Health Literacy and Behaviour among Pregnant Women with Obesity: A Qualitative Interpretive Description Study

Background: Obesity in pregnant women is increasing worldwide, affecting the health of both mother and baby. Obesity may be associated with inadequate health literacy, a central competence when navigating antenatal health information and services. This study explores women’s health literacy experiences among a sample of pregnant women with a prepregnant body mass index (BMI) >25 kg/m 2 . Methods: An inductive, qualitative study using an interpretive description methodology. Data was collected through ten semi-structured interviews with pregnant women with a prepregnancy BMI >25 kg/m 2 attending antenatal care at the midwifery clinic at Aarhus University Hospital in the Central Denmark Region. Results: Pregnant women with obesity understand general health information provided by health professionals, but translating this knowledge into specic healthy behaviours presents a challenge. Although diculties navigating booking systems and available digital services contribute to this problem, apps can help facilitate navigation. However, successful navigation may depend on adequate e-health literacy. Conicting information from health professionals, social media and families also present a challenge for pregnant women, requiring a broad skillset for critical evaluation and resolution. Conclusions: Adequate health literacy is necessary for pregnant women receiving antenatal care to (i) translate general health information into personalised healthy behaviour, (ii) access and navigate complex and digitalised systems, and (iii) critically evaluate conicting information. Person-centred differentiation in the organisation of antenatal care may benet vulnerable pregnant women with inadequate health literacy. study


Introduction
Social inequality in health continues to increase among pregnant women worldwide, including access to and use of maternity care services (1)(2)(3). Due to the increasing emphasis on an individual's role and responsibilities in their health care, health literacy has gained importance on the European and global health agenda (4)(5)(6). Health literacy is de ned as the ability to access, understand, evaluate and communicate health information to promote, maintain and improve health in various settings across the life course (7). As a multidimensional, changeable concept encompassing the interacting capacities of pregnant women, health professionals and services, health literacy has been recognised as a critical factor in reducing health inequality (11). A high degree of health literacy and self-care is required to successfully navigate, understand and convert health information during pregnancy (8-10).
Given the increasing prevalence of obesity among pregnant women, pregnant women with a body mass index (BMI) above 25 kg/m 2 are a high-risk group warranting particular attention. In the United States, 39% of pregnant women aged 20-39 years were classi ed as obese in 2017-2018 (12). In Denmark, the percentage of overweight or obese women of childbearing age has increased from 39% in 2010 to 44% in 2017 (13). Overall, almost 50% of women in developed countries begin their pregnancy with a body mass index (BMI) above 25 kg/m 2 (14,15). Obese women have a higher risk of complications during pregnancy and childbirth than women with a BMI <25 kg/m 2 (16), and obesity in pregnancy is associated with unfavourable health outcomes for both mother and child. Maternal complications include an increased risk of gestational diabetes mellitus (GDM), preeclampsia, metabolic syndrome and later-life stroke (17,18), and children born to obese women have an increased risk of obstetric morbidity, childhood and adulthood obesity and later-life development of diabetes mellitus (19,20).
Low health literacy in pregnant women -de ned as an inability to understand, navigate and apply health information during pregnancy -may be associated with maternal obesity (21). Both low health literacy and obesity can cause complications during pregnancy and birth for both mother and child. Increased health literacy has been suggested as a way to reduce the long-term consequences of maternal obesity (22,23). Pregnancy may represent a "teachable moment" for health promotion interventions, since primiparous women are preparing to adopt the maternal role for the rst time and may have concomitant expectations of lifestyle and self-image changes (24).
Research on health literacy among pregnant women with obesity remains limited, however (25). A more comprehensive understanding of pregnant women's health literacy experiences is crucial for identifying their needs and skills in relation to antenatal care. Increased knowledge of pregnant women's health literacy experiences may help reduce inequality in pregnancy and guide healthcare systems' maternitycare plans (26). Exploring pregnant women's experiences of health literacy may help identify vulnerable pregnant women.
Our study's objective is to explore (i) the knowledge, motivation and skills of pregnant women with obesity to access, understand and evaluate health information during pregnancy, and (ii) how this impacts their health behaviour in connection with health professionals, services and information.

