Lexis Dotson-Dufault’s second pregnancy, like her first, was marked by incessant vomiting.
She suffered from the pregnancy-related condition hyperemesis gravidarum, and she wasn’t prepared to parent. So in late summer of 2022, after deciding to terminate at a California reproductive health clinic where she was already a patient, she was surprised when the doctor refused to perform the scheduled abortion procedure, or to even meet her. All because of one metric in her chart: her body mass index (BMI).
“I was like, ‘You’re telling me that I’m too fat to get the basically safest procedure in the world? Like, OK, I guess,’” said Dotson-Dufault, who is now the executive director for Abortion Fund of Ohio.
Like more than 2 in 5 U.S. adults, Dotson-Dufault has a BMI above 30, which is considered obese and which the American Medical Association recognized as a chronic disease in 2013. BMI — a person’s weight in kilograms divided by their height in meters squared — has been criticized as an unreliable single metric to determine someone’s overall health, as it doesn’t account for factors like muscle mass, bone density or body composition.
But for the past decade, BMI has been used to deny or delay abortion care, despite researchers finding little evidence of increased adverse outcomes during abortion procedures based on higher body weight alone. Reproductive health advocates and researchers told States Newsroom blanket BMI policies that cropped up at abortion clinics have created unnecessary barriers to a population that is already marginalized by the U.S. health care system.
Some of these policies have been reversed in the last few years, but it remains unknown how many pregnant people have been and continue to be impacted by BMI-based restrictions. Some clinics continue to refer patients to hospitals if they are above a certain BMI. Dotson-Dufault’s provider, FPA Women’s Health in California, which has 25 locations throughout the state, declined to comment for this story but directed States Newsroom to their guidelines limiting procedural abortions to patients with a BMI above 60, labeled “extremely obese.”
Dotson-Dufault said she was not told what the BMI limit was at the time, and that hers was 53.
“I have experienced so much bias in my life and in my medical experiences because of my weight, that it was just not ever considered to me in terms of abortion access,” said Lexis Dotson-Dufault, who said in 2022 she was denied an abortion procedure because of her high body mass index. (Photo courtesy of Lexis Dotson-Dufault)
“I have experienced so much bias in my life and in my medical experiences because of my weight, that it was just not ever considered to me in terms of abortion access,” she said.
Why the BMI?
Emerging weight-based policies did not apply to the U.S. Food and Drug Administration’s approved medication abortion regimen, but to formerly “surgical abortions,” now commonly referred to as “procedural abortions,” because they don’t involve surgery in the technical sense. First-trimester abortions are outpatient procedures that typically involve minimally invasive techniques such as vacuum aspiration or dilation and curettage, which do not require general anesthesia but do involve sedation or pain medication. Concern of potential complications related to pain management motivated many of the restrictions on procedural abortions.
In 2015, just two years after the AMA classified obesity as a chronic illness, Planned Parenthood Federation of America issued new guidelines barring sedation to people with a BMI above 45.
In the decade since, little evidence has turned up to support the theory, with a new systematic review out of Emory University concluding that the existing peer-reviewed evidence does not show a statistically significant relationship between increased complications during procedural abortion and higher body weight.
The U.S. Centers for Disease Control and Prevention still promotes BMI as “a simple, reliable, and low-cost screening measure of health.” But in 2023, the AMA released a statement saying it is imperfect as a sole measure of bad health outcomes and should be used in conjunction with “other valid measures of risk” but should not be used to deny insurance reimbursement. The AMA also recognized that the BMI does not account for differences across race, ethnicity, sex, gender and age.
Three years later, Dotson-Dufault, now 26, said she has a renewed sense of anger, realizing blanket BMI policies were never based on hard evidence.
“We yell at antis for sowing misinformation and stigma [about abortion], but us over here saying we support it, why are we not being held to a higher standard to ensure that fat phobia is not integrated into our practices and ensuring that the care is accessible to all people?” Dotson-Dufault said.
Delayed or denied care
With hyperemesis gravidarum, Dotson-Dufault rapidly lost weight, estimating she dropped about 30 pounds a month during both of her pregnancies. She said she was sick all the time and could barely function.
“I could not fathom being pregnant for one more minute than I had to be,” said Dotson-Dufault, noting she couldn’t afford the higher cost and extra hurdles to get an abortion at a farther away hospital.
So, she went with the other option the clinic offered her, since she was still in her first trimester: abortion pills.
Medication abortion has become the most available termination method in the U.S., though that could soon change due to pending legislative and legal efforts. This method involves inducing a miscarriage with mifepristone and misoprostol. The regimen has a high safety and efficacy record, but for some people the symptoms can be severe and scary, and include a risk of incomplete abortion, which could lead to infection if not treated medically. In surveys, some patients say they prefer the medication because the process feels more natural and allows them to have the abortion in private. But others, especially Black individuals, say they prefer an in-clinic procedure, which especially in the first trimester, is generally low risk.
Dotson-Dufault, who is Black, said her second experience with medication abortion ended up going much better than her first, which she said was very painful, because this time she knew what to expect and had a support system.
But for people past the first trimester, telling them they have to go to a hospital creates a potentially impenetrable barrier, said Hayley McMahon, a doctoral fellow at Emory University’s Center for Reproductive Health Research in the Southeast (RISE), the lead author of “Weight and Procedural Abortion Complications: A Systematic Review,” published this month in Obstetrics & Gynecology and available online in January.
