so I just ate absolute rubbish, and just
wanted to get through the day basically. . . . . . and then I put on
all that weight again’’ (I14, L116).

Table 1
Demographic information of study participants.

Participant Parity Gestation Pre-pregnancy Pre-pregnancy Pre-pregnancy Previous stillbirth GDM Obesity class
height (m) weight (kg) BMI (kg/m2) or miscarriage

1 3 28 1.55 95.0 39.5 Yes Yes Obese class II

2 1 31 1.60 96.0 37.5 No No Obese class II
3 5 28 1.56 94.0 38.7 Yes No Obese class II
4 1 22 1.65 120.0 44.1 No Yes Obese class III
5 4 28 1.60 126.0 49.2 Yes Yes Obese class III
6 5 30 1.73 154.0 51.5 Yes Yes Obese class III
7 1 32 1.70 119.0 41.2 No Yes Obese class III
8 0 36 1.67 130.0 46.6 No Yes Obese class III
9 3 16 1.70 120.0 41.5 Yes No Obese class III
10 0 19 1.59 80.0 31.6 No No Obese class I
11 2 12 1.52 104.0 45.0 No Yes Obese class III
12 1 38 1.72 105.0 35.5 No Yes Obese class II
13 0 37 1.76 120.0 38.7 No Yes Obese class II
14 1 36 1.60 108.0 42.2 No No Obese class III
15 2 14 1.65 110.0 40.4 Yes No Obese class III
16 1 37 1.75 121.0 39.5 No No Obese class II

Please cite this article in press as: Knight-Agarwal CR, et al. The perspectives of obese women receiving antenatal care: A qualitative
study of women’s experiences. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.10.008
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4 C.R. Knight-Agarwal et al. / Women and Birth xxx (2015) xxx–xxx

Table 2
Codes, themes and indicative quotes.

Examples of codes Themes Indicative quotes

Lifelong struggle with weight
Postnatal weight retention is an issue
Obese women want a normal pregnancy
Weighing not routine
Limited awareness of effect of GWG on baby
Limited awareness of GWG targets
Differing GWG advice
Not enough information out there
Motivation is the key
Women want on-line resources
Obese during pregnancy
as part of a long history
of obesity
Lack of knowledge of the
key complications of obesity
for both mother and child
Communication about weight
and GWG can be conflicting,
confusing and judgemental
Most women are motivated to
eat well during pregnancy and
want help to do so
‘‘I really want to go natural but because of my weight I might not be able
to go natural. it might be too much of a health risk’’ (P15, L40)
‘‘I think for me the time that I struggled the most was actually after the
birth (of last child)’’ (I14, L116)
‘‘no one has even taken my weight. . ..’’ (I2, L48)
‘‘I guess it would have to be your normal weight plus 15 kilograms or
something? (P14, L60)
‘‘I was told because I started over weight I am not allowed to gain any and
I should be losing . . .. that is what they (doctors) told me so no pressure!’’
(I13, L57) and following this ‘‘(the) midwives told me (putting on)
10 kilos is normal’’ (I13, L60)
‘‘I think that you sort of get mixed messages. . ..’’ (I14, L147)
‘‘You can know what you’re supposed to be doing until you’re black and
blue in the face but that doesn’t mean I’m doing what I’m supposed to be
doing and that is a huge problem’’ (I3, L109)

