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RESEARCHARTICLEOpenAccessConcerns,attitudes,beliefsandinformationseekingpracticeswithrespecttonutrition-relatedissues:aqualitativestudyinFrenchpregnantwomenCléliaM.
Bianchi1,Jean-FranoisHuneau1,GalleLeGoff2,EricO.
Verger3,FranoisMariotti1*andPatriciaGurviez2AbstractBackground:Fromalifecourseperspective,pregnancyleadstoariseinnutritionawarenessandanincreaseininformationflowinfavourofadoptinghealthiereatingbehaviours.
ThisqualitativestudywasdesignedtobetterunderstandthedeterminantsofeatingbehavioursinFrenchpregnantwomenbyfocusingontheirconcerns,attitudesandbeliefsandtheirnutrition-relatedinformationseekingpractices.
Methods:Sevenfocusgroupswereconducted,involvingatotalof40Frenchpregnantwomen.
Aninductivethematicapproach,adaptedfromthegroundedtheory,wasadoptedtoanalysethedata.
Twomajorthemeswereidentified:eatingbehaviourandnutrition-relatedinformationbehaviour.
Results:Theeatingbehaviourthemewasdividedintofoursub-themesusingtheattributiontheory.
Threeexternalcausesaffectedtheeatingbehaviourofpregnantwomen(foodrestrictions,physiologicalchangesandweightgain),andledtofrustrationandaperceivedlossofcontrol.
Bycontrasttheadoptionofahealthierdietwasperceivedasinternalbypregnantwomen,andresultedinself-fulfilmentandempowermentregardingthehealthandthewell-beingoftheirbabyandthemselves,andtheirweightgainmanagement.
Greaterattentionwaspaidtonutrition-relatedinformationobtainedfromhealthcareproviders,thesocialenvironmentandthemassmedia.
Informationwaspassivelyabsorbedoractivelysoughtbypregnantwomen,butmostwasperceivedascontradictory,whichledtoconfusion.
Conclusion:Pregnancyisaccompaniedbyariseinnutritionawareness,substantiatedbyeatingbehaviourmodificationsduetoexternalandinternalcauses.
However,conflictsbetweenandwithininformationsourcesresultinconfusionthatcanlimittheadoptionofhealthiereatingbehaviour.
Keywords:Pregnancy,Maternalnutrition,Qualitativemethods,Eatingbehaviour,Dietarymodifications,InformationbehaviourBackgroundAccordingtothelifecourseperspective,therearecrit-icalperiodsinanindividual'slife,relatedtonutritionandhealthbehaviours,thatmaycausespecificandlast-ingchangestolifestyletrajectories[1,2].
Thesetrajec-tories,modelledacrosslifebyanaggregationofcultural,contextualandsocialfactors,remainquitestableanddifficulttomodify,exceptduringsometransitionalpe-riods[3].
Pregnancyrepresentsa'transition'or'turningpoint'inawoman'slifewhenbiological,physiological,socialandemotionalchangesareexperienced[1,2,4].
Therefore,duringthepericonceptionalperiod,womenmaybecomekeenertoengageinglobalandnutrition-relatedhealthierbehaviourswhichmightbesustainedovertimeandpositivelyaffectboththeirfuturehealthandthatoftheirfamily.
Withintheframeworkofthelifecourseperspective,previousstudiesdescribedarisein*Correspondence:mariotti@agroparistech.
fr1UMRPhysiologiedelaNutritionetduComportementAlimentaire,AgroParisTech,INRA,UniversitéParis-Saclay,16,rueClaudeBernard,75005Paris,FranceFulllistofauthorinformationisavailableattheendofthearticle2016TheAuthor(s).
OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.
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0/),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinktotheCreativeCommonslicense,andindicateifchangesweremade.
TheCreativeCommonsPublicDomainDedicationwaiver(http://creativecommons.
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0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.
Bianchietal.
BMCPregnancyandChildbirth(2016)16:306DOI10.
1186/s12884-016-1078-6nutritionawarenessduringthepericonceptionalperiod[5,6].
Theriseinnutritionawarenessalsoexistsinsecond-timepregnantwomenbutislessintense,becausethehealthierdietarypatternstheyadopteddur-ingtheirfirstpregnancyhaveatleastpartiallybeeninte-gratedintheirfoodhabits[6].
Theacquisitionofinformationisacrucialstepwhenadoptinghealthierbehaviour[7].
Greaternutritionawarenessisaccompan-iedbyanincreaseinnutrition-relatedinformationseek-ingbehaviour[8,9].
Informationcanbeobtainedfromhealthcareprofessionals,bybenefitingfromotherpeople'sexperiencesintheirsocialenvironmentorviathemedia[8].
Healthcareprovidersaremostlikelytoofferagoodresponsetopregnantwomenseekingnutrition-relatedinformation,butthequalityofante-nataldietaryinformationvariesmarkedly,dependingontheprofessional'sexperienceandtime[10],sopregnantwomenoftenseekfor,andfind,informationbythem-selves[8,11].
Understandinghowbehaviourtowardsnutrition-relatedinformationaffectstheeatingbehav-iourofpregnantwomenremainscritical.
Becauseofgrowingevidencethatadequatematernalnutritioniscriticaltothehealthofboththemotherandheroff-spring[12–16]andmayevenimpactthatofthechild'sinthefuture[17–21],eatingbehavioursduringpreg-nancyhaverecentlybeendescribedinthenutritionre-searchliteratureusingqualitativemethods.
Itneverthelessremainsanunder-investigatedarea.
Untilnow,mostqualitativestudiesfocusedonpregnantwomen'sweightgain[4,22–27],especiallyamongover-weightandobesewomen[22,23,26,27].
Theirresultsconfirmedtheriseinnutritionawarenessthatoccursduringpregnancytobeahealthymotherwithlimitedweightgainandahealthybaby.
Pregnantwomenadoptedahealthierdietbysubstitutinghealthieroptions,planningtheirmealsahead[22],eatingmorefruitsandvegetables,complyingwithdietaryguidelines[24],andeatingfewerunhealthyfoods[23,24].
Yetthispositiveriseinnutritionawarenessislimitedbyconfusedfeelingsregardingthepreciseissuesthatnutri-tionneedstotackleduringpregnancy.
Pregnantwomenperceiveafragmentationbetweentheir"self"and"theirpregnancy"whichinfluencesthecontrolandacceptabil-ityofgestationalweightgain[25].
Theyfeelstigmatisedbyhealthcareprovidersregardingtheirweightgain[26]andconstantlyneedtojustifytheirbehaviour[25].
Inthiscontext,issuesrelatedtoweightgainmayoutweighothernutrition-relatedconcerns.
ArecentqualitativestudyonthedietarybehavioursofSwedishpregnantwomenshowedthatnutrition-relatedissuescouldbeassociatedwithnegativefeelingssuchasfear,guiltanduncertainty[11].
Finally,thereisstillapaucityofdataonhowpregnantwomenperceivetheircontrolofeatingbehaviourandhowthecombinationofallnutrition-relatedissuesmightshapethetrajectoriesfollowedbyallpregnantwomen(notrestrictedtoobeseorover-weightwomen)towardshealthiereatingbehaviourduringpregnancy.
Themainobjectiveofthisexploratorystudywastobet-terunderstandthedeterminantsofeatingbehavioursinFrenchpregnantwomenbyfocusingontheirconcerns,attitudesandbeliefsandtheirnutrition-relatedinforma-tionseekingpractices.
MethodsStudydesignThispaperreportsondatacollectedduringaqualitativestudydesignedtoinvestigatethenutritionconcerns,beliefsandattitudesofFrenchpregnantwomen,theirnutrition-relatedinformationseekingbehaviourandtheirneedtobenefitfromtailoreddietaryadviceduringpregnancy.
