Episode 170 Weight Stigma in Pregnancy

Have you ever considered the impact of a simple medical term on a person's experience? Midwife Jenny Cunningham and Catriona Forbes of a research collective join us to unravel the complex issue of weight stigma in pregnancy.  Jenny shares her path from hands-on midwifery to academic research, while Catriona offers a personal narrative on the stigma she faced as an expectant mother, lending depth to our understanding of these early, often negative categorizations.

Language has power, especially in healthcare, and this episode sheds light on the need for respectful terminology when discussing body weight during maternity care. We've replaced the word "obesity" with "higher weight" to foster a stigma-free environment. Catriona provides invaluable insights into the response from individuals with higher body weights, and together, we discuss the evolution of our research methodology to ensure it's inclusive, community-based, and sensitive to the needs of those it aims to serve. We also tackle the practicalities of prenatal care, such as folic acid dosages and the importance of creating a healthcare environment free from anticipatory anxiety.

Lastly, we navigate the emotionally charged waters of maternity scans and medical conversations about body size. From the choice between induction and cesarean delivery to the importance of transparent and patient-centered communication, we underscore the crucial need for honesty and personalized care in addressing weight-related health risks. As we invite more voices to join our ongoing research, particularly from communities that are often unheard, we reaffirm our commitment to enhancing support for all expectant mothers through respectful dialogue and care.

Want to know more?
https://shameandmedicine.org/maternity-care-for-women-of-a-higher-weight-how-is-shame-experienced/
Contact Jenny  by email k2030248@kingston.ac.uk or DM via twitter or Instagram. Twitter: @djennymidwife  Instagram: @phdjennymidwife   

Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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Its easy to explore my back catalogue of episodes here https://padlet.com/WhoseShoes/TheObsPod I have a wide range of topics that may help you make decisions for yourself and your baby during pregnancy as well as some more reflective episodes on life as a doctor.
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Transcript

Florence: 0:01

Hello, my name's Florence. Welcome to the OBSPod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy Call the Midwife. Maybe birth fascinates you or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth. Perhaps you work in maternity and want to know what makes your obstetric colleagues tick, or you want some fresh ideas and inspiration. Whichever of these is the case and, for that matter, anyone else that's interested, the OBS pod is for you.

Florence: 0:53

Episode 170, weight Stigma in Pregnancy. Today I have two very special guests. I have Jenny Cunningham, who's a midwife, and I have Catriona Forbes, part of a research collective, and we are going to be talking all things weight stigma in pregnancy, which kind of builds on the episode I did recently episode 163, I saw on social media that Jenny was looking for people who'd experienced pregnancy, who were overweight or had a bigger BMI and we'll talk about whether BMI is a good thing or not and I was interested because she's doing research in this area and that's kind of how we connected and we've got lots to talk about today. But I don't know if you want to start Jenny with perhaps how you got interested in this as a topic.

Jenny Cunningham: 2:00

Hi Florence, thank you very much and thank you for the invite. Very pleased to be here. It was some years ago when I was working clinically as a community midwife and we were suddenly given a kind of sheet, a checklist sheet, a brand new sheet which came in the booking pack so the packs we use when we first meet women who are pregnant to talk about their pregnancy and kind of go through various kind of conversations and blood pressure and that kind of thing. And this new checklist was for women with a raised body mass index of 30 or more and at the time we hadn't been alerted to this coming.

Jenny Cunningham: 2:37

So it literally landed on the desk and I found it very negative. It was talking about risks, really fairly negative kind of of. You know, tick, have you talked about shoulder dystocia? Tick, have you talked about this? And that it felt quite a difficult conversation to have with women right at the outset and my kind of colleagues we kind of talked about this and we just found it quite difficult and we were quite surprised by it Because of course a lot of the things we talk about affect all women in pregnancy potentially. That's where my interest came started at. So I did a small study, interview study a couple of years later in my hospital trust, asking women about their feelings, about the conversations we had. So that that was the kernel of the idea and I've just kept that with me. I kind of follow lots of weight neutral kind of people and activists and it just raised my interest and I had an opportunity to do a PhD and I chose this topic and that's why we are here today.

Florence: 3:39

Fantastic. So I agree, I remember the kind of start of the idea that one should have a guideline and of different rules in inverted commas applying to depending on what the body mass index was what one should or shouldn't talk to people about, and I think it came from a place of good intention in terms of analysis, in perhaps things like embrace the maternal morbidity and mortality that we were seeing, perhaps a disproportionate number of women that that fitted into those categories represented in those reports. But I agree, I remember having many conversations with women in my clinic where they were kind of saying, well, I'm pregnant already and you telling me now, when there's nothing I can do about it, but I have the risk of this and the risk of that and of that, and making me absolutely petrified of my pregnancy is really unhelpful. Yeah, catriona, I'm sure you might like to chip in here and tell us a bit about yourself and why you're involved in the research collective. Uh, sure, florence.

Catriona Forbes: 5:24

I got involved in the Research Collective Sure Florence. I got involved in the Research Collective after a call was put out on a group on social media that I follow, and it was Jenny's call for participants to contribute to her Research Collective as part of her PhD study into weight stigma in pregnancy. I had already had my child by that point, so I have a almost three and a half year old and my I mean my pregnancy was an interesting one in that it took place entirely in 2020. So that in itself had its own flavour, unique to that period. But, yeah, there were multiple points, I think, through my experience experience of pregnancy that had me asking a lot of questions about how I like my experiences, I guess.

Catriona Forbes: 6:13

So I, from that first conversation that Jenny references as the one that you know you have as you're booking an appointment with your midwife which, checking back on my own notes of it from four years ago, was a 51 minute telephone call for me in COVID times, and from that 51 minute call of questions that then decided a pathway, which was obviously that my pregnancy would follow, I think a weight management pathway.

