In the UK, 19% of women of childbearing age are reported to be obese (BMI >30kg/m2) and 26% are reported to be overweight (BMI >25kg/m2) (Health and Social Care Information Centre, 2016). Being obese or gaining excessive weight during pregnancy can increase the risks of maternal and neonatal morbidity and mortality (Lewis, 2007). Evidence demonstrates that a healthy diet and increased physical activity levels in pregnancy reduce excessive gestational weight gain (Choi et al, 2013; Muktabhant et al, 2015). This in turn reduces the risk of adverse outcomes and long-term health complications (Thangaratinam et al, 2012; Reiner et al, 2013).
The UK recommends using the Eatwell Guide (Public Health England, 2018) to maintain a healthy diet and for adults to undertake 30 minutes of moderate intensity physical activity (exercise where the heart rate is raised slightly but where it is still possible to hold a conversation) per day (Department of Health, 2011). However, evidence suggests that pregnant women do not always maintain a healthy diet (Crozier et al, 2009; Reyes et al, 2013) and/or perform the recommended amount of physical activity (Sui et al, 2013; Denison et al, 2015). Women are not always aware of the health benefits of diet and exercise (Crozier et al, 2009; Sui et al, 2013; Denison et al, 2015) and advice from health professionals can be inconsistent and lack detail (Brown and Avery, 2012; Ferrari et al, 2013).
Previous research has focused on either a healthy diet or physical activity in pregnant women, rather than the combining both to examine a healthy lifestyle. Research that has combined the two aspects has targeted women with a raised BMI (Choi et al, 2013), rather than women within a normal weight range (BMI 18.5-24.9 kg/m2) who need to avoid excessive weight gain in pregnancy. In addition, little evidence could be found exploring perceptions of pregnant women from different black, Asian and minority ethnic (BAME) groups, despite the evidence that sociocultural beliefs about a healthy lifestyle can influence obesity levels (James et al, 2006; Satfford et al, 2010; El-Sayed et al, 2012; Castaño et al, 2013). Consequently, this study aimed to explore barriers and motivations to maintaining a healthy lifestyle during pregnancy. The sample included women with a normal, as well as raised, BMI and women from different BAME groups. The objectives were:
Methods
The theory of planned behaviour was used to underpin this study. This is a psychological theoretical framework that links barriers and motivations to behaviour change with behavioural, normative and control beliefs about the behaviour (Ajzen, 2019). The three elements that influence beliefs and predict behaviour were examined: women's attitudes, subjective norms and perceived behaviour (Table 1). Perceived barriers and motivations to women adopting a healthy lifestyle in pregnancy were explored and mapped against these three elements in order to understand how any barriers could be addressed.
| Behavioural beliefs | Attitude towards the belief | A person's favourable or unfavourable evaluation of a behaviour |
|---|---|---|
| Normative beliefs | Subjective norms | Perceived social pressures towards performing or not performing the behaviour |
| Control beliefs | Perceived behavioural control | Perceived ability, ease or difficulty to perform the behaviour |
The research was conducted in a multicultural city in northern England, comprising 63.9% white British, 20.3% Pakistani, and 15.8% other ethnic backgrounds. This city has a high level of deprivation and a lower life expectancy compared to other areas in England.
The study focused on women attending the maternity unit for their 26-week glucose tolerance test appointment. This is offered to all women in the city to monitor for gestational diabetes and women who attend have been found to be representative of the general population (Wright et al, 2013). The inclusion criteria were women aged over 16 years with an ongoing, low-risk pregnancy and a good understanding of written and verbal English. Women with medical conditions were excluded. Stratified sampling was undertaken based on social and ethnic background and BMI to ensure maximum variation, representing the local population.
Ethical approval was granted by HRA Yorkshire and the Humber and Leeds West ethics committee.
