Dietary habits and supplementation practices of young women during pregnancy: an online cross-sectional survey of young mothers and health care professionals

A healthy diet and lifestyle during pregnancy is essential to ensure fetal growth and development is optimised. This is of a particular importance for young adolescent mothers in whom poor nutrition [1] and adverse outcomes such as stillbirth, preterm birth and low birthweight have been frequently reported [2–4]. Adolescent pregnancy (birth among women aged 15–19 when the pregnancy ended) has been considered a major contributor to maternal and child mortality worldwide [5] and is a major public health concern in United Kingdom (UK) with a rate of 19.7 births per 1000 women [6].

Young or adolescent mothers have specific requirements for macro- and micronutrients to support fetal development in addition to their own growing needs [7]. Systematic evidence [1] in addition to the recent UK ‘National Diet and Nutrition Survey’ (NDNS) [8] highlight that many adolescents' diets do not provide the recommended intakes for iron, zinc, calcium and folate and that those with the lowest incomes had significantly lower mean intakes than those from the highest income groups. Spending money on healthy food is often a lower priority compared to other fixed financial pressures such as housing, transport and utility bills [9]. With many competing priorities, it can be a challenge for health professionals to support women in making positive dietary changes and providing practical advice such as guiding on recipes that are suitable for circumstances with limited budget, cooking skills or facilities.

The Department of Health guidance and National Health Service (NHS) Choices [10] website provide standard healthy eating and food safety information for pregnant women in the UK. However most of the routinely provided information is not tailored to the specific nutritional requirements of adolescent mothers or in an adolescent friendly format. Midwives traditionally give every pregnant woman ‘The NHS Pregnancy Guide’, but the 200 page printed book can now only be read online so is likely to be only read by the most motivated of mothers with internet access. Tommy’s, a UK baby charity, has produced the ‘Young Woman’s Guide to Pregnancy’ which provides dietary advice in a booklet format more accessible to adolescents, but distribution of this free resource by midwives is variable [11]. It is therefore paramount to explore where and how young women access information and their preferences so that future resources are more appropriate to their needs.

Young mothers in the UK are entitled to standard antenatal care, although they are more likely to present for their first appointment later and miss appointments [12]. Various models of care are provided for adolescent pregnant mothers. In some areas, specialist teenage pregnancy midwives provide all or some of their care which may involve slightly longer appointment times and signposting to other services such as parenting classes. The Family Nurse Partnership (FNP) scheme provides intensive support for the young pregnant mother from 14 weeks and family for up to 2 years postnatal but only the most vulnerable are eligible and it is not available nationally. Understanding how young women are supported and guided regarding nutrition and healthy eating during pregnancy, and how they would like to be supported in future is essential to optimise care and enhance birth outcomes for this vulnerable group of women.

A previous study surveying adolescent's views of healthy eating during pregnancy in the USA [13] found that while young women reported that they considered healthy eating to be important the majority of their snacks consisted of unhealthy foods. The results from this study are however unclear in terms of the foods eaten at meal times and the frequency of consuming fruit and vegetables. There are no previous studies of this type undertaken in the UK, nor have any studies been conducted which include exploring the views of health professionals' dietary advice and support for this particular vulnerable group of women.

In an in-depth qualitative study [11] we have explored dietary patterns and supplementation adherence, and the facilitators and barriers in achieving a healthy diet and lifestyle during adolescent pregnancy. This qualitative study suggested that many young mothers have a dietary pattern consisting of high fat snacks, carbonated drinks and occasional meals, but their diet often depends on their living arrangements with those still at home more likely to have more traditional eating habits. A larger study was required to verify these provisional findings with a specific focus on what, if any, changes young women made to their diets during pregnancy; what motivated them to make such changes; where they obtained information and how in future they would like to receive information and support regarding diet and supplements during pregnancy. This study therefore aimed to explore diet and supplementation practices, information and advice during pregnancy from the perspectives of adolescent pregnant or new mothers and their health care professionals.

Two cross-sectional surveys were developed, one using a questionnaire which was specifically designed, piloted and administered for young women and the other for health care professionals. The questionnaires were informed by the findings from our previous qualitative study on exploring views of adolescent pregnant women and their health care professionals on pregnant adolescents' dietary pattern and, facilitators and barriers for improvement [11].

Ethical approval was obtained from Sheffield Hallam University Research Ethics Committee. An information sheet was provided at the beginning of the questionnaires, providing information about the study, contact details for further information. Young women were invited to participate if they were aged between 16–20 years of age at the time of their pregnancy, with a recent pregnancy experience. Health care professionals were invited to participate if their role included providing antenatal care to adolescent pregnant women. Consent was assumed inherent for the respondents who completed the questionnaire voluntarily.

