#77 Challenging Weight Bias in Perinatal Care with Heather Bradford

Sarah: This guest here, I have been anticipating for a long time. Actually, we went on the prowl trying to find somebody who is an expert in this topic that we’re going to talk about today. I’ll let her introduce herself. I want to welcome Heather Bradford here to the podcast today. She, I’m going to say, is an expert at weight bias. We’re going to talk all about working with patients that exist in larger bodies today and what that means for our care and really bring some challenge.
I hope to bring some challenge. I’ve given full permission that this is the community that is up-leveling their care, that cares to do the right thing, that cares to be better, that is challenging the norm and asking the right questions so that we can be better for our patients and therefore lead to better outcomes. Welcome to the podcast, Heather. Why don’t you go ahead and introduce yourself and tell us who you are and what your expertise is?
Heather Bradford: Thank you so much. It’s a real honor to be here. I really appreciate the opportunity. I have been a midwife for 22 years. I can’t believe it’s been that long. I was a full-scope practicing CNM, certified nurse midwife, right out of graduate school and really enjoyed practicing as a full-scope midwife. Then for varying reasons, transitioned to academia. I’ve now been full-time faculty. I’m an assistant professor and also the assistant program director for our nurse-midwifery and women’s health nurse practitioner programs. In the middle of working full-time, I went back to school and got my PhD in nursing science.
I started really getting interested in weight bias, working with my two thought partners and other faculty who we really started talking about, “We need to talk about weight bias with our students,” because this is something that we’re seeing. Students are not really sure what words to use, how to take care of this patient population. We worked on developing some content for our graduate students getting their midwifery or women’s health nurse practitioner degree. I was really interested in this topic.
As a clinician, I was the stats person for our practice. We keep a birth log, every single birth that the midwives have attended. We track their name and the name of the baby and all those fun things. We also track their risk factors and the birth outcomes. I was in charge of keeping that up to date. I was noticing that of our patients who needed a cesarean birth, our C-section rate was very low, like 8% or 9%, most of them had elevated BMI listed as their antepartum risk factor. I wondered, why is an elevated BMI contributing to higher rates of C-sections?
We really practice true midwifery care. We’re very much hands-on. We’re with our patients. We’re working with the nurse, really advocating for physiologic birth. We don’t regularly induce our patients unless there’s an indication. We really provide, I consider, just outstanding– I’m very proud of our practice and the care we provide. There was still this association that I was noticing of elevated BMI listed as a risk factor in cesarean birth, not with every patient, but with a fair number.
Then I remember talking to a patient who lived in a larger body. It was her second pregnancy. I remember reflecting on her first birth. She was getting close to term, and I remember reflecting on her first birth. She talked about the length of her birth. That just was a long, long labor, but she had a vaginal birth. I remember saying, “Well, it’s your second. That most likely won’t be an issue. Second births are always much faster.” Sure enough, her second labor was just longer than one would expect for a multip. I remember wondering, “Why? What’s going on?”
I really was interested in understanding the physiology of thinking about oxytocin and what happens when people live in larger bodies and length of labor and all of that. That’s what led me to be thinking about weight bias a little bit. Is this something that we, as providers, could be contributing to unnecessary cesarean birth because of the care that we’re providing because of bias that we might have towards a patient?
Then the other thing that had happened that really led to my PhD dissertation work was– I don’t even remember the patient. It was just a regular day seeing patients in the office. I’d seen a patient for a routine prenatal visit. Later on, the lead midwife came to me and said, “Heather, I just want to let you know that that patient that you saw this morning, you didn’t make her feel very good. You said something about her weight that really was– it hurt her feelings.” I felt so awful.
I was just so bothered by that. I was like, “What did I say? What did I do?” I had no recollection of the words that had come out of my mouth. I thought, “That’s not okay. I need to do something about this.” It was really the combination of the patient that said Heather didn’t make me feel good and the patient that really had a long second labor. Then really thinking about our data, our C-section rates, and associated elevated BMI, that led to my PhD dissertation work where I studied weight bias among midwives.
