Thirty-one weeks pregnant with her first child, Sara Lindberg thought her consultation with an obstetrician at Ridge Meadows Hospital would bring her some peace of mind about giving birth in the thick of the first pandemic wave in 2020.
She had done painstaking research to find a hospital that was 10 minutes from her new home in Maple Ridge and would offer the best skin-to-skin contact support for her and her baby.
Lindberg, who is fat, had a smooth pregnancy. When she developed gestational diabetes in her second trimester, her midwife team wasn’t worried because she was not diabetic or otherwise in poor health. She did need insulin, and welcomed the chance to meet with an obstetrician about it.
However, like many prior prenatal appointments, Lindberg said the consultation with the hospital’s head obstetrician, Dr. Rick Mentz, left her feeling like a victim of “just fat shaming.”
The doctor “basically told me I was there because I was ‘obese,’” she said.
Many fat people consider the term “obese,” which originates from the Latin phrase meaning “to eat oneself sick,” offensive because it pathologizes their bodies’ sizes. The fat justice movement is reclaiming the term “fat” as a descriptor like “tall,” rather than an insult.
Lindberg remembers Mentz calculating her body mass index in front of her, and then informing her it made her too “high risk” to deliver at Ridge Meadows.
The BMI is a single number determined using someone’s weight divided by their height squared. It has, in recent years, been challenged and discredited as a reliable indicator of an individual’s health.
But as a result of her BMI, Lindberg had to scramble to find new prenatal care nine weeks before she was due. Her midwives only had privileges to deliver at Ridge Meadows.
On the way back home with her husband, Lindberg clutched a handout on fatness and pregnancy she was given that she says implied her body was a danger to her baby. She cried. And cried.
“It was probably one of the worst days of my life,” Lindberg said. Now, more than two years after delivering her healthy daughter Ellee with no complications at Royal Columbian Hospital in New Westminster, Lindberg is pursuing a human rights complaint against Mentz and the Fraser Health authority alleging weight discrimination deprived her of the same standard of care afforded to people with lower BMIs.
“If I truly was so high risk, why wasn’t there urgency to ensure I had care providers?” she asked in a statement to the tribunal.
Lindberg has learned that women with lower BMIs were allowed to deliver at Ridge Meadows, despite being deemed “high risk” because of other health conditions like diabetes. And she said she has been in touch with women with high BMIs who had similarly been denied delivery at the hospital.
“Having a birth like that made me feel like my body could do this,” said Lindberg. “It was very affirming for me.”
At Ridge Meadows, which is categorized as a “low risk” maternal hospital, a BMI higher than 40 automatically meant a person couldn’t give birth there. At the time of her pregnancy, Lindberg’s BMI was 41. In 2021, the benchmark was changed to 45, which would have allowed her to deliver in the hospital.
Lindberg wants to see BMI benchmarks removed from hospital policies entirely so that other fat people are not deprived of essential care in their own communities.
“BMI is a very outdated way to assess someone’s health,” Lindberg said. “There are much more comprehensive ways of assessing risk and I really feel like we need to take a lot of these discriminatory policies out of health care.”
There are BMI limits and cutoffs for other types of health services in B.C., such as gender-affirming surgeries and organ transplants. But Lindberg argues the BMI should not be the sole determinant of risk for pregnancies.
When asked by The Tyee what, if any, BMI limits are in place for people giving birth in hospitals, all five B.C. health authorities said there is no universal standard. Rather, risk is determined by individual hospitals and on a case-by-case basis, and patients with higher BMIs, as per guidance from the Society of Obstetrics and Gynaecology and the British Columbia College of Nurses and Midwives, may have their care transferred to other hospitals to prevent adverse outcomes.
At Ridge Meadows, the BMI limit was established by Mentz and other hospital supervisors, according to an explanatory letter Mentz sent to Lindberg in February 2021.
There is evidence that shows correlation between higher BMI and increased risks of pregnancy complications, such as inductions or the need for a caesarean section, Mentz wrote in the letter.
Mentz also noted that should a C-section or induction be required, calling staff back after they go home at 11 p.m. could cause a dangerous delay.
“We can deal with the majority of emergencies that walk through our door,” wrote Mentz. “The difference however in obstetrics is, we can identify patients during the antepartum period who have the potential to develop serious complications, and we feel it would be dangerous to not inform them of these potential complications and have them deliver at our site.”
The Fraser Health authority declined to comment while the Human Rights Tribunal case is ongoing and did not make Mentz available for interview with the Tyee.
Good health at any size
The BMI was first developed in the 1830s by a Belgian scientist seeking to understand the characteristics of the “average” white man. It doesn’t account for bone density, weight distribution, muscle mass or many other factors that describe someone’s body more accurately than just its size.
According to Patty Thille, an assistant professor at the University of Manitoba, BMI calculations — which don’t account for how genetics, poverty and intergenerational trauma impact body size and composition — have been used to justify eugenicist policies and to pathologize Black, Indigenous and racialized people’s bodies.
