TELAAH ISSUE JURNAL

“Postpartum follow-up of women with preeclampsia:

facilitators and barriers-A qualitative study”

Disusun Untuk Memenuhi Tugas Kelompok Mata Kuliah

Qualitative Research and Issue in Midwifery

Dosen Pengampu
Dr. Finta Isti Kundarti, M.Keb

Anggota Kelompok
1. Dyah Ayu Zenedine D P17321245012
2. Nur Ainy Laily P17321245016
3. Desi Andrawati P17321245021

KEMENTERIAN KESEHATAN REPUBLIK INDONESIA

POLITEKNIK KESEHATAN KEMENKES MALANG
JURUSAN KEBIDANAN
PROGRAM STUDI SARJANA TERAPAN KEBIDANAN KEDIRI
TAHUN 2024
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 BMC Pregnancy and Childbirth
https://doi.org/10.1186/s12884-023-06146-8

RESEARCH

Postpartum follow-up of women

with preeclampsia: facilitators and barriers —
A qualitative study
Eirin Arntzen1†, Ranveig Jøsendal1†, Heidi Linn Sandsæter1,2 and Julie Horn1,2*

Abstract
Background Pregnancy causes physiological changes to the maternal organ systems that can be regarded as a car-
diometabolic stress test for women. Preeclampsia, a pregnancy complication characterized by new onset of hyperten-
sion in combination with proteinuria or end-organ dysfunction, affects approximately 2–8% of pregnancies. Adverse
pregnancy outcomes, including preeclampsia, have been described as a failed stress test and have been consistently
linked with increased risk of cardiovascular disease later in life. The postpartum period is therefore often regarded
as a window of opportunity for cardiovascular disease prevention. However, we lack knowledge about how women
with preeclampsia experience current postpartum care in the Norwegian health system. The aim of this qualitative
study is to uncover women’s perspectives and preferences regarding postpartum follow-up. Commented [NL1]: Background :
Methods Semi-structured telephone interviews were conducted with 17 women following a six-month lifestyle Preeclampsia merupakan gangguan hipertensi yang terjadi
intervention study. Participants were 9–20 months postpartum, following a pregnancy complicated by preeclampsia. selama kehamilan, memengaruhi sekitar 2-8% dari
kehamilan, dan meningkatkan risiko penyakit kardiovaskular
Data were analyzed using Malterud’s systematic text condensation.
(CVD) jangka panjang bagi ibu. Periode pascapersalinan
Results We identified five themes, each with 2–3 subthemes, that demonstrate how women with recent preeclamp- dianggap sebagai peluang untuk mencegah risiko ini melalui
sia experience postpartum follow-up: (1) fear and uncertainty (a body out of balance and facing an uncertain future), perawatan preventif dan perubahan gaya hidup. Namun,
(2) a conversation on lifestyle – not really that difficult (preeclampsia as a gateway, a respectful approach, and a desire masih kurang pemahaman mengenai bagaimana perempuan
for more constructive feedback), (3) when your own health is not a priority (a new everyday life, out of focus, and lack dengan riwayat preeklampsia di Norwegia merasakan
perawatan pascapersalinan.
of support), (4) motivation for lifestyle changes (an eye opener, lack of intrinsic motivation, and a helping hand),
and (5) lack of structured and organized follow-up (there should be a proper system, a one-sided follow-up care,
and individual variation in follow-up care).
Conclusions Findings from this study highlight the need for more systematic postpartum follow-up for women
after a pregnancy complicated by preeclampsia. Further research is required to explore the potential use of standard-
ized guidelines and routine invitations to postpartum care. Furthermore, exploring health care professionals’ experi-
ences is crucial to ensure their engagement in postpartum care after complicated pregnancies.
Keywords Cardiovascular disease prevention, Lifestyle change, Preeclampsia, Postpartum, Qualitative research

†
Eirin Arntzen and Ranveig Jøsendal joint first authorship.
*Correspondence:
Julie Horn
Julie.Horn@ntnu.no
Full list of author information is available at the end of the article

© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 2 of 11

Background developing short- and long-term cardiovascular sequelae.

Pregnancy causes physiological changes to the maternal A qualitative study in the US using data from the Preec-
organ systems that can be regarded as a cardiometabolic lampsia Foundation described how women called for
stress test for women [1]. Adverse pregnancy outcomes improved postpartum counseling and management after
have been described as a failed stress test and have been PE [17]. Furthermore, qualitative studies in Norway and
consistently linked with increased risk of cardiovascu- the Netherlands reported that women appreciated post-
lar disease (CVD) later in life [2, 3]. Preeclampsia (PE), a partum risk counseling and were motivated to make life-
hypertensive disorder of pregnancy characterized by new style changes [18, 19].
onset of hypertension in combination with proteinuria However, we lack knowledge about how women with
or end-organ dysfunction, affects approximately 2–8% PE experience current postpartum care in the Norwegian
of pregnancies [4, 5]. Beyond acute morbidity and mor- health system. Our aim is to explore the perspectives of
tality, PE is associated with a two-fold increased lifetime women with a history of PE participating in a lifestyle
risk of ischemic heart disease, stroke, and cardiovascular intervention study, their risk perception, interaction with
death, and a four-fold increased risk of subsequent heart their health care providers, and their knowledge and atti-
failure and hypertension [6]. The American Heart Asso- tudes regarding postpartum preventive care. A better
ciation considers PE to be a CVD risk factor compara- understanding of how women with complicated preg-
ble to smoking and diabetes mellitus that could unmask nancies experience their postpartum care may help to
early vascular or metabolic disease [7]. There is consist- improve the current postpartum management of PE and,
ent evidence that adherence to healthy lifestyle behaviors, in the longer run, to reduce the overall cardiovascular
including healthy diet, physical activity, alcohol modera- risk in women.
tion, and smoking cessation can optimize modifiable car-
diovascular risk factors and reduce the risk of CVD [8]. Methods
As part of routine postpartum care, it is usually rec- Study design
ommended that women have a check-up scheduled 6– This study has a qualitative design, which is appropri-
8 weeks after the birth [9]. International guidelines on ate when the purpose is to obtain insight and under-
postpartum follow-up of women with PE differ and there standing, such as when assessing personal experiences,
is no international consensus on whom to include, when understanding and interaction [20]. The research team Commented [NL2]: Methods :
to start or how to follow up [10, 11]. The most compre- consisted of two female medical students interested in Desain studi ini adalah kualitatif, yang sesuai ketika
hensive clinical guidelines for postpartum follow-up after the topic of women’s health but without previous expe- tujuannya adalah untuk memperoleh wawasan dan
PE recommend up to yearly blood pressure monitoring rience in postpartum care (EA and RJ), an experienced pemahaman, seperti saat menilai pengalaman pribadi,
and assessment of CVD risk factors [11]. Norwegian midwife and doctoral student (HLS) with broad theo- pemahaman, dan interaksi
national guidelines on postpartum follow-up after PE retical knowledge and practical experience in qualitative
recommend that women with PE should be informed of research, and an obstetrician (JH) with clinical experi-
the increased cardiovascular risk and receive subsequent ence in postpartum care, qualitative research experience
follow-up care with assessment of CVD risk factors [12]. and interest in the association of pregnancy complica-
However, postpartum risk counseling is often not routine tions and later maternal cardiovascular health.
among primary health care providers [13], and although The data used in this project were provided by ‘Mom’s
women with PE are more likely to attend the recom- Healthy Heart’ (MHH), a single arm lifestyle interven-
mended postpartum visit, the overall rates of follow-up tion study for women with recent PE or gestational dia-
are low [14]. betes [21]. This six-month lifestyle intervention program
In a scoping review from 2019, six out of seven studies included phone-based counseling by a registered dieti-
found that women had limited to no knowledge on the tian and access to the MHH website containing informa-
increased risk of future CVD following a hypertensive tion on a healthy diet, physical activity and motivation
pregnancy disorder [15]. The review revealed that even for lifestyle changes. MHH focused not primarily on
though the majority of health care providers were aware weight reduction but on increasing adherence with the
of the long-term risks and existing guidelines, follow-up Norwegian food-based dietary guidelines and physical
care was still inadequate [15]. Another study found that activity [22]. MHH collected data through questionnaires
women who were aware of the link between hyperten- and clinical measurements at baseline, and at three- and
sive disorders of pregnancy and CVD were significantly six-month follow-up study visits. Further, all participants
more likely to receive antihypertensive monitoring and were invited to a semi-structured telephone interview
treatment than their unaware peers [16]. This represents after completing the intervention program.
a substantial missed opportunity to provide postpartum Potentially eligible participants in the MHH study were
counseling, screening and treatment to women at risk of women aged 18 years or older with a recent pregnancy
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 3 of 11

