“ It ’ s a Wild Ride ” : A Phenomenological Exploration of High Maternal , Gestational Weight Gain

High maternal, gestational weight gain is associated with high birthweight, large-for-gestationalage birthweights, cesarean delivery, child overweight, and shortand long-term postpartum weight retention. In this phenomenological study, the meaning and experiences of weight gain for pregnant women with high gestational weight gain were investigated. Data were collected through interviews with pregnant women from Atlantic Canada. van Manen’s method of phenomenology was utilized. The data analysis revealed four patterns or major themes: being caught off guard; losing your bearings; hanging on for dear life; and hoping for health. The participants experienced their gestational weight gain as an unexpected “wild ride” that they could not control. The findings highlight the need for health care professionals to provide pregnant women with more support concerning gestational weight gain.


Introduction
High maternal, gestational weight gain is associated with high birthweight, large-for-gestational-age birthweights, cesarean delivery, child overweight, and short-and long-term postpartum weight retention [1]- [3].With subsequent pregnancies, maternal overweight and obesity are associated with higher rates of cesarean delivery, gestational diabetes mellitus, preeclampsia, pregnancy-induced hypertension, and postpartum anemia [2] [4].In monetary terms, high gestational weight gains and associated health risks exact a high toll on health care costs [5].For instance, in a recently published study, maternal obesity increased the total hospital costs by $5 million in Queensland, Australia in 2008 [6].In the United States, the medical cost incurred by obesity-associated hospitalizations during pregnancy was $107 million in 2005, although this figure is likely a low estimate due to the limitations of the study [7].Excess gestational weight gain is associated with greater length of hospital stay, which has negative financial implications, independent of prepregnancy body mass index (BMI), maternal lifestyle, pregnancy complications, and cesarean delivery [8].Excessive gestational weight gains have become more prevalent among pregnant women in western countries [2] [9].The National Research Council [10] reported on data from the Pregnancy Nutrition Surveillance System in the United States showing 46% of pregnant women gained more than the Institute of Medicine (IOM) guidelines in 2004, as compared to 37% in 1993.A secondary data analysis of the Maternity Experiences Survey indicated that 49% of Canadian pregnant women exceeded the weight gain guidelines in the 2005/2006 survey cycle [9].National health organizations, such as the IOM and the Society of Obstetricians and Gynaecologists of Canada, strongly recommend that health care professionals counsel pregnant women about gestational weight gain [2] [11] [12].Qualitative research on the maternal experience of high gestational weight gain might help health care professionals understand the experience from the perspective of pregnant women, which could, in turn, help inform their counseling efforts.Although peripheral qualitative research has been conducted in this area [13]- [31], the author could not locate a phenomenological study in the literature by the researcher(s) that specifically investigated the entire lived experience of overgaining while pregnant regardless of prepregnancy BMI.The purpose of this study was to explore the whole lived experience of weight gain for pregnant women with high gestational weight gain.

Methods
van Manen's [32] phenomenological method was used in this study.The goal of phenomenology is to obtain a deeper understanding of everyday experiences [32].Phenomenologists provide descriptions of what an experience is like from the viewpoint of those that live the experience.Lived or existential meanings in our life world can be elucidated through this research method [32].The research question for this phenomenological study was: What is the meaning and experience of gestational weight gain for pregnant women with high gestational weight gain?

Setting
This study was conducted in Newfoundland and Labrador (NL) in Atlantic Canada.In 2007, the rate of high gestational weight gain in NL was 52.3% [33].Each interview for this study took place at a convenient location and time for the participant.All of the initial, face-to-face interviews were held in the researcher's office or the participant's home.Every follow-up interview was conducted over the telephone.

