In many places, midwives are no longer permitted to care for obese women, or at least obese women over a certain BMI (often 35 or 40).
Many women of size these days are "risked out" of midwifery care, homebirth, birth centers, waterbirth, and even some hospitals. Some OBs are even refusing to see obese patients at all. A fat woman's only choice for care may become a high-risk specialist, even if she is healthy and has no complications.
It is done based on hyperbole around the risks of obesity and does not reflect the fact that many obese women are healthy, do not develop complications, and do just fine with midwifery or other "alternative" care.
In the following recent Dutch study, although more obese women had their care transferred to OBs (some of which could simply represent bias or exceeding BMI cutoffs rather than actual complications), the obese women who were cared for by midwives had no more adverse outcomes than other women.
This shows that, providing there are no major complications, obese women (and even "morbidly obese" women) can be safely cared for by midwives.
There is no need for automatic transference of care, and definitely no need for routinely ghettoizing obese women into high-risk, high-intervention care.
*Midwives, let's see some more formal studies of midwifery care of obese women. Personally, I'd love to see a study comparing outcomes of healthy obese women routinely assigned to OB care and those routinely assigned to midwifery care.
OBJECTIVE: To assess the impact of obesity on the likelihood of remaining in midwife-led care throughout pregnancy and childbirth. DESIGN: Secondary analysis of data from a prospective cohort study. SETTING: Dutch midwife-led practices. POPULATION: A cohort of 1369 women eligible for midwife-led care after their first antenatal visit. METHODS: First-trimester body mass index (BMI) was calculated as weight measured at booking divided by height squared. Obstetric data were retrieved from medical records. Multiple logistic regressions were performed to examine the effects of BMI classification on midwife-led pregnancies and childbirths. MAIN OUTCOME MEASURES: Percentages of women remaining in midwife-led care throughout pregnancy and throughout childbirth. RESULTS: Of women in obesity classes II and III, 55% remained in midwife-led care throughout pregnancy and 30% remained in midwife-led care throughout birth. Compared with women of normal weight, women in obesity classes II and III had fewer midwife-led pregnancies (OR 0.38, 95% CI 0.21-0.69), and women who were overweight or in obesity class I had fewer midwife-led childbirths (OR 0.63, 95% CI 0.44-0.90; OR 0.49, 95% CI 0.29-0.84, respectively). Compared with women of normal weight, women who were obese had higher referral rates for hypertensive disorders (4 versus 14%), prolonged labour (4.6 versus 10.4%), and intrapartum pain relief (4 versus 10.4%). The women who were eligible for midwife-led birth and who were overweight or obese, had no more urgent referrals than women of normal weight. Women who were obese and who completed a midwife-led birth had no more adverse outcomes than women of normal weight, with the exception of higher rates of large for gestational age (LGA) babies (>97.7 centile; 12.1%, versus 1.9% in normal weight and versus 3.3% in overweight women). CONCLUSIONS: Although fewer women who were obese remain in midwife-led care during pregnancy and childbirth, there was no increased risk of unfavourable birth outcomes for women who were obese and eligible for a midwife-led birth when compared with women of normal weight. This indicates that when primary care midwives use a risk assessment tool throughout pregnancy and childbirth they are able to safely assign women who are obese to either midwife-led or obstetrician-led care.
Here is the abstract for a recent study that found that use of a prenatal vitamin in the first trimester of pregnancy substantially reduced the risk for development of pre-eclampsia, especially in "overweight" and "obese" women.
The most intriguing finding of the study was that taking a prenatal vitamin in the first trimester lowered the risk for pre-eclampsia by 55% in "overweight" women, and by 62% in "obese" women.
Surprisingly, only about 1/3 of women of any size in this study actually took a prenatal vitamin during the first trimester. Other studies of relatively affluent first-world countries show that only about 30-60% of women routinely took prenatal vitamins before or in the first trimester. This is why improving prenatal vitamin use is a public health intervention which could have significant potential impact.
This may be especially true in obese women, since women of size tend to have lower rates of prenatal or preconception supplement use (45% vs. 60% in one study).
The $64,000 question is whether we can lower pregnancy complication rates in obese women by encouraging them to routinely take prenatal vitamins, even when not actively trying to get pregnant.
