Weight stigma in the preconception, pregnancy, and postpartum periods: A systematic review of women's perspectives

Summary

Weight stigma presents a significant challenge for women throughout the preconception, pregnancy, and postpartum (PPP) periods, manifesting in multiple areas of life, including interpersonal relationships, healthcare settings, and broader social contexts. This systematic review investigates weight stigma in women across their reproductive years, examining its impact, and exploring the socioecological factors that contribute to its persistence. We searched Medline, PsycINFO, Embase, Maternity and Infant Care (MIDIRS), and Global Health for peer‐reviewed articles published since 2010. Of the 3486 records identified, 38 were included in a narrative synthesis. Inductive thematic analysis was used to explore women's personal experiences of weight stigma. We then applied a socioecological lens to examine the interrelationships between individual, interpersonal, organizational, and societal factors contributing to weight stigma. Five overarching themes were identified: (1) the impact of weight stigma on PPP women; (2) weight stigma experiences across the socioecological contexts; (3) coping strategies; (4) women's voices as a call to action; and (5) interrelationships of weight stigma contexts. Our findings provide critical insights into the multifaceted nature of weight stigma, highlighting the need for future research, and the development of practical strategies that prioritize women's perspectives, and challenge harmful societal norms for positive change.

1. INTRODUCTION

Individuals perceived to carry excess body weight are highly stigmatized, and are subject to widespread prejudice and discrimination due to their body size. ¹ Weight stigma is one of the most pervasive forms of social discrimination experienced among adults in Western societies. ² It is especially common among women under 45 years of age and is comparable to that of racial discrimination. ³ Indeed, weight stigma is particularly prevalent among women during the pregnancy and postpartum period due to weight gain associated with childbearing, and gender norms that uphold the Western ‘slimness’ ideal. ⁴ Despite extensive research on the topic of weight stigma in the general adult population, less is known about its impact on women across the preconception, pregnancy, and postpartum (PPP) life‐stages.

Current evidence shows that weight stigma is experienced among pregnant and postpartum women across multiple contexts, including through their close interpersonal relationships, interactions with healthcare providers, the media, and society in general. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ Further, half of all women in the preconception phase (i.e., the time period preceding pregnancy when individuals actively plan to conceive), are living with overweight or obesity, and are at risk of experiencing weight stigma. ¹¹ The negative health effects of weight stigma among PPP women include decreased healthcare quality, psychological distress, body image dissatisfaction, and maladaptive coping strategies. ¹² Often perpetrators of weight stigma enact this stigma as a means to motivate individuals to lose weight. ¹ However, weight‐stigmatizing experiences have been associated with increased food consumption and reduced motivation to exercise, contributing to weight gain during pregnancy, and the retention of weight after childbirth. ¹³ Consequently, weight stigma is a significant barrier to weight loss, which may increase the risk of, or exacerbate maternal obesity, potentially contributing to adverse offspring outcomes. ¹³

The common misconception that body‐weight regulation is entirely under individual control, and can be reversed by simply having the willpower to “eat less and exercise more”, is a key driver of weight stigma. ¹⁴ This attribution to personal responsibility; frequently perpetuated by the media and reinforced by society, overlooks the multitude of complex factors influencing body size. Moreover, it adds to the reinforcement of harmful stereotypes. ¹⁵ To comprehensively understand the complexities of weight stigma, we must shift our focus beyond the individual, and consider the broader societal influences that may underlie and perpetuate such stigma. The ecological systems theory model is a useful framework for understanding the interconnected relationships between individuals and their social environment. ¹⁶ Adopted by Hill, ¹⁷ this model emphasizes the impact of interpersonal (e.g., family, friends), organizational (e.g., healthcare, media), community (e.g., culture, society), and public policy (e.g., policies and laws) layers on the individual (including their knowledge, attitudes, and behaviors). Given relationships play a significant role in shaping individual health behaviors, (i.e., supportive relationships encourage healthier attitudes and behaviors), ¹⁸ it is crucial to examine the experiences of weight stigma among PPP women within these wider social contexts. Incorporating women's voices into the development of strategies for preventing weight stigma is also critical, as their experiences are frequently underestimated despite their profound negative impact.

To our knowledge, no systematic review has comprehensively examined the weight stigma experiences of PPP women by focusing on their unique perspectives. Furthermore, there is still a critical gap in our understanding of how this pervasive phenomenon impacts their health and social wellbeing within the contexts of their everyday interactions and relationships. We chose a systematic review approach to provide a comprehensive analysis of the evidence, allowing us to draw conclusions and inform practice and policy in this growing field. Our aim was to characterize the experiences of weight stigma among PPP women, with a specific focus on translating evidence into actionable strategies. To achieve this aim we took a two‐pronged approach. Firstly, we conducted an inductive thematic analysis of the literature to explore women's personal experiences of weight stigma. Secondly, we applied the socioecological lens to deductively explore the interrelationships between individual, interpersonal, organizational, and societal factors contributing to weight stigma. Our research question was: What are the experiences and impacts of weight stigma among PPP women as reported from their own perspectives, across various settings and sources?

2. METHOD

This systematic review was registered in PROSPERO (CRD42022370807). The conduct and reporting were guided by the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement. ¹⁹

2.1. Search strategy

A systematic search for peer‐reviewed journal articles was initially conducted in October 2022 and updated in August 2024, across five electronic databases: Medline, PsycINFO, Embase, Maternity and Infant Care (MIDIRS), and Global Health. The search strategy was developed collaboratively with an expert librarian using the OVID platform and involved adapting keywords and Medical Subject Headings (MeSH) to each database. The concepts “weight”, AND “stigma”, AND “preconception, OR pregnant OR postpartum women”, AND “socioecological” were used to conduct both searches. The full search strategies are presented in Table S1. Backward citation searches of included articles were also conducted.

