Healthy Birth Practices: Avoid Unnecessary Interventions

We've been doing an ongoing series about the Six Lamaze Healthy Birth Practices, why they are helpful, why they tend to be used less with women of size, and how that negatively affects births in this group in particular.

The previous Health Birth Practices we've already discussed were:

1. Let Labor Begin On Its Own
2. Walk, Move Around, and Change Positions During Birth
3. Bring a Loved One, Friend, or Doula for Continuous Support

The Healthy Birth Practice to be discussed this time is:

4. Avoid unnecessary interventions

As one study puts it:

In the last 50 years, a rapid increase in the use of technology to start, augment, accelerate, regulate and monitor the process of birth has frequently led to the adoption of inadequate, unnecessary and sometimes dangerous interventions.

"Pushed Births" Are The Norm Now

The typical hospital birth in the USA (and many other Western countries) involves a great deal of intervention. In fact, it is an extremely rare hospital birth these days that does not involve any intervention at all. But is all this intervention a good idea?

Jennifer Block calls overly interventive births "Pushed Births" in her book, Pushed. (If you are thinking about having a baby, you should definitely read this book!)

Here's her summary of what a "pushed birth" is:

A pushed birth is one that is induced, sped up, and/or heavily medicated for no good reason, and all too often concludes with surgery, invasive instruments, an episiotomy, or a bad vaginal tear---outcomes you don't want. Decades of research show that the healthiest birth for you and your baby...is a normal, vaginal birth with minimal intervention and maximum support.

How often are these interventions "pushed"? Merging a quote from the publisher's blurb on Jennifer's book with one from her website:

In the United States, more than half the women who give birth are given drugs to induce or speed up labor; for nearly a third of mothers, childbirth is major surgery---the cesarean section.

1 in 3 vaginal birthers get an episiotomy — surgical scissors cutting your vagina. And most women will put their pelvic floors at risk by lying in a bed throughout labor and pushing the baby out while while flat on their back.

Why? Because most L&D wards aren’t following best practices.

Women's bodies have developed to birth optimally over thousands of years. There is a process of labor that is meant to happen biologically, and when undisturbed, usually happens very well.

Of course, nature isn't perfect and "natural" isn't always better; sometimes things do go wrong, and thank goodness for intervention when that does happen. No one is arguing for no intervention.

But routinely intervening in a natural process often causes unforseen consequences. Sometimes you pay an unexpected price...and most doctors are greatly underestimating the price of the routine interventions they use.

About 1 in 3 women in the USA today have their babies surgically. Some cesareans are medically necessary, but a 30%+ rate is causing far more harm than good. In some states (see page 14), the cesarean rate is near 40%; in some cities and in Puerto Rico, the rate is nearer to 50%. In a few hospitals, the cesarean rate is nearer an astounding 70%.

Even when women have a vaginal birth, about a third will have an episiotomy, according to Block's book; the numbers are far higher in some third-world countries. Episiotomy (plus its repair) is yet another form of surgery. It can have huge effects on women's quality of life too.

Inductions, augmentations, breaking the waters, continuous electronic fetal monitoring, epidurals, IV drips, and urinary catheters are other commonly-used interventions. Again, each has a place and can be useful at times, but routinely used in most women, the cumulative harm can be significant as well.

A Human Rights and Women's Rights Issue Too

"Pushed" births are not just a medical issue, they are also a women's rights and a human rights issue.

Ideally, women are given informed consent about interventions, and their choices are honored. Sometimes that does happen; some hospitals and care providers do well in honoring women's decisions. And some women do choose interventions, which is completely their right.

However, far too often women's decisions are not honored, and their choices are taken from them. Sometimes women are literally bulled into interventions with threats; more often they are seduced into them with misleading information or scare tactics.

Talking people into potentially harmful interventions without fully informed consent and the freedom to refuse the intervention is a human rights violation. Everyone has the right to bodily integrity and to informed decision-making. No one should be able to take that right from you.

The fact that strong-arm interventions are so common in the obstetrics field on childbearing women makes it a women's rights issue as well.

Violence and intimidation against women does not just occur via domestic violence or rape. Unfortunately, it also happens during childbearing, but our society does not view it as an abuse of rights.

It's time to see unnecessary and coercive interventions as the human rights and women's rights violation that they are.

How Common Are Interventions?

It is a rare woman who births in a hospital and is not subject to at least one or more of the following interventions. Some interventions are more risky than others, of course, but all carry some risk of complications.

It is difficult to know exactly how often these interventions are used across the U.S.A.; the CDC collects data only on select interventions. The following figures represent intervention rates from the Listening To Mothers II survey from the Childbirth Connection.

