Excessive gestational weight gain (eGWG) for women of any prepregnancy Body Mass Index (BMI) is associated with adverse maternal and infant outcomes, including diabetes, preeclampsia, caesarean section, fetal macrosomia, admission to neonatal nursery, increased risk of postpartum weight retention, and risk of chronic disease for both mother and baby [
Routine weighing of women throughout their pregnancy used to be standard practice. In the first half of the twentieth century weight monitoring was conducted primarily to ensure that patients complied with the then common policy of encouraging weight restriction with target weights considerably lower than today. It was thought that excess weight gain caused preeclampsia, complicated births, and obesity [
Informed by a growing evidence base, international guidelines are increasingly suggesting that assessment and promotion of appropriate gestational weight gain (GWG) should be reintroduced as a part of routine antenatal care for all women [
Routine weighing may help facilitate conversations about weight, enable more appropriate goal setting, and lead to more accurate measurement, and it may reduce GWG for all women. It has been shown that if health practitioners do not raise the issue of weight, women perceive it as not important [
A range of barriers to regularly weighing pregnant women have been reported. Although many health professionals are aware of the adverse consequences of overweight/obesity in pregnancy [
To effect change in the delivery of health care it is necessary for interventions to be targeted to known barriers and designed in accordance with psychological and organisational theory that explains behavioural change. Specifically, interventions should be founded in theory that recognises the context and conditions required for behaviour and practice change to occur in health professionals. Indeed, evidenced-based behaviour change interventions have been shown to be more effective than interventions that are designed around situational or intuitive solutions [
This study was conducted in a large Australian tertiary maternity hospital with approximately 6000 public births/year. Interviews were conducted prior to the introduction of a policy of weighing all pregnant women at every antenatal clinic visit. To investigate barriers and enablers to routine weighing of women during pregnancy at our hospital, this qualitative study explored clinicians’ responses to the proposed introduction of this procedure.
All staff who would potentially provide care for women around gestational weight gain were included in this study. Obstetricians, midwives, and dietitians providing care to pregnant women at the study site were eligible to participate. Staff were informed about the study at routine meetings and via emails sent by managers inviting voluntary participation in focus group interviews. Consent was obtained immediately prior to interviews, which were recorded and transcribed by an external professional service.
An interview topic guide was developed with questions addressing four main areas: current practice; general attitudes to regular weighing; perceived patient factors that would influence weighing; perceived clinician factors that would influence weighing. Each question had a series of prompts to help elicit or expand on responses from interviewees (Table
Interview topic guide.
Question | Prompts |
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Describe the various measurements you undertake during an antenatal clinic visit. | (i) Specifically what measurements do you undertake concerning weight and calculating BMI? |
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We are planning on introducing routine weighing for all pregnant women at every antenatal clinic visit. What do you think about this? | (i) Are there practical obstacles you think might make regular weighing difficult? |
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What patient factors influence whether they will be weighed in the antenatal clinic? | (i) Does the woman’s baseline weight influence whether you will weigh a woman? |
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What clinician factors influence whether they will be weighed in the antenatal clinic? | (i) Some studies have found that overweight clinicians find it more difficult to counsel patients about weight. Do you think a clinician’s weight effects their likelihood to weigh women? |
The hospital Human Research Ethics Committee reviewed and approved the study. Interviews were conducted from May to September 2015. Two authors (Tim Hasted and Shelley A. Wilkinson) independently coded the transcripts to extract key themes [
Forty-four staff participated in four separate group interviews: 16 hospital staff midwives; 12 midwifery group practice (MGP) midwives; two dietitians; and 14 medical staff, comprising obstetric registrars and consultant obstetricians.
In addition to reporting on current weighing practices, four main themes were identified from the interviews, including (1) Systems and Resources; (2) Patient and Clinician’s Personal Characteristics; (3) Advantages and Disadvantages of Routine Weighing; and (4) Evidence for Routine Weighing and Interventions.
The interviews identified wide variation in current practice. Both dietitians reported weighing all women at every visit. Some doctors reported almost never weighing women while others weighed only demonstrably obese patients. Midwives based in the hospital antenatal clinic reported varying practices, from weighing all women to rarely weighing any woman but always weighing if they were concerned about whether women were gaining appropriate weight. MGP midwives reported recording weight only at the booking in visit. When asked to assess the number of women individual clinicians had weighed in their last clinic session, dietitians had weighed all women; most midwives had weighed a minority or none. With the exception of one doctor who had weighed one woman, doctors did not record the weights of women booked into their clinics.
