The Healthy Eating and Lifestyle in Pregnancy cluster randomised controlled trial: a 24 months postpartum follow-up study. An evaluation of the effect of a weight management intervention for maternal obesity, on maternal and child outcomes at 24 months following birth.

Background: Obesity in pregnancy, and excessive gestational weight gain, are associated with short and long-term adverse health outcomes for mothers and their offspring, including childhood obesity. The Healthy Eating and Lifestyle in Pregnancy (HELP) cluster randomised controlled trial compared the effectiveness of a group-based weight management intervention, delivered during pregnancy and postpartum, with National Health Service routine maternity care. In total, 598 pregnant women, aged 18 years and over, with a BMI of ≥30 kg/m2, and between 12 and 20 weeks gestation, were recruited across 20 study centres in England and Wales, United Kingdom. The aim of the HELP trial was to improve health outcomes in these women with obesity. The present study followed up these women and their children at 24 months postpartum and aimed to assess longer-term maternal and child outcomes. It also aimed to explore the experiences of these women. Methods: A sequential mixed methods approach was used. The first, quantitative phase, examined the effectiveness of the HELP intervention on primary outcomes, maternal BMI and child BMI-for-age z-scores, and secondary outcomes, including weight, diet, and physical activity behaviours of mothers and children. Outcomes were analysed using multilevel linear, logistic and ordinal regression models. The second, qualitative phase, used telephone interviews to explore women’s experiences. Thematic analysis was used to organise and interpret the interview data. Findings from the two approaches were triangulated for discussion. Results: The 24 months postpartum follow-up included 241 women and children, across 19 clusters. The analyses found no evidence of between groups differences in the primary outcomes, maternal BMI at 24 months postpartum (adjusted percentage difference: -0.01, 95% CI -0.04 to 0.02; ICC <0.001; p= 0.664) and child BMI-for-age z-scores (adjusted difference in means: 0.24, 95% CI -0.17 to 0.64; ICC <0.001; p=0.250), or the secondary outcomes. Subsequently, 18 of these women completed a telephone interview. Maternal attitudes towards their own and their child’s weight and health behaviours, before, during and after pregnancy, were described in three themes: 1) pregnancy specific attitudes and behaviours; 2) wider weight control attitudes and experiences; and, 3) maternal perceptions and influences on children’s weight, diet and activity. Discussion: The HELP intervention did not improve outcomes for women and their children at 24 months postpartum. Women have a strong desire to be healthy for their unborn babies during pregnancy. Non-judgmental support may help them adopt healthier behaviours to achieve short-term goals. However, more support would be needed to help women achieve better long-term outcomes. Women’s lived experiences of obesity are complex, and it is important to incorporate their beliefs and motivations into interventions. Rather than viewing pregnancy as a short window of opportunity for initiating behaviour change, it should be used as a unique motivator which could give women a purpose for change over a longer term. Exploring options for intervening in the preconception period to address attitudes and weight loss before pregnancy, supporting women during pregnancy to be healthy for their babies, and building on this postpartum to help women shift their goals to weight loss, self-regulation of weight management, being a positive role model for their children and health-promoting feeding practices; may be more effective for improving maternal and child outcomes

Smoking during pregnancy, stigma and secrets: Visual methods exploration in the UK

Background: Moral judgements are commonly directed towards mothers through reference to health behaviour in pregnancy, and working-class mothers are particularly subject to this moral gaze. Aim: To gain an in-depth understanding of the health issues affecting 10 low income pregnant women from deprived areas of south Wales, UK. Methods: Participants completed visual activities (timelines, collaging or thought bubbles and dyad sandboxing) prior to each interview. Participants’ visual representations were used in place of a topic guide, to direct the interview. Guided by feminist principles, 28 interviews were completed with 10 women. Data were analysed thematically. Findings: Smoking was discussed at length during interviews, and this paper focuses on this issue alone. Five of the participants had smoked during pregnancy. Negative reactions were directed towards pregnant women who smoked in public, resulting in maternal smoking being undertaken in private. Participants also reported awkward relationships with midwives and other health professionals, including receipt of public health advice in a judgemental tone. Discussion: Smoking during pregnancy is a particularly demonised and stigmatised activity. This stigma is not always related to the level of risk to the foetus, and instead can be seen as a moral judgement about women. We urgently need to move from individualised neo-liberal discourses about the failure of individual smokers, to a more socio-ecological view which avoids victim blaming. Conclusion: Stigma from friends, family, strangers and health professionals may lead to hidden smoking. This is a barrier to women obtaining evidence based stop smoking support

Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (Capability, Opportunity, Motivation-Behaviour) model

