CURRENT LITERATURE suggests pregnant patients with overweight and obesity experience weight stigma during patient-provider communication.1,2 Yet, a universally accepted definition of weight stigma related to pregnancy has not been identified. Obesity rates within the United States continue to negatively impact the health and well-being of the nation, including women of childbearing age. The majority (60%) of reproductive-aged women in the country are considered overweight or obese.3 The Centers for Disease Control and Prevention classifies persons as overweight if their body mass index (BMI) is greater than or equal to 25, and obese with a BMI greater than or equal to 30.4 The purpose of this concept analysis is to delineate the concept of weight stigma, as it applies to pregnant and postpartum women.
Weight stigma, discrimination or stereotyping based on weight,5 routinely surfaces within the maternal-child health literature, especially during patient-provider communication with overweight and obese pregnant women. Health care providers including obstetrics and gynecology residents, fellows, family physicians, midwives, nurses, and registered dieticians agreed that they made negative assumptions about a pregnant patient's character or intelligence based on her weight in qualitative survey responses.6 Offensive comments were often directed toward obese pregnant patients compared with those without obesity. In fact, 66% providers recognized that more derogatory comments were directed toward obese pregnant patients compared with those of normal weight.6 Similar findings were discovered through the work of Schmied et al,7 who used focus groups and in-person interviews and found a high degree of intolerance and discomfort among health care providers when treating and communicating with obese pregnant patients. Providers stated they lacked confidence in communicating with obese pregnant women, especially in how to best introduce the topic of weight. Additionally, they identified that it was embarrassing or difficult talking with “large women.” Smith et al8 also highlighted this reality, as health care providers felt reluctant to introduce the topic of weight with obese patients for fear of “offending” women or due to feelings of embarrassment within the provider.
Other subtle forms of weight stigma exist during patient-provider communication with overweight and obese pregnant patients including inconsistency in type and quality of gestational weight gain advice.9,10 According to the Institute of Medicine (IOM), overweight and obese women are recommended to gain a total of 15 to 25 lb and 11 to 20 lb, respectively.11 However, current literature emphasizes that provider-offered weight gain advice tends to be inconsistent with these guidelines. Waring et al10 found that 71% of obese women recalled receiving gestational weight gain advice above the IOM guidelines. Only 7% of obese pregnant women reported receiving gestational weight gain advice consistent with the 11 to 20 lb per the IOM.10
Experienced and perceived weight stigma continues beyond pregnancy and affects women in the postpartum period. Through qualitative research investigating the experience of obese breastfeeding women, researchers discovered that respondents felt socially and physically awkward when breastfeeding around others, and faced “mental strain” when exposing their body in public.12,13 Another psychosocial challenge obese breastfeeding women experience is a significantly higher degree of body image dissatisfaction compared with normal-weight breastfeeding mothers—reinforcing the need to consider body image when discussing breastfeeding with patients.14,15
The purpose of this article is to provide an analysis of the concept of weight stigma, particularly in the context of pregnancy, using the framework described by Walker and Avant.16 This 8-step method requires identifying all uses of the concept, determining defining attributes, identifying a model and “other” cases, identifying antecedents and consequences, and defining empirical referents.16
Statement of Significance
What is known or assumed to be true about this topic:
Women with prepregnancy overweight or obesity frequently experience weight stigma during patient-provider communication and in the health care setting. Weight stigma results in numerous negative psychological, behavioral, and physiological consequences. Pregnant and postpartum women with overweight or obesity are especially prone to the detrimental impact of weight stigma.
What the article adds:
The concept of weight stigma related to pregnancy is undefined in both the nursing and health care literature. This article offers an in-depth examination of weight stigma related to pregnancy. As a result of this concept analysis, stereotyping, social devaluation, and alienation directed toward women with overweight or obesity were identified as key attributes of weight stigma related to pregnancy. Conceptually understanding the attributes of weight stigma in a pregnancy context can contribute to the success of future nursing interventions related to communication techniques reducing perceived and experienced weight stigma in the obstetric setting.