2.2. Inclusion and exclusion criteria

Inclusion and exclusion criteria were defined according to the participants, intervention, comparator, outcome, and study type (PICOS) framework (Table S2). ²⁰ Eligibility included: (1) peer‐reviewed; (2) original primary research articles; (3) available in English (due to financial and time constraints related to document translation); (4) published since 2010 (as weight stigma research in PPP women is an emerging field of study); and (5) reported on weight‐stigmatizing experiences. Stigma pertaining to culture, ethnicity/race, mental health, or socioeconomic status was not considered in this review. Diabetes stigma was also not considered except in instances associated with body weight. Moreover, women identifying as transgender were excluded, since findings may have been confounded by intersectional factors. Lastly, systematic reviews, conference abstracts, dissertations, editorials, opinion pieces, commentaries, and gray literature were excluded.

Preconception was defined as pre‐pregnancy, and/or prior to pregnancy in women aged 18 to 45 years, as this is the time most women are likely to become pregnant. We defined postpartum as mothers who have given birth within the 24‐month period preceding participation, to ensure we captured potential weight‐gain retained over time. Weight stigma was defined as the social devaluation and denigration of individuals because of excess body weight. ²¹

2.3. Study selection process

Studies identified through the search were exported to EndNote X20 (Clarivate Analytics, USA). After removing duplicate records, title, abstract, and full‐text screening was conducted in duplicate by two independent reviewers (MD and EG), based on the predefined inclusion and exclusion criteria. Differences of opinion were resolved through discussion until a consensus was reached. Reasons for exclusion during full‐text screening are presented in Table S3.

2.4. Assessment of study quality

Study quality was assessed in duplicate (MD and HH). Due to the diversity of designs (qualitative, quantitative, and mixed methods), two appraisal tools were utilized. Qualitative research studies were assessed using the Critical Appraisal Skills Programme (CASP). ²² This checklist includes 10 questions that assess the aim of the research, suitability of methodology and recruitment strategy, relationship between researcher and participants, ethical issues, appropriate data collection methods and research design, quality of data analysis, clear statement of findings, and research value. Quantitative studies were evaluated according to the Centre for Evidence‐Based Management (CEBMa) survey checklist. ²³ The CEBMa checklist contains 12 questions that address the clarity of the research question, suitability of study design, selection of participants and potential selection bias, subject representation with regard to the population, pre‐study power analysis for sample size, satisfactory response rate, validity of questionnaires, assessment of statistical significance, inclusion of confidence intervals, and consideration of confounding factors. Question 12 (applicability of results to your organization) was excluded due to irrelevance. Both checklists were used to assess mixed‐methods studies. All questions were assessed as “yes”, “no”, or “can't tell”, with each study given a rating of high, moderate, or low quality. Any disagreements between reviewers were resolved through discussion.

2.5. Data extraction

Data extraction was conducted in duplicate by two independent reviewers (MD and HH) using a customized template in Microsoft Excel. The following information was extracted from each article: author, year of publication, country, study aim, sample size, inclusion/exclusion criteria, demographic characteristics (e.g., age, ethnicity, body mass index [BMI], pregnancy status), study type and data collection methods, key findings (e.g., stigma experiences, and socioecological perspectives), qualitative themes where applicable, and study limitations. Disagreements were resolved by discussion.

2.6. Data synthesis

Data from quantitative studies were combined with qualitative data into a narrative synthesis. To achieve our first aim, we applied an inductive thematic analysis to explore PPP women's personal experiences of weight stigma. The first author (MD) performed the thematic analysis using Braun and Clarke's six‐step process, ²⁴ including (1) familiarization of data, and noting down initial ideas; (2) generation of initial codes to identify reoccurring patterns within and between studies; (3) identifying overarching themes; (4) reviewing themes; (5) defining themes; and (6) final analysis and write up. This approach aligns with the methodology described by Braun & Clarke (2019), which values deep engagement by a single researcher. They emphasize that while multiple coders may yield varied results, this does not necessarily enhance accuracy and often results in different, rather than ‘better,’ coding. Our focus on quality and thorough engagement with the data over inter‐coder reliability is consistent with best practices in qualitative research. ²⁵ To ensure rigor, the analysis was verified by the senior author (BH), discussed with the first author, and then all authors. To achieve our second objective, we took a deductive approach by applying the socioecological framework to the themes identified in the inductive analysis. Utilizing this framework alongside the six‐step process allowed us to explore the interrelationships between individual experiences, interpersonal, organizational, and broader societal factors.

3. RESULTS

3.1. Study selection

The study selection flow chart (PRISMA) is presented in Figure 1. The search identified 3486 records. An additional six articles were identified through a backward citation search. After the removal of 577 duplicates, 2915 titles and abstracts were screened, followed by 66 full‐text articles. Thirty‐eight studies were deemed eligible and included in this review.

FIGURE 1.

PRISMA flowchart of studies included in the review.

