Wednesday, May 27, 2015

Obese Women Need Increased Access to Midwifery Care

Here is a study that looked at the pregnancy care of "obese" women with a BMI of 40 or more.

98% of these women saw a midwife only at the first screening appointment and never again, despite the fact that the majority of them did not develop complications.

And guess what, their cesarean rate was nearly 50%. This is far too high.

One of the most potent ways to lower the cesarean rate for women is to give them access to midwifery care. Yet this study shows that most higher-weight women are routinely being re-directed out of midwifery care.

This is not an isolated trend. If anything, maternity care is tilting towards an approach where women of size are not allowed to access midwives or low-intervention care.

We need to EXPAND midwifery care for healthy women of size, not restrict it.

In some areas, women of moderate obesity are able to access midwives and other low-intervention care choices, but Class III obese women (BMI of 40 or more) are often routinely given NO choice. In some areas, not even women of moderate obesity are being given access to low-intervention care.

Basing a decision like this simply on a number on a chart is short-sighted and probably results in many unnecessary cesareans. Instead, the decision should be made on a case-by-case basis, based not on the woman's size but on her health and particular circumstances.

If high BMI women have or develop complications, then sure, they should at least have an OB consult at some point, and can be co-managed by a midwife and OB if circumstances necessitate it. If their complications are significant enough, then care should be managed by a OB specialist or in a special bariatric center in some cases.

But women of size who do not experience complications do NOT need to be managed in a high-risk, high-intervention model of care, and they should not be routinely re-directed out of midwifery care. 

That includes Class III obese women (BMI 40+) ─ and Class IV obese women (BMI 50+) too. In fact, most probably would do better NOT being managed in a high-intervention model of care.

Size alone should NOT disqualify women of size from midwifery care, yet in the real world it often does. This needs to change.


Women Birth. 2013 Sep;26(3):179-84. doi: 10.1016/j.wombi.2013.05.001. Epub 2013 Jun 5. Pregnancy care and birth outcomes for women with moderate to super-extreme obesity. Slavin VJ1, Fenwick J, Gamble J. PMID: 23746783
PURPOSE: To describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity. BACKGROUND: Maternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40. METHOD: Women with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women. RESULTS: 153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1-16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n=150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n=74, 48.4%). CONCLUSION: Clinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.


Mich said...

I would like to have children someday, and that time is running out as I'm 33. I was born 2 days after my mom turned 32. I worry that I will be given shoddy care. Sometimes I wonder if I should take the prenatal vitamins and only go the hospital as the baby is crowning. That way I spend the least amount of time in anyone's care, and don't have to worry about a caesarian!

Well-Rounded Mama said...

Mich, I had my first child at 33 and 3 more after that. Although fertility does decrease as you age, it really depends on the person. I had my last one at nearly 43, and had no trouble conceiving. It really wasn't a big deal.

I can't promise that would be true for you, but you never know. I do think it helps to do fertility charting, even if you are not trying now, because then at least you know if you are ovulating and whether you have a good luteal phase etc. If you don't have the book, "Taking Charge of Your Fertility," I highly recommend it.

As far as finding size-friendly care, I think it's important to remember that there ARE size-friendly care providers out there. When I highlight the poor care for some women of size in order to advocate for improvement, it can make it sound like there aren't any decent size-friendly care providers out there.....but there ARE. I would personally start with a midwife in my search because they are less intervention-happy as a group, but it's really not about the initials after the name, it's about the attitudes and birth philosophy of the provider. There are great OBs and family docs and terrible midwives, and vice-versa. You just have to find the right provider for YOU.

As far as a cesarean goes, sometimes they are very needed and/or prudent. If you had one, it wouldn't be a tragedy, and although more challenging than vaginal birth, it doesn't have to be a rough start either. I'm writing more about the over-use of them, especially in women of size, and the public health implications of them. I know you understand that, but it does bear repeating. If you had a cesarean, it's okay and it's not a personal failure or anything. We just want to give you the best chance to avoid one unless it's truly needed.

Many loving thoughts to you, Mich, as you navigate all these things. You have a good head on your shoulders, you think things through, and I know you'll be fine.

Shelaine said...

In my area you can not use the midwife through our local hospital if you have a BMI over 35 with child #1 and 40 with subsequent children.

My OBGYN is working with me (I have a high BMI) to help us have a kiddo. He said he'd prefer not to label me as "high risk" unless I develop any other factors. He also said he wanted to avoid C sections if we could. I was delighted to hear this. I start clomid in a few weeks and we go from there. :-)

I recommend this blog to anyone who will listen. Thank you for your well researched advise and information. (I fact check stuff and you are spot on. I feel confident recommending you to everyone I know)