Data collection and analysis
An interview schedule underpinned by the theory of planned behaviour was constructed. This examined possible barriers and motivations that could influence a woman's knowledge, attitudes and behaviour towards a healthy lifestyle during pregnancy (Table 2). After gaining informed consent, semi-structured interviews were undertaken in a private room during the 2-hour period of the appointment while women who had been given a sugary drink were waiting for the subsequent blood test.
| 1. Have you heard of the Eatwell Guide? If no: describe and check understanding. If yes: can you describe the Eatwell guide to me? |
| 2. Thinking about your diet before pregnancy, and looking at the Eatwell Guide, how does it compare? Probe: can you expand on your answer? |
| 3. Thinking about your diet now, and looking at the Eatwell Guide, how does it compare? Probe: can you expand on your answer? |
| 4. Do you think a healthy diet is important in pregnancy? Probe: If yes, why? Can you expand on your answer? |
| 5. What do you think will happen to you if you don't eat a healthy diet? Probe: can you expand on your answer? |
| 6. Do you know the term ‘physical activity’? If no: inform them what it is. If yes: can you tell me what it is? |
| 7. How much physical activity did you do before pregnancy (30 minutes of daily activity recommended)? Probe: how much per day? What type of activity? |
| 8. How much physical activity do you do now during pregnancy (30 minutes of daily activity recommended)? Probe: how much per day? What type of activity? |
| 9. What do you believe are the benefits of doing 30 minutes of exercise per day? Probe: can you expand on your answer? |
| 10. If your midwife or another health professional asked you to keep a healthy lifestyle during pregnancy, do you believe you would be able to achieve this? Probe: can you expand on your answer? |
| 11. What advice has your midwife or other health professional given you regarding diet and or physical activity during pregnancy? |
| 12. Has this advice influenced the way you behave around diet and physical activity decisions during pregnancy? |
| 13. Have you followed their advice? Probe: Can you expand on your answer? |
| 14. What advice have your friends, family or other people (work colleagues, general public) given you regarding diet and or physical activity during pregnancy? |
| 15. Has this advice influenced the way you behave around diet and physical activity decisions during pregnancy? |
| 16. Have you followed their advice? Probe: can you expand on your answer? |
| 17. Where else have you found advice from regarding diet and or exercise during pregnancy? (For example magazines, posters, internet, gym, other groups) Probe: can you expand on your answer? |
| 18. Can you think of anything that will help you to eat a healthy diet? Probe: can you expand on your answer? |
| 19. Can you think of any barriers that will keep you from being able to achieve a healthy diet during your pregnancy? |
| 20. Can you think of anything else that will help you to perform 30 minutes of physical activity daily? Probe: can you expand on your answer? |
| 21. Can you think of any problems that will make it difficult or stop you from being able to perform 30 minutes of daily physical activity during pregnancy? |
| 22. Do you think you be able to achieve a healthy lifestyle during pregnancy? |
| 23. Is there anything else you think is important that you may not have had the chance to say? |
The interviews were audio recorded and transcribed verbatim by the researcher. Deductive thematic analysis was undertaken (Attride-Stirling, 2001), using the theoretical assumptions of the theory of planned behaviour to drive the coding and theme development. This ensured that the themes focused on barriers and motivations, rather than the overall data collected (Braun and Clarke, 2006), but also provided flexibility for the themes to be broader than the concepts in the model. To ensure credibility of the process, coding and themes were checked by the researcher's academic supervisor.
Findings
A total of 12 women were interviewed between December 2016 and May 2017. Of these women, four were British, four were from a Pakistani background and four were Polish. The women's ages ranged from 22-36 years. Five women had a normal BMI, two women were overweight and five were obese. Half of the women lived within the most deprived areas in the UK (Ministry of Housing, Communities and Local Government, 2015). Half the women had been educated beyond the age of 16 years old, with four having university degrees (Table 3).
