Wednesday, March 31, 2010

Choosing a Birth Care Provider - Which Type?

Some online friends of mine wrote this article for their local paper.  I gave feedback and helped during the editing process, and liked the final product so much I thought I'd share it here on my blog.  I offer it for those of you who are scratching your heads over figuring out how midwives and doctors differ. 

Again, I emphasize that no one type of provider is suitable for all women.  Some women prefer high-tech care with lots of tests and/or an epidural in the parking lot.  Some women prefer low-tech care, with minimal or no tests and birth as natural as possible.  Others want something in between.  There's nothing wrong with any of these types of births as long as you are clear on what you want and why.

Some women prefer that their doctors do all the decision-making, while other women prefer to be partners in their decision-making.  Some women prefer to birth in the hospital, and some prefer to birth outside the hospital (at a birth center or at home).

There no one "right" way to give birth for everyone. But if they explore their feelings, most people find they have ideals about how they want to be treated in pregnancy and birth, how they picture birthing their babies, and what kind of care they are looking for.  When I teach childbirth classes, I always encourage parents to explore the spectrum of possibilities and consider what fits best with their ideals.  In time, they usually find the right path (and provider) for them.

It's important to remember that the care provider's job title does not necessarily mean they practice in that same care model.  In other words, some doctors actually follow the hands-off tenets of the midwifery (physiological) model of care, while some midwives are high-tech and interventive like the medical (technological) model of care.  Although job titles and degree letters give you generalized clue to their practice style and philosophy, it's not a guarantee of anything.  You always have to ask questions.

Readers of the blog know that I tend to favor midwifery (as does the following article; fair warning) and have usually had my best experiences with midwives, but one of the worst experiences I ever had was with a homebirth midwife who was actually a high-intervention OB in sheep's clothing...at home, no less.  I also have met OBs who are very hands-off and low-tech.You can't tell someone's philosophy solely from their job title; interview carefully to see what their real pattern of practice is like.

I usually suggest that prospective parents interview several types of care providers, including some OBs, some CNMs, and some homebirth midwives.  Reflecting on these interviews usually helps clarify their choices for them.  Most people come away with a clearer idea of the type of care (and care provider) they prefer.

Here then is the article.  I hope you find it helpful.


Choosing a birth provider can be difficult

By Christa Billings and Amy Poe
From the Portland Tribune, Mar 25, 2010
http://www.portlandtribune.com/opinion/story.php?story_id=126946379588406800
Regarding Peter Korn’s article “Natural birth? Nope, C-Section rates on rise” (Feb. 18), one of the most important decisions new parents are faced with is choosing a birth provider. It is also one of the most difficult and confusing decisions to make.

The truth is that there is no one perfect location or type of provider for all women. We all come to our births with our own experiences, beliefs, personal health and genetics, and each mother has to come to know her own needs in order to choose the most optimal provider and setting for her birth.

There are two basic models of maternity care: the physiological (midwifery) model and the technological model (obstetrics). Each has its own advantages.

The physiological/midwifery model recognizes birth as a natural event. Care is centered on the woman and baby as a pair, and each pair is recognized to have its own set of experiences and unique health considerations. In this model, the birth providers spend a considerable amount of time with the parents, getting to know their physical and emotional needs and providing them with important information on their pregnancy and birth choices.

While the midwifery model emphasizes the partnership between the mother and provider in the birth process, the technological model views the birth provider as the expert whose job it is to control and manage the pregnancy, labor and birth. Normal birth is narrowly defined, and the provider is trained to treat any deviation from normal as a pathology needing intervention. The provider relies heavily on testing, monitoring and technological intervention in assessing and controlling the situation.

Statistically, both models of care can and do result in healthy babies most of the time. The primary differences between the two models are the type of care the mother receives during the pregnancy and her role in the actual birth – whether she is the active decision-maker (in partnership with her provider), or whether she delegates the control of her labor to an expert.

Naturally, it is always important to check the credentials and references of any provider you are considering, be it a direct-entry midwife, certified nurse-midwife, naturopath, family practice doctor, or obstetrician. But it is just as important to understand which model of care the provider practices, and whether that is compatible with your own beliefs about birth.

It’s important to realize that the provider’s title does not guarantee which model of care they practice. Midwives can order the same labs and screening tests as doctors, and some are very technology-oriented. Conversely, an OB-GYN may firmly believe in the normalcy and diversity of birth, and have a low technological intervention rate.

