Gestational Weight and Dietary Intake During Pregnancy

Prepare a 1-2 page report that evaluates thisreport, discuss how the research methodology applies to theresearch conclusions. Do not focus on the topic of the article, butinstead focus on how the results were obtained using qualitativemethods.Gestational Weight and Dietary Intake During Pregnancy:Perspectives of African American Women Mable Everette Publishedonline: 7 November 2007 Springer Science+Business Media, LLC 2007Abstract Objectives This investigation explored the participants’perspective on weight, nutrition, and dietary habits duringpregnancy. The data of interest were culled from a largerethnographic research study designed to gather information andideas about the socio-cultural, psychological, and behavioralinfluences on maternal health during pregnancy (N = 63). Methods Mystudy focused on the six participants (including three teenagers)who delivered low birth weight and/or preterm babies and 13participants aged B18 years (teenagers) who delivered normal weightbabies. Data were analyzed utilizing qualitative methodology.Results Four of the participants who delivered low birth/weightpreterm infants reported weight related concerns during pregnancy.These included: weight loss, lack of weight gain, and exceedingtheir expected weight gain. Frequently, the nutrition knowledge wasbased on miseducation, misconceptions, and/or ‘a grain of truth’i.e. folk beliefs. Support group members had an influential role onparticipants’ dietary habits during pregnancy. Conclusion The nextstep appears to be more qualitative work, with health careproviders, the Women Infants and Children Program (WIC) nutritioncounselors, clinical dietetic professionals, and women who alreadyhave children, to explore strategies for improving diet quality aswell as address the issue of inadequate and excessive weight gainduring pregnancy. Keywords Qualitative research Pregnancy AfricanAmerican women Nutrition Dietary intake Gestational weightIntroduction The Centers for Disease Control and Preventionreported that the rate of preterm births (37 completed weeks ofgestation) had increased 30% in the last two decades [1]. AfricanAmerican women deliver their infants at 37 weeks gestation twice asoften as women of other races and deliver their infants before 32weeks of gestation three times as often as white women [1]. Thesame ethnic disparity is also evident for low birth weight (2,500g/5.51 lb). In 2001, for singleton births, the rate was 4.9% fornon Hispanic whites and 11.9% for non Hispanic blacks [2]. Littleis known about why African American infants are at risk of adverseoutcomes. Many believe that scientists must take a fresh look atthe problem and approach it from a different vantage point [3].Rowley [4] purported that understanding the cause of the gap inpreterm delivery and the potential interventions to eliminate thisdisparity required a multidisciplinary approach; this methodologywould elucidate the biological pathways, stressors, and socialenvironment associated with preterm birth. The aim of this analysiswas to describe the participants’ perspective on weight, nutrition,and dietary habits during pregnancy. I examined the hypothesis thatgestational weight, nutrition information/knowledge, and dietaryhabits are associated with neonatal weight outcome. In order totest the hypothesis, the analysis included the most vulnerableparticipants: (1) six participants (50% of whom were teenagers)delivering low birth weight and/or preterm babies and (2) 13teenagers who delivered normal weight babies. MC Ganity et al. [5]define a biologically mature female as a young woman who is atleast 5 years postmenarchal. The growth demands of the pregnancyand the fetus superimposed on the growth demands of an adolescentM. Everette (&) Community Nutrition Education Services, Inc,110 S LaBrea Avenue, #213, Inglewood, CA 90302, USA e-mail:mleverette@ca.rr.com 123 Matern Child Health J (2008) 12:718–724DOI 10.1007/s10995-007-0301-5 during the first year after menarchemay result in undesirable reproductive outcomes [5]. Maternal ageyounger than 18 years of age and 35 years or older has beenassociated with preterm birth, but the effect seems to be confinedto the female who has never borne an offspring [6]. Among the otherfactors that have been implicated as possible contributing factorsto preterm delivery are: low pregravid weight; inadequate weightgain during pregnancy; iron deficiency anemia early in pregnancy;and poor diet [7]. A positive relationship between weight gain andbirth weight has been consistently reported in both developingcountries and among different ethnic groups [8, 9]. Maternalpregravid weight or Body Mass Index (kg/m2 ) and weight gain appearto have independent and additive effects on birth weight outcome[10]. Although total weight gain is an important predictor of birthweight, the pattern of weight gain and rates appear to play asignificant role in predicting preterm delivery [10–12]. Scholl[13] noted that the increasing evidence for an association betweenlow rates of maternal weight gain and preterm delivery does notimply causality. The importance of optimal body mass index (BMI) atthe start of pregnancy was emphasized in a study conducted by Jainet al. [14]. The researchers noted that of the women consideredoverweight or obese before conceiving, more than half gainedexcessive weight during pregnancy [14]. Poor maternal nutritionstatus (diet low in most necessary food nutrients) has beenimplicated as a possible contributing factor to preterm delivery[7]. In terms of overall calories, after controlling forconfounding variables, women with inadequate gestational weightgain consumed fewer kilocalories/day (-173 kcal/d) than did thosewomen whose pregnancy weight gain was adequate for gestation [13].Sufficient energy is a primary dietary requirement of pregnancy. Ifenergy needs are not met, available protein, vitamins and mineralscannot be used effectively. Limited information is availableregarding the nutrient needs of pregnant adolescents [15, 16]. Whendetected early in pregnancy, iron deficiency anemia was associatedwith a lower caloric and iron intake, an inadequate gestationalweight gain over the whole pregnancy, as well as with a greaterthan twofold increase in the risk of preterm delivery [13, 17].Vitamins and minerals, referred to collectively as micronutrients,have important influences on the health of pregnant women and theirgrowing fetuses [18]. Previous observational studies in both youngand older gravidas have shown that low intakes of iron and zincwere related to preterm deliveries [13, 15]. The risk of pretermdelivery with low dietary zinc intakes was particularly strong(threefold increased risk) for those whose rupture of membranepreceded labor [15]. Other studies on micronutrients await largerstudies before recommendations on their appropriate levels ofintake can be made [19]. Methods The data of interest were culledfrom an ethnographic study conducted by the Healthy AfricanAmerican Family I Project (HAAF 1). The project was funded by theCenters for Disease Control and Prevention (CDC), Division ofReproductive Health, at the University of California Los Angeles(UCLA) and Charles R Drew University of Medicine and Science. Theaim was to study the reasons for low birth weight and infantmortality among African Americans in Los Angeles, California. Datawere collected during the years 1992–1995. All of the researchparticipants were selected using a convenience samplingmethodology. During the life of the project, over 100 pregnantAfrican American women were interviewed at home, work, or in acommunity setting. Sixty-three women qualified for the HAAF1 study.Written informed consent was obtained from all women and family andcommunity members interviewed. Approval to conduct the ethnographicstudy was obtained from UCLA’s Human Subjects Protection Committee.While women under 18 years of age fell within the sample, pregnantminors are considered ‘‘emancipated minors’’ by the State ofCalifornia, and as such may give informed consent to participate ina research project without the involvement of parents. TheEthnographers were recruited and trained in qualitative interviewtechnique methods including didactic instructions, readings,practice interviews, and feedback by the HAAF I Project’sAnthropologist. The study utilized data triangulation methodsacross data sources in order to check the data from variousperspectives [20]. All interviews were audiotape recorded. Toretain the colloquial flavor of the client’s language, their wordswere reported verbatim from the audiotapes. In those instanceswhere the Ethnographer or the Anthropologist felt the transcriber’sinterpretation of the taped interview was sufficiently ambiguous,bracketed changes or substitutions were made to aid the reader incomprehending what the client was communicating. Questions (ofinterest for this analysis) explored the participants’ perceptionson weight, nutrition, and eating habits during pregnancy. A semistructured open-ended interview style was used to elicit open-endedresponses. For example, ‘‘What did you eat yesterday?’’ Probesfollowed the question, for example: ‘‘So tell me what you have beeneating? What did you have yesterday? Like from morning toevening?’’ Another question addressed prepregnancy weight, ‘‘Howmuch did you weigh before you got pregnant?’’ Probes followed thequestion, for example: Matern Child Health J (2008) 12:718–724 719123 ‘‘Are you concerned about gaining weight?’’ Another questionaddressed vitamin and mineral supplements, ‘‘What kind of prenatalmedications were you taking?’’ Probes followed the question, forexample: ‘‘So when they gave you your prenatal vitamins and stufflike that, who did-did you have questions or anything like that?’’Prior to analysis of the data of interest, a coding template wasdeveloped based on a content analysis of the transcripts [21]. Theresponses were categorized under two broad themes for all 63subjects: (1) ‘‘Maternal Weight Gain’’ and (2) ‘‘Eating Habitsduring Pregnancy.’’ The latter category also included, ‘‘Vitaminand Mineral Supplements Use.’’ Two coders independently coded thedata. Interrater reliability was 82% percent, an indication of goodconsistency. These codes were reviewed by both coders until 100%agreement was achieved. Following the agreement, the major themesand subthemes were assigned a code, the codebook was finalized, andthe analysis was conducted. The study used self reported data forsocioeconomic status (SES), prepregnancy weight, and weight gainedduring gestation. The height of participants was not available forthis analysis. The actual neonatal birth weights were provided bythe medical care facility. Results The Results for the 13 TeenagersDelivering Normal Weight Babies Follow Each of the Tables in thisSection The characteristics of the participants delivering preterm/low birth weight babies are presented in Table 1. Five of the 63participants delivered preterm/low birth weight babies; one subjectdelivered a small for gestational aged infant at full term. Thistotal group of six comprised 10.5% of the total sample. One-halfthe participants delivering preterm/low birth weight babies were 18years or younger; the other 50% were over age 18. Four of the sixparticipants (67%) reported themselves as being, ‘‘ low income.’’This was the first pregnancy for a participant under the age of 18.The 13 teenagers (21% of total sample of 63) ranged in age from 14to 18 years. Ninety two percent of the teenagers reportedthemselves as ‘‘low income.’’ Fifty four percent (n = 7) reportedat least one prior pregnancy (data not shown). The subthemesrelated to weight gain during pregnancy for those participantsdelivering LBW/preterm babies are noted in Table 2. Four of theparticipants who delivered LBW/preterm infants reported weightrelated concerns during pregnancy. These included: lack of weightgain, weight loss, and exceeding their expected weight gain. Thesubthemes (followed by selected quotes) for the teenagers reflectedmisconceptions about weight including justifications for weightgain/loss, for example, ‘‘weight gain not always related to beingpregnant’’ and ‘‘ weight loss was planned prior to pregnancy.’’Subtheme: (1) Weight gain not always associated with beingpregnant. ‘‘ When I first-when I was 3 months, I put-by the time Iwas 3 months, I had gained 30 lb already. I didn’t even know I waspregnant because I was spotting still when it was time for myperiod to come…when she [Aunt] took me to the doctor and I waspregnant.’’ Subtheme: (2) Depression related to body image. ‘‘I getdepressed when I look at myself…[referring to weight gain].That’s why I don’t look at myself. Only my face.’’ Subtheme: (3)Planned weight loss prior to pregnancy. ‘‘…but I lost some weightbefore I got pregnant so I can get pregnant because I did not wantto weigh because then I would have been bigger so I just went downto 112–115 something like that…then I got pregnant so I would bean even weight when I have the baby.’’ The subthemes related to therole of diet/nutrition during pregnancy for those participantsdelivering low birth weight (LBW)/preterm babies are noted in Table3. The issues included skipping meals/inadequate food intake, therole of cultural influences on food selections, and a specific foodbeing related to the health of the baby. Table 1 Characteristics ofparticipants delivering preterm/low birth weight babies (n = 6) AgeSES # Children # Previous pregnancy Education achieved Weight ofnew baby 18(1) Middle 2 2 12 4 lbs, 9 oz 21(2) Low 2 2 13 4 lbs, 14oz 22(1) Low 2 2 12 4 lbs, 12 oz 14(1) Low 1 1 8 2 lbs, 13 oz 22(1)(a) Middle 0 0 12 4 lbs, 8 oz; 5 lbs, 8 oz 16(1) Low 0 0 10 5 lbs,8 oz (1) Indicates birth outcomes that were both pre-term and lowbirth weight (LBW); (2) Indicates birth outcomes that were LBW; (a)Indicates twins; SES (self-reported socio-economic status) 720Matern Child Health J (2008) 12:718–724 123 The subtheme (followedby selected quote) for teenagers delivering a normal weight babyalso reflected a specific food being related to both the health ofmother and baby. Subtheme: Specific foods related to the health ofbaby. ‘‘…I have to drink a lot of milk-I drink at least 2 gallonsof milk a week, ‘cause I love milk.’ And plus, I have to drink alot of milk because my mother was telling me that since I have badteeth, the baby will take all the milk from me, and my teeth willstart hurting.’’ The subthemes related to family/support group forthose participants delivering LBW/preterm babies are noted in Table4. The influence of members of the support system was evident inthe selected quotes presented. The subthemes for the teenagersdelivering normal weight babies also reflected the role ofsupport/family members. The subthemes are noted as follow(subtheme/ selected quote). Subtheme: (1) Father of baby. ‘‘She gota lot of cravings, too. All of a sudden. Once she gets finished,like, she’ll say, pour her some juice, and she finished that, Iwant some of this, some of that, you know, so it builds up. So Iguess I have to get used to that.’’ Subtheme: (2) Mother of oneteenager. ‘‘She [mother] started keeping, since I like to snack,she started keeping like fruits and I like fruits, I just, it neverwas around.’’ Other findings: The subthemes related to the use ofprenatal vitamin and mineral supplements for participantsdelivering pre/term low birth weight babies. (1) ‘‘Took prenatalvitamins, calcium and iron.’’ (2) ‘‘Prenatal vitamins caused nauseaand vomiting when taken on an empty stomach.’’ (3) ‘‘Three times aday [iron and calcium] and then a prenatal vitamin once a day.’’The subthemes related to the use of vitamin and mineral supplementsfor the teenagers delivering normal weight babies are noted asfollow: (1) ‘‘Started taking supplements Table 2 Gestational weightgain subthemes for the participants delivering low birthweight/preterm babies Weight focus subthemes Selected quotesillustrating themes The lack of weight gain was noted as a sign ofnot looking pregnant to others ‘‘People used to always be like, yousure you pregnant?…[I] Never got bigger. But I used to like-Iused to throw up in the end [vomiting].’’ Weight loss occurredduring pregnancy ‘‘Well, I have lost weight-I went in the doctor at183 and now I/m 170. So the Doctor’s worried about my weight. By medropping so much weight [during pregnancy]…He said that, youknow, you’re just need to eat more.’’ Weight gain during pregnancywas not seen as related to weight of baby ‘‘You know I gained 43lbs, you know when I sit have the baby, this baby is 4 lbs and 14ounces and I—like why it happen?’’[full term birth, delivered @ 40+ weeks gestation.] Exceeded expected weight gain ‘‘I ran over 5lbs and then that was bad.’’ Table 3 Nutrition subthemes forparticipants delivering low birth weight/preterm babiesNutrition/food intake sub themes Selected quotes illustratingthemes Eating habits secondary to emotional issues ‘‘…Then fordinner, I had some cereal because I had a roommate here an um, andwe were going through some motions, you know what I’m sayin’ withher. So my mind wasn’t really focused on eating. So I didn’t reallyeat too much-eat too good yesterday.’’ Cultural influences on foodintake ‘‘Been pro-Black…Don’t eat no pork. Cut off a lot of junkfood. A lot of cookies and junk food like that. Cut out a lot offast foods.’’ Specific foods related to the health of baby ‘‘I hadsome corn, some brown rice with some chicken with something on theside. But, um, ‘cause I like brown rice better than white ricebecause brown rice is better for the baby, my mom said.’’ Table 4Family/support for women delivering pre term/low birth weightbabies Family/support group-influence on foods eaten Selectedquotes illustrating themes Father of baby ‘‘He (baby’s father)pretty much wants me to eat everything, I mean regardless to howmany calories it is or if I should eat it or if I shouldn’t eatit.’’ Mother of one teenager ‘‘And I don’t be eating a lot of junkfood and candy. I used to drink beer and stuff but I do everythingin front of my mom to let her know I ain’t trying to hide, shefigures as long as I do it in front of her, it’s ok.’’ Matern ChildHealth J (2008) 12:718–724 721 123 when 6 months pregnant.’’ (2)‘‘Learned how these should be taken in a class.’’ (3) ‘‘Takingprenatal care pills, but made me vomit.’’ (4) ‘‘Mother made mestart taking.’’ There was one reference to the use of the WomenInfant and Children (WIC) Program. The Question: ‘‘How did you findout about WIC?’’ The answer, ‘‘You know…as part of information onthe different kind of programs available to pregnant women.’’Discussion The hypothesis examined was that gestational weight,nutrition information/knowledge, and dietary habits were associatedwith neonatal weight outcome. Although a wide range of themes andsubthemes emerged from the ethnographic study, the data wereindividualized for each participant. Four of the participants whodelivered low birth/weight preterm infants reported weight relatedconcerns during pregnancy. The lack of sound, basic informationrelated to the importance of and the role of weight gain and itsrelevance to the health of the infant for both the teenagers andthe participants delivering low birth weight/preterm babies wasevident. Frequently, the nutrition knowledge was based onmiseducation, misconceptions and/or ‘a grain of truth’ i.e. folkbeliefs. Vitamin and mineral supplement intake was problematic forparticipants. The support group members had an influential role ondietary habits of participants during pregnancy. An importantstrength of the data was that the actual birth weights wereprovided by the medical care facility. Kramer [22] stated birthweight, defined as the sum result of the rate and duration of afetus’ growth, is a reliably collected variable and is stillfrequently used as a predictor of the mortality and morbidity ofinfants. The data for this study have several limitations. Thesample size was small; larger studies are recommended. A potentiallimitation is ‘‘researcher bias’’ where the researcher’s age, sex,ethnicity, personality traits, and other characteristics couldinfluence what the researcher is told or allowed to see and how heor she perceives events and people. The larger study utilized thetriangulation methodology [20] in order to lessen the ‘researchereffect.’ The study relied on the participant’s self reportedinformation, particularly for pregravid weight and weight gainduring pregnancy. The reliability of the self reported data givesrise to the question: ‘‘How accurate are self-reported data?’’ Cookand Campbell [23] pointed out that participants tend to report whatthey believe the researcher expects to see, or report what reflectspositively on their own abilities, knowledge, beliefs, or opinions.Self reported data also centers on whether participants are able toaccurately recall past behaviors. Cognitive psychologists havewarned that the human memory is fallible [24] and thus thereliability of self-reported data is tenuous. The semistuturedinterviewing techniques interwove questions regarding pregravidweight, nutrition and dietary habits, and vitamin and mineralsupplements among the total of all questions asked related tosocio-cultural, psychological, and behavioral influences onmaternal health during pregnancy. The data were ascertained indifferent ways by Ethnographers. The results were difficult toquantify. This investigation explored the participants’ perspectiveon weight during pregnancy. The lack of credible informationrelated to the importance of and the role of weight (bothinadequate and excessive) during pregnancy appeared to be thedominant theme for all participants. In the interviews participantsusually justified weight gain from a cosmetic point of view ratherthan the relationship of weight to pregnancy outcomes. According toHenderson-King [25], women have long been evaluated in terms oftheir appearance as contemporary North American society haswitnessed increased pressure on women to aspire to ideal images ofbeauty. The exact nature of the ideal is subject to change asfashion trends dictate; however, a focus on weight and body shape,with an increasing trend toward slenderness has characterized the‘‘contemporary ideal.’’ Harris et al. [26] further amplifies thistheme noting that very few empirical studies to date haveadequately examined non-white women’s attitudes toward theirbodies. The researchers further noted that absent from existingstudies is an examination of the demographic and socio-culturalvariables that related to the perception of and feeling toward thebody among African American women. The second focus of this studywas an examination of nutrition information and dietary habits inthe context of the environmental and family situations. Animportant component of note was the influence of family/supportgroup members in determining/overseeing foods eaten by theparticipants. The research of Mullings et al. [27] noted thatpregnancy served to mobilize greater action by women to addresshousing, environmental and economic, and other social stressorsthat existed before pregnancy; among these were an active attemptto assess quality health care and nutrition. Chomitz et al. [28]purported that the health behaviors should not be isolated from theenvironment (society, community, and family) that fosters andsupport them, and thus a change in the elements within theenvironment will facilitate an individual’s ability to changebehaviors. Bronner [29] stated that nutrition counseling has notbeen as family centered as it could be. The involvement of thepregnant client’s network of support in the nutrition 722 MaternChild Health J (2008) 12:718–724 123 and health educationcounseling would begin to address the family centered concept.Further Research and Conclusion Multi-disciplinary researchapproaches have been recommended in order to determine the complexfactors that are involved in preterm birth [4, 30]. Further studiesthat group outcome measures according to the proximate causes ofpreterm delivery and target individuals (versus populations) atrisk are required to determine whether poor nutrition is a markerfor or cause of preterm birth. Access to medical records in orderto obtain prepregnancy weight as well as gestational weight gainwould serve to strengthen the study results. Evidence suggests thatpopulations at high risk of preterm births appear to have a poorerquality diet [11, 31]. Thus, the research should focus onmacronutrients as well as micronutrients and the relevance topreterm/low birthweight infants. The next step appears to be morequalitative work, with health care providers, the Women Infants andChildren Program (WIC) nutrition counselors, clinical dieteticprofessionals, and women who already have children, to explorestrategies for improving diet quality as well as address the issueof inadequate and excessive weight gain during pregnancy.