Introduction

In recent years, abnormal body mass among women of reproductive age has become a serious public health concern. According to data from the World Health Organization (WHO), alongside the rising prevalence of obesity in the general population, the number of women of reproductive age (15-44 years) living with obesity has increased to 100 million [1]. In Poland, the percentage of women with obesity in the periconceptional period significantly increased between 2009 and 2019, for example, by 53% in the 15-19 age group [2, 3]. Obesity in pregnant women is diagnosed when the pre-pregnancy body mass index (BMI) is ≥ 30 kg/m², and depending on its value, three classes of obesity are distinguished (Class I: 30-34.9, Class II: 35-39.9, Class III: ≥ 40 kg/m²) according to the WHO classification [1].

Abnormal body mass in women of reproductive age, primarily overweight and obesity, constitutes a significant and multifaceted challenge for modern obstetrics. Due to its prevalence, this problem significantly complicates pregnancy management, childbirth and the postpartum period, often hindering the implementation of birth plans and adversely affecting the health of both the mother and the child. This challenge encompasses not only clinical and organizational dimensions, such as the need for healthcare facilities to be equipped with specialized devices such as reinforced wheelchairs and operating tables adapted for higher body weight, but also a psychological one. The latter manifests in stigmatization, lowered self-esteem among patients and associated feelings of shame. This can hinder the building of a trust-based relationship with medical staff and may result in avoiding or delaying necessary consultations [4, 5].

From a physical health perspective, women with obesity experience difficulties conceiving and are exposed to numerous complications during pregnancy. The catalog of complications is extensive, affecting the mother, fetus and the course of delivery itself. On the maternal side, there is an increased risk of recurrent miscarriages, hypertension and its most severe form – preeclampsia, hyperglycemia, as well as gestational diabetes, venous thromboembolic disease, and urinary tract infections. For the fetus and newborn, the consequences include congenital malformations, growth disorders, both impaired growth (fetal growth restriction – FGR) and excessive body mass (large for gestational age – LGA, macrosomia), as well as intrauterine fetal demise. The perinatal period is associated with an accumulation of adverse events, including instrumental deliveries (vacuum or forceps), failure of labor progression, shoulder dystocia, massive hemorrhages, as well as anesthesiological and infectious complications, including difficulties in wound healing following both episiotomy and cesarean section [2, 4-12].

The challenges do not end with childbirth. Women with obesity more frequently experience problems with the initiation and maintenance of lactation, including later initiation of breastfeeding and a shorter total duration of breastfeeding [13, 14]. In Danish studies, it has been confirmed that higher BMI values correlate with earlier cessation of breastfeeding. Furthermore, the postpartum period carries a higher risk of postpartum depression [15].

In response to these complex challenges, the Polish Society of Gynecologists and Obstetricians (PTGiP) has developed detailed recommendations. They provide a comprehensive guide for management across all stages of care. In the pre-conception period, the promotion of weight reduction and folic acid supplementation at a dose of 800 µg is recommended. Particular attention is paid to vitamin D, the deficiency of which is frequently observed in individuals with obesity, partly due to its sequestration in adipose tissue. Vitamin D plays an important role in the functioning of the skeletal and immune systems as well as in metabolic processes, and an adequate level may also be important for reproductive health. Therefore, many recommendations emphasize the need for vitamin D supplementation in women of reproductive age, especially in groups at increased risk of deficiency. In pregnant women, the standard supplementation dose is 1500-2000 IU per day; however, in patients with obesity it is recommended to increase the dose up to 4000 IU per day, which results from the reduced bioavailability of vitamin D associated with its storage in adipose tissue [16]. During pregnancy, the recommendations include implementing thromboprophylaxis for women with higher classes of obesity, intensive monitoring of blood pressure and glucose metabolism, and performing at least four ultrasound scans while informing the patient of the technical limitations of diagnostic imaging. At the delivery stage, active management of the third stage of labor, antibiotic prophylaxis in the case of cesarean section, as well as the use of special techniques for suturing the skin and subcutaneous tissue are essential. In the postpartum period, the guidelines recommend continuing thromboprophylaxis, ensuring obligatory lactation support and active screening for mood disorders [2].

Despite the well-documented risks, a low level of awareness among women regarding the consequences of obesity in the perinatal period may significantly limit their motivation for weight control and participation in preventive measures. While health education delivered by professionals appears crucial, its effectiveness may be limited without understanding the differences in risk perception between patients and medical staff. This study fills this gap by conducting a comparative analysis concerning the perception of challenges related to obesity in obstetric care.