Study design
We designed this study as an inductive, qualitative study using an interpretive description (ID) methodology. Developed by Thorne, the ID methodology was chosen for its explorative nature, allowing researchers to generate knowledge relevant to clinical practice (27,28). By examining health literacy from the perspective of pregnant women with obesity, we aimed to generate knowledge supporting a personcentred preventative maternity service. ID is particularly suitable for generating knowledge relevant to the clinical context of applied health disciplines, as it can address complex experiential questions such as pregnant women's health literacy experiences in relation to maternal services and care. Furthermore, ID allows us to examine the topic through a theoretical lens. In this study, we applied theories of health literacy for developing the interview guide (29).

Setting and informants
We undertook the study in the Central Denmark Region, one of ve administrative regions in Denmark.
Due to the COVID-19 pandemic, interviews were conducted via online media such as Zoom, Skype or Facetime.
We used purposeful sampling to select rst-time pregnant women with obesity for study participation (27,30). The study sample was selected to investigate the health literacy behaviours of pregnant women with a pre-pregnant BMI ≥ 25 kg/m 2 . Danish-speaking primiparous women with a pre-pregnancy BMI of ≥ 25 kg/m 2 , a minimum age of 18 and at least 20 weeks of gestation were eligible for participation.
Due to the COVID pandemic, participants were recruited from the Aarhus University Hospital (AUH) Antenatal Midwifery Clinic's Facebook page. Women willing to participate in the study were invited to contact the research team, who forwarded the relevant project information, including a study description and consent form. A.D. or M.M. then telephoned potential participants to schedule convenient interview dates with them. Interviews were only initiated once participants had signed an informed consent declaration and the interviewer was con dent they understood the nature and scope of study participation. Current antenatal practice and frequently used terms are described in Table 1. and exibility to answer freely and fully. We used open-ended interview questions to explore and describe primiparous pregnant womens' views, experiences and perceptions of their health literacy behaviour. We also collected participants' self-reported demographic data before interview, including height and weight (for calculating BMI).
All interviews were recorded with a dictaphone. The interviewer followed the interview guide and was responsible for time management. However, questions were allowed to develop naturally based on the information provided by the respondent. At the end of each interview, the researcher outlined the most signi cant elements of each interview and wrote up a brief re ective summary of the overall interview experience, any key discussion topics that arose, and the respondent's emotional responses and reactions during the interview. Interviews were digitally audio-recorded with consent and transcribed verbatim in timespans in NVivo. Interviews lasted for approximately one hour. After the initial coding process, we began cataloguing codes to identify patterns or themes in the data. A constant comparative analysis was undertaken whereby researchers could rede ne or restructure themes at any point during the analytic process.

Results
A total of ten pregnant women with a pre-pregnancy BMI ≥ 25 kg/m 2 and aged between 23 and 41 years participated in this study. All were rst-time mothers in gestation week 20 or more. Participant characteristics are presented in Table 2. The receipt of test results is another example of the gap between the information provided by health professionals and pregnant women's ability to receive, understand and apply it. Participants receive information from health professionals about their BMI status and glucose tolerance but are unsure how to understand and respond to these details. Aware that these results might negatively in uence both their own and their child's health but unsure how to positively change their behaviour, they require more support and guidance from health professionals. ID8 expresses a need for further explanation with a personalised "how-to" focus, illustrating a desire for a more precise explanation of what such results mean for pregnancy and everyday life and whether or not there is a need to change behaviour accordingly.
In summary, there is a gap between pregnant women's knowledge and their ability to change their behaviour accordingly, despite their motivation.
Di culties navigating a complex health system Participants described positive experiences using the Emento app, which guides and supports pregnant women in navigating health services during pregnancy. However, participants also described di culties navigating booking systems and understanding when and how to book particular types of appointments, which they experienced as barriers to fully utilising antenatal services.
"I think that it could be easier to navigate the booking system, or perhaps we could be given better instructions for using it." ID4 "It's been unclear sometimes whether I should book appointments myself or wait to be invited. These examples suggest that the organisation of antenatal appointments is not always adequately managed by the clinic or other health professionals. Such ambiguity presents a challenge for pregnant women, who feel responsible for booking appointments and utilising available services at the right time via a navigation process that is not transparent for them.
In summary, participants described di culties successfully navigating antenatal booking systems and services. Therefore, not all pregnant women can meet navigation requirements, leading to uncertainty and disorientation. Participants expressed a need for health professionals to accommodate their navigation barriers and help them manage their pregnancy course.

