Midwivesrsquo strategies in challenging dietary and weightcounselling situationsAnna Lena Wennberg ab Katarina Hamberg a Aringsa Houmlrnsten b

a Department of Public Health and Clinical Medicine Family Medicine Umearing University Umearing Swedenb Department of Nursing Umearing University Umearing Sweden

A R T I C L E I N F O

Article historyReceived 20 February 2014Received in revised form 18 June 2014Accepted 1 July 2014

KeywordsDietary counsellingPregnancyMidwivesQualitativeNon-adherenceEmpowerment

A B S T R A C T

Objective By enhancing maternal nutritional status midwives can help women lower the risks of preg-nancy complications and adverse birth outcomes as well as improve maternal health during pregnancyand in the long run Dietary counselling is on the other hand not reported to be effective Poor com-munication and conflicting messages are identified as possible barriers to adherence with recommen-dations Midwivesrsquo experiences of providing dietary advice and counselling during pregnancy are sparselyreported The aim of this study was therefore to explore midwivesrsquo strategies when faced with challeng-ing dietary counselling situationsMethods Seventeen midwives from different parts of Sweden and working within antenatal health carewere interviewed by telephone The interviews were analysed using qualitative content analysisResults Challenges were commonly experienced when counselling women who were overweight obesehad eating disorders or were from different cultures The midwives talked in terms of ldquothe problematicwomenrdquo when addressing counselling problems Strategies used in challenging counselling situationswere Getting acquainted Trying to support and motivate Pressure to choose ldquocorrectlyrdquo Controlling andmastering and Resigning responsibilityConclusions The results indicate that Swedish midwivesrsquo counselling strategies are quite ambiguous andneed to be questioned and that counselling of vulnerable groups of women should be highlighted Wecould identify a need for education of practicing midwives to develop person-centred counselling skills

copy 2014 Elsevier BV All rights reserved

Introduction

Dietary advice during pregnancy has changed over time anddiffers between countries In general avoidance of toxins contami-nants drugs and other food safety issues are important for preg-nant women and the foetus and recommended by midwives inantenatal care Furthermore according to the Nordic Nutrition rec-ommendations from 2012 energy requirements increase slightlyduring pregnancy by approximately 100 kcal in the first trimesterto about 500 in the last [1] The aim of dietary counselling in preg-nancy is a nutritionally balanced and ldquohealthyrdquo diet [12] and a re-stricted weight gain to reduce the risks of obstetric complications[3ndash5] Avoiding unnecessary weight gain is especially important sinceaccording to the Swedish Medical Birth Register [6] overweight (BMIgt25) among women in early pregnancy increased from 25 in 1992to 38 in 2011

Dietary counselling in pregnancy has benefits By enhancingmaternal nutritional status pregnant women lower their risks of

pregnancy complications and adverse birth outcomes while im-proving their own health in the long run [7] A Dutch study showedthat pregnant women were reported to have higher nutrition aware-ness than non-pregnant women especially concerning food itemsto avoid [8] A meta-analysis including 44 trials (7278 women) foundthat dietary and lifestyle interventions during pregnancy reducedmaternal gestational weight gain and improved outcomes for boththe mother and child Interventions based on diet were the mosteffective and were associated with reductions in gestational weightgain and improved obstetric outcomes [9]

Dietary counselling is on the other hand reported to be less thaneffective In a Swedish focus group study pregnant women notedthey received insufficient information and counselling about dietFeelings of fear and guilt as well as feelings of being controlled bythe midwives and by their own families and friends were de-scribed [10] A study from the US revealed that less than half of theparticipating pregnant women reported receiving dietary advice froma health care provider and younger women with low income andmultiparous women were least likely to get sufficient dietary advice[11] In an international review reporting adherence to dietaryrecommendations pregnant women with low income obesity andpoor food habits prior to the pregnancy were reported as having

Corresponding author Tel +46 90 7869061E-mail address annalenawennbergumuse (AL Wennberg)

httpdxdoiorg101016jsrhc2014070011877-5756copy 2014 Elsevier BV All rights reserved

Sexual amp Reproductive Healthcare 5 (2014) 107ndash112

Contents lists available at ScienceDirect

Sexual amp Reproductive Healthcare

journal homepage wwwsrhcjournal org

problems adhering to dietary recommendations [12] The effect ofdietary counselling in a group of pregnant women in UK was re-ported to increase if they were given food vouchers [13]

Problems in counselling and associated poor adherence have beenreported in the scientific literature Poor communication of adviceand conflicting messages have been identified as possible barriersto adherence [1415] Furthermore inability among midwives toprovide person-centred advice is reported as another barrier to ef-fective dietary counselling [71116] Differences in what is seen asculturally accepted food individual dietary preferences and lowlevels of food literacy also play a role in non-adherence [1415] Allthese aspects constitute challenges for midwives working in ante-natal care but to the best of our knowledge studies of midwivesrsquoexperiences and ways of acting in challenging counselling situa-tions are sparse

The aim of this study was therefore to explore midwivesrsquostrategies in challenging dietary counselling situations that is insituations where they experienced problems communicating withpregnant women about the benefit of changing dietary habits

Materials and methods

Context

Antenatal health care in Sweden is provided free of charge bythe public sector The standard care program includes 8ndash10 check-ups by a midwife during non-complicated pregnancies Accordingto the guidelines for midwives these check-ups should include healthcounselling in various areas including information about the neg-ative effects of smoking and alcohol and providing advice about ahealthy diet

Participants and settings

Seventeen female midwives working within Swedish antenatalhealthcare participated in the study The midwives were selectedby strategic geographic sampling and recruited with help from localcoordinating midwives local managers and through ldquosnowball sam-plingrdquo implying that one participating midwife suggested names ofother midwives who could be contacted In total 22 participantswere suggested contacted and informed by telephone and letter

about the study Five midwives declined participation The partici-pantsrsquo came from eight different counties in Sweden from the northto the south and their work experiences in primary health careclinics varied between 6 months and 31 years with a median of15 years The midwives are de-identified with codes in the text andquotations but in Table 1 the working area and work experienceof each participant are described

Interviews

An interview guide with the following three question areas wasused When and what kind of dietary advice is given to pregnantwomen Examples of successful and challenging counselling situ-ations Own experiences of difficult and challenging dietary coun-selling The first author conducted the semi-structured telephoneinterviews lasting 20ndash40 minutes in the spring of 2012

Analysis

The audio-recorded interviews were transcribed verbatim Qual-itative content analysis was used to highlight similarities and dif-ferences between and within codes and categories [17] The methodaddresses the manifest and latent content in the text After thor-ough reading meaning units corresponding to the aim were iden-tified When required the meaning units were condensed andshortened but core content was retained The meaning units werethen compared coded into categories organised at different levelsand in a particular order with each three to four underlying sub-categories During all steps of the analysis the members of the re-search group discussed the interpretations until agreements aboutthe content and labelling of categories were resolved in order toenhance the trustworthiness of the findings

Ethical considerations

We have not identified any risks for the midwives related to theirvoluntary participation in the interview study The study has beenapproved by the Regional Ethics Board in Umearing Sweden (Dno 2011-426-31 Ouml)

Table 1Midwivesrsquo working areas and work experiences

Midwife code Geographical workingarea (N = NorthM = Mid-SwedenS = South)

Working ruralcentral(Rural = RCentral = C)

Work experienceas midwife (years)

Work experience inantenatal care (years)

M1 N C 5 4M2 N R 2 15M3 N C 1 05M4 S C 31 22M5 M C 19 16M6 N C 23 17M7 N C + R 29 3M8 M R 26 24M9 M C 32 25M10 S C 26 16M11 M C 35 25M12 N C 38 31M13 N R 15 15M14 M C + R 2 2M15 S R 38 17M16 M R 28 13M17 M C 17 15Total 7 N

7 M3 S

5 Rural10 central2 both rural and central

Mean 19 (median 26) Mean 12 (median 16)

108 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

Results

The midwives described their general dietary information focuswas on prevention and the risks associated with unhealthy eatingSpecific advice included eating cooked meals on a regular basisavoiding alcohol toxins and contaminants and following theSwedish National Food Administrationrsquos (NFA) recommendationsInformation was given in early pregnancy and in connection withroutine oral glucose tolerance tests in mid-pregnancy Counsel-ling strategies used in challenging situations could be separated intofive categories with three to four subcategories each which are pre-sented in Table 2 and in text with quotations as examples

Strategies used in challenging situations

Challenges in dietary counselling were a common experience forthe midwives particularly with women diagnosed as overweightobese or with eating disorders Immigrant women vegans andwomen living in socio-economic deprivation were also men-tioned as being challenging to counsel The midwives often talkedin terms of ldquothe problematic womenrdquo In such counselling the mid-wives described various strategies which we have sorted into thefollowing five categories Getting acquainted Trying to support andmotivate Convincing about choosing ldquocorrectlyrdquo Controlling and mas-tering and Resigning responsibility (Table 2) These strategies weresometimes used as part of a process ie the more difficulty themidwife experienced connecting with the woman and more au-thoritative the midwives became On the other hand there were mid-wives who used only one or two strategies Overall the use ofcounselling strategies differed greatly among midwives The sub-categories are written in bold italics and are exemplified by orig-inal quotations in the text

Getting acquaintedIn this strategy which could be the first step of a counselling

process the midwives were striving to understand the women intheir contexts and life circumstances When women did not seemconcerned or bothered about their habits the midwives tried to un-derstand them and their problems better The midwives also de-scribed trying to evaluate the pregnant womenrsquos interests andmotivation by relating to them and offering them help and guid-ance based on individual needs Being curious about the womenrsquosown ideas and experience regarding how to solve problems wasdescribed as important

I think you must be very curious or curious about their experi-ences and their own ideas and telling them that if they wanthelp they can get it When you are too pushy then it will notwork out well irrespective of what you are saying You lead the wayand they are left behind (M 5)

When the midwives felt that they had problems reaching thepregnant women they commonly tried to adapt to the women bychanging counselling style to fit with an individual womanrsquos needs

I feel I have to meet her in the position she is in I have to startthere and maybe not talking only about their diet because theyoften know this very well Instead it is more about lifestyle pat-terns (M 10)

The participants were careful when asking about and discuss-ing lifestyle issues particularly with women who were either over-weight or underweight The midwives described how they wouldtread carefully when addressing the problems so as not to violatethe womenrsquos trust Counselling in weight issues was mentionedas even more difficult than addressing tobacco use or alcoholconsumption

You donrsquot really know [how to counsel women with weight prob-lems] Itrsquos like walking in a minefield You do not really know whatmight trigger them But on the other hand itrsquos nothing you haveto be frightened of Because itrsquos the only thing they think of them-selves FOOD By talking about it you might de-dramatize it (M 5)

Trying to support and motivateIn the second step of the process the midwives described how

they tried to listen actively in order to support womenrsquos motiva-tion for change By this they meant that they listened gave feed-back asked for further explanations and also confirmed their viewsof their problems

I listen actively and ask them how long it has been like this and howlong they want to keep it like this (M 5)

To support inner motivation for change the midwives also triedto facilitate reflection about habits and to problematise themSeveral midwives described how they discussed the costs and ben-efits of making lifestyle changes

Her BMI was 44 at the first visit so it was really large I asked herif she used to walk outdoors and reflected about physical activi-ties and about the costs related to her Coca-Cola consumption andsugar intake (M 6)

Supporting goal setting was another strategy to facilitate changeSetting goals that were too high and not realistic would not workDividing main goals into smaller ones and reaching them one at atime was seen as positive for self-efficacy and inner motivation Themidwives said that then women felt they had succeeded with atleast some part of the goal

It is realistic goals we are setting We donrsquot set 25 kg as a first goalbecause this is not achievable Instead we have smaller goals becauseif you take it stepwise it goes easier In this case we decidedtogether that she should simply not gain any weight during thepregnancy (M 6)