Sarah: I want to hear what your PhD was in. What ended up happening with all the research that you did, and what did you learn?
Heather: I was curious. I really wanted to understand, is there an association between the type of care that midwives and obstetricians and labor nurses are providing? Is there an association with cesarean birth? I was really like, “I want to answer that question.” That was my initial plan for my dissertation. As you think about, even setting aside prenatal care, from the moment someone walks into the labor unit in spontaneous labor, even taking inductions off the list, you walk in into the labor unit to the moment you end up on the OR table with the cesarean birth, there’s so many things that happen along the way that could impact leading to that outcome, right?
Sarah: Totally.
Heather: Can we say it’s the bias that the nurse or the midwife or the obstetrician has towards the patient that could contribute to that? It’s a really big question. I think it was an ambitious idea that I had to try to tackle that. That’s really ultimately where I’d like to go in my research in the future, but that’s not what I tackled because it was too big of a question. Because of all those pieces and parts along the way, I think we have to tease that out a lot more.[
I really just looked at what data do we have around weight bias. What I noticed was there’s been extensive studies on prevalence of weight bias among nurses, all types of nurses, physicians, medical students, physical therapists, nutritionists, diabetes educators, all extensive research that shows all those different types of healthcare providers have implicit and explicit weight bias towards patients that live in larger bodies. Nothing had been studied among nurse midwives. I was like, “Okay, there’s a gap. I’m going to just start with the basics. This is going to be my long career in research. I’m just going to start it at the beginning.”
I also was thinking, midwives, the word midwife means with woman, as we’re more patient-centered in our approach, maybe midwives don’t have weight bias. Maybe that’s just where– Of course, that was not the case. My findings were that midwives do have implicit and explicit weight bias, a very similar rates to– actually, similar rates to female physicians. I looked at specific data and our rates were– essentially, there was no difference. If you add men into the group, male physicians have slightly higher weight bias. There’s a lot there, the intersectionality of gender and all that. In general, in a nutshell, we were not immune. Midwives have worked to do just like every other healthcare professional.
Sarah: Did you find any data in your research about how that does impact outcomes? Because for your practice, you were seeing this anecdotal correlation with the C-section, but what do we know as far as as that leads to what?
Heather: That’s next on my research–
Sarah: Good.
Heather: –moving forward. There’s a lot of data that I collected that I still haven’t even published yet. I’ve published two articles about it. Interestingly, I looked at variations among midwives. It was 2,200 midwives approximately that filled out my survey, and very thankful to those that did. I looked at if a midwife had been practicing for longer versus shorter period of time, the age of the midwife, the race and ethnicity, how they identified in terms of race and ethnicity, and if the midwife lived in a larger body, did any of that vary in terms of their level of weight bias?
Interestingly, midwives who are more recent graduates, slightly lower rates, midwives who– just, basically, the same, younger midwives, the midwives who have been practicing less number of years. Other than that, not a lot of really significant findings. Oh, but of course, midwives that do live in larger bodies, slightly lower rates of weight bias, also not surprising. I always say, when you finish your PhD, you have more questions than answers in the end.
Sarah: I’m sure.
Heather: That was–
Sarah: How I feel about life.
Heather: Yes, exactly. I’m so curious of so many other things that I am excited to study. I also asked a qualitative question. I asked midwives their experience of caring for people that live in larger bodies. I’m working on– this fall, I’m going to be analyzing that data. That’s next.
Sarah: So wild. What, from your research, is the impact of weight bias? Those of us that do have some weight bias, how does that influence or impact our patients?
Heather: Great question. My focus is really on how we, as providers, can do a better job of taking care of people because right now, we know that we’re causing harm and the care we’re providing. Weight bias is prevalent in someone who lives in a– and you’re noticing I’m using the phrase lives in a larger body or a higher weight. That was the language I used. Later on, we can maybe put a parking lot and talk about use of BMI because using BMI as a marker of health is flawed as well.
I think that there are three main ways that weight bias causes problems. One, it leads to adverse behaviors. Someone who has experienced weight bias from those around them, family members, classmates, work colleagues, and of course, healthcare providers, those microaggressions and discrimination lead to increased cortisol levels and stress, which leads to, basically, more problems with your health outcomes, and also can lead to weight gain. That’s one problem is, we’re essentially causing adverse health behaviors and outcomes from that.
