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WOMEN living with overweight or obesity experience weight stigma on average three times every day. That does not stop when they are pregnant, with our research showing that many of the health professionals women see throughout their pregnancy will add to the chorus of perceived criticism about their weight.
Most women with obesity report at least one stigmatising encounter during their pregnancy care. Research shows these women feel disrespected, hurt, judged, shamed, embarrassed and humiliated, blamed for their gestational weight gain and pregnancy complications, and subjected to assumptions about their food intake or physical activity level.
Even in women who feel their pregnancy offers a reprieve from fat-shaming, this soon disappears after the birth, when there is pressure to bounce back to pre-pregnancy weight.
For a woman living with obesity, it only takes mutters of “how are we going to birth this woman, we are going to need a larger bed”, or to see her weight status recorded on her medical record, to set off a chain reaction that can lead to poorer outcomes for both mother and baby.
Our research shows that obesity stigma among health care professionals can lead to low self-esteem, body dissatisfaction or depression. Weight stigma is associated with greater odds of developing gestational diabetes and with increased long term risk of excessive gestational weight gain and postpartum weight retention.
Women in larger bodies are more likely to report negative experiences of health care during their pregnancy than lower weight women (here and here). Research indicates in it not uncommon for health care providers to view women living with obesity as being “fat” or lazy, lacking self-control, or unwilling to improve their lifestyle. A focus on fetal outcomes, which inherently involves blaming the mother living with obesity, runs the risk of perpetuating weight stigma and creates a barrier to open and effective communication between clinician and patient.
We know that health care professionals are trying their best amid a rising tide of obesity in their pregnant patients. Our research shows that clinicians are often uncertain of whether obesity prevention is within their remit. The prevailing mindset is often around telling patients what to do and expecting them to go away and do it, and then treating obesity-related complications if they occur.
But that is not a useful narrative for women living with overweight and obesity, who know that the reasons for their weight gain go beyond personal responsibility.
For example, it is well acknowledged in the draft National Preventive Health Strategy and by the World Health Organization that obesity is driven by a complex interaction of factors, including the environments to which people are exposed.
These factors include access to affordable, nutritious food, a built environment that supports physical activity, socio-economic status, employment, education, and health literacy – all of which are outside women’s control.
Rather than place the responsibility on the individual, it would be more worthwhile and meaningful for health care professionals to acknowledge the role played by the system and to find effective suggestions for supporting lifestyle health through pregnancy.
With over 50% of women in Australia now experiencing overweight or obesity during the reproductive years, there also needs to be a better way for health professionals to approach discussions about healthy lifestyle during pregnancy.
Since shame is a significant barrier to women in asking for help with their weight, the best way to start is to remove stigmatising language. We need to shift the shame and the onus away from the individual and to really understand how we can support women better.
For example, rather than putting an emphasis on dieting, the discussion could be around supporting women to be the healthiest weight they can be through making healthier choices. And this support should reach women where they live, work and play.
The National Health and Medical Research Council Centre of Research Excellence in Health in Preconception and Pregnancy (CRE HiPP) is focused on developing evidence-based strategies and interventions, codesigned with women for women and culturally tailored to be relevant, meaningful and applicable for all women.
As one example, CRE HiPP is developing HiPP workplace portals — one-stop shops that women and their partners can access easily to source information about maternity leave and return to work entitlements, policies, and procedures, evidence-based lifestyle health information and the opportunities available at their workplace to be the healthiest they can be before conception and during pregnancy. This portal engages the workplace in supporting women, taking away the focus on individuals and celebrating the importance of valuing female employees who are trying to become, or who are, pregnant.
Some good resources for health professionals can be found on the following websites: The Obesity Collective, the Weight Issues Network, ObesityUK’s Language Matters Guide, and CRE HiPP’s website.
Women will see numerous health professionals throughout their pregnancy and their children’s early years. If we all start from a point of non-judgement and focus on the importance of lifestyle without stigma, we are more likely to see better pregnancy and infant outcomes.
Indeed, maternal obesity is a societal issue that we must all tackle with a shared vision to protect women’s health during pregnancy and the health of their children, our next generation.
Professor Helen Skouteris is Director of the Centre of Research Excellence in Health in Preconception and Pregnancy.
Dr Claire Pearce is Assistant Professor in Occupational Therapy at the University of Canberra.
Dr Briony Hill is an NHMRC Early Career Fellow at the CRE HiPP.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Corrected version:
I wholeheartedly agree with commenter Cat. Yes, language does matter. I am still not convinced that the “person first” (“…a person with obesity…”) language solves very many problems. And lumping “overweight” together with “obese” only serves the purpose of making your audience more horrified at the high percentages. I do believe that there is a component of personal responsibility that should be assigned here: It is your responsibility to refuse to accept society’s judgmental vview of you and your larger body; responsibility to fire any doctor who makes you feel badly about yourself, or refuses to treat your actual medical problems without prejudice; and filters out the chorus of healthcare professionals who want to surgically intervene and ruin your digestive tract because they want to make you thinner—but at what cost?
My first wife had two normal births despite the fact she was fat, and she chose ob/gyn specialists to help her through pregnancy and delivery, on the basis that they had reputations for being even-handed in dealing with the larger patient. She was not disappointed, and one of her doctors told me that he considered her weight to be a minor risk factor, exceeded by a list of 20 or so other conditions he considered riskier. He also apologized for the negative attitude so many of his colleagues exhibited toward their higher-weight patients!
And the comments here exemplify the problem perfectly. The attitude and language in these comments are unhelpful (and potentially dangerous) for all the reasons discussed in this article. It is time for the medical curriculum to evolve and for current health professionals to leave their own weight-shaming attitudes in the past where they belong.
I rarely comment on anything online but as someone who provides anaesthesia and epidural analgesia to obstetric women I feel compelled in this case. I work in an area of very low socio-economic status and the BMIs of women are typically over 40 or 50 or even more. It is a major challenge to provide these women with safe medical / anaesthetic care or meet their needs for epidural analgesia during labor. The stress levels are enormous and the outcomes often unsatisfying. My colleagues and I are respectful and supportive and provide the best anaesthetic care we can. I don’t think it is too much to ask for women to be responsible for their own bodies.
I was recently involved in rewriting a clinical guideline on obesity in pregnancy. There was a push by some authors to change the wording from overweight and obesity to “women with larger bodies”. I personally find this term condescending. A questionnaire was circled and completed, with very few medical practitioners supportive of the changes. I’m disappointed to see the same push in “Insight”.
Only two comments 1) personal responsibility: are we responsible for adults who don’t really grow up? 2) Bariatric surgery: the treatment of an overwhelmingly psychological condition by surgical means. References freely available if you search the literature.