Matern Child Health J DOI 10.1007/s10995-014-1577-x

COMMENTARY

Obesity Stigma as a Determinant of Poor Birth Outcomes in Women with High BMI: A Conceptual Framework Sharon Bernecki DeJoy • Krystle Bittner

 Springer Science+Business Media New York 2014

Abstract Obesity stigma has been linked to poor health outcomes on an individual and population basis. However, little research has been conducted on the role of chronic or recent obesity stigma in the health disparities experienced by pregnant women with high body mass index. The purpose of this article is to discuss poor birth outcomes in this population from an integrated perinatal health framework perspective, incorporating obesity stigma as a social determinant. In studies of non-pregnant populations, obesity stigma has been associated with stress, unhealthy coping strategies, psychological disorders, and exacerbations of physical illness. This article examines the mechanisms by which obesity stigma influences health outcomes and suggests how they might apply to selected complications of pregnancy, including macrosomia, preterm birth and cesarean delivery. Given the rates of obesity and associated pregnancy complications in the United States, it is critical to examine the determinants of those problems from a life course and multiple determinants perspective. This paper offers a conceptual framework to guide exploratory research in this area, incorporating the construct of obesity stigma. Keywords Obesity stigma  Obesity  Pregnancy  Social determinants

S. B. DeJoy (&)  K. Bittner Department of Health, West Chester University of Pennsylvania, 211 Sturzebecker Health Sciences Building, West Chester, PA 19383, USA e-mail: [email protected] K. Bittner e-mail: [email protected]

Purpose Stigmatization of a health condition can increase its disease burden through various mechanisms, including discrimination-related stress, stress-related exacerbation of underlying pathophysiology, differential access to determinants of health such as income and employment, and promotion of unhealthy coping mechanisms [1–3]. Obesity is a stigmatized condition, with overweight individuals being perceived as lazy, less competent, and having less social status than normal-weight or thin individuals [4]. Overweight and resulting health problems are blamed on one’s personal choices and lack of willpower, without regard to obesogenic environmental factors [3]. The stigma associated with obesity has negative consequences for both individuals and populations, as weight bias can lead to unhealthy lifestyle choices, psychological disorders, stress-induced pathophysiology, decreased utilization of health care, and poorer quality of care [3]. Stigmatization of obese pregnant women may play a role in health disparities experienced by this population; however, little research has been conducted on the effects of either lifetime or recent obesity stigma on the birth outcomes of women with high body mass index (BMI). A search of Medline, PsychInfo and Web of ScienceTM databases using the terms ‘‘obesity stigma’’ or ‘‘weight bias’’ and ‘‘pregnancy’’ or ‘‘childbirth’’ generated only a handful of studies that addressed the issue, and few that explicitly suggested causal links between obesity stigma and poor birth outcomes. Given that more than half of pregnant women in the United States are overweight or obese [5] and are at increased risk for numerous poor birth outcomes [6], understanding the root causes of those disparities and designing interventions to address them becomes a critical

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public health priority. The purpose of this article is to review the available, limited research on weight bias in pregnancy and then discuss poor birth outcomes in this population from an integrated perinatal health framework perspective [7]. This discussion includes the hypothesis that experiencing weight bias is a risk factor for disparities in birth outcomes by BMI. Finally, we present a conceptual framework that describes potential causal pathways for selected poor birth outcomes in obese women.

Description Maternal Obesity and Related Stigma In the United States, more than one third of all women are obese. In terms of the prevalence of obesity in the perinatal and preconception periods, more than half of pregnant women are overweight or obese, and 8 % of women in their reproductive years are extremely obese [5]. The stigmatization of overweight individuals is widespread in all medical settings. Research involving multiple health care professions across different countries has identified weight bias as a pervasive problem, particularly for women [8–11]. Patients who experience stigma from providers may feel powerless, experience emotional problems, receive shorter visits, and receive differential treatment; as a result, they may experience suboptimal care and avoid or reduce contact with the health care system [12]. Given these findings, it is probable that obese women bring a lifetime of experience with weight bias from health care providers to their first antenatal care appointment. Qualitative studies suggest the experience of discriminatory treatment continues unabated in maternity care. In a Scandinavian study, women experienced accusatory responses to their weight from health care providers and lack of helpful information about obesity in pregnancy [13]. An Australian study found obese pregnant women reported less satisfaction with care than their normalweight peers, and maternity care providers reported less positive attitudes towards caring for them [14]. In the UK, women receiving maternity care were self-conscious about their size, and interactions with their provider increased their discomfort [15]. These women reported more medicalized pregnancies. Although it has been suggested that victims of obesity stigma may avoid interactions with health care professionals [12], one study found no difference between obese and non-obese women in timing of entry into prenatal care [16]; however, it did not explore the association between internalized experiences of weight bias and timing of care or adequacy of care. In addition to medical settings, obese individuals experience stigma and discrimination in multiple domains in

