Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

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


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

women of size Hilary-tublabor

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 macrosomiaearly amniotomyinternal 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.


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) 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 & Promoting Optimal Birth Outcomes

November 8, 2012 07:00 AM by Science & Sensibility » Welcoming All Families Series: Welcoming … | Health Advice
[...] a cesarean can be found here and here. Like other women, women of … … Read more: Science & Sensibility Welcoming All Families Series: Welcoming … ← 20 Diet Tips for Busy Executives | Funny [...]

Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

November 9, 2012 07:00 AM by Jen @PlusSizeBirth
Extremely informative and helpful article for women of size! I'm truly honored you listed Plus Size Doula Connections and Midwife/OB-GYN Connections as resources.

Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

November 11, 2012 07:00 AM by Christine H Morton, PhD
This topic is very important as the population of the US increases in size. Just got back from meetings with the CDC and ACOG around the issue of maternal mortality. Obese women are over-represented among certain causes of death, like deep vein thrombosis and cardiovascular diseases. Caregivers are extremely concerned about the health impacts of obesity for women and babies, and there is increased interest in coming up with guidelines for maternity providers around caring for women of size. Some health care systems are considering 'centers of excellence' which would have the infrastructure (beds; toilets; scales and gurneys), equipment (blood pressure cuffs; sequential compression devices), medication algorithms and trained personnel to best meet the unique needs of extremely obese women (BMI>50). There is also concern about the health impact on health care personnel with regard to lifting and moving large patients. I don't know much about the impact of bariatric surgery on subsequent pregnancies and/or breastfeeding- that would be an interesting topic. Thanks so much for this post!

Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

November 11, 2012 07:00 AM by The Well-Rounded Mama
Thank you for your comment. I understand (and do not dismiss) the concerns that lead caregivers to propose these "centers of excellence" for obesity. There are special concerns that we must look at frankly. *However* the downside is that this ghettoizes women of size and takes away their freedom of choice regarding birth choices. How much perceived risk does it take to justify overriding a woman's right to patient autonomy? To bodily integrity? The ethical questions here concern me greatly. Many women of size are not being "allowed" to choose midwifery care or birth centers, for example, or are being forced into specialized bariatric centers and perinatologist care, even without complications that necessitate such care. Many are pressured into high-intervention care on the assumption that it will improve outcomes, without ANY examination of whether or not it actually does so. Far too often, such high-risk centers become induction and c-section factories for women of size (which is a strong risk factor for complications like pulmonary embolisms that lead to maternal deaths). This is not optimal care, and this does not respect the right to patient autonomy for people of size. Many of us (including me) find we have better outcomes when we utilize LOW intervention models instead of high intervention models, yet this choice is rapidly being taken away from us in some areas. This raises very serious ethical questions. I think there is room for bariatric centers for women of size who present with serious complications and extra risk factors or special needs that necessitate a higher level of care. But many do not, and should not be forced into such care on the basis of BMI alone. Many women of size, even those of very large size, can and DO have normal pregnancies and births if given the chance to do so. What happens to these women with no complications when forced into an atmosphere of over-testing and over-intervention? Why shouldn't they have the option for midwifery care, waterbirth, or other choices? Is anyone studying whether having those lower-tech choices available actually improves outcomes instead? The Kentucky and the UK c-section studies linked to in the article above show that labor management and attitudes can make a big difference in c-section rates and outcomes, even within the same BMI (over 50) and similar patient characteristics. It's not just about patient size, it's ALSO ABOUT CAREGIVERS PERCEIVE AND MANAGE THESE WOMEN. Specialized bariatric care centers might well be a path to POORER outcomes, not better ones. I've written about this before. You can read more here: http://wellroundedmama.blogspot.com/2009/12/reply-turned-post-ghettoizing-fat.html http://www.scienceandsensibility.org/?p=3094 http://www.scienceandsensibility.org/?p=3064 http://www.scienceandsensibility.org/?p=3030 As far as the impact of bariatric surgery on pregnancy and bfing, I've written about that here: http://wellroundedmama.blogspot.com/search/label/WLS Proposing special Bariatric Centers are all the rage in certain healthcare circles, but they bring up a slippery slope of serious ethical questions.

Welcoming All Families Series: Welcoming Women of Size & Promoting Optimal Birth Outcomes

November 13, 2012 07:00 AM by Christine H Morton, PhD
Wow, thanks so much for your considered response. The system I know most about is Kaiser Northern California, so definitely NOT an induction/Cesarean factory, and I was impressed with the focus on systems AND attitudes in their work. But I can well imagine that not all centers are the same. Thanks so much for these resources and the discussion of ethical issues around caring for women of size.

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