complicated by PE and/or gestational diabetes result- Table 1 Participant demographics and pregnancy
ing in a live birth 3–12 months prior to recruitment at characteristics (n = 17)
Levanger Hospital or St. Olavs University Hospital, two Characteristics n (%)
hospitals in central Norway. Potential participants were
identified by the electronic patient administrative sys- Age (years)
tem of the two hospitals. For practical reasons, eligible < 30 9 (53)
women had to live at most two hours’ drive from one of 30–34 5 (29)
the two hospitals. Diagnoses of PE and gestational diabe- ≥ 35 3 (18)
Ethnicity
tes were validated according to international diagnostic
criteria based on their medical records [3, 6]. A diagno- Norwegian 15 (88)
sis of PE required de novo hypertension after 20 weeks of Other European 2 (12)
gestation in combination with proteinuria or with other Marital status
signs of organ dysfunction. Severe PE was characterized Married 3 (18)
by severe hypertension (blood pressure ≥ 160 mmHg sys- Cohabiting 14 (82)
tolic or ≥ 110 mmHg diastolic) or PE with signs of signifi- Education
cant end-organ dysfunction [12]. Secondary education 4 (24)
Participants were recruited by mail and interested Lower tertiary education (< 4 years) 6 (35)
women returned a signed consent form. After this, the Upper tertiary education (≥ 4 years) 7 (41)
last author (JH) or a registered dietitian contacted poten- Household income
tial participants by phone, explained the study, answered < 450,000 NOK 2 (12)
questions, and assessed exclusion criteria. These included 450,000 – 1,000,000 NOK 7 (41)
the inability to speak and read Norwegian, current preg- > 1,000,000 NOK 8 (47)
nancy, diagnosis of chronic hypertension, diabetes mel- Parity
litus or hypercholesterolemia, current use of medication Primiparous 15 (88)
to lower blood pressure or cholesterol, diagnosis of eat- Multiparous 2 (12)
ing disorder, heart disease, stroke, or kidney disease, and Gestational age
previous gastric bypass surgery. Forty-four women were < 37 weeks 8 (47)
included in the study, and forty (17 preeclampsia, 23 ges- ≥ 37 weeks 9 (53)
tational diabetes) completed the six-month intervention Time since delivery
program. < 12 months 3 (18)
≥ 12 months 14 (82)
Participants Severity of preeclampsia
Commented [nl3]: Participant :
Our study population comprised 17 women with a recent Moderate 8 (47)
Peserta dalam penelitian ini terdiri dari 17 wanita dengan
history of PE who had completed a 6-month postpartum Severe 9 (53) riwayat preeklampsia yang telah menyelesaikan intervensi
lifestyle intervention. They were 9–20 months postpar- Smokinga gaya hidup pascapersalinan selama 6 bulan
tum when participating in the semi-structured interview Never 13 (76) Mereka berpartisipasi dalam wawancara semi-terstruktur
Former 4 (24) antara 9 hingga 20 bulan setelah melahirkan
as a final assessment of the MHH study. Table 1 provides
Current 0 (0) Semua wanita yang berpartisipasi sudah menikah atau
information on demographic and pregnancy characteris- tinggal bersama pasangan, dan setengah dari peserta
tics. The participants varied in age, educational level and Body mass indexa mengalami preeklampsia berat dan kelahiran prematur
household income. The majority were Norwegian, two < 25 kg/m2 4 (24)
reported other European nationalities and most women 25- < 30 kg/m2 7 (41)
were primiparous. All women were married or cohabit- ≥ 30 kg/m2 6 (35)
ing. Half of the participants had experienced severe PE a At baseline after recruitment in MHH
and preterm birth.

MHH study and had short prior contact to some of the

Data collection
participants under the recruitment process to answer
Interviews were conducted by telephone by the last
questions about the study and assess exclusion criteria.
author (JH) and audiotaped between January and Octo-
Ranging from 15 to 70 min duration (average of 34 min),
ber 2021. Although more direct forms of communica-
the interviews were conducted individually (one-on-one)
tion would normally have been preferable, face-to-face
and followed a semi-structured format based on a prede-
interviews were not possible due to national COVID-19
fined interview guide (Additional file 1). The interview
restrictions, and some cases of women living remotely.
guide was developed specifically for MHH to explore the
The interviewer was the principal investigator of the
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 4 of 11

participants’ experiences with the intervention study as In the fourth step of the analysis, the data were re-con-
well as with their postpartum follow-up (apart from par- ceptualized, i.e., the pieces were put back together. Our
ticipation in MHH). Three researchers contributed to the end goal was to provide credible stories that could make
development of the interview guide based on their expe- a difference by elucidating the topic under study [20]. The
rience and prior literature: the last author (JH), a regis- condensates were converted into analytic texts by care-
tered dietitian with experience in postpartum lifestyle fully retaining the participants’ voices, while describing
counseling and a qualitative researcher with background all the content from an outsider’s point of view.
in intensive care nursing. Socio-demographic data were Consolidated criteria for reporting qualitative studies
collected using a questionnaire at baseline. (COREQ) 32-item checklist was used for reporting [23].
Women in the study were offered a choice of several
dates and times for the interview. They were reminded Ethics
that the interview was voluntary, informed about privacy Ethical approval for the Mom’s Healthy Heart study,
protection, and told that they could skip any question. In including this qualitative study, was obtained from
the interview, they were asked to detail their experiences the Central Norway Regional Committee for Medical
of interaction with different health care providers dur- Research Ethics (REK Central, 2018/1803). All partici-
ing their postpartum follow-up. Further, the interviewers pants provided written informed consent prior to inclu-
explored their perceptions of their CVD risk, postpartum sion. In addition, verbal consent to audio record the
screening and preventive care. conversation was obtained before each interview. Tran-
scripts were anonymized using pseudonyms.

