Thursday, August 21, 2008

So Why the BMI Restrictions in Waterbirth?

Waterbirth offers unique advantages to women in labor. According to,

Lying in warm water increases venous pressure so that veins can return blood to the heart more efficiently and your baby receives more oxygen. It enhances cardiac action and slows the pulse rate. Total relaxation in the warmth and comfort of the water helps the uterus to contract more effectively. Water also counteracts the force of gravity and any pressure a woman feels inside her body, so there is a further pain relieving effect. Water helps the woman surrender to the birth process and it creates a feeling of tranquility to the whole birth experience.
However, as we discussed previously, some birth facilities have restricted fat women from having access to water during labor and/or birth.

On the other hand, some facilities are very supportive of it, even in very large women. It all depends on the facility and the provider.

However, with the increasing trend towards seeing fat women's pregnancies as extremely "high risk" (regardless of whether they actually experience complications), I anticipate that we will see more and more BMI restrictions against waterbirth and other "alternative" birth modalities take root.

But are they justified?

So Why Not Have Waterbirth Access for Fat Women?

The following are some of the reasons typically given for restricting fat women's access to waterbirth, along with an analysis of the attitudes and reasoning behind them.

Waterbirth Is Only For "Low-Risk" Women

Of the hospitals that have embraced waterbirth, some have embraced it tepidly, with many restrictions. In particular, hospitals that are tentative about waterbirth usually restrict its use to "low-risk" patients only.

Since fat women are automatically seen as "high-risk" by many doctors (even when they have not developed any complications at all), some hospitals have BMI cutoffs, above which waterbirth is not an option anymore.

Applying the "high risk" label (and accompanying restrictions) across the board to all women of size is ridiculous. If a fat woman has had a healthy pregnancy, developed no complications, and is a reasonably active and mobile person, there is no justification for keeping her from resources in labor (like walking, immersion in water, a birth ball, position changes, etc.) that just might help her labor progress more "normally" and avoid an unnecessary cesarean.

The Ticking Time Bomb Theory

Another reason some hospitals restrict waterbirth in women of size is the perception of all obese women as having blood pressure issues (latent or overt), and therefore being at risk to stroke out at any moment during labor. This is a direct result of hyperbole about the perceived risks of obesity and increasing promotion of the idea that a fat woman's pregnancy is ultra high-risk.

Ironically, research shows that being immersed in water actually tends to lower blood pressure, and may actually be a good way to help prevent such an issue. Although it's not true that fat women are ticking time bombs just waiting to stroke out in labor, if it were, hospitals might actually be preventing these women from one intervention likely to help them KEEP normal blood pressure. Talk about short-sighted!

The Shoulder Dystocia Fear

Another concern is shoulder dystocia (baby's head is born but the shoulders get stuck on the way out). Fat women are perceived to be more at-risk for shoulder dystocia, and doctors are afraid that taking time to get the mother out of the water might delay emergency measures needed to get the child born safely.

However, several studies have shown that when baby size and diabetes are controlled for, obese women are no more likely to experience shoulder dystocia than women of average size. Just being fat does NOT increase the risk for shoulder dystocia, and forbidding waterbirth on that basis alone is illogical and unfair.

However, fat women do tend to have bigger babies, on average (although it should be noted that even so, MOST fat women do not have big babies). Because bigger babies have higher rates of shoulder dystocia, many healthcare providers fear having ANY fat woman birth in the water.

Their concern is that being in water might cause a delay in the maneuvers that may be needed to relieve shoulder dystocia. But healthcare providers experienced in waterbirth know that shoulder dystocia may be less likely in waterbirth because of the mother's ability to shift position easily and open up more space in the pelvis by being off the tailbone. One study found a shoulder dystocia in waterbirth rate of 0.16%, hardly a raging epidemic.

Experienced waterbirth providers point out that when they have encountered a shoulder dystocia in the water, often all that needed to be done was have the mother shift to hands and knees, or to stand up in the water with one leg on the side of the tub, creating an asymmetrical space in the pelvis that helps free up the baby's shoulders.

If that didn't work, they note that the process of helping the woman get out of the tub was usually enough to rotate the mother's pelvis around baby's shoulders and get the baby out without further maneuvers. And if it was not, the birth attendant can then do all of the usual maneuvers once the woman is out of the water.

Most providers who are experienced in waterbirth do not believe that potential shoulder dystocia concerns are a reason for forbidding waterbirth.

The Fear of a Getting a Fat Woman Out of Water

Probably the biggest reason why women of size are restricted from waterbirth is the fear of a fat woman passing out or having a medical emergency while in the water, and what might be necessary to deal with that. Because they see fat women as SO high-risk, they view this as a likely possibility, and are acting accordingly.

Although one can understand how a hospital might be concerned about how they would get such a large person out of the water or initiate emergency treatment quickly, we must remember that such a medical emergency is rarely instantaneous and there are almost always warning signs that suggest a change in laboring location and closer monitoring.

The nightmare scenario they fear is extremely unlikely (especially in a spontaneous labor with no drugs or medications, which is what a waterbirth should be). To restrict ALL fat women based on such an unlikely scenario is an extremely unfair balancing of the risks/benefits ratio.

However, let's be frank....the hospital's administration is also worried about potential workmans' compensation claims if a worker injured his/her back trying to get a woman of size out of the water during an emergency. These are understandable concerns from a hospital's risk management point of view, but Barbara Harper (director of Waterbirth International) addresses this below. The long and the short of it is that they may actually put their workers at greater risk by making supersized women birth outside the water, especially since immersion in water tends to make obese women more mobile and easier to help maneuver.

The Solution: Individualize Waterbirth Decision-Making Instead

Barbara Harper suggests that instead of facilities instituting across-the-board BMI restrictions on access to water, they should make case-by-case judgments, taking into account the mother's blood pressure status, her fitness, her general mobility, and whether there there have been any complications during the pregnancy.

Instead of forbidding waterbirth to all women of size, decision-making could be individualized to acknowledge the differences in the spectrum of fat women giving birth. This is a common-sense approach that makes a LOT of sense.

Finally, an important question is whether such BMI restrictions on waterbirth are justified by actual research, or just hospital administrators' fears of risk. Doctors and hospitals are striving to become more evidence-based in their practices; what does the evidence say here?
I wrote to Barbara Harper and asked her this question, and this was her reply:

Thank you for writing in your question about waterbirth studies and policies concerning BMI restrictions for women wanting waterbirths.

I am very much in opposition to such practices, but acknowledge that they do exist in many hospitals and some birth centers.

The water is THE VERY BEST PLACE for an overweight parturient woman. She can move in the water, control her body, respond better to the movements of the baby and feel much better physically after the birth because of the buoyancy effect on her muscles and cardiovascular system.

I don't see why every hospital isn't seeing that they could save hundreds of cesareans on plus-size women by PUTTING them in water as an intervention.

But, the great liability monster raises its ugly head and the hospital then becomes fearful of employees hurting their backs if they had to get a woman out of the water during an obstetric emergency. Thus the development of policies to protect the hospital against workers compensation cases.

When I teach the professional Waterbirth Credentialing workshop I do address BMI weight restriction policies and insist that hospitals treat each woman individually and not restrict the woman who presents in labor at 250 pounds who has gained 60 pounds during her pregnancy, just on the basis of the final number. I implore them to look at activity levels and pre-pregnancy weight and pre-pregnancy activity levels.

I have been successful in having the BMI policies removed from some hospital protocols, but not with others.

There is no available scientific evidence one way or the other, with the exception that we did a search both in the US and in the UK to find workers compensation cases for back injuries in labor and delivery settings. There were some, but none related to water. Holding the leg of a 300 pound woman while she is pushing is much harder than helping her in and out of the bath.

--Barbara Harper, RN, CLD, CCE
Founder/Director of Waterbirth International

Waterbirth IS a Reasonable Choice for Fat Women

Waterbirth is a very viable choice for women of size. Although it offers advantages for all women, it offers additional advantages for women of size, ones which might help improve birth outcomes in this group.

If doctors and hospitals really are interested in lowering the rate of cesareans and other complications in women of size, waterbirth is one more important tool to have in their toolbox. It shouldn't be automatically removed from the equation, based simply on size.

Although some fat women are discouraged from waterbirth, rest assured that many women of even very large sizes have labored and even birthed their babies in the water. If this is something YOU are interested in, it IS still a choice. As a woman of size, you might have to work harder in order to access this choice than a woman of average size, but it IS still a choice.

Some birth centers have waterbirth options. Some of these may have BMI restrictions, but some do not. Some may be amenable to negotiation about these restrictions; some may not. It can't hurt to ask. If they won't permit waterbirth in a woman of size, take your business elsewhere.

Most hospitals these days offer the option to at least labor in water. Again, some deny this to obese women, but many do not. However, if you encounter a hospital that won't allow you even to labor in water simply because of size, it's likely that they are not size-friendly in many other ways either, and you should strongly consider another birth place if at all possible.

Although waterbirth (actually pushing out the baby in water) is not as common in US hospitals as it is in European hospitals, there ARE a number of hospitals that do offer it. If you prefer to birth in a hospital, you can check with Barbara Harper to see if there are any in your area that are open to waterbirth. She keeps a list of waterbirth-friendly hospitals.

Additionally, Barbara's organization, Waterbirth International, has worked in the past with hospitals who have a "no waterbirth" policy. If you give plenty of advance notice so they can review this policy, if you have a provider supportive of the idea of waterbirth, and if you are willing to act as a strong advocate with the hospital, they may be able to help you establish waterbirth policies in that hospital, or to at least allow an exception to the rule for you as an individual. They do ask that you join Waterbirth International and make a donation to help cover their costs while doing this, but they say they are able to work with many hospitals and find an acceptable compromise.

And of course, waterbirth is always a choice at home, and homebirth is a more reasonable option than most people think. Many homebirth midwives offer waterbirth services (often including rental of a waterbirth tub, or information on other waterbirth choices) as part of the spectrum of their care. Many of the women of size that I have known who have actually given birth in water have done so at home. It's where I had my own waterbirth.....and it was an AWESOME experience.

Wherever you choose to give birth, waterbirth remains a possibility.....and it may be especially advantageous in women of size. It's definitely something for you to further research if you interested in it. I also urge hospitals, birth centers, and birth professionals to work to keep immersion during labor and waterbirth itself an option for women of ALL sizes.

*The waterbirth photo at the top of the entry is of a "morbidly obese" medical professional who gave birth to her third child in the water at home.

There is also a lovely waterbirth video at:


Anonymous said...

I've enjoyed this series very much. Both of my children were born at home. Being able to submerge in warm water for my second birth was so relaxing that labor lasted a scant 2.5 hours before I was holding my son. I weighed 280 when labor started and was quite healthy and competent throughout.

Anonymous said...

Why do you have to use the word "fat"? I clicked on this article hoping to find helpful, scientific information, not to read body shaming words in every other sentence.

Well-Rounded Mama said...

"Fat" is not a body shaming word. In fact, it is simply a physical description, not a judgmental term, and one embraced by many in the body positive community. To use it is an act of empowerment, not of condemnation. I'm sorry you've had such negative programming in your life that you cannot hear this word in anything but a negative way, but it is actually quite a powerful act of positivity.

Read the section on "terminology" in the pages bar at the top of the blog for further clarification. You always get to choose the term that is most comfortable for you, of course, but I choose to use a wide selection of terms because it reflects the variety of terms that real people of size use for themselves, because it helps search engine optimization, and because it challenges people to look more deeply into the terminology they routinely use and why they use it.