DEFINITIONS AND USES OF THE CONCEPT—WEIGHT STIGMA
The historical use of the term “stigma” dates to the Ancient Greeks. In Ancient Greece, the concept of stigma referred to visual signs, often burnt into the body, that signified the moral status of the individual. These “stigmas” would be burned onto bodies of criminals, slaves, traitors, etc, to demarcate the individual as one to be avoided in public. Christians later contributed to the conceptual definition of stigma, purporting that a stigma is a lesion on the skin, believed to be a bodily sign of the holy grace. Christians also viewed visible signs of physical illness as “stigmas.”17 Currently, stigma most often pertains to invisible disgrace or shame directed toward or felt by individuals—rather than an outward expression.17
Stigma is a concept that is often examined through a sociological lens. While explorations of the concept of weight stigma related to pregnancy are lacking, both sociologists and psychologists have offered investigations into the general concept of “stigma.” One sociological perspective suggests stigma pertains to when an individual who would otherwise be accepted in society carries a characteristic or trait drawing upon the attention of others.17 In this case, Goffman17 refers to an individual who possesses an undesired differentness from the expectations of society.
Merriam-Webster defines stigma as “a.) a mark of shame or discredit b.) an identifying mark or characteristic c.) the usually apical part of the pistil of a flower which receives the pollen grains and on which they germinate, or d.) a small spot, scar, or opening on a plant or animal.”18(p1) Within the theoretical literature, Link and Phelan19 contest that the concept of stigma may be applied to a variety of topics such as cancer or mental health, justifying flexibility in the definition to ensure a contextually sound description. Several components must occur for stigma to exist: “distinguishing and labeling human differences ... then linking dominant cultural beliefs and labeling persons with undesirable characteristics or negative stereotypes.”19(p367) Finally, the labeled individuals are separated into “us” versus “them.” Those who are labeled subsequently experience some degree of status loss and discrimination leading to unequal outcomes.19
While not addressed in the theoretical literature, weight stigma is defined by the National Eating Disorders Association as “discrimination or stereotyping based on a person's weight.”5(p1) More specifically, the American Academy of Pediatrics offers another definition of weight stigma, stating that weight stigma “refers to the societal devaluation of a person because he or she has overweight or obesity” and may include stereotypes categorizing obese people as “lazy, unmotivated, and lacking discipline or willpower.”20(p2) Similarly, Puhl and Huer21 noted that weight-based discrimination has become increasingly prevalent in society, fostering negative stereotypes and rivaling the prevalence of racial discrimination. Prevalent negative stereotypes categorize overweight or obese individuals as unsuccessful, unintelligent, lacking self-discipline, and noncompliant with weight-loss recommendations.21 In seeking to examine associations between weight stigma and psychological health of overweight or obese individuals, Wu and Berry identify weight stigma as “individuals experiencing verbal or physical abuse secondary to being overweight or obese.”22(p1030) A similar definition is posited by Tomiyama, who states weight stigma is “the social devaluation and denigration of people perceived to carry excess weight and leads to prejudice, negative stereotyping and discrimination toward those people.”23(p8)
Weight stigma has also been defined from the perspective of individuals with overweight or obesity—emphasizing the negative attitudes and behaviors they have experienced.24 The perception and internalization of weight stigma may result in feelings of alienation or humiliation within the affected person.25 Therefore, weight stigma is a multifaceted concept that may be defined in terms of the affected individual and his or her perceptions and by the person actively participating in stigmatizing behaviors and attitudes.
To ensure a comprehensive concept analysis approach is utilized, one must first identify subdimensions of the concept of interest. Weight stigma contains several subdimensions, including enacted stigma, felt stigma, and internalized stigma. Enacted stigma is the negative treatment of an individual who carries a stigmatized condition (such as overweight or obesity). Felt stigma pertains to the subjective experience of the individual being stigmatized based on a certain characteristic (weight status), including his or her anticipation of this stigmatization. Internalized stigma refers to the reduction of one's self-worth or confidence experienced by an individual suffering stigmatization, which may ultimately lead to psychological distress.26 Once stigma is internalized, the individual is aware that he or she has a stigmatized identity, and therefore applies negative stereotypes toward his- or herself.27 These subdimensions must be recognized and explained to fully appreciate and comprehend the conceptual underpinnings of weight stigma related to pregnancy.
