"Your body's too fat to carry babies"
An interview with size-inclusive OB/GYN Dr. Anna Whelan
Welcome to Chief Complaint! For those of you who are new, this newsletter features intermittent musings about medicine, gender, parenting, and body liberation — all from your friendly neighborhood primary care doc. I’m so happy you’re here.
A brief note: I’m feeling a lot of grief about the election results, and I’m sure many of you are, too. I edited this piece before election day, and I debated whether or not to share it this week.
I obviously decided to go with it – it feels even more urgent, now, to remember that there are many good people fighting for a better world. And Dr. Anna Whelan, whom I interviewed for this post, is one of them.
Also: Today, I’m on ’s podcast, Burnt Toast! What an honor. We recorded our conversation pre-election – I hope it helps in this difficult week.
When I was pregnant with my son, I felt like I was having a perpetual out-of-body experience.
I found out I was pregnant in that intense pandemic winter after the brief reprieve of summer 2020, and in some ways, being so isolated was a kind of a gift. I still saw patients and my husband, but my changing body was under less scrutiny. I didn’t feel the perpetual gaze of others. It helped me start to reframe some of my thinking about my body. It helped radicalize me.
On the other hand, like every pregnant person in the history of the world – probably – I suddenly felt like my body was public property. Family members, coworkers, and occasional strangers all felt compelled to comment on my body and the way I treated it.
I was trying to treat it well, but it was hard. I felt overwhelmed by an anxiety I’ve never felt before – or thankfully, since – and I felt sick. Really sick.
For the first time in my life, I felt uninterested in food, because everything I ate I immediately vomited up. I drank a lot of ginger ale and ate a lot of Saltines. Which, come to think of it, is the “Presby Cocktail,” a snack I ate at 2 a.m. many times in residency at Presby(terian) Hospital, foraged from the patient snack closets on the hospital wards. (An authentic Presby Cocktail also involves mixing the ginger ale with sugar-free cranberry juice. Bonus points for authenticity if they’re salt-free Saltines. Boy, do we torture our hospitalized patients with terrible food – an essay for another time.)
Even though I felt nauseated all the time, I was praised by the midwives I was seeing because I wasn’t gaining weight. “Congratulations on keeping that weight gain slow,” one told me at a visit right before I gave birth. Which, of course, made me feel awful.
Was feeling terrible all the time what it took to keep me from gaining weight? And was that the only thing that might reduce my risk of diabetes or high blood pressure in pregnancy? Which then might help my son reduce his risk of diabetes or high blood pressure? Was this the cost of “being healthy?”
Luckily, there is another way. Today, I’m happy to share a discussion I had with the amazing Dr. Anna Whelan, an OB/GYN and maternal fetal medicine specialist at UMass Chan Medical School, who is leading the way towards size-inclusive pregnancy and childbirth.
I’ve gotten to know Anna because we are both on the board of the Association for Weight and Size Inclusive Medicine, and let me tell you: she is a total badass. She’s a researcher who studies mental health in pregnancy, she just ran the New York City Marathon, she is a mom of two, and when we spoke, she was just about to go deliver triplets! Anna is fighting for a world where people of all body sizes have the resources they need to have safe pregnancies and deliveries, free of discrimination and shame.
Please note: we talk about some heavy stuff, including pregnancy loss and disordered eating, so just skip this one or come back to it later if you aren’t feeling up for it.
Mara: What got you interested in maternal fetal medicine? Not everyone knows what the field is.
Anna: Maternal fetal medicine is high risk pregnancy care. We’re focused on taking care of pregnant people who have medical conditions, which can range from conditions they were born with, to things they develop in pregnancy, like diabetes, high blood pressure, and problems with the way the baby has formed in the womb.
I got into medicine because I wanted to empower people to understand their bodies. When I was a pre-teen, I was disturbed by how little I knew about my own body and how much shame there was around my body.
My other interest is in research and in advocacy. I wanted to use my knowledge and my expertise to help advocate for access to reproductive health care, and help policymakers understand that making somebody continue an unwanted pregnancy is incredibly dangerous.
Mara: It comes down to reproductive justice, which is an activist framework that has its origins in Black intersectional feminism, that advocates for the right to bodily autonomy, the right to have children or not have children, and parent the children we have in safe and sustainable communities.
