Are You a Size-Friendly Midwife?
by Pamela Vireday

© 2002 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 61, Spring 2002.]

• Fat Women Speak Out
• Rules of the Road for Becoming a Size-Friendly Midwife
• Size-Friendly Resources

Fat women are tired of being marginalized by the medical community. They tell stories of egregious bias, of being treated as less than human. They also tell stories of subtle bias, of providers who seem to be size-friendly but ultimately are not.

The very thought of a fat woman reproducing is extremely threatening to some people. Some fat women have actually been told they should terminate a pregnancy because of their size. One mother was told that her baby would have a heart attack and die during labor, so she should get an abortion. Another doctor told a woman that she was too fat to get pregnant, but that if she did, he would insist that she have an abortion. Even family members have been known to pressure fat women to abort their children.

If a fat woman defies her family and providers and becomes pregnant anyhow, she is often faced with tremendous pressure to avoid having more. Some women report strong pressure in the middle of labor to consent to sterilization afterwards. One supersized woman would not agree to sterilization, so her OB punished her by using a classical incision during a cesarean, and then told her she should not have any more pregnancies because her uterus "would explode." Afterward, the doctors and midwives took turns coming in her room and berating her for her size. They told her that she would never live to see her child grow up, that she would not be able to adequately care for her child as he grew, and that her son would hate her for being fat. She has not had any more children.

Fat women are often punished with harsh treatment for daring to be pregnant. Some are yelled at during prenatals or humiliated during weigh-ins, and any problem is automatically blamed on their size. Staff and even friends and family often make rude remarks about their increasing size, tummy, shape, etc.

Fat women experience a higher rate of surgical birth (1). Some of this is undoubtedly related to higher rates of complications such as pregnancy-induced hypertension and gestational diabetes, but some of it is due to size bias, both overt and subtle. Some fat women regularly report that their doctors told them all along they'd probably need a cesarean or that their fat would prevent the baby from being born vaginally. Some fat women have been required to sign elective cesarean permission forms at the first prenatal exam for no reason other than size.

Other, subtler forms of bias may raise the cesarean rate for larger women. Fat women are induced at higher rates than average-sized women, (2, 3) even when only women with normal pregnancies are considered. (4) Doctors are convinced that all fat women will have huge babies, so they often induce for suspected macrosomia, which research shows can raise the cesarean rate, (5) sometimes to greater than 50 percent. (6) In fact, even the suspicion of macrosomia significantly raises the c-section rate. (7) Yet research that documents the higher rate of cesareans in heavy women almost never examines the relationship between higher induction rates and higher cesarean rates. They simply imply that being fat prevents vaginal birth.

Supersized women are often treated especially brutally, particularly during a cesarean. When one woman needed a cesarean during labor, she and her husband were told to prepare funeral plans and asked whether she was an organ donor. Her providers reduced her to tears and terrible fear just at the moment that was supposed to be the most joyous for them. Many doctors seem to feel that supersized women need to be "punished" for daring to have children, or scared out of having any more.

Some doctors still believe that a classical or low vertical incision is "necessary" in supersized women in order to prevent infection, despite evidence that a low transverse incision is just as good or better. (8) Fat women have been told that they had a vertical incision because, after all, "You are not likely to ever wear a bikini." Or they are told to cheer up, "At least while they're in there they can do a tummy tuck."

Doctors also often do not know how best to minimize problems in large women when a cesarean really is needed. Suturing the subcutaneous layer and/or using a surgical drain lowers the rate for infections and wound complications in fat women (9, 10). But many doctors do not do this routinely. (11) Few doctors or nurses know that the simple step of using a blow-dryer on "cool" on the incision several times a day can often help prevent infection in large people. In fact, many complications could probably be reduced if doctors would just bother to study more how to lower the risks in this group and then utilize these techniques more often.

