Understanding the pathway between work and health outcomes for women during the preconception, pregnancy, and postpartum periods through the framing of maternal obesity

Summary

The link between work and health outcomes for preconception, pregnant, and postpartum (PPP) working women is complex. Further, innovation and enhanced understanding are required to address the work‐related determinants of maternal obesity. However, workplace health promotion is not typically systems‐based nor attuned to the specific needs and context of individual PPP women. We propose that to improve health outcomes for PPP women, we must understand the pathways between paid work and health for the individual woman by taking a systems‐thinking approach. In this paper, we (a) outline the rationale for why the oversimplification or “dilution” of individual context may occur; (b) present a systems‐informed pathway model (the “Context‐Exposure‐Response” Model) and overview of potential work‐related impacts on health and wellbeing outcomes for PPP women using maternal obesity to provide context examples; (c) further investigate the role of motivational factors from a systems perspective; and (d) briefly examine the implications for policy, practice, and intervention design. It is anticipated that this research may act as a starting point to assist program developers, researchers, and policymakers to adopt a systems‐focused perspective while contributing to the health improvement and obesity prevention of PPP women.

Abbreviations

CER

context, exposure, response

PPP

preconception, pregnancy, and postpartum

1. INTRODUCTION

There is an established link between paid work and health for women. Workplace factors, including work role, ¹ , ² employment grade, ³ gender discrimination, ⁴ shift work, ⁵ scheduling, ⁶ hours worked, ⁷ and access to paid maternity leave ⁸ can all have demonstrable effects on the health, wellbeing, or health equity of working women. Furthermore, by providing income, status, and access to social capital, paid work is considered a key determinant of health. ⁹ , ¹⁰ For women working across the preconception, pregnancy, and postpartum (PPP) life phases, ^* the link between paid work and health may have added importance. Although women remain strongly engaged in the workforce as they transition through the reproductive years, ¹⁴ they face specific challenges in the workplace to their health mediated by weight, health practices, and wellbeing. ¹⁵ , ¹⁶ , ¹⁷ Given the associated health risks, high preconception weight status, excessive gestational weight gain, and postpartum weight retention of PPP women are well‐documented public health priorities. ¹⁸ , ¹⁹ However, this emphasis on weight is a less well understood priority for this population within the context of paid work. ¹⁴ Further, the connection between work and health may operate dependently or independently of weight and health practices, thus necessitating a well‐considered and informed approach to intervention design. Understanding the complex relationships and intermediaries between paid work and health for PPP women is, therefore, of the utmost importance.

The overall aim of this paper was to unpack the pathways between paid work and health outcomes, specifically relating to health practices and wellbeing of working women across the PPP life stages. To address this aim, we have used the example of “maternal obesity” to frame our understanding and drawn upon theory and literature to (1) highlight current challenges in connecting paid work and health from the broader ecological and highly contextualized perspective of the individual PPP woman, (2) introduce a pathway model to provide an overview of high‐level interconnecting relationships, (3) explore the role of motivation from an ecological systems perspective, (4) examine proximal (via health practices and patterns) and distal influences on health outcomes, and (5) identify implications for policy, practice, and intervention design.

1.1. Current challenges in connecting work and health for preconception, pregnant, and postpartum working women

Despite the importance of paid work in women's lives and considering many working women go on to have children, workplace health promotion is routinely siloed from pregnancy, parenthood, and public health specificities concerning the PPP population. ¹⁴ Such an approach is usually attuned to workplace safety or psychosocial wellbeing requirements, and aligned with legislation and industry standards, rather than employee consultation and exploration of specific needs. ⁹ In reality, most health‐related outcomes (e.g., maternal obesity) can be attributed to multiple complex contextual factors and intersecting pathways. ²⁰ While these pathways have not been examined from the perspective of PPP working women, Schulte and colleagues ²⁰ have conceptualized a number of mechanisms detailing how paid work factors and personal risk factors may affect health outcomes. The authors suggest that disease may result from independent, cumulative, and disease or effect modifying interactions between paid work and the individual. ²⁰ This thinking also helps to explain how work may impact health outcomes via weight, for example independently through health practices, cumulatively through the influence of psychological wellbeing on health practices, ²¹ , ²² or by modifying the severity of gestational diabetes through the interaction of weight‐related insulin resistance and low workplace autonomy. ²³ Importantly, this approach prescribes to systems thinking, whereby pathways between exposure and outcome are not inherently linear and instead consist of interconnecting relationships, feedback (i.e., elements within a system may be reinforced or balanced by themselves), and emergent (i.e., the whole is more than the sum of its elements) properties. ²⁴ , ²⁵ This allows us to think of workplaces as complex ecological systems, of which the woman and their own unique context are a part of. ²⁶

