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Ills from the womb? A critical examination of clinical guidelines for obesity in pregnancy

Shannon JetteUniversity of Maryland, USA

Geneviève RailConcordia University, Canada

AbstractIn this article, we critically examine the clinical guidelines for obesity in pregnancy put forth by the Society of Obstetricians and Gynaecologists of Canada (SOGC) that are underpinned by the rules of Evidence-Based Medicine (EBM), a system of ranking knowledge that promises to provide unbiased evidence about the effectiveness of treatments. While the SOGC guidelines are intended to direct health practitioners on ‘best practice’ as they address pregnancy weight gain with clients in the clinical context, we question their usefulness, arguing that despite their commitment to objectivity, they remain mired in cultural biases that stigmatize large female bodies and associates them to ‘unfit’ mothers.

KeywordsBiopower, eugenics, health, maternity, obesity

It is also critical that provincial and federal authorities recognize the impact on future populations and health care costs of pregnancies complicated by obesity. A long-term national information campaign is required to exploit women’s interest in having as healthy a pregnancy as possible by giving them the information they need to become fit and have a normal BMI before they consider pregnancy. (Society of Obstetricians and Gynaecologists of Canada, 2010: 172)

Corresponding author:Shannon Jette, Department of Kinesiology, School of Public Health, University of Maryland, 2318 SPH Building, College Park, MD, 20742, USA. Email: jette@umd.edu

460702 HEA0010.1177/1363459312460702Health:Jette and Rail2012

Article

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Introduction

The above statement is an excerpt from the clinical practice guidelines for obesity in pregnancy released by the Society of Obstetricians and Gynaecologists of Canada (SOGC) in 2010. Underpinned by the rules of Evidence-Based Medicine (EBM), a sys-tem of ranking knowledge that promises to provide unbiased evidence about the effec-tiveness of treatments, the guidelines are intended to direct health practitioners on ‘best practice’ as they address pregnancy weight gain with overweight/obese clients in the clinical context. The guidelines were created in light of concern that pregnancy is a major contributor to the so-called ‘obesity epidemic’ in western society (Murphy Paul, 2008). It is argued that women are beginning pregnancy overweight, gaining too much weight during pregnancy, and failing to lose the extra weight post-pregnancy (Catalano, 2003; Reece, 2008). Within the health care and medical community, there is considerable con-sternation about this situation as it is suggested that obesity and overweight during preg-nancy are linked to numerous health risks for both the mother and fetus (McKnight et al., 2011; NRC and IOM, 2007). For instance, overweight and obese women are said to be at increased risk for developing gestational diabetes mellitus and pregnancy-induced hypertension, giving birth to a ‘too-large’ baby and requiring a Caesarean section. Researchers have also identified a link between obesity during pregnancy and increased risks of still birth and birth defects (PACTS, 2006), and it has been suggested that women who are overweight or obese during pregnancy are altering the intrauterine environment and possibly ‘programming’ the fetus to develop diabetes and/or overweight/obesity later in life (Lau et al., 2011). Within much of the medical literature that is recuperated by the mass media, women are positioned as responsible not only for the health of their own offspring but also for their cost to the community should they be unhealthy (Jette, 2008, 2009). The excerpt at the beginning of this article illustrates a level of anxiety such that medical organizations are advising policy makers to ‘exploit women’s interest in having as healthy a pregnancy as possible by giving them the information they need to become fit and have a normal BMI before they consider pregnancy’ (SOGC, 2010: 172, emphasis added). Perhaps even more striking, in 2006, the British Fertility Society rec-ommended banning fertility treatment to women who are pre-obese and obese, and their European and Canadian counterparts fiercely debated the issue at their respective 2011 annual meetings (Abraham, 2011). Some experts are also of the opinion that modest weight loss during pregnancy can benefit the health of a too-large mother and her fetus (Artal et al., 2010; McKnight et al., 2011).

