Monday, November 29, 2010

Failure to Wait

New research is showing what many critics have been saying for years ─ that too many cesareans performed for "failure to progress" in labor are actually cesareans for "failure to wait." 

In other words, some doctors don't wait long enough for labor to progress on its own before declaring that a cesarean is needed. 

The problem of "failure to wait" cesareans is often particularly prevalent in women of size and may be one reason for a higher rate of cesareans in "obese" women.

A Lack of Patience for Women of Size

Since "failure to wait" is especially common in induced labors (recent research shows that "half of cesarean[s] for dystocia in induced labor were performed before 6 cm of cervical dilation"), and since women of size are induced at far higher rates than other women, discussions about "failure to wait" cesareans in this group are very important.   

Adding into this is the fact that labors tend to be longer in women of size, perhaps reflecting more malpositioned babies or induction for longer gestations (i.e., bodies not quite ready for labor yet).

If labor tends to be longer in women of size and caregivers do not allow for that, more "failure to wait" cesareans are going to occur.

For example, Pevzner 2009 found that induced labors took longer and required more induction drugs in "obese" women. Even when controlled for induction, Nuthalapaty 2004, and Hamon 2005 showed that "obese" women had longer labors, especially in the first stage. 

In addition, Vahratian 2004 showed that the slower duration was concentrated around 4-6 cm of dilation, exactly when most "failure to wait" cesareans are performed. They concluded:
Labor progression in overweight and obese women was significantly slower than that of normal-weight women before 6 cm of cervical dilation. Given that nearly one half of women of childbearing age are either overweight or obese, it is critical to consider differences in labor progression by maternal prepregnancy BMI before additional interventions are performed.
In other words, doctors need to wait a little longer in women of size to give labor every chance to progress further before performing a cesarean.

Another classic example of "failure to wait" is found in the first VBAC study on "obese" women, which is often cited as a reason not to let very fat women try to VBAC.  The study found only a 13% success rate in this group, and so it was widely concluded by many authors that very fat women were not appropriate candidates for VBAC.  (Don't worry; later studies have found much higher success rates.)

A closer look at the study reveals that there were only 30 women in the trial of labor (TOL) group, certainly not a large enough sample size on which to make sweeping policy decisions for a whole demographic group. The study also showed that, of these women, 57% had their labors induced, which research clearly shows lowers the rate of VBAC success.  (In the 13% VBAC study, none of the women who had their labors induced had a VBAC; all the VBACs went into labor spontaneously.)

Most tellingly, the average dilation at the time of the decision for repeat cesarean during labor was 4.5 cm.  This shows that these women of size were not really given an adequate chance at labor, and were sectioned far too early, as is so common in the labor management of "obese" women.

Is it any wonder that the women in this study only had a 13% VBAC success rate?  Their doctors clearly did not believe that very fat women could give birth vaginally on their own, and so induced more than half of them, despite all the evidence showing induction lowers VBAC success rates.  Furthermore, they gave up on the trial of labor very early, before the women had really even reached the active stage of labor

Although I'm sure the physicians justified intervening earlier in order to avoid difficult and risky emergency surgery later on, it shows a troubling pattern in not letting fat women even have an adequate trial of labor before jumping to a surgical conclusion. 


Yes, surgery in very fat women is harder and takes longer, so it is understandable that doctors don't want to wait until there is an emergent situation before intervening.  But more and more, they are moving towards only giving "obese" women a token trial of labor (if they let them labor at all), and moving prematurely to a surgical solution if the baby doesn't practically fall out.  This is not a reasonable alternative.

Given the increased risks of surgery in women of size and the long-term implications of surgical births, I would argue that the better solution is not to section fat women prematurely, but instead to give fat women every chance to deliver vaginally by awaiting spontaneous labor whenever possible, and to apply a tincture of patience, knowing that labor may simply take a little longer in women of size. 

As long as mother and baby are doing well, a tincture of patience is the best option for long labors in many women, and may be particularly appropriate in women of size.

"Failure To Progress" cesareans are far too often "Failure To Wait" cesareans, and especially so in women of size.