Its use continues to disproportionately prevent racialized people from accessing necessary medical care, Thille said.
“It’s a very strongly held cultural belief that weight is some transparent measure of health, and specifically body fatness,” said Thille, who specializes in weight discrimination in health care. “But the BMI tells you nothing about someone’s health status.”
While the BMI was never intended to be used as an indicator of an individual’s health, its use as a measure of health and life expectancy proliferated in medicine — and for insurance purposes — throughout the 20th century.
There is also a misconception that weight is simply the result of individual behaviour and is easy for someone to change. But studies have shown that significant weight loss is not sustainable long-term for the vast majority of people, and that weight cycling and constant dieting damages an individual’s metabolism, making it more likely for them to gain back the weight — and more.
Dr. Katarina Wind, a family medicine resident physician in Vancouver, doesn’t calculate her patients’ BMI anymore. She is a proponent of good health at every size, noting how many fat people have died of treatable conditions like cancer when doctors dismissed their ailments and told them to “lose weight.”
“If we start thinking of weight as something that’s non-modifiable, like someone’s height, then we can start thinking about it properly and starting to treat them differently,” Wind said.
Much of the evidence she learned in medical school, Wind said, is “tainted” by the assumption that being fat is inherently unhealthy or reflects individual failings.
In recent years, mainstream medical organizations like the Canadian Medical Association have recognized that the BMI is a poor predictor of health.
Lindberg’s claims echo what academic research is starting to show and other fat women have long said about their experiences with reproductive health care: that “mother blame” is prevalent and they face stigma at nearly every stage of their pregnancy that deters them from seeking care in the first place.
Weight stigma expert Dana Solomon said while there is evidence of correlation between BMI and more difficult pregnancy outcomes such as caesarean sections, that doesn’t mean BMI and complications are causally linked.
Poverty, nutrition, housing, trauma, genetics, hormone and metabolic conditions all impact someone’s BMI, as well as their likelihood of having pregnancy complications, Solomon said. Low-income and Black, Indigenous and racialized people, particularly in the United States where much of the research is, also don’t have as much access to proactive care that would prevent complications down the road.
“When you control for those factors, the [BMI and complications] correlation really recedes,” said Solomon, who is a researcher at the University of British Columbia’s Birth Place Lab.
Solomon cited a recent study that suggests when fat people have their care managed correctly during pregnancy, there is virtually no difference in C-section rates.
Solomon pointed out that weight stigma and discrimination in pregnancy itself increases the risk of complications and birth interventions, and deters people from seeking care. That can lead to missed or incorrect diagnoses, which cascade to inattentive care or increased interventions such as C-sections when not needed. Weight stigma also increases rates of postpartum depression and makes fat people hesitant to seek health care for even minor issues, she added.
In addition, some hospitals may not have the staffing levels or right equipment to be able to safely care for fat people, which Solomon said is no excuse.
“It’s like saying, ‘We don’t have a ramp, so we won’t treat people who use wheelchairs.’”
“Fat people are treated badly by health-care professionals and all these things get more prevalent the bigger you are,” said Solomon. “It affects people’s health on so many different levels, like access to care, types of interventions you’re able to get, how people talk to you and how they treat you. It’s systemic and creates individual harms.”
Weight stigma — not the weight — is the real issue, Solomon said, which perpetuates the idea that people are fat as a result of poor individual choices and are therefore undeserving of proper care.
Blaming and shaming worsens anxiety, depression
Lindberg has always had a larger body. She grew up active, playing basketball and hiking, and her body stayed the same size.
She has hypothyroidism and polycystic ovary syndrome, two conditions that slow her metabolism and affect how her body processes nutrients and holds onto dietary fats. Her ability to exercise has also been reduced as she heals from a car accident.
Since delivering Ellee, Lindberg has dealt with postpartum anxiety and depression, which she feels has been worsened by the blaming and shaming she experienced.
“It’s incredibly ableist to blame me for my size,” she said. “There is very little I can do to control my weight.”
Lindberg also questions why concerns about the number of staff needed to lift her, if required, were used as justification to deny her care at Ridge Meadows.
“It’s as if somehow my life and the life of my baby meant less than the hypothetical thin women they would have to treat as well,” she says.
After an unsuccessful mediation with Fraser Health and Mentz, Lindberg is continuing her claim with the Human Rights Tribunal.
This process has made it difficult to seek health care for herself and for Ellee at Ridge Meadows. After the active toddler bonked her head, Lindberg felt on edge taking her to the emergency room to get checked out.
She and her husband also wonder if they are willing to experience more stigma should they choose to have another child.
The hospital’s policy felt like an attempt to shame and blame her into losing weight, said Lindberg. “But it actually increases our risks by disrupting our care,” she said.
“I hope other women don’t have to go through this.”