Catriona Forbes: 6:40

I don't know what it's called higher weight pregnancy. I have no idea what the actual official name for it is, but essentially it meant I was consultant-led care Maybe that's the actual name of it. So I was immediately kind of under that pathway, based on that initial conversation which, to be fair, my midwife just was very much like it was just a very master of fact thing. You've ticked a certain number of boxes. Anyone who ticks a certain number of boxes can end up on this pathway. These are the boxes that have obviously kind of made you eligible for it. But it just did set a tone, I think, for then what felt like how my pregnancy was then going to be perceived and experienced, I think.

Florence: 7:22

That's really interesting that it was just was just kind of automatic default, is that right? So you didn't have any kind of say in it?

Catriona Forbes: 7:31

Well, I mean I maybe did have a say. I guess I didn't question having a say. It was I'd gone over a threshold that meant I was under consultant-led care and I didn't question that. I just went to the appointments that I received the letters telling me to go to. So, um, I didn't, I didn't question why I, why that was entirely necessary, or, or, yeah, I guess part of the kind of go to the appointments that you're given is because you know you expect you're given them for a reason and you're pregnant and are effectively now responsible both for yourself and someone that's growing inside you.

Florence: 8:07

So, uh, you, you do as you think you're supposed to be doing and did that feel like I'm being well looked after because I've ticked these boxes and therefore I'm going to have this pathway, or did that make you feel apprehensive or worried about your pregnancy?

Catriona Forbes: 8:31

I mean I was apprehensive before becoming pregnant about my body size. In healthcare in general, I very much fit the classic that's now been studied extensively about people who will avoid seeking medical advice or conversations based on the encounters of how your body starts to become or your weight starts to become, part of the discussion around anything that you might actually be seeking health care for. So I think pregnancy wasn't something that I was fairly apprehensive about anyway, and then became pregnant and so then it just felt like, well, definitely do all the things you're told to do for fear of something going wrong, and most pregnant people, I think, feel that way. I don't think that's specific to people of a higher weight. I think it's very much.

Catriona Forbes: 9:20

You don't necessarily question much, especially perhaps the first time around, and just go with it. I guess I had some experiences through it that I did have a particular negative reaction to, and then so when I saw Jenny's call and the work that she was doing, I was just really interested, I guess, in the fact that you know Jenny is a midwife and has worked firsthand in delivering babies and working with pregnant people, and so I always think it's great if clinicians are actually looking to speak to the people that are impacted by the decisions that are, you know, kind of taken at whatever level.

Florence: 10:01

Definitely that sort of has really nicely led us into this idea of stigma and and weight stigma. And, jenny, you sent me a great blog which I will put in the show notes for people to read. But do you want to talk a bit about what we mean by stigma or weight stigma?

Jenny Cunningham: 10:26

Sure, I've got a really, I think, a really nice definition of weight stigma, which I'll read out. Is that OK?

Florence: 10:32

Yes.

Jenny Cunningham: 10:33

And this one which was published just two years ago. So weight stigma can be defined as prejudice and discrimination due to weight or body size. It includes experiences of being stigmatized by others, internalized weight or self-stigma, and anticipated or expectation of stigma, all of which have been linked to negative health outcomes and potentially life-limiting disparities of evidence. So that's not particularly about pregnancy, but that's just about weight stigma as a whole, and I think that to me is a really kind of holistic definition. It talks about self stigma, which not all weight stigma talks about, because we internalize as human beings in society what others feel about us. And it also talks about expectation of stigma, that anticipation that you're going to walk into that room be kind of humiliated or judged in some way. So I kind of really like this definition.

Jenny Cunningham: 11:28

And also the other thing it doesn't use the words I'm going to use it now. I don't like it obesity. It doesn't use the word body mass. It will determine body mass index either, and I think when clinicians speak to I'm going to just talk about kind of in the maternity field to women and birthing people, they will rarely say obesity to their faces, but it will be in all the written documents and of course it's always in the press around. You know the original words on TV etc.

Jenny Cunningham: 12:01

And obesity is known to be a stigmatising word. So I really try not to use it. And you mentioned earlier Florence body mass index and we we know it's a contested term. It doesn't accurately say anything about someone's health. It just tells us about people's weight. So I try, so I'm using higher weights or higher weight bodies, and I talk to the research collective about what language I should use, which is kind of why I really wanted to have a group of women and birthing people to support this work. And I think, Catriona, we felt higher weight seemed satisfactory, it seemed OK, it didn't seem particularly good or bad, it was fairly neutral enough, I think. Was that how you'd agree?

Catriona Forbes: 12:44

Yeah, I would agree with that. What was interesting, though, is that in the discussions with the collectives, when we did meet to have that kind of conversation the first meeting to talk about some terminology and how Jenny might want to approach things there there wasn't a universal response or agreement in. You know, we didn't all think the same way about what words were or weren't okay, and that, I think, relates to kind of the different relationships or points that we all were at with our own bodies at that time and and how we'd experience things. So, you know, there is kind of movement around removing the stigmatization of the word fat and to use fat as a descriptor and fat is just a description it's in the context that you use a word that gives it its meaning. However, there's a lot of other people that would have responded really poorly or negatively to to the use of the word fat, and I think, certainly, if you'd put that in a research call to say I'm interested in talking to fat people who are pregnant, I don't I don't think you'd have necessarily had a a positive response.

Catriona Forbes: 13:48

So, yeah, even in the research collective, it what it's been an interesting experience, because we've been hearing each other's stories and experiences and even how we relate to the language around, uh, how bodies are spoken about. But yeah, higher weight, I think the one we all just kind of agreed was most neutral fundamentally. It didn't instill really any negative responses from anyone, so it just felt like the most neutral and kind of safest approach. And then, obviously, for research purposes, jenny was then able to kind of put a little asterisk with a definition of what that would mean, you know, in BMI terms, because ultimately I guess there just has to be kind of put a little asterisk with a definition of what that would mean, you know, in BMI terms, because ultimately I guess there just has to be kind of a clinical outlook on it from a research perspective. So there was an ability to expand on that without it centering on BMI as kind of the measure.