Here's the abstract of that new study:

Zhang J et al. The Consortium on Safe Labor. Contemporary Patterns of Spontaneous Labor With Normal Neonatal Outcomes. Obstet Gynecol. 2010 Dec;116(6):1281-1287.

OBJECTIVE: To use contemporary labor data to examine the labor patterns in a large, modern obstetric population in the United States.

METHODS: Data were from the Consortium on Safe Labor, a multicenter retrospective study that abstracted detailed labor and delivery information from electronic medical records in 19 hospitals across the United States. A total of 62,415 parturients were selected who had a singleton term gestation, spontaneous onset of labor, vertex presentation, vaginal delivery, and a normal perinatal outcome. A repeated-measures analysis was used to construct average labor curves by parity. An interval-censored regression was used to estimate duration of labor, stratified by cervical dilation at admission and centimeter by centimeter.

RESULTS: Labor may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to progress from 5 to 6 cm of dilation. Nulliparous and multiparous women appeared to progress at a similar pace before 6 cm. However, after 6 cm, labor accelerated much faster in multiparous than in nulliparous women. The 95 percentiles of the second stage of labor in nulliparous women with and without epidural analgesia were 3.6 and 2.8 hours, respectively. A partogram for nulliparous women is proposed.

CONCLUSION: In a large, contemporary population, the rate of cervical dilation accelerated after 6 cm, and progress from 4 cm to 6 cm was far slower than previously described. Allowing labor to continue for a longer period before 6 cm of cervical dilation may reduce the rate of intrapartum and subsequent repeat cesarean deliveries in the United States.

PMID: 21099592

Wednesday, November 24, 2010

Third Annual Turkey Awards: Jumping To Conclusions

Well, it's that time of year again.....time for my Annual Turkey Award!

This is an award I created to annually "honor" fat-phobic healthcare providers everywhere.  And believe me, there are plenty of them...a veritable cornucopia of turkeys to choose from for this delightful award.

This year, I want to highlight the caregivers who have made the leap of logic that if a fat woman is at increased risk for a complication, that means there's a GUARANTEE that she will experience that complication. 

Like the recent commenter to my blog who was told that at her size, she WOULD have a deformed baby.  Not a reasoned discussion about possible increases in risk for birth defects or ways to possibly lower that risk, but the doctor telling her that she WILL experience a "deformed" baby, simply because of her size.  Never mind that the chance is actually quite low in terms of actual numbers, the doctor just concluded that it WOULD happen because of her weight.

Or another reader who recently sent me an email about her first pregnancy appointment, where she was lectured about her fat and basically informed she "should neither expect or deserve to have a healthy baby." 

Or there are the the doctors who tell fat pregnant women that they WILL get pre-eclampsia or they WILL get gestational diabetes during their pregnancies.  No discussion of actual numerical risks (which show that the risk, while increased, is still relatively low), no discussion of things they might do to help mitigate that risk ─ just the assumption that these complications WILL occur in all women of size.

[Yes, there are increased rates of PE and GD in women of size, but there is NO study that shows a 100% rate of pre-eclampsia or gestational diabetes in "obese" women, "morbidly obese" women, or even "super-obese" women.....not even close.]

Or there's the recent spate of doctors telling "obese" women that if they try to have a VBAC (Vaginal Birth After Cesarean), they, their baby, or both WILL die (or have a very low chance of survival).  Never mind that there's NO actual evidence to support an increased risk for maternal or fetal death among fat women trying for a VBAC; who needs evidence?  They just know that it's far too dangerous for fat women to even try and therefore fat women shouldn't even be allowed the choice.

This is one of the major problems with over-emphasis on the risks of "obesity" in public health campaigns. People begin getting a distorted picture of the actual numerical risk.

In time, a numerically-low-but-somewhat-increased-risk for a complication somehow gets transformed into a widespread perception that ALL fat people will experience that complication and eventually the perception develops that DEATH will be the inevitable result.

This exaggerated ramping of risk perception occurs even among healthcare providers, who really ought to know better, and in the end, results in people's choices and autonomy being taken away from them.

It's not that we cannot discuss possible risks.  Of course we can; that's an important part of the healthcare conversation.  However, public health discussions about "obesity" have gone from discussing possible risks realistically and without judgment, to making sweeping generalizations and exaggerations of risk in the public's mind, to scapegoating, barbaric scaremongering, and suspension of basic rights by healthcare professionals.

