Introduction

Latinos are the largest and fastest-growing minority group in the U.S. [1], and Latina women represent the largest portion of minority births, having the highest birth rate in the U.S. for over 20 years [2]. In addition, evidence shows Latina women are at increased risk of entering pregnancy overweight or obese [3].

Excessive gestational weight gain (GWG) is a risk factor for obesity that has short- and long-term adverse health outcomes for the woman (e.g., gestational diabetes, postpartum weight retention, risk of obesity, etc.) and her child (e.g., birth weight, risk of obesity) [3,4]. Moreover, evidence suggests that excessive GWG contributes to disparities in obesity among Latino children [5,6], which first emerge in the transmission of intergenerational risk factors for obesity in the earliest life stage (i.e., pregnancy through 24 months of age) [5,6].

A range of factors influence excessive GWG, including maternal sociodemographic characteristics [5,6], medical care [7], gestational conditions [3,4], pre-pregnancy body mass index (BMI) [7,8], maternal factors (such as maternal age) [9], parity [8], and maternal behaviors such as smoking [9], dietary intake [9], and physical activity [10]. Additionally, a growing body of literature indicates that structural inequalities (e.g., access to health care, health insurance coverage, physical and financial resources, material hardships, etc.) influence low-income minority women’s risk of excessive GWG [3,4,10,11]. Research also suggests that women’s knowledge, beliefs, and attitudes about GWG are influenced by sociocultural factors (e.g., income, education, social support and social networks, race and ethnicity, language, and acculturation) [12,13].

Despite an understanding of a range of factors associated with excessive GWG, interventions to prevent excessive GWG in the general population [14,15] and among Latina women [16–19] have had mixed results. A systematic review and meta-analysis of antenatal dietary and lifestyle interventions (n = 9) including studies involving multiracial women to reduce excessive GWG concluded that the number and quality of published trials was insufficient to allow evidence-based recommendations for clinical practice to be developed [8]. Similarly, another systematic review of behavioral interventions for weight management in pregnancy including studies involving multi-racial samples and including quantitative and qualitative studies (five controlled trials and eight qualitative studies), found no significant difference in GWG among participants in the intervention group compared with the control group [15].

In contrast, a more recent systematic review and meta-analysis including studies involving multiracial women showed positive intervention results and found that most dietary and lifestyle interventions in pregnancy reduce GWG without having an adverse effect on the risk of babies being small for gestational age [14]. Overall, findings of this systematic review and meta-analysis showed that interventions focusing on healthy eating had a larger effect size in limiting GWG than interventions that addressed both healthy eating and physical activity [14]. On the other hand, interventions that focused solely on physical activity did not show a significant pooled effect [14].

Furthermore, other studies conducted among multiracial pregnant women including Latinas have found a lack of awareness among women who are overweight or have obesity regarding excessive GWG and have identified barriers (e.g., getting time off from work; location of services offered; intensity of intervention, which limited compliance) that impede the use of resources to address excessive GWG [13,14,16,17].

Moreover, preliminary findings of a recent feasibility study of a randomized controlled trial of a lifestyle intervention with Latina women, Proyecto Mamá, suggested that the intervention helped mitigate a decline in vigorous physical activity over the course of pregnancy among Hispanic women who were overweight or had obesity [16–18]. Although the study had a relatively small sample size (n = 68), it demonstrated that strategies for helping pregnant Latina (Hispanic) women overcome barriers to physical activity participation and to attending group sessions are needed for such interventions to be successful [18].

Similarly, another recent trial designed to test the feasibility and efficacy of a prenatal behavioral intervention in a sample of low-income, predominantly Latina women showed initial positive results [19]. Compared to usual care, fewer healthy-weight women in the intervention arm exceeded recommendations for GWG (47.1% usual care vs. 6.7% intervention; absolute difference 40.4%). Nonetheless, frequently changing work schedules made it challenging to ensure that women attended a sufficient number of group sessions or developed behavior change skills through other modalities [19].

These findings combined suggest that a greater understanding of low-income women including Latinas’ beliefs, attitudes, and experiences with GWG is needed to further identify and address barriers to participation and compliance to interventions designed to promote healthy GWG. The present qualitative study further explored these topics.

Methods

The present study (n = 23) was part of a larger ongoing, community-based, mixed-methods exploratory research study (n = 150) [20]. The overall goal of the larger study is to explore and identify factors associated with risk of obesity in the first 1,000 days of life in multi-ethnic Hispanic and Brazilian families living in Massachusetts (MA) and Rhode Island (RI). We used the socioecological model (SEM) as a framework for this study [21]. The SEM considers intrapersonal, interpersonal, environmental, organizational, and policy influences on health and can be used to identify factors that are potentially amenable to intervention and modification [21]. In addition, we also considered the social contextual model (SCM), an adaptation of the SEM developed by Sorensen et al. [22], which integrates social class and culture to the levels posited by the SEM. The SCM emphasizes the expression of cultural pathways that may explicitly inform the design of health promotion interventions [22].