Caveats to the Study
The findings of this study are intriguing and deserve to be followed up. However, keep in mind that this is a relatively small study and that these results need to be duplicated multiple times before a true correlation can be established.
Also keep in mind that other studies on prenatal vitamin use (multiple or single vitamins) in the overall population havefound more ambivalent results or even poorer outcomes with routine supplementation.
So it's important not to over-interpret this one study or make broad policy recommendations based on it.
Still, it was significant that prenatal vitamin use made such a difference in women of size in this study. Why might this be?
It might be that supplementation is most beneficial only for those with significant nutrient deficits. A more sensible policy might be routine pre-conception nutrient testing for those most at risk rather than routine supplementation across the board for everyone.
Since obese women are at significant risk for pre-eclampsia and certain birth defects, pre-conception nutrient testing is something that women of size who are considering pregnancy might want to consider.
Personally, I favor pre-conception testing and emphasizing the use of whole foods and excellent nutrition as the best approach to lowering the risk for complications in women of size.
To me, the best approach is always to emphasize nutrition before pills. I think artificial pills only go so far in helping nutrient deficiencies, and vitamin supplements of one or two particular vitamins can sometimes induce imbalances of other vitamins or minerals. Frankly, focusing on increasing dietary intake of fruits and vegetables may be the safest way to improve nutritional status and decrease risks before and during pregnancy.
Still, there is a place for vitamins and/or medications at times. A prenatal vitamin before pregnancy and during the first trimester might be helpful for many people. It seems like a common-sense public health strategy that might help and is at minimal risk for harm if it's done in moderation.
But the bottom line is that we need more studies showing the effect of routine prenatal vitamin use in subgroups such as overweight and obese women. I would particularly like to see research stratified by class of obesity, nutritional intake, pre-conception nutrient status, and insulin resistance status so we could have a more nuanced examination of potential confounders as well.
Only when such nuanced research is done will we truly know for sure whether routine pre-conception and prenatal vitamin supplementation is an effective strategy for lowering the risk of complications in women of size.
Reference
Matern Child Nutr. 2014 May 22. doi: 10.1111/mcn.12133. [Epub ahead of print] First trimester multivitamin/mineral use is associated with reduced risk of pre-eclampsia among overweight and obese women. Vanderlelie J1, Scott R, Shibl R, Lewkowicz J, Perkins A, Scuffham PA. PMID: 24847942
The use of pregnancy-specific multivitamin supplements is widely recommended to support maternal homeostasis during pregnancy. Our objective was to investigate whether multivitamin use during pregnancy is associated with a reduced risk of pre-eclampsia.
The effect of multivitamin use on incidence of pre-eclampsia in lean and overweight/obese women was analysed using data collected between 2006 and 2011 as part of the Environments for Healthy Living Project, Griffith University, Australia. A total of 2261 pregnancies were included in the analysis with pre-eclampsia reported in 1.95% of subjects.
Body mass index (BMI) ≥ 25 was associated with a 1.97-fold [95% confidence interval (CI): 0.93, 4.16] increase in pre-eclampsia risk. First trimester multivitamin use was reported by 31.8% of women and after adjustment, was associated with a 67% reduction in pre-eclampsia risk (95%CI: 0.14, 0.75).
Stratification by BMI demonstrated a 55% reduction in pre-eclampsia risk (95%CI: 0.30, 0.86) in overweight (BMI: 25-29.9) and 62% risk reduction (95%CI: 0.16, 0.92) in obese (BMI: ≥30) cohorts that supplemented with multivitamins in the first trimester of pregnancy. This finding may be particular to the Australian population and reflect inherent nutritional deficits.
First trimester folate supplementation was found to reduce pre-eclampsia incidence [adjusted odds ratios (AOR) 0.42 95%CI: 0.13, 0.98] and demonstrated significance upon stratification by overweight status for women with BMI >25 (AOR 0.55 95%CI: 0.31, 0.96). These results support the hypothesis that multivitamin supplementation may be beneficial in reducing the incidence of pre-eclampsia during pregnancy and be of particular importance for those with a BMI ≥25.
One of my favorite Vaudeville performers was Sophie Tucker (1884–1966).