Fat women are often discouraged from a trial of labor after cesarean as well. One woman was told by her OB that she was overweight and out of shape and she should not waste her time or his by trying for a VBAC (she found a new provider and went on to have 2 VBACs, the second one at home). Women have been told that being overweight prevents having a VBAC, and one mother was even told that her pudgy tummy made a VBAC attempt dangerous, because if she ruptured a doctor "would not be able to tell."

Even today, fat women are still often told not to gain any weight during pregnancy, and some are even told to diet during pregnancy. Some modern researchers still report putting their fat pregnant clients on 1200-calorie diets. (12) One fat woman pregnant with twins was told to drink SlimFast to keep her weight gain down, and another fat mom's doctor told her to lose 40+ lbs. during her pregnancy. Many women have been harassed by unkind comments about how "huge" they are getting, lectures during weigh-ins, and frequent admonishments that pregnancy "is not an excuse to eat for two." One mother (who weighed about 200 lbs.) was told, "It's a good thing you kept your weight down. Five more pounds and you could have died!"

On the other hand, some fat women have been harassed because they didn't gain enough weight, even though low weight gain is very common among larger women, and usually doesn't seem to harm the baby. When it comes to weight gain, fat women are damned if they do and damned if they don't!

Size bias can also be subtle. It's assuming that a fat mom will almost certainly get gestational diabetes, so therefore she should take the glucose challenge test every month. It's failing to realize that a regular-sized blood pressure cuff produces artificially high readings when used on a large arm. (13) It's assuming automatically that a big mom will have a huge baby and must be induced early. It's expecting a size 32 woman to have the same fundal height measurement as a size 5 woman. It's pressing too hard during an ultrasound, simply on the assumption that this is necessary to see through "all that fat." It's telling a fat woman that she may never feel her baby move or hear the baby's heartbeat because of her fat. It's telling a fat woman that her breasts are too large to nurse, that fat women usually can't nurse, or that she will be hard-pressed to find an effective nursing position because of her girth.

Many midwives believe that such stories come only from doctors, but doctors do not have a monopoly on fat-phobia. Midwives have told fat women to diet during pregnancy, have told them to have gastric bypass surgery before attempting pregnancy, or have harassed them about weight gain. They have discriminated in many other ways, too. For example, one fat woman tells of her experience planning a VBAC at a birth center across from a hospital. Her midwives knew all along of her size and never mentioned weight as a concern. Suddenly, at 35 weeks, new reasons were invented why she should not labor at the birth center. Finally, the midwives admitted their real reason for directing her to the hospital—her size. She writes:

Even midwives who regularly accept supersized clients and who pride themselves on being more open-minded about size than most can still show size bias. One midwife confessed that she was concerned about the dietary compliance of her fat clients, so she regularly made a point of refusing them care to make them cry, telling them that she could not take them as clients because they would "break her heart and develop high blood pressure." When they would come back the next day and beg to be reconsidered, she felt she had made her point about good nutrition and would consider them as clients.

This midwife genuinely cared about these women and did take larger women as clients, but her approach is still size-phobic because it assumes that all her fat clients have very poor nutrition, will automatically develop high blood pressure, and need to be saved from themselves. This treatment humiliates them and forces them to beg for care. Average-sized women can have poor nutrition and high blood pressure too, but only the fat women were singled out for this treatment.

Although doctors tend to be more fat-phobic than midwives, midwives can also exhibit size prejudice. All providers need to examine their equipment, protocols, and attitudes to see if they are truly size-friendly.

Fat Women Speak Out

Fat women are tired of being marginalized. They are tired of equipment that doesn't fit, judgmental attitudes from providers, unjustified assumptions, lectures on weight loss, and mistreatment based on size. They want respectful, dignified treatment that does not discount possible risks but does not assume them either. They want to be able to trust their provider to treat them as individuals instead of as statistics.

