Perinatal weight stigma delays care, disrupts trust
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Bias based on size during pregnancy is a common experience particularly for women with overweight or obesity and can delay prenatal and postnatal care for women who fear weight stigma in the health care setting, according to experts.
“Weight stigma is common, and almost all people experience it. No one is immune from weight stigma — people of all body sizes, people of all genders, people of all life experiences,” Angela C. Incollingo Rodriguez, PhD, assistant professor of psychological and cognitive science and neuroscience at Worcester Polytechnic Institute, Worchester, Massachusetts, told Healio. “But for a very long time, there was no research looking at weight stigma in the context of pregnancy, and there were a lot of people who thought it’s maybe an exception. But it turns out, it is no exception.”
Women who have experienced weight stigma may avoid seeking needed care surrounding pregnancy. Those with overweight or obesity tend to have a longer time to pregnancy, have higher rates for miscarriage and are more likely to experience pregnancy complications. In addition, women with obesity have double the risk for infertility compared with women with normal weight, according to Wendy S. Vitek, MD, associate professor in the department of obstetrics and gynecology at the University of Rochester Medical Center in New York.
Physicians also tend to see a higher rate of stillbirth among women with a higher BMI compared with women with lower BMI, Vitek noted. Women who had gastric bypass surgery, who remained in the obese BMI category, also continued to have increased risk for growth disruption with higher rates of small for gestational age infants.
“Other more common complications that are increased with BMI are conditions like gestational diabetes, preeclampsia, cesarean section and complications around birth that may lead to blood transfusion, prolonged hospital stay and neonatal ICU time,” Vitek told Healio. “As for the neonates, there may be a higher rate of congenital anomalies among women who are obese during pregnancy, higher rate of neonatal ICU admission depending on the maternal weight history, and there may be a higher rate of large for gestational age infants, particularly if there is diabetes complicating the pregnancy.”
In reproductive medicine, some clinics in the U.S. have BMI cutoffs to determine access to certain treatments, such as ovulation induction or in vitro fertilization, without consideration of other comorbidities, according to Vitek. This means that a woman with an elevated BMI might not be able to undergo IVF and may be required to attend a weight management program, which women may consider to be weight stigma.
Weight stigma in prenatal care
Weight stigma is a barrier to seeking health care and substantially affects women’s health. Weight stigma is associated with delayed cancer screenings, mammograms and cervical screening. Weight stigma affects prenatal and postnatal care when women who do not meet the ideal of “a nice, round bump just in the front,” perceive criticism for their weight, Incollingo Rodriguez said.
“[Weight stigma] interrupts continuity of care, it increases health care burden if records don’t transfer over or if you change providers, and then there’s this lapse in care. That’s problematic at any time of life, but especially in pregnancy, the time where you’ve got regular doctor visits and screenings and you really don’t want to interrupt continuity of that care,” Incollingo Rodriguez said.
In a study published in BMC Pregnancy and Childbirth, Incollingo Rodriguez and colleagues surveyed 501 pregnant women about perinatal weight stigma. Nearly 20% reported experiencing weight stigma in health care, 8% reported changing providers due to how they were treated regarding their weight, and 11% reported not trusting their provider due to past experiences of weight stigma.
Regarding breastfeeding, in particular, Incollingo Rodriguez noted that women of different body sizes have different rates of breastfeeding, and this likely has something to do with stigma. In her study, 25% of postpartum participants reported feeling uncomfortable seeking help with breastfeeding from a health care provider.
“There’s data about weight stigma delaying treatment, worsening obesity, hypertension, depression and anxiety,” Vitek said. “We need to look at that more critically in reproductive medicine and obstetrical care.”
Weight stigma affects not only women with a higher BMI, but also those with a BMI less than 18.5 kg/m2. Women who present as underweight to fertility clinics may need to be treated for an eating disorder to gain weight to restore ovulation or to be a candidate for fertility interventions.
