Of the four million women who give birth in the USA each year, almost 30% gain more weight than recommended by the Institute of Medicine guidelines (Rasmussen and Yaktine, 2009). It has been established for many years that pregnancy may lead to subsequent weight problems. In the Stockholm Pregnancy and Women's Nutrition (SPAWN) longitudinal study, weight retention at the end of the first year postpartum was the main predictor of being overweight 15 years later (Linné et al, 2004).
In the UK, 24% of women of reproductive age are now obese, and the prevalence is predicted to increase (Butland et al, 2007). Maternal obesity increases health risks for the woman and child, both during and after pregnancy, including hypertensive disorders, thromboembolism, gestational diabetes mellitus, induction of labour, prolonged birth, caesarean section, postpartum haemorrhage and either low birth weight or macrosomia in the infant (Scott-Pillai et al, 2013). The more weight the woman gains during pregnancy, the more likely it is that the weight may be retained postpartum (Johnson et al, 2013). Women who enter a subsequent pregnancy overweight or obese have a higher risk of adverse outcomes for themselves and/or their infants.
Given that the antenatal period involves regular contact with health professionals, pregnancy may be considered an opportune time to encourage weight management and prevent excess weight gain, thus preventing the vicious circle of weight accumulation across successive pregnancies and associated health risks. However, a 2011 study reported that the majority of obese women taking part in either semi-structured interviews or focus groups in London felt that pregnancy was not the best time to address weight, as general concerns about pregnancy and complications were felt to be the priority (Khazaezadeh et al, 2011). Instead, those interviewed reported that the motivation for weight management efforts would be higher following childbirth, or prior to conception (Khazaezadeh et al, 2011). This finding is reinforced by Hodgkinson et al (2014), who concluded that the postpartum period is a time when women need more support.
UK National Institute for Health and Care Excellence (NICE, 2015) public health guidance for supporting women after childbirth currently recommends that health professionals use the 6–8 week postnatal check, or a follow-up appointment within the next 6 months, as an opportunity to discuss a woman's weight and offer support and up-to-date advice about how to lose weight safely after childbirth. The NICE guidance recommends that during follow-up appointments, breastfeeding should be encouraged along with a healthy diet and building moderate-intensity physical activity into daily life. Women with a body mass index (BMI) > 30 kg/m² should be made aware of the increased risks that being obese poses and encouraged to lose weight via a structured weight-loss programme.
Successful weight management in the period following childbirth not only decreases the risk of entering further pregnancies overweight or obese, but also has the potential to reduce long-term health risks such as heart disease, obesity, cancer, cardiovascular disease and type 2 diabetes (Scott-Pillai et al, 2013).
It is widely accepted that new mothers experience huge changes in lifestyle once they have given birth, and there is a tendency for women to put their own health second to their child's health. Previous evidence has identified a number of barriers that prevent women from successfully engaging in postnatal weight management, including lack of time, changes in body image, depression, lack of motivation and lack of support (Montgomery et al, 2011), but there is little knowledge available as to what might increase motivation levels.
Previous trials have assessed different approaches to weight management in the postnatal period, but evidence regarding the most effective method is still lacking; there is uncertainty surrounding the optimal method and recruitment stage (van der Pligt et al, 2013).
Group-based commercial weight management (CWM) interventions are successful when implemented in the general population (Stubbs et al, 2011) and are currently recommended in the UK (NICE, 2014). The CWM organisation Slimming World (SW) has worked in partnership with the Royal College of Midwives to develop a policy to support women to manage their weight through all stages of pregnancy and postpartum, including while breastfeeding. The multi-component group-based programme, including behavioural change strategies, emphasises the importance of maintaining a healthy diet that is varied and flexible and being physically active, detailing the benefits to both the woman and baby.
The aim of this service evaluation is to investigate, through an online survey, members' motivations to lose weight postnatally, to consider the barriers and to determine the weight loss achieved and impact on women's wellbeing, confidence, self-esteem and body image, in order to continually improve the support offered.
Materials and methods
An online survey was hosted on the group-members-only section of the SW website during September 2013. It was advertised to current members who had given birth in the previous 2 years. The survey was specifically developed for this service evaluation, with the intention being that it was easy to complete and written in language with which the participants in the SW programme were familiar.
