Systematic review
DOI: 10.1111/j.1471-0528.2011.02924.x
www.bjog.org
The maternity experience for women with a
body mass index ‡ 30 kg/m2: a meta-synthesis
D Smith, T Lavender
The School of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
Correspondence: Dr D Smith, The School of Nursing, Midwifery and Social Work, The University of Manchester, Jean McFarlane Building,
Oxford Road, Manchester M13 9PL, UK. Email [email protected]
Accepted 12 January 2011. Published Online 9 March 2011.
2
Background Maternal obesity (body mass index, BMI ‡ 30 kg/m )
Main results Three cluster themes (eight initial themes) were
is a global public health issue. There is a dearth of evidence
regarding an effective maternal care pathway for pregnant women
with a BMI ‡ 30 kg/m2.
highlighted: acceptance and inevitability of weight gain in
pregnancy; depersonalisation of care as a result of medicalisation;
and healthy lifestyle benefits for self and baby.
Objectives This meta-synthesis aims to increase our
Author’s conclusions Pregnancy is an ideal period for health
professionals to intervene, as women with a BMI ‡ 30 kg/m2
perceive their weight as more acceptable than when they were not
pregnant, and are aware of the benefits of having a healthy
lifestyle. Antenatal care should include postnatal weight
management advice, as this is the period when women with a
BMI ‡ 30 kg/m2 want to lose weight; this may enable subsequent
pregnancies to start with a lower BMI. Such advice should be
sensitive and tailored to the individual. Social representations
theory provides a framework for understanding maternal
obesity.
understanding of the maternity experience for pregnant women
with a BMI ‡30 kg/m2.
Search strategy Six electronic databases were searched using
predefined search terms.
Selection criteria English-language studies using qualitative data
to explore the maternity experience for women with a
BMI ‡ 30 kg/m2 were included (defined by a quality appraisal
framework).
Data collection and analysis An interpretative approach was taken
and the constructivist framework was central to the synthesis.
Searches were conducted in September 2010, and resulted in six
papers being synthesised.
Keywords Maternal obesity, pregnancy, qualitative and meta-
synthesis.
Please cite this paper as: Smith D, Lavender T. The maternity experience for women with a body mass index ‡ 30 kg/m2: a meta-synthesis. BJOG 2011;118:
779–789.
Introduction
Background
Having a body mass index of 30 or more (BMI ‡ 30 kg/m2)
is classified as clinically obese, a BMI ‡ 35 kg/m2 is classified as morbid obesity, and a BMI ‡ 40 kg/m2 indicates
extreme obesity.1 Obesity is a ‘global epidemic’,1 and is a
key area for public health intervention because of increasing
prevalence rates and the association with coronary heart
disease (CHD). Predictions suggest that prevalence rates in
England will rise to almost nine in ten adults and two-thirds
of children by 2050.2 Rates of obesity in women of childbearing age are increasing, and as a result, cases of maternal
obesity in antenatal clinics are growing. In England, a study
of 34 maternity units found that the percentage of pregnant
women who have a BMI ‡ 30 kg/m2 in the first trimester
of their pregnancy has increased from 7.6 to 15.6% over a
19-year period.3 Prevalence rates are highest in women of
lower socio-economic status and amongst some ethnic
groups.4
Maternal obesity is quickly emerging as a key public
health issue in the developed world, as in addition to the
increased risks associated with obesity seen in the general
population (e.g. CHD), risks for adverse maternal and fetal
outcomes are also increased. For example, obesity in pregnancy is associated with an increased risk of gestational
diabetes,5 hypertensive disorders of pregnancy including
pre-eclampsia,6 prolonged pregnancy,7 induction of labour,
caesarean sections,8 greater risk of miscarriage,9 and
increased stillbirth and neonatal death rates.10 Obesity was
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
779
Smith, Lavender
highlighted in the recent Confidential Enquiry into Maternal Deaths (CEMACH) report, Saving Mothers’ Lives 2003–
2005, as one of the greatest and growing overall threats to
the UK childbearing population.11 Fifteen percent of
women who died from direct and indirect causes had a
BMI of 35 or over (morbidly obese), with half of these
having a BMI exceeding 40 (extremely obese). A further
12% of women had a BMI in the range of 30–34 (obese),
and 24% had a BMI of 25–29 (overweight). For the child,
there is an increase in neural tube defects, cleft lip and palate, and other congenital anomalies,12 a greater number of
large birthweight infants,13 and obesity in later life.14
Maternity services are a vital component of care for
pregnant women with a BMI ‡ 30 kg/m2, as a healthy
pregnancy determines a baby’s life chances, and interventions are needed to ensure that maternal obesity is associated with minimal maternal and fetal risk and adverse
outcomes. Therefore, pregnancy has been suggested as the
ideal time to intervene to reduce adult obesity and prevent
obesity in the next generation. National recommendations
from the National Institute for Clinical Excellence (NICE)15
suggest that healthy pregnancy advice should ‘ideally’ be
provided before 10 weeks of gestation in the UK, and at a
similar stage in pregnancy in Canada.16 Advice regarding
physical activity and healthy eating during pregnancy is
highlighted in the Government’s obesity strategy as being
‘crucial’ to the development of the baby.17 It is vital that
women must be given correct information about weight
management in pregnancy by the health professionals caring for them (i.e. obstetricians and midwives), as is stressed
in the NICE report.18 This advice will not just impact on
the woman, but also on her children, so they must receive
correct and detailed advice regarding food and nutrition in
pregnancy and beyond.
