Obese Postpartum Women Research Articles

Estimating the value of future research into thromboprophylaxis for women during pregnancy and after delivery: a value of information analysis

BackgroundRisk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis. ObjectivesTo estimate the value of potential future studies that would reduce the decision uncertainty associated with offering thromboprophylaxis according to available RAMs in the following groups: high-risk antepartum women (eg, prior VTE), unselected postpartum women, and postpartum women with risk factors (obesity or cesarean delivery). MethodsA decision-analytic model was developed to simulate clinical outcomes, lifetime costs, and quality-adjusted life-years for different thromboprophylaxis strategies, including thromboprophylaxis for all, thromboprophylaxis for none, and RAM-based thromboprophylaxis. The expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty. The value of future research studies was estimated using expected value of sample information analysis. Costs were assessed from a health and social services perspective. ResultsThe expected value of perfect information analysis identified high decision uncertainty for high-risk antepartum women (£21.8 million) and obese postpartum women (£13.4 million), which was largely attributable to uncertainty regarding the effectiveness of thromboprophylaxis in reducing VTE. A randomized controlled trial of thromboprophylaxis compared with none in obese postpartum women is likely to have substantial value (£2.8 million; 300 participants per arm). A trial in women with previous VTE would have higher value but would be less acceptable. ConclusionFuture research should focus on estimating the effectiveness of thromboprophylaxis in obese postpartum women with additional risk factors who have not had a previous VTE.

Experiences of Physical Activity, Healthy Eating and Quality of Life During and Following Pregnancy in Overweight and Obese Postpartum Women

ObjectivesThis retrospective study explored the experiences of women with overweight or obesity regarding physical activity, diet and quality of life leading up to, during, and following pregnancy.MethodsA qualitative descriptive design was adopted, whereby data collected through semi-structured interviews were analysed using thematic analysis. Throughout the interviews, individuals were asked to describe their barriers to a healthy lifestyle during and following pregnancy.ResultsTen women (34.5 ± 5.2 years old, BMI 30.4 ± 3.5 kg·m− 2) who were between 12 and 52 weeks postpartum participated. A range of themes were identified when discussing barriers to physical activity and healthy eating during and following pregnancy. For example, tiredness, especially in the third trimester of pregnancy, and a lack of support at home, was often cited as preventing engagement in exercise and healthy eating practices. A lack of convenience when attending exercise classes, medical complications following the birth and the cost of attending pregnancy-specific classes were identified as barriers to exercise engagement. Cravings and nausea were identified as barriers to healthy eating during pregnancy. Quality of life was positively associated with exercise and healthy eating, whilst a lack of sleep, loneliness and a loss of freedom since the baby had arrived negatively influenced quality of life.DiscussionPostpartum women with overweight and obesity experience many barriers when attempting to engage in a healthy lifestyle during and following pregnancy. These findings can be used to inform the design and delivery of future lifestyle interventions in this population.

IDF2022-1112 The gut microbiome of obese postpartum women with and without gestational diabetes mellitus and of their babies

IDF2022-1112 The gut microbiome of obese postpartum women with and without gestational diabetes mellitus and of their babies

Effect of group cognitive behavioural therapy on self-efficacy and anthropometric indices among overweight and obese postpartum women

Objective: While usually associated with weight gain, pregnancy and the postpartum period are also considered as an opportunity to prevent weight gain and its complications. Therefore, the prevention of ‘excessive/unnecessary’ weight gain is a necessary issue. The aim of this study was to determine the effect of group cognitive behavioural therapy (CBT) on self-efficacy and lifestyle to control weight and anthropometric indices among overweight and obese postpartum women. Design: Quasi-experimental study. Setting: Public health centres in Izeh, Iran. Subjects: Sixty eligible women were divided into two groups of intervention (n = 30) and control (n = 30) using a simple randomisation method. A demographic questionnaire, a checklist and Weight Efficacy Lifestyle Questionnaire (WELQ) were used to collect the data. The intervention group received eight sessions of group CBT, while the control group received routine care. All variables were measured at baseline and four weeks after the completion of the intervention. Data were analysed using an independent t-test, paired t-test, chi-square and analysis of covariance using SPSS version 24. Outcomes measures: Self-efficacy, weight, height, body mass index, waist, hip, and arm circumference, waist/hip ratio,and body fat percentage were measured at baseline and 12 weeks after intervention. Results: The results showed that in the CBT group, there was a significant increase in the total score of self-efficacy and its components, while weight, body mass index, waist circumference, hip circumference, waist/hip ratio, mid-upper arm circumference and body fat percentage significantly reduced in comparison with the control group (p < 0.05). Conclusion: Cognitive behavioural therapy can improve self-efficacy, affecting weight and anthropometric indices in overweight and obese postpartum women. Therefore, CBT can be used as an adjunct to weight-loss intervention such as physical activity and diet or it can be used as a sole form of therapy to facilitate weight loss among overweight/obese postpartum women.

