Wednesday, December 2, 2009

Reply turned post: Ghettoizing Fat Pregnant Women

Kathy at Woman to Woman Childbirth Education has a good post on a recent article from the UK, discussing the banning of "obese" women from birthing in certain "low-risk" hospital birth units because of their weight.

I commented on her blog, but the more I think about it, the more I think it deserves its own post here on my blog too. So I'm going to hijack the discussion over to here.

This is part of a new trend towards "bariatric obstetrics." The idea is that the "obese" mother is at SUCH INCREDIBLY HIGH RISK that she is better off delivering at a hospital that is specially equipped for her needs and where doctors can specialize in such "high-risk" deliveries.

Although some folks setting up these policies may have good intentions, what they are actually doing is "ghettoizing" fat women.

By taking away low-risk care options for fat women, they virtually guarantee a high-risk, high-intervention, high-complication delivery for them.

But no one is actually studying whether switching to special "bariatric obestetrics" practices and hospitals actually improves outcomes among "obese" women. They just assume it does.

And it assumes a level of extreme risk for all fat women when many don't experience that at all.

Yes, pregnancy in women of size has more risks of some things, like gestational diabetes, pre-eclampsia, macrosomia, etc. Yes, some women of size have complications. You'll never hear me pretending otherwise. And sometimes a woman of size does have complications that needs a higher-intervention approach or a higher-risk hospital or practice.

But many women of size have healthy pregnancies and births, and many more probably could if they access to proactive, low-intervention care via the midwifery model of care.

If fat women don't have any complications, do they really need a high-risk practice or location, based on weight alone? Do they really benefit from it? Or does it cause more harm than benefit?

And even those who experience mild complications, can't they usually still be cared under the midwifery model of care and benefit from that model?

Research shows that when comparing clients of the same level of risk, midwifery clients experience fewer inductions, fewer augmentations, fewer epidurals, fewer episiotomies, and fewer cesareans, yet their outcome is just as good or better.

Some research suggests that women of moderate risk also benefit from the midwifery model of care. Although not specifically addressing obesity alone, Cragin and Kennedy 2006 concluded,
Even among moderate-risk patients, the midwifery model of care with its limited use of interventions can produce outcomes equivalent to or better than those of the biomedical model.
To take away the choice for that low-intervention model across the board based only on size, regardless of actual complications, is a total miscarriage of justice.

And I think that's the thing that has me most enraged....the paternalistic, condescending attitude of making my decisions for me, for my own "good"....because I'm fat. Taking away my best chance of having a safe, unintervened-in birth....because I'm fat.

As Susan Hodges of Citizens For Midwifery states, "How much 'risk' does it take to supercede the mother's right to bodily integrity?" Or self-determination?

I've got news for these folks. My weight does not give you the right to make my choices for me or to dictate whom I can see or what kind of birth I am "allowed" to have. This is my body, and *I* get to decide.

Unable To Access Low-Tech Care?

Unfortunately, I think that more and more in the next few years, we will see fat women denied the right to obtain low-risk maternity care, the right to see midwives, and the right to have homebirths or birthing center births.

It's already happening. Some birth centers already deny access to women above a certain BMI or weight limit. Some homebirth midwives/doctors turn away "obese" women, even those without complications, simply based on their weight.

Some homebirth midwives want to serve women of size but know that if there is a transfer or anything goes wrong, the authorities in their area will skewer them for daring to care for an obese woman at home.

(It's already happened; a friend of mine recently planned a homebirth and her midwife backed out on her for this very reason. She eventually found another midwife but it was not easy to find one so late in pregnancy. Fortunately, the birth went fine and no one got taken to task for serving a fat woman at home....but the fact remains that the fear of this caused her first midwife to desert her, and near the end of pregnancy too.)

So more and more fat women---even those who want alternative, low-tech care---are being forced into the high-tech medical model, one in which "morbidly obese" women often end up with a nearly 50% c-section rate---or more.

In fact, even being forced to be in the hospital with an OB isn't enough now. Some hospitals (like this one above in the UK or this one in Australia) are forcing fat women into specialized centers, so that they can't even access the low-risk, low-intervention hospitals.

