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. Author manuscript; available in PMC: 2019 Feb 1.
Published in final edited form as: Health Psychol. 2017 Oct 2;37(2):132–138. doi: 10.1037/hea0000555

Maternal Conception of Gestational Weight Gain Among Latinas: A Qualitative Study

Grace E Fletcher 1, Leah Teeters 2, David Schlundt 3, Kemberlee Bonnet 3, William J Heerman 2
PMCID: PMC5794623  NIHMSID: NIHMS909655  PMID: 28967775

Abstract

Objective

Interventions to support healthy gestational weight gain are often ineffective. The objective was to develop a model of how pregnant Latinas—who have higher risk of poor maternal and neonatal weight-related outcomes—conceptualize healthy gestational weight gain, providing guidance for future interventions.

Methods

Ten focus groups with 50 pregnant Latinas were conducted by a native Spanish-speaking female moderator. Based on participant responses, we used grounded theory to inductively develop a personal conceptual framework for gestational weight gain.

Results

Commonly identified barriers to being active and healthy eating included negative emotions, body image, physical discomfort, low energy, and lack of motivation Women identified sociocultural issues like a sense of isolation from family (among immigrants) and the degree of perceived social support as important contributors to health behaviors. Two personal health schemas emerged from participant responses. The “mother-child health schema” describes the degree to which participants recognized the inter-relatedness of health needs for baby and for themselves. The “attention to gestational weight gain schema” describes how a respondent’s attention to and perceived importance of gestational weight gain influences health-related behaviors during pregnancy.

Conclusions

Women’s sociocultural and interpersonal context influence weight-related behaviors through the lens of personal health schemas. Understanding how cognitive aspects relate to traditional behavioral determinants suggests several opportunities for intervention such as focusing on healthy behaviors instead of numerical targets for healthy weight gain. While derived from Spanish-speaking Latin American women, these results may also be potential leverage points for other minority groups.

Keywords: conceptual framework, gestational weight gain, Latina, qualitative, pregnancy

Introduction

Healthy gestational weight gain is a priority for obstetrical care, as it is necessary to support healthy fetal growth and can prevent maternal and child health complications (Butte, Ellis, Wong, Hopkinson, & Smith, 2003). In 2009, the Institute of Medicine (IOM) identified excess gestational weight gain as an adverse determinant of maternal health and child growth, citing higher rates of cesarean section, gestational diabetes, and pre-eclampsia among mothers and high rates of infant adiposity and childhood obesity among their children (Institute of Medicine, 2009). Recognizing the range of recommended healthy gestational weight gain varies by a woman’s pre-pregnancy body mass index, clinical care providers have endeavored to implement balanced approaches that reduce excess maternal gestational weight gain. In the U.S., this is especially challenging among traditionally underserved populations who have a higher likelihood of both inadequate and excess gestational weight gain (Deputy, Sharma, Kim, & Hinkle, 2015).

To date, weight-related interventions for pregnant women have been minimally successful in improving maternal and neonatal weight-related outcomes. A recent systematic review by Skouteris et al. found that gestational weight gain interventions usually did not change gestational weight gain enough to meet the IOM recommendations, and that successful gestational weight gain interventions were most often effective for select population sub-groups (Skouteris et al., 2010). Consequently, understanding the cultural perceptions of gestational weight gain among traditionally underserved populations may be an important next step for developing population-level solutions to address this public health problem.

The most consistent determinant of excess gestational weight gain among Latinas is pre-pregnancy overweight/obesity (Rosal et al., 2016). However, gestational weight gain is a complex phenomenon, influenced by many behavioral, environmental, and cognitive factors (Gesell, Katula, Strickland, & Vitolins, 2015; Kapadia et al., 2015; Wang, Arroyo, Druker, Sankey, & Rosal, 2015). The research that has been conducted on factors that contribute to gestational weight gain for Latina women, like physical activity (Evenson, Moos, Carrier, & Siega-Riz, 2009), diet (Chasan-Taber, 2012), social support (Thornton et al, 2006), and provider advice (Ferrari, Siega-Riz, Evenson, Moos, & Carrier, 2013; Tovar et al, 2010) demonstrate that Latinas often do not meet recommended diet or physical activity guidelines and often do not receive weight gain advice from their physicians. However, comparatively less attention has been paid to cognitive or perceptual influences on gestational weight gain among Latina women. Namely, how do women think about gestational weight gain? And how should clinical interventions account for or address these cognitive perceptions?

