The WRISK Project is a collaboration between researchers, advocates, healthcare professionals, and members of the public. Our Oversight Committee members bring their own expertise and experiences to the project- and help keep us on track! As we are nearing the end of the WRISK Project’s funded period we’re reflecting on our personal and professional highlights of the last few years with “WRISK Conversations…”
Our first conversation is between Amber Marshall , founder of Big Birthas, and Rebecca Blaylock, the research and engagement lead for WRISK.
Rebecca: Hi Amber! Could you please introduce yourself and tell us a bit about what you do?
Amber: Hello! I’m Amber Marshall and I’m the founder of a website called Big Birthas– we also have a Facebook group which has about 500 Members. The website provides support and information for people who have a BMI of 30 and above who are trying to conceive, or are already pregnant, or post pregnancy. It all started 10 years ago when I had my first child and there was no one website that collected all the information that is specific to being pregnant and having a high BMI in the UK. I read quite a lot of stuff from America, but of course their system is very different to ours. Having put all this information together in my head, it felt a bit unfair that it would then just get lost in the ether, so I thought I would try and set up a website. It’s become kind of a bit of community and the group members are really supportive of each other and really even-handed in their understanding that everybody’s risks are different, and everybody’s approach to risks are different. It’s been really, really lovely watching this kind of community grow over time.
RB: I think that sharing of knowledge and peer support is completely invaluable. In our research we found that women with high BMIs were really stigmatised and bore the brunt of a lot of messages about how much of a risk their bodies posed to their babies. This sort of support is so important to help them navigate their pregnancies. How has being involved in WRISK been for you, and has it informed your work at Big Birthas in any way?
AM: Being involved in WRISK has been amazing. It’s been really cool to have a seat at the table with so many knowledgeable and passionate people in their own fields, and has been just wonderful because I’ve been doing this for so many years completely on my own. I’ve always felt totally welcomed and supported to put my point across. In terms of how it has impacted on my work; it has definitely brought Big Birthas and our issues to a bigger audience. Off the back of WRISK I’ve been invited to be on lay advisory groups, and I’ve been invited to provide input into new research. I absolutely credit WRISK for some of that.
Off the back of WRISK I’ve been invited to be on lay advisory groups, and I’ve been invited to provide input into new research. I absolutely credit WRISK for some of that.
RB: This is making me feel really warm and fuzzy! We’ve really valued having your input on the project- it is so important that these voices are heard, because women with high BMIs are so often ignored or side-lined in society. What are your biggest concerns about risk, communication, and pregnancy? From your perspective?
AM: From my perspective, and from the messages I receive daily through the website and through the Facebook Group, messages that people are getting are conflicting. They are in some ways quite inflammatory and quite scaremongering. People are getting the message that “you’re probably going to have gestational diabetes because you’re overweight” and actually, the risk of gestational diabetes is 9.5% for somebody with a high BMI. Don’t get me wrong, we are more likely to have an instrumental birth or C-section; we are more like to have interventions; we are more likely to develop high blood pressure or gestational diabetes- but it’s the question of how much more likely and whether that is the huge problem that it’s portrayed to be.
There’s also an impression that you’re going to struggle to get pregnant because women who are overweight struggle with their fertility and actually that’s not necessarily true at all. It’s true for some women. So there’s a problem where it’s really difficult to pull these statistics apart. A lot of people come out of appointments really stressed by what’s being said and how it’s being said to them. They come on our group saying “I’m really glad I found you guys. I’ve had a really upsetting appointment with midwife. You know, she’s told me X, Y and Z. Is this true? What should I do?” I’ve even had people ask “Should I have a termination so I can lose weight to be in a better state to get pregnant?” and it’s just like, oh Lord, you know if that’s the message that people are coming away with, what are we doing to people? At the point of being pregnant, actually the advice is that you shouldn’t try and lose weight that can be detrimental for you and the baby. So you should just try and maintain healthy eating and healthy exercise, which most people do when they’re pregnant anyway. So you should try to maintain you know, healthy eating, not going kind of too mad on anything. Nagging us doesn’t help the rapport building with the care providers and in some cases it does lead to people who are pregnant just withdrawing from that care. So they start to reject appointments with certain consultants or certain midwives. Or they start to reject interventions like scans and glucose tolerance tests. I’m worried about the disconnect.
RB: If there’s one thing that someone, whether that’s a health care professional or a journalist or whoever, can do to improve things for women in your group, what would it be?
AM: I would suggest they read the blog article I’ve written about how to be a plus size friendly professional because it explores (helpfully, I hope!) what many professionals do, what they think they’re doing, and how that actually impacts on us, with suggestions for alternative approaches. It’s very easy, I think, as a professional to tick the boxes and think “I’ve told them they’re obese and therefore they’re probably going to need X, Y and Z”, forgetting how that comes across. Especially when statistically, we probably won’t need those things, we’re just marginally more likely to than we would if we were thinner. This is the most important thing we will probably ever do with our bodies in our lives, but it’s every day to someone working in the field. They’re not gonna remember us at the end of the day when they go home and eat their tea, but we can remember what was said for the next week, and often much longer! It’s about being careful with language. Often assumptions are made like they say, “right, OK, well, you could do with getting a bit more exercise,” but they haven’t asked you how much exercise you’re getting in the first place. It’s about establishing a baseline. It’s about believing us. It’s about trusting us and treating us as individuals. It’s about appreciating that we totally want to do the best for our babies.
