“Trust yourself and your body”: advice from fat individuals on how to navigate fat fertility, pregnancy, and birth

ABSTRACT Weight stigma contributes to healthcare-related stress and can make pregnancy difficult for people in larger bodies who are frequently denied reproductive healthcare treatment or receive poor quality care. Support from similar others – those who have experienced the same stressor – is particularly useful for navigating these challenges. Our goal in this study was to solicit advice from fat individuals who have tried to conceive, been pregnant, or had a baby. Survey responses from 150 people included 225 units of advice. We used content analysis to code the advice into 10 types that fell under three main categories: intrapersonal advice, communication advice, and social support advice. The two most prevalent pieces of advice were to trust yourself and your body (n = 57) and find an inclusive provider (n = 56). Based on our results, we suggest finding fat-affirming and inclusive providers, seeking nourishment rather than a restrictive diet, engaging in joyful movement, and connecting with a community of other fat individuals.

Weight bias is well-documented in reproductive healthcare, with individuals experiencing discrimination, poor treatment, and adverse health outcomes while trying to conceive, during pregnancy, and postpartum (e.g., Basinger, Quinlan, and Rawlings 2022;Ward and McPhail 2019).Shame governs the fat pregnancy experience, constantly reminding parents-to-be of the ways they are failing their child and setting them up for a lifetime of poor health (Parker and Pausé 2019).Ultimately, weight stigma and body-related shame culminate in healthcare stress and avoidance of healthcare services, and pregnant people do not get the prenatal care they need (Mensinger, Tylka, and Calamari 2018).On top of avoiding needed care, people who are shamed for their bodies during pregnancy may engage in destructive weight management behaviors like dieting or over-exercise, over-test themselves for conditions like gestational diabetes or high blood pressure, or try to compensate for their bodies by avoiding actions they perceive as risky, like accepting pain medication during described feeling "not quite human" because of their poor treatment (Lindhardt et al. 2013, 142).The dehumanizing of fat individuals also shows up in the highly medicalized nature of their pregnancies as they are subjected to extra labs and sonograms, tests of the fetus, dietary counseling, and monitoring (McPhail et al. 2016;Parker 2017).At worst, participants report feeling bullied by their providers (Parker 2017), with one provider even telling a participant, "I hope you don't break [the scale]" (DeJoy, Bittner, and Mandel 2016, 221).
Poor treatment of fat people before, during, and after pregnancy is not isolated to healthcare providers but extends to friends, family members, and even strangers.For example, in one study, participants reported messages they received about their pregnancies from providers, romantic partners, family members, coworkers, and others.Most (77%) of those messages were negatively valenced (Basinger, Quinlan, and Rawlings 2022).Another study documented 12 sources of stigmatizing messages about weight, with healthcare providers, media, and society at large being the most frequently-cited sources of stigma for people in larger bodies (Rodriguez, Schetter, and Tomiyama 2020).As an example of the latter, fat individuals feel social pressure to conform to "good mothering practices" like exercise and lack of weight gain during pregnancy (Cook and Wilson 2019;Ward and McPhail 2019), lest they be blamed for any poor health outcomes in their children (Parker 2014).Fat pregnant bodies are rarely represented in the media, and messages to "lose the baby weight" are common (Cook and Wilson 2019;Rodriguez and Nagpal 2021).Taken together, this body of work suggests that fat people face a host of negative messages and experiences across the pregnancy trajectory.

