Tuesday, February 14, 2012

"You and the Baby are About 85% Likely To Die on the Table"

The hype around the risks of pregnancy and obesity is so extreme at times that some doctors have developed an exaggerated fear of the possibilities of deadly complications in "morbidly obese" women.

In particular, some have begun to routinely tell very fat women  that they are quite likely to die during pregnancy or birth.  This is their way of bullying them out of further pregnancies or at least scaring them into massive weight loss.

Sigh. Here we go again.  We've seen the Dead Mama Card before.

Some women of size have been told that they are so fat, they'll surely have a heart attack and die during labor, that they or their baby will probably not survive a pregnancy, that choosing to be pregnant while fat is committing suicide by pregnancy, or they have been pointedly asked about their funeral arrangement preferences before surgery.

There was yet another blood pressure-raising example of this from My OB Said What?!? recently, where one OB said to a "morbidly obese" mother:
I can't believe I have been put in this position!  I absolutely resent that I am now responsible for your life and delivering this baby, you have no right thinking you can safely deliver a child when you are so overweight.    
In the comments section on the My OB Said What?!? website, the original poster gave some more details behind the case. The mother weighed in the upper 200s in her pregnancy and had had a healthy pregnancy.  At one week overdue, she had a slow leak of her amniotic fluid (normally not a big deal, but in this case it had leaked out enough that contractions were pressing on the baby's umbilical cord and interfering with his heart rate).  They took her back for a cesarean, where the on-call OB began to berate the patient and her husband with the above statement ─ and more:
This was the LEAST of the horrible things he said to my husband and I.  He lectured my husband so severely that my big tough husband started to cry.  He told us that I and the baby were about 85% likely to die on the table during the surgery and it was all hubby's fault because I am SO fat. 
What the hell.....??!!!  Where does this doctor get off treating a patient, ANY patient, no matter her risk factors, like this?

Now, up to a point, I can understand the on-call OB feeling put on the spot at having to do what he perceived as risky surgery on a larger-sized person.  This wasn't his patient, but because he was on-call, he ended up having to the surgery on a patient whose risks he was uncomfortable with.  Fair enough, even though really, that's the nature of being on-call for another doctor's patients.

But this doctor had such an exaggerated sense of fear around the pregnancy and cesarean of this woman of size.  An 85% chance of dying during the surgery?  Really?  What orifice did he pull that statistic from?

Did he really believe that statistic, or was he just trying to scare and bully this woman?  Or maybe a little of both?

Now, to be fair, some research does suggest that obesity is over-represented as a risk factor in the very few women in developed countries who die during pregnancy or birth.  It does look like it is a risk factor for some cases of maternal mortality and near-misses. And that's a legitimate cause for concern.

However, the part that gets ignored by the media is that obesity usually is a co-factor along with other factors like low socioeconomic status, non-white ethnicity, cesarean surgery, pre-eclampsia, or receiving substandard medical care (like inadequate prophylaxis against blood clots, or faulty intubation during general anesthesia).

But of course, it is often obesity only that gets the focus instead of seeing it as just one of several co-factors, and rarely do authorities seriously examine how substandard care for obese women contributes to maternal mortality.

And of course, the only cure is always seen as pushing weight loss before pregnancy instead of the more uncomfortable task of looking at how poor care for obese women has impacted outcomes. Far more effective would be studying how to improve care in obese women (by improving blood clot prophylaxis, by improved recognition of pulmonary embolisms, by more careful follow-up postpartum, by doing fewer damn cesareans in women of size in the first place).

Also conveniently ignored in the media hype is that the risk of dying during pregnancy is actually extremely small, even in women with risk factors. 

So this doctor telling this woman that she (and her baby) had an 85% chance of dying during the c-section is total and unadulterated bullsh*t.  

As I said, either this doctor has a distorted-in-the-extreme sense of risk around c-sections in obese women, or he is trying to bully this woman ─ or more likely, a bit of both.

