Monday, June 28, 2010

Defective Cervixes in "Overweight" Women

From the blog, My OB Said What???

"Women With A BMI Higher Than 26 Tend To Have Cervixes That Won’t Dilate…."

"Well, in my experience, women with a BMI higher than 26 tend to have cervixes that won’t dilate without chemical induction.”

– CNM to overweight woman

Oh puleeeeze.  I know doctors and even some midwives say a lot of stupid things to women, but OMG, what an idiotic thing to say.

Well, apparently my cervix didn't get the memo, despite me having a BMI in the 40s.  It dilated just fine in all four pregnancies, induced or not induced.  I know an awful lot of other fat women whose cervixes didn't get the memo either.

Alas, we can roll our eyes at it all we want, but there are an awful lot of medical professionals that actually believe this crap. It's not the first time I've heard it or something like it, but it's especially appalling to hear it from a midwife, for heaven's sake.

Yet another reason for the epidemic of inductions in women of size........and since inductions raise the risk for cesareans strongly, for the epidemic of cesareans in women of size.

But rest assured, fat women's cervixes dilate just fine too.....and especially when our pregnancies are dated correctly (adjusted for cycle length), and when our own bodies' timelines are respected.  [Oh wait, that's a whole 'nuther pet peeve post!]

Thursday, June 24, 2010

Happy Birthday to Me!

Happy birthday to me!!  Or at least, happy birthday to my blog. 

2 years ago this month I started this blog to try and reach out to more people in the fat acceptance community and in the birth community.  Although a number already knew about my website, many did not, so it was a good way to raise awareness about pregnancy in women of size, birth politics in general, and size acceptance issues in general as well. 

To celebrate my blog's birthday, I have redesigned its template a bit.  Tell me what you think.  And thank you all for coming and reading my thoughts and for sharing yours!

Tuesday, June 22, 2010

Ultrasounds in Women of Size, part 1

Recently, a commenter asked about ultrasounds in women of size, and I'd like to briefly address that here and then refer folks to the very in-depth article I have on the topic over at my regular website

Remember, if you don't see your question answered here on this blog, I do have my website that covers a lot of these topics in far more detail, complete with research references. The two sites are meant to be complementary.  If you don't see an answer here, be sure to check out my main website.

[Normally, I'd answer the commenter's question on the page of the original post, but I can't easily figure out which post that is.  If there is some way on Blogger to know which post a comment goes to once approved, please let me know!  Otherwise I end up having to go back through zillions of posts trying to figure it out.  I make a best-guess stab at it and if I can't find it easily, I give up.]

Ultrasounds in Women of Size - General Information

Ultrasounds in women of size can be more difficult to do than in women of average size, but most of the time they are quite doable and most women of size get an adequate ultrasound result. 

It is true that extra adipose tissue on the abdomen CAN make it harder to get a completely accurate ultrasound "picture" so the task is definitely harder in fat women. Because of this, it is possible to sometimes "miss" a problem in women of size that might be caught in a smaller woman.  In particular, research shows that it is particularly difficult to get complete evaluations of the fetal heart in women of size. To a lesser degree, there can be difficulties with visualizing the fetal spine, the cranio-facial system, the fetal kidneys/urinary system, and the mother's ovaries.

Therefore, it's not uncommon for the ultrasound report to note the mother's obesity and whether there were any problems completely visualizing anything.  Don't take such comments personally; it's simply CYA for the ultrasonographer, in case something turns up later that was not noted in the ultrasound report.

Simply noting adiposity on a report is not fat-phobia; it's for liability purposes, not to make you feel badly.  However, berating you about your fatness, telling you that they'll never get a decent picture because you are so fat, or treating you roughly with the justification that it's "harder" to get good images because of your fatness is fat-phobic treatment. 

It's not just what they say, but how they say it, the intent behind saying it, and how they treat you.  Most women of size have unremarkable ultrasound experiences, but now and then some do experience fat-phobic treatment and that is never acceptable.

Transvaginal vs. Transabdominal Ultrasounds

There are two methods typically used for ultrasound in pregnancy:
  • Transvaginal ultrasound
  • Transabdominal ultrasound
In the beginning of pregnancy, fetal structures are particularly difficult to see via abdominal ultrasound in most women, regardless of size, so most women have transvaginal procedures if they have ultrasounds in their first trimester. 

To do a transvaginal ultrasound, doctors take a long cylindrical ultrasound transducer, cover it with a condom, and put it inside the woman's vagina where they can move it around as needed. This gets the ultrasound closer to the fetus, there is less intervening tissue to impede transmission, and it therefore improves the quality of the images.

Transvaginal ultrasounds are common in the first trimester of pregnancy in women of all sizes.  They are usually done in order to date the pregnancy more accurately and/or to tell if the pregnancy is viable.

In the second trimester, doctors usually switch to transabominal ultrasounds in most patients, which are commonly used to look for any problems with fetal structure (birth defects) and to check placental placement.

However, because it is more difficult to visualize the fetus adequately in women of size, doctors may still need to use transvaginal ultrasounds in women of size early in the second trimester (especially women with a lot of abdominal adiposity) in order to get a clearer picture.  By the end of the second trimester, however, doctors are usually able to get adequate images via transabdominal ultrasounds, even in women of very large size.

These are the main differences between ultrasound in women of average size and women of increased size. However, most of the time, reasonably adequate images are obtained and the procedure is very similar, regardless of size.