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daily life [3, 17]. Individuals experiencing obesity stigma report that the subtle forms of discrimination and disgust pervasive in society have the greatest effect on their physical and mental health [17]. Women experience more obesity-related stigma than men, and the effects appear to diminish with age [18], suggesting that preconception- and childbearing-aged women are at higher risk than older women or males. The influence of obesity stigma on health may be mediated by racial identity. In one study, weight-based stigma generated more psychological distress in white adolescent girls than in black ones [19]. Adult AfricanAmerican women reported more complex and nuanced body image than white women, expressing both satisfaction and experiences of stigma due to larger body size [20]. Overall, these studies suggest a troubling pattern: if one third of all women are obese, and half of all pregnant women are overweight or obese, then substantial numbers of childbearing women in the United States are at risk for discrimination and associated stress in multiple settings and throughout their life course. Maternal Obesity and Birth Outcomes Maternal obesity increases the risk for infertility, miscarriage, stillbirth, thromboembolic and hypertensive complications of childbirth, cesarean section, birth defects, preterm delivery, fetal overgrowth, and gestational diabetes [6]. A comprehensive review of the physiological mechanisms by which obesity induces maternal and fetal complications is beyond the scope of this paper; however, it is fair to state that many of the normal physiologic changes of pregnancy are exacerbated and complicated by obesity, including cardiopulmonary functioning, insulin resistance, and inflammatory processes [21]. There is no argument that obesity in pregnancy is associated with suboptimal maternal and fetal health status, and there are plausible biological mechanisms by which adiposity and associated metabolic changes lead to poor birth outcomes. For these reasons, clinical guidelines recommend that pregnant women enter pregnancy at a healthy weight, gain within recommended guidelines, and receive individualized counseling about weight management in pregnancy [22, 23]. However, clinical guidelines for managing weight in pregnancy exemplify what Misra and colleagues critique as ‘‘current policy and practice approaches to improving the outcome of pregnancy and perinatal care… based, generally, on an individual-level epidemiologic model of addressing known risk factors [7] ’’. Instead, they call for an integrated perinatal health framework that takes into account multiple determinants of health across a woman’s life span. While personal lifestyle choices play a major role in pre-pregnancy BMI and gestational weight gain, these

Matern Child Health J

choices are embedded in a complex web of social, cultural, environmental and policy contexts across the preconception and perinatal periods. Therefore, understanding how multiple determinants of health influence obesity and related complications in pregnancy can lead to more comprehensive and effective interventions. Given that obesity stigma has been implicated in poor health outcomes in other populations, it may be worthwhile to examine its impact on the maternal child health population. A review of the specific mechanisms by which obesity stigma influences health can inform a discussion of poor birth outcomes in obese women and suggest areas for further research. Obesity Stigma and Macrosomia Macrosomia is a well-known complication of pregnancy in obese women. Studies have demonstrated that pre-pregnancy BMI, central obesity and gestational weight gain are all risk factors for large-for-gestational-age infants [24–26]. Larger infants may be more challenging to deliver, and thus macrosomia is associated with an increased risk of cesarean delivery and birth injury to both mother and fetus [23, 27]. Prevention recommendations include counseling obese women to lose weight prior to conception, closely monitoring the weight of obese women during pregnancy, and encouraging applicable lifestyle changes [23]. However, the stigmatization of body size has been suggested as an unethical and counterproductive approach to health promotion [3, 28]. ‘‘Experiencing weight stigma increases the likelihood of engaging in unhealthy eating behaviors and lower levels of physical activity, both of which exacerbate obesity and weight gain [3] ’’. Weight discrimination has been associated with emotional eating and binge eating, with weight bias internalization as a mediator [29]. Internalized weight bias has been associated with eating disorder pathology [30]. Thus, these studies suggest that maternity care providers who focus on BMI in a stigmatizing manner may exacerbate unhealthy eating patterns and actually increase the risk their clients will overeat during pregnancy. Further research is needed to determine whether pregnant women with high BMI receive stigmatizing weight management advise and, if so, whether they respond with healthy coping mechanisms. Obesity Stigma, Preterm Birth, Low Birth Weight and Stress Paradoxically, while infants born to obese mothers are at risk of being large-for-gestational age, they are also at risk of being preterm and at low birth weight [31–33]. In one study, while obesity was not independently associated with preterm birth in African-American women, it was in white,