3.2. Characteristics of included studies

Characteristics of the included studies are presented in Table S4. Studies were primarily cross‐sectional in design; distributed across qualitative (n = 23, 61%), quantitative (n = 11, 29%), and mixed methods (n = 4, 13%) studies. Studies were included from a range of countries: 14 from the USA ⁵ , ⁶ , ⁹ , ¹⁰ , ¹³ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ ; seven from the UK ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ ; six from Canada, ⁷ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ three from Australia ⁴⁷ , ⁴⁸ , ⁴⁹ ; two each from Sweden ⁵⁰ , ⁵¹ and Denmark ⁵² , ⁵³ ; one each from Ireland, ⁵⁴ Scotland, ⁵⁵ Turkey, ⁵⁶ and the USA/Canada. ⁵⁷ Individual sample sizes ranged from five in one qualitative study ⁵² to 19,145 for a quantitative survey. ³² Studies predominantly involved pregnant, ⁵ , ⁶ , ⁷ , ⁹ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ and postpartum women. ⁵ , ⁶ , ⁷ , ⁹ , ¹³ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³¹ , ³² , ³³ , ³⁵ , ³⁶ , ⁴⁰ , ⁴⁴ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵¹ , ⁵⁵ Three studies included preconception women. ⁷ , ²⁷ , ⁵⁰ In the majority of studies, participants were of White ethnicity, ⁵ , ⁶ , ⁷ , ⁹ , ¹⁰ , ²⁶ , ²⁸ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴¹ , ⁴³ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ African/American, ¹³ , ²⁹ , ³¹ , ⁴⁴ or Hispanic. ³⁰ One study included women with Pacific Island backgrounds, ⁴⁸ and another study involved Turkish women. ⁵⁶ Ethnicity/race was not stated in two studies. ²⁷ , ⁴⁰ In terms of socioecological factors, 19 (50%) studies concerned women's experiences of weight stigma with healthcare providers. ⁶ , ⁷ , ²⁸ , ²⁹ , ³² , ³⁴ , ³⁵ , ³⁷ , ³⁸ , ³⁹ , ⁴¹ , ⁴² , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵³ , ⁵⁵ Ten (26%) studies investigated weight stigmatizing experiences across multiple relationships (e.g., from friends, strangers or care providers). ⁹ , ²⁶ , ²⁷ , ³⁰ , ⁴⁰ , ⁴³ , ⁵⁰ , ⁵² , ⁵⁴ One study focused on the media, ⁵ and two studies focused on close relationships. ¹⁰ , ⁴⁶ Nine (24%) studies assessed weight stigma and psychological outcomes. Two studies focused on weight stigma and depression, ¹³ , ²⁶ and one study on body dissatisfaction. ⁴⁵ Weight Bias Internalization (WBI) was measured in five studies. ²⁹ , ³¹ , ³³ , ⁵⁶ , ⁵⁷ Several studies incorporated women's suggestions for reducing weight stigma. ³⁰ , ³⁸ , ⁴² , ⁴³ , ⁴⁸ , ⁵¹ , ⁵² , ⁵⁴ , ⁵⁵ No studies explicitly evaluated women's experiences of weight stigma in relation to policy, including health and social policies that provide necessary guidelines and regulations to address the issue.

Several measures of weight stigma were used across all studies. Quantitative assessments included modified versions of the Interpersonal Sources of Weight Stigma Scale, ⁵ , ⁶ , ⁹ Satisfaction with Family Life Scale, ⁴⁶ Friendship Network Satisfaction Scale, ⁴⁶ Body Image in Pregnancy Scale (BIPS) sub‐scale, ⁵² Weight Stigma Concerns Scale, ⁹ original or modified version of the Adult Weight Bias Internalization Scale (WBIS), ²⁹ , ³¹ , ³³ , ³⁴ , ⁵⁷ the Weight Self‐Stigma Questionnaire (WSSQ), Attitude Scale toward Sexuality during Pregnancy (ASTSDP), ⁵⁶ Approving Sexuality during Pregnancy (ASDP), ⁵⁶ and original or modified version of the Everyday Discrimination Scale. ¹⁰ , ¹³ , ²⁶ Semi‐structured interviews were the predominant method of data collection in qualitative studies.

3.3. Study quality

The quality assessment of the included studies is presented in Tables S5 (quantitative) and S6 (qualitative). All studies had clear aims and appropriate research methodology to address their research questions. However, some factors impacted study quality. For quantitative studies, these included the use of unvalidated questionnaires (n = 2), inadequate accounting for confounding factors (n = 3), and sample sizes not based on pre‐study power considerations (n = 3). Qualitative studies were primarily affected by the researcher‐participant relationship (n = 13). Overall, however, studies were found to be of medium to high quality according to both the CEBMa and CASP checklists.

3.4. Findings from thematic analysis

Thematic analysis was guided by two main objectives, the first of which was to inductively investigate PPP women's personal experiences of weight stigma (addressing aim 1), and second to deductively explore the interrelationships between various socioecological factors contributing to weight stigma (addressing aim 2).

Inductive analysis revealed four key themes. Theme 1, Breaking the Silence: The impact of Weight Stigma on PPP Women; provides background and context to the data extracted from the literature, and highlights the negative impact of weight stigma on women's health and wellbeing. Theme 2, Beyond Weight Sigma: Experiences across the Socioecological Contexts highlights the broader social factors in shaping weight stigma experiences, moving beyond an individual‐level perspective. Theme 3 Coping with Weight Stigma: Strategies and Responses; and Theme 4, Women's Voices: A Call to Action provided insight into the various strategies that PPP women use to overcome weight stigma, and highlights the importance of considering their voices in addressing the issue. The deductive thematic analysis identified Theme 5, The Missing Connection: Interrelationships and Weight Stigma, and sheds light on a significant research gap – the lack of existing literature exploring the interconnected nature of socioecological factors in the perpetuation of weight stigma.

3.4.1. Theme 1. Breaking the silence: the impact of weight stigma on PPP women

The literature clearly demonstrated that pregnant and postpartum women experience a significant and broad impact of weight stigma. Both quantitative and qualitative studies revealed the pervasive nature of these experiences across the weight spectrum, with societal biases particularly evident against larger‐bodied women. This prejudice persisted even during the natural and expected body changes of pregnancy and postpartum, reflecting a deep‐seated societal failure to accommodate the inherent diversity of women's bodies during reproduction.