Data analysis
Results
Malterud’s systematic text condensation, a four-step anal-
We identified five themes, each with 2–3 subthemes,
ysis method based on a thematic understanding [20], was
that described how participants with recent PE experi-
used in the data analysis. Systematic text condensation
ence postpartum follow-up: (1) fear and uncertainty,
is inspired by Giorgi’s phenomenological approach and
(2) a conversation on lifestyle – not really that difficult,
aims for meaning and content of data across cases [20].
(3) when your own health is not a priority, (4) motiva-
First, the interviews were transcribed verbatim. Tran-
tion for lifestyle changes, and (5) lack of structured and
scripts were then read several times by the first authors
(EA and RJ) simultaneously, who made reflective notes
organized follow-up. Commented [nl4]: Temuan dan Tema:
to become familiar with the data and explore preliminary 1. fear and uncertainty (Ketakutan dan Ketidakpastian)
Fear and uncertainty 2. a conversation on lifestyle (Diskusi Gaya Hidup)
themes associated with the participants’ experiences of
A body out of balance 3. when your own health is not a priority (Kesehatan Diri
postpartum follow-up [20]. bukan Prioritas)
Most participants in this study were unprepared for the
Step two involved developing preliminary code groups 4. motivation for lifestyle changes, (Motivasi untuk
challenges that awaited them after a pregnancy compli-
with underlying subgroups. Corresponding meaning units Perubahan Gaya Hidup)
cated by PE. A few women wondered why they in par- 5. Lack of structured and organized follow-up. (Kurangnya
were further sorted into these code groups. The research
ticular developed this complication. They had no history Tindak Lanjut yang Terstruktur )
group resolved discrepancies found in step one through
of health problems and associated hypertensive disorders
reflective discussion until consensus was reached. By
with older people. Some participants even began to won-
identifying and sorting meaning units that were poten-
tially related to our new themes, we worked our way
der if they were to blame for getting PE. Furthermore, Commented [nl5]: 1.Fear and Uncertainly
they explained that it was difficult to process information Peserta merasa tidak siap menghadapi tantangan setelah
through the coding. The codes were developed continu-
on risk factors and causes of PE given to them by health mengalami preeklampsia (PE) dan kesulitan dalam
ously as the analysis led to ideas and suggestions [20]. memproses informasi tentang kondisi mereka sambil
professionals. It was challenging to process any input
In step three, the empirical data were reduced to a decon- mengelola peran sebagai ibu baru. Mereka mengungkapkan
while trying to recover from a complicated pregnancy
textualized selection of meaning units sorted as thematic perasaan diabaikan dan ketidakpastian mengenai kesehatan
and simultaneously being responsible for a newborn
code groups across individual participants [20]. Con- masa depan mereka
baby. One participant summed up her thoughts well: Banyak peserta merasa cemas tentang bagaimana PE dapat
densates were created from the meaning units to form a
coherent text that embodied the content of the interviews. “I don’t think you can absorb that information until mempengaruhi kesehatan mereka di masa depan dan
bertanya-tanya tentang implikasi dari kondisi tersebut.
The analysis process was iterative, and we made an ongo- you’re ready for it. And I don’t think you’re ready Beberapa dari mereka mencari klarifikasi dari profesional
ing effort to capture information that had previously been until you’ve given birth, recovered from preeclamp- kesehatan tetapi tidak mendapatkan jawaban yang
missed as the code groups evolved. Although data satura- sia, and some time has passed. Because you’re in membantu, yang menyebabkan perasaan ditolak saat
tion was evident around interview number 12, we decided quite a state of shock afterwards. I was at least. I mencoba mencari dukungan
to continue to explore data as planned from all 17 partici- was shocked at how things could go so fast and so
pants to ensure that no new codes or themes were identified. wrong.” (Participant 10)
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 5 of 11

Several participants emphasized that external stress regardless of whether they felt they had a healthy life-
and hormonal changes contributed to their overall strain. style or were dissatisfied with it and wanted a change. A
They also pointed out how their needs for support and national checklist of topics that should be included in a
reassurance were often met by family members or part- conversation on lifestyle was suggested. One of the par-
ners, not by health professionals as some had expected to ticipants put it this way:
a greater extent.
“It should be mandatory. Just as natural as taking your
baby to the health center, it should be a natural part
Facing an uncertain future of becoming a mother with the challenges that obesity
Many participants were anxious about how PE might presents. Rat way, you would also be prepared for that
impact their future health. They wondered what the conversation, and perhaps it would be easier to talk
condition implied and what awaited them in the future. about lifestyle with health care staff”. (Participant 6)
A few sought clarification from health care profession-
On the other hand, some participants pointed out that
als without receiving any helpful answers. The hospital
they did not have a weight problem and therefore did not
never confirmed that they in fact had suffered from PE.
need a conversation on lifestyle. One participant stated
A number of participants were hospitalized for several
that it would be more natural to discuss lifestyle and
days, some even for weeks. Despite this, there was lit-
health if it was a mandatory topic of conversation after
tle talk of what had happened. Some of the participants
PE. PE as a gateway to talking about lifestyle changes
were rebuffed when they tried to reach out to health care
could perhaps make it a more accessible topic.
professionals.
In different ways, many participants expressed a feel-
ing of neglect. One participant recalled thinking: “I did A respectful approach Commented [nl7]: Pendekatan yang Respectful
not feel prioritized. I was just lying there in uncertainty.” Many participants emphasized how a respectful approach Banyak peserta menginginkan umpan balik yang lebih
(Participant 11). was important for them to feel that lifestyle counselling by membangun dalam diskusi gaya hidup, yang harus
The feeling of abandonment persisted even after their healthcare provider was constructive. An open and mencakup lebih dari sekadar saran untuk mengubah pola
friendly dialog was highlighted by several participants as makan dan meningkatkan aktivitas fisik.
discharge from hospital. Some stated that they would Sementara peserta health provider menganggap diskusi
never get pregnant again without having their own more crucial to their experience of the conversation than
tentang diet dan berat badan adalah hal yang sensitif
blood pressure monitor. Others mentioned how they the content or topic itself. One participant emphasized that sehingga mudah menyinggung perasaan pasien
used Google to learn about their need for blood thin- health care professionals should have an objective, advisory Tujuan dari percakapan tersebut seharusnya untuk
ners in any future pregnancies. Some still wondered role. After all, they already talked to their patients about mengkomunikasikan fakta dan pengetahuan kepada wanita
what might happen if they developed high blood pres- other serious and sensitive topics. Lifestyle counseling
sure again. A common perception among these new should not be an exception. Several participants clearly
mothers was that their concerns were not taken seri- had different emotions related to weight and lifestyle. One
ously and properly followed up. Some participants participant put it this way: “I think it’s difficult and sad that
expressed concern that health care professionals with- I didn’t succeed. I’m not proud of myself and I wish things
held information about the causes and consequences were different. But it’s still okay to talk about it. I won’t be
of PE. “I was upset that no one had a conversation with down in the dumps because of that”. (Participant 6).
me to explain what it really means and why I got preec- Several approaches that could help maintain the wom-
lampsia while other people don’t get it. And also what en’s self-esteem during such a dialog were presented. A
the consequences would be.” (Participant 14). common suggestion was to start with open and neutral
The participants had varying previous health knowl- questions to invite women to present their subjective
edge, personal coping resources and social support to understanding of their lifestyle. Their desire and will-
help them get through their ordeal. Afterwards, they gave ingness to change could then be identified. The partici-
much of the credit for how things turned out well to their pants emphasized how self-awareness and willingness to
own resilience and their strong family support. change were crucial to utilize the help offered by health
care professionals. One of them suggested the following:

A conversation on lifestyle – not really that difficult “Ask her carefully what she thinks of her lifestyle. Commented [nl6]: 2. Conversation on Lifestyle
Preeclampsia as a gateway Is it anything she would like to change? And is she PE sebagai alasan :
Several participants argued that lifestyle counsel- aware that it can affect this or that? But my opinion Karena adanya PE para partisipan menganggap konseling
ling should be mandatory after PE. Some participants is that if someone has a musculoskeletal injury due postpartum wajib dilakukan mengingat banyak hal yang
believed that fear of offending patients was a common to obesity, you have to be a bit direct as well. Only jarang diketahui mengenai do & don’ts postpartum terlebih
then might she be able to think, ‘Hey, now I gotta do tentang diet, dan penanganan obesitas,
barrier for health care professionals when addressing
weight and lifestyle. The participants shared this view something’.” (Participant 13)
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 6 of 11

A desire for more constructive feedback participants found it natural to focus strongly on the Commented [nl8]: A desire for more constructive
Many longed for a more fruitful lifestyle conversation. baby, but later realized that things should have been feedback
They emphasized that it had to include more than just different: beberapa peserta meminta feedback yang lebih dari sekedar
advice to change one’s diet and increase one’s physical perbaikan gizi maupun perbaikan aktifitas, mereka
activity. The purpose of the conversation should be to “So there wasn’t much information and attention menginginkan Fakta dan pengetahuan yang terjadi pada diri
communicate facts and knowledge to the women. “Health for me, and the fact that I’d had a major operation mereka
care professionals have a responsibility to raise people’s (...). Of course I think it was good to focus a lot on the Peserta mengatakan bahwa konseling seharusnya berisi
baby, but it would have been nice to get some infor- motivasi bukannya membuat mereka semakin takut dan
awareness about lifestyle and so on (…) I just don’t under- down
mation about my health and my body and my reac-
stand why they don’t bring it up.” (Participant 16).
tion after that kind of experience.” (Participant 13)
Several participants also wanted advice on how to
organize exercise and on what a healthy diet consists By the time the interview took place, a few months
of. Most of them understood that the aim of a lifestyle after the baby was born, the majority of the participants
conversation was to help and motivate them, rather had come to the conclusion that they themselves needed
than to make them feel guilty. As long as a respectful more care following discharge. There were regular check-
approach was adopted, several participants wanted a ups at the health center for the baby, but few or no check-
more direct and honest way of communication. They ups for the mother. One participant pointed out that the
also called for specific advice and long-term follow-up. appointments at the health center were for the baby, not
One participant said: the mother, which made it difficult to ask questions about
her own health. She was left with many unanswered
“I would have appreciated a conversation on life-
questions, as she had not seen a midwife or physician
style, but it would have to be more constructive than
again since discharge.
just instructions to exercise and eat healthy food (...).
Re fact that we have a weight problem comes as no
surprise to us who struggle with overweight. Maybe
Lack of support Commented [nl10]: Lack of support
we should think that we’re not afraid of that conver-
The interviews revealed that the participants’ partner, Banyak peserta merasa bahwa pasangan, anggota keluarga,
sation, but not just to hear that we’re fat, but to be
family members and colleagues were not always sup- dan rekan kerja mereka tidak selalu mendukung perjalanan
told about the help that’s available.” (Participant 4)
portive of their journey towards recovery and better mereka menuju pemulihan dan kesehatan yang lebih baik.
health, and how the participant and the others involved Mereka sering kali merasa memiliki tanggung jawab yang
were often not fully aware of this. Many participants felt besar terhadap rumah tangga, yang menyita banyak waktu
When your own health is not a priority mereka
an overriding responsibility for their household, which Beberapa peserta mengungkapkan bahwa jika mereka
Participants described several external barriers to health
occupied much of their time. Some said that if they pri- memprioritaskan diet sehat dan menolak makanan manis
promotion specific to early parenthood.
oritized a healthy diet and refused cake during family saat kunjungan keluarga, mereka dianggap sebagai orang
visits, they were viewed as obstinate. A few told stories yang keras kepala. Hal ini menunjukkan kurangnya
of how their partners could be very supportive in their dukungan dari lingkungan sekitar mereka dalam upaya
A new everyday life menjaga kesehatan
words, but rarely in their actions, in terms of letting the
Most participants found that their daily lives changed
participant get more “me-time”. When there were short- Commented [nl9]: When your own health is not a
after giving birth. They had less time and energy to
ages of staff at work, many felt pressured to work over- priority
pursue a healthy lifestyle. Many fell back into old hab-
time. “Maybe I don’t prioritize myself because I get such a 1.Berapa peserta mengatakan kesulitan dalam menjalani
its despite a strong desire to care for themselves and lifestyle yang sehat, mereka merasa kurang energi dan
make healthy lifestyle choices. One of the participants guilty conscience if I do.” (Participant 6).
waktu dan akhirnya kembali ke kebiasaan lama.
explained it all very succinctly: “It’s my everyday life that External pressure from several sources surrounding the
2.Salah Fokus terhadap perhatian : beberapa peserta karena
challenges what was supposed to be my healthy lifestyle.” new mothers resulted in a guilty conscience if they pri- sibuknya aktifitas ibu baru, mereka sampai lupa untuk
(Participant 5). oritized themselves and their own health over their chil- mengurus diri, beberapa responden tidak mengetahui
According to these participants, a busy life was often dren, partner, family, and work. kapan mereka harus follow ups / medical cek. Mereka
mengatakan kurangnya informasi mengenai follow ups
what prevented them from making lifestyle changes after mereka, mereka mengira follow ups hanya untuk bayi.
PE. At times they found it difficult to get enough sleep.
Caring for their baby came first, which, coupled with Motivation for lifestyle changes
studies or a full-time job, compromised any plans to Although many participants experienced PE as a wake-up
improve their health. call for health promotion, they described social support Commented [nl11]: Motivation for lifestyle changes
as a critical factor in enhancing their intrinsic motivation. Setelah mereka mengalami PE mereka menjadi tertarik
untuk melakukan perubahan gaya hidup dengan dukungan
Out of focus
An eye‑opener beberapa faktor untuk menyemangati lifestyle change
Just like any other new mother, the participants focused mereka
on the newborn baby during the postnatal period. Having experienced PE was a wake-up call for many of
Beberapa responden yang mengetahui efek jangka panjang
Several stated that this also applied to the staff. Many the participants for how they perceived their health. PE akan bersemangat merubah lifestyle mereka, sementara
yang tidak mengetahuinya menyayangkan kenapa tidak ada
yg memberitahu mereka
Kurangnya motivasi internal dan dukungan eksternal
menjadi penghalang untuk mempertahankan perubahan gaya
hidup
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 7 of 11

