Reflections on Primary Care and Public Health Conference 2019

Well, that sure was an exhausting but very worthwhile couple of days!

NEC Loading Bay – Hi-vis really sets off my outfit beautifully!

As my first experience as a conference exhibitor it was possibly a bit of a baptism of fire doing two days @PrimaryCareShow, plus set-up and take down. Definitely a steep learning curve, but really excellent to have the opportunity to put our Parenting Science Gang Research findings before a wider (and very receptive) audience!

Met many, many lovely healthcare professionals across the two days, the vast majority of whom are totally sympathetic to the rough deal bigger mums often experience, and are all too aware of some of the hurtful and unnecessary things that can be said and done while navigating maternity services; some of whom knew from personal experience!

Some interesting discussions too with healthcare professionals who clearly thought their practice was empathetic, encouraging, and open, but whose use of language belied a weight bias, or a propensity to be dictatorial in their provision of care…

What Women Wanted
Postcard – Words used by women in our research to describe the birth experiences they hoped for

Did they notice my (hopefully subtle) efforts at positively reframing their words? Who knows, but I didn’t get into any heated debates, so my challenging of attitudes was at least successful in that I seemingly didn’t make any enemies or get anyone’s backs up, I just hope my words didn’t fly completely undetected under the radar!

We did raise some eyebrows with some of the quotes from the research, even from very experienced midwives, and hopefully prompted some thoughts and reflective practice. Also gained a few new followers on Twitter and some new sign-ups to the Facebook chat group, hi if you’re reading!

Although most of the time was spent in the exhibition hall speaking to delegates, I did manage to get along to 4 conference presentations across the two days – two in the Mother & Baby programme and two of the Obesity & Weight Management sessions, with mixed reaction!

What Women Got
Words used by women in our research to describe their actual birth experiences

I was shocked and frustrated to listen to Judith Stephenson, a Professor of Sexual and Reproductive Health, waxing lyrical about a 2018 study which promoted a ‘drink only semi-skimmed milk for 8 weeks’ diet in order to facilitate rapid weight loss and thus be in a better position to enter into pregnancy – when all studies I have ever encountered suggest that restrictive diets and rapid weight loss do more harm than good, and while seemingly effective in the short term, are rarely successful in the medium to long term.

I was also frustrated that she feels that obese women planning pregnancy need to be told that they would decrease risks by losing weight. “This isn’t about blaming women” (except it sounds a lot like it!!). In my experience women are VERY aware that we should lose weight, and it’s not that bloody simple; repeatedly telling us this fact does nothing to help us, and just increases blame, guilt, and disengagement. If you actually want to help us, just ask if we’d like to do something about weight management/fitness or like to hear about local options available to help, and if we say no, move on!

I was at least able to put these points in questions after the session, and several attendees came and sought me out afterwards to thank me/agree/discuss further, so definitely glad I attended that one!

On the plus side, I do agree with her that healthcare services are missing a trick when women attending a family planning clinic for removal of a long-term contraceptive device are not given basic information about preconception health, e.g. to take folic acid, and offering signposting to services available to help with weight loss, smoking cessation etc. given that pregnancy is a very pivotal moment in a woman’s life and the likelihood is that we are at our most receptive and motivated to change any perceived negative behaviours, for the benefit of the planned-for baby.

I later attended an excellent talk by Debra Bick of the University of Warwick on the Care of Women with Obesity in Pregnancy which was far more supportive in the use of language, remembered that there’s often a husband or partner in this equation, and a really useful review of recent studies and their results – which I now need to seek out and read!

The following day was more of the same – firstly a really aggravating talk on
Weight Management During Pregnancy and the Post-Natal Period by
Dr Amanda Avery… who was billed as the chair of the BDA Obesity Specialist Group and an Associate Professor in Nutrition and Dietetics, but just so happens to be on the payroll of Slimming World and who uses a LOT of ‘they’/’other’ and presumptive-generalisation-speak when talking about women with obesity. Very judgemental/dictatorial/patronising – pregnancy is a “teaching opportunity”. All right, we get it: you’re not and never have been a fatty, and those of us who are overweight just need you to swoop in and educate us! Grrrrrr. Haven’t we moved on AT ALL?!?

