Supporting Birth At Every Size #040

This week tune in as we discuss all the ways we can be supportive of our clients at higher weights. 
How do we talk to people about their weight & their nutrition & their health without lecturing or shaming?
When & why might it be relevant to discuss weight during pregnancy...and when is it unnecessary?
How can we be size-inclusive in our approaches to caring for people who are pregnant and preparing to give birth?
This discussion between Ray Rachlin of Refuge  Midwifery, Sarah Marotto, GestationDietitian, & Maggie explores addressing our biases and shifting culture around the role of weight in health.

Transcript

Maggie, RNC-OB  0:06  
Welcome to your birth partners, where our mission is to cultivate inclusive collaborative birth gear communities rooted in autonomy, respect and equity. I'm your host, Maggie Runyon, labor and birth nurse, educator and advocate. And I invite you to join us in conversation. As we step out of our silos, break down barriers and hierarchies and step into the future of better birth care. 

Welcome to this week's episode, we'll be exploring supporting Birth at Every Size, which is a play on the term Health at Every Size, which is often used to just talk about creating more inclusive health care. So how do we celebrate body diversity? And, you know, honor the fact that we all come in different sizes? So how can we kind of challenge those biases that we have about, you know, weight and larger sizes? And how do we help those in our care to really just embrace the body they're in and exploring health and nutrition, outside of just a focus on weight and size. And I think this is a really important conversation to have around birth, which is already just a time that so many people are hyper conscious of their body, and how it's changing. And then the role that we have, as you know, birth professionals as providers, in terms of how we either kind of, you know, reinforce that focus, and, you know, really make it central to care, versus considering overall health and nutrition, and how the person feels in their body, rather than examining BMI and recommending weight ranges to you know, stay within and less one size fits all nutrition counseling in pregnancy, and really caring about the person who's in front of us and what their body needs. And I am excited to have Ray Rachlin, and Sarah on to talk about this, and share a little bit more about their experiences supporting nutritional counseling, and books of all sizes, who are having babies.  Onto the show! 

All right. Well, welcome. I am so excited to be having this conversation today with Ray and Sarah and just really diving into all the ways that we can show up and support everyone in our care and making sure that we're creating size inclusive communities and not letting you know, weight be something that brings stigma and bias and shame into pregnancy and birth. So if we can just get started, Sarah, Ray, do you want to just tell our audience a little bit about yourself and what brings you here?

Ray, CPM  2:41  
Sarah, you want to go for it?

Sarah, RDN  2:42  
That sounds good to me. My name is Sarah. I am a registered dietician and diabetes educator primarily working in gestational diabetes, working within the prenatal and postpartum nutrition world over the past 10 plus years.

Maggie, RNC-OB  2:59  
Awesome.

Ray, CPM  3:00  
I'm Ray Rachlin, I'm a certified professional midwife in Philadelphia, my practice is Refuge Midwifery, and I do home birth number free care as well as fertility care and home IUI and like the greater Philly and South Jersey area, my pronouns are she & they.

Maggie, RNC-OB  3:15  
Thank you so much. Alright, so yeah, so I wanted to maybe start, I feel like this conversation, this could be an entire podcast that just constantly discusses it, because I think there's so many different angles to this and how it really shows up in our care. But I wanted to maybe just start by kind of laying some groundwork about how we can talk to clients about weight, if there are ways that you have found in your practice, that you can talk about it, they really avoid a lot of the you know, body shaming and fat phobia and a lot of things that are just so rampant in kind of typical medical healthcare when we talk about, you know, weight and nutrition.

Sarah, RDN  3:47  
Yeah, so for myself, you know, one of the areas that a major area I work in is medical nutrition therapy. So by the time I see somebody, it's usually because of a diagnosis, and often that diagnosis is gestational diabetes, right. But I've also worked with individuals who are referred for one reason per their request for general nutrition discussions during pregnancy. And for myself, the focus obviously is not on weight, or if the scale is moving. So we know that weight is often the driving force in conversations and during pregnancy or can be and then how is that message of weight I, in my experience, it's not often a positive message regarding weight is often comes with a warning or work guidelines or restriction or with pause. And what's been really interesting for me during the pandemic is the shift away from the scale. So as we've transitioned over to telehealth and the movement away from in office to appointments, especially last spring, and over the summer, it was really great to see the shift in conversation away from the assessment of how or if the scale changed when somebody went to see provider.