When asked what size-friendliness means, a number of fat women replied:

• "To me it means that you are treated with the same respect and consideration that you would give a smaller-sized person. It means that you wouldn't look at me with disgust on your face just because I look a certain way, and that you don't make judgments, diagnoses, etc. based on the amount of weight on my body. It means that you would do everything possible to make my experience with you a pleasant experience (i.e., have gown, b.p. cuffs, scales, etc. that fit a variety of sizes and not just the 'standard size')."
• "I think it means that you need to treat the problems with the person and really listen to them… It means not blaming everything that happens on that person's weight… It means treating them like a real live human being, not some fat woman who sits on the couch eating bon-bons and watching TV all day because she is too lazy to do anything else… When you are size-friendly, weight just doesn't matter. It isn't the first thing brought up. You aren't told, 'Oh, didn't anyone tell you that you should have lost weight before you got pregnant?'… I have heard of doctors telling women at 8–12 weeks along that they would be induced or have a c-section at 36 weeks because there would be 'complications' when there was NOTHING showing complications at that point."
• "I think that size-friendly doctors and midwives should treat EVERYBODY with the same respect and care that they themselves want to be treated! We are all human and we all want the care and respect that we deserve!"
• "Size-friendly care is any care that is sensitive to and prepared for the emotional issues and physical needs of the plus-sized person."
• "For me it means not mentioning my weight over and over and blaming each and every complication on my weight."
• "If the scale doesn't go to my weight, make a note of it in my chart… it is embarrassing to have to remind the nurses that the scale doesn't go high enough. The same thing goes for gown and blood-pressure cuffs, make sure you have the right ones BEFORE I come into the examining room. I can't tell you how many times… nurses have tried to put a small blood pressure cuff on my 400 lb.+ arm. Also, have some fat-friendly chairs in the office, ones without arms preferably!!!!"
• "I think being a size-friendly health care provider means not making assumptions or judgments based on a person's weight."

Rules of the Road for Becoming a Size-Friendly Midwife

The following are some guidelines for becoming more size-friendly in your practice. Hopefully, they will help each midwife to observe the way she perceives fat women, question her assumptions, and carefully evaluate the care she plans for them.

Treat us as Individuals.

All fat people are not alike. Don't make assumptions about why we are fat. Sure, some people are fat because they don't get enough exercise or don't eat wisely, but not all of us are. Don't assume we're all sitting on the couch, watching TV and eating chips all the time. People who are born into naturally slim bodies have a hard time understanding what it is like being fat or to struggle with weight, but it is possible for women to eat reasonably, exercise regularly, and still be fat. Some fat people are fat because they have lousy habits, but it is possible to have good habits and still be fat, and it happens more often than you might think.

Don't assume we all have eating disorders either. Some of us do, some of us don't. Some are fat because of emotional eating, but some are fat because of genetics or hormonal imbalances. Some of us used to be only chubby, but dieted ourselves up the scale and permanently raised our setpoints. Most of us are fat because of multiple combinations of these factors. Avoid simplistic thinking. Ask about our diet and weight history before making assumptions about what we need to do. Individualize our care.

Don't Try to Fix Us

We've heard the fat lecture many times before; we don't need to hear it again. If it were simple to lose weight and keep it off, we would have done so by now. It's not simple, it doesn't respond well to easy solutions, and it may not even be what we want. Some fat people do want to lose weight, but for others, being at a stable higher weight instead of constant yo-yo dieting is the more healthy choice. Don't make judgments without hearing all of our history.

Respect What We Are Here For

We are not here to try and lose weight during pregnancy; we are not here to try and reform our lives to fit what you think is best for us. We are here for pregnancy and for birth, not to be reformed, and not to have your agenda and opinions imposed on us. Listen to what we want.