This study was conducted in accordance with guidelines for the Consolidated Criteria for Reporting Qualitative Research (COREQ) [23]. Using an exploratory descriptive qualitative methodology [24], individual, in-depth interviews were conducted with first-time pregnant immigrant Latina women to explore (a) beliefs about, attitudes toward, and experiences with GWG during pregnancy; and (b) perspectives about and current experiences with patient-provider communication related to GWG during pregnancy.

Qualitative research methods allow researchers and participants to discover and explore topic areas without predetermined quantitative questions [25]. In-depth, semi-structured interviews were the qualitative research method chosen for this study because they allow for the collection of valuable information in diverse cultural settings [25]. Moreover, individual interviews were preferred over focus groups given the challenge of assembling a group of pregnant women, most of whom, were in their third trimesters. This study received ethical approval from the University of Massachusetts–Boston Ethics Board (IRB#2013132).

Data collection

Native Spanish (AH) and Portuguese (ACL, GDA) speakers trained in qualitative research methods conducted all interviews in Spanish or Portuguese from the same semi-structured interview guide, which included open-ended questions and probes (see Table 1). Interviews were held at public locations (library, community agency, church) convenient for participants or, if requested, at the participant’s house. Trained bilingual (Portuguese and English or Spanish and English) research assistants took notes during all interviews.

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Table 1. Interview questions on Latina women’s beliefs about, attitudes toward, and experiences with gestational weight gain during their first pregnancy.

https://doi.org/10.1371/journal.pone.0219371.t001

Interviews took place between June 2016 and March 2017 and lasted approximately 45 minutes. Prior to the start of all interviews, participants were given written information—either in Spanish or Portuguese—about the study. All interviews were audio-recorded after participants provided signed and oral informed consent.

The pilot-tested interview guide explored three primary domains of inquiry: (1) participants’ beliefs about and attitudes toward GWG; (2) participants’ experiences with GWG; and (3) patient-provider communication and advice related to GWG and PA during pregnancy. This paper focuses on the first two domains of inquiry (i.e., beliefs and attitudes toward GWG and experiences with GWG). Results of the third domain of inquiry are presented elsewhere [20].

All participants completed a brief, self-administered survey after the interview ended. The survey assessed participants’ socio-demographics (education, marital status, country of origin, length of time living in the U.S., etc.), self-reported perceived weight status prior to start of pregnancy, and level of acculturation via the Short Acculturation Scale for Hispanics (SASH), [26]. The SASH is a 12-item measuring scale validated for use in Latino groups such as, Mexican Americans, Cuban Americans, Puerto Ricans, Dominicans, and Central and South Americans that assesses language use, media use, and ethnic social relations [26]. An acculturation score was computed by averaging across 12 items as measured on a scale of one to five (1 = least acculturated, 5 = fully acculturated) [26]. Participants received a $25 gift card at the end of the interview for their participation.

Results

A total of 23 individual semi-structured interviews were conducted with a diverse sample of Latina pregnant women (12 multi-ethnic Hispanics and 11 Brazilians). Participants’ characteristics are presented in Table 2. Women’s (n = 23) ages ranged from 22 to 35 (mean = 24.1, SD = 2.3) years of age. Nearly all participants (n = 22, 96%) were foreign-born and had lived in the U.S. for an average of 8.2 years (SD = 2.4). No participants spoke English as their primary language, and participants had a mean acculturation score of 1.62 (SD = 0.37), indicating that they identified more closely with Latino culture than with U.S. culture. About 83% of women were married. About 44% had completed high school (n = 10) or obtained a general education degree (GED; n = 4; 17.3%), and the majority (n = 19; 87.3%) reported family annual income of ≥ US $20,000 and < US $40,000/year. Last, a little over half (n = 12; 53.2%) of the participants reported being a healthy weight prior at the start of pregnancy, while about 44% (n = 10) reported being overweight, and only one participant self-reported having obesity prior to the start of pregnancy.

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Table 2. Sociodemographic and acculturation characteristics and self-reported weight status of study participants (n = 23).

https://doi.org/10.1371/journal.pone.0219371.t002

Thematic content analysis identified 13 emergent themes within two examined domains: (1) women’s beliefs about and attitudes toward GWG (eight themes), and (2) women’s experiences with GWG (six themes). Themes were organized using the SEM and SCM [41,42]. Emergent themes are presented in Table 3, with representative quotes translated to English to illustrate findings.