Maggie, RNC-OB  5:01  
Mmm.

Ray, CPM  5:02  
Yeah, so I think for me, I start off as like a weight neutral provider, there's not evidence that weighing people in pregnancy changes how much they gain. So it tends to be like this cultural, like, I think it's a lazy assessment tool, I think what people are putting in their body matters so much more than the number on the scale. And talking to people about numbers, just kind of feeds into diet culture where they don't, people want to know how to like nourish their, their self and their baby. And you can do that by like talking about what they eat, and what they're craving, and how to, like get nutrients, and how to get movement in how like, those two things together are really great at preventing complications in pregnancy. And like, none of that has to do with the number on the scale. You know, correlation does not equal causation, you know, and so these things that are associated with like, higher BMI, and pregnancy, like doesn't mean that you're a high risk pregnancy, because you're starting off, like at a heavier number on the scale. And so I treat my fat clients like I treat all my other clients, you know, like, I assume health and well being and I provide appropriate screenings. And when we're in certain categories, I talk about the difference of how the medical model assesses and manages and how the midwifery model of like, assesses and manages and like ways that, like if they want to use the tools and the medical model and the risks and benefits of those, but otherwise, you just do normal care, and you treat problems if they come up and not treating people like a ticking time bomb.

Maggie, RNC-OB  6:24  
Mmm. 

Sarah, RDN  6:25  
It doesn't have to be complicated, right? Weight inclusive care is not complicated. In fact, when weight gets involved, it's complicated. So I find it's the least complicated when that's absolutely not the driving force of any compensation.

Ray, CPM  6:38  
Yeah, it's like you can just treat people like people and what I mean, I think, like, the times that weight matters to me as a midwife is like if someone's not gaining anything, or if we're seeing like a really sudden jump, like, extreme to the time that like, indicates a problem, but it's not a nutrition. It's like indicating like another health problem, like hyperemesis, or possibly preeclampsia, but like, you know, things that are moving within the range of normal is typically that stuff that just is like used to like body shame, pregnant people, which just sucks like it's a vulnerable time as it is.

Sarah, RDN  7:14  
Absolutely, like those-that trend. So like you said, is that at least opportunities for some dialogue to support the person. It's good to hear that is your model! You know, I think it's common for us to connect through like minded people, right? It's but it's, when I remove myself from Instagram, or for the people I've met in like minded spaces, it's absolutely not what I'm hearing. And it's you know, and that's the frustrating part. So these will be these are great conversations, and then it's getting the message across.

Maggie, RNC-OB  7:48  
Yeah, I agree. I mean, obviously, it is, it's, we add in weight, and that adds a complication. It's like, there's just another variable that people think that they're supposed to be tracking, or, you know, keeping an eye on and I think there is the piece of it in, you know, the medical model that often just likes the black and white-ness of numbers, right? You know, like, I've been having conversation this week about like the VBAC calculator, all these different things that we really like to have, like, there's a percentage, there's a statistic, so the BMI, you know, like using that as a tool, even though the BMI was never created, it was created as a population health measure, it was never created for individual health, we use it like that, because that seemed all of a sudden, that seemed easy to someone like, "Oh, great, I can just make these categories and have this really firm line to measure everyone." And that takes away that piece of actually being able to have like conversations with someone. Because we know that there are certainly people at higher weights who are very healthy. They're eating with a great nutrition, they're metabolically very healthy, they're confident, they're feeling great with where they're at, just as there are people who are perhaps lower weights, who they're not actually very healthy. They're not getting good nutrition to fuel their bodies for any number of reasons. You know, they have different issues that are creeping up behind the scenes. And if we're only if we're not ever talking about weight, if we're not engaging in a conversation about nutrition, if we're not asking them what they're craving, and we're just saying like, yeah, oh, yeah, your weight falls in a "normal range," check. Right? We lose that opportunity. And I think one of the things too, I wanted to talk about this and I don't know if you could speak to a little bit of like how you do nutritional counseling with clients, but they think they're, it's easy for us to fall into just that, that weight category. And there's also a piece about like food access, and what is considered nutrition "healthy food," because I think that the diet culture piece has just it's warped so much about how we think about what food is going into our body and what the purpose of food is. 

