Table 2.

Themes and representative quotations that emerged for each topic addressed during qualitative interviews with 16 obstetric clinicians

Topic	Themes	# of clinicians who addressed topic	Representative quotations
Impact on health
Impact on pregnancy outcomes	GWG has a strong influence on pregnancy outcomes	8/16	“Clearly excessive weight gains are associated with increased Caesareans, diabetes, and hypertension, and macrosomia”
	GWG has a modest influence on pregnancy outcomes	3/16	“Some, but I don’t think it’s huge”
	Influence of GWG depends on other factors	5/16	“What’s important is where people start” “Is it the weight gain that’s the problem? Or is it the inability to exercise and not being in good shape that’s the problem?” “It really is on the physiology of the mother.”
Impact on longer-term child health	Yes – and scientific evidence supports an association	11/16	“There’s some interesting studies” “I know the literature says it’s pretty high” “They’ve seen some association with problems”
	Don’t know/Don’t recall	4/16	“I don’t know whether it was based on prepregnancy weight gain or a mixture of the both of them. I don’t know”
Patient perspective	Patients do not believe GWG is important	7/16	“I don’t think they think it’s as important as I do.”
	Patients who think GWG is important may worry too much	3/16	“They focus on every number.” “A lot of them in the population that I’m working with are very scared about weight gain.”
	Patient characteristics influence how they feel	5/16	“There is a difference between ethnicities.” “It really depends on their level of education.” “It’s important to those who it was important to throughout their life”
Usual practices
EMR use during visit	Use EMR during every patient encounter	11/16	“I open it within the first five minutes.” “It’s not the first thing I do. First I just engage the patient in a conversation.”
	EMR use depends on patient factors	4/16	“If the patient asks me a question about her labs and I need to pull them up so she can see, then I will get into Epic when she asks or when it’s brought up.”
	Environmental factors and computer availability influence whether EMR can easily be used during visit	4/16	“The rooms are really small and any time you’re at the computer, your back is always to the patient.” “It’s… opened by the medical assistant. She goes in. She inputs everything. She brings the patients up on the screen. She secures the screen. When I put in my password it comes right up to the patient, so all her information is right there.” “I use a tablet, and I go into the patient’s room with my tablet, with her chart open.”
Patient communication	Ask patient her own GWG goal	1/16	“I have, yeah. I have, and then I have learned that a lot of people don’t necessarily know, so I ask them, you know, what their thoughts are on how much weight they’re supposed to gain. In my short experience at this particular practice, a lot of women don’t necessarily know, so I kind of end up answering that question for them and kind of addressing questions that come up based on the answer.”
	Communicate gain to patient depending on circumstances	6/16	“If it’s going heavy, you know, I’ll mention it for like, one or maybe two visits.”
Tools and resources currently used
Total GWG calculator	Calculator shared with patients, helpful to support discussions	6/16	“If there’s a problem with her weight gain… I open it up and I show her what her weight gain has been over the time.”
	EMR used to support GWG tracking, not counseling	14/16	“Not counseling…Tracking is in the grid. Yeah, and that’s what I use to track.”
Suggestions for additional features within EMR
General comments on EMR tools	EMR tools may promote consistency within and across providers	8/16	“It would just catch me when I’ve missed the math, if I’m not doing it.” “I think what can be really hard, is if, a woman is gaining too much weight, but for some reason it’s missed at an appointment.”
	Information on GWG should be delivered with sensitivity	4/16	“We don’t want them skipping meals and starving themselves.” “It has to be gentle.” “Not punitive in any way.”
	EMR features should not interfere with workflow	4/16	“I wouldn’t want it to require I click on something to make it go away so I could close the chart. I wouldn’t want it to add more.” “If it’s, you know, however many pounds off, it highlights in red. You know, that’s a little less obtrusive than something that pops up and you have to clear out of it.”
	Pre-pregnancy weight is key for all EMR tools	9/16	“But you only get that if you put in the pre-pregnant weight…and my peers often do not.”
Electronic ‘smart phrases’	Smart phrases would save work, be helpful	4/16	“If there are smart phrases in there that give you how much weight she should be gaining or the weight gain chart or the recommendations … like, if I have a hypertensive patient, if I type in … ‘pre-eclamptic something smart phrase,’ it will come up and give me the recommendations… I am not aware of any of those things for weight gain and pregnancy.”
	Smart phrases helpful only if knowledge gaps are present	4/16	“I have no idea … what’s the cut-off. I don’t even know. And that really annoys me about this whole, like, health insurance thing where we’re supposed to put whether the patient’s normal weight, overweight or obese… you can’t just put BMI in it, and it like translates it… Why can’t it say 18, normal?” “I don’t think that’s really necessary. I feel like it’s pretty much in everyone’s head.”
GWG calculator improvements	GWG calculator should incorporate pre- pregnancy BMI and past pregnancy history	4/15	A “tool to show you how much weight she should have gained at this point. Where you could type in gestational age and her starting BMI or whatever, and have it calculate something that might be helpful.” “If there was a way we could compare this pregnancy to last, for instance, I think that would be a good idea”
GWG charts	GWG charts would provide a helpful visual especially for patients, less so for providers	9/16	“I would primarily use that not for myself to see how she’s doing but ato show patients.” “Now as I think about it, the useful piece of it is to show the patients what’s happening.”
	GWG charts should include recommended ranges	2/16	“There is a graph I use regularly. What it doesn’t have is the parameters.”
Alerts for out of range GWG	An alert would be likely to elicit a response from the clinician	12/16	“I guess it would just generate the same discussion, but maybe I would hopefully miss less opportunities to have that discussion.” “I would really drill down into what choices are being made and what if anything can be done to modify it.” “I would get a diet recall from the patient. If she hasn’t seen a nutritionist, recommend a nutritionist” “I’m doing that anyway, just by the math. It would just catch me when I’ve missed the math.”
	Alerts should be tailored to patient weight, timing of visits	5/16	“What happened to the last visit from this visit. If she’s gained 10 pounds since the last visit, well maybe that’s something we should address today. Versus if she’s gained two or three pounds. It also depends on the interval of time and when it is during the pregnancy.” “Based on BMI, you know, because that would take into account height and weight.”
Behavior change supports	Diet assessment/ information	11/16	“I think having something, a diet log, that would be helpful for patients. With lines maybe and like a week at a time. Maybe one page with portion sizes. I don’t think most people, the calories can be really deceptive. But portion sizes maybe.”
	Physical activity assessment/information	5/16	“Safe exercise regiments for a pregnant woman”
	Support for behavior change counseling	4/16	“For other issues where counseling is a big part of delivering care. Like there is almost like a question, it’s that series of questions that we go through with patients, like, for example, like smoking cessation to kind of help formalize it and make it a little bit less individualized and more something that we know that every patient is being asked or address.” “I think it would be very helpful to show the patients some statistics. How many obese patients ended up with a C-section. How many children of obese patients ended up with diabetes or obesity themselves. I think that would be enough to show the patient that yes, there is a risk, and this is what the studies show.”
	Educational handouts should be tailored	4/16	“A lot of those are in our initial obstetric visit packet, but if I have a patient who’s gaining too much or too little and she’s like 28 weeks I have to have the [medical assistant] photocopy that part… which is just kind of a pain in the butt for them.” “We could have some better information, really specific nutrition and exercise information in there.”

GWG – gestational weight gain. EMR – electronic medical record.