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Table 3. Interview themes and supporting quotes from Latina women (n = 23) regarding their beliefs, attitudes, and experiences with gestational weight gain.

https://doi.org/10.1371/journal.pone.0219371.t003

Discussion

The findings of this exploratory qualitative study provide insight into sociocultural and interpersonal influences on first-time pregnant, low-income immigrant Latina women’s beliefs, attitudes, and experiences with GWG. This study’s findings indicate that participants were uncertain if their GWG was within a healthy range. Overall, findings showed that participants knew that GWG should be limited, but were not sure what the amount should be. Furthermore, the majority of participants reported attitudes of acceptance of and resignation to excessive GWG as being part of pregnancy. Several women appeared to believe that they did not have control over their weight gain during pregnancy. These findings concur with prior research conducted among Latina women [8,16–18,28] and have implications for the interventions designed for this population, a group at increased risk of excessive GWG and associated adverse consequences [9,15,16,18].

Women in the current study appeared to be more concerned about their baby’s health than about excessive GWG and their personal health. Women felt that that as long their baby was developing healthfully they did not yet need to worry about excessive GWG. This finding may reflect that participants in this study were not aware of the close link between a mother and child’s health and suggests the need for education about the short- and long-term consequences of excessive GWG for both mother and baby [9,10].

Women’s acceptance of GWG above a healthy range appeared to be shared and reinforced by their friends and family members. This finding is supported by prior research among Latina women revealing widespread sociocultural beliefs that reinforce that greater GWG is associated with healthier babies [3,4,28]. Combined, these studies indicate the need for increased awareness and education of the potential adverse consequences of excessive GWG for both mothers and babies. Furthermore, interventions designed to address GWG among Latina women should include women’s immediate social support networks of family members and friends [4,28].

Similar to previous studies, findings of the current study revealed that low-income Latina women perceived pregnancy as a time to set aside worries about eating habits [3,12,13,29]. Furthermore, as found in the current study, prior research shows that cultural beliefs enforce the idea that pregnancy is a unique time when women are allowed to give into cravings and eat for two [12,28]. Additionally, findings from the current study concur with previous research [12,28,29] and suggest that women’s social support networks influenced their sociocultural beliefs about weight gain during pregnancy. For example, nearly all women in this study reported that the social acceptance of the weight gain during pregnancy tended to alleviate the pressures they felt about what they perceived as the right amount of GWG. As mentioned above, these findings suggest that effective interventions aimed at prevention of excessive GWG among low-income Latina women should target not only pregnant Latina women but also their immediate social support networks [12,13,28,29].

Limitations

Findings of the present study should be interpreted in light of some limitations. This was an exploratory study of first-time pregnant Latina women’s beliefs, attitudes, and experiences with GWG, and findings are based on a nonrandom, purposive, and relatively small sample of women living in MA and RI. Study participants may have been motivated to participate in the study due to heightened interest in the topic (GWG) since recruitment materials indicated the topic was a focus of the study. This study did not assess women’s physical activity levels and or perceptions of physical activity and diet, both of which are factors influencing GWG. Finally, this study relied on self-reported information from participants, including the self-reported BMI category, which may lead to misclassification (underestimation). Overweight women or women with obesity may be more likely to misclassify their weight status than women in a healthy weight range [30]. Finally, this study did not assess health care providers’ counseling practices, and prior studies suggest that women and health care providers report conflicting views on counseling [31].

Future research can address these limitations by examining perspectives from health care providers from these and other communities across the U.S. and comparing differences by women’s country of origin. Additionally, future studies focusing on Latina women should assess physical activity and diet using both objective and subjective assessment methods. Moreover, quantitative research that builds on the qualitative findings reported in the present study is needed on both pregnant Latina women and health care providers to quantify women’s beliefs, attitudes, and experiences with GWG.

Conclusions

Latina women represent the largest portion of minority births and have had the highest birth rate in the U.S. for over 20 years. Therefore, understanding factors that influence pregnant Latina women’s beliefs, attitudes, and experiences with GWG is central to the prevention of excessive GWG and its related adverse health consequences for both mothers and their babies. Findings from the current study revealed that sociocultural and interpersonal factors influence the beliefs, attitudes, and experiences with GWG of low-income, immigrant Latina women pregnant with their first child. This information can be used to tailor prenatal care practices and interventions aimed at altering modifiable risk factors associated with excessive GWG.

Supporting information

Acknowledgments

The authors thank the women who participated in the study as well as the programs and community-based agencies in Massachusetts and Rhode Island, United States, for support in data collection. We are also grateful to Ms. Amina Hetu, BA, and Ms. Gabriela De Andrade, BS, for collaborating in data collection.