“I had a sonographer pat my stomach and say, ‘It’s difficult to get a clear picture because of this,’ meaning the extra weight I have.”
Amber, 26, lives in Cheshire and is currently pregnant. Because of her weight, she is classed as ‘high risk’ and is monitored closely for any issues. So far nothing has gone wrong relating to her weight but she says that doesn’t stop healthcare providers making comments like this.
“I think professionals need to stop expecting something to go wrong because of the mother’s weight,” she tells R29. “By all means monitor us more closely but don’t humiliate us by informing us each time we have an appointment and making us feel guilty.”
To be pregnant in 2022 is to have your behaviour and your body policed – by those closest to you, by strangers, by medical professionals, by the media. There’s never been more research available about the risks that can arise during pregnancy and the impact that can have on your future child. Mothers and parents are constantly warned about what to eat, how to behave, where they are going wrong.
These risks are particularly heightened in the public’s minds in relation to weight. In a fatphobic society we are already taught to be hyperaware of our weight and how it affects our health. This is compounded in pregnancy, where the weight shaming ranges from ‘jokes’ like the one made by Amber’s sonographer to shaming higher BMI (body mass index) women for getting pregnant at all to being constantly reminded that your weight means you and your baby are at ‘high risk’.
Undeniably there are risks associated with higher weight and pregnancy. But there are risks associated with any pregnancy, irrespective of weight. The way in which the weight risk is communicated and how pregnant women and people are treated strips them of their humanity.
In pregnancy, healthcare providers have a duty of care to explain that a BMI of 25 or above is associated with an increased chance of some complications for both mother and baby, says Dr Virginia Beckett, consultant obstetrician and gynaecologist and spokesperson for the Royal College of Obstetricians and Gynaecologists.
“Some of these risks associated with a higher BMI include an increased chance of thrombosis, gestational diabetes, high blood pressure, pre-eclampsia, induction of labour and caesarean birth.” These risks and how they can be reduced will be discussed within antenatal appointments.
“Over 70% of women will give birth to a baby that is an average weight for the time in pregnancy they were born, regardless of BMI,” she adds. “However, the chance of having a larger baby increases as BMI increases. This can increase the chance of women experiencing severe bleeding after birth and shoulder dystocia, where the baby’s shoulders become stuck during birth and extra help may be needed to deliver the baby.” Additionally, you are advised to take a higher dose of folic acid (5mg per day) if your BMI is 30 or above.
However, the way that risk is communicated is not proportional as it generally focuses just on weight as a risk factor, without taking other factors into account.
Ria is a 20-year-old expecting mum from Leicester. She tells R29 that she will happily say she’s fat and had no shame about it until her first midwife appointment. “As she took my BMI she turned really rude towards me and said my weight was going to harm my baby because of how big I am and that I’d have to go through so much to make sure my pregnancy is safe for my baby.” Ria cried for half an hour after that appointment. Since then no one else has been fazed by her weight, thanks to her healthy diet and regular supplements. She feels as if some midwives still look at larger women and “think we shouldn’t be mums because of how big we are and it’s just not a nice experience at all”.
Amber Marshall founded the group Big Birthas after her BMI was recorded at 45+ during her first pregnancy, putting her in the high risk group. “It was a healthy, unremarkable pregnancy, and a healthy, unremarkable birth. But in the hospital, my high BMI pregnancy status meant I was treated as if I was a ticking bomb,” she writes on the Big Birthas site.
Since that experience Amber has gone on to found the support group and dedicate her time to understanding exactly what the risks are and how they are communicated.
We had some women tell us that their weight dominated conversations to an extent that they were so convinced they wouldn’t bring a baby home that they didn’t put up a cot – that is how strongly they felt they were going to experience a bad outcome.
Rebecca Blaylock, WRISK
As Amber puts it to R29, the research tends to lump all people into BMI categories regardless of any comorbidities. This inadvertently skews the data, implying that weight is the only determining factor in risk. “If you drill down into the data on the studies where they have looked at other comorbidities, they’ve been able to see that the risk of shoulder dystocia, for example, is higher but potentially only because there are more people in that higher BMI group that have gestational diabetes, and if you have gestational diabetes, you’re more likely to have shoulder dystocia. Therefore, because there are more people in that group that have that comorbidity, it affects the numbers for the whole group.”
