Diverse Women’s Beliefs about Weight Gain in Pregnancy

Abstract

This research was conducted to describe ethnically diverse new mothers’ perceptions of gestational weight gain. Forty-nine low-income women of diverse racial and ethnic origins who birthed an infant within the past year completed a semi-structured interview in a pediatric clinic waiting room. Interviews were designed to elicit views on gestational weight gain, including expectations and perceived consequences. Data were analyzed using content analysis techniques. Women believed that others like themselves were concerned about pregnancy weight gain. Many focused on the effects of insufficient pregnancy weight gain on the infant but were not aware of the infant risks of excessive gain. Several had inaccurate knowledge of appropriate gestational weight gain, and many suggested an amount below current recommendations. One-third of the women believed women will weigh more following pregnancy, yet others assumed that even with excessive weight gain there would be a return to pre-pregnant weight following pregnancy. Pregnancy-related weight gain is disturbing to women. Health care providers have the opportunity to intervene by acknowledging these concerns and providing information and support to help women make positive choices and achieve appropriate weight gain.

The childbearing years are a time of weight gain for many women, and many attribute this to weight retained from pregnancy. A large proportion of pregnant women of differing ages, pre-pregnant body mass indexes (BMIs), and racial/ethnic groups gain more weight than is needed during pregnancy.^1–3 One maternal consequence of excessive gestational weight gain is postpartum weight retention,^{2, 4, 5} which can contribute to long-term obesity.⁶ The effect of high gestational weight gain extends beyond immediate pregnancy and is detrimental to the health and well-being of women.

An understanding of what women believe about appropriate weight change in the context of pregnancy would enable women’s health care providers to effectively assist women in attaining or maintaining a healthy weight during the childbearing years. We conducted a brief waiting-room interview in an urban northeastern clinic to elicit new mothers’ thoughts about pre-pregnant weight, gestational weight gain, and post-pregnancy weight. The objective of this descriptive study was to describe the perceptions of a small group of ethnically diverse mothers about gestational weight gain.

BACKGROUND/LITERATURE REVIEW

Risks and Consequences of Excessive Pregnancy Weight Gain

The Institute of Medicine (IOM) established gestational weight gain recommendations in 1990 for women with normal, low, and high pre-pregnant BMI (weight for height)⁷ that became the standard guidelines for obstetric practice. Yet the IOM recently confirmed that we fall short in our knowledge of gestational weight gain and its impact on women and their offspring.⁸

Weight gain above the IOM recommendations contributes to long term-weight retention ⁴ and the risk of overweight in offspring.⁹ In a sample of 1300 women, Gunderson et al⁴ found that the odds of becoming obese were 3.19 (CI 1.87–5.44) for women with high gestational weight gain, compared to women with weight gain within the recommendations. Schieve et al³ examined weight gain trends from 1990 to 1996 among 120,531 white, black and Hispanic low-income women attending prenatal nutrition programs in the United States who delivered full-term infants. They found that although 34% of the women gained within the recommendations during that time period, the proportion gaining more than recommended increased from 41.5% to 43.5%, and over 60% of women who were overweight before pregnancy gained more than the recommendations Similarly, in a sample of 330 African-American primigravida adolescents, 35% gained more than was recommended during pregnancy.² Regardless of pre-pregnant BMI category, adolescents who gained above the IOM recommendations were 4.6 times more likely to be obese after pregnancy than those who gained within recommendations. Butte et al ¹⁰ examined the body composition of 63 women before, during, and after pregnancy. They concluded that gestational weight gain was positively correlated with postpartum weight and fat retention, and fat retention was significantly higher in the women who gained more than recommended.

Failing to lose pregnancy weight by 6 months postpartum results in more weight retention over the long term.⁵ In a cohort of 540 women, Rooney and Schauberger found that women who gained more than recommended had a weight increase of 8.4 kg 8–10 years after pregnancy, whereas those who gained within the recommendations had a weight increase of 6.5 kg.⁵ However, women who lost their pregnancy weight by 6 months postpartum were 2.4 kg heavier 8–10 years later, while those who did not were 8.3 kg heavier.

