by Jake Peterson, Unsplash

A midwifery perspective of pregnancy and birth care in women with high BMI

Otago Polytechnic: In Aotearoa over 95% of women choose a midwife as their Lead Maternity Carer.

Midwives work in partnership with each woman to promote normal birth and a positive and empowering transition to parenthood. Despite this, current literature around high body mass index (BMI) in pregnancy in Aotearoa is predominantly medicalised, risk-focussed and negative.

Jade Wratten, Principal Lecturer in Midwifery at Otago Polytechnic, set out in her Master of Midwifery research to understand and showcase the perspectives of midwives supporting women with high BMI in pregnancy.

Wratten undertook a qualitative study, which included focus groups and interviews with 17 midwives across three different geographical locations in New Zealand. Locations were withheld from publication to protect the anonymity of the midwives who took part.

Interviews were semi-structured and focussed on midwives’ views of the provision of care for women with high BMI. Wratten used feminist standpoint theory to frame her research.

‘The theory looks at marginalised groups and gives a voice to often silenced perspectives. That was a good fit because most of the research on maternal obesity is from a medical and risk-focused point-of-view and that informs practice. So, while midwives are the dominant group caring for women their perspectives are not always shown,’ explains Wratten.

Wratten undertook a thematic analysis and identified four main themes – many which reflected concern over the current medicalised system of maternity care to women with a high BMI.

The first theme entitled ‘a flawed approach’ reflects midwives’ perspectives that too much emphasis is placed on BMI. BMI has become a single indicator of risk and dictates a medicalised pathway of care. Midwives see this single measure approach as being flawed and would like to see a more holistic focus to risk assessments for pregnant women with a high BMI.

‘There is a lot of hype around BMI and there is an assumption that women with increased BMI won't birth normally, or that bad things will happen. This results in a lot of screening and intervention when practitioners see a high BMI number,’ says Wratten.

Secondly, midwives detailed their concern around the ‘experience of women’ throughout pregnancy and childbirth when they have a high BMI. Midwives recounted that the tools of surveillance that are offered and used in pregnancy are often inaccurate when applied to women with increased BMI.

‘Women’s experiences of these scans are often really poor, and they get a result that's not completely accurate, or a heart rate can’t be found, and the woman may think her baby has died but that isn’t the case. The tools we recommend are actually quite limiting,’ recounts Wratten.

Midwives in the study were aware of the existence of weight bias and weight stigma in our maternity system and were concerned about the potential impact on women with increased BMI. Midwives see women being initially really excited about their pregnancy, but they can quickly become fearful and disempowered as they travel down what is a very medicalised process. Midwives see the importance of promoting a positive and empowering experience of pregnancy which fosters engagement and holistic wellbeing, something that they worry is being eroded by the more medicalised pathway. Midwives know that women who have had a negative experience were more likely to disengage with the system creating further inequity and barriers to care.

Thirdly, midwives spoke of a feeling of ‘being stuck,’ that they felt vulnerable as individuals and as part of a profession. Midwives believed that working with women to avoid unnecessary intervention was important. However, they witnessed women being ushered down a medicalised path, where intervention became normalised and where the risks of increased BMI were frequently communicated, but not the risks of medicalisation and intervention. Midwives also felt stuck as they are spending more time undertaking the recommended screenings and working within the medicalised pathway leaving little time left for their core work of providing midwifery care.

Finally, the fourth theme to emerge from the data was that of ‘sticking together’. While midwives felt stuck, there was potential to work together to find solutions, to let women lead their care, by offering choices and a holistic assessment that is unique for each woman. This can be achieved more easily by not seeing BMI as the number one indicator for risk.

Wratten’s research will contribute a positive midwifery perspective to the existing literature. 

She goes on to explain that 'there is a growing awareness of discrimination within our health system and that weight discrimination is definitely occurring in the maternity system in Aotearoa. Eradicating weight discrimination is needed to provide a space for women’s mana (dignity) and their experience of birth to be valued.’

Wratten says there is definite scope for more research on how to promote a normal birth for women with high BMI, such as questioning the recommendation of epidurals in the very early stages of labour.

‘We need more resources for midwives and maternity care providers on how we can promote normal birth with women with increased BMI. Midwives have got some really great ideas which I believe will support normal birth and women's experiences of birth,’ explains Wratten.

  • Jade Wratten is a registered midwife based in Palmerston North with over 18 years’ midwifery experience. She has worked in both hospital and community settings and is a Principal Lecturer within the College of Health/School of Midwifery at Otago Polytechnic. Jade is completing a Master of Midwifery thesis on the experience of midwives providing care to women who are obese in Aotearoa. Contact Jade Wratten.

  • Visit Otago Polytechnic's website.