Be Aware of Your Own Prejudices and Assumptions

Carefully examine your own beliefs about fat. Do you automatically assume that a fat woman in your practice is going to develop gestational diabetes or high blood pressure? Do you assume that a fat woman is eating large amounts of sugar and junk foods and will need major nutritional counseling? Do you assume that a fat woman is going to gain a lot of weight in pregnancy and will probably need to be strongly reminded to watch what she eats so she won't gain too much? Do you feel that you have to "save" a fat woman from herself? Do you really believe that "soft tissue dystocia" exists, that a woman's fat can prevent a baby from coming out? Do you think there's a point at which a woman is too fat to become pregnant or to have a baby vaginally? Did you know that women have conceived babies and had vaginal births at weights over 400 lbs.? Did you know that while fat women have higher rates of some complications, the majority of fat women actually have healthy pregnancies and normal births?

What body issues do you have in your life, and how do they influence your perceptions of us as fat women? The sad reality is that some of the most biased treatment comes from women with their own body issues, which influence their agenda for others.

Beware the Self-Fulfilling Prophecy

Many fat women report that their pregnancy experiences follow the expectations of the provider. Look carefully at your own policies of management, your own assumptions, and your own expectations for the births of fat women. Open your mind and take things as they come instead of expecting complications or difficulties. Work with the woman to be as proactive as possible, and then accept how her pregnancy progresses without expectations or judgments.

Use Size-Appropriate Equipment

Do you have equipment to fit all your clients? Do you and other staff know the importance of a large-sized blood pressure cuff and use it without question? If you practice in a clinic, do you have gowns that fit and actually offer full coverage? Do you have a scale that can be adjusted for supersized women? Do you have at least one or two armless chairs in your waiting area for the comfort of your larger clients?

If you do not have equipment that fits all women, get it! Blood pressure readings taken with a regular-sized cuff on large arms are artificially inflated, causing treatment decisions based on invalid data! One study found that 37 percent of obese hypertensives actually had normal blood pressure when the correct cuff was used. (13) Make sure all staff knows why the large cuff is important, where it is stored, and that it is to be used automatically, without protesting at having to go get it. Many practices have large-sized cuffs but don't use them; many large women report having to fight to have the large cuff used.

Supersized gowns can be bought, or offices can allow women to bring their own gowns that fit. Some offices buy full-sized real sheets to use on those occasional visits when the little paper sheets won't do. Large-sized blood pressure cuffs, scale adaptors, and supersized gowns are all available from medical supply stores or through size-acceptance companies on the Internet. If you cannot easily afford this equipment, consider bartering—let one of your fat clients get the proper equipment for your practice as part of her fee. In short, get the right equipment for the job, and don't base treatment decisions on invalid data.

Don't See Us as Statistics

It's true that fat women have higher rates of certain complications (2)—being size-friendly doesn't mean you have to ignore that. It does mean, however, that you do not assume that a complication is going to happen, that you are aware that most fat women actually do not experience complications, and that you do not treat us as a statistic waiting to happen. Be watchful, but expect normalcy.

However, if we do experience a complication, please don't be judgmental. Don't assume automatically that the complication is caused by size; average-sized women experience complications, too. Or a hormonal problem like Poly Cystic Ovarian Syndrome that often accompanies fatness may be the real problem instead of the fatness itself. Don't judge, just be matter-of-fact and open about the problem.

We are real human beings. We have the same hopes and fears and dreams for our babies as anyone else. We are not a statistic on a page. See us as more than mathematical projections—see us as the human beings we really are.

Emphasize Nutrition

Research seems to show that while the most optimal weight gain for average-sized women is about 25 to 35 lbs., the weight gain range associated with the best outcomes in fat women is about 15 to 25 lbs. (14, 15) However, the highest priority should be excellent nutrition, not trying to artificially meet arbitrary weight gain guidelines. Eat healthily and well, and the body will gain the amount that is necessary for that body!

Women of size report a wide range of weight gains in pregnancy. Generally speaking, the larger the pre-pregnancy size, the less weight a woman tends to gain, although of course there are exceptions. The most common weight gain pattern in fat women seems to be a loss during the first trimester, then a slow regain of the weight lost during the second and third trimesters until a small overall gain is established. While many books caution that large women must gain at least 15 lbs., many women of size gain less and their babies are just fine. Women who have recently lost a lot of weight or who are chronic dieters often gain much more than 15 lbs. Although the general goal for larger women is to aim for around 15 lbs., a gain smaller or larger than this should not be a cause for great concern as long as baby is growing well, nutrition is excellent, and all tests are fine. Nutrition is the priority, not arbitrary weight gain guidelines.

