Reply turned post: Ghettoizing Fat Pregnant Women

Kathy at Woman to Woman Childbirth Education has a good post on a recent article from the UK, discussing the banning of "obese" women from birthing in certain "low-risk" hospital birth units because of their weight.

I commented on her blog, but the more I think about it, the more I think it deserves its own post here on my blog too. So I'm going to hijack the discussion over to here.

This is part of a new trend towards "bariatric obstetrics." The idea is that the "obese" mother is at SUCH INCREDIBLY HIGH RISK that she is better off delivering at a hospital that is specially equipped for her needs and where doctors can specialize in such "high-risk" deliveries.

Although some folks setting up these policies may have good intentions, what they are actually doing is "ghettoizing" fat women.

By taking away low-risk care options for fat women, they virtually guarantee a high-risk, high-intervention, high-complication delivery for them.

But no one is actually studying whether switching to special "bariatric obestetrics" practices and hospitals actually improves outcomes among "obese" women. They just assume it does.

And it assumes a level of extreme risk for all fat women when many don't experience that at all.

Yes, pregnancy in women of size has more risks of some things, like gestational diabetes, pre-eclampsia, macrosomia, etc. Yes, some women of size have complications. You'll never hear me pretending otherwise. And sometimes a woman of size does have complications that needs a higher-intervention approach or a higher-risk hospital or practice.

But many women of size have healthy pregnancies and births, and many more probably could if they access to proactive, low-intervention care via the midwifery model of care.

If fat women don't have any complications, do they really need a high-risk practice or location, based on weight alone? Do they really benefit from it? Or does it cause more harm than benefit?

And even those who experience mild complications, can't they usually still be cared under the midwifery model of care and benefit from that model?

Research shows that when comparing clients of the same level of risk, midwifery clients experience fewer inductions, fewer augmentations, fewer epidurals, fewer episiotomies, and fewer cesareans, yet their outcome is just as good or better.

Some research suggests that women of moderate risk also benefit from the midwifery model of care. Although not specifically addressing obesity alone, Cragin and Kennedy 2006 concluded,

Even among moderate-risk patients, the midwifery model of care with its limited use of interventions can produce outcomes equivalent to or better than those of the biomedical model.

To take away the choice for that low-intervention model across the board based only on size, regardless of actual complications, is a total miscarriage of justice.

And I think that's the thing that has me most enraged....the paternalistic, condescending attitude of making my decisions for me, for my own "good"....because I'm fat. Taking away my best chance of having a safe, unintervened-in birth....because I'm fat.

As Susan Hodges of Citizens For Midwifery states, "How much 'risk' does it take to supercede the mother's right to bodily integrity?" Or self-determination?

I've got news for these folks. My weight does not give you the right to make my choices for me or to dictate whom I can see or what kind of birth I am "allowed" to have. This is my body, and *I* get to decide.

Unable To Access Low-Tech Care?

Unfortunately, I think that more and more in the next few years, we will see fat women denied the right to obtain low-risk maternity care, the right to see midwives, and the right to have homebirths or birthing center births.

It's already happening. Some birth centers already deny access to women above a certain BMI or weight limit. Some homebirth midwives/doctors turn away "obese" women, even those without complications, simply based on their weight.

Some homebirth midwives want to serve women of size but know that if there is a transfer or anything goes wrong, the authorities in their area will skewer them for daring to care for an obese woman at home.

(It's already happened; a friend of mine recently planned a homebirth and her midwife backed out on her for this very reason. She eventually found another midwife but it was not easy to find one so late in pregnancy. Fortunately, the birth went fine and no one got taken to task for serving a fat woman at home....but the fact remains that the fear of this caused her first midwife to desert her, and near the end of pregnancy too.)

So more and more fat women---even those who want alternative, low-tech care---are being forced into the high-tech medical model, one in which "morbidly obese" women often end up with a nearly 50% c-section rate---or more.

In fact, even being forced to be in the hospital with an OB isn't enough now. Some hospitals (like this one above in the UK or this one in Australia) are forcing fat women into specialized centers, so that they can't even access the low-risk, low-intervention hospitals.

And some regular OB practices refuse to care for obese women, requiring them to instead see high-risk OBs....regardless of whether they actually have any complications or not.

To these providers, the mere fact of being "obese" is complication enough, even without any actual complications to inconveniently complicate their biases, so to speak.

In other words, the hyperbole of risk around fat mothers is so out of control now that we are ghettoizing them. And it's only going to get worse.

Show Me The Money, Baby

The real question here is whether the centralizing of "obese" women together into specialized centers and under the "high-risk" umbrella improves outcomes or not.

My bet is that it simply leads to an atmosphere of unchecked and unquestioned intervention, and many many unnecessary cesareans.

But we don't know that because no one is documenting the outcomes. As far as I can tell, no one is even asking the questions.

Where is the proof that these bariatric specialties improve outcome?

Where is the publication of the protocols routine to these bariatric obstetrics practices? Are all these women being told to diet during pregnancy? Are they all being induced early for fear of a big baby? If they go outside the approved protocols of xxx pounds of weight gain or xxx pounds of expected baby size, are they just automatically sectioned?

Where is the documentation of the intervention rates of these practices? What is the induction rate, what is the c-section rate, what is the VBAC rate, what are the complication rates?

Where is the prospective study of high-tech, high-intervention specialized bariatric care for obese women, compared to a control group of women of similar size and complications who instead are exposed to the low-tech, low-intervention midwifery model of care?

Show me the money, people. Ah, but that's the problem right there. This is a new cash cow in obstetrics these days....the specialized practice of "bariatric obstetrics."

Just think of all the money they can charge insurance companies to force these women to see bariatric specialists! Just think of all the money they can charge for "specialized" bariatric equipment! Just think of all the billable services they'll "need" in the hospital! And just think of all the extra money from all the extra c-sections!

Sorry, I don't care if you have no financial incentive to study this or not. You have to SHOW ME that this high-tech, high-intervention, high-risk attitude towards birth in "obese" women actually improves outcomes before you dictate where I "have" to give birth in order to birth "safely."

PROVE IT. In a good study, with a good control group of similar fat women being treated in a true low-intervention midwifery model to compare it with.

Until then, stop taking away the rights of women of size to birth where they want to, to have equal access to low-tech birth, to have equal access to "alternative" techniques like waterbirth and full mobility in labor.

Stop forcing fat women to have early epidurals "just in case," mandatory internal monitoring, and automatic confinement to bed. Stop pushing fat women to induce labor early "before the baby gets too big." Stop sectioning fat women whose weight gains or whose baby size fall outside your definition of "desirable." And stop forcing women into bariatric obstetrics practices and high-risk hospital wards if they don't want it or need it.

Stop ghettoizing fat women, damn it. And stop telling us how and where we are "allowed" to give birth. These are our bodies and our babies, and we are the ones who get to have the final say.

Thankful Mamas

A little thing of beauty for all us mamas, and especially us wellrounded mamas, to celebrate our thankfulness for our wonderful children.

And for those with and without children, take a moment to consider thankfulness to your own mother, or to whomever was important in a positive way in your life.

