Thursday, December 29, 2011

Fourth Annual Turkey Awards: Leaps of Logic, the Dead Baby Card, and Scorched Earth Tactics

Well, it's that time of year again...time for my Fourth Annual Turkey Awards.

The Turkey Awards are my opportunity to highlight a biased or ignorant remark or media coverage of "obesity and pregnancy," a particularly insensitive treatment by a care provider towards a woman of size, or a trend in the care of women of size that is troubling and frustrating.

As always, I have plenty of candidates to choose from.  The hard part is limiting myself to just one.

Here's this year's nominee, another gem from My OB Said What.  I picked this one because it fails on several different levels:
“I am sure you have gestational diabetes because you are overweight, you need to be on Glucophage. If you are not comfortable taking that medication you will end up with a stillborn.”   – OB to mother, as found here
Sigh. This doctor may have meant well, but his statement has several things that demonstrate some of the troubling trends and perceptions around obesity and pregnancy, including:
  • Jumping To Conclusions About Risks
  • Scorched-Earth Tactics To Deal With Inflated Perception of Risk
  • Pulling the Dead Baby Card To Ensure Compliance with Intervention.
Jumping To Conclusions About Risk

Okay, let's start with the obvious ─ the exaggeration of risk around obesity and pregnancy. We've discussed this before, but it always bears repeating because it's such a common issue.

The problem with the coverage of risk around obesity and pregnancy is that providers often start doing "mental inflation" of the actual numerical risk, and then they start making unfounded leaps of logic from there.

A statement with some truth to it, such as "Obese women are at increased risk for gestational diabetes," gets hyped in the press and in the research until it becomes transformed in some caregivers' minds into "Most obese women get gestational diabetes."  Then it's just a short jump to "Nearly all obese women get gestational diabetes" to "This obese woman no doubt ALREADY HAS gestational diabetes right now."

But the fact of the matter is that while the risk for gestational diabetes is definitely increased in women of size, most women of size still don't get GD.  You can cherrypick whatever study you want, but no study shows a 100% GD rate in obese women, even the most obese women.

Many studies show around a 15% risk for GD in "morbidly obese" women.  This is definitely higher than the 2-4% range found in a "normal BMI" population, but hardly universal.  What most providers fail to do is the opposite math.....that is, if 15% of morbidly obese women get GD, then that means that 85% do NOT.

Yes, that's right.....the majority of even very fat women will not get GD.

Are fat women at increased risk for getting GD?  Yes, absolutely.  Do all of them get it?  No, not even remotely close.  In fact, most do not get it.

And remember, just because a particular group is at increased risk for a complication does not mean that everyone in that group will get that complication, nor does it mean that you can predict the outcome for any individual within that group.

Of course, you can make a case for this being a rogue doctor, jumping to conclusions. Hopefully, most providers who care for women of size understand that GD is by no means a foregone conclusion in this group.  But I'm hearing stories like these more and more often.

There are a lot of care providers out there who have a distorted sense of risk around obese women and GD, from the ones who force their obese clients to undergo really frequent GD testing to those that push weight loss during pregnancy as a way to avoid GD (despite evidence that weight loss in pregnancy is risky).

So this comment is a candidate for this year's Turkey Award because of this individual doctor's mental inflation of risk ─ turning a mere potential of risk into an inevitable outcome in his mind.

But this comment also gets nominated because it's not just about this doctor's individual bias; it demonstrates an overall troubling trend of a distorted sense of risk about pregnancy in women of size.

Scorched Earth Tactics for Inflated Perception of Risk

Another issue I see in the comment is the kind of Scorched Earth, over-the-top tactics that some providers take in order to try to reduce the risks associated with obesity and pregnancy.  There is little research on these tactics, mind, but because care providers have such an exaggerated sense of risk around obese pregnancies, they feel justified in taking the Napalm Option...just in case.

For example, in the past, some care providers have advocated extremely restrictive diets for obese women in pregnancy.  Obese pregnant women have been put on 1200 calorie or even 1000 calorie diets during pregnancy, or told to drink Slim-Fast in order to limit their weight gain. Some are told that they have to lose weight during pregnancy....10, 20, even 50 pounds, during pregnancy.  It doesn't matter how this is achieved, the main goal is for them to lose weight in pregnancy, even if it sacrifices nutritional adequacy, since many care providers erroneously believe that fat women have extra nutritional stores to draw from instead.

This is the Napalm Option; resorting to extreme measures because you don't know what else to do or you are convinced that the risk is SOO high that only extreme measures will improve outcomes.

