Science & Sensibility

In the occasional series on Welcoming All Families, we have explored how to make our classes and practices welcoming for women of size and lesbians.  Today on Science & Sensibility, Certified Nurse Midwife Simon Adriane Ellis shares how to offer care and classes that are sensitive to gender variant families. Recently the American College of Nurse-Midwives (ACNM) released a position statement on Transgender/Transexual/Gender Variant Health Care. The ACNM stated that they “support efforts to provide transgender, transsexual, and gender variant individuals with access to safe, comprehensive, culturally competent health care and therefore endorses the 2011 World Professional Association for Transgender Health (WPATH) Standards of Care.”  Simon Ellis served on the task force and played a significant role in writing and advocating for this recently released position paper and worked with ACNM to see it through Board of Director approval in December 2012. – Sharon Muza, Science & Sensibility Community Manager

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Note: The term “gender variant” is used throughout this post to describe individuals whose gender identity is in some way different than the sex they were assigned at birth. Other related words you may have heard before include transgender, gender non-conforming, and gender non-binary. In this post, I specifically address the needs of gender variant people who undertake pregnancy. The needs of gender variant partners and family members also warrant deep consideration, but will not be the focus of this piece. 

http://flic.kr/p/5vHahr

When asked, many birth professionals will tell you that they’ve never cared for a gender variant patient. Many of us claim that we don’t have the skills or the knowledge to do so. Turns out we’re usually wrong, on two fronts. First, chances are many of us have served gender variant people, without knowing it. And second, we are competent, compassionate, and well-trained professionals who already have what we need to provide excellent care and services to our gender variant patients. This post will provide a basic framework for approaching care, as well as some specific resources and suggestions to make your practice more inviting. I write it from both my perspective as a practicing Certified Nurse Midwife, and my perspective as a gender variant person (female-to-male).

Focus on What You Bring to the Table

We all bring ourselves – rich in beauty and flaws and experience – to each client encounter. We are our own building blocks of clinical or professional practice. Accordingly, when striving to provide care or services across difference, the first place to start is within ourselves. What do we bring? Among other things, we bring skills and biases.

Skills

As professionals who serve families in pregnancy and birth, the core of what we provide is compassion; we are incredibly dexterous at meeting people where they are at. We offer a strong and loving presence even in the intense terrain of labor, which takes a whole lot of humanity and skill. This is your number one asset for providing culturally responsive care to gender variant patients and clients. So keep doing what you do best! 

Biases

If someone asks you why you choose to do birth work, what do you say? Many of us would say that we are passionate about serving women, that we value women’s bodies and autonomy and we honor the journey to motherhood. Which is fantastic! We should! But what if your pregnant client doesn’t happen to identify as a woman? Does that change anything about the importance of their journey to parenthood? Does it make their birth experience less authentic and worthy of support? Of course not. Birth is birth, regardless of gender identity. And birth is our specialty. But many of us have a very hard time imagining pregnancy outside the concept of “woman,” which casts doubt on gender variant people who choose to carry a pregnancy. Being aware of and challenging your own biases and personal attachments to the concept of gender will help you prepare yourself for working with a more diverse client base. 

Don’t Pass the Buck

It is convenient to fall back on the idea that we, as birth professionals, are only trained to work with women and therefore are simply not qualified to work with gender variant people. In saying this, we falsely join two separate concepts – sex and gender – and we falsely absolve ourselves from responsibility. The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s wellbeing. But the truth is: with very few exceptions, there is no one with more experience.

In my work with gender variant parents, every single one of their doulas, childbirth educators, midwives, and OBs stated they had never before worked with a gender variant patient. There was no research these providers could review on the physical and emotional health needs of this population, no information on best practices. Each provider had to rely on the skills and knowledge base they already had, and do the best they could. And with compassion and clinical/professional acumen as their guide, it turns out they usually did an awesome job. The lesson to take from this is that 1) you are capable of doing a good job, and 2) a suggestion that the patient see “someone who has more experience” is usually little more than a referral to nowhere. 

Make Your Practice More Inviting

While there is no simple list of do’s and don’ts that you can follow (and the golden rule is, as always, to cater your approach to the needs of the specific client), I do think there are some basic principles that can be helpful in adapting your practice to meet the needs of gender variant patients and clients.

1. Build trust and offer accommodations

Fear of discrimination by providers and fellow patients or class participants presents a huge barrier to care for gender variant people. It is a source of great emotional and physiological stress. I can tell you that it is truly a terrible feeling. Take time to build trust, and to assess your client’s need for accommodations. Some clients will desire as much anonymity as possible, in which case you can offer one-on-one class sessions or facility tours, appointments at the beginning or end of the clinic day, assurances of privacy, and continuity of care. Other clients will desire facilitated integration, in which case you can offer assurance that you will address problems proactively, be available to address questions raised by other clients, and make a point to check in regularly on how things are going. If you need to refer the client to another provider, be sure to offer to call ahead and provide the patient’s background. Taking over the burden of explanation can be an enormous weight off your client’s shoulders.

2. Plan to offer additional emotional support

We all know that pregnancy is an intense and vulnerable time. Gender variant parents-to-be often have the additional struggle of profound isolation, coupled with the likelihood of heightened gender dysphoria during the course of pregnancy. With these things in mind, make yourself available to provide additional emotional support as necessary. Research LGBTQ friendly mental health providers in your area so you are able to make appropriate referrals if needed.