Focusgroupswereusedtocollectthesedata.
Theconductandreportingofthisstudycompliedwiththeguidelinesoutlinedintheconsolidatedcriteriaforreportingqualitativeresearch(COREQ)[28];alldetailsareprovidedinAdditionalfile1.
RecruitmentofparticipantsWeconductedsevenfocusgroupsessionsthatinvolvedatotalof40Frenchpregnantwomen:fivesessionsinParis(Ile-de-France,France;n=27)andtwoinAix-en-Provence(ProvenceAlpesCted'Azur,France;n=13).
Thecriteriaforeligibilityrequiredthatwomenshouldbepregnant,French-speaking,hadnotdevelopedgestationaldiabetesandwerenotexperiencingamultiplepregnancy.
Becausetheobjectiveofthisstudywastoelicitverbalinteractionsonthesubjectofdietandnutritionbetweenpregnantwomenfromvariousfamilial,socialanddietarybackgrounds,eachsessioninvolvedpregnantwomenwhosepre-pregnancybodymassindex(BMI),parityandsocio-occupationalstatusalldiffered.
ThecharacteristicsofalltheparticipantsareshowninTable1.
DatacollectionEach120-minsessionwasvideo-recordedandconductedaccordingtostandardproceduresforfocusgroups[29].
Thefirstandlastauthors(CBandPG)designedaninter-viewguidethatincludedthekeytopicstobeinvestigatedafteraliteraturereviewandconsultationwiththeprojectteam.
Theguidefocusedonthreemaintopics:(1)con-cerns,beliefsandattitudestowardsdietandnutritionduringpregnancy,(2)nutrition-relatedinformationseekingbehaviourand(3)needtobenefitfromtailoreddietaryadvice.
Onlydataregardingtopics(1)and(2)areconsideredinthisstudy.
Asummaryofthekeyquestionsofthetopics(1)and(2)intheinterviewguideispresentedinTable2.
Allthequestionswereopen-ended.
Thefirstauthor(CB)wasthemoderatorwholedallthesessions.
Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page2of14Anassistantmoderatorattendedeachsessiontoassistwithnotetaking,timemanagementandvideo-recording,aswellasdealingwithissuessuchasnon-verbalinterac-tionsbetweentheparticipants.
Participantsreceivedanincentivepaymentof40aftercompletionofthestudy.
DatacollectionwasensuredbythefirstauthorbetweenMarchandJune2015.
DataanalysisAllfocusgroupdiscussionsweretranscribedinfullbythemoderator.
AsnopreviousstudyhadbeenperformedontheeatingbehavioursofFrenchpregnantwomen,wedidnotdeclareanypre-determinedtheorybeforedatacollec-tion.
Aninductivethematicapproach,adaptedfromthegroundedtheory,wasthereforeimplementedtoanalysethedata.
Thisapproachinvolvesfamiliarisationwiththedata,anopen-codingprocessanddatainterpretationinthemesderivedfromidentifiedcodes[30,31].
Thetran-scriptsweredouble-codedindependentlybythesametworesearchers(CBandGLG)usingNvivo11ProforWindows(QSRInternationalPtyLtd,Victoria,Australia).
Discrepanciesbetweenthetworesearchersregardingthecodedcategorieswereidentifiedthroughthesoftwareandresolvedthroughdiscussion;thefinalcodebookwasthendefined.
Thecodeddatawerethengroupedintwomajorthemesandtheirsub-themes(Table3).
Thefirstthemerelatedtotheeatingbehaviourofpregnantwomenwasanalysedusingtheattributiontheory.
Identifiedsub-themesweredefinedwhethertheircauseswereattributedtoanoutsideeventorperson(external)ortothemselves(internal)bythepregnantwomen[32].
Thesecondthemeconcernednutrition-relatedinformationseekingbehaviourandwasdividedintothreesub-themes:thetwoaspectsofinformationbehaviour(thepassiveabsorptionofinforma-tionandactiveinformationseeking)andtheselectionofinformationtointegrateintheireatingbehaviour[33].
Eachquotationillustratingthethemesandsub-themeswasidentifiedwiththeparticipant'snumberfollowedbythequotationnumber,andthesearepresentedinFrenchinAdditionalfile2.
CharacteristicsofeachparticipantaccordingtohernumberarepresentedinAdditionalfile3.
ResultsEatingbehaviourofpregnantwomen1.
Externalattribution:foodschangingfrombeingusualtodangerousThe"impressiveandfrustratinglistofforbiddenfoods"Forfoodsafetyreasons,theconsumptionofsomefoodsisstronglydiscouragedduringpregnancy.
Mostparticipantsreportedthatthehealthcareprovidermonitoringtheirpregnancyprovidedthemwith"animpressivelistofforbiddenfoods".
"Mygynaecologistgavemealist,tellingmeallthedifferentfoodIcouldnteat[…].
Shetoldme:"Youmustadherestrictlytotheinstructionswrittenonthislist,stickitonyourfridgeandcheckeverythingthatgoesinandout!
""(P31-1)Boththelackofexplanations,andthequantityanddiversityofthefooditemsTable2KeyquestionsintheinterviewguideSummaryofkeyquestionsTopic1:Concerns,beliefsandattitudestowardsdietandnutritionduringpregnancyIfyouheardthephrase"eatingwhilepregnant",whatwouldbethefirstthingyouwouldthinkofHaveyouinpracticechangedinyourfoodhabitssinceyoubecamepregnantWhatdoyouthinkaboutthewell-knownsaying"eatingfortwowhenyouarepregnant"WhatdoyouthinkaboutfoodrestrictionsduringpregnancyTopic2:Nutrition-relatedinformationseekingbehaviourWheredidyouobtainallyournutrition-relatedinformationAmongtheinformationsourcesyouhavequoted,whichoneappearstobemostrelevantAmongallinformationsourcesyouhavequoted,whichoneappearstobethemostreliableWhydoyouthinkitisthemostreliableOntheotherhand,whichoneappearstobetheleastreliableWhydoyouthinkitistheleastreliableDoyoulookfornutrition-relatedinformationyourselfWhattypeofnutrition-relatedinformationareyoulookingforTable1CharacteristicsofparticipantsbyregionofrecruitmentAix-en-Provence(n=13)Paris(n=27)Total(n=40)Agea(years)31.
9±5.
529.
7±3.
430.
5±4.
2Pre-pregnancyBMIa(kg/m2)21.
8±3.
022.
5±3.
722.
2±3.
4Trimesterofpregnancyb1st2nd3rd15.
4%(2)23.
1%(3)61.
5%(8)11.
1%(3)63.
0%(17)25.
9%(7)12.
5%(5)50.
0%(20)37.
5%(15)Primiparasb46.
2%(6)51.
9%(14)50.
0%(20)Householdincomeb(permonth)4000Don'twishtoanswer23.
1%(3)38.
5%(5)30.
8%(4)7.
7%(1)11.
1%(3)55.
6%(15)22.
2%(6)11.
1%(3)15.
0%(6)50.
0%(20)25.
0%(10)10.
0%(4)HadpreviouslyfollowedadietbNeverOnceSeveraltimes30.
8%(4)30.
8%(4)38.
5%(5)51.
9%(14)11.
1%(3)37.
0%(10)45.
0%(18)17.
5%(7)37.
5%(15)aAllvaluesaremean±SDbAllvaluesarepercentagesfollowedbythecorrespondingnumberofparticipantsbetweenbracketsBianchietal.