Typically, what docs like this are trying to do is shock fat women into either losing massive amounts of weight (usually through weight loss surgery....funny how that surgery is not seen as "too risky" eh?), or to frighten them out of ever daring to have a baby again.

This kind of over-the-top scare tactic is a major exaggeration of the risks around obesity and pregnancy and is a new form of Medical Bullying.  It's trying to scare women of size out of having babies, rather than giving nuanced and evidence-based counseling about possible risks and reasonable ways to mitigate those risks.

There are so many ways that this type of tactic is wrong, but one of the things that bugs me most is that they are trying to become the gate-keepers for who is "allowed" to procreate, and they have deemed fat people unworthy of procreating.  This far exceeds their mandate as physicians, and worse, it smacks of eugenics.

It's deeming some types of risk factors (like type 1 diabetes) as worthy of having babies despite the risks, and other types of risk factors (obesity) as unworthy of having babies.

But it's not up to doctors to decide which patients with which risk factors should procreate.  

Rather, it is up to the couple to look at their particular risks and make an informed decision about having children or not. Reasonable risk counseling is appropriate, medical bullying through risk hyperbole is not.

Thankfully, most care providers do not use extreme tactics like this with women of size, but the fact that some do (and get away with it) is a terrible stain on the medical profession.  I've said it before but I'll say it again.....this is a unique and insidious form of eugenics and IT MUST STOP.

**I have a more in-depth piece about obesity and maternal mortality in the works, but seeing this entry on My OB Said What?!? necessitated a quicker response.  Stay tuned for more on this topic in the future.


Anonymous said...

Well said.

Unknown said...

While I would rather that, for their own sake, a morbidly obese person not be complacent with their weight, I'm shocked and appalled at such medical practices. Ignoring the fact that its utterly wrong, it is also utterly counter productive. What is the point of yelling at somebody before a surgery? Its going to make them stressed, which in itself probably increases risk during a surgery.

I'm a scientist, I fully recognize in many overweight people, genetics and physiological imbalances are rigged to cause weight gain, and fighting that is a very hard thing. While the genetic causes remain impossible to fix as of now, the physiological issues behind weight gain CAN be tackled.

I wonder whether you are aware of the Vitamin D connection- low levels of vitamin D are risk factors for both diabetes and PCOS, it also increases morbidity or mortality risks within a pregnancy itself, and moreover,in a vicious cycle, obese people have much less bio-available vitamin D and hence are much more likely to be deficient.

Becoming Vitamin D replete improves insulin resistance, and many studies (Some done in obese teens) show that it really helps with weight loss. Nanogram increases in blood levels correlate with higher amounts of weight loss, sometimes, it is just like magic.

I think everybody who wants to go through pregnancy, should get their vitamin D checked. People with PCOS, diabetes and obesity issues just HAVE to get their vitamin D levels checked, and everything indicates that this simple fix will really help.

While many in the medical feild are becoming aware of global pandemic of vitamin D deficiency, many medical professionals (who should be reading up and telling their patients all this) live with their heads buried under a rock. These are probably the same guys who yell at a woman before she goes in to surgery!

Well-Rounded Mama said...

Jay, I am well aware of Vit D issues in people of size, as well as implications for pregnancy etc. I've written about it before here:


However, while I think it's important to check vit D levels and correct them if possible, I have to note that research is still pending on whether vit D supplements truly alleviate the risks associated with low D levels.

So often in the past, a low level of a particular vitamin is associated with a problem, everyone decides that supplements will magically fix those problems, and then everyone is surprised when research doesn't necessarily bear this out. We need more research before we can truly say that normalizing vit D levels "fixes" various problems.

And while I do personally think that bringing D levels up is helpful in many ways, I and many other fat folk with low D levels have brought our D levels up without experiencing weight loss. It's certainly not a universal "cure" for obesity. I think it may help with insulin resistance and fatigue and joint issues, so I'm in favor of more awareness of vit D levels, but I don't think it can be promoted as a way to lose weight.

