Well, here we are in a New Year. Time to consider the old year as well as transition to the new. That means it's time for the Second Annual Turkey Awards! So much fun.
The Turkey Awards are my chance to highlight the most biased, bigoted, or just plain ignorant coverage of "obesity" and pregnancy in the media in the last year, or discuss the most prejudiced and insensitive "care" examples for women of size I've learned about.
Hmmmmm. So many possibilities, so little time to write about them all.
But one new article was brought to my attention by a fellow blogger, and I have to say that the distortion, bigotry, and sheer vitriol of the piece makes it a strong contender. After considering all the alternatives (and there were quite a few), this is the one that made me most feel like I'd been swimming in a vat of sewage after reading it.
So this year, the Turkey Award goes to (drum roll.......) Abe Sauer (who really is as sour as his name might suggest)---and all the other scare-mongering and judgmental authors out there like him, trying to scare and shame fat women out of reproducing.
I absolutely refuse to link to Abe's article and give it more linkage in the search engines, but if you google it I'm sure you'll find it. It's titled Fat, Fetuses, and Felonies.
And trust me when I say it is a hate-filled rant (warning: major Sanity Watchers points!) full of fat-phobic half-truths about risks and complications, suggesting that fat women who have babies show irresponsibility akin to pregnant alcoholics, and that no fat women deserves to ever receive fertility assistance.
Basically he combines a rant exaggerating the dangers of obesity and pregnancy with a rant about the Fetal Personhood movement, which (if taken to the extreme logical end) he says could result in persecution of obese women whose babies experienced a complication.
He doesn't endorse this of course, no no no no noooo! But he prominently implies that fat women have no business getting pregnant and that we as a society simply lack the moral strength to condemn them when they do irresponsibly get pregnant.
Here are some choice quotes from his article (again, major Sanity Watchers Points ahead):
- Obesity creates a murderers' row of obstetrical miseries.
- A mountain of recent data shows being obese during pregnancy is as dangerous as being a pregnant alcoholic.
- Obese patients...have a frequent inability to follow diets and self care regimens. Many nod along with doctors' directions while in clinic, and do not follow them.
- Deliveries are messy and dangerous. There's the anecdote of a baby who almost drowned in the wall of fat of a severely overweight c-section patient. Adipose tissue suffocation is just one—albeit rare—risk of maternal obesity.
- Studies of women who were obese before pregnancy, or gained too much weight during pregnancy, reveal a whole grab-bag of fetal development horrors.
- Obstetricians hate c-sectioning the obese because the procedure is more dangerous. Paradoxically, being obese drastically increases the chance of c-section. Obstetricians tell tales of cutting slabs off pregnant women.
- It turns out that the question is wrong; it shouldn’t be “What can’t I eat when I’m pregnant?” but “What can’t I eat before I get pregnant?”
- Now, combine our sticking it in nature's ear by enabling the morbidly obese to become pregnant with data clearly demonstrating how dangerous such obesity might be to a fetus with the “personhood" movement and you have got yourself a genuine possibility of prosecuting a fat pregnant woman with child abuse or child endangerment or even homicide.
- Agreeing that some IVF providers are ethically bankrupt and that the criminalization of pregnancy is stupid does not dismiss society's responsibility on the issue. The threat to a potential child from obesity-related complications is no different than the one posed a generation ago by alcohol...The fact that obesity does not even rate on our often overboard collective contempt for the pregnant is preposterous. And it should be embarrassing. But it isn’t and it won’t be. More than anything, we are fat. And the ramifications of our children suffering for our inability to control ourselves is beyond contemplation by a nation that is getting fatter only slower than it is getting selfish.
Obviously, some of this phrasing is so over the top and vitriolic ("Drowning" in a "wall of fat" in a c-section patient? Telling tales of "cutting slabs" off pregnant women? A "whole grab-bag of fetal development horrors?" A "murderers' row of obstetrical miseries"?) that he shoots down any pretense to objectivity and thoughtfulness with his own inflammatory tone and purple prose.
