1. Introduction

Pregnant women are expected to gain weight due to physiological changes during pregnancy [1]. There are a number of gestational weight gain (GWG) guidelines [2, 3]. However, most of them were adapted from and similar to the 2009 United State Institutes of Medicine (IOM) recommendations guideline [2]. None of these guidelines were developed for Ethiopia or contexts similar to Ethiopia. The IOM recommends weight gain of 5 to 9 kg for obese women; 7 to 11 kg for overweight women; 11.5 to 16 kg for normal weight women, and 12.5 to 18 kg for underweight women [1].

Gaining gestational weight outside of the IOM recommendations can pose health risks for the baby [4] and the mother [5, 6]. Pregnant women who gain inadequate weight are at high risk of bearing a baby with low birth weight (LBW) and pre-term birth [7–10]. On the other hand, excessive GWG increases the risks of caesarean delivery [11], hypertension during pregnancy [5, 6, 10], postpartum weight retention [12], and development of long-term obesity [13]. Women are at a high risk of transitioning from normal weight to overweight or obesity following the pregnancy or during the postpartum period [13, 14]. Counselling pregnant women on gestational weight gain and dietary management increases the likelihood of gaining appropriate gestational weight [15, 16], and therefore helps to influence women’s future health [13, 17].

Pregnancy related weight management is influenced by several factors [18, 19]. These factors include women’s knowledge [18, 20], attitudes [19], and concerns [21] towards weight management during pregnancy; care providers’ knowledge and confidence on GWG counselling [14, 22], perceived sensitivity of GWG by care providers [23–25], scepticism about the impact of counselling on women’s behaviour [14], level of priority placed on GWG issues [14, 25, 26], shortage of time to discuss weight and nutrition during pregnancy care [27], and lack of familiarity with GWG guidelines [14, 26].

The 2016 Ethiopian Demographic and Health Survey reported that 13.4% of women of childbearing age were underweight; 57.2% were normal weight; 21.7 were overweight and 7.7% were obese; and almost half (49%) of these women were illiterate [28]. There are wide-ranging misconceptions and poor knowledge about nutrition during pregnancy [29]; and more than 70% (67–69% gain inadequate weight; 3–4% gain excess weight) of pregnant women in major cities of Ethiopia like Harar and Addis Ababa gain inappropriate gestational weight [30, 31].

Midwives and obstetricians are well positioned to advise pregnant women about how much weight to gain and how to manage nutrition and GWG appropriately during antenatal care visits [17, 32]. However, despite the 2016 World Health Organization (WHO) antenatal care (ANC) model recommending a minimum of eight ANC contacts [33], in Ethiopia the focused antenatal care model is still practised, resulting in around 90% of women in settings such as Addis Ababa receiving four ANC contacts (first contact before 16 weeks of pregnancy; second between 24 and 28 weeks of pregnancy; third at 32 weeks of pregnancy; and the fourth visit at 36 weeks of pregnancy) [34]. In the public health facilities of Addis Ababa, women with uncomplicated pregnancies receive care from midwives at the health centre level while women with complicated pregnancies receive care from obstetricians at the hospital level. As key maternity care providers [35, 36], midwives and obstetricians are the most trusted source of information regarding nutrition and GWG [37].

Few studies have been conducted in Ethiopia focusing on GWG [4, 30, 31, 38]. No studies have addressed the issue of midwives’ and obstetricians’ views and practices regarding GWG and postpartum weight management. Given the influence of midwives [39, 40] and obstetricians [39, 41] on perinatal women, understanding their views, perceived barriers to managing GWG, and GWG management practices is important [42]. The aim of this study was to explore obstetricians’ and midwives’ views and practices related to GWG and postpartum weight management in this setting.

