Structural weight stigma in healthcare toward preconception, pregnant, and postpartum women: A systematic review

Summary

Introduction

Structural weight stigma for reproductive‐aged women can limit healthcare access and increase physical and mental health concerns, with adverse intergenerational outcomes. The aim of this systematic review was to synthesize evidence of structural weight stigma in healthcare and determine how that impacts the care for women across the preconception, pregnant, and postpartum periods.

Methodology

The concepts of stigma, weight, healthcare, and women of reproductive age were combined and searched in five databases (Ovid Medline, PsycINFO, Web of Science, Scopus, CINAHL) and 12 gray literature sources. Inclusion criteria consisted of any peer‐reviewed study or government policy that described a structural element within healthcare (e.g., guidelines, funding, insurance, equipment, physical environment) relevant to women of reproductive age (18–50 years) between 2001 and 2023. A narrative synthesis using a convergent approach was employed to analyze results.

Results

A total of 70 studies were included in this review; 24 qualitative, 21 quantitative, 10 policies, 3 dissertations, and one mixed‐method study. Structural weight stigma in healthcare presented across: 1) institutional policies that are weight‐centric and often placed women in larger bodies on “high‐risk” pathways; 2) the lack of government funding and insurance coverage for weight‐related services; 3) uncertainty amongst healthcare professions regarding their roles and responsibilities, 4) stigmatizing physical environments; and 5) lack of appropriately sized equipment.

Conclusions

Structural weight stigma impacting preconception, pregnant and postpartum women living in larger bodies was highly prevalent. Reducing structural weight stigma is important to improve healthcare access and improve the quality of care.

1. INTRODUCTION

Weight stigma is a characterized by labeling and negative stereotyping toward individuals due to body weight, shape, and/or size, which can lead to differential treatment, making it a human rights issue. ¹ , ² It is often perpetuated by structural factors embodied in systems and society that cause intentional or unintentional disadvantage to the stigmatized population. ³ Examples of structural factors in healthcare that can impact people in larger bodies include policies that recommend body mass index (BMI) cut‐offs for certain health services (e.g., fertility support), inappropriately sized equipment, and lack of weight management training for healthcare professionals. ⁴ Structural factors within healthcare can reinforce negative weight stigmatizing experiences for people who are living in bigger bodies, as structural factors can influence individual behavior. ^{5 , 6} Whilst there is no universally accepted definition of structural stigma, in this review, we focus on three broad domains conceptualized in Link and Phelan's influential 2001 article ⁷ : ‘institutional policies, cultural norms, and societal‐level conditions’ (Table 1). As such, structural weight stigma typically refers to factors that occur outside of the individual control. ^{9 , 10}

TABLE 1.

Definition of structural stigma and its three domains. ⁷ , ⁸

Term	Definition
Structural stigma	Institutional practices, cultural norms, and societal‐level conditions that constrain opportunities, resources, and wellbeing for stigmatized populations
Institutional policies	Factors relating to enacted or planned legislation, including government policies, funding, and insurance coverage for weight‐related practices and procedures
Cultural norms	Standards set by healthcare workers which overtime become engrained in the healthcare system
Societal‐level conditions	Encompasses a broad range of characteristics including elements of the physical environment, the structure, design, and implementation of education content, and the availability of relevant resources.

Weight stigma is commonly experienced by females, particularly during the preconception, pregnancy, and postpartum (PPP) periodsdue to body changes, ¹¹ and increased healthcare service demands (e.g., preconception counseling, labor, and postpartum care), that are characterized by intensive monitoring of body weight and size. ¹² Amongst this group of women, approximately 68% of women living in larger bodies reported delaying healthcare due to fear of stigmatizing environments. ¹³ Experiencing weight stigma during the PPP period has been associated with body dissatisfaction, stress, and postpartum depression, ¹¹ , ¹⁴ , ¹⁵ which can potentially contribute to intergenerational impacts such as large for gestational age babies, breastfeeding difficulties, and unfavorable developmental and cognitive outcomes. ¹⁶ , ¹⁷ , ¹⁸ Reducing or eliminating weight stigma in women's healthcare can improve both quality of care and health outcomes. ¹⁹ , ²⁰

Structural weight stigma can compromise access to healthcare through inequitable distribution of resources or withholding of services and/or fragmented care. ²¹ There is an urgent need to identify and understand structural weight stigma in maternity healthcare. Prior research focusing on pregnant women living in larger bodies identified that structural stigma led to reduced quality of healthcare. ⁴ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ However, a gap remains in our understanding of how structural weight stigma takes place for all PPP women. To address this gap, this study aimed to conduct a systematic review of structural weight stigma in healthcare toward PPP women. Our two objectives were:

1. To identify what structural weight stigma factors exist in healthcare and understand how it impacts the quality of care provided to PPP women; and

2. To identify suggestions for reducing structural weight stigma within healthcare.

2. METHODS

This review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement. ²⁶ It was registered on PROSPERO (CRD42023434638) on July 26, 2023.

2.1. Data sources and searches

In June 2023, five electronic databases (Ovid Medline, PsycINFO, Web of Science, Scopus, and CINAHL) and 12 relevant gray literature sources were systematically searched (S1 ‐ Tables 1–6). The search strategy, developed in consultation with a research librarian, combined the concepts of stigma, weight, healthcare, and women of reproductive age (S1 ‐ Table 7).

2.2. Study selection

To be included, a study had to be focused on women in the PPP periods, explore structural weight stigma and how it impacted the quality of care (Table 2). We included PPP women between the ages of 18–50 years. Women younger than 18 are more likely to receive healthcare in the presence of a guardian, and they may not be able to accurately reflect on structural factors that are experienced by women going through standard maternal care. ²⁷ Additionally, young pregnant women may also face stigma due to pregnancy at a younger age, and this stigma may be conflated with experiences of weight stigma. ²⁸ Despite chances of natural conception falling to 4% at age 41, ²⁹ women above 45 are still utilizing reproductive healthcare services, thus women up to 50 were included. ³⁰ Healthcare students were excluded from inclusion as they have not fully engaged in the professional environments where structural factors, such as organizational policies are encountered on a day‐to‐day basis. Although certain structural factors such as healthcare professional education may seem relevant to students, their ability to critically reflect on these experiences may be limited while they remain immersed in their educational environment. ³¹ As students, their understanding of how these structural factors function in real‐world practices may lack the depth of understanding that comes with professional experience. ³¹

TABLE 2.

Eligibility criteria.

Criteria	Inclusion	Exclusion
Population	Preconception, pregnant, and postpartum women between the ages of 18–50 and/or any healthcare professional who care for these women	Women outside 18–50 years, males, general population, and/or healthcare students
Phenomenon	Structural weight stigma	Weight stigma that was not structural (e.g., internalized biases, implicit biases, interpersonal stigma) Stigma related to ethnicity, mental health, or diabetes
Context	Healthcare setting	Communities, universities, workplaces
Outcome	How structural weight stigma impacted the quality of care for women	Evaluating interventions and/or validating measures
Study type	A primary study or a government policy, written in English	Nonprimary research designs (e.g., commentaries) or systematic reviews

Structural stigmas are the macro‐level factors that include institutional practices, cultural norms, and societal‐level conditions that constrain opportunities, resources, and well‐being for stigmatized populations. ⁸ Examples of structural weight stigma were obtained using guidance from literature from other health and social conditions (e.g., mental illness, HIV, racial stigmatization ⁴ , ³² , ³³ , ³⁴ ) as well as studies exploring weight stigma broadly in healthcare. ²³ , ²⁴ One author (CT) developed a list of structural weight stigma examples for each domain, which was reviewed by two authors (BH, SP) and adjustments were made via discussion as required (Table 3). Examples not originally considered that emerged throughout data extraction were added to the list if they met the definition of structural weight stigma (Table 1).