The gut microbiome of obese postpartum women with and without previous gestational diabetes mellitus and the gut microbiota of their babies

BackgroundThe incidence of gestational diabetes mellitus (GDM) is increasing worldwide, and has been associated with some changes in the gut microbiota. Studies have shown that the maternal gut microbiota pattern with hyperglycemia can be transmitted to the offspring. The study aimed to evaluate the gut microbiota of obese postpartum women with and without previous GDM and their offspring.MethodsWe evaluated a total of 84 puerperal women who had (n = 40) or not GDM (n = 44), and their infants were also included. Stool samples were obtained 2–6 months after delivery. The molecular profile of the fecal microbiota was obtained by sequencing V4 region of 16S rRNA gene (Illumina® MiSeq).ResultsWe found that the gut microbiota structures of the puerperal women and their infants were similar. Stratifying according to the type of delivery, the relative abundance of Victivallis genus was higher in women who had natural delivery. Exposure to exclusive breastfeeding was associated with a greater abundance of Bacteroides and Staphylococcus. The differential abundance test showed correlations to clinical and laboratory parameters. This work showed no difference in the microbiota of obese puerperal women with and without GDM and their offspring. However, breastfeeding contributed to the ecological succession of the intestinal microbiota of the offspring.ConclusionThis work can contribute to understanding the potential effects of GDM and early life events on the gut microbiome of mothers and their offspring and its possible role in metabolism later in life.

Awareness, Beliefs and Perspectives Regarding Weight Retention and Weight Gain among Postpartum Women in India: A Thematic Analysis of Focus Group Discussions and In-Depth Interviews.

Background and AimsThe pregnancy weight is usually retained in the form of abdominal fat during the postpartum period. The willingness to lose weight is influenced by knowledge, attitude, beliefs and practices. This study aims to comprehend the awareness, beliefs and perspectives of postpartum women regarding their perceived factors, barriers and facilitators associated with post-pregnancy weight status.MethodsOverweight and obese postpartum women aged between 20 and 40 years and had delivered an infant in the last 2 years were recruited via convenience and purposive sampling techniques. The final sample comprised 27 participants with a mean age of 29.96 ± 4.50 years. Four focus group discussions and eight in-depth interviews carried out were audio-recorded and transcribed verbatim. Codes, sub-themes and themes were generated using Atlas.ti 9 software.ResultsMajor themes identified were perceived factors causing postpartum weight retention/weight gain including social and cultural beliefs related to diet and exercise specifically associated with this period, perceived motivators and deterrents of weight loss including eagerness to lose weight and perceived facilitators and barriers to weight loss including intrinsic and extrinsic factors such as time, energy, evidence-based knowledge about diet and physical activity, family support and obligation to family’s advice.ConclusionThe unique challenges and barriers associated with postpartum weight loss efforts should be taken into consideration by healthcare professionals and public health policy-makers to design strategies specific to postpartum women.Supplementary InformationThe online version contains supplementary material available at 10.1007/s13224-022-01644-9.

Developing a lifestyle intervention program for overweight or obese preconception, pregnant and postpartum women using qualitative methods

The time period before, during and after pregnancy represents a unique opportunity for interventions to cultivate sustained healthy lifestyle behaviors to improve the metabolic health of mothers and their offspring. However, the success of a lifestyle intervention is dependent on uptake and continued compliance. To identify enablers and barriers towards engagement with a lifestyle intervention, thematic analysis of 15 in-depth interviews with overweight or obese women in the preconception, pregnancy or postpartum periods was undertaken, using the integrated-Promoting Action on Research Implementation in Health Services framework as a guide to systematically chart factors influencing adoption of a novel lifestyle intervention. Barrier factors include time constraints, poor baseline knowledge, family culture, food accessibility, and lack of relevant data sources. Enabling factors were motivation to be healthy for themselves and their offspring, family and social support, a holistic delivery platform providing desired information delivered at appropriate times, regular feedback, goal setting, and nudges. From the findings of this study, we propose components of an idealized lifestyle intervention including (i) taking a holistic life-course approach to education, (ii) using mobile health platforms to reduce barriers, provide personalized feedback and promote goal-setting, and (iii) health nudges to cultivate sustained lifestyle habits.

