Three major themes
Perceived Control and Responsibility, Risk Perception and Confused Messages were identified. These themes and sub themes are summarised in Figure 1 and will be discussed in turn.
Perceived control and responsibility
The posters discussed a range of sources of perceived control and responsibility for being overweight or obese, and these were related to perceptions of blame and guilt.
Guilt and blame
Within this sub-theme posters wrote about feeling selfish and responsible for the increased risks of being overweight or obese during pregnancy and that this was potentially impacting on their child. For some this was associated with feelings of guilt.
I suppose I am just selfish for wanting a baby even though I am fat.... (F3A49)
Others described feeling judged by others, including the medical profession.
I feel ugly and judged more than enough as it is,……without feeling that medical professionals are looking down their nose at me and seeing me as some selfish fat person who chooses KFC over a baby. (F3A45)
No woman should be made to feel guilty about her weight when pregnant, she should be guided and supported. It’s a tough enough time without going through it with a side order of guilt. (F3A42)
When I’m sick everyday and so only eat toast, I don’t want to be lectured about my weight and made to feel even more guilty. (F3A21)
Other posters expressed a view that the problem was the responsibility of the overweight person and that they should acknowledge the additional risks. They also felt in some cases that health professionals should be more explicit about informing overweight and obese individuals about the risks.
People seem to regard being overweight as a legitimate lifestyle choice - “It’s my body, I don’t see why I should have to lose weight” - but if you are pregnant, it may have long-term consequences on your children. I wish people would just face up to it and one way of doing that is if someone presents at a GP’s surgery saying “I can’t get pregnant”, doctors should have the courage to tell them their weight could be a factor. I‘ve spoken to some on this issue and the consensus seems to be that they don’t like to as it’s a sensitive issue. (F3B10)
Some posters related this responsibility to the limited resources of the NHS and the fairness of using those resources when the problem is under their control.
The NHS needs to spend its resources wisely and so it’s fair to expect people to make lifestyle modifications to improve their chances of a straight forward pregnancy. (F3A26)
Concerns for the baby
Some women wrote of feeling bad that they could be harming their unborn child’s health and wellbeing, and so felt extra pressure to do everything perfectly during pregnancy.
I was diagnosed with Gestational Diabetes yesterday and cannot bare the guilt that I am feeling that my choosing to get pregnant even though I knew I was not in the “normal” BMI category may have health implications for my baby. (F3A49)
I truly wish I could be slim and toned and perfect BMI, but it won’t ever happen and I’m sick of the pressure. (F3C01)
Maintaining healthy behaviour during pregnancy (or before when trying to conceive)
Some women were aware of the risks and complications of maternal obesity, and made efforts to control their weight before and during pregnancy.
I am now exercising and eating smaller portions to get my weight down to what it was when I last conceived. I don’t particularly enjoy having to do it but it makes sense, makes me feel better, and pregnancy is such a strain on the body that surely it’s good to be as fit as you can before you start trying to conceive. It must be such hard work for 9 months to be obese and carry a baby on top of that. (F3A48)
I gained 1 stone. I was slim before pregnancy and perhaps a bit too controlling. I have relaxed my eating but am keeping up my 5 mile swim, it makes me feel better. (F2C19)
I plan every week our food and have done all pregnancy to minimise weight gain. It’s so easy to reach for the fatty food and blame the baby. (F3A69)
Social norms
Some women commented on societal expectations that all pregnant women should follow a healthy lifestyle by eating a balanced diet, abstaining from alcohol and cigarettes, exercising regularly and maintaining a healthy weight.
Women’s bodies are considered public property; something to be legislated about or publically shamed into different shapes. (F3A01)
Some reported that others felt able to make public judgements about dietary choices using the baby as a reason to justify this expression.
