Of the 30 pregnant and postpartum women screened for participations, 23 women elected to complete their interview (7 declined). All eleven providers offered an interview participated. Tables1 and 2 describes participant characterisitcs. Figure1 shows the application of the PRECEDE-PROCEED framework to the 6 themes identified within the categories of predisposing (facilitate or hinder motivation for change), enabling (make possible a desired change) and reinforcing (influence continuation of the behavior) factors that can influence behavior change. Below we describe each of the themes aligned with these factors with representative quotes from pregnant or postpartum women and obstetric providers.

Six key themes in the PRECEDE-PROCEED model (14) that influence behavior change in pregnancy and postpartum

The first predisposing theme was womens level of motivation for making behavior changes in pregnancy and postpartum. In pregnancy, women were motivated by wanting to have a healthy baby and delivery and, in the postpartum period, women were motivated by wanting my body back. One pregnant woman stated:

I just want to make sure that I have a healthy delivery...and the baby will just be health [y] both of us will be healthy...And, of course take care of him. You know all throughout his life, and you know... [I] have to be healthy first so I can take care of him. (Pregnant woman).

In addition to motivation for having a healthy baby, women were motivated to have an uncomplicated labor and delivery and for many, to successfully breastfeed their infant. Obstetric providers also considered womens motivation to have a healthy baby as an opportunity for counseling about behavior changes. One nurse midwife, illustrated this opportunity to engage pregnant women in the following way:

Youre catching them at a time when they know theyre in this pregnancy for a limited amount of time, you know? So its not [as] overwhelming were initially just asking them to focus on being healthy just for this [finite] amount of time. (Certified Nurse Midwife)

During the postpartum period, women described their motivation to make healthy lifestyle changes to improve their body image and feel like me again. One postpartum woman said,

I mean pregnancy just kind of not destroys your body, but it makes you feel like you are a different person I guess exercising is more for me to feel like me again, and to feel happy with the way that I look and the way that I feel. (Postpartum woman)

Another postpartum woman illustrated a desire for wanting her clothing to feel similar to how it felt before her pregnancy as follows:

It would it would be nice to have the ten pounds off and be back to sort of fitting into things a little bit better. I think that itll be better for my body. I could fit in more clothing which it would be nice because thats definitely like an ugh feeling when you like, try to put something on and you are like, Oh yeah, that doesnt fit anymore. (Postpartum woman)

The second predisposing theme was womens pre-pregnancy knowledge and experiences about importance of healthy behaviors, including eating well and physical activity in pregnancy and postpartum. Although many pregnant and postpartum women expressed basic knowledge about the importance of eating well and being physical active, they had different opinions on what they should and should not do to achieve a healthier lifestyle. One pregnant woman described the benefits of physical activity in pregnancy in the following way:

I wanted to bounce back quickly and you know, if I go [to] the gym maybe labor will be a little easier, my body will be conditioned to that sort of thing, so (Pregnant woman)

Some women described having health goals like taking prenatal vitamins during pregnancy and breastfeeding after pregnancy, because of past knowledge and experiences with previous pregnancies. In the postpartum period, women commented on their lack of preexisting knowledge about the challenges of breastfeeding their infants, and expressed a desire to have had more information during pregnancy, and support in the postpartum period:

[Before I had my baby] I was under the impression that if you tried [to breastfeed your infant] and you just sat there [then] you did it. And [if] you just breastfed all day, it would work. But it just didnt. (Postpartum woman)

Obstetric providers described examples of women who already had knowledge and skills about the importance of physical activity and nutrition noting that these women were able to continue a healthy lifestyle. For example, one obstetric provider stated:

I think the patients that come in already at a normal healthy weight and that have good healthy behaviors already are the ones who are more likely to ask specific questions, like can I keep running? Can I keep going to yoga? I had somebody recently who was asking me about weight lifting in, like getting into the third trimester, and those are usually the people who are already doing these things and they want to be able to continue. (Obstetrician)

Pregnant and postpartum women described the importance of overall wellness as enabling them to make and maintain behavior changes. Wellness was defined broadly and beyond their pregnancy-related health, including mental/emotional health, sleep quality, feeling in control of their own time and reducing stressors.