Midwifery care is a natural, holistic and wellness-oriented view of pregnancy and birth. Midwifery care focuses on the pregnancy as normal and healthy, rather than pathological. Most midwives believe in a proactive approach to wellness. They try to prevent complications in the first place by emphasizing healthy behaviors. If complications do arise, they take steps to work with you and your baby to deal with them instead of treating a complication like a disaster waiting to happen.

Time and patience can be one of the biggest benefits of midwifery care. Many doctors have strict time limits for labor, after which a cesarean is performed. Midwives believe that if the mom and baby are not in distress and all vital signs are reassuring, there is no need to hurry a birth. Every woman’s body and birth are different, and not all strictly adhere to a “typical” labor curve. Many babies come out naturally if given a bit more time and patience.

Many women have heard of midwives but are unaware of research showing improved outcomes with midwives. Examples include the interspecialty differences in the obstetric care of low-risk women, on the Web at www.ncbi.nlm.nih.gov/pubmed/9096532, and the outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia, on the Web at www.cmaj.ca/cgi/content/full/181/6-7/377.

Midwives are experts in normal birth, and most births proceed normally, with good outcomes, if allowed a little time and patience. However, sometimes more intervention is needed, and midwives are trained to recognize when intervention or technology is needed. At that time, they have obstetric colleagues to whom they refer their clients, while still following up to assure continuity of care. It is at those times that we can be grateful for the surgical skills and capabilities of our obstetricians and hospitals.

Not only does midwifery care lead to fewer infections, inductions, episiotomies, vacuum/forceps extractions and cesarean sections, but midwives also tend to the emotional, spiritual, and health and nutritional needs of the mother from the start of the pregnancy through labor and birth and for several weeks after the baby is born.

Choosing your type of birth provider is a critical choice in your care. Oftentimes, parents spend more time researching and picking out nursery d├ęcor than they do choosing a provider who meets all their needs. For some women, an OBGYN is the right type of provider and for others it is a midwife. Taking the time to do your research on choosing the right provider for you can have an effect on the outcome of your birth.

Christa Billings of Beaverton, and Amy Poe of http://www.birthmatters.info/

Friday, March 26, 2010

You Have The Right To Decline To Be Weighed

A while ago there was a discussion over at the blog "Fat Positive Femin[IS]m" about getting weighed at routine doctor appointments. This is one of my hot buttons, so I started commenting, then realized I should probably save it for a post here.

Here's the bottom line: You really can decline to be weighed. You do NOT have to submit to being weighed at every appointment.

I decline being weighed all the time. Sometimes I get hassled for it, but most of the time I don't anymore. I make it clear that this is NOT negotiable. I do keep track of my own weight, informally, at home, but I don't agree to weigh-ins at the doctor's office unless there is a clear, pressing need for it. 

Some people don't have a problem being weighed routinely at the doctor; some do.  Some people weigh themselves regularly at home if they don't at the doctor; some don't. I'm not telling you what you should or should not do; I'm just reminding people that they have a right to decline being weighed at the doctor's if they prefer to avoid it.  This is something that some people of size don't realize.

Your Right To Informed Refusal

As a patient, you have the RIGHT TO DECLINE ANY MEDICAL TEST OR PROCEDURE at any time. It's your body, and you have the final say.

We don't think of weighing as a medical test, but it is a form of one. And you always have the right to informed refusal of a test or medical procedure. So no, you do NOT need to be weighed every time you go to the doctor. It is a test or procedure that you can refuse.

If you do plan to refuse weigh-ins, use strong, clear language when declining; don't be unpleasant, just polite and firm. I usually say something along the way of, "I don't do weigh-ins, thanks" if I'm not anticipating trouble.

If you meet resistance, use stronger language than "I'd rather not" or "I'd prefer not to." That leaves arguing room and sooner or later you'll get arguments. Just state clearly and categorically "I decline to be weighed" or something similar.

If they press it or claim it's necessary, remind them that you have the right to decline any test or procedure at any time and you are declining this one. If they really push (I've had it happen), use legal language, like "I DO NOT CONSENT." Any medical person worth their salt knows that this carries legal heft and that carrying out a procedure on someone after a phrase like this could potentially be construed as assault.

