We need to stop discriminating against plus-size pregnant women

Shelley Malcolm* was counting down the days until her first appointment with her obstetrician, but as soon as she stepped into the waiting room with her fiancé, she knew something wasn’t right. There were posters about healthy eating and exercise on the wall, she was weighed on a supersize scale and all of the expectant moms were fat. Instead of exchanging shy smiles with them, she avoided eye contact out of embarrassment.

Shelley, who is 5’9” and 280 pounds, had been funnelled into a program for pregnant women with a body mass index (BMI) of 35 or greater without her knowledge or consent after her family doctor referred her to an OB. She’d wondered if the doctor would bring up her weight, but she didn’t expect what happened in the examination room.

“I was looking forward to hearing the baby’s heartbeat, but the OB didn’t even check it. She didn’t even touch me,” says Shelley, now a mom to a one-year-old son. “She just talked about how bigger ladies have more problems.”

The obstetrician listed off a litany of risks, including experiencing epidural complications and post-delivery infections. She encouraged Shelley to attend the clinic’s group sessions on basic nutrition and exercise but didn’t ask about her health or lifestyle. “I was treated like I was just a BMI number. I felt really humiliated.”

If the doctor had asked, she would have learned that Shelley is active and regularly goes to the gym, but has struggled with her weight since childhood and suffered from anorexia in high school. She was on Weight Watchers when she found out she was pregnant.

Shelley was hoping to discuss her birth plan, but the obstetrician insisted she would be induced at 37 weeks, explaining that it’s easier for larger women who are more likely to tire out easily. Bigger woman often have bigger babies, which can make delivery longer and more difficult. Still, when Shelley mentioned her desire to go into labour naturally and try to avoid a C-section, her preferences were dismissed.

“I was immediately anxious and filled with fear that my dreams were suddenly being controlled by someone who wasn’t going to listen to me,” she says. “Not only was I was facing fat discrimination, but I was also being talked to as if I was unintelligent. I left horrified and crying, filled with shame.”

Facing weight discrimination Weight stigma is widespread in healthcare and can lead to anxiety, stress, depression, low self-esteem and negative body image. It can be particularly harmful during pregnancy, when women are at an increased risk of developing mental health issues and their bodies are being scrutinized more than usual. And discussions about things like how extra weight can put the baby at risk can lead to intense feelings of guilt when not handled properly.

“I was triggered emotionally when healthcare professionals would talk about my BMI or weight, as if I was less capable of having a child physically,” Shelley says. “There was definitely an underlying assumption that fat people choose food over health because they are undisciplined or lazy.”

Among Canadian women ages 20 to 44—primary childbearing years—38 percent are overweight or obese. The prevalence of weight stigma in maternity care hasn’t been documented, but a study published in the journal Obesity found that 69 percent of overweight and obese women have experienced discrimination from doctors, often in the form of inappropriate comments about their bodies. The study also found that doctors were the most frequent source of stigma experienced by women.

Several qualitative studies have found stigmatizing attitudes among maternity care providers, including feelings of discomfort and repulsion in treating obese women, as well as assumptions that they are unhealthy and lack the motivation to manage their weight. Women who are obese, in turn, report negative interactions with rude care providers who don’t take them seriously and leave them feeling shamed, isolated and ill informed. According to a study published in the journal BMC Pregnancy & Childbirth, weight stigma can lead women to delay medical appointments, avoid exercise and even develop eating disorders.

“People with obesity don’t get the same care,” says Yoni Freedhoff, founder of the Bariatric Medical Institute in Ottawa. “There can be a lot more judgment, which in turn affects the doctor-patient relationship and that person’s care.”

Shelley transferred to a different obstetrician, but she still experienced weight stigma. At her preadmission appointment at the hospital, a nurse was supposed to work with her on a birth plan, but quickly concluded that she would be having a C-section because her baby was still breech. Shelley said she was hopeful her baby would turn and inquired about having a breech delivery, but the nurse wouldn’t even entertain the scenario.

Research shows that healthcare workers spend less time with overweight patients and engage in less discussion. “I didn’t get to talk about anything,” says Shelley. “It felt very rushed and impersonal. There was a lot of disappointment.”

Shelley’s baby did turn and she went into labour naturally at 42 weeks but, after 30 hours of labour, she had an emergency C-section when her baby’s heart rate suddenly dropped. While she was signing the consent form for the surgery, one remark from the doctor stood out: “It just makes it a little trickier with all the extra…” he said, trailing off. “And I was wondering, the extra what?” Shelley says. “He literally couldn’t bring himself to say ‘the extra body fat.’”

The truth about weight and pregnancy There are some real risks that come with extra weight. Women who are clinically overweight or obese are more likely to have gestational diabetes, preeclampsia and C-sections, with the risk for each increasing with body mass, according to a study of 226,000 births in British Columbia. Their babies are also more likely to be bigger, have birth defects and develop obesity later in life. Some risks, however, may be overstated. For example, the BC study found that the rate of stillbirth only increased 0.1 percent among obese women.

Carrying extra weight in pregnancy is not benign, says Freedhoff. “But it certainly doesn’t mean that people should be discriminated against.”

Weight stigma stems from the belief that people are fat because they lack self-discipline. There’s a perception that obesity is reversible, which may be true in principle, but often not in practice. Several studies have shown that intensive exercise and diet programs typically only result in a weight loss of three to six kilograms, and many people gain it all back—and more.

While the most common factors behind obesity are overeating and inactivity, there’s often much more at play, including poverty, lack of education or physical or mental illness. Genetics, taking certain medications and diseases such as hypothyroidism and polycystic ovarian syndrome (PCOS) can also contribute to weight gain.