Recruitment and Participants
Seven pregnant women participated in this study.To meet the eligibility criteria for the study, the participants were 19 years of age or older and were overgaining according to Health Canada guidelines, which are based on the IOM recommendations [2] [34].The sample size for this study is in accordance with Morse and Field's [35] recommendation to have 6 -10 participants in phenomenological studies in order to explore a lived experience in-depth.Purposive sampling was used to recruit participants with first-hand experience of overgaining in pregnancy.Regional obstetricians were contacted to request their assistance with recruitment.Obstetricians told pregnant women, who met the inclusion criteria, about the study.Potential participants were informed by the obstetricians that their decision about whether or not to participate in the study had no influence on their health care.Study posters were also displayed in the obstetricians' waiting and examination rooms.Pregnant women contacted the researcher, who further explained the study.Interviews were arranged with pregnant women, who met the inclusion criteria and expressed interest in participating in the study.
The mean age of the participants was 27.3 years (SD = 4.9 years; range = 21 -36 years).With respect to their level of education, one woman did not graduate from high school, one earned a high school diploma, one had some post-secondary education, and four women were university or college graduates.Besides one student and two stay-at-home mothers, the women were employed.Of the seven participants, four were married or in a common-law relationship and three were single.Most of the pregnant women (n = 5) were primiparous and two were multiparous.All of the women were White and three were in their third trimester, whereas the remaining four women were in their second trimester.

Ethical Considerations
This study was approved by the Human Investigation Committee of Memorial University of Newfoundland.Written informed consent was obtained by the researcher before beginning the first interview.The researcher read the information letter describing the study and the consent form out loud to each participant.Then, the researcher provided each participant the opportunity to ask questions prior to signing the consent form.It was possible that the participants could have felt upset while talking about their experiences of gestational weight gain.However, none of the participants in this study were visibly upset during the interviews.In the event that a participant became upset, the researcher would have asked the participant if she wanted to stop or reschedule the interview.Also, the participant would have been given the option to call a local Mental Health Help Line at a toll-free telephone number.All of the participants were given a $30 grocery gift certificate as a token of appreciation.

Data Collection
The data were collected in this study via one face-to-face interview with each participant.Furthermore, followup interviews were conducted to clarify the women's experiences and to obtain feedback on the preliminary findings.One participant was lost to follow-up and, therefore, did not participate in the follow-up interviewing process.All of the interviews took about 30 to 90 minutes to complete.Open-ended questions were asked by the researcher and the women told their stories about overgaining in pregnancy in a free manner.Examples of questions the researcher posed included "Could you please tell me your story about gaining weight during pregnancy?"and "Could you please tell me a story about someone commenting on your weight in pregnancy?"Interview prompts were also used if the researcher wanted the participants to elaborate further on aspects of their experiences (e.g., "Could you please tell me more about that?" and "How did that make you feel?").A sociodemo graphic questionnaire, which addressed items such as level of education and employment status, was completed at the end of the first interview.Recruitment and data collection continued until a good phenomenological gestalt in the findings was obtained [36].

Data Analysis
The researcher followed van Manen's [32] method, which includes six research activities involving a dynamic and iterative process: 1) turning to the nature of lived experience; 2) investigating experience as we live it; 3) reflecting on essential themes; 4) writing and rewriting; 5) maintaining a strong and oriented relation; and 6) balancing the research context.In the first activity, the researcher turned her attention to the lived experience and developed a research question.Moreover, van Manen's [32] process of reduction was followed, whereby the researcher reflected on her preunderstandings and assumptions about the lived experience in order to suspend them as much as possible while carrying out the research.In the second activity, the researcher traced etymological sources of phenomenon-related words, sought previous phenomenological research on the topic, and conducted interviews.The researcher determined that one definition of the word weight is "to oppress with a burden" [37].An etymological investigation of the word weight revealed that the figurative sense of the word weight as a burden is from the late 14th century [38].The word overweight meant "in excess of proper or ordinary weight" in the 1630s [38].The researcher considered the etymological roots of these words during phenomenological reflection.In the third activity, the researcher used van Manen's [32] selective or highlighting approach to isolate thematic statements.The researcher reflected on the women's stories in light of the following existentials: 1) temporality or lived time; 2) spatiality or lived space; 3) corporality or lived body; and 4) relationality/communality or lived human relation [32].In order to grasp the essential nature of the lived experience, the researcher distinguished between incidental and essential themes.The fourth and fifth activities involved a process of writing and rewriting, while remaining oriented to the research question.The sixth and last activity was balancing the research context, in which parts of the experience were considered in view of the whole experience.For example, when reading and reflecting on one participant's story, the researcher asked "How does this particular experience relate to the total experience for all of the women?"