She points to PCOS (polycystic ovary syndrome) as another factor that can cause problems with fertility and a higher likelihood of miscarriage and is linked to (and often causes) higher weight. “But then to say to somebody like me, who never had gestational diabetes or PCOS or high blood pressure, that my risk of miscarriage is higher may not be correct. Until the research starts checking these kinds of problems, a lot of the data we’ve got is not that reliable.”
There has been some pushback against directing every instance of higher BMI into a high risk category. A 2011 study looking at the association between BMI and gestational diabetes concluded that “BMI can be used to counsel regarding the risk of developing GDM [gestational diabetes mellitus], but alone it is not a good screening tool.” And a 2013 study from Oxford University showed that looking at weight without looking at other health measurements does not determine the course of a pregnancy. “The increased risk was fairly modest for obese women who did not have conditions such as high blood pressure, diabetes or a previous caesarean section, and the risks were quite low if the woman had given birth previously,” said lead researcher Dr Jennifer Hollowell of the National Perinatal Epidemiology Unit at Oxford University at the time.
WRISK is a recently concluded research engagement project funded by the Wellcome Trust and run in collaboration with the British Pregnancy Advisory Service (BPAS) and Cardiff University, trying to understand the way in which risk is communicated in pregnancy and how it can be improved. Rebecca Blaylock, research lead of the project, tells R29 that the stories about weight that emerged from their 7,000 were “the most disturbing thing of this whole research project”.
In their research they found that about a quarter of people who responded to the survey felt judged for their weight (though they didn’t specify whether that was being overweight or underweight). “The main thing that came out for us was a routine dehumanisation and depersonalisation within the maternity care system,” she says. They spoke to women who had been told they were at an increased risk of becoming incapacitated during labour and were then present for conversations where medical staff talked about how they would handle their body should they become incapacitated. “That’s a really depersonalising way to talk about someone. The participants acknowledged that that was probably something that might have to be discussed, between staff, but not necessarily in front of them.”
My mother-in-law constantly asks if I’m having twins due to my weight, how big I am and how I’m carrying the baby. It made me really self-conscious. I went through severe depression after losing my son and struggled to work out. Then the comments made it worse and triggered me even more.
Samantha
Another strong theme was that people’s weight dominated every single interaction with the healthcare provider. “At the moment, within maternity care, the vast majority of women will see a different midwife for every single appointment and there’s no acknowledgment that your weight was discussed before,” Rebecca points out. Having to have the same conversation over and over again every time you see a new midwife is really difficult and demoralising, and can have a huge impact. “We had some women tell us that their weight dominated conversations to an extent that they were so convinced they wouldn’t bring a baby home that they didn’t put up a cot – that is how strongly they felt they were going to experience a bad outcome.”
One of the most significant themes was, again, a failure to contextualise risk. There’s a difference between being told you are at greater risk and being told what that risk is in relation to ‘normal’ weight pregnancies.
“Best practice in terms of risk communication,” says Rebecca, “is to report relative risk – how much more likely are you to develop gestational diabetes, for example, compared to an absolute or a baseline risk?” The problem is that we often don’t have that baseline risk to provide as a comparison. “So all you hear is your 40% more increased risk of something happening, for example, and alarm bells ringing but if there’s only a 0.001% risk of that thing happening anyway, a 40% relative increased risk isn’t a great concern.”
Using BMI in this way also doesn’t take into account the many different factors that can impact your weight. Samantha is a 34-year-old expecting mother who had a stillbirth last year and didn’t lose all of the weight before trying again. “During the first trimester I looked more like 20 weeks – my body just went back into pregnancy body. My mother-in-law constantly asks if I’m having twins due to my weight, how big I am and how I’m carrying the baby. It made me really self-conscious. I went through severe depression after losing my son and struggled to work out. Then the comments made it worse and triggered me even more.”
Even if you have made the decision to lose weight ahead of your pregnancy but are still considered ‘overweight’, that journey often goes unappreciated. “One woman we spoke to had lost six stone in the 18 months up to the point that she became pregnant,” says Rebecca, “and that was never acknowledged during her pregnancy. The response was always, ‘But you’re still fat’. She felt that the efforts that she had made just hadn’t been recognised and she was made to still feel like a failure.”
