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. 2014 Jul 18;12(2):349–361. doi: 10.1111/mcn.12135

Barriers to weight‐related health behaviours: a qualitative comparison of the socioecological conditions between pregnant and post‐partum low‐income women

Meredith Graham 1,✉, Keriann Uesugi 1,2, Christine Olson 1
PMCID: PMC4556594  NIHMSID: NIHMS711764  PMID: 25040706

Abstract

The association between socioecological factors and poor health outcomes for low‐income women and their children has been the focus of disparities research for several decades. This research compares the socioecological conditions among low‐income women from pregnancy to post‐partum and highlights the factors that make weight management increasingly difficult after delivery. As part of the formative research for an online health intervention, group and individual interviews were conducted with low‐income pregnant and post‐partum women. Five pregnancy group interviews (n = 15 women), five post‐partum group interviews (n = 23 women) and seven individual interviews with a total of 45 participants were conducted in Rochester, New York. All interviews were audio‐recorded. The constant comparative method was used to code interview notes and identify emergent themes. Subjects faced many challenges that affected their attitudes, beliefs and their ability to maintain or improve healthy weight behaviours. These included unemployment, relationship issues, minimal social support, lack of education, limited health care access, pre‐existing medical conditions and neighbourhood disadvantage. Compared with pregnant women, post‐partum women faced additional difficulties, such as child illnesses and custody issues. The most striking differences between pregnancy and post‐partum related to the family's medical problems and greater environmental constraints. Many factors detracted from women's capacity to engage in healthy weight behaviours post‐partum, including challenges present prior to delivery, challenges present prior to delivery that worsen after delivery, and new challenges that begin after delivery. These additional post‐partum challenges need to be considered in designing programmes, policies and interventions that promote healthy weight.

Keywords: pregnancy, post‐partum, socioeconomic factors, healthy behaviour, body weight, low income

Introduction

Risk for obesity is disproportionately carried by low‐income and minority women in the United States (Ogden et al. 2010). In addition, both pregnancy and becoming a parent, especially for the first time, are transitional periods that put women at higher risk for becoming obese later in life (Ohlin & Rossner 1990, 1996; Rooney & Schauberger 2002). Excess gestational weight gain (Rooney & Schauberger 2002) and weight retention at 1 year are strong predictors of becoming overweight a decade or more later (Linne et al. 2004). Therefore, the pregnancy and post‐partum time periods are especially critical for changing behaviours to promote healthy weight management (Krummel 2007). This is especially true for low‐income and minority women who are more likely to enter pregnancy overweight, gain excessively during each pregnancy, and fail to return to their pre‐pregnancy body weight, which leads to increased body fat and likelihood of becoming obese (Linne et al. 2004).

This increased risk of excessive gestational weight gain occurs in the context of low‐income women's lives. Pregnancy outcomes are impacted by many biological and socioecological factors such as: pre‐pregnancy body mass index, gestational weight gain, cigarette smoking, alcohol use, drug use, physically demanding work, access to quality of prenatal care, stress and anxiety (Kramer et al. 2000). Less educated, non‐white and unmarried women are more likely to have risky and unhealthy behaviours (Ebrahim & Gfroerer 2003) making drug, smoking and alcohol cessation higher priorities for intervention than weight management during pregnancy. Among Latino pregnant women, Kieffer et al. (2002) found numerous social, cultural and environmental barriers, including household responsibilities that left them with little time or energy, lack of knowledge about how to exercise safely, social isolation, weather and lack of access to safe facilities. In a different population of low‐income Latino women, eating and physical activity patterns were influenced by cultural beliefs concerning safe and appropriate foods and physical activity during and after pregnancy, as well as family routines such as eating out on weekends (Thornton et al. 2006).