And some regular OB practices refuse to care for obese women, requiring them to instead see high-risk OBs....regardless of whether they actually have any complications or not.

To these providers, the mere fact of being "obese" is complication enough, even without any actual complications to inconveniently complicate their biases, so to speak.

In other words, the hyperbole of risk around fat mothers is so out of control now that we are ghettoizing them. And it's only going to get worse.

Show Me The Money, Baby

The real question here is whether the centralizing of "obese" women together into specialized centers and under the "high-risk" umbrella improves outcomes or not.

My bet is that it simply leads to an atmosphere of unchecked and unquestioned intervention, and many many unnecessary cesareans.

But we don't know that because no one is documenting the outcomes. As far as I can tell, no one is even asking the questions.

Where is the proof that these bariatric specialties improve outcome?

Where is the publication of the protocols routine to these bariatric obstetrics practices? Are all these women being told to diet during pregnancy? Are they all being induced early for fear of a big baby? If they go outside the approved protocols of xxx pounds of weight gain or xxx pounds of expected baby size, are they just automatically sectioned?

Where is the documentation of the intervention rates of these practices? What is the induction rate, what is the c-section rate, what is the VBAC rate, what are the complication rates?

Where is the prospective study of high-tech, high-intervention specialized bariatric care for obese women, compared to a control group of women of similar size and complications who instead are exposed to the low-tech, low-intervention midwifery model of care?

Show me the money, people. Ah, but that's the problem right there. This is a new cash cow in obstetrics these days....the specialized practice of "bariatric obstetrics."

Just think of all the money they can charge insurance companies to force these women to see bariatric specialists! Just think of all the money they can charge for "specialized" bariatric equipment! Just think of all the billable services they'll "need" in the hospital! And just think of all the extra money from all the extra c-sections!

Sorry, I don't care if you have no financial incentive to study this or not. You have to SHOW ME that this high-tech, high-intervention, high-risk attitude towards birth in "obese" women actually improves outcomes before you dictate where I "have" to give birth in order to birth "safely."

PROVE IT. In a good study, with a good control group of similar fat women being treated in a true low-intervention midwifery model to compare it with.

Until then, stop taking away the rights of women of size to birth where they want to, to have equal access to low-tech birth, to have equal access to "alternative" techniques like waterbirth and full mobility in labor.

Stop forcing fat women to have early epidurals "just in case," mandatory internal monitoring, and automatic confinement to bed. Stop pushing fat women to induce labor early "before the baby gets too big." Stop sectioning fat women whose weight gains or whose baby size fall outside your definition of "desirable." And stop forcing women into bariatric obstetrics practices and high-risk hospital wards if they don't want it or need it.

Stop ghettoizing fat women, damn it. And stop telling us how and where we are "allowed" to give birth. These are our bodies and our babies, and we are the ones who get to have the final say.


Janeen said...

Excellent, thank you for posting this. I shared this on my facebook page. I'm on my second pregnancy as a supersized woman (got that from your pregnancy page :D ) and I was really hoping you would respond to this article. I was in tears one night because that article was posted on Facebook and the comments that followed were just SO hurtful! I even replied and mentioned that maybe I should look into an abortion then because I'm overweight and carrying a child, even though my first pregnancy had almost no complications (some pelvic pain in the end which was likely due to malposition) and that while I ended up with a cesarean, it was likely due to a bunch of interventions and the fact that I just did not have much in the way of support or sleep during very trying back labor.

Anyway, fortunately, my OB was very good about not treating me like some high risk pregnant lady but gave me the care I needed and treated me with respect the whole time. She never felt I was high risk at all and for that, I'm very grateful.

I just wish people weren't so fat phobic. It's hard enough being pregnant without the feeling that you're doing something horribly wrong because you weren't thin when you got pregnant and considering this pregnancy was a surprise, it's even harder this time around to not think this way. The night I read those comments, I sought out your website and read and read and that helped me feel so much better. I just hope I get the birth I want and more this time around. It should be interesting as I won't even be giving birth in the US this time around but in South Korea.

