Background: Obesity is of growing concern across the sub-Saharan region especially among urban women and therefore one of the most common factors creating risk during pregnancy. An attempt to prevent the associated complications should be sought through lifestyle changes aiming at a minimal pregnancy-related weight gain. The literature suggests a greater acceptance of a larger body size and a tendency to develop body size misperceptions among women of African descent. This cultural construct may challenge efforts to introduce lifestyle changes. Objective: To investigate body image perceptions, body size misperceptions and attitudes towards life style changes among obese, pregnant women in Nairobi, Kenya. Design & Methodology: A qualitative study comprising of 18 semi-structured interviews with antenatal attendees of African descent at < 20 weeks of gestation with a BMI > 30 kg/m2. Body image, body size misperceptions and body image ideals were explored using a figure rating scale. Results: The introduction of lifestyle changes among obese, pregnant women in urban Kenya might be challenged in several ways; Body size misperceptions and tolerance of a larger body size were common findings. Lack of any acute health concerns, limited knowledge about obesity related pregnancy complications and skepticism regarding the relationship between health and body size represented additional barriers to change. Physical barriers to exercise such as fatigue and nausea were mentioned though the fear of miscarriage was the most important hindrance to engage in physical activity during pregnancy. Possible facilitators to initiate lifestyle changes were awareness of the weight problem among all respondents, previous attempts to lose weight among all except one and a positive attitude towards exercise in pregnancy and weight gain control when informed of its safety and the possible weight related complications. Conclusion: Health care providers managing obese pregnant women in urban Kenya must consider the cultural perception of body size, the possibility of body size misperceptions and the socio-cultural determinants guiding lifestyle choices in the development of targeted interventions addressing obesity in pregnancy.