| Participant | Gestation | Gravidity | Parity | Type of birth | Age (years) | Ethnicity | BMI (kg/m2) | Smoker? | Drug misuse? | Alcohol intake | Highest academic qualification | IMD decile* |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 001 | 26+5 | 1 | 0 | N/A | 33 | White British | 20.8 | No | No | No | Postgraduate study | 9 |
| 002 | 28+0 | 3 | 2 | 2 x NVD | 33 | White British | 32.9 | No | No | No | A-level | 3 |
| 003 | 26+6 | 1 | 0 | N/A | 22 | Pakistani | 20.8 | No | No | No | Undergraduate degree | 2 |
| 004 | 26+3 | 1 | 0 | N/A | 26 | White British | 37.6 | No | No | No | GCSE | 3 |
| 005 | 26+5 | 3 | 1+1 | 1 x NVD | 23 | White British | 26.4 | Ex-smoker (quit after conception) | No | No | GCSE | 6 |
| 006 | 29+4 | 2 | 1 | 1 x NVD | 30 | Pakistani British | 39.2 | No | No | No | NVQ level 4/PTLLS | 1 |
| 007 | 26+0 | 2 | 1 | 1 x NVD | 27 | Pakistani | 32.7 | No | No | No | Undergraduate degree | 1 |
| 008 | 29+1 | 4 | 0+3 | N/A | 34 | Pakistani | 26.3 | 4 per day (reducing) | No | No | GCSE | 1 |
| 009 | 26+2 | 1 | 0 | N/A | 21 | Polish | 20.9 | No | No | No | Left school at 18 | 1 |
| 010 | 27+1 | 1 | 0 | N/A | 26 | Polish | 23.3 | No | No | No | Left school at 20 | 4 |
| 011 | 26+3 | 1 | 0 | N/A | 33 | Polish | 30.6 | 10 per day (reducing) | No | No | College (Beautician) | 1 |
| 012 | 26+1 | 3 | 0 | N/A | 34 | Polish | 23.7 | No | No | No | Masters (Teacher) | 1 |
NVD: Normal vaginal delivery; IMD: Index of Multiple Deprivation (Ministry of Housing, Communities & Local Government, 2015); NVQ: National vocational qualification; PTLLS: Preparing to teach in the lifelong learning sector qualification
Four themes were developed from the data, reflecting women's perceived barriers and motivations and fitting into the theory of planned behaviour framework (Table 4): knowledge of healthy lifestyle, sociocultural influences, physical health and health professional support.
| Theme | Link to theory of planned behaviour | Description of codes |
|---|---|---|
| Knowledge of healthy lifestyle | Behavioural belief | Woman's physical health |
| Sociocultural influences | Subjective norms towards the behaviour | Family and friends influences |
| Physical health | Individual control | Pregnancy ailments |
| Health professional support | Behavioural belief | Diet and physical activity advice |
Knowledge of a healthy lifestyle
Women's knowledge of a healthy diet was limited, with half of the women not having heard of the Eatwell Guide (Public Health England, 2018) and a further five women having limited knowledge of what the guide detailed. Only one woman had good knowledgee of the guide and healthy eating in pregnancy. Despite this, nine women felt that their pre-pregnancy diet was similar to the Eatwell Guide.
‘I try eat some vegetables, some fruits, um, some milk … so it's not bad how I am eating.’
Most women perceived healthy diet in pregnancy to be important for their health and their baby but there was a limited understanding of why this was the case. One Pakistani woman, whose BMI registered in the ‘obese’ range, believed that healthy eating would develop good eating habits in her baby:
‘I believe what you eat will build up on the taste buds of my baby … I want my baby to be healthy.’
Despite believing that a healthy diet in pregnancy was important, half the women appeared to lack sufficient amounts of fruit and vegetables in their diet and two had too much fatty and sugary food.
Knowledge of physical activity was also limited, with eight women understanding that this was related to movement but unable to accurately recall the recommended levels of physical activity in terms of duration and frequency. Most women believed that regular physical activity improved their fitness, reduced their weight gain and alleviated pregnancy aliments and all women stated they had undertaken at least 30 minutes of physical activity, where they felt slightly warm and out of breadth before pregnancy, each day. Generally, they reported that they had reduced these levels during pregnancy. Four women were concerned about whether physical activity was safe for them and their babies and consequently two women had adopted a more sedentary lifestyle:
‘When I found out I was pregnant, I was scared to start again, you know, that's why.’
Some women talked about the positive effect of physical activity on labour; however, only two women believed that regular physical activity in pregnancy would be beneficial for their baby's health.
Sociocultural influences
Most women received advice on a healthy lifestyle during pregnancy from friends and family. This included advice about increasing intake of healthy foods, cutting down on junk food and avoiding ‘eating for two’. However, some women were told the opposite or were encouraged to eat anything appetizing, whether it was healthy or not.
In this study, advice from family appeared more prevalent in women from Pakistani backgrounds. One woman was advised by her grandparents to increase her intake of milk, fish and pomegranate. Another woman was advised to avoid foods such as nuts, pickles and fish, before 12 weeks' gestation due to a belief that it would increase the risk of miscarriage.
‘Don't eat fish because it makes you warm inside and that causes you to bleed.’
The same woman reported that she was advised to eat warm foods towards the end of her pregnancy to assist with the onset of labour:
‘When I was 9 days over with my son, [my mother] gave me milk, honey and nuts basically blended and mixed in milk and that was really hot, that will kick start your labour and I had them for 5 days and it was quite good, you know.’
