A Qualitative Study of Factors Affecting Pregnancy Weight Gain
in African American Women
Kara Goodrich•Mary Cregger•Sara Wilcox•
Published online: 22 April 2012
? Springer Science+Business Media, LLC 2012
women are at increased risk for excessive gestational
weight gain (GWG) and postpartum weight retention.
Interventions are needed to promote healthy GWG in this
population; however, research on exercise and nutritional
barriers during pregnancy in African American women is
limited. The objective of this qualitative study is to better
inform intervention messages by eliciting information on
perceptions of appropriate weight gain, barriers to and
enablers of exercise and healthy eating, and other
influences on healthy weight gain during pregnancy in
overweight or obese African American women. In-depth
interviews were conducted with 33 overweight or obese
African American women in Columbia, South Carolina.
(8–23 weeks gestation, n = 10), mid to late pregnancy
(24–36 weeks, n = 15), and early postpartum (6–12 weeks
postpartum, n = 8). Interview questions and data analysis
were informed using a social ecological framework. Over
50 % of women thought they should gain weight in excess
of the range recommended by the Institute of Medicine.
Participants were motivated to exercise for personal health
benefits; however they also cited many barriers to exercise,
including safety concerns for the fetus. Awareness of the
maternal and fetal benefits of healthy eating was high.
Commonly cited barriers to healthy eating include cravings
and availability of unhealthy foods. The majority of women
were motivated to engage in healthy behaviors during
pregnancy. However, the interviews also uncovered a
African Americans and overweight or obese
number of misconceptions and barriers that can serve as
future intervention messages and strategies.
Pregnancy ? Exercise ? Healthy eating ?
Overweight and obesity are major public health concerns.In
the US, 68 % of adults are overweight (body mass index
[BMI] 25–29.9 kg/m2) or obese (BMI C 30 kg/m2) .
Pregnancy is a period where women are at higher risk for
development of overweight or obesity due to postpartum
weight retention . One of the strongest predictors of
postpartum weight retention and long-term obesity is
excessive weight gain during pregnancy [3, 4]. Table 1
contains the Institute of Medicine (IOM) guidelines for
gestational weight gain (GWG) . Up to 50 % of US
women gain weight above the range recommended by the
IOM [6, 7]. Excessive GWG is also associated with an
increasedriskof overweightand obesity in the offspring .
African Americans and overweight or obese women are
at increased risk of excessive GWG [9, 10] and postpartum
weight retention [11–14]. Over 75 % of African American
women of reproductive age are overweight or obese ,
increasing their already high risk for obesity-related
adverse pregnancy outcomes and comorbidities [15–23].
African American women, particularly those who are
financially disadvantaged, face unique barriers to physical
activity and healthy eating. These barriers include unsafe
environments that hinder walking [24–26], lack of physical
activity opportunities [24, 26], food insecurity and limited
accessibility to low cost healthy foods [27–30], and cultural
beliefs regarding diet and physical activity [31, 32].
K. Goodrich (&) ? M. Cregger ? S. Wilcox ? J. Liu
University of South Carolina, 921 Assembly St., Suite 318,
Columbia, SC 29208, USA
Matern Child Health J (2013) 17:432–440
A useful model to conceptualize the complex barriers
faced by this population is the social ecological model .
This theoretical framework considers multiple levels of
influence that impact health behaviors and outcomes,
including: (1) intrapersonal factors (psychological and
biological), (2) interpersonal processes (social network and
support systems), (3) organizational factors (social insti-
tutions), (4) community factors (relationships among
organizations and networks), (5) and public policy (local,
state, and national laws and policies). Ecological models
have been applied to a variety of health behaviors,
including physical activity and healthy eating [34–36].
Guidelines for prenatal care recommend regular physi-
cal activity and a balanced diet to decrease excessive GWG
. Healthy women should get at least 150 min of mod-
erate-intensity aerobic activity per week during pregnancy
. Regular participation in moderate to vigorous physi-
cal activity has been associated with reduced risk for
excessive GWG . However, activity levels tend to
decrease during pregnancy [39, 40]. Excess caloric con-
sumption is also linked with overweight and obesity, and
dietary intake increases during and after pregnancy [41–
43]. Increasing physical activity and controlling dietary
intake are two key factors in reducing the risk of excessive
Research on physical activity and nutritional barriers
during pregnancy in African American women is limited.
