The lived experiences of women exploring a healthy lifestyle, gestational weight gain and physical activity throughout pregnancy

Abstract Background Weight gain is inevitable during pregnancy. However, high prepregnancy body mass index and excessive gestational weight gain are associated with poor pregnancy outcomes. Understanding the experiences, social influences and decisions women make to maintain a healthy lifestyle during pregnancy are essential to consider how to improve services and interventions to help women engage in a healthy diet and physical activity (PA) behaviours. Objective The study investigated women's opinions and lived experiences of engaging in a healthy diet, promoting optimal gestational weight gain and PA during and after pregnancy. Design and Methods Twenty‐two pregnant women contributed to qualitative data collection for this Grounded Theory (GT) study. Nineteen women completed semi‐structured interviews and three patient and public involvement (PPI) representatives sought to validate the analysis and GT framework. Results Two substantive categories were constructed: (1) Evolving from ‘I’ to ‘we’, as informed by two subcategories and (2) the power of information and guidance, as informed by three subcategories. These categories informed the core category, ‘A navigational journey and evolution of the pregnant self’. The navigational journey involves constantly searching for knowledge and information to support and balance the interests of personal beliefs, the health of their unborn baby, their social circle and the wider world. A woman's psychological capability (e.g., their knowledge of a healthy lifestyle and confidence to implement such knowledge) is continuously tested. Conclusions Pregnancy may create a ‘teachable moment’ but there is a need for appropriate guidance from professionals to assist with lifestyle choices during pregnancy. The findings showed a significant influence of online resources, and lack of guidance on behaviour during pregnancy and may highlight areas of focus for future research and intervention. Public Contribution Three pregnant women were recruited to act as PPI representatives to assist with the validation of the analytical findings and aid the final theoretical saturation of the GT framework. Commentary from these PPI representatives was used to validate the analysis and support the interpretation of the data. In addition, these PPI representatives were also invited to provide commentary on the draft manuscript and those involved in this later process have been included as coauthors.

Conclusions: Pregnancy may create a 'teachable moment' but there is a need for appropriate guidance from professionals to assist with lifestyle choices during pregnancy.
The findings showed a significant influence of online resources, and lack of guidance on behaviour during pregnancy and may highlight areas of focus for future research and intervention.
Public Contribution: Three pregnant women were recruited to act as PPI representatives to assist with the validation of the analytical findings and aid the final theoretical saturation of the GT framework. Commentary from these PPI representatives was used to validate the analysis and support the interpretation of the data. In addition, these PPI representatives were also invited to provide commentary on the draft manuscript and those involved in this later process have been included as coauthors.
experiences, gestational weight gain, Grounded Theory, obesity, physical activity, pregnancy, qualitative 1 | BACKGROUND Weight gain is inevitable during pregnancy. 1 However, high prepregnancy body mass index (BMI) and excessive gestational weight gain (GWG) are associated with poor pregnancy outcomes, such as pre-eclampsia, gestational diabetes, caesarean section, high blood pressure, congenital disorders and perinatal death. [2][3][4][5][6] Currently, in the United Kingdom, there are no official clinical guidelines regarding appropriate GWG. 7 However, the American Institute of Medicine (IOM) 8 provides specific recommendations on GWG concerning prepregnancy BMI: for example, women classified as healthy weight are advised to gain between 25 and 35 lbs (11.5-16.0 kg); compared to women living with obesity, advised to gain less at 11-20 lbs (5-9 kg) in total. However, evidence, 9 which has evaluated over one million global pregnancies, found that 47% of women gained more than the IOM recommendations, indicating a high prevalence of excessive GWG and increased risk of complications (regardless of initial BMI).
Despite a lack of UK guidelines regarding appropriate GWG, there are guidelines regarding physical activity (PA), recommending at least 150 min of PA per week during pregnancy. 10 UK clinical guidelines 11 also state that all pregnant women should receive advice about healthy eating and PA from midwives. During pregnancy, women are more interested in nutrition, have increased motivation and are more likely to seek advice about their health. 12,13 However, pregnant women have identified a lack of information and support from healthcare professionals, which is a barrier to maintaining a healthy lifestyle during pregnancy. 14 In addition, research shows that levels of PA often decrease during pregnancy 15 or stop altogether. 12,13,16,17 Literature investigating views of healthcare professionals suggests that midwives do not utilize opportunities to discuss weight management and lifestyle choices 18 and report a lack of time, knowledge and skills to deliver such information. Moreover, midwives report a lack of confidence in discussing issues related to weight management, specifically in regard to GWG, and therefore conversations about appropriate GWG are often avoided. 19 Interventions for promoting optimal GWG have varying results, with limited success. For example, researchers 20,21 have designed and delivered interventions to promote a healthy diet, increased PA and implemented GWG guidance, and found that this positively influenced GWG in their study populations. However, other studies have found that interventions during pregnancy were unsuccessful when attempting to change PA behaviour or reduce excessive GWG, 22 or that attrition rates from interventions were high. [23][24][25] Understanding the experiences, social influences and decisions women make to maintain a healthy lifestyle during pregnancy are essential to consider how to improve services and interventions to help women engage in a healthy diet and PA behaviours throughout and post-pregnancy. However, there is limited research that explores the experiences and perceptions of pregnant women, their diet and PA behaviours. Qualitative methods permit an exploration of experiences and knowledge to understand behaviour and develop new insights. 26 Specifically, Grounded Theory (GT) is appropriate when there is little known about a phenomenon and focuses on creating conceptual frameworks via an inductive analysis of the data. 27 The study aimed to investigate women's opinions and lived experiences of participating in a community intervention for women, promoting optimal GWG and PA during and after pregnancy.

