Being pregnant and fat
Readers of this blog might recall a post I put up last year about how I was trying to lose weight for a specific (but secret) purpose. Well, the cat is now out of the bag — I am about 6 months pregnant as a gestational surrogate for dear friends of mine. It’s been, in so many ways, a completely wonderful journey and I am honoured to play a role in helping this amazing couple start a family. BUT… the one exception is to do with how I feel treated, as a pregnant person with a high BMI.
The latest instance of this provides a good illustration of the patterns and problems with the system. I received a letter in the post inviting me to have an electrocardiogram (ECG) in five weeks’ time. So far so harmless? But let’s explore the context a bit more.
I know that this pregnancy is classed as high risk, not just because of my high BMI but also my age (I’m 43), the IVF conception process and the fact I had a c-section last time I delivered a baby. Other factors shift in and out of relevance too, depending on the outcome being considered, such as the long gap between this pregnancy and my last, and the fact that this is a third-pregnancy for me. These factors combined resulted in a referral to a specialist antenatal metabolic clinic. My consultant listed off all “your risks” (meaning things that have been associated with poor outcomes in population-based research studies, such as older age and high BMI) and all “the risks” (meaning the poor outcomes themselves, such as pre-eclampsia and gestational diabetes, which are in turn risk factors for things like early delivery or fetal growth problems).
Setting aside the abysmal communication — none of these risks (with limited distinction between predictors and outcomes) were quantified for me leaving me totally vague as to the actual chances of something bad happening. Nor was there any attempt to clarify how “bad” a bad outcome would be — is this life-threatening stuff? Or just increased chance of assisted delivery? In the context of a surrogacy, it becomes especially important as well to understand whether the baby or the pregnant person is the one we need to worry about.
In an effort to be reassuring, presumably, she told me “not every woman has all of these risks” — a totally topsy-turvy statement when the truth is that most women, even with my “high risk” profile, will have none of these outcomes!
But I’m supposed to be setting that part aside. Sorry. Anyway, through this 45 minute call, what was absolutely not mentioned was any concern about my heart. So the letter I received inviting me for an ECG came completely out of the blue. I’m lucky that I am not particularly worried about my heart, which by all accounts seems to be doing a stand up job. But the shock of finding out yet another way in which the system seems to view me as a ticking time bomb, just waiting to cause devastating harm to the tiny infant I am growing for my friends, was devastating.
Poor communication was also in evidence in the letter itself. In actual fact, what I received was a copy of a letter I had already received, inviting me for an in-person visit to the metabolic clinic. This has been in the diary for a little while. A hand-written note had been added asking me to go to get my ECG at “OPD3” (there’s nothing like an unexplained acronym to clarify and reassure) before the clinic appointment. I was also given a standard flyer explaining what to expect which, while it did a decent job of explaining the ECG procedure, said next to nothing about why I had been referred and what the chances were that my heart might be struggling. I was merely told that pregnancy puts a lot of strain on the heart and so it should be checked out.
Missing info I would very much have liked includes
• What proportion of pregnant people actually have heart problems in pregnancy and how raised the baseline risk is for someone like me
• Whether there are any signs of a heart problem that I should be looking out for and what to do about them
• Whether there is anything preventative I should be doing to protect my heart? Is cardio exercise OK?
• What the next steps might be if my ECG shows a problem
• What the impact would be on me and on the baby
The final kicker here is that this standard flyer says I should come for an ECG at 28 weeks but this has been crossed out and “30 weeks” written in by hand, leaving me with the deeply uncomfortable feeling that this check is happening a bit later than is optimal.
Instead of even a glimmer of reassurance or clarity, I now have a month to wait, wondering if things are going to be OK or not. I am very fortunate not to be much of a worrier, and to have a superbly supportive network around me. But, especially in the context of knowing that floods of stress hormones are really not great for babies, it is incredibly remiss of the team to rely on my personal coping networks to keep me and my friends’ baby safe.
This delightful pack of info also included a couple more treats. One is the official referral note which I presume I hand over to the ECG team. It gives my details, the name of the referring doctor, and hand-written in the space for Reason For Referral: “BMI over 40 pregnant”. Charming.