Possible Problems To Be Aware Of

Although ultrasounds usually go just fine with women of size, there are some possible problems to be aware of.  The first we already discussed; doctors may need to use transvaginal ultrasounds longer in women of size, and the quality of images can be decreased, regardless of the method.

Another problem women of size sometimes encounter is that doctors and ultrasound technicians may press extra hard on women of size to try and compensate for less-clear images. (This has happened to me...ouch!)

Sometimes pressing firmly does help get a better image, but pressing extremely hard can also cause more problems than it solves by distorting the image that they do get.  There have been women of size who have been misdiagnosed with birth defects due to the ultrasound tech pressing too hard.

One woman wrote to me about her experience with this; the ultrasound tech pressed extremely hard, despite her protestations, and they got a devastating diagnosis.
Jessica's Story (paraphrased): I had an ultrasound at 18 weeks. I was told my weight made it impossible to scan the baby, and they saw encephaly [Kmom note: Hydrocephaly?] on the scan. They told me he was going to have a grossly misshapen head and that I'd need a c-section. They sent me to a high-risk OB. He saw the scan and said, "Wait a minute, you're pushing too hard! Do a vaginal!" They did the vaginal and there was our rascal, safe and sound, the right size, and no deformity. I was sore for a week after the abdominal scan, the transducer hurt so bad.

What happens when they push too hard is they distort and add artifact to what they can't see, and the baby looks deformed to their measurements.
If you are told that your baby has deformities or other problems based on an ultrasound scan and they seemed to be pushing pretty hard, ask for the scan to be repeated with a transvaginal scan or by a perinatologist (who usually has the most advanced equipment). Although it is uncommon for images to be distorted from too-strong pressure, it has happened, and should be ruled out as a cause before making a final diagnosis.

Although more firm pressure may be needed on women of size, you should NOT have to endure pain during an ultrasound. If you experience this problem, let the tech know that he/she is hurting you. Let them know that you realize that doing an ultrasound on a heavy person can be more difficult, but suggest that they try more gently at first and only increase pressure if needed. Remind them that if the results they get are suboptimal, there is always the option of a transvaginal ultrasound instead. If they don't listen, then end the session and ask for another session at another time with someone who will listen to and respect your concerns and discomfort.

Improving Image Quality in Women of Size

If your doctor or ultrasound tech is having difficulty getting an adequate image on you, there are several ways to improve image quality in a woman of size. 

For example, often just coming back for another ultrasound in a few weeks is enough to "see" everything more clearly. The baby is older, the uterus has lifted up out of the pelvis a bit more, and the baby may be in a better position the second time. These factors can be very important. 

Research shows that just waiting a few weeks is usually enough to get adequate ultrasounds in most women of size.  Probably the best alternative is simply to wait until 18-20 weeks to do an ultrasound at all in women of size, since after that point, most scans are able to get adequate results. 

Requesting that a follow-up ultrasound be done on a more powerful machine in a center that specializes in prenatal ultrasound may also improve results as well. Not all ultrasound machines are of equal quality; the ones in a doctor's office tend to be the least effective.  Furthermore, it can be very helpful to see someone who specializes in prenatal ultrasound for a living, because they often have the best skills in how to elicit clearer images. 

There are also several other refinements that can be done if the technician has difficulty resolving the images adequately. First, if you have a large "apron" (saggy belly), pull it up and hold it back so the transducer can go underneath/below it. This reduces the amount of adipose tissue the transducer has to go through and can therefore improve the image.  Don't be embarrassed if you are asked to do this; your body is simply your body, lots of people of all sizes have droops and sags in various bits, and it's not that uncommon in diagnostic tests to have to pull and push things this way and that a bit. Be matter-of-fact about it and just do it. It really can help.

Turning on your side and putting the transducer on the side may also help clarify the images, especially if the baby's position is less than optimal, or if there are multiple babies inside.

Another technique they can use to clarify images later in pregnancy is to put a vaginal transducer inside your belly button. Some research has reported success with this, especially with visualizing the fetal heart.

Rosenberg (1995) reported on their experience using transvaginal probes in the belly buttons of obese women to help improve ultrasound resolution. 19 of the 25 cases involved incomplete imaging of the fetal heart. Techs filled the women's belly buttons with ultrasound transmission gel, and then a transvaginal probe was inserted into the belly button. This improved image resolution and resulted in satisfactory heart images in 18 of the 19 women with incomplete fetal cardiac reports. All told, 24 of the 25 heavy women (96%) were able to have a 'complete fetal survey' using this technique.

Remember also that not all problems with ultrasound imaging result from fatness.  If the baby is in a poor position or if the placenta is anterior (in the front), this can decrease the accuracy and clarity of the images.  Technician skill and the power of the ultrasound machine can also impact results.

So although it's true that ultrasound accuracy is definitely lessened in women of size as a group, it's difficult to know whether the problem in any particular scan is due to adiposity or any one of many other factors.  Don't take it as a personal indictment if there is a problem with your scan; be aware of the possible problems, know the possible fixes, and consider trying again in a few weeks if you feel it's really important to have a complete scan. 

Coming Soon: Do Women of Size NEED Extra Ultrasound Scans? What are the pros and cons of having ultrasounds?

Thursday, June 17, 2010

Healthy Birth Practices: Keep Baby With You

We've been discussing the Six Lamaze Healthy Birth Practices.

This is the last in a series on the Lamaze Healthy Birth Practices, why they are important in birth, and how they are less commonly "allowed" in women of size. The previous entries have been:

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
4. Avoid Unnecessary Interventions
5. Get upright and follow urges to push

And the final Healthy Birth Practice is [drumrollllllllllll] :

6. Keep baby with you

Although you'd think that this one was a no-brainer, it's surprising how many women are kept from early and frequent contact with their babies after birth, which then can impact bonding and breastfeeding. 