Anyway, keep up the good work but on your website and on your blog, I look forward to reading both, they are a great comfort to me during this time.

bibliophibian said...

Could you share a little more about your experience carrying and (eventually) birthing a child here in South Korea? I am planning to live here for several more years. The possibility of becoming pregnant is the only thing causing me to question that decision. If you could help to demystify what it is like to be a foreign woman of size giving birth here, I would be EXTREMELY grateful.

Heather said...

I am considered "obese" I guess. I remember when I was pregnant with my first daughter, I was told by my HMO that I would only be allowed to deliver at a certain hospital in the area because of my weight. Even though there was a hospital less than 5 minutes from me I was not "allowed" to go there and had to go to another one about 30 minutes away. I thought it was weird, but just went with it. I honestly never understood the logic behind it. I did not have a high risk pregnancy at that time, or for any subsequent pregnancies. I did drive to that "special" hospital and luckily didn't end up with a c-section (although I did end up with almost every other intervention- pitocin, AROM, epidural, episiotomy, etc...). My following two births were wonderful homebirths. I just really think that people shouldn't focus on fat. Every woman has a different situation in pregnancy regardless of their size. If more people in the medical world realized this then there wouldn't be these issues of overweight women birthing where they want. I don't know what I would do if I wasn't allowed to birth at home or a birth center simply because of my weight and nothing else.

Anonymous said...

Thank you for posting this - I love your blog!
Prior to becoming pregnant, I had read a number of media articles about fat women being refused local midwifery care and referred to major hospitals in my city. It scared me, and I attended my first appointment with my obstetrician with some trepidation. I was sure he'd probably weigh me and would possibly tell me I couldn't birth at the hospital I had booked into. This was not the case at all - he did not weigh me once, or hassle me in any way, and kept telling me how 'normal' my pregnancy was. I think he was a little surprised that my blood pressure and glucose levels never gave any cause for concern, but he didn't make a big deal out of it. Expectant management philosophy is such a nice thing! Anyway - I had a trouble-free pregnancy and I birthed my babe easily with no intervention, recovered super-fast post partum and breastfed her. It was all very 'textbook normal'.
I am now fatter than I was then. I will be devastated and enraged if this means that if I have another child, my choices will be restricted (I'd like to go to a birth centre or midwifery care model next time.) You're completely right - my body, my choice.

Anonymous said...

Thanks for this post. I just found out that the ONE freestanding birth center in my area (actually might be the only one in whole state of NC) turns away clients over a certain BMI as being 'high risk' even if they are otherwise perfectly healthy.

Anonymous said...

WOW. this is just scary. i have never heard about any of this. i am obese, age 35, and 5 weeks into my first pregnancy. i live in a rural area where there is only one local hospital, and the idea that they could refuse to take me there is terrifying. i will definitely be asking my OB about this at my upcoming appointment.

Kathleen said...

I'm at 5 months along with my first baby. The people at the WIC clinic were "concerned" that I have gained no weight yet. The more I read I wonder if in the eyes of some, we larger women can do no right with our pregnancies. My obstetrician isn't worried about my lack of weight gain because the baby is healthy. His only concern so far was my blood pressure has gotten higher since becoming and is now at the lower end of pre-hypertension. But so far he hasn't labeled me as being high risk based on my weight alone. I have an family history of type 2 diabeties so he did think my risk for GD is higher but with both my dad and his mother being type 2 diabetics I wasn't bothered by it. If I didn't have the family history I might have been. Risk shouldn't be based on obesity alone during pregnancy but it often is and that's sad.

Janeen: that's awful that people said you should get an abortion based on your weight alone. That's none of their business. If you and your baby are healthy during the pregnancy then your weight should not matter.

I didn't plan my pregnancy. It came as a big surprise too and I was 4 months along before I knew due to my irregular menstrual cycles.

Tami said...

I just saw this on a midwife's facbook page--actual research about the effects of forced weight loss during pregnancy. It's not good.

serenity said...