BMCPregnancyandChildbirth(2016)16:306Page3of14usuallyeateninFrancethatwereincludedonthislist,resultedinthedevelopmentofconsiderablefrustrationamongtheparticipantswhowantedtofollowtheseguidelines,becausetheyhadamajoreffectontheirdailydietaryhabits.
Duringsocialevents,aswellasbeingfrustrated,someparticipantsrevealedthattheyfeltexcludedbecausetheycouldnoteatthesamethingsaseveryoneelse.
IntheFrenchcontext,whereeatingiscloselylinkedtosharing,thisissuewasproblematic.
"Duringmylastpregnancy,IwasquitefrustratedinChristmasbecauseIcouldnteatsmokedsalmonlikeeveryoneelsearoundme.
"(P62-2)Afterfrustrationcomeanxiety,fearandthenguiltThediscourseofourpregnantwomenalsohighlightedtheiranxietiesandfearsregardingfoodconsumption.
Thelistofinadvisableitemscouldnotbeexhaustiveandspecific.
Theybecameworriedabouteatingmeatthatmightnothavebeencookedenough,acheesetheyhadnotidentifiedasbeingpotentially"forbidden",orrawvegetablesthathadnotbeenwashedthoroughlyenough.
"Ihaveaquestion:Iknowgoat'scheeseisnotallowed,butforexampleifitiscookedisitokaythen""Forexample,goatcheeselogsthatarepasteurised,noworries.
"(P53/P56-3)Weidentifiedthreesourcesforthisanxiety.
Firstandforemost,theywereanxiousthatriskyeatingbehaviourmightaffecttheirbaby'shealthwhichwouldmeanthattheywerenota"good"mother.
Furthermore,theriskswereunclearbecausetheycouldnotbewellidentifiedandevaluated.
Lastly,participantsfelttheyweresometimesbeingjudgedbytheirrelativesregardingtheirfoodconsumption.
Peopleintheirsocialenvironmenthadheardaboutfoodswhoseconsumptionisnotrecommendedduringpregnancy,sotheyquestionedthem,thusexacerbatingtheirguilt.
"IthinktomyselfthatIwouldliketoeatthat,becausethemainaimistohaveahealthybabyanyway,[…]Whenpeoplesay,"Ah!
Butwhyareyoueatingthat",Ifeelguilty.
[…]ButIambeingcareful;ifIhaveanydoubts,Idon'teatit.
"(P22-4)NormsversuspersonalpracticesAgreatmajorityofourparticipantswereawareofthesenorms.
TheymightallowthemselvesTable3ThemesandsubthemesidentifiedThemesSub-themesEatingbehaviourofpregnantwomenExternalattribution:1.
Foodschangingfrombeingusualtodangerous-The"impressiveandfrustratinglistofforbiddenfoods"-Afterfrustrationcomeanxiety,fearandthenguilt-Normsversuspersonalpractices2.
Physiologicalchangesimpactingfoodintakes-Pregnancypainsthatrestrictwomen'sfoodchoices-Pregnancy-relatedphysiologicalchangesthatmodifyfoodchoices3.
Weightgain-Losingcontroloverbodyweight-Externalsurveillanceofweightgain-ReassuringthemselvesInternalattribution:4.
Theempowermentendeavour:buildingahealthierdietformothersandtheirbabies-Strategiestoachieveahealthierdiet-Maintainingsomefoodindulgences-Settingpersonalgoalstointernaliseweightgain-Contributingtotheirownandtheirbaby'shealthandwell-being:thebeginningofmotherhoodNutrition-relatedinformationbehaviour1.
Passiveabsorptionofinformation-Fromhealthcareproviders-Fromtheirsocialenvironment-Fromthemassmedia-Difficultcross-checkingofinformationfromallsources2.
Activeinformationseekingbehaviour-Benefitingfromtheexperiencesofpeopleintheirsocialenvironment-AmbiguoususeoftheInternet-Theultimatestep:askingtheirhealthcareproviderforguidance3.
TranslatinginformationintoeatingbehaviourBianchietal.
BMCPregnancyandChildbirth(2016)16:306Page4of14somedeviancefromthesestrongandconfusingnorms.
However,eachdevianceneededtobejustified,inordertocopewiththeguiltitinducedofnotbeinga"good"mother.
Participantsmostlyjustifiedanydeviancesbymentioningtheirhealthcareproviders("Mygynaecologisttoldmethateatingsushiwasallright.
"(P75-5)),theirusualandgeneralcompliancewiththesenorms,ortheirpastexperiences("Intheend,therewerenoeffectsonmanyotherpregnancies.
"(P33-6)),particularlyinmultiparas.
2.
Externalattribution:PhysiologicalchangesimpactingfoodintakesOurparticipantsreportedmanyphysiologicalchangesthatimpactedtheirfoodchoices,resultinginmodificationstotheirpre-pregnancydiet.
Thesephysiologicalchangesledtoavarietyofconstraintsaffectingtheirdailylife,includingtheirfoodchoices.
Theywereperceivedas"external"becausetheywereaninherentpartofpregnancy,notduetotheirpersonalwill.
Pregnancypainsthatrestrictwomen'sfoodchoicesOntheonehand,whennausea,gastroesophagealreflux,lossofappetiteorfoodaversionsduetoanincreasedsensitivitytoodourswereexperiencedbyparticipants,theywereperceivedaspathologicalsituationsthatweredifficulttomanageintheirdailylifeandrestrictedtheirfoodchoices.
Theycouldbereferredtoas"pregnancypains".
Allparticipantshadexperiencedatleastoneofthesenegativephysiologicalchanges.
"Ialwaysfeelsick,duetofoods,orsmells,orotherthingslikethat,itshorrible!
[…]Therearesomethingsthatdisgustme,suchasmydaughter'sfavouritecheese;whenIgivehersome,Icouldcry,it'ssodisgusting!
"(P31-7)Pregnancy-relatedphysiologicalchangesthatmodifyfoodchoicesOntheotherhand,enhancedsensations,changestofoodpreferencesorfoodcravingswereperceivedasnon-pathologicalsituationsthatformedpartoftheirdailyexperienceofpregnancyandcausedchangestotheirfoodchoices.
Foodcravingswereverycommonamongparticipants.
Theymainlyconcernedsweetproductsorveryspecificfoodsthatdifferedfromthewomen'susualdiets,andusuallyhadtobesatisfiedassoonaspossible.
"Ihadsomeweirddesires,suchasspringrollsandvanilladessert[…]SoforawhileIatealotofspringrollsandvanilladesserts,eventhoughIhadnotbeenaparticularfanbefore.
"(P24-8)Finally,theparticipantsconsideredthesechangestobenormalbecausetheywerepregnancy-related,soeveniftheydidaffecttheirfoodchoices,theyacceptedthemasaresponseoftheirbodytopregnancy.
"ButIthinkwhateverwedo,therearepainsthatwe'llalwayshave.
"(P26-9)3.
Externalattribution:WeightgainPregnantwomeninourstudyclaimedthatweightgainisa"normal"processthatisinevitableduringpregnancy,theonlytimeintheirliveswhentheycouldputonweight.
Itrepresentedanon-pathological,pregnancy-relatedphysiologicalchangeinthesamewayasnauseaorfoodcravings,exceptforitsvisibleandquantifiableaspect.
Asaphysiologicalchange,theyperceiveditas"external"becauseitwasbeyondtheirownwill.
LosingcontroloverbodyweightParticipantsrevealedthattheyfelttheywerelosingcontrolovertheirweight.
Theyexperiencedweightvariationsmorethanusual.
Theexpectedidealmonthlyweightgainwasfarfromwhattheparticipantsactuallyexperienced.
Theyattributedweightgaintoaquantifiablebutnoteasilypredictableresponseoftheirbodytopregnancy.
