A midwife I was talking to asked me the other day:
'How can I give diet advice to obese pregnant women, when I'm overweight myself?'
I've thought and read about midwives and obesity for a few days, and I've got an answer. But first I want to talk about what I found when reading: we overlook the intense psychological anxiety obese people feel. Surely this is significant?In background to this topic, 25% of women in the UK were obese in 2012. You probably know already that obese women are more at risk of miscarriage, stillbirth, abnormalities in their babies, gestational diabetes, pre-eclampsia, thromboembolism, and caesarean birth (according to RCOG). 
There's intense stigma towards obese people, and it definitely stretches to healthcare. I'm not even going to quote studies, just think about the last time you cared for someone who was morbidly obese. Can you remember anything unpleasant that was said about them? I certainly can, and my last work place was staffed by compassionate and empathetic midwives.
Assumptions include: obese women are lazy, stupid, and have got themselves into this mess by being weak willed. But there's every reason to suspect losing weight isn't the simple 'eat less move more' idea we're pushing, and we're making it worse by pushing shame.
For a start, advice is confusing:
- The NHS say base your diet around starch, fruits and veg, reduce saturated fat, and perhaps try orlistat, which blocks 1/3 fat absorption
- WHO recommend reducing fat intake as well, but say you can eat <10% 'free sugars' (don't really know what that means?!)
On the other hand...
- Many obesity researchers recommend animal protein and especially saturated fat, arguing you can't possibly lose weight if you base your diet around carbs...
- ...but, a very large cohort study among other sources suggested eating red meat is associated with increased risks of cancer, cardiovascular disease, and faster mortality.
- There's growing evidence suggesting fasting is good for weight loss (how surprising!), and can also slow aging, reduce cancer, heart disease and cognitive decline....but the NHS say fasting isn't the best idea.
How are obese women supposed to commit to a life changing, usually if we're honest, quite painful regime without knowing if it's safe, healthy, or even if it'll work?
One study from the University of Florida found patients who'd got to a more normal weight through gastric band surgery said they'd rather be blind, deaf, or an amputee than be obese again.
And there's this heartbreaking quote from an obese woman:
I don’t like looking at my body. Not at all. When I look at it I feel sick. My legs rub together, my belly hangs and every minute I’m trying to pull my trousers down and put my top down when I'm walking.
That's how much people want to avoid being obese. So this being the case, can we really just assume it's a matter of willpower?
I know there are some people out there who'd argue shame can be a powerful motivator. And to be fair, I can relate to this, there have been times
during my life when I've been 'shamed' into working hard because I've failed a test or done something silly. But I can tell you if I had absolutely no-one who thought I was worthy of respect, I'd have found it really hard to put that work in.
And also, should we as healthcare professionals push shame on clients in our care? Should we use shock tactics? Last time I checked with the NMC code our role was about supportive and respectful care.
Back to the original question which was asked me by a gorgeous midwife who's desperate to do right by her client. How can you advise on weight loss when clearly you're struggling with this issue yourself?
My answer is, I believe obese mothers are even more in need of a 'with woman' midwife. And overweight midwives can be in a really good place to provide this care.
How are obese women supposed to have the energy make complex changes if they have no confidence? This is one of the areas where midwives can make most impact. I think we need to get women talking about how they feel, what the options are and try and get them support.
For instance, intuitive eating is one area of research that looks promising (the scope of the topic is outside this post, but the link is to a study showing that diets can actually cause long term weight gain - so learning to eat in a psychologically healthy way might be a good way forward).
If you're overweight, I believe you're in an excellent position to support these women with empathy. Obviously, the risks of gaining weight in pregnancy and not losing weight when postnatal are too big to be ignored. We have to give accurate information. But I'd be ashamed if I didn't listen, respect and empathise with women experiencing such sensitive pain.
I'm not perfect and to my embarrassment I have had those judgemental times - but I recognise this is me at my worst as a midwife.
I've scoured the official guidelines of RCOG, and WHO, and I can't find any info on how we're supposed to address the stigma. Or how to care for obese or overweight women psychologically, which seems a bit of an oversight.
More focus is needed on the psychological and emotional issues linked to weight management.
As midwives, can we start this now?
I'd love to hear from you. Do you have experience as an overweight mum or midwife? Do you think it's safe for midwives to show respect for obese women? Or should we be using shock tactics?