The objective of this study is to better inform intervention
messages by eliciting information on perceptions of
appropriate weight gain, barriers to and enablers of exer-
cise and healthy eating, and other influences on healthy
weight gain during pregnancy in overweight or obese
African American women.
The Healthy Weight in Pregnancy and Postpartum (HIPP)
study was designed to develop and test the feasibility of an
intervention for pregnant and postpartum women to pre-
vent excessive GWG and assist with postpartum weight
loss. The project was conducted in two phases, beginning
with in-depth interviews with pregnant or postpartum
overweight or obese African American women (phase 1).
Qualitative analysis of the interviews led to phase 2 of the
research study, or development and implementation of an
intervention. This paper presents findings from phase 1.
Palmetto Health and the University of South Carolina
Institutional Review Boards approved all study protocols.
Participants were recruited during their initial obstetric
(OB) appointment, routine clinic visit, or 6 week post-
partum checkup through an OB-GYN practice associated
with Palmetto Health Richland Hospital or two private
women’s health centers. The inclusion criteria were: (1)
18–39 years old, (2) African American, (3) pre-pregnancy
BMI of 25–40 kg/m2, (4) able to speak and read English,
(5) started prenatal care before 16 weeks gestation, (6)
singleton pregnancy, and (7) not affected by any medical or
physical conditions that prohibit exercise or regular phys-
ical activity. Women were recruited in early to mid-preg-
nancy (8-23 weeks gestation), mid to late pregnancy
(24–36 weeks), and early postpartum (6–12 weeks post-
partum). Medical records were used to determine pre-
pregnancy BMI and gestational age at enrollment.
Semi-structured, in-depth interviews were conducted in
2010–2011. The social ecological model  guided the
prompted to discuss topics at all levels of the social eco-
logical model. The focus of the present paper is to examine
perceptions of appropriate weight gain and barriers, risks,
motivators, and enablers of exercise and healthy eating.
Interviews took place at the participant’s prenatal clinic
or home and lasted between 40 and 90 min. Informed
consent was obtained prior to each interview. Participants
also completed a demographic and background question-
naire. Physical activity was assessed through self-report.
Table 1 2009 Institute of Medicine recommendations for total and rate of weight gain during pregnancy, by pre-pregnancy BMI
BMI (kg/m2)Total weight
gain range (lbs)
Rates of weight gain
2nd and 3rd Trimester
(mean range lbs/week)
28–40 1 (1–1.3)
Normal weight25–351 (0.8–1)
Obese (includes all classes)C30.011–200.5 (0.4–0.6)
aRecommendations for weight gain differ by pre-pregnancy BMI to increase the percentage of women who have appropriate for gestational age
(2.5–4.0 kg) infants 
Matern Child Health J (2013) 17:432–440433
Women were asked if they perform moderate or vigorous
physical activities (MVPA) for at least 10 min at a time,
and if so, how many days per week and total time per day
do they spend in these activities . Participants were
categorized as sedentary (no MVPA in last month),
underactive (some MVPA but \150 min/week), and
meeting recommendations (C150 min/week of MVPA)
[37, 45]. Women were compensated $20 for their partici-
pation. Thirty-three interviews were conducted with preg-
nant (n = 25) and postpartum (n = 8) women.