"It'sdifficultwhenyouarepregnant[tomanageyourweightgain]:thebodyisincommandandIreallyfeellikeIlostcontrol…"(P16-10)Iftheydidnotputenoughonweight,theyworriedabouthavinganundernourishedchildwithalowbirthweight.
Puttingonweightduringpregnancywasperceivedas"normal",sothatalowweightgaincouldbeseenasanabsenceofthemostvisibleandwell-knowncharacteristicofpregnantwomen.
"[…]I'veonlyputononekilosinceIhavebeenpregnant!
[…]Peoplearoundmeareworried,becauseapregnantwomanissupposedtoputonweight.
[…]Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page5of14Butthenthedoctorsreassuredme.
[…]However,itcanbedisturbing,becauseunconsciously…"(P53-11)However,iftheyputonweighttoomuch,theywereworriedaboutkeepingitafterthebirth.
Multiparaswhohadexperiencedexcessivegestationalweightgainduringpreviouspregnanciestendedtobemorestressedbyweightgainthanprimiparas,becauseoftheproblemofgoingonapostpartumdiet.
However,neitherprimiparasnormultiparaswantedtodeprivethemselvesortheirchildforreasonsofappearance.
"I'malsotryingtobecareful,becauselosingweightafterwardsisnotatalleasy.
Duringmypreviouspregnancies,Igainednineteenandseventeenkilos.
Butthat'sthewayitgoes,wecan'tstarveeither!
"(P62-12)ExternalsurveillanceofweightgainInFrance,pregnantwomenbenefitfromamonthlyvisittoahealthcareprovider.
Ateachmonthlyappointment,theyareweighedbythegynaecologistormidwife,whowilljudgewhethertheirweightgainisappropriate.
Iftheirweightgainisconsideredtobemorethanexpectedfromthepreviousappointment,healthcareprovidersclearlyadvisethemtoeatless.
"Evenifyoudon'twanttocheckityourself,thegynaecologistwillweighyoueverymonth!
"(P64-13)Accordingtotheparticipants,thismonthlycheckcouldbestressful,becauseofthegapbetweentheexternalcontrollabilitytheyperceivedontheirweightgainandtheinternalcontrollabilitythehealthcareproviderattributedtoit.
Fromahealthperspective,theyknewthatadequateweightgainiscriticaltolimitadversepregnancyoutcomes,suchasgestationaldiabetesmellitusorbirthcomplications,andtooptimisefoetalgrowth.
Nevertheless,thereactionofhealthcareproviderstoexcessiveweightgaincouldbeveryguilt-inducingandtraumaticforthewomen.
"[Formyfirstpregnancy]onthedayofbirth,Iwasscolded,andthedoctorcalledmeabigfatcow.
"(P25-14)ReassuringthemselvesMostofthepregnantwomentriedtoreassurethemselvesandjustifytheirweightgainbyfollowingthetraditionalbeliefthatwhatevertheirweight,andcontrarytowhattheyhadbeentold,therewasnoclearrelationshipbetweenmaternalweightgainandthebaby'sweightatbirth.
Accordingtotheparticipants,thefoetusdrewonitsmother'sreservestosatisfyitsneeds.
"Butthebaby'sweightisn'tlinkedtoyourweightgain.
""No,theweightwegaindoesn'tmeananything.
"(P41/P42-15)4.
Internalattribution:Theempowermentendeavour:buildingahealthierdietformothersandtheirbabiesStrategiestoachieveahealthierdietAllparticipantsstatedthattheyweremoreawareofnutritionduringpregnancy,andidentifiedpregnancyasaperiodduringwhichtheyshould"eatmorehealthilythanbefore"(P15-16).
Mostparticipantssaidtheyhadanincreasedappetiteandtheyhadbeeneatingmoresincethestartoftheirpregnancy.
However,althoughtheyagreedtheywereeatingmorethanusual,abovealltheywantedtoeatbetterandnottoexcess.
"Eatingfortwo"wasfarfromtheparticipants'perceptionsoftheirpregnancy,whichtheytendedtoattributetooldmisconceptions,andthishadturnedinto"Eatingfortwoinqualitybutnotinquantity".
Threecategoriescouldbeidentifiedregardingtheadoptionofhealthiereatingbehaviour:thenutrientadequacyofthediet,thedietaryplanningandtheoriginsoftheirfood(Table4).
Thedegreeofapplicationofthesestrategiesvariedamongparticipants.
Eventhosewhosaidtheywerenotveryinterestedindietandnutritionmadesomechangestotheirusualdiets.
Whileprimiparasmightreportanunhealthypre-pregnancydiet,mostmultiparasexplainedthatthefoodhabitsoftheirfirstpregnancieshadbeenpartlymaintained.
Dietarysupplementswerenotfavouredinordertoconsumemorevitaminsandminerals;theygaveprioritytofoodsrichinvitaminsandminerals.
MaintainingsomefoodindulgencesFoodindulgencewascriticaltoparticipants'well-beingastheyfeltsufficientlyrestrictedalready.
Theyallowedthemselvestoeatsometreats,suchassweetorchocolateproducts,because"chocolateistheonlything[they]caneatthat[they]knowissafe"(P12-27).
Theyfeltthatbeingtoofrustratedwouldimpacttheirwell-being,whichtheyassociatedwiththatoftheirbaby.
Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page6of14SettingpersonalgoalstointernaliseweightgainTheyfeltpowerlessregardingweightgain,buttheyneverthelesssetpersonalgoalsinordertolimitit.
Sopregnancymeantnotonly"weightgain"but"weightgainmanagement".
Eatingahealthierdietallowedthemtoattainthesegoalseveniftheirappetiteincreased.
Thisjustifiedtheirweightgainandreducedtheirguilt.
"ThecookiesIdreamaboutIneverbuyitnottobreakdown,nottogrowfat.
"(P31-28)Contributingtotheirownandtheirbaby'shealthandwell-being:thebeginningofmotherhoodTheultimateaimofapregnantwomanistogivebirthtoahealthybaby.
Adoptingahealthierdietisoneofthefirstactionstheycantaketoachievethis.
Ourparticipantsnaturallywantedthebestfortheirbabiesandtheyfeltresponsibleforwhattheyatebecausetheyknewthat"everything[they]eatthebabywilleatwith[them]"(P41-29).
Theysometimesallowedthemselvestoeatunhealthyfoods,butthentheyfeltguiltyaboutfeedingtheirbabyinanunhealthymanner.
"Forexample,whenIeatafastfoodmeal[…],Itellmyselfthatit'snotnicewhatIamdoingtomybaby[…]It'scrammedwithadditives,it'snotevenrealfood!
"(P56-30)Adoptinghealthiereatingbehaviourcanpositivelyimpactthebaby'shealthandwell-being,andrepresentsafirststepintomotherhood.
Pregnantwomenstarttoactlikeamotherandtakeresponsibilitybycontrollingthebaby'sdiet.
"Buttherearetwoofusnow,youbecomelessegocentric!
[…].
BecauseIcan'tcontrolanythingbecausesheisgrowingalone,let'ssaythat[diet]istheonlythingIcanmanage.
Ican'tinterferewiththecolourofhereyesorhair,butIshareresponsibilityforherwell-being.
"(P52-31)Theirownhealthwasalsoanobjective,becauseifaninadequateintakeofnutrientscouldharmthebaby,itcouldalsoleadtocomplicationsduringdeliveryandafterwards.
Theself-fulfilmentofourparticipants,andtheirwell-beingaswomenwerecrucialtotheirperceptionofbeinga"goodmother".
"It'salsoimportantafterthepregnancy,becauseyou'reamum,you'reawoman,you'reawife,you'reprofessionalandformethat'ssomethingthat'ssuperimportant.