Sarah, RDN  9:49  
Yeah, yeah, sure. So I've also worked with WIC, so I've worked at the community on the state level with the WIC program. So when you mentioned food access you know, it definitely connects when we think about for the WIC program and general nutrition. So taking a step away from somebody coming with a medical nutrition diagnosis in general nutrition and still it's, again, it sounds very similar to what you both have mentioned is whether somebody is coming to me for a diagnosis or if they're just seeking general advice it's pretty much the same you know, there's not much of a change it's: How is their appetite? Are they do they feel hunger? Are is their consistent intake or food patterns? What are their cravings? It's not a situation or environment where we I have never thankfully witnessed and nutrient analysis during pregnancy and it's just not something you know, we have prenatal vitamins that can cover a possible deficiencies. So when we look we are guided more by the person what they're stating what they are interested in, how their appetite is, are they feeling hunger? And looking at it's so nuanced? As mentioned before? Is there a hyperemesis? Are they having food aversions? So it's it's not clear nutrition guidelines because of food aversions alone during pregnancy? Right? So we it's not a food focused at all it's patterns and variety and how they're feeling overall and what they you know, what their goals are.

Ray, CPM  11:28  
So when I start nutritional counseling, I usually do in the first visit, I love to kind of just ask people like how they like to feed themselves, like what their life looks like, you know, where, like, are they eating at home, are they eating out, my typically I start with, like, my counseling is like, my hierarchy of needs, and pregnancy is protein and water at the top, and then calories, and then nutrients and fruits and vegetables and probiotics and everything else for that. Because most, you know, people who are assigned female at birth in our culture, do not get enough protein in their diet. And for me, it's like the thing that's going to keep your blood sugar stable, which helps prevent gestational diabetes, it's the thing that's going to be the building block of your baby, it's going to help your liver function as you like, make more blood, it's gonna help you make more blood. And sometimes it's like a pretty doable switch. Like I really like nutritional counseling that's about adding and switching things out. And so giving like a lot of different tools, I have handouts on, like, how to get protein rich foods in your diet, how to like easily get 20 grams, and starting off with like, you know, having people do a diet diary for like, you know, five days or so and checking in at the next appointment and then being like, okay, like, yeah, you're kind of getting this or like, okay, let's strategize on protein first. And then like, after we get protein, then we move on to other things. And just kind of keep checking in. And also using food as a tool for like when things like heartburn come up, or constipation, because a lot of pregnancy issues can be treated nutritionally. And also like, sometimes people have like issues with appetite or nausea. And those are also things that can be managed nutritionally, but it's just about like asking a lot of questions. And then like, having some strategies and tools coming back to me if they work or not, if they don't like reevaluating, and the more that I learned how my clients eat, the better recommendations I can make, because you know, if I tell somebody to eat hard boiled eggs, and they think eggs are disgusting, I'm like, that's not useful for either one of us. So like, if I know how you'd like to feed yourself that I can make recommendations that are in line with that, and then like, help you like, make changes that feeling doable and empowering. And I know like, I forgot where I learned this, but I never make more than three nutrition recommendations, like ever. It's just like, there's a cap of like, three total that like in the new I try things and reassessment, that doesn't work, then you just try those same three, again, like really trying to make things like doable, manageable and empowering because you're able to make the change.

Sarah, RDN  13:42  
Absolutely. When we're looking at somebody the same whether they have a diagnosis or not, I look at very similar I look at fluid, fiber and protein. So those also help with blood sugar stabilization, right, but they also can help with constipation. You say for protein add in, like, absolutely the message often is restrict, avoid decreased, oh, it or they'll be, oh, no, we want you to have everything, but just the small amount. So same exact approach, the add in takes off so much pressure when the message is excellent. And you know, what can you add, and I call him sometimes defensive foods, when we're talking about blood sugar stabilization, which is usually protein, nut seeds, nut butters. You know, having that just that shift in conversation and language of add-ins, like you said is exactly something that can remove this where people assume that we're going to ask them to cut down or eliminate or avoid other foods. So that's great to hear. Again, it's not common for me to hear people even talk about nutrition mess.