If it gets unpleasant, ask to speak to the office manager, the care provider, or just leave. A letter of complaint afterwards, reminding them of your legal right to informed refusal of any test or procedure, can also help change their tune.

The Power of Complaint

Complaining can be powerful. As I've mentioned before, I once visited an urgent care facility whose large blood pressure cuff was "out for repair." I declined to have my BP taken with a too-small cuff (which can strongly elevate BP readings). Long story short, they manipulated/badgered me into agreeing, the numbers were very high, and I was furious that those inaccurate numbers were now in my medical record.

So I wrote a letter of complaint to the clinic, to my insurance company, and to the head of medicine. I reminded them that I had the right to refuse any medical test or procedure, I included research that showed how much BP can be altered with a too-small cuff, and I quoted the American Heart Association's policy on cuff size. I demanded that they get a working large cuff, that they train their staff on the importance of its use, and that they remind staff of the right of patients to decline testing. Boy, did THAT get results.

So I'm just saying, if this is an important issue to you, feel free to resist being badgered into it. Start by politely refusing to be weighed.  Try to keep things low-key whenever possible.....but if pushed it can be very effective to complain verbally, to ask to see a superior, or even to write a letter afterwards and remind them of your LEGAL RIGHT to informed refusal.

I've had a couple of tussles with med techs who insisted I had to get weighed routinely.  One tried the excuse that the insurance companies were really cracking down and everyone had to be weighed now at every visit.  I noted that they might be trying to encourage that, but it was still my right to decline it. She kept arguing, so I asked whether I was going to need to talk to the office manager.  At that point she backed down, and my nurse-practitioner noted wryly afterwards that no one could ever accuse me of not being able to stand up for myself.  No one in that office bugs me about it now. We do a little dance out of formality; they take me to the scale every time, I politely remind them that I decline to be weighed, and we go on our merry way without any more hassle.

Sometimes, you might find a provider will not keep you as a patient if you decline being weighed.  I haven't found that yet, but I'm sure it could happen.  In that instance, you have to decide if avoiding weigh-ins is worth it or not to stay with that particular provider. Generally speaking, my view is that if they don't recognize that routine weighings are a fairly meaningless measurement and that you always have the right to decline such things, they're not worth having as a care provider anyhow.  I would worry what other medical procedures or interventions they might try to bully me into, and I would not want to stay with a provider who tried such strong-arm tactics.

When Weighing is Appropriate

Most med techs have been matter-of-fact about it when I decline to be weighed, but occasionally one will fight me. I have no doubt that regular weighing is encouraged but the fact is that they cannot "require" it because legally you can always refuse tests or procedures.

That said, sometimes I'll pacify them by telling them that I'd be happy to weigh later in the appointment IF there is something in the appointment that requires an accurate weight. Examples of that might be:
  • Certain types of prescription drugs (although most drugs do not use weight-based dosing, some do and an accurate weight would be important for these)
  • Before a surgical procedure (anesthesiologists need an accurate weight for anesthesia dosing)
  • Prenatal blood tests for birth defects (an accurate weight is very important for these tests)
  • If the doctor has reason to be concerned about something like Congestive Heart Failure (weight gain from fluid retention can be a marker for worsening CHF)
These are all legitimate reasons for weighing at certain appointments, and a history of CHF would be a legit reason for weighing on a regular basis.  No doubt there are other reasons that could justify weighing too, but these are the ones that spring to mind most readily.

Sometimes they will tell you they need to track your weight so that if there is a big increase or decrease, they know to look for possible problems like diabetes (which often causes a sudden, unexplained weight loss), etc.  This is an accurate point. As Living ~400 lbs. notes, it certainly is true that a big change in weight can indicate problems, and there are certainly advantages to tracking your weight trends. I'm not opposed to that, and in fact I track my own weight for just that reason. 

However, it's your choice whether you prefer to do that for yourself or have your doctor do that for you.  Personally, I prefer to track my own weight trends and stop being a slave to the medical weigh-ins. I simply reassure my healthcare providers that I am perfectly capable of watching for any alarming patterns myself and that I will report in if there are any concerns.  They know me well enough to know that I care very much about my health and that I really will follow up on it if there is a problem.

Because there may be other situations in which weighing really is important medically, be open to listening to reasons. If it seems reasonable and in your best interests, do it. If you don't mind routine weighings and it's no big deal to you, it's probably easier to just go along with it; there's no law that says that if you are into fat-acceptance you have to decline being weighed.