Tobeafulfilledmum,Ineedtobeafulfilledwoman;Ithinkitstartsfromyourdiet,soIneedtofeelgoodinmybodyifIamtobefulfilledasamum.
"(P74-32)Table4ClassificationofstrategiestoachieveahealthierdietduringpregnancyStrategiesCategoriesFoodoriginNutrientadequacyofthedietDietaryplanningEatingmorefruitsandvegetables:"Iforcemyselftoalwaysincludefruitsandvegetablesinmydiet,atbreakfast,lunchanddinner.
"(P31-17)XBalancingthediet:"Ireallydidn'tcarebefore!
NowIamtryingtoeatmorefish,morevegetables.
"(P55-18)XFavouringfoodsknowntoberichinspecificvitaminsandminerals:"IhaveaddedthingstomydietthatIdidnoteatmuch,suchaslentilstoobtainiron.
"(P33-19)XSubstitutingunhealthyfoodswithhealthieroptions:"EvenifIcontinuetosnack,I'lleatadairyproduct,somethingmorebalanced,moresensible.
"(P42-20)XEatinglesssugar:"IhavereallybackedoffsugarsbecauseIwastooaddictedbefore.
"(P13-21)XEatingthreeorfourmealsaday:"Beforebeingpregnant,IwasononeoreventwomealsadayandnowItrytodothreeregular.
"(P24-22)XFavouringorganic,localorfarmfoods:"Asformeat,Ialwayschosethebestqualitycutsfromthebutcher'sanyway[…]andthesamegoesforvegetables.
NowI'mmoreintobuyingdirectlyfromtheproducer[…]andfindingmoreorganicfoods.
"(P11-23)XSplittingfoodintakes:"Iskipdessertatlunch-time,andtheneatitataroundthreeorfourpm.
"(P33-24)XXAvoidingprocessedproducts,aboveallready-to-eatmeals:"Ibuyfewerprocessedfoods,oronlytheleastprocesseditems.
"(P67-25)XXCookingmore:"Wealsotrytodomore'home-made'dishes,becausethenIknowwhathasgoneintothem.
"(P41-26)XXXBianchietal.
BMCPregnancyandChildbirth(2016)16:306Page7of14Nutrition-relatedinformationseekingbehaviourInthenextsection,wefocusonthenutrition-relatedinformationthatthewomenabsorbedpassivelyorsoughtactively,andspecificallyduringpregnancy.
Nutrition-relatedinformationsourcescanbedividedintothreecategories:(1)healthcareproviders,(2)thesocialen-vironmentand(3)themassmedia.
1.
PassiveabsorptionofinformationFromhealthcareprovidersAccordingtopregnantwomeninvolvedinourstudy,theirhealthcareprovidersweremainlythegynaecologistand/orthemidwife.
Theparticipantsidentifiednutritionasacomponentoftheirbabies'healthandwell-being,sotheystronglytrustedtheirhealthcareproviderswhoappearedtobethegoldstandard.
However,professionalsdidnotspendmuchtimediscussingnutrition-relatedissues.
Inmostcases,theyquicklyreferredtodietaryrestrictionsduringpregnancy,beingfocusedmainlyonthepatient'sweightgain.
Intheeventofexcessiveweightgain,theymightreferpregnantwomentoadietician.
Pregnantwomenbenefitedfromverylittleinformationonthefoodstheyshouldfavour,andtheadvicewasmuchmoreaboutnegativesthanpositives.
"Theydon'tallremembertotellusifwearesufferingfromadeficiency,orsuggestthatweshouldeatthisorthat!
"(P52-33)Duringtheirantenatalcare,pregnantwomenoftensawdifferenthealthcareproviders,whoseinterestinandopiniononnutrition-relatedissuescouldvary.
Conflictinginformationonnutrition-relatedissuesledtoincomprehensionandirritation,andthusincreasedtheiranxiety.
"Amongdoctors,therearetwosortsofstories:somesayyes,othersno.
[…]mygynaecologistisagainstdietarysupplements,butwhenIarrivedatthematernityhospital,[themidwife]gavemeaprescription[totakedietarysupplements].
WhatamIexpectedtodo"(P53-34)FromtheirsocialenvironmentIntheirsocialenvironment,relativesveryoftenadvisedparticipantsaboutnutrition,basedontheirexperienceoronhearsay.
Because"everyonehastheirownstory"(P14-35)aboutnutrition-relatedissues(withoutanyscientificbackground),tryingtocross-checkthisinformationalsoresultedininconsistency.
"Friendsandrelativestalkabouttheirownstoriesandtheydrawhastyconclusions.
OnepersontoldmeIshouldeatayoghurteveryday,otherwise[…]mychildwouldnotbeabletodealwiththesun!
"(P32-36)Thesocialenvironmentwasnotperceivedasareliablesourceofinformation,exceptfortheirmothersorthoseofothers.
Pregnantwomenweremorereceptivetothetransmissionofhealthorcookinghabitsfromtheirmothers.
"Ihavelearnedfrommymotherwhattodoandhowtocook.
"(P15-37)FromthemassmediaPregnantwomenarebecomingmorereceptivetogeneralinformationonfoodandnutritiongainedfromthemassmedia.
MoreandmorereportsarebroadcastonTVorpublishedinthepressonboththenutritionandsafetyaspectsofthediet,andtheyoftenhighlighttheunhealthyaspectsofproductsandprocessesusedbyfoodindustries.
Suchinformationcancreateanxietywithrespecttofood.
Althoughthisinformationwasnotpregnancy-specific,participantsfeltmorereceptivetowardsit.
"IstoppedwatchingTVshowsbecauseIbegantofeelthatIcouldn'teatanythingatall!
[…]Eachtimetheycomeupwithanewproblem!
"(P11-38)Difficultcross-checkingofinformationfromallsourcesParticipantstriedtodealwiththeinformationonnutrition-relatedissuestheyobtainedfromallthesesources,towhichtheygavemoreorlesscredence.
Theinconsistenciestheyperceivedwithinasourcewasheightenedwhentheycross-checkedinformationbetweendifferentsources.
"Healthprofessionalstellusspecificallynottoeatfortwoandtoeatasusual.
Butourfamiliesandfriendstellustohavesecondhelpingsbecausetherearetwoofus.
Iexperiencedthisagainattheweek-end.
"(P52-39)Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page8of14Inreactiontothisconfusion,mostofthemdevelopedaninformationseekingbehavioursothattheycouldachievenutrition-relatedempowerment.
2.
ActiveinformationseekingbehaviourWeidentifiedtwotypesofnutrition-relatedinformationseekingbehaviour:searchingatanytimetoobtaingeneralnutritionalknowledgeandsearchingspecificinformationinresponsetoapregnancy-relatedproblemorquestion.
Multiparastendedtoseeklessgeneralinformation,relyingontheirpreviouspregnancyexperience.
However,because"everypregnancyisdifferent"(P42-40),theyfelttheyhadnotbenefitedfromorsoughtenoughnutrition-relatedinformationduringtheirpreviouspregnancy.
BenefitingfromtheexperiencesofpeopleintheirsocialenvironmentNutrition-relatedinformationseekingbehaviourwasimplementedduringinterpersonalexchangeswithothermothers(especiallytheirownmothers)orpregnantwomenintheirsocialenvironment.
However,theirmother'sexperienceswerejudgedasbeinginthepast,andtheupdatingofinformationwasquestioned.
"Iasked[mymother]lotsofquestionsatthestart.
Buteachtime,shetoldmethatithadbeenalongagoforher[…]andatthattime,itwasmucheasier,pregnantwomencouldeatwhatevertheywanted!