DEFINING ATTRIBUTES OF WEIGHT STIGMA IN PREGNANCY
Walker and Avant suggest that identifying defining attributes of a concept and its necessary characteristics is the most essential step of a concept analysis. Attributes are the characteristics necessary for the concept, weight stigma related to pregnancy, to exist. In examining the available literature, several key attributes emerged including: it is directed toward pregnant or postpartum persons with overweight or obesity, stereotyping, social devaluation, and alienation.
Directed toward pregnant or postpartum persons with overweight or obesity
Current literature supports the prevalence of weight stigma within the maternal child health setting.1,2,6–8,28 Central to conceptualizing weight stigma in the obstetric setting includes that it is enacted toward or experienced by pregnant or postpartum individuals with overweight or obesity. Providers and obstetric patients with increased BMIs recognize and experience the presence of weight stigma during communication, leading to misinformation and vague, indirect messages (especially during gestational weight gain conversations).1
Another prominent characteristic of weight stigma is stereotyping. Many researchers and theorists describe negative stereotypes commonly attributed to those with overweight or obesity.20,21,29 Friedman et al30 note that overweight or obese individuals are routinely viewed as lazy, stupid, dishonest, and self-indulgent by friends, coworkers, and strangers. Stereotypes marking overweight and obese pregnant women as dishonest are highlighted through the work of Washington Cole and colleagues,28 as providers were less likely to agree or strongly agree that women with obesity provided an accurate health history compared with normal-weight women. False conceptions of obese pregnant women as unintelligent surface through the work of Furness et al,1 as midwives reported obese pregnant women do not understand consequences of increased BMI during pregnancy and lack cooking skills. This stereotyping may eventually lead to harmful discriminatory behaviors, as obese individuals may experience unequal treatment when seeking health care.30,31 In fact, weight-based discrimination is associated with an increased incidence of postpartum depressive symptoms 1 month after delivery and increased gestational weight gain among women who self-identified as overweight or obese.32 Unequal treatment toward women with increased BMIs in the obstetric setting is emphasized when considering obese women are less likely to experience pro-breastfeeding practices in the hospital after delivery compared with normal-weight women.33 Obese pregnant women describe feeling vulnerable to negative attitudes and judgments when meeting with health care providers and are often subject to negative weight-based stereotypes (and subsequent discrimination) during obstetric contacts.2
Another identifiable property of the concept of weight stigma includes social devaluation. Individuals who experience weight stigma are viewed as less valuable members of society due to their weight status. This sentiment is reflected through the work of Phelan et al,25 who noted health care pro-viders may develop feelings of anger, disgust, and blame when encountering or interacting with obese patients. In fact, women with prepregnancy obesity reported an accusatorial response from health care providers.2 Furthermore, health care providers report high levels of discomfort and reluctance when communicating with overweight and obese pregnant women.7,8
A common theme within the examined definitions of weight stigma includes alienation between those engaging in stigmatizing attitudes/behaviors and individuals who are pregnant with overweight or obesity. Those with overweight or obesity who experience weight stigma may feel estranged from the rest of society due to the negative weight-based stereotypes and discrimination. Weight stigma is often marked by a labeling of “us” versus “them,” as those with the stigmatized identity (overweight or obese) are set apart from others based on this characteristic.17,19 Feelings of alienation from family and friends are especially prevalent within obese women. Obese women are particularly more dissatisfied with family and partner relationships and have fewer close friends compared with their normal-weight counterparts.34,35 Additionally, health care providers express concern about alienating or offending obese pregnant women during patient-provider communication.7
To further illuminate the concept of weight stigma, the following model case or exemplar illustrates the key attributes of the concept of weight stigma related to pregnancy.
S. K., a 30-year-old pregnant woman with a BMI of 37, walked into a prenatal health clinic. Upon entering the clinic, S. K. noticed patients turning their attention to the entrance, shifting their gaze from their phones and magazines to focus upon her for a moment. As she proceeded to the registration window, S. K. felt angry stares (social devaluation) from other patients penetrate the back of her head, as if she was a novelty from another planet. After signing in, the nurse glanced up from her work, handed S. K. a health history questionnaire and told her she must “honestly” complete the lifestyle history portion (stereotyping). S. K. found one open seat in the packed waiting room next to a middle-aged woman, who proceeded to vacate her seat once S. K. settled in next to her. S. K. felt as though people did not want to be around her because of her weight, leaving her self-conscious. Despite a waiting room full of people, she experienced feelings of isolation (alienation). She then became worried the doctors and nurses would treat her differently because of her weight or fail to fully listen to her health-related concerns.