Women’s Beliefs and Attitudes toward Pregnancy Weight Gain

In an observational study of 130 low-risk pregnant women, some women reported negative attitudes toward weight gain while pregnant, even if their weight gain was within the recommended range.¹¹ Some women restricted their pregnancy weight gain by methods such as dieting, and became distressed about their pregnancy-related weight gain. Conversely, women who considered body changes to be a positive result of being pregnant had a more positive attitude about their weight gain and gained more weight than those with more negative attitudes.¹¹

Beliefs about appropriate pregnancy weight gain appear to be related to pre-pregnant BMI and influence actual gestational weight gain. In a longitudinal study of more than 1000 women, Stotland et al found that women with higher BMI designated higher target weight gains than women who weighed less, and BMI was the strongest predictor of target weight gain.¹² In another sample of 2,237 women, provider-advised gestational weight gain was associated with actual weight gain.¹³ Many women received no gestational weight gain advice, and these women were more likely to have weight gain outside of the recommendations. Women may also be given incorrect advice regarding what they should gain.^{12, 13} Stotland et al reported that overweight and underweight women were more likely than normal weight or obese women to have been given incorrect advice.¹²

Summary of Evidence to Date

Weight gain within the IOM recommendations increases the likelihood of positive health outcomes for both mother and infant. Yet, at least 40% of pregnant women gain above the recommended range. Women’s misconceptions regarding appropriate gestational weight gain, attitudes and beliefs about weight and weight gain, and inaccurate or absent advice regarding gestational weight gain can affect the amount of weight women gain while pregnant. To inform the design of effective interventions to prevent long-term weight retention, the focus of this study was how new mothers view gestational weight gain and weight following pregnancy.

METHODS

The study was approved with exempt status by the University of Rochester Institutional Review Board. The sample included 49 adult women who birthed an infant within the past year. Women were purposively sampled to attain racial/ethnic diversity and were recruited in the outpatient setting of the Pediatric Practice at Golisano Children’s Hospital in Rochester, NY.

Data Collection

At the time of a well child visit, women who were fluent in English and had delivered a child within the past year were invited to participate in the study by means of an introductory letter distributed by the pediatric personnel. If women verbally agreed to participate interviews were conducted on site that same day by the investigator or a trained research assistant, who asked the participant each research question using a semi-structured questionnaire and manually documented responses using the woman’s own words. Because of the somewhat public nature of the study setting due to space constraints at the clinical site, interviews were not taped, and the women were not asked to sign consents or provide any identifiable or personal health information. No personal data about the participants’ own pregnancy weight gain experiences were collected, because the goal was to elicit women’s views of gestational weight gain, rather than to obtain a factual report of their own weight change.

The questionnaire was structured to ask general questions on attitudes and beliefs about pregnancy weight, along with specific questions designed to elicit brief responses that could be answered in a public venue related to gestational weight gain, and physical activity following pregnancy.¹⁴ In response to the evidence reviewed above on the importance of attitudes and beliefs to women’s weight gain behavior, questionnaire items included a subset of six questions on the amount of weight women should gain during pregnancy, as well as what happens to weight following pregnancy. Two content experts reviewed the questionnaire and supported its content validity.

Analysis

Content analysis techniques, which included both qualitative and quantitative strategies, were used for data analysis.¹⁵ Study team members read the participant responses, selected exact words from the text that depicted key concepts, and wrote notes on first impressions and initial analysis.¹⁶ Then labels or codes for the concepts were developed and sorted into categories. Recursive interactions with the data lead to further code refinement. When all responses were coded, responses were counted to determine frequencies. Statistical tests of differences in distributions across subgroups were not attempted, both because of the small sample size and because the statistical assumption of equal opportunity to make a specific response was not met in this open-ended qualitative design. Instead, patterns of responses were interpreted qualitatively using a minimal level of inference to reflect the women’s original intentions as closely as possible.¹⁷

RESULTS

The women ranged in age from 18–42 (mean = 24.9) and were of racially diverse origins: white (n= 12), black (n= 24) and Hispanic (n= 13). Women were primarily low-income, which was defined by their report of enrollment in federally-supported health insurance.