I have gone into work and had a comment made about everything I ate today (some celery, 2 apples and some ham salad sarnies on wholemeal, for the record - no cake, crisps or biscuits) - “you mustn’t eat for two you know, they said so on the telly”. (F3A66)
I had strangers touch my tummy without asking, all sorts of personal questions and even someone condemn me out loud in a supermarket for buying a prawn sandwich. (F3A74)
This may reflect a societal change in the acceptability of obesity in pregnancy. While smoking in pregnancy is considered unacceptable [19], views about overweight and obesity in pregnancy are less clear.
Factors out of their control
Some women spoke about other issues in their lives which impacted on their ability to eat well and exercise in pregnancy. These included tiredness, morning sickness, caring responsibilities and work pressures.
……it’s not like women who have struggled with their weight all their lives don’t realise that it’s a bad idea to be massively overweight when pregnant - but like everything else, it’s not necessarily within your control. (F3A01)
I was going to have such a healthy pregnancy, eat only good food and be worthy, but then the sickness started, so I eat what I can keep down. (F3A25)
Lost a little weight so far, despite not being able to do my normal running, because it makes me sick. (F3A25)
Some women suggested that their weight was not in their control due to medical conditions such as auto-immune diseases or thyroid problems.
Smoking is a choice - weight sometimes isn’t. One of the treatments for my medical condition for instance is steroids for the rest of my life. (F3B04)
In summary this theme included a range of views about the relative responsibilities of obese or overweight women, before and during pregnancy. Some were critical of health professional’s failure to raise these issues. Others felt that in some instances the situation was not under the control of the overweight or obese person and therefore they should not be blamed. Underlying these comments were issues around societies’ reaction to obesity and stigma.
Risk perception
The second theme related to women's perception and interpretation of the risks of overweight and obesity in pregnancy.
Assessing risk
Some posters acknowledged and understood that they were at some risk and related the additional risks of being obese in pregnancy to other possible risks.
The doctors just said ‘yes, you have an increase for complications of about 50%, but all that means is that if 1 in a 100 women have a complication then 2 in a 100 at your size will have the same complication’. Put everything in perspective for me. (F3A38)
Some were questioning the route of the problem of obesity in pregnancy, in terms of complexity of contributing factors and their impact on pregnancy outcomes.
Is it because being overweight/obese causes medical problems in pregnancy? Or is it also because overweight or obese women are more likely to be poor, undereducated or from marginalised groups which always have riskier pregnancies? Both. (F3A61)
Weight categorisation and care options
Some women felt their circumstances were not fully considered to make informed choices about their care options, due to their BMI category. They felt they were labelled in certain BMI categories which negatively impacted on their pregnancy experience.
My BMI was 34 when I got pregnant, so I am not allowed to go in the birthing centre (even though I exercise regularly, run 10 K races, eat healthy)… So far I have only put on a stone and will diet after birth to get my BMI under 30 just to avoid being put in this bracket in future as it is so irritating to have my choices removed. (F3A29)
They were specifically frustrated by the lack of flexibility to apply the guidelines to different settings, or to be able to holistically assess each woman individually.
I was annoyed at the ruling that midwife led units were out of bounds as NICE classes all MLUs together. I understand why I couldn’t go to one half an hour away from the obstetrician, but why wasn’t I allowed to go to one that’s one floor below labour ward?...... But if I had less confidence or a less strong birth partner, the obese protocol would make the birth harder and with possibly unnecessary interventions because health care professionals get caught up with protocol instead of looking at individuals. (F3A15)
Others questioned the categorisation of obesity by health professionals.
I am currently 17 stone. I am 5 foot 7. I am obese by their standards, my baby is healthy, I am healthy, and I won’t be dictated to! I listen to what my body needs. (F1A08)
Reinforcement of perception of low risk
Many women posted about other individuals with a high BMI or large gestational weight gain who had healthy babies. These examples served to reassure them that they should be fine too.
