Prepare a 1-2 page report that evaluates this
report, discuss how the research methodology applies to the
research conclusions. Do not focus on the topic of the article, but
instead focus on how the results were obtained using qualitative
methods.
Gestational Weight and Dietary Intake During Pregnancy:
Perspectives of African American Women Mable Everette Published
online: 7 November 2007 Springer Science+Business Media, LLC 2007
Abstract Objectives This investigation explored the participants’
perspective on weight, nutrition, and dietary habits during
pregnancy. The data of interest were culled from a larger
ethnographic research study designed to gather information and
ideas about the socio-cultural, psychological, and behavioral
influences on maternal health during pregnancy (N = 63). Methods My
study focused on the six participants (including three teenagers)
who delivered low birth weight and/or preterm babies and 13
participants aged B18 years (teenagers) who delivered normal weight
babies. Data were analyzed utilizing qualitative methodology.
Results Four of the participants who delivered low birth/weight
preterm infants reported weight related concerns during pregnancy.
These included: weight loss, lack of weight gain, and exceeding
their expected weight gain. Frequently, the nutrition knowledge was
based on miseducation, misconceptions, and/or ‘a grain of truth’
i.e. folk beliefs. Support group members had an influential role on
participants’ dietary habits during pregnancy. Conclusion The next
step appears to be more qualitative work, with health care
providers, the Women Infants and Children Program (WIC) nutrition
counselors, clinical dietetic professionals, and women who already
have children, to explore strategies for improving diet quality as
well as address the issue of inadequate and excessive weight gain
during pregnancy. Keywords Qualitative research Pregnancy African
American women Nutrition Dietary intake Gestational weight
Introduction The Centers for Disease Control and Prevention
reported that the rate of preterm births (37 completed weeks of
gestation) had increased 30% in the last two decades [1]. African
American women deliver their infants at 37 weeks gestation twice as
often as women of other races and deliver their infants before 32
weeks of gestation three times as often as white women [1]. The
same ethnic disparity is also evident for low birth weight (2,500
g/5.51 lb). In 2001, for singleton births, the rate was 4.9% for
non Hispanic whites and 11.9% for non Hispanic blacks [2]. Little
is known about why African American infants are at risk of adverse
outcomes. Many believe that scientists must take a fresh look at
the problem and approach it from a different vantage point [3].
Rowley [4] purported that understanding the cause of the gap in
preterm delivery and the potential interventions to eliminate this
disparity required a multidisciplinary approach; this methodology
would elucidate the biological pathways, stressors, and social
environment associated with preterm birth. The aim of this analysis
was to describe the participants’ perspective on weight, nutrition,
and dietary habits during pregnancy. I examined the hypothesis that
gestational weight, nutrition information/knowledge, and dietary
habits are associated with neonatal weight outcome. In order to
test the hypothesis, the analysis included the most vulnerable
participants: (1) six participants (50% of whom were teenagers)
delivering low birth weight and/or preterm babies and (2) 13
teenagers who delivered normal weight babies. MC Ganity et al. [5]
define a biologically mature female as a young woman who is at
least 5 years postmenarchal. The growth demands of the pregnancy
and the fetus superimposed on the growth demands of an adolescent
M. Everette (&) Community Nutrition Education Services, Inc,
110 S LaBrea Avenue, #213, Inglewood, CA 90302, USA e-mail:
mleverette@ca.rr.com 123 Matern Child Health J (2008) 12:718–724
DOI 10.1007/s10995-007-0301-5 during the first year after menarche
may result in undesirable reproductive outcomes [5]. Maternal age
younger than 18 years of age and 35 years or older has been
associated with preterm birth, but the effect seems to be confined
to the female who has never borne an offspring [6]. Among the other
factors that have been implicated as possible contributing factors
to preterm delivery are: low pregravid weight; inadequate weight
gain during pregnancy; iron deficiency anemia early in pregnancy;
and poor diet [7]. A positive relationship between weight gain and
birth weight has been consistently reported in both developing
countries and among different ethnic groups [8, 9]. Maternal
pregravid weight or Body Mass Index (kg/m2 ) and weight gain appear
to have independent and additive effects on birth weight outcome
[10]. Although total weight gain is an important predictor of birth
weight, the pattern of weight gain and rates appear to play a
significant role in predicting preterm delivery [10–12]. Scholl
[13] noted that the increasing evidence for an association between
low rates of maternal weight gain and preterm delivery does not
imply causality. The importance of optimal body mass index (BMI) at
the start of pregnancy was emphasized in a study conducted by Jain
et al. [14]. The researchers noted that of the women considered
overweight or obese before conceiving, more than half gained
excessive weight during pregnancy [14]. Poor maternal nutrition
status (diet low in most necessary food nutrients) has been
implicated as a possible contributing factor to preterm delivery
[7]. In terms of overall calories, after controlling for
confounding variables, women with inadequate gestational weight
gain consumed fewer kilocalories/day (-173 kcal/d) than did those
women whose pregnancy weight gain was adequate for gestation [13].