The following three subthemes were identified: (i) available resources; (ii) standardising and normalising the process; and (iii) documentation.
Available resources concerned clinicians’ access to weighing scales, the use of a hospital-developed weight tracker, and the availability of dietitians to receive referrals.
All groups interviewed identified a lack of calibrated scales as an impediment to weighing all patients at every visit:
Hospital staff (dietitians, clinic midwives, and doctors) also commented on the lack of privacy, as the scales were in a highly visible and busy location alongside the reception counter:
All staff groups suggested that placing scales in all clinic rooms would make routine weighing easier.
The MGP midwives objected to carrying scales with them to appointments on the ground that they were too heavy/bulky and issues concerned with maintaining accurate calibration:
All staff groups volunteered opinions about the hospital’s Personalised Pregnancy Weight Tracker [
However some ANC midwives felt it easier if it had already been explained:
This was reinforced by the dietitians, who reported that some women they see had been given a weight tracker but not been told how to use it.
Midwives and doctors all expressed concerns about not usually having their first contact with women until well into the second trimester, by which time clinicians had
All groups discussed the need for appropriate follow-up if women were going to be weighed at every visit. The midwives and doctors stated that it was important to have sufficient numbers of dietitians to whom they could refer women:
Many staff members discussed using a single, agreed upon approach that reinforced the process as routine and did not single out specific (high) BMI women. It was suggested that staff discuss the importance of monitoring weight gain in all women and that this discussion should be documented earlier in pregnancy:
While guidelines can standardise practice, dietitians stated that some maternity staff appeared to be unaware of hospital guidelines and the evidence around weight gain in pregnancy. Indeed as one doctor declared: “
One doctor reflected on the issue of continuity of care and building rapport, stating that it was easier to weigh his private patients rather than these public patients:
It was also thought that the way “weight” and “weighing” is discussed makes it easier to weigh women:
[At other sites it’s an expectation]
Many doctors agreed that they would find it difficult to find the time to weigh women and then discuss excessive weight gain, in addition to the other routine aspects required during a consultation. Furthermore, doctors and midwifery group practice midwives suggested that women could just weigh themselves and inform clinicians at each visit:
The subtheme of documentation highlighted the need to have weights recorded in a systematic way and in a standard place, as well as the benefits of regular recording. This would make it easier to weigh as a reminder would exist and it would be part of the flow of each consultation. Both midwifery groups and the doctors felt that if Matrix (the computerised hospital database) had a prompt or a field that required populating (as is the case for blood pressure, fetal heart rate, and other routine measurements) this would encourage a change in practice towards routine weighing:
Participants were asked if there were characteristics that made weighing women difficult or easier.
Both midwifery groups agreed that it was easier to introduce the topic and to weigh women who were proactive and interested in their own weight gain or who mentioned weight themselves. The hospital staff midwives felt it was more difficult to weigh women who were “in denial,” or if their partners were with them. Doctors reported that women’s anxiety was a barrier to weighing, while dietitians reported that often women with a higher BMI or those who had gained excessive amounts of weight were less likely to want to be weighed, as were those who were self-conscious or “worried about judgment.” However, according to clinicians women generally agree to be weighed with reassurance from the clinician with “
The training that clinicians had received influenced their confidence and attitude in discussing and monitoring weight. Dietitians felt that some clinicians lacked knowledge in monitoring gestational weight gain and one doctor confirmed this:
Another doctor asked,
The ANC midwives also stated that they had limited training in this area, with one midwife stating,
Additionally, one doctor noted they did not raise or pursue a discussion around weight due to a concern about the effectiveness of their advice.
All groups discussed staff attitudes; dietitians and MGP midwives stressed the importance of a nonjudgemental approach, although one midwife stated,
Additionally, both midwifery groups mentioned that their own weight influenced their approach around monitoring gestational weight gain: [The/my]
Participants pointed to a number of general advantages and disadvantages to the introduction of a policy of routine weighing.