3. Keep your wording flexible

The language of birth work is extremely gendered. This can be isolating for gender variant clients. Work to make your language more inclusive by incorporating terms such as “pregnant parents,” “parents-to-be,” “new parents,” and “gestational parents.” Ask your clients what name, pronoun, and parenting term they would like to be addressed by, then respect their wishes in both individual and group settings. If you slip up and use the wrong name or pronoun, acknowledge it promptly and succinctly, then move on. If you work with a staff, make sure that all staff members are addressing the patient or client appropriately as well. Including fields asking for “preferred name” and “pronoun” on your intake or registration forms will send a clear (and very relieving!) signal to potential clients.

4. Don’t let curiosity get the best of you

I can tell you from personal experience that gender variant people are constantly asked about our gender identities. Regardless of the context or topic of discussion, we are expected to be willing and able to explain our innermost sense of self (or defend our right to exist!) at all times. This is stressful! While your curiosity may stem from a desire to better understand your client’s gender experience, and you should be open to hearing about their experience, focus on the pertinent issues at hand. Maintain your professional integrity and ask only what you need to know in order to provide excellent care.

5. Address issues proactively, especially in group settings

If you see clients in a group setting, consider a handout or brief talk at the beginning of each class (regardless of who is in attendance) affirming that there are many different types of families and that intolerance will not be allowed. Name behavior firmly but gracefully when someone acts inappropriately, and follow up with them individually outside of the class setting. Do not place the burden on your gender variant clients to defend themselves – instead, show them that you are a dependable professional who has their back and is willing to help other clients grow and become more accepting.

Thank you so much for your commitment to serving gender varient people!

Creating a class or practice that is welcoming to all families can involve sharing stories of all different families.  Choosing your media, handouts, posters and class material that includes all the different ways that families can look is important.  Please share your favorite resources for these types of supplies.  There is not a lot to choose from and we can all benefit from sharing information.  What do you do (or what have you done) to welcome gender variant families into your classes and practices?  Please share your experiences in the comments section.- Sharon Muza

Resources

Resources on this issue are few and far between, unfortunately, but here are some good places to start:

Basic vocabulary and introduction to the issue of gender variance: http://srlp.org/trans-101

2010 healthcare discriminatory survey: http://www.thetaskforce.org/downloads/resources_and_tools/ntds_report_on_health.pdf

Blog by a transgender dad who breastfeeds his son – lots of good information as well as personal reflections: http://www.milkjunkies.net/

Resources for gender variant parents – includes legal resources and family support resources: http://www.transparentcy.org/Resources.htm

Gender and the Childbirth Professional Facebook group – connect with other providers who work with gender variant clients, ask questions, post resources, etc.: https://www.facebook.com/groups/265359336861854/?fref=ts

My personal blog – occasional updates on midwifery, sexual health, and what’s it’s like to be a gender variant midwife: www.boimidwife.wordpress.com

It’s My Body, My Baby. My Birth – DVD for use in class that shows 7 natural births and interviews the couples.  One couple is gender variant.  http://www.itsmybodymybabymybirth.com/Home.html

Additionally, the ACNM Position Statement contains additional resources on this topic.

Thank you so much for your commitment to serving gender varient people!

 About Simon Adriane Ellis

Simon Adriane Ellis is a Certified Nurse Midwife, trained doula, and queer and gender variant person. He has a long history of social justice organizing around issues of racial and economic justice and LGBTQ rights, and brings these values to his work as a midwife. His practice is focused on providing empowering sexual and reproductive health services across the lifespan for people of all gender identities. He is currently working to publish his original qualitative research on the conception, pregnancy, and birth experiences of gender variant gestational parents. He hopes that this work will provide a broad call to challenge conventional assumptions about what pregnancy looks and feels like for all of our clients, regardless of gender identity. Simon can be reached through his midwifery practice, Essential Healthcare + Midwifery Services.

Sharon Muza Childbirth Education, Guest Posts, Legal Issues, Midwifery, Series: Welcoming All Families ACNM, ACNM Position Statement, American College of Nurse-Midwives, Childbirth Education, Gender Variant, Midwifery Care, midwives, Sharon Muza, Simon Adriane Ellis, Transgendered, welcoming all families

Continuing along in our occasional series on “Welcoming All Families” to our childbirth classes, this two part guest post is written by Pam Vireday,  creator of the Well-Rounded Mama blog.  Today, Pam shares how to promote optimum outcomes at the births of plus sized mothers. Click here to read the first post in the series, where Pam shared how to create childbirth education classes with women of size in mind. – Sharon Muza, S&S Community Manager

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In part one of the series,  we discussed how birth professionals can make women of size feel more welcome by creating a size-friendly space, by addressing special needs, by finding size-positive images and birth stories, and by addressing potential risks in a proactive, non-judgmental way.  Today, in part two, let’s discuss ways to promote optimal outcome in women of size.

Nutrition and Exercise

photo courtesy of Pamela Vireday

Many women of size find they feel better and have more stable blood sugar when they combine carbohydrates with protein instead of consuming carbohydrates by themselves. Modestly limiting carbohydrates at meals, eating smaller and more frequent meals, and using whole grains instead of refined carbs may also help promote euglycemia.