[Remember that rates of interventions vary significantly from area to area, from doctor to doctor, and from facility to facility. The rate of interventions in your area may be higher or lower than these, but this is a good way to get a "snapshot" idea of intervention rates happening today.]

Induction

More and more women today have their labors induced artificially instead of being allowed to start labor on their own. In the LTMII study, 41% of mothers reported induction attempts by a caregiver. That's nearly half of mothers being subjected to the risks of induction.

Labor Augmentation

Even when they go into labor on their own, many women's labors are strengthened or speeded up artificially ("augmented") with synthetic pitocin. In the LTMII study, 47% of women received pitocin to speed up labor.

Many hospitals routinely augment virtually all women, across the board, as their standard of care. They find that this speeds up labor and gets the doctors home faster, but such convenience for the providers comes at a price for the mother, because induced and augmented labors are much more painful and mothers request pain meds at higher rates. They can also cause fetal distress and necessitate a cesarean.

Artificial Rupture of Membranes

Most women also have their water broken artificially at some point. Ostensibly this can speed up labor slightly, but it can also have risks (see the next section). In the LTMII survey, 47% of mothers had their waters broken artificially after labor began.

Epidural or Spinal Analgesia

Many women choose to have an epidural for pain relief during labor. This is their right and no one should be made to feel guilty for choosing it.

However, many women who do not want to have an epidural are strongly pressured by staff to have one during labor so that they are quieter and less demanding as patients.

Other women would like to go natural but find that they cannot handle the pain of induced or augmented labor without help. As is so common, one intervention often leads to another, each with accumulating risks.

In the LTMII study, 76% of women had epidural or spinal analgesia.

Urinary Catheters, IV Drips

In the LTMII survey, 56% had a urinary catheter at some point, and 83% had an IV drip. This makes it difficult to move around freely and basically tethers most women into bed, flat on their backs or sides. This makes it difficult to cope with the pain of labor and makes it difficult for women to maneuver to get the baby out most efficiently.

Electronic Fetal Monitoring

In the LTMII survey, 94% of mothers had Electronic Fetal Monitoring (EFM). This is alarming because EFM is a classic case of an intervention that has little benefit in normal labor, and clear evidence of significant harm.

As Dr. Christiane Northrup, OB-GYN, says in her recent Huffington Post article, Reclaim Your Right To Birth Right:

Data indicates that the only thing EFM has done reliably is increase the rate of Cesarean section (C-section) births.

Episiotomies

For years, episiotomies were used routinely on nearly all birthing women. Doctors did them to get babies out faster (in the days when all birthing women were heavily drugged and tied down) and because they thought that a straight surgical cut would heal better than a jagged tear.

However, research has since shown that routine episiotomies in fact cause great harm. In most cases, women tear far more seriously after an episiotomy, sometimes all the way from the vagina into the rectum. Most of the time, women fare better if an episiotomy is not done, because any tears that do occur are usually small and heal better than a surgical cut.

Yet in the LTMII study, 25% of women who birthed vaginally still experienced an episiotomy.

Cesarean Sections

In the LTMII survey, 1 in 3 women experienced a cesarean section, in line with the U.S. national cesarean rate.

More than three-quarters of c-section mothers in the survey reported pain at the site of the incision 2 months after birth, and 33% cited this pain as a major problem. 18% had ongoing pain at the scar at least 6 months after giving birth.

For many women, a cesarean section is hardly the routine and easy operation that it is usually portrayed to be.

The Road to Hell is Paved With Good Intentions

Most doctors think they are doing well by women when they employ their interventions.

Used when truly needed, they probably are helping. However, time after time, research has shown that routine use of interventions tends to worsen outcome, not improve it.

It's time to trust women's bodies to work well. It's time to trust the birth process that has evolved over thousands of years to work well.

It's okay to have interventions available, on reserve, so that in the small percentage of cases where something does go wrong, outcomes can be improved. But it's time to stop utilizing them routinely, across the board, for most women.

As the Healthy Birth Practices Care Practice Paper notes:

In many hospitals, obstetric interventions such as restrictions on eating and/or drinking, intravenous lines, electronic fetal monitoring, augmentation (speeding up labor), and epidural analgesia are used routinely on all women, even without a specific medical reason, "just in case"....

These interventions, when used routinely, have unintended consequences that ultimately increase risk for mothers and babies. The routine use of these interventions does not make birth safer for women and babies. In fact, unless there is a clear medical reason for the use of technology or other interventions, interfering with the natural process of labor and birth is not likely to be beneficial and actually may be harmful.

It is safer and healthier to allow labor to unfold and not to interfere in any way with the natural process, unless there is a clear medical indication to do so.

Common Interventions in Women of Size

Women of size are often subjected to an even higher rate of interventions than women of average size.