Jenny Cunningham: 14:39

Thank you, catriona, that's a really helpful expansion of what I started to say. So thank you. And I did have to choose, you're quite right, bmi of 30 or more, because that's a really helpful expansion of what I started to say. So, thank you. And I did have to choose, you're quite right, bmi of 30 or more because that's when interventions start happening to pregnant women and people. So under that, as you know, people are treated the same generally, unless there's a particular medical condition. But 30 or more is when those conversations start happening. So I had to define it otherwise because I wanted to particularly look at people who have those conversations as additional interventions potentially.

Jenny Cunningham: 15:09

And just to perhaps just add on here about the collective, which is more commonly talked about as an advisory group. So I'm using the word research collective, I'm using an approach called critical participatory action research. So what I'm trying to do within this approach is kind of flatten the hierarchy a bit between researcher and topic and people, and by using a collective rather than advisor group, I'm trying very much to not just be advised by them but to actually do what is suggested. You know, it's perhaps a more direct um use of advice and there's nine people, nine in the research collective, some I've had one to one meetings with, because not everyone can make a meeting. I think the biggest meeting we've had is six, six or seven at one time and it's been immensely valuable to me that really fits in with a lot of the work I do in terms of co-production.

Florence: 16:02

That idea that from the get-go, you're working alongside people with no hierarchy that's the other thing that, when I looked at what you were doing, made me think this is really good stuff, because this is from the get-go. You've got the people, the right people, with you to really understand the questions. I'm interested in what you just said about avoiding interactions with health professionals in general, or not seeking medical advice. And now you've said that to me. I can see that's obvious. But I'm thinking oh, I hadn't really thought about that. So consciously consciously, even before you've got pregnant, you're thinking oh crikey, I'm gonna have to go and deal with health professionals. Glug, is that kind of what you're saying yeah, absolutely so.

Catriona Forbes: 16:58

One of the things and it was something that came up in one of the collective meetings as we were talking about how a few of us knew that if you're a higher weight in early pregnancy, you'll be prescribed a higher level of folic acid, but it is available as prescription only and before getting pregnant.

Catriona Forbes: 17:19

If you're attempting to get pregnant, you are advised to be taking folic acid to prepare for pregnancy, but I personally certainly did not have any conversation with my general practitioner about whether I was attempting to get pregnant to then ask if I could therefore have the prescription for the higher level folic acid that would be recommended, even though I knew that that's a thing, and so I did not seek out that prescription in advance of trying to get pregnant, because I wasn't interested in the conversation about whether getting pregnant at my size was something that they perhaps should be doing or is recommended, because we don't want to have that conversation about decisions that we're taking about starting a family or expanding our family for those that already had children, and so, yeah, it's a key example of the way that we before pregnancy, even if you are aware of that being something, and the best recommendation would be that perhaps we should go and get that prescription as part of the preparing for pregnancy journey, and we don't um, or you know those of us who are discussing it, haven't?

Florence: 18:34

perhaps some do so we've got two kind of barriers there, I'm thinking, because you've got the barrier of it's prescription only, whereas anyone else can go and buy what they need over the counter, yeah, and then the barrier of you don't actually want to go and talk to the person that's able to do the prescription. Yeah, it's like a bit of a double whammy.

Catriona Forbes: 18:58

Well, I certainly purchased what you can purchase over the counter and use that, but I was aware that it may not really be what I needed.

Jenny Cunningham: 19:08

you know, at my at my weight that was an eye-opener for me in that meeting because I had read research around people not wanting to go to their doctor, their family doctor, because, as Katrin has described really well, you know you go in with whatever pain or problem and weight can be the kind of the first conversation or maybe all that appointments around weight or losing weight. I should say that's what it's about, isn't it? So it's kind of known that people of a higher weight will often not go to appointments with delay, so diagnosis gets delayed, they may get iller because of this, etc. Etc. So there's a really poor outcome, potentially poor outcome.

Jenny Cunningham: 19:49

But and I was wondering whether it was different in maternity and then the the research I'd read up until you know, hearing that conversation was around people may again anticipate stigma, but they will turn up because they're pregnant and this is what katherine said earlier. You turn up, you go down the pathway because you're pregnant and you're not there just for yourself, you're there for your baby. So weight stigma plays a different role but of course, preconceptually it really plays into that kind of people not wanting to see a healthcare professional, and that's really important information to know.

Florence: 20:24

So, talking about weight, stigma and shame, you have given some good examples in the work you've done about various moments in that pathway that you might encounter that sort of stigmatizing moment or shame. So you mentioned actually being weighed, but also things about ultrasound scan and stuff like that. So I don't know if you want to talk a bit about that, of course, thank you, yeah so I have completed a type of systematic review.

Jenny Cunningham: 21:09

It's called a meta-ethnography it's enough to put anyone off reading about research these terms. But basically I've systematically reviewed the evidence and all the studies which included a finding of weight stigma or with a weight stigma focus around maternity kind of pregnant women, people. So I was looking at studies where people were interviewed or part of focus groups, so it was kind of the written word. In the end I found 38 studies and one of the key findings of these 38 studies from around the world was shame. So I conceptualised the findings into the first person so I experienced shame during maternity care was across all but I think one of the studies. So shame is a factor.

Jenny Cunningham: 21:55

During the ultrasound scan it can be realized as like mother blaming, mother blame where, uh, in this case it's the woman's size. Maybe the sonographer says I can't see your baby very well, or maybe maybe all the measurements are taken satisfactorily as far as the woman knows. But when she gets her notes back, there's a little comment in the notes saying visibility restricted due to maternal habitats. I think it's a common one and it appears that even when the sonographer at the time has said yes, everything's fine and appears to be ticking everything off. Even in those situations can this little sentence be written in the notes? And of course the woman might not see it till she's home, and then that's a really can be potentially quite humiliating thing to read, because that wasn't addressed in person at the time. So that was found in quite a few studies and that's also popped up in my own study too, when this scan seems particular area, particular time, and I don't know why because I haven't talked to sonographers about this. But I will do.

