All women were interviewed in late pregnancy. Semi-structured, in-depth interviews based on a topic guide were used to enable a detailed exploration of women's views and experiences using a flexible and responsive approach [ 19 ]. Interviews were audio-recorded at the participant's home, with participant permission, and lasted between minutes.
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The topic guide included the following prompts to elicit participant views and experiences: i what a 'healthy lifestyle' means and its relative relevance for pregnancy; ii physical activity in pregnancy the benefits, barriers and influences ; iii healthy lifestyle interventions in pregnancy and the improvements that could be made.
Data analysis was undertaken using a Framework Approach to manage, describe and explore the original data in relation to the underlying TPB [ 19 ]. The interview transcripts were indexed and mapped on the basis of recurring themes. The synthesised data were examined to identify explanatory accounts, and preliminary typologies were developed [ 19 ]. It is important that researchers reflexively examine their research as "knowledge is produced in specific circumstances and that those circumstances shape it in some way" Rose, , p.
For the research design and analysis phases of the study there were three checks on validity i A topic guide was used to ensure a similar range of topics was discussed with each participant. Although only a small number of interviews were conducted, data saturation i. The findings are presented according to the analytical typologies: i behavioural beliefs and attitudes, ii control beliefs and iii normative beliefs. Participants were aware of, and broadly endorsed, the importance of a 'healthy diet' and 'being physically active' in pregnancy. The antenatal period was often viewed as an opportunity to make positive lifestyle changes:.
And to start making choices which will continue after you're pregnant. However, awareness of needing to adopt a healthy lifestyle during pregnancy was not always enough to initiate behavioural change:. I think people are aware and choose to ignore it. A range of perceived benefits of being physically active during pregnancy were elicited. Regaining pre-pregnancy weight and body shape were the most commonly cited benefits:.
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Other perceived physical benefits of being physically active in pregnancy included an easier pregnancy and labour:. You get through your pregnancy a lot better. And you're supposed to have an easier time giving birth. The more you do You feel better about yourself.
However, perceived benefits of being physically active in pregnancy were only articulated by our study participants in relation to their own health. Specific benefits associated with physical activity for the baby were not mentioned spontaneously i. Indeed some women were concerned that undertaking physical activity during pregnancy may have a harmful effect on their baby:.
That was my main worry. All of study participants appeared relatively unconcerned about weight gain during pregnancy. Weight gain was perceived to be a "natural" and "acceptable" part of being pregnant. For many women, any action to address pregnancy weight gain was deferred to the postnatal period:.
Study participants also tended to feel that healthy eating was more important than being physically active in pregnancy.
They often cited the baby as being the main beneficiary of a healthy diet which was in marked contrast to their views on physical activity described earlier :. Only one participant was classified as an 'activity-emphasiser; she acknowledged the importance of healthy eating but felt physical activity could act as an important 'compensator' to burn off excess intake.
The study participants cited several perceived internal and external barriers to physical activity in pregnancy. Personal health problems associated with pregnancy were the most commonly cited 'internal' barrier to physical activity. Such barriers included sickness, lack of energy, and feeling uncomfortable due to size:. If I feel exhausted I just kind of go with it really, rather than push myself. Other internal barriers associated with physical activity in pregnancy included lack of self-confidence and motivation:.
Work was the most commonly cited external barrier to physical activity. It was perceived to have a negative impact on available time and energy levels, the ability to commit to a regular exercise class, and also meant having to prioritise in relation to other day to day life activities:.
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I didn't have time during the working week to do it. Study participants with children often cited barriers to physical activity which included lack of time, lack of suitable childcare, guilt, and wanting to spend time with their family:. I don't see it as a great sacrifice" Age 33, obese, MP. I don't think there's a huge amount offered.
Other perceived barriers to physical activity mentioned by the study participants included not feeling safe when they were "out and about" in their local neighbourhood especially at nights , the weather, and financial constraints. The study participants often highlighted how they felt they had not had adequate levels of information, support, or advice regarding physical activity in pregnancy:. But there's nothing that's standing out in my head that I can think of at the moment that's provided me with that sort of information or, or that kind of guidance about, about lifestyle or exercise or diet or anything.
Although study participants felt that all health professionals had a responsibility to provide advice and guidance about the benefits or resources available, they generally felt that the midwife was the most appropriate person to provide support and guidance. Typologies developed around the perceived behavioural expectations of midwives emphasised how most of the study participants felt that their midwife had assumed a 'non-advisory' role, i.
No midwives had been perceived to offer an 'active advisory' role, i. Whilst study participants had lacked guidance on physical activity during pregnancy from health professionals they had often been the recipients of lay knowledge and expertise from family members and partners.
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Often such advice was conflicting. For example, some participants had described how their mothers had actively discouraged physical activity, whereas partners were more likely to be sources of encouragement:. Most of the study participants had accessed some form of media-based pregnancy information during their pregnancy e. Some had also read pregnancy books. However, the lifestyle in pregnancy information which had been accessed by the study participants was perceived to be negative, conflicting and impersonal:.