Sometimes these interventions are necessary but often they spring from the belief that the bodies of women of size are defective and cannot/will not labor and birth "properly."

Even many birth attendants who otherwise belive in natural birth do not believe that a fat woman's body can birth properly. Therefore, it can be difficult for women of size to find a truly non-interventive birth attendant, even in the "alternative" birth community. Even there, a number of care providers utilize or promote interventions like these for women of size.

Inductions

We've already discussed how labor is artifically started (induced) in women of size more often than in women of average size, and how induction raises the cesarean rate compared to spontaneous labor.

A high induction rate is probably one of the most significant factors in the extremely high cesarean rate seen in "obese" women in modern obstetrics.

It also probably leads to many problems with their babies after birth. One Welsh study found that induction was the beginning of many problems in the babies of "obese" women. The logical conclusion to this (but one ignored by the study) is maybe we shouldn't be inducing this group so frequently!

Aggressive Augmentation of Labor for "Dystocia"

Even when labor starts on its own, many women of size in the hospital have their contractions augmented with artificial labor drugs and their bag of waters broken early. They often have these interventions at increased rates compared to women of average size.

This is because "obese" women are generally seen as having slower, more ineffective labors, so the need for labor augmentation is anticipated in this group and often initiated extra early.

Of course, some research does show that women of size do have slower labors on average, but usually, all that's needed for this is a liberal tincture of patience, not an automatic initiation of early labor augmentation. Immersion in water can also be effective at helping speed up labor without use of automatic interventions like augmentation or breaking the waters.

Furthermore, the rate of malpositions like occiput posterior may be higher in women of size, and malpositions are known to slow the progress of labor. Instead of automatically breaking the waters or augmenting labor, it may be more effective to investigate proactive repositioning of the baby instead. One recent study on manually turning posterior babies showed that proative repositioning of the baby lowered the cesarean rate from 34% to 2%.

Being more proactive about fetal position might help avoid the unnecessary use of interventions in women of size, and lower the cesarean rate to boot.

Internal Monitors

Because electronic fetal monitoring can be more difficult in "obese" women, a higher rate of internal monitors are used with women of size. Some hospitals even encourage early placement of internal fetal monitors in women of size.

But while this may help monitor the baby more easily than an external monitor, it also has drawbacks. Placing an internal monitor necessitates breaking the mother's bag of waters and that brings its own risks with it (see below). Prolonged use of internal monitors is also associated with a higher risk for infection.

Breaking The Waters

Breaking the mother's waters (a.k.a. amniotomy or AROM), especially early in labor, places her at greater risk for infection. Furthermore, breaking the water early in labor may also increase the risk of cesarean section and/or a diagnosis of fetal distress.

Yet the routine use of early amniotomy is often found in the labors of "obese" women.

Early Placement of Epidurals

Many hospitals encourage "obese" women to get early epidurals because of the difficulty placing them in women of size.

To be fair, epidurals are harder to place in women of size because they have more back fat and it can be difficult to predict just how far in the needle must go in order to get to the right space in the spine. Multiple tries are often needed to place epidurals properly in women of size.

Furthermore, women of size have a higher rate of cesareans as well, and many doctors see fat women as a cesarean waiting to happen --- or at least a case of fetal distress waiting to happen. Therefore, they often recommend that obese women have an epidural placed early, before the hardest part of labor and before any emergencies occur.

If an emergency were to occur and they had to use general anesthesia, this presents a higher risk for complications, and especially so in the presence of obesity. So to avoid even the smallest possibility of needing to use general anesthesia in a fat person, they recommend drugging ALL fat women very early in labor, just as a precaution.

The problem is that placing an epidural early in women of size automatically starts restricting their movement and may encourage a malpositioned baby. It may increase the risk for slow or non-progressive labors (labor dystocia). It definitely increases the risk for instrumental delivery (forceps or vacuum extraction), probably because of the malposition issue. And with forceps comes an increased rate of episiotomy, which increases the risk for severe perineal damage.

So the recommendation for routine across-the-board early epidural placement in "obese" women---while well-intentioned to prevent emergency general anesthesia (which is riskier in people of size)---may actually cause more harm than good.

Again, it subjects ALL "obese" women to a significant level of risk and further problems in order to try to avoid a rare complication that might occur only in a few.

An Alternative Approach To Preventing Labor Dystocia in Women of Size

Shields et al (2007, Am Fam Physician), discussing women of all sizes, suggests that although augmentation of labor and other interventions have their place, prevention of operative delivery due to slow or obstructed labor may also need to be proactive:

Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously.

Unfortunately, most of these (avoiding induction, judicious instead of routine use of epidurals, and deferring hospital admission until the woman is well-established in labor) tend to be actively discouraged in management of women of size.