The purpose of this study was to use qualitative methods to develop a conceptual model of how Latinas understand a healthy pregnancy and to gauge their understanding of how gestational weight gain and nutrition affect their health and the health of their developing child. Because Latinos are the fastest growing minority population in the United States, have a disproportionately higher burden of obesity, and have a unique set of cultural perspectives, there may be important population differences that could inform optimal care (Ogden, Carroll, Kit, Flegal, 2014; Thornton et al, 2006; Tovar et al, 2010). We do not take essentialism’s view of the Latino experience in the U.S., wherein the stereotypical experience of a Latina would be presumed for every member of the population (Rhodes, Leslie, Saunders, Dunham, & Cimpian, 2017). However, we do believe population trends have some explanatory power (Gutiérrez & Rogoff, 2003). While work on this topic has been conducted with African American and White women (Deierlein, Siega-Riz, Adair, & Herring, 2011; Groth, Morrison-Beedy, & Meng, 2012; Whitaker, Wilcox, Liu, Blair, & Pate, 2016), and with low-income women (Paul, Graham, & Olson, 2013), the literature on Latinas is sparse. By developing a more nuanced perspective on how Latinas view the relevance of their weight-related behaviors and subsequent weight gain during pregnancy, we aim to inform novel, culturally tailored approaches to health behavior interventions that could support healthy gestational weight gain.

Materials and Methods

Ten focus groups were conducted with 50 pregnant Latinas to reach data saturation. Each focus group ranged from three to twelve participants, with an average of five participants per focus group. The length of each focus group ranged from 40 to 95 minutes. The focus group format allowed participants to feel comfortable discussing a potentially sensitive topic and highlighted themes around which there was more or less consensus. Participants were recruited in person by study staff (trained research assistants who were native Spanish speakers) from waiting rooms of obstetric clinics in Nashville, Tennessee (both academic and private clinics). Participants were compensated with a $20 gift card for their participation in sessions conducted at local community centers. Inclusion criteria consisted of 1) women, who 2) self-identified as Latina, 3) spoke Spanish, and 4) were pregnant at the time of recruitment. Participants were recruited during the second trimester of their pregnancies to minimize recall bias and because this is the time when most gestational weight gain interventions are conducted. All participants signed an informed consent document prior to participation. The Vanderbilt University Medical Center Institutional Review Board approved this study.

Discussion questions were designed to uncover participants’ attitudes, knowledge, experiences, and beliefs regarding healthy weight gain during pregnancy without leading or framing participants’ responses. A moderator’s guide developed for this study incorporated both open-ended questions and follow-up prompts to solicit additional detail (See Appendix A). One of two native Spanish-speaking female moderator facilitated all ten focus group sessions.

Each focus group was audio recorded, transcribed in Spanish, and then translated into English by bilingual study staff. Two trained observers of the focus groups recorded non-verbal communication and took notes.

Prior to the focus group, each participant completed a survey to measure the following characteristics: age, estimated gestational age, pre-pregnancy height and weight, the number of years living in the United States, whether this was the participant’s first pregnancy, educational attainment, and country of birth.

Analysis

Drawing on grounded theory (Strauss et al, 1990) to emphasize participant voices, each statement was treated as a separate quote and coded using a hierarchical coding system. This coding system was developed using an iterative inductive-deductive approach based on the study questions and a preliminary assessment of focus group transcripts (Charmaz, 2006). The deductive (i.e., theory-driven) aspects of the coding scheme were based on the tenets of social cognitive theory, recognizing the triadically reciprocal nature of environment, behavior, and cognition for behavior change (Bandura, 1986). Inductively derived codes were organized into major categories with subcategories further expanded to capture detail. Though there was some variability in the frequency of themes across focus groups, all of the categories and themes abstracted recurred in more than one focus group.

Two trained coders independently coded the quotes using a simple spreadsheet and established agreement on the codebook and the meaning of each code. We analyzed 1,371 quotes, and each quote was assigned as many codes as matched (range 1–5 codes). Once each quote was coded, it was organized into thematic categories. Themes were then re-evaluated against the original quotes to confirm that the model was an accurate reflection of the participants’ ideas.

