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Original Research

A Mixed-Methods Study on Factors Influencing Prenatal Weight Gain in Ethnic-Minority Women Barbara Hackley, CNM, MS, Holly Powell Kennedy, CNM, PhD, Diane C. Berry, PhD, ANP-BC, Gail D’Eramo Melkus, EdD, C-NP

Introduction: Gaining too much weight in pregnancy is associated with perinatal complications and increases the risks of future obesity for both women and their infants. Unfortunately, women enrolled in intervention trials have seen little improvement in adherence to prenatal weight gain recommendations compared to women receiving standard prenatal care. Therefore, the purpose of this descriptive mixed-methods study was to explore factors related to excessive weight gain in pregnancy. Methods: Nonpregnant nulliparous women, currently pregnant women, and postpartum women (N = 43) were recruited from a health center serving an inner-city minority community. Women completed questionnaires on knowledge, self-efficacy, and behaviors related to nutrition, exercise, and prenatal weight gain. Fifteen of these women participated in focus groups. Focus group data were analyzed using ATLAS.ti (Scientific Software Development GmbH, Berlin, Germany). Codes were created, themes were identified, and consensus was reached through multiple iterations of the analysis by study personnel. Results: Excessive weight gain was common. Nutritional knowledge was poor and significantly lower among nonpregnant nulliparous women. Women felt sure that they could engage in healthy behaviors, but few did so. Participants in focus groups identified multiple barriers to healthy behaviors in pregnancy and made suggestions on how to help women more readily make improvements in these behaviors. Discussion: Strategies identified in this study such as providing focused education directed at nonpregnant nulliparous women, stressing portion control, helping women better manage their cravings, and providing more pragmatic support and resources need to be explored in future research. c 2014 by the American College of Nurse-Midwives. J Midwifery Womens Health 2014;59:388–397  Keywords: cravings, exercise, nutrition, prenatal weight gain, social support

INTRODUCTION

Gaining more weight than recommended by the Institute of Medicine (IOM) is the most common complication in pregnancy today, affecting 40% of normal-weight women and 60% of overweight women.1, 2 It is associated with immediate perinatal complications such as gestational diabetes and preeclampsia, greater postpartum weight retention, and being overweight or obese 10 to 15 years or more after birth.3–6 Becoming overweight or obese is associated with significantly greater risks of developing future diabetes and cardiovascular disease.7, 8 These risks are of particular concern for AfricanAmerican and Hispanic women, who are more likely to begin pregnancy overweight or obese and have twice the lifetime risk of developing diabetes compared to non-Hispanic white women.9, 10 Infants are also at risk; those exposed to excessive prenatal weight gain in utero compared to infants born to women who adhered to prenatal weight-gain guidelines have a 2-fold increased risk of being overweight at age 3 years11 and are more likely to remain heavier into young adulthood.12, 13 The purpose of this exploratory study was to identify factors related to excessive prenatal weight gain in low-income minority women. Interventions designed to help women gain the recommended amount of weight in pregnancy have met with mini-

Address correspondence to Barbara Hackley, CNM, MS, Montefiore South Bronx Health Center, 871 Prospect Ave, Bronx, NY 10459. E-mail: [email protected]

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1526-9523/09/$36.00 doi:10.1111/jmwh.12170

mal success, resulting in weight reductions in 3 meta-analyses of 0.22 to 1.19 standardized units less than women in routine care.14–16 Of these 3 meta-analyses, only one reported their results in a unit of weight. In pooled analysis of 10 studies, Gardner et al16 found that women enrolled in the intervention arms gained 1.19 kg less (95% confidence interval [CI], −1.740.65; P ⬍ .0001) than women in the control arms. In addition, a fourth meta-analysis found that interventions were ineffective,17 and a fifth reported that the evidence was of insufficient quality to make any judgment about the effectiveness of interventions.18 One possible reason that interventions have been minimally effective at best is that they do not include strategies that address women’s actual experiences of being pregnant. In an extensive examination of the methodology of the 10 trials included in their meta-analysis, Gardner et al16 concluded that the most commonly used strategies in interventions addressing prenatal weight gain were self-monitoring, performance feedback, and goal-setting. No single strategy appeared to be more effective than another because these strategies were used in trials that had both effective and ineffective results.16 Yet, these same techniques have been found to be effective in improving dietary and exercise behaviors in nonpregnant populations.19 Minimizing the risks associated with excessive prenatal weight gain for minority women likely requires developing interventions that reflect their unique experiences. Culturally tailored interventions have been found to be associated with greater weight loss in nonpregnant low-income populations

