Respectful care for pregnant people living with obesity
=======================================================

* Naomi Cahill

[See related article at www.cmaj.ca/lookup/doi/10.1503/cmaj.221450](http://www.cmaj.ca/lookup/volpage/196/E250)

Pregnant people living with obesity are at elevated risk of severe maternal and fetal complications.1 Reducing the incidence of adverse outcomes necessitates the accurate and respectful communication of these risks to people living with obesity. In related research, Ramji and colleagues add to this evidence with their analysis of more than 650 000 births in Ontario, observing that prepregnancy body mass index (BMI) greater than 30.0 was associated with an increased incidence of stillbirth.2 The association persisted after adjusting for comorbidities, suggesting that obesity is an independent risk factor for this tragic outcome. Higher prepregnancy BMI is also associated with increased risk of gestational hypertensive disorders, gestational diabetes, miscarriage, preterm birth, macrosomia, and cesarean deliveries, and the risk is greater if gestational weight gain is excessive.1 These findings underscore the importance of adhering to current clinical practice guidelines, which recommend monitoring gestational weight gain and increased surveillance of pregnant people at higher weights.3 However, focusing discussions on the weight of patients may be counterproductive, and a nuanced approach to providing prenatal risk counselling is needed.

Focusing on weight during communications of risk may reinforce weight bias, weight stigma, and discrimination for pregnant people. Negative weight-related attitudes, beliefs, assumptions, and judgments prevalent in society, and harmful social stereotypes that are held about people living with obesity, are associated with adverse physical and mental health consequences. 4 Weight stigma experienced by pregnant people with obesity manifests as inappropriate or judgmental comments (e.g., related to their fitness to parent a child) and unfounded assumptions or misconceptions surrounding lifestyle behaviours, including assumption of laziness.5

The few, predominantly qualitative, studies that have evaluated weight stigma during pregnancy suggest that health care providers feel they have insufficient training and lack the skills to confidently counsel pregnant people about weight-related risks and gestational weight gain.6 Concerns over the sensitivity of the topic and fear of offending patients are potential reasons for this discomfort.6 In contrast, some pregnant people feel that providers place undue emphasis on their weight and high-risk status, and convey an expectation that weight-related pregnancy complications will be inevitable.5 Weight stigma experienced by pregnant people can result in feelings of anxiety, guilt, and shame, which may lead to avoidance or delay in seeking care, and reduced trust in and engagement with providers.7 Pregnancy-related weight stigma can also catalyze poor health behaviours, such as disordered eating and physical inactivity, resulting in gestational weight gain and postpartum weight retention.7 Emerging research on the complex biopsychosocial pathways underlying how the experience of stigma might modify the association between BMI and pregnancy outcomes8 underscores the need to optimize prenatal care so as to avoid compounding the problem.

A collaborative effort is required by providers to foster a sensitive, culturally appropriate, person-centred approach when caring for pregnant people living with obesity. The provision of weight-inclusive or weight-neutral care, which aims to avoid weight stigma by shifting the focus from weight control to optimizing sustainable, healthy behaviours in all pregnant people regardless of a person’s prepregnancy BMI, should be prioritized. 9 This approach is rooted in social justice and aims to increase equity and access to people of all identities across the weight spectrum.

Weight-inclusive health care starts with ensuring that perinatal settings are equipped to meet the needs of pregnant people living with obesity, such as the ready availability of suitable equipment (e.g., waiting room chairs, beds, and wheelchairs), appropriately sized medical items (e.g., blood-pressure cuffs, compression stockings, and gowns), and positioning scales to weigh patients in private. Health care providers should ask permission before discussing and evaluating weight, and should centre conversations around metabolic indicators, reported symptoms, and the patients’ overall health and well-being, rather than BMI. While individuals may have preferred ways of referring to their body, neutral terminology such as “higher weight” or “larger body” are considered more suitable than other terms such as “excess weight” and “morbid obesity.” Providers are encouraged to examine their implicit weight-related biases through completing tools such as the Weight Implicit Association Test9 and engaging colleagues in conversations on ways to avoid perpetuating weight bias.

Promising strategies that can be adopted as part of weight-inclusive pregnancy care include sensitivity training to foster open communication around healthy pregnancy weight gain10 and adoption of The Canadian Obesity Networks 5As of Healthy Pregnancy Weight Gain toolkit.11 Advice regarding healthy eating and physical activity remain important, and educating pregnant people about intuitive eating and mindfulness are approaches that align with weight-inclusive care.12,13 Intuitive eating involves eating according to hunger and satiety cues rather than external or emotional reasons. Mindfulness-based interventions that support pregnant people to be purposefully and nonjudgmentally more in the present moment may enhance diet quality, increase movement, and reduce anxiety.13

More evidence is needed, but pregnant people living with obesity should receive respectful prenatal care, free from stigma, that realizes the goals of both health care providers and patients to ensure positive maternal and fetal outcomes.

## Footnotes

*   Competing interests: None declared.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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