The survey consisted of 36 questions. Participants were asked to select from a drop-down menu to describe age, height, date of birth, parity, breastfeeding status, duration of membership and the amount of weight gained during the most recent pregnancy. Weight at the time of survey and on joining the programme was confirmed from the weekly weight data electronically recorded during group sessions as part of each participant's membership. The same calibrated scales were used each week at a given group to record weight and weight change. Weight data were screened for outlying data and BMI changes were calculated using the confirmed weight data and self-reported heights.
The remainder of the questionnaire took the form of 5-point Likert scales, checkboxes or multiple choice where one or more options could be ticked as appropriate, to determine motivation and lifestyle behaviours. The survey asked questions on: motivations to join SW; changes in self-confidence, self-esteem, wellbeing, body shape and image before and since joining SW; how long after giving birth participants joined and whether having a baby contributed to the decision to join; whether they were breastfeeding; barriers to attending the group; how easy it was to attend the group; and benefits from attending. The questionnaire was constructed and administered using Checkbox v4.4-Web Survey Software © 2007, Prezza Technologies, Inc.
Participants
Group members, irrespective of their starting BMI, were only invited to complete the survey if they had given birth in the last 2 years and they had joined SW after having their baby (i.e. were not attending before becoming pregnant or while pregnant). Women who were currently pregnant were excluded from the study. Members were provided with online information about the study before participating and were informed that, by completing the survey, they were voluntarily consenting to participate in the study. As part of the membership contract, it is clear that unidentifiable personal weight data may be used for service evaluation purposes.
Statistical analysis
Data analysis was performed using SPSS for Windows (version 21) and Microsoft Excel. Descriptive data are summarised as frequency, mean + standard deviation and percentages of participants responding to each question or sub-question where indicated. Data were analysed using paired t-tests to determine significant differences between weight reported at baseline and at the time of survey. Pearson's r-correlation, following adjustment for length of membership, was used to determine the relationship between motivations for weight loss and actual weight loss as a result of attending the weight management programme.
Ethics
The work was carried out in accordance with the principles set out in the Code of Ethics according to the Declaration of Helsinki 1964.
Results
Participant characteristics
A total of 1015 women responded. Mean age was 32.2 ± 5.1 (range 18–45) years. Mean parity was 1.8 ± 0.9, with a range between 1 and ≥5 children. Mean BMI on joining (n = 971 owing to missing height data for some participants) was 33.3 ± 5.8 kg/m² and at the time of the survey was 30.5 ± 5.9 kg/m², representing a BMI change of –2.8 ± 0.2 kg/m² (P < 0.01; 95% CI 2.76–3.11). Weight change was significantly different between joining weight (baseline) and weight at time of survey, with an 8.6% mean weight loss reported (–7.9 ± 0.05 kg) (P < 0.01). Figure 1 shows the absolute weight changes dependent on the length of time the women were attending the weekly groups.
At the time of survey, current duration of membership varied between participants, 52.5% (n = 533) reported being members for less than 3 months, 22.4% (n = 227) were members for 3–6 months, 15.7% (n = 159) for 7–12 months, 6.2% (n = 63) for 13–18 months and 3.3% (n=33) for 19 months to 2 years. Figure 1 illustrates a positive association between duration of attendance at the groups and mean amount of weight loss achieved up to 19–24 months' group membership.
Participants reported joining the weight management programme at a variety of time points after having their baby (Figure 2). Almost half the participants (45.6%, n = 463) started attending the weight management programme between 6–26 weeks postnatal, and 23.4% (n = 238) commenced > 1 year postnatal.
More than three quarters of participants (76.8%, n = 780) stated they had retained more than 1 stone (6.4 kg), and 61.0% (n = 619) agreed that having a baby contributed to their decision to join SW, with 51.3% (n = 521) reporting that gaining weight during their pregnancy affected their self-esteem.
More than half of the participants who responded (62.8%, n = 626) reported breastfeeding their most recent child, with the length of breastfeeding varying between respondents:
A sub-analysis was performed to compare current weight loss (recorded from electronic records) with start date of joining the CWM programme (when adjusted for membership length), to identify whether time of commencing a weight management programme affected weight-loss outcomes. This analysis indicates that participants who engaged in the weight management service between 6–12 weeks postnatal recorded greater weight losses than those who engaged 41–52 weeks or > 1 year postnatal (P < 0.05) (Figure 3).