Sufficient energy is a primary dietary requirement of pregnancy. If
energy needs are not met, available protein, vitamins and minerals
cannot be used effectively. Limited information is available
regarding the nutrient needs of pregnant adolescents [15, 16]. When
detected early in pregnancy, iron deficiency anemia was associated
with a lower caloric and iron intake, an inadequate gestational
weight gain over the whole pregnancy, as well as with a greater
than twofold increase in the risk of preterm delivery [13, 17].
Vitamins and minerals, referred to collectively as micronutrients,
have important influences on the health of pregnant women and their
growing fetuses [18]. Previous observational studies in both young
and older gravidas have shown that low intakes of iron and zinc
were related to preterm deliveries [13, 15]. The risk of preterm
delivery with low dietary zinc intakes was particularly strong
(threefold increased risk) for those whose rupture of membrane
preceded labor [15]. Other studies on micronutrients await larger
studies before recommendations on their appropriate levels of
intake can be made [19]. Methods The data of interest were culled
from an ethnographic study conducted by the Healthy African
American Family I Project (HAAF 1). The project was funded by the
Centers for Disease Control and Prevention (CDC), Division of
Reproductive Health, at the University of California Los Angeles
(UCLA) and Charles R Drew University of Medicine and Science. The
aim was to study the reasons for low birth weight and infant
mortality among African Americans in Los Angeles, California. Data
were collected during the years 1992–1995. All of the research
participants were selected using a convenience sampling
methodology. During the life of the project, over 100 pregnant
African American women were interviewed at home, work, or in a
community setting. Sixty-three women qualified for the HAAF1 study.
Written informed consent was obtained from all women and family and
community members interviewed. Approval to conduct the ethnographic
study was obtained from UCLA’s Human Subjects Protection Committee.
While women under 18 years of age fell within the sample, pregnant
minors are considered ‘‘emancipated minors’’ by the State of
California, and as such may give informed consent to participate in
a research project without the involvement of parents. The
Ethnographers were recruited and trained in qualitative interview
technique methods including didactic instructions, readings,
practice interviews, and feedback by the HAAF I Project’s
Anthropologist. The study utilized data triangulation methods
across data sources in order to check the data from various
perspectives [20]. All interviews were audiotape recorded. To
retain the colloquial flavor of the client’s language, their words
were reported verbatim from the audiotapes. In those instances
where the Ethnographer or the Anthropologist felt the transcriber’s
interpretation of the taped interview was sufficiently ambiguous,
bracketed changes or substitutions were made to aid the reader in
comprehending what the client was communicating. Questions (of
interest for this analysis) explored the participants’ perceptions
on weight, nutrition, and eating habits during pregnancy. A semi
structured open-ended interview style was used to elicit open-ended
responses. For example, ‘‘What did you eat yesterday?’’ Probes
followed the question, for example: ‘‘So tell me what you have been
eating? What did you have yesterday? Like from morning to
evening?’’ Another question addressed prepregnancy weight, ‘‘How
much did you weigh before you got pregnant?’’ Probes followed the
question, for example: Matern Child Health J (2008) 12:718–724 719
123 ‘‘Are you concerned about gaining weight?’’ Another question
addressed vitamin and mineral supplements, ‘‘What kind of prenatal
medications were you taking?’’ Probes followed the question, for
example: ‘‘So when they gave you your prenatal vitamins and stuff
like that, who did-did you have questions or anything like that?’’