Advice from similar others as a resource for navigating fat pregnancy
Given the challenges accompanying fat fertility, pregnancy, and birth, social support is an essential resource for people as they manage stigmatizing, sometimes even cruel, interactions with providers, family, friends, and strangers.In general, social support is intended to alleviate the impact of stress, providing a buffer against negative psychological and physical outcomes (Hatteberg 2021).Overwhelmingly, research suggests that people prefer to receive support from similar others, or people who have experienced the same circumstances as the stressed person (Thoits 2021).Many people prefer support from similar others even over that from significant others (e.g., partners, family members), so much so that about half of the time, people approach similar others rather than close others for support (Small 2013;Thoits 2021).Advice is a beneficial type of support because it offers distressed individuals suggestions as they prepare for difficult interactions.Adviser characteristics, including similarity to the advice receiver, are critical in determining whether the advice is persuasive or credible (Faraji-Rad, Samuelsen, and Warlop 2015;Hatteberg 2021).Scholars have proposed various explanations for why this may be true, including (a) we perceive that similar others have similar preferences for managing stress, (b) we are motivated to connect with people that we like, and we like people who are similar to us, and (c) similarity is familiar and gives us a sense of certainty (Faraji-Rad, Samuelsen, and Warlop 2015).Thus, individuals will likely trust advice from similar others.
Theoretical work also supports the notion that similarity is a valuable social resource.Social comparison theory, for example, suggests that when we want to know how we are doing in the face of stress, similar others provide the most relevant information about coping (Festinger 1954).Within the context of social comparison, people form common bonds to share experiences and find out what they have in common, which helps reduce feelings of uniqueness and therefore addresses distress.Similarly, the stress buffering hypothesis (Cohen and McKay 1984) argues that support helps people most when it directly meets their needs (e.g., damage to self-concept requires esteem support).Optimal matching may also mean that support comes from the ideal person, and "similarly-experienced individuals would be more likely to understand the individual's concerns, emotional reactions, and nuances of the situation" (Thoits 2021, 647).Nearly 75% of participants in one study rated having "been through it" or "knowing what they're going through" as the most important aspects of support because those traits offered a foundation for empathy (Thoits 2021, 656).
Because similar others offer persuasive, empathetic, and credible support, our study nominates fat individuals who have tried to conceive, been pregnant, had a baby, or experienced infertility as local experts on managing the unique challenges of this context.In service of our goal of offering advice for managing fat fertility, pregnancy, and postpartum experiences, we asked people with lived experience what advice they would give to someone else in similar circumstances.The following research question guided our investigation: RQ: What advice do fat individuals have for navigating pregnancy, birth, postpartum, and fertility experiences in a fat body?

Method
We collected online survey data from 259 people across the pregnancy experience to answer our research question.We received institutional review board approval from the corresponding university (Protocol #21-0107).To be included in the study, participants had to identify as "plus size," be between the ages of 18-50, and have had one or more of the following experiences: tried to conceive, experienced infertility, been pregnant, had a baby, or lost a baby or pregnancy.Ten people who began the survey did not meet these criteria and were directed to the end of the survey, leaving 249 people in the sample for analysis.For this study, we analyzed data from one open-ended question: "What advice would you give to someone else in a plus size body who is navigating the process of trying to conceive, pregnancy, postpartum, or experiencing infertility?"Our final sample consisted of responses from the 150 participants who responded to this question (60.2% of the total sample).
To collect the data, we advertised the study online via social media (e.g., parenting groups, body positive or fat-inclusive groups) and listserv e-mails (e.g., to academic organizations).People who met the inclusion criteria were invited to click the link to a survey hosted by Qualtrics, where they answered demographic questions and provided information about their pregnancy experiences.Then, they described messages they received before, during, and after their pregnancies; these data are published elsewhere (see Anonymized for Blind Review).Finally, they responded to the question about advice for others.

