Friday, June 3, 2011

Florida OBs Who Won't Take Fat Patients

A number of people have blogged about the recent story of a group of OBs in Florida who won't accept fat women as clients because they are "too high risk" and therefore they are afraid they might get sued more. 

Their cutoff for "too" fat?  200 lbs., a ridiculously low cutoff.  There is no way the risks of complications at that size justify denying these women care across the board, and there is no way that they should be denying care to an entire group of women based on complications some individuals might develop. 

Other people have covered the story just fine so I don't feel the need for extensive comments, but I do like the coverage from The Unnecesarean.  One commenter ("Mel") there, had a good summary:
I think the point of it all, the reason this is such an ugly decision, is that this group of doctors (and many others) have isolated the risks of obesity as THE ONLY risk, right off the bat, that makes people "too risky" to serve. What can account for this?

...These are OBs, who by nature of their training, are best equipped to help people with any remotely moderate to high level of risk, right up to the sorts of very high risks that are better attended to by MFM [maternal fetal medicine] specialists. I don't see them passing on caring for multiple pregnancies, or a woman who will need a 5th c-section for instance.   
Why single out obesity as a risk factor? The only plausible answer, given the scope of their practice, is bias. Prejudice. It's an excuse so they don't have to treat people they don't like and of whom they disapprove.

...I don't buy for a moment that these doctors won't treat overweight patients because it's SO risky! I could understand a person by person decision for women with really high risks that included being very obese. But that's not what they're doing here. 
The Florida doctors use the excuse that it's more difficult to get a good quality image during an ultrasound of an obese woman, and their office machines can't handle that.

The answer to that?  Train your docs and techs in techniques that improve the image for women of size, delay the scan by a few weeks, and if that isn't enough, send the woman to a specialty center with more advanced equipment....for the ULTRASOUND. No need to transfer all of her care to a high-risk maternal fetal medicine specialist just for ultrasounds!

The doctors also complain about their potential for being sued. Now, I generally have great sympathy for doctors who are sued unjustly (as does happen sometimes in obstetrics), and I do think many docs are between a rock and a hard place in terms of malpractice insurance.

But I'm sorry, many doctors face high malpractice rates and don't deny care to fat women. Other docs (and midwives) somehow manage to care for a variety of women, not all of whom are super low-risk.

Categorically denying care to "obese" women, regardless of actual complications, is the result of an inflated perception of risks around this group and sheer outright weight bias.

Another wrinkle to this story is that not only won't they see fat pregnant women, they won't see fat non-pregnant women either now.  That's new...but it's a trend that started with obesity and pregnancy and is now extending to non-pregnant fat folk as well.  So all of you in the fatosphere who read my posts about weight bias from OBs and think it doesn't apply to you because you don't plan to have contraire.  Now it's spread to GYN care.  Apparently pregnancy weight bias is just the canary in the mine, warning of further dangers to come regarding equal access to care for all fat people.

Some in the birth world have commented cynically that the one bright spot in this story is that at least fat women in Florida know the worst fat-bigoted practices up front and will be able to avoid them. Too many doctors smile and nod and pretend to be size-friendly, then turn on the mom at term and tell her she "needs" a cesarean or an induction or whatever because of her size.

So, yeah, I suppose that's the one good side to all this. But I'm sorry, I just can't celebrate that.

This is just a further step along an ominous trend to segregate people of size into the care of ultra-high-risk docs, based on their size alone, regardless of whether or not they actually have poor health or develop complications, and regardless of whether such high-intervention care actually improves outcomes. 

It's another step along the path of denying people of size health care choices and life choices, "for their own good," and I find that extremely ominous.

We've discussed before in "Ghettoizing Fat Women" that there is an increasing trend to shunt all women of size, regardless of actual complications, into specialized "bariatric obstetrics" practices and regional high-risk hospitals, and denying them access to midwives and a low-intervention model of care. Sadly, I only see that practice increasing.  I've heard from women of size who have been denied care from homebirth midwives (despite prior births with them with good outcomes), from birth centers, from regular OBs, and even from some hospitals.....simply because of their size. 

No, these are not "super obese" women; these are often "mid-sized" fat women.  The idea now is that ALL "obese" women, pregnant or not (and regardless of actual health status and health habits), are being considered far too high risk for any care but the most centralized, most interventionist, most high-risk practices and centers─without actually proving that this sort of care improves outcomes.

And it's a very frightening step down the road of taking birth and healthcare choices away from a substantial group of women.  Where is the respect for patient autonomy?  For people having the right to choose the kind of care they prefer?  For people having a say in their own care?  For people being able to say no a style of care they don't want?

Each person needs to have their care individualized, based on their health status, their healthcare preferences, and their needs.  We should not have our healthcare choices taken from us, simply because we are fat.  And this latest story is just another step along the path of denying patient autonomy to people of size.

An ominous canary in the mine indeed.


E said...

