Midwives’ knowledge and health guidance practices regarding gestational weight gain in Mongolia: A cross-sectional study

This cross-sectional study used a web-based questionnaire. Participants included approximately 1,200 midwives registered with the Midwives’ Association of Mongolia. Midwives who were on long vacations or otherwise unable to participate in the survey were excluded. Inclusion criteria of the analyses were midwives who had provided health guidance to pregnant women in outpatient or antenatal classes (group guidance).

An email was sent to the director of the Mongolian Midwives’ Association requesting their cooperation. The director sent emails to almost all medical facilities in the country, and midwives were informed about the study. Participants were asked to read the study description attached to the e-mail; if they agreed to participate, they were asked to access the web-based questionnaire via a QR code or URL attached to the document. After completing the questionnaire, the participants were asked to submit their responses online. The survey was conducted between July and August 2024.

2.3.1Participants’ characteristics

2.3.2Knowledge about BMI

2.3.3Practice of health guidance on GWG

In this study, the following definitions were used:

Able to calculate BMI: If participants were able to calculate their BMI correctly, they were considered to be “able to calculate BMI.”

Having the knowledge of BMI categories: If participants could correctly answer the range of “normal weight” according to the WHO BMI classification, they were considered as “having the knowledge of BMI categories.” This is because if they knew the range of “normal weight,” they would understand the upper limit of “underweight” and the lower limit of “obesity.”

Provide GWG health guidance: For the 10 health guidance items related to GWG, based on the results of a study, if participants answered that they provided health guidance to more than 90% of the pregnant women, we considered that the health guidance item was provided.^[11] The health guidance items provided to pregnant women were counted; one item was counted as 1 point, whereas when the health guidance items were not provided to pregnant women, the item was counted as 0. Of the total health guidance score out of 10 points, scores above the average were defined as the “high score group,” and scores below the average were defined as the “low score group.”

For participants’ characteristics and the situation of health guidance regarding GWG, continuous values were expressed as mean ± standard deviation, and categorical data were expressed as n (%). The numbers below the age at which a person could become a midwife were treated as missing values. If BMI could not be calculated owing to missing self-reported height and weight, it was considered a missing value and excluded from the analysis. In addition, participants’ characteristics and health guidance situation regarding GWG were analyzed for significant differences between the two groups using the t-test for continuous variables and the chi-squared test or Fisher’s exact test for categorical variables.

Multiple logistic regression analysis was performed to identify the factors related to low GWG health guidance scores. Variables related to BMI knowledge (if they knew how to calculate BMI, could calculate BMI correctly, and understood BMI categories); variables suggested in studies to be related to GWG health guidance; variables related to whether they had studied about GWG, if they had overseas training; and variables of basic characteristics were used as independent variables in the analysis.

In addition, multiple logistic regression analysis was conducted to identify factors related to incorrect BMI calculations. Variables related to knowledge of BMI categories, experience studying GWG, experience with overseas training, and basic characteristics were used as independent variables in the analysis.

Furthermore, multiple logistic regression analysis was conducted to identify factors related to poor knowledge of BMI categories. Variables related to BMI knowledge (if they knew how to calculate BMI and could calculate it correctly), if they had experience of studying GWG, if they had experience of overseas training, and basic characteristics were used as independent variables in the analysis.

Multicollinearity was not an issue for any model, with all tolerances > 0.455 and variance inflation factors < 2.20. All data were analyzed using IBM SPSS Statistics 29.0 for Windows (IBM Corp., Armonk, NY, USA). Two-tailed p values of < .05 were considered statistically significant.

Midwives nationwide were recruited, and 494 responded to the survey. Data from 10 duplicate responses were excluded. We excluded 70 midwives who indicated that they had never provided health guidance to pregnant women in outpatient or antenatal classes (group guidance). The final analysis included data from 414 participants.

Table 2 shows the participants’ characteristics. The mean age of the participant population was 37.7 ± 10.5 years. Most participants were female (405, 97.8%); 264 (63.8%) had 4-year-degree educational status; 99 (23.9%) worked in Ulaanbaatar, the capital city of Mongolia; and 181 (43.7%) were currently working in the hospital ward. The mean clinical experience was 15.0 ± 11.0 years, and the mean years of obstetrics experience was 10.6 ± 10.1 years.