Research has identified barriers to healthy behaviours during the post‐partum period, including low behaviour‐specific self‐efficacy for physical activity (Hinton & Olson 2001; Albright et al. 2006), post‐partum depression (Banti et al. 2011; Boothe et al. 2011), neighbourhood deprivation (Cubbin et al. 2008), smoking (Ripley‐Moffitt et al. 2008), lack of social support (Kanotra et al. 2007; Boothe et al. 2011), breastfeeding (Walker et al. 2004; Kanotra et al. 2007; Gould Rothberg et al. 2011), newborn care (Kanotra et al. 2007) and lack of health insurance (Black et al. 2006; Setse et al. 2008; Banti et al. 2011). Multiple studies have identified the significant barriers post‐partum women face related to maintaining and/or improving overall health, mental health and healthy behaviours such as diet and physical activity (Lucan et al. 2010; Glasgow et al. 2011). In addition, researchers have recommended that additional programmes and services be provided to low‐income post‐partum women to address the significant barriers to optimal health (Ristovski‐Slijepcevic et al. 2010).

To reduce the likelihood of increasing weight with the birth of each child, a better understanding of the role and influence of socioecological conditions experienced by low‐income post‐partum women is needed. This paper examines:

  1. the socio‐demographic constraints and priorities that impede healthy weight behaviours in low‐income pregnant and post‐partum women, and

  2. the potential pathways through which socioecological conditions may impede or promote the capacity for healthy weight behaviours in the post‐partum period for low‐income women.

Key messages

  • The health conditions of children in a family need to be a key consideration for health professionals when they are attempting to improve maternal health and well‐being.

  • Socioecological conditions vary across the childbearing period for low‐income women of childbearing age. These conditions appear to become more significant barriers to maternal and infant health in the post‐partum period.

  • Food insecurity remains an issue for low‐income women despite public health nutrition programmes aimed at preventing food insecurity.

  • The social services and policies in the United States for low‐income women currently do not adequately address maternal and child health needs such that post‐partum women are constrained in their capacity to engage in healthy weight‐related behaviours.

Materials and methods

As part of the formative research conducted between 2010 and 2011 for a large randomised controlled trial, five semi‐structured pregnancy group interviews (Spring 2010, n = 15 women), five semi‐structured post‐partum (≤18 months post‐partum) group interviews (December 2010 to February 2011, n = 23 women) and seven structured post‐partum (≤18 months post‐partum) individual interviews (February to March 2011) were conducted (blinded). Low‐income women aged 18–35 years and living in the greater Rochester, New York (NY) area were included. The criteria for low income were self‐reported eligibility for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and/or the expanded health care coverage during pregnancy (PCAP). WIC provides nutritious foods, nutrition education and health care referrals to pregnant women, new mothers, infants and children who live in households at 185% or less of US federal poverty line. PCAP provides insurance coverage for women who have incomes less than 200% of the US federal poverty line to ensure prenatal care. In other words, participants were considered low income if their household incomes were less than 200% of the US federal poverty level.

The pregnancy sample (n = 15) was distinct from the post‐partum sample (n = 23) with the exception of one woman who participated in both interviews. All interviews were conducted in English. Participants provided written informed consent and received a cash incentive for participating ($40 for group interviews and $25 for individual interviews). The group interviews lasted about an hour and a half and were hosted at either the Healthy Start Program, the Child Care Council, Inc. or at the Center for Community Health. Transportation and day care were provided for group interviews hosted at the Healthy Start Program. The individual interviews took place at the Center for Community Health. The discussion guides for the pregnancy and post‐partum group interviews were piloted in Ithaca, NY, and revised based on the pilots. The Institutional Review Boards of Cornell University, Unity Health System and Child Care Council, Inc. of Rochester approved all study procedures.