An even more powerful tool for optimizing blood sugar is exercise. Intensity of exercise is far less important than regularity of exercise, with daily exercise being optimal. Many women of size find walking, swimming, prenatal yoga, and water aerobics particularly friendly to larger bodies.

Nutrition Diaries

One of the most trying things for some fat women is the pregnancy nutrition diary. If used, these must be done with care.

After years of having every bite nit-picked, pregnancy food diaries can be very triggering for women with long histories of dieting or eating disorders. In addition, many providers don’t believe women of size no matter what they say. As one mom shared, “[My midwife] refused to believe what I recorded. She flat-out accused me of lying, telling me that I ‘must be living on ice cream and donuts.’”  This can be very disillusioning.

If you decide to use food diaries, question your assumptions about what fat women “must” be eating.  Some people eat normally and are still fat, while some thin women have terrible habits and yet are thin. Leave out assumptions, scolding, and lecturing, and find a way to neutrally help women analyze their own intake and gently adjust if needed.

Prenatal Weight Gain

Current weight gain recommendations from the Institute of Medicine are 11-20 lbs. for obese women, and 15-25 lbs. for overweight women.  However, many care providers these days are strongly pressuring obese women to diet to restrict weight gain, or even to deliberately lose weight during pregnancy.

This is a dilemma for women of size, because research suggests that very low gain or gestational weight loss may actually increase the risk of small-for-gestational-age or premature babies. Some research suggests differing weight gain recommendations for differing classes of obesity, but studies on limiting weight gain have many design flaws, so providers must tread carefully to balance potential benefits and risks.

Another alternative is to take a Health At Every Size® approach. Good nutrition and regular exercise is promoted, but without the scale as a goal.  The finger-wagging, shaming approach of most dietary intervention is absent, and although particular weight gain goal ranges can be encouraged, good nutrition is put ahead of rigid goals. Many women with a long history of dieting find a Health At Every Size® approach very freeing because it still emphasizes healthy behaviors, but without the scale as judge and jury.

Weight gain among women of size is extremely variable. A lot depends on the woman’s individual circumstances. Differing amounts can be normal as long as you are eating nutritiously.

As one big mom notes:

Talk about weight gain, but explain that every body is different. Some people gain lots and have healthy babies. Some people gain very little or even lose and have healthy babies. Don’t focus on the scale, but on healthy eating and assure people their bodies will then do what they need to do.

Another mom agrees, saying, “Providers can get across the point that excellent nutrition is key to a healthy pregnancy and birth without making mom stress over it.”

Finding a Size-Friendly Caregiver

Finding a size-friendly caregiver is critical to having a positive birth experience. Unfortunately, bias and mistreatment are not uncommon. Some of it is egregious mistreatment, while other examples show a more subtle bias.  In particular, many well-meaning care providers overutilize interventions in the labors of women of size.

Research shows that obese women are induced at much higher rates, experience a higher rate of interventions, and that caregivers have a lower threshold for surgical intervention in their labors. Although it is commonly believed that obesity predisposes to a cesarean, recent research suggests that cesarean rates can vary dramatically within the same weight class, depending on how the labor is managed.  This suggests that labor management and attitudes may be more of a factor in c-section rates than obesity itself.

High-BMI women need to ask careful questions about special protocols they may be pressured into (like early inductions for suspected macrosomia, early amniotomy, internal monitoring, or early epidurals) and how much wiggle room there is for working around these.

 One plus-sized postpartum nurse states bluntly:

As far as labor, the best advice I could give another [plus-sized] mom is to STAY MOBILE!!!!! Staying in bed, getting an epidural too soon, not being able to change positions frequently [equals] dysfunctional labor and c-section.

Other tips for lowering an obese woman’s chances for a cesarean can be found here and here.

Like other women, women of size need information on patient rights, how to advocate for themselves, their right to decline procedures, and information on filing a complaint if needed.  Knowing that they have the right to stand up for themselves and say “no” is a new concept to far too many plus-sized women.

Pay Attention to Fetal Position

There is some research and anecdotal evidence that suggests that women of size have a higher rate of malpositioned babies, and that this may play a role in their increased cesarean rate. Talk with women about fetal position, discuss ways to promote optimal fetal positions, and mention the possibility of chiropractic adjustments for those who are interested.

Since some very heavy women have pendulous bellies which may make it harder for the baby to engage in the pelvis, include some information about the “abdominal lift and tuck” exercise, as well as other positions that can help babies to engage during labor.

Birthing Positions for Women of Size

Encourage women of size to experiment with finding useful laboring and birthing positions that work with their bodies. Remember that like all women, women of size will vary in how athletic and flexible they are. Explore each position without judgment.

Many women of size find the all-fours position or a forward-leaning kneeling position useful. If the woman has an epidural, side-lying can be extremely helpful. Although “soft tissue dystocia” is an unproven concept, if there is any question of pelvic capacity frequent position changes and asymmetric positions like lunging may be helpful.  A birth ball (appropriate for height and weight) can also help relax the perineum, open the pelvis, and allow easier rotation among positions.

Many women of size report loving laboring in water. The buoyancy of the water allows position changes with greater ease, and eases pressure on the knees. The pain-relieving effect of water is another bonus, since epidurals can be harder to place in larger women.

