Pregnancy is a key time point in a woman's life where behavioural changes can be made (Phelan, 2010). As a result, researchers have started to explore the best way for health professionals to provide advice and support to women during pregnancy to help them make lifestyle changes that will have an impact on them and their families. Maternal obesity (i.e. body mass index (BMI) ≥ 30 kg/m2 during pregnancy) is one such example in which researchers and practitioners have begun designing and testing interventions for gestational and postnatal weight management with the long-term aim of improving lifestyle behaviours for women and their families (Centre for Maternal and Child Enquiries (CMACE) and Royal College of Obstetricians and Gynaecologists (RCOG), 2010; National Institute for Health and Care Excellence (NICE), 2010).
Over the last few years, a group of researchers from a university in the North West of England have been conducting a programme of research including a feasibility and pilot study of a community-based antenatal lifestyle intervention (for more details see Smith et al, 2010; Smith and Lavender, 2011; Smith et al, 2012). The programme of research was predominantly interested in exploring the suitability and acceptability of an antenatal lifestyle intervention for women who started their pregnancy with a BMI ≥30 kg/m2 and those health professionals providing care for them. This approach was deemed suitable due to the lack of consistent and robust findings regarding an evidence-based intervention for this target group (Campbell et al, 2009). This article discusses the important role of social support in pregnancy for women who start their pregnancy with a BMI ≥30 kg/m2 and the role of health professionals in providing women with the opportunity to build relationships with other pregnant women. Central to this discussion, is the presentation of observations of the health professionals involved in the study and data regarding one group of women who met through their involvement in the feasibility study.
The experiences of these women provide some insight into the influence of attendance at The Lifestyle Course (TLC) on the participants. Various data sources were collected from the eight women at five time points during the feasibility study (questionnaires at baseline, start of the programme, end of the programme, 4-6 weeks postnatal and 1-year postnatal and focus groups at 4-6 weeks postnatally) and field notes in the form of weekly reflections from the health professionals involved in this study (research midwife and health psychologist). In particular, it was evident to the health professionals leading TLC, that the women attending became a source of social support for each other and formed their own social support network which extended beyond 1 year after the 10-week intervention ended.
This short discussion article has been written following a process of member-checking with the group of eight women being shown the findings. Member-checking is a quality assurance process used in qualitative research to ensure that the data analysis truly reflects the experience of the participants (Creswell, 2007). The women were shown this article and, with their input, it was edited until they felt it demonstrated a true and clear picture of their experience of being involved in this programme of research.
The women were all recruited to the programme by a research midwife following the inclusion criteria of being pregnant, having a BMI ≥30 kg/m2 and due to deliver in a Greater Manchester hospital (where the study was being conducted). The group of eight women, who met through the research study, were White-British, with BMIs ranging from 32.8 to 48.8 kg/m2 (mean=38.2 kg/m2), had one to four children and were all having singleton pregnancies. Twenty women were invited to attend each 10 week antenatal intervention (TLC), which was run in the community setting by a group of health professionals, including a research midwife and health psychologist. Initially, attendance was high but towards the end of the 10 weeks a group of around 10 women (including these eight women) were attending weekly. This level of attendance was attributed, by the researcher's observations, to no crèche being provided and the sessions being run over the summer months.
Discussion points
One of the main benefits reported by the women attending TLC, and observed by the research team, was the friendships that they made with others in their group. It was clear in the weekly reflections recorded by the health professionals running the intervention that during the 10 weeks, friendships were developing for some of the women and, at the end of the 10 weeks, many of the women continued their friendship via the social network site, Facebook. These lasting friendships were observed by researchers in this group and among women in the other groups within the main trial and no apparent demographics acted as a reference other than similar BMI and being pregnant. One of the women said to the research team 1 year after they had attended the 10-week programme that after the 10 weeks they had developed a bond which meant they wanted to see each other's babies, otherwise it would have felt like:
‘…having your hair done and never being able to look in the mirror’.
These Facebook friendships soon developed into the women meeting every few weeks for coffee as the women said that although they felt that they have all came from ‘different walks of life’ they had two very important things in common.
Firstly, they had all just had babies so felt ‘isolated’ while on maternity leave and secondly, they all had similar BMIs, which they referred to as being all ‘fatties’. These coffee mornings soon developed into meeting every Friday for lunch, going walking together once a week, playdates during school holidays, hen and birthday parties, weekends away and offering support through traumatic life events. The group now see themselves as ‘normal friends’ who have fun together, do exercise together and offer support to each other. One of the group reported in the 1-year postpartum questionnaire that the study had an impact on her lifestyle:
‘I have met a group of eight friends which helped me through some tough times we are still friends now and we see each other a lot.’
