Seeing it through their eyes: a qualitative study of the pregnancy experiences of women with a body mass index of 30 or more

Abstract

Background

Maternal obesity [body mass index (BMI) ≥ 30 kg/m²] is associated with numerous complications, but currently, little is known about the pregnancy experiences of these women.

Objective

To gain insight into the experience of pregnant women with BMI ≥ 30 kg/m², when accessing maternity services and attending a community lifestyle programme.

Design

Qualitative methodology, utilizing focus groups and semi‐structured interviews with post‐natal women who had an antenatal BMI ≥ 30 kg/m². The sample was obtained from a larger study.

Results

Thirty‐four women participated. Three main themes were identified using thematic analysis. Women described disappointment with their pregnancy. In particular, their informational expectations were not met; some health professionals appeared uninterested, insensitive or unconfident. Women described readiness to make a lifestyle change, but this was not encouraged during routine care. Attending the programme began the process of behavioural change. Women's beliefs that small changes make a big difference led to them being spurred on by success; driven by a desire to improve the health of their family.

Discussion and Conclusion

Pregnant women who are obese know this is the case and expect to be provided with information to assist them in making lifestyle changes. Health professionals should be aware of women's readiness for change and view pregnancy as an ideal time to communicate. Pregnant women with a BMI ≥ 30 kg/m² should contribute to health professional training, to highlight the reality of the maternity system journey; first‐hand accounts may improve the way health professionals' approach these women. Lifestyle interventions should be developed with input from the intended target group.

Introduction

Rates of maternal obesity (body mass index [BMI] ≥ 30 kg/m²) in England have increased over the last 19 years from 5.6 to 15.6% of women booking their pregnancy.1 The Centre for Maternal And Child Enquiries (CMACE) report outlines the adverse maternal effects associated with maternal obesity.2 Guidance has been devised by the National Institute for Health and Clinical Excellence (NICE) for weight management before, during and after pregnancy. Guidance to address this emerging public health issue highlights the importance of health professionals discussing healthy lifestyle behaviours with women at an early stage in pregnancy.3 However, to date, there is no global agreement on guidance regarding weight management before, during and after pregnancy,4 and no suitable interventions have been proposed, due to a dearth of robust evidence regarding weight management before, during and after pregnancy.5, 6, 7 Studies are starting to be published evaluating antenatal interventions for obese women with mixed findings.8, 9, 10 However, prior to implementing any such interventions, it is important to understand the views of the key stakeholders, that is pregnant women with a BMI ≥ 30 kg/m².

A meta‐synthesis exploring the maternity experiences of women with a BMI ≥ 30 kg/m² included six papers deemed to be of medium–high quality.11 Women were concluded to be more accepting of their weight during pregnancy and were aware of the benefits of a healthy lifestyle, supporting claims that women are more motivated in pregnancy as it is a time of transition.12 However, although their intentions to manage their weight were conceived in the antenatal period, any action would be deferred until the post‐natal period. The meta‐synthesis suggested that women received depersonalized, medicalized care, by health professionals who often failed to meet their needs. Women have been found to feel confused about the meaning of gestational weight management13 and low knowledge about maternal obesity,14 highlighting the need for suitable interventions. Obesity prevalence rates are associated with lower social classes and with certain minority ethnic groups,15 and it has been argued that we need to be more aware of the social inequalities in obesity.16 As outlined in several recent English Government documents, the involvement of consumers in directing services is essential to ensure adequate care is provided.17 As discussed by others, gaining understanding of the lived experience of those who are obese is integral to ensuring that interventions are successful.18

As part of a programme of work examining the feasibility of a community‐based antenatal lifestyle programme for pregnant women with a booking BMI ≥ 30 kg/m², we explored the views of participating women to gain insight into their pregnancy experience. The overall feasibility study included 227 women who had a BMI ≥ 30 kg/m² and were <30‐week gestation when they started a 10‐week lifestyle programme. The antenatal lifestyle programme ran for 10 weeks, each session lasting for a minimum of 90 min. The programme was underpinned by behaviour change theory (Social cognitive theory19), with an emphasis on the following behaviour change techniques (BCTs);20 information about health consequences, demonstration of behaviours, feedback on behaviour, social support, goal setting (behaviour) and review of behavioural goals. Content was multicomponent and addressed physical activity, diet and emotional well‐being in pregnancy. The sessions were facilitated by a midwife and health psychologist with input from a community nutrition team and qualified exercise instructor. The feasibility findings are presented elsewhere.21 Womens' experience of attending the lifestyle programme was an important aspect of our exploration, as input during this developmental phase directed future interventions for this target group.

