Are you plus size and pregnant?
You deserve to have respectful care, good information, and choices for your birth.
Professionals and birth workers should support you in finding and evaluating your options so you can decide what’s right for you.
Your caregivers should have read the evidence, and not be weight biased.
Unfortunately, this isn’t the reality for everyone.
Sadly, if you’re plus size and pregnant then you probably already know that some health care providers and birth workers have negative opinions about your weight and shape.
Many studies show that health care providers are often giving inaccurate information in ways that are disrespectful (Wickham 2023). When I talked to women while researching my book on this topic, they reported misinformation and weight bias from birth workers as well.
I’m a researcher and author who wants to challenge this, and help women and families to understand the evidence and the issues for themselves.
So I have written this blog post as a starting point to let you know some of the key things that you might want to know if you’re plus size and pregnant, or thinking about pregnancy.
If you’d like more information on any of these topics (and many others), you can grab a copy of my Plus Size Pregnancy book here.
1. Weighing is the first screening test. You can say no.
Let’s start with the item of equipment that many plus size people dread in any health care encounter – the scales.
Being weighed in a health care setting sometimes comes with raised eyebrows, pointed looks, or inappropriate noises from health care professionals, so it’s no wonder that some people feel nervous just thinking about being weighed.
So let me tell you from the outset that you don’t have to step on the scales if you don’t want to.
There are some specific situations in which you might want or need to be weighed. For instance if you want to have certain screening tests or interventions, or if you want or need medications whose doses are calculated according to body weight.
But the weighing that comes as a standard part of an antenatal visit is a screening test. As with all screening tests, you can decline if you want to. Your body, your baby, your decisions.
You might want to practice what you’re going to say ahead of time. Remember that you don’t need to justify yourself though. No means no. And ‘no’ is a complete sentence.
You may also want to bear in mind that health care professionals or their assistants often simply lead you to the scales and expect you to step on them without saying anything. You still don’t have to get on the scales.
There’s lots more about this, on the pros and cons of being weighed, and on the situations where you might decide you want to be weighed, in my Plus Size Pregnancy book.
2. The right equipment matters. Sometimes more than you might think.
There are a few situations in which it’s preferable to have equipment that is designed for larger bodies. Size friendly seats without arms that dig into ones’ hips or legs are welcoming and more comfortable, for example. And in health care facilities, size friendly operating tables and lifting equipment are essential for safety.
Sometimes, larger people feel embarrassed when health professionals ‘make a meal’ out of not having the right size equipment to hand. We could all do without that, but please don’t be tempted to let them use something made for people with smaller bodies. And, if someone tries to do that, speak up and ask them to use the appropriate equipment.
That’s not just because of comfort and safety, although those are important.
Having the right equipment is also about getting accurate measurements, because inaccurate measurements can mean that you get diagnosed with something you don’t really have. If you’re plus size and pregnant, the last thing you want is a false diagnosis that can negatively affect your options.
The blood pressure example
For example, when researchers measured the accuracy of blood pressure measurements according to cuff size, using a regular blood pressure cuff on people with larger arms resulted in higher mean systolic blood pressure readings.
A smaller cuff added an average of +4.8 mmHg onto the systolic blood pressure result for those needing a large cuff. And a smaller (regular sized) cuff added an average of +19.5 mmHg onto the systolic blood pressure result for those needing an extra-large cuff. (Ishigami et al 2023).
The researchers concluded that, “Using a regular BP cuff size for all individuals regardless of arm size resulted in strikingly inaccurate BP readings with an automated device; a renewed emphasis on individualized BP cuff selection is warranted, particularly in individuals with larger arm sizes.” (Ishigami et al 2023).
That’s why I say that the right equipment matters. The false increase in blood pressure that comes about with the use of a smaller cuff could mean that you are told you have pregnancy induced hypertension or suspected pre-eclampsia. Both of those diagnoses come with further screening and intervention that you might not want.
3. There might be a slightly higher chance that you’ll experience certain outcomes, but the majority of women with a higher BMI don’t experience any of these
The full title of my book is Plus Size Pregnancy: what the evidence really says about higher BMI and birth.
I’ve written the title out in case you don’t already know that the focus of my work is to look at what the research evidence really says about certain things. And I also want to explain why I take this focus. It’s because, often, the evidence doesn’t correlate with what happens in maternity care settings. And I think women and families need to know that, so they can decide whether or not they want to go along with what is recommended in the guidelines.