The absence of systems thinking becomes clear upon examining the literature centered on the improvement of health outcomes for PPP women and alleviating the “problem” of maternal obesity. Firstly, problem framing and intervention typically occur at the individual level and specifically relating to lifestyle modification. For example, pregnancy outcomes would be improved with diet and physical activity changes ²⁷ ; gestational weight gain and postpartum weight retention could be controlled using effective lifestyle interventions ²⁸ ; and confounders have been limited to individual factors (e.g., education or parity) in statistical analyses of maternal body mass index (BMI) and offspring outcomes. ²⁹ Similarly, while systematic reviews and meta‐analyses are considered the “gold standard” of evidence, the tendency to prescribe individual‐level interventions to overcome excess weight in PPP women ³⁰ is derived from a somewhat contradictory and weight‐centric evidence base, not typically consistent with systems thinking. ³¹ Secondly, to our knowledge, there are no conceptual frameworks or models to outline the systemic processes linking paid work, individual context, and health outcomes for PPP women to guide policymakers or researchers in decision making, intervention development, or implementation of systems‐based solutions to support maternal obesity prevention and wellbeing.

Although we know that paid work impacts the health and wellbeing outcomes of PPP women, context and individualism (i.e., the tendency to group individuals, thereby affecting the granularity of individual needs and context) are subject to attrition during the research process. Moreover, while the ultimate aim of stakeholders engaged in maternal obesity prevention may be to improve health outcomes, evaluation of interventions may center on individual behavior change and weight alone. ³¹ We suggest that there are two potential and related reasons for this. Firstly, “lifestyle drift” is thought to result from a power imbalance, whereby whole‐of‐society problems (i.e., maternal obesity) shift from being a problem of society to one of individual responsibility as a result of political or upstream influences. ³² , ³³ , ³⁴ , ³⁵ This concept commonly focuses on at‐risk or marginalized populations (i.e., PPP women) and often results in stigmatization and blame, ³² including for women experiencing weight‐related discrimination in their workplace. ¹⁷ , ³⁶ , ³⁷ Interventions become geared towards addressing downstream influences, thus leaving upstream influences (i.e., work) unchanged. ³² The second reason relates to dilution of individual context and exposure, where salient aspects contributing to individual health and wellbeing are diminished by the research and knowledge translation process (Figure 1).

FIGURE 1.

The dilution of individual context and exposure in research and practice. Note: (1.) The context of preconception, pregnancy, and postpartum (PPP) women is made of layered factors. Depending on the individual context, some factors have a greater effect on the weight, health practices, and wellbeing of the individual. These are “exposure factors” and may act in a positive or negative manner. Not all aspects of context will be important to the woman, ³⁸ and similarly, not all aspects of context will automatically confer risk or opportunity to the woman. It must be noted that individuals belong to multiple groups, not just PPP, including culture, age, socio‐economic status, nationality, and religion, and each contributes to context and exposure. (2.) Interventionists conduct a comprehensive needs assessment to interpret and capture the individual context and most exposure factors. (3.) Interventionists create programs based on the needs assessment but are constrained by time, funding, expertise, positionality (i.e., external factors that influence and bias your perception of the world), and so on. Mechanisms of change are often assumed to be the same for all individuals ³⁹ and consistent over time. ⁴⁰ As a result, context and exposure factors are diluted. (4.) Workplaces or policymakers may reject aspects of the program that are too costly, incongruent with the dominant weight‐centric paradigm, ³¹ or decide the timing for implementation is sub‐optimal. Additionally, implementation may be intervention or setting specific, rather than aimed at preserving contextualized elements from the original needs assessment.

The concept of emergence, from systems thinking, suggests that we cannot simplify a woman's context and expect to know which properties will emerge as most important ²⁵ ; this is not a one size fits all approach. Similarly, the public health priorities of maternal obesity prevention may not align with the priorities of PPP women. In order to address maternal obesity and achieve the overall goal of improving maternal health within the paid work context, we must determine the pathways between paid work and health outcomes for PPP women and ensure their applicability to the individual. To do this, we must first understand context as broadly and deeply as possible. Only then may we begin to understand how exposure factors direct the responses of individual PPP women and, ultimately, health outcomes.