I was obese through both of my pregnancies. I remember reading once in my notes the the 12 weeks scan was technically difficult due to maternal bodily habitus. I immediately googled the meaning and was devastated. I am not sure why that term was needed on my scan but it hurt a lot. As far as I was aware my weight had no effect on either of my pregnancies so I would say that unless help was sought from a women, her weight doesn’t need to be addressed. She will be more than aware of her weight and by lecturing her or judging her you are doing more harm than good. A simple question of “are you eating healthily” should suffice.
Thanks Gemma, it’s great to have your point of view as a mother experiencing care.
My big worry now is whether my weight will affect my chance of becoming a student midwife :/
Hi Gemma. I’m sorry you felt hurt by this.
However the term is needed on the scan. If the sonographer found the ultrasound difficult for whatever reason (late gestation, baby in the wrong position or a large amount of adipose tissue) then they need to report it as it can affect the image quality and interpretation of the scan. The ultrasound sound waves can only reach so far – it would make sense that if there is a large amount of adipose tissue (fat) that sound waves have to travel through (and then bounce back) that it can be difficult to view the baby properly.
Good luck with your studies.
I have an underactive thyroid and although controlled by medication, just the thought of being overweight, never mind obese
makes me shudder and I’m convinced if I ended up like that I would literally be suicidal. There is no doubt that if you don’t eat
well and go long periods without food, as I’m sure midwives do while on shift, then your stomach shrinks and even when you
do eat you cannot eat as much. I have absolutely no problem with race, religion, or cultural issues, but I do find obesity a difficult subject to deal with. As a person who was diagnosed as chronically and clinically depressed, 25 years ago, I can honestly say that comfort eating is not something I would ever indulge in. If anyone out there can offer me advice to deal
with this, before I even start training as a midwife, I would be extremely grateful.
Hi Rona, thanks for your comment. Do you think you’ll find it difficult to care for and be empathetic towards obese clients? Thanks for the honesty of your comment, just wanted to be clear x
I had a long reply with lots of thoughts but the internet ate it, hopefully I’ll have the energy to try again but if I don’t, I think this is a complex issue. It’s one that needs less judgement, shame and blame. Empathic support that is genuine is key – being with women and discussing concerns or considerations genuinely and respecting her experience and wishes. We don’t blame people for other health issues, especially ones we know so little about at this point in time. There’s no ‘right way’ that means you’ll lose or won’t gain weight and that’s true no matter how focused you are on one or the other.
It’s my job as a student midwife to provide the best care I can, supportively and respectfully to achieve the best outcomes – and I don’t think shame should ever come into that. Ellie, your point about feeling worthless and awful not being motivating is well made. This issue isn’t as simple or isolated as not having studied enough for a test – it’s bigger and more complicated. Especially with outdated stereotypes like people being lazy – often that’s not the case and that prevailing attitude only makes the entire thing harder to deal with.
Thanks for the encouragement and your well written comment Transcendancing, it is a very complex issue.
I have experienced caring for obese patients a few times in the few months I have been practising midwifery in UK. I am usually very worried, also because English is not my mother tongue, that something I could say or do may be felt as unrespectful or unpleasant, by the ladies I am caring for. The point is that sometimes you HAVE to point out some things on paper, such as that you can’t determine fetal position by palpating due to maternal weight, or ask them some things explaining the reasons behind them and that the reason is obesity. If I ask the lady if I can put an FSE on baby, I HAVE to explain that in order to check baby’s heartrate I recommend this as there is a lot of loss of contact with the external monitoring because of her weight. Once it was actually impossible to examine without someone holding the flesh of the lady’s legs apart, as even when she had her legs apart, the thighs were touching together. I felt very much for her, and hope she felt she had the best possible care in that situation as well. It is difficult for the ladies, I am sure, and it is difficult for us, as well. It is not a matter of being unrespectful of not wanting to give the best care. We need to explain things and recommend what is best and sometimes obesity is the explanation for what we reccomend or do or can’t do.
It is a very hard part of care to achieve Daniela, thanks for your comment and I can imagine if English isn’t your first language it would be even harder. And yes, the risks are too great not to give clear information to women about the health concerns caused by obesity. I suspect if you’re thinking about how best to support women through that kind of situation, and you’re very empathetic (it sounds like you are!) you will achieve sensitive care.
