"What My Doctor Didn't Tell Me": Examining Health Care Provider Advice to Overweight and Obese Pregnant Women on Gestational Weight Gain and Physical Activity.
ABSTRACT Appropriate gestational weight gain (GWG) is vital, as excessive GWG is strongly associated with postpartum weight retention and long-term obesity. How health care providers counsel overweight and obese pregnant women on appropriate GWG and physical activity remains largely unexplored.
We conducted semistructured interviews with overweight and obese women after the birth of their first child to ascertain their experiences with GWG. A grounded theory approach was used to identify themes on provider advice received about GWG and physical activity during pregnancy.
Twenty-four women were included in the analysis. Three themes emerged in discussions regarding provider advice on GWG: 1) Women were advised to gain too much weight or given no recommendation for GWG at all, 2) providers were perceived as being unconcerned about excessive GWG, and 3) women desire and value GWG advice from their providers. On the topic of provider advice on exercise in pregnancy, three themes were identified: 1) Women received limited or no advice on appropriate physical activity during pregnancy, 2) women were advised to be cautious and limit exercise during pregnancy, and 3) women perceived that provider knowledge on appropriate exercise intensity and frequency in pregnancy was limited.
This study suggests that provider advice on GWG and exercise is insufficient and often inappropriate, and thus unlikely to positively influence how overweight and obese women shape goals and expectations in regard to GWG and exercise behaviors. Interventions to help pregnant women attain healthy GWG and adequate physical activity are needed.
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ABSTRACT: The objective of this study was to characterize pregnant women's gestational weight gain (GWG) knowledge and awareness of healthy eating behaviors known to impact GWG. Formative research was conducted including semi-structured individual interviews and focus group interviews. The participants were mostly Caucasian pregnant women (N = 30; Mage = 28 years old) residing in a suburban/rural region of Central Pennsylvania. Descriptive and thematic analyses were used to examine the primary outcomes of GWG and healthy eating knowledge and informational sources. Many women had no knowledge of how much GWG they should gain in pregnancy (42%). Women appeared to have adequate knowledge on foods they should avoid eating during pregnancy. However, one-fourth of women indicated that they did not feel as though they received adequate information from their healthcare provider about the foods they should be eating and how to meet the healthy eating recommendations. Therefore, one-fourth of women reported using non-healthcare provider resources (e.g., magazines, internet) with questionable reliability to obtain healthy eating guidance. These exploratory findings show that pregnant women have some knowledge of the GWG and healthy eating guidelines; however, most women received this information from a non-healthcare provider resource. Focused efforts are needed to educate pregnant women about GWG and healthy eating using accurate and reliable sources andencourage strategies to meet guidelines in an effort to promote healthy GWG.Journal of women's health care. 3.
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ABSTRACT: In Sweden, midwives play prominent supportive role in antenatal care by counselling and promoting healthy lifestyles. This study aimed to explore how Swedish midwives experience the counselling of pregnant women on physical activity, specifically focusing on facilitators and barriers during pregnancy. Also, addressing whether the midwives perceive that their own lifestyle and body shape may influence the content of the counselling they provide.BMC Pregnancy and Childbirth 09/2014; 14(343). · 2.15 Impact Factor
“What My Doctor Didn’t Tell Me”: Examining Health Care Provider Advice
to Overweight and Obese Pregnant Women on Gestational Weight Gain
and Physical Activity
Michael R. Stengel, BSa, Jennifer L. Kraschnewski, MD, MPHb,c, Sandra W. Hwangd,
Kristen H. Kjerulff, MA, PhDc,e, Cynthia H. Chuang, MD, MScb,c,*
aPenn State College of Medicine, Hershey, Pennsylvania
bDivision of General Internal Medicine, Penn State College of Medicine, Hershey, Pennsylvania
cDepartment of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
dCornell University, Ithaca, New York
eDepartment of Obstetrics and Gynecology, Penn State University College of Medicine, Hershey, Pennsylvania
Article history: Received 21 June 2012; Received in revised form 11 September 2012; Accepted 13 September 2012
a b s t r a c t
Background: Appropriate gestational weight gain (GWG) is vital, as excessive GWG is strongly associated with post-
partum weight retention and long-term obesity. How health care providers counsel overweight and obese pregnant
women on appropriate GWG and physical activity remains largely unexplored.
