Reviewer ’s report  
 
Title: Perspectives of pregnant and postpartum women and obstetr ic providers to promote 
healthy lifestyle in pregnancy and after delivery: A qualitative in -depth interview study  
 
Version: 0 Date: 20 Aug 2019  
 
Reviewer: Sue Pullon  
 
Reviewer's report:  
 
Overall, this was a clearly written paper reporting on a study of considerable interest. However, 
it does need some revision to be suitable for publication.  
 
 
Background  
 
Is this study about weight gain management during pregnancy or lifestyle factors more 
generally? The background emphasizes and reports on literature about weight gain management, 
but via an interview structure which refers to 'lifestyle modifications' the participants themselves 
identify a far more nuanced approach to healthy lifestyles, with weight management being only 
one facet of a more complex health and social picture. The background needs to tell us more 
about what is already known in the internation al literature about behaviours and lifestyle 
modifications as a whole, and what evidence is already out there about what works, with less 
emphasis on weight management in isolation.    
 
 
Methods  
 
This needs to start with a clear explanation of, and justificat ion for, the methodology. For the 
journal's readership, who may be relatively unfamiliar with qualitative methodology, the 
PRECEDE -PROCEED framework needs better explanation as to what it entails and why it was 
considered an appropriate approach here.  
 
How  did the physician interviewer ensure diverse voices were heard in the interviews? What 
techniques were used to mitigate undue bias? What interviewing credentials did he/she bring to 
the interviews? And who was the other interviewer? Did they do all the in terviews with the 
women, or was there some other combination? Please provide more detail on these points - you 
mention researcher reflexivity as a limitation in the Discussion section - but give no detail here.  
 
 
Results  
 
The key themes are presented without any differentiation between the women and the providers. 
Surely this is important here, as the stated aim of the study is to inform programme development 
of behaviour change intervention - presumably mainly designed by one group (the health 
providers) but to be enacted by the other group (the women) ?  
 
Were similarities and differences between perceptions of the women, and the providers, 
considered in the earlier stages of the analysis? There may be good reasons for the eventual 
presentation, but more expla nation is required to justify this combined presentation, when more 
commonly, some health providers would hold views about so -called 'healthy behaviours' which 
would be likely at variance from those of the pregnant and postpartum women they care for.  
 
For e xample, quite apart from possible perceptions of differences in power and influence, the 
demographic characteristics of the women as a group and the health providers as a group indicate 
significant differences in both age and presumed ethnicity (based on t he 'race' attribute detail). 
Provide more detail as to how the stages of the analysis proceeded with respect of theme 
development, and how you arrived at the conclusion that these six wide ranging themes 
narrowed into 'weight related self -management' (as i n figure 1).  
 
 
Discussion  
 
There is a good discussion here about the multi factorial nature of self -care and the success or 
otherwise of lifestyle behaviours, with due attention paid to factors such as adequate sleep, 
particularly in the post -partum period . But much of the comparative literature cited is still 
focused heavily on weight management, with or without recognition of associated anxiety and 
stress and a range of other issues. Consider also including reference to studies which have a 
focus in more generic 'lifestyle modification', where weight management is not the focus.   
 
The concluding statement (our study explored…) more accurately reflects the results than the 
claims made in the abstract (themes… to manage weight and achieve health goals), but neither 
are particularly well supported by the results. Your results show a wide range of factors that may 
influence lifestyle health behaviours as a whole - whether these observations can be extrapolated 
to successful weight gain management per se is conj ecture.  
 
Abstract -Reads well and reflects the article, although as above the conclusion here makes more 
claim than the conclusion in the main text. The claims in the abstract conclusion need review, 
and will need further adjustment following text revisio ns.  
 
Style and presentation - Generally well written although needs editing for occasional 
typographical and grammatical errors.  
 
 
References  
 
Ref 4 - incomplete  
 
Reference 13 - this single reference to weight watchers does not support the statement that 
'commercially available weight loss programs universally exclude pregnant women  
Are the methods appropriate and w ell described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adeq uately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommend ed, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1.  Have you in the past five years received reimbursements, f ees, funding, or salary 
from an organisation that may in any way gain or lose financially from the 
publi cation of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publication of this manuscrip t, either now or in the 
future?  
 
3.  Do you hold or are you currently applying for any patents relating to the content 
of the  manuscript?  
 
4.  Have you received reimbursements, fees, funding, or salary from an organization 
that holds or has applied for patents relating to the content of the manuscript?  
 
5.  Do you have any other financial competing interests?  
 
6.  Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have  no com peting interests' 
below. If you r reply is yes to any, please give details below.  
 
I declare I have no competing interests  
 
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on my report to the authors and, if the manuscript is accepted for p ublication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
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which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
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