Midwives’ views and experiences of providing healthy eating advice to pregnant women: a qualitative content analysis of semi-structured interviews

Midwives who attended a healthy eating workshop/webinar were invited to participate in a follow-up semi-structured interview (6–8 weeks post-education). From a total of 19 midwives who completed the healthy eating education workshop/webinar and post-follow-up questionnaire, a purposive sample of seven midwives consented and were interviewed. Of these, six midwives were interviewed face-to-face, and one preferred a telephone interview. The selection criteria included midwives who were working in metropolitan and rural antenatal clinics, midwifery group practices, and/or undertook prenatal parent education classes in South Australia and had completed the healthy eating workshop/webinar.

The interviews were audio-recorded and ranged from 25 to 45 min. Face-to-face and telephone interviews were conducted by the primary researcher, in a private room at the University of South Australia (UniSA), and Women and Children's Hospital to maintain privacy and confidentiality of participants.

The interviews were transcribed verbatim. Data was collected in December 2018, and the transcription and analysis were completed between April 2019 and August 2019, by the primary researcher and two co-authors. Data saturation was achieved when no new information/codes were generated which guided the decision to stop recruiting new participant midwives.

All interviews were transcribed by the primary researcher. Two authors reviewed transcripts for accuracy. Data were analyzed using conventional content analysis¹⁵ to explore midwives’ knowledge, attitudes, and behaviors related to healthy eating education and health benefits.¹⁶ Content analysis described in this article aimed to achieve a clear broad description of midwives’ views and experiences after attending the healthy eating education, with results being presented in categories. This approach was utilized through a three-phase framework for representing the content analysis process¹⁷ as follows:

Five strategies and principles were used to ensure and maintain rigor and trustworthiness, these include credibility, dependability, confirmability, transferability, and reflexivity.^18,19 Several strategies were used to ensure the credibility of the data, such as prolonged engagement, triangulation, and member checking.²⁰ On prolonged engagement, the first author (SO) provided the healthy eating education and conducted the interview with the midwives to build trust and familiarity with the researcher. The first author completed the initial data analysis and data triangulation and two co-researchers carried out data coding and interpretation. Member checking was conducted during the interview to seek clarification, and examples were provided to confirm the correct meaning.

Transferability was maintained through a sufficient sample size, clear explanation of data collection, and analysis as per the developed and published protocol.¹⁰ A detailed description of the participants’ characteristics, experiences, and views is provided with quotes and recommendations for future research. An audit trail for dependability and confirmability was maintained through all steps, and procedures are described in the published study protocol.¹⁰

Reflexivity included critical self-reflection to maintain a balance between researcher and research relationship. The authors are registered midwives and nurses who are engaged in midwifery and nursing education, teaching and clinical practice, they are engaged in conducting quantitative, qualitative and mixed-methods research and publish in reputable journals with up to 35 years of experience.

Nineteen midwives were invited to participate in a semi-structured interview after attending an education workshop/webinar, from those seven midwives provided written consent and took part in an interview. All midwives were female and had completed a workshop/webinar and post-education questionnaire. Participants’ details are presented in Table 1.

Three principal categories were identified from the content analysis. The first category was midwives’ perceived role including midwives’ knowledge and confidence, education delivery, and available resources. The second category was limited health literacy including midwives’ level of education, need for CPD, and the pregnant women perceived level of knowledge and education. The third category was models of care which midwives described impacted their ability to develop relationships, allocate time and follow-up, particularly if they did not work in a continuity of care model. See Figure 1.

Figure 1

Midwives perceived themselves in a position to provide and influence healthy eating education as part of their daily practice at antenatal clinics; however, this perceived role is not aligned with their current level of knowledge and confidence. Midwives interviewed reported that they had general basic nutritional knowledge but identified limitations that challenged them when providing healthy eating education to pregnant women. These limitations align with previous studies findings that midwives have general nutrition knowledge.^23,24 However, a literature review identified few exploratory and descriptive studies and reported that midwives lacked basic knowledge of nutrition requirements during pregnancy.²⁵

Some midwives reported that should women need detailed nutrition advice, they would be referred to a dietician, i.e. being overweight or special dietary requirements, such a vegans and vegetarians. Reasons for referral included midwives who lacked the confidence to provide nutrition education and limited advanced nutritional knowledge. These findings align with previous studies that midwives provide general nutrition advice and refer women with specific conditions to a dietitian.^9,23 However, a few midwives provided detailed nutritional education to address pregnant women's individual circumstances.²³ Of the midwives who made a referral to a specialist, the most common reasons were diabetes and/or obesity, complex medical conditions, and special diets such as vegans or vegetarians pregnant women.²³ All midwives provided similar examples of circumstances when they would refer to a dietician, advice given for these risk factors were often based on personal experiences rather than actively seeking professional development for these risk factors. However, all these circumstances were mentioned by midwives equally in this study.