We had two research questions:

• What are the pregnancy experiences of women with a BMI of 30 or more?

• What were women's experiences of attending a lifestyle programme aimed at women with a BMI of 30 kg/m² or more?

Method

Approach

A general interpretive approach22 was adopted to develop a picture of women's overall pregnancy experiences. The study was conducted in two areas of North West England with a high concentration of ‘more deprived' neighbourhoods.23 Ethical approval was gained from the local NHS Research Ethics Committee (Ref: 09/H1003/80), local NHS Research and Development Departments and the University.

Recruitment

In the feasibility study (described earlier), 12 programmes were run. All the women attending the first five programmes were invited to contribute to the qualitative part of the study that constitutes this study. All women were aware of the post‐natal interview/focus group when they were recruited for the study, and their participation did not affect their participation in the main study. Interviews were continued until data saturation.

Data collection

Women were invited to attend either a focus group or individual interview 4–6 weeks post‐natal. The timing of interviews was to allow reflection on the overall experience, whilst reducing the potential bias towards the birth. Focus groups were desired as the women were homogenous in the fact that their BMI ≥ 30 kg/m² and they had all attended the lifestyle programme24 However, due to birth dates being varied and women's limited availability, some individual interviews were necessary. To enable women to speak freely, the three interviewers were unknown to the women, despite being qualified midwives with knowledge of the programme. Two of the interviewers led on the questioning, and the third interviewer was present in the dual moderator role. A semi‐structured topic guide was developed through discussion with a lay advisory group, the authors' knowledge of the literature and discussion with an expert advisory group. The interview guide reflected the two primary questions; the interview included questions related to participation in the lifestyle programme (for example, approach to participate expectations of programme, what was liked and not liked within the programme, what impact the programme has had on them and their families) and their general experience of being pregnant (communications with health professionals, communications with family and friends, advice received, maternity service provision, positive and negative aspects of care). Weight loss was not a direct focus of any questions as the emphasis was on a healthy lifestyle. That being so, some participants did question whether they should be losing weight whilst pregnant, leading to discussions regarding post‐natal weight loss goals. All interviews were conducted in the community, were audio recorded and transcribed verbatim.

Analysis

Thematic analysis was used to analyse the interviews due to its theoretical freedom and ability to reduce data into themes without losing description.25 A manual process was performed in six phases: (i) Familiarization: The research team immersed themselves in the data; reading and re‐reading transcripts; (ii) Coding: Initial codes were generated manually and systematically; (iii) Searching for themes: the codes were refocused into broader themes and subthemes, by collating data of relevance to the potential theme. Themes were explored across all transcripts as the maternity experience was viewed as a holistic care pathway; no horizontal comparisons were made between programmes, areas or by personal characteristic; (iv) Reviewing themes: The themes were discussed and refined by the research team; (v) Defining and naming: names and meanings were assigned to individual themes and (vi) Reporting: the final phase of analysis was selecting quotes, as evidence, to support the themes.

Member checking was not conducted; however, recapping was used throughout the interviews to prevent any misinterpretation. Rigour was maintained through a clear audit trail during analysis, the recording of field notes following each interview, presentation of sufficient quotes and reflexivity of interviewers. All interviewers were midwives, two had children and none were obese.

Results

Eighty women were asked whether they would like to be interviewed; 34 participated. Data saturation was reached prior to this; however, the team did not want to deny women the opportunity to tell their stories. The personal characteristics of participants are displayed in Table 1. The qualitative sample are representative of the main feasibility study sample (N = 227) in terms of personal characteristics and are representative of an obese population. For example, just over a quarter were from a minority ethnic group.15

Table 1.

