9th Turkey Awards: Obesity Eugenics Media Campaigns

A fairly recent article in an Australian newspaper ─ October 2016 ─ had the inflammatory headline, "Call to stop obese women from having babies." The picture below it featured a woman with a slight double chin and said, "Experts warn obese women should not have children."

Well, here we go again with the Obesity Eugenics Wars. This incredibly discriminatory movement is the winner of not one but two Turkey Awards. It's time to call these egregious practices out.

If you aren't familiar with them, the Turkey Awards are the "prizes" I hand out to highlight fat-phobic treatment of people of size from care providers, biased attitudes or studies from researchers, or troubling trends in the care of fat pregnant women these days.

In past years of the Turkey Awards, we've talked about:

• #1: fat-phobic care providers
• #2: scare-mongering and shaming tactics
• #3: jumping to conclusions about risks
• #4: scorched earth tactics
• #5: prenatal weight gain extremism
• #6: fat-phobic attitudes around treatment of PolyCystic Ovarian Syndrome(PCOS)
• #7: astronomically high cesarean rates in women of size
• #8: weight bias in the treatment of lipedema 

I haven't done a Turkey Award in quite a while, so I'm doing two years in a row now. To make it easier to read, I'm splitting one giant post up into two. Today's post is about attention to the Obesity Eugenics Media Campaign and its impact on women. In the future, we will highlight the egregious lack of access to fertility treatment for high BMI women and how this plays into Obesity Eugenics.

Obesity Eugenics: The Media Campaign

Headline from 2016 Australian news article

There has been a concerted public health campaign in recent years to vilify fat pregnant women, scare them away from pregnancy via risk hyperbole, and present only negative stories about fat pregnancy in the media.

This is because many doctors seem to believe that fat people have no business having children. Here's a recent comment from one OB:

Obese women shouldn't even get pregnant. 

This is a common opinion among some healthcare providers. While having a miscarriage, one women of size was scolded for being upset. She was told:

Why are you crying? It’s not like you lost anything. A woman your size has no business being pregnant anyway.

The caption under the picture for the above news headline is

Experts warn obese women should not have children. 

Although these experts justify their actions by saying it's for the sake of the children to get around criticism, that's baloney. This is nothing more than weight bias, pure and simple, combined with the arrogant belief that doctors should be the gatekeepers to who is allowed to reproduce. 

And that is completely unacceptable.

Objective Reporting?

Article from the New York Times, 2015

There have been a series of media articles in recent years designed to discourage obese women from having children unless they reach a "normal" BMI first. These articles have hardly been objective. They use scary headlines, cite worst-case scenarios, use emotionally manipulative language, and rarely represent any other point of view.

Because of our society's dogged belief that obesity is all about willful sloth and gluttony, communication about pregnancy in people of size has taken on an ominous moral overtone. The implication is that if the mother would only show a little self control, she could stop irresponsibly putting her baby at risk. Some imply that obesity during pregnancy is equivalent to child abuse.

Some articles portray fat mothers as despicable food addicts, akin to drug addicts and alcoholics, endangering their babies with their addiction. In the U.K., National Health Services health chief Jonathan Sher recommended in 2016 that certain women should be advised not to have children:

He wrote that “health professionals, pharmacists and community workers” should all take part in giving the advice to these groups of women, who include the obese, drug addicts, domestic violence victims, and women who suffer from depression.

Lovely. So now fat people are looked at the same as drug addicts? A 2015 article trumpets that it's time to "make obesity the new pregnancy taboo."

Well, we are certainly well on our way towards doing that. Look at the titles of a number of recent articles or books about obesity and pregnancy.

• 10 Scary Reasons to Fight Obesity Before Pregnancy  (2011)
• Pregnant, Obese, and in Danger  (New York Times, 2015)
• Obese Mums-to-be Risking Their Own and Their Babies' Health (The Mirror, UK, 2012)
• Obese and Pregnant: Bad for Mother and Baby (Real Clear Science blog, 2015)
• Growing Obesity Increases Perils of Childbearing (New York Times, 2010)
• Obesity: A Ticking Time Bomb for Reproductive Health (ebook, Elsevier, 2013)
• Call to Stop Obese Women from Having Babies  (The New Daily, 2016)
• Don't Have Babies, Health Chief Tells Addicts and Obese (Metro News, 2016)
• Don't Call It Fat-Shaming - There are Good Reasons Obese Women Shouldn't Get Pregnant - The Spectator, 2017

These are not the titles of objective pieces. These articles don't just raise awareness about risks. These articles have an obvious overt agenda, and that is to strongly discourage fat women from having children at all.

These articles are not meant to inform, but rather to scare, shame, and intimidate women of size. They're meant to promote a climate of hostility towards high BMI women among healthcare providers and society in general. It's meant to paint people of size as irresponsible and out of control. It's fat-shaming and scare-mongering, pure and simple.

Often, these articles feature an apocryphal story of an obese woman with severe complications as a cautionary tale. This is often a woman of color, accelerating the stigma even further. These stories imply that fat women are all at equal risk for such a dire outcome, and that anyone who dares to be Pregnant While Fat is the ultimate Bad Mother. Or as one blogger puts it, "fat is the new crack" in bad-mother blaming.

Anyone reading these articles might well conclude that virtually no fat woman has EVER had a healthy pregnancy or a healthy baby, that the ONLY way to have a healthy pregnancy is to lose vast quantities of weight first, and that the vast majority of fat women experience MAJOR complications and bear only deformed or doomed babies. And that simply doesn't jibe with the experiences of most fat mothers.

