General practitioners’ perspectives of caring for larger-bodied preconception women: A descriptive qualitative study

Abstract

Background

High-quality preconception care can optimise health and wellbeing and reduce adverse maternal and infant outcomes. Larger-bodied preconception women are more likely to experience weight stigma and discrimination in healthcare due to their body size, and thus receive lower-quality care. General Practitioners (GPs) are key healthcare providers in preconception care, yet there is a limited understanding on their perspectives caring for larger-bodied preconception women.

Objectives

To better understand the experiences and viewpoints of GPs’ caring for larger-bodied preconception women.

Design

Descriptive qualitative study design using thematic analysis.

Methods

Semi-structed interviews with GPs (N = 15) who provided preconception care in Australia were conducted online via Zoom. Participants were purposively recruited via word of mouth, emailing digital flyers to GP clinics, and posting information on social media platforms. Interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted and themes were continuously refined through collaborative discussions with the research team.

Results

Three overarching themes were identified: 1) narratives and assumptions about larger-bodied preconception women, with a focus on how these can prevail throughout general practice and contribute to weight stigmatising interactions with preconception women; 2) factors influencing GPs’ approaches to caring for larger-bodied women, highlighting how approaches to care are impacted by external factors within healthcare; and 3) challenges to providing non-stigmatising care to larger-bodied preconception women, emphasising that significant effort is required to contest common assumptions and narratives associated with higher body weight.

Conclusion

Findings demonstrated that whilst GPs have a strong desire to provide high-quality preconception care to all women, the pervasiveness of weight stigma in healthcare can impact the care they provide. Supporting GPs to provide non-stigmatising care to larger-bodied preconception women is urgently warranted to improve health outcomes for all women equitably.

Introduction

The preconception period is a key opportunity to optimise conception and pregnancy outcomes for both mothers and their babies. ¹ The importance of preconception health is highlighted by health policies and strategies globally ² and has received recognition from the World Health Organisation (WHO) as a critical component of preventive healthcare. ³ It involves counselling on a range of topics including biomedical assessments, vaccinations, promoting mental and social well-being, ceasing harmful substances (e.g., smoking, alcohol, certain medications), and managing co-morbidities (e.g., diabetes, polyendocrine metabolic ovarian syndrome). ⁴ Whilst there are several definitions of when the preconception period begins, optimising preconception health prior to conception is crucial as interventions delivered in the pregnancy period alone are often too late to achieve the most favourable pregnancy and birth outcomes. ⁵

One of the key components of achieving effective preconception health is healthcare providers delivering high-quality and equitable preconception care. Whilst a range of providers can contribute (i.e., nurses, midwives, dietitians, etc), ⁶ general practitioners (GPs) have been recognised globally as the best-placed provider to deliver preconception care. ⁷ General practitioners are uniquely positioned to counsel women on a range of preconception factors and can support them throughout their reproductive healthcare journey. ⁸ Their role is particularly pertinent given that the general public’s awareness of addressing health prior to pregnancy is low. ⁹ Women planning a pregnancy generally consult a GP as their source of information and care, and their trust in providers is driven by previous positive and helpful experiences in healthcare. ¹⁰ Some women report difficulty identifying GPs who meet their needs, ¹⁰ which is a challenge more often experienced by larger-bodied women (BMI > 25kg/m²), who have described feeling dismissed by healthcare providers due to their body weight. ¹¹

Women entering pregnancy with a larger body are likely to experience weight stigma and discrimination in healthcare due to their body size, ¹¹ however, few studies have explored weight stigma explicitly in the preconception period.^12,13 The limited evidence available demonstrates that preconception women in larger bodies experience stereotypes and assumptions about nutrition and physical activity, ¹⁴ with weight loss prioritised over holistic care, and health issues often attributed to weight.^13,15 Three studies exploring preconception women’s perspectives further identified insensitive language from healthcare professionals as a driver of weight stigma, ¹² and being denied fertility treatment until weight loss was achieved.^16,17 Therefore, many women attempt to reduce their weight during the preconception period. ¹⁸ Whilst a reduction in weight during preconception has been widely discussed and validated,^19,20 novel evidence suggests that rapid preconception weight loss may have negative impacts on a future developing fetus. ²¹ Additionally, focusing on weight during preconception care can prevent healthcare providers from identifying potential underlying health issues (e.g., endocrine problems, eating disorders). ²² This becomes particularly important for preconception women as it creates a cycle of shame where health issues are attributed to their weight, ²³ further reducing uptake of reproductive healthcare.

