By Kathleen Kendall-Tackett
Illustrations by Ken Tackett
Bias against fat people remains the last socially acceptable prejudice. It’s in science, the world, and in healthcare. Plus-size women encounter prejudice in almost every type of health care setting, but for some reason, it seems particularly harsh in maternity care. Women are bullied and shamed into doing things that are not healthy, such as a 15-pound weight gain during their pregnancies or an unnecessary cesarean. What’s worse, many providers feel justified when they act this way, claiming only to be concerned about the mother’s health. When providers say, “It’s just not healthy,” they are often hiding baser feelings that have little to do with the health of the mother and more to do with providers’ sense of aesthetics (“it’s not attractive”), and even their sense of right or wrong (“fat = lazy, undisciplined, poor, dumb, etc.”).
The same thing happens in lactation care. Weight bias is rife. I’ve heard it in the way providers talk about mothers and in conferences on “obese mothers.” Is it any surprise that breastfeeding rates are lower among women with higher BMIs?
You’ve most likely run into these judgments already. Don’t buy into it! That’s their problem, not yours. Here are some of the myths you might run into. These myths are even in the scientific literature.
Myths about Plus-Size Mothers and Breastfeeding
Previous studies have found lower breastfeeding rates in plus-size mothers. The question is, why? Weight-biased scientists have often hypothesized something like this; “If ‘obese mothers’ cannot breastfeed, it must be their fault.” Their “fatness” somehow made it impossible. Research articles, published in generally decent journals, beat the tattoo of the fat-hating culture. Although clinicians often repeat these myths, none of the problems they’ve identified have a shred of evidence to support them. Some of these would be funny if they weren’t so poisonous.
- Your nipple is too big.
This one’s odd. Skinny women sometimes have larger nipples. Not a bit deal. Nipple size is not related to weight.
Workaround: Sometimes, a nipple can be too big in the early days, especially if your baby was born small or a bit early. If your baby is having trouble, you may need to express for a few days to give her a chance to catch up. Keep offering and keep expressing milk to establish your milk production. Try some different positions. If it hurts, stop, and give it a bit longer. It will happen.
- Your areola is too big.
So what? Your baby doesn’t need to get the whole areola in her mouth. She only needs to take enough in to get a deep latch, one that doesn’t hurt you and helps her transfer milk well.
Workaround: While you don’t need to worry about “big areolas,” you do need to pay attention to whether your baby has a deep latch. If your nipples are sore and/or you don’t hear audible swallowing, have a lactation specialist take a look. Many times, it can be quite easily sorted with skilled help. But it’s better to get that help sooner rather than later.
- Your breasts will “crush” your infant.
This is a particularly hateful myth. New mothers are already sensitive enough. Saying that they will harm their infants with their bodies is the worst kind of fat-shaming, and it’s not even close to true.
Workaround: You’ve been handling your breasts since puberty. I’m sure you can figure out a comfortable way for you and your baby to sit while nursing. Some mothers find that a rolled-up washcloth under their breast takes some of the weight off the baby. The truth is that many different positions can work. Feel free to experiment.
Remember, this is your body and your baby. You don’t have to do it like anyone else. The “right” position is the one that works.
- You have no lap, so you won’t be able to use all the standard positions. The no-lap argument is laughable. Lap size depends on people’s height and body shape. You can’t make a blanket statement that supposedly includes all plus-size women. For example, short women may not use much space for the baby to be. Are we going to say they can’t breastfeed? Or course not! You also do not need to use all the standard positions. That’s just silly. And since when do mothers breastfeed from their laps?
Workaround: Biological Nurturing (laid back breastfeeding) is your friend here. By using it, you increase the ventral space area where your baby can lie. Here’s a quick overview.
a) Sit comfortably and pretend like you are watching TV. It can be any angle you like.
b) Put your baby at what Dr. Suzanne Colson calls the “right address.” Your baby should be face down on your body, letting gravity do the work to hold her in place. Scoot the baby up so that your baby’s cheek is on your breast. From that position, you should comfortably be able to see your baby’s face.
c) Hang out and enjoy being close to your baby. When your baby gets hungry, she will start bobbing her head towards your breast. Feel free to support your baby’s movements and adjust yourself, your breasts, and your baby as needed. From this position, babies tend to latch well and feed efficiently.
d) Try different positions. Don’t feel like you have to do it the way that anyone else does. Here is a link to her site so you can see this in action.
You can also purchase her book here. PraeclarusPress.com
- “Obese women” have less of a prolactin response to suckling.
This myth is insidious because it sounds so scientific and so sure, and it comes from a particular study (Rasmussen & Kjolhede, 2004). This study has gained importance because everyone cites it and uses it for evidence about why plus size women can’t breastfeed. It’s even on the exam we take to become IBCLCs. But here’s the thing: this belief was a hypothesis. The study included only 17 mothers (some of whom were “overweight,” not “obese”). Tiny sample. It’s interesting, but you can’t conclude much from it. Strike one.