In women of size, many midwives find better results by:

• Encouraging spontaneous labor
• Encouraging laboring at home for as long as possible
• Encouraging women of size to utilize water, upright positions, and mobility during labor
• Leaving the waters intact whenever possible
• Avoiding routine use of internal monitors or early epidurals
• Applying a tincture of patience for longer labors
• Being vigilant and proactive about fetal malpositions in labor

Research is urgently needed to prove which care protocols improve outcome in women of size and which harm it, but until that happens, the above model (which honors the innate wisdom of women's bodies----including fat women's bodes) should be the norm.

Following the physiologic model of birth, the one developed over thousands of years to be the most efficient for the most people, should be the norm for ALL women, including women of size. It is the intervention that should have to be proved to be of benefit and free from harm, not the physiologic model.

Women of size should not be automatically subjected to increased levels of interventions merely on the basis of their size. Many women of size have discovered that the natural process works for them too----if they are given a realistic chance at it.

Conclusion

Many interventions in childbirth can be life-saving. No one is saying that interventions should never be used. Clearly, in some situations, it is completely medically appropriate to use interventions, and at times, they can lower the cesarean rate or even save lives.

This is true for women of all sizes.

But just as clearly, some interventions are overused and present more risk than benefit. Sometimes they even cause great harm.

This is particularly true for women of size.

Today, more and more women are experiencing "pushed births" because such births are more convenient for care providers, provide more billable services (and profits) for hospitals, and are perceived as good "defensive" medicine to protect from legal liability. And women of size experience "pushed births" even more often.

"Pushed births" are better for hospitals and doctors and their bottom lines, but are they really better for mothers and babies?

As Maureen Corry, executive director of Childbirth Connection says:

The typical childbirth experience has been transformed into a morass of wires, tubes, machines and medications that leave healthy women immobilized, vulnerable to high levels of surgery and burdened with physical and emotional health concerns while caring for their newborns.

Here is the Lamaze/Injoy video about Avoiding Unnecessary Intervention. You can see birth practice papers (with research citations supporting their conclusions) here and videos discussing each of the Healthy Birth Practices here.

Midwives Do Gyn Care Too

Let's talk today about gynecological care. Specifically, who do YOU see for GYN care?

The reason this is on my mind is because I recently stumbled across Kate Harding's original post on "Why Don't Fat Women Get Checked for Cancer of the Nasty Bits?" I don't know how I missed the original post but I did.

If you haven't read it yet, it's a post well worth reading, especially if you are a healthcare provider or are not a woman of size yourself.

It can help you gain some insight into the negative contacts women of size have had with the medical profession and why we can be so reluctant to go to the doctor. It may also shed light on why we don't get screened as often for cancer, or why our cancer may be more advanced by the time it is discovered.

Definitely a post worth reading.

However, as I read the comments on the post, I thought it was telling how not ONE person talked about using a midwife for GYN care instead of an OB.

Midwives Do Well-Woman Care Too

Newsflash: Midwives don't just catch babies. They do well-woman and GYN care too.

And chances are you'll get better treatment with them.

Although not universally perfect on fat-acceptance issues by any means, most midwives are far more size-friendly than most OBs. And even if they don't perfectly "get" size acceptance issues and HAES, most midwives will take far more time and care with you than most doctors will, and most midwives listen to your perspective and work with you on healthcare issues more than doctors will.

Why is an OB the automatic go-to when women think about getting well-woman care? Do people not know that midwives are perfectly competent at doing regular well-woman and GYN care? Why don't more women automatically go to a midwife for such care?

Most Certified Nurse-Midwives (CNMs) are covered by insurance, are well-trained and experienced in doing well-woman and GYN care, and work in a practice with OBs so that if something comes up that needs to be seen by a specialist, they can refer you to a person within their own practice group.

Most homebirth midwives (who can have various letters after their names, but who are most often Certified Professional Midwives/CPMs and/or Licensed Midwives/LMs in the USA) do GYN care as well. Some are covered by insurance, some are not.

The advantage of CPMs/LMs is that they are likely to be able to take even more time and care with you than OBs and CNMs, because their time is not so tightly controlled by insurance guidelines. Some are also trained in certain birth control methods (like cervical cap) that most doctors (and even many CNMs) are not.

The disadvantage of CPMs/LMs is that you may have to pay out of pocket (or at least out of network) for your care. Some women feel the extra time and support is well worth the extra money. Financially, I wish it were a realistic choice for all women....but if you can't do the out-of-pocket or out-of-network thing for a CPM/LM, you can usually get coverage for a nurse-midwife.