While not dismissing the idea that there may be risks associated with obesity in preg-nancy (just as there are risks associated with insufficient gestational weigh gain), in this article we critically examine the SOGC clinical guidelines for obesity in pregnancy, arguing that despite their commitment to objectivity, they are highly problematic as they are based upon questionable scientific evidence and put forth advice that is irrelevant and unhelpful to the vast majority of women. In our view, it is not a coincidence that the pregnant body is currently a focus of medical and societal concerns regarding excessive weight gain in pregnancy. Following feminist scholars such as Sawicki (1991) and Weir (2006), we recognize the pregnant body as the perfect site for the administration of what French philosopher Michel Foucault termed ‘biopower’ (2009 [1977]). According to

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Foucault (2009 [1977]), a transformation in the exercise of power emerges with the birth of liberalism and the idea of a government that must control life and better manage the labor force. Power must be increasingly less the power to put to death (sovereign power) and increasingly more a productive power to intervene and ‘make live’. Biopower is the term Foucault uses to refer to modern states’ new focus on life through the subjugation of bodies and the control of populations (e.g. the regulation of habits, reproductive prac-tices, family, sexuality, hygiene, well-being, health). The pregnant body is an obvious site for the implementation of tools, techniques and means intended to produce a healthy social body; by disciplining the individual pregnant body, the health of the (future) popu-lation is also regulated. In a contemporary western society characterized by a neoliberal emphasis on personal responsibility for health and management of risk, feminist scholars have demonstrated how pregnant women are subject to an ever-growing number of exhortations to manage their behaviors in order to both mitigate against a multitude of risks to their fetus and have a healthy baby (Lupton, 1999; Weir, 2006). Currently, one such risk is being too ‘fat’ during pregnancy.

Although pressure to manage pregnancy-related risks may be greater in the cur-rent era of ‘intensive motherhood’ – which authors have conceptualized as the requirement for mothers to always put their child’s needs before their own and invest copious amounts of time, energy, and material resources on the child in order to be a ‘good’ mother and lead a ‘fulfilled’ life (Douglas and Michaels, 2004; Hays, 1996) – prenatal health emerged as a biopolitical project in North America in the early 20th century in an effort to stem high rates of infant and maternal mortality (Jette, 2009). Indeed, the current move to restrict pregnancy weight gain echoes a previous trend that began in the 1920s when toxaemia (a form of hypertension that occurs in preg-nancy and that can potentially develop into eclampsia) was identified as a major contributor to high rates of maternal mortality – and a threat to the strength of the White, imperial state already perceived to be diminishing due to lower birth rates and the ‘pollution of the race’ through infectious diseases and high rates of immigra-tion (Hall, 2002). A sudden and significant increase in maternal weight gain related to fluid retention was identified as a symptom of toxaemia and, despite some contro-versy as to whether the occurrence of excessive weight gain had any relationship to severity or type of toxaemia, a number of physicians began to advocate for the need to carefully monitor and limit maternal weight gain to between 12–15lb (see Bingham, 1932; Harding and VanWyck, 1934; McIlroy and Rodway, 1937). However, it soon became common for physicians to conflate rapid weight gain in pregnancy due to fluid retention (and possibly toxaemia) with pregnancy weight gain due to accumulation of body fat. These physicians began to state that all women who gain excess weight in pregnancy (even if not due to fluid retention) would benefit from strict dieting with no harm to the growing fetus. Reflecting on this practice some years later, one physician has noted that:

the accumulation of excess body water was being treated, somewhat illogically, by an attack on energy balance. Nevertheless, the idea that weight gain should be restricted by dieting in order to prevent the onset or development of pre-eclampsia became … an article of faith among obstetricians all over the world. (Hytten, 1979: 461; see also Schwartz, 1990; Stearns, 1997)

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By the early 1960s, it was not uncommon for physicians to prescribe pregnant women diet pills to help them keep their weight gain in check or avoid it altogether (see Mullins, 1960; Paul and Martin, 1964; Sands, 1962).