"(P23-41)AmbiguoususeoftheInternetNutrition-relatedseekingbehaviourmostlyconcernedthemassmediaandparticularlytheInternet,butuseofthelattertendedtobeambiguous.
Ontheonehand,itwasthefirstideaintheparticipants'mindsbecauseofitsimmediacy,continuousavailabilityandtheassuranceoffindingatleastoneanswertotheirquestion.
"Ontheweb,youcanfindinformationstraightaway,whenyouwantresultstheyareimmediate,youdon'tneedtowaitforthenextappointmentwiththemidwife.
"(P42-42)However,theydidnotreallytrustthiseasilyaccessibleinformationbecauseofthelackofidentificationofitssourcesandthecountlessandconflictingnumbersofarticlesandforumdiscussions.
Often,insteadofansweringtotheirquestions,thisheightenedtheirconfusion.
However,theydrewadistinctionbetweengenericandprofessionalwebsites,whichwereconsideredtobetrustworthy,becausetheauthorscouldbeidentified.
"Ontheweb,apartfromreallyspecialisedwebsites,therearesomesiteswhenyoudon'tknowwhattobelieve.
"(P42-43)Theultimatestep:askingtheirhealthcareproviderforguidanceWhenaspecifichealthproblemoccurred,aninternetsearchwasconsideredasafirststep,butthefindingshadtobeconfirmedbyahealthcareprovider.
"[…]itisnecessarytochecktheinformation,eitherwithaspecialistorwithsomeoneelse.
Thewebcannotbetheonlysourceofinformation…"(P12-44)Asidefromhealthproblems,theyfeltitwasnotappropriatetobothertheirmidwivesorgynaecologistswithquestionsaboutnutrition.
3.
TranslatinginformationintoeatingbehaviourThisactivesearchforinformationincreasedtheconfusionexperiencedbyourparticipants.
Theywerenotsatisfiedwiththeinformationtheyreceivedandsought,andneededtoreaffirmtheirempowermentregardingtheireatingbehaviour.
Participantsthereforeusedtheircommonsenseinordertofilterinformationdependingontheperceivedreliabilityofbothcontentandsource,beforeapplyingittotheirdiet.
"Youcantalkaboutallthesourcesofinformationondietduringpregnancy[…]butintheend,itisuptoyoutomaketherightdecisions!
"(P53-45)Furthermore,pregnantwomeninourstudyalreadyhadabasicknowledgeofthecomponentsofahealthydiet.
Theywereabletoremobilisenutritionknowledgetheyhadabsorbedpassivelybeforepregnancy,andtranslateitintotheireatingbehaviour.
"Youalreadyknowitinstinctively,youknowthatyoushouldnoteattoomanyfattyorsweetfoods;youshouldbeeatingvegetables.
Weareawareofthebasicideas[ofahealthydiet].
"(P12-46)Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page9of14DiscussionDuringthisstudy,wewereabletodemonstrateariseinnutritionawarenessamongFrenchwomenduringpregnancy,inlinewithwhathasbeenreportedinotherde-velopedcountries[4–6,11,24].
ThenovelfindingofthisstudywasthedescriptionoftheentireprocessresultingintheadoptionofahealthierdietbyFrenchpregnantwomen,highlightingtheimportanceoftheirempowermentwithrespecttodietandnutrition(Fig.
1).
Thesewomensawadoptingahealthierdietasafirststepintomotherhood,ameansofstartingtocarefortheirbabybeforebirth,andalsoasawayofregainingcontrolovertheirdietandtheirbody.
Indeed,manyelementsthatwereoutoftheircontrolrestrictedtheirfoodchoices.
ThisstudyalsoemphasisedthefactthatFrenchpregnantwomenreceivedheteroge-neousandconflictinginformationonnutrition-relatedissues,whichledthemdevelopingactiveinformationseekingbehaviour.
However,theperceivedconfusionbetweenandwithininformationsourcesjeopardisedtheadoptionofahealthierdietforthemandtheirbaby.
Inthispopulation,nutritionawarenesscannotbere-ducedtosimplygainingknowledgeaboutnutrition-relatedissues.
Itbecomes"hot"or"active",i.
e.
theirla-tentcognitionbecomesmoresalient,theybecomemorepreoccupiedbynutritionasasubjectof"continuousattention"and"deliberatesupervision"[5].
Pregnantwomentranslatetheirknowledgeintobehaviourandthenmakedietarymodifications.
Thesemodificationsmaybemoreorlessintense,dependingonindividuallifestyletrajectories.
Indeed,therearewomenwhowill"continuethesameway"[6],butinourstudytheyrep-resentedaminority.
Asinotherqualitativestudiesin-cludingnormal-weightwomen,mostofourparticipantscouldbecharacterisedas"goingalltheway"or"takingtheflexibleway"[6]andexperiencedmajorshiftsintheirnutritionawareness.
Aquantitativestudyper-formedinasmallgroupofFrenchpregnantwomenhadconcludedtoanincreaseintheconsumptionoffruitsandvegetablesandareductioninsugarconsumptionwhencomparedwiththeprenatalperiod[34],thussup-portingourqualitativefindingsinFrenchwomen.
More-over,evenifallthesemodificationswerenotsustainedduringthepostpartumperiodbymultiparas,changestoeatingbehaviourduringafirstpregnancywerepartlyex-tendedandtransmittedtoothermembersofthefamily.
Pregnancythusoffersawindowofopportunitytoadopthealthiereatingbehaviours,whicharguesinfavourofthelifecourseperspective[1].
However,thisincreaseinnutritionawarenessdoesnotsimplyrelatetohealthyeating.
ThisperiodoflifeisFig.
1Diagramoftheeatingbehaviourandthenutrition-relatedinformationseekingpracticesofpregnantwomenparticipatinginourstudy(n=40)Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page10of14markedbynutrition-relatedtensions,thecausalattribu-tionofwhichisexternalfrompregnantwomen.
Becauseofpregnancy-relatedphysiologicalchanges[35,36]andfoodrestrictions[37,38]womenneedtoreconsidertheirdietinearlypregnancy.
Althoughpregnancy-relatedphysiologicalchangesareoutofawoman'scon-trol,theyarewellacceptedbecausetheyareperceivedasatypicalfeatureofpregnancy[35].
Bycontrast,thenormsconcerningfoodrestrictionsarenumerous[39]andperceivedasintrusiveandoppressive.
InFrance,wherefoodhasastrongculturalmeaning,theserestric-tionsconcernfoodsthatareveryfrequentlyconsumed,suchascoldcutsandcheeses[40],whichcanresultinsocialexclusionandanegationoffoodpreferences.
Thereisconsiderableconfusionwithrespecttotheserestrictions,whichnecessarilygeneratesfear,asalsodemonstratedinarecentqualitativestudyperformedinSwedishfirst-timepregnantwomen[11].
Theydonotknowpreciselywhichspecificfoodstheycannoteat[11,39]buttheyknowthateatingsomething"wrong"mightbeharmfultotheirbabies[11].
Morethanjustdietarynorms,"forbidden"foodsareacomponentofthenutrition-related"motheringnorms"thatwereidentifiedbyCopeltonetal.
[41].
Thesacrificeoffoodpreferencesrepresentsoneofthestartingpointsofmotherhood,andpregnantwomenwillprefertodeprivethemselvesforawhileratherthanriskinganyharmtotheirbabyandactingasa"bad"mother[41].
Nevertheless,mostpregnantwomenallowthemselvessometransgressionsinexceptionalcases,butitappearstheyneedtojustifysuchdeviancesfromanormtheyknowtocopewiththeguilttheywillcause.
