Gestational Weight Gain Among Nulliparous Women
Gestational Weight Gain Among Nulliparous Women
Nineteen patients and seven obstetricians completed interviews. Patient characteristics are presented in Table 4. Patients were diverse with respect to age and race. Patients were nulliparous; two patients had previously experienced miscarriages earlier than 12 weeks gestation and had not experienced GWG prior to their current pregnancy. With the exception of one patient who was carrying twins, patients had singleton pregnancies. Physicians were diverse with respect to sex (3 men, 4 women), years since graduation from medical school (1985–2005), and years on the faculty at the clinic (2–20).
Analysis of transcripts revealed four prominent themes related to patient-provider communication about GWG: (1) communication about the amount and pace of GWG; (2) the content of nutrition and physical activity communication; (3) communication about postpartum weight loss; and (4) patients' feelings about their provider's weight-related counseling.
As previously described, we coded and analyzed obstetrician and patient transcripts separately. In what follows, we report them together (interspersed) by theme, in order to make clear the similarities and differences in the perspectives of the two groups.
Obstetricians generally preferred that their patients gain weight within the guidelines set by the IOM but reported differences in the frequency and timing of their weight-related discussions. Some said they addressed the topic with patients early in the pregnancy so patients would know upfront what to expect, while others reported that they intentionally did not discuss weight at the first few prenatal visits because other topics are more important. One obstetrician said that she discussed weight with every patient at every prenatal visit.
Patients reported that weight did not seem like a high priority for their obstetricians during prenatal visits. Most women said that their doctors talked to them early in their pregnancy, most often at their first appointment, about how much weight they should expect to gain, but that weight was not a focus of subsequent appointments. A few patients speculated that doctors might avoid the topic because they assume it is uncomfortable for women, or that doctors would address weight gain if it became a serious problem.
[There was] not much conversation nutrition-wise, weight-wise. And by not much, I guess not any…Maybe it's because… since I carry the weight well, apparently, I don't look as heavy as I am, even though he's got it in the charts. And they weigh me at every visit…[Maybe he hasn't brought it up] because I haven't gained too much and I haven't put on the 40 pounds, or the 60 pounds, or some of these stories that you hear, and I wasn't morbidly obese. –Patient, pre-pregnancy Body Mass Index (BMI) 30.1, 6.8 kg (15 pounds) gained at 35 weeks
Obstetricians appeared to take patient characteristics into account when they communicated with patients. Obstetricians reported that they might not focus on weight with every patient because they tailor their counseling depending on several factors, including pre-pregnancy BMI (advising women with higher BMIs to gain less weight than women with lower BMIs), the amount of weight the woman has gained, and patients' anxiety about weight gain. For example:
If she's neurotic about it and we're talking about it every visit because she's driving that, it doesn't matter [whether I think we need to discuss it], I'm still gonna have to talk about that. I've still gotta talk her off the ledge each time, whether it's appropriate or inappropriate or whatever it is, we gotta have the conversation. –Obstetrician, Male
When a patient has gained weight within expectations, they do not mention GWG. When weight gain is outside expectations, most doctors said they would open a dialogue with the patient about her nutrition and physical activity. If this conversation satisfies the doctor that the woman's habits are healthy, most doctors will reassure the patient that her weight gain is fine. If this conversation does not, then doctors described taking several different approaches with their patients.
One approach obstetricians described is to offer additional counseling by reviewing what the woman is eating and then identifying areas for improvement. In addition to this counseling, several doctors discussed methods they use to persuade women to moderate their weight gain. One means of persuasion is discussing the complications of pregnancy and childbirth that can arise with excessive weight gain.
The most effective way I know to help them change things is to let them know the baby could be really big. And if the baby gets bigger there's an increased risk the baby won't fit so they would need a caesarean, and depending on their response to that we will go on to the next step, whether it's an increased risk of the shoulder being trapped and the baby, tiny chance, but real chance, of lifelong disability from it. So I try to slowly ratchet it up if they're clearly not following a good eating plan. –Obstetrician, Male
A second approach obstetricians used to persuade women to moderate their weight gain was to focus on the difficulties of postpartum weight loss for women with high GWG.
