Received: 8 August 2023 | Revised: 14 December 2023 | Accepted: 16 December 2023

DOI: 10.1111/hex.13956

ORIGINAL ARTICLE

Views and preferences of food‐insecure pregnant women

regarding food insecurity screening and support within
routine antenatal care

Julia Zinga Bachelor Health Science (Nutrition & Dietetics), Dietitian1,2 |

3,4
Paige van der Pligt PhD, Senior Lecturer | Fiona H. McKay PhD, Associate Professor1

1
School of Health and Social Development,
Institute for Health Transformation, Faculty of
Health, Deakin University, Melbourne,
Victoria, Australia
2
Department of Nutrition and Dietetics, Royal
Women's Hospital, Parkville, Victoria,
Australia
3
School of Exercise and Nutrition Sciences,
Institute for Physical Activity and Nutrition
(IPAN), Deakin University, Geelong, Victoria,
Australia
4
Department of Nutrition and Dietetics,
Western Health, Footscray, Victoria, Australia
Correspondence
Julia Zinga, Bachelor Health Science (Nutrition
& Dietetics), Department of Nutrition &
Dietetics, Royal Women's Hospital, Locked
Bag 300, Grattan St & Flemington Rd,
Parkville 3052, Victoria, Australia.
Email: jzinga@deakin.edu.au
Funding information
Deakin University
Abstract
Background: Food insecurity is a public health concern that has profound impact on
physical and mental health, and on social well‐being. Pregnancy is a period in which
food insecurity is likely to be particularly deleterious, due to the serious impact on
both mother and child. Food insecurity is not routinely screened in antenatal
healthcare settings, and the preferences of pregnant women regarding food
insecurity screening and support are poorly understood. This study aimed to
determine the views and preferences of food‐insecure pregnant women regarding
food insecurity screening and support within antenatal healthcare.
Methods: This qualitative descriptive study used face‐to‐face semi‐structured
interviews, conducted in February and March 2023, to gain the views of purposively
sampled food‐insecure, pregnant women in Melbourne, Australia. Food insecurity
was evidenced by an affirmative response to at least one of three assessment items
in a screening questionnaire. Qualitative content analysis was conducted to
summarise the views and preferences of women.
Results: Nineteen food‐insecure pregnant women were interviewed. Three themes
were identified: (1) acceptability of being screened for food insecurity, (2) concerns
about the consequences of disclosure and (3) preferences regarding food insecurity
screening and supportive strategies that could be offered within an antenatal
healthcare setting.
Conclusion: Women were accepting of food insecurity screening being conducted
within routine healthcare. Women identified potential benefits of routine screening,
such as feeling supported by their clinician to have a healthy pregnancy and less
pressure to voluntarily ask for food assistance. Women gave suggestions for the
implementation of food insecurity screening to optimise their healthcare experience,
maintain their dignity and feel able to disclose within a safe and caring environment.
These results indicate that food insecurity screening in the antenatal setting is likely

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2024 The Authors. Health Expectations published by John Wiley & Sons Ltd.

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https://doi.org/10.1111/hex.13956
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2 of 11 | ZINGA ET AL.

to have support from pregnant women and is urgently needed in the interest of
promoting optimal nutrition for women and children.
Patient Contribution: Pregnant women with lived experience of food insecurity
were purposively sampled to obtain their insights regarding screening and support
within a pregnancy healthcare setting. Member‐checking occurred following data
collection, whereby all participants were offered the opportunity to review their
interview transcript to ensure trustworthiness of the data.

KEYWORDS
food insecurity, patient preferences, pregnancy, screening

1 | INTRODUCTION Obstetricians and Gynaecologists is that clinicians should assess,