c 2014 by the American College of Nurse-Midwives 

✦ Women had significant knowledge deficits about exercise, dietary intake, and weight gain in pregnancy, and few engaged

in healthy dietary and exercise practices. ✦ Counseling women specifically on portion control is highly recommended for all women, but particularly for nulliparous

women who are at the highest risk of excessive prenatal weight gain. ✦ Education should begin before pregnancy; nonpregnant nulliparous women had significantly more deficits in their knowl-

edge than did pregnant or postpartum women. ✦ Education should be tailored for each woman. Suggested strategies should be specific, achievable, and limited. Too many

suggestions were perceived by some women as being overwhelming and resulted in women abandoning attempts to adopt healthier behaviors. ✦ Strategies to prevent excessive prenatal weight gain should move beyond those directed to the individual to those that

address the obesogenic environment. Making structural changes such as providing a better quality and variety of foods in government food programs will promote healthy dietary consumption in pregnancy.

compared to usual care.20 Therefore, similar adaptations in care may be beneficial for pregnant ethnic-minority women. Results of this study will be used to inform the development of more effective interventions designed particularly for an atrisk population. METHODS

We used a mixed-methods design to obtain qualitative and quantitative data on knowledge, attitudes, and behaviors related to nutrition and exercise in pregnancy. This study received institutional review board approval from Yale University and Montefiore Medical Center. Sample and Setting

A convenience sample of women was recruited from an urban community health center between October 2004 and June 2005. More than 50% of the individuals who receive care at this health center receive public insurance, and 19% are uninsured. The surrounding community is composed of ethnicminority residents, with 97% of the population being either Hispanic or black.21 Almost half of families with children live below the poverty line.21 To be eligible to participate in this study, women needed to be either 1) a nonpregnant nulliparous woman, 2) currently pregnant, or 3) a new mother with an infant less than 12 months of age. Women were excluded if they were aged less than 18 years, aged more than 35 years, or had underlying medical conditions such as diabetes or hypertension. Recruitment

Women receiving prenatal care in an inner-city community health center were notified of the study through posters and informational brochures placed in the waiting room. Women who were interested in learning more about the study completed the bottom part of the brochure, which asked for their contact information, and placed the brochure in a special mailbox in the waiting room. Interested candidates were then contacted by the research assistant by phone. After describing

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the study and determining eligibility, women were scheduled for an intake visit to obtain consent and complete the survey packet. Data Collection

At the time of the intake visit, the research assistant reviewed the study objectives, discussed the risks and benefits of participating in the study, and obtained written consent. After informed consent was obtained, women were asked to complete survey instruments on demographic data, dietary and exercise behaviors, and knowledge and attitudes about factors related to prenatal weight gain. Completion of the survey packet took approximately 30 minutes. To participate in this study, women needed to have a command of conversational English. The research assistant, who was bilingual in English and Spanish and a licensed practical nurse, reviewed the survey packet after completion and answered any questions the women might have. Women were then invited to participate in a follow-up focus group. Women were assigned to a focus group depending on their reproductive status; separate groups were held for nonpregnant nulliparous women, currently pregnant women, and postpartum women. Each focus group was conducted in English. The research assistant was present for each session and was available to translate if help was needed for women to understand certain phrases or words. Each focus group lasted 60 to 90 minutes and was audiotaped. One of the study personnel served as a note taker for each session and wrote up a summary of each session. Focus groups were led by an experienced focus group facilitator, who used an interview guide to ask participants about their understanding of and ability to engage in healthy dietary intake, physical activity, and weight gain in pregnancy. The questions were designed to elicit facilitators and barriers related to healthy eating and exercise in pregnancy. Sample questions from this guide are as follows: “Thinking about pregnant women in this community, what helps or makes it harder to exercise and eat right in pregnancy,” and “What kinds of help do you get/did you get in pregnancy? From whom?”

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Instruments

Quantitative Data Analysis

Demographic and medical information was obtained at the time of the initial interview, or it was abstracted from the medical records. Data included baseline body mass index (BMI) information on all women. For pregnant and postpartum women, data also included their total prenatal weight gain, parity, estimated date of birth, and date of birth.

