Friday, May 30, 2014

Midwives Can Safely Care for Obese Women

Image Credit: Andy Ellison
In many places, midwives are no longer permitted to care for obese women, or at least obese women over a certain BMI (often 35 or 40). 

Many women of size these days are "risked out" of midwifery carehomebirthbirth centers, waterbirth, and even some hospitals. Some OBs are even refusing to see obese patients at all. A fat woman's only choice for care may become a high-risk specialist, even if she is healthy and has no complications.

I've written about this before. I call it Ghettoizing Women of Size.

It is done based on hyperbole around the risks of obesity and does not reflect the fact that many obese women are healthy, do not develop complications, and do just fine with midwifery or other "alternative" care. 

In the following recent Dutch study, although more obese women had their care transferred to OBs (some of which could simply represent bias or exceeding BMI cutoffs rather than actual complications), the obese women who were cared for by midwives had no more adverse outcomes than other women.

This shows that, providing there are no major complications, obese women (and even "morbidly obese" women) can be safely cared for by midwives.

There is no need for automatic transference of care, and definitely no need for routinely ghettoizing obese women into high-risk, high-intervention care.

*Midwives, let's see some more formal studies of midwifery care of obese women. Personally, I'd love to see a study comparing outcomes of healthy obese women routinely assigned to OB care and those routinely assigned to midwifery care. 


BJOG. 2014 Mar 12. doi: 10.1111/1471-0528.12684. [Epub ahead of print] The impact of obesity on outcomes of midwife-led pregnancy and childbirth in a primary care population: a prospective cohort study. Daemers D1, Wijnen H, van Limbeek E, Budé L, Nieuwenhuijze M, Spaanderman M, de Vries R. PMID: 24618305
OBJECTIVE: To assess the impact of obesity on the likelihood of remaining in midwife-led care throughout pregnancy and childbirth. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. POPULATION: A cohort of 1369 women eligible for midwife-led care after their first antenatal visit. METHODS: First-trimester body mass index (BMI) was calculated as weight measured at booking divided by height squared. Obstetric data were retrieved from medical records. Multiple logistic regressions were performed to examine the effects of BMI classification on midwife-led pregnancies and childbirths. MAIN OUTCOME MEASURES: Percentages of women remaining in midwife-led care throughout pregnancy and throughout childbirth. RESULTS: Of women in obesity classes II and III, 55% remained in midwife-led care throughout pregnancy and 30% remained in midwife-led care throughout birth. Compared with women of normal weight, women in obesity classes II and III had fewer midwife-led pregnancies (OR 0.38, 95% CI 0.21-0.69), and women who were overweight or in obesity class I had fewer midwife-led childbirths (OR 0.63, 95% CI 0.44-0.90; OR 0.49, 95% CI 0.29-0.84, respectively). Compared with women of normal weight, women who were obese had higher referral rates for hypertensive disorders (4 versus 14%), prolonged labour (4.6 versus 10.4%), and intrapartum pain relief (4 versus 10.4%). The women who were eligible for midwife-led birth and who were overweight or obese, had no more urgent referrals than women of normal weight. Women who were obese and who completed a midwife-led birth had no more adverse outcomes than women of normal weight, with the exception of higher rates of large for gestational age (LGA) babies (>97.7 centile; 12.1%, versus 1.9% in normal weight and versus 3.3% in overweight women). CONCLUSIONS: Although fewer women who were obese remain in midwife-led care during pregnancy and childbirth, there was no increased risk of unfavourable birth outcomes for women who were obese and eligible for a midwife-led birth when compared with women of normal weight. This indicates that when primary care midwives use a risk assessment tool throughout pregnancy and childbirth they are able to safely assign women who are obese to either midwife-led or obstetrician-led care.


Maitri said...

I was considered morbidly obese during both of my pregnancies, and my OB told me that I was "high risk" due to that. Yet I had perfectly healthy pregnancies, two normal births in hospital (one with epidural and one without) and two perfect children. I'd love to see statistics that show obese women having more pregnancy/birth complications because I just don't believe it.

Well-Rounded Mama said...


Actually there are plenty of statistics that show that. It's important to acknowledge that and be open about it. Read my Science and Sensibility articles to get more specifics.

However, also note that these studies show that while our risk for complications is increased, even so MOST of us do not get these complications. To force us all into high-risk, high-intervention care that most of us will not need is senseless.

Mich said...

And just imagine: before obstetrics, everyone was born with the help of a midwife. Fat and thin, rich and poor. We seem to have got out of it ok.

I was reading something somewhere, maybe here, that the size of your baby is determined mostly by what size you were at birth, your mother, your grandmother, etc., since it's genetic. So maybe these LGA babies are products of women who were LGA babies as well.

Cassandra said...

"Super obese" mama of two, one waterbirth in free standing center, one dry at home, no interventions necessary! Love my hands off midwives!

crystal_b said...

I wonder how many of the statistics that show worse outcomes for women of size are actually due to provider bias, though? Couldn't some of it (or even a lot of it) be due to an unfortunate self-perpetuating cycle? (Belief that obese women are intrinsically at risk -> more interventions -> worse outcomes)?

Well-Rounded Mama said...

Oh yes, absolutely. One of my major points on this blog is that providers often inadvertently ADD TO or even CAUSE risks in women of size by over-intervention and exaggeration of risks. Read my many posts on c-section rates, for example, as well as my Science and Sensibility articles.

However, even so, there are consistently higher rates of complications like pre-eclampsia, GD, and several other things. So some added risk is inherent, but it's very true that quite a bit of it is in how we are perceived and treated.