Here is a study that looked at the pregnancy care of "obese" women with a BMI of 40 or more.
98% of these women saw a midwife only at the first screening appointment and never again, despite the fact that the majority of them did not develop complications.
And guess what, their cesarean rate was nearly 50%. This is far too high.
One of the most potent ways to lower the cesarean rate for women is to give them access to midwifery care. Yet this study shows that most higher-weight women are routinely being re-directed out of midwifery care.
This is not an isolated trend. If anything, maternity care is tilting towards an approach where women of size are not allowed to access midwives or low-intervention care.
We need to EXPAND midwifery care for healthy women of size, not restrict it.
In some areas, women of moderate obesity are able to access midwives and other low-intervention care choices, but Class III obese women (BMI of 40 or more) are often routinely given NO choice. In some areas, not even women of moderate obesity are being given access to low-intervention care.
Basing a decision like this simply on a number on a chart is short-sighted and probably results in many unnecessary cesareans. Instead, the decision should be made on a case-by-case basis, based not on the woman's size but on her health and particular circumstances.
If high BMI women have or develop complications, then sure, they should at least have an OB consult at some point, and can be co-managed by a midwife and OB if circumstances necessitate it. If their complications are significant enough, then care should be managed by a OB specialist or in a special bariatric center in some cases.
But women of size who do not experience complications do NOT need to be managed in a high-risk, high-intervention model of care, and they should not be routinely re-directed out of midwifery care.
That includes Class III obese women (BMI 40+) ─ and Class IV obese women (BMI 50+) too. In fact, most probably would do better NOT being managed in a high-intervention model of care.
Size alone should NOT disqualify women of size from midwifery care, yet in the real world it often does. This needs to change.
Women Birth. 2013 Sep;26(3):179-84. doi: 10.1016/j.wombi.2013.05.001. Epub 2013 Jun 5. Pregnancy care and birth outcomes for women with moderate to super-extreme obesity. Slavin VJ1, Fenwick J, Gamble J. PMID: 23746783
PURPOSE: To describe the health service utilisation and birth outcomes of pregnant women with moderate to super-extreme obesity. BACKGROUND: Maternal obesity is increasingly recognised as a key risk factor for adverse outcomes for both women and their babies. Little is known about the service utilisation and perinatal outcomes of women with obesity beyond a body mass index of 40. METHOD: Women with a self-reported pre-pregnancy BMI of 40 or more, who had received care and birthed a baby at the study site between 1 January 2009 and 31 December 2010. Clinical audit was used to identify the health service utilisation and birth outcomes of these women. RESULTS: 153 women had a BMI of 40 or more. Women saw 6 different health professionals during pregnancy (1-16). Most of their visits were with a medical practitioner, often with limited experience, and almost all women only saw a midwife once at their booking visit (n=150, 98.0%). While the majority of women experienced a normal pregnancy, free from any complications, almost half the women in this study experienced a caesarean section (n=74, 48.4%). CONCLUSION: Clinical audit has been useful in providing additional information which suggests current maternity care provision is not meeting the needs of this group of women. The model of antenatal care provision may be a mediating factor in the birth outcomes experienced by obese women. The development of effective, targeted antenatal care, designed to meet the needs of these women is recommended.