And because of the incredibly high rate of interventions used with "obese" women, women of size often have even less contact with their babies after birth, which strongly contributes to lower rates of breastfeeding in this group.

Why Skin-To-Skin Contact and Rooming In Is Important

You wouldn't think you would have to fight for contact with your baby after birth, but sadly, mothers and babies are separated far too often postpartum and it can have long-lasting consequences on breastfeeding and bonding.

This separation seems to happen even more in high-tech, high-intervention births, especially cesareans.  Breastfeeding initiation rates are lower in women who have had cesareans, skin-to-skin contact is often not available (even though it could be), and contact is often delayed, sometimes for hours or even longer. In the meantime, babies are often given pacifiers and bottles of formula or glucose water, which decrease the baby's desire to nurse and which often interfere with a good latch. 

Even when the baby is born vaginally, the mother often gets only a few moments with baby before it is whisked off, cleaned up, weighed and measured, examined, given eye goop, and then bundled into a blanket.  When the mother gets the baby back, no skin-to-skin contact is available anymore and critical early moments together have been missed. In addition, many mothers are discouraged from having their babies "room in" with them at night, yet frequent nursing at night is very important in establishing a good milk supply.

Research shows that early skin-to-skin contact and continuous time (rooming in) with the mother improve outcomes.  Babies sustain their temperature better when skin-to-skin with their mothers, they maintain higher and better blood sugar, and have better cardio-respiratory function.  Skin-to-skin contact decreases crying behaviors, increases maternal gestures of affection, and long-term bonding seems improved after rooming in.  In addition, both short-term and long-term breastfeeding rates are improved with skin-to-skin contact and rooming in.Yet hospital routines often get in the way of this important time.

One study in Pediatrics in 2008 looked at six "Baby-Friendly" practices to see which were associated with less cessation of breastfeeding before 6 weeks. These "baby-friendly practices" included:
  • Breastfeeding initiation within 1 hour of birth
  • Giving only breast milk
  • Rooming in
  • Breastfeeding on demand
  • No pacifiers
  • Fostering breastfeeding support groups
Sounds pretty basic, right?  Not so.  Only 8.1% of the mothers in the study experienced all 6 "Baby-Friendly" practices.  According to the study (my emphasis):
The practices most consistently associated with breastfeeding beyond 6 weeks were initiation within 1 hour of birth, giving only breast milk, and not using pacifiers. Bringing the infant to the room for feeding at night if not rooming in and not giving pain medications to the mother during delivery were also protective against early breastfeeding termination. Compared with the mothers who experienced all 6 "Baby-Friendly" practices, mothers who experienced none were approximately 13 times more likely to stop breastfeeding early.
Interventions, Women of Size, and Impact On Breastfeeding

These practices may be even more important in women of size.  Research shows that there is a lower rate of breastfeeding among "obese" mothers. Some of this may be because of legitimate supply issues from PolyCystic Ovarian Syndrome (PCOS), a metabolic disease that many fat women have.  Other factors that may impede breastfeeding establishment include possible subclinical hypothyroidism, subtle or overt discouragement of breastfeeding in women with large breasts, more difficult mechanics with a larger body, or postpartum anemia.  [More on this in a future post.]

However, the role of aggressive birth interventions in the lower rate of breastfeeding among obese women typically goes conveniently unexamined in the research. Breastfeeding failure is blamed solely on fatness, when in fact, the high level of interventions in obese pregnancies and births may also play a significant role.

For example, "obese" women are induced at a higher rate than women of average size, with most induced women receiving pitocin at some point in labor.  Pitocin is an anti-diuretic, and when combined with aggressive IV fluids, can cause significant edema in the mother.  This can cause greater breast engorgement and make it difficult for the baby to latch on and nurse efficiently.

A high rate of inductions usually means a high rate of pain medication use in the mother, and some research indicates that more pain meds results in impaired breastfeeding behaviors in the baby, especially with IV narcotics. In particular, some research shows that the combination of pain meds and separation of mother and baby after birth significantly inhibits initial breastfeeding behaviors, while other research shows that avoiding pain medications in labor is protective against early breastfeeding cessation.

Because the rate of cesareans in women of size is so high, it also has strong impact on breastfeeding rates. Research shows that lactogenesis (the mother's milk "coming in") can be delayed after a cesarean compared to a vaginal birth.  This may be due to some inherent hormonal differences between vaginal birth and cesareans, or it may be due to decreased immediate contact after birth. Delayed initiation of breastfeeding may also be a factor; research shows that in women delivered by cesarean, aggressive early suckling leads to better breastfeeding rates than delayed suckling. 

Another possible reason for breastfeeding difficulties in fat women is the excessive intervention commonly seen with big babies, which are more common in women of size. Big babies have a higher risk of low blood sugar after birth, so there is often aggressive testing and formula supplementation of these babies after they are born, but all the separation, testing, and supplements can end up further sabotaging breastfeeding.

Research shows that most of the time routine testing and supplementing is not necessary in big babies if the baby is not symptomatic and is nursing well.  Furthermore, as noted above, skin-to-skin contact has been shown to improve blood sugar rates and stability of babies after birth, so the common interruption of time between women of size and their babies is usually unnecessary.