Women’s Attention to Pregnancy Weight Gain

The majority of study participants (66%), especially the white respondents (83%), reported that pregnant women do think about gestational weight gain. Many of the participants (44%) said that women are concerned about being overweight following pregnancy—“if she gains too much weight after having the baby [she] will be too fat” and “not how much they should gain—how much they have gained, because they are worried about their figure and how they will look afterwards.” Others (20%) focused more on weight gain as it relates to the infant. Women reported, “weight gain is good for the baby—it’s no longer about the woman, it’s about the baby” and “you think the weight gain is for the benefit of the baby.” One participant expressed women’s ambivalence about pregnancy weight gain: “[you] don’t want to gain too little because it will affect the baby, but if [you] gain too much [you] will be fat after the baby.”

A few of the participants indicated that women do not really think about gestational weight gain because “we don’t keep track of it—we go as we go” and “it is the only time to eat what you want.” One participant said, “If weight is not already a problem they [women] don’t think about it during pregnancy.”

Beliefs about Appropriate Pregnancy Weight Gain

When asked how much weight a woman should gain during pregnancy, nearly half of the participants gave a number or range within the IOM recommendations for weight gain of normal-BMI women (n = 23). The remaining women were almost equally split between suggesting ranges below (n = 10) or above (n = 8) the IOM recommendations, while a few either did not know (n = 2) or indicated the amount of weight gain varied (n = 6). More of the white women than black or Hispanic women cited a desirable weight gain that fell within the IOM recommendations. Black women more often suggested less weight gain than the recommended range for normal weight women.

Some women were aware of differences in the amount of weight women should gain depending on pre-pregnant BMI—“depends on her size” and “if you are thin you can gain a lot—if you are overweight before getting pregnant [you] should not gain a lot” (see Table 1). The group as a whole was split on whether or not pre-pregnant weight affects how much weight women should gain during pregnancy. Black women more often than white or Hispanic women believed that pre-pregnant weight has no effect on pregnancy weight gain recommendations.

Table 1.

Beliefs on role of pre-pregnant body mass index (BMI) in appropriate weight gain

	No. (%)
	Total	White	Black	Hispanic
	(N = 49)	(n = 12)	(n = 24)	(n = 13)
Makes a difference	24 (49)	6 (50)	10 (42)	7 (54)
Does not make a difference	21 (43)	5 (42)	13 (54)	3 (23)
Underweight should gain more	9 (18)	3 (25)	4 (17)	2 (15)
Overweight should gain less	9 (18)	4 (33)	2 (8)	3 (23)
Don’t know	3 (6)	1 (8)	3 (13)	1 (8)

Beliefs about Effects of Pregnancy Weight Gain

Respondents expressed that pregnant women have concerns that the infant would be adversely affected if they gained less than is recommended (see Table 2). If women gain less than recommended, they “will not be able to give baby the minerals he needs” and it “has a toll on the baby—maybe baby’s health is affected.” Still, several of the respondents felt under-gaining would not make a difference; a few noted it would be easier to lose weight afterward, so it might be better for the woman to gain less—“they would be happy after having the baby because they will be small.”

Table 2.