She then went on to minimise the risks to the unborn of weight loss while pregnant, recommend Slimming World (of course!), push for encouraging obese women to lose weight while pregnant, and advocate for a return to weighing women at every antenatal appointment to encourage this – “it’s a low-cost intervention – you only need a set of scales!” – yes, that was dropped because it was stigmatising, anxiety inducing, disengaging, and showed no benefit to fetal and neonatal health!?! Then she suggested that the reason that childhood obesity has increased since the 1990s is because that’s when we stopped doing regular antenatal weighing! For goodness’ sakes – oversimplification maybe!?! I think quite a few other things may have changed in those two decades!?!

So. Many. Issues… I was really struggling to work out which points I was going to challenge about her talk when it came to question time – would it one of the above concerns, the persistent conflation of pregnancy weight gain with obesity, or for failing to adjust macrosomia figures to account for gestational diabetes… but no need – there was no opportunity for questions unless you stayed to listen to the following talk too! Arrrgh!

Fortunately my confidence was later restored by a lovely talk by Karen Gaynor, a senior dietitian from Dublin, talking about The Impact of Stigma and Bias in Obesity Treatment, who totally gets it: You want to build an inclusive empowering dietician service? Then ask your patients what they want and involve them in designing it!

Don’t push for dramatic and unachievable weight loss goals – 10% is about the realistic limit! Remember that around 85% of obesity is due to genetic factors – only 15% down to environmental factors, with only a proportion of that down to personal willpower. Never forget we’re in an obesogenic environment and change is a massive uphill struggle and life-long commitment! Don’t use shaming imagery – there are plenty of online free-to-use gallery images featuring empowering pictures of overweight and obese people (try https://easo.org/media-portal/obesity-image-bank/ ) – and if you see stigmatising imagery or language used in practice or the media, call it out!! Honestly, the talk, and the questions/comments from delegates which followed were so uplifting! What a great session to end on!

I totally need to namecheck our lovely neighbours at https://littlepeopleuk.org/ and https://www.burningnightscrps.org/ with whom we shared laughs (and confectionery when energy was flagging)!

Most special thanks go to (in order of appearance) the wonderful El, Serena, Mawgen, and Dani; who worked charmingly and tirelessly along with me (with the aid of sugar and caffeine) in talking to dozens? hundreds? (wish I’d had the foresight to bring a tally counter – lesson learnt) of healthcare professionals across the two days.

Lastly (this is starting to feel like an Oscar acceptance speech, I’m sure someone somewhere is frantically gesturing me to get a move on as the orchestra pipes up!) huge thanks have to go to The Parenting Science Gang for making this happen, and Wellcome for funding it!

Lots of contacts made, lots of thoughts provoked, lots of ideas forged, lots of avenues opened.

Big Birtha x

Post-show carnage
Post-show carnage

#FatFertilityMatters Q&A with Nicola Salmon

Are you affected by fertility issues?

Sick to the back teeth of hearing “have you thought about losing weight?”

Want to talk about it, or listen to someone else talk with experience of the issue?

Then join us on Monday April 15th at 9pm.

Nicola Salmon, author of ‘The Fat Girl’s Guide To Getting Pregnant’ and the originator of the #FatFertilityMatters hashtag is going to be with us for an hour to answer your questions on all things fertility related!

To get involved you’ll need to join the Facebook group set up specially (do it now, before you forget!)
https://m.facebook.com/groups/366477067323511

Find out more about Nicola and #FatFertilityMatters at nicolasalmon.co.uk

See you there!

BigBirthas PSG Research Results!

So, you’ll want to know what happened to the BigBirthas PSG research results? What did we get up to in collaboration with the Parenting Science Gang?