The primary aim of this study was to assess the perception of risk associated with obesity in the context of obstetric care and its relationship with the level of self-esteem among women of reproductive age. An additional objective was to identify the challenges and key competency areas for the obstetric team in caring for patients with obesity.

Material and methods

Study design

A cross-sectional observational study was conducted between March and June 2025, in accordance with the STROBE guidelines. A non-probability convenience sampling method with voluntary response was used. The online survey was administered to self-selected women of reproductive age recruited via Facebook groups dedicated to pregnancy and childbirth: “Gdzie rodzić na Pomorzu?” (“Where to give birth in Pomerania?”), “Rodzę na Polnej” (“Giving birth at Polna”), and “Położne” (“Midwives”). Before distribution, a post requesting completion of the questionnaire was submitted to the administrators of each group, and their approval was obtained, which constituted consent to publish the survey link. Healthcare professionals were recruited using a snowball sampling method. The survey link was initially shared within the professional networks of the research team, and medical professionals were encouraged to forward the link to their colleagues. This approach allowed the questionnaire to reach a broader community of obstetricians, midwives, anesthesiologists, and other perinatal care providers.

The study tested three main hypotheses: 1) the existence of a relationship between body mass and women’s perception of various aspects of childbirth, 2) the association between body mass and women’s level of self-esteem, and 3) the presence of a relationship between patients’ body mass and healthcare professionals’ perception of clinical challenges.

Inclusion and exclusion criteria

The inclusion criteria for women of reproductive age were: age 18-45 years, residence in Poland, and provision of informed consent to participate in the study. No restrictions regarding body mass index or obstetric history were applied, allowing for broad representation of this population. Exclusion criteria for this group were: the presence of pregnancy complications requiring hospitalization at the time of the survey, diagnosed psychiatric disorders, and incomplete questionnaires. These criteria were applied to ensure that participants could meaningfully engage with the survey content and to minimize confounding factors related to acute medical or psychological conditions. For healthcare providers, inclusion criteria consisted of current employment in obstetric or perinatal care. Individuals without current clinical practice and those who submitted incomplete questionnaires were excluded. After applying all criteria and removing incomplete responses, the final study sample comprised 200 women and 200 healthcare providers.

Data collection tools

For this study, an original questionnaire was developed based on a review of the literature on obstetric risk associated with obesity and perinatal care standards. The questionnaire was developed based on a review of the literature and finalized through an expert consensus process involving a team of obstetric care specialists to ensure content validity. It consisted of closed-ended questions assessing knowledge and perception of obesity-related risk during pregnancy, childbirth, and the postpartum period. In the absence of a validated knowledge scale, the term ‘low awareness’ was used descriptively, based on a post-hoc observation that the proportion of affirmative responses for the majority of knowledge-based questions remained consistently low (ranging from 20% to 40%) across all BMI categories, with no significant differences between groups. The version intended for medical staff focused on perceived clinical challenges, monitoring methods, and organizational needs related to the care of women with obesity.

Each question addressed a distinct aspect of risk perception and was analyzed individually; therefore, internal consistency reliability (e.g., Cronbach’s ) could not be computed, as the items were not designed to form a unidimensional scale. The only exception was the Rosenberg Self-Esteem Scale (SES), a standardized instrument with well-established psychometric properties.

An online survey with required response fields, designed to ensure data completeness, was administered to women of reproductive age and medical staff recruited through medical groups and social media platforms. For women, it included sociodemographic questions, queries on risk perception, and the Polish adaptation of the Rosenberg Self-Esteem Scale (Cronbach’s  0.77-0.88). The Rosenberg Self-Esteem Scale consists of 10 items rated on a 4-point Likert scale. Five items are reverse-scored. The total score ranges from 10 to 40, with higher scores indicating greater self-esteem [17]. The staff questionnaire focused on assessing clinical challenges and methods for monitoring patients with obesity. The study was conducted in accordance with the principles of the 1964 Declaration of Helsinki, having received a positive opinion from the Bioethics Committee for Scientific Research at the Medical University of Gdańsk (No. KB/81/2025).

Statistical analysis

The results were analyzed using Statistica 13.3 software. A significance level of  = 0.05 was set for all analyses. In response to the research questions, frequency analysis and the chi-square (²) test were used to assess qualitative data. Analysis of differences in quantitative measurements was performed via analysis of variance (ANOVA), supported by the partial eta-squared (²p) effect size. The proportion of missing data was negligible in both the patient (0%) and medical professional (3.47%) studies. Observations containing missing values were retained in the dataset and were not excluded or imputed, except in cases of completely blank questionnaires, which were removed prior to analysis. The presence of missing data was documented and considered during the interpretation of the results.

