Supporting plus size pregnancy in a fatphobic world
Interview with Stephanie O’Brien
I chat with Newborn Mothers graduate Stephanie O'Brien from Postpartum with Steph. We discuss why BMI shouldn’t be used as a sole indicator of health, what it’s like navigating the hospital system as a plus-size woman, and how Steph’s personal experience led her to become a postpartum doula. We explore how postpartum care providers can better support plus-size women.
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About Stephanie
Stephanie is a postpartum doula, passionate about supporting mothers in the fourth trimester. It was her own experience of postpartum in 2018 that sent her on a path to discovering how we can better support mothers after the baby arrives.
She likes to advocate and educate about plus-size pregnancy to help remove the fatphobia and weight stigma that exists for plus-size women and birthing people.
She’s a mother to two boys, a wife, a gift-giver, a hugger, and witty with a heart of gold (and a little bit sweary).
We explore the following questions:
How did your experiences of having babies lead to your interest in BMI?
Why does BMI exist in maternal care?
What are the risks of using BMI as the only way to measure health?
As postpartum care providers, what can we do better to support our plus-size clients?
Additional resources we spoke about:
Postpartum with Steph - http://www.postpartumwithsteph.com/
BMI course coupon code - NEWBORN10
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Transcript
Julia Jones:
Hello and welcome to this podcast with Steph, whose business is Postpartum with Steph. Steph, I should have checked this before, but you did the training with Newborn Mothers quite a few years ago, I think. Was that during COVID times, I think?
Stephanie O'Brien:
Yeah, it was in 2020.
Julia Jones:
And from there, you've gone to a lot of things. I know that you do a lot on Instagram, and a lot of our students really enjoy their advocacy and having your voice there. And I know that what you've been doing a lot of lately and why we've got you here today is talking about BMI and what that means for pregnancy care. So do you want to introduce yourself in your own words?
Stephanie O'Brien:
Sure. So, first off, thank you for having me. So I'm Steph. As mentioned, I'm a postpartum doula working on Wadawurrung country in Geelong. I work in person with my clients and online as well. I'm a mom of two boys, just sort of coming out of that postpartum phase myself. So I've got a 16-month-old, and what else? That's pretty much me in a nutshell. And I've got a background in social media and that kind of thing, so I've sort of brought that into my business, something I like to just nerd out on.
How did your experiences of having babies lead to your interest in BMI?
Julia Jones:
I know, and it really shows too. I know a lot of people really love the content that you put out and find it really valuable. But do you want to tell us a little bit about those experiences of having babies, and what that was like for you, and how that's brought you to here?
Stephanie O'Brien:
How it's brought me to being a doula? Or-
Julia Jones:
Well both, and to BMI, because I guess that's both part of the same journey, isn't it?
Stephanie O'Brien:
So I should have mentioned too, I'm a plus-size woman, and my first pregnancy in 2018, I was just completely unprepared for what it would be like to be plus-size and pregnant. I remember going to my first midwifery appointment and I thought, this is going to be so great. I'm so excited. And probably within the first couple of minutes, the midwife was asking me to get on the scales and then deemed me as high risk because of my BMI. And it was just very negative, and not very respectful.
And I have a history of disordered eating, and she was saying, you need to go and see a dietician, and you're going to get gestational diabetes. And it was sort of this big snowball of catastrophe, and it was just such a horrible experience. I ended up changing hospitals because I felt really unheard. This person wasn't listening to me. I switched hospitals, slightly better treatment, but still, it was very much like, your weight is a problem, your baby's at risk of all of these things.
And I just felt so guilty, and I was failing my baby purely for existing in my own body. And no one ever really asked me, what do you eat? Do you move your body? How's your mental health? It was just purely based on this number on a scale that was determining my health. And the knowledge that I have, being a plus size woman and being part of the body positivity community, so to speak, is that health is not a size. It can't be determined by number on a scale because that's not a full picture of an individual person's situation.