I do tell them that if they gain in the recommended range they're most likely to get back to their pre-pregnancy weight. So, I use it kind of as a way to encourage women to not over-gain during a pregnancy. –Obstetrician, Female
Patients' accounts of these encounters were somewhat different. Nearly all women, even those who had gained weight outside the IOM recommendations, said that their doctor had little if anything to say about their weight. When conversations about the amount or pace of weight gain did occur, patients reported that they had prompted the discussion, with doctors rarely raising the subject. Patients said that in these conversations, their doctors reassured them that their weight gain was appropriate. Most women said they were comfortable raising the topic of weight with their doctors, but a few were hesitant about initiating conversations about certain weight-related topics, such as disordered eating habits.
Six of the seven physicians reported that they talk about nutrition with every patient at some point during her pregnancy, generally encouraging women to consume a "healthy diet".
I tell women to stay away from the fatty foods, sugar foods, just the junk food type things. Just to try to eat healthy, but not to worry about the weight gain…there's myths that you're going to have all these cravings for ice cream, craving for all this bad food and it's all fine to eat all this bad food that you never would eat normally. So, [I provide] more counseling that you should still eat a healthy diet. –Obstetrician, Female
In contrast, patients reported that their doctors either offered general advice about eating a "balanced diet" or did not discuss nutrition at all. A few women mentioned handouts about nutrition that they received from the clinic but added that their physicians had not reviewed the material with them. Several expressed surprise that they did not receive counseling about foods that pregnant women should avoid, though most women said they looked into this information on their own.
Five of the seven obstetricians reported that they counsel pregnant women on exercise, but less so than on nutrition. Those that discussed exercise emphasized that activity is a key component of a healthy pregnancy and weight control and focused on walking as a safe and low-impact form of exercise.
As with nutritional advice, a few patients reported that they had received clinic handouts about physical activity but said they had not reviewed the materials with their obstetrician. Others said that they had had general conversations about exercise with their doctors, who encouraged them to continue to be active, especially by walking. Some women reported asking their obstetrician about physical activity. Many women reported that exercise had not been discussed.
Obstetricians reported that they generally do not directly advise women on postpartum weight loss, either during pregnancy or during the postpartum period.
I don't say much at all! And I will say that I'm not actually very diligent about checking their weight at their postpartum [visit] either and comparing it. I think sometimes I do, but it's certainly not one of the areas I stress. –Obstetrician, Female
Obstetricians said that postpartum weight loss most often comes up in conversations with patients during discussion of topics that are tangentially related to postpartum weight, such as breastfeeding.
Yet patients discussed several questions and concerns about postpartum weight that they hoped obstetricians would address. Most patients said that they hoped their doctors would give them tips about healthy weight loss and information about the normal timeline for weight loss in the postpartum period, so they could plan and adjust their expectations accordingly. Several women were interested in more specific information about nutrition and appropriate exercise while they were breastfeeding, or advice about when they could safely return to their pre-pregnancy physical activities. Many women expressed general uncertainty about what the post-partum period would be like for their bodies, their moods, and even their relationships with their doctors.
I don't even know what kind of support I'm going to get with postpartum-- like I don't even know if I'm going to see [my obstetrician] or what, so I'm just curious about the kind of the support you get for postpartum weight-loss. You get all of these appointments and everything to talk about when you're pregnant, and I wonder if there's a similar sense of having support afterwards. – Patient, pre-pregnancy BMI 25.1, 14.1 kg (31 pounds) gained at 32.5 weeks
However, not all women desired weight-related postpartum counseling, especially before giving birth. Some said that they feared it might cause counterproductive anticipatory anxiety about the postpartum period, and that they would prefer to address the issue when the time came (though with perhaps a misguided sense of the frequency of seeing the obstetrician postpartum).