It’s about believing us. It’s about trusting us and treating us as individuals. It’s about appreciating that we totally want to do the best for our babies.
RB: Do you think midwives’ working conditions contribute to some of this?
AM: Yeah, they’re under a lot of pressure. They’re under a lot of tight time constraints. They’re expected to do a million and one things at each appointment. So in an ideal world you wouldn’t go to your third midwifery appointment and be asked the same questions that you were asked in the previous two. But when midwives haven’t had time to read your notes beforehand and see something isn’t happening they just ask you again and that becomes very frustrating, particularly if it’s something you said you don’t want. You have discussed X treatment and said no, and it feels like you’re being badgered, but you’re perfectly entitled to say no. I would hope that people involved in birthing babies could still see some of that magic, but I see in them that some of that magic has drained away and it is a tiring job, it’s an exhausting job. I don’t think generally people intend to be mean, but I think sometimes you do get an impression that their feeling is, “How have you let yourself get to this situation where you’re this overweight and you’re pregnant?”
I don’t think generally people intend to be mean, but I think sometimes you do get an impression that the feeling is, “How have you let yourself get to this situation where you’re this overweight and you’re pregnant?”
RB: That is something that came out in the WRISK interviews which was then reflected in the way that other sorts of information was communicated- almost treating women with higher BMIs like they won’t be able to understand other complex information. Is that something you’ve experienced or seen from the members of Big Birthas?
AM: Yeah, actually I did have one really interesting conversation with an anaesthetist when I was pregnant. I met him and he picked up my notes and he went “Oh, I see you’ve got a degree (it’s on the front of the notes, but no-one had ever looked at it in my presence before!). Well, I’ll talk to you at what I think is an appropriate level then.” That’s the first time anybody ever had done that. Most appointments are “So mum, how have you been?”, using non-medical words and such, and it’s super patronising. I’ve also heard many times that “the appointment was going fine; the rapport with the midwife was lovely, then she did my height and weight and suddenly her whole demeanour changed” and it causes anxiety for people. There are some really great midwives. I mean my midwife in my second pregnancy, I sought her out after having her for a couple of postnatal appointments with my first and thought she was brilliant. She was just great because she was very much like “Right, new guidance has come out about X. The advice is that if you’ve got a BMI over whatever, then this happens. You might want to go away and read up about that and see what you think” and I would come back to her and go, “right, I’ve read all about this and my concern is Y” then she’d go “don’t know anything about that. I’ll go and have a look myself”, and it felt fully cooperative. It felt like we were both on the same page. We both wanted the same thing. And she was prepared to support me and she was prepared to challenge if anything came up that she thought I wasn’t doing that I should be.
It’s all about informed consent and we see these conversations on our forum board all the time where people are challenged for not wanting to induce, or for not wanting to take this medication, or that test, or wanting to birth outside the obstetric unit, and so on. The response has been “well, if you want to harm your baby…” Well of course they don’t! Nobody does, but if your only way of persuading me is to scare me or to like pull that “I am the expert” card then you’re not doing your job. Your job is to convince me through the facts and the evidence, or at least say “There’s a sparsity of evidence actually, but we think on balance, that this is probably the better way to go.” Then that’s fine, but if you just say, “Well, but what if your baby dies?” or “I know best, this is our policy” it’s really unhelpful and frustrating. It’s manipulative, it breaks down trust, and we are seeing plenty of it still. It’s not changing.
If your only way of persuading me is to scare me or to like pull that “I am the expert” card then you’re not doing your job.
RB: Do you think anyone else besides medical professionals have a part to play in this?
AM: Yeah, I’d say journalism and the media have a part to play. I appreciate they just want a story and it’s really tricky because if you don’t write something sensationalist then people aren’t going to want to read it. But if you write the truth it’s much less scaremongering.
RB: Yeah, absolutely, it’s so interesting because in our work that we are about to publish, we’ve found that it is often university press offices that misreport and sensationalise research findings- which I think is contrary to popular belief! Is there anything else you’d like to share with our readers?
AM: Yeah, for people in Big Birthas it has been about finding that support. It’s really lovely to get messages from people. We’ve had two birth announcements this week and people share their experiences, for example “I ended up having an emergency C-section, but I was really glad for all your support because I could still advocate for the best emergency C-section I wanted.” There’s such a camaraderie and some people stay on even after having their baby because what they’ve learned and experienced might be helpful to other people. I think it’s important to find your community, find your tribe; I think that’s true for anything really.