Rigor
The researcher used Guba and Lincoln's [39] [40] four criteria for establishing rigor.The four criteria are: 1) credibility; 2) fittingness; 3) auditability; and 4) confirmability.The participants in this study were pregnant women with first-hand experience of gaining more weight than medical recommendations during their current pregnancy.The researcher was cognizant of her preunderstandings and assumptions concerning the phenomenon in order to suspend them during the research activities, with recognition that a complete reduction is impossible [32].The researcher continued to recruit participants until redundancy was apparent about what the experience was like.Under the findings section of this article, direct quotes from the participants are presented to illustrate the themes of the lived experience.An audit trail was maintained for all research decisions and activities.Follow-up interviews were held with six of the seven participants.During the follow-up interviews, the researcher clarified ambiguities in the narratives and discussed the findings to date to ensure that the researcher accurately captured their experiences.

Findings
Threads of meaning that are interwoven in the text are called themes [41] and patterns encompass interrelated themes.In this study, a total of four patterns and ten themes were identified (see Table 1).

Being Caught off Guard
The first pattern was being caught off guard, which incorporated three themes: 1) being body conscious; 2) being surprised by sudden weight gain; and 3) struggling with a new body.

Being Body Conscious
In telling their stories, the pregnant women spoke about their perceptions and experiences of their prepregnancy bodies.All of the women described themselves as being body and weight conscious.Some of the participants said they were very physically fit and cared a lot about their weight beforehand, while other women divulged that they struggled throughout their lives with being overweight.The following direct quotes from participants illustrate their prepregnancy body consciousness: I was always a small person before I got pregnant, very small, and… weight has always been an issue with me even before I got pregnant I never wanted to be big.Like all growing up… I never put on weight.I was always the skinny one because like I always hated gaining weight.

Well, for me normally, before I was pregnant, I cared a lot about my weight… I'm not really used to such a big change in my body because… I've been like always focused on eating healthy and maintaining a certain weight and so it's definitely been a big change… I was really big into running… I don't really like [my pregnant body]… I'm not used to it I guess. Normally I'm body conscious… I'm just so used to having a fit body.
Well, you know, all my life I struggled with weight, weight gain, and weight loss.Before my pregnancy… I had lost a lot of weight.I was… the lowest that I've been all my life… and I was really watching my weight and I went to the gym almost every day and I was really cautious.

Being Surprised by Sudden Weight Gain
Against a backdrop of body consciousness, the pregnant women experienced sudden weight gain.They were taken aback by the abrupt nature of their weight gain.The theme of being surprised by sudden weight gain is evident in the following quotations:

I can't believe I've put on so much weight… Since I've been pregnant, the weight has just [gone] boom! I can't believe it.
I was surprised how fast I gained it.Like I was always a big eater and like most people… in my family are bigger women.So I always thought when I would get pregnant that I would get really big… I changed my eating habits for the better, but… it just came really quick anyway.

Struggling with a New Body
With little time to adjust to a quickly changing body, the pregnant women struggled with their new body.Their body felt foreign to them and they were only happy with weight gain appearing on their breasts or belly.Furthermore, other people implied that only belly weight gain was desirable.

Losing Your Bearings
The second pattern entitled losing your bearings had two themes: 1) having an uncertain body size; and 2) experiencing confusion.

Having an Uncertain Body Size
The pregnant women in this study received conflicting messages from other people, including their health care providers, about their weight and body size.[It] depends on who I'm talking to.They'll give me different comments.

Experiencing
The conflicting statements the participants heard from other people led to confusion.The pregnant women were unsure if their weight gain was excessive or not and they were confused about what they should be doing, if anything.Family members and friends encouraged the pregnant women to dismiss the medical advice they received if it entailed the idea that their weight gain was high.Participants shared the following:

Hanging on for Dear Life
The third pattern entitled hanging on for dear life subsumed three themes: 1) lacking control; 2) gaining fast; and 3) fearing danger.

Lacking Control
The pregnant women in this research study believed their weight gain was beyond their control.From the vantage point of the pregnant women, morning sickness, a "license to eat," and strong, dietary cravings aggravated their situation.These points are raised in the following quotations: It's a wild ride… You just hang on and hope for the best.

Gaining Fast
In the context of a sudden onset of weight gain and a perceived lack of control over their weight, the participants experienced additional, rapid weight gain.This situation is captured in the following remarks: I gained weight really, really fast… The last time I [saw] my family doctor, she did say to me, "When are you due again?" and I told her and she was like, "Wow!You've got all summer to go."So I think she was kind of surprised how much I grew since I'd seen her because I grew so quick.

