Keenan, Julia and Stapleton, Helen, 2010, Bonny babies? Motherhood and nurturing in the age of obesity, Health, Risk and Society, Vol. 12, No. 4, 369-383
This article grabbed my attention as I am very interested in issues of feeding and nurturing as core activities of motherhood practice, as well as in body image issues. In this article, Keenan and Stapleton draw on women’s accounts of their interactions with health professional and families to see how the prevalent and powerful biomedical discourse around obesity plays out in practice. The authors describe the importance of this discourse for this study as involving the medicalisation and moralisation of large bodies in pregnancy as ‘obese’ and thus the creation of subjects ‘at risk’ to themselves and their foetus/infant.
This paper is based on findings from a qualitative research project, conducted from 2006-2008 in a city in the north of England, and this paper draws mainly on accounts and experiences told by participants with large bodies.
First they discuss the World Health Organisation’s definition of obesity as ‘excessive fat accumulation that may impair health’. This definition is operationalised many times through the use of Body Mass Index (BMI), based on a height to weight relationship, which is a simple and cheap tool. A BMI of over 30 is most commonly seen as obese. For children, categories are based on the percentile position on ‘normal’ growth scales. Obese children are considered those which surpass the 95th or 98th percentile.
The authors discuss the different problems that the use of BMI to figure out risks brings, and show how critical studies of obesity question the link between BMI and health, which often are translated into policy in oversimplified ways that create definitions of certain bodies as fat and problematic.
The authors show how biomedical research links appropriate pre-pregnancy weight, weigh gain and nutrition in pregnancy with satisfactory foetal outcomes, and more and more with infant health over the life-course.
In the biomedical literature, a BMI over 30 is linked with
‘increased risks of miscarriage, gestational diabetes, high blood pressure and pre-eclampsia, blood clots, haemorrhage following birth, increased risk of induction and instrumental delivery, post-caesarean wound infection, genital and urine infections, giving birth to an infant with an abnormally high birth weight and problems with breastfeeding; obesity is significantly implicated in maternal deaths (CEMACH 2007). Babies born to ‘obese’ mothers are at increased risk from premature birth, still birth and birth abnormalities and are more susceptible to health problems, including obesity and diabetes in later life.’
However, as the authors point out, there is still debate about how much of an increased risk obesity brings, and these risks are not exclusive to women with BMI over 30. And there are contestations to the notion that adult health is predetermined by infant body size.
But this discourse comes strongly through social and cultural norms concerning the right way to prepare for pregnancy, and is framed in the media in this terms. This authors point out how health has increasingly moral connotations, and how being obese, this ‘risky’ bodily state is seen as an individual and moral failure.
However, given this atmosphere, the authors were surprised to find that women in antenatal interviews reported that health workers did not discuss ‘obesity’ with them. Very few were under consultant care due to their weight, and most of them were not aware of any of the risks listed above, apart from those few who were self-informed. In the UK, maternal weight in pregnancy is not monitored. So apart from a one-off measurement of weight and height at the beginning, weight is only informally monitored by midwives. Women with a family history of diabetes, or with a BMI over 30, where tested for gestational diabetes, and monitored if the results were positive.
The authors argue that it is understandable that health workers were reluctant to broach the subject, as despite the urgency of the obesity debates, there are still no clear policy guidelines, support or resources, and health workers do not want to make women feel guilty, uncomfortable, or encourage them into weight regulation. Although the authors do not go into this in detail, they highlight that negative comments were always given by family, their social circle or the media.
In this way, weight was not made an issue during pregnancy by health workers, and while attempts at discussing this issue by participants were met with reassurance, some women found this helpful, while others found it frustrating, as they would have liked some support and discussion. This was especially the case for women in terms of birth plans. Most of them were led to believe that they could just plan whatever birth they wanted, but they were unaware of the regulations that prohibit certain options for women with BMI over 30, and they felt that, at the last minute, they were snatched of their choices.
Furthermore, the lack of dialogue about the risks for women and their babies meant that when health professionals, especially higher rank ones, mentioned weight as the cause of ‘poor outcomes’, these were dismissed by women. The approaches that higher ranking health professionals used were crude, induced blame and were insensitive, and did not work in terms of the goals of these professionals – raising awareness about the risk of excess adiposity – but made women, quite rightly, discredit their comments.
In terms of infant size, the authors note that across their data as a whole, underweight or premature babies generated much more anxiety around their weight than a baby deemed to be ‘big’. The authors show that the much like the more traditional understandings of ‘bonny’ babies, bigness and a good appetite were seen positively, and not as a problem. The only exception to this unproblematised view of weight gain was done by women who managed diabetes through pregnancy.
The authors end up concluding that while they do not want to contest the studies that relate excess adiposity with increased risks for women and infants, they want to identify the problems that using a measure such as BMI can bring in terms of policy, or in its translation in the treatment of individual women to improve birth outcomes and health. This article shows the disparity between discourses and practices. At the moment, health workers do not encourage women to manage biomedical risks, within pregnancy, but there are many policy and guidelines in the pipeline that are probably going to change this. Moreover, this article underlines how it is not possible to understand the medicalisation and moralisation through the work of one type of actor, such as health workers, but other social actors need to be included.
I liked this article because it tackles a sticky issue: how to understand in a measured way the risks that ‘obesity’ might bring, while problematising deterministic studies and the individualisation and moralisation of this problem. At least I find it tricky. I am worried about what these studies are showing, and scared, frankly, but at the same time, am wary about how this might be translated. If I had to bet, I would say it will probably end up in blaming the mum, and not only for a difficult pregnancy and or birth, but for the health of their children now and forever. Which is not the outcome I would like to see, but it is one that is taking shape in the media for instance. But just because it is sticky does not mean we can ignore it, or act as if nothing happened….It is the same with women’s bodies and fat shaming. We don’t need more of that, and we do not need more women who are not happy in their bodies. In this case, how could there be support for women, without it being medicalising, moralising and individualising the problem? As I say, tricky.