Anna: I want people to make decisions about their own bodies: whether it's how they want to receive medical care, when they want to become pregnant, when they want to have families, or if they even want to have a family. It is about choice, and not being pressured or forced into something.
These principles are related to fatphobia, too – such as a doctor saying, “You can't get the surgery unless you lose weight.” Or, “You can't get pregnant, I won't prescribe you [fertility medications known as] ovulation induction unless you lose weight.” One of the things that makes me the most irate about some OB/GYNs is when they tell patients that they shouldn't become pregnant, or they withhold reproductive care because of someone's size.
Mara: Can you tell us more about the ways in which fatphobia shows up in pregnancy care and obstetrics?
Anna: Just like when people are not pregnant, people can't control their weight gain during pregnancy. There’s a lot of shame around that.
Patients in bigger bodies also face overt discrimination. Their doctor can't believe that they don't have gestational diabetes. I've had patients that come to me who have been tested four times for gestational diabetes, who have been told, “There's no way you can't have gestational diabetes. You're fat.”
I had a patient who had three miscarriages, and was sent to me during their fourth, and their doctor told them, “I think it's time to stop trying. Your body's too fat to carry babies.” Which is just awful and heartbreaking and not true. That patient got a new provider and went on to have a healthy pregnancy.
I receive transfer calls about patients who have been planning to have a birth at one hospital with their provider [whom they’ve seen for all of their prenatal care], and they feel safe. And they come to labor and delivery, and the anesthesiologist says, “I won’t intubate somebody who has a body mass index over 50 [which might be necessary during an emergency C-section]. So you can't deliver here.” And so they're in labor, and they get transferred to a different hospital. It’s terrible when it happens in the most vulnerable time in a patient's pregnancy, and possibly in their life.
Here’s another story that illustrates some of the fatphobia in pregnancy care. A patient came to me for a preconception consultation after she lost the baby at 38 weeks in a prior pregnancy. She's healthy. She passed all her diabetic screening. She had no infectious diseases, no medical problems, and her BMI was 38. And she said, “You know, the week before my baby died, I kept going in, and I told them I couldn't feel my baby. And they would do a spot check of the heartbeat, and said that my baby was fine, and I just couldn't feel him because I was fat.” And so instead of listening to her and hearing her, her providers were like, “Well, of course she's too fat to feel her baby.” When we know that doesn't physiologically make sense. You're not feeling your baby on the outside. You're feeling them on the inside. She should have been listened to and she wasn't. And I think that that is just a tragic example of how patients’ concerns are dismissed or blamed on body size.
Mara: That’s bringing tears to my eyes. That’s so upsetting.
Let’s talk about some of our cultural assumptions around body size in pregnancy. It’s such a strange time of mixed messages about our bodies: It’s okay to gain weight, but not too much weight, and you’re expected to lose all the weight immediately after delivery. And pregnant bodies are treated like public property.
Anna: I spend a lot of time talking to my patients about how to set boundaries about their body size and pregnancy. Because I totally agree with you. Like, people stop you at Starbucks and tell you not to have a coffee. People stop you and ask you if you're having twins and you’re having one. Or they say, “Are you sure you're not going to deliver soon? You look like your’re full term!”
And the weight gain in pregnancy is not really a modifiable thing. It's related to underlying medical conditions, your genetics, the baby's genetics, the hormonal makeup, the placenta.
Mara: A lot of prenatal providers talk about weight gain in pregnancy as if it is modifiable.
Anna: The science is incredibly lacking in this area. The majority of data that we have about pregnancy weight gain and risk of adverse outcomes – things like gestational diabetes, preeclampsia, stillbirth – comes from population level data. And so they take these big studies of, you know, hundreds of thousands of people in pregnancy, and then they make these arbitrary cutoffs to see, “Okay, when does it become a significant increase in the odds ratio [a statistical measure that looks at increased risk] of diabetes?” And then they look back and say, “Okay, if you start with a BMI of 35 and you gain 11 to 20 pounds, you're probably okay. Your odds ratios are not significantly increased for all these adverse outcomes.” But they're not looking at the individual data, in which we see that if you counsel people on weight gain in pregnancy, they have very little control over it.