[I don't want weight loss advice] right now. I'll see [my obstetrician] postpartum frequently enough when we get there. I [think] that if he would have said something to me today about, 'well, have you thought about postpartum weight?' I probably would have smacked him. – Patient, pre-pregnancy BMI 28.8, 15.0 kg (33 pounds) gained at 38 weeks
With rare exception, women said they were happy with the obstetric care and counseling they had received. Most said their obstetrician allowed them to raise issues that are of concern, rather than providing information about all possible concerns. Many women appreciated this approach because they feared that too much information about potential problems could lead them to worry unnecessarily, and they trusted that their doctors would alert them to serious problems.
I feel [my obstetrician is] really approachable if I had any questions that I certainly could ask her…And I think too she's good at not -- she doesn't bring up too many extra concerns. I think that's reassuring to me. – Patient, pre-pregnancy BMI 23.7, 7.7 kg (17 pounds) gained at 31.5 weeks
A few women said that while they were happy with their obstetrician's care overall, they would have preferred that their doctor raise issues without waiting for them to ask questions, such as the purpose of GWG, especially since the weight of a newborn constitutes only a fraction of that weight gain. Another woman suggested that obstetricians should perhaps be more forthcoming about the appropriateness of their weight gain and about specific nutrition advice.
I was just amazed that when I came in for my very first time pregnancy, the doctor doesn't say, 'okay, here's what you can't eat, here's what you can't do, here's what.' Six months into the pregnancy I find out you shouldn't be eating this, or you shouldn't be doing this, and I thought, 'well, someone should have said something if that's really serious for a baby.' – Patient, pre-pregnancy BMI 18.2, 11.8 kg (26 pounds) gained at 37 weeks
I think it would have been beneficial once I started hitting closer to that over the normal range or expected range, for someone to say, 'hey, take a look at what you're doing, you're getting close, let's try to keep your weight down, or in control.' – Patient, pre-pregnancy BMI 23.7, 22.7 kg (50 pounds) gained at 37 weeks
Results
Nineteen patients and seven obstetricians completed interviews. Patient characteristics are presented in Table 4. Patients were diverse with respect to age and race. Patients were nulliparous; two patients had previously experienced miscarriages earlier than 12 weeks gestation and had not experienced GWG prior to their current pregnancy. With the exception of one patient who was carrying twins, patients had singleton pregnancies. Physicians were diverse with respect to sex (3 men, 4 women), years since graduation from medical school (1985–2005), and years on the faculty at the clinic (2–20).
Analysis of transcripts revealed four prominent themes related to patient-provider communication about GWG: (1) communication about the amount and pace of GWG; (2) the content of nutrition and physical activity communication; (3) communication about postpartum weight loss; and (4) patients' feelings about their provider's weight-related counseling.
As previously described, we coded and analyzed obstetrician and patient transcripts separately. In what follows, we report them together (interspersed) by theme, in order to make clear the similarities and differences in the perspectives of the two groups.
Communication About Gestational Weight Gain
Obstetricians generally preferred that their patients gain weight within the guidelines set by the IOM but reported differences in the frequency and timing of their weight-related discussions. Some said they addressed the topic with patients early in the pregnancy so patients would know upfront what to expect, while others reported that they intentionally did not discuss weight at the first few prenatal visits because other topics are more important. One obstetrician said that she discussed weight with every patient at every prenatal visit.
Patients reported that weight did not seem like a high priority for their obstetricians during prenatal visits. Most women said that their doctors talked to them early in their pregnancy, most often at their first appointment, about how much weight they should expect to gain, but that weight was not a focus of subsequent appointments. A few patients speculated that doctors might avoid the topic because they assume it is uncomfortable for women, or that doctors would address weight gain if it became a serious problem.