Whilst the importance of GPs delivering high-quality preconception care has been established, little is known about how GPs approach caring for larger-bodied preconception women, despite their impact on women’s experiences and weight stigma. Addressing this knowledge gap is crucial for reducing weight stigma in healthcare. With over 50% of women entering pregnancy in a larger body, ²⁴ evidence is required to identify factors that might influence the provision of preconception care by GPs for larger-bodied women. Additionally, whilst it is important to prioritise preconception health for all individuals involved in family planning, the current landscape of preconception care predominantly focuses on women. ²⁵ This is reinforced in the existing preconception clinical guidelines where most recommendations are directed towards addressing the health and wellbeing of women, ⁴ as well as general biases in society that allocate familial and reproductive responsibilities to women. ²⁶ As a result, many preconception women have reported feeling a heightened sense of pressure and scrutiny to maintain good preconception health as there is an overemphasis on their individual behaviours alone. ¹⁰

The aim of this study was to explore GPs perspectives of caring for larger-bodied preconception women. The findings may inform strategies to achieve more equitable and stigma free preconception care for women regardless of body weight, shape, or size.

Methods

Study Design

This descriptive qualitative study was approved by the Monash University Human Research Ethics Committee (project ID: 41831). Qualitative descriptive studies aim to provide a comprehensive summary of experiences and are helpful for gaining insights into novel areas. ²⁷ The study was reported in accordance with the COnsolidated criteria for REporting Qualitative Research (COREQ) checklist (Supplementary Table 1). ²⁸ Additionally, the study describes women’s body size (i.e., BMI) using the terms “higher weight” or “larger bodies” as agreed upon by international weight stigma academics, bioethicists, obesity organisations, and lived experience experts at the International Weight Stigma Conference. ²⁹

Participants and Recruitment

Eligible participants included any GP who provided preconception care in Australia at the time of recruitment or within the past year. Healthcare students and GPs who did not care for preconception women were excluded to ensure the scope of findings were relevant to the current landscape of preconception care. Participants were recruited purposively between June and October 2024 via word of mouth, emailing digital flyers to GP clinics, posting information on social media platforms (e.g., X, LinkedIn), and distributing to GP organisational groups (e.g., The Royal Australian College of General Practitioners) for circulation. A total of 58 GPs from a previous quantitative survey, as well as an additional 36 GP clinics, were contacted and 16 responded, with one lost-to-follow up. Interested participants were directed to click on a link for access to the explanatory statement. Written consent was received from participants and interviews were scheduled with participants. The sample size was guided using the concept of information power, which assesses the richness of information provided by participants (where greater information power allows for a smaller sample size).^30,31 Recruitment ceased when the authors deemed information power was sufficient. All participants received an AU$50 gift card upon completion of their interview.

Data Collection

Audio-recorded, semi-structured interviews (N = 15) were conducted by one researcher (CT) via Zoom ³² between June and November 2024. The interview guide was developed by a review of weight stigma literature^17,33,34 and input from a steering and advisory group comprised of GPs, researchers, community members, dietitians, obstetricians, and midwives with expertise across women’s health, weight stigma, psychology, and public health. This guide was developed originally to assess structural factors within healthcare that contributed to weight stigma (Supplementary Table 2). The overarching feedback from the steering and advisory group highlighted the need to consider different approaches to asking questions and to ensure questions were specific to the population of interest. Additionally, participants were informed that this study used the ‘intentional’ preconception perspective, that is, women who were not currently pregnant and had made a conscious decision to conceive. ³⁵ During the interviews, GP participants naturally discussed their general thoughts about caring for larger-bodied preconception women; the current study focused on those broader discussions and presents the findings of those GP insights here.

Data Analysis

Interviews were transcribed via Microsoft ³⁶ and were analysed using a thematic approach. Thematic analysis allows researchers to identify, analyse, and interpret meaning within the data, ²⁷ and thus was appropriate for this study. Themes were identified inductively through Braun and Clarke’s ³⁷ six-step process: 1) CT listened to the recordings and re-read all of the transcripts to become familiar with the data; 2) preliminary labels and codes related to the research aim were applied to all transcripts in NVivo software ³⁸ ; 3) preliminary themes and subthemes describing patterns and meanings across codes were identified; 4) themes were refined through collaborative discussion amongst the research team, ensuring thematic analysis was active, iterative, and an inductive interpretive process; 5) themes and subthemes were named to represent the data accurately; and 6) themes were reported narratively with supporting quotes in the manuscript. ²⁷

Reflexivity Statement

Members of the research team all had expertise in weight stigma research and qualitative methods, and one is a practicing GP. One author identified as living in a larger body whilst the remaining did not, and thus were aware of their external positionality to the topic of interest. However, the interviews did not focus on the lived-experience of weight stigma, rather, the findings reflect GPs’ perceptions of caring for women living in larger-bodies. All researchers identify as women who take a weight-inclusive approach to the reproductive healthcare space. Qualitative rigour was guided by Lincoln and Guba’s four qualitative concepts: credibility, transferability, dependability, and confirmability (Supplementary Table 3).