1.2. The Context‐Exposure‐Response (CER) model

Considering the evidence base, where maternal obesity prevention is dominated by individual behavior change strategies and limited application of indirect or environmental impacts on health, a systems‐based approach is needed. Carey et al. ³² suggest that both upstream and downstream processes must be aligned to overcome systemic issues like obesity. However, first we must understand the pathways and relationships involved in shifting towards health during PPP for working women. This understanding could then be incorporated into both individual and population‐level approaches and would likely highlight the need for additional workplace strategies for obesity prevention and health enhancement and protection. Our conceptual pathway model aligns with systems thinking and proposes that paid work and health outcomes for PPP working women are connected through multiple complex pathways and incorporate both upstream and downstream factors, including maternal obesity. Thus, we propose the CER model to provide a high‐level understanding of the pathways between work, context, exposure factors, and outcomes for PPP women (Figure 2). The conceptualization, theory, and evidence explaining each level of the model (from individual context and exposure through to outcomes) are hereafter.

FIGURE 2.

The Context‐Exposure‐Response (CER) model demonstrates the pathways between work and health outcomes for the individual across the preconception, pregnancy, and postpartum periods.

2. INDIVIDUAL CONTEXT AND EXPOSURE

Individual context and exposure detail the interconnectivity between individual, environmental, and systemic workplace factors and highlight the breadth of contextual factors involved in outcomes for PPP women. While this paper has focused on a heteronormative male–female dynamic, complementary research is needed to explore the specific experiences of those with diverse gender identities and in same‐sex partnerships. ⁴¹

2.1. A sex and gender lens

Within the literature, the reality of the individual PPP woman and the diversity of her needs and motivations are predominantly viewed through a sex and gender lens. For example, despite the potential health benefit afforded by work role complexity and their increased uptake of tertiary‐level education, ⁴² many women remain heavily engaged in female‐dominated work roles synonymous with lower pay and lower status. ⁴³ Such work roles usually have lower levels of both flexibility and autonomy, thereby constraining the ability of working women to make independent decisions related to their health practices. ⁴⁴ , ⁴⁵

Whether women elect not to work in male‐dominated professions due to prevailing social norms, incompatibility with parenting demands, ⁴⁶ or workplaces opt women out of opportunities due to bias and discrimination, each aspect culminates in potential exposure to health inequity. Occupational segregation in female‐dominated work roles tends to be associated with the devaluation of professions dominated by women ⁴⁷ and reinforcement of restrictive gender stereotypes. ⁴⁸ Conversely, one longitudinal study found that working mothers are more likely to leave male‐dominated professions due to overwork, compared with women without children and men. ⁴⁹ Additionally, high‐income roles may not support the career interruptions associated with having children or the lower number of paid hours worked by women each week. ⁴⁶ This intentional opting out of workplace opportunities highlights how women may be forced to prioritize their PPP‐related needs, rather than those which confer increased resources and health equity.

Valenziano reports that many organizations tend to perceive racial and ethnic identity in a “color blind” manner and therefore may not understand the needs of specific groups. ⁵⁰ Similarly, several authors have highlighted the gender‐neutral nature of the workplace, whereby men's needs are considered normal and women's atypical, particularly during pregnancy. ⁵¹ , ⁵² These “gendered” needs position women outside business norms ⁵³ and can cultivate a culture of secrecy around pregnancy, ¹⁵ discrimination, ⁵² a de‐emphasis on gender, ⁵³ and guilt for those who feel they cannot meet business expectations due to parenting demands. ¹⁶ Further, the dissociation between gendered needs and paid work may validate the perception that workplaces have no specific responsibility to the health or weight status of PPP women, nor to understanding what the responsibility may entail. ⁵⁴ , ⁵⁵

2.2. The complexities of workplace dynamics for PPP employees

The reproductive years coincide with several key transitions during the life course, including leaving home, commencing employment and building a career, achieving financial independence, developing new relationships and social networks, and identity exploration. ⁵⁶ Accordingly, this stage spans a diverse spectrum of needs that may not be met by traditional occupational health and safety measures. ¹⁵ , ¹⁶ The idea of individual responsibility for health and weight continues to dominate within organizations, ¹⁵ , ⁵⁵ as well as the aforementioned research space. It has been suggested that provision of workplace health and wellbeing initiatives (e.g., healthy food landscape) may be indicative of the prevailing workplace culture and the importance of worker health to employers ⁵⁴ ; however, access may vary across countries and organizations. ¹⁶ , ⁵⁷ For example, availability of private breastfeeding spaces and pumping breaks have been shown to support the continuation of breastfeeding following the return to paid work; however, national survey data from the United States showed that only 40% of women had access to these resources in their workplace. ⁵⁷ An absence of such PPP‐related supports may result in early cessation of breastfeeding, ⁵⁸ difficulties with postpartum weight loss, ⁵⁹ and perceptions of low social value within a work organization. ¹⁶