*Painting called "Maternal Kiss" (1896) by Mary Cassatt; image from Wikimedia Commons.

The Scarlet Letter F: A College Requirement?

Several folks on the fatosphere have already commented on Lincoln University story. Now, normally I wouldn't beat the topic to death in a "me too" chorus. However, this one really bugs me, so I feel compelled to add in my 2 cents also. And yeah, I'm going to SHOUT a little bit here and there because this one hits a couple of hot buttons for me.

As most of you have heard by now, the press picked up the story recently that Lincoln University in Pennsylvania requires all their students to be weighed and measured, and if their BMI is over 30 ("obese") then they are required to take a Fitness For Life course at some point before graduating. No Fitness For Life course, no graduation....but only for the fatties. (You skinny folks, you obviously don't need any fitness courses.)

This offends me on so many levels I can't even tell you....but I'm going to try.

1. First and foremost, it is not the college's business. THEIR FOCUS SHOULD BE ON LEARNING, PERIOD. They are an institute of higher learning, not a institute of higher fascism. Whether I'm fat or not has nothing to do with my academic abilities or accomplishments and should have nothing to do with whether or not I get a college degree. College is about learning, it's about academics, it's about hard work and accomplishment. The work I have done during college should dictate whether or not I get my college degree. Whether I'm fat and whether or not I exercise is completely irrelevant and should have no bearing. GAH!


2. This policy assumes that all thin folk are perfectly fit and have no poor eating or exercise habits. This is absurd, as others have pointed out. BMI is no marker for good eating or exercise habits. We all know people who are thin but who eat crappy and rarely exercise. They are simply blessed with skinny genes, but that doesn't make them healthy, for heaven's sake! And there are a lot of fat people who eat a lot healthier than a lot of thin people, but because of differing genetics, they'll never be thin. That doesn't mean they need re-education camps or drastic measures. BMI is a lousy marker for habits, period.


3. If their objective is to promote fitness for life, THEN THE REQUIREMENT SHOULD BE FOR ALL STUDENTS, WHATEVER THEIR SIZE. People of all sizes can benefit from a greater emphasis on fitness if it's properly done. I don't really object to the idea of a P.E. requirement for college because exercise is a good counterbalance to the mind exercise of academics, but if it's going to be part of graduation requirements, it should be required for all. Singling out only the fat students is wrong, and no one needs a scarlet letter F on their transcript. It's shaming and has potentially long-lasting discriminatory effects.


4. If they are going to have a PE/fitness requirement, then it should only be about fitness and health (not weight judgments), and it needs to be accessible for people of different abilities. It needs to be a class that people of varying athletic talents can be successful at. If your objective is for people to want to exercise their whole life and thus be more healthy, they need something they feel successful at and can do joyfully. A fitness class in which students are lectured at negatively, shamed, or forced to do activities unsuitable to them or that they are really bad at is not going to acheive that objective. They need to seriously look at their objectives and see if their activities really dovetail to them.


5. This course has great potential to backfire. College is a hotbed of eating disorders and this kind of approach may well worsen that. Is that really the kind of healthy outcome they are looking for? Is there a way for them to track whether they are achieving their objectives in the long-term, or whether they are actually making things worse?


6. They assume that more exercise will automatically result in weight loss and less obesity. But as the wonderful Marilyn Wann pointed out (comment #32 in this article), "Science shows that regular physical activity magically makes people healthier; it does not turn fat people into thin people." I think many of us who have tried the exercise "cure" can attest to this. We should exercise because of the health benefits it can bring, but to promote exercise as a sure-fire way to weight loss is misleading and a good way to turn people off to exercising when it doesn't magically succeed in keeping all that weight off.


7. Fat people face enough discrimination as it is. There are enough barriers in place to our success; we don't need to add more. Fat people of color face even more barriers. Do you really want to make it more intimidating for fat folk to go to college? Don't you think that a requirement like this would be humiliating enough to keep some people away from college? Think through the possible implications this class might have.


8. This policy sets a precedent for other schools and you know that other fitness fascists at other schools are going to say, "Ahhh, what a great idea!" Now, some folks point out that if you don't like this college's policies, don't go there. But the problem is the precedent. Let it be "okay" in one place and soon enough all the colleges will have policies like this---or harsher. Taken far enough (and you know there are health fascists out there who would like to do this), this could lead to policies that might well keep a whole class of people---fat people---from access to higher education degrees or to a certain quality of university. Discrimination is discrimination and it shouldn't be in place anywhere. And especially not in a place of higher learning where the emphasis should be on academics.

My Fitness Course Experience

My college had a PE requirement for graduation, but at least it was for all students, not just the fatties. I was still in my dieting years, so instead of the fun stuff like dancing, I took a fitness course in order to try and halt the strong weight gain I was experiencing (from PCOS and undiagnosed hypothyroidism, but that's another story).

The course was probably much like this course would be. The emphasis was on improving fitness and getting lots of exercise with a view towards encouraging life-long exercise. They didn't mandate losing weight, but we were weighed at the beginning and end of the class as part of their tracking of our progress.

I exercised more in that class than I ever did in my life (and I was not a sedentary child). We ran laps, ran up and down stadium steps like crazy, swam laps, biked, lifted weights, you name it. I was worse than my peers at things like running and stairs, but I was significantly better than most of my peers at things like bench press and swimming. Basically, I did OK.

All this time, I was also going to Weight Watchers in an effort to rein in my weight gain. But by the end of the semester, I had gained 25 pounds, all while doing a huge amount of exercising and being on Weight Watchers. (And no, it wasn't from muscle gain either.) The coach was so incredibly disappointed in me; I could see in his face that he thought I was lying about food and must have been binge eating like crazy. But no, I wasn't; not at all.

That was beginning of the end for me in terms of dieting. I still dieted for several more years, mind, but it was the beginning of the end of my belief in the validity of the formula of calories in/calories out, that if I just exercised more and ate less I could lose weight, and that it was all about habits, period.

I did pass the class, but thank God I took the thing pass/fail. If I hadn't, it would have messed up my GPA and might have lost me my magna cum laude status. I completed all the assignments and did everything they asked....but because I couldn't match some of the benchmarks of the skinnier people and because I gained weight instead of losing it, my grade was docked.

(Thank goodness the university let people take this PE stuff pass/fail! That way it couldn't ruin my college GPA the way it torpedoed my 4.0 GPA in high school.)

Sadly, the long-term legacy of the class was all negative. I went away with an increased hatred of exercise. I exercised less after that class rather than more. I went away with shin splints and some significant pain, and a real distaste for athletic trainers and gyms and everything associated with them because of their judgmental attitude. It had the opposite effect than they wanted and to this day, I still struggle with negative attitudes towards exercising. Even as I read all the research on the benefits of exercise and knowing I feel better when I exercise, I struggle with actually doing it sometimes.

So while I'm sure the coaches and administration of Lincoln University have the best of intentions, I'm afraid they may end up having quite the opposite effect they intended. Is that really a productive use of this course?

It's an alarming policy, no matter which way you look at it.