It's sad when something can make you feel lucky to live in Alabama (where midwifery and home birth are all but illegal, and midwife attended home birth is illegal). At my first prenatal appointment I weighed 292. I lost down to 282 during the 1st trimester, gained up to a high of 302, and I weighed 299.5 when I checked into the hospital to be induced. If you want proof I was(am) big, I'm E from the belly pic post from a few weeks ago. I've lost about 50 lbs (with no effort other than the dairy/soy/gluten free diet that my daughter requires to keep her reflux in check combined with nursing and having a baby, lol) since my daughter was born 14 weeks ago but, for those of you who can do math, still well over 200 which would have probably sent OBs like these off running. And yet (and these were my OB's words) I had an "almost completely textbook pregnancy" until the very end when I ended up with a c-section because of a posterior asynclitic baby who wouldn't turn 11 days past my guess date. And while these OBs probably wouldn't believe it, the day I was induced I was still driving and walking up and down the stairs to my third floor apartment (and back up them 3 days after a c-section, which while hell just goes to show that the idea that all fat people are incapable of doing anything physical is baloney), and the first pain medication I got at the hospital was in the OR when they did the spinal. There were never any issues with doing an u/s, and the u/s tech was able to pick up my daughter's heartbeat trans-abdominally at 12 weeks though admittedly the picture was crap. The only issue my OB's office had was one nurse finding fetal heart tones during NSTs, and that had more do with positioning (which I think isn't uncommon with posterior babies) since the u/s tech was able to find it no trouble immediately after an u/s, and my ob found it no problem as well. I did have some high blood pressure issues which were managed with medication, but never developed into pre-eclampsia. I had great numbers at the end of my pregnancy to the point that we didn't even discuss induction until after my guess date, and I was able to stop the medication at the hospital with no recurrence. It's completely wrong that OBs like these make me feel lucky that my OB treated me like a pregnant woman instead of like a walking disaster and is supportive of me having a VBAC (even going so far as to give me a copy of the NIH VBAC study to read at my postpartum visit) if DH and I have any more children. The only time we discussed my weight was when we talked about how much weight to gain during pregnancy (10-20 lbs), at weight checks at each visit where the nurse would just tell me how many lbs I'd gained or lost, and (when I brought it up) at my postpartum visit in regards to the efficacy of the mini-pill. The only pro-weight loss comments that were made was at my postpartum visit where the nurse said, "you go girl" at my being about 20ish lbs below my pre-pregnancy weight which I was quick to point out that I hadn't done anything but feed my daughter.

Adirondack Autumn said...

It's a real shame that overweight women get caught in the crossfire of a war on liability. It's an excuse on the OB's part to avoid a percieved risk of lawsuit and the whole thing could be alleviated by tort reform.

Strangely enough tort reform got pushed to the sidelines by so many because it's not a huge driver of health care costs...until you factor in defenceive medicine and people refusing to treat whole groups of people because they happen to weigh more than 200 pounds...

Anonymous said...

As a woman who had 5 healthy pregnancies/easy labors and started a current pregnancy at 218 lbs that is currently just as healthy as the rest (with hardly any weight gain), I fail to understand the logic here. This is fat-phobic discrimination at its worst, and all it does is churn up more slagging of people who are considered beyond the culturally acceptable level of weight. It is an offensive move, and is ultimately a betrayal of women.

Hopefully more women will be encouraged to go to midwives, who are generally more woman-centered and do not have this kind of stupidity problem.

Janeen said...

Midwives aren't always much better. I seem to recall a reader on here who left a link and she happened to have an entire post about weight and all the problems it can cause including not being able to deliver vaginally due to fat tissues in the vaginal area.

I had a midwife I had emailed and told my weight to who told me she would not be willing to take me on because of my weight because working with someone of my weight, she would have a hard time with my girth and being able to determine what position the baby was in in order to be able to do a homebirth. She never even met me. Thing is, both a midwife I did see AND the OB I was seeing was able to tell just by feeling, no ultrasound needed so her excuse was simply that, an excuse.

It's discrimination, no two ways about it and I can't help but wonder if some it goes to not just weight but also is a way to discriminate on other factors too such as gender and race. The fact that this is allowed and is legal tells me that there's a big civil rights issue at hand and something needs to be done.

What amazes me is that this is something that is only getting worse. I don't remember my mother telling me of any issues she had with her provider when she was pregnant with my sister and I and not only was she obese but she was also 34 and 39 for her pregnancies. And I didn't have any issues with my last pregnancy from my provider. But this time, WOW, I simply cannot believe the crap I went through from providers this last pregnancy and all due to my weight and no other reason because I had NO complications with that pregnancy (other than emotional ones) or my first pregnancy.

E said...

That and telling women to just see a midwife isn't much help to women who literally don't have that as an option. My dh is in the military, so there's a good chance we'll be living somewhere else by the time we have another baby, but for my daughter's birth we had to deal with Alabama laws. I live in the state capital and I know of no independent CNM practices, and of one ob/gyn practice that has CNMs on staff. And that practice is a huge practice who probably wouldn't have deemed me low-risk enough to even see the midwives. My only options really (especially since I didn't want a practice with a dozen doctors) was an ob either at a hospital or at home(the latter while legal is unlikely to ever happen in reality), an unassisted homebirth, driving to Florida or Tennessee to give birth, or an illegal midwife attended homebirth. And while there are no legal implications if you have a midwife attended homebirth for the parents, there is for the midwife. If my husband wasn't in the military I might have considered it, but since he is there could be consequences for him at work. What are women supposed to do? Alabama isn't the only place in the US where this is an issue.

Peachy T said...

200lbs? I'm 5'4 and 212lbs and I don't consider myself 'fat'! I HAVE fat, but I'm also very muscular. Kind of built like a football player.

what if someone is 6'4 and 200 lbs? ABSOLUTELY ridiculous. they should be sued for discrimination!