The Far-Reaching Effects of Weight Bias in Reproductive Care
The impact of weight stigma in healthcare has been studied for decades—and the results are alarming and far-reaching. These biases impact the quality of care someone might receive, as well as their diagnosis and treatment.
A 2005 study in the International Journal of Obesity indicated that "disrespectful treatment, embarrassment at being weighed, negative attitudes of providers, unsolicited advice to lose weight, and medical equipment that was too small to be functional" are barriers that deter larger patients from seeking care. Of the almost 500 women surveyed, 73 percent reported experiencing one or more of these barriers.
Additionally, "healthcare providers reported that they had little specific education concerning care of obese women, found that examining and providing care for large patients was more difficult than for other patients, and were not satisfied with the resources and referrals available to provide care for them."
So, it's not just that fat women may be less apt to schedule their annual exams and preventive screenings—they receive less quality care when they do.
These findings begin to chisel away at the looming factor of why fat women may delay their OB-GYN appointments: weight bias.
Weight bias prevents preventive screenings
Weight bias contributes to fat ciswomen being less likely to receive cervical cancer screenings and mammograms, according to a 2009 study published in the research journal Obesity.
A 1993 study in the research journal Women & Health noted 17 percent of doctors report reluctance to provide pelvic exams for very fat women. That number jumps to 83 percent when the women also express reluctance.
Similarly, a 2003 study of 620 primary care physicians published in Obesity Research found that more than 50 percent of the doctors surveyed "viewed obese patients as awkward, unattractive, ugly, and noncompliant." Fat bias by providers translates directly to reproductive care—or lack thereof.
Weight stigma can lead to incorrect diagnoses
It's a knee-jerk reaction for doctors to tell fat patients to lose weight, no matter what brought them to an appointment.
The issue is exacerbated by Medicare and Medicaid's Merit-based Incentive Payment System (MIPS), which requires physicians to document a discussion, treatment plan, and follow-up for anyone with a BMI over 24.9 once per "performance period." This is part of a doctor's "quality score," which is closely tied to the reimbursement they receive. Basically, doctors will be paid less for the services they did provide and get a lower "quality score" if they don't have a conversation about weight.
The implications of this unsolicited advice affect the emotional well-being and physical health of patients. Attributing symptoms to weight takes the focus off other potentially dangerous symptoms for disorders, such as endometriosis or polycystic ovary syndrome (PCOS).
'Their health concerns are often not met with further tests to rule out potential issues, only told to go away and lose weight.'
"In general gynecological care, fat folks are routinely told that any concerns are related to their weight, and that weight loss will solve issues such as heavy or painful periods and irregular cycles," said Nicola Salmon, fat-positive fertility coach and author of the book "Fat and Fertile."
"Their health concerns are often not met with further tests to rule out potential issues, only told to go away and lose weight," she added.
"Doctors miss key diagnostic information because they refuse to test people until they've lost weight. This leads to a big delay in when folks are diagnosed and treated for conditions," Salmon continued. "That time lost could be really valuable in the disease progression and their recovery."
Pregnancy and fertility care
Providers automatically label many larger-bodied people as high risk even if they aren't. Jen McLellan, a certified childbirth educator and founder of Plus Size Birth, explained access to maternity care for people with larger bodies is incredibly frustrating. Labeling all larger patients as high risk is not a recommendation by the American College of Obstetricians and Gynecologists (ACOG).
Weight bias in OB-GYN care can start even before you arrive at an appointment. Google "fat pregnancy" or "fat-friendly OB-GYN," and you'll likely see why. Online material for having a successful plus-size pregnancy is overwhelmingly negative, and there are scarce resources for finding a fat-friendly or body-neutral OB-GYN.
McLellan encourages meeting low-risk patients with individualized healthcare and says the language we utilize around risk can make all the difference in how someone feels about the care they receive. "There are increased risks for people of size," McLellan said, "but how those risks are framed, and how people are talked to, is where the harm is coming into play."
Arbitrary BMI guidelines also directly impact access to fertility treatments and abortion services without regard to someone's overall health. "In the U.K., folks with a BMI over 30 are unable to access any form of reproductive care, often even basic blood tests," Salmon stated. "In the U.S., there is a huge disparity around which clinics will treat folks based on their BMI. Services such as IVF and IUI are often withheld, citing a risk of problems with anesthetic, which is not supported by the research."
"Having a blanket BMI statement is doing a lot more harm than good," McLellan said. "The odds are, people who are low-risk going into pregnancy with a higher BMI are in favor [of having] a healthy pregnancy."
Utilizing an HAES approach
Providers frequently tell larger-bodied people to lose weight before getting pregnant, even if the weight-loss procedures come with high risks.
"The marketing of dangerous (and highly profitable) 'treatments' like drugs and weight-loss surgeries that are often offered by OB-GYNs in lieu of the actual healthcare being sought by fat patients indicate to practitioners and patients that it's worth risking fat patients' lives and quality of life for the smallest chance of making them thin," said Ragen Chastain, an internationally recognized thought leader in weight stigma and Health at Every Size (HAES).
Health at Every Size is one approach for providing care regardless of BMI. HAES is a weight-neutral lens for treatment and "shifts the focus from trying to make fat patients thin, to supporting fat patients in the bodies they have," Chastain said.
"This is especially important since there is not a single study where more than a tiny fraction of people succeed at long-term weight loss," she continued. "But even if weight loss was possible, patients of all sizes deserve to be supported in the bodies they have now, not in a hypothetical future body that is smaller."
"When practitioners aren't taught to see their fat patients as walking, talking pathologies, they can begin to see them as people who deserve care, and they can begin to work on their own weight bias," Chastain said.
Finding the right provider
McLellan created a size-friendly directory to connect patients with qualified providers. She suggests that when searching for a size-friendly care provider, find out if they have BMI restrictions before the appointment.
A pertinent question to ask, according to McLellan, is if there is "anything that I should be aware of now—any additional testing, procedures, or recommendations that you're going to make?
"There's no reason why a provider doesn't have a large adult or extra-large blood pressure cuff, and there's no reason why they don't have a gown that fits people of size," McLellan stated. "When we don't provide these basic tools, we strip people of their dignity, and we compromise their health and well-being because people are told that their blood pressure is high when the wrong cuff is being used."
Weight bias has health consequences. When you see a medical provider, you put your well-being in their hands. When that's not met with gratitude, compassion, and evidence-based care, it can impact people for a lifetime. Bias can also influence how likely patients are to seek care in the future. Stigma creates poor health outcomes, psychologically and physically.
"Patients and care providers want healthy pregnancies and healthy babies—we both want healthy outcomes," McLellan said. "How can we work together to make this happen? Because we know that shame is not an effective tool."