Healthy Birth Practices: Have Continuous Support

We've been talking about the Six Lamaze Healthy Birth Practices, why they are helpful in labor, what the research says about them, why these birth practices are often utilized less with women of size and how that affects our births.

The previous Healthy Birth Practices we discussed were:

1. Let Labor Begin On Its Own
2. Walk, Move Around, and Change Positions During Birth

Now, the third Healthy Birth Practice is:

3. Bring a loved one, friend, or doula for continuous support

In my opinion, although this is helpful anywhere, this may be particularly helpful to women who are birthing in the medical model at a hospital, and especially women of size birthing in the medical model at a hospital.

But frankly, it's most helpful if the labor support person is non-judgmental and knowledgeable about supporting women of size, and if the care provider is also size-friendly and birth-friendly.

Historic Birth Support

As the Lamaze care practice paper on Continuous Support During Labor notes, there is a long history of providing support for women during childbirth, but who provides it and how has changed over the years:

In times past, women learned about childbirth from their mothers and sisters. Stories and family traditions helped women to have confidence in their ability to give birth. Family members and women friends surrounded the laboring woman, offering her encouragement and support. Babies were born at home with a midwife.

Then, early in the 20th century, birth moved into the hospital. No longer could family or friends be present with a woman during labor. Nurses offered support, but they had to care for several women at the same time. Their responsibilities were divided among other patients, so the laboring woman was often left alone.

During the 1960s, Lamaze International and other childbirth organizations succeeded in changing the rules, so that fathers could be present in the labor room. Fathers give special, loving support to their partners and deserve to be there for the birth of their child. No longer did women have to labor alone.

Currently, women are rediscovering the value of having additional support during labor, especially from individuals who are experienced with and knowledgeable about birth. Women often assume that a nurse or midwife will stay with them throughout their labor. Sometimes this happens, but most often, other duties prevent care providers from being with only one person continuously.

So, bring a loved one, a friend, or a doula with you for continuous support during your labor. You will receive the emotional and physical support you need from one or more caring individuals. Before your baby’s birth, decide who will provide this support, and make a plan with them.

The important thing to note here is that women have traditionally sought out and gotten labor support for a reason, because this support often plays an important part of helping a woman through labor and having a more positive birth experience.

However, while doctors and nurses do their best to help, continuous support is often not available from medical personnel at the birth, because they are often busy dealing with other medical duties and therefore cannot give the kind of one-to-one support a mother may need.

This is why it is helpful to bring along someone else to help provide that continuous support during labor. This support can be helpful in any type of birth----from a totally natural homebirth to a highly medicalized hospital birth (and anything in between). It can be provided by a husband or partner, a friend, the woman's relatives, or a "doula."

Of course, there is no one "right" way to give birth. Different choices are right for different people. The important thing is that women have access to all choices, that they have adequate information about the pros and cons of these choices, and that when they make choices, their choices are respected.

However, labor can be stressful and emotional, and women and their friends and family are not always aware of the variety of care options available or the pros and cons of each. Therefore, it helps to have labor support personnel who are experienced with birth, knowledgeable about the variety of choices available during birth, and willing to support the mother in her birth wishes, whatever they are.

That's where a doula comes in.

What is a Doula?

A doula is a person who provides professional pregnancy and labor support. This is their career, so they tend to be more experienced, have more training, and be more educated about birth choices than a family support person might be.

The word "doula" comes from Greek and means "woman's servant." It referred to the women who traditionally provided support to mothers in labor.

The Doulas of North America organization defines a modern-day doula in the following way:

A birth doula is a person trained and experienced in childbirth who provides continuous physical, emotional and informational support to the mother before, during and just after childbirth.

Some doulas only work during labor itself, but most doulas work with women before and just after the birth as well. They give emotional support and information as needed during pregnancy, provide support and encouragement during labor, and then give early post-partum and breastfeeding support.

Some doulas (known as "postpartum doulas") specialize in helping the mother for a longer period after the birth, generally for a few weeks or months. They help with breastfeeding issues, physical recovery, household chores, assisting with older children, or doing whatever is most needed at the time. They can be particularly valuable after a difficult birth, during a surgical recovery, or when the mother has several older children and little family help.

But most doulas work during pregnancy, birth, and for a few days immediately after birth. In particular, they specialize in labor support.

It's the doula's job to know all the "tricks of the trade" to help a woman cope during labor, to have a grab bag of ideas to try if difficulties arise, to help parents examine their choices in difficult situations, and to provide emotional support for the parents however the birth proceeds.

Doulas do not make medical decisions for you and they don't intervene with the hospital staff. They are not there to tell you how to give birth or what your choices should be. It's up to you and your partner to make your own medical decisions and to advocate with staff on your own behalf.

However, doulas can help you talk through the benefits and risks of all the options when there are choices to make, and they can give you ideas about alternatives that might help. It can be incredibly valuable to have this objective "third eye" during labor.

Doulas are an important addition to overworked nurses and doctors who have a limited time with each patient. Partners, friends and relatives try to help out as best they can, but they may not have the experience or knowledge to help very well. Thus, doulas play an important role in helping "fill in the gap" in providing much-needed yet experienced labor support.

That doesn't mean that friends or relatives cannot help. Research shows that outcomes improve even when non-professional support is utilized. Sometimes just having continuous, loving support is the most important factor.

However, if you plan to use friends or family instead of a doula, it's best if they have some idea of how to support a laboring woman. Ask them to take a non hospital-based childbirth education course with you, or to read some books about supporting women in childbirth, such as The Birth Partner by Penny Simkin, or The Labor Support Handbook by Penny Simkin and Ruth Ancheta. These can help fill in some of the blanks and help them be the best possible support they can be.

But generally speaking, it is most helpful to hire someone who specializes in labor support and has a lot of experience in it.

Common Concerns Over Hiring a Doula

When discussing hiring a doula, several concerns commonly crop up. These are usually based on misconceptions about doulas and what they do.

Doulas might take away from the Dad's role

One fear that many folks have is that the doula might make the dad/partner feel superfluous or somehow make the experience less emotionally intimate between the couple.

However, in real life, many partners find that they are actually greatly relieved to have a doula. [My husband was!] It helps take the pressure off of them so they can concentrate on just being there emotionally for their partners.

Too often, partners are expected to advocate for their loved ones with very little preparation. And because they are emotionally involved with the mother, they can become overwhelmed by the strong emotions a birth can bring and forget what they do know. That's why it can be helpful to have an objective and experienced eye to remember what questions to ask, what position changes may help, what techniques can help lessen pain, and what the pros and cons of a proposed intervention might be.

Another point is that the birth can be tough on the partner as well as the mom. A doula can be much-needed support for both the mother and the partner. She can help the partner remember comfort measures that might help in labor, she can give a second set of hands to help with rubbing and holding and other physical tasks, she can stand in while the partner takes a bathroom or meal break, and she can give much-needed emotional support to both the mother and her partner.

As for interfering with emotional intimacy, a doula knows how and when to step back. She is not there to be the main support person, but rather to help the couple. She will help in whatever way they want and she adjusts her role to the needs and desires of each couple and each birth.

