Plus Size Pregnancy: Podcast Episode #179

Kristin chats with Jen McLellan of Plus Size Birth, about the misconceptions surrounding pregnant plus size women.  You can listen to this complete podcast episode on iTunes, SoundCloud, or wherever you find your podcasts.

Welcome.  You’re listening to Ask the Doulas, a podcast where we talk to experts from all over the country about topics related to pregnancy, birth, postpartum, and early parenting.  Let’s chat!

Kristin:  Hello, this is Kristin with Ask the Doulas, and I’m here to chat with Jen McLellan today.  Jen is a published author, founder of Plus Size Birth, and host of the Plus Mommy Podcast.  She helps people navigate the world of plus size pregnancy, shares tips for embracing your body, and laughs her way through the adventures of parenthood.  With over seven million page views, Plus Size Birth is the premier plus size pregnancy resource trusted by parents and professionals alike.  As a public speaker, Jen has featured at numerous events, including presenting at the National Institute of Health.  Jen’s also a certified childbirth educator, wife, and mother to a charismatic 12-year-old.  Welcome, Jen.  So happy to have you here.

Jen:  Hi, Kristin.  Hi, doulas.  Hi, listeners.  Thanks so much for having me.

Kristin:  You are my go-to resource for clients who want evidence-based information when they’re navigating the healthcare system with everything from figuring out how to handle interventions or VBACs or connecting with the right provider.  So I am excited to chat with you and see where this goes!

Jen:  I’m so touched.  Thank you so much.

Kristin:  So how did you decide to specialize in such a niche area as a childbirth educator?

Jen:  I think for many of us birth professionals, our story begins with our own births, and that’s my case, too.  And as a plus size person, when I found out I was pregnant in 2010, I went on to Google.  I mean, I called my partner.  Then I went on to Google.  He was at work in the middle of a work review.  Then I went on to Google, and I’m like, “plus size and pregnant.”  And it was like, doom and gloom.  And it was really depressing.  There wasn’t much positive information.  It was really hard to find clothes that would fit my body, plus size maternity clothes.  And I just read that I would have poor outcomes.  But I hired a doula who introduced me to the midwifery model of care, and I just assumed I was having a high risk pregnancy because of my size.  And she was like, nope.  And switching from the obstetrical model of care to the midwifery model of care five months into my pregnancy was one of the best decisions I ever could have made in my life, including hiring that doula, because I had a completely healthy pregnancy as a plus size woman, and I gave birth on my knees in a hospital and was forever transformed.  I could no longer hate a body that had done something so magnificent, and it helped to rewrite all these myths and misinformation I had just believed about myself for so long.  So when my son was four months old, I started blogging, having no idea what that was, and it took over my life, and it just blew up.  And that’s when I became certified as a childbirth educator, and the rest is history.

Kristin:  I love it, and I agree with you as far as searching Google.  There is so much fear-filled information.  So when I came across your website first and later your podcast, it really – I am all about giving my clients uplifting, positive information, as well as, again, the evidence-based facts so they can make their own informed decisions for their care.

Jen:  Right, yes.  There wasn’t information on how to have a healthy pregnancy as a plus size person.  There was just like, “If you get a pregnant in a higher BMI, you will encourage gestational diabetes, preeclampsia,” all these things.  And then because of the internet and weight bias, it was also comments, like “You’re a horrible person for wanting to be a parent in a larger body.”  And I was just like, wait, no, what?  What is this?  So I really worked to create all the resources I struggled to find.  And then becoming a certified childbirth educator gave me a lot of the knowledge and ability and working all the time on continuing education, but also the ability to walk through doors, and I’ve traveled the country speaking to care providers about confronting weight bias in maternity care, and how do we treat people with evidence-based compassionate care?

Kristin:  So important.  And I’m thrilled that you’ll be training my team of birth and postpartum doulas.

Jen:  Yes!  I’m so excited.  Thank you for bringing me on.  Talking to doulas and student midwives is like my favorite thing in the whole wide world.  So often, these people are hungry for this information and want to learn more, and it’s an amazing experience.  And then I get a little more nervous talking to labor and delivery nurses and other care providers.

Kristin:  I feel the same way about nurses, yes.