Methods: We conducted semistructured interviews with overweight and obese women after the birth of their first child
to ascertain their experiences with GWG. A grounded theory approach was used to identify themes on provider advice
received about GWG and physical activity during pregnancy.
Results: Twenty-four women were included in the analysis. Three themes emerged in discussions regarding provider
advice on GWG: 1) Women were advised to gain too much weight or given no recommendation for GWG at all, 2)
providers were perceived as being unconcerned about excessive GWG, and 3) women desire and value GWG advice from
their providers. On the topic of provider advice on exercise in pregnancy, three themes were identified: 1) Women
received limited or no advice on appropriate physical activity during pregnancy, 2) women were advised to be cautious
and limit exercise during pregnancy, and 3) women perceived that provider knowledge on appropriate exercise
intensity and frequency in pregnancy was limited.
Conclusions: This study suggests that provider advice on GWG and exercise is insufficient and often inappropriate, and
thus unlikely to positively influence how overweight and obese women shape goals and expectations in regard to GWG
and exercise behaviors. Interventions to help pregnant women attain healthy GWG and adequate physical activity are
Copyright ? 2012 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
The Institute of Medicine (IOM) and National Research
Council’s (NRC) 2009 report titled “Weight Gain During Preg-
nancy” has set the current standard for recommended weight
gain during pregnancy. Excessive gestational weight gain (GWG)
is associated with postpartum weight retention and is a positive
predictor of overweight and obesity after pregnancy (Olson &
Blackwell, 2011; Siega-Riz et al., 2009). Unfortunately, rates of
excessive GWG have been increasing over time, with more than
40% of normal-weight women and 60% of overweight women
exceeding GWG recommendations (Chu, Callaghan, Bish, &
This research was supported by a grant from the Association of Faculty and
Friends, Penn State College of Medicine. Dr. Chuang is supported by the Eunice
Kennedy Shriver National Institute of Child Health and Human Development
(K23 HD051634). Dr. Kraschnewski is supported by the National Center for
Research Resources and the National Center for Advancing Translational
Sciences, National Institutes of Health, through Grant UL1RR033184 and
KL2RR033180. Further, we acknowledge the support of the First Baby Study by
the Eunice Kennedy Shriver National Institute of Child Health & Human Devel-
opment (R01 HD052990). The contents are solely the responsibility of the
authors and do not necessarily represent the official views of the funding
sources. The authors have no financial conflicts of interest to disclose.
* Correspondence to: Cynthia H. Chuang, MD, MSc, 500 University Drive,
H034, Hershey, PA 17033. Phone: 717-531-8161; fax: 717-531-7726.
E-mail address: firstname.lastname@example.org (C.H. Chuang).
1049-3867/$ - see front matter Copyright ? 2012 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.
Women's Health Issues 22-6 (2012) e535–e540
D’Angelo, 2009; Martin et al., 2007). Excessive GWG is particu-
larly concerning for overweight and obese women given their
already increased risk for pregnancy complications (Chu et al.,
2009; IOM & NRC, 2009).
The current IOM/NRC guidelines recommend that women
with normal prepregnancy weight gain 25 to 35 pounds during
pregnancy, whereas overweight and obesewomen are advised to
gain 15 to 25 pounds and 11 to 20 pounds, respectively (IOM &
NRC, 2009). Although the rationale for these GWG guidelines
are well-delineated in the IOM/NRC report, how health care
providers advise pregnant women about GWG goals, and
whether this advice is effective in helping women to gain an
appropriate amount of weight, remains underexplored. Studies
have estimated that between one third and one half of women
received no advice from practitioners on appropriate GWG
(Phelan, Phipps, Abrams, Darroch, Schaffner, & Wing, 2011a;
Stotland et al., 2005). Stotland and colleagues’ qualitative study
revealed that prenatal care providers perceive GWG counseling
to be useless, and generally only approach the topic of GWG
when asked owing to fear of offending or causing stress to the
patient (Stotland et al., 2010). Whether these concerns represent
true barriers or just perceived barriers to GWG counseling is
Pregnancy may present an ideal opportunity to discuss
healthful lifestyle changes givenwomen’s desireto improvetheir
health for the benefit of their baby (Phelan, 2010). Physical
activity during pregnancy can limit excessive GWG and prevent
postpartumweight retention (Phelan, 2010), and thus represents
a behavioral target for providers to counsel pregnant women.