Food insecurity, the limited or uncertain availability of nutritionally
adequate and safe foods, or limited or uncertain ability to acquire
acceptable foods in socially acceptable ways,1 is a public health
concern that has profound impact on physical and mental health, and
2
on social well‐being. The burden of food insecurity can be felt by
individuals across all life stages. Due to the serious and negative
impact on both maternal and child health in women who are deemed
food‐insecure, pregnancy is a period in which food insecurity is likely
to be particularly deleterious. Food insecurity has been linked with
impaired maternal mental health,3 inadequate and excess gestational
4 5 3
weight gain, congenital abnormalities and preterm birth. This
relationship is in part due to food insecurity contributing to
disordered eating patterns induced by the stress of food scarcity6
and restricted access to a nutritionally adequate diet during
pregnancy.3 Approximately 14% of Australian pregnant women
experience food insecurity,7 with similar rates reported in other
8,9
high‐income countries.
Food insecurity during pregnancy is influenced by a range of
economic and social risk factors, the strongest predictor being
income‐poverty.10 Women are more likely than men to experience
poverty,11,12 and thus, disproportionately bear the burden of food
insecurity.13 The financial and social conditions that underpin food
insecurity persist during pregnancy as women are more likely than
men to be employed in lower‐wage roles,12,14 particularly when they
become mothers,14 and forego their food intake in favour of the
nutritional needs of other household members.15–17 Alongside
income‐poverty, other risk factors for food insecurity relevant to
this population group are low maternal age, low education attain-
10,18
ment, single‐parent households, ethnicity and acculturation. The
wide range of risk factors is indicative of the complex and
19
multifactorial nature of food insecurity and emphasises the
difficulty in delivering relief strategies to this priority population
group.
The growing evidence base regarding the impact of food
insecurity during pregnancy3 has propelled advocacy for food
insecurity screening and interventions within antenatal health-
care.20,21 For instance, the position of the American College of
document and address ‘social and structural determinants of health
that may influence a patient's health … such as access to food’.20
Nurses have similarly been called to action to advance health equity
for women by addressing social determinants of health within routine
healthcare.22 Despite these calls, food insecurity screening is not
routinely conducted during antenatal healthcare.23 A recent system-
atic review found seven published studies investigating screening
procedures within the antenatal healthcare setting, comprising four
screening tools, with varying methods of implementation and minimal
evaluation of effectiveness.24 There are also few interventions that
address food insecurity during pregnancy within healthcare settings,
beyond the screening process.25–27
Government‐level food assistance programmes have been
established in some high‐income countries, to improve dietary quality
of priority groups such as pregnant and postpartum women. The
Special Supplemental Nutrition Program for women, infants and
children (WIC) in the United States28 and the Healthy Start program
in the United Kingdom29 provide access to nutritious foods and
micronutrient supplements to low‐income pregnant women who
have been deemed to be at nutritional risk. The Canada Prenatal
Nutrition Program provides funding for community resources that
promote the health of pregnant women, including micronutrient
supplements and nutrition education.30 No nutrition assistance
programmes for antenatal health promotion exist in Australia.
Although there is good evidence to suggest that these programmes
are effective at promoting dietary quality and food security,31,32
uptake of WIC by eligible women is declining,33 and below target for
the Healthy Start programme.34,35 Cited reasons for low uptake
include administrative burdens for participants,34 misconceptions
about eligibility36 and stigma.37
Interventions that are ‘internally’ based in a healthcare setting
are considered a viable option to screen and address food insecurity,
to complement a referral to these established ‘external’ food
assistance programmes.27 Healthcare‐based interventions are con-
sidered valuable by clinicians as well as patients, based on research in
general, nonpregnancy healthcare settings.25,38–41 However, the
acceptability and preferences of pregnant women regarding food
insecurity screening and support within antenatal healthcare are