I also just wrote a blinking long replay and tinternet has eaten it!! Basically, I too agree this is a complex issue however I believe that health care professionals can make small changes that can have a significant impact on a woman’s psychological wellbeing. How many midwives have a range of cuffs readily available when taking a woman’s BP? How many times have you personally or witnessed another midwife use a standard cuff then say “I’ll just go grab the bigger one”, what message does this send out? Midwives are ideally placed to tackle obesity due to the numerous contacts they have with women and the trusting relationship they aim to build. This coupled with the fact that research suggests pregnancy is a time when women are more likely to be able to make significant changes means that midwives really can have a positive impact however women must never feel judged or victimised. Midwives need to think about their actions and comments and the subliminal messages that are sent to women.
Laura – thank you – as an obese woman I experienced this MANY times – my community midwife was an absolute rock – she ALWAYS automatically brought a large cuff with her in her words ” so I can obtain an accurate reading” and never made me feel less of a person due to my size. – That is a rarity I can tell you! She was always so supportive and with her advice i gained only 10lbs in my first pregnancy ( baby was 6lbs 10ozs) and 13lbs in my second ( baby was 10lbs13.5 ozs) and in fact weighed less after each birth than before it- but her understanding was paramount to my confidence as an expectant mother.
I agree with this. Whilst obese women may have had well pregnancies and didn’t develop any medical complications – there is still the practicalities of everything.
Putting in cannula’s, siting epidurals, monitoring the baby, palping contractions, vaginal examinations, putting in catheter’s, caesarean sections, even a normal vaginal birth are all things that are made very difficult if not impossible when obesity comes into play. I’ve had to have 2 people help me hold the labia apart whilst I hunted for a urethra one day. It’s taken 3 of us to hold up a women’s “apron” to check her caesarean wound dressing.
When it comes to stuff like this you have to very tactfully and sensitively explain that the reason you’re having so much trouble is because there’s a “bit of extra padding”.
Interesting thread and one issue that I’ve been thinking about quite a lot recently. Obesity used to be a personal private issue; now I believe the obesity is the’ new drugs and alcohol problem in society. And pregnant women are part of the problem and part of the solution especially as they will be the mothers of the next generation. Reading through the comments is very revealing and without a shadow of a doubt.. obesity touches nerves! Words such as shame, blame, judged, victimised,unrespectful. As health care professionals I want to see words such as honesty, openness, empowerment, responsibility being used when we are working with women who are obese.
Thanks for such a beautifully put reply. I agree, choice of language is very important when supporting mothers who feel any kind of shame.
There are many causes of obesity. Shiftwork, strssful workloads, conflicting dietary advice, PCOS, eenvironment al exposures, wheather you were breastfed, thyroid dysfunction and thyroid antibodies (the test for this is not covered by Medicare) and the list goes on. Education is the key, and we need a variety of midwives representing all these categories of body shapes and experience s to support a corresponding group of pregnant women. and their experiences. There needs to be a balance.
Thanks for your comment, totally agree with balance and education being needed Karen. It’s a shame women are still so judged by appearance. I know men are too, but I feel the idealised woman in our society is quiet, pleasant – and thin. I think things are changing and hopefully if I have a daughter she won’t feel so dominated by this. But midwives of many body shapes are perhaps a good way of starting conversations x
With reference to the ‘>10% free sugars’ bit you were unsure of, I think it refers to monosaccharides? Because starches are just lots of glucose joined with a glycosidic bonk (i.e. the sugar in the molecule is bound up and not ‘free’), so they take a while to metabolise (so you can have more as they increase blood sugar slower). Whereas simple sugars are absorbed straight into the blood stream (so you can have less).
Ah, I see. That’s very helpful, thank you.
The only thing with this is would it be the same if the mother or midwife was underweight or even anorexic. Anorexia is a mental illness and shaming them would be horrible and I very much agree that obesity is too. What do you do if a mother is the weight she is supposed to be but incredibly unhealthy? An overweight mother may be incredibly healthy. There are ways to approach things and shaming people is never the way to do it. I understand that being overweight can cause problems like the other comment said but if you said “ah this would be a lot easier if you lost some weight” what would you gain? If anything the mother who probably comforts herself with food as many people do would go and have something to eat as she would be embarrassed. As a midwife you wouldn’t make a woman get changed with the curtain open as that would be embarrassing and wouldn’t protect her dignity so surely ‘fat shaming’ is doing the same.
Absolutely! Dignity is something not always thought of in this context but it’s absolutely true and one of the 6cs.