Convincing about choosing ldquocorrectlyrdquoSome midwives used this strategy exclusively but most only re-

sorted to it in situations when they felt that dialogue and counsel-ling did not work and they could not connect They then tried toconvince and persuade pregnant women about making the ldquocorrectchoicesrdquo in lifestyle and daily habits One common method used wasto transfer general medical knowledge about risks such as diabe-tes and hypertension and potential consequences of an unhealthy

Table 2Overview of categories and sub-categories

Strategies used in challenging situations

Getting acquainted Relating to and offering the women help and guidanceAdapting to the womenTreading carefully when addressing the problems

Trying to supportand motivate

Listening activelyFacilitating reflections about habitsSupporting goal setting

Convincing aboutchoosingldquocorrectlyrdquo

Transferring general medical knowledgeClarifying the messageRepeating the message

Controlling andmastering

Confronting the women with their poor lifestylesForming an alliance with the womenrsquos partnersFrightening them with medicals risks and complicationsMoralising about ldquogood motherhoodrdquo obligations andldquonormalrdquo family life

Resigningresponsibility

Referring the women to other health care professionalsTransferring responsibility to the womenDistancing from the womenGiving up ndash letting go

109AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

diet for the pregnancy the delivery the child and also for the ex-pecting motherrsquos future health

To convince them to change you tell them that it is important thatthe child avoids high blood sugars so as not to become obese in thefuture I asked her ldquoWhat do you believe is the reason for your highblood sugars Can it be that you eat a high amount of carbohy-drates that are wearing down your insulin receptorsrdquo (M 10)

Trying to clarify the message to reach a better understandingamong the women of the problem and how to solve it was also de-scribed as a common way to convince the women about the ldquorightchoicerdquo Using pedagogical approaches such as visualising and com-paring foods and nutritional issues were examples of this

It is easier to use a brochure to point things out in somewhat liketeaching the patients might not always want to keep the bro-chures and take them home but at least we have looked at themand read them and pointed things out and so on Therefore I cansee that they understand what I am talking about (M 9)

A few participants spoke of repeating the message over and overagain throughout the pregnancy when they sensed no response fromwomen and doing this even if the midwives thought their messagewas falling on deaf ears

She [the pregnant woman] doesnrsquot want me to butt into her eatinghabits but maybe it is something that will develop My hopeis that if you meet several times maybe sometime during the preg-nancy you will reach her and she will possibly listen to what youare saying (M 14)

Even if the midwife felt that her message continued to be ignoredrepeating it calmed her own worries about doing what was de-manded from her as midwife

Controlling and masteringIn order to influence women who did not adhere to dietary advice

some midwives described how they tried to control and master thewomenrsquos behaviour for example by telling them exactly how muchand how often they were allowed to eat ldquounhealthy foodrdquo Alter-natively they might ask women to keep diaries on food intake in-cluding kinds amounts and frequencies to present at the next visitThey would then confront the women with their bad habits andpoor lifestyle The midwives also spoke of situations when preg-nant women claimed that they had changed their dietary habits androutines although the midwives doubted if this was true

At the end of the pregnancy we were making a kind of summaryand at that meeting she said ldquoI am usually outdoors walkingrdquo ThenI touched her gently on her arm and asked ldquoAre you really honestnowrdquo ldquoNordquo she answered ldquoI have not been exercising at allrdquo(M 12)

As a way to insist on adherence to recommendations the mid-wives sometimes attempted getting into an alliance with thepartner of the expecting woman to get help in controlling andmastering her dietary habits

Then I turned to the guy and said ldquoPerhaps you then are inter-ested in food issues and can take this brochure and then wersquoll seeif there is something you would like to talk about something youdonrsquot really understandrdquo (M 5)

Some of the midwives also thought that to catch the womenrsquosattention they had to frighten them with medicals risks and com-plications Womenrsquos insufficient dietary habits were presented asa direct threat to the health and life of the foetus and also an obviousrisk for complications in delivery

I talk about and address some of the complications that occur if yougain 25ndash30 kg [I tell them that] many times this ends up in vacuumextraction and Caesarean section and prolonged labour (M 12)

Another patronising strategy to control the expecting women wasto moralise about the womanrsquos behaviour and relate that to normsabout ldquogood motherhoodrdquo obligations such as cooking and gath-ering the family around the dinner table If women were not suc-ceeding in their struggle to change to healthy dietary habits duringpregnancy the midwives appeared to sometimes question theirsuccess as mothers

I usually ask about which lifestyle they have thought of when be-coming a mother about what kind of role model they want to becomefor the child What is okay and not okay It is not only about eatingit is about other parts too (M 6)

Many of the midwives stated that the pregnancy is a period whenexpecting mothers have to adapt to new circumstances and a newrole with new responsibilities and that the midwife could influ-ence this process through counselling In the following quotationthe midwifersquos perception of what constitutes ldquonormalrdquo family lifealso becomes heteronormative and moralising

If I think forward in time and about the social importance that sur-rounds sitting down together as father mother and children to eatyou have the social aspects that are so meaningful and important(M 8)

Resigning responsibilityIn difficult situations when neither the communication nor the

relation between midwife and pregnant woman worked and themidwife comprehended the woman as non-adherent resigning re-sponsibility could be a last step One way to handle non-adherentwomen who were seen as problematic was to refer her to otherhealth care professionals such as dieticians physicians orpsychologists

Furthermore I find it difficult with vegetarians and vegans or thosewho have had different surgeries But in these cases they get a doctorwhom they can contact so you as a midwife can get away from theproblem (M 14)

When the midwives felt that they could not reach the womenwith any strategy or if they lacked knowledge or tools to motivateor persuade them to change they could transfer the responsibil-ity to the women themselves

It ends up with me saying ldquoBut you chose yourself what to do Iam not going to force anyone or say that it is absolute that one mustkeep to low-fat foodsrdquo (M 11)

Under these circumstances the midwives described how theysometimes were distancing themselves from the women and theirdietary problems This occurred for example when midwives foundthat they did not have sufficient knowledge or when they hadnothing more to add and therefore chose to focus on anything otherthan diet in their counselling

I explained that we would simply discontinue this and it didnrsquot feelgood It certainly did not but it felt like there were so many otheraspects around her that focusing on her diet was totally wrong atthat time At the same time you know itrsquos so important But noI could not take it anymore No (M 17)

Finally some midwives described how they also resigned re-sponsibility in counselling of women with many problems and par-ticularly when counselling immigrants from various cultures withunfamiliar dietary habits The midwives expressed helplessnessin counselling these women and used the strategy we have la-belled as giving up ndash letting go

110 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

These ones [immigrants] are really really hard You just have to leavethem to eat as usual They donrsquot eat this and they donrsquot eat thatand they eat this and that Well what should I do about it then(M 6)

Discussion

The interviewed midwives talked about ldquoproblematic womenrdquowhen describing those who were seen as challenging to counselIn so doing midwives defined the problem as arising from the in-dividual woman rather than her behaviour the interaction or fromthemselves and their limited understanding or counselling skill

When using the strategy Getting acquainted and Trying to supportand motivate the pregnant women the midwives described how lis-tening relating adapting and tiptoeing also facilitated reflec-tions problematising and goal setting We have interpreted thesestrategies as expressions of person-centred care (PCC) which is morethan just a method of communication and the midwives seemedto be considering the womenrsquos preferences experiences needs andvalues when using this approach Ekman and co-authors [18] pointedout the partnership as an important expression of PCC and suggestthree simple routines to facilitate and also safeguard the transi-tion to PCC which are (1) letting the patientrsquoswomanrsquos narrativesbecome the first step in establishing a partnership with the pro-fessional (2) shared decision-making which is built on this part-nership and (3) documentation in the patientrsquos record to contributeto the continuity and transparency of the partnership Another ofthe goals of PCC is to build an alliance between patients and healthcare professionals [1920] Such alliances were sought by the mid-wives using the get acquainted approach as they tried to identifythe expectant motherrsquos barriers and attitudes towards dietarychanges [21]

In line with our findings Abrahamsson et al [22] showed thatmidwives who tried to support pregnant women to quit smokingused strategies that they labelled ldquoFriend-makingrdquo and ldquoCo-operatingrdquo in which it was important to use the womanrsquos view asa starting point for the intervention Corcoran [21] stated that ef-ficient and satisfying communication plays an important role in anyefforts to improve health Furthermore she stated that the com-munication process is a multi-dimensional transaction influencedby a variety of factors in which both ldquocontentrdquo and ldquorelationshiprdquoare prominent The content is about how the message is transmit-ted and this is influenced by the relationship between the midwifeand the woman

We interpret the following strategies (Table 2) as less person-centred When using the strategy Convincing about choosing ldquocor-rectlyrdquo the midwives described a quite traditional patient educationapproach including transferring general medical knowledge andclarifying and repeating messages but also insisting on adher-ence Historically patient education in health care has been builton expectations of compliance which might be one reason for usingthis strategy In this approach health care professionals define theproblems and solutions and patients are expected to accept the givenadvice Vlasnik et al [23] stated that adherence represents a broaderinterpretation and understanding than compliance because adher-ence includes more components of shared decision-making The termadherence has been argued to have a larger focus on the providerndashpatient relationship and the patientrsquos involvement in care and ad-herence has been seen as a somewhat more contemporary conceptthan compliance However supporting womenrsquos choice and controlfits well into person-centred care approaches and more and morestudies are reporting positive outcomes from such interventionscompared with the relative ineffectiveness of trying to convincewomen [24]

When using the strategy Controlling and mastering women themidwives described that they were labelling and confronting preg-

nant women with their bad habits and lifestyles frightening themwith medical risks and complications and moralising about moth-erhood related to these habits Another aspect of control was to seeksupport from the womenrsquos partners in persuading women to makechanges The wordings of the subcategories ndash confronting fright-ening and moralising ndash tell us that counselling about diet can includepower relations In gestational diabetes Persson et al [25] foundthat the midwife acted as a medical guardian and explained thatthe mother-to-be had a moral obligation towards the foetus to makehealthy choices such as not gaining excessive weight As a healthissue and a matter for policies and interventions overweight andobesity have frequently been presented in the public discourse withinan existing moral framework that links these characteristics withmoral failure [26] Both midwives and mothers are actors in this dis-course A study about diet during pregnancy reported that preg-nant women constructed their identities as good mothers throughtheir monitored prenatal diets [27] In counselling about diet mid-wives must be aware of how they might impose guilt If the focusof a counselling session is on risk reduction then this strategy mightbe useful However because the outcome can be precarious controlshould be used with caution Although risk reduction is often themain focus for dietary counsellors who believe that insights intorisks will change diet practices knowledge of risks might not bethe most important determinant of food choices for individualsKnowledge of the benefits of healthy eating alone might also be in-sufficient to motivate dietary change Factors such as culture andsocial norms including taste preferences attitudes and beliefs avail-ability and accessibility influence peoplersquos food choices and shouldbe targeted to achieve changes in behaviour [28]

The last strategy resigning responsibility involves the midwivesdistancing themselves from the women transferring responsibili-ty to them and referring them to other health care professionalsThis strategy suggests that the midwives are giving up ndash letting goSimilar findings labelled ldquoavoidingrdquo were reported in a study aboutsmoking cessation during pregnancy Lack of competence withsmoking issues was expressed as a reason to abstaining from sucha discussion [22] Counselling women from other cultures withdeeply rooted dietary habits were also found to be difficult A studyof pregnant immigrant women in Norway revealed that dietary in-formation offered was very general weight management was neverdiscussed and information was incongruent with the womanrsquosculture [29] Persson et al [25] also described that when mid-wives found women with gestational diabetes failed to follow theiradvice they returned the responsibility to the women

Our results concur with those of a current systematic review [30]of qualitative evidence concerning weight management during preg-nancy reporting that health professionals are reluctant to discussweight management with obese women According to the authorsthis might be related to a fear of offending overweight women withbut also could be related to a lack of knowledge andor time for coun-selling challenging cases The review concludes that midwives requirespecialised knowledge about nutrition and physical activity duringpregnancy and appropriate referral information but also that somemidwives may lack communication skills Counselling around dietaryhabits that does not consider the multiple dimensions of decision-making associated with food and eating has limited effectiveness[30]

