Participants
Recruitment targeted women 18 years and older who were at least 13 weeks pregnant or less than one year postpartum. Exclusion criteria were living outside the United States and having a multiple gestation pregnancy. The final sample consisted of 501 women (28.5%, n = 143 pregnant; 71.5%, n = 358 postpartum). These women resided in 48 states around the United States, with California being the most represented state (16.8% residence).
Some background information on the United States pre- and postnatal guidelines may be useful in contextualizing this sample: The American Congress of Obstetrics and Gynecology and the American Academy of Pediatrics recommend the following prenatal healthcare visit schedule: every four weeks until 28 weeks of gestation; every 2 weeks from 28 weeks until 36 weeks gestations; and weekly from there until delivery. Healthy births without complications should be followed by a visit six weeks after delivery [23]. Data from every registered birth across all 50 states in the United States in 2016 revealed that more than 75% of women received adequate prenatal care, defined by completing more than 80% of recommended visits [24]. This report also documented that more than two thirds of women (77.1%) initiate care in the first trimester (i.e., less than 13 weeks gestation), and most women pay for their prenatal care via Medicaid, private insurance, or self-pay. Based on United States national guidelines and the above data, these women were currently or had very recently received prenatal and/or postpartum healthcare.
Procedure
The university’s Institutional Review Board approved all procedures. Data were collected between August and November of 2017. Recruitment activities included posting flyers in healthcare offices, cafés, childcare facilities, and baby retail locations in the wider Los Angeles, California area. These flyers included pull-off tabs with a link to Qualtrics. Qualtrics is an online platform with secure software using secure data centers that adhere to the Health Information Technology for Economic and Clinical Health Act, HIPAA, 21 CFR 11 (and other regulation provisions relevant here), and EU data privacy directives. Further information on data security is available at https://www.qualtrics.com/security-statement/. Participants were also recruited through online forums for expectant and new mothers, such as on Facebook, Yahoo!, and Instagram. An electronic version of the flyer was posted on these forums along with the Qualtrics link for participation. Participants were able to read the informed consent electronically and check a box indicating their agreement to participate. Those who agreed then completed the web-based survey, consisting of questionnaires and open-response questions. Participants could skip any question they were uncomfortable answering and still remain in the study. All data were collected anonymously, but participants had the option of providing an email address for a raffle of five $100 prizes. Email addresses were examined to ensure no one had participated twice. Data were stripped of this information prior to analyses. Responses were stored in Qualtrics until data collection was completed, at which point data were removed from the online platform and stored on a secure server.
Measures
Measures were adapted from the weight stigma and pregnancy/postpartum literatures. New measures were also designed for this study based on semi-structured pilot interviews that were conducted with six pregnant and postpartum women.
Weight stigma in healthcare
Participants were asked if they had ever been treated differently or made to feel bad or uncomfortable because of their weight since becoming pregnant. This characterization of a weight-stigmatizing experience was adapted from previous work [25, 26]. Participants selected all the following sources that applied: work, immediate family, extended family, friends, church, partner/spouse, healthcare providers, strangers, media, other mothers, society, or other. For each source endorsed, participants were asked to provide an example of their experiences in open-response format. The prompt read as follows: “So that we can fully understand what happened, for each of the people or situations you selected above, please provide an example of one of these experiences. Make sure to describe who/what made you feel bad or treated you differently and how it happened.” A total of 92 participants endorsed healthcare provider as a source of weight stigma, and of those, 80 provided an example.
Lastly, they reported the frequency of weight-stigmatizing experiences for each source. Response options ranged from “less than once a month” to “3 or more times daily.”
Healthcare experiences
All participants received the following questions designed based on pilot interviews:
Participants characterized their overall experiences with prenatal, labor and delivery, and postpartum healthcare, separately, selecting from a five-point scale from one “very negative” to five “very positive.” A score of three represented the “neutral” point on the scale.
Participants were asked if they had ever felt any of the following during healthcare interactions because of their weight: valued, important, accepted, judged, shamed or ashamed, guilty, less worthy, invisible, unimportant, disrespected, negatively compared to other patients, disliked, or as though the provider thought they were stupid or unintelligent. Participants selected all providers who had made them feel this way from the following: physician, nurse or nurse assistant, physician’s assistant, midwife or doula, ultrasound technician, office staff, fill in the blank. They were also asked in what type of practice the weight stigma had occurred: hospital-affiliated OBGYN, private practice OBGYN, birthing center, public clinic, urgent care, hospital emergency room or other specialist, fill in the blank.
Participants reported if they had ever changed prenatal healthcare providers because of how the provider had treated them regarding their weight. Participants also indicated whether they felt that too little, the right amount, or too much attention was paid to their weight or weight gain. Lastly, participants were asked if they had felt they could not trust their doctor or had to advocate for or stand up for themselves because the doctor focused too much on weight.
Breastfeeding
Participants reported whether they believed they would feel uncomfortable or had ever felt uncomfortable seeking help with breastfeeding from a healthcare professional. If affirmative, they were asked if this was because of their weight.
Pregnancy and postpartum status
Participants reported on parity dichotomously (primiparous or multiparous) and weeks of gestation or months postpartum.
Weight information
Participants reported height in inches and pre-pregnancy weight in pounds. Pre-pregnancy BMI was calculated as weight (lb)/[height (in)]2*703 and categorized according to the standard cutoffs for “underweight” (< 18.5), “normal weight” (18.5–24.9), “overweight” (25.0–29.9), and “obese” (≥ 30.0).
Demographic information
Participants reported age, highest completed education, race/ethnicity, household size, zip code, and household income. Household size and income were used to calculate household income per capita and poverty status for 2017 ($12,060 plus $4180 for each additional person).
Exhaustive information on methods is available elsewhere [21, 27]. See supplementary material for the original versions of the weight stigma, healthcare experiences, and breastfeeding questionnaires developed for this study.
Data analytic plan
Descriptive statistics evaluated frequency of weight stigma from healthcare providers and characterized ratings of healthcare experiences. Correlation analyses and one-way ANOVAs tested the role of continuous BMI in these relationships. A chi-square analysis examined differences in endorsement rates by BMI category. Open-ended responses were subjected to thematic analysis using Braun and Clark’s six-step guide [28]. Step 1: The first and second authors familiarized themselves with the responses provided by participants. Step 2: The second author developed a coding scheme to capture recurrent themes that emerged during step 1. The second and third authors independently coded all responses based on this scheme. The first and third authors resolved any discrepancies in these two waves of coding. Step 3: The third author reviewed the coding results for overarching themes across the responses. Steps 4–5: The first author reviewed, defined and named these themes and aggregated key examples of each. Step 6: The first, third, and fourth authors together produced the coding report and overarching themes.