Thursday, January 29, 2009

Joan of Arcadia alert

Just a quick alert and follow-up on the thread about Joan of Arcadia.

SciFi channel is apparently doing a Joan of Arcadia marathon on Thursday, February 5th, starting early in the morning. If you don't already own the series and want to check it out (or see it again), set your recorders!!

Alas, it doesn't look like they are going to do the episodes in order, but I only did a quick glance so I could be wrong. Even so, it's worth watching.

If you have not yet seen this series, please check it out. It really is worth a look. Really thoughtful and engaging, especially if you watch more than one episode.

Wednesday, January 28, 2009

Timing of Planned Cesareans

As we have discussed before, cesareans are at epidemic level among "obese" women. Although rates vary from study to study, on average up to one-half of all "morbidly obese" women today give birth by cesarean, many of them planned (done before labor). In some areas and hospitals, the rate approaches three-quarters.

[Of course, the c-section rate does NOT need to be that high in women of size, but because of current practice patterns, it is skyrocketing. For more on this topic, read this.]

This is a travesty because surgery is riskier on larger people; more problems with anesthesia, more risk of infection, hemorrhage, blood clots, and wound complications. And cesareans have long-term health implications for women of all sizes, both for future pregnancies and the woman's own health.

But let's leave that for another rant and talk instead about the timing of planned cesareans, and why this is such an important issue, particularly for women of size.

Timing Is Everything

A woman's "due date" is about 40 weeks, and a "full-term" pregnancy is anywhere from 37 to 42 weeks. If, for whatever reason, an "elective" cesarean is planned, what is the most favorable time for scheduling that surgery?

Many doctors in recent years have been scheduling cesareans early. A repeat c-section at 38 weeks is routine in many communities, and 37 is not unheard of. Sometimes, women themselves advocate for a little early because they are uncomfortable and "tired of being pregnant."

Doctors, too, often want to "just get things over with" and get that patient off their books. Scheduling a c-section at 38 weeks means two less appointments cluttering up their busy schedules. They also have talked themselves into believing that scheduling a little early might prevent a few unexpected stillbirths at term (even though that risk is extremely low and outweighed by the risks of being born early).

So, over time, doctors decided that "term is term" and a few more days doesn't make an appreciable difference in the baby's condition.

However, new research shows that planned cesareans should not be performed prior to 39 weeks at the earliest.

The Benefits of Waiting

Before 39 weeks, the risk of breathing difficulties in the baby is quite a bit higher. The older the baby is, the more ready they are to breathe on their own.

In addition, younger babies have more difficulties regulating their blood sugar, have more jaundice, and have more difficulties learning to breastfeed. But it's the breathing difficulties that puts the babies most at risk.

In particular, cesareans without labor put babies at much higher risk for breathing difficulties. Babies born by cesareans after labor has begun have less trouble breathing, and vaginally-born babies have the least difficulty breathing of all. The baby that has the most difficulty breathing on its own is the baby born by planned cesarean before 39 weeks.

Why is this? Labor contractions help squeeze the baby's chest and expel the fluid there. Hormones that are produced during labor help the baby's body be ready to breathe independently. In addition, the umbilical cord gets cut very quickly at a cesarean, cutting off a significant portion of the placental blood meant to perfuse the baby's lungs and help them get ready to start working.

Gestational age also influences a baby's readiness to breathe independently. Preemies have a much harder time initiating breathing and maintaining it without apnea or oxygen saturation issues. Until recently, gestational age was not thought to be that important once babies reached "term" (at least 37 weeks), but now we know differently.

For some time now, research has shown that babies born before 39 weeks have higher rates of Transient Tachypnea of the Newborn (TTN), Respiratory Distress Syndrome (RDS), and Persistent Pulmonary Hypertension (PPH). These babies then need to go to neonatal intensive care (NICU), experience many interventive procedures, and accrue significant costs. Some experience long-term effects.

Because of this, many hospitals have begun strongly encouraging doctors to schedule cesareans no earlier than 39 weeks, and ACOG (American College of Obstetricians and Gynecologists) has recommended that planned cesareans be delayed until at least 39 weeks. Unfortunately, not all doctors follow this recommendation, and many many cesareans are still being done at 38 weeks.

New Evidence for Waiting

A new study, recently published in the New England Journal of Medicine, once again highlights the importance of delaying planned cesareans until at least 39 weeks. Here are some excerpts from the press release:

NEW YORK – Babies do better after a scheduled Caesarean section if they're born no sooner than seven days before their due date, a new large study of U.S. births shows. Those delivered earlier had more complications, including breathing problems, even though they were full term, the researchers reported in [the] New England Journal of Medicine. Even just a few days made a difference, they said....

The study supports recommendations that elective C-sections be scheduled after 39 weeks unless tests show the infant's lungs are fully mature....

In the new study, the researchers, led by Dr. Alan Tita of the University of Alabama at Birmingham, examined a C-section registry from 19 academic medical centers to see how many of the surgeries were being done before the recommended 39 weeks and if the timing made a difference in the risk of complications.

They focused on 13,258 women who had a single child at a planned Caesarean and who had previously given birth the same way. Excluded were cases where medical issues warranted an early or immediate delivery. The infants were followed until they left the hospital or for four months.