Descriptive statistics were used to analyze demographic data. Baseline BMI was calculated from measured height and weight taken at the time of the interview for nonpregnant nulliparous women or from the medical record for pregnant and postpartum women. Prenatal weight gain was calculated for those pregnant and postpartum women who had a measured weight less than or equal to 14 weeks and more than or equal to 37 weeks’ gestation. The earliest and latest weight within these categories, respectively, was used to calculate gestational weight gain. Adherence to prenatal weight gain guidelines was based on 2009 IOM guidelines, which recommend weight gain of 28 to 40 lbs in underweight women (⬍ 18.5 kg/m2 ), weight gain of 25 to 35 lbs in normal-weight women (18.5-24.9 kg/m2 ), weight gain of 15 to 25 lbs in overweight women (25.0-29.9 kg/m2 ), and weight gain of 11 to 20 lbs in obese women (≥ 30 kg/m2 ).34 Demographic and survey data were analyzed using SPSS, version 20. Nutrition-related knowledge was measured by the percent of correct responses to the nutrition knowledge survey. Frequencies of individual items and means with standard deviations of the subscales were calculated for the self-efficacy, nutrition, and exercise surveys described above. Differences between the means of the subscales for nonpregnant nulliparous women, pregnant women, and postpartum women were analyzed using one-way analysis of variance.

Nutrition Knowledge

The National Adolescent Student Health Survey (NASHS), which was administered to more than 11,000 adolescents nationally in 1987, was designed to assess adolescent’s knowledge, attitudes, and behaviors in 8 key areas affecting health, including nutrition.22 Items were taken from the NASHS and adapted for use in a study by Gutierrez23 investigating the dietary behaviors of adolescent Mexican-American pregnant women. The nutrition survey used in this study took the 7 items related to portion size from the 20-item survey used by Gutierrez; this subset of questions tested subjects’ knowledge of the recommended daily number of servings (with corresponding serving sizes) of foods in various food groups.23 The percentage of correct responses was calculated for each participant. Nutrition and Exercise Behaviors

Healthy behaviors were assessed using the nutrition and exercise subscales of the Health Promoting Lifestyle ProfileII (HPLP-11), which is a 52-item instrument consisting of subscales on spiritual growth, health responsibility, interpersonal support, and stress management, as well as nutrition and exercise.24 This instrument has been used in studies of minority25–28 and pregnant29–31 women. Mean scores of the full and subscales have been used to describe differences in health behaviors of Hispanic adults by age, gender, and acculturation.25 It has also been used to compare the effectiveness of usual care to a 2-prong intervention (group 1: beginning in pregnancy and continuing for 6 months postpartum; group 2: beginning at birth until 6 months postpartum) designed to reduce postpartum weight retention.32 The nutrition and exercise subscales have acceptable internal consistency, with alpha coefficients of .757 and .809, respectively.24 Response choices include never, sometimes, often, and routinely. Self-Efficacy

The self-efficacy subscale of the psychosocial measures for understanding weight-related behaviors in pregnant women asks women how sure they are that they can eat healthfully, exercise regularly, and lose weight after birth. The Likert scale ranges from very sure, sure, unsure, to very unsure. This subscale has an alpha coefficient of .85.33 To understand the underlying attitudes related to healthy eating and exercise, as well as the degree to which women engaged in healthy behaviors, the responses to the self-efficacy, nutrition, and exercise subscales were collapsed into dichotomous categories: very sure/sure versus unsure/very unsure for the self-efficacy subscale and routinely/often versus sometimes/never for the nutrition and exercise subscales. 390

Qualitative Data Analysis

Focus group sessions were audiotaped and transcribed. Notes were taken by a trained observer at each session. After each session, the research team met to review the notes; the depth, quality, and range of discussion generated by the interview guide; and whether the interview guide needed to be adapted for use in the next session. Because this was an exploratory study, the focus group leader was free to deviate from the interview guide, as needed, to follow up in greater detail on issues of concern expressed by the participants. As is consistent with qualitative descriptive studies, content analysis was used to examine the data for codes or meaning units, patterns, and themes.35 Transcripts of the focus group discussions and focus group notes were coded independently by each member of the research team using ATLAS.ti software for qualitative analysis (version 6). The team then met as a group to resolve differences. After multiple iterations of the review process, consensus was achieved on codes and themes related to knowledge, attitudes, and behaviors, as well as facilitators and barriers to healthy weight gain in pregnancy. RESULTS Quantitative Results

A total of 43 women (14 nonpregnant nulliparous, 16 currently pregnant, 13 postpartum) completed survey data. Table 1 compares baseline BMI and demographic characteristics of women by reproductive status. Women self-identified their race and ethnicity by choosing as many descriptors as they desired. None identified themselves as white. Twentyfive percent of the pregnant women were expecting their first Volume 59, No. 4, July/August 2014

Table 1. Sample Characteristics

Nonpregnant Total

Nulliparous

Pregnant

Postpartum

(N = )

(n = )

(n = )

(n = )

Race/ethnicity, n (%) Black Native American Hispanic

12 (27.9)

4 (28.6)

2 (4.7)

2 (14.3)

33 (76.7)

10 (71.4)

3 (18.8) 0

5 (38.5) 0

14 (87.5)

9 (69.2)

Age, mean (SD), y

21.3 (3.9)

20.0 (2.4)

22.2 (6.2)

21.7 (4.6)

Baseline BMI,a mean (SD), kg/m2

26.3 (6.4)

25.2 (5.2)

28.0 (7.0)

25.7 (7.0)

Abbreviations: BMI, body mass index; SD, standard deviation. a Missing BMI for 2 nonpregnant nulliparous and 2 pregnant women.

child, whereas 75% of postpartum participants were first-time mothers. There were no differences between groups in age, baseline BMI, or race/ethnicity.