Two, when people experience harm in the healthcare setting, they’re less likely to seek care because they’ve experienced such a negative– just had such a horrible time going in for an annual exam or contraception or pregnancy care. The number of people that have come to me and said, “Heather, this was my experience,” and they tell stories of just the awful things that people have said to them point blank of, you don’t take care of your body. Why are you so lazy? Why don’t you take better care of yourself? Those explicit bias-type comments. People think they’re doing someone a favor by saying, “Oh, if you just did this, this would change.”
Really, people who live in larger bodies have experienced this their whole life. For many people, they don’t really need any advice whatsoever. The harm is there. Bringing up the conversation is, for multiple reasons, problematic. People don’t want to seek care because they have experienced harm in the healthcare setting. We actually have data that says higher rates of GYN cancer because people don’t want to have pap smears because they’re having a terrible experience going in for their annual exam, or higher rates of breast cancer because they don’t want to go in for a mammogram because they’ve been harmed in the healthcare setting.
We have an influence on healthcare utilization. Then what I’m really interested in terms of perinatal research is thinking about outcomes. We know that people who experience weight bias, there’s research that said they just have a shorter life expectancy just from the experiences of weight bias their whole life. It’s just so hard to imagine of that causing harm in that way. I just really want to do a better job. I want to help. My research, I’m really focused on the services part of it. I’m more interested in how can we do a better job of taking care of people.
Sarah: Which we’re going to put a plug in because that is exactly where we’re going with this because I’m sure everybody listening is like, “Well, but I don’t want to be that person.” Before we get there, we got to hold and keep them on the line. I’d love from your perspective– you’ve given some examples, but I think it’s easy to listen to this at any time we talk about bias, no matter what the bias is. It’s easy to be like, “Well, but I don’t have bias. There’s no way. I’m so kind to all my patients, and I give the same care no matter who they are.”
There’s a little defense coming up. This is why I love a podcast is the perfect avenue because I can’t– I don’t know who’s listening to this. There’s not even a way to comment on this episode. For those that are listening, can you help us understand what weight bias might sound like, look like? How do you self-identify internally and do that work to ask the question of, do I have some weight bias internally?
Heather: I want to just give a pause because for some people hearing this, someone who lives in a larger body, this might be hard. I also just want to recognize, we always say when we talk to students about this, if you need to step away or step out, because this can be hard to just have this conversation. People have experienced harm from family members, from their coach, they weren’t picked for the captain for the team. This is pervasive since childhood of weight bias. Interestingly, there’s more higher levels of bullying for someone’s weight as a child than any other form, more than racial discrimination or gender discrimination. It starts very early.
Sarah: Myself included. I grew up with that. I have a lot of issues around weight because of being bullied in 1st grade was the worst year. Just six years old y’all. Yes, I have lived experience with that one.
Heather: It’s very early, yes.
Sarah: What might it look like? What might be some alerts or like, “Oh, I didn’t realize that that was a form of weight bias”?
Heather: Weight bias can be both implicit and explicit. Explicit is, as I was sharing earlier, just saying something really awful of making an assumption that because of someone’s body habitus, that they are lazy, that they don’t take care of themselves, that they don’t care about themselves. Implicit bias can be, “I’m not going to offer the tub to this laboring patient because I’m not sure that they can get in and out of the tub on their own. I’m not sure that they want to get in the tub because they might not want to be exposed in that way.”
You’re making assumptions, left and right. “I’m not going to recommend walking for this patient to promote physiologic birth because I’m not sure they have the stamina to walk.” This is all going on in your mind. You’re never saying this. This is implicit. “I don’t know about doing position changes because I don’t think it’s going to work. I think this patient’s going to end up with a C-section anyway because patients who live in larger bodies, they oftentimes just end up with a C-section, so why bother?” All this adiposity, “I’m not really sure that this baby can turn.” There’s misunderstanding about adiposity and ability for the baby to go through the cardinal movements.