Thus, most couples find that a doula enhances their experience, not detracts from it.

A doula might judge me if I don't end up with a totally natural birth

Another fear of some women is that a doula might be judgmental if they decide to choose an epidural, pain meds, or other interventions like induction, breaking the waters, or a cesarean.

The truth is that there are all kinds of doulas out there. Some do tend towards pushing a natural childbirth agenda, but others know that they are there to support the mother in whatever choices she makes. Many know how to optimally support a woman with an epidural, or how to make the best of challenges like induced labor. They should know how to roll with the flow and still help you find the very best birth experience under the circumstances, without judgment.

Choosing a doula is like choosing a birth attendant---it's best to find one that aligns with your own birth desires. If you think there is a strong chance you will be wanting an epidural during your birth, then make sure you hire a doula and a birth attendant who can be supportive of that and who know tricks for supporting a woman who has an epidural. Likewise, if you know you prefer natural childbirth, hire a birth attendant and doula who are supportive of that and who won't be pushing drugs or interventions on you unnecessarily. Both kinds really do exist.

Also remember that birth sometimes carries unexpected surprises, and sometimes the person who really wanted an epidural doesn't have time to get one, or the person who really wanted a totally natural birth ends up with interventions. Having a birth attendant and doula that are flexible, non-judgmental, and who have a wide range of skills and experiences can be helpful in meeting the unexpected with grace and flexibility.

Doulas are too expensive

Another reason many parents don't hire a doula is the added expense. Doulas are not usually covered by insurance plans, and adding any extra cost during the expensive time of pregnancy and birth may not seem worth it.

However, most women who have hired doulas felt it was well worth the extra expense, and most find a way to afford a doula again in future births. Most parents find them that valuable.

Furthermore, there are many ways to be able to afford a doula, even for those who think they cannot possibly afford it.

Doulas vary greatly in cost, from very expensive to very cheap. Generally, the cost is several hundred dollars, but that may go up or down depending on how experienced your doula is, how much training she has, and the general cost of living in your community.

Shop around and see what costs tend to run in your community. Remember that doulas deserve to earn enough to help support their families, and that their time investment is usually considerable. If you figure out how much time a doula spends with you, you'll find that their flat fee often ends up being only a few dollars per hour and thus is more affordable than you might think.

If money truly is too tight to afford a doula, remember that some doulas will work on a sliding scale basis, some will barter services with you, some accept payment plans, and some doulas will work for free while they are fulfilling certification requirements (check Craigslist for ads from those who are offering free services while they train).

Many people opt out of hiring a doula because of the money, but more could probably afford it than they think. Check into all your options before you decide to opt out of a doula solely for financial reasons.

Finding a Doula

For further information about hiring a doula, contact:

• Doulas of North America - www.dona.org
• Birthworks - www.birthworks.org
• Childbirth International - www.childbirthinternational.com
• The Organization of Labor Assistants for Birth Options and Resources - www.tolabor.com

There are even organizations that specialize in doulas for special needs, such as a doula for a mother whose husband has been deployed (or injured/killed) in the military, or for teen moms, etc. If you have a special situation or need, contact several doulas in your area and ask them for the names of local doulas who could offer particular support for your concern. Chances are you will be able to find someone who could meet your needs.

Click here for questions to ask when interviewing a doula. It's best to interview several doulas before you decide, and to take your time to be sure this is really the right person for you.

Not every person "needs" a doula, and many women do fine without one. If you decide to go without one, that's okay. But research shows that outcomes would probably improve overall if more women had doulas as part of their birth support team.

What Does Research on Labor Support Show?

Research shows that having a continuous labor support present at your birth lowers your risk for many interventions significantly:

Numerous research studies show important benefits to mothers and babies of continuous labor support by a loved one, friend, or doula. Labor support is a safe and effective practice with no negative side effects, yet the practice is underused (Sakala & Corry, 2008).

According to a review of studies from the Cochrane Pregnancy and Childbirth Group—a part of the highly respected, international Cochrane Collaboration that identifies best care practices based on research—continuous support for women during labor and childbirth is clearly beneficial (Hodnett et al., 2007). Study findings indicate that, compared to women who do not receive continuous labor support, women who receive continuous, one-to-one support are less likely to:

• have cesarean surgery;
• give birth with vacuum extraction or forceps;
• have regional analgesia (e.g., an epidural);
• have the need for any analgesia (pain medication); and
• report dissatisfaction with or negative feelings about their childbirth experience (Hodnett et al., 2007).

There are good, clearly proven benefits to having a continuous support at your birth. Therefore, it is to your advantage to strongly consider a doula or other support person.

Women of Size May Benefit from Knowledgeable Doula Support Even More

Because women of size tend to be subjected to more labor interventions and restrictions and have higher cesarean rates than women of average size, professional labor support is probably even more important for women of size.....yet some women of size may be hesitant about hiring a doula because they fear judgment about their size and needs.

Many women of size know all too well that society views their bodies with disgust and judgment, and makes many assumptions about how they "must" be eating or behaving simply because they are fat. Certainly this is often true in the medical community, but sadly, this is often also true even in the "alternative" birth community.

Women of size may fear that a doula will judge their bodies harshly, or they may feel embarrassed or hesitant about exposing their curves, sags, and bags to even more people. Or they may want to avoid yet another person who will assume that they have "bad" nutrition and exercise habits that "need" fixing. Or if they do have food issues, they may be embarrassed to discuss these and face the kind of moralistic judgments that often come from folks who do not have these struggles. Fear of judgment is one of the main reasons women of size don't take advantage of doulas more often.

Furthermore, knowledgeable support for the special needs of women of size is often lacking among doulas and labor/delivery nurses. They may not know how to physically support larger women during labor, they may not realize the tremendous importance of a correctly-sized blood pressure cuff, they may be hesitant to support women of size in laboring in water, they may not question some hospitals' protocol for encouraging internal fetal monitoring and early epidural for "morbidly obese" women, and they may not really believe that fat women are capable of birthing normally.

This may lead many fat women to choose to only have loved ones with them for support during labor. But although friends and loved ones can provide good support during labor too, they may have their own secret fears, concerns, or judgments about pregnant women of size.

Too often, doctors capitalize on these fears by convincing partners and family members that the mother "needs" a cesarean or induction for reasons that are not supported by research, like macrosomia (suspected big baby). Unless the friend or loved one is really savvy about birth issues, it's all too easy for them to become another voice in the chorus telling fat women to just take the cesarean and move on.

Women of size need to know that there are doulas out there who won't be judgmental about their body, who won't assume that they have terrible habits simply because they are big, who won't try to "fix" them or sniff in disdain if they end up having a cesarean or less-than-perfectly-natural birth.

There are doulas who don't buy into the medical model consensus that obesity "necessitates" a high-tech approach to birth, and who understand that fat women can give birth vaginally too, if given a real chance. And there are doulas who can and will support fat women lovingly, however their births proceed.

It can be very helpful for women of size to find such doulas and utilize them in their labors---especially in a hospital setting where an extremely interventive approach to birth for "obese" women is very common.