For years, I got all my pap smears and breast exams etc. from an OB-GYN office. I just thought that's where you went. I tried to get a female doctor (or a female nurse-practitioner) for these exams, but I went through an OB-GYN most of the time.

I did not realize until after I'd had kids that I could use a midwife for my well-woman care. Doh!

Now I go see either the nurse-practitioner at my family doctor's practice, or I go see the CNMs associated with my local hospital. I'd really prefer to use a CPM, frankly (and I do on occasion), but generally speaking I don't because of insurance coverage. (Sad, because the best care I ever got was from a CPM.)

I find I get MUCH more woman-friendly care by seeing midwives, and much more size-friendly care too.

That's not to say that all midwives are automatically size-friendly (clearly some are not, and I have heard a few bad stories), and of course, not all OBs are fat-phobic. There are good doctors out there too, so let's not knock them all. The good ones deserve our business too.

But generally speaking, you are more likely to find woman-friendly care and size-friendly care from a midwife than you are from an OB.

The Take-Away Message?

Challenge the dominant paradigm that means GYN care = a visit to an OB. Consider going to a midwife instead.

They're not just for catching babies!

Anemia and Hypothyroidism

So, at the same appointment where I learned that my TSH was up but my access to Armour thyroid meds was gone, I also learned that I'm borderline anemic again. In particular, I'm very iron-deficient. My ferritin levels are down the tubes.

Ferritin is a protein that binds with iron and keeps it available for use, if I understand it correctly. It's one measure of stored iron in your body, basically.

Online, ferritin levels considered "normal" vary from source to source. The lab I used listed 11-307 as "normal." Medline Plus lists normal ferritin levels as:

Male: 12-300 ng/mL
Female: 12-150 ng/mL

"The lower the ferritin level, even within the "normal" range, the more likely it is that the patient does not have enough iron."

Most online sources I've read state that while "normal" may be as low as 12, people should start getting concerned with levels below about 50.

Guess what my level was? 7.2. Definitely below any measure of "normal" and basically in the toilet. Great.

Now, my hemoglobin and hematocrit are in the "normal" range.....but only just barely. My hemoglobin was 11.6 and the cutoff is 11.5; my hematocrit was 35.4 and the cutoff is 34.7 at my lab. So not "officially" anemic, but barely above the cutoffs. And the ferritin is definitely abnormally low (7.2 when it should be at least 11).

The good news is that we had other levels tested last year to figure out which kind of anemia I had. My folate levels are good (I have aggressively supplemented these over the years because of pregnancy and breastfeeding) and my B12 levels are also good. So with the really low ferritin levels, it looks like it's iron deficiency anemia.

I've been struggling with this for a while. I've often been a bit borderline anemic over the years, but not enough to cause big problems. In pregnancy, I used "Floradix" - an herbal over-the-counter preparation - and that helped immensely without causing constipation, the way that iron pills can. It's great stuff, much better than OTC iron. It's what got my hemotocrit and hemoglobin levels up this past year.....but apparently it doesn't have as much effect on ferritin levels. Bummer.

As I've gotten older, I've had more issues with anemia, enough so that I was no longer able to donate blood to the Red Cross anymore. I'm a fairly rare blood type so they love me, but I haven't been able to donate now in several years because of the anemia. In fact, my donations probably exacerbated my low iron issues.....but I haven't donated in several years now, and my ferritin levels are still down to 7.2, so obviously it's much more than just blood donation going on.

Part of the problem is being perimenopausal. One symptom of impending menopause you don't hear a lot about is extremely heavy periods, called "menorrhagia." Colloquially, it's called the "blood flood" and sadly, it's very aptly named.

My periods were always reasonably normal, not usually too heavy or too painful. I skipped months periodically because of the PCOS, but once my hypothyroidism was finally diagnosed and treated, I never skipped a period again. (Still have other PCOS symptoms but as long as they hypothyroidism is treated, they stay relatively mild. Now, with my TSH going up, they're starting to act up more again. Ugh.)

As I've become perimenopausal, the periods became heavier and heavier. So this is quite likely a big cause of the low ferritin levels too. But I'm happy to report that as I move closer to menopause (and with the help of acupuncture), the heavy periods have eased up, thank goodness! And yet, despite this, my ferritin levels are still at an all-time low. So obviously, menorrhagia is not the only cause for my low ferritin levels.

I eat plenty of iron foods, I cook in iron skillets, I regularly take vitamin C with my iron, I avoid calcium etc. with the iron, I eat plenty of red meat (a more easily absorbed source of iron), and basically do all the things that are supposed to "fix" this problem. And none of them are working.

What I learned recently, though, is that hypothyroidism and anemia tend to go hand in hand. When you have one, you often have the other, especially if there are any other challenges to your system (like pregnancy, birth, blood donation, heavy periods, etc.).