Motivations for weight loss
Participants were asked to select from a series of statements all applicable reasons why they decided to lose weight. The results indicate the main motivations were ‘to improve how I feel about my body size and shape’ (85.2%, n = 865), ‘to improve my self-confidence’ (76.6%, n = 777), and ‘to lose the weight I gained during my pregnancy’ (66.5%, n = 675). Social pressure (8.6%, n = 87), media pressure and celebrity culture (3.9%, n = 40) were reported less frequently as a contributing factor to wanting to lose weight postnatally (Table 1). Reasons for deciding to lose weight were correlated with actual weight loss to determine whether initial intentions to lose weight transferred into reported weight loss: only ‘to improve health’ was positively correlated, with ‘to lose baby weight before having another baby’ negatively correlated to weight loss.
| Reason | Frequency (n = 1015) | Percentage % | Correlation with weight loss | P-value |
|---|---|---|---|---|
| To improve how I feel about my body size and shape | 865 | 85.22 | 0.031 | 0.336 |
| To improve my self confidence | 777 | 76.55 | –0.016 | 0.620 |
| To lose the weight I gained during my pregnancy | 675 | 66.50 | 0.002 | 0.940 |
| To improve my health | 666 | 65.62 | 0.114* | <0.001 |
| It felt like the right time to lose weight | 654 | 64.43 | 0.056 | 0.078 |
| To lose baby weight before having another baby | 181 | 17.83 | –0.095* | 0.003 |
| Social pressure made me feel I was expected to lose weight | 87 | 8.57 | –0.004 | 0.889 |
| A health professional recommendation | 66 | 6.50 | 0.063 | 0.050 |
| Media pressure and celebrity culture made me want to lose weight | 40 | 3.94 | –0.008 | 0.812 |
Wellbeing, self-esteem, confidence and body image
Just over half the participants (51.3%, n = 521) reported that weight gain during pregnancy had affected their self-esteem, rising to 82.27% (n = 835) when retaining weight after pregnancy. Participants also reported how they felt their self-esteem, self-confidence, general wellbeing, and confidence in body weight and size had been affected since joining the CWM group, and whether they felt under social or media pressure to be an ‘ideal’ weight following their pregnancy (Table 2). Participants reported improved self-confidence (77.6%, n = 788), improved self-esteem (78.6%, n = 798), improved sense of wellbeing (85.2%, n = 865) and felt more confident in their body shape and size (70.0%, n = 711). In response to the statement that they felt under social or media pressure to be an ideal weight following their pregnancy, 39.6% (n = 402) disagreed, 31.0% (n = 315) agreed and 29.4% (n = 298) neither agreed nor disagreed.
| Statement | Strongly agree | Slightly agree | Neither agree nor disagree | Slightly disagree | Strongly disagree | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| n = 1015 | % | n = 1015 | % | n = 1015 | % | n = 1015 | % | n = 1015 | % | |
| I have improved self-confidence | 402 | 39.61 | 386 | 38.03 | 202 | 19.90 | 18 | 1.77 | 7 | 0.69 |
| I have improved self-esteem | 402 | 39.61 | 396 | 39.01 | 193 | 19.01 | 15 | 1.48 | 9 | 0.89 |
| I have an improved sense of wellbeing | 490 | 48.28 | 375 | 36.95 | 131 | 12.91 | 12 | 1.18 | 7 | 0.69 |
| I have confidence in my body size and shape | 408 | 40.20 | 303 | 29.85 | 234 | 23.05 | 42 | 4.14 | 28 | 2.76 |
| I feel under social/media pressure to lose my baby weight | 127 | 12.51 | 188 | 18.52 | 298 | 29.40 | 156 | 15.37 | 246 | 24.24 |
Practicalities of taking part in the weight management programme
Participants were asked to report on the practicalities of attending the CWM group as a member after having a baby. Participants reported their group location (n = 896, 88.3% agree ‘quite a lot’ or ‘very much’) and time (n = 846, 83.3% agree ‘quite a lot’ or ‘very much’) was convenient for them. In addition, of those who took their children (n = 737) and/or buggies (n = 743) to a SW group, around three quarters reported their group to be child-friendly (76.5%, n = 564) and buggy-friendly (73.4%, n = 545).
Discussion
The aim of the current investigation was to determine women's motivations for losing weight in the postnatal period, investigate the impact of social pressure and explore the effect that the weight management programme had on women's health, confidence, self-esteem and body image, wellbeing and weight.