Jen:  Wonderful.  I love nurses.  Anyone listening, I love you, but you intimidate me a bit.

Kristin:  Yes.  Because, again, we’re nonmedical and getting into – just having that line clearly drawn.

Jen:  Oh, yeah.  I always stay within my scope, and I talk about consumer perspective of what it is like to be plus size and pregnant and the obstacles faced, but also, you know, sharing tips and tricks on things that can help support people throughout pregnancy, labor, birth, postpartum.

Kristin:  Exactly.  So I would love to get into some of the misconceptions, Jen.  I know you mentioned some of them, one that you would need to see an OB and be labeled high risk.  So let’s tackle that one first.

Jen:  Sure.  The American College of Obstetricians and Gynecologists, ACOG, does not state that because someone has a higher BMI, and that would be a BMI of 30 and above, that they are classified as high risk.  However, this is very care provider specific, as well.  So we see, and there’s this common misconception, that people with a BMI above 30 are high risk.  And they will be labeled so, and they will have to have additional screening and testing and oversight.  And unfortunately, there are states, the state regulations around home birth and birth centers that do have BMI restrictions, so it’s really important that you look into your own community and your own state regulations.  There are also a lot of rural hospitals in areas that aren’t as populated that don’t have an anesthesiologist on staff 24/7 that have BMI restrictions.  So it is – that’s why there’s a lot of misconceptions, because you’re like, wait, but I’m not high risk, but I really wanted to go to this birth center, and they have BMI restrictions.  Or I really heard there’s this great OB, and they have restrictions.  So it’s really important as professionals to be aware of BMI restrictions.  I always say that doulas are the gatekeepers of their communities, and they know so well.  Like, who are those fantastic home birth midwives who have worked through all biases around racism and supporting the LGBTQ+ community and people of size, like working through so many layers of biases and know who are those go-to recommendations for those wanting a home birth or what birth centers have BMI restrictions, what don’t.  Those things are so important.  And hospitals, too, right?  Like, we know hospitals two miles apart, three miles apart, can have very different Cesarean birth rates.  All of that is so important for clients of all sizes, but especially clients of size.

Kristin:  And as you mentioned everything as far as restrictions vary state to state, and the midwifery model of care and so doulas are up to date on your options, both in and outside of the hospital.  And you mentioned that you worked with midwives within the hospital system.  So some of our listeners may not be familiar with the role of a nurse midwife.

Jen:  Yeah.  I mean, a nurse – so the midwifery model of care is more individualized care.  It’s a bit more holistic care.  These are highly trained care providers who are trained in birth and postpartum and also wellness care, as well, and often in a hospital setting, there would be – not often; there is in a hospital setting an obstetrician, an OB-GYN who oversees things.  But when I switched from the obstetrical model of care to the midwifery, I was fully with midwives, and it was such a dramatic change from these 15-minute rush, oh, we’re glad you’re 30.  We’re just going to keep an eye on – you know, you’re younger, but you’re bigger, so we’re just going to keep an eye on things.  To, like, 45-minute long appointments where I felt as a plus size person that my midwife was really the first care provider to touch my body with compassion, to empower me to know that I am healthy and was having a healthy pregnancy.  And I remember being like, I read online.  I have big hips and big girls make big babies.  And she’s like, yeah, you have big amazing birthing hips.  Like, you can birth your baby.  It was just so affirming, and it really changed my whole perspective on accessing healthcare as someone in a larger body because for so many people, and those listening, too, who exist in larger bodies, and there might be some topics that we talk about that can be triggering, so please take good care of yourselves.  But for many of us, we have cumulative trauma.  We’ve experienced a lot of weight bias in healthcare.  And so to go into birth and pregnancy, something that most first time people don’t know a lot about, right?  Like, our bodies do this.  It’s amazing.  But we don’t have a lot of education around it, and even if you take a childbirth ed class, like, a bit, but it’s not everything.  So we’re so heavily reliant upon our care team, and that’s why doulas are just such an amazing gift to help provide that education and that emotional support and then that physical support during labor, as well.  So I highly encourage people to look into the midwifery model of care if they’re wanting more of that individualized, holistic approach.  And just because I had an unmedicated birth with midwives in a hospital doesn’t meant that you have to.  In fact, that’s not the norm.  Most people in the hospital setting do have a medicated birth and can still work with midwives, so that’s another misconception, too.  Like, you can have an epidural in a hospital and work with midwives.