After bringing a new life into the world, they also empha- their partner to be involved in any initiative, as they
sized the long-term perspective on their health. Many felt alone in their desire to make healthy choices. “After
expressed fear of the long-term consequences of PE and all, my partner and I eat the same food and go for walks
of getting PE in their next pregnancy. This often resulted together. It would be easier if we were both making healthy
in a strong desire to take preventive measures. “Rere’s a choices.” (Participant 9).
lot of heart disease in my family. Rat’s a trigger to start Several participants felt that lifestyle change was mainly
with, and now getting preeclampsia too, so … now some- about finding the will to change and being aware of vari-
thing has to change. Now I have to start taking care of ous choices related to food or activities. Some already
myself.” (Participant 10). had an interest in health and exercise and felt that their
Several participants reported having received no infor- lifestyle was healthy. However, despite many attempts,
mation about long-term consequences or the association others had been unable to make changes on their own.
between PE and lifestyle. They therefore lacked knowl- One participant said: “I’ve been trying for 10 or 15 years to
edge of how to take preventive measures. Most wanted to figure out what to do, but I still haven’t found the miracle
receive information about the risks and long-term con- cure to get a healthier life. What I find difficult is how to
sequences after the postnatal period, while the dramatic get there.” (Participant 3).
experience was still fresh in their minds.
“Right after the birth is a bit early, but the six- Lack of structured and organized follow‑up Commented [nl12]: Lack of structured and organized
week check-up would have been a good time for There should be a proper system follow‑up
me. It’s okay to address it while you’re still a bit Many participants reported feeling well cared for when Banyak peserta merasa bahwa mereka mendapatkan
admitted to hospital, but found that things changed fol- perawatan yang baik saat dirawat di rumah sakit, tetapi
affected by it, you shouldn’t wait too long. I think situasi berubah setelah mereka keluar. Mereka menganggap
the information should be given early, especially if lowing discharge. They perceived follow-up care after PE
perawatan lanjutan setelah preeklampsia (PE) tidak
you want to change your diet and start being more as completely or partially inadequate. Those who consid-
memadai, baik secara keseluruhan maupun sebagian.
active.” (Participant 4) ered themselves resourceful had contacted health pro- Beberapa peserta yang tahu dapat menghubungi profesional
fessionals themselves in order to initiate follow-up care. kesehatan sendiri untuk memulai perawatan lanjutan, dan
They worried about what happened to the women who mereka khawatir tentang wanita lain yang tidak mencari
Lack of intrinsic motivation did not seek help on their own. “Rings at the hospital bantuan secara proaktif.
were great. Afterwards there was absolutely nothing.” (Par- Peserta menganggap bahwa seharusnya ada program yang
In order to achieve their goals for exercise and diet, sev- lebih baik untuk memastikan tidak ada yang diabaikan
eral participants sought external support. Some even ticipant 1).
sistem kesehatan, seperti program pengingat untuk
wanted others to be strict and tell them what to do. That Several participants reflected on what could have been pemeriksaan serviks.
would have made them accountable for their progress or done differently to ensure that no one was neglected by
lack of it. Others wanted a setting where they could learn the health care system. One participant made the fol-
about nutrition and physical activity. “I want more knowl- lowing statement: “Re follow-up should have been like
edge about nutrition, it’s easy to be overwhelmed if you the cervical screening program, where you get a reminder.
start on your own.” (Participant 13). Rere should a proper system.” (Participant 13).
Some participants had previous experience of diet-
ing and admitted that quick results were crucial for their A one‑sided focus in follow‑up care
motivation. Others pointed out how the weather and Each participant had a personal story about her post-
time played a major role in whether they prioritized exer- pregnancy follow-up experience. The follow-up care they
cise and diet. Some were motivated by partner involve- received had varied considerably. Some felt lucky to have
ment, while others found it demotivating that their had a good conversation about the birth, future contra-
partner was in better physical condition than they were ception and blood pressure monitoring for the next year.
themselves. Others had not even been to their physician for a post-
natal check-up. Most of the participants knew that a six-
week check-up existed, but were not sure about whether
A helping hand or not they actually had attended one. The majority had
Support from others was seen as a crucial factor for their blood pressure checked during a consultation, but
maintaining lifestyle changes. Several participants found this was not followed up for most of them. Some had
it helpful to talk to others about diet and exercise, both their abdomen checked, while others were only asked if
professionals and women with similar experiences. Many everything was fine. Thus, their experiences of follow-up
strongly emphasized the value of having someone to sup- care or the lack of it varied considerably.
port and motivate them. In that context, several men- Three participants told us what they felt was miss-
tioned how they missed an organized lifestyle initiative ing: “My doctor checked my blood pressure, but he
targeting women who had had PE. Some also wanted never brought up anything else. Nothing about my
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 8 of 11