Although 374 (90.3%) participants indicated that they knew how to calculate their BMI, only 159 (38.4%) calculated it correctly. A total of 156 (37.7%) participants accurately identified the BMI categories.

The practices of GWG guidance are presented in Table 3. The GWG guidance with highest and lowest rates of practice were “Weighing women at every visit” (322, 77.8%) and “discussing the recommended rate of weight gain (kg/week) based on their weight gain target” (160, 38.6%), respectively. The average score of the GWG health guidance items provided to more than 90% of pregnant women was 5.2 point out of 10. Consequently, scores below five were classified as the low-scoring group, and scores above six were classified as the high-scoring group. A comparison of characteristics between the low and high GWG health guidance score groups revealed significant differences in the type of medical facility (p = .002), working section (p < .001), experience of learning GWG (p = .002), and “Do you know how to calculate BMI?” (p < .001) (see Table 2).

Table 4 shows factors related to low scores of GWG health guidance. Compared to midwives working at outpatient departments, those working at wards had higher risk of having a low score of GWG health guidance (adjusted odds ratio [AOR]: 2.96, 95% confidence interval [CI]: 1.78–4.92). Moreover, compared to midwives with 11 or more years of clinical experience, those with three or fewer years had a higher risk for a low score of GWG health guidance (AOR: 2.82, 95% CI: 1.03–7.69). Compared to midwives who answered that they knew how to calculate BMI, those who answered that they did not had a higher risk of a low score of GWG health guidance (AOR: 3.10, 95% CI: 1.30–7.39). In addition, compared to midwives who responded that they had experience of learning weight control, those who responded they did not had a higher risk for a low score of GWG health guidance (AOR: 2.09, 95% CI: 1.34–3.25).

Table 5 shows factors related to incorrect BMI calculation. Compared to midwives who had knowledge about BMI category, those who had poor knowledge had a higher risk of incorrect BMI calculations (AOR: 2.15, 95% CI: 1.39–3.32).

Table 6 shows factors related to poor knowledge of BMI categories. Compared to midwives with three or fewer years of clinical experience, those with 4–10 years had a higher risk of poor knowledge of BMI categories (AOR: 2.56, 95% CI: 1.20–5.44). Moreover, compared to midwives who had experience of training overseas, those who had never trained overseas had a higher risk of poor knowledge of BMI categories (AOR: 1.80, 95% CI: 1.01–3.19). Compared to midwives who responded that they know how to calculate BMI, those who responded they did not had a higher risk of poor knowledge of BMI categories (AOR: 3.73, 95% CI: 1.36–10.22). Additionally, compared to those who accurately calculated BMI, those who did not were at a higher risk of poor knowledge of BMI categories (AOR: 1.84, 95% CI: 1.18–2.87).

In this study, although 90.3% of the participants indicated that they knew how to calculate BMI, 38.4% were able to do it correctly, and 37.7% had knowledge about BMI categories. In a study conducted in Australia, 11.9% of the participants were able to correctly answer the range of “normal weight”;^[14] thus, the correct answer ratio of our participants (37.7%) was higher than that of the previous study, although the percentage is still low.

In this study, 49.5% of participants had practiced the item of “Checking the BMI of pregnant women at her first prenatal care,” and 39.9% had practiced the item “Providing pregnant women with a weight gain target based on their pre-pregnancy BMI.” However, only a few participants had correct knowledge about BMI calculations and BMI categories, suggesting that some midwives may provide GWG health guidance to pregnant women based on incorrect BMI values. In the present study, 77.8% of participants answered that the item “Weighing women at every visit” was implemented for more than 90% of the pregnant women. This is similar to the results of a study in Canada in which 76% of the respondents practiced it.^[11] Meanwhile, some items such as “Providing pregnant women with a weight gain target based on their pre-pregnancy BMI,” “Discussing the recommended rate of weight gain (kg/week) based on their weight gain target,” and “Discussing the impact that inappropriate weight gain can have on the mother during pregnancy” were practiced with higher percentage than those in study.^[11]

A study conducted among obstetricians and gynecologists showed that 79.2% practiced “Calculate BMI at first prenatal visit” and 78.2% practiced “Use BMI to modify weight gain recommendations,” which was higher than the results of this study.^[15] However, because this study had only two answer options, “yes” or “no,” it is likely that the percentage of participants who answered that they provide health guidance was higher, and the results cannot be compared simply.