Further information (and pictures) on birthing positions for women of size can be found here and here. Some care providers actively discourage mobility in women of size, so having a supportive caregiver is key. Practice multiple positions beforehand, emphasize the importance of frequent position changes, and promote having a labor support person who can help women utilize position changes more easily.

Summary

Although women of size are more at risk for certain complications, remember that women of all sizes can experience complications. All women benefit from the same basic advice for excellent nutrition, regular exercise, reasonable weight gain, choosing good providers, attention to fetal position, and use of flexible birthing positions. Emphasize proactive health behavior across the board.

What has been your experience in helping prepare women of size for birth?  How have the women you might have had in your classes or practice found the experience of pregnancy and birth as a large sized woman?  Do you have suggestions to add about your observations and favorite resources? Please share with our community.- SM

Plus-Sized Resources

Finding Size-Friendly Care

• http://www.cat-and-dragon.com/stef/Fat/ffp.html – size-friendly providers of all types
• http://plussizebirth.com/plussizedoulaconnections – size-friendly doulas
• http://plussizebirth.com/midwife-ob-gyn-connections – size-friendly midwives and OBs
• http://www.aafp.org/afp/2002/0101/p81.html – guidelines from the American Academy of Family Practitioners for improving care for obese patients
• www.amplestuff.com – catalogue with products sized for larger people, such as larger blood pressure cuffs, scales that go to higher weights, larger exam gowns, etc.

General Size Acceptance and Health At Every Size® Resources

• http://www.jonrobison.net/Health_Every_Size.pdf – pamphlet on Health At Every Size®
• http://healthateverysizeblog.org/ – blog about Health At Every Size® issues
• www.sizediversityandhealth.org – Association for Size Diversity and Health
• www.cswd.org – Council on Size and Weight Discrimination
• http://www.lindabacon.org/HAESbook/excerpts.html – info on Health At Every Size®
• http://danceswithfat.wordpress.com/blog/ – size acceptance and Health At Every Size®
• http://www.healthyweight.net/cntrovsy.htm – Healthy Weight Network
• www.naafa.org – National Association to Advance Fat Acceptance
• http://www.cat-and-dragon.com/stef/Fat/ffp2.html – tips on obtaining good health care
• http://www.fwhc.org/health/fatfem.htm – Large Women’s Healthcare Experiences

Books on Health At Every Size®

• Bacon, Linda. Health at Every Size: The Surprising Truth About Your Weight. BenBella Books, 2010.
• Campos, Paul. The Obesity Myth: Why America’s Obsession With Weight is Hazardous To Your Health, Gotham Books, 2004.

 About Pamela Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

Sharon Muza Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, informed Consent, Maternal Obesity, Series: Welcoming All Families, Uncategorized Childbirth Education, guest posts, maternal obesity, obesity in pregnancy, Pamela Vireday, risks of maternal obesity, welcoming all families

Continuing along in our occasional series on “Welcoming All Families” to our childbirth classes, this two part guest post is written by Pam Vireday,  creator of the Well-Rounded Mama blog.  Are your childbirth classes friendly to women of size?  What special accomodations and resources do larger-sized mothers-to-be need if any? In today’s post, Pam discusses a check list of items that you might consider when teaching childbirth classes and on Thursday, Pam shares how to promote in your classes optimum outcomes at the births of these mothers.- Sharon Muza, S&S Community Manager

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MatthiasKabel GFDL www.gnu.org/copyleft/fdl.html Wikimedia Commons

Although the exact numbers vary according to the source used, it is no secret that many women of childbearing age are “overweight” or “obese”* by government standards.  This means that, sooner or later, most doulas, childbirth educators and health care providers will have women of size as clients or patients.

Many birth professionals are unsure of how to address the unique needs of this group. At a time when the media messages around obesity and pregnancy are almost uniformly negative and scare-mongering, it is important that birth professionals create a place for women of size to discuss their unique concerns without judgment.

Terminology*

Research shows that many larger people find the terms “obese” and “overweight” stigmatizing. Although size-acceptance activists prefer the word “fat,” some people cannot hear this term neutrally, and euphemisms like “fluffy” can feel patronizing.

Birth professionals are encouraged to notice and adopt the terminology used by clients for themselves. Until then, use more neutral terms like “plus-sized” or “women of size.” (Further discussion of the relative merits of various terms can be found here.)

Create a Safe Space

Most larger women have been negatively judged by others for their weight, and the disapproval is never stronger than when they consider pregnancy. Women of size need a non-judgmental space where they can feel free to discuss their concerns for pregnancy without being shamed, lectured to, or made to feel like “bad mothers.”

Your job as a birth professional is to create this safe place. Examine your own biases about weight, eating, and health.  Question your assumptions and engage with each woman as an individual. Utilize reflective listening, assist them in researching special issues, and neutrally explore proactive behaviors that might help address their concerns.

Make Sure Facilities Are Size-Friendly

Ask yourself ─ are your facilities friendly to larger bodies?  Do you have armless chairs? Seating that is easy to get up from?  Restrooms that accommodate larger people?  Comfortable facilities set the tone for a space that is welcoming to all sizes.