Exaggerated Scare Tactics

Article from The Spectator, 2017

One of the main ways the media and some doctors discourage childbearing in fat women is by using exaggerated scare tactics. We've talked about scare tactic hyperbole before in our 2nd Annual Turkey Awards on Scaremongering and Shaming Tactics. But of course, this tactic is still alive and kicking, as demonstrated in the above articles.

This is where "experts" get to pretend that they only have the best interests of women and children at heart when they publish inflammatory articles like these. It's not weight bias, oh no! After all, pregnancy while obese has risks, right?

The 2017 article article above claims it's not stigma, it's just their concern for you. In other words, it's the medical version of Health Concern Trolling.

Don't call it fat shaming ─ there are good reasons obese women shouldn't get pregnant. Some will say that this is ‘fat shaming’, but it’s just what we do in the medical profession; the identification of risk and its amelioration. We can’t sacrifice the health of mothers and babies on the altar of political correctness.

The article then goes on to recite in scary language how obese women have higher risks for various poor outcomes, without giving any context to those risks, and without acknowledging that only fat people are targeted in this way.

Yes, women of size have increased risks of some outcomes, such as gestational diabetes, blood pressure issues, certain birth defects, and stillbirth. It serves no one to pretend otherwise, and I believe firmly that women of size should understand the potential risks. I write about these potential risks so that women of size can come from an educated and empowered point of view, and decide for themselves what to do about them.

However, it is important to have context to any discussion of risk. 

For example, a recent 2015 article is a meta-analysis of the risks of obesity and pregnancy. Again, as so many of these scare tactic articles do, it distorts risks by using relative risk ratios without any actual numerical risks. This makes the risks sound far more grave and life-threatening than they are.

For example, past research has suggested that obese women have an increased risk for certain birth defects such as Neural Tube Defects (NTDs). Scare-mongering articles always highlight the birth defects risk in particular in media campaigns because it holds so much emotional resonance. Fat women are giving birth to deformed babies! If they weren't so selfish, these birth defects could be prevented!

It's true that obese women have an increased risk for NTDs; some studies have found 2-4 times the risk for Neural Tube Defects (NTDs) in obese and very  obese women. Sounds scary, doesn't it? Yet rarely do the articles mention that double or even quadruple a very small risk (about 1-2 per thousand) is still a very small risk. Do the math. Even if there is an increased risk, less than 1% of obese women will probably have a baby with a NTD.

Expressing it in relative risk (Two times the risk! Four times the risk!) makes it sound scarier and provides a juicier sound bite for the media. But what high BMI people really need to know is what the absolute numerical risk is and what they can do to lower their risk for a NTD. [Answer: To lower the risk for NTDs be sure your blood sugar is normal before pregnancy, stays normal during pregnancy, and possibly take a higher dose of folic acid before and during early pregnancy.]

Gestational diabetes (GD) is another risk that is frequently mentioned in these articles. The risk for GD is about 3-5% among the general population, but it increases to around 15% or so in high BMI women. This is definitely a substantial increase and a potential cause for concern because it may lead to other complications.

However, reverse the statistics and you realize that about 85% of high BMI women do NOT get gestational diabetes. The risk is definitely increased but it is hardly overwhelming. Do you come away from articles on obesity and pregnancy with the impression that more than three-fourths of very fat women will NOT be diagnosed with gestational diabetes? Nor do most articles point out that even if someone develops GD, it is a very manageable condition. Most people with GD are able to control it and have healthy babies.

Yes, women of size are at increased risk for some complications, but being at increased risk does not mean that complications will happen. Many women of size have healthy pregnancies and healthy babies, a fact conveniently ignored by these media articles. They only feature stories of scary complications in order to frighten people of size out of considering pregnancy. You don't scare people away from pregnancy with stories of normal pregnancies and good outcomes.

Nor should facing potential risk disqualify you from motherhood. All kinds of women are at increased risk for complications due to various factors (age, family history, racial or ethnic status, various health conditions) but are rarely told that they have "no business being pregnant." Their risk status is acknowledged and counseling toward risk mitigation is given. The same can be done for women of size.

In dealing with women with risk factors, the focus should be on helping them have the healthiest pregnancy possible, while acknowledging possible complications ─ not trying to keep them from ever having a baby.

It's deeming people with some types of risk factors (like type 1 diabetes) as worthy of having babies despite the risks, and people with other types of risk factors (obesity) as unworthy of having babies. This suggests a bias and stigma, a real implication of a eugenics agenda, even if it is an unconscious one.

Many caregivers recognize that plenty of people of size will have perfectly fine pregnancies and healthy babies despite their size. They also know that in those who do experience complications, the emphasis should be on kind and empathetic care in helping that person towards the best possible outcome, not on scolding and judgment. Even complicated pregnancies can often have good outcomes with supportive care.

It is NOT an irresponsible act to have a baby at a larger size. Yet many of these alarmist articles imply that it is. It's NOT up to doctors to decide which patients with which risk factors should procreate. Rather, it is up to the couple to look at their particular risks and make an informed decision about having children or not. 

Reasonable risk counseling is appropriate, medical bullying through risk hyperbole is not.

It's not that we cannot discuss possible risks. Of course we can; that's an important part of the healthcare conversation. However, public health discussions about weight have gone from discussing possible risks, to making sweeping generalizations and exaggerations of risk in the public's mind, to scapegoating, scaremongering, and suspension of basic rights by healthcare professionals.