Telephone interviewing is an efficient method for data acquisi-tion It provides an opportunity for a good dialogue and procure-ment of personal experiences despite the lack of face-to-face contactWe performed and analysed 17 interviews with midwives butwe experienced a kind of data saturation after analysing about 12interviews However we had already interviewed 17 based on pre-vious experiences of qualitative content analysis and includedall interviews in the results Our sample of midwives from thewhole country from north to south and from different antenatal

111AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

settings rural and central was beneficial Because there is cultur-al diversity and difference in meaning about diet across Sweden thesample should and did this variety The interviewer in this studyis also a midwife which could be a strength in that the interview-er was knowledgeable about midwivesrsquo work and working condi-tions but simultaneously could pose a risk that latent meaning andcontent might get lost due to collegial agreement The inter-viewed midwives seemed to be especially interested in dietary coun-selling and this might have influenced the findings Despite thesepotential limitations we have interpreted our results as suggest-ing that several aspects of dietary counselling might need improve-ments We also find the method of telephone interviewing beneficialas midwives seemed able to express their opinions and narrate aboutpositive and negative experiences openly This may relate to the factthat the researcher and the participants were not known to eachother beforehand

Conclusion

In conclusion weight-related counselling and counselling ofwomen on special diets non-adherent women and immigrants orwomen from different cultures was described as particularly chal-lenging Midwives may need cooperation with dieticians to managesuch challenges Midwives also need improved education and train-ing to develop counselling skills such as motivational interview-ing for person-centred care during pregnancy Despite theireducation Swedish midwives may benefit from opportunitiesto train reflect and be observed when counselling This studyindicates that Swedish midwivesrsquo counselling strategiesrsquo can beambiguous controlling and coercive although also can be person-centred and that midwives struggle providing care to vulnerablepregnant women

Conflict of interest

None

Statement of authorship

ALW KH and AringH designed the study ALW recruited and inter-viewed the participants ALW analysed the data under supervi-sion of KH and AringH ALW drafted the manuscript but all authorscontributed to and approved the final version of the manuscript

Acknowledgements

We thank all participants for their contribution in the study aswell as the local coordinating midwives and local managers whowere helpful in the recruiting processThe study was supported bygrants from the County Council of Vaumlsterbotten Sweden

References

[1] Nord NNR 2012 ndash Nordic nutrition recommendations vol 002 5th edCopenhagen Nordic Council of Ministers 2014 p 180ndash3

[2] Kaiser L Allen LH Position of the American Dietetic Association nutrition andlifestyle for healthy pregnancy outcome J Am Diet Assoc 2008108553ndash61

[3] McMillen IC MacLaughlin SM Muhlhausler BS Gentili S Duffield JLMorrison JL Developmental origins of adult health and disease the roleof periconceptional and foetal nutrition Basic Clin Pharmacol Toxicol200810282ndash9

[4] Institute of Medicine and National Research Council (IOM) Weight gain duringpregnancy reexamining the guidelines Washington DC The NationalAcademies Press 2009

[5] Rasmussen KM Yaktine AL editors Weight gain during pregnancy reexamingthe guidelines Institute of Medicine National Research Council lthttpwwwnutrinfocombibliotecalibros_digitalesembarazopdfgt 2009

[6] The Swedish Medical Birth Register Official statistics of Sweden statisticsndashhealth and medical care pregnancies deliveries and newborn infants TheSwedish Medical Birth Register 1973ndash2010 Assisted reproduction treatment1991ndash2009 The National Board of Health and Welfare 2012

[7] Widen E Siega-Riz AM Prenatal nutrition a practical guide for assessment andcounseling J Midwifery Womenrsquos Health 201055540ndash9

[8] Szwajzer E Hiddik GJ Maas L Koelen M van Woerkum C Nutrition awarenessbefore and throughout different trimesters in pregnancy a quantitative studyamong Dutch women Fam Pract 201229i82ndash8

[9] Thangaratinam S Rogozinska E Jolly K Glinkowski S Roseboom T TomlinsonJW et al Effects of interventions in pregnancy on maternal weight and obstetricoutcomes meta-analysis of randomized evidence BMJ 2012344e2088

[10] Wennberg AL Lundqvist A Houmlgberg U Sandstroumlm H Hamberg K Womenrsquosexperiences of dietary advice and dietary changes during pregnancy Midwifery201329(9)1027ndash34

[11] Phelan S Phipps MG Abrams B Darroch F Schaffner A Wing RR Practitioneradvice and gestational weight gain J Womens Health 2011201ndash7

[12] Girard AW Olude O Nutrition education and counselling provided duringpregnancy Effects on maternal neonatal and child health outcomes PaediatrPerinat Epidemiol 201226S191ndash204

[13] Baker M Laurence W Crozier S Robinson S Baird J Margetts B et al Universityof South Hampton Educational attainment perceived control and the qualityof womenrsquos diets Appetite 200952631ndash6

[14] Joint WHOFAO Expert Consultation on Diet Nutrition and the Prevention ofChronic Diseases Diet nutrition and the prevention of chronic diseases reportof a joint WHOFAO expert consultation Geneva lthttpwwwwhointnutritionpublicationspublic_health_nut9pdfgt 2003

[15] National Preventative Health Taskforce Australia the healthiest country by2020 Technical report no 1 Obesity in Australia a need for urgent actionincluding addendum for October 2008 to June 2009 Canberra Commonwealthof Australia 2009

[16] Heslehurst N Russell S McCormack S Sedgewick G Bell R Rankin J Midwivesrsquoperspective of their training and education requirements in maternal obesitya qualitative study Midwifery 201329(7)736ndash44

[17] Graneheim UH Lundman B Qualitative content analysis in nursing researchconcepts procedures and measures to achieve trustworthiness Nurs Educ Today200424105ndash12

[18] Ekman I Swedberg K Taft C Lindseth A Norberg A Brink E et al Person-centered care ndash Ready for primetime Eur J Cardiovasc Nurs 201110248ndash51

[19] Mead N Bower P Patient-centredness a conceptual framework and reviewof the empirical literature Soc Sci Medi 2000511087ndash110

[20] Swedish Agency for Health and Care Services Analysis Patient centerednessin Swedenrsquos health system-an external assessment and six steps for progressReport 2012131ndash84

[21] Corcoran N Theories and models in communicating health messages InCorcoran N editor Communicating health ndash Approaches for health promotionLondon Sage 2007 p 5ndash95

[22] Abrahamsson A Springett J Karlsson L Haringkansson A Ottosson T Some lessonsfrom Swedish midwivesrsquo experiences of approaching women smokers inantenatal care Midwifery 200521335ndash45

[23] Vlasnik JJ Aliotta SL DeLor B Medication adherence factors influencingcompliance with prescribed medication plans Case Manager 200516(2)47ndash51

[24] McCourt C Supporting choice and control Communication and interactionbetween midwives and women at the antenatal booking visit Soc Sci Med2006621307ndash18

[25] Persson M Houmlrnsten Aring Winkvist A Mogren I ldquoMission impossiblerdquo Midwivesrsquoexperiences counseling pregnant women with gestational diabetes mellitusPatient Educ Couns 20118478ndash83

[26] Townsend L The moralizing of obesity a new name for an old sin Crit SocPol 200929171ndash90

[27] Copelton DA ldquoYou are what you eatrdquo nutritional norms maternal devianceand neutralization of womenrsquos prenatal diets Deviant Behav 200728467ndash94

[28] Kapur K Kapur A Ramachandran S Mohan V Aravind SR Badgandi M et alBarriers to change dietary behaviour J Assoc Physicians India 20085627ndash32

[29] Garnweidner LM Pettersen KS Mosdoslashl A Experiences with nutrition-relatedinformation during antenatal care of pregnant women of different ethnicbackgrounds residing in the area of Oslo Norway Midwifery 201329(12)e130ndash7

[30] Johnson M Campbell F Messina J Preston L Woods HB Goyder E Weightmanagement during pregnancy a systematic review of qualitative evidenceMidwifery 201329(12)1287ndash96

112 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

Results

The midwives described their general dietary information focuswas on prevention and the risks associated with unhealthy eatingSpecific advice included eating cooked meals on a regular basisavoiding alcohol toxins and contaminants and following theSwedish National Food Administrationrsquos (NFA) recommendationsInformation was given in early pregnancy and in connection withroutine oral glucose tolerance tests in mid-pregnancy Counsel-ling strategies used in challenging situations could be separated intofive categories with three to four subcategories each which are pre-sented in Table 2 and in text with quotations as examples

Strategies used in challenging situations

Challenges in dietary counselling were a common experience forthe midwives particularly with women diagnosed as overweightobese or with eating disorders Immigrant women vegans andwomen living in socio-economic deprivation were also men-tioned as being challenging to counsel The midwives often talkedin terms of ldquothe problematic womenrdquo In such counselling the mid-wives described various strategies which we have sorted into thefollowing five categories Getting acquainted Trying to support andmotivate Convincing about choosing ldquocorrectlyrdquo Controlling and mas-tering and Resigning responsibility (Table 2) These strategies weresometimes used as part of a process ie the more difficulty themidwife experienced connecting with the woman and more au-thoritative the midwives became On the other hand there were mid-wives who used only one or two strategies Overall the use ofcounselling strategies differed greatly among midwives The sub-categories are written in bold italics and are exemplified by orig-inal quotations in the text

Getting acquaintedIn this strategy which could be the first step of a counselling

process the midwives were striving to understand the women intheir contexts and life circumstances When women did not seemconcerned or bothered about their habits the midwives tried to un-derstand them and their problems better The midwives also de-scribed trying to evaluate the pregnant womenrsquos interests andmotivation by relating to them and offering them help and guid-ance based on individual needs Being curious about the womenrsquosown ideas and experience regarding how to solve problems wasdescribed as important

I think you must be very curious or curious about their experi-ences and their own ideas and telling them that if they wanthelp they can get it When you are too pushy then it will notwork out well irrespective of what you are saying You lead the wayand they are left behind (M 5)

When the midwives felt that they had problems reaching thepregnant women they commonly tried to adapt to the women bychanging counselling style to fit with an individual womanrsquos needs

I feel I have to meet her in the position she is in I have to startthere and maybe not talking only about their diet because theyoften know this very well Instead it is more about lifestyle pat-terns (M 10)

The participants were careful when asking about and discuss-ing lifestyle issues particularly with women who were either over-weight or underweight The midwives described how they wouldtread carefully when addressing the problems so as not to violatethe womenrsquos trust Counselling in weight issues was mentionedas even more difficult than addressing tobacco use or alcoholconsumption

You donrsquot really know [how to counsel women with weight prob-lems] Itrsquos like walking in a minefield You do not really know whatmight trigger them But on the other hand itrsquos nothing you haveto be frightened of Because itrsquos the only thing they think of them-selves FOOD By talking about it you might de-dramatize it (M 5)

Trying to support and motivateIn the second step of the process the midwives described how

they tried to listen actively in order to support womenrsquos motiva-tion for change By this they meant that they listened gave feed-back asked for further explanations and also confirmed their viewsof their problems

I listen actively and ask them how long it has been like this and howlong they want to keep it like this (M 5)

To support inner motivation for change the midwives also triedto facilitate reflection about habits and to problematise themSeveral midwives described how they discussed the costs and ben-efits of making lifestyle changes

Her BMI was 44 at the first visit so it was really large I asked herif she used to walk outdoors and reflected about physical activi-ties and about the costs related to her Coca-Cola consumption andsugar intake (M 6)

Supporting goal setting was another strategy to facilitate changeSetting goals that were too high and not realistic would not workDividing main goals into smaller ones and reaching them one at atime was seen as positive for self-efficacy and inner motivation Themidwives said that then women felt they had succeeded with atleast some part of the goal

It is realistic goals we are setting We donrsquot set 25 kg as a first goalbecause this is not achievable Instead we have smaller goals becauseif you take it stepwise it goes easier In this case we decidedtogether that she should simply not gain any weight during thepregnancy (M 6)