“We’re trying not to put their dream of having a baby at odds with their weight history, because weight and reproduction are inherently intertwined,” Vitek said. “But we don’t want to withhold the opportunity for a woman to become pregnant and fulfill a lifelong dream because it’s not her fault that she’s had to deal with either obesity or disordered eating.”
Being more size friendly
It is up to all providers to make health care facilities safer for and more sensitive to individuals of any body type, Incollingo Rodriguez said.
“If we’re talking about people with elevated BMI and larger bodies, then these are people who probably already dread health care because before they were a pregnant woman in health care, they were a person in health care and probably had negative experiences,” Incollingo Rodriguez said. “In that sense, it’s really on all providers — not just prenatal care providers, but all providers — to be more size friendly. Your young female patient who you stigmatize now is going to be nervous about and maybe even resistant to getting care when she’s looking into prenatal care down the line.”
Providers can demonstrate that they are a safe place for any body type by labeling themselves as “size friendly” through website information and office design, Incollingo Rodriguez said.
Different seating options in waiting rooms, weight measurements and scales housed in a private area, and availability of appropriate equipment for all patient sizes — including blood pressure cuffs, gowns, tables and medical equipment used specifically for women — can all counter weight stigma in medical practices, according to Vitek.
Another area where providers can help patients feel more comfortable is in their dialogue. It is important to ask for permission to discuss weight with a patient. Avoiding terms linked to weight stigma, such as “obese” or “overweight,” or using more sensitive coding in visit summaries and electronic medical records can help make the health care setting more welcoming for all body sizes.
In regard to pregnancy, specifically, the main focus should be the mother’s and baby’s current health rather than the mother’s weight.
“One of the most important things providers can do is just focus on health promotion vs. weight intervention,” Incollingo Rodriguez said. “Because No. 1, if somebody’s got an obese BMI, you’re not going to change that in the course of 9 months. And even if you could, you wouldn’t, because it’s not recommended during pregnancy to have dramatic weight loss, or really any weight loss, or to diet.”
This can also be true in some cases of prenatal care. Weight loss does not improve likelihood of becoming pregnant or reducing the risk for miscarriage, according to Vitek. Loss of 5% to 10% of body weight prior to fertility treatments did not improve the likelihood of becoming pregnant, so this is not an area on which providers should focus, she said.
“Rather we try to promote leading a healthy lifestyle leading into pregnancy and minimizing obesity-related comorbidities, like poorly controlled hypertension and poorly controlled diabetes, more so than the actual weight because not every patient who is obese has obesity-related comorbidities,” Vitek said. “But for those who do, it is oftentimes the prepregnancy comorbidities that get worse in pregnancy, particularly if they’re not being managed.”
Weight stigma is a health threat
Researchers are working on linking weight stigma to concrete health endpoints.
“If we can show that weight stigma itself, not BMI, is undermining health, now that translates into weight stigma being to blame for health care dollars and health care burden,” Incollingo Rodriguez said.
Weight stigma that prevents women from seeking care would be a threat to women’s health.
“Patient-provider relationships are really important for adherence, they’re really important for positive health outcomes,” Incollingo Rodriguez said. “If somebody’s walking into your office feeling judged, shamed, unworthy, guilty and disliked, then they’re definitely not going to take your medical recommendations.”
Many women with obesity have healthy pregnancies despite physician warnings about preeclampsia, gestational diabetes or cesarean section, Incollingo Rodriguez noted.
Regarding future areas of research, concrete data are needed on whether weight stigma experiences delay entry into fertility care, whether provider-related factors contribute to delay, and whether providers are aware of their own implicit weight biases, Vitek said.
“There is more awareness around all types of implicit bias, be it around race, sexual orientation, but also weight,” Vitek said. “So, there is a reckoning in medicine for providers to be aware of any biases they can carry into their clinical interactions with patients and to take proactive steps to mitigate those biases so that we deliver standard high-quality care to all patients.”
For more information:
Angela C. Incollingo Rodriguez, PhD, can be reached at acrodriguez@wpi.edu.
Wendy S. Vitek, MD, can be reached at wendy.vitek@urmc.rochester.edu.
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