And that’s on top of other layers that can make abortion care more difficult to access by people with higher body weights, McMahon said, noting that this community disproportionately overlaps with other communities that face discrimination and barriers in the health care system, such as people of color or who have disabilities or low incomes. She said people with higher body weights often delay or forgo preventative care and are more likely to learn about an unplanned pregnancy too late to have an abortion, depending where they live.
A study in Perspectives on Sexual and Reproductive Health measuring obesity and abortion delays found that patients referred to a hospital in Philadelphia in 2016 waited twice as long as other patients and paid 66% more in up-front costs.
“In what turned out to not be based in evidence, clinic-level policy was adding an additional barrier, and I’m sure continues to add an additional barrier to folks who are already disproportionately impacted,” McMahon said. “At the very best, they’re delayed in care, but often it can lead to even being denied care, because we know hospital-based care is so incredibly difficult to access. … We know that folks experience a lot of distress and a lot of financial burden when their care is delayed.”
Changing BMI policies
When McMahon and her research team first set out to learn why clinics were setting restrictions based on BMI, she assumed the research would at least be mixed. She was wrong.
“I was really surprised at how consistently the data that’s out there conflicted with what some of the clinical guidance has been,” McMahon said.
After scouring medical research databases, McMahon and her co-researchers found six large U.S.-based peer-reviewed studies published between 2010 and 2022 that, all combined, involved approximately 39,000 participants and assessed at least one outcome of procedural abortion safety stratified by a measure of body weight.
None of the studies found a significant relationship between abortion complications and body weight overall. But one subgroup analysis from one study did identify a significant increase in complications among participants with BMIs higher than 40 who had second-trimester abortions. The authors note that a stark difference about this study is that the abortion cases included had to be approved by an ethics committee and only in cases of serious threats to the health of the pregnant person or severe fetal impairment.
McMahon said many of the studies looked at, and did not find, a higher incidence of sedation-related complications during procedural abortions for people with high BMIs.
“There is this perception in medicine that people with higher weights are at a higher risk for a lot of different procedures, particularly in relation to anesthesia,” McMahon said. “So I think that just kind of blurred into abortion care.”
Planned Parenthood Federation of America adopted new guidance in 2022 and no longer prohibits affiliates from offering sedation to women with a BMI above 45.
“The clinical data is now clear that there is not an association of increased complications with procedural abortion care and for folks of higher body weight, so Planned Parenthood has recognized that and removed all mention of weight or BMI when considering appropriate patient selection for abortion care in our outpatient health centers,” said Dr. Robin Wallace, the family planning advisor for the medical services team at PPFA.
In 2024, National Abortion Federation, the country’s largest professional association of abortion providers, adopted new guidelines that for the first time called for an end to blanket weight-based policies, asserting that body weight and BMI alone are not contraindications for abortion care and that these metrics should not limit appropriate anesthesia. The updated policy says that pain management “depends on the desired level of sedation and the individual patient response.”
“We know now that people of different body weights can be able to receive procedural or medication abortion, and that their body weight will not have a negative impact on the efficacy of the care that they will receive,” NAF president and CEO Brittany Fonteno, noting that a delay in care is what is more likely to cause increases in complications.
At Partners in Abortion Care in College Park, Maryland, one of the few all-trimester clinics in the country, certified nurse-midwife and cofounder Morgan Nuzzo said patients are not charged more solely based on their weight, but that they do have a weight limit of 450 pounds because of their equipment. She said patients are heavily screened on the phone in advance.
“We see each patient on a case-by-case basis,” Nuzzo said. “That has never been a standing protocol for us to say, this is somebody’s BMI, let’s do a cutoff. …. It is a justice issue for folks to be able to access health care at any size and to not see a price increase related to that.”
McMahon said she’s heard few people speaking out about how weight-based barriers and fat phobia impacts care, beyond anonymous posts online. But she said that since her study came out, several abortion clinic workers have requested copies to show to their clinic directors.
“When you get those effects of weight stigma and abortion stigma tied up together, it is really difficult for folks to talk about,” she said.
Weight is also factor in emergency contraception
While there is no evidence showing that weight has any bearing on abortion drugs, there is evidence that higher body weight is associated with decreased efficacy of the most commonly available forms of emergency contraception. According to the American Society for Emergency Contraception, some studies have found that drugs such as levonorgestrel (known as the brand Plan B) and ulipristal acetate (known as the brand ella) may be less effective for patients weighing more than 165 or 194 pounds, respectively.
This has created a double-edged sword for people with higher body weights because some get the message emergency contraception will not work at all, while others do not realize their weight could make emergency contraception less effective. Lexis Dotson-Dufault said she never tried emergency contraception, assuming it would not work for her.
“It’s a huge problem,” said Stephanie Kraft Sheley, an attorney and the director and founder of Missouri-based nonprofit Right by You, which provides pregnancy options information and resources to teenagers. “A lot of people don’t know, and that concerns me a lot.”
Planned Parenthood Federation of America’s Dr. Robin Wallace said people with higher body weights are often left out of pharmaceutical research, which partially accounts for why there are not better alternatives for emergency contraception for people with higher body weights.
She said there is an extremely effective form of emergency contraception for everyone regardless of body size, which is to have an intrauterine device (IUD) inserted within five days of unprotected sex. But unlike getting emergency contraceptive pills over the counter, there are often more financial and logistical barriers involved with getting an IUD within five days, exacerbated by cash-strapped and shuttering reproductive health clinics.
“It’s a really great option for folks who may have been considering an IUD anyway,” Wallace said. “But I think folks are, number one, maybe not aware of that, and number two, [it’s a] logistic challenge.”