There's little point in commenting on his over-the-top phrasing; he condemns himself enough with that. However, I can and I will open a giant can of whup-ass on the fat-phobic hyperbole and assumptions that are rife in the piece because these are so typical of the media messages on obesity and pregnancy.
Hyperbole about Risks
Sauer spent a lot of time in his essay linking breathlessly to studies that document that there are increased risks for complications in the pregnancies of women of size.
Well, duh, Sherlock. No one is pretending that there isn't. It's not as if that information isn't trumpeted EVERYWHERE a fat woman looks these days, constantly. Believe me, fat women have heard this message already, loud and clear, and they will hear it many more times in their lifetimes, ad nauseum.
(I could link to many examples, but I refuse to give these scare-mongerers more linkage for the search engines.)
However, the problem is that these messages are not a calm, reasoned disclosure of possible risks, but vastly exaggerated hyperbole about said risks. An associated problem is the prejudiced assumptions about fat women themselves that abound in these warning articles.
These articles are not meant to inform, but rather to scare, shame, and intimidate women of size, and to promote a climate of hostility towards them among healthcare providers and society in general.
And it's this lack of balance and fairness that really irritates me. These authors have an agenda and it's not information or balance. It's shame and scare-mongering, pure and simple.
Anyone reading the summaries in these types of articles might well conclude that virtually NO fat woman has EVER had a healthy pregnancy or a healthy baby, that the ONLY way to have a healthy pregnancy is to lose vast quantities of weight, and that the vast majority of fat women experience MAJOR complications and bear only deformed or doomed babies. And that simply doesn't jibe with the experiences of most fat mothers.
The Need for Straight, Honest Talk Without Hyperbole
But what about his criticisms about risk around obesity and pregnancy? Do we leave those unaddressed? Do we take a polyanna-ish attitude and pretend that there are no risks?
No, it's important to be intellectually honest. There are risks to pregnancy at larger sizes, some fat women do experience complications, and some fat women do have poor habits and might have better outcomes with improvement of these habits.
We should be concerned about that, and we as women of size do have a responsibility to do what we can to attenuate our risks---just as every woman does, no matter what her size. I don't think anyone's arguing that.
[In fact, I'm starting a new periodic series on the blog, highlighting various potential risks of obesity and pregnancy and what the research really says about them---and what we can do to be proactive about them. This is something I've had on the to-do list for a long time, long before Abe published his sour mud-fest, because I think it's important that women of size have all the facts about risk and prevention. Alas, it seems particularly timely to finish it now.]
But if we're being really intellectually honest here, the fact is that these risks, while not negligible, are not huge either. The truth is that the majority of fat women have healthy babies, and many sail through pregnancy without complications---which you'd never know from reading some of these articles. Certainly you'd never guess that from reading ole Abe's article.
Where is the middle ground of informing women of size about possible risks without making it sound like they are committing suicide by pregnancy?
Where is the honest, accurate information about pregnancy in women of size---without scare tactics or judgment? Where is the calm consideration about proactive prevention that is not limited only to losing weight or keeping the mother from gaining any weight in pregnancy?
A calm, reasoned middle ground is what's missing in the discussions about obesity and pregnancy. So it's time to do that here on this blog, and on my website, http://www.plus-size-pregnancy.org/. You'll be seeing more on this in the coming weeks and months.
Our "Inability to Control Ourselves"
Another frustrating thing in dealing with critics like Sauer is their steadfast belief that obesity is always simply a matter of our "inability to control ourselves" and our "inability to follow diets and self care regimens," as Sauer so accusingly says in his article.
In this view, all obese people are lazy pigs who sit on their couches constantly stuffing down bon-bons and donuts, and any fat person who protests differently is obviously lying---either outright or to themselves.
No matter what you say you cannot convince these people that many fat women actually have very normal habits, and that there are often genetic or metabolic differences that account for differences in size. No, no, noooo, they must be deceiving themselves about their habits---or outright lying about them. And since some fat people do have "bad" habits, therefore they all do; the others are just lying about them.
Consequently, then, if these lying, self-deceiving, lazy, and gluttonous fat people (who "choose to be unhealthy," to quote a recent commenter) decide to procreate, these critics see this as the ultimate crime of being Pregnant While Fat.
