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Are You a Size-Friendly Midwife?
I can't even begin to tell you how betrayed I felt. They claimed it hadn't occurred to them earlier that it could be a problem. It's not like I was hiding my weight, I think it's probably one of the first things people notice, you know? If they had just been honest at the beginning, I would have looked for someone else. So next time, if there is a next time, I really want someone to be up front about any fat issues they have. I can totally accept that there are medical folks out there who will look at a fat patient as a bundle of risks. I don't think they are right, but I realize such attitudes exist. I just want honesty from the start of the relationship.
Even midwives who regularly accept supersized clients and who pride themselves on being more open-minded about size than most can still show size bias. One midwife confessed that she was concerned about the dietary compliance of her fat clients, so she regularly made a point of refusing them care to make them cry, telling them that she could not take them as clients because they would "break her heart and develop high blood pressure." When they would come back the next day and beg to be reconsidered, she felt she had made her point about good nutrition and would consider them as clients.
This midwife genuinely cared about these women and did take larger women as clients, but her approach is still size-phobic because it assumes that all her fat clients have very poor nutrition, will automatically develop high blood pressure, and need to be saved from themselves. This treatment humiliates them and forces them to beg for care. Average-sized women can have poor nutrition and high blood pressure too, but only the fat women were singled out for this treatment.
Although doctors tend to be more fat-phobic than midwives, midwives can also exhibit size prejudice. All providers need to examine their equipment, protocols, and attitudes to see if they are truly size-friendly.
Fat women are tired of being marginalized. They are tired of equipment that doesn't fit, judgmental attitudes from providers, unjustified assumptions, lectures on weight loss, and mistreatment based on size. They want respectful, dignified treatment that does not discount possible risks but does not assume them either. They want to be able to trust their provider to treat them as individuals instead of as statistics.
When asked what size-friendliness means, a number of fat women replied:
The following are some guidelines for becoming more size-friendly in your practice. Hopefully, they will help each midwife to observe the way she perceives fat women, question her assumptions, and carefully evaluate the care she plans for them.
All fat people are not alike. Don't make assumptions about why we are fat. Sure, some people are fat because they don't get enough exercise or don't eat wisely, but not all of us are. Don't assume we're all sitting on the couch, watching TV and eating chips all the time. People who are born into naturally slim bodies have a hard time understanding what it is like being fat or to struggle with weight, but it is possible for women to eat reasonably, exercise regularly, and still be fat. Some fat people are fat because they have lousy habits, but it is possible to have good habits and still be fat, and it happens more often than you might think.
Don't assume we all have eating disorders either. Some of us do, some of us don't. Some are fat because of emotional eating, but some are fat because of genetics or hormonal imbalances. Some of us used to be only chubby, but dieted ourselves up the scale and permanently raised our setpoints. Most of us are fat because of multiple combinations of these factors. Avoid simplistic thinking. Ask about our diet and weight history before making assumptions about what we need to do. Individualize our care.
We've heard the fat lecture many times before; we don't need to hear it again. If it were simple to lose weight and keep it off, we would have done so by now. It's not simple, it doesn't respond well to easy solutions, and it may not even be what we want. Some fat people do want to lose weight, but for others, being at a stable higher weight instead of constant yo-yo dieting is the more healthy choice. Don't make judgments without hearing all of our history.
We are not here to try and lose weight during pregnancy; we are not here to try and reform our lives to fit what you think is best for us. We are here for pregnancy and for birth, not to be reformed, and not to have your agenda and opinions imposed on us. Listen to what we want.
Carefully examine your own beliefs about fat. Do you automatically assume that a fat woman in your practice is going to develop gestational diabetes or high blood pressure? Do you assume that a fat woman is eating large amounts of sugar and junk foods and will need major nutritional counseling? Do you assume that a fat woman is going to gain a lot of weight in pregnancy and will probably need to be strongly reminded to watch what she eats so she won't gain too much? Do you feel that you have to "save" a fat woman from herself? Do you really believe that "soft tissue dystocia" exists, that a woman's fat can prevent a baby from coming out? Do you think there's a point at which a woman is too fat to become pregnant or to have a baby vaginally? Did you know that women have conceived babies and had vaginal births at weights over 400 lbs.? Did you know that while fat women have higher rates of some complications, the majority of fat women actually have healthy pregnancies and normal births?
