Monday, March 2, 2015

Weight Bias in Maternity Care: Weight Harassment and Over-Testing

Here is an email I received some time ago, detailing one plus-size woman's experiences with weight bias and harassment during pregnancy. I have redacted her name and location to protect her identity.

Her story perfectly illustrates several common forms of weight bias and obesity stigma that negatively impacts her medical care.

Is it any wonder that many people of size avoid seeing care providers when this is the treatment they get?

The Story
My name is xxxx, I live in xxxx with my [four children] and husband and I am a plus-size mama expecting my 5th child...I am 5' 5" and weigh around 200 lbs. (sometimes more, sometimes less).  I am a very active person, work out every day, keep a vegetarian diet and have never had any health problems whatsoever. 
When I had my first child I weighed 180. For my first 4 children I had an OB who is around 5 feet tall and a size zero who lectured me CONSTANTLY about the perils of being an "obese mom" and hounded me about every single ounce I gained.  
With all of my children I had terrible hyperemesis for the first 18-25 weeks, sometimes longer (and have had it again this time around, too) and that OB would tell me what a "Godsend" the hyperemesis was because it caused me to LOSE weight during that portion of my pregnancies (because of the hyperemesis I have only ever gained 20 pounds or less during any pregnancy). Her harassment got so bad I would wake up on the morning of appointments crying because I knew I had to go for a weigh-in. 
She even told me it would be better if I DIDN'T breastfeed any of my babies so I could immediately put myself on a 1000-calorie a day diet and take caffeine pills post partum to start losing weight rapidly before my obesity "killed" me. Thank goodness I didn't listen to this and breastfed all my girls till they were over 2. I believe I put up with all this treatment from my OB for years because I thought as a plus-size mom I "deserved" all the hostile behavior. 
When I found out I was pregnant with this baby (due in June) I decided enough was enough and switched my care to a highly recommended midwife practice so I would never have to see my previous OB ever again. At my first midwife check-up I was sick as a dog and weighed in at 207 lbs. My blood pressure was completely normal (as it always has been). I liked the midwife and I thought all was going well, had a positive prenatal exam, put on my clothes and was about to go to reception to make my next appointment when the midwife suddenly came back in and said she "forgot" to talk about an "issue."  
I sat back down and she proceeded to tell me my BMI labels me as obese (like I didn't know!) and as a result she wanted me to sign on for gestational diabetes testing EVERY FOUR WEEKS (I have NEVER tested positive for this, by the way!), wanted me to come in for "blood pressure checks" at the office every week even when I didn't have an appointment because she was sure I would develop high blood pressure due to my size, and then told me if I gained more than 5-10 lbs while pregnant I was seriously endangering my life!!  
I practically burst into tears! I've still been getting my care from her because I haven't been able to get in to see any of the other midwives in the practice with my schedule and don't have time to find another practice. I haven't been doing the monthly gestational diabetes testing (I tested negative on my first check and haven't been back) because I don't have time for it AND haven't been in for any of the aggressive extra blood pressure checks (I haven't had any high readings for appointments).  
I don't understand the rationale in the medical community for harassing, scaring and berating plus-size expectant moms. I plan to try again to get to a weight that I (and only I) find more comfortable/ideal for me after I have this baby, when I think it is healthy to do so - but where is the wisdom in treating me like a "weight criminal" now?  
You were right in your article that midwives need to treat every expectant mom AS an expectant mom, not as a patient who needs aggressive treatment for weight who also happens to be pregnant. If I have NO signs of any health issues or pregnancy complications, and everything is fine with my baby, then how is it necessary to focus on my weight RIGHT NOW? It's frustrating and demoralizing, and that isn't how any woman should spend her pregnancy! 
The Lessons To Be Learned

It's important to share this mother's experience because many in the medical field are in denial about the amount and scope of weight bias in medicine.

There seems to be a particular lack of recognition of weight bias and its impact on maternity care of heavier women.

This woman's experience highlights several common forms of size bias in maternity care, and it's important that caregivers become more aware of not only of the more egregious harassment, but also of the subtle biases that negatively influence care of women of size.

1. First, the most obvious bias in this woman's experience is her care providers' constant harassment of her about prenatal weight gain.

It's one thing to encourage "obese" women to have good nutrition and to be careful about weight gain, it's another to harass women to the point that they cry just at the thought of having to go in and be weighed. That's just wrong on so many different levels.

Women should not have to be afraid to go to their care providers, and they should always be treated with dignity and respect, regardless of what the number on the scale is or whether that number has gone up or down. Duh.

2. Second, the scare tactics this doctor used over prenatal weight gain were WAY over the top.

Yes, current recommendations recommend that obese women gain 11-20 lbs., and there are some in the medical field who advocate even less gain. But as we have pointed out before, there are risks to very low gains (including more prematurity and small-for-gestational-age infants), and deliberately restricting to achieve very low gains may result in poor outcomes

I would also point out that this woman's BMI puts her in the "Class I Obesity" category (BMI between 30 and 35). Research is clear that very low gains in this group is particularly dangerous. Yet here is a woman of Class I Obesity being told to gain only 5-10 lbs.!

This is the risk of hyperbole around restricted weight gain in pregnant women of size; many care providers hear the media stories and are taking the advice to an extreme, especially for those in the overweight and Class I obesity categories.

3. Third, it's beyond irresponsible for this woman's first care provider to pressure her away from breastfeeding so that she could focus solely on weight loss postpartum.

For one thing, breastfeeding often helps women lose weight and fat more efficiently postpartum (though this experience varies from person to person). If the OB truly cared about weight loss, she would be encouraging this mother to breastfeed.