Results

Fifty participants were involved in 10 focus group sessions conducted over 8 months. The median age of the participants was 29 years (IQR 24, 33), and the median pre-pregnancy body mass index was 27.5 kg/m2 (IQR 23.9, 32.0). The median estimated gestational age at the time of the focus group was 25.5 weeks (IQR 20, 32.5), and only 12% of participants were primiparous. The median time living in the U. S. was 9.9 years (IQR 7, 12). Participants reported highest level of education as follows: less than high school (64%), high school graduate (26%), and some college or higher (10%). Participants reported their place of birth as follows: Mexico (64%), Central America (24%), the U. S. (6%), the Caribbean (4%), and South America (2%).

Five themes emerged from focus groups: 1) specific issues with diet or physical activity during pregnancy, 2) facilitators and barriers to healthy gestational weight gain, 3) avoiding negative health outcomes & previous health history, 4) external influences on behavior, and 5) the sociocultural context. A pictorial representation of the interactions among these components is shown in Figure 1, including two personal health schemas that emerged as the relationships between themes were analyzed. The themes that emerged from the focus groups are described in the following sections.

Figure 1.

Figure 1

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A Personal Conceptual Framework for Gestational Weight Gain. Inductively developed from focus group responses.

Diet and Physical Activity During Pregnancy

Diet

Participants reported a range of experiences with diet during pregnancy. Some participants described a poor appetite during pregnancy, saying things like: “it has just been difficult for me because I can’t really eat, I try, but my stomach won’t let me.” This group of participants tended to report difficulties with insufficient weight gain or even weight loss during pregnancy. One participant said, “Well like the lady is saying, the difficulties, you can’t always keep down what you eat. A lot of times the body rejects it and that is what makes one lose weight, the vomiting, and the nausea.” Another group of participants talked about challenges with overeating, and often described gaining too much weight during pregnancy. One participant said, “So I don’t know if I can control it. Well to be honest, I eat everything. I don’t hold myself back.” Overeating was often related to cravings, which many participants described as phenomena that could not be disobeyed without serious consequences, saying “Well, some cravings are dangerous, because it has happened that some women don’t eat something that they see, and they crave it. If you don’t eat it or you don’t buy it, a lot of women lose the baby.”

Physical Activity

Physical activity during pregnancy was widely seen as challenging, mostly because of tiredness, physical limitations, or a lack of motivation. One representative participant commented, to the laughing agreement of others, “that is a lie, that I’m going to work out while I’m pregnant. I get too tired." Another participant said, “There is nothing that makes it easy. I tell you, with exercise, well I am very sleepy and I am just being lazy.” There were conflicting points of view on whether the mother’s physical activity was connected to the baby’s health. One woman said “I worry more about having a healthy baby than about my own physical activity,” while another commented that “if you don't do active things that can harm the child… they tell you that you could lose it [the child], they told me that.”

Facilitators and Barriers to Healthy Pregnancies

Participants reported that their diet and physical activity during pregnancy were influenced by a number of facilitators and barriers to healthy pregnancies. Participants commonly identified negative emotions and body image as well physical discomfort, low energy, and lack of motivation as barriers to being active and eating healthy meals. When discussing these barriers, one participant said, “Without doing anything, I feel tired. I cannot even go up a staircase. And I am just exhausted.” Another participant said, “Yes, because a pregnancy, always, if it’s not a headache, your body hurts, and that sometimes kills your appetite. So it is difficult to carry out a healthy diet.” Addressing issues around body image, one participant commented, “When I want to put clothing that does not fit me, is when I have a mental trauma, because it does not fit me. I get depressed. When I look at myself in the mirror, and say from all the clothing I have, after having the baby, it might not fit me again.”

Social support, especially from a male partner, was identified as a critical component that could be both a facilitator and a barrier to healthy behaviors during pregnancy. For example, one participant attributed her difficulty in maintaining a healthy diet during pregnancy to her partner, saying “He likes fried beans, fried pork chop, butter, cheese, avocado, and chicken for dinner. A full meal so he can be satisfied.” Yet, another participant described how her husband helped her to be more physically active, saying: “He likes running a lot, so he’ll ask me to go with him and I’ll go. We even bought my boy a bike so that he can come with us…” Participants infrequently mentioned lack of time or limited financial resources as barriers to healthy behaviors.