Personal characteristics of participants in this sample (n = 34) and the larger study (n = 227)

	Interview sample (n = 34)	Total sample (n = 227)
Mean BMI	39	38
Mean age	26	28
Marital status
Married	15	96
Single/single supported	9	66
Living with partner	3	34
Engaged	5	14
Partner	2	6
First child	12	87
Smoker	4	41
Ethnicity
White British	25	179a
Asian Pakistani	3	19
Black African	2	2
Asian British	2	5
Asian Bangladeshi	1	5
White Black African	1	1
Employed	20	125
Personal deprivation
Lower than school leaving age qualifications	1	18
School leaving age qualifications	18	108
Further education qualifications	11	50
Higher education qualifications	4	51
Index of multiple deprivationb
Quintile 1 (most deprived)	16	123
Quintile 2	9	52
Quintile 3	4	27
Quintile 4	3	18
Quintile 5 (least deprived)	2	7

^aMore ethnic groups were reported but are not mentioned here as do not feature in this subsample.

^bDeprivation was based on 7 dimensions: income, employment, health and disability, education, crime, housing and services, living environment

Ten focus groups and nine interviews were conducted with 34 women; four focus groups and eight interviews were conducted with 16 women in Site 1, and seven focus groups and one interview were conducted with 18 women in Site 2. Participation in the focus groups ranged from two to five women. The focus groups/interviews ranged in length from 14.17 to 80.45 min (a mean length of 48.48 min).

Three main themes were identified and represented below with anonymous quotes (see Table 2): disappointment with their pregnancy; readiness to make a lifestyle change; and spurred on by success.

Table 2.

Themes from interviews/focus groups with 34 post‐natal women

Disappointment with their pregnancy journey
Ready to take a journey of change
Being offered the community antenatal lifestyle programme
Reasons for attending the community lifestyle programme
Motivation to continue the journey
Changes to dietary/nutritional behaviours
Changes to physical activity

Disappointment with their pregnancy

Women knew that they were obese and expected to discuss this when they attended their antenatal booking visit. However, information received from health professionals lacked information regarding their weight and gestational weight management. This lack of discussion about their BMI in the early stages of their pregnancy forced them to seek out information from other sources such as magazines:

…when I booked in … with my midwife, she never really mentioned anything about my weight … and all I'd read up was what was in baby magazines that you know, some overweight mothers do have complications…. (BMI of 38.9 kg/m², aged 21)

The lack of discussion about weight in pregnancy meant that, for many women, the risks of having a BMI ≥ 30 kg/m² in pregnancy were not explained to them by a health professional. Some women were therefore unaware of the increased risks associated with obesity. This lack of discussion led some women to believe that they were having a ‘normal pregnancy' (Woman with a BMI of 38.9 kg/m², aged 21); believing that they were at low risk of complications lulled them into a false sense of security:

I've never been told before either by my doctor, or anything, that I needed to lose weight either which has surprised me because I'm like really overweight,…so they must have thought, right, well, you're fairly healthy, you're just overweight (BMI of 50.1 kg/m², aged 24)

Yeah, it felt like she didn't think I was a great risk and, you know, I wasn't that much of a problem….. if it was a problem to me, she didn't think it was a problem, thank God (BMI of 38.9 kg/m², aged 21)

In a few cases, women recalled their BMI being mentioned in reference to receiving extra maternity care; however, no rationale for this extra care was provided and women expressed confusion:

But I didn't even know when my appointments were at the hospital…I didn't even know if I was coming or going and I got quite upset……. and I thought what if something happens (BMI of 48.1 kg/m², aged 28)

A few women relayed positive accounts of their experience of weight discussions with health professionals:

Yeah he [Family doctor] were brilliant yeah…you know like he was full of options and stuff (BMI of 51.1 kg/m², aged 26)

However, there appeared to be a general belief that the attending health professionals were uncomfortable discussing weight with them. Women provided this perceived lack of confidence as a reason why discussions regarding BMI were not offered:

…it was the way like, the midwives were really nice but I think, she [the sonographer] didn't know how to word it, I felt awkward for her because she didn't know how to approach it [weight to assess bed suitability] with me… (BMI of 49.78 kg/m², aged 26).