Remember that getting up and down from the floor can be difficult for many women in pregnancy, not just heavier women.  Have a few low stools around that women can use to help boost themselves up.  Also be sure your birth balls are appropriate for heavier women; a little higher and a little more heavy-duty balls can be helpful.

Address Special Equipment Needs

The correct blood pressure cuff size is vital for larger people.  A too-small cuff can artificially inflate blood pressure readings and result in unnecessary intervention.

According to guidelines from the American Heart Association, people with upper arm circumferences above about 13.4 inches (34 cm) need a “large adult” cuff, while those with a circumference above about 17.3 inches (44 cm) need a “thigh” cuff.  If in doubt, measure the client’s arm and cross-check it against the reference range printed on the BP cuff.

Some care providers resist using larger cuffs, so women or their support people may need to be quite assertive about utilizing the correct cuff size.

Discuss Breastfeeding When Well-Endowed

Some high-BMI women are quite well-endowed. This can present special challenges in breastfeeding, yet many women receive no information on how to meet these challenges. Cover a variety of nursing positions and techniques, including the football hold, which may be more useful for well-endowed women.

Have Additional Resources Available for Women of Size

A consistent problem for women of size is the difficulty in finding resources for their specific needs. For example, finding maternity clothes or a nursing bra in a larger size can be a major problem. Many women appreciate having a list of companies that specialize in plus-size maternity products.

Address Potential Risks and Complications

While the possibility of complications must be acknowledged, remind women that having a risk factor for a complication does not inevitably mean developing that complication. An individual’s outcome cannot be predicted by risk factors alone. Treat women of size like any other pregnant woman by expecting normalcy as much as possible.

Share websites that examine weight-related research with a neutral, critical eye, which acknowledge that complications are possible and promote proactive prevention, but which also point out that larger women can and do have normal, healthy pregnancies and births.

Find Positive Images and Stories of Women of Size

photo courtesy of Diaz Family

Media images of heavy people in our society are highly stigmatizing.  Most pictures of fat people are headless (dehumanizing them), unflattering (focusing on bellies or behinds in tight clothes), or reinforce stereotypical behavior (eating junk food or being sedentary).

Media discussions of pregnancy and obesity focus only on the risks for complications, tell apocryphal stories of worst possible outcomes as if they are commonplace, or compare fat pregnancy to child abuse.

Books that focus on obesity and pregnancy pay lip service to being size-friendly, but contain a preponderance of negative stories, highly-interventive births, and scare tactics about complications.  As one doula reviewer on Amazon wrote, “More time was spent telling me how much more likely I am to have a cesarean than to tell me how I can best avoid one.”

It’s very important to counteract these negative messages and images with positive ones.  Direct your client to websites which have plenty of positive images of women of size pregnant, giving birth, and breastfeeding (see list below).  Connect them with a community of like-minded women if they are interested.

Respect Patient Autonomy

Different people will look at the same information with differing values and make varying choices.  The same is true for women of size.  Some will respond to information about obesity-related risks by choosing a more-interventive childbirth model, and some will respond by choosing a less-interventive model.  Neither choice is right or wrong. Respect each person’s right to choose for themselves.

 

“All in all I think I just want to be treated the same as anyone else. Give me the information, not opinions, not value judgments. Let me decide what to do with it. Give me all the information, not what you perceive or decide I need. Treat me as thinking adult. Treat me with respect. Don’t belittle me, and do not treat me with kid gloves either.” Lexi Diaz, plus-sized mother of four.

Do you do anything different when women of size attend your classes?  Do you feel like your classes already accomodate any special needs they might bring? Do your visual aids and resource lists include pictures of women of size and resources designed for their needs?  Do you feel that any woman of size attending your class feels welcome or alone?  What have been your experiences with larger sized women taking your classes or being your client or patient.  Let us know your experiences in the comments section and share additional resources if you would like.  Read on Thursday, when Pam shares how CBEs can help women have optimum outcomes at their births.- SM

Plus-Sized Resources

Plus-Sized Pregnancy Information

• www.wellroundedmama.blogspot.com
• www.plus-size-pregnancy.org
• http://www.facebook.com/theamplemother
• www.plussizebirth.com
• www.facebook.com/plussizemommymemoirs
• http://pregnancy.about.com/od/plussizepregnanc/Plus_Size_Pregnancy.htm
• http://www.facebook.com/pages/Plus-Maternity-Australia/107067319323331
• www.fertilityplus.org
• http://community.babycenter.com/groups/a425315/plus_size_and_pregnant

Finding Maternity Clothing in Plus Sizes

• Plus-Size Maternity Clothing FAQ – help for finding maternity clothing, nursing clothing, nursing bras, and maternity-related products in plus sizes, both in the U.S. and abroad
• http://plus-size-pregnancy.org/BBWBabyCarriers.html – help for finding baby carriers and slings in plus sizes
• www.plusmaternity.com.au – resources on plus-sized maternity and nursing clothing in Australia
• http://plussizebirth.com/2012/04/babywearing-for-the-plus-size-mom.htm – info on finding baby carriers for plus sizes