Restrictions from fertility care Tania Leclerc tried for four years to get pregnant before she finally went to her doctor. She had delayed seeking help because she was worried she’d just be told to lose weight—something she’d been trying to do for a long time. After two years of health and fertility testing, she was diagnosed with PCOS, which makes it both difficult to lose weight and to conceive. Leclerc was treated with Clomid, a medication that stimulates ovulation, and conceived on her first cycle.

When Tania and her husband were ready to have their second child, they figured it would be straightforward—they knew why they had trouble conceiving and had found a solution. But they had moved since conceiving their first child and were now seeing a different doctor. After waiting nearly a year to get into a fertility clinic in Ottawa, they were eager to move forward. But when the hopeful couple walked into the consultation room, the doctor shot them down before they even had a chance to tell their story.

“She literally looked at me and said, ‘Well, when you’ve lost weight, you can come back in, but until then there’s nothing we can do for you,’” Tania recalls. “She didn’t ask me any lifestyle questions.”

Tania didn’t even get a chance to tell the doctor about her PCOS or how her first child was conceived. After all the paperwork, she was shocked that she was rejected due to her size. The doctor sent them off with only a cursory suggestion to check out Weight Watchers.

“I was just floored,” Tania says. “I barely made it to the elevator and as soon as the doors closed, I started crying. I was so humiliated and unsure of where to go next. If the fertility specialist won’t help us, what are our options? We so badly wanted to have more children and I felt like I had failed yet again."

Many women are turned away by fertility clinics due to their size and some are even refused care by midwifery practices, often because their pregnancies are presumed to be high-risk. A 2014 survey found that roughly half of all Canadian IVF programs impose a BMI cutoff, citing reasons such as increased risks to mother and child, lower success rates and difficulty seeing and safely accessing the ovaries.

While some of these concerns are valid, it’s impossible to know if there will be obstacles accessing the ovaries until an ultrasound has been done. And there are still many successes when given the chance. A study published in the journal Fertility and Sterility looked at 239,000 IVF cycles and found that 34 percent of obese women got pregnant compared to 38 percent of women with a normal BMI. The live birth rate was 26 percent compared to 31 percent. Among women receiving intrauterine insemination, studies have found that the pregnancy rate is unchanged or even higher among women with obesity. However, women with obesity may not respond as well to fertility drugs.

Tania took matters into her own hands and called around to obstetricians until she found one who would prescribe her Clomid. She conceived her second child after about six rounds. But many women often have no other options. Their treatment may require the care of a fertility specialist and travelling to a clinic that doesn’t impose a BMI cutoff may be too costly or inconvenient. Sometimes, women may not even realize that there are clinics that don’t refuse care based on BMI, and so they take unhealthy measures to try to lose weight or give up on their dreams of having children.

A better way The Canadian Fertility and Andrology Society is preparing to release a clinical practice guideline on obesity and reproduction that does not endorse BMI cutoffs. The committee who wrote the guideline concluded that diet, exercise and even weight-loss medications typically don’t help patients reduce their weight (or keep it off) enough to meet BMI restrictions. Instead of a BMI cutoff, they recommend careful counselling of the risks and screening for metabolic abnormalities, such as uncontrolled diabetes and hypertension. Montreal fertility doctor Neal Mahutte, who chaired the committee, urges his colleagues to speak to women with “honesty, empathy and respect.”

“We’re not saying that there are not risks associated with obesity,” he says. “But at the end of the day, we believe in informing the patient, encouraging them to lose weight, but also recognizing that they may not be able to do that and that they have a right to make an informed decision and balance the risks and benefits.”

Change is also happening at a grassroots level. Three women in Winnipeg recently launched a website called Good Fat Care to help people find healthcare professionals and other wellness service providers who have made a commitment to providing inclusive, respectful care regardless of weight. Service providers who are featured on the site must pledge, among other things, not to make assumptions about health based on body size, not to promote a particular BMI as “normal” and not to encourage the pursuit of weight loss. More than 150 practitioners across the country have already taken the pledge.

“What people with abundant bodies really need is compassion,” says Lisa Naylor, a counsellor and one of the founders of the site. “We have to make healthcare more accessible to those who have experienced stigma or shaming by providers.”

The Women’s Health Clinic in Winnipeg is an example of one care team that’s making this happen. The clinic, which offers midwifery services and operates a birth centre, has chairs and medical equipment that can accommodate larger bodies, promotional materials featuring people of different shapes and sizes, and signs above the scales that read, “The number on the scale is not a measure of your worth.” The word “obesity” is off limits at the clinic because the care providers believe it pathologizes fatness.

“People come in different shapes and sizes. They always have, they always will,” says Trina Larsen, director of maternal health and wellness at the Women’s Health Clinic. “This societal notion that there is one shape or size that’s appropriate during pregnancy is completely destructive.”

The clinic offers community programs for women before, during and after pregnancy, with an emphasis on body acceptance and maternal mental health. In a postnatal workshop called Coping with Change, for example, there are discussions about how body changes can affect your mood and how you can be active with a new baby in a way that feels good for your body and your life. Women can also meet with dietitians who take a non-dieting approach to eating well and counsellors who understand the serious ramifications of weight stigma.

“We want our clients to feel valued and respected as a whole person, not just a number on a scale,” Larsen says. When you build a trusting relationship with women, they can be honest about some of the challenges they’re having, Larsen says. “It creates a much more open, therapeutic relationship.”

Shelley would like to expand her family, but her plans are on hold as she desperately tries to lose weight so she doesn’t experience the same harsh judgement again. “If I hadn’t faced any weight discrimination, I probably wouldn’t feel that way,” she says. “It would be great if I could find healthcare providers who don’t make me feel bad.”

*Name has been changed.

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