2. Methods

We used a qualitative descriptive study design. A qualitative descriptive approach provides a comprehensive understanding of given circumstance, a rich description of the participants’ experiences or actions from the participants’ perspectives [43]. Given midwives’ and obstetricians’ perspectives have not been explored in the Ethiopian context, a qualitative descriptive approach is an appropriate form of inquiry to describe how the midwives and obstetricians feel and manage GWG and postpartum weight retention. Therefore, we did not use a conceptual model or theory as a qualitative descriptive study aims to explore the who, what and where of midwives’ and obstetricians’ perspectives about pregnancy related weight management in Ethiopia. A qualitative descriptive approach is foundational to qualitative research and is a valuable methodological approach in and of itself without the need for a theoretical framework [44]. Moreover, qualitative descriptive findings can inform new interventions within the sociocultural context of the participants [45]. Ethics approval for the study was obtained from the Haramaya University Institutional Health Research Ethics Review Committee [IHRERC/200/2018], Addis Ababa Health Bureau Institutional Review Board [A/A/HB/2576/227] and the University of Technology Sydney, Human Research Ethics Committee [UTS HREC18-2610].

2.2 Data collection

Following written informed consent, we conducted 21 in-depth interviews, 11 with midwives and 10 with obstetricians, from January 2019 to March 2019. The primary author conducted the interviews in the local language, Amharic. The primary author is not a midwife or obstetrician, he is a public health professional and postgraduate student and did not have any influence over the participants. The data collection was performed through face-to-face interviews. The interviews were held in a private room within the health facility (hospital or health centre), at a convenient time to the participants. We used open ended questions to elicit their views, perceptions and counselling experiences in relation to GWG and postpartum weight management. We developed the interview guide after reviewing the literature [14, 25, 46, 47]. The interview guide questions (both English and Amharic versions) are provided in the additional file (S1 Table). To test the interview questions, we conducted preliminary interviews with three midwives. Data collection continued until data saturation was reached.

Due to the qualitative nature of the study, we did not collect detailed demographic data about the participants other than to note professional affiliation, gender, employment location and years of work experience in maternity care (Table 1).

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Table 1. Summary of participant characteristics, Addis Ababa, Ethiopia, 2019.

https://doi.org/10.1371/journal.pone.0244221.t001

2.3 Data analysis

All audio recorded interviews were transcribed verbatim into English. The accuracy of transcripts was checked by comparing the text with each recorded interview, by the author (FA), who is a fluent Amharic and an English language speaker. We used Nvivo software version 11 (QSR International) [48] to manage written transcripts and to facilitate the coding process, categorising similar codes, and storage of the data. Due to practicality issues (i.e. data analysis was conducted in Australia), the data collected from the participants was not verified by the participants to determine whether the analysis of the data was consistent with the participants understanding of the comments made by them. The data was compared and contrasted by all authors to ensure rigour.

We analysed the data using thematic analysis [49] to assess repeated views, perspectives, and practices across all data. Data was collected until saturation was reached, that is hearing the same themes over and over. Different themes and sub-themes were developed from the data as described in Table 2 where an example of the coding is provided. During the analysis, we followed the six phases of thematic analysis according to Braun and Clarke’s (2006) recommendations [50]. First, we began the analysis by reading and rereading to become familiar with the data and noted the main ideas from the data. Second, we examined transcripts line by line to identify dominant ideas and to draft codes. Third, we categorised similar codes into similar categories to search for possible themes and sub-themes. Fourth, we checked for the identified themes and sub-themes in relation to the coded extracts and the full data set. Fifth, we defined and named the themes and sub-themes while writing the overall findings that the analysis revealed. Finally, we developed the final report by selecting illustrative quotes. While using the quotes, participants were de-identified to maintain their anonymity and the quotes were presented in terms of participant numbers such as Obst.1 (obstetrician 1), or Mid.1 (midwife 1).

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Table 2. Examples of themes, initial codes, and quotations, Addis Ababa, Ethiopia, 2019.

https://doi.org/10.1371/journal.pone.0244221.t002

3. Findings

We identified three themes and associated sub-themes: 1) knowledge of optimal gestational weight gain; 2) gestational weight gain counselling experience; 3) Ethiopian culture influences postpartum weight gain.

