Body Image and Pregnancy Weight Gain

Our society is so fixed on the ideal body type - skinny, fit, active, toned. No one wants to gain wait, to be “obese” based on their BMI, and there is so much focus on not gaining weight or only gaining appropriate amounts of weight that we can’t seem to discuss weight gain in pregnancy without someone leaving the conversation feeling inadequate. The recommendations for weight gain in pregnancy seem to change constantly, with diet recommendations changing almost as frequently. And it makes you wonder, does body image insecurity feed into pregnancy weight gain and what can happen because of it?

The social pressure to be thin and fit is far reaching. Even small children are picking up on this and wanting to be thinner. Weight Watchers even created a new program for kids, as if any child needs to be on a restrictive diet! Weight is such a tender topic, and so many are blaming the body positive movement for the rise in obesity, when there are many other factors at play. However, in pregnancy, weight gain should be the normal for every pregnant person, regardless of weight before pregnancy, and it can lead to a lot of heavy emotions and some people even end up diet restricting so they gain inadequately or not at all, and in some cases, even lose weight.

Even with that, this is the first time in many people’s lives that they are encouraged to gain weight, which is at odds with what they’ve been told their entire life. It can be hard to change your mindset around weight gain, even when you want to do everything possible to have a healthy pregnancy and healthy baby. A paper published by the WHO states, “During pregnancy and postpartum, women’s dissatisfaction with their bodies increases irrespective of how satisfied they were prior to the pregnancy. Evidence suggests that pregnant women who are affected negatively by changes to their body are less likely to initiate breastfeeding.” ¹ The breastfeeding aspect was a huge shock to me, I hadn’t thought of the connection to body image with the rates of breastfeeding or even just the initiation of breastfeeding. And the bit before that about stating that it didn’t matter how satisfied they were before pregnancy, the dissatisfaction with their body increased as pregnancy progressed.

A study published in 2009 about prepregnancy BMI, gestational weight gain, and likelihood of major depressive episodes discusses the impact of weight gain on incidences of depression during pregnancy.² Their findings weren’t very shocking, even with the body shaming attitude of obesity and BMI, and they showed that all sized people had an increased risk and chance of depression in pregnancy, though the risk was higher with those classified as “obese” before pregnancy. Interestingly enough though, those that were normal BMI before pregnancy had a much higher chance of depression if they had inadequate weight gain during their pregnancy. It almost feels like a doubled-edged sword - gain weight and it’s an issue, don’t gain weight and it’s an issue. I feel that the bigger issue isn’t how much or little is gained but the inner feelings around weight gain itself. Another paper published even discusses how weight stigma actually increases the chances of excessive weight gain, leading to higher rates of postpartum depression and weight retention.³ She wants communities and providers to focus more on how they’re treating pregnant people overall versus focusing on weight and all the factors that deals with.

And to turn it around a little bit, knowing how hard it is to be okay with weight gain in pregnancy and all that entails, I found an amazing post⁴ about some concrete ways you can feel a little more positive about your body during pregnancy. One of the big ones that I love to tell people is to get rid of the scale! You are not based on the number that shows up. You should be gaining weight, because your body is growing another human, expanding your blood volume, and creating a placenta, but weighing yourself regularly and at every appointment can be doing more harm than good to your mental health. And all this isn’t to say you won’t have bad days! “You’re going to have negative thoughts and feelings about your body sometimes so forget trying to be positive all the time. These thoughts are not a personal failure—we live in a culture that breeds body insecurity and bombards us with unrealistic beauty ideals daily.” One of their suggestions is to find positive sources instead, like the 4th Trimester Bodies Project.⁵

Just like any other time in your life, you are not defined by your weight. Pregnancy should be a time when you are eating well, growing healthy, building another human, not a time to focus on what the numbers mean or how our old clothes don’t fit anymore. Take it one day at a time and try to embrace the difference in your body. It’s not easy, but even small acts can help you feel better and have less depression and mental health issues than the focus on how your body is changing in a negative light.

Resources:

1. Breda, Joao. Body Image, Pregnancy, and Birth. http://www.euro.who.int/__data/assets/pdf_file/0003/277734/Body-image-and-pregnancy.pdf?ua=1

2. Bodnar, Lisa M. Prepregnancy Body Mass Index, Gestational Weight Gain, and the Likelihood of Major Depression During Pregnancy. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2760651/

3.Rodriguez, Angela C. Association of Weight Discrimination During Pregnancy and Postpartum with Maternal Postpartum Health. https://medicalxpress.com/news/2019-02-pregnant-women-weight-stigma-decreased.html https://www.ncbi.nlm.nih.gov/pubmed/30762402

4. Davidson, Megan. 7 Steps for a Body Positive Pregnancy. https://www.nationaleatingdisorders.org/blog/steps-for-body-positive-pregnancy

5. The 4th Trimester Bodies Project. https://www.4thtrimesterbodiesproject.com/

Hemoglobin and Pregnancy

Hemoglobin is the oxygen carrying component of red blood cells, and is a screening marker for problems, not a diagnostic tool. Your fingertip is pricked with a small lancet, a drop of blood taken and tested. All in all, it only takes a few minutes to know your hemoglobin status. It’s a valuable tool in any practice, but it isn’t the end all diagnostic for iron levels. Hemoglobin can also be checked in a blood draw lab test, included in the CBC, and those results can be more accurate than the quick finger prick.