The initial purpose of the interviews was a needs assessment for the development of an online intervention to promote appropriate gestational weight gain and return to pre‐pregnancy weight post‐partum. Thus, the interview guides were not specifically designed to identify barriers to weight‐related health behaviours, but many of the questions asked ultimately elicited these types of barriers (Table 1). Pregnancy group interview topics included beliefs and behaviours around health, weight gain, diet and physical activity during pregnancy. Post‐partum group interview topics included beliefs and behaviours around health after delivery, priorities after delivery, weight loss and control of body weight, and diet and physical activity during the post‐partum period. The group interview guides were developed following the methods of Krueger (1994). The individual interviews were conducted to inform development of online social support tools for the post‐partum intervention. Topics included the presence of certain types of social support after delivery and the role of social support in promoting or discouraging healthy behaviours. The individual interview guide was developed based on methods outlined by Creswell (2003) and Salant & Dillman (1994).

Table 1.

Interview guide questions

Section Question
Health and priorities

  1. What are some of the things you are thinking about more now that you are pregnant?

  2. Considering all of these priorities, how would you rank your health among all of these things?

  3. What does it mean to you to be healthy during pregnancy?

  4. You've added a new person to your family. How, if at all, has that changed your life and your priorities?

  5. Thinking back to the priorities that we talked about initially, where does your personal health fit in among these priorities?

  6. What are your major priorities when it comes to your health? What about your priorities for your baby's health?

  7. How have you dealt with your personal health priorities since you had your baby? For those that have turned attention to them: When did you start working on them? For those that have not yet turned attention to them: When do you think you will start trying to work on them? Why then?

  8. Did you make any changes during your pregnancy to be healthier? Are you still doing those things? Why or why not?
Behaviour change

  1. Think about a time when you have made a change or think about a change that you might want to make in the future.

  2. What made you or is making you decide to try these things?

  3. What sort of things made it difficult to make the changes you did?

  4. What sort of things helped you or would help you make this change?
Social support

  1. Do you have any friends or family with children the same age that are going through some of the same stuff that you are? Tell me a little bit about that.

  2. Who do you rely on when you need help with these priorities or other things in your life?

  3. How have the people or the ways that people help you changed since you had a baby?
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For both the pregnancy and the post‐partum group interviews, one researcher (Author 1) moderated the discussions while another researcher (Author 2) observed and recorded detailed notes on the women's responses, interactions and physical appearances (e.g. observed weight status, race and ethnicity). Each group interview was audio‐recorded in case any responses that were missed could be filled in by listening to the audio‐recording afterward. The detailed notes captured as many of the verbatim responses as possible. Both Author 1 and Author 2 debriefed after each group interview to identify initial themes that were used in coding, according to the methods by Krueger (1994, 1997). Author 1 took detailed notes during the individual interviews and filled in her notes by re‐listening to the audio.

Data coding and analysis

Rather than utilising a specific qualitative computer analysis program, the researchers found it more efficient to hand code and utilise an Excel spreadsheet for matrix building (Miles & Huberman 1994) and definition coding. As both researchers had first‐hand exposure to the interviews, Author 2 did the coding using the initial themes for the pregnancy and post‐partum group interviews, and Author 1 did the coding using the initial themes for the post‐partum individual interviews. Both researchers then discussed and agreed on new themes. This method combines elements of note‐based analysis and tape‐based analysis (Krueger 1994). The constant comparative method was used to code individual and group interview notes and to identify additional emergent themes (Glaser 1965; Strauss & Corbin 1998; Boeije 2002). The post‐partum individual and group interviews were considered together and they were compared with the pregnancy group interviews.