Across the reproductive lifespan, women encountered various stigmatizing experiences related to their weight and body size. These ranged from overt, inappropriate comments about body shape and weight gain, ⁶ , ⁹ , ¹⁰ , ²⁶ , ²⁷ , ³⁰ , ³⁶ , ³⁷ , ⁴⁰ , ⁴³ , ⁴⁴ , ⁴⁷ , ⁵² to more subtle prejudicial assumptions about diet and lifestyle behaviors. ⁶ , ⁷ , ⁹ , ¹⁰ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴⁴ , ⁴⁷ , ⁵² The impact of these encounters was profound, leading to feelings of shame, humiliation, self‐loathing, and guilt, which undermined self‐worth and negatively impacted body image. ⁶ , ⁹ , ²⁹ , ³⁰ , ³⁵ , ³⁶ , ³⁷ , ⁴⁴ , ⁴⁸ , ⁵¹ , ⁵³ For larger‐bodied women the impact was even more pronounced. Despite many experiencing healthy pregnancies, the persistent focus on weight contributed to increased anxiety regarding potential medical complications and adverse fetal outcomes. ⁶ , ⁷ , ⁹ , ²⁷ , ³⁶ , ⁴² , ⁴⁷ , ⁴⁸ , ⁵¹ This excessive focus on weight reflects a concerning trend towards the over‐medicalization of weight during pregnancy, which may exacerbate the negative effects of weight stigma.

Quantitative studies offered nuanced insights into the multifaceted relationship between BMI, self‐perceived weight, and experiences of weight stigma across the weight spectrum. Evidence demonstrated that while weight stigma impacted pregnant and postpartum women of all sizes, those with a higher BMI experienced it more often and from more sources. ⁹ Notably, self‐perceived weight emerged as a significant mediator between pre‐pregnancy BMI and weight stigma concerns, ⁹ illustrating the complex relationship between objective weight measures and subjective perceptions. The relationship between body perception and stigma experiences was further highlighted in a study of 182 pregnant women, which found that those who viewed themselves as overweight, or had attempted weight loss before pregnancy, reported higher levels of body dissatisfaction. ⁴⁵ These findings point to a cyclical pattern where negative body image may increase sensitivity to stigma, leading to heightened body dissatisfaction. This cycle illustrates the reciprocal nature of psychological factors and stigma experiences.

Studies indicated that the impact of weight stigma extended beyond mere perception, influencing various aspects of psychological health, behaviors, and internalized beliefs. A mixed‐methods study involving 501 pregnant and postpartum women with diverse body types (54% classified as living with obesity) found associations between experiencing weight stigma from multiple sources, (i.e., healthcare providers, family members, strangers) and increased depression, maladaptive dieting and stress; more emotional eating during pregnancy, and higher postpartum weight retention. ²⁶ Similarly, a longitudinal study involving 214 pregnant and postpartum women found that weight‐related discrimination was associated with greater pregnancy weight gain, gestational weight gain above recommendations, and an increased risk of postpartum depression irrespective of race/ethnicity, or pre‐pregnancy BMI. ¹³ These findings demonstrate how weight stigma can trigger a cascade of adverse health behaviors, potentially worsening the very issues it aims to address.

Weight bias internalization emerged as a common theme among women, regardless of BMI, albeit the extent varied based on body size, obesity diagnosis, and ethnicity. Studies identified higher rates of WBI among White women compared to African American women during pregnancy, highlighting the intersectionality of weight stigma with cultural and racial factors. ²⁹ , ³¹ , ³⁴ , ⁵⁷ Subsequent analyses of WBI revealed its broader implications. A study of 328 Turkish pregnant women living with obesity‐associated higher levels of WBI with more negative attitudes toward sexuality during pregnancy, ⁵⁶ suggesting the influence of WBI extends to intimate aspects of women's lives. Additionally, research on White postpartum women (50% living with overweight or obesity) found significant associations between greater gestational weight retention, increased WBI, and depressive symptoms, with WBI mediating this relationship. ³³

3.4.2. Theme 2. Beyond weight stigma: experiences across the socioecological contexts

Family, friends, and partners

The included studies illustrated that weight stigma during pregnancy and postpartum was intricately connected to close relationship dynamics, with family, friends, and partners acting as both sources of stigma and support. Quantitative analyses provide insights into the prevalence of weight stigma in intimate social circles. One study found that nearly half of pregnant and postpartum women experienced weight stigma from close relations, ⁹ while other research indicated higher rates. ⁴⁶ Notably, this stigma from key support systems was correlated with reduced relationship quality during pregnancy. ⁴⁶

Consistent findings across multiple studies indicated that close relationships contributed to negative experiences through various stigmatizing behaviors. Women's accounts frequently described hurtful comments and misguided assumptions about weight gain from family and friends. ⁹ , ¹⁰ , ²⁷ , ³⁰ , ³⁶  Remarks on how quickly other mothers had lost postpartum weight heightened some women's insecurities about their own weight gain. ¹⁰ Additionally, the studies revealed a pattern of friends and family misattributing weight gain to perceived unhealthy behaviors, such as overeating or lack of exercise, often in direct contradiction to women's actual lifestyle choices. ¹⁰ , ³⁶ , ⁴⁰

However, the role of close relationships in weight stigma experiences was complex and often contradictory. For instance, one study found a discordance, where stigmatizing experiences during pregnancy were contrasted with the advocacy for increased food consumption by family and friends. ³⁰ In this study, pregnancy was described as a ‘refuge from weight shaming’, with concerns that a restricted diet would deprive the fetus of essential nutrients. ³⁰

Despite being identified as a key source of weight stigma, close friends, family, and partners often served as sources of positive encouragement and mutual support, particularly for higher‐weight women during pregnancy. ²⁷ , ³⁹ , ⁵⁴ , ⁵⁵  Some women found solidarity from partners who shared similar weight experiences, promoting a sense of mutual understanding. ⁵⁵ The complexity of these relationships was further illustrated by findings showing how a woman's support person could both enact stigma and be supportive simultaneously. ³⁹ While some pregnant women experienced positive support ‐ such as partners making lifestyle changes alongside them, others faced resistance from partners unwilling to modify their own behaviors, creating additional stress for these women. ³⁹ However, the examination of the extent of close relationships' involvement in perpetuating this issue is limited in the included studies, making it difficult to address its underlying causes.