Hispanic and Asian women [34]. Although fetal growth restriction and fetal excessive growth have different causes, both are associated with components of the metabolic syndrome, including insulin resistance, hyperleptinemia, and hypothalamic changes [31]. Biological mechanisms may partially explain the increased risk of preterm birth and low birth weight in this population; however, psychosocial stress may also play a role. Psychosocial stress has been implicated as a risk factor for preterm birth [35]. The exact mechanisms are not completely clear; however, maternal lifestyle and neuroendocrine and inflammatory processes are thought to be contributory factors [35]. Experiencing weight bias is distressing for individuals and affects their quality of life [36, 37]. Obesity stigma has been associated with depression [30, 38], particularly in women [39] and in adolescents [40]. Therefore, women who enter pregnancy while overweight may have experienced chronic stress and depression related to their body size. They may also experience pregnancy-related stress and anxiety related to negative experiences with maternity care providers. [13–15]. As applied to African-American women, the life course perspective suggests that poor birth outcomes are associated with multiple interrelated exposures to chronic and recurrent stress across a woman’s life, particularly race-based oppression. [41]. Racism and obesity stigma are different forms of discrimination; however lifelong experience with either form may be a source of chronic stress. ‘‘Chronic stress places a strain on physiologic systems that maintain homeostatsis and leads to chronic wear and tear…’’ [42, p. 2094] This ‘‘weathering’’ of physiological systems due to chronic stress has been postulated to explain health disparities in African-American women and infants [43], and may play a role in disparities among women of size. In addition, obesity stigma may play an even further downstream role in the relationship between stress and preterm birth. Mason asserts that the intersection of weight and gender is major source of inequity in the US [44]; obese women tend to have lower levels of educational attainment, income and a lower marriage rate than their thinner peers [3, 44]. These social disadvantages can reduce obese women’s access to valuable resources such as income, affordable health insurance, and partner support. In addition, socially and economically disadvantaged persons are exposed to a higher number and greater variety of stressors [45], which can exacerbate the chronic stress associated with stigmatization. Obesity Stigma and Cesarean Delivery Women with high BMI experience approximately double the risk of cesarean delivery as normal-weight women [46].

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Potential explanatory factors for the increased rate of cesarean delivery include co-morbidities associated with obesity, excessive weight gain during pregnancy, suspected macrosomia and increased induction rates [23, 46–48]. In addition, it has been suggested that high BMI is associated with an abnormally slow labor pattern and postdates pregnancy [49–51]. However, a systematic review suggests that concerns about slower labors and shoulder dystocia may not be supported by evidence, and that further research is needed to determine appropriate thresholds for cesarean delivery in women with high BMI [48]. The same review found variation in cesarean rates, with some studies showing obese women at a reduced risk of cesarean than women of normal BMI, and some with no significant different in risk [48]. Cesarean delivery, like all medical procedures, includes elements of clinical judgment, and rates of the procedure may vary by the type of provider and his or her labor management style [52]. A Canadian study found that the increased risk of cesarean delivery in obese women was attributable to labor management, not BMI, suggesting that obese women are managed differently in labor than thinner women [53]. These findings raise an intriguing question: does the differential management of obese women in labor reflect an appropriate response to emerging complications or an inappropriate stigmatization of all women of size as pathophysiological? This is a critical question, because obese women are at increased risk of complications from cesarean delivery, including venous thromboembolism and anesthetic and wound complications [23, 48]. If providers assume that an obese but otherwise healthy woman is at increased risk for complications such as failure to progress or shoulder dystocia, they may be quicker to intervene to prevent those complications and, in the process, inadvertently place mother and infant at risk for others. Assessment and Conclusion A growing body of literature suggests that obesity stigma has significant public health implications due to its role in promoting poor coping mechanisms, mental health issues, comorbidities of obesity, avoidance of health care, and negative interactions with providers [3]. Given the recent emphasis in maternal child health on social determinants of health and a life course perspective, it is time to investigate the role obesity stigma may play in poor birth outcomes. Based on associations between obesity stigma and the determinants and outcomes of health documented in other populations, we propose a theoretical model for examining weight bias as a determinant of health in the maternal child health population. The model displayed in Fig. 1 provides a conceptual framework by which obesity stigma may influence birth outcomes in women of size.