Kristin:  Yes.  And again, depending on your insurance and where you are location-wise, nurse midwives may not be an option, or you might have other medical issues that you put at a high risk status that would need to be seen both obstetricians as well as maternal fetal medicine, for example.  So let’s get into how to connect with size friendly care providers and if you have an OB-GYN that you’ve been working with throughout your journey as a woman, you don’t necessarily have to have the same provider for your birth experience, for one thing.  Many people think that just because their yearly appointments, they have an OB, that that is a person that should deliver their baby.

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Jen:  Correct.  I mean, there can be some comfort of, oh, you know, I go to this person, and they’ve seen it all, so I might as well work with them through pregnancy.  But like Kristin just said, that’s not always the case.  I think when researching for a size friendly care provider, you want to start by reaching out to your plus size friends who have had babies.  Like, did you like your care provider?  Did you have a positive experience?  Join – even if you’re not a parent yet, join a local moms group, and if you feel comfortable posting, “Hey, any fellow plus size moms here?  I’m a mom to be and really want to find someone who’s size friendly,” you’ll often get many recommendations.  And then do your research.  Google that care provider, whether it’s an OB-GYN, a midwife, a nurse practitioner.  Like, Google them and research.  And then when you’re setting up your appointment, ask if there are any BMI restrictions because unfortunately, that’s not something that is screened for, so often I hear from people that are like, “Oh, I was really excited to go to this birth center, and then once I was there and paid my copay and had my initial experience, I was told I was too big to be seen here,” and that just makes you feel kind of crummy and not the way you want to start off things.  So definitely ask if there are BMI restrictions.  Ask if they see people of all sizes.  Ask if they have larger blood pressure cuffs.  Like, ask those questions, and then when you go for your first appointment, assess.  Are there chairs without arms?  Can you sit comfortably?  Were you provided options for being weighed, including a blind weight where you’re not seeing the number?  You can also stand back on a scale, backwards on the scale.  You can also say, I don’t really want to be weighed right now.  I mean, knowing those things and feeling supported in those things is really important.  And then paying attention to how you’re talked to.  Is everything related back to your BMI, or are you provided with that individualized care looking at your whole health and possibly your birth history and really trusting your intuition and trusting your gut is so, so important.

Kristin:  Right.  And I’m all about having a simple birth preference sheet or plan and using that as a talking point to get on the same page with your provider.  Because, I mean, instead of waiting until you go into labor to have that discussion, so really making sure that you’re being heard, that your questions are answered, and having that conversation with a simple birth plan, and many hospitals can provide a sheet with checklists that are very easy for nurses and providers to read, and I feel like that is such a good point to begin some of those difficult conversations about, say, inductions and again, like you talked about, BMI; any restrictions that you might have for labor.

Jen:  Yeah, and I think specifically for plus size people during that first prenatal visit, because you’re likely not talking about your birth plan during the first, but I think like you said, it’s really important to bring up anything that’s very important to you about birth that may – you know, you can ask your care provider their birth philosophy if you want to connect with someone who’s very medically minded.  That’s great, too, and you want to know that.  Or if you want to connect with someone that’s more holistic and is going to be open to you giving birth in multiple positions – like, I gave birth on my knees in a hospital.  You can give birth in different positions.  You don’t always need to be on your back.  But that might be a preference of your care provider.  And so those are good questions.  But I think really important for people of size is to ask, are there any specific tests or recommendations you’re going to make because of my BMI, and you can point blank at that point ask them, are you going to recommend induction based only upon my BMI?  So you can kind of assess, and for some people, and I’m sure Kristin is the same way, like, you make your own decisions.  We will provide you with evidence based information, but I will support you if you’re like, yeah, there is some evidence to show a lower Cesarean birth rate for people of size who are induced at 39 weeks, and there’s a study I can provide to put in the show notes.  I have a lot of questions about that study, and I think people should ask questions and ultimately make their own decision, but there is some small evidence there.  So if you are comfortable with that, then that’s great, and you want a care provider that might be more hands on.  But if you’re like, actually, I really want, if I’m having a healthy pregnancy, there doesn’t really seem to be another reason to induce.  I want my body to go into labor on its own as long as I’m within a time frame that’s comfortable for myself and my care team.  So those can be some really good questions to kind of assess in the beginning that will give you a really good idea.  Like, will you be labeling me high risk based only upon my BMI?  If they say yes, then if that is not what you want, then you say bye.  Those are important things early on.