Florence: 22:59

But it is a real issue and it's obviously partly to the technology maybe not being good enough or may not be the right type of technology you're correct, it is partly related to the technology and its ability to go through different layers and different depth of layers, because it's ultrasound that is bouncing back and forth between the probe and the baby. I feel that maternal body habitus thing is a little bit like when you buy something and it's like a little guarantee don't sue us if we've done it wrong. So when they go, all this and the other can't be excluded because of you were nodding along there. Cat Catriona, would you like to share anything about your experience of scanning or what was making you nod?

Catriona Forbes: 23:54

Well, I had a fairly straightforward experience of scanning. I was quite open in going into the appointment and asking if it would help if I held my tummy in a particular way. That would allow them to obviously get to wherever they need to be. That would allow them to obviously get to wherever they need to be. So I was just fairly open about the fact that, you know, I may in fact have body fat that gets in the way and you know it's perhaps helpful to just move it back or whatever that might be to hold it in place. So I was quite open about that in the scans. But I definitely had the experience that Jenny describes, where a scan took place, all the measurements were taking place. There was, you know, a discussion about whether all the measurements, whether they captured everything they needed In one scan my 20, my first attempt at a 20 week scan.

Catriona Forbes: 24:38

We couldn't, but it was entirely about the baby's position and that's what they'd said and I'd had to do. You know I'd done everything. I'd had to go for a walk, I'd had to try drinking very cold water to shock the baby into moving, bit and go and empty my bladder, wait a while again and see. So I'd done various things in this appointment to attempt to move baby and then baby was not up for moving. I don't think I've ever done such bizarre movements on a kind of hospital table thing to try and get a baby to move. It didn't work so I had to go back for a repeat scan. Then we went up for a repeat scan, baby was in the right place and they got all the measurements, but then, yeah, I went home and that note was added.

Catriona Forbes: 25:15

So then I think the experience is you then question well, hold on, did you get all the measurements you need? Like I thought we did get everything we needed, but now this note's there. So did you get everything you needed? And then, obviously it's, it turns out on all the notes. So then you kind of have the question of wait, have we ever had the measurements we need?

Catriona Forbes: 25:35

And so it just kind of puts that uncertainty in place of particularly, I think, because scans started to become part of the discussion about, obviously the size of my baby and then what that might mean for delivery of my baby and it, I think, because there's that note and then there's not really been a conversation about what that actually means. You then start to question well, how can you be basing so much on something that you've added a note that may be inaccurate yourself? How am I supposed to take this as an accurate assessment for something else, when you yourself have said it's possibly not an accurate assessment? So there's this kind of weird conflict of what advice am I supposed to take here? Because, on the one hand, this is the most accurate evidence that you have to make clinical decisions, but on the other hand, you've acknowledged that it may, in fact, not at all be accurate because of my body. So it does kind of presents quite a juxtaposition of how to even like participate in the conversations about plans going ahead based on scans.

Florence: 26:41

That's a really good point, because I'm assuming you're then thinking about at the end of pregnancy, if someone tells you your baby's big and is starting to talk about decisions to do with that, because higher weight women there seems to be a correlation with a higher weight baby, although I don't know if that's actually true, but that's certainly what we've written in our guidance, that we should be doing a 36-week scan to decide. But then you're right, how accurate are those measurements and then influencing all sorts of choices rippling out from there. Just I wanted to pick up on what you said about being very open in appointments and that your body fat. You might need to hold it out the way.

Florence: 27:34

I always find it really difficult to know the right way to approach a conversation, particularly if a woman has perhaps been, like you said, put on the pathway to see me because she's ticked a certain box. Then to say, well, you're here because you're a heavier weight, and yet that just seems very rude. But then you can't not mention it because that's why the woman's potentially been asked to come to the clinic. So do you have some? And I guess I usually open up the conversation by asking the woman why are you here? What can I do for you today and that sort of open question. But do you think there's a good way to approach that?

Catriona Forbes: 28:34

it's a good question. What is the good way to approach that? I mean, I guess the challenge is there is no one good way to approach it. Everybody is their own. You know, I, I guess, approached it the way I did in scans because I guess I was a bit more matter of fact. I, you know, there was that mention at the start where I'm already pregnant. How helpful is it to be talking about my body size at this point? You know, this is the body that is going to be, you know, if all goes well, birthing a child later. So we might as well all just wrap our heads around that now this is the body that will be doing that. So you know I guess that was kind of a part of my mindset was well, this is the body I have, so this is the body we're working with.

Catriona Forbes: 29:19

There's nothing really to discuss or expand on there um, I don't really remember how my first discussion went with my consultant because it was over the telephone and I really don't remember what the opener of it was, but I do remember I do hypermobile EDS and so I did have questions relating to that Because that for me was actually like a large concern for me. I remember trying to ask questions about it and it was just dismissed as kind of that was not something that was of any concern to my consultant and in a way, initially that seemed like a positive thing. It's like, oh, it's not a worry for them, they're actually fine with this. And I think as things went on and because I started to have more questions about that, I actually started to feel really frustrated that that wasn't a concern actually because we were talking about things. That obviously was the concern. That had been the reason that I was flagged to the pathway, but then there wasn't room for me to talk about the concerns I had, it felt like. So I don't remember my opener conversation, but I also feel like there's just something powerful in someone saying the reason that you've been referred to this is because of these risk markers that have been checked off.

Catriona Forbes: 30:37

I do have a tale of a really positive experience, which is one of my best friends who also ended up on a consultant-led pathway of BMI kind of being the driving factor who in the first appointment with her consultant basically the consultant had obviously looked at records and then looked up and was kind of like, okay, and I think he had actually said, well, you know, your referral is based on your BMI because you've ticked this thing, but having looked through your records, um, this is going to be an incredibly boring pregnancy for me.