In the same envelope I also received a total non-sequitur, a leaflet advising me to meet with an anaesthetist before going into labour. The leaflet starts by saying that general anaesthetic is not a good idea for people with a high BMI — something that feels totally out of the blue given how incredibly rare general anaesthetic is in labour and delivery. It advises me to decide if I want an epidural early on in labour in case it is difficult to administer [1] and reiterates that I should meet with an anaesthetist — while giving me absolutely no clue about how to set this up, or when. The leaflet ends by advising me to ask to talk to the on-duty anaesthetist upon arrival at hospital in labour, which seems to completely contradict the “meet someone in advance” message of the rest of the flyer. One final detail which is really the shitty icing on this crappy cake is that these leaflets are some of the most grainy, wonky and generally poorly photocopied materials I’ve ever seen.
The collective result? A total lack of feeling like any of this qualifies as “care”. I feel judged, pushed about, uninformed and neglected. Not what any of the very lovely individuals working to support me want, I have no doubt, but the end result all the same.
All of this is against a backdrop of actively being and always feeling judged for my weight through this whole process. I won’t dive into the BMI-based gatekeeping at the IVF clinic stage, but suffice to say close monitoring of my weight was not a fun part of the surrogacy journey. On top of that, at no stage did this group of — very expensive — doctors and nurses think to explain to me what the NHS pregnancy pathway would be like for someone with my BMI. So, there’s this weird combination of obsessive focus on weight with minimal explanation, which really enhances the feeling of just being told off for being fat, rather than empowered to make informed choices.
Another relevant piece of context is that fact that everything that has been measured up to this point — my blood pressure, the baby’s size, endless blood tests and urine samples — have all come back absolutely fine. I’m also looking after myself very conscientiously, diligently taking all the prescribed supplements, exercising five times a week as well as cycling and walking everywhere, monitoring my weight gain, eating a high-iron, low-fat diet and so on. It’s demoralising to be working so hard to stay healthy and be constantly faced with the message that your profound lack-of-health is all anyone notices or cares about.
A great example of this was my recent referral to a nutritionist — which might at first seem sensible, apart from I do wonder what magical effects she thinks she is going to have on my fat body when I am just three months away from giving birth? Presumably the assumption here is that being so grotesquely massive I must be incapable of consuming a basic array of vitamins and minerals?? But the truth is, it is really easy to be overweight while eating a very healthy and balanced diet, just by having a croissant or a chocolate digestive whenever you fancy it. Contrary to popular belief, a BMI of 40 is not achieved by exclusively eating junk food, though I did once have a healthcare provider ask if I could lose weight by “just cutting out some of the cheeseburgers?”
My journey as a surrogate has been littered with moments which really challenge my identity as a healthy, active person. Hearing via voicemail that I am at risk of blood clots and need to administer daily injections. Being told by the IVF clinic that I need to get weighed at a doctor’s surgery and have it printed on headed paper because my self-reported weight was doubted. When the midwife got to her notes section on exercise, I said yoga, and she typed it in and went to move on to the next section. I had to stop her and add pilates, cycling, swimming and the gym. Yes, I am no marathon runner, but I’m not taking root on my sofa either.
I am certain that a huge part of my experience is down to the austerity policies which have crippled the NHS. I’m sure staff would love to update their materials, send out nicely printed letters with carefully framed, reassuring information — and they can’t because just handling frontline patient needs absorbs every ounce of resource. If anyone from my care team read this, then I’m sorry if you are feeling condemned — though I would note that is how I feel a lot of the time too…
Someone somewhere needs to recognise how counter-productive this all is. My doctors presumably want me to feel grateful for and reassured by their care, and weren’t hoping to trigger a bout of weeping at my kitchen table. How much low-level but chronic maternal stress is being created by a system that shunts us about and disempowers us [2] at every turn? Surely there’s a better way to protect against the risk of a poor outcome, while actually making the pregnant person feel supported and reassured, even if they have committed the sin of getting pregnant while being fat?
[1] I’d be fascinated to know how much research funding is being spent on discovering ways to provide treatment including anaesthetic to fat people, versus money being spent on new dietary intervention development and assessment…
[2] Don’t even get me started on the fact that nearly every routine over-the-counter medication warns that it is “not recommended in pregnancy” and we need to check with our doctor, while the NHS website reassures us we can go ahead…