Six Weeks Effects of Dynamic Neuromuscular Stabilization (DNS) Training in Obese Postpartum Women With Low Back Pain: A Randomized Controlled Trial.

The worldwide prevalence of obesity and low back pain (LBP) has recently dramatically increased and is mainly indicated among postpartum women, leading to a range of adverse health consequences. This study aimed to investigate the effects of 6 weeks of Dynamic Neuromuscular Stabilization training (DNS) in obese postpartum women with LBP. This was a pretest-posttest study design. The study was conducted with 40 obese postpartum women with LBP randomized to receive DNS (n = 20) or General Exercise (GE, n = 20) 6 times a week for 6 weeks. The data were gathered before and after the 6-week intervention. Forty participants completed the study (mean ± SD, age 29.30 ± 3.77 years; weight 88.10 ± 6.09 kg; height 165.40 ± 6.31 cm; and BMI, 32.19 ± 1.07 kg/m2). The overall group-by-time interaction was significant for Numeric Pain-Rating Scale, Modified Oswestry Disability Questionnaire, Fear-Avoidance Beliefs Questionnaire, Inspiration and Expiration Breath Hold Time, and Respiratory Rate outcomes. The global rating of change was significantly different between groups (p < .05). The rate of improvement was higher in the DNS group compared to the GE group in all 6 tests. The present study confirms that DNS is applicable in obese postpartum women with LBP and effectively improved NPRS, MODQ, FABQ, BHT, and RR. It is clinically suggested that DNS is imperative based on ideal ontogenetic patterns to attain optimal results for obese postpartum women with LBP.

Sleep and weight loss in low-income overweight or obese postpartum women

BackgroundWe conducted secondary data analyses to examine the associations between sleep duration, sleep quality, sleep disturbance and ≥ 5% of weight loss in low-income overweight or obese postpartum women enrolled in a community-based lifestyle behavior intervention study aimed at prevention of weight gain.MethodsParticipants were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children in Michigan. The Pittsburgh Sleep Quality Index was used to assess sleep duration, sleep quality, and sleep disturbance. All participants were assessed and weighed at baseline (T1, 569 participants), 4-month (T2, 367 participants), and 7-month from T1 (T3, 332 participants). Descriptive statistics and mixed-effects regression analysis were performed.ResultsParticipants reported longer sleep duration (p = 0.048), better sleep quality (p = 0.003) and less sleep disturbance (p < 0.001) over time. There were no significant mean body weight changes at T2 and T3. However, a significantly higher proportion of women lost ≥5% of body weight at T3 (23.1%) than T2 (12.5%, p = 0.001). Sleep duration, quality, and disturbance were not significantly associated with ≥5% of weight loss.ConclusionImprovements in sleep duration, sleep quality and sleep disturbance over time were not associated with ≥5% of weight loss in low-income overweight or obese postpartum women.Trial registrationClinical Trials NCT01839708; retrospectively registered February 28, 2013.

High protein diet promotes body weight loss among Brazilian postpartum women.

There is evidence in the general population that adhering to a high protein and low carbohydrate diet may help in losing weight. However, there is little evidence among postpartum women. The aim of this study is to evaluate the effect of a high protein diet on weight loss among postpartum women. A parallel-randomized controlled trial with 94 postpartum women was conducted in a maternity ward in Mesquita county (recruitment from February 2009 to December 2010) and in a polyclinic in Rio de Janeiro city (recruitment from December 2010 to December 2011). Women were randomized to the intervention group (IG) or control group (CG), and both groups received an isocaloric diet (1,800kcal). Additionally, the IG received approximately 25g of protein obtained from 125g per week of sardine to increase daily dietary protein content and was advised to restrict carbohydrate intake. The CG received nutritional counselling to follow the national nutrition guidelines (15% protein, 60% carbohydrates, and 25% lipids). A linear mixed-effects model was used to test the effect of high protein intake and macronutrient intake on weight loss during the postpartum period. Body weight decreased in the IG compared with the CG (ß=-0.325; p=0.049) among overweight and obese postpartum women. The percentage of energy intake from lipid (ß=-0.023; p=0.050) was negatively associated with body weight, and carbohydrate intake (ß=0.020; p=0.026) was positively associated with body weight over time among all women. Protein intake and lower carbohydrate intake may be used as a dietary strategy to improve body weight loss during the postpartum period.