But think through your feelings so you are making a conscious decision about routine weighing; if it doesn't seem reasonable, if it's just routine and you prefer to keep track on your own, or if you find being weighed triggering or judgmental, feel free to decline it.

Remember, you have the power to refuse or acquiesce.

Conclusion

Weighing every time you go to most doctors is not a requirement. If it bothers you to be weighed, if it's triggering to you, or if you just refuse to be constantly subjected to scale scrutiny, just say no.

Personally, I always agree to be weighed the first time I visit a new care provider, so they have a ballpark figure on record for med dosing or whatever. I think that's a reasonable request.  But after that, I decline to be weighed routinely. Some days it's a battle to have that decision honored, but I don't ever back down.

I do consider circumstances individually; if there is a justifiable reason to get an accurate weight, then I agree to it gracefully and without making it into a big deal.  But only if there's a real reason for it.

I do have a scale at home and I do weigh regularly in order to watch for any alarming trends. I find that just relying on the fit of your clothes is not enough to really monitor your weight trends and that a closer watch than that can be useful, so I do weigh.

However, I don't need to rely on a doctor's office for that; I'm perfectly capable of monitoring my own weight trends. It doesn't take a medical degree to weigh yourself and keep track of those numbers.

I am in a place emotionally where I don't fear seeing the number on the scale....it's more a matter of principle.  I was a slave to the scale for many many years and I lived and died emotionally about what the damn thing said and on the reactions of the people weighing me.  I refuse to go to that place anymore.  I know what I weigh and I don't have a problem with that number, but I don't need to submit that number to public review unless I choose to or there's a compelling medical reason to do so.

Most of the time, it's just routine to weigh people, not truly necessary. And it's ALWAYS your right to accept or decline.

What do you choose to do in your life?  Do you agree to routine weighings at the doctor's office, or do you refuse?  Do you keep track of your weight at home, or do you find simply monitoring the fit of your clothes is enough?  Why do you make these choices?

*Coming Soon:  The Debate Over Routine Weighing During Pregnancy

Sunday, March 14, 2010

Why VBAC Bans are a Violation of Human Rights

The International Cesarean Awareness Network (ICAN) recently held a blog carnival about why VBAC is a vital option.  If you can, you should definitely go check out some of the different entries about why having the choice to VBAC is important.

[For those unfamiliar with the terms, VBAC stands for Vaginal Birth After Cesarean, pronounced "vee-back."  In the United States today, more than 90% of women who have a cesarean will have cesareans with future children.  Some women choose this happily, but many are forced into it because the option to have a VBAC has been taken away in nearly 50% of U.S. hospitals today.  Not because VBAC is unsafe or women don't want to have them, but because doctors and administrators -- or malpractice insurance companies -- refuse to "let" women have them.]

VBAC bans are a Human Rights Issue, plain and simple. No one should be forced to have surgery against their will. 

Doctors will argue that not offering VBACs is not "forcing" a woman into surgery, but in essence it is if there are no other options in her area for having a VBAC or if the conditions in places that do "offer" VBAC are so restrictive that almost no one will get one. 

Doctors need to stop pussyfooting around the issue and quit splitting hairs; if their hospital or practice does not offer VBAC as a choice, they are denying women the right to choose how they give birth, and in essence, FORCING women into surgery.  How does that align with the oath of "First, Do No Harm?"

Ideally, women are given true informed consent about VBAC vs. Elective Repeat Cesarean Section (ERCS), and their choices are honored. Of course, sometimes that does happen; but far too often women's decisions for VBAC are not honored, and their choices are taken from them.

Sometimes women are literally bulled into repeat cesareans with threats (like calling Child Protective Services). Sometimes they labor at home and go in pushing.....only to be put under anesthesia and forced into a repeat section when they get to the hospital.  (Yes, I know women to whom this has happened.)

More often women are seduced into repeat cesareans with distorted information about risks of VBACs vs. cesareans, inaccurately gloomy assessments of their ability to VBAC, or scare tactics about possible complications of VBAC without similar information about possible complications of repeat cesareans. 

Talking people into potentially harmful interventions without fair and balanced informed consent -- and the freedom to refuse the intervention -- is a human rights violation.