ZINGA ET AL.
poorly understood.27 Pregnant women have also been inadequately
consulted to develop or evaluate government‐level food assistance
42
programmes. The lack of inclusion of women's views is a crucial
evidence gap that must be addressed before the development of
screening and support processes that are effective, yet sensitive to
the needs of this population group. Although research in non-
pregnant food‐insecure adults suggests that patients perceive it
appropriate for food insecurity to be screened during routine
healthcare,43,44 there is evidence that screening may inadvertently
cause harm when implemented poorly.45,46 The unique circum-
stances of pregnancy, a transitory situation but one that precipitates
the construction of maternal identity that redefines a woman's self‐
perception,47 mean that disclosure of food insecurity may be
affected. The views of food‐insecure pregnant women regarding
screening and support are required for an informed approach to
future screening and possible intervention. Furthermore, given the
lack of Australian nutrition assistance programmes for antenatal
health promotion, the views of Australian women are particularly
warranted before the potential establishment of new services for
specific implementation within antenatal healthcare settings. This
study aimed to determine the views and preferences of food‐
insecure pregnant women attending a large maternity hospital in
Melbourne, Australia, regarding food insecurity screening and
support within routine antenatal healthcare.
2 | M E TH O D S
2.1 | Study design
This qualitative descriptive study used face‐to‐face semi‐structured
interviews to gain the views of purposively sampled food‐insecure,
pregnant women in Melbourne, Australia, between February and
March 2023. Qualitative descriptive studies provide a ‘straight
description’ of the phenomenon,48 meaning that researchers stay
close to the data in the analytical process.49 Although description is
the aim of these studies, interpretation is also present and, thus,
influenced by the perceptions and sensitivities of the researcher.50
Qualitative descriptive studies are an appropriate methodology to
gain insights from informants regarding a poorly understood
phenomenon,48 to answer questions about human behaviour, views
and barriers50 and are considered particularly suited to health
51
sciences research. The consolidated reporting criteria for qualita-
tive studies were used to design and report this study.52 Ethics
approval was granted by Royal Women's Hospital (RWH) Hospital
HREC (02773/22‐33) and Deakin University HREC (2023‐016).
2.2 | Recruitment and participants
Recruitment occurred at the Royal Women's Hospital, one of
Australia's largest maternity hospitals with over 8000 annual births
and a culturally diverse patient population that is representative of
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| 3 of 11
over 190 world nations.53 The first author is employed at the hospital
as a clinical dietitian to provide nutritional care to pregnant women.
Recruitment occurred in three ways: via advertising flyers, directly
approaching women and social media advertisements. Advertising
flyers, accessible in clinic rooms and patient waiting areas, featured a
QR code linked to a screening questionnaire that was administered
either online using Qualtrics software54 or in paper format. The
screening questionnaire and advertising flyers were available in the
five languages most commonly spoken by women attending the
hospital (English, Hindi, Arabic, Vietnamese, Chinese).55 For direct
recruitment, the first author invited pregnant women, who were at
varying stages of gestation, to complete the questionnaire in paper
format. Direct approach to all pregnant women waiting for their
appointments in the hospital antenatal clinics occurred over six, 4‐h
pregnancy outpatient clinics during February 2023. Lastly, recruit-
ment occurred via one social media post about the study, embedded
with an internet link to the screening questionnaire, and uploaded on
hospital‐managed social media platforms (Facebook and Instagram).
The 27‐item eligibility screening questionnaire featured demo-
graphic questions relating to country of birth, household income,
receipt of government welfare payments, current or previous use of
food aid and three questions to assess food insecurity that were
previously piloted with Australian pregnant women.7 The food
insecurity assessment items were as follows: ‘I worried whether
my/our food would run out before I/we got money to buy more’, ‘The
food that I/we bought just didn't last, and I/we didn't have money to
get more’ and ‘I/we couldn't afford to eat balanced meals’, relating to
the previous 12 months. Response options were ‘often true’,
‘sometimes true’, ‘never true’ or ‘don't know.; a response of ‘often
true’ or ‘sometimes true’ was considered to be an affirmative
response.7 The final questionnaire item invited respondents to
register their interest in participating in an individual interview by
providing their name and phone number.
Eligible participants were pregnant women attending RWH for
antenatal care who were experiencing food insecurity, evidenced by
an affirmative response to at least one of the three food insecurity
questions, or were currently or previously using food aid. Eligible
participants who provided their name and phone number were
contacted by the first author to discuss the study in more detail and
obtain their email address to issue an additional plain language
statement for informed consent to an interview. Recruitment
continued until sufficient conceptual depth was obtained from the
participants' accounts for a rich network of concepts and themes to
be developed.56
2.3 | Data collection
Interview guides used in qualitative descriptive studies tend to be
more structured than in other qualitative methodologies, due to
being typically based on expert knowledge to focus on areas that are
poorly understood in a healthcare context and/or amenable to
intervention.50 Thus, the interview guide for the present study was