She was known as the "Last of the Red-Hot Mamas."
She combined an earthy sense of humor with a big rounded body and never let others keep her down.
Life
Sophie was born to a Jewish family in Russia as they were emigrating to the United States. They settled in Connecticut when she was just a baby.
Her original name was Sophia [or Sonia] Kalish, but the family changed its last name to Abuza when it emigrated. Later, during a brief marriage at age 19, she took her husband's last name, "Tuck," which she later adapted to Tucker for her stage name.
She worked in her family's restaurant business as she grew up, often singing for tips. According to the website, Jewish Women's Archive, she recounted:
I would stand up in the narrow space by the door and sing with all the drama I could put into it. At the end of the last chorus, between me and the onions there wasn't a dry eye in the place.
Sophie and her son, Bert
She was married 3 times in her life but none of her marriages lasted for long. She had a son, Bert (see picture to left), with her first husband.
After they divorced, she left Bert with her parents while she went to New York City to make a career and often sent home money from her earnings to help support them.
She married twice more but each experience was unhappy and left her determined to be independent and happy on her own:
Sophie Tucker married and divorced twice more before giving up on marriage, proclaiming, in song, "There isn't going to be a fourth Mr. Ex/ And I'll be damned if I'm paying any more alimony checks/ I'm living alone and I like it."
She felt that philanthropy was very important and supported many charities. She died at age 82, from lung and kidney ailments.
Career
Sophie Tucker had a long and varied career.
She started in vaudeville with a comic shtick routine, and this vaudeville material influenced her style for the rest of her life.
She was briefly in the Ziegfeld Follies, but was so popular that many of the other performers refused to go on with her because she upstaged them.
In time, she branched out to (rather forgettable) movies, then developed a nightclub act in which she revisited her vaudeville material while also developing more sentimental songs.
In her later years, she was a frequent guest on music and variety shows on TV like The Ed Sullivan Show.
She toured incessantly and performed right up until a few weeks before her death.
Weight
Although actually not that large, Sophie was always considered a big girl in the entertainment world. Even as a young teenager, she was often called "the fat girl." Her early managers were afraid she was "too fat and ugly" to make it on stage.
Rather than let it work against her, she used it as part of her act, and was often self-deprecating about it. As one source comments:
Tucker's stage image emphasized her "fat girl" image but also a humorous suggestiveness. She sang songs like "I Don't Want to Be Thin," "Nobody Loves a Fat Girl, But Oh How a Fat Girl Can Love."
Late in her career she sang a song called, "I'm the 3-D Mama with the Big Wide Screen."
In her most famous song she sang, "You're gonna miss your big fat momma some of these days."
She took a perceived negative and turned it into a positive by playing the underdog and making her audiences root for her. The fact that the "fat and ugly girl" became most famous for her racy, sexy material was an irony not lost on her.
Bawdy Overtones
A lot of Tucker's stage personality was based on a bold, brassy, sexy persona, singing songs of humorous raciness.
This earned her the billing, "The Last of the Red Hot Mamas" but her material was just ambivalent enough that it could be interpreted innocently or not-so-innocently, which kept her away from the worst censorship of the time.
Some of her racy songs included, "I May Be Getting Older Every Day (But Younger Every Night)," "When They Start to Ration My Passion, It's Gonna Be Tough on Me," "Making Wicky-Wacky in Waikiki," and "You've Got to Make It Legal, Mr. Siegel."
Singing "The Angle-Worm Wiggle" got her removed from the stage in 1910 but the judge threw out the case.
Performing Style
As her act progressed, Tucker hired Ted Shapiro as her accompanist. He became a long-time part of her act, exchanging witty banter with her in between numbers. He also wrote some of her songs.
She usually used a narrative, half-speaking style in her songs, especially as she aged, but could sing when needed.
Her voice was not very good, but her comic style and brassy delivery influenced later entertainers like Mae West, Ethel Merman, and Bette Midler (who has a stage character named "Soph" and who supposedly named her daughter after Tucker).