Unknown said...

Yes, the clinical trials are just starting and are a mixed bag for the most part. I think the most favorable evidence for supplementation has come in the areas of autoimmunity and cardiovascular disease, and maybe mental health too. Yahoo ran a story on it, with over a 1000 comments in response, I was surprised how many people said it helped them with depression.


The thing that should be emphasized, especially with overweight individuals, its important to take ENOUGH vitamin D. Because fat cells (adipocytes)'trap' vitamin D, an obese person will have to take a lot more to increase their blood levels.


As far as vitamin D and weight loss goes, more trials are needed, yes, and there is probably evidence to the contrary as well.

Here is the original research I quoted: that nanogram increases in blood vitamin D levels resulted in higher levels of weight loss


Overall, I'd say for obese individuals, 4000-6000 IU/day is that way to go. If it helps with weight loss,great, but even if it does not, it probably is working towards lowering your risk for stroke and cardiovascular disease. Moreover, I'm absolutely convinced that not being replete during pregnancy is really dangerous, especially if you are overweight, because pregnancy is already a state where your overall levels go down. This cannot be emphasized enough, IMO. It probably is a part of why the risk factors for obese individuals in pregnancy are so high.

Well-Rounded Mama said...

Jay, we're not too fond of the "o" words around here. I use them at times for SEO, but they are not the terms of choice to use on a fat-acceptance blog. See my page on "terminology" for why. You'll make your points better for THIS audience if you respect that they finds those terms stigmatizing.

I appreciate you citing your sources. I always look for that in a commenter, and I'll check those articles out when I have time. Still, I question the quality of some of the megadose vitamin D articles out there and remain dubious about the value of really high megadoses.

That said, I do think that fat people need higher D doses in general to bring up their levels. But I still urge some caution. I just think it's very easy to over-consume one vitamin and cause an imbalance in others in your system. That's my biggest concern with a mega-D approach.

As far as pregnancy goes, I would note that my low vit D levels were not discovered till after my FOUR pregnancies, all of which resulted in healthy babies and no major complications. Did the pregnancies use up some of my vit D stores? I'm guessing yes, but even the final pregnancy, in my 40s, was fine, despite low D levels. So while I think there may well be an *association* between low D levels and some complications (like pre-eclampsia), I doubt it's causal and direct.

You'd be interested to know that some researchers are experimenting with vit D supplements in women of size to see if that lowers the risk for complications, but at this point any connection remains speculative. I think it's an interesting possibility, well worth researching, but I'm guessing it's more complex than that. After all, many of us with low D levels do just fine.

To close out this discussion now, I'd point out that I'm WELL aware of Vit D issues and I often tell people of size to get their D levels checked and treated if needed. But I remain dubious of many of the overzealous claims about D out there, and concerned that megadose advice may result in imbalances in other ways. So my basic message to people is check their levels, treat in a reasonable way, don't go overboard in doses, and don't jump to conclusions about supplementing D as a way to cure everything.

Thanks for your input. We return to our regularly scheduled programming now.

Anonymous said...

Im not sure where I could add this comment but well decied to leave it here, I love your site, and find it very informative, I am a South African woman who weighs 138kg, and am currently 28 weeks pregnant, so far I have had a very healthy and normal pregnacy with no complications, (thank the good Lord) however I can share that I have not experienced any negative or scare tactics with any person attending to me, never have I been treated differently or in such a way that made me feel horrid. I just read all these sad stories of woman who have been and are not treated very well, this makes me proud to be a south african, my health care provider has been so positve and optimistic, and ive been treated with great respect. Just thought it was important that you know not all woman of size are being treated this way.

Anonymous said...

I know this is an old article but I wanted to say that I would assume that any OB who said I had an 85% chance of dying on his table is just not very good at his job. I wonder what his personal statistics are! Scary.