4 of 11 | ZINGA
developed following the review of existing literature relating to views
towards food insecurity screening in nonpregnant populations57–60
and pregnant women's views about other antenatal screening
61
processes. Questions aimed to gain insights into enablers and
barriers to women's disclosure of food insecurity, as well as
preferences for subsequent support strategies that could be offered
by the hospital to address food insecurity. The interview guide was
piloted with one pregnant woman experiencing food insecurity who
was not a RWH patient (who was also compensated for her time);
minor revisions to question sequencing were subsequently made (see
the Supporting Information material for the interview guide).
In‐depth one‐on‐one interviews were conducted by the first
author (an Australian‐born, food‐secure, dietitian and mother) over
the phone, via videoconferencing or face‐to‐face, based on partici-
pant preference. In‐depth interviews are a key data collection
method used in qualitative studies to gather data on participants'
views and feelings about specific topics.48,50,62 Participants were
aware that the interviewer (the first author) was employed at RWH as
a clinical dietitian; however, they were not receiving consultative
healthcare from the interviewer. A reflexive approach to data
collection63 was used by the interviewer, whereby nonjudgemental
curiosity and active listening enabled participants to comfortably
share their insights. The potential for participants to become
distressed during the interview was recognised and addressed by
the development of a distress protocol. Additionally, the participant
information and consent form forewarned participants about possible
distress and included potential management strategies such as halting
the interview, referral to internal counselling services and locally
available food aid. A $AUD40 gift card was sent to participants after
the interview in acknowledgement of their time and contribution.64
Interviews were audio‐recorded and transcribed verbatim by an
external transcription company. All participants were offered the
opportunity to review their interview transcript; three participants
accepted, and no amendments to their individual responses
were made.
2.4 | Data analysis
Qualitative content analysis was conducted by the first author to
summarise participants' information.49,50 The interview guide served
as an initial organising framework for deductive data analysis, with
concepts also inductively derived from the interview transcripts. This
reflexive process of modifying the treatment of data as new insights
arise is a feature of qualitative content analysis, whereby pre‐existing
coding systems may begin data analysis but they are modified to
ensure best fit to the data. 49
Data analysis, guided by the approach
set out by Miles et al.,62 commenced with data immersion; transcripts
were read and reread to become familiar with the data. Portions of
text from the interview transcripts were then coded according to the
main areas of interest to answer the research questions, developed a
priori to data collection. Regularly occurring concepts that were
inductively derived from the data were also coded.62 This resulted in
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ET AL.
a coding manual that was revised iteratively as data collection and
analysis proceeded, and then used to recode previously coded data,
in a constant comparative approach.65 Second‐cycle coding was then
conducted to reorganise and reanalyse data, for the development of a
coherent metasynthesis of the data.62 Trustworthiness and credibility
of the analysis were enhanced through strategies such as taking field
notes during interviews and memo‐writing. NVivo software66 was
used for data management and coding.
3 | RESULTS
Of the 295 women who completed the screening questionnaire, 97
were eligible for the study and 19 consented to be interviewed.
Interviews were on average 32 min in length (range: 14–81 min).
Sixteen participants completed the paper version of the screening
questionnaire, two participants completed the survey online after
taking a flyer and one participant responded to the social media
advertisement for the study. The mean age of the participants was
32.8 years and ranged from 19 to 42 years. Nine responded
affirmatively to all three food insecurity screening items, seven
participants gave only one affirmative response. Most participants
(n = 11) identified as culturally diverse/migrant from a range of low‐
to high‐income countries, and most (n = 12) were multiparous (had
previously given birth to at least one child). Household income varied,
with the same number of participants categorised as earning over
$AUD120,000/year (n = 5) as participants categorised as earning
$AUD20,000–$50,000/year (n = 5); two participants earned less than
$AUD20,000/year. Table 1 describes participants' demographic
characteristics.
Three themes were identified through analysis of the interviews.
These themes relate to (1) the acceptability of being screened for
food insecurity, (2) concerns about the consequences of disclosure
and (3) the preferences regarding food insecurity screening and
supportive strategies that could be offered within an antenatal
healthcare setting.
1. Acceptability of being screened for food insecurity
Food insecurity screening was considered an appropriate
component of antenatal healthcare for all participants. Several
factors influenced participants' acceptability of this process.
These included ‘pragmatism’, ‘inferences of care and support’
and ‘inclusivity’.
Participants held pragmatic views towards food insecurity
screening, based on practical considerations for a healthy
pregnancy. These views stemmed from an understanding of the
need for nourishment where food was considered a ‘basic thing’
that ‘comes first in every sense’. Participants' awareness of the
importance of antenatal nutrition was a factor in their views about
food insecurity screening during antenatal healthcare.
Because eating properly while you're pregnant is one
of the most important things for development of the
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ZINGA ET AL. | 5 of 11

TABLE 1 Participant characteristics. which pregnant women are commonly subjected.

Characteristic n (%) Food insecurity screening was conceptualised by

participants as analogous to questions about mood,
Gestational age
sleep and other pregnancy symptoms.
Trimester 1 (<13 weeks) 0

Trimester 2 (13–26 weeks) 9 (47)
Trimester 3 (>26 weeks) 10 (53)
Number of children at home
0 7 (37)
1 4 (21)
2 4 (21)
3 2 (11)
4 2 (11)
Household annual gross income (AUD)
I think it's just a pregnancy thing … you get asked so
many random things when you're pregnant, when
you're in hospital and with doctors. And it would just
be another topic that just gets covered. (36 years,
second child, Australian)
Others went on to suggest that screening at other
life stages may not be acceptable. Pregnancy was
viewed by participants as being an exceptional time
where sensitive topics could be discussed within the
context of optimising well‐being.

$0–$20,000 3 (16) I say it's appropriate because of, if I'm not pregnant, I

$21,000–$50,000 5 (26)
don't need somebody to ask these questions. But if I'm
pregnant, you don't know my situation, what's going
$51,000–$70,000 4 (21)
on. So maybe to ask this question, like, are you safe?
$71,000–$90,000 0 Or about your food. I think that's appropriate. Both
$91,000–$120,000 1 (5) questions are appropriate. (34 years, third child, South

>$120,000 5 (26) Asian)

Participants commented that maternal instinct to
Ethnicitya
care for their baby, via an improved access to
Australian/Oceanianab 8 nourishing food, drove this change in attitude about
South Asian 3 screening acceptability during pregnancy. This was
Middle Eastern 3 particularly true for multiparous participants.

