Weight stigma in maternity care: women’s experiences and care providers’ attitudes

Weight stigma is the exhibition of prejudiced attitudes (e.g., attribution of negative labels such as lazy, unclean, and unintelligent) and discriminatory actions (e.g., teasing, providing inferior quality education, health or other services) towards an individual based upon their weight and body size alone (see [1] for a review). Weight stigma is the fourth most common form of discrimination in the United States, and studies from Australia, Europe and North America document its presence across a range of professional settings [2]. Weight stigma has serious negative consequences for targeted individuals’ psychological and physical health. These include poor psychological functioning [3], body dissatisfaction [4], increased episodes of binge-eating [5, 6] and exercise avoidance [7], even after controlling for the direct effect of actual body size. People who report experiencing weight stigma in healthcare settings are more likely to delay medical appointments and preventive healthcare procedures [8].

Despite its associated negative health outcomes, a large number of studies have documented weight stigma in healthcare settings. Healthcare providers respond differentially to patients on the basis of their body size [9]. Stigmatisation of overweight and obese people has been observed among doctors, nurses, psychologists, obesity specialists and pre-service health students [10]. One study found that physicians are likely to assume that overweight or obese patients are less healthy, less self-disciplined and take poorer care of themselves than lower-weight patients [11]. The same study showed that physicians report being more annoyed and experiencing less work enjoyment when treating obese patients.

The prevalence of weight stigma in the maternity care sector has been relatively unexamined. This is an important gap, given an increased focus on both the risks and management of maternal overweight and obesity during pregnancy in recent years. A burgeoning literature is concerned with risks associated with obesity in pregnancy [12, 13]. This increased scientific focus has been accompanied by the recent emergence of clinical guidelines on the management of obesity in pregnancy [14, 15] and increased attention to obesity in pregnancy in the media [16]. Greater preoccupation with obesity in the maternity care sector may have increased the salience of a woman’s body shape and size for maternity care providers and thus increased the likelihood of weight stigma occurring in the provision of maternity care [17].

The potential for weight stigma in maternity care is of particular concern, given that women are at increased risk for depression and other mental health issues during pregnancy and the puerperium [18]. Given the demonstrated negative impact of weight stigma experiences on mental health, it is possible that such experiences in maternity care may increase the risk of psychological difficulties during a period of already increased vulnerability. However, relatively few studies have examined the presence of weight stigma in maternity care settings.

Three recent qualitative studies found stigmatising attitudes among maternity care providers, including high levels of discomfort, intolerance, and feelings of repulsion in caring for obese pregnant women [19, 20], as well as the assumption that obese women lacked necessary skills, awareness, or motivation to manage their weight [21]. Together, these findings suggest that care providers’ attitudes were stigmatising and ultimately unhelpful. The exact prevalence of weight stigma in the maternity care sector, however, remains unknown. In particular, it is unclear whether discriminatory attitudes and behaviours are widespread in the maternity care sector or, instead, whether incidents of discrimination are perpetrated by a small group of care providers with a specific anti-fat bias. Accordingly, there is little evidence for determining if calls for anti-weight stigma initiatives in other health professions e.g., [22] should be extended to maternity care settings.

Qualitative studies also suggest that overweight and obese maternity care consumers perceive discrimination on the basis of their weight. These studies found that obese women reported instances of negative interactions with maternity care providers, including perceptions that care providers were rude, angry and abrupt, did not take them seriously, and did not adequately respond to their needs [23, 24]. Women report feeling embarrassed, isolated, receiving insufficient and/or inconsistent information about appropriate engagement in health behaviours in pregnancy, and desiring greater support from health professionals throughout the perinatal period [21, 25]. The women in these studies attributed their perceived negative treatment from care providers to their ‘larger–than-normal’ body size and weight, providing preliminary support for the existence of weight stigma in the maternity care sector. Overall, however, these studies failed to include a normal-weight comparison group of pregnant women, precluding definitive conclusions that perceptions of poor quality care are actually higher among individuals who are overweight and obese, than among normal-weight individuals. Further, these studies were conducted in the UK [21, 23, 25] and Sweden [24]; it is important, then, to investigate whether experiences of weight stigma in maternity care are also evident among women in the Australian context, where obesity is increasingly on the agenda in maternity healthcare settings [12, 15].