| Design
The study's primary aim was to construct a theory that offers an understanding from and is connected to the very reality that the theory is derived to explain. 28 Two philosophical stances influenced this GT study. Firstly, symbolic interactionism 29 explored the pregnant women's lives and behaviours surrounding diet and PA, and secondly, constructivism, the process of how the women understood their pregnancy and lifestyle advice (meanings) and how that understanding subsequently informed their actions. 27

| Participants and procedure
Recruitment of participants took place at a local lifestyle intervention for pregnant women across Merseyside (England, UK). This intervention aimed to promote optimal GWG and PA during and after pregnancy. Upon the first contact and before attending the intervention itself, the pregnant women were invited (initially via email and then followed up via face-to-face meeting) to participate in this study. This study recruitment was an independent process and was neither informed nor influenced by the women's engagement with the intervention itself.
The research inclusion criteria invited women with a BMI greater than 20 kg/m 2 , aged 18 or over, in their third trimester (>27 weeks gestation) and who had a noncomplicated (single) pregnancy. Due to the nature of the research, participants were required to speak English to enable them to communicate their thoughts and beliefs via interview. In addition, women were excluded from participating if deemed a high-risk pregnancy 11 (defined as women requiring additional care). The purpose of this study was explained both verbally and in writing, allowing time to consider participation. Participants provided written consent; this included consent to the interviews being audio-recorded, subsequently transcribed verbatim and selected anonymized quotations to be used as evidence to support the analysis and publication by the research team. Interviews were conducted in a private environment to allow participants to feel comfortable and encourage them to talk freely. 30 In line with GT methodology, we engaged in both purposeful 31 and theoretical sampling, 32 alongside simultaneous data collection and analysis to guide both the sampling and analytical strategies and aid the development and refinement of the categories and theory construction. 33 Theoretical sampling facilitated variability in the sample of women and supported further exploration of the developing categories and theory formation. In the later stages of theory construction, it was apparent that a greater level of understanding from women carrying their first pregnancy was needed, and therefore these women were targeted for recruitment. In addition, further exploration of the barriers to PA and healthy eating before maternity leave commenced was required; therefore, recruitment became more focused upon women in the earlier stages of pregnancy as identified by the pregnancy intervention service lead.
In total, 22 pregnant women participated. Nineteen women completed digitally recorded semi-structured one-to-one interviews (interviewed by L. S. n = 8 and B. A. W., n = 11; mean duration: 64 min). Of these, 79% were White British, mean age 24-42 years old, with 62% of women expecting their first child. An initial GT was constructed, and to validate the findings and aid the final theoretical saturation of the GT framework 34 another three pregnant women acted as patient and public involvement (PPI) representatives and engaged in discussions directed around the analytical findings. These PPI representatives were recruited as per the original recruitment procedure, and we considered these representatives to be heterogeneous in their pregnancy experiences (though not experienced in academic research processes). PPI representative 1 (Rep1) was aged 30 (Table 1). Questions in the interview were expanded upon throughout and were not utilized as a strict script; for example, a vital part of the interview process involved listening and following-up answers to interviewee responses, and in addition, iterations were made to the interview schedule for later interviews so to explore emerging categories during theoretical sampling. Sensitivity to dialogue and linguistic context 35 (Table 1).