Data analysis
We used content analysis to analyze participants' responses (Neuendorf 2002).Data analysis unfolded in six steps.To begin, all authors read through participants' responses multiple times to familiarize themselves with the data.Second, the first and third authors completed open coding, in which they labeled each person's response with a word or phrase that captured the meaning of that portion of the data.They used constant comparison during this phase, adding new categories as they came across unique ideas until all data were labeled.Third, all three authors met to compare the open coding efforts and finalize a list of categories.This effort resulted in the identification of 10 categories.The first author then constructed a codebook containing each category's label, definition, and examples.
Fourth, the first author divided the data into codable units.This step was necessary because some responses contained multiple distinct pieces of advice.The number of pieces of advice in the responses ranged from one to five (M = 1.50, Mdn = 1), for a total of 225 units.We used these units for the remainder of our analyses.In the fifth step, the first and third authors applied the codebook to the unitized data.They began by coding the first 57 units (25.3% of the data) and then confirmed that their coding was consistent by calculating Krippendorf's (2004) alpha.Scholars recommend Krippendorff's alpha because of its (a) ability to handle both agreement and disagreement between coders, (b) usefulness with multiple coders, (c) flexibility for use with different types of data, especially nominal data, and (d) capacity to handle many categories (Kerr and Reulke 2015;Shabankhani et al. 2020;Zapf et al. 2016).Coding was reliable (α = .85),and we resolved coding disagreements via discussion among all three authors.Then, the same two authors coded the remainder of the data.The final step in data analysis involved theoretical sorting, in which we identified connections across categories and reassembled the data to best represent the story of the data, which we present in the following section.

Results
Participants offered 10 categories of advice about navigating the process of trying to conceive, pregnancy, and postpartum.Four categories centered on the self, two focused on communication, and three referenced the importance of social support.One category, not included below, consisted of only two responses in which participants were unsure what advice to offer.We describe each category of advice below and offer exemplar quotes in Tables 1-3.All remaining quotes are provided in available at supplemental file (https://doi.org/10.1080/21604851.2023.2248364).

Intrapersonal advice
Intrapersonal advice was self-focused and encouraged practices one can engage in alone in preparation for the challenges accompanying fertility, pregnancy, birth, and postpartum for fat individuals (see Table 1).Four themes were represented: (a) trust your body, (b) focus on health, not weight, (c) do your own research, and (d) lose weight.Advice to trust yourself and your body (n = 57 units) was the most common, representing more than 25% of responses.This category included statements about larger bodies being strong, beautiful, and capable of having a healthy pregnancy.They also noted that people should trust their intuition about their pregnancy experiences since they are experts on their own bodies.Participants explicitly recommended enjoying pregnancy and embracing the fat, pregnant body and said that all bodies deserve love and care, regardless of size.Finally, participants noted that it is not the fat person's fault if they have negative interactions with providers or if they struggle with infertility or lose a pregnancy, something for which fat people frequently take the blame.
Second, individuals offered advice to focus on your health, not your weight (n = 24 units).They recognized that treating the body well before, during, and after pregnancy is essential.However, they also said that focusing on health does not need to include intentional weight loss -or attention to weight at all.For example, several participants mentioned the importance of eating nutrient-dense foods or moving their bodies for exercise, though their goal in doing those activities was not to alter their bodies.For several people, attending to their health meant seeking mental health support from a therapist or other professional.
Third, advice to do your own research (n = 15 units) emphasized the importance of being armed with accurate information.Participants noted the prevalence of incorrect or biased information about fat pregnancy available online or from well-intended family members, friends, and healthcare providers.Thus, they suggested seeking up-to-date, sound information about navigating pregnancy in a large body.Many participants specifically named Health At Every Size® as a valuable resource.Finally, a small minority of participants (n = 3 units) suggested weight loss during or in preparation for pregnancy.Given empirical research that indicates the harms (or, at the very least, the lack of  1.We recognize that this choice censors the responses of the three participants who recommended weight loss.Though we honor their participation in our study, our stance is that it would be irresponsible for us to publish advice that is harmful to readers' mental, physical, or reproductive health (Boyle et al. 2023;Parker andPausé 2018, 2019;Shaw and Fehoko 2023).Instead, we prioritize the ethics of offering advice that is grounded in lived experience and consistent with best practices from a weight-inclusive perspective (Tylka et al. 2014).