The implication in these articles is that the fat mother is simply too gluttonous, slothful, ignorant, or selfish to bother to eat healthfully or exercise at all (which would obviously have already solved her weight problems if she'd only bothered to try it), and that because she obstinately refuses to give up the donuts and her couch-potatoness, she is dooming her child to a similar life of gluttony, sloth and early death.
Therefore, because she is so irresponsible, such a fat woman should be scared out of becoming a parent at all (or scared shitless about it, if she dares to consider it anyhow). That's the basic underlying attitude of articles like these because they are based on the premise of the fat person as out-of-control, ignorant, and selfish glutton.
Shaming Fat Mothers As A Control Tactic
Fat mothers are compared to addicts and child abusers in these articles in an attempt to shame any fat woman from even contemplating pregnancy, or to intimidate her into vast amounts of weight loss first (by whatever extreme means are needed).
Given the notorious fail rate of diets involving large amounts of weight, this basically amounts to trying to neuter fat women in a desperate attempt at eugenics. If they can't sterilize her surgically, they'll attempt to sterilize her via scare-mongering.
Or, if they fail to prevent conception until "ideal" weight is achieved, at least they've shamed fat pregnant women into meekly accepting any and all interventions shoved at them, including possibly forcing them to diet during pregnancy, undergo extreme levels of prenatal testing (because heaven knows something is just gonna be wrong with that baby), and in many cases, endure "elective" pre-emptive delivery of that child (because everyone knows fat women can't go into labor or give birth safely on their own).
Shame, guilt, and scare-mongering are the favorite tactics of the Obesity Mafia, and nowhere are the strong-arm tactics more forceful than those applied to fat women about pregnancy. Sauer is dead wrong that our society has no will to condemn fat pregnant women; the condemnation is everywhere you look in the media, and is in SO many of the negative contacts fat women have with healthcare providers and even family members.
Far from lacking the will to condemn obese pregnant women, society and the media do it all too consistently.
Why Not Just Lose Weight First?
So why would any fat women consider pregnancy? Is it simply because they aren't aware of the possible risks? Have they not been adequately informed of them, are they just in denial about them, or are they just too stupid to understand them?
Or is it because they are too lazy to get off their fat asses and "eat right and exercise" first? Is it simply because they are too selfish to care about what might happen to their babies?
Why not just get exercising and lose a whole bunch of weight before even getting pregnant? Cause it's just that easy, right?
The problem is that the answers are not so simple as people like Abe would make them. The fact is that nearly all fat people have tried repeatedly to lose weight, and rarely is it lost permanently.
Most fat people have lost weight time after time, only to see it come back over time. Many of us end up fatter after a weight loss attempt than before we began it. In fact, for many of us, yo-yo dieting is what actually put us in the "morbidly obese" category in the first place.
Most fat people continue on the diet treadmill regardless, hoping against hope that Next Time It Will Be Different---but some of us recognize that it's not simply a matter of "calories in, calories out," that strong genetic and hormonal factors are at work in many of us, and that reaching that "ideal" weight is statistically extremely unlikely.
Many of us stop the weight loss attempts because we recognize that all the yo-yoing is hurting our health far more than it is helping it.
When we do this, we are not "giving up" or "letting ourselves go," but instead focusing on healthy habits instead of weight loss as a measure of health. These habits often do not lead to significant weight loss, but we are still healthier by simply emphasizing good habits and weight stability. This approach is called "Health At Every Size" (HAES).
For some of us, the decision to have a pregnancy at a larger size is one chosen once we recognize that long-term weight loss is not likely to happen and if we wait to reach that "ideal" weight range, we may never have a baby.
Furthermore, dieting before pregnancy may deplete the body's stores of vital nutrients (particularly iron), just at the time they are needed most. Many "morbidly obese" people have significant micronutrient deficiencies; although the definitive cause is unknown, repeated dieting may be a risk factor. Some of us know how deprived and unhealthy we feel after a major diet, so some of us consciously choose not to be restricting intake or undergoing malabsorptive surgeries before we decide to have a baby. We do this out of love and concern, not out of selfishness.