Federal guidelines recommend that pregnant women who are
not already highly active or doing vigorous intensity activity get
at least 150 minutes of moderate intensity aerobic activity
a week during pregnancy. Despite the known safety of physical
activity for most pregnant women and the apparent health
benefits for both mother and fetus (Physical Activity Guidelines
Advisory Committee, 2008), it is unclear whether pregnant
women are advised by their providers on healthy goals for
physical activity during pregnancy.
Excessive GWG is an important contributor to postpartum
weight retention and long-term obesity in women. The GWG
guidelines set forth by the IOM/NRC in 2009 offer prenatal care
providers optimal GWG ranges to counsel their patients about.
However, whether pregnant women are receiving appropriate
advice regarding GWG and physical activity during pregnancy is
unclear. The aim of this qualitative study was to describe the
health care provider advice received during pregnancy on GWG
and exercise in overweight and obese women, and how the
women viewed that advice. Better understanding these issues
will aid in shaping how prenatal care providers should be
advising women on healthy GWG.
Materials and Methods
In summer 2011, we conducted qualitative interviews with
women after the birth of their first child to ascertain their
experiences with GWG. We recruited a convenience sample of
womenwho were active participants of the Penn State First Baby
Study (PI, Kristen Kjerulff). The First Baby Study is an on-going,
longitudinal cohort study of 3,006 nulliparous women aged 18
to 35 recruited during pregnancy and are being followed for 3
years postpartum. Participants of the First Baby Study were
invited to participate in the current qualitative study on GWG.
Interested women were screened by telephone or e-mail to
determine if they met the eligibility criteria of being overweight
(body mass index [BMI] 25.0–29.9 kg/m2) or obese (BMI ? 30.0
kg/m2) before pregnancy, had a singleton pregnancy, and English
speaking. Women were not eligible if their GWG was less than 5
pounds. Telephone interviews were conducted by one of two
investigators (MS, SWH), and took approximately 30 minutes to
complete. Verbal consent was obtained at the start of the tele-
phone interview, which included permission to link their
responses with their First Baby Study data. Each participant
received a $20 gift card for participating in the study. Women
were continuously enrolled until thematic saturation was
reached, with representation of participants who both exceeded
and did not exceed GWG recommendations. This study was
approved by the Institutional Review Board at the Penn State
College of Medicine.
The interview guide consisted of open-ended questions
inquiring about the woman’s experiences with GWG during her
pregnancy. This manuscript reports the results of questions
focused on provider advice received on GWG and physical
activity during pregnancy (Table 1). All interviews were audio-
taped and transcribed bya professional transcription service. We
linked participants with their First Baby Study data in order to
ascertain sociodemographic data, prepregnancy height and
weight, and GWG.
Frequencies for participant characteristics are presented.
Three members of the research team (MS, CHC, JLK) indepen-
dently analyzed each transcript, using a grounded theory
approach to identify themes related to the topics of health care
practitioner advice received about GWG and physical activity
during pregnancy (Corbin & Strauss, 1990). Grounded theory is
a systematic approach to qualitative analysis emphasizing
concept and theory formation that are grounded in empirical
observations in the data. The investigators then jointly decided
on the major themes, for which there was full agreement. Illus-
trative examples of the themes were selected and presented.
Twenty-four women were included in the analysis. The
sample included 12 overweight women and 12 obese women,
with a median BMI of 29.8 kg/m2(range, 25.1–39.2). Eight of the
12 overweight women exceeded recommended GWG (median
GWG for overweight women was 38 lbs; range 16–60) and 9 of
Interview Questions: Provider Advice on GWG and Exercise during Pregnancy
Provider advice on GWG
When you were pregnant, did you receive advice [from your doctor] on
how much weight you should gain during your pregnancy?
Who brought up this discussion? Did you feel comfortable discussing your
weight with your doctor?
Did you use other resources (friends/family, internet, books) to determine
how much weight to gain?
Of the advice you received regarding weight gain, whose advice did you
Did your doctor discuss the risks of gaining too much weight or too little
weight during pregnancy with you? If so, what was discussed?
Provider advice on exercise during pregnancy
Did your doctor talk with you about exercise during pregnancy?
What types of exercise were discussed/recommended?