TABLE 3.

Examples of structural weight stigma in healthcare.

Domain	Examples of structural weight stigma
Institutional practices	Guidelines related to referrals, resource allocation, and/or body mass index restrictions Legislation prohibiting weight discrimination or bullying in healthcare settings Weight‐related policies/guidelines Insurance coverage and/or government funding for weight‐related procedures
Cultural norms	Roles and responsibilities of healthcare professionals Measuring weight status in a compassionate way free of simple assumptions and categorization Culturally shared expectations among healthcare professionals
Societal‐level conditions	Clinics and hospitals not having appropriately sized equipment (e.g., scales, gowns, hospital beds, Magnetic Resonance Imaging machines) Insensitive signage in clinics/hospitals Training for healthcare professionals in weight‐related topics, communication skills, sensitivity, and/or caring for patients in larger bodies

2.3. Data extraction

Both title/abstract and full‐text screening were completed in duplicate (CT, SP, HH, PK, or BH) via Covidence ³⁵ or manually via a spreadsheet (for gray literature) with discrepancies resolved through discussion. Data was extracted into an author‐designed data extraction form by one reviewer (CT), with a random subset of 10% extracted by a second reviewer (HH), and 73% agreement was achieved. Extracted data included lead author, country, healthcare setting (e.g., maternity units, hospitals), life stage of women (e.g., pregnant, postpartum), type of healthcare professional (e.g., midwife, physician), sample size, study design, outcome measures, and aim. Disagreements between the two authors were predominantly related to defining and categorizing structural weight stigma. To overcome this, further details and examples were discussed for each broad domain of structural stigma until agreement was achieved.

2.4. Quality assessment

Methodological quality of included studies was assessed by one author (CT), with 10% assessed by a second reviewer (PK). For qualitative studies, quality was assessed via the Critical Appraisal Skills Program (CASP), ³⁶ assessing research aims, methodology, reflexivity, consideration of ethical issues, quality of data analysis, and a statement of findings. The ‘how valuable is the research’ item in the CASP tool was based on 1) if the authors discuss their contribution to existing knowledge, 2) if the authors identify new areas where research is necessary, and 3) discuss how findings can be transferred to other populations. Studies that addressed all three points were deemed as ‘highly valuable’, studies that addressed two points were deemed ‘valuable’, and studies that addressed none or one were deemed as ‘not applicable’. Quantitative studies were assessed using the Centre for Evidence‐Based Management (CEBMa) checklist, which measures methodological quality irrespective of study design. ³⁷ Studies that met eight or more criteria were deemed as high quality, studies that met the criteria for 4–7 items were deemed as moderate quality, and studies that met the criteria for less than four items were deemed low quality. For both tools, each question was marked as “yes”, “no”, or “cannot tell”. Studies were not excluded on the basis of quality.

2.5. Data analysis

A narrative synthesis using a convergent integrated approach, adopted by the Joanna Briggs Institute, was used for analysis. ³⁸ This approach involves combining data from quantitative and qualitative studies that answer the research question, rather than by study methods. One author (CT) conducted a preliminary synthesis for quantitative and qualitative studies separately by organizing results into the three domains of structural stigma. This synthesis was then further organized according to the population (as seen in Table 4). Once studies were categorized accordingly, one author (CT) conducted a subsequent narrative synthesis for the quantitative and qualitative studies. Results with the same or similar meaning across both quantitative and qualitative studies were then grouped together. To ensure the accuracy and rigor of the analysis, two additional reviewers (BH and SP) cross‐checked the categorization of results and provided feedback. Any differing interpretations were resolved through group discussions.

TABLE 4.

Characteristics of included primary studies.

