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 terrified.....as 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 article.....to 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.

Summary

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 births.....you 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.