Monday, February 28, 2011

Further Belly Thoughts

About a month ago, I published a post called Belly Thoughts that was quite controversial to some people. 

I've been writing a follow-up for a while, but I've been working on a big project at work and have had sick/injured kids, so I have had a hard time finishing it. I have also been struggling to clarify my dismay and surprise over people's response to that post. Honestly, the response upset me and I thought it best to wait a bit before replying so I could make a more measured response.

But I think it's time now to continue the discussion.  Forgive me if it's a bit rambly.  It's just time to get it out there, imperfect as it is, so we can discuss it and then move on.

Trigger Warning: Frank discussion of body image issues and body ambivalence will follow.

First, thank you to those who commented, even if I didn't agree with you or like what you said.  Dialogue is important and it's not always a bad thing to hear dissenting voices.  It generates discussion and can clarify issues or further the conversation. Obviously, this topic provokes some strong feelings, and I think that's an important point to explore. 

One complaint that was made was that the post needed a Trigger Warning.  With some reflection, I can see that point. I thought about putting one in the original post, but I thought it was not needed because I felt I was pretty clear in the intro paragraphs what was going to be in the post.  However, I can appreciate that some people in their journey need a really clear and obvious warning about these things. So that point is noted and I have already gone back and added a trigger warning to the original post and to this one as well.  My apologies to anyone who I inadvertently triggered.

Some folks objected to the Shamu word. That may have been a bad choice, but I was actually being ironic, and I think folks missed that. I see people on the feed mockingly use words commonly used to deride us (like "deathfat" etc.), so that's where I was going with Shamu, but the ironic intent may not have been clear enough. I was trying to point out the tremendous irony of worrying about what I'd look like at 9 months pregnant and then not looking pregnant at all. By using the term Shamu, I thought it made for a better, more pointed bit of irony. But alas, I think the term is so emotionally loaded for some that they didn't see an ironic use of it. I'm sorry it caused bad feelings for some.

One thing I think it's important to clarify is that what I was talking about was body ambivalence, not body loathing.  No, I don't always have perfectly happy loving feelings towards every part of my body 24/7 (who does?), but sharing that does not mean that I hate my body or am engaged in fat-based self-loathing. It only means that I have mixed feelings towards parts of my body sometimes.  It doesn't mean that I don't have good feelings towards my fat body at times, or that I've been hiding secret loathing behind a facade of fat acceptance.  It's just body ambivalence, not body hatred.

Perhaps I wasn't clear enough in the post that most of the time, I'm pretty at peace with my body ─ a lot more than a lot of the thinner women I see around me, in fact.  But not 24/7/365, and some parts are more challenging to love than others, you know?  I was just trying to be up front about that, because I think we NEED more of this kind of honesty, especially among mothers, and especially among mothers of size.  But it wasn't about hating myself, just my struggle to love the changes that pregnancy has wrought.

Before pregnancy, my most difficult part to love was my chest, because I'm very well-endowed and that has all kinds of physical and emotional burdens attached.  After pregnancy, once breastfeeding worked out, that actually was the part that experienced the most positive self-image improvement.  The part of me that had previously only been a burden before suddenly was responsible for nourishing and protecting my babies for  months ─ years ─ on end, and my babies certainly loved that part of me, so why couldn't I?  I just had a totally different take on my breasts after that, even as I still sometimes struggle with loving them fully.

My belly was a different matter, much to my surprise.  Before pregnancy, I was pretty much fine with my belly.  But I was really surprised how much challenge I had with it during and after my pregnancies ─ especially after multiple pregnancies.  It does take a toll on your body shape and your body image, and I was just trying to articulate how that challenged me in my fat-acceptance and body-acceptance process.

So folks, if you were worried about me loathing my body or that I was suddenly revealing secret reservoirs of self-hate, please be reassured that most of the time, I'm pretty self-accepting.  But I don't think it's a problem to share that I'm not always that way, or that certain things really challenge my body image more than others.  I think a combination of pregnancy and recent aging-related changes of perimenopause gave rise to more reflection than usual on that, that's all. 

One thing I was very much troubled by was the fact that some folks questioned whether my posts belonged on the Fatosphere.  That in particular really shocked me, considering all the work I've done in Fat-Acceptance over the years.  Heck, I've been in the Fat-Acceptance movement for longer than some of my readers have been alive.  I'm not just talking the talk, but have been actually walking the walk for many years, and have been writing, researching, publishing, and presenting at conferences on the topic of fatness and pregnancy for more than a decade.  I've been a quite vocal and active FA-advocate, and have been a member of NAAFA for years.  To be questioned in my own backyard about my "FA-ness" was quite distressing.

