Tuesday, October 26, 2010

Too Out Of Shape For Birth?

Here's another little gem from the blog, My OB Said What?.  It covers the common misperception among obstetric caregivers that fat women are too "out of shape" to give birth vaginally and/or naturally. 
“You are quite overweight and you need to be healthy to naturally birth a baby. You wouldn’t make it because you would get puffed out and tired.”
-OB to overweight mom who wanted a natural birth
This is a very common belief among many people, both lay and medical.  The idea is that you have to be in great athletic shape in order to give birth naturally. 

There are two problems with this. 

First is the common assumption that "overweight" and "obese" women never get any exercise and therefore this mother couldn't possibly be in decent shape. (The corollary, of course, is that all average-sized women obviously do get exercise and are always more fit than fat folk.)  Neither is true.

Second is the assumption that you have to be fit in order to give birth naturally, that labor and birth is like running a marathon and only the most fit and tough can do it naturally.  Baloney.  Fitness helps, but it's no guarantee either way.

Assumption: "Obese" Women Never Exercise And Aren't In Shape

Many doctors and laypeople assume that fat people never exercise and can't possibly be in decent shape.

This is nonsense.  Many fat women do exercise and of course, many skinny ones do not.  You can't tell by looking at body size who gets exercise and who does not. 

It goes back to that common societal belief that if you are fat, it must be because you don't eat well and don't exercise at all.  Anyone who made any real effort at it would obviously be "normal-sized" or pretty darn close to it.  Therefore, in that mode of thinking, all fat people are, by definition, not fit.

I would agree that it's possible that fat people, on average, may be less fit than average-sized people....certainly fatness can be more physically challenging in some ways (especially as we age), there are many barriers to exercise for people of size, and some fat people really are sedentary....but you just cannot make assumptions about individuals based on size.  I know "overweight" and "obese" people who run, bike, and hike regularly and are very fit.  I also know ones who are not.  But you can't really tell by looking.

This doctor should not be making assumptions about fitness level based simply on the mother's size.

Assumption: Only The Most Fit Can Birth Naturally

Although I think it's true that it helps to be reasonably fit for pregnancy and birth, it's certainly not a requirement for normal vaginal birth.  The uterus is a muscle and works independently of the fitness of the rest of the person. 

I mean, for heaven's sake, there have been cases on record where paralyzed women have given birth vaginally.  If a person who cannot actively help push out her baby can birth vaginally, then obviously fitness is not an absolute pre-requisite for giving birth vaginally. The uterus can do it on its own, if the baby is well-positioned.

That said, pregnancy is wearing on the body and labor is certainly not a walk in the park.  I do think that folks who get regular exercise in pregnancy tend to have fewer complications in pregnancy (less gestational diabetes and perhaps less pre-eclampsia), and it may help them have an easier birth.  It also helps to have some endurance on board if the labor is hard or long. 

However, fitness and athleticism are not an absolute requirement for having a vaginal birth or a med-free childbirth.  I know plenty of very fit, very athletic women who have had cesareans, and plenty of not-very-fit women who have had vaginal births (and natural, unmedicated vaginal births at that). 

My Experience

In my own life, I exercised quite a bit in pregnancies #2 and #3, but because of coincidental life issues, not as much with #1 and #4.  (I was "morbidly obese" and of similar weight with each, so that was not a relevant variable on its own.)

I had very little exercise and a cesarean with the first, exercised a lot with #2 but still had a cesarean, exercised a lot with #3 but had a vaginal birth, and exercised not-a-lot with #4 and still had a vaginal birth (a completely natural, unmedicated birth in the water to boot). 

I did notice a difference in how I tolerated pregnancy; I definitely was most comfortable in the pregnancies in which I exercised regularly.  So I'm a big fan of promoting exercise for pregnant women of all sizes.  But not getting as much exercise in my last pregnancy didn't prevent me from having a vaginal birth. 

I absolutely encourage women (and especially women of size) to exercise regularly in pregnancy because it really does help you feel better, lowers your risk for complications, may help you during labor, and will help your body recover faster afterwards.

But do you have to be skinny or an athlete to have a vaginal birth?  Of course not.  Just read the comments on the My OB Said What? page.  Many were from fat women who birthed vaginally and all naturally just fine, with or without regular exercise.  And I have birth stories on my website from fat women, even supersized women, who have had natural vaginal births without problems.