Kristin:  You have options as a consumer, for sure.

Jen:  Yeah, yeah.

Kristin:  And so how did you know?  You said that you switched providers later in pregnancy.  What was your point?  Was it a conversation of just not being on the same page?  How challenging was it for you to make a switch?  Because, I mean, some of my clients don’t like confrontation, and they would rather just go through with everything as it is and not have the birth that they wanted than to have a difficult situation or switch providers.

Jen:  I feel that, and I totally cried.  I don’t like to disappoint people.  I don’t like to break up with people.  So I cried when I did, but I now would have handled that situation different.  So why did I switch?  It was when I was five months pregnant, and my doula came for my first – I think it was just even her interview to see if she was the right fit for my family, and she was like, okay, you want an unmedicated birth, but you’re at this posh OB-GYN clinic that has a very high Cesarean birth rate.  Like, you should have a home birth.  And I was like, what?  I just didn’t even think that my body – you know, that I was healthy.  And I was like, okay, well, I know I want unmedicated because my mom had an unmedicated birth with me and my sister and had always talked about it.  I honestly as a big person just was really afraid also of people having to move my body for me and not having control.  So I wanted unmedicated, and I was very – like, that is what I wanted.  And so I was like, all right.  I totally respect people want a home birth, but I just don’t – I didn’t trust my body at the time.  And she’s like, okay, well, then I’m really going to encourage you to interview with these two hospital midwifery programs.  And we went for our first one at Denver Health, which is a county hospital, and I assumed in my naiveness about birth that, oh, this posh place is probably the best.  I don’t know that I’d want to give birth at the county hospital.  And while the county hospital had plastic chairs instead of fluffy couches, it’s one of the best places to give birth actually in the nation, Denver Health.  I don’t know current statistics, but for a very long time, they were one of the lowest Cesarean birth rates in the nation.  Like, it is an outstanding facility to give birth.  So don’t judge, right?  So many misconceptions about birth in general.  It’s really about becoming educated about the facility and the care providers.  And so we interviewed with this one midwife, and we just knew.  It’s like you meet the one, right?  My husband and I knew that we didn’t even need to go to that other interview.  We wanted to be with this midwife because she just immediately made me believe in my body’s ability to birth my baby and just made me feel so empowered.  So then – what I wish I would have done is just called my OB-GYN’s office and been like, “Cancelling.  I’m going to switch care providers.  Have a nice day,” and let the receptionist know.  But I went to my next appointment and let them know, and what was interesting is they said, “Can I ask you why?  Because we’ve had a lot of people been switching care recently,” and I know now, oh, yeah, that would be a red flag.  I’m glad I’m switching, but at the time, I was just like, I’m sorry and I just feel like this is better for me, and I never needed to put myself through that stress.  I could have just called.  So for anyone listening, I feel like we’d know if our care providers are just like, eh, maybe they could be okay.  I mean, we can feel comfortable getting a pelvic exam, but are they making us feel empowered?  Are they giving us time to ask all of our questions?  Are they really listening to our questions or rushing us?  Yes, there are often time constraints, but there’s a balance with that.  And so never, ever, ever be afraid to switch.  And I know there are obstacles and I know it’s not easy, but switching changed my whole life, and I feel like the outcome for my pregnancy and birth.  I am forever thankful that I switched, and I don’t know what would have happened had I not and had I stayed with that other provider at that other facility where she “only allowed” people to give birth on their backs.

Kristin:  Right.  Yeah, and movement is key, and again, doulas support whatever decisions our clients make and however they want to birth, whether it’s at home, in the hospital, medicated, unmedicated.  You had mentioned that earlier about providing the information but being supported.  So I appreciate that.