It can be very, very subtle, but it’s there. I think just even stopping and thinking about, “Wow,” thinking about your personal experience, your interaction with others, the way that you have chosen your friends in your lifetime, it’s so pervasive. Our US culture is so accepting of weight bias that we think it’s okay to say things out loud to people.
There’s a really, really great– it’s getting old now, but I strongly encourage, there’s a great James Corden clip. It’s less than 10 minutes long. James Corden did this late night talk show clip about his experience of living in a larger body and what that was like. It just captures it so well. He just talks about, “I’ve endured this my whole life.” Bill Maher had made an attack on James Corden, and so James Corden responded with this clip. I just strongly encourage folks to watch it because it speaks to– he, of course, makes it funny, but he speaks to, “This has been a lifelong journey for me. People don’t understand. Self-reflection is a great first place to start.”
Sarah: When I first read your research study on midwives and their bias and whatnot, I went on stories. If you don’t follow us on Instagram, feel free because there’s a lot of random stuff that pops up like that surrounding these conversations. I got some very interesting DMs, and I think that there’s a lot of explicit, but there’s also implicit bias. What I think was really helpful for me was the people that do live in larger bodies that chimed in and said– There was this debate. Let me lay the stage. There’s this debate where people were saying, “Don’t you dare speak for me. I live in a larger body. Don’t tell me how to talk about it. It’s none of your business.”
Then there was also the, “We need to talk about it because there are adverse outcomes that are associated with weight for labor. What about risk factors? I need to say something about that. I need to address it. It’s my responsibility as the nurse.” Then this in between of the awkward. Does that make sense? There’s these different categories I was seeing appear. What is your recommendation, especially for those that are saying, “I’m doing this internal work. I may identify that I have some bias. This is an awkward situation. I don’t know what to do. I don’t want to offend.”
I know this is probably getting into the approach side of things, but one of the objections that I’m hearing is, “But I need to address their weight because it’s my responsibility because it’s a risk factor for certain things.” What would you say to that piece?
Heather: Who are we to say? Your job is to care for people specifically in labor. We have our responsibilities to take care of the laboring patient and the fetus. For me, I can’t really even conjecture that that ever would feel appropriate as we think about how to reframe this. I guess I want to also add one other piece is a lot of the focus is on weight loss. It’s really about what the scale says. What we strongly learned in our research and what we recommend as we’re teaching our students, it’s not about the number on the scale. It’s about achieving health. That’s [inaudible 00:23:32] the focus is being your best self.
That involves moving your body, that is about eating nutritious foods, but it’s not about what the scale says. Really reframing that understanding of we all, as our job as healthcare providers, encourage folks to be their best selves. Our body shapes come in all shapes and sizes. What do you think the scale says for Serena Williams or LeBron James? People can be in incredible shape and the scale is high. It’s not really about the number, it’s about being your healthiest self.
There’s a framework that we use called Health at Every Size, HAES, and included in the HAES framework is really about those two components, eating for nutrition, eating nutritious foods. Instead of calling foods clean or healthy, really thinking about nutritive eating or intuitive eating. Then also thinking about moving your body in a way that feels good to you. Instead of the prescribed, you must do 30 minutes of cardio four times a week– that’s the ACOG recommendation.
Sure, cardio exercise is great for some people, but maybe that means gentle yoga. Maybe that means just going for walks. I think it’s really about movement that helps you feel good, what they call life-enhancing movement. It’s really a movement that you enjoy. I think that those components are what, as healthcare providers, we can talk about, but nothing about anything about your BMI, what the scale says. It’s really about focusing on healthy behaviors.
Sarah: I think about these nurses are there for labor and delivery. I’m sorry. They’re showing up at whatever weight they are and you’re addressing their weight or their lifestyle choices or whatever you’re concerned about. Do they have preeclampsia? No. Then they don’t. Do they have gestational diabetes? No matter what size their body is, yes or no. Even that to me is like, now I’m having this, I probably have some bias in it as well. What’s our responsibility now? First of all, we’re not even letting them eat in labor anymore. What difference does it make? Are you going to cause more harm than good by addressing it is what I’m hearing.