The high rate of interventions commonly used in the births of "obese" women often leads to a "perfect storm" of conditions that inhibit neonatal adaptations to life outside the womb, and interfere with bonding and breastfeeding in babies of women of size. 

Alas, my own first birth was a good demonstration of the negative effects of such interventions on breastfeeding. 

My Experience

Breastfeeding came very close to "failing" with my first child....for all the reasons cited above.

The doctor feared a big baby, so he induced labor. Labor was long and hard, high doses of pitocin and IV fluids were pushed, and pain meds were eventually needed. The induction failed, and we ended with an extremely traumatic cesarean. 

After the cesarean itself, there was no skin-to-skin contact, and only a brief moment of bonding in the post-op recovery room, after which I was separated from my baby for EIGHT HOURS. By the time we tried nursing, she had had many bottles of formula, glucose water, and had been regularly given a pacifier.

Even after I started breastfeeding her, the nurses pushed more bottles of glucose water to "flush out the jaundice" (jaundice is a common side-effect of pitocin). Never mind that glucose water doesn't flush anything and actually prolongs or worsens jaundice.

I experienced massive fluid overload postpartum because of the anti-diuretic properties of pitocin combined with an over-zealous IV protocol. I had severe edema everywhere, including my breasts. That made it very difficult for baby to latch on, and baby was very sleepy from the jaundice caused by all the pitocin. This made breastfeeding very inefficient even when it did happen.

I had a long, stressful labor and a horrible cesarean experience. A cesarean plus a stressful labor can cause real problems with lactogenesis. My milk didn't come in for a week....and when it did come in, the baby could hardly latch on because I was so severely engorged.  Add into that her sleepiness, all the formula and glucose water, all the resultant infrequent nursing....and you have a classic recipe for delayed lactogenesis and breastfeeding issues.

So was the problem here really my fatness? Or was it all the interventions that I experienced because of the way the doctors treated my fatness, interventions that snowballed into the classic cascade of complications?

I did eventually manage to preserve the breastfeeding relationship, but mostly through sheer luck and stubborness. But it took about 2-3 months before things really started to work, and I almost gave up any number of times.

I should also note that I never had problems again with breastfeeding in my subsequent pregnancies. If fatness was really to blame, the problems with breastfeeding would have been consistent.  Instead, the difference was in the interventions used and my insistence on early and frequent nursing, rooming in, and constant contact with my babies.  For me, that made all the difference in the world.

What Can You Do To Avoid This?

While there may definitely be something to the idea of hormonal imbalances like PCOS causing breastfeeding issues, it is important not to overlook the negative influence of the aggressive interventions commonly used in women of size. These can also affect breastfeeding, but are rarely controlled for in most research.

For fat women to have the best possible chance to succeed at breastfeeding, the best approach is to:
  • promote a vaginal birth with spontaneous labor
  • not use routine birth interventions unless truly medically indicated, especially IV fluids and pitocin
  • encourage early contact and breastfeeding as soon as possible after birth
  • avoid separations between mother and baby
  • promote skin-to-skin contact as much as possible and as early as possible
  • have the baby "room in" after the birth, and especially at night
  • avoid routine neonatal testing for low blood sugar unless baby is symptomatic
  • strongly discourage formula and sugar-water supplementations unless necessary
  • encourage frequent breastfeeding (every 2 hours or more)
  • give help and information about positioning to women with very large breasts
  • provide strong encouragement for breastfeeding to women of size
Of all these recommendations, I think the most important are to breastfeed early as possible, as often as possible, and to avoid separations whenever possible.

Some women of size may still experience breastfeeding problems--even when they do everything "right"--because of the hormonal imbalances that PCOS can cause. However, that doesn't mean that breastfeeding should be discontinued or discouraged, because any amount of breastmilk a baby receives is extremely beneficial immunologically.

Instead, these women should be given information and support for increasing milk supply through the use of herbs and medications if needed, they should be given emotional support while working on breastfeeding issues, they should be given information and support for improving baby's latch (craniosacral therapy can work wonders in some babies), and they should be provided information about supplementation alternatives like Lact-Aid or the Supplemental Nursing System if the addition of formula is needed.

Of course, sometimes weaning is the only sane thing to do under certain circumstances, and it deserves to be grieved and accepted if that becomes necessary.  But too often, women are not told that breastfeeding does not have to be an all-or-nothing proposition. Many women who experience problems can breastfeed at least partially, short-term or long-term, thereby giving baby much-needed immunological protections while still providing formula supplements if necessary.

But most of the time, most women can breastfeed, and more would probably breastfeed successfully if there were fewer interventions routinely used around labor and birth, if early skin-to-skin contact were uniformly utilized, if early and frequent breastfeeding was encouraged, if better breastfeeding support were given after birth, and if rooming-in became the standard of care. 

Question: How many of the "Baby-Friendly" practices (breastfeeding initiation within 1 hour of birth, giving only breast milk, rooming in, breastfeeding on demand, no pacifiers, breastfeeding support groups) did you experience with your babies?

Thursday, June 10, 2010

Exaggerating the Risks Again

Here we go again. 

Yet another article has been published in the mainstream media (the New York Times, disseminated through its news service), hyperventilating about the risks of "obesity" in pregnancy.  And it includes the typical distortions, exaggerations, and apocryphal personal stories as part of  the usual tactics to scare fat women into either drastic measures to lose weight before pregnancy, into draconian interventions during pregnancy, or to scare them out of even contemplating pregnancy at all. 