On average, 46% of nonpregnant nulliparous women checked the response “don’t know” to an individual item compared to 27.7% of pregnant women and 12.1% of postpartum women (F[2,18] = 8.8; P = .002).

Prenatal Weight Gain

Weight gain data were available for only 15 of 29 pregnant and postpartum women because many of the participants entered prenatal care after the first trimester of pregnancy. Of the women for whom data were available, 53% gained more weight than recommended, which is similar to that seen in large observational studies. Women who exceeded IOM recommendations gained on average 60% more than the upper limit of the recommended weight gain range.

Nutrition Knowledge

Scores on the nutrition knowledge survey varied significantly by reproductive status (F [2, 40] = 5.08; P = .01) (Table 2). Total scores were lowest for nonpregnant nulliparous women, approaching significance compared to pregnant women (P = .06), and reaching significance when compared to postpartum women (P = .01). Nonpregnant nulliparous women also were more likely to not know an answer to a question.

Self-Efficacy, Nutrition, and Exercise Surveys

No differences were seen in the mean scores of the selfefficacy, nutrition, or exercise subscales between groups. Table 3 describes the frequency that women reported they felt very sure or sure they could engage in healthy behaviors, as well as the frequency of actually performing these behaviors. In general for all groups, the frequency of being very sure/sure that a woman could engage in healthy behaviors was higher than the frequency of performing those behaviors. Compared to currently pregnant or postpartum women, nonpregnant nulliparous women reported engaging less frequently in healthy eating for 4 of the 7 behaviors included in the nutrition subscale of the HPLP11. Except for eating breakfast, fewer than 50% of pregnant women regularly engaged in healthy nutrition and exercise behaviors. Exercise levels were low in all groups. Most women obtained exercise through the performance of usual activities.

Table 2. Nutrition Knowledge

Nonpregnant Nutrition Knowledge Items

Total

Nulliparous

Pregnant

Postpartum

(N = )

(n = )

(n = )

(n = )

43.5% (0.3)

27.6%a (0.2)

48.2% (0.3)

55.0%b,c (0.2)

Full Scale Nutrition knowledgea,b,c mean %, correct (SD) Individual Items, % correct No. daily glasses of milk

60.5

35.7

75.0

69.2

Serving size of milka,b,c

76.7

57.1a

75.0

100b,d

Recommended no. daily servings of carbohydrates

2.3

0

6.3

0

Serving size of bread

44.2

28.6

56.3

46.2

Serving size of rice

41.9

35.7

37.5

53.8

Recommend no. daily servings of proteina,b,c

48.8

21.4a

56.3

69.2b,d

Serving size of protein

30.2

14.3

31.3

46.2

a,b c

Different superscripts indicate significant differences between groups. P = .01; d P ⬍ .05.

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Table 3. A Comparison of Nutritional and Exercise Self-Efficacy and Nutritional and Exercise Behaviors in Nonpregnant Nulliparous, Currently Pregnant, and Postpartum Women

Groups, n () Nonpregnant Nulliparous

Currently Pregnant

Postpartum

(n = )

(n = )

(n = )

Eat balanced meals

8 (57.1)

13 (81.3)

9 (69.2)

Eat healthy foods even when busy

6 (42.9)

11 (68.8)

7 (53.8)

Choose a diet low in fat

0 (0.0)

3 (20.0)b

3 (23.1)

Limit sugar and sugary foods

2 (14.3)

5 (31.3)

5 (38.5)

Eat fruit 2 to 4 times a day

4 (28.6)

9 (56.3)

6 (46.2)

Eat vegetables 3 to 5 times a day

4 (28.6)

2 (12.5)

4 (30.8)

NUTRITION Nutrition self-efficacy After my baby is born, I am sure or very sure that I cana :

Nutrition behavior I often or routinely:

Eat protein 2 to 3 times a day

8 (50.0)

4 (25.0)

5 (38.5)

Eat breakfast

5 (21.4)

11 (68.8)

5 (38.5)

Get regular exercise

8 (57.1)

9 (56.3)

9 (69.2)