This participant emphasises the importance of postnatal
support, particularly regarding weight control, and this appears
to be of particular concern for multiparous women.
3.2. Lack of knowledge of the key complications of obesity for both
mother and child
Interestingly, very few women were able to articulate why
excess maternal weight may contribute to adverse health out-
comes for the offspring as one woman exclaimed: ‘‘I have no idea. . .
. . . I have no idea’’ (P2, L44). Some women possessed knowledge
about (and had experienced) maternal complications associated
with high BMI as one woman commented: ‘‘I’ve got to have a
caesarean so obviously there’s more dangers health wise going
through the caesarean being heavier than if I wasn’t’’ (P3, L73).
Nevertheless, health professionals appeared to do little to discuss
the desirable range of gestational weight gain. As a result of the
health professionals not speaking about pregnancy BMI or
gestational weight gain this apparently implied to the women
that weight was not a priority: ‘‘no one has even taken my weight. . .
. . .. I have jumped on the scales a few times just for my own sake to see
what’s happening’’ (I2, L48). Other women recognised that talking
about weight is a sensitive issue and that this may be a reason why
some health professionals ‘shy away’ from such conversations. One
participant commented: ‘‘I mean I suppose maybe there is. . . . . . a
little bit of shying away from that um with pregnancies now, maybe
because I think too much of an emphasis can make you feel awful, and
terrible the whole time’’ (I14, L88).
Others had experienced the reverse situation with almost every
health professional bringing up the issue of weight during routine
antenatal visits as one woman exclaimed:
‘‘The last appointment I had here I had two doctors and one
diabetes specialist all hounding me [about my weight] and they
can just be so nasty sometimes, they really can. Just all three of
them in my face and. . .. It’s like one person is enough you
know?. . . . . . I don’t need to be told every appointment, you
know, you’re not doing good enough’’’ (P13, L102).
As outlined previously, some women expressed an awareness
that high gestational weight gain may lead to post-partum weight
retention thus exacerbating their already high BMI. Despite this,
when asked about optimal gestational weight gain the majority of
participants were unable to correctly identify the IOM recom-
mendations for their pre-pregnancy weight as one woman stated:
‘‘I think it’s like. . . . . . between 7 and 12 kilos I believe? I don’t know, I
really don’t know to be honest’’ (P2, L37) and another commented ‘‘I
guess it would have to be your normal weight plus 15 kilograms or
something? (P14, L60). One woman posed the question back to the
interviewer ‘‘as much as the baby is gonna be?’’ (P10, L29).
3.3. Communication about weight and GWG can be conflicting,
confusing and judgemental
Women were asked if they had received GWG advice during
routine antenatal visits. The message that came across was that
information was often inconsistent and confusing. For example
one participant reported receiving contradictory weight gain
advice from two separate health professionals: ‘‘I was told because I
started over weight I am not allowed to gain any and I should be losing
. . .that is what they [doctors] told me so no pressure! and following
this ‘‘[the] midwives told me [putting on] 10 kilos is normal’’ (I13,
L60).
For other women the advice they received was delivered in a
non-specific blasé fashion: ‘‘She said [diabetes educator] you’ve got
plenty of reserves so there is not really any concern about weight gain’’
(I11, L53). Another woman commented that she was used to being
judged by people around her due to her fuller figure and that this
contributed to her already low self-esteem: ‘‘Any weight I put on is
very visual and you know everyone is always saying to me oh my God
what happened? What happened to you?’’ (I1, L42).
In many cases dietary advice was delivered by a health
professional other than dietitians in a negative rather than a
positive tone. One participant commented:
‘‘I didn’t really feel the advice was focused on nutrition and sort
of making us as healthy as possible and the baby as healthy as