Communication advice
Two categories of advice focused on communicating effectively with others before, during, and after pregnancy (Table 2).First, advice to ignore negative feedback (n = 22 units) suggested that healthcare providers, family members, friends, coworkers, and strangers will make negative comments throughout pregnancy.Participants emphasized how important it is to be prepared for this inevitability.Specifically, this advice said that negativity about bodies, weight, and health is ultimately unhelpful and should be disregarded.A few people specifically talked about the importance of expecting poor treatment and hurtful comments because knowing it is coming can help develop a "thick skin" and prevent feeling caught off guard.Second, participants stressed the importance of fat people advocating for themselves (n = 17 units).Here, advice centered on speaking up during doctor's appointments or with friends and family, asking for what they needed, and advocating for competent, compassionate care.Participants were adamant that everyone deserves to be treated well across the pregnancy trajectory.For fat individuals, that may require asking questions of providers or standing up for themselves, even when it feels uncomfortable.

Social support advice
The last three categories of advice affirmed how vital support is in this context (Table 3).The second most common piece of advice in the data was to find an inclusive provider (n = 56 units).The difference between supportive healthcare providers and providers who shamed or discriminated against fat people seemed palpable.Hence, participants underscored the importance of seeking out an inclusive practice.Some called out discriminatory practices like excluding fat patients from accessing infertility care or not having equipment that fit larger bodies and noted how important it was to avoid such facilities.Several participants discussed the freedom to change doctors when the experience is not positive.
Second, participants offered advice to seek support from close others (n = 15 units).Participants spoke about the importance of getting emotional support Even if the circle is small, the positivity will keep you uplifted."Find an online community "Follow 'body positive' pregnant people on social media, read their books.""Surround yourself with people/social media accounts/podcasts that will counteract the fatphobic messages of our society and culture.Curate your Instagram feed to show you pregnant bodies like yours.""Read the positive messaging on the Plus Size Pregnancy blog.Find community with women who have been through the issues related to birth and bigger bodies.""Talk to other women who were plus-sized when they were at this point in their lives.
There are wonderful social media accounts that share information, provide hope, and serve as a place to vent." "Check out Plus Size Birth" directly from the people they could access face-to-face, including romantic partners, family members, and friends.Although participants talked about how important advocating for themselves is, in this category they also discussed how helpful it could be to have a trusted family member or friend to advocate for them, especially during appointments with healthcare providers.Finally, participants talked about how useful it can be to find an online community (n = 14 units).The fat pregnancy experience can be stigmatizing and isolating, but our participants found connection and comfort in people with similar experiences online.Some online support took the form of social media accounts for influencers and researchers, and participants named a few specific accounts that were helpful to them (e.g., Plus Size Birth, Plus Mommy).This category also included suggestions to join online groups to talk to other people in larger bodies who had experienced infertility, pregnancy, or birth and who could provide inspiration, community, or support by discussing their experiences or providing advice.

Discussion
The goal of our study was to offer practical advice for fat individuals navigating the process of trying to conceive, pregnancy, birth, and postpartum.Because the people in our study have had these experiences, they are uniquely poised to offer persuasive and empathetic suggestions to others, and theoretical work suggests that their similarity gives them particular credibility (Faraji-Rad, Samuelsen, and Warlop 2015;Hatteberg 2021;Thoits 2021).Our analyses revealed 10 distinct categories of advice, organized by their relevance to the self (intrapersonal advice), their focus on messages (communication advice), and their emphasis on the role of others (social support advice).