Tucker was fiercely independent after all her failed marriages, and that was often reflected in her repertoire. Some of her songs included "A Good Man Is Hard to Find," "You Can't Deep-Freeze a Red-Hot Mama," "Too Much Lovin'," "Never Let the Same Dog Bite You Twice," "I'm Living Alone and I Like It," "I Ain't Takin' Orders from No One," and "No Man is Ever Gonna Worry Me."
Her songs about independence from men made her popular with women, but men liked her for her bawdy humor. She toured vaudeville houses and music halls through the United States and Europe, taking on a more nostalgic style as the years progressed and vaudeville went out of vogue.
Although she could be quite flamboyant, dressing in furs, jewels, feather boas, and outrageous wigs and hats, she also could effectively deliver serious or highly sentimental songs, earning her the title of "The First Lady of Show Business" by the end of her career.
Controversies
As with many other performers of that era, her early career is deeply entwined with racist practices common to the time, like singing in blackface and doing covers of African-American songs.
In 1907, when Tucker got her first break in vaudeville, they insisted that she perform in blackface. However, one day when her costume trunks got lost, she had to go onstage without it and became more popular without it, thereafter dropping the practice.
She hired African-American composers to write songs for her and sang in a style influenced by ragtime and blues. She hired vaudeville and blues greats Mamie Smith and Ethel Waters to give her singing lessons in those styles. In 1910, African-American composer Shelton Brooks wrote "Some of These Days." Tucker purchased exclusive rights to sing it and it became the signature song of her act and the title of her 1945 autobiography.
Tucker also made a name for herself by singing for Jewish audiences. She sang songs like "My Yiddishe Momme" by Jack Yellen and Lew Pollack, a highly sentimental song about a mother's sacrifice, which she began singing after the death of her own mother. She explained:
Even though I loved the song and it was a sensational hit every time I sang it, I was always careful to use it only when I knew the majority of the house would understand Yiddish. However, you didn't have to be a Jew to be moved by 'My Yiddish Momme.' 'Mother' in any language means the same thing.
In addition to performing, Tucker was active in efforts to unionize professional actors, and was elected president of the American Federation of Actors in 1938. This did not endear her to show business executives but her efforts to gain better conditions made her popular with performers and those working behind the scenes. In one story, the Teamsters were on strike when she died, but the hearse drivers put down their signs temporarily for her funeral procession to honor her memory.
Tucker was known for her reverence of the Hebrew principle of tzedaka, charity and acts of good will toward others. In 1945, she established the Sophie Tucker Foundation, donating time, energy, and resources to an ecumenical assortment of causes. Tucker contributed to the Jewish Theatrical Guild, of which she was a life member, the Negro Actors Guild, and the Catholic Actors Guild, as well as the Will Rogers Memorial Hospital, the Motion Picture Relief Fund, synagogues, and hospitals. She supported Israel Bonds, and her foundation endowed a Sophie Tucker chair at Brandeis University in 1955.
In 1959, on the first of several trips to Israel, Tucker dedicated the Sophie Tucker Youth Center at Beit Shemesh in the Judean Hills. Two years later, she sponsored another youth center at Kibbutz Be'eri in the northern Negev near Gaza. In 1962, she sponsored the Sophie Tucker Forest near the Beit Shemesh amphitheater and raised money for another forest. She also donated time and money to numerous hospitals and homes for the aged.
Tucker used her economic independence to empower herself and others, which created tensions in her personal life. Early in her career, Tucker had helped many of the prostitutes who lived in the same rooming houses as she, stashing money from their pimps, noting that, "Every one of them supported a family back home, or a child somewhere." While on tour, she brought her band to play in houses of prostitution for women who'd taken the night off in her honor.
Tucker felt that it was her economic independence that doomed her marriages to Tuck, accompanist Frank Westphal, and manager Al Lackey, all of which ended in divorce. As she explained it: "Once you start carrying your own suitcase, paying your own bills, running your own show, you've done something to yourself that makes you one of those women men like to call 'a pal' and 'a good sport,' the kind of woman they tell their troubles to. But you've cut yourself off from the orchids and the diamond bracelets, except those you buy yourself."
Stories and Quotes
Here are some of Sophie Tucker's most famous quotes:
"I've been rich and I've been poor. Believe me, honey, rich is better." [Whether she or someone else actually said this is disputed, but it's generally attributed to her.]