That said, there is a dearth of evidence regarding a suitable and effective maternal care pathway or intervention to
improve the health of pregnant women with a
BMI ‡ 30 kg/m2. No formal training or guidelines exist for
health professionals regarding how to approach the issue of
obesity with pregnant women. A systematic review of
weight maintenance interventions concluded that there is
minimal evidence to inform maternal obesity strategies,19
and recently NICE commissioned evidence reviews that
concluded there is ‘inconsistent and inconclusive evidence’
on the effectiveness of weight management interventions
during pregnancy and the postpartum period.20,21
The fact remains that health professionals are not sure
what support and advice to provide to this group of
women, and how best to talk to them about the issue of
their weight. A study in the North East of England found
that the only dietary advice women were given in pregnancy
was from the UK’s National Health service (NHS) patient
information booklet.22 This booklet is vague in detail,
780
focusing on safe and healthy eating, and does not address
the issue of weight gain or dietary intake in relation to BMI.
This study also highlighted a number of concerns related to
safety and practicalities, including no or limited continuity
of care from midwives.22 Reflecting on the experience of
running a clinic for pregnant women who are morbidly
obese, Richens and Lavender23 state that it is a midwife’s
duty to inform women about the risks associated with their
weight in pregnancy, to both themselves and their baby.
However, before implementing this behaviour in the clinical
setting, health professionals must be clear on how much
information they should impart to motivate change but
prevent anxiety, the most acceptable time for women to
hear this information, and what support to offer as a result.
This detail is not currently covered in training or guidance;
therefore, the experiences of women with a BMI ‡ 30 kg/m2
during pregnancy under the current maternity service
provision must be used as a basis.
The current meta-synthesis aims to create a better
understanding of the pregnancy experience for women with
a BMI ‡ 30 kg/m2. This meta-synthesis is the first to be
conducted on this topic, and will help to develop knowledge and theory about the needs of pregnant women with
a BMI ‡ 30 kg/m2, and their experiences of attending
maternity services and receiving antenatal and postnatal
support, by synthesising relevant qualitative research studies. The meta-synthesis findings will have clinical and
research implications, contributing to the design and delivery of accessible and available maternity services for pregnant women with a BMI ‡ 30 kg/m2 that are evidencebased, and suggesting areas for future research.
Objective
Our research asks the question:
What is the maternity experience for women with a
BMI ‡ 30 kg/m2?
To better understand the maternity experience for pregnant women with a BMI ‡ 30 kg/m2, a meta-synthesis of
qualitative research studies was conducted. This research
technique was deemed suitable to answer the question as
qualitative research methods have predominantly been used
to explore the maternity experience for pregnant women
with a BMI ‡ 30 kg/m2.
Meta-synthesis is a technique that combines the rich and
detailed findings of numerous qualitative research studies
to offer a new interpretation and improve our knowledge
of a chosen topic. In summary, this technique involves
conducting a systematic literature search to uncover relevant studies, followed by a critical re-interpretation of the
findings of these studies. The role of the researcher at this
stage has been defined as ‘…carefully peeling away the surface layers of studies to find their hearts and souls in a way
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
The maternity experience for women with a BMI ‡ 30 kg/m2
that does the least damage to them’ (p. 370).24 This is
opposed to meta-analysis, which accumulates quantitative
findings in what can be a reductionist manner.
An interpretative approach was undertaken, and the constructivist framework of meta-synthesis was central to the
synthesis. Thus, the authors reinterpreted studies exploring
the maternity experience for women with a BMI ‡ 30 kg/
m2 conducted by different researchers using different
research methods: this process aims to develop a sense of
an underlying reality (of the maternity experience) by
aligning the participants’ (pregnant women with a
BMI ‡ 30 kg/m2) constructions of meaning and understanding in individual studies, with existing scientific concepts and theories.25
Methods
Search strategy and selection criteria
Studies of the maternity experience for women with a
BMI ‡ 30 kg/m2 were included in the meta-synthesis if
they were published in an English language journal and
used a qualitative research method (alone or mixed-methods approach). The search was not restricted by country of
origin. However, it was pre-specified that context would be
integrated into the interpretation. Additionally, search
terms were refined by running a preliminary search. As stated above, a constructivist approach was taken, meaning
that all types of qualitative research methods were included
in the synthesis.24 No restriction was set by start date, as
no key time points are relevant, and a preliminary search
found a small number of relevant studies.
The databases searched were CINAHL Plus, MEDLINE,
PsycINFO, British Nursing Index, AMED, and the National
Research Register. Using a standardised systematic search
strategy ensured rigour and flexibility, and allowed for replication in the search for relevant papers for the synthesis.
Therefore, an adaptation of the population/problem of
interest, intervention, comparison and outcome (PICO)
framework was used to find qualitative research studies
exploring the maternity experience for women with a
BMI ‡30 kg/m2 (Table 1). Keywords were truncated, and
synonyms of key search terms were used where appropriate
to guarantee that all relevant studies were identified. In
addition, a colleague recommended a study that was still
in press.
Quality appraisal
The quality of a meta-synthesis is influenced by the quality
of the included papers; therefore, it is vital to assess the
quality of the studies uncovered in the search before synthesis. A quality appraisal tool, devised by Walsh and
Downe,26 was used by both authors independently. This
tool uses a checklist and grading system to rank the papers
on an A–D scale. In this meta-synthesis, studies graded D
were automatically excluded, and those graded A were
automatically included; those graded C or B were discussed
between the authors regarding inclusion in the final synthesis (see key in Table 2 for an outline of the checklist and
grading).