So, getting back to the question you asked. In my second pregnancy, I was like, you know what? I'm not putting up with any of this. The second time around, I was much more informed. In between those two pregnancies, I became a doula as well, and just had a lot more information about, I could say no to things. And I didn't have to do an extra ultrasound if I didn't want to, and I didn't have to do a particular test if I didn't want to. And I was much better at weighing up the pros and cons of things. And so my second pregnancy was still challenging, but much more enjoyable in terms of me advocating for myself. And I just had an idea towards the end of that pregnancy that it would be great to sort of put all of the information that I've learned into a course or something for plus-size pregnant people to draw on and help them in their experiences.
Why does BMI exist in maternal care?
Julia Jones:
I love that. In the doula world, we talk a lot about the baby's weight, too, and how just looking at weight alone isn't an indication of health. It's often an indication of, oh, let's just check everything's going well, that's all it is. It's like a, oh, let's just look a bit closer. But you shouldn't really judge someone on their weight alone. And yet we still do it to mothers as well, which is, sadly, not really that surprising. So you became a postpartum doula, you became good at advocating for yourself, and now you teach other moms about sort of standing up for themselves in that kind of fat-phobic system. But let's rewind a little bit too about, why does BMI exist, and why do we even have it in our maternal care?
Stephanie O'Brien:
That's a great question. So BMI was invented in 1830 by a statistician, so not a doctor, not a medical professional. And it was invented to assess whether there was a correlation between weight, height, and death because, at the time, there were a lot of people dying for whatever reason, so these statisticians sort of wanted to work out if there was a correlation.
Then we fast-forward to 1972, when a man called Ancel Keys adopted the BMI system, named it BMI, Body Mass Index. Because, he said, it was essential in quantifying health. But the tests or the way he sort of structured it was based on the health of 7,000 healthy men, healthy white men, to help insurance companies have a quick way to assess the health of their customers so they could calculate insurance premiums. And from there, we've just adopted it as this is the be-all and end-all in measuring an individual's health.
It doesn't cost people money to use, you can do it very quickly, and within 10 seconds, you can learn what your BMI is. But the problem with the way it was developed is that it doesn't take into account the differences between men's and women's bodies, the differences in pregnant women's and pregnant people's bodies, and people of colour, people with disabilities. So it's very problematic in that respect.
It also doesn't take things into account like muscle mass versus body fat. We know that muscle weighs more than fat. So, there are world-class athletes who are considered overweight and obese according to BMI. It doesn't take in things like whether you smoke, whether you drink alcohol, or whether you have high cholesterol. It just in and of itself is not a great measure of an individual's health. And yes, so the reason that it's being used in maternity care is because used in medical professions around the world. It's cheap and easy, and yeah, they're sticking with it.
What are the risks of using BMI as the only way to measure health?
Julia Jones:
So it's kind of like a shortcut, but it doesn't actually give people the medical professionals necessarily the real data that they need to give you proper care and advice. So I'm wondering what are, I guess, obviously, everyone uses the BMI, and you found that even switching hospitals it was still an issue. But let's talk about the risks of it as well, because I mean, we talk a lot about the risks of being overweight, which I think are probably overstated, but can you talk about the risks of using BMI as the one and only way to measure someone's health?
Stephanie O'Brien:
So I guess in maternity care in Australia specifically, obviously where I was pregnant and where I've drawn on the research from. In public hospitals in Australia, if you have a BMI of over 30, you are deemed high risk. And so what that means is generally you are put through obstetric-led care as opposed to midwifery-led care. You are automatically ruled out of things like hospital home birth programs, ways that you can birth, having a water birth. Most hospitals have a limit, like a weight limit on who can have a water birth. So it's very limiting in the options that you can have within a hospital setting.
Julia Jones:
And then what happens is, I guess as well, what is the experience of a woman when that's happening too? What do people say? How does that feel?
Stephanie O'Brien:
It's horrible.