Let me be clear.  I don't see my post as contrary to the purpose of the feed at all, or to Fat Acceptance in general. The Fatosphere is SUPPOSED to be a place where we can work through a lot of our feelings, good and bad, about our bodies. In my view, it's not a "you can only express positive things about your body no matter what" place.

Certainly, I surely see a lot of body ambivalence on other blogs. Why would my blog be exempt from being able to talk about that? The fatosphere is supposed to be the one place where we CAN talk about these things without being judged. And yet, there I was, being judged for some pretty normal feelings, ones extremely common to mothers after pregnancy, and I wanted to talk about how that interacted with my self-acceptance beliefs. I see that as very much in concordance with what the Fatosphere is supposed to be about.

I'm also very frustrated with the idea that I can't express ambivalence about the droopy baby belly, the "flap" if you will. Nearly all mothers have some ambivalence about this ─ it's very normal in women of all sizes, and I think it's intensified for many women of size. Why is this okay for women of average size to talk about ─ but not for us as women of size?  We all have to process it; it's a very normal feeling.  Some people experience the belly flap more than others, but we all have to process body changes to some degree.

It's not like because we are fat-accepting, we have a magic shield against negative feelings from body changes.  We have these issues too, and it may be intensified in those with previous body image issues.  Even those of us who are pretty far along on the fat-acceptance spectrum can still feel challenged by these things ─ and that's okay. And it doesn't mean that we are now body-haters and full of self-loathing and about to sign up for surgery.  It means we're processing normal feelings.

My whole point is that the changes in my body (and specifically my belly) resulting from several pregnancies, lipedema, and age are challenging my fat- and self-acceptance in a way it's not been challenged in a long time, and I continue to struggle with that. I think being honest about these kinds of struggles is absolutely VITAL to the fat-acceptance discussion. What are we here for if we can't discuss that kind of thing?

I'm not telling others how THEY should feel about their bellies. If you came through pregnancy perfectly positive about your belly, more power to you. I'm simply trying to express that even in me, a VERY self-accepting and fat-accepting person, dealing with this pregnancy after-effect has been quite challenging, even years after my last pregnancy, and how surprising this has been to me as an activist.

I certainly think that postpartum feelings about your body (and the unique challenges that might bring to fat women) is an appropriate topic for my blog, don't you? I KNOW a lot of other women of size have struggled with the same feelings because they've written me about it. I was articulating my own struggles as a way to not only help me with my own ambivalence, but to help others explore their own.

It was such a shock to me, how pregnancy challenged my fat-acceptance in so many ways. For example, as I've written about before, I went from a take-no-guff-from-doctors FA person to a meek little sheeple who got railroaded and frightened into a whole bunch of unneeded and fat-phobic interventions in my first pregnancy. It took me quite a while to get past that, but working through that and empowering myself enough to question the doctors led me to create my website and my blog. The journey was worth it ─ but it didn't happen overnight, and it took a lot of emotional processing to get there.  Sharing that is helpful to other fat women struggling to figure out what interventions are needed in their pregnancies and which ones are questionable,  what choices they really have in birth, and cutting through the anti-fat rhetoric that surrounds so much of the information out there on pregnancy and fatness.

I think a similar journey is worth it on the whole belly ambivalence question too. Pregnancy (and especially post-partum) totally challenged my FA-ness, and I still work through it. I don't think talking about that is in opposition to the fatosphere at all. I think it will help other women on their journey, which is why I talked about it in the first place. People are at all different points on their journey to fat acceptance, and I think it's extremely helpful to see someone else struggle with that journey too. To have my FA credentials questioned because of that is extremely frustrating to me.

Another thing that frustrated me was that while I discussed my belly ambivalence very frankly, I also made a real point of bringing the question back to positiveness at the end of my post. I made a point of honoring our bellies anyhow, even in the face of ambivalence, and acknowledging the incredible work they did. I thought I made that point pretty strongly, using my words and my belly-painting pictures, because it's very much how I feel. So it's upsetting to me to have that conclusion ignored or negated. Yes, I talked frankly about belly ambivalence and the challenges I've experienced, but then I brought the discussion back to a positive conclusion. That's an important point that got ignored by some.