Clare Livingstone, the professional policy advisor and lead on public health at the Royal College of Midwives, emphasises to R29 that there are structural inequalities that impact people’s weight. “Being overweight and obese is more prevalent among women living in areas of high deprivation so there’s a clear inequality gradient there. Healthy eating is not always affordable for many women and some of the healthy eating advice that is given may not be culturally appropriate.”
The kicker in this scenario is that the advice is very clear: you should not diet while pregnant. “It is not advised that anyone who has a BMI over 30 and is pregnant should try to lose weight during pregnancy as this may not be safe and there is no evidence that losing weight while pregnant will reduce the chance of developing complications,” Virginia tells R29. It is important to stay active and eat well during pregnancy but this should stay within the range that is usual for you as that can help the body adapt to the changes brought on by pregnancy.
I really felt that the impression that healthcare providers and others have of women who are living with obesity is, ‘If you’re stupid enough to get yourself in this position (this position being overweight), then what other information can you not be trusted with?’
Rebecca Blaylock, WRISK
But the constant pressing of the weight button implies that weight loss is a) easy, and b) recommended in pregnancy. As Amber from Cheshire puts it: “Yes, I know I am overweight. If it was that easy to fix, I would have done so already. There is no use constantly raising the issue as nothing can be done until after the baby has arrived.”
Weight shaming can have major negative effects for anyone. It has been shown not to encourage weight loss and is associated with various health consequences including heightened cortisol and inflammation as well as unhealthy or disordered eating and weight gain. For mother or parent and child in particular, weight-based discrimination is related to more symptoms of depression and stress and predicts more symptoms of both postpartum depression and a retention of ‘baby weight‘ in the first year after having the baby.
Perhaps more insidiously, a byproduct of that shaming is a breakdown of boundaries between patient and caregiver as the former is repeatedly demeaned and dismissed.
Women with higher BMIs are treated as though they are stupid, Rebecca says. “This is just my personal reflection but I really felt that the impression that healthcare providers and others have of women who are living with obesity is, ‘If you’re stupid enough to get yourself in this position (this position being overweight), then what other information can you not be trusted with?’”
This leads in some instances to huge violations of privacy and personal boundaries. In the WRISK study, researchers spoke to a couple of people who had their details passed on to third party weight loss providers after declining that intervention when suggested by midwives. “But when they turned up at their next appointment with their midwife there was a representative from that organisation,” says Rebecca. “This is incredibly worrying from the perspective of patient consent but also how we can interact with third party organisations through the course of someone’s maternity.”
Ultimately, this can drive people away from healthcare intervention altogether. Amber of Big Birthas said that she was made to feel her pregnancy was “doomed from the start” and was denied a birthing pool on the day despite being told she could have one. She decided to have a home birth the second time around. “A lot of us the second time around are saying, ‘No, I’m not going to see the consultant. No, I’m not going to have the scans. No, I’m not going to take the glucose tolerance test,’ and I think that’s worrying too. Those checks and balances are in place to support us and protect us but when people aren’t feeling supported and protected and only feeling got at, they start avoiding other professionals who are meant to be there to help them.”
Pregnancy is scary and confusing enough without the added pressure and stress of fatphobia and weight stigma. And because of the way that risk is communicated, many women who have higher BMIs feel that they are simply ‘lucky’ to have had no issues and are therefore isolated from other expecting mothers. It’s only when these parents form communities – such as the support groups on the Peanut app that Ria, Amber from Cheshire and Samantha are all part of, or Amber Marshall’s Big Birtha groups on Facebook – that they realise they are far from alone. It allows higher BMI women to see that they’re not a lucky exception if they have a healthy baby and an easy birth ‘despite’ their weight, and opens the door for them to advocate for themselves.
The trouble of course is that fatphobia and fat stigma stretches far beyond maternity or even healthcare – it is endemic in society. And healthcare providers, as part of society, are just as susceptible to stigma and bias. Communities and information-sharing are key but things won’t change until healthcare providers stop seeing any person with a higher BMI, but particularly pregnant women, as potential ‘after’ photos.
As Amber Marshall puts it: “You’re trying to compare me with somebody I’m not. You shouldn’t be losing weight in pregnancy so at the point you’re pregnant, that’s where we’re at. And I need to know the risks for me, not the risks for me if I was three stone lighter.”
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