Results

Participant Characteristics

Interviews were on average 35 minutes long (range 20-60 minutes). All participants identified as female and were aged between 31 and 56 years (mean age = 37). Nearly all (n = 14) practiced in metropolitan areas and were predominantly from New South Wales (n = 7). Approximately half (n = 7) of the participants self-identified as living in a larger body. The majority of participants were Asian (n = 9) and most (n = 13) either had children or were currently pregnant (Table 1).

Table 1.

Participant Demographics.

Participant number	Age	State	Race	Self-perception of living in a larger body	Have children or are currently pregnant	Area
P1	47	VIC	Middle Eastern	Yes	Yes	Metropolitan
P2	31	VIC	Asian	No	No	Metropolitan
P3	39	VIC	Asian	No	Yes	Metropolitan
P4	31	NSW	Asian	No	No	Metropolitan
P5	35	QLD	Asian	Yes	Yes	Metropolitan
P6	56	NSW	Caucasian	Yes	Yes	Regional
P7	30	NSW	Caucasian	No	Yes	Metropolitan
P8	37	NSW	Asian	No	Yes	Metropolitan
P9	N/P	NSW	Asian	No	Yes	Metropolitan
P10	33	VIC	Asian	No	Yes	Metropolitan
P11	37	SA	Caucasian	Yes	Yes	Metropolitan
P12	39	NSW	Asian	No	Yes	Metropolitan
P13	38	NSW	Asian	No	Yes	Metropolitan
P14	35	TAS	Caucasian	Yes	Yes	Metropolitan
P15	35	TAS	Caucasian	Yes	Yes	Metropolitan

N/P: Not provided; NSW: New South Wales; QLD: Queensland; TAS: Tasmania; VIC: Victoria.

Themes

The themes and sub-themes generated from the data reflect GPs’ perspectives of providing care to larger-bodied preconception women (Table 2). Three main themes were identified: (1) narratives and assumptions about larger-bodied preconception women; (2) factors influencing GPs’ approaches to caring for larger-bodied preconception women; and (3) challenges to providing non-stigmatising care to larger-bodied preconception women. Within these three themes, eight corresponding subthemes were established. Participant identifiers regarding whether they self-identify as living in a larger body (LB) or not (NLB) are included for each quote.

Table 2.

Themes and subthemes of GPs’ perspectives caring for larger-bodied preconception women

Theme	Subthemes
Theme 1: Narratives and assumptions about larger-bodied preconception women	• Higher body weight is a risk factor • Weight loss is achieved through behavioural changes • Larger-bodied preconception women are motivated to lose weight
Theme 2: Factors influencing GPs’ approaches to caring for larger-bodied preconception women	• Previous experiences caring for larger-bodied women • Weight-focused preconception care policies and guidelines • Preconception care education and training
Theme 3: Challenges to providing non-stigmatising care to larger-bodied preconception women	• Supporting women with previous experiences of weight stigma • Tension between risk-focused narratives and non-stigmatising care

Theme 1: Narratives and Assumptions About Larger-bodied Preconception Women

The first theme describes narratives and assumptions about larger-bodied preconception women. General practitioners’ reflections on caring for lager-bodied women revealed three common narratives: 1) higher body weight is a risk factor; 2) weight loss is achieved through behavioural changes; and 3) larger-bodied preconception women are motivated to lose weight. Overall, GPs described how these common narratives or assumptions could impact their approach to providing care. For some GPs, narratives and/or assumptions underpinned weight-centric practices, such as recommending weight loss, whereas other GPs did not ascribe to common assumptions and tended to prioritise holistic care.

Subtheme 1.1 – Higher Body Weight Is a Risk Factor. Participants frequently framed body weight as a risk factor for infertility and adverse pregnancy childbirth outcomes. This narrative shaped clinical encounters, often underpinning the rationale for recommending weight loss to larger-bodied preconception women:

“There are some ladies who have come in and they've struggled to fall pregnant and so a discussion regarding weight as well as other contributing factors may come up in the consultation.” – P9, NLB

This risk assumption resulted in variable approaches to care. For instance, some participants focused on weight management and delayed pregnancy planning as they assumed larger-bodied women would have challenges falling pregnant:

“It’s just too much information when you’re not pregnant yet and… if they’re overweight they might struggle to get pregnant for a while so yeah I wouldn’t really be bringing that up.” – P7, NLB

Several GPs framed their weight loss recommendations as a method to improve fertility and minimise risks. In some instances, GPs suggested delaying conception in order to achieve weight loss first to increase the chances of conception:

“I would also think about stopping trying to conceive and then trying to lose weight with you know, medication or other things like just to like kick start it a bit and then stop the medications and then try later.” – P7, NBL

Further, GPs spoke about the pressure to lose weight that women felt due to the fear of not being able to conceive:

“It’s like all in their hands as a woman. I have to take control of all these factors because this is what’s preventing me and my partner, so it becomes another emotional toll…they kind of start to go down that path of thinking they’re not worthy.” – P12, NLB

In contrast, participants who challenged weight-related risk assumptions spoke about providing more holistic care that included a range of preconception health factors and how the preconception women responded:

“I got the feedback from them [women] that oh you actually just talk to me about everything in preconception like a “normal person”… they just felt comfortable in the fact that I would not point out their weight as being the centre focus.” – P5, LB

Several participants called for specific evidence-based training to develop new knowledge on the actual magnitude of risk associated with weight, and guidance on whether and how to discuss weight in a non-stigmatising way in preconception care:

“Having a specific training about what the actual risk is… and what interventions are likely to make a difference to then know what to bring up and how to actually help.” – P10, NLB

Subtheme 1.2 – Weight Loss Is Achieved Through Behavioural Changes. Several GPs held the assumption that weight loss could be achieved through behavioural changes alone, particularly diet and physical activity. In practice, GPs described how initial preconception appointments with larger-bodied women were often focused on food and exercise in order to reduce weight and increase the chances of conception:

“Let’s go through your daily life, talk about your physical activity level, incidental and planned, and then let’s talk about then nutrition, timing of food, what’s the type of food are you looking at and your macros?” – P12, LB

Notably, the advice in GP preconception appointments around using food and exercise to reduce weight was encouraged more frequently for larger-bodied preconception women. The following participant highlights how care does not largely differ except for discussions about behavioural changes:

“You’re still providing the same care; you would just have more of a discussion around like exercise and weight with a larger bodied person.” – P3, NLB

Participants noted that recommendations for weight loss were also dependent on women’s family planning timelines. For women planning pregnancy in the near future, advice typically focused on diet and physical activity. However, when more time was available, some GPs encouraged weight-loss medication or surgery:

“If they’re planning pregnancy in the year, I’m pretty sure they have time… to go on injections, injectables, or even the oral tablets to lose weight before pregnancy, and I highly recommend it.” – P1, LB

GPs’ experiences demonstrate how behavioural change was positioned as the primary pathway to weight loss in order to reduce conception/pregnancy risk. Some participants acknowledged the limitations of this approach as it ignores a myriad of structural, psychosocial, or biological factors (e.g., affordability, access to dietitians, food insecurity, history of eating disorders, polyendocrine metabolic ovarian syndrome):

“I think not only the cost of access [to dietitians]…but not give a blanket statement like eat this and this and this and you’ll be fine, it’s not going to work.” – P12 , NLB

Subtheme 1.3 – Larger-Bodied Preconception Women Are Motivated to Lose Weight. The third common assumption held by participants was that larger-bodied women were inherently motivated to lose weight prior to pregnancy. Whilst not all participants had these experiences, repeated accounts of caring for larger-bodied preconception women for some GPs reinforced the perception that this population were motivated to lose weight:

“Women are really motivated and they tell you they want to get healthier and lose weight before pregnancy.” – P8, NLB

This perceived motivation shaped how some GPs decided who was ‘ready’ for support, with care plans and referrals often contingent on whether women were viewed as sufficiently committed. This could perpetuate weight stigma and exacerbate inequities in preconception care, as care pathways differed for women based on their perceived motivation:

“I don’t offer care plans to everyone who’s overweight with a BMI over 25. If they’re motivated to do it and their private health insurance wasn’t covering allied health visits then I would I consider doing a care plan.” – P8, NLB

Further, some GPs described how perceived motivation of larger-bodied women was an ideal entry point to initiate weight loss discussions, reinforcing the assumption that being in a larger-body is a risk factor for conception:

“A lot of them do want to lose weight before they conceive or while they’re trying to conceive…they’ve always found it difficult to lose weight and now they’ve got this extra incentive.” – P3, LB

Several participants described how assuming motivation could narrow the scope of holistic preconception care, as GPs may unintentionally overlook or misinterpret women’s individual goals and concerns. For example, one participant highlighted the relationship between weight stigma and eating disorders and the detriment of allowing weight to overshadow this:

“If we’ve got someone with a previous history of an eating disorder then it’s absolutely imperative that we’re not mentioning numbers like weight and BMI…so I’d much prefer not to [discuss weight] because of the wider implications of an eating disorder.” – P14, LB

GPs described the high prevalence of weight stigma in the broader societal and healthcare setting, as many of the larger-bodied women they care for come into appointments wanting to lose weight. The following GP highlights the importance of providing compassionate and individualised care that does not assume weight loss as a shared goal:

“If there is someone who you can see has more fixed ideas about diet culture or weight generally, then I’ll be more gentle in my approach and I might say that there’s no evidence to say that weight causes fertility issues, that its correlation and not causation … how about we explore some other reasons as to why there might be fertility issues.” – P14, LB

Theme 2: Factors Influencing GPs’ Approaches to Caring for Larger-bodied Preconception Women

The second theme explores the factors influencing different approaches to caring for larger-bodied preconception women. General Practitioners discussed three key factors within healthcare: 1) previous experiences caring for lager-bodied preconception women; 2) weight-focused preconception care policies and guidelines; and 3) preconception care education and training. Overall, this theme demonstrates how different healthcare factors can underpin or reinforce GPs’ assumptions about larger-bodied preconception women and subsequent approaches to care.

