Tuesday, October 19, 2010

Gaining weight in pregnancy means a cesarean?

A very telling question was recently asked on the Lamaze Forums, one that seems like a perfect footnote to the discussion we've been having about extreme weight gain restriction in women of size in pregnancy:
I have a friend who is finally pregnant after 5 years of infertility. She went to her doctor's appt today and was told that if she gained anymore weight she would need a c-section. She admits that she is overweight, but has been vigilant in her diet and is exercising daily, unfortunately she can't seem to keep the weight off. Is there any reason that being overweight would automatically equal c-section?
Henci Goer moderates the questions on these forums.  Here is her reply:

No, but her doctor's statement is a good reason to find another care provider ASAP. Her doctor's belief in her inability to birth vaginally is extremely likely to become a self-fulfilling prophecy. The research is rock solid that cesarean rates depend far more on the individual care provider's judgment and practices than on factors that have to do with the woman.
Amen to that.  Let's say it again:

Cesarean rates depend far more on the individual care provider's judgment and practices than on factors that have to do with the woman.
In this case, the care provider believes that a fat woman should have an automatic cesarean if she gains "too much weight" in pregnancy, no matter how healthfully the weight is gained.

This belief that fat women "need" a c-section because they either "cannot" birth vaginally or because it is "far too dangerous to allow them to try if they gain too much weight" is another reason the cesarean rate in women of size is so high. 

This is reflected by a comment left by another midwife who has since learned differently:
I was an OB nurse for 10 years prior to becoming a midwife.  There is a strong bias against overweight women on the OB floor.  We always talked about how long we'd have to wait before the decision was made to have a c-section.  We truly believed an overweight woman's body truly couldn't accomplish a natural birth. 
This is the kind of attitude that we, as women of size, are up against. Most of the care providers don't believe we CAN birth vaginally, or that we even SHOULD. Many believe that it is far too risky to "allow" us to even try and it's better to just schedule that c-section in advance to "save" the baby from our toxic bodies.  Or to schedule that induction early before that baby gets "too big" from all our out-of-control eating, don'tyaknow.

And now the trend is that women of size who gain "too much weight" in pregnancy (which might mean very little in comparison with other women) should be scheduled for a cesarean. 

This is one of the major problems with the push to restrict weight gain in women of size; those who gain "too much" weight may be punished for it, consciously or unconsciously.  They are assumed to have grown very big babies, and so are scheduled for either early induction or planned cesarean as a result, despite strong research showing that these practices actually increase harm.

The push to restrict weight gain in women of size, while ostensibly to prevent more cesareans, may actually result in many "obese" women having cesareans who may not have needed it, simply because they gained "too much weight" for their doctor's comfort level.  (And "too much" may mean anything from gaining more than 15 lbs. to gaining ANY weight at all or failing to LOSE weight, which is what many doctors are pushing for now.)

It's the perfect Catch-22.  Set the weight gain limits so low that very few fat women will be able to meet them, even when nutrition and exercise habits are great.  Make those who don't meet the goals have planned cesareans or early inductions because otherwise, "it's too dangerous." 

Fewer pesky and inconvenient labors to attend, a schedule that's easier to work around your office hours, plenty of convenient and quick cesareans to do, and plenty of money for the NICU for all those babies who then experience breathing problems, fetal distress, low blood sugar, or jaundice.

The perfect score for hospitals everywhere.

I'm not so conspiracy-minded as to think that most hospitals and doctors consciously think this way because they are "out to get" fat women.  I think most truly believe they are doing the babies of women of size a favor by scheduling them for cesareans or inductions to "save" them from the "dangers" of natural vaginal birth in obese women. 

But are they really better off?  I don't think so.  Babies of cesareans often have significant issues getting started, and end up in intensive care more often than babies born vaginally. And the women themselves are certainly not better off after a c-section, and especially women of size, in whom surgery is inherently more risky.

This push for extremly restricted gain in women of size has many scary implications, and one of them is the punishment for fat women who gain "too much." 

Apparently, they really believe that everyone can keep from gaining "too much" if women are dedicated enough and work hard enough, and that gaining "too much" must be because women are eating excessively and being a couch potato.  But there are far more factors at work here, and I'm not convinced how much prenatal weight gain is 100% under our control.  Some yes, but not all.  There are too many other variables.

I don't have a problem with programs that focus on excellent nutrition and increased exercise, as long as goals are reasonable and the protocols are sensible, not restrictive.  Granted, I think everyone could benefit from such programs and dislike seeing them target only fat women, but reasonable programs humanely done are not my big worry.

I do have problems with programs that are highly restrictive in nature, use emotional manipulation and scare tactics to try and scare fat women "straight," press extreme weight gain restriction agendas, make women feel guilty and neurotic about their weight gains, and which punish women who exceed the "recommended" gain.

THAT I definitely have a problem with.


Cassandra said...

Got a chance to catch up on your posts today. I had an amazing waterbirth on 10/4 after my water broke with meconium on 9/30. Four hours of active labor, half hour of pushing and out my 9 lb 12 oz 22.5" (ie not fat) baby popped. First time mom, gestational diabetes and I weighed 393 lbs pre-pregnancy with basically no net gain, though I didn't check it in the last month. I'm living proof that fat women can not only have vaginal births, but FAST ones too! And another example of fat women not having fat babies. Also, thank you for providing so many resources on your plus size pregnancy website - it greatly contributed to my having a healthy pregnancy. My beautiful, healthy daughter thanks you too.

crystal_b said...

Thank you for an excellent post!

A good friend of mine was dumped by her provider at 28 weeks because she would not agree to a c-section based on her weight alone. She found another provider at 30 weeks and went on to have a healthy (if smallish! -- less than 7 pounds) baby vaginally after 30 hours of (spontaneous) labor *at a hospital* no less! I really shudder to think what would have happened if she had gone along with the care provider's bullying that somehow a scheduled c-section would be so much better for her and her child.