Synthesis
Once the studies to be included had been selected, both
authors read them independently. Themes and concepts for
each study were fully understood, and this involved the
authors reading the studies several times and discussing
their understanding of the findings. To enable the results
to reflect all of the studies, highlighted concepts and
themes were ‘synthesised’ in two ways: firstly, similarities
were demonstrated between the studies and findings; secondly, the studies and findings were looked at in opposition to each other to indicate any differences. Finally, the
findings of this synthesis process were combined to produce a line of argument.27
Main results
Included studies
One of the authors (DS) independently conducted the
search for studies in late September 2010. Of 1218 studies
identified using the initial search criteria, 1158 were
excluded by title for failing to meet the inclusion criteria.
A detailed review of the abstracts of the remaining 60 studies
Table 1. PICO search strategy for meta-synthesis
Population
Intervention
Comparison
Outcome
Meta-synthesis
Search terms
Women with a BMI ‡ 30 kg/m2
Pregnancy
None
Qualitative research methods
Obes* OR raised BMI OR BMI ‡ 30 kg/m2
Pregnan* OR Mater* OR antenatal OR prenatal
–
Qualitative OR interpret* OR mixed method* OR experience*
OR attitude* OR belie* OR understand* OR view* OR explor*
In OVID searches BMI ‡ 30 kg/m2 was replaced with BMI > 30 because of syntax errors with the symbols ‡ and /.
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
781
782
method was used
contact with
and 26% were
workers)
skilled non-manual
75% were white
these changes
social
were approached
and overweight
backgrounds (i.e.
mixed ethnic and
3-month period
normal weight
explanations of
later, and had
hospitals over a
questionnaire
women, and their
from the data
completed
of gestation or
approached)
centres in four
experienced by
to extract themes
questionnaire was
were at 30 weeks
rate; 94 were
or the midwifery
free-response
pregnancy
administered
changes in
method was used
free-response
A self-administered It is not clear which
primigravidas,
(81% inclusion
hospitals
Seventy-six women All women were
multiparous
and seven were
were primiparous
Three women
antenatal classes
(UK)
To compare the
using a self-
2006 and
and birth
Women attending
and 90 minutes
between October
during pregnancy
Four London
lasted between 35
western Sweden
professionals
Not given
babies. Interviews
hospital in
delivered
homes
September 2007.
method
birth of their
birth in one
health
phenomenological
6 weeks after the
and had given
after they
using the
Data were analysed
conducted 4–
Interviews were
interviewed once
2 years were
9 months and
aged between
who had a child
thematically
women’s
Cohort study
were approached)
Sweden or the were approached
psychological
experiences of
body image
5
spoke Swedish
inclusion rate; 16
booking BMI > 30
western
Women who had a Ten women (63%
phenomenological
The empirical
9-months old.
Thirty women
child was
constructed)
The women all
and when the
which it is socially
Interview study A hospital in
was 3-months old,
obese
of the way in
women’s
To describe obese
role of food
Yamaguchi,30
Fox and
(Sweden)
Nyman et al.,29
birth, when child
how many were
personal contacts
‘problem’ because
times: before
was 30–57
all were obese
techniques and
England
constructionist
motherhood,
(UK)
and it is not clear
interviewed three
family life, and the view (obesity is a
Analytic
approach
Thirty women were Data were analysed
Data collection
methods
the obese women
The BMI range for
Participant
characteristics
total sample. Not
3
Sample size
Purposively selected Sixty women in
Sampling
strategy
via snowballing
Interview study City in the
Context
north of
Critical
Design
approach—social
To explore the
Theoretical
framework
transition into
1
Keenan and
Aim
Stapleton,28
Study
Author
(country)
Table 2. Characteristics of included studies following quality appraisal
B
A
B
Quality
rating
Smith, Lavender
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
10
Weir et al.,32
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
Theoretical
framework
Participant
characteristics
class, marital
status, and
number of
children
the community.
Their GPs were
asked for approval
before contacting
One maternity
and between 3
and 9 weeks
postnatally. Field
notes were also
used
English
sufficiently, had a
BMI between 35
and 54, and all
had singleton
hospital for their
glucose tolerance
test (GTT)
interviews
childbearing
data
the transcribed
used to analyse
methods were
B
A
B
Quality
rating
dependability, and/or confirmability of the study.
confirmability of the study; C, some flaws that may affect the credibility, transferability, dependability, and/or confirmability of the study; D, significant flaws that are likely to affect the credibility, transferability,
Quality rating key: A, no or few flaws, the study credibility, transferability, dependability, and confirmability is high; B, some flaws, unlikely to affect the credibility, transferability, dependability, and/or
pregnancies
the third trimester
and could read
process
conducted: during
20 and 44, spoke
when attending
England
structured
approached)
10-month period
North of
two semi-
interviews were
The women ranged Two semi-structured Framework analysis
women in the
19 women (13%
approached over a inclusion rate; 150 in age between
Women were
morbidly obese
service in the
press33 (UK)
design using
Qualitative
experiences of
Not given
education
based on BMI and
To explore the
had degree-level
was selected
to physical activity
parity
employed and five
purposive sample
pregnancy
white, 13 were
stratified
approach
obese pregnant
women in regards
conducted in late
Thirteen were
were approached)
participated. A
study
behaviour (TPB)
informed by TPB
interview was
were primiparous.