What body issues do you have in your life, and how do they influence your perceptions of us as fat women? The sad reality is that some of the most biased treatment comes from women with their own body issues, which influence their agenda for others.
Many fat women report that their pregnancy experiences follow the expectations of the provider. Look carefully at your own policies of management, your own assumptions, and your own expectations for the births of fat women. Open your mind and take things as they come instead of expecting complications or difficulties. Work with the woman to be as proactive as possible, and then accept how her pregnancy progresses without expectations or judgments.
Do you have equipment to fit all your clients? Do you and other staff know the importance of a large-sized blood pressure cuff and use it without question? If you practice in a clinic, do you have gowns that fit and actually offer full coverage? Do you have a scale that can be adjusted for supersized women? Do you have at least one or two armless chairs in your waiting area for the comfort of your larger clients?
If you do not have equipment that fits all women, get it! Blood pressure readings taken with a regular-sized cuff on large arms are artificially inflated, causing treatment decisions based on invalid data! One study found that 37 percent of obese hypertensives actually had normal blood pressure when the correct cuff was used. (13) Make sure all staff knows why the large cuff is important, where it is stored, and that it is to be used automatically, without protesting at having to go get it. Many practices have large-sized cuffs but don't use them; many large women report having to fight to have the large cuff used.
Supersized gowns can be bought, or offices can allow women to bring their own gowns that fit. Some offices buy full-sized real sheets to use on those occasional visits when the little paper sheets won't do. Large-sized blood pressure cuffs, scale adaptors, and supersized gowns are all available from medical supply stores or through size-acceptance companies on the Internet. If you cannot easily afford this equipment, consider bartering—let one of your fat clients get the proper equipment for your practice as part of her fee. In short, get the right equipment for the job, and don't base treatment decisions on invalid data.
It's true that fat women have higher rates of certain complications (2)—being size-friendly doesn't mean you have to ignore that. It does mean, however, that you do not assume that a complication is going to happen, that you are aware that most fat women actually do not experience complications, and that you do not treat us as a statistic waiting to happen. Be watchful, but expect normalcy.
However, if we do experience a complication, please don't be judgmental. Don't assume automatically that the complication is caused by size; average-sized women experience complications, too. Or a hormonal problem like Poly Cystic Ovarian Syndrome that often accompanies fatness may be the real problem instead of the fatness itself. Don't judge, just be matter-of-fact and open about the problem.
We are real human beings. We have the same hopes and fears and dreams for our babies as anyone else. We are not a statistic on a page. See us as more than mathematical projections—see us as the human beings we really are.
Research seems to show that while the most optimal weight gain for average-sized women is about 25 to 35 lbs., the weight gain range associated with the best outcomes in fat women is about 15 to 25 lbs. (14, 15) However, the highest priority should be excellent nutrition, not trying to artificially meet arbitrary weight gain guidelines. Eat healthily and well, and the body will gain the amount that is necessary for that body!
Women of size report a wide range of weight gains in pregnancy. Generally speaking, the larger the pre-pregnancy size, the less weight a woman tends to gain, although of course there are exceptions. The most common weight gain pattern in fat women seems to be a loss during the first trimester, then a slow regain of the weight lost during the second and third trimesters until a small overall gain is established. While many books caution that large women must gain at least 15 lbs., many women of size gain less and their babies are just fine. Women who have recently lost a lot of weight or who are chronic dieters often gain much more than 15 lbs. Although the general goal for larger women is to aim for around 15 lbs., a gain smaller or larger than this should not be a cause for great concern as long as baby is growing well, nutrition is excellent, and all tests are fine. Nutrition is the priority, not arbitrary weight gain guidelines.
Nutrition for pregnant women of size is essentially the same as for every other pregnant woman. Larger women may need slightly fewer calories because they do not need to add the fat layer for energy that smaller women need, but restricting calories can lead to complications and has not been proven to be safe.
One of the most powerful things you can do as a midwife is to emphasize your expectation that all will be well, and to actively help your client to expect that as well. Fat women have had so much negative feedback that many have difficulty believing in their body's ability to work well. Some may need help in learning to trust their bodies and feel comfortable with them; active attention to emotional preparation for birth and working through fears may be especially important for women of size.