Exploring the Ovarian Reserve Within Health Parameters: A Latent Class Analysis.

The process of ovarian aging is influenced by a complex and poorly understood interplay of endocrine, metabolic, and environmental factors. The purpose of this study was to explore the feasibility of using latent class analysis to identify subgroups based on cardiometabolic, psychological, and reproductive parameters of health and to describe patterns of anti-Müllerian hormone levels, a biomarker of the ovarian reserve, within these subgroups. Sixty-nine lean (body mass index [BMI] ⩽ 25 kg/m2) and severely obese (BMI ⩾ 40 kg/m2) postpartum women in Edinburgh, Scotland, were included in this exploratory study. The best fitting model included three classes: Class 1, n = 23 (33.5%); Class 2, n = 30 (42.2%); Class 3, n = 16 (24.3%). Postpartum women with lower ovarian reserve had less favorable cardiometabolic and psychological profiles. Examining the ovarian reserve within distinct subgroups based on parameters of health that affect ovarian aging may facilitate risk stratification in the context of ovarian aging.

Feasibility and Acceptability of Delivering a Postpartum Weight Loss Intervention via Facebook: A Pilot Study

ObjectiveTo evaluate the feasibility and acceptability of a Facebook-delivered postpartum weight loss intervention. MethodsOverweight and obese postpartum women received a 12-week weight loss intervention via Facebook. Feasibility outcomes were recruitment, retention, engagement, and acceptability. Weight loss was an exploratory outcome. ResultsParticipants (n = 19) were 3.5 (SD 2.2) months postpartum with a baseline body mass index of 30.1 (SD 4.2) kg/m2. Retention was 95%. Forty-two percent of participants visibly engaged on the last day of the intervention, and 100% in the last 4 weeks; 88% were likely or very likely to participate again and 82% were likely or very likely to recommend the program to a postpartum friend. Average 12-week weight loss was 4.8% (SD 4.2%); 58% lost ≥5%. Conclusions and ImplicationsFindings suggested that this Facebook-delivered intervention is feasible and acceptable and supports research to test efficacy for weight loss. Research is needed to determine how best to engage participants in social network–delivered weight loss interventions.

Effect of Low Dietary Glycemic Index on Blood Lipids Profile among Obese Postpartum Women

AbstractObjective: Postpartum obesity leads to long-term maternal obesity and promotes drastic health complications. Low glycemic index diet is suggested to have a beneficial impact on blood lipid levels. Therefore, we conducted a study to explore the effect of low glycemic diet on blood lipid profile in obese postpartum women.Methods: In a randomised controlled trial, 38 obese postpartum women in intervention and 36 obese post-partum women in control group were analysed. Subjects in the intervention group were assigned low glycemic index diet and to follow this protocol for 12 weeks and the control group was advised to continue their routine diet.Results: Low glycemic diet had a positive impact on low density lipoprotein (LDL), triglyceride and highdensity lipoprotein (HDL) concentration (p &lt; 0.05). A strong positive correlation was observed between the glycemic index and LDL (mg/dl), (r = 0.57; p = 0.02) and between glycemic index and triglyceride (mg/dl), (r = 0.51; p = 0.01) in control and intervention group. A negative correlation was identified between glycemic index and HDL (mg/dl), (r = -0.45; p = 0.01).Conclusion: Study concluded that low glycemic index diet reduced low density lipoprotein and triglyceride level and increased HDL level in blood; further more a significant association was found between glycemic index and blood lipids profile.

Changes in food choice during a successful weight loss trial in overweight and obese postpartum women.