While women's engagement in the workforce has been rising in high‐income countries, ⁶⁰ the time and energy needed to care for children remains largely unchanged due to the gendered division of unpaid domestic labor. ⁶¹ , ⁶² It has been proposed that role conflict (e.g., work–family conflict) may limit the positive health benefits associated with paid work to part‐time women with children, compared with full‐time working mothers. ⁶³ However, our research suggests that while part‐time women without children may use their “extra” time towards their own health and wellbeing needs (e.g., physical activity), mothers working part‐time may use extra time to manage their children's needs. ¹⁶ This is notable as this life stage is associated with increased weight, energy intake, and decreased physical activity. ⁶⁴ While contributors to such gendered norms may appear to be outside the sphere of organizational influence, initiatives like the 4‐day work week and the associated benefits to health (e.g., physical activity increased by an average of 20 min per week in the Australasian trial of the 4‐day work week) and improved division of domestic labor (e.g., 27% of men in heterosexual relationships increased their share of housework) suggest otherwise. ⁶⁵

2.3. Looking to organizational health and performance

Employee wellbeing is integral to organizational health, ⁶⁶ and, from a business perspective, organizations that take steps to improve employee health and wellbeing may perform better. ¹⁰ In turn, “healthy” organizations provide their employees with the resources to counteract unreasonable job demands and reduce potential health risks. ⁶⁷ Modifiers of organizational health include practices directed at work–life balance and health promotion, work design (e.g., autonomy over tasks and scheduling), and leadership development. ⁶⁷ However, executives may not understand the specific needs of their PPP employees, ¹⁵ and many feel they lack the information necessary to improve their organization's long‐term health. ⁶⁸ Further, there is a danger that focusing on employee wellbeing or weight is not considered an essential part of business operations, particularly for smaller employers. ⁶⁹ This is not to suggest that cultivating a weight‐discriminatory working environment would be in anyway beneficial, and in fact, the opposite is true, ³¹ but rather employers may not foresee the extensive influence the workplace may have on the ability of an employee to thrive and be well. For example, workplaces may opt to comply with minimum legal requirements or follow a best practice approach when deciding parental leave policy. However, research shows that paid parental leave may facilitate recovery after birth, ⁷⁰ attachment and bonding with the new infant, ⁷¹ and commencement and continuation of breastfeeding to 6 months ⁷² and provide time to cook healthier meals. ⁷³

2.4. Shortcomings in policy integration: Implications for gender equity and health outcomes

Policy and legislation signal expectations for gender roles, enshrine rights and entitlements in the workplace, and impact advancement towards an equitable dual‐breadwinner model. ⁷⁴ , ⁷⁵ However, despite the high engagement of women of reproductive age in the workforce, ¹⁴ integration of gendered needs into policy and legislation has been mixed in high‐income countries. ⁷⁴ , ⁷⁶ Populations in higher income countries have longer lifespans, lower birth rates, increased female workforce participation, advanced maternal age, and smaller family sizes (meaning there are less family members to divide caring responsibilities). ⁷⁷ Carers with the dual responsibility of providing care to children and their elderly parents (typically women) have been dubbed “the sandwich generation,” ⁷⁸ and workplace policy has not kept pace with best practice and social change to facilitate these external demands. Consequently, time pressures particularly for those with caregiving responsibilities may mean that women are less likely to engage in physical activity or consume a healthy balanced diet. ⁷⁹ , ⁸⁰

Inadequate incorporation of gendered needs into national workplace‐related policy is exemplified in Australia and Britain by the predominance of women engaged in part‐time paid work, limited state childcare provisions, and short parental leave entitlements for partners. ⁷⁴ Such outcomes normalize the male‐breadwinner model and may sanction its contribution to gender inequity at a national level. Equally, the persistence of the male‐breadwinner model comes at the expense of working single mothers, who must contend with the gender wage gap, social security protections preferencing married couples, ⁸¹ increased parental responsibility compared with partnered mothers, and the financial impacts from unpaid caring responsibilities (e.g., unpaid leave for sick child). ⁸¹ , ⁸²