Notably, two recent studies have sought to incorporate a normal-weight comparison group to investigate weight stigma in maternity care, though these have been limited to investigating perspectives of pregnant women, without looking at maternity care providers’ attitudes. A recent Australian large-scale survey explicitly investigating women’s experiences of discrimination in maternity care found an association between obesity in pregnancy and perceived discrimination [26]. A recent Swedish survey found that women with a BMI above 30 reported a less positive experience of pregnancy, and experienced less continuity of care, than women with a lower BMI [27]. However, women were quite satisfied with the care they received, with no differences observed on the basis of BMI. Hildingsson and Thomas [27] hypothesised that this may be due to midwives’ reluctance to raise weight issues throughout pregnancy care, leading to a generally positive experience among higher-BMI women who desire the focus in their maternity care to be placed on their pregnancies and births, and not their weight. The authors highlighted a need to investigate any differences in health professionals’ provision of maternity care to women of differing body size.

Overall, our understanding of the nature and extent of weight stigma in the maternity care sector is limited by the relatively small number of studies investigating weight stigma from women’s and care providers’ perspectives, the qualitative focus of the majority of studies, and design limitations of some of this research. This paper comprises the first quantitative investigation of weight stigma in maternity care, from the perspectives of both women and care providers. It describes two complementary studies to examine the existence of weight stigma in maternity care in Australia from the perspective of normal-, overweight and obese pregnant women, and pre-service medical and midwifery maternity care providers.

Study One examined the relationship between a woman’s self-reported pre-pregnancy body mass index (BMI) and perceived quality of her treatment by care providers during and after pregnancy, using a large sample of women who had recently given birth in Queensland, Australia. In this study, quality of treatment focused largely on the quality of interpersonal treatment from care providers (including a sense of being listened to and understood; being treated with respect), which is increasingly regarded as an important aspect of women’s experience of maternity care [28]. Importantly, this study used two measures of perceived quality of treatment from care providers: perceived positive treatment (assessing women’s general experiences of feeling respected and cared for) and perceived negative treatment (assessing women’s experiences of instances where they were not treated with respect, care or understanding). In light of evidence that higher BMI is associated with more negative treatment in general healthcare settings [11, 29], it was expected that women with a higher pre-pregnancy BMI would perceive less positive and more negative treatment from maternity care providers.

Study Two examined the effect of a hypothetical pregnant woman’s pre-pregnancy BMI on the attitudes of pre-service medical and midwifery maternity care providers^a towards the woman, and perceptions of her self-management behaviours and health. A student sample was used to gain an understanding of attitudes among maternity care professionals of the future, and to identify any need for intervention during formative stages of training. Pre-pregnancy BMI was experimentally manipulated in case management test cases to assess its effect on pre-service care providers’ perceptions of, and attitudes towards, caring for the patient. We hypothesised that pre-service care providers would report more negative perceptions and attitudes towards women with an overweight and obese BMI, compared to women with a normal-weight BMI.

We were also interested in whether any effect of pre-pregnancy BMI on care providers’ perceptions and attitudes was moderated by care providers’ more general weight stigmatising attitudes (i.e., ‘anti-fat’ attitudes not specific to maternity care settings), to establish whether incidences of weight stigma in maternity care settings were only evident among care providers with high general weight stigmatising attitudes. We hypothesised that an association between negative attitudes/perceptions and higher patient BMI would be strongest among pre-service care providers with higher levels of general weight stigma, compared to those with lower levels. Finally, we also explored whether any effects of pre-pregnancy BMI on care providers’ perceptions and attitudes were moderated by the BMI of the care providers themselves.

This paper describes the first quantitative investigation of weight stigma in maternity care from both mothers’ and maternity care providers’ perspectives, and extends recent qualitative research in the field [19–21, 23, 24]. As hypothesised, findings from Study One revealed associations between a higher pre-pregnancy BMI and poorer perceived quality of treatment during pregnancy and after birth by patients. Further, in Study Two we found that pre-service care providers hold less positive perceptions of patient self-care of, and attitudes towards caring for, overweight and obese compared to normal-weight, pregnant women. These effects were evident in pre-service care providers with both low and high levels of weight stigmatising attitudes. Together, this preliminary evidence suggests that, like in other healthcare settings, weight stigma is present in maternity care.