We invoke this example to illustrate how prescriptions regarding weight gain in preg-nancy have never been ‘objective’ but rather shaped by the socio-historic context in which they have been produced and informed by the biopolitical aims of governance. These aims themselves shifted from a concern with the collective strength of the State in the first half of the 20th century to a neoliberal concern with the cost of unhealthy bodies in contemporary western society. Indeed, after encouraging pregnant women to ‘eat for two’ from the 1970s onwards in an effort to reverse the 1960s policy of severe weight restriction (a policy believed to cause low birth weight and to be linked to high rates of infant mortality, disability and mental retardation (see Abrams et al., 2000; Katz Rothman, 1982)), excess weight gain during pregnancy is again being viewed as a problem within the medical community in the context of the so-called ‘obesity epidemic’. Part of the ‘solution’ has been the creation of the SOGC clinical practice guidelines on obesity in pregnancy, designed to direct health practitioners on how to help overweight/obese women ‘fix’ their problematic bodies. In what follows, we argue that these guidelines are no more objective than the advice provided in the first half of the 20th century and instead are mired in cultural biases that stigmatize large female bodies and associate them to ‘unfit’ mothers. Before turning to our critique of the guidelines, however, we provide an overview of two relevant bodies of literature and outline how our analysis contributes to them.

Review of literature

Our examination of the guidelines builds upon two areas of scholarship that question the manner in which, in contemporary biomedicine, medical knowledge is often boiled down into simple ‘truths’ about bodies and health. The first is critical obesity research, which challenges many of the taken-for-granted assumptions about obesity put forth in the biomedical literature (see Gard and Wright, 2005). In answer to the unrelenting bar-rage of research suggesting that we are in the midst of a global health crisis of unprec-edented proportions, recent studies by social scientists and biomedical researchers have challenged the use of the term ‘epidemic’ (Campos et al., 2006; Gard, 2011), the notion of obesity as a disease (Oliver, 2006), the burden of disease due to obesity (Mark, 2005), the attribution of deaths to obesity (Flegal et al., 2005; Mark, 2005) and the identification of obesity as a public health priority (Campos et al., 2006). These authors and others have also noted contradictions regarding obesity’s measurement, causes, solutions and interventions (Gaesser, 2009; Holm, 2007; Komesaroff and Thomas, 2007; Rail, 2012). Importantly, the most common health prescription for individuals at ‘risk’ of obesity is weight loss, a prescription that has been critiqued as ineffective (Lyons, 2009), non-permanent (Campos et al., 2006; Gaesser, 2009), and potentially leading to poor body image (Beausoleil, 2009) as well as unhealthy practices such as weight-cycling (Campos, 2004) and eating disorders (Clift and Wright, 2010; Rich and Evans, 2005). Also problematized has been what critical obesity scholars have invaria-bly termed the ‘dominant obesity discourse’ which offers a mechanistic view of the

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body and focuses on the assumed relationship between inactivity, poor diet, obesity and health (Campos et al., 2006; Gard and Wright, 2005). In the same breath, this discourse presents obesity in moral and economic terms: obese and ‘at-risk’ bodies are constructed as lazy/expensive bodies that should be controlled and submitted to expert investigation (Groskopf, 2005). The dominant obesity discourse draws upon a neoliberal notion of individualism that positions individuals as primarily responsible for changing their life-style in relation to exercise and diet in order to be a morally ‘fit’ citizen (Campos, 2004; Gard and Wright, 2005).