Structural determinants of health have repercussions for women's income, opportunities, and, therefore, health. For example, one Swedish study found that each additional month of parental leave taken by fathers corresponded to a 6.7% increase in a mothers' future earnings. ⁸³ While income is inversely correlated with obesity, ⁸⁴ the reverse is also true: obesity has negative effects on subsequent income, and this effect is greater in women compared with men. ⁸⁵ Research has also shown that partner access to, and uptake of, paid parental leave has led to significant mental health advancements for mothers, ⁸⁶ a decreased risk of health complications and need for healthcare during the postpartum period, ⁸⁷ and improved partner involvement and investment in offspring care. ⁸⁸

3. RESPONSE TO CONTEXT AND EXPOSURE

Motivation is typically described as a series of internal psychological processes that give rise to behavior. ⁸⁹ However, motivation may also be regarded as socially informed and a property of systems and less so dictated by forces centered within the individual. ⁹⁰ While sustained motivation for change necessitates the inclusion of a supportive environment, ⁹¹ many workplace interventions do not incorporate the environmental aspect of behavior change. ⁹² A supportive environment and exposure to opportunity decrease the personal investment needed to actively self‐regulate behavior and form improved habits, including healthy eating. ⁹¹

Identified barriers and facilitators to healthy “lifestyle” behaviors ⁹³ among PPP women encompass multiple levels including cognitive, environmental, physiological, and social. ⁹⁴ , ⁹⁵ , ⁹⁶ Correspondingly, motivation is not as simple as a pathway model might imply. Motivational factors are filtered through context and exposure and can only relate to the collective and unique experience of being an individual within specific groups and society as a whole. Therefore, we suggest motivational factors (expectations, experiences, knowledge, priorities, and skills) may be more accurately conceptualized as a “response” to individual context and exposure for PPP women. This distinction has important ramifications not only for preventing lifestyle drift and dilution of context and exposure but also in steering support for obesity‐related policies towards environmental solutions and away from ineffective ²⁵ and potentially stigmatizing and discriminatory approaches to health improvement. ⁹⁷

Interventions to improve the health practices and patterns of women across the PPP periods have tended to underscore the importance of capacity building and motivation in changing behavior. ⁹⁵ Intervention components or techniques, such as motivational interviewing, counseling, goal setting, problem solving, and education, have been applied to enhance the knowledge, beliefs, and skills of women of reproductive age, including to reduce gestational weight gain. ⁹⁸ , ⁹⁹ However, this emphasis often neglects a more ecological approach, exclusive of context. ¹⁰⁰ In part, this may be due to the inconsistent application of theory to intervention design and evaluation. ¹⁰⁰ Few interventions to improve diet, physical activity, and weight‐related outcomes in working women have incorporated named theories into intervention design. ⁹² Further, where theory is referenced in behavior change interventions, its usage is often fragmented and loosely applied. ¹⁰⁰ Then, there is the misuse of theory: theories commonly applied to interventions for this population, including social cognitive theory, health belief model, and self‐determination theory are among the most frequently used theories for behavior change in general (i.e., theories may have been chosen based on popularity, rather than suitability). ¹⁰⁰ Such theories place the woman in a central role for determining behavioral influence and other contextual factors in a supporting, secondary role. ³⁰ Further, some theories have fixed boundaries and may treat behaviors as static and unchanging over time (e.g., regarding physical activity as a simple binary, either performed or not, without considering factors like time of day or whether a woman is heavily pregnant). This approach overlooks the influence of time on behavior across weeks, months, and years ³⁹ , ⁴⁰ and transitions across the PPP life stages and, therefore, may not fully capture the complexity of how behavior evolves over longer durations and according to changing needs.

3.1. Mediating the pathways between work and health via motivation

In the absence of research to outline the complexity required to inform systems‐based intervention development, we propose a series of simplified example pathways involving motivational factors from a systems perspective (Table 1). Motivational factors and examples have been developed through our qualitative and co‐design work with women of reproductive age, ¹⁵ , ¹⁶ , ¹⁰¹ theory (including aspects of Social Ecological Model ³⁰ , ¹⁰² ; Social Cognitive Theory ¹⁰³ ; Feminist Theory ¹⁰⁴ ; Maslow's Hierarchy of Needs ¹⁰⁵ ; Theory of Planned Behavior ¹⁰⁶ ; Capability, Opportunity, and Motivation of Behavior Model ⁸⁹ ; and Bandura's Self‐efficacy Theory ¹⁰⁷ ), and the “Theory and Techniques Tool.” ¹⁰⁸ To take “priorities” and Maslow's Hierarchy of Needs as examples, ¹⁰⁵ if behaviors do not fulfill basic needs, then they are less psychologically salient, and equally, this logic can be extended to coping behaviors. ¹⁰⁵ Coping behaviors are considered beneficial for improving short‐term emotional needs. ¹⁰⁹ However, if healthy coping strategies (e.g., social support) are ineffective or unavailable, then the emotional need(s) remains unresolved. ¹⁰⁹ Consequently, the individual may adopt unhealthy coping strategies (e.g., emotional eating), potentially resulting in negative health impacts. ¹⁰⁹

TABLE 1.