Survey design: Questions were drafted and formatted in SurveyMonkey and results downloaded for analysis into SPSS (Version 23). The young women's questionnaire was designed to gather data from young women who were currently pregnant or those who had been pregnant recently, so care was taken to word the questions and question logic in order to capture all possibilities. There were a total of 26 questions in the young women’s survey and 25 in the survey for health care professionals both using a mixture of question types, including some free text questions and some where participants selected one from a list of options and matrices. Demographic data was collected from the young women including the first part of their postcode, age and number of pregnancies and, job role, grade and year of qualification were collected from health care professionals.

Questions for young women focussed around changes to their diet and supplement use, beliefs about why they made changes, current information sources and suggestions for future resources or services. Questions for health care professionals focused on when and how information and advice on diet, nutrition and supplements was offered to young women and their confidence in giving this advice.

Descriptive statistics are reported for all demographic data and for closed answer questions including proportions, means, standard deviation (SD) and ranges as appropriate. Average score or proportions in percent are presented for individual survey items. A simple content analysis was used for the open ended questions to establish categories.

Young Women’s Questionnaire.

The majority of respondents (94.6%) described their ethnicity as White British and a small proportion identified themselves as Black, Asian or Mixed race (Table 1).

About 60% of participants had only one pregnancy and the remaining had two or more pregnancies. Fifty-eight women were currently pregnant, ranging from 3 to 40 weeks (mean 25.6, SD10.2) with 30 as their first pregnancy.

Valid postcode district data was available for 180 participants, of whom 141 were resident in England, 20 in Scotland, 15 in Wales and 4 in Northern Ireland [14].

Young women were asked if they had taken any supplements before, during and/or after their pregnancy, with 93.2% reporting taking supplements at any stage of pregnancy and 5.8% stated they have never taken supplements during pregnancy. Folic acid was the most commonly used supplement with 75.1% stated having taken it at some stage in their pregnancy, followed by pregnancy multivitamins (42.9%) and iron supplements (40.0%) also being prevalent (Fig. 1).

A total of 84.5% took a folic acid supplement before or during their pregnancy, although the remainder might be getting their folic acid from Healthy Start (18.6%), a combined form of iron and folic acid (19.0%) or pregnancy multivitamins (48.3%) in this period.

Out of 205 participants, 54.6% stated that on average they took supplements daily, 24.9% took it 5–6 days a week, 12.2% 1–4 days a week, 4.4% never and 1% didn't know. Of 87 (out of 205) who reported taking supplements less than 7 days a week, 88.5% said it was mainly due to 'forgetting' and only a few stated it to be because of other reasons such as making them feel unwell, being too expensive, not liking to take tablets or not knowing what they are for.

Information about healthy eating during pregnancy was provided by 98% of midwives and 100% of FNPs, but how this information was provided differed. The FNPs have more time compared to midwives for goal setting (87% vs 14%) and provided more physical resources such as Tommy’s Young Woman's Guide to Pregnancy (96% vs 57%) providing other leaflets (94% vs 71%) and worksheets (88% vs 1%) which form a major part of the FNP programme. Bounty packs were handed out by 48% of midwives but no FNPs.

The food topics discussed with young women by health care professionals are shown in Fig. 8. All 13 food topics were covered by at least 70% of FNPs, but only six (healthy eating, regular meals, iron rich foods, food safety, foods to avoid and caffeine) were covered by at least 70% of midwives. Those less often covered by midwives were energy drinks, healthy snacks, 5 A Day, fortified foods, calcium foods, oily fish and weight gain.

All FNPs and 85% of midwives feel they adequately cover nutrition during pregnancy. The midwives who thought they didn’t adequately cover it stated time pressure (4) and lack of clear guidelines as reasons.

When asked where they accessed information on diet and supplements, they reported accessing dietary advice from most sources listed (90–100%) including dieticians, internal and external training, journals, media and slimming clubs; while less sources were used to access supplement information (17–55%). Only 38% of midwives and 55% of FNPs learnt about supplements in prequalification training, however this may be due to some qualifying decades ago when the recommendations were different.

This cross-sectional study of young mothers and their health care providers gives an insight into the pattern of dietary changes, supplement intake, current sources of information and preferred information sources in addition to the reasons behind their preferences for information support. Addressing eating behaviour and nutritional requirements of adolescent pregnant women in order to enhance their pregnancy and birth experiences is important as an association between poor nutritional status and adverse pregnancy outcomes is well documented [2–4, 15, 16]. This survey allowed a wider verification of the identified issues in a series of in-depth explorative interviews of young women and health care professionals from Doncaster, Manchester and London, details of which are reported elsewhere [11].