Catriona Forbes: 31:11

And you know it was very much like unless something actually happened, you know, unless her BMI suddenly shot up or unless you, you know, developed gestational diabetes or unless she any other number of conditions that can occur in pregnancy happened. It was otherwise just going to be a meeting someone with a perfectly normal pregnancy that just happened to be on his book because her BMI was too high, and so I think that kind of brought like just, you know, it was an opener. This is why you're coming to me. There's really nothing interesting for me to talk about yet.

Catriona Forbes: 31:48

Hopefully that will remain and that was just kind of a nice way to open it with, like you're here because of this, but looking at these papers, you're quite boring at this point, um, and hopefully you'll stay that way, um. So you know, I think there's something powerful in just acknowledging, you know, it's actually quite boring, I would imagine, to just have to. You know, even for medical practitioners, you just like, this is just a process we're also going through, that there's certain thresholds that are met and that need to be ticked, and that we have to follow the protocol. But fundamentally, x number of people will never even become interesting in this kind of medical context. So you know, she had a really positive experience in that respect because and she did remain boring, uh, right through to the end- I like that story.

Florence: 32:33

That's really great. Can I just come in here?

Jenny Cunningham: 32:37

yes, do me again going back to my kind of not my, but this this theme around shame and how people are shamed, um, with higher weight and pregnancy. It's those assumptions and the kind of preconceptions people have. You know, midwives and doctors, when that woman walks in the door who all we see is someone of a higher weight. And inevitably obviously I'm paraphrasing what people might think but inevitably this person is going to end up with X and Y. But the example Catriona just gave of her friend was there was none of that kind of preconception of those judgments given to that woman, which is kind of what you want. So it is completely reducing, minimizing any kind of feelings she may have about her size, because this doctor is just saying well, it might not be the right system, but you're here.

Jenny Cunningham: 33:25

But you know I'm not anticipating anything bad's going to happen and I think people in the review I did women are tend to be being told that you're going to have a cesarean section, you're going to be induced, you know you can't go to the midwife led unit. So right at the beginning, throughout, they're being restricted, they're being told bad things will probably happen. But of course we don't know they're going to happen, do we, and maybe by saying this bad, you know these kind of giving those expectations, maybe we as healthcare professionals is what these things are more likely to happen and I haven't done the research to say that but who's to say that isn't the case as well?

Florence: 34:01

yeah, I worry about that. I was thinking about what Catriona said about actually I was interested in my hypermobility and you know Stannis syndrome and the consultant wasn't at all interested in that. They were focused on the weight and that's a kind of classic really not listening to and thinking about what matters to the person in front of you. I agree, I worry.

Florence: 34:28

One of the things I see quite a lot is the idea of oh, it might be difficult to put in an epidural, so we're going to make you be on the obstetric unit because you're in inverted commas, high risk, and you can't go to the birth centre and you can't use the birthing pool, all sorts of restrictions we're going to place on you.

Florence: 34:52

And then we're going to tell you you ought to have an epidural because it might be difficult to put it in and therefore we should put one in just in case, and then we can even. I've even had people be told well, I know you don't want an epidural, but we'll put one in in case, but we don't necessarily need to put any medication down it, but it's just there when and if we need it or you need an induction. But that increases your chance of emergency cesarean and a planned cesarean would be safer than an emergency cesarean. So maybe we should just do a planned cesarean rather than having an induction. We start to kind of perpetuate more complications, more interventions, because we're so worried about the possibility they might happen, we actually make them happen. So worried about the possibility they might happen, we actually make them happen. Catriona, I'm interested in what conversations you may have had or choices you felt you did or didn't have when you were thinking about giving birth well, yeah, so at 35 weeks I developed a hypertension.

Catriona Forbes: 36:10

So pregnancy induced hypertension kicked in at 35 weeks for me and that was exactly the point. I was about to be having birth conversations and then a lot of things went out of the window. Anyway, I never had any intention of having a home birth. That was never a discussion. I was actually very comfortable with the idea of hospital birth. Anyway, I was intending or planning to have hospital birth, ideally a water birth, but that would unlikely have been granted, even if not for the hypertension, because of policies around water births and weight. But I did have a birth preferences conversation I had. I was in and out of hospital stays to try and get the medication at the right level to manage it. My midwife still had a birth preferences conversation with me. So I checked out of hospital one day and came home and think I had the conversation later that day with my midwife, came to my house but we could talk through what the options were at that point.

Catriona Forbes: 37:09

Obviously, induction had been spoken about, uh, quite extensively on when I was on the hospital ward and I was very against induction.

Catriona Forbes: 37:18

So I was very much of the mindset that if my baby wasn't choosing to come out and there was a medical reason why my baby needed to be delivered with any sense of immediacy, then that would be the cesarean, because to my mind I don't see how an induction really is about dealing with an emergency delivery situation, given that they can take so long.

Catriona Forbes: 37:40

So for me those were kind of my thresholds was that unless I went into labour naturally and my baby was obviously ready to come, then cesarean was the only route that I was willing to discuss as the alternative delivery, I guess. So I did have hard lines around what I did and didn't want, and when I had the same discussion, I guess, with my midwife, we obviously spoke about the pain options and what I might or might not want to consider, and I'd done an NCT class, albeit entirely online also, with another group of expectant parents, so kind of. I had enough knowledge about all of those processes and the kind of delivery things anyway and all the different pain medications and the different phases of labor and things like that. But yeah, I guess I had quite a hard line on it's a, it's a natural kind of own accord or if it's that emergency, then a cesarean is the way we'll need to go.

Florence: 38:36

Then I guess, and it we did end up with a cesarean, the timing of which, yeah, for the days leading up to my cesarean they'd everything had remained pretty stable, but there was a fear about allowing me to go over the weekend, and then they're not being more senior staff, so friday delivery it was by cesarean yeah, I'm interested in that and whether you felt that choice was respected, because we can often think about restrictions in terms of being allowed in inverted commas to use birth centre or have midwifery led birth or home birth, but in the kind of modern era where we accept maternal request or maternal wishes as being a valid reason for a cesarean birth. I do remember the first time a higher weight woman came and asked me for a cesarean because that's what she wanted. And I mean, just to be clear, she she had the cesarean she wanted. Yes, it did give me pause for a moment, suddenly thinking well, some of the complications are potentially higher for this woman.