Did your doctor discuss how much exercise is recommended for pregnant
M.R. Stengel et al. / Women's Health Issues 22-6 (2012) e535–e540
the 12 obese women exceeded recommended GWG (median
GWG for obese women was 33 lbs; range, 7–55). Other partici-
pant characteristics are shown in Table 2.
Provider Advice on GWG
Three major themes emerged in discussions with first time
mothers on GWG advice received from their providers (Table 3).
Women were advised to gain too much weight or given no
recommendation for GWG at all
Out of the 24 women in the study, 9 reported that their
providers did not discuss GWG at all with them. Of the remaining
15 women, 1 was given nonspecific advice “not to gain too
much,” 2 women (who were obese) were advised to gain an
appropriateamount (<20 pounds), and the remaining 12 women
were advised to gain too much weight for their prepregnancy
weight category. The majority of these women were advised to
gain 25 to 35 pounds, which is the recommended GWG for
normal weight women. Of note, some women commented that
the advice they received was appropriate because they believed
themselves to be normal weight. For example, one overweight
woman with excessive GWG said:
They said 25 to 30 pounds, ‘cause that’s the normal weight
gain, considering I was at a healthy weight level tobeginwith.
Although many women did not recall getting specific advice
on GWG at the start of pregnancy, all women reported that their
weight gain was being monitored during their prenatal visits.
However, women received little, if any, feedback regarding
whether their weight gain during pregnancy was healthy or not.
One obese woman with excessive GWG said, “They just took my
weight, and said, ‘Okay, everything looks good.’” One overweight
woman who gained 30 pounds during her pregnancy reported
her obstetrician became concerned when she had “only” gained
10 pounds by the end of the second trimester:
She [didn’t tell me I was gaining] too much weight, because
that was never a factor. She just told me that I needed to start
gaining more. That was all she said, “I need you to start
One obese woman who gained 42 pounds during her preg-
nancy reported that she was concerned about gaining too much
weight, but her provider reassured her that she was not:
I put on a lot of weight toward the end of my pregnancy, and
whenever I went to the doctor, they said it was okay, so I
believed them.. . I was concerned that I was gaining too
much, but the doctor always said it was okay.
Most women received their prenatal care in obstetrical group
practices, so some women in the study reported receiving con-
flicting advice on GWG from different providers in the same
practice. One overweight woman who gained 60 pounds
I received conflicting [advice]. . The one doctor said, “You
don’t wanna gain more than 30 pounds,” and I certainly
gained more than that. And the other doctor kept saying
[about my weight gain], “We know you’re fine; you’re fine.”
Providers were perceived as being unconcerned about excessive
Because many women reported not being counseled about
GWG, they developed the opinion that their health care
providers were notveryconcerned about them gaining too much
weight, or did not think that gaining a lot of weight was worri-
some. For example, one overweight woman with excessive GWG
recalled her doctor saying:
[The doctor said], “Yeah, they tell you to only gain such and
such weight, but as long as you feel healthy, and your baby’s
doing fine, that’s all that matters.”
Other women assumed that if they were gaining too much
weight during pregnancy, their providers would have let them
know if there was a problem:
I went through a period of freaking out [about my weight
gain.] “Oh my gosh, I already don’t really like the weight I’m
at. I don’t wanna gain a bazillion pounds.”. I always just
reliedon the fact that, if [my doctor] thought I was notgaining
appropriately, she would’ve said something.
One obese woman with excessive GWG expressed frustration
because she did not think her provider had been concerned
enough about her GWG, and wanted more guidance about how
to achieve appropriate GWG:
I think just a little more time needs to be spent on [GWG];
a little more time spent talking about, “This is how you would
eat to maintain your weight throughout the pregnancy, and
then the ultimate weight that you’re gaining is..” or “This is
how to combat hunger, or morning sickness, or things like
that.” Whereas, I think most of that information that you
Participant Characteristics (n ¼ 24)
Prepregnancy body mass index category
Gestational weight gain
Exceeded recommended GWG
Did not exceed recommended GWG
Age, yrs, median (range)
Less than college graduate
College graduate or higher
Women were advised to gain too much weight or
given no recommendation for GWG at all
Providers were perceived as being unconcerned
about excessive GWG
Women desire and value GWG advice from their
Women received limited or no advice on appropriate
physical activity during pregnancy
Women were advised to be cautious and limit exercise
Women perceived that provider knowledge on
appropriate exercise intensity and frequency in
pregnancy was limited
Source: IOM & NRC (2009).