rate; 22 women
which 65 women
interview
of planned
overweight and
approach
(64% inclusion
A framework
‘in-depth’
obese and eight
Fourteen women
larger study in
experiences of
into the views and realism and theory structured
study
This is part of a
Eight women were A semi-structured
varied in social
hospital, and in
interviews
Not clear
postnatally
25 and 45. They
hospital, a rural
theory—two
A combined subtle Cohort semi-
6-weeks
a BMI of between
midwife in a city
grounded
To provide insight
pregnancy and
35 years, and had
hospital notes or a contacted)
based on
weight gain
them about the
conducted: late
the ages 16 and
women were
through their
until saturation
interviews were
bodied, between
rate; 108 eligible
12-month period
methodology
on-going process
semi-structured
Grounded theory—
Analytic
approach
white, able-
Two ‘in-depth’
Data collection
methods
(35% response
Thirty-seven women All women were
Sample size
identified over a
Women were
Sampling
strategy
qualitative
outlined
weight’s beliefs
England
South of
Context
about gestational
interpretative
perspective
Design
of above average
To examine women No clear theoretical An
Aim
McGowan, in
Furber and
12
8
Wiles,31 (UK)
(UK)
Study
Author
(country)
Table 2. (Continued)
The maternity experience for women with a BMI ‡ 30 kg/m2
783
Smith, Lavender
1218 papers
CINAHL Plus (n = 418), MEDLINE (n = 613), PsycINFO (n = 167), British Nursing
Index (n = 17), AMED (n = 2), National Research Register (n = 0) and word of mouth
(n = 1)
60 papers (abstracts)
CINAHL Plus (n = 15), MEDLINE (n = 16), PsycINFO (n = 19), British Nursing Index
(n = 9), AMED (n = 0), National Research Register (n = 0) and word of mouth (n = 1)
After removal of:
non-pregnant participants (n = 12), non-obese participants (n = 9),
focus of data is not antenatal (n = 8), no qualitative data collected
and presented (n = 10) and not peer-reviewed (n = 2)
19 papers (full text)
CINAHL Plus (n = 8), MEDLINE (n = 5), PsycINFO (n = 3), British Nursing Index
(n = 2), AMED (n = 0), National Research Register (n = 0) and word of mouth (n = 1)
After removal of:
non-obese participants (n = 1), no qualitative data collected and
presented (n = 4) and duplicates (n = 7)
Seven papers (full text)
After removal of paper that did not meet the quality criteria
sizes were small, ranging from 10 to 76 women. In the five
studies that explained their sample frame in detail, the local
maternity services were used for recruitment (i.e. hospitals,
antenatal clinics, or community midwives). Several studies
had samples of women that were not exclusively obese; in
these cases, data was only used from the women with a
BMI ‡ 30 kg/m2. Participants included women aged
16 years and older, primigravidas and multigravidas
women, women with a BMI ‡ 30 kg/m2, women with a
BMI ‡ 40 kg/m2, and women with singleton pregnancies.
The ethnicity and social backgrounds of the participants
were mentioned in three studies.30–32 One of these papers
reported the ethnic mix of participants as being ‘varied’,30
whereas the other two samples were predominantly white.
Social class was reported as varied in two studies30,31 and
predominantly employed in the other.32
Eight initial themes were concluded from the six studies.
These eight themes were summarised by three cluster themes:
acceptance and inevitability of weight gain in pregnancy;
depersonalisation of care as a result of medicalisation; and
healthy lifestyle benefits for self and baby. Table 3 includes a
list of the initial themes, with the main themes and core concepts highlighted in the six synthesised studies. Each of the
cluster themes will be discussed, and qualitative data from
the six studies will be used as evidence for the themes.
Six papers
Figure 1. Flow chart of search strategy and outcomes.
was conducted by one of the authors (DS), and resulted in
a further 41 studies being excluded (Figure 1). Additionally, seven studies were excluded for being duplicates.
The remaining 12 studies were subject to full text review
by both authors, independently. Following evaluation and
discussion, a further five studies were excluded as they
failed to meet the criteria (Figure 1). This left seven studies
to be assessed for quality by both authors independently.
An agreed grade for each paper was reached by consensus.
One study failed to meet the quality requirements, as it
was decided that the data focused heavily on the postpartum experience and did not include a substantial level of
qualitative data about the antenatal experience to allow for
synthesis. Characteristic summaries for each of the six studies can be seen in Table 2. The remaining six studies were
included for synthesis as stated in Table 2.
Findings
Five of the included studies were conducted in
England.28,30–33 The sixth study was a Swedish study.29 The
six studies were conducted over a 13-year period: ranging
from 199730 to the study that was in press.33 Two data collection methods were used: questionnaires30,31 and interviews.28,29,32,33 In keeping with qualitative research, sample
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Acceptance and inevitability of weight gain in pregnancy
Obesity is accepted in pregnancy. In one study, women with
a BMI ‡ 25 kg/m2 reported feeling more positive about the
changes to their body in pregnancy than women with a
BMI £ 25 kg/m2. Women reported feeling that this positive
feeling is isolated to pregnancy.32 One reason for this positive feeling was that the women felt free from the stigma of
being overweight. The following quote summarises the
negative stigma of being overweight as a female held in
Western society. This view is interpreted by the women to
mean that it is socially acceptable for a woman to have a
larger body size when pregnant.
Pregnancy is socially acceptable, but being fat is not.29
The social acceptance of the pregnant body is further
reflected by women expressing feeling that pregnancy is
the only time it is acceptable to have and display ‘…a big
stomach…’ 30
Moreover, several women with a BMI ‡ 25 kg/m2
(including those with a BMI ‡ 30 kg/m2) reported feeling
physically attractive as a result of the changes to their body
shape in pregnancy.