More than a third of the C-sections were performed before 39 weeks, the researchers found. Those delivered at 37 weeks were twice as likely to have health problems, including breathing troubles, infections, low blood sugar or the need for intensive care. Fifteen percent of those born at 37 weeks and 11 percent born at 38 weeks had complications, compared to 8 percent of the babies delivered at 39 weeks.

Note that one-third of the planned c-sections in the study were done at 38 weeks, despite years of prior evidence that delaying till 39 weeks improves outcomes.

It is simply unconscionable that despite considerable, long-standing evidence to the contrary, one-third of contemporary elective cesareans were still carried out so early. When will doctors finally align their practice patterns with the evidence?

Some of the press releases also implied that it was mostly maternal request that was driving this trend towards 38-week cesareans, but in fact, the push for early cesareans is usually physician-driven. This is another recent trend in research and press releases: blame the mothers for problems instead of physician mismanagement.

One might also ask, why not delay a planned cesarean until at least 40 weeks? Even at 39 weeks, about 1 in 12 babies still had breathing difficulties. Although the difference did not reach statistical difference, the rate of complications was lower at 40 weeks than at 39.

There is no good reason for an arbitrary dictate to have planned cesarean done at 39 weeks, before a woman's due date. Unless there is a compelling medical reason, delay until the due date or until after spontaneous labor begins and outcomes will improve even more.

Second, I wish the medical journals would also press doctors to stop doing so many planned cesareans. The most optimal timing of cesareans is a red herring issue. Research is VERY clear that vaginally-born babies do better overall in so many ways, a point conveniently left out of the report.

The cesarean rate in the whole country is unconscionably high (over 30%), with cesarean rates in some hospitals exceeding 40 or even 50%. There is NO need for a cesarean rate this high. Most mothers and babies do better if they are given a chance at a vaginal birth.

A cesarean is an excellent thing for true emergencies, and there are also times when a planned cesarean is justified. But the overuse of cesareans today is putting a whole generation of babies, future babies, and mothers at risk unnecessarily.

Debating the timing of cesareans is not the real issue here; the overuse of unnecessary cesareans is.

Cesarean Timing and "Obesity"

Finally, timing of a planned cesarean may be particularly critical for women of size. Research shows that women of size tend to have longer menstrual cycles, which should delay their due dates, yet cycle length is rarely adjusted for by most doctors.

If a woman's cycle is 35 days, that means her "due date" by Last Menstrual Period (LMP) will be too early by a week. This is a critical point, especially when discussing planned cesareans.

Even if doctors follow the latest recommendations and schedule an "obese" woman's elective cesarean at 39 weeks, in reality this may well mean the baby is only 38 weeks, and subject to the higher risk of breathing issues noted above.

If the cesarean is scheduled at 38 weeks instead (as 1/3 of cesareans were in the report above), her baby will actually be born at 37 weeks, raising the risk for problems even more.

Of the women of size I know who have had elective cesareans, many of them had them at 38 weeks. This is putting these babies at risk unnecessarily; putting off the surgery just a little more really improves outcomes and helps babies in so many ways.

But even better in most cases would be to give those babies and mothers the benefits of labor.

*Image from Wikimedia Commons.

Thursday, January 22, 2009

Cause You're Just Not Trying Hard Enough

So, I went to an orthopedist for the first time this week. I was in a car accident last spring...a guy rear-ended my car at a high speed, and my car was totaled. Did a number on my body too, including my knees.

I have been concerned about a distinct decline in the function of my knees (and increase in pain level) since the accident. I've been seeing a chiropractor and acupuncturist regularly for most of this time, which have helped my other problem spots dramatically. There's still some residual issues, mind, but I've had a lot of improvement in those areas. Not so much in my knees. So my chiropractor suggested that perhaps it was time to see an orthopedist to check things out further.

I was surprised by how anxious I was about this visit. I'm usually a good advocate for myself and my size with doctors and I generally don't take crap from anyone, so I was surprised to have so many nerves about this visit.

On the other hand, I know orthopedists can be very fat-phobic, and I was worried that I'd be severely lectured or even yelled at about the need for weight loss, yadda yadda. I knew I'd have to have my youngest child with me at the appointment and I was worried about getting into this kind of crap in front of her, I think. She's young, but she's old enough now to "get" a lot more of what she hears, and I didn't want her to pick up on this kind of crap.

Also, I looked up the bios on the practice I was seeing and saw that they were all mega-athletes; the particular doc I was seeing went on and on about his training for the Iron Man Triathlon during medical school and residency. Great, someone who judges everyone else's exercising by his own quasi-compulsive standards. I knew I'd never measure up there either, even though one of the reasons I was there was because the knee issues were keeping me from getting back into exercising. Crap.

Well, the appointment was both better and worse than I expected. The doctor was nice, at least. That always counts for a lot with me. They didn't weigh me (which I was prepared to battle over). There was no yelling, no nasty over-the-top lecturing, none of the really hard-sell tactics you often see. So that was refreshing, and frankly, quite a relief. But that doesn't mean there wasn't size bias, just that it was couched more nicely. Sigh.