Healthcare providers

An analysis of weight stigma experiences in healthcare settings revealed a complex landscape for PPP women. Findings indicated that providers' treatment of PPP women varies according to their weight and body size, reflecting broader systemic issues within medical practice. The studies uncovered a wide range of experiences, highlighting both progress and persistent challenges in addressing weight bias in maternal care.

Positive and appropriate care was reported by some women, though these experiences were disproportionately observed among specific groups: pregnant women within normative BMI ranges, ⁶ , ⁷ , ²⁷ , ²⁸ , ²⁹ , ³⁹ , ⁴⁷ , ⁴⁸ , ⁵²  postpartum African American women with high self‐confidence in relation to weight and body image, and pregnant and postpartum women who received supportive and empowering care. ²⁷ , ²⁸ , ³⁵ , ³⁸ , ⁴⁸ , ⁵² However, a concerning trend emerged across the majority of studies: a significant number of women, particularly those with higher BMI, reported at least one negative experience due to their weight. ⁶ , ⁷ , ²⁷ , ²⁸ , ³⁰ , ³² , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ Quantitative analysis supported this finding, showing higher rates of suboptimal treatment and negative interactions for women with higher BMI. ⁶ , ⁴⁹

These challenging interactions manifested in various ways, each contributing to a healthcare environment that can be hostile and detrimental to women's physical and psychological well‐being. Accounts from multiple studies consistently described healthcare providers, including physicians, nurses, and obstetricians, as frequently lacking empathy and employing approaches perceived as insensitive, tactless, and sometimes cruel, leading to unnecessary distress. ⁶ , ⁷ , ²⁷ , ³⁵ , ³⁷ , ³⁹ , ⁴⁷ , ⁵⁰ For higher‐weight women, studies revealed an additional layer of complexity. Healthcare providers frequently overemphasized potential pregnancy complications and exaggerated fetal health risks. ⁶ , ⁷ , ²⁷ , ²⁸ , ³⁰ , ³¹ , ³⁵ , ³⁶ , ³⁸ , ⁴⁸ , ⁵⁰ , ⁵¹ , ⁵³ While some women appreciated risk information to ensure a healthy pregnancy, they resented the extreme extent to which risk was emphasized, indicating a need for more balanced and sensitive risk communication. ⁶ , ⁷ , ³⁶ , ⁴⁷ , ⁵¹

The use of stigmatizing language such as ‘obese’, ‘morbid’, ‘fat’, and ‘high risk’ was particularly problematic. ⁷ , ³⁵ , ³⁹ , ⁴⁰ , ⁴² , ⁴⁸ This language not only caused emotional harm but also failed to motivate positive health behaviors. As one woman stated, “I think they believe using words like that will shock you into thinking, ‘Oh, I need to lose weight,’ and that's not what happens”. ^{42 (p.116)} This quote highlights the counterproductive nature of stigmatizing language and the need for more effective, empathetic communication strategies.

In some instances, weight stigma manifested in the denial of essential services. Studies reported cases where larger PPP women were refused physical examinations, vaginal births, birthing pools, basic screening, weight management support, and breastfeeding advice. ²⁸ , ³² , ³⁹ Some providers even refused to treat higher‐weight preconception women or denied them fertility care, ⁷ , ²⁷ raising concerns about equitable access to healthcare. ²⁸ , ³² , ³⁹

Despite the prevalence of negative experiences, the relationship between weight stigma and healthcare interactions appears complex. A quantitative study involving 195 pregnant women revealed an intriguing paradox: although higher levels of experienced stigma and WBI were associated with lower trust in providers and increased avoidance, a higher BMI was surprisingly associated with greater trust and reduced avoidance when controlling for WBI. ³⁴ This unexpected finding highlights the need for a deeper exploration into how provider interactions and patient resilience influence healthcare experiences.

Societal influences

Societal weight stigma was pervasive, manifesting through multiple sources including public interactions with strangers, cultural norms, and media representations. This stigma was largely attributed to the negative portrayal of obesity in the media and the cultural fixation on the ‘thin beauty ideal’. ⁵ Such narratives not only define beauty in narrow terms but also shape societal attitudes towards weight, creating biases that affect PPP women during these vulnerable periods.