Mara: Even if patients don’t have control over their BMI, what do we know about the relationship between higher BMIs and risk of developing pregnancy complications like gestational diabetes or preeclampsia?
Anna: The jury is out. I don't think there is good data for it.
We OB/GYNs used to say, “Oh, if you're Black, your risk of preeclampsia is elevated, and it's probably something genetic from being Black.” What it really is, is racism. And over the last 5 to 10 years, OB/GYNs have been grappling with the racism of how our field was started, how procedures we do were studied on women who did not consent to them, how race inequalities affect medical care. And so we've changed the whole paradigm of preeclampsia: Oh, it's actually not race. It's probably some allostatic load related to racism.
This is analogous to weight. There is good data out there that weight stigma increases allostatic load and increases stress level for people. And so I don't know if these associations are due to some physiologic process, or if they're due to the experience of weight stigma, or if they're due to patients' concerns being minimized.
Mara: One framework I often think about in my clinical practice is if I have a patient with a higher BMI: how would I treat this person if they were thin? In obesity medicine, they have an “obesity-first” paradigm - tell the patient to lose weight before you do any other treatments, which can be really dehumanizing. My approach is the opposite: Let’s approach our treatment options as if the patient had a BMI of 25.
So I’m curious to apply this to pregnancy. What can people do to minimize their risks of preeclampsia that don’t have to do with trying to lose weight prior to pregnancy, or without focusing on weight gain in pregnancy?
Anna: The biggest risk factors for preeclampsia are poorly controlled diabetes and high blood pressure at baseline. Getting those under control with medications and having regular checkups is the best thing you can do to decrease that risk. Once you become pregnant, starting a baby aspirin between 12 and 16 weeks is the only real preventative measure we have to prevent preeclampsia.
There are people who run marathons and have preeclampsia. There are people who are in bigger bodies who get preeclampsia. And then there are people who are in bigger bodies who are totally healthy and deliver without any anesthesia. So really, just having good preconception care, getting any chronic medical conditions to a point where they are well managed, and starting baby aspirin. Weight shouldn't play a role in it.
Mara: I took my baby aspirin when I was pregnant. I'm very glad I had excellent prenatal providers who got me on that bandwagon. What about gestational diabetes? What can people do to reduce their risk?
Anna: The best prevention is being active. Gestational diabetes is due to the placenta – you can’t always prevent it. There’s also a significant genetic component. But we do know that 30 minutes of activity, five times a week, can help. Like walking – because people are pregnant! They're not studying people doing, like, high intensity training. Walking has been shown to decrease the risk of gestational diabetes.
Mara: What would a truly size-inclusive approach to pregnancy care look like?
Anna: Focusing on the patient as a whole, and not reducing them to their weight. I would love to see opt-in measuring of weight in prenatal care clinics. I don't make my patients get weighed. There's no good data or evidence that supports weighing people at every prenatal visit.
Why are we weighing people at every visit? Weighing patients is not the way to tell they have preeclampsia or gestational diabetes or fetal growth restriction. We have many other techniques that are better at looking at fetal size other than following maternal weight. We're testing for gestational diabetes with a really good test. We're checking blood pressure with good, calibrated cuffs every visit.
Mara: What got you interested in size-inclusive medicine?
Anna: I’ve dealt with an eating disorder for the majority of my adult life, and have been lucky enough and financially well-off enough to receive care throughout. It has really shaped the way that I view my doctors. It’s made me realize how little weight actually matters, and how I spent so much of my time trying to shrink my body that it made me unhealthy. I have so much more energy and brain power and joy having worked through those behaviors and those thoughts. I hate to perpetuate a science that doesn't exist.
Mara: Thank you so much for sharing this.
Anna: It’s why I was so interested in medicine and making it better.
Thank you for this. I’m a healthcare professional, and I did so much performative compliance when I had gestational diabetes in my second pregnancy.
I wanted to prove that I was worthy, and I realized, after I delivered, that I had actually lost weight during my pregnancy, which I was praised for.
Of course, this weight all came back on when I resumed normal eating habits after delivery.
It’s taken years to recover from this.
I appreciate the work both of you are doing to care for patients thoughtfully— and I’m grateful for this interview. It feels relevant to the psychic difficulties of being a woman in the US this week.