Heather: Absolutely.
Sarah: You teased out the BMI piece. Can you talk about BMI and why you would maybe say that’s maybe not the best thing to use?
Heather: Yes, absolutely. It’s really used as a fifth vital sign. It’s quite common in any healthcare setting. Before you walk in to see a patient, you’re looking at their BMI. It’s a terrible marker of health. It’s so interesting as we were studying this, it was designed by a Belgian mathematician in the 1800s, and it was set up to measure populations, so really to measure many, many people at once. It was never designed to measure one person’s individual health status. Of course, one thing led to another, and here it is. It’s quite common. In pregnancy, we have Institute of Medicine or CDC both have cutoff criteria, BMI of this means overweight.
Again, I would say what is Serena Williams’ BMI? It’s not any representation of how healthy you are. Now, there are other ways to measure someone’s health status, thinking about their hemoglobin A1C or their cholesterol levels or their blood pressure. It’s just a terrible marker of health. Consequently, because it has become so prevalent in healthcare, it’s used to determine whether someone can birth in one setting versus another. It’s used to determine whether someone can access a birth tub or not, or other– Even infertility, are you eligible to have– will insurance cover infertility treatment for some patients? Even getting health insurance.
It’s just used so extensively, and it’s just a terrible– It doesn’t account for bone density, it doesn’t account for muscle mass, it doesn’t account for genetics. When the Belgian mathematician set it up, it was set up for white men. It was never designed, let alone for pregnant women. It’s just really should not be used in pregnancy at all. It is mandated by CMS. Oftentimes when I’m charting, I can’t sign off a chart unless this box has been checked. It’s very problematic. It’s really, I think, a policy change that needs to happen. It really needs to be very much part of the conversation of things that we need to just get rid of in healthcare.
I don’t think a pregnant patient, when they come in for the office for a regular visit, that they need to step on the scale. We’re measuring fundal height to make sure that the fetus is growing. For someone who lives in a larger body, stepping on a scale is going to be very traumatic, can be very, very difficult. Is that necessary? Let’s just skip that step altogether. Our office has taken one small step, which I appreciate. The scale is in the exam room. It’s not in the hallway anymore.
Sarah: Hallelujah, even for me.
Heather: It’s one step in the right direction, but it’s still– As I said, we can measure fundal height in other ways. We don’t use swelling as the only criteria for diagnosing preeclampsia. I just think that it just needs to go away altogether.
Sarah: I’m once again hearing nurses in our DMs, just hear or listen to this piece and go, “But we need to know their weight. We need to know their weight.” Would there be any reason to know their weight?
Heather: Great question. Absolutely. There are some times when having someone’s weight is important. We’re doing dosing. Specifically in the pediatric population, it’s really important. In terms of labor, I can understand maybe there are some– if you have a patient that lives in a larger body and the bed does not accommodate, [inaudible 00:30:38] very, very rare circumstances. We’re talking a very, very small percentage of the population. I just think, in general, for most of our laboring patients that we’re taking care of, it’s just not required.
Sarah: Fascinating change. I can just imagine. First of all, how freeing that would be. What I’m hearing here is, once again, this challenge to prioritize our mental health over our training. Sometimes I may take this question out, just so you know, but I will say that when I was reading the study and I was online and I’d read the sentence on BMI in your article. How I read it was that BMI is problematic because it was created by white men. I went immediately into my own bias, which I then had to publicly call out on social, which is great. It’s good for conversation.
What I had interpreted was, it is a part of perpetuating the patriarchal system of OB-GYN medicine that has become over the last however many, we’re at now 60, years later. Do you agree with that, or am I totally off base, or is there any correlation that you know? Again, I can cut this too. I’m just more curious for my own because I got called out by one of my educators, who’s on my team, whom I love and adore, and that’s why we’re in community together. We’re like, it’s a perfect example of my own accountability.
The feminist in me is like, I fully understands the history of OB. To me, this is another potential way that potentially there might be some overlap there. I don’t know. Do you have any thoughts on that? You don’t have to.
