For most women, pregnancy and birth should be a time of excitement, anticipation and promise. However, women of a higher weight* can have a negative experience of maternity care due to experiencing weight stigma from healthcare professionals.
Stigma involves negative attitudes or discrimination against someone, or a group, based on a distinguishing characteristic or attribute. Weight stigma means that someone experiences such attitudes and discrimination simply due to their weight and appearance. This negativity can also become internalised and experienced as internalised weight stigma.
My recent meta-ethnography of the literature answered the question of how women with a higher weight experience weight stigma in maternity care. Shame was clearly experienced by many women in the studies included in my review. This included feelings of guilt and humiliation as well as those of being judged and blamed.
There were particular times when shame was felt, one of which was being weighed at an antenatal appointment. Standing on the scales is routine in pregnancy and it first occurs during the initial midwife appointment. Many women disliked being asked to stand on the scales as it made them feel vulnerable, visible and like a failure. It is therefore not a neutral intervention, but rather a “loaded ritual” (McCullough 2013) which women feel forced to undertake, but some seek to disengage psychologically from the process. The anticipation of being weighed meant that some women would dread the appointment.
The ultrasound scan was another occasion which provoked feelings of judgement and shame. Women are routinely scanned twice in pregnancy, once in the first and once in the second trimester. Some women experienced ‘mother blame’ at the scan due to the diagnosis of a big baby. ‘Mother blame’ is where the woman is held responsible for the health of her unborn baby, although some women were able to resist such blame by seeing a big baby as a positive attribute and by rejecting the accuracy of the scan. Mother blame was also felt if women had complications such as diabetes, or simply because they felt shamed due to their size.
It was common for women to internalise these feelings of judgement and to view their bodies negatively. For many women, stigmatising encounters, including those from family, friends, healthcare professionals and even strangers, had been part of their childhood or teenage years onwards. Women described fat shaming and bullying behaviour which they carried with them into maternity care. During pregnancy, women described how they disliked their bodies which elicited feelings of embarrassment, stress, low self-esteem and discomfort, particularly when they had to expose them to healthcare professionals.
Women experienced microaggressions from healthcare professionals, which ranged from hurtful stigmatising language to the lack of provision of appropriate equipment. The use of the word ‘ob*se’** was considered rude and hurtful, but it was still used in communication. Women also felt that healthcare professionals attributed character flaws such as laziness and lack of intelligence due to their weight. These are common stereotypes seen in society where individuals who are of a higher weight are less likely be seen in a positive light. Some women felt that their healthcare professionals believed that they ate poorly or exercised insufficiently and lacked the knowledge to know how to live a healthy lifestyle. These harmful attitudes and beliefs caused upset. Shame could also be experienced when there was a lack of appropriate equipment, such as blood pressure cuffs, suitable chairs, clothing, which meant that women felt ‘othered’ and vulnerable.
Women sought to resist weight stigma and feelings of shame by using a variety of techniques and approaches. These included trying to find a healthcare professional who is not fat phobic, researching the evidence and using the experiences of others to be able to advocate for themselves. There were also personal and cultural beliefs about weight and health that women used to resist stigmatising attitudes and behaviours by healthcare professionals. The constant need to advocate for themselves to prepare for stigmatising encounters meant these women undertook a large amount of hidden – and unrecognised – emotional work to protect themselves.
However, there were occasions when women were protected from stigma and shame and this is where they had a warm relationship with their healthcare professional – often their midwife. Receiving individualised care was a protective factor which allowed women to feel like a regular pregnant or birthing woman, rather than part of separate group of ob*se women. In rare cases, such care was transformative, when a woman found her body to be powerful and positive in giving birth, rather than feeling ashamed of it.
My next piece of work will be to gather an advisory group and interview pregnant women, to explore ways of reducing shame and improving the maternity care of women with a higher weight.
*In clinical terms ‘higher weight’ means a Body Mass Index (BMI) of 30 kg/m² or more
** This is a stigmatising word, and I have omitted the first ‘e’ so I can include it in this piece
McCullough, M.B. (2013) ‘CHAPTER 10 Fat and Knocked-Up: An Embodied Analysis of Stigma, Visibility, and Invisibility in the Biomedical Management of an Obese Pregnancy’, in CHAPTER 10 Fat and Knocked-Up: An Embodied Analysis of Stigma, Visibility, and Invisibility in the Biomedical Management of an Obese Pregnancy. Berghahn Books, pp. 215–234. Available at: https://doi.org/10.1515/9781782381426-013.
Jenny Cunningham, Midwife and PhD student, Kingston University London
28th February 2023