We've covered this territory before, and I'm sure we'll cover it again in the future, but let's chat about why this is more scare tactics and marketing than anything else.  I don't have time right now to do a detailed smack-down of the numbers and studies but we'll talk about the main problems with the article.

Lack of Use of Real-Life Numbers

First, they need to stop discussing the risks of "obesity" in pregnancy exclusively by the means of odds ratios, which distort the sense of risk around an issue.  Include the real-life occurrence of such problems, so women of size can assess for themselves just how risky (or not) something is. That helps put the risk in better perspective.

For example, the article states that there is a higher rate of birth defects in "obese" women.  And it's true that some studies have suggested that there is 2-4x the risk for birth defects in obese women.  Sounds scary, doesn't it?

Yet rarely do the studies (and especially the press releases) mention that doubling a very small risk is still a very small risk.  Yes, the risk for Neural Tube Defects in "obese" women seems to be increased in some studies, but even so, the actual numerical risk is still likely less than 1%. 

That means that 99% of "obese" women will not have a baby with a Neural Tube Defect.  Do you come away from reading these stories feeling like the actual risk is that small?

Although odds ratios can be useful at times, be careful when articles don't also include the actual numerical occurrence. It's too easy to distort the sense of risk around something otherwise.

Distorted Risk Perspective

The article mentions prominently that "obese" women are more likely to have diabetes and high blood pressure complications.  This is true, and definitely a concern.  But the article fails to mention that most obese women will not experience these complications. 

For example, Weiss (AJOG, 2004), a large study of more than 16,000 women in multiple hospital centers, found that 9.5% of "morbidly obese" women (BMI more than 35) experienced Gestational Diabetes during their study.  The number certainly is higher than the 2.3% with a BMI less than 30, so it is definitely a risk (4x the risk---gasp!) that should be communicated to women of size. 

However, it also means that 90% of "morbidly obese" women did not develop Gestational Diabetes.  So while the risk increased, it should be remembered that the vast majority of morbidly obese women will not get GD. 

Pre-eclampsia is another risk that is substantially increased in "obese" women, and this one can be life-threatening to both mother and baby.  It is definitely a risk that must be discussed as a possibility and taken very seriously.  But in the Weiss study, only 6.3% of "morbidly obese" women developed Pre-eclampsia....higher than the 2.1% of non-obese women (3.3x the risk---gasp!) who developed PE, but hardly universal.  Remember, 93% of "morbidly obese" women did not develop Pre-eclampsia in that study. 

Again, the majority of these women did not get GD or PE, the two most common risks for women of size.

So while these risks are real and it's only sensible that the possibility be discussed with women of size (and that women of size be proactive about lessening their risk for them), it's important that the magnitude of the risks not be exaggerated or to imply that such a complication is virtually inevitable. 

[For the data wonks: Every study finds a somewhat different range of occurrence of these conditions, so you can definitely find studies out there that find both higher and lower rates of GD and PE than the Weiss study cited here.  However, many of these studies have significant weaknesses (too-small sample size, differing thresholds for defining various things, lack of recognition of the role that iatrogenic interventions may play) so each study must be vetted carefully.  The Weiss study is a multi-center study, has a very large sample size (16,000+ patients), and has information about a number of common risks, so it is a fairly robust study to use to look at the rates of these complications.]

Correlation Does Not Equal Causation

Another common mistake these articles make is to conflate correlation with causation.  The implication is that if anything goes wrong, obesity itself caused the problem, and therefore the solution is easy.....just lose weight beforehand.

But if being fat caused all these various complications, all fat women would get the complications, and they do not.  Furthermore, many women of average size get these complications too.  The picture is more complicated than simple cause-and-effect.

Another possible theory is that underlying metabolic differences is really behind these complications, and the fatness is merely a byproduct of these metabolic differences, a symptom if you will. 

Making the women diet will likely not help much unless the underlying metabolic differences are also addressed.  Trying to fix things by losing large amounts of weight is too simplistic an approach.

Furthermore, losing weight carries risks as well.  Women who lose a great deal of weight before pregnancy tend to have large weight gains during pregnancy as their body compensates, and that has its own risks.  Losing weight before pregnancy also puts the woman at risk for nutritional shortfalls, a big concern just when nutritional demands are about to be at their peak. 

A simplistic cause-and-effect view of obesity and complications can lead to many dubious conclusions and harmful therapies.  Yet researchers and authors continue to conflate correlation and causation in obesity research all the time.

Simplistic Approach

Another consistent problem with articles like these is their simplistic treatment of obesity and fat people's health habits.  But fatness is not a simple topic. All fat people are not alike and therefore one "fix" for them all is unlikely to work.  It may even harm. 

Some folks really are fat because they eat poorly and don't get enough exercise, and some folks really are fat because they have an eating disorder.  But research clearly shows that fatness also has a very strong genetic component.  Some people have underlying hormonal or metabolic disturbances (like PCOS) that create a propensity to being fat and great difficulty in losing weight.  Environmental factors (easy access to highly processed foods, less opportunities for exercise) plays a role for some people, yet many thinner people eat highly processed foods and get little exercise but are not fat.

There simply are no easy answers as to why some people are fat and some are not, but researchers and authors of articles like these want to pretend that there are because it makes them feel better.  They want to continue the simplistic mantra that fat people are fat simply because they eat terribly and get little exercise.  They want to believe that if everyone just ate right and exercised enough, everyone could be "normal" in size and therefore all complications from obesity could be avoided.  But this is not realistic and the abysmal long-term success rates of weight loss studies demonstrates this all too well.