Author (year)	Country	Healthcare setting	Life stage of women or type of HCP	Sample size (mean age/range)	Study design	Outcome measure	Aim
Studies that included women's perspective only
Arden et al., 2014	UK	Parenting support forums	PPP	202 (N/A)	Qualitative	Participant‐reported perceptions	To explore women's perspectives about the weight gain guidance in NICE guidelines.
Basinger et al., 2022	US	Maternity units	PPP	249 (N/A)	Quantitative – cross‐sectional	Global self‐reported	To describe memorable messages about fat peoples bodies across the pregnancy trajectory
Basinger et al., 2023	US	Fertility clinics	PPP	69 (37.4)	Qualitative	Participant‐reported perceptions	Examine the communication larger bodies women received from healthcare providers related to infertility and their bodies through pregnancy and postpartum.
Baker et al., 2005	UK	Maternity units	Pregnancy	24 (35.9)	Qualitative	Participant‐reported perceptions	To explore the impact of maternity care staff on women's experiences, and feelings associated with the childbirth process.
Brown et al., 2012	UK	Antenatal and maternity units	Pregnancy	59 (32.7)	Quantitative – cross‐sectional	Global self‐reported	To explore the advice given to pregnant women of different pre‐pregnancy BMI to establish whether women were receiving a consistent message, and whether NICE guidelines were being followed.
DeJoy et al., 2016	US	Maternity units	Pregnancy	16 (31.1)	Qualitative – descriptive	Participant‐reported perceptions	Explore the experiences of women with obesity in the maternity care system.
Dinsdale et al., 2016	UK	Hospitals	Postnatal	24 (20–42)	Qualitative	Participant‐reported perceptions	Explore the accounts of postnatal women who had been through one of the three pathways in pregnancy.
Furber et al., 2011	UK	Maternity units	Pregnancy	19 (20–44)	Qualitative	Participant‐reported perceptions	To explore the experiences of in women with a body mass index >35 kg/m2 during the childbearing process.
Ingraham et al., 2014	US	Abortion clinics	Pregnancy	651 (25.4)	Quantitative – cross‐sectional	Global self‐reported	Exploring obese women's experiences receiving or avoiding family planning care.
Jarvie et al., 2017	UK	Diabetic antenatal clinics	Pregnancy and postpartum	27 (19–43)	Qualitative – sociological design	Participant‐reported perceptions	To explore the lived experiences of women with coexisting maternal obesity and GDM during pregnancy and post‐birth.
Kair et al., 2016	US	Maternity units	Preconception, pregnancy	19,145 (19–35)	Quantitative, cross‐sectional	Self‐reported and objective measures	Aim to examine the extent to which a mothers pre‐pregnancy BMI category is associated with exposure to pro‐breastfeeding hospital practices.
LaMarre et al., 2020	Canada	Reproductive healthcare	Preconception and pregnancy	17 (28–44)	Qualitative – descriptive	Participant‐reported perceptions	To explore the experiences of people in larger bodies seeking fertility and or pregnancy care through a reproductive justice lens.
Lindhardt et al., 2013	Denmark	Midwifery‐led antenatal clinics	Preconception	16 (N/A)	Qualitative	Participant‐reported perceptions	To examine the experience of women with a pre‐pregnant BMI > 30 kg/m2, in their encounters with HCPs during pregnancy.
Maheshwari et al, 2009	Scotland	Antenatal clinic	Preconception	11,756 (26‐39)	Quantitative – retrospective cross‐sectional	Objective data from two state databases	To estimate and compare the cost per live birth across different BMI groups (as defined by WHO).
McDonald et., 2011	Canada	Antenatal clinics	Pregnancy	310 (29.5)	Quantitative – cross‐sectional	Global self‐reported	To determine the information that pregnant women report receiving when being counseled about weight gain.
Mills et al., 2013	Australia	Antenatal clinics	Pregnancy	14 (25–42)	Qualitative – descriptive	Participant‐reported perceptions	To explore the experiences of pregnant women living with overweight attending two maternity units in Sydney, Australia.
Pandey et al., 2014	Scotland	Fertility clinic	Preconception	2643 (32.1)	Quantitative – retrospective cohort	Objective data from two state databases	To explore the impact of different age and BMI groups on total treatment costs in women attending a secondary/tertiary care fertility clinic.
Parker et al., 2017	NZ	Maternity units	Pregnancy	27 (N/A)	Qualitative	Participant‐reported perceptions	To describe women in larger bodies experience of being on the receiving end of discourses and practices in maternity care that problematize their bodies.
Riggan et al., 2023	US	Fertility clinics	Preconception	40 (23–44)	Qualitative – grounded theory	Participant‐reported perceptions	To explore patients experience of BMI restrictions that limit fertility care.
Shaw et al, 2023	NZ	Fertility clinics	Preconception	11 (20–45)	Qualitative	Participant‐reported perceptions	To explore the experiences of Māori and Pacific women where a BMI cut‐off presents as a barrier to fertility services.
Shahbazzadegan et al., 2019	Iran	Maternal health care centers	Pregnancy	10 (32)	Qualitative	Participant‐reported perceptions	To explain the pregnancy experience in women with high BMI.
Swift et al., 2016	UK	Antenatal clinics	Pregnancy	193 (32.8)	Quantitative – cohort	Self‐reported and objective (anthropometric data)	To examine women's experiences of routine antenatal weight management provision in Nottingham.
Tovar et al., 2010	US	Medical clinic	Pregnancy	29 (18–40)	Qualitative	Participant‐reported perceptions	To evaluate knowledge, attitudes, and beliefs regarding weight gain during pregnancy among predominantly Puerto Rican women.
Studies that included healthcare professionals perspectives only
Amy et al., 2006	US	Gynecological units	Physicians, nurse practitioners & midwives	129 (24–72)	Quantitative – cross‐sectional	Global self‐reported	To investigate the factors that contribute to lower rates of gynecological cancer screening as related to women's body size.
Agaronnik et al., 2021	US	Medical clinics	Rheumatologist, neurologist, obstetricians, orthopedics, and ophthalmologists.	22 (51.3)	Qualitative	Participant‐reported perceptions	Explore attitudes and practices of US physicians related to caring for patients with obesity and mobility disability.
Christenson et al., 2018	Sweden	Antenatal clinics	Midwives	17 (N/A)	Qualitative	Participant‐reported perceptions	To explore how midwives perceive and approach communication about gestational weight recommendations.
Ferrante et al., 2009	US	Medical clinics	Physicians	255 (48)	Quantitative – cross‐sectional	Global self‐reported	Aim to assess family physicians practices and attitudes regarding care of extremely obese patients and factors associated with them.
Garner et al., 2015	US	Hospital	Physicians, midwives, nurses, lactation specialists	34 (31–84)	Qualitative – descriptive	Participant‐reported perceptions	Describe HCPs experiences providing breastfeeding care for obese women during the pre, peri, and postpartum periods.
Grohmann et al., 2012	Canada	Obstetric clinics	Obstetrician, physician, midwife, nurse, dietitians	96 (20–50)	Quantitative – cross‐sectional	Global self‐reported	Identify perceptions of HCPs in communicating GWG recommendations and to identify potential gaps and opportunities that could be addressed.
Hasted et al., 2016	Australia	Maternity units	Midwives, medical staff, dietitians	44 (N/A)	Qualitative	Participant‐reported perceptions	To identify clinicians' perspectives of barriers and enablers to routinely weighing pregnant women and variations in current practice, knowledge, and attitudes.
Harris et al., 2011	US	Fertility clinics	Fertility physicians	43 (N/A)	Quantitative, cross‐sectional	Global self‐reported	To assess the practice patterns and personal beliefs of fertility physicians who care for obese patients seeking assisted reproduction.