M.R. Stengel et al. / Women's Health Issues 22-6 (2012) e535–e540
glean is from people around you, that aren’t necessarily
professionals. I think they need to spend a little bit more time
coaching people through it.
Women desire and value GWG advice from their providers
Women desired advice on GWG from their providers because
they thought it would be the most medically informed and
specifically tailored for them. One obese woman said:
[I valued] my doctor’s [advice on GWG], simply because they
were the ones, I felt, that had more of a medical opinion.. I
would definitely say I looked at their advice a little bit heavier
than everyone else’s.
An overweight woman said:
I thought [my doctor’s advice] was more specifically tailored
to me, in terms of how much weight I should be putting on.
Not surprisingly, women were receiving advice about GWG
from other sources, including books, the Internet, magazines,
family members, and friends who were mothers. Although
women generally expressed interest and desire in discussing
GWG with their providers, womenwould look to other sources if
they either were not getting advice from their practitioners or
the advice was conflicting:
I read stuff on line, [because] the doctor. neversaid anything
I respect [my doctor] very much, but I just knew that not
everything that theyalways say is the only way. and they all
have different opinions and some of them are more lax.. So I
think that’s why I preferred the book.
Although it was uncommon for pregnant women to receive
correct information on appropriate GWG, most women trusted
that their medical care team was leading them in the right
direction. One woman, who was advised to gain more than the
IOM recommendations, said,
As long as your doctor is telling you that you are healthy, I
don’t think it really matters what weight you have gained.
Provider Advice on Exercise
On the topic of provider advice on exercise in pregnancy,
three themes were identified (Table 3).
Women received limited or no advice on appropriate physical
activity during pregnancy
In the 24 interviews, only 10 women could recall having any
discussion at all about exercise with their providers during
pregnancy. When asked if their provider recommended certain
types of exercise, the other women responded, “No.” If women
did receive advice on physical activity during pregnancy, it was
only at the initial prenatal visit and sometimes limited to written
patient education handouts. Many women stated that if there
was any discussion with their provider about exercise, they
initiated this interaction.
Women were advised to be cautious and limit their exercise
Among the 14 (out of 24) women who did discuss exercise
during pregnancy with their providers, the focus of the
providers’ counseling was on being cautious about exercise. Only
4 of thesewomenwereadvisedtocontinue theircurrent levels of
physical activity, while the other 10 were advised to be cautious
and limit their levels of physical activity. One woman stated:
“As long as there wasn’t any kind of contact, or risk of falling.
About riding my bike- one doctor said- that that wasn’t
a good idea, because of the risk of falling, or hitting a rock, or
something, and then falling off the bike and hurting yourself.
Another women said,
[Some]one . at the doctor’s office had mentioned to me that
you have to be careful what type of exercise you’re doing, and
nothing that’s high impact.
No women were advised to increase their physical activity
levels, even though many of the women were sedentary (and all
were overweight or obese) before pregnancy. Thus, this advice
was interpreted to mean that they should not be exercising at all
during pregnancy. One overweight woman stated:
I remember asking at the beginning [of pregnancy]dI was
a little worried because I wasn’t where I wanted to be weight-
wise.dcould I start exercising more? And he had said that if
you haven’t exercised rigorously before, it wasn’t the time to
No women reported being counseled on how much time they
should be spending exercising, or that they should be engaging
in moderate or vigorous intensity exercise, as stated in the
federal guidelines. If women were advised to engage in a specific
type of exercise, it was usually limited to stretching or walking.
Nowomen recalled their providers discussing the health benefits
of exercise during pregnancy.
Women perceived that provider knowledge on appropriate
exercise intensity and frequency in pregnancy was limited
Owing to a lack of concrete recommendations on how much
and what types of exercise to engage in, women did not view
their providers as knowledgeable on the topic. Most women
were aware that having a prenatal exercise routine was in their
best interest, yet, according to the interviews, almost no
providers seemed to know what was appropriate or safe for
a pregnant woman. One overweight woman recalled,
That was one thing that I would say was sad, because no one
could really answer me as to how much I should or shouldn’t
be doing when I was pregnant. And nobody was real good at
[that]. Everyone’s like, ‘Walking’s good. Walking’s good; you
I went by how my body felt, and I did that until the end, but I
don’t think there’s a lot of good, knowledgeable people on
The lack of information being conveyed on exercise was
concerning, even angering, to some women. An upset, obese
woman who had excessive GWG voiced her concern, saying:
My body image is so poor and I’m just mad at myself ‘cause I
gained this much weight, and kind of mad that people didn’t
warn me. I don’t feel like I was warned enough. I don’t
think they educated me enough.
