Supporting pregnant women to develop healthy eating and physical activity behaviours

Universal care (regardless of maternal weight)

One of the challenges when supporting pregnant women with healthy eating and physical activity is that it can be easy to assume a “healthy weight” means a “healthy diet” (i.e., if someone looks a healthy weight, many of us assume they also eat healthily and are physically active, and there is no need to discuss these behaviours). This is not necessarily the case, however. Women with a healthy weight may not be eating a healthy diet or may be inactive, and women living with obesity may be under nourished and not getting the required nutritional intake (as this 2021 study from Margaret Charnley and colleagues showed).

As a result of these misplaced assumptions, conversations to discuss nutrition and physical activity can be missed and the health of the unborn child may be placed at risk.

It is therefore important midwives, and other practitioners where relevant, integrate discussion of healthy eating and physical activity with all pregnant women (regardless of BMI). Doing so will mean:

• Women living with overweight or obesity do not feel ‘singled out’ for receiving advice and there is less chance of causing offence.
• All women receive advice they need about reliable sources of nutrition for fetal development (see nutrition during pregnancy section) and about appropriate physical activity for their mental and physical health (see physical activity during pregnancy section).

Supporting women pre-conception

The nutrition and physical activity guidance within this module is also relevant pre-conception. If you are supporting women or families who may be planning a second child, try and draw on the information in this module to discuss weight, healthy eating and physical activity when the opportunity arises.

There is emerging evidence to suggest that being moderately physically active may increase chances of becoming pregnant, whereas vigorous physical activity may decrease fertility. Women wishing to conceive are therefore recommended to take part in regular, moderate intensity physical activity (e.g., walking, swimming, cycling where heart rate is raised but talking is still possible).

How to bring the topic of weight, healthy eating and physical activity up

In this module we have outlined the key guidance for pregnant women when it comes to healthy eating, physical activity and optimal gestational weight gain.

Yet, knowing what advice to provide is only half of the challenge. As discussed in the communicating about weight module, many practitioners feel nervous or awkward about raising conversations to do with weight for fear of upsetting people or causing offence. Or perhaps you feel there is not time or capacity within your schedule.

Any change in practice will take time to achieve. Therefore it is important you don’t put pressure on yourself to perfect things overnight, and recognise it may take time before you feel fully able to integrate weight-related conversations with pregnant women into your routine practice.

Try the following steps to facilitate the process:

1. Focus on the health of the child - This is your shared purpose with every pregnant woman. Establishing common ground will help build rapport, and by helping pregnant women understand the ways in which nutrition, physical activity and gestational weight gain can impact on fetal development (and future child health), you are providing them with a meaningful rationale to reflect on their own lifestyle. If you feel fear or discomfort creep in at the thought of raising the topic, remind yourself what a difference a short conversation (if done appropriately) could have on the future health of the child.

2. Integrate weight-related discussion as part of your universal care for pregnant women - Depending on your professional role and current responsibilities, this may be relatively straightforward or it could be a mile away right now.

   A good starting point is to reflect on the following questions (you might find this useful to do together with your team):

   a. How often in your interactions with pregnant women do you discuss nutrition, physical activity or gestational weight gain?
   b. What stops you having these conversations more frequently? What might you be able to do, either on your own or as a team, to overcome these barriers?
   c. Are pregnant women routinely weighed in your service and what conversations do you currently have with women around this? Is this conversation dependent on what the scales say?

   Then work with your team to consider together how you might be able to integrate weight-related discussion across all consultations with pregnant women. For example, is there a routine consultation early on in pregnancy when 5 minutes could be devoted to advice about healthy eating and physical activity?

3. Look out for “organic” opportunities to raise the topic of weight - As well as routine consultations, there may be situations (formal or informal) where weight, heathy eating or physical activity naturally arise during conversation. These situations present “windows of opportunity” to raise the topic of weight within a context relevant at that moment in time, which will likely mean the pregnant woman is interested and may be more motivated to address any advice. The “asking permission” strategy (see communicating about weight module) can provide a useful “in” to these conversations.

   For example, if a pregnant woman happens to mention how busy she’s been all week and how she’s been feeding all her older children takeaways, you might say something like “I notice you mentioned you’ve struggled with your children’s diets this week, would you mind if we talk a little more about eating at home and see if I can support you in any way with that?” If she is open to this discussion, you might then ask if she has previously been given any advice about healthy eating during pregnancy and whether she’d be open to you going through this together.

4. Make use of communication strategies for fostering autonomous motivation (see communicating about weight module) - Just as important as what you say (or arguably more), is how you say it. By using open questions, asking permission, and listening to the pregnant woman’s perspective, you can ensure she feels heard and empower her to take ownership over any changes she chooses to make.

   If you’re weighing the pregnant woman as part of a routine consultation, it may help to have a conversation about healthy eating and physical activity before taking her weight, as this can reduce feelings of being judged and gives you something to refer back to if you then need to have a discussion around optimal gestational weight gain. For example, if she has already mentioned she is consuming a lot of “empty calories” then you observe she is putting on excessive gestational weight, you are able to return to the initial conversation to support her to set a collaborative action plan (see behaviour change technique module).

5. Be mindful of your unconscious biases - We all have unconscious biases and may make judgements without being aware of them. But if we let these judgements go unnoticed it can impact on the service we provide (e.g., the example above when assuming a healthy weight equals a healthy diet therefore not discussing the issue). Try to put your judgements aside and provide a universal service regardless of initial assumptions you may make about a woman’s need, motivation or current lifestyle.

   Approach the consultation from the perspective of the pregnant woman you are trying to help. How does it feel to be her? What might her fears and concerns be and how can you help with these?

   Try the exercise in box A to reflect on your own unconscious biases and how these might impact your practice.

   BOX A – Exploring Unconscious Bias Imagine you meet with each of the pregnant women below (note each description outlines what you can see only). Ask yourself honestly, what assumptions do you make about: Their current diet and physical activity behaviours? Their income? Their suitability as a parent? Their likelihood of following your advice? Then ask yourself: Where do these judgements come from, and do you have any evidence for any of your assumptions? By making these judgements, what effect could this have on the discussions you have with these women about their diet, physical activity and weight behaviours? This may be an uncomfortable activity to do, but for it to be helpful you will need to dig deep and be honest with yourself. There is no requirement to share this with anyone else, but if you’re feeling brave there may be value in doing this activity within a team of close colleagues. If you choose to do this, make sure you establish a safe psychological space by agreeing “rules” at the outset, such as being open and honest, respecting each others’ views and not sharing outside of the group. Jasmine, 16 years, 6 months pregnant – comes in wearing a cropped top, chews gum, speaks with a strong Northern accent. Lorraine, 42 years, 3 months pregnant – comes in wearing a designer coat, and speaks with strong “Queen’s English” accent. Carrying a bottle of water. Ellie, 25 years, 3 months pregnant – comes in with a scruffy looking coat, hair looks unwashed and living with obesity.

6. Help pregnant women feel empowered by focusing on what they “can” do (rather than what they “mustn’t” do) - Dietary advice during pregnancy has commonly been dominated with foods to avoid. Focusing on these aspects can feel quite negative and is of limited use to the pregnant woman’s health and fetal development. Instead focus on what pregnant women can do to include reliable sources of key nutrients within their diets (see nutrition in pregnancy section), and support them to set realistic action plans that fit in with their personal lives.

7. Integrate partners into discussions - Where possible, it can be helpful to involve partners or close family members in discussions about healthy eating, physical activity and gestational weight gain. Partners and family members can provide a “second pair of ears” for absorbing information, and are important sources of both practical and emotional support. Where changes to existing dietary or physical activity habits are required, it can be helpful to approach behaviour change as a whole family, rather than focusing on the mother alone. This will make it easier to put changes into place and may benefit the health of the whole family.

8. Practice - Communication is a skill, and when learning any new skill practice is crucial. We can’t be expected to read what to do one day, and do it perfectly the next. You might start by practising with colleagues who are also doing the HealthyWEY e-learning – this can be particularly useful as it offers a safe environment in which you can offer peer feedback and reflect together.

   When you feel ready, start practicing with pregnant women themselves. Be open with them that you have recently done some training in this area and ask their permission to discuss healthy eating and physical activity with them (this can also be a useful “in” to that difficult conversation!). Ask them how they found it afterwards, and remember it doesn’t need to be perfect. You may be surprised how much this conversation helps the pregnant women you’re working with and how, by showing you’re human too, it enhances their motivation to put your advice into action.

Resources that might help

Talking about nutrition - The British Dietetic Association and World Health Organisation provide some useful fact sheets that practitioners can use to talk through a healthy diet with women who are pregnant, and to check they are eating a balanced diet that includes all four food groups:

• British Dietetic Association, Pregnancy & Diet: Food Fact Sheet
• World Health Organisation, Good Maternal Nutrition: The best start in life

Tommy’s charity provide information about foods and drinks to avoid during pregnancy, including a free guide to download with tips for a healthy diet in pregnancy.

Talking about physical activity – The Department of Health and Social Care have produced an infographic outlining key points regarding physical activity during pregnancy (as part of the UK Chief Medical Officers’ Physical Activity Guidelines, 2019). This can be useful to download/print and use as a visual tool when talking through the guidance with pregnant women:

• UK Chief Medical Officers’ Physical Activity Guidelines (2019) – infographic

The NHS also provide information about exercise in pregnancy, including examples of specific exercises for pregnant women:

• https://www.nhs.uk/pregnancy/keeping-well/exercise/
• https://www.nhs.uk/start4life/pregnancy/exercising-in-pregnancy/

Recognising boundaries

Whilst health and early years practitioners are ideally placed to offer healthy eating advice during and after pregnancy, it is important to highlight that living with underweight or overweight in pregnancy are often highly complex issues and managing such conditions can be challenging.

Midwives and health visitors are part of a multidisciplinary team of expertise and it is important to be aware of when and how to refer women for more specialist support (e.g., dietitian or mental health professional). This is particularly important if there are concerns surrounding mental health, if an eating disorder is suspected or when pregnancy is complicated by a medical condition (e.g., diabetes, coeliac disease, cystic fibrosis or an inborn error of metabolism).

See roles and responsibilities module for further information regarding signs and symptoms to look out for, and development of local referral pathways.

Key messages:

• All pregnant women will benefit from advice about healthy eating, physical activity and gestational weight gain, regardless of Body Mass Index
• To foster motivation for change and ensure conversations are sensitive to women’s needs, it is important to give consideration to how you raise the topic of weight and how this can be integrated within universal practice
• When supporting pregnant women to achieve optimal weight gain, it is important to remain aware of risks linked to eating behaviours, obesity and/or underweight and seek specialist input where required

Quiz

Below is a short quiz to help you evaluate your learning from this module. You may take the quiz as many times as you like.