Herring et al., 2010	US	Hospital	Obstetricians, nurse practitioners, midwives	58 (N/A)	Quantitative – cross‐sectional	Global self‐reported	To determine the knowledge, attitudes, and practice patterns of obstetric providers regarding obesity in pregnancy.
Heslehurst et al., 2007	UK	Maternity units	Midwives, obstetricians, physiotherapists, dietitians, diabetes nurse specialist	33 (N/A)	Qualitative	Participant‐reported perceptions	To understand HCPs perceptions of the impact that caring for obese pregnant women has on maternity services.
Heslehurst et al., 2011	UK	Maternity units	Midwives, obstetricians, physiotherapists, dietitian, sonographer	30 (N/A)	Qualitative	Participant‐reported perceptions	To identify developments in maternal obesity services and understand how maternity services need to be further developed.
Heslehurst et al., 2013	UK	Maternity units	Midwives	46 (N/A)	Qualitative	Participant‐reported perceptions	To explore midwives' perceptions of their training and education requirements in relation to maternal obesity.
Kelley et al., 2019	US	Fertility clinics	Reproductive specialists and fertility specialists	599 (30–50+)	Quantitative – cross‐sectional	Global self‐reported	To explore the attitudes of specialists regarding the necessity and appropriateness of BMI cut‐offs for women seeking fertility treatment.
Kerrigan et al., 2015	UK	National Health Service Hospitals	Obstetricians, anesthetists, midwives	24 (N/A)	Qualitative	Participant‐reported perceptions	To explore practitioners' experiences of and strategies for providing intrapartum care to obese women.
Knight‐Agawral et al., 2014	Australia	OBGYN unit	Obstetricians, gynecologists	33 (N/A)	Qualitative ‐ IPA	Participant‐reported perceptions	To investigate the views and attitudes of providers of antenatal care for women with a BMI of 30 kg/m2 or over.
McCann et al., 2018	UK	Hospital and community center	Midwives	17 (N/A)	Qualitative	Participant‐reported perceptions	Determine midwives' perceptions, knowledge, and experiences of providing healthy eating and weight management advice to pregnant women.
McParlin et al., 2017	UK	Hospitals	Midwives	192 (N/A)	Quantitative – cross‐sectional	Global self‐reported	To investigate barriers and facilitators to physical activity guideline implementation for midwives when caring for pregnant women living with obesity.
Paik‐Nicely, 2012	US	OBGYN units	Obstetricians, gynecologists	331 (40–65)	Dissertation – quantitative	Global self‐reported	This study explored the knowledge, attitudes, and practices of OBGYNs in providing contraceptive services to obese women.
Power et al., 2006	US	University hospital	Obstetricians, gynecologists	900 (37–46)	Quantitative – cross‐sectional	Global self‐reported	To describe obesity prevention and treatment practices of U.S obstetricians– gynecologists.
Stewart et al., 2012	Australia	Antenatal clinics	Obstetricians, midwives	103 (N/A)	Quantitative – cross‐sectional	Global self‐reported	The aim of this study was to determine the practice and knowledge regarding appropriate GWG.
Stotland et al., 2010	US	Antenatal clinics, health centres, hospitals, organizations	Physician, nurse practitioner, midwife	52 (29–69)	Qualitative	Participant‐reported perceptions	To study prenatal care providers about their knowledge, attitudes, and practices regarding the prevention of excessive weight gain during pregnancy and their approach to nutrition and physical activity counseling during pregnancy.
Singleton et al., 2014	US	Maternity unit	Midwives	11 (20–60)	Qualitative – IPA	Participant‐reported perceptions	To explore the experiences of midwives caring for obese women in labor.
Schmied et al., 2011	Australia	Maternity units	HCPs in general	37 (N/A)	Qualitative – descriptive	Participant‐reported perceptions	To explore the experiences and concerns of HCPs who care for childbearing women who are obese.
Smith et al., 2012	UK	Hospitals	Midwives, sonographers, anesthetists, obstetricians	30 (N/A)	Qualitative	Participant‐reported perceptions	Explored HCPs experiences of caring for women with a BMI ≥ 30 kg/m2 and their views of the proposed lifestyle programme.
Wilkinson et al., 2012	Australia	Maternity hospital	Obstetricians, gynecologists midwives, allied health specialists	84 (N/A)	Quantitative – cross‐sectional	Global self‐reported	To assess practice gaps in the multidisciplinary management of overweight and obesity pregnancy to inform an intervention to facilitate translating obesity guidelines into practice in a tertiary maternity service.
Wilkinson et al., 2013	Australia	Maternity hospital	Obstetricians, gynecologists midwives, allied health specialists	73 (N/A)	Quantitative – cross‐sectional	Global self‐reported	To assess staff knowledge about, adherence to, and characteristics that influence the delivery of care according to these guidelines.
Yager et al., 2023	Europe (16 countries)	Healthcare setting overall	HCPs in general	257 (41.2)	Quantitative – cross‐sectional	Global self‐reported	To conduct a needs assessment to determine the extent, nature, and format of health professional education in relation to body image and perinatal mental health.
Studies that included both women and healthcare professionals perspectives
Channon et al., 2022	UK	Sexual health clinic	Preconception women	20 (16–48)	Mixed‐methods	Participant‐reported perceptions and objective data from a database of electronic health records	To assess the acceptability and practicability of a weight‐loss intervention which asked people to delay contraception removal in order to lose weight before conceiving.
			Physicians	10 (N/A)
Doughty et al., 2019	UK	Midwifery clinic	Pregnancy, postpartum	N/A (20‐45)	Dissertation – qualitative	Participant‐reported perceptions	Explore and interpret the experiences of obese mothers and the views of midwives who have experience of providing care for women living with obesity during pregnancy.
			Midwives	N/A (30‐50)
Forde et al., 2019	UK	Medical clinic, diabetes specialist center	Preconception, pregnancy	N/A (25‐44)	Qualitative	Participant‐reported perceptions	To elicit the views and experiences of women with Type 2 diabetes and HCPs relating to the pregnancy and pre‐pregnancy care they have received or provided.
			Physicians, nurses, diabetes specialists	N/A (N/A)
Gasper et al., 2022	France, Spain, Brazil	Private diabetic clinics	PPP	86 (18–29)	Qualitative	Participant‐reported perceptions	To understand and compare social representations of obesity and overweight amongst dietitians from 3 nationalities (Brazilian, French, and Spanish).
			Dietitians	45 (22–57)
Heslehurst et al., 2015	UK	Midwifery unit	Pregnancy	17 (N/A)	Dissertation – mixed methods	Participant‐reported perceptions, self‐reported and objective data (clinical audit)	This research evaluated the implementation of maternal obesity care pathways from multiple stakeholder perspectives.
			Midwives, medical clinicians	243 (N/A)
Holton et al., 2017	Australia	Teaching hospital	Pregnancy	17 (24–43)	Qualitative	Participant‐reported perceptions	To describe women's and midwives experiences and perspectives of care for weight management during pregnancy in Melbourne.
			Midwives	2 (N/A)
Lessard, 2015	US	Reproductive healthcare	PPP	5606 quant 18 qual	Dissertation – mixed methods	Participant‐reported perceptions and self‐reported	Exploring whether obesity impacts contraception use and women's choice in contraception type and if so, how does HCP bias toward obese individuals contribute to this impact.
			HCPs in general
Olander et al., 2011	UK	Medical clinics	Pregnancy	23 (18–30)	Qualitative	Participant‐reported perceptions	To explore HCPs views concerning their provision to prevent unhealthy weight gain in pregnancy.
			Centre managers, midwives, social workers	6 (N/A)
Washington Cole et al., 2016	UK	Obstetric outpatient unit – teaching hospital	Pregnancy	117 (22.9)	Quantitative – cross‐sectional	Global self‐reported	To examine the association of women's body weight with provider communication during prenatal care.
			Nurses, midwives	22 (N/A)