Positive Images of Plus-Sized Pregnant Women

*Do not use any of these photos without asking permission first

• Plus-Sized Pregnancy Photo Gallery – series of blog posts with many pictures of plus-sized pregnancy and birth
• Plus-Sized Pregnancy Breastfeeding Gallery – pictures of women of size breastfeeding
• http://plussizebirth.com/gallery- gallery of plus-sized baby bumps, birth pictures, breastfeeding pictures, and babywearing pictures
• http://oneyawn.blogspot.com/2012/06/belly-pictures-baby-number-three.html – belly diary of a plus-sized mom, week to week in pregnancy
• http://www.facebook.com/theamplemother/photos_stream – plus-sized pregnancy photos
• http://birthislife.blogspot.com/2012/08/nursing-portrait-session.html – lovely breastfeeding photos of a woman of size
• http://www.yaleruddcenter.org/press/image_gallery.aspx – free for educational purposes with attribution to the Rudd Center for Food Policy and Obesity (no pregnancy images)

Birth Stories of Plus-Sized Women

• http://www.plus-size-pregnancy.org/BBWBirthStories/bbwstrindex.html – stories with a wide range of outcomes and experiences
• http://www.plus-size-pregnancy.org/BBWBirthStories/bbwvagnlstories.htm – stories of normal vaginal births in women of size
• http://www.plus-size-pregnancy.org/BBWBirthStories/bbwspecvagstories.htm – stories of normal vaginal births in women of size despite special circumstances

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pamela Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

Sharon Muza Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Obesity, Maternal Quality Improvement, Maternity Care, Series: Welcoming All Families breastfeeding, Childbirth Education, evidence-based care for women of size, guest post, maternal obesity, obesity, Pamela Vireday, pregnancy in women of size, series, welcoming all families

A Guest Post by Anna Deligio, MSW, LCCE, CD(DONA)

Today’s post is the second in an occasional series on welcoming all families to your childbirth class and honoring the diversity that different family models bring to pregnancy, birth and parenting.  You can read the first part in this series here, to learn about the non-biological mom’s experience in a childbirth class from Anna’s partner, Cathy Busha.  Look for more on this topic of diversity in future months. – SM

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“The real voyage of discovery consists not in seeking new landscapes but in having new eyes.” Marcel Proust

There have been variations on the definition of family for as long as there has been a definition of family. It is not news that there are women creating families without partners – either by choice or because the male involved is not involved. Nor is it news that lesbians, gay men, bisexual and transgendered folk have been quietly having and raising children for generations.

What is news is the increase in the number of women choosing to parent without partners and the increase in LGBT (lesbian, gay bisexual, transgendered) families in the last couple of decades. According to the New York Times article, “For Women Under 30, Most Births Occur Outside Marriage” from February of 2012, now more than half of births to American women under 30 occur outside of marriage[i]. Studies done by the Family Equality Council, a non-profit that works to connect, support and represent LGBT families, show that there are currently an estimated 1 million LGBT parents in the United States raising an estimated 2 million children[ii].

Are these increases evident in the students and clients you serve as a birth professional? Do you see more women choosing friends or family members as their labor support people rather than the male who supplied the sperm? Have you worked with any LGBT couples as they prepared for and experienced the birth of their child?

If your answer to the above questions is “no”, there might be an opportunity for you to examine how welcoming and affirming of diverse family structures your materials and teachings are. We know these families are out there, so why aren’t they in our classes (if they are not)?

My partner Cathy and I recently had the opportunity to attend a two-part childbirth preparation class offered through our insurance. We are pregnant (I am carrying) for the first time and expect a birth sometime around the end of July. Like many pregnant people, we chose the class that was offered through our insurance and attached to the hospital where we will be birthing.

As a Lamaze Certified Childbirth Educator in a hospital setting, I came to the class open to learning strategies I could take back to my classes. As a pregnant lesbian, I came curious if the materials would reflect our family and wondering how inclusive the language would be.

© Marco Santi Amantini - Fotolia.com

As expected, the materials lacked diversity because diverse materials don’t exist. I have searched for posters and videos that include diverse families and have come up with a few that involve young, single mothers but none that show LGBT families or more mature women who chose from the start to parent without a partner. This is a real problem to me. You can be as inclusive as possible in your use of language, but if the materials you use show only female-male dyads, you continue to give the message that they are really your intended audience.

Lack of materials would be an insurmountable challenge if birth professionals weren’t such a crafty and persistent lot. Make your own. Search online for images of diverse family structures and use them (with permission) on your websites and in your handouts. (See notes below.) Make your own posters with these images. Use your persistence and advocacy skills to lobby InJoy and other video manufacturers to include diverse families. Let them know you want films with diverse families – LGBT families, families of women who choose to parent without partners (not just pregnant adolescents who are forced into single parenting). If you’re super-crafty, create your own birth films with these families (and then please link them far and wide so we all can benefit from your wild talents).

As for language, our instructors, like a lot of professionals, used the term “partner” rather than “husband” or “father”. Partner creates a little more space for diversity, but maintains with a couple of problems: if the subsequent pronouns are all male, it suggests that partner doesn’t include females, but just men who aren’t legally married to the pregnant woman; partner continues to exclude women who are not parenting with an intimate partner, regardless of that partner’s gender.

To that end, I believe that “support person” is the most inclusive term available. Some might think that it diminishes the role of the father. Fathers have a lot of privilege in the birth world, so the impact on them is minimal. More than that, their role during the labor and birth is about being a support person. It does not matter if they supplied the sperm or if they will be parenting the child – those actions address their past and future relationships with the baby, not their relationship to the birthing person during labor.