Get regular exercise when busy

4 (28.6)

9 (56.3)

7 (53.8)

5 (35.7)

6 (37.5)

4 (30.7)

4 (28.6)

5 (31.1)

6 (46.2)

Do stretching exercises at least 3 times a week

4 (28.6)

2 (12.5)

4 (30.1)

Get exercise during usual activities such as walking at lunch, using stairs,

9 (64.3)

6 (37.5)

7 (53.8)

EXERCISE Exercise self-efficacy After my baby is born, I am sure or very sure that I cana :

Exercise behavior I often or routinely: Exercise vigorously for 20 minutes or more 3 times a week (ie, brisk walking, biking, dancing) Take part in light to moderate activity such as walking 30 to 40 minutes 5 times a week

parking car away from my destination and walking a Questions were adapted by reproductive status. Nonpregnant nulliparous women were asked to anticipate in the future how sure they were that they could engage in healthy behaviors after giving birth. Pregnant women were asked these questions in the future tense. Postpartum women were queried about their level of self-efficacy since giving birth. b Missing information for one subject, reported as valid percent.

Focus Groups Results

Fifteen women participated in focus groups (7 nonpregnant nulliparous, 4 currently pregnant, and 4 postpartum). Women described the difficulties that they faced in engaging in healthy behaviors and suggested strategies to help women eat and exercise appropriately in pregnancy. The major barriers identified in this study were inaccurate and incomplete knowledge about nutrition and exercise, being pregnant, and lack of access to resources. Helpful strategies were receiving targeted advice and support from families. However, the helpfulness of these strategies depended on their execution. Poor execution of these strategies, such as receiving advice that was perceived as being overbearing, irritating, or too complex, or families that did not prepare or purchase 392

healthy food for themselves or the pregnant woman, undermined women’s ability to eat a healthy diet and be active in their pregnancy. Figure 1 depicts these themes and subthemes. Barriers: Inaccurate and Incomplete Knowledge

Nonpregnant nulliparous women knew that the amount of allowable weight gain in pregnancy should vary by a woman’s starting weight, but they were uncertain about what amount of weight gain was necessary. Of the 8 pregnant and postpartum women, 5 did not think that gaining an appropriate amount of weight was a high priority. The main concern was to go to the doctor to confirm that the fetus was healthy. When asked about whether gaining too much in pregnancy was risky, one stated, “The books say so, but really I don’t Volume 59, No. 4, July/August 2014

Being Pregnant Cravings Physical discomfort Change in appe te and taste Too much change from pre-pregnancy behaviors Access to Resources Food of high quality and variety Need to share limited resources Inadequate and incomplete knowledge Appropriate weight gain Sufficient exercise Por on size

Barriers Healthy Unhealthy Advice Advice

Irrita ng, overbearing, or complex Support No control over food purchasing or prepara on

Strategies Targeted advice Family Support

Specific, encouraging, knowledgeable, respec ul Support Healthy family meals

Figure 1. Facilitators and Barriers to Healthy Behaviors in Pregnancy

know.” One woman did not pay attention to her weight gain until she saw the “shocked response” of her provider when she gained 12 pounds in one month. Another woman was unconcerned about her weight gain until late in her pregnancy. She commented, “After coming to the doctor I realized how much weight I was. I limited myself to what I ate because I did not want to have a nine-pound baby. I was really scared of diabetes.” Women in the nonpregnant nulliparous groups felt that “going from point A to point B” was a sufficient amount of exercise in pregnancy. The consensus was that pregnant women did not and should not exercise beyond what was needed to function in their daily lives. Nonpregnant nulliparous women were concerned that exercise could precipitate complications such as miscarriage or “tangled tubes.” Exercising in the gym was believed to be excessive. Walking, housework, stretching, and yoga were safer and more appropriate during pregnancy. Several women in the pregnant and postpartum focus groups also felt that activities in their daily lives supplied all the exercise that was necessary. A few women reported that they first learned exercise was safe during their pregnancy, and they heard conflicting messages about its safety from their family and friends. Misunderstandings about the amount of food that women need to eat in pregnancy were common. An extended conversation about appropriate portion sizes occurred in the nonpregnant nulliparous group. In the end, women agreed that pregnant women needed to eat substantially more food in pregnancy.