You know things have gone too far when even healthcare professionals are believing the scaremongering sensationalism that goes against every bit of science and reason that they should have been trained to employ, and when they suspend every sense of medical ethics they have been taught.

*Turkey image from Wikimedia.

Monday, November 22, 2010

Open Thread Ranting: Obesity Journalism Clichés I Could Do Without

Oy.  I've had a heck of a month so far, with medical crises in 3 of 4 children that included an MRI, MRA, and neurological testing in one child, several weeks of missed school and minor surgery in another child, and an ultrasound, hospital visit, and possible major surgery (not needed in the end) in another child.  Not to mention all the GAZILLION doctor appointments that went with all of this.  Oh, and a bunch of meetings at school to develop a plan get various medical needs met.

So I'm definitely feeling stressed out, and that's why there haven't been any major posts in a while.

The good news is that in the end, these were only minor blips on the scale of Things That Could Go Wrong, so I'm counting my blessings even as I acknowledge the stress and its toll.  At least most of this stuff ended up being relatively minor, thank goodness.

And since things tend to come in threes, I'm reassuring myself that this means I'm done.  Child #4 is under strict instructions that he does NOT need to complete the set and make us four for four.  We've had our three bad things, now we're done and can move on, thank you very much. (I'll just plug my ears, sing la-la-la loudly, and ignore the fact that ski season is looming.)

The bad news is that I'm behind in my blogging.  I have a number of major posts in the works but they are research-heavy and so need some real dedicated TIME to finish, time which has been spent in doctors' offices, at the hospital, and in meetings recently.  So please, keep checking back.  There's lots more to come, once people stop being sick long enough for me to finish it.

In the meantime, in the interest of at least posting something, here's a mini-rant about "obesity journalism" clichés that's been brewing in my mind for a long time.  Feel free to rant along.

MY RANT: Whenever I read journalistm stories about the "obesity epidemic," I am appalled at all the tacky clichés used.  Journalists are supposed to avoid clichés ─ but somehow editors look the other way when it comes to "obesity" stories.  (Apparently, rules of good writing are not needed when discussing obesity?)

For example, I would love to banish the phrase, "packing on the pounds."  Yeah, sure, it's alliterative, but it's insulting and inflammatory.  Same with the phrase, "ballooned up pounds."  Both are overused and not very imaginative ─ just lazy journalism. 

I'm sure if I sat down and thought about it for a while, I could come up with a lot more clichés....but I'll let you do that for me.

Which "obesity journalism" clichés drive you nuts?  Do you have other pet peeves about the writing style and content of these types of "obesity epidemic" stories?

Open Thread Ranting starts now.

Friday, November 12, 2010

Size Bias in British Obstetrics

I received the following email recently, describing the poor treatment one pregnant woman of size received from the British healthcare system.  (I have edited it a bit for clarity.)
I am a 'plus-size' mum...or extra-morbidly obese as my paperwork says. I am British and living in the UK...We have free health care, which I have always been very grateful for and happy with. However, new government policies over the last few years have made being even over-weight and pregnant a problem, let alone as large as I am! (I'm a UK size 22/24.)

For example...anyone who is deemed overweight when they 'present as pregnant to their GP' is now offered a strict diet program overseen by weight watchers or slimmers world, or a termination 'until weight is acceptable'.

Those of us that go against GP advice are ostracised and treated as both unworthy and stupid. My current treatment includes being 'seen' by my GP in a corridor whilst people walk past, rather than in the privacy of an office; and being blatantly lied to about statistics (I was actually told it was physically impossible to give birth vaginally after a c-section, as the baby would 'go the wrong way'!).

My consultant told me I was so fat it made the radiographers sick to have to perform a scan on me...The same consultant insisted I have huge stitches after my C-section, and refused to allow me anything other than normal paracetamol [kmom note: Tylenol] as painkillers after the spinal block wore off to 'teach' me a lesson!

When I refused to have a coil fitted as contraception, I was told 'Well, you probably don't need anything, there can't be many men desperate enough to have sex with someone your size' a room with 3 other mums.

