Implementing gestational weight gain guidelines in midwifery practice: a qualitative study using Normalisation Process Theory

: Gestational weight gain (GWG) is an important component of antenatal care, yet most women do not achieve healthy GWG and implementation of guideline-recommended care remains inconsistent in Australia. : To explore factors influencing adherence to GWG guidelines, using Normalisation Process Theory (NPT) as an implementation framework. : A qualitative study, involving semi-structured interviews with 12 midwives from diverse clinical settings across Australia. Thematic analysis was conducted, guided by implementation theory constructs. : Midwives described varied understanding and prioritisation of GWG care. Limited education and professional development (Coherence) contributed to uncertainty about its importance and scope, with some questioning BMI-based targets and favouring holistic approaches focused on nutrition and wellbeing. Continuity of care (Collective Action) supported trust and personalised discussions but also allowed selective practice shaped by beliefs. Systemic barriers including time constraints, fragmented models, and restrictive referral pathways (Cognitive Participation) hindered consistent implementation. Midwives critically reflected on GWG care (Reflexive Monitoring), noting potential stigma and harm to therapeutic relationships. Many adapted practices by softening language, tailoring conversations, and prioritising relational safety over strict weight targets, while calling for clearer guidance, better monitoring systems, and supportive interventions. : GWG care is influenced by intersecting individual, professional and system-level factors. Targeted training in trauma-informed, non-stigmatising care and addressing structural barriers are essential to strengthening guideline adherence. : Embedding GWG care into routine antenatal practice requires multi-level strategies that leverage midwives’ professional strengths while addressing gaps in knowledge, training, resources and governance.