4. Discussion

The present study explored the views, practices and observations of midwives and obstetricians regarding GWG and postpartum weight management. Study participants had limited knowledge regarding the optimal amount of gestational weight gain. Almost all participants were unaware of the existence of the IOM GWG recommendations. The participants discussed the need for a GWG guideline that is appropriate for Ethiopia. They observed the presence of widespread misconceptions among women about pregnancy weight management; that women did not want to gain weight during pregnancy but want to gain weight after birth. Participants reported that they did not provide counselling for pregnant women about weight management. The most common reason for the lack counselling was lack of attention to GWG and postpartum weight loss issues.

All participants reported that pregnant women need to gain weight due to physiological changes throughout pregnancy. However, they observed that women were not interested in gaining weight during pregnancy. Other studies in the major cities of Ethiopia like Harar and Addis Ababa have reported that more than 67% of pregnant women in Ethiopia gain below the IOM recommendations [30, 31]. This may be due to women decreasing food consumption during pregnancy perceiving that overeating or eating foods with high energy density may cause a large for gestational age baby that will make the birth difficult [29, 51] or that the IOM guidelines are not appropriate for this setting.

The amount of GWG recommendations stated by the study participants varies with each other and with the IOM recommendations. This could partly be explained by the lack of appropriate GWG guidelines for Ethiopia so that obstetricians use a variety of foreign sources such as textbooks and websites. By contrast, almost all midwives described a target weight gain for normal weight women only, and there was uncertainty among midwives regarding the description of the expected amount of GWG for underweight, overweight or obese women. Our finding is consistent with other studies in which midwives lack knowledge of the appropriate amount of GWG, even in high-income country settings [14, 22, 52]. This indicates that there is a need for improving understanding regarding the recommended amount of GWG, the importance of GWG and providing midwives and obstetricians with guidance to manage GWG [25].

Almost all study participants were not aware of the existence of or the recommendations in the IOM guideline. They suggested the need for developing GWG guidelines for Ethiopia. Obstetricians stated the need for information about the nutrition and energy density of local foods, and the amount of energy intake needed during pregnancy, to be included in such a guideline. In addition, midwives lacked the confidence to offer nutritional counselling. Another study set in Ethiopia [53] recommended short-term in-service training for midwives to help them carry out nutrition and GWG counselling tasks.

Almost all study participants revealed that they routinely measure the weight of pregnant women but do not counsel appropriately on GWG. They either never raise the issue of weight at all or do not provide women with specific information such as how much weight they gained or need to gain. Some participants felt that telling women how much weight to gain is unnecessary. Most participants did not encourage women with normal weight to monitor their own weight. However, some counselled women about gestational weight when a woman either did not gain weight or had a loss of weight; had abnormal weight; or presented with conditions such as hypertension or gestational diabetes mellitus. Studies also revealed that physicians and prenatal specialists are more likely to counsel women who are at higher risk of or with disease than low-risk women [26, 27]. Midwives and obstetricians need to be encouraged to provide counselling about gestational weight gain management consistently for all pregnant women. The main reasons for lack of counselling about GWG in our study was a lack of knowledge and guidance in advice to provide women. Our participants also stated counselling around appropriate weight gain was a low priority. This finding is consistent with several other studies [14, 25, 26]. This indicates that midwives and obstetricians need to be well informed about the impact of inappropriate GWG on the health of the mother and baby so that they can appropriately prioritise the issue. Other reasons for lack of counselling was the high workload midwives and obstetricians experienced, and pregnant women in this setting did not generally enquire about their weight. However, while most of our study participants believed that initiating discussions about GWG was primarily their responsibility, they typically waited for the woman to raise this issue. Continuing education for midwives and obstetricians to develop skills in counselling women about nutrition during pregnancy and the postpartum period could help to improve the quality of maternal care provided for pregnant women in Ethiopia and ultimately reduce the workload for clinicians. An alternative approach could be to increase the health literacy of women and families in the community about the issue of GWG and the need to ensure pregnant and postnatal women receive optimal nutrition. Both of these recommendations would require resources and intervention at the level of government.