Current guidelines recommend specific GWG targets for
pregnant women based on prepregnancy weight categories
M.R. Stengel et al. / Women's Health Issues 22-6 (2012) e535–e540
Obstetricians and Gynecologists, & March of Dimes Birth Defect
Foundation, 2007). Our data suggest that overweight and obese
women are either not receiving advice about how much weight
they should gain or are being advised to gain too much weight
during pregnancy. Further, women in our study were not
receiving specific counseling on exercise during pregnancy.
Instead, women looked to books, magazines, friends, family, and
the Internet for guidance in navigating the challenges of preg-
nancy. Yet, few women valued these sources as much as they
valued the opinion of their providers, suggesting that provider
advice on GWG and physical activity would be well-received.
Although it was uncommon for many women in our study to
report receiving specific advice on GWG, it was even more
unusual for that advice to be appropriately adjusted for her
prepregnancy weight. Many of the overweight and obese women
in our study reported being told to gain what would be expected
for normal weight women. This message is consistent with
findings from a survey of U.S. obstetricians where only 64%
modified their GWG advice based on a woman’s prepregnancy
weight (Power, Cogswell, & Schulkin, 2006). The reasons behind
why providers may be giving inaccurate advice are unclear, and
are likely multifactorial (Stotland et al., 2010). It may be owing to
providers’ lack of understanding of the risks associated with
excessive weight gain in overweight and obese women during
pregnancy; however, this is unlikely (Stotland et al., 2005). More
likely, providers may find it awkward to acknowledge that the
patient is either overweight or obese in fear of embarrassing the
patient (Stotland et al., 2010). Additionally, providers may not be
calculating the patient’s prepregnancy BMI and identifying the
patient as overweightorobese, and thus notadjusting their GWG
recommendations accordingly. Providers certainly have time
limitations during clinical encounters, which may restrict their
ability to counsel patients on appropriate weight gain and
physical activity, a barrier to counseling frequently found in
primary care clinical settings (Orleans, George, Houpt, & Brodie,
1985; Yarnall, Pollak, Ostbye, Krause, & Michener, 2003). Further,
providers may feel inadequately trained to appropriatelyaddress
weight and physical activity counseling or believe that such
counseling is ineffective (Foster et al., 2003; Stotland, et al., 2010;
Sussman, Williams, Leverence, Gloyd, & Crabtree, 2008). Women
may welcome pregnancy as a time that they are allowed to “eat
for two,” and providers may find themselves reluctant to counsel
Women often reported that their providers did not stress the
importance of appropriate GWG and lacked concern when they
seemed to be gaining a lot of weight. Stotland and colleagues’
qualitative study of prenatal care providers found that some
providers avoided offering GWG counseling for fear of causing
anxiety in the patient (Stotland, et al., 2010). Thus, the providers
employed a “reactive” approach tocounseling patients onweight
gain, that is, waiting for cues from the patient to address the
issue (Stotland, et al., 2010). Such cues are unlikely to come from
women until they have already gained too much weight, at
which point detrimental effects on health may have already
occurred. The women in our study seemed to describe a similar
“reactive” approach, where GWG was not proactively discussed,
but only discussed when the woman brought it up. Although this
“reactive” approach was intended to be a more sensitive
approach by the prenatal care providers in the Stotland study, it
was perceived as a lack of concern by the women in our study. A
lack of counseling on appropriate GWG leaves women to estab-
lish their own expectations for the course of their weight gain
Academyof Pediatrics, AmericanCollegeof
based on their perception of what is acceptable. Waiting for the
patient to bring up the issue is also problematic when over-
weight women do not recognize themselves to be overweight,
which was the casewith severaloverweight women in our study.