Quantitative analyses demonstrated that over a third of pregnant and postpartum women experienced weight stigma in their interactions with the public on a weekly basis, regardless of their body size. ⁹ This often involved unsolicited comments about weight from strangers, ⁹ , ⁴⁴ reflecting the invasive nature of weight stigma in everyday interactions. For instance, one woman reported being told, “You look too fat to be pregnant. You need to lose weight.” ^{9 (p.215)} Such comments not only violate personal boundaries but also reflect a broader societal assumption that women's bodies are subject to public scrutiny. Studies consistently found that women's pregnancies were often mistaken for overweight, further intensifying their feelings of stigma, and highlighting the pervasive nature of weight bias in society. ³⁶ , ⁴⁷ , ⁵²

Societal stigma also influenced perceptions of character and intelligence. Pregnant women frequently faced stereotypes that unjustly equated increased weight with laziness and lack of willpower. ⁹ , ⁵⁴ As one study participant noted, “People treated me as if I was just really fat instead of pregnant and treated me as if I was lazy”. ^{9 (p.215)} Some pregnant women felt their intelligence was being questioned due to their larger size, ³⁹ , ⁵⁰ while postpartum women often felt obliged to explain their recent pregnancy to justify their body shape. ³⁷

The media played a significant role in perpetuating societal weight stigma through negative portrayals of larger‐bodied women, and a lack of representation of diverse body types. ⁵ , ⁴³ Research indicated that media‐related stigma was a common experience among pregnant and postpartum women, irrespective of BMI; yet those living with obesity were four times more likely to experience weight stigma in the media compared to women with lower BMIs. ⁹ On average, women in larger bodies encountered media‐related stigma at least once a week to several times a week. ⁹ This high frequency of exposure suggests that media representations may have a considerable impact on this group, intensifying the overall societal stigma they face.

Women with higher body weights often felt stigmatized by media portrayals, particularly in comparison to pregnant and postpartum women with average body sizes and ‘thin’ celebrity mothers. ⁵ The media's depiction of the ‘ideal pregnant body’, typically characterized by slender figures and rapid postpartum weight loss, created unrealistic standards that many women feel pressured to meet. This stigma had tangible implications. Women reported feeling excluded from prenatal fitness activities due to insufficient representation of diverse body types in fitness‐related media. ⁴³ Additionally, women expressed frustration with the lack of representation in maternity imagery and the scarcity of plus‐size maternity clothing options, reflecting broader systemic issues in societal attitudes toward body diversity during pregnancy and postpartum. ⁹ These gaps in representation and accessibility not only highlight the exclusion of larger‐bodied women but also signal a broader societal failure to embrace and support body diversity during these critical life stages.

3.4.3. Theme 3. Coping with weight stigma: strategies and responses

Collectively, the included studies provided insight into the various ways in which PPP women respond to and cope with experiences of weight stigma. These coping strategies ranged from adaptive to maladaptive, highlighting the diverse ways women navigate stigma during these critical reproductive periods.

Silence and withdrawal were frequently observed responses, particularly among higher‐weight women. ⁵¹ When confronted with disrespectful treatment from healthcare providers, many women chose to withhold their opinions, refrain from asserting their rights, and suppress their emotions in an effort to avoid compromising their chances of receiving adequate medical care. ⁵¹ This hesitancy highlights a profound power imbalance in patient‐provider interactions, placing women in the difficult position of balancing their healthcare needs with preserving their personal dignity.

Avoidance behaviors, such as intentionally missing or arriving late for appointments, were commonly reported by PPP women across all body weights. ⁶ , ⁹ , ²⁸ , ³⁷ , ⁴⁰ This disengagement reflects a deep mistrust in the healthcare system, driven by past experiences of stigma and a desire for self‐protection. However, this coping strategy carries significant risks, potentially jeopardizing both maternal and fetal health outcomes.

In response to weight stigma, many pregnant women living with overweight sought to normalize their weight to alleviate stress and anxiety. ³⁰ , ⁴⁰ , ⁵² , ⁵⁵ This often involved refuting the label of obesity, challenging the medicalization of their bodies, and rejecting associated stigma. ⁵⁵ This resistance was particularly evident in the rejection of mother‐blame, where women shifted the focus from their weight to other health behaviors considered riskier during pregnancy, such as drinking alcohol or smoking. ⁵⁵ Such strategies represent attempts to reframe societal perceptions and assert control over their health experiences.

During pregnancy, higher‐weight women often used self‐deprecating humor or put themselves down as a way to alleviate the distress caused by negative experiences. ³⁵ , ⁵¹ While this approach may offer momentary relief, and help maintain social connections, it can become problematic. Self‐deprecation, in this context, becomes a double‐edged sword, offering temporary relief while simultaneously reinforcing harmful beliefs about one's body.

Comfort eating emerged as a common response to weight‐based stigma, with pregnant and postpartum women across the weight spectrum reporting increased food consumption to manage emotions triggered by disparaging societal comments. ²⁶ , ⁴⁰ , ⁴⁷ , ⁵¹ Stigmatizing encounters with healthcare providers also led to increased eating and comfort eating. ⁴⁰ , ⁵² For larger‐bodied preconception and pregnant women, the link between stigma and eating behaviors was particularly pronounced. These women reported being less likely to follow dietary and weight‐management advice from healthcare providers who failed to take them seriously or listen to their concerns. ³⁰ , ⁵⁰ , ⁵⁵ This breakdown in patient‐provider communication can further entrench unhealthy eating patterns, creating a cycle where stigma leads to behaviors that, in turn, may reinforce negative stereotypes. Some women resorted to avoiding social situations altogether as a coping mechanism, ¹⁰ further isolating themselves during a time when social support is crucial for psychological and physical wellbeing.