They did have me do an x-ray, and while they did have a pair of shorts in my size for me to wear for the x-ray and exam, they were pretty tight and not comfortable. If I'd known, I would have brought a pair of my own shorts so I could at least be comfortable. [Hint: If you ever think you might need knee/leg x-rays, bring your own shorts. I wore pants that easily pull up above the knee but that wasn't enough. Next time, I'll bring my own shorts.]

The x-ray showed arthritic changes, which I expected. I'm well into my 40s and we knew a little of this had started. My concern was that something else must be going on too, because my knee function had gone down so quickly. Well, the arthritis has certainly progressed (how depressing to write that, ugh) and the x-rays showed that. However, what was upsetting was that he wouldn't consider that something ELSE might be going on too.

When doctors see fat people with body pain, arthritis is their automatic assumption, to the extent that they get tunnel vision about if nothing else could be going on too. How often do fat people get misdiagnosed or underdiagnosed for non-fat-related issues because their doctors have this kind of tunnel vision?

He mentioned in passing that I "might" have a small tear in my meniscus, but that I wasn't a great candidate for surgery because of the arthritis' narrowing of the gaps. Okay, I understand I may not be the best candidate for surgery (I didn't go there wanting surgery anyhow) but the meniscus idea deserves a little more exploration, doesn't it? But it was mentioned so briefly, in passing, that I really didn't pick up on it until after the appointment was over. Now I'm kicking myself for not pressing him more on that possibility.

Of course, at one point, weight loss was mentioned. I knew it would be. I tried to fend it off ahead of time by telling him my main concern was feeling better and getting back to exercising (and mentioned prominently that I didn't do exercise for weight loss but simply to improve fitness).

Of course, then he brought up later that even though I don't exercise for weight loss, losing weight would reduce the pressure on those arthritic knees. Well, okay, that's a legit point, and I don't think it's improper for docs to mention that.....extra weight is harder on your joints. But that doesn't alter the grim statistics on losing weight and keeping it off. Chances are losing weight would be my best ticket to actually worsening the situation because of the rebound afterwards, so I mentioned that as why I wasn't interested in losing weight.

His response was to question whether I'd really tried to lose weight....not in a mean way, mind, but still, clearly dubious about whether anyone could do it "right" and not lose permanently. He asked whether I'd ever really worked with a nutritionist or worked with an exercise specialist, and started to go off about how he could set me up for that. I shut that line of discussion down fast, laughingly noting how I'd DEFINITELY worked with specialists like that before, rolling my eyes, and noting I wasn't going down that path again.

At that point he dropped it, not because he was convinced but because the appointment clock was ticking and this clearly wasn't going anywhere with me. In the end we agreed I would give Physical Therapy a try (which is fine with me; it's why I was there) and he offered me a cortisone shot for the pain, which I declined because acupuncture has been pretty successful at helping with the worst of the pain.

After the appointment was over, I was mostly relieved that it didn't turn into some giant lecture fest (especially in front of my daughter), and disappointed in myself that I didn't more aggressively question him about the possibility of a meniscus tear. I'll be looking into that further later.

But later, after I'd had time to really think about the experience, two things about it really struck me. First, the doctors are SO focused on your weight and the possibility of arthritis that they literally cannot see any other possibilities for your joint issues, even when something like a car accident is on board. Hello?!!?? Fat people get trauma-related injuries too!

And second, there was this big underlying assumption that if I hadn't lost weight up till now, it HAD to be because I hadn't REALLY tried. I might have dieted, sure, but not hard enough, not intelligently enough, not with the "right" experts, the right program, yadda yadda.

Cause, ya know, we're all just not trying hard enough.

Monday, January 19, 2009

Adoption and People of Size

Not only do authorities want to discourage people of size from pregnancy, in some places they routinely discriminate against them in adoption too.

A fat man in Leeds, England, has been denied the right to adopt a child because he is "morbidly obese," i.e., his BMI is over 40. He has been told to lose weight and get his BMI under 40 and then demonstrate the ability to maintain that loss over time, which as we know, is very unlikely.

England has done this before. The very talented comedian and writer seen here, Dawn French,(The Vicar of Dibley, and Gryffyndor's Fat Lady portrait in Harry Potter) experienced similar size discrimination.

She tried to adopt a child a number of years ago and was told she had to lose weight first. She lost weight on a crash diet, they adopted the child, and then, as she stopped dieting, slowly regained the weight. (She has been frank about that in the press, so this may account for the new requirement to demonstrate the ability to maintain the weight loss over time.)

Nor is this requirement unique to England. Not long ago, a fat woman with PCOS from Australia was told something similar. She weighed 277 lbs. and was told she had to lose about 110 lbs. in order to be considered for adoption.

Furthermore, some countries (like Korea and China) have put official weight limits on adults wanting to adopt children from their countries. Other countries (like England and Australia) don't seem to have official national policies on weight limits but a number of news stories in the last few years suggests that it is becoming more common.

Here in the United States, weight limits on adoption seem to be much less common, although stories do exist. I personally know several fat women who have successfully adopted without their weight being made an issue; Rosie O'Donnell is an example of a fat celebrity who was able to adopt several times without weight becoming an issue.