I feel much better about my body now. I am fascinated
by my stomach and body; it is becoming rounder but
beautifully shaped.29
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The maternity experience for women with a BMI ‡ 30 kg/m2
Table 3. Themes and the core concepts from the six included studies
Initial themes
Obesity is accepted in pregnancy
Gestational weight gain is acceptable,
and weight loss will be initiated in the
postnatal period
The existence of a ‘normal’ baby size
and growth
Negative treatment from health
professionals
Aware of need to be healthy for self
and baby
A number of perceived barriers to
physical activity in pregnancy
Relevant studies
Cluster themes
Core concept
3, 5, 8, 1, 12
8, 10
Acceptance and inevitability of
weight gain in pregnancy
1, 12
Depersonalisation of care as a
result of medicalisation
Obesity and weight gain are acceptable
in pregnancy. Therefore, healthy
lifestyle changes are conceived in the
antenatal period and are executed in
the postnatal period. Barriers to
change include a lack of advice and
perceived negative treatment from
health professionals
3, 12
10
Healthy lifestyle benefits for self
and baby
10
The changes to the body in pregnancy were reported to
make some women feel less self-conscious about people
looking at them. Attention from strangers who were interested in their pregnancy increased their feelings of selfworth.
Now that I am pregnant, strangers smile at me as if I am
someone special. They look at my stomach and not me,
and so I feel more confident about my body and myself
in general.29
A lack of information from health professionals about
the increased maternal and fetal risks associated with
maternal obesity led the women to think that maternal
obesity was acceptable, and that they were not at an
increased risk. For some women, this approach was viewed
as ‘helpful’, making them not feel negative about themselves and the impact that their weight may have on their
baby.28
…nobody’s mentioned my weight. I’ve asked them if I’m
likely to have more trouble in labour or anything because
of my weight and they’ve said no, unless I’ve been having
trouble all the way through, which I haven’t, so…28
However, a few women discussed the existence of a ‘normal’ pregnancy body size and shape; they continued that
they felt their bodies did not ‘fit’ this mould as they are
obese, resulting in a negative experience (e.g. no maternity
clothes fit and comments about their size are made by
health professionals and friends/family).
Gestational weight gain is acceptable, and weight loss will
be initiated in the postnatal period
Gestational weight gain was perceived by the women as a
‘natural’ and ‘acceptable’ aspect of being pregnant; as a result
they felt that they ‘will put on weight’ during their preg-
nancy. Therefore, it was not surprising that women reported
making a conscious decision to focus on weight loss in the
postnatal period only.
I’m conscious that I’m going to try to do more after this
baby is born.32
The level of control that women feel over weight gain
during pregnancy influenced their intentions. Some women
feel that they have control over their gestational weight
gain, as they fear the postnatal result if they do not manage
their gestational weight gain.
I suppose you tend to think, ‘Oh well, your weight
doesn’t matter quite so much while you’re pregnant’. But
obviously, at the back of your mind is the fact that you
only have nine months of this and that sooner or later
you’re going to have to pay the price.31
The issue of weight gain in pregnancy was further complicated as some women felt that there was a contradiction
between eating the right foods to ensure that their baby
receives the necessary nutrients, and not gaining excessive
weight in pregnancy.
They said [at the antenatal clinic], ‘Are you getting enough
protein? You should have plenty of milk and cheese’. I
don’t normally have things like that because they are very
fattening, but because they went on about it you feel like
you should be doing it…I mean when it’s your first baby
you do take notice of what they tell you to do.31
Depersonalisation of care as a result of medicalisation
The existence of a ‘normal’ baby size and growth. Health
professionals expressed concern about the ‘large’ babies
that the women were more than likely to have, and as a
result the women were frequently monitored towards the
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
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Smith, Lavender
end of their pregnancies.28 In some cases this resulted in
the woman being anxious about the birth.
fits in eating a healthy diet were centred on their unborn
baby.
I was told it was 11 pounds already…It’s really frightening. I mean if it was last week 11 pounds, God knows
what it is this week.33
The fitter you are throughout your pregnancy, the more
supple you are. And you’re supposed to have an easier
time giving birth.32
Conflict was also reported in the postnatal period
between the beliefs of mothers and health professionals
about a baby’s growth and feeding behaviour. The mothers
were concerned if their babies were not feeding, whereas
the health professionals were only concerned if the mothers
were feeding their babies too much.
…when the surgeon came up to see me, he said, ‘You
know why you had a big baby, don’t you?’, he said,
‘because you are big’…28
Negative treatment from health professionals. The treatment
received from health professionals was reported as a central
theme in several studies, as being perceived by the women
as negative. However, few examples of negative treatment
were given in the form of quotes in these studies. The studies included reports of women reporting being treated in a
‘sarcastic and negative manner’ and being ‘suspicious’ of
health professionals.29 Embarrassment and guilt were
reported as feelings experienced by the women when receiving health care, especially at ultrasound appointments.
She’d told me that she was finding it hard to find the
baby’s heartbeat because I was overweight. I come out
and I was in floods of tears. You think that you’re doing
the baby some wrong.33
As mentioned above, the women reported increased
experiences of screening and monitoring. Because of a lack
of explanation from health professionals, women reported
not being clear on the reasoning for increased screening
and monitoring, and in some instances this resulted in the
women feeling that the focus was on their baby and not on
their health care.
…so what they’ve done is denied me the right to my
health, for the sake of the baby.33
Healthy lifestyle benefits for self and baby
Aware of need to be healthy for self and baby. The women
were all knowledgeable at some level about the beneficial
role of a healthy lifestyle. Furthermore, many of the women
saw pregnancy as a perfect time for them to start making
changes to their lifestyle.
