Centering Women of Size in Birth - "Talk to me, not at me"

Birthing women and people of size deserve no less than to be respected, honored, and wholeheartedly supported during their pregnancy and postpartum experiences. Pregnant women with higher body mass index (BMI) may be discriminated against. They may be presented with a barrage of anticipated risks rather than getting individualized support when seeking health services. BMI has (finally) been taken down a notch in the medical community, at least “on paper.” The American Medical Association published a new policy in June of 2023 that aimed to clarify the role of BMI. They called out “historical harm,” “use for racist exclusion,” and other limitations of the measure. In BMI We Trust, Reframing the Body Mass Index as a Measure of Health, medical sociologist Iliya Gutin argued that we should use BMI as only part of a holistic view of health, recognize its limitations, and be more flexible about its interpretation. 

But how do people of size actually feel when seeking health services? I am especially interested these days in the experiences of people who are pregnant, birthing and postpartum. I want to share a study done in Norway that collected stories on the experiences of plus-size birthing women (identified as "obese" by BMI measurement). The stories reveal shaming behaviors on the part of birth attendants like doctors and midwives. Some of the stories tell us what made these women feel empowered though – when they were treated like individual humans instead of being characterized by numbers.

“Talk to me, not at me.” This is a key takeaway from qualitative interviews with 10 pregnant and birthing women, defined as obese, in a 2020 study. The authors wanted to understand the experiences of plus-size women during their birthing experiences, to learn how they were treated by birth attendants. 

Many of the women said they felt they were discriminated against because of “preconceptions and prejudice.” For example, their healthcare providers made assumptions that because of their body size, they must be unhealthy. They felt they were lectured (my interpretation here) repeatedly on diet and exercise without regard for their individual lifestyle. It didn’t seem to matter to the healthcare staff that they were educated and did their best to lead healthy lifestyles.

Some women faced unfair practices like being forced to have an epidural catheter placed even though they didn’t want one – simply because of their body size. There were reports that there was such a large focus on risk that they stopped feeling like individuals. One woman was initially denied the waterbirth she wanted and had to advocate hard, by showing evidence she gathered, that this was an acceptable choice. 

There were themes of feeling shamed and being unable to exert autonomy.

Women who felt more positively about their experiences reported that they felt supported when birth attendants learned about who they were as people, when they were encouraged to listen to their own intuition and body and were considered important in decision-making. 

To me, this seems really obvious. When we are caring for birthing people (whether as a healthcare provider, an advocate, a doula, whatever it may be), the first guideline is to recognize that the birthing person is the center of everything. We (speaking as a doula and person working in the healthcare system) are supposed to be centering our person – whether we call them our patient, our client, our participant. What is most important is ensuring their health and well-being by treating them like an individual, unique and beautiful human – and honoring their preferences in what happens to their bodies.

If you're reading this from the perspective of someone who lives in a plus-size body, I want you to know that you deserve to be listened to and seen as a human and not a set of numbers.

I encourage everyone to give the article a read – and check out the referenced articles as well. 

I leave you with this, a quote taken from the authors: “The importance of mutual decision-making shines through in many of the participants’ stories. What they all have in common is the expression of wanting to feel included and involved in their own care and treatment, and to possess some degree of control over their own birth. As one of the participants responded, when asked what she wished for in regard to communication, information and respect: ‘Talk to me, not at me.’”

Citation:

Thorbjörnsdottir KE, Karlsen IE, Dahl B, Røseth I. "Talk to me, not at me": obese women's experiences of birth and their encounter with birth attendants-a qualitative study. Int J Qual Stud Health Well-being. 2020  Dec;15(1):1845286. doi: 10.1080/17482631.2020.1845286. PMID: 33180659; PMCID: PMC7671589.

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