However, doulas are not miracle workers. They can't override choices made by birth attendants. If you hire a high-intervention provider and he/she decides to induce by 39 weeks because "we don't want the baby to get too big," there are only limited things a doula can do to mitigate the increased risk for cesarean that such a choice brings.

Therefore, while a doula can be very helpful, it's best to find both a birth attendant and a doula who are both size-friendly, and whose birth philosophy and approach align with yours.

Conclusion

Continuous labor support during labor and birth can lower the risk for cesareans or other operative birth (forceps or vacuum extraction), it can lessen the need for pain medications and epidurals, and mothers who have continuous labor support report less dissatisfaction with their birth experiences.

Continuous labor support can come from friends, partners, family, or professional labor support personnel (doulas). Professional doulas are probably the most ideal choice because of their wide experience and knowledge base, but research shows that even non-professional continuous support improves outcomes.

However, if you choose to use non-professional support, be sure that person is well-versed in labor support techniques and understands the pros and cons of various birth choices. A childbirth class and a book on labor support can be very helpful in preparing them to be on your labor support team.

If you do choose to hire a doula, it's important to shop around for a truly size-friendly doula....but the good news is that there ARE size-friendly doulas out there and that they may be particularly helpful in lowering the risk of unnecessary interventions in women of size, particularly those birthing in the medical model at a hospital.

However, it's the combination of a truly size-friendly, birth-friendly doula and birth attendant that is most optimal.

Cold and Wet Weather Gear

This past weekend, I took my kids to their soccer games as I usually do on weekends in the fall. It was a total Mud Bowl. Yuck.

Personally, I hate soccer in November because the weather is invariably nasty---rain, wind, cold, or worse.

Saturday was all of those....plus the worse. As in thunder and lightning. The ref wouldn't call the game at first because they only heard thunder. (Well, duh, if there's thunder then there must be lightning somewhere nearby as well! Potential safety issue, anyone?)

Finally, in the second half of the game, in the TORRENTIAL rain, winds blowing like crazy, and wind chill near freezing, there's a clear flash of lightning and a crash of thunder soon after. So finally, the game was called.

One more week of soccer to go. Hopefully it won't snow at next week's game, but I'm not holding my breath.

Ugh. I've got to get some new cold-weather clothing.

Why I Need Cold-Weather Gear More Than Most

First, you should know that I'm a VERY cold person....as in, I hate the cold and I get cold very very easily.

I think it's part of my hypothyroidism---I have a very narrow range of temperature in which I am comfortable, and a real tendency towards being cold, even when others around me are okay. Even though (with medication), my TSH and other readings are in the "ideal" range now, I still feel cold with very little provocation. And when I'm cold, I'm miserable.

My family laughs about how cold I am. I went RV camping a couple of years ago and sleeping beside me, my toddler was wearing a diaper and nothing else and was on top of the comforter....and she was fine. My DH had on only shorts and a t-shirt and he was fine. I was wearing full WARM clothes with mittens and was under a down comforter....and I was still freezing.

I just have very poor temperature regulation, for whatever reason, even with supposedly "well-treated" hypothyroidism. So when I say I need good gear for cold weather, I mean it.

Items That Work For Me

This summer I was talking with my nephews (who are avid hikers) and they recommended "Smartwool." So I got some Smartwool socks and gloves when I was at REI, buying fitness clothes for my kids.

Saturday was my first real chance to use them. They were awesome. I had thought, wool....ugh. But really, they were very comfortable and not itchy at all. And they did keep me noticeably warmer than cotton or fleece. It wasn't a cure-all---my hands still got cold by the end---but it was definitely better than what I already had, while being less bulky to boot.

Unfortunately, some of the best cold gear doesn't come in plus sizes. When I saw all the nice stuff available at REI for my kids, I really was struck by the difference in what's available in "regular" sizes and what's available in "plus" sizes. Additionally, I was frustrated at just how inferior a lot of the stuff available in plus sizes is, especially the higher range of plus sizes. Frustrating!!!

For example, Junonia is where I usually go when I want something for sports, fitness, or outdoors in my size. I typically wear about a 4x or 26/28 (anything from 3x to 5x, depending on the company, but I like things loose and I've got a 'rack,' so I prefer to be generous in sizing) and Junonia is one of the few places where I can get that kind of gear in my size, not just the "tweenie" sizes.

Junonia carries a lot of great stuff in many ways, so I do generally recommend them as a company----but I've also been disappointed by some of their stuff before. Many things have been fine, but I've ordered more than a few things from them that really disappointed me...which is bad cause they are not cheap. And just when I find a type of swimsuit or fitness pant that I do really like from them, they discontinue it. Augh!

However, I had a revelation this fall. I realized that a number of companies carry good outdoor gear in MEN'S plus sizes, often up to 2-4x (generously sized), and because MEN'S plus-sizes run larger than women's plus sizes, it's one way to find gear in extended sizes for me.

This is a decent way to fill in the gap, I've discovered. Women's plus sizes often end at XL or 2x if you're lucky, but a Woman's 2x is a lot smaller than a Man's 2x. Some Men's 2x sizes fit me (depends on the company), whereas a Woman's 2x usually won't.

And oftentimes, the Men's plus-size range extends into larger sizes than the Women's plus sizes. So Men's plus sizes can be a great way to get decent cold-gear stuff in extended sizes for women who need a little extra room.

For example, L.L. Bean carries a lot of great outdoorsy stuff....but most of their women's stuff ends at an XL, or about a size 18. However, their men's stuff mostly ends at a 2x, some of which fits me (a Woman's 4x).

At Lands' End, women's sizes go to 3x in some limited items, with a couple of new 4x and 5x items (but their size chart only goes to 3x, so it's hard to tell what their "4x" and "5x" really means in real life). BUT men's sizes at Lands End go to 4x, and it's likely that their 4x is much bigger than the equivalent in women's sizes.

But isn't it maddening that men's plus sizes are readily available in a much wider range of sizes than women's plus sizes are? And particularly in practical stuff like cold and fitness gear?

Another sign of the double standard out there....it's okay for MEN to be plus-sized and even very plus-sized....but not for women. Women are only allowed to be a little bit plus-sized, if at all.

And of course, why bother to supply cold or fitness gear for very plus-sized women because we all know they can't be doing any activities that require such gear, right? But on the other hand, we all know that very plus-sized men do need this sort of thing....just not the chicks. Ugh!!! (Fashion Pet Peeve #548 and #549, I guess.)

So anyhow, I took a chance and ordered a wool long underwear/sweater from L.L. Bean in a Men's 2x. I didn't think it would fit me but it did. A little snugger across the behind than I prefer but definitely workable. It's been GREAT.

I also ordered a really nice Men's hoodie coat, lined with a special fleece, from L.L. Bean. I was looking for something for that "in between" weather----don't quite need a full-on winter coat, but a light jacket just won't cut it. But this works great for in between weather and even into light winter weather. I'm loving this jacket more and more each day, and just discovered that they have an even more insulated version of the same coat, so I'm thinking about getting that too.