This is a time when I’m thinking of health things…32
Interestingly, the benefits reported from engaging in
physical activity in pregnancy were personal, and the bene-
786
It’s just important that you give the baby good nutrients
and good food.32
A number of perceived barriers to physical activity in pregnancy. As reported above, the women believe the benefits
of engaging in physical activity in pregnancy to be personal. However, they reported many internal and external
barriers to increasing their physical activity as part of a
healthy lifestyle. Internal barriers included feelings of low
confidence and motivation, and ill health.
You just get heavier and you are bigger and it is harder
to move and everything is more uncomfortable.32
Whereas external barriers included a lack of information
and advice, as well as a lack of available physical activity
classes.
Other than my midwife just saying, you know, just carry
on as normal…[there was] nothing specific from any
health professionals.32
Line of argument. The final stage of analysis was to combine the meta-synthesis findings into a line of synthesis.28
The unique findings highlighted in this meta-synthesis, and
what they add to the literature, is summarised as follows.
Women with a BMI ‡ 30 kg/m2 perceive their weight as
being more acceptable during pregnancy than when they
are not pregnant. They tend to be aware, in the antenatal
period, of the benefits of having a healthy lifestyle in pregnancy, and plan to manage their weight during the postnatal period, as they see weight gain as unavoidable in
pregnancy. Therefore, healthy lifestyle changes are conceived in the antenatal period, and are planned to be
executed in the postnatal period. The medicalisation of
pregnancy (through maternity care by health professionals)
because of their weight leads to an impersonal experience,
and leaves women feeling that they receive a lack of advice
and guidance, and receive negative treatment from some
health professionals.
Discussion
A meta-synthesis was conducted to examine the current
qualitative literature, and to gain a greater understanding
of the maternity experience for pregnant women with a
BMI ‡30 kg/m2. The majority of the included studies were
English, and recruited women from a range of maternity
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
The maternity experience for women with a BMI ‡ 30 kg/m2
services, thus making this meta-synthesis fairly generalisable
to the current population of pregnant women with a
BMI ‡ 30 kg/m2 in England. Although the included papers
differed in their approach to exploring the maternity experience, the findings were summarised in three cluster
themes: acceptance and inevitability of weight gain in pregnancy; depersonalisation of care as a result of medicalisation; and healthy lifestyle benefits for self and baby. The
analysis adequately summarised these three cluster themes
in a unique line of argument, as discussed here.
These findings support the belief that understanding
women’s experiences is key to improving their health.
According to the 2008 Darzi report,34 patient satisfaction
and involvement in healthcare services are central to the
success of the NHS in promoting health. Likewise, satisfaction is a key component in Ley’s cognitive model of adherence.35 Using Darzi’s recommendation and Ley’s model as
a framework to predict adherence to maternity services, the
first stage when designing maternity services and for health
professionals delivering care is to explore and understand
the needs of the target population. Therefore, the needs
and experiences of pregnant women with a BMI ‡30 kg/m2
need to be central to the design and implementation of
their care if recommendations and regulations are to be
met; this in turn should increase their satisfaction with the
maternity service and thus improve their attendance and
health. Understanding the lived experience of obesity in
pregnancy, as demonstrated in these findings, helps maternity services at the policy, commissioning, and clinical level
to address some of the health consequences of obesity for
women and babies.
Women with a BMI ‡ 30 kg/m2 perceive their weight as
being more acceptable during pregnancy than non-pregnancy, and saw weight gain in pregnancy as unavoidable.
This suggests that the bodies of women with a
BMI ‡ 30 kg/m2 are more socially acceptable to them
during pregnancy. This is interesting, as it suggests that
pregnancy is the ideal time for health professionals to follow
the NICE and Royal College of Obstetricians and Gynaecologists (RCOG) recommendations to discuss weight
management with women.18,36 However, these findings also
highlighted that the treatment received by health professionals was perceived negatively by several of the women.
These women expressed feelings of personal guilt and
embarrassment regarding their weight prior to contact with
health professionals, suggesting that their perceptions of
healthcare treatment may be mediated by these personal
negative views of their weight. Thus, when health professionals do address the issue of weight management with
pregnant women with a BMI ‡ 30 kg/m2 they must be
aware of the possibility that the women may hold pre-existing negative views about their weight. They must ensure
that the issue is approached in a sensitive manner, by not
using words that can cause embarrassment, and by avoiding
statements that can cause women to feel guilty because they
perceive weight-related complications to be their fault.
In addition, these findings highlight that the focus for
lifestyle changes needs to be in the postnatal period, as
women indicate this stage as being when they want to initiate change. These findings suggest that further research
should examine women’s intentions to manage their weight
in the postnatal period. A greater understanding of
women’s motivations and reasons for focusing this intention in the postnatal period would be of interest, as it
could focus on factors that either help or hinder the process of these intentions becoming healthy behaviours. These
findings could then be used by health professionals and
researchers to design and evaluate interventions to help
women with a BMI ‡ 30 kg/m2 adopt a healthy lifestyle
and manage their weight in the postnatal period.
The medicalisation of the pregnancy experience was
found to leave women feeling negative towards health professionals and the level of advice and guidance received.
If lifestyle advice is to be given in the antenatal period,
then women need to feel that the maternity service is providing them with personalised care. Understanding what
causes them to view the maternity service as ‘medicalised’
will help health professionals, policy makers, and commissioners to design and deliver a more ‘personalised’ maternity service. Training for health professionals working with
pregnant women with a BMI ‡30 kg/m2 is a necessity to
ensure that the care pathways deliver a personalised level of
care that does not focus solely on the women’s weight.