Justifica-tionisintenseandnecessaryforpregnantwomeninordertolegitimisetheireatingbehaviourswhentheirdeviancehasquestionedtheidealgestationalenvironmenttheyhavebuiltfortheirbaby[25,41].
Weightgain,likeotherpregnancy-relatedphysiologicalchanges,isinevitableduringpregnancy[26].
Indeed,pregnancycouldbeperceivedasatimetorelaxtherulesrelatedtoweightgainthatexistedpriortopregnancy[25],buttheexternalsurveillanceofweightgainbyhealthcareprovidersplacespregnantwomenunderpres-sure.
Pregnantwomenfeeljudgedonanissuetheyarefindingdifficulttohandleandthatshouldbe"normal"duringpregnancy.
Thisalsoresultsinajustificationprocessthatreferseithertobiology(i.
e.
puttingonweightisanuncontrollablebodilyresponsetopreg-nancy)ortothedenialofinjury(i.
e.
weightgainisnotassociatedwiththeirbaby'shealth)[41].
Finally,theeatingbehaviourofpregnantwomencanbemarkedbytensionsandgraduallyslipsoutofcontrol.
Pregnantwomenregaincontrolovertheireatingbehaviourbyadoptingstrategiestoachieveahealthierdiet.
Manyotherstudieshavereportedthesedietarymodificationsinpregnancy,suchasincreasingthecon-sumptionoffruitsandvegetables[24,41,42],complyingwithdietaryguidelines[24],reducingtheconsumptionofunhealthyfoods[23,24,41],introducinghealthieroptions,orplanningtheirmealsahead[22].
Inallstud-ies,thehealthofboththebabyandmotherwerereportedasbeingthemainobjectiveswhenadoptingahealthierdiet.
Ourfindingsrevealedthatanadditionaldimension,quicklymentionedinotherstudies[4,6]butnotdeeplyinvestigated,wasoperatinginthebehaviourofthesewomen:thewell-being.
IntroducedbyBlocketal.
,the"foodwell-being"paradigm,definedasa"positivepsychological,physical,emotionalandsocialrelationshipwithfoodatboththeindividualandsocietallevels",pro-videsanewdimensionwhenconsideringfood.
While"foodashealth"is"paternalisticandnormative"andmadeupof"restraintsandrestrictions","foodaswell-being"is"holisticandintegrative","consumeroriented"andbasedona"positiveapproach"[43].
Actingposi-tivelyasa"good"motheroftheirownwill,constitutesare-appropriationofeatingbehaviourapartfromexternalnormsoruncontrollablesituations.
Inthisempower-mentprocess,theirbehaviourismainlybaby-focusedbutitisalsoself-focused,becausethismakesweightgainmanagementpossibleandactspositivelyontheirwell-being.
Pregnantwomenwanttofollowadiet"whichisgoodfortheirchildorthemasamother"and"whichisgoodforthemasawoman"[44].
Fragmenta-tionoftheselfbetween"me"and"mypregnancy"[25]orbetween"measawoman"and"measamother"[44]seemstobethefoundationforconstructinganidentityduringpregnancy.
Ourfindingsshowedthatareunifica-tioncouldexistthroughtheadoptionofahealthiereat-ingbehaviour,notthehealthiestbehaviour.
Gradually,theguiltlessideaisemergingthatself-fulfilmentandwell-beingasawomaniscrucialtobeingfirsta"goodexpectantmother"andthena"good"mother.
Itshouldbenotedthatthepregnantwomeninourstudyalreadyknewalotaboutgeneralnutritionalprin-ciples.
Beforetheirpregnancy,thesewomenhadheardpublichealthmessagesaboutnutrition[45]butthesewereonlyappliedtotheirdietinalimitedmanner.
Ifwomenpassivelyabsorbthisinformationbeforetheirpregnancy,allnutrition-relatedconcernsthatthisphysiological,socialandemotionaltransitionmaytriggerwillplacetheminamore"active"position[6,8].
Devel-opingknowledgeaboutnutritionshouldresultinempowerment,butfromthethreetypesofinformationsourceidentifiedduringpregnancy(healthcarepro-viders,thesocialenvironmentandthemedia)[8],theyfoundlittlereliableandpregnancy-focusedinformationonnutrition-relatedissues.
Thegoldstandardrepre-sentedbyhealthcareproviderswassomewhattarnishedwhenitcametoquestionsonnutrition-relatedissues.
Bianchietal.
BMCPregnancyandChildbirth(2016)16:306Page11of14Healthcareproviderstendtofocuson"hard"healthissues,witheasilymeasurableeffectsandobservedwithinashortperiod.
Thus,restrictionandsurveillancetendtobestrongerthansupport[46].
Theylackthetime,resourcesandtrainingtoadvisepregnantwomenaboutnutrition[10,26].
Consequently,nutrition-relatedinformationisscarceandmayvaryfromonehealthcareprovidertoanother.
Finally,pregnantwomenfeeltheyshouldnotbotherthembyaskingforguidanceonissuesnotrelatedto"hard"healthproblemsorlaboratorydevi-ances[11].
Healthcareprovidersremaintiedto"foodashealth".
Disappointedbytheadvicetheydidordidnotreceivefromhealthcareprovidersonnutrition-relatedissues,pregnantwomenmightseekforinformationbyaskingforguidancefromtheirmothersorotherveteranmothersintheirsocialenvironment[8,11,42,47],butthisraisedquestionsastowhetherthisinformationwasuptodateandthusreliable.
Finally,activenutrition-relatedseekingbehaviourwasmainlyimplementedviatheInternet,becauseofitseaseofaccess,continuousavailabilityandimmediacy.
Mostofpregnantwomeninourstudyhadsearchedatleastoncefornutrition-relatedinformationontheInternet,which,paradoxicallywasthemostwidelyusedsourcebutnotthemostreli-able,aswasalsofoundbyotherstudies[8,9,11,42].
Indeed,thequantityofinformationavailableviatheInternetisconsiderable,butalsoconflictingandcomingfromunidentifiedsources[26,48].
Thenutrition-relatedinformationreceivedandsoughtbypregnantwomenwasmainlyrestrictive,frustrating,andaboveallcontra-dictorywithinandbetweensources.
Thiscouldleadtoconfusion,thuscomplicatingtheadoptionofahealthierdiet.
Pregnantwomenwouldexpectsupportformitigat-ingnutrition-relatedtensions.
StrengthsandlimitationsOuruseofaholisticdietperspectivetoinvestigatetheeatingbehaviourofpregnantwomenwasthemajorstrengthofthisstudy.
Byfocusingnotonlyonweightgainitwaspossibleforustodescribeeatingbehaviourduringpregnancyasawhole.
Theweightgainperspec-tivehadpreviouslybeenchosenformanyqualitativestudiesdesignedtoinvestigatenutrition-relatedissuesduringpregnancy,especiallyintheUKandUS,wheretheyweremainlyperformedinoverweightorobesewomen[22,23,27,42,49].
Inoursample,75%ofthewomenhadanormalweightbeforetheirpregnancy,similartothatreportedamongFrenchwomenagedbetween18and44years(63–82%)[50],sothatothercomponentsofdietduringpregnancyappearedtobeofgreatimport-anceforthesewomen.
Inourstudy,theattributionthe-ory[32]wasusefultounderstandhownutrition-relatedissuesareperceivedbypregnantwomenandtorevealtheproblemstheyencounterininternalisingthem.
Regardingthemethod,ourqualitativeapproachenabledustocollectdeeperinformationratherthanproduceaquantitativesurvey.
Thiswasparticularlyrelevantinourgroups,wherethewomensharedamajor,visibleandalsoverypersonalfeature:theirpregnancy.