More than half of the women responded to advice received about diet from family and friends, while the other women distrusted and therefore chose to ignore the advice. Some women reported that their diets were influenced by family, saying for example that they cooked unhealthy food due to their partner's preference. However, this was also a motivator for one Pakistani woman living with her extended family, who chose healthy foods for the family.
Eight women received advice about physical activity levels during pregnancy from their friends and family, with some encouraging physical activity and others discouraging it. This appeared to be culturally influenced, with both Polish and Pakistani woman being advised to rest during pregnancy:
‘Our culture they don't understand that, they think that as soon as you find out you are pregnant that's it, you shouldn't get up.’
Women who received advice encouraging physical activity reported that they followed the advice, and those who received discouraging advice reported that they ignored it:
‘I want to listen to myself and I think so, everybody knows [their] own body and you know what you need.’
Most women sourced additional information about a healthy lifestyle during pregnancy from internet sites, such as NHS Direct and medical portals; social media sites, such as Whatsapp, Facebook and YouTube; and pregnancy apps, which they felt were easily accessible and very informative.
‘[Pregnancy apps] give you that scientific explanation … this particular food gives you this vitamin etc.’
Cost and a lack of time were considered barriers to maintaining a healthy lifestyle. Some women did not cook healthy foods as this was perceived to be time-consuming and more expensive:
‘I have spent sometimes £15 on one meal that is going to be really healthy and I could just go buy a pizza for £2.’
Competing priorities, such as childcare responsibilities, work commitments and housework were also considered barriers to increasing physical activity. Some women cancelled their gym memberships to save money in pregnancy, thereby reducing their physical activity levels.
Physical health
Most women felt that their physical health during pregnancy negatively influenced their ability to maintain a healthy lifestyle. Minor ailments such as heartburn and nausea influenced women's diets and some mentioned snacking on unhealthy foods to relieve symptoms.
In addition, pregnancy-related health problems, such as sciatica, shortness of breath, dizziness, headaches, sickness, backache and tiredness, were cited as the main barriers to undertaking physical activity in pregnancy:
‘Sometimes I don't feel like doing anything at all, I just want to stay in my pyjamas and just not move, because I just feel tired.’
However, some women who were active during pregnancy noticed benefits such as improved self-confidence, enhanced sleep and reduced stress. This good health was motivation to continue with physical activity during pregnancy:
‘I cannot live without exercise, that's how I feel, like I am not achieving something if I am not exercising. It makes me feel different physically as well, I feel very heavy, but when I am exercising I actually find myself having more energy.’
Professional support
Only half of the women remembered being provided with dietary advice from health professionals during their pregnancy. Other women could recall foods to avoid but not what to eat to stay healthy:
‘At first she [midwife/health professional] said blue cheese … and fish, first couple of weeks and then after that … [she said] “just carry on doing what you are doing.”’
Other women felt that the advice varied in terms of its format and content. Women who were overweight were told to keep control of their weight by opting for healthy snacks.
The majority of participants felt that advice influenced their eating decisions; however, some women felt that the advice had no effect because they were already healthy, or because they were multiparous and had heard it before.
‘I am listening and I am like, “Yeah I know that”, but I wasn't really.’
Less than half the women recalled receiving advice about physical activity in pregnancy from health professionals, while others suggested that the advice appeared inconsistent. Two women received written information but few women could remember being advised to undertake 30 minutes of activity daily. Two women recalled that swimming was discussed as an option in pregnancy.
Women felt that more support from health professionals would encourage a healthy lifestyle. They suggested that this could include more information about the benefits of healthy eating and how to ensure the right levels of vitamins were consumed. Participants also suggested that more information on safe levels of activity would encourage them to exercise more.
Women felt that support could be face-to-face as part of routine antenatal appointments or classes, or that it could be offered through a pregnancy app produced by health professionals.
‘A session for mums or something … because if you are, like, on your own, you are not motivated or you are not … confident maybe, or you are thinking that exercising can damage the baby, or you might do something wrong or over-exercise, so, like, doing it as a group with someone professional, maybe.’
Discussion
This study identified barriers and motivations to women from diverse backgrounds eating a healthy diet and undertaking physical activity in pregnancy. Four key themes that appeared to influence women's beliefs, intentions and behaviour were identified from the data. Although similar barriers have been found in previous research (Cramp et al, 2009; Leiferman et al, 2011; Reyes et al, 2013; Sui et al, 2013; Fieril et al, 2014; Redmond et al, 2014; Denison et al, 2015; Thompson et al, 2017), this study focused on a combination of diet and physical activity, rather than a single factor. In addition, this study focused on women with different BMIs and sociocultural backgrounds, which appear influence their healthy lifestyles.