African 2
I think I've learned to drop my pride and ego a bit since
Southeastern European 1
becoming a mum. Before I'd say no, I can do things on
North American 1 my own. I don't need anyone's help … I think now
Southeast Asian 1 having, being a mum and now having another baby, I
understand why women need the support. (29 years,
Government welfare recipient
second child, South Asian)
Yes 10 (53)
Participants' practical consideration of screening
No 9 (47) meant that their concern of embarrassment in discussing
Food aid recipient (current or previous) food insecurity would be outweighed by the benefit of
being supported, both for themselves and their baby.
Yes 7 (37)
Participants predicted that a positive outcome of food
No 12 (63)
insecurity screening would be worth the risk of feeling
a
Australian/Oceanian comprises Australia (Indigenous and non‐ vulnerable by disclosure to antenatal clinicians.
Indigenous), New Zealand and nearby Pacific Islands.
b
Based on country of birth response in the questionnaire and self‐
Yeah, it is hard but I think it just needs to be addressed
reported cultural background in the interview.
… There's no way you can really beat around the bush
with it. If you're struggling, you're struggling. (22 years,
baby and brain development and stuff, so maybe there first child, Australian)
wouldn't be as much problems with babies if women The prospect of food insecurity assessment within
were getting the right support. (40 years, first child, the antenatal healthcare setting was an indicator to
Australian) participants that their healthcare provider was caring
Such was their fundamental acceptance of food and supportive. The screening was inferred as an
insecurity screening that participants considered example of compassionate, holistic healthcare, which
screening an example of the routine surveillance to participants highly valued.

6 of 11 | ZINGA
…it just tells them, okay, this person is caring for me or
this person want to know how I'm feeling so they can
express themself which is actually really good. There is
nothing bad about it. (31 years, third child, African)
Removing the pressure from women to instigate
their own request for support was considered a way
for antenatal clinicians to provide support for the
burden of food insecurity. Participants were not
comfortable advocating for their own health, prefer-
ring routine assessment.
Yeah, it's not like I have to be seeking out help, I have
to recognize I have a problem. They're just asking it
anyway. (24 years, first child, Australian)
Participants' acceptability of screening also drew
from notions of inclusivity. Knowing that all pregnant
women would be screened as part of routine
healthcare was considered positive as this would help
reduce the stigma associated with food insecurity.
I think I would respond to that quite well … especially
if I knew that context of it being asked to everyone, I
would think that was a good thing. (39 years, second
child, Australian)
The feeling of inclusivity was also fostered by the
knowledge that many other women were experiencing
financial hardship that was considered societal and
commonly experienced, which enabled disclosure.
I think now I'm way more transparent because I think a
lot more people need help and they're talking about it
or amongst themselves. (31 years, third child,
Australian)
2. Concerns about the consequences of disclosure
Although all participants were supportive of food insecurity
screening, this acceptance was accompanied by trepidation from
some participants. Concerns about the consequences of disclosing
food insecurity were centred on a fear of being judged by
clinicians, and of domestic tension.
Some participants were aware of the stigma associated with
an inability to provide enough quality food for their family and
were concerned that the identification of food insecurity would
result in clinician's misjudgement and suboptimal quality of care.
There's a big stigma on pregnant women as well, so
that people will be like, oh, how she can look after the
baby when she has it, if she can't look after, you know,
stuff now. (40 years, first child, Australian)
Other participants worried that disclosure of food
insecurity could open further invasive enquiry and
forced validation of their circumstances. These con-
cerns stemmed from some participants' negative
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ET AL.
experiences when interacting with government wel-
fare agencies. One participant feared that routine
screening and identification could lead to her children
being removed from her care, a concern based on her
own childhood experience of out‐of‐home care.
I'd be scared you're gonna—you know—if I had kids, do
you know what I mean? … Questions like that scare
mums, especially my mum. (19 years, first child,
Australian)
In addition to clinician misjudgement, participants
were concerned that disclosure could instigate domes-
tic tension if their partner reacted negatively. One
participant anticipated that her partner would have
wounded pride, as the main income earner, and
another participant predicted that her husband would
be angry to be portrayed as one that could not provide
for the family.
Nothing would stop me, except for the fear of my
husband finding out. [That would] make a bad
situation an even worse situation. (33 years, fifth
child, Middle Eastern)
For migrant participants, cultural norms in domes-
tic relationships were drawn upon to anticipate the
tension caused by food insecurity disclosure. One
participant stated,
Let's say, there wasn't enough money and you're not
working, and the man is. You're never going to meet a
cultural woman that's going to say that they don't
have enough food, which would infer that it's their
husband's fault. The next question they would ask is,
what else did you say? And that's already leading to a
fight. (38 years, third child, Southeastern European)
The cultural lens on this issue was shared by
another migrant participant, where the concern that
disclosure of inability to provide food could lead to
shame was considered potentially problematic for the
relationship dynamics.
Because some appointment, husband is there. If my
husband will come, I'll say yes, yes. I will not say
anything unusual of course, because I have to go back
with him … He might ask ‘Why? I'm earning enough’.
Yeah, I think so because in our culture, again that
shame thing. (34 years, third child, Southeast Asian)
However, these perceived cultural norms were not
shared by all migrant participants.
There is nothing to hide from the partner, that's fine
with me. If my husband is there with me and then the
midwife or the doctor or somebody is asking me this