Scope of analysis

The study analyzed a range of parameters related to the perception of obesity-related risk in perinatal care, examined separately for women of reproductive age and healthcare staff.

Among women of reproductive age, the analyses focused on three main areas. First, organizational aspects of childbirth were assessed, including the perceived necessity of delivery in a higher-reference-level hospital, opinions on the specifics of labor management in women with obesity, and awareness of potential limitations in adopting vertical positions during labor. Second, the perception of clinical risks associated with maternal obesity was evaluated, covering contraindications to epidural anesthesia, the likelihood of cesarean section delivery, difficulties in fetal heart rate monitoring, the risk of shoulder dystocia, the need for instrumental delivery, and the risk of failure of labor progression. Third, postpartum challenges were examined, including the perceived impact of maternal obesity on the child’s birth weight, the risk of postpartum hemorrhage, susceptibility of the birth canal to tissue damage, and prolonged wound healing. Additionally, women’s self-esteem was assessed using the SES to examine its potential association with body mass and risk perception.

In the healthcare staff group, the analyses covered two main dimensions. The first concerned the perception of clinical challenges in caring for women with obesity, including more difficult labor management, increased risk of cesarean section, higher risk of perineal tears, and complications in wound healing following both episiotomy/perineal tear and cesarean section. The second dimension explored the preferred methods for monitoring fetal well-being in women with obesity during labor.

Characteristics of the study groups

Among women of reproductive age (N = 200), age distribution was relatively even, with the highest proportion aged > 40 years (27%). Most had secondary or higher education (37%), and urban and rural residents were similarly represented. In the healthcare staff group (N = 200), midwives (52.5%) and obstetrician-gynecologists (16%) were the most common professions. Staff were predominantly under 30 years of age (67%) and had 1-10 years of professional experience (65.5%). Detailed characteristics are presented in Table 1.

Results

Perception of childbirth challenges among women and their body mass index

The analysis did not show statistically significant relationships between women’s body mass and their perception of key aspects of childbirth. Regardless of BMI values, women rated aspects such as the necessity of delivery in a higher-reference-level hospital, specifics of labor management, potential limitations in adopting vertical positions, contraindications for epidural anesthesia, risk of cesarean section, difficulties in monitoring fetal heart rate, and the risk of instrumental delivery similarly (for all analyzed variables p > 0.05). The percentages of affirmative responses across all weight groups remained low, generally within the 20-40% range, indicating a limited awareness of risk in the studied female population of reproductive age. The only exception concerned the perception of risk for shoulder dystocia during labor. Respondents were asked to indicate whether this intrapartum complication was more likely to occur in women with obesity, in women of normal weight, or whether they considered the risk to be unrelated to maternal weight. A statistically significant relationship was observed (²(4) = 14.45, p = 0.006). Women with obesity were considerably more likely to associate shoulder dystocia with maternal obesity (41.9%) than were women of normal weight (15.8%). In contrast, the view that the risk is unrelated to maternal weight was expressed by 35.2% of obese women and by the same proportion (15.8%) of those with normal weight, as detailed in Table 2.

Women’s perceptions of the impact of obesity on selected perinatal outcomes

The results indicated that the body weight of women of reproductive age did not significantly correlate with the assessment of how body weight affects the infant’s birth weight (²(4) = 8.43, p = 0.077, V = 0.15), the perceived higher risk of peripartum hemorrhage in obese women (²(4) = 5.10, p = 0.278, V = 0.11), the increased susceptibility of the tissues of the birth canal to damage in obese women (²(4) = 0.23, p = 0.994, V = 0.02), and the impact of body weight on prolonged wound healing in obese women (²(4) = 2.84, p = 0.585, V = 0.08). The responses from women in these areas were similar. Detailed results are presented in Supplementary Table 1 in the Supplementary Material.

Demographics and perinatal risk perception among women

Further analysis revealed that neither age nor education level significantly influenced women’s perception of perinatal risk associated with obesity. As presented in Supplementary Tables 2 and 3 (see Supplementary Material), no statistically significant differences were observed across any of the analyzed intrapartum complications or obstetric interventions (all p > 0.05), with effect sizes ranging from small to negligible (0.06-0.17).

Relationship between body mass and women’s self-esteem

Analysis of variance showed that women with normal body weight (M = 24.30, SD = 3.43), overweight (M = 25.08, SD = 3.52), and obese (M = 25.31, SD = 3.03) did not differ significantly in their self-esteem levels. The self-esteem levels were similar across the normal weight, overweight, and obesity groups, as shown in Table 3.