Nutrition for pregnant women of size is essentially the same as for every other pregnant woman. Larger women may need slightly fewer calories because they do not need to add the fat layer for energy that smaller women need, but restricting calories can lead to complications and has not been proven to be safe.

Emphasize Emotional Preparation and Expectations for a Normal Birth

One of the most powerful things you can do as a midwife is to emphasize your expectation that all will be well, and to actively help your client to expect that as well. Fat women have had so much negative feedback that many have difficulty believing in their body's ability to work well. Some may need help in learning to trust their bodies and feel comfortable with them; active attention to emotional preparation for birth and working through fears may be especially important for women of size.

Carefully assess your client's background; does she have issues of pregnancy loss, fertility concerns, mistreatment by medical professionals, mistrust of authority, body hate, eating disorders or past abuse? What are her fears about pregnancy, birth and parenthood? What are her hopes? How does she see herself giving birth? What kind of messages is she receiving from her friends and family about this pregnancy?

Helping a fat woman work through her fears and emotional issues is a very potent tool towards helping her have a good birth experience. A birth journal, birth art, visualizations, hypnotherapy and guided imagery are very powerful tools for change. If you do not have enough time to address this adequately during appointments, encourage the woman to see a therapist who specializes in birth issues, or to take one of the childbirth education programs that emphasizes emotional as well as physical preparation for birth. Many fat women have reported this to be extremely useful, especially after prior negative birth experiences.

Learn What Works for Fat Women

Confer with colleagues and share what you have found to work with larger women. Online, midwives have reported great success in helping fat women birth normally by helping them to stay out of bed, to utilize lots of position changes (especially hands and knees), to use birth balls, and to pay very close attention to fetal position. Some midwives report that using a Rebozo or other scarf tied around the middle may help keep baby aligned better for birth if abdominal muscles tend to be lax. Mobility in labor may be especially important for larger women. If cephalopelvic disproportion (CPD) is a concern, use positions that maximize gravity and pelvic opening, and consider having the woman see a chiropractor to be sure the pelvis (including the pubic symphysis area) is well-aligned. Laboring in water and waterbirth may be particularly helpful too.

Discuss with other midwives what laboring techniques or positions have worked well with women of size. Ask your fat clients what is working best for them, too. Trust that a fat woman's body will tell her how she needs to labor, just as any other woman's body speaks during labor. Empower her to listen to it and trust in it. Help her to go with the flow of what her body is telling her.

Treat Us with Respect and Dignity

We deserve the same respect that every other person gets. That means treating us as equals and having respect for our intelligence. It means not patronizing or condescending to us. It means recognizing that many of us have a long history of negative contact with health-care providers that we may need to overcome. It means honoring our ability to make decisions for ourselves, even if you do not agree with them. It means understanding that we are the ultimate authority on our bodies, not you. As one mother puts it, "[Show] respect for the individual person, regardless of the body they wear."

It also means being honest about your own misgivings. If you don't think you can be size-friendly or if you have real misgivings about possible complications or accommodations, be upfront with us. Tell us honestly but respectfully what your concerns are, how you would probably suggest handling things, and then let us decide if we can live with that or not.

Treating us with respect means looking for and seeing the beauty of our bodies—curves, dimples, sags, folds and all. It means honoring our desires to become mothers just like anyone else, and realizing that the ability to love and nurture, not size, is the most important qualification for parenthood. And it means respecting that the miraculous magic of making a baby can happen in a lush body as well as a sparse one.