And apparently, undertreated hypothyroidism in particular tends to result in low ferritin levels.

So it will be interesting to see whether getting my TSH levels back to where they feel better to me will also coincide with an improvement in my ferritin levels. I am also taking supplemental iron and Floradix. Hopefully all of that will be enough to get things back to normal. Keep your fingers crossed!

[Anyone else with hypothyroidism had problems with anemia and low ferritin in particular? I'd love to hear about other people's experiences and what helped you.]

Emergency Preparedness

The earthquake in Haiti has reminded me of a post I've wanted to make for a while now, about Emergency Preparedness.

Are you ready for an emergency if one happened in your own community?

Do you have at least a 72-hour kit, with:

• Drinkable water (lots!) and a way to purify more water
• Battery-powered or hand-crank radio
• Flashlight and extra batteries (or alternate power)
• Food and a manual can opener
• First Aid Kit
• Plastic Sheeting and Duct Tape to help shelter in place if needed
• Garbage Bags, ties, TP, moist towelettes for personal sanitation
• Wrench or pliers to turn off utilities if needed
• Whistles to signal for help
• Utility knife
• Dust Mask or bandanna to help filter contaminated air (dust etc.)
• Local maps to help find shelters or to help evacuate if needed
• Cell phone with alternate ways to charge it

Probably the most important thing on the list is water. It's the thing you can do without the least, and it's often the thing in shortest supply in an emergency. Even in a flood with water everywhere, the water may not be potable (i.e. drinkable); you need a way to have or get drinkable water.

Sadly, I think this is the item people are least prepared for in an emergency. I think it's best to have a combination of stored potable water and a way to purify water so it can be drinkable. And remember, you have to swap out the stored water every so often and put in a fresh supply.

Really, a 72-hour kit is not much; it's better to have 1-2 weeks' worth of preparation or more. But a 72-hour kit (3 days) is the minimum you should have. And it's surprising how many people don't even have that.

Other Items To Consider

If you already have the basics, start adding "extras"---the things that might come in handy, even beyond the basics. For example, a fire extinguisher, matches in a waterproof container, and ways to keep warm and/or dry (tarps, coats, sleeping bags, rain ponchos or garbage bags, blankets) seem like a no-brainer to me.

I think it's also important to have dependable access to sturdy shoes, gloves, a headlamp, and tools, in case you have to dig through wreckage. Extra cash on hand might also become useful in an extended emergency, as things can become pricey in an emergency.

Some people think it's helpful to have a "grab-and-go" kit in case you need to evacuate your area very quickly. This should be in a container like a sealable plastic tote, a duffel bag, camping backpack, or even a sealable trash can, ready to go in an easily accessible place. Or you can have a small emergency backpack for every member of the family (with snacks, flashlight, small comfort item, and a change of clothing), plus a tote for family needs (sanitation supplies, more food, water purification tablets, flashlight, radio, etc.). An updated family picture in a plastic baggie is a good idea in case anyone goes missing.

You should also have a mini-emergency kit in your car at all times in case you get stuck somewhere or have to evacuate without access to home....simple things like water, some non-perishable food, flashlight, first-aid supplies, a blanket, seasonal supplies, flares, jumper cables, etc.

If you really want to be prepared, experts recommend copies of insurance information, deeds, important phone numbers, credit card information, photo ID, bank account numbers, birth certificates, health insurance etc. in a safe place in a waterproof container. If your home is badly damaged, you may not be able to get to documentation needed in order to expedite insurance or emergency paperwork. Extra copies in a safety deposit bank are a good idea. If you can afford it, a fire safe in your home is also a good additional precaution.

Specialty Items

Beyond the basic items for emergency kits, consider whether there are any special needs that may need accommodation.

For example, for people of size, I think it's really important to have a change of clothes or two handy (as well as a warm coat or rain poncho) because emergency resources are not likely to have extra clothing in our sizes and stores will probably be closed. If you become injured, wet, cold, or have to be away from home for an extended time, extra clothes in the proper size might be really helpful.

If you are a parent, it's important to have items to address the special needs of your kids. Breastfeeding is a huge advantage during an emergency because clean water is often a problem, you can easily run out of formula, and of course breastfeeding provides important immunological protection that formula does not....so most of the time, breastfeeding mothers are in a far better position to provide for babies during an emergency. However, you do have to remember that mama might be injured or killed in an emergency (or might get stuck far away from home) and so a small emergency supply of ready-made formula might be a reasonable precaution, even for breastfeeding families.

(I had some frozen breastmilk on hand as our primary back-up. Of course, if the electricity failed for long, that pumped milk would not have lasted very long, so we did keep some ready-to-go formula on hand in case of emergencies.)