Convincing about choosing ldquocorrectlyrdquoSome midwives used this strategy exclusively but most only re-

sorted to it in situations when they felt that dialogue and counsel-ling did not work and they could not connect They then tried toconvince and persuade pregnant women about making the ldquocorrectchoicesrdquo in lifestyle and daily habits One common method used wasto transfer general medical knowledge about risks such as diabe-tes and hypertension and potential consequences of an unhealthy

Table 2Overview of categories and sub-categories

Strategies used in challenging situations

Getting acquainted Relating to and offering the women help and guidanceAdapting to the womenTreading carefully when addressing the problems

Trying to supportand motivate

Listening activelyFacilitating reflections about habitsSupporting goal setting

Convincing aboutchoosingldquocorrectlyrdquo

Transferring general medical knowledgeClarifying the messageRepeating the message

Controlling andmastering

Confronting the women with their poor lifestylesForming an alliance with the womenrsquos partnersFrightening them with medicals risks and complicationsMoralising about ldquogood motherhoodrdquo obligations andldquonormalrdquo family life

Resigningresponsibility

Referring the women to other health care professionalsTransferring responsibility to the womenDistancing from the womenGiving up ndash letting go

109AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

diet for the pregnancy the delivery the child and also for the ex-pecting motherrsquos future health

To convince them to change you tell them that it is important thatthe child avoids high blood sugars so as not to become obese in thefuture I asked her ldquoWhat do you believe is the reason for your highblood sugars Can it be that you eat a high amount of carbohy-drates that are wearing down your insulin receptorsrdquo (M 10)

Trying to clarify the message to reach a better understandingamong the women of the problem and how to solve it was also de-scribed as a common way to convince the women about the ldquorightchoicerdquo Using pedagogical approaches such as visualising and com-paring foods and nutritional issues were examples of this

It is easier to use a brochure to point things out in somewhat liketeaching the patients might not always want to keep the bro-chures and take them home but at least we have looked at themand read them and pointed things out and so on Therefore I cansee that they understand what I am talking about (M 9)

A few participants spoke of repeating the message over and overagain throughout the pregnancy when they sensed no response fromwomen and doing this even if the midwives thought their messagewas falling on deaf ears

She [the pregnant woman] doesnrsquot want me to butt into her eatinghabits but maybe it is something that will develop My hopeis that if you meet several times maybe sometime during the preg-nancy you will reach her and she will possibly listen to what youare saying (M 14)

Even if the midwife felt that her message continued to be ignoredrepeating it calmed her own worries about doing what was de-manded from her as midwife

Controlling and masteringIn order to influence women who did not adhere to dietary advice

some midwives described how they tried to control and master thewomenrsquos behaviour for example by telling them exactly how muchand how often they were allowed to eat ldquounhealthy foodrdquo Alter-natively they might ask women to keep diaries on food intake in-cluding kinds amounts and frequencies to present at the next visitThey would then confront the women with their bad habits andpoor lifestyle The midwives also spoke of situations when preg-nant women claimed that they had changed their dietary habits androutines although the midwives doubted if this was true

At the end of the pregnancy we were making a kind of summaryand at that meeting she said ldquoI am usually outdoors walkingrdquo ThenI touched her gently on her arm and asked ldquoAre you really honestnowrdquo ldquoNordquo she answered ldquoI have not been exercising at allrdquo(M 12)

As a way to insist on adherence to recommendations the mid-wives sometimes attempted getting into an alliance with thepartner of the expecting woman to get help in controlling andmastering her dietary habits

Then I turned to the guy and said ldquoPerhaps you then are inter-ested in food issues and can take this brochure and then wersquoll seeif there is something you would like to talk about something youdonrsquot really understandrdquo (M 5)

Some of the midwives also thought that to catch the womenrsquosattention they had to frighten them with medicals risks and com-plications Womenrsquos insufficient dietary habits were presented asa direct threat to the health and life of the foetus and also an obviousrisk for complications in delivery

I talk about and address some of the complications that occur if yougain 25ndash30 kg [I tell them that] many times this ends up in vacuumextraction and Caesarean section and prolonged labour (M 12)

Another patronising strategy to control the expecting women wasto moralise about the womanrsquos behaviour and relate that to normsabout ldquogood motherhoodrdquo obligations such as cooking and gath-ering the family around the dinner table If women were not suc-ceeding in their struggle to change to healthy dietary habits duringpregnancy the midwives appeared to sometimes question theirsuccess as mothers

I usually ask about which lifestyle they have thought of when be-coming a mother about what kind of role model they want to becomefor the child What is okay and not okay It is not only about eatingit is about other parts too (M 6)

Many of the midwives stated that the pregnancy is a period whenexpecting mothers have to adapt to new circumstances and a newrole with new responsibilities and that the midwife could influ-ence this process through counselling In the following quotationthe midwifersquos perception of what constitutes ldquonormalrdquo family lifealso becomes heteronormative and moralising

If I think forward in time and about the social importance that sur-rounds sitting down together as father mother and children to eatyou have the social aspects that are so meaningful and important(M 8)

Resigning responsibilityIn difficult situations when neither the communication nor the

relation between midwife and pregnant woman worked and themidwife comprehended the woman as non-adherent resigning re-sponsibility could be a last step One way to handle non-adherentwomen who were seen as problematic was to refer her to otherhealth care professionals such as dieticians physicians orpsychologists

Furthermore I find it difficult with vegetarians and vegans or thosewho have had different surgeries But in these cases they get a doctorwhom they can contact so you as a midwife can get away from theproblem (M 14)

When the midwives felt that they could not reach the womenwith any strategy or if they lacked knowledge or tools to motivateor persuade them to change they could transfer the responsibil-ity to the women themselves

It ends up with me saying ldquoBut you chose yourself what to do Iam not going to force anyone or say that it is absolute that one mustkeep to low-fat foodsrdquo (M 11)

Under these circumstances the midwives described how theysometimes were distancing themselves from the women and theirdietary problems This occurred for example when midwives foundthat they did not have sufficient knowledge or when they hadnothing more to add and therefore chose to focus on anything otherthan diet in their counselling

I explained that we would simply discontinue this and it didnrsquot feelgood It certainly did not but it felt like there were so many otheraspects around her that focusing on her diet was totally wrong atthat time At the same time you know itrsquos so important But noI could not take it anymore No (M 17)

Finally some midwives described how they also resigned re-sponsibility in counselling of women with many problems and par-ticularly when counselling immigrants from various cultures withunfamiliar dietary habits The midwives expressed helplessnessin counselling these women and used the strategy we have la-belled as giving up ndash letting go

110 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

These ones [immigrants] are really really hard You just have to leavethem to eat as usual They donrsquot eat this and they donrsquot eat thatand they eat this and that Well what should I do about it then(M 6)

Discussion

The interviewed midwives talked about ldquoproblematic womenrdquowhen describing those who were seen as challenging to counselIn so doing midwives defined the problem as arising from the in-dividual woman rather than her behaviour the interaction or fromthemselves and their limited understanding or counselling skill

When using the strategy Getting acquainted and Trying to supportand motivate the pregnant women the midwives described how lis-tening relating adapting and tiptoeing also facilitated reflec-tions problematising and goal setting We have interpreted thesestrategies as expressions of person-centred care (PCC) which is morethan just a method of communication and the midwives seemedto be considering the womenrsquos preferences experiences needs andvalues when using this approach Ekman and co-authors [18] pointedout the partnership as an important expression of PCC and suggestthree simple routines to facilitate and also safeguard the transi-tion to PCC which are (1) letting the patientrsquoswomanrsquos narrativesbecome the first step in establishing a partnership with the pro-fessional (2) shared decision-making which is built on this part-nership and (3) documentation in the patientrsquos record to contributeto the continuity and transparency of the partnership Another ofthe goals of PCC is to build an alliance between patients and healthcare professionals [1920] Such alliances were sought by the mid-wives using the get acquainted approach as they tried to identifythe expectant motherrsquos barriers and attitudes towards dietarychanges [21]

In line with our findings Abrahamsson et al [22] showed thatmidwives who tried to support pregnant women to quit smokingused strategies that they labelled ldquoFriend-makingrdquo and ldquoCo-operatingrdquo in which it was important to use the womanrsquos view asa starting point for the intervention Corcoran [21] stated that ef-ficient and satisfying communication plays an important role in anyefforts to improve health Furthermore she stated that the com-munication process is a multi-dimensional transaction influencedby a variety of factors in which both ldquocontentrdquo and ldquorelationshiprdquoare prominent The content is about how the message is transmit-ted and this is influenced by the relationship between the midwifeand the woman

We interpret the following strategies (Table 2) as less person-centred When using the strategy Convincing about choosing ldquocor-rectlyrdquo the midwives described a quite traditional patient educationapproach including transferring general medical knowledge andclarifying and repeating messages but also insisting on adher-ence Historically patient education in health care has been builton expectations of compliance which might be one reason for usingthis strategy In this approach health care professionals define theproblems and solutions and patients are expected to accept the givenadvice Vlasnik et al [23] stated that adherence represents a broaderinterpretation and understanding than compliance because adher-ence includes more components of shared decision-making The termadherence has been argued to have a larger focus on the providerndashpatient relationship and the patientrsquos involvement in care and ad-herence has been seen as a somewhat more contemporary conceptthan compliance However supporting womenrsquos choice and controlfits well into person-centred care approaches and more and morestudies are reporting positive outcomes from such interventionscompared with the relative ineffectiveness of trying to convincewomen [24]

When using the strategy Controlling and mastering women themidwives described that they were labelling and confronting preg-

nant women with their bad habits and lifestyles frightening themwith medical risks and complications and moralising about moth-erhood related to these habits Another aspect of control was to seeksupport from the womenrsquos partners in persuading women to makechanges The wordings of the subcategories ndash confronting fright-ening and moralising ndash tell us that counselling about diet can includepower relations In gestational diabetes Persson et al [25] foundthat the midwife acted as a medical guardian and explained thatthe mother-to-be had a moral obligation towards the foetus to makehealthy choices such as not gaining excessive weight As a healthissue and a matter for policies and interventions overweight andobesity have frequently been presented in the public discourse withinan existing moral framework that links these characteristics withmoral failure [26] Both midwives and mothers are actors in this dis-course A study about diet during pregnancy reported that preg-nant women constructed their identities as good mothers throughtheir monitored prenatal diets [27] In counselling about diet mid-wives must be aware of how they might impose guilt If the focusof a counselling session is on risk reduction then this strategy mightbe useful However because the outcome can be precarious controlshould be used with caution Although risk reduction is often themain focus for dietary counsellors who believe that insights intorisks will change diet practices knowledge of risks might not bethe most important determinant of food choices for individualsKnowledge of the benefits of healthy eating alone might also be in-sufficient to motivate dietary change Factors such as culture andsocial norms including taste preferences attitudes and beliefs avail-ability and accessibility influence peoplersquos food choices and shouldbe targeted to achieve changes in behaviour [28]

The last strategy resigning responsibility involves the midwivesdistancing themselves from the women transferring responsibili-ty to them and referring them to other health care professionalsThis strategy suggests that the midwives are giving up ndash letting goSimilar findings labelled ldquoavoidingrdquo were reported in a study aboutsmoking cessation during pregnancy Lack of competence withsmoking issues was expressed as a reason to abstaining from sucha discussion [22] Counselling women from other cultures withdeeply rooted dietary habits were also found to be difficult A studyof pregnant immigrant women in Norway revealed that dietary in-formation offered was very general weight management was neverdiscussed and information was incongruent with the womanrsquosculture [29] Persson et al [25] also described that when mid-wives found women with gestational diabetes failed to follow theiradvice they returned the responsibility to the women

Our results concur with those of a current systematic review [30]of qualitative evidence concerning weight management during preg-nancy reporting that health professionals are reluctant to discussweight management with obese women According to the authorsthis might be related to a fear of offending overweight women withbut also could be related to a lack of knowledge andor time for coun-selling challenging cases The review concludes that midwives requirespecialised knowledge about nutrition and physical activity duringpregnancy and appropriate referral information but also that somemidwives may lack communication skills Counselling around dietaryhabits that does not consider the multiple dimensions of decision-making associated with food and eating has limited effectiveness[30]