Themes about the women's beliefs and behaviours were initially categorised within the integrative model of behavioural prediction (Fishbein & Yzer 2003), which was the guiding theory for the intervention being developed. The model states that behaviours are directly predicted by a strong intention to perform the behaviour in addition to an individual's skill level and her environmental constraints. Intentions are in turn influenced by the set of behavioural beliefs (what outcome will occur if I do this behaviour), normative beliefs (what do other people tell me is the right behaviour) and efficacy beliefs (what do I believe I am capable of doing) that a person holds and values related to that behaviour. The themes explored in detail as part of this particular research focus on how environmental constraints may directly impact behaviour or how distal variables, such as demographic characteristics and culture, influence behaviour by impacting behavioural beliefs, normative beliefs and efficacy beliefs. As themes emerged from these data, it became necessary to incorporate a theoretical framework that was more systems theory oriented and less individual behaviour change focused. Stokols' (1996) social‐ecological approach to health promotion provides a framework that encompasses the intrapersonal, physical environmental, organisational and cultural constructs that account for the occurrence and prevalence of increasing weight through the childbearing years and also integrates the contextual factors that are likely to influence the effectiveness of interventions designed to promote weight management.

Results

Sample characteristics

Pregnant and post‐partum women were similar in parity and researcher‐observed race/ethnicity and weight status (Table 2). All of the women were eligible for and most women received WIC and attended classes at a community outreach programme for new mothers called Healthy Start. Thus, the sample of women who participated in our interviews did not represent low‐income women who were isolated from social services. The sample closely resembled the demographic composition of Rochester where 31% of individuals live below the federal poverty level and where 44% of individuals are Caucasian, 42% are African American and 16% are Hispanic (U.S. Census Bureau 2013). Eleven of the post‐partum interview participants had zip codes (14604, 14605, 14608 or 14613) that indicate residence in high‐poverty neighbourhoods. Two post‐partum participants had zip codes that are not in the city of Rochester, but in a suburban town bordering Rochester. The residence locations for pregnancy interview participants are unknown because zip codes were not collected.

Table 2.

Participant characteristics

Pregnancy n (%) Post‐partum n (%) Total n (%)
No. of women 15 (33) 30 (67) 45 (100)
Race/ethnicity †
African American 11 (73) 23 (77) 34 (76)
Asian 0 0 0 (0)
Hispanic 3 (20) 5 (17) 8 (18)
White 4 (27) 7 (23) 11 (24)
BMI †
Normal weight 7 (47) 15 (50) 22 (49)
Overweight/obese 8 (53) 15 (50) 23 (51)
Parity
Having/had first child 7 (47) 11 (37) 18 (40)
Already had one child or more 8 (53) 19 (63) 27 (60)
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BMI, body mass index. †Observed, not self‐reported.

Table 3 presents a summary of the themes that emerged as challenges to engaging in healthy weight behaviours during pregnancy and post‐partum. These are described more fully below.

Table 3.

Challenges of low‐income pregnant and post‐partum women

Theory and theme Pregnancy Post‐partum
Demographic characteristics/intrapersonal
Education Finishing school, GED, dropping out of school Finishing school, GED, dropping out of school, starting community college
Employment Unemployment Unemployment, underemployment, disability, job seeking
Other Minority race and ethnicity Minority race and ethnicity
Low income Low income
Competing unhealthy behaviours/intrapersonal
Smoking Smoking cigarettes in pregnancy Smoking cigarettes in pregnancy and after delivery
Drinking Drinking alcohol late into pregnancy Drinking alcohol late into pregnancy
Drug use Mention of smoking weed, abusing drugs, overdosing prior to pregnancy and during pregnancy Mention of smoking weed, abusing drugs, overdosing prior to pregnancy and during pregnancy
Social support/interpersonal
Relationship Significant other, baby daddy, husband Significant other, baby daddy, husband
Family Present or past relationship with mom, dad, siblings, broader family Present or past relationship with mom, dad, siblings, broader family, supporting family members
Lack of support Lost friends, no help from baby's daddy, no help from boyfriend Lost friends, no help from baby's daddy, no help from boyfriend
Sex Sexy body image and importance of sex
Health conditions and health care access/interpersonal and intrapersonal
Health issues Mention of pre‐existing health conditions Mention of pre‐existing health conditions, mental health issues, post‐partum depression, stress, anger
Pregnancy Short pregnancy interval, parental responsibility, birth control Short pregnancy interval, parental responsibility, birth control
Health care Interactions with health care providers and system Interactions with health care providers and system
Children's medical issues Asthma, in and out of hospital, seizures, child behaviour problems, hypoxia, autism, developmental issues
Appointments Having appointments, attending appointments, priority of appointments
Environmental constraints/community and intrapersonal
Food environment Fast food environment, soul food preferences Fast food environment, soul food preferences
Violence/crime Money laundering, criminal activity environment, fear about violence Money laundering, criminal activity environment, fear about violence
Food insecurity Not eating much, food pantries, food stamps, providing food for others
Homelessness Being homeless, staying in shelters/group homes, not on streets
Shopping Grocery and clothes shopping
Transportation Bus
Lack of resources No phone, computer, diapers, furniture, clothes, formula, housing
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Note: Differences between pregnancy and post‐partum are shown in bold. GED, General Educational Development test.

