Obesity is defined as a body mass index (BMI) of 30 or greater with categories of class I (30-34.9) through III (greater than 40; American College of Obstetricians and Gynecologists [ACOG], 2021). In 2015, nearly half of all women who became pregnant were either overweight (24%) or had obesity (24%; U.S. Preventive Services Task Force, 2021). From 2016 to 2019, prepregnancy obesity in the United States rose 11%, from 26.1% to 29% with every state seeing increased rates except Vermont (Driscoll & Gregory, 2020). Although obesity rates increased among all education levels, ages, and racial groups, rates were highest among women with less than a bachelor's degree, those over 20 years old, and non-Hispanic Black women (Driscoll & Gregory) and lowest among non-Hispanic Asian women (ACOG).

There are many known risks of obesity on pregnancy yet counseling on these pregnancy-specific risks are not always routinely included in primary care. The increased risk of spontaneous abortion and adverse pregnancy outcomes can be reduced with even small weight reductions before getting pregnant (ACOG, 2021). Pregnant women with obesity have a higher chance of having a fetus with congenital anomalies, macrosomia, impaired growth, and stillbirth (ACOG). Women with prepregnant obesity are also at increased risk of cardiac issues, proteinuria, obstructive sleep apnea, fatty liver disease, preeclampsia, cesarean birth, endometritis, wound rupture or dehiscence, venous thrombosis, early termination of breastfeeding, postpartum anemia, and depression (ACOG). Considerations for labor and birth should be noted. Regional anesthesia may be difficult to adequately achieve due to body habitus leading to issues in identifying landmarks and can lead to a higher failure rate, but general anesthesia carries increased risk in patients with high BMI, though is not contraindicated (ACOG). If a patient needs a cesarean birth, consideration should be given to increasing the broad-spectrum, presurgical antibiotic prophylaxis to weight-based dosing and though the ideal skin incision is not yet known, it may be beneficial to alter surgical technique to decrease the chance of would issues (ACOG).

Although the increasing trend and risks associated with obesity are known, there has not been a consistent recommendation about counseling or prevention. The U.S. Preventive Services Task Force (USPSTF) commissioned a review of behavioral counseling interventions targeted at preventing prepregnancy obesity and excess gestational weight gain for pregnant adolescents and adults in primary care settings (USPSTF, 2021). They found with moderate certainty that effective behavioral counseling aimed at limiting excessive gestational weight gain improves health outcomes for pregnant women and their infants (USPSTF). They suggest patients should be offered individualized suggestions for nutrition, physical activity, lifestyle, and behavioral changes with multiple components such as supervised or led exercise programs and counseling about diet and physical activity modifications (USPSTF). ACOG (2021) recommends all women with obesity be given behavioral counseling interventions with the aim of a healthy diet, adequate exercise, and weight loss with the goal of achieving a healthier weight before a future pregnancy.

Viewing obesity as a medical condition warranting treatment and counseling is critical in keeping women with obesity and their infants as safe as possible. Perinatal nurses are vital to eliminating obesity bias in maternity care. Approaching the conversation with compassion and without judgment may help women to be more receptive to treatment and being motivated to accept and achieve behavioral modification goals. If a woman is not receptive to counseling or recommended diet and lifestyle changes, all effort should still be given to achieving the safest prenatal, intrapartum, and postpartum care possible.

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