For example, it can be harder for health professionals to
perform abdominal palpations and hear a fetal heartbeat
with a woman who has a BMI ‡ 30 kg/m2, and thus an
approach using terminology that is acceptable to these
women is needed. Women express confusion over the
information they received about the risks associated with
maternal obesity and the increased level of intervention
(i.e. screening and monitoring), as demonstrated in the
contradiction they felt in obtaining a healthy balance
between getting the needed nutrients for a growing fetus
and weight gain. If health professionals receive more tailored training the required information could be portrayed
to women in a more efficient and acceptable manner.
Research such as this meta-synthesis is vital in the developing of this training, as it improves our understanding of
these women’s needs and their representations of health
professionals.
Social representations theory (SRT) claims that we use
social representations to understand the world. These are
cognitions shared by a group of people: they consist of
ideas, thoughts, meanings, and images, and are based on
our past experiences, actions and interactions with others.37
When dealing with new social health issues such as obesity,
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
787
Smith, Lavender
it has been suggested that social representations need to be
examined.38 SRT, therefore, provides a framework for
understanding how the social health issue of obesity can be
met with varying levels of acceptance. This theoretical
framework sees the association between personal characteristics (e.g. ethnicity and age) and maternal obesity as a set
of processes influenced by cultural and subcultural beliefs.
Adopting this framework requires an examination of the
nature and source of representations of obesity, and more
specifically maternal obesity. In addition, research needs to
be conducted to understand how social representations are
communicated and interpreted in different cultural groups,
and how they form subcultural values, which in turn influence an individual’s lifestyle decisions and risk of obesity.
Obesity prevalence rates are associated with lower social
classes and with certain minority ethnic groups.4 Therefore,
to understand the pregnancy experience for women with a
BMI ‡ 30 kg/m2, and the social representations of obesity
and pregnancy, women from all social and cultural groups
must be recruited; this detail was missing from the highlighted studies in this meta-synthesis.
Disclosure of interests
Conclusion
References
In conclusion, these findings are important for policymakers and commissioners to ensure that the needs of pregnant
woman with a BMI ‡30 kg/m2 are central to the design
and implementation of tailored maternity care pathways.
The findings also have clinical and research implications.
Pregnancy is highlighted as the ideal period to intervene, as
women with a BMI ‡ 30 kg/m2 perceive their weight as
more acceptable than when they were not pregnant, and
they are aware of the benefits of having a healthy lifestyle
in pregnancy. SRT is a suitable framework for understanding how maternal obesity is met with varying levels of
acceptance and prevalence rates in certain groups. Antenatal interventions should provide women with information
and advice about health lifestyle changes so that the women
can implement these changes in the postnatal period, as
suggested in these findings. Weight loss in the postpartum
stage would enable women to start subsequent pregnancies
with a lower BMI and decrease their risk for adverse maternal and fetal outcomes. A clear picture of the holistic pregnancy experience for women with a BMI ‡ 30 kg/m2 is
vital if the recent NICE and RCOG/CEMACE guidelines
are to be implemented in clinical practice in an acceptable
and accessible manner for them,18,36 and increase their satisfaction with healthcare services (as suggested as being
important by both Darzi and Ley).34,35 The need for
focused training for health professionals was also highlighted to ensure that they deliver a personalised level of
care that does not focus solely on the women’s weight, but
provides adequate information and guidance.
1 World Health Organization. Obesity. Preventing and Managing the
Global Epidemic. Report of a WHO consultation on obesity. WHO/
NUT/NCD/981. Geneva: WHO, 1991.
2 Avlott J, Brown I, Copeland R, Johnson D. Tackling Obesities: The
Foresight Report and the Implications for Local Government 2008.
London: Improvement and Development Agency.
3 Heselhurst N, Rankin J, Wilkinson JR, Summerbell CD. A nationally
representative study of maternal obesity in England, UK: trends in
incidence and demographic inequalities in 619323 births, 1989–
2007. Int J Obes 2009;34:420–8.
4 Kinra S, Nelder RP, Lewendon GL. Deprivation and childhood obesity: a cross sectional study of 20 973 children in Plymouth, United
Kingdom. J Epidemiol Community Health 2000;54:456–60.
5 Hedderson MM, Gunderson EP, Ferrara A. Gestational weight gain
and risk of gestational diabetes mellitus. Obstet Gynecol
2010;115:597–604.
6 Catalano PM, Ehrenberg HM. The short and long-term implications of
maternal obesity on the mother and her offspring. BJOG 2006;113:
1126–33.
7 Stotland NE, Washington AE, Caughey AB. Prepregnancy body mass
index and length of gestation at term. Am J Obstet Gynecol 2007;
197:378.
8 Chereshneva M, Hinkson L, Oteng-Ntim E. The effects of booking
body mass index on obstetric and neonatal outcomes in an inner
city UK tertiary referral centre. Obstet Med 2008;1:88–91.
9 Lashen H, Fear K, Sturdee DW. Obesity is associated with increased
risk of first trimester and recurrent miscarriage: matched case–
control study. Hum Reprod 2004;19:1644–6.
10 Kristensen J, Vestergaard M, Wisborg K, Kesmodel U, Secher NJ.
Pre-pregnancy weight and the risk of stillbirth and neonatal death.
Maternal obesity more than doubled the risk of stillbirth and neonatal death in this study. Br J Obstet Gynaecol 2005;112:403–8.
11 Lewis G. The Confidential Enquiry into Maternal and Child Health
(CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to
788
None.