Avoiding Negative Health Outcomes and Previous Health History

Many participants made choices about diet and physical activity to avoid negative health consequences rather than seek positive health outcomes, which was often influenced by their previous health history with conditions like gestational diabetes or cesarean section. For example, one woman spoke about her baby, saying, “I try a little to eat healthy things, walk a little more, drink more water, for example, so that this doesn’t happen. So that something [e.g., blood pressure or blood sugar levels] doesn’t increase in me.” Another participant commented, “As long one has the weight that it should be, there is a lower risk for some of the illnesses, also for one self. Because going over weight also comes with having high blood pressure, cholesterol and all that.”

External Influences

Medical providers were cited most frequently as participants’ primary source of information, though other sources also emerged as important, including family and the media/internet. For example, one participant commented “And well, what’s it called, well it’s from my mom, it’s from my grandma, they’ve told me, drink this water so that your pains calm, or this, or do this or the other thing, but always, always taking into account many of the doctor’s things and the opinions.“ Another participant said of her family, “Well, I trust because since she has had kids, she already knows, or they share their experiences and they share them and if one wants to take them, then they do, and if not, well, that’s it, one now has the experience or the commentary that they said, I did this, or this happened to me, you can do this.” When commenting on finding information on the Internet, one participant said, “"Well, for me, everything having to do with food, in the Internet, no. But about how to take care of a baby, that is, because I, even though I already have a child, I'm like it's my first time because it's been so long, so, what I most look at on the Internet is how to bathe the baby, in the Internet, or how, how to clean them, all of that. So, that's more why I go on the Internet. But yes, with food and things like that, I am doing what the doctor has recommended. Yes.” While participants shared that medical providers were a source of information, they readily reported that they “forgot” the recommended guidelines for weight gain shared by their provider. They explained that when doctors often focused on quantitative guidelines for weight gain (“you should gain no more than 20 pounds”), as opposed to specific behaviors, (“you should eat no more than one tortilla with each meal”) they “forgot” the numerical recommendation, yet remembered and aimed to follow the behavioral recommendation.

Additionally, several participants acknowledged the difficulty of incorporating advice from multiple sources: “Everyone in the world gives you advice, and your mother too.” Most participants reported high levels of trust in their doctors and adhered to provider-recommended diets, seeing positive or neutral results.

Sociocultural Context

Participants described a high degree of social vulnerability and isolation. Illustrating the link between social isolation and healthy behaviors for gestational weight gain, one participant commented, “if I had my mom here after pregnancy she could cook for me without fat. Being alone as I am, I cannot, I have no time for cooking. I send my husband to buy something.” In addition, many of the participants shared a feeling of being dependent on the men in their lives, especially when pregnancy entailed stopping work outside of the home. The participants noted how this dependency was in contrast to their social structure in their home country, where they had extensive support systems and familial networks. These issues sparked complicated emotions and behaviors, especially around weight gain during pregnancy, as demonstrated by this woman’s experience:

He’s [her partner] the one that makes me feel bad because he says that he doesn’t like a skinny woman, and to be honest I do feel rejected by him in these pregnancy days when I need him the most. I’m not trying to talk [bad] about him, because he’s good to me and everything, but now that I can’t work, he’s the one supporting me and my family in Honduras…And I have lost a lot of weight, and he says that he doesn’t like a skinny woman, and it does hurt—his indifference towards me…and I have to tell him that it is not because I want to be, but because I have his daughter inside me and she is the one making me change my body.

Most participants did not correlate their weight-related behaviors to their cultural background unless specifically prompted by the moderator. When cultural issues were identified, they were often comparative. For example, one participant commented, “I am Mexican, my family is used to doing, like in this cold season, the food. So we eat more than what the Americans eat. The Americans don't do a meal with a full table. You, you fill it [the table], and you eat until you can't eat anymore.”