Telephone interviewing is an efficient method for data acquisi-tion It provides an opportunity for a good dialogue and procure-ment of personal experiences despite the lack of face-to-face contactWe performed and analysed 17 interviews with midwives butwe experienced a kind of data saturation after analysing about 12interviews However we had already interviewed 17 based on pre-vious experiences of qualitative content analysis and includedall interviews in the results Our sample of midwives from thewhole country from north to south and from different antenatal

111AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

settings rural and central was beneficial Because there is cultur-al diversity and difference in meaning about diet across Sweden thesample should and did this variety The interviewer in this studyis also a midwife which could be a strength in that the interview-er was knowledgeable about midwivesrsquo work and working condi-tions but simultaneously could pose a risk that latent meaning andcontent might get lost due to collegial agreement The inter-viewed midwives seemed to be especially interested in dietary coun-selling and this might have influenced the findings Despite thesepotential limitations we have interpreted our results as suggest-ing that several aspects of dietary counselling might need improve-ments We also find the method of telephone interviewing beneficialas midwives seemed able to express their opinions and narrate aboutpositive and negative experiences openly This may relate to the factthat the researcher and the participants were not known to eachother beforehand

Conclusion

In conclusion weight-related counselling and counselling ofwomen on special diets non-adherent women and immigrants orwomen from different cultures was described as particularly chal-lenging Midwives may need cooperation with dieticians to managesuch challenges Midwives also need improved education and train-ing to develop counselling skills such as motivational interview-ing for person-centred care during pregnancy Despite theireducation Swedish midwives may benefit from opportunitiesto train reflect and be observed when counselling This studyindicates that Swedish midwivesrsquo counselling strategiesrsquo can beambiguous controlling and coercive although also can be person-centred and that midwives struggle providing care to vulnerablepregnant women

Conflict of interest

None

Statement of authorship

ALW KH and AringH designed the study ALW recruited and inter-viewed the participants ALW analysed the data under supervi-sion of KH and AringH ALW drafted the manuscript but all authorscontributed to and approved the final version of the manuscript

Acknowledgements

We thank all participants for their contribution in the study aswell as the local coordinating midwives and local managers whowere helpful in the recruiting processThe study was supported bygrants from the County Council of Vaumlsterbotten Sweden

References

[1] Nord NNR 2012 ndash Nordic nutrition recommendations vol 002 5th edCopenhagen Nordic Council of Ministers 2014 p 180ndash3

[2] Kaiser L Allen LH Position of the American Dietetic Association nutrition andlifestyle for healthy pregnancy outcome J Am Diet Assoc 2008108553ndash61

[3] McMillen IC MacLaughlin SM Muhlhausler BS Gentili S Duffield JLMorrison JL Developmental origins of adult health and disease the roleof periconceptional and foetal nutrition Basic Clin Pharmacol Toxicol200810282ndash9

[4] Institute of Medicine and National Research Council (IOM) Weight gain duringpregnancy reexamining the guidelines Washington DC The NationalAcademies Press 2009

[5] Rasmussen KM Yaktine AL editors Weight gain during pregnancy reexamingthe guidelines Institute of Medicine National Research Council lthttpwwwnutrinfocombibliotecalibros_digitalesembarazopdfgt 2009

[6] The Swedish Medical Birth Register Official statistics of Sweden statisticsndashhealth and medical care pregnancies deliveries and newborn infants TheSwedish Medical Birth Register 1973ndash2010 Assisted reproduction treatment1991ndash2009 The National Board of Health and Welfare 2012

[7] Widen E Siega-Riz AM Prenatal nutrition a practical guide for assessment andcounseling J Midwifery Womenrsquos Health 201055540ndash9

[8] Szwajzer E Hiddik GJ Maas L Koelen M van Woerkum C Nutrition awarenessbefore and throughout different trimesters in pregnancy a quantitative studyamong Dutch women Fam Pract 201229i82ndash8

[9] Thangaratinam S Rogozinska E Jolly K Glinkowski S Roseboom T TomlinsonJW et al Effects of interventions in pregnancy on maternal weight and obstetricoutcomes meta-analysis of randomized evidence BMJ 2012344e2088

[10] Wennberg AL Lundqvist A Houmlgberg U Sandstroumlm H Hamberg K Womenrsquosexperiences of dietary advice and dietary changes during pregnancy Midwifery201329(9)1027ndash34

[11] Phelan S Phipps MG Abrams B Darroch F Schaffner A Wing RR Practitioneradvice and gestational weight gain J Womens Health 2011201ndash7

[12] Girard AW Olude O Nutrition education and counselling provided duringpregnancy Effects on maternal neonatal and child health outcomes PaediatrPerinat Epidemiol 201226S191ndash204

[13] Baker M Laurence W Crozier S Robinson S Baird J Margetts B et al Universityof South Hampton Educational attainment perceived control and the qualityof womenrsquos diets Appetite 200952631ndash6

[14] Joint WHOFAO Expert Consultation on Diet Nutrition and the Prevention ofChronic Diseases Diet nutrition and the prevention of chronic diseases reportof a joint WHOFAO expert consultation Geneva lthttpwwwwhointnutritionpublicationspublic_health_nut9pdfgt 2003

[15] National Preventative Health Taskforce Australia the healthiest country by2020 Technical report no 1 Obesity in Australia a need for urgent actionincluding addendum for October 2008 to June 2009 Canberra Commonwealthof Australia 2009

[16] Heslehurst N Russell S McCormack S Sedgewick G Bell R Rankin J Midwivesrsquoperspective of their training and education requirements in maternal obesitya qualitative study Midwifery 201329(7)736ndash44

[17] Graneheim UH Lundman B Qualitative content analysis in nursing researchconcepts procedures and measures to achieve trustworthiness Nurs Educ Today200424105ndash12

[18] Ekman I Swedberg K Taft C Lindseth A Norberg A Brink E et al Person-centered care ndash Ready for primetime Eur J Cardiovasc Nurs 201110248ndash51

[19] Mead N Bower P Patient-centredness a conceptual framework and reviewof the empirical literature Soc Sci Medi 2000511087ndash110

[20] Swedish Agency for Health and Care Services Analysis Patient centerednessin Swedenrsquos health system-an external assessment and six steps for progressReport 2012131ndash84

[21] Corcoran N Theories and models in communicating health messages InCorcoran N editor Communicating health ndash Approaches for health promotionLondon Sage 2007 p 5ndash95

[22] Abrahamsson A Springett J Karlsson L Haringkansson A Ottosson T Some lessonsfrom Swedish midwivesrsquo experiences of approaching women smokers inantenatal care Midwifery 200521335ndash45

[23] Vlasnik JJ Aliotta SL DeLor B Medication adherence factors influencingcompliance with prescribed medication plans Case Manager 200516(2)47ndash51

[24] McCourt C Supporting choice and control Communication and interactionbetween midwives and women at the antenatal booking visit Soc Sci Med2006621307ndash18

[25] Persson M Houmlrnsten Aring Winkvist A Mogren I ldquoMission impossiblerdquo Midwivesrsquoexperiences counseling pregnant women with gestational diabetes mellitusPatient Educ Couns 20118478ndash83

[26] Townsend L The moralizing of obesity a new name for an old sin Crit SocPol 200929171ndash90

[27] Copelton DA ldquoYou are what you eatrdquo nutritional norms maternal devianceand neutralization of womenrsquos prenatal diets Deviant Behav 200728467ndash94

[28] Kapur K Kapur A Ramachandran S Mohan V Aravind SR Badgandi M et alBarriers to change dietary behaviour J Assoc Physicians India 20085627ndash32

[29] Garnweidner LM Pettersen KS Mosdoslashl A Experiences with nutrition-relatedinformation during antenatal care of pregnant women of different ethnicbackgrounds residing in the area of Oslo Norway Midwifery 201329(12)e130ndash7

[30] Johnson M Campbell F Messina J Preston L Woods HB Goyder E Weightmanagement during pregnancy a systematic review of qualitative evidenceMidwifery 201329(12)1287ndash96

112 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

diet for the pregnancy the delivery the child and also for the ex-pecting motherrsquos future health

To convince them to change you tell them that it is important thatthe child avoids high blood sugars so as not to become obese in thefuture I asked her ldquoWhat do you believe is the reason for your highblood sugars Can it be that you eat a high amount of carbohy-drates that are wearing down your insulin receptorsrdquo (M 10)

Trying to clarify the message to reach a better understandingamong the women of the problem and how to solve it was also de-scribed as a common way to convince the women about the ldquorightchoicerdquo Using pedagogical approaches such as visualising and com-paring foods and nutritional issues were examples of this

It is easier to use a brochure to point things out in somewhat liketeaching the patients might not always want to keep the bro-chures and take them home but at least we have looked at themand read them and pointed things out and so on Therefore I cansee that they understand what I am talking about (M 9)

A few participants spoke of repeating the message over and overagain throughout the pregnancy when they sensed no response fromwomen and doing this even if the midwives thought their messagewas falling on deaf ears

She [the pregnant woman] doesnrsquot want me to butt into her eatinghabits but maybe it is something that will develop My hopeis that if you meet several times maybe sometime during the preg-nancy you will reach her and she will possibly listen to what youare saying (M 14)

Even if the midwife felt that her message continued to be ignoredrepeating it calmed her own worries about doing what was de-manded from her as midwife

Controlling and masteringIn order to influence women who did not adhere to dietary advice

some midwives described how they tried to control and master thewomenrsquos behaviour for example by telling them exactly how muchand how often they were allowed to eat ldquounhealthy foodrdquo Alter-natively they might ask women to keep diaries on food intake in-cluding kinds amounts and frequencies to present at the next visitThey would then confront the women with their bad habits andpoor lifestyle The midwives also spoke of situations when preg-nant women claimed that they had changed their dietary habits androutines although the midwives doubted if this was true

At the end of the pregnancy we were making a kind of summaryand at that meeting she said ldquoI am usually outdoors walkingrdquo ThenI touched her gently on her arm and asked ldquoAre you really honestnowrdquo ldquoNordquo she answered ldquoI have not been exercising at allrdquo(M 12)

As a way to insist on adherence to recommendations the mid-wives sometimes attempted getting into an alliance with thepartner of the expecting woman to get help in controlling andmastering her dietary habits

Then I turned to the guy and said ldquoPerhaps you then are inter-ested in food issues and can take this brochure and then wersquoll seeif there is something you would like to talk about something youdonrsquot really understandrdquo (M 5)

Some of the midwives also thought that to catch the womenrsquosattention they had to frighten them with medicals risks and com-plications Womenrsquos insufficient dietary habits were presented asa direct threat to the health and life of the foetus and also an obviousrisk for complications in delivery

I talk about and address some of the complications that occur if yougain 25ndash30 kg [I tell them that] many times this ends up in vacuumextraction and Caesarean section and prolonged labour (M 12)

Another patronising strategy to control the expecting women wasto moralise about the womanrsquos behaviour and relate that to normsabout ldquogood motherhoodrdquo obligations such as cooking and gath-ering the family around the dinner table If women were not suc-ceeding in their struggle to change to healthy dietary habits duringpregnancy the midwives appeared to sometimes question theirsuccess as mothers

I usually ask about which lifestyle they have thought of when be-coming a mother about what kind of role model they want to becomefor the child What is okay and not okay It is not only about eatingit is about other parts too (M 6)

Many of the midwives stated that the pregnancy is a period whenexpecting mothers have to adapt to new circumstances and a newrole with new responsibilities and that the midwife could influ-ence this process through counselling In the following quotationthe midwifersquos perception of what constitutes ldquonormalrdquo family lifealso becomes heteronormative and moralising

If I think forward in time and about the social importance that sur-rounds sitting down together as father mother and children to eatyou have the social aspects that are so meaningful and important(M 8)

Resigning responsibilityIn difficult situations when neither the communication nor the

relation between midwife and pregnant woman worked and themidwife comprehended the woman as non-adherent resigning re-sponsibility could be a last step One way to handle non-adherentwomen who were seen as problematic was to refer her to otherhealth care professionals such as dieticians physicians orpsychologists