Subtheme 2.1 – Previous Experiences Caring for Larger-Bodied Preconception Women. There were large variations in GPs’ frequency of caring for lager-bodied preconception women, which appeared to influence their approaches to preconception care. Some participants reported that “more than 50% of the women I have worked with in a preconception care setting would be living in a larger body” (P11, LB), whereas others noted they “rarely see women come for preconception care” (P2, NLB). Generally, GPs with more frequent experience of caring for larger-bodied women demonstrated greater awareness of weight stigma and the common narratives and assumptions that impact this population, and thus were more mindful in providing compassionate care:

“We see a lot of women who are living in larger bodies…and with all of the discrimination that they face on the day to day side of things we are trying to link them into the medical care they need…really making sure there’s less stigma involved, the last thing I want to do is isolate and alienate them and put everything down to their weight.” – P4, NLB

In contrast, some participants who described having limited experience caring for larger-bodied preconception women often expressed uncertainty and lower confidence in providing care:

“My personal fears is I don’t have much experience looking after obese [sic] preconception patients.” – P2, NLB

As a result of reduced confidence, participants described defaulting to common high-risk narratives and focusing on weight management:

“Well, there would be a need to limit the weight, not gaining too much weight…it may be difficult for them to fall pregnant compared to other women and they’re at higher risks of preeclampsia, gestational diabetes, and possibly other complications, premature delivery and so on.” – P2, NLB

Notably, the number of years being a GP was not linked to weight-inclusive approaches to preconception care. The following participant who had been a GP for 31 years spoke about how they focused on weight, diet, and exercise with larger-bodied preconception women as “old GPs like me tend to just fall into habits…that’s just the way I’ve always done it” (P6, LB). As such, participants demonstrated that GPs’ approaches to care (weight-centric or weight-inclusive) were shaped less by overall years of experience.

Subtheme 2.2 – Weight-Focused Preconception Care Policies and Guidelines. General practitioners described how the use of weight-focused preconception policies and guidelines shaped their approach to caring for larger-bodied preconception women. The extent to which participants followed preconception guidelines appeared to influence how strongly weight-related assumptions were embedded within their practice. Participants reported how preconception policies and guidelines were entrenched with language that focuses on weight and body mass index (BMI), with participants stating that “weight is just one of the things we do” (P8, NLB) and “guidelines identify weight as a major risk factor” (P4, NLB). For some, the alignment of their care practices with preconception guidelines translated into routinely measuring weight:

“I’ve always done it [measure weight] and I think most of the guidelines and things I’ve read talk about BMI, BMI greater than 30.” – P6, LB

Several participants reflected on how weight-focused framing of policies led to larger-bodied preconception women being automatically classified as high-risk when considering pregnancy care pathways, often without considering other factors:

“Guidelines are super helpful…if someone was obese [sic] they’re high risk for gestational diabetes and they’re a high risk pregnancy in general, so you automatically know they are not doing GP shared-care.” – P7, NLB

Similarly, GPs described how the guidelines directly prompted them to focus on weight and recommend weight loss to women in order to meet weight restrictions in policies:

“I have a few patients who have to try and optimise their weight…because they’re actually not allowed to go down that route [In Vitro Fertilisation] or not allowed to commence that process until their BMI was below… 30 or so… and then the consult becomes more around okay so how can we successfully lose the weight quickly… let’s talk about your physical activity level, incidental and planned, then let’s talk about the nutrition.” – P12, NLB

Several GPs highlighted the importance of balancing adherence to guidelines with the principles of person-centred care. Whilst weight was frequently embedded in preconception policies, GPs suggested that the approach should be tailored to the individual preconception woman and their needs:

“We have to dig a bit deeper and add to those guidelines…for example if someone who finds having weight taken very stigmatising and very difficult, even though it’s in the guidelines that we need a weight…the way that’s approached may be quite different…more gently approaching it.” – P4, NLB

Subtheme 2.3 – Preconception Care Education and Training. Participants reported limited formal education during medical training related to caring for larger-bodied preconception women, which reduced their confidence caring for this population. Most GPs reported that “I feel like I’ve not learned anything specifically for overweight and obese [sic] women doing preconception care” (P7, NLB). As a result, GPs lacked confidence in caring for lager-bodied preconception women with some defaulting to the common medical assumptions and narratives outlined in Theme 1:

“It would probably have just been one sentence during GP training or two sentences on a slide about you know these women will have some extra difficulties falling pregnant and extra possible complications.” – P3, LB

Participants described how the training and education available about caring for lager-bodied women emphasises weight as a risk factor, similar to preconception policies:

“I went to a webinar last year…and they talked about obesity and pregnancy and all the risks and things…I wrote a little cheat sheet and I’ve got that on my computer.” – P6, LB

Participants reflected on how weight-focused training influenced their early practice, shaping the way they communicated with larger-bodied preconception women. This often meant conveying risk-focused messaging which could frighten some women, as described by the following participant:

“I think I initially scared a lot of women with regards to their weight and the risks…because when I first started training it was this big red flag and anyone who was overweight you need to make sure you’re testing…and as times gone on I’ve kind of calmed down…it’s probably not that big red flag.” – P5, LB

In contrast, participants who had sought out self-directed content focusing on holistic, person-centred care reported greater confidence and adopted a more holistic approach to care:

“I do my own like professional development, I do try to read modules on how to better provide assistance to women who are larger-bodied, whether it’s nutritional advice or regarding their sleep or how to you know, general health sort of stuff and their mental health…I’ve just sort of sought out myself.” – P5, LB

Theme 3: Challenges Providing Non-stigmatising Care to Larger-bodied Preconception Women

The final theme explores the challenges GPs face when trying to deliver non-stigmatising care for larger-bodied preconception women. Several GPs discussed their efforts providing non-stigmatising care through altering their language, de-emphasising the risk of weight, and assessing women’s relationships with their bodies. Participants described how their efforts were often complicated by the following challenges: 1) supporting women with previous experiences of weight stigma; and 2) tension between risk-focused narratives and non-stigmatising care. Overall, this theme demonstrates how some GPs actively work to challenge the common assumptions and narratives associated with higher weight.

Subtheme 3.1 – Supporting Women with Previous Experiences of Weight Stigma. This subtheme explores the challenges that arose for GPs when caring for larger-bodied preconception women who had previously experienced weight stigma within healthcare. Participants described how women often arrived to consultations already carrying the emotional impact of past encounters where their body size had been positioned as the main risk factor:

“What I find is that they’ve already received a lot of weight stigma before they come and see me, a lot of them have been told they can’t have children because of their weight.” – P14, LB

Participants described difficulty building rapport with preconception women who had previously experienced weight stigma in healthcare. General Practitioners noted how this created barriers to open discussion and engagement and required additional effort to reassure women that they were a non-stigmatising practitioner:

“It can take a lot longer to build rapport and it can make it harder to just generally share information and have that really productive working relationship when they’ve had those negative experiences in the past and they’re feeling that stigma, even if you yourself as a practitioner are not expressing anything like that… but they come with that notion that you may say something problematic.” – P11, LB

Several participants also highlighted the need for greater self-awareness of their own biases towards larger-bodied women, as some GPs emphasised how unexamined weight stigma can shape the quality of care provided to larger-bodied preconception women:

“I think we are not reflecting, I think that’s because we’re letting our own biases come into view as opposed to addressing it, like what makes us feel uncomfortable, does it bother us, do we have an unconscious bias that maybe a larger bodied woman shouldn’t fall pregnant… is there some sort of bias about what we think someone who’s pregnant should look like.” – P5, LB

Subtheme 3.2 – Tension Between Risk-Focused Narratives and Non-Stigmatising Care. The final subtheme highlights the challenges GPs experience when trying to provide non-stigmatising support to women in an environment where assumptions about body weight remain deeply entrenched. Participants were aware of the tension between delivering evidence-based care to larger-bodied women and their desire to avoid perpetuating stigma:

“It’s hard to know how to deliver the care that’s evidence based that’s still not kind of worsening the stigma around it and it’s actually helpful in the long run.” – P15, LB

Many GPs recounted attempts to provide compassionate and non-stigmatising care but expressed challenges navigating their perceived responsibility to discuss risks associated with weight.

“Obviously, we can see the impact that weight as a risk factor does do and that’s very understandable but also taking that a step further and realising that we’ve tried shaming for years and years and years, it clearly hasn’t worked… we’ve got better ways of dealing with it, evidence-based ways to kind of change that attitude.” – P4, NLB

Participants stated that their attempts to adopt weight-inclusive practices required conscious and persistent efforts. Some GPs also reported actively challenging common narratives and assumptions about weight, such as deliberately changing the language they used in consultations to avoid reinforcing stigma:

“The strategy that I use for any kind of fixed belief about anything is that I maintain a non-judgmental approach about how they feel about whatever the issue is… and the language is not sort of saying that you’re the problem you know because you’re a high-risk pregnancy or because you’re fat [sic].” – P14, LB

Others attempted to counteract weight-based assumptions and narratives by providing evidence-based reassurance:

“Part of it is breaking down that misconception and saying well you know women who live in a larger body can fall pregnant and carry pregnancies to term…there are some cases we need to monitor closely…but there is no reason to assume that they will happen to you.” – P11, LB

This subtheme illustrates how providing non-stigmatising care requires GPs to consciously unlearn ingrained, weight-focused practices to counteract persistent weight assumptions in healthcare. GPs recommended the reframing of preconception care for larger-bodied women as an individualised and person-centred approach to give women the best chances of falling pregnant:

“I think that really what it comes down to is that nuanced, individualised care that a GP is really best place to provide because we know our patients and we can build those relationships overtime.” – P11, LB

Discussion

The findings of the current study provide novel insights into GPs’ perspectives of caring for larger-bodied preconception women. Three themes were identified: 1) narratives and assumptions about larger-bodied women; 2) factors influencing GPs’ approaches to caring for larger-bodied women; and 3) challenges to providing non-stigmatising care to larger-bodied women. The findings suggest that whilst GPs have a strong desire to provide high-quality preconception care to all women, they are constrained by several factors in healthcare that may reinforce weight-stigmatising approaches to care. Whilst the impacts of weight stigma in healthcare have been well documented,^11,13,17 the preconception period is a unique time where weight stigma can be amplified due to the future-oriented and risk-focused nature of this time.^1,39 Therefore, this study demonstrates for the first time how weight stigma can potentially impact larger-bodied preconception women from the perspectives of GPs.

We found that GPs practice in an environment where they felt that common assumptions and narratives about larger-bodied preconception women persist. The findings revealed how stigmatising assumptions and narratives, such as weight loss being achieved though behavioural changes alone, can reinforce weight-focused approaches to care. This finding reflects explicit weight stigmatising attitudes and beliefs ⁴⁰ as preconception weight loss is prioritised. Our findings align with healthcare and society more broadly, where weight has commonly been assumed as a health risk and that body weight is controllable and should be reduced.^13,41 In the current study, many GPs prioritised weight loss for future conception and pregnancy outcomes, despite recognising that weight-focused approaches can negatively shape women’s entire preconception and overall reproductive care journey. Therefore, whilst broader evidence has demonstrated that being larger-bodied is associated with a range of adverse reproductive and pregnancy outcomes,^14,20 the current findings highlight that weight stigmatising narratives and labels could also be adding additional pressure onto larger-bodied preconception women and negatively impacting their care. Furthermore, there is existing evidence demonstrating that preconception women in larger bodies can have uncomplicated conception journeys.^42,43 Overall, our findings highlight how narratives and assumptions in preconception care may reinforce explicit weight stigmatising attitudes amongst some GPs, ³⁴ and weight-centric practices in general practice can overshadow other important factors of preconception health. Navigating weight-related discussions in a way that discusses evidence-based risk, whilst ensuring communication is respectful, avoids stigma, and promotes the autonomy of preconception women could prevent harm related to weight stigma. ⁴⁴

Our findings also indicate that the current narratives and assumptions about preconception women are underpinned by key external factors within the general practice setting, including preconception policies and the GP education and training curriculum. Currently, preconception information in policies and education state that being in a larger body prior to conception is a potential risk factor.^2,17 This can contribute to weight-stigmatising experiences for larger-bodied preconception women as some GPs can adopt this framing in practice when caring for larger-bodied preconception women. For example, evidence demonstrates that medical students have a high level of explicit weight stigma, often perceiving body weight as purely controllable and linked to a lack of will power. ⁴⁵ Alongside the current findings, this suggests that weight-centric curriculum and policies that emphasise weight loss can contribute to weight stigmatising narratives, and thus weight-centric care for larger-bodied women, which has its own negative consequences.^46–48 Indeed, some researchers have highlighted that the harms of weight stigma may exceed those of being in a larger-body. ⁴⁸ The current findings suggest that GPs who prioritised person-centred care and used their clinical judgement alongside policy guidance typically practiced in a more holistic manner. This highlights the importance of communicating risk in a respectful and person-centred way. It is also important for preconception policies and the education curriculum to be improved to include integrating evidence about weight stigma, how to facilitate compassionate and non-stigmatising conversations, avoiding inadvertent blame, and integrating the voices of lived experience. ⁴⁹ Additionally, it is suggested that healthcare professional training and policy content be shifted to encourage more GPs to practice in a weight-inclusive manner. This may facilitate the adoption of holistic care for preconception women that goes beyond automatically reducing body weight for conception. Shifting messages in preconception policies and medical education can support healthcare professionals to discuss weight in a compassionate and respectful way that ultimately improves patient-provider relationships.