Some women of size do choose to try and lose some weight before pregnancy; not necessarily down to "ideal weight" but at least a little bit in hopes of lowering risks. It's possible that in some people, this might help lower the risk for some problems. The problem is that there's not a lot of research about whether this really improves outcomes in the long run; doctors mostly just assume it does.
But remember, this can also backfire. Many of these women find that, once pregnant, the body rebounds with a vengeance, gaining far more weight than "should" be gained as the body tries to store fat for the starvation period it thinks it is in. And it's clear that gaining a great deal of weight in pregnancy is not ideal for anyone, mother or baby. So while losing even "just a few pounds" before pregnancy may seem prudent, it often has unforeseen consequences.
Furthermore, while some research suggests that losing small amounts of weight can lower blood pressure, yet other research suggests that weight cycling can actually greatly increase the risk for developing high blood pressure.
The truth is that the decision is just not that simple. Sometimes weight loss seems to help, but sometimes it actually worsens outcomes.
Furthermore, if there really were an easy, foolproof way to lose weight permanently, we'd all be skinny. It's NOT just a matter of willpower, and research shows that long-term weight loss is very unlikely.
Some of us choose not to wait till we are "ideal weight" before having kids because we know from bitter experience that the ideal weight thing (and therefore, children) may never happen. We know there are risks to getting older too, and we may decide that it's better to act sooner than later.
Some of us realize that if we continue dieting, we are likely to be far more fat in the long run, and it makes more sense to us to have a child at this weight than at a higher weight.
Some of us believe that having a child at our present weight makes more sense than losing weight and then trying to keep the resultant pregnancy weight gain to "acceptable" levels, or to start out a pregnancy nutritionally-compromised from recent weight loss attempts.
Having a child at a higher weight does not mean we are ignorant about nutrition and exercise, that we are recklessly exposing children to potential risk because we are too lazy or stupid to "eat right."
For some of us, the smart thing to do is to practice Health At Every Size concepts, which promote healthy and reasonable eating and exercise without emphasizing weight loss as a goal or measure of health.
Many of us prefer to emphasize good habits and good health before conception and during pregnancy, rather than to try to achieve some arbitrary designation of "proper" body size before being "permitted" to reproduce.
This is not an act of selfishness but an act of love, hard as that may be for critics like Sauer to understand.
Conclusions for Healthcare Providers
No, we should definitely not ignore the potential risks that can accompany pregnancy in women of size. Duh. But for God's sake, STOP EXAGGERATING THEM.
STOP trying to scare and shame fat women out of reproducing and pretending that you only have the noblest of intentions at heart instead of eugenics.
STOP implying that fat women are child abusers for even considering reproducing, or that the only safe way for a fat woman to have a baby is if she goes out and loses a bunch of weight first. The fact is that many fat women have healthy pregnancies and babies without losing weight. Study those women and see what you can learn from them.
STOP trying to force fat women to be so ashamed and cowed about daring to be pregnant at a higher weight that they meekly accept overly-interventive and risky care.
STOP promoting protocols that limit choices for fat women, keeping them from accessing midwifery care, birth centers, waterbirth, or other low-tech "alternatives."
STOP the assumptions that fat women "must" be eating in a certain way simply because they are fat, and the patronizing attitude that pregnancy represents the perfect window of opportunity to reform their gluttonous ways by using their children as tools for emotional manipulation. We are not stupid, and we know that simplistic platitudes about nutrition do not result in long-term weight loss for most of us.
REMEMBER that fat people are not all alike. Some fat folk have bad habits, but many do not. Some skinny folks have bad habits, yet remain skinny. Genetics plays a very strong role in body size. You simply can't tell how a person eats just by looking at them.
ASK women (of all sizes!) about their nutrition and exercise habits and believe what they say. Stop assuming they must all be lying.
STOP giving advice on a "one size fits all" basis and start individualizing it to each woman's habits and needs. Take into account their dieting history and understand how that influences them. Emphasize nutrition instead of the scale; emphasize reasonable and realistic habits, not unattainable pie-in-the-sky scenarios.