The alternative to that? Well, there isn't really one...I have 'opted out of care'...basically no-one sees me, so there isn't anyone to make the comments! I've had 3 antenatal appointments so far, and am under 'GP care', but as he won't see me in his office and I don't feel comfortable discussing my pregnancy or ailments in a corridor for all to hear, I basically don't see him either.

Now all this would be bad enough with a 'normal' pregnancy, but this is my 7th baby...of my last 3 pregnancies, one was a messy late miscarriage, the other two were c-sections (I'd managed normal births until then).

The first [c-section] was as my son was breech (obese women can't deliver breech babies naturally apparently!), the second c-section gave me one 7 week premature daughter and a still-born not exactly 'perfect' births...then there's my BP (normally high, but I'm currently proud of the level I am managing to keep it at!)....and the added bonus, that if I step into the hospital prior to the baby actually crowning I will have to have another C-section, and likely a hysterectomy, as is hospital policy on third C-sections....

I spoke to an independent midwife over the phone at the beginning of my last pregnancy, and she told me that it was a load of rubbish about the 'too fat for a breech' and 'one c-section means always a c-section'. Without her encouragement I wouldn't have had the guts to stand up to the midwives and doctors as much as I have so far, and she also told me to demand a 30 week scan and to avoid induction as that can increase the chance of a scar rupture.  Unfortunately, I couldn't afford a private midwife and as that pregnancy ended in a late miscarriage, I lost contact with the midwife who I'd spoken to over the phone.

My GP said after 2 C-sections I have a high risk of dying during labour.  [Kmom note: This is totally bogus and not supported by the research at all.]

Aside from worrying about the labour going wrong, I have to admit this is a nice pregnancy---no rushing around for weekly antenatal appointments, no fortnightly blood tests to seen if my organs are failing, no monthly scans and far fewer lectures from 'professionals'!

I just wish people realised that just because I got this big my brain hasn't shrunk. I'm not stupid and I do have feelings.  If belittling me or telling me obvious things like 'you need to lose weight' seriously helped the situation, I'd have been a size 0 years ago!  I know I'm fat, I do have mirrors in my house and have to walk past shop windows during my week!

I have my scan for abnormal placenta (placenta previa and placenta [accreta], I believe) in 6 weeks, and then that's me back on my own until I give birth. We planned this pregnancy and it didn't seem so scary then, but now I have re-occuring nightmares.

Kmom's Follow-up Note: I was able to put this mother in touch with a couple of Independent Midwives in Britain so at least she has some better emotional support and a chance at other care.  Thank you to those who have helped me find other resources for this mother.

As for British policy, I'm sure the attitude varies from consultant to consultant, but I'm hearing more and more stories of egregious size bias in the UK system.  If you are a British woman of size and encounter this kind of treatment, I would remind you of the option of Independent Midwives.  Yes, you'd have to pay out of pocket, but that's better than being subjected to crappy treatment and the risks of a cesarean you don't really need.  And besides, many independent midwives will work with you to find a way to afford their care. 

The same is true in the USA and Canada.  Don't forget the choice of birth center or homebirth midwives.  Yes, there are people who truly cannot afford that and have fewer choices, but too many people write it off as something they cannot possibly afford when there often ARE ways to make it work. Most midwives will find a way to help you afford it via sliding scale fees, payment plans, bartering, etc., and some insurances that say they "do not" cover homebirth actually do (mine did).  Explore the possibilities thoroughly before you decide .

If at all possible, don't let cost keep you from having real childbirth choices and truly supportive care.  It's priceless. 

Tuesday, November 9, 2010

Breastfeeding Lowers the Risk for Diabetes And Other Maternal Disease Later In Life

There's an interesting new study out on breastfeeding and later diabetes in the mother. 
It found that breastfeeding for at least one month lowered the mother's risk for developing diabetes later in life, even after controlling for many confounding factors such as physical activity status, BMI, etc. 

Interestingly, women who had given birth but not breastfed for at least a month were at greater risk for diabetes later on than women who had never given birth at all.  That was a surprising finding.

According to a discussion of the study at the Breastfeeding Medicine blog:
The study included 2,233 women between the ages of 40 and 78 who were members of a large integrated health care delivery organization in California. Strikingly, one of every four mothers who had never breastfed had developed type 2 diabetes.