Furthermore I find it difficult with vegetarians and vegans or thosewho have had different surgeries But in these cases they get a doctorwhom they can contact so you as a midwife can get away from theproblem (M 14)

When the midwives felt that they could not reach the womenwith any strategy or if they lacked knowledge or tools to motivateor persuade them to change they could transfer the responsibil-ity to the women themselves

It ends up with me saying ldquoBut you chose yourself what to do Iam not going to force anyone or say that it is absolute that one mustkeep to low-fat foodsrdquo (M 11)

Under these circumstances the midwives described how theysometimes were distancing themselves from the women and theirdietary problems This occurred for example when midwives foundthat they did not have sufficient knowledge or when they hadnothing more to add and therefore chose to focus on anything otherthan diet in their counselling

I explained that we would simply discontinue this and it didnrsquot feelgood It certainly did not but it felt like there were so many otheraspects around her that focusing on her diet was totally wrong atthat time At the same time you know itrsquos so important But noI could not take it anymore No (M 17)

Finally some midwives described how they also resigned re-sponsibility in counselling of women with many problems and par-ticularly when counselling immigrants from various cultures withunfamiliar dietary habits The midwives expressed helplessnessin counselling these women and used the strategy we have la-belled as giving up ndash letting go

110 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

These ones [immigrants] are really really hard You just have to leavethem to eat as usual They donrsquot eat this and they donrsquot eat thatand they eat this and that Well what should I do about it then(M 6)

Discussion

The interviewed midwives talked about ldquoproblematic womenrdquowhen describing those who were seen as challenging to counselIn so doing midwives defined the problem as arising from the in-dividual woman rather than her behaviour the interaction or fromthemselves and their limited understanding or counselling skill

When using the strategy Getting acquainted and Trying to supportand motivate the pregnant women the midwives described how lis-tening relating adapting and tiptoeing also facilitated reflec-tions problematising and goal setting We have interpreted thesestrategies as expressions of person-centred care (PCC) which is morethan just a method of communication and the midwives seemedto be considering the womenrsquos preferences experiences needs andvalues when using this approach Ekman and co-authors [18] pointedout the partnership as an important expression of PCC and suggestthree simple routines to facilitate and also safeguard the transi-tion to PCC which are (1) letting the patientrsquoswomanrsquos narrativesbecome the first step in establishing a partnership with the pro-fessional (2) shared decision-making which is built on this part-nership and (3) documentation in the patientrsquos record to contributeto the continuity and transparency of the partnership Another ofthe goals of PCC is to build an alliance between patients and healthcare professionals [1920] Such alliances were sought by the mid-wives using the get acquainted approach as they tried to identifythe expectant motherrsquos barriers and attitudes towards dietarychanges [21]

In line with our findings Abrahamsson et al [22] showed thatmidwives who tried to support pregnant women to quit smokingused strategies that they labelled ldquoFriend-makingrdquo and ldquoCo-operatingrdquo in which it was important to use the womanrsquos view asa starting point for the intervention Corcoran [21] stated that ef-ficient and satisfying communication plays an important role in anyefforts to improve health Furthermore she stated that the com-munication process is a multi-dimensional transaction influencedby a variety of factors in which both ldquocontentrdquo and ldquorelationshiprdquoare prominent The content is about how the message is transmit-ted and this is influenced by the relationship between the midwifeand the woman

We interpret the following strategies (Table 2) as less person-centred When using the strategy Convincing about choosing ldquocor-rectlyrdquo the midwives described a quite traditional patient educationapproach including transferring general medical knowledge andclarifying and repeating messages but also insisting on adher-ence Historically patient education in health care has been builton expectations of compliance which might be one reason for usingthis strategy In this approach health care professionals define theproblems and solutions and patients are expected to accept the givenadvice Vlasnik et al [23] stated that adherence represents a broaderinterpretation and understanding than compliance because adher-ence includes more components of shared decision-making The termadherence has been argued to have a larger focus on the providerndashpatient relationship and the patientrsquos involvement in care and ad-herence has been seen as a somewhat more contemporary conceptthan compliance However supporting womenrsquos choice and controlfits well into person-centred care approaches and more and morestudies are reporting positive outcomes from such interventionscompared with the relative ineffectiveness of trying to convincewomen [24]

When using the strategy Controlling and mastering women themidwives described that they were labelling and confronting preg-

nant women with their bad habits and lifestyles frightening themwith medical risks and complications and moralising about moth-erhood related to these habits Another aspect of control was to seeksupport from the womenrsquos partners in persuading women to makechanges The wordings of the subcategories ndash confronting fright-ening and moralising ndash tell us that counselling about diet can includepower relations In gestational diabetes Persson et al [25] foundthat the midwife acted as a medical guardian and explained thatthe mother-to-be had a moral obligation towards the foetus to makehealthy choices such as not gaining excessive weight As a healthissue and a matter for policies and interventions overweight andobesity have frequently been presented in the public discourse withinan existing moral framework that links these characteristics withmoral failure [26] Both midwives and mothers are actors in this dis-course A study about diet during pregnancy reported that preg-nant women constructed their identities as good mothers throughtheir monitored prenatal diets [27] In counselling about diet mid-wives must be aware of how they might impose guilt If the focusof a counselling session is on risk reduction then this strategy mightbe useful However because the outcome can be precarious controlshould be used with caution Although risk reduction is often themain focus for dietary counsellors who believe that insights intorisks will change diet practices knowledge of risks might not bethe most important determinant of food choices for individualsKnowledge of the benefits of healthy eating alone might also be in-sufficient to motivate dietary change Factors such as culture andsocial norms including taste preferences attitudes and beliefs avail-ability and accessibility influence peoplersquos food choices and shouldbe targeted to achieve changes in behaviour [28]

The last strategy resigning responsibility involves the midwivesdistancing themselves from the women transferring responsibili-ty to them and referring them to other health care professionalsThis strategy suggests that the midwives are giving up ndash letting goSimilar findings labelled ldquoavoidingrdquo were reported in a study aboutsmoking cessation during pregnancy Lack of competence withsmoking issues was expressed as a reason to abstaining from sucha discussion [22] Counselling women from other cultures withdeeply rooted dietary habits were also found to be difficult A studyof pregnant immigrant women in Norway revealed that dietary in-formation offered was very general weight management was neverdiscussed and information was incongruent with the womanrsquosculture [29] Persson et al [25] also described that when mid-wives found women with gestational diabetes failed to follow theiradvice they returned the responsibility to the women

Our results concur with those of a current systematic review [30]of qualitative evidence concerning weight management during preg-nancy reporting that health professionals are reluctant to discussweight management with obese women According to the authorsthis might be related to a fear of offending overweight women withbut also could be related to a lack of knowledge andor time for coun-selling challenging cases The review concludes that midwives requirespecialised knowledge about nutrition and physical activity duringpregnancy and appropriate referral information but also that somemidwives may lack communication skills Counselling around dietaryhabits that does not consider the multiple dimensions of decision-making associated with food and eating has limited effectiveness[30]

Telephone interviewing is an efficient method for data acquisi-tion It provides an opportunity for a good dialogue and procure-ment of personal experiences despite the lack of face-to-face contactWe performed and analysed 17 interviews with midwives butwe experienced a kind of data saturation after analysing about 12interviews However we had already interviewed 17 based on pre-vious experiences of qualitative content analysis and includedall interviews in the results Our sample of midwives from thewhole country from north to south and from different antenatal

111AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

settings rural and central was beneficial Because there is cultur-al diversity and difference in meaning about diet across Sweden thesample should and did this variety The interviewer in this studyis also a midwife which could be a strength in that the interview-er was knowledgeable about midwivesrsquo work and working condi-tions but simultaneously could pose a risk that latent meaning andcontent might get lost due to collegial agreement The inter-viewed midwives seemed to be especially interested in dietary coun-selling and this might have influenced the findings Despite thesepotential limitations we have interpreted our results as suggest-ing that several aspects of dietary counselling might need improve-ments We also find the method of telephone interviewing beneficialas midwives seemed able to express their opinions and narrate aboutpositive and negative experiences openly This may relate to the factthat the researcher and the participants were not known to eachother beforehand

Conclusion

In conclusion weight-related counselling and counselling ofwomen on special diets non-adherent women and immigrants orwomen from different cultures was described as particularly chal-lenging Midwives may need cooperation with dieticians to managesuch challenges Midwives also need improved education and train-ing to develop counselling skills such as motivational interview-ing for person-centred care during pregnancy Despite theireducation Swedish midwives may benefit from opportunitiesto train reflect and be observed when counselling This studyindicates that Swedish midwivesrsquo counselling strategiesrsquo can beambiguous controlling and coercive although also can be person-centred and that midwives struggle providing care to vulnerablepregnant women

Conflict of interest

None

Statement of authorship

ALW KH and AringH designed the study ALW recruited and inter-viewed the participants ALW analysed the data under supervi-sion of KH and AringH ALW drafted the manuscript but all authorscontributed to and approved the final version of the manuscript

Acknowledgements

We thank all participants for their contribution in the study aswell as the local coordinating midwives and local managers whowere helpful in the recruiting processThe study was supported bygrants from the County Council of Vaumlsterbotten Sweden

References

[1] Nord NNR 2012 ndash Nordic nutrition recommendations vol 002 5th edCopenhagen Nordic Council of Ministers 2014 p 180ndash3

[2] Kaiser L Allen LH Position of the American Dietetic Association nutrition andlifestyle for healthy pregnancy outcome J Am Diet Assoc 2008108553ndash61

[3] McMillen IC MacLaughlin SM Muhlhausler BS Gentili S Duffield JLMorrison JL Developmental origins of adult health and disease the roleof periconceptional and foetal nutrition Basic Clin Pharmacol Toxicol200810282ndash9

[4] Institute of Medicine and National Research Council (IOM) Weight gain duringpregnancy reexamining the guidelines Washington DC The NationalAcademies Press 2009

[5] Rasmussen KM Yaktine AL editors Weight gain during pregnancy reexamingthe guidelines Institute of Medicine National Research Council lthttpwwwnutrinfocombibliotecalibros_digitalesembarazopdfgt 2009

[6] The Swedish Medical Birth Register Official statistics of Sweden statisticsndashhealth and medical care pregnancies deliveries and newborn infants TheSwedish Medical Birth Register 1973ndash2010 Assisted reproduction treatment1991ndash2009 The National Board of Health and Welfare 2012

[7] Widen E Siega-Riz AM Prenatal nutrition a practical guide for assessment andcounseling J Midwifery Womenrsquos Health 201055540ndash9

[8] Szwajzer E Hiddik GJ Maas L Koelen M van Woerkum C Nutrition awarenessbefore and throughout different trimesters in pregnancy a quantitative studyamong Dutch women Fam Pract 201229i82ndash8

[9] Thangaratinam S Rogozinska E Jolly K Glinkowski S Roseboom T TomlinsonJW et al Effects of interventions in pregnancy on maternal weight and obstetricoutcomes meta-analysis of randomized evidence BMJ 2012344e2088

[10] Wennberg AL Lundqvist A Houmlgberg U Sandstroumlm H Hamberg K Womenrsquosexperiences of dietary advice and dietary changes during pregnancy Midwifery201329(9)1027ndash34

[11] Phelan S Phipps MG Abrams B Darroch F Schaffner A Wing RR Practitioneradvice and gestational weight gain J Womens Health 2011201ndash7

[12] Girard AW Olude O Nutrition education and counselling provided duringpregnancy Effects on maternal neonatal and child health outcomes PaediatrPerinat Epidemiol 201226S191ndash204

[13] Baker M Laurence W Crozier S Robinson S Baird J Margetts B et al Universityof South Hampton Educational attainment perceived control and the qualityof womenrsquos diets Appetite 200952631ndash6

[14] Joint WHOFAO Expert Consultation on Diet Nutrition and the Prevention ofChronic Diseases Diet nutrition and the prevention of chronic diseases reportof a joint WHOFAO expert consultation Geneva lthttpwwwwhointnutritionpublicationspublic_health_nut9pdfgt 2003