Perceived effects of pregnancy weight gain

	No. (%)
	Total	White	Black	Hispanic
	(N = 49)	(n = 12)	(n = 24)	(n = 13)
Effect of gaining too much
Harder to lose after	19 (39)	6 (50)	8 (33)	5 (38)
Doesn’t matter	15 (31)	4 (33)	9 (38)	2 (15)
Overweight	7 (14)	0	3 (13)	4 (31)
Affects health	6 (12)	3 (25)	2 (8)	1 (8)
Affects self esteem	5 (10)	0	3 (13)	2 (15)
Depression	2 (4)	0	0	2 (15)
Gestational diabetes	1 (2)	0	1 (4)	0
Effect of gaining too little
Risk for infant	21 (43)	5 (42)	12 (50)	4 (31)
No difference	9 (18)	2 (17)	4 (17)	3 (23)
Baby will be small	8 (16)	3 (25)	4 (17)	1 (8)
Maternal health problems	8 (16)	1 (8)	5 (21)	2 (15)
Easier to lose weight after	4 (8)	0	2 (8)	2 (15)
Don’t know	4 (8)	3 (25)	1 (4)	0
Better for woman	1 (2)	0	0	1 (8)
Something is wrong	1 (2)	0	1 (4)	0
Problems with delivery	1 (2)	0	1 (4)	0

When asked about the impact of gaining more than is needed during pregnancy, approximately one-third of the respondents indicated it didn’t matter if women gained above the IOM recommendations. Others focused on the difficulty of losing weight after high weight gain, thought that it did matter: “they will be heavier,” “mother would be stuck with pregnancy weight,” and “hard to get the weight off, low self esteem” (see Table 3). Some women recognized that gaining too much could have an effect on childbirth and health during the pregnancy—“she will have a hard time delivering her baby” and “gestational diabetes, health problems, a big baby.” One woman indicated “it’s harder to lose and probably unhealthy to gain more than you need.”

Table 3.

Expectations of post-pregnancy weight

	No. (%)
	Total	White	Black	Hispanic
	(N = 49)	(n = 12)	(n = 24)	(n = 13)
Weigh about the same	18 (37)	5 (42)	8 (33)	5 (38)
Weigh more than before	16 (33)	4 (33)	7 (29)	5 (38)
Depends on the woman	7 (14)	2 (17)	3 (13)	2 (15)
Less than before	3 (6)	1 (8)	2 (8)	0
Depends on breastfeeding	3 (6)	1 (8)	0	2 (15)
Don’t know	3 (6)	0	3 (13)	0
Weight will be a lot different	2 (4)	0	1 (4)	1 (8)
Depends on maternal age	1 (2)	1 (8)	0	0
Depends on stress level	1 (2)	1 (8)	0	0

Beliefs about Post-Pregnancy Weight

The sample lacked consensus on what a woman’s weight would be approximately one year after she had a child (see Table 3). Responses included, “[she] should be getting close to her pre-pregnant weight,” and “she may have 5–10 extra pounds,” while some put constraints on that belief: “depends on her age—metabolism and weight gain,” “if she exercises she will be back to her size,” or even “weigh less after having the baby if breastfeeding, but some people will have trouble losing.” Others reported that a woman “will be fatter,” “still pretty high—15–20 pounds left from pregnancy weight” or “a lot different—end up with more [weight] than before you had the baby—won’t lose a lot of weight in one year.” One woman predicted that a woman will weigh “more than she was—it is hard to lose baby weight—it is different than losing regular weight.”

DISCUSSION

Impact of Women’s Beliefs on Pregnancy Weight Gain

Most women in this sample gave thought to pregnancy weight gain, and many focused on the risks and benefits for infant health, which has been the focus prevalent in the medical field. ⁷ Low gestational weight gain was considered to be a risk for infants, yet none in the sample recognized that excessive maternal gain could be detrimental to the infant beyond higher birth weight. ^{18, 19}

Prior studies have indicated that weight gained during pregnancy influences long-term weight retention, especially when the gain is above the recommended range.^{2, 4, 5, 20, 21} Although nearly one-half of the women in this sample endorsed a weight gain within a recommended range for normal weight women, the range of responses was broad, and many of the women were not clear about appropriate gestational weight gain. With an increasing prevalence of overweight in the population and evidence that overweight women tend to gain above the recommendatons,³ along with evidence that pre-pregnant BMI outside the normal range is linked to inaccurate weight gain beliefs,¹² it is possible that women who are unaware of how appropriate weight gain varies based on pre-pregnant BMI will gain more than is recommended, which can increase the risk of weight retention and the long-term health consequences of obesity.