In no other situation is a person forced to undergo surgery for the benefit of another person.  Furthermore, one could argue that with VBACs, people are being forced to undergo surgery for the medico-legal security and the financial benefit of others

This is such a complete and total breach of medical ethics it's breathtaking.....and yet many doctors, hospital administrators, and insurance company officials readily advocate it.  They refuse to see the implications of their decisions and policies.

Everyone has the right to bodily integrity and to informed decision-making. No one should be able to take that right from you, not "even" during childbearing.

Violence and intimidation against women does not just occur via domestic violence or rape. Unfortunately, it also happens during childbearing, but our society does not view it as an abuse of rights....but it is.

It's time to see VBAC bans as the human rights violation that they are.

Shame on ACOG, and shame on the doctors and hospitals who are going along with these bans. 

Sunday, March 7, 2010

Back from Paradise

Well, I'm back from Paradise.  So now I'm going to indulge in a fluff post and tell you all about it.  Feel free to either start yawning or turning green with envy now!

There are really just no words to describe how beautiful Hawaii is.  It's so stunning and so unexpected.  I mean, I knew it would be beautiful, but wow, just WOW. 

I have not yet been to the other islands to compare, but I can't recommend the island of Kaua'i enough.  It's called the "Garden Island" for a reason.  It's really stunning in all its variety. 

East, South, North, West

The island is fairly small and yet has so much variety on it.  In the middle is Mount Wai'ale'ale, reputed to be one of the wettest spots in the world, getting more than 400 inches of rain per year.  Just a few miles south is the Poipu area, which I read somewhere has only about 30 inches of rain per year.  Difference much?  And in only a few miles!

The terrain varies from huge mountains in one area, a spectacular canyon in another area, and mostly flat stretches of farming in yet another area, all on an island only 550 square miles wide. And of course, surrounding them all are some of the most spectacular beaches around.

The east side of the island is where the airport is (see left), in Lihue.  It's called the Coconut Coast, because there used to be a coconut plantation nearby.  This area of the island is now the most populous, and it has lots of shopping and a goodly amount of hotels, condos and rentals.  It's usually warm and reasonably dry.  If you are looking for a cheap place to stay on this island, consider the east side, around Kapa'a.  It has the most economical choices, but the downside is that the vibe here is more touristy, crowded, and busy. 

We stayed on the south side of the island, near Poipu.  This area of the island gets the least amount of rain, especially in winter, and is almost always sunny and warm whatever the time of year.  It has one of the best beaches on the island for swimming and snorkeling (Poipu Beach, left).  If you want to vacation for sunshine and warmth, this is the place to go on Kaua'i.

The terrain is mostly flat in the south, and while there is a strong tourism industry, development has been strictly limited in order to preserve much of this flat land for farming or ranching. Thus the area has lovely amenities without feeling overly developed or too touristy.

The north side of the island has the most beautiful scenery.  It transitions into mountains, but with great beaches in Hanalei Bay.  However, in the winter, the surf is too strong for swimming, and it does rain more often in the north than in the the south, so not everyone likes to go here in the winter.

But if you want scenery, the north side is the place to be.  It's just breathtaking, and as a result, has a number of spectacular resorts and condos.  Its tourism industry is strong, with many luxury amenities, but the area also has a "crunchy" vibe, with a small artist's colony near the Hanalei area.  In the summer, the north area is the most popular area on the island. 

Also not to be missed is the Kiluea Lighthouse Park (left).  It was an important  guide in the shipping trade from the Far East, and the views are spectacular.  We saw some whales there too.

The west side of the island (the Na Pali Coast) is nearly inaccessible and has been preserved as a wild area.  The mountains there are huge and usually go right up to the ocean.  This part of the island is famous and often featured in photographs because it truly is breathtaking.  It's mostly toured via boat off the coast, or by helicopter. 

Helicopter tours are not cheap, around $200 per person for a 1-hour flight, but it's really the only decent way to see the Na Pali coast in a way that truly does justice to the vistas. If you have the chance to take a flight, you should do so. 

Because the island has a huge amount of rainfall in the center and much less on the edges of the island, the rain flowing down the mountains has created the side effect of beautiful waterfalls and an amazing canyon.

Waimea Canyon is called the Grand Canyon of the Pacific for a reason.  (This picture doesn't begin to do it justice.) You can drive up into the canyon, and the trip is well worth taking. There is also a beautiful park at the end of the road, Koke'e State Park, with lots of hiking trails and beautiful views.