Personal Health Schemas

As women responded to questions regarding whether there was an “appropriate” amount of gestational weight gain, two personal health schemas emerged: “the maternal-child health schema” and the “attention to gestational weight gain schema”. Personal health schemas are fundamentally held ways of understanding one’s self in the context of health, influencing the way that women make decisions about their health and behaviors important for gestational weight gain.

Mother-Child Health Schema

A key lens through which participants viewed healthy/unhealthy behavior in pregnancy was the mother-child health schema: a woman’s understanding of herself as a person, of her baby, and the extent to which the mother or child exerts agency or influence over the other for health.

This maternal-child health schema first became apparent when participants were responding to the question: “Do you think there is a ‘right’ amount of weight to gain when you are pregnant?” While some mothers recognized a link between healthy gestational weight gain and healthy pregnancy outcomes, many made a distinction between the weight that the baby gained and the weight that the mother gained. For example one participant said, “for me, I feel like I’m the only one gaining weight and not the baby, because I can’t keep down what I eat so I feel like I’m the only one receiving and not the baby.” When participants perceived clear boundaries between themselves and their babies, they implicitly acknowledged the agency of the baby. For example, one woman described how “If you don't eat everything that the baby asks you for, that then it is born with an open mouth” [i.e., hungry; asking for more].

Furthermore, participants who partitioned their weight gain—allotting separate quantities of weight to themselves and to their developing child—made more comments about overeating. One participant said, “Well it depends. Me, during my girl’s pregnancy I hardly ate. But then with the boy’s [pregnancy], I ate a lot of sweet things, and that is where I would go over weight, but the weight was for me, not for the baby, so that is why it is hard to maintain a balanced, adequate weight.” Conversely, participants who viewed weight gain during pregnancy as a combined mother-baby weight gain were more likely to recognize the inter-relatedness of the health needs for baby and the health needs for themselves.

Attention to Gestational Weight Gain Schema

This personal health schema describes a woman’s awareness of gestational weight gain and its perceived importance. Despite specific and probing questions, it was clear that many participants had not given much thought to whether there was an appropriate amount of weight to gain during pregnancy. In fact, to most participants, the idea of “appropriate” or “adequate” weight gain during pregnancy was a foreign concept. For example, one woman commented, “It's that, I just don't think about my weight, I think about what I am craving.” Other participants were aware of gestational weight gain but assigned less importance to it, saying, “I try to not eat too much, just enough not to gain too much weight but also not lose any.” When the moderator shared the IOM gestational weight gain guidelines with participants, most interpreted the ranges as minimums to achieve, not as limits. Generally, weight during pregnancy, and the idea of appropriate weight gain, was not a concept that resonated with this group.

Discussion

These focus groups suggest that healthy diet and physical activity during pregnancy are influenced by a person’s sociocultural context as well as their own personal heath schema. Based on these findings we propose a personal conceptual model for healthy gestational weight gain (Figure 1). At the center of the model are behavioral determinants of healthy gestational weight gain, including diet, physical activity, and common facilitators and barriers to those behaviors. Also central to the model are external influences that both shape a mother’s behavior but also her own personal health schemas. The most important external influences that women identified included their medical providers, their families, and Internet or media sources. Finally, based on participant responses and consistent with the socio-ecological model, the components of this framework operate within a larger sociocultural context (Huang, Drewnosksi, Kumanyika, & Glass, 2009). Our inductively generated personal conceptual model of gestational weight gain suggests opportunities for intervention that may be specific to population subgroups (i.e., Latinas in the United States) but also are potential leverage points for all women. Interestingly, participants frequently remembered conversations with health care providers about weight gain targets, but could not remember the specific numerical targets, even though the participants were eager to follow health recommendations during pregnancy. This suggests an area for targeted future research to develop appropriate health care interventions where obstetric care providers focus on healthy behaviors, particularly specific diet- and exercise-related behaviors, rather than numerical goals for gestational weight gain.