2.6. Reflexivity

The review team had a background in women's health, health psychology, public health, weight stigma, dietetics, exercise science, and the reproductive years. Team members considered their positionality on the topic of weight stigma throughout the PPP periods. All authors critically reflected on their personal and professional experience, particularly surrounding the beliefs of weight‐inclusive care. Efforts were constantly made to ensure the analysis and findings were presented in a balanced and objective manner. Specifically, it was important to not place blame or judgment on healthcare professionals who may not practice weight‐inclusive care.

3. RESULTS

After the removal of duplicates, 3572 titles and abstracts were screened, followed by 735 full‐texts. After applying the inclusion and exclusion criteria (S1 – Table 8), 33 documents were deemed eligible. Searching reference lists of included studies identified 37 additional records, resulting in a total of 70 included studies (Figure 1). Characteristics of included studies can be found in Table 4 and a summary of government polices can be found in S1 ‐ Table 10. The most frequent reason for exclusion was studies not being related to structural stigma (S2 – Table 1). Thirty‐two studies were qualitative, ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ¹⁰⁶ twenty‐two were quantitative, ⁷⁰ , ⁷¹ , ⁷² , ⁷³ , ⁷⁴ , ⁷⁵ , ⁷⁶ , ⁷⁷ , ⁷⁸ , ⁷⁹ , ⁸⁰ , ⁸¹ , ⁸² , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁷ , ⁸⁸ , ⁸⁹ , ⁹⁰ , ⁹¹ two were a mixed‐method study, ⁹³ , ¹⁰⁸ three were dissertations, ⁹⁴ , ⁹⁵ , ⁹⁶ and eleven were government/organization policies and guidelines. ⁹⁷ , ⁹⁸ , ⁹⁹ , ¹⁰⁰ , ¹⁰¹ , ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ The majority of studies were conducted in the United Kingdom (n = 26), ⁴⁰ , ⁴³ , ⁴⁹ , ⁵⁸ , ⁶⁰ , ⁷² , ⁸² , ⁸⁷ , ⁹² , ⁹³ , ⁹⁹ , ¹⁰³ followed by the United States (n = 19), ⁶⁸ , ⁷¹ , ⁷⁶ , ⁷⁷ , ⁷⁸ , ⁷⁹ , ⁹⁶ , ³⁹ , ⁴² , ⁴⁶ , ⁶¹ , ⁶⁵ , ⁶⁷ , ⁷⁰ , ⁷³ , ⁷⁵ , ⁸⁴ , ⁹¹ , ⁹⁵ Australia (n = 11), ⁴⁸ , ⁵² , ⁵⁵ , ⁵⁹ , ⁶² , ⁸⁵ , ⁸⁸ , ⁸⁹ , ⁹⁷ , ⁹⁸ Canada (n = 3), ⁵⁶ , ⁷⁴ , ⁸¹ Europe (n = 6), ⁴¹ , ⁴⁷ , ⁵⁷ , ⁸⁰ , ⁸³ , ⁹⁰ New Zealand (n = 2), ⁶⁴ , ⁶⁹ Australia/New Zealand (n = 1), ¹⁰¹ and one study from Israel. ⁶³ Of the studies that included healthcare professionals, the most common profession was midwives (n = 24), ⁴¹ , ⁴⁶ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵⁴ , ⁵⁵ , ⁵⁸ , ⁶⁰ , ⁶² , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁷⁰ , ⁷⁶ , ⁸² , ⁸⁵ , ⁸⁸ , ⁸⁹ , ⁹⁰ , ⁹² , ⁹⁴ followed by obstetricians (n = 13), ⁴⁶ , ⁵⁰ , ⁵⁴ , ⁶⁶ , ⁷⁴ , ⁷⁶ , ⁸⁴ , ⁸⁵ , ⁸⁸ , ⁸⁹ , ⁹⁶ physicians (n = 8), ³⁹ , ⁴⁴ , ⁶⁷ , ⁷⁰ , ⁷³ , ⁹² nurses (n = 6), ⁴⁴ , ⁴⁶ , ⁶⁷ , ⁷⁰ , ⁷⁶ , ⁹⁰ dietitians (n = 4),^47–50 gynecologists (n = 3) ⁵⁵ , ⁸⁴ , ⁸⁷ , sonographers (n = 2), ⁵⁰ , ⁶⁶ fertility specialists (n = 2), ⁷⁵ , ⁷⁹ allied health (n = 2), ⁸⁸ , ⁸⁹ anesthetists (n = 2), ⁶⁶ lactation consultants (n = 1), ⁴⁶ and diabetes specialists (n = 1) (S1 ‐ Table 11). ⁴⁴ One study did not specify the profession of the healthcare professionals included in the study, rather, they stated that the inclusion criteria were healthcare professionals who remove long‐acting reversible contraception for women of reproductive age. ⁹³ The most common life stage of women in the studies was pregnancy (n = 23), ⁴⁰ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁵² , ⁵³ , ⁵⁶ , ⁵⁷ , ⁵⁹ , ⁶³ , ⁶⁸ , ⁶⁹ , ⁷¹ , ⁷⁸ , ⁸¹ , ⁸⁶ , ⁸⁷ , ⁹¹ , ⁹² , ⁹⁴ , ¹⁰⁶ preconception (n = 10), ⁴⁴ , ⁵⁶ , ⁶¹ , ⁶⁴ , ⁷¹ , ⁸⁰ , ⁸³ , ⁹¹ , ⁹³ , ⁹⁵ postpartum (n = 4) ⁴³ , ⁶⁰ , ⁷¹ , ⁹¹ , and one included women aged 18–50 years but did not specify the life stage. ¹⁰⁷ Four of the studies that included preconception women, were specifically seeking in vitro fertilization (IVF) services. ⁷⁵ , ⁷⁹ , ⁸⁰ , ⁸³  Of the quantitative and mixed methods studies, 17 used self‐reported questionnaires, including a range of open and close‐ended questions. ⁷¹ , ⁷² , ⁷³ , ⁷⁴ , ⁷⁶ , ⁷⁷ , ⁷⁸ , ⁸⁰ , ⁸² , ⁸³ , ⁸⁵ , ⁸⁶ , ⁸⁸ , ⁸⁹ , ⁹⁰ , ⁹² , ¹⁰⁸ Two quantitative studies used objective information from the Aberdeen Maternity and Neonatal Database, as well as the Aberdeen Reproductive Unit database logs. ⁸¹ , ⁸⁴ Finally, four quantitative studies used a combination of self‐reported (e.g. surveys) and objective measures (e.g., electronic records). ⁴¹ , ⁷⁹ , ⁸⁷ , ⁹⁵

FIGURE 1.

Flow of studies included in the review.

A detailed description of the aim, participants, healthcare setting, methodology, and results for qualitative quantitative, and policy documents is available in S1 (Tables 9–10). In terms of study quality (S1 – Table 12,13), several qualitative studies were deemed high quality. ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁷ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁵ , ⁵⁶ , ⁵⁹ , ⁶¹ , ⁶² , ⁶⁵ , ⁶⁷ , ⁶⁹ , ⁹⁴ Given that there is no universal threshold for what is deemed a high, low, or moderate quality in the CASP tool, the authors made overall judgments after considering each criterion. Typically, high‐quality studies adequately described the specific qualitative method employed, considered the researcher‐participants relationship, provided a detailed analysis process, and presented a clear statement of the findings. Several studies did not adequately describe one or more of the following: research design, recruitment strategy, data collection, and data analysis process, and thus were deemed as lower‐quality studies. ⁶³ , ⁶⁶ Overall, the most commonly missed criteria were many studies not acknowledging the relationship between the researcher and participants. Regarding the 21 quantitative studies, five demonstrated high methodological quality by addressing several criterion such as minimizing selection bias, ensuring sample representativeness, and providing confidence intervals for the main results. ⁷³ , ⁷⁸ , ⁸¹ , ⁸³ , ⁹⁵ Reasons for poorer quality quantitative studies included not providing clarity around the validity of measures, high likelihood of selection bias, and poor representativeness of the included sample. ⁷⁰ , ⁷¹ , ⁷⁵ , ⁷⁹ , ⁸⁹ , ⁹⁰ , ⁹² , ⁹⁶ Additionally, only two studies calculated the sample size based on statistical power.

3.1. Objective 1: structural weight stigma in healthcare and how it impacts the quality of care for preconception, pregnant and postpartum women

The following section synthesizes: (a) structural stigmas and their impact on care; and (b) women's experiences identified across institutional policies, cultural norms, and societal‐level conditions (Table 5).

TABLE 5.

Results of included studies separated by element of structural stigma and study design.