| Data analysis
Interviews were audio-recorded and transcribed verbatim. Postinterviews, reflective notes and commentaries regarding the interview process and initial insights from the participants were made, these reflections were entered into the analysis as additional supporting data linked to the transcribed scripts for each participant. Field notes during, and reflection notes following, the interviews acted as initial memos and aided understanding as analysis commenced.
Throughout this process, the research team reflected on the interviewing techniques and considered iterations to the interview schedules in response to the analytical coding, category creation and theory construction.
Upon construction of the provisional GT, the categories and framework were analysed against the context of previous research 38 (known as 'sampling the literature' in GT 34,38 ). Finally, the PPI process (conducted by K. B. and L. N.) sought to aid the theoretical saturation of the GT to invite a further selection of pregnant women to coconstruct and validate the final analysis. These PPI discussions were not digitally recorded although written notes and verbatim quotes were made throughout the process. Following the PPI workshops, the analysis was refined to account for this additional insight (by K. B. and L. N.). In line with best practice for PPI, to promote transparency and partnership working, the PPI representatives were each invited to co-produce the final analysis; to support the discussion, particularly in regard to the implications for practice and to provide additional commentary and feedback on the draft of this manuscript. For those involved in this process, they have been included as co-author (Z. I.).

Interview question Probes a
What does the definition of healthy mean to you?
-How would you describe your eating and physical activity habits before pregnancy? -Do you feel like your habits have changed during pregnancy?
-Can you tell me a bit more about that? How much and in what way?
-What are your thoughts surrounding physical activity during your pregnancy? -What advice have you been given about participating in physical activity or exercise during pregnancy?
-Healthy eating? -Who gave you or where did you get this information? -Was the advice clear/did you understand the advice? Did you follow it or ignore it? Explain.
-Can you think of ways pregnant women can be physically active?
-Give me a list. Consider all types of activities, including leisure, walking for transportation, work activity, home activities and so forth.
-Were you satisfied with your prepregnancy weight? -How do you feel about gaining weight during pregnancy?
-Tell me more about why you were or were not satisfied with your weight.
-Why do you feel like this?
-What should women eat during pregnancy? -Is there anything that keeps you from eating the kinds of foods that you want and need to be healthy? Please explain.
-Shopping, transportation, time constraints for shopping or preparing foods, finances, work or household responsibilities, other children, healthy food choices, not sure? Etc.
-What encouraged you to join this intervention? -Are you happy with the support and guidance you have received from health professionals?
-Tell me more about the advice you received?
PPI agenda and example from a discussion -Welcome, thank you and introductions -Process and seeking consent -Overview of project -Seeking insight and experiences of individuals -Analytical discussion. Example: One of the categories describes the women's experiences of encouragement and support to engage in PA. The role of the midwife was considered important but women reported varied advice regarding diet, foods and physical activity-perhaps signposted to PA but not reinforced, mixed messages or misunderstanding of some advice. Diet and PA not prioritized in Midwife role. Do you think these comments/quotes are representative of women's/your experiences? What's happening here? Have we understood this correctly, do you believe our analysis reflects their experiences? -Consideration for improvement and future work -Summary, thank you and close Abbreviations: PA, physical activity; PPI, patient and public involvement. a Probes were used to get more information from the participants if answers were very short or lacked substance. If participants gave some information but needed to expand, the researcher would use probes such as 'That's interesting, tell me more'. 3.1 | Substantive category-Evolving from 'I' to 'we'

| Ethics and data availability
A key motivator for behaviour change during pregnancy was the identification of 'being pregnant' and the formation of a maternal bond. A further influence on motivations, expectations and the evolving pregnant self was the impact of the changes experienced by the mother-to-be, particularly in relation to the transition from thinking about herself and her unborn child.
Moving from I to we, I definitely thought of that, I was aware, and I wanted a balanced diet. PPI REP 1 This substantive category portrays the impact of emotional and physiological changes during pregnancy, the mother's attachment to the foetus and the roles that these factors have in manipulating lifestyle behaviours.

Interview 15
Although participants reported a decrease in PA, they expressed an interest in low-intensity exercise. However, limited availability and knowledge of classes were frustrating for the women.
I was looking myself for some Pilates classes, and I haven't been able to find any locally. Interview 17 The difficulty of engaging in high-intensity activities alongside pregnancy symptoms was often present, and the limited availability of low-intensity PA classes meant PA levels were reduced for many women.
This reflects the need for more formal guidance for safe PA during pregnancy and indicates, especially regarding low-intensity activity, the need for more availability of pregnancy lifestyle interventions. Social influences often encouraged engagement in healthy eating and PA to pursue a healthy lifestyle and healthy pregnancy. However, negative comments from others would incite worry and panic.
Couldn't argue with them because I didn't know myself whether it's right or wrong, so I listened and avoiding it.