Previous qualitative research suggests that overweight and obese women report experiencing sub-optimal treatment in maternity care settings, and attribute this to their larger body size and weight [23, 24]. Higher-weight individuals have also been shown to perceive more discrimination in healthcare settings than normal-weight adults in the general population [29]. Consistent with this research, in Study One we found that a higher BMI was significantly associated with a tendency to perceive more negative treatment during pregnancy, and to perceive less positive treatment after birth. Such findings suggest that women of larger body size may be differentially disadvantaged with respect to perceived quality of treatment at certain stages of maternity care, in comparison to normal-weight women.

Pre-pregnancy BMI was not related to perceived quality of treatment measures at all stages of maternity care, however, suggesting that the nature of the relationship between BMI and perceived treatment changes throughout the maternity care experience. During pregnancy, BMI was related to perceived negative treatment, but was not related to perceived positive treatment, suggesting that women with larger bodies may be more likely to experience discrete incidences of negative treatment from one (or possibly more) care providers during pregnancy, but are no less likely to perceive positive treatment from care providers collectively. Maternity care providers may perceive pregnant women with larger body sizes to be at greater risk for complications, and to require extra equipment and intervention [32]. Such perceptions may lead to frustration by care providers and give rise to incidences of negative treatment towards the pregnant woman. Possible incidences of negative treatment are of concern in light of the potential harmful consequences of weight stigma for larger women’s psychosocial wellbeing and health [3, 8, 33].

Further, women’s pre-pregnancy BMI was not related to perceived quality of treatment during labour and birth. It is possible that for women, during labour, safety and technical proficiency are more salient than is interpersonal treatment from healthcare professionals. Alternatively, weight differences from early pregnancy may be less pronounced in later pregnancy, or at the time of labour and birth, resulting in less difference in quality of treatment according to body size.

Pre-pregnancy BMI was significantly related to perceived positive treatment after birth, but not perceived negative treatment. This suggests that women with a higher BMI perceived less positive treatment overall after birth, compared to lower-BMI women, but were not more likely to experience instances of negative treatment during this time. Perceived risks of obesity in pregnancy [34], and any extra pregnancy management requirements for larger women [32], by their very definition, no longer apply after birth. This may explain the fact that body size did not predict reported negative treatment after birth. Lower perceived positive treatment may reflect a lower general positivity towards women of larger body size among postnatal care providers, possibly on the basis of perceptions that such women are unhealthy [11] or unattractive [35].

Overall, the findings from Study One demonstrated that as BMI increases, women report more negative treatment throughout pregnancy and less positive treatment after giving birth. This contrasts with Hildingsson and Thomas’ [27] finding of no difference in satisfaction with maternity care between women with a BMI below 30 and those with a BMI above 30. However, as noted by the authors, this finding may have related to midwives’ reluctance to discuss weight or diet, in the context of having little training or guidance in Sweden about how to discuss such issues with obese pregnant women. In the Australian context, however, recently-developed clinical guidelines recommend that maternity care professionals discuss weight gain, diet and exercise in pregnancy e.g., [15]. Indeed, the current findings are consistent with a recent large-scale Australian survey that found associations between obesity and perceived discrimination in maternity care [26]. It is important to note, however, that research findings of Study One comprise only women’s perceptions of care, and may not be a true reflection of the care provided. Women with a higher BMI are more prone to lower self-esteem and greater depressive symptoms [36], and it is possible that pre-existing differences between groups in mental health may bias women’s perceptions of care and treatment. In light of this possibility, Study Two manipulated the BMI of a hypothetical pregnant patient, and assessed pre-service maternity care providers’ responses.

Study Two found that pre-service maternity care providers responded to hypothetical pregnant women differentially based on their BMI, suggesting that associations between BMI and quality of treatment in Study One are unlikely to be explained (solely) by inaccurate perceptions on the part of women. Firstly, pre-service maternity care providers perceived that pregnant patients with a higher BMI had poorer self-management and overall health. Such findings concur with those of Hebl and Xu [11], who found that general physicians perceived poorer self-management and health among patients with a higher BMI. Importantly, there is no evidence to suggest that overweight and obese patients have poorer self-management behaviours and abilities [37, 38]. Accordingly, pre-service maternity care providers’ inaccurate perceptions of differences in self-care between pregnant women of differing body size may negatively impact on their care of pregnant women with a higher BMI.