Pamela Vireday, size-acceptance activist, is the plus-sized mom of three beautiful and healthy children. She is the owner of the Plus-Size-Pregnancy Web site, is finishing her certification as a childbirth educator with Birth Works, and is active in ICAN (International Cesarean Awareness Network) as well.

References

1. Crane, S.S. (February 1997). Association Between Pre-Pregnancy Obesity and the Risk of Cesarean Section. Obstetrics and Gynecology. 89(2): 213–6.
2. Michlin, R., et al. (January 2000). Maternal Obesity and Pregnancy Outcome. Israeli Medical Association Journal. 2(1): 10–13.
3. Johnson, J.W. et al. (August 1992). Excessive Maternal Weight and Pregnancy Outcome. American Journal of Obstetrics and Gynecology. 167(2): 353–70.
4. Giacalone, P.L. et al. (1997). Delivery of the Overweight Woman. Analysis of 115 Patients. Journal de Gynecologie, Obstetrique et Biologie de la Reproduction. 26(3): 288–92.
5. Leaphart, W.L., et al. (March/April 1997). Labor Induction with a Prenatal Diagnosis of Fetal Macrosomia. Journal of Maternal-Fetal Medicine. 6(2): 99–102.
6. Combs, C.A., et al. (April 1993). Elective Induction versus Spontaneous Labor After Sonographic Diagnosis of Fetal Macrosomia. Obstetrics and Gynecology. 81(4): 492–496.
7. Weeks, J.W., et al. (October 1995). Fetal Macrosomia: Does Antenatal Prediction Affect Delivery Route and Birth Outcome? American Journal of Obstetrics and Gynecology. 173(4): 1215–1219.
8. D'Heureux-Jones, A.M. (April 2001). Incision Choice for Cesarean Delivery in Obese Patients: Experience in a University Hospital. American Journal of Obstetrics and Gynecology. 97(4):62S–63S.
9. Allaire, A.D., et al. (April 2000). Subcutaneous Drain vs. Suture in Obese Women Undergoing Cesarean Delivery. A Prospective, Randomized Trial. Journal of Reproductive Medicine. 45(4): 327–31.
10. Naumann, R.W., et al. (March 1995). Subcutaneous Tissue Approximation in Relation to Wound Disruption After Cesarean Delivery in Obese Women. Obstetrics and Gynecology. 85(3): 412–6.
11. Perlow, J.H. and Morgan, M.A. (February 1994). Massive Maternal Obesity and Perioperative Cesarean Morbidity. American Journal of Obstetrics and Gynecology. 170(2): 560–5.
12. Hellmuth, E. et al. (July 2000). Oral Hypoglycemic Agents in 118 Diabetic Pregnancies. Diabetic Medicine. 17(7): 507–11.
13. Maxwell, M.H. et al. (July 3, 1982). Error in Blood-Pressure Measurement Due to Incorrect Cuff Size in Obese Patients. Lancet. 2(8288): 33–6.
14. Cogswell, M.E., et al. (February 1995). Gestational Weight Gain Among Average-Weight and Overweight Women—What Is Excessive? American Journal of Obstetrics and Gynecology. 172(2 Pt. 1): 705–12.
15. Bianco, A.T., et al. ( January 1998). Pregnancy Outcome and Weight Gain Recommendations for the Morbidly Obese Woman. Obstetrics and Gynecology. 91(1): 97–102.

Editor's Note: It is ironic that big women suffer so much prejudice around their pregnancies and births. It is likely that some part of their size is rooted in the horrendous practices that happened to their own mothers during pregnancy and birth. Pregnant women have routinely been told not to gain more than 10 to 15 pounds, literally starving the baby in utero. These babies often came out forever hungry and needing to eat in the cellular effort to avoid starvation at any cost. Breastfeeding is another factor that contributes to body size. The fat cell is completely different in the bottle fed baby, especially when you're bottle fed a formula like the one my sister received as a baby: canned milk and white corn syrup. Genetics also plays a role in body size. Whatever the cause, discrimination is still wrong. Love never fails.

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