During pregnancy, hemoglobin is a touchy subject. In some cases, it is the only tool used to monitor iron levels and risk of anemia, but as stated above, hemoglobin is simply a screening marker. One of the biggest changes to hemoglobin is a physiological decrease response to an increase in blood volume, which is normal in a healthy, well-nourished pregnancy. Falling hemoglobin levels and a well-growing baby coincide with each other, and they are an important factor in monitoring a healthy pregnancy.

Hemoglobin levels in pregnancy can be tested at any time, but generally are done at the first prenatal visit and then at the beginning of the third trimester, around 28 weeks. The first visit is a baseline value, normally done before 8 weeks of pregnancy, and shows what your hemoglobin is before your blood volume has expanded. Sometimes this first test can point to a lower than optimal beginning hemoglobin which can be corrected in most cases with diet and nutrition changes and supplements when needed.

In general, hemoglobin in the first trimester of pregnancy should be around 12-13g/dL, giving you enough room for a 2g fall by 28 weeks. At 28 weeks, Anne Frye says that the lower limit of normal is 10g/dL, but even then, hemoglobin is again just a screening marker.

During pregnancy, your hemoglobin will drop gradually as your blood volume increases, and you should see a 2g/dL drop by 28 weeks, IF you live in an area that is less than 5000 feet above sea level. Altitude matters in cases of hemoglobin levels! If you live between 5000 and 8000 feet, you may only see a drop of 1-1.5g/dL. If you are above 8000 feet, you may not see a drop at all. Your body has to compensate for the lower levels of oxygen in your area, and your hemoglobin will show that.

If your hemoglobin didn’t drop at all by 28 weeks and you live below 5000 feet, it’s a sign that your blood volume hasn’t expanded well, and can lead to problems with your baby’s growth and issues with blood loss and its effects after the birth.

Along this line, anemia is a marker of a problem, not a diagnosis, and hemoglobin alone is misleading as pregnancy advances. If your hemoglobin is low, or lower than where your provider would like, more tests are needed before any diagnosis is made.

LOW HEMOGLOBIN IS JUST A SCREENING MARKER.

If it’s low, the additional tests that may be run are serum iron, total iron binding capacity, transferrin saturation, and serum ferritin. In most cases, the serum ferritin may be the only additional test that is needed.

Ferritin is the major iron-storage protein, and the serum ferritin test is checking for available iron stores in bone marrow. This is more of an indicator of iron deficiency than hemoglobin. In normal menstruating women, the value should be 25-200ng/mL.

If your hemoglobin is low (again, below 10g/dL), serum ferritin should be the next test ordered to make sure your levels are within normal range. For most pregnant people, levels of ferritin below 30ng/mL confirms iron deficiency anemia. If this is run at the beginning of pregnancy, a hemoglobin level less than 11g/dL and serum ferritin level of less than 25ng/mL is the biggest sign that changes are necessary to increase both levels. In some cases, that can also point to other issues with iron and red blood cells, but that is more rare than simply being iron deficient.

Remember: Normal hemoglobin levels after 28 weeks of pregnancy are above 10g/dL, but it is simply a screening tool. More testing is needed, specifically a serum ferritin, which should be between 30-200ng/mL, showing that you are not anemic, your risk of bleeding during birth is not increased, and your hemoglobin level is not an issue.

RESOURCES:

Understanding Diagnostic Tests in Childbearing Year by Anne Frye, pages 258-298, Normal Hemodilution, Anemia, and Red Cell Disorders in Pregnancy.

Holistic Midwifery Vol 1 by Anne Frye, pages 195, 580, 828-832, 1007-1008.

Perinatology Reference Values

https://www.uptodate.com/contents/maternal-adaptations-to-pregnancy-hematologic-changes/abstract/5" target="_blank">Hematological Changes

https://www.ncbi.nlm.nih.gov/pubmed/19935037" target="_blank">Pregnancy and Laboratory Studies

Experience Doesn't Pay the Bills!

I’ve been a birthworker for ten years, from doula to midwifery assistant to midwife myself, and one thing I’ve seen over and over is the idea that experience is a currency we can use to avoid paying actual money to those that help us.

Unpaid internships are almost a staple in the United States, a thing of privilege, and in my opinion, a thing that needs to be dismantled. I’m not saying it will happen overnight, but I think steps need to be taken to get rid of this archaic system, propped up by privilege and tradition.

“I had to do my apprenticeship for free (or even had to pay for it), and it made me learn better/faster/what have you, and I think we should continue it.”