Heather: I just think, yes, there are– Our fallopian tubes were named after a man. Cesarean section was named after a man. I think that there’s a lot that can be reimagined in a different way. I just think that the part that I think is important is that it was never– the BMI was not designed to measure one individual person’s health. It was really designed to measure populations of white men. The other– Oh, here’s a fun tidbit that you might be interested to hear.
As I mentioned, we have these guidelines of our height, our weight over height develops your BMI, and that creates these categories. The categories changed in one particular year because driven by the weight loss, it was called the International Obesity Task Force that was funded by weight loss drugs, changed the criteria in 1998, the cutoff to be 27 for being considered overweight, and then it changed to 25. In 1998, a lot more people became overweight overnight by this one change that was led by weight loss drug companies. Again, it’s very arbitrary.
Sarah: Yes. Once again, it just goes to show how very often we are taught something and we just ingest it and we believe it and we don’t question it. Then we’re potentially doing harm without even knowing that we’re doing harm, which I know breaks my heart and breaks the people listening hearts as well. With that, I want to know what we can do. Please give us the guidebook. What can we say? What can’t we say? What is the recommendation? Once again, I love the emphasis, and this is very much aligned with everything that we do that– one of our mantras here at Bundle Birth is there’s nothing worth your mental health.
Often in medicine, we forget that the brain is an actual organ system in the body or organ in the body that is the guiding force of all things and has a trickle-down effect into all of our organ systems. You talk about these adverse outcomes that are related to weight bias, of course, because when you feel, and what I’m hearing with everything you’ve said, is this shame. To me and to the world, I didn’t make this up, but shame is such a deeply impactful feeling that is worse than embarrassment or worse than anger. It’s the lowest as it gets on the emotion scale to shame anyone, as a parent to shame a child.
Our words are so incredibly important. What I’ve taken already is that talking about weight as a labor nurse is just unimportant, and it probably does more harm than good. Now, mind you, if I need to request or make a question about what their preferences are based on their body size, is that okay, et cetera. I love that focus. I think that’s been really helpful for me already, but tell us all the tips. Give us the expert answers to how we can better our care for this population.
Heather: I’ve used certain language as we’ve been chatting, and there was a study that was done that asked people, what words do they want people to use when referring to their body? It was a systematic review, looked at many, many, many, many studies and lots of different opinions about words that people prefer living in a larger body, having a higher body weight. Some people prefer the word fat. In my family growing up, that was a very derogatory word, but some people, fat positivity movement is a very strong movement. The number one word that everyone said please do not use, was the word obesity or obese.
Everything in my writing, everything in my language, I never use the word obese or obesity. I really encourage, with everyone’s help, we can move away from it. There are journals that have obesity in the title. There’s obesity specialists. It’s going to be hard, obviously. It’s an uphill battle, but I think for sure when you’re talking to patients, avoiding using that word because it was offensive. The word obese actually means to eat oneself fat, the definition of it. It’s [sound] because people live in larger bodies for so many different reasons.
Obviously, for some people, it is related to consumption of food and lack of body movement, but it also is related to environmental factors and genetic factors and socioeconomic factors. often say to people, rethink about living in a larger body as a non-modifiable part of their body. Their eye color is blue, their skin color is tan, and they live in a larger body, and that is not modifiable. I think if we learn to accept all different sizes and shapes of people, that the shame will go away. I have some other specific strategies that I will talk about, but language is number one.
Sarah: What about overweight?
Heather: Some people did prefer overweight using that word. Actually, I’m so glad that you asked that, Sarah. The question should be, what words do you want to use? Ask the patient. If you need to ask the question about it, say, “What words do you prefer to use as you describe your body?” Someone might say, “I’m very comfortable with this word or that word.” The language we should use should mirror what they prefer, as what’s comfortable to them.
Sarah: I see that almost being inserted with pronouns.
Heather: Oh, absolutely.
Sarah: What pronouns do you prefer? What language do you prefer to use when describing your body? I don’t know. There might be other things we could add to that list, but it’s that respect level and just neutralization of emotion. That, to me, as a practicing person, I want to remove judgment from my work just in general across the board regardless of who the person is in front of me. Some of those types of questions are very therapeutic to help and adapt my care based on the patient’s preference, not my own even, what I believe.