3.4.4. Theme 4. Women's voices, a call to action

The literature revealed valuable insights on how to address weight stigma gained from women's perspectives on this issue. Notably, the majority of these suggestions were qualitative in nature, and concerned pregnant and postpartum women's experiences with healthcare providers. ³⁰ , ³⁸ , ⁴² , ⁴³ , ⁴⁸ , ⁵¹ , ⁵² , ⁵⁴ , ⁵⁵ Across all reproductive stages, women requested that healthcare professionals acknowledge the complex nature of obesity, and address their weight in a positive and supportive manner that recognizes their individual circumstances and weight histories. ³⁰ , ⁴² , ⁴⁸ , ⁵⁰ It was recommended that providers consider other underlying health factors that may prevent weight loss, or increase weight gain during pregnancy. ⁴²

Pregnant and postpartum women expressed their desire to be treated as individuals, not statistics, and personalized and tailored advice was seen as a practical way to address stigma, boost self‐confidence, and provide them with a more positive experience. ²⁹ , ³⁰ , ³⁵ , ³⁸ , ⁴² , ⁴³ , ⁵² , ⁵⁵ Participation in their own care was paramount, and women requested that their diet and exercise goals be taken into consideration before recommendations were made. ⁴³ , ⁵¹ Larger‐bodied preconception women suggested that healthcare providers reduce the emphasis on weight alone, ⁷ while pregnant women requested that providers take the time to understand each woman's unique situation and provide care accordingly. ⁴² When discussing pregnancy and postpartum weight management, it was helpful to refrain from making general assumptions. ⁵¹ Women emphasized the importance of feeling listened to, understood, and taken seriously by healthcare providers, ⁴⁸ , ⁵⁰ , ⁵¹ and requested that information about the risks and complications associated with higher body weight during pregnancy be accompanied by a treatment plan. ⁵⁰

For larger pregnant women to feel valued, it was recommended that healthcare professionals use open body language, smile, and maintain eye contact. ⁵⁰ Expressions such as weight, overweight, weight category, weight‐change, and bigger were the terms most preferred by women and seen as less frightening and non‐judgemental. ³⁵ , ³⁹ , ⁴² , ⁴⁸ , ⁵⁰ Higher weight pregnant and postpartum women expressed their desire to be seen as healthy. ⁵¹ The use of fear‐based tactics to motivate lifestyle change was not considered helpful. ⁴² , ⁵⁰ Encouragement and positive reinforcement were favorable. ²⁹ , ³⁰ Pregnant women suggested that health promotional campaigns be inclusive of all body types in order to depict that all women can be active and healthy. ⁴³ Larger‐bodied pregnant women expressed their need for additional support in relation to weight management from peers and professionals. ³⁷ The strategies recommended by PPP women to reduce weight stigma are summarized in Box 1, offering a comprehensive guide for healthcare providers to create a more inclusive and supportive environment.

Box 1. Strategies recommended by PPP women to reduce weight stigma.

• Acknowledge the complex nature of obesity.

• Approach weight in a positive and supportive manner that respects women's personal circumstances and weight history.

• Consider other factors that may prevent optimal health or increase weight gain during pregnancy.

• Provide personalized and tailored advice that aligns with women's diet and exercise goals, and is achievable and realistic.

• Collaborative healthcare and active participation.

• Reduce emphasis on weight alone and shift the goal to health promotion.

• Refrain from making general weight‐based assumptions and judgments.

• Avoid fear‐based tactics to motivate life‐style changes.

• Treatment plans that account for the risks and complications of weight gain during pregnancy.

• Open body language (positive gestures, eye contact).

• Appropriate language and terminology that does not stigmatize.

• Encouragement, positive reinforcement, and support in achieving weight‐management goals.

• Access to weight‐management support services.

• Promoting inclusivity in health promotional campaigns and respecting all body types and sizes.

3.4.5. Theme 5. The missing connection: interrelationships and weight stigma

While examining the impact of weight stigma on women during the PPP life stages, we aimed to investigate the interrelationships between socioecological factors that contribute to weight stigma. However, there was a clear lack of explicit evidence exploring how these factors interrelate with one another. Consequently, the interrelationships between these factors remain unclear. For example, current literature provided limited insight into how family dynamics and support structures contribute to or mitigate weight stigma, hindering our understanding of the interrelationships between individual and interpersonal factors. Similarly, while the majority of studies in this review were primarily centred on women's negative experiences of weight stigma within healthcare, there was a clear lack of research examining the existence of policies aimed at addressing the issue, and improving the quality of care for these women. There was also an absence of studies investigating the experiences of weight stigma in both society and the media among women, and hence understanding the potential bi‐directional role of the media and society in general in perpetuating weight stigma against PPP women cannot yet be explicated.

4. DISCUSSION

The purpose of this systematic review was twofold. Firstly, we explored PPP women's personal experiences of weight stigma as viewed by women themselves. Secondly, we examined the interrelationships between various socioecological factors that contribute to weight stigma. Notably, this is the first review that, to our knowledge, presents evidence of women's suggestions to reduce their experienced weight stigma. It is also the first comprehensive unpacking of the interrelationships (or lack thereof) between the contexts and settings where weight stigma is perpetuated.

While the literature did not focus on unpacking the intricate nature of weight stigma and its multi‐level interrelationships with socioecological factors, it was apparent when synthesizing across the literature that weight stigma is prevalent among PPP women across multiple contexts, including in their close interpersonal relationships, interactions with healthcare providers, the media, and society in general.

Within the family, friends, and partners context, PPP women with higher weights often experience both positive and negative attitudes. Although these relationships may provide valuable support and encouragement, they can also be a source of weight stigma and additional stress for many women. ³⁹ At the healthcare provider level, women with higher weights frequently face discrimination and negative treatment from providers. Our review identified a clear lack of research examining policies to address weight stigma and improve the quality of care for these women, highlighting a critical gap in our understanding of how policies can be used to mitigate the impact of weight stigma, and promote positive maternal health outcomes. Indeed, policy change or amendments to clinical guidelines have the potential to impact care approaches. ⁵⁸ , ⁵⁹ , ⁶⁰ A prior systematic review highlights the importance of policies in influencing societal norms of weight stigma. ⁶¹ Furthermore, our review highlights the need for the media and society to shift towards more realistic representations of beauty and motherhood, to one that promotes diversity and inclusivity.