Well, we’re all done. We put out the initial calls to join our Facebook group back in March 2018. Thank you to everyone who joined in. 161 people joined the Facebook group, and we’re still actively discussing issues even now the research has concluded! We held dozens of expert Q&A sessions, and some of the experts sounded like they enjoyed it as much as we did!

Join our Facebook group!

The BigBirthas PSG Research Topic

Conversations within our group revealed that many of us felt our choices were unfairly limited during pregnancy and labour. Our experience suggested that a high BMI leads to health care professionals restricting the choices which are normally available. We also felt that often, there was no medical evidence to suggest that our preferences weren’t perfectly reasonable. Many of us had had very negative experiences, even when our pregnancies were otherwise uncomplicated.

We decided to research how choice is presented to mothers with a high BMI and how that affects maternity experience. Were our situations typical? Or had our negative experiences made us unaware of high-BMI women with less traumatic stories?

We recruited volunteers from anywhere and everywhere in the UK we could think to ask. We were then overwhelmed by the enthusiastic response! Almost immediately, 60+ women responded to our request for research interviewees. 20 of those swiftly completed the full-length responses we needed to do our qualitative study using thematic analysis methods.

Then we stopped asking for respondents, because 20 was about the limit we could manage! Especially with just a small group of first-time thematic analysts running the show!

But that’s the point of Parenting Science Gang; let the parents be in charge of asking the questions they want answered, and of working out how to do it!

The Full BigBirthas PSG Research Findings

Please be aware, that for some, reading other people’s stories can trigger upsetting memories of our own experiences at a time of our most intense vulnerability, so if you do read the full document, please bear this in mind.

You can read our BigBirthas PSG Research Results here: Big Birthas’ Findings

What did we find out?

We did not uncover any great surprises. Our results confirmed that the conversations our group had had were pretty typical. There were a few great stories about knowledgeable health care professionals treating mothers with dignity, but we also found clear themes of unsatisfactory treatment. Several reported observing an immediate change of tone after being weighed:

“When I’d been weighed and measured she immediately started saying things like “Oh, there will be a problem because of your weight” but wouldn’t explain what the problem was. She wasn’t as friendly then and wouldn’t explain things to me”

Language changed, and some mothers felt lectured and patronised. There were almost constant warnings about potential problems (most of which never transpired), repeated tests for conditions (many of which never developed), with some health care professionals resorting to “persuading” mothers using guilt tactics.

“I felt that I was coerced and guilted into an additional scan by one particular midwife.”

“Felt that I didn’t have a choice, I was scared into decisions.”

“I was told ‘Well you must have known the risks when you decided to get pregnant, being the weight you are.”

First Pregnancies

In most cases, first-time around, mothers reported following the recommendations of health care professionals unquestioningly. This too echoed our experiences in the group. It was only after the first birth that many realised that they should have had a choice.

“I didn’t realise you could refuse induction”

“In both labours vaginal examination was presented as a non-option.”

Some mothers reported being ignored:

“I was given all the interventions including an epidural that I had refused”

“First time round I agreed to one [vaginal examination] and the midwife swept me without my consent.”

Disagreements Between Health Care Professionals

Worryingly, many mothers reported finding a great discrepancy between health care professionals, in terms of knowledge and subsequent behaviour. Sometimes mothers found that their weight was the scapegoat for everything with a few professionals, but that others didn’t agree.

“The first sonographer very harshly said that the reason she had trouble was because I was quite fat so it was harder to get a good picture. During other scans I was told that weight doesn’t necessarily come into it and it really does depend on the competency of the sonographer and the position of the baby/womb/placenta”

Many mothers received conflicting messages about risk and options from different professionals. This was both confusing and upsetting, and didn’t inspire confidence in the system to provide for their needs.

“I felt that people knew best, but when professionals are literally disagreeing about the well-being of your unborn baby, it’s a bit disheartening.”

Stress

This lack of consistency, coupled with feeling judged and unsupported had a strong effect on mothers, many of whom reported that pregnancy had been an extremely stressful time for them.

“I found it scary and confusing during my first pregnancy.”

“I left some midwife appointments afraid that I might die in labour!”