According to the concept analysis methodology offered by Walker and Avant, borderline cases are those that contain most of the defining attributes of the concept, but not all of them.16 The model case is modified to exemplify the use of some attributes: S. K. entered the waiting room at the prenatal clinic and received unpleasant and disgusted looks from other patients in the waiting room. She sat down in an open seat in the crowded room and overheard a young child tell his mother to look at the “big, lazy lady.” This describes stereotyping (“lazy lady”) and social devaluation (subject received looks of disgust) but does not illustrate the sense of alienation that is felt by those experiencing weight stigma in pregnancy.
Related cases include instances when the attributes of weight stigma are related but not clearly reflective or specific to weight stigma in the obstetric setting. On close examination the attributes and concepts are different. Related concepts include stigma consciousness and stereotype threat. Stigma consciousness refers to the extent to which an individual expects to be stereotyped, while stigma threat is a fear of behaving in a way that confirms the stereotype about a group.36–38 The following modification illustrates qualities that could be misperceived as weight stigma related to pregnancy.
Before walking into the prenatal health clinic, S. K. became worried that she would walk too slowly or appear apathetic and tired. She worried that others would view her as lazy and unmotivated and feared she would confirm negative weight-based stereotypes. This is an example of stereotype threat. It describes an individual's concern about acting in a way that confirms commonly held stereotypes but does not include perceived or actual alienation or social devaluation.
In this instance, the portrayal does not meet any of the defining attributes of weight stigma. Instead, the example reflects the opposite—a welcoming, inclusive experience. As an example, the model case is modified accordingly: S. K. walked into a prenatal health clinic, was greeted warmly by the nurse, engaged in fruitful conversation with another patient and felt welcome and comfortable in the obstetrician's office. S. K. was confident her physician and nurse would provide compassionate, effective care during her office visit.
According to the concept analysis methodology of Walker and Avant, identifying antecedents and consequences aid in developing a clear and contextually appropriate discussion of the concept of interest. Antecedents are events or incidents that must exist before the occurrence of the concept of interest (weight stigma related to pregnancy) and provide insight into its context. Traditional stigma theory argues social interaction is necessary for any form of stigma, including weight stigma, to exist.17,39 When considering weight stigma related to pregnancy, a specific antecedent includes gender and the perception of an individual carrying excess weight. In fact, obese women in particular were found to be less likely to be accepted into prestigious colleges and universities and are more likely to experience negative outcomes due to weight stigma compared with men.30 Ethnicity and socioeconomic status were also revealed as antecedents to weight stigma, as white women with lower incomes were more severely impacted by weight stigma internalization compared with other groups.40 These findings are reinforced through the work of Puhl et al, as researchers determined white women of lower economic status and education level displayed higher rates of weight stigma internalization. Another compelling antecedent for weight stigma includes the assumption that obese individuals are responsible for their own condition and are directly responsible for their problems because of overeating and laziness.21 The existence of this supposition within society lays the groundwork for weight stigma to perpetuate.
Contrary to antecedents, consequences of weight stigma are events that occur as a result of the concept. Consequences of weight stigma are varied and range in severity. Psychological distress has been implicated as a result of weight stigma, including lowered self-esteem, sadness/depression, and embarrassment.40,41 Perceived weight stigma is also associated with psychiatric morbidity and comorbidity in adults, as weight stigma was significantly related to prevalence of psychiatric and substance abuse disorders.42 Furthermore, the emotional impact of weight stigma contributes to lower quality of life among affected individuals.25 Behavioral consequences of weight stigma also exist, especially considering adults and children who experience weight stigma are less likely to exercise, have lower levels of self-efficacy, and are more likely to overeat.22,43 In fact, weight stigma is an ineffective means to encourage overweight and obese individuals to engage in positive health promotion behaviors. Overall, weight stigma increases negative lifestyle behaviors among overweight and obese people, essentially perpetuating rather than ameliorating the condition.21,31 This counterproductive relationship may lead to eventual weight gain and hinder weight-loss efforts of those experiencing weight stigma.44 Untoward behavioral outcomes due to weight stigma also include those relating to eating patterns, as weight stigma was found to be significantly associated with disordered eating behaviors including emotional eating and uncontrolled (binge) eating.4,45 Physiological impacts of weight stigma have also been identified, specifically regarding cortisol levels. The physiological stress response is activated in the presence of weight stigma, thereby leading to the release of stress hormones (cortisol), which in turn supports fat storage and unhealthy eating behavior.23,46 These emotional and behavioral consequences must be considered with pregnant and postpartum women to promote maternal and infant well-being.