The scarcity of literature on the interrelationships between weight stigma and socioecological factors may be attributed to several causes. Firstly, weight stigma is a complex and multifaceted issue, and the stigma surrounding weight gain and body size is often deeply embedded in societal attitudes and beliefs that can make it challenging to address and overcome. ¹² Additionally, the tendency to over‐focus on individual‐level factors such as personal responsibility, particularly in relation to diet and exercise as the primary determinants of weight gain and obesity, has resulted in a significant gap in the knowledge of how the broader societal factors contribute to weight stigma. By neglecting socioecological factors, we risk perpetuating harmful stereotypes and stigmatizing beliefs about weight and body size, contributing to a culture of weight bias and discrimination.

The included studies also shed light on how women persevere with weight stigma, and how to effectively address the issue from their perspectives. Women use various strategies to cope with negative weight‐based comments and assumptions, including healthcare avoidance, increased eating, comfort eating, and social withdrawal. While these coping mechanisms may provide temporary relief from weight‐stigma‐related distress, they potentially carry long‐term negative consequences for the health and well‐being of PPP women. This underscores the need for resilience‐based interventions and systemic changes to reduce weight stigma in both healthcare and broader societal contexts. Women highlighted the need for healthcare professionals to address weight in a positive and supportive manner that considers their individual circumstances and weight histories. This includes acknowledging the complexity of obesity, and other underlying factors that may prevent optimal health, or increase weight gain during pregnancy. Specifically, PPP women requested personalized and tailored advice, avoiding stigmatizing language, participation in their own care, and additional support from peers and professionals. These recommendations align with a recent review, ⁶² which identified similar reduction strategies to minimize weight stigma among healthcare providers (not specific to the reproductive years). Strategies included educating all current and future healthcare providers about the complex factors regulating body weight, acknowledging both genetic and socioenvironmental determinants, and moving towards a more health‐focused and weight‐inclusive approach. The review recommended revising current healthcare curricula to address both the oversimplified views on weight responsibility and the stigma associated with higher body weight. ⁶²

4.1. Proposed solutions

To effectively address weight stigma requires a shift in the cultural narrative around body size and weight, as well as a deeper understanding of the complex social factors that contribute to weight gain. Addressing weight stigma requires a concerted effort from healthcare providers, policymakers, and society at large, to create a more inclusive and supportive environment for all PPP women, regardless of their weight or size. Our findings emphasize the need for ongoing research and education to increase awareness and understanding of weight stigma, and its impact on PPP women's health and wellbeing. Women's voices must become central to this effort.

One potential approach to create more inclusive and supportive healthcare environments that addresses weight stigma is the use of co‐design. ⁶³ This collaborative approach involves working with key stakeholders including women themselves, healthcare professionals, patient representatives, and consumer groups to develop patient‐centred healthcare services that are sensitive to the needs and preferences of women of all body sizes. By leveraging co‐design, current care models can be improved, and clinical guidelines better implemented, leading to improved patient satisfaction, treatment compliance, and improved healthcare outcomes for all women across the PPP stages of life.

4.2. Strengths and limitations

Our study has limitations which should be considered when interpreting the results. Specifically, we did not incorporate gray literature which may have resulted in the exclusion of some relevant information in relation to the key themes. Nonetheless, our primary goal was to consolidate and analyze women's perspectives which are most adequately represented in peer‐reviewed evidence. Given the substantial amount of data analyzed, it is also possible we may have uncovered only a fraction of expressed meaning within the identified themes. Our methodology, however, was consistent with the majority of included studies, which focused primarily on documenting women's lived experiences rather than engaging in more extensive interpretive analysis. A significant gap in the literature is the limited understanding of how socioecological factors interrelate and contribute to weight stigma. The scarcity of evidence on these interactions hinders a comprehensive understanding of their collective impact. Future research should address these gaps to clarify their influence on women's experiences of weight stigma. While we also acknowledge that a lack of quantitative studies prevents us from drawing definitive conclusions about the prevalence and impact of weight stigma among PPP women, by integrating qualitative studies alongside quantitative evidence we have been able to strengthen our main findings by providing a comprehensive analysis of their lived experiences.

5. CONCLUSION

Our systematic review illustrates the ubiquity and complexities of weight stigma for women across the PPP period. We also explicated a need for future research to explore associations and interrelationships between socioecological contexts where weight stigma occurs. Our findings offer a valuable roadmap for future research and action, with practical strategies that prioritize the voices and experiences of women at the forefront of prevention efforts. These strategies include personalized and inclusive care, taking individual circumstances and health factors into consideration, reducing the emphasis on weight alone, sensitive communication, providing information on risks and complications, encouraging a healthy lifestyle through positive reinforcement, and providing weight‐management support. Additionally, our study emphasizes the importance of women's participation in their own care, and inclusivity in health promotional campaigns. We hope that these findings will help challenge harmful societal norms and guide interventions and policies aimed at reducing the negative impacts of weight stigma and improving the lives of all women across the PPP period.

CONFLICT OF INTEREST STATEMENT

The authors declare that there are no conflicts of interest to disclose.

Supporting information

Table S1. Full search strategy

Table S2. PICOS framework: Eligibility criteria

Table S3. Reasons for exclusion at full‐text screening

Table S4. Characteristics of included studies

Table S5 Quality assessment of Quantitative studies: CEBMa checklist of surveys

Table S6. Quality assessment of Qualitative studies: CASP Qualitative Studies Checklist

Dever M, Skouteris H, Incollingo Rodriguez AC, Hailu H, Galvin E, Hill B. Weight stigma in the preconception, pregnancy, and postpartum periods: A systematic review of women's perspectives. Obesity Reviews. 2025;26(5):e13891. doi: 10.1111/obr.13891