Barriers: education and employment

Regardless of time period, similar issues related to education and employment emerged. Participants mentioned trying to finish school, which for some was high school and for others was an associate degree. Several participants mentioned dropping out of school and not being able to finish school. In the post‐partum interviews, starting or restarting one's education after delivery was mentioned. This theme did not emerge in the pregnancy discussions. Comparing before and after having her daughter, a first‐time mom in group interview A said:

Before I didn't care about anything and I was living with roommates and partying, dropped out of school, never talked to my parents, I didn't care. Now I took my GED test last week, I do work here (Healthy Start Program) and got my license and I don't party anymore, don't do drugs anymore and so I have chilled out a lot.

Lack of education impacted the types of employment that participants had and limited their options for future employment. For employment during pregnancy, one participant mentioned no longer working due to pregnancy complications, and another participant was no longer working as an exotic dancer. Post‐partum participants tended to focus more on finding work or working outside of the formal employment sector by babysitting or providing childcare to other children as well as her own children. Several participants were looking for work and had found work after delivery. Lack of income from employment after delivery negatively impacts the already limited financial capability that low‐income women have to stay food secure and purchase healthy foods for themselves and their children. No post‐partum participant mentioned being employed during pregnancy and having the same job at the time of the post‐partum interview. Lack of consistent employment from pregnancy through post‐partum meant paid maternity leave was not present for these women. There was one post‐partum participant who mentioned receiving disability and unemployment benefits.

Barriers: competing unhealthy behaviours

Competing unhealthy behaviours in this sample included smoking cigarettes, smoking marijuana, use of other drugs and drinking alcohol. These behaviours are described for pregnancy in blinded paper (Paul et al. 2013). When asked about how personal health fits in with their other priorities, one post‐partum participant from group interview D said, ‘Ha! Mine sucks. Mine is poor, very poor. I smoke cigarettes, I drink. There ain't no personal health going on here. I go to all my appointments, but I wouldn't if I didn't have Healthy Start here to take me to all of those appointments.’ Drinking, smoking and abusing drugs in the post‐partum period were mentioned in four of the five group interviews.

Barriers: lack of social support

During the pregnancy group interviews, participants talked about healthy relationships with boyfriends, unhealthy relationships with boyfriends, and how the father of the child planned to be involved even if he was not a current boyfriend. For the pregnant sample, the family members' involvement was sometimes helpful and supportive by getting food for the soon to be mother and taking her to appointments. Often the family was a negative influence encouraging unhealthy behaviours, supporting risky decisions, and making it difficult for the pregnant woman to make her health a priority. Pregnant and post‐partum women talked about losing friends or how they spent time now compared with before they were pregnant or had children. A first‐time mom from group interview A compared her priorities from before to after having her child:

For me, it changed, it changed tremendously a lot, I went from being a little school girl to being a mom and I couldn't hang out and chill with my friends like I used to and it's more responsibilities. You have to get money for wipes and diapers and they don't come cheap and they run out a lot and you have to get clothes and everything and it's not all about you it's about you and your kids or you and your baby. I'm glad that I had my mom there for moral support to help me out a lot because if I didn't I wouldn't be here right now cause I was going crazy.