A new Scorched-Earth Tactic being considered is a move among some care providers to prophylactically prescribe metformin to all obese women during pregnancy in order to prevent big babies and other complications.

The use of Glucophage (metformin) in pregnancy is already somewhat controversial, even in women with strong indications for it (PCOS, severe insulin resistance, gestational diabetes). Its use prophylactically in all obese women, even those without other risk factors, should be even more controversial...yet many care providers are not questioning it at all.

Metformin is probably relatively safe during pregnancy for those with strong indications for it but some docs are very conservative about its use because the trials on it so far are small and some have found an increase in pre-eclampsia in women on metformin (while others have not). More data is needed.

Therefore, many docs err on the side of taking women off metformin during pregnancy, but there are a number of practices where the protocol is to continue metformin (with informed consent) because it lowers the risk for GD and possibly miscarriage and big babies as well.

I'm not opposed to the use of metformin in pregnancy in those for whom it is indicated and in those who have been given full informed consent.  They get to evaluate the research and decide for themselves whether they think it's a worthwhile intervention. However, I think across-the-board use of metformin on all obese women is highly questionable.

One early trial of metformin in pregnancy found an increase in both pre-eclampsia and stillbirth in the metformin group, so caution is clearly indicated.  [However, it has to be noted that there are two major confounding factors here. The women on metformin were mostly type 2 diabetics with pre-existing diabetes and poorer control; they also put these same women on 1200 calories a day, which might also be a factor.] Later trials have found no increase in stillbirth with metformin.

Another study of metformin vs. insulin for treatment of GD found a slightly higher rate of spontaneous-labor prematurity in the metformin group, although the confidence intervals were wide and crossed 1.0, so the trend could be attributable simply to chance.

Bottom line, we need more long-term data from larger groups on the safety of metformin during pregnancy in women with PCOS or GD, as well as the benefits and risks of metformin used in a wider population of women. Right now, the best data shows it lowers the risk for GD and miscarriage in women with PCOS, and probably does not increase the risk for birth defects. Other results vary from study to study. It’s probably a reasonably safe med for women with PCOS or GD, but we need more data to be sure.

Despite this, there is a trend to put ALL women of size on metformin prophylactically (there is a trial of this in the UK right now) and THAT I have problems with. It’s one thing to put a woman with severe PCOS or GD on this med, it’s entirely another to put all healthy high-BMI woman with no known glucose issues on it prophylactically. Ugh.

So this comment gets an individual nod for the Turkey Award because not only does the doctor assume the woman is automatically going to get gestational diabetes, he also wants to put her on metformin prophylactically, just on the basis of her being "overweight" (without proof of GD).

But it also gets a Disturbing Trend nod because it represents a new willingness among some care providers to prescribe extreme measures ─ like prescribing weight loss during pregnancy or putting all fat women on metformin ─ because of their inflated sense of risk around pregnancy in women of size.

Remember, the Napalm Option often harms more than it helps.  We must be cautious about being overly-interventive without proof that such interventions actually improve outcomes.

Pulling the Dead Baby Card to Ensure Compliance

Yet another problem highlighted by this quote is the issue of what we cynical activists call "The Dead Baby Card."

The Dead Baby Card is telling women in an emotionally manipulative way, your baby will die if you don't do exactly what I tell you.

(Its corollary is, And If You Question Me, You're A Bad Mother and Must Not Love Your Child.)

It's not merely informing a woman of the possibility of a poor outcome, it's medical bullying trying to force a woman (via scaring or shame or guilt etc.) to go along with a particular kind of highly interventive care the physician wants.

It's not a reasonable or sensible precaution in the face of an extremely high-risk situation, it's using the mother's fears to manipulate her into some dubious intervention the doctor wants, usually for his own convenience or fear of litigation.  And it's implying that the woman is a Bad Mother if she even thinks about questioning these interventions.

It's statements like, "We think your baby is going to be 9 lbs., so you have to have a planned cesarean or your baby will get stuck and die," even though research shows that elective cesareans for macrosomia do not improve outcome and may actually worsen it.

Or telling a woman that if she chooses Vaginal Birth After Cesarean, her baby will almost certainly die. And if the woman dares to question the provider, it's using scare tactics or implying that she's selfish to even consider such another choice. It's using emotionally manipulative language to bully a mother into following a questionable course of treatment the doctor wants.

In the Metformin example above, telling the mother that if she does not go along with the doctor's preferred treatment plan (i.e. use of metformin), her baby will probably die is medical bullying, a.k.a. Pulling The Dead Baby Card.  The doctor is trying to scare her into complying with his questionable intervention by using the biggest scare tactic he knows.