"I couldn't make [her mother] understand that it wasn't a career that I was after. It was just that I wanted a life that didn't mean spending most of it at the cookstove and the kitchen sink."
"Gradually, at the concerts, I began to hear calls for 'the fat girl'.... Then I would jump up for the piano stool, forgetting about my size, 145 pounds at age 13, and work to get all the laughs I could get."
“I was never sylph-like. I was always big and husky.”
From Raymond Stanley's Show Buzz: Kenn Brodziak, who engaged her, had never met her before but, immediately she alighted from the plane and he had introduced himself, she took him aside and clutched his arm. Very gently she said: “Don’t let the TV cameras near me - it’ll hurt your box office!”
"From birth to age eighteen, a girl needs good parents. From eighteen to thirty-five, she needs good looks. From thirty-five to fifty-five, she needs a good personality. From fifty-five on, she needs good cash."
"I would start off with a lively rag, then would come a ballad, followed by a comedy song and a novelty number, and finally, the hot song. In this way, I left the stage with the audience laughing their heads off."
"I've never sung a single song in my whole life on purpose to shock anyone. My 'hot numbers' are all, if you will notice, written about something that is real in the lives of millions of people."
"Laugh and the whole world laughs with you. Weep and you sleep alone."
"Success in show business depends on your ability to make and keep friends."
Bette Midler incorporated some of Sophie Tucker's more bawdy humor into her stage show, or used it as inspiration for her own naughty comic riffs in Soph's personality. You can read more about these here. [Keep in mind, these are definitely not for the easily offended.]
Videos of Performances
Here is a recording of Sophie performing "Red Hot Mama."
If an emergency or health crisis hits, it's vital to have a list of important phone numbers handy to help you through the crisis.
It's even more helpful if you have generated this list of emergency numbers ahead of time, so you don't have to spend precious time scrambling to find the numbers you need.
This is one thing our family has learned from experience. It's especially important if you have children or elderly people who are dependent on you.
Making an Emergency Phone Number List
If you don't already have an emergency phone list, start making one now. Make it a word processing document so you can update it as needed. Make the document as easy-to-read as you can.
Then program these phone numbers into your cell phone AND print them as a hard copy.
Many people have their emergency phone numbers only in their cell phones, but then have none of them available if their cell phone runs out of battery power, is stolen, or is damaged. If you also have a hard copy of the numbers, you have a back-up to refer to if needed. Ideally, you should know the most important numbers by memory also (and train your children to know them too), but a hard copy is helpful because memory is sometimes unreliable in an emergency situation when under stress.
At home, hang a copy of these emergency numbers up on the wall by all your major phone receivers (or in a prominent place in the home, like on the kitchen refrigerator and in the master bedroom, if you only have cell service).
Include your name, home address, and phone number at the top of the page; many children (and even adults) forget their own contact information in the adrenaline rush of an emergency and find a nearby reminder to be helpful. If a family member has a known medical condition or significant allergy, you should include that information near the top as well.
Carry a hard copy of these emergency numbers in your purse/wallet, emergency supplies backpack, diaper bag, and car. You never know when you might need them while away from home.
Your family's emergency phone number list should include:
Parent names and phone numbers (work, home, and cell)
Guardian names and phone numbers (work, home, and cell)
Relative names and phone numbers (work, home, and cell)
Doctor names and phone numbers (for each member of the family)
Dentist names and phone numbers (for each member of the family)
Poison Control (1-800-222-1222)
Nearby hospital phone numbers
Your pharmacy's name and phone number
Your veterinarian's name and phone number (and an animal hospital) if you have pets
Neighbors (and their phone numbers) who could help out at your home until you could return
Trusted local emergency contacts who you could call for help if needed
Names and phone numbers for your children's schools (and daycare/babysitters, if applicable)
Names and phone numbers for adult helpers at kids' activities (Scouts, sports, church, etc.)
Your home, medical, and car insurance agents' names and contact information
Your utility company contact numbers (water, electric, gas, etc.)
Ambulance, Police, and Fire phone numbers if you are in an area not covered by 911 service
In each car/diaper bag, try to have a current picture of each member of the family. Keep both a hard copy and a digital copy, if possible, because there are certain scenarios in which one or the other form might be most useful. Having both digital and hard copies covers all eventualities.