Unfortunately, in other countries, obesity seems to be seen as a "legitimate" reason for denying adoption.

Why Keep Fat People From Adopting?

Oftentimes, size bias in adoption is disguised under the dubious cover of being concerned "about the future of the child." Authorities are afraid that:

  • Fat people won't live long enough to raise the adopted child to adulthood
  • Fat parents will teach bad habits and make the adopted child fat and unhealthy too
  • Fat parents are emotionally unhealthy and will make the child unhappy or emotionally unstable too
The authorities in these cases no doubt mean well, but the reasoning behind these mistaken policies is faulty at best. Bottom line, they reflect common prejudices about obesity rather than realistic problems.

First and foremost, adoption weight restrictions are based on the assumption that fat people are about to keel over at any moment and so will not live long enough to raise a child to adulthood, further scarring a child who has already suffered the loss of biological parents.

Sandy from Junkfood Science addresses the fallacies in this argument well; most fat people live plenty long enough to raise a child. Look around you; there are plenty of adults who have fat parents, and there are plenty of middle-aged and older fat people in our society. That alone should tell you that fat people live plenty long enough to raise a child to adulthood.

Amazingly, there are people who believe that fat people shouldn't adopt because they might make the adoptive child fat too. From an ABC news story:

Medical experts told ABC News that obesity — and the associated health risks — may be something that adoption agencies should consider more often when finding a permanent home for a child.

"Kids learn what they see and parents, whether they like it or not, are role models for our kids," said Keith Ayoob, an associate professor of pediatrics at Albert Einstein College of Medicine in New York, who argues that the environment in which a child is raised plays an important role in reducing their risk of obesity.
This is completely contrary to what we know about the biology of obesity. Adoption studies clearly show that body size is most strongly influenced by genetics, not environment. Chances are that a child with a biological predisposition to "normal" weight would stay in the "normal" range, whether or not they are adopted by fat parents.

What about the idea that fat people are emotionally unhealthy (warning: major Sanity Watchers points!) and will cause the adopted child to grow up emotionally unhealthy too? Dr. David Katz spoke to this concern in an ABC editorial on the change in Chinese adoption guidelines. He wrote:

China announced tighten restrictions on adoptions by foreigners...Stated bluntly, if you are too fat, you can't adopt a Chinese baby.

The laundry list of new restrictions on adoptions by foreigners is ostensibly aimed at assuring the babies a stable home conducive to good physical, mental and financial health...This policy is misguided, discriminatory and shameful.

Preventing adoption based on weight, no matter what weight, only makes sense if there is evidence that parental BMI is legitimately linked to the quality of a child's life and health or the kind of parenting he or she receives. To my knowledge, that link doesn't exist.

I've searched the medical literature for studies that link parental weight or BMI with quality of life in children and found nothing. I could find no studies that demonstrate a link between the BMI and the capacity to love. I found no system that correlates weight, waist circumference or any other measure of body size with the quality of parenting.

As for a link between parental weight and weight in their biological children, that's a well established fact in the medical literature: heavy parents are more likely to have heavy children. You barely even need to search the medical literature to make this case —just look around. Kids tend to look like their parents...

The science clearly and consistently indicates that body shape and size in children resembles that of their biological parents for the same reason that eye color does — because of genes.

There is no link — repeat none — between the weight of adults who were adopted as children and the weights of their adoptive parents, as has been confirmed by the famous decades-long Danish Adoption Study. More than 20 years of scientific studies have shown that nature, not nurture, explains the weight outcomes of adopted children.

Adopted children don't take on the body type or body weights of their adoptive parents. The science that supports that fact is not only persuasive, it is almost shocking. Virtually none of the variation in the BMI of adults who were adopted as children is explained by the weight of their adoptive parents, according to the research...

The biggest reason China is imposing restrictions on adoption is because it can, I suppose. A lot of foreigners are trying to adopt Chinese babies, and the government can afford to set limits. There are far more non-Chinese adults wanting to adopt than there are Chinese babies available. In the crudest of terms, it is a seller's market.

The Chinese presumably could, if they wanted to, require that applicants be able to juggle or knit or play the piano. If their intent is to create arbitrary barriers so that the mismatch between supply and demand is resolved, these would work just fine. If their intent is to ensure babies a nurturing and loving home, however, these restrictions would be ridiculous.

So is the notion that you can measure the quality of a parent on a bathroom scale.
Denying adoption rights to obese people because of a concern over life expectancy or because of a fear that the fat parent might make the child fat or emotionally unstable is an example of cultural bias against fatness. It has no basis in reality and it should have no basis in the law either.

Size should have nothing to do with adoption. What really matters most is a parent's ability to love and take care of a child, period.

For those interested in adopting, there is an article about adoption and people of size on my website, including hints on dealing proactively with size bias.

*Picture of Dawn French from Wikimedia Commons.

Sunday, January 11, 2009

Love Your Cervix, Learn Your Body

Do you know what a cervix looks like? Do you know how it changes during a woman's monthly menstrual cycle? Have you ever seen a cervix in real-life pictures, up close? If you are a woman, have you ever seen your own cervix?