Midwives described a lack of confidence in advising women about GWG and nutrition as a barrier to their practice. This is consistent with other studies in which maternity care providers reported a lack of confidence in communicating about nutrition and weight as a major barrier to the management of GWG [14, 25, 54]. One study has shown that new midwifery graduates in Ethiopia have limited competency in nutrition counselling [53], which may be linked to inadequate nutrition education provided in midwifery programmes [52]. In contrast, although obstetricians felt that they were relatively confident to give nutritional advice, they underscored the necessity of involving nutritionists in antenatal counselling and the need for a GWG guideline. Studies also suggested a multidisciplinary approach, such as involving a nutritionist, in counselling and guidance of appropriate GWG [26, 32]. The most common nutritional advice that study participants provided for pregnant women was to increase their frequency of meals and to eat foods that were affordable or easily accessible at home. Counselling on specific nutrients and nutrition recommendations appeared to be even more difficult when the midwife or obstetrician believed the woman could not afford to buy specific foods. Affordability of appropriate nutrition is an issue that needs to be addressed by the Ethiopian government through improving pregnant women’s income so that they can access and afford recommended foods during pregnancy.

In our study, all participants perceived that the postpartum weight management of Ethiopian women was inappropriate (i.e. most of the women aimed to gain weight during the post-partum period). According to the participants, the main factors that led women to gain weight during this period were an increase in food consumption and lack of physical exercise. Postpartum ceremonies include the family, relatives and even neighbours who prepare foods with high energy density such as porridge and gruel with butter for puerperal women. An increased intake of food during the postnatal period is aimed at replacing blood and energy lost during the birth; to facilitate the healing process for any injury that happened during childbearing; and to increase milk production. The participants believed that women’s energy needs and their intake during the postpartum period were not balanced.

Participants stated that postpartum women do not engage in exercise and typically stay inside for up to three months of the postnatal period in Ethiopia. Confinement to the home is a common practice in other cultures too [55, 56], but the length of time is usually shorter (up to 40 days). Although a reasonable amount of rest is important to facilitate the transition to mothering, a prolonged time of decreased activity may lead to postpartum weight retention [57]. Therefore, postpartum women should be encouraged to take gentle exercise as early as appropriate following the birth [58].

Participants perceived that weight gain was encouraged during the post-partum period by most of the Ethiopian people and that women considered gaining weight after birth is a normal phenomenon. Losing weight or not gaining weight during the postpartum period was perceived as lack of proper care after birth. None of the participants provided proper postpartum weight management counselling for women. The participants reported several reasons related to lack of postpartum weight counselling. Some of these reasons–including a lack of attention to weight (postpartum weight); having a high workload; and a belief that women do not ask about their weight were similar to the reasons for lack of GWG counselling. Other reasons were the perception that postpartum weight counselling was not a common practice; postpartum weight counselling was not considered as their role; and fear that discussion of postpartum weight loss would be unacceptable to the Ethiopian society. Failure to address women’s weight management during pregnancy, birth and postpartum period is a missed opportunity to influence a woman’s future health [13, 59, 60]. According to the American College of Obstetricians and Gynaecologists, ensuring proper communication of postpartum issues with women is a responsibility of maternity care providers including obstetricians [17]. Since postpartum care or counselling is an ongoing process [17, 60], counselling on postpartum weight management should be started during pregnancy. Midwives and obstetricians require some ongoing education in regard to counselling around postpartum weight retention and information for pregnant women should be made available to ensure they understand the risks and benefits of inactivity and excessive weight gain in the postpartum period.

5. Conclusions

This study explored the perspectives of midwives and obstetricians in Ethiopia regarding GWG and postpartum weight retention. The study found the awareness and practices of participants in relation to counselling pregnant women about appropriate weight gain were inconsistent. According to the midwives’ and obstetricians’ observations, there are widespread misconceptions about pregnancy weight management among women. Midwives lacked confidence to counsel women about GWG and nutrition whereas obstetricians considered other health issues to be a higher priority. The Ethiopian Ministry of Health (with concerned stakeholders such as the Ethiopian Society of Obstetricians and Gynecologists, and the Ethiopian Midwives Association) need to consider designing an education package or short-term in-service training concerning GWG for both midwives and obstetricians; adapting (preparing) a GWG guideline and integrating sufficient information about weight management into antenatal care guidelines as essential.

Supporting information