Fearing Danger
The participants were aware of and, to some extent, feared some pregnancy complications associated with high weight gain, such as gestational diabetes.However, they tried not to worry about it and, as expressed in the next pattern, they hoped for a healthy outcome.One participant in this study summed up these thoughts in the following manner: I had been eating constantly because of the nausea because it made it go away… So, yeah, when I saw the weight on the scale… there was fear… Where was I headed?How much was I going to gain?Knowing it's unhealthy to gain too much weight and thinking, "I hope I don't develop gestational diabetes."

Hoping for Health
The fourth and last pattern entitled hoping for health incorporated two themes: 1) hoping for personal health; and 2) hoping for a healthy baby.

Hoping for Personal Health
As one participant pointed out in the last quotation, the women hoped to maintain their personal health.Furthermore, the women hoped to lose weight postpartum.One pregnant woman voiced her concerns as follows: [I'm] always concerned about after you have your baby how long it's going to take you to get back to the way you used to be… That's always something that's always on my mind.Yeah, that's a question that I'm asking people all the time, "How long did it take for you to get back to that?" The women linked postpartum weight loss with better health outcomes.This point is underscored in the following comments made by a participant:

Hoping for a Healthy Baby
While the women had some concerns about their own health, above all else, they were concerned about the health of the baby.
Like my doctor told me, "You're fine where you're to.You're up to par," but then I read online… that for where I'm to now, I should [have] gain [ed] between twenty-five and… thirty-two pounds and I'm way past that.So I feel like I'm past everyone… I'm not going to let it bother me… as long as the baby's healthy that's all.

Discussion
This study concentrated on the whole, lived, maternal experience of gaining more weight in pregnancy than medically recommended.Four patterns were anchored in the women's stories: 1) being caught off guard; 2) losing your bearings; 3) hanging on for dear life; and 4) hoping for health.Each pattern is discussed in sequence.
The pregnant women in this study were caught off guard by their sudden weight gain.They came to the embodied, pregnancy experience immersed in a body conscious society.It is not surprising that the women talked about being body and weight conscious because current research showed that the thin, Western body ideal and pervasive body dissatisfaction among females are global phenomena outside of destitute regions [42].As Iris Marion Young [43] raised in her landmark work on feminine body comportment, women are aware of being objectified as objects of others' gazes.The participants in this study struggled to adjust to their rapidly changing new body.Consistent with prior research [15] [43]- [48], their bodies felt foreign to them and they only desired weight gain on the breasts or belly.While the pregnant body was shunned and concealed from view in the past, the age the "baby bump", "yummy mummy", and "MILF" has dawned, in which pregnant bellies are flaunted even in wedding dresses and mothers are viewed as attractive and sexy [13] [15] [44] [48]- [53].In other words, "fat" stigmatization and the sexual objectification of women have taken pregnancy and motherhood by storm, leaving women today with no reprieve from body image concerns.Nash [54] uncovered in her inquiry of breasted experiences in pregnancy that pregnant women have conflicting desires to both resist and accommodate cultural ideologies concerning sexuality and pregnancy.Given that the women in this study were caught off guard by their weight gain and they also struggled in coping with their new body, health care professionals should challenge the discourse that positions women as sexual objects, with unrealistic idealized dimensions, and provide anticipatory guidance and support concerning gestational weight to women during pregnancy and the preconception period.As opposed to conventional weight management care, an approach that focuses on health promotion [55] might be appropriate in pregnancy, as well as addressing the social determinants of health, but research is needed in this area.
The participants in this research also lost their bearings in that they were uncertain about their position, with respect to weight and body size, and they were confused about what they should do about their weight gain, if anything.As the study was held in Atlantic Canada where obesity levels and gestational weight gains are high [33] [56]- [58], perhaps the normalization of obesity influenced some of the weight-related advice they received from family members and friends.According to the participants' accounts, the women were on the receiving end of contradictory advice from their medical practitioners, which also sparked confusion.Allegedly, when they were informed about their high gestational weight gain status, they were not instructed on specifically what actions they could take to address their weight.Pregnant women in other studies called into question the adequacy of health provider education/counseling on topics such as gestational weight gain [2] [25] [27] [29]- [31] [44] [45] and smoking cessation [59].It is conceivable that health care providers assume that pregnant women are accessing this information elsewhere.Research buttresses the view that today's generation of pregnant women actively seeks out health information through a variety of sources, including the Internet, on their own accord [60].However, collective reports of inadequate counseling by health care professionals and misinformation among pregnant women should serve as a stark reminder that pregnant women can and do slip through the cracks, leaving them feeling lost and abandoned by their health providers [44] [59].
The third pattern embedded in the participants' narratives was hanging on for dear life.From the women's standpoint, they were swiftly gaining weight and they were aware of some potential risks involved with overgaining, but they perceived their weight as being beyond their control.Other authors noted that the whole female body is considered to be animalistic and uncontrollable in and outside of pregnancy [61]- [64].As a case in point, Fahs [65] recently published on her qualitative study with 20 women about their relationship with their genitals.Among other themes, the 20 women described their genitals as being dirty and mysterious and requiring constant maintenance or control.Historically, female bodies have been connected with nature, irrationality, unpredictability, sensuality, uncleanliness, and evil [61]- [64].For instance, artists frequently depicted the womb as hell from classical to Renaissance times [64] [66].In this research, the women were under the strong impression that they could not control their weight gain whatsoever, which is consistent with other studies [14] [23] [29] [44] [67] [68].While recognizing that uncontrollable factors, such as macro-and meso-level influences that exceed the micro-or individual-level (e.g., the broad determinants of health), impinge on gestational weight gain, health care professionals need to provide pregnant women with specific information concerning pregnancy weight gain, dietary, and physical activity recommendations.Stotland and colleagues [69] and Chang et al. [70] discussed measures to overcome barriers to effective weight gain counseling.The idea of a "license to eat" in pregnancy, which surfaced in this research, has been cited in other publications [71] and might be related to the relaxation of weight expectations during pregnancy in former years [15] [16] [72] [73] and normative constructions of the "good" mother, who deserves pampering during pregnancy [74].
The fourth and last pattern in the participants' narratives was hoping for health.The pregnant women hoped to maintain their health, but above all, they hoped for a healthy baby.Having the baby's health as a paramount concern is in keeping with past research [23].Furthermore, being selfless and putting the baby before oneself is in line with the dominant ideology of the "good" mother [75] [76].In this study, hoping for personal health also included yearning to return to their prepregnancy weight, as the participants linked their body weight to health outcomes.Pregnant women often voice a desire to get their "body back" [23] [44] [67] [71] [77] [78], which harks back to their immersion in a body conscious society.With pregnant women's focus on health, health care professionals could use this window of opportunity to promote healthy lifestyle choices during pregnancy, the postpartum, and beyond.