Do you know the subtle fertility signs a woman's body puts out that can help you determine when you are most likely to get pregnant and when you are not? Do you know about the Fertility Awareness Method of birth control? (No, it's not the rhythm method.)

Do you know why the fluids your body gives off "down there" (yes, from your vagina) change from day to day? Why sometimes they are copious and slippery, why sometimes they are tacky and kind of dry, why sometimes they are in-between----and what these changes indicate?

There is a new and very cool website out there that records--in pictures--the changes in one woman's cervix over one menstrual cycle. If you answered "no" to any of the above questions, you should definitely check out this woman's site. Even if you answered yes to all of the above questions, you'd probably find the site fascinating, as it documents everything you've already learned but in more detail than you've probably seen.

The site is called "My Beautiful Cervix" and an explanation about it can be found at actual daily pictures of her cervix can be found at

Be aware that these pictures are very detailed, and that the first pictures start during her menstrual flow, so proceed at your own "squick" factor. But unless you are extremely upset by these sorts of things, I highly recommend this site to you, male or female. It's important to expand our knowledge about the human body, and in this case, it's so helpful in learning about fertility, menstruation, and how best to achieve....or avoid....pregnancy.

Some Basic Information About Fertility

Unfortunately, very few women in our patriarchal society really understand how their body changes over their menstrual cycle, know their own fertility signs, have really seen their own genitals, or know how to control their own fertility without having to rely on artificial drugs, barriers, or chemicals.

If you have never read the book, Taking Charge of Your Fertility, by Toni Weschler, you really should check it out. It is an amazing book, and so educational. It is particularly helpful for women with PCOS and for women whose cycles last longer or shorter than the usual 28-day cycle doctors consider "typical." It's also very helpful if you want to find a less chemical form of birth control, or conversely, if you plan to try and conceive soon.

In Fertility Awareness, you track your body's fertility by keeping track of 2 or 3 primary fertility signs, usually Basal Body Temperature (BBT, a temp taken first thing in the morning on a special thermometer), cervical mucus, and cervical position.

You are not equally fertile on all days of your cycle. Your cervical mucus gets more slippery and copious as you get more fertile, and on your days of highest fertility it has more of an "egg-white" quality, looking like you have egg whites stretched between your fingers when you check it. (The picture above shows one example of fertile mucus.)

Similarly, your cervix will change position too, getting higher or lower, softer or harder, less or more open, depending on where you are in your cycle.

Your BBT will spike once ovulation has taken place, because the body has upped its production of progesterone in order to support a pregnancy if fertilization were to occur. This jump in temperature will stay elevated until just before your period starts; once your menses begins, your temperature will decrease significantly as progesterone production drops off.

However, if you are pregnant, your temperature will remain elevated. This is often the first sign of pregnancy and can tell you that you are pregnant well before any pregnancy test will.

Utility of Fertility Awareness

I can't tell you how useful this information is, in so many ways, even if you don't use it as a form of birth control (or to help you conceive).

So many women see the increased/changing fluids during their cycles and wonder if they have some sort yeast infection. You have to wonder how much unnecessary over-the-counter yeast medicine is being bought each year, simply because women have not been taught about their natural variations in cervical mucus!

Also, if you have unusual-length or highly variable cycles, knowing the signs of fertility and ovulation can help you know when to expect your period. If your cycles vary a lot, this can be a god-send!

The time from ovulation to the start of your period is pretty uniform in most women. It varies from woman to woman, averaging anywhere from 12-16 days or so, but within the same woman, this "luteal phase" length stays pretty consistent. So if you recognize the signs of ovulation, you can predict with pretty good accuracy about when your period will arrive afterwards.

It can also keep you from panicking too much about whether or not you are pregnant! When I was first married, I had many scares wondering whether I could be pregnant because my period simply didn't show up when the doctors said it should. Even once I knew my cycles were longer than "typical," I was never sure when I should start worrying, always wondering if our birth control method had failed somehow. Fertility Awareness would have saved a lot of money on unnecessary pregnancy tests!

Fertility Awareness can also help prevent unwanted pregnancies. Many women have a mistaken idea of when they are fertile and when they are not. I know I had a lot of incorrect ideas about this, and it helped to lead to my first child! It was a welcome surprise, mind, at a time in life when we were ready for it, but not everyone is ready to be so welcoming. Looking back with FA knowledge, I could understand exactly why we goofed, and I was able to prevent any repeat of this surprise until I was ready for more kids.

Once you decide you are ready for children, Fertility Awareness is great at helping you achieve that. Once my first pregnancy was done, a friend of mine taught me about Fertility Awareness. When my husband and I were ready to try for #2, we used Fertility Awareness and were able to achieve pregnancy the first month we tried. Same for my later children, despite being an old geezer by obstetric standards.

Turns out I ovulate much later than most women (thus the longer cycles). Trying to conceive during the usual times recommended would not have worked for us....too far away from my normal ovulation times. Learning my cycles made the process so much easier and less stressful.

It was also fantastic to know really early on from my temperature charts that I was pregnant. Helped remind me to take my prenatals plus extra folic acid religiously, and to be extra careful of my nutrition and exercise.