Almost half of the respondents had been members of the CWM group for more than 3 months and significant mean weight losses were achieved. The results indicate that obese women engage in weight management programmes at various times in the postnatal period, from as early as 6 weeks to more than 1 year after giving birth. The findings suggest women want to lose weight and engage in the programme to improve how they feel about their body shape and size, their health, and their self-confidence, and to lose the weight gained during their pregnancy. While body shape and size, improving self-confidence and losing the weight gained during pregnancy were the strongest motivators reported, improving health was the only motivator that was significantly positively correlated to actual weight loss.
The results also indicate that recommendation from health professionals currently plays a minimal role in motivating women to lose weight. This could be a result of health professionals not fully understanding the importance of postnatal weight management, or there being few opportunities where a health professional is able to raise the issue and encourage postnatal women to lose weight. Currently, the emphasis in the postnatal period tends to be on the health and wellbeing of the infant (Montgomery et al, 2011). The low response rate to this statement highlights a need to further develop the role that health professionals play in influencing the health of postnatal women. Only 17.8% (n = 181) of the study participants claimed their motivation was to lose weight before having another baby.
The present survey reported 64.4% (n = 654) of members felt that joining a weight loss group at the right time was a motivator to lose weight postnatally. This suggests there may be an opportune time to initiate a weight management intervention in postnatal women. Current UK guidelines (NICE, 2010) recommend the 6–8 week postnatal check as an ideal time to raise the issue of excess weight retained post-pregnancy and offer support about how to lose weight. The findings from this evaluation support this recommendation.
Very few of the women cited media or social pressure as reasons for wanting to lose weight. This indicates that although celebrity pressure may be one factor in making women feel they need to lose weight after birth, it does not actually have a major influence on engagement in a weight loss programme.
It might be assumed (particularly by media or critics) that engaging in a weight loss programme may add to the pressures faced by postnatal women, inducing feelings of low self-esteem or guilt that they ‘need’ to lose weight. However, the responses provided in the current survey demonstrate that the participants actually had low self-esteem before they joined a SW group—which may have been related to excess weight gain during and weight retention after pregnancy—and that their attendance and weight loss was associated with increased self-esteem, self-confidence and wellbeing.
The reported breastfeeding rates at 6 weeks and beyond are higher than current reported UK rates, at 58.5% vs 55% (NHS England, 2015), which may reflect the additional benefits of social support and improved self-esteem.
Previous evidence has identified time and childcare as potential barriers to engaging in weight management services (Montgomery et al, 2011). However, responses from participants in the current survey suggest that the weight management group location and time were convenient, and child-and buggy-friendly.
Limitations
The survey relied on retrospective self-reporting to establish the motivations for losing weight up to 2 years post-birth, and the survey only provides a snapshot of the potential motivators.
The self-reported increases in self-esteem and self-confidence may have been the result of reasons other than weight loss.
Despite the high number of respondents reported in this survey, it is likely that this sample is a specific, self-selected sub-group, representing individuals who successfully engage in a CWM organisation. As such, the responses may not represent all postnatal women attempting to lose weight, or the general population as a whole. The results, therefore, should be considered in the context in which they were obtained and the population in which they represent.
In addition, a number of key distinguishable participant characteristics were not collected, including ethnicity and sociodemographic status. This information is of importance as social deprivation is highly associated with obesity in pregnancy (Heslehurst et al, 2010), and motivators and barriers to losing weight postnatally may differ in these populations. The authors were unable to adjust for the magnitude of weight gained during pregnancy in the statistical analyses.
Implications for practice
Health professionals need to seek every opportunity possible to encourage women in the early postnatal period to lose weight, particularly if the woman is likely to become pregnant again. They should not be concerned about increasing anxiety levels, as encouraging women to engage in certain CWM programmes in the postnatal period may increase levels of self-confidence and self-esteem. Encouraging women as early as 6 weeks after giving birth may help to improve weight loss outcomes in the postnatal period.
Conclusions
This survey indicates that postnatal women with an overweight or obese BMI engage in a group-based weight management programme because of personal reasons around improving body shape and size, health and self-confidence, rather than as a result of media or celebrity pressure. Participants reported concerns around retention of excess pregnancy weight gain affecting their self-esteem. However, engaging in a CWM programme, using a multi-component behavioural approach, resulted in significant weight loss and increases in self-esteem, self-confidence, wellbeing and body image. The groups were reported to be very accessible in terms of location and time, and were considered child-friendly. These results could have significant public health implications for promoting suitable weight management interventions for postnatal women.