Critical obesity scholars have also questioned the pathologization and medicalization of obese individuals as well as those ‘at-risk’ for obesity (Murray, 2007; Oliver, 2006), including in the context of pregnancy (Jette, 2008, 2009; Keenan and Stapleton, 2010; McNaughton, 2011). McNaughton’s (2011) examination of current medical literature on obesity in pregnancy is especially illuminating. Pointing to the weak ‘evidence’, McNaughton is particularly critical of the assertion that the source of obesity is the womb (intrauterine environment) and that the only way to slow the obesity epidemic is to inter-rupt the cycle of obesity by intervening throughout a woman’s reproductive life. She also observes that although underweight and overweight are both constructed as a risk for mothers and babies, overweight and obese mothers are the focus of the gestational weight gain literature. In short, she questions several key assumptions regarding the inherent dangers of fatness in relation to pregnancy and reproduction, asserting that they serve to ‘affirm certain moral, neo-liberal ideas and values while at the same time rendering invisible the political economy that produces ill health in the first place (poverty, racism, classism, sexism, etc.)’ (McNaughton, 2011: 187).

The second body of literature is produced by scholars concerned with the growing dominance of EBM within the health sciences over the past decade (see Lambert et al., 2006; Timmermans and Berg, 2003; Traynor, 2003). A hallmark of EBM is the system-atic review and/or meta-analysis of all studies deemed relevant to a topic, and the use of a standardized ‘Hierarchy of Evidence’ to rank evidence according to the reliability and verifiability of the research design: ‘from randomized controlled trials at the top to physicians’ anecdotal reports and case studies at the bottom’ (Lambert et al., 2006: 2613). Hypothetically, any empirical data may be included in the ‘evidence’ pool; how-ever, the validity continuum is largely based upon the degree to which ‘evidence’ can be quantified and relevant health factors thus made available to measurement and compari-son (Cronje and Fullan, 2006). The promise of EBM is to increase the reliability and quality of care in the clinical setting by providing health care workers with ‘best prac-tices’ that will guide them along a ‘rational’ decision-making process, while also saving money by demonstrating to policy makers and administrators which therapeutic inter-ventions are most effective (Lambert et al., 2006). The belief is that quantification leads to a repeatable, rule-driven algorithm that will guarantee necessary and universal out-comes; EBM is thus built upon the Enlightenment model of rationality bound up in scientific reasoning (Cronje and Fullan, 2006). As Cronje and Fullan (2006) explain, however, patient narratives regarding their bodily experiences and health behavior deci-sions are messy, complex and mostly incompatible with EBM’s impulse toward rule-driven quantification. The authors do not call for a complete dismissal of EBM but argue for a new model of rationality that opens up what counts as evidence, mostly by

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assigning greater credence to patient viewpoints. Other social scientists have taken a more critical stance, questioning EBM’s ‘way of knowing’ whereby certain types of knowledge are celebrated for their ‘objectivity’, while ignoring the social, historical and political contexts that lend them their currency and power (Goldenberg, 2006; Murray et al., 2007). According to Murray et al. (2007: 514), the problem with EBM is that ‘at best, it downplays, and at worst, it utterly disavows the subjective elements operating at the heart of its own system’. EBM’s unproblematic view of ‘evidence’ as ‘fact’ or ‘truth’ about the world has similarly been critiqued by Goldenberg (2006) and Rail et al. (2010). Of particular relevance to our article is the work of health practitioners in the realm of obstetrics who caution against ignoring clinical experience and women’s lived experiences in favor of EBM ‘best practice’ guidelines that do not account for the com-plexities (biological and social) of pregnancy (Berg et al., 2008; Downe, 2010; Enkin et al., 2006; Wendland, 2007).