Readiness to make a lifestyle change

The second theme encompasses the women's views towards the introduction of the lifestyle programme into their pregnancy experience. In particular, this theme highlights women's willingness to adapt and make healthy changes to their lifestyle behaviours. This theme incorporates two subthemes: being offered the lifestyle programme and reasons for attending the lifestyle programme.

Being offered the lifestyle programme

For the majority of women, the only gestational weight management advice that they were offered was a referral to the lifestyle programme.

Women were receptive to this referral, but felt that they also wanted healthy lifestyle advice from the health professionals supporting their care. Women were pleased that they were approached to participate in the study as they felt that this gave them the opportunity to get some support in their pregnancy, something that had been lacking:

Uhm, I was quite pleased really…they've pointed something out that I have a problem, but I can act on it and do something about it and personally felt like yes, really eager to participate (BMI of 32.9 kg/m², aged 34)

Women were grateful for the time that the research midwife spent with them explaining the details of the programme. This individual approach was likely to be responsible for the women agreeing to take part in a study that involved them attending the lifestyle programme:

…I think if I had just received something in the post from the hospital saying, ‘You've been invited to'…I probably wouldn't have done anything but because of the way she's so friendly… (BMI ≥30 kg/m², aged 22)

The research midwives discussed the study with women, in private, providing information in a direct, yet sensitive way. None of the women interviewed objected to this approach. In fact, only two women that were approached for the overall study were upset; although these women had a BMI ≥ 30 kg/m², both had recently lost weight and expressed frustration that their efforts had not been realized. Women repeatedly reported that the level of explanation about the study and the personal traits of the research midwives were the reasons that they gave consent to participate in the study. The personality traits of the research midwives that were frequently reported included being ‘…really sensitive about it' (BMI of 48.1 kg/m², aged 24).

…And I wasn't embarrassed…I was actually quite glad that somebody was helping (BMI of 37.7 kg/m², aged 33)

Reasons for attending the lifestyle programme

The reasons the women gave for giving consent to the study and attending the lifestyle programme varied. A few women had been attending weight management services prior to pregnancy and wanted to maintain the momentum of support. The lifestyle programme offered them what they considered to be a replacement:

…I used to go to Weight Watchers but, obviously, I couldn't do that when I was pregnant…. And this [the lifestyle programme] actually helped me not just spiral off and start eating everything (BMI of 50.1 kg/m², aged 24)

The opportunity to gain healthy lifestyle information was a further reason for consenting to the study. Women stated that they liked the emphasis on promoting a healthy lifestyle, as opposed to a sole focus on losing weight:

I found all the food, nutritional stuff really interesting….I know a bit about it from dieting in the past but it was more like looking at having a balanced diet rather than losing weight (BMI of 37.27 kg/m², aged 24)

Women complained that, in the past, they had been ‘preached' to, by health professionals, whereas in the lifestyle programme, they did not feel the health professionals were treating them this way. They felt that this informal style, which allowed opportunities for interaction, would empower them to make individual informed choices. Women's expectations of the programme were met; the varied delivery of materials (information giving in fun forms and demonstration of behaviours in innovative ways), by different experts, was particularly welcomed:

It was lots of fun, and it beats someone just standing up in front of you saying, do this, do that or this is …you know, learn this, I think we learned so much from the activities that we did….the stuff we did with the food chart and you had to know where stuff went and everything else… (BMI of 34.9 kg/m², aged 21)

Many of the women in this study were from more deprived backgrounds and were often socially isolated. Several women attended the programme as an opportunity to meet other women in similar situations to themselves. Getting out of the house and doing something different was seen as a reason for participating in the course. Several women talked of feeling lonely and the programme offered them a chance of ‘…getting out once a week…' (BMI of 37.6 kg/m², aged 37).