What these experts fail to realize is that weight stigma in public health campaigns often backfires and leads to worse outcomes, not better ones. Stigma affects health negatively. Increasing stigma for people of size does not improve outcomes.

When media coverage quotes "experts" who criticize women of size in inflammatory language for even considering pregnancy at a larger size, when it refuses to acknowledge that many women of size DO have healthy pregnancies and babies at higher weights, when it distorts risk, when it makes sweeping behavioral generalizations, and when it attempts to keep plus-size people from procreation through guilt and dire predictions, that IS indeed fat shaming.

Just Lose Weight First?

Headline from 2012 article in The Mirror

Some doctors are very supportive of people of size, but others are uncompromising and rigid about weight. They believe that no one should get pregnant unless they are at a "normal" BMI. From a 2017 article from the U.K.:

It is imperative that women should be discouraged from trying to get pregnant until they have attended to any excess weight.

These doctors just don't get it. Being fat and wanting children poses a difficult set of choices, and that it's not always as simple as "eat better and exercise and you'll magically lose weight and be healthy enough for a pregnancy."

Getting to so-called "ideal" weight is simply not a realistic goal for most fat people before pregnancy. Even when eating well and exercising regularly, many people of size stay fat. Even the fall-back stance of "lose just 5-10% of your weight" can have negative outcomes in real life too, as it often triggers a rebound to a weight greater than the starting point.

Doctors want simple answers, but there are none. The fact is that nearly all fat people have tried repeatedly to lose weight, and rarely is it lost permanently. Frankly, if there really were an easy, foolproof way to lose weight permanently, we'd all be skinny. It's NOT just a matter of willpower, and research shows that long-term weight loss is very unlikely.

Most fat people have lost weight time after time, only to see it come back over time. Many of us end up fatter after a weight loss attempt than before we began it. In fact, for many of us, yo-yo dieting is what actually put us in the "morbidly obese" category in the first place. For others, strong genetic and hormonal factors may be at work, making reaching that "ideal" weight statistically extremely unlikely.

When faced with people like this, doctors often suggest bariatric surgery. Weight loss surgery does reduce BMI, but research shows significant trade-offs. There are reduced risks for gestational diabetes and large babies, but also increased risks of prematurity, too-small babies, and possibly neonatal mortality. Nutrient deficits are common and there is an increased risk for intestinal hernias; pregnancies after bariatric surgery must be monitored closely. There are no easy answers here.

Many people stop weight loss attempts because they recognize that all the yoyo-ing is hurting their health far more than it is helping it. When they do this, they are not "giving up" or "letting themselves go" but instead focusing on healthy habits instead of weight loss as a measure of health. These habits often do not lead to significant weight loss, but people are still healthier by simply emphasizing good habits and weight stability.  This approach is called "Health At Every Size" (HAES).

For some, the decision to have a pregnancy at a larger size is one chosen once we recognize that long-term weight loss is not likely to happen and if we wait to reach that "ideal" weight range, we may never have a baby.

Don't think that experts don't realize that. They do. Either they are deliberately deluding themselves about the long-term success of weight loss, or they are subtly trying to take fat people out of the reproductive pool.

Another factor to consider is that dieting before pregnancy may deplete the body's stores of vital nutrients (particularly iron), just at the time they are needed most. Many "morbidly obese" people have significant micronutrient deficiencies already; repeated dieting may be part of that. Some consciously choose not to restrict intake or undergo malabsorptive surgeries before deciding to have a baby because of this concern. We do this out of love, not out of selfishness.

Some people of size do choose to try and lose some weight before pregnancy; not necessarily down to "ideal weight" but at least a little bit in hopes of lowering risks. Everyone is an adult and gets to make their own choices. There is some research that it might improve some outcomes modestly. But is that the effect of actual weight loss or an effect of a change in habits?

On the other hand, weight loss before pregnancy can also backfire, even modest amounts. Many of these women find that once pregnant, the body rebounds with a vengeance, gaining far more weight than "should" be gained in pregnancy as the body tries to store fat for the starvation period it thinks it is in. And gaining a great deal of weight in pregnancy is not ideal for anyone, mother or baby.

There is also some research that suggests that dieting behaviors or weight loss product use just before or around the time of conception increases the risk for birth defects. So while losing even "just a few pounds" before pregnancy may seem prudent, it could have unforeseen consequences too.

The bottom line is that there are no simple solutions. The best thing a person of size can do is to focus on improving health habits before pregnancy. This doesn't have to center on weight loss. For example, regular exercise is one of the most powerful things people of all sizes can do to improve their health before pregnancy. Checking that you have normal blood sugar and blood pressure before conceiving is a very important way to improve outcomes. Starting a prenatal vitamin and extra folic acid before conception is also a good idea. Emphasizing good nutrition can also be helpful, regardless of whether it results in weight loss.

Some people of size choose not to wait till we are "ideal weight" before having kids because we know that there are risks to getting older too. Age decreases fertility and increases some pregnancy risks. We may decide that it's better to act sooner than later. 

Some of us believe that having a child at our present weight makes more sense than putting off pregnancy for years in an effort to lose weight. It's better than gambling on losing weight and then trying to keep the resultant pregnancy weight gain to "acceptable" levels, or to start out a pregnancy nutritionally-compromised from recent weight loss attempts or bariatric surgery.

Having a child at a higher weight does not mean we are ignorant about nutrition and exercise, that we are recklessly exposing children to potential risk because we are too lazy or stupid to "eat right." Many of us have very normal eating habits and do not fit the stereotypes of junk food, overconsumption, and gluttony.