Pre-service maternity care providers also had less positive attitudes towards caring for overweight and obese pregnant women than normal-weight patients. This result was consistent with evidence from outside the maternity care setting which has shown that healthcare providers have less positive attitudes towards caring for higher-weight than normal-weight patients [11, 35]. Pregnant women with large body sizes may be differentially disadvantaged with respect to care providers’ attitudes towards caring for them, negatively affecting the development of warm, sensitive relationships between care providers and higher-BMI pregnant women relative to normal-weight women [11].

In sum, pre-service maternity care providers who read about a normal-weight pregnant woman had more positive perceptions of her self-management and health, and more positive attitudes towards providing care for this patient, than those who read about overweight and obese pregnant women. Interestingly, these relationships were not moderated by general levels of weight stigmatising attitudes. Even care providers with only minor general weight stigmatising attitudes responded less positively to overweight and obese pregnant women compared to normal-weight women. The more participants indicated that they held weight stigmatising attitudes, however, the worse their perceptions of patient self-management and care, and the more negative their attitudes were towards providing care for patients. This unexpected finding suggests that weight stigmatising attitudes may reflect a general negativity bias, and play a role in disrupting patient care, irrespective of patient weight.

Together, our results provide evidence that weight stigma is prevalent in Australian maternity care settings. The observed effects, however, were small. This raises questions about the probable magnitude of disparity between care of normal-weight, overweight and obese pregnant women in clinical practice, and further research is needed to clarify such effects. Nevertheless, it is feasible that our results are only conservative estimates of effects, due to the possible impact of several methodological characteristics. For example, survey data used in Study One was not originally collected for the purpose of investigating weight stigma in maternity care. Items regarding perceived quality of treatment were not developed specifically to tap into differential treatment experienced by pregnant women on the basis of their BMI. Therefore, it is plausible that measures designed specifically to examine weight stigmatising experiences in maternity care may be more sensitive and thus provide stronger evidence for the presence of weight stigma in this context. Additionally, the effects found in Study Two are likely to be conservative estimates of the extent of weight stigma in maternity care. Social desirability bias may have led to under-reporting of both general weight stigma attitudes and negative attitudes towards the patient. Furthermore, we relied on a student sample, and studies have found that healthcare professionals and students with fewer years of working experience display a lower degree of weight-based prejudice than those with more working experience [39, 40]. Prolonged exposure to a workplace culture which condones weight stigmatising attitudes, as has been described in qualitative research [41], may inflate weight-based prejudice among health care providers. Future research, both qualitative and quantitative, should determine whether the findings of the current study generalise to clinical settings. It should also assess the impact of differences in care provision on the quality of relationships between maternity care providers and women in practice, as well as on women’s health and other outcomes.

Although the present studies have a number of strengths, including the triangulation of quantitative date from both patients and providers and the inclusion of normal-weight comparison participants, they also contain some methodological limitations. In Study One, sampling via birth notifications with minimal exclusions allowed us to reduce biases associated with sample selection, but the low response rate for this study highlights the importance of careful consideration of potential response bias. Further, the measure of pre-pregnancy BMI in Study One may be prone to recall bias (being asked to report such information from almost a year prior) and social desirability bias. In their systematic review, Gorber, Tremblay, Moher and Gorber [42] found that participants within all weight categories tend to overestimate height and underestimate weight and BMI in self-report, and there is some evidence to suggest that those who are obese under-estimate weight and over-estimate height by greater amounts [43]. In the present study, our analysis of BMI as a continuous variable mitigated against problems of misclassification, though reporting bias may have restricted the range of BMI values. As such, associations between pre-pregnancy BMI and outcome variables are still likely to be valid, though a restricted range of BMI values may have reduced the strength of associations. Stronger relationships between BMI and quality of care may be observed if BMI values are objectively measured rather than self-reported.