The beauty of Kaua'i is so remarkable that a number of movies and TV shows have been filmed here, including parts of South Pacific, Jurassic Park, Raiders of the Lost Ark, Donovan's Reef, Six Days Seven Nights, and the remake of King Kong.  The island was also the setting for the animated film and TV series, Lilo and Stitch.

One of the strangest things about Kaua'i is the huge population of feral chickens. Originally brought over as a food source by the Polynesians who settled the islands, they have multiplied into a significant wild population and can be seen everywhere on the island.

One of the more puzzling things to me about Kaua'i was the lack of vegetable gardens.  This is an island with gorgeous weather, around 80 degrees (give or take) year-round; it should be perfect for raising your own veggies.  Not to mention the fact that the cost of living is very high here, and shipping food is very expensive. 

So you'd think I'd have seen tons of veggie gardens there, right?  Not so.  I saw a few, yes, especially with citrus trees, and plenty of gardens with exotic plants and blooms, but very few actual vegetable gardens. I don't know why.   (If anyone does know why, I'd be interested in hearing the reasons.)  It just seemed strange that when we went shopping in the supermarkets of this tropical paradise, most of the veggies and fruits were imported from California, Mexico, and Chile. 

We were lucky we took our vacation when we did. We got home shortly before the big earthquake off of Chile caused a tsunami alert. I checked the Kaua'i newspaper and it looks like the warning sirens went off at 6 a.m. and our resort was evacuated by 9:30 a.m. to higher land in the interior. Thankfully, the tsunami turned out to be much ado about nothing, but it would have been a bummer to lose a day of vacation like that. Still, it's good to know the local businesses are prepared for such things and the alerts are working, and I'm certainly greatly relieved that no one was hurt or lost their livelihood/home.

Slower and Less Tourist-y

Kaua'i has been purposely preserved as a semi-rural island.  There were sugar plantations here until a few years ago, and there are still large plantations that raise cattle and other products.  Zoning for tourist development and residential areas is very strict in order to keep the semi-rural nature of the island intact.

This means that while there are tourist areas, they have not taken over the entire island.  There is still plenty of touristy stuff, mind, and there is no shortage of shops --- but reportedly the tourist stuff is not nearly as overwhelming as it is in other parts of Hawaii. 

Should you consider Kaua'i?  Well, if you love the night life and want to spend lots of time partying and shopping, Kaua'i is probably not for you.  The night life and high-end shopping choices were definitely limited. Or if you like to get totally away from it all, don't want any touristy stuff, and want to rough it for all of your stay, Kaua'i may not be for you either.  Its amenities fall somewhere in between these two extremes.

On the other hand:
  • If you like nice accommodations but without feeling overwhelmed by touristy stuff, Kaua'i may be more up your alley.  It's reputed to be much more laid back than many of the other islands.
  • If you are the adventurous nature type and want to do lots of hiking, kayaking, surfing, canoeing, etc., there is a whole cottage industry devoted to the tourist-adventurer on Kaua'i.  There are some amazing opportunities for this type of traveler, especially those who like to come home to a little pampering afterwards in their hotel.
  • If you are the type that likes to lay back in the sand or by the pool and just soak up the sun, there are many choices for accommodations to let you do just that. 
  • Hotels, time-shares, and rental condos and houses are available in all parts of the island except the west.  http://www.vrbo.com/ is a good place to search for rentals, but book well ahead, since many of the best choices get snapped up far in advance. 
  • If you are the type that wants to be pampered in true luxury, there are a few beautiful resorts of that quality available.  The Grand Hyatt Resort near Poipu and the St. Regis Princeville Resort in the north are luxury personified, and have reputations as two of the finest resorts in the world.  
Size-Friendliness

Overall, I found my trip to Hawaii to be pretty size-friendly.

I flew the day after Keven Smith got kicked off of Southwest Airlines for being "too fat," so I went into the flight with some anxiety, even though I was flying Hawaiian Airlines instead of Southworst. Of course, I always fly with seatbelt extenders, just in case they might be needed, but I didn't have to use them once on the whole trip. And no one threw me off the flight, glared at me, or tried to make me buy two seats.  That was refreshing.

The car we rented was a little small. I was trying to save money; next time I'd upgrade a bit. This one was okay but it was very low to the ground and with my knee injury from that stupid car accident a while ago, it was hard to get in and out of easily. There was no problem with fit or anything, it was just a little low to get into and cramped for leg room, which was a bad combo with a cranky knee.

