The American College of Obstetricians and Gynecologists (ACOG) noted that the dramatic increase in obesity in the United States in the later part of the 20th century is reflected among childbearing women.1 The National Health and Nutrition Examination Survey of obesity among adults, conducted in 2011 to 2012, found that 36.1% of adult women were obese; among African American women, the figure reached 56.6%, and among Hispanic women, it was 44.4%.2 Those alarming statistics not only have important clinical significance but also reflect social, political, and ecological trends that provide the context to and contribute as risk factors to poor pregnancy outcomes.
In this chapter, I use two social science conceptual paradigms to understand obesity in pregnancy: social determinants and stigma. The chapter reviews published studies, national-level data, as well as studies and data from Syracuse, New York, conducted by my colleagues and me.
SOCIAL DETERMINANTS OF OBESITY AMONG PREGNANT WOMEN
The most useful definition of social determinants of health is that of the World Health Organization: “the causes of the causes.”3 Social determinants, in this model, are political, societal, and ecological risk factors that increase the likelihood of disease. They can be distinguished from clinical causes of ill health, in that clinical causes address immediate biological etiologies, whereas social determinants address a broader context of risk that takes place at an earlier phase in the condition. In the case of obesity, for example, the Centers for Disease Control and Prevention succinctly stated the clinical etiologies as “eating too many calories and not getting enough physical activity.”4 The social determinants approach, looking at the broader context in which obesity occurs, takes into account the factors that lead to poor diet or inadequate exercise or even altered metabolism. Understanding those social factors helps to explain why disadvantaged populations experience greater obesity and with it obesity-related health conditions.
A growing literature considers the influence of food deserts on health and obesity. Food deserts are geographical areas with few or no retail sources of fresh produce, low-fat dairy, or other healthful food.5 In many US cities, urban renewal led to the displacement of low-income residents, movement of wealthier people to the suburbs, and closing of neighborhood food markets. What food outlets remain in many communities are corner stores mostly selling lottery tickets, cigarettes, and malt liquor, as well as fast food franchises.6
In Syracuse, New York, our research team found food deserts to be significantly associated with intrauterine growth restriction (IUGR).7 Women residing during pregnancy in census tracts without access to full-service grocery markets had nearly four times the rate of IUGR, compared with those living in areas with greater access to healthy food and controlling for both race and Medicaid insurance as a proxy for poverty. In a subsequent analysis, which included all Syracuse births for a 2.25-year period among woman ...