Florence: 40:04

Yeah, such as wound infection, maybe, or deep vein thrombosis. Yeah, such as wound infection, maybe, or deep vein thrombosis. And I did have to kind of sense, check in my head that this was still a valid choice for her, just otherwise I would be discriminating against her on account of her being higher weight. Yeah, you know, and I think that's something I had to consciously wrap my head around. I mean, it's quite a few years ago now, I'm pleased to tell you, but I can't imagine that I'm the only obstetrician that has perhaps suddenly thought oh, actually, that needs to be a valid choice, just in the same way as if a woman of higher weight asks me for a home birth. That has to be a valid choice. Just in the same way as if a woman of higher weight asked me for a home birth. That has to be a valid choice.

Catriona Forbes: 40:52

Yeah yeah, I mean, you know, I guess it is an interesting conundrum. I guess for me my choice wasn't cesarean, my choice was that I wanted a natural birth. My choice would have been a water birth. But that choice probably would not have been available to me even if I had gone down the perfectly straightforward, boring pregnancy route. So I think that the challenger sticking point came, that I was comfortable, I guess, in continuing with pregnancy as it was, but my medical team weren't comfortable, and so this sticking point then came around induction versus cesarean. And I know that there's a higher incidence of cesarean from induction. I just turned 37 weeks pregnant at the point at which I had my cesarean. I was very clear about it, but I would say that a number of different staff did keep seem to taking it in turns to just double check about my response to the induction question. So I did face a number of different people coming in to have the discussion around.

Catriona Forbes: 42:08

We need to talk about induction yeah my response being well, we don't, because I'm not going to have one yeah and and that kind of being a bit of a hard line, uh sticking point of I'm happy for my baby to stay where it is. So if you're not happy for my baby to stay where it is, then it seems like we're gonna have to talk about a cesarean yeah and so that was kind of the sticking point I guess for me, like I'm happy my baby is where it is.

Catriona Forbes: 42:32

I'd I've been having the extra doppler scans and blood flow was fine. You know, as I say, my um blood pressure in the days the I guess four or five days, which had been the longest period it had stabilized. In the two-week period that this had kicked off, um had in effect stabilized, but there was just that fear of if it became unstable, I guess. So for me I was like I'm happy for my baby to stay where my baby is and they weren't. So that was kind of the but yeah, I definitely had numerous conversations about induction, but that was very much my red line of no, we don't need to talk about that, I won't be having one.

Florence: 43:13

Yeah, I definitely recognize that. Just checking, repeatedly, just checking thing, yeah, I'm sorry to say that that does that absolutely is something that I think we do. Yeah, it's. It's difficult, isn't it, to get the right balance between making sure it's a really well informed decision and then constantly challenging someone's decision.

Catriona Forbes: 43:38

Yeah, so for me I had raised concerns around, you know, for induction I had concerns about epidural and the positions that my legs may have to be held in and what that could mean, because I wouldn't be able to feel pain or if my joints were being pushed too far or if I was in a position for an extended period that I couldn't recognize that my body was actually in pain because of my hypermobility as well. I guess I'm more aware of that and so those things were my concerns and I did raise those as the concerns of these are the reasons why I have these concerns. It's interesting because I'd had the birth preferences conversation with my midwife and she was really supportive of, like, the reasonings that I was giving and that I had reasons. And you know I'd thought about why I had these concern.

Catriona Forbes: 44:29

You know, I guess it was difficult because there'd been points where I had raised questions or concerns around, you know, being hypermobile up until that point anyway and they'd always been dismissed and even in trying to have the discussion at that point there wasn't much in the way of attempting to provide reassurance around that specific concern or issue. But I definitely had the conversation as well where I was made aware of the higher risk of infection with my wound and you know anesthesiologists discussions as well about the ease of that and things as well, and so all of the risks associated with cesarean were also obviously raised and discussed as well. But on balance I had kind of other concerns around induction and also just wasn't convinced that they don't end up in cesarean anyway. So all of the things to attempt to put me off a cesarean that would ultimately be forgotten about if a cesarean was determined and needed we're just a bit like.

Catriona Forbes: 45:26

Well, there's scenarios in which you'll completely ignore all of these concerns too, so I don't know why I'm going to put them at the forefront of my mind excellent.

Florence: 45:37

Yeah, I would like to know a bit. So, jenny, in terms of you, you've kind of talked about some protective things, some things, that good things that we could do as as health professionals. Um, so we've talked about quite a lot of negative things. Now, what are some good things that people could think about or that you've discovered?

Jenny Cunningham: 46:03

yeah.

Jenny Cunningham: 46:03

So I don't think you'll be surprised to hear. But what people really value are individualised care. There's this expression I read a couple of times women feeling invisible behind the very visibility of their bodies. So we just see this kind of person who's a higher weight, not actually their aspirations and who they are, so being seen as a person, a human being, connecting with them, individualizing their care.

Jenny Cunningham: 46:30

Um, the evidence also showed a few women spoke about kind of didn't necessarily call it continuity, but seeing the same midwife or even the same doctor, it was more commonly the midwife they found really helpful because they didn't have to start that conversation, as with any issue or whatever you know it was, it was there, it was understood and it would have been spoken about and a kind of protective factor that a couple of the studies talked about. About midwives, this is more around the birth, but they're kind of like a birthing bubble, kind of supporting them. For these examples they were, um vaginal births they weren't well, I think they're in a midwife led unit, but being really supportive and kind of supporting what their bodies could naturally do in those situations to birth their baby. And the women themselves felt really empowered at the end of that and really kind of proud of themselves but also really recognized that support those health care professionals had given. So I think, yeah, individualized care, not having we talked before about those kind of preconceptions and judgments people might bring about what we might expect someone of a high weight to have in terms of their pregnancy or their birth, but kind of leaving that to one side, I suppose, addressing your implicit beliefs, which we all hold, don't we? And leave them at the door, so to speak, and kind of talk to the person one to one and being open to as Catrina's friends heard, and they're open to it being really boring.