Pregnancy can be stressful due to the new experiences and lifestyle changes (psychosocial factors) experienced by women, their partners and their families. Social support is associated with improved physical and mental health (O'Donovan and Hughes, 2008) and acts as a buffer to stressful life events (Thoits, 2010). The ‘buffer’ or ‘buffering’ hypothesis is widely researched and accepted in the stress literature, it states that interpersonal relationships can act as a buffer for people when faced with psychosocial stressors. As a result, these relationships are termed as ‘social support’. Antenatal social support is also a mediator of pregnancy outcome (Orr, 2004), with stressful situations such as childbirth being perceived as less stressful when social support is present (Taylor, 2011). Likewise, postnatal mental health symptoms are associated with a lack of postnatal social support and few leisure activities (Gjerdingen and Chaloner, 1994). However, social support only acts as a buffer if it is effective in meeting the needs of the person experiencing the stressful situation. Research has found that social support sources required by women change in the postnatal period. For example, Morinaga and Yamauchi (2003) found that marital support acts as a buffer to stress at 1-week post-birth but at 4 months post-birth, support from other family members and friends had a greater buffering effect than marital support. The research team propose that attending the TLC created an opportunity for women to make friends, who acted as social support and helped to buffer any psychosocial stressors. Social support is often used as a behavioural change technique (BCT) in interventions due to a strong evidence base (Michie et al, 2013) and was indeed one of the key components used in TLC to support the women in making healthy lifestyle behaviour changes. These observations and reports from the women reinforce the use of social support as a BCT to increase healthy lifestyle but also suggest that social support can help women cope with the effects of psychosocial stressors and can extend beyond the intervention period.
The women did report gaining knowledge from the course content that led to behavioural change in addition to gaining antenatal social support from the other women in the TLC group. One of the women started to cook fresh food as a result of what she learnt during the food sections of TLC and another reported, in her 1-year postpartum questionnaire, that she was
‘…more aware of my weight and health as an impact on day to day life’.
A few of the women set a goal during the 10-week antenatal intervention to be more physically active in order to minimise gestational weight-gain. They achieved their goal and attributed this to the social support they received from each other. It is positive to see that the women were offering each other the opportunity to engage in walking as a way to increase their postpartum physical activity. A recent meta-analysis found interventions to increase social support to be associated with heightened engagement in physical activity for non-pregnant people with a BMI ≥30 kg/m2 (Olander et al, 2013). However, it must also be stated that not all women find pregnancy a time for change and therefore may not want to make changes to their health behaviours. As a result, these women may not receive the same benefits from a peer group such as those mentioned for the eight women in this short discussion article. In addition, not all women will experience the same level of social support from a peer group, and other levels of support may be more important and relevant to them during pregnancy or postnatally (Morinaga and Yamauchi, 2003). Health professionals should be aware of the role of social support as a possible buffer to psychosocial stressors and a way to encourage lifestyle behaviour change and must ensure that they speak to women about their needs in terms of who and where they would like to receive social support. In addition, more research is needed to further understand the personality and demographic characteristics that predict whether women require social support as a buffer for psychosocial stressors and the characteristics that they form a reference group based on.
These women formed a reference group through a friendship group based on their pregnancy and BMI, which extended past attending the 10-week programme. Being overweight or obese has been reported, in a recent qualitative study, as something women are aware of during pregnancy and that they do not want health professionals to ignore (Mills et al, 2013). The women used this reference group as a source of social support that acted as a buffer in stressful situations and encouraged them to engage in healthy walking behaviours. This change in physical activity behaviour can be explained in terms of social learning theory (SLT). SLT views learning as an interaction between the person, their behaviour, and the environment (Bandura, 1977). Self-regulation is a central component in this theory of behaviour. People form reference groups in which they have similar norms towards behaviours and thus self-regulate their behaviour based on the actual and perceived views of those in the group whom they trust. It must also be noted that in the subsequent pilot study, a similar effect has been seen with a group of women meeting up regularly as a form of postpartum social support. BMI was a key factor to the women in forming a reference group, which is an important point as it suggests that services (including clinics and educational programmes) should group women based on their BMI to encourage women to attend and receive social support.
Conclusion
This short discussion article suggests that the maternity experience cannot be viewed by health professionals and policy makers as an event that occurs in isolation of social factors (both existing and new due to the pregnancy) and as such the role of social support from friends must be viewed as important. As suggested by Gjerdingen, et al (1991), health professionals are ideally placed to provide pregnant women with information outlining the importance of social support ante- and postnatally. In particular, they should provide information about the different types of social support required from a range of sources during and after pregnancy. The antenatal period may be the best time for women to initiate new sources of social support that are in place to buffer possible psychosocial stressors after birth. Health professionals and care providers have a role to play in the provision of opportunities for pregnant women to meet and form these initial bonds that reference groups can then develop from.
Acknowledgements
Thank you to Tommy's for all their support with this programme of work. This data is from a programme of work funded by The Department of Health and The Department for Education. We would like to thank Jane Gething and Catherine Chmiel for their work as research midwives on this programme of work. Finally, thank you to the women in this case study.