Prior to analysis of the data of interest, a coding template was
developed based on a content analysis of the transcripts [21]. The
responses were categorized under two broad themes for all 63
subjects: (1) ‘‘Maternal Weight Gain’’ and (2) ‘‘Eating Habits
during Pregnancy.’’ The latter category also included, ‘‘Vitamin
and Mineral Supplements Use.’’ Two coders independently coded the
data. Interrater reliability was 82% percent, an indication of good
consistency. These codes were reviewed by both coders until 100%
agreement was achieved. Following the agreement, the major themes
and subthemes were assigned a code, the codebook was finalized, and
the analysis was conducted. The study used self reported data for
socioeconomic status (SES), prepregnancy weight, and weight gained
during gestation. The height of participants was not available for
this analysis. The actual neonatal birth weights were provided by
the medical care facility. Results The Results for the 13 Teenagers
Delivering Normal Weight Babies Follow Each of the Tables in this
Section The characteristics of the participants delivering preterm/
low birth weight babies are presented in Table 1. Five of the 63
participants delivered preterm/low birth weight babies; one subject
delivered a small for gestational aged infant at full term. This
total group of six comprised 10.5% of the total sample. One-half
the participants delivering preterm/low birth weight babies were 18
years or younger; the other 50% were over age 18. Four of the six
participants (67%) reported themselves as being, ‘‘ low income.’’
This was the first pregnancy for a participant under the age of 18.
The 13 teenagers (21% of total sample of 63) ranged in age from 14
to 18 years. Ninety two percent of the teenagers reported
themselves as ‘‘low income.’’ Fifty four percent (n = 7) reported
at least one prior pregnancy (data not shown). The subthemes
related to weight gain during pregnancy for those participants
delivering LBW/preterm babies are noted in Table 2. Four of the
participants who delivered LBW/preterm infants reported weight
related concerns during pregnancy. These included: lack of weight
gain, weight loss, and exceeding their expected weight gain. The
subthemes (followed by selected quotes) for the teenagers reflected
misconceptions about weight including justifications for weight
gain/loss, for example, ‘‘weight gain not always related to being
pregnant’’ and ‘‘ weight loss was planned prior to pregnancy.’’
Subtheme: (1) Weight gain not always associated with being
pregnant. ‘‘ When I first-when I was 3 months, I put-by the time I
was 3 months, I had gained 30 lb already. I didn’t even know I was
pregnant because I was spotting still when it was time for my
period to come…when she [Aunt] took me to the doctor and I was
pregnant.’’ Subtheme: (2) Depression related to body image. ‘‘I get
depressed when I look at myself…[referring to weight gain].
That’s why I don’t look at myself. Only my face.’’ Subtheme: (3)
Planned weight loss prior to pregnancy. ‘‘…but I lost some weight
before I got pregnant so I can get pregnant because I did not want
to weigh because then I would have been bigger so I just went down
to 112–115 something like that…then I got pregnant so I would be
an even weight when I have the baby.’’ The subthemes related to the
role of diet/nutrition during pregnancy for those participants
delivering low birth weight (LBW)/preterm babies are noted in Table
3. The issues included skipping meals/inadequate food intake, the
role of cultural influences on food selections, and a specific food
being related to the health of the baby. Table 1 Characteristics of
participants delivering preterm/low birth weight babies (n = 6) Age
SES # Children # Previous pregnancy Education achieved Weight of
new baby 18(1) Middle 2 2 12 4 lbs, 9 oz 21(2) Low 2 2 13 4 lbs, 14
oz 22(1) Low 2 2 12 4 lbs, 12 oz 14(1) Low 1 1 8 2 lbs, 13 oz 22(1)
(a) Middle 0 0 12 4 lbs, 8 oz; 5 lbs, 8 oz 16(1) Low 0 0 10 5 lbs,
8 oz (1) Indicates birth outcomes that were both pre-term and low
birth weight (LBW); (2) Indicates birth outcomes that were LBW; (a)
Indicates twins; SES (self-reported socio-economic status) 720
Matern Child Health J (2008) 12:718–724 123 The subtheme (followed
by selected quote) for teenagers delivering a normal weight baby
also reflected a specific food being related to both the health of
mother and baby. Subtheme: Specific foods related to the health of
baby. ‘‘…I have to drink a lot of milk-I drink at least 2 gallons
of milk a week, ‘cause I love milk.’ And plus, I have to drink a
lot of milk because my mother was telling me that since I have bad
teeth, the baby will take all the milk from me, and my teeth will
start hurting.’’ The subthemes related to family/support group for
those participants delivering LBW/preterm babies are noted in Table
4. The influence of members of the support system was evident in
the selected quotes presented. The subthemes for the teenagers
delivering normal weight babies also reflected the role of
support/family members. The subthemes are noted as follow
(subtheme/ selected quote). Subtheme: (1) Father of baby. ‘‘She got
a lot of cravings, too. All of a sudden. Once she gets finished,
like, she’ll say, pour her some juice, and she finished that, I
want some of this, some of that, you know, so it builds up. So I
guess I have to get used to that.’’ Subtheme: (2) Mother of one
teenager. ‘‘She [mother] started keeping, since I like to snack,
she started keeping like fruits and I like fruits, I just, it never
was around.’’ Other findings: The subthemes related to the use of
prenatal vitamin and mineral supplements for participants
delivering pre/term low birth weight babies. (1) ‘‘Took prenatal
vitamins, calcium and iron.’’ (2) ‘‘Prenatal vitamins caused nausea
and vomiting when taken on an empty stomach.’’ (3) ‘‘Three times a
day [iron and calcium] and then a prenatal vitamin once a day.’’