Furthermore, it makes me frustrated to feel censored in what I'm "allowed" to talk about as a "good" fattie. Ambivalent feelings are part and parcel of the journey to FA, even for people well along on that journey. Other people can talk about this on the feed (and do), but for some reason it created a lot of reaction when I did it. Perhaps it's harder to hear it in relationship to pregnancy (society really tends to discourage expressing negative or ambivalent feelings about pregnancy).  Or perhaps it's hard to hear someone who doesn't usually express much body-ambivalence actually express some.

But the whole point was that this is a NORMAL and VERY COMMON response to pregnancy and post-partum body image in women of all sizes, and that it's often intensified for women of size and we should be discussing that.

Expressing that doesn't make someone anti-FA. It just acknowledges a common feeling among many women of size, something many of the women in the comments commiserated with, you'll note.

The fall-out from all this is that right now, I don't feel safe choosing topics for the blog, and that alarms me. I was planning a big series addressing the risks of pregnancy in women of size, because the fat-phobic doctors contend that a pollyanna approach ("everything will be fine") to fatness and pregnancy is misleading and intellectually dishonest. Research is clear that there are more risks for certain complications in women of size in pregnancy ─ the problem is that doctors DISTORT that information and use it as a scare tactic or a way to pressure women into questionable interventions. I want my series to look at the research dispassionately, acknowledge what risks there are, make sure people understand these potential risks, discuss how we can be proactive to lessen those risks, and make sure people understand that, though there, these risks are still generally small ─ that most fat women will have healthy babies just fine.

But now I'm questioning whether I should even attempt such a series, whether this will be seen as too negative or not "FA enough" for some. Yet I think not doing that series would be a tremendous disservice to women of size.  The whole purpose of my website and my blog is honest and accurate information, not just rah-rah cheerleading and a polyanna approach.

Women of size NEED intellectually honest discussions about the research, good and bad, along with primers for understanding it and using it to help improve our outcomes and experiences.  We don't need more "everything will be just fine" or "oh my God you're going to die" extremism.  We need a more nuanced approach.

I just am frustrated with the idea that we should only be fat cheerleaders and never be allowed to go beyond that.  Fat Acceptance is a journey, and I think it's important that we be allowed to fully process our feelings, even the ambivalent ones, along the way, without people jumping to conclusions about our FA-ness. 

Okay, so now I've vented a bit and expressed my concerns too.  Feel free to discuss in the comments section.  Just please be respectful and polite, even if you disagree and need to argue a point, okay?  I'm feeling particularly tender and touchy on this subject right now and would appreciate some delicacy, even as I know that dialogue is important.

But I don't think the discussion ends here.  This is of necessity a rather negative post, and I'm okay with that up to a point.  I think the frustrations needed to be aired and perhaps some good will come of the dialogue.

However, I prefer to bring the discussion back to the positive whenever possible.  So I decided to put the negative things in this post and do a whole different post next time that focuses things a little differently, a little more positively without being false, that puts things back on a more constructive footing. 

I'd like to propose a Belly Blog Carnival next time ─ more on that soon!!

Thursday, February 17, 2011

“You Are Short Of Breath Because You Are Overweight”

Another "gem" from My OB Said WHAT?!?"

“You are short of breath because you are overweight.”Doctor to a mother a few days after birth. One week later she was treated for pulmonary embolisms.

This is a particularly frustrating example of weight bias in medicine.  This was a woman who had recently had a cesarean, and had a documented family history of blood clots, and the doctor still dismissed her shortness of breath ─ a classic symptom of a blood clot that has traveled to the lungs (pulmonary embolism) ─ as being due to her weight alone. 

Because, you know, nothing else could possibly be wrong with a fat person except fatness.

So obviously, the main lesson here is that doctors need to stop blaming fatness for everything and be alert to the possibility of other complications when a symptom presents.

But another cautionary side note to this tale is how important it is to lower the cesarean rate in women of size.

One reason that the high cesarean rate in women of size is so dangerous is the risk of blood clots like these.  Blood clots are a rare but extremely serious complication of any kind of surgery; do enough surgery, and the rate of life-threatening blood clots like these will rise significantly. 

Remember, pregnancy increases the risks of blood clots in women of all sizes already, and "obesity" increases your risks for blood clots a bit more on top of that.  Then add into that major surgery ─ and cesarean rates of nearly 50% (or more) in some hospitals for "obese" women ─ and blood clots afterwards will be seen more and more often.

Mind, it's still a fairly rare occurrence, but it can ─ and does ─ kill.  Yet it's one risk doctors can proactively prevent much of the time by making sure that only truly needed cesareans are done in women of size, and when a cesarean is truly indicated, by considering the pros and cons of a blood thinner in that situation.