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Because you are pregnant doesn’t mean you’re going to eat every little thing you see in sight. Everyone is different . . . You can eat one big plate and then wait until your lunch and then eat one big plate, like when you go out to eat [at a restaurant]. . . . Sometimes you can’t eat the whole thing cause it’s too much. But when you’re pregnant it will probably be just enough. Many pregnant and postpartum women ate large portions throughout the day. One woman, who was counseled about appropriate portion sizes using food models, commented: “Like the little cups [the nutritionist] showed me . . . What is that? A swallow?” She preferred “manly” portion sizes. Barrier: Being Pregnant

The consensus among all groups was that consuming a healthy diet was very important to having a healthy newborn, but few women did so. Nonpregnant nulliparous women understood that pregnant women needed to eat more in pregnancy but attributed pregnant women’s unhealthy dietary intake to a lack of self-control, taking advantage of being pregnant to eat whatever they liked, and letting themselves go. The major barriers to healthy eating from the perspective of pregnant and postpartum women were the amount of change from their usual intake that they needed to make to meet dietary recommendations, as well as pregnancy symptoms and lack of access to resources. An inability to effectively deal with heartier appetites, changing tastes, and cravings undermined good nutrition.

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Several women would wake in the night with an overwhelming need to eat. Others reported desiring less healthy food in pregnancy and found that the quality of their dietary intake was worse during their pregnancy than before their pregnancy. Seven of the 8 pregnant and postpartum women reported cravings, most often for savory or sweet foods, although 3 reported craving beer. Most women understood that alcohol could be harmful to the fetus. However consumption of alcohol during pregnancy was common in their communities. One stated, “My sister-in-law, she’s 7 months pregnant. She’ll do the Coronas.” Another woman added, “In my country, women drink. Most of the time [in pregnancy] they drink and drinking is not harmful for the baby.” A participant in the nonpregnant nulliparous focus group stated that 2 women in her building were overdue and planned to go out drinking because “it would help to break the [water].” For most, cravings were specific, persistent, compelling, and difficult to ignore. Cravings prompted women to go out of their way to obtain the craved item, which was consumed daily and in large amounts. Some women called upon their families for help in controlling them. Others became defensive if too much change was demanded. The right of pregnant women to eat whatever they wanted was acknowledged by women attending the nonpregnant nulliparous focus group. One nonpregnant nulliparous woman commented, “You can’t tell a pregnant person they can’t have 2 plates. Girl, they’ll fight you down.” Most pregnant women attributed cravings or changes in dietary preferences to the hormonal changes inherent in pregnancy, others to the desires of the fetus. However, several ate to excess as a way to cope with stress: I love cake, even when I’m not pregnant. When I was pregnant it was harder. I did a good job up until a certain point where I was going through something. I guess that’s when the hormones kicked in. I stopped at the store and ordered a birthday cake. [The clerk] goes, “What do you want me to put on it?” I was like “Nothing . . . Do you have a fork?” She goes “Yes.” And I said thank you. I got to my car and my husband looks at me and goes “Whose birthday is it?” “Nobody’s.” I went and I just ate my cake. Being pregnant also made it more difficult to stay active. Women in the pregnancy and postpartum groups felt that time constraints and pregnancy symptoms such as fatigue and body aches made it difficult to do more exercise than what was required in their day-to-day life. Barrier: Lack of Access

Women also cited other barriers to healthy nutrition, such as the lack of access to higher quality food in stores and restaurants and the monotony of the food that was available to them. One woman who gained more than 65 pounds commented, “I always eat the same, I mean, bread, eggs, milk, sometimes rice. I do not buy food. I eat what my father brings home and what I get from WIC [Women, Infants, and Children Program].” Women also reported finding it difficult to eat healthy because of the need to share their limited resources with others in their households. 394

It was hard for me ’cause I was living at my mother’s house. I had to buy food that I could keep in my room that doesn’t need to be refrigerated. If I had it in the refrigerator, they’ll [my family] eat it. I had to buy stuff that was canned or dry or whatever. And, so I wasn’t eating that healthy. Facilitators: Targeted Advice

Receiving targeted advice specific to a woman’s situation was very helpful to several pregnant and postpartum women, but was very distressing to others and undermined healthy dietary behaviors. Too many suggestions, the lack of recognition of a woman’s efforts, and the inability to adhere to complex dietary advice led some women to give up and tune out further advice from their health care provider. As one woman explained: My doctor [told me] to drink water. I managed to drink one bottle a day. To me that was big, because I come from not drinking water at all; water is not part of my vocabulary. But to her, it was like, you’re not drinking anything . . . I like milk with sugar or I would drink milk with cereal. She goes, “No that’s not good . . . If you’re going to drink milk don’t put nothing in your milk.” Then she was making me change from whole milk to some low milk that didn’t have any fats or anything. She said vegetables, but then there were certain kinds of vegetables that were good, certain kinds of vegetables that weren’t. It was just too complicated for me. I just started tuning her out. One participant gained more than 60 pounds and stopped monitoring her weight in the fourth month of pregnancy because, “It would get me depressed. I feel guilty about not eating healthy.” Her plan was to focus on weight loss after she gave birth. Correcting the misconception that pregnant women needed to consume large portions helped several women who struggled with gaining too much weight in pregnancy. Consulting written materials, eating smaller portions instead of forgoing desired foods, and choosing healthier versions of desired foods were strategies that women found helpful. Facilitators: Social Support