This is a wonderful post and I’m so glad you shared it. This is a subject close to my heart. I’m a second year student midwife and I think I’m the only morbidly obese one on the course. It can be difficult when studying too as I’m always worried about fat shaming especially when learning about obesity in pregnancy. However luckily it has been handled very well by the uni and have never had a problem on placement. However I have heard derogatory comments made about women or their partners when obese and it’s just makes me sad. Of course it’s important to give women the correct evidence based info on obesity and I don’t dispute that at all but it’s so important that midwives are caring and compassionate and I wish that we could be the change that helps empower women to feel good in their bodies regardless of what they look like. ??????
Thanks Adele, I think the feeling good part comes before the being able to have the strength to make changes part?! Great to hear it’s being well handled in Uni ad here’s hoping this will be the case everywhere one day 🙂
We need to look more at the evidence base. Slimming clubs ‘seem to work’- except if you take into account the damage they do, the lack of results after 5 years, repeated cycle of weight loss and gain, psychological impact of ‘failure’, going ‘off plan’ and restarting on Monday after bingeing due to your failings. Look at the evidence on persistent metabolic adaptation- these groups are marketing machines, making the majority of profits from repeat joining, inventing ‘syn’ values and points with no nutritional scientific basis in order to mass sell ‘syn’ free products and push massive amounts of artificial sweeteners to cause long term addiction. Diets make people fatter and more miserable long term- and they pass on the dieting mentality to their children. What we need are educational groups, family cooking opportunities and less shame. And far more emphasis on the huge amount of fizzy drinks being reduced. The RCM alignment with Slimming World contradicts the evidence and our NMC requirement to practise on the basis of the best available evidence.
‘Educational groups, family cooking opportunities and less shame’ << what wisdom! Thanks Holly!
This is a topic very close to my heart as I was myself always overweight peaking at a massive 25st in my early 20s and super morbidly obese. I was bullied, mocked and even healthcare providers would blame my weight for any ailment that I might develop. For me eating was definitely not a lack of will power or a weakness of my character but very much linked to my emotional well being. I didn’t eat because it was delicious I ate to comfort myself and I truly believe that in many people food becomes an addiction. Historically, there has been little empathy or help due to food not being recognised in this way. I have now through supportive groups such as weight watchers and slimming world lost the weight right down to 11st 10Ib (only putting on weight because of my pregnancies and in the process of losing again after my sons birth recently).
Even thought during pregnancies I was lighter and size 12 I was still high in the bmi scale so was still treated as obese even though I’d taken years to finally feel like I wasn’t. My midwives were great and made me feel like I wasn’t still fat but it can be very hard with overweight women to discuss weight and food. I do feel that because of my experiences that I could be successful at supporting women who far obesity as I have come from the same issue as them. Carefully tho as I would not want to make them feel bad that I have succeeded where they have not. It is all about communicating compassionately, sensitively and listening to them as some may know they have a problem but some don’t and it’s a skill to discuss healthy eating effectively without isolating them. It’s a complex issue but one that we could have such a positive impact on for the woman and the future generations. Sorry for the long post.
It’s a huge achievement to have been able to change your emotional pattern and lose all the weight and I’m sure once you have done it once, you have gained tools to do it again. It sounds like you have a huge amount of empathy and skill with people in this regard! You’re totally right about compassionate communication and thanks for such a well written and wise comment!
Student midwife from Australia here. I just listened to an incredible podcast about shifting perspectives on fatness. It’s totally worth a listen…from the podcast series “This American Life”. I am including the link: https://m.thisamericanlife.org/radio-archives/episode/589/tell-me-im-fat
It gave me insight into life as an obese woman and how I could be more supportive and understanding, what to say and how to perhaps think more clearly.
Thanks so much Talia, that sounds like a great podcast!
I believe the way we speak to people stems from our personal prejudices,whether you think you are OK with obesity or not you will likely have some prejudice to it, it would be hard not too. It’s all around us everyday in the media. Although there is an element of choice surrounding obesity, this too exists with mothers who choose to smoke, so treatment should be fact based and not judgemental. I agree with points above about having the correct equipmnet to hand being a subtle but important way that standards can be pushed up. Would you think highly of a restaurant whose cutlery had not been polished? As an obese mother of 2 I would say the best way I have been ‘dealt’ with is by asking the questions that are asked to everyone, listening to the answers and then moving on. There was no need to comment any further on my weight, other than the practicalities of giving birth. A key word is ‘could’. And these complications could happen to other mothers too. It’s just a risk that needs to be discussed. Sorry for my waffle.