In particular, lack of quality sleep was a major barrier to dietary and physical activity changes, especially postpartum when women had newborns. One postpartum woman described lack of sleep as a barrier to exercise as illustrated by the following quote:

Between four and six months [my baby] was waking up like every hour like every night. It was just it was really bad. It just made me feel so tired during the day that the idea of moving, getting up and doing things was really not [feasible] So I feel like thats been a big problem. (Postpartum woman)

Some women shared their struggles with emotional changes during and after pregnancy, even postpartum depression. One postpartum woman described her mood in the following way:

I dont think I had full scale postpartum depression with either of my pregnancies, but I definitely had the baby blues pretty badly especially with the first one . Thinking back to it ugh I was not in a good mood for the first bunch of months, I think my husband noticed it more, but Im not sure he necessarily wanted to like drag me to a doctor (Postpartum woman)

Another postpartum woman described her lack of energy in pregnancy as, [W] hen I come home Im just like I dont want to do anything. I dont [want to talk with anyone] my [low] energy level kind of sometimes puts a strain on [me]. A postpartum woman described how stress can be a trigger for her to eat high calorie foods:

I end up eating [or] drinking a soda or having some candy or something, because I'm like oh Im felling stressed [and] this would make me feel better. (Postpartum woman)

Obstetric providers noted the importance of addressing womens wellness in pregnancy, including mood and sleep, and not just focusing on the patients weight. One certified nurse midwife said, I think its important not just to focus on the number [her weight] but just being healthy in general.

The majority of participants shared stories highlighting the importance of strong social support from family and friends, to enable them to make and sustain health behavior changes in pregnancy. One pregnant woman highlighted the benefit of having peer support from another pregnant friend:

Sometimes you need another pregnant womens point of view so they can say, I know what youre going through. (Pregnant woman)

Social support from friends and peers with similar experiences was especially important in the postpartum period:

I just had a baby two weeks ago. [My family member] was like oh, really-- Look at your cheeks, look at your belly. I felt like I wasnt doing [well] with my weight. When I read about [and saw other women
s] experiences, I knew I wasnt alone in this. Actually, I was doing [well]. (Postpartum woman)

Obstetric providers also commented on their role as providing support for their patients through behavioral changes:

[W]omen want to get a little pampered and feel like, you know, theyre being taken care of and you want to make sure that shes feeling okay and that shes doing okay and that shes getting what she needs and, you know, just basically a little extra attention um, from a healthcare provider I think can do a lot (Certified Nurse Midwife)

Participants described the importance of knowing someone outside of their immediate family and friend network to be an accountability partner who could provide positive reinforcement to help them stay on track with reaching health goals in pregnancy and postpartum. For most women, their healthcare providers served this role. One participant stated,

You know so the one thing is accountability I would eat more, exercise less [if] no one else [was] looking. . . (Postpartum woman)

Another woman described,

[I like] feeling like you have some sort of support, you know, whether you needed it or not, but to know that someones checking in on you and they really care about how youre doing and the baby and trying to make your life easier. (Postpartum woman)

One obstetric provider highlighted the importance of positive reinforcement and said, It might be something you just say, [like] hey, youre doing great with the weight Keep up the good work.

Participants were specifically asked about how their clinics could support their efforts in achieving healthy lifestyles in pregnancy. In particular, participants discussed their use of technology, including mobile phones and mobile applications, which could facilitate their behavior change and enable communication with providers between visits. One woman remarked I would use [it] everyday with regard to the ability to interface with her moble phone to help with behavior change. Another woman remarked that her health care providers would know where Im coming from and they can work with me better noting this would also help them on their end.

Obstetric providers discussed the importance of integrating future clinical programs on healthy lifestyle within the electronic medical record to facilitate their ability to review patients progress. One obstetric provider discussed this point in the following way:

Im a bigger fan of an [electronic] referral [to a healthy lifestyle program] just because then theres tracking of it . Reading other providers notes or reading the [behavioral counselor, i.e. health] coaches notes thats something you can eventually weave in to your other visits and things like that . And then too, [to] read what the patients .responses [are] or if theres trends or repeating issues you can touch base [about these isues] in [the] visit, you know? [In real time]. (Certified Nurse Midwife)

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Perspectives of pregnant and postpartum women and obstetric providers to promote healthy lifestyle in pregnancy and after delivery: a qualitative...