The present study was not sufficiently powered to conduct analyses stratified by professional group (midwifery or medical students), and it is possible that the professional group to which one belongs might change or qualify the associations observed. Thus, further research also may seek to investigate differences between professional groups. Additionally, both Study One and Study Two utilised measures which have not been widely used or validated in other research. However, the measure of perceived quality of treatment in Study One was adapted from those used by the UK National Perinatal Epidemiology Unit in their ongoing surveys of maternity care (see [44]). The “perceptions” and “attitudes” variables in Study Two were developed using items from Hebl and Xu [11], who used a similar research design to compare general physicians’ attitudes towards a hypothetical normal-weight versus obese patient. Given the current dearth of research into weight stigma in maternity care, there are no standard questionnaires assessing the constructs we investigated. Thus, future research should seek to identify accurate and useful measures to assess weight stigmatising attitudes and behaviours in maternity care settings.

Overall, the prospect that patient body size alone could influence quality of treatment and care relationships in maternity care, as suggested by the results in Study One, and particularly, Study Two, is of concern. There is a demonstrated detrimental impact of negative weight-related health treatment, and weight stigma more broadly, on psychosocial wellbeing [3, 4, 33] and health behaviours [5, 7]. Such findings should be taken seriously, given the increased vulnerabilities to anxiety, depression and a range of other pressures for women during pregnancy and the postpartum period [18, 45]. Notably, findings of Study Two also indicate that a degree of weight-based prejudice manifests among medical and midwifery students. Pending further investigation to confirm such effects, this implies that there is a need to address weight stigmatising behaviours, attitudes, and beliefs in these formative years of study. Further, findings also indicate that a patient’s body size has an independent effect on students’ attitudes, regardless of general weight stigmatising attitudes. Even students with low levels of general weight stigma attitudes may automatically respond more negatively to overweight and obese patients, highlighting the need for further work to determine the underlying mechanisms for differential treatment of patients on the basis of body size. Finally, future research should expand its focus to investigate the occurrence of any differential or stigmatising treatment of under-weight women in maternity care as well. There is a growing focus on risks and management of underweight women in pregnancy e.g., [46, 47], yet a lack of information about experienced stigma among this group.

Greater frustration with the management of obese pregnant patients [32], lower perceived confidence and knowledge regarding obesity [48], and perceptions of higher risks [34] may all contribute to weight stigma among maternity care providers. Such factors may also be exacerbated by a working environment with a lack of appropriate resources and adequate support for maternity care professionals, negatively impacting on their ability to properly support and care for pregnant patients with a higher BMI. Furness et al. [21] found that midwives often felt uncomfortable raising weight-related issues with women, but that women attending a clinic with specialist midwives (with additional training and experience working with pregnant women with a higher BMI) benefited from clear, non-judgmental advice and support about issues related to their weight and pregnancy. Greater support and training from specialist midwives, and/or clear referral pathways to specialist midwives, may assist less experienced midwives in providing better care for women with a higher BMI. Accordingly, further research investigating the systemic barriers to providing individualized, non-judgmental high quality care for obese women, and the effectiveness of strategies to overcome them, including from providers’ perspectives, is required.

These studies used population data and an experimental design to provide preliminary evidence for weight stigma in Australian maternity care from the perspective of care recipients and providers, respectively. Our findings provide sufficient basis for further research to uncover contributing factors to weight stigmatising attitudes and behaviours among maternity care providers. As the factors contributing to weight stigma become clearer, effective ways to target such factors to reduce weight stigmatising behaviour should be investigated and implemented, both in clinical settings and in medical and midwifery university training programs (see [22] for an example of an anti-weight bias intervention developed for health professionals in training). It is of great importance that any experienced disadvantage or inequality among overweight and obese women in maternity care is removed. All women, regardless of body size, deserve equal access to safe and supportive maternity care, and equal opportunities to experience full enjoyment of such a significant life event.

^aPre-service maternity care providers refers to students in their final year of a three-year Midwifery degree, or students in their final two years of either a four-year graduate medical degree or a six-year undergraduate medical degree. In Australia, some universities offer a four-year graduate medical degree which students may apply to after the completion of an undergraduate program, whereas others offer an undergraduate medical degree which students may apply to upon completing school. Both medical and midwifery students obtain experience in hospitals and other clinical settings from the first year of their program, with medical students completing more intensive clinical rotations in hospitals in their final two years. General medical practitioners, obstetricians and midwives are the main providers of maternity care in Australia, hence the focus on pre-service care providers in these two disciplines in this study.

^bA General Practice rotation within a Medical Degree usually involves training and experience in pregnancy/antenatal care, and typically lasts 8 to 10 weeks.