Ray, CPM  14:53  
 Yeah, I think it's one of those things that like, it's not just midwifery model care. It's also being a home birth provider and being outside the system. You know, as a certified professional midwife, I did get a lot of nutritional counseling training, but also, because my clients do not have good insurance reimbursement, and they're just paying out of pocket for their care, right, I can do hour long appointments. And if you can do hour long appointments, you can do really good nutritional counseling and get to know people in their diet and have continuity of care. So you can also do really good follow up. And there's, you know, I think more and more conversations I'm having with other midwives are just like, probably part of our poor outcomes is like has in our society have to do with like the insurance payer system. And like if you HAVE to do such a high volume, and see so many people that have a hospitalist model, because that's the only way you can get paid to do your job, then all the things that are preventative care are going to fall through the cracks, because you cannot do nutritional counseling and a five or 15 minute appointment very well. We're not care that's going to be like motivating and empowering and like help you make like positive change. 

Maggie, RNC-OB  15:56  
Yeah, absolutely. It's so hard to find that, that time and like you said, that's a system issue. That's not just on, you know, one provider and obviously some some try and you know, manage to squish some in but it is hard in that sort of model to just to have enough time to actually do it to review someone's the, you know, food diary. Like that's gonna take time for you to go, you know, go through it with them and then and have a whole conversation. I wonder, Sarah, in your, your work? Do you hear when when clients come to you? Have they had any, like any nutritional counseling, or like talking with their provider? Usually up till that point, or pretty much like nothing?

Sarah, RDN  16:33  
Nope, they'll get the standard, here are the foods that you need to avoid? Right? There's even somebody who's had type two for 20 years, it's just not common so many times. So I start off with what have you heard or read or been told, you know, about nutrition, just to see, you know, where they're coming from? And so No, absolutely. What I'm hearing tonight is just, unfortunately, not the norm in my experience. Yeah, and having a consistent message of support to a pregnant person is just fantastic to hear.

Maggie, RNC-OB  17:09  
Yeah, I know, I've certainly seen more of it in in providers or hospitals that offer like Centering Pregnancy classes, or that kind of like group prenatal care, that then allows for more talking especially like earlier stages, you know, of appointments, you know, kind of intake eight weeks or 10-12 weeks, anytime in that frame, you're first coming in, you're kind of just assessing that overall, like pregnancy health, what are some of the things we're in, you know, interested in? And I think, outside of that type of, you know, group model, and or, like you said, people who are, you know, kind of getting private care homebirth, you know, care outside of it. It's just, unfortunately, really rare. And I think another thing I would just, you know, you both touched on the piece of focusing on what we're adding, you know, instead of taking away and I think that's a really simple shift that providers in any of these settings, though, could make. So instead of having a handout that's just lists of restrictions, or you know, some sort of weight gain limit or range that you're handing people instead, can you just focus on that? Could you have another handout, instead, that focuses on like you said, you know, protein, water fiber, and really encouraging that you only have a minute to talk to someone about their nutrition, that you start with something like that, instead of starting from this really, like stigmatizing restrictive standpoint.

Sarah, RDN  18:27  
When they do receive information for nutrition is gestational diabetes. And just last week, one person said, Well, the first provider said, avoid pasta, breads and pizza, and then then subsequent appointment at a different provider stated, don't even worry about that. Just follow keto. Because then at least with keto, you'll be able to find some keto breads and so so the a lot so the nutrition information, there's a lot of undoing so you know, just having a conversation, first of what have you heard been told, not just by providers, but by family members and peers or their partner, so to see if there's some information that can be undone, because I can tell you, you know, the amount of people who cry during their appointment because of the stress and the worry, the guilt, the shame, and then feel like they have to hyper focus on food also can revisit, you know, previous poor relationships with food at a time when their body is being assessed and examined. So it's really a challenging time for people last thing that any provider should do is play shame or guilt. And we all think as humans, that that's a simple basic expectation. Yeah, I hear it every day.

