Wednesday, July 16, 2008

Bariatric Obstetrics, Part 1

Bariatric Obstetrics is the new term some doctors have invented for practices that specialize in seeing fat women during pregnancy and birth. The New York Times just did a big article on this, called "Too Fat and Pregnant." (Pbbbttthhhh to the editor who came up with that title.)

But is "Bariatric Obstetrics" a good idea? Doesn't it just "ghettoize" fat women? It punishes them for being fat by limiting their weight gain (or even telling them to lose weight while pregnant), and targets them for extensive interventions all through pregnancy because they're assumed to be "so high-risk." It makes a cesarean and/or complicated delivery practically a self-fulfilling prophecy. And most of these women then get pressured for significant weight loss after the pregnancy, using whatever scorched-earth techniques du jour the clinic favors, ignoring the role that yo-yo dieting plays in increasing long-term weight.

And has anyone even studied whether this high-tech, high-intervention approach to birth in fat women actually improves outcome? Or do they just assume it must? The truth is that these interventions go almost unquestioned in obstetrics today, with pressure to do more and more, despite lack of proof that these are free from harm.

Unfortunately, "Bariatric Obstetrics" is a concept that is only going to get more and more wide-spread, until most average doctors will be pressured to refer all their fat patients to these "specialists," and most midwives will be forbidden to attend women of size at all. This is already happening: anecdotally I am hearing of this more and more often now. All without any proof that this approach improves outcome and is not harmful. And all while taking away the possibility of CHOICE for fat women in determining the kind of care they prefer to receive.

I understand the concept behind "Bariatric Obstetrics," and I'm sure most of the doctors involved think they're doing fat women a favor by creating practices just for their needs. Most doctors aren't bad people, just people trained into a mind-set around obesity that is so extreme they can't even begin to question what they are taught. Some genuinely want to help, and have been taught that this approach, in all its extremity, is the best way to do so. But the road to hell is paved with good intentions, and policies undertaken with the best of intentions often still lead to poor outcomes and discriminatory treatment in the end.

Most of the doctors in these clinics cloak their practices under of false banner of fat-friendliness by promising equipment that fits larger people, bigger chairs in the waiting room, understanding nurses, etc. They probably go out of their way (like weight-loss surgeons and diet companies) to do the fat-support double-talk, where they SEEM like they are fat-friendly and only doing this in YOUR best interests, REALLY. They only want to HELP you have a healthy baby, TRULY. And they might even mean it.

But the reality is that, whatever their intentions, they are perpetuating fat bias, discriminatory policies, and scorched-earth interventions. As with fen-phen and orlistat and weight loss surgery, in the end, fat people often end up worse off than they started. Only now they're doing it to fat people's babies too.

The premise of these practices are based SO much on fat-phobia and mistaken beliefs about obesity (fat people all eat too much and the wrong foods, they never exercise, they are at extreme high risk for problems, they are a danger to their poor babies, they have to be taught different habits for the sake of the children, etc.) that it is doubtful they can provide objective and respectful care for these women. And the fact that more and more fat women will be railroaded into this type of care, restricted from access to any kind of "alternatives," is especially frustrating.

Although they are not publishing them, I'd bet the cesarean rates and induction rates at these bariatric clinics are practically off the charts. However, then they'll just blame those high rates on the effects of obesity ("See how high-risk they are?"), rather than actually looking to see whether their policies had anything to do with that or not. Convenient, no? All while getting to charge insurance companies more and more money for such specialized care, and all while racking up more and more billable interventions for their clinic/hospital. "Bariatric Obstetrics" is going to be a profitable sub-specialty indeed.

The best way to fight against this mentality is to opt out of the medical model altogether. Your best bet for size-friendly care in pregnancy, frankly, is a midwife instead of a doctor. Although there are good and bad in every profession (not every midwife is size-friendly, and some doctors really can be size-friendly), midwives in general are much more size-friendly than doctors, especially in this current climate of extreme intervention around obesity. And your chances for induction, cesarean, episiotomy, and many other interventions are also much lower in general with a midwife.

If you are pregnant and looking for a care provider, don't let them bully you into this model of extreme intervention and fat-phobic care. Just because you are fat does NOT mean you "need" to see a high-risk specialist. Just because you are fat does NOT mean you need every prenatal test in the universe, or to be induced early for a "smaller baby," or to have an automatic early epidural or internal monitor placed, or to be pressured into a c-section "just in case." Just because you are fat does NOT mean you have to go to a "Bariatric Obstetrics" clinic.

In fact, unless there is some special complication that necessitates closer care, your best bet is usually midwifery. Anecdotally, many fat women have found that they have had much better births (with much better outcomes) when they saw midwives instead of OBs for their care. I certainly found this to be true, as have many other fat women I know.

Too Fat and Pregnant? Bariatric Obstetrics? Just say NO.


Anonymous said...

Part of the problem is that our societal mindset itself is technocratic so that successful litigation is always based on what doesn't get done rather than what does get done. Intervention is the gold standard. I really take my hat off to doctors who are hands-off except in cases of actual medical need -- I'm as alternative/progressive as they come regarding birth issues, and I don't know if *I* could practice that way in such a fear-based environment. I really don't.

Anyway, yes. If you're fat, your best chance is with care outside of the mainstream. Plenty of things impede normal body function in birth; there is no proof that fatness is one of them, aside from correlation. And although you would think that doctors would understand that correlation is not the same as causation, most do not. Which would lead one to wonder whether medical school is more technical training than scientific endeavor.

I started with a typical obstetric clinic (Kaiser, fwiw) and was very unimpressed -- the quality of care improved dramatically when I switched to a homebirth midwife (so many hospital-based midwives are, unfortunately, just OBs without the surgical skills.)

Throughout my birthing career the less managed my care was the safer I felt. And that's because there was a focus on me as an individual and how I was feeling rather than on machines and numbers. I also became more naturally intuitive when I wasn't relying totally on someone else to diagnose my state of health and tell me what to do. Obviously some women need medical care during pregnancy, but for the rest I think it undermines their natural instincts.

-Linda (who has had four normal and healthy pregnancies and births despite being "obese" and of "advance maternal age" to boot)

Anonymous said...

I read the NYT article - too ghastly and depressing. Apparently, having a baby is only a good thing if you're thin- pregnancy in fat women is considered "ground zero" for their babies' obesity... which is, of course, just too nasty. Fat babies? Why coo over those lumpy monsters when there are admirable thin babies to love? And really - all those depressing plus-sized diapers - but maybe we can make diet baby formula to slim those brutes down before they hit preschool!

Articles like that make me wonder what measures are being planned 'for our own good'- things creep a little to close to eugenics when we talk about the undesirability of fat women having fat babies, and the need to intervene in that process.

wriggles said...

I'm sorry but due to the current climate I would state that this is most certainly not, a good idea. The question is what is the purpose of it? If they need to get equipment suitable for fat women, why should that necessitate a new field of obstetrics? That's surely a matter of management.

Predictably enough, the obsession with slimming people at all costs rears it's ugly head and women are supposed to slim down during pregnancy, even though as the article said, we don't know what this will mean for the child, let alone the mother.

If the body is already seemingly reluctant to use up fat stores, are they sure that it will release them to feed the foetus in utero?

The object of this is not to help, but as you say to ghettoise, fat women, which means they will let go even more of treating these women as prospective mothers first and fat women second, which I suspect is the point, to bring the obesity crisis to the labour ward. Has the introduction of the obesity crisis to anything resulted in any benefits for the fat people/ children supposedly concerned? Exactly, it's just going to be more of the same fanaticism.

Anonymous said...

I'm a fat chick, about six weeks pregnant with my first child, and that NYT article made me wonder why I'm even bothering. I'm smart enough to know that most of the data in there is total bunk. I know at least 5 women, who were quite thin before pregnancy, and gained upwards of 50 lbs while pregnant, and none of their children are overweight now. I also know 3 tiny women who had 10 lb babies, and several larger women who had babies in the 6-8 lb range. (I'm not an expert or anything, but in my experience, women have babies of all different sizes. Is it really solely dependent on the mother's size? Are fat women really to blame for everything?)

Also, that whole argument about how the "environment" in fat uteruses somehow results in fat children? It's based on a study of animals! It hasn't even been established in humans. (That wasn't the rat study that Sandy over at Junkfood Science discussed, was it?) Finally, I have two very skinny parents, and I am a fat woman who does yoga every day and eats a low GI vegan diet. Over the last few years, I've worked hard to eat intuitively and well, and focus on overall health (this approach has resulted in more unintentional weight loss than any diet I was ever on--and I was on them all). I refuse to let dieting screw with my head any more.

However, I'm worried that this pregnancy is awakening an eating disorder that I'd finally come to peace with and put to rest. I'm terrified of gaining an ounce, so I'm watching the scale like a hawk, and tracking everything I put in my mouth, not because I don't trust my body's ability to have a healthy baby, but because I am afraid that people in the healthcare industry will be mean to me and deny me and my child good care. And it's articles like the ones in the NYT that are causing this. (Your blog, on the other hand, is wonderful.)

All this stress can't be good for my child. How do I get my head back in a good place?

Anonymous said...

I'd just like to second the recommendation to get a midwife. I've had two different midwives now (and I've had 3 kids) and in both cases, the midwives delivered in the hospital and I had great deliveries.

When I delivered with my third, I was about 270lbs or thereabouts, and very healthy, and I delivered naturally with no complications at all. My midwife and her assistant midwife-in-training were wonderful and my weight was never an issue.

If you're fat and pregnant, you have to be a well-educated self-advocate.

Inanna said...

I'm a fat woman, 38 years old, healthy, currently 4 months pregnant with my first child. When I started thinking about getting pregnant two years ago, my partner and I went to interview a highly recommended, ostensibly feminist ob/gyn; she told me that I had to lose 40 pounds before I got pregnant and that because of my age, I had to start trying to get pregnant right away. I pointed out that those were mutually exclusive goals and that I didn't agree with either of them. Needless to say, I didn't choose her for my care.

Next we interviewed an independent midwife. I asked her if she was concerned about either my age or my size. Unfazed, she shrugged and said, "I've delivered women much larger than you, and I've delivered women much older than you--no problem." I'm working with her and planning a homebirth in December. The care has been excellent.

I loathe the medicalization of pregnancy and childbirth. It's bogus, fear-based, and not at all woman-friendly.

Anonymous said...

I'm sorry, but the way Annie Murphy Paul writes that article is so harsh. It's obvious she's writing it from a 'greater than thou' attitude and it p***es me off!!! How rude! If she wanted to write an article about it, she could have at least done it from an objective point of view. Man, she's made me wild!

Anonymous said...

I came across the NYT article because it featured a doctor at U of M where I delivered. My experience with that institution makes me even more disgusted about the slant of this article--fat women are the cause for C sections.

I am thin and kept extremely fit during my pregnancy and ended up with an "emergency" C section at 9cms after inexperienced residents cranked up the Pit so high my son's heart rate declined. This was after I was told to do nothing but lay on my left side, was prohibited from eating or drinking, and convinced by a nurse to take a sleeping pill to conserve energy for pushing. Little did I know I would never even make it there.

In the past 18 months, I know 6 women who went there and five of them had C-sections for similar reasons. These women were all young, healthy, and fit and most certainly were put through the same BS as I was during labor. Yet article after article by the OBs there (and elsewhere) blame their rise in C sections on the obese and even "super obese". I pity any woman who gets care at the new Bariatric Obstetrics center there or through any of their doctors or midwives. Except for the lactation consultants, everyone I encountered there was useless.

Anonymous said...

I'm a physician. I chose to have my first child delivered with a midwife and a doula, and I had a very positive experience. My second child was delivered by an obstetrics resident at the University of Michigan, and it was also a very positive experience. I think blanket comments like "go with a midwife" or "go with a high-risk obstetrician" are simple fixes that don't work for all people.

Unfortunately, obesity during pregnancy is associated with a higher risk of baby birth defects. The clinic at U of M wasn't designed just to bully women into Cesarean section. It is also true that most obese women and their babies do just fine during pregnancy and delivery. The clinic was set up to try to identify who would do just fine and who wouldn't. The way to tell who does okay is by ultrasounding the baby. It is invasive, but there isn't anything else available now, sadly.

Obese women should be allowed to choose where they get their care, and the options (like ultrasound) that would improve their care. No one is being forced to the bariatrics clinic, but it is difficult to get regular vaginal ultrasounds otherwise. No one is being told not to have babies because they're fat.

Well-Rounded Mama said...

Anonymous, thank you for posting. I'm glad some doctors are reading the blog. I AM interested in what you have to say, whether or not we always agree on everything.

It's good you had a great experience with both a midwife and with an OB resident. It's true you can't make simplistic dictates like "you'll automatically have a great birth with a midwife and a bad birth with a doctor" because life just isn't that simple. I have noted that in the past and will continue to do so.

But I stand by the assertion that women are much less likely to have an unneeded cesarean, induction, and/or episiotomy with a midwife. The research clearly backs that up. And often, midwives have more leeway around protocols that many doctors follow strictly, like more leeway in dating pregnancies, not automatically inducing by 41 weeks, not inducing early for macrosomia etc. These policies tend to increase the c/s rate in women of size in particular, so IN GENERAL, midwifery care tends to be more size-friendly.

But it's true that there are some very size-unfriendly midwives out there and some great docs too. That's always worth pointing out; thank you for doing so. I like doctors, I appreciate the work they've gone through to be where they are, and I'm not a doctor-basher. I hope it doesn't seem so on the blog.

Generally speaking, though, women need to know that they are more likely to avoid unnecessary interventions with a midwife, and unless there is a pressing complication that needs the care of an OB, they are generally better off with a midwife.

Obese women do appear to have a higher rate of birth defects, but the rate is still quite low overall. That risk tends to get exaggerated in people's minds. It's certainly not absolutely mandatory to have an ultrasound, even for obese women. As with all prenatal testing, these tests bring risks as well as benefits. It can occasionally identify some babies who might do better delivered by c/s, but false-positives (and false-negatives) do exist as well and can negatively impact care. Women of all sizes should be given the pros and cons and be able to choose for themselves.

(BTW, I had vaginal ultrasounds in my first 2 pregnancies without having to go to an bariatric obstetrics specialty. Many clinics are capable of this. And I had abdominal ultrasounds in my last 2 pregnancies without any issues at all; vaginal u/s aren't always needed, even on "morbidly obese" women.)

Right now, perhaps no one in your area is being forced to go to the bariatric obstetrics clinic, but there are places where they are being pushed into that model. I know of cases where fat women (with no risks other than size) are being turned down for care from anyone *but* a high-risk perinatologist, are being required to sign the paperwork for a planned cesarean at the first visit etc. I'm glad it has not reached this level in your community, but we are seeing more and more of this. I hope you will speak up against it in your community.

Finally, your last statement, "No one is being told not to have babies because they're fat" is unfortunately not true. I received an email only last year from a woman who went to the clinic at Univ. of Michigan, and was told she would almost certainly DIE if she continued her pregnancy at her size. Check out the fat bias horror stories on this site and you'll see that some doctors ARE NOT supportive of fat women having babies at all. Some ARE telling fat women they can't/shouldn't have babies at their size, some are telling fat women they'll DIE if they have babies at their size, and some ARE pressuring fat women to abort their pregnancies.

I don't believe that is what MOST fat women are being told, and I agree there ARE some fabulous and very size-friendly doctors out there....but it IS happening, even in a place where you received good care. And alas, I only see it increasing in the future.

I do thank you for offering your input, however. I welcome reasonable dialogue with doctors and other providers. It's good you are not seeing such overt bias where you are...but rest assured, it IS there from some providers, in some areas. You might be surprised.

I hope you will be a voice for reason in your area.

Amy Philo said...

I would just love to add that throughout my adulthood I have been told I weighed too much. This started in my early 20s. When I weighed 137 pounds, nobody thought I was fat. But once I got to be 155 pounds, suddenly I was... fat by all "normal" standards. Then I got to be 167 pounds, and my doctor told me I was FAT. Then I got to be 180 pounds, but then lost weight back down to about 165. At that point I went to a doctor for a regular physical exam for some reason and he decided to tell me that I was too fat and needed to lose weight. I informed him that I had been losing weight, and he said that I needed to lose more and definitely never get any heavier.

Well, long story short, a couple of years after that I started having children. My first pregnancy I got up to 226 by the end of it. My first OB never said anything, but when I went to a different OB after moving states, I was told that I was definitely overweight (while 9 months pregnant) and should start dieting as soon as my son was born.

Bad idea!!! I know too many women who use extremely toxic artificial sweeteners to try to lose weight. I also believe very much in the brewer diet for pregnancy. There are so many people I know who have had hypertension and to solve it they were told to go on a diet. Instead, they should just be eating MORE PROTEIN and lots of calories to support their blood volume needs.

One thing that did annoy me after my home delivery was the assumption that the amount of blood loss I had was too high. I figured if I just gave birth to a 10 pound baby and gained 60 or more pounds during the pregnancy that I should automatically have more blood coming out after birth... if anyone knows if this is true, please tell me...
Instead I was told I NEEDED a shot of pitocin to stop the bleeding. I wonder how different I could have felt if I could have had no drugs at all.

Incidentally, I weighed a ton more during my second birth than my first, and the only thing it has adversely affected in terms of outcomes is my wardrobe.

My kids are both healthy and I had no complications during or after the midwife attended birth at home with my second.

I do feel that I nee to lose more weight but I am not willing to starve myself, especially while nursing, and it should be looked on as a gradual process and women definitely need to stop trying to crash diet when they have new babies. And we wonder why so many women get depressed. Because they are not eating enough to recover from birth... there's one reason for you anyway.

Amy Philo said...

To the anonymous doctor: how do you suppose that fatness would cause birth defects? Please explain to us the theory behind why people are associating the correlation with birth defects in the first place.

If I found a correlation between eating celery (I could easily do this by gathering up some women on mood stabilizers, antidepressants, and antipsychotics or getting ECT while pregnant and have them all eat some celery as part of a placebo group) and birth defects, and declared celery to be unsafe, and suggested that instead women drink chocolate milkshakes from McDonald's or perhaps even a starbucks coffee for breakfast lunch and dinner instead, would the oh-so-logical world of drugging birthing women and cutting them up and killing babies with drugs 100 times stronger than you would give a newborn agree with the scientific conclusion that coffee is better than celery? Because if it's in a "study," especially one funded by some vested interest, then it MUST be true...

P.S. Even if it were true that fat women had more birth defects, how does this justify adding on top of that drugs that are likely to hurt the defective baby during labor? Wouldn't it be better to perhaps encourage NON-obstetric attendance in a hospital so the baby can be cared for immediately, if it's known that the baby is at risk for birth defects?

And has anyone in this investigation bothered to control for the factors that most often lead to birth defects, such as drug exposure? I would have to check to make sure, but I somehow doubt it. Furthermore, certain drugs that cause birth defects cause weight gain and diabetes in women, so it would not be that hard to find some obese diabetic women who got that way because of antipsychotics, and then have them participate in the pregnancy studies. After all, in the oh-so-helpful world of obstetrics we are seeing one third of all pregnant women in the U.S. on psychotropic drugs.

JJ said...

I would like to offer a couple of pages regarding a connection between this topic and the Brewer Diet perspective on these issues (please forgive me if there are already links to these pages which I have overlooked)...

I hope that this helps.