Perception of childbirth challenges according to medical staff

Medical staff consistently recognized challenges in caring for patients with obesity, demonstrating a clear trend in perceiving increased risks of complications. The analysis showed significantly more frequent signs of more difficult labor management, higher risk of cesarean section, perineal tears, and wound healing issues (all p < 0.001). Detailed results are provided in Table 4.

Work experience and perinatal risk perception among medical staff

Data obtained from healthcare providers were analyzed for associations with their professional experience. A statistically significant, though weak, correlation was found between experience and the perception of wound healing complications after episiotomy/perineal tear (p = 0.031, V = 0.16). As professional experience increased, the proportion of negative responses (“No”) regarding this complication rose, while affirmative responses (“Yes”) declined. No significant associations were observed between experience and the remaining perinatal risk areas, including difficult labor management, risk of cesarean section, perineal tears, or healing complications after cesarean section (all p > 0.05). Detailed results are provided in Table 5.

Methods for monitoring fetal well-being in women with obesity

The majority of the surveyed medical staff expressed the view that it is necessary to implement additional methods for monitoring fetal well-being in women with obesity. Among the most frequently proposed methods were modern telemetric systems and advanced ultrasound examinations, as well as a range of other specialized technological solutions. This question was conditional and was answered only by respondents who answered affirmatively to the preceding question (those who supported the implementation of additional monitoring methods); consequently, the number of responses shown in Figure 1 reflects only this subgroup.

Discussion

Maternal obesity constitutes a significant risk factor for complications during pregnancy, childbirth, and the postpartum period; therefore, appropriate planning and coordination of medical care are essential. During pregnancy, regular monitoring of blood pressure and glycemia is particularly important due to the increased risk of hypertensive disorders and gestational diabetes. Early diagnosis of carbohydrate metabolism disorders, including performing an oral glucose tolerance test (OGTT) already in the first trimester, enables the prompt identification of patients at risk of developing diabetes and allows for the implementation of appropriate management. Regarding peripartum planning, elective induction of labor may be considered after 39 weeks in women with obesity, while for BMI > 40 kg/m² induction is recommended; for BMI > 50 kg/m², induction between 38+0 and 39+0 weeks is recommended to reduce complications. The postpartum period requires special attention, particularly for venous thromboembolism prevention: early mobilization, compression therapy, and prophylactic low-molecular-weight heparin. For BMI > 40 kg/m², thromboprophylaxis may be needed throughout the postpartum period. Lactation support is important, as women with obesity more often experience breastfeeding difficulties. After caesarean section, specialized dressings (e.g., honeycomb dressings, negative‑pressure therapy such as PICO 7) are recommended to reduce wound healing complications. Antibiotic prophylaxis may need modification: for weight > 100-120 kg, 3 g of cefazolin 30-60 minutes before incision is often recommended instead of the standard 2 g. Current recommendations also support management according to the ERAS (Enhanced Recovery After Surgery) protocol and metabolic follow-up after the postpartum period, including an OGTT approximately six weeks after delivery in women with gestational carbohydrate metabolism disorders [18]. According to the recommendations of the Polish Society of Gynecologists and Obstetricians and the Royal College of Obstetricians and Gynaecologists, care for pregnant women with obesity should include close monitoring of metabolic parameters, appropriate planning of delivery, and thromboprophylaxis in the postpartum period [2, 13, 19-21].

The present study provides new insights into the challenges of managing labor in patients with obesity by examining the perspectives of both women of reproductive age and healthcare professionals. The key finding reveals a significant discrepancy in risk perception between these groups, independent of the women’s BMI. While the vast majority of professionals identified numerous obesity-related obstetric risks, consistent with the extensive literature [22-24], this awareness was not reflected in the perceptions of the study participants.

In clear contrast to healthcare professionals, women’s knowledge of these risks was limited and, crucially, showed no statistically significant association with BMI. This suggests a widespread, systemic lack of knowledge across the entire population of women of reproductive age, rather than only among women with obesity. This finding is consistent with the recent nationwide Polish study by Froń and Orczyk-Pawiłowicz, which demonstrated that over half of the surveyed women presented low levels of knowledge regarding obesity-related perinatal risks, with deficits particularly pronounced in the area of fetal complications and energy requirements across trimesters. Similarly to our results, those authors found no association between knowledge level and maternal BMI, confirming the population‑wide nature of the problem. Notably, despite more than 75% of women experiencing excessive gestational weight gain, more than half did not receive professional dietary counseling and instead relied on internet‑based information [25]. This “perception gap” highlights a key barrier to building trust and cooperation between patients and healthcare professionals [26-28] and reinforces the need for sensitive, non‑stigmatizing communication [29].