Ray, CPM  19:43  
Yeah, also, I think it's kind of wild that you know, the time that people typically get international intervention to larger systems is if they get a gestational diabetes diagnosis. You know, I've definitely had the experience of like carrying people with previous gestational age. Diabetes diagnosis is that we were able to prevent the second time around by doing dietary interventions earlier, where people who require medication, their first pregnancy is not requiring it. And the second because we just did a lot more things earlier and had the support and follow up to kind of do that. And it's just, you know, like preventative care versus like, yeah, system.

Sarah, RDN  20:21  
Yeah, I have somebody that I'm working with right now. And this is her second gestational diabetes diagnosis within about a year and a half. And the only thing if so has been self monitoring all along, just out of curiosity, all beautiful, but then 1 hour glucose tests elevated, but that all of her self monitoring is beautiful. So because she kept with the, the approaches, the, the changes the movement in her life. And that's another thing. So when we talk about movement, right, so movement, gentle movement, meditation, dancing, you know, as part of the picture, it's, I talked about stress, sleep movement, what do they enjoy doing? It's not just, it isn't just fiber, protein and fluids, even though you know, that's something that I enjoy talking about for add-ins so much a part of their health is not just that,

Maggie, RNC-OB  21:10  
a lot of it, there's that desire to control, right? So being able to, like control someone's weight, and to stay on that, instead of again, looking at the overall picture of health and movement and engaging in a conversation around that. And I think you touched on as well, in terms of when we've talked to people about nutritional, you know, concerns or their approaches? And I think that kind of leads us into like, the, the why piece of it, like when and why are we caring about weight and size and nutrition. And it feels like what I heard, you know, from a lot of people is that they, they come into pregnancy, they're at a higher weight. And right away, the kind of first thing that gets talked them with their providers about their weight. And then sometimes it feels a little bit like, somewhat like the ship sailed, like, here we are, we're already there, we're pregnant, we're at a higher weight, and that there is still this kind of picking at that piece of it. Which at that point, we're not expecting anyone to to lose weight, we know that everyone needs to continue to gain weight in their pregnancy to to maintain a healthy pregnancy to grow a healthy baby. So I also want her to but just like, why are we doing that assessment at that time? And what do we what do we possibly think it's really, that information is giving it that we that we couldn't get in a different way?

Ray, CPM  22:27  
I mean, I feel like I just want to say fat phobia is lazy medicine, you know, like, using BMI to assess health is a way to lump large groups of people together, instead of asking them questions about their diet, their life, doing health screenings, like blood pressure, or, you know, lipid panels, I think it's you know, we have a lot of fatphobia in our society, you know, the diet industry funds, a lot of medical studies. So there's like this is these kind of these two institutions just kind of keep bouncing off of each other and creating a system that's really hostile to, like pregnant people and bigger bodies, and like anyone and bigger bodies, like the stories of people who like, got mis diagnosed with like, major issues, because they were fat, and were just told to lose weight or pretty horrific and also pretty common. And it's Yeah, using BMI as a tool to assess health is just like really a good way to like not see the person in front of you and not care for them well.

Sarah, RDN  23:29  
Right, like what? So are they taking the same approach for a different size body? So is their approach for treatment or care the same regardless of body size? And that's where it's really always I'm curious about because when somebody comes in, for example, with hypertension, the weight focused discussion versus absolutely no discussion regarding weight based on unfortunately, incorrect measure regarding BMI. So when that is leading, you know, the discussion. It's harmful. 

