Authors: Sophie Relph aff001; Melissa Ong aff002; Matias C. Vieira aff001; Dharmintra Pasupathy aff001; Jane Sandall aff001 Authors place of work: Department of Women and Children’s Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom aff001; Guy’s, King’s and St Thomas’ School of Medical Education, King’s College London, London, United Kingdom aff002 Published in the journal: PLoS ONE 15(1) Category: Research Article doi: https://doi.org/10.1371/journal.pone.0227325
Between 7–35% of the maternity population are obese in high income countries and 1–40% in lower or middle-income countries. Women with obesity are traditionally limited by the choices available to them during pregnancy and birth because of the higher risk of complications. This evidence synthesis set out to summarise how women with obesity’s perceptions of pregnancy and birth risk influence the care choices that they make.
A search of medical and health databases for qualitative studies written in the English language, published Jan 1993—April 2019 and reporting on pregnant women with obesity’s perception of risk and influence of pregnancy and birth choices. Data was extracted by two reviewers onto a questions framework and then analysed using a thematic synthesis technique. Confidence in the qualitative findings was assessed using GRADE-CERQual.
23 full texts were included. The common themes on perception of risk were: ‘Self-blame arising from others’ stereotyped beliefs ‘, ‘Normalisation’, ‘Lack of preparation’, ‘Fearful acceptance and inevitability’ and ‘Baby prioritised over mother’. For influence of choices, the themes were: ‘External influences from personal stresses’, ‘Restrictive guidelines’, ‘Relationship with healthcare professional’ and ‘Perception of Risk’.
Evidence on what influences women with obesity’s pregnancy choices is limited. Further research is needed on the best methods to discuss the risks of pregnancy and birth for women with obesity in a sensitive and acceptable manner and to identify the key influences when women with obesity make choices antenatally and for birth planning.
body mass index – Women's health – Birth – pregnancy – Qualitative studies – obesity – Database searching – Antenatal care
Prevalence estimates of maternal obesity (pre-pregnancy body mass index (BMI) >30kg/m2) vary across high income countries with an estimated 7.1% of the pregnant population having obesity in Poland (the lowest European rate), 21% in the UK and 31.8% in the USA[1, 2]. In lower and middle-income countries, rates of obesity in women of reproductive age vary between 1% in Ethiopia to 39.6% in Egypt[2]. Obesity is associated with adverse outcomes in pregnancy, but a secondary analysis of a large UK study (Birthplace, 2011) found that over 60% of women with obesity but no other comorbidities or complications prior to term labour, had vaginal births without maternal complication or intervention and over 95% had births without neonatal unit admission or perinatal death[3].
The recently published UK Royal College of Obstetricians and Gynaecologists (RCOG) guidance on Care of Women with Obesity in Pregnancy recommends that pregnant women with obesity be integrated into all antenatal clinics, that otherwise low-risk, multiparous, women with obesity can be offered choice of care setting for birth in obstetric or midwifery-led units and that all women should have informed discussions which consider their wishes when planning for labour and birth[4, 5]. Older UK guidance previously advised that women with BMI>35kg/m2 should give birth in consultant-led birthing centres and that women with BMI 30-35kg/m2 should be individually assessed when deciding place of birth[6]. Internationally, neither the International Federation of Gynaecology and Obstetrics, the American College of Obstetricians and Gynaecologists nor the World Health Organisation make recommendations on place of care, lead health professional or maternal choice during pregnancy for women with obesity.
A UK study (2016) examining influences of birthplace choices in healthy women with straightforward pregnancies found that women were influenced by the information that they received, including about the right to choose. Women’s choices were also influenced by previous birth experiences, views of family, friends or healthcare professionals (HCPs) and the women’s beliefs about risk and safety[7]. This was not specific to women with obesity in pregnancy, who are often restricted by the choices of care they are offered.
A qualitative synthesis was conducted which aimed to summarise the current qualitative evidence on how women with obesity’s perceptions of pregnancy and birth risk influence their care choices.
The protocol for this systematic review and thematic synthesis was pre-planned and registered on PROSPERO (reference CRD42018091990)[8]. This study has been reported in line with the recommendations of the ENTREQ statement (Enhancing Transparency in REporting the synthesis of Qualitative research)[9]. The ENTREQ checklist can be viewed in S1 Table.
A comprehensive search was pre-planned using the SPIDER tool (S2 Table)[10] and conducted using the BNI, CINAHL, EMBASE, Medline, Web of Science and Cochrane databases. See S3 Table for the full search terms.
The search was limited to publication year January 1993 - April 2019 and to English language studies. 1993 was chosen because this was the date the UK Changing Childbirth report was published. This recommended that future policy for maternity services be centred around the wants and needs of women[11]. Only primary qualitative research studies were included. Conference abstracts were excluded because of insufficient detail for analysis. Reference lists of review articles were screened for additional relevant papers.
Studies were included if they reported data on perceptions of antenatal and/or labour risks or influences of choices during pregnancy or birth, amongst women with obesity. Studies were excluded if they reported only on the views of healthcare professionals or family members, collected data more than six months postnatally (because of the risk of recall bias) or only described postpartum experiences (e.g. breastfeeding).
Following removal of duplicates, the titles and abstracts were screened against the inclusion and exclusion criteria by SR and MO. The remaining full texts were then screened against the same criteria, and for extractable primary and secondary construct data which answered the following questions:
How do women with obesity perceive obstetric risks and discussions about risks during pregnancy?
What influences the non-lifestyle choices that women with obesity make during pregnancy?
Only quotations or interpretations which were directly inferred from participants with obesity were synthesised, from studies which also included women in other weight ranges.
Study selection was conducted independently by SR and MO, who subsequently agreed the final list. Since the list of included studies was not large (n = 23), a comprehensive sampling strategy involving data extraction from all studies was deemed feasible.
Following an initial familiarisation of the included literature and consultation of the RETREAT guidance for choosing an evidence synthesis methodology[12], we chose to undertake a two-step coding process. First, data was coded onto a question framework (S4 Table). This allowed the data to be sorted into the multiple question components of the review. Following this, a thematic synthesis technique was used to code inductively, describe and analyse the data within the question framework[13].
SR and MO independently generated inductive codes from the primary and secondary data constructs within the ‘Findings’ section of each paper, then met to agree the final codes. SR imported the data and codes onto the pre-agreed framework in NVivo (v12). SR and MO then reviewed the codes within each aspect of the framework, developing descriptive inductive themes. Finally, themes were explored within and across framework components, searching for similarities, conflicts and explanations, and amalgamating the data to produce synthesised findings.
The GRADE-CERQual approach was adopted to assess the level of confidence that the review findings were reasonable representations of the phenomenon of interest [14, 15]. With this approach, each finding is assessed as having no or very minor concerns, minor concerns, moderate concerns or serious concerns for: methodological limitations, the consistency across multiple contexts (coherence), relevance to the review question and adequacy/richness of evidence. For this review, methodological limitations of included primary studies were assessed independently by SR and MO, using the CASP Qualitative checklist[16, 17]. The overall CASP score was then agreed. Studies with serious methodological concerns were then excluded from the study. Following assessment of each component, overall conclusions on the confidence in the evidence (very low, low, moderate or high confidence) are then drawn for each review finding. High confidence was applied to a review finding which had no or only one minor concern regarding the contributory components. Moderate confidence was determined where a review finding had one moderate or more than one minor concerns in the components. An overall rating of low confidence was determined by one component having serious concerns, or the at least two components having moderate concerns. A score of very low confidence was given to study findings which had more than one component with serious concerns.
The 2,226 studies identified from electronic searches and one study identified from handsearching references were screened. After application of the inclusion and exclusion criteria, 23 studies were included in the final review (Fig 1, S5 Table).
The characteristics of the included studies have been summarised in S6 Table. Only seven studies set out to explore either of the questions of this review[18–24]. Most studies set out to document women’s experiences of healthcare when obese and pregnant.
With regards to the CASP-guided methodological appraisal, we have serious concerns regarding the reported methodology of one study[25], moderate concerns regarding three studies[26–28] and minor or no concerns regarding the methodology of the remaining 19 studies[18–20, 23, 24, 29–41]. See S7 Table for further detail on the appraisal of each included study. The study with serious methodological concerns was then excluded from further analysis[25].
The results of the GRADE-CERQual appraisal of each synthesis finding are summarised in Table 1, reported sequentially as they present through the continuum of counselling. S8 Table details the fully explained GRADE-CERQual assessment, including all data which contributed to the findings.
Five major themes were identified to answer the first study questions on how pregnant women with obesity perceive risk during pregnancy. The key findings are summarised in Table 1 and Fig 2. Table 2 lists the types of risks discussed in the included papers.
Women exposed to behaviours arising from stereotyped beliefs of their healthcare professionals, feel blamed and blame themselves for potential risks associated with their obesity. Data to support this finding was from women with all classes of obesity.
Women with obesity perceive that healthcare providers make assumptions about them based on pre-conceived ideas[21, 33]. They feel judged for their weight and are fearful of consultations because of the perceived stigma around being obese [31, 33]. This led to perceived over-inflation of the risk likelihood [18, 30, 31, 33]. In only one study, women believed it was the increased weight which inflated the risk and did not blame the provider’s stigma [35]. As a result of these stereotyped attitudes and perceived judgements, women felt that they were ‘boxed in’ with other women affected by obesity [18, 33, 40], penalised for their weight [33, 34] and blamed for complications which arose [29–31, 33].
Only one woman stated the opposite, because the counselling was “backed up by evidence” [41]. Another woman appreciated being identified within a group, because it made her feel that she was not at fault; risk happened to other women too [29].
Whilst any woman with obesity might have altered perceptions of risk due to the external influence of stereotyped thought, the following three themes refer to distinctly different ways in which women approach risk in pregnancy, which appears to be heavily influenced by the women’s experience of antenatal counselling [29, 32, 33, 37–39].
In the first theme, women are informed of the increased risk of complications but deny the association or try to normalise their weight. Much of this data comes from studies in which the participating women had co-existing gestational diabetes or BMI>40kg/m2. These women attribute obesity-related risks to other aetiology, such as smoking, glucose metabolism, hereditary factors or to supposedly falsified scientific studies in which they don’t believe [21, 27, 33].
Keely (2011) describes how pregnant women with obesity consider risk to be just as likely to happen to them as to any other member of the pregnant population[21]. Some women with obesity justify the belief that their weight does not elevate their risk of complications by referring to the good state of their health, despite their weight[19, 21]. Other women evidence their beliefs by looking to women with uncomplicated pregnancies in their social networks (e.g. friends, family, members of online forums)[21].
Whilst this theme was well-supported, it was not exclusively the case for women who were informed of the risks of pregnancy; some of whom managed this knowledge pragmatically and used it as a motivating factor[35].
It was quite clear from the data that the increased risk of obesity-related pregnancy complications was often avoided by both women and their healthcare professionals [19, 20, 29, 32, 36–38]. This was despite women expecting the risks to be raised when they were counselled in early pregnancy [36, 38]. Discussion was often deferred unless the risks occurred, by which time the women realised it was too late to change their behaviours to improve their outcomes [29]. Women found themselves needing to research potential risks externally, from peers or from the internet [29].
In avoiding the topic of obesity-related risks, healthcare professionals provided women with false reassurance regarding the potential course of their pregnancy [20, 36, 38]. Eventual realisation of the risks, either because of external reading or being presented with the reality of the risks when they arose, caused shock amongst the women [18, 19, 37]. It is important to note that this was not exclusively the case and that there were examples of women who felt they had been adequately counselled in advance and given time to adjust their behaviours to minimise the risk [35].
Many women were aware of the risk of pregnancy and accepted these, but knowledge of the risks caused them to worry or panic, taking away the expected pleasure of pregnancy [19, 27, 31–33, 38, 40]. In some cases, this panic was caused by insensitive counselling led by healthcare professionals[38].
Despite counselling on lifestyle choices which have the potential to minimise pregnancy complications, many women still felt that the risks were either inevitable, or their occurrence was out of their control. This finding was only evident amongst women with BMI>40kg/m2 [21, 23]
This final, smaller theme was discussed by multiple women in several studies. Women often felt forgotten about during the antenatal care, with the health and needs of their baby prioritised over their own [18, 30, 38].
With regards to our second research question–what influences the care choices that pregnant women with obesity make during pregnancy?—only two studies were identified which set out to elicit influencing factors for decision making during women with obesity’s antenatal care [21] and intrapartum care [24]. Nevertheless, women interviewed in several other studies have commented on their influences when making choices during antenatal care and planning their birth wishes. Table 2 lists the types of choices which women felt they were presented with and raised during interviews for the included studies.
Factors within women’s personal and professional lives affected the antenatal choices that they made. Women preferred the convenience of community appointments with flexible timing and closer location. Some women also felt restrained by social and economic stresses e.g. financial concerns, loss of employment or caring for children and older relatives. Similar external pressures also affected women’s ability to make the recommended healthy lifestyle changes for pregnancy, or even to attend their appointments at all [18, 33].
Women perceived guidelines to be restrictive of both their antenatal and birth choices and frequently were the driving influences of decisions that they made [18, 26, 31]. Whilst they did not blame the healthcare professionals for this practice, they did remark that this led to loss of individual assessments and management plans [18, 26].
In most cases, a negative relationship with the HCP prevented women from feeling as if they had a choice in their antenatal care, including forcing them to disengage from routine care [26, 30, 31, 33]. Women were afraid to question decisions made by HCPs, who they felt stigmatised and over-medicalised them [26, 31, 33]. In another example, women felt coerced into making choices which suited the HCPs and were afraid of defying the healthcare professional [31].
Conversely, women who had a positive relationship with their HCP felt empowered by this and trusted in their ability to provide quality antenatal care [18, 26, 31]. Whilst there were examples of women who felt empowered by non-judgemental and supportive relationships with HCPs, there were no direct examples of how this led to them being supported in making choices around labour.
Women’s knowledge regarding current or past risks influences the choices that they made [18–20, 24, 30, 31]. Women who had previously experienced risk expected to have their choices limited in this subsequent pregnancy [31]. Where women were aware of risks, they were afraid of the outcomes and chose what they considered to be the safest route [20, 30]. Where risks were negatively presented, women were more likely to shy away from choices. In some cases, women felt confused about their choices because of contradictory counselling regarding risks [19, 30].
We have reviewed qualitative evidence documenting women with obesity’s perceptions of risk during pregnancy and how this, and other factors, influence the choices they make for antenatal and intrapartum care. With high confidence, we have identified that women feel penalised for their weight by being ‘boxed in’ with other women when counselled about risks and that an insensitive approach to risk-counselling can cause personal blame for potential complications. This association of weight stigma and personal blame is well-established in wider obesity literature [42, 43] and negative treatment and impersonal experience was also noted in a meta-synthesis on maternity experience by Smith et al (2011) [44], although this review did not set out to review how women perceive risks and make choices.
In previous qualitative work on risk perception in pregnancy, the paramount importance of the baby’s safety is common [45–47]. This is also evident as a motivator for lifestyle modifications in pregnancies affected by maternal obesity [35, 40, 48, 49]. On the contrary, with high confidence, we have evidenced the phenomenon, that women with obesity perceive their baby’s safety to overshadow their own psychological and physical wellbeing, leading them to feel neglected [18, 30, 38].
We conject with moderate levels of confidence the nature of counselling received by women with obesity influences their risk perception. Downe et al (2016) also found that the attitudes and behaviours of healthcare professionals were important to pregnant women [50]. Van Wagner (2016) documents the difficulty clinicians face in presenting risk to pregnant women in a balanced manner [51]. The choices that women with obesity make when planning for labour and birth are subsequently influenced by their perception of risk. Coxon et al (2017) similarly found that the choices of healthy women of normal weight were influenced by the views of healthcare professionals and the women’s beliefs about risk[7].
We have also demonstrated that both women with obesity and healthcare professionals avoid discussion regarding complications in pregnancy. This falsely reassures the women and later, causes shock when complications occur. Smith (2011), Johnson (2013) and Jones (2017) have all concluded a similar finding through study of women with obesity or weight management in pregnancy [44, 52, 53] and Carter (2017) noted shock in women at risk of pre-eclampsia, who were not informed of the risk and required inpatient admission following routine antenatal appointments[54]. Unfortunately, the current literature is insufficiently rich to determine whether discussions are avoided because of the immateriality of risk, or the desire to avoid the stigmatising topic of obesity. The difficult balance between fully counselling women to increase awareness of early symptoms or behaviour modifications or causing anxiety regarding complications which may never arise is particularly important in the context of the duty of care to ensure women are fully informed regarding all potential consequences and choices. This is even more apparent in the UK following the Montgomery versus Lanarkshire Health Board court case[55], where Mrs Montgomery successfully won a civil Supreme court case against Lanarkshire Health Board for medical negligence because her obstetrician did not offer her an elective Caesarean section antenatally despite a big baby with a high risk of shoulder dystocia. The clinician did not offer this because they considered the risk of serious damage to the baby to be low and a Caesarean section to not be in the maternal interest. Unfortunately, the complication did arise, and the neonate was later diagnosed with cerebral palsy as a result.
With regards to influences of pregnancy and choices, we conject from the limited data that where women perceive their relationship with the healthcare provider negatively, they feel limited in the choices that they can make, either through fear to speak up or perceived coercion. Previous literature has identified that the way in which risk is framed, including risk where the potential is over-emphasised, may limit perceived choice[53, 56]. We evidenced that women perceive guidelines to be restrictive of their choices and whilst they understand this, they desire more individual assessments and an increase in offered choice. Coxon also argues that a health service facing increasing litigation has pushed clinicians towards strong adherence with guidelines, which affects women by a loss of autonomy[57]. What differs between our work and that of Coxon, is that where women of normal weight can make choices and discuss the influences, women with obesity are unaware of their right to discuss personalised risks and benefits and to make choices. An evaluation of what influences the choices they make is therefore limited.
We set out to include all papers written in the English language, which does make the results less generalisable to countries where English is not primarily spoken—only three included studies arose from such settings, and to low or middle income countries—from which no studies were identified. Whilst two of the key findings were found to be relevant only to women with BMI>40kg/m2, most of the studies included women with any class of obesity. We therefore consider the findings to be generalisable to all pregnant women with obesity in the UK, North America and Australasia, although this should be interpreted with caution in the context of women with obesity and co-existing social or medical risk factors. Since the included studies were conducted using women with obesity attending standard local antenatal care, these findings likely represent the feelings of women interacting with today’s maternity care providers. This may not come as a surprise to some healthcare providers, yet there remains no evidence that style of counselling is changing for the better.
A common limitation of the included studies was that the primary researcher had not documented consideration of their personal bias when conducting the data collection and analysis. We have accounted for this in the GRADE-CERQual assessment of confidence but should also consider the bias of the primary researcher in this evidence synthesis, being an obstetrician with an academic interest in improving individualised care and greater choices for pregnant women with obesity. A thorough search of the included data has yielded very little evidence to refute the idea that women with obesity want more personalised care, and the assistance of a second researcher from a more general background to code the data and develop her own ideas has reduced this potential bias.
The limited data for synthesis was particularly problematic when assessing women with obesity’s influences when making choices during pregnancy and birth. Traditionally in the UK (from where over half of the included studies arose), all women with obesity have been placed into high risk pathways, they therefore have had limited choices. In the light of recent guidance which permits clinicians and women with obesity more flexibility and choice regarding their lead carer and setting in pregnancy[4], further evidence is needed regarding the best methods to inform women with obesity regarding the potential risks of pregnancy in a sensitive and acceptable manner.
Further research should include how pregnant women with obesity respond to counselling and information provided in different formats (e.g. paper literature or mobile phone applications, group versus individual counselling), and by different health professionals. The potential for using decision tools or personalised risk calculators accounting for factors which confer better outcomes to pregnancy and birth is also of interest, enabling personalised and targeted counselling. Separate, robust research should be conducted to evaluate the safety of women with obesity but at otherwise low risk of complications being cared for in lower risk settings (e.g. multiparous women with uncomplicated pregnancy and birth being offered the choice of being cared in community clinics and giving birth in midwifery-led settings), and to identify the key influences when women with obesity make such choices antenatally or for birth planning.
S1 Table [docx] ENTREQ checklist.
S2 Table [docx] Criteria used to define the components in the SPIDER literature search tool.
S3 Table [docx] Full search strategy and terms.
S4 Table [docx] Elements of the data extraction framework.
S5 Table [docx] Papers included and excluded following full text review.
S6 Table [docx] Characteristics of included studies.
S7 Table [docx] CASP Assessment of included studies.
S8 Table [docx] Full details of the GRADE-CERQual assessments.
1. NMPA project team. National Maternity and Perinatal Audit: Clinical Report 2017. 2017.
2. Poston L, Caleyachetty R, Cnattingius S, Corvalan C, Uauy R, Herring S, et al. Preconceptional and maternal obesity: epidemiology and health consequences. Lancet Diabetes Endocrinol. 2016;4(12):1025–36. Epub 2016/10/17. doi: 10.1016/S2213-8587(16)30217-0 27743975.
3. Hollowell J, Pillas D, Rowe R, Linsell L, Knight M, Brocklehurst P. The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study. BJOG. 2014;121(3):343–55. Epub 2013/09/17. doi: 10.1111/1471-0528.12437 24034832.
4. Denison FC, Aedla NR, Keag O, Hor K, Reynolds RM, Milne A, et al. Care of Women with Obesity in Pregnancy: Green-top Guideline No. 72. BJOG. 2019;126(3):e62–e106. Epub 2018/11/23. doi: 10.1111/1471-0528.15386 30465332.
5. NHS Litigation Authority. Clinical Negligence Scheme for Trusts: Maternity Clinical Risk Management Standards. Version 1. London: NHS Litigation Authority, 2013.
6. National Institute for Health and Care Excellence. Intrapartum Care for healthy women and babies. Clinical Guideline CG 190. 2014.
7. Coxon K, Chisholm A, Malouf R, Rowe R, Hollowell J. What influences birth place preferences, choices and decision-making amongst healthy women with straightforward pregnancies in the UK? A qualitative evidence synthesis using a ‘best fit’ framework approach. BMC Pregnancy Childbirth. 2017;17(1):103. Epub 2017/04/01. doi: 10.1186/s12884-017-1279-7 28359258.
8. Relph S. PROSPERO International prospective register of systematic reviews 2018 [cited 2019 21 March]. https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=91990.
9. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ. BMC Med Res Methodol. 2012;12 : 181. Epub 2012/11/29. doi: 10.1186/1471-2288-12-181 23185978.
10. Cooke A, Smith D, Booth A. Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012;22(10):1435–43. Epub 2012/07/26. doi: 10.1177/1049732312452938 22829486.
11. Department of Health. Changing Childbirth: Report of the Expert Maternity Group. London: HMSO, 1993.
12. Booth A, J N, K F, Gerhardus A, Wahlster P, Van der Wilt GJ, et al. Guidance on choosing qualitative evidence synthesis methods for use in health technology assessments of complex interventions. 2016.
13. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8 : 45. Epub 2008/07/12. doi: 10.1186/1471-2288-8-45 18616818.
14. Lewin S, Bohren M, Rashidian A, Munthe-Kaas H, Glenton C, Colvin C, et al. Applying GRADE-CERQual to qualitative evidence synthesis fundings—paper 2: how to make an overall CERQual assessment of confidence and create a Summary of Qualitative Findings table. Implementation Science. 2018;13(Suppl 1).
15. Lewin S, Booth A, Glenton C, Munthe-Kaas H, Rashidian A, Wainwright M, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings: introduction to the series. Implement Sci. 2018;13(Suppl 1):2. Epub 2018/02/01. doi: 10.1186/s13012-017-0688-3 29384079.
16. Critical Appraisal Skills Programme [cited 2018 30 July]. https://casp-uk.net/casp-tools-checklists/.
17. Munthe-Kaas H, Bohren MA, Glenton C, Lewin S, Noyes J, Tuncalp O, et al. Applying GRADE-CERQual to qualitative evidence synthesis findings-paper 3: how to assess methodological limitations. Implement Sci. 2018;13(Suppl 1):9. Epub 2018/02/01. doi: 10.1186/s13012-017-0690-9 29384078.
18. Mills A, Schmied VA, Dahlen HG. ‘Get alongside us’, women’s experiences of being overweight and pregnant in Sydney, Australia. Maternal and Child Nutrition. 2013;9(3):309–21. doi: 10.1111/j.1740-8709.2011.00386.x 22168548
19. Keely A, Gunning M, Denison F. Maternal obesity in pregnancy: Women’s understanding of risks. British Journal of Midwifery. 2011;19(6):364–9.
20. Knight-Agarwal CR, Williams LT, Davis D, Davey R, Shepherd R, Downing A, et al. The perspectives of obese women receiving antenatal care: A qualitative study of women’s experiences. Women and Birth. 2016;29(2):189–95. doi: 10.1016/j.wombi.2015.10.008 26563638
21. Keely A, Cunningham-Burley S, Elliott L, Sandall J, Whittaker A. "If she wants to eat…and eat and eat … fine! It’s gonna feed the baby": Pregnant women and partners’ perceptions and experiences of pregnancy with a BMI > 40 kg/m(2). Midwifery. 2017;49 : 87–94. doi: 10.1016/j.midw.2016.09.016 27756643
22. Sui Z, Turnbull D, Dodd J. Enablers of and barriers to making healthy change during pregnancy in overweight and obese women. Australas Med J. 2013;6(11):565–77. Epub 2013/12/19. 24348873.
23. Denison FC, Weir Z, Carver H, Norman JE, Reynolds RM. Physical activity in pregnant women with Class III obesity: A qualitative exploration of attitudes and behaviours. Midwifery. 2015;31(12):1163–7. Epub 2015/09/15. doi: 10.1016/j.midw.2015.08.006 26365374.
24. Hastings-Tolsma M, Clark L, Nodine P, Teal S. Sterilization Decision Making Among Medically At-Risk Obese Pregnant Women. Qualitative Health Research. 2010;20(6):743–54. doi: 10.1177/1049732310364626 20354238
25. Keenan J, Stapleton H. Bonny babies? Motherhood and nurturing in the age of obesity. Health, Risk & Society. 2010;12(4):369–83.
26. Nyman VM, Prebensen AK, Flensner GE. Obese women’s experiences of encounters with midwives and physicians during pregnancy and childbirth. Midwifery. 2010;26(4):424–9. Epub 2008/12/23. doi: 10.1016/j.midw.2008.10.008 19100667.
27. Kominiarek MA, Gay F, Peacock N. Obesity in Pregnancy: A Qualitative Approach to Inform an Intervention for Patients and Providers. Maternal and Child Health Journal. 2015;19(8):1698–712. doi: 10.1007/s10995-015-1684-3 25652058
28. Khazaezadeh N, Pheasant H, Bewley S, Mohiddin A, Oteng-Ntim E. Using service-users’ views to design a maternal obesity intervention. British Journal of Midwifery. 2011;19(1):49–56.
29. Dinsdale S, Branch K, Cook L, Shucksmith J. "As soon as you’ve had the baby that’s it…" a qualitative study of 24 postnatal women on their experience of maternal obesity care pathways. BMC Public Health. 2016;16 : 625. Epub 2016/07/28. doi: 10.1186/s12889-016-3289-1 27449265.
30. Furber CM, McGowan L. A qualitative study of the experiences of women who are obese and pregnant in the UK. Midwifery. 2011;27(4):437–44. Epub 2010/05/21. doi: 10.1016/j.midw.2010.04.001 20483513.
31. DeJoy SB, Bittner K, Mandel D. A Qualitative Study of the Maternity Care Experiences of Women with Obesity: "More than Just a Number on the Scale". Journal of Midwifery & Womens Health. 2016;61(2):217–23. doi: 10.1111/jmwh.12375 26840998
32. Heslehurst N, Dinsdale S, Brandon H, Johnston C, Summerbell C, Rankin J. Lived experiences of routine antenatal dietetic services among women with obesity: A qualitative phenomenological study. Midwifery. 2017;49 : 47–53. Epub 2016/12/18. doi: 10.1016/j.midw.2016.11.001 27986354.
33. Jarvie R. Lived experiences of women with co-existing BMI>/ = 30 and Gestational Diabetes Mellitus. Midwifery. 2017;49 : 79–86. Epub 2016/12/25. doi: 10.1016/j.midw.2016.12.009 28011058.
34. Furness PJ, McSeveny K, Arden MA, Garland C, Dearden AM, Soltani H. Maternal obesity support services: a qualitative study of the perspectives of women and midwives. Bmc Pregnancy and Childbirth. 2011;11. doi: 10.1186/1471-2393-11-69 21982306
35. Sui Z, Turnbull DA, Dodd JM. Overweight and Obese Women’s Perceptions About Making Healthy Change During Pregnancy: A Mixed Method Study. Maternal and Child Health Journal. 2013;17(10):1879–87. doi: 10.1007/s10995-012-1211-8 23263891
36. Lavender T, Smith DM. Seeing it through their eyes: a qualitative study of the pregnancy experiences of women with a body mass index of 30 or more. Health Expectations. 2016;19(2):222–33. doi: 10.1111/hex.12339 25601510
37. Lindhardt CL, Rubak S, Mogensen O, Lamont RF, Joergensen JS. The experience of pregnant women with a body mass index > 30 kg/m(2) of their encounters with healthcare professionals. Acta Obstetricia Et Gynecologica Scandinavica. 2013;92(9):1101–7. doi: 10.1111/aogs.12186 23710944
38. Atkinson S, McNamara PM. Unconscious collusion: An interpretative phenomenological analysis of the maternity care experiences of women with obesity (BMI > = 30 kg/m(2)). Midwifery. 2017;49 : 54–64. doi: 10.1016/j.midw.2016.12.008 28069317
39. Holton S, East C, Fisher J. Weight management during pregnancy: a qualitative study of women’s and care providers’ experiences and perspectives. BMC Pregnancy Childbirth. 2017;17(1):351. Epub 2017/10/13. doi: 10.1186/s12884-017-1538-7 29020931.
40. Heslehurst N, Russell S, Brandon H, Johnston C, Summerbell C, Rankin J. Women’s perspectives are required to inform the development of maternal obesity services: a qualitative study of obese pregnant women’s experiences. Health Expectations. 2015;18(5):969–81. doi: 10.1111/hex.12070 23617245
41. Cunningham J, Endacott R, Gibbons D. Communication with health professionals: The views of pregnant women with a raised BMI. British Journal of Midwifery. 2018;26(9):598–604. doi: 10.12968/bjom.2018.26.9.598
42. Kirk SF, Price SL, Penney TL, Rehman L, Lyons RF, Piccinini-Vallis H, et al. Blame, Shame, and Lack of Support: A Multilevel Study on Obesity Management. Qual Health Res. 2014;24(6):790–800. Epub 2014/04/15. doi: 10.1177/1049732314529667 24728109.
43. Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010;100(6):1019–28. Epub 2010/01/16. doi: 10.2105/AJPH.2009.159491 20075322.
44. Smith D, Lavender T. The maternity experience for women with a body mass index > = 30 kg/m2: a meta-synthesis. Bjog-an International Journal of Obstetrics and Gynaecology. 2011;118(7):779–89. doi: 10.1111/j.1471-0528.2011.02924.x 21385305
45. Chadwick R, Foster D. Negotiating risky bodies: Childbirth and constructions of risk. Health, Risk & Society. 2014;16(1):68–83.
46. Coxon K, Sandall J, Fulop NJ. To what extent are women free to choose where to give birth? How discourses of risk, blame and responsibility influence birth place decisions. Health, Risk & Society. 2013;16(1):51–67. doi: 10.1080/13698575.2013.859231
47. Mitchell M, McClean S. Pregnancy, risk perception and use of complementary and alternative medicine. Health, Risk & Society. 2014;16(1):101–16.
48. Faria-Schutzer DB, Surita FG, Alves VL, Vieira CM, Turato ER. Emotional Experiences of Obese Women with Adequate Gestational Weight Variation: A Qualitative Study. PLoS One. 2015;10(11):e0141879. Epub 2015/11/04. doi: 10.1371/journal.pone.0141879 26529600.
49. Fieril DP, Olsen PF, Glantz D, Premberg DA. Experiences of a lifestyle intervention in obese pregnant women—A qualitative study. Midwifery. 2017;44 : 1–6. Epub 2016/11/20. doi: 10.1016/j.midw.2016.10.011 27863294.
50. Downe S, Finlayson K, Tuncalp, Metin Gulmezoglu A. What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women. BJOG. 2016;123(4):529–39. Epub 2015/12/25. doi: 10.1111/1471-0528.13819 26701735.
51. Van Wagner V. Risk talk: Using evidence without increasing fear. Midwifery. 2016;38 : 21–8. Epub 2016/05/14. doi: 10.1016/j.midw.2016.04.009 27174012.
52. Johnson M, Campbell F, Messina J, Preston L, Buckley Woods H, Goyder E. Weight management during pregnancy: a systematic review of qualitative evidence. Midwifery. 2013;29(12):1287–96. Epub 2013/02/26. doi: 10.1016/j.midw.2012.11.016 23434033.
53. Jones C, Jomeen J. Women with a BMI > = 30 kg/m(2) and their experience of maternity care: A meta ethnographic synthesis. Midwifery. 2017;53 : 87–95. doi: 10.1016/j.midw.2017.07.011 28779644
54. Carter W, Bick D, Mackintosh N, Sandall J. A narrative synthesis of factors that affect women speaking up about early warning signs and symptoms of pre-eclampsia and responses of healthcare staff. BMC Pregnancy Childbirth. 2017;17(1):63. Epub 2017/02/15. doi: 10.1186/s12884-017-1245-4 28193255.
55. Mongomery vs Lanarkshire Health Board, (2015).
56. Coxon K, Homer C, Bisits A, Sandall J, Bick D. Reconceptualising risk in childbirth. Midwifery. 2016;38 : 1–5. Epub 2016/06/18. doi: 10.1016/j.midw.2016.05.012 27313002.
57. Coxon K. Risk in pregnancy and birth: are we talking to ourselves? Health, Risk & Society. 2014;16(6):481–93. doi: 10.1080/13698575.2014.957262
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