Simply put then, critiques of obesity science and EBM both challenge the manner in which complex issues concerning bodies, health and well-being are reduced to simple ‘truths’ when viewed through a biomedical lens. Critical scholars take the position that the body and health are not purely biological or epidemiological in nature, but instead must be considered in relation to the historical and cultural context in which they are produced. Similarly, we suggest that we cannot reduce our understanding of pregnancy and obesity, two complex issues bound up in relations of power, into a simple set of rec-ommendations for health practitioners to follow as they interact with pregnant women. While health practitioners and social scientists have begun to challenge the uncritical application of EBM to the realm of obstetrics (Berg et al., 2008; Downe, 2010; Enkin et al., 2006; Keirse, 2011; Wendland, 2007) and to question medicalized constructions of ‘fat’ pregnant bodies in historical (Katz Rothman, 1982; Schwartz, 1990; Stearns, 1997) and contemporary (Jette, 2009; Keenan and Stapleton, 2010; McNaughton, 2011) con-texts, lacking is a close consideration of clinical guidelines for obesity in pregnancy underpinned by EBM and of the growing number of clinical guidelines for the treatment of obesity in the general population (see Lau et al., 2007; NICE, 2010; NIH, 1998).

We contend that such an examination is of critical importance. Guided primarily by a poststructuralist perspective (Rail, 2009; Weedon, 1997), we view reality as ‘constructed’ through language and cultural practices and are therefore cognizant of the power of knowledge that is accepted as ‘truth’ in shaping the way individuals make sense of and act in the world. Given the growing influence of EBM in biomedicine, EBM-endorsed clinical guidelines become part of a ‘regime of truth’, constructing ‘norms’ that inform policies and procedures, and ultimately, how we understand bodies. In this view, the SOGC clinical practice guidelines for obesity in pregnancy (the first in North America to be informed by EBM) have the potential to significantly impact the lives of pregnant women as they work to classify them as normal or abnormal, healthy or pathological, fit or unfit mothers, good or bad citizens. While we do not assume that all health practition-ers will simply disseminate the advice provided in the SOGC guidelines without critical reflection, it is possible that physicians will look to this ‘legitimate’ source of knowledge to help guide their interactions with pregnant women who are overweight/obese, espe-cially given the current panic about maternal obesity. In what follows, we therefore seek to bring to light the hidden moral assumptions and neoliberal ideologies underpinning

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the SOGC guideline recommendations, and point to the negative impact they may have on how women understand and experience their pregnancies.

Deconstructing the ‘evidence’: SOGC guidelines for obesity in pregnancy

Questioning classification: arbitrary norms

In Canada, the clinical practice guidelines were created by two committees, the SOGC’s Maternal Fetal Medicine Committee (11 medical doctors and one registered nurse) and the Clinical Practice Obstetric Committee (six medical doctors, one nurse with an MSc, and one registered midwife) who operated under the leadership of three principal authors who are medical doctors. The two committees reviewed and evaluated studies on a vari-ety of topics considered relevant to the issue, including pregnancy and childbirth compli-cations related to obesity (as well as management of complications) and perinatal outcomes. The studies considered were restricted to systematic reviews, randomized controlled trials, controlled clinical trials and observational studies pertaining to the above topics. Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventative Health Care. In this EBM configuration, two dimensions are used to rate the strength of a recommendation. The first is the typical quality of evidence assessment, which ranks ‘proper’ RCTs at the top and opinions of respected authorities (based on clinical experience, descriptive studies or reports of expert committees) at the bottom, with non-randomized controlled trials and cohort stud-ies in between. Notable by its absence is qualitative research based on layperson accounts or experiences. The second dimension is the classification of recommendations based on the quality of evidence to recommend the clinical preventive action, with A (good evi-dence), B (fair evidence); C (unclear/conflicting evidence); D (fair evidence to recom-mend against); E (good evidence to recommend against); and I (insufficient evidence). The Task Force altered this second dimension in 2003 (see Woolf et al., 2003) to place a new emphasis on the importance of patient–clinician communication, as well as consid-eration of the broader context that is part of the decision-making process. For example, the ‘C’ grade is now reserved for situations where ‘evidence’ of adequate quantity/qual-ity may exist, but is conflicting in that the effectiveness remains unclear (before it could also indicate that evidence was lacking/inadequate). The assignment of this grade, according to the Task Force, signals a situation where existing evidence might need to be considered in light of a patient’s specific context (i.e. other factors such as ‘values and individual patient characteristics’ (Woolf et al., 2003: 208)). If used properly, the creation of the new ‘C’ grade appears to crack open the door to other ways of knowing within the EBM system, including patient narratives.