Structural stigma		Quantitative	Qualitative	Impact to women
Institutional practices	Policies and guidelines	Denial of fertility treatment for women living in larger bodies 72 , 76 , 80 Women in larger bodies denied choice of childbirth 72	Guidelines lack flexibility, are too broad, and are used reatively 45 , 57 , 91 Denial of fertility care until BMI was lower 62 , 65 , 91 , 93 Denied choice for childbirth 46 , 50 Labeling women in larger bodies as ‘high‐risk’ 55 , 66 , 70	Additional testing Fewer women in larger bodies received fertility treatments 80 , 93 Lack of individualized care 60 Medialization of pregnancy 70 , 95 Increased stress Unable to have delivery of choice 43 , 46 , 50 , 66 , 91 Restricted the care midwives could give and affected the normality of the birth process 55
	Funding	Cost increased for fertility services for women in lowest BMI category 81 , 84	Lack of funding was a barrier to implementing dietitian‐led antenatal classes 56 Lack of funding to set up the healthcare setting appropriately 50	Differences in cost for fertility services 81 , 84
	Referral pathways	Guidelines suggest referral to a dietitian when BMI is > 30 kg/m2 from a GP 90	Women in larger bodies automatically referred to anesthetists, 46 midwife specialist 110 without consent Different maternal pathways for women depending on their body size 44 , 50 , 55 , 95 Lack of clarity about when to refer to a dietitian 49 , 51 , 59	Automatic referrals without discussing with women 110 Some women thought the different maternal pathways were beneficial to provide additional support
	Insurance	Women in larger bodies without insurance were less likely to have a pelvic exam, use contraception, and attend preconception care 96	N/A	Lower uptake of preconception care and complete physical exminations 96
Cultural norms	Discussions about weight	Less than 30% of providers made GWG recommendations 82 Fertility providers recommend diet and exercise for weight loss 76 , 78 , 80 Weighing patients in clinics is part of routine care in some settings 71 Approximately 50% of provider's' used visual assessment to measure weight 85	Pregnancy weight gain advice was most consistent for women in lower body weights 61 , 69 Fertility providers recommend diet and exercise for weight loss 76 Some midwives were reluctant to discuss weight 42 , 55 , 66 , 92 , others believed it was part of their responsibility 42 , 95 Women in larger bodies who wanted long active reversible contraceptive removed were counseled about weight compared to those in lower body weights 41 Some provider's measure weight status according to the definition in the World Health Organization, whereas some use visual body assessment 47 , some did not measure weight at all 86	Differences in the number of times women in larger bodies were being weighed compared to women in lower bod weights 59 , 73 , 82 , 87 , 108 Some women decline being weighed 71 Women in larger bodies were more likely to receive unsolicited lifestyle, physical activity, and dietary recommendations 78 , 88
	Roles and responsibilities	Hospital staff unaware of who's responsibility it is to refer to dietitians 77 , 89 , 90 Women living in larger bodies had lower odds of receiving pro‐breastfeeding support 78 Discussions about body image part of routine care 92 Majority of women in larger bodies were counseled about physical activity and limiting food intake from obstetricians or gynecologists 85	Despite guidelines recommending women in larger bodies receiving a postnatal weight loss program, women did not receive this 54 Provider's were uncertain of who's responsibility it was to refer specialist supports 67	Decreased odds of exclusively breastfeeding for mothers in larger bodies Women reported a lack of advice and support from providers' which lead to anxiety and mistrust 73
Societal‐level conditions	Equipment and medical tools	Lack of appropriately sized equipment (e.g., speculums, blood pressure cuffs, hospital gowns, scales, exam tables, chairs) 71 , 72 , 74 , 78 , 95 , 96 Scales were in a highly visible public area 108	Scales were in a highly visible and busy location 49 Lack of appropriately sized equipment (e.g., speculums, blood pressure cuffs, hospital gowns, scales, exam tables, chairs) 40 , 43 , 50 , 53 , 60 , 64 , 67 , 107 , 110	Women felt blamed for their bodies 72 Women felt angry, disrespected and uncomfortable 72 Women transferred to different locations 40 Women in larger bodies did not receive the same level of care 57 , 60 Prevented the insertion of intrauterine devices for women in larger bodies 96 , 97 Delays in receiving care as equipment needed to be rented, borrowed, or bought 63
	Time	Limited time in consults to do complete examinations and screenings 57 , 71 , 95 Maternity staff had limited time to provide nutrition advice 89 Limited time to discuss the challenges of pregnancy in a larger body 77	Limited time in general practice to provide preventive care 45 Limited time to have pro‐breastfeeding discussions with women in larger bodies 47 Limited time to discuss the challenges of pregnancy in a larger 41 , 49 , 59 , 67 Midwives reported lack of time to discuss nutrition in a compassionate way 42	N/A
	Training	Approximately 71% of midwives felt confident to provide nutrition advice 108 The majority of provider's did not receive formal training on how to have discussions about weight 77 , 80 , 85 , 86 , 90 Approximately 20% received training in caring for pregnant women living in larger bodies 71 , 83 , 89	Midwives report not receiving training about nutrition 59 Midwives did not receive any formal training on how to discuss weight 52 , and there were differences in OBGYN's receiving training in prenatal nutrition, weight gain, and physical activity counseling was inadequate 68 , 97 Lack of training about safe transfer methods of women living in larger bodies 40	Women did not receive adequate nutrition advice 59 Women did not receive information about appropriate weight gain 61
	Environment	N/A	Images in waiting rooms were not weight inclusive 65 Having 1–2 ‘larger chairs’ amongst the ‘normal’ chairs 66	Women felt shamed and embarrased 65 , 66

3.1.1. Institutional practices

The domain of ‘institutional practices’ refers to factors relating to enacted or planned legislation, including government policies, funding, and insurance coverage relevant for PPP women. Policies commonly included recommendations that categorized pregnant women in larger bodies as “high‐risk”, which led to additional scans, ⁸⁴ and regular weighing. ⁷⁰ , ⁹⁵ , ⁹⁹ Both policy, ¹⁰² and empirical studies ⁷² , ⁷⁶ , ⁸⁰ described denied in‐vitro fertilization (IVF) treatment when BMI was greater than 35 kg/m². Women described feeling upset, disappointed, and discouraged when fertility clinics canceled their fertility appointments because of their weight. ⁶² One quantitative, ⁷² and five qualitative studies ⁴³ , ⁴⁶ , ⁵⁰ , ⁶⁶ , ⁹¹ reported that women in larger bodies were unable to choose their method of childbirth due to policy recommendations, which placed pregnant women on specific pathways or models of care. ⁹⁹ Government policies also described limiting gestational weight gain (GWG) for women in higher BMI categories. ⁹⁹ Overall, healthcare guidelines relevant for PPP women lacked flexibility and did not promote holistic care. ⁵⁷

Other areas within institutional practices identified in this review, demonstrated that pregnant women in larger bodies were often automatically referred to anesthesists, ⁴⁶ specialist midwives, ¹¹⁰ or placed on different maternal pathways ⁴⁴ , ⁵⁰ , ⁵⁵ , ⁹⁵ without their consent. Healthcare professionals stated that promoting normality during labor is an integral part of their role, yet acknowledged guidelines that recommend continuous monitoring during pregnancy impacted the chances of normal birth for women in larger bodies. ⁶⁶ We found that healthcare for PPP women in larger bodies was hampered by a lack of funding. ⁵⁰ Studies reported on the lack of government funding to implement dietitian‐led antenatal classes, ⁵⁶ and to adequately set up healthcare settings. ⁵⁰ Finally, one study in the US reported that women living in larger bodies with no insurance were less likely to have a pelvic exam, use contraception, and attend family planning compared to those with insurance and with a lower BMI. ⁹⁶ Overall, government policies were mainly weight‐centric with a strong focus on weight/BMI or weight loss/gain rather than health as an endpoint. ⁵⁸