preeclampsia or anything else about the birth.” (Partici- health behavior changes in the postpartum period [24].
pant 16), “Re only thing my doctor told me was infor- The women in our study likewise described a contrast
mation from my hospital discharge letter. Nothing about between close antenatal monitoring and little contact
diet or exercising.” (Participant 13) and “My doctor forgot with health care providers postpartum. Although both
about what’s supposed to be basic blood tests after preg- antenatal and postpartum care in Norway are mainly pro-
nancy.” (Participant 10). vided by midwives and physicians in primary health care,
After a challenging pregnancy complicated by PE, these sub-optimal interprofessional collaboration and a lack of
participants missed a more nuanced first consultation knowledge of the association between PE and CVD may
after giving birth, preferably with more focus on lifestyle affect the transition of care [25]. One potential reason for
changes and their future health. fragmentation in Norwegian primary health care is the
role distribution, where antenatal care is commonly pro-
vided by midwives, while primary care physicians mostly
Individual variation in follow‑up care deliver postpartum follow-up care. Other researchers Commented [nl13]: Individual variation in follow‑up
Despite the broad consensus among participants about have found poor knowledge of the link between PE and care
various inadequacies in their follow-up, some of the cardiovascular risk among health care providers, espe- 1.Setiap peserta memiliki cerita pribadi tentang
participants were very positive about the care they had pengalaman follow-up pasca kehamilan mereka, dengan
cially internists and primary care physicians [24, 26]. perawatan yang diterima bervariasi secara signifikan.
received. Some participants felt very cared for and seen They suggested that this might be attributed to the low
by their primary care physician, as the physician had 2.Beberapa merasa beruntung mendapatkan percakapan
prevalence setting of primary care [24]. yang baik mengenai kelahiran, kontrasepsi di masa depan,
addressed their hypertension and continued to moni- In line with previous studies, our findings suggest that a dan pemantauan tekanan darah, sementara yang lain tidak
tor it for a long time. In addition, they spoke of good pernah melakukan pemeriksaan post-natal.
routine invitation to postpartum follow-up, similar to the
conversations about how their birth had actually been. 3.Sebagian besar peserta mengetahui adanya pemeriksaan
invitation to cervical cancer screenings, could encour-
Others told stories of proactive midwives who were enam minggu, tetapi tidak yakin apakah mereka benar-
age participation of women with recent pregnancy com-
the ones who discovered how these participants were benar menghadirinya. Meskipun mayoritas peserta
plications [25, 27]. Furthermore, discharge information memiliki tekanan darah yang diperiksa selama konsultasi,
severely ill after discharge from hospital and quickly
written for women with PE discharged from maternity tidak ada tindak lanjut yang dilakukan untuk kebanyakan
referred them directly to the hospital or their physician.
wards could improve their understanding of their medi- dari mereka.
“I also had a conversation at the hospital. One of those cal condition and their ability to ask questions and make 4.Beberapa peserta merasa bahwa konsultasi pertama
debriefings. And that was a very nice conversation where informed choices regarding their postpartum health care. setelah melahirkan kurang mendalam, dengan kurangnya
I got to ask about everything I was wondering about. And Despite existing guidelines for postpartum follow-
pembahasan tentang preeklampsia, diet, atau olahraga.
how to go about things if we want more children in the Mereka menginginkan konsultasi yang lebih terfokus pada
up after PE, women in our study often found postpar- perubahan gaya hidup dan kesehatan masa depan mereka
future.” (Participant 17). tum care to be inconsistent and unsystematic. This is in setelah mengalami kehamilan yang sulit akibat PE.
When the participants were asked directly about whom
accordance with previous studies from Germany, the US,
they would have preferred to be in charge of their follow-
and India, which indicated suboptimal adherence to clini-
up care, their answers varied. The majority said either
cal guidelines for postpartum follow-up after PE [28–30].
their primary care physician or a midwife, while a few
Simplified checklists for postpartum care providers, such
participants considered a specialist in obstetrics or gyne-
as those developed by Morgan et al. [31], could provide
cology to be more suitable. However, the participants’
the structure which is lacking today. It is recommended
main point was that someone should take responsibility
that lifestyle and CVD should be addressed as part of the
for follow-up care. “Either the midwife or the doctor could postpartum follow-up, as PE is considered a manifesta-
do the follow-up, but one of them should have the main tion of cardiovascular vulnerability [13, 32]. However, as
responsibility, so they know who’s actually doing it.” (Par- Commented [nl14]: Discussion
in previous studies, we found that even motivated women
ticipant 4). 1.Peserta memiliki pengalaman yang bervariasi terkait
did not receive advice about lifestyle change during post- perawatan lanjutan pasca kehamilan, dengan beberapa
partum visits [24, 33, 34]. Both the women and the health merasa beruntung mendapatkan percakapan yang baik
Discussion care professionals might find this conversation challeng- mengenai kelahiran dan pemantauan kesehatan, sementara
ing, and including lifestyle advice in routine postpartum yang lain tidak mendapatkan pemeriksaan pasca-natal
This qualitative study identified multiple factors that can
care could help to reduce these barriers in the long run sama sekali. Hal ini menunjukkan adanya kebutuhan
impact postpartum follow-up of women with PE. Lack untuk sistem perawatan lanjutan yang lebih terstruktur dan
of knowledge on the association between PE and future [35–37]. The lack of intrinsic motivation for lifestyle
konsisten setelah kehamilan yang rumit, seperti
CVD risk, poor transition from obstetric to primary care, changes that the participants in our study described sug- preeklampsia (PE)
inconsistency of follow-up, and a lack of support for life- gest that the use of counseling strategies such as moti- 2.Banyak peserta merasa bahwa konseling gaya hidup
style changes are factors contributing to missed opportu- vational interviewing might be important to support seharusnya menjadi bagian yang wajib setelah mengalami
nities for CVD prevention. individuals to implement healthy lifestyle changes [38]. PE, dan mereka menginginkan pendekatan yang lebih
Similar to previous work on lifestyle behavior interven- konstruktif dan mendukung dari penyedia layanan
Prior research on postpartum care after PE has sug- kesehatan. Mereka menekankan pentingnya komunikasi
gested a fragmented health care system and poor obstet- tion adherence in adult populations in general [39], our
yang terbuka dan jujur, serta dukungan dalam membuat
ric-primary care transition as barriers to the initiation of study highlights the importance of social support for perubahan gaya hidup yang positif
3.Peserta juga mencatat bahwa perawatan lanjutan yang
lebih baik dapat membantu mengurangi kekhawatiran
tentang kesehatan jangka panjang mereka, terutama terkait
dengan risiko penyakit kardiovaskular setelah mengalami
komplikasi kehamilan
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 9 of 11

behavior change. This may be especially important for healthcare [3]. Further research is required to explore
women after adverse pregnancy outcomes given the the potential use of standardized guidelines and routine
additional challenges in early parenthood. invitations to postpartum care. Furthermore, explor-
In our study, neither the women themselves nor their ing health care professionals’ experiences is crucial to
health care providers focused on maternal health post- ensure their engagement in postpartum care following
partum. As maternal lifestyle is strongly associated with complicated pregnancies.
the risk of obesity in offspring [40, 41], this represents a
wasted opportunity not only to improve maternal health
Abbreviations
but also to interrupt a generational downward spiral. We CVD Cardiovascular disease
therefore agree with other researchers who have sug- MHH Mom’s Healthy Heart
gested that lifestyle interventions postpartum should take PE Preeclampsia