The committees came up with nine key recommendations, all of which received a rating of ‘B’; it was decided that there was ‘fair’ evidence to support the preventive actions. Before discussing the recommendations in more detail, however, it is important to point out that despite the apparent concern with the ‘hierarchy of evidence’ underpin-ning the clinical practice guidelines, many of the actual recommendations are based upon a problematic classification system with no apparent critical consideration of its use,

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namely the BMI. Scholars have questioned the simplistic links drawn between BMI and health (see Evans and Colls, 2009), one particularly pertinent critique being the arbitrary and fluid nature of the cut-off points that define someone as overweight or obese (Ross, 2005). For adults, these cut-off points have changed in the past and ‘produced’ obese individuals out of previously overweight ones. For pregnant women, a similar situation has occurred. Health Canada (1999) used an upper limit of 27 as the cut-off to be classi-fied as ‘normal’ but this upper limit has now been changed to 24.9 in line with the Institute of Medicine (IOM) guidelines (Rasmussen and Yaktine, 2009), and the SOGC (2010) guidelines follow this trend. Women who were previously categorized as ‘nor-mal’ at a BMI of 25, 26 or 27 are now classified as ‘overweight’ and advised to gain about 10lbs less. It is somewhat ironic that the SOGC uses the standards of EBM in order to assess and recommend the most valid and reliable ‘evidence’ available, but base their recommendations on problematic categories and changing definitions of what is over-weight and obese.

The recommendations: measurement and scare tactics

The shifting BMI classifications are the basis of the recommendations surrounding obe-sity and pregnancy. The first recommendation states that:

• Periodic health examinations and other appointments for gynaecologic care prior to pregnancy offer ideal opportunities to raise the issue of weight loss before con-ception. Women should be encouraged to enter pregnancy with a BMI <30 kg/m2 and ideally <25 kg/m2. (SOGC, 2010: 172)

According to the recommendation, health care providers should be recording the height and weight of all women of childbearing age even considering pregnancy, calculating their BMI and counseling them to wait until they fall within the appropriate category (‘normal’) before they become pregnant. The eugenic undertones are striking, especially when we consider that certain sub-populations of women (African Americans and Aboriginal Canadians) are more likely to be classified as overweight/obese based on the BMI classification system (see Davis et al., 2009; Lowell and Miller, 2010). This recom-mendation was rated III-B, the ‘III’ indicating that it is based on expert opinion (the ‘lowest’ quality of evidence in the hierarchy given that it is not quantifiable) and the ‘B’ that the committees view it as ‘fair’ to recommend this clinical preventive action. We wonder: if obese women’s narratives of their experience of being told not to conceive until they lose weight ranked high enough on the evidence hierarchy to be included in the studies reviewed, perhaps this recommendation would have received a different ranking (such as ‘C’) or not been included at all (the previous statement is based on our assump-tion that women would likely express their indignation and/or distress at such advice). In large part, the ability of systematic review committees to put forth such a recommenda-tion is a function of power relations, namely who is on the committees. The answer in this case is: not obese laywomen who might interpret ‘expert’ opinion in a different light than the experts on the panel. Yet in the published guidelines, this power relation is hid-den from view. Other recommendations of interest include (SOGC, 2010: 172):

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• BMI should be calculated from pre-pregnancy height and weight. Those with a pre-pregnancy BMI > 30 are considered obese. This information can be helpful in counseling women about pregnancy risks associated with obesity.

• Obese pregnant women should receive counseling about weight gain, nutrition, and food choices.

• Obese women should be advised that they are at risk for medical complications such as cardiac disease, pulmonary disease, gestational hypertension, gestational diabetes and obstructive sleep apnea. Regular exercise during pregnancy may help reduce some of these risks.