3.1.2. Cultural norms

The domain of ‘cultural norms’ refers to the standards set by healthcare workers that overtime become engrained in the healthcare system. Studies revealed inconsistencies in how healthcare professionals define and assess overweight and obesity, with up to 47% of providers using visual inspection alone, ⁸⁵ some using the WHO definition of overweight/obesity, ⁴⁷ and several did not measure or discuss weight at all. ⁸⁶ This led to heightened feelings of body stereotyping and assumptions made by health professionals. ⁵⁷ It also led to differences in the number of women who were being counseled to lose weight. ⁵⁹ , ⁶⁷ , ⁷³ , ⁸² , ¹⁰⁸ Additionally, studies reported confusion amongst healthcare professionals about who was responsible for tasks and procedures for women living in larger bodies. Specifically, providers were uncertain about who's responsibility it was to refer to dietitians, ⁶⁷ , ⁷⁷ , ⁸⁹ , ⁹⁰ provide physical activity and nutrition advice, ⁸⁵ have body image discussions, ⁹² and provide breastfeeding support. ⁷⁹ As a result, women had lower odds of exclusively breastfeeding their newborns, ⁷⁹ and felt a lack of advice and support from providers. ⁷⁸

3.1.3. Societal‐level conditions

The ‘societal‐level conditions’ domain encompasses medical equipment, the physical environment, design and implementation of education content, and the availability of relevant resources (e.g., time). Staff reported limited time and a shortage of healthcare staff to provide dietary advice, ⁴² , ⁸⁹ discuss risks associated with high adiposity in pregnancy, ⁷⁷ provide physical activity guidance, ⁸³ complete routine assessments and screenings, ⁹⁴ and have adequate discussions about breastfeeding ⁴⁷ for women in larger bodies. This often increased stress and pressure for providers, ⁹⁴ which affected their willingness to discuss weight‐related factors. ⁴⁰ , ⁴² Additionally, up to 50% of providers' had not received sufficient training in weight counseling, ⁴¹ safe transfer methods of larger‐bodied women, ⁴⁰ referral pathways for tailored support, ⁶⁷ risks associated with excess adiposity during pregnancy, ⁶⁷ and cultural sensitivity. ⁴⁷ , ⁶⁵ This impacted provider capability and confidence to provide support, ⁸⁵ thus often avoiding the conversation all together. ⁵⁹ Conversely, healthcare providers with additional weight management knowledge and training felt more confident, ⁷⁷ , ⁹⁷ were more motivated to discuss sensitive topics, ⁵² and had fewer negative attitudes. ⁷⁴

A lack of appropriately‐sized equipment (e.g., blood pressure cuffs, speculums for pelvic exams, hospital gowns, scales, exam tables, and needles for epidurals) was reported broadly across both quantitative ⁷¹ , ⁷² , ⁷⁴ , ⁷⁸ , ⁹⁵ , ⁹⁶ and qualitative studies. ⁴⁰ , ⁴³ , ⁵³ , ⁶⁰ , ⁹⁷ , ¹¹⁰ This led to challenges in completing examinations, such as separating thighs on a pelvic exam ⁷⁴ and inserting intrauterine devices. ⁹⁶ , ⁹⁷ Equipment often needed to be rented, borrowed, or bought, resulting in delayed procedures and inability to provide complete physical examinations, ⁴⁰ , ⁶³ leaving women feeling embarrassed, uncomfortable, ⁵⁸ , ⁷² and the perception that they were not receiving the same quality of care as women in smaller bodies. ⁶⁰ Finally, several studies described elements within the physical environment as stigmatizing (e.g. resources with images of “skinny people”, larger scales in a public area), ⁴⁹ , ⁷⁵ which led to women feeling embarrassed, ⁶⁵ uncomfortable, ⁶⁶ and distressed. ⁷⁵

3.2. Objective 2: suggestions to reduce structural weight stigma in healthcare toward preconception, pregnant, and postpartum women

Many included studies highlighted suggestions and recommendations to reduce structural weight stigma in healthcare within the PPP periods across all three domains of structural weight stigma (summarized in Box 1). Overall, a flexible approach to guidelines, greater fertility support, increased funding, and more inclusive insurance policies were recommendations made by providers and women. Some midwives recommended not discussing weight or BMI the first time they meet women (as per practice guidelines), as this typically coincides with the beginning of building rapport with patients. ⁹⁵ Suggestions to improve the cultural norms amongst healthcare providers included developing clearer practice guidelines outlining who is responsible for what task and including physical activity advice in routine antenatal care regardless of body size. ⁶⁶ In alignment with the identified societal‐level structural stigmas, recommendations included ensuring the availability of adequately sized equipment, ⁹⁶ allocating more time in appointments, ⁴² and providing healthcare professionals with more training, and education to help them address weight‐related topics. ⁶⁷ , ⁷⁵ Overall, women believed that structural changes are required to ensure no one is denied medical services based on weight alone. ⁸⁰

Box 1. Summary of recommendations within included studies to reduce structural weight stigma in healthcare for PPP women.

Institutional practices

• Flexible approach to maternal guidelines to allow for individualized care that is attentive to the complexity of human bodies, and specialized support services for women who encounter BMI restrictions ⁵³ , ⁹⁵

• Polices acknowledging the multifactored nature of weight status ⁵⁷

• Further support and resources to support women through fertility treatment, specifically involving fertility diatitians ⁶² , ⁹⁴

• Avoid discussing weight or BMI during the first interaction with new healthcare providers to avoid impacts on patient‐provider relationships, or if required discuss it in a compassionate and non‐judgemental manner ⁹⁵

• Increased government funding to ensure all healthcare environments are well‐equipped with appropriately sized equipment ⁴⁹

• Including obesity treatments in insurance policies ⁷⁴

• Clearer referral guidelines throughout the entire preconception, antenatal, and postnatal period ⁹⁴

Cultural norms

• Developing clear practice guidelines for midwives when caring for women living in larger bodies in regard to tasks and responsibilities ⁶⁶

• Healthcare professionals are to provide physical activity and dietary advice to all women regardless of body weight

• Healthcare providers should highlight the importance of movement and a nutritious diet throughout all PPP stages regardless of body weight ⁸³

Societal‐level conditions

• Ensure all healthcare settings are equipped with appropriately sized equipment (e.g., scales, blood pressure cuffs) ⁴⁹ , ⁹⁶

• Longer appointment times to foster compassionate conversations ⁴²

• Further training and education on providing weight‐inclusive care that includes a mixture of online and in‐person activities. ⁶⁷ , ⁷⁵ , ⁹² For example, breastfeeding‐related education for women living in larger bodies, ⁴⁷ interacting with patients in affirming ways, ⁵⁷ raising awareness on existence and effects of weight stigma, guidance on language and communication, ⁹² and cultural sensitivity. ⁵⁷

4. DISCUSSION

To our knowledge, this is the first systematic review to identify and summarize evidence related to structural weight stigma within healthcare settings for PPP women. We found structural weight stigma within healthcare may impact the quality of care across the three domains evaluated: institutional practices, cultural norms amongst healthcare professionals, and societal‐level conditions. Structural factors that may drive weight stigma and reduce the quality of healthcare include refusal to provide care based on weight, increased monitoring during pregnancy, receiving less healthcare support, and poorer patient‐provider relationships. Given that the PPP stages involve more frequent healthcare visits and motivated patients, there is a unique opportunity to impact the health of women and their families. Below is a summary of our findings, as well as our recommendations for healthcare providers' to consider moving forward (Box 2).

Box 2. Recommendations to reduce structural weight stigma in healthcare for PPP women.