[Side note: If you are a person of size and have surgery planned, you should discuss the pros and cons of blood thinners with your surgeon ahead of time, especially if you have a clotting disorder or any family history of blood clots, strokes, or heart attacks.  It's not always a clear-cut decision; there are benefits and risks to the use of blood thinners.  However, you might want to discuss ahead of time the pros and cons of them for your particular situation.]

Furthermore, doctors should have a high index of suspicion for possible pulmonary embolism in an "obese" woman who has just had a cesarean, let alone one with a family history of blood clots.
This mother told her doctor about her symptoms a few days after the birth, and despite her recent cesarean, her size, and her family history of blood clots, the doctor dismissed her symptoms and told her the problem was because she was overweight.  She was sent home.

She lived with that blood clot for more than a week and is lucky she didn't die.  She was fortunate that she was seen by 2 visiting nurses postpartum, who recognized a strong possibility of a blood clot to the lungs and sent her to a hospital.   The emergency room took it seriously, did the testing needed to diagnose a pulmonary embolism, and got her to intensive care right away.

From her acccount, things were a bit touch-and-go for a while, but she did survive.  However, she was separated from her newborn baby for two weeks (any mother who has been separated from her newborn for any amount of time knows just how heartbreaking that is!) and had to stop breastfeeding.  This doctor's dismissal of her symptoms cost her a lot, emotionally and physically. 

(Fortunately, she was able to re-establish breastfeeding eventually, but many times breastfeeding doesn't survive a separation like that.)

This is yet another example of the common problem of doctors missing serious health problems in fat people because they are so busy blaming every health complaint on fatness. As if nothing else could ever be wrong!

Tuesday, February 8, 2011

More Proof of Failure to Wait

We've talked before about recent research that indicates that many cesareans are performed for "failure to wait" ─ that is, doctors jump to a cesarean too soon, when waiting a bit longer might well have avoided the cesarean alttogether. 

We know that far too many inductions are happening, and that inductions on a first-time mom or a mom with an unripe cervix raises the risk of cesarean substantially.  Here's yet more proof that, when done, far too many inductions are given up on too soon, and that a tincture of patience can often make a world of difference.

But of course, better yet to avoid inductions entirely that are not truly medically indicated.

Obstet Gynecol. 2011 Feb;117(2, Part 1):267-272. Failed Labor Induction: Toward an Objective Diagnosis.

Rouse DJ, Weiner SJ, Bloom SL, Varner MW, Spong CY, Ramin SM, Caritis SN, Grobman WA, Sorokin Y, Sciscione A, Carpenter MW, Mercer BM, Thorp JM Jr, Malone FD, Harper M, Iams JD, Anderson GD; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU).


OBJECTIVE: To evaluate maternal and perinatal outcomes in women undergoing labor induction with an unfavorable cervix according to duration of oxytocin administration in the latent phase of labor after ruptured membranes.

METHODS: This was a secondary analysis of a randomized multicenter trial in which all cervical examinations from admission were recorded. Inclusion criteria: nulliparas at or beyond 36 weeks of gestation undergoing induction with a cervix of 2 cm or less dilated and less than completely effaced. The latent phase of labor was defined as ending at a cervical dilation of 4 cm and effacement of at least 90%, or at a cervical dilation of 5 cm regardless of effacement.

RESULTS: A total of 1,347 women were analyzed. The overall vaginal delivery rate was 63.2%. Most women had exited the latent phase after 6 hours of oxytocin and membrane rupture (n=939; 69.7%); only 5% remained in the latent phase after 12 hours. The longer the latent phase, the lower the vaginal delivery rate. Even so, 39.4% of the 71 women who remained in the latent phase after 12 hours of oxytocin and membrane rupture were delivered vaginally. Chorioamnionitis, endometritis, or both, and uterine atony were the only maternal adverse outcomes related to latent-phase duration: adjusted odds ratios (95% confidence intervals) of 1.12 (1.07, 1.17) and 1.13 (1.06, 1.19), respectively, for each additional hour. Neonatal outcomes were not related to latent-phase duration.

CONCLUSION: Almost 40% of the women who remained in the latent phase after 12 hours of oxytocin and membrane rupture were delivered vaginally. Therefore, it is reasonable to avoid deeming labor induction a failure in the latent phase until oxytocin has been administered for at least 12 hours after membrane rupture.

PMID: 21252738