DO start realizing that being fat and wanting children poses a difficult set of choices for women, and that it's not always as simple as "eat better and exercise more and you'll magically lose weight and be healthy enough for a pregnancy."
REMEMBER that getting to "ideal" weight is simply not a realistic goal for most fat women before pregnancy. Even when eating well and exercising regularly, many women of size stay fat. Even the fall-back stance of "lose just 5-10% of your weight" can have negative outcomes in real life too.
RESPECT that ultimately, the final choice about whether or not to lose weight before pregnancy is the woman's, and that choosing not to lose weight ahead of time doesn't mean we are ignorant, uncaring, or unhealthy. Instead, for many of us, it may represent what we think is our best chance for a healthy pregnancy and baby.
DO give us accurate information about possible complications, but stop over-emphasizing risk ratios that distort the risk picture; give us real numbers about the real likelihood of a problem occurring so we can make decisions from a more informed and empowered basis.
STOP the binary thinking about obesity and pregnancy that focuses only on weight loss before pregnancy and limiting weight gain during pregnancy as the "cure" for all problems. This is red herring research, focusing only on fixes whose successes are highly unlikely, instead of on real-life solutions that are practical and achievable.
START making research on pregnancy and obesity risks more meaningful. Start researching why fat women have more risk of certain complications instead of merely documenting that they have higher rates. Compare those fat women who do not experience complications to those that do and figure out what differences there may be and if those differences can lead to meaningful interventions.
FIND OUT if there are ways to lessen risks that don't necessarily involve weight loss as the goal. Uncouple "lifestyle interventions" from weight loss and see if emphasizing more exercise, independent of weight loss, lessens the rate of gestational diabetes or pre-eclampsia. Examine whether other simple interventions, like increasing the dose of folic acid given to women of size, might lessen the risks of problems like birth defects, independent of weight loss. Stop worshipping at the rigid and unrealistic altar of weight loss as cure-all and start considering alternative ways to prevent problems.
QUESTION the assumption that fatness prevents vaginal birth and that therefore, there is no need to examine the role that iatrogenic attitudes and interventions plays in the high c-section rate in women of size. Obese women in the past had high rates of vaginal birth; why don't they now? Examine biases and intervention rates and see how these influence things like cesarean rates.
RESEARCH what type of care protocols actually do improve outcomes in women of size; don't just assume that high-tech, high-intervention models are better and will improve outcomes. Many fat women find they actually do better in low-intervention models. Do more research to find out what works and what doesn't and then implement those models and rigorously test the conclusions.
STOP demonizing fat women who decide to have children, and stop treating them like pariahs, worthy only of contempt and mistreatment.
STOP seeing the world in simplistic, black-and-white terms and acknowledge the grayness that more typically characterizes the decisions women make around obesity and reproduction.
STOP exaggerating risks. Do present information on potential risks associated with size, but use real statistics on the actual occurrence rather than speaking only in risk ratios that create a distorted sense of danger. Remember to also point out the number of women of size who do not experience that particular complication so women have a realistic risk picture.
STOP thinking in binary terms, considering only weight loss or lack of gain in pregnancy as the only realistic way to prevent complications.
START considering other ways of being proactive that do not depend on highly unlikely weight outcomes, and realize that restrictive dieting or surgical weight loss has its own set of risks to consider.
CONSIDER the negative influence of iatrogenic complications caused by size bias among providers. Remember to separate correlation from causation in the research
and understand that negative beliefs and exaggerated fears about obesity can negatively impact outcomes.
ACKNOWLEDGE that many women of size actually do have healthy pregnancies and babies; study these women and see what can be learned from them.
RESPECT that wome of size have the same right to informed consent and decision-making as any other woman. Stop imposing arbitrary rules about our care onto us; give us the pros and cons of possible interventions and sit with us as we consider our options and make our decisions. Remember that ultimately, the decisions on how to proceed are up to us.
START listening to us instead of preaching at us, and treat us as responsible partners in our own care. We have brains, we can understand data, and we can consider the benefits and risks of the many choices available to us. Do everything in your power to make sure we DO continue to have these choices, and then support us in our choices.
STOP the scare-mongering and work with us.