Our findings uniquely revealed that GPs face significant challenges in their attempts to provide non-stigmatising care to larger-bodied preconception women. Women who experience weight stigma are more likely to disengage from healthcare, have less positive patient-provider relationships, and report lower trust in healthcare services.^13,50,51 In our study, GPs acknowledged that preconception women’s previous experiences of weight stigma also impacted how they delivered care even when they had no intentions of discussing weight in a stigmatising manner. This is important to acknowledge given that evidence has demonstrated that preconception women with the intention of conceiving already feel a heightened sense of pressure, ¹⁰ and the addition of weight stigma can make this further challenging for providers. Compounding this, GPs in the current study faced tension between delivering non-stigmatising care and following their medical training about the risks of higher body weight. This aligns with broader literature beyond the preconception period, showing that many healthcare professionals have felt uncomfortable caring for larger-bodied women due to the sensitive nature of discussing body weight. ⁴⁸ Under these circumstances, non-stigmatising care may be deprioritised or overlooked, increasing the risk of weight stigma in preconception care. ⁴⁰ Overall, our findings add to the literature by highlighting that weight stigma permeates throughout the preconception space and that GPs need greater support and resources to provide non-stigmatising care.

Implications and Future Directions

In line with our findings and the WHO’s call for zero discrimination in healthcare, ⁵² we recommend that GPs and the broader general practice setting identify ways to reduce weight stigma in the preconception period. Our findings suggest further support is provided to GPs to ensure they can provide non-stigmatising and compassionate care to larger-bodied preconception women. This can include assessing the messages about body weight in policies and medical education content to ensure it does not become the sole focus of preconception care and supporting GPs in adopting weight-inclusive language. Without weight-inclusive training and education, larger-bodied preconception women will continue to receive weight-focused care. ⁵³ Additionally, policymakers should re-consider weight restrictions for services and pathways to ensure preconception women are not engaging in harmful restriction or weight loss. We recommend that GPs continuously reflect and challenge weight-based assumptions and narratives about larger-bodied women. This starts with acknowledging the persistence of weight stigma in healthcare and reflecting on their own potential biases, recognising how these may influence the care they provide to larger-bodied preconception women. Using person-first language and creating an inclusive physical space can create a safe environment for preconception women. ¹⁷ Fostering compassionate relationships with women is crucial, through encouraging GPs to seek consent for when and if weight is discussed. Supporting GPs in providing non-stigmatising care to larger-bodied preconception women requires researchers, clinicians, policymakers, lived experience experts, and public health professionals to collaboratively challenge common assumptions and narratives in all realms of preconception care (i.e., education content, physical settings, polices, etc).

Strengths and Limitations

A strength of this work is the inclusion of GPs with varying experiences caring for larger-bodied preconception women. However, all GPs but one practiced in metropolitan areas, thus information power regarding practice location may not have been achieved. The sample only included female GPs who practiced in the Australian healthcare context and thus perspectives may differ from male GPs and healthcare professionals in countries with different healthcare systems. Nonetheless, several themes identified in this study including the influence of clinical guidelines, assumptions about the controllability of weight, and challenges delivering non-stigmatising care have been reported across international health settings,^15,47,54 suggesting these findings can be transferable to other primary care settings. However, further research should continue to expand the understanding of weight stigma in preconception care by including a broader range of GPs, including Indigenous GPs, those practicing in rural/remote areas, and those who identify as males to provide additional insights into the landscape of preconception care. The interview guide focused on structural factors within healthcare systems rather than weight specifically, which allowed for more natural discussions about GPs experiences caring for larger-bodied women, reducing the likelihood of socially desirable responses. Finally, despite extensive recruitment efforts, all participants were women, perhaps reflecting the current landscape of primary care, preconception care, and qualitative interview studies. Indeed, perhaps the lack of male GPs in the current sample reflects the overall gendered nature of preconception care, where it is largely framed as a woman’s responsibility.^10,26 Future research should attempt to explore male providers’ experiences of preconception care, specifically for lager-bodied women.

Conclusion

This study explored GPs’ perspectives of caring for larger-bodied preconception women. The findings demonstrate how factors such as education content and policies may perpetuate narratives and assumptions about larger-bodied women that can contribute to explicit weight stigma held by GPs, showing this relationship in preconception care for the first time. GPs found it challenging to provide non-stigmatising care in an environment that is embedded with stigmatising narratives and assumptions. Key areas for attention include adapting GP training curriculum and reframing policy recommendations to ensure they are weight-inclusive. Ultimately, ensuring high-quality preconception care for all women regardless of body weight is essential to increase the uptake of preconception care and enhance health outcomes for women and future generations.

ORCID iDs

Chloe Tran https://orcid.org/0009-0000-5886-1696

Briony Hill https://orcid.org/0000-0003-4993-3963

Ethical considerations

This study was approved by the Monash University Human Research Ethics Committee (project ID: 41831) in May 2024.

Consent to participate

All participants read and signed a consent form prior to participating in the study. The privacy and confidentiality of participants were assured and all data collected were kept safe and used for the purposes of the study only.