A specific aspect of the social support theme that only emerged post‐partum was the participant as the supporter of the family and of the boyfriend/father of the child. Similarly, lack of support from a boyfriend and father of the child was a barrier to health. One participant from group interview E explained:

It has been really, really stressful, dealing with post‐partum depression and financial issues, and support wise and also the father is involved, but not feeling like he is giving it his all and same for my sister she is going through the same thing too with the father of one of her kids with him not giving it his all and it is just really frustrating.

Post‐partum women discussed being attractive as important and thought of as a health priority, particularly getting back to a previous body size, as that was more sexually appealing to the current boyfriend or father of the child.

Barriers: other health‐related issues

Health issues emerged in pregnancy and post‐partum discussions, but the focus on health issues, severity of health issues and number of health issues was far greater post‐partum. In the pregnancy sample, participants mentioned having health conditions such as fibromyalgia that interfered with their comfort and healthfulness during pregnancy. They also mentioned the particular pregnancy being in close succession to the previous pregnancy and not having a chance to recover and get back in shape in between pregnancies. In the post‐partum period, there was an increase in health conditions, and a great deal more emerged about mental health, depression, stress and anger. The following quote from group interview B describes the health conditions, medical care access and prioritising of the children over the mother's health:

I do have a lot of medical and mental health problems going on, like I never went to my six‐week check‐up after my daughter and I'm pregnant again and it is good to look out and make sure you get back on birth control or whatever. And I have back pain, which started way before I ever got pregnant with my daughter and now I'm pregnant again so here comes some more back pain … At a point it is good to take care of your health and everything and of course you care about it, but then you have a kid and your priorities should be towards your kids.

Furthermore, the health issues of children including autism, asthma, seizures and premature births were discussed as barriers to focusing on personal health priorities for post‐partum women. For one participant, she missed her first group interview appointment because her 8‐month‐old son had to go to the hospital due to seizures on the original date of the interview. Another participant had a health emergency for her child just before the group interview (B):

Before I came here I just got done taking my daughter to the hospital. She keeps having these little blue spells where her fingers and her mouth turn blue and they say she is low on oxygen. So now they want to keep her like with one of those things at night to keep her breathing.

Lastly, health care access may sometimes mean coordinating appointments for the mom and child(ren) and then getting to those appointments via public transportation as one mother detailed from group interview F:

Doctor's appointments they're kind of harder because I usually have to take both of them and on the bus with both kids and the stroller and the baby bag and then there's people on the bus that are so rude they don't even get up so that you can sit down with the kids.

The health issues facing the moms and their children arose in all five of the post‐partum group interviews and in two of the post‐partum individual interviews.

Barriers: environmental constraints

The community level constraints faced by low‐income pregnant and post‐partum women were similarly related to the food environment and the violent/crime neighbourhoods likely because they all live in the same area. Related to the food environment, after one participant in group interview D indicated that she eats whatever food is around her, like frozen or prepared foods, due to lack of time to cook after having a kid, three other participants talked over each other about how they prefer to eat fast food and said, ‘Not me. For me it's McDonald's. I had a cheeseburger for breakfast. Oh and Arby's and Burger King. I've had all three of them in the past week. Anything that is quick. This morning was the first morning that I ate in a long time and it was only because I had a buy one get one free McDonald's steak bagel.’

Several additional community level themes emerged for the post‐partum women, which included food insecurity and homelessness. There were two group interviews and two individual interviews where homeless shelters and group homes were discussed, which seemed to indicate a higher level of homelessness in these women than was expected. In addition, women frequently mentioned skipping meals, not eating for days at a time, forcing themselves to eat and running out of food. In response to the question about what things make it difficult to eat a healthy diet, a participant in group interview C said the following related to transportation, lack of resources, the food environment and food insecurity:

Time and sometimes you don't have a way for you to get to the store for stuff for a healthy meal and so you just have to eat what is close to you. Money, cause eating healthy is not that easy and I think it is more expensive. So truly, the vegetables are just more expensive than getting junk food. Money wise we only have one income and it is hard to eat healthfully. The lack of stuff that is in your house and making sure that the children eat first so that you don't take from the children.