To examine changes in intake across food groups during a weight loss trial that produced significant and sustainable weight loss in lactating women receiving dietary treatment. At 10-14 wk postpartum, 61 overweight and obese lactating Swedish women were randomized to a 12-wk dietary (D), exercise (E), combined (DE), or control (C) treatment. Food intake was assessed by 4-d weighed diet records which were used to examine changes in intake across seven food groups from baseline to 12 wk and 1 y after randomization. Differences in changes in food choice between women receiving dietary treatment (D+DE) and no dietary treatment (E+C) were examined using multivariate linear regression. At baseline, sweets and salty snacks contributed to 21±10 percent of total energy intake (E%). During the intervention period, women receiving dietary treatment reduced their E% from sweets and salty snacks and caloric drinks and increased their E% from vegetables more than did women not receiving dietary treatment (all P < 0.010). At 1 y, the increased E% from vegetables was maintained significantly higher among women receiving dietary treatment (P = 0.002). Lactating women receiving dietary treatment achieved sustainable weight loss through changes in food choice in line with current dietary guidelines.

Eating frequency, energy intake and body weight during a successful weight loss trial in overweight and obese postpartum women

To examine associations among eating frequency, energy intake and body weight at baseline, as well as associations among change in eating frequency and change in energy intake and weight during a 12-week successful weight loss intervention in overweight and obese postpartum women. Sixty-one Swedish women with pre-pregnancy body mass index of 25-35 kg/m(2) completed a 4-day diet record at 10-14 weeks postpartum (baseline) and 12 weeks later (post-intervention), which were used to calculate energy intake and eating frequency, that is, the mean number of intake occasions per day. The women had a mean eating frequency of 5.9 ± 1.2 intake occasions at baseline. A positive association was found between eating frequency and energy intake at baseline (β: 307 ± 46 kcal, P<0.001), whereas no significant association between eating frequency and weight was observed (β: 2.3 ± 1.2 kg, P=0.063). During the intervention period, reduced eating frequency was positively associated with energy intake reduction (β: 169 ± 69 kcal, P=0.017) whereas no significant association was found with weight loss (β: 0.9 ± 0.7 kg, P=0.179). Women receiving dietary intervention reduced their eating frequency more during the intervention period than did women not receiving dietary intervention (-1.0 ± 0.7 vs -0.5 ± 1.1, P=0.001). A positive association was found between eating frequency and energy intake at baseline and between reduced eating frequency and reduced energy intake during a 12-week weight loss intervention in overweight and obese postpartum women. Intervention studies on eating frequency are warranted to elucidate its effect on energy intake and weight among postpartum women.

Changes in Physical Activity Among Postpartum Overweight and Obese Women: Results from the KAN-DO Study

Few studies have assessed physical activity at multiple time points in the postpartum period or used both self-reported and objective measures of assessment. The purpose of this study was to describe physical activity and sedentary behavior at two time points in a cohort of overweight or obese postpartum women using both self-reported and objective measures. In total, 132 women completed physical activity assessments at a median of 24 weeks postpartum and again approximately 10 months later. At both time points, women wore an Actical accelerometer for one week and completed the Kaiser Physical Activity Survey. Adjusted Poisson regression models were used to determine whether physical activity changed over time for the cohort. Overall counts per minute and moderate to vigorous physical activity increased from baseline to 10 months later, although the absolute levels were modest (median 6.9 to 8.8 minutes/day). A median of 64%–71% at baseline and 63%–67% at follow-up of their monitored times were sedentary. More intensive interventions are needed to help postpartum women integrate physical activity and reduce sedentary behavior. [Supplementary material is available for this article. Go to the publisher's online edition of Women & Health for the following resource: three figures that show the distribution of physical activity and sedentary behavior by study periods among control participants]

Predictors of Postpartum Weight Change Among Overweight and Obese Women: Results from the Active Mothers Postpartum Study

The postpartum period may be critical for the development of midlife obesity. Identifying factors associated with postpartum weight change could aid in targeting women for healthy lifestyle interventions. Data from Active Mothers Postpartum (AMP), a study of overweight and obese postpartum women (n=450), were analyzed to determine the effect of baseline characteristics, breastfeeding, diet, physical activity, and contraception on weight change from 6 weeks to 12, 18, and 24 months postpartum. The repeated measures mixed model was used to test the association of these effects with weight change. Although mean weight loss was modest (0.49 kg by 24 months), the range of weight change was striking (+21.5 kg to -24.5 kg, standard deviation [SD] 7.4). Controlling only for baseline weight, weight loss was associated with breastfeeding, hormonal contraception, lower junk food and greater healthy food intake, and greater physical activity. Only junk food intake and physical activity were significant after controlling for all other predictors. Eating less healthy foods and being less physically active put overweight and obese women at risk of gaining more weight after a pregnancy.