After a hospital birth I HAD to have thanks to my doctor telling me I was overweight and had 'no choice in the matter' 9 years ago, I still have nightmares about that experience. From the surgery because I was forced to push when I didn't need to, to the hiv test because they decided a student should sew me up and slipped badly (requiring a cafita and 5 days in hospital)to the missed meals and drinks, being told it was my own fault I was asleep at meal times, and No I couldn't have any food (overheard midwives laughing saying it would do me good to miss a few!)I was ignored, jerred, harassed and felt awful from start to finish, 6 horrific starved days later. Even my midwife at the visits made me feel awful and ugly and forced me to go for so many blood tests my arms were always blue and black even though I have NO health problems before or during my pregnancy other than I didn't fit into a size 10. Larger woman are made to feel stupid, incompitant, and totally out of control of our own decisions. Thank you So much for starting this topic, attitudes NEED to be changed.

Burrowing In said...

I've only just come across your blog in the last couple of days, and I just wanted to say "Amen" to this post!

I am a larger woman. Even with my homebirth midwife, the second question out of her mouth was, "Have you always been...fluffy?" And she is a rotund woman herself. I had to let the shock pass over me and remind myself to close my mouth and then answered her patiently that I had not, but that so far my fatness had not been the cause of any other sort of unpleasantry. I don't have high blood pressure or cholesterol. I am not diabetic. I am active and limber, etc.

Anyway, I myself am a doula, educator, and lactation counselor and will be checking here often. I also linked to you on my own blog!

Sarah R said...

Thank you for your blog.I have just discovered I am 6 weeks pregnant and I guess I am around 350lb which is quite large,and I've always been told I'm supposed to have all these health problems like diabetes,high blood pressure and high cholesterol and none of these are true.I've also been told since I have endimetriosis and because of my size it wouls be highly unlikely I would fall pregnant.Imagine my surprise and delight when at 31,married to a wonderful man with an education and stable career behind me,I discover I'm pregnant..yay! I went to the Dr yesterday,with my husband to confirm it and get some advice etc.I'm particularly concerned because I am a vegetarian and wanted to ensure I got the right balance for my baby, as I'm getting conflicting info on tofu and nuts etc while pregnant.Although The Dr said "well it's great that you're pregnant" several times,he dismissed my request to be referred to a dietitian saying "well thats not really going to be a problem,the main problem is your size" and then proceeded to ask me how I even got fat being a vegetarian...I thwn felt obligated to provide an explanation even though I really shouldnt have had to and said that i'd stopped eating meat at 8,my parents had then filled my plate with potatoes and bread as replacements,I'd never been taught any nutrition along with coming from a "fat family" not enjoying or being encouraged to do any exercise.He looked uimpressed and said he would refer me to a specialist and his attitude alternated between trying to reassure me and trying to scare the hell out of me..he wouldnt even tell me what any of these "risks" were just kept repeating my poor husband is now convinced I'm going to be seriously ill or die and I'm now left waiting for some specialist to contact,when or how I don't know,no nutritional advice and no idea about whether I should get a midwife or if anyone is actually taking and responsibility for my pregnancy care..I'm also worried that the specialist might try to pressure me to abort...all I really want is partical advice and support so I can enjoy my pregnancy and look forward to my baby's arrival,so I',m so glad to have come across your site and got some reasurance :) sorry for unloading,I just needed to let it out

Anonymous said...