The newly proposed conceptual model was developed using both inductive and deductive reasoning. While many of the components have been evaluated in previous literature, they have most often been evaluated as individual constructs, without exploring their interrelationships. Using previously developed multi-level models, like the one developed by Huang et al. to describe obesity, we initially postulated the immediate upstream determinants of gestational weight gain would include health behaviors like diet and physical activity, as well as facilitators and barriers (Huang, Drewnosksi, Kumanyika, & Glass, 2009). These focus groups added detail to those constructs by providing specific examples of the most important types of behaviors (i.e., the serious health consequences that participants expected if cravings were ignored). By using inductive reasoning from the focus group data we identified two additional upstream determinants including a participant’s previous health history and the desire to avoid negative health outcomes. With the high rates of weight-related complications among Latinas during pregnancy (i.e., gestational diabetes) this is one potential area that could inform future interventions, with the goal of reframing healthy behaviors as a means to achieve positive health outcomes as opposed to merely avoiding negative health outcomes. The most novel aspect of the conceptual model, and one that we did not expect, was the importance of what we call maternal child health schemas. These schemas had a foundational influence on health-related behaviors and interacted with all other aspects of the model. What’s more, these schemas were not fixed, and many women indicated that external influences (especially health care providers) could influence how they viewed weight gain during pregnancy and how that weight gain affected their children. This again provides an opportunity for healthcare providers to recognize areas for intervention, acknowledging that all women may not place the same importance on weight gain during pregnancy.

The similarity of our findings among Latinas in Nashville, TN to other qualitative work among a wide range of women suggests the potential generalizability of the findings. Most notably, what we inductively identified as a “maternal-child health schema” is similar to what Padmanabhan and colleagues, in a similar study with pregnant British women, describe as “fragmentation of the self” (Padmanabhan, Summerbell, & Heslehurst, 2015). In addition, our participants reported a high degree of trust in their medical providers, which is consistent with other reports in the literature (Ferrari et al., 2013). Furthermore, many participants commented that their doctor told them how much weight they should gain but could not remember specific numerical goals, which aligns with the literature that shows a low knowledge of gestational weight gain guidelines across cultural contexts (McPhie, Skouteris, Hill, & Hayden, 2015; Olagbuji, Olofinbiyi, Akintayo, Aduloju, & Ade-Ojo, 2015), particularly for Spanish-speaking women (Smid, Dorman, & Boggess, 2015). Importantly, participants reported that their providers’ focus on the numerical guidelines for gestational weight gain was not as effective in changing behaviors like diet as was specific dietary instructions from their providers. Our focus groups also identified similar patterns of facilitators and barriers to healthy gestational weight gain that have been reported previously, with the notable exception that these participants mentioned barriers like a lack of time or resources much less frequently (Marquez et al., 2009; Paul et al., 2013).

This study has several important limitations. We were unable to relate comments from individuals to their specific sociodemographic characteristics, which limits our ability to draw conclusions about important potential associations (i.e., primiparity) that could drive how women understand weight gain during pregnancy. Some groups had poor attendance and others were oversubscribed, which may have limited meaningful discussion in those groups. Because participants were recruited from a clinic setting, this study underrepresents the perspectives of those women who are less connected to the healthcare system. As discussed above, even though our findings are consistent with other literature, we cannot strictly generalize the findings beyond this specific population of pregnant Latinas in Nashville. Furthermore, since the focus groups were conducted only in Spanish, the findings only apply to Spanish-speaking Latinas. We do believe our sample to be reasonably representative of the Latino population in Nashville, which comprised 10% of the county’s population in 2014, with 60% being of Mexican origin (Pew Research Center, 2016).

Conclusion

In conclusion, clinical care providers should be aware of the possibility that weight-related behaviors during pregnancy might be driven by cognitive schemas that they do not share. Future interventions to promote healthy gestational weight gain for vulnerable pregnant Latinas should take into account women’s worldviews, particularly of gestational weight gain, and focus on specific behavioral instead of numerical targets for healthy gestational weight gain.

Supplementary Material

1

Acknowledgments

None

Funding Source

The project described was supported by a K12 grant from the AHRQ (K12HS022990), a K23 grant from the NHLBI (K23 HL127104), and the Center for Diabetes Translation Research at Vanderbilt (P30 DK92986).

Role of the Funding Source

The funding source had no involvement in the research or production of this paper.

Footnotes

Disclosures

The authors report no conflict of interest.

Paper Presentation:

An abstract of preliminary results was presented at the 34th Annual Scientific Meeting of the Obesity Society, New Orleans, Louisiana, October 31–November 4, 2016

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