ZINGA ET AL.
question, he will feel happy to even participate in it.
(31 years, third child, African)
Participants in this study were fundamentally accept-
ing of food insecurity screening because of the perceived
benefits that identification and support could bring.
However, some women predicted difficulties if they
chose to disclose, which highlights that, for some women,
the challenges of experiencing food insecurity could be
matched by the tension caused by disclosure.
3. Preferences regarding food insecurity screening and support
Participants offered insights into how the process of food
insecurity screening could be conducted to optimise the patient's
healthcare experience, to maintain their dignity and encourage
disclosure in a safe and caring environment. This included views
about screening modality, who should conduct screening and when
and expected supportive strategies offered by the antenatal hospital.
In general, participants were comfortable with clinician‐
facilitated, face‐to‐face screening. However, there was a suggestion
that screening could occur via self‐administered assessment, specifi-
cally paper‐based, to avoid embarrassment.
I like the paper version. Just write on it and no one
else can see what's on there. And then you can just
fold it up and put it in a box. (22 years, first child,
Australian)
For participants who were comfortable with clinician‐facilitated
screening, it was imperative that clinicians approached screening in a
nonjudgemental, sensitive manner and provided person‐centred care.
When you get some help, it should make you happy
[and] proud. But when you get some help and you feel
like, I wish this is not the way I get help … It makes you
not someone who gets help, although you know that
you want it. (33 years, fifth child, African)
Most participants did not have a preference about the screening
clinician's occupation and reiterated that the more important factor
was the sensitive, nonjudgemental approach to screening. Partici-
pants could foresee that clinicians who had already demonstrated a
caring nature would be their preference.
I would trust that question from someone who knows
me a lot … I've now developed a relationship with my
midwife, she's really lovely. But if it were a random
person who might be really rushed, or I'd never met
before … I think that those contexts are so important.
(33 years, first child, North American)
Other participants perceived that a sensitive approach could be
taken by clinicians regardless of whether they were to provide
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| 7 of 11
continuous healthcare, for example, in the case of an initial
assessment by a midwife at the first antenatal appointment. It
seemed logical to participants to include food insecurity screening
within a comprehensive assessment of key antenatal health
indicators, such as mental health and family violence, usually
conducted at the initial appointment.
I think it should be in that initial conversation, when
they ask you privately about domestic violence,
wellbeing and your stress level … because you're
already asking the person confronting questions, and
then you're just saying, can you also afford to eat food
and have the right nutrition? (29 years, second child,
South Asian)
Participants who were comfortable with clinician‐facilitated
screening also provided suggestions for multimodal screening, with
the presumption that not all pregnant women would feel comfortable
with face‐to‐face screening. Suggestions included private mobile
phone messaging via SMS, QR codes at the pregnancy clinic linking to
an online screening survey and the option to complete screening via
the ‘patient portal’ functionality of an electronic medical record.
Participants also had strong views about subsequent supportive
strategies that could be offered by antenatal clinicians, and
universally believed that the hospital was well placed to provide
support. Such was the solutions‐based view regarding the ultimate
purpose of screening that one participant stated that it was pointless
to enquire about food insecurity if there was nothing the clinician
could offer in support. Some participants suggested that a list of
potential support strategies could be provided to all pregnant women
at their first visit to an antenatal healthcare setting, before screening
even occurring, to pre‐emptively prepare the women for the
experience of screening. In another suggestion to reduce the stigma
associated with accessing food security support, one participant
suggested that the clinician could write a referral letter for pregnant
women to present to their chosen support service, rather than be
forced to articulate her need. The range of supportive strategies
suggested by participants was indicative of the Australian context in
which there is no established government‐led nutrition assistance
programme for pregnant women. Strategies included referral to
internal support services, referral to external support services such as
food pantries, provision of free multivitamins, grocery vouchers, fruit
and vegetable boxes delivered to home and education on healthy
eating within a budget. Table 2 describes participants' suggestions.
4 | D IS CU SS IO N
This is the first qualitative study to explore the views and preferences
of Australian food‐insecure pregnant women regarding food
insecurity screening and support within an antenatal healthcare
setting. Women in this study were accepting of food insecurity
screening being conducted as part of their routine healthcare and
 13697625, 2024, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/hex.13956 by EBMG ACCESS - ETHIOPIA, Wiley Online Library on [21/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 of 11 | ZINGA ET AL.

TABLE 2 Supportive strategies suggested by participants.