Please cite this article in press as: Knight-Agarwal CR, et al. The perspectives of obese women receiving antenatal care: A qualitative
study of women’s experiences. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.10.008
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possible. . .. There was a real focus on what to avoid and what’s
going to give you food poisoning. . .. There wasn’t so much a
focus on what you should be eating. . . . . . and I think that is
more important for overweight women’’ (I14, L45).
Some women felt advice was given by health professionals in a
repetitive fashion and over time this had eroded the meaning for
these women. This seemed particularly true for women who had
experienced previous pregnancies: ‘‘Um, yeah like I’ve heard it all
before and it gets kind of old [the advice] after a while’’ (I9, L91). Some
others commented that their eating habits have been judged
purely by their outward physical appearance. The implication has
been made that obese women do not make healthy food choices
and that their ‘size’ is indicative of this as one woman commented:
‘‘They just look at you and go ‘ooh’ you just must eat junk’’ (I13, L112).
Women wanted messages to be clearer and for GWG advice to
be more individualised: ‘‘Um, I think that you sort of get mixed
messages really, about whether you should be trying to lose weight
or trying to maintain weight or if its ok to gain weight and so, I
don’t know, maybe some sort of tailored personal. . . . . . advice
would be good’’ (I14, L147).
3.4. Women are motivated to eat well during pregnancy and want
help to do so
Many of the women reported that good nutrition is important
in pregnancy and were motivated to make healthy food choices not
only for themselves but also for their growing baby. They saw
pregnancy as a time to start making positive changes to their
lifestyle. One participant stated: ‘‘[Diet] was the first thing that I
looked into when I found out that I was pregnant. . . . . . what I should
and shouldn’t eat. . .. . .me and my partner straight away thought we
have to eat a lot better’’ (I13, L50) and another made the comment
‘‘[Eating] well. . .. . . is making sure it [baby] gets all the nutrients it
needs’’ (I14, L48). While others felt that nutrition was not a high
priority during pregnancy as one woman commented: ‘‘I know I’m
probably supposed to say yes but I reckon no, it’s less important when
you’re pregnant, there’s many other things going on I reckon nutrition
just goes way down the list. . . . . . all [my] complications have
overshadowed nutrition for me’’ (I2, L27).
Some women expressed a desire to minimise their gestational
weight gain as one way to help control health problems which had
developed during pregnancy: ‘‘It’s horrible to say but probably having
the gestational diabetes. . .. . . has kind of been a good thing for me’’
(I1, L63). On the other hand, one woman who had had GDM in a
previous pregnancy reported: ‘‘I suspected I was going to get
gestational diabetes again so I asked if I could get like some information
on that but they couldn’t give it until I had gestational diabetes. . . . . .. So
I thought that was a bit (beep). . . . . .. I’ve just had it now [the
information] at 32 weeks when I could have had it at 24 weeks. . ..’’
(I7, L48). This woman felt that development of her GDM could
have been avoided (or delayed) if the opportunity of receiving help
early in her pregnancy had been made available to her.
Women were motivated to attend antenatal education classes
through the antenatal clinic and it was acknowledged by some that
health professionals were a motivating force behind their desire to
follow a healthy lifestyle as one participant commented: ‘they sort
of drill it into you pretty hard. . . . . . it’s really useful’’ (I6, L74).
Conversely, another woman had not been influenced or motivated
to make healthy lifestyle changes by anyone or anything as she
declared: ‘‘I don’t follow the [listeria related] rules cause I don’t see the
difference. . .. With my last pregnancy I didn’t follow the rules and my
son’s fine’’ (P9 L155).
Some women felt that the internet was the best way to receive
information and that it did not bother them that the resources they
required were not available through their health care provider: ‘‘I
Please cite this article in press as: Knight-Agarwal CR, et al. The perspectives of obese women receiving antenatal care: A qualitative
study of women’s experiences. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.10.008
5
google just about everything. . .. So it’s important that it’s online’’ (I11,
L126). This raises the issue of the credibility of resources being
accessed in this way. Other participants were pleased with the
resources made available to them but emphasised that individua-
lising weight and dietary advice would be beneficial as one woman
commented: ‘‘I’ve been really happy with what I have received so
far. . . but a bit more information on the weight gain side of things
would be good’’ (I11, L136). Some participants relayed a desire for
better access to dietetic services during pregnancy: ‘‘I guess I feel
like it should kind of be compulsory that you see a dietitian early on
because I didn’t get to until the gestational diabetes and by that point
[was already 34 weeks] (I13, L139) and another woman claimed: ‘‘I