Second Pregnancies

Not unexpectedly, mothers prepared for subsequent pregnancies with care. No one mentioned losing weight, but many mothers talked about being much better informed. Many read up on guidelines and risks, were more confident in asserting their views and wishes, and challenged health care professionals to explain themselves, their actions and their recommendations.

“I had the confidence (or some might say bad attitude) to say, I’m not having all of those scans – they aren’t necessary and are a waste of my time.”

Many approached their relationships with health care professionals differently second time around. This manifested itself in their making a concerted effort to form respectful and supportive relationships from the start, either by seeking out professionals they had found supportive in their first pregnancies, or by actively avoiding certain individuals. In several cases women said they had paid for independent midwives or doulas to support and advocate for them.

Sadly, in several second pregnancies, mothers also reported avoiding health care professionals wherever possible; engaging as little as possible and refusing appointments. More than once, mothers reported needing to do this for the sake of their own mental health. This is clearly a very worrying result; it cannot be ideal for any mother, irrespective of medical needs, to be avoiding the service provided to support her. This did however, seem to be a common reaction to prior bad experiences.

Risk Presentation

We know (and I have complained many times!) that many of the risks in pregnancy are delivered in terms which make them sound excessively alarming. For example, where a risk changes in likelihood from 0.1% to 0.3%, it is often represented as “THREE TIMES THE RISK” in big, bold letters, which makes the difference seem very extreme, when it is actually still very low risk.

These alarm bells are also usually rung when the mum is already pregnant, so NOT a safe time to diet or do anything about it, and just increases the stress and feelings of guilt. This is not helpful, and given that no respondents mentioned consciously trying to lose weight between pregnancies, such an approach is clearly not serving any weight-loss motivational purpose either.

There are examples of great care, but until we are able to universally provide larger mums with a respectful and compassionate experience, ensuring they feel in control, then many more mothers will suffer from unnecessary stress during pregnancy, with the result that some will avoid health care professionals altogether, potentially putting themselves and their pregnancies at greater risk.

Thank you to the Parenting Science Gang Team!

Huge thanks to the Parenting Science Gang Team for bringing this project to fruition, for being such lovely, patient, intelligent, enthusiastic ladies, and particularly to Sophia for birthing PSG in the first place. Long may PSG continue gaining funding and doing Citizen Science into all sorts of topics, because it’s bloody ace.

Go and have a look at the Parenting Science Gang page! This link says pretty much everything I’ve said above, worded pretty similarly, but if you have a mooch around, there’s all sorts of fascinating information about the other groups and their experiments on breastmilk, baby wearing, picky eating, homeschooling and more: http://parentingsciencegang.org.uk/experiments/big-birthas-findings/

If you’d like to join us, the BigBirthas Facebook group is still going. Feel free to come and pick our collective brains, have a chat, discuss unicorns, it’s all good! We chat about all topics BigBirthas related, and anyone can post a question for the wisdom of the hivemind to respond. You’d be very welcome.

xx

Big Birtha

Help us with our research!!

Exciting news! For a few months now, I’ve been working with an organisation called Parenting Science Gang – we are a group of mums (there may be a few dads, but it’s mostly mums) doing research into what interests us – and we’ve got a special Big Birthas Parenting Science Gang Group.

We’ve discussed what research we’d like to see, researched what science and data is already out there, and we’ve interviewed other scientists to get their views on what we should research and how to go about it, and now we’re finally ready, have received ethics approval, have volunteers ready to send out, receive, and analyse questionnaires – all we need are a few individuals who fit the criteria we’ve set to answer our email questions!

Could you help us?

We need people who:

  • are over 18
  • have had 2 or more pregnancies where their BMI was over 29
  • whose youngest child is under 3
  • whose births took place in the UK
  • are happy to be interviewed by email about their experiences

If you can say yes to all three, please follow this link for more information and sign up here to be interviewed –

http://parentingsciencegang.org.uk/experiments/big-birthas-research/

your thoughts could really make a difference!