'I was about to give birth when my doctor said something about my body.'

During their pregnancies, Jane* and Belle* had no health complications. Their blood work? Perfect. Every test set before them, they passed with flying colours. And yet, they were treated as "high risk" cases.

Their stories start the same way, by a request from a doctor without so much as a 'hello'.

"It's quite humiliating when you go in for your appointment and [the doctor] immediately says, 'Okay, jump on the scales,'" Jane told Mamamia. "I've also had a false accusation of having type two diabetes. It's like, 'You're Polynesian, you are this big, so you must have this'."

Belle can relate.

"[I was] weighed as the first thing before even meeting any health professional," she shared. "Then blood pressure was taken, and a big red note was made in the front of my file: 'LARGE BLOOD PRESSURE CUFF'."

Insensitivities and assumptions like this, while they might seem innocuous, are actually manifestations of what is called "weight stigma".

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"Weight stigma is negative stereotypes, prejudiced attitudes and discriminatory behaviours towards individuals because they are living in a larger body," said Haimanot Hailu, a PhD candidate in Monash University's Health and Social Care Unit.

In other words, weight stigma involves "behaviours that make women in larger bodies feel disrespected, devalued or humiliated".

"Some of the common examples include the use of insensitive language and blaming women for getting pregnant while living in larger bodies, the immediate assumption of pregnancy complications (labelling the women as 'high risk') based only on body size, and giving vague pregnancy and gestational weight gain-related education."

Despite their healthy test results, both Jane and Belle were classified as "high risk" during their respective pregnancies due to their individual BMI (Body Mass Index) scores. This gives an indication of body size by calculating height and weight.

"Even though it is well documented that [BMI] is a 'flawed' measure, it is still being widely used to determine the health status of the general population and establish 'risk' in pregnancy because of its ease and affordability," said Hailu.

According to scientific evidence, explained Hailu, BMI does not consider overall body composition (including bone, fat, muscle mass,and waist circumference), so it may not be an accurate measure for individuals with high muscle mass or pregnant women.

"BMI also does not consider the genetic and demographic factors that influence natural variations in body size because it was originally developed based on the European white men population. Hence it may not accurately indicate the health risks of other ethnic groups and gender," she added.

According to the medical world, a BMI of over 30 can interfere with pregnancy plans. This was certainly the case for Jane and Belle, who wanted intervention-free births — but faced many hurdles along the way.

"The BMI cut-off points that dictate an individual change from healthy to unhealthy are basically arbitrary," explained Hailu. "In general, using this measure to determine risk for pregnant women is concerning because it may lead to automatic labelling as 'high risk'. This leads to over-medicalisation and surveillance of their pregnancy, limiting their desired birthing and caring options and increasing perinatal interventions, which are all the manifestations of weight stigma."

During her pregnancy, Jane would frequent online BMI calculators and think 'Oh no, I'm gaining too much weight'.

"It's frustrating on the side of just not having any other health complications but one little bug stick," she said.

As for Belle, when she met her midwife, she requested a water birth. The consent form was signed and everything looked fine. But as she was ready to welcome her baby, she was told it wasn't possible.

"Once I was at the hospital and well and truly in labour I asked my midwife — who had taken my weight throughout the pregnancy and who had processed my water birth consent forms — if I could get in the bath," Belle recalled.

"She chose that moment to inform me that she would require me to get on the scales because I wouldn't be allowed to get in the bath if I were over a certain weight."

Feeling "exhausted and vulnerable", a dejected Belle walked away "feeling disappointed and let down".

"I was really needing support and I ended up in a crisis of confidence, feeling like I couldn't stand the intensity of the labour and doubting my body all of a sudden because it was wrong for being so big," she said.

"Not being allowed this choice was based purely on outdated and not evidence-based hospital policy that frankly makes no sense. An individualised clinical assessment would have shown that it was safe for me to have used that bath."

Jane, meanwhile, described "fighting against the grain" to achieve her natural birth outcome. Due to her BMI, she was faced with threat of induction and the threat of hospital transfer to one with more resources.

"When you're living rural, hospitals that are closer to you are generally low risk hospitals, and they don't have the facilities or the capacity to really take on 'complicated' cases," Jane explained.

"Going to the hospital for my first two babies was a two and a half hour drive, and then I heard, 'Okay, you're 37 weeks pregnant, and we're thinking you can't go to this hospital. You're going to have to go to one which is another 45 minutes further, because we can't tick that box as far as BMI is concerned. You have a decision to make.'"

According to Hailu, "lack of appropriate size equipment" and "discriminatory healthcare policies" can "negatively impact the women's psychological, physical, mental health".

"It results in a range of harmful consequences to women's mental, physiological, and behavioural health. For example, higher stress, depression, body image concerns, disordered eating symptoms, reduced motivation or self-efficacy to engage in healthy behaviours which may lead to further weight gain and continued cycle of weight stigma," she said.

This was certainly true for Jane who, in an attempt to keep her weight down during pregnancy, developed an eating disorder.

"I found I was happy not to be gaining weight in my first trimesters, and I almost encouraged it," she told Mamamia. "I was checking my weight a lot and trying to reduce it. I was eating minimally, or trying to do intermittent fasting or things like that."

Both Jane and Belle's mental health was also impacted by the stigma.

"Ultimately, as a larger-bodied mother, I felt like I could not let my guard down and could not trust the midwives and doctors to treat me and my individual health," Belle said.

"I had to work hard to believe that my body was healthy and functional and capable of birth because it was implied that my body was wrong and unsafe because of my weight."

On a larger level, weight stigma means that women "lose trust in the health system," said Hailu, citing a study which showed affected women "would avoid or delay seeking reproductive healthcare due to fear of judgement".

This was Jane's reality.

"If we didn't have that weight stigma, I would have happily had more kids," she said. "By the time we were pregnant with baby number five, I said [to my partner], 'You're getting the snip, I don't want to go through the health system anymore'."

So, what's the solution? According to Hailu, there's a long way to go.

"Some of the things we can do include shifting the focus from weight to promoting actions that improve the overall health and well-being (for all individuals regardless of their body size), to be empathetic with larger-bodied women, and always evaluate our conscious and unconscious biases," said the PhD candidate.

"Another important area would be to make healthcare policies more inclusive, and creating more size-friendly equipment and facilities."

Belle also advocates for policy change and "evidence-based care that takes into account the individuals' needs".

"My advice to all pregnant women is to advocate for individualised care for yourself and inform yourself on birth beyond what the hospital and popular culture tells you," she said,

"Specifically for larger-bodied women, I would advise to get to know the policies and guidelines of your hospital on all things related to weight, look at the evidence and research, and hold boundaries on the things that are non-negotiable for you in your care.

"But also, your body is incredible and capable, and you are worthy of professional healthcare without weight stigma."

*Jane and Belle are known to Mamamia but have chosen to stay anonymous for privacy reasons.

If you or anyone you know needs support for eating disorders, please contact the Butterfly Foundation National Support Line and online service 1800 ED HOPE (1800 33 4673) or email support@thebutterflyfoundation.org.au.

Feature Image: Getty