Don’t worry about it! I was 40 and obese when I fell pregnant. I was weighed at my booking appointment, and no comment was ever made about my weight during my pregnancy…….. Thankfully it didn’t cause me any issues during pregnancy. After the birth I hadn’t actually put on much at all and I lost what I had by breastfeeding and lots of walking. (F3A44)
I gained 4 stone in pregnancy… everyone’s different, not to worry, if you are hungry-eat. (F2C04)
Thanks to everyone who has posted about their weight not being a problem - it’s nice to have some reassurance! (F2B07)
Healthy and obese
Some women reported having a very positive self-image and felt that they were currently healthy and obese as having no existing medical conditions prior to pregnancy, so should stay healthy in pregnancy.
I’m morbidly obese but eat a healthy diet. (F3A09)
They reported that they do not consider their own obesity a negative health issue, when they still can live a normal life.
….for me obesity is a problem when you can no longer walk to the shop or tie your own shoe laces, NOT when you can still run with your dog and walk the length of the seafront daily, I am morbidly obese, yet I have No health issues. (F1A04)
Scaremongering
Some women indicated a lack of trust in NICE to provide unbiased evidence, and a belief that there must be a NHS cost saving agenda.
It’s not just a question of individual behaviour - we live in a divisive, unequal society. And neither NICE nor the government dare wrap their heads around that. Much easier to blame the women. (F3A61)
There were also examples of comments indicating distrust for the media who have highlighted the increased risks and caused panic and guilt around the topic.
I saw this on the news this morning and thought it was a scare tactic more than anything! I don’t know if what they are saying is strictly true, as there are plenty of normal weight women who miscarry and loads of obese women who have perfect babies!!! (F2B04)
In summary, women did not accept the risks of overweight and obesity in pregnancy on face value. They questioned the validity of motives of the source of the information, the categorisation of women with a high BMI as ‘unhealthy’ and the impact of on their choice of care options, and focused on anecdotal accounts of positive outcomes.
Confused messages
Women reported being confused by the kinds of messages they received and the way in which these messages were received.
Dieting versus healthy eating
Some women wrote about their interpretations of the healthy eating message being about calorie control.
You just eat the recommended varied healthy diet and stick roughly to the calorie recommendations - for many people this will be lower than what they were eating pre-pregnancy, myself included. (F3A51)
I was good foodwise until pregnancy and have tried hard but crave fast food. I have been a bit naughty, as was living on 1500cals a day, 2000 now is bliss. (F2B09)
Others wrote about the quality and types of food as being more important.
I don’t care about my weight really, just the quality of food I eat. (F2C18)
But that even this was not always considered appropriate in pregnancy.
I lost a stone since becoming pregnant just by cutting out junk, had no morning sickness just cut out junk. Some people are saying “that can’t be healthy in pregnancy” well I believe it is healthier than to be snacking on fizzy drink, chocolate and crisps all day. Sometimes you can’t win! (F2B01)
Inconsistent advice from health professionals
Comments indicated a lack of consistency in advice given by different health professionals. Some health professionals appear to be supporting their belief that being overweight is not harmful, by not mentioning it or normalising it.
I’m a large lady but even my midwife said most people are nowadays so as long as we try to eat as healthily as possible then we will be fine. (F2A04)
I can assure you that nothing has ever been mentioned to me about my weight in 9 months of antenatal appointments with midwives and consultants. (F3A12)
My midwife never weighs me, so I guess she’s not too worried either. (F2C11)
Or by not wanting to offend the mothers,
I raised the topic once and was advised that they no longer commented on weight unless there were actual and immediate health problems caused by it, as it only made women feel bad about themselves and during pregnancy was not the time to deal with it. (F3A44)
Some women mention they have had their raised BMI treated differently by a range of specialists.