Furthermore,groupswereorganisedintwodifferentregionsofFrance:inthecountrysideintheSouthandinParis,whichallowedustogainaccesstopopulationswithdifferentwaysoflifeandeatinghabits.
Thefocusgroupmethodchosenforthisstudycouldhavebeenproblematic.
Ourfocusgroupsinvolvedwomenatdifferentstagesoftheirpregnancyandofdifferentparity.
Thischoicewasdeliberatebecauseitfavouredinteractionsandthetransmissionofinforma-tionbetweenparticipants.
However,groupsthatwerehomogeneouswithrespecttostagesofpregnancyandparitycouldhavebeenusefultoinvestigatedifferencesinnutritionawarenessandperceptionsofnutrition-relatedissuesacrosstrimestersofpregnancyorbetweenprimiparasandmultiparas.
Anotherlimitationofthisstudymayhavebeenthatthewomenwhowererecruitedwereinformedaboutthemaintopicofdiscus-sions.
Thisinitialknowledgemayhaveinducedarecruit-mentbias,becausethewomenwhovolunteeredtotakepartinthediscussionmighthavebeenmoreinterestedinnutrition-relatedissuesthanotherpregnantwomen.
However,theincentiveweofferedmayhaveenabledareductioninthisbias.
ConclusionsInthelifecourseperspective,pregnancyisatransitionperiodthatoffersawindowofopportunityforwomentochangetowardshealthierdietswhichcanresultinimprovingthehealthandwell-beingofboththemotherandbaby.
Althoughweobservedariseinnutritionaware-nessduringpregnancyamongFrenchwomen,wefoundthatdietduringpregnancyisrestrictedbyelementsthatareoutofthecontrolofpregnantwomen.
Womenhadreceivedagreatdealofinformationonnutritionduringpregnancy,buthadalsodevelopedactivenutrition-relatedinformationseekingbehaviourasawayofregainingcontrolovertheirdietandbuildingahealthierdietforthemandtheirbaby.
However,theconfusiontheyperceivedclearlylimitedtheadoptionofahealthierdiet.
ImplicationsforpracticePositivedietaryinformationiscriticaltodietaryself-negotiationandempowerment.
InFrance,dietaryguide-linesrelativetoantenatalcare,thatcouldbeusedasabasisforantenatalcounsellingbythegynaecologistorthemidwiferesponsibleforthefollow-upofthepreg-nancy,aremostlybasedonfoodrestrictionsandweightgainsurveillance[51].
ItisnecessarytotakeaccountofBianchietal.
BMCPregnancyandChildbirth(2016)16:306Page12of14nutrition-relatedtensionsduringpregnancyandtohelppregnantwomentorelievethesebydevelopingpositivecommunicationonahealthydiet,focusedonthewell-beingofboththebabyandmother.
Thiscouldleadtotheadoptionandmaintenanceofahealthierdietbecauseitwillbepositivelyinternalised.
Ourpregnantwomenidentifiedtheirhealthcareprovidersasthemostreliablesourceofinformationonnutrition-relatedissues,sotheseprofessionalscouldbethebestvehicletodisseminatepositiveinformationonnutrition,withoutneglectingsurveillanceandmonitoring.
Asgynaecolo-gistsandmidwivesdonothaveaspecificnutritionbackground,theycouldcollaboratewithdieticiansandadvisedpregnantwomentomeetwithadieticianduringindividualorgroupsessionstoreceivenutritioncounsel-lingadaptedtotheirpregnancy.
ImplicationsforfutureresearchDietarymodificationsduringpregnancyarenotwellcharacterised.
Alongitudinalstudywouldbeusefultoevaluatefoodintakesofwomenduringthespecificperiodoftheirlivesbetweenpreconceptionandbirth.
Asreportedinourstudy,multiparasgenerallyseemedtohaveahealthierpreconceptionaldietthanprimiparas,soacomparisonatthisspecifictimebetweenmultiparasandprimiparaswouldalsobenecessarytoprovideelementsinfavourofthelifecourseperspective.
Furthermore,arandomisedcontrolledtrialwouldbeusefultodeterminewhethertheprovisionofpositiveinformation(i.
e.
tailoreddietarycounsellingprovidedbyadieticianorbyanadaptedmHealthoreHealthprogram)ondietduringpregnancywouldimpacttheeatingbehaviourofpregnantwomenandresultinmiti-gatingnutrition-relatedtensionsandimprovingnutrientintakesofpregnantwomen.
AdditionalfilesAdditionalfile1:Detailsofthestudyrelativetotheresearchteamandreflexivity,studydesignandanalysisandfindingsaccordingtotheconsolidatedcriteriaforreportingqualitativeresearch(COREQ)[28].
(DOCX16kb)Additionalfile2:QuotationsinFrench(nativelanguageofparticipants)identifiedwiththeparticipantsnumberfollowedbythenumberofthequotationaspresentedinthearticle.
(DOCX20kb)Additionalfile3:Identificationnumber,session,recruitmentplace,trimesterofpregnancyandparityofeachparticipant.
(DOCX15kb)AbbreviationsBMI:Bodymassindex;UK:UnitedKingdom;US:UnitedStatesofAmericaAcknowledgementsTheauthorsgratefullythankthe"L'Etoile"maternityunitinAix-en-Provenceforallowingthemtoconductpartofthestudyontheirpremises.
Theauthorsalsothankalltheparticipantsforsharingtheirtime.
FundingThisstudywascarriedoutwithintheframeworkoftheECAPproject(http://alimentation-sante.
org/aap2013-projet2-2/)supportedbyagrantfromtheFondsFranaispourl'AlimentationetlaSanté(FFAS:http://alimentation-sante.
org).
Thefunderproviderswerenotinvolvedinthestudydesign,datacollectionandanalysis,decisiontopublish,orpreparationofthemanuscript.
AvailabilityofdataandmaterialsThedatasets(videorecordsofthefocusgroupsessionsandwrittentranscripts)generatedandanalysedduringthecurrentstudyarenotpubliclyavailablebecausetheyareconfidentialinordertoprotecttheparticipants'anonymity.
However,anonymisedquotationsfromparticipantswereincludedinthemanuscripttosupportourfindings.
Authors'contributionsCBandPGconceivedtheresearch.
CBcollectedthedata.
CB,GLGandPGwereinvolvedintheanalysisandinterpretationofthefindings.
CBproducedtheinitialdraftofthepaperandFM,EOV,JFH,GLGandPGprovidedfeedbackandcontributionstovarioussections.
Allauthorscriticallyreviewedandapprovedthefinalcontent.
Authors'informationNotapplicable.
CompetinginterestsAllauthorsdeclarethattheyhavenocompetinginterests.
ConsentforpublicationAllparticipants'claimswereanonymised.
Allparticipantsconsentedforpublicationofthefindingsofthisstudythroughtheinformedconsenttheysigned.
EthicsapprovalandconsenttoparticipateThestudywasapprovedbytheComitédeProtectiondesPersonnesIle-de-FranceX(StudyNI-2016-03-01),aFrenchEthicsCommittee.
Informedconsentwasobtainedfromallparticipantsatthetimeofthefocusgroupsessions.
Authordetails1UMRPhysiologiedelaNutritionetduComportementAlimentaire,AgroParisTech,INRA,UniversitéParis-Saclay,16,rueClaudeBernard,75005Paris,France.
2UMRIngénierieProcédésAliments,AgroParisTech,INRA,UniversitéParis-Saclay,1,avenuedesOlympiades,91300Massy,France.
3IRD(InstitutdeRecherchepourleDéveloppement),UMRNUTRIPASSIRD-UM-SupAgro,34000Montpellier,France.
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