a family-focused approach due to the crucial role of part-

ner and family support for lifestyle changes [42, 43]. Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12884-023-06146-8.
Study strengths and limitations
To enhance validity, the research process is clearly Additional file 1.
described and the study findings are illustrated with orig-
inal quotes. Most study participants were born and raised
Acknowledgements
in Norway and reported a high income and educational We would like to thank the women who participated in the interviews, shared
level. However, our sample showed variation in socio- their thoughts and experiences, and provided rich descriptions and examples
economic status, place of residence, parity, and sever- of antenatal and postpartum care. We would like to express our sincere
gratitude to Hege Selnes Haugdahl for providing guidance throughout the
ity of PE. It is important to note that participants were research process.
recruited from an intervention study for women with
recent PE and had completed a lifestyle intervention pro- Authors’ contributions
JH designed the study, conducted the interviews and supervised the analysis.
gram. Standard postpartum care in Norway includes a EA and RJ analyzed the data, while EA, RJ, JH and HLS contributed to the inter -
postpartum contact with a midwife or primary care pro- pretation of the data. EA and RJ drafted the manuscript, and all the authors
vider 6–8 weeks after delivery. Participants entered the critically revised the manuscript and approved the final version.
intervention study 3–12 months after delivery and study Funding
participation is unlikely to have altered their standard Open access funding provided by Norwegian University of Science and
postpartum care. However, participants were probably Technology This study was supported by the Faculty of Medicine and Health
Sciences, Norwegian University of Science and Technology, NTNU. HLS and
more motivated for lifestyle changes than women with JH were supported by the Liaison Committee for Education, Research and
recent PE in general and their views on postpartum care Innovation in Central Norway. The funding sources had no role in study
may therefore differ from those of other women with a design, data collection and analysis, decision to publish, or preparation of the
manuscript.
history of PE. Although the use of telephone interviews
instead of face-to-face interviews resulted in a lack of Availability of data and materials
non-verbal communication, conducting phone inter- The interviews transcribed for the present study are not publicly available due
to individual privacy considerations. All data requests should be submitted
views provided greater flexibility for participants and to the corresponding author for consideration. Access to anonymized data
may also have reduced visual biases and socially desirable may be granted upon reasonable request, subject to approval by the Central
responses [44]. There was a strong commitment from the Norway Regional Committee for Medical and Health Research Ethics.
research group to maintain reflective notes and regularly
discuss data analysis and interpretation to limit personal Declarations
biases. However, the research group has a strong back- Ethics approval and consent to participate
ground in obstetrics and the inclusion of primary health The study was approved by the Central Norway Regional Committee for
care researchers may have enabled us to view the partici- Medical and Health Ethics (REK Central) in 2018 (2018/1803). All participants
provided written informed consent. All methods were performed in accord-
pants’ experiences within a broader perspective. ance with the relevant guidelines and regulations.

Conclusions Consent for publication

Not applicable.
Findings from this study highlight the need for more
systematic postpartum follow-up care for women after Competing interests
a pregnancy complicated by PE. Women with other The authors declare no competing interests.
adverse pregnancy outcomes associated with increased Author details
risk for cardiovascular disease would presumably also 1
Department of Public Health and Nursing, Faculty of Medicine and Health
benefit from a greater focus on preventive postpartum Sciences, Norwegian University of Science and Technology, Postbox 8905,
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 10 of 11