Supportive strategy Exemplar quote

Referral to support services (internal and ‘It'd be nice … if they offered me, would you be keen on going to a dietitian? This might help with your
external) thyroid and help with your iron. I would love for someone to have told me that with both my
pregnancies, instead of me having to outsource this out of my own pocket’.

‘So if you could offer them supports from other services [like] the Salvation Army … they give you food
parcels, stuff like that. Helping them get organized with services like that to help with food supply …
that would help’.

Vouchers for groceries and nutrition ‘I feel like the first place to start are little vouchers … if you are in financial hardship and you don't want to
supplements tell anyone, you're going to take a voucher and you don't have to tell anyone about that’.

‘…supplements, maybe Elevit, offer any supplements or maybe, I think they mentioned Sustagen or
something’.

Food packs or hampers ‘…have food packs [in the clinic waiting room] … that's got everything that you need. There's a piece of
fruit, there's dairy, like milk or yogurt and sandwich or a muesli bar, that you could get at your
appointments. And I know that doesn't fix a whole problem, but even one meal when someone might
be struggling to get three on the table could be helpful. A volunteer [could] come around and kind of
offer it’.

‘…food delivery, maybe it might be weekly, fortnight, I don't know how. It will really help them at least
weekly if they will be able to until they deliver that baby. Wherever they are located so they can get
deliveries with the food that they select or the food that they want’.

Education for meal planning on a budget ‘I think some kind of access to education, whether that be classes or online or I don't know what it would
be, could be helpful if people were open to that’.

endorsed having a range of supportive strategies offered to them if
required. Women displayed a pragmatic attitude towards screening
and identified potential benefits, such as feeling supported by their
clinician to have a healthy pregnancy, and reduced pressure to
voluntarily articulate their hardship. The women in this study gave
suggestions for the implementation of food insecurity screening in
antenatal healthcare, to optimise their healthcare experience,
maintain their dignity and feel able to disclose within a safe and
caring environment. These results indicate that universal food
insecurity screening and support in the antenatal setting is likely to
have support from pregnant women and should be considered in the
reorientation of healthcare delivery to include this practice within
routine care. Identifying and responding to food insecurity during
pregnancy is a key step in laying a foundation that promotes optimal
nutrition and health for all pregnant women and their offspring and is
urgently needed to help mitigate adverse maternal and child health
outcomes associated with poor antenatal nutrition.
Women in this study perceived food insecurity screening to be
more acceptable during pregnancy than at other life stages. Women's
understanding about the importance of antenatal nutrition and their
perception of maternal responsibility to nourish their child in utero
contributed to this viewpoint. This finding highlights an enabling
factor towards food insecurity disclosure that may influence
antenatal clinicians to engage in routine screening. It also shows
that pregnancy could be an important time to initially identify food
insecurity within a household, given that women may be more likely
to disclose at this time for the sake of a healthy pregnancy. Other
research in the United States and Australia has shown that food‐
insecure, nonpregnant mothers often sacrifice the nutritional
adequacy of their own diet for the sake of their children.16,58,67 This
strategy of intrahousehold food allocation, among other coping
strategies to manage the household food supply, may lead
nonpregnant mothers to perceive that their food insecurity is
manageable and not serious enough for disclosure to healthcare
providers.58 Our study suggests that this may not be true for
pregnant women, who hold an alternative view to disclosure that
could be driven by their maternal identity. Although pregnant women
are not a homogeneous group of ‘unilateral devoted nurturers’,68 it is
important to consider that pregnancy may represent a window of
opportunity to identify and address food insecurity, highlighting the
need for screening to be embedded in routine antenatal healthcare.
When considering the operationalisation of screening, women in
this study expressed comfort with clinician‐led, in‐person assess-
ment. However, their approval was conditional on the sensitivity
shown by the clinicians they would encounter when disclosing their
food insecurity. The importance of clinicians' compassion to
encourage women's disclosure of sensitive information during
antenatal healthcare has been reported in other studies. For instance,
a synthesis of qualitative research into the experiences of help‐
seeking for perinatal psychological distress emphasised the impor-
tance of a clinician's nonjudgemental approach.69 Women included in
the systematic review valued discussing their concerns with a
clinician who seemed genuinely interested in their well‐being, who
did not seem too rushed and who was familiar to them,69 all findings
that concur with the views held by women in our study. Several
studies to determine reasons for pregnant women to disclose
intimate partner violence (IPV) have indicated similar findings relating
to the clinician's caring approach.70–72 Spangaro et al.70 used