Julia Jones:
What advice are you given?
Stephanie O'Brien:
I mean, I can speak anecdotally, I can speak from my own experience. But from stories that I'm told constantly from plus size women in the way they were treated, just things like, you're going to have a big baby, you're at risk of stillbirth, you're at risk of gestational diabetes, you're going to have shoulder dystocia. Just every bad thing that could happen in a pregnancy or in a birth is then basically put on you, and it feels horrible because you are pregnant, you're doing the best you can in your own body, and you're made to feel like you're a terrible person because of your size. It's not an evidence-based kind of assessment.
Julia Jones:
I think that makes total sense. Going back to the very beginning, you were saying way back, I think it was in the 1800s, the idea was, is there a correlation between weight, height, and death? Do you know what the outcome of that was? Is there a-
Stephanie O'Brien:
I actually don't know the answer to that question. I would say probably not.
Julia Jones:
Again, it might be a clue to say, let's check this person's exercising. Let's check this person is well, let's check if this person needs more support. But it shouldn't necessarily be like, you're done.
Stephanie O'Brien:
And that's what it seems to be like. You step on the scale, they measure your height, they work out your BMI, and then it's like, okay, you are high risk. Without any conversation around, you know, what food do you put in your body? Do you move your body? All that kind of stuff. And to be quite honest, even if a woman, she's the most unhealthy, she's the fattest woman that's currently pregnant in the world, she deserves respectful and dignified care. She doesn't deserve assumptions to be made about her health. Nobody owes you health. And we're pathologizing it to the point where it's really affecting the way pregnant women are birthing; it's affecting their mental health, and something has got to change.
As postpartum care providers, what can we do better to support our plus-size clients?
Julia Jones:
And I think from your experience of saying you were so happy to be pregnant and you were so excited about that first appointment, and then you walk away feeling like a total failure, feeling guilty, feeling ashamed, and that's just not at all how anyone should feel about having a baby. I've got one more question for you. As postpartum doulas, what can we do better to support our plus-size clients?
Stephanie O'Brien:
I think there's a lot. I mean, really understanding a plus-size person's experience in pregnancy and not just saying, "Oh, I work with plus-size clients. I'm plus-size friendly." Really understanding weight stigma and anti-fat bias, and language. I'm not saying, I don't know this personally, but I'm sure there have been situations where a doula might say something that could be quite offensive to a fat person, whether it's they're mentioning, "Oh, I ate some chocolate cake on the weekend, I'm so bad." Or just little things like that to be aware of how we speak about bodies and food and fatness.
Julia Jones:
And I guess using the language that the client prefers as well. You are obviously quite comfortable with the word fat, but I know some people don't feel comfortable with it.
Stephanie O'Brien:
Yeah, and look, it's everyone's personal preference. I think for me when a straight-sized person says fat as an insult or sees the word... Like if I said to someone, "Oh, I'm fat." And like, "Oh, no, you're not. No, you're not. It's fine." No, no. It's like me saying I'm tall or I have brown hair. It's a fact. It's a very neutral word to me. It's no different from saying that I'm thin or I have size 10 feet. It's just, that is my body, and it's nothing to be, it's not a negative thing to me. I would rather use that term or plus-size than I'm overweight or I'm obese. I hate those words.
Julia Jones:
Yes, because they are pathologized words, aren't they?
Stephanie O'Brien:
And overweight really implies that there's a weight that you should be, and you shouldn't be over it. I think getting back to your question about what doulas, what postpartum doulas can do. I mean, there are a few different courses and workshops and things around about plus-size pregnancy or doula care that are specifically tailored to doulas who want to or do work with plus-size women. But I think really just asking questions from the plus-size community, and I guess probably confronting any biases that you might hold yourself because I'm sure most of us do. And just sort of getting curious there.
What do you teach in your workshop, BMI is Bullshit, Getting Prepared for your Plus-size Pregnancy?