You might also need to plan for other members of the family with special needs, like older family members or those with mobility concerns, etc. Pets take special planning too.

But first, get the basics down. You can fill in the special items later.

Everyone Should Plan, No Matter Where They Live

Years ago, I lived near an area that had a bad earthquake. I was not close enough to be really affected, but I saw the first-hand news reports on the devastation and everything that happened afterwards. I also had friends who were first-responders to the area and heard stories from them about it. That experience made a deep impression on me.

I also had a wildfire nearly destroy my home once. It started unexpectedly and quickly spread to within about a half-mile of my house before it was put out. We had our animals in crates and had thrown a few emergency things into the car, but by and large we were not prepared for such a quick evacuation. That brought home the value of a grab-and-go kit.

So perhaps you can understand why I'm a little more aware of emergency preparation than most people. That doesn't mean I'm perfect at it, but I do seem to have more preparation than most.

It amazes me how many people do not even have a 72-hour kit with the very basics of emergency preparedness in it......even people who live in areas that are very likely to experience emergencies. Why is that?

I know, I know. Denial is a very potent force that keeps people from becoming as prepared as they should be, and procrastination (my specialty) is a close second. Finances can be another barrier. Plus we are all just busy people and it's not easy to find the time to get all this stuff organized.

But think about it -- there is not one place on this earth that is not prone towards some kind of emergency. Think about what kind of emergencies are most likely in your area (blizzards, floods, earthquakes, hurricanes, tornadoes, mudslides, wildfires, etc.) and start taking steps towards the emergency preparedness that would be most useful in the types of emergencies you'd be most likely to experience. That's the place to start.

Of course, the sad fact is that perfect preparedness is a dream. We cannot prepare for everything. Unexpected things can happen, and we may not be perfectly prepared for every type of emergency that could ever happen. And sometimes, even when we are prepared, our kits are destroyed or become inaccessible somehow. Preparing won't guarantee survival. But it does make it more likely.

Remember, in the first few days after a major disaster, essential services are often not available. It may take days or even weeks for the authorities to be able to get help to you. You have to be ready to act on your own.

Getting Started

Preparing emergency kits can seem overwhelming in terms of organization, finances, time or just plain fear. (Even I don't have all of these supplies yet, and what I do have is certainly not optimally organized.) Sometimes the task just seems too overwhelming to do, too scary, too costly, or too much work.

That's okay. The key is baby steps. Take a deep breath and start putting together things for your kit, little by little. And start right now.

Start by evaluating what you have, list what needs to be added or updated, and then decide what items to add to your shopping list for your next trip out. Decide where the best place is to store your kit, and start gathering things together and putting them in a container there. (It doesn't have to be the perfect container; just get a collection started for now.)

If finances are a barrier, prioritize your list and shop secondhand. Instead of trying to buy everything at once, buy one or two items for your kit every few months so the cost is more spread out. Think of building your kit as a long-term project --- starting with the most important stuff, like making arrangments for storing and purifying water.

Make your time commitments in small blocks too. Next weekend, organize something---a grab-and-go bag, your emergency car supplies, refresh your emergency water supplies, update your sanitation supplies---just tick one item off your to-do list. Then schedule another couple of hours in another week or two to work on another aspect of your kit. Or, if procrastination is your issue, schedule bigger chunks of time and get the rest of the family involved so you have more momentum for getting things done.

Little by little, you'll get a handle on things. Just start whittling away at preparedness, one baby step at a time. Anything is better than nothing, and if you add a bit at a time, eventually you will have a more complete kit. Think of it as an ongoing project and remember to update it too.

But the first step is to get a 72-hour kit going. Here are some links to help you plan.

http://www.ready.gov/
http://www.dola.state.co.us/dem/public_information/emergency_kit.htm
http://www.fema.gov/plan/prepare/basickit.shtm

What's in YOUR emergency kit? Feel free to chime in with your favorite emergency preparedness hint, website link or book on emergency preparedness, other items that should be in emergency kits, things to talk about with family ahead of time, etc.

thyroid updates

So I went to my family doctor recently for a check-up and my thyroid bloodwork.

The bad news is that my thyroid is out of whack again, and the even worse news is that Armour thyroid is no longer producing the natural T3 medications that are so much more effective for me.

What the heck? What I am supposed to do for meds now?

Another frustrating thing is that if your TSH is higher than normal for you....yet still within the range of "normal" the docs go by.....they won't change your prescription.

My NP (nurse-practitioner) listens better than most, and she knows I have a long history of trying to establish the best TSH level for me. She knows I feel best when my TSH is under 1.5 (preferably more like 1.0), and that if it gets up around 2 or more, I start experiencing more symptoms like fatigue, cold, and weight gain...all of which I've been having again.