Despite having PCOS, I was able to get pregnant without any problems. I am fortunate in that my case is fairly mild on the PCOS spectrum. But in many women, PCOS prevents them from ovulating, or they ovulate only irregularly. Fertility Awareness is helpful in establishing whether or not they are really ovulating, and at what point in their cycle this is taking place. If they ovulate irregularly, Fertility Awareness can help them clue in on the signs that ovulation may be about to occur so they can take advantage of it.

Like any birth control method, Fertility Awareness has its pros and cons. It's not for everyone, at least as a birth control method. And using it as a conception aid won't guarantee you'll get pregnant. But even so, it's a great idea to learn about your body and its natural cycles, to learn what your cervix really looks like up close, and to understand exactly how your body works.

I highly recommend visiting the Beautiful Cervix website, and reading up more about Fertility Awareness.

*Image from Wikimedia Commons.

Saturday, January 10, 2009

Twin Pregnancy - Day by Day Video

This is just the coolest video. It's of a woman of size, pregnant with twins, who was kind enough to share her journey with us.

Her partner took a picture of her just about EVERY DAY in the same place, same pose, throughout her pregnancy, ending with the twins in carseats on the floor beside her. Then he made a stop-motion video of how her body changed, and they generously shared it.

Now, this video has already been shared on the fatosphere, over at Body Impolitic. Normally I'd just send y'all over there to see it instead of reposting it here.

However, one of my goals for this site is to share more pictures of women of size in pregnancy, birth, and breastfeeding. We see so few pictures of this in the media that I believe it's vitally important to have these pictures available; I get requests for it frequently on my website.

Women of size are so curious to know what they will look like when pregnant and giving birth. These pictures help answer that question for them.

Of course, what we look like pregnant and birthing is as different as what we look like non-pregnant. Not all women of size carry the same way; pregnant "apples" don't look quite the same as pregnant "pears" or "hourglasses," etc. So what this mom looks like may or may not be what you would look like in pregnancy.

Still, many women of size do look a lot like this in pregnancy. And how wonderful of her to show us this journey in the nude!

What a great thing to have more images to add to my plus-sized pregnancy photo gallery. And so cool to have these images of a twin pregnancy!

Thank you so much to this family for sharing. (I have their permission to embed the video here so there is a permanent entry in the blog for other well-rounded mamas to look at.)

You may never realize how many lives you touch because of this. Bless you, and bless your sweet little babies.

Video by Guy Gayle.

p.s. Random Factoid: Did you know that women of size have higher rates of twins?

Edited to note that this video was taken by a partner, not a husband. Thank you for the correction.

Tuesday, January 6, 2009

Thoughts about breast reduction surgery

So, discussion about breast reduction surgery was all over the fatosphere a few weeks ago. I debated whether to get involved in those discussions because things got a little heated. After thinking it over for some time, though, I decided to weigh in with my own thought process on the topic because I went down this road too.

[Please keep in mind that in no way is this post meant to criticize the decisions of anyone else, either in having or not having the surgery, nor in any parenting/breastfeeding decisions either. I'm just sharing my own experience with reduction surgery, why I've made the decisions I've made so far, and reflecting back on those decisions. I'm not judging anyone else or telling them what they should or shouldn't do. It would probably be easy to read judgment into what I'm going to say, but I sincerely don't mean it that way.]

My Story

I came within a day or two of having breast reduction surgery when I was in my 20s. I did all the consults, got all the information, did all the required paperwork and pictures (ugh), got insurance approval, and was ready to go. Then at the last minute, the insurance company balked at paying for a significant part of it and there was no way at that point we could realistically afford it, and so the surgery got put off.

We wrangled with the insurance company but couldn't resolve it. In the end, we just decided to cancel the surgery rather than risk being stuck with huge medical bills. I was relieved in some ways, but incredibly bummed and angry too. I had desperately wanted to be rid of the problems associated with being so well-endowed.

Yet now, in my 40s, I have to say I'm incredibly glad I didn't do it.


I chose to consider breast reduction surgery because of all the usual reasons. I'm extremely well-endowed (anywhere from an F to a J cup, depending on brand) and it's been a tremendous burden in many ways, both physically and emotionally. The shoulder pain, the back pain, the difficulty with exercising comfortably, the difficulty in getting clothes that fit properly, the difficulty in finding comfortable bras in your size, the difficulty in getting guys to look you in the eye when speaking to you, the ordeal of being harassed by strangers, etc. etc. You know the reasons usually cited, and they were absolutely all true for me too. It most certainly was a very real burden at times.

Weight loss didn't help; I stayed proportionately large. So I decided to consider a breast reduction. The doctor explained to me in graphic detail what would be involved, and emphasized that because of the extensive changes required for my particular case, I might very well lose most sensation, and I might very well never be able to breastfeed.

The idea of losing sensation really bothered me, but the idea of not being able to breastfeed didn't seem like a big deal to me, honestly. I was formula-fed and I was okay, no one I really knew had breastfed their kids, and the whole idea of breastfeeding seemed more than a little squicky to me. Even then I knew breastfeeding was the "healthy" thing to do, so I hoped that my ability to breastfeed would not be too compromised, but frankly, I was not particularly concerned about it. Other concerns were higher on my list of drawbacks.