Mothers who had not breastfed were almost twice as likely to develop diabetes as women who had breastfed or women who had never given birth. These long-term differences were notable even after considering age, race, physical activity and other factors which affect risk of diabetes such as alcohol and tobacco use...
In other words, breastfeeding is part of the way mothers’ bodies recover from pregnancy. When this process is interupted, and an infant is fed something other than...mother’s milk, a mother’s body suffers.
The authors did control for BMI and physical activity in the analysis, among other things. According to the study's abstract:
Multivariable logistic regression was used to control for age, parity, race, education, hysterectomy, physical activity, tobacco and alcohol use, family history of diabetes, and body mass index while examining the impact of duration, exclusivity, and consistency of lactation on risk of having developed type 2 diabetes.
A couple of limitations of the study are its fairly small size --- 2233 women total, only 1828 of whom were mothers --- and its low threshold for length of breastfeeding (greater than or equal to 1 month of breastfeeding). 

That means the study had only 1024 women who breastfed 1 month or longer, and while that's nothing to sneeze at, you really need a bigger data set, looking at a longer duration of breastfeeding, to prove population-wide effects most clearly. 

Sadly, only 56% of the women in the study had breastfed their children for more than one month, another limitation of the study.  This very low rate almost certainly reflects the age of the women in the study (40-78) and the active discouragement of breastfeeding many of the older women encountered.

Still, the study reports a striking finding and yet another reason to pursue breastfeeding. 

It also points out what a disservice doctors did to women years ago when they actively discouraged breastfeeding, and the dangers of sweeping health policies that interfere with the way our bodies were designed to undergo pregnancy, birth, and postpartum.

Previous research on Breastfeeding and Later Diabetes

Some previous research has also tied length of breastfeeding to a lower risk for later diabetes in mothers. 

A Chinese study (Villegas 2008) found that breastfeeding modestly lowered the risk for later diabetes in women followed for just under 5 years.  They reported:
Women who had breastfed their children tended to have a lower risk of diabetes mellitus than those who had never breastfed [relative risk (RR)=0.88; 95% CI, 0.76-1.02; p=0.08]. Increasing duration of breast-feeding was associated with a reduced risk of type 2 diabetes mellitus. The fully adjusted RRs for lifetime breast-feeding duration were 1.00, 0.88, 0.89, 0.88, 0.75 and 0.68 (p trend=0.01) for 0, 0 to 0.99, 0.99 to 1.99, 1.99 to 2.99, 2.99 to 3.99, and greater than or = 4 years.
One of the largest studies on breastfeeding and maternal diabetes was published in The Journal of the American Medical Assocation (Steube 2005).  It used large datasets from the Nurses Health Study (121,700 women from 11 states) and the Nurses II Health Study (116,671 women from 14 states) to study the effect of lifetime duration of breastfeeding on later risk for diabetes. They found:
Among parous women, increasing duration of lactation was associated with a reduced risk of type 2 diabetes. For each additional year of lactation, women with a birth in the prior 15 years had a decrease in the risk of diabetes of 15% (95% confidence interval, 1%-27%) among NHS participants and of 14% (95% confidence interval, 7%-21%) among NHS II participants, controlling for current body mass index and other relevant risk factors for type 2 diabetes...
Longer duration of breastfeeding was associated with reduced incidence of type 2 diabetes in 2 large US cohorts of women. Lactation may reduce risk of type 2 diabetes in young and middle-aged women by improving glucose homeostasis.
So there's a study with a very large dataset that found that breastfeeding -- the longer the better -- lowered the risk of mothers developing type 2 diabetes later on.

Keep in mind that this study also reflected our society's tendency towards short breastfeeding periods.  They traced a woman's lifetime exposure to lactation (how long she breastfed all her children cumulatively), and their highest category was "greater than 23 months." 

Greater than 23 months over your lifetime?  Heck, I breastfed every single one of my kids at least that much each time, so how does that affect my risk for type 2 diabetes?  My total lifetime exposure to lactation is right around 10 years.  Does each additional cumulative year above 23 months help lower my risk that much more?  The Chinese study cited above seems to suggest so, but its maximum lifetime exposure category was greater than or equal to 4 years.