Simplified systems‐informed diagrams of motivation pathways as they progress from context and exposure towards outcomes across the preconception, pregnancy, and postpartum periods.

Life stage	Response	Example	Systems‐informed diagram
Preconception	Wellbeing outcomes	Management encourages staff to take lunch breaks and keep regular hours but do not model their own advice.
Preconception	Expectations	A woman has received another fixed‐term (temporary) contract.
Pregnancy	Experiences	Previous pregnancies within the work team have been met with support and understanding.
Pregnancy	Knowledge	A woman (8 weeks pregnant) is unsure of organizational policies around pregnancy and is not ready to discuss her pregnancy with colleagues.
Postpartum	Priorities	A woman struggles to make time for self‐care while prioritizing work and child needs.
Postpartum	Skills	A workplace adopts a “healthy food” policy for work events, e.g., morning teas and meetings.

Note: Previous research has detailed the important role that psychological wellbeing may play in directing the health practices of preconception and pregnant women by mediating motivation. ²¹ , ²² Further, it has been suggested that the relationship between psychological health and health practices is bidirectional, thus demonstrating the far‐reaching potential of work to impact wellbeing (e.g., depressive symptoms) or health practices (physical inactivity), and therefore contributes to weight gain and/or health outcomes. ²¹ Not all arrows have been provided with polarity in order to maintain simplicity. Box colors/line style match Figure 2. Key: No Polarity; Positive Polarity; Negative Polarity; Context and Exposure; Response to Context and Exposure; Health Practices and Patterns; Outcomes.

In the context of women working across the PPP periods, denial of a need (e.g., being unable to adhere to recommended health practices for the management of gestational diabetes due to the demands of paid work) impedes satisfaction and results in a reprioritization of the most essential need. ¹⁰⁵ However, many studies, including our own, have described the conflict experienced by women in terms of work–life or work–family balance, which renders women unable to fully reconcile their needs relating to both paid work and life. ¹⁶ , ¹¹⁰ , ¹¹¹ Postpartum women may also experience compounded temporal pressures to provide the necessary energy and attention needed to care for young children, whereby the child effectively contends for priority over the mother's own needs during a period of intense change. ⁹⁶ , ¹¹² Thus, women may be inclined to deprioritize their own “less important” health needs (e.g., health practices or weight maintenance), while unfulfilled essential needs persist. ¹⁶ , ¹⁰⁵ Supporting a reprioritization of health needs is in the best interests of employers as health practices (e.g., physical activity) have been shown to improve factors relating to job performance, including quality sleep, vigor, task focus, and task and creative performance. ¹¹³

4. MOVING TOWARDS OUTCOMES

Interventions to improve the weight or health practices of PPP women have often focused on physical activity, diet, or a mixture of diet, physical activity, and/or behavior change strategies. ⁹⁸ , ¹¹⁴ , ¹¹⁵ While interventions suggest modest positive effects on PPP weight at a population level, considerable variation in efficacy is apparent. ⁹⁸ , ⁹⁹ , ¹¹⁴ , ¹¹⁵ , ¹¹⁶ , ¹¹⁷ This suggests that influences on motivation and behavior are far reaching and may vary across the PPP periods and according to the individual.

In our model (Figure 2), we have illustrated the direct relationship between health practices and patterns, and also the overall systems influence which may bypass the motivational factors and/or health practices of PPP women to impact outcomes. To provide an example of a direct pathway from individual context and exposure to outcomes, job insecurity is a by‐product of policy and work systems that have shifted towards greater labor market flexibility, ¹¹⁸ including outsourcing and temporary contract work (e.g., fixed term and casual contracts), a steady fall in union memberships, ¹¹⁹ work intensification, ¹⁰ and the rise of the “gig economy.” ¹²⁰ Job insecurity translates to greater inequalities throughout the life course ¹⁰ and, for women, may be associated with overweight, obesity, psychological distress, and work–family life imbalance, compared with women without job insecurity. ¹¹⁹ Further, our findings suggest that precarious working arrangements may hinder women's capacity to make decisions regarding family planning and preconception health. ¹⁶ Insecure work may also mean that workers are less likely to cultivate a sense of belonging and dedication to their organization, as well as generating a disconnect for those who adopt their job or profession as an integral part of their identity. ¹²¹ Further, such conditions may have a significant impact on job performance and absenteeism. ¹²²

