AIMS Journal, 2011, Vol 23 No 4
Rosemary Mander talks about the perceived problem of being pregnant and fat
Media attention is currently focusing strongly on the problems of obesity and being overweight; they are widely said to have reached 'epidemic' proportions. It is likely that the media has actually contributed to this perception of an epidemic, although the responsibility of the USA, where obesity is even more prevalent, cannot be ignored. Most of the concern about obesity has related to its incidence among children and young people, largely because of its adverse effects on their health and, possibly, shortening their lives. While obesity among childbearing women does not appear to have merited so many column inches, it is reported to be not only the cause of ill health among childbearing women and newborn babies, but also possibly associated with an increased risk of death.
In thinking about overweight and obesity, it is not possible to separate the current spate of condemnation from thoughts about fashion and the desirability of being 'size zero'. Thus, cultural, social, economic and political factors, as well as illness, are likely to be having an influence on attitudes to body size.
Public awareness of the problems of obesity among childbearing women is quite a recent phenomenon. It was the 'Confidential Enquiries' of 2007,1 that really highlighted the links between the mother being obese and the risk of poor health outcomes, such as clot formation, infections, hear t problems and anaesthetic difficulties. This awareness has only been increased in the more recent report.2
Prior to the widespread introduction of the Body Mass Index (BMI), maternity staff were more interested in the woman's weight gain during pregnancy as an indicator of fetal and maternal well-being, than in the woman's longterm size. The BMI, computed by dividing your weight in kilograms by your height in metres squared, is a relatively simple calculation, which may account for its general popularity and frequent use.
While the BMI is a straightforward formula, the messages which the result carries are more complex. These include a wealth of value judgements about the obese person's lifestyle and responsibility (or lack of it) for their body shape. Such judgements feature many real or imaginary personality characteristics, particularly those relating to overeating and to lack of physical exercise, which have been summarised as 'gluttony' and 'sloth' respectively. Judgements like these bring to mind the phenomenon encountered in many situations when the person who is the victim is actually blamed for the problem or illness that has befallen them.
Among both the popular media and professional publications the link between obesity and health problems has all-too-frequently been assumed to be direct. This has taken the form of perceiving obesity to be the reason for the condition; that is, the cause of the effect. Such simplistic assumptions are common among health professionals; one example was the Peel Report,3 which concluded that the fall in the number of babies dying around the time of birth was directly due to more women giving birth in hospital. This direct cause and effect link manifested itself in a recent CMACE report,4 when the Foreword mentioned:
'the impact that obesity has on women's reproductive health and that of their babies.' (2010:xiii)
Obviously, for the overweight or obese woman the picture is not that clear-cut. A woman's obesity may be associated with less-than-healthy eating habits, due to multiple family obligations and a hectic lifestyle; which, in turn, means that she may smoke and face other health problems.
The costs of obesity to the health service, the poor maternal health rates and the association between the mother's obesity and the baby's unsatisfactory condition have all been well-publicised. What has attracted far too little attention is the woman's experience of being overweight or obese in the maternity care system. The woman's view is starting to be considered, but there has been minimal interest in what she is able to actually do about the situation in which she finds herself. This lack of interest manifested itself most obviously in the recent CMACE report,4 which specifically and deliberately excluded consideration of any self-care interventions during pregnancy. The focus of the CMACE report was largely on the need for the woman to be advised and to undertake weight reduction interventions preconceptually, that is, prior to becoming pregnant. While such advice may be very helpful to some groups of women, for others it represents an unrealistically idealised recommendation. For women whose relationships are something other than conventional or who feel that their body clock is ticking relentlessly away, planning weight loss before conceiving may be little more than a counsel of perfection.
That women are all too aware of the problems caused by being overweight or obese during pregnancy and try to do something about it should come as no surprise to health care providers. This was the finding of a large research project in the USA which Bish and her colleagues published in 2009.5 Increasing numbers of women reported that they tried to lose weight either by reducing their food intake or by increasing their physical exercise, or both. These researchers indicated that such weight loss strategies were in direct contradiction to the advice given by health care providers. Although the researchers admit that there is a lack of research into the effects of weight loss during pregnancy, they do suggest that it may be associated with the baby being low birth weight due to being born prematurely.
A more recent and more authoritative systematic review by Dodd and her colleagues6 sought to address specifically the value of any things that the overweight or obese woman could do during pregnancy to reduce any harm to herself and her baby. Again the possibility of change of diet was considered as well as the introduction of an exercise regime. The studies that have been undertaken have not been of a sufficiently high quality to draw any definite conclusions or to be able to offer the childbearing woman meaningful advice about what she is able to do to help herself.
Childbearing women are being bombarded with criticisms about their body size by the popular, professional and other media and by those who should be providing care. These negative messages are conveyed without being able to give help or information about what the woman is able to do to remedy the situation. This sad scenario inevitably leads to the question of, if there are really so many obese women and being overweight carries such serious implications, why has there been so little research on interventions during pregnancy?
This may be one of those situations in which health care providers should admit that they have no remedy to offer the woman who is pregnant. This admission should be made before berating and condemning the childbearing woman on the grounds of the size of her body.
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