Dietitians and hospital staff midwives were of the opinion that the practice would normalise weighing and reduce stigma. Staff midwives seemed to generally agree that if routine weighing was approached in the same way as measuring blood pressure, women would come to expect it. One doctor stated that it would allow for opportunistic counselling “
Some staff focussed on the benefit of having recorded weights for future research:
Some clinicians were concerned about the effect of the policy on the patient-practitioner relationship. Both the doctors and MGP midwives felt that women would find the practice intrusive. Doctors were concerned about women being made to feel uncomfortable at their antenatal clinic appointments:
Both dietitians and MGP midwives expressed concern that some patients might respond to closer monitoring of their weight with unhealthy eating habits. One of the dietitians was concerned that some patients might restrict their food intake and in turn “
Doctors were the most vocal group in questioning the evidence behind routinely weighing pregnant women and interventions for women who gained more weight than the recommended guidelines. One doctor stated,
Most doctors agreed that current evidence confirmed that counselling by clinicians did not result in sustained weight loss. One doctor stated,
Both doctors and MGP midwives agreed that while women were once routinely weighed throughout pregnancy, robust evidence to reintroduce the practice was currently lacking:
However, one of the dietitians disagreed, saying that
While many clinicians identified benefits to routine weighing, various challenges need to be addressed in order to successfully implement the process of routine weighing of all women at every antenatal visit.
It is apparent from these results, and as highlighted in the literature, that availability and/or dissemination of guidelines alone do not change practice [
In formulating effective solutions to overcome these barriers (Table
Solutions.
Theoretical domains | Barriers | Solution |
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(i) scales in public places, lack of scales in every room, MGP midwives not having access to scales |
(i) Funding was secured to purchase scales for every ANC room and for MGP midwives |
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(i) lack of knowledge about effects of eGWG, how to counsel women on weight, and what interventions to recommend |
(i) Written materials and guidelines have been circulated and training sessions and workshops will be arranged to update staff on evidence around: the impact of eGWG, how best to approach the issue of weight with women, and interventions that have been shown to result in healthier GWG and better outcomes |
The training content will specifically target the barriers outlined above (knowledge of guidelines, of the evidence regarding interventions, and of available resources and referral pathways within the service) and will be informed by the implementation science literature to facilitate skill development and behaviour change. Our results suggest that staff education about the role of weighing and the evidence for available interventions would need to form part of an implementation strategy for all groups, but particularly doctors and MGP midwives.
The majority of pregnant women engage in low amounts of physical activity and they become increasingly more sedentary as their pregnancy progresses [
While strong evidence in favour of routine weighing is currently lacking, identifying eGWG may guide management and other interventions, for which there is a growing evidence base. The 2015 Cochrane review concluded that “high-quality evidence indicates that diet or exercise, or both, during pregnancy can reduce the risk of excessive GWG” [
This study has a number of limitations. We acknowledge that the use of a group forum for interviews did allow for some robust discussion and it is possible that more outspoken participants prevented contrary opinions and experiences to be raised by others. Nevertheless, the group format did allow for some views to be interrogated or affirmed by others and for a group consensus to form on issues after they had been debated.
We also acknowledge that we had relatively small sample sizes, especially in our dietitian group, although we interviewed 2 of the 3 dietitians working in the service.
Future research could also look at the practices and attitudes of general practitioners, who provide antenatal care for over one-quarter of Australian women and who care for nearly all of our women prior to referral to maternity services and who are therefore critical in any strategy to reduce eGWG.
The impact of the introduction of routine weighing on eGWG and subsequent fetal and maternal outcomes at our hospital will be the subject of another longitudinal study.
While many clinicians support the idea of routine weighing in antenatal clinic, a variety of barriers to its introduction have been identified. Clinicians raised concerns about existing resources, time constraints, and clinician and patient characteristics; clinicians’ knowledge base; and access to evidence-based interventions and follow-up. Implementation strategies at our hospital will be tailored to these specific barriers to ensure all clinicians within the service are supported to be able to deliver evidence-based health care to ensure optimal outcomes for women and their babies.
The authors declare that they have no competing interests.
Funding for this study was provided by the Centre for Translating Research Into Practice, Mater Research Institute, University of Queensland. The authors would like to acknowledge the assistance of A/Prof Vicki Flenady and Ms Aleena Wojcieszek for their advice and guidance, particularly in the design of the project. The authors would also like to thank the midwives, doctors, and dietitians who took part in the study.