Ultimately, the final choice about whether or not to lose weight before pregnancy is up to each individual. Some may decide to, and that's their choice. However, choosing not to lose weight first doesn't mean we are ignorant, uncaring, or unhealthy. Instead, for many of us, it may represent what we think is our best chance for a healthy pregnancy and baby. This is not an act of selfishness but an act of love, hard as that may be for some critics to understand.

Researchers need to STOP trying to scare and shame fat women out of reproducing and pretending that they only have the noblest of intentions at heart. They need to STOP implying that fat women are irresponsible for considering reproducing, or that the only safe way for a fat woman to have a baby is if she loses weight first. The fact is that many fat women have healthy pregnancies and babies without losing weight. Experts need to study those women and see what can be learned from them.

Intersectional Stigma

Headline from The New York Times, 2010

These media articles don't just stigmatize fatness; they often reflect other societal stigmas. This is intersectional eugenics, where women of color who are also women of size or disabled in some way are being stigmatized even more.

In the New York Times article above, the cautionary apocryphal story about obesity in pregnancy is a woman of color. Of course, it's an extreme story. The woman, in her 30s, was already diabetic with kidney issues when she became pregnant. She gained a lot of weight in pregnancy, had a stroke, and her baby was born prematurely. She is pictured mournfully sitting by her extremely small son, touching his tiny feet, in the Neonatal Intensive Care Unit (NICU), and looking regretful.

Imagine what happens when people with multiple marginalized social identities present for pregnancy care. Stigma increases even more. And it's no mistake that people with multiple stigmas are used as the "bad examples" in media articles, especially in the U.S. It's an unconscious desire to increase the "othering" of people of size in the minds of the public.

Weight stigma in pregnancy is already considerable. Caregivers report being repulsed and having less respect for people of size, along with concern on how to deal with fat pregnant women. They often assume that fat people lack "necessary skills, awareness, or motivation to manage their weight." They may view people who have become pregnant at a higher weight as irresponsible. One article notes:

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.

Various racial groups, particularly African-Americans, also often experience great stigma in pregnancy. This may help explain why they have a higher risk for some poor outcomes. An excellent 2017 article from National Public Radio (NPR) explored black maternal health in pregnancy and found that blacks had far higher rates of maternal death during and after birth. The NPR article summarized (my emphasis):

According to the CDC, black mothers in the U.S. die at three to four times the rate of white mothers, one of the widest of all racial disparities in women's health...In a national study of five medical complications that are common causes of maternal death and injury, black women were two to three times more likely to die than white women who had the same condition.

According to the NPR article, the difference in maternal mortality between blacks and whites is not attributable to education, socioeconomic status, or access to healthcare. African-American women with every advantage still have poorer outcomes in general. Much of this is due to the stress of long-term exposure to racism and stigma.

What has been surprising recently is the discovery that black women are particularly vulnerable after the birth. More than half of maternal deaths occur postpartum, and people who experienced high blood pressure or cesareans are particularly vulnerable. Black women have higher rates of both blood pressure issues and cesareans. Add in chronic stress from racism and care models that chronically neglect women after birth and you have a recipe for poor outcomes.

The intersection of race and weight leads to even more stigma. The NPR article related the story of a young black Florida mother-to-be whose breathing problems were blamed on obesity when in fact her lungs were filling with fluid and her heart was failing. Getting providers to listen and take your concerns seriously is difficult, especially if you are a person of color and size.

That's why it's even more shameful when articles about the dangers of obesity and pregnancy feature women of color as their bad-mother examples; it multiplies stigma. As Abigail Saguy and Kjerstin Guys of UCLA note, articles that feature a cautionary example of a poor person of color "reinforces social stereotypes of fat people, ethnic minorities, and the poor as out of control and lazy...In the contemporary United States, body size intersects with other dimensions of inequality."

Most researchers and care providers do not consciously wish to stigmatize women of color or women of size. They want to improve outcomes, which is a good goal. But some are tone deaf. They refuse to understand that the public health campaigns they are waging around obesity and pregnancy are far MORE stigmatizing and have begun to venture into the eugenics realm.

Direct Pressure for Sterilization or Termination 

Article from The Daily Mail, 2016

The attempt to limit who can procreate doesn't just stop with scary media campaigns, hyperbole about risk, and pressure to get to a "normal" BMI first. Pressure for sterilization or termination (abortion) is another way that providers try to limit family size in high-BMI women.

We should be clear that most providers don't do this. However, it is real and it has happened. And that is inexcusable.

In the U.K. story behind the above headline, pressure for sterilization was direct and over the top. Her 5th pregnancy was a surprise pregnancy with twins, conceived despite being on birth control (which may be less effective in larger women). She was diagnosed with gestational diabetes during the pregnancy, not an uncommon finding in twin pregnancies. She was told in no uncertain terms that another pregnancy could kill her and that she needed to strongly consider sterilization:

'At 31 weeks pregnant the consultant sat me down and was blunt. Firstly he said the diabetes could cause the girls to grow quite large so I would need a C-section. And then he said another pregnancy would most likely kill me as even if I weren't pregnant, I was at a high risk of becoming a diabetic, ending up in a wheelchair and having a heart attack. As such doctors suggested I should not become pregnant again and I could be sterilised during the C-section.

And indeed, that's what this mother chose to do. The doctor was sufficiently scary in his predictions that she permanently ended her childbearing.

Sometimes the pressure is subtle, as in refusing to remove birth control devices. One Canadian woman recounted the story of her doctor who refused to remove her IUD because he felt it would be a "disaster" for her to become pregnant. Although this is not permanent irreversible sterilization, it is a de facto sterilization.