Carefully assess your client's background; does she have issues of pregnancy loss, fertility concerns, mistreatment by medical professionals, mistrust of authority, body hate, eating disorders or past abuse? What are her fears about pregnancy, birth and parenthood? What are her hopes? How does she see herself giving birth? What kind of messages is she receiving from her friends and family about this pregnancy?
Helping a fat woman work through her fears and emotional issues is a very potent tool towards helping her have a good birth experience. A birth journal, birth art, visualizations, hypnotherapy and guided imagery are very powerful tools for change. If you do not have enough time to address this adequately during appointments, encourage the woman to see a therapist who specializes in birth issues, or to take one of the childbirth education programs that emphasizes emotional as well as physical preparation for birth. Many fat women have reported this to be extremely useful, especially after prior negative birth experiences.
Confer with colleagues and share what you have found to work with larger women. Online, midwives have reported great success in helping fat women birth normally by helping them to stay out of bed, to utilize lots of position changes (especially hands and knees), to use birth balls, and to pay very close attention to fetal position. Some midwives report that using a Rebozo or other scarf tied around the middle may help keep baby aligned better for birth if abdominal muscles tend to be lax. Mobility in labor may be especially important for larger women. If cephalopelvic disproportion (CPD) is a concern, use positions that maximize gravity and pelvic opening, and consider having the woman see a chiropractor to be sure the pelvis (including the pubic symphysis area) is well-aligned. Laboring in water and waterbirth may be particularly helpful too.
Discuss with other midwives what laboring techniques or positions have worked well with women of size. Ask your fat clients what is working best for them, too. Trust that a fat woman's body will tell her how she needs to labor, just as any other woman's body speaks during labor. Empower her to listen to it and trust in it. Help her to go with the flow of what her body is telling her.
We deserve the same respect that every other person gets. That means treating us as equals and having respect for our intelligence. It means not patronizing or condescending to us. It means recognizing that many of us have a long history of negative contact with health-care providers that we may need to overcome. It means honoring our ability to make decisions for ourselves, even if you do not agree with them. It means understanding that we are the ultimate authority on our bodies, not you. As one mother puts it, "[Show] respect for the individual person, regardless of the body they wear."
It also means being honest about your own misgivings. If you don't think you can be size-friendly or if you have real misgivings about possible complications or accommodations, be upfront with us. Tell us honestly but respectfully what your concerns are, how you would probably suggest handling things, and then let us decide if we can live with that or not.
Treating us with respect means looking for and seeing the beauty of our bodies—curves, dimples, sags, folds and all. It means honoring our desires to become mothers just like anyone else, and realizing that the ability to love and nurture, not size, is the most important qualification for parenthood. And it means respecting that the miraculous magic of making a baby can happen in a lush body as well as a sparse one.
Pamela Vireday, size-acceptance activist, is the plus-sized mom of three beautiful and healthy children. She is the owner of the Plus-Size-Pregnancy Web site, is finishing her certification as a childbirth educator with Birth Works, and is active in ICAN (International Cesarean Awareness Network) as well.
Large Blood Pressure Cuffs
Medical Supply and Scale Stores
These companies may carry counterweights that can be used on beam balance scales to extend a 350 lb. scale up to 450 lbs. Be sure to know what brand scale you have; you may need to order the exact kind that goes with that brand. Most counterweights run between $35–60 (averaging about $45), depending on the brand and the company.
Editor's Note: It is ironic that big women suffer so much prejudice around their pregnancies and births. It is likely that some part of their size is rooted in the horrendous practices that happened to their own mothers during pregnancy and birth. Pregnant women have routinely been told not to gain more than 10 to 15 pounds, literally starving the baby in utero. These babies often came out forever hungry and needing to eat in the cellular effort to avoid starvation at any cost. Breastfeeding is another factor that contributes to body size. The fat cell is completely different in the bottle fed baby, especially when you're bottle fed a formula like the one my sister received as a baby: canned milk and white corn syrup. Genetics also plays a role in body size. Whatever the cause, discrimination is still wrong. Love never fails.
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