The postpartum period is a transitional phase involving lifestyle and body weight changes. Postpartum weight retention is common [1, 2] and can have long-term impacts on health [2, 3]. This weight retention is as much associated with modifiable lifestyle factors, including diet and physical activity, as with characteristics such as prepregnancy body weight [4–6]. Thus, behavioral interventions to reduce postpartum weight retention are warranted.

Participating in such programs, however, can be a challenge. Only two community-based randomized trials to reduce postpartum weight retention have been conducted [7], in which the drop-out rates were 27% [8] and 40% [9], respectively. Participation in such interventions may be complicated by factors unique to this period, including difficulty and lack of time to attend structured activities while caring for infants [10]. However, data collected directly from postpartum women are lacking.

Through semi-structured, in-depth personal interviews, we explored barriers faced by women who refused participation in a postpartum weight loss lifestyle intervention. Understanding factors that impact participation in such programs is critical to designing appropriate and successful interventions, and the following cases illustrate reasons why postpartum women interested in losing weight declined to participate.

Active Mothers Postpartum (AMP) was a randomized controlled behavioral intervention trial to promote postpartum weight loss via sustainable lifestyle changes, including decreased calorie intake and increased physical activity [11]. Women were contacted for screening at 4 weeks postpartum, to facilitate an enrollment visit at 6 weeks postpartum. The intervention consisted of 10 physical activity classes and 8 nutrition education classes over a 9 month period. Classes were offered multiple times a week, including nights and weekends. Four hundred fifty overweight and obese postpartum women in the Triangle area of North Carolina were randomized to the trial from September 2004 to March 2006.

Women were identified for the present case studies during the last stages of recruitment (October 2005 – March 2006). Women in this period who refused to complete telephone screening for the AMP trial (n = 48) but remained engaged long enough to have the study explained to them in full (n = 10) were asked about their willingness to participate in a one-time interview regarding barriers to participation. Four women agreed to be contacted by phone to be interviewed, and three were successfully reached to schedule an interview time. These three women completed an informed consent and brief survey of demographics, support network size, parity, and transportation.

Semi-structured interviews with each woman were audio-taped and subsequently transcribed [12]. The one-hour interviews included questions on: roles and responsibilities since the newborn's birth; support provided by others; and what it would take to participate in a lifestyle modification program. Explored were barriers to healthy lifestyle changes and motivating forces that would have encouraged them to engage in the intervention. Transcripts were independently coded for primary themes by the first three authors (LCE, TØ and LAB) and reviewed for concordance. This qualitative study was approved by the Duke Institutional Review Board.

Ms. X, a Caucasian woman, age 41 years, is a mother of five children whose fifth child is a 5-month old infant. Her husband is a pastor of a church. Ms. X, who is college educated, does not work outside the home and homeschools her children. The one health behavior change she would like to make is to lose weight. She used to walk with a partner, but does not have the time that she used to. Given her array of responsibilities, Ms. X is tired much of the time and gets little rest. In terms of life priorities, her spirituality comes first, followed by her relationship with her husband and her children. Her primary concern is her responsibility to her newborn, within the context of her other children and family tasks. Since the birth of this child, the family has re-prioritized their activities by limiting the amount of time spent on social events outside of the home. Her husband helps more with the household chores, and the neighboring mother-in-law has become involved with the children's education.

Ms. X felt that the costs in geographic location, time commitment, effort, and general inconvenience were not worth the overall benefits of participation in the AMP study. She felt that she would have to perceive her health issues to be more serious to be encouraged to change her lifestyle. Ms. X felt that social support, such as good friends in the program with her, would motivate her to participate.

Ms. Y is a 25-year-old Caucasian stay-at-home mother of two, 3 years old and 5 months old, who lives on the outskirts of the city. The one health behavior change she would like to make is to eat regularly instead of waiting to eat a large meal in the evening. She mentioned difficulty finding personal time to eat during the day while caring for her children's needs, and financial constraints in affording healthier food. She eats quick, healthy snacks, and feeds her children healthy food while she nurses her newborn; however, she also purchases and eats less nutritious snacks out of convenience. She believes that she should only be living now for her children, not for herself, and that her children's welfare should take precedence over her taking care of her own health.

Ms. Y did not participate in the AMP Study because she would only have been permitted to bring her newborn and not her other two children to the program classes. She is used to taking her children with her everywhere she goes. She keeps her children close because her mother did not spend a lot of time with her during her childhood, and because she lost a son 8 1/2 months in gestation. She may have participated, if she had the option of attending a limited number of classes.

Ms. Z, 23 years of age, is a Caucasian full-time employee at a pharmacy and mother of three young children, 5 years old, 3 years old, and 2 months old. She is married and lives on the outskirts of the city. The one health behavior change she would like to make is to exercise more, since it makes her feel better. Ms. Z does not understand why she is often tired, yet regularly gets at least eight hours of sleep at night. She is constantly in motion at home and on her job, which requires her to be on her feet. She believes her husband does not understand her need for time to herself because he works 10-hour shifts. Although her husband does not initiate support, if she asks him to do something specific he will fulfill her request. However, he has difficulty handling more than one child at a time.

She wanted to be involved in the AMP study, but the timing of classes, her work schedule and that of her husband, and her mother's varied availability to watch the children after work hours, prohibited her commitment.

All three women described their responsibilities to their families and expressed the impact the increased efforts with the newborn added to their already busy schedules. There are several common themes in the barriers these women faced that may also be common for other postpartum women.

Barriers postpartum women face in adopting healthier lifestyles include child care and time management issues; perceptions of their health in the context of competing responsibilities; support from family members, friends, and/or co-workers; and lack of flexibility in the intervention structure, including distance. Each mother has multiple responsibilities to those around them, even to the expense of improving their health [16].

Interventions to address lifestyle behaviors of postpartum women must take these multiple inter-related barriers into account. It does appear that for the participants in this research, the demands of caring for an infant made prioritizing their own health or attending activities outside the home too overwhelming of a commitment [10]. Social support from family and friends is a potential motivator to engage in lifestyle behavior changes, and the form of that support (i.e., meeting together to walk, talking on the phone) may be useful strategies for sustainable behavior change [17, 18]. Although interventions may not be able to address every barrier, successful behavior modification may depend on identifying women's priorities and designing interventions that effectively incorporate them.