And the information is conflicting This paper has explored views and experiences of physical activity during pregnancy among overweight and obese women. By adopting a combined Subtle Realism and TPB approach we have been able to highlight a range of behavioural, control and normative beliefs which impact on women's intentions to being physically active in pregnancy. These views and experiences should be taken into account when designing interventions to promote increased physical activity during pregnancy.
In interpreting the findings of this study, it is important to acknowledge its limitations. The sample size was small and derived from women who had already participated in a study of physical activity in pregnancy and thus may have already been motivated to maintain a healthy lifestyle. The participants were also relatively well educated with a high level of employment. The findings may therefore not be generalisable to other settings or to women from black and minority ethnic groups since there was only one non-white participant in the sample.
In order to strive for objectivity and neutrality in research it is important to reflect on how bias may creep into the qualitative research and thus threaten validity [ 19 ]. In particular, it is essential to reflect on how the interviewer was "placed" by participants [ 23 ]. The interviewer for this study was a health professional, and someone who was pregnant during the interviews. Whilst the interviewer distanced herself from the role of the 'expert' at the start of each interview, and stressed she was only interested in participant's own beliefs and attitudes stressing there were no right or wrong answers , participant 'placing' may still have influenced the interview dialogue.
In this study validity was maximised by a topic guide being used and two researchers deriving a thematic framework from the data which provided a reliable and trustworthy context for data interpretation. A number of further steps were taken to enhance the validity of the study. A topic guide was used, and interviewing continued until data saturation was achieved although achieving data saturation after only 12 interviews is likely to have been influenced by the homogenous study sample.
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Also, many of the themes which arise from the study are similar to those reported from studies undertaken in other settings. This gives further confidence in the reliability of the findings. The main perceived benefits of being physically active during pregnancy highlighted by this study, were 1 to minimise pregnancy-related weight gain and 2 facilitate a return to pre-pregnancy body weight and shape.
However, beliefs about the potential harm to the baby from physical activity were also evident and specific benefits to the baby were not elicited by the research participants without prompting by the interviewer. The findings also suggest that whilst study participants often advocated the importance of maintaining healthy eating and activity behaviours during pregnancy, healthy eating was generally perceived to be of greater importance, particularly for the baby's health, than physical activity.
These perceptions are likely to be influenced by the information sources that women have access to in pregnancy and the conflicting messages contained within them [ 24 ].
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Participants were often positively motivated towards eating healthily due to the perceived positive effects of a healthy diet on their baby's health and growth. Other studies have also identified the baby as a primary motivator for enhancing nutrition awareness in pregnancy [ 25 , 26 ]. Interventions to promote recommended levels of physical activity in pregnancy need to provide specific information on fetal safety and also stress the potential benefits to the mother.
It is notable that most of the study participants who were interviewed were unconcerned about weight gain during pregnancy. They tended to defer any intention to address pregnancy-related weight gain to the postnatal period. This attitude may reflect the current absence of formal recommendations for pregnancy weight gain in the UK. This is in direct contrast to the US [ 27 ].
Whilst there is strong epidemiological evidence which suggests excessive pregnancy weight gain is associated with adverse outcomes for mother and infant [ 28 ], there is only limited evidence that weight management interventions in pregnancy are effective [ 29 , 30 ]. Thus, there is a need to develop and evaluate new approaches to diet and activity interventions in pregnancy.
And in particular, to establish the relative importance of dietary composition and physical activity levels, as well as weight gain, in determining pregnancy outcome. In relation to control beliefs, study participants highlighted a large number of barriers to participating in physical activity in pregnancy. These included both internal physical and psychological and external work, family, time and environmental barriers. These findings are broadly consistent with other studies [ 13 — 17 ]. Since many of these barriers were perceived to be outside of a women's control, any behaviour change interventions need to support women to find solutions which effectively overcome these barriers.
One approach may be to emphasise practical and feasible strategies, such as building in an activity like walking, into a pregnant women's everyday life routines. Encouraging physical activity, particularly during the second trimester when nausea and fatigue have diminished and women are not constrained by physical size, may also be effective. The exploration of normative beliefs arising from the findings suggests women are influenced by the attitudes of partners, family members and by sources of information in the media, books and website.
Partners were cited as having positive influences in maintaining activity, in contrast to other family members. One of the most important issues arising from this study was the perceived lack of accessible information and advice on the benefits of physical activity during pregnancy. Midwives were viewed as being ideally placed to advise and support women about physical activity in pregnancy.
However, many of the study participants described how their midwives had not given them any advice or guidance on physical activity. It has also been suggested from the findings of previous research that healthcare providers are often reluctant to advise on diet and activity changes during pregnancy [ 31 ]. Little is known about why this is the case.
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