[There was] not much conversation nutrition-wise, weight-wise. And by not much, I guess not any…Maybe it's because… since I carry the weight well, apparently, I don't look as heavy as I am, even though he's got it in the charts. And they weigh me at every visit…[Maybe he hasn't brought it up] because I haven't gained too much and I haven't put on the 40 pounds, or the 60 pounds, or some of these stories that you hear, and I wasn't morbidly obese. –Patient, pre-pregnancy Body Mass Index (BMI) 30.1, 6.8 kg (15 pounds) gained at 35 weeks
Obstetricians appeared to take patient characteristics into account when they communicated with patients. Obstetricians reported that they might not focus on weight with every patient because they tailor their counseling depending on several factors, including pre-pregnancy BMI (advising women with higher BMIs to gain less weight than women with lower BMIs), the amount of weight the woman has gained, and patients' anxiety about weight gain. For example:
If she's neurotic about it and we're talking about it every visit because she's driving that, it doesn't matter [whether I think we need to discuss it], I'm still gonna have to talk about that. I've still gotta talk her off the ledge each time, whether it's appropriate or inappropriate or whatever it is, we gotta have the conversation. –Obstetrician, Male
When a patient has gained weight within expectations, they do not mention GWG. When weight gain is outside expectations, most doctors said they would open a dialogue with the patient about her nutrition and physical activity. If this conversation satisfies the doctor that the woman's habits are healthy, most doctors will reassure the patient that her weight gain is fine. If this conversation does not, then doctors described taking several different approaches with their patients.
One approach obstetricians described is to offer additional counseling by reviewing what the woman is eating and then identifying areas for improvement. In addition to this counseling, several doctors discussed methods they use to persuade women to moderate their weight gain. One means of persuasion is discussing the complications of pregnancy and childbirth that can arise with excessive weight gain.
The most effective way I know to help them change things is to let them know the baby could be really big. And if the baby gets bigger there's an increased risk the baby won't fit so they would need a caesarean, and depending on their response to that we will go on to the next step, whether it's an increased risk of the shoulder being trapped and the baby, tiny chance, but real chance, of lifelong disability from it. So I try to slowly ratchet it up if they're clearly not following a good eating plan. –Obstetrician, Male
A second approach obstetricians used to persuade women to moderate their weight gain was to focus on the difficulties of postpartum weight loss for women with high GWG.
I do tell them that if they gain in the recommended range they're most likely to get back to their pre-pregnancy weight. So, I use it kind of as a way to encourage women to not over-gain during a pregnancy. –Obstetrician, Female
Patients' accounts of these encounters were somewhat different. Nearly all women, even those who had gained weight outside the IOM recommendations, said that their doctor had little if anything to say about their weight. When conversations about the amount or pace of weight gain did occur, patients reported that they had prompted the discussion, with doctors rarely raising the subject. Patients said that in these conversations, their doctors reassured them that their weight gain was appropriate. Most women said they were comfortable raising the topic of weight with their doctors, but a few were hesitant about initiating conversations about certain weight-related topics, such as disordered eating habits.
The Content of Advice: Nutrition and Physical Activity
Six of the seven physicians reported that they talk about nutrition with every patient at some point during her pregnancy, generally encouraging women to consume a "healthy diet".
I tell women to stay away from the fatty foods, sugar foods, just the junk food type things. Just to try to eat healthy, but not to worry about the weight gain…there's myths that you're going to have all these cravings for ice cream, craving for all this bad food and it's all fine to eat all this bad food that you never would eat normally. So, [I provide] more counseling that you should still eat a healthy diet. –Obstetrician, Female
In contrast, patients reported that their doctors either offered general advice about eating a "balanced diet" or did not discuss nutrition at all. A few women mentioned handouts about nutrition that they received from the clinic but added that their physicians had not reviewed the material with them. Several expressed surprise that they did not receive counseling about foods that pregnant women should avoid, though most women said they looked into this information on their own.
Five of the seven obstetricians reported that they counsel pregnant women on exercise, but less so than on nutrition. Those that discussed exercise emphasized that activity is a key component of a healthy pregnancy and weight control and focused on walking as a safe and low-impact form of exercise.