There are also multiple examples of the proximal effect on outcomes via health practices and patterns, within a (paid) work system. A meta‐analysis of individual participant data (over 67,000 women) found that women working in high strain (high demands, low control) or passive jobs (low demands, low control) had greater odds of leisure‐time physical inactivity. ¹²³ Research suggests that paid work factors may negatively affect coping strategies and decrease self‐efficacy, thereby cultivating poor health patterns. ¹²⁴ During periods of high stress or exhaustion, diminished personal resources impair the ability to self‐manage behaviors and increase the likelihood that an individual will revert to habitual behaviors. ⁹¹ Furthermore, knowledge alone is unlikely to help overcome (paid) work impediments to health and wellbeing including long hours, workload, shift work, and job stress given their impact on the health practices and outcomes (e.g., obesity). ¹²⁵ , ¹²⁶ In addition, and as we have indicated in Table 1, negative impacts on psychological wellbeing may impair the health practices of preconception and pregnant women by affecting their motivation. ²¹ Thus, the proximal and distal effects of the work system may interact in a bidirectional relationship with health outcomes, which may contribute to direct effects on wellbeing and resources, or indirect and direct effects on weight gain and health practices (Box 1).

Box 1. Examples of relationships leading to the development of maternal obesity.

Direct Impact of Work

A lecturer has recently recommenced work on a part‐time basis following a period of parental leave. Prior to going on leave, she worked full‐time in a combined teaching and research role. She was busy but still managed to walk with her colleagues during lunch and participate in workplace health promotion activities (e.g., yoga or 10,000 steps). However, the new workload assigned to the lecturer does not match the hours associated with her part‐time contract. The norms within the sector and her workplace support this culture of overwork. To keep up, the lecturer works through each lunch break, in the evenings when her child has gone to bed, and during weekends with the support of her partner. The resulting time compression leaves her with little opportunity to plan, buy, cook, and enjoy healthy home‐cooked foods and leads to an increasing dependence on takeaway meals for dinner. As the lecturer works part‐time, she feels she cannot “also” attend workplace health promotion activities. The combined effect of her sedentary work role, increased consumption of convenience foods, and little opportunity for movement during the workday contribute to her difficulties with postpartum weight retention.

Indirect Impact of Work

A case worker in a community services organization becomes pregnant. Her employer takes care to prevent her being exposed to workplace violence and alters her case load. However, the case worker is assigned to a family where one of the members has just had a stillbirth. The visible nature of the case worker's pregnancy becomes a source of stress that carries over to her home life. She performs the additional emotional labor required by her workplace and external agencies (e.g., Department of Health and Human Services) to minimize her personal needs and maintain the expected level of professionalism. She experiences burnout and psychological distress and, as a result, begins to engage in emotional eating that results in weight gain, exceeding the recommendations for gestational weight gain.

5. FUTURE DIRECTIONS

There is ample evidence to demonstrate how the pathways between work factors and individual health outcomes for PPP women may operate. The relationships described in this paper help explain how seemingly disconnected elements may directly or indirectly affect the health, wellbeing, weight, and equity of PPP women. While a certain degree of simplicity is necessary to relay broad concepts and connections across three distinct yet overlapping life stages, it is hoped that application of the CER model may assist interventionists, researchers, and policymakers to adopt a systems‐focused perspective, capitalize on possible new leverage points, overcome “policy resistance,” ¹²⁷ and consider the variation in context and exposure between individuals.

Decision makers may find value in the unique evidence‐ and theory‐based merger of PPP, paid work, and individual outcomes in the model, whereby the need for health‐focused change, obesity prevention measures, and workplace accommodations for the PPP population are prioritized. Application of the model within organizations could better acquaint senior figures and management, potentially lacking in lived experience, with the needs of PPP employees by broadening the depth of their understanding. Further, this understanding may contribute to the development of a more psychologically safe, compassionate, and health‐focused workplace. ¹²⁸ , ¹²⁹ We suggest that the CER model could help facilitate and evaluate organizational change by identifying novel or untested strategies or domains for improvement and by bridging the wellbeing gap between the “default” employee and PPP women.

