Hilary was 23 years old and newly married when her doctor confirmed she was pregnant with her first baby.
As soon as she heard the good news, the doctor hit her with some bad news: He said her weight ― 211 pounds at 5 feet, 1 inch ― would be a problem.
She was less than six weeks’ pregnant, but her doctor started talking about labor. He announced she was “too obese” to give birth vaginally and would have to have a cesarean section.
He didn’t elaborate and Hilary, caught off-guard, didn’t ask questions. “I was stunned,” she said.
Hearing that her weight was already limiting her and her baby’s options left her “terrified and ashamed,” recalled Hilary, who asked that her last name be withheld for privacy reasons. When she got back to her car, she cried.
The potential need for a C-section is just one of the risks that women with a body mass index higher than average are told to expect when they conceive. They are warned about complications like pre-eclampsia, gestational diabetes and “dangerous blood-clotting.” Some are even told that their vagina is “too fat” to give birth.
The reality is that the vast majority of overweight and obese women have perfectly normal pregnancies. But medical professionals are not immune to society’s tendency to disrespect fat people. The stigmatizing message many heavy women get in the doctor’s office is that by their own poor decision-making, they have put themselves and their unborn children in danger.
Assessing The Actual Risks
Pregnancy entails risk and the expectant mother’s weight is one among many factors to be considered. A major study by the University of Oxford in 2013 found that women who were overweight, obese or very obese (the last meaning a BMI above 40) faced risks of complications during childbirth that were 6 to 12 percent higher than those of their normal-weight counterparts.
That’s a broad statistic, however, that covers a lot of people. Some 25.6 percent of pregnant women in the U.S. are considered overweight at the onset of pregnancy and another 24.8 percent are considered obese. As Dr. Mark Turrentine, chair of the committee that produced the American College of Obstetricians and Gynecologists’ guidance on obesity and pregnancy, notes: Statistics without context can be needlessly scary.
“You know no matter what’s going on in your body, the first thing that’s going to be talked about is your weight.”
Take the risk of stillbirth. For women with BMIs in the “normal” range, the risk of stillbirth is about 4 for every 1,000 births. For women who are classified as overweight or obese ― meaning those with a BMI above 25 ― that risk nearly doubles, skyrocketing to … 7 per every 1,000 births.
Consider a somewhat more common complication: gestational diabetes. A normal-weight woman’s risk falls somewhere around 2 to 5 percent, while an obese or “super-obese” (BMI over 50) woman’s risk doubles or even triples to 10 to 15 percent. That is significant, but as childbirth educator and fat activist Jen McLellan points out, an obese woman still has “an 85 to 90 percent chance of not developing gestational diabetes.”
“Some of those potential risks, although they’re increased compared to normal-weight women, they’re still at a lower percentage,” Turrentine said. “We’re not saying there’s this great high rate of complications.”
Bias Against Big Women
Yet it is the most extreme evaluations of the statistical data that seem to drive the treatment of pregnant women with high BMIs in many doctors’ offices. That and a deep-seated and sometimes unconscious bias against big bodies.
The approach isn’t unique to pregnancy. Study after study finds that heavy people are routinely treated worse than normal-weight patients in doctors’ offices and that this discrimination can directly contribute to many of the diseases that we associate with obesity, such as heart disease and stroke, as well as mental health conditions such as depression and anxiety disorders.
“There’s an embarrassment that comes along with being a heavy person going into a doctor’s office,” Hilary said. “You know no matter what’s going on in your body, the first thing that’s going to be talked about is your weight. You’re immediately on the defense.”
Many physicians look down on heavier women. One Australian study found that maternity care providers perceived overweight and obese women as worse at self-management than thin women. They also had less positive attitudes toward caring for these women than for their normal-weight counterparts.
For the duration of her first pregnancy, Hilary said she faced hostility from her doctor and nurses, who made jokes about her weight.
“Some women of size have been told that if they get pregnant they’ll surely die, ... that they should abort their baby because it would never survive anyhow, or that they better make funeral arrangements before their cesarean.”
Humiliating and shaming patients does not lead to better medical outcomes. But as the research shows, it does cause people to shut down and avoid doctors. It also pushes people to internalize the stigma against being fat ― whether or not their weight is the real issue with their health.
A few weeks into her pregnancy, Hilary began experiencing some light bleeding, which as many as 20 percent of pregnant women see in their first trimester. When she went to talk to her doctor about what might be causing the spotting, he ordered her on bed rest for the seven months until her due date. She was “high risk” because of her weight, he said.
“They never told me that spotting can be very normal in pregnancy, especially early on,” Hilary said. “So coming from our last conversation about my weight and my C-section, all I could think while I was on bed rest was, ‘This is because I’m heavy.’”
A Lot Of Bad Advice
Pregnant women with other risky conditions ― like having a family history of diabetes or high blood pressure or being over age 35 ― don’t seem to be chastised or dismissed like fat women are. People tend to believe that obesity, unlike those other factors, is completely within a person’s control ― even though it’s generally not.
Of course it’s the responsibility of any physician to share risk factors with their patients. But when faced with overweight women, rather than discussing the remote chance of a complication and coming up with a plan to screen for and treat it if necessary, some doctors opt to prematurely recommend interventions, offer bad medical advice and ultimately provide substandard care.
Pam Vireday, a childbirth educator who has contributed to Our Bodies, Ourselves and other pregnancy literature, writes:
Some obese women report that they aren’t just being told about their increased risk for complications, they’re being told that they will get that complication; some are told to just schedule their cesarean from the beginning of their pregnancy. Some women of size have been told that if they get pregnant they’ll surely die, that they’re committing suicide by pregnancy, that their baby will have only a 5 [percent] chance of survival, that their baby will be deformed, that they should abort their baby because it would never survive anyhow, or that they better make funeral arrangements before their cesarean.
McLellan, who runs a Facebook page about plus-size pregnancy, said women in her group have similarly reported being advised to have an abortion, lose weight and then try getting pregnant again.
Women who are fat are sometimes even encouraged to lose weight while pregnant. Eating a healthy diet is good advice for all pregnant women. But attempting to lose weight is dangerous, according to Dr. Neel Shah, assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. Restricting calories enough to induce weight loss puts your body into “starvation mode,” he said, which is bad for baby (and mom).
“You never want a pregnant woman to lose weight. Ever,” said Shah, who directs the Delivery Decisions Initiative at Harvard’s Ariadne Labs.
More often than not, he said, obese women have healthy pregnancies. Instead of scare tactics and frightening advice, what they really need is encouragement.
“What we need to be doing is figuring out how we create a system where women are guaranteed not only safety, but support and empowerment,” Shah said. “If you go into labor and you don’t think that you can do it, it makes it a lot harder to be successful.”
He described giving birth as “like running a marathon.”
“You need support and coaching and to believe in yourself,” he said. “And you should have that, irrespective of your BMI.”
“If you go into labor and you don’t think that you can do it, it makes it a lot harder to be successful.”
Despite the horror stories, it is possible for obese women to have a good birth experience, McLellan said. They just have to shop around a bit more for a doctor who is size-friendly.
Although Hilary had that C-section with her first child ― during which the anesthesiologist joked about how many people it would take to lift her off the table ― Hilary found more supportive health care providers for her next two babies.
“The best one was my third,” she said. “He made sure that there was so much laughter and happiness in the room.”
He reassured her throughout her pregnancy that she and the baby were healthy and normal.
“It was just a different experience and I really felt healed afterward,” she said.