Tuesday, May 29, 2012

Plea for Help in the U.K.

This comment was left on a recent post on this blog.  It is a plea for help from a pregnant women in the U.K.

I am only going to address one aspect of her concerns, the one I find most disturbing; I hope others will step up and address some of the rest of her concerns.
Please please please, can someone help me. I am 10 weeks pregnant and currently have a BMI of 35.  
Firstly, I have suffered with severe sickness since 5 weeks and doctor said it was ok as I 'could do with losing some weight' and refused to give me medications, and now I have had my first midwife appointment today and was told that more than 50 percent of maternal deaths in pregnancy and childbirth are obese mothers and that I will have to have special monitoring and won't be allowed to have a natural birth at the birth centre and will have to be under consultant care and be constantly monitored throughout labour (meaning no water birth, no moving around, no getting into positive positions to birth).  
I am so scared and disappointed, I feel like I am an unfit mother already and feel that the drs think I do not care about the health of my unborn baby. Now I know that this will not go down well with some people but I am considering a termination so that I can lose more weight before carrying a child (I have currently lost 70 pounds). 
I came across this blog and I am aware that you are based in the US and I am in the UK so some things are different...for instance I can't actually choose a provider and am stuck with who I have :(...but please, any advice would be so appreciated. Both myself and my partner are concerned and do not know what to do. 
There are so many things to cover here, it's hard to know where to start.  Please comfort and reassure this woman that she CAN do this.  She needs to hear from many people, not just me.  Please leave some encouraging comments at the end of this post.*

In the meantime, here is my response.  First, dear Reader, please don't terminate this pregnancy over these scare tactics or your fears.  Chances are that everything will be okay.  Many MANY women with a BMI well over 35 have had healthy pregnancies and babies.  My BMI is 48, far over yours, and I had 4 healthy pregnancies and babies, and am none the worse for wear for it. I know so many women your size and far larger who have had healthy happy babies.  You can read some of their birth stories here and here.

No, no one can promise you with 100% certainty that you and this baby will be fine, but the odds are certainly in your favor, "obese" or not. Most obese women have healthy babies; some do have complications like GD or high blood pressure, but even then, most of the time, these conditions are able to be treated and everyone is still fine.  So don't panic over the scare tactics they are giving you.

To be fair, the doctors and midwives are trying to do what they think is their job, to apprise you of possible risks associated with "obesity" and pregnancy, but the problem is that they have gone so far overboard in stating these that they are frightening women unduly, making them think that almost no women of size have healthy pregnancies or babies, when in fact, most do.

In some cases, care providers lay on the scare tactics so strongly that they bully women into weight loss surgery, risky diets, over-intervention, and even terminating the pregnancy.  That is NOT good health care, that's medical bullying. And for God's sake, this poor woman has already lost 70 lbs., but despite the fact that she followed typical medical advice to lower her BMI before pregnancy, she is still being punished and scared half to death.  Where is the justice in that?

Yes, there are some risks associated with pregnancy in obese women, but NO, the answer is not in scaring women into terminating an established pregnancy until they reach a "normal" BMI.

Shame on these providers for laying the scare tactics on so strongly that someone would even consider terminating a pregnancy simply because of their weight.

Yes, among those rare women who have died during pregnancy or birth, obese women are overrepresented somewhat.  That does NOT mean that 50% of obese women who are pregnant die during pregnancy─that's a misunderstanding of what the care providers were trying to say. Death is an extremely rare occurrence for childbearing women in the developed world, and although very high BMI women are somewhat overrepresented in that group, the actual numerical risk of it happening to any one obese woman is quite low.

And the reason why fat women do die during pregnancy or birth boils down to three main causes, some of which is preventable:
  • Complications from general anesthesia during a cesarean
  • Complications from hypertensive disorders (high blood pressure and resulting disorders) in pregnancy
  • Blood clots (usually in conjunction with cesareans)
So to lower the risk for these problems, consider the following:
  • Don't let them push you into a cesarean you don't need. If a cesarean is required at some point, make sure they are prepared to use an epidural or spinal block instead of general anesthesia. Have an anesthesia consult ahead of time to be sure they have the equipment needed on hand if it were needed
  • Make sure you are monitoring your blood pressure carefully (you can get a home BP monitor if your readings are questionable at all), make sure they use the correct-sized BP cuff so that that readings are accurate, and get regular exercise and have great nutrition to lower your risk for developing gestational diabetes or blood pressure issues 
  • Regular exercise also lowers the risk for a blood clot during pregnancy; for certain people, low-dose aspirin therapy (only under the supervision of a care provider) is sometimes advised. If you have a cesarean, discuss with your provider the use (and proper dosage) of blood thinners, and be sure to move your legs around and walk as early as you can tolerate after the surgery. There are also special wraps and cuffs that can help reduce your chances of a blood clot after a cesarean; make sure to request these if you have a cesarean, and note any increase in shortness-of-breath to your providers
If this woman were in the U.S., I'd tell her to change care providers ASAP because it's difficult to overcome a really deep-set provider bias about obesity in just a few months, and it often influences the care a high-BMI mother receives.  However, I'm not sure what your options are for alternatives in the U.K.

There are, of course, private midwives that you could hire from outside the NHS system, and it seems to me like this would be well worth the money to do if you can manage it.  I bet we could find a private midwife who would take you on as a client and who would work with you to find a way to make it financially feasible.  I know there have been women of size who have had great out-of-hospital births in the U.K. with private midwives.

But if that's absolutely not an option, then you will have to work within the system, and the way to do that is to push back against the care providers who are giving you a hard time.  I'm hoping some of my U.K. readers will pop in and leave some suggestions about how to do that.

At the very least, one of the best things you can do is to find a Pregnancy Buddy, an advocate familiar with size-friendly care practices, who will come with you to appointments and help you speak up for quality care and question fat-phobic practices.  A doula who really "gets" weight stigma and has a Health At Every Size approach could be a great help for you in advocating for more size-friendly care.

Best wishes to you, and I sincerely hope you will not let your fears (and the scare tactics of the providers) keep you from enjoying this pregnancy and this baby.  Be as healthy as you can in your habits without obsessing over them, find a Pregnancy Buddy or Size-Friendly Doula to help you speak up for yourself, and don't be afraid to push back against the bias of your providers and even report them to their superiors if necessary.

Pregnancy is one of the best times to learn how to advocate for yourself, your baby, and your needs (whatever size you are), and you deserve to have loving, respectful care, regardless of your BMI or whether you lose enough weight to fit into their narrow definition of "normal".  Start demanding that care now, and don't settle for second-best.  You and your baby deserve no less.

*Please keep your comments civil and kind and aimed towards helping this woman's specific situation or about commenting on weight-biased scare tactics, rather than about pushing a particular point of view on abortion. This is not a forum for abortion debates, and I will be vetting comments before I publish them.  Please stay kind and helpful in your words.  Thank you.

Wednesday, May 23, 2012

A 50-75% Chance of "Needing" a Cesarean?

Another gem from My OB Said What?!?
“You Have A 50-75% Chance Of Needing A Cesarean Section Next Time…” 
“You have a 50-75% chance of needing a cesarean section next time, because you are short and overweight.” 
– Perinatologist to mother during preconception meeting...after the mother had already had a successful vaginal birth
This is how many doctors perceive us because of our size (both height and weight).  They simply conclude that there is virtually no way for us to birth a baby vaginally, never considering that their own biases around size and their common interventions with short/fat women (inducing early, having a low threshold for surgery) influences these outcomes.

The kicker here is that this woman has already had a vaginal birth, and despite difficult conditions too.  Once you've had a vaginal birth, your chances of having another is greatly increased....yet in his eyes, this doesn't really count at all if you are fat and short.

Older women get the same kind of grief.  And so do VBAC moms.  And it's all nonsense, frankly.

Yes, there is some research showing higher c-section rates in fat women, older women, short women, blah blah blah.  But RARELY do they consider whether it's really that "risk factor" or instead the way they manage the labors of these women and the fear they have around these risk factors that increases the cesarean rate more than the risk factor itself.

In obstetric research,the problem is always assumed to be with the woman.  Not the care provider's management or perceptions of risk, but somehow the fault of the woman herself (or her obesity, or her age, or her shortness, yadda yadda). I almost never see studies raise the question of provider perception or management at all.

It's time for care providers to recognize that their management of women is an integral part of high c-section rates in certain groups...not the only factor, but a much stronger factor than is generally acknowledged.

I have a dear online friend who is currently having a difficult time finding a provider who will support her for a VBAC.  This despite the fact that she has already had TWO VBACs.  It doesn't matter; they just see that she's fat and had a prior cesarean.

This is really pissing me off. Especially since I'm all of the above.  I'm short, "morbidly obese", old, and a VBAC mom.  Most doctors would look at me and tell me I had NO chance of having a vaginal birth because of these four risk factors....and yet I did.  Twice.

Risk factors are not absolute sentences. MOST women, even with risk factors, can birth just fine, if they can just get care providers to "let" them have an adequate chance at it.

It's long past time for care providers (and researchers) to recognize that the way providers manage and perceive women with risk factors has a lot to do with the outcomes associated with them.

Saturday, May 19, 2012

Birth Story Video: Jennifer's Waterbirth

Here is the birth story and wedding/birth video of a plus-sized mama I thought readers might enjoy.  It's not a short video (about 6 minutes) but it's well worth watching!

Below is the mother's story (which includes 4 previous miscarriages) and what she wants other women of size to know about pregnancy and birth.
My name is Jennifer. I live in southern Oregon and am a midwife apprentice. I have attended many births and have caught 4 babies under supervision. Of the many births I have attended, a good handful have been to plus-size mommas. 
Two off the top of my head were between 300-400 lbs. Both mommas had very healthy uneventful pregnancies and wonderful easy labors, and both mommas delivered in water at home. Water is great for plus-size mommas because it allows you to move more easily into different positions.  
I myself am a plus size momma. I am 5'6" and started my pregnancy at 232 lbs., about size 18. I finished my pregnancy at 276. I know doctors like to tell you to only gain 15 lbs. if you're "obese" but that's one of many reasons I didn't choose a doctor! I am a firm believer that as long as you gain your weight on healthy food then you gain what you need, and restricting food can cause issues in pregnancy. Nutrition is key in pregnancy, especially protein!   
I had a wonderful very healthy pregnancy with a midwife, and gave birth to a beautiful baby at home on Christmas eve.  A baby girl,  9 lbs. 12 ounces, 20.5 inches. 
Being plus size and pregnant is a challenge but I think it's because we set up obstacles in our minds. Will I look pregnant, how much weight will I gain, will I be able to handle the physical demands of labor, will I be bullied into tests and procedures because I'm overweight? 
Remember that you are a strong, intelligent, beautiful woman who can birth a healthy baby, regardless of your weight. If you aren't comfortable being your own advocate, then hire a doula! Get educated, know your options, and don't forget to celebrate this beautiful rite of passage!

Tuesday, May 8, 2012

Fetal Over-testing in the Last Trimester Because of Fat?

This is a comment that was left on my blog recently, in the "Will I Feel My Baby Move If I'm Fat?" post. It's a new twist on the old wives' tale (more like old OB's tale) that fat women supposedly have too much abdominal fat to feel their babies move in pregnancy.
"I am 29 weeks today and a nurse practitioner I saw last week told me I have to have nonstress tests 2X week because of my weight. She claims I won't feel the baby's movements so they need to monitor them. Has anyone else been told this? I'm a very busy woman and incredibly stressed about having to go to the hospital 2X week, plus she says I have to do an ultrasound monthly, plus do my weekly doctors appts. Advice would be great because I don't want to do this but I feel I have to so the baby will be monitored appropriately."
Seriously?  A non-stress test 2x per week from 29 weeks on because a fat woman supposedly won't feel her baby's movements? 

This is pure and unadulterated bullsh*t.  Women of size feel their babies move perfectly well, thank you. There's no fat between the baby and the inside of the uterus; we feel every roll and punch and kick.

Nearly every woman of size I've ever spoken to has said that yes, they feel their babies move just fine; I certainly did. Yet this myth about fat "preventing" women from feeling their babies still persists. That it persists among the public is disappointing but attributable to ignorance; that it persists among some healthcare providers is nothing short of appalling.

But the second question here is whether fat women are so incredibly high-risk from "obesity" alone that we have to be monitored 2x/week from the middle of the second trimester on?  Yet other women only start monitoring around week 41? Oh puleeeze.

Even most diabetics aren't monitored this aggressively. Insulin-dependent diabetics usually start fetal surveillance around 32 weeks. For gestational diabetics not on insulin, the need for fetal surveillance is widely debated; if used at all, it is usually introduced around the end of pregnancy.  Only diabetics with severe comorbid complications like vascular issues or kidney disease usually benefit from this kind of aggressive monitoring starting in the late second trimester. Are the providers in the above scenario seriously comparing the risk of an uncomplicated pregnancy in an obese woman to that of a brittle type 1 insulin-dependent diabetic with pre-existing kidney damage?

The only time I can see this kind of over-the-top monitoring being truly needed in a woman of size would be in someone who has experienced serious major poor outcomes in a previous pregnancy, or who is experiencing major complications in a current pregnancy (HELLP syndrome, hypertensive disorders, prior stillbirth, brittle or uncontrolled diabetes, diabetes with comorbidities, IUGR, or various other serious complications). The commenter didn't mention any such comorbidities.

Now, the argument some docs make for increased fetal surveillance in "obese" women is that some studies have shown an increase in the risk for stillbirth in these women.  However, not all studies have shown an increase in the risk of stillbirth in obese women. Moreover, there is no data to prove that aggressive monitoring in obese women lowers the risk for stillbirth.  

It is questionable whether obesity itself, without concurrent complications like HELLP or uncontrolled diabetes, necessitates this kind of frequent monitoring.  It is telling that most care providers do not require it. The American College of Obstetricians and Gynecologists (ACOG) does not currently recommend increased antepartum surveillance in the last trimester for obese women.  Nor does the Society of Obstetricians and Gynaecologists of Canada (SOGC).  And research suggests that obese women don't have more poor results on non-stress tests.

Although there may be a somewhat higher risk for stillbirth in women of size, and although non-stress tests and biophysical profiles can sometimes help identify babies at high risk for stillbirth, these tests don't always help and come with downsides too. The rate of  false-positives is quite high, and often results in unnecessary interventions like early induction of labor or cesareans, and these also carry risks.

So while I can understand some providers wanting to offer this as an option to women of size (especially those who experience comorbid complications like hypertension disorders or restricted growth), I strongly question the value of its routine use in women of size with uncomplicated pregnancies. Furthermore, the testing schedule this woman has been put on is quite excessive (barring some complication we are not aware of).

Awareness of the possibility of complications in women of size is one thing, but clinicians must remember that over-testing brings its own risks and often becomes a self-fulfilling prophecy.

I've been through four pregnancies as a "morbidly obese" woman and I was never required to do this kind of monitoring. Nor do I know many other fat women who have been required to do this extreme amount of monitoring. And I can assure you that I most definitely felt my baby well enough to do kick counts by the end of pregnancy.  The idea that non-stress tests or biophysical profiles are required because fat women are too fat to adequately keep track of their baby's movements is ludicrous.

Commenter, unless you have some major complication we don't know about, you might want to think about running far and fast from this practice so you can find one that doesn't see you as such a ticking time bomb.  Pick a practice that knows that fetal surveillance testing has both pros and cons, that knows there is a high risk of false positives and over-intervention with these tests, and that is willing to discuss these pros and cons with you and let you make the final decision on their use instead of compelling you to follow an arbitrary schedule of testing virtually designed to find problems and intervene.

*How about you?  If you are a woman of size, have you been required to have such aggressive fetal surveillance from so early on?  What kind of fetal testing was recommended for you as a woman of size by your providers?

Tuesday, May 1, 2012

Supersized Women and Cesareans: A Tale of Two Cities

Although most care providers mean well when caring for high-BMI women, one consistent blind spot has been providers recognizing how the  high level of interventions used with many high-BMI women influence outcome.

In other words, are poor outcomes only due to "obesity" or do some poor outcomes reflect the interventive way that obese women are often managed in pregnancy and birth?

This is a particularly relevant question for the high cesarean rates found in "morbidly obese" women (BMI of 40 or more).  If a high-BMI woman is perceived as ultra high-risk, and is therefore subjected to increased rates of interventions (like inductions, early epidurals, and a lower threshold for surgery), does the resulting high cesarean rate really reflect problems with obesity itself, or with the way obese women are managed?

Here are two studies of cesarean rates in women of size that demonstrate that iatrogenic (provider-caused) influences can have a very strong effect on cesarean rates, and that a high cesarean rate in morbidly obese women is NOT just about the obesity itself.

These two studies examined cesarean rates in "super obese" women (BMI of 50 or more), one from Kentucky and one from the U.K.  The Kentucky study found a super-high c-section rate, and the U.K. study did not.

Yet the two studies basically were looking at very similar study groups, women with a BMI of 50 or more. If cesarean rates really are tightly tied to obesity and obesity alone, shouldn't the cesarean rates in these two studies be similar?

In the Kentucky study, women with a BMI over 50 had a whopping 56% cesarean rate. Compare that with the British study that found a 30% cesarean rate in women with a BMI over 50.

The Kentucky cesarean rate was nearly DOUBLE the rate of the British group, even though the size of the women was similar. 

This strongly suggests that management of labor around the pregnancies of supersized women differed and highly influenced the resulting cesarean rate, and that it's NOT just about a woman's size, but also her care provider's management.

We can't tell for sure from these particular studies why the cesarean rates in women of size in these two places are so different, but it's a good bet that it's NOT because the uteri of British women are that much more efficient than those of Kentucky women. No, the contrast in rates is much more likely to be due to differences in care, attitudes, and interventions.

A couple of strong possibilities spring to mind.

First, midwives are the most prevalent form of care provider for most women in the U.K., whereas most women in the USA get their care from OBs.  Research shows that on the whole, midwives tend to have lower cesarean rates, even when the risk profiles of patients are similar.  So perhaps the cesarean rate is lower because more of the "super obese" women in the U.K. had access to midwifery care.  If so, this is yet another reason to be alarmed about the move towards restricting fat women's access to lower-tech birthing alternatives and midwifery care.

Second, we don't know that much about the types of intervention, induction rates, and threshold for surgical intervention in each study.  My guess is that the Kentucky study had very high induction rates (which tends to lead to higher cesarean rates), a higher rate of interventions, and a lower threshold for doing a cesarean in labor.

I would love to see more research that focuses on why there can be such different outcomes in "morbidly obese" women.  We need to really shine a spotlight on differing management protocols and how they impact cesarean rates ─ and particularly so in women of size.

Interestingly, the Kentucky study notes that pitocin augmentation in labor led to lower cesarean rates in these women, although this difference did not rise to statistical significance.  They speculated, therefore, that "a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient."

This is a theory that is often bandied about in obstetric research (without any supporting proof, but often accepted as gospel anyhow). Yet if this were true, why were 70% of British women able to birth vaginally? It's far too easy and convenient to blame fat women's hormones instead of looking more closely at your own management practices instead.

It's time for doctors to stop scapegoating obesity alone for high cesarean rates in women of size, and long past time for them to start examining more closely how their own biases and high-intervention protocols negatively influence outcomes in this group.

This is not an emotionally comfortable thing to study, because care providers are human and no one wants to acknowledge that their own biases and management can affect outcome so strongly.  I understand that.

But if care providers are truly interested in improving outcomes in "obese" women, then this is the kind of work that MUST be done.  

The contrast between these studies shows that most very fat women CAN give birth vaginally....if caregivers would just stand aside and let them. It's time to take off the blinders and see how management protocols can  influence that.


Am J Perinatol.  2011 Jun 9. [Epub ahead of print] Extreme Morbid Obesity and Labor Outcome in Nulliparous Women at Term.  Garabedian MJ, Williams CM, Pearce CF, Lain KY, Hansen WF.  PMID: 21660900

Source: Department of Obstetrics and Gynecology, University of Kentucky, Lexington, Kentucky.
We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m (2)) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥50) from morbid obesity (BMI ≥40 to less than 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed.

CD was most common among women with a prepregnancy BMI ≥50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22).

Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.
BJOG. 2011 Mar;118(4):480-7. Planned vaginal delivery or planned caesarean delivery in women with extreme obesity. Homer CS, Kurinczuk JJ, Spark P, Brocklehurst P, Knight M.  PMID: 21244616

Source: National Perinatal Epidemiology Unit, University of Oxford, UK.
OBJECTIVE: To compare the outcomes of planned vaginal versus planned caesarean delivery in a cohort of extremely obese women (body mass index ≥ 50 kg/m(2)). 
DESIGN: A national cohort study using the UK Obstetric Surveillance System (UKOSS). 
SETTING: All hospitals with consultant-led maternity units in the UK. 
POPULATION: Five hundred and ninety-one extremely obese women delivering in the UK between September 2007 and August 2008. 
METHODS: Prospective cohort identification through UKOSS routine monthly mailings. 
MAIN OUTCOME MEASURES: Anaesthetic, postnatal and neonatal complication rates. 
RESULTS: After adjustment, there were no significant differences in anaesthetic, postnatal or neonatal complications between women with planned vaginal delivery and planned caesarean delivery, with the exception of shoulder dystocia (3% versus 0%, P = 0.019). There were no significant differences in any outcomes in the subgroup of women who had no identified medical or antenatal complications. 
CONCLUSIONS: This study does not provide evidence to support a routine policy of caesarean delivery for extremely obese women on the basis of concern about higher rates of delivery complications, but does support a policy of individualised decision-making on the mode of delivery based on a thorough assessment of potential risk factors for poor delivery outcomes.