The quote above not only indicates environmental constraints, but also is an example of one of the many statements that participants made indicating that they knew about recommendations for eating healthy diets. In response to a question about what would make it easier to eat a healthy diet, three respondents from the same group interview said:

Transportation to the store. That and support other than the simple welfare that's out there. Isn't there something more than welfare? Food stamps would be helpful. And healthy food isn't as available as junk food is. As soon as you walk outside your house there's a corner store here and that there and you think quick and it isn't healthy instead of going all the way to the grocery store.

This quote highlights both the food environment and the difficulties shopping for food and transportation issues and identifies a need for additional resources beyond what ‘welfare’ is present and for ‘food stamps’. Other community level difficulties included taking a stroller on the bus to go food or clothes shopping, needing to have clothes, diapers, formula and food for their children, and feeling like that need exceeds what the women are most often able to do.

Discussion

The results from this research suggest that making behavioural changes to promote healthy weight during the post‐partum period may be very difficult for low‐income, minority women due to the barriers they face. The differences in the socioecological conditions between the post‐partum and pregnancy time periods were predominantly personal health conditions as well as children's health problems and environmental constraints (Table 3). In Fig. 1, multiple pathways were identified that impeded healthy weight behaviours during the post‐partum period. These multiple pathways identified highlight new specific barriers for low‐income women to engage in a healthy lifestyle post‐partum. By identifying specific barriers that are not solely individual factors, this research raises concerns about behaviour change theories and enhances the understanding of this population's experiences and the unique challenges with which they are confronted. To reduce the likelihood of increasing weight with the birth of each child, the socioecological conditions experienced by low‐income post‐partum women cannot be ignored.

Figure 1.

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Conceptual framework for behaviour change for low‐income moms. Bolded items reflect the thematic categories that emerged for post‐partum low‐income women.

Strengths of this research include the recruitment of participants from the same area and programmes during the same calendar year by the same researchers. This provided measurement consistency. In addition, the interview discussion guides had a theoretical basis and were piloted and revised prior to conducting the first group interviews for both pregnancy and post‐partum. Lastly, the sample, while not representative, was purposive and resembled the low‐income population in the geographical area of interest.

The findings of this research should be taken in the context of the limitations of the study. The difference in themes that emerged from the sample post‐partum in our study compared with the women in pregnancy does not necessarily mean that the same themes may not have emerged from a different sample of low‐income women during pregnancy. If the group interviews had been longitudinal in design, then the additional issues expressed after delivery could have been attributed to the post‐partum time period. Themes that emerged cannot be generalised and may not apply to other populations of low‐income pregnant and post‐partum women. Post‐partum women may have been more likely to discuss issues that they were facing than pregnant women given potential stigmatisation for pregnant women expressing difficulties for prioritising personal health and taking care of one self. The limited amount of demographic data, including social services programmes received and age of all participants, is a limitation in the present research.

Post‐partum interventions across incomes have struggled to be effective in behaviour change (Heppner et al. 2011; Skouteris et al. 2012; Vesco et al. 2012). Ryan et al. (2011) examined post‐partum weight loss using path analysis and the Theory of Integrated Behaviour and found significant differences by race. These differences could be due to the influence of environmental constraints, lack of social support and health issues faced by lower income minority women. In both the pregnancy interviews and the post‐partum interviews, knowledge about diet and nutrition was discussed by participants. Lack of nutrition knowledge was not a significant barrier to eating well during both time periods.