Women’s social networks also influenced their dietary and exercise behaviors in positive as well as in negative ways. Advice from family and friends was not always based on accurate or complete information. Women in all of the focus groups felt that their social networks frowned on exercising during pregnancy. A participant in the nonpregnant nulliparous focus group commented, “I’m from the Dominican Republic. My family is like ‘You pregnant, don’t do nothing. Don’t worry, we got it.’” A participant of one of the pregnancy focus groups from Puerto Rico echoed this sentiment; her family felt that pregnant women should “just stay still.” In terms of dietary advice, the primary message from family and friends was to eat more in pregnancy; concerns about dietary quality and weight gain were secondary. One woman’s family advised her to avoid junk food, to eat a little of everything, but mostly to eat foods like rice and beans that would fill her up. As she explained, Volume 59, No. 4, July/August 2014

No, it’s not to gain weight, it’s to eat. It’s not like [your family and friends] want you to get big and fat, it’s just that people will have something. They’ll say ‘Oh, here you go.’ They do not tell me not to eat something because it is bad. They give me anything I like. Other pregnant and postpartum women received more explicit advice to eat less fast food and/or fatty foods and consume more water, fruits, and vegetables. None received any advice about how much weight to gain in pregnancy from their family or friends. Food was also used in celebrate the pregnancy. Food sharing was a common way to recognize the pregnancy and prompted family and friends to more readily share limited resources. My family is real stingy about things, especially money. My grandfather, my grandmother, even my little cousins, age 9 and 10, are spoiling me. They giving me money, here, like “Go get something to eat.” It was nice, real nice. I should be pregnant all the time. Being pushed to stay more physically active and to eat healthier by having someone to walk with or to help prepare healthy meals was suggested as a healthier alternative to paying for junk food for families desirous of acknowledging a woman’s pregnancy. Eating healthy also required many women to eat differently than others in the family. Having to prepare food specifically for themselves and to deny themselves junk food or other unhealthy food present in the household made eating healthy too difficult for some. Women who fared better lived alone and had control over food purchasing and preparation. Women also ate better if they lived with family members who were following a healthy diet to manage their own medical problems. DISCUSSION

This study is the only one known to the authors to explore nutritional knowledge, attitudes, and behaviors of lowincome, ethnic-minority nonpregnant nulliparous, pregnant, and postpartum women. Many women lacked critical knowledge. Nationally, 35% to 40% of Hispanic and black women begin prenatal care in the second or third trimester of pregnancy.36 Women who begin care later in pregnancy have less time to learn about and adopt nutritional and physical activity practices that can prevent excessive prenatal weight gain. Therefore, public health campaigns, which have been associated with improvements in nutritional and physical activity behaviors in the general population, are essential and may lead to substantial improvements in healthy behaviors.37 For example, a meta-analysis of 9 studies promoting walking reported that mass media campaigns increased the likelihood of meeting sufficient walking goals (defined as brisk walking for 150 minutes a week) by 53% (pooled relative risk 1.53; 95% CI,1.25-1.87).38 Because many women in our study reported that it was difficult to make too many changes from their prepregnancy patterns of eating and exercise, these campaigns ideally should begin before women become pregnant. Journal of Midwifery & Women’s Health r www.jmwh.org