Instead, the mother should be counseled about the possibility of gestational diabetes, the pros and cons of GD testing, the small but real possibility for stillbirth if there was uncontrolled pre-existing diabetes, and offered GD testing.  She should be informed that some care providers are using Glucophage to prevent/treat GD, she should be informed of the pros and cons of metformin, and offered the choice to consider it.

She should not be ordered to take metformin, or told that if she doesn't take it her baby will undoubtedly die.  That's classic Dead Baby Card territory, and that's unethical and unconscionable medical bullying.

So this comment is a "winner" a third time because of this doctor trying to scare this mother into an extreme intervention by using emotional manipulation, and because it sadly represents a tactic that's being used against women of size far too often these days.

Medical bullying is being used far too often these days, and particularly against women of size.  This kind of over-the-top manipulation has to stop.

Final Thoughts

This comment is nominated for my Fourth Annual Turkey Award because it demonstrates an Epic Fail on several different levels.

It presumes an "overweight" woman will automatically get gestational diabetes (when most will not), it orders her to take metformin prophylactically just on the basis of her weight alone (without proof of GD), and tries to scare her into compliance by suggesting that her baby will die if she doesn't agree to this intervention.  It's a classic case of medical bullying.

Of course, we need to make it clear that most providers don't treat women of size like this.  And hopefully most would never result to medical bullying like this.

But this comment does represent several troubling trends in the care of women of size, including the tendency to Jump to Conclusions about Risks, the increasing use of Scorched-Earth Tactics, and the use of the Dead Baby Card to scare women of size into whatever extremist intervention the doctor wants to use on them.

And that's why this little comment gets this year's nomination for a Turkey of the Year Award.

*By the way, My OB Said What is looking for submissions on the idiotic things caregivers sometimes say to women.  If you have more doozies on things they say to fat pregnant women, I hope you will submit them so we can document this kind of treatment.

Do note, they also accept submissions for positive, helpful things caregivers say to women─it doesn't always have to be bad. If you have had a really supportive caregiver as a woman of size, be sure to nominate those stories too.  It's so important to highlight the positive stuff too!

Either way, email your story to


dee.calarco said...

Thanks so much for keeping track of these issues, posting regularly, and being such a voice of sanity. Happy New Year!

Rachel said...

You know what? I am fat and had GD during my last pregnancy. I worked with my doctor, and a dietician and took my insulin properly and got my numbers so within range that my A1C both times I had it done while pregnant was a 5.2. You know what? I still had a dead baby. Cord accident. Nothing I could have done. Could have happened to anyone- but for 10 months now I have spent the time going over and over, if I had been thinner would I have known something was wrong. Stupid sure, but one off hand comment by an idiot OB I saw early can make you crazy for a lifetime.

Well-Rounded Mama said...

Rachel, I'm so sorry that your baby died. Sometimes there really isn't anything you can do to prevent it, but self-blame is so common in these scenarios.

If you work in birth circles long enough, sooner or later you know someone who lost a baby to a cord accident. Statistically it's rare, but it's SO incredibly hard when it does happen.

Most of the ones I have known who have lost a baby this way were average-sized. And every single one of them has found something to agonize over, a what-if that haunted them.

When something bad happens to women of size, though, it's nearly always their fatness they focus on. It's our go-to blame card, and it's made worse when it's a care provider's go-to blame card too, or when people make careless or insensitive remarks along the way.

You worked really hard at self-care and something still happened. It's a hard lesson that sometimes things just happen. Then we look around for something to blame, and our cultural training is to go first to our weight. It's a hard pattern to get out of.

I'm so sorry for your loss. I hope you have connected with the many online resources available to women whose babies have died.
Ended Beginnings by Panuthos and Romeo

Rachel said...

Oh, I also HIGHLY recommend the book Tear Soup for people dealing with grief. You might want to add it to your list of resources. A friend who had gone through an early miscarriage sent it to us with a not about she knew it was not the same, but she had gotten a copy of this book and thought it might be of help to us. We now order and send it to people dealing with any sort of trauma or grief on an (unfortunatly) regular basis. It is not about dealing with child-loss or pregnancy loss in particular. It takes the form of a children's book but is excellently set out.

Thank you for your kind words.

Unknown said...

I was pregnant back in 88. I did NOT have GD. I had one doctor tell me my baby was going to be huge, and I'd better hope I went into labor 2 weeks early or else I'd end up with a Cesarean, which was bound to get infected due to my size. In fact I went 10 days past my due date and she was a perfectly average 7.5 lbs, delivered naturally with a midwife who was great.