Interviews were transcribed verbatim by a professional
transcription service. Staff members verified transcripts
against the audio recordings. Transcripts were examined for
key, overarching themes and were coded to indicate gesta-
tional age so themes could be compared across pregnancy
stages. Two investigators independently read and coded two
transcripts and met to compare definitions and codes to
determine if they had similar data interpretations (SW and
MC). Using the method of ‘‘open coding,’’  researchers
reached consensus about each code’s definition and mean-
ing, creating a composite code list. The code list was con-
ceptually organizedby the research team to reflectthe social
ecological model, forming the first codebook draft. The
codebook was entered into QRS NVivo 8 for computer-
assisted qualitative data management. To promote consis-
tency, one researcher coded all manuscripts (KG). A second
investigator experienced in qualitative analyses (SW)
reviewed the work to ensure codes were correctly
applied. The codebook was revised as additional data were
collected. All prior transcripts were recoded to reflect these
Themes are defined as seven or more women addressing a
topic. Trimester is only noted when responses differed by
this variable. Barriers, motivators/benefits, and strategies/
enablers to exercise and healthy eating are reported
reflective of the ecological model. Each level is presented
in the results section only if a theme is present.
All participants (N = 33) were African American and
averaged 25.9 years of age. As shown in Table 2, 69.7 and
30.3 % of the participants were overweight and obese,
respectively. Four women were in the first trimester, 10 in
the second, 11 in the third, and 8 in the postpartum period.
Over 50 % of women were not meeting physical activity
recommendations. Most women were single (72.7 %),
parous (48.5 %), had B12 years of education (60.6 %) and
worked full time (51.5 %).
Table 2 Characteristics of women
CharacteristicnMean ± SD (range)
Pre-pregnancy BMI, kg/m2
3329.0 ± 3.6 (25.0–38.3)
Age at interview, years33 25.9 ± 4.9 (18.3–39.3)
Age at interview
Gestational age at interview
1st Trimester4 12.1
2nd Trimester 1030.3
3rd Trimester11 33.3
Very good14 42.4
Physical activity level
Married/member of unmarried couple824.2
1 Child5 15.2
C2 Children 16 48.5
Out of work824.2
434Matern Child Health J (2013) 17:432–440
Perceptions of Appropriate Weight Gain During
Almost 70 % of participants (n = 22) provided incorrect
estimates of appropriate GWG based on the ranges rec-
ommended by the IOM for their pre-pregnancy BMI, with
9 % reporting too little (n = 3), 54 % reporting too much
(n = 18), and 1 not knowing how much weight to gain.
Safe and Unsafe Exercises
As shown in Table 3, 97 % of women thought that walking
was the safest exercise during pregnancy (n = 32), and
some said they were afraid to try other activities. For
example, one participant said ‘‘0nly one exercise I think is
probably safe for pregnancy is walking. That’s about it,
because like I said I was kind of scared to do other things
or whatever, so I just mainly walk. I don’t know nothing
else that’ll, you know, be safe’’ (Age 27, Overweight).
Women also listed swimming (n = 21), yoga (n = 11),
and biking (n = 10) as safe, relaxing exercises that do not
Many women believed running or jogging was an unsafe
exercise (n = 18) because it would shake the baby. ‘‘I
really don’t think running is that safe ‘cause when you’re
running you’re, you know, bouncing the baby and it’s not
really that good’’ (Age 23, Overweight). Many women who
cited running did not know why it was an unsafe exercise,
but felt it was something they should not do when pregnant.
Other unsafe exercises included lifting heavy objects
(n = 12), sit-ups or crunches (n = 10), and push-ups or
pull-ups (n = 8). Women discussed how these exercises
overly strained the body, possibly inducing miscarriage.
Women were more likely to cite lifting and sit-ups/crun-
ches as unsafe in their first trimester.
Barriers to Exercise
The most commonly cited intrapersonal barrier to exercise
was fatigue, especially in the 1st and 3rd trimesters
(n = 21). Women discussed how they quickly became
fatigued when physically active, losing motivation for
exercise. Participants also mentioned different types of
pain (n = 20), and nausea (n = 18) as barriers. Pain was
more commonly discussed in the 3rd trimester, and inclu-
ded pain of the muscles, joints, stomach, head, and feet.
Laziness was the top cited psychological intrapersonal
barrier (n = 15). ‘‘What else made it hard was I just got
lazy when I first found out I was pregnant—just got so lazy,
didn’t wanna do nothing, and just wanted to sit around,
and that’s it’’ (Age 21, Overweight). An interpersonal
barrier to exercise was lack of childcare support (n = 10).