Heather: Yes. I would actually say with pronouns, I would say, what pronouns do you use? We always say not prefer, it’s what, how do you refer to yourself? I would say many people say, “I’ve never been asked that question before,” in terms of their body habitus.
Sarah: Sure.
Heather: I think that asking that question, you make some great points. I agree 100%. Other parts of this is really thinking about how someone feels in the healthcare space. They come into the room and then you say, “Oh, I’m not sure I have a gown that fits you. Let me go grab another size.” Already recognizing, you’re not the standard size. I need to get something different, or let me go get a different size blood pressure cuff. This one isn’t working. It’s having all the equipment, all the options right there in the room and that someone can just feel like, “Yes, they were ready for me and they have everything that they need to take care of me.” I think that’s important.
Sarah: Blood pressure cuff, gown, any other things you’d suggest to have in the room?
Heather: In the office, the chair size, but the space to move into in and out of a bathroom, most of that is not a problem in a labor unit. I think chairs are important too. A rocking chair, what is the width of a rocking chair? What are options? Can we look at that? I think the next piece is really about the artwork that they see on the wall. What are they seeing? What’s on the website for the hospital? Do we have diversity of size in everything that we see? Because again, we come in all shapes and sizes.
Making someone feel comfortable and identifying with what they see in the media, on the social media for the hospital or the birth center or the artwork, the magazines that are sitting out, having images of body diversity is really, really important. Then I think consent is absolutely a must. One of the number one stories that people share with me is, “Heather, I thought I had a sinus infection, and I went in and they told me that I needed to lose weight.” It had nothing to do with the reason that they were seeking care, but people think they’re doing someone a favor by saying, “Hey, I learned about this new diet pill, and I think you should try it. It worked for my cousin.”
That had nothing to do with why they’re seeking care. Asking permission in a circumstance when it’s appropriate. Someone comes in for an annual exam, and typically in an annual exam, we talk about A, B, and C, and is that okay if we talk about these topics today? They might say no, and then you would just move on. Seeking consent to have that conversation I think is really important. Being curious about hearing their lived experience. People are willing to share if we seek curiosity as we approach, but if it’s more of a shaming judgmental way, you’re not going to build trust with your patient in that way.
Sarah: As you were talking, I had this thought because I also had a couple of anesthesiologists in my DMs. This may be totally outside the scope, but I also think that not only are we interacting with labor nurses and are labor nurses paying attention to this, but also you talked about OB-GYNs and midwives but also anesthesia. I think that that was a surprise to me that I hadn’t fully thought through that when someone is requesting an epidural that is it appropriate in that circumstance for them to discuss weight? I know neither one of us are anesthesiologists, but the anesthesiologist was like, “It does make my epidural more challenging.”
Do you have any tips for addressing that or even the little bit of bias I have internally of how doctors approach the bedside versus even midwives or nurses? I almost want to protect my patient and be like, “Hey, the doctor’s going to come in. They’re going to ask you these questions.” We prep them for the anesthesia. Is that something that you would recommend us saying anything ahead of time, specifically around anesthesia?
Heather: Yes. I feel like I should have added anesthesia dosing to the list of when having a weight [inaudible 00:45:12] because I mentioned pediatric dosing [inaudible 00:45:15]. Agreed. Anesthesia, I think that my understanding is that is a number that they need to have. Someone’s height as well. To me, I would hope that anesthesiologists would also just be aware of potential weight bias that they have and could approach the patient with kindness and use language that is person-centered as well. I don’t necessarily think that we need to do any protecting or preloading around that. I would just hope that everyone is going to approach the patient with grace and having their best health and interest at heart.
Sarah: An epidural can be challenging regardless of the size of the patient. There’s lots of different reasons. If it’s challenging– I’ve heard, there was one in particular anesthesiologists that I worked with for a long time that frequently would, I think, cause harm because of that. Would be like, “Lean over, push over.” I specifically remember a patient like looking up from her epidural and saying, “I can’t lean over anymore.”