Everything at the hotel was great. We got a huge cost-saving deal because of the economy and so decided to splurge on staying in one of the luxury resorts.....because you only have your 25th wedding anniversary once, right? So while we could have found a cheaper option, we decided to splurge at the Grand Hyatt Resort in Poipu, and it was fantastic.

At first glance, I was dismayed that there were a lot of stairs coming in and out of the main building. Now, although going up stairs hurts, it's going down that is so much harder. So when I saw all those stairs I was more than a little dismayed. However, on closer examination, there is a way around all those stairs; it's just not obvious at first look. I almost always I took the stairs anyhow---figured I should use it or lose it---but I was glad that the option of elevators was there for those who needed it. 

I also noticed that most of the paths to the pools were on ramps rather than stairs, which was definitely welcome.  And they had an easily accessible saltwater pool lagoon down at the bottom of the pool complex that was amazing.  I didn't go there till my last day, but it was warmer and nicer than all the other pools so I regret having left it till the last day.  It was awesome.

One thing we didn't do was take a helicopter tour.  I really regret that now.  One company would have had us pay an extra fare ($600 instead of $400) for a third seat on the smaller helicopter.  We really debated it but decided that kind of money for about an hour's worth of time just wasn't worth it, and I was not pleased to have to pay an extra two hundred dollars because of our size. On the other hand, I now feel like we really missed out on something special.  I think we should have tried harder to find a company that would accommodate us without that much extra charge.  Perhaps if we'd researched all the companies, we would have found one.

Buying clothing souveneirs in extended sizes was an issue.  Most stores do not carry very large sizes, and what sizes they have tend to run small.  If you are mid-sized person, you can probably find souveneir t-shirts fairly easily.  A lot of stores have XL or 2X shirts. But those who wear 3x or above have to really search for resources.

I prefer to buy roomy rather than snug, especially with the old rack'o'doom, so I generally buy 3x or 4x. For a while there I thought I was going to have to leave my beautiful vacation without any wearable souveneirs of it.  That would have been a total bummer. But eventually, I did find a few stores that carried t-shirts in my size. 

The Waimea Canyon General Store in Kekaha (right at the turnoff to Waimea Canyon) had clothing to 3x-4x.  They had a few men's shirts in 4x that fit me just fine.  They did have a few other things for women in 4x-6x, but frankly the choices were limited and the sizing ran small.  They had some great Hawaiian shirts for men up to 6x; why do stores always have more choices for men of size than women of size?  Grrrr.  Still, at least they had some t-shirts in my size that I could use, even if I had to buy a man's cut to get it.

http://www.dirtshirt.com/ is another shop that carries t-shirts in larger sizes.  Some of them are processed with lava rocks to create a washed-out look; others are dyed with the iron-rich red dirt of Hawaii for a unique red-brown look.  I got some 4x shirts here that fit me.  Again, sizes seemed to run small in general.

My best shopping was at the Bodacious Plus Size Apparel shop in the Coconut Marketplace in Kapa'a.  They carried sizes up to 6x in most things, and I was able to get some absolutely gorgeous sundresses, skirts, and nice shirts there.  (Ironically, though everything else fit, their t-shirts were too small.)  The owner is a plus-sized woman herself who got tired of having to go to the other islands to find clothing in her size, so be sure to support her business.  We want to make sure clothing in larger sizes stays on the island.

Overall I found Hawaii a pretty size-friendly place to be.  This is logical since many of the native Hawaiians are larger people.  The vibe in the tourist areas definitely tends towards the skinny, but I didn't feel stared at or put-down in my bathing suit, and generally found facilities fairly accommodating.

Final Thoughts

Our last night in Hawaii, we went down to Shipwreck Beach and watched the sunset.  As the sun disappeared, a small school of whales passed by, including a young one who was cavorting and having a heck of a lot of fun.  What a lovely way to end our trip!!!

Overall, I found Kaua'i just absolutely wonderful. I can't say enough about it. If you get a chance to go, you should definitely go check it out.  (And right now is a great time to travel, with lots of bargain prices available.)  It's definitely on my "must return someday" list!!!!!!


*Source of these pictures: Wikimedia Commons. And trust me, the pictures do NOT do justice to the scenery at all.  You have to see it yourself to believe it.