Jen:  Oh, yeah.  My doula would have been like, you want an epidural?  Great.  It would have been whatever I wanted.  But especially because she knew I wanted unmedicated.  She knew I existed in a larger body.  And when we do, our Cesarean birth rate is pretty astronomical.  I mean, there are a lot more obstacles.  And I think a lot of it is care provider bias against people of size, and we have new studies finally to confirm what anecdotally people have been saying for a very long time.  In 2020, we finally had studies that came out about weight bias specifically in maternity care.  We’d had plenty of studies showing weight bias in health care, but not in maternity care.  So that has come out, and it has really confirmed everything.  And interestingly enough, it’s not just weight bias for people of size.  It’s weight bias for people of all sizes, feeling shamed about their weight, but we see poor outcomes and more things happening to people of size that are just completely unacceptable.

Kristin:  Yes.  So let’s get into VBACs when it comes to – again, you had talked about Cesarean rates and surgical births and BMI potentially being a factor for a lot of decision making.  What are you learning about plus size patients and their VBACs?

Jen:  Yeah, for vaginal birth after Cesarean for people of all sizes, it’s connecting with a supportive care provider.  And interestingly enough, I’ve found especially through talking to other people like Jen Kamel of VBAC Facts that specializes in vaginal birth after Cesarean that care providers that are VBAC friendly tend to also be size friendly because they’re evidence based, compassionate providers.  Not everyone, but more often, that they’re not – we look at it like oh, the fears and the concerns and the increased risks via VBAC.  Yes, but they’re really small, and yet some care providers are like, I’m not supportive of VBAC at all.  And you’re like, but if you look at the evidence, our increased risks are relatively small, so why wouldn’t you at least support someone’s ability to have a trial of labor for a vaginal birth after Cesarean?  So again, it’s really key to connect with a care provider that is size friendly and also supportive of your VBAC.  We can look at the VBAC calculator, and BMI does play into it as something that shows not as strong outcomes.  But also I think it’s important that we look at the evidence, that we know that it takes people during the first stage of labor, people of size, longer.  It takes longer to labor.  We have the evidence to prove that it takes longer.  But the pushing phase can actually be shorter.  So we know now that people need more time.  But often when you’re in a medical setting, there’s a real eye on the clock and not giving people enough time to labor.  So it’s pushing for that extra time.  And all of these things, like, okay, we’re not progressing.  Let’s have the Cesarean.  Let’s go.  As opposed to pushing, like – actually, there’s evidence to show I just need a little bit more time, but when you’re in the middle of labor, that’s not what you’re possibly going to be able to vocalize.  Your doula can talk to you and remind you, but it’s hard to be able to have those conversations in labor.  It’s far better to have these conversations early on with a supportive care provider who wants to support your decision to have a vaginal birth after Cesarean.

Kristin:  100%, yes.  So any other misconceptions that we should address?

Jen:  Oh, gosh, I mean, just the societal bias is tough, right?  Like, we have this idea that only thin white women with perfectly round D-shaped bellies are pregnant, and that’s so far from the truth, right?  And it’s really common for people in larger bodies to have bellies that are shaped more like Bs than Ds, a B belly.  And that’s really common.  It’s common to have an apron belly or a belly that hangs, and that can be common, not just for people of all sizes, but for people who’ve maybe lost a lot of weight or had multiple pregnancies.  I feel like we live in this – we think it’s secret that we’re different, and we’re actually quite common.  We look statistically, and about 60% of women in their childbearing years are classified as overweight or obese, and I hate those words, but that’s the classification for the BMI.  So 60%, that’s a pretty high percentage, and of that, about 36% are in that BMI category over 30.  So these are big percentages, so know that you’re not alone.  Know that you are deserving of evidence based care, and you’re deserving of a maternity dress if you want it, and you’re deserving to babywear if that’s important to you.  And you’re deserving to have a nursing bra that fits if you’re planning to breastfeed.  So all of these resources are available, and I have lists on my website.  They are harder to find, and it is more difficult to have those in store shopping experiences, but know that there are maternity clothing available, and I even have lists that go up to 6x and even 7x options.  So just know that they are out there because I think that there is something so affirming about wearing a belly band, even if you’re not showing yet, because it can take longer to show when you exist in a larger body.  But having some of those items just really helps you to feel pregnant.  So I think body image, how our bodies look, setting healthy boundaries with loved ones and family members who might have well meaning “concern” about your health that just maybe makes you feel icky if they’re like, oh, well, you’re going to get gestational diabetes.  You can let them know, actually, unless you already are prediabetic, the odds are in your favor of not incurring gestational diabetes, and that’s something that can happen to people of all sizes.  There is no one thing that only plus size people incur during pregnancy.  So you can reassure them.  I’ve got a great care team.  They’re focused on my health.  I’m focused on my health, and I just need you to support – love and support me.  And set those boundaries.  People of all sizes; set those boundaries.  They’re so important.