Spurred on by success

The final theme focused on the women's reported lifestyle changes as a result of attending the lifestyle programme, and how these changes were motivating them to continue making improvements. Women were proud of the relatively small changes that they made, spurred on by the belief that such changes could become part of daily family life:

‘Well yeah, like I say I want to kind of set habits that will last a lifetime and I need to do that early on, and not just for them but for me' (BMI of 51.1 kg/m², aged 26)

Two subthemes highlight the behaviour changes that women reported; changes to diet/nutrition and changes to physical activity.

Changes to diet/nutrition

Several women discussed the way their food shopping had changed as a result of the skills they learnt during the programme. In particular, women gained new understanding of the meaning of food labels. For example, women encountered ‘…a few shocks…when [they] read them things like Special K [a breakfast cereal] with hardly any fat, but lots and lots of sugar' (BMI of 38.4 kg/m², aged 34). They talked positively about being taught how to determine contents of foods and used this to monitor their eating behaviour:

…just doing this programme, that's helped, because it makes… it, it, makes you realise, you know, you don't realise what you shouldn't be doing. And it kind of opened my eyes, you know, when I'm going shopping I'm looking at my labels, and when I'm cooking as well (BMI of 51.1 kg/m², aged 26)

The nutritional information received influenced women's shopping habits. In particular, the women reported continuing to use the traffic light scheme (a UK Government initiative that quantifies food on their sugar, salt and fat content; red indicates a high content; amber shows medium levels and green has low levels – http://www.eatwell.gov.uk/foodlabels/trafficlights/) listed on foods when making decisions about food purchases:

…some of that stuck with me as well, like he [the food and health advisor] showed us, you know, the traffic lights on food, and stuff… always when I buy stuff I think, oh gosh, look at that, it's like nearly all green, I'll buy that… (BMI of 49.77 kg/m², aged 26)

Women prioritized finding healthier options once they had reviewed the nutritional content of their usual foods:

…now when we are shopping I… look for a healthier substitute, which never really used to be a priority to me (BMI of 49.5 kg/m², aged 25)

Buying more fruit and vegetables was also reported; a change that may impact on the whole family. The use of fresh ingredients, and including vegetables, in cooking was a major change for some women:

Yeah they've got the fresh bolognaise sauce and that… is the recipe they gave us …and he's [nutritional advisor] like ‘oh no you can actually add carrots and things like that when you're cooking your mince, it's really nice' I wouldn't have thought to do that (BMI of 50.1 kg/m², aged 24)

Changes to physical activity

The women reported incorporating physical activity into their daily lives as a result of the physical activity information and the practical exercise they participated in as part of the programme. Walking was a popular physical activity that women reported engaging in; many abandoning the bus or car to increase their exercise:

…I mean since I left work two months ago, my car has literally been off the drive four or five times, that's it…I walk everywhere now with the buggy (BMI of 37.7 kg/m², aged 33)

Some of the women reported that information from the lifestyle programme had a direct impact on them making changes to their physical activity through learning about new forms of physical activity (e.g. exercise balls) and the setting of personal goals:

Well mine (referring to a goal) was to use my gym membership more…and I went to aqua natal class, which was really good and I just got a Wii fit at Christmas so I started using that… (BMI of 37.27 kg/m², aged 24)

Exercise was also reported as being incorporated into daily lives. The exercises demonstrated within the programme were practiced by some of the women, as they were considered ‘…very simple…' (BMI of 36.2 kg/m², aged 30).

Instruction on exercises to do with their children was also given to women within the programme; these exercises were a particular motivator for women.

… I try doing it at home as well, and my little un [one] she still does it with me, my two year old, she helps me. She was like copying me trying to do…the same thing as me… (BMI of 42.4 kg/m², aged 20)

The women discussed changes to their physical activities within their daily lives particularly when there was ‘…family involvement…' (BMI of 32.9 kg/m², aged 34). The lifestyle programme appeared to have an effect on the whole family, with the mothers' attendance at the programme being the catalyst for change:

…we've started to bring like, loads of outdoor things for them… I go outside with them and do whatever they want to, like their getting a new trampoline, they've bikes, and things, just making them active instead of lazing inside watching TV (BMI of 37.32 kg/m², aged 23).

