Higher-Weight Patients and Obstetrics

Collaboration with Nicola Salmon Part 3

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This is the third article from Nicola Salmon, fat-positive fertility coach and author of “Fat and Fertile" who agreed to work with me on a series of articles for the newsletter. You can find the first piece (about gyn care and PCOS) here and the second piece (about fertility) here! I’m beyond grateful for her expertise! Please check out her work at http://nicolasalmon.co.uk/

A quick note – Nicola has included end note references here, please be aware that the studies cited often come from a place of weight bias and pathologizing higher-weight bodies in harmful ways and can be triggering.

One of the biggest challenges that fat folks face when navigating pregnancy is the idea of risk - both to them and their baby.

It is common for folks to be labeled as “high risk” from the beginning of their pregnancy based purely on their BMI. There is no shortage of research about the increased risks that fat folks have navigating pregnancy but when we start to explore this research with a more critical eye, some alarming trends appear.

Is the risk even there?

The first thing that you see is that the evidence from current research is not clear-cut. It's never the case that all the studies show fat folks have an increased risk of a particular pregnancy complication. There are often some that show there is, some that show there isn't and some with statistically insignificant results. What's even more worrying is when the author then concludes that the higher risk does indeed exist based on their bias rather than the data. 

Let’s take pregnancy loss as an example.

“Maternal Obesity” edited by Matthew Gillman and Lucilla Poston (1), is a highly regarded textbook in this field. In their research of early pregnancy loss, they found four studies that looked at early pregnancy loss and “ob*sity”*, only two of which showed an association between BMI and early pregnancy loss. They lead with the study that shows the highest association (2), which showed that in a group of 383 women undergoing IVF/ICSI, the rate of early pregnancy loss was double for overw*ight or ob*se women when compared to lean women. In the next study (3) looking at 2660 women, the data showed early pregnancy loss occurred in 4.8% of pregnancies for normal weight women, 5.4% for overw*ight women and 7.8% for ob*se women. However, the two largest studies (4,5) representing 7696 IVF/ICSI cycles, showed no relationship between BMI and early pregnancy loss.

Looking at clinical pregnancy loss, a large meta-analysis (6) showed that women with a BMI over 25 had a 67% greater chance of experiencing a miscarriage when compared with a woman with a normal BMI. They also found a further 8 studies that had been undertaken since the meta-analysis, 3 of which found no evidence of a link and 2 of which showed a link with no statistical significance, leaving only 3 that actually showed a statistically significant link. The research is not conclusive. It is the researcher bias that leads to these correlations becoming “fact”.

If we assume the risk is there, how big is it?

If we take the research around the likelihood of fat folks experiencing complications during pregnancy at face value, it’s important to understand what this means so that fat folks can make fully informed decisions about their healthcare. 

Often in healthcare conversations, fat people are infantilized and their body autonomy taken away from them around healthcare choices. Only with all the facts, can folks make a fully informed choice.

Another condition that’s raised often around pregnancy and folks in higher weight bodies is Gestational Diabetes (GD). For folks with a BMI of 19-25, the commonly cited incidence of GD is 2.3% (7) ie roughly 2 in 100 people experience GD. For folks with a BMI of 35+, the incidence of GD is 11.5%. Ie roughly 11 people in 100 experience GD.

This increase in likelihood is often communicated as a certainty to folks in higher weight bodies or by saying “you are five times more likely to get GD”, which whilst technically true based on these figures, excessively scares people when the data shows that close to 90% of folks in the highest weight bodies do not experience GD.

If there is a risk, why is it there?

If we do assume that the increased risk is present, what also becomes clear from the research is that there are no known causative factors. No research paper has found a biological mechanism that shows that extra fat on your body causes complications during pregnancy, they are correlative at best. Yet, this data is used to deny folks care and to shame them in healthcare settings. 

None of these studies take into consideration weight cycling and weight stigma. We know both of these increase the incidence of healthcare issues that fat folks face and easily explain any potential increased incidences of complications that may occur during pregnancy.

What is clear is that regardless of why these increased risks may or may not occur in fat folks, they deserve caring and non-judgmental pregnancy support. Pregnancy complications occur in people of all sizes and can be successfully managed without weight loss or dieting.

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More research and resources:
https://haeshealthsheets.com/resources/

*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’s Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.

References

1. Gillman M, Poston L, editors. Maternal Obesity. Cambridge: Cambridge University Press; 2012.

2. Fedorcsák P, Storeng R, Dale PO, Tanbo T, Abyholm T. Obesity is a risk factor for early pregnancy loss after IVF or ICSI. Acta Obstet Gynecol Scand. 2000 Jan;79(1):43-8. PMID: 10646815.

3. Fedorcsák P, Dale PO, Storeng R, Ertzeid G, Bjercke S, Oldereid N, Omland AK, Abyholm T, Tanbo T. Impact of overweight and underweight on assisted reproduction treatment. Hum Reprod. 2004 Nov;19(11):2523-8. doi: 10.1093/humrep/deh485. Epub 2004 Aug 19. PMID: 15319380.

4. Bellver J, Ayllón Y, Ferrando M, Melo M, Goyri E, Pellicer A, Remohí J, Meseguer M. Female obesity impairs in vitro fertilization outcome without affecting embryo quality. Fertil Steril. 2010 Feb;93(2):447-54. doi: 10.1016/j.fertnstert.2008.12.032. Epub 2009 Jan 26. PMID: 19171335.

5. Winter E, Wang J, Davies MJ, Norman R. Early pregnancy loss following assisted reproductive technology treatment. Hum Reprod. 2002 Dec;17(12):3220-3. doi: 10.1093/humrep/17.12.3220. PMID: 12456627.

6. Metwally M, Ong KJ, Ledger WL, Li TC. Does high body mass index increase the risk of miscarriage after spontaneous and assisted conception? A meta-analysis of the evidence. Fertil Steril. 2008 Sep;90(3):714-26. doi: 10.1016/j.fertnstert.2007.07.1290. Epub 2008 Feb 6. PMID: 18068166.

7. S. Kim, L. England, H. Wilson, Percentage of Gestational Diabetes Mellitus Attributable to Overweight and Obesity, American Journal of Public Health, Issue 100, June 2010, Pages 1047-1052 https://doi.org/10.2105/AJPH.2009.172890