think that dietitians would be useful to hear from. . . . . .dietitians who
actually understand pregnancy and what your [GWG and nutrient]
needs are’’ (I14, L131). Some women felt that all maternity care
providers should have the ability to provide basic nutrition advice:
‘‘From a public health point of view anybody who is asked a [nutrition
related] question should give the basic [answer] and refer on if they
need to’’ (P16, L164).
4. Discussion
The findings from this qualitative exploration provide an
important and useful insight into the views and perspectives of
obese women receiving antenatal care at a public health facility in
Australia.
Many women in our study reported a long history of weight
struggles. They recognised that being obese and excessive gesta-
tional weight gain increases the risk of maternal pregnancy
complications such as caesarean section however their understand-
ing of possible adverse perinatal outcomes was poor. An Australian
survey conducted by Shub et al.16 reported that women were more
aware of personal long term health risks rather than perinatal risks
associated with pregnancy. Likewise, the Nitert et al.17 study
reported that more than 60% of their cohort identified that obesity
increases the risk of caesarean section but less than half identified
that there was an increased risk of adverse neonatal outcomes. A
review of the literature found that women make a conscious effort to
be healthy in pregnancy for the sake of their growing baby.29 Better
awareness of the perinatal complications of obesity and excess
gestational weight gain might add an additional motivating factor
for women to improve outcomes for their offspring.
Our study reinforced the results of similar research that obesity
is a sensitive topic to discuss. Some women reported that weight
issues had not been mentioned by their maternity care providers.
One participant believed the lack of discussion about weight was
the result of ‘shying away’ from such discussions in order to
prevent women feeling ‘terrible’ and ‘awful’. Furness et al.30
similarly reported that some midwives in their qualitative
investigation admitted feeling awkward and anxious about using
obesity terminology which the authors believe demonstrates that
weight stigma in healthcare is still very much alive. Other
qualitative research has reported similar findings.31 Brown and
Thompson32 found that primary care nurses in the UK use a range
of strategies when managing and discussing sensitive issues such
as obesity for example motivational interviewing techniques.
Women in our study described negative encounters with health
professionals. One participant reported being ‘hounded’ by
obstetric staff regarding her diet and weight which led to feelings
of guilt and resentment. Similar experiences of obese pregnant
women have been reported in the literature.8,18,19,33,34 Previous
qualitative research has recommended that students and health
professionals working in antenatal care should be educated
regarding the best way to approach the issue of obesity and
appropriate gestational weight gain and should relay this
information in both a non-judgemental and informative way.9
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6 C.R. Knight-Agarwal et al. / Women and Birth xxx (2015) xxx–xxx
Our study reinforced the results of other research that women
have poor knowledge of current gestational weight gain recom-
mendations.35 Shub et al.16 found that overweight and obese
women were more likely to report inaccurate gestational weight
gain targets than women with a normal BMI. In a US survey, 71% of
pregnant women did not know their appropriate gestational
weight gain.36 Interestingly, the authors reported that only 46% of
obese women claimed that their maternity care provider had
initiated discussions around gestational weight gain. Some women
in our study acknowledged that post-natal weight retention was of
concern to them. Yet with poor knowledge of recommended
gestational weight gain targets and the fact that weighing has all
but disappeared from routine antenatal care this fear is more likely
to become a reality. Avoiding excessive gestational weight gain is
important for women’s long term health given the risk factor for
overweight and obesity postpartum.37 Results from the US
National Longitudinal Survey of Youth revealed that parous
women were up to four times more likely to develop obesity in
the 5 years after childbirth compared to non-parous women
followed over the same time period.38 Interventions to help
women minimise their gestational weight gain should perhaps
extend into the post-natal period and parity should be a
consideration when planning such interventions.
Several of the women in this study reported that advice about
gestational weight gain, was inconsistent, an issue that has been
reported elsewhere.39 This is probably unsurprising given the lack
of Australian evidence based guidelines for gestational weight
gain. What is of particular concern is that some women are
receiving gestational weight gain advice from health professionals
that is significantly different from the current Institute of Medicine
guidelines for example no weight gain for women with a high BMI.
A recent systematic review and meta-analysis emphasised that