One of the areas that I looked at in depth when I wrote the book was whether the evidence really did show that larger women have poorer outcomes. That’s because so many of us are told that we are ‘at risk’ of awful things happening to us and our babies, simply because of our size, weight or BMI.
We hear that we are more likely to have pre-eclampsia, gestational diabetes, a stillborn baby – all sorts of scary-sounding things.
And the overall thing I learned was that that yes, there are some things that you’re a bit more likely to have if you’re larger than if you have a lower BMI.
But…
Well, there are a few ‘buts,’ actually.
First, the difference isn’t always that big. I detail the exact numbers for different conditions in the book, and was really surprised at some of them.
Most women with a higher BMI won’t experience these problems.
There may be things you can do to reduce your chance of experiencing or developing unwanted conditions or outcomes.
And in many situations, it may be better to avoid very medicalised maternity care, as this may mean you are more likely to experience the very outcomes you’re wanting to avoid.
As I wrote in the book, “The vast majority of women who have a higher BMI are more than capable of experiencing a healthy, happy pregnancy, a straightforward, physiological labour and birth, and a joyful start to life as a new parent.”
And read on, because the next point has another key bit of information that also relates to this.
4. There are also advantages to being larger
Most health professionals don’t tell you this, but there are actually advantages to having a higher BMI.
One example here relates to postpartum bleeding.
Research has shown that women with a BMI over 35 kg/m2 are less likely than women with a lower BMI to have significant bleeding after birth (see Wickham 2023). And all plus size women have another advantage in this area.
Larger people have more blood in their bodies than slimmer people. This means that larger women can ‘afford’ to lose more blood after they give birth than slimmer women before their health is compromised. We simply have more reserves. This may be why larger people have some other health advantages in general as well.
We are constantly told that we are more ‘at risk.’ We rarely hear that there are situations in which we actually have more resilience.
There are other advantages, too. Some midwives report that larger women cope better with longer labours, and a number of studies and audits have shown that woman with a higher BMI are less likely to have an obstetric anal sphincter injury than women with a lower BMI (see Wickham 2023).
We are rarely told about these advantages either. I think this is partly because it doesn’t fit with the unevidenced and unkind ‘fat is unequivocally bad’ rhetoric. However, if we could get more researchers and clinicians to open their minds, do better research, and look at what the evidence actually shows, I suspect we might find more advantages to having a higher BMI, as well as more nuance.
So, if you’re plus size and pregnant, know that your size and higher BMI gives you advantages as well.
5. There is no evidence that induction improves outcomes for women with a higher BMI
This is going to be a really quick one to write about, because I have a whole blog post on this topic.
In a nutshell, no trials have looked at outcomes relating to larger women and induction, and there is no robust evidence that induction improves outcomes for women with a higher BMI.
There is evidence that induction is associated with more interventions and adverse outcomes, however.
And, as both agreeing to induction and having a higher BMI mean you are more likely to be told you need a caesarean, this is an important thing to consider when making your decision.
You can read my blog post on induction of labour and larger women here:
6. Midwifery-led care and low-tech settings mean a greater chance of good outcomes
Last but not least, I want to come back to something I mentioned above, about how you can make decisions to improve your chance of a good outcome.
There is an abundance of evidence which shows that, while women with a higher BMI do have a slightly higher chance of experiencing some unwanted outcomes, setting and caregiver play a significant part in this situation.
By setting, I simply mean where you give birth – at home, in a birth centre, or in hospital.
There is a good amount of research which shows that women who are larger have better outcomes if they opt for midwifery-led care and give birth in low-tech settings.
By low-tech, we mean in birth centres or at home.
This might be because they are less likely to encounter routine interventions, people who are weight biased, and care providers who don’t believe in their ability to labour and birth physiologically.
In a midwifery-led setting, you’re far more likely to be supported to labour and birth in the way you want to. And, while I understand that some women are told that they are ‘not allowed’ to give birth in a midwifery-led setting because of their BMI, this isn’t as black and white as it sounds. Nor are policies about birth pools, or the interventions that people are told they need.
As I said at the beginning of this blog post, these are your decisions to make.
If you have a higher BMI and are pregnant, or planning to be pregnant, I would LOVE for you to read my book.
It’s the antidote to the weight-biased approach you might experience in health care settings.
I’m a larger woman who is experienced in unpacking and explaining research evidence, and I was shocked when I realised how many things the maternity services are getting wrong in this area.
My book is friendly, full of good news, and based on sound evidence to help you make the decisions that are right for you.
Find out about my book and where you can get it here.