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On a physiological level, obesity may result in pregnancy complications that are a proximate cause of poor birth outcomes. From a social determinants perspective, experiencing obesity stigma in daily life may be a downstream source of chronic stress and social disadvantage. Demographic factors such as race and SES may influence the extent to which one experiences or internalizes obesity stigma, and may mediate the relationship between stigma and chronic and episodic stress. In turn, persistent and pregnancy-related stress may exacerbate metabolic dysfunction and complications of pregnancy. It may also promote poor coping mechanisms, such as overeating and substance use, which can affect infant health, birth weight, and gestational age. Weight bias from health care providers may add to the cumulative stress experienced by women of size; in addition, it may exert an independent effect by placing women at risk for stigmatizing or unnecessary interventions that increase the risk of poor birth outcomes, such as unnecessary cesarean delivery and insensitive weight management counseling. From a life course perspective, should this causal pathway result in a macrosomic infant who is at risk for a lifetime trajectory of overweight [31] and related bias, the stigma experienced by the mother may have a multigenerational impact. This conceptual model draws on existing knowledge of the effects of obesity stigma in non-pregnant populations and an integrated perinatal health framework to hypothesize a relationship between obesity stigma and pregnancy outcomes. To test this relationship, researchers must first quantify the extent to which weight bias is encountered and internalized by pregnant women in both the preconception and perinatal periods and across medical and community settings. A related need is to measure the extent to which maternity care providers exhibit weight bias in their attitudes and clinical judgment. An interesting question is whether pregnancy moderates women’s experience of obesity stigma; i.e., does ‘‘eating for two’’ and an expected increase in body size during pregnancy provide a sociallyacceptable ‘‘excuse’’ for high BMI, or does pregnancy increase stigmatizing beliefs and behaviors due to concerns over fetal wellbeing? If, as hypothesized, pregnant women experience weight bias, further research will be needed to explore the effect of this experience on outcomes of pregnancy. Study designs should include measures of perceived weight discrimination as variables of interest in studies of poor birth outcomes among obese women. Specific research questions of interest include the following: What is the interaction between discrimination related to race, gender, and body size among pregnant women? How does weight bias influence chronic stress across the life course and anxiety during pregnancy? Do providers with higher rates of bias and disgust towards obese clients have differential rates of

Matern Child Health J Fig. 1 Conceptual framework for obesity stigma as a determinant of poor birth outcomes

medical intervention? Do women who experience more obesity stigma or are most distressed by it have poorer birth outcomes than those who do not? Findings from these proposed studies can be used to identify effective programs and policies to reduce the potential negative impact of obesity stigma on birth outcomes. Provided our hypothesis is correct, and weight bias is found to have a negative effect on perinatal health, then such programs and policies could include providing stress reduction and coping strategies for obese pregnant women, training providers in sensitive and non-stigmatizing approaches to weight management, and more advanced clinical guidelines for the care of obese women during pregnancy and labor. In preventing poor birth outcomes in obese women, attention should be paid not only to the physiology of obesity, but also to the psychosocial context in which women gain excess weight and experience the consequences of increased body size. We provide this conceptual framework as a starting point for exploring the relationship between obesity stigma and downstream outcomes in the perinatal period. It is our hope that the maternal child health research community will test, modify, strengthen and expand upon this proposed model.

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Obesity stigma as a determinant of poor birth outcomes in women with high BMI: a conceptual framework.

Obesity stigma has been linked to poor health outcomes on an individual and population basis. However, little research has been conducted on the role ...
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