Footgear - A Special Problem

Footgear is a particular problem for me because I have abnormally large legs, probably from lipedema. Most people have never heard of lipedema, and most fat people don't have it....but lucky me, I probably do. Here's a definition from biglegwoman's blog:

Lipedema -- sometimes spelled lipodema or lipoedema -- is a hereditary condition which causes patients (almost always women) to store excess fat in the lower body, particularly the lower legs.

This is not the same as lymphedema, mind. In lipedema, the size is from excess fat being deposited there, not a malfunction of the lymph glands as in lymphedema (although lymphedema can sometimes be a side effect of lipedema). Also, lipedema is bilateral (on both legs) and lymphedema usually is not.

Anyhow, that's another post. The relevance here is that it's hard for me, with my very large-sized calves (and cankles, I haz dem too), to get boots for wet or cold weather. Impossible, in fact---at least so far. Even the places I've found online that cater to boots for wide calves don't go up to my size. Not even the ones that specialize in super-wide calves. I could have a pair custom-made, but that's prohibitively expensive.

So I have yet to find boots to wear to keep my chronically-cold tootsies warm and dry.

Instead, I try to buy warm footwear that ends at the ankle.

In the past I've used Duck Shoes, but find they tend to cut off the circulation in my feet. Wore them to one soccer game this fall and didn't feel my pinky toe on one foot for most of the rest of the day. Sounds like a recipe for disaster to me.

So I went to Lands End recently to see if there were any men's or women's shoes for winter weather and found these. I wore them with my Smartwool socks this weekend and my feet did indeed stay warm and dry, despite the Mud Bowl conditions. Huzzah!!

If I were walking in deep puddles or got really splashed, I'd still get wet and cold, but hey, I'd get the same with the duck shoes and at least I don't lose feeling in my feet in these shoes.

What I Still Need

One thing I forgot to wear this weekend was long underwear on my legs so they'd stay warmer. I do have a pair from L.L. Bean---so next time, I'm definitely going to remember to try them out.

But my pants to totally wet last weekend because the wind was blowing the rain so hard. So I've decided that I have to get some rain pants, preferably some that keep you warm too.

I'm contemplating buying these or these from Junonia, so if you have feedback on either, I'd like to hear it.

I'd also like to know if there are any other choices out there. Men's clothing isn't really an option here because I'm really short, more curvy in the hip than most men, and I'm not handy enough with a needle to hem or size them properly.

So does anyone have any fabulous options or recommendations for wind/rain/cold weather gear for the higher range of plus sizes? Especially rain pants?

Are there any other decent companies out there that specialize in sports, fitness, or cold-weather gear for women and have extended plus sizes? (I'm not talking about Lane Bryant or Roaman's or Just My Size, I mean companies that specialize in this type of item.) I'd love to have some more options to choose from.

Let me know what you've used that works for you, and any other resources you find. Share it in the comments section so others will know about it too.

And send me some warm, dry thoughts for Saturday! (And tonight too, I have an outdoor activity going tonight as well.)

Fashion Peeve #547

Not a lot to say today on birth; have plenty of big things in the works regarding birth but nothing ready to post yet.

However, wanted to air a pet plus-size fashion peeve and I figured, who else would understand like the fatosphere?

Here's plus-sized fashion pet peeve #547:

Why oh WHY do they cut plus-sized necklines so wide?

Granted, I hate crew neck shirts because they feel too snug around my neck, and we probably do generally want a little more room in the neck than thinner folk.

But do they always have to cut plus-sized shirt necklines so wide? Isn't there a happy medium somewhere?

Ugh, I can't tell you how many great shirts I've gotten rid of because the neckline is cut just a tad too wide and my bra strap ends up showing during normal activities.

Obviously if it shows my bra straps a lot when I try it on, I don't buy it. But what looks fine in the store often slips and slides around at home during normal wearing and I find my bra straps are often exposed.

I'm not a prude. I don't get shocked or offended if someone's bra straps show for a bit. And some shirts are designed to show bra straps...that's okay too.

But I do think it's tacky when a shirt that's not designed to show bra straps does. And especially in those of us with a rack who have to wear industrial-strength bras that don't have pretty, delicate little bra straps to show. It just looks tacky, nothing more.

Also, I work with kids a lot and it's just distracting and inappropriate to have your bra straps hanging out all the time. So I want a shirt where I don't have to constantly monitor what my neckline is doing or whether my straps are showing. Is that so much to ask?

I was trying to find a shirt this weekend for various activities, and I was just struck by how many shirts I have in my closet that I don't wear except around the house because of the neckline/bra strap issue.

AUGH!! So much wasted money, so much wasted cute clothing....all because someone doesn't take the time to understand REAL plus-sized women's proper fit.

And don't even get me started on how all the shirts are either too short or too long!

Healthy Birth Practices: Walk, Move, and Change Position

We're talking about the Six Lamaze Healthy Birth Practices, taking each one in order, discussing why it's helpful and important, and then discussing why these practices are often discouraged with women of size and how that impacts their birthing and cesarean rates.

The second Healthy Birth Practice is:

2. Walk, move, and change position

Walking around, moving, and changing positions make labor and birth easier and more comfortable.

But far too often, women are stuck in bed during labor and birth with a fetal monitor and tubes all over the place and are no longer really able to move.

This needs to change---and nowhere moreso than for women of size.

Why It's Important To Stay Mobile in Labor


Watch a typical birth on TV reality shows and you'll see that most women who labor and birth in the hospital are stuck in bed. Although hospitals now allow more movement in early labor than they used to, by the time labor has progressed very far, most women are still flat on their back, semi-sitting on their behinds, or propped a little to one side. Very few are up and moving about. And even fewer push the baby out in any position other than semi-sitting with the knees pulled back or their feet in stirrups.

This reflects our modern medical culture's expectation that women should labor and birth reclining in bed, and this positioning is strongly encouraged by doctors because it is more convenient and comfortable for them to attend.

However, if you look at labor behavior in non-Western cultures, women tend to move around in labor a lot. They may labor standing, sitting, walking, dancing, leaning over, in water, or on all fours.

Some choose to give birth lying down in bed, it's true, but more often they birth upright in a standing, squatting or in a "supported squat" position (someone holding them in a semi-squat from above and behind).

Some women give birth leaning on a table or bed, or sitting on a special "birth stool" that keeps them semi-upright. Many homebirth midwives today have special birth stools that women can choose to use. Others create a birth stool-like position by having the dad sit on a chair, knees apart, and having the mother hook her legs over his knees.


Some women have a strong instinct to pull or push against something during labor, especially when pushing out the baby. They may give birth hanging onto a bar or dangling from a rope or a person's hands. This is not unlike the "supported squat" position mentioned above, only now the woman is supporting her own weight.


Some women find themselves pulled towards laboring or giving birth in asymmetric positions, such as walking up stairs, or standing/kneeling with one foot up and one foot down. Others "do the hula" and circle their hips a lot.

This lifts up one side of the pelvis and creates extra space for poorly-positioned babies to reposition and rotate more easily. If the baby has trouble negotiating its shoulders past the mother's pubic bone, some midwives think a kneeling lunge or the all-fours position is particularly helpful for resolving things.