I would love to seen the JAMA researchers collect information about a far greater lenth of total lactation in U.S. women than 23 months, but the fact is that our long-term breastfeeding rates in this country are so poor that they probably would  have had trouble finding enough women to make such a sub-analysis statistically meaningful. How sad is that?

The study did have a small subanalysis on how lactation affected risk for diabetes in women with significant risk factors, like women with high BMIs, women who had gestational diabetes during pregnancy, etc. They found:
In the NHS II cohort, higher BMI at age 18 years was associated with shorter duration of breastfeeding, and in both cohorts, duration of lactation was inversely associated with family history of diabetes. Gestational diabetes was not associated with duration of lactation. Nevertheless, adjustment for family history and BMI at age 18 years did not substantially diminish the inverse association between lactation and risk of type 2 diabetes, suggesting that the association we observed was not an artifact of pregravid or pregnancy obesity and its associated insulin resistance. However, stratification by history of gestational diabetes revealed that in this high-risk group of women, lactation did not affect risk of subsequent type 2 diabetes.
While it was encouraging that the protective effect of breastfeeding was present for women of size too, it was certainly discouraging that the protective effect did not seem present in women with gestational diabetes.  However, a recent smaller tudy (Gunderson 2010) found a lower rate of metabolic syndrome in women with GD who breastfed longer, so further study seems to be indicated.

Regardless, breastfeeding is always worthwhile because of the tremendous immunological benefits and superior nutrition that breastmilk provides to the baby.  Furthermore, there is research that suggests that breastfeeding is protective against the baby developing diabetes later in life.  For example, Pettitt 1997 found that breastfed infants of Pima Indians (a group at very high risk of diabetes) had less than half the risk for diabetes later in life compared to those who had been bottlefed:
The odds ratio for NIDDM in exclusively breastfed people, compared with those exclusively bottlefed, was 0.41 (95% CI 0.18-0.93) adjusted for age, sex, birthdate, parental diabetes, and birthweight.
One important question is how long the maternal benefits of breastfeeding last. The JAMA study did find that as time went on, the protective effects of breastfeeding against maternal diabetes began to fade. They noted:
In these analyses of 2 large prospective cohorts, we found that duration of lactation was inversely associated with risk of type 2 diabetes in young and middle-aged women, independent of other diabetes risk factors, including body mass index, diet, exercise, and smoking status. This association appeared to wane with time since last birth.
Perhaps long-term breastfeeding has more of a delaying effect than a prevention effect on diabetes, especially in women with very strong risk factors for the disease. 

Another interesting finding was that the longer the period of exclusive breastfeeding, the greater the effect against diabetes.  As the authors noted in their discussion:
Our data on exclusive breastfeeding and duration stratified by parity suggest that the length and intensity of breastfeeding with each pregnancy affect the association with diabetes risk. We found that each year of exclusive breastfeeding was associated with a greater risk reduction than total breastfeeding. This may reflect the greater metabolic burden imposed by exclusive breastfeeding.
We also found that longer durations of breastfeeding per pregnancy were associated with a greater benefit, with 1 year’s lactation for 1 child resulting in a 44% reduction in age-adjusted risk, compared with 1 year’s lactation between 2 children resulting in a 24% reduction in risk.
It appears from our analysis of primiparous women that the beneficial association begins to accrue after 6 months of lactation. These data suggest that sustained lactation-associated metabolic changes have more profound effects on diabetes risk.
This was an encouraging study because it shows in yet another way just how important breastfeeding is --- not just for the baby, but also for the mother. 

However, on a personal note, despite research showing that long-term breastfeeding decreases the risk for type 2 diabetes, I still think there's a very strong possibility that I will get it at some point, despite my 10 years of breastfeeding exposure.  PCOS reflects an underlying metabolic abnormality that no one knows how to "fix" at this point, and breastfeeding's improvements in insulin sensitivity and glucose tolerance probably only end up delaying the progression of that metabolic abnormality, not fixing it permanently.

Still, the less time you have diabetes, the less cumulative damage there is from it to your body, so even a delaying effect could have considerable impact on your long-term health.  I hold that thought close. And of course I do what I can to lower my risk in other ways.