Yes, fat women have more cesareans.  But is that really only because of their fatness, or because of a combination of more complications, an extremely high rate of induction in fat women, the extremely interventive way that fat women's labors are managed, a higher rate of malpositions, and a very low threshold for surgery for fat patients among their OBs?


Focusing on fitness/exercise as a requirement for natural birth is just another argument that doctors (and sometimes midwives, alas) use to convince fat women that they:
  • will "need" a cesarean
  • couldn't possibly push out a baby because they are too unfit or too fat
  • couldn't possibly push out a baby without help from forceps or vacuum extractor because they aren't strong enough to push hard enough
  • are too weak to endure labor without drugs
  • won't produce strong-enough contractions on their own and will definitely "need" pitocin
  • couldn't possibly have a vaginal birth without losing tons of weight or taking up marathons beforehand
(Yeah, those are all real things that have been told to women of size.)

Let's be clear. Fat women can and often do exercise.  Just because you are fat doesn't mean you don't exercise.  Could many fat women exercise more?  You betcha.  Could many average-sized women exercise more?  Yes. You simply cannot make assumptions about exercise habits and fitness based on a person's size.

Second, exercise and fitness is NOT necessarily a pre-requisite for birthing vaginally.  It definitely helps, and women should definitely be encouraged to be active in pregnancy....but the story is much more complex than that.  There are far more factors than fitness and athleticism at work in birth.

So is fitness an absolute requirement for birthing vaginally or without medications? Heck no.

And can fat women, fit or unfit, birth vaginally? Hell yes.


Sharon Muza, New Moon Birth said...

thanks well rounded mama! You raise many good points. In my experience as a doula, my observations have at times been that the extremely fit/trim/toned/strong athletic women sometimes have had a hard time being "loose enough" to birth! they are so tight and powerful that letting/getting their muscles to relax in their thighs and bottom can sometimes be challenging. I just attended the birth of a rock climber, unbelievably strong and flexible, not an ounce of extra body fat, rippling muscles woman who had to work very hard to have her HBAC, getting the baby out was hard, hard work for her. I do not want to stereotype that this is the case for all, but just some of my observations, in these cases, fit seems to slow things down. Sometimes i will take my larger size mamas any day!

Mrs. Gamgee said...

This post is so timely for me! I am 35 weeks pregnant and am morbidly obese. I have been struggling with the confidence that I will be able to deliver vaginally. I admit that I have not been as active as I could have been throughout this pregnancy, but I still hope and pray that I will be able to deliver this baby vaginally.

Heidi said...

That a doctor would ever even offer that idea as criticism of a fat woman is ludicrous to me - I was in labor (and back labor at that) with my son for 42 hours but once they let me push (they were concerned about heartbeat decelerations and did a fetal scalp blood sample on him to make sure he was getting enough oxygen to go through with a vaginal birth) I got him out in a half an hour flat, which I'm told isn't bad for a first-time mom.

I'm DEATHFAT! and wouldn't claim to be a paragon of exercise and fitness, although I was walking 30-40 minutes each day at that point to get to and from work.

I managed just fine.

Jen said...

I have been freaked out about this for awhile now. I was walking many days a week until my second trimester, when I hurt my foot-- I figured it was just overpronation. When the chiro couldn't do more about it, and I finally took the time to see a podiatrist, I found I have a mean case of plantar fasciitis.

I am not good at honoring time for exercise at home, and won't pay for a gym, so walking was what worked best for me.

I've been concerned, even though I haven't gained nearly as much this pregnancy as I have in the past, that I would be too out of shape for our planned home water birth. My birth team has reassured me that women in comas can give birth, and I can do it too-- that I just need to trust birth and trust myself. I feel guilty about the lack of exercise, but I'm glad of this reiteration!

Elizabeth said...

I'd email this, but you don't have an address listed on your blog. I thought you'd be interested in this post on inductions: Induction of labor should be restricted to medical indications

Anonymous said...

Elizabeth, there is an email listed on the side of the blog if you look closely. kmom AT plus-size-pregnancy DOT org is my email addy.

But thanks for the link! When I get a moment I will follow it. Sounds interesting. I've read a few other articles like it; it will be interesting to see this doctor's take on it.

I applaud the movement towards reducing inductions by tightening the acceptable indications for induction. The problem is that this won't change behavior much among the docs who want to practice daylight obstetrics. They'll just "invent" a "medical reason" for inducing and justify it that way.

It will take very close monitoring by hospital review boards before the behavior of a lot of induction-happy OBs is changed. At this point, most hospitals won't monitor that closely and so the induction epidemic goes unchecked.

Trying and trying said...

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