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.