Evaluating the advice
Generally, advice is a type of persuasive message that advocates for individual action (Cody, Canary, and Smith 1994;Wilson, Aleman, and Leatham 1998).Frameworks like advice communication theory explain why people offer advice and how advice can be effectively communicated, arguing that advice-seeking and advice-giving behaviors are influenced by factors like the nature of the problem, the relationship, the advice itself, and the communication context (e.g., MacGeorge et al. 2004;MacGeorge, Feng, and Thompson 2008).For example, the more expertise the advice giver has in a specific situation, the more persuasive the advice is, and message characteristics like usefulness and feasibility influence the persuasiveness of a message (Feng andMacGeorge 2006, 2010;Goldsmith and MacGeorge 2000;MacGeorge et al. 2004;MacGeorge, Feng, and Thompson 2008).Other factors that are less applicable to our study are how close of a relationship the advice giver and receiver have and the ability of the advice giver to dictate the behavior of the advice receiver.Advice communication theory also suggests that the effectiveness of advice can be influenced by the degree to which it enhances the recipient's perceived control over the situation.In other words, advice is more likely to be effective if it helps the recipient feel they have the knowledge, skills and resources to take action and possibly solve the issue.
Though it is tempting for us to attempt to evaluate the advice our participants provided, there are no universally accepted metrics for which pieces of advice are easy or efficient to implement, as this can differ between individuals.In fact, advice communication relies on situational, cultural, and personal interpretation factors that are widely varied (Goldsmith and Fitch 1997).We sought a specific type of participant and asked a direct, open-ended question about advice, thereby reducing many factors that impact the quality of advice, including evaluations of the relationship, the situation, and the need to perceive the advice giver as either being caring versus "butting in" (Goldsmith and Fitch 1997).Nevertheless, the body of work on advice communication does not account for other factors that may be at play, including the possible mediating role of internalized stigma/fatphobia or intragroup anti-fat stigma on the impact of advice.Because fatness is moralized, especially in the context of pregnancy (Parker 2014;Parker andPausé 2018, 2019), it is possible that advice to "love yourself" or "ignore negative feedback" is too challenging for those who have deeply internalized anti-fat messages (Puhl et al. 2021;Puhl, Himmelstein, and Quinn 2018;Ratcliffe and Ellison 2015).Thus, evaluating advice objectively is a challenging task.
Instead, we suggest that our readers evaluate our participants' advice in terms of its applicability to their goals.Advice communication is a form of social support, and social support quality is defined as "the extent to which an utterance is adaptive to multiple desired outcomes" (Goldsmith and Fitch 1997, 455).Ultimately, the reader will need to define the desired outcome for themselves and evaluate from that standpoint whether advice like "find which OBGYNs in your area are rated the highest in HAES support" or "trust that you can make the right decisions for your own body, even if your doctor disagrees" is more aligned with their personal goals.

Theoretical and practical implications
Generally, the theories we have highlighted in this study (e.g., social comparison theory, social support frameworks, stress buffering hypothesis, advice communication theory) discuss how people evaluate communication in their interactions, specifically highlighting cognitive and interpersonal factors that influence appraisals.Though this is a valuable endeavor, our study highlights how those theories overlook or underestimate the role of structural or systemic barriers that impact the effectiveness of support.People from marginalized social identity groups -including people in larger bodies -may face stigma or discrimination while trying to access advice or care.For example, fat people are frequently denied access to fertility treatment based on their body size, so they are unable to even solicit advice related to their infertility (Basinger, Quinlan, and Rawlings 2022).Thus, interpersonal advice to "advocate for yourself in your appointments" or to "do your own research to prepare for interactions with providers" is ineffective for those who are not granted access to healthcare in the first place.We suggest an ecological approach to explaining social support processes that pays attention to the broader social, cultural, and political factors that shape communication.
In addition, most theories of support or advice focus on the advice people give and receive rather than the advice they wish they had received.Many participants in our study reflected on messages that would have helped them had they heard them earlier in their own journeys.We see this line of inquiry as an extension of research on counterfactual thinking, which is the cognitive process of imagining alternatives to past events or actions (Epstude and Roese 2008;Roese and Epstude 2017).Applied to the context of advice, researchers could investigate counterfactual advice, or advice that people believe would have been helpful or effective, highlighting missed opportunities or alternative paths that were not considered at the time of the decision.
We offer several practical recommendations to people navigating the fat pregnancy experience.However, we add a caveat that recommendations should always be tailored to specific needs and circumstances because everyone's experience with fertility, pregnancy, and postpartum is unique.First, we suggest seeking fat-affirming, compassionate, evidence-based healthcare whenever it is available, though we note that geographical areas that are less densely populated are less likely to have access to inclusive care providers.Second, we advocate for people to nourish themselves sustainably rather than restrictively.We nominate intuitive eating (Tribole and Resch 2020) as an approach emphasizing body respect and fat inclusivity.Third, we note the importance of joyful movement rather than rigid exercise goals; this could involve activities like prenatal yoga, swimming, gardening, walking, and playing with children, modifying movement and taking breaks whenever the body needs them.Fourth, connecting with a community of fat individuals online or in-person is healing and health-promoting for many people because it offers space for connection, shared experiences, and validation to combat the isolation often triggered by the stigma that pervades the fat pregnant experience.Finally, we emphasize that self-care and self-compassion are ways of prioritizing mental health and well-being, which is particularly important as individuals navigate significant physical, emotional, and social changes.