[15] National Preventative Health Taskforce Australia the healthiest country by2020 Technical report no 1 Obesity in Australia a need for urgent actionincluding addendum for October 2008 to June 2009 Canberra Commonwealthof Australia 2009

[16] Heslehurst N Russell S McCormack S Sedgewick G Bell R Rankin J Midwivesrsquoperspective of their training and education requirements in maternal obesitya qualitative study Midwifery 201329(7)736ndash44

[17] Graneheim UH Lundman B Qualitative content analysis in nursing researchconcepts procedures and measures to achieve trustworthiness Nurs Educ Today200424105ndash12

[18] Ekman I Swedberg K Taft C Lindseth A Norberg A Brink E et al Person-centered care ndash Ready for primetime Eur J Cardiovasc Nurs 201110248ndash51

[19] Mead N Bower P Patient-centredness a conceptual framework and reviewof the empirical literature Soc Sci Medi 2000511087ndash110

[20] Swedish Agency for Health and Care Services Analysis Patient centerednessin Swedenrsquos health system-an external assessment and six steps for progressReport 2012131ndash84

[21] Corcoran N Theories and models in communicating health messages InCorcoran N editor Communicating health ndash Approaches for health promotionLondon Sage 2007 p 5ndash95

[22] Abrahamsson A Springett J Karlsson L Haringkansson A Ottosson T Some lessonsfrom Swedish midwivesrsquo experiences of approaching women smokers inantenatal care Midwifery 200521335ndash45

[23] Vlasnik JJ Aliotta SL DeLor B Medication adherence factors influencingcompliance with prescribed medication plans Case Manager 200516(2)47ndash51

[24] McCourt C Supporting choice and control Communication and interactionbetween midwives and women at the antenatal booking visit Soc Sci Med2006621307ndash18

[25] Persson M Houmlrnsten Aring Winkvist A Mogren I ldquoMission impossiblerdquo Midwivesrsquoexperiences counseling pregnant women with gestational diabetes mellitusPatient Educ Couns 20118478ndash83

[26] Townsend L The moralizing of obesity a new name for an old sin Crit SocPol 200929171ndash90

[27] Copelton DA ldquoYou are what you eatrdquo nutritional norms maternal devianceand neutralization of womenrsquos prenatal diets Deviant Behav 200728467ndash94

[28] Kapur K Kapur A Ramachandran S Mohan V Aravind SR Badgandi M et alBarriers to change dietary behaviour J Assoc Physicians India 20085627ndash32

[29] Garnweidner LM Pettersen KS Mosdoslashl A Experiences with nutrition-relatedinformation during antenatal care of pregnant women of different ethnicbackgrounds residing in the area of Oslo Norway Midwifery 201329(12)e130ndash7

[30] Johnson M Campbell F Messina J Preston L Woods HB Goyder E Weightmanagement during pregnancy a systematic review of qualitative evidenceMidwifery 201329(12)1287ndash96

112 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

These ones [immigrants] are really really hard You just have to leavethem to eat as usual They donrsquot eat this and they donrsquot eat thatand they eat this and that Well what should I do about it then(M 6)

Discussion

The interviewed midwives talked about ldquoproblematic womenrdquowhen describing those who were seen as challenging to counselIn so doing midwives defined the problem as arising from the in-dividual woman rather than her behaviour the interaction or fromthemselves and their limited understanding or counselling skill

When using the strategy Getting acquainted and Trying to supportand motivate the pregnant women the midwives described how lis-tening relating adapting and tiptoeing also facilitated reflec-tions problematising and goal setting We have interpreted thesestrategies as expressions of person-centred care (PCC) which is morethan just a method of communication and the midwives seemedto be considering the womenrsquos preferences experiences needs andvalues when using this approach Ekman and co-authors [18] pointedout the partnership as an important expression of PCC and suggestthree simple routines to facilitate and also safeguard the transi-tion to PCC which are (1) letting the patientrsquoswomanrsquos narrativesbecome the first step in establishing a partnership with the pro-fessional (2) shared decision-making which is built on this part-nership and (3) documentation in the patientrsquos record to contributeto the continuity and transparency of the partnership Another ofthe goals of PCC is to build an alliance between patients and healthcare professionals [1920] Such alliances were sought by the mid-wives using the get acquainted approach as they tried to identifythe expectant motherrsquos barriers and attitudes towards dietarychanges [21]

In line with our findings Abrahamsson et al [22] showed thatmidwives who tried to support pregnant women to quit smokingused strategies that they labelled ldquoFriend-makingrdquo and ldquoCo-operatingrdquo in which it was important to use the womanrsquos view asa starting point for the intervention Corcoran [21] stated that ef-ficient and satisfying communication plays an important role in anyefforts to improve health Furthermore she stated that the com-munication process is a multi-dimensional transaction influencedby a variety of factors in which both ldquocontentrdquo and ldquorelationshiprdquoare prominent The content is about how the message is transmit-ted and this is influenced by the relationship between the midwifeand the woman

We interpret the following strategies (Table 2) as less person-centred When using the strategy Convincing about choosing ldquocor-rectlyrdquo the midwives described a quite traditional patient educationapproach including transferring general medical knowledge andclarifying and repeating messages but also insisting on adher-ence Historically patient education in health care has been builton expectations of compliance which might be one reason for usingthis strategy In this approach health care professionals define theproblems and solutions and patients are expected to accept the givenadvice Vlasnik et al [23] stated that adherence represents a broaderinterpretation and understanding than compliance because adher-ence includes more components of shared decision-making The termadherence has been argued to have a larger focus on the providerndashpatient relationship and the patientrsquos involvement in care and ad-herence has been seen as a somewhat more contemporary conceptthan compliance However supporting womenrsquos choice and controlfits well into person-centred care approaches and more and morestudies are reporting positive outcomes from such interventionscompared with the relative ineffectiveness of trying to convincewomen [24]

When using the strategy Controlling and mastering women themidwives described that they were labelling and confronting preg-

nant women with their bad habits and lifestyles frightening themwith medical risks and complications and moralising about moth-erhood related to these habits Another aspect of control was to seeksupport from the womenrsquos partners in persuading women to makechanges The wordings of the subcategories ndash confronting fright-ening and moralising ndash tell us that counselling about diet can includepower relations In gestational diabetes Persson et al [25] foundthat the midwife acted as a medical guardian and explained thatthe mother-to-be had a moral obligation towards the foetus to makehealthy choices such as not gaining excessive weight As a healthissue and a matter for policies and interventions overweight andobesity have frequently been presented in the public discourse withinan existing moral framework that links these characteristics withmoral failure [26] Both midwives and mothers are actors in this dis-course A study about diet during pregnancy reported that preg-nant women constructed their identities as good mothers throughtheir monitored prenatal diets [27] In counselling about diet mid-wives must be aware of how they might impose guilt If the focusof a counselling session is on risk reduction then this strategy mightbe useful However because the outcome can be precarious controlshould be used with caution Although risk reduction is often themain focus for dietary counsellors who believe that insights intorisks will change diet practices knowledge of risks might not bethe most important determinant of food choices for individualsKnowledge of the benefits of healthy eating alone might also be in-sufficient to motivate dietary change Factors such as culture andsocial norms including taste preferences attitudes and beliefs avail-ability and accessibility influence peoplersquos food choices and shouldbe targeted to achieve changes in behaviour [28]

The last strategy resigning responsibility involves the midwivesdistancing themselves from the women transferring responsibili-ty to them and referring them to other health care professionalsThis strategy suggests that the midwives are giving up ndash letting goSimilar findings labelled ldquoavoidingrdquo were reported in a study aboutsmoking cessation during pregnancy Lack of competence withsmoking issues was expressed as a reason to abstaining from sucha discussion [22] Counselling women from other cultures withdeeply rooted dietary habits were also found to be difficult A studyof pregnant immigrant women in Norway revealed that dietary in-formation offered was very general weight management was neverdiscussed and information was incongruent with the womanrsquosculture [29] Persson et al [25] also described that when mid-wives found women with gestational diabetes failed to follow theiradvice they returned the responsibility to the women

Our results concur with those of a current systematic review [30]of qualitative evidence concerning weight management during preg-nancy reporting that health professionals are reluctant to discussweight management with obese women According to the authorsthis might be related to a fear of offending overweight women withbut also could be related to a lack of knowledge andor time for coun-selling challenging cases The review concludes that midwives requirespecialised knowledge about nutrition and physical activity duringpregnancy and appropriate referral information but also that somemidwives may lack communication skills Counselling around dietaryhabits that does not consider the multiple dimensions of decision-making associated with food and eating has limited effectiveness[30]

Telephone interviewing is an efficient method for data acquisi-tion It provides an opportunity for a good dialogue and procure-ment of personal experiences despite the lack of face-to-face contactWe performed and analysed 17 interviews with midwives butwe experienced a kind of data saturation after analysing about 12interviews However we had already interviewed 17 based on pre-vious experiences of qualitative content analysis and includedall interviews in the results Our sample of midwives from thewhole country from north to south and from different antenatal

111AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

settings rural and central was beneficial Because there is cultur-al diversity and difference in meaning about diet across Sweden thesample should and did this variety The interviewer in this studyis also a midwife which could be a strength in that the interview-er was knowledgeable about midwivesrsquo work and working condi-tions but simultaneously could pose a risk that latent meaning andcontent might get lost due to collegial agreement The inter-viewed midwives seemed to be especially interested in dietary coun-selling and this might have influenced the findings Despite thesepotential limitations we have interpreted our results as suggest-ing that several aspects of dietary counselling might need improve-ments We also find the method of telephone interviewing beneficialas midwives seemed able to express their opinions and narrate aboutpositive and negative experiences openly This may relate to the factthat the researcher and the participants were not known to eachother beforehand

Conclusion

In conclusion weight-related counselling and counselling ofwomen on special diets non-adherent women and immigrants orwomen from different cultures was described as particularly chal-lenging Midwives may need cooperation with dieticians to managesuch challenges Midwives also need improved education and train-ing to develop counselling skills such as motivational interview-ing for person-centred care during pregnancy Despite theireducation Swedish midwives may benefit from opportunitiesto train reflect and be observed when counselling This studyindicates that Swedish midwivesrsquo counselling strategiesrsquo can beambiguous controlling and coercive although also can be person-centred and that midwives struggle providing care to vulnerablepregnant women

Conflict of interest

None

Statement of authorship

ALW KH and AringH designed the study ALW recruited and inter-viewed the participants ALW analysed the data under supervi-sion of KH and AringH ALW drafted the manuscript but all authorscontributed to and approved the final version of the manuscript

Acknowledgements

We thank all participants for their contribution in the study aswell as the local coordinating midwives and local managers whowere helpful in the recruiting processThe study was supported bygrants from the County Council of Vaumlsterbotten Sweden

References

[1] Nord NNR 2012 ndash Nordic nutrition recommendations vol 002 5th edCopenhagen Nordic Council of Ministers 2014 p 180ndash3

[2] Kaiser L Allen LH Position of the American Dietetic Association nutrition andlifestyle for healthy pregnancy outcome J Am Diet Assoc 2008108553ndash61

[3] McMillen IC MacLaughlin SM Muhlhausler BS Gentili S Duffield JLMorrison JL Developmental origins of adult health and disease the roleof periconceptional and foetal nutrition Basic Clin Pharmacol Toxicol200810282ndash9

[4] Institute of Medicine and National Research Council (IOM) Weight gain duringpregnancy reexamining the guidelines Washington DC The NationalAcademies Press 2009

[5] Rasmussen KM Yaktine AL editors Weight gain during pregnancy reexamingthe guidelines Institute of Medicine National Research Council lthttpwwwnutrinfocombibliotecalibros_digitalesembarazopdfgt 2009

[6] The Swedish Medical Birth Register Official statistics of Sweden statisticsndashhealth and medical care pregnancies deliveries and newborn infants TheSwedish Medical Birth Register 1973ndash2010 Assisted reproduction treatment1991ndash2009 The National Board of Health and Welfare 2012

[7] Widen E Siega-Riz AM Prenatal nutrition a practical guide for assessment andcounseling J Midwifery Womenrsquos Health 201055540ndash9