The subthemes related to the use of vitamin and mineral supplements
for the teenagers delivering normal weight babies are noted as
follow: (1) ‘‘Started taking supplements Table 2 Gestational weight
gain subthemes for the participants delivering low birth
weight/preterm babies Weight focus subthemes Selected quotes
illustrating themes The lack of weight gain was noted as a sign of
not looking pregnant to others ‘‘People used to always be like, you
sure you pregnant?…[I] Never got bigger. But I used to like-I
used to throw up in the end [vomiting].’’ Weight loss occurred
during pregnancy ‘‘Well, I have lost weight-I went in the doctor at
183 and now I/m 170. So the Doctor’s worried about my weight. By me
dropping so much weight [during pregnancy]…He said that, you
know, you’re just need to eat more.’’ Weight gain during pregnancy
was not seen as related to weight of baby ‘‘You know I gained 43
lbs, you know when I sit have the baby, this baby is 4 lbs and 14
ounces and I—like why it happen?’’[full term birth, delivered @ 40
+ weeks gestation.] Exceeded expected weight gain ‘‘I ran over 5
lbs and then that was bad.’’ Table 3 Nutrition subthemes for
participants delivering low birth weight/preterm babies
Nutrition/food intake sub themes Selected quotes illustrating
themes Eating habits secondary to emotional issues ‘‘…Then for
dinner, I had some cereal because I had a roommate here an um, and
we were going through some motions, you know what I’m sayin’ with
her. So my mind wasn’t really focused on eating. So I didn’t really
eat too much-eat too good yesterday.’’ Cultural influences on food
intake ‘‘Been pro-Black…Don’t eat no pork. Cut off a lot of junk
food. A lot of cookies and junk food like that. Cut out a lot of
fast foods.’’ Specific foods related to the health of baby ‘‘I had
some corn, some brown rice with some chicken with something on the
side. But, um, ‘cause I like brown rice better than white rice
because brown rice is better for the baby, my mom said.’’ Table 4
Family/support for women delivering pre term/low birth weight
babies Family/support group-influence on foods eaten Selected
quotes illustrating themes Father of baby ‘‘He (baby’s father)
pretty much wants me to eat everything, I mean regardless to how
many calories it is or if I should eat it or if I shouldn’t eat
it.’’ Mother of one teenager ‘‘And I don’t be eating a lot of junk
food and candy. I used to drink beer and stuff but I do everything
in front of my mom to let her know I ain’t trying to hide, she
figures as long as I do it in front of her, it’s ok.’’ Matern Child
Health J (2008) 12:718–724 721 123 when 6 months pregnant.’’ (2)
‘‘Learned how these should be taken in a class.’’ (3) ‘‘Taking
prenatal care pills, but made me vomit.’’ (4) ‘‘Mother made me
start taking.’’ There was one reference to the use of the Women
Infant and Children (WIC) Program. The Question: ‘‘How did you find
out about WIC?’’ The answer, ‘‘You know…as part of information on
the different kind of programs available to pregnant women.’’