Weight stigma especially exerts negative consequences on pregnant and recently pregnant women. Weight stigma is related to greater postpartum depression symptoms at 1 month after delivery and greater gestational weight gain.32 Similarly, discrimination based on weight led to an increased risk of gaining excessive weight during pregnancy in Black and Latina women.47 Excessive gestational weight gain is associated with increased risk of cesarean birth, hypertensive disorders of pregnancy, and large-for-gestational age babies.48 Emotional impacts of weight stigma include body image concerns and feelings of discomfort when breastfeeding in public.13,14 Due to the nascent body of literature examining the impact of weight stigma on obstetric patients, future research is warranted to more fully understand the nature and breadth of its consequences on this vulnerable and increasingly prevalent population.
Per recommendations of Walker and Avant, empirical referents are classes or categories of actual phenomena that by their presence demonstrate the occurrence of weight stigma. Attributes and empirical referents are often defined identically; however, empirical referents serve as recognizable indicators aiding in the measurement of the concept.16 Specifically, empirical referents are observable phenomena confirming the existence of a concept in patients and are especially useful to practitioners. Validated measures are available to operationalize weight stigma into an observable concept. Given the importance of studying weight stigma, especially in the obstetric setting, several quantitative tools have been developed to measure weight stigma.24,36,49,50 Common dimensions used by researchers to measure the concept of weight stigma include feelings or circumstances of unfair treatment, judgment, and instances of discrimination experienced by overweight and obese individuals. These validated measures, including the Stigmatizing Situations Inventory and Weight Bias Internalization Scale, frequently employ a Likert-type scale, requiring subjects to indicate how often or to what extent certain situations or statements apply to him- or herself.24,50 Despite the advances in weight stigma research, a weight stigma scale for obstetric patients has yet to be developed. Thus, our future research will aim to contribute to the limited body of evidence regarding weight stigma related to pregnancy.
CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE AND RESEARCH
The purpose of this article was to dissect the concept of weight stigma related to pregnancy to promote clarity and mutual understanding within nursing and other health care professions. Doing so will facilitate advancement in the state of science surrounding this minimally studied, yet timely and important concept. The definitions, attributes, and consequences of weight stigma within the obstetric setting presented in this article describe and quantify the influence of this concept on pregnant and postpartum women with overweight or obesity. However, the unique weight stigma experience of this population represents a gap in nursing science. Through this concept analysis, we provide a novel assessment of weight stigma in a pregnancy context. In reviewing and synthesizing available theoretical and scientific literature, we offer a discussion on the significance of the concept and identified 4 essential attributes of weight stigma related to pregnancy: (1) directed toward pregnant/postpartum women with overweight/obesity, (2) stereotyping, (3) social devaluation, and (4) alienation. Through this initial work, we aim to qualitatively and quantitatively examine the weight stigma experience of overweight and obese pregnant women and investigate pregnancy-specific health outcomes in relation to perceived or experienced weight stigma. Our concept analysis will increase awareness and understanding of the complex and significant nature of weight stigma related to pregnancy and will guide future research endeavors explicitly examining the impact of weight stigma on maternal and child health indicators. It is our hope that, through this concept analysis and future research endeavors, nurses and other health care professionals will become more aware of weight stigma in the obstetric setting. Recognizing and then addressing personal biases toward this population will improve quality of care and optimize maternal and infant well-being. To mitigate weight stigma related to pregnancy and its deleterious maternal and infant consequences, nurses and health care providers are urged to offer patient education and health behavior counseling void of biases.
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