Maggie, RNC-OB  24:02  
Yeah, I think I mean, this whole season, we've been talking about biases, right. And the ones that we hold that we picked up from, from training, from society, just those things that we haven't really, maybe thought enough about. And I think this is one of those pieces where there's obviously a ton of information from like every major kind of pregnancy or birth resource, talking about weight and pregnancy and, you know, potential risks and all of that, and I with all those in reading through the research, and there's just that piece of it that absolutely sure some people at higher weight might have some of these complications. They seem to have some more rigorous, you know, information that show that okay, yes, in this population, they were studying the higher weight did have, you know, higher incidence of complication. But there's just that the devil's advocate piece of me that I just really wonder how much of that is about the actual higher weight itself and how much of it is the bias that the provider already has about taking care of someone at a higher weight and how that impacts the care that they then provide. And we've talked about this with other subjects, but I just think it's one of those things that like, we need to continue to be self reflexive and thinking about like, okay, right now, what am I actually looking at? Am I really concerned because of this higher higher weight in its own, like as its own entity? Or am I actually looking at like the clinical picture in front of me, because it really seems like in some of those cases, so many of birth care choices are very dictated by the provider, both in terms of when they just act on their own without really consulting or waiting for it, you know, informed consent or anything like that, and in the way that they talk to risk about, you know, patients. And so, if you have someone, you know, in front of you, and you really leading them down this like very high risk path. I don't know, I wonder then and how, in terms of how that actually impacts, you know, these results? I, I guess I feel like what I know, when one of my pregnancies, I, my one hour glucose test was high. And at the time, I was like, reassured by provider like, oh, it happens, we're going to do the three hour like, you're probably fine. I know multiple people, though, who are at higher weights, were told by their provider, like, let's not even bother with the three hour glucose test, like, let's just call it GDM. and move on. It's not the same provider, who knows, maybe they tell everyone within one hour that, you know, but they they felt that that like stigma piece and that question that like, I don't know, is that Is that normal? Why are you recommending that for me? Is it based on something more than just a higher number on the scale?

Ray, CPM  26:37  
Yeah, I think like, I mean, statistically, like, that people who are pregnant, like have more testing done, they have more evaluation, they have more inductions, they have more c sections. And I don't feel like we can trust the data. Because the data like that people gathering data have a lot a lot of bias around high BMI. And so we don't see great literature about blood pressure issues that Yeah, kind of stuff that like low risk and high risk like, same with a BMI like we just don't, we don't see like a separation. And so it's really, really hard to interpret. And for someone to like, try and see like, is my baby safe or not, like, based on all this research, there was a really, like, decently done study that just came out, around like birth center birth, with high BMI that like found, like, people who are in bigger bodies have like the same transfer rate and same vaginal birth rate as people who started off pregnancy at like, like an average BMI. So we're like, oh, we're seeing like, actually similar data with like, low risk pregnancies for people in bigger bodies that we are for people who are like, you know, straight size bodies, but how that's going to correlate to like, general practice? Who knows, I always send my clients to Plus Size Birth, there's a really, really good breakdown, or about like, what would be normal to expect having care, you know, in pregnancy, what would be like abusive care or like, kind of fatphobia in your healthcare, kind of like questions to ask and how to find a size friendly provider, which I will definitely say like, there are not size friendly providers available in all areas. But just to like, start understanding, like, you know, like, yeah, we summed like, sometimes may see like, a little bit more of this, like, so maybe like, like I can say, as a provider, like, it might be a little bit harder for me to feel your baby's position. But that's like a me problem. It's not a huge problem. But we have tools, you know, to try and like figure that out, like ultrasound, and maybe a grow scan at 32 weeks, like a little bit more appropriate in this population, just because of ways that our assessment tools with our hands are, like less helpful, and that's still like a provider problem, not a patient or client problem. But, but yeah, like, there's just like, Where's the line of like, you know, appropriate for like, possibly, like, possibly getting more information is going to be helpful and what's just like, bias and fat phobia. And I think probably the majority of it is bias and fat phobia, unfortunately. 

