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

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
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 normalcyas 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

Lexi Birth 028

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

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.


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

November 6, 2012 07:00 AM by Stacey Atwell-Keister, LCCE
Hear hear! Thank you for this thoughtful post. There is so much fat-shaming and fat-phobia among providers (OBs, Family Practice, and midwives alike!) that it can be hard to just be a pregnant woman at an appointment. What I think needs to be addressed is the current asinine weight gain recommendations for obese women (as referenced in this WebMD article http://www.webmd.com/baby/news/20090602/pregnancy-no-weight-gain-for-obese-women). What about the Lamaze chart showing where the weight goes? 7 - 9 pounds of baby 2 pounds of placenta 2 pounds of amniotic fluid 4 - 5 pounds of increased blood volume 2 pounds uterine enlargement 3 - 4 pounds of fluid in maternal tissue 1 pound of breast enlargement to prepare for breastfeeding Any remaining pounds are a general deposit of fat required by the body for breastfeeding and energy stores Do they think obese women somehow don't follow the rules of thermodynamics like everyone else? Not to mention the fact that a woman who weighs 250lbs when she gets pregnant is going to have MORE blood volume to increase (blood volume is about 7% of your body weight) and MORE breast tissue to enlarge, and might have MORE water retention in the last weeks of pregnancy. The above article lauded the idea that women with BMI's over 30 could gain as little as 5lbs during pregnancy and still, in their words, "No side effects were reported during the study, and the babies were born healthy and at a normal weight. "They were not little peanuts," Thornton says." And yet, women still have to have 35 pounds worth of "stuff" happen while they're pregnant - did the women who only gained 5 pounds somehow NOT increase their blood volume by 40%? Did they NOT have a 7 pound baby? Did they NOT have an enlarged uterus, a placenta, amniotic fluid, breast tissue, etc, etc? Of course they had all those things! So, in reality, they LOST 30 POUNDS during pregnancy, an average of 3 pounds a month, which is the kind of weight you lose on a calorie-restricted diet. And the study authors do not see the contradiction. "'We're not saying that pregnant women should lose weight. We're not advocating that," Thornton says. "We're saying, 'Forget about the pounds, already ... Let's talk about eating well and whatever happens, happens.'" The women in the control group gained about 31 pounds each. And all the babies were normal and healthy? Hmm...and no side effects were reported in either group? Hmm... And no mention about ketones in the urine of those who did not gain much weight, even though it is apparent that those women were losing fat and/or muscle during pregnancy? This is just one example where a poorly-reported study can have very detrimental effects on plus-sized women, by reinforcing existing provider bias and ignoring the fact that fat women have healthy babies too! Many of the "risks" for obese women during pregnancy are iatrogenic. Do obese women have more cesareans because they're fat? Or because their doctors think they'll need a cesarean because they're fat, and it becomes a self-fulfilling prophecy? I could talk about this all day, but the bottom line is, there are a lot of myths about nutrition, weight gain, and obesity in general, and these can be compounded and magnified during pregnancy. Stacey, plus-sized mother of 2, pregnant with #3

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

November 6, 2012 07:00 AM by Danielle Cruz
The article is excellent and I thank you for compiling these resources in such an organized and usable way. I plan to immediately incorporate them into my doula practice and utilize them when teaching childbirth classes. Many thanks!

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

November 6, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
Thank you Pam for this comprehensive post. ALL women need evidenced based info and resources. I appreciate your passion and common sense approach, along with all the resources. I look forward to your second post on Thursday!

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

November 6, 2012 07:00 AM by The Well-Rounded Mama
@Stacey I will address the issue of weight gain restrictions in Thursday's post. You're right, it's an important one! I have written about it quite a bit on my blog, if you want to read a more detailed summary. http://wellroundedmama.blogspot.com/search/label/weight%20gain%20in%20pregnancy

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

November 7, 2012 07:00 AM by Janie
Thank you so much for your work - I am training to be a childbirth educator and as a plus size homebirthing mom myself I plan to create a safe haven for moms of size in my work. I just am not sure how to reach them in the first place. Many discredit themselves from intervention free birth before they start.

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

November 7, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
@Janie If you build it, they will come! Get the word out, offer a quality product that generates excitement amongst the attendees! Let your community know what you are doing. Share the information with providers, doulas, midwives...once you start doing this, I think you will find that the women who "need" your class will find you! Blog about it, facebook...use all the options open to you to create that safe place! And thank you!

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

November 7, 2012 07:00 AM by Kathy Kendall-Tackett
I'm really glad to see this post. It's a good reminder for us to treat women of size with courtesy and respect. They are likely encountering prejudice in many other areas of their lives. Let's not perpetuate that. And for God's sake, let's stop putting all of our negative expectations on them for both birth and breastfeeding. I wonder how many of these negative effects are due to our telling them that they will likely fail.

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

November 30, 2012 07:00 AM by Elle
I love Pam's work. Pam's writing helped me feel ok about my chances at a healthy pregnancy. I was 250 pounds when I got pregnant and weighed the exact same amount the day after I delivered my 7lb 7oz son, despite the kerfuffle about a 20 pound pregnancy weight "gain." I would add to these suggestions that caregivers should try not to act shocked when a fat pregnant woman has consistently normal blood pressure, and try not to assume that she has or will get gestational diabetes. It is important to watch out for these complications, but not to assume they will happen. On the other hand, I also wish someone HAD taken my size into account in considering suggesting a screening for thyroid deficiency. I found out six months after I delivered that I had Hashimoto's. No one tested me for low thyroid during my pregnancy, and while my son seems to be fine, my understanding is that low thyroid during the pregnancy could have caused serious problems.

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