Women discussed how they could not leave the house to
Table 3 Major themes (N = 33)
Themes (C7 participants)n
Safe exercisesWalking 32
Unsafe exercises Running or jogging18
Lifting heavy objects 12
Sit-ups or crunches10
Push-ups or pull-ups8
Barriers to exercise Fatigue21
Lack of childcare support 10
Risks of exercise Falling13
Premature labor 11
Umbilical cord around baby’s neck7
Motivators and benefits
Limiting pregnancy weight gain 23
Improves maternal health20
Easier labor 19
Postpartum weight loss 17
Support from family/friends13
Strategies and enablers
Living in safe environment 19
Availability of parks11
Support from family 10
Barriers to healthy eatingCravings 22
Availability of fast food 14
Unhealthy food at the workplace 13
Seeing others eat unhealthy foods9
Risks of unhealthy eating Unhealthy baby15
Development of diabetes9
Development of heart disease8
Excessive gestational weight gain7
Motivators and benefits
of healthy eating
Weight control 15
Improves maternal health14
Prevention of chronic diseases 12
Support from family8
Strategies and enablers
to healthy eating
Substituting healthier options12
Availability of grocery stores10
Support from family8
Matern Child Health J (2013) 17:432–440435
exercise because no one was available to watch the chil-
dren. The workplace was commonly cited as an organiza-
tional barrier (n = 10). For example, one woman said that
her job required her ‘‘to sit at a computer all day’’ (Age 27,
Risks of Exercise
The most commonly cited risk of exercise was falling,
particularly during the second trimester (n = 13). You
might—if you run or something, you might trip over
something and fall on your stomach or just fall down and
you can harm the baby (Age 23, Obese). Other perceived
risks included premature labor (n = 11), miscarriage
(n = 10), or having the cord wrap around the baby’s neck
(n = 7). I was told you’re not supposed to reach your arms
over your head and the cord will get wrapped around their
neck or something. So I guess that’s what that is, real
serious (Age 21, Overweight).
Motivators and Benefits of Exercise
Women primarily cited intrapersonal motivators/benefits to
(n = 23). Women also stated that exercise makes them
healthier (n = 20), leads to an easier labor (n = 19), and
contributes to postpartum weight loss (n = 17). Yeah, it’s
more of a mental thing, just thinking that it [exercise] will
make your labor better, make it faster, probably not as
much pain. Of course you’re going to have pain but not as
much pain. Loosen up your muscles and everything like
that, so it’s more of a mental thing than it is a physical
thing (Age 21, Overweight). An interpersonal motivator
was support from family and friends (n = 13). Many
women discussed how they were given verbal encourage-
ment to exercise, while others had family and friends offer
to walk with them.
Strategies and Enablers to Exercise
The most commonly cited intrapersonal enabler to exercise
was enjoyment (n = 14). Family support was cited as an
interpersonal enabler (n = 10). My husband, he would
always encourage me, you want to go outside, you want to
walk? (Age 23, Overweight). Top cited community level
enablers were living in a safe neighborhood (n = 19) and
the availability of parks (n = 11).
Barriers to Healthy Eating
Cravings were the top cited intrapersonal barrier to healthy
eating (n = 22). I’d say mostly the cravings, ‘cause when
you crave stuff it’s like I’ve got to have that taste, so when I
crave things, that’s what makes it hard for me to stay to the
vegetables and the fruits and things. And sometimes I slip
and go get the bag of chips and the stuff and eat them
‘cause I’m craving it (Age 18, Obese). Seeing others eat
unhealthy foods was an interpersonal barrier (n = 9).
Organizational barriers included unhealthy food at the
workplace (n = 13). Some women talked about how
working in a fast food restaurant made it harder to eat
healthy. Others discussed holiday or birthday celebrations,
where unhealthy foods were brought to the workplace.
Availability of fast food restaurants was cited as a com-
munity barrier (n = 14).