For another thing, research has clearly shown that long-term breastfeeding actually lessens the risk of developing diabetes and heart disease, not to mention certain types of cancer.

If she had succeeded in discouraging this mother from breastfeeding, this OB might have actually caused worse health outcomes. What kind of an idiot doctor does not know this research?

4. Weight bias can take more subtle forms, too, like over-testing for complications.

Because obese women are at increased risk for blood sugar or blood pressure issues in pregnancy, many care providers assume that an obese woman will (or almost surely will) develop gestational diabetes or pre-eclampsia. As a result, may implement extreme over-testing. (I'm hearing about this more and more these days.)

This mother was encouraged to undergo monthly testing for gestational diabetes (rather than one test early and one test around 26 weeks or so) and WEEKLY blood pressure checks. This is an outrageous amount of over-testing and completely unnecessary, especially given the fact that the mother had never had blood sugar or blood pressure issues in her four previous pregnancies.

Most care providers do not require such frequent testing of blood sugar or blood pressure for their high-BMI clients ─ but some do, showing an inflated sense of risk about plus-sized pregnancies.

There is NO study ANYWHERE which shows that 100% of obese women develop these complications. In fact, although the prevalence of these conditions is increased in high BMI women, the research shows that many obese women do NOT develop them.

Over-testing is costly, invasive, and also has potential for harm. While it is important to be aware that high-BMI women are at increased risk for certain complications, it is also important to keep that risk in perspective and not over-react. Excessive testing is a major form of over-reaction to exaggerated perceived risk, and seems to be becoming more common.

5. Finally, the use of The Death Card is particularly offensive. 

"The Death Card" is frequently used with fat patients and is often used for the purpose of medical bullying, shaming, or scaring that person into compliance with the caregiver's directions. Counseling about risk is one thing, but The Death Card has no place in good medical care.

This mother was told that she would "seriously endanger" her life if she gained more than 5-10 lbs. in her pregnancy. This is complete nonsense. There is NO research to suggest that if an obese woman gains more than 10 lbs. that she is endangering her life.

Furthermore, the anecdotal experience of thousands of obese women (who typically gain somewhere between 10 and 25 lbs. in pregnancy and somehow manage not to die) contradicts this scare tactic. So does the experience of this mother herself, who had gained around 20 lbs. with previous pregnancies and was just fine.


The over-the-top mistreatment of obese women has gone too far. While there are care providers who provide gentle, respectful care to women of size (thank you!), I hear stories of weight bias like this far too often.

This kind of treatment is the result of researchers' (and media people's) exaggeration around risk in the pregnancies of women of size. It is also the result of the shaming, dehumanizing medical school "education" many care providers received on the topic of obesity.

It is time for medical schools and researchers to lay off the rhetoric and the shaming, and to focus on how to provide real health care for people of all sizes.

Women of size should not be treated like "weight criminals" when they are pregnant...or indeed, at any time EVER. Gentle, respectful care should be the norm for ALL people, whatever their size. 

*What would you like to tell this mom's care providers?


Kate said...

The over testing in pregnancy has got to stop. One of the reasons I left the practice where I had my first child was that when I went in to have my IUD removed they told me that once I got pregnant they wanted me to come in for GD testing every month starting at 6 weeks because my son was 10 lbs 4 oz at birth. Nevermind that his blood sugar levels were fine, I had a blood sugar level in the 90s during my screen and my husband in 6' 4" so there was literally no medical reason to think I was at risk for GD.

With this pregnancy (my 3rd) I started out 10 lbs heavier than with my first which apparently pushed me over the BMI edge to the point where the (new) midwives talked to me about it. They only talked about it though and offered me early GD screening instead of telling me I needed to do it. I passed, my numbers at the 26 week screening were the lowest I've ever had (83) and this baby is still on track to be a 10 pounder like his siblings (one of the nurses jokingly called me a "repeat offender"). The doctors at the ultrasound clinic on the other hand wanted me to spend a week checking my blood sugar 4 times a day and come in for a bunch of extra scans despite acknowledging that my history indicates that I just have big babies. Needless to say I passed on that with the support of my midwives but still...

Anonymous said...

This is shocking! I am first time fat mum, but my OB has been fantastic. I have been weighed exactly twice, the first when my pregnancy was confirmed, and the second at week 12 (I am now at nearly 30 weeks). I was asked to do the early GD test, which I did, as well as the later one. I passed both, I don't have the numbers but my OB wasn't concerned so I don't think it was close. My OB has never mentioned my weight at any appointment. My blood pressure has always been on the high side of normal and did increase during the pregnancy. By week 18 the OB decided to start on some drugs. The only time she asked for a weekly check up on blood pressure was a week after I started the meds just to be sure I was getting the right dose. We have also never talked about anything other than having a 'natural' birth, and no mention of needed to be induced early. Some of the stories I hear about how people are treated are just so awful.

Holly said...

With my second child I was subject to this type of abuse as well. I ended up having the exact birth I wanted - at home with midwives but it was a constant fight during my entire pregnancy to achieve this. I agreed to tests I didn't want or feel that I needed, just to get the midwives off my back! I really had to assert myself and remind them that my birth choices are MINE to make and that I was well aware of the risk factors associated with my high BMI. It was a lot more stressful then it needed to be.

It is a good thing we had the support of our Doula. To give birth a woman needs to feel supported and believe in herself. That is so much harder to do if you feel your caregivers don't even believe in you!

Anonymous said...

Fat shaming by "care" providers is one of the reasons why I chose an unassisted pregnancy and birth with two of my five children. I am pregnant with number five and I am feeling the shaming all over again from the midwives at a birthing center. I was looking for more support but I am not receiving it, so not sure if I will continue with them.