Further, women in this study had poor understandings of recommended portion sizes. Understanding the basics of portion control, an essential component of healthy weight management, requires knowing both the numbers and size of recommended daily servings from the various food groups. Without this knowledge, women can inadvertently overeat, particularly carbohydrates and proteins, which are often eaten as mixed foods or out of large packages. These characteristics make it more difficult for an individual to determine an appropriate serving size for these foods than to do so for whole fruits and vegetables. Lack of knowledge may be particularly problematic for nonpregnant nulliparous women, who are more likely to gain more weight in pregnancy than multiparous women.1 Counseling done before conception or as early as possible in pregnancy may increase the chance that they will gain an appropriate amount of weight prenatally. Focusing on portion control was found by several pregnant women to be particularly useful. This strategy may be particularly cogent for nonpregnant nulliparous women who scored the lowest on the nutrition knowledge survey and who indicated in focus group discussions that daily consumption of restaurant-sized portions was a sufficient (and not excessive) amount of food to consume during pregnancy. Like other studies,39 women frequently cited lack of time and concerns over the safety of exercise as impeding healthy eating and exercise in pregnancy. However, in this study women highlighted pregnancy symptoms as being a major barrier to eating healthfully. Cravings were common and intense and were triggered for some by emotional distress. While the evidence is limited, studies have reported that cravings in pregnancy are correlated with greater dietary intake.40, 41 Other cross-sectional studies have found that stress, anxiety, or depression are associated with poorer quality intake42 or higher caloric intake43 in pregnancy. If this is a common pattern, then helping women develop more effective ways to manage stress may have secondary benefits by reducing emotional eating. Pregnancy is often deemed to be a “teachable moment,” a time in life during which women may be more willing to adopt healthier behaviors. However, few women engaged in healthy behaviors in this study. Of the 10 healthy behaviors listed in Table 3, pregnant women had lower frequencies of engaging in 7 of these behaviors than nonpregnant nulliparous or postpartum women. Other studies have reported only marginal improvements, if any, in the dietary quality of pregnant compared to nonpregnant women.44, 45 Women faced multiple barriers to adopting healthy behaviors in pregnancy. Women reported lack of access to healthy food. They had limited resources, which they often had to share with others. Others reported that the monotony of their diets left them feeling unsatisfied. These issues need to be addressed by policy changes that support healthy environments and add more variety, particularly of fresh fruits and vegetables, in food programs. Moving away from interventions based on personal change to those that use regulatory power have led to increased immunization rates, use of seat belts, and improvements in occupational safety.37 Similar strategies can be enacted to fight obesity.46 Examples include subsidizing the price of fresh fruit and vegetables and taxing 395

nutrient-poor foods; changing the food packages provided by WIC to include more fruits and vegetables and less carbohydrates; enacting standards for the way that foods are marketed and displayed in grocery stores, fast food establishments, and restaurants—and in the media to improve the image of healthy relative to less healthy foods; and requiring daily physical activity for all students enrolled in school. This exploratory study describes underlying factors associated with unhealthy dietary and exercise practices in pregnancy for low-income, ethnic-minority women, but it is limited by its small sample size and cross-sectional design. Recruiting pregnant and postpartum women was more difficult than anticipated. Many women entered care late in pregnancy. Others felt that participation in pregnancy or after birth was too burdensome given other demands on their time. Weather was also a factor; recruitment occurred in the fall and winter months. The convenience sample was drawn from one urban health center located in an impoverished neighborhood in New York City. Women in this study needed to be conversant in English and were affiliated with many different countries, most commonly Mexico, Dominican Republic, and Puerto Rico, all of which have different cultural norms about food, exercise, and self-care in pregnancy. Therefore, the results of this study are preliminary and cannot be extrapolated to other populations. CONCLUSION

The results of this study suggest several strategies that may help women better follow recommended guidelines. Few women have the necessary nutrition knowledge, pragmatic support, and resources needed to prevent excessive weight gain. Few women engage in healthy behaviors in pregnancy. Consequently, focusing on early education, skill development, and emotional support may help women on a personal level improve their ability to gain weight appropriately in pregnancy. However, equal to, if not more important, are policy changes that expand healthy food options in government programs and promote public health campaigns may be even more fruitful. Given the difficulty in helping women gain a healthy amount of weight in pregnancy, multiple and diverse strategies need to be developed and tested in future studies. AUTHORS

Barbara Hackley, CNM, MS, is in clinical practice in the South Bronx and the Co-Director of the Resiliency Initiative, a program of the Children’s Health Fund and Montefiore South Bronx Health Center. Holly Powell Kennedy, CNM, PhD, FACNM, FAAN, is the Varney Professor of Midwifery at Yale School of Nursing. Her research focuses on linking care processes with short-term and long-term health outcomes. Diane C. Berry, PhD, ANP-BC, FAANP, is Associate Professor at the University of North Carolina at Chapel Hill School of Nursing. Dr. Berry’s research focus is on obesity and type 2 diabetes prevention and management in ethnic minority families. 396

Gail D’Eramo Melkus, EdD, C-NP, FAAN, is on faculty at New York University College of Nursing and is a recognized clinical and research expert in the prevention and management of diabetes and related risk factors across diverse populations and settings. She has earned a reputation as a leader in the development and testing of culturally competent self-management models nationally and internationally. CONFLICT OF INTEREST

The authors have no conflicts of interest to disclose.

ACKNOWLEDGEMENTS

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A mixed-methods study on factors influencing prenatal weight gain in ethnic-minority women.

Gaining too much weight in pregnancy is associated with perinatal complications and increases the risks of future obesity for both women and their inf...
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