What About Other Maternal Diseases?

Findings from other studies show that longer breastfeeding duration is not only protective against diabetes, but also against hypertension, high cholesterol, and heart disease.  In Schwarz 2009, for example, data from the large Women's Health Initiative study found that longer breastfeeding was associated with lower risk factors and less cardiovascular disease:
Dose-response relationships were seen; in fully adjusted models, women who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension (odds ratio [OR] 0.88, P less than .001), diabetes (OR 0.80, P less than .001), hyperlipidemia (OR 0.81, P less than .001), or cardiovascular disease (OR 0.91, P=.008) than women who never breast-fed, but they were not less likely to be obese. In models adjusted for all above variables and BMI, similar relationships were seen...
Over an average of 7.9 years of postmenopausal participation in the Women's Health Initiative, women with a single live birth who breast-fed for 7-12 months were significantly less likely to develop cardiovascular disease (hazard ratio 0.72, 95% confidence interval 0.53-0.97) than women who never breast-fed...
Among postmenopausal women, increased duration of lactation was associated with a lower prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease.
These findings were echoed in another large study (Steube 2009) that found that women who had a lifetime breastfeeding exposure of at least 2 years had lower risk for heart attacks/cardiovascular disease than parous women who had never breastfed. 
Compared with parous women who had never breastfed, women who had breastfed for a lifetime total of 2 years or longer had 37% lower risk of coronary heart disease (95% confidence interval, 23-49%; P for trend less than .001), adjusting for age, parity, and stillbirth history. With additional adjustment for early-adult adiposity, parental history, and lifestyle factors, women who had breastfed for a lifetime total of 2 years or longer had a 23% lower risk of coronary heart disease (95% confidence interval, 6-38%; P for trend = .02) than women who had never breastfed.
These findings mean that there's a lot of potential room for prevention (or or at least delaying) of diabetes, heart attacks, and other health issues, just by promoting higher rates of breastfeeding....and in particular, promoting breastfeeding for longer durations.

Thursday, November 4, 2010

Drowning in Fat Pregnant Women?

'Not waving but drowning': a study of the experiences and concerns of midwives and other health professionals caring for obese childbearing women. Schmied VA, Duff M, Dahlen HG, Mills AE, Kolt GS.  Midwifery. 2010 Apr 6.

School of Nursing and Midwifery, College of Health and Science, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC, NSW 1797, Australia.


OBJECTIVE: to explore the experiences and concerns of health professionals who care for childbearing women who are obese.

BACKGROUND: obesity is increasing nationally and internationally and has been described as an epidemic. A number of studies have highlighted the risks associated with obesity during childbirth, yet few studies have investigated the experiences and concerns of midwives and other health professionals in providing care to these women.

DESIGN: a descriptive qualitative study using focus groups and face-to-face interviews to collect data. Interviews were audio recorded and transcribed verbatim. Data were analysed using thematic analysis.

SETTING: three maternity units in New South Wales, Australia.

PARTICIPANTS: participants included 34 midwives and three other health professionals.

FINDINGS: three major themes emerged from the data analysis: 'a creeping normality', 'feeling in the dark' and 'the runaway train'. The findings highlight a number of tensions or contradictions experienced by health professionals when caring for childbearing women who are obese.

These include, on the one hand, an increasing acceptance of obesity ('a creeping normality'), and on the other, the continuing stigma associated with obesity; the challenges of how to communicate effectively with pregnant women about their weight and the lack of resources, equipment and facilities ('feeling in the dark') to adequately care for obese childbearing women. Participants expressed concerns about how quickly the obesity epidemic appears to have impacted on maternity services ('the runaway train') and how services to meet the needs of these women are limited or generally not available.

CONCLUSION AND IMPLICATIONS FOR PRACTICE: it was clear in this study that participants felt that they were 'not waving but drowning'. There was concern over the fact that the issue of obesity had moved faster than the health response to it. There were also concerns about how to communicate with obese women without altering the relationship. Continuity of care, training and skills development for health professionals, and expansion of limited services and facilities for these women are urgently needed.

PMID: 20381222

*Comments?  Reactions?  Suggestions?