When the midwives provided examples of educating pregnant women, all midwives discussed educating pregnant women with gestational diabetes; however, these pregnant women were also more often referred to receive healthy eating education from dietitians or diabetic educators. Interestingly, midwives did not appear to focus their education on women without medical conditions, often appearing to assume they were already educated or could access their own information. This finding is consistent with a previous study which reported that (n = 182, 59.5%) of midwives would only discuss healthy eating education for women with a medical condition such as gestational diabetes.²³

The current findings showed that the scope of the midwives’ role was not only to provide nutrition education but also included discussion of different nutrition-related aspects during pregnancy such as food safety, portion size, supplements, and side effects, as well as exercises sleep and rest. Furthermore, all midwives provided this education quickly at antenatal appointments, which was different from previous studies in which only some midwives were active in providing individualized healthy eating education to pregnant women^8,9,26 and focused on nutrition-related aspects such as macro-nutrients and portion size, and exercise.²⁶ However, it has been reported that some midwives avoid discussing nutrition-related issues such as listeria and folic acid, and junk food.⁹

Nevertheless, midwives’ perceived role and their influential position to provide education to pregnant women may be impeded by other factors such as the women's level of motivation, health literacy, and sociodemographic characteristics. There has been a previous pre-, post-test intervention study to assess pregnant women's nutritional knowledge using nutrition education modules developed by the Ministry of Health in Turkey.²⁷ This study revealed that according to the level of education at pre-test, the high school graduates, pregnant women had higher scores than the primary school graduates, as well as those who were illiterate and literate. The study concluded that pregnant women needed adequate and appropriate healthy eating education according to their sociodemographic characteristics. A randomized controlled trial in Iran assessed the effects of two antenatal classes (2 h sessions, 1 week apart) based on the Health Belief Model to influence the dietary behaviors of pregnant women.²⁸ The findings of this study also reported that women's motivation is essential to make behavior modifications and produce excellent nutritional performance. In addition, the combination of classes and group consultations was shown to increase pregnant women's nutritional knowledge and eating behaviors.

Midwives, in the current study provided healthy eating education depending on available brochures in the hospital, their background education, and personal experience. Arrish et al. reported that from a sample size of n = 329, midwives seek nutrition information sources from (other health care professionals (n = 249, 81.4%), general knowledge (n = 231, 75.5%), and midwifery education (n = 192, 62.7%).²³ Similarly, another study with a sample size of n = 370 reported that midwives seek information from nutrition organizations (n = 316, 85.6%), general knowledge (n = 307, 83.2%) and midwifery education (n = 268, 72.6%) or midwifery journals (n = 236, 64.0%).²⁹

In terms of using available educational resources reported in the current study most midwives educated pregnant women through discussion using brochures, pamphlets, information sheets, and online resources and provided them with a written copy. This finding is similar to a previous qualitative study where pregnant women received leaflets and booklets on relevant health topics from midwives during antenatal appointments to supplement their verbal education.³⁰ Conversely, some midwives used a passive approach as they relied on the written information, especially for pregnant women they perceived to be healthy^9,31 or midwives referred to a package of brochures as part of the pregnancy booklet that contained other materials, and they did not mention or discuss the nutrition brochure.³²

In the current study midwives reported they only occasionally referred to national standard guidelines for healthy eating during pregnancy or other prenatal practice guidelines as educational resources. This finding has concurred with earlier studies, which indicate that midwives did not adhere to national standard guidelines.^23,33 Nevertheless, one New Zealand study identified that midwives were well-educated to discuss nutrition issues related to pregnancy and strictly used the national standard guidelines when providing healthy eating education to pregnant women.²⁹ Whereas, some of the midwives reported that the hospital resources were descriptive, not comprehensive, and out-of-date, and they felt conflicted while using them. A previous cross-sectional postal survey study reported that hospital resources were utilized by the majority of pregnant women (n = 246/350,70%) as information sources provided by midwives to meet their needs.³⁴ It is, therefore, important that guidelines and resources are kept up to date to enable women to access reliable information.

This main category has highlighted that midwives’ reported their level of knowledge and confidence increased significantly after attending a healthy eating education workshops/webinar, in particular, to provide education to vegans and vegetarians pregnant women. This is important as previous studies suggest midwives’ level of knowledge and confidence are moderate to low, in particular reinforcing the need for healthy eating education to support vegans and vegetarians pregnant women.^23,29 This finding demonstrates the need to include these women and specific information in education sessions. All findings indicate that most midwives have a good understanding of the importance of healthy eating education and well-being during pregnancy. However, some midwives might lack support and training based on the most recent guidelines.

Health literacy is related to a person's ability to obtain, interpret, understand, and use health information to promote and maintain health status.³⁵ Nutrition literacy is a subordinate concept of health literacy.³⁶ In this article, limited health literacy, for example, skills required to understand and communicate health information³⁷ was found for both midwives and pregnant women. Many factors were found to affect their role such as some midwives reported limited knowledge about nutrition guidelines, or awareness of their scope of practice, or they may have incorrect perceptions about the pregnant women's level of education. These factors may impede midwives from seeking regular CPD of recent nutrition guidelines.