gestational weight gain below the guidelines should not be
routinely recommended.40
Women expressed the need for a variety of different pregnancy
resources. The internet was suggested as one way to reach the
target audience and provide credible information. This has been
reported elsewhere.41 Garnweider and colleagues investigated
pregnant women’s experiences of nutrition related information
and found the internet to be the most popular source. One of their
key findings was that women did not seem to ‘‘critically evaluate’’
the quality of information they accessed.42 If healthcare institu-
tions are to suggest women use the internet to obtain pregnancy
related material then links to credible sites should be provided as
part of routine antenatal care.
Women in this study expressed the belief that pregnancy is an
opportunistic time to undertake positive lifestyle changes and
these results are mirrored elsewhere.43,44 Women felt that there
was a lack of specialist nutrition support available and, in
particular, noted a scarcity of dietitians in routine antenatal
clinics. The need for dietetic intervention in the prevention and
treatment of maternal obesity has been recognised previously but
is currently lacking in practice.9,45 Nevertheless, women felt that it
would be useful for all maternity care providers to be equipped to
provide basic gestational weight gain and dietary advice. While
midwives are well placed to do this, a recent review of the
literature29 reported that the Australian standards of accreditation
of nursing and midwifery courses provide no content on nutrition.
The authors recommended that midwives may find benefit in
collaborating with dietitians in the development and implemen-
tation of pregnancy nutrition best practice guidelines.
5. Strengths and limitations
The findings from this study may assist the future develop-
ment of more effective health care for pregnant women who are
Please cite this article in press as: Knight-Agarwal CR, et al. The perspectives of obese women receiving antenatal care: A qualitative
study of women’s experiences. Women Birth (2015), http://dx.doi.org/10.1016/j.wombi.2015.10.008
obese. This was a small study from one geographical area and
the perspectives of the women who participated in the
interviews may not reflect those of women elsewhere. Only
one hospital in the area health service was involved however
that hospital is the major provider of antenatal services in the
region. The researchers were trained in interview procedures,
necessary to reduce interviewer bias and to ensure questions
were administered in a standardised way. It is also important to
note that the study was an exploration of the perspectives of
obese, pregnant women and was not intended to be an
evaluation of current antenatal practice.
6. Implications for practice, policy and future research
The study identified several key issues from the women
interviewed. The current evidence of the effectiveness of inter-
ventions for managing pregnant women with high BMI is limited
and therefore the design of any new intervention should include
consultation with key stakeholders. The themes generated by this
study may form a foundation from which to conduct new empirical
research and inform clinical policy and practice.
7. Conclusion
The study shows that women would find regular weighing
during antenatal care, as part of routine practice, useful and that
women are motivated to stay healthy for themselves and their
unborn child. However, while women acknowledge some con-
sequences of maternal obesity for themselves, they are largely
unaware of the negative physical consequences for their offspring.
Women need clear gestational weight gain guidelines, better
access to credible dietary information and ongoing support.
Ideally, dietitians would be involved in a service supporting
midwives to provide women in their care with basic nutrition and
weight gain advice. Motivational interviewing is a communication
technique that obstetricians, midwives and dietitians may find
useful to employ with women in their care. Women may be
receptive to regular weight monitoring if this is undertaken in a
sensitive and non-judgemental way, with a clearly defined
purpose.
Contribution to authorship
CRKA was the principle investigator and contributed to study
design, recruitment, data collection and produced the first draft of
the paper. RS, KL and AD assisted with recruitment and data
collection. Coding of transcripts was undertaken by CRKA and LJW
separately. LJW, DD and RD were co-applicants and contributed to
the study design and drafting the final paper.
Ethical approval
Ethical approval to conduct this research was received from the
University of Canberra and ACT Health Human Research Ethics
Committee’s (No: ETH.6.11.124).
Funding
A small part of Australian Government Research Training
Scheme (RTS) was used.
Conflict of interests
None.
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C.R. Knight-Agarwal et al. / Women and Birth xxx (2015) xxx–xxx
Acknowledgements
We would like to thank Dr David C. Knight FRANZCOG for his
assistance with recruitment and commenting on previous drafts of
the manuscript. We would also like to thank Ms Emma Agnew for
assisting with proof reading of the transcripts.
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