Gestational Weight Gain Among Nulliparous Women
Gestational Weight Gain Among Nulliparous Women
We found that obstetrician and patient accounts of prenatal communication about GWG diverged in several ways. Compared with their patients' reports, obstetricians more frequently reported that appropriate weight gain, nutrition, and physical activity were explicitly discussed in prenatal visits. Obstetricians also reported that they tend to offer little weight-related counseling postpartum, while patients expressed anticipatory concerns about postpartum weight loss and a desire for postpartum guidance from their obstetricians.
The obstetricians generally agreed that weight is a medical concern and that pregnancy is an appropriate time to address weight and weight-related behaviors with women; however, they were not always sure about how best to counsel women. This was consistent with another study, in which obstetric care providers said they were "confused about what counseling approach to take, and disagree about how to be effective without offending, stigmatizing, or discouraging patients". Likewise, patients may be conflicted about weight-related counseling. Patients in our study reported that their obstetricians take a "reactive" approach to counseling, waiting for women to ask questions and raise concerns rather than offering unsolicited advice. This approach to GWG counseling has been previously identified by obstetricians, nurse practitioners, family physicians, and certified nurse midwives in other qualitative studies conducted in the United States. Our study supports this finding from the perspective of patients. The patients we interviewed diverged, however, in their feelings about "reactive" counseling practices, with some expressing concern that they may not be receiving all the information they need to have a healthy pregnancy if they do not know what questions to ask providers to draw out appropriate counseling.
Our findings contrast with related work from other countries, including Japan, where researchers found both patients and providers believed minimal GWG was optimal, and England, where patients reported that they and their providers were unconcerned about GWG, and providers were not sure how much weight to recommend their patients should gain, or even how much weight they were gaining, since British guidelines do not recommend monitoring GWG. Our study offers evidence of more considered interactions about GWG and a more nuanced approach to weight gain counseling and goal-setting.
Our analysis revealed some discrepancies between obstetricians' accounts of typical clinical interactions and patients' accounts. It is possible that when a public health researcher asked them about pregnancy weight gain and how they counsel patients about nutrition and physical activity, physicians may have reported the behavior they knew is best, that is, counseling all patients about healthy behaviors. In a meta-analysis of published research assessing both physician self-report of adherence to evidence-based guidelines and objective measures of adherence, Adams et al. found that the majority of studies shows that physicians self-report that they are much more adherent to medical guidelines in their counseling of patients than they actually are, potentially leading to "gross overestimation of performance". The authors suspect that physicians are not intentionally misleading researchers, but that they may be subject to desirability bias, which leads them to want to give researchers responses that they deem socially desirable. Alternatively, it is possible that the discrepancies in patient and provider accounts are influenced by patient recall bias. Patients may not fully remember all that their doctors told them earlier in their pregnancies. In particular, women for whom pregnancy weight gain was not a concern may not recall their obstetricians' comments about weight because other interests trumped those concerns. Other women who indicated that healthy lifestyle advice is common knowledge may have tuned out their physicians' advice because they presumed nothing novel was being communicated.
This research is subject to several limitations that affect the generalizability of findings. The sample is drawn from a single center and is not representative of all US gravid women or obstetricians. Both obstetrician and patient participants self-selected into the study, raising the possibility that individuals most concerned about GWG were more likely to enroll than individuals who were not concerned with or interested in GWG. Demographic factors may or may not be associated with obstetricians' weight-related counseling, but future research could target larger and more diverse samples of women and obstetricians to explore whether sample heterogeneity changes findings. In addition, as discussed previously, obstetrician responses may be influenced by desirability bias and patient responses may be affected by recall bias.
Discussion
We found that obstetrician and patient accounts of prenatal communication about GWG diverged in several ways. Compared with their patients' reports, obstetricians more frequently reported that appropriate weight gain, nutrition, and physical activity were explicitly discussed in prenatal visits. Obstetricians also reported that they tend to offer little weight-related counseling postpartum, while patients expressed anticipatory concerns about postpartum weight loss and a desire for postpartum guidance from their obstetricians.
The obstetricians generally agreed that weight is a medical concern and that pregnancy is an appropriate time to address weight and weight-related behaviors with women; however, they were not always sure about how best to counsel women. This was consistent with another study, in which obstetric care providers said they were "confused about what counseling approach to take, and disagree about how to be effective without offending, stigmatizing, or discouraging patients". Likewise, patients may be conflicted about weight-related counseling. Patients in our study reported that their obstetricians take a "reactive" approach to counseling, waiting for women to ask questions and raise concerns rather than offering unsolicited advice. This approach to GWG counseling has been previously identified by obstetricians, nurse practitioners, family physicians, and certified nurse midwives in other qualitative studies conducted in the United States. Our study supports this finding from the perspective of patients. The patients we interviewed diverged, however, in their feelings about "reactive" counseling practices, with some expressing concern that they may not be receiving all the information they need to have a healthy pregnancy if they do not know what questions to ask providers to draw out appropriate counseling.
Our findings contrast with related work from other countries, including Japan, where researchers found both patients and providers believed minimal GWG was optimal, and England, where patients reported that they and their providers were unconcerned about GWG, and providers were not sure how much weight to recommend their patients should gain, or even how much weight they were gaining, since British guidelines do not recommend monitoring GWG. Our study offers evidence of more considered interactions about GWG and a more nuanced approach to weight gain counseling and goal-setting.
Our analysis revealed some discrepancies between obstetricians' accounts of typical clinical interactions and patients' accounts. It is possible that when a public health researcher asked them about pregnancy weight gain and how they counsel patients about nutrition and physical activity, physicians may have reported the behavior they knew is best, that is, counseling all patients about healthy behaviors. In a meta-analysis of published research assessing both physician self-report of adherence to evidence-based guidelines and objective measures of adherence, Adams et al. found that the majority of studies shows that physicians self-report that they are much more adherent to medical guidelines in their counseling of patients than they actually are, potentially leading to "gross overestimation of performance". The authors suspect that physicians are not intentionally misleading researchers, but that they may be subject to desirability bias, which leads them to want to give researchers responses that they deem socially desirable. Alternatively, it is possible that the discrepancies in patient and provider accounts are influenced by patient recall bias. Patients may not fully remember all that their doctors told them earlier in their pregnancies. In particular, women for whom pregnancy weight gain was not a concern may not recall their obstetricians' comments about weight because other interests trumped those concerns. Other women who indicated that healthy lifestyle advice is common knowledge may have tuned out their physicians' advice because they presumed nothing novel was being communicated.
Limitations
This research is subject to several limitations that affect the generalizability of findings. The sample is drawn from a single center and is not representative of all US gravid women or obstetricians. Both obstetrician and patient participants self-selected into the study, raising the possibility that individuals most concerned about GWG were more likely to enroll than individuals who were not concerned with or interested in GWG. Demographic factors may or may not be associated with obstetricians' weight-related counseling, but future research could target larger and more diverse samples of women and obstetricians to explore whether sample heterogeneity changes findings. In addition, as discussed previously, obstetrician responses may be influenced by desirability bias and patient responses may be affected by recall bias.
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