Table 1 .
Intrapersonal Advice Quotes.That your body is just as amazing and capable as all other mom's.And you may not experience some of the same things (people may not realize your pregnant, your bump may take longer to show than others, etc.), but this experience is yours and don't let comparing to others steal your joy." "Take selfies that show you how beautiful you are, and don't be ashamed of wanting that validation.""That plus sized bodies are capable of growing and delivering healthy children.""Trust yourself, trust your body, and know that it's not nearly as unusual as the medical professionals like to make it out for fat women to successfully conceive and give birth.""Listen to your gut.If it feels wrong, get a second opinion."Focus on your health, not your weight "Do the best you can to maintain a healthy lifestyle, which includes supporting your mental health.""Do what makes you happy.Focus on staying healthy regardless of what the scale says or the size clothes you are wearing.Babies do not carry if their mother has extra rolls.""Health is not equivalent to weight and weight is not always an indicator of health.""Look holistically at your situation -managing my stress levels made a huge positive impact on every area of my health and this was barely discussed by my first RE, but a focus of the second.""To not spend time trying to lose weight when you could be moving forward with trying to conceive."Do your own research "Find respectful sources of information that are not fat phobic and do not buy into BMI.The process of trying to conceive and pregnancy (and I'm sure the others) are already full of worries, why add more worry?" (Benito et al. 2020;Boyle et al. 2023)s.""Askwhy!Hospitals have blanket rules about overweight = high risk, regardless of how healthy you actually are.This can limit lots of birthing opportunities etc." "Do your research!Evidence based birth.""Ask a lot of questions.Find good healthcare and a moms [group] that will help you think about questions and things you might be experiencing."benefits) of this practice(Benito et al. 2020;Boyle et al. 2023), we do not include this advice in Table

Table 2 .
Communication Advice Quotes.let them know that they're bound to face challenges because society deems our body size as unacceptable, unhealthy, and unattractive.There will be people who compliment you when you lose weight, and people who shame you when you gain.There's no winning, but to remember that their opinions belong to them.""To not listen to the advice in books about losing weight before even trying to get Don't be scared to make your boundaries known and stick to them.You don't owe someone a compromise to your mental health, even if they're your family, your partner, or your doctor.You don't owe anyone weight loss, a gain-free pregnancy, or perfect health.Your responsibility is to yourself and your baby.""Stand up for yourself.If they shame you, walk out and report them.I wish I had." "You know your body best, don't let anyone dismiss your concerns due to their issues with your body.""Also, advocate for yourself.Don't allow for anyone to reduce your experience to your body size/shape.Demand the best care and push for what you know you and your body needs.""Be honest with yourself and your medical providers about your concerns."

Table 3 .
Social support advice exemplar Quotes.Seek out doctors and other healthcare providers that don't have a strong anti-fat bias.It makes a huge difference.""Find a health at every size provider.""On the infertility front, make sure your clinic has no weight requirement UP FRONT.""Find healthcare providers who see you as human not as a walking risk.Be clear about your needs and boundaries.Don't let their fatphobia get you down, be vocal.""Find supportive doctors.Get an understanding doula."Seek support from close others "Tell your partner if/when you need validation, and trust them when they give it to you." "Have a friend or partner available to help advocate for you when you are at your most vulnerable, since you will have to work with medical providers at the hospital who may not be personally vetted by you in advance.""Surround yourself with people that are supportive.""Reach out to others when experiencing stress or anxiety.""Surround yourself with those that are cheering for you throughout your process.