Conclusion
The purpose of this study was to explore the entire lived experience of weight gain for pregnant women with high gestational weight gain.The findings indicated that the pregnant women in this study experienced their gestational weight gain as an unexpected "wild ride" that they could not control.In the midst of confusion, they could only hope for the best for themselves and their unborn children.The study findings should serve as a wakeup call to health care professionals that pregnant women need better direction on how to reach their healthy gestational weight gain goals.

Table 1 .
Patterns and themes identified in the participants' stories of high gestational weight gain.
A lot of my family and friends they've all, I guess they're trying to be nice, but they only tell me, "It's only belly.It's only belly."Like [it's] definitely not.I can tell myself.I know I've gained a lot more than I should have because I can feel it.I can feel it in my face and my arms and my legs and stuff.It's not just belly.So, it's been kind of, it's depressing… (Partner's name), he's been really supportive.I'm always talking about it when I'm home.Like, "I feel really fat today," but he's like, "You're pregnant.Just stop.You'll be fine after the baby, you know, when you get back to your old self."He's really reassuring, really, really.If I didn't have him, I'd probably lose my mind… I know myself I've probably gained a lot more than I should have… Like my legs don't feel like my own legs and my arms don't feel like my own arms and my face and stuff.So, it was hard to see myself.You don't recognize yourself in the mirror.I loved the belly, but all the rest of it was a bit hard… You get comments from friends and family about your size and you realize that it's all for the best in the end for the baby's sake, but it is still something that you struggle with… When you look in the mirror and you see something different than what you're used to looking at, it's confusing… You just do a double take in the mirror and [you] have to get used to this new body.
where it's coming from.I suffered from severe nausea at the beginning and… the only way that I felt better was by eating… The nausea would go for a half an hour to 45 minutes.When that wore off, I had to eat again.So I went through this for… eight weeks [or] ten… That was responsible for the bulk of the early weight gain.