My midwife at the booking in appointment wasn’t fazed at all by my BMI of 32, just said “try to eat healthily”. Then at my scan and bloods at the hospital it was totally different it was all “we have to monitor your weight carefully and if you go over 40 then you have to be under consultant care”. (F3A94)
I was informed of the risk of preeclampsia and diabetes by the consultant but he mentioned nothing about stillbirth and that’s the bit that panics me! I was told that I would have to be monitored more closely by the consultant, but when I saw him he said everything was fine and didn’t want to see me again until I was 34 weeks! So I guess I can’t be THAT much of a risk! (F2B26)
Lack of advice
Some posts suggested that there is a lack of information and advice regarding ideal gestational weight gain with some reporting using online gestational weight gain calculators to fill this gap.
I typed my weight and height into a pregnancy weight estimator tool online and it told me I should gain 3 stone. I have gained approximately that now and am due. I’m convinced that half will fall off with the baby, placenta, water, blood etc. and the rest I will lose breastfeeding. (F2C15)
They also mention wanting personalised advice, rather than being judged purely on their pre pregnancy BMI.
I know NICE’s guidelines are what they are and fair enough. But whatever happened to personalised healthcare. It seems pretty bad to me that professionals should see which boxes a patient fits into and then decide on the best treatment or advice on that basis…….. I am a person not a statistic and I deserve healthcare advice that’s right for me, not my demographic. (F3A55)
There was mixed advice as to what to eat in pregnancy with some mentioning booklets, others mentioning a commercial slimming group which has a healthy eating plan for pregnancy, and others just airing their personal views about a healthy diet. They wanted more advice on how to cope with morning sickness and suitable exercises during pregnancy, asking each other for suggestions and sharing what has worked for them.
There was little practical advice in there about how you balance cravings, sickness and exhaustion with a varied diet and then to say when you do gain weight don’t try to lose it too fast. (F2B11)
They wanted clarity in the guidance and from their healthcare teams as to why being obese increased their risks and what they could do to reduce them.
I want to know the comparative risks of dieting while pregnant vs being overweight and pregnant. (F3A51)
I think what this guidance fails to address is why overweight/obese woman are at higher risk. (F3A61)
…. simply saying “you and your baby are at risk because of your weight” really doesn’t help address the issue. I have no idea what the solution is, but just warning about the risks clearly isn’t the answer! (F3A75)
Communication of advice
Many reported that the health care professionals think obesity is just an energy imbalance, without considering other medical, psychological or social factors involved. They also questioned whether midwives had the time and resources to tackle obesity,
Then they can go on about effective weight management all they want. The reality is most of us know it, we find it hard to do and in the seven minutes or so a midwife has, she’s not going to break a lifetime of habits that have been too hard for the woman trying to be slim to break. (F3A68)
I think the “back up” advice is simplistic. The majority of women are well aware what constitutes a healthy diet. I find the tone of the document simplistic and patronising given the complexity of women’s issues with weight. (F3A68)
and repeatedly mentioned how they wanted to be treated without prejudice for being a ‘larger lady’.
They are there to advise but their main job is to support a lady no matter what shape/size she is and without prejudice. (F2C14)
They have said I need the blood pressure cuff “for larger ladies”. (F3A30)
Mainly I am saying that it is a good idea to raise awareness but as previous posters have said, maybe the way it is delivered is not great. (F3B03)
The tone of the guidance was repeatedly mentioned as being ‘anti fat’ and too patronising, comparing it to the abstaining from alcohol advice, or a ‘nanny state’.
We are no longer credited with having the brains or common sense to assess for ourselves the risks we are taking, and so they err on the side of not so much caution but absolute suppression……. If it has happened with booze, nuts, cheese, pate, liver and mayonnaise, why shouldn’t it happen with BMI? (F3A27)
I don’t know where they get their stats from but I am sure they are biased. Anti fat people. (F2B02)
In summary, there was confusion about what the guidance meant in terms of dietary and exercise behaviour, and a lack of consistency in how advice and messages are delivered by health care professionals. When weight, obesity and risks were not raised by health professionals or not done so in a consistent way, this served to reinforce a belief that the message was less important and therefore lowered perceptions of risk. Women wanted personalised, practical advice delivered sensitively.