Emphasizing health instead of weight may be a better approach, and might help prevent some of the complications, regardless of whether a person actually experiences weight loss.  For example, research shows that regular exercise can lower the rate of Gestational Diabetes in fat women.  It may or may not help them lose weight, but it can lower the rate of GD. 

And we must not forget that multiple weight loss attempts are often associated with greater weight gain in the long run Ironically, by emphasizing weight loss as the main "cure", doctors are likely recommending the one thing most likely to actually cause a worsening of fatness in the long run. 

Doctors and researchers want simplistic answers because then they can feel like they can "fix" things for women, but the answers are rarely that simple.  The best "fix" for obesity-associated concerns may be to emphasize health habits rather than weight loss.

Ignoring the Risks of Intervention

Doctors like to "do" things when presented with a possible risk, but they are slow to realize that sometimes the "doing things" does more harm than good or causes the very problem they are trying to prevent. 

For example, one of the things that really frustrated me when I read the article was the following:
Very obese women, or those with a B.M.I. of 35 or higher, are three to four times as likely to deliver their first baby by Caesarean section as first-time mothers of normal weight, according to a study by the Consortium on Safe Labor of the National Institutes of Health. 

While doctors are often on the defensive about whether Caesarean sections, which carry all the risks of surgery, are justified, Dr. Howard L. Minkoff...said doctors must weigh those concerns against the potential complications from vaginal delivery in obese women.
The implication here (and alas, many doctors share this perception) is that cesarean sections in women of size are safer than vaginal birth.  Barring major complications, nothing could be further from the truth. 

The truth is that cesarean sections are FAR more risky than vaginal birth for all women, and especially so for "obese" women.  There is the risk of anesthesia complications, hemorrhage, blood clots, and a very serious risk for infection.  Doing surgery on a very fat woman is complicated, and the relative lack of vascularity in adipose tissue means that oxygenation and therefore healing is more difficult. 

Yet despite the documented increased risk from cesareans to "obese" women, more and more doctors are doing them pre-emptorily.  They have such an exaggerated sense of risk around vaginal birth in women of size that they no longer are willing to let fat women even try.....or will only "let" them try if they induce labor early.  And therein lies the answer to much of the high cesarean rate in women of size.

Virtually every study shows an increased rate of inductions in women of size.  We know from other studies that high rates of induction often result in high rates of cesareans, but none of the studies on cesarean rates in obese women actually connect the dots and acknowledges that their excessive induction rates may be a primary cause of the high cesarean rates.  Nor does this article bother to mention this possibility. Instead it implies the obesity causes the cesareans. (Again we're back to correlation versus causation.)

If fat really prevented giving birth vaginally, it would have done so in the past too. But if you look at studies from the past, the cesarean rate in "obese" women was similar to that of average-sized women.  Obesity doesn't cause cesareans.  What has changed is the PERCEPTION of risk around women of size, and the MANAGEMENT of their pregnancies and labors, and that has resulted in higher cesarean rates. 

Being perceived as high-risk and treated as high-risk often creates a self-fulfilling prophecy. 

Doctors are so fearful about the hyperbole around obesity and pregnancy that they seek to control this sense of risk by overusing early inductions and planned cesareans, but there is no proof that this improves outcome.  Instead they merely expose women of size disproportionately to the substantial risks of surgery.

Using Worst-Case Scenarios To Scare Women

Another typical tactic in these stories is using a fat woman with a worst-case scenario story and implying that this experience is common. 

Ironically, the women in these stories typically aren't even very fat.  This illustrates the point they want to make of Just.How.Dangerous.Obesity.Must.Be because this terrible thing happened to a woman who was not even that fat!!  [Imagine the risks for a woman who was really fat!!!]

One of the first scary newspaper stories I read years ago about pregnancy and obesity used a moderately fat woman (less than 200 lbs.) as its bad-mother example. She developed pre-eclampsia, the placenta abrupted, and her baby died.  The article ended with the woman swearing to lose weight so that the same thing wouldn't happen next time. The implication was that if she developed pre-eclampsia and a stillbirth at her weight, all the bigger fatties out there had no hope. 

I remember the article because I'd just had my first baby. I was quite a bit heavier than she was and yet I hadn't developed pre-eclampsia, I didn't have an abruption, and my baby didn't die.  Either I was a walking miracle or the risk of pregnancy in someone my size might be more variable than they were implying. (I was just glad I had read the article after I'd had my baby, or I would have been they no doubt wanted me to be.)

In the New York Times article a woman named Patricia Garcia is used as the bad-example-du-jour.  She had a stroke during pregnancy, she developed pre-eclampsia, and her baby had to be delivered 11 weeks prematurely because its growth was not progressing properly. 

The study mentioned in passing that she had a "constellation of illnesses related to her weight, including diabetes and weak kidneys."  This makes it sound like her weight is to blame. 

But if so, why don't most fat women have diabetes and resulting kidney damage during their childbearing years?  Only a small percentage of fat women have pre-existing diabetes before pregnancy. And if this was caused by weight, why aren't we then seeing very high rates of strokes in "obese" women? I know of no study to quantify how many "obese" women have pre-existing diabetes, get pre-eclampsia, and then have a stroke, but the number is surely quite small, given the numbers in the Weiss study.  Yet this article makes it sound like it's a common occurrence.

Of course, the ironic thing is that she's not even very large to begin with.  Near delivery she was 261 pounds, but most of that was edema, a common byproduct of pre-eclampsia.  Before pregnancy she was only 195 pounds. I'm considerably larger than her; if weight causes diabetes, why didn't I have pre-existing diabetes plus kidney damage before pregnancy?