Hopefully you will never need these emergency contacts, but in life, unexpected things happen. It's good to be prepared for the possibility of a civic emergency, an unexpected medical crisis, an extreme weather event, a sudden school closure, or even just a protracted traffic jam. And having both digital and hard copies of these numbers keeps you ready to respond even when your cell phone isn't working or available. And if cell service is out or overloaded, remember that often a text will go through when nothing else does.
Have children practice making an emergency phone call so they could do it without adult help if needed. Use a disconnected or toy phone and have them play-act dialing 911, telling emergency services about their emergency, and saying their phone number and address. If they are calling from a cell, they should know they may need to describe where they are so they can be located more easily. Emphasize the importance of staying calm and speaking as clearly as possible so the operator can understand them and help get the information needed. They should also know to unlock and open the front door so EMTs can get in, or to have somebody outside waiting for the ambulance.
Role-playing what to do in an emergency can help children respond more effectively, and having an easy-to-read, clear emergency contact list helps children convey information even if they become upset or disoriented. It may help save lives ─ maybe even yours.
Be Ready for Special Needs Family Members
Finally, if you are taking care of an elderly parent or other family member with significant health issues, you know what a hard job this can be.
To make this job easier, consider putting together an updated list of your loved one's medical conditions, health history, current medications, and doctor contact info. Keep this list with you at all times. You may also want to have a file folder at home that you can grab quickly, containing a copy of healthcare power of attorney, living will, and pertinent medical files if this might be needed.
This is the system I developed when I took care of my mother in her final years. Although she lived a long and mostly healthy life, by her mid-80s she did have quite a number of health conditions (as older people often do), including cardiac and neurological issues. After struggling to remember all her complicated medical history every time we went to the doctor or hospital, I developed this system to make things easier. (I kept her medical history on the back of my emergency phone contacts list so I had both critical items on the same piece of paper.)
Having a system like this can improve health and save lives. When I took over my mother's care, she was on a truckload of medications, many of which had interactions with each other. Through careful questioning and care coordination, we were able to reduce her medications considerably and minimize drug interactions. Her condition improved considerably when her medications were more carefully overseen, and my list was helpful in this process.
In addition, by keeping a detailed list of her prescriptions and their proper schedule, I was able to catch a number of medication errors before they happened at the hospital and at her nursing home. This was critical in keeping her quality of life good for as long as possible.
Like many elderly people, she did have a gradual health decline by the end and became a "frequent flyer" at the local hospital. Sometimes we were called into the E.R. in the middle of the night or on very short notice because of a complication. Those doctors depended on me to quickly fill in the blanks of her health history until they could get further details from her physicians, but it was often hard to remember everything on such short notice or in the middle of the night.
Having a pre-existing list of her conditions, history, prior surgeries, medications, and doctors made all of our lives so much easier. All I had to do was pull out the list, have them make a copy of it, and then answer any questions they had. This streamlined her treatment and minimized medication delays. They often thanked me for being so organized and told me they wished everyone kept such a list.
Taking care of a loved one with special medical needs is a hard job. It's also difficult for medical professionals, who must formulate a quick treatment plan for complicated cases. If they are delayed in finding out the patient's medications and medical history, critical treatment may also be delayed.
Having a special patient's updated medical history summary with you at all times can help expedite treatment and prevent many medical errors. It also can considerably lighten the heavy burden of overseeing the care of such family members.
Summary
Having an emergency contacts list with you at all times can help you deal with unexpected situations like weather emergencies, medical crises, or other challenges. Although most people carry emergency numbers in their cell phones, many don't have all the recommended numbers above in their cell phones, and few think to carry a hard copy too in case they don't have access to their cells.
Similarly, if you are one of the many people who care for a family member with special medical needs, it can be very helpful to also have their medical history summary on the back of your emergency contacts hard copy. List the person's conditions, doctors, doctor contact info, and medications/dosages/schedule and keep it nearby at all times. That way, if you are called in to help, you don't have to scramble to try to remember all the details accurately. The medical professionals you deal with will appreciate a concise summary like this.
Resources Forms to help make an emergency contact list:
