Background: Obesity (BMI ≥30) during pregnancy is becoming an increasing public health issue and is associated with adverse maternal and perinatal outcomes. Excessive gestational weight gain (GWG) further increases the risks of adverse outcomes. However, lifestyle intervention can help pregnant women with obesity to limit their GWG. This study evaluated whether an antenatal lifestyle intervention programme for pregnant women with obesity, with emphasis on nutrition and physical activity, could influence GWG and maternal and perinatal outcomes. Methods: The intervention was performed in a city in Sweden 2011–2013. The study population was women with BMI ≥30 in early pregnancy who received standard antenatal care and were followed until postpartum check-up. The intervention group (n = 459) was provided with additional support for a healthier lifestyle, including motivational talks with the midwife, food advice, prescriptions of physical activity, walking poles, pedometers, and dietician consultation. The control group was recruited from the same (n = 105) and from a nearby antenatal organisation (n = 790). Results: In the per-protocol population, the intervention group had significantly lower GWG compared with the control group (8.9 ± 6.0 kg vs 11.2 ± 6.9 kg; p = 0.031). The women managed to achieve GWG < 7 kg to a greater extent (37.1% vs. 23.0%; p = 0.036) and also had a significantly lower weight retention at the postpartum check- up (− 0.3 ± 6.0 kg vs. 1.6 ± 6.5 kg; p = 0.019) compared to the first visit. The most commonly used components of the intervention, apart from the extra midwife time, were support from the dietician and retrieval of pedometers. Overall compliance with study procedures, actual numbers of visits with logbook activity, and dietician contact correlated significantly with GWG. There was no statistically significant difference in GWG (10.3 ± 6.1 kg vs. 11.2 ± 6.9 kg) between the intervention and control groups in the intention-to-treat population. Conclusion: Pregnant women with obesity who follow a lifestyle intervention programme in primary health care can limit their weight gain during pregnancy and show less weight retention after pregnancy. This modest intervention can easily be implemented in a primary care setting. Trial registration: The study has been registered at ClinicalTrials.gov, Identifier: NCT03147079. May 10 2017, retrospectively registered. Keywords: Pregnancy, Obesity, Lifestyle intervention, Gestational weight gain * Correspondence: firstname.lastname@example.org Primary Health Care, Research and Development Unit, Närhälsan, Region Västra Götaland, Gothenburg, Sweden Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Haby et al. BMC Obesity (2018) 5:16 Page 2 of 12 Background almost 300,000 pregnancies, showed that a GWG below In line with rising global figures for the general popula- 6 kg in obese women was associated with a lower risk of tion, obesity in relation to pregnancy is becoming an in- adverse maternal and neonatal outcomes . creasing global public health issue. Across Europe, the Programmes are being introduced in antenatal care majority of countries in 2013 had high rates of over- that address obesity to prevent excessive GWG, and weight and obesity in early pregnancy; Scotland showed there has been a tendency towards decreasing GWG in the highest prevalence (48%) and Slovenia the lowest Swedish women with high BMI . Diet, exercise, or (18%), with Sweden in between (38%) . both can reduce the risk of excessive GWG , and Of women assigned to antenatal care in Sweden in diet- and physical activity-based interventions during 2016, 26.6% had overweight (body mass index [BMI] pregnancy reduce GWG and lower the odds of caesarean ≥25) and 14.1% had obesity (BMI ≥30). The prevalence section . On one hand, evidence suggests that exer- was higher in pregnant women with elementary educa- cise is a strong part of controlling GWG , while tion (vs. high school or university) and women born in other studies support interventions based on diet foreign countries . Women with lower education also appearing to be most effective . Behavioural inter- had the largest BMI increase between pregnancies . ventions may be effective in reducing GWG in obese Living in communities with low socioeconomic stan- women during pregnancy, but the variation in interven- dards is associated with higher BMI. Moreover, women tions that have been tested makes comparisons difficult in disadvantaged neighbourhoods are more likely to gain . Evaluations of interventions have yielded mixed re- unhealthy weight, which supports the need for improved sults, and specific characteristics of effective interven- preconception and antenatal care . The well-being of tions are under-reported in the literature . Also, the next generation is at risk, since maternal obesity is a there is a demand for interventions that facilitate posi- significant factor leading to obesity in offspring, with tive future outcomes and decreased negative effects for further negative health consequences [5, 6]. Thus, even the offspring . Routine weighing alone appears not if healthy living habits are the responsibility of the indi- to be effective in reducing GWG, especially in women vidual, potential social and environmental factors in- with obesity [26, 27], and there is thus a demand for im- volved must also be considered, so that children, youth, plementation of evidence-based strategies to enhance and women have the possibility of living healthy lives to healthy lifestyle in routine antenatal care . prevent obesity and its negative consequences . The primary aim of this study was to evaluate whether According to a systematic review of 22 reviews, obesity a structured antenatal lifestyle intervention at primary in pregnancy was associated with increased risk of gesta- care level for pregnant women with obesity can result in tional diabetes, preeclampsia, gestational hypertension, lower mean GWG; a larger proportion of women with a depression, preterm birth, large-for-gestational-age babies, GWG less than the target of 7 kg, a limit used in earlier congenital anomalies, instrumental and caesarean birth, research ; and lower weight at the postnatal check- perinatal death, and surgical site infection . Obesity in up, compared with women receiving standard care. The early pregnancy was a predictor for excessive gestational secondary aims were to study whether the intervention weight gain (GWG)  and excessive GWG per se was a had impact on maternal and child perinatal health out- predictor for postpartum weight retention [8–10]. Exces- comes, and to identify which subcomponents of the sive GWG has been associated with high foetal birth- intervention were favoured by the participants who were weight  and with offspring becoming overweight or successful in limiting GWG. obese in childhood and adolescence [12–14]. In addition, women with excessive GWG were more likely Methods to experience postpartum weight retention and long- The Mighty Mums (MM) project was a standardised term obesity [8, 15], in particular, those with first- programme delivered during regular antenatal care, aim- trimester weight gain . ing to reduce GWG in pregnant women with obesity. To minimise the risks of negative health consequences Results from a pilot study have been described elsewhere of both inadequate and excessive GWG, American . Theories of empowerment , motivational inter- guidelines on limiting GWG have been developed by the viewing (MI) , and person-centred care  inspired Institute of Medicine (IOM) , which are used inter- the individualised approach used in the intervention. nationally. However, these guidelines have not been systematically implemented in Sweden, since a Swedish Study population study showed that if GWG is even lower than the IOM The study, conducted in a city area in western Sweden recommendation, the increased risk of complications for over 3 years (2011–2013), involved 3300 pregnant both woman and offspring can be reduced, especially women with BMI ≥30 at the first visit to the antenatal among women with obesity [18, 19]. The study, with care. Based on the organisation of the antenatal care, the Haby et al. BMC Obesity (2018) 5:16 Page 3 of 12 intervention was conducted in the major part of the city off, and some women having a true BMI of less than 30 with 2500 pregnant women having BMI ≥30. A smaller were included (n = 37, see Table 1). catchment area within the city with 800 pregnant women having BMI ≥30 was assigned as a control area. After informed consent, women enrolled in the inter- Standard antenatal care and the intervention vention group (n = 459) and the control group (n = 105) All women received standard antenatal care. This com- were followed from the first trimester of the pregnancy prised care by a midwife during pregnancy and the post- until postpartum check-up, in registers and during ante- partum visit, usually a total of nine visits to the midwife. natal care. All women’s weights were checked at the first visit, at An adjacent area with 790 pregnant women with BMI weeks 25 and 37, and at the postnatal check-up, accord- ≥30 was added to the control group. Altogether, 1354 ing to the regular antenatal programme. This also in- women were enrolled, 459 in the intervention and 895 cluded referral to the anaesthetic unit for women with in the total control group (Fig. 1). Due to clinical rou- BMI ≥40 for assessment and planning of the upcoming tines and the medical record system, BMI was rounded labour and birth. Fig. 1 Flow chart of women in the study. ITT = intention-to-treat population; PP = per-protocol population. There is some overlap between reasons for exclusion from the PP population in the intervention group Haby et al. BMC Obesity (2018) 5:16 Page 4 of 12 Table 1 Baseline characteristics of participants Variable Intention-to-treat population Per-protocol population Intervention Controls Intervention Control Mean (SD) Mean (SD) Mean (SD) Mean (SD) Median (range) Median (range) Median (range) Median (range) (n = 438) (n = 871) (n = 116) (n = 845) Weeks pregnant at 8.6 (2.5) 7.9 (2.3) 8.3 (2.1) 7.9 (2.3) first pregnancy visit 8.2 (3–20) 7.9 (5–18) 7.9 (4–15) 7.7 (5–18) Age, years 30.9 (5.5) 30.7 (5.1) 30.7 (5.4)30.1 (20.7–47.4) 30.7 (5.1) 30.5 (18.2–47.4) 30.4 (17.6–46.1) 30.3 (17.6–46.1) Weight at first 94.0 (13.9) 93.4 (11.5) 94.1 (14.7) 93.3 (11.3) pregnancy visit, 92.0 (63.0–152.0) 92.0 (69.0–153.0) 91.0 (67.0–152.0) 92.0 (69.0–144.0) transformed to week 15, kg Height at first 165.8 (7.5) 166.4 (6.2) 165.8 (7.2) 166.4 (6.2) pregnancy visit, cm 165.0 (133.0–187.0) 166.0 (148.0–185.0) 165.0 (148.0–180.0) 166.0 (148.0–185.0) n = 437 BMI at first pregnancy visit, 34.1 (4.0) 33.7 (3.2) 34.1 (3.7) 33.6 (3.1) transformed to week 15 33.3 (27.7–57.2) 32.8 (29.7–50.0) 33.1 (29.3–49.6) 32.8 (29.7–47.0) n = 437 n (%) n (%) n (%) n (%) Overweight 28 (6.4) 5 (0.6) 6 (5.2) 5 (0.6) BMI < 30.0 Obese Class I 271 (62.0) 611 (70.1) 74 (63.8) 596 (70.5) BMI 30.0–34.9 Obese Class II 98 (22.4) 210 (24.1) 25 (21.6) 204 (24.1) BMI 35.0–39.9 Obese Class III 40 (9.2) 45 (5.2) 11 (9.5) 40 (4.7) BMI ≥40 Primipara 204 (46.6) 338 (38.8) 63 (54.3) 326 (38.6) Born outside Sweden 131 (29.9) 92 (10.6) 35 (30.2) 89 (10.5) Use of translator 46 (10.5) 17 (2.0) 14 (12.1) 17 (2.0) Education 269 (61.6) 564 (64.8) 68 (58.6) 545 (64.6) ≤12 years Other than 151 (34.5) 194 (22.3) 43 (37.1) 187 (22.2) employed Use of nicotine 33 (7.5) 79 (11.0) 8 (6.9) 77 (11.1) Values represent mean (SD) and median (range) for continuous variables, and n (%) for categorical variables Due to clinical routines, BMI has been rounded off and some women having a true BMI less than 30 have been included, n =37 Below university studies Being subsidised by parental leave, unemployment benefits, student loans, or social security The MM project was designed to function in everyday pregnancy, about 5 min of each appointment with the practice and one of the fundaments was MI . midwife were dedicated to the follow-up of lifestyle. The Women in the intervention group received additional woman’s weight was checked at every appointment, ap- care in the form of motivational talks and personalised proximately 11 check-ups in total, including postpartum counselling on food and physical activity, delivered by check-up. the midwife at two extra appointments, around 30 min Moreover, at one of the first visits to the midwife, food each, during early pregnancy. Based on each participant’s and activity habits were mapped, and a logbook was in- choice, the women were also offered individualised diet- troduced. The woman and the midwife used the logbook ary advice from a dietician, food discussion groups with throughout the pregnancy and at the postpartum check- a dietician, aqua aerobics led by a physiotherapist and a up to register weight and record comments on successes midwife, prescriptions for physical activity, walking and drawbacks as well as enablers and obstacles in man- poles, pedometers, and information about community aging the planned lifestyle changes. With the logbook it health centres offering lifestyle education and lighter ex- was possible for the woman and the midwife to work to- ercise. Apart from the two extra appointments in early gether in partnership with the lifestyle changes, and for Haby et al. BMC Obesity (2018) 5:16 Page 5 of 12 the woman to take responsibility for her choices and included multivariable binary logistic regression for di- adapt the plan to her own capacity. The activities in the chotomous variables, analysis of covariance (ANCOVA) programme were built on the idea that the woman for normally distributed continuous variables, and multi- should be active and take part in all decisions of the variable binary logistic regression for non-normally dis- programme, which is crucial and a cornerstone in tributed continuous variables and ordered categorical person-centred care . variables, respectively. Correlations for adherence to the Before the start of the project, the midwives were intervention were performed using Spearman’s correl- given education about obesity, and about current recom- ation coefficient. mendations on nutrition and physical activity during To address potential lack of adherence to the pregnancy. They were also trained in MI  and how programme, and to the standard antenatal care, to use the logbook. Information on the project and ad- additional analyses were conducted for an identified vice on food and physical activity were available on the per-protocol (PP) population. Women were included antenatal care website for the midwife to use for self- in the PP population if they had registered weight education, and to hand out to women in the interven- and height at first visit to antenatal care and regis- tion. A network with the surrounding community was teredlastweightinpregnancy. Forthe womeninthe formed, and healthcare providers and doulas (coaches intervention, it was furthermore required that they for the woman during pregnancy and labour) were con- hadparticipatedatadefinedminimum level: adher- tacted to find areas for interaction and support. Collab- ence to activities with food and physical activity, with oration was initiated with community health centres. at least level 2 (of 1–4where 1is “not followed” and 4is “followed”), according to at least three (of six Data collection possible) notifications in the logbook. The criteria for Data were collected from the antenatal medical records the intervention group were established before statis- and included country of birth, language, need for inter- tical analyses were performed. A composite variable preter, educational level, employment status, smoking was constructed, indicating the number of activities status, height, weight (as measured in light clothing on a that each woman chose to participate in. digital scale in the antenatal clinic), mode of delivery and the child’s weight and Apgar score (numerical sum- Power calculation mary of the health of the newborn). Information on With 100 women in each group, the power of this study pregnancy complications (gestational hypertension, pre- was 80% for finding a difference between groups of at eclampsia, gestational diabetes) was gathered from the least 1.1 kg at a significance level of 0.05. antenatal record. Data on the intervention were col- lected from the logbook. The weight measured at the Results first antenatal visit was used to calculate baseline BMI. Characteristics of the study participants The information on education was collected from the Descriptive data for the women’s baseline characteristics national maternity health register. are given in Table 1. Significant differences were seen Weight at the first visit to antenatal care was trans- between the intervention group and controls, for the formed to week 15 using data from the national mater- ITT population with regard to country of birth, need of nity health register, if first weight was measured after translator, employment status, and BMI at enrolment, week 15 (n = 11) . For missing data on postpartum and for the PP population, to country of birth, use of weight, stochastic imputation was performed using fully translator, and employment. These variables were con- conditional specifications (FCS) with seed = 4918. GWG trolled for in the statistical analyses. was calculated as the difference between weight at the postpartum check-up and first visit weight. Gestational weight gain Analyses The PP analysis (Table 2) showed that the women in the The main analyses were comparisons between the total intervention group had a significantly lower GWG com- intervention and control groups (intention to treat ana- pared to controls (8.9 ± 6.0 kg vs 11.2 ± 6.9 kg; p = 0.031) lyses, ITT), including all women and adjusted for signifi- (Fig. 2). A significantly larger number of these women cant confounders (p ≤ 0.05), including weeks pregnant at managed GWG < 7 kg (37.1% vs. 23.0%; p = 0.036) first visit, height, country of birth (mother), need of (Fig. 3), and also had a significantly lower weight re- translator, main occupation, and BMI at first visit trans- tention at postpartum check-up (− 0.3 ± 6.0 kg vs. 1.6 formed to 15 weeks of pregnancy. The adjusted mean ±6.5 kg; p = 0.019) (Fig. 2). There were no significant differences, for GWG and secondary outcome variables, differences for variables connected to birth size in the were estimated with 95% confidence intervals. Analyses PP population. Haby et al. BMC Obesity (2018) 5:16 Page 6 of 12 Table 2 Results from the per-protocol and intention-to-treat analyses Variable Intention-to-treat population Per-protocol population Intervention Controls Adjusted Intervention Controls Adjusted a a Mean (SD) Mean (SD) p-value Mean (SD) Mean (SD) p-value Median (range) Median (range) Median (range) Median (range) (n = 438) (n = 871) (n = 116) (n = 845) Week of delivery 39.1 (2.5) 39.8 (2.0) 0.001 39.6 (1.5) 39.8 (2.0) 0.142 40.0 40.0 40.0 40.0 (24–42) (23–42) (36–42) (23–42) n = 429 n = 866 Weight change: 10.3 (6.1) 11.2 (6.9) 0.695 8.9 (6.0) 11.2 (6.9) 0.031 from first pregnancy 10.0 11.0 9.00 11.0 visit to last (−6.0–41.0) (−15.0–46.0) (−6.0–28.0) (−15.0–46.0) pregnancy visit, kg Weight change: 1.4 (6.4) 1.6 (6.5) 0.731 −0.3 (6.0) 1.6 (6.5) 0.019 from first pregnancy 1.0 2.0 −1.0 2.00 visit to postpartum (−19.0–23.0) (−27.0–27.0) (− 17.0–18.0) (−27.0–27.0) check-up, kg Child weight at delivery, g 3591 (594) 3695 (637) 0.037 3603 (505) 3703 (627) 0.300 3605 3705 3515 3705 (830–5430) (418–5760) (2480–5430) (418–5760) n = 420 n = 866 n = 113 n (%) n (%) n (%) n (%) GWG < 7 kg 120 (27.4) 204 (23.4) 0.882 43 (37.1) 194 (23.0) 0.036 Macrosomia 22 (5.0) 77 (8.8) 0.017 5 (4.3) 76 (9.0) 0.172 SGA 34 (7.8) 45 (5.2) 0.196 10 (8.6) 38 (4.5) 0.199 Values represent mean (SD) and median (range) for continuous variables, and n (%) for categorical variables Adjusted for weeks pregnant at enrolment, height at enrolment, country of birth (mother), translator needed, main occupation, and BMI at enrolment transformed to 15 weeks Small for gestational age In the ITT population (Table 2) there was a slightly, Child weight was significantly higher, and macrosomia but not significantly, lower GWG compared to the con- (i.e. birth weight > 4500 g) significantly more common in trol group (10.3 ± 6.1 kg vs. 11.2 ± 6.9 kg) and 27.4% of the control group. women in the intervention group managed to keep Overall, the prevalence of adverse maternal outcomes GWG < 7 kg in comparison with 23.4% among controls. (gestational diabetes, gestational hypertension, and Fig. 2 Change in mothers’ weight during and after pregnancy, by group (PP) Haby et al. BMC Obesity (2018) 5:16 Page 7 of 12 Fig. 3 Gestational weight gain < 7 kg, by group (PP) preeclampsia) and perinatal outcomes (preterm delivery, activities with physical activity (i.e. pedometers, walking intrauterine foetal death, caesarean delivery, Apgar) did poles, and aqua aerobics) did not correlate with GWG. not differ significantly between groups. The logbook gave an idea of which food advice was agreed upon and how it was discussed. Most mid- Adherence to the programme wives gave general food advice from the website, but Maximum attendance (Table 3) implied seven notifica- it was also common to note individual advice in the tions in the logbook, corresponding to seven discussions logbook: “restrict carbohydrates”, “eat regularly”, “cut on the topic with the midwife: one initial visit, five follow- out sweets and sweet drinks”,and more positively, ups throughout the pregnancy, and one at the postpartum “increase fruit and vegetables”, “eat fish”,and “savour check-up. Of the women in the intervention (n = 438), 27. the food”. 2% (n = 119) fulfilled the criterion of adherence to the study protocol, that is, fulfilled the prescribed activities at Discussion level two on at least three follow-ups with the midwife This study shows that an antenatal care programme re- during pregnancy. All extra activities were optional; 39.0% sulted in a significantly lower GWG, significantly lower (n = 170) had contact with the dietician (individually or in weight retention at the postnatal check-up, and signifi- food discussion groups), 34.7% (n = 148) used pedometers, cantly more women being successful in limiting GWG 20.0% (n = 86) used walking poles and 16.9% (n =73) par- to less than 7 kg if they followed the individually ticipated in aqua aerobics. Most women chose to organise planned lifestyle changes. physical activities on their own, and the most common ac- The results from this study are in line with other life- tivity was walking, often on a level of 30 min 5–7days a style studies where effect on GWG has been shown week. The mean number of visits with logbook activity after nutritional advice alone, or in combination with was higher (6.3 ± 0.6) in the PP population than in the advice on physical activity [28, 34–37]. Interesting find- ITT population (4.7 ± 2.3). Dietician counselling and use ings from trials seem to be that the effect of getting in- of walking poles and pedometers as well as participation formation from brochures, seminars, and websites in aqua aerobics were more common in the PP popula- should not be underestimated [35, 37, 38], and that tion, and this group also had a slightly higher score con- more intense interventions do not always give the best cerning the composite variable for all activities (4.3 ± 1.1 results [28, 36]. Oneexplanation maybethatdelivery vs. 3.5 ± 1.7). of objective information in group settings or electronic- Overall compliance with study procedures (number of ally is successful, since pregnant women with BMI ≥30 visits with both food and physical activity on at least have the experience of being addressed in a judgemen- level 2) correlated significantly with GWG (Table 4), as tal way about their weight, and request accurate and did actual numbers of visits with logbook activity and appropriate information about the benefits of limited having contact with the dietician. Participating in gestational weight gain . Haby et al. BMC Obesity (2018) 5:16 Page 8 of 12 Table 3 Adherence to the Mighty Mums study protocol Variable Intention-to-treat population Per-protocol population Mean (SD) Mean (SD) Median (range) Median (range) n = 438 n = 116 Food adherence , of all visits 2.9 (0.8) 3.2 (0.7) 3(1–4) 3(2–4) n = 346 Physical activity adherence , 2.5 (0.8) 2.8 (0.6) of all visits (1–4) 3(2–4) n = 356 Number of logbook visits 4.7 (2.3) 6.3 (0.6) 6(0–7) 6(5–7) Composite variable for 3.5 (1.7) 4.3 (1.1) all activities 4(0–7) 4(3–7) n (%) n (%) Adherence to both food 119 (27.2) 116 (100) and physical activity criteria Adherence to food criteria 276 (63.0) 116 (100) Adherence to physical activity criteria 295 (67.4) 116 (100.0) Use of pedometer 148 (34.7) 45 (38.8) Use of walking poles 86 (20.0) 34 (29.3) Contact with dietician 170 (39.0) 49 (42.2) Participated in aqua aerobics 73 (16.9) 24 (20.7) At least one visit with follow-up 333 (76.0) 116 (100) of food activities At least one visit with follow-up 317 (72.4) 116 (100) of physical activity At least one logbook visit 391 (89.3) 116 (100) Number of logbook visits 0–4 136 (30.9) 0 (0) 5–6 220 (50.2) 70 (60.3) 7 82 (18.7) 46 (39.7) Values represent mean (SD) and median (range) for continuous variables, and n (%) for categorical variables Adherence = at least level 2 on at least three visits according to registration in logbook Several reviews conclude that behavioural GWG inter- practice, and one of the fundaments was the skill in MI ventions, even if successful, should be more systematic- that all midwives exerted, or were educated in before ally designed and evaluated, as well as based on insights start of the project. The correlations between GWG and from behavioural science [22, 24, 40, 41]. The MM pro- the specific activities (pedometers, walking poles, aqua ject was designed to function in structured everyday aerobics) were non-significant, which is in line with Table 4 Correlation between adherence and weight gain among women in the intervention group, ITT population Variable Number of observations Spearman correlation coefficient P-value Adherence to both food and physical activity criteria 402 −0.157 0.002 Number of visits with adherence to both food and physical activity criteria 402 −0.162 0.001 Adherence to food criteria 402 −0.127 0.011 Number of visits with adherence to food criteria 402 −0.129 0.010 Adherence to physical activity criteria 402 −0.119 0.017 Number of visits with adherence to physical activity criteria 402 −0.179 < 0.001 Contact with dietician 400 −0.122 0.015 Number of logbook visits 402 −0.169 0.001 Adherence = above level 1 on more than two visits according to registration in logbook Haby et al. BMC Obesity (2018) 5:16 Page 9 of 12 previous findings that extra activities do not always have reported by women with obesity , as well as more the expected effect [28, 35–38]. The women in the MM unpleasant experiences from attending health care intervention described the opportunity to set their own services [43, 46]. goals for lifestyle change as crucial, and experienced as The fact that 38% of women declined participation supportive being in a group setting with other obese might be explained by their not wanting or feeling able pregnant women . to adhere to the intervention, or being less health literate An important result of the present study is that the . A possible selection bias is that the most motivated midwives had the opportunity to develop skills for work- women opted to join . Both the midwives who in- ing with obesity and lifestyle issues in the everyday vited the women and the women accepting participation clinic, a topic that midwives in earlier research had (as interventions or controls) may have been more com- expressed having difficulties with [43, 44]. The midwives fortable in dealing with lifestyle issues (the midwife) [45, thus had the opportunity of being empowered to see 46] and had a higher readiness to cope with lifestyle that their advice would make a difference, since feeling changes (the woman) . Since less than one third of confident in giving advice on GWG is an important pre- the women in the intervention group fulfilled the criter- dictor of higher guideline adherence . To feel ion of adherence to the study protocol, the conclusions confident and be able to accomplish an efficient and of the PP population are drawn from a rather small pro- worthy handling of obesity, midwives should have access portion of those eligible for participation. to nutrition and lifestyle expertise . On the other hand, participation in lifestyle interven- A strength of the MM programme is that it was tions in pregnancy is reported to be low, with 40–60% of population-based and that the women who were eligible women eligible to participate declining to do so . A for MM were from geographically as well as socio- reason for the relatively high participation rate in the economically similar compositions. Women with Mighty Mums programme could be the possibility of ex- languages other than Swedish were also invited, since it ercising one’s own choice regarding which areas to focus was possible to use interpreters. To avoid biased results on or which activities to take part in. This in turn low- caused by an over-representation of highly motivated ered the numbers of women participating in the separate women, the intervention was delivered through the activities, and individuals may have missed out on cer- standard antenatal care system. MM was originally de- tain aspects of the intervention. Attracting the women signed as a development project, and a further strength to participate is thus of paramount importance, and the is that the midwives were not involved in the project be- person-centred approach with individualised advice cause they had a particular interest, but were representa- formed the base of Mighty Mums. tive of the regular staff. Another strength is that the A related possible source of bias is that the women weight of the woman in the beginning of pregnancy was taking part in the intervention to a greater extent were registered, not reported by the woman, as is often the born in countries other than Sweden, had higher use of case in similar studies. interpreters, and were more often not engaged in work. A limitation is that the intervention was not rando- Also, more women in the intervention than in the con- mised. Also, the area first selected for the control group trol group were in Obese Class III (BMI ≥40) and fewer did not recruit enough women, which led to extending were in the lowest Obese Class I (BMI 30.0–34.9). to an adjacent area. However, all three areas were ex- Higher BMI may have contributed to a lower GWG in pected to have similar sociodemographic structures. the intervention group compared to controls, since Analyses were adjusted for socioeconomic differences on GWG usually is lower in women with higher BMI [2, an individual level. 19]. The challenge of counselling women with obesity Another limitation is that even though the MM pro- and eating disorders has been described by midwives ject was intended to reach all women with BMI ≥30 en- , and pregnant women with obesity have asked for tering pregnancy, it turned out that 35% were not culturally adapted programmes . Being born in an- invited. The low contact level might have been due to other country and being less fluent in Swedish may have midwives neglecting or forgetting to inform women, or negatively affected the ability to keep GWG below the abstaining because of a full agenda. The fact that not all determined limit, due to difficulties in understanding midwives and staff feel comfortable in addressing and assimilating the information and advice from the women with obesity has been described elsewhere [43, midwife. On the other hand, midwives in areas with 46, 47], and may explain why only 65% of the women higher socio-economic and cultural demands might have were asked about participation. Correspondingly, the ex- had to develop certain working skills to cope with this, planation for why only 62% of the women who were since counselling women from other cultures is de- approached chose to participate could be that more scribed as a certain challenge . However, the results negative attitudes towards being pregnant have been from this study indicate that the intervention was as Haby et al. BMC Obesity (2018) 5:16 Page 10 of 12 relevant to women with a foreign background as to . Also, for the pregnant woman with obesity, the those born in Sweden, potentially due to its person- health-promoting ambition of the health care service centred focus on the women’s own capabilities. can result in additional demands. It is likely that this is Women in the control group may have been influ- not the first time the woman is addressing concerns enced by the ongoing MM project, since there is formal about her body weight. The woman’s acceptance of her and informal communication between midwives, and actual weight and lack of motivation for lifestyle change, pregnant women move between areas and voluntarily as well as sensitivity to being scrutinised and observed tell each other pregnancy-related health tips. Women in for weight matters, has been suggested to negatively im- the control group may also have been referred to a diet- pact the possibility of succeeding in restricting GWG ician or physiotherapist, taken part in community activ- and may have hindered some women from participating ities related to lifestyle or other issues independent of [48, 54]. The fact that the public health and community the project, or enrolled in other health-related research services generally lack structured maternal obesity objec- studies. These circumstances could in reality have tives aggravates the possibility of succeeding with life- decreased the differences between women in the inter- style interventions and calls for more strategic and vention and control groups. national support concerning evidence and guidance to Another limitation is that the intervention programme plan, develop, and implement effective maternal obesity with free choice of activities makes it difficult to differ- services . entiate exactly which parts of the MM intervention con- The many barriers that exist for both women and tributed to the difference in GWG between the health care providers affect the successful initiation of intervention and control groups. The variety in support behavioural change during pregnancy . Midwives de- and activities and the possibility to choose may be fac- scribe pregnancy as an ideal time for interventions con- tors contributing to success, but it is difficult to define cerning health among pregnant women, and say that which measure was most effective within the current they require support and better cooperation with other study design. The extra time with the midwife or contact healthcare professionals to be able to carry forward with the dietician, both weakly correlating with GWG, greater collaboration with the women they care for . may also be of importance. Being weighed at every visit Person-centred care in pregnancy is sparsely studied, has been described with conflicting results [26, 27], and and the extent to which person-centred care may im- it is unclear whether this contributed to limiting weight prove health outcomes and satisfaction with care in this gain. However, women in the MM intervention reported population needs further research . that being weighed regularly encouraged them to con- tinue the positive lifestyle changes . Another factor Conclusions influencing GWG could be the network that was formed This study, which is based on relatively modest changes with the surrounding community and health centres. in the routine visits in primary care, shows that it is pos- Two extra appointments with the midwife were planned sible to guide the pregnant woman with obesity towards for the intervention group. The extra time with the mid- everyday lifestyle changes that decrease GWG and lessen wife, as such, and not the content of the intervention weight retention after pregnancy. The number of visits visits, may have helped empower the women in the inter- with logbook activity on both food and physical activity vention to succeed with the lifestyle project. In the pilot as well as dietician consultation correlated significantly study of MM, where visits to the midwife were counted with GWG. The individual choice of level of activity and manually, there was a similar number of visits among engagement, as well as the personal support and docu- women in the intervention and women in the control menting in the logbook, may also be factors in success. group . In the full study, however, it was not possible However, measures need to be evaluated to have a larger to obtain reliable data on the number of midwife visits for proportion of participants taking full advantage of the all women, due to differences in routines for reporting to programme, and future studies are warranted to put the register, both in time and between areas. strategies in antenatal care into perspective regarding Also, there are concerns about how well the effect of the whole health care system and society’s handling of an intervention like MM can be studied, since pregnant overweight and obesity in pregnant women. women choosing to enter a lifestyle intervention will have a high motivation to make healthy changes during Implications for clinical practice pregnancy, regardless of being in a study or not . The findings in this study suggest that a programme The low participation in the MM intervention might starting in early pregnancy, monitoring weight regularly be surprising, since pregnancy, preconception, and post- and with an opportunity to discuss nutrition and phys- natal periods often are viewed as important and timely ical activity with the midwife or other professionals stages in the life course for public health intervention throughout pregnancy, can be an important part of Haby et al. BMC Obesity (2018) 5:16 Page 11 of 12 active antenatal care concerning lifestyle issues. Also, the Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published postpartum check-up may be an opportunity for the maps and institutional affiliations. woman with obesity to be addressed about her current weight and lifestyle and offered further monitoring in Author details Primary Health Care, Research and Development Unit, Närhälsan, Region primary care. However, for an optimal effect, women Västra Götaland, Gothenburg, Sweden. Institute of Health and Care Sciences, need to receive better information on risks and advice Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. on losing weight even before getting pregnant . GPCC – University of Gothenburg Centre for Person-centred Care, Gothenburg, Sweden. Department of Pediatrics, NU Hospital Group, Region Activities in the intervention programme that corre- Västra Götaland, Uddevalla, Sweden. Institute of Clinical Sciences, lated significantly with GWG (extra midwife visits, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. advice on food and physical activity, and dietician Received: 30 June 2017 Accepted: 26 April 2018 consultation; Table 4), together with mandatory weigh- ing, have been picked up in regional guidelines for ante- natal care. However, the implementation of guidelines References and optimal antenatal care of obesity require a support- 1. 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Published: Jun 4, 2018