Because it too helps create more space in the pelvis, many women are pulled towards laboring and birthing on all fours.

This is often helps lessen back labor, and may help turn a "sunnyside up" (posterior) baby to an easier position for birth. If the baby is large or its shoulders are a tight fit, this position may help them slip out more easily.

All of these positions are much more commonly seen in non-Western cultures, and also in non-technological approaches to birth here in the West.

Why do women birth in all these different positions? Cultural expectations play a part of course---but research shows that when Western women are given access to a room in which the bed is not the central feature and are encouraged to labor and birth as they feel most comfortable, most do not choose to birth lying down in bed either.

The reason that most women prefer to move around a lot in labor and birth is because it's physiologically sensible and logical. It helps them give birth more easily and more comfortably.

Their bodies intuitively tell them they need to move and so they do it. Even in high-tech medical model births where women are stuck in bed, many still try to move as much as they can, shifting in bed, rocking their bodies, turning to their sides, trying to arch their backs. In fact, women with an epidural may have better results pushing in a side-lying position than in stirrups because there is more mobility of the pelvis in this position. Yet it is often not even tried.

This is not to say that women should never give birth lying down or in the semi-sitting position. Actually there are times when lying down can help a baby get past the mother's pubic symphysis more easily, and of course, many women in the hospital do manage to give birth vaginally in the semi-sitting position despite its challenges.

It can be done--but most women, when given true freedom of movement, do not choose these positions for birth, and there are times when other positions probably facilitate birth much better than these. The point is that women should have the choice.

What Research Says and Why

Research shows that being more upright in labor shortens the first stage of labor (dilation of the cervix) and lessens the need for epidurals. Alternative positions may also help increase the pelvic space available for the baby

Gravity helps move the baby further down into the pelvis, putting more pressure directly on the cervix, which helps it dilate more quickly and evenly. Mobility also helps change the internal dimensions of the pelvis, creating a little extra room for a baby when needed. (This is a little like how, if your boot or your jeans are a bit tight, you wiggle back and forth to get into it anyhow.)

Lying on the back or in a semi-sitting position means that the tailbone basically gets pushed into the pelvic outlet, making the space available for the baby a little smaller. Because the woman is sitting on the bed, the bed prevents the tailbone from moving out of the way as the baby is coming out, and it compresses the pelvic outlet. When women give birth in more upright positions or on all fours, they often arch their back at the last moment, moving that tailbone out of the way and creating more space at the pelvic outlet instead of less.

Another concern with lying flat on your back or in a semi-sitting position is that it can compress the blood flow to the uterus, compromising baby's oxygen supply. In fact, doctors often warn women during pregnancy not to sleep or lie on their backs for too long---yet once the mother is in labor, suddenly this advice is no longer followed and women are left for hours in this position. Moving around freely keeps the weight of the baby and the uterus off of the blood supply to the uterus, and helps ensure a better continuous oxygen supply to the baby.

Movement is also the body's natural response to discomfort. Think about how people respond to pain in daily life. Animals in pain are often restless and move around a room. If you stub your toe, you hop about for a while until the throbbing subsides a bit. If you are too sick to move around a lot, you may rock back and forth to deal with the discomfort you are feeling, or shift position frequently.

Many women handle labor pain in the same way. Some relax deeply and become more motionless to handle labor pain, but many respond to labor pain by moving. They may shift position frequently, walk around the room, rotate their hips, push actively against the doorframe or wall, dangle from a squat bar or pull against someone's hands, or rock back and forth as they deal with the surges of labor contractions.

Being stuck in bed on your back makes it more difficult for your body to move in response to the pain and makes you more likely to need drugs for pain relief. Pain meds are not "bad" (and we can be glad they are an option when needed), but they do come with risks to the baby and the mother. It's much simpler and safer to reduce the need for pain medications by allowing the mother to move freely in response to her pain and her body's instincts, reserving the meds for when they are truly needed.

Furthermore, many women find that their bodies intuitively tell them how they "need" to move during labor and birth in order to best facilitate the descent and rotation of the baby through the pelvis. Many women feel the need to get up and move about, to go onto hands and knees, to lift one leg, or to arch their backs during labor. Often, well-meaning nurses discourage this kind of movement near the end of labor, seeing it as counter-productive to getting the baby out, when in fact it may be exactly what is needed to get the baby out. We simply need to respect women's instincts more.

This is not to say that mobility is absolutely forbidden in hospitals these days. There is progress from the past when many hospitals required women to lie flat for labor, using drugs and physical restraints in order to keep them immobilized. Many hospitals today recognize that movement in labor is beneficial and "allow" the mother to change positions, walk, use a birth ball, or even labor in water.

Many doctors will tell women that they can labor in whatever position they'd like---and the nurses will absolutely support that---BUT when it comes time to actually catch the baby, most doctors insist the woman be back in bed, semi-sitting, with her knees pulled back and her body curved into a "C" position.

Alas, this is only the best position for birth if you are the attending doctor. It allows the doctor to sit on a stool and catch the baby without discomfort. But it makes the mom essentially push the baby out "uphill," makes pushing both more painful and harder to deal with, and diminishes the pelvic space. How sad that the priority in hospitals today is on the comfort and convenience of the doctor, not the comfort, convenience, and health of the mother and baby.

The research on mobility during labor is summarized in the Healthy Birth Practice Paper: Walk, Move Around, and Change Positions Throughout Labor and its accompanying video:

When you walk or move around in labor, your uterus, a muscle, works more efficiently. Changing position frequently moves the bones of the pelvis to help the baby find the best fit, while upright positions use gravity to help bring the baby down the birth canal. The diameter of the pelvic inlet and outlet can increase as a woman moves around in labor....

Researchers who examined all of the published studies on movement in labor found that, when compared with policies restricting movement, policies that encourage women to walk, move around, or change position in labor may result in the following outcomes:

• less severe pain,
• less need for pain medications such as epidurals and narcotics,
• shorter labors,
• less continuous monitoring, and
• fewer cesarean surgeries

In fact, no woman who participated in any of the research studies said that she was more comfortable on her back than in other positions. No study has ever shown that walking in labor is harmful in healthy women with normal labors....

Walking, moving around, and changing positions make labor easier and safer...Lamaze International encourages you to plan to be active throughout labor, to practice labor and birth positions during pregnancy, and to choose a care provider and birth setting that provide many different options for using movement.

Ah, and that is the key.

You must choose a birth setting and a care provider that not only "allows" but believes in the importance of mobility in labor and will do everything possible to help promote that.

Yes, "even" in women of size.

And therein lies the problem.

Mobility Restrictions Affect Women of Size Disproportionately

Even in hospitals that pay lip service to mobility in labor for other women, oftentimes "obese" women are not allowed the same freedoms.

In many hospitals, fat women are restricted to their beds--or if not outright restricted, strongly discouraged from moving about during labor. This is because of several erroneous beliefs or concerns about "obesity" and pregnancy.

Fear of Stroking Out

First, some care providers have the erroneous belief that all fat people have high blood pressure and are about to stroke out or have a heart attack at any moment. Even when a fat person's blood pressure is perfectly normal, care providers often believe that their high BP has simply yet to be unmasked and may well spike during the work of labor.

Because women with high blood pressure are typically kept relatively immobile in bed during labor, many doctors and nurses assume that fat women should be kept immobile in bed too, "just in case." But if the woman's blood pressure has been normal throughout pregnancy and is normal in early labor, chances are it will remain so, and keeping a woman of size immobile "just in case" is unnecessary and overkill.

Fetal Monitoring Issues

Another reason fat women tend to be kept immobilized is fetal monitoring issues. The baby of an "obese" woman is viewed as being at ultra-high risk for problems, so continuous electronic fetal monitoring (EFM) is often seen as obligatory in them, even in spontaneous labor with no drugs or pain meds (when EFM is usually not mandatory). This fear of problems for the baby is largely exaggerated, as the vast majority of babies of fat women do just fine--but in this litigious society, doctors tend to err on the side of interventions, even though continuous fetal monitoring has not been shown to improve outcomes.

Although theoretically, EFM should permit the woman to move around somewhat during labor, in practice it often means that the woman must lie still in bed in order to get an uninterrupted reading. Because women of size have extra adipose tissue that makes getting reliable EFM more difficult, they often have to keep extra still to get a reading.

Although telemetry (wireless) monitoring is available, it is usually not offered to women of size. Furthermore, because external EFM can be more difficult in women of size, an internal fetal monitor is often encouraged or even made mandatory for "obese" women in many hospitals. An internal monitor requires that the mother's waters be broken and a small electrode screwed into the baby's scalp. These wires go up into the mother's vagina, further restricting her ability to move around, and many women are told that once their water is broken, they are no longer allowed out of bed.

So external and internal fetal monitoring often are a big part of why women of size tend to have less access to full mobility during labor.

Fears of Falls and Worker's Comp Claims

Other reasons for restricting movement in women of size are fears about them falling, the strain on healthcare workers who might have to move them or help support their weight, and the financial burden of workers comp claims that might be filed as a result.

Although falls like this are quite uncommon in labor, the concern that a healthcare worker might injure themselves having to help a fat person is a common concern and has often been used to justify denying a woman of size access to waterbirth, to birth centers, and to movement during labor.

Barbara Harper, director of Waterbirth International, addresses the issue of denying fat women access to waterbirth based soley on BMI and fears of worker's comp claims. She says:

When I teach the professional Waterbirth Credentialing workshop, I do address waterbirth BMI restriction policies and insist that hospitals treat each woman individually...I implore them to look at pre-pregnancy activity levels.

I have been successful in having the BMI policies removed from some hospital protocols, but not in others.

There is no available scientific evidence one way or the other, with the exception that we did a search in both the US and the UK to find workers compensation cases for back injuries in labor and delivery settings. There were some, but none related to water.

Holding the leg of a 300 pound woman while she is pushing is much harder than helping her in and out of the bath.

Stereotypes about Strength and Mobility Levels

Many birth attendants also don't believe that fat women are strong enough or flexible enough to be mobile in labor. They don't encourage mobility because they've been programmed to believe that all fat people are unfit, weak, and sedentary, so why bother trying?

Unfortunately, these unconscious stereotypes about fatness also discourage medical staff from suggesting mobility and change of position options to their fat patients, most of whom could handle them just fine. Many fat women are far more flexible and fit than is commonly believed.

Summary

All of these factors combine to keep fat women in bed, on their back or semi-sitting, and strongly discouraged from moving around at all. Yet this may be the group that can most benefit from mobility in labor in many ways.

Why Mobility in Labor May Be Even More Important in Women of Size

No one has ever really studied mobility in labor in an "obese" population, so it's difficult to conclusively prove that mobility is important in this group. However, if it is helpful in women of average size, there is no reason to believe it wouldn't also be helpful in women of size.

Anecdotally, "obese" women who have had access to full freedom of movement during labor and birth usually report having fewer cesareans and fewer other problems compared to their previous births in which movement was restricted. (This was certainly true for me and a number of women of size I know from ICAN.)

Now, that's only anecdata at this point, but many women of size and their birth attendants find they achieve better results when they move freely and use non-traditional birthing positions. Waterbirth in particular seems to be VERY helpful to many women of size because the water buoyancy makes it easier for them to shift positions and maintain them with less stress.

One thing that many doctors worry about in fat women is the dubious concept of "soft tissue dystocia." Basically, this means that they worry that extra adipose tissue "down there" will make it harder for a baby to fit through easily. Many (in all seriousness) blame the higher cesarean rate in "obese" women on soft tissue dystocia (or "fat vaginas" as some doctors call it).

Ironically, almost no research has been done on "soft tissue dystocia" to see if it really is a valid concern or not, but doctors everywhere have been trained to believe it with every ounce of their being. A minor detail like lack of proof makes no difference. (I seriously doubt its validity as a real factor for fat women, but that's a whole 'nuther post.)

But let's pretend for a moment that soft tissue dystocia might be real, and that a fat vagina might reduce the pelvic space available to push the baby out. IF that were true (and that's a big IF), then mobility in labor would be even more important for "obese" women because it could open up the pelvic dimensions and give their babies a little more room to get out. It might make the difference between a cesarean and a vaginal birth, or a shoulder dystocia and a normal spontaneous vaginal birth. Every centimeter counts and mobility in labor can help add a little extra room that might make a difference.

And yet, fat women are the ones least likely to be given access to full mobility in labor. Ironic how the logic is so inconsistently applied, isn't it?

Conclusion

If you are pregnant, the most critical issue is to find a care provider and a birth setting that is supportive of you moving around as needed, whatever your size, and which will encourage you to labor spontaneously as much as possible (which will help you retain the ability to move freely).

Major red flags would be facilities that require or strongly encourage"obese" women to have constant EFM (especially mandatory internal monitoring), have BMI limits on access to waterbirth or other "alternative" modalities, or who assume that you will be induced and/or "need" an epidural because of your size. These are not birth settings where you will be encouraged to be as mobile as possible, and you are likely to have a higher risk for a cesarean under these conditions.

However, some hospitals and birth centers (and even homebirth midwives) talk a good game but
it's only lip service. In the end, some don't really support full mobility or spontaneous labor for fat women either. These have to be a little more carefully vetted because they can be wolves in sheep's clothing, pretending to be something they are not.

Tour the hospital and birth center and see just how many woman in labor are out walking the halls, ask how many use the tubs to labor in water, and how many have full mobility not only in labor but to actually push the baby out too. Ask your care provider what the weirdest position is that he/she has ever caught a baby in, and how often women in his/her care give birth in any position other than semi-sitting. Ask to interview former clients and see whether they felt they were encouraged to be truly mobile in labor.

If you observe carefully and ask a few open-ended but pointed questions, you'll be able to find the providers who truly support mobility and spontaneous labor instead of the ones who just give lip service to it. That won't guarantee you a better birth, of course, but it's a good step on the journey towards it.

Graphics from Wikimedia Commons or excerpted from www.transitiontoparenthood.com/ttp/foreducators/arthome.htm. (Many thanks to Janelle Durham for making these latter illustrations and information available freely!)