Maggie, RNC-OB  29:01  
Yeah, I really like how you said that piece of it, where we're taking the onus on us as like, as a professional as a provider, that if our tools are limited, okay, what other tools are available to help aid that, you know, assessment, I think, you know, working in a hospital setting, you know, there are a couple of things we can do to make people with large BMIs feel more comfortable when they come in. So like even from when they first come in to be admitted? Like, are we encouraging them to wear clothes that are comfortable for them, that they brought that they they already are able to move in well, and that don't feel constraining? Or you know, if they need a gown? Are we making sure that there's one that's available that doesn't make them feel uncomfortable? are we offering monitoring tools? If there's someone who's a candidate and needs to be on, you know, external fetal monitoring continuously? Do we have tools have we gotten, you know, the Monica monitor or you know, some of the other monitoring tools that they've shown work equally well for people with different sized bodies like, there are steps that we take as, as providers as institutions, to create a better experience for those in our care, rather than somehow feeling like, put off that someone in a larger body, it, you know, is seeking care with you. And somehow, I think this is one of those pieces, like you were saying, read that we have to kind of take, there's an ownership for the care we're providing, that we need to be responsible for. And certainly having any conversation, you know, it's a dialogue, you're caring for someone, and they, you know, they really the birthing parent should be the one who's making those kinds of care decisions, and that you're talking about this, and you're having these, you know, informed conversations, but that we are the ones who are bending, we were the ones who are trying to figure out, Okay, how do we make this system that there's so many things not? Well, how can we make it work a little bit better for you right now, instead of putting so much the onus on on them? There's another piece of that, too, when I know, Sarah, you've talked to kind of the shaming that can happen around, you know, a GDM diagnosis. And I know, we talked about this in a previous conversation, I wonder if you just kind of speak a little bit more, we touched on it already. Kind of that, you know, when someone received a GDM diagnosis, what are the ways that they are treated? If they are, you know at a lower BMI? How is that kind of acknowledged by a care provider? What are the things that that you kind of see? What do they what story are they told, versus the story that they're told if they have a diagnosis, and they're at a higher weight?

Sarah, RDN  31:37  
Yeah, so just recent experiences where we had somebody who, where weight was not the focus of the providers concern, and the the person with the diagnosis of gestational diabetes stated, I'm an active person, I'm not overweight, I'm surprised to even have this and the affirmation from the provider is Yeah, me too. You know, so that messaging right there of affirmation of were surprised when absolutely, I am sure both of you can stay, there should be no surprise of any person and having the diagnosis of gestational diabetes, I, if I was a betting person, I every single time I would get it wrong, like you may be if they have a history, a strong history of gestational diabetes, right. But when you look at the physical appearance of a person's body, it should not be like that person received affirmation of surprise that you have it because you're physically active, and you're in a body size that we would not expect this. And on the other hands. Food is brought up more and often food like, including like sodas and juices, and pizzas and cakes for people where the provider might be more focused on their weight, where then they go into the canned conversation have an initial diagnosis. But fortunately, where I am, we have most of the time, we have the conversation before the provider. So they have the diagnosis. Unfortunately, they receive that messaging of, quote, unquote, you failed right over the phone from the providers office. But when we get them within 48 business hours, so we can lay the groundwork and the foundation and prep them and some anticipatory guidance, and we know who their provider is, of what to just kind of filter out or prepare them for of how the compensation will go. So that's, that's a fortunate part is when we can have a conversation with them pretty immediately after diagnosis.

Maggie, RNC-OB  33:43  
 Yeah, and then the other thing too, and I don't know, Ray, if you can speak to this for how you kind of see this happening and, you know, otherwise low risk. Birth community, I think there's also a piece where I've heard people who are being turned away from care, because they have a higher BMI. Because they're, you know, not at a, I believe, quote, unquote, trauma center was the the term that was used to deny care. Someone was sharing a story recently...

Ray, CPM  34:14  
Yeah, I mean, the birth center in our area, which is the only birth center has a BMI cut off. A lot of states, who are the states that have newer midwifery regulations also have BMI cut offs. So like, in Maryland, if I had a Maryland license, I believe the BMI caught off is like pretty ridiculous, like 35. So there are places where you are legally not allowed to at home or for because of weight bias and weight stigma. And yeah, so I think like yeah, fatphobia is really ingrained in our medical system and that really shows up with obstetrics and therefore like hurts people who are not necessarily sick. They just need care. You know, I think there's this, there's assumption, they make a lot of assumptions about bigger bodies, which could be true for some people, but aren't true for other people. But when larger systems try to standardize things to try and protect providers systems, overall well being, and they do it from a place of bias, like, yeah, harm is done. 