Other fat women have been pressured to have their tubes tied when they have babies. Gina Marie's story from my website shared the tale of a woman who was pressured for sterilization during labor. This is an ethical violation; ethics guidelines state that women should never be pressured for sterilization when particularly vulnerable, such as during labor. But it happened to Gina Marie anyway.

Her labor was induced early due to fear of a big baby, and not surprisingly, she ended up with a cesarean. The OB was very vocal about how she shouldn't be having children at her size, and pressured her to agree to have her tubes tied during the cesarean. When she would not agree to having her tubes tied, they tried to frighten her by exaggerating the risk of complications during the cesarean and asking her and her partner about her funeral plans during consent for the cesarean. Then they punished her by doing a classical cesarean (a giant incision, up and down, far more risky than a side-to-side incision), blaming it on her obesity, and telling her that her uterus would "explode" if she had any more pregnancies. She never did. In this case they did not succeed in directly sterilizing her but they did succeed in a de facto steriilization.

Although most care providers will not go this far or be this coercive, there is subtle pressure towards sterilization for fat women. We know there is a long and shameful history of forced sterilizations or sterilizations without consent in the United States. This is just the latest version of that, dressed up as "concern" for your health. Eugenics policies were often directed at women of color, poor women, and "disabled" women because medical authorities thought they should not be reproducing.

Although forced sterilization was not systematically applied to fat women across the board, there have certainly been stories of strong pressure for sterilization and even abortion. A number of women have written to me over the years and shared some of their stories. Care providers (or even family members) have implied that it's far too dangerous to be fat and pregnant, that they must terminate the pregnancy in order to save their own lives. Or they imply that the baby is sure to have health problems, birth defects, or be stillborn. Here are a few of the stories:

• "I also was told I could not have kids. Then when I got pregnant I was told by various doctors for various reasons that I should abort."
• "[The doctor] even suggested that we consider having an abortion because the likelihood was great that [problems with the baby were] going to happen....We had 2 weeks to decide about the abortion because legally you have up to 24 weeks to abort the baby." 
• "[The doctor said:] 'No fat woman can ever have a healthy pregnancy. Besides, if you did get pregnant, I'd order you to have an abortion. But that's a moot point anyway, because you're too fat to get pregnant.' "

Another story of a fat person pressured for abortion can be found on the blog, First Do No Harm:

The doctor walked in holding my chart. The first thing she said was, “We all know you don’t want to be here.” ... She continued, “Thirty six years old and a third baby. Hmm. We all know your eggs aren’t any good any more.” [The OB] spoke on and on about why it probably wasn’t a good idea for me to have the baby and that time was running short for me to terminate the pregnancy. I finally held my hand up and said, “I am not terminating the pregnancy. Let’s just move on from there.”

Sometimes the pressure for abortion is not quite as direct. The potential for death for mother or baby is emphasized and the parents are left to fill in the dots as to what their next action should be. Sometimes providers imply that fat women will die if they try to carry a pregnancy to term, that having a baby is committing "suicide by pregnancy."  They hope that the women will be too scared to continue the pregnancy or try to conceive in the first place. Or they imply that the baby is likely to be deformed or die.

• "I went to see a doctor today...He basically made me feel my baby is a death sentence...In his "honest opinion" I am going to die during labor/delivery or recovery."
• "I used to go to a really Fat phobic doctor; he was so awful he told me that I couldn't even consider the idea of having another baby or I would die for sure (due to my weight)."
• "[My doctor] was appalled when she heard I was not on any form of BCP [birth control pills] and said that "at your age and with your size" that either the baby or I would die."
• "According to him I'm probably going to die of a heart attack sometime during my pregnancy or shortly after."
• A reproductive endocrinologist refused to help a high BMI woman get pregnant, saying it would be unethical to do so. He says if she did somehow manage to get pregnant, "The baby would only have a 5% chance of survival."

One of the very first stories I heard years ago when I started my website was the woman who was told that she would "die on the table" while giving birth. Others have been told that they would surely have a heart attack during pregnancy or shortly after, or that they were "85% likely to die on the table" during the birth.

Although these doctors didn't directly pressure the women to have an abortion, statements implying that death is practically inevitable for a fat mother or baby are certainly going to be interpreted as pressure to terminate a pregnancy. Here is a story of a woman in the U.K. who was so frightened by the "obesity risk" talk" from her care providers that she was strongly considering termination of the pregnancy.

Please please please, can someone help me. I am 10 weeks pregnant and currently have a BMI of 35...I have had my first midwife appointment today and was told that more than 50 percent of maternal deaths in pregnancy and childbirth are obese mothers and that I will have to have special monitoring and won't be allowed to have a natural birth at the birth centre and will have to be under consultant care and be constantly monitored throughout labour (meaning no water birth, no moving around, no getting into positive positions to birth). 

I am so scared and disappointed, I feel like I am an unfit mother already and feel that the drs think I do not care about the health of my unborn baby. Now I know that this will not go down well with some people but I am considering a termination so that I can lose more weight before carrying a child (I have currently lost 70 pounds).

Here is another similar story. The woman was so scared by all the death talk around obesity and pregnancy that she was considering ending her pregnancy, even though she'd already had one successful pregnancy and healthy baby. She was particularly afraid of the risk for a blood clot (DVT).

I am pg with my 2nd child. With my first I was overweight with a BMI of 37 but had a textbook perfect pregnancy with low blood pressure, blood sugar etc and a small baby, natural birth no issues etc and everything was hunky dory. 