Background: Health behaviours during pregnancy and the early years of life have been proven to affect long term health, resulting in investment in interventions. However, interventions often have low levels of completion and limited effectiveness. Consequently, it is increasingly important for interventions to be based on both behaviour change theories and techniques, and the accounts of pregnant women. This study engaged with pregnant women from deprived communities, to understand their subjective experiences of health in pregnancy. Methods: The study adopted a women-centred ethos and recruited a purposive sample of ten pregnant women, who lived in deprived areas and were on low incomes. Participants engaged with three creative techniques of visual data production (timelines, collaging and dyad sandboxing), followed by elicitation interviews. One participant only engaged in the initial activity and interview, resulting in a total of 28 elicitation interviews. This in-depth qualitative approach was designed to enable a nuanced account of the participants’ thoughts, everyday experiences and social relationships. Data were deductively coded for alcohol, smoking and infant feeding and then mapped to the COM-B model (Capability, Opportunity, Motivation – Behaviour). Results: Five participants had experience of smoking during pregnancy, four had consumed alcohol during pregnancy, and all participants, except one who had exclusively formula fed her child, disclosed a range of infant feeding experiences and intentions for their current pregnancies. Considerable variation was identified between the drivers of behaviour around infant feeding and that related to abstinence from tobacco and alcohol during pregnancy. Overall, knowledge and confidence (psychological capability), the role of partners (social opportunity) and support from services to overcome physical challenges (environmental opportunity) were reported to impact on (reflective) motivation, and thus women’s behaviour. The role of the public in creating and reinforcing stigma (social opportunity) was also noted in relation to all three behaviours. Conclusions: When designing new interventions to improve maternal health behaviours it is important to consider the accounts of pregnant women. Acknowledging pregnant women’s subjective experiences and the challenges they face in negotiating acceptable forms of motherhood, can contribute to informed policy and practice, which can engage rather than isolate potential user groups

Text messaging to help women with overweight or obesity lose weight after childbirth:the intervention adaptation and SMS feasibility RCT

Background There is a need to develop weight management interventions that fit seamlessly into the busy lives of women during the postpartum period. Objective The objective was to develop and pilot-test an evidence- and theory-based intervention, delivered by short message service, which supported weight loss and weight loss maintenance in the postpartum period. Design Stage 1 involved the development of a library of short message service messages to support weight loss and weight loss maintenance, with personal and public involvement, focusing on diet and physical activity with embedded behaviour change techniques, and the programming of a short message service platform to allow fully automated intervention delivery. Stage 2 comprised a 12-month, single-centre, two-arm, pilot, randomised controlled trial with an active control. Setting This study was set in Northern Ireland; women were recruited via community-based approaches. Participants A total of 100 women with overweight or obesity who had given birth in the previous 24 months were recruited. Interventions The intervention group received an automated short message service intervention about weight loss and weight loss maintenance for 12 months. The active control group received automated short message service messages about child health and development for 12 months. Main outcome measures The main outcomes measured were the feasibility of recruitment and retention, acceptability of the intervention and trial procedures, and evidence of positive indicative effects on weight. Weight, waist circumference and blood pressure were measured by the researchers; participants completed a questionnaire booklet and wore a sealed pedometer for 7 days at baseline, 3, 6, 9 and 12 months. Outcome assessments were collected during home visits and women received a voucher on completion of each of the assessments. Qualitative interviews were conducted with women at 3 and 12 months, to gather feedback on the intervention and active control and the study procedures. Quantitative and qualitative data were used to inform the process evaluation and to assess fidelity, acceptability, dose, reach, recruitment, retention, contamination and context. Results The recruitment target of 100 participants was achieved (intervention, n = 51; control, n = 49); the mean age was 32.5 years (standard deviation 4.3 years); 28 (28%) participants had a household income o

"Keeping it on your radar"- assessing the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood: a qualitative study from the early detection of type 1 diabetes in youth study

Aims The aim of this study was to explore from the perspectives of key stakeholders involved in the pathway to diagnosis, the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood. Methods Qualitative interviews and free‐text analyses were undertaken in 21 parents with a child diagnosed with type 1 diabetes, 60 parents without a child diagnosed with type 1 diabetes, 9 primary healthcare professionals, 9 teachers and 3 community diabetes liaison nurses. Data were analysed thematically and 30% double coded. Results Two key themes were identified, namely the importance of widespread awareness and knowledge and seeking healthcare professional help. Parents with a child diagnosed with type 1 diabetes described seeking opinions from a number of individuals prior to seeking health professional help. Healthcare professionals recognized the rarity of the condition and the need for it to be kept on their “radar”, to ensure they considered it when examining an unwell child. The process of obtaining a primary healthcare appointment was identified as potentially playing a crucial role in the diagnostic process. However, most parents with a child diagnosed with type 1 diabetes described receiving an appointment on the day they sought it. Conclusions Knowledge and awareness of type 1 diabetes in childhood remain limited in the general population and misconceptions persist relating to how children present with this serious condition. An effective community‐based intervention to raise awareness amongst key stakeholders is required to ensure children receive a timely diagnosis once symptomatic