This study clarified that several midwives provide health guidance for GWG based on pre-pregnancy BMI; however, there are currently no standardized guidelines for recommended weight gain in Mongolia. Therefore, it is necessary to develop guidelines for recommended weight gain adjusted for pregnant Mongolian women, considering their race and skeletal structure. However, further studies are required to validate these guidelines.

Compared to midwives with three or fewer years of clinical experience, those with 4–10 years had a 2.56 times higher risk of having poor knowledge about BMI categories. Although we expected that midwives with more years of clinical experience would have more knowledge of BMI categories, the results were the opposite. Meanwhile, no significant differences were observed between midwives with less than three years and those with more than 11 years of clinical experience. A possible reason for this is that midwives with more than 11 years of clinical experience are at an age when obesity is more prevalent;^[16] thus, they may be more aware and knowledgeable about BMI.

It was also found that midwives who had no experience of training overseas had 1.80 times higher risk of having poor knowledge of BMI categories than those who had experience of training overseas. It is assumed that midwives with overseas training experience have more opportunities to gain knowledge. These findings suggest that in addition to learning about BMI as a basic nursing and midwifery education course, it is necessary to improve post-graduate education so midwives can maintain their knowledge through regular training and other programs after graduation. In Mongolia, medical licenses, including midwifery licenses, are renewed every five years and require participation in lectures and training programs to obtain the necessary credit.^[17] Therefore, it may be necessary to maintain midwives’ knowledge by providing training on BMI and weight control or other measures.

This study identified the factors contributing to lower health guidance scores on the GWG as working in a ward, having less than three years of clinical experience, and having no experience learning about weight control. Those working in wards have fewer opportunities to provide health guidance on GWG than those working in outpatient departments, which may mean that their knowledge of health guidance is not updated or that they give less priority to GWG health guidance.

Participants who did not know how to calculate BMI had an approximately three times higher risk of having a low health guidance score than those who did. Studies have reported that being aware of IOM recommendations is associated with both frequently or always calculating BMI at the first prenatal visit and modifying weight gain recommendations using BMI; further, individuals who are aware of IOM recommendations are more likely to frequently or always counsel patients about GWG.^[15] Moreover, those who are aware of IOM recommendations are more likely to inform pregnant women that excessive weight gain increases the risk of pregnancy complications and may adversely affect their fetal health.^[15] Therefore, the awareness of BMI and its guidelines may be associated with health guidance practices. All midwives must understand how to calculate BMI because without such awareness, providing appropriate health guidance on GWG is not possible.

The strength of this study is that it is the first to investigate midwives’ knowledge of GWG, health guidance, and factors related to GWG health guidance in Mongolia. Additionally, our survey was conducted among midwives across Mongolia. As there are differences in population distribution^[18] and access to healthcare^[19] between Ulaanbaatar and other provinces, targeting midwives in all regions would have captured the differences in both urban and rural characteristics.

However, this study has some limitations. First, information about the practice of health guidance regarding GWG was self-reported and does not reflect the actual practice or the accuracy of its content. Additionally, participants could have been subjected to social desirability bias, leading them to describe their health guidance implementation in a better way than what is actually the case. Second, the health guidance score of the GWG used in this study was not a scale that had been tested for reliability and validity; therefore, interpretation of the actual situation of GWG health guidance should be performed carefully. However, the 10 items regarding health guidance used in this study were also used in previous studies, which is a strength, as it allows for comparison with previous studies. Third, because this study used a web questionnaire, the target population may have been limited to Internet users. However, because Mongolia has a high Internet penetration rate of 83.91%,^[20] and each medical facility is equipped with a computer connected to the Internet, the number of participants who were unable to participate due to a lack of Internet access is expected to be minimal. Fourth, fewer participants were in their 20s and more were in their 50s or older than the general population. Therefore, the generalizability of our results is limited.