Fast forward 2 years and I have since suffered anxiety and depression, mostly directed towards my health. I have become a hypochondriac which is mental torture some days. I have gained a weight since I had my dd...I am so upset and disgusted with myself , I have beat myself up all day about this. I have done a lot of research the past few days and there's a lot of scary articles about how maternal death and infant death is linked to obesity, how overweight women have a much bigger chance of dying during pregnancy etc, developing DVTs (which is one of my massive hypochondriac fears).

I am terrified I am going to die during this pregnancy because of my weight that I am considering not going ahead with the pregnancy. I am losing sleep and every ache or pain I am worrying about a DVT. It has been mental torture so far and another 8 months of this seems unbearable.

Again, this speaks to the importance of presenting risk realistically. It's true that obesity is a risk factor for DVT, but the actual chances of having a blood clot are pretty small, even in a "morbidly obese" pregnant woman. Many women of similar size (including me) have had pregnancies without blood clots, but these are not the stories being promoted by the media or shared by the doctors.

Furthermore, if she is really worried about a clot, she could speak to her provider about taking a low-dose aspirin prophylactically. Some providers do this regularly with obese women; while no research on its benefit for obese women has been done, it is a choice that can be considered if she is really worried or has a strong family history of clots. She also needs treatment for her anxiety so she can deal with her fears.

Doctors may not intend to be actively promoting eugenics but they cannot overlook what the real-world effects are of discriminatory scare tactics. And shamefully, some are fully aware of these effects and employ them deliberately.

Eugenics Towards People of Size

Headline from Metro.co.uk 2016

How many women of size have had their family size limited, directly or indirectly, through medical bullying? How many people of size have decided not to have children because of the over-the-top public health campaigns against obesity and pregnancy? How many have put off pregnancy until they get to a "normal" BMI, only to find that day never comes? How many have faced pressure for sterilization or de facto sterilization? How many have considered ending their pregnancies because their doctors told them they might die? How many have been pressured to abort a wanted pregnancy because of their size?

There is more than a whiff of eugenics in these latest media campaigns, whether providers mean it to be that way or not. Some researchers have suggested that such stories "hint at so-called soft eugenic practices to keep obese women from reproducing."

From a National Post article from 2016 by Sharon Kirkey:

Canadian researchers say that amid a flurry of press about the dangers of excess fat during pregnancy, overweight and obese women are being made to feel they’re “disgusting” or “bad mothers” for putting their fetuses at risk.... 

Doctors have legitimate reasons to warn women of the complications related to excess maternal weight, they acknowledge. However, much of the obesity “risk talk” is sensationalized, moralizing and shouldn’t position heavy women as “always-already diseased and dangerous to their child,” they write in the latest issue of Social Science & Medicine. Larger women, they argue, can have perfectly healthy, incident-free pregnancies and births. 

“We’re certainly not trying to say that any of the healthcare providers that are referred to in the study is actually a eugenicist,” co-first-author, Andrea Bombak, an assistant professor at Central Michigan University said in an interview. 

“What we’re trying to say is that anytime we refuse care in these areas, or potentially limit people’s care, we could be unintentionally and inadvertently echoing some of these histories that we’ve seen in the past about who is it that society would prefer to reproduce — and who they would prefer to not have reproduce,” she said... 

Many women had positive experiences. But many others also described being made to feel as if they were “disgusting” or unfit to be mothers. 

Bravo to these researchers for calling out the hyperbole and stigma in these media articles and public health campaigns. It's time for others to take up their call.

When obese women are counseled about pregnancy risks with scare tactics and judgment, when newspaper articles use hyperbole to scare high-BMI women away from pregnancy, when obesity in pregnancy is viewed as child abuse or treated as the equivalent of drug addiction, and when women are pressured towards sterilization or termination because of their size ─ then it cannot be denied that these things begin to cross over into the repulsive realm of eugenics. 

Reproductive Policing is WRONG

Article from National Post, 2016, found here

Sadly, some medical professionals would like to prevent ALL fat women from having babies if they could. Remember the media article that states starkly that "Obese women should not have children"? This comes directly from a public health campaign started in the U.K. and endorsed by leading "experts."

Most of the time these days it's considered wrong to question a woman's basic right to motherhood, even in a mother at risk for complications. Yet reproductive policing and shaming does not seem to be equally applied among groups considered at risk for complications. It seems to be focused mostly on obese people, and worse yet, this practice is widely defended in medical circles.

Many doctors want to be the gatekeeper of who gets to procreate and who does not, and many of them particularly want to keep fat women from procreating so they don't pass along their fat genes to the next generation. A 2015 article reveals the real concern about obesity and pregnancy ─ that it will lead to more  fat people:

The kicker of all these consequences is that obesity begets obesity. "Maternal obesity is the most significant factor leading to obesity in offspring and, coupled with excess weight gain in pregnancy, also results in long-term obesity for women," the reviewers write.

Although doctors tell themselves they are just looking out for their patients, the underlying agenda here is about ridding the world of fat people. What better way than to prevent as many fat pregnancies as you can?

Because medical providers have have been taught that obesity only occurs because of sloth and gluttony, many care providers see fat people unworthy of procreating. They use whatever means they can to discourage fat women from having a family. This far exceeds their mandate as physicians, and worse, it smacks of eugenics.

Sorry, but NO ONE has the right to forbid reproduction. The government, medical authorities ─ history has shown time and again that these people should NOT be the gatekeepers of reproduction. Whether to have a baby is a decision for the woman and her partner to make and no one else.