During labor, their relationship is as support person to the birthing person. This applies to any who will be supporting – female partners, mothers, best friends, husbands, etc. Once the baby is born, they can go on to be mother, father, grandmother, aunt, etc., but during the labor their role is support to the birthing person. (Their potential inability to separate those roles during labor speaks, always, to the value of having a Labor Doula).

Just as with any language that challenges the mainstream, it is important to be explicit. Take a moment at the start of your class and in your materials to explain why you are using the term “support person” rather than “father” or “partner”. Demonstrate your dedication to inclusivity and create a space that is affirming to all the stories in the room. Spread your educating beyond the stages and phases of labor to teachings on the importance of honoring all families. Do this whether or not you think you have any diverse families in your class – it’s dangerous to assume another’s story and, at the very least, you’re educating a new batch of allies to diverse families.

Top 10 Ways to Create an Inclusive Childbirth Education Practice 

1. Remember that Pictures Say A 1,000 Words – make sure that your website, flyers, handouts, posters, and other promotional materials show diverse family structures. Include images of LGBT families and women who chose to parent without partners. If you don’t have these images from your own client interactions, utilize stock photos and magazine images to create these materials until you can use your own client images, with permission, of course. (See Copyright Information.)
2. Use Inclusive Language – change all of the places that say “father” or “partner” to “support person.” Explicitly explain that, while you honor all of the other roles in your clients’ lives that their loved one (husband, female partner, mother, sister, best friend, etc.) plays, you will focus on their role during labor – that of support person. Explain that you use this term to make sure that all families feel welcome in your work.
3. Advocate and Advocate Some More – regularly contact manufacturers of childbirth educational materials and videos and tell them that you want materials that include all families, and celebrate diversity.  Use your purchasing power to create change.
4. Use the Power of Stories – make sure that the stories you share in class include the stories of diverse families. If you don’t personally have any of these stories yet, change the pronouns in some of your stock stories to make the families more diverse. Change the fathers to lesbian partners. Omit the partners altogether and make the story about a professional woman who chose to parent without a partner.
5. Put Yourself in a Place to Learn – find where these diverse families are in your neighborhoods. Join their groups, attend their meetings, show up with the intent to listen and learn. Build bridges with these communities and learn how to be an ally to them. Join the email list of the Family Equality Council and learn from the work they do with LGBT families.
6. Don’t Guess the Stories of Your Students – take the time at the start of class to learn the stories of your students. Don’t assume because everyone there is in a male-female pair that the male provided the sperm and is planning on co-parenting. Even if everyone in your class falls under that model, use your inclusive language and materials. Explain why you do. Spread your educating past the stages and phases of labor to the importance of honoring all family structures, whether or not they are currently reflected in that cohort of students.
7. Stop Assuming Everyone Has Access to Sperm – when talking about ways to naturally bring on labor, avoid the saying, “What got the baby in will get the baby out”, as some women have become pregnant in a very clinical way, and clearly that does not apply in this situation. When talking about sex as an induction tool, talk about orgasm (achieved with or without a partner) and the release of oxytocin.
8. Blow Up the Gender Boxes – when talking about parenting, leave out stories and examples that are overly reliant on limiting gender roles.  Keep your information to the tasks at hand and assume that everyone in the room is fully capable of equal parenting. Make sure you also speak to women who will parent without a partner and emphasize the need for everyone – regardless of relationship status – to have a community of supporters willing to help out with the raising of the child.
9. Be a Good Ally – interrupt limiting language when you hear it from colleagues. Teach them the phrase “support person” and explain why you choose to use it instead of “father” or “partner”. Challenge speakers at conferences to be more inclusive in their presentations. Thank those who are.
10. Give Yourself Some Grace – unlearning unhelpful paradigms takes a lot of energy and work. Give yourself some grace as you do the work of unlearning limiting language. Like all good things, it’s a process and takes time to truly integrate.

• The New Essential Guide to Lesbian Conception, Pregnancy, and Birth
• The Ultimate Guide to Pregnancy for Lesbians: How to Stay Sane and Care for Yourself from Pre-conception through Birth, 2nd Edition
• Confessions of the Other Mother: Nonbiological Lesbian Moms Tell All

Sharon Muza Childbirth Education, Guest Posts, Series: Welcoming All Families

Guest post by Cathy Busha, MSW

This post is the first in an occasional series on CBE teaching strategies that embrace the diverse populations that take childbirth classes.  Childbirth educators that want to welcome all families to their classes will find information and resources in the series for making their classes a positive place for all.  The second post in the series, to be posted on Thursday, will offer insights on specific things that educators can do, from a LCCE and lesbian mom.  Please welcome this guest post by Cathy Busha, MSW. – SM

My partner and I are expecting our first baby in July; she is carrying.  To prepare, like many first-time expecting parents, we signed up for a birth class offered through our insurance. Rather than seek a private class, it felt important to us to attend this class because 1) it’s free and our budget is tight 2) it’s at the hospital where we are having the baby and 3) from a social change place, I believe in integration not segregation; the birth class that is offered for everyone should be welcoming and have information inclusive of us, too.