Jenny Cunningham: 47:51

And as a midwife I used to like saying this is gonna be, hopefully again, really boring, really mundane, not mundane, but you know nothing's going to happen because it's all just going to kind of go along smoothly, as we hope, and not kind of, yeah, not sowing seeds of doubt. But of course you know we have to talk about certain aspects of what pregnancy might bring. You know what someone might bring to their pregnancy. So it's not, it's not to shy away from conversations. Again being direct and honest and open and, florence, when you were asking earlier to catch her, and what should you say? Or what should one say to a woman who comes to a clinic because she is a higher weight?

Jenny Cunningham: 48:29

And I think being really honest about you know you being really honest and transparent with that individual, that woman, you know you've come here because because the evidence I've read women don't always know why they appear at consultants rooms or even there's studies around weight management services another expression I don't like but I don't even know why they've they've attended this clinic because it's all been hidden, because everyone's a bit embarrassed about it. So it's being open and honest and being more nuanced around the around the evidence. I think if we just say your risk is higher or you know your risk is double, that says nothing. So I think definitely being honest about we don't actually know this. There is some evidence that says it goes from a 0.5% risk to a 1% risk, but that's still you know it's not scaring people with statistics and being informed as a professional yourself, so you're not just repeating not very well explained risks which I think we're all guilty of at times. You know becoming the expert so you can give good guidance and good advice.

Florence: 49:37

That makes sense. Catriona, you were nodding away there. Do you want to add to that?

Catriona Forbes: 49:42

Yeah, there is something interesting, I think, in what Jenny said about being invisible whilst also being so visible based on your size, yeah, is that it's not a secret to a higher weight person that they are a higher weight. They know they have mirrors in their home, they buy the clothes that they wear, so they know their size. So it is a challenging thing, I think, to you know, I don't think there is that sense of let's just pretend that's not a thing. But I think being open about the reason that you're here, there's probably more than one tick that went into the boxes to justify it and to then just create space to say these are the things and these are why you're here. Everything else if that for that person, everything else is falls entirely within the normal spectrum, it's very much a so, unless anything special happens, we'll just have a nice chat every time you come in. So I think just that openness of why someone is there, I don't think anyone should shy away from it in the sense of these are the reasons and you know, yes, there may be some people that will get really combative.

Catriona Forbes: 50:54

You know who've done their research and might know that it's like well, what are these based on and what studies are these? You know who've done their research and might know that it's like, well, what are these based on and what studies are these about? You know, I'm sure there are patients that might try that Maybe I read some stuff. But you know, there's just that sense of you know some people will want to rail against the pathway or the reason that they've been referred as well. So I think if that's kind of the opener as well, you'll be able to kind of have that discussion up front too, because the person who is sceptical of it all can then share their scepticism, and you as a professional may also have some scepticism of your own. You don't necessarily just say, oh yeah, I know these are just guidelines and we're just having to follow them. We're all in the process.

Catriona Forbes: 51:39

You know, it's not that there's an expectation of that. It's just that sense of saying, yeah, I can understand that these are based on studies and particularly in your first pregnancy, you definitely couldn't have been part of them. So it's not about you, it's actually just about numbers. But you're a person and, okay, let's work with you through your pregnancy. Um, so yeah, I think that openness, probably at the beginning, would be a more, a more positive opener in my, in my opinion, but I don't know, maybe there would still be people that found it incredibly confronting to be told that that's the reason that they've got this referral.

Jenny Cunningham: 52:10

But I suppose that's something that can then at least be gauged or understood from that starting point, if that's how it opens and I think, also remembering people can decline, decline appointments, decline to be weighed, decline a glucose tolerance test, and not again, not shame them into making an informed choice about what they want to do their pregnancy. When you work for you know the nhs you're so kind of used to these conversations, aren't you? And what? We know what the expectation is. Sometimes we're a bit flawed if someone says no.

Jenny Cunningham: 52:41

And again, you know, catriona's, the kind of point you're making really nicely about how you kept having healthcare. You know doctors or midwives, whoever it was, coming through your door saying are you sure? Are you sure? And it's kind of you shouldn't have had that. I don't think they could have been documented in your notes. Catriona is sure? Or maybe whoever spoke to you first would say someone will ask you one more time and you can have that discussion. But we should allow people to decide and not infantilise them by thinking we know best. So allow people not to be weighed, not to have a test, that's fine, as long as they understand asja only said the the rationale behind it. As much as we know, from as much evidence as we know, we people can make their own choices and sometimes we forget that.

Florence: 53:25

I think yes, I agree with you. I think sometimes we tiptoe around a bit and I find it a big relief when a woman will say to me well, I'm here, you know, because of this, or I know my body's this, that and the other, or I know I might look like this, but actually I run, or you know, whatever they challenge my assumptions, and it makes it much easier to have a conversation than if we're all kind of ignoring or tiptoeing around it. So I think the advice you've given there, catriona is, is really helpful, even though it sounds so basic. We need it, I think. Jenny, in terms of research, are you still looking for people to contribute and, if so, how do they do that or how do they get in touch?

Jenny Cunningham: 54:21

Yeah, I'd love to kind of speak to a couple more women. I particularly would be interested to speak to someone of South Asian heritage, because I've not spoken to anyone from that background. So that would be great if anyone could get in touch. The university email address I'm also on twitter called x, and instagram as jenny midwife or phd jenny midwife, so you can find me there.

Jenny Cunningham: 54:46

I've, having done this kind of review as I spoke about before, I'm now interviewing people hopefully three times twice in pregnancy and once physically to find out about their experiences. And I've interviewed 10 people so far, which is great. Someone more than once and everyone has a very different experience, as you can imagine. But I think common throughout is it's anticipated fear is perhaps too strong word, but that expectation they're going to be kind of told off or have weight discussed or be embarrassed, so that's that's common throughout. All that kind of told off or have weight discussed or be embarrassed, so that's that's common throughout.