The researchers hypothesized that progesterone in adipose (fat) tissue suppress es prolactin, the hormone necessary for milk production. That wouldn’t be a good thing. (Progesterone is another hormone that helps sustain pregnancy and drops to low levels after birth.)
Unfortunately, the data did not support their hypothesis. They only found the effect of suppressed prolactin on day one but not on day two (so it could be anything, really, including a measurement error). Further, progesterone appeared to have no role in this process whatsoever.
So what does this mean? It means that this theory, in all its fat-shaming glory, was not supported by the findings. What do you need to do about it? Absolutely nothing! But do be aware that some of your providers may harbor this belief—mainly because most have not read the actual study.
The Real Reason for Lower Breastfeeding Rates in Plus-Size Mothers
Let’s go back to our original question. Why do plus-size women breastfeed at lower rates than women with lower BMIs? The answer is one you might suspect. A study of more than 19,000 women in the U.S. found that plus-size mothers were significantly less likely to get the support that we know they need to successfully breast feed (Kair & Colaizy, 2016). They were less likely to have their babies with them in the first hour, less likely to have skin to skin time, and less likely to be instructed on cue-based breastfeeding. Further, their babies were less likely to room in and were more likely to use pacifiers. They were even less likely to get a handout listing breastfeeding resources in the community.
There is no excuse for this. We (as a field) have spent years looking for ridiculous hormonal explanations or looking at the mothers’ characteristics. While we have been pointing fingers at you, we should have noticed that three fingers are pointing back at us.
Things to Watch For
While you don’t have to believe the myths, there are a couple of things that may be related to BMI, so they are important to watch for.
- You may have more edema.
This isn’t always true, but it can be, especially if you’ve had a lot of fluids during your delivery.
Workaround: If you have engorgement or your breasts feel so full that your baby can’t latch, use reverse-pressure softening to push some of the fluid away from your nipple and areola. It’s important to breastfeed as much as you can during this time. Here’s a link to show you how.
Engorgement is caused by your milk “coming to volume,” but also excess blood and fluid. It’s important for you to address for your own comfort and because it can influence your milk production. Breastfeed or express your milk frequently. Use some cool compresses to comfort. You might also try some very gentle breast massage. The best expert on this is lactation consultant Maya Bolman. You don’t need a deep massage. The lymph nodes are near the skin. You just need enough so that they can help move excess fluid. Here’s a link for her site below. The first half is on hand expression, and the second part is on breast massage. https://player.vimeo.com/video/65196007
- Watch out for the effects of insulin resistance.
If you have a condition related to insulin resistance (e.g., polycystic ovarian syndrome (PCOS) or type II diabetes), it’s important to keep it under good control. Excessive insulin can affect the hormones necessary for lactation. If you are on medication to control excessive insulin, don’t stop. Exercise is your friend here. It’s good to have some gentle exercise every day if you can. Put your baby in a sling or stroller and take a walk. If you’ve had a particularly carby meal, go take a walk. It will help a lot.
Exercise will make it easier for you to breastfeed. The goal is not weight loss; it’s to use exercise as a way to control insulin. You may lose some weight too, but you will get major health benefits even if you are not smaller.
If you are a breastfeeding mother, or want to be, what do you need to do? First, know that you may not get the support you need from your providers. I wish that it was different, but it’s important to acknowledge the landscape. Fortunately, knowledge is power. If you know what you might run into, you can gather what you need for yourself. Find people you connect with and who will help you. I’m sorry that you will have to do it this way. You deserve better. But you can make it work.
Breastfeeding is your right. Don’t let anyone tell you differently. You’ll be amazing.
Kathleen Kendall-Tackett, PhD, IBCLC, FAPA, is a health psychologist and international board-certified lactation consultant. She lectures extensively across the U.S. and Canada, and in 15 countries outside of North America. She became interested in the topic of weight bias in maternity care after attending several conferences in a row on the topic of “obese mothers.” They made her mad. After being bumped off of a plane, she wrote a particularly snarky piece for the Science and Sensibility blog called “Weighing in on Obesity and Breastfeeding,” which lead to many opportunities to speak on the topic. She served on the U.S. Office of Women’s Health’s Taskforce on Obesity and Trauma, and lectures frequently on the topic of weight/BMI, trauma, and bias in healthcare providers. Dr. Kendall-Tackett is the founding editor for Clinical Lactation and served as Editor-in-Chief for 11 years. She is also Editor-in-Chief of Psychological Trauma and is currently serving her second term. She continues to advocate for plus-size women in every setting that she is in. You can find out more at www.kathleenkendall-tackett.com.
Kair, L. R., & Colaizy, T. T. (2016). Obese mothers have lower odds of experiencing pro-breastfeeding hospital practices than mothers of normal weight: CDC Pregnancy Risk Assessment Monitoring System (PRAMS), 2004-2008. Maternal & Child Health Journal, 20(3), 593-601.
Rasmussen, K. M., & Kjolhede, C. L. (2004). Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics, 113, e465-e471.
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