While I have not experienced overt homophobia during our pregnancy, as the non-biological mom, I have experienced moments of invisibility. For example, when we found out we were pregnant, a well-meaning friend said, “Congrats! Anna is going to be a mom!” I didn’t know if the educator or our classmates would have judgment or visible discomfort about two women having a baby. While the advertisements for the class talked about partners, all the images were of heterosexual couples. As a genderqueer lesbian, I had some nervousness about attending the class.

My partner is a Lamaze certified childbirth educator, so I have learned a lot about the birth process through conversations about her work. That said, it felt important to me that we take a class together – to make sure I had a strong foundation of understanding of the birth process and how to support her. While we had been watching videos together at home, I wanted to take a class with her so we could learn, talk about the information and create our birth plan together, as a couple.

LGBT News, Facebook 2012

As I’ve explored books and blogs and birth websites, it seems the birth world, like the rest of the world, is hyper-heterosexist with rigid gender roles. Heterosexism assumes that everyone is straight: there are no pictures or stories of lesbian births on mainstream birth websites. At best, the word ‘partner’ is used, but all images, examples and stories are of straight couples.  I have grown weary of having to translate my role (non-biological mom) from mainstream books, videos and materials that assume all families are one man, one woman.

As for gender roles, on birth websites, women are portrayed with long hair, flowy white dresses, surrounded by flowers, brimming with nurturing instincts. Men, on the other hand, are described as bumbling, strong, masculine providers who may or may not know how to hold a baby or change a diaper, but patiently suffer through their wives’ crazy cravings and mood swings. I don’t identify with either of these paradigms and wondered how I would fit into the birth class we had chosen to take.

I fully anticipated that we’d be the ‘token’ lesbians in the birth class and I was right; however, there was also a single woman in our class who attended with her best friend.

Our childbirth class was two Saturdays with two different and wonderful educators.  As they taught us about the “stages and phases,” I felt affirmed and included when the educators said statements like:

• “…partners are continuous labor support for the mom…”
• “…a doula helps the woman and her partner through the birthing process…”
• “…research shows that just holding your partner’s hand during contractions has strong emotional and physical results…”
• “…it is important to start talking to your baby now – the baby can also hear the partner’s voice…”

Then I realized that while both childbirth educators went out of their way to talk about the birth mom and partner, I felt empathy for the single mom — the word partner rendered her and her friend invisible.  I wondered how can educators honor and include everyone in the room?

While our educators clearly tried to use inclusive language like partner there were still comments such as:

• “…you fathers will also produce high levels of oxytocin during birth…”
• During hand massage training, “…most of you guys in here have bigger hands then your partners…”
• and “…when the baby is born, everyone wants to look at it and figure out – does the baby look like mom or dad?”

We also did a break-out session,  where the pregnant women made a list of what would be helpful from their support person during labor; we support people left the room and were asked to also make a list of what we thought would be helpful for us to do. When we returned to the room to share our lists, the educator said, “Dads – let’s hear your list,” which made the best friend and me invisible again. It felt hurtful and dis-empowering for the educator to use the word “dads,” particularly after working in our small group – where I felt very included and acknowledged by the other support people. It’s no surprise to me, but in working through this exercise in our small groups, it became clear that as support people, our hopes and fears for the birth process were exactly the same.

In the class, we practiced massage, counter-pressure and other comfort measures. My partner and I are very comfortable in public with our sexual orientation/gender identities. As I rubbed her back, I wondered how comfortable this activity might be for a lesbian couple who was less ‘out’ or if someone in the room was openly homophobic.

Overall in the class, I felt we were acknowledged and accepted by the educators and classmates; however, all the videos, print material and photos were of straight couples. It would have been validating to see even one same-sex couple depicted. While childbirth educators should check out the Family Equality Council or Gay Parent Magazine to learn more about the LGBTQ (lesbian, gay, bisexual, transgender, queer/questioning) community, the assumption that pregnant women “must be in relationship with a man” is what needs to change. Queer families are not the only non-traditional family structures that have been increasing; the solo parent (aka Single Mothers by Choice) community is a growing and vibrant one, too.

Overall, the class was a positive experience for my partner and me. I feel more knowledgeable and prepared to support my partner through childbirth. It may have been easier for us to take a private class, but it was more important for us to connect with other families and develop a sense of community. In meeting our needs, we believe we also helped break down stereotypes and increased awareness. I am eagerly counting down the weeks until I can put into practice everything I learned in class and help my partner birth our baby.

A native of Lancaster, Pennsylvania, Cathy Busha is a Human Services/Social Work Faculty member at a community college in Salem, Oregon. A former middle school English teacher and high school basketball and track and field coach, Cathy has a Master’s of Social Work degree from Arizona State University.  The focus of her work includes diversity/inclusion, organizational development and multi-issue community organizing, particularly LGBT (lesbian, gay, bisexual, transgender) people of color, youth and immigrants. Cathy and her partner moved to Oregon from the Boulder, Colorado area this past August and are expecting their first child in July. She welcomes all parenting advice. She can be reached at cbusha@hotmail.com.

Sharon Muza Childbirth Education, Guest Posts, Series: Welcoming All Families, Uncategorized Cathy Busha, Childbirth Education, childbirth education class, lamaze, lesbian, series, welcoming classes