Jenny Cunningham: 55:18

All that kind of planning the next appointment or planning the first appointment comes up a lot. The scan I've already mentioned that. That comes up quite a bit. Checklists of risks that seems to be quite a common theme too. So maybe not a great discussion but kind of ticking off a list of things we.

Jenny Cunningham: 55:34

The risk we've talked about and actually interesting, certainly haven't but we've touched on is a lack of discussion about where to have the baby. It seems to me and I don't know if this just generally happens, you know, because time's so tight at the moment in the NHS with appointment times but I'm being told that women have themselves have to initiate where I might have my baby. Again, whether it's to do with someone's high weight and the midwife isn't sure, the doctor isn't sure, and I spoke to someone the other day. She was actually in active labour before she was told definitely she could birth in the midwife led unit. She kind of asked and asked and so she actually was in hospital in active labor and then got there. So there's something about putting off those discussions which kind of interests me. So we'll see if that continues.

Florence: 56:25

So yeah, I'd love to talk to two or three more people if they're interested that's fine, and I can put all those links and things in the in the show notes. So I think I've probably taken up enough of your time. So we're kind of coming to the end and I normally end with a zesty bit, a bit the kind of real essence key bit that we want people to remember from our conversation. And my audience is mixed, so we have midwives, student midwives, obstetricians listening, but also women and birthing people themselves. So it may be the same for both of them or it may be that there's a different one for each group.

Florence: 57:08

I think what I'm going to take away is higher weight as a phrase. That's really very simple, but something that immediately I think I can use in opening up the conversation in my clinic by saying one of the reasons you've been sent to see me is because you're of higher weight. Let's talk about that. What do you know about that? You know, but also, what do you want to talk to me about today? You know that's one of the things I need to talk to you about. But what do you want to talk to me about? Because I'm really taking on board what Catriona has said about. Actually that wasn't what she wanted to talk about. So so have either of you got, or you can have your own zesty bit or a joint zesty bit, depends what. What do you think you really want people to remember? Perhaps if we start with katriana?

Catriona Forbes: 58:02

I guess the takeaway or the wraparound for everything is that maybe let's not approach everything as if there's a problem before there's a problem. That's nice so yeah, let's go into things. Until there's a problem, there is no problem and, and maybe that's the the easiest approach to take things with and to to be able to have those safe and neutral discussions that allow people to listen and also to be heard, I guess.

Florence: 58:35

I think that's a really good point. Taking out of it being higher weight in itself is not a problem.

Catriona Forbes: 58:45

Yeah, until a problem happens, yeah, which may or may not be related, might be something completely different exactly, and I think it's that that point as well, about let's not treat something as a problem until it's actually a problem is also um, I guess that's also the advice I should have given to myself in going into those appointments, as well as these kind of anticipations and assumptions of how it was going to be. I was having that before it had happened. So it's it's not just about practitioners approaching it as a until there's a problem, let's not think there's a problem.

Jenny Cunningham: 59:21

I think that's how most women learned. You know, when they first had their midwife, they'd have had appointments, negative appointments, probably throughout their lives yeah, I think it's just that challenge.

Catriona Forbes: 59:32

Isn't it to yourself that it's like? If you expect a healthcare professional to treat you as an individual, perhaps we also need to treat them as individuals and not assume that they're coming in with the same baggage and opinions and load as another health practitioner has brought into the room when you've seen them, so it's. I know that obviously there's a system that everyone exists within, but right now I'm speaking to an obstetrician and a midwife that both don't necessarily subscribe to that system. So you know, it's also a lesson to think about from a user's perspective. If I want to be treated as an individual, maybe I'll just approach appointments as I don't know this person. I've not met this person yet. I don't know what their opinion or approach with me is. So until there's a problem, there is no problem.

Florence: 1:00:21

I like that.

Jenny Cunningham: 1:00:22

I like that too.

Florence: 1:00:23

Thank you that, I'll write that do you want to add anything to that, jenny, or is that the last word, do you think?

Jenny Cunningham: 1:00:33

I mean I was, I would have said in a different way, but I liked Catriona's way far better. It's, yeah, seeing the person be, you know, human to human connection, seeing the person for who they are and their hopes, and don't prejudge. Catriona says it much better than I do. She always does excellent.

Florence: 1:00:54

Well, thank you both very, very much. I think that's been a really interesting conversation which will hopefully give people lots to think about and hopefully have some better conversations and more holistic conversations with less assumptions.

Catriona Forbes: 1:01:13

So thank you both very, very much thank you, it's been really great to talk to you.

Florence: 1:01:20

I very much hope you found this episode of the OBS pod interesting. If you have, it'd be fantastic if you could subscribe, rate and review, on whatever platform you find, your podcasts, as well as recommending the OBS pod to anyone you think might find it interesting. There's also tons of episodes to explore in my back catalogue from clinical topics, my career and journey as an obstetrician and life in the NHS more generally. I'd like to assure women I care for that I take confidentiality very seriously and take great care not to use any patient identifiable information unless I have expressly asked the permission of the person involved on that rare occasion when it's been absolutely necessary.

Florence: 1:02:19

If you found this episode interesting and want to explore the subject a little more deeply, don't forget to take a look at the programme notes, where I've attached some links. If you want to get in touch to suggest topics for future episodes, you can find me at theobspod, on twitter and instagram, and you can email me theobspod at gmailcom. Finally, it's very important to me to keep the ObBS pod free and accessible to as many people as possible, but it does cost me a very small amount to keep it going and keep it live on the internet. So if you've enjoyed my episodes and, by chance, you do have a tiny bit to spare. You can now contribute to keep the podcast going and keep it free via my link to buy me a coffee. Don't feel under any obligation, but if you'd like to contribute, you now can. Thank you.