Rather than the problem being from her weight itself, likely there is something metabolic going on.  She mentions that she is the smallest one in her family; her brother weighed more than 700 lbs before having a gastric bypass.  To have a sibling be that supersized and to have yourself have diabetes badly enough to have developed significant kidney damage by age 38 means that something else is going on, likely something metabolic.  This is not just someone who "can't control themselves" but rather someone who likely has a lot of genetic and metabolic blocks stacked against her. It doesn't mean that all fat women of her size are facing a similar level of risk

My heart truly goes out to this woman and all she has been through.....but especially because of all the guilt they have laid on her about her weight "causing" this complication.  She has enough to deal with already.

Of course, the article ends with the mother pledging to lose weight and reform so she can see her baby graduate from college:
Voila.....bad mother becomes good mother by pledging to buckle under and toe the line. Cue the violins....even though there is no way to know whether going on a "strict, strict, strict diet" would have prevented this from happening, will prevent future complications, or will instead just result in yet another yo-yo that will end with her being fatter than she even started. 
I'm going on a strict, strict, strict diet," she said.  "I'm not going through this again.

It's not that we should never discuss worst-case scenarios; some fat women do experience major complications and their stories deserve to be told.  The problem is that the worst-case scenarios are presented in these articles as if they are a commonplace occurrence, as if that level of complication is common to most fat women......and it's not. 

And NONE of these articles ever tell the story of fat women who experience healthy, normal pregnancies, when that is actually a more common story. 

It's the lack of balance in these stories that is so bothersome.

Ulterior Motives

Underneath all of this lies the real purpose of the promote bariatric obstetrics. It's subtle, but if you read carefully there is hint of an underlying agenda in the article. 

Re-read the article again and notice how prominently the article emphasizes what a terrible burden obesity is on neighborhood hospitals, how they are having to buy all this specialized equipment for all these fat people, and how much Ms. Garcia's medical bills cost, etc. 

Then notice how it conveniently mentions that a bunch of hospitals in the NYC area are considering banding together to provide a specialized clinic for obese clients.  As the article says:
One possibility is to create specialized centers for obese women.  The centers would counsel them on nutrition and weight loss, and would be staffed to provide emergency Caesarean ssections and intensive care for newborns, said Dr. Adam P. Buckley, an obstetrician and patient safety expert at Beth Israel Hospital North who is leading the group. 
The idea of a centralized clinic to deal with the specialized needs of "obese" women is not a brand new one; several places around the country (and world) already do this.  But it is a trendy one, and one with powerful economic incentives.

The advantages of specialized centers is that only one place has to buy the specialized equipment that may be needed for supersized clients.....larger BP cuffs, longer anesthesia needles, sturdier tables, etc.  Since getting doctors and hospitals to supply and regularly use large BP cuffs etc. can be a problem, this might actually have some benefits.  But really, don't these hospitals also serve fat non-pregnant people?  Shouldn't they be stocking larger equipment anyhow?  Or are we going to start centralizing care for all fat people next?

The problem with the idea of centralized care is that it ghettoizes fat pregnant women, as we've discussed before.  It creates a climate rife for over-intervention, with little questioning about whether the interventions are prudent or even necessary.  It applies the "super high risk" label to all fat pregnant women, whether or not they actually experience complications, and subjects them to extreme amounts of intervention they may not need.

The induction and c-section rate in a bariatrics obstetrics specialty is likely to be even more astronomically high, because the doctors automatically see the obese woman as super high-risk.  And it's likely that the fat women at these centers will not be offered access to midwifery care, waterbirth, positioning options, or choices that can help lower the rate of sections and complications instead of adding to them. 

Historically, little good has come from classifying various pregnant populations as high-risk and treating them as such before any such complication occurs.  All that really happens is that more women undergo risky inductions and planned cesareans, and their infants experience higher levels of interventions that interfere with breastfeeding and bonding.  The high-risk label often leads to increased intervention without improvement in outcomes, and this is likely true also for women of size.

Furthermore, postpartum interventions will no doubt also include being bullied even more strongly than usual about nutrition and weight loss, and there will probably be a lot of gastric bypasses coming out of these programs, another financial boon for the hospitals.

Before such bariatric obstetrics centers are embraced across the country, they need to prove that their high-tech, high-intervention approach actually improves outcomes.  The cesarean rate should be lower in such bariatric centers, the fetal outcomes should be better, and they should have a high rate of long-term weight loss success.  But nowhere is there any research proving any such thing.  Instead these centers are allowed to open and operate without any closer review, and their intervention rates are allowed to go unchecked and unreviewed.

Another even more compelling issue is that the right to self-determination of care will be taken away from fat mothers if they are forced into these "obesity ghettos."  As long as the baby is healthy and there are no major complications, fat women should have the right to choose the style of care they want, the amount of intervention they prefer to use, and the way they want to give birth, just like any other woman does. 

If they want the high-risk ticket, they should be able to choose that.  But if they have little or no complications, are otherwise low-risk, and want alternative options like midwives or waterbirth, they should have the right to determine that for themselves, not be forced or scared into the Fat Farm Chophouse.

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

Apparently, all it takes is extra pounds.


It's not that the possible risks of "obesity" and pregnancy should never be discussed with women of size.  Of course they should.  Women deserve to be informed of the possible risks.

However, this article was full of distortions and worst-case scenarios, and it implied that experiences such as stroke during pregnancy are extremely common in fat women.