Julia Jones:
I love that. That's so important for so many different things, isn't it? To just be curious about our own biases. Let's talk about your workshop. What do you now teach?
Stephanie O'Brien:
So the workshop is called BMI is Bullshit, Getting Prepared for your Plus-size Pregnancy. It's pregnancy-focused as opposed to birth. That's going to be a separate course one day. But it's really just sort of goes through the history of BMI, and why it's not an accurate measure of health. And I go through all of the different tests and things that you'll be offered as a plus-size person because there's a lot more that you'll be offered as opposed to if you're a straight-size person. What your options are there, questions to ask your care providers to make sure they're the right person to be caring for you. I also run through the research as well around birth outcomes for plus-size women, what the actual chances or risks are of certain things happening, and what that can mean for how you're cared for. I'm just trying to think what else is in the course.
Julia Jones:
That sounds amazing already.
Stephanie O'Brien:
Okay, good. Just, I guess because I've drawn from my own personal experience as well, and being a postpartum doula, I've put stuff in there about how to cope with the heaviness of it that you can feel sometimes of that real emotional toll that it can take to advocate for yourself if you are plus-size. And I'm very honest in the course, my second pregnancy wasn't perfect by any means. I definitely had moments where I still just felt defeated, or I didn't have the energy to sort of advocate for myself. So how do we cope with that? Yeah, so some little kind of-
Julia Jones:
When it does wear you down, because-
Stephanie O'Brien:
I think that's really important too.
Julia Jones:
Do you think, as you're saying all of this, I am just putting it together that it would be great if you could do this as professional development in hospitals.
Stephanie O'Brien:
The course, I mean, the way I've sort of positioned it, is directed to pregnant women and birthing people, but it's completely relevant for doulas, midwives, just really anyone that works with plus size people, just to give you a bit of... Pregnant plus-size people, I should say. Just to give you a bit of insight into some of the things that will come up. Even like yoga instructors or osteos, or... It's relevant for anyone really who's working with women in that space.
Julia Jones:
Yeah, because funny that people still seem to think it's okay to comment on other people's bodies. It's still just so rampant, and I'm constantly surprised, and I should stop really being surprised, but how many people do just think they have the right to comment on someone else's body, particularly publicly, like you are playing in a yoga class or something like that. So I think there's a lot of work to be done in this area, and I really appreciate that you are sort of telling your story, but also sharing... Because I mean, I guess lots of people would show up and be told they have to do a test. They wouldn't even realize that other people aren't offered that test. So just knowing why is that and what your rights are, and what you can ask.
Stephanie O'Brien:
I think I was like that with my first pregnancy. I didn't know that not everyone did two gestational diabetes tests. And I really felt like I had to be the good girl, I had to say yes to everything, do every test, do every scan, have every single thing that they threw at me to have the best care. And that's such a misconception.
You deserve respectful and dignified care no matter what choice you're kind of making within that system. You don't have to say yes to certain things if you don't want to or if you're uncomfortable. So that was definitely a key thing in my second pregnancy that I sort of held onto just so that I wasn't put in those positions again of just like, oh, I don't want to do this again.
Where's the best place for people to find out about you?
Julia Jones:
And then now you can share that with other people. So I appreciate that you've turned that into something that, it's a horrible experience to go through, but that you can now hopefully stop other people from having such a horrible experience. So people can find out more about you at postpartumwithsteph.com. We'll put a link up, and the workshop is called BMI is Bullshit. Do you have anything else you want to add before we close?
Stephanie O'Brien:
No, just thank you so much for having me and for allowing plus-size voices on your podcast. Because these conversations are just so important. And I just really appreciate you taking the time to have me on.
Julia Jones:
I appreciate you, too. It's a topic I've actually wanted on the podcast for many years. Because I know from talking to a lot of my students that these experiences are unfortunately common. So to have you be able to put your lived experience together with some of the research and be able to share that, that's really valuable. So thank you so much.
Stephanie O'Brien:
Thank you.