Interview 8
However, negative comments from others also motivated the women to seek information and, when able, to join the lifestyle intervention, as women strived for further information and wished to be with other pregnant women. The social pull of the lifestyle intervention was reported as a key motivator for many of the participants.

| Worries, fears and concerns
A key consequence of the absence of available reliable information surrounding knowledge growth during a women's pregnancy is the manifestation of worry and concern. This lack of knowledge feeds into the worry of self-blame; therefore, this results in the avoidance of PA as there is a lack of knowledge surrounding potential consequences. Inconsistent information can elicit worry and concern, which was evident throughout the study, especially concerning GWG and participation in PA.
What do you do when your midwife tells you something, or worse, tells you nothing at all, and the internet says something different. You can't help but worry. Interview 16 Prior knowledge of and engagement in PA did not necessarily reduce concerns. Participants who were active before pregnancy often did not want to continue until they were sure it was safe. This was one of the motivations regularly mentioned for attending the lifestyle intervention. Participants who had access to the lifestyle intervention felt reassured by the guidance provided, a key finding in this current study. This encouraged them to continue or begin exercising, whereas, in previous studies, women did not engage in PA due to fears of harming their unborn baby. [47][48][49][50] Comments inferred that pregnant women would continue PA in pregnancy if knowledge of its positive influence was increased.
However, they currently lack trust in their abilities and the knowledge held by others. The majority felt that the risk of engaging in PA was too high, and further guidance was needed, especially considering the health of their unborn child was a priority during pregnancy.
I'm not going to any classes…I go to the council gyms and…like not to be like disrespectful to them, but I don't get the impression that they would tell you if you were doing something wrong. Interview 9

| Core category-A navigational journey and evolution of the pregnant self
The navigational journey of pregnancy (see Figure 2)  behaviours. 59 In the present study, pregnancy increased participants' awareness of their diet providing support for pregnancy as a teachable moment. 60 Foetal health motivated participants to seek information about diet and PA during pregnancy, especially from online resources. Due to the easy access and seemingly limitless information, the internet was a quick and easy way to answer queries and aid healthy choices. Past research shows that the internet is a common source of information during pregnancy 43,44 and may positively influence behaviour, 45  A key strength within this study was the acquirement of data through the thorough process of analysis guided by GT. 32 Qualitative interviews were conducted with a range of pregnant women recruited within an area of mixed (including high) deprivation, and the interview schedules were reviewed and expanded throughout the research process.
This resulted in substantial amounts of data being collected and the formation of strong categories leading to the construction of new knowledge. Moreover, to our knowledge, this is the first study that has sought to validate theoretical analysis through PPI involvement.
The findings may be transferred to other pregnancy settings and offer recommendations for improvements to healthcare services.
However, we acknowledge that the women recruited into this study, who had made contact with a lifestyle intervention may have been more motivated and knowledgeable regarding a healthy lifestyle during pregnancy. This may suggest that some women are less motivated and may possibly experience additional challenges to engage in PA and healthy lifestyle behaviours throughout pregnancy.
Further expansion of recruitment could be employed for pregnant women who do not attend antenatal appointments or engage in F I G U R E 2 A grounded theory model unpicking the navigational journal and evolution of the pregnant self.
pregnancy behavioural interventions. In addition, it is noteworthy that the participant sample was not diverse in terms of ethnicity, but deemed representative of the local area, the sample was mostly White. It is therefore important to consider the inequality in healthcare for women from Black or Minority Ethnic groups 64,65 who may have perceived their access to care and pregnancy experience, differently from the findings presented.

| CONCLUSIONS
This study explored the capabilities, motivations and opportunities of pregnant women to achieve optimum diet and PA behaviours throughout their pregnancies. Findings demonstrate that women are highly motivated to engage with positive behavioural lifestyle changes throughout Bronte Aspin-Wood: Conceptualization, methodology, recruitment of participants, data curation, formal analysis, writingoriginal. Lauren Sinclair: Conceptualization, methodology, recruitment of participants, data curation, formal analysis, and writingoriginal. Zainab Ikramullah: Analysis, visualization, writingreview and editing. Julie Abayomi: Conceptualization, recruitment of participant strategy, validation, writing review and editing, visualization.