Posts Tagged ‘evidence-based care for women of size’

Welcoming All Families Series: Welcoming Women of Size In Your Birth Classes

November 6th, 2012 by avatar

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


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.


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


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.




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 , , , , , , , , ,

Maternal Obesity from All Sides

June 6th, 2011 by avatar

[Editor’s note: This week and next on Science & Sensibility, we will discuss the issue of maternal obesity.  With increasing numbers of overweight and obese women approaching pregnancy, labor and birth, complication and intervention rates are sky rocketing in this population—in sometimes controversial ways.  This series of posts will attempt to answer the ultimate question:  how do we tenderly care for these women, employ evidence-based practices, and still support and honor normal birth whenever possible?]

Globesity:  A World-Wide Epidemic
Maternity care providers bemoan the increased risks associated with caring for overweight and obese pregnant women.  The recipients of their care feel unfairly judged, overly intervened-upon and ghettoized for their body habitus.  As this issue continues to grow, maternity care providers, doulas and childbirth educators need to find a way to interact with these women with equal amounts of compassion and scientific evidence.  And the evidence, in and of itself, is sometimes controversial.

As it turns out, maternal overweight and obesity isn’t just an American thing anymore.  The World Health Organization has made a surveillance tool available on their website, where you can view charts, graphs and maps detailing the rates of adult obesity by country.  Here in America, nearly 36% of adults are obese, including 1 out of 3 women.  The UK reports a similar rate, with 34% of adults considered obese, including 1 out of 5 women.  And pregnant American women are found to be obese 18-38% of the time.

While different countries sometimes use different methods to categorize weight status, the Body Mass Index calculator is most commonly employed:


The problem with using BMI as a body weight categorization tool, is that it does not take into account bony structure, muscle mass or percentages of lean mass compared to adipose tissue.  At best, Body Mass Index is a crude measure of health.  However, academic literature that analyzes weight in relation to pregnancy outcomes typically uses BMI (pre-pregnancy, first prenatal appointment weight or weight at time of delivery) as a primary indicator for study group categorization.

Not only do studies use BMI to include or exclude study participants, but reports have recently emerged that some medical practices are also using BMI as a screening tool: for either accepting or rejecting patients altogether.

The Baltimore Sun recently reported on a slowly emerging trend in southern Florida, in which some maternity care practices are turning away potential new patients, if they weigh more than, say, 200 pounds.  Other doctors practicing in the same area admonish their colleagues for maintaining such policies, despite the increased risk for pregnancy, labor and birth complications many in the industry believe to be an inherent part of attending pregnant women of size.

Other obstetricians, like Dr. Cynthia Maxwell at the University of Toronto Department of Obstetrics & Gynecology, are implementing clinical changes with the aim to improve treatment of and outcomes for overweight expectant mothers, as outlined in this SOCG clinical practice guideline (for which Dr. Maxwell was a principal author).

What the Evidence Shows:  Risks Associated with Maternal Obesity
The basis for heightened concern—whether fueling the exclusion of certain women from their practices, or adopting new approaches to their patient care in response to the growing obesity epidemic—is in the list of complications that are known to coexist with maternal overweight, obesity and morbid obesity.  It should be noted that these weight categories are not all equivalent, and that many of the risk factors we will cover here, and in subsequent posts, become riskier the more overweight or obese an expectant woman is.

In Dr. Tahir Mahmood’s article, Review:  Obesity and pregnancy: an obstetrician’s viewa compilation of statistics from twenty different papers on the subject (British Journal of Diabetes and Vascular Disease 2009; 9: 19-22)—Table 1 provides a an overview of some of the problematic conditions that can be associated with pregnancy in the overweight and obese population:

Other concerns, not listed in this table, but discussed elsewhere in Mahmood’s aricle, as well as in other recent literature include:

-gestational Diabetes (GD)
-fetal macrosomia  (birth weight >4,000g)
-difficulty fighting postpartum infections
-maintained overweight/obesity between pregnancies
-prolongation of pregnancy/increased likelihood to deliver postdates
-other short and long term impacts on fetus/infant/child (neural tubes defects, lifetime increased risk of diabetes and obesity…)
-increased risk of stillbirth
-increased risk of maternal mortality
-postpartum hemorrhage

Complicating this issue beyond the fear factor of increasing a woman’s risk of, say, postpartum hemorrhage or fetal loss…is the fact that statistically, the morbidities associated with maternal weight are less than a slam dunk.  While many women of size will go on to develop one or more of the above-listed complications, some of these women will go on to experience completely normal pregnancies, labors and births. At the same time,  some normal–or underweight–women will go on to develop significant morbidities not typically associated with women boasting BMIs less than 25.

For the professionals working with these women during (or, hopefully, before) their pregnancies, the challenge becomes finding a way to communicate the gravity of these possibilities, without assuming every overweight expectant mother is a ticking time bomb—and all the while treating all expectant mothers with the best evidence-based care, no matter what their size.

[In tomorrow’s installment of this series, we will look at some of the particular co-morbidities associated with maternal overweight/obesity, and the types of provider interactions and interventions that evidence does–and does not–support.]

Posted by:  Kimmelin Hull, PA, LCCE

Maternal Obesity, Uncategorized , , , , ,

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