My level this past test was 2.4, but her hands are tied. She can't up my prescription when my levels are still in the "normal" range.....even though they are not in the range that is optimal for me and which keeps me from gaining weight.

And furthermore, if I stay in her care, I have to be on all levothyroxin, a T4-only medicine, instead of on the combo of T4 and T3 etc. meds that come in Armour. AND in effect I would be getting an even lower dose, because she didn't raise my levothyroxine dose to compensate for the loss of the Armour because my TSH is still within "normal."

Augh. I am so frustrated with this. She really is better than most docs I have had, but it frustrates me no end that they are required to rely on this TSH test so heavily and completely discount symptoms as a guide. My T4 and T3 levels are "normal," but just barely....but that doesn't matter, because they ARE normal, and so is the TSH. Doesn't matter if you are experiencing symptoms and you've experienced a deterioration trend in your levels....you are either normal or not, and that's that.

Here we go again with the binary approach in medicine. You are either normal or abnormal and there's nothing in between. If the cutoff is 140 (pulling a number out of the air for demo purposes), you are normal at 141 and no changes need be made, but you are abnormal at 139 and changes should be made. There's only two points difference, for crying out loud! But one is above an arbitrary cutoff and one is below it, so it doesn't matter.

My test results are clearly trending negatively and I'm experiencing more symptoms.....but because I'm still marginally in the normal range, they aren't going to change my dosage.

This frustrates me so much. If they care so much about my weight (she suggested briefly that perhaps we might think about "carving off a few pounds".....ugh, I am NOT a turkey), then they ought to be LISTENING to me about the one thing which DOES help with my weight.

I don't really lose much weight when my thyroid levels are more well-regulated, but I stop gaining and am more easily able to keep my weight steady. Isn't that a worthy goal? The last thing she wants is for me to gain more weight....but she won't do the one thing which is most effective at preventing that.

Now, I'm making her sound like an ogre, which she really is not. She's been more sympathetic and listened more than a lot of docs I have had, and she's a genuinely nice person. I was unhappy about her bringing up the weight loss thing, but she backed off quickly when I reminded her that my history showed that this was the fastest route for me to actually gain weight and if we wanted to avoid me that, dieting was the worst thing I could be considering. She acknowledged that I was the person who knew my own history best and what was most/least likely to work for my body. So that was something, anyhow.

Also to her credit, she knows I feel strongly about the whole Armour thyroid thing and about titrating my TSH levels more carefully. She said HER hands were tied, but suggested that I might consider going to see a local naturopath for further consultation. There are some alternatives for Armour out there (according to the thyroid websites) but she is not allowed to prescribe them; she thought perhaps the naturopaths might have access to them instead.

So I guess that's what I'm down to. Personally, I'm a bit leery about seeing a naturopath. I think some are okay and have decent training, and I'm okay with considering some alternative modalities of care. I'm not always convinced every alternative modality works, but I'm open to considering some. I figure I can always say no if it sounds too "woo-woo" for me.

[To my surprise, I actually have found a couple of "alternative" modalities -- like chiropractic and acupuncture -- pretty darn useful and effective for me, so I try to at least keep an open mind to considering other forms of "alternative" care.]

On the other hand, I do think there are some nutcase naturopaths out there, and some "alternative" modalities are potentially harmful. Just because one alternative modality works for me doesn't mean they are all going to, nor that they are going to be perfectly safe. And the science part of me squirms a bit when considering some of this stuff. I'd rather have some really good studies showing me what's effective and what's not, what's safe and what's not.

On the other other hand, though, traditional allopathic medicine has been mostly unhelpful for me in dealing with this thyroid stuff, and right now I feel like I'm stuck between a rock and a hard place and don't have many choices left. Stay with my traditional practice and have my thyroid needs undertreated, or go try an alternative practice that might meet my needs better but which might also try to rook me into some bizarro stuff.

After thinking about it, I think I'm going to check out a couple of local naturopaths who are trained in both allopathic and naturopathic medicine and see what they say. I'll be taking along a healthy sense of doubt and ability to say NO, never fear, but I know I need to figure this thyroid thing out better. I know from experience that this thyroid thing is the most important thing to keeping me healthy, so the bottom line is that's just GOT to get addressed better.

Levothyroxine may be the "accepted" med in the allopathic world, but it's not the better med for me, and I know I'm incredibly sensitive to even very small changes in TSH levels. If I have to go to a more "alternative" practitioner to get my needs addressed adequately, then so be it.

I'm just pissed as hell that it's come to this. UGH.

Second Annual Turkey Awards: Scare-mongering and Shaming Tactics

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.

In summary:

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.