Our findings also indicate that most women received insuf-
ficient and inappropriate advice from their providers on exercise
during pregnancy. No women remembered receiving advice on
exercise frequency or duration. Rather than receiving advice on
specific exercise activities and howmuch to do, pregnant women
were more often being advised what not to do. Additionally,
women were advised not to exercise more intensely than before
pregnancydbecause most women were not exercising before
pregnancy, this advice was interpreted to mean that they should
not exercise at all. Unfortunately, this is in conflict with the
federal physical activity guidelines that recommend 150 minutes
per week of moderate intensity exercise in healthy pregnant
women, even in previously sedentary women. According to the
guidelines, pregnant women who were previously engaging in
vigorous intensity aerobic exercise can continue to do so during
pregnancy (Physical Activity Guidelines Advisory Committee,
2008). Physical activity during pregnancy has been found to be
beneficial in limiting GWG (Phelan et al., 2011b). The most
common forms of exercise recommended were stretching and
walkingdeven if advice to do stretching/walking is realized, it
may not be sufficiently intense to constitute “moderate inten-
sity” physical activity as recommended by the federal guidelines.
The main strength of our study is the use of qualitative
methods to explore women’s experiences and their reactions to
provider advice about GWG and exercise during pregnancy that
could not have been obtained in a quantitative survey study. Our
study also has limitations. We recruited a convenience sample of
first-time mothers in Pennsylvania, so our results may not be
generalizable to later order pregnancies or pregnant women’s
experiences in other states. The women in our sample were all
married, highly educated, and nearly all White, so is not repre-
sentative of women of more sociodemographically diverse
backgrounds. Further qualitative and quantitative research on
this topic is needed in larger, more diverse groups of women.
Another potential limitation was that women were interviewed
after their pregnancy, so their responses may have been
susceptible to recall bias.
Implications for Practice
These findings suggest that provider advice during pregnancy
is insufficient and often inappropriate, and thus unlikely to
positively influence how overweight and obese women shape
goals and expectations in regard to GWG and exercise behaviors.
It is necessary for providers to understand women’s prepreg-
nancy BMI and physical activity levels, so that individualized and
accurate advice can be delivered. Simple office-based tools, such
as automated BMI calculators, may help providers to identify
patients as overweight or obese and provide appropriate
preconception counseling for women before pregnancy and
accurate GWG targets for pregnant women. It is common for
pregnant women to be seen for their first prenatal visit when
they are well into the first trimester, when women may already
be on an excessive weight gain trajectory. Whether women
would benefit from earlier prenatal care or educational materials
before the first visit could be explored. Overweight and obese
women need to feel empowered to ask for advice about healthy
GWG and be ensured that they will receive useful, nonjudg-
mental advice. Common misconceptions, such asthe need to “eat
M.R. Stengel et al. / Women's Health Issues 22-6 (2012) e535–e540
for two,” need to be debunked. Interventions are needed that can
inform pregnant women of the importance of healthy GWG and
physical activity during pregnancy, and encourage behavioral
changes that reduce the proportion of overweight and obese
women with excessive GWG. Although some resource-intensive
behavioral interventions for preventing excessive GWG exist
(Mottola et al., 2010; Phelan et al., 2011b; Polley, Wing, & Sims,
2002), effective strategies that can be widely disseminated
without significant cost and clinical burden are needed. Strate-
gies of this type will have significant potential to not only reduce
short-term pregnancy complications, but also reduce the long-
term morbidity that is associated with postpartum weight
retention and chronic overweight and obesity.
American Academy of Pediatrics, American College of Obstetricians and Gyne-
cologists, & March of Dimes Birth Defect Foundation. (2007). Guidelines for
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Michael R. Stengel, BS, is a medical student at the Penn State College of Medicine.
His academic and career interests are in preventive medicine.
Jennifer L. Kraschnewski, MD, MPH, is Assistant Professor of Medicine and Public
Health Sciences at the Penn State College of Medicine. She is a primary care
clinician-investigator with a research focus on weight control interventions.
Sandra W. Hwang is an undergraduate student at Cornell University.
Kristen H. Kjerulff, MA, PhD, is Professor of Public Health Sciences and Obstetrics
and Gynecology at the Penn State College of Medicine and has been conducting
research in women’s health for more than 20 years.
Cynthia H. Chuang, MD, MSc, is Associate Professor of Medicine and Public Health
Sciences at the Penn State College of Medicine. Her research focuses on repro-
ductive health care for women with chronic medical conditions.
M.R. Stengel et al. / Women's Health Issues 22-6 (2012) e535–e540