From a practical perspective, workplace accommodations are contextual (i.e., unique to the workplace, the individual, and their life stage) and subject to a needs assessment and policy impact analysis. For example, flexible working arrangements (i.e., organizational policy) benefit PPP employees (e.g., to care for children, attend appointments, or participate in physical activity during the workday. ¹⁵ , ¹⁶ However, work intensification and the extension of paid work into the home (i.e., social factors, workplace culture and norms, organizational health, policy and legislation, and individual needs) may counteract these advantages ⁴⁴ , ¹³⁰ by contributing to job stress, work–family conflict, and fatigue—all factors that may result in weight gain. ¹³¹ , ¹³²

While the CER model is a useful starting point, understanding and improving individual health practices and patterns will require the development of highly tailored interventions. ⁴⁰ Researchers, employers, and policymakers may be hampered by an approach to behavior change that groups, categorizes, and simplifies. ¹³³ , ¹³⁴ Defining individuals and identifying strategies for behavior change through group‐informed social identities ¹³⁴ would likely prove difficult for PPP women, given their wide‐ranging needs, priorities, contrasting identities, and the contextual realities of being “othered” in workplaces. ¹³⁵ Certainly, as Reynolds et al. have indicated, there is a need to understand a person as both an individual and member of a group. ¹³⁴ However, the need to measure and understand the complexity of individual behavior warrants the use of innovative approaches, including computational modeling and simulation techniques. ⁴⁰ Such techniques would allow for greater precision at the individual‐level and facilitate the incorporation of temporal and contextual features associated with change across the lifespan of PPP women into behavior change theories. ⁴⁰ Further, our notion of “tailoring” must also evolve. As Chevance and colleagues have highlighted, the tailoring applied to many interventions is derived from data taken from a single time point. ⁴⁰ Continuous refinement of interventions in real time, or “continuous tuning,” may facilitate adjustment to complex behavioral systems for PPP women. ⁴⁰

From a broader public health and health equity perspective, “workplace wellbeing” should be expanded to align with employee expectations that paid work should not negatively impact health. ¹⁶ Consequently, employer acceptance and mitigation of the adverse effects of paid work on physical wellbeing (e.g., sedentary practices) should grow to match that of psychological wellbeing, thereby presenting an additional route for targeting maternal obesity. ¹³⁶ Workplaces should provide appropriate training and education to ensure leaders and decision makers have a high‐level of understanding of PPP employees' needs pertaining to these life stages, which they may then transfer and model to others (e.g., the importance of being active).

Another consideration for employers is the movement towards a more equitable workplace model for women and men. To facilitate this, organizational leaders should look for ways to minimize incompatibilities between paid work, wellbeing, and family life. Progressive steps towards a healthy workforce and equity in the workplace may also assist organizations to attract and retain talent, to maximize their profile, and to counter absenteeism and impediments to productivity. However, solutions cannot solely rely on provision of amenities or supportive policies as employees must also have confidence that they can avail of these workplace resources without compromising on career opportunities. Policy support for male caregiving may help improve this. Attending to the caregiving needs of partners (e.g., providing adequate paid leave for partners and facilitating uptake) and movement towards a dual‐breadwinner society will likely require broad spectrum political support and may also necessitate improved access and availability of childcare for employees.

6. CONCLUSION

Understanding the contextual realities of individual PPP women is key to improving their health practices and wellbeing outcomes. Health‐related problems, such as maternal obesity, must be addressed using a whole‐of‐systems approach, encompassing emerging individual, environmental, and systemic workplace factors. This paper has demonstrated a high‐level overview of the pathways between work and health, including those directly or indirectly impacting maternal obesity, and serves to broaden our knowledge of how paid work and health are inextricably linked for women working across the PPP life stages. The existing focus on the individual serves to homogenize and distill the individual experience during the knowledge translation process. This article has presented specific examples, from across the PPP life phases, conceptualizing the complexity of the relationship between paid work, motivation, weight, and health practices of PPP women. Furthermore, we have emphasized that structural components of systems may bypass motivation to act on health outcomes directly. In this manner, we urge researchers and decision makers to redirect the “blame” typically associated with individual health outcomes and weight status in order to progress towards greater health equity and systems‐driven solutions that acknowledge the impact the paid work environment has on health.

CONFLICT OF INTEREST STATEMENT

The authors declare they have no known conflict of interest that may have influenced the work presented in this paper.

Madden SK, Ahuja KDK, Blewitt C, Hill B, Hills AP, Skouteris H. Understanding the pathway between work and health outcomes for women during the preconception, pregnancy, and postpartum periods through the framing of maternal obesity. Obesity Reviews. 2023;24(12):e13637. doi: 10.1111/obr.13637