How many times as a birthworker have you heard that? Did it make you more excited to get into the field, or did it seem like an impossible barrier so your dream would never come to fruition?

Being on call for weeks at a time has its own set of challenges, and doing it for free makes it even more challenging. Most birthworkers have children that need care while you’re away, a working car with a full gas tank, and some apprenticeships even require you to have certain equipment before you can begin or to pay a fee to attend the birth, and if you are working for free, your partner needs to be working a great job to cover your expenses, or you need to have another source of income while doing this work while also having the freedom to be on call and leave whenever you need. All of this can lead to burnout, additional stress and worries, and for a lot of people, the inability to even be able to do an apprenticeship which would line up in every other way except for finances.

If we are requiring certain trainings, tools, resources, and more as a minimum for people to even consider working for and with us, why are we letting an antiquated system decide how we can support them in their process? Why are we content with putting our past experiences in the forefront, saying that nothing can change because we didn’t have the option of not only payment, but more things on top of that?

In a world that is ever changing, why are we so content in the idea that experience is equivalent to cash?

It’s not a new idea. Artists, freelancers, and many more careers off the beaten path have been told for years that exposure = payment, and it’s just not true. Why is it that interns in a hospital are paid (though it is bare minimum), but apprentices for a midwifery practice are told to find another way to make it work because the experience is the payment? In what world is experience a currency that can not only pay bills and keep a roof over your head, but make you want to truly be in that field and not feel like someone just there as unpaid labor?

Our world requires money to live. I wish it wasn’t that way. Insurance is expensive, cars are expensive, housing is expensive, food is expensive. Experience doesn’t pay for any of that.

When I did my apprenticeship, I was privileged to have a supportive partner and supportive friends. I didn’t have to worry about what to do with my child if I was called to a birth, which was a massive load off my mind. I didn’t have to worry about filling the tank to get to a birth because we had a bit of money to spare to make sure I could.

And yet, I can’t help thinking about what it would have been like to not put all that pressure on my partner and our relationship. What would it have been like if I had been able to provide at least a little bit back to help buy food, to buy gas, to pay for our car insurance. I would have been more willing to be a part of the experience, I would have eagerly joined in on more events. Being paid would have given me a buffer, an ability to breathe a little should something outside our very tight budget happen.

What if we decided to change this paradigm and tradition. What if instead of saying “Well I had to….” we instead said, “I did mine for free, but you don’t have to.” What if instead of putting the responsibility outside ourselves, watching person after person quit, leave, or burnout, we gave them a little bit of financial security in exchange for their presence, training, and help. Even if the relationship doesn’t last as long as we want, or they decide to pursue another path, what if we put the effort in and showed our appreciation with a little bit of monetary compensation for the work they do so we can focus elsewhere.

We don’t need to perpetuate a harmful tradition anymore.

Just think of how many more birthworkers we could create if we simply said, “No more.”

Open, Open, Open

I wrote this last year, a poem about the last fifteen or so minutes of my last labor and birth. It was the longest and shortest six hours of my life, and time had no meaning until it did. Everything was quiet, and I loved it. I worked with my body, I moved, I moaned, I spoke, I whispered.

In the end, it was the most amazing experience of my life.

"Open, Open, Open"
Kayce Pearson

“Open…open…open…”
I chant to myself as I float in the pool.
Silence aside from me.
My family sleeps in the other room

My friend rests on the couch, keeping vigil.
I turn inward, willing my body to relax;
Another contraction.
I lift my body, floating on my back.

“Open…open…open…”
Peak. Tears well.
Can I do this?
I float back down to rest.

Time has no meaning; I float.
I smell steam.
The water engulfs me.
My body is no concern.

Just the sensations; the air, the water.
My phone rings, its sound jars me from my mind.
ANGRY! Disjointed.
How can it be 7:15?

Why aren’t you born??? I growl.
Did I say it aloud?
No. No. I can’t.
Another contraction; this time so long to focus.

“Open…open………”

It feels different.
My pelvis moves.
I gasp. 

I feel it, a head rotating
Moving down
I know then the work is beginning.
I flip over onto my knees,
I lean over the edge of the pool.

Focused.

“Get Blake!” I yell. I regret it.
No time. Work to do.
I feel my uterus push. I growl and help it. Yes.
The air feels heavy.

Everyone runs out. Blake wraps his arms around me;
He whispers to me.
I tune it out. I just needed his strength.
Another push.
“I see a head!”

Head is out.
I push. My uterus pushes.
Nothing.
Anger. Why won’t you move?!

I feel a body inside me rotate.
No logical thought.
All that matters is the feeling.
Is he stuck?

Push. Turns. Growls. Push.

Release.

All emotions cease.
The room is silent.
Breath is held.
I turn over, grab my baby.

I pull him to the surface of the water,
“It’s a boy!” I yell.
Noise all around. “You did it!”
I sit higher.

“Come on baby. Breathe for mommy.”
He wiggles. No breath.
I talk to him. I rub him.
I love him.
I am calm.

Then.
A cry.