Risks of Unhealthy Eating
Having an unhealthy baby was the top cited risk of
unhealthy eating during pregnancy (n = 15). I don’t think
they [the baby] would develop as well as they would if you
were eating healthy, trying to give them all the food groups
(Age 31, Overweight). Some women said unhealthy eating
might cause the baby to be underweight, while others
thought it would cause macrosomia. Other risks included
development of maternal diabetes (n = 9), heart disease
(n = 8), and excessive GWG (n = 9).
Motivators and Benefits of Healthy Eating
Better weight control was one intrapersonal motivator/
benefit to healthy eating discussed by many women,
especially in their 3rd trimester (n = 15). Improved
maternal health (n = 14) and prevention of chronic dis-
eases (n = 12) were commonly discussed. Eight-five per-
cent of women cited having a healthy baby as a top
motivator/benefit of healthy eating (n = 28). So whatever I
can do for him before and even after he gets here, I’m
gonna do it. It’s more so for him, even than it is for me. And
I know I have to take care of myself while he’s in me. I’m
still gonna have to take care of myself while he’s outta me.
You got to lead by example. So I can’t be over here eating
on a big greasy corn dog and expect him to eat his little
green leafy salad (Age 27, Overweight). Family support,
through encouragement of healthy eating, was an inter-
personal motivator (n = 8).
Strategies and Enablers to Healthy Eating
Substituting healthier options (n = 12) and planning ahead
(n = 11) were commonly cited intrapersonal strategies/e-
nablers for healthy eating. I try to eat at home before I go
like places where I don’t really know how the food’s going
to be. I try to either bring my own food, it depends, or try to
eat something at home before I go to other places, so I
won’t be tempted to eat the bad food for me or whatever
436Matern Child Health J (2013) 17:432–440
(Age 18, Obese). Interpersonal factors included family
support (n = 8). Women talked about family buying fruits
and vegetables for the home, and helping with food prep-
aration. A community enabler was the availability of gro-
cery stores with healthy options (n = 10).
Few studies have examined factors influencing GWG in
African American women, a population at risk for over-
weight, obesity, and excessive GWG. Results from this
study could help inform the development of future
interventions in this population. It is notable that the
majority of women we interviewed were motivated to
engage in behaviors that would maximize the likelihood
of a healthy pregnancy. Interventions that emphasize the
benefits of exercise and healthy eating for a healthy
pregnancy and baby are likely to resonate with this
population. However, these interviews also uncovered a
number of misconceptions and barriers that can serve as
intervention targets. The remaining sections highlight our
findings relative to suggested intervention strategies and
Most often, women’s perception of appropriate weight
gain exceeded the range recommended by the IOM .
Lack of healthcare provider advice or advice that is
inconsistent with recommendations has been consistently
reported as a barrier to appropriate GWG [9, 47–51].
During pregnancy, most women have frequent interactions
with their healthcare provider. These interactions may be
an opportune time for providers to assist women in making
positive lifestyle changes that affect GWG. It may be
beneficial to work with providers to ensure that clear,
consistent GWG recommendations are given.
The majority of women (54.5 %) were not meeting
physical activity recommendations for pregnant women
[37, 45]. This is likely an underestimate given self-report
measures are prone to overreporting of physical activity
. Consistent with other findings, women noted their
activity levels decreased with pregnancy [39, 40]. This was
primarily due to intrapersonal factors such as fatigue, pain,
and nausea. These barriers have been commonly cited in
other studies that predominately examined Caucasian
Women feared that exercise may harm their fetus, which
prevented them from engaging in certain activities. Many
participants talked about how exercise could cause the
umbilical cord to wrap about their baby’s neck, a theme
absent in the existing literature. This may be a cultural
belief specific to this population. Interventions should seek
to educate women on safe exercises and expel myths about
Participants also cited numerous factors that moti-
vated them to exercise during pregnancy, including
improvements in their health, easier labor, and postpartum
weight loss. All outcomes were expressed in terms of their
own health; women did not discuss the benefits of exercise
for the fetus. Weir reported similar findings in a sample of
overweight and obese women . Returning to pre-
pregnancy weight, and having an easier pregnancy and
labor were the top cited benefits of exercise. None of the
participants associated benefits with the fetus unless
prompted, perhaps because they thought exercise may
harm the fetus. Interventions should emphasize that exer-
cise during a healthy pregnancy is safe and is associated
with health benefits. For example, exercise throughout
pregnancy may be protective against birth weight extremes
, thereby increasing the probability of an appropriate
for gestational age infant. Maternal exercise may also
provide long-term health benefits in the child by triggering
beneficial adaptations to environmental stressors [59–62].