As with nutritional advice, a few patients reported that they had received clinic handouts about physical activity but said they had not reviewed the materials with their obstetrician. Others said that they had had general conversations about exercise with their doctors, who encouraged them to continue to be active, especially by walking. Some women reported asking their obstetrician about physical activity. Many women reported that exercise had not been discussed.
Postpartum Weight Management
Obstetricians reported that they generally do not directly advise women on postpartum weight loss, either during pregnancy or during the postpartum period.
I don't say much at all! And I will say that I'm not actually very diligent about checking their weight at their postpartum [visit] either and comparing it. I think sometimes I do, but it's certainly not one of the areas I stress. –Obstetrician, Female
Obstetricians said that postpartum weight loss most often comes up in conversations with patients during discussion of topics that are tangentially related to postpartum weight, such as breastfeeding.
Yet patients discussed several questions and concerns about postpartum weight that they hoped obstetricians would address. Most patients said that they hoped their doctors would give them tips about healthy weight loss and information about the normal timeline for weight loss in the postpartum period, so they could plan and adjust their expectations accordingly. Several women were interested in more specific information about nutrition and appropriate exercise while they were breastfeeding, or advice about when they could safely return to their pre-pregnancy physical activities. Many women expressed general uncertainty about what the post-partum period would be like for their bodies, their moods, and even their relationships with their doctors.
I don't even know what kind of support I'm going to get with postpartum-- like I don't even know if I'm going to see [my obstetrician] or what, so I'm just curious about the kind of the support you get for postpartum weight-loss. You get all of these appointments and everything to talk about when you're pregnant, and I wonder if there's a similar sense of having support afterwards. – Patient, pre-pregnancy BMI 25.1, 14.1 kg (31 pounds) gained at 32.5 weeks
However, not all women desired weight-related postpartum counseling, especially before giving birth. Some said that they feared it might cause counterproductive anticipatory anxiety about the postpartum period, and that they would prefer to address the issue when the time came (though with perhaps a misguided sense of the frequency of seeing the obstetrician postpartum).
[I don't want weight loss advice] right now. I'll see [my obstetrician] postpartum frequently enough when we get there. I [think] that if he would have said something to me today about, 'well, have you thought about postpartum weight?' I probably would have smacked him. – Patient, pre-pregnancy BMI 28.8, 15.0 kg (33 pounds) gained at 38 weeks
Feelings About Obstetrician Advice
With rare exception, women said they were happy with the obstetric care and counseling they had received. Most said their obstetrician allowed them to raise issues that are of concern, rather than providing information about all possible concerns. Many women appreciated this approach because they feared that too much information about potential problems could lead them to worry unnecessarily, and they trusted that their doctors would alert them to serious problems.
I feel [my obstetrician is] really approachable if I had any questions that I certainly could ask her…And I think too she's good at not -- she doesn't bring up too many extra concerns. I think that's reassuring to me. – Patient, pre-pregnancy BMI 23.7, 7.7 kg (17 pounds) gained at 31.5 weeks
A few women said that while they were happy with their obstetrician's care overall, they would have preferred that their doctor raise issues without waiting for them to ask questions, such as the purpose of GWG, especially since the weight of a newborn constitutes only a fraction of that weight gain. Another woman suggested that obstetricians should perhaps be more forthcoming about the appropriateness of their weight gain and about specific nutrition advice.
I was just amazed that when I came in for my very first time pregnancy, the doctor doesn't say, 'okay, here's what you can't eat, here's what you can't do, here's what.' Six months into the pregnancy I find out you shouldn't be eating this, or you shouldn't be doing this, and I thought, 'well, someone should have said something if that's really serious for a baby.' – Patient, pre-pregnancy BMI 18.2, 11.8 kg (26 pounds) gained at 37 weeks
I think it would have been beneficial once I started hitting closer to that over the normal range or expected range, for someone to say, 'hey, take a look at what you're doing, you're getting close, let's try to keep your weight down, or in control.' – Patient, pre-pregnancy BMI 23.7, 22.7 kg (50 pounds) gained at 37 weeks
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