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After I started the "Viktig Project" (which I wrote about earlier) at SÖS, focusing on including pregnant women with a BMI>= 35 at registration at the Maternity Care Center in the Stockholm region, many of my thoughts have revolved around how society and healthcare actually handle overweight women, especially when they become pregnant. 35% of Sweden's population is overweight, and the numbers are rising. 25% of the women who register at the Maternity Care Center in Stockholm are overweight, and an additional 16% are obese (BMI>30). That's a significant number!
As the responsible doctor/midwife, we know that the group of overweight pregnant women is a high-risk group. Being pregnant with overweight is associated with more pregnancy and childbirth complications than in women with a normal weight, as repeated research studies have shown.
But how do we really treat these women?
Could we learn more and act differently?
Should everyone be treated the same way?
Attitudes and thoughts among Swedish midwives about being being pregnant and overweight
Many women testify to the sadness and shame they feel when they register at the Maternity Care Center if they are overweight. How the midwife, with an uncomfortable expression, says:
"You weigh too much. You should lose weight now that you're pregnant. Think about what you eat. Here's the number for a dietitian."
Often, the information and conversation end there. A Swedish study conducted among Swedish midwives in 2020 (1) shows that one-third of the participating midwives considered obesity to be a more sensitive issue to discuss with pregnant women than, for example, smoking or alcohol habits. It's quite fascinating when we know that approximately 1 in 10 women who register at the Maternity Care Center in Stockholm are obese according to the definition (BMI>30).
20% of midwives agreed that they sometimes avoid discussing a woman's weight to avoid making her feel ashamed, sad, or worried. Having received training in "motivational interviewing" seemed to be positively associated with the midwife's inclination to discuss the patient's body weight.
However, only 46% of the surveyed midwives believed that they had sufficient knowledge to provide dietary and exercise advice to pregnant women with obesity. This means that more than half of Swedish midwives lack this knowledge!
What conclusion can be drawn from the study?
Well, Swedish midwives show empathy towards pregnant women with obesity, which is good. But the fact that almost one-fifth of the midwives avoid the topic of body weight out of fear of upsetting or embarrassing the pregnant women feels somewhat alarming.
Education on obesity, training in person-centered communication, motivational interviews, and access to dietitians were strong desires to facilitate the management of weight during pregnancy among our midwives at the Maternity Care Centers. But what about the opinions of the overweight women themselves?
A Norwegian study
A qualitative study with in-depth interviews of overweight women who had recently given birth was conducted in Norway in 2020 (2). The women shared their experiences of being pregnant and overweight. Many of the women described how they underwent a number of more or less unnecessary examinations during their pregnancy. The reasons for these tests were rarely explained in a comprehensible way.
The women described feeling "watched over," which in turn increased their anxiety and often added to their sense of shame. They felt like objects of prejudice, and discrimination, and as if everyone was waiting for them to fail because of their established overweight.
As a common thread
Many of the women expressed a strong desire to be recognized as individuals but often felt more like objects. The almost unanimous wish was to be regarded and treated as a normal pregnant woman, not "one among the group of fat women." They described a lack of individualized care, lack of information, and lack of autonomy - something almost all of them perceived as unfair.
It was concluded that it was crucial to feel included in decision-making during pregnancy and childbirth, to be heard and seen, and to take responsibility for one's pregnancy and life.
The goal is personalized maternity care
In order to provide personalized maternity care for everyone, including overweight women, their voices and wishes must be listened to and taken into account. That is my firm conviction.
We must acquire knowledge. More knowledge! Regardless of the woman's BMI. The actions taken should be evidence-based and up-to-date. Guidelines must be in place, but consideration must also be given to considerations of autonomy and personal preferences. This is equally important for overweight women, perhaps even more so.
Being treated as if one is normal
Several participants in the Norwegian study emphasized how important it was to feel normal - not to stand out or feel different. As one woman in the study stated:
"When it is constantly pointed out that you are overweight, regardless of why you seek care, then you feel like someone who is outside of the norm, and doesn't everyone want to be normal? Yes, maybe even more so when you actually know that you are fat. It's so tiring. I'm well aware that I am fat; it's actually not news to me."
Those responsible at Swedish Maternity Care Centers should encourage their staff to engage in ethical reflection and discuss among themselves the personal reactions and perhaps preconceived notions that exist at their specific clinics regarding overweight women.
Each individual woman, regardless of whether she is at risk or not, should be approached as a "unique pregnant woman among all the other unique pregnant women." That is my firm conviction.
Best regards,
Doctor Eva
Are you interested in the "Important Clinic" at SÖS? Contact us: viktigmottagning@gmail.com
or through our Instagram account: viktigmottagning
References if you want to read the studies I mentioned:
Christenson, A., et al. (2020). "Attitudes and beliefs in Swedish midwives and obstetricians towards obesity and gestational weight management." BMC Pregnancy Childbirth 20(1): 755.
Thorbjörnsdottir, K. E., et al. (2020). ""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 15(1): 1845286.