These surveys which included responses from all regions in England as well as Scotland, Wales and Northern Ireland showed that young mothers are motivated and keen in adopting healthy dietary changes as indicated in their responses for making positive changes during pregnancy. However it was important that a considerable proportion of responding women were not consuming red meat, eggs, oily fish and soft cheese (such as cream cheese or spreadable cheese). It was encouraging to see a high level of interest and enthusiasm for making positive changes however such a high proportion of adolescents indicating avoiding foods which are potentially valuable sources of vitamins and minerals, such as B vitamins and iron (red meat and eggs) or vitamin D and calcium (oily fish and soft cheese) [17] are of concern. Attention to adequate nutrition in supplying sufficient amount of nutrients are increasingly realised due to its impact on healthy pregnancy and birth outcomes [18].

The poor dietary habit identified in this study is in line with other investigators’ findings showing a poor nutritional intake in young mothers [1, 8]. The low intake of foods such as soft cheese and eggs may suggest inadequate communication with young women and a state of confusion regarding prohibiting raw/runny eggs or unpasteurised mould ripened soft cheeses rather than avoiding all types of eggs or pasteurised soft cheeses. It is likely that food avoidance be due to personal taste or cultural restrictions in which case health professionals’ role in guiding for alternative sources becomes essential for all particularly this group of women.

It is therefore of prime importance to provide sufficient support and appropriate education for health professionals who have direct contact with young pregnant mothers to enhance their knowledge and dietary behaviour with the overall aim of optimising pregnancy and birth outcomes. This is particularly noteworthy, considering the level of awareness and appreciation of the role, and the trust these young women place in their health professionals, especially in midwives, to obtain nutritional information. This ultimately affirms the need for equipping health professionals with appropriate support, skills and knowledge for effective communication of nutritional messages during pregnancy and postpartum.

The majority of midwives and family nurse practitioners felt that they were providing nutritional support to young women during pregnancy as part of their role but acknowledged there were some areas where they lacked confidence and would like further training. The role of midwives in promoting dietary changes has been explored in previous studies and it has been shown to be central in supporting women to make positive changes [19, 20]. The qualitative interviews with young women and health professionals undertaken as part of the earlier stages of this study however found that while most health care professionals provided some nutritional support and information, the extent to which this was tailored to young women's individual needs varied considerably [11]. There are significant barriers to providing individualised nutritional support particularly in terms of time pressures and a lack of appropriate resources [21]. It is therefore important that the need for post-registration training, both relating to the specific nutritional issues identified in this study and wider skills regarding how behaviour change techniques can be applied in this context [22].

There were differences in the resources provided by midwives and FNPs to young women and also in the resources used for their own information. These differences however largely reflect the different models of support and care offered by the different professions. This is further supported by open answer comments from young women, although indicating a high satisfaction and trust in midwifery care, expressing a sense of time limitation or insufficient resources to provide adequate and appropriate support during pregnancy. Young women were aware of risks and biases associated with accessing information via websites or commercial sources due to a lack of consistency and trustworthiness. The findings however were indicative of their desire to receive specific, robust, trustworthy and standardised information from authoritative sources; the potential for alternative digital formats is also indicated via mobile technology (e.g. apps) or interactive websites (e.g. easy to follow recipes, healthy eating guidance). Although they acknowledged mobile technology and digital sources should not replace face to face contacts, they appreciated additional support to allow continuous access, facilitate healthy dietary change and maximise benefits in between appointments. A lack of using online technologies either as tools to facilitate discussion or for helping young women to access further support was evident in the data collected from health care professionals. Young women have been found to routinely access online information [23] and support [24] during pregnancy; however research has suggested that health care professionals lack confidence in using these technologies effectively [25]. This suggests that further investigation to develop and evaluate dietary and lifestyle interventions delivered through mobile technology and interactive websites as an adjunct to care provided by health care professionals may be advantageous.

A stated positive change in dietary intake by majority of young women in this survey indicates willingness to adapt a healthy lifestyle. This in addition to their trust in health professionals provides an opportunity for health interventions to improve birth outcomes. Avoiding or reducing foods such as red meat, eggs, oily fish or soft cheeses as major sources of required vitamins and minerals is of concern. Improving confidence among health professionals in using a range of resources, including online technologies, to support young women would be advantageous.