Kristin:  Again, communication during pregnancy versus having difficult conversations day of delivery about who’s in the room with you, if there are restrictions due to the pandemic, who is on the same page because, you know, even in the postnatal recovery time and just that nesting time with your new baby or multiple babies, it’s important to have your family and friends who want to be involved, to have a conversation about boundaries.

Jen:  Yeah.  My motto is boundaries are sexy.

Kristin:  Yes, I love it.

Jen:  Because boundaries are so hard, right?  And they’re confusing, and what are boundaries?  But when you say boundaries are sexy, it just feels affirming.  Like, I am prioritizing myself and my family, and that’s sexy.  So I just make it fun because it is hard to say, I’m not going to have this conversation, or let’s talk about something else.  Like, it can be hard.  But when you remind yourself, hey, I just advocated for myself, and that’s pretty sexy.  Like, that’s how I got over my fear of boundaries.  I’m like, okay, this is my new motto because it is so empowering to put ourselves first.  And I think going back to our whole conversation so far about finding a care provider that’s the right fit for you and needing to advocate for yourself – you’re going to be doing that for your baby, right?  Like, you’re going to want to find the best pediatrician, and if a pediatrician were to make a recommendation that didn’t make you feel good or wasn’t evidence based, you likely wouldn’t go back to that pediatrician.  So care for yourself the same way you’re going to care for that baby because you are caring for that baby while caring for yourself.

Kristin:  Absolutely.  So true.  So Jen – I could talk to you all day, first of all.

Jen:  I could talk to you all day, too.

Kristin:  It has been so helpful, and I love your website for resources.  So again, you mentioned plussizebirth.com.

Jen:  Yeah, that’s for anything plus size, trying to conceive, pregnancy, birth, postpartum.  A lot of postpartum resources, too, like where do I find a breastfeeding pillow that’s large enough to fit my body and all of those things and tips around breastfeeding and pumping for people in larger bodies.  That’s really helpful, as well.

Kristin:  Yeah, my team can’t wait to talk to you about feeding options.  And you’re also on social media.  You’ve got your Facebook page, Instagram?

Jen:  I’m everywhere.  So for everything pregnancy, it’s Plus Size Birth.  But I also am the host of the Plus Mommy Podcast, so my main social following is Plus Mommy.  But you can find me wherever it fits.  For Plus Mommy Podcast, the tagline is: From bumps from bellies, we talk about it all.  So there’s a lot of great birth stories and interviews with experts, but there’s also really fun interviews with people who I admire, like some contestants on America’s Got Talent and The Voice and just amazing humans that are out there living their best lives, existing in larger bodies, and who inspire me.  So it’s a lot of fun, and I hope you’ll tune in.

Kristin:  You’re such a charismatic host.  I love your podcast.

Jen:  Oh, thank you.  Thank you so much.

Kristin:  Thanks so much for your time, Jen, and I appreciate everything you’re doing in this space.  You are amazing.

Jen:  Well, I appreciate you and every doula and every birth professional out there for the work that you do because my life would not look like it does now if it wasn’t for that care and compassion I receive.  So for everyone listening, if you’re a parent or parent to be, doulas are just amazing, so definitely consider.  That was one of the greatest gifts my parents ever gave us was helping to fund our doula fund, so it’s a wonderful thing you can ask from your loved ones, as well, because trust me, you don’t need 14 swaddles.  You do need a doula.

Kristin:  Exactly, I love it.  Thanks, Jen!

Jen:  Thank you!

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