An important and unexpected finding of our study was the absence of a statistically significant association between BMI and self-esteem. This result, which contradicts common social stereotypes, indicates the complex and multidimensional nature of self-esteem in women. It suggests that psychosocial factors (e.g., quality of relationships, sense of competence, social support) may exert a stronger influence on self-esteem in this group than body weight alone. This finding should be interpreted with caution, as the SES measures global self-worth rather than body-specific satisfaction – meaning that women with obesity may have a lower body image but compensate in other domains – and selection bias cannot be ruled out, given that women with very low self-esteem might have been less willing to participate in a survey explicitly addressing body weight. Consequently, healthcare professionals should avoid making assumptions about patients’ self-esteem solely based on their appearance or body weight, which is essential for building an appropriate therapeutic relationship. Reduced self-esteem may lead to avoidance of contact with the healthcare system, delays in diagnosis or treatment, and lower effectiveness of weight-reduction therapy [30, 31].

In our study, the only statistically significant association in women’s responses concerned shoulder dystocia: women with obesity were more likely to attribute this complication to maternal weight (41.9%) than normal‑weight women (15.8%, p = 0.006). One possible explanation is salience – shoulder dystocia is a dramatic, acute obstetric emergency frequently described in birth stories and media. In contrast, complications such as wound healing difficulties or perineal tears, though more common, are less ‘newsworthy’. This suggests that women’s risk perception is shaped more by the vividness of a complication than by its actual probability, a phenomenon consistent with the availability heuristic [32, 33].

The awareness gap identified in our study represents only part of a broader systemic challenge. This issue also concerns healthcare professionals themselves, as confirmed by recent reports. In a study by Dzedzej et al., it was clearly demonstrated that the level of knowledge among Polish obstetrician-gynecologists regarding the management of pregnancy in patients after bariatric surgery is insufficient and requires urgent improvement [34]. This finding highlights the multi-level nature of the challenge: on the one hand, there is a need to educate patients about the basic risks associated with obesity; on the other hand, it is necessary to ensure that healthcare professionals have access to specialized knowledge in rapidly developing areas such as the care of patients after bariatric treatment. Furthermore, the low level of awareness of obstetric risk among women is not a function of low self-esteem but rather an educational and informational problem that equally affects both patients and the medical education system.

Practical implications

There is an urgent need to develop and implement comprehensive educational campaigns targeting all women of reproductive age, focusing on the actual impact of obesity on pregnancy, childbirth and the postpartum period. The fact that medical staff are aware of the challenges underscores the necessity of equipping them with appropriate tools. This includes both specialized equipment for monitoring and caring for patients with obesity (e.g., wireless monitors, reinforced beds) and training in communication strategies for effective patient counseling and education.

Study strengths and limitations

The main strength of the study is its comparative design, incorporating both patient and medical staff perspectives and utilizing a standardized tool (the SES), which represents a novelty in the Polish literature.

A primary limitation stems from the use of convenience sampling and an online survey. This approach likely introduced selection bias, as participants may have been predominantly women with greater health awareness and access to the internet, limiting the generalizability of the findings to the broader population. The limitations include the cross-sectional nature of the study, which precludes causal analysis; potential measurement errors associated with the online questionnaire; and limited generalizability of the results due to the single-country context. The study was not preceded by an a priori statistical power analysis. Although the sample size (N = 400) and its equal-group structure favor comparative analyses, the results should be interpreted with this methodological context in mind. Future cohort and multi-center studies are recommended to verify our findings, supplemented by qualitative research to explore in-depth the beliefs, emotions, and lived experiences related to obesity in perinatal care.

Conclusions

Analysis of the study results enabled the formulation of practical conclusions for prenatal education and highlighted the need to prepare staff as well as hospitals for the care of patients with obesity. A marked discrepancy in the perception of obesity-related risk was revealed in the study: while the majority of medical staff recognized complications (p < 0.001), women’s level of knowledge regarding the risk of obesity-related complications was limited and showed no association with their BMI. It is necessary to implement widespread health education for women and to provide healthcare centers with specialized equipment and staff training. An important finding is the lack of association between body mass and the self-esteem of patients with obesity, which requires an individual, holistic approach to this group. There is an urgent need to employ standards of care for obese women in the perinatal period, incorporating technical and communication aspects to ensure effective care.

Disclosures

This research received no external funding.

The study was approved by the Bioethics Committee for Scientific Research at the Medical University of Gdańsk (Approval No. KB/81/2025).

The authors declare no conflict of interest.

Supplementary materials are available on the journal’s website.

References