• Obese women should be advised that their fetus is at an increased risk of congeni-tal abnormalities and appropriate screening should be done.

• Obese pregnant women have an increased risk of Caesarean section, and the suc-cess of vaginal birth after Caesarean section is decreased.

All of the recommendations, in some shape or form, promote the measurement and clas-sification of the pregnant body, followed by the advice that practitioners then share a list of negative consequences for the unborn child with women who are identified as ‘obese’. It is difficult to see how these recommendations are supported by evidence, how they are helpful or how they could be at the basis of patient–practitioner interactions that would positively impact women’s experience of pregnancy and how they understand their bod-ies. In terms of evidence, these recommendations assume that because they are obese, pregnant women are in need of counseling about weight gain, nutrition, and food choices – a problematic assumption. The section of the text that reviews evidence for ‘Therapy and Management’ is instructive in this regard. Citing another expert panel, it is explained that pregnant women should exercise four times a week at moderate intensity; yet the next sentence states: ‘the actual effect of these recommendations is hard to measure because of the difficulty of behavioural change assessment; however, the rising obesity rate in the Canadian pregnant population and the maternal and neonatal sequelae described above are most disturbing’ (SOGC, 2010: 171). It appears that moral commen-tary (‘most disturbing’) trumps evidence (‘the actual effect … is hard to measure’). Next it is stated that ‘nutritional counselling and dietary records may be helpful in guiding overweight and obese women with respect to adequate weight gain during pregnancy’ (SOGC, 2010: 171). It is then explained that the role of behavioral therapy and caloric restriction in obese women to prevent excess weight gain has not been established and that RCTs using behavioral interventions in normal weight and obese women with the goal of preventing excess weight gain have been inconclusive. ‘Evidence’ is obviously not a factor in this recommendation, either. Three of the recommendations also conclude to individual risks to the mother and fetus, something that cannot be concluded from populational studies on BMI and various diseases from which emerge the risk ratios. Moreover, the use of the term ‘increased risk’ in the actual guidelines is vague, but when used to refer to an obese woman’s likelihood of having a child with congenital deformi-ties due to her ‘fatness’, it is potentially terrifying. The actual articles reviewed, however, indicate that obese pregnant women had an approximate two-fold greater risk of having off-spring with neural tube defects over non-obese women. This number sounds dra-matic, but we actually require a huge difference between populations of obese and

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non-obese women to conclude on a significant effect (i.e. 10 to 1 or, as is roughly the case for lung cancer when we look at smokers versus non-smokers, 30 to 1). In terms of their usefulness and impact, the recommendations are questionable in the clinical con-text, particularly when dealing with women with differing backgrounds and experiences. Keenan and Stapleton (2010), for instance, used qualitative interviews to explore how being classified as ‘obese’ played out in British women’s experiences of pregnancy. Their results speak to how health professionals’ attempts to motivate women to lose weight after birth were crude, blame-inducing, highly insensitive, and had the ultimate effect of hardening and disenfranchising the women as opposed to encouraging them to lose weight. The authors further explain that the majority of the larger women in their study did not personally identify with the clinical categories of obesity underpinned by the BMI. We cannot help but wonder how Keenan and Stapleton’s participants might have reacted if clinical guidelines had been in place in Great Britain and they had been encouraged to identify as obese (as recommended by the SOGC guidelines) or been cited a list of frightening consequences around obesity during pregnancy (as recommended by the SOGC guidelines). This leads us to another central problem with the SOGC guide-lines. It is taken-for-granted that women just need to be told to change and that they will then be in a position to make the required changes. The guidelines are built upon the neoliberal assumption that individuals are autonomous, rational subjects who have ‘choice’ and ‘control’ in their lives. Ignored are the cultural differences and socioeco-nomic disparities that make the lifestyle-related recommendations put forth totally irrel-evant for many women and impossible for others.