[8] Szwajzer E Hiddik GJ Maas L Koelen M van Woerkum C Nutrition awarenessbefore and throughout different trimesters in pregnancy a quantitative studyamong Dutch women Fam Pract 201229i82ndash8

[9] Thangaratinam S Rogozinska E Jolly K Glinkowski S Roseboom T TomlinsonJW et al Effects of interventions in pregnancy on maternal weight and obstetricoutcomes meta-analysis of randomized evidence BMJ 2012344e2088

[10] Wennberg AL Lundqvist A Houmlgberg U Sandstroumlm H Hamberg K Womenrsquosexperiences of dietary advice and dietary changes during pregnancy Midwifery201329(9)1027ndash34

[11] Phelan S Phipps MG Abrams B Darroch F Schaffner A Wing RR Practitioneradvice and gestational weight gain J Womens Health 2011201ndash7

[12] Girard AW Olude O Nutrition education and counselling provided duringpregnancy Effects on maternal neonatal and child health outcomes PaediatrPerinat Epidemiol 201226S191ndash204

[13] Baker M Laurence W Crozier S Robinson S Baird J Margetts B et al Universityof South Hampton Educational attainment perceived control and the qualityof womenrsquos diets Appetite 200952631ndash6

[14] Joint WHOFAO Expert Consultation on Diet Nutrition and the Prevention ofChronic Diseases Diet nutrition and the prevention of chronic diseases reportof a joint WHOFAO expert consultation Geneva lthttpwwwwhointnutritionpublicationspublic_health_nut9pdfgt 2003

[15] National Preventative Health Taskforce Australia the healthiest country by2020 Technical report no 1 Obesity in Australia a need for urgent actionincluding addendum for October 2008 to June 2009 Canberra Commonwealthof Australia 2009

[16] Heslehurst N Russell S McCormack S Sedgewick G Bell R Rankin J Midwivesrsquoperspective of their training and education requirements in maternal obesitya qualitative study Midwifery 201329(7)736ndash44

[17] Graneheim UH Lundman B Qualitative content analysis in nursing researchconcepts procedures and measures to achieve trustworthiness Nurs Educ Today200424105ndash12

[18] Ekman I Swedberg K Taft C Lindseth A Norberg A Brink E et al Person-centered care ndash Ready for primetime Eur J Cardiovasc Nurs 201110248ndash51

[19] Mead N Bower P Patient-centredness a conceptual framework and reviewof the empirical literature Soc Sci Medi 2000511087ndash110

[20] Swedish Agency for Health and Care Services Analysis Patient centerednessin Swedenrsquos health system-an external assessment and six steps for progressReport 2012131ndash84

[21] Corcoran N Theories and models in communicating health messages InCorcoran N editor Communicating health ndash Approaches for health promotionLondon Sage 2007 p 5ndash95

[22] Abrahamsson A Springett J Karlsson L Haringkansson A Ottosson T Some lessonsfrom Swedish midwivesrsquo experiences of approaching women smokers inantenatal care Midwifery 200521335ndash45

[23] Vlasnik JJ Aliotta SL DeLor B Medication adherence factors influencingcompliance with prescribed medication plans Case Manager 200516(2)47ndash51

[24] McCourt C Supporting choice and control Communication and interactionbetween midwives and women at the antenatal booking visit Soc Sci Med2006621307ndash18

[25] Persson M Houmlrnsten Aring Winkvist A Mogren I ldquoMission impossiblerdquo Midwivesrsquoexperiences counseling pregnant women with gestational diabetes mellitusPatient Educ Couns 20118478ndash83

[26] Townsend L The moralizing of obesity a new name for an old sin Crit SocPol 200929171ndash90

[27] Copelton DA ldquoYou are what you eatrdquo nutritional norms maternal devianceand neutralization of womenrsquos prenatal diets Deviant Behav 200728467ndash94

[28] Kapur K Kapur A Ramachandran S Mohan V Aravind SR Badgandi M et alBarriers to change dietary behaviour J Assoc Physicians India 20085627ndash32

[29] Garnweidner LM Pettersen KS Mosdoslashl A Experiences with nutrition-relatedinformation during antenatal care of pregnant women of different ethnicbackgrounds residing in the area of Oslo Norway Midwifery 201329(12)e130ndash7

[30] Johnson M Campbell F Messina J Preston L Woods HB Goyder E Weightmanagement during pregnancy a systematic review of qualitative evidenceMidwifery 201329(12)1287ndash96

112 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112

settings rural and central was beneficial Because there is cultur-al diversity and difference in meaning about diet across Sweden thesample should and did this variety The interviewer in this studyis also a midwife which could be a strength in that the interview-er was knowledgeable about midwivesrsquo work and working condi-tions but simultaneously could pose a risk that latent meaning andcontent might get lost due to collegial agreement The inter-viewed midwives seemed to be especially interested in dietary coun-selling and this might have influenced the findings Despite thesepotential limitations we have interpreted our results as suggest-ing that several aspects of dietary counselling might need improve-ments We also find the method of telephone interviewing beneficialas midwives seemed able to express their opinions and narrate aboutpositive and negative experiences openly This may relate to the factthat the researcher and the participants were not known to eachother beforehand

Conclusion

In conclusion weight-related counselling and counselling ofwomen on special diets non-adherent women and immigrants orwomen from different cultures was described as particularly chal-lenging Midwives may need cooperation with dieticians to managesuch challenges Midwives also need improved education and train-ing to develop counselling skills such as motivational interview-ing for person-centred care during pregnancy Despite theireducation Swedish midwives may benefit from opportunitiesto train reflect and be observed when counselling This studyindicates that Swedish midwivesrsquo counselling strategiesrsquo can beambiguous controlling and coercive although also can be person-centred and that midwives struggle providing care to vulnerablepregnant women

Conflict of interest

None

Statement of authorship

ALW KH and AringH designed the study ALW recruited and inter-viewed the participants ALW analysed the data under supervi-sion of KH and AringH ALW drafted the manuscript but all authorscontributed to and approved the final version of the manuscript

Acknowledgements

We thank all participants for their contribution in the study aswell as the local coordinating midwives and local managers whowere helpful in the recruiting processThe study was supported bygrants from the County Council of Vaumlsterbotten Sweden

References

[1] Nord NNR 2012 ndash Nordic nutrition recommendations vol 002 5th edCopenhagen Nordic Council of Ministers 2014 p 180ndash3

[2] Kaiser L Allen LH Position of the American Dietetic Association nutrition andlifestyle for healthy pregnancy outcome J Am Diet Assoc 2008108553ndash61

[3] McMillen IC MacLaughlin SM Muhlhausler BS Gentili S Duffield JLMorrison JL Developmental origins of adult health and disease the roleof periconceptional and foetal nutrition Basic Clin Pharmacol Toxicol200810282ndash9

[4] Institute of Medicine and National Research Council (IOM) Weight gain duringpregnancy reexamining the guidelines Washington DC The NationalAcademies Press 2009

[5] Rasmussen KM Yaktine AL editors Weight gain during pregnancy reexamingthe guidelines Institute of Medicine National Research Council lthttpwwwnutrinfocombibliotecalibros_digitalesembarazopdfgt 2009

[6] The Swedish Medical Birth Register Official statistics of Sweden statisticsndashhealth and medical care pregnancies deliveries and newborn infants TheSwedish Medical Birth Register 1973ndash2010 Assisted reproduction treatment1991ndash2009 The National Board of Health and Welfare 2012

[7] Widen E Siega-Riz AM Prenatal nutrition a practical guide for assessment andcounseling J Midwifery Womenrsquos Health 201055540ndash9

[8] Szwajzer E Hiddik GJ Maas L Koelen M van Woerkum C Nutrition awarenessbefore and throughout different trimesters in pregnancy a quantitative studyamong Dutch women Fam Pract 201229i82ndash8

[9] Thangaratinam S Rogozinska E Jolly K Glinkowski S Roseboom T TomlinsonJW et al Effects of interventions in pregnancy on maternal weight and obstetricoutcomes meta-analysis of randomized evidence BMJ 2012344e2088

[10] Wennberg AL Lundqvist A Houmlgberg U Sandstroumlm H Hamberg K Womenrsquosexperiences of dietary advice and dietary changes during pregnancy Midwifery201329(9)1027ndash34

[11] Phelan S Phipps MG Abrams B Darroch F Schaffner A Wing RR Practitioneradvice and gestational weight gain J Womens Health 2011201ndash7

[12] Girard AW Olude O Nutrition education and counselling provided duringpregnancy Effects on maternal neonatal and child health outcomes PaediatrPerinat Epidemiol 201226S191ndash204

[13] Baker M Laurence W Crozier S Robinson S Baird J Margetts B et al Universityof South Hampton Educational attainment perceived control and the qualityof womenrsquos diets Appetite 200952631ndash6

[14] Joint WHOFAO Expert Consultation on Diet Nutrition and the Prevention ofChronic Diseases Diet nutrition and the prevention of chronic diseases reportof a joint WHOFAO expert consultation Geneva lthttpwwwwhointnutritionpublicationspublic_health_nut9pdfgt 2003

[15] National Preventative Health Taskforce Australia the healthiest country by2020 Technical report no 1 Obesity in Australia a need for urgent actionincluding addendum for October 2008 to June 2009 Canberra Commonwealthof Australia 2009

[16] Heslehurst N Russell S McCormack S Sedgewick G Bell R Rankin J Midwivesrsquoperspective of their training and education requirements in maternal obesitya qualitative study Midwifery 201329(7)736ndash44

[17] Graneheim UH Lundman B Qualitative content analysis in nursing researchconcepts procedures and measures to achieve trustworthiness Nurs Educ Today200424105ndash12

[18] Ekman I Swedberg K Taft C Lindseth A Norberg A Brink E et al Person-centered care ndash Ready for primetime Eur J Cardiovasc Nurs 201110248ndash51

[19] Mead N Bower P Patient-centredness a conceptual framework and reviewof the empirical literature Soc Sci Medi 2000511087ndash110

[20] Swedish Agency for Health and Care Services Analysis Patient centerednessin Swedenrsquos health system-an external assessment and six steps for progressReport 2012131ndash84

[21] Corcoran N Theories and models in communicating health messages InCorcoran N editor Communicating health ndash Approaches for health promotionLondon Sage 2007 p 5ndash95

[22] Abrahamsson A Springett J Karlsson L Haringkansson A Ottosson T Some lessonsfrom Swedish midwivesrsquo experiences of approaching women smokers inantenatal care Midwifery 200521335ndash45

[23] Vlasnik JJ Aliotta SL DeLor B Medication adherence factors influencingcompliance with prescribed medication plans Case Manager 200516(2)47ndash51

[24] McCourt C Supporting choice and control Communication and interactionbetween midwives and women at the antenatal booking visit Soc Sci Med2006621307ndash18

[25] Persson M Houmlrnsten Aring Winkvist A Mogren I ldquoMission impossiblerdquo Midwivesrsquoexperiences counseling pregnant women with gestational diabetes mellitusPatient Educ Couns 20118478ndash83

[26] Townsend L The moralizing of obesity a new name for an old sin Crit SocPol 200929171ndash90

[27] Copelton DA ldquoYou are what you eatrdquo nutritional norms maternal devianceand neutralization of womenrsquos prenatal diets Deviant Behav 200728467ndash94

[28] Kapur K Kapur A Ramachandran S Mohan V Aravind SR Badgandi M et alBarriers to change dietary behaviour J Assoc Physicians India 20085627ndash32

[29] Garnweidner LM Pettersen KS Mosdoslashl A Experiences with nutrition-relatedinformation during antenatal care of pregnant women of different ethnicbackgrounds residing in the area of Oslo Norway Midwifery 201329(12)e130ndash7

[30] Johnson M Campbell F Messina J Preston L Woods HB Goyder E Weightmanagement during pregnancy a systematic review of qualitative evidenceMidwifery 201329(12)1287ndash96

112 AL Wennberg et alSexual amp Reproductive Healthcare 5 (2014) 107ndash112