The primary motivator and benefit of exercise during
pregnancy was limiting weight gain. While studies gener-
ally show that African American women report less pres-
sure to be thin , less dissatisfaction with their weight
[64, 65], and greater acceptance of being overweight [66,
67], these findings are not universal  and African
American women view health as an important reason to
lose weight  and are aware of obesity-related health
risks . Thus, while our study participants may have felt
comfortable with their weight from an aesthetics perspec-
tive, the experience of being pregnant may have led them
to want to control their weight gain for their own health and
the health of their fetus.
Women were motivated to eat a healthy diet during
pregnancy for the health of the baby. Participants cited
improved health, and prevention of chronic diseases.
Although awareness of the benefits of healthy eating was
high, women also cited many barriers, including cravings
and the availability of unhealthy foods. Interventions
should incorporate strategies to help women overcome
barriers to healthy eating. Approaches used in other suc-
cessful behavior change interventions include problem
solving to overcome barriers, identifying and dealing with
eating triggers, self-monitoring, goal setting, and increas-
ing healthy eating opportunities [70–72].
Similar to other studies, intrapersonal factors were most
commonly cited as barriers, motivators and enablers to
exercise and healthy eating [53–55]. This study also
identified the importance of family support as a motivator
and enabler for both exercise and healthy eating. Similarly,
Thornton found that husbands and female relatives were
important sources of support for weight, diet, and exercise
beliefs and behaviors among pregnant Latino women .
Matern Child Health J (2013) 17:432–440 437
As is true in evidence-based behavioral programs in gen-
eral, interventions during pregnancy should help women
identify the type of support they need, who can provide it,
and how they can effectively solicit it [70, 74].
A major strength of this study lies in its qualitative
approach, which allowed women to fully express their
thoughts and experiences. This study was also stratified by
trimester of pregnancy, which allowed us to explore dif-
ferences in findings based upon phase of pregnancy.
Existing research has been predominately limited to highly
educated Caucasian women [53, 54, 56, 57]. This study
helps fill a gap in the existing literature by targeting a high
risk, financially disadvantaged population.
Several study limitations are noted. All women were
recruited from three clinics in Columbia, SC that pre-
dominately serve low-income women. These findings may
not be generalizable to other settings, women of higher
socioeconomic status, or to those of other ethnicities.
However, the interviews were conducted to guide the
development of an intervention for financially disadvan-
taged African American women. The relatively small
sample size (N = 33) may limit the reliability of the
results, however, saturation of barriers and motivators was
quickly reached (i.e., no new themes emerged). Other
qualitative studies of pregnant women have been of com-
parable size [53, 54, 73].
A healthy lifestyle during pregnancy may help control
weight gain and improve pregnancy outcomes. This study
uncovered a number of meaningful barriers and motivators
for exercise and healthy eating that can help guide clinical
practice and subsequent intervention messages and strate-
gies. We found that women lacked knowledge regarding
healthy GWG recommendations. Women were motivated
to exercise for personal health benefits but fear exercise
may harm the fetus. Awareness of the benefits of healthy
eating was high, however women also cited many barriers.
Number R21HD061885 from the Eunice Kennedy Shriver National
Institute of Child Health & Human Development. The content is
solely the responsibility of the authors and does not necessarily rep-
resent the official views of the Eunice Kennedy Shriver National
Institute of Child Health & Human Development or the National
Institutes of Health. We are grateful to the women who took time out
of their busy lives to take part in our interviews. We also thank the
HIPP staff and the staff at the participating clinics for their assistance
with participant recruitment and other study logistics. The study was
supported by award number R21HD061885 from the Eunice Kennedy
Shriver National Institute of Child Health and Human Development.
The research was conducted in accord with prevailing ethical
The project described was supported by Award
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