Yes, women of size have higher risks in pregnancy as a group. So do many other groups. Fat people should not be singled out. People of size should be counseled (with compassion, not scare tactics) about their risk status and possible complications, and they should given information about how to mitigate or manage those risks. Whether or not they experience complications, they should be always be treated with dignity, respect, and support.

The ability to reproduce is one of the basic rights of people in society; the state and/or medical caregivers have NO business trying to govern that.

People should never be subject to shaming or scolding for the simple act of wanting to have a family. That principle applies just as much to people of size as to those in any other group.

Thankfully, many care providers are supportive of women of size, but the fact that some resort to extreme tactics to prevent or discourage people of size from reproducing is a terrible stain on the medical profession. This is a unique and insidious form of obesity eugenics and IT MUST STOP.

Forced Cesareans Because of Weight

Photography by Leticia Valverdes, Birth Marks Photography
Photo and story at A Beautiful Body Project

April is Cesarean Awareness Month. I had a different post for it planned for this week, but then I came across this outrageous, infuriating story of a women of size in Brazil who was basically forced into two cesareans simply because of her weight. I simply HAD to comment and bring this to people's attention.

Here is the photographer's summary of her situation (my emphasis):

Elaine was two times forced into caesarean sections for no medical reason other than her obesity, including second one where she arrived in hospital already 9 cm dilated but was forced into a c-section as the obstetric doctor said she would not look after her and the baby if she insisted on a natural labour. She locked herself in the toilette with her doula but got scared and allowed the C when already 10 cm dilated. She was told she was too fat to labour.

Too fat to labor? Yet she was already dilated! She'd done all of labor except pushing. But her doctor could not be bothered to attend her in labor for pushing; I'm sure he felt she was too "high-risk" to push out a baby. Yet other fat women can push out their babies ─ when they are given a real opportunity, which is far too rare these days.

Also frustrating to me is the fact that EVERYONE so far has missed the fact that she almost certainly has lipedema. Look at her legs and her behind. Classic shape and texture of advanced lipedema! They are blaming her for her fatness (and she blames herself, as you can see from her comments about herself in the article) when likely a great deal of it is beyond her control. But that certainly doesn't mean she can't push out a baby. Many of us with lipedema have. It's just bias, pure and simple, on the part of the doctor. And that highlights a troubling trend in cesareans these days.

As the Cesarean Awareness Month logo above notes, the overall cesarean rate in the United States is too high, with almost 1 in 3 women having a cesarean. Yes, some of those are absolutely necessary and life-saving, and no woman should ever be shamed or feel like less of a mother or a woman if she has had a cesarean. Please don't think I'm putting you down if you've had a cesarean.

But a too-high cesarean rate has major public health implications that we are ignoring, and women's health is being impacted by this.

Sadly, high BMI women are being disproportionately affected by this high cesarean rate, and this has major implications for our health. 

Sure, this story is from Brazil where the cesarean rate is sky-high, but don't be naive; there are "obese" women here who are being railroaded into cesareans only because of their weight.

I have written about the high cesarean rate in obese women many times. If you want to read a post with extensive research details on it, read this one ─ Astronomical Cesarean Rates in Women of Size. It has plenty of references and explanations, but here are a few highlights.

Too many care providers have taken the view that fat women "can't" birth normally or are "too risky" to birth normally. One recent study showed that about 1 of 3 "morbidly obese" women are being pressured into cesareans before labor. So the 1 in 3 national c-section figure above? The same rate happens in high BMI women ─ except that's only the pre-labor cesareans in obese group.

What about those who labor? Even when women of size are "allowed" to labor, the high-intervention and high-risk way that they are often managed mean that the resulting cesarean rate is even higher.

In many recent studies, the cesarean rate in obese women is around 50%, or ONE IN EVERY TWO WOMEN. 

Where's the graphic that reflects that?!? Where is the outrage in the birthing community? Where is the accountability for providers? Where are the hospital programs to try to reduce the enormous cesarean rate in high BMI women? NOWHERE.

Check out this study from 2013 which documented cesarean rates in high-BMI women in Tennessee. Note how this cesarean-oriented culture results in especially high rates in "morbidly obese" women:

"Underweight" women (BMI less than 18.5) -      26.0%
"Normal Weight" women (BMI 18.6 - 24.9) -      31.4%
"Overweight" women (BMI 25 - 29.9) -               39.1%
"Obese" women (BMI 30 - 34.9) -                       40.8%
"Morbidly Obese" women (BMI 40+) -               56.6%

This reminds me of a similar study from Kentucky, showing cesarean rates in morbidly obese women near 60% also.

You can find studies with even higher rates too, like this very large, multi-state study from more than a decade ago which found a c-section rate of 71% for women with a BMI of 52 or more.

Or a more recent study that found a nearly 70% c-section rate in women with a BMI of 35 or more.

Then there's this study from Michigan, which had a total cesarean rate of MORE THAN 80% for women with a BMI over 50.

And the cesarean rate in obese women continues to rise unabated and unchecked.

One German study we discussed recently showed that while cesarean rates have increased in all groups over time, they've increased the most in "morbidly obese" women. In just 22 years, the cesarean rate in Class III Obese women doubled, going from 26.9% to 55.2%.

Why? What changed? These stats compare women of the same size, so it wasn't the women who changed. Most likely it was the management of those women that changed, and the fear levels around their pregnancies. 

If the cesarean rate in fat women has increased from 27% to 55% in 22 years, how far will it go in the next 22?

How Can We Change This Trend?

The good news is that it doesn't have to be this way. 