Contribution to authorship
TL conceived the idea for the meta-synthesis, reviewed the
papers, conducted the synthesis, and helped write the final
draft. DS wrote the draft of the article, conducted the
search, reviewed the papers, and conducted the synthesis.
Both authors reviewed and analysed the papers.
Details of ethics approval
This is a review of the literature, so no ethical approval
was required.
Funding
This is a review of the literature, so no funding was
required.
Acknowledgement
Thank you very much to Jane Gething and Wendy Taylor
for their help in proofreading and editing this article. j
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
The maternity experience for women with a BMI ‡ 30 kg/m2
12
13
14
15
16
17
18
19
20
21
22
23
Make Motherhood Safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.
London: CEMACH, 2007.
Cedergren M, Kallen B. Maternal obesity and the risk for orofacial
clefts in the offspring. Cleft Palate Craniofac J 2005;42:367–71.
Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel
CW, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med 2004;350:2362–74.
Pirkola J, Pouta A, Bloigu A, Hartikainen A-L, Laitinen J, Järvelin MR, et al. Risks of overweight and abdominal obesity at age 16 years
associated with prenatal exposures to maternal prepregnancy overweight and gestational diabetes mellitus. J Diabetes Care 2010;33:
1115–21.
National Institute of Clinical Excellence (NICE). NICE Clinical Guidance 62. Antenatal Care: Routine Care for the Healthy Pregnant
Woman. London: NICE, 2008.
Davies GA, Maxwell C, McLeod L, Gagnon R, Basso M, Bos H, et al.
Obesity in pregnancy; SOGC clinical guidelines. BJOG 2010. 239.
[www.sogc.org/guidelines/documents/gui239ECPG1002.pdf]. Last
accessed 25 October 2010.
Cross-Government Obesity Unit. Health weight, healthy lives: a
cross-government strategy for England. 2008 [www.dh.gov.uk/en/
Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/
DH_082378]. Last accessed 24 November 2009.
NICE. Dietary interventions and physical activity interventions for
weight management before, during and after pregnancy. London:
NICE Public Health Guidance, 2010.
Bell R, Weir Z, Stothard K, Pearce M, Adamson A. Maternal obesity:
when should we intervene? A systematic review of lifestyle interventions in women before, during and after pregnancy. Int J Obes
2007;31:S40.
Campbell F, Messina J, Johnson M, Guillaume L, Madan J, Goyder E.
Systematic Review of Dietary and/or Physical Activity Interventions
for Weight Management in Pregnancy. Sheffield: The University of
Sheffield, ScHARR Public Health Collaboration Centre, 2009.
Messina J, Johnson M, Campbell F, Everson Hock E, Guillaume L,
Duenas A, et al. Systematic Review of Weight Management Interventions After Childbirth. Sheffield: The University of Sheffield,
ScHARR Public Health Collaboration Centre, 2009.
Heselhurst N, Lang R, Rankin J, Wilkinson J, Summerbell C. Obesity
in pregnancy: a study of the impact of maternal obesity on NHS
maternity services. Br J Obstet Gynaecol 2007;114:334–42.
Richens Y, Lavender T. Antenatal assessment and care. In: Richens
Y, Lavender T, editors. Care for Pregnant Women Who are Obese.
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
London, UK: Quay Books Division, MA Healthcare Ltd; 2010.
pp. 41–58.
Sandelowshi M, Docherty S, Emden C. Qualitative meta-synthesis:
issues and techniques. Res Nurs Health 1997;3:365–71.
Asper P. Interpretative Phenomenology: An Approach for Qualitative
Research. Papers in social research methods qualitative series number 9. London: London School of Economics and Political Science,
2004.
Walsh D, Downe S. Appraising the quality of qualitative research.
Midwifery 2006;22:108–19.
Noblit G, Hare R. Meta-Ethnography: Synthesising Qualitative Studies. Newbury Park: Sage, 1988.
Keenan J, Stapleton H. Bonny babies? Motherhood and nurturing in
the age of obesity Health Risk Soc 2010;12:369–83.
Nyman VMK, Prebensen AK, Flensner GEM. Obese women’s experiences of encounters with midwives and physicians during pregnancy
and childbirth. Midwifery 2010;26:424–9.
Fox P, Yamaguchi C. Body image change in pregnancy: a comparison of normal weight and overweight primigravidas. Birth 1997;24:
35–40.
Wiles R. The views of women of above average weight about appropriate weight gain in pregnancy. Midwifery, 1998;14:254–60.
Weir Z, Bush J, Robson DC, McParline C, Rankin J, Bell R. Physical
activity in pregnancy: a qualitative study of the beliefs of overweight
and obese pregnant women. BMC Pregnancy Childbirth 2010;10:18.
[www.biomedcentral.com/1471-2393/10/18]. Last accessed 10 September 2010.
Furber CM, McGowan L. A Qualitative study of the experiences
of women who are obese and pregnant in the UK. Midwifery
(in press).
Darzi AR. High Quality Care for All: NHS Next Stage Review Report.
London: The Stationary Office, 2008.
Ley P. Satisfaction, compliance and communication. Br J Clin Psychol
1982;21:241–54.
CEMACE/RCOG Joint Guidelines. Management of women with obesity in pregnancy. 2010 [www.rcog.org.uk/womens-health/clinicalguidance/management-women-obesity-pregnancy]. Last accessed
9 November 2010.
Moscovici S, Duveen G. Social Representations: Explorations in Social
Representations. Cambridge: Polity, 2000.
Flick U. Qualitative inquires into social representations of health.
J Health Psychol 2000;5:315–24.
ª 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology ª 2011 RCOG
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