Discussion The hypothesis examined was that gestational weight,
nutrition information/knowledge, and dietary habits were associated
with neonatal weight outcome. Although a wide range of themes and
subthemes emerged from the ethnographic study, the data were
individualized for each participant. Four of the participants who
delivered low birth/weight preterm infants reported weight related
concerns during pregnancy. The lack of sound, basic information
related to the importance of and the role of weight gain and its
relevance to the health of the infant for both the teenagers and
the participants delivering low birth weight/preterm babies was
evident. Frequently, the nutrition knowledge was based on
miseducation, misconceptions and/or ‘a grain of truth’ i.e. folk
beliefs. Vitamin and mineral supplement intake was problematic for
participants. The support group members had an influential role on
dietary habits of participants during pregnancy. An important
strength of the data was that the actual birth weights were
provided by the medical care facility. Kramer [22] stated birth
weight, defined as the sum result of the rate and duration of a
fetus’ growth, is a reliably collected variable and is still
frequently used as a predictor of the mortality and morbidity of
infants. The data for this study have several limitations. The
sample size was small; larger studies are recommended. A potential
limitation is ‘‘researcher bias’’ where the researcher’s age, sex,
ethnicity, personality traits, and other characteristics could
influence what the researcher is told or allowed to see and how he
or she perceives events and people. The larger study utilized the
triangulation methodology [20] in order to lessen the ‘researcher
effect.’ The study relied on the participant’s self reported
information, particularly for pregravid weight and weight gain
during pregnancy. The reliability of the self reported data gives
rise to the question: ‘‘How accurate are self-reported data?’’ Cook
and Campbell [23] pointed out that participants tend to report what
they believe the researcher expects to see, or report what reflects
positively on their own abilities, knowledge, beliefs, or opinions.
Self reported data also centers on whether participants are able to
accurately recall past behaviors. Cognitive psychologists have
warned that the human memory is fallible [24] and thus the
reliability of self-reported data is tenuous. The semistutured
interviewing techniques interwove questions regarding pregravid
weight, nutrition and dietary habits, and vitamin and mineral
supplements among the total of all questions asked related to
socio-cultural, psychological, and behavioral influences on
maternal health during pregnancy. The data were ascertained in
different ways by Ethnographers. The results were difficult to
quantify. This investigation explored the participants’ perspective
on weight during pregnancy. The lack of credible information
related to the importance of and the role of weight (both
inadequate and excessive) during pregnancy appeared to be the
dominant theme for all participants. In the interviews participants
usually justified weight gain from a cosmetic point of view rather
than the relationship of weight to pregnancy outcomes. According to
Henderson-King [25], women have long been evaluated in terms of
their appearance as contemporary North American society has
witnessed increased pressure on women to aspire to ideal images of
beauty. The exact nature of the ideal is subject to change as
fashion trends dictate; however, a focus on weight and body shape,
with an increasing trend toward slenderness has characterized the
‘‘contemporary ideal.’’ Harris et al. [26] further amplifies this
theme noting that very few empirical studies to date have
adequately examined non-white women’s attitudes toward their
bodies. The researchers further noted that absent from existing
studies is an examination of the demographic and socio-cultural
variables that related to the perception of and feeling toward the
body among African American women. The second focus of this study
was an examination of nutrition information and dietary habits in
the context of the environmental and family situations. An
important component of note was the influence of family/support
group members in determining/overseeing foods eaten by the
participants. The research of Mullings et al. [27] noted that
pregnancy served to mobilize greater action by women to address
housing, environmental and economic, and other social stressors
that existed before pregnancy; among these were an active attempt
to assess quality health care and nutrition. Chomitz et al. [28]
purported that the health behaviors should not be isolated from the
environment (society, community, and family) that fosters and
support them, and thus a change in the elements within the
environment will facilitate an individual’s ability to change
behaviors. Bronner [29] stated that nutrition counseling has not
been as family centered as it could be. The involvement of the
pregnant client’s network of support in the nutrition 722 Matern
Child Health J (2008) 12:718–724 123 and health education
counseling would begin to address the family centered concept.
Further Research and Conclusion Multi-disciplinary research
approaches have been recommended in order to determine the complex
factors that are involved in preterm birth [4, 30]. Further studies
that group outcome measures according to the proximate causes of
preterm delivery and target individuals (versus populations) at
risk are required to determine whether poor nutrition is a marker
for or cause of preterm birth. Access to medical records in order
to obtain prepregnancy weight as well as gestational weight gain
would serve to strengthen the study results. Evidence suggests that
populations at high risk of preterm births appear to have a poorer
quality diet [11, 31]. Thus, the research should focus on
macronutrients as well as micronutrients and the relevance to
preterm/low birthweight infants. The next step appears to be more
qualitative work, with health care providers, the Women Infants and
Children Program (WIC) nutrition counselors, clinical dietetic
professionals, and women who already have children, to explore
strategies for improving diet quality as well as address the issue
of inadequate and excessive weight gain during pregnancy.