As I've pointed out before, there was a large recent British study that found a 30% cesarean rate in "super-obese" women (BMI 50 or more) who were given a chance to labor.

Yes, 70% of these super-obese women were able to give birth vaginally ─ when given the chance to do so.

Yet hospitals in Kentucky and Tennessee, as cited above, had c-section rates of around 60%, nearly TWICE the British rate. And the Michigan study had rates even higher than that. Why?

These differences suggest that there are key differences in how high BMI women are being managed that is resulting in such wide variations in cesarean rates in this group, both over time and by location.

It's time for care providers to start focusing on the cesarean practice rate variation in obese women and learning from it. Once we acknowledge that there is a wide range in the obese cesarean rate, we can more easily start studying the things that help lower the risk for cesarean in this group, and hospitals can work on meaningful changes that will improve outcomes. But I have yet to see one study that seriously addresses this issue.

What Can Be Done?

Even if we have no study that directly addresses this issue, there almost surely are things that can be done to lower the cesarean rate in higher weight women. You start with the things that have been shown to lower the cesarean rate in women of all sizes and make sure these things are applied to women of size as well (which they often aren't).

Based on the evidence (references and explanations in the last section of the original article), the most logical ideas would include:

• A strong emphasis on preventing the first cesarean, especially scheduled cesareans that occur before labor. Far too many doctors are not giving fat women a chance to labor at all and then repeat cesareans become nearly automatic. Prevent the first cesarean and you quickly impact the overall cesarean rate in this group 
• Less early induction of labor unless it is truly medically indicated since induction often increases the chance of cesarean; when induction is used, wait until the mother's cervix is ready for labor whenever medically possible 
• Dating pregnancies more accurately in women of size with longer menstrual cycles so that more are truly ready for labor at term and not being induced too early
• Reduction in the overuse of common interventions in obese women, like early breaking of water, early epidurals, and routine pitocin augmentation
• Encouraging women of size to stay home longer in early labor, since research shows that coming into the hospital too early is strongly associated with higher cesarean rates
• Giving women of size MUCH more time and patience in labor to account for a possibly slower dilation curve and a longer first stage of labor
• More utilization of midwifery and/or a midwifery-laborist model of care for low-risk obese women since this has been shown to decrease the risk for cesareans
• Strongly encouraging use of doulas and professional labor support for women of size since doulas have been shown to reduce cesarean rates significantly
• A re-emphasis on the importance of properly-sized equipment like blood pressure cuffs so interventions are only undertaken when truly needed, based on accurate data
• More attention to preventing and treating fetal malposition in women of size (who may be more at risk for fetal malpositions)
• More freedom of movement in labor and utilization of alternative positions in pushing, instead of immobilizing the obese woman in bed and reducing her pelvic space
• Fewer late ultrasounds for estimating fetal weight, since prediction of fetal weight increases the chance of cesarean beyond the baby's size alone
• A revival of VBAC access for high BMI women, with fewer VBAC inductions and more patience during a "trial of labor" to give it the maximum chance to happen

Start with these ideas, then hospitals should organize some serious trials to see if they help. Make reducing cesarean rates in high-BMI women a strong priority in research and in practice. 

Conclusion

It's outrageous that this poor woman from Brazil was forced into a cesarean TWICE simply because of her weight, even after she arrived at the hospital nearly fully dilated. 

It reminds me of the story, told by an OB, of getting into trouble with her colleagues because she let a morbidly obese woman VBAC. The woman arrived at the hospital fully dilated (and with a history of a prior vaginal birth). Her colleagues raked her over the coals for not doing an automatic c-section, simply based on the mother's size. They would have forced this mother into another cesarean, even though her body had already proven it could give birth safely, and even though she was fully dilated, based on nothing more than her weight. And this was in the U.S., not very long ago!

I've heard from other fat women who were strongly encouraged or even coerced into signing papers for an elective cesarean early in pregnancy, based only on size. While it's by no means universal, it does still happen. Higher-weight women ARE being forced into cesareans based on their size alone, even here and now. 

Thank goodness, not all providers are like this. Even as we are outraged by stories like these, we must remember and acknowledge that there are wonderful midwives and doctors out there who are truly size-friendly, who give women of size every chance at vaginal birth, and who do support them in VBAC as well. Some maternity providers are wonderful with women of size and it's vitally important that higher-weight women seek out and find these size-friendly providers. 

On the other hand, there is a real callousness around care of high-BMI women among some providers, even an outright viciousness at times. The lack of caring among many providers about the extreme cesarean rates in high-BMI women says a lot. Most shrug off a cesarean as a natural consequence of obesity, pretending that their hands are tied. Baloney.

Historically, cesarean rates in high-BMI women were not as different from average-sized women as they are today. As we have seen, the cesarean rate has increased markedly in obese women in recent years, and there is a great deal of variation in the obese cesarean rate between institutions. 

This means that a high cesarean rate is not an inevitable outcome of obesity, and that many fat women can give birth vaginally with the right support. It also means that there are ways to lower the cesarean rate in higher-weight women ─ if we are willing to study it and make change a priority.

Far too many of the cesareans in women of size today are “iatrogenic”— influenced more by the attitudes and management protocols of the care providers than by the woman’s size. Far too many high BMI women are sectioned before labor even starts, induced before their bodies are ready, or have their labors cut short out of impatience or fear. But research has shown that most women of size can give birth vaginally if they are just given a real chance to do so.

It's time we work to make that happen. Let's not hear about any more cases like poor Elaine. 

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.

Summary

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?