Anyone reading 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 first, and that the vast majority of fat women experience major complications and have unhealthy babies. And that simply doesn't jibe with the experiences of most fat mothers.

Yes, women of size are at increased risk of some complications. But the article distorts the magnitude of that risk and presents weight loss and highly interventive care as the only paths to a healthy pregnancy.

In fact, many women of size have healthy pregnancies and healthy can read many of these stories on my website.  I was one of them. I somehow managed to have four healthy babies at a much higher starting weight than the woman in the article. Despite being larger than her, I never had diabetes, I never had pre-eclampsia, I never had kidney problems, and I never had a stroke. And I know many more fat women just like me, in all sizes of fatness, who had healthy pregnancies and babies, in all sizes of fat. But THAT part of the obesity story doesn't get publicized.

It's not that you cannot discuss the possible risks of obesity in pregnancy with women. But it needs to be done in a fair and balanced way. This article was not well-balanced, it didn't discuss the possible risks in a reasoned and calm manner, nor did it acknolwedge that many women of size can have healthy pregnancies and babies.

Sensationalistic articles like this are done to shame and scare women out of pregnancy, or into compliance with draconian interventions like weight loss surgery, lack of weight gain during pregnancy, extreme prenatal testing, unnecessary inductions, or planned cesareans.  Postpartum, they try to shame women into emphasizing weight loss at any cost, despite the fact that long-term research shows that nearly all diets will fail, many of the women with weight loss surgery will experience nutritional complications, and that weight loss attempts are one of the major factors in weight gain over the long run. Approaches like this will likely just worsen the problem, not improve it.

Furthermore, while I'm sure some of these doctors have good intentions towards helping women of size, there is an undertone of economic incentives here that is being ignored. 

By exaggerating the risks of obesity in pregnancy, doctors, hospitals, and insurance companies can push for centralized services that cater primarily to "obese" women, and bill for more services and interventions because these women are "so high risk."  This"bariatric obstetrics" approach is a tremendous potential cash cow for providers, and it's no coincidence this article appeared in the Times just as the hospitals there are considering creating a centralized treatment clinic.  This article was not meant just to inform but also to market the new profitable field of bariatric obstetrics to other doctors and to obese women themselves.

Although there can be advantages to centralized facilities for women who experience major complications, fat women with healthy pregnancies should not be forced into these facilities to receive care. It is wrong to imply that all fat women are at the same level of risk as the woman in this story, or that we all require such specialized care. Many of us actually do better in low-tech, low-intervention care.

Yet more and more I am hearing from fat women who are being DENIED the opportunity for homebirth, birth center birth, or a VBAC trial of labor, simply because of weight, regardless of actual health or complications. I am hearing from women of size who are being REQUIRED to go to these bariatric obstetrics hospitals where they are not given access to midwives or low-tech/alternative options. Their rights and choices are being taken away from them, simply because they are fat and perceived as ultra high-risk.

Being fat does not mean your right to choose your own preferred style of care is forfeit. Right to bodily autonomy is everyone's right, regardless of fatness. But by exaggerating the risks of obesity and concentrating on the worst-case scenario stories, the authorities try to make a case for taking away just that.

No, we don't have to ignore potential risks, and information about proactive ways to lessen risk can be helpful.  But stop the hyperbole about risk, stop treating obesity so simplistically, stop using only worst-case scenario stories in these articles, and stop trying to create a new profit margin by ghettoizing fat women and exploiting them for profit.

P.S. I hope other fatosphere bloggers and birth bloggers will dissect the Times article and blog about its  weaknesses.  I should not be the only one blogging about this issue, and we need a greater chorus of voices protesting such articles out there.

Tuesday, June 1, 2010

Obesity Stigma Not Helpful - No, Really?

This just out!!  Obesity stigma harms more than helps!! 

[No, really????]  

Amazing they have to have an actual research journal article debating this.  Isn't it obvious?  Well, evidently not, sigh

I suppose I should be grateful that someone is taking time to disprove the kinds of lame claims that more stigma is needed, not less. 

On the flip side, though, is that while they are concerned about the negative effects of obesity stigma on fat people, the big concern is that this stigma gets in the way of obesity intervention efforts

I know these authors have good intentions, but I don't think they quite get it, do you?  Pretty typical of the Rudd Center, I gather.

But at least they are saying something against obesity stigma and countering the usual nonsense out there. It just amazes me that some idiots can actually believe that obesity stigma is really an effective tool for health improvement.

Here's the abstract of the study.  [Obviously, emphasis mine.]

Obesity stigma: important considerations for public health.

Am J Public Health. 2010 Jun;100(6):1019-28. Epub 2010 Jan 14.
Puhl RM, Heuer CA.
Director of Research and Weight Stigma Initiatives, Rudd Center for Food Policy and Obesity, Yale University, 309 Edwards St, New Haven, CT 06520-8369, USA.


Stigma and discrimination toward obese persons are pervasive and pose numerous consequences for their psychological and physical health. Despite decades of science documenting weight stigma, its public health implications are widely ignored.

Instead, obese persons are blamed for their weight, with common perceptions that weight stigmatization is justifiable and may motivate individuals to adopt healthier behaviors. We examine evidence to address these assumptions and discuss their public health implications.

On the basis of current findings, we propose that weight stigma is not a beneficial public health tool for reducing obesity.

Rather, stigmatization of obese individuals threatens health, generates health disparities, and interferes with effective obesity intervention efforts.

These findings highlight weight stigma as both a social justice issue and a priority for public health.

PubMedID: 20075322