Sarah: I looked at the doctor and I was like, “She’s leaning–” Yes. Like, “Hello.” I was like, “You’re doing great. None of that matters. You’re doing great.” It’s just, I think, an awareness. Now even that story, I remember being very– clearly, I’m still bothered by it. Years later, I remember very specifically this patient’s face and the shame and the discomfort and the like, “I’m sorry, I am who I am,” was what I interpreted. It just totally broke my heart.
I think what I love about even just opening up this conversation is that awareness of, oh, open your eyes and look around you to what you’re experiencing. We all need to be honest, this is 100% an issue. Not only do we know internally because we know we’ve seen it, but also the research you’re talking about, it’s extremely clear. This is an area for us and why I love that we’re talking about it. Any other tips for us or anything you want to leave us with that you would hope for our community?
Heather: I feel like sometimes when I talk about weight bias– I speak to obstetricians and I speak to nurses and I talk to all sorts of audiences. Sometimes what happens is I see someone start to cry during the talk because it’s hard to hear. People feel like, “I have caused harm,” and they feel terrible that– or people have been harmed in their lifetime, and it’s just hard. I guess I just want to say, we always can do better. Just start today. I always say I can do better. I’m learning so much as a researcher and as a midwife and educator. I just would say, keep on keeping on. I think it’s important to really just be open to potentially doing some self-reflection that might be hard.
There’s a great resource through– it’s called the Implicit Association Test, that I used to measure implicit bias among midwives. It’s free. It takes less than 10 minutes. You, basically, look at a series of images and you can answer questions, and it helps you understand if you have weight bias. Starting with some self-reflection. Then I think just talking about it, surrounding yourself with materials, going to different resources to learn more about this because it’s not something that you can just– it’s implicit. Most of the time, it’s not something that you can just say, “Okay.” It’s really about growing and learning as a person.
Sarah: I love that. Thank you so much for being here. If they wanted more from you, is there a place that you want to send them?
Heather: I want to give credit to Dr. Rebecca Puhl. She was on my dissertation committee. She is faculty. She’s my external member, and she is the leading international and national expert on weight bias. She has a wonderful resource. It’s called the UConn Rudd Center for Food Policy & Health. I highly recommend checking out her website. She has a lot on there for healthcare providers in thinking about weight bias and how we can do a better job. I’m curious to see what’s going to pop up on Instagram. I think having the conversation is really important. Happy to continue to just have this conversation. As I said, I’m learning, so I really appreciate feedback so we can all just do a better job of taking care of people.
Sarah: What she’s referencing is that this is a part of a little mini-side passion project of mine that’s come out of our physiologic birth class. One of the major objections that I’m hearing across the board, whether that be in person with many of you or online, is that while I can’t do anything I learn in the physiologic birth class, or maybe not all of it, that’s an extreme, but there are components I can’t do because of my patients BMI, their word choice.
That has bothered me, and it has actually led me here and has led me to put together a advanced physiologic birth training that will specifically address weight, weight bias, adaptations for various sizes of bodies, and what we can do specifically with some of these tips to help downregulate their nervous system because we know, and you’ve learned in everything that we do, that that brain is so incredibly important. A lot of times we are doing harm without knowing that we are doing harm, whether that be with somebody in a larger body, or that be with somebody that’s different from us, or that be with somebody that has the exact same preferences that we may have for our own labor and birth.
Our jobs are so incredibly important, and we have so much impact on their psyche but also on their actual labor. If you don’t know about that and you want to learn about that, you can head over to bundlebirthnurses.com. I highly recommend our physiologic birth class as your foundational class to get you going, but we have so many other resources over there. We’ll link everything that was mentioned in this episode in the show notes down below. Thank you again, Heather, for sharing your knowledge and your wisdom with us and for just bringing some invitation and some challenge to this unique side of our jobs that is so frequently not addressed.
Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram. Now, it’s your turn to go and do some internal reflection with so much grace and love for yourself because you’ve showed up here and you are doing the work because once we know better then we can do better. We’ll see you next time.