First of all, I'll say- I havent read everything, on this blog or elsewhere
But did anyone consider that this might actually improve the service provided?
It may lead to better classification of risk through results - a woman who is "high risk" in a normal obstetric unit, may be "low risk" in a specialised bariatric obstetric unit, and therefore they may recieve more individualised midwifery care.
Call me utalitarian, but in creating and implementing a specialised unit "just in case" may relieve strain on low risk units, leaving more funds to improve the overall service. A specialist unit will indeed recieve more funding. By having more patients and "higher risk" clientelle, it will recieve more money to deliver better care.
I believe the crux of the matter, the issue at the heart of every complaint regarding choice (or lack of), negligence, and general dissapointment with how a birth went, is that nowadays its normal to give birth in an obstetric unit (hospital). This is socially normal. And who regulates hospitals? The NHS. Who regulates the NHS? The government. Who pays for the government? We do.
Regardless of your size, on entering a hospital you are opening yourself up to obstetric practice - not midwifery care.
In the NHS, if you exceed your budget, they try to make you cut it. If, miraculously, you come in under budget, they think you dont need it, and cut your budget.
More money = more staff/equipment, regardless of what its used for. Remember we are now being demanded to deliver client choice regarding birth. Choice costs money.
To some people, any risk is a risk. This can be viewed in two ways - financial and life preserving.
I think no matter how small the risk in labour, its a risk to life. Ive seen it - its damn bloody scary. You have to make the choice of whether you choose to fight the risk, or run with it.
Sp on the other hand of this argument, why not promote home birth? The other school of thought is that being comfortable and in control of your surroundings improves birth outcomes. If a healthy woman, regardless of weight, size, colour, shape or anything else, in your eyes, is low risk, why not call upon them to rise up for homebirth, not degrade a new specialist unit.
One last thing, I agree that people should be happy in their bodies. I would consider myself "fat". On the BMI scale, I am obese, but only I can call myself fat. That is my decision. If I decide to belong to a group of "fat people" I am isolating myself. Today, "fat" is a derogatory term, like it or not. British people dont say "fat" in a polite way. Fashion, celebrities, TV and the rest of the media facilitate this. So Im wondering why you use it?
Is it to raise awareness of stigma and normalise it - if so great!
Or is it being used to implicate that fat women are being stereotyped and therefore discriminated in this particular instance and many others? In so creating an anger?
Either way, in studies, media and blogs, persuasive writing is persuasive writing. You have to make your own research and evaluations.
Ps i forgot, relating to money in NHS - note the specialist equipment that is needed simply to sleep in hospital for bariatric patients (costs money)

Anonymous said...

I'm a plus sized woman and was for both of my pregnancies. My first boy was born by emergency c-section and the second at home with no pain meds. I breastfeed on-demand and more so when my little guy is having a tough day. It may be that our culture promotes that to be fat is to be "lazy" and this brainwashing in turn seeps into a fat mom's pysche and she fails to be motivated enough to try for her baby. Our culture is not one of understanding or faith in people. Our culture is like a high school bully. I am fat, but I breastfeed my baby when he tells me he's hungry, insecure, or not feel good/grumpy. It takes work to breastfeed and at times, takes more effort to sit for long periods because...let's face it, fat or not...this mom has a house to clean, bills to pay, and an older child needing help with homework. I think fat has something to do with motivation, but lets face it, motherhood and all its complexities are not seen as noble or important. So, where's the support for the basic motivation to care for our own babies? Never mind, those who want to (but can't) breastfeed. Fat moms or not, we're all expected to be Superwoman, and get back to work; leaving our babies in the care of others.

big beautiful native american said...