Di culties reconciling con icting information and options
There is a wealth of con icting advice about how to behave "correctly" during pregnancy. Participants reported receiving numerous different opinions from their social network, family, health professionals and via social media.
"There are many different opinions about how you should behave when pregnant. You should do this and that." ID6 Pregnant women's ability to critically navigate con icting advice and recommendations is therefore essential. However, even pregnant women with a health professional background might nd such con icting information challenging.
"Even as a health professional myself, I nd it hard to navigate." ID3 Pregnant women encounter many different health professionals during their pregnancy. Participants described challenges in knowing whom to seek clari cation from about con icting information.
"They say that you should just ask your midwife, and I think to myself, 'who is that?'" ID5 Uncertainty about whom to ask for advice about con icting information presents a challenge for pregnant women. The above example suggests that ID5 encountered numerous midwives during her pregnancy but did not feel she had a relationship with any particular midwife. Confusion about which midwife to ask may impact a woman's ability to interact with health professionals when necessary.
Some participants' experiences suggest that the various antenatal health professionals they interact with are not adequately collaborating and communicating with one another.
"I explained to my physician about the test my midwife performed, but I don't think she had any understanding of it. It was as if she didn't know about the test." ID2 The Covid vaccination is an example of a topic that participants felt particularly con icted over. Even though their health professionals recommended the vaccination, they reported strong and con icting opinions from their family and social network.
"I have many family members who are against vaccination. I cannot decide what is right or wrong." ID6 "Then a family member sends you 10,000 posts and pictures about the side-effects of vaccination." ID1 These accounts suggest that family members' opinions may signi cantly in uence pregnant women; they are unsure whether to trust information received from health professionals if it con icts with the opinion of one or more family members.
However, others report that they reconcile such contradictions by trusting information received from their health professionals. Hence, not all participants experienced the same level of struggle in response to con icting advice. This difference may suggest different levels of health literacy among pregnant women.
"I think you should distinguish between the information you receive from a health professional and, for example, the information you receive from your friend about her opinion on something." ID3 "When it is from my social network, I am friendly and say that it was nice of them to share, but I don't immediately believe it as others might do. I consider it critically before I make any decisions." ID2 Contradictions between the advice offered by health professionals versus that offered by family, friends or social media present a clear challenge for pregnant women.