Lack of social support and environmental constraints appeared to play a more prominent role in preventing healthy behaviours among low‐income post‐partum women than the Theory of Integrated Behaviour suggests. Therefore, socioecological conditions should be included in any conceptual framework for weight‐related behaviour change. The additions made by this research to the Theory of Integrated Behaviour are shown in Fig. 1 and these may be quite important in the development of healthy weight interventions for low‐income, minority women. In the intervention developed from this formative research, a social network was added to improve the lack of social support and listings of local services, and events such as food assistance and single parent resources were added to try and address some of the environmental constraints. To address the maternal health issues that emerged, a problem‐solving tool, using barriers and problems that emerged in the interviews, was developed for the online intervention. While those features were included to address the socioecological barriers, the results that emerged here need further exploration before fully leveraging these insights in a more systems theory‐driven intervention. As of the present, the question of whether health promotion can be effective in this population without wider social and policy change is unanswered.

There are several potential policy implications of this research. The familial and social prioritisation of providing food to a pregnant woman but not to providing food to a post‐partum woman coupled with the greater prevalence of food insecurity and homelessness among post‐partum women, despite the presumed receipt of either SNAP and/or WIC by the mothers, is quite concerning. The level of support and services provided by these programmes, particularly when mothers are single parenting, supporting other family members and having children in quick succession, appears to be insufficient as a safety net for mothers and their young children.

The gaps in health insurance for low‐income childbearing women are of current policy relevance. The fundamental issue of expanding insurance coverage during pregnancy and then contracting insurance coverage after delivery creates a system in which women of childbearing age are falling through the cracks of preventive health care and family planning. Several post‐partum women missed their 6‐week after‐delivery visits and were not seen for medical care again until they were pregnant again. Others have explored this particular issue with quantitative research (Al‐Saleh & Di Renzo 2009; Walker et al. 2011), but the present research adds depth and description to what has been previously articulated.

This research addresses an important gap in the literature by comparing the barriers to weight‐related healthy behaviours between pregnant and post‐partum low‐income women. This research also adds to the literature supporting non‐individual level models of health such as a socioecological approach or a post‐structuralist approach (Lupton 2000; Petersen & Lupton 2000). Previous research has shown low retention in post‐partum research (Van der Pligt P. et al. 2013) and this particular study gives some concrete reasons for why women may not be participating in research after delivery. In addition, this research highlighted the prevalence of environmental constraints as well as family health issues, which indicate a need for action at the community level and policy level for significant improvements to be made.

In conclusion, socioecological conditions interfered with low‐income, minority women's capacity to engage in healthy weight behaviours post‐partum. The ways in which these intrapersonal, interpersonal and community aspects were different after delivery compared with before delivery were predominantly related to environmental constraints, health conditions and health care. As such, multiple pathways were identified that impeded healthy behaviours during the post‐partum period. These multiple pathways articulate more than previous work has shown what the specific barriers for engagement in a healthy lifestyle post‐partum intervention are for low‐income women. These factors merit consideration in the design of programmes, policies and interventions aimed at successful weight management in this population at this time of their lives.

Sources of funding

This work was funded by the National Heart, Lung, and Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NIH Grant No. HL096760).

Conflicts of interest

The authors declare that they have no conflicts of interest.

Contributions

MG, KU and CO designed the individual and group interview guides. MG designed this research study. MG and KU analyzed the data. MG, KU and CO wrote the paper. All authors read and approved the final manuscript.

Acknowledgement

We gratefully acknowledge Jeff Niederdeppe from Department of Communication, Cornell University, Jennifer Cowan, Kimberly O'Brien and Jeff Sobal from Division of Nutritional Sciences, Cornell University.

Graham, M. , Uesugi, K. , and Olson, C. (2016) Barriers to weight‐related health behaviours: a qualitative comparison of the socioecological conditions between pregnant and post‐partum low‐income women. Matern Child Nutr, 12: 349–361. doi: 10.1111/mcn.12135.

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