Poor understanding of healthy lifestyles during pregnancy was an identified barrier to adopting a healthy diet and undertaking recommended levels of physical activity. This included a lack of knowledge of the Eatwell Guide, the NHS recommended tool for discussing diet (Public Health England, 2018). In addition, there was a lack of understanding of why healthy eating was important, especially in terms of fetal health, which is shown in previous studies (Reyes et al, 2013; Sui et al, 2013; Denison et al, 2015). Women were not aware of the national recommendations for physical activity levels, and although they had insight into the health benefits, they lacked knowledge of why it was beneficial and what was safe during pregnancy, reflecting previous research (Leiferman et al, 2011).
Health professionals, especially midwives, have a role in advising pregnant women about healthy lifestyles; however, in this study, women reported that the advice that they received during pregnancy was minimal and variable. Some women were informed about specific foods to avoid, while others were provided general advice about healthy eating. Very few women were informed about physical activity levels in pregnancy and the advice received was inconsistent and minimal, echoing previous studies (Brown and Avery, 2012; Ferrari et al, 2013). As previously found (Choi et al, 2013), women said that they would follow health professional advice regarding healthy lifestyles during pregnancy if they received it, suggesting a good opportunity to promote health in this population. Women suggested that antenatal groups focusing on healthy lifestyle or an app would be useful.
There were sociocultural barriers and motivators identified by the women in relation to both diet and physical activity. Family and friends were influential, with some providing appropriate advice about diet and others providing advice that was incorrect. Cultural beliefs were also influential, and women were advised to avoid certain foods associated with bleeding and miscarriage and eat other foods to aid the onset of labour. Polish and Pakistani women suggested that physical activity in pregnancy was considered taboo by their families, although women reported that they ignored the advice as they were aware that exercise was safe.
Cost and time were also seen as barriers, reflecting previous research (Sui et al, 2013; Reyes et al, 2013). In this study, cost was mentioned in the context of gym and exercise class memberships, suggesting that women associated adequate physical activity levels with structured programmes, rather than increasing physical activity in everyday life, for example by brisk walking.
Conclusions
This study was small, carried out in one location, with self-selecting women who may have had a bias towards a healthy lifestyle. There were inadequate numbers of women from different ethnic backgrounds to draw generalisable conclusions and with increasing migration, more research is needed in this area. Many of the findings support previous research; however, there were some new findings that could provide an insight into these issues for midwives and other health professionals.
It is vital to improve information-sharing with women. Information needs to be standardised, consistent and culturally and socially sensitive. Women may be demotivated if they are unaware of the risks of non-adherence to a healthy lifestyle, leading to potential for obesity, which puts pressure on women's health, the economy and clinical practice (British Dietetic Association, 2017). Pregnancy is an ideal time to inform women, as they are a captive audience, attending appointments to check on their health.
The influence of family and friends suggests that healthy eating and physical activity levels in pregnancy should be promoted in local communities to ensure that women receive positive influences from family. This would appear particularly important for Polish and Pakistani families, who may not believe that physical activity in pregnancy is safe.
To increase knowledge, women used apps, social media, and websites to search out additional dietary and physical activity advice. No previous studies could be found examining the use of health technology in this context. There is a plethora of apps and websites available to women and it is important that this information is evidence-based. Health professionals should therefore recommend NHS-approved health technology or develop technology that addresses barriers to a healthy diet and physical activity, which could be undertaken, pilot-tested and evaluated with service users' input. Having a mobile application for all supports the NHS Long Term Plan (NHS, 2019). The Department of Health supports the Baby Buddy app (Best Beginnings, 2019), which contains general information about healthy lifestyle, but it is not tailored to the individual or necessarily culturally appropriate. In addition, although the app contains information about pregnancy, childbirth and childcare, anecdotal information suggests that the lifestyle information is not readily available and that the app is targeted at younger women, requiring the creation of an avatar, which may not appeal to all women.
This study has found that enhanced health professional advice may empower and encourage pregnant women to adopt a healthy lifestyle through healthy eating and exercise, and that interventions to support this could include midwife-led health technology. Further research would need to consider the effect of such interventions. This could help reduce costs incurred through complications that arise when women gain excessive gestational weight, or are overweight or obese at the start of their pregnancies.