I am 314lbs. on my scale at home and when i where shoes 314lbs. at the high risk specialty center and 309lbs. at my wic clinic. My pre pregnancy lb. was 309 and i have been morbidly obese for many years now I am 33 yrs. old 2 children and am pregnant 5 half months now. I have had 5 pregnancies total. my first 2 children i had healthy normal pregnancies and lb was never over 235lbs. my last pregnancies I have complications and miscarried at 13 weeks. this pregnancy was high risk due to a blood clot from the birth control i was on at the time before i was pregnant so i am limited on birth control i can only have depot morena or copper iud condoms but not much more. i am also pre diabetic and my father and mother have it on both sides. I also had a leep done not to long ago and they check my cervix every 2 weeks but so far its been great. the baby i have now is healthy so far and i am scheduled to have an echo test in june. since my blood clot it wont matter ever how much lb i lose i will always remain high risk and also cause if the pre diabeties my ob put me at high risk due to my last high risk pregnancy now at the same specialty center i fear with all the tests and ultra sounds every 2 weeks starting in my 2nd trimester and then every week after my 3rd trimester its like i live at the center i am on lovenox and prenatal but nothing more. I feel like a cow being herded appointment to appointment and all the pokes and tests and it takes the joy out of pregnancy my diabetic nurse said are you concerned for you children with all this lb and do you think of them and like i am some constant grazing cow that thinks nothing of her children and asks are your children obese too this is serious and you should really think about that. and its like all the doctors i see say things like do not gain any more lb. but do not diet just eat better and exercise and i really feel like the tests and all that make it real hard to enjoy pregnancy and to feel good about it the providers scorn or look down on you and treat you like your stupid if your obese like i do not even know how to eat right or be pregnant right and one doctor said since i have such a problem with birth control that i should get my tubes tied and i was not even thinking of that my partner now wants more children and loves me at my size and my family loves me at my size i love me at my size but when i go to these appointments it like they make it impossible to feel anything but like a herded cow and like i have no choice in the matter a doctor didn't explain the echo procedure or talk to me about it just made the appointment after i went home and didn't ask if that day worked for me i had to research online what it was. how rude.

Anonymous said...

I was over 400 pounds when I was pregnant. I lost 75 pounds within the first 3 days of birth. My water broke, but I wasn't contracting hard or regularly. I went to the hospital. They pushed platocin and I refused pain killers, because I didn't want to slow down labor, or birth a high baby. After 17 hours, labor had gotten way more intense and regular. I was still only dilated 4 cm. Despite them pushing drugs to make it dilate. I was so weak I couldn't think. My son's father was to make the decisions, and my doctor told us it was becoming too stressful for me AND the baby, and that we had 2 options. Either deliver with a c-section, or deliver us both to the morgue. I wanted a natural birth. They wouldn't even let me get out of bed. At first I could to pee, and then they refused me even that. I wanted so bad to walk the halls. To move, to get out of that deng uncomfortable bed. But they wouldn't let me because of my weight, and my water having broke. I still have pain from my surgery... the anesthesiologist failed big time. I felt them cut me open, I told them I could feel it. I began panting, and sweating, and panicking and they just pushed anti-anxiety meds into my line. I felt them cut me open. I told them I did. Being on state aide, I didn't think I could take action. I still don't know if I could have. I spent the rest of the night being pumped full of morphine and toridol which resulted in a severe allergic reaction. It wasn't until my ex brought me our baby that I calmed down enough to not be screaming every time I woke up from my drug induced daze. And was able to tell them that the medications they were giving me weren't doing ANYTHING for pain, and instead caused a rash that felt like I was being burned with FIRE. It was very visible. The nurses and doctors refused to listen to my ex. I remember waking up to him begging them to do something else while I just screamed in agony. Well... that's my super awesome birthing story... made worse by doctors and nurses who refused to listen

Anonymous said...

Wow, This was an eye opener! I am considered obese and I had three girls within 4yrs. Each pregnancy perfect, no complications and all vaginal birth with labors lasting an hour or minutes! To add to that, I was also AMA being 38, 40 and 41 when I gave birth. I'm now approaching 50. I can't believe how discriminated these pregnant women are over their size, so sad :(

Alice Elizabeth said...

I just have to say that my biggest problem with all this is using BMI for ANY healthcare decision making. I am of Northern European descent (Ukrainian, Norwegian, Swedish, et. al) and have the large, heavy bone structure to prove it. I weigh a little over 300 lbs, but I can fit into some of my mother's clothes and she is only 200 lbs--does that REALLY make me "extremely obese"? I am a nurse, and I avoid the BMI chart like leprosy. Even when I was very fit and healthy, with "normal" amounts of body fat, I weighed 170 lbs and wore a size 12/14 pants. I am so encouraged recently to hear of health researchers promoting the idea that someone can be fit AND fat. I am a little out of shape right now, but I can do pretty much anything I want to activity-wise, and I eat a healthful diet, and have for years, but I am so tired of getting the fat lecture I've been hearing since I was 13. Thank you for your blog and helping women like me realize that there are others out there in the same boat.