Midwives’ role in health promotion³⁸, is to provide a holistic approach that includes healthy eating education and advice and to discuss nutrients from available food sources according to the pregnant woman's health needs. However, most midwives regularly provided education and recommended vitamin supplements and discussed side effects; this type of discussion is medically directed and does not provide a holistic focus for nutritional education. However, a previous study highlighted that some midwives viewed food sources and diet as the first medicine, and they recommended food sources over supplements when discussing nutrition issues with pregnant women.⁹

In this study midwives reported that pregnant women who used vitamin supplementations were influenced to do so by their health behavior and cultural background. Even when women are aware of pregnancy vitamin supplements, education should be provided on dietary intake and lifestyle choices. A recent Australian study that explored women's attitudes regarding preconception health behaviors and information preferences revealed that women perceived adopting lifestyle behaviors included a healthy diet, physical activity, and vitamin supplementations as good practice.³⁹ Interestingly, findings from this current study suggest that midwives were making several assumptions that pregnant women were well-educated, motivated, and doing their own search for information. Midwives would then only provide education when pregnant women asked questions or when problems arise. Previous studies clarified that pregnant women were concerned that midwives made incorrect assumptions about the extent of their knowledge.^9,23,30 Therefore, pregnant women sought their own information as they felt the information provided was inaccurate or inadequate or caused confusion.^40,41,42

Some midwives assumed that pregnant women from different cultural backgrounds were eating healthier than Australian women. However, these assumptions were not based on scientific evidence. Previous studies found that migrant pregnant women from low or middle-income countries were often associated with the adoption of less healthy dietary habits.^41,42

Further, this current study highlighted that most midwives require education for recent standard healthy eating guidelines and cultural food preferences for ethnic minority groups. Midwives identified barriers when providing education to pregnant women from an ethnic minority group, including language, traditions, change, and culture. Moreover, some midwives were not aware of other cultures’ food types, and food groups, reporting they needed additional resources and education to explore different cultures. These findings confirmed the previous results from phase 1¹¹ of this research project. Literature suggests that midwives rarely discussed healthy eating education for different cultural food groups (n = 54/329, 20.7%).⁸

In the United Kingdom, studies that explored midwives’ perception and knowledge of maternal obesity did not view healthy eating education as a priority, midwives did not recognize the national guidelines sources, and they recognized their limitations.^43,44 Further, midwives did not tailor advice for women's cultural influences, and specific diet such as vegans, vegetarians.^43,44 A previous study explored the experiences of women of different ethnic backgrounds in Norway when receiving nutrition-related information.⁴⁰ The study found the nutrition information provided by midwives was different to the pregnant women's original food culture and resulted in confusion; therefore, this led to women seeking their own nutrition information by themselves.⁴⁰ The study concluded that nutrition communication skills should be tailored toward women's cultural background, level of nutritional knowledge and nutrition literacy.⁴⁰

It has been reported that the provision of health care services provided for maternity care is varied according to locations in Australia.⁴⁵ These health care services are delivered at different levels, according to the workforce, the size of the maternity units, and the pregnant woman's needs.⁴⁵ Midwives, in the current study described midwifery continuity of care to be the best model of care for pregnant women and her developing baby and felt women might miss valuable care when they did not have that model of care. Previous studies are consistent with the findings of this study that is reported that in the continuity of care model, midwives had the opportunity and time to discuss healthy eating education with pregnant women, and midwives were able to work on their knowledge, skills and obtain resources required for pregnant women needs.^46,47 Another study revealed that the continuity of care model had several benefits for pregnant women's health outcomes, as well as benefits for midwives such as high job satisfaction and less occupational burnout.⁴⁸ Cochrane and systematic reviews have concluded that pregnant women who were in the continuity of care models were less likely to experience interventions and be satisfied with their care with less adverse outcomes for them and their developing baby's health status.^49,50 Moreover, pregnant women experienced building trust and empowered relationships with their midwives.^49,50

According to the current findings, midwives reported that the limited availability of continuity of care models resulted in fragmented care which created barriers for them to provide healthy eating education during the booking visits and follow-up for continuous support for pregnant women. Similarly, a previous study identified few women had accessed to the continuity of care model, and it offered inequality in the public sector.⁵¹ Congruently, Arrish et al. described that midwives who worked in the public or private sector in fragmented care had many barriers that hindered them from providing effective healthy eating education and advice, such as limited time, less opportunity to see the pregnant women again or late involvement with the pregnant women.⁹

Findings that have emerged from the content analysis of the midwives’ interviews have identified several professional and health services barriers such as nutritional knowledge, health literacy, time, and models of care, which impede them to fulfill their role in providing healthy eating education to pregnant women.

The current study is the first to report on midwives’ views and experience after attending a healthy eating education workshops/webinar. The interviews were conducted after 6–8 weeks to follow-up some midwives who participated in the healthy eating education to explore their views and experience when providing healthy eating education to pregnant women. Independent analysis from two authors (SO), (JF) helped to maintain and ensure rigor, as well as reduce subjectivity bias. However, the participants included only experienced midwives who had between 8 to 35 years of midwifery practice experiences, and no recent midwifery graduates were interviewed. Therefore, the findings reported in this study should be interpreted with caution to other cohorts. Further research to explore the experiences of newly graduated midwives would be beneficial.