Multiple dimensions of self A longitudinal grounded theory study exploring women’s experiences of maternity care when they present in pregnancy with a BMI of 35 or above

Abstract

Over 20% of women embarking on a pregnancy are ‘obese’ by Body Mass Index (BMI) definition in the United Kingdom (UK). The subsequent maternal and fetal complications arising from this has led to the implementation of maternity policy and practice to manage these women to ensure a good outcome.

This thesis aims to answer the question of: What are women’s experiences of their maternity care when they present in pregnancy with a BMI of 35 kg/m² or above? This question arises in the context of practices that exist within maternity services which medically manage women who present in pregnancy with a high BMI and how this management is received and perceived. While medical studies abound, these women’s experiences in relation to choice, consent and control in terms of how their pregnancies are managed are little researched. This is despite choice and control being an integral aspect of maternity policy in the UK, with informed consent a legal and ethical requirement. This thesis seeks to fill this gap.

The first part of this thesis, a meta-narrative review, considers how maternal ‘obesity’ discourses have evolved over time and across disciplines. A historical timeline was captured considering the reviewed literature in relation to evolving maternity policy and practice. Over time the management of ‘obesity’ has shifted from a focus on weight gain and diet in pregnancy, to increasing medicalisation, to a renewed focus on management using a public health approach. Four themes: ‘women’s beliefs and experiences of weight’; ‘social determinants’; ‘being risked-managed’; and ‘attitudes of caregivers’ were also identified. Increased medicalisation of maternal obesity, which includes defining and managing weight as pathological was found to limit women’s choice and control over their maternity care, although this was not explicitly explored within the literature. Lack of consideration of choice, consent and control was evident. It is imperative therefore that this gap in the literature is fully explored, of which this thesis aims to address.

The second part of the thesis presents the findings of a constructivist grounded theory study underpinned by poststructuralist feminist epistemology. A longitudinal study was undertaken across the pregnancy continuum, with interviews undertaken at four time points. Eleven women were recruited to the study and 30 interviews conducted between January 2018 and April 2020.

The findings suggest that there are multiple factors that influence women’s perceptions of weight and care which impact on choice, consent and control, namely: social and cultural factors, maternity practices, maternity service provision and maternity policy. From this, emergent theorising of; ‘the conditioned body’; ‘the (in)visible body’; and ‘the contesting body’ evolved. In order to develop a deeper theoretical interpretation of the findings, the works of three prominent 20th Century theorists - Simone De Beauvoir (1906-1986), Michel Foucault (1926-1984), and Erving Goffman (1922-1982) were explored. Further theorising from the findings that appear to impact on choice, consent and control was then constructed; ‘disciplined self’; ‘surrendering self’; ‘embodied self’; ‘marginalised self’; ‘resisting self’; and ‘self- agency’. Collectively these make up the substantive grounded theory of; ‘multiple dimensions of self’.

This study offers unique interpretations, with ‘multiple dimensions of self’ appearing to affect women’s abilities to exercise choice, give consent and feel in control. Reconsideration of maternity policy, practice and risk processes are needed to avoid a reductionist approach to body size, providing individualised, compassionate care which is woman/person centred. Development of enhanced communication skills and knowledge of public health strategies for health professionals will promote positive relationships, avoiding a paternalistic approach to care. It is imperative that the psychology of self is further understood by health professionals through education strategies in order to support women who present in pregnancy as ‘obese’. Further research examining ‘dimensions of self’ and how self impacts on perceptions of weight and maternity care is needed to understand the complexities for those living with ‘obese’ who access these services.