For government

• Healthcare policies should support holistic care for PPP in larger bodies that does not solely focus on weight

• Increase funding to ensure healthcare settings are adequately equipped

• Medicare rebates to support women in larger bodies access the care they need to promote their overall health and well‐being

For healthcare providers'

• Asking women for their consent, as well as how they feel about discussing weight

• Ensure all decisions related to women's care are made in discussion with the woman

• Ensure the clinic room and overall healthcare environment is well equipped, and comfortable for women prior to arriving for their appointment

For researchers

• Explore what, how, and where education about weight stigma can be integrated into the medical training program

• Generate new knowledge about structural weight stigma toward PPP women

Our findings identified that institutional policies and practices often medicalized women living in larger bodies and focused on the negative consequences of excess adiposity for the mother and/or child's health, ⁹⁵ which often resulted in the refusal of healthcare services provision (e.g., IVF). Similarly, existing research demonstrates policies with a reliance on BMI not only increased the risk of anxiety but overall deprioritized healthcare concerns and increased the financial burden for these patients. ¹¹² Research suggests there is a significant funding gap related to the care for people living in larger bodies who do not have adverse co‐morbidities. ¹¹³ For example, pregnant women with larger bodies are often counseled to lose weight and to seek a dietitian, however, there are currently no financial support for women to access these services. ¹¹⁴ As a result, larger‐bodied women often seek early access to their superannuation to fund treatments, ¹¹³ or purchase weight‐related medication that is not subsidized by publicly funded health systems. ¹¹⁵ Incorporating a holistic approach to women's healthcare (including policy development), that is not solely reliant on weight/BMI as the outcome, may be a solution to avoid undue burden being placed on both women and health services. Further exploration could consider the fiscal suitability of government funding and insurance companies covering healthcare services for women regardless of body weight. ¹¹⁶ Some experts in clinical practice and academia have called for weight‐related diseases to be considered as chronic diseases (similar to the Australian Medical Association ¹¹⁷ ) as a potential mechanism to increase accessibility to services and provide higher reimbursement of allied health care. ¹¹³ , ¹¹⁸ However, it is important to ensure that any such change does not further medicalize larger‐bodied women or further stigmatize those who seek care. ¹¹⁹

We identified that healthcare professionals felt uncertain in their role when caring for women in larger bodies, which culminated in the perception of inconsistent and inadequate care. For example, Hyer et al, found that some healthcare providers believed that consistently measuring weight leads to shared decision‐making and patient empowerment, ²³ while others believed that measuring weight hindered patient‐provider relationships. ¹²⁰ From the women's perspective, weighing led to shame, embarrassment, lack of provider trust, negative body image, and concerns about discrimination. ¹²¹ To combat this, it is proposed that having clearer descriptions and allocations of tasks and procedures, as well as involving women in decision making can be a key to consistent healthcare. ²³ Additionally, healthcare professionals who require to discuss and measure weight should ask women for their consent, and explain the process and reasons clearly. ¹²¹ Research and clinical settings should consider moving toward weight‐neutral care. Such care prioritizes weight inclusivity, well‐being, respect, flexible and individualized eating, and enjoyable physical activity, with the potential to improve health and wellbeing outcomes without weight change being the goal. ¹²² , ¹²³ It is important for healthcare professionals to have comprehensive guidance around their roles and responsibilities when caring for PPP women in larger bodies. However, guidelines must be clearly adaptable to ensure they meet the needs of PPP women.

Inadequately prepared healthcare settings (e.g., time, workforce, equipment, environment, training) were identified as a substantial structural barrier to receiving optimum quality of care for reproductive‐aged women living in larger bodies. We found that women and healthcare professionals wanted readily available equipment that is suitable for all body types, greater focus on how to sensitively discuss weight, and improved multi‐disciplinary care. This is similar to previous studies, where lack of knowledge and equipment were frequently cited as barriers to effective care for women in larger bodies. ¹²⁴ We propose a stronger focus on healthcare training that includes multiple components (e.g., causal attribution of weight, communication, sensitivity) embedded into undergraduate and postgraduate education. ¹¹³ , ¹²⁵ Perhaps, incentives to complete non‐stigmatizing weight management training for health professionals may increase its uptake. ¹¹³ Additionally, extending the involvement of practice nurses in the primary care setting may allow for structured evidence‐based care for patients without increasing physician workload. ¹²⁵ Healthcare settings and providers have a responsibility to reduce stigmatizing structural barriers and ensure healthcare environments are designed in such a way that is appropriate and comfortable for people of all body sizes.

Strengths of this review include our systematic approach, following the PRISMA guidelines, and assessing the quality of all included peer‐reviewed papers, which were of moderate to high quality. This review also has limitations. Given that structural weight stigma is a relatively new concept, potentially eligible studies may have been missed as many studies related to weight stigma did not directly include the words ‘structural stigma’. The definition of structural weight stigma was based on other health and social conditions (e.g., HIV, mental health, ethnicity), and studies related to structural weight stigma were often identified indirectly. Additionally, only articles written in English were considered for inclusion, therefore the application of findings to healthcare settings globally is likely underrepresented.

5. CONCLUSION

We identified structural weight stigma across institutional‐level practices, cultural norms amongst healthcare providers, and the societal‐level environment within the healthcare setting involving PPP women. Structural weight stigma appeared to impede healthcare professionals' endeavors to provide high‐quality care. It also impacted care through inequitable access to required services and treatment, increased monitoring, reduced autonomy for women, and poorer patient‐provider relationships, which ultimately undermines the quality of care. Organizational and policy changes within healthcare settings will support healthcare professionals to provide high‐quality, evidence‐based care, and help reduce stigmatizing experiences for PPP women living in larger bodies.

AUTHOR CONTRIBUTIONS

Conceptualization: Chloe Tran, Briony Hill, Stephanie Pirotta. Methodology: Chloe Tran, Briony Hill, Stephanie Pirotta, Haimanot Hailu, Pragya Kandel. Analysis: Chloe Tran, Briony Hill, Stephanie Pirotta. Writing – original draft preparation: Chloe Tran. Writing – review and editing: Briony Hill, Stephanie Pirotta, Helen Skouteris. All authors reviewed and approved the final manuscript.

CONFLICT OF INTEREST STATEMENT

None to disclose.

Supporting information

Table S1: Search strategy for Ovid Medline Search conducted: 26/06/2023.

Table S2: Search strategy for PsycINFO Search conducted: 27/06/2023.

Table S3: Search strategy for CINAHL Search conducted: 27/06/2023

Table S4: Search strategy for Web of Science Search conducted: 27/06/2023.

Table S5: Search strategy for Scopus Search conducted: 27/06/2023.

Table S6: Gray literature sources, search terms, and results.

Table S7: Overall search terms used in review (adapted to each database.

Table S8: Detailed eligibility criteria based on PICOS(population, intervention/exposure, comparison, outcome, study type) model.

Table S9: Characteristics of included quantitative, qualitative, and mixed‐methods studies.

Table S10: Characteristics and recommendations of government policies related to women of reproductive age.

Table S11: Summary table of characteristics for primary studies and government policies.

Table S12: Quality assessment for qualitative studies using the CASP checklist.

Table S13: Quality assessment for quantitative studies using the CEBMa.

Table S1: Reasons for exclusion.

Tran C, Pirotta S, Hailu H, Kandel P, Skouteris H, Hill B. Structural weight stigma in healthcare toward preconception, pregnant, and postpartum women: A systematic review. Obesity Reviews. 2025;26(9):e13933. doi: 10.1111/obr.13933

DATA AVAILABILITY STATEMENT

None to disclose.