Discussion
Implications for practice, policy and future research A need for clear and speci c action-oriented knowledge We found that participants feel well-informed about general health recommendations in pregnancy. The pregnant women in this study were interested and motivated, consulting multiples sources of information. This nding is consistent with a study by Garnweidner et al., who found that pregnant women actively sought information about nutrition (31). Vamos et al. also found that pregnant women described rich, contextual health literacy experiences (25).
However, multiple studies have found that pregnant women struggle to understand health information (32)(33)(34)(35). In our study, participants struggled to align their behaviour with their health knowledge and lacked support from health professionals. Wilhelmova et al. reported similar results: although the pregnant women in their study received adequate health information, most of their lifestyles remained far from optimal (36). Compared to women with adequate health literacy, Poorman et al. also found that pregnant women with limited health literacy were less likely to take a daily vitamin pill during pregnancy or breastfeed their child (37). Moreover, Dayyani et al. found that, among pregnant women with GDM, those with limited health literacy struggled to implement the recommended behaviour changes (38).
Pregnant women in this study experienced recommendations about health-related topics such as diet and physical activity as general and non-speci c. Similar results were reported by Garnweidner et al (31), whose study of rst-time pregnant women with a pre-pregnancy BMI above 25 kg/m 2 showed that participants perceived health information as very general and focused on food safety.
Although the women in our study were informed about their BMI and glucose tolerance results, they lacked con dence about how to act on them, requiring speci c behaviour-oriented knowledge and advice. Pregnant women with limited health literacy might need particular help and support for positive behaviour change. This conclusion is supported by Sahin et al., who found that pregnant women with high health literacy led more health-promoting lifestyles (39). Health professionals need to support pregnant women with information, goal setting, planning and follow-up to help them respond to unfavourable health indices. There is a need for health promotion and care to support healthy behaviour development.
Di culties navigating a complex health system Some of the women in our study struggled to navigate booking systems. They felt that it is their responsibility to book appointments and, therefore, their responsibility when they miss or fail to book them.
As booking systems and reminders are often digitalised, pregnant women need speci c skills to interact with the associated technology. Women with limited e-health literacy (the ability to seek, nd, understand, and appraise health information from electronic sources and apply the knowledge gained to addressing or solving a health problem (40)) may nd this challenging. This offers a possible explanation for the barriers some women experience when booking appointments during pregnancy. For example, Brusniak et al. found that most pregnant women in their study showed low compliance and engagement with digital monitoring (41). Health professionals are aware of this problem. A systematic review published in 2020 concluded that midwives are ambivalent about using e-health technologies as a one-size-ts-all communication platform in antenatal care and point out the risk associated with it (42). There is thus a need for further research into e-health literacy and the barriers pregnant women experience with booking antenatal appointments as variables affecting their ability to navigate a complex health system. Health professionals must be educated to identify and support different levels of e-health literacy among pregnant women.
Di culties reconciling con icting information and options Our study suggests that women receive con icting information during pregnancy and may struggle to critically evaluate and reconcile these con icts. Similar results were found in other studies of pregnancyrelated health topics, including medication use, diet and physical activity (43)(44)(45)(46). For example, Findley et al. found that decision-making about physical activity during pregnancy was in uenced by pressure from others, pressure from social media and beliefs about physical activity (45).
Participants mentioned con icting advice about the Covid vaccination as a particular challenge in this respect. Similarly, several studies have shown that pregnant women experience a wealth of contradictory opinions and guidance about other vaccination programmes during pregnancy (47)(48)(49). This inconsistency may be problematic if women choose to trust information from their social network over information from health professions, with potentially severe consequences for both the mother and child's health. Knowledge of distributed health literacy (de ned as health literacy distributed through family, friends and network) among pregnant women may help understand how they reconcile con icting information. Distributed health literacy may also provide a valuable resource for understanding decisionmaking about health (50).
Pregnant women engage with many different midwives in Aarhus Midwifery Clinic. A review by Sandall et al. suggests that midwife-led care and continuity increases satisfaction with care, information and decision-making (51). The midwifery-led organisation of antenatal care might also help address problems arising from the con icting information and opinions women are subject to during pregnancy.
In addition, health professionals must recognise and accommodate women's differing critical appraisal capacities for responding to con icting information. Health professionals need to address these challenges and provide the information pregnant women need to make informed choices. However, they should also be aware that such challenges affect women in different ways. Some of our participants described using what they called a "critical view" and trusting health professionals' recommendations. Different levels of health literacy among pregnant women potentially explain their varying skills in responding to contradictory information and opinions during pregnancy (5). The Danish Health Authority suggests reorganising antenatal care according to four socioeconomic-and-obstetric-risk levels to support women's different antenatal needs (52). Differentiation would help support all levels of health literacy, potentially ameliorating the rising social inequality in health (53).

Strength and limitations
Our study design provided unique insight into women's experiences of their health literacy behaviour during pregnancy. Collaboration with Aarhus University Hospital also enabled access to their antenatal Facebook group, where informants were invited to participate.
Interviews were necessarily conducted online because of the global Covid pandemic, which may have affected their content. Physical separation of the interviewer from the interviewee introduced a risk that they missed important non-verbal cues and information, e.g. body language. Also, there are potential limits to establishing trust and connection between interviewer and interviewee in a virtual setting (54).
However, conducting carefully planned interviews under such circumstances can also be considered a strength, as it may have encouraged a more open-minded response to the interview questions (54).

Study participants were recruited via an invitation posted on the Aarhus University Hospital Midwifery
Clinic's Facebook page. This introduces the possibility of self-selection bias since the women who responded to the Facebook invitation may have had a higher level of health literacy, interest and motivation than those who did not (55,56). As participants were recruited from a limited geographical area, they may also be unrepresentative of the experiences of women attending antenatal care elsewhere.

Conclusion
There is a gap between participants' receipt of professional healthcare information and their ability to translate it into action, along with a concomitant lack of behaviour-change support. Navigation of digital health services also presents a challenge, potentially explained by inadequate e-health literacy. Although apps and digitalisation support successful navigation, they depend on su cient skills to access and utilise the associated technology. Con icting health information from social networks versus health professionals also presents a dilemma for pregnant women. Inadequate skills for critically appraising contradictory information, advice and opinions leads to uncertainty, anxiety and disorientation.
There is a need to support pregnant women's health-promoting behaviour change, navigation of digital services and apps and reconciliation of con icting health information. This study underlines the need for increased awareness of pregnant women's health literacy levels and their relationship to antenatal needs.
Evidence suggests that a midwifery-led continuity of care may address some of the challenges described by the women in this study. It would be bene cial to explore health professionals' understanding of health literacy levels among pregnant women.