NO-7491 Trondheim, Norway. 2Department of Obstetrics and Gynecology, cardiovascular and metabolic risk: a focus-group study. Hypertens
Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway. Pregnancy. 2012;31(1):147–55.
19. Sandsæter HL, Horn J, Rich-Edwards JW, Haugdahl HS. Preeclampsia,
Received: 25 July 2023 Accepted: 20 November 2023 gestational diabetes and later risk of cardiovascular disease: Women’s
experiences and motivation for lifestyle changes explored in focus group
interviews. BMC Pregnancy Childbirth. 2019;19(1):448.
20. Malterud K. Systematic text condensation: a strategy for qualitative analy-
sis. Scand J Public Health. 2012;40(8):795–805.
References 21. Horn J, Kolberg M, Rangul V, Magnussen EB, Åsvold BO, Henriksen HB,
1. Seely EW, Celi AC, Chausmer J, Graves C, Kilpatrick S, Nicklas JM, et al. Car- et al. Feasibility of a postpartum web- and phone-based lifestyle program
diovascular health after preeclampsia: patient and provider perspective. J for women with a history of preeclampsia or gestational diabetes: a pilot
Womens Health. 2021;30(3):305–13. intervention study. Womens Health Rep. 2023;4(1):345–57.
2. Rich-Edwards JW. The womb and the heart: more connected than we 22. Nasjonalt råd for ernæring. Kostråd for å Fremme Folkehelsen og Fore-
knew. J Am Coll Cardiol. 2019;74(22):2755–7. bygge Kroniske Sykdommer: Metodologi og Vitenskapelig Kunnskapsg-
3. Okoth K, Chandan JS, Marshall T, Thangaratinam S, Thomas GN, Niran- runnlag. Oslo: The Norwegian Directorate of Health; 2011.
tharakumar K, et al. Association between the reproductive health of 23. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative
young women and cardiovascular disease in later life: umbrella review. research (COREQ): a 32-item checklist for interviews and focus groups. Int
BMJ. 2020;371:m3502. J Qual Health Care. 2007;19(6):349–57.
4. Abalos E, Cuesta C, Grosso AL, Chou D, Say L. Global and regional esti - 24. Dijkhuis TE, Bloem F, Kusters LA, Roos SM, Gordijn SJ, Holvast F,
mates of preeclampsia and eclampsia: a systematic review. Eur J Obstet et al. Investigating the current knowledge and needs concerning a
Gynecol Reprod Biol. 2013;170(1):1–7. follow-up for long-term cardiovascular risks in Dutch women with a
5. Klungsoyr K, Morken NH, Irgens L, Vollset SE, Skjaerven R. Secular trends preeclampsia history: a qualitative study. BMC Pregnancy Childbirth.
in the epidemiology of pre-eclampsia throughout 40 years in Norway: 2020;20(1):1–10.
prevalence, risk factors and perinatal survival. Paediatr Perinat Epidemiol. 25. Roth H, Morcos V, Roberts LM, Hanley L, Homer CS, Henry A. Preferences
2012;26(3):190–8. of Australian healthcare providers regarding education on long-term
6. Maas AH, Rosano G, Cifkova R, Chieffo A, van Dijken D, Hamoda H, et al. health after hypertensive disorders of pregnancy: a qualitative study. BMJ
Cardiovascular health after menopause transition, pregnancy disor- Open. 2022;12(5):e055674.
ders, and other gynaecologic conditions: a consensus document from 26. Young B, Hacker MR, Rana S. Physicians’ knowledge of future vas-
European cardiologists, gynaecologists, and endocrinologists. Eur Heart J. cular disease in women with preeclampsia. Hypertens Pregnancy.
2021;42(10):967–84. 2012;31(1):50–8.
7. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, 27. Nielsen JH, Melendez-Torres G, Rotevatn TA, Peven K, Fonager K, Over-
et al. Effectiveness-based guidelines for the prevention of cardiovascular gaard C. How do reminder systems in follow-up screening for women
disease in women–2011 update: a guideline from the American Heart with previous gestational diabetes work?-a realist review. BMC Health
Association. J Am Coll Cardiol. 2011;57(12):1404–23. Serv Res. 2021;21(1):535.
8. Barbaresko J, Rienks J, Nöthlings U. Lifestyle indices and cardiovascular 28. Scholz AS, Hassdenteufel K, Gutsfeld R, Müller M, Goetz M, Bauer A, et al.
disease risk: a meta-analysis. Am J Prev Med. 2018;55(4):555–64. Observational database study on preeclampsia and postpartum medical
9. UNICEF. Pregnancy, childbirth, postpartum and newborn care: a guide for care up to 7.5 years after birth. Sci Rep. 2022;12(1):21230.
essential practice. 2015. 184. 29. Nagraj S, Hinton L, Praveen D, Kennedy S, Norton R, Hirst J. Women’s and
10. Schmidt GB, Christensen M, Knudsen UB. Preeclampsia and later cardio- healthcare providers’ perceptions of long-term complications associated
vascular disease–What do national guidelines recommend? Pregnancy with hypertension and diabetes in pregnancy: a qualitative study. BJOG.
hypertension. 2017;10:14–7. 2019;126 Suppl 4(Suppl Suppl 4):34–42.
11. Gamble DT, Brikinns B, Myint PK, Bhattacharya S. Hypertensive disorders 30. Levine L, Nkonde-Price C, Limaye M, Srinivas S. Factors associated with
of pregnancy and subsequent cardiovascular disease: current national postpartum follow-up and persistent hypertension among women with
and international guidelines and the need for future research. Front severe preeclampsia. J Perinatol. 2016;36(12):1079–82.
Cardiovasc Med. 2019;6:55. 31. Morgan J, Bauer S, Whitsel A, Combs CA, Medicine SfM-F, Committee
12. Staff AC, Kvie A, Langesæter E, Michelsen TE, Moe K, Strand KM, et al. Q. Society for maternal-fetal medicine special statement: postpartum
Hypertensive-svangerskapskomplikasjoner-og-eklampsi: Norsk gynekolo- visit checklists for normal pregnancy and complicated pregnancy. Am J
gisk forening Veileder i fødselshjelp; 2020 [Available from: https://www. Obstet Gynecol. 2022;227(4):B2–8.
legeforeningen.no/foreningsledd/fagmed/norsk-gynekologisk-forening/ 32. Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteris-
veiledere/veileder-i-fodselshjelp/hypertensive-svangerskapskomplika tics and women’s future cardiovascular health: an underused opportunity
sjoner-og-eklampsi/. to improve women’s health? Epidemiol Rev. 2014;36:57–70.
13. Triebwasser JE, Janssen MK, Sehdev HM. Postpartum counseling in 33. Andersson ME, Rubertsson C, Hansson SR. The experience of provided
women with hypertensive disorders of pregnancy. Am J Obstet Gynecol information and care during pregnancy and postpartum when
MFM. 2021;3(1):100285. diagnosed with preeclampsia: a qualitative study. Eur J Midwifery.
14. Lewey J, Levine LD, Yang L, Triebwasser JE, Groeneveld PW. Patterns of 2021;5:37.
postpartum ambulatory care follow-up care among women with hyper- 34. Barlow JH, Hainsworth J, Thornton S. Women’s experiences of hospitalisa -
tensive disorders of pregnancy. J Am Heart Assoc. 2020;9(17):e016357. tion with hypertension during pregnancy: feeling a fraud. J Reprod Infant
15. Roth H, LeMarquand G, Henry A, Homer C. Assessing knowledge gaps Psychol. 2008;26(3):157–67.
of women and healthcare providers concerning cardiovascular risk after 35. Christenson A, Johansson E, Reynisdottir S, Torgerson J, Hemmings-
hypertensive disorders of pregnancy—a scoping review. Front Cardio- son E. “… or else I close my ears” How women with obesity want to be
vasc Med. 2019;6:178. approached and treated regarding gestational weight management: a
16. Atkinson J, Wei W, Potenza S, Simpson G, Middleton A, Walker S, et al. qualitative interview study. PLoS ONE. 2019;14(9):e0222543.
Patients’ understanding of long-term cardiovascular risks and associ- 36. Furness PJ, McSeveny K, Arden MA, Garland C, Dearden AM, Soltani H.
ated health-seeking behaviours after pre-eclampsia. Open Heart. Maternal obesity support services: a qualitative study of the perspectives
2023;10(1):e002230. of women and midwives. BMC Pregnancy Childbirth. 2011;11(1):1–11.
17. Shree R, Hatfield-Timajchy K, Brewer A, Tsigas E, Vidler M. Information 37. Heslehurst N, Moore H, Rankin J, Ells LJ, Wilkinson JR, Summberbell CD.
needs and experiences from pregnancies complicated by hypertensive How can maternity services be developed to effectively address maternal
disorders: a qualitative analysis of narrative responses. BMC Pregnancy obesity? A qualitative study. Midwifery. 2011;27(5):e170–7.
Childbirth. 2021;21:1–12. 38. Spahn JM, Reeves RS, Keim KS, Laquatra I, Kellogg M, Jortberg B, et al.
18. Hoedjes M, Berks D, Vogel I, Franx A, Duvekot JJ, Oenema A, et al. Motiva- State of the evidence regarding behavior change theories and strategies
tors and barriers to a healthy postpartum lifestyle in women at increased
Arntzen et al. BMC Pregnancy and Childbirth (2023) 23:833 Page 11 of 11

in nutrition counseling to facilitate health and food behavior change. J

Am Diet Assoc. 2010;110(6):879–91.
39. Deslippe AL, Soanes A, Bouchaud CC, Beckenstein H, Slim M, Plourde H,
et al. Barriers and facilitators to diet, physical activity and lifestyle behavior
intervention adherence: a qualitative systematic review of the literature.
Int J Behav Nutr Phys Act. 2023;20(1):1–25.
40. Dhana K, Haines J, Liu G, Zhang C, Wang X, Field AE, et al. Association
between maternal adherence to healthy lifestyle practices and risk of
obesity in offspring: results from two prospective cohort studies of
mother-child pairs in the United States. BMJ. 2018;362:k2486.
41. Qi Y, Lv R, Zhao M, Huang Y, Zhang Y, Zhang H, et al. Associations between
parental adherence to healthy lifestyles and risk of obesity in offspring: a
prospective cohort study in China. Lancet Glob Health. 2023;11:S6.
42. Makama M, Awoke MA, Skouteris H, Moran LJ, Lim S. Barriers and facilita-
tors to a healthy lifestyle in postpartum women: a systematic review of
qualitative and quantitative studies in postpartum women and health-
care providers. Obes Rev. 2021;22(4):e13167.
43. Jelsma JG, van Leeuwen KM, Oostdam N, Bunn C, Simmons D, Desoye G,
et al. Beliefs, barriers, and preferences of European overweight women
to adopt a healthier lifestyle in pregnancy to minimize risk of develop-
ing gestational diabetes mellitus: an explorative study. J Pregnancy.
2016;2016:3435791.
44. Drabble L, Trocki KF, Salcedo B, Walker PC, Korcha RA. Conducting qualita-
tive interviews by telephone: Lessons learned from a study of alcohol
use among sexual minority and heterosexual women. Qual Soc Work.
2016;15(1):118–33.

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