Concluding thoughts: better ‘evidence’ = better babies?

In short, we believe that the issue of pregnancy and obesity is too complex to be rendered into lifestyle-based recommendations that are given the status of ‘best practice’ because they are underpinned by the rules of EBM. We are not alone. The creation of EBM in the realm of obstetrics has increasingly come under fire from health care practitioners (see Downe, 2010; Enkin et al., 2006; Wendland, 2007). Strikingly, two of the original authors of the landmark text, A Guide to Effective Care in Pregnancy and Childbirth (Enkin et al., 1989), have since reflected upon their hand in the creation of an EBM movement that is blind to other types of knowledge (see Enkin et al., 2006; Keirse, 2011). Discussing the difficulties with EBM in maternity care, Enkin et al. (2006) have explained that the fundamental mistake of evidence-based obstetrics is to treat complex problems as if they were merely complicated. Enkin and his colleagues (2006: 268) have noted how certain problems cannot be reduced to their simple components and addressed within the current paradigm: ‘clinical problems, like pre-term labor or small-for-gestational-age babies, do not fit into our predefined slots. Neither do more broadly based problems like overex-tended facilities, shortage of maternity care practitioners, [or] the current epidemic of caesarean sections.’ To such issues, we would add the topics of weight gain and obesity during pregnancy. Indeed, while appearing to subscribe to EBM in principle, some obe-sity scientists have questioned the usefulness of traditional evidence hierarchies (as used in EBM) for guiding obesity policy developments and public health prevention efforts, with Swinburn et al. (2005: 23) arguing that ‘evidence base for obesity prevention needs

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many different types of evidence and often needs the informed opinions of stakeholders to ensure external validity and contextual relevance’. It is with these critiques in mind that we caution against the use of simplistic recommendations such as those provided in the SOGC ‘obesity in pregnancy’ guidelines and argue in favor of using other ways of knowing – including patient narratives – to delve into the societal and cultural complexi-ties around pregnancy and obesity, with the aim of creating more relevant and positive strategies.

Through this analysis, we have also tried to caution against the assumption that soci-etal progress is inevitable and that our knowledge is always improving in a linear manner (i.e. becoming more objective and less embedded in relations of power as per the tenets of scientific reasoning that underpin biomedicine). It would be tempting to look at the pregnancy weight gain prescriptions in the 1930s and into the 1970s that were so obvi-ously based on shaky assumptions and spurious correlations regarding weight gain and toxaemia, and argue that today’s guidelines are somehow ‘better’. As we have attempted to illustrate here, pregnancy weight gain prescriptions remain embedded in relations of power, making moral judgments about fat bodies and unfit mothers that are hidden behind the rhetoric of ‘evidence’ and the neoliberal notion of ‘choice’.

Acknowledgements

This work was supported by the Canadian Institutes of Health Research (grant number 223680).

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Author biographies

Shannon Jette, PhD, is an Assistant Professor in Physical Cultural Studies, Department of Kinesiology at the University of Maryland. She is currently looking to feminist poststructuralist theory to explore how pregnant women of differing socio-cultural backgrounds discursively

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construct and experience health, physical activity and pregnancy weight gain. Overall, her research agenda is linked by a focus on the multiple ways that active bodies are articulated into the opera-tion of social power, with the aim of illuminating power inequalities and giving voice to subjugated knowledge(s).

Geneviève Rail, PhD, is Principal of the Simone de Beauvoir Institute at Concordia University. Well known as a feminist critic of body-related institutions (e.g. health industries and systems, so called ‘Evidence-Based’ Medicine, media, sport), she favors feminist poststructuralist, postcolo-nial and queer approaches. Geneviève is currently working on a series of CIHR- and SSHRC-funded research projects involving women from varying sexuality, race, ethnicity, dis/ability, and socio-economic milieus. She is particularly interested in the articulation of these women’s identi-fications with the discursive constructions and embodied experiences of the body, health, and health care.