A higher percentage of white women in this sample correctly reported how much normal weight women should gain during pregnancy, which could be reflective of the greater importance placed on weight within white American culture. It also could be that more of the white women were within a normal weight range when they became pregnant, and were instructed accordingly during pregnancy. Responses of Hispanic women were aligned with those of the white women and the possibility that they also place greater importance on weight merits further exploration. The responses of black women suggesting weight gains under the recommendations could be the result of inaccurate medical advice, in keeping with a previous report that black women were more likely to report being told to gain less than is recommended,¹³ or they may have been overweight during pregnancy and therefore may have been given advice tailored to larger women. Despite the finding that many of the women’s inaccurate beliefs were lower than the IOM recommendations, this may not protect them from excessive gain, as in reality it is more common for women to gain more than is recommended.^1–3

Women recognized the risk of long-term weight retention with excessive weight gain, yet many had a false sense that there would be a return to pre-pregnant weight if given enough time. Some acknowledged the challenge of losing excess weight afterward, but many respondents believed that women would weigh about the same, even with excessive gestational weight gain, which is contrary to current evidence.^{2, 4, 5, 21} Some accepted that women would be heavier after pregnancy, which raises concern about detrimental effects both on health and in psychosocial areas such as self-esteem.

Clinical Implications

One–third of this sample believed women will weigh more following pregnancy. However, gestational weight gain within the recommendations can reduce this risk. From a public health education perspective, this finding points out the importance of providing women with correct information and guidance regarding gestational weight gain and the effects it can have on long-term weight and overall health. The IOM has established gestational weight gain guidelines that are the current standard for obstetric practice. These guidelines are based on pre-pregnant BMI and recommend that women who are underweight gain more weight (28–40 pounds), and overweight women gain less weight (15–25 pounds) than normal weight women (25–35 pounds).⁷

If women do not believe or understand that excessive gestational weight gain carries risks such as labor complications, infant health implications/complications, and long-term weight retention, there is no incentive to avoid high gestational weight gain. Women’s health care providers can reinforce the benefits of gaining within the recommendations by providing education and continued guidance about weight gain throughout pregnancy.

A frequently expressed concern was that inadequate weight gain would be harmful to the infant. It is possible that if women had an understanding of the optimal weight gain for the best infant outcome, there might be greater conformity with the IOM recommendations. Ensuring that women have an adequate knowledge of the range of weight gain specific for them that would most likely result in a positive outcome for both mother and infant might motivate women to aim for appropriate weight gain.

Health care providers can be informed by these findings and recognize that pregnancy-related weight gain and its associated risks disturb women across racial/ethnic groups. Providers have the opportunity to intervene by acknowledging women’s weight-related concerns and providing the information and support to make positive choices during pregnancy and conceivably prevent excessive pregnancy weight gain. Although not addressed in this study, it is reasonable to extrapolate that health care providers have a responsibility to continue to assess weight changes after pregnancy and encourage postpartum women to engage in healthy behaviors that promote attainment of an ideal body weight following childbirth.

Conclusions

Women of diverse ethnic and racial groups were cognizant of gestational weight gain and concerned about the potential consequences of the weight gain for themselves and their infants. They were aware of the risk of weight retention following pregnancy, but not consistently aware of appropriate gestational weight gains or the consequences of excessive gestational weight gain. Therefore, they were not likely to engage in behaviors that could prevent weight retention after pregnancy, which provides an opportunity for women’s health care providers to intervene by encouraging positive choices during pregnancy.

Our next step is to answer the question of what behaviors women of different racial/ethnic groups would be willing to engage in while pregnant to achieve appropriate gestational weight gain. These results will then be integrated into behavioral interventions to prevent excessive weight gain during pregnancy.

Biographies

Susan W. Groth PhD, RN, WHNP-BC is an Assistant Professor of Nursing at the University of Rochester School of Nursing and practices as a WHNP at Hillside Family of Agencies in Rochester, NY.

Margaret H. Kearney is the Independence Foundation Professor and PhD Programs Director at the University of Rochester School of Nursing and a former women’s health nurse practitioner.