ZINGA ET AL.
qualitative configurational analysis to model pathways of pregnant
women's nondisclosure of IPV to antenatal clinicians. The key
conditions for nondisclosure included a sense of feeling uncared for
by the screening clinician, demonstrated by their apparent discomfort
and closed body language, lack of explanation and framing the
purpose of screening and reading questions off the computer
70
screen. The synthesis of evidence that encompasses antenatal
screening of other sensitive topics such as IPV suggests that the
approach taken by the screening clinician is of particular importance
to decisions of disclosure. Findings in these fields point to the
significance of connection with the clinician, for pregnant women to
feel empowered to disclose.73 Further research into pathways to
disclosure and nondisclosure of food insecurity to clinicians could
provide more insight into training programmes for clinicians to
establish a safe environment for pregnant women to disclose.
Beyond screening comes the important action of managing food
insecurity within an antenatal healthcare setting. This is particularly
important for Australia, where there is no government‐led nutrition
assistance programme to support pregnant women, placing more
pressure on individual antenatal healthcare settings to respond.
Women in this study endorsed the opportunity to be offered support
by clinicians to address food insecurity, viewing this as a logical
follow‐up to screening and an expected component of clinical care.
Supportive strategies suggested by women ranged from grocery
vouchers to food packages; referral to external food aid organisations
was also welcomed. One previous study has reported high participant
satisfaction with a healthcare‐based intervention to address food
insecurity during pregnancy. In this small, quasi‐experimental study,
Fitzhugh et al.74 offered an emergency food package to pregnant
women who answered affirmatively to the Health Vital Sign, a
validated two‐item food insecurity screening tool, as well as a third
item that aimed to identify urgent need for food. Survey‐measured
participant satisfaction was ‘positive’, with over 71% of participants
rating their healthcare experience as ‘extremely’ satisfactory. 74
Further research into the efficacy and acceptability of healthcare‐
based interventions is needed to ensure that the needs of food‐
insecure pregnant women can be met within the resource limitations
of antenatal clinics. Given the potential challenges that some women
may face if they choose to disclose, such as domestic tension or
violence, the types of supportive strategies are important to consider
for women's safety and dignity. Therefore, supportive strategies
should include discreet options, like grocery vouchers and nutrient
supplements, for women's private access to avoid potential conflict at
home. Hybrid effectiveness–implementation studies would be
appropriate to explore food insecurity interventions during preg-
nancy and have previously been conducted in nonpregnancy
healthcare settings.75,76
4.1 | Limitations
Despite these clear and important study findings, there are limitations
to be considered. Selection bias is a limitation, as participants who
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| 9 of 11
were unwilling to or uncomfortable with being interviewed may have
alternative views towards screening and support compared to the
women who self‐selected to participate. Furthermore, this study was
confined to one metropolitan hospital; women attending rural
hospitals or other healthcare settings were not included. Future
research should investigate the views of food‐insecure pregnant
women living in rural and remote areas to complement these study
findings, given the additional barriers to obtaining food in rural versus
urban areas.77 A key strength of the present study is participant
diversity, including migrant women, which is an important considera-
tion as migrants and culturally diverse individuals experience food
insecurity at disproportionate rates.78
5 | CONCLUSION
The findings of this study that food‐insecure pregnant women
endorse routine food insecurity screening and support is important
for the delivery of antenatal healthcare to address this health issue.
This study provides understanding about the preferences of food‐
insecure pregnant women regarding food insecurity screening and
support, given the unique circumstances of pregnancy that may
influence disclosure and acceptance of help. Food insecurity
screening and support could be embedded within routine antenatal
healthcare, with care taken to maintain patients' dignity for safe
disclosure within a caring environment. Specifically targeting antena-
tal screening will leverage the multiple clinical encounters to identify
food insecurity and provide timely intervention, positively impacting
pregnancy outcomes for women and children.
A UT H O R C O N T R I B U TI O NS
Julia Zinga: Conceptualisation; investigation; writing—original draft;
formal analysis; methodology; data curation. Paige Pligt: Conceptua-
lisation; methodology; writing—review and editing; supervision. Fiona
H. McKay: Conceptualisation; writing—review and editing; method-
ology; supervision.
ACKNOWL EDGEM ENTS
Deakin University Higher Degree of Research funding was used to
fund this research. Open access publishing facilitated by Deakin
University, as part of the Wiley ‐ Deakin University agreement via the
Council of Australian University Librarians.
CONFLIC T OF INTEREST STATEM ENT
The authors declare no conflicts of interest.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the
corresponding author upon reasonable request.
ETHIC S S TATEM ENT
Ethics approval was granted by Royal Women's Hospital HREC
(02773/RWH‐22‐33) and Deakin University HREC (2023‐016).

10 of 11 | ZINGA
ORCID
Julia Zinga http://orcid.org/0000-0003-3339-9102
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SUPP ORTING INFO RM ATION
Additional supporting information can be found online in the
Supporting Information section at the end of this article.
How to cite this article: Zinga J, van der Pligt P, McKay FH.
Views and preferences of food‐insecure pregnant women
regarding food insecurity screening and support within
routine antenatal care Health Expect. 2024;27:e13956.
doi:10.1111/hex.13956