Maggie, RNC-OB  35:19  
Yeah, I know. And I think like we said, I think that's just one of those places where we have to interrogate that in ourselves, you have to be aware of it and recognize, see all these threads for how it shows up in our healthcare system at large to start to dissect it a little bit. And like you said, realize the parts where it's, you know, it's appropriate to perhaps offer different monitoring or, you know, additional tests or when is it really just another one the constructs, we've, you know, that we've just decided that this is something that, you know, we have to care about, and that you know, weight is inexplicably tied to health. And then we're going to put all these, you know, regulations on on top of it. And I think there's hard parts like that, where you're fighting a system that might be like legally telling you like, Oh, you could lose your license if you care for this person, because they're, you know, at a higher BMI, those of us who are operating in like bigger, you know, health care systems and hospitals, like having these conversations, addressing them on, you know, a broader level to see how are we using, how we're using weight? Why are we using it that way, and seeing where we can start to make some of those changes that happen little by little to make it. So everyone gets just everyone has access to good care, the care that they want and care that doesn't make them feel bad, just for existing in their body? Is there anything else that you all want to share on this topic, as we wrap up?

Ray, CPM  36:48  
Maybe I want to add on. So something I've definitely noticed and experiences, my clients who have bigger bodies would experience a lot of discrimination, by time they come into prenatal care, and learning how fatphobia like leads people to avoid care, and can make you feel really small. But learning how to be your own advocate, and like learning how to be a consumer and client instead of a patient, I think is one of the most essential skills for finding safety in your body. And also like, having a positive like healthcare experience, where you're a partner with someone in care versus like something that's being done to you. And that involves shopping around and involves interviewing providers and practices, asking if, you know, there's, you know, things that that would be required of them because of their BMI, or even asking what what's the section rates are for bigger bodies versus not, and like, learning what answers people give, and if you don't, if something is unsettling to like, to run, you know, or leave and shopping around. And like finding a provider that like, sees you here as your respect, who is going to change your experience of care dramatically, because then you can have more nuanced conversations, and you might want all the things that are, you know, often like, you know, recommended to people in big bodies, but like, just having someone that like, respects you and sees you as a person will make a really big difference. Absolutely. I mean, yeah, plus size. birth is like such an amazing resource page. They have a blog, they have, yeah, a podcast, like there's a lot, there's community of people who are just like, I'm pregnant, I'm not ill and like, just like, I'm just like, let me live in my body. And you know, so you don't have to start from square one. There's like lots of people to learn from.

Maggie, RNC-OB  38:32  
Great, well send people there in the show notes. Everyone can kind of reference that. 

Sarah, RDN  38:37  
So I can share some there's a couple of social media accounts, I can send them over to you. So if you want to link 

Maggie, RNC-OB  38:42  
Yeah, absolutely. And we'll link those for every one of them on social as we're sharing about this episode, so everyone can follow along and learn with them. So thank you both so much for coming on and having this conversation.

Sarah, RDN  38:55  
Thank you for having the conversation with us. It's needed and let's get it out to as many people right to have them listen.

Maggie, RNC-OB  39:02  
Thank you!

I hope you really enjoyed that conversation with Sarah and Ray and that it helps you to just think a little bit more about the way we view weight as a society. And you know, how that impacts the the care that we provide to folks and and how it impacts the way that we think and talk about health and you know, weight and size and BMI and just that we're turning a critical lens to it. We're not trying to abandon the idea of health or helping our clients to make choices that support their overall nutrition. And, you know, certainly we want to you know, be aware of potential complications that can come up along in pregnancy. But there is so much of the how we do that, that matters to those in our care and I hope in this conversation, you're you know, prompted to just explore a bit more about how that shows up in your practice and you know what you can do to create more size inclusive care practices so that everyone ends up feeling supported. We would love to hear from you about, you know, if you've thought about these principles before, if you've applied them to your practice, if you think it wouldn't work in, you know your population, we would love to dive into it. You can find us across social media at Your BIRTH Partners, or join our community group on Facebook, which is Your BIRTH Partners Community. We would love to connect there and you know, talk more about this week's episode and, and hear from you. So you can also tune into the show notes. We'll be linking to some interesting articles to read about this plus as birth and some other social media accounts that you can enjoy following to learn a little bit more about this, that we hope you'll enjoy those resources. Till next time.