TABLE 2.

Summary of results from the analysis of 5 focus groups with 22 pregnant women from the Boston area¹

Themes	Major subthemes	Representative comments from focus group participants
1. Knowledge	Fish contain mercury—a toxin that is harmful to the brain.	“Developmental delays…um, just something you want to steer away from.”
	Fish contain DHA and omega-3 fatty acids. These are healthful, but many women did not know why.	“Omega 3 fatty acids. I don't know what they do, but I know they're supposed to be good for us.”
	Fish consumption once a week, or less often, is recommended for pregnancy.	“I heard once a week somewhere. And I don't know if it was in a handout that my midwife gave me, or if it was in a book, but I definitely have heard the once a week thing somewhere.”
	Women do not know much about which fish types are healthful to eat.	“I think really just more information about which fish is good, would…probably help me. Like I'm kind of feeling like now I should figure out which fish are good fish and then we can start eating those again.”
	Many women liked tuna fish but were confused about whether they could continue to eat it and, if so, which types to eat.	“I used to eat canned tuna, and then I read that you shouldn't eat tuna, but I didn't know it was the more fatty one, so I just didn't eat it at all.”
	Many women were also confused about whether they could eat shellfish.	“I'll be at a place that has shellfish and I'm not totally sure if I can have that.”
2. Advice	Some received written information about the risks of fish intake, but few had a discussion with their obstetrician.	“They just say stay away from it, I don't really have a reason, just you know, it's not safe for the baby.”
	Women were not told which fish types are safer to eat.	“My take away from the conversations I've had is like, ‘you should avoid fish because of the high mercury content’ and there wasn't really the distinction made between good fish vs. bad fish. I mean, some, but, you know, the overall takeaway message with fish was ‘avoid it.’ So had there been more discussion about like, ‘here are the good fish you can eat’ and, you know, the positive aspects, I might be eating more fish.”
	Women received no encouragement to eat fish during pregnancy.	“I haven't eaten fish at all during these entire 36 wk and no one's really pushed me or told me, ‘you should probably increase your fish intake’ ”
3. Behaviors	Sushi was a main source of fish intake before pregnancy that was eliminated during pregnancy.	“I love sushi so that was a huge one for me and that just went out the window.”
	Many women reduced or eliminated their fish intake with pregnancy.	“My husband and I were trying to get pregnant, so I stopped.”
	Some women tried to get more DHA via supplements or supplemented foods.	“I definitely like the eggs and I eat a lot more eggs than I used to.”
4. Barriers	Women could not remember which fish types were better to eat during pregnancy.	“I just don't remember which of the 10,000 fish I can have and I can't. So I think I just lean toward the safe ones, because I've remembered that I can have them.”
	Advice to avoid fish led many women to eat less fish than they otherwise would have.	“I often wish I could eat more than one serving a week…just because I like it and for the protein.
	Some women perceived fish to be costly and something that needed to be eaten very fresh.	“I've always thought of fish as being expensive. Where with chicken I leave for a couple days in the fridge, fish I would want to make sure I use right away.”
	Some women experienced pregnancy-related aversions to fish.	“For a while, I was feeling really nauseous so I wasn't cooking anything because opening the fridge was problematic ’cause it smelled bad. So… the fish would not be an appealing smell in the fridge, so it's not allowed anymore.”
5. Facilitators	Women were more likely to eat fish if their families also ate fish.	“If my husband is willing to cook it, we'll have it, but otherwise we're not having it.”
	A portable list would help women eat more fish.	“I don't like fish that well, but yeah, I would be more comfortable in the grocery store if I had this little card that I could pull it out and say ‘oh, look and I shouldn't have it,’ or ‘hey, it's on this list and I haven't had it a couple weeks, so I should get it.’”
	If their obstetricians advised them to eat fish, they would do so.	“I wouldn't say ‘no’ to eating it if I knew it was beneficial to me and the baby.”
6. Emotions	It can be scary to eat fish.	“I try to, of course, keep away from the seafood, just because that's what scares me the most.”
	Fish consumption messages are conflicting and confusing.	“You know, it's a double-edged sword though because I've also read that if you don't eat enough fish you don't get enough omega vitamins and so to, like manage this balance between don't get enough mercury, but eat enough fish and it can get really confusing.”
7. Diet philosophies	It is better to be safe than sorry.	“I know high, high, high levels can certainly do damage, I don't know if I believe that low levels can, so, but its just like it's not worth the anxiety to thinking that there could be some effect of the mercury.”
	Women elsewhere eat fish and are fine.	“But I do think about like, I don't know, there are some communities like around the world where people eat a whole lot of fish. Some of these rules, I just put them in the context of history and it just doesn't feel right and it feels kind of arbitrary sometimes.”

¹DHA, docosahexaenoic acid.