Unmet Social Support for Healthy Behaviors Among Overweight and Obese Postpartum Women: Results from the Active Mothers Postpartum Study

In the United States, about two thirds of women of reproductive age are overweight or obese. Postpartum is a transitional period. Life changes during this time can put mothers under high levels of stress when interpersonal support is inadequate. This study sought to explore predictors of unmet social support (support inadequacy) for healthy behaviors among postpartum women who were overweight or obese before pregnancy. Potential predictors of unmet social support for healthy behaviors were derived from baseline and 6-month postpartum data from the Active Mothers Postpartum (AMP) study. The Postpartum Support Questionnaire queried three dimensions of social support: (1) informational support, (2) emotional support, and (3) instrumental support. The main outcome, the overall Unmet Social Support Score (USSS), was the sum of the differences between the perceived need of support and perceived receipt of support in all three dimensions. Subscores were defined for each of the three support dimensions. One hundred ninety women completed the 6-month Postpartum Support Questionnaire. Depression (p=0.018), unmarried status (p=0.049), and postpartum weight gain (p=0.003) were crude predictors for the overall USSS. After controlling for covariates, depression (p=0.009) and living with a spouse (p=0.040) were significant predictors for overall USSS. In adjusted analysis, depression remained a significant predictor for unmet emotional (p=0.035) and instrumental (p=0.001) social support. Certain psychosocial factors predict support inadequacy expectations among postpartum women. Targeting the factors related to unmet social support may be a helpful way to promote healthy behaviors among overweight postpartum women.

Postpartum Physical Activity in Overweight and Obese Women

Low physical activity (PA) during the postpartum period is associated with weight retention. While patterns of PA have been examined in normal weight women during this period, little is known about PA among overweight and obese women. The aim of this cross-sectional study was to investigate PA and determine the proportion of women meeting recommendations for PA. Women (n = 491), with a body mass index (BMI) ≥ 25 kg/m² were enrolled in a behavioral intervention. PA was assessed at six weeks postpartum using the Seven-Day PA Recall. Women averaged 923 ± 100 minutes/day of sedentary/ light and 33 ± 56 minutes/day of combined moderate, hard, and very hard daily activity. Women with a BMI ≥ 40 kg/m² reported more time in sedentary/light activities and less hours of sleep than those with a lower BMI. Only 34% met national PA guidelines; this proportion was significantly lower among blacks (OR 0.5, CI 0.3-0.9). These overweight and obese postpartum women reported a large percentage of time spent in sedentary/light activity, and a high proportion failed to meet minimal guidelines for PA. Promotion of PA in the postpartum period should focus on reducing sedentary behaviors and increasing moderate PA.

Multiparity is Associated With High Motivation to Change Diet Among Overweight and Obese Postpartum Women

Pregnancy is associated with weight gain and obesity. The aim of this study was to identify the effect of parity and other factors on motivation to change diet to lose weight in a cohort of overweight and obese postpartum women. Active Mothers Postpartum is a randomized, controlled trial aimed at postpartum weight reduction. At baseline, we measured motivation to change diet to lose weight among 491 overweight/obese postpartum women. Logistic regression was used to model the effect of parity on motivation to change diet at baseline while adjusting for potential confounders including age, race, education, body mass index category, and breastfeeding status. Approximately two thirds (68%) of participants were highly motivated to change their diet to lose weight. In the multivariable model, women with three or more children had 2.5 times the odds of high motivation compared with primigravid women, and women not breastfeeding had 1.6 times the odds of high motivation compared with any breastfeeding. Although risk for obesity is incurred starting with a woman's first pregnancy, women in this study were more motivated to change their diet to lose weight after their third pregnancy. Further research is needed to understand how to best capitalize on the high motivation in women with several children as well as how to improve motivation for primigravid women and women who are breastfeeding.