Discussion

The aim of this study was to explore the maternity care experiences of women who had an antenatal booking BMI ≥30 kg/m² and their attendance at a lifestyle programme. Although this was a relatively large qualitative study, several limitations need to be acknowledged. Firstly, the 34 participants were self‐selecting; they had not only volunteered to participate in the interviews but were also participants in a larger study. One may argue that this group was more motivated than the general population of pregnant women with a BMI ≥ 30 kg/m². However, the sample is representative of the obese population and had a large number of women from more deprived areas, who are less likely to engage in research; just over a quarter of the sample, for example, were from a minority ethnic group. Health inequalities have been ignored in most obesity research, and understanding the social and economic situations of those with obesity is essential for successful intervention design.16 A further limitation is that women were interviewed post‐natally, yet were predominantly discussing their antenatal experiences. This may have introduced an element of recall bias.26 However, it is our experience, as midwives and researchers, that women usually relay fairly accurate accounts of their experience. Moreover, women's perceptions, regardless of accuracy, can act as valid motivators or barriers to change; a factor that cannot be underestimated. In line with recent research, women were interviewed in the post‐natal stage as this is when they want to make changes to their weight and change their behaviours.11 Finally, it was not possible, within this current study, to validate the behaviour changes that women reported. However, having interviewers not known to the participants and providing reassurance regarding anonymity will have reduced this possibility. Finally, a few interviews were short in length, but the discussion was detailed, and this was not a reflection of the quality of the data.

Despite some limitations, the findings have provided understanding related to the maternity needs of women with a BMI ≥30 kg/m² and has also increased our knowledge of factors that are important to these women, when designing future lifestyle interventions.

Knowledge gained about the maternity needs of women with a BMI ≥ 30 kg/m²

Pregnancy has been suggested as the perfect time for women to receive healthy lifestyle advice, women being more accepting of their weight than they were before pregnancy.11, 12 In our study, women welcomed being approached about their weight, but as found in other research, information from health professionals was not forthcoming; this left them disappointed and seeking help elsewhere.27 The women's openness to being approached and their readiness to make changes are reflected in the fact that they agreed to participate in a study that involved attending a lifestyle programme dependent on weight. These findings suggest that the NICE recommendations for best practice are not being implemented, as women are not being offering advice about weight and healthy lifestyles at an early stage of their pregnancy.3 The lack of discussion about weight, weight gain and physical activity in pregnancy, highlighted in this study, resonates with the findings of others.26, 28 Moreover, this study provides insight into the negative impact that the lack of advice from health professionals may have on women's maternity experiences. The absence of appropriate advice can lead women to construct personal views about optimum levels of weight gain29 or feel confused about health messages.13 In this current study, women either ‘normalized' their pregnancy weight or sought information that was external to the health service. Both actions are likely to be detrimental to women's health. Normalizing their weight may prevent vigilance in observing for signs of pregnancy complications. Seeking less reliable external sources of information (e.g. magazines) may mislead women into inappropriate actions. The use of external information resources is an important topic of debate,30 with little consensus on the role of health professionals in guiding women. Women must be given the opportunity to make informed choices about health care at each stage of their pregnancy.

When the subject of weight was introduced by health professionals, women sensed their discomfort; this suggests that health professional training is urgently needed. This finding reflects other findings that health professionals lack confidence initiating weight with women13, 28, 31 and find discussing weight with women hard due to a lack of training.32 Training is required to assist not only for approaching the topic of obesity with women, but also to guide women about the potential need and rationale for additional appointments. This latter point is important as a lack of understanding is a cause of non‐adherence.33 One must acknowledge, however, that a lack of intervention by health professionals regarding weight in pregnancy may be the result of limited referral options.34 Alternatively, as suggested in one qualitative study in the North West of England, midwives may feel that weight, diet and exercise are the least important health promotion issues to discuss with women, perceiving that they have the least impact on the baby.35 Midwives who attended a training package covering all aspects of weight management reported increased confidence and knowledge regarding weight management as a result in a Welsh study.36

The current research could inform health professional training by (i) providing evidence that women want to be approached, (ii) reflecting on the positive approach to women adopted by the research midwives and (iii) using vignettes of the women's experiences with health professional discussion triggers. Having training available may help to standardize the approach taken by health professionals when discussing weight in pregnancy and meet the vision of world‐class commissioning that ‘better care for all' will be provided.37 ^{, page 4}.

The design of future maternity care and interventions

Pregnancy was highlighted as being an ideal time for intervention, offering support for pregnancy as a ‘teachable moment'.12 ^{, page 135}. These post‐natal women were keen to implement the skills that they learnt on the lifestyle programme and make changes that would become the future behaviours of them and their families. It is important that women with a BMI ≥30 kg/m² receive support that can be implemented in the post‐natal stage as they are more likely to suffer symptoms of post‐natal depression38 and post‐partum weight retention.39 Expected improvements to the health of their family appeared to be important to the women and in line with Social Cognitive Theory could be suggested as influencing behaviour by acting as an expectancy of the consequences of their behaviour.19 Little is understood about pregnant women with a BMI ≥30 kg/m² expectancies of changing behaviour; therefore, it is not understood what expectancies have an impact on behaviour and should be focused upon.

This qualitative study provides details about the suitability of an intervention for pregnant women with a BMI ≥30 kg/m². The feasibility study findings are published elsewhere.21 Women were positive in their discussion of the intervention, providing examples of individual intervention components that they deemed acceptable. Perceived benefits of the lifestyle programme highlighted the success of the BCTs that were implemented in this study. The use of small achievable goals and self‐monitoring were reported as having a positive impact on the women, helping them to focus their attention on certain behaviours. Self‐monitoring of the behaviour outcome was concluded in a meta‐analysis as significantly increasing obese individuals' self‐efficacy and physical activity.40 Thus, more research is needed with pregnant women with a BMI ≥30 kg/m² to further understand the processes through which BCTs are encouraging behaviour change.

The women reported that the sessions empowered them. They felt that the BCTs used in the tasks were a good way to both learn and have fun. Feeling stigmatized due to weight was not explored in the current study, but other research highlights pregnant women's feeling of stigmatization.13, 28, 41 The fun element was attributed to the women's desire for social support; an important element was therefore the group work and feedback. A lack of social support has been recognized for years as having an adverse effect on health.42 A lack of social support was highlighted in focus groups with 25 overweight and obese post‐partum women in the US as a barrier to weight loss.43 Social support should be measured in future interventions as a mediator of antenatal and post‐natal behaviour change.

Women reported changing their physical activity and dietary behaviours. Women have been found to think that healthy eating was more important in pregnancy than physical activity.44 These findings highlight the importance of these two lifestyle behaviours to these women and emphasizing their inclusion in future antenatal interventions, in particular post‐natal information must be included, so that women have this knowledge ready to make changes to their behaviour.11

Rolling out a lifestyle programme, such as the one described, would be possible within the NHS if members of the multidisciplinary health teams each contributed to the components that reflected their own expertise (e.g. nutritionists providing dietary advice). Peer support from those who have gained from attending the programme could also provide direction and motivation to participants. Rolling out of such a programme would need to be assessed for cost‐effectiveness; however, given the increased cost of supporting pregnant women who are obese (estimated as 37% more than those of normal weight),45 this is likely to be an efficient use of resources.

Conclusion

The current findings provide us with some insight into the maternity needs of women with a BMI ≥30 kg/m² and suggest recommendations to improve their care. Training for health professionals to improve their knowledge of maternal obesity is a priority. Future research must test the effect of attending antenatal lifestyle programmes on long‐term lifestyle behaviour change. Lifestyle interventions will benefit from incorporation of the views of those that they are hoping to support.

Sources of funding

The study has been funded by the Department of Health and the Department for Education (formally the Department for Children, Schools and Families).

Declaration of conflict of interest

No conflict of interests