But then the surgery fell through, so I decided to postpone a decision about it. Then I became unexpectedly pregnant and it was too late, at least for a while.

Looking Back in Hindsight

Now I look back, many years later, and am incredibly glad the insurance company got in the way of that surgery. Because had I had that surgery, I likely would never have known the incredible joy and healing I got from breastfeeding my children.

I know, I know. A lot of folks will read that and roll their eyes. I know how strange it sounds to some; how weird it would have sounded to me back in my 20s. But really, it was life-changing and I'm incredibly grateful I got to experience it.

[I should probably clarify here that I know that not everyone finds breastfeeding as amazing and life-changing as I did. That's okay; people experience pregnancy, childbirth and breastfeeding in an amazing diversity of ways, which is to be expected.]

I should probably also point out that I had a HECK of a time breastfeeding at first----it certainly wasn't easy sailing right away. It took about 4-5 months before things really smoothed out and got easy; the hospital did a lot of things that made breastfeeding nearly fail for us, and I didn't always have the information and support I needed. So breastfeeding certainly had a rough start for us and I wasn't all that enamored of first.

Actually, I never intended to breastfeed long-term at all, regardless. I just felt I "should" do it at least that long for the health benefits for the baby, and honestly, because I wanted to be seen as a "good" mother in the eyes of my in-laws. So I determined to "tough it out" for at least 3 months. And believe me, it was tough at first.

But then something changed. The harder I fought to make breastfeeding work and the more I realized what I was missing, the more I came to value it. The more I read, trying to figure out how to make breastfeeding work, the more I really realized how very beneficial it was in so many ways I hadn't realized before, especially immunologically. And the longer I breastfed my daughter, the more I fell in love with the process....and with my daughter.

Surprisingly, in time, breastfeeding became a tremendous force of healing in my life. My first child's birth went so badly that I actually developed post-traumatic stress from it. Breastfeeding was a big part of what helped me come back "into" my body and to really connect with my baby afterwards, despite the PTSD. It was something that only *I* could do for my baby, and those hormones released during breastfeeding really made a huge difference in helping me over the difficult bumps of early the four months of terrible colic she had at first.

The one time when I didn't have to deal with her crying? When she was nursing, and right afterwards, when she'd been stunned by the "happy milk" hormones. It was the one time she was happy. It was the one time we could just sit and connect and really bond. It was the one time I could get her to interact, smile, and look around. It saved us; it totally saved us.....thank goodness for breastfeeding.

So when my 3-month deadline was up, I extended it for another month. Then for another month, and then another. Soon I realized I loved nursing so much I didn't want to give it up until both my child and I were ready to stop. And we didn't.

That breastfeeding relationship with my babies was one of the best experiences of my life and I wouldn't trade it for anything.

Emotional Healing

Somewhere along the line, I realized that not only did breastfeeding help me bond with my children, but it was also helping to heal my self-esteem issues around my breasts.

This part of myself that I was so ashamed of when I was younger somehow transformed into one of the most important parts of me. In my children's eyes, my breasts became the most beautiful part of my body. They became the very symbol of mother-love to them. How could I continue to hate my breasts when they were so very beautiful, so very essential to my children? I began to see my breasts through the eyes of my children and they were transformed for me.

It's so incredibly difficult to explain this to someone who has not experienced it. I would not have understood it before I had children. I would not have thought I was giving up that much. How can you miss what you do not know, what you do not value except in the most abstract of ways?

And yet, I found breastfeeding my children to be one of the most profoundly moving experiences of my life, and one of the most profoundly healing.

If I had had that breast reduction surgery, I might never have known that experience, and that makes me truly sad. Of course, if I'd had the surgery, I'd never have known what I missed and it wouldn't have been a big deal to me. But now, on the other side, knowing what I would have missed, it almost makes me weep to think that I might have missed that experience. It's that powerful and that vital to me.

So when women decide to have a breast reduction surgery before they have children, I have ambivalent feelings. Part of me wants to say, "Way to go! You do what you need to to feel better physically and emotionally." I know how hard it is to deal with being well-endowed, and I am all for women empowering themselves and doing what they need to do. And yet, part of me weeps to think of what they may miss if their surgery leaves them unable to breastfeed.

In the end, of course, it has to be their decision, and we have to respect their judgment about the relative strength of the pros and cons to them. I wouldn't tell anyone not to do it, but I do want to point out just how powerful some women find the breastfeeding experience, about how breast reduction surgery really can interfere with breastfeeding. I also want to inform women of the resources out there on breastfeeding after reduction for those who decide to go through with surgery first.

Caveats and Resources

Of course, there have been many advances since I nearly had this surgery ~20 years ago. Surgeons now can preserve a lot more function to the breasts than they could then. Many more women are able to breastfeed now after reduction than in the past. Still, a lot depends on how much reduction is needed, on the skill of the surgeon, on the techniques used, and sometimes on just plain luck. You just don't know for sure how things will turn out.

I know of women who have had breast reductions and gone on to breastfeed, so it can be done. Sometimes it doesn't work with the first child but is more successful with the second child because the milk ducts are able to re-connect. But most women I know who have had breast reductions struggle to some degree with supply issues, and many must supplement with formula. And that does come with a price, both financial and emotional.

Low milk supply issues are much more physically difficult and emotionally painful than most people realize, and few people who have not been through it understand just how devastating it can be. With enormous admiration, I salute the women who so value the immense benefits of breastfeeding that they work so hard to get their babies every drop of breastmilk possible.

But while partial breastfeeding is possible after reduction, full breastfeeding often is not. Now, some might what? You give the baby what you can and you supplement when you need to, big deal. And for some it really isn't a big deal. But for others it is, and you never know which camp you're going to fall into ahead of time.

It's hard to understand until you are in that situation just how stressful and disappointing low milk supply and breastfeeding difficulties are, especially for women who never anticipated that it would be important to them at all. For some, the struggle ends up being far more devastating than they ever realized it might be.

Some women regret having had reductions because of this; some do not. Some wish that they had waited until after they had their children to have the reduction.....and yet others do not. People's reactions to this are very individual, but no reaction is "right" or "wrong." People feel how they feel.

But it's also important not to shrug off too easily the impact that reductions can have on breastfeeding and women's ambivalent feelings and experiences with that.

For those who are looking into this surgery seriously before having children, I highly recommend the website, Breastfeeding After Reduction, It has excellent, non-judgmental information for those considering the choice, and great resources and support for those who have had the surgery and are looking for breastfeeding information and help afterwards.

It also has an excellent, thoughtful discussion on the pros and cons of delaying the surgery until after childbearing, with women weighing in on both sides of that question and offering a full range of perspectives. It is truly an outstanding resource.

Now what?

As for me, my pregnancy and breastfeeding days are basically over. So how do I feel about a breast reduction now?

In one word.......ambivalent. On the one hand, all the reasons that were there before (back and shoulder pain, bra issues, comfort while exercising etc.) are still there. Even while breastfeeding, those negatives certainly didn't go away; they were always a pain. And these issues will only get worse with time. The thought of dealing with this into my 60s and 70s and 80s.....well, the thought of reduction becomes quite attractive again when I look at it that way.

And yet. It's still major surgery, especially for someone like me. That's a lot of re-arranging and chopping out and reconnecting, you know? A lot of chances for things to go wrong, a lot of chances for infection to take hold, a lot of chances for painful scar tissue to form.

And having gone through a very bad surgery with my first cesarean, I will never take surgery lightly again. I know women as well-endowed as me who have had the reduction surgery and were totally unprepared for how much pain and recovery there was afterwards. Even though most felt it was worth it, they generally had months of recovery, not just a few weeks, and most had far more pain than they had anticipated beforehand. I know firsthand how much surgical recovery can suck, and I really have no wish to go there again.

Also, I've forced myself to watch videos of breast reduction surgery on cable TV, on the surgery/medical channels. Now, I like medical stuff; surgery rarely bothers me. I find it really fascinating, frankly. So I thought that perhaps if I could watch the procedure, really understand exactly what would be done, then I'd be more okay with the idea of it.

But actually, I found myself incredibly repulsed by it, unlike most surgeries. It seemed to me like they treated the body with such disrespect, pushing and pulling it around, jiggling it, mashing it, cutting it up, treating it like a slab of meat. It literally made me ill to watch it. I realize that that's the nature of surgery, but the thought of subjecting my own beloved body to such meat-cleavering made me want to throw up.

Honestly, I'm not sure why. I speculate now that perhaps it's because it takes a certain degree of emotional or physical disconnect from your body to consider doing something so radical to it, and pregnancy and breastfeeding helped me live so intensely in my body that I came to love and respect it and be connected to it in a way that would make altering it like that seem like a disfigurement, a sacrilege.

That doesn't mean that someone else choosing to do that is wrong or disfiguring; I can see how it can be helpful and even a good choice for many women. I'm not criticizing anyone for making that choice. I like the the abstract. But when I think of it for me, I get a profound sense of disquiet, of self-disrespect inside. And I need to listen to that feeling and honor it.

Yes, I have days when I am bothered by back pain, days when I see a picture and I see how very much my appearance is dominated by this feature....and I have moments when I absolutely want to consider a breast reduction again.

So I do not rule it out for the future; I might, at some point, consider having one......but at this point, it just seems wrong, almost sacrilegious to do it to my body. I honestly don't know if I'll change my mind on this, so I leave room for flexibility and for reversing the decision. I also leave room for choosing to leave my body intact. At this point, I have decided not to decide.

Either way I choose in the future, I can't escape the profound gratitude that my surgery was unable to go forward in the past, that I was able to experience the wonderful and profound healing that I found through breastfeeding my children, and that I was able to give them (and me) the amazing health benefits of breastfeeding.

I understand and respect that not everyone feels that way, and I understand and respect that some people will move forward with their surgeries regardless, feeling that a reduced ability to breastfeed is more than enough of a trade-off for the benefits they will get. That's their right, and I truly wish them well. I just felt that